Prevention and Control of Influenza during a Pandemic for All Healthcare Settings
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V. Foundations for a Pandemic Influenza IPC/OH Plan for all Healthcare Settings
1. Public Health Assumptions
following public health assumptions regarding pandemic influenza that are
relevant to IPC and OH planning, originate from the Canadian Pandemic Influenza
Plan (CPIP) for the Health Sector (see Key Planning Assumptions),
December 2006(5) and have been adapted to include the epidemiology of the pH1N1
It is important to note that assumptions about the epidemiology and impact of pandemic influenza viruses may change as knowledge emerges about a specific pandemic influenza virus. The level of Pandemic Influenza Precautions required may need to be adapted (e.g., initially, precautions may need to be initiated at a higher level and then relaxed as information becomes available).
- The incubation period, period of communicability and method of
transmission for the novel strain are assumed to be consistent with other known
influenza strains, as follows:
period: one to three days (this may vary depending on the viral strain).
of communicability: 24 hours before(25) and up to seven days after
symptom onset (usually up to three to five days in immunocompetent adults, up
to seven days in young children; the period of communicability may be increased
in immunocompromised adults and children).
of infection by asymptomatic individuals is possible but likely to be more
efficient when symptoms, such as coughing or sneezing, are present and viral
shedding is high (i.e., early in the symptomatic period).
- The novel influenza virus may be transmitted efficiently from
- As a pandemic wave passes through a community, it is likely that
most cases of influenza will be caused by the pandemic strain(5).
- The initial clinical presentation should be consistent with that of known influenza strains.
- Sub-clinical infections may occur.
- The pandemic strain may cause more than one wave of illness.
- It is unlikely that an effective vaccine will be available at the
start of pandemic influenza activity in Canada. An effective vaccine may be
available for a second wave of the pandemic through the community.
immunization campaigns may occur when sufficient quantities of the vaccine
containing the pandemic influenza strain are available increasing the demand
for human resources.
influenza vaccine may be a good match to the circulating pandemic influenza
virus. However, once available, one dose may not be fully protective(5)and two doses may be required. See The Canadian Pandemic Influenza Plan for the Health Sector - Annex D.
- Individuals who recover from infection caused by the pandemic influenza
strain should be immune to further infection from that specific strain.
- The novel pandemic influenza strain and first human cases of
influenza caused by the pandemic viral strain will likely be identified outside
measures are in place to detect influenza-like illness (ILI) and severe
respiratory illness (SRI) across Canada.
2. Infection Prevention and Control Assumptions used in Annex F
A well functioning IPC program working in concert with a well functioning OH program, is the basis for an effective IPC response during an influenza pandemic(26-29). Well functioning IPC programs should prevent, limit or control the acquisition of healthcare-associated infections (HAIs) for everyone (i.e., patients, HCWs, visitors, contractors, etc.) in the healthcare setting.
Recommendations in this Annex are based on the assumption that an effective and fully supported IPC program is functioning within each healthcare setting(2;3;30;31). An effective IPC program should consist of the following:
- Adequate numbers of trained Infection Control Professionals for
the population size and case-mix of the healthcare organization who are able to
carry out the pandemic influenza planning and implementation activities
recommended in this document(32-36).
- A HAI surveillance program that is capable of tracking trends in
key HAIs, including respiratory infections(33).
- Infection prevention and control measures such as “Routine
Practices”(2;3) to ensure that all patients are cared for in a
manner that prevents or minimizes the transmission of infection from an
individual and/or environment to another person.
A HCW’s decision to wear PPE as part of Routine Practices should
be based on his/her assessment of the risk of exposure to blood, body fluids,
non-intact skin and excretions or secretions, including respiratory secretions.
prevention and control measures such as “Additional Precautions”(2;3)
to provide guidance for the care of patients with infections insufficiently
contained by Routine Practices. These patients should be cared for with additional
measures to prevent the transmission of specific infectious agents or
infectious syndromes spread via contact, droplet or airborne mechanisms.
- Contact Precautions (see Section V.4.4.1.),
Droplet Precautions (see Section V.4.4.2.) and Airborne Precautions
(see Section V.4.4.3.), are based on the three modes of
exposure and transmission of infectious diseases.
- All HCWs decisions about whether the patient requires Additional
Precautions should be based on an assessment of the presence of a specific
infectious agent or syndrome (diagnosed or suspected).
- Pandemic Influenza Precautions is a synthesis of Additional Precautions
critical to the prevention and control of pandemic influenza virus in
- Elements of Routine Practices and Additional Precautions (RPAP)
include policies and procedures for:
- Hand hygiene(10;11) for HCWs.
- Respiratory hygiene for patients, HCWs(3).
- Infected source control, for example:
- Patient spatial separation policies and practices;
- Processes and procedures to identify and limit/modify clinical
procedures with increased risk of infectious agent exposure;
- A screening program for early identification of patients, and HCWs
with acute respiratory infections;
- Means to apply Additional Precautions(2;3) when
patients or residents with a specific infectious agent are identified;
- Processes to ensure appropriate immunization of patients (for HCWs
see Section V.3.);
- Processes to identify and manage outbreaks of infectious agents,
including outbreaks caused by respiratory viruses.
- Patient assessment, placement, and movement within the facility.
- Aseptic technique.
- Reprocessing medical equipment.
- Cleaning the patient environment.
- Handling of medical waste.
- Handling of patient care linens.
- Visitor access policies and practices.
3. Occupational Health Assumptions
A well functioning OH program working in concert with a well functioning IPC program, is the basis for an effective OH response during an influenza pandemic(26;28;29;37). Well functioning OH programs should identify workplace hazards and provide appropriate processes and training to ensure employees can perform their duties in an environment that minimizes exposure to environmental hazards (e.g., Respiratory protection). The OH program should also provide required immunization to employees.
The OH recommendations in this document are based on the
assumption that the healthcare setting has a functioning OH program that is
working in concert with a functioning IPC program. This assumption is the basis
for an effective response to protect HCWs from acquiring the pandemic influenza
virus while at work during an influenza pandemic.
Agencies that provide contract workers (e.g., HCWs) to a
healthcare organization should ensure they are trained to meet the Occupational
Health and Occupational Health and Safety requirements of the receiving
organization, including fit testing for the N95 respirators used in the
organization. Depending on the jurisdiction, either or both the contracting
agency or the providing agency may hold the responsibility to provide the
An effective OH infectious disease program should consist
- A hazard assessment
process to evaluate the workplace to identify, assess and analyze risks related
to work activities that may result in exposure to the identified biological
hazards, including infectious agents.
- The application
of systematic controls and personal protective equipment (i.e., engineering and
administrative controls, and the use of PPE) to enable employees to perform
their duties in an environment that minimizes their risk of exposure to
hazards, including infectious agents.
- The cumulative impact of utilizing all three levels of control will
provide more protection than the application of any one control level alone. The
degree of protection offered by effective engineering and administrative controls
are greater and more systematic than those provided with the use of personal protective
equipment (PPE) alone.
- Provision of the
necessary resources (e.g., adequate numbers of gloves, gowns) to HCWs to
perform their work activities safely.
- Measures to ensure
appropriate immunization and immunization documentation of HCWs.
- Measures to
ensure that policies, procedures and programs are consistent with current
recommendations, achieve their stated objectives, and are in compliance with
current workplace occupational health and safety legislation and regulations (e.g.,
Occupational Health and Safety, Workplace Safety, Labour codes).
Respiratory Protection Program (RPP) focused on the respiratory protection
needs of all HCWs. The program should provide health screening, fit testing,
and instruction in the care, use and limitations of respirators for all HCWs
who may wear a respirator or other respiratory protective device during the
provision of health care (see Section V.6.2.4.).
- Respiratory protection requires the use of a respirator to
prevent inhalation of chemical or biological hazards.
- The processes of fit testing and the frequency of fit testing
should be in compliance with relevant (federal, provincial, territorial)
regulations. In the absence of regulations from the jurisdictional region, the
frequency of fit testing should be in compliance with the Canadian Standards
- Each time HCWs put on a respirator, they should perform a seal
check (previously referred to as a "fit-check") to enable proper
functioning of the respirator(15).
- Facial hair may interfere with the seal of the respirator and as
a result the respirator may not form a tight facial seal. Healthcare
organizations should develop policies related to facial hair and the use of
respirators. These policies should be in compliance with relevant occupational
health and safety legislations and regulations.
- Fit testing results are NOT transferable between respirator
manufacturers or models. Note: Powered air purifying respirators are NOT
recommended for influenza care. Other options are available for healthcare
workers with facial hair and should be made available if required. (See Section V.6.2.4.e.).
- Healthcare organizations that perform AGMPs (see Section
V.4.4.4.), and/or care for patients infected with airborne infectious agents
(e.g., tuberculosis) should have an active RPP.
- Healthcare organizations that require personnel to wear
respirators should have written policies and procedures for their RPP.
Note: The use of N95
respirators in the prevention of most respiratory virus infections, including
influenza, remains controversial(38;39).
NOTE: During an influenza pandemic, HCWs, like others in the larger community, are at risk of exposure to the pandemic influenza viral strain as they go about their daily activities in the community (e.g., grocery shopping, attending school meetings, caring for ill family members, playing group sports).
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