OSHA enforcing N95 respirators for HCWs treating H1N1 flu patients
OSHA: 'We're looking for a good-faith effort.'
By Gary Evans and Michelle Marill, Editors, Hospital Infection Control & Prevention, Hospital Employee Health
Particulate respirators - a controversial step beyond common surgical masks - are now mandated by the Occupational Safety and Health Administration (OSHA) to protect health care workers from acquiring H1N1 pandemic influenza A from patients. With respirator shortages feared, "good-faith efforts" by health care employers will be recognized by OSHA, which nevertheless is warning that citations and fines may result from inspections that will be primarily prompted by employee complaints.
"Employers should do everything possible to protect their employees," said Jordan Barab, acting assistant secretary of labor. He emphasized, however, that where respirators are not commercially available, an employer will be considered to be in compliance if the employer made every effort to acquire respirators. Health care employers will need to be able to show documentation of orders that have been placed or statements from a manufacturer that the respirators are on back order. N95 respirators - already used by many hospitals for the treatment of tuberculosis patients - are the minimum level acceptable for H1N1.
"We're looking for some evidence that the employer has attempted to purchase N95 respirators," Barab said. "We're looking for a good-faith effort."
OSHA is issuing a compliance directive to enforce the Centers for Disease Control and Prevention's recently issued "Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel." (Available at http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm.)
The CDC disappointed infection preventionists in the guidance by reaffirming its stance that surgical masks are not sufficient to protect workers from H1N1 patients. The CDC recommends the use of respiratory protection that is at least as protective as a fit-tested disposable N95 respirator for health care personnel who are in close contact (within 6 feet) with patients with suspected or confirmed 2009 H1N1 influenza. The president-elect of the Society for Healthcare Epidemiology of America said the CDC decision appeared to be made for reasons other than science, which has not shown burdensome, scarce N95s to be more effective in clinical studies.
"They are recommending a respirator that is not readily available, for transmission that has never been shown to be clinically relevant," said Neil Fishman, MD. "It presents a hardship to health care workers and health care providers that is unnecessary and offers nothing in [additional] degree of protection."
On the other hand, the CDC is under considerable pressure from health care unions and worker safety advocates since at least four nurses nationally have reportedly died of complications related to H1N1. Noting that H1N1 surveillance systems do not provide occupational data, the National Institute for Occupational Safety and Health (NIOSH) is asking for information from the public on health care worker H1N1 illnesses and deaths. (Information can be e-mailed to [email protected].) NIOSH is asking for contact information so the agency can follow up on cases that have primarily been reported through the media.
"Once we get that information, we can make decisions about whether we want to do a more thorough investigation, whether it is a Health Hazard Evaluation or another kind of study," says Christina Spring, health communications specialist with NIOSH in Washington, DC.
Meanwhile, OSHA inspectors will ensure that health care employers implement a hierarchy of controls, including source control, engineering, and administrative measures, and to encourage vaccination and other work practices recommended by the CDC. Where respirators are required to be used, the OSHA Respiratory Protection standard must be followed, including worker training and fit testing. While the ruling clearly applies to hospitals, as this report was filed OSHA had not responded to a written request for clarification regarding other medical settings. Employee complaints from clinics and physician offices could potentially result in an inspection because OSHA's respiratory protection standards also apply to small businesses.
CDC casts wide net
The CDC clarified that the scope of its guidance includes a wide range of medical settings: "This guidance provides general recommendations for health care personnel in all health care facilities," the CDC stated. "For the purposes of this guidance, health care personnel are defined as all persons whose occupational activities involve contact with patients or contaminated material in a health care, home health care, or clinical laboratory setting."
Since a shortage of disposable N95 respirators is possible, employers are advised to monitor their supply, prioritize their use of disposable N95 respirators according to guidance provided by CDC, and to consider the use of reusable elastomeric respirators and facemasks if severe shortages occur, OSHA advised. Health care workers performing high- hazard, aerosol-generating procedures (e.g., bronchoscopy, open suctioning of airways, etc.) on a suspected or confirmed H1N1 patient must always use respirators at least as protective as a fit-tested N95, even where a respirator shortage exists. In addition, an employer must prioritize use of respirators to ensure that sufficient respirators are available for providing close-contact care for patients with aerosol-transmitted diseases such as tuberculosis.
Where OSHA inspectors determine that a facility has not violated any OSHA requirements but that additional measures could enhance the protection of employees, OSHA may provide the employer with a Hazard Alert Letter. OSHA will inspect health care facilities under the Respiratory Protection Standard "to ensure that health care workers are protected and that protection is in line with CDC [guidance]," Barab said.
The CDC guidance to use respirators has been controversial and hotly debated almost since the onset of H1N1 last spring. Many infection preventionists argue that H1N1 is comparable to seasonal influenza in its virulence and transmission routes, and that droplet precautions (e.g., surgical masks) are sufficient. In fact, some state health departments diverged from CDC and called for surgical masks unless health care workers were performing aerosol-generating procedures.
The Healthcare Infection Control Practices Committee, a CDC advisory panel, endorsed the use of surgical masks rather than respirators. But an Institute of Medicine (IOM) panel charged with reviewing the available science concluded that surgical masks would not protect workers from airborne influenza particles. "[T]here is evidence that work-related exposures to patients infected with H1N1 virus result in health care workers becoming infected," the IOM report stated.
The answer, decided CDC director Thomas Frieden, MD, is to use respirators but to limit their use through other measures. "Use a scarce resource carefully," he said in a briefing on the guidance. "Follow a hierarchy of controls and limit the number of people who are potentially exposed and would need a higher level of protection."
The CDC is no longer recommending contact precautions - the use of gowns and gloves - but Frieden noted that influenza is spread through droplet, fomite, and aerosol transmission. "It is an unfortunate fact that we do not have definitive evidence on the portion of transmission that occurs from each of those three routes," said Frieden, noting that "the preponderance of belief" was that droplets were the most common route. "With that lack of knowledge and with the newness of H1N1 ... we are recommending that N95s ... would be clearly superior to surgical masks."
Still, CDC is providing some flexibility to hospitals. That means in some circumstances, health care workers may reuse respirators, continue to wear them while caring for more than one patient, or may even wear surgical masks as a last resort option. CDC states that extended use (in which the respirator is not removed while the health care worker cares for more than one patient) is preferred over reuse.
"We recognize that there may be shortage situations," said Frieden. "The need is for us not just to provide respiratory protection now, but the flu season lasts through May. We need to ensure we have a reliable supply."
The CDC guidance states that "when in prioritized respirator use mode, respirator use may be temporarily discontinued for employees at lower risk of exposure to 2009 H1N1 influenza or lower risk of complicated infection."
Particulate respirators - a controversial step beyond common surgical masks - are now mandated by the Occupational Safety and Health Administration (OSHA) to protect health care workers from acquiring H1N1 pandemic influenza A from patients. With respirator shortages feared, "good-faith efforts" by health care employers will be recognized by OSHA, which nevertheless is warning that citations and fines may result from inspections that will be primarily prompted by employee complaints.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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