The purpose of this guidance document is to assist members of the American College of Occupational and Environmental Medicine (ACOEM), and the organizations for which they work, in managing the impact of a pandemic of influenza or other contagious respiratory disease on patients, employees, and business. This guidance document outlines actions to take before and during an influenza pandemic on the basis of two main strategies: (1) reducing the spread of the virus within facilities; and (2) providing medical care and medical surveillance to client/patient populations.
Facilities in which ACOEM members serve include government agencies and the military, universities, and corporations, which generally have multiple locations/sites and their own medical staff, with members responsible for medical care and disease control. This guidance is for organizations with outpatient occupational medicine services, to be used as appropriate. Medical centers should also use guidance that addresses additional employee and external patient care needs.1–3 The ACOEM fully supports implementation of occupational influenza programs that conform with guidance from the Centers for Disease Control and Prevention (CDC), with other guidance from the US Department of Health and Human Services (DHHS), and Occupational Safety and Health Administration (OSHA) regulations and guidance.
BACKGROUND AND RATIONALE
The impact of pandemic influenza on workplaces and business functions could be devastating, as up to 15% to 35% of the population—including workers and patients—could be affected, with significant mortality depending on severity.4 In pandemics, a vaccine for a novel virus strain may not be available until up to 6 months after the pandemic is recognized.1,3 In any location, the peak pandemic-related emergency may be prolonged 4 to 8 weeks or more. To reduce disruption to workplace function, planning for the next influenza pandemic is imperative.
This ACOEM Pandemic Influenza Guidance incorporates and expands on the aspects of plans and checklists for business available from federal and state agencies and from corporate plans offered by ACOEM members.1,3,5–7 As stated in ACOEM's Guidance Statement for Seasonal Influenza Prevention in Health Care Workers, influenza prevention programs must use a comprehensive approach that includes immunization, education, and proper infection control practices.8 Also, these programs must include standard principles of hazard control in occupational health, using engineering controls, administrative controls, proper work practices, and personal protective equipment (PPE). Principles of immunization, education, and program evaluation, as outlined in the ACOEM seasonal influenza guidance, also apply to pandemic influenza.
Some of the rationale behind recommended measures is based on the characteristics of influenza viruses. First, the sudden appearance and severity of a novel virus and the expected delay in vaccine availability require policy setting, planning, and stockpiling of supplies, all in advance. Second, because of the viral shedding before the onset of symptoms, rapid spread, and short incubation period of influenza, individual containment measures such as isolation and quarantine are less likely to be effective for disease control than are the community-based containment measures. For all influenza outbreaks, multiple measures are needed to protect employees and maintain business continuity. The CDC terms it a “layered approach”—these include vaccines and emphasizing individual actions to reduce risk of infection (eg, hand hygiene and respiratory etiquette). Outbreaks with severe disease have high hospitalization rates and case fatality ratios (CFRs); for such outbreaks, additional nonpharmaceutical measures may include social distancing (eg, closing facilities and restricting public gatherings).7 The recommended medical measures herein include those found in the ACOEM seasonal influenza guidance and also include monitoring for levels of disease that may affect the capacity of the organization and the medical department. These measures include standard influenza prevention and treatment with vaccine and antivirals and special measures for pandemics, including screening for influenza-like illness (ILI), syndromic surveillance, triage, and administrative efforts.1,2,5–7
The CDC Pandemic Severity Index (PSI) allows interventions to be made on the basis of pandemic severity, using CFR as the index of severity.9 The CDC guidance for the employers for the 2009 to 2010 H1N1 pandemic suggested planning and response measures both for the severity of that outbreak and for more severe scenarios.7 Because past pandemics have varied in severity, from a CFR of <0.1% in 2009 to 2010 to more than 2% in the 1918 Spanish flu, this guidance recommends actions for three severity levels. Employers and ACOEM members should adopt plans that allow a flexible response, according to both disease severity and local conditions. The following spreadsheet (Table 1) lists these measures in detail, by PSI category, which members can use to design or improve their institutions' pandemic influenza plans. Except for prepandemic planning, actions apply to World Health Organization pandemic alert phase 6.
A. Planning, developing policy, and training
* Sources of information for pandemic plans and education are numerous and include the Web sites of federal (eg, CDC) and state agencies and of the military, universities, and corporations, which have downloadable documents and links to other specific information. For employee training and patient education, these sources can be used freely to create corporate/medical center documents and make sustainable Web links. The pandemic plan can be incorporated into the emergency operations plan or all-hazards plan, or such plans can be written by using this document's format and content.
* Plans should address at least the following2,5,10:
1. Planning team—include management, occupational medicine, occupational health, legal, training office, security, safety and emergency management, human resources, communications, pur-chasing, and supply. Workplace pandemic coordinator—appointed in advance—will coordinate all pandemic-related issues, including contact with local and state health departments. Seek input from employee and labor organizations.
2. Predicted schedule changes/absences—establish policies for sick leave, employee compensation, travel, and special needs populations (employees, customers, and patients). For pandemics with severe disease (eg, high hospitalization and death rates), establish leave policies for isolated/quarantined employees and family members, and policies for geographic separation of key personnel, distant work (“telecommuting/tele-work”), and “staggered” shiftwork (without which there will be more absences during a pandemic). These policies should be communicated well, be nonpunitive and flexible, and should address personal illness, family illness, community quarantines, and closures of schools, businesses, and public transportation.
3. Business continuity—coordinate this plan with general business continuity plans (eg, plans for natural disasters), including how to maintain or reduce operations with supply-chain disruptions and reduced staff. Include overseas operations.
4. Essential employees and medical and emergency response personnel—identify and designate these personnel for immunizations, antiviral medication, PPE, and other appropriate requirements and equipment.
5. Communications plan(s)—inter-nal and external plans, to include key points of contact (inside facility, at both institutional/outside health care facilities, at public health agencies, and at business contacts), chain of communications (including suppliers), and processes for tracking and communicating employee and corporate/medical center status internally and to the public and public health agencies. Specify additional needed communication and information technology infrastructure. In all communications, clearly define medical or technical terms in understandable and unambiguous language.
6. Health care, mental health, and social services—evaluate employee and patient access and their availability; arrange contingencies as necessary. Plan for surge capacity, both outpatient and inpatient. Include plans to distribute antiviral medications and administer mass immunization.
7. Collaboration with other organi-zations—corporations/health care facilities/health plans/state and local public health and emergency response agencies; include sharing plans, mutual aid agreements, and your potential contributions to communities. Incorporate relevant actions from state/local health department plans. Attend meetings of local, regional, and/or state emergency planning groups.
8. Forecast numbers/costs—calcu-late expected numbers and costs for each category within this section.
9. Exercises/drills—perform periodic exercises/drills to test the plan, and revise the plan accordingly. Practice with the institution's emergency operations center.
10. Multiple business locations—give local managers authority to implement actions appropriately based on local conditions.
* Employee training and education: Address at least the following2,5,7–10:
1. Pandemic facts—use bulletins and Web site information from CDC and DHHS (eg, www.flu.gov), as well as from state and local public health departments and emergency response agencies. Topics should include details of the institution's plan, facts about influenza and ILI (signs and symptoms, how the virus is transmitted, and when to stay home/return to work), vaccine facts, reducing workplace spread (see sections on Social Distancing and Hygiene), and preparing home and family (including storing food and medical supplies and at-home care of ill employees/family members).
2. Reducing workplace spread—training should address good infection control practice to be used regardless of immunization status, including standard precautions, CDC hand-washing guidance, respiratory etiquette (ie, cough into a tissue or upper sleeve), and social distancing (≥6 feet). Place posters (for both employees and patients) that describe these actions.
3. Cross-training—with increased absences during a pandemic, cross-training will be necessary within the institution/medical center. Consider training of ancillary workers (eg, contractors and retirees).
4. Multiple offering—provide training at multiple times, formats, languages and venues, for example, both at meetings and via Web-based training.
5. Tracking, reporting, and enforcement of required training—assign education coordinator and set organizational goals.
* Coordinate (in advance) with local public health agencies regarding vaccine availability, professional information for occupational health practitioners, and when to trigger pandemic plan actions.
* Advance-purchase antivirals and vaccine (if possible): determine numbers required, including high-priority staff and patients; give estimate for vaccine to the supplying health agency; and obtain when available. Sensitivity to the impact on external high-risk populations should be part of the advance purchase considerations.
* Ample supplies of the following are needed for a minimum duration of several weeks:
1. Hygiene-related supplies—hand sanitizer, soap, hospital disinfectant, disposable towels, tissues, no-touch trash cans, and PPE such as disposable gowns and gloves.
2. Medical-related supplies—N-95 respirators, surgical masks, and protective eye wear to prevent airborne spread of virus; thermometers (mercury-free advised); and treatment-related supplies.
3. Pandemics with severe disease—food and water as necessary and located as required for confined personnel (employees, medical staff, and patients).
* Stockpiling—since the same supplies are useful against seasonal influenza and other respiratory pathogens, stockpiling of supplies need not be considered as a “wasted” or an undue expenditure, and most can be routinely rotated on a “first-in-first-out” basis.
C. Social distancing
* Definition—CDC defines social distancing as “measures to increase the physical space between people and reduce frequency of contact.” It includes canceling events such as large gatherings and closing/restricting access to buildings, and it applies to groups, not just individuals.11
* Visiting—discourage visits to medical departments and hospital emergency departments by the “worried well” and by those with symptoms of uncomplicated ILI, as such visits encourage spread of influenza virus. (However, those having signs of severe disease, per CDC guidance, should seek prompt medical attention.)
* Exclude/segregate persons with ILI:
1. The ILI symptoms: fever/chills, sore throat, cough, gastrointestinal symptoms; fever—temperature more than 100°F (37.8°C); and
2. Urge employees with ILI to stay home, promptly exclude the people with ILI from work, and separate sick employees while on site (designate rooms to do so). Put patients with ILI into respiratory isolation.
* Training and education—should address these social distancing policies and measures, so that employees are familiar with them.
* For pandemics with severe disease—aim to reduce frequency and types of face-to-face contact between employees, customers, and patients. Consider implementation at World Health Organization pandemic levels 5 and 6. Measures may include canceling nonessential meetings; avoiding handshaking; closing venues such as child-care centers and cafeterias; and changes in office layout and use of shared equipment and seating during meetings. Plan the use of remote communication (eg, telephone/Web-based meetings and business functions) and needed information technology infrastructure; deploy these as needed; give priority to workers at high medical risk for influenza complications (ie, those with chronic medical conditions or who are pregnant). Observe travel restrictions and advice to travelers from public health authorities; recall traveling/overseas personnel as feasible.
* During training—emphasize CDC recommendations for respiratory hygiene (eg, cover coughs and sneezes) and hand hygiene (hand wash and hand sanitizers), applicable at all times in health care settings. Monitor and enforce standard infection control practices as critical elements of job performance.
* Deploy supplies as noted above—including in clinical areas for patient use; use them according to DHHS and OSHA guidance. Hand sanitizer can be used with both seasonal and pandemic influenza.
* Increase workplace cleaning—both with increased frequency and increased number of locations such as common surfaces (eg, shared work stations, telephones, and doorknobs). In patient care areas, use standard methods, including EPA-registered hospital disinfectants, and manage laundry, medical waste, and eating utensils according to seasonal influenza methods.
* For pandemics with severe disease (ie, high hospitalization rates and CFR ≥1.0%):
1. Restrict access by visitors/patients—to places such as employee work areas, designated rest rooms, and eating places. Involve facility security and implement access control (eg, close some entrances and screen all who enter the facility).
2. Engineering controls—consider deploying methods such as drive-through windows and sneeze guards between customers, patients, and employees, and use of rooms with negative pressure and/or filtered ventilation.
* Vaccine priorities—CDC recommends that the following groups at high risk of complications from influenza should receive all influenza vaccines12–14:
1. Pregnant women;
2. Persons of any age with underlying medical conditions that increase their risk for complications from influenza (eg, heart and lung disease and immunodeficiencies);
3. Health care workers and emergency medical services personnel;
4. Children between the ages of 6 months and 18 years of age; and
5. Household contacts of high-risk persons.Members of the above groups except children are abundant in the workplace. For the 2009 novel-H1N1 influenza virus and during other past pandemics, an additional high-risk group was that of children and young people between the ages of 6 months and 24 years of age. In future pandemics, persons in this age range may also be at high risk.12
* Distribution of vaccine and antiviral medications—public health agencies will announce the availability and best use of vaccine (when available) and antivirals. Medical centers and institutional medical departments should implement mass immunization programs. Priority groups for vaccine receipt and recommendations for which antiviral to use may change during the pandemic, as they have during seasonal outbreaks. Organizational programs may resemble programs used for seasonal influenza, but a severe pandemic may require other distribution systems such as points of distribution managed by public health agencies.
* Access to medical services—increased demand for medical services will occur in most organizations/corporations, particularly medical centers.
1. Increased outpatient services (needing more clinical staff)—may include acute care and sick call.
2. Pandemics with severe disease—make medical consultation available on a 24-hour/7-day basis. Increased services may include mental health, employee-assistance programs, and decedent affairs. Expect inpatient facilities to use their surge capacity beds, including the intensive care unit. Develop phone triage protocols.
* Syndromic surveillance3:
1. Prepandemic—report unusual cases of ILI (eg, summer cases or other unexpected patterns) to public health agencies. Implement tracking and reporting of training and vaccine compliance for seasonal influenza.
2. During pandemic—collect and report to management and health agencies the following: data on vaccine compliance, workplace screening, known cases of ILI in employees/patients, and among medical personnel (the latter affects treatment capacity), and their recovery/return to work. Medical facilities can enroll in the National Healthcare Safety Network on-line at www.cdc.gov/nhsn, for tools to track employee immunization and health status. Within the facility, track daily which employees have contact with ILI patients, and their work status and health status.
* Pandemics with severe disease—consider the following other aspects of clinical care1,3:
1. Implementation—implement active workplace screening for ILI; consider screening all employees, visitors, and patients.
2. Scheduling—reschedule routine/nonessential office visits or designate times for care of ILI and non-ILI patients.
3. Triage—assign staff; consider phone and e-mail triage, having separate triage, waiting areas, and examination/treatment rooms for patients with ILI symptoms. Consider screening of employees and visitors for fever during pandemics with high mortality and prevalence, and consider legal and human resources aspects of screening.
4. Reassignment—protect staff at high medical risk for influenza complications (listed previously): assign them to lower-risk duties (eg, administrative work, non-ILI patient care). Conversely, clinical staff members who have recovered from pandemic influenza, and now are presumed immune, may be well suited for care of patients with acute disease.
5. The PPE and droplet precautions—for health care workers and emergency responders who use respirators, a comprehensive respiratory protection program that complies with OSHA standards (29 CFR 1910.134) is required.15 Perform prepandemic fit testing. Issue N-95 respirators to medical and emergency medical services personnel who care for ILI patients; keep a supply of powered-air-purifying respirators available. Place surgical masks on persons with ILI in the facility to reduce virus spread. Droplet precautions (private room, gowns, respiratory protection, and eye protection, eg, face shields) are indicated during direct care (within 3 feet) of ILI patients.3
F. Other Organizational Needs
1. Inpatient facilities—guidance is available for the detailed plans required, such as the CDC Hospital Pandemic Influenza Planning Checklist16 and the OSHA Pandemic Influenza Preparedness and Response Guidance for health care workers and health care employers.3 The latter contains a sample detailed, generic medical center preparedness plan for epidemic respiratory tract infections.
2. Organizations with overseas facilities—use guidance such as CDC's Pandemic Preparedness Planning for US businesses with overseas operations.17
3. Postpandemic—continue related services as needed, for example, surveillance, training, vaccine compliance, employee-assistance program, and decedent affairs. Resupply, calculate pandemic costs, hold debriefings, and revise plans accordingly.
This article was developed by ACOEM's Emergency Preparedness Task Force under the auspices of the Council on Occupational and Environmental Medicine Practice. Task Force members are Drs Curtis Cummings, lead author, William Buchta, Lee Glass, John Halpin, Marilyn Howarth, Warner Hudson, Margaret Kitt, Ann Kuhen, and Mark Russi. This article was peer reviewed by the council and was approved by the ACOEM Board of Directors on November 6, 2010.