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

The 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 influenza virus.

1. 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:
   • Incubation period: one to three days (this may vary depending on the viral strain).
   • Period 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).
   • Transmission 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).
2. The novel influenza virus may be transmitted efficiently from person-to-person.
3. As a pandemic wave passes through a community, it is likely that most cases of influenza will be caused by the pandemic strain⁽⁵⁾.
4. The initial clinical presentation should be consistent with that of known influenza strains.
5. Sub-clinical infections may occur.
6. The pandemic strain may cause more than one wave of illness.
7. 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.
   • Mass immunization campaigns may occur when sufficient quantities of the vaccine containing the pandemic influenza strain are available increasing the demand for human resources.
   • Pandemic 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.
8. Individuals who recover from infection caused by the pandemic influenza strain should be immune to further infection from that specific strain.
9. The novel pandemic influenza strain and first human cases of influenza caused by the pandemic viral strain will likely be identified outside of Canada.
   • Surveillance 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

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:

1. 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).
2. A HAI surveillance program that is capable of tracking trends in key HAIs, including respiratory infections⁽³³⁾.
3. 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.
4. Infection 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 healthcare settings.
5. 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

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 training.

An effective OH infectious disease program should consist of:

1. 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.
2. 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.
3. Provision of the necessary resources (e.g., adequate numbers of gloves, gowns) to HCWs to perform their work activities safely.
4. Measures to ensure appropriate immunization and immunization documentation of HCWs.
5. 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).
6. A 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 Association standards⁽¹⁵⁾.
   • 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).

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