1. 2009 H1N1 Creating a Respiratory Protection Program

2. Introduction Creating a Respiratory Protection Program Eileen Franko, DrPH, MS Bureau of Occupational Health, Director New York State Department of Health

3. Overview Of H1N1 Fall 2009 Module 1

4. Cannot distinguish between seasonal influenza, novel influenza and infections with other respiratory viruses based solely on patient’s clinical presentation Initial patient management decisions need to be based on: – Current levels of seasonal and novel influenza activity in the community – Severity of patient’s illness – Presence of any underlying conditions (including young/old age and pregnancy) that places the patient at higher risk for complications H1N1 Symptoms

5. Symptoms – Influenza-like illness (ILI): Fever >100°F (37.8°C) and cough or sore throat – Other symptoms Chills, malaise, headache, fatigue, runny nose, shortness of breath, vomiting, diarrhea – Similar to infection with seasonal influenza virus Incubation period - 1 –7 days, more likely 1–4 days Viral shedding can begin 1 day prior to illness onset – Spread by respiratory droplets and indirect transmission Human Infection with Novel Influenza A (H1N1)

6. CDC Surveliance Report http://www.cdc.gov/flu/weekly/

7. Distribution by age group 7/14/09

8. Flu-like Illness in NYS Hospital Emergency Departments (3 month snapshot)

9. Hospitalized Flu Patients, Current and Prior Flu Seasons

10. Pandemic Influenza Control Measures 1. Delay disease transmission and outbreak peak 2. Decompress peak burden on healthcare infrastructure 3. Diminish overall cases and health impacts

11. http://www.health.state.ny.us/ diseases/communicable/influenza/ surveillance/2009-2010/ New York State Department of Health 2009-2010 Flu Monitoring Weekly Reports

12. Centers for Disease Control Guidance for Healthcare October 14, 2009 Healthcare personnel are persons whose occupational activities involve contact with patients in a healthcare setting. The guidance includes those working in a clinical setting within a non-healthcare institution such as a school nurse.

13. Now What Do We Do? Evaluate using a hierarchy of controls to limit exposure If N-95 Respirators are needed you will need: Written Respiratory Protection Program Employee Medical Assessments Fit Testing Training Recordkeeping Hierarchy of controls and each component of a program will be described in one of the following modules

14. End of Module 1 - Introduction Click here for Module 2

15. Module 2 - Hierarchy of Controls

16. Hierarchy of Controls Prevention methods in order of most effective to least effective: Elimination of exposure Engineering controls Administrative controls Personal protective equipment (PPE) – N95 respirators

17. Elimination of Exposure Having students and staff stay home when sick Denying visitors to school who are sick Social distancing Have persons with ILI wear surgical mask until they can be sent home Stay a minimum of 6 feet from a person with ILI

18. Engineering Controls Designate separate room or area for sick students waiting for a ride home Use barriers or partitions when a separate room is not available or feasible Install hand washing stations with soap and water. If not possible use sanitizing stations in common areas to encourage good hygiene

19. Administrative Controls Vaccination Enforcing exclusion of sick students and staff Implementing respiratory hygiene/cough etiquette strategies Minimize the number of staff interacting with students identified to have flu-like symptoms

20. Vaccination Although vaccination is an administrative control, it is one of the most effective interventions for preventing transmissions of influenza Prevents transmission in work, community, and home settings

21. Personal Protective Equipment (PPE) Respirators (N95) Facemasks Gloves

22. Respirators Least effective control in the hierarchy Relies on the individual to use and maintain properly Implementation of policies for eliminating exposures, engineering controls and administrative controls reduces the need to rely on N95 respirators

23. End of Module 2 - Hierarchy of Controls Click here for Module 3

24. Module 3 - Components Of A Respiratory Protection Program

25. Components of a Respiratory Protection Program Written program specific to the workplace – Specify employees from each department/ unit that are included in respiratory protection program – Assign a qualified administrator to implement program A person is qualified when they have had the appropriate training or experience to administer or oversee the program and conduct the required program evaluation

26. Selecting a Respirator Must be NIOSH - Certified Respirator used in compliance with the conditions of its certification Based on respiratory hazards and activities encountered in the workplace Provide sufficient number of models and sizes to fit a variety of staff facial morphology (2009 H1N1 demand may limit ability to provide a variety of sizes and models)

27. Employee Medical Evaluation The employer must select a Physician or Other Licensed Health Care Professional (PLHCP) to perform medical evaluations The PLHCP may be a physician, registered nurse, nurse practitioner, physician assistant or other licensed health care professional acting within the scope of their state license, registration, or certification (OSHA Directive CPL 2-0.120) The PLHCP uses a medical questionnaire from the OSHA Respiratory Standard, Appendix C, that is considered an initial medical examination (NOTE: the ASTM Z88 standard provides some guidance for medical qualifications for respirator use.)

28. Respirator Fit Testing Procedures Qualitative fit test method using Saccharin or Bitrex Utilize same make, model and size employee will use Fit test will be performed annually

29. Employee Respirator Training Provide effective training to employees required to use respirators Conduct annually: comprehensive and understandable Include proper use, inspection and reasons for use

30. Record Keeping Program Evaluation For Proper Implementation Medical Evaluations Respirator Fit Testing Employee Training

31. End of Module 3 - Components of a Respiratory Protection Program Click here for Module 4

32. Module 4 - Medical Evaluation

33. Initial Medical Evaluation (Questionnaire or Medical Exam) A respirator may place a respiratory burden on employees that varies with the job and workplace conditions, and the medical status of the employee The employer shall provide a medical evaluation to the employee before the employee is fit tested or required to use the respirator The employer shall identify a physician or other licensed health care professional (PLHCP) to perform medical evaluations (as defined on the Employee Medical Assessment slide) The PLHCP shall obtain information specified by the OSHA Respirator Medical Evaluation Questionnaire (see Appendix C of 29CFR1910.134)

34. Follow-up Medical Examination The employer shall ensure that an employee receives a follow-up medical examination (physical exam) when the initial medical evaluation warrants one The follow up medical examination must be performed by a licensed physician, nurse practitioner, or physician’s assistant. The follow-up medical examination shall include any medical tests, consultations, or diagnostic procedures that the PLHCP deems necessary to make a final determination that the user can safely wear a respirator.

35. Administration of the Medical Questionnaire and Examinations Both the questionnaire and the examinations shall be administered confidentially during the employee's normal working hours or at a time and place convenient to the employee The questionnaire shall be administered in such a manner that is understood by the employee The employer shall provide the employee with an opportunity to discuss the questionnaire and examination results with the PLHCP

36. Employer Provides the PLHCP with the Following Information: Type and weight of the respirator to be used by the employee Duration and frequency of respiratory use Expected physical work effort Additional protective clothing and equipment to be worn Temperature and humidity extremes Copy of the company's written respiratory protection program Copy of the medical evaluation section of the OSHA respiratory protection standard

37. Medical Determination Employer shall obtain a written recommendation from PLHCP to determine the employees ability to use a respirator. The written recommendation shall specify: – limitations on respiratory use related to medical condition of the employee – limitations on respirator use related to the workplace conditions – whether or not the employee is medically able to use the respirator – a statement that the PLHCP has provided the employee with a copy of the written recommendation

38. Sample PLHCP Approval Physician or other Licensed Health Care Professional Medical Evaluation (PLHCP) for N95 Respirator Use Employer Name: _________________________________________________________ Employee Name: ____________________________Last 4 #’s of SS#: _________ Medical Evaluation: The employee had the following medical evaluation for respirator use: (check all that apply) □---Respirator Medical Evaluation Questionnaire (1910.134 Appendix C) □---Initial Respirator Medical Exam □---Follow-up Respirator Medical Exam Medical Determination: (check all that apply) □---Medically cleared for use of a disposable N95 respirator without restrictions. □---Not medically cleared for use of a disposable N95 respirator. □---Medically cleared for use of a disposable N95 respirator with the following restrictions: □---Limitations on respirator use related to medical condition of employee. □---Limitations on respirator use related to workplace conditions. □---Details of limitations are noted below: (ex.─ limiting duration or frequency of use, discontinuing if symptoms occur, etc.)

39. Sample PLHCP Approval (cont) □---Re-evaluation of medical clearance recommended in ____ years. □---The employee and employer were sent a copy of this written recommendation and were apprised of the medical evaluation results. □---Additional Comments/Information: _______________________________________ _______________________________________________________________________ ________________________________________________________________________ PLHCP: Printed Name of Physician or LHCP: __________________________________________ Title: (Physician or LHCP) __________________________________________________ Physician or LHCP Signature: ________________________________________________ Date: ____________________________________________________________________

40. Negative Medical Determination If the PLHCP finds a medical condition that may place the employee's health at increased risk if a negative pressure respirator such as a N-95 is used, the employer should reevaluate if another person can fill the role with the ILI student. Alternatives should be considered from the administrative, engineering and workpractice controls.

41. Additional Medical Evaluations Shall be Provided When: An employee reports medical signs or symptoms that are related to ability to use a respirator A PLHCP, supervisor, or the respiratory program administrator determines the need for a re-evaluation Workplace conditions and employee work activities change

42. End of Module 4 - Medical Evaluation Click here for Module 5

43. Module 5 - Employee Training

44. Employee Training about Hazards and Proper Use of N-95 Respirators Employers are required to provide training to employees who are required to wear N-95 respirators This training program is intended for health care personnel identified in the CDC October 14, 2009 guidance on infection control

45. When Should the Training be Provided? Prior to requiring the employee to use a respirator (initial use) Annually When there are changes in the workplace When there are changes in the type of respirators selected or used When there are inadequacies in the employee's knowledge or skill of respirator usage

46. What Subjects Should Employee Training Cover? Why the respirator is necessary When it should be used What are the limitations and capabilities of the respirator How improper fit, usage, or maintenance can compromise the protective effect of the respirator How to inspect, put on and remove, use and check the seals of the respirator

47. Employee Training Subjects (cont.) The procedures for maintenance and storage of the respirator How to recognize medical signs and symptoms that may indicate a respiratory problem The procedure for reporting a problem associated with the respirator

48. Storing N-95 particulate respirators Supplies should be placed in clean, secure, temperature-controlled environments to prevent damage or contamination Avoid storage areas that are damp or have temperature extremes Use oldest supplies first

49. End of Module 5 - Employee Training Click here for Module 6

50. Module 6 – Fit-Testing

51. If a respirator does not form a tight seal around the face, contaminated air may leak around the edges of the face seal. Respirator effectiveness relies on this face-to-mask seal. The only way to determine if a respirator fits and is capable of protecting properly is to fit-test the respirator. You will be fit-tested with a specific make, model, style and size of respirator. Fit tests should be provided by personnel trained in the OSHA Respirator Standard fit-testing procedures (29CFR 1910.134 and 1910.134 Appendix A) OSHA requires this fit-testing prior to initial use and then annually. Fit-Testing

52. Simple “pass” or “fail” test. Wearer provides subjective response to tasting or smelling the test agent that is released … state if detect taste or odor. Test agent may be saccharin (sweet) or bitrex (bitter). If the wearer can taste or smell the substance the fit is inadequate - “fail”. If the wearer can NOT taste or smell the substance during the test - “pass”. Qualitative Fit-Testing

53. Components of a fit test kit

54. Fit test solutions

55. Sensitivity Testing

56. Sensitivity Test Key Points

57. Fit-Test Demonstration

58. Wearer must put the respirator on without help. If wearer cannot “pass” the fit-testing after 2 attempts, move on to testing another size or another make, model and style if available. Tester should never manipulate the respirator to obtain a fit. Modifications should never be made to the respirator (for example, tying a knot in the straps) to make it fit. Wearer should not eat, drink (except plain water), smoke or chew gum for 15 minutes before the fit-test. Precautions For Fit-Testing

59. End of Module 6 – Fit-Testing Click here for Module 7

60. Module 7 – Putting On A Respirator, Performing A User Seal Check, and Removing A Respirator

61. BEFORE handling a respirator, wash hands thoroughly with soap and water. Select the make, model, style and size of respirator you were tested on and “passed”. Check that the respirator is clean, undamaged and the straps have elasticity. If your respirator has been damaged - DO NOT USE IT. Get a new one. Anything that comes between the respirator and your face will make the respirator less effective. Do NOT allow facial hair, hair, jewelry, glasses or clothing to come between your face and the respirator. Putting On A Respirator - Preparation

62. 1.Position the respirator in your hands with the nosepiece at fingertips. 2.Cup the respirator in your hand, with nosepiece at your fingertips and headbands hanging freely. 3.Position the respirator under your chin with the nosepiece up. The bottom strap is positioned around your neck, below the ears. The top strap rests high at the top back of your head. Straps do not cross. 4.Place the fingertips of both hands at the top of the metal nose clip. Slide your fingertips down to mold the nose area to the shape of your nose. Putting On A Respirator

63. Putting On A Respirator - Demonstration

64. Putting On A Respirator (cont) - Demonstration

65. User Seal Check Perform a user seal check each time the respirator is used. 1. Place both hands completely over the respirator to block as much air as possible. Take a quick breath in to see if the respirator seals tightly to the face. The respirator should collapse. Be careful not to disturb the position of the respirator. 2. Place both hands over the respirator and exhale. Check for leakage around the face, such as forehead hair movement or fogging of glasses. Do NOT attempt to get a better fit by tying the straps into knots. If air leaks around your nose, readjust the nosepiece. If air leaks at the mask edges, work the straps back along the sides of your head until a proper seal is achieved. If you cannot achieve a proper seal, see your respiratory protection program administrator.

66. User Seal Check - Demonstration

67. Removing A Respirator If wearing gloves, first discard gloves Front of respirator may be contaminated – DO NOT TOUCH! Lift the bottom elastic strap of the respirator over your head first without touching respirator Then lift off the top elastic strap and carefully remove Respirator may be discarded in waste containers Immediately wash your hands thoroughly

68. Removing A Respirator - Demonstration

69. End of Module 7 – Putting On A Respirator, Performing A User Seal Check, and Removing A Respirator

70. Contacts and Additional Information New York State Education Department Office of Student Support Services 518-486-6090 usny.nysed.gov/swine-flu-info.html New York Statewide School Health Services Center www.schoolhealthservicesny.com/h1n1.cfm New York State Department of Health Eileen M. Franko – emf03@health.state.ny.us www.health.state.ny.us/diseases/communicable/influenza/h1n1 Board of Cooperative Educational Services www.boces.org NIOSH Respirator Trusted Sources Information www.cdc.gov/niosh/npptl/topics/respirators/disp_part/RespSource.html New York State Department of Labor Bureau of Occupational Health 518-402-7900 www.labor.state.ny.us/workerprotection/safetyhealth/DOSH_PESH.shtm 518-457-1263