NJ issues respirator guidance
To resolve disagreement about what protection is needed to treat victims of bioterrorism when the agent is pneumonic plague, the New Jersey Depart-ment of Health and Senior Services (NJDHSS) in Trenton issued this guidance:
To resolve disagreement about what protection is needed to treat victims of bioterrorism when the agent is pneumonic plague, the New Jersey Depart-ment of Health and Senior Services (NJDHSS) in Trenton issued this guidance.NJDHSS recognizes the challenges in reconciling conflicting infection control guidance from our federal partners, CDC and OSHA, as they continue to argue for their respective recommendations. These same issues have remained unresolved since TOPOFF2, and it is likely that these issues will continue throughout TOPOFF3. Therefore, NJDHSS will continue to provide our best interpretations of federal guidance as it evolves. As additional information for your TOPOFF3 preparatory activities, please review the message below regarding (1) NJDHSS clarification of CDC’s “Interim Guidance for Protecting Health Care Workers Caring for Patients Potentially Exposed to Aerosolized Yersinia pestis from a Bioterrorism Event,” (2) contacts of plague patients, and (3) historical information on person-to-person transmission of pneumonic plague. NJDHSS thanks you in advance for all your efforts related to next week’s exercise.
1. NJDHSS would like to clarify the CDC “Interim Guidance for Protecting Health Care Workers Caring for Patients Potentially Exposed to Aerosolized Yersinia pestis from a Bioterrorism Event.”
The interim guidance mentions the following:
(1) Case reports describing occurrences of pneumonic plague have found that transmission of Y. pestis from persons (or animals) with pneumonic plague usually occurs among persons in direct and close contact with the ill person (or animal). . . . Therefore droplet precautions have been recommended for health care workers caring for patients with pneumonic plague.
(2) “When there is a suspicion of a biological attack, infection control practice should include airborne and contact precautions. Historical and contemporary epidemiological evidence from naturally occurring pneumonic plague outbreaks indicates that the infection is not easily transmitted from person to person, and that a surgical mask in combination with other droplet precautions provides adequate protection for health care workers. However, given the initial uncertainties associated with a bioterrorism event, additional precautions may be prudent, and the use of an N95 filtering facepiece respirator will offer an additional degree of protection. Other complementary strategies should also be in place, including temperature monitoring of unprotected close contacts. In addition, the use of antibiotic prophylaxis may be considered. These precautions should be continued at least until a definitive diagnosis is established and antimicrobial sensitivity of the agent is known, and the presence of other agents is ruled out.”
In other words, during the initial response to caring for patients with unknown potentially infectious respiratory illnesses (including situations where bioterrorism is suspected), individuals should use N95 respirators. However, once plague is confirmed (or is ruled out), individuals may then follow standard and droplet precautions, in light of evidence demonstrating that droplet precautions provide adequate protection while working with patients with pneumonic plague. The above information is consistent with previous guidance issued by the NJDHSS. Health care workers should follow standard, contact, and airborne precautions when caring for patients with unknown, potentially infectious respiratory or influenza-like illnesses. Airborne precautions include the use of properly fitted N95 respirators. Once the illness is diagnosed, health care workers should use precautions appropriate for the etiologic agent. For plague, standard and droplet precautions are recommended; current evidence suggests that droplet precautions provide adequate protection while caring for patients with pneumonic plague. A health care worker may choose to wear an N95 respirator; however, surgical masks are considered adequate to prevent infections transmitted via drop-lets. NJDHSS continues to be actively involved in discussions with the CDC and other stakeholders regarding this matter and will provide updates as they become available.
2. Current CDC guidance defines a close contact as any person who has been within 6-7 feet of a symptomatic plague patient. However, distance cutoffs should NOT be used as a hard and fast rule for identifying contacts who should be monitored for illness or given antimicrobial prophylaxis. In addition to distance, duration and nature of exposure are important factors that should be considered when assessing contacts. For instance, one example of a high-risk exposure that is not necessarily predicated on distance is sharing eating or drinking utensils with a symptomatic pneumonic plague patient.
3. Finally, for your information, please also review the attachment, “Risk of Person-to-Person Transmission of Pneumonic Plague” by Jacob L. Kool, from CDC’s Division of Vector-Borne Infectious Diseases (also available in Clinical Infectious Diseases 2005; 40:1,166-1,172). This article provides a historical overview regarding risk of Y. pestis transmission.
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