The thin white line: H1N1 flu threatens hospital work force
The thin white line: H1N1 flu threatens hospital work force
EHPs seek to provide protection, post-exposure response
As waves of novel H1N1 influenza swept communities across the country, hospitals struggled to avoid the potential impact of infected health care workers: Absenteeism, short-staffed units, and severe illness.
A California nurse died of complications from H1N1 in July, the first reported death among U.S. health care workers. The 51-year-old nurse had been a previously healthy triathlete, marathon runner, and skydiver, but died of pneumonia and a severe respiratory infection related to H1N1, according to a report in the Sacramento Bee. It was not clear whether she acquired the disease in the community or at the hospital, and the California Division of Occupational Safety and Health (Cal-OSHA) is investigating. The death certificate also noted methicillin- resistant Staphylococcus aureus infection as a contributing factor.
Meanwhile, as a harbinger of possible pain to come for U.S. hospitals, hospitals in Australia, Argentina, and other Southern Hemisphere countries reported staff shortages related to H1N1 as health care workers fell ill.
"There's a substantial surge in every place this is happening," says Joshua Mott, PhD, MA, EMT-P, coordinator of the international pandemic response for the Centers for Disease Control and Prevention's Influenza Division. "Because there are more cases overall, it is leaving facilities short-handed in places trying to figure out how to handle the surge."
Critical care physicians and ICU personnel have been among those infected with H1N1 in the Southern Hemisphere, Mott says.
Even some U.S. communities faced outbreaks during the summer months. In Salt Lake City, Russell R. Miller III, MD, MPH, of the Division of Pulmonary and Critical Care Medicine at the Intermountain Medical Center, reported that the emergency department was seeing about 250 patients a day, compared to a usual count of about 150. About 100-150 patients a day presented with influenza-like illness, he said, and the ICU treated 60 critical inpatients.
"It came on so fast that we were, like most places would be, unprepared," Miller told an Institute of Medicine (IOM) panel reviewing personal protective equipment needs for novel H1N1. About 6% of the hospital's health care workers became infected, with an even higher percentage in the ICU, he said.
How to protect patients became a hot-button issue as the fall flu season approached. California nurses staged a protest, asserting that their hospitals were not providing N95 respirators, weren't tracking occupational exposures, and hadn't provided enough education on novel H1N1 vaccine.
With news that novel H1N1 vaccine production would be slower than anticipated, debate over the proper protective gear for health care workers took on a new sense of urgency. Infection control practitioners argued for droplet and contact precautions, similar to the protocol used with seasonal influenza: Surgical or procedure masks, gowns, and gloves. They were supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), an advisory panel to CDC, as well as infection control associations.
However, occupational health and industrial hygiene experts cited evidence of the airborne spread of influenza and the failure of surgical masks to provide protection. Surgical masks do not qualify as personal protective equipment and their filtration properties are not certified by any governmental agency.
"Decision makers with no particular expertise of aerodynamics, ventilation, aerosol physics, biosafety, and airborne spread of disease, nor about respiratory protection, and who are under great political pressure, are formulating scientifically unfounded policies and inconsistent and confusing regulations," says Gabor Lantos, MD, PEng, MBA, president of Occupational Health Management Services in Toronto.
Labor union advocates also pointed out that the Occupational Safety and Health Act requires employers to reduce workplace hazards - even if those same hazards exist in the community. "Employers have to take reasonable steps to protect workers from exposures," says Bill Borwegen, MPH, occupational safety and health director of the Service Employees International Union (SEIU). "The minimum level of protection from airborne hazards is a NIOSH [National Institute of Occupational Safety and Health]-certified respirator."
The IOM panel was scheduled to issue its findings by Sept. 1, and CDC director Thomas Frieden said he will make a decision on whether CDC will recommend masks or respirators by Oct. 1.
Meanwhile, hospitals wrestled with issues of symptom screening and antiviral prophylaxis. Variation in novel H1N1 symptoms may make it more difficult to screen health care workers. "We have a lot of people coming in with the flu who did not have fever," says Bruce Cunha, RN, MS, COHN-S, manager of employee health and safety at the Marshfield (WI) Clinic. "One of the problems you have with this disease is it doesn't have clear-cut symptoms."
In fact, the CDC recommends that in communities with novel H1N1 or in units with patients being assessed for novel H1N1, health care workers should be monitored for "signs and symptoms of febrile respiratory illness."
Cunha suggests that health care workers be monitored for all symptoms of influenza, including sore throat, cough, headache, fatigue, and body aches. At the least, health care workers should be educated about novel H1N1 and the potential for afebrile illness, and they should be instructed to wear a mask at work if they have possible symptoms but no fever, he says.
As of August, the CDC recommended antiviral prophylaxis for health care personnel who had "a recognized, unprotected close contact exposure to a person with novel (H1N1) influenza virus infection (confirmed, probable, or suspected) during that person's infectious period."
However, Marshfield Clinic was considering the use of prophylaxis to minimize the impact of the community outbreak on its health care workers - to reduce absenteeism and staffing shortages in key areas during a time of patient surge, says Cunha. Marshfield Clinic has 7,000 employees and had stockpiled antiviral medications in preparation for a pandemic, he says.
Nurses cite lack of protection
In the summer outbreaks of novel H1N1, there were troubling reports of hospitals that were not doing enough to communicate with health care workers and provide them adequate protection.
"Health care workers who have died from this, in some cases at least, have not been offered appropriate antivirals immediately when they started to get sick," Rosemary Sokas, MD, director of occupational medicine for the U.S. Occupational Safety and Health Administration told the IOM panel investigating appropriate personal protective equipment. She did not elaborate on what situation she was referring to.
The California Nurses Association/National Nurses Organizing Committee in Oakland surveyed nurses at 75 hospitals in California, Illinois, Nevada, and Maine and found gaps in infection control, including failure to promptly notify nurses that they had an unprotected exposure to a patient with suspected or confirmed novel H1N1. One in 10 did not have access to N95 respirators, the survey found.
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Where are the H1N1 shots? This summer, the Centers for Disease Control and Prevention optimistically estimated that it would have 120 million doses of novel H1N1 vaccine by mid-October. Soon after, that was revised to a projected initial delivery of 45 million to 52 million, with a gradual increase up to 195 million doses by the end of 2009. In a process similar to the Vaccines for Children program, a central distributor will receive vaccine from the five manufacturers, and then it will be distributed through the states, said Jay Butler, MD, director CDC's H1N1 Vaccine Task Force. "Everyone is doing everything they can to get as much vaccine available as early as possible," he said at a press briefing. Health care workers are among the priority groups for the vaccine, but as of late August, it wasn't clear how much of the initial supply would go to hospitals. The Advisory Committee on Immunization Practices recommended vaccination for up to 159 million people; but if supplies are short, the priority groups are: health care and emergency medical services personnel; pregnant women; people who live with or care for children younger than 6 months of age; children 6 months through 4 years of age, and children 5 through 18 years of age who have chronic medical conditions. |
"There are places where policies aren't followed consistently. Doors are left open, nurses have masks on but unprotected visitors come in and out," says Jan Rodolfo, RN, communications specialist with the CAN/NNCC. "Lots of nurses are complaining about not having communication on the unit about swine flu."
Even with the nation's first aerosol transmissible disease standard, California did not avoid confusion over the use of respirators and masks. The California Department of Public Health makes a determination about what is a novel pathogen or an airborne disease. So far, California has continued to follow the CDC guidance recommending the use of respirators for health care workers with direct patient care of patients with novel H1N1. But not all health departments in the state have followed suit.
In Sacramento County, where the nurse died, the health department has recommended the use of surgical or procedure masks. "The CDC hasn't produced any evidence that this virus behaves any differently from seasonal virus in terms of infectivity," says Glennah Trochet, MD, Sacramento County's public health officer. "I couldn't justify the use of N95s that we may need later on [if or] when in fact the virus does change."
As waves of novel H1N1 influenza swept communities across the country, hospitals struggled to avoid the potential impact of infected health care workers: Absenteeism, short-staffed units, and severe illness.Subscribe Now for Access
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