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## H1N1 Flu

### H1N1 Flu

            - CDC Response: A Year In Review                - Overview of a Pandemic                  - Background on Influenza
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Content on this page was developed during the 2009-2010 H1N1 pandemic and *has not been updated*.
                  - The H1N1 virus that caused that pandemic is now a regular human flu virus and continues to circulate seasonally worldwide.
                  - The English language content on this website is being archived for  historic and reference purposes only .
                  - For current, updated information on seasonal flu, including information about H1N1, see the  CDC Seasonal Flu website .

# Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel

July 15, 2010, 12:30 PM ET

#### On this Page

                          - Definition of  Healthcare Personnel
                          - Background
                          - Symptoms of Influenza and Viral Shedding
                          - Modes of 2009 H1N1 Influenza Transmission
                          - Review Pandemic Plans 
                          - Use a Hierarchy of  Controls to Prevent Influenza Transmission in Healthcare Settings
                          - Specific Recommendations
                          - Duration of Isolation Precautions for Patients
                          - Monitor and Manage Ill Healthcare Personnel
                          - Antiviral Treatment and Chemoprophylaxis of Healthcare Personnel
                          - Training and Education of Healthcare Personnel
                          - Healthcare Personnel at Higher Risk for Complications of Influenza
                          - Environmental Infection Control
                          - Appendix: Additional Information for Specific Healthcare Settings

CDC is releasing  updated interim guidance on infection control measures to prevent transmission  of 2009 H1N1 influenza in healthcare facilities. The updated interim guidance applies  uniquely to the special circumstances of the current 2009 H1N1 pandemic and will be updated as necessary as new  information becomes available throughout the course of this influenza season.  It provides general guidance for all healthcare facilities. The updated  guidance expands on earlier guidance by emphasizing that successfully  preventing transmission requires a comprehensive approach, beginning with  pandemic planning that includes developing written plans that are flexible and  adaptable should changes occur in the severity of illness or other aspects of  2009 H1N1 and seasonal influenza. Revisions from earlier guidance include:  criteria for identification of suspected influenza patients; recommended time  away from work for healthcare personnel; changes to isolation precautions based  on tasks and anticipated exposures; expansion of information on the hierarchy  of controls which ranks preventive interventions in the following order of  preference: elimination of exposures, engineering controls, administrative  controls, and personal protective equipment; and changes to guidance on use of  respiratory protection.

Please  note that CDC is in the process of updating and replacing this interim  guidance.  Click here for more information.

### Definition of  Healthcare Personnel

For the purposes of this guidance, healthcare personnel are  defined as all persons whose occupational activities involve contact with  patients or contaminated material in a healthcare, home healthcare, or clinical  laboratory setting. Healthcare personnel are engaged in a range of occupations,  many of which include patient contact even though they do not involve direct  provision of patient care, such as dietary and housekeeping services. This  guidance applies to healthcare personnel working in the following settings:  acute care hospitals, nursing homes, skilled  nursing facilities, physician’s offices, urgent care centers, outpatient  clinics, and home healthcare agencies.   It also includes those working in clinical settings within  non-healthcare institutions, such as school nurses or personnel staffing  clinics in correctional facilities. The term “healthcare personnel” includes  not only employees of the organization or agency, but also contractors,  clinicians, volunteers, students, trainees, clergy, and others who may come in  contact with patients.

### Background

More communities are being affected by 2009 H1N1 influenza  in fall/winter 2009-2010 than were in spring/summer 2009. Seasonal influenza  viruses may also cause illness this fall and winter, possibly at the same time  that 2009 H1N1 virus outbreaks are occurring. Although the severity, amount and  timing of illness that 2009 H1N1 influenza and seasonal influenza will cause is  uncertain, as with any influenza season, some people will require medical care  as a result of their influenza virus infections.  In view of these and other uncertainties,  healthcare facilities will need to be ready to adjust their pandemic influenza  plans as dictated by changing conditions. Staff in healthcare settings should  monitor the CDC and state and local health department websites for the latest information.

### Symptoms of Influenza  and Viral Shedding 

The symptoms of influenza, including 2009 H1N1 influenza,  can include fever, cough, sore throat, runny or stuffy nose, body aches,  headache, chills, fatigue, nausea, diarrhea, and vomiting.  Depending on the case series, the proportion  of persons who have laboratory confirmed 2009 H1N1 infection and do not have  fever can range from about 10 to 50%. Because influenza symptoms are  nonspecific, it can be difficult to determine if a person has influenza based  on symptoms alone. Nonetheless, decisions for clinical management, particularly for  outpatients, in most cases can be made on the basis of clinical and  epidemiological information. Information on diagnostic testing for 2009 H1N1 viral  infection is available.

In general, the incubation period for influenza is estimated  to range from 1 to 4 days  with an average of 2 days.  Influenza  virus shedding (the time during which a person might be infectious to another  person) begins the day before illness onset and can persist for 5 to 7 days,  although some persons may shed virus for longer periods, particularly young  children and severely immunocompromised persons. The amount of virus shed is  greatest in the first 2-3 days of illness and appears to correlate with fever,  with higher amounts of virus shed when temperatures are highest.

### Modes of 2009 H1N1  Influenza Transmission

2009 H1N1 influenza virus appears to be transmitted from  person to person through close contact in ways similar to other influenza  viruses. Although the relative contribution of each mode is uncertain,  influenza virus can potentially be transmitted through:
                  - Droplet       exposure of mucosal surfaces (e.g., nose, mouth, and eyes) by respiratory       secretions from coughing or sneezing; 
                  - Contact,       usually of hands, with an infectious patient or fomite (a surface that is       contaminated with secretions) followed by self-inoculation of virus onto       mucosal surfaces such as those of the nose, mouth, and eyes; and
                  - Small       particle aerosols in the vicinity of the infectious individual.

Transmission of influenza through the air over  longer distances, such as from one patient room to another, is thought not to  occur. All respiratory secretions and bodily fluids, including diarrheal  stools, of patients with 2009 H1N1 influenza are considered to be potentially  infectious.

### **GENERAL  RECOMMENDATIONS**

### Review Pandemic Plans  for the 2009-2010 Fall/Winter Influenza Season

                              Facilities should review and, if not already in place,  develop written pandemic influenza plans anticipating widespread transmission  of 2009 H1N1 influenza in communities. CDC, with input from other federal  partners, has developed checklists  to help healthcare facilities in their planning and preparedness for pandemic  influenza. OSHA has also developed detailed guidance for healthcare settings.  Links to specific checklists and other planning resources are provided in the  Appendix. Facilities should also check with state and local health departments  for local guidance. During the planning process, facilities should review their  work areas and job tasks to identify workers who will routinely be in close  contact with influenza patients so that preventive strategies can be targeted  and exposure that is not essential can be limited. Facilities also should  consider their own unique circumstances and needs that may not be addressed in  guidance documents. Planning committees can facilitate this process. Strong  sustained management commitment and active worker participation in a  comprehensive, coordinated prevention program are extremely important in  promoting implementation of, and adherence to, prevention recommendations.

### Use a Hierarchy of  Controls to Prevent Influenza Transmission in Healthcare Settings

Facilities should use a hierarchy of controls approach to prevent  exposure of healthcare personnel and patients and prevent influenza transmission  within healthcare settings. The hierarchy of controls to protect workers from  occupational injury or illness places preventive interventions in groups that  are ranked according to their likely effectiveness in reducing or removing the  source of exposure. To apply the hierarchy of controls to prevention of  influenza transmission, facilities should take the following steps, in order of  preference:
                  - Elimination of potential exposures :  Eliminating the potential source of exposure  ranks highest in the hierarchy of controls. Examples of interventions in this  category include: taking steps to minimize outpatient visits for patients with  mild influenza-like illness who do not have risk factors for complications,  postponing elective visits by patients with suspected or confirmed influenza  until they are no longer infectious, and denying entry to visitors who are sick.
                  - Engineering  controls :  Engineering controls rank  second in the hierarchy of controls. They are particularly effective because they  reduce or eliminate exposures at the source and many can be implemented without  placing primary responsibility of implementation on individual employees. In  addition, these controls can protect patients as well as personnel. Examples of  engineering controls include installing partitions in triage areas and other  public spaces, to reduce exposures by shielding personnel and other patients;  and using closed suctioning systems for airways suction in intubated patients.
                  - Administrative  controls : Administrative controls are required work practices and policies  that prevent exposures. As a group, they rank third in the hierarchy of  controls because their effectiveness is dependent on consistent implementation  by management and employees. Examples of administrative controls include promoting  and providing vaccination; enforcing exclusion of ill healthcare personnel,  implementing respiratory hygiene/cough etiquette strategies; and setting up  triage stations and separate areas for patients who visit emergency departments  with influenza-like illness, managing patient flow, and assigning dedicated  staff to minimize the number of healthcare personnel exposed to those with  suspected or confirmed influenza.
                  - Personal  protective equipment (PPE) : PPE ranks lowest in the hierarchy of controls.  It is a last line of defense for individuals against hazards that cannot  otherwise be eliminated or controlled. While providing personnel with  appropriate PPE and education in its use is important, effectiveness of PPE is  dependent on a number of factors. PPE is effective only if used throughout  potential exposure periods. PPE will not be effective if adherence is incomplete  or when exposures to infectious patients or ill co-workers are unrecognized. In  addition, PPE must be used and maintained properly, and must function properly,  to be effective.                                 

Careful attention to elimination  of potential exposures, engineering controls, and administrative controls will  reduce the need to rely on PPE, including respirators. This is an especially  important consideration during the current year, when shortages of respirators  have already been reported by many healthcare facilities. 

It should be recognized that  individual interventions may have a level of importance different from that  suggested by their classification within the hierarchy of controls. For  example, vaccination is an administrative control that depends upon the actions  of both management and employees. However, vaccination is one of the most  important interventions for preventing transmission of influenza to healthcare  personnel. Its ability to prevent influenza transmission in both work and  community settings is especially important, because influenza is a  community-based infection that is transmitted in household and community  settings. Other interventions that work in healthcare settings alone will not  prevent such transmission.

Examples of preventive  interventions that can be used to prevent or reduce influenza infections,  grouped according to the hierarchy of controls, are provided in Table 1. 

### Specific Recommendations

#### **Promote and administer the 2009 H1N1 influenza and  seasonal influenza vaccines**

Healthcare and  emergency medical services personnel are among the priority  groups recommended to receive the 2009 H1N1 influenza vaccine.  To improve adherence, vaccination should be  offered to healthcare personnel free of charge and during working hours.  Vaccination campaigns with incentives such as lotteries with prizes should be  considered. Healthcare facilities should require personnel who refuse  vaccination to complete a declination form. The Veterans Health Administration  Influenza Manual is a useful source of information on best practices and  strategies for increasing immunization rates. 

It is not  anticipated that the seasonal influenza vaccine will provide protection against  the 2009 H1N1 influenza virus. However, it is anticipated that seasonal  influenza viruses will also be present in the U.S. during the 2009-2010 influenza  season.  Influenza vaccination is  effective against these seasonal viruses and should continue to be provided to healthcare personnel and given to unvaccinated patients. 

#### **Enforce respiratory hygiene  and cough etiquette**

In addition to limiting numbers of ill people in the  facility (e.g., by access control), should be incorporated into infection control practices as part of Standard  Precautions to prevent the transmission of all respiratory infections including  2009 H1N1 influenza.  This form of source  control should be implemented by everyone in healthcare settings - patients,  visitors, and staff alike. Respiratory hygiene and cough etiquette procedures  should continue to be followed for the entire duration of stay. 

#### **Establish facility access  control measures and triage procedures**

                  - Establish non-punitive policies that       encourage or require ill health care personnel workers to stay home. This       should include contractors as well as staff.
                  - Post signage at entry points       instructing patients and visitors about hospital policies, including the       need to notify staff immediately if they have signs and symptoms of influenza.
                  - Establish mechanisms to identify       patients with symptoms of respiratory illness at any point of entry to the       facility. Provisions should be made for symptomatic patients to cover       their nose and mouth with tissues when coughing or sneezing, or put on       facemasks   for source control, if tolerated, and for their prompt isolation and       assessment. Information on diagnostic testing of       patients for  2009 H1N1 influenza infection  is available.
                  - Establish triage procedures and       engineering controls (e.g., partitions) that separate ill and well       patients and limit the need for PPE use by staff.  
                  - Consider limiting points of entry to       the facility. 

#### **Manage visitor access  and movement within the facility**

Establish  procedures for managing visitors to include:
                  - Limiting visitors for patients in       isolation for influenza to persons who are necessary for the patient's       emotional well-being and care. Visitors who have been in contact with the       patient before and during hospitalization are a possible source of influenza       for other patients, visitors, and staff.
                  - Scheduling and controlling visits to       allow for:                                                       - Screening for symptoms of acute respiratory illness before entering        the hospital.
                    - Instruction, before entering the patient’s room, on hand hygiene,        limiting surfaces touched, and use of PPE according to current facility        policy while in the patient's        room. 
                    - Visitors should not be present during aerosol-generating procedures.
                    - Visitors should be instructed to limit their movement within the        facility. 

#### **Establish policies and procedures for  patient placement and transport**

Any patient with respiratory illness consistent with influenza should  promptly be asked to wear a facemask for source control, if tolerated, or cover  their nose and mouth with tissues when coughing or sneezing, and placed  directly in an individual room with the door kept closed, where medically  appropriate. The precautions required for entry into patient rooms should be  posted on the door. Once placed in rooms, patients with suspected or confirmed  2009 H1N1 influenza should be encouraged to practice respiratory hygiene and  cough etiquette when they are coughing or sneezing throughout their duration of  stay.- When a single patient room is not       available, consultation with infection control personnel is recommended to       assess the risks associated with other patient placement options (e.g.,       cohorting, keeping the patient with an existing roommate). Morel information on  cohorting, including other factors that may       affect cohorting decisions  is available.
**Follow current facility  procedures for transport and movement of patients under isolation precautions,  including:**- Communicating       information about patients with suspected, probable or confirmed influenza       to appropriate personnel before transferring them to other departments in       the facility (e.g., radiology, laboratory) and to other facilities. 
- Limiting patient transport and movement of patients outside of the       room to medically necessary purposes and       minimizing waiting times and delays associated with transport and       procedures conducted outside the patient’s room. 
- Providing influenza patients with facemasks to wear for source control, as       tolerated, and tissues to contain secretions when outside of their room.
- Encouraging patients who are able to perform hand       hygiene to do so frequently and to follow  respiratory       hygiene and cough etiquette practices .
- Providing portable x-ray equipment       in cohort areas to reduce the need for patient transport.
**Limit the number of healthcare personnel  entering the isolation room**- Healthcare personnel entering the       room of a patient in isolation should be limited to those truly necessary       for performing patient care activities.
**Apply isolation precautions**
The following isolation precautions are recommended for  healthcare personnel who are in close contact with patients with suspected or  confirmed 2009 H1N1 influenza. **For the  purposes of this document, close contact is defined as working within 6 feet of  the patient or entering into a small enclosed airspace shared with the patient  (e.g., average patient room)**:- Standard Precautions  - For all patient  care, use nonsterile gloves for any contact with potentially infectious  material, followed by hand hygiene immediately after glove removal; use gowns  along with eye protection for any activity that might generate splashes of  respiratory secretions or other infectious material.

Respiratory Protection –                               Recommendation: CDC continues to recommend the use  of respiratory protection that is at least as protective as a fit-tested  disposable N95 respirator for healthcare personnel who are in close contact  with patients with suspected or confirmed 2009 H1N1 influenza. This  recommendation applies uniquely to the special circumstances of the current  2009 H1N1 pandemic during the fall and winter of 2009-2010 and CDC will continue  to revisit its guidance as new information becomes available, within this  season if necessary   

Basis: The current recommendation is based on the  unique conditions associated with the current pandemic, including low levels of  population immunity to 2009 H1N1 influenza, availability of vaccination  programs well after the start of the pandemic, susceptibility to infection of  those in the age range of healthcare personnel, increased risk for  complications of influenza in some healthcare personnel (e.g., pregnant women),  and the potential for healthcare personnel to be exposed to 2009 H1N1 influenza  patients because of their occupation.

Supply considerations: CDC recognizes that some  facilities are currently experiencing shortages of respiratory protection equipment  and that further shortages are anticipated. Although the exact total supply in  the public and private sectors is not known, a large gap between supply and  demand is predicted. In the face of shortages, appropriate selection and use of  respiratory protection is critical. A  key strategy is to use source control, engineering, and administrative measures  to reduce the numbers of workers who come in contact with patients who have  influenza-like illness in order to reduce the consumption of respiratory  protection equipment. For example, combining the use of triage procedures and  use of partitions or other engineering controls might reduce exposures and the  need for PPE.  Other strategies could include  taking steps to either reduce consumption of disposable N95 filtering facepiece  respirators or extend their use.  Some  facilities that are experienced in their use may also be able to use  alternative PPE for certain applications including more protective filtering  facepiece respirators, reusable elastomeric tight-fitting respirators, and  reusable powered air-purifying respirators (PAPRs).  For facilities that are able to use  alternatives such as elastomeric respirators or PAPRs, processes must be in  place to ensure that they are used properly and are reliably decontaminated. Additional  information about these strategies, including frequently asked questions, are posted  on the CDC 2009 H1N1 website. 

Special care should be taken to ensure that respirators  are available for situations where respiratory protection is most important,  such as performance of aerosol-generating procedures on patients with suspected  or confirmed 2009 H1N1 influenza or provision of care to patients with other  infections for which respiratory protection is strongly indicated (e.g.,  tuberculosis).   

Prioritized respirator use: Where a shortage of  respirators exists despite reasonable efforts to obtain and maintain a  sufficient supply for anticipated needs, in particular for very high exposure  risk situations such as some aerosol-generating procedures (listed below), a  facility should consider shifting to a prioritized respirator use mode. In this  mode, respirator use is prioritized to ensure availability for healthcare  personnel at most risk from 2009 H1N1 influenza exposure. Even under conditions  of prioritized use, personnel attending aerosol-generating procedures on  patients with suspected or confirmed 2009 H1N1 influenza should always use  respiratory protection at least as protective as fitted N95 respirators. An  example of prioritization for personnel not attending aerosol-generating  procedures is shown in Table 2. Prioritization should be adapted to local  conditions and should consider intensity and duration of exposure, personal  health risk factors for complications of infection, and vaccination status. When in prioritized respirator  use mode, respirator use may be temporarily discontinued for employees at  lower risk of exposure to 2009 H1N1 influenza or lower risk of complicated  infection. Gathering of personal information for the  purposes of pandemic planning and response must be done in a fashion that is  compliant with all applicable rules and regulations, including the Americans  with Disabilities Act (ADA).  Contingency crisis planning is critical to efficient implementation of  prioritized use during supply shortages. In making decisions about  prioritization, facilities should consider needs for managing patients with  diseases other than influenza that require respiratory protection (e.g.  tuberculosis) and also considerations related to the timetable for obtaining  more respirators. To assure that respirators are likely to be available for the  most important uses, facilities should maintain a reserve sufficient to meet  the estimated needs for performing aerosol-generating procedures and for  managing patients with diseases other than influenza that require respiratory  protection until supplies are expected to be replenished.  

Facemasks for healthcare personnel who are not provided  a respirator due to the implementation of prioritized respirator use: If a  facility is in prioritized respirator use mode and unable to provide  respirators to healthcare personnel who provide care to suspected and confirmed  2009 H1N1 influenza cases, the facility should provide those personnel with  facemasks. Facemasks that have been cleared for marketing by the U.S. Food and  Drug Administration have been tested for their ability to resist blood and body  fluids, and generally provide a physical barrier to droplets that are expelled  directly at the user. Although they do not filter small particles from the air  and they allow leakage around the mask, they are a barrier to splashes, droplet  sprays, and autoinoculation of influenza virus from the hands to the nose and  mouth. Thus, they should be chosen over no protection. Routine chemoprophylaxis  is not recommended for personnel wearing facemasks during the care of patients  with suspected or confirmed 2009 H1N1 influenza.

**Hand Hygiene**
- Healthcare       personnel should perform hand hygiene frequently, including before and       after all patient contact, contact with respiratory secretions, and before       putting on and upon removal of PPE. Soap and water or alcohol-based hand       sanitizers should be used.

**Aerosol-generating  procedures**                              Some procedures  performed on patients are more likely to generate higher concentrations of  respiratory aerosols than coughing, sneezing, talking, or breathing, presenting  healthcare personnel with an increased risk of exposure to infectious agents  present in the aerosol. Although there are limited objective data available on  disease transmission related to such aerosols, many authorities view the  following procedures as being very high exposure risk aerosol-generating procedures  for which special precautions should be used:
- Bronchoscopy
- Sputum induction
- Endotracheal intubation       and extubation
- Open suctioning of airways
- Cardiopulmonary       resuscitation
- Autopsies

Although some  have suggested that administration of nebulized medications (due to risk of  inducing cough), acquisition of nasopharyngeal swabs/samples, and use of  high-flow oxygen might create infectious aerosols of concern, less is known  about the magnitude or potential for exposure.                               A combination of measures should be used to reduce exposures  from high-risk aerosol-generating procedures, including:
- Only       perform these procedures on patients with suspected or confirmed influenza       if they are medically necessary and cannot be postponed. 
- Limit       the number of healthcare personnel present during the procedure to only       those essential for patient care and support.
- Conduct       the procedures in an airborne infection isolation room (AIIR) when       feasible.  Such rooms are designed       to reduce the concentration of infectious aerosols and prevent their       escape into adjacent areas using controlled air exchanges and directional       airflow. They are single patient rooms at negative pressure relative to       the surrounding areas, and with a minimum of 6 air changes per hour (12       air changes per hour are recommended for new construction or renovation).       Air from these rooms should be exhausted directly to the outside or be       filtered through a high efficiency particulate air (HEPA) filter before       recirculation. Room doors should be kept closed except when entering or       leaving the room, and entry and exit should be minimized during and shortly       after the procedure. Facilities should  monitor and document  the proper       negative-pressure function of these rooms. 
- Portable       HEPA filtration units may be used to further reduce the concentration of       contaminants in the air. Some of these units can connect to local exhaust       ventilation systems (e.g. hoods, booths, tents) or have inlet designs that       allow close placement to the patient in order to assist with source       control; however, these units do not eliminate the need for respiratory       protection for individuals entering the room because they may not entrain       all of the room air. Information on air flow/air entrainment performance       should be evaluated for such devices.
- Healthcare       personnel should adhere to  standard precautions ,       and wear respiratory protection equivalent to a fitted N95 filtering       facepiece respirator or higher level of protection during       aerosol-generating procedures. 
- Unprotected healthcare personnel should not be   allowed in a room where an aerosol-generating procedure has been conducted until   sufficient time has elapsed to remove potentially infectious particles. More information on  clearance rates under differing ventilation conditions  is available. This table assumes perfect mixing. For example, based   on the table, an AIIR with 6 air changes per hour and perfect room mixing will   require 46 minutes to reduce the concentration of airborne particles by 99%.    For a more realistic assumption of good mixing, the clearance times provided in   this table should be multiplied by a mixing factor of 3. Thus, for an AIIR with   6 air changes per hour and normal room mixing, over two hours will be required to reduce the concentration of airborne   particles by 99%). Environmental surface cleaning also is necessary to   ensure that environmental contamination does not lead to infection   transmission.   
Duration of Isolation  Precautions for Patients
The  recommended duration of isolation precautions for hospitalized patients is  longer than that recommended for other populations because duration of virus  shedding is likely to be longer than for outpatients with milder illness.  Isolation precautions for patients who have  influenza symptoms should be continued for the 7 days after illness onset or  until 24 hours after the resolution of fever and respiratory symptoms,  whichever is longer, while a patient is in a healthcare facility. Shedding of influenza viruses generally  diminishes over the course of 7 days, with transmission apparently correlating  with fever. Given this, if isolation resources (e.g. private rooms) become  limited, these resources should be prioritized for patients who are earlier in  the course of illness. Clinical judgment may be used for patients with  only cough as a symptom, since cough after influenza infection may be prolonged  and may not be an indicator of viral shedding.  Because some patients with influenza may not  have fever but may be shedding influenza virus, patients with any respiratory  symptoms should follow hand and respiratory hygiene recommendations, and  healthcare personnel working with such patients should continue to follow  standard precautions. Patients should be discharged from medical care when  clinically appropriate, not based on the period of isolation.

In  some cases, facilities may choose to continue isolation precautions for longer  periods such as in the case of young children or severely immunocompromised patients,  who may shed influenza virus for longer periods of time and who might be  shedding antiviral resistant virus. Clinical judgment should be used to  determine the need for continued isolation precautions for such patients. Communications  regarding the patient’s diagnosis with post hospital care providers (e.g.  Home-healthcare agencies, long-term care facilities) as well as transporting  agencies is essential.
Monitor and Manage Ill Healthcare Personnel
Employee health services should establish  procedures for tracking absences; reviewing job tasks and identifying personnel  at higher risk for complications; assuring that employees have access via  telephone to medical consultation and, if necessary, early treatment; and  promptly identifying individuals with possible influenza. Healthcare personnel  should self-assess for symptoms of febrile respiratory illness. An active  approach in which personnel are asked daily about symptoms of febrile  respiratory illness is also recommended. In most cases, decisions about work  restrictions and assignments for personnel with respiratory illness should be  guided by clinical signs and symptoms rather than by laboratory testing for  influenza. Personnel should  be provided with information about risk factors for complications of influenza,  so those at higher risk know to promptly seek medical attention and be  evaluated for early treatment if they develop symptoms of influenza. All  personnel should be provided with specific instructions to follow in the event  of respiratory illness with rapid progression, particularly when experiencing  shortness of breath. Anyone with the following emergency warning signs needs urgent medical  attention and should seek medical care promptly:
- Difficulty breathing or shortness of breath 
- Pain or pressure in the chest or abdomen 
- Sudden dizziness 
- Confusion 
- Severe or persistent vomiting 
- Flu-like symptoms improve but then return with  fever and worse cough 

Healthcare  personnel who develop a fever and respiratory symptoms should be:
- Instructed not to report to work, or if at work,  to promptly notify their supervisor and infection control  personnel/occupational health. 
- Excluded  from work for at least 24 hours after they no longer have a fever,  without the use of fever-reducing medicines. 
- If returning to work in areas where severely  immunocompromised patients are provided care, considered for temporary  reassignment or exclusion from work for 7 days from symptom onset or until the  resolution of symptoms, whichever is longer. Clinical judgment should be used  for personnel with only cough as a symptom, since cough after influenza  infection may be prolonged and may not be an indicator of viral shedding.  Healthcare personnel recovering from a respiratory illness may return to work  with immunocompromised patients sooner if absence of 2009 H1N1 viral RNA in  respiratory secretions is documented by real-time reverse  transcriptase-polymerase chain reaction (rRT-PCR). Additional  information on  diagnostic testing  for 2009 H1N1 influenza infection is available. 
- Reminded  of the importance of practicing frequent hand hygiene (especially before  and after each patient contact) and respiratory hygiene and cough etiquette  after returning to work following an acute respiratory illness. 

Healthcare personnel who develop acute respiratory  symptoms without fever should be: 
- Allowed  to continue or return to work unless assigned in areas where severely  immunocompromised patients are provided care. In this case they should be considered  for temporary reassignment or exclusion from work for 7 days from symptom onset  or until the resolution of symptoms, whichever is longer. Clinical judgment  should be used for personnel with only cough as a symptom, since cough after  influenza infection may be prolonged and may not be an indicator of viral  shedding. Healthcare personnel recovering from a respiratory illness may return  to work with immunocompromised patients sooner if absence of 2009 H1N1 viral RNA  in respiratory secretions is documented by rRT-PCR. Additional  information on  diagnostic testing  for 2009 H1N1 influenza infection is available. 
- Reminded  of the importance of practicing frequent hand hygiene (especially before  and after each patient contact) and respiratory hygiene and cough etiquette  after returning to work following an acute respiratory illness. 
Facilities and organizations  providing healthcare services should:
- Ensure  that sick leave policies for healthcare personnel (e.g., staff and contract  personnel) are flexible and consistent with public health guidance and that  employees are  aware of the policies . 
- Ensure that sick employees are able to stay home  without fear of losing their jobs.
- Consider offering alternative work environments  as an accommodation for employees at higher risk for complications of 2009 H1N1  influenza during periods of increased influenza activity or if influenza  severity increases.
- Not require a doctor’s note for workers with  influenza to validate their illness or return to work. 
Antiviral Treatment and Chemoprophylaxis of  Healthcare Personnel 
Please refer to  the CDC web site for the most current recommendations on the use of antiviral  agents for treatment and chemoprophylaxis.  All healthcare personnel concerned about symptoms of influenza should seek  advice from their medical provider promptly.
Training and  Education of Healthcare Personnel
All healthcare personnel should receive training on  influenza prevention and risks for complications of influenza. The training  should include information on risk assessment; isolation precautions;  vaccination protocols; use of engineering and administrative controls and  personal protective equipment; protection during high-risk aerosol-generating  procedures; signs, symptoms, and complications of influenza; and to promptly  seek medical attention for any concerns about symptoms of influenza.
Healthcare Personnel  at Higher Risk for Complications of Influenza
Personnel at higher risk for complications from influenza  infection include pregnant women, persons 65 years old and older, and persons  with chronic diseases such as asthma, heart disease, diabetes, diseases that suppress  the immune system, and certain other chronic medical conditions. Vaccination and early treatment with antiviral  medications are very important for healthcare personnel at higher risk for  influenza complications because they can prevent hospitalizations and deaths.  Healthcare personnel at higher risk for complications should check with their  healthcare provider if they become ill so that they can receive early  treatment.
Environmental Infection Control
Routine cleaning  and disinfection strategies used during influenza seasons can be applied to the  environmental management of 2009 H1N1 influenza.  Management of laundry, utensils and medical  waste should also be performed in accordance with procedures followed for  seasonal influenza. More information is available.
**Table 1. Examples    of Use of a     Hierarchy of Controls to Prevent Influenza Transmission**
**Elimination of sources of    infection**
Postponing elective visits and procedures for    patients with suspected or confirmed influenza until they are no longer    infectiousDenying healthcare facility entry to those wishing    to visit patients if the visitors have suspected or confirmed influenzaMinimizing outpatient and emergency department    visits for patients with mild influenza-like illness who do not have risk    factors for complicationsKeeping    personnel at home while they are ill to reduce the risk of spreading    influenza
**Engineering controls**
Installing    partitions (e.g., transparent panels/windows/desk enclosures) in triage areas    as physical barriers to shield staff from respiratory dropletsUsing    local exhaust ventilation (e.g., hoods, tents, or booths) for    aerosol-generating proceduresUsing    hoods for the performance of laboratory manipulations that generate    infectious aerosolsUsing    ventilation controls in ambulancesInstalling    hands-free soap and water dispensers, and receptacles for garbage and linens    to minimize environmental contactConducting    aerosol-generating procedures in an airborne infection isolation room (AIIR)    to prevent the spread of aerosols to other parts of the facilityUsing    closed suctioning systems for airways suction in intubated patientsUsing    high efficiency particulate filters on mechanical and bag ventilators Ensuring    effective general ventilation and thorough environmental surface hygiene
**Administrative controls**
Vaccinating    as much of the healthcare workforce as possible (once vaccine is available)Identifying    and isolating patients with known or suspected influenza infectionsImplementing    respiratory hygiene/cough etiquette programsSetting    up triage stations, managing patient flow, and assigning dedicated staff to    minimize the number of healthcare personnel exposed to those with suspected    or confirmed influenza.Screening    personnel and visitors for signs and symptoms of infection at clinic or    hospital entrances or badging stations and responding appropriately if they    are presentAdhering    to appropriate isolation precautionsLimiting    the number of persons present in patient rooms and during aerosol-generating    proceduresArranging    seating to allow 6 feet between chairs or between families when possibleEnsuring    compliance with hand hygiene, respiratory hygiene, and cough etiquette Making    tissues, facemasks, and hand sanitizer available in waiting areas and other    locationsEstablishing    protocols for cleaning of frequently touched surfaces throughout the facility    (elevator buttons, work surfaces, etc.)Locating    signage in appropriate language and at the appropriate reading level in areas    to alert staff and visitors of the need for specific precautionsPlacing    facemasks on patients, when tolerated, at facility access points (e.g.,    emergency rooms) or when patients are outside their rooms (e.g. diagnostic    testing).Placing facemasks on patients during transport; when    tolerated; limiting transport to that which is medically necessary; and    minimizing delays and waiting times during transport
**Personal protective    equipment**
Wearing    appropriate gloves, gowns, facemasks, respirators, eye protection, and other    PPE 
 
    Table 2.  Prioritization of Respiratory Protection During Respirator Shortages for Healthcare Personnel Not Participating in Aerosol-Generating Proceduresa    (Numbers 1 through 4 indicate relative priorities for respiratory protection, with 1 the highest priority and 4 the lowest priority)  
**Exposure Scenario**

**Not Vaccinatedb**

**Vaccinatedc**

**Personnel Without Risk Factors for    Influenza-Related Complicationsd**

** **

** **

Routine    care – frequent close exposuree

2

4

Routine    care – infrequent close exposuref

3

4

 

 

 

**Personnel With Risk Factors for    Influenza-Related Complicationsg**

 

 

Routine    care – frequent close exposure

1 

3

Routine    care – infrequent close exposure

2

4

**a** – This table is provided as an  example of prioritization that considers intensity and duration of exposure,  personal health risk factors for complications of infection, and vaccination  status. Advance planning is critical to efficient implementation of prioritized  use during supply shortages.**b** – Not vaccinated: not vaccinated or  less than 14 days after vaccination. Consider including those with  immunosuppressive conditions or treatment with immunosuppressive therapies  anticipated to impair vaccine response in this group.**c** – Vaccinated: 14 or more days after  vaccination.**d** - See section on “Healthcare  Personnel at Higher Risk for Complications of Influenza” for list of personal  risk factors for influenza-related complications. **e** – Personnel frequently in close  contact with patients with suspected or confirmed 2009 H1N1 influenza. For the  purposes of this document, close contact is defined as working within 6 feet of  the patient or entering into a small enclosed airspace shared with the patient  (e.g., average patient room). This generally includes personnel working in  settings where cases of suspected or confirmed 2009 H1N1 influenza are  routinely seen (e.g. emergency departments and primary care in environments  such as clinics in outpatient settings, employee healthcare facilities, and  correctional facilities).**f** – Personnel infrequently in close  contact with patients with suspected or confirmed 2009 H1N1 influenza. This generally  includes personnel working in settings where cases of suspected or confirmed  2009 H1N1 influenza are not routinely seen and/or having job duties not  involving close contact.**g**– Gathering of personal information for the purposes  of pandemic planning and response must be done in a fashion that is compliant  with all applicable rules and regulations, including the Americans with  Disabilities Act (ADA). A short  technical assistance document is available. Consider offering alternative work environments as an accommodation for  employees at highest risk for complications of influenza during periods of  increased influenza activity or if influenza severity increases.
Appendix: Additional Information for Specific Healthcare  Settings
Additional information is available online to assist in  customizing guidance to specific healthcare settings.  CDC, together with other agencies, is  actively producing new and updated documents.   Many of these can readily be accessed via the following web pages:
- H1N1       Flu Clinical and Public Health Guidance  (CDC)
- Infection       Control in Health Care Facilities  (CDC)
-  Health Care Planning  (U.S. Department of Health and  Human Services)

**Hospitals**
- Hospital Pandemic Influenza Planning Checklist
- Pandemic  Influenza Preparedness and Response Guidance for Healthcare Workers and  Healthcare Employers . OSHA Publication 3328-05, (2007). Also available as a  405 KB  PDF ,  104 pages.
- Frequently Asked Questions on Pandemic Influenza Preparedness and  Response Guidance for Healthcare Workers and Healthcare Employers   

**Emergency Medical  Services**
- Emergency Medical Services and Non-Emergent (Medical)  Transport Organizations Pandemic Influenza Planning Checklist
- Interim Guidance for Emergency Medical Services  (EMS)  Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of  Patients with Confirmed or Suspected Swine-Origin Influenza A (H1N1) Infection.
- Interim Guidance for Cleaning Emergency Medical Service  (EMS) Transport Vehicles during an Influenza Pandemic
- Managing Calls and Call Centers  during a Large-Scale Influenza Outbreak: Implementation Tool

**Medical Offices  and Clinics**
- Medical Offices and Clinics Pandemic Influenza Planning  Checklist
- 10 Steps You Can Take: Actions for Novel H1N1 Influenza  Planning and Response for Medical Offices and Outpatient Facilities

**Obstetric Settings**
- Considerations Regarding Novel H1N1 Flu Virus in Obstetric  Settings

**Outpatient  Hemodialysis Settings**
- Interim Additional Guidance for Infection Control for Care  of Patients with Confirmed, Probable, or Suspected Novel Influenza A (H1N1)  Virus Infection in Outpatient Hemodialysis Settings

**Long-Term Care and  Other Residential Services**
- Long-Term Care and Other Residential Facilities Pandemic  Influenza Planning Checklist

**Home Health Care**
- Home Health Care Services Checklist :
- Home Care Guidance: Physician Directions to Patient/Parent
- Home Health Care During an Influenza Pandemic: Issues and  Resources

**Pathology /  Clinical Laboratory**
- Post-mortem Care and Safe Autopsy Procedures for Novel H1N1  Influenza
- Interim Biosafety Guidance for All Individuals handling  Clinical Specimens or Isolates containing 2009-H1N1 Influenza A Virus (Novel  H1N1), including Vaccine Strains

**Educational  Institutions**
- School Planning web page  (provides links to numerous  resources)

**Correctional  Institutions**
- Correctional Facilities Pandemic Influenza Planning  Checklist
- Interim Guidance for Correctional and Detention Facilities  on Novel Influenza A (H1N1) Virus

Respirator use should be in the context of a complete respiratory protection  program in accordance with Occupational Safety and Health Administration (OSHA)  regulation 29 CFR 1910.134.  Information on respiratory protection programs and fit test procedures is available.  Staff should be medically cleared, fit-tested, and trained for respirator use,  including: proper fit-testing and use of respirators, safe removal and  disposal, and medical contraindications to respirator use. Additional  information on N95 respirators and other types of respirators certified by  NIOSH are available.  A complete listing of NIOSH-approved  disposable particulate respirators (filtering facepieces) by  manufacturers/suppliers and model numbers are available.
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