1. Experience with Cal/OSHA’s Aerosol Transmissible Disease Standards Deborah Gold, MPH, CIH, dgold184@gmail.com APHA October 2015 Protecting Health Care Workers from Infectious Disease

2. Presenter Disclosures The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Deborah Gold “No relationships to disclose”

4. 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

5. 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.

6. 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

7. 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

8. “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)

9. 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

10. “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

11. 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

13. 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)

14. 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

15. 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?

16. 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

17. 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 “fluid- resistant” or impermeable gowns, gloves, mask and goggles or faceshield. Respirator for aerosol generating procedures

18. 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

19. 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

20. 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.

21. 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)

22. 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.

23. 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?

24. 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

25. 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

27. 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

28. 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