Transcript Laboratory Aspects of the Proposed Airborne Infectious

Protecting Health Care Workers from
Infectious Disease
Experience with Cal/OSHA’s Aerosol
Transmissible Disease Standards
Deborah Gold, MPH, CIH,
[email protected]
APHA October 2015
Presenter Disclosures
Deborah Gold
The following personal financial relationships with
commercial interests relevant to this presentation existed
during the past 12 months:
“No relationships to disclose”
In May 2009 California Adopted
the ATD standards
• Standard development began in 2003
• SARS outbreak started in Asia in 2002, Canada 2003
• California TB cases about 3000 per year
• 10 advisory meetings 2004-2007
• Pandemic flu planning 2005-6
• Health Care Surge planning 2005-8
• Proposals noticed June 2008
• H1N1 influenza pandemic detected spring 2009,
continued through year
• ATD standard applies to Health care
corrections, drug treatment programs,
homeless shelters, clinical, academic and
research biological labs, some law
enforcement and public health operations,
aerosol generating procedures on cadavers,
first receiver, and maintenance operations
on contaminated equipment or areas
• Zoonotic ATD standard applies to workers
with contact with animals or their wastes.
What is an Aerosol Transmissible
Disease?
• A disease
• That is transmitted by
aerosols (A gaseous
suspension of fine solid
or liquid particles)
• Particles of different
sizes
Aerosols
• Aerosols are generated from the
respiratory tract when we talk, sneeze,
cough, sing, etc.
• These aerosols are warm and moist, and
evaporate quickly, leaving smaller
droplets (droplet nucleii), which can
remain in the air for periods long enough
to be inhaled by others
• Aerosols also can be generated from the
digestive tract, cleaning, flushing
“Airborne” or “Droplet”?
• ATD Standard basically adopted CDC distinction
between diseases primarily spread by:
• larger droplets >5 microns (droplet precautions) travel less
than 3 feet (or 6 feet)
• Small droplets, droplet nucleii, dusts containing the pathogen
(airborne isolation)
• Particles of up to 100 microns can be inhaled
• Coughs and sneezes create plumes which may travel
much farther than 3-6 feet
• There is evidence for an “aerosol” route for many
diseases (E.g Jones, RM, Brosseau, LM. Aerosol Transmission of
Infectious Disease. JOEM Volume 57, Number 5, May 2015)
ATD Standard Expanded Airborne
• Precautionary principle -- “novel and
unknown pathogens” classified as
airborne (e.g. SARS 2003)
• If CDPH or LHD recommends “airborne”
standard requires it
• Enhanced respirator requirements for
AGP
“One example was the debate during SARS
over whether SARS was transmitted by large
droplets or through airborne particles. The
point is not who was right and who was
wrong in this debate. When it comes to
worker safety in hospitals, we should not be
driven by the scientific dogma of yesterday
or even the scientific dogma of today. We
should be driven by the precautionary
principle that reasonable steps to reduce risk
should not await scientific certainty.” SARS
Commission Final Report, Volume 3, p. 1157
CDC Revised Paradigm in 2010
• CDC Recommended respirator use for
2009 H1N1 as a “novel” pathogen
• In 2010, H1N1 classified as seasonal flu
• CDC recommended use of respirators and
AII for aerosol generating procedures
(AGP) for influenza (and later Ebola)
• CDPH followed; that allowed Cal/OSHA to
require respirators based on their
recommendation for AGP
Public Health Events
• Pandemic flu prep, H1N1, Ebola, “run” by
local, state and federal agencies under
“emergency response” paradigms
• Occupational health and safety low priority
• Incident command
• Regular communication with “stakeholders”,
primarily seen as hospitals and local health
departments
• Emergency medical services often considered part of
public safety response
• Avoid public panic -- reassuring messaging
(e.g. Shulman, The Ebola Gamble, The Atlantis, Spring 2015)
Limitations of Incident Command
Paradigm for Public Health
• Incident command is intentionally:
• Centralized
• Hierarchical
• Limited inputs
• Limited term
• Public health response is:
• Decentralized -- based in LHDs
• Requires coordination between different
agencies/organizations
• Requires the inputs of many constituencies
• May go on for many months
Public Health and Occupational
Health
• What risks are acceptable for health care
workers, and who has the right to accept those
risks?
• What role/influence is accorded to
occupational health agencies?
• Health care facilities are seen as part of the
public health response, so employers are often
included in planning. But how are employees
and their representatives included in planning
for public health emergencies and response?
PPE Supplies – 2009 H1N1
• By May 2009 respirator purchasers reported
that prices had increased
• By June 2009 some distributors reported
shortages
• Lack of standardized triggers or mechanisms
for requesting/releasing stockpiled respirators
• Respirator manufacturers claimed to have
addressed respirator shortages during SARS
• As shortages developed, new products were
introduced
Ebola Virus Disease
• 10,000 recorded deaths in 2013-2015
outbreak in Africa; 24,000 cases
• 2007 CDC Guidance:
• Single patient room preferred
• Ebola requires droplet precautions
• Contact precautions, specifically including “fluidresistant” or impermeable gowns, gloves, mask and
goggles or faceshield.
• Respirator for aerosol generating procedures
ATD Standard and EVD
• Requires employers to plan for health care
surge, and emergencies, to ensure supply of
PPE, and to train employees
• Revise plan, new training, with employee input
for new hazards
• Ebola is covered as droplet, also requires
contact precautions as recommended by CDC
• CDPH recommended AII for EVD patients,
triggered “airborne” isolation under ATD
Standard, and respirator requirements,
including, in some cases, PAPRs
PPE Supplies – Ebola 2014
• Emergency response grants and exercises in years
following 2001 to
• Hospitals
• Federal, state and local agencies
• Occupational health and safety professionals not
consulted in developing CA stockpiles; predominant
N95 not in common use and didn’t fit people
• Hospitals had purchased full-cowl PAPRs and
chemical resistant coveralls for first receiver drills
• By 2014, CA stockpile in disarray, many hospitals
stated they had no full-cowl PAPRs or suits
• Grants had only covered initial purchase, not
maintenance
Training (ATD and BBP)
• Initial and annual (within 12 months)
• Required training topics
• Additional training when changes, such as
introduction of new engineering,
administrative or work practice controls,
modification of tasks or procedures or
institution of new tasks or procedures,
affect the employee's occupational
exposure.
What does “interactive” mean?
“Trainees must have direct access to a
qualified trainer during training. OSHA's
requirement can be met if trainees have
direct access to a trainer by way of a
telephone hot line. The use of an
electronic mail system to answer employee
questions is not considered direct access to
a qualified trainer, unless the trainer is
available to answer e-mailed questions at
the time the questions arise.”
(federal OSHA CPL 02-02-069)
Employee Involvement in Program
Review (California)
• Plan must include, “An effective procedure
for obtaining the active involvement of
employees in reviewing and updating the
exposure control plan with respect to the
procedures performed in their respective
work areas or departments.”
• Employees must be trained in how can
participate in plan update and review.
What are effective procedures?
• Many employers have no procedures
• “Suggestion box” often gets no
response
• Some options:
• Safety committee or subcommittee
• Safety meeting as part of annual training
• Always close the loop – how was employee
comment investigated? What was outcome?
Was outcome communicated to employee and
unit?
Cal/OSHA Guidance for Hospital
Workers exposed to EVD Patients (11/14)
• EVD patients to be placed in areas with
separate patient room, donning and
doffing areas
• Protective ensemble to provide
impermeable covering of body, including
head and feet
• Use of PAPR, preferably with full
impermeable hood or cowl
• Training must be hands on
Cal/OSHA Guidance for Hospital
Workers exposed to EVD Patients (11/14)
• PPE must be consistent with doffing and
decontamination procedures
• PPE for doffing assistant
• Written procedures and training, with
effective employee involvement
• Precautionary removal protection for
exposed HCWs
Advantages of ATD Standard
• Creates clear enforceable requirements –
provides notice up front to employers and
employees
• Gives Cal/OSHA a “seat at the table” for
infectious disease events
• Worker participation required
• Mandates preparedness for health care
employers
• Makes CDPH requirements enforceable
ATD Standards on the Web
Standards
• http://www.dir.ca.gov/Title8/5199.html
• http://www.dir.ca.gov/Title8/5199-1.html
Rulemaking docs:
• http://www.dir.ca.gov/oshsb/atd0.html
• http://www.dir.ca.gov/oshsb/zoonotics0.html