H1N1 vaccine: First doses go to HCWs treating high-risk patients
H1N1 vaccine: First doses go to HCWs treating high-risk patients
Hospital protections rely on vaccines, N95, masks
As limited amounts of the first doses of novel H1N1 vaccine were expected to reach providers in early October, hospitals placed a top priority on vaccinating health care workers who provide care to the most vulnerable patients. Even health care workers who have had flu-like symptoms and were diagnosed with novel H1N1 should receive the vaccine, according to the Centers for Disease Control and Prevention.
Only health care workers who had a case that was confirmed through PCR testing should consider themselves immune from infection with novel H1N1, CDC said. "Tests such as rapid antigen detection assays, and diagnoses based on symptoms alone without RT-PCR testing, cannot specifically determine if a person has 2009 H1N1 influenza," the CDC said.
While there are no federal recommendations on which health care workers should be first in line for the vaccine, hospitals have targeted those who care for at-risk patients, such as pediatric emergency departments and pediatric and neonatal intensive care units (since the novel H1N1 disproportionately affects a younger population), labor and delivery (since pregnant women are at increased risk), and units serving immunocompromised patients.
Meanwhile, at press time, employee health professionals awaited updated guidance from CDC on the appropriate personal protective equipment for health care workers caring for patients with novel H1N1. Throughout the pandemic, CDC has recommended the use of fit-tested N95 respirators as the minimal protection.
An Institute of Medicine panel issued findings on Sept. 1, endorsing the use of respirators, saying "these guidelines should be continued until or unless further evidence can be provided to the effect that other forms of protection or other guidelines are equally or more effective."
That finding was lauded by health care worker advocates, but criticized by infection preventionists who support using the same precautions as used with seasonal influenza - that is, surgical masks.
"Their charge, consistent with the OSHA mandate, required them not to look at the economic or logistic situations, but just look at their view of the most recent science on protecting health care workers," CDC director Thomas Frieden, MD, said at a press briefing after the IOM report was released.
The panel's conclusions are undermined by the fact that it did not consider "feasibility, acceptance, or supply" issues, noted William Schaffner, MD, an infectious disease expert and professor and chairman of the Department of Preventive Medicine at Vanderbilt University in Nashville. "Hello?! This is not a decision being made on Mars, but here on Earth where we have to apply things," he remarked.
Bill Borwegen, MPH, health and safety director of the Service Employees International Union (SEIU), asserts that supply issues can be managed by controlling the number of potentially exposed health care workers. "We're missing the entire risk assessment piece here," he says. "We have an industry that continues to operate in an environment of denial when it comes to occupational safety and health.
"Without doing a risk assessment, you can't make an intelligent decision on how you would allocate a limited supply of respirators," he says.
Vaccination is considered a major line of defense against novel H1N1, as well as seasonal flu, and hospitals are trying to boost their vaccination rates. That effort became a bit easier when CDC said only one dose of novel H1N1 vaccine will be needed to provide immunity in adults.
"Right now, there's every indication that we have a good match between the virus that's causing disease and the vaccines we have to be able to prevent it," said Jay Butler, MD, chief of the 2009 H1N1 Vaccine Task Force at a press briefing.
The first 3.4 million doses were expected to be the nasal spray vaccine, which uses live, attenuated virus. In adults, it is indicated for people under 50, and it is not recommended for pregnant women or people with weakened immune systems or certain chronic medical conditions such as asthma or heart disease.
Eventually, CDC expects 195 million doses of the vaccine from five manufacturers to be available through 90,000 vaccine providers around the country. Distribution will be through state health departments.
By mid-September, 54 million of an expected 115 million doses of seasonal influenza vaccine also had been distributed. While most influenza circulating now is the novel H1N1 virus, public health experts cautioned that seasonal flu strains may strike as the traditional flu season approaches.
Some health care facilities reported a strong response to their fall influenza campaigns. "I had been worried that with all our focus on H1N1 that seasonal flu might have been forgotten, but it turned out there was a big demand," says Schaffner.
"It has been standing room only. The lines have been very long," says Irena B. Kenneley, PhD, APRN-BC, CIC, public/community health clinical nurse specialist and assistant professor at Case Western Reserve University Frances Payne Bolton School of Nursing in Cleveland. Kenneley is a member of the Scientific Research Council of the Association for Professionals in Infection Control and Epidemiology in Washington, DC.
"They have responded in far greater numbers than in recent past years, which I am very glad to see," she says.
Meanwhile, throughout the pandemic, hospitals have varied in their response to the guidance to use respirators to protect health care workers from H1N1.
The Institute of Medicine panel concluded that airborne transmission is one form of transmission of the H1N1 virus, and that surgical masks are "unlikely to be effective against airborne transmission" because of inadequate fit characteristics. "[T]here is evidence that work-related exposures to patients infected with H1N1 virus result in health care workers becoming infected," the IOM report stated.
The IOM panel also expressed concern about gaps in research and noted "a paucity of studies on the clinical effectiveness of respirators vs. medical masks for influenza." It also noted that health care workers do not always use personal protective equipment when it is recommended.
"To improve the compliance rates and thereby improve worker protection, a 'culture of safety' for workers must be established in all health care organizations evidenced by senior leadership commitment," the panel said.
The IOM panel does not advocate using respirators for every health care worker with patient care responsibilities. "It is not the intention of the committee to recommend that all health care workers use N95 respirators, rather the use of respirators should be for those in initial contact with individuals presenting with unidentified febrile respiratory illnesses and those health care workers in close contact with individuals with confirmed or suspected H1N1," it stated.
Meanwhile, it's not clear what impact new guidance would have on hospitals around the country. Despite CDC's previous guidance recommending respirators, many hospitals have used surgical masks (droplet precautions) and some state or local health departments have recommended the lower level of protection unless health care workers were involved in aerosol-producing procedures.
When HCWs are exposed to novel H1N1 transmission
This guidance was excerpted from documents released by the Centers for Disease Control and Prevention:
If HCWs are sick with flu-like symptoms ...
Health care personnel should not report to work if they have a febrile respiratory illness. In communities where novel H1N1 transmission is occurring, health care personnel who develop a febrile respiratory illness should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.
In communities without novel H1N1 transmission, health care personnel who develop a febrile respiratory illness and have been working in areas of the hospital where swine influenza patients are present, should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.
In communities where novel H1N1 transmission is not occurring, health care personnel who develop febrile respiratory illness and have not been in areas of the facility where swine influenza patients are present should follow facility guidelines on returning to work.
If HCWs are at risk of novel H1N1 exposure ...
In communities where novel H1N1 virus transmission is occurring, health care personnel should be monitored daily for signs and symptoms of febrile respiratory illness. Health care personnel who develop these symptoms should be instructed not to report to work, or if at work, should cease patient care activities and notify their supervisor and infection control personnel.
In communities without novel H1N1 virus transmission, health care personnel working in areas of a facility where there are patients being assessed or isolated for novel H1N1 infection should be monitored daily for signs and symptoms of febrile respiratory infection. This would include health care personnel exposed to patients in an outpatient setting or the emergency department. Health care personnel who develop these symptoms should be instructed not to report to work, or if at work, should cease patient care activities and notify their supervisor and infection control personnel.
Health care personnel who do not have a febrile respiratory illness may continue to work. Asymptomatic health care personnel who have had an unprotected exposure to novel H1N1 also may continue to work if they are started on antiviral prophylaxis.
If a HCW has an unprotected exposure ...
Post exposure antiviral chemoprophylaxis with either oseltamivir or zanamivir can be considered for...health care personnel, public health workers, or first responders who have had a recognized, unprotected close contact exposure to a person with confirmed, probable, or suspected 2009 H1N1 or seasonal influenza during that person's infectious period.
Chemoprophylaxis generally is not recommended if more than 48 hours have elapsed since the last contact with an infectious person.
Patients given post-exposure chemoprophylaxis should be informed that the chemoprophylaxis lowers but does not eliminate the risk of influenza and that protection stops when the medication course is stopped. Patients receiving chemoprophylaxis should be encouraged to seek medical evaluation as soon as they develop a febrile respiratory illness that might indicate influenza. For antiviral chemoprophylaxis of 2009 H1N1 influenza virus infection, either oseltamivir or zanamivir is recommended. Duration of post-exposure chemoprophylaxis is 10 days after the last known exposure to 2009 H1N1 influenza.
... [H]ealth care personnel who have occupational exposures, can be counseled about the early signs and symptoms of influenza, and advised to immediately contact their health care provider for evaluation and possible early treatment if clinical signs or symptoms develop.
Persons at ongoing occupational risk for exposure (e.g., health care personnel, public health workers, or first responders who are working in communities with influenza outbreaks) should carefully follow guidelines for appropriate personal protective equipment. Appropriate administrative controls (e.g., having health care personnel stay home from work when ill, and triaging for identification of potentially infectious patients) and personal protective equipment should be used to reduce the need for post-exposure chemoprophylaxis among health care workers.
(Editor's note: More information is available at www.cdc.gov/h1n1flu/guidelines_infection_control.htm and www.cdc.gov/h1n1flu/recommendations.htm.)As limited amounts of the first doses of novel H1N1 vaccine were expected to reach providers in early October, hospitals placed a top priority on vaccinating health care workers who provide care to the most vulnerable patients. Even health care workers who have had flu-like symptoms and were diagnosed with novel H1N1 should receive the vaccine, according to the Centers for Disease Control and Prevention.
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