Health care workers infected with novel H1N1 influenza A virus
One HCW reported transmission despite mask
With persistent outbreaks but milder-than-expected disease severity, novel H1N1 posed a unique dilemma for hospitals. They first needed to assuage fear, then to prevent against complacency. They needed to monitor employee illnesses and provide adequate precautions, yet encountered varying guidance.
By mid-May, at least 100 health care workers were among the nation's 5,700 confirmed and probable novel H1N1 cases, according to the Centers for Disease Control and Prevention. It was not clear how many of them contracted the illness in the community and how many cases were work-related.
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Will California lead the way? First state to adopt aerosol disease standard As this issue went to press, California became the first state to adopt an aerosol transmissible disease standard, which requires hospitals to conduct a risk assessment, maintain an exposure control plan and provide annual training to employees. Specific requirements differ based on the employees' potential for exposure, but respiratory protection (an N95 or greater) would be required for employees caring for patients with a novel or unknown pathogen. It would allow biannual fit-testing for some health care workers but require the use of powered air-purifying respirators (PAPRs) with most high-hazard procedures, such as bronchoscopy and sputum induction, unless this use would interfere with patient care. The standard becomes effective in July. Hospital Employee Health will provide full coverage of this landmark regulation in the August issue. The Center for Occupational & Environmental Health at the University of California Berkeley is offering a seminar on the new standard, July 27-28, 2009. More information is available at www.coehce.org/suminst/suminst.htm. |
In Wisconsin, for example, nine health care workers contracted novel H1N1 from the state's first confirmed case in late April in a chain of transmission that still was being sorted out a month later. "They had the patient in droplet precautions at that time. There were health care workers who were not using surgical masks when they went in to take care of the patient," says Gwen Borlaug, CIC, MPH, infection control epidemiologist with the Wisconsin Division of Public Health in Madison.
In one case, the health care worker reported that she wore a surgical mask and gloves at all times while caring for the patient, which may indicate that droplet precautions were not sufficient to protect against transmission, says Borlaug. "It's something we need to further investigate," she says.
Nationally, health care workers contracted novel H1N1 from their coworkers who came to work sick, says Daniel Jernigan, MD, PhD, deputy director of CDC's influenza division. "If [employees] are sick, they should stay home, not only to protect patients but also to protect other health care workers from getting ill as well."
Meanwhile, the emergence and continued spread of the novel influenza virus caused confusion as hospitals sought to respond. Respiratory protection was a particular area of concern.
"We heard of some hospitals that had a run on their N95 [respirators]. Clinical units were hoarding them to make sure they had enough," says Eric Toner, MD, senior associate in the Center for Biosecurity at the University of Pittsburgh Medical Center.
Some hospitals gave health care workers prophylactic antiviral medication even if they were protected when they had contact with a single patient, Toner says. Another hospital asked its employees to wear N95s at all times - although no cases had been reported in the community, he says. "It was my understanding they reversed that [policy] pretty quickly," he says.
In other locales, hospitals were reluctant to provide employees with N95s, perhaps because they feared a shortage or additional expense, according to labor advocates for health care workers. At one hospital in New York state, for example, a nurse reported that nurses were told they could have only one N95 per shift. "They're not taking the threat seriously and they're not thinking of the people at the bedside," said the nurse, who asked not to be identified.
CDC allows guidance 'flexibility'
While CDC maintained its "interim" guidance for health care workers to wear N95s when caring for patients with the novel H1N1 virus, numerous state and local health departments developed their own, less stringent recommendations.
CDC did not try to unify those disparate recommendations. "We allow for there to be some flexibility so that states can take into account the unique activities and the unique amount of disease ... in their jurisdictions and come up with the appropriate guidance," Jernigan said at a media briefing.
Wisconsin stuck steadfastly with the CDC guidelines. Some studies indicate that influenza viral particles could be aerosolized, notes Borlaug. "We really don't want to transmit seasonal influenza or any kind of respiratory virus," she says. "We have to decide what is the best way [to protect health care workers] in the absence of a vaccine."
Labor advocates for health care workers decried the guidance that sanctioned surgical masks rather than respirators for those caring for patients infected with the novel virus. While the novel virus produced symptoms similar to seasonal flu, cases continued to grow in the late spring, a time when seasonal influenza usually wanes.
And unlike seasonal influenza, there is not yet a vaccine for the novel virus, notes Bill Borwegen, MPH, health and safety director for Service Employees International Union (SEIU) in Washington, DC. "It's an interesting juxtaposition because when there is a vaccine, people want to make it mandatory. But when there is no vaccine, people don't want to require respirators," he says.
Underscore need to stay home if sick
The University of Chicago Medical Center was the first hospital to report infections among health care workers, a discovery that occurred because of the cautious attitude of a nurse manager.
It was mid-April, before the "swine" flu had captured the attention of the U.S. news media, when a nurse manager began to feel sick after returning from a trip to Mexico. She stayed home until she began to feel better, then restricted herself to her office so she wouldn't have any chance of patient contact.
She also asked the hospital's lab for viral testing so she could find out what was causing her symptoms. The test came back positive for influenza A - and was later typed as an early case of novel H1N1.
The nurse manager's office mate contracted the virus, but because of the precautions she took, there was no other transmission, says Stephen Weber, MD, hospital epidemiologist and medical director of infection control at the University of Chicago Medical Center.
Lesson learned: It's critical for employees to stay home if they're sick, and they must feel comfortable to do so without repercussion. "Define, articulate and enforce a policy that discourages people from coming to work ill," he urges.
Employee health also should monitor absenteeism and have a mechanism for screening for symptoms, he says. "This was serendipity that we identified this case," he says. "This person might have gotten sick, and office mates gotten sick, and no one would have had the good sense to report it to us [in infection control] or employee health."
Once the hospital was aware that an employee had been sick with the novel H1N1, the University of Chicago Medical Center enacted its pandemic preparedness plan. They doubled the number of cough etiquette stations - containing masks, hand sanitizer, and tissues - and placed them close to all entrances to the hospital.
They contacted manufacturers to obtain additional N95 respirators. "Before most hospitals had even called an alert, we were stocking up on additional personal protective equipment," Weber recalls.
Ultimately, by mid-May, the hospital had treated two patients with confirmed novel H1N1 and other probable cases. Any health care worker who had unprotected exposure to those patients received prophylactic oseltamivir.
"[Initially,] it was totally unclear how serious the actual illness would be," says Weber. "We did presume that it could be severe. The measures we took, while very visible, were things that allowed us to continue the operations of the medical center in ways that were safe."
However, as the virus displayed a virulence that was similar to seasonal influenza, the Chicago Department of Public Health issued guidance recommending the use of surgical masks, and the University of Chicago chose to follow that recommendation, he says.
With persistent outbreaks but milder-than-expected disease severity, novel H1N1 posed a unique dilemma for hospitals. They first needed to assuage fear, then to prevent against complacency. They needed to monitor employee illnesses and provide adequate precautions, yet encountered varying guidance.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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