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Presentation on theme: "AEROSOL TRANSMISSIBLE DISEASE STANDARD"— Presentation transcript:

Riverside County Department of Public Health 2010

2 Learning Objectives At the conclusion of this presentation participants will be able to: Identify at least 3 common Aerosol Transmissible Diseases (ATD) that present a risk in the workplace. 2. Identify the levels for potential exposure of employees to ATD based on job responsibilities.

3 Learning Objectives (continued)
Discuss the difference between droplet precautions and airborne infection isolation. Discuss appropriate action to take if exposed to an ATD in the workplace. 5. Discuss the recommended Personal Protective Equipment (PPE) for Novel Influenza Viruses.

4 Disease Trends

5 Tuberculosis Rate Riverside County, 1997-2009

6 MULTI DRUG RESISTANT (MDR) Riverside County - TB Cases 2000-2009

7 Vaccine Preventable Diseases
Incident of Reportable Vaccine Preventable Diseases, Riverside County

8 Pertussis Cases by Year 1999-2010 Riverside County Data through July 15, 2010
For current numbers go to

9 H1N1 Riverside County April 2009 –March 31, 2010
Total Cases: 2,573 Number Hospitalized: 389 Number of Deaths: 40

10 What is an Aerosol Transmissible Disease
A disease or pathogen that is transmissible by aerosols (gaseous suspension of fine solid or liquid particles) Airborne precautions: small droplets, or droplet nuclei Droplet precautions: larger droplets, 5 microns or greater

11 Symptoms of ATDs (vary based on the disease)
Varicella: fever, vesicular rash, crops of vesicles Measles: cough, fever, rash, conjunctivitis, koplik spots Smallpox: rash with sudden onset of high fever, malaise, severe back ache Pertussis: initial irritating cough gradually progressing to repeated violent coughing, may be followed by high pitched inspiratory whoop

12 Symptoms of ATDs (vary based on the disease cont.)
Meningococcal meningitis: sudden onset of fever, intense headache, nausea/vomiting, stiff neck, may have petechial rash (purplish pinpoint spots) Mumps: fever, swelling or tenderness of salivary glands

13 Symptoms of ATDs (vary based on the disease)
Tuberculosis: productive cough, fever, unexplained weight loss Overview of Tuberculosis TB is caused by Mycobacterium tuberculosis Can cause infection in almost any organ of the body (secondary infections) Spread by droplet nuclei from infected person

14 Classification of Tuberculosis
Description TB-0 No history of exposure, negative TST: No follow-up TB-1 Contact, negative TST: Close contacts offered (window) Prophylaxis TB-2 Infected positive TST, no clinical, radiographic, or bacteriologic evidence: LTBI criteria for INH TB-3 Current disease may have positive TST, clinical, radiographic, or bacteriologic evidence: Pulmonary & Laryngeal TB present communicability risk TB-4 Radiographic evidence of previous disease, positive TST, adequate treatment, inadequate or no treatment, no current clinical or bacteriologic evidence of disease TB-5 Diagnosis pending, may have a positive TST, abnormal CXR, cannot rule out active process: cough, wt loss, fever, hemoptysis, noc sweats, positive smear or culture, ID pending

15 Risk of Developing TB Persons at high risk for developing TB once infected: HIV/AIDS – 10% risk per year Recently infected People who inject illicit drugs History of inadequately treated TB

16 Risk of Developing TB (Cont.)
Certain medical conditions Diabetes End-stage renal disease Pulmonary fibrosis or silicotic process on chest x-ray Gastrectomy Certain Drugs High dose cortisone/prednisone Methotrexate

17 Precautions for ATDs Airborne Infection Isolation (AII)
Negative Pressure Isolation UV light (TB) N-95 Respirator Required for Diseases such as: Measles Novel Influenza Smallpox Tuberculosis

18 Pandemic H1N1 Influenza

19 H1N1 Virus Is a type A Influenza Virus
Human Infections occur and can spread from person to person through coughing and sneezing.

20 H1N1 Virus (continued) A person can be infectious 1 day before and up to 7-10 days after onset of symptoms Symptoms: Fever > 100° F and an upper respiratory illness with cough, may also have nausea, vomiting, diarrhea or a sore throat

21 Specific Infection Control Precautions Needed for Novel Influenza Viruses
Standard Precautions Effective Hand Hygiene (before and after all patient contact) Contact Precautions Use gloves and gown for all patient contact

22 Precautions needed for Novel Influenza (continued)
Eye Protection Wear when within 6 feet of the patient Airborne Precautions Place the patient in a negative pressure isolation room Use at least a NIOSH approved N-95 respirator

23 Vaccinia Virus Virus used to make Smallpox vaccine does
not contain Smallpox virus. Similar to Smallpox virus, but less harmful. The vaccination site contains vaccinia virus starting four (4) days after vaccination and up to twenty-one (21) days. Not airborne – (Smallpox is airborne) Requires contact precautions

24 Example of Vaccinia Virus infection.
Child’s father vaccinated with smallpox vaccine. Child had contact with uncovered vaccination site. Site was cultured and was positive for vaccinia virus. Abdomen and chest of a 2-year-old boy with a rash of dimpled lesions caused by eczema vaccinatum— a rare severe adverse reaction caused by exposure to the vaccinia virus. Photo courtesy of John Marcinak

25 Droplet Precautions Droplet precautions include procedures designed to reduce the risk of transmission of infectious agents through contact with secretions. Required for diseases such as: Meningococcal disease (H. influenzae; Neisseria meningitidis) Rubella Mumps Pneumonic Plague Pertussis

26 Source Control Measures For Persons with ATDs
Procedures to minimize the spread of airborne particles and droplets Important to educate patients with ATDs to cover their cough and effective hand hygiene Patients must wear surgical mask not N-95 respirators Information can be communicated to patients via posters/signs


28 Scope of the ATD Standard
A variety of health care facilities, services, operations Hospitals, clinics Public health services (e.g. communicable disease, contact tracing or screening) High risk environments Corrections Homeless shelters Drug treatment

29 Four Types of Employers defined by the Cal/OSHA ATD Standard
Referring employers: don’t provide care beyond initial to cases and suspected cases of AirIDs diseases, and don’t do high hazard procedures on them Full standard: hospitals and others that are not referring employers Laboratories Conditionally exempt: dentists and outpatient medical specialty practices that don’t treat ATDs and have screening procedures

30 Required Elements of the ATD Standard (Title 8, California Code of Regulations, Section 5199)
Identification of an Administrator Written procedures/plans Source control Engineering, work practice, administrative controls and PPE Respirators Communication Training

31 Required Elements of the ATD Standard (cont
Required Elements of the ATD Standard (cont.) (Title 8, California Code of Regulations, Section 5199) Recordkeeping Medical services Vaccinations Annual TB testing Post exposure follow up Precautionary removal Respirator medical evaluations, if applicable

32 Required Training Employers shall ensure that all employees with occupational exposure participate in a training program Employers shall provide training as follows: At the time of initial assignment to tasks where occupational exposure may take place At least annually thereafter, not to exceed 12 months from the previous training When changes, such as introduction of new engineering or work practice controls, modification of tasks or procedures or institution of new tasks or procedures, affect the employee's occupational exposure or control measures. The additional training may be limited to addressing the new exposures or control measures

33 Required Training (cont.)
Training material appropriate in content and vocabulary to the educational level, literacy, and language of employees shall be used An opportunity for interactive questions and answers with a person who is knowledgeable in the subject matter as it relates to the workplace that the training addresses and who is also knowledgeable in the employer’s infection control procedures * The standard outlines the minimum elements that must be included in the training program (refer to the ATD Standard, pages 23-24)

34 Exposure Determination Table

35 High Hazard Procedures
Sputum induction Transporting infectious ATD patients Process ATP-L in the laboratory Repairing, replacing or maintaining air systems or equipment that may contain ATDs

36 List of Assignments or Tasks Requiring Personal Protective Equipment

37 Respiratory Protection Program
All HCWs with occupational exposure to ATDs must be fit-tested with a N-95 respirator Multiple use vs. Single use Effective September 1, 2010 Powered Air Purifying Respirators (PAPR) must be used for high hazard procedures

38 Respiratory Protection Program (cont.)
Exception 1: If performed in a booth, hood enclosure –may use N-95 respirator Exception 2: Paramedics and other personnel in field operations may use a P-100 respirator

39 Specific Requirements for Laboratories
The ATD Standard requires lab employers to use feasible engineering and work practice controls to limit exposure and to provide PPE and respirators when that equipment is necessary to control exposures The Public Health Laboratory is required to develop, implement and annually review a written Biosafety Plan (BSP) that includes the following: Safe handling procedures and list of prohibited practices Engineering controls, including containment facilities such as biosafety cabinets Procedures requiring the use of PPE and/or respirators

40 Specific Requirements for Laboratories (cont.)
Effective decontamination/disinfection procedures A requirement that all incoming materials containing ATPs-L be treated as containing the virulent or wild-type pathogen, until proven otherwise Inspection procedures to be performed annually Emergency procedures for uncontrolled releases within the lab & untreated releases outside the lab, including reporting incidents to the local health officer

41 Medical Services for HCWs
Medical surveillance – TB Routine screening Post-exposure screening HCWs with significant TST or Blood Assay Test (BAT) Latent TB Infection vs. TB Disease Risk Assessment for TB MDR – TB TB converters 5 to 10% will progress to active TB in 1-2 years

42 Medical Services for HCWs (cont.)
Effective September 1, 2010 , recommended vaccinations shall be made available to all employees who have occupational exposure after the employee has received the training required in subsection (c) or (i) and within 10 working days of initial assignment unless: The employee has previously received the recommended vaccination(s) and is not due to receive another vaccination dose A PLHCP has determined that the employee is immune in accordance with applicable public health guidelines The vaccine(s) is contraindicated for medical reasons

43 Medical Services for HCWs (cont.)
Recommended Vaccinations Influenza – One dose annually Measles – Two doses Mumps – Two doses Rubella – One dose Tdap – One dose, booster as recommended Varicella – Two doses Additional vaccine doses must be made available to employees within 120 days of the issuance of new applicable public health guidelines recommending additional dose

44 Medical Services for HCWs (cont.)
Declination statement required for employees who decline a recommended and offered vaccination (refer to Policy DOPH P-102) Must sign a statement for each declined vaccine Disease Control must inform Administration, Human Resources and Occupational Health if a recommended vaccine is not available Must check on vaccine availability at least every 60 calendar days and inform employees when available

45 Occupational Exposure
Work activity or conditions create an elevated risk of contracting disease if protective measures are not in place Elevated exposure risk vs. other public contact operations Presumed for at least some employees in every facility, service or operation listed in (a)(1) Examples: Direct contact with cases or suspected cases of ATDs Works within range of at-risk populations (e.g. homeless shelter staff) Laboratory areas where ATPs-L are handled Contaminated equipment (e.g. AIIR ventilation systems)

46 Post Exposure Follow-up for ATDs
Administrative procedures Employees must notify supervisor Supervisor evaluates exposure and ensures required paperwork is completed Follow workers compensation procedures Must determine if employee had a significant occupational exposure Must implement corrective measures if indicated

47 Precautionary Removal from Work
When a post exposure evaluation is done for exposure to ATDs, or TB conversion, an assessment must be made to determine if precautionary removal is needed to prevent potential disease transmission If the PLHCP or the Public Health Officer recommends precautionary removal, DOPH must maintain employee earnings, seniority and other benefits until the employee is cleared

48 Post Exposure Follow-up for ATDs (cont.)
Depends on the ATD Novel Influenza Evaluation for post-exposure prophylaxis with anti-viral medication Monitoring for development of signs and symptoms Assess for need to exclude from work for 7-10 days

49 Post Exposure Follow-up for ATDs (cont.)
Pertussis Evaluation for post exposure treatment with recommended antibiotics Monitoring for development of signs and symptoms Assess for need to exclude from work

50 Post Exposure Follow-up for ATDs (cont.)
Varicella Evaluation for antiviral therapy or varicella vaccination (if given within 3 days) Monitoring for development of signs and symptoms Assess for need to exclude from work (day 10-21)

51 Post Exposure Follow-up for ATDs (cont.)
Measles Evaluation for measles vaccination or IG to be given 72 hours of exposure Monitoring for development of signs and symptoms Assess for need to exclude from work

52 Referral of Patients with ATDs
As part of the referral process, must notify receiving HCF, PT has or suspected to have an ATD. Transporting personnel (e.g. ambulance, air transport) must be informed patient has/may have ATD Patient must wear a surgical mask for transport

53 Containment of ATDs Triage of persons with respiratory symptoms to be done by designated licensed staff Non-licensed staff must be educated to screen persons with respiratory symptoms and refer to licensed staff for triage Symptomatic patients must be placed in a negative pressure isolation room or outside Prompt medical evaluation must be done by a licensed health care professional

54 Surge Procedures All DOPH employees are designated as disaster workers and are expected to respond in an emergency Staff must complete NIMS/SEMS training and core public health competencies at level I, II or III as determined by supervisor/manager Each branch is to maintain an emergency notification system Specific procedures for stockpiling and accessing respiratory protection and PPE are part of the SNS and DOPH Emergency Response Plans

55 Zoonotic ATD Standard Zoonotic diseases /pathogens that are transmissible from animal to humans Capable of causing human disease that may be transmitted by droplets or an airborne route Examples include: SARS TB H1N1 Influenza

56 Scope of Zoonotic ATD Standard
Services that capture, sample, transport or dispose of birds and other wildlife Farms producing animals or animal products Slaughterhouses Veterinary animal inspection Importers of live or untreated animals or animal products Zoos Animal parks Pet stores Laboratory operations

57 Requirements of the Zoonotic ATD Standard
Establish procedures that minimize production of aerosols Controls for cleaning and decontaminating PPE and respiratory protection Posting of signs in areas containing identified or suspected cases Training Recordkeeping Provision of medical services to exposed workers

IS AVAILABLE AT CHA INSIDER’S PAGE (under policies, procedures and guidelines tab)



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