[Federal Register Volume 75, Number 119 (Tuesday, June 22, 2010)]
[Notices]
[Pages 35497-35503]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-15015]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
Updated Guidance: Prevention Strategies for Seasonal Influenza in
Healthcare Settings
AGENCY: Centers for Disease Control and Prevention (CDC), Department of
Health and Human Services (HHS).
ACTION: Notice with comment period.
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SUMMARY: The Centers for Disease Control and Prevention (CDC), located
in the Department of Health and Human Services (HHS), seeks public
comment on proposed new guidance which will update and replace previous
seasonal influenza guidance and the Interim Guidance on Infection
Control Measures for 2009 H1N1 Influenza in Healthcare Settings.
The updated guidance emphasizes a prevention strategy to be applied
across the entire spectrum of healthcare settings, including hospitals,
nursing homes, physicians' offices, urgent-care centers, and home
health care, but is not intended to apply to settings whose primary
purpose is not health care. It focuses on the importance of
vaccination, steps to minimize the potential for exposure such as
respiratory hygiene, management of ill healthcare workers, droplet and
aerosol-generating procedure precautions, surveillance, and
environmental and engineering controls.
CDC will consider the comments received and intends to publish the
final guidance prior to the 2010-2011 influenza season.
DATES: Written comments must be received on or before July 22, 2010.
Comments received after July 22, 2010 will be considered to the extent
possible.
ADDRESSES: You may submit written comments to the following address:
Influenza Coordination Unit, Centers for Disease Control and
Prevention, U.S. Department of Health and Human Services, Attn:
Prevention Strategies for Seasonal Influenza in Healthcare Settings,
1600 Clifton Road, NE., MS A-20, Atlanta, GA 30333.
You may also submit written comments via e-mail to:
[email protected].
FOR FURTHER INFORMATION CONTACT: Julie Edelson, Influenza Coordination
Unit, Centers for Disease Control and Prevention, 1600 Clifton Road,
NE., MS A-20, Atlanta, GA 30333; telephone 404-639-2293.
SUPPLEMENTARY INFORMATION: In 2009, CDC posted on its Web site Interim
Guidance on Infection Control Measures for 2009 H1N1 Influenza in
Healthcare Settings, Including Protection of Healthcare Personnel. At
the time it was posted, uncertainties existed regarding the novel H1N1
influenza strain, and the vaccine was not yet widely available. As
stated in that document, CDC planned to update the guidance when new
information became available. Since then, circumstances have changed. A
safe and effective vaccine has become widely available, and is being
included in the 2010-2011 seasonal influenza vaccine. Further, we now
have information about the number of cases of disease,
hospitalizations, and deaths caused by 2009 H1N1, which can be compared
to historical seasonal influenza data. At this point, an update of the
guidance to address current circumstances is warranted.
Additionally, recommendations for prevention of seasonal influenza
in healthcare facilities are currently found throughout the influenza
section of the CDC Web site. By posting this proposed guidance, CDC
will consolidate a range of evidence-based strategies into a
comprehensive, easily-accessible document.
[[Page 35498]]
Proposed Updated Guidance
CDC proposes to update and replace previous seasonal influenza
guidance and the Interim Guidance on Infection Control Measures for
2009 H1N1 Influenza in Healthcare Settings, Including Protection of
Healthcare Personnel, as follows below.
Dated: June 16, 2010.
Tanja Popovic,
Deputy Associate Director for Science, Centers for Disease Control and
Prevention.
Prevention Strategies for Seasonal Influenza in Healthcare Settings
This guidance supersedes previous CDC guidance for both seasonal
influenza and the Interim Guidance on Infection Control Measures for
2009 H1N1 Influenza in Healthcare Settings, which was written to apply
uniquely to the special circumstances of the 2009 H1N1 pandemic as they
existed in October 2009. As stated in that document, CDC planned to
update the guidance as new information became available. In particular,
one major change from the spring and fall of 2009 is the widespread
availability of a safe and effective vaccine for the 2009 H1N1
influenza virus. Second, the overall risk of hospitalization and death
among people infected with this strain, while uncertain in spring and
fall of 2009 is now known to be substantially lower than pre-pandemic
assumptions. The current circumstances and new information justify an
update of the recommendations. This updated guidance continues to
emphasize the importance of a comprehensive influenza prevention
strategy that can be applied across the entire spectrum of healthcare
settings. CDC will continue to evaluate new information as it becomes
available and will update or expand this guidance as needed. Additional
information on influenza prevention, treatment, and control can be
found on CDC's influenza Web site: www.cdc.gov/flu.
Definition of Healthcare Settings
For the purposes of this guidance, healthcare settings include, but
are not limited to, acute-care hospitals; long-term care facilities,
such as nursing homes and skilled nursing facilities; physicians'
offices; urgent-care centers, outpatient clinics; and home healthcare.
This guidance is not intended to apply to other settings whose primary
purpose is not healthcare, such as schools or worksites, because many
of the aspects of the populations and feasible countermeasures will
differ substantially across settings. However, elements of this
guidance may be applicable to specific sites within non-healthcare
settings where care is routinely delivered (e.g., a medical clinic
embedded within a workplace or school).
Definition of Healthcare Personnel
For the purposes of this guidance, the 2008 Department of Health
and Human Services definition of Healthcare Personnel (HCP) will be
used [http://www.hhs.gov/ophs/programs/initiatives/vacctoolkit/definition.html]. Specifically, HCP refers to all persons, paid and
unpaid, working in healthcare settings who have the potential for
exposure to patients and/or to infectious materials, including body
substances, contaminated medical supplies and equipment, contaminated
environmental surfaces, or contaminated air. HCP include but are not
limited to physicians, nurses, nursing assistants, therapists,
technicians, emergency medical service personnel, dental personnel,
pharmacists, laboratory personnel, autopsy personnel, students and
trainees, contractual personnel, home healthcare personnel, and persons
not directly involved in patient care (e.g., clerical, dietary,
housekeeping, laundry, security, maintenance, billing, chaplains, and
volunteers) but potentially exposed to infectious agents that can be
transmitted to and from HCP and patients. This guidance is not intended
to apply to persons outside of healthcare settings for reasons
discussed in the previous section.
Introduction
Influenza is primarily a community-based infection that is
transmitted in households and community settings. Each year, 5% to 20%
of U.S. residents acquire an influenza virus infection, and many will
seek medical care in ambulatory healthcare settings (e.g.,
pediatricians' offices, urgent-care clinics). In addition, more than
200,000 persons, on average, are hospitalized each year for influenza-
related complications [http://www.cdc.gov/flu/keyfacts.htm].
Healthcare-associated influenza infections can occur in any healthcare
setting and are most common when influenza is also circulating in the
community. Therefore, the influenza prevention measures outlined in
this guidance should be implemented in all healthcare settings.
Supplemental measures may need to be implemented during influenza
season if outbreaks of healthcare-associated influenza occur within
certain facilities, such as long-term care facilities and hospitals
[refs: Infection Control Guidance for the Prevention and Control of
Influenza in Acute-care Settings: http://www.cdc.gov/flu/professionals/infectioncontrol/healthcarefacilities.htm; Infection Control Measures
for Preventing and Controlling Influenza Transmission in Long-Term Care
Facilities: http://www.cdc.gov/flu/professionals/infectioncontrol/longtermcare.htm].
Influenza Modes of Transmission
Traditionally, influenza viruses have been thought to spread from
person to person primarily through large-particle respiratory droplet
transmission (e.g., when an infected person coughs or sneezes near a
susceptible person) [http://www.cdc.gov/flu/professionals/acip/clinical.htm]. Transmission via large-particle droplets requires close
contact between source and recipient persons, because droplets
generally travel only short distances (approximately 6 feet or less)
through the air. Indirect contact transmission via hand transfer of
influenza virus from virus-contaminated surfaces or objects to mucosal
surfaces of the face (e.g., nose, mouth, eyes) may be possible.
Airborne transmission via small particle aerosols in the vicinity of
the infectious individual may also occur; however, the relative
contribution of the different modes of influenza transmission is
unclear. Airborne transmission over longer distances, such as from one
patient room to another has not been documented and is thought not to
occur. All respiratory secretions and bodily fluids, including
diarrheal stools, of patients with influenza are considered to be
potentially infectious; however, the risk may vary by strain. Detection
of influenza virus in blood or stool in influenza infected patients is
very uncommon.
Fundamental Elements To Prevent Influenza Transmission
Preventing transmission of influenza virus and other infectious
agents within healthcare settings requires a multi-faceted approach.
Spread of influenza virus can occur among patients, HCP, and visitors;
in addition, HCP may acquire influenza from persons in their household
or community. The core prevention strategies include:
Administration of influenza vaccine.
Implementation of respiratory hygiene and cough etiquette.
Appropriate management of ill HCP.
Adherence to infection control precautions for all
patient-care activities and aerosol-generating procedures.
Implementing environmental and engineering infection
control measures.
[[Page 35499]]
Successful implementation of many if not all of these strategies is
dependent on the presence of clear administrative policies and
organizational leadership that promote and facilitate adherence to
these recommendations among the various people within the healthcare
setting, including patients, visitors, and HCP. These administrative
measures are included within each recommendation where appropriate.
Furthermore, this guidance should be implemented in the context of a
comprehensive infection prevention program to prevent transmission of
all infectious agents among patients and HCP.
Specific Recommendations
1. Promote and Administer Seasonal Influenza Vaccine
Annual vaccination is the most important measure to prevent
seasonal influenza infection. Achieving high influenza vaccination
rates of HCP and patients is a critical step in preventing healthcare
transmission of influenza from HCP to patients and from patients to
HCP. According to current national guidelines, unless contraindicated,
vaccinate all people aged 6 months and older, including HCP, patients
and residents of long-term care facilities [refs: http://www.cdc.gov/flu/professionals/vaccination/ and http://www.cdc.gov/vaccines/recs/provisional/downloads/flu-vac-mar-2010-508.pdf].
Strategies to improve HCP vaccination rates include providing
incentives, providing vaccine at no cost to HCP, improving access
(e.g., offering vaccination at work and during work hours), and
requiring personnel to sign declination forms to acknowledge that they
have been educated about the benefits and risks of vaccination. While
some have mandated influenza vaccination for all HCP who do not have a
contraindication, it should be noted that mandatory vaccination of HCP
remains a controversial issue. Tracking influenza vaccination coverage
among HCP can be an important component of a systematic approach to
protecting patients and HCP. Regardless of the strategy used, strong
organizational leadership and an infrastructure for clear and timely
communication and education, and for program implementation, have been
common elements in successful programs. More information on different
HCP vaccination strategies can be found in the Appendix: Influenza
Vaccination Strategies.
2. Take Steps To Minimize Potential Exposures
A range of administrative policies and practices can be used to
minimize influenza exposures before arrival, upon arrival, and
throughout the duration of the visit to the healthcare setting.
Measures include screening and triage of symptomatic patients and
implementation of respiratory hygiene and cough etiquette. Respiratory
hygiene and cough etiquette are measures designed to minimize potential
exposures of all respiratory pathogens, including influenza virus, in
healthcare settings and should be adhered to by everyone--patients,
visitors, and HCP--upon entry and continued for the entire duration of
stay in healthcare settings [http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm].
Before Arrival to a Healthcare Setting
When scheduling appointments, instruct patients and
persons who accompany them to inform HCP upon arrival if they have
symptoms of any respiratory infection (e.g., cough, runny nose, fever)
and to take appropriate preventive actions (e.g., wear a facemask upon
entry, follow triage procedure).
During periods of increased influenza activity:
Take steps to minimize elective visits by patients with
suspected or confirmed influenza. For example, consider establishing
procedures to minimize visits by patients seeking care for mild
influenza-like illness who are not at increased risk for complications
from influenza (e.g., provide telephone consultation to patients with
mild respiratory illness to determine if there is a medical need to
visit the facility).
Upon Entry and During Visit to a Healthcare Setting
Take steps to ensure all persons with symptoms of a
respiratory infection adhere to respiratory hygiene, cough etiquette,
hand hygiene, and triage procedures throughout the duration of the
visit. These might include:
[cir] Posting visual alerts (e.g., signs, posters) at the entrance
and in strategic places (e.g., waiting areas, elevators, cafeterias) to
provide patients and HCP with instructions (in appropriate languages)
about respiratory hygiene and cough etiquette, especially during
periods when influenza virus is circulating in the community.
Instructions should include:
How to use facemasks or tissues to cover nose and mouth
when coughing or sneezing and to dispose of contaminated items in waste
receptacles.
How and when to perform hand hygiene.
[cir] Implementing procedures during patient registration that
facilitate adherence to appropriate precautions (e.g., at the time of
patient check-in, inquire about presence of symptoms of a respiratory
infection, and if present, provide instructions).
Provide facemasks (See definition of facemask in Appendix)
to patients with signs and symptoms of respiratory infection and
supplies to perform hand hygiene to all patients upon arrival to
facility (e.g., at entrances of facility, waiting rooms, at patient
check-in) and throughout the entire duration of the visit to the
healthcare setting.
Provide space and encourage persons with symptoms of
respiratory infections to sit as far away from others as possible (at
least three feet but preferably six feet away from others, if
feasible). If available, facilities may wish to place these patients in
a separate area while waiting for care.
During periods of increased community influenza activity,
facilities should consider setting up triage stations that facilitate
rapid screening of patients for symptoms of influenza and separation
from other patients.
3. Monitor and Manage Ill Healthcare Personnel
HCP who develop fever and respiratory symptoms should be:
Instructed not to report to work, or if at work, to stop
patient-care activities, don a facemask, and promptly notify their
supervisor and infection control personnel/occupational health before
leaving work.
Excluded from work until at least 24 hours after they no
longer have a fever, without the use of fever-reducing medicines such
as acetaminophen.
Considered for temporary reassignment or exclusion from
work for 7 days from symptom onset or until the resolution of symptoms,
whichever is longer, if returning to care for patients in a Protective
Environment (PE) such as hematopoietic stem cell transplant patients
(HSCT) [http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf].
HCP recovering from a respiratory illness may return to
work with PE patients sooner if absence of influenza viral RNA in
respiratory secretions is documented by real-time reverse transcriptase
polymerase chain reaction (rRT-PCR).
[cir] Patients in these environments are severely
immunocompromised, and infection with influenza virus can lead to
severe disease. Furthermore, once
[[Page 35500]]
infected, these patients can have prolonged viral shedding despite
antiviral treatment and expose other patients to influenza virus
infection. Prolonged shedding also increases the chance of developing
and spreading antiviral-resistant influenza strains; clusters of
influenza antiviral resistance cases have been found among severely
immunocompromised persons exposed to a common source or healthcare
setting.
Reminded that adherence to respiratory hygiene and cough
etiquette after returning to work remains important because viral
shedding may occur for several days after resolution of fever. If
symptoms such as cough and sneezing are still present, HCP should wear
a facemask during patient-care activities. The importance of performing
frequent hand hygiene (especially before and after each patient contact
and contact with respiratory secretions) should be reinforced.
HCP with influenza or many other infections may have fever
alone as an initial symptom or sign. Thus, it can be very difficult to
distinguish influenza from many other causes, especially early in a
person's illness. HCP with fever alone should follow workplace policy
for HCP with fever until a more specific cause of fever is identified
or until fever resolves.
HCP who develop acute respiratory symptoms without fever may still
have influenza infection but should be:
Allowed to continue or return to work unless assigned to
care for patients requiring a PE such as HSCT [http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf]; these HCP should be considered
for temporary reassignment or excluded from work for 7 days from
symptom onset or until the resolution of all non-cough symptoms,
whichever is longer. HCP recovering from a respiratory illness may
return to work with patients in PE sooner if absence of influenza viral
RNA in respiratory secretions is documented by rRT-PCR.
Reminded that adherence to respiratory hygiene and cough
etiquette after returning to work remains important because viral
shedding may occur for several days following an acute respiratory
illness. If symptoms such as cough and sneezing are still present, HCP
should wear a facemask during patient care activities. The importance
of performing frequent hand hygiene (especially before and after each
patient contact) should be reinforced.
Facilities and organizations providing healthcare services should:
Develop sick leave policies for HCP that are non-punitive,
flexible and consistent with public health guidance to allow and
encourage HCP with suspected or confirmed influenza to stay home.
[cir] Policies and procedures should enhance exclusion of HCPs who
develop a fever and respiratory symptoms from work for at least 24
hours after they no longer have a fever, without the use of fever-
reducing medicines.
Ensure that all HCP, including staff who are not directly
employed by the healthcare facility but provide essential daily
services, are aware of the sick leave policies.
Employee health services should establish procedures for
tracking absences; reviewing job tasks and ensuring that personnel
known to be at higher risk for exposure to those with suspected or
confirmed influenza are given priority for vaccination; ensuring that
employees have access via telephone to medical consultation and, if
necessary, early treatment; and promptly identifying individuals with
possible influenza. HCP should self-assess for symptoms of febrile
respiratory illness. In most cases, decisions about work restrictions
and assignments for personnel with respiratory illness should be guided
by clinical signs and symptoms rather than by laboratory testing for
influenza because laboratory testing may result in delays in diagnosis,
false negative test results, or both.
4. Adhere to Standard Precautions
During the care of any patient, all HCP in every healthcare setting
should adhere to standard precautions, which are the foundation for
preventing transmission of infectious agents in all healthcare
settings. Standard precautions assume that every person is potentially
infected or colonized with a pathogen that could be transmitted in the
healthcare setting. Elements of standard precautions that apply to
patients with respiratory infections, including those caused by the
influenza virus, are summarized below. Additional details about these
recommendations can be found in the CDC Healthcare Infection Control
Practices Advisory Committee (HICPAC) guideline titled Guideline for
Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings and Guidelines for Preventing Healthcare-Associated
Pneumonia [http://www.cdc.gov/hicpac/2007IP/2007ip_part4.html#4;
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm].
Hand Hygiene
HCP should perform hand hygiene frequently, including
before and after all patient contact, contact with potentially
infectious material, and before putting on and upon removal of personal
protective equipment, including gloves. Washing with soap and water or
using alcohol-based hand rubs can be used in healthcare settings. If
hands are visibly soiled, use soap and water, not alcohol-based hand
rubs.
Healthcare facilities should ensure that supplies for
performing hand hygiene are available.
Gloves
Wear gloves for any contact with potentially infectious
material. Remove gloves after contact, followed by hand hygiene. Do not
wear the same pair of gloves for care of more than one patient. Do not
wash gloves for the purpose of reuse.
Gowns
Wear gowns for any patient-care activity when contact with
blood, body fluids, secretions (including respiratory), or excretions
is anticipated.
5. Adhere to Droplet Precautions
Droplet precautions should be implemented for patients
with suspected or confirmed influenza for 7 days after illness onset or
until 24 hours after the resolution of fever and respiratory symptoms,
whichever is longer, while a patient is in a healthcare facility. In
some cases, facilities may choose to apply droplet precautions for
longer periods based on clinical judgment, such as in the case of young
children or severely immunocompromised patients, who may shed influenza
virus for longer periods of time [http://www.cdc.gov/hicpac/2007IP/2007ip_part4.html#5.
Place patients with suspected or confirmed influenza in a
private room or area. When a single patient room is not available,
consultation with infection control personnel is recommended to assess
the risks associated with other patient placement options (e.g.,
cohorting [i.e., grouping patients infected with the same infectious
agents together to confine their care to one area and prevent contact
with susceptible patients], keeping the patient with an existing
roommate). For more information about making decisions on patient
placement for droplet precautions, see CDC HICPAC Guidelines for
Isolation Precautions [section V.C.2: http://www.cdc.gov/hicpac/2007IP/2007ip_part4.html#5].
[[Page 35501]]
HCP should don a facemask when entering the room of a
patient with suspected or confirmed influenza. Remove the facemask when
leaving the patient's room, dispose of the facemask in a waste
container, and perform hand hygiene.
[cir] Based on their local needs, facilities and organizations may
opt to provide employees with alternative personal protective equipment
as long as it offers the same protection of the nose and mouth from
splashes and sprays provided by facemasks (e.g., face shields and N95
respirators or powered air purifying respirators which would also
protect against inhaling airborne particles).
If a patient under droplet precautions requires movement
or transport outside of the room:
[cir] Have the patient wear a facemask, if possible, and follow
respiratory hygiene and cough etiquette and hand hygiene.
[cir] Communicate information about patients with suspected,
probable, or confirmed influenza to appropriate personnel before
transferring them to other departments in the facility (e.g.,
radiology, laboratory) or to other facilities.
Patients under droplet precautions should be discharged
from medical care when clinically appropriate, not based on the period
of potential virus shedding or recommended duration of droplet
precautions. Before discharge, communicate the patient's diagnosis and
current precautions with post-hospital care providers (e.g., home-
healthcare agencies, long-term care facilities) as well as transporting
personnel.
6. Use Caution When Performing Aerosol-Generating Procedures
Some procedures performed on patients with suspected or confirmed
influenza infection may be more likely to generate higher
concentrations of infectious respiratory aerosols than coughing,
sneezing, talking, or breathing. These procedures potentially put HCP
at an increased risk for influenza exposure. Although there are limited
data available on influenza transmission related to such aerosols, many
authorities [refs: WHO, http://www.who.int/csr/resources/publications/aidememoireepidemicpandemid/en/index.html] recommend that additional
precautions be used for the following procedures: Bronchoscopy; sputum
induction; endotracheal intubation and extubation; open suctioning of
airways; cardiopulmonary resuscitation; autopsies. A combination of
measures should be used to reduce exposures from these aerosol-
generating procedures performed on patients with suspected or confirmed
influenza, including:
Only performing these procedures on patients with
suspected or confirmed influenza if they are medically necessary and
cannot be postponed.
Limiting the number of HCP present during the procedure to
only those essential for patient care and support. All HCP that are
required to perform or be present during these procedures should
receive influenza vaccination.
Conducting the procedures in an airborne infection
isolation room (AIIR) when feasible. Such rooms are designed to reduce
the concentration of infectious aerosols and prevent their escape into
adjacent areas using controlled air exchanges and directional airflow.
They are single patient rooms at negative pressure relative to the
surrounding areas, and with a minimum of 6 air changes per hour (12 air
changes per hour are recommended for new construction or renovation).
Air from these rooms should be exhausted directly to the outside or be
filtered through a high-efficiency particulate air (HEPA) filter before
recirculation. Room doors should be kept closed except when entering or
leaving the room, and entry and exit should be minimized during and
shortly after the procedure. Facilities should monitor and document the
proper negative-pressure function of these rooms. [http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm]
Considering use of portable HEPA filtration units to
further reduce the concentration of contaminants in the air. Some of
these units can connect to local exhaust ventilation systems (e.g.,
hoods, booths, tents) or have inlet designs that allow close placement
to the patient to assist with source control; however, these units do
not eliminate the need for respiratory protection for individuals
entering the room because they may not entrain all of the room air.
Information on air flow/air entrainment performance should be evaluated
for such devices.
HCP should adhere to standard precautions [http://www.cdc.gov/hicpac/2007IP/2007ip_part4.html#4], including wearing
gloves, a gown, and either a face shield that fully covers the front
and sides of the face or goggles.
HCP should wear respiratory protection equivalent to a
fitted N95 filtering facepiece respirator (i.e., N95 respirator) or
higher level of protection (e.g., powered air purifying respirator)
during aerosol-generating procedures (See definition of respirator in
Appendix). When respiratory protection is required in an occupational
setting, respirators must be used in the context of a comprehensive
respiratory protection program that includes fit-testing and training
as required under OSHA's Respiratory Protection standard (29 CFR
1910.134) [http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=12716].
Unprotected HCP should not be allowed in a room where an
aerosol-generating procedure has been conducted until sufficient time
has elapsed to remove potentially infectious particles. More
information on clearance rates under differing ventilation conditions
is available [http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm#tab1].
Conduct environmental surface cleaning following
procedures (see section on environmental infection control).
7. Manage Visitor Access and Movement Within the Facility
Limit visitors for patients in isolation for influenza to persons
who are necessary for the patient's emotional well-being and care.
Visitors who have been in contact with the patient before and during
hospitalization are a possible source of influenza for other patients,
visitors, and staff.
For persons with acute respiratory symptoms, facilities should
consider developing visitor restriction policies that consider location
of patient being visited (e.g., oncology units) and circumstances, such
as end-of-life situations, where exemptions to the restriction may be
considered at the discretion of the facility. Regardless of restriction
policy, all visitors should follow precautions listed in the
respiratory hygiene and cough etiquette section. Visits to patients in
isolation for influenza should be scheduled and controlled to allow
for:
Screening visitors for symptoms of acute respiratory
illness before entering the hospital.
Facilities should provide instruction, before visitors
enter patients' rooms, on hand hygiene, limiting surfaces touched, and
use of personal protective equipment (PPE) according to current
facility policy while in the patient's room.
Visitors should not be present during aerosol-generating
procedures.
Visitors should be instructed to limit their movement
within the facility.
If consistent with facility policy, visitors can be
advised to contact their healthcare provider for information about
influenza vaccination.
[[Page 35502]]
8. Monitor Influenza Activity
Healthcare settings should establish mechanisms and policies by
which HCP are promptly alerted about increased influenza activity in
the community or if an outbreak occurs within the facility and when
collection of clinical specimens for viral culture may help to inform
public health efforts. Close communication and collaboration with local
and state health authorities is recommended. Policies should include
designations of specific persons within the hospital who are
responsible for communication with public health officials and
dissemination of information to HCP.
9. Implement Environmental Infection Control
Standard cleaning and disinfection procedures (e.g., using cleaners
and water to preclean surfaces prior to applying disinfectants to
frequently touched surfaces or objects for indicated contact times) are
adequate for influenza virus environmental control in all settings
within the healthcare facility, including those patient-care areas in
which aerosol-generating procedures are performed. Management of
laundry, food service utensils, and medical waste should also be
performed in accordance with standard procedures. There are no data
suggesting these items are associated with influenza virus transmission
when these items are properly managed. Laundry and food service
utensils should first be cleaned, then sanitized as appropriate. Some
medical waste may be designated as regulated or biohazardous waste and
require special handling and disposal methods approved by the State
authorities. Detailed information on environmental cleaning in
healthcare settings can be found in CDC's Guidelines for Environmental
Infection Control in Health-Care Facilities [http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm] and Guideline for Isolation Precautions:
Preventing Transmission of Infectious Agents in Healthcare Settings
[section IV.F. Care of the environment: http://www.cdc.gov/hicpac/2007IP/2007ip_part4.html].
10. Implement Engineering Controls
Consider designing and installing engineering controls to reduce or
eliminate exposures by shielding HCP and other patients from infected
individuals. Examples of engineering controls include installing
physical barriers such as partitions in triage areas or curtains that
are drawn between patients in shared areas. Engineering controls may
also be important to reduce exposures related to specific procedures
such as using closed suctioning systems for airways suction in
intubated patients. Another important engineering control is ensuring
that appropriate air-handling systems are installed and maintained in
healthcare facilities [http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm].
11. Train and Educate Healthcare Personnel
Healthcare administrators should ensure that all HCP receive job-
or task-specific education and training on preventing transmission of
infectious agents, including influenza, associated with healthcare
during orientation to the healthcare setting. This information should
be updated periodically during ongoing education and training programs.
Competency should be documented initially and repeatedly, as
appropriate, for the specific staff positions. A system should be in
place to ensure that HCP employed by outside employers meet these
education and training requirements through programs offered by the
outside employer or by participation in the healthcare facility's
program [http://www.cdc.gov/hicpac/2007IP/2007ip_part4.html#1].
Key aspects of influenza and its prevention that should be
emphasized to all HCP include:
[cir] Influenza signs, symptoms, complications, and risk factors
for complications. HCP should be made aware that, if they have
conditions that place them at higher risk of complications, they should
inform their healthcare provider immediately if they become ill with an
influenza-like illness so they can receive early treatment if
indicated.
[cir] Central role of administrative controls such as vaccination,
respiratory hygiene and cough etiquette, sick policies, and precautions
during aerosol-generating procedures.
[cir] Appropriate use of personal protective equipment including
respirator fit testing and fit checks.
[cir] Use of engineering controls and work practices including
infection control procedures to reduce exposure.
12. Administer Antiviral Treatment and Chemoprophylaxis of Patients and
Healthcare Personnel When Appropriate
Refer to the CDC Web site for the most current recommendations on
the use of antiviral agents for treatment and chemoprophylaxis. Both
HCP and patients should be reminded that persons treated with influenza
antiviral medications continue to shed influenza virus while on
treatment. Thus, hand hygiene, respiratory hygiene and cough etiquette
practices should continue while on treatment http://www.cdc.gov/flu/professionals/antivirals/index.htm.
13. Considerations for Healthcare Personnel at Higher Risk for
Complications of Influenza
HCP at higher risk for complications from influenza infection
include pregnant women and women up to 2 weeks postpartum, persons 65
years old and older, and persons with chronic diseases such as asthma,
heart disease, diabetes, diseases that suppress the immune system,
certain other chronic medical conditions, and possibly morbid obesity
[www.cdc.gov/hn1flu/highrisk.htm]. Vaccination and early treatment with
antiviral medications are very important for HCP at higher risk for
influenza complications because they can decrease the risk of
hospitalizations and deaths. HCP at higher risk for complications
should check with their healthcare provider if they become ill so that
they can receive early treatment. For HCP who identify themselves as
being at higher risk of complications, consider offering work
accommodations to avoid potentially high-risk exposure scenarios, such
as performing or assisting with aerosol-generating procedures on
patients with suspected or confirmed influenza.\1\
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\1\ In considering this guidance, employers should familiarize
themselves with the Americans with Disabilities Act of 1990 (Pub. L.
101-336) (ADA), as amended, which may impact how they implement this
guidance. Details specific to the ADA and influenza preparedness are
provided on the U.S. Equal Employment Opportunity Commission Web
site [http://www.eeoc.gov/facts/pandemic_flu.html].
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Appendix: Additional Information About Influenza
Information about Facemasks:
www.cdc.gov/Features/MasksRespirators/
www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/PersonalProtectiveEquipment/ucm055977.htm
A facemask is a loose-fitting, disposable device that
creates a physical barrier between the mouth and nose of the wearer and
potential contaminants in the immediate environment. Facemasks may be
labeled as surgical, laser, isolation, dental or medical procedure
masks. They may come with or without a face shield. If worn properly, a
facemask is meant to help block large-particle droplets, splashes,
sprays or splatter that may contain germs (viruses and bacteria) from
[[Page 35503]]
reaching your mouth and nose. Facemasks may also help reduce exposure
of your saliva and respiratory secretions to others. While a facemask
may be effective in blocking splashes and large-particle droplets, a
facemask, by design, does not filter or block very small particles in
the air that may be transmitted by coughs, sneezes or certain medical
procedures.
Facemasks are cleared by the U.S. Food and Drug
Administration (FDA) for use as medical devices. Facemasks should be
used once and then thrown away in the trash.
Information about Respirators:
www.cdc.gov/Features/MasksRespirators/
www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/PersonalProtectiveEquipment/ucm055977.htm
www.cdc.gov/niosh/npptl/topics/respirators/disp_part/RespSource3.html#e
A respirator is a personal protective device that is worn
on the face, covers at least the nose and mouth, and is used to reduce
the wearer's risk of inhaling hazardous airborne particles (including
dust particles and infectious agents), gases, or vapors. Respirators
are certified by the National Institute for Occupational Safety and
Health (NIOSH), CDC. A commonly used respirator is a filtering
facepiece respirator (often referred to as an N95).
To work properly, respirators must be specially fitted for
each person who wears one (this is called ``fit-testing'' and is
usually done in a workplace where respirators are used).
OSHA Respiratory Protection eTool: https://www.osha.gov/SLTC/etools/respiratory/index.html.
Key Facts about Influenza: http://www.cdc.gov/flu/keyfacts.htm
Clinical Information (signs and symptoms, modes of transmission, viral
shedding): http://www.cdc.gov/flu/professionals/acip/clinical.htm
World Health Organization (WHO). Epidemic- and pandemic-prone acute
respiratory diseases--Infection prevention and control in health care:
http://www.who.int/csr/resources/publications/aidememoireepidemicpandemid/en/index.html
Control of Influenza Outbreaks in Acute-care Settings: http://www.cdc.gov/flu/professionals/infectioncontrol/healthcarefacilities.htm
Infection Control Measures for Preventing and Controlling Influenza
Transmission in Long-Term Care Facilities: http://www.cdc.gov/flu/professionals/infectioncontrol/longtermcare.htm
Preventing Opportunistic Infections in HSCT/Bone Marrow Transplant
Recipients (p. 18): http://www.cdc.gov/mmwr/PDF/rr/rr4910.pdf
Seasonal Influenza Vaccination Resources for Health Professionals:
http://www.cdc.gov/flu/professionals/vaccination/#patient
Guidance for Prevention and Control of Influenza in the Peri- and
Postpartum Settings: http://www.cdc.gov/flu/professionals/infectioncontrol/peri-post-settings.htm
Clinical Description & Lab Diagnosis of Influenza: http://www.cdc.gov/flu/professionals/diagnosis/
Treatment (Antiviral Drugs): http://www.cdc.gov/H1N1flu/antivirals/
Influenza Vaccination Strategies:
Health and Human Services Toolkit to Improve Vaccination among
Healthcare Personnel: http://www.hhs.gov/ophs/programs/initiatives/vacctoolkit/index.html
Veterans Health Administration Influenza Manual: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1978
[FR Doc. 2010-15015 Filed 6-21-10; 8:45 am]
BILLING CODE 4163-18-P