[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