Pandemic Influenza Preparedness 

and Response Guidance for

Healthcare Workers and Healthcare Employers

www.osha.gov

OSHA 3328-05 2007
Employers are responsible for providing a safe and

healthful workplace for their employees. OSHA’s

role is to assure the safety and health of America’s

working men and women by setting and enforcing

standards; providing training, outreach, and education; establishing partnerships; and encouraging

continual process improvement in workplace safety

and health.

This publication is in the public domain and may

be reproduced, fully or partially, without permission.

Source credit is requested, but not required.

This information is available to sensory impaired

individuals upon request. Voice phone: (202) 693-

1999; teletypewriter (TTY) number: (877) 889-5627. 

Edwin G. Foulke, Jr.

Assistant Secretary of Labor for

Occupational Safety and Health
Pandemic Influenza Preparedness 

and Response Guidance for

Healthcare Workers and Healthcare Employers

Occupational Safety and Health Administration

U.S. Department of Labor

OSHA 3328-05 

2007
2

Occupational Safety and 

Health Administration

This document is not a standard or regulation, and it creates no new legal obligations. Likewise, it

cannot and does not diminish any obligations established by Federal or state statute, rule or standard. The document is advisory in nature, informational in content, and is intended to assist

employers in providing a safe and healthful workplace. The Occupational Safety and Health Act

requires employers to comply with hazard-specific safety and health standards. In addition, pursuant to Section 5(a)(1), the General Duty Clause of the Act, employers must provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm.

Employers can be cited for violating the General Duty Clause if there is a recognized hazard and

they do not take reasonable steps to prevent or abate the hazard.

ACRONYMS

CDC Centers for Disease Control and Prevention

EPA U.S. Environmental Protection Agency

HEPA high-efficiency particulate air

HHS U.S. Department of Health and Human Services

JCAHO Joint Commission on Accreditation of Healthcare 

Organizations

LRN Laboratory Response Network

NIOSH National Institute for Occupational Safety and Health

OSH Act Occupational Safety and Health Act of 1970

OSHA Occupational Safety and Health Administration

PAPR powered air-purifying respirator

PLHCP physician or another licensed healthcare professional

PPE personal protective equipment

RT-PCR reverse transcriptase polymerase chain reaction

SARS severe acute respiratory syndrome

SNS Strategic National Stockpile

SPN Sentinel Provider Network

WHO World Health Organization
Contents

Introduction 5

References 6

Influenza: Clinical Background

Information 7

Clinical Presentation of Influenza 8

Clinical Presentation of Seasonal Influenza 8

Clinical Presentations of Prior Influenza

Pandemics 9

Clinical Presentation of Highly Pathogenic 

Avian Influenza in Humans 9

Diagnosis 9

Clinical Diagnosis of Seasonal Influenza 9

Laboratory Diagnosis of Seasonal Influenza 10

Clinical Diagnosis of Pandemic Influenza 10

Laboratory Diagnosis of Avian and 

Pandemic Influenza 11

Modes of Transmission 11

Seasonal Influenza Transmission 11

Pandemic Influenza Transmission 12

Treatment and Prevention 13

Seasonal Influenza Treatment and Prevention 13

Pandemic Influenza Treatment and Prevention 13

References 13

Infection Control 15

Standard Precautions and TransmissionBased Precautions 15

Standard Precautions 15

Contact Precautions 16

Droplet Precautions 16

Airborne Precautions 16

Compliance with Infection Control 17

Hand Hygiene Compliance 17

Respiratory Protection Compliance 17

Organizational Factors that Affect

Adherence to Infection Control 18

Facility Design, Engineering, and 

Environmental Controls 18

Facility Capacity 19

Engineering Controls in Improvised Settings 19

Airborne Infection Isolation Rooms 19

Engineering Controls for Aerosol-Generating 

Procedures for Patients with Pandemic 

Influenza 19

Cohorting 20

Engineering Controls in Diagnostic and

Research Laboratories 20

Autopsy Rooms for Cases of Pandemic

Influenza 20

Administrative Controls 21

Respiratory Hygiene/Cough Etiquette 21

Pandemic Influenza Specimen Collection

and Transport 21

Patient Transport within Healthcare Facilities 22

Pre-Hospital Care and Patient Transport 

Outside Healthcare Facilities 22

Staff Education and Training 22

Care of the Deceased 24

Patient Discharge 24

Visitor Policies 24

Healthcare Worker Vaccination 24

Antiviral Medication for Prophylaxis and 

Treatment in Healthcare Workers 25

Occupational Medicine Services 25

Worker Protection 25

Recommendations for Occupational

Health Administrators 26

Occupational Medical Surveillance and

Staffing Decisions 26

Personal Protective Equipment 27

Gloves 27

Gowns 27

Goggles/Face Shields 27

Respiratory Protection for Pandemic

Influenza 27

PPE for Aerosol-Generating Procedures 31

Order for Putting on and Removing PPE 31

Work Practices 32

Hand Hygiene 32

Other Hygienic Measures 32

Facility Hygiene—Practices and Polices 32

Laboratory Practices 34

References 34

Pandemic Influenza Preparedness 36

Healthcare Facility Responsibilities During 

Pandemic Alert Periods 36

Healthcare Facility Responsibilities During

Pandemic Alert Periods (HSC Stages 0, 1) 36

Healthcare Facility Responsibilities During

the Pandemic (HSC Stages 2-5) 37

Healthcare Facility Recovery and Preparation

for Subsequent Pandemic Waves

(HSC Stage 6) 37

Incorporating Pandemic Plans into 

Disaster Plans 37

Pandemic Planning for Support of

Healthcare Worker Staff 37

Define Essential Staff and Hospital Services 38

Human Resources 39

Information Technology 39

Public Health Communication 39 

Surveillance and Protocols 40

Psychological Support 41

Occupational Health Services 42

Developing and Providing Employee 

Screening for Influenza-Like Illness 42

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

3
4

Occupational Safety and 

Health Administration

Developing and Providing Immunization and 

Treatment Strategies 42

Continuing Baseline Occupational Health 

Services 43

Training 43

Security 43

Stockpiles of Essential Resources 44

Pandemic Influenza Vaccine 44

Antiviral Medication 45

Personal Protective Equipment 46

Outpatient Services and Clinics 46

Alternate Care Sites 47

References 47

OSHA Standards of 

Special Importance 50

Respiratory Protection Standard -

29 CFR 1910.134 50

Personal Protective Equipment Standard - 

29 CFR 1910.132 50

Bloodborne Pathogens Standard - 

29 CFR 1910.1030 50

General Duty Clause 51

References 51

Appendix A 

Pandemic Influenza 

Internet Resources 52

Appendix B 

Infection Control Communication 

Tools for Healthcare Workers 54

Appendix B-1

Factors Influencing Adherence to 

Hand Hygiene Practices 55

Appendix B-2 

Elements of Healthcare Worker Educational 

and Motivational Programs 56

Appendix B-3

Strategies for Successful Promotion of Hand

Hygiene in Hospitals 57

Appendix B-4 

Pandemic Influenza Precautions for Veterans 

Administration Healthcare Facility Staff 58

Appendix B-5

Public Health Measures Against Pandemic 

Influenza for Individuals, Healthcare Providers, 

and Organizations 60

Appendix C 

Implementation and Planning for

Respiratory Protection Programs 

in Healthcare Settings 62

Appendix C-1

Respiratory Protection Programs 62

Appendix C-2

Readiness Plan for Epidemic Respiratory 

Infection: A Guideline for Operations for Use 

by the Dartmouth-Hitchcock Medical Center –

Lebanon Campus and the Dartmouth College 

Health Service 67

Appendix D 

Self-Triage and Home Care Resources 

for Healthcare Workers and Patients 82

Appendix D-1

Sample Self-Triage Algorithm for Persons 

with Influenza Symptoms 82

Appendix D-2

Home Care Guide for Influenza 83

Appendix E

References for Diagnosis and 

Treatment of Staff During an 

Influenza Pandemic 85

Appendix E-1

Influenza Diagnostic Table 85

Appendix F 

Pandemic Planning Checklists 

and Example Plans 87

Appendix F-1 

Sample Emergency Management Program 

Standard Operating Procedure (SOP) 88

Appendix G 

Risk Communication Resources 94

Appendix G-1

Risk and Crisis Communication: 77 Questions

Commonly Asked by Journalists During 

a Crisis 95

Appendix H 

Sample Supply Checklists 

for Pandemic Planning 96

Appendix H-1 

Examples of Consumable and Durable 

Supply Needs 96

Appendix H-2 

Suggested Inventory of Durable and Consumable

Supplies for Veterans Administration Healthcare

Facilities During a Pandemic Influenza 96

OSHA Assistance 97

OSHA Regional Offices 99
Introduction

A pandemic is a global disease outbreak. A flu pandemic occurs when a new influenza virus emerges

for which people have little or no immunity, and for

which there is no vaccine. The disease spreads easily person-to-person, causes serious illness, and

can sweep across the country and around the

world in a very short time.

It is difficult to predict when the next influenza

pandemic will occur or how severe it will be.

Wherever and whenever a pandemic starts, everyone around the world is at risk. Countries might,

through measures such as border closures and

travel restrictions, delay arrival of the virus, but

they cannot stop it.

An especially severe influenza pandemic could

lead to high levels of illness, death, social disruption, and economic loss. Everyday life would be

disrupted because so many people in so many

places become seriously ill at the same time.

Impacts can range from school and business closings to the interruption of basic services such as

public transportation and food delivery.

An influenza pandemic is projected to have a

global impact on morbidity and mortality, thus

requiring a sustained, large-scale response from

the healthcare community. The 1918 influenza pandemic was responsible for over 500,000 deaths in

the United States, while the 1957 and 1968 pandemic influenza viruses were responsible for 70,000

and 34,000 deaths, respectively.1 More recently, one

modeling study estimated that an influenza pandemic affecting 15 to 35 percent of the United

States population could cause 89,000 to 207,000

deaths, 314,000 to 734,000 hospitalizations, 18 to 42

million outpatient visits, and 20 to 47 million additional illnesses.2 In contrast, from 1990 to 1999, seasonal influenza caused approximately 36,000

deaths per year in the United States.3

A substantial percentage of the world’s population will require some form of medical care.

Healthcare facilities can be overwhelmed, creating

a shortage of hospital staff, beds, ventilators and

other supplies. Surge capacity at non-traditional

sites such as schools may need to be created to

cope with the demand.

It is expected that such an event will quickly

overwhelm the healthcare system locally, regionally, and nationally.4 An increased number of sick

individuals will seek healthcare services. In addition, the number of healthcare workers available to

respond to these increased demands will be

reduced by illness rates similar to pandemic

influenza attack rates affecting the rest of the population. Finally, healthcare workers and healthcare

resources will also be expected to continue to meet

non-pandemic associated healthcare needs. 

In order to mitigate the effects of an influenza

pandemic on the healthcare community, it is important to identify healthcare providers and recognize

the diversity of practice settings. 

• The delivery of healthcare services requires a

broad range of employees, such as first

responders, nurses, physicians, pharmacists,

technicians and aides, building maintenance,

security and administrative personnel, social

workers, laboratory employees, food service,

housekeeping, and mortuary personnel.

Moreover, these employees can be found in a

variety of workplace settings, including hospitals, chronic care facilities, outpatient clinics

(e.g., medical and dental offices, schools, physical and rehabilitation therapy centers, health

departments, occupational health clinics, and

prisons), free-standing ambulatory care and

surgical facilities, and emergency response settings. 

• The diversity among healthcare workers and

their workplaces makes preparation and

response to a pandemic influenza especially

challenging. For example, not all employees in

the same healthcare facility will have the same

risk of acquiring influenza, not all individuals

with the same job title will have the same risk

of infection, and not all healthcare facilities will

be at equal risk although all will be similarly

susceptible. During an influenza pandemic,

healthcare workers may be required to provide

services in newly established healthcare facilities to accommodate patient overflow from traditional healthcare settings (e.g., convention

centers, schools, and sports arenas).

Consequently, the cornerstone of pandemic

influenza preparedness and response is an

assessment of risk and the development of

effective policies and procedures tailored to

the unique aspects of various healthcare settings.

Collaboration with state and federal partners is

vital to ensure that healthcare workers are adequately protected during an influenza pandemic.

The goal of this document is to help healthcare

workers and employers prepare for and respond to

an influenza pandemic.

The guidance document is organized into four

major sections:

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

5

Introduction
• Clinical background information on influenza

• Infection control 

• Pandemic influenza preparedness

• OSHA standards of special importance 

Given the technical nature and breadth of information available in the document, each section has

been subdivided (see Table of Contents) in order to

allow readers to quickly focus on areas of interest. 

The document also contains appendices which

provide pandemic planners with samples of infection control plans, examples of practical pandemic

planning tools and additional technical information.

Topic areas include Internet resources, communication tools, sample infection control programs, selftriage and home care resources, diagnosis and

treatment of staff during a pandemic, planning and

supply checklists and risk communication. This

educational material has been provided for informational purposes only and should be used in conjunction with the entire document in order to ensure

that healthcare workers are adequately protected

during a pandemic. OSHA does not recommend

one option over the many effective alternatives that

exist.

OSHA has prepared additional, general information to assist workplaces in their preparation for an

influenza pandemic entitled, Guidance on Preparing

Workplaces for an Influenza Pandemic which is

available at www.osha.gov. 

References

1 U.S. Department of Health and Human Services

(HHS). Pandemicflu.gov, General Information. Last

accessed June 7, 2006: http://www.pandemicflu.

gov/general/.

2 Meltzer M.I., N.J. Cox, K. Fukuda. 1999. The economic impact of pandemic influenza in the United

States: priorities for intervention. Emerg Infect Dis

5:659-71.

3 Thompson W.W., D.K. Shay, E. Weintraub, et al.

2003. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA

289:179-86.

4 Waldhorn R., E. Toner. 2005. Challenges to hospital medical preparedness and response in a flu pandemic. Center for Biosecurity, University of

Pittsburgh Medical Center. October 12, 2005. Last

accessed June 7, 2006: http://www.upmc-biosecurity.org/avianflu/facts-hospitalprep.html

6

Occupational Safety and 

Health Administration
Influenza: Clinical

Background Information

Historically, influenza has caused outbreaks of respiratory illness for centuries, including three pandemics (worldwide outbreaks of disease) in the

20th century.1 There are three types of influenza

viruses: types A, B, and C. Only type A influenza

viruses cause pandemics. Seasonal influenza outbreaks can be caused by either type A or type B

influenza viruses. Influenza type C viruses cause

mild illness in humans but do not cause epidemics

or pandemics. This guidance is aimed at protecting

healthcare workers in the event of an influenza pandemic; therefore, the focus will be on the characteristics of type A influenza viruses. 

Of the three types of influenza viruses, only type

A is divided into subtypes. Subtype designations

are based on the presence of two viral surface

proteins (antigens): hemagglutinin (H) and neuraminidase (N). To date, 16 different hemagglutinin

and 9 different neuraminidase surface proteins

have been identified in influenza A viruses.2

Subtypes are designated as the H protein type

(1–16) solely or followed by the N protein type (1–9)

(e.g., H5N1). Three different subtypes (i.e., H1N1,

H2N2, and H3N2) have caused pandemics in the

20th century. Influenza A viruses vary in virulence,

infectivity to specific hosts, modes of transmission,

and the clinical presentation of infection. 

Seasonal, avian, and pandemic influenza can

occur in humans. It is important to have a basic

understanding of the terms seasonal, avian and

pandemic influenza in order to appreciate the guidance in this document. 

• Seasonal influenza or “flu” refers to periodic

outbreaks of acute onset viral respiratory infection caused by circulating strains of human

influenza A and B viruses. Seasonal “flu” is the

kind of influenza with which healthcare workers and the public are most familiar. In temperate regions of the world, seasonal influenza

generally occurs most frequently during the

winter months when the humidity and outdoor

temperatures are low (generally from December

until April in northern temperate regions).

Between 5–20 percent of the population may

be infected annually. Most people have some

immunity to the currently circulating strains of

influenza virus and, as a result, the severity

and impact of seasonal influenza is substantially less than during pandemics. Each year, a

trivalent influenza vaccine is prepared in

advance of the anticipated seasonal outbreak

and it includes those strains (two type A and

one type B) that are expected to be the most

likely to circulate in the upcoming “flu” season. Influenza vaccine is currently targeted

toward those at greatest risk of influenza-related complications and their contacts, such as

healthcare workers.

• Avian influenza, also known as the bird flu, is

caused by type A influenza viruses that infect

wild birds and domestic poultry. Some forms

of the avian influenza are worse than others.

Avian influenza viruses are generally divided

into two groups: low pathogenic avian influenza and highly pathogenic avian influenza. Low

pathogenic avian influenza naturally occurs in

wild birds and can spread to domestic birds. In

most cases it causes no signs of infection or

only minor symptoms in birds. In general,

these low pathogenic strains of the virus pose

little threat to human health. Low pathogenic

avian influenza virus H5 and H7 strains have

the potential to mutate into highly pathogenic

avian influenza and are, therefore, closely

monitored. Highly pathogenic avian influenza

spreads rapidly and has a high death rate in

birds. Highly pathogenic avian influenza of the

H5N1 strain is rapidly spreading in birds in

some parts of the world. 

Highly pathogenic H5N1 is one of the few avian

influenza viruses to have crossed the species barrier to infect humans, and it is the most deadly of

those that have crossed the barrier. Most cases of

highly pathogenic H5N1 infection in humans have

resulted from contact with infected poultry or surfaces contaminated with secretion/excretions from

infected birds.

As of November 2006, the spread of highly

pathogenic H5N1 avian influenza virus from person

to person has been limited to rare, sporadic cases.

Nonetheless, because all influenza viruses have the

ability to change, scientists are concerned that

highly pathogenic H5N1 avian influenza virus one

day could be able to sustain human-to-human

transmission. Because these viruses do not commonly infect humans, there is little or no immune

protection against them in the human population.

If the highly pathogenic H5N1 avian influenza virus

were to gain the capacity to sustain transmission

from person to person, a pandemic could begin.

• Pandemic influenza refers to a global disease

outbreak. A flu pandemic occurs when a new

influenza type A virus emerges for which peoPANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

7

Influenza: Clinical Background Information
ple have little or no immunity, and for which

there is no vaccine. The disease spreads easily

person-to-person, causes serious illness, and

can sweep across the country and around the

world in a very short time. Such a virus is likely

to have origins from avian viruses or possibly

from other animal sources (e.g., pigs). Many

scientists believe that since no pandemic has

occurred since 1968, it is only a matter of time

before another pandemic occurs. A pandemic

may occur in waves of outbreaks with each

wave in a community lasting 8 to 12 weeks.

One-to-three waves may occur.

Rapid detection of unusual influenza outbreaks,

isolation of possible pandemic viruses and the immediate notification of national and international health

authorities is critical for mounting a timely and effective response to a potential pandemic. The World

Health Organization (WHO) maintains a global surveillance system of circulating influenza strains and a

Global Influenza Preparedness Plan.3 The WHO Plan

describes six phases of increasing public health risk

associated with the emergence of a new influenza

virus subtype that may pose a pandemic threat. The

WHO bases alerts on these six different phases. 

The first two phases of the WHO Pandemic Alert

System comprise the “Inter-pandemic Period” in

which there is a novel influenza A virus in animals,

but no human cases have been observed. Phase 2

indicates that an animal influenza subtype that

poses a risk to humans has been detected. The

next three phases (Phases 3–5) compose the

“Pandemic Alert Period” in which a novel influenza

virus causes human infection with a new subtype,

but does not exhibit efficient and sustained humanto-human transmission. Once a new influenza A

virus develops the capacity for efficient and sustained human-to-human transmission in the general population (Phase 6), the WHO declares that an

influenza pandemic is in progress (this is known as

the “Pandemic Period”). 

For additional information visit WHO’s Epidemic

and Pandemic Alert and Response website at

http://www.who.int/csr/disease/avian_influenza/

phase/en/index.html. Federal government response

stages to these WHO phases are described in the

National Strategy for Pandemic Influenza:

Implementation Plan which can be found at 

http:// www.whitehouse.gov/ homeland/pandemic

influenza-implementation.html.

Clinical Presentation of Influenza

It may be useful for healthcare providers to be

aware of the clinical presentation of seasonal

influenza, prior influenza pandemics, and highly

pathogenic avian influenza in humans to assist

them when evaluating patients who present with

influenza-like illness.

The clinical picture of influenza infections can

vary from no symptoms at all in seasonal influenza

to fulminant (fully symptomatic) disease in pandemic strains that result in severe illness and death,

even among previously healthy adults and children.4

Fever and respiratory symptoms are characteristic

of all forms of influenza. The Centers for Disease

Control and Prevention’s (CDC’s) Sentinel Provider

Network (SPN) monitors influenza timing and

severity. The SPN5 is comprised of approximately

2,300 primary care providers that provide weekly

reports on outpatient “influenza-like illnesses” to

state health departments and to the CDC. The SPN

uses “fever >100° F or 37.8° C and sore throat

and/or cough in the absence of a known cause

other than influenza” as its definition of influenzalike illness. 

Clinical Presentation of Seasonal Influenza 

Seasonal influenza typically has an abrupt onset,

with symptoms of fever, chills, fatigue, muscle

aches, headache, dry cough, upper respiratory congestion, and sore throat.6 The time from exposure

to disease onset is usually 1 to 4 days, with an

average of 2 days. Most patients recover within 3 to

7 days.7 In adults, fevers usually last for 2 to 3 days,

but may last longer in children. Cough and weakness can persist for up to 2 weeks. Except for fever,

the physical examination has few specific findings.

Typically there is weakness and mild inflammation

of the upper respiratory tract. Routine outpatient

laboratory findings are also non-specific. Available

laboratory tests that are specific for influenza are

described in the Diagnosis section on page 9 of this

document. 

Adults are possibly infectious from about 1 day

before until about 5 days after the onset of clinical

illness. Children and the immunocompromised

(e.g., people with HIV infection, organ transplantation or receiving chronic steroids) have a much

longer period of infectivity. Children can be infectious for 10 or more days, and young children can

shed the virus for several days before the onset of

illness. Severely immunocompromised persons can

shed the virus for weeks or months.7

Seasonal influenza is responsible for approximately 36,000 deaths and 226,000 hospitalizations

annually in the United States.8 The risk of death is

highest among the elderly, the very young, and

patients with cardiopulmonary and other chronic

conditions.7

8

Occupational Safety and 

Health Administration
Clinical Presentations of Prior Influenza

Pandemics 

The 1918 influenza pandemic, caused by subtype

H1N1 viruses, had signs and symptoms of far

greater severity than seasonal influenza. It resulted

in death for an estimated 500,000 U.S. citizens and

as many as 40 million people worldwide. The 1918

pandemic disproportionately affected young,

healthy adults, between the ages of 15 and 35. A

significant proportion of patients developed fulminant disease, accompanied by a striking perioral

cyanosis, leading to death within a few days.

Postmortem examinations in these patients frequently revealed denuding tracheobronchitis, pulmonary hemorrhage, or pulmonary edema. Others

survived the initial illness, only to die of a secondary bacterial pneumonia.6

The 1957 (caused by subtype H2N2 viruses) and

1968 (caused by subtype H3N2 viruses) influenza

pandemics killed an estimated 70,000 and 34,000

U.S. citizens, respectively.8 The clinical features of

the pandemics of 1957 and 1968 were also typical

of influenza-like illness, including fever, chills,

headache, sore throat, malaise, cough, and coryza,

but were milder compared to the 1918–19 pandemic.6 The 1957 influenza pandemic was notable for

severe complications, such as primary viral pneumonia, particularly in pregnant women. As in the

pandemic of 1918, some people survived the initial

viral infection, only to later die of a secondary bacterial pneumonia. 

Clinical Presentation of Highly Pathogenic 

Avian Influenza in Humans 

The highly pathogenic H5N1 avian influenza virus

that caused outbreaks in Hong Kong, Thailand,

Vietnam, and Cambodia, like the 1918 pandemic

virus, primarily resulted in disease in children and

young adults.9 Hospitalized patients initially developed typical seasonal influenza symptoms such as

high fever and cough, but unlike seasonal influenza, there were lower respiratory tract rather than

upper respiratory tract symptoms. Because of the

involvement of the lower respiratory tract, patients

typically had shortness of breath and almost all

patients had developed viral pneumonia at the time

of hospitalization. Also unlike typical seasonal

influenza, diarrhea, abdominal pain, and vomiting

were frequently reported. Common laboratory findings were lymphopenia, thrombocytopenia and elevated aminotransferase levels. 

As of November 13, 2006, highly pathogenic

H5N1 viruses had not been detected in animals or

humans in the United States. For up-to-date information regarding the number of human cases of

avian influenza and deaths worldwide, visit the

WHO Confirmed Cases of Human Influenza A

(H5N1) website at http://www.who.int/csr/disease/

avian_influenza/country/en/.

An outbreak of another avian influenza virus,

H7N7, occurred among poultry farm employees

and those helping to contain the outbreak in the

Netherlands in 2003.10 The clinical course of this

influenza virus was unusual in that conjunctivitis

was a common finding and fewer affected persons

had respiratory symptoms, although the one fatality among the 89 human cases was associated with

respiratory disease. No further outbreaks were

reported through April 24, 2006 (http://www.cdc.

gov/flu/avian/gen-info/avian-flu-humans.htm).

Diagnosis

Accurate and timely influenza diagnosis requires

knowledge of the likely clinical presentations of

seasonal influenza and of any circulating strains of

novel viral subtypes, an awareness of the risks for

exposure, and knowledge of the capabilities and

limitations of laboratory diagnostic tests. 

The more quickly a new pandemic virus can be

identified, the sooner actions can be taken to isolate the initial cases and initiate other public health

measures to prevent spread through the community and the sooner infection control measures can

be implemented to protect the community’s healthcare workers. 

Clinical Diagnosis of Seasonal Influenza

Uncomplicated seasonal influenza presents as a

sudden onset of fever and respiratory illness with

muscle aches, headaches, nonproductive cough,

sore throat, and runny nose. Children can also have

ear infections and/or gastrointestinal symptoms.7

The diagnosis of the influenzas will be primarily

through recognizing symptom complexes such as

those used in surveillance. The SPN definition for

influenza-like illness is used for seasonal influenza

surveillance.5 However, this definition is not specific

and may share features with other respiratory illnesses present in the community. 

The likelihood of a clinical sign or symptom to

accurately detect influenza infection in a group of

patients is called sensitivity. Conversely, the likelihood of a clinical sign or symptom to exclude

influenza infection in a group of patients who do

not have influenza is called specificity. Both the

sensitivity and specificity of clinical signs and

symptoms of influenza infection vary with multiple

factors, including patient age, vaccination status,

hospitalization status, degree of co-circulation of

other infectious agents that cause respiratory

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

9
symptoms in the community, and the percentage of

the population infected with influenza (prevalence).

The clinical signs and symptoms of influenza have

been studied using viral cultures as the criteria for

definitive influenza diagnosis in groups of mostly

young adults when influenza was circulating in their

community. It has been reported that the use of the

influenza-like case definition is 63 to 78% accurate

in identifying culture-confirmed cases of influenza

(a sensitivity of 63 to 78%) and 55 to 71% accurate

in excluding influenza (specificity of 55 to 71%).7

The sensitivity and specificity will vary based on the

percentage of all respiratory illnesses that are due

to influenza. Other studies have addressed influenza signs and symptoms in different groups.11, 12

There is considerable overlap in the clinical presentation of seasonal influenza and other viral and

bacterial respiratory infections. Influenza surveillance case definitions and laboratory testing can

assist in differentiating among these infections.

However, clinicians must always maintain a level of

awareness that co-infections with bacterial respiratory infections or non-influenza viruses can occur

with seasonal influenza. Clinical judgment regarding diagnosis and treatment is needed in conjunction with laboratory testing in order to differentiate

between potential infectious organisms. 

Laboratory Diagnosis of Seasonal Influenza

During Inter-pandemic and Pandemic Alert Periods,

use of laboratory diagnostic tests for influenza supports seasonal influenza surveillance and provides

laboratory detection of novel influenza subtypes.

There are multiple laboratory techniques for identifying influenza viruses, including the rapid antigen

test, the reverse transcriptase polymerase chain

reaction (RT-PCR) assays, virus isolation, and

immunofluorescence antibody assays.13

When respiratory secretions are used for seasonal influenza diagnosis, nasopharyngeal samples

are more likely to yield a positive result than are

pharyngeal swab samples.14 Commercial rapid testing can detect influenza virus in less than 30 minutes. However, some of these tests are not very

sensitive9 (false negative results are common) and

not all of these tests are able to distinguish between

influenza A and B viruses (see Safety Tips for

Laboratorians: Cautions in Using Rapid Tests for

Influenza A Viruses at http://www.fda.gov/cdrh/oivd/

tips/rapidflu.html). When influenza is suspected during an outbreak of respiratory illness, both rapid

testing and viral cultures should be done. Although

viral cultures require five days or more to perform,

they can provide specific information on the strain

and subtype of the influenza virus tested, and provide information on the sensitivity to antiviral medication as well.14 The HHS/CDC Influenza (Flu)

Laboratory Diagnostic Procedures for Influenza

website (http://www.cdc.gov/flu/professionals/

labdiagnosis.htm) maintains a table of the available

diagnostic tests for the influenza virus.14

Clinical Diagnosis of Pandemic Influenza

Patients with pandemic influenza will likely have

clinical signs and symptoms similar to seasonal

influenza, although the clinical presentation and

course of illness may be severe in a higher percentage of the cases of pandemic influenza. In general,

if the next pandemic is comparable to the 1918

Type A H1N1 virus, the pandemic influenza is likely

to be far more severe than seasonal influenza, and

might disproportionately affect a younger population. 

An important factor to look for when evaluating

patients for the presence of pandemic influenza

during all phases of a WHO Pandemic Alert Period,

when human infection with a new subtype is detected, is a possible source of exposure. For instance,

the current sources of exposure to highly pathogenic H5N1, the avian influenza virus of most concern,

would likely involve international travel or occupational exposure to infected poultry or wild birds.

Emergency room physicians and other healthcare

personnel interviewing patients with influenza-like

illness should ask about recent travel history.

A patient who has a history of travel to a country affected by a novel influenza virus and who has

the onset of influenza-like illness within the known

incubation period for that virus should be suspected to be infected with the novel influenza virus.

Seasonal influenza incubation is usually 1 to 4

days, but novel influenza viruses may have longer

incubation periods, possibly up to 10 days.6 A frequently updated report of countries that have had

human infections with highly pathogenic H5N1

avian influenza viruses is available at the WHO

Web website at http://www.who.int/csr/disease/

avianinfluenza/en/. 

Individuals who handle or process animals with

a novel virus, laboratory personnel who analyze

specimens containing a novel virus and healthcare

workers who care for patients infected with a novel

virus are at risk for contracting that viral infection. If

the virus of concern has not yet been shown to be

capable of sustained human-to-human transmission, occupational risk would be higher for employees with exposure to animal or animal products.6

1 0

Occupational Safety and 

Health Administration
Laboratory Diagnosis of Avian and 

Pandemic Influenza

Currently, the highly pathogenic H5N1 avian

influenza virus is considered to have the greatest

potential for mutation to a pandemic virus given

how widespread the virus is and because it has

already caused illness and death in people. This

virus has spread rapidly in bird populations

throughout Asia, Europe, and Africa. Recently,

HHS/CDC developed a 4-hour RT-PCR assay for the

detection of the gene coding for the H5 surface protein of the Asian lineage of the highly pathogenic

H5N1 avian influenza virus.15 These RT-PCR reagents

have been distributed to approximately 140 designated laboratories of the Laboratory Response

Network (LRN) which has laboratories located in all

50 states.15 The RT-PCR testing should be done

when a patient has severe respiratory illness and

clinical or epidemiological risk. Clinicians should

contact their local or state health department as

soon as possible to report any suspected human

case of influenza H5N1 in the United States.

Positive tests for influenza A H5N1 in the United

States should be confirmed by HHS/CDC, which

has been designated as a WHO H5 Reference laboratory. An HHS/CDC guidance document Updated

Interim Guidance for Laboratory Testing of Persons

with Suspected Infection with Avian Influenza A

(H5N1) Virus in the United States is distributed via

the Health Alert Network (HAN) at http://www2a.cdc.

gov/han/ArchiveSys/ViewMsgV.asp?AlertNum=

00246. Tests for other avian viruses with pandemic

potential are also being developed.

Modes of Transmission 

Information on the mode of seasonal influenza

transmission is based on previous influenza outbreaks. However, the transmission characteristics of

a pandemic influenza virus will not be known until

after the pandemic begins. This section covers the

transmission patterns of seasonal influenza and

past and potential pandemic influenza outbreaks. 

Seasonal Influenza Transmission

The usual method of seasonal influenza transmission is assumed to be through coughs and sneezes

of infected persons within close proximity. A susceptible person may develop symptoms within 1 to

4 days after exposure to an infected patient who is

shedding the influenza virus. The newly infected

person is then infectious for about 6 days, usually

beginning 1 day prior to the onset of symptoms.

This varies with age and disease, as discussed previously. 

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

1 1

The relative importance of the various routes of

transmission is not known, although it is now commonly accepted that the spread of seasonal influenza requires close proximity—via exposure to large

droplets (droplet transmission), direct contact

(contact transmission), or near range exposure to

aerosols.16 The term “near range” is used to differentiate influenza airborne transmission from the

long-range airborne transmission seen in diseases

such as tuberculosis, where disease spread can

occur over long distances and prolonged periods

of time.

Droplet Transmission 

Epidemiologic patterns suggest that droplet transmission is a major route of influenza spread.

Susceptible individuals are subject to infection by

large particle droplets from infected patients.

Droplets are produced by coughing, sneezing, or

talking, or by therapeutic manipulations such as

suctioning or bronchoscopy. Infected droplets may

enter the susceptible individual through the conjunctiva of the eye or the mucus membranes of the

mouth or nose. Droplets travel only about 3 feet

and do not remain in the air, so special ventilation

procedures and advanced respiratory protection is

not required to prevent this type of transmission.16

Airborne Transmission

Airborne transmission, as occurs in tuberculosis, is

spread through small infectious particles such as

droplet nuclei.17 Unlike the larger droplets, these

very small airborne droplet nuclei can be readily

disseminated by air currents to susceptible individuals. They can travel significant distances and can

penetrate deep into the lung to the alveoli where

they can establish an infection. The presence of significant airborne transmission would indicate the

need for ventilation procedures and respiratory protection greater than that afforded by a surgical

mask, e.g., a NIOSH-certified N95 or higher respirator. 

No study has definitively established airborne

transmission as a major route of influenza transmission, but multiple studies suggest that some

airborne influenza transmission may occur.

Experiments in mice have demonstrated that air

exchange can decrease influenza virus transmission, and have demonstrated infectious particles

that are smaller than ten microns.18 A ferret study

demonstrated that influenza virus transmission can

occur through a vent with right angles. A human

volunteer study demonstrated that, when a small

droplet aerosol is used, influenza transmission can
occur with lower virus concentrations.19 Another

human observational study documented the spread

of influenza to 72 percent of the passengers and

crew on an airplane with a ventilation system that

was not functioning for 3 hours.20 While these studies suggest that airborne influenza transmission

occurs under certain conditions, the proportion of

influenza illness resulting from this route of transmission is unknown. 

Contact Transmission

Contact transmission can be direct or indirect.

Direct contact transmission occurs by touching skin

to skin, usually during direct patient care activities

such as turning or bathing patients, or by shaking

hands. Indirect transmission occurs when infected

material from the patient is deposited in the environment and is taken up by a susceptible individual.16

There is limited data on the survivability of

influenza A and B viruses outside of the human

host. One study,21 conducted by Bean et al., suggests that that if a heavily infected person contaminated a stainless steel surface, there might be

enough viable viral particles remaining after 2-8

hours to allow contact transmission to a susceptible person. It should be noted that this study was

conducted at a relative humidity of 35 to 40 percent, a level that favors the survival of influenza

viruses. Other studies have clearly demonstrated

that humidity plays a significant role in influenza

viral survival with survival times being longer at

lower humidity.

Further research is needed to more fully appreciate the role of contact transmission for various

strains of influenza and the effect of varying environmental conditions. Although it is assumed that

influenza spreads by contact transmission, the proportion of spread that occurs through this mechanism is unknown.16

Pandemic Influenza Transmission 

This section discusses observational studies on

human-to-human transmission during previous

influenza pandemics and observations about implications for transmission of current avian influenza

virus infections that are of concern for possible

future influenza pandemics.

Transmission, Past Pandemics 

One influenza transmission study conducted during

the 1957 pandemic indicated the importance of person-to-person spread while another suggested the

apparent importance of airborne transmission. The

first study, an epidemiological study demonstrated

influenza transmission from a newly hospitalized,

infected patient who had no isolation precautions

to three healthcare workers and one adjacent

patient. Ultimately, 30 of the 62 exposed patients

and ward staff became ill.22 Although the authors

did not address the likely mode of transmission, a

later analysis of the data was interpreted as not

consistent with a single source pattern as would be

seen in airborne transmission.17 The second study,

an observational influenza transmission study during the 1957 pandemic conducted at a Veterans

Administration Hospital suggested airborne transmission. The study compared the influenza illness

rates in tuberculosis patients in wards with and

without ultraviolet ceiling lights and found rates of

2 percent and 19 percent, respectively. The authors

of this study suggest this finding implies that transmission of influenza was significantly blocked by

radiant (UV) disinfection of droplet nuclei.23

Transmission, Possible Future Pandemics 

The influenza viruses that are currently of greatest

concern for possible future pandemics are the highly pathogenic avian influenza viruses, most notably

strains of H5N1 and H7N7, which have caused outbreaks among humans. 

A summary of the clinical features of hospitalized patients with highly pathogenic H5N1 avian

influenza described a clinical course that differed

from seasonal influenzas. The highly pathogenic

H5N1 avian influenza had an initial presentation

with lower respiratory tract symptoms and viral

pneumonia (seasonal influenzas present more

often with upper respiratory symptoms), a higher

ribonucleic acid detection in pharyngeal samples

(seasonal influenzas have higher viral detection in

nasal samples), and more frequent diarrhea,

abdominal pain, and vomiting. The detection of

infectious virus and ribonucleic acid in the blood,

cerebrospinal fluid (CSF) and feces of one patient, a

child,9 raises concern that transmission of this virus

may be possible by contact with blood, CSF and

feces in addition to respiratory secretions, but this

remains unknown. 

An outbreak of highly pathogenic H7N7 avian

influenza virus occurred in poultry farm employees

in the Netherlands in 2003.10 This influenza’s clinical

course was unique in that it was mainly associated

with conjunctivitis. Seasonal influenza transmission

is considered to take place primarily through the

respiratory tract, but the conjunctivitis component

of highly pathogenic H7N7 avian influenza suggests

that its transmission may also occur via the mucous

membranes of the eye.

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PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

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1 3

Treatment and Prevention

Treatment and prevention of influenza involves

multiple infection control measures, including vaccination, antiviral medications, and management of

influenza complications. This section concentrates

on immunization and antiviral medications. 

Seasonal Influenza Treatment and Prevention

Medications available for influenza A treatment and

prophylaxis include the M2 ion channel inhibitors

(also known as adamantanes) amantadine and

rimantadine and the neuraminidase inhibitors

zanamivir and oseltamivir. Presently, only the neuraminidase inhibitors are available for treatment

and prophylaxis of both influenza A and B. Current

HHS/CDC drug recommendations, announced during the 2005-2006 influenza season (see http://

www.cdc.gov/flu/han011406.htm), advise against

the use of adamantanes for seasonal influenza due

to resistance. Therefore, the neuraminidase

inhibitors oseltamivir and zanamivir are the only

drugs currently recommended for treatment and

prophylaxis of influenza. Neuraminidase inhibitors

are prescription drugs and they are most effective

for treatment when use begins within two days of

symptom onset. Clinicians should adhere to

HHS/CDC recommendations regarding the use of

antivirals.24

Antiviral medications can be used to prevent

influenza, but the primary strategy for preventing

influenza infections is vaccination. Vaccines are

available in two forms: 1) as an intranasal live

attenuated vaccine and 2) as an injectable, inactivated trivalent vaccine. Indications and contraindications differ among the preparations.25 Annual

vaccination has been shown to reduce the incidence of influenza infections in healthcare workers.25, 26, 27 Infection control measures are another

means to prevent infection, but their benefit is less

well established.

Pandemic Influenza Treatment and Prevention

The appropriate use of antiviral drugs during a

pandemic could reduce mortality and morbidity. At

the time of this writing, HHS recommendations for

treatment of novel viruses are to use the neuraminidase inhibitors zanamivir and oseltamivir

because of influenza resistance to amantadine and

rimantadine.24

Although the magnitude of drug effect against

infections with novel strains cannot be predicted

precisely, early use is expected to be important for

drug effectiveness. The availability of adequate

antiviral supplies during a pandemic is far from certain, and, therefore, the HHS Pandemic Influenza

Plan provides antiviral drug use priority recommendations. Healthcare workers are included in the priority group recommendations.28

A vaccine against a specific pandemic influenza

strain will likely not be available until after the pandemic begins. But vaccinations against seasonal

influenza during the WHO’s Interpandemic and

Pandemic Alert Period can reduce co-infections and

might ameliorate pandemic effects. HHS recommendations are for enhanced levels of seasonal

influenza vaccinations in groups at risk for severe

influenza and healthcare workers. In addition, HHS

recommends enhanced pneumococcal polysaccharide vaccination for some individuals.29 A limited

amount of H5N1 avian influenza vaccine is being

stockpiled. However, as the pandemic virus cannot

be predicted, it is unknown if stockpiled vaccine will

provide protection against a future circulating pandemic influenza virus. A monovalent vaccine is

expected to start becoming available within fourto-six months after identification of a specific pandemic virus strain. As noted above, the HHS

Pandemic Influenza Plan recommends that healthcare workers be included on the priority list (which

has not been fully defined) when the availability of

pandemic influenza vaccinations is limited.28, 29

References

1 Murphy B.R., R.G. Webster 1996. Orthomyxoviruses. In Fields Virology. Third Edition. Fields B.N.,

D.M. Knipe, P.M. Howley, editors. Philadelphia, PA:

Lippincott-Raven, New York. pp. 1397-445.

2 Perdue, M.L., D.E. Swayne. 2005. Public Health

Risk from Avian Influenza Viruses. Avian Dis 49:317-

327. September.

3 HHS. 2006. Pandemic Influenza Plan, Appendix C.

U.S. Department of Health and Human Services.

Last accessed April 12, 2006: http://www.hhs.gov/

pandemicflu/plan/appendixc.html.

4 CDC. 2005. Pandemic Influenza Key Facts. Centers

for Disease Control and Prevention. Last accessed

June 6, 2006: http://www.cdc.gov/flu/keyfacts.htm. 

5 HHS. 2005. Pandemic Influenza Plan, Supplement

1. U.S. Department of Health and Human Services.

Last accessed February 2, 2005: http://www.hhs.

gov/pandemicflu/plan/sup1.html.

6 HHS. 2005. Pandemic Influenza Plan, Supplement

5. U.S. Department of Health and Human Services.

Last accessed February 2, 2006: http://www.hhs.

gov/pandemicflu/plan/sup5.html.
19 Alford R.H., J.A. Kasel, V. Knight. 1966. Human

influenza resulting from aerosol inhalation. Proc

Soc Exp Biol Med 122(3):800-804.

20 Moser M.R., T.R. Bender, H.S. Margolis, G.R.

Nobel, A.P. Kendal, D.G. Ritter. 1979. An outbreak of

influenza aboard a commercial airliner. Am J

Epidemiol 110(1):1-6. July.

21 Bean, B., B.M. Moore, B. Sterner, L.R. Peterson,

D.N. Gerding, H.H. Balfour. 1982. Survival of influenza viruses on environmental surfaces. J Infect Dis

146(1):47-51. July.

22 Blumenfeld H.L., E.D. Kilbourne, D.B. Louria, D.F.

Rogers. 1959. Studies on influenza in the pandemic

of 1957-1958. I. An epidemiologic, clinical and serologic investigation of an intrahospital epidemic,

with a note on vaccination efficacy. J Clin Invest

38(1 Part 2):199-212. 

23 McLean R.L. 1961. General discussion. Am Rev

Respir Dis 83:36-8.

24 HHS. 2005. Pandemic Flu Plan, Supplement 7.

U.S. Department of Health and Human Services.

Last accessed February 20, 2006: http://www.hhs.

gov/pandemicflu/plan/sup7.html..

25 MMWR. 2006. Influenza vaccination of health

care personnel. Last accessed March 21, 2006:

http://www.cdc.gov/mmwr/preview/mmwrhtml/

rr5502a1.htm.

26 Wilde, J.A., et al. 1999. Effectiveness of Influenza

Vaccine in Health Care Professionals. JAMA March

10, 1999 – Vol 281, No. 10.

27 Salgado C.D., et al. 2004. Preventing Nosocomial

Influenza Infection by Improving the Vaccine

Acceptance Rate of Clinicians. Infection Control and

Hospital Epidemiology. 2004 Nov: 25(11):923-8.

28 HHS. 2005. Pandemic Influenza Plan, Appendix D.

U.S. Department of Health and Human Services.

Last accessed March 21, 2006: http://www.hhs.gov/

pandemicflu/plan/appendixd.html.

29 HHS. 2005. Pandemic Influenza Plan, Supplement

6. U.S. Department of Health and Human Services.

Last accessed March 21, 2006: http://www.hhs.gov/

pandemicflu/plan/sup6.html.

7 CDC. 2006. Influenza Clinical Description and

Diagnosis. Centers for Disease Control and Prevention. Last accessed February 2, 2006: http://

www.cdc.gov/flu/professionals/diagnosis/ 

8 HHS. 2005. Pandemic Influenza Plan, Appendix B.

U.S. Department of Health and Human Services.

Last accessed February 2, 2006: http://www.hhs.

gov/pandemicflu/plan/appendixb.html.

9 Beigel J.H., J. Farrar, A.M. Ham, et al. 2005. Avian

influenza A (H5N1) infection in humans. A/H5. N

Engl J Med 353(13):1374-85. 

10 Du Ry van Beest Holle M., et al. 2005. Human-tohuman transmission of avian influenza A/H7N7, the

Netherlands, 2003. Euro Surveill 1;10(12).

11 Walsh E.E., C. Cox, A.R. Falsey. 2002. Clinical features of influenza A virus infection in older hospitalized persons. J Am Geriatr Soc 50(9):1498-503.

September 8.

12 Monto A.S., S. Gravenstein, M. Elliot, M. Colopy,

J. Schweinle. 2000. Clinical signs and symptoms

predicting influenza infection. Arch Intern Med

160(21): 3243-7. November 27. Comments in Arch

Intern Med 161(10):1351-2.

13 HHS. 2005. Pandemic Influenza Plan. Supplement

2: Laboratory Diagnostics. U.S. Department of

Health and Human Services. Last accessed March

21, 2006: http://www.hhs.gov/pandemicflu/plan/

sup2.html.

14 CDC. 2005. Laboratory Diagnostic Procedures for

Influenza. Last accessed March 21, 2006: http://

www.cdc.gov/flu/professionals/labdiagnosis.htm.

15 MMWR. 2006. New laboratory assay for diagnostic testing of avian influenza A/H5. Morbidity and

Mortality Weekly Report (MMWR). Last accessed

March 21, 2006: http://www.cdc.gov/mmwr/

preview/mmwrhtml/mm5505a3.htm.

16 HHS. 2005. Pandemic Influenza Plan, Supplement

4. U.S. Department of Health and Human Services.

Last accessed February 20, 2005: http://www.hhs.

gov/pandemicflu/plan/sup4.html.

17 Bridges C.B., M.J. Kuehnert, C.B. Hall. 2003.

Transmission of influenza: implications for control

in health care settings. Clin Infect Dis 37(8):1094-

1101. 

18 Schulman J.L. 1967. Experimental transmission

of influenza virus infection in mice: IV. Relationship

of transmissibility of different strains of virus and

recovery of airborne virus in the environment of

infector mice. J Exp Med 125(3):479-88.

1 4

Occupational Safety and 

Health Administration
Guideline for Isolation Precautions in Hospitals

website at http://www.cdc.gov/ncidod/dhqp/gl_

isolation.html. 

Standard Precautions

Standard precautions should be used for all

patients receiving care, regardless of their diagnosis or presumed infection status. Standard precautions apply to (1) blood; (2) all body fluids, secretions, and excretions except sweat, regardless of

whether or not they contain visible blood; (3) nonintact skin; and (4) mucous membranes. Standard

precautions are designed to reduce the risk of

transmission of microorganisms from both recognized and unrecognized sources of infection in

healthcare settings. 

A risk assessment to determine necessary PPE

and work practices to avoid contact with blood,

body fluids, excretions, and secretions will help to

customize standard precautions to the healthcare

setting of interest. Standard precautions include:

• The use of gloves and facial (nose, mouth, and

eye) protection by healthcare workers when

providing care to coughing/sneezing patients. 

• Hand hygiene before and after patient contact,

and after removing gloves or other PPE.

Routine hand hygiene is performed either by

using an alcohol-based hand rub (preferably)

or by washing hands with soap and water and

using a single-use towel for drying hands. If

hands are visibly dirty or soiled with blood or

other body fluids, or if broken skin might have

been exposed to infectious material, healthcare

workers should wash their hands thoroughly

with soap and water. 

• Standard operating procedures to handle and

disinfect patient care equipment, patient rooms,

and soiled linen; prevent needlestick/sharp

injuries; and address environmental cleaning,

spills-management, and handling of waste.

Poor compliance with standard precautions

among healthcare workers has been well described

in the scientific literature.3 Additionally, it has not

been the routine practice of healthcare workers in

many healthcare facilities to wear facial protection

or to encourage respiratory hygiene among patients.

Implementation and enforcement of all standard

precautions, including appropriate use of facial

(eyes, nose, and mouth) protection when caring for

respiratory patients, should be prioritized in all

healthcare facilities in order to mitigate pandemic

influenza transmission.

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

1 5

Infection Control

A successful infection control program for pandemic influenza utilizes the same strategies implemented for any infectious agent, including facility and

environmental controls (i.e., engineering controls),

standard operating procedures (i.e., administrative

controls), personal protective clothing and equipment, and safe work practices. These strategies

form the basis of standard precautions and transmission-based precautions. Given that the exact

transmission pattern or patterns will not be known

until after the pandemic influenza virus emerges,

transmission-based infection control strategies may

have to be modified to include additional selections

of engineering controls, personal protective equipment (PPE), administrative controls, and/or safe

work practices.

The infection control section of this document

includes information about standard precautions

and transmission-based precautions as they relate

to the protection of healthcare workers.

Standard Precautions and 

Transmission-Based Precautions 

Standard precautions are designed for the care of

all patients, regardless of their diagnosis or presumed infection status. Transmission-based precautions are used for patients known or suspected to

be infected or colonized with epidemiologically

important pathogens that can be transmitted by airborne, droplet, or contact transmission. Some

infectious agents require the application of several

types of precautions to prevent transmission. For

example, HHS/CDC recommends that standard,

contact, and airborne precautions be implemented

when caring for patients with varicella infection.1, 2

Initially designed for the hospital setting, standard

precautions and transmission-based precautions

can be applied to a variety of healthcare settings,

including the outpatient environment, the pre-hospital setting, and alternate care sites. 

The infectious characteristics of pandemic

influenza will not be known until after it emerges.

Consequently, infection control plans will have to

be adapted to the current knowledge of transmission and updated as new information becomes

available. The Department of Health and Human

Services (HHS) and its partners will provide updated epidemiologic information and infection control

guidance at www.pandemicflu.gov. For a more

complete discussion of standard precautions and

transmission-based precautions, visit the HHS/CDC

Infection Control
Contact Precautions

In addition to standard precautions, contact precautions are indicated for patients known or suspected

to have serious illnesses easily transmitted by

direct patient contact or by contact with items in

the patient’s environment. In addition to standard

precautions, contact precautions include: 

• Putting on PPE (such as gowns) prior to entry

into a patient room and taking off PPE prior to

exit.

• Dedicating patient care equipment.

• Limiting patient movement.

• Placing the patient in a private room or with

patients who have active infection with the

same microorganism or who are suspected to

have active infection with the same microorganism but with no other infection (cohorting).

Some studies have shown contact transmission

of human influenza. However, the importance of

this transmission route remains unknown. Contact

precautions are necessary during aerosol-generating procedures or when contact with infectious fluids is anticipated. Whether full contact precautions

are indicated depends on the transmission pattern

of the emerging pandemic influenza strain. If the

pandemic virus is associated with diarrhea, contact

precautions should be added.4

Droplet Precautions

Droplet precautions are indicated for patients

known or suspected to have serious illnesses transmitted by large particle droplets, such as seasonal

influenza, invasive Haemophilus influenzae type b

disease and invasive Neisseria meningitidis. In

addition to standard precautions, droplet precautions include the use of a surgical mask when working within 3 feet of the patient and the placement of

the patient in a private room or with patients who

have an active infection with the same microorganism but with no other infection (cohorting). 

Although human seasonal influenza virus is transmitted primarily by contact with infectious droplets,

some degree of airborne transmission occurs.

Additionally, droplet precautions do not protect

healthcare workers from infections resulting from

aerosol transmission or during patient care activities

that are likely to generate infectious aerosols, such as

sputum induction or bronchoscopy.

Airborne Precautions

Airborne Precautions are designed to reduce the

risk of airborne transmission of infectious agents. In

addition to standard precautions, airborne precautions are used for patients known or suspected to

1 6

Occupational Safety and 

Health Administration

have serious illnesses. Current clinical guidelines

recommend that airborne precautions be used for

such illnesses as H5N1 avian influenza, severe

acute respiratory syndrome (SARS), measles, varicella, and tuberculosis.1, 5, 6

Airborne precautions include:

• Place patient in a negative pressure room (airborne infection isolation room) or area, if available. 

• If a negative pressure room is not available or

cannot be created with mechanical manipulation of the air, place patient in a single room.

• If a single room is not available, patients may

be cohorted in designated multi-bed rooms or

wards.

• Doors to any room or area housing patients

must be kept closed when not being used for

entry or egress.

• When possible, isolation rooms should have

their own handwashing sink, toilet, and bath

facilities.

• The number of persons entering the isolation

room should be limited to the minimum number necessary for patient care and support. 

• HHS/CDC recommends the use of a particulate

respirator that is at least as protective as a

National Institute for Occupational Safety and

Health (NIOSH)-certified N95.1, 2 For a more

complete discussion of respirator use during

an influenza pandemic, see the section

Respiratory Protection for Pandemic Influenza

on page 27.

Airborne precautions against a respiratory illness

should be implemented, as availability permits,

when the circulating pathogen is known to cause

severe disease, and the transmission characteristics

of the infecting organism are not well characterized. 

For patients for whom influenza is suspected or

diagnosed, surveillance, vaccination, antiviral

agents, and use of private rooms as much as feasible is recommended.7 In contrast to tuberculosis,

measles, and varicella, the pattern of disease

spread for seasonal influenza does not suggest

transmission across long distances (e.g., through

ventilation systems); therefore, negative pressure

rooms are not needed for patients with seasonal

influenza.8 Many hospitals encounter logistic difficulties and physical limitations when admitting

multiple patients with suspected influenza during

community outbreaks. If sufficient private rooms

are unavailable, consider cohorting patients or, at

the very least, avoid room-sharing with high-risk

patients. For additional information regarding the
airborne infection isolation rooms, see the section

Airborne Infection Isolation Rooms on page 19.

Compliance with Infection Control

Healthcare administrators should emphasize those

aspects of infection control already identified as

“weak links” in the chain of infectious precautions—adherence to hand hygiene, consistent and

proper use of PPE, and influenza vaccination of

healthcare workers. The following section describes

factors influencing compliance with infection control measures. Healthcare employers and employees should work together address

these factors and enhance compliance with infection control recommendations. 

Hand Hygiene Compliance

Although handwashing is wellknown as a critical factor for infection control, low rates of healthcare

worker compliance have been well

documented. The HHS/CDC

Healthcare Infection Control

Practices Advisory Committee (HICPAC), in collaboration with the

Society for Healthcare Epidemiology

of America (SHEA), the Association

for Professionals in Infection Control

and Epidemiology (APIC), and the

Infectious Diseases Society of

America (IDSA) reviewed 33 studies

from 1981 to 2000. They concluded

that adherence of healthcare workers to recommended hand hygiene

procedures has been poor, with

mean baseline rates of 5 - 81 percent and an overall average of 40 percent.3 

Several factors influence adherence to hand

hygiene practices, including

• Being a physician or a nursing assistant, rather

than a nurse

• Wearing gowns/gloves

• Understaffing and overcrowding

• Handwashing agents that cause irritation and

dryness

• Lack of knowledge of guidelines

• Perceived lack of institutional priority for hand

hygiene

It is important to recognize that healthcare workers report compliance with hand hygiene recommendations despite observations to the contrary.

Recognition of the factors that influence compliPANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

1 7

ance to hand hygiene practices is important in

order to enable healthcare employers to prioritize

and customize compliance strategies. These strategies should be implemented to promote hand

hygiene and may include staff education, reminders

in the workplace and routine observation and feedback. 

Appendix B contains extended information

regarding risk factors for non-compliance with

hand hygiene recommendations and strategies for

successful promotion of hand hygiene. For a more

complete discussion of the recommendations for

hand hygiene and the scientific evidence, see the HHS/CDC Guideline

for Hand Hygiene in Healthcare

Settings at http://www.cdc.gov/handhygiene/. 

Respiratory Protection

Compliance

Studies have shown that healthcare

worker compliance rates with respiratory protection are highly variable.9, 10

Healthcare workers fail to wear

respirators for a number of reasons,

and it is important to understand the

nature of this resistance in order to

overcome it. The following are the

most frequently cited reasons for

not wearing respirators:11

1. They are hot and uncomfortable.

2. They produce “pain spots” if

poorly fitted.

3. They interfere with communication and performance.

4. They are not easily accessible

when you need them.

5. They put the burden of safety on the wearer

rather than the company.

6. They make the wearer look “funny,” alarmist, not

macho, or unattractive.

7. They produce labored breathing, increased heart

rate, and perspiration.

8. They impair vision and can actually be a safety

hazard.

9. They produce feelings of claustrophobia and

anxiety.

The National Institute for Occupational Safety

and Health (NIOSH) has published a guide that provides guidance on developing and implementing a

respiratory protection program in the healthcare setting, TB Respiratory Protection Program in Health

Care Facilities, September 1999, accessible at http://

www.cdc.gov/niosh/99-143.html. Initially intended

Key Messages 

Recognition of the factors

that influence compliance

with with infection control

practices is important in

order to enable healthcare

employers to prioritize

and customize compliance

strategies. 

Compliance strategies

may include staff education, reminders in the

workplace and routine

observation and feedback. 

Healthcare employers and

employees should work

together to develop an

institutional safety climate

that encourages compliance with recommended

infection control practices.
• Cleanliness and orderliness of the worksite

• Minimal conflict and good communications

among staff

• Frequent safety-related feedback and training

by supervisors

• Availability of PPE and engineering controls16

This scale is available in the original reference

and may be useful to assess problem areas of an

institutional safety climate and increase adherence

to infection control practices. Healthcare employers and employees should work together to develop an institutional safety climate that encourages

compliance with recommended infection control

practices. 

Facility Design, Engineering, and

Environmental Controls

Engineering controls are the preferred method to

reduce transmission of

infectious aerosols in areas

used to house or evaluate

patients with respiratory illness. The appropriate use of

engineering controls and

other control efforts will

require frequent analysis of

pandemic influenza transmission patterns in designated wards, in the facility,

and in the community.

Existing healthcare facility layouts should be evaluated for potential enhancements of infection control.

A SARS investigation in

Ontario17 noted that hospitals designed with open,

public spaces encountered

logistical difficulties and

great expense in their efforts

to control entry and, therefore, to control introduction

of infectious diseases.

Hospitals had an inadequate

number of isolation rooms

and negative pressure

rooms. Triage areas were

designed to streamline patient flow and enhance

patient satisfaction, rather than to prioritize infection isolation or healthcare worker protection. 

A desirable emergency room design includes a

triage area that can be closed off as an isolation

area, in the event of inadvertent contamination.

1 8

Occupational Safety and 

Health Administration

for protection against tuberculosis, the guidance can

be adapted to address a variety of infectious

pathogens, including pandemic influenza.

Healthcare employers should work hard to overcome employee resistance to wearing respirators

and promote full compliance with the respiratory

protection program. Strategies should be implemented to promote respirator use, such as staff

education, reminders in the workplace and routine

observation and feedback. 

Organizational Factors that Affect 

Adherence to Infection Control

Lessons from the SARS outbreak showed that the

most important factors affecting healthcare worker

perceptions of risk and adherence to infection control practices were healthcare workers’ perception

that their facilities had clear policies and protocols,

having adequate training in infection control procedures, and having specialists

available.12

In a study among 1,716

hospital-based healthcare

workers, Gershon et al.

(1995) found that employees who perceived a strong

commitment to safety at

their workplace were over

2.5 times more likely to

comply with universal precautions.13 Another study of

nurses found that the perception of PPE interference

with work was the strongest

predictor of failure to comply

with universal precautions.14

The same researchers examined the relative importance

of safety climate, the availability of PPE, and individual

employee characteristics as

determinants of compliance

with universal precautions.

Safety climate was found to

have the greatest association

with proper infection control

behaviors.15

Gershon et al. (2000)

developed a safety climate scale (46 questions) to

measure six different areas of a hospital safety climate: 

• Senior management support for safety programs

• Absence of workplace barriers to safe work

practices 

Key Messages

An influenza pandemic will increase the

demand for hospital inpatient and intensive care unit beds and assisted ventilation

services.

Infectious disease and disaster management experts have predicted the need to

use schools, stadiums, and other converted settings in the event of a pandemic that

results in severe disease.

The National Strategy for Pandemic

Influenza calls for communities to anticipate large-scale augmentation of existing

healthcare facilities. 

Limit admission of influenza patients to

those with severe complications of influenza who cannot be cared for outside the

hospital setting. 

Admit patients to either a single-patient

room or an area designated for cohorting

of patients with influenza.

If possible, and when practical, use of an

airborne isolation room may be considered when conducting aerosol-generating

procedures.
Isolation areas should have adjacent rooms for staff

to put on and take off scrubs, and to take showers.

Facility planning should include storage space for

augmented infection control items, including

durable goods such as ventilators, portable highefficiency particulate air (HEPA) filtration units,

portable x-ray units, and respirators.

Thoughtful facility design includes rest and recuperation sites for responders. These sites can be

stocked with healthy snacks and relaxation materials (e.g., music and movies), as well as pamphlets

or notices about workforce support services.

Facility Capacity

An influenza pandemic may increase the demand

for hospital inpatient and intensive care unit beds

and assisted ventilation services by more than 25

percent.18 Toronto clinicians reported that the intensive care unit capacity was a key factor that determined the number of SARS patients that could be

managed. It was determined that approximately 20

percent of SARS patients required intensive care;

therefore, a maximum number of SARS patients

per facility could be calculated.19

HHS/CDC provided instructions that allow public

health officials to estimate the demand for hospital

resources and to estimate the number of deaths,

both for a 1968-type of influenza pandemic and for

a 1918-type of pandemic.20 FluAid 2.0 and FluSurge

2.0 software estimate the number of deaths, hospitalizations, outpatient visits, and the increased

demand for hospital resources (e.g., beds, intensive

care, or ventilators for both scenarios). For additional information see Appendix A.

Alternate care sites may be developed at federal

or state discretion to ease the burden of care on

healthcare facilities. For additional information

regarding alternate care sites, see section Alternate

Care Sites on page 47.

Engineering Controls in Improvised Settings

Infectious disease and disaster management

experts have predicted the need to use schools, stadiums, and other converted settings in the event of

a pandemic that results in severe disease. The

National Strategy for Pandemic Influenza21 calls for

communities to anticipate large-scale augmentation

of existing healthcare facilities. 

During the SARS outbreak of 2004, the North

York General Hospital in Toronto converted two

nearly constructed hospital wings into SARS wards.

Additionally, a tent clinic was built on an ambulance loading dock to triage the general public presenting with possible SARS. A more detailed

description of the converted healthcare settings,

including the implementation of engineering of

controls, is available in Loutfy et al. 2004.19

Airborne Infection Isolation Rooms

Although the need to isolate patients with highly

pathogenic infections is a central tenet of infection

control, a large percentage of U.S. hospitals have

no isolation rooms. Only 61.7 percent of hospitals

responding to the American Hospital Association

2004 annual survey reported having an airborne

infection isolation room.22

Airborne infection isolation rooms receive

numerous air changes per hour (ACH) (>12 ACH for

new construction as of 2001; >6 ACH for construction before 2001), and is under negative pressure,

such that the direction of the air flow is from the

outside adjacent space (e.g., the corridor) into the

room. The air in an airborne infection isolation

room is preferably exhausted to the outside, but

may be recirculated provided that the return air is

filtered through a high-efficiency particulate air

(HEPA) filter. 

For more information, consult the HHS/CDC

Guidelines for Environmental Infection Control in

Health Care Facilities, available at http://www.cdc.

gov/ncidod/dhqp/gl_environinfection.html.

For care of pandemic influenza patients in the

hospital:4

• Limit admission of influenza patients to those

with severe complications of influenza who

cannot be cared for outside the hospital setting. 

• Admit patients to either a single-patient room

or an area designated for cohorting of patients

with influenza. 

• If possible, and when practical, use of an airborne isolation room may be considered when

conducting aerosol-generating procedures.

Engineering Controls for AerosolGenerating Procedures for Patients 

with Pandemic Influenza

If possible, and when practical, use of an airborne

isolation room may be considered when conducting aerosol-generating procedures,4, 6 such as the

following:

• Endotracheal intubation

• Aerosolized or nebulized medication administration

• Diagnostic sputum induction/collection

• Bronchoscopy

• Airway suctioning

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1 9
• Positive pressure ventilation via face mask

(e.g., BiPAP and CPAP)

• High-frequency oscillatory ventilation

If a negative pressure room is not available, the following strategies may be considered. However,

there is only limited scientific evidence to support

these strategies:6, 23, 24

• Perform the procedure in a private room, separated from other patients.

• If possible, increase air changes, increase negative pressure relative to the hallway, and

avoid recirculation of the room air.

• If recirculation of the air is unavoidable, pass

the air through a HEPA filter before recirculation.

• Keep doors closed except when entering or

leaving the room, and minimize entry to and

exit from the room.

Cohorting

If single rooms are not available, patients infected

with the same organisms can be cohorted (share

rooms). These rooms should be in a well-defined

area that is clearly separated from other patient

care areas used for uninfected patients. 

During a pandemic, other respiratory viruses

(e.g., non-pandemic influenza, respiratory syncytial

virus, parainfluenza virus) may be circulating concurrently in a community. Therefore, to prevent

cross-transmission of respiratory viruses, whenever

possible assign only patients with confirmed pandemic influenza to the same room. Management of

cohort areas should incorporate the following:4

• Designated areas should be used for cohorting

pandemic influenza-infected patients. At the

height of a pandemic, laboratory testing to

confirm pandemic influenza is likely to be limited, in which case cohorting should be based

on having symptoms consistent with pandemic influenza. Suspected cases of pandemic

influenza should be housed separately from

confirmed cases of pandemic influenza.

• Whenever possible, healthcare workers assigned to cohorted patient care units should be

experienced healthcare workers and should

not “float” or be assigned to other patient care

areas.

• The number of persons entering the cohorted

area should be limited to the minimum number necessary for patient care and support.

• Limit patient transport by having portable x-ray

equipment available in cohort areas, if possible.

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Occupational Safety and 

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• Healthcare workers assigned to cohorted

patient care units should be aware that pandemic influenza-infected patients may be concurrently infected or colonized with other pathogenic organisms (e.g., Staphylococcus aureus

and Clostridium difficile) and should use

standard and applicable transmission-based

infection control precautions to prevent transmission of healthcare-associated infections.

Engineering Controls in Diagnostic and

Research Laboratories

During the Pandemic Alert Period, specimens from

suspected cases of human infection with novel

influenza viruses should be sent for testing to public health laboratories with proper biocontainment

facilities. For example, reverse transcriptase polymerase chain reaction (RT-PCR) can be done in a

Biosafety Level 2 laboratory but highly pathogenic

avian influenza and highly pathogenic pandemic

influenza virus isolation should be conducted in a

Biosafety Level 3 laboratory with enhancements or

higher as dictated by an appropriate risk assessment.

Additional information on laboratory biocontainment is provided in the HHS publication Biosafety

in Microbiological and Biomedical Laboratories.

25

Pneumatic tube systems are not advisable to transport specimens that may contain a highly pathogenic, live virus. Guidelines on when to send specimens or isolates of suspected novel avian or

human strains to HHS/CDC for reference testing are

available in Appendix 3 of the HHS Pandemic

Influenza Plan at http://www.hhs.gov/pandemicflu/

plan/sup2.html#app3.26 The American Society for

Microbiology maintains a list of emergency contacts in state public health laboratories.27

Autopsy Rooms for Cases 

of Pandemic Influenza

Safety procedures for pandemic influenza-infected

human bodies should be consistent with those

used for any autopsy procedure with potentially

infected remains. In general, the hazards of working

in the autopsy room seem to depend more on contact with infected material, particularly with splashes on body surfaces, than to inhalation of infectious

material. However, if the pandemic influenza-infected patient died during the infectious period, the

lungs may still contain virus and additional respiratory protection is needed during procedures performed on the lungs or during procedures that generate small-particle aerosols (e.g., use of power

saws and washing intestines). 
Specimens should be hand delivered where

possible. Pneumatic tube systems are not advisable

to transport specimens that may contain a highly

pathogenic, live virus. For additional information

about specimen collection, visit WHO’s website at

http://www.who.int/csr/disease/avian_influenza/

guidelines/humanspecimens/en/index.html. 

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2 1

Protective autopsy settings for pandemic

influenza-infected humans include the use of an airborne infection isolation room (see the section

Airborne Infection Isolation Rooms on page 19).

Exhaust systems around the autopsy table should

direct air (and aerosols) away from healthcare

workers performing the procedure (e.g., exhaust

downward). It is important to use containment

devices whenever possible (e.g., biosafety cabinets

for the handling of smaller specimens). Therefore,

an examiner conducting postmortem exams of

pandemic influenza-infected patients will use airborne precautions, including a particulate respirator, as is recommended for postmortem exams of

avian influenza-infected patients and SARS-infected

patients.28

Administrative Controls

Respiratory Hygiene/Cough Etiquette

Respiratory hygiene/cough etiquette, procedures

should be used for all patients with respiratory

symptoms (e.g., coughing and sneezing). The

impact of covering coughs and sneezes and placing

a mask on a coughing/sneezing patient on the containment of respiratory droplets and secretions or

on the transmission of respiratory infections has

not been quantified. However, any measure that

limits the dispersion of respiratory droplets should

reduce the opportunity for transmission. Masking

some patients may be difficult, in which case the

emphasis should be on cough etiquette. The elements of cough etiquette are listed below.

For additional information, see Respiratory

Hygiene/Cough Etiquette in Healthcare Settings

at http://www.cdc.gov/flu/professionals/infection

control/resphygiene.htm.

Pandemic Influenza Specimen Collection 

and Transport

All human specimens of secretions and excretions

should be regarded as potentially infectious.

Healthcare workers who collect or transport clinical

specimens should consistently adhere to recommended infection control precautions to minimize

their exposure. Potentially infectious specimens

should be placed in leakproof specimen bags for

transport, labeled or color coded for transport and

handled by personnel who are familiar with safe

handling practices and spill clean-up procedures.

Healthcare workers who collect specimens from

pandemic-infected patients should also wear PPE

as described for employees performing direct

patient care. 

Respiratory Hygiene/Cough Etiquette

Educate persons with respiratory illness and

coughing or sneezing to:

• Cover their mouths and noses with a tissue

and dispose of used tissues in no-touch

waste containers.

• Use a mask when tolerated, especially during periods of increased respiratory infection activity in the community.

• Perform hand hygiene after contact with

respiratory secretions and contaminated

objects or materials (e.g., handwashing

with soap and water, alcohol-based hand

rub, or antiseptic handwash).

• Stand or sit at least 3 feet from other persons, if possible.

Healthcare facilities should promote respiratory hygiene by:

• Posting signs requesting that patients and

family members immediately report symptoms of respiratory illness on arrival to the

facility and use cough etiquette.

• Posting signs requesting that persons with

respiratory illness refrain from visiting the

healthcare facility if they are not seeking

medical treatment.

• Providing conveniently located masks, tissues, and alcohol-based hand rubs for waiting areas and patient evaluation areas to

facilitate source control.

• Providing no-touch receptacles for used tissue disposal.

• Ensuring that supplies for handwashing

(i.e., soap, disposable towels) are consistently available where sinks are located.

• Educating healthcare workers, patients,

family members, and visitors on the importance of containing respiratory droplets and

secretions to help prevent transmission of

influenza and other infections.
Patient Transport within Healthcare Facilities

Influenza-infected patients’ respiratory secretions

are the principle source of infectious material in

healthcare settings. Maintaining source control of

patient secretions will limit the opportunities for

nosocomial (in hospital) transmission. The following methods of source control are consistent with

those recommended for other serious respiratory

infections (e.g., SARS, avian influenza, and tuberculosis).4, 28,29 

• Surgical and procedure masks are appropriate

for use by pandemic influenza-infected patients

to contain respiratory droplets and should be

worn by suspected or confirmed pandemic

influenza-infected patients during transport or

when care is necessary outside of the isolation

room/area.

• Limit the movement and transport of patients

from the isolation room/area for essential purposes only. Inform the receiving area/facility as

soon as possible, prior to the patient’s arrival,

of the patient’s diagnosis and of the precautions that are indicated. Use mobile diagnostic

services (e.g., mobile X-ray and CT scan) when

available.

• If transport outside the isolation room/area is

required, the patient should wear a surgical

mask and perform hand hygiene after contact

with respiratory secretions.

• If the patient cannot tolerate a mask (e.g., due

to the patient’s age or deteriorating respiratory

status), instruct the patient (or parent of pediatric patient) to cover the nose and mouth with

a tissue during coughing and sneezing, or use

the most practical alternative to contain respiratory secretions. If possible, instruct the

patient to perform hand hygiene after respiratory hygiene. 

• Identify appropriate paths, separated from

main traffic routes as much as possible, for

entry and movement of pandemic influenza

patients in the facility, and determine how

these pathways will be controlled (e.g., dedicated pandemic influenza corridors and elevators).

• If there is patient contact with surfaces, these

surfaces should be cleaned and disinfected.

• Healthcare workers transporting unmasked

patients with suspected or confirmed pandemic influenza-infected patients should wear an

N95 or higher NIOSH-certified respirator. 

Pre-Hospital Care and Patient Transport

Outside Healthcare Facilities 

During an influenza pandemic, patients will still

require emergency transport to a healthcare facility.

The recommendations in the table on page 23 are

designed to protect healthcare workers, including

emergency medical services personnel, during prehospital care and transport. These recommendations can be instituted when patients are identified

as having symptoms consistent with an influenzalike illness or routinely, regardless of symptoms,

when pandemic influenza is in the community.

Staff Education and Training 

It is incumbent upon healthcare employers to educate employees about the hazards to which they

are exposed and to provide reasonable means by

which to abate those hazards. The independent

SARS Commission established by the government

of Ontario noted that many healthcare staff were

not adequately trained in protecting themselves

against infectious agents. The Commission noted

deficiencies in safety training and the proper use of

personal protective equipment.30

Effective staff training is consistent with facility

policies and reinforces infection control strategies.

Support from the healthcare institution at the top

management and supervisory levels is essential for

a successful program. Examples of educational

goals and objectives for pandemic infection control

strategies include: 

• Educate healthcare workers about recommended infection control precautions for suspected

or confirmed pandemic influenza-infected

patients. At a minimum, healthcare workers

should follow contact and droplet precautions

for all patients with acute respiratory illness.

• Ensure that clinicians know where and how to

promptly report a pandemic influenza case to

hospital and public health officials.

• Communicate planning strategies that address

when confirmed pandemic influenza-infected

patients have been admitted to the facility,

nosocomial surveillance should be heightened

for evidence of transmission to other patients

and staff. 

• Educate healthcare workers and visitors on the

correct use of PPE and hand hygiene.

• Recommended steps for placement and

removal of PPE and performance of hand

hygiene.

• Appropriate procedures to select a particulate

respirator that fits well.

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Occupational Safety and 

Health Administration

(continued on page 24)
PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

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2 3

*The Sentinel Provider Network definition of influenza-like illness is fever (>100°F or 37.8°C) and sore throat

and/or cough in the absence of a known cause other than influenza.

Screen all patients for influenza-like 

illness.* 

If influenza is suspected, implement the 

following strategies:

• Optimize the vehicle’s ventilation to

increase the volume of air exchange during transport. The vehicle’s ventilation system should be operated in the non-recirculating mode and should bring in as

much outdoor air as possible.

• When possible, use vehicles that have

separate driver and patient compartments

that can provide separate ventilation to

each area. In this situation, drivers do not

require particulate respirators.

• Educate healthcare workers engaged in

medical transport about the risks of

aerosol-generating procedures.

• Notify the receiving facility as soon as

possible, prior to arrival, that a patient

with suspected pandemic influenza infection is being transported to the facility and

of the precautions that are indicated.

• Minimize the opportunity for contamination of supplies and equipment inside the

vehicle (e.g., ensure that all cabinetry

remains closed during transport). 

• Continue to follow standard infection control procedures, such as standard precautions, recommended procedures for waste

disposal and standard practices for disinfection of the emergency vehicle and

patient care equipment. 

• If tolerated by the patients, place a surgical

mask on all patients with respiratory illness to contain droplets expelled during

coughing. If this is not possible (i.e.,

would further compromise respiratory status, or is difficult for the patient to wear),

have the patient cover the mouth and

nose with a tissue when coughing, or use

the most practical alternative to contain

respiratory secretions.

• Healthcare workers transporting patients

with influenza-like illness should use a respirator (N95 or higher). If respirators are

not available, healthcare workers should

wear a surgical mask. 

Without relying on patient screening,

routinely implement the following strategies:

• Optimize the vehicle’s ventilation to

increase the volume of air exchange during transport. The vehicle’s ventilation system should be operated in the non-recirculating mode and should bring in as

much outdoor air as possible.

• When possible, use vehicles that have

separate driver and patient compartments

that can provide separate ventilation to

each area. In this situation, drivers do not

require particulate respirators.

• Educate healthcare workers engaged in

medical transport about the risks of

aerosol-generating procedures.

• Notify the receiving facility as soon as

possible, prior to arrival, that a patient

with suspected pandemic influenza infection is being transported to the facility and

of the precautions that are indicated.

• Minimize the opportunity for contamination of supplies and equipment inside the

vehicle (e.g., ensure that all cabinetry

remains closed during transport). 

• Continue to follow standard infection control procedures, such as standard precautions, recommended procedures for waste

disposal and standard practices for disinfection of the emergency vehicle and

patient care equipment.

• Consider routine use of surgical or procedure masks for all patients during transport when pandemic influenza is in the

community.

• Healthcare workers transporting patients

should use a respirator (N95 or higher). If

respirators are not available, healthcare

workers should wear a surgical mask. 

Personal Protective Equipment Administrative Controls Engineering Controls
• Train persons who will be likely to use particulate respirators on how to put them on and

how to perform user seal checks.

• Provide respiratory etiquette educational materials and supplies to coughing individuals.

• Train infection control monitors to observe and

correct deficiencies in healthcare worker and

visitor adherence to proper hygiene and PPE

use. 

• Use simulations (i.e., “table top” or other exercises) to test the facility’s response capacities.

The exercise should be realistic and should

continue until limiting factors and deficiencies

are identified.

• Develop risk communication materials for

healthcare workers, patients, and patient families/visitors.

Staff education and training should be available in

formats accessible to individuals with disabilities

and/or limited English proficiency; and should also

target the educational level of the intended audience.

Care of the Deceased 

Follow standard facility practices for care of the

deceased. Practices should include standard precautions for contact with blood and body fluids. For

more information regarding care of deceased, see

Avian Influenza, Including Influenza A (H5N1), in

Humans: WHO Interim Infection Control Guideline

For Health Care Facilities, April 24, 2006, available

at: http://www.who.int/csr/disease/avian_influenza/

guidelines/infectioncontrol1/en/.

Patient Discharge

If the patient is discharged while possibly still infectious, family members should be educated on hand

hygiene, cough etiquette, the use of a surgical or

procedure mask by a patient who is still coughing

and any additional infection control measures identified in forthcoming guidance or recommendations. Updated guidance and recommendations will

be posted on www.pandemicflu.gov whenever they

become available.

Visitor Policies

Visitors should be strictly limited to those necessary for the patient’s well-being and care, and

should be advised about the possible risk of acquiring infection. Care of patients in isolation becomes

a challenge when there are inadequate resources,

or when the patient has poor hygienic habits, deliberately contaminates the environment, or cannot be

expected to assist in maintaining infection control

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Occupational Safety and 

Health Administration

precautions to limit transmission of microorganisms (e.g., children, patients with an altered mental

state, or elderly persons). Such patients should be

managed on a case-by-case basis, balancing the

rights of the patient with the risk they may present

to others. 

• Visitors should be provided PPE to comply

with recommended precautions and should

be instructed on how to properly put on, take

off, and dispose of PPE. They should also be

instructed on proper hand hygiene practices

prior to entry to the patient isolation room/

area.

• Communication of policies and procedures to

visitors should be available in formats accessible to individuals with disabilities and/or limited English proficiency; and should also target

the educational level of the intended audience.

• Legal guardians of pediatric patients should

be allowed, when possible, to accompany the

patient throughout the hospitalization.

• Parents/relatives/legal guardians may assist in

providing care to pandemic influenza-infected

patients in special situations (e.g., lack of

resources, pediatric patients, etc.) if adequate

training and supervision of PPE use and hand

hygiene is ensured.

• Because family members may have been

exposed to pandemic influenza via the patient

or similar environmental exposures, all family

members and visitors should be screened for

symptoms of respiratory illness upon entry to

the facility.

• Symptomatic family members or visitors

should be considered possible pandemic

influenza cases and should be evaluated for

pandemic influenza infection.

Healthcare Worker Vaccination

An influenza pandemic occurs when a new version

of an influenza virus develops the capability to

infect humans and to spread easily and rapidly

between people. Sometimes such new virus versions come from influenza viruses that previously

affected only birds or animals, but which have

mutated and thus have developed the capabilities

to infect humans and spread easily among

humans.

It is believed that humans will initially have little,

if any, immunity to a pandemic influenza virus and,

therefore, that everyone will be susceptible to infection. The HHS Pandemic Influenza Plan assumes

that one in five working adults will experience clinical disease in a pandemic influenza outbreak.18 It
also presumes that, in an affected community, a

pandemic outbreak will last about 6 to 8 weeks

with at least two pandemic disease waves likely to

occur. 

Influenza vaccination is the most effective

method currently available to prevent people from

getting infected. During outbreaks of seasonal

influenza, vaccination against that season’s influenza subtypes usually prevents infection. If infection

is not fully prevented, a vaccination may lessen the

severity of the resulting illness.

Once a new type of influenza virus emerges, it

usually takes four to six months to produce a vaccine for that virus, using currently available vaccine

production methods. There may be limited or no

pandemic influenza vaccine available for administration to individuals in the first six months or

longer during a pandemic. However, HHS plans to

work with the pharmaceutical industry to produce

and stockpile up to 20 million courses of vaccine

against each circulating influenza virus with pandemic potential during the pre-pandemic period.31

Stockpiled vaccine will be designated for personnel

who perform critical and essential functions.

Medical and public health employees who are

involved in direct patient contact and other support

services essential for direct patient care are likely to

be given high priority for receipt of stockpiled vaccine.32

Annual seasonal influenza immunization rates

among healthcare workers in the United States

remain low; coverage among healthcare workers in

2003 was 40.1 percent.33 Therefore, to diminish

absence due to illness, it is advisable for healthcare

facilities to encourage and/or provide seasonal

influenza vaccination for their staff, including volunteers, yearly, during the months of October and

November. 

Vaccination strategy recommendations for healthcare facilities in preparation for or in response to a

pandemic influenza outbreak include:34

• Promote annual seasonal influenza vaccination

among staff and volunteers.

• Communicate with state and local health

departments as to the availability of stockpiles

of vaccine for the specific pandemic influenza

subtype and follow federal and local recommendations for administering the vaccine to

healthcare workers.

• Plan for rapid vaccination of healthcare workers as recommended by federal agencies and

state health departments, if vaccine for the

pandemic influenza virus becomes available.

• Have a system for documentation of influenza

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

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2 5

vaccination of healthcare workers, since vaccination for pandemic influenza may require two

doses.

Antiviral Medication for Prophylaxis and

Treatment in Healthcare Workers

The HHS Pandemic Influenza Plan assumes that

oseltamivir will be the antiviral medication of

choice in the event of an outbreak of pandemic

influenza.31 It assumes that supplies will be limited31

and that the primary source of oseltamivir will be

from federal stockpiles. Oseltamivir can be used to

treat persons who are diagnosed with influenza;

however, for optimal effectiveness, the treatment

should be initiated within 48 hours of the onset of

flu-like symptoms. 

Oseltamivir may also be used prophylactically to

decrease the chance of infection in persons, such

as healthcare workers, who have had exposure to

pandemic influenza patients. Information on the

advisability of using other antiviral medications

during an influenza pandemic will be determined

and communicated after the susceptibility of the

causative viral subtype has been studied. 

Healthcare facilities should maintain contact

with federal and local health departments concerning the availability of antiviral medications and the

recommendations to administer antiviral medications as treatment or as prophylaxis to healthcare

workers and emergency medical personnel who

have direct patient contact.34 Regardless of the

availability of antiviral medication, it should not be

used in lieu of a full infection control program.

• When considering antiviral prophylaxis, be

sure to evaluate appropriate candidates for

contraindications, answer their questions,

review adverse effects, and explain the risks

and benefits.

• Maintain a log of persons on antiviral medications, persons evaluated and not receiving prophylaxis, doses dispensed, and adverse effects.

• Periodically evaluate and update antiviral prophylaxis policies and procedures.

Occupational Medicine Services

Employee Protection

Transmission in healthcare facilities was a major

factor in the spread of SARS during the 2003 global

epidemic. Factors that likely contributed to the disproportionate rate of transmission in healthcare

settings included (1) exposure to infectious droplets

and aerosols via use of ventilators, nebulizers,

endotracheal intubation, and other procedures and
(2) frequent and prolonged close contact of employees to patients, their secretions, and potentially

contaminated environments.35 Case recognition and

implementation of appropriate precautions greatly

reduced the risks of SARS transmission. However,

even with appropriate precautions, there were isolated reports of transmission to healthcare workers

in the settings of aerosol-producing procedures and

lapses in infection control techniques.29

Healthcare workers are also members of the

community, and during seasonal influenza outbreaks their infectious illnesses may or may not be

related to workplace infectious exposures. Seasonal

vaccines will not protect against pandemic influenza, but will help prevent concurrent infection with

seasonal influenza and pandemic influenza, which

will minimize the possibility of reassortment of the

virus. Protective levels of antibodies are usually

detectable 2 to 4 weeks after vaccination with seasonal influenza vaccine. In addition, healthcare

workers who provide direct patient care may be

exposed to pandemic influenza viruses. These

employees should be monitored for illness and

supported as needed.

Recommendations for Occupational 

Health Administrators 

Protecting healthcare workers benefits both the community and the individual employee. Comprehensive

occupational health programs can limit transmission

from infected employees and allow them to continue

working while their services are in extreme demand.

Surveillance Activities

• Keep a register of healthcare workers who

have provided care for pandemic influenzainfected patients (confirmed or probable

cases).

• Keep a register of healthcare workers who

have recovered from pandemic influenza (confirmed or probable cases).

• Have a healthcare worker influenza-like illness

surveillance system in the healthcare facility,

including encouragement for self-reporting by

symptomatic healthcare workers.

• Have a system to monitor work absenteeism

for health reasons, especially in healthcare

workers providing direct patient care. 

• Screen all healthcare workers providing care to

pandemic influenza-infected patients for

influenza-like symptoms before each daily

shift. Symptomatic healthcare workers should

be evaluated and excluded from duty.

• Clinical employees believed to have had significant clinical exposure to a highly pathogenic

influenza strain should be evaluated; counseled about the risk of transmission to others;

and monitored for fever, respiratory symptoms, sore throat, rhinorrhea (runny nose),

chills, rigors, myalgia, headache, and diarrhea.

Vaccination and Antivirals

• Vaccinate healthcare workers against seasonal

influenza and monitor compliance. 

• Coordinate with public health officials for local

policy on antiviral prophylaxis of healthcare

workers and assistance for obtaining adequate

supplies of neuraminidase inhibitors for prophylaxis of healthcare workers providing care

for pandemic influenza-infected patients.28

Develop a system to provide neuraminidase

inhibitors to healthcare workers exposed to

pandemic influenza-infected patients according

to local and national policies.

Occupational Medical Surveillance and

Staffing Decisions

Occupational health played a major role in determining which healthcare workers should return to

work during the SARS outbreaks.19 In future outbreaks, individual risk assessment and fitness for

duty determinations should be accomplished more

efficiently with the support of updated staff medical

records and with serologic testing results, if available.

• If possible, perform serologic and other testing

for pandemic influenza on healthcare workers

with influenza-like illness and who have had

likely exposures to pandemic influenza-infected

patients.

• Healthcare workers with serological evidence

of pandemic influenza infection should have

protective antibodies against this strain and

can be prioritized for the care of pandemic

influenza patients. These employees could

also be prioritized to provide care for patients

who are at risk for serious complications from

influenza (e.g., transplant patients and neonates).

However, be aware that subsequent “waves”

of influenza infection may be caused by a different influenza strain.

• Some healthcare workers have an increased

risk of complications due to pandemic influenza (e.g., pregnant women, immunocompromised persons and persons with respiratory

diseases). Care should be taken to provide

appropriate education, training and policies

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Occupational Safety and 

Health Administration
that comply with federal, state and local laws

to adequately protect these employees.

• Healthcare workers who are ill should not be

involved in direct patient care since they may

be more vulnerable to other infections and

may be more likely to develop severe illness if

infected with pandemic influenza. In addition,

ill healthcare workers can transmit their illness

to vulnerable patients.

Personal Protective Equipment 

Gloves

HHS recommends the use of gloves made of latex,

vinyl, nitrile, or other synthetic materials as appropriate, when there is contact with blood and other

bodily fluids, including respiratory secretions. 

• There is no need to double-glove. 

• Gloves should be removed and discarded

after patient care. 

• Gloves should not be washed or reused. 

• Hand hygiene should be done after glove

removal. 

Because glove supplies may be limited in the

event of pandemic influenza, other barriers such as

disposable paper towels should be used when

there is limited contact with respiratory secretions,

such as handling used facial tissues. Hand hygiene

should be practiced consistently in this situation.4

Gowns4

• Healthcare workers should wear an isolation

gown when it is anticipated that soiling of

clothes or uniform with blood or other bodily

fluids, including respiratory secretions, may

occur. HHS states that most routine pandemic

influenza patient encounters do not necessitate

the use of gowns. Examples of when a gown

may be needed include procedures such as

intubation or when closely holding a pediatric

patient.

• Isolation gowns can be disposable and made

of synthetic material or reusable and made of

washable cloth. 

• Gowns should be the appropriate size to fully

cover the areas requiring protection.

• After patient care is performed, the gown

should be removed and placed in a laundry

receptacle or waste container, as appropriate.

Hand hygiene should follow.

Goggles/Face Shields 

The HHS Pandemic Influenza Plan does not recommend the use of goggles or face shields for routine

contact with patients with pandemic influenza;

however, if sprays or splatters of infectious material

are likely, it states that goggles or a face shield

should be worn as recommended for standard precautions.4 For additional information about eye protection for infection control, visit NIOSH’s website

at http://www.cdc.gov/niosh/topics/eye/eyeinfectious.html.

If a pandemic influenza patient is coughing, any

healthcare worker who needs to be within 3 feet of

the infected patient is likely to encounter sprays of

infectious material. Eye and face protection should

be used in this situation, as well as during the performance of aerosol-generating procedures.

Respiratory Protection for Pandemic Influenza

While droplet transmission is likely to be the major

route of exposure for pandemic influenza, as is the

case with seasonal influenza, it may not be the only

route. Given the potential severity of health consequences (illness and death) associated with pandemic influenza, a comprehensive pandemic

influenza preparedness plan should also address

airborne transmission to ensure that healthcare

workers are protected against all potential routes of

exposure. Establishment of a comprehensive respiratory protection program with all of the elements

specified in OSHA’s Respiratory Protection standard

(29 CFR 1910.134) is needed to achieve the highest

levels of protection. Additional information on the

Respiratory Protection standard is included in

Appendix C in this document. More information on

the elements of a comprehensive respiratory protection program and the use of respirators can be

found at http://www.osha.gov/SLTC/respiratoryprotection/index.html.

Healthcare workers are at risk of exposure to airborne infectious agents, including influenza. For

some types of airborne infectious agents (such as

SARS), healthcare workers are not only at risk for

illness but may become a potential source of infection to patients and others. Selection of appropriate

respiratory PPE requires an understanding of the

airborne infectious agents, their infectious and

aerodynamic properties, the operating characteristics of the PPE, and the behaviors and characteristics of the healthcare workers using the PPE. Many

different types of respiratory PPE are available to

protect healthcare workers, each with a different set

of advantages and disadvantages. 

There will continue to be uncertainty about the

modes of transmission until the actual pandemic

influenza strain emerges. It is expected that there

will be a worldwide shortage of respirators if and

when a pandemic occurs. Employers and employPANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

2 7
and the person’s face. A proper seal between the

user’s face and the respirator forces inhaled air to

be pulled through the respirator’s filter material and

not through gaps between the face and respirator.

Surgical masks, however, are not designed to seal

tightly against the user’s face. During inhalation,

potentially contaminated air can pass through gaps

between the face and the surgical mask, thus

avoiding being pulled through the material of the

mask and losing any filtration that it may provide. 

When personal protective equipment is necessary to protect against droplet transmission of

infectious agents, employees must place a barrier

between the source of the droplet (e.g., a sneeze)

and their mucosal surfaces. Such protection could

include a surgical mask to cover the mouth and

nose and safety glasses to cover the eyes. Recent

studies show that aerosol penetration through a

surgical mask is highly dependent on particle size,

mask construction, and breathing flow rate. One

study showed that penetration rates for submicron

particles could be as high as 80 percent for surgical

masks.36 Even relatively unconventional uses (e.g.,

the wearing of multiple surgical masks) have been

shown to be less protective than NIOSH-certified

respirators. For example, research has shown that

the use of up to five surgical masks worn by volunteers results in particle reduction of only 63 percent

for one mask, 74 percent for two masks, 78 percent

for three masks, and 82 percent for five masks,

compared with a recommended reduction of at

least 95 percent for properly fitted N95 respirators.37

To help employers and employees better understand respirators, the following paragraphs discuss

their construction, classification, and use. 

Respirators

A respirator is a personal protective device that is

worn on the face, covers at least the nose and

mouth, and is used to reduce the wearer’s risk of

inhaling hazardous gases, vapors, or airborne particles (e.g., dust or droplet nuclei containing infectious agents). The many types of respirators available include: 

• Particulate respirators that filter out airborne

particles. 

• “Gas masks” that filter out chemical gases and

vapors. 

• Airline respirators that use a hose/pipe to provide a flow of clean air from a remote source.

• Self-contained breathing apparatus that provide clean air from a compressed air tank worn

by the user. 

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Occupational Safety and 

Health Administration

ees should not count on obtaining any additional

protective equipment not already purchased and

stockpiled. Therefore, it is important for healthcare

facilities to consider respiratory protection for

essential personnel to assure that employees are

ready, willing, and able to care for the general population. 

Surgical Masks and Respirators

Although some disposable respirators look similar

to surgical masks, it is important that healthcare

workers understand the significant functional difference between disposable respirators and surgical

masks.

• Respirators are designed to reduce an individual’s exposure to airborne contaminants, such

as particles, gases, or vapors. An air-purifying

respirator accomplishes this by filtering the

contaminant out of the air before it can be

inhaled by the person wearing the respirator.

A type of respirator commonly found in healthcare workplaces is the filtering facepiece particulate respirator (often referred to as an “N95”).

It is designed to protect against particulate hazards. Since airborne biological agents such as

bacteria or viruses are particles, they can be filtered by particulate respirators. To assure a

consistent level of performance, the respirator’s filtering efficiency is tested and certified

by NIOSH. 

• In comparison, surgical masks are not

designed to prevent inhalation of airborne contaminants. Their ability to filter small particles

varies greatly and cannot be assured to protect

healthcare workers against airborne infectious

agents. Instead, their underlying purpose is to

prevent contamination of a sterile field or work

environment by trapping bacteria and respiratory secretions that are expelled by the wearer

(i.e., protecting the patient against infection

from the healthcare worker). Surgical masks

are also used as a physical barrier to protect

the healthcare worker from hazards such as

splashes of blood or bodily fluids. When both

fluid protection (e.g., blood splashes) and respiratory protection are needed, a “surgical

N95” respirator can be used. This respirator is

approved by FDA and certified by NIOSH.

Another important difference in protecting healthcare workers from airborne infectious agents is the

way respirators and surgical masks fit the user’s

face. Respirators are designed to provide a tight

seal between the sealing surface of the respirator
In addition, filters in this family are given a designation of N, R, or P to convey their ability to function in the presence of oils. 

“N” if they are Not resistant to oil. 

“R” if they are somewhat Resistant to oil.

“P” if they are strongly resistant (i.e., oilProof). 

This rating is important in work settings where

oils may be present because some industrial oils

can degrade the filter performance to the point that

it does not filter adequately. (Note: This is generally

not an issue in healthcare facilities.) Thus, the three

filter efficiencies combined with the three oil designations leads to nine types of particulate respirator

filter materials:

Recent HHS/CDC infection control guidance documents provide recommendations that healthcare

workers protect themselves from diseases potentially spread through the air by wearing a fit tested

respirator at least as protective as a NIOSH-certified

N95 respirator. Employees can wear any of the particulate respirators for protection against diseases

spread through the air, if they are NIOSH-certified

and if they have been properly fit tested and maintained. As noted above, NIOSH-certified respirators

are marked with the manufacturer’s name, the part

number, the protection provided by the filter, and

“NIOSH.”

Employees who will be exposed to respiratory

hazards other than airborne infectious agents

(e.g., gases) should consult the NIOSH Respirator

Selection Logic for more detailed guidance on

appropriate respiratory protection at http://www.

cdc.gov/niosh/docs/2005-100/default.html.

Particulate respirators can be divided into several types:

• Disposable or filtering facepiece respirators,

where the entire respirator facepiece is comprised of filter material. It is discarded when it

becomes unsuitable for further use due to

excessive breathing resistance (e.g., particulate

clogging the filter), unacceptable contamination/soiling, or physical damage.

• Reusable or elastomeric respirators, where the

facepiece is cleaned, repaired, and reused, but

the filter cartridges are discarded and replaced

when they become unsuitable for further use. 

• Powered air-purifying respirators, where a battery-powered blower pulls contaminated air

through filters, then moves the filtered air to

the wearer.

All respirators used by employees are required

to be tested and certified by NIOSH. NIOSH uses

very high standards to test and approve respirators

for occupational uses. NIOSH-certified particulate

respirators are marked with the manufacturer’s

name, the part number, the protection provided by

the filter (e.g., N95), and “NIOSH.” This information

is printed on the facepiece, exhalation valve cover,

or head straps. If a respirator does not have these

markings and does not appear on one of the following lists, it has not been certified by NIOSH.

A list of all NIOSH-certified disposable respirators is available at http://www.cdc.gov/niosh/npptl/

respirators/disp_part/particlist.html. NIOSH also

maintains a database of all NIOSH-certified respirators regardless of respirator type (the Certified

Equipment List), which can be accessed at http://

www.cdc.gov/niosh/celintro.html. 

Classifying Particulate Respirators and 

Particulate Filters

An N95 respirator is one of nine types of particulate

respirators. Particulate respirators are also known

as “air-purifying respirators” because they protect

by filtering particles out of the air as you breathe.

Particulate respirators protect only against particles—not gases or vapors. Since airborne biological

agents such as bacteria or viruses are particles,

they can be filtered by particulate respirators. 

Respirator filters that remove at least 95 percent

of airborne particles, during “worst case” testing

using the “most-penetrating” size of particle, are

given a 95 rating. Those that filter out at least 99

percent of the particles under the same conditions

receive a 99 rating, and those that filter at least

99.97 percent (essentially 100 percent) receive a 100

rating.

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

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2 9

Particulate

Respirator

Filter Type

N95

N99

N100

R95

R99

R100

P95

P99

P100

Percentage

(%) of 

0.3 μm 

airborne

particles 

filtered 

out

95

99

99.97

95

99

99.97

95

99

99.97

Not

resistant

to oil

X

X

X

Somewhat

resistant 

to oil

X

X

X

Strongly

resistant 

to oil 

(oilproof)

X

X

X
Replacing Disposable Respirators

Once worn in the presence of an infectious patient,

the respirator should be considered potentially contaminated with infectious material, and touching

the outside of the device should be avoided. Upon

leaving the patient’s room, the disposable respirator should be removed and discarded, followed by

proper hand hygiene. 

If a sufficient supply of respirators is not available during a pandemic, healthcare facilities may

consider reuse as long as the device has not been

obviously soiled or damaged (e.g., creased or torn),

and it retains its ability to function properly. Data

on reuse of respirators for infectious diseases are

not available. Reuse may increase the potential for

contamination; however, this risk must be balanced

against the need to provide respiratory protection

for healthcare workers.

Reuse of a disposable respirator should be limited to a single wearer (i.e., another wearer should

not use the respirator). Consider labeling respirators with a user’s name before use to prevent reuse

by another individual. 

If disposable respirators need to be reused by an

individual user after caring for infectious patients,

employers should implement a procedure for safe

reuse to prevent contamination through contact

with infectious materials on the outside of the respirator. 

One way to address contamination of the respirator’s exterior surface is to consider wearing a

faceshield that does not interfere with the fit or seal

over the respirator. Wearers should remove the barrier upon leaving the patient’s room and perform

hand hygiene. Face shields should be cleaned and

disinfected. After removing the respirator, either

hang it in a designated area or place it in a bag.

Store the respirator in a manner that prevents its

physical and functional integrity from being compromised. 

In addition, use care when placing a used respirator on the face to ensure proper fit for respiratory

protection and to avoid unnecessary contact with

infectious material that may be present on the

outside of the mask. Perform hand hygiene after

replacing the respirator on the face.

Exhalation Valves

Some filtering facepiece (and all elastomeric) respirators come equipped with an exhalation valve,

which can reduce the physiologic burden on the

user by reducing the resistance during exhalation.

An exhalation valve may also increase the user’s

comfort by reducing excessive dampness and

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Occupational Safety and 

Health Administration

warmth in the mask from exhaled breath. The valve

opens to release exhaled breath and closes during

inhalation so that inhaled air comes through the filter. Healthcare workers may wear respirators with

exhalation valves unless the patient has a medical

condition (such as an open wound) for which a

healthcare worker would normally wear a surgical

mask to protect the patient. Similarly, respirators

with exhalation valves should not be placed on a

patient to contain droplets and prevent spread of

infectious particles; surgical masks can be used for

this purpose. 

Powered Air-Purifying Respirators

Powered air-purifying respirators use HEPA filters,

which are as efficient as P100 filters and will protect

against airborne infectious agents. Powered airpurifying respirators provide a higher level of protection than disposable respirators. Healthcare facilities have used higher levels of respiratory protection, including powered air-purifying respirators, for

persons present during aerosol-generating medical

procedures, such as bronchoscopy, on patients

with infectious pulmonary diseases. When powered

air-purifying respirators are used, their reusable elements should be cleaned and disinfected after use

and the filters replaced in accordance with the manufacturer’s recommendations. All used filters

should be considered potentially contaminated with

infectious material and must be safely discarded.

Powered air-purifying respirators may also increase

the comfort for some users by reducing the physiologic burden associated with negative pressure respirators and providing a constant flow of air on the

face. In addition, there is no need for fit testing of

loose-fitting hood or helmet models.

Special Considerations for Pandemic Preparedness

If employers prepare appropriately, respiratory protection against pandemic influenza will be more

effective. Establishment of a comprehensive respiratory protection program with all of the elements

specified in OSHA’s Respiratory Protection standard

(29 CFR 1910.134) is needed to achieve the highest

levels of protection. (See the section OSHA

Standards of Special Importance on page 50 and

Appendix C-1 of this document) Acquiring adequate supplies of appropriate respirators, ensuring

that they fit key personnel, conducting appropriate

training, and performing other aspects of respiratory protection can be accomplished in advance of a

pandemic influenza outbreak. These measures

should be repeated annually, prior to a pandemic

being declared, to assure continued preparedness.
If this is done, and the virus has an element of airborne transmission, the likelihood that employees

will be effectively protected will be increased.

• Protection against pandemic influenza requires

a comprehensive approach that includes both

hygienic practices (e.g., handwashing and

cough etiquette) and respiratory protection.

• Surgical masks are not considered adequate

respiratory protection for airborne transmission of pandemic influenza. However, FDAcleared surgical masks are fluid resistant and

may be used for barrier protection against

splashes and large droplets.

• Respiratory protection requires the use of a

NIOSH-certified respirator and implementation

of a comprehensive respiratory protection program that considers the following:

• Use NIOSH-certified respirators that are N95

or higher. When both fluid protection (e.g.,

blood splashes) and respiratory protection are

needed, use a “surgical N95” respirator that

has been certified by NIOSH and cleared by

the FDA. 

• Consider elastomeric respirators for essential

employees who may have to decontaminate

and reuse respirators in the event that there is

a shortage of disposable respirators.

• Consider powered air-purifying respirators for

essential employees who may have to decontaminate and reuse respirators, wear respirators for prolonged periods of time, be

exposed to high-risk procedures (e.g., bronchoscopy), or work in high-risk environments.

Loose-fitting hooded powered air-purifying

respirators have the additional advantage of

not requiring fit testing.

• Employers, especially those whose employees

are likely to be highly exposed to the flu virus

(e.g., healthcare workers), should develop

and implement a plan, train employees, and

purchase/stockpile respiratory protection in

advance for use during a pandemic since there

will likely be shortages of necessary equipment

during a real pandemic.

For more information regarding the use of respirators and surgical masks during a pandemic see,

Interim Guidance on Planning for the Use of

Surgical Masks and Respirators in Health Care

Settings during an Influenza Pandemic at http://

www.pandemicflu.gov/plan/healthcare/ 

maskguidancehc.html.

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

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3 1

PPE for Aerosol-Generating Procedures 

During procedures that may generate increased

small-particle aerosols of respiratory secretions,

healthcare personnel should wear gloves, gowns,

face/eye protection, and N95 respirators, surgical

N95 respirators or other appropriate particulate respirators. Respirators must be used within the context of a respiratory protection program that

includes a written program, fit testing, medical

clearance, and training (see the section OSHA

Standards of Special Importance and Appendix C-1

for more information). Consider the use of an airborne isolation room when conducting aerosolgenerating procedures, whenever possible.4

Examples of procedures that generate aerosols

include:6

• Endotracheal intubation

• Aerosolized or nebulized medication administration

• Diagnostic sputum induction

• Bronchoscopy

• Airway suctioning

• Positive pressure ventilation via face mask

(e.g., BiPAP and CPAP)

• High-frequency oscillatory ventilation

Additional procedures that may result in aerosolization of respiratory secretions are listed in the

World Health Organization (WHO) document, Avian

Influenza, including Influenza A (H5N1), in Humans:

WHO Interim Infection Control Guideline for Health

Care Facilities Annex 4 at http://www.who.int/csr/

disease/avian_influenza/guidelines/infection 

control1/en/. 

Order for Putting on and Removing PPE

Based on the risk assessment, several items of PPE

may be needed by healthcare workers when entering the room of a patient infected with known or

suspected pandemic influenza. 

When PPE is necessary for the specific situation,

HHS/CDC recommends that personal protective

equipment be put on in the following order:38

• Gown

• Respirator (or mask, when appropriate)

• Face shield or goggles

• Gloves

Upon leaving the room, HHS/CDC recommends

that PPE be removed in a way to avoid self-contamination, as follows:38

• Gloves 

• Faceshield or goggles
gloves and other PPE.

• Healthcare facility leaders should make adherence to hand hygiene an institutional priority.

Other Hygienic Measures 

Healthcare workers working with pandemic influenza patients should also take care to:4

• Avoid touching their eyes, nose, or mouth with

contaminated hands (gloved or ungloved) to

avoid self-inoculation with the pandemic

influenza virus. 

• Avoid contaminating environmental surfaces

that are not directly related to patient care such

as light switches and doorknobs.

Facility Hygiene—Practices and Polices

When handling supplies and equipment contaminated with blood and other potentially infectious

materials, employees must comply with OSHA’s

Bloodborne Pathogens standard.

Dishes and Eating Utensils

Standard precautions are recommended for handling dishes and eating utensils used by a patient

with known or suspected pandemic influenza.4

• Healthcare workers, including housekeeping

staff, should wear gloves when handling pandemic influenza patients’ trays, dishes, and

utensils.

• The healthcare facility should wash reusable

dishes and utensils in a dishwasher at the recommended water temperature.

• If disposable dishes and utensils are used,

these may be discarded with other general

waste.

For information regarding recommended water

temperatures, consult the Guidelines for

Environmental Infection Control in Health-Care

Facilities at http://www.cdc.gov/ncidod/dhqp/

gl_environinfection.html. 

Linens and Laundry

The following precautions are recommended for

handling linens and laundry that might be contaminated with respiratory secretions from patients with

pandemic influenza:4

• Healthcare workers should place soiled linen

directly into a laundry bag in the patient’s room.

The linen should be contained in a manner that

prevents the bag from opening during transport

and while in the soiled linen holding area.

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Occupational Safety and 

Health Administration

• Gown

• Respirator or mask

Remember to always use hand hygiene after

removing PPE. A printable poster on the sequences

for putting on and taking off PPE, which can be

used for employee training and can be posted outside respiratory isolation rooms, is available at

http://www.cdc.gov/ncidod/sars/ic.htm.

Work Practices

Hand Hygiene 

To reduce the risk of becoming infected with influenza, healthcare workers working with influenza

patients should follow rigorous hand hygiene

measures. The HHS/CDC Guideline for Hand

Hygiene in Healthcare Settings provides the recommendations for hand hygiene and the scientific

support for the recommendations at http://www.

cdc.gov/handhygiene. 

Basic hand hygiene recommendations that help

protect healthcare workers working with influenza

patients are:3, 4 

• Healthcare facilities should ensure that sinks

with warm and cold running water, plain or

antimicrobial soap, disposable paper towels,

and alcohol-based hand disinfectants are readily accessible in areas where patient care is provided.

• When hands are visibly dirty or contaminated

with respiratory secretions, wash hands with

soap (either non-antimicrobial or antimicrobial)

and water.

• When washing hands with soap and water, wet

hands first with water, apply the amount of

product recommended by the manufacturer to

hands, and rub hands together vigorously for

at least 15 seconds, covering all surfaces of the

hands and fingers. Rinse hands with water and

dry thoroughly with a disposable towel. Use a

disposable towel to turn off the faucet.

• If hands are not visibly soiled, use an alcoholbased hand rub for routinely decontaminating

hands in all clinical situations including contact, whether gloved or ungloved, with an

influenza patient.

• When decontaminating hands with an alcoholbased hand rub, apply product to the palm of

one hand and rub hands together, covering all

surfaces of hands and fingers, until hands are

dry. Follow the manufacturer’s recommendations regarding the amount of product to use. 

• Always use hand hygiene after removing
• Healthcare workers should wear gloves and

gowns when directly handling soiled linen and

laundry (e.g., bedding, towels, and personal

clothing), as per standard precautions. There

should be no shaking or handling of soiled

linen and laundry in a manner that might create an opportunity for disease transmission or

contamination of the environment. 

• Healthcare workers should wear gloves when

transporting bagged linen and laundry. 

• Healthcare workers should perform hand

hygiene after removing gloves that have been

in contact with soiled linen and laundry. 

• The healthcare facility should ensure that

linens and laundry are washed and dried in

accordance with infection control standards

and procedures. 

For additional information, see the section Laundry

and Bedding, in Guidelines for Environmental

Control in Health-Care Facilities at http://www.cdc.

gov/ncidod/dhqp/gl_environinfection.html. 

Patient Care Equipment 

To protect healthcare workers, standard practices

for handling and reprocessing used patient care

equipment, including medical devices, should be

followed.4

• Healthcare workers should wear gloves when

handling and transporting used patient care

equipment. 

• Healthcare workers should wipe heavily soiled

equipment with a U.S. Environmental Protection

Agency (EPA)-approved hospital disinfectant

before removing it from the patient’s room and

follow current recommendations for cleaning

and disinfection or sterilization of reusable

patient care equipment. 

• Healthcare workers should wipe external surfaces of portable equipment (e.g., for performing x-rays and other procedures) in the patient’s

room with an EPA-approved hospital disinfectant upon removal from the patient’s room.

For additional information, see the section

Environmental Services, in Guidelines for

Environmental Control in Health-Care Facilities at

http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html.

Environmental Cleaning and Disinfection

Healthcare workers should use precautions when

cleaning the rooms of pandemic influenza patients

or of influenza patients who have been discharged

or transferred.4

Cleaning and Disinfection of Patient-Occupied Rooms 

• Wear gloves in accordance with facility policies

for environmental cleaning.4

• Wear a surgical mask in accordance with

droplet precautions.4 Use a respirator when airborne precautions are warranted by the circumstances.

• Gowns are usually not necessary for routine

cleaning of an influenza patient’s room.4

However, a gown must be worn when cleaning

a patient’s room if soiling of the employee’s

clothes or uniform with blood or other potentially infectious materials may occur. 

• Wear face and eye protection if cleaning within

3 feet of a coughing patient. 

• Keep areas within 3 feet of the patient free of

unnecessary supplies and equipment to facilitate daily cleaning.4

• Use any EPA-registered hospital detergent-disinfectant.4

• Give special attention to frequently touched

surfaces (e.g., bedrails, bedside and over-bed

tables, TV controls, call buttons, telephones,

lavatory surfaces including safety/pull-up bars,

doorknobs, commodes, and ventilator surfaces) in addition to floors and other horizontal

surfaces.4

Cleaning and Disinfection after Patient Discharge

or Transfer 4

• Follow standard facility procedures for postdischarge cleaning of an isolation room. 

• Clean and disinfect all surfaces that were in

contact with the patient or might have become

contaminated during patient care. 

Disposal of Solid Waste 4

Standard precautions are recommended by HHS

for disposal of solid waste (medical and non-medical) that might be contaminated with a pandemic

influenza virus. 

• Contain and dispose of contaminated medical

waste in accordance with facility procedures

and/or local or state regulations for handling

and disposal of medical waste, including used

needles and other sharps, and non-medical

waste.

• Discard used patient care supplies that are not

likely to be contaminated (e.g., paper wrappers) as routine waste.

• Healthcare workers should wear disposable

gloves when handling waste and should practice hand hygiene after removal of gloves.

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

3 3
Laboratory Practices

Follow standard facility and laboratory practices for

the collection, handling, and processing of laboratory specimens.4 Follow airborne precautions when

engaging in aerosol-generating procedures for

specimen collection, such as diagnostic sputum

induction.

References

1 HHS. Centers for Disease Control and Prevention,

Atlanta, Georgia. Garner JS, Hospital Infection

Control Practices Advisory Committee. Guideline

for isolation precautions in hospitals. Infect Control

Hosp Epidemiol 1996; 17:53-80.

2 Garner JS, Guideline for isolation precautions in

hospitals. Part I. Evolution of isolation practices,

Hospital Infection Control Practices Advisory

Committee. Am J Infect Control 1996; 24:24-52.

3 HHS. Centers for Disease Control and Prevention

(CDC) Guideline for Hand Hygiene in Health-Care

Settings. MMWR. October 25, 2002/51 (RR16); 1-44.

4 HHS. 2005. Pandemic Influenza Plan, Supplement

4. U.S. Department of Health and Human Services.

Last accessed February 20, 2005:

www.hhs.gov/pandemicflu/plan/sup4.html.

5 CDC, Interim Recommendations for Infection

Control in Healthcare Facilities Caring for Patients

with Known or Suspected Avian Influenza, May 21,

2004, http://www.cdc.gov/flu/avian/professional/

infect-control.htm.

6 HHS. CDC, Public Health Guidance for

Community-Level Preparedness and Response to

Severe Acute Respiratory Syndrome (SARS)

Version 2 Supplement I: Infection Control in

Healthcare, Home, and Community Settings, III.

Infection Control in Healthcare Facilities May 3,

2005 accessed 4/11/2006 at http://www.cdc.gov/ ncidod/sars/guidance/I/healthcare.htm.

7 HHS. Centers for Disease Control and Prevention

(CDC) Guidelines for the Prevention of Health-CareAssociated Pneumonia. MMWR, March 26, 2004 /

53(RR-03);1-36.

8 HHS. Interim Guidance on Planning for the Use of

Surgical Masks and Respirators in Health Care

Settings during an Influenza Pandemic. October

2006. Accessed 3/7/07 at www.pandemicflu.gov/

plan/healthcare/maskguidancehc.html.

9 Kellerman SE, Saiman L, San Gabriel P, Besser R,

Jarvis WR. Observational study of the use of infection control interventions for Mycobacterium tuberculosis in pediatric facilities. Pediatr Infect Dis J.

2001 Jun;20(6):566-70.

3 4

Occupational Safety and 

Health Administration

10 Ofner-Agostini, et al., Cluster of Cases of Severe

Acute Respiratory Syndrome Among Toronto

Healthcare Workers After Implementation of

Infection Control Precautions: A Case Series Infect

Control Hosp Epidemiol 2006; 27: 473-478.

11 HHS. Public Health Service, Centers for Disease

Control and Prevention, National Institute for

Occupational Safety and Health, TB Respiratory

Protection Program in Health Care Facilities

Administrator’s Guide, September 1999.

12 Imai, et al., SARS risk perceptions in healthcare

workers, Japan. Emerg Infect Disease 2005; 11: 404-

410.

13 Gershon RRM, et al. Compliance with universal

precautions among health care workers at three

regional hospitals. Am J Infect Control 1995;23:225-

36.

14 DeJoy DM, et al. The influence of employee,

job/task, and organizational factors on adherence to

universal precautions among nurses. Int J Ind

Ergon 1995;16:43-55.

15 DeJoy DM, et al. Behavioral-diagnostic analysis of

compliance with universal precautions among

nurses. J Occup Health Psychol 2000;5:127-41.

16 Gershon RR, et al. Hospital safety climate and its

relationship with safe work practices and workplace

exposure incidents. Am J Infect Control 2000;28:

211-21.

17 SARS Key Learnings from the Perspective of

University Health Network, Notes for the Campbell

Commission, Available at:

http://www.uhn.ca/uhn/corporate/community/docs/

campbell_presentation_100103.pdf. 

18 HHS. Pandemic Influenza Plan, Part 1, Strategic

Plan, November 2005 Available at http://www.hhs.

gov/pandemicflu/plan/part1.html.

19 Loutfy, et al., Hospital Preparedness and SARS,

Emerg Inf Dis, Vol. 10, No. 5, May 2004. p 771-776.

20 Centers for Disease Control and Prevention,

Instructions to Estimate the Potential Impact of the

Next Influenza Pandemic Upon Locale Y, Available

at http://www.cdc.gov/flu/pandemic/impactestimate.htm; accessed 6/19/06.

21 National Strategy for Pandemic Influenza:

Implementation Plan, November 2005, Available at

http://www.whitehouse.gov/homeland/pandemicinfluenza-implementation.html. 

22 AHA Hospital Statistics 2006 edition, Health

Forum LLC.
31 HHS. 2005. Pandemic Influenza Plan. Part II. Sup

7. November.

32 HHS. 2005. Pandemic Influenza Plan, Appendix D.

U.S. Department of Health and Human Services.

Last accessed March 21, 2006: www.hhs.gov/pandemicflu/plan/appendixd.html.

33 Centers for Disease Control and Prevention (CDC).

Interventions to increase influenza vaccination of

healthcare workers—California and Minnesota.

MMWR Morb Mortal Wkly Rep. 4;54(8):196-9, Mar

2005. www.cdc.gov/mmwr/preview/mmwrhtml/

mm5408a2.htm.

34 HHS. 2005. Pandemic Influenza Plan. Part II. Sup

6. November.

35 Varia, M, et al. Investigation of a nosocomial outbreak of severe acute respiratory syndrome (SARS)

in Toronto, Canada. CMAJ 2003; 169(4):285-292.

36 Chen CC, Willeke K. Aerosol penetration through

surgical masks. Am J Infect Control 1992; 20(4):177-

184.

37 Derrick JL, Gomersall CD. Protecting healthcare

staff from severe acute respiratory syndrome: filtration capacity of multiple surgical masks. J Hosp

Infect 2005; 59(4):365-368.

38 HHS. CDC Poster: Sequence for Donning and

Removing Personal Protective Equipment (PPE)

(May 7, 2004) accessed 4/11/2006 at

http://www.cdc.gov/ncidod/sars/ic.htm.

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HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

3 5

23 Mead K, Johnson D. An evaluation of portable

high-efficiency particulate air filtration for expedient

patient isolation in epidemic and emergency

response. Ann Emerg Med 2004; 44: 635-645.

24 Rosenbaum R, et al., Use of a portable forced air

system to convert existing hospital space into a

mass casualty isolation area. Ann Emerg Med 2004;

44: 628-634.

25 Biosafety in Microbiological and Biomedical

Laboratories (BMBL), 4th edition, May, 1999,

http://bmbl.od.nih.gov/, accessed 6/23/06.

26 HHS. Pandemic Influenza Plan Supplement 2

Laboratory Diagnostics. Available at

http://www.hhs.gov/pandemicflu/plan/sup2.html.

27 State Public Health Laboratories Emergency

Contact List November 2005. Available at

http://www.asm.org/ASM/files/LeftMarginHeaderList

/DOWNLOADFILENAME/000000000527/LabState

Contacts.pdf.

28 World Health Organization. Avian Influenza,

including Influenza A (H5N1), in Humans: WHO

Interim Infection Control Guideline for Health Care

Facilities. Revised April 24, 2006. Accessed on

August 23, 2006 at http://www.who.int/csr/disease/

avian_influenza/guidelines/infectioncontrol1/en/.

29 CDC. Public Health Guidance for Community

Level Preparedness and Response to Severe Acute

Respiratory Syndrome (SARS) January 8, 2004,

Supplement C: Preparedness and Response in

Healthcare Facilities, pp. 1-34., Available at: http://

www.cdc.gov/NCIDOD/SARS/guidance/C/index.htm.

30 SARS Commission Interim Report SARA and

Public Health in Ontario, April 15, 2004, http://www.

sarscommission.ca/report/Interim_Report.pdf. 
Pandemic Influenza

Preparedness

An influenza pandemic is projected to have a

worldwide impact on morbidity and mortality, thus

requiring a sustained, large-scale response that has

the potential to quickly overwhelm hospitals and

the healthcare system regionally and nationally.

Because an influenza pandemic may quickly overwhelm the healthcare community (hospitals, outpatient clinics, the pre-hospital environment, nursing

homes, assisted living centers, and private home

healthcare) planning should address: (1) internal

continuation of care and (2) coordination of services with local, state, and federal healthcare agencies.

Healthcare resources are not easily shared or

redistributed; a pandemic will magnify and strain

resources on a much larger scale. Collaboration

with state and federal partners is vital to ensure

that healthcare facilities have assistance with consumables, medication, and vaccines during the

pandemic.1, 2, 3

This section addresses pandemic planning

issues affecting healthcare personnel, the most

valuable resource in a pandemic crisis.1, 2, 3 It is

beyond the scope of this document to give specific

details on resource management for individual

healthcare settings. Instead, comprehensive planning for these issues, such as surge capacity, facility space management, and consumable and

durable equipment utilization should be developed

in coordination with local, state, and federal agencies. There are several checklists, toolkits, and

guidelines that will assist healthcare providers and

service organizations in planning for a pandemic

outbreak available at http://www.pandemicflu.gov/

plan/healthcare/index.html. For additional influenza

pandemic planning resources, see the Appendix

section of this document.

Healthcare Facility Responsibilities 

During Pandemic Alert Periods

In the event of a pandemic, HHS/CDC will coordinate support and intelligence with U.S. public

health departments regarding the pandemic situation in the U.S. and in foreign countries. The

Homeland Security Council (HSC) National Strategy

for Pandemic Influenza Implementation Plan has

identified stages for federal government actions

during a pandemic. The stages are based on

spread of the virus in other countries and in the

United States. These stages can be incorporated

into healthcare pandemic planning to identify triggers for implementation of different aspects of the

facility plan. Below is a broad outline of pandemic

planning for healthcare facilities based on stages of

the Homeland Security Council National Strategy

for Pandemic Influenza Implementation Plan and

the HHS Pandemic Influenza Plan recommendations.1,4

Healthcare Facility Responsibilities Before a

Pandemic (HSC Stages 0, 1)

• Develop planning and decision making strategies for responding to pandemic influenza. 

• Define roles for disaster response, including

responsibility for coordination of a pandemic

plan. For example, identify the individuals

within your organization who will be responsible for coordinating communications, integrating public health recommendations,

establishing security, and developing a written plan. 

• Note that individual circumstances may affect

specific facilities (e.g., rural vs. urban medical

facilities, hospital vs. pre-hospital and general

practices vs. specialized medical facilities). 

• Understand how to access state and federal

information and supplies, and to ensure communication with local, state, and federal health

and security agencies. Identify supply chain

issues and develop alternatives as needed

(e.g., overseas sources).

• Develop written plans that address disease surveillance, isolation and quarantine practices,

hospital capacity criteria, hospital communication, staff education and training, triage, clinical evaluation and diagnosis, security, facility

access, facility infrastructure (e.g., isolation

rooms), occupational health for employees,

use and administration of vaccines and antiviral drugs, facility surge capacity (e.g., durable

and consumable supplies), supply chains (purchase, distribution and transportation of supplies), access to critical inventory supplies, and

mortuary issues (e.g., storage capacity). This is

not a comprehensive list. Planning should be

tailored to the specific facility and community.

• Work with local, state and national emergency

planning committees to integrate with community, state and national pandemic plans and

training. 

• Participate in pandemic influenza response

exercises and drills on local and, if possible,

state and federal levels. Incorporate lessons

learned into the pandemic disaster response

plans.

3 6

Occupational Safety and 

Health Administration

Pandemic Influenza Preparedness
Healthcare Facility Responsibilities During the

Pandemic (HSC Stages 2 – 5)

If there are confirmed human outbreaks overseas

(Stages 2 – 3):

• Heighten institutional surveillance of patients

and facility/clinic staff for influenza-like illness.

• Prepare to activate institutional pandemic

influenza plans, as necessary.

• Establish communications with local, state, and

federal agencies regarding surveillance issues

and recommendations.

If pandemic influenza begins in or enters the

United States (Stages 4 – 5):4

• Activate institutional pandemic influenza plans

to protect staff and patients.

• Heighten institutional surveillance of patients

and facility/clinic staff for influenza-like illness.

• Implement surge capacity plans to sustain

healthcare delivery.

• Identify and isolate potential pandemic influenza patients.

• Implement infection control practices to prevent influenza transmission and monitor staff

and patients for nosocomial transmission.

• Ensure rapid and frequent communication

within healthcare facilities and between healthcare facilities, state health departments, and

the federal government.

• Ensure that there is a process for reporting

influenza cases and fatalities.

Healthcare Facility Recovery and Preparation

for Subsequent Pandemic Waves (HSC Stage 6)

• Continue institutional surveillance of patients

and facility/clinic staff for influenza-like illness.

• Return to normal facility operations as soon as

possible.

• Review pandemic influenza plan based on

experience during the first pandemic wave.

Incorporate lessons learned into preparation

for subsequent pandemic waves.

• Identify and anticipate resource and supply

chain issues.

• Continue to emphasize communication within

healthcare facilities and between healthcare

facilities, state health departments, and the federal government to identify subsequent pandemic waves.

Incorporating Pandemic Plans into

Disaster Plans 

Hospitals already address emergency management

plans as part of the Joint Commission on

Accreditation of Healthcare Organizations (JCAHO)

standards. Standards EC.4.10 and EC4.20 address

emergency management and require hospitals to

conduct a hazard vulnerability analysis as a first

step in disaster planning. A hazard vulnerability

analysis allows hospitals to assess the type, probability, impact, and severity of specific hazards and

disasters. This information allows hospitals to

anticipate the effects of these events and facilitates

customized planning and resource stockpiling.

Specific information on conducting a hazard vulnerability analysis can be obtained though the Joint

Commission Resources, an affiliate of JCAHO.5, 6 

In 2003, the National Hospital Ambulatory

Medical Care Survey reported that about 97 percent

of surveyed hospitals had plans for responding to

natural disasters and 85 percent had plans to

respond to bioterrorism events. Although 75.9 percent reported cooperative planning with other facilities, only 46.1 percent had written Memoranda of

Understanding regarding acceptance of patients

during a disaster. The survey revealed that hospitals drilled for natural disasters more than for terrorism events and drilled even less for severe epidemics.7 Despite recommendations and requirements for disaster planning, some institutions may

be unprepared for a pandemic event. To address

this concern, healthcare institutions should consider incorporating pandemic influenza planning into

disaster planning by developing an algorithm that

would group biologic agents with similar characteristics (i.e., smallpox, plague, influenza, severe

acute respiratory syndrome (SARS)).3 Plans should

address some key differences in biological disaster

plans and influenza pandemic plans.

Pandemic Planning for Support of 

Healthcare Worker Staff

Although a pandemic will be a nationwide event, it

will be experienced on a local level. An important

difference between pandemic planning and mass

casualty planning is the understanding that during

an influenza pandemic, hospital staff will be a limited resource, without an opportunity for replenishment from other communities. Plans must address

protection of this vital and critical resource.

Planning assumptions in the National Strategy for

Pandemic Influenza Implementation Plan include a

30 percent attack rate in the U.S. population, 50

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

3 7
percent of those ill will seek medical attention, and

an absenteeism rate of up to 40 percent. For information regarding planning assumptions, see

http://www.pandemicflu.gov/plan/pandplan.html.

These assumptions could also be adapted for local

pandemic planning purposes to address hospital

staffing shortages and surge requirements.1

Define Essential Staff and Hospital Services 

Defining essential staff and services is typically one

of the first and most vital steps in pandemic planning. During a pandemic, non-pandemic hospital

services such as trauma care, obstetrics, cardiac

care, and psychiatry will still need to be provided or

a referral service made available. Hospitals need to

identify crucial administrative staff, food services

staff, housekeeping, security, and facilities staff.

Once these essential personnel and positions are

identified, consider implementing cross-training to

ensure that these processes will continue. Also,

identify and develop methods and policies in compliance with federal, state and local requirements

for keeping nonessential staff out of the facility

such as through reassignment, administrative leave

or furlough policies. However, even if an individual’s position is considered nonessential, these personnel may be cross-trained and utilized as a contingency workforce.3, 4, 8, 9, 10

Physicians and nurses with crucial knowledge of

infectious disease, pulmonary medicine and critical

care medicine will need to be identified. Nurses are

currently an understaffed profession; in a pandemic

situation, this shortage will be even more pronounced. Consider how to maximize nursing care

by estimating the number of staff needed to care

for a single patient or multiple patients, and then

plan how to meet those needs when there is an

increase in patients or a decrease in staff. Medical

and nursing students may be a potential resource

to meet staffing shortages and to extend care. The

HHS Pandemic Influenza Plan advises that patients’

family members could be used in an ancillary

healthcare capacity. Identify other critical care personnel such as respiratory therapists, pharmacists,

laboratory employees, blood bank and morgue

staff. To prepare for staffing shortages, consider

cross-training staff for essential areas such as the

emergency department or intensive care units.4, 8, 9, 10

3 8

Occupational Safety and 

Health Administration

Influenza Pandemic Planning Issues

• Healthcare facilities may have more warning time and response time for pandemic

influenza, especially if the initial outbreak

develops in another country. Mass casualty

and weapons of mass destruction events

are typically a surprise. 

• Influenza pandemic is not a contained or

local event. Since it is widespread, less federal, state and local support is available at

the individual facility level.

• Unlike a mass casualty or weapons of mass

destruction event, emphasis on cohorting

practices, isolation practices, and sterilization procedures is more important for pandemic infection control than decontamination.

• An influenza pandemic is a sustained crisis.

Expect the response to have a longer duration (12 to 24 months). 

• Unlike an isolated mass casualty scenario,

a pandemic may come and go in waves,

each of which can last for six to eight

weeks.

• Prevention options (vaccine) and treatment

options (medications) are fewer and more

uncertain for pandemic influenza. A vaccine

will likely not be available early in the pandemic. Antiviral medication is in short supply, is highly susceptible to resistance, and

may not be effective.

• Due to the uncertainty of the nature of pandemic, pandemic plans must be flexible

with integrated processes for reviewing

current recommendations and updating the

plan accordingly.

Essential Personnel and Processes

• Designate a multidisciplinary planning

committee responsible for pandemic 

preparedness and response.

• Empower managers and planners with 

the authority and resources to formulate

policies, implement training and enforce

work practices to protect employees and

patients. 

• Identify essential facility staffing and functions.

• Recognize deficiencies such as potential

staffing shortages, lack of written guidelines and develop targets for improvement.

• Prepare contingency plans to address critical services.

• Cross-train individuals for leadership roles

and to identify a contingency workforce.
Human Resources 

Hospital staff and healthcare workers will be a limited resource during a pandemic influenza outbreak

due to illness and/or absenteeism. There will be a

need for people with healthcare training, of any

level, to meet the increased demands on the local

healthcare community. Begin working with other

facilities and clinics to develop Memorandums of

Understanding for staffing support. Work with

these medical clinics to ensure that healthcare

workers in the community are aware of institution

planning, protocols and training. Provide communication infrastructure to ensure that practitioners in

the community have the resources to integrate with

larger facilities.1, 4, 8

Healthcare employers should be prepared to

support existing employees and to accommodate

an influx of new providers, both volunteers and

recruited individuals. Healthcare facilities should

work with JCAHO and state medical boards to

ensure an expedited but legal credentialing

process. A potential resource for personnel augmentation is state Emergency Systems for

Advance Registration of Health Professions

Volunteers (ESAR-VHP). These state systems are

being developed in partnership with HHS to register, classify and verify credentials of potential health

professional volunteers in each state (http://www.

hrsa.gov/esarvhp/) Local Medical Reserve Corps

units may also be sources of volunteer health professional personnel in the immediate vicinity of a

facility (http://www.medicalreservecorps.gov/

HomePage).1, 4

Pandemic influenza planners should also address

workers’ compensation issues in advance, including workplace injuries and illness to volunteers and

new recruits working in response to a pandemic.

Experience during the SARS outbreak showed that

wages and salary issues may also arise as healthcare workers are requested to work with infectious

cases.8, 9 Workplace issues arising in the context of

a pandemic (e.g., reassignment, payment of wages

or salaries, voluntary or involuntary sick leave,

delegation of work duties) should be resolved in

compliance with federal, state, and local laws,

including equal employment opportunity laws.

Human resources should be involved in planning for other employee support concerns such as

the possible need for housing, meals, places to

rest, and child care services. Prepare and plan how

the healthcare facility will provide these services in

planning stages so that during a crisis, employees

will already have this information.11 

Information Technology 

During a pandemic situation, communication capabilities to provide risk communications internal and

external to facilities are essential. Adequate communication infrastructure (computers, Internet, and

radios) will ensure that providers, patients and

community resources can exchange accurate, timely information about the situation. Equipment

should be tested to ensure compatibility with emergency services, law enforcement, security and public health. Inability to communicate effectively

because of technology incompatibility could result

in further strain on the healthcare system and

healthcare workers.12, 13, 14

It is anticipated that during an influenza pandemic the members of the healthcare community

will increase their reliance on information technologies. Quarantine requirements during the SARS

outbreak made it difficult for hospital staff to receive

current information about the outbreak situation,

particularly changing treatment strategies, and recommendations for personal protective measures.

The cancellation of medical rounds and business

meetings further exacerbated the lack of personal

communications. E-mail, telephone conferences,

and Internet access enabled healthcare providers to

access treatment specialists external to the facility,

and obtain the information required to maintain the

most current standards of care from public health

experts. Once these processes were in place,

healthcare providers were able to address effective

patient treatment and personal protective measures. Pandemic planning should address the anticipated increased reliance on information technologies and ensure that the communication infrastructure enables healthcare workers to access the most

current recommendations.4, 8, 9, 10, 12, 13, 14, 15 

Public Health Communications

Healthcare facilities need to develop strong risk

communications resources as part of pandemic

planning for both the community that they serve

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

3 9

Human Resources

• Identify community volunteer and available

medical support professionals.

• Develop processes for training, credentialing, and communicating with community

professionals.

• Plan for health and compensation concerns

of healthcare workers.
and their employees. Risk communications should

be available in formats accessible to individuals

with disabilities and/or limited English proficiency,

and should also target the educational level of the

intended audience.

Communication with the community, including

public relations and risk communications, will be

required to ensure that the general public is educated in self-care techniques, social distancing and

access to the appropriate level of care.15 Healthcare

facilities and outpatient clinics should consider telephone hotlines and websites to provide health

advice to the public. Hotlines and websites can educate the public in self-care or direct ill individuals to

the appropriate level of care and decrease the burden on healthcare facilities. Healthcare facilities and

clinics can also institute follow-up phone or e-mail

communication to ensure that discharged or homecare patients are adequately managed.1, 4, 15

HHS has developed resources for avian influenza and pandemic influenza communications using

the communication science-based message mapping development process. “Message maps” are

risk communications tools used to help organize

complex information and make it easier to express

current knowledge. The development process distills information into easily understood messages

written at a sixth grade reading level. These pandemic influenza and avian influenza message maps

may be copied and redistributed on paper or electronically (http://www.pandemicflu.gov/ 

rcommunication/pre_event_maps.pdf).

During a pandemic there will be rumors and

misinformation that can impact healthcare staff and

the community. Fraudulent information about

counterfeit vaccines and antiviral medications may

be circulated via multiple communication sources.1, 16

Malicious misinformation may also be launched

against local, state and federal agencies.16 Without

a reliable means to communicate accurate information, misinformation may adversely impact healthcare facilities and the public health infrastructure. 

For additional information regarding public

health communications see:

• Department of Health and Human Services

Pandemic Influenza Plan, Supplement 10, available at http://www.hhs.gov/pandemicflu/plan/

sup10.html#I.

• Pandemicflu.gov “Risk Communication” website, available at http://www.pandemicflu.

gov/news/rcommunication.html.

4 0

Occupational Safety and 

Health Administration

Surveillance and Protocols

Surveillance is a cornerstone of disaster preparedness. Healthcare facilities and outpatient clinics

both need to address and implement the capacity

to identify and track influenza-like illness. This capability includes identifying appropriate laboratory

capacity, the ability to conduct epidemiology on

influenza-like illness and to report collected data to

the appropriate state and federal agencies. Once a

surveillance program is established, healthcare

facilities will be able to identify the onset of a

severe influenza season, identify biologic weapons

(anthrax, plague, etc.) and monitor for pandemic

influenza and/or other emerging respiratory infections (i.e., SARS, Hantavirus pulmonary syndrome).

Healthcare facilities should conduct internal surveillance to monitor for nosocomial transmission of

influenza to staff and other patients. Internal surveillance for nosocomial transmission could be

used to identify inadequate infection control practices/procedures.1, 12, 17, 18, 19

Effective disease surveillance depends on cooperation with local, state, and federal health agencies

to ensure that healthcare facilities have access to

influenza diagnostic criteria, confirmatory laboratory tests, and an understanding of the reporting

process in the event of an influenza pandemic.

Health departments in all fifty states and Chicago,

New York City and Washington, D.C. have dedicated influenza surveillance coordinators who promote year-round influenza surveillance. These are

important resources for both hospitals and clinics.

In the outpatient setting, the Sentinel Provider

Information Technology and 

Public Health Communications

• Develop information technology and communication infrastructure.

• Provide effective risk communication to

staff and community.

• Consider implementing hotlines/websites 

to communicate with the public and

employees.

• Identify misinformation and counter with

timely, accurate information. 

• Make communications available in formats

accessible to individuals with disabilities

and/or limited English proficiency, and also

target the educational level of the intended

audience.
Network (SPN) is a network of healthcare providers

who report the number of weekly influenza-like illness visits and submit samples for testing. State

public health departments can assist outpatient

providers who wish to participate in the surveillance program. Healthcare facilities can participate

in the Emerging Infections Program (EIP) and New

Vaccine Surveillance Network (NVSN). Like the

SPN, the EIP and NVSN are administered through

state health departments and coordinated with

federal agencies such as HHS/CDC. Information

about participation in these surveillance activities is

coordinated through state health departments.1, 17

Healthcare organizations, hospitals and outpatient

clinics at least should develop a process to monitor

the following federal and global sources to obtain

the latest information on seasonal influenza, avian

influenza, pandemic influenza, and other novel respiratory illnesses:

• Department of Health and Human Services

http://www.pandemicflu.gov/outbreaks/#ussurv.

• Centers for Disease Control and Prevention

http://www.cdc.gov/flu/weekly/fluactivity.htm. 

• World Health Organization

http://www.who.int/csr/disease/influenza/

influenzanetwork/en/index.html. 

Another important aspect of pandemic planning

is establishment of protocols for patient screening,

treatment, and flow. Patients with influenza-like

symptoms should be identified as quickly as possible. Planning should include contingencies to isolate patients with influenza-like illness from other

patients and staff. Criteria should be developed for

triage, admission, care, and discharge of patients.

Additional protocols should be developed to address

points of entry into a facility, screening of healthcare workers, pharmacy access, emergency medical services transport priority, altered standards of

care, and procedures for handling the deceased.

During the SARS epidemic, triage criteria and

changing protocols were a source of confusion and

stress for healthcare workers. Staff that are trained

and comfortable with triage, admission, treatment

and discharge criteria, experience reduced stress

and provide quality patient care during a crisis.4, 8, 11, 20

Facilities should also develop visitor screening

and access policies for a pandemic. If these policies

are not developed in advance, visitor access becomes

a security issue and a source of stress for staff,

patients, and families. Visitor policies should

address access to ill family members, particularly

pediatric patients, and policies for visitation of

deceased patients.21 Visitation policies will be easiPANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

4 1

er for the public to accept if the justification and

rationale are explained before a crisis.4, 21

Psychological Support

Psychological and behavioral health support for

hospital staff is a recommended part of pandemic

planning.11, 20, 22, 23, 24 Personnel will be exposed to

public education and outreach with the potential for

conflicting messages, public health surveillance

efforts, and community containment strategies in

addition to work-related efforts involving mass prophylaxis strategies, ethical dilemmas due to shortages of critical supplies and surges in demand for

healthcare service, and possible work-related stigma or maladaptive responses of coworkers due to

changes in work practices or loads. Pandemic planning should address numerous areas of potential

distress, health risk behaviors, and psychiatric disease amongst healthcare system personnel. 

The importance of psychological support for

healthcare staff was illustrated during the SARS

outbreak in Canada. During the initial outbreak in

Toronto, there was a high perception of risk due to

lack of information about infection control, morbidity and mortality.8, 13, 14, 20, 25 Healthcare workers, particularly those working directly with SARS patients,

reported feeling afraid, helpless, angry, guilty, and

frustrated. One of study of nurses who treated

SARS patients in Taiwan demonstrated an 11 percent rate of traumatic stress reactions, including

depression, anxiety, hostility, and somatization

symptoms.26 However, despite the risk, healthcare

workers in Toronto and Asia continued to report to

work.8, 13, 20 

The psychological impact of SARS was not only

felt among personnel directly involved in caring for

SARS patients, but also among hospital employees

who were restricted from work either because they

were not in essential positions or quarantined due

to exposure or illness. Supervisors and employees

Surveillance and Protocols

• Develop surveillance capabilities for

influenza-like illness.

• Ensure infrastructure for reporting influenza

cases to state and federal agencies.

• Develop protocols for transport, triage,

admission, treatment, discharge and other

patient services.

• Develop visitation policies for ill and

deceased patients.
reported feeling isolated and ineffective, and

expressed relief when reassigned to duties in the

facility. Reintegrating employees back into work

was also difficult. Employees reported feeling disorganized and disconnected and reported some

resentment between employees who had been

required to work and those who had been

removed.11, 20

The impact of treating SARS cases was not isolated to the workplace. In order to protect their families, healthcare workers often isolated themselves

at home. Healthcare workers and their families

reported experiencing ostracism outside the workplace and stated that people in the community

were afraid to associate with them and their families.8, 11

Healthcare facilities should plan and implement

psychological resources for hospital staff during and

after a pandemic. If there are adequate resources,

facilities should consider extending services to

employee family members.11 The following

resources provide detailed recommendations for

incorporating psychological support for healthcare

workers and their families into pandemic planning:

• Supplement 11 of the HHS Pandemic Influenza

Plan at www.hhs.gov/pandemicflu/plan/

sup11.htm/.

• Center for the Study of Traumatic Stress.

Mental Health and Behavioral Guidelines for

Response to Pandemic Influenza. http://www.

usuhs.mil/psy/CSTSPandemicAvianInfluenza.

pdf 

4 2

Occupational Safety and 

Health Administration

Occupational Health Services 

Identifying and collaborating with institutional

occupational health services is vital to effective

pandemic influenza planning. Occupational health

services can coordinate and participate in a variety

of pandemic influenza preparedness and response

activities.

Developing and Providing Employee

Screening for Influenza-Like Illness

Occupational health services can monitor employee

absentee rates in both the pre-pandemic planning

stages and during a pandemic in order to gauge

the impact and progression of the pandemic on

the facility and the community. In the event of an

influenza pandemic, all staff should be screened for

illness before contact with patients or other healthcare workers. Planning should include processes to

screen employees, track ill healthcare staff and reintegrate staff back into the workplace after recovery.4, 9, 27 

A sample screening form is available from the

WHO document Influenza A (H5N1): WHO Interim

Infection Control Guidelines for Healthcare

Facilities, Annex 10 at http://www.who.int/csr/ 

disease/avian_influenza/guidelinestopics/en/index3.

html. The form screens employees for signs and

symptoms of infection over multiple days, providing a mechanism to ensure that exposed individuals are symptom-free before contact with patients

and staff. 

Developing and Providing Immunization and

Treatment Strategies

Occupational health services should be prepared

to work with state and federal agencies in order

to facilitate pandemic influenza vaccination for

employees and the public. Healthcare facilities and

organizations need be aware of and coordinate

with state pandemic planners to assure access to

available vaccine.1, 4 The pandemic vaccine may

require multiple doses, so occupational health services should develop a system to identify and record

vaccination status for pandemic vaccine recipients.

In addition to a pandemic influenza vaccine

planning strategy, a current, aggressive vaccination

program against seasonal influenza is integral to

institutional preparedness. An effective seasonal

influenza program can be adapted for a pandemic

vaccination campaign.4

Antiviral medication may be a treatment option

for ill healthcare staff. To maximize effectiveness,

these medications should be given as soon as posPsychological Support

• Incorporate psychological support of

healthcare workers into pandemic planning.

• Reinforce to healthcare workers their value

and importance to the community.

• Consider extending resources to cover families of healthcare workers.

• Psychological resources should be offered to

healthcare workers for an extended time period after the pandemic crises has resolved.
sible within 48 hours of the onset of symptoms.

Screening for appropriate, early treatment of

influenza cases among healthcare workers and

essential staff could decrease the duration and

severity of staffing illness and absence. Occupational

health services should also be prepared to treat

secondary bacterial infections in healthcare workers. Treatment and prophylaxis recommendations

will be determined by HHS, but planning for

employee screening and treatment should be

implemented during the pandemic process.4, 27

Continuing Baseline Occupational Health

Services

During an influenza pandemic, protection against

existing occupational hazards (e.g., bloodborne

pathogens and tuberculosis) will need to continue.

Pandemic influenza planning should include a

process to quickly integrate volunteers and recruited staff into healthcare facilities to ensure that

healthcare workers are adequately protected.

Despite the demands of a pandemic, infection control practices will still need to be maintained.

Bloodborne pathogens exposure control plans, respiratory protection programs, and tuberculosis

screening must be continued during an influenza

pandemic. New staff and volunteers should be

included in these programs to ensure facility and

employee safety and health.

Training

Training for a pandemic is essential to ensure continued effective operation of the facility. Cross-training and volunteer training for essential functions

should be initiated early in pandemic preparedness

planning. If advance training is not an option, then

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

4 3

ensure that protocols and resources for just-intime training are in place. If possible, identify pools

of back-up staff or volunteer staff and began training these individuals in infection control practices

and respiratory protection (including fit testing) to

ensure smooth integration in the healthcare facility

in the event of a pandemic.

It is important to remember that patient care

providers are not the only personnel that need pandemic preparedness training. For example, food

services, housekeeping, information technologists,

facility managers and human resources are critical

functions and may require pandemic-specific training (i.e., hygiene practices).4, 9

Healthcare facilities should also consider developing training for families of employees. Ensuring

that families of healthcare workers are educated

about hygiene and disease can protect healthcare

systems and reduce employee absence.11

JCAHO requirements include training and drills

as part of disaster planning. Drilling for a pandemic

situation ensures that facilities are prepared for

surge capacity, supply chains, communication infrastructure, and adequate occupational safety and

health protocols. Disaster drills allow planners to

identify hidden complications that may arise in the

event of a pandemic.5, 6

Security

A pandemic crisis will intensify the need for facility

security. Security will be an essential function and

additional personnel may be needed during a pandemic.1, 2, 4 A pandemic will require facilities to limit

access and implement isolation measures to sepaOccupational Health Services

• Incorporate institutional occupational

health services into pandemic preparedness.

• Develop surveillance, screening and treatment protocols.

• Coordinate with local, state and federal

agencies for access and recommendations

for administration of antiviral medications

and pandemic influenza vaccination.

• Ensure that all employees and volunteers

are safely integrated into the healthcare

facility.

Training

• Advance training is essential for facility

pandemic preparedness.

• Identify critical functions and identify individuals for training in these functions.

• Infection control and use of PPE are appropriate training topics in pandemic preparedness planning.

• Disaster drills are an optimal approach to

testing pandemic preparedness. 

• Training should be available in formats

accessible to individuals with disabilities

and/or limited English proficiency, and

should also target the educational level of

the intended audience.
rate potential cases from staff, visitors, and other

patients. In a pandemic, healthcare facility security

may need to be ready to address crowd control and

physical protection of the facility and hospital staff.4

Security staff will be interfacing with a scared

and potentially dangerous public. Not only will

security personnel be at risk for infection, but they

may have to confront violent individuals demanding resources and healthcare. Training and providing personal protective equipment (PPE) is essential

for these hospital personnel. Facilities should incorporate training and support for security personnel

in the pandemic planning process. 

Healthcare facilities should also work with local

and federal law enforcement agencies to address

facility security. Consider preparing security plans

with local and state law enforcement. This will

allow law enforcement agencies to develop procedures for entrance to and egress of from the facility,

public access issues, and protection of critical supplies. Ensure that law enforcement understands

facility structure and layout in advance of a crisis.

Identify key individuals to liaison with law enforcement agencies and coordinate planning and communications (i.e., radios). Without adequate security and the cooperation of law enforcement agencies, healthcare facilities may not be able to function during a crisis.

Stockpiles of Essential Resources

An issue that all healthcare facilities must address

as part of pandemic planning is stockpiling resources. Due to logistic and economic concerns,

this element of disaster planning is often neglected.

In 2004, the state of Kentucky conducted a survey

of mass casualty planning in healthcare facilities.

Thirty-eight percent of respondents had emergency

plans that addressed stockpiling antibiotics and

supplies and only 25 percent of hospitals actually

had a separate cache of antibiotics for staff in the

event of a bioterrorist event.28

Influenza pandemic planning adds additional

challenges for disaster stockpiling. An influenza

pandemic will be sustained and widespread, and

pharmaceutical interventions are currently in short

supply or nonexistent. These factors limit the ability

of facilities to stockpile pandemic resources. For

this reason, healthcare facilities should ensure that

pandemic plans address the ability to access local,

state and federal stockpiles. Integration with these

resources is vital to ensure distribution and rotation

of essential supplies during a crisis.1, 3, 4, 29 

HHS has recommended that healthcare facilities

consider developing institutional stockpiles of

resources to counter supply shortages and transportation issues that may impact the ability to

access federal and state supplies.4 JCAHO disaster

guidance recommends that hospitals have a 48-to72 hour stand-alone capability;30 however, an

influenza pandemic may surge through a community for 6 to 8 weeks. Consequently, stockpile planning will have to balance economic and logistical

demands with the duration of pandemic waves and

healthcare supplies. Because of resource shortages

and economic concerns, healthcare facilities could

further optimize assets by developing coordinated

stockpiles with other local facilities.1

HHS/CDC has medical supplies and medications

stored in the Strategic National Stockpile (SNS)

(http://www.bt.cdc.gov/stockpile). Pandemic and

disaster planning should include working with state

and federal resources to address access to this supply. 

Pandemic Influenza Vaccine 

In the event of a pandemic, it is currently estimated

that production of initial doses of a vaccine against

a novel strain of influenza would take approximately 4 to 6 months. Influenza vaccines are typically

grown in fertilized chicken eggs, a process that

takes several months. Federal funding has been

made available for the development of cell-based

vaccine technologies that have the potential to

expedite the production of a novel influenza vaccine. In May 2006, HHS awarded contracts totaling

more than $1 billion for development of cell-based

vaccine technologies.1, 31, 32

Pandemic planning should include protocol

development and the stockpiling of supplies for

administering pandemic influenza vaccine.

4 4

Occupational Safety and 

Health Administration

Security

• Security will be an essential requirement

during a pandemic.

• Train security personnel on specific roles

and pandemic scenarios.

• Ensure that security personnel have adequate infection control resources.

• Integrate facility security with local and

state law enforcement agencies to ensure

adequate protection and support of the

healthcare facility and employees.

• Inform and train employees about expected

security measures during a pandemic.
Distribution and vaccination recommendations will

be coordinated through state and local public

health departments. It is critical that healthcare

services coordinate with these agencies in order to

obtain and administer pandemic vaccine.1, 32 HHS

will determine pandemic vaccine recommendations

and prioritization groups (e.g., number of doses

recommended, indications, contraindications and

ranking of various groups for priority for immunization). Current recommendations regarding pandemic influenza vaccine are available in Part I.

Appendix D and in Part II. Supplement 6 of the HHS

Pandemic Influenza Plan at http://www.hhs.gov/

pandemicflu/plan/appendixd.html and http://www.

hhs.gov/pandemicflu/plan/sup6.html. Prioritization,

based on HHS recommendations, may change.

Planning activities should include a process for

obtaining and integrating up-to-date pandemic

vaccination recommendations.

A vaccine against a pandemic influenza strain

may require two doses to provide adequate immunity, therefore, pandemic planning should include

developing a procedure to register, track and contact individuals who have received immunizations.18, 32, 33 Research is currently being conducted

into the development of more immunogenic vaccines. Vaccines which contain chemical additives

called adjuvants can increase the immune response

and require the use of less viral protein which

could extend the vaccine supply. Research into

other methods of developing vaccines or vaccine

delivery systems is ongoing, but as of October

2006, none have received an FDA license.18, 32, 33

An important part of pandemic planning is institution of an effective, seasonal influenza campaign

which includes encouraging healthcare workers to

get vaccinated for seasonal influenza. Unfortunately,

current rates of healthcare worker influenza vaccination are not encouraging; only about 40 percent

of healthcare workers were vaccinated in 2003.34

Antiviral Medication 

In contrast to the vaccine, antiviral medications for

the treatment of influenza do not need to be specific to the circulating pandemic strain and, thus, are

more amenable to stockpiling. There are two classes of antiviral drugs that are U.S. Food and Drug

Administration-approved for the treatment of

influenza: the neuraminidase inhibitors (oseltamivir

and zanamivir) and the M2 inhibitors (adamantine

and rimantadine). Unfortunately, influenza A viruses can develop resistance to either class of antiviral

drug, and especially rapid emergence of transmissible resistant virus has been reported after treatPANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

4 5

ment with adamantanes.33, 35, 36 Although hospitals

are encouraged to stockpile these drugs, it is

impossible to predict which medication will appropriately treat the pandemic virus or if the pandemic

virus will develop resistance to one or both classes

of medications. Resistance to amantadine and

rimantadine has already occurred in the H3N2

seasonal influenza A viruses. As of July 2006, the

HHS recommendation for treatment of H5N1 avian

and seasonal influenza is to use the medication

oseltamivir.35, 36 Because of worldwide demand,

healthcare facilities may have difficulty stockpiling

this medication. 

The federal government is building a national

stockpile with a long-term plan to acquire enough

antiviral medications to treat approximately 25 percent of the U.S. population. As of March 2006, there

were approximately 5.5 million treatment regimens

of antiviral medication in the SNS and approximately 14 million more were on order. The SNS

contains both classes of antiviral drugs, but the

largest stockpiled medication will be the neuraminidase inhibitor oseltamivir. The targeted SNS

level is 50 million courses by 2008. The federal government also plans to subsidize the states’ purchase of an additional 31 million courses.29 State

allocations from the national stockpile can be found

at http://www.pandemicflu.gov/plan/states/ 

antivirals.html.

The decision to deploy federal assets from the

SNS will be made by HHS officials. Each state and

federal agency will need a designated representative to make emergency requests and coordinate

with HHS to access SNS resources. These representatives will provide logistic guidance on receipt

and distribution of the requested assets. Healthcare

facilities should integrate and communicate with

state planners or there could be difficulty accessing

critical medications.1, 37

Healthcare plans should be developed for the

allocation of antiviral medication with the assumption of limited supplies. Strategies for treatment

will be outlined by HHS. Recommendations for use

of antivirals may be updated throughout the course

of an influenza pandemic based on epidemiologic

and laboratory data. Pandemic influenza plans

should incorporate the ability to update and adapt

to the latest HHS guidance. Planning must include

methods to screen patients and employees and to

ensure that these medications are administered in a

fair manner consistent with HHS recommendations.37, 38, 39

A local plan for distribution, point-of-care loca-
mated that the cost to Ontario province’s healthcare

system for the SARS outbreak in Toronto was

approximately $763 million.40, 41

The impact of pandemic influenza would be

much greater than the impact of SARS. HHS/CDC

modeled a pandemic influenza crisis in the metro

Atlanta area with a 25 percent gross attack rate.

The model estimated that there would be 412 hospital admissions a day, with a total of 2,013 cases

hospitalized in one week during the peak of the outbreak.42 This is about 4.5 times the number of

patients hospitalized during the Toronto SARS outbreak. Although only a model, this example illustrates how complicated the issue of stockpiles and

resources will be during a pandemic. Storage of a

large supply of PPE may be difficult and costly.

Some hospitals are working with distributors to

have a stockpile maintained at distributor sites.

If there is careful planning for access, transport

and delivery of the required PPE, this could be an

acceptable option.4 

HHS suggests stockpiling the following PPE

resources:4

• Disposable N95 respirators, surgical masks

• Face shields (disposable or reusable)

• Gowns

• Gloves

Influenza A (H5N1): WHO Interim Infection

Control Guidelines for Healthcare Facilities, Annex

10 (http://www.who.int/csr/disease/avian_influenza/

guidelinestopics/en/index3.html) contains additional

consumable resource recommendations. 

Outpatient Services and Clinics

HHS/CDC estimates that in a pandemic, approximately 45 million people with pandemic influenza

will seek outpatient medical care in the United

States (http://www.pandemicflu.gov/plan/pandplan.

html). Outpatient clinics should prepare for a surge

in utilization of services for pandemic-related illness

while continuing to provide medical services for

treatment of other acute and chronic medical conditions. Clinics and urgent care centers must identify

which services can be curtailed in a pandemic and

which services will need to expand. Optimally, clinics should coordinate planning efforts with local

hospitals, healthcare organizations and public

health agencies. Outpatient clinics could serve as

resources to augment healthcare facilities or alternatively, be utilized to reduce the impact on hospitals by treating and addressing care for pandemic

patients not requiring hospitalization. Clinics should

identify essential personnel and services, identify

4 6

Occupational Safety and 

Health Administration

tions and establishment of priority groups is crucial. Because of the resource limitations and time

constraints for efficacy of the medication, developing plans and infrastructure to access, deliver, and

prioritize use of this medication must be done in

advance. As with vaccinations, this process should

be transparent and healthcare facilities should

develop a risk communication plan that will keep

both healthcare workers and the community updated on current treatment recommendations.37, 38, 39 

Stockpiles of antiviral medication may be a

security issue if there is large pandemic. Consider

not only working with hospital security, but also

with local and state law enforcement officials to

ensure adequate security during a crisis.

Healthcare facilities should also consider stockpiling additional medications to treat secondary

infections and pneumonia. Antibiotics and pulmonary medications such as inhalers and nebulizers are stockpile options for treatment and care.

Hospitals should arrange for occupational or

employee health clinics to develop distribution

plans that address employee illness and exposure.

These plans need to be flexible to accommodate

HHS guidance for distribution and prioritization

when a pandemic virus emerges. Once developed,

the policy for using stockpiled supplies and administration of antiviral medications should be transparent to employees and the community, including

the rationale and justification for the policies. 

2005 HHS recommendations for antiviral medical priority groups can be located in Appendix D

of the HHS Pandemic Influenza Plan at http://www.

hhs.gov/pandemicflu/plan/sup7.html.

Personal Protective Equipment

Given that pandemic influenza vaccine will likely

not be available until 4 to 6 months into the pandemic and that shortages of antiviral medications

are anticipated, PPE will be especially important for

protecting healthcare workers. However, logistic

and economic considerations may impact the

ability for healthcare facilities to stockpile PPE. For

example, the SARS outbreak in Toronto lasted

approximately 6-7 months. One large hospital

reported that at the height of the epidemic the daily

consumption of PPE equipment included 3,000 disposable gowns, 14,000 pairs of gloves, 18,000 N95

respirators, 9,500 ear loop masks, and 500 pairs of

goggles. In the first week of the SARS outbreak, the

hospital purchased $1 million worth of supplies,

although their annual hospital budget was only $50

million per year.9, 40 There were 438 confirmed or

suspected SARS cases in Canada.8 In total, it is esti-
critical supplies and prepare for expanded services.4

Further guidance and information can be found at

http://www.pandemicflu.gov/plan/medical.html.

Outpatient service providers should prepare for

staffing shortages and develop contingency operations plans. Additionally, protocols for triage and

education of patients should be developed. In

preparing for an influenza pandemic, HHS recommends that clinics stockpile at least one week of

consumable supplies, including PPE, when there is

evidence that a pandemic has begun in the United

States. Performing triage, ensuring social distancing and isolation of potentially infectious patients

will be a challenge in the outpatient care community. Pandemic phone hotlines and websites can be

an option to provide education and self-care for

clinic patients in order to avoid unnecessary clinic

visits. Isolation of potentially ill patients could be

difficult; clinics will need protocols and procedures

to maintain appropriate distancing and provide

education to patients on infection control.43

In addition to providing care for patients, clinics

have the responsibility for ensuring that employees

and healthcare workers are adequately protected

during an influenza pandemic. Many of these recommendations in this document can be tailored to

the outpatient setting, including these use of appropriate PPE. Clinics may need to develop respiratory

protection programs and develop appropriate infection control training for employees. Integration with

other clinics and healthcare facilities and public

health agencies may assist clinics in this process.

Alternate Care Sites 

Alternate care sites may be developed at federal or

state discretion to ease the burden of care on

healthcare facilities. Some alternate care sites may

support the community by providing triage and

teaching self-care to individuals who are not critically ill. Vaccination and medication distribution

centers may also be opened depending on the

availability of these resources.1, 4 The use and

deployment of these facilities will vary, but the

requirement to provide a safe workplace does not

diminish. 

It is important that local and state plans address

these alternate sites and determine adequate training and PPE for employees assigned to these facilities. Respiratory protection programs and infection

control programs will need to be developed and

implemented before the facilities are opened to the

public. Healthcare facilities should consider how

they can facilitate the provision of training and safety resources to the community before a pandemic

situation arises. Primary care providers who have

clinics in the community will need to be trained in

the use of PPE and infection control practices. HHS

has developed a checklist to help clinics develop

pandemic disaster plans (http://www.pandemicflu.

gov/plan/medical.html).4 Local and state pandemic

planning should include outreach programs to provide necessary training to these healthcare workers.

JCAHO has guidance for the development of surge

hospitals at http://www.jointcommission.org/

PublicPolicy/surge_hospitals.htm.

References

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Influenza Implementation Plan, Homeland Security

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2 Zinkovich L., D. Malvey, et al. 2005. Bioterror

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3 Gensheimer, K., M. Meltzer, et al. 2003. Influenza

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1645-1648. December.

4 HHS. 2005. Pandemic Influenza Plan, Supplement

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5 OSHA. Best practices for hospital-based first

receivers of victims from mass casualty incidents

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10 Hawryluck L., S. Lapindky, T. Steward. 2005.

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12 Johnson M., E. Bone, G. Predy. 2005. Taking care

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19 McDonald L.C., Simor A.E., et al. 2004 SARS in

Healthcare Facilities, Toronto and Tiwan. Emerg

Infect Dis. 10(5): 777-781. May.

20 Maunder R., J. Hunter, et al. 2003. The Immediate

psychological and occupational impact of the 2003

SARS outbreak in a teaching hospital. Can Med

Assoc J. 168(10): 1245-1251. May.

21 Ovadia K., I. Gazit, et al. 2005. Better late than

never: a re-examination of ethical dilemmas in coping with severe acute respiratory syndrome. J Hosp

Infect 61: 75-79.

22 Reissman D., P. Watson, et al. 2006. Pandemic

influenza preparedness: adaptive responses to an

evolving challenge. Journal of Homeland Security

and Emergency Management, 3(2):1-26.

23 CSTS. Mental Health and Behavioral Guidelines

for Response to Pandemic Influenza. http://www.

usuhs.mil/psy/CSTSPandemicAvianInfluenza.pdf.

Last accessed January 18, 2007.

24 U.S. Department of Veterans Affairs.

Psychological First Aid Manual. http://www.ncptsd.

va.gov/pfa/PFA.html. Last accessed January 18,

2007.

25 Rambaldini G., W. Kumanan, et al. 2005. The

impact of Severe Acute Respiratory Syndrome on

medical house staff. J. Gen Intern Med 20:318-385.

26 Chen C.S., H.Y. Wu., et al. 2005. Psychological distress of nurses in Taiwan who worked during the

outbreak of SARS. Psychiatr Serv 56(1): 76-9.

27 HHS. 2005. Pandemic Influenza Plan, Supplement

4, Infection Control. U.S. Department of Health and

Human Services. November.

28 Higgins W., C. Wainright, et al. 2004. Assessing

hospital preparedness using an instrument based

on the Mass Casualty Disaster Plan Checklist:

Results of a statewide survey. Am J Infect Control

32(6): 327-332. 

29 HHS. 2006. Pandemic Planning Update A Report

from Secretary Michael O. Leavitt. Department of

Health and Human Services. March 13.

30 JCAHO. 2003. Health Care at the Crossroads:

strategies for creating and sustaining communitywide emergency preparedness systems. Joint

Commission on Accreditation of Healthcare

Organizations.

31 News Release. May 4, 2006 HHS Awards

Contracts Totaling More than $1 Billion to Develop

Cell-Based Influenza Vaccine.

http://www.hhs.gov/news/press/2006pres/20060504.

html. Last accessed January 18, 2007.

32 HHS. 2005. Pandemic Influenza Plan, Supplement

6, Vaccine Distribution and Use. U.S. Department of

Health and Human Services. November.

33 Monto A., Vaccine and Antiviral Drugs in

Pandemic Preparedness. Emerg Infect Dis. 12(1);

55-60. January.

34 MMWR. 2005. Interventions to increase influenza

vaccination of health-care workers – California and

Minnesota. Morbidity and Mortality Weekly. 54(08):

196-199. March 4.

35 CDC. 2006. CDC Recommends against the use of

amantadine and rimantadine for the treatment or

prophylaxis of influenza in the United States during

the 2005-06 influenza season. CDC Health Alert,

Centers for Disease Control and Prevention. Last

4 8

Occupational Safety and 

Health Administration
accessed January 18, 2007: http://www.cdc.gov/flu/

han011406.htm.

36 WHO. 2006. Avian Influenza, including Influenza

A (H5N1), in Humans: WHO Interim Infection

Control Guideline for Health Care Facilities. World

Health Organization. February 9. Last accessed on

January 18, 2007 at http://www.who.int/csr/disease/

avian_influenza/guidelines/infectioncontrol1/en/.

37 HHS. 2005. Pandemic Influenza Plan, Supplement

7, Antiviral Drug Distribution and Use. U.S.

Department of Health and Human Services.

November.

38 Cinti S. 2005. Pandemic influenza: are we ready?

Disaster Manag Response 3:61067.

39 Cinti S., C. Chenoweth, A. Monto. 2005. Preparing

for Pandemic Influenza: should hospitals stockpile

oseltamivir? Infect Control Hosp Epidemiol 26(11);

852-854. November.

40 Friesen S. 2003. The impact of SARS on healthcare supply chains. Logistics Quarterly 9(2). Last

accessed March 28, 2006:

www.lq.ca/issues/fall2003/articles/article01.html.

41 Osterholm M. 2005. Preparing for the next pandemic. Foreign Aff. July/August. Last accessed

June 30, 2006: http://www.foreignaffairs.org/

20050701faessay84402/michael-t-osterholm/ 

preparing-for-the-next-pandemic.html.

42 FluSurge 2.0 Manual. Last accessed June 30,

2006:

http://www.cdc.gov/flu/pdf/FluSurge2.0_Manual_060

705.pdf.

43 Medical offices and clinics pandemic influenza

preparedness checklist. Last accessed August 3,

2006 http://www.pandemicflu.gov/plan/

medical.html.

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

4 9
OSHA Standards of 

Special Importance

The role of OSHA is “to assure safe and healthful

working conditions for working men and women.”1

Employers have a responsibility to furnish employees “a place of employment which is free from recognized hazards that are causing or are likely to

cause death or serious physical harm.”1 In addition,

employers must comply with occupational safety

and health standards promulgated by OSHA or by

a state with an OSHA-approved state plan. (More

information about state occupational safety and

health programs can be found at http://www.osha.

gov/fso/osp/index.html.) OSHA standards applicable

to healthcare facilities are addressed in the standards for General Industry. In addition, the

Respiratory Protection standard, the Personal

Protective Equipment standard, and the Bloodborne

Pathogens standard have special importance to

pandemic preparedness and response.

Respiratory Protection Standard - 

29 CFR 1910.134

The primary objective of OSHA’s Respiratory

Protection standard is to protect employees against

inhalation of harmful airborne substances or oxygen-deficient air. This standard applies to all occupational airborne exposures where employees are

exposed to a hazardous level of an airborne contaminant. The inhalation of pathogenic organisms

known to cause human disease is covered by this

standard. 

Employers are required to use feasible engineering controls as the primary means of controlling air

contaminants. Respirators should be used for protection only when engineering controls have been

shown to be technologically or economically infeasible or while they are being instituted for the control of the hazard.

Healthcare facilities requiring the use of respirators must implement a comprehensive respiratory

protection program. These programs are to be

overseen by a qualified program administrator and

have key elements that include respirator selection,

training, medical certification, fit testing, maintenance and cleaning, and program review.

Additional information on the Respiratory

Protection standard is included in Appendix C in

this document. Information describing all of the elements of a comprehensive respiratory protection

program and the use of respirators can be found at

http://www.osha.gov/SLTC/respiratoryprotection/

index.html.

Personal Protective Equipment Standard -

29 CFR 1910.132

When engineering controls, work practices, and

administrative controls are infeasible or do not provide sufficient protection, employers must provide

appropriate personal protective equipment (PPE)

and ensure its proper use. PPE is worn to minimize

exposure to a variety of workplace hazards. PPE

can include protection for eyes, face, head, and

extremities. Gowns, face shields, gloves, and respirators are examples of commonly used PPE within

healthcare facilities. 

Employers must conduct a workplace hazard

assessment to determine if hazards are present that

necessitate the use of PPE. The employer must verify that the required workplace hazard assessment

has been performed through a written certification

that identifies the workplace evaluated; the person

certifying that the evaluation has been performed;

the date(s) of the hazard assessment; and, which

identifies the document as a certification of hazard

assessment. Based on the hazard assessment,

employers are to select PPE that will protect

employees from the identified hazards. Employees

are to receive training to ensure that they understand the hazards present, the necessity of the PPE,

and its limitations. In addition, they must learn how

to properly put on, take off, adjust, and wear PPE.

Finally, employees must understand the proper

care, maintenance, and disposal of PPE.

Healthcare employers can receive more information about the Personal Protective Equipment

standard at http://www.osha.gov/SLTC/personal

protectiveequipment/index.html.

Bloodborne Pathogens Standard - 

29 CFR 1910.1030

OSHA’s Bloodborne Pathogens standard is a regulation that protects employees against health hazards related to the occupational exposure to bloodborne pathogens. The standard applies to any

employee who is occupationally exposed to human

blood or certain other potentially infectious materials (e.g., pleural fluid, any body fluids visibly contaminated with blood, any unfixed human tissue or

organ). The Bloodborne Pathogens standard has

provisions requiring exposure control plans, engineering and work practice controls, PPE, hepatitis B

vaccination, hazard communication, training, and

recordkeeping. 

Additional information on the Bloodborne

Pathogens standard is available at http://www.osha.

gov/SLTC/bloodbornepathogen/index.html.

5 0

Occupational Safety and 

Health Administration

OSHA Standards of Special Importance
General Duty Clause

In addition to compliance with the hazard-specific

safety and health standards, employers must provide their employees with a workplace free from

recognized hazards likely to cause death or serious

physical harm. Employers can be cited for violating

the General Duty Clause of the OSH Act if they do

not take reasonable steps to abate or address such

recognized hazards.2

References

1 OSHA. Occupational Safety and Health Act of

1970 (OSH Act).

2 29 U.S.C. 654(a)(1).

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

5 1
Appendix A 

Pandemic Influenza Internet

Resources

Federal/State pandemic disaster planning resources; updated as new information becomes available.

Checklists for specific healthcare services, hospitals, clinics, home health,

long-term care, EMS.

The FluAid program is a resource for

state and local planners to estimate

range of deaths, hospitalizations, and

outpatient visits for a community.

The FluSurge program estimates 

the impact of a pandemic on the

surge capacity of individual healthcare

facilities, (i.e., hospital beds, ventilators).

AHRQ disaster planning website

Issues addressing bed capacity

Opening shuttered hospitals to

address surge capacity

Conferences to optimize surge 

capacity

Development of models for 

emergency preparedness

Emergency preparedness resource

inventory

Altered standards of care in mass

casualty event

Alternate site use during an emergency

Computer staffing model

Integrating with public health agencies

Bioterrorism and Epidemic Response

Model

5 2

Occupational Safety and 

Health Administration

Department of Health 

and Human Services

Department of Health 

and Human Services

Centers for Disease 

Control and Prevention

Agency for Healthcare

Research and Quality

General Pandemic Planning Resources

http://www.pandemicflu.gov

http://www.pandemicflu.gov/plan/tab6.html

http://www2a.cdc.gov/od/fluaid

http://www.cdc.gov/flu/flusurge.htm

Multiple resources on disaster planning

including surge capacity, stockpiles, and

developing alternate care sites:

http://www.ahrq.gov/browse/bioterbr.htm

http://www.ahrq.gov/research/havbed/

http://www.ahrq.gov/research/shuttered/

shuttools.pdf

http://www.ahrq.gov/news/ulp/btbriefs/

btbrief3.htm

http://www.ahrq.gov/research/devmodels/

http://www.ahrq.gov/research/epri/

http://www.ahrq.gov/research/altstand/

http://www.ahrq.gov/research/altsites.htm

http://www.ahrq.gov/research/biomodel.htm

http://www.ahrq.gov/research/health/

http://www.ahrq.gov/research/biomodel3/toc.a

sp#top
http://www.publichealth.va.gov/flu/pandemicflu.htm 

http://www.who.int/csr/resources/publications/i

nfluenza/WHO_CDS_CSR_GIP_2005_5/en/index.

html

http://www.who.int/csr/en/

http://www.fda.gov/oc/opacom/hottopics/

flu.html

http://www.astho.org/

http://www.heics.com/

http://www.jointcommission.org/PublicPolicy/

ep_guide.htm

http://www.jointcommission.org/PublicPolicy/

surge_hospitals.htm

http://www.ahrq.gov/research/biomodel3/

http://www.pandemicflu.gov/vaccine

http://www.hhs.gov/nvpo/pandemics/tabletop

ex.html

The VA has information on infection

control and other pandemic

resources.

International planning strategies and

global pandemic information

Information on vaccine, antiviral

medication, fraud investigations.

Resources for pandemic planning,

including state health department

listings and state pandemic plans.

Hospital Emergency Incident

Command System (HEICS), an

example of an emergency management plan for healthcare facilities.

Resources for integrations with

community disaster planning. Surge

hospital planning and implementation.

Part of the Weil/Cornell Bioterrorism

and Epidemic Response Module

(BERM), specifically addressing

planning for mass prophylaxis.

Up-to-date information on vaccines,

medication and tests for pandemic

influenza.

Tools to assist planning and conducting tabletop exercises for pandemic

influenza planning.

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

5 3

Department of 

Veterans Affairs

World Health 

Organization

Food and Drug

Administration

Association of State

and Territorial 

Health Officials

California

Joint Commission

on Accreditation

of Healthcare

Organizations

Agency for Healthcare

Research and Quality

Department of Health

and Human Services

Department of Health

and Human Services

Resources for Coordination with State and Local Agencies

Resources for Medications and Vaccination Information and Planning

Disaster and Pandemic Influenza Tabletop Exercises and Drills
Appendix B 

Infection Control Communication Tools 

for Healthcare Workers

5 4

Occupational Safety and 

Health Administration

1. Hand Hygiene, Centers for Disease Control and Prevention:

MMWR Recommendations and Reports October 25, 2002/51(RR16); 1-44. 

Guideline for Hand Hygiene in Healthcare Settings

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm 

Posters:

http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

http://www.cdc.gov/od/oc/media/pressrel/fs021025.htm

http://www.cdc.gov/handhygiene/materials.htm

2. PPE Donning and Doffing Procedures, Centers for Disease Control and Prevention

Posters:

http://www.cdc.gov/ncidod/sars/pdf/ppeposter1322.pdf

http://www.cdc.gov/ncidod/sars/pdf/ppeposter148.pdf

3. Department of Veterans Affairs

Posters:

http://www.publichealth.va.gov/InfectionDontPassItOn/index_hand.htm

http://www.publichealth.va.gov/InfectionDontPassItOn/index_hand_resp.htm

http://www.publichealth.va.gov/InfectionDontPassItOn/Index_ppe.htm

4. Occupational Safety and Health Administration, guidance on the proper use of PPE:

http://www.osha.gov/dts/osta/bestpractices/html/hospital_firstreceivers.html
Appendix B-1 

Factors Influencing Adherence to Hand Hygiene Practices

Reproduced from MMWR Recommendations and Reports October 25, 2002/51(RR16); 1-44. 

Guideline for Hand Hygiene in Healthcare Settings, Box 1.

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

5 5

Observed risk factors for poor adherence to recommended hand hygiene practices

• Physician status (rather than a nurse)

• Nursing assistant status (rather than a nurse)

• Male sex

• Working in an intensive care unit

• Working during the week (versus the weekend)

• Wearing gowns/gloves

• Automated sink

• Activities with high risk of cross-transmission

• High number of opportunities for hand hygiene per hour of patient care

Self-reported factors for poor adherence with hand hygiene

• Handwashing agents cause irritation and dryness

• Sinks are inconveniently located/shortage of sinks

• Lack of soap and paper towels

• Often too busy/insufficient time

• Understaffing/overcrowding

• Patient needs take priority

• Hand hygiene interferes with healthcare worker relationships with patients

• Low risk of acquiring infection from patients

• Wearing of gloves/beliefs that glove use obviates the need for hand hygiene

• Lack of knowledge of guidelines/protocols

• Not thinking about it/forgetfulness

• No role model from colleagues or superiors

• Skepticism regarding the value of hand hygiene

• Disagreement with the recommendations

• Lack of scientific information of definitive impact of improved hand hygiene on 

healthcare–associated infection rates

Additional perceived barriers to appropriate hand hygiene

• Lack of active participation in hand hygiene promotion at individual or institutional level

• Lack of role model for hand hygiene

• Lack of institutional priority for hand hygiene

• Lack of administrative sanction of noncompliers/rewarding compliers

• Lack of institutional safety climate

Source: Adapted from Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol

2000;21:381–6.
5 6

Occupational Safety and 

Health Administration

Appendix B-2 

Elements of Healthcare Worker Educational and Motivational Programs

Reproduced from MMWR Recommendations and Reports October 25, 2002/51(RR16); 1-44. 

Guideline for Hand Hygiene in Healthcare Settings, Box 2.

Rationale for hand hygiene

• Potential risks of transmission of microorganisms to patients

• Potential risks of healthcare worker colonization or infection caused by organisms acquired from the patient

• Morbidity, mortality, and costs associated with healthcare–associated infections

Indications for hand hygiene

• Contact with a patient’s intact skin (e.g., taking a pulse or blood pressure, performing physical exami

nations, lifting the patient in bed) (25,26,45,48,51,53)*

• Contact with environmental surfaces in the immediate vicinity of patients (46,51,53,54)*

• After glove removal (50,58,71)*

Techniques for hand hygiene

• Amount of hand hygiene solution

• Duration of hand hygiene procedure

• Selection of hand hygiene agents

— Alcohol-based hand rubs are the most efficacious agents for reducing the number of bacteria on 

the hands of personnel. Antiseptic soaps and detergents are the next most effective, and nonantimi-crobial soaps are the least effective (1,398).

— Soap and water are recommended for visibly soiled hands.

— Alcohol-based hand rubs are recommended for routine decontamination of hands for all clinical 

indications (except when hands are visibly soiled) and as one of the options for surgical hand 

hygiene.

Methods to maintain hand skin health

• Lotions and creams can prevent or minimize skin dryness and irritation caused by irritant contact 

dermatitis

• Acceptable lotions or creams to use

• Recommended schedule for applying lotions or creams

Expectations of patient care managers/administrators

• Written statements regarding the value of, and support for, adherence to recommended hand

hygiene practices

• Role models demonstrating adherence to recommended hand hygiene practices (399)*

Indications for, and limitations of, glove use

• Hand contamination may occur as a result of small, undetected holes in examination gloves 

(321,361)*

• Contamination may occur during glove removal (50)*

• Wearing gloves does not replace the need for hand hygiene (58)*

• Failure to remove gloves after caring for a patient may lead to transmission of microorganizations 

from one patient to another (373)*

*The numbers in parentheses after some of the elements refer to references in the original MMWR document. 
PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

5 7

Appendix B-3 

Strategies for Successful Promotion of Hand Hygiene in Hospitals

Adapted from MMWR Recommendations and Reports October 25, 2002/51(RR16); 1-44. 

Guideline for Hand Hygiene in Healthcare Settings, Table 9. Strategies for Successful Promotion 

of Hand Hygiene in Hospitals.

Strategies for Successful Promotion of Hand Hygiene in Hospitals

• Education

• Routine observation and feedback

• Engineering control

• Make hand hygiene possible, easy, and convenient

• Make alcohol-based hand rub available (at least in high demand situations)

• Patient education

• Reminders in the workplace

• Administrative sanction/rewarding

• Change in hand hygiene agent

• Promote/facilitate skin care for healthcare workers’ hands

• Obtain active participation at individual and institutional level

• Improve institutional safety climate

• Enhance individual and institutional self-efficacy

• Avoid overcrowding, understaffing, and excessive workload

• Combine several of above strategies
Airborne

Infection

Isolation

+ 

Contact 

Hand cleaning

• Between

patients 

• Immediately

after glove

removal 

• Whenever

hands may be

contaminated

by secretions

or body fluids

• Use an alcohol-based

hand rub or

wash with

antimicrobial

soap and

water 

5 8

Occupational Safety and 

Health Administration

Appendix B-4 

Pandemic Influenza Precautions for Veterans Administration Healthcare Facility Staff

Reproduced with permission from the Department of Veterans Affairs Pandemic Plan, Appendix E-2:

Chart of Pandemic Influenza Precautions for VA Healthcare Facility Staff.

Airborne Infection Isolation and Contact Precautions, in addition to Standard Precautions 

This combination of precautions offers the best protection for health care facility staff, especially at the

onset of a pandemic before transmission patterns are well understood. 

Gloves

• When caring

for patients 

• When touching areas 

or handling

items 

contaminated

by patients

Gowns

• With patient

contact 

Eye protection

• When within 

3 feet of

patient 

• With aerosolgenerating

procedures 

Respiratory

protection

• Use fit-tested

N95 mask 

OR positive

air purifying

respirator

(PAPR) or 

fit-tested 

elastomeric

respirator 

Patients 

• Wear masks

during transport. 

• Use masks

with elastic

straps; avoid

masks that tie

on. 

Room

• Negative airflow private

room when

possible 

• Air exhausted

outdoors or

through highefficiency filtration. 

• Door kept

closed. 
PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

5 9

Droplet

Hand cleaning

• Between

patients 

• Immediately

after glove

removal 

• Whenever

hands may be

contaminated

by secretions

or body fluids

• Use an alcohol-based

hand rub or

wash with

antimicrobial

soap and

water 

Gloves

• When caring

for patients 

• When touching areas 

or handling

items 

contaminated

by patients

Gowns

• Not required 

Eye protection

• With aerosolgenerating

procedures 

Respiratory

protection

• Wear surgical

or proceduretype masks 

in patient

rooms or

when within 

3 feet of

patients;

change when

moist 

• Wear fittested N95

respirator or

equivalent

with aerosol

generating

procedures

Patients 

• Wear masks

during transport. 

• Use masks

with elastic

straps; avoid

masks that tie

on. 

Room

• Private room

when possible 

• Door may be

open. 

Droplet Precautions, in addition to Standard Precautions 

This combination of precautions should be used if droplet transmission appears to be the common mode

of transmission or when incapable of using Airborne Infection Isolation and Contact Precautions. 
6 0

Occupational Safety and 

Health Administration

Who Can Act? 

Individuals 

What Public Health Measures? 

Cleaning hands regularly.

Following respiratory hygiene

rules (covering the mouth and

nose with tissues when 

coughing or sneezing). 

Getting seasonal influenza 

vaccinations.

Avoiding contact with sick 

persons—staying at least three 

to five feet away. 

Staying home when sick—from

work, school, public places. 

Wearing masks when sick with

influenza, if able to tolerate. 

Appendix B-5 

Public Health Measures Against Pandemic Influenza for Individuals, Healthcare

Providers, and Organizations

Reproduced with permission from Department of Veterans Affairs Pandemic Plan, Appendix E-3: 

Chart of Public Health Measures Against Pandemic Influenza Precautions for Individuals, Health Care

Providers, and Organizations.

The measures in the chart below may be important to reduce transmission of pandemic influenza in VA

facilities and other settings. 

Why? 

Reduces transfer of microorganisms from the hands to the eyes,

nose, or mouth. Reduces transmission of microorganisms carried on

hands from person to person.

Prevents dispersal of respiratory

viruses in the air. 

Prevents individuals from

getting/transmitting seasonal

influenza, which reduces burden on

health care system, and keeps the

individual well and able to conduct

daily business. Reduces likelihood

of genetic reassortment of influenza

strains when a person is infected

with more than one strain. Helps

people become accustomed to getting vaccinations. 

Reduces likelihood of one’s getting

and transmitting influenza. 

Reduces transmission of influenza

to other persons. 

Reduces transmission to others. 
PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

6 1

Who Can Act? 

Health care providers 

Business, community, regional,

and national organizations and

leaders 

What Public Health Measures? 

Tracing contacts. 

Isolating people with suspected 

or confirmed influenza. 

Quarantining people exposed 

to influenza. 

Wearing personal protective

equipment—masks or respirators,

gowns, gloves, goggles. 

Developing, manufacturing, 

stockpiling, and distributing 

antiviral medications. 

Developing, manufacturing, stockpiling, and distributing vaccine. 

Reducing non-essential travel. 

Closing schools. 

Declaring “snow days” (temporarily

closing businesses, offices), postponing public gatherings.

Enabling employees to work 

from home; making

teleworking/telecommuting 

possible. 

Partitioning space. 

Why? 

Locates and allows potentially

exposed persons to be informed

and able to take measures to avoid

exposing others. 

Reduces transmission of influenza

to others. 

Reduces transmission of influenza

to other persons. Because the 

incubation period of influenza is

about 2 days, quarantine time

would also be short (actual time 

will be determined by the 

characteristics of the pandemic

influenza virus). 

Reduces risk of getting influenza

and potential of transmitting it to

others. 

Treats influenza or prevents its

spread. 

Prevents influenza. 

Reduces the number of persons 

an individual has contact with and

slows the spread of influenza from

region to region. 

Children usually have many 

more close contacts than adults;

closing schools greatly reduces

transmission of influenza within

schools, within families, and 

within communities. 

Reduces contacts among 

persons; has potential to reduce

transmission. 

Reduces contacts among 

persons; has potential to reduce

transmission. 

Limiting access to a building or

facility by screening those who

enter for fever, respiratory symptoms, and possible recent exposure. 
Appendix C-1 

Respiratory Protection Programs

OSHA Respiratory Protection Standard

The OSHA Respiratory Protection standard (29 CFR

1910.134) requires employers to establish and

maintain a respiratory protection program to protect their respirator-wearing employees. Employers

must provide respirators when such equipment is

necessary to protect the health of employees. The

respirator provided must be suitable for its intended purpose. When an employer is required to provide respirators, the employer must establish and

maintain a respiratory protection program.

Respiratory Protection Program

A respiratory protection program is a cohesive collection of worksite-specific procedures and policies

that addresses all respiratory protection elements

required by the standard. For example, a respiratory protection program must contain specific procedures describing how respirators will be selected,

fitted, used, maintained and inspected in a particular workplace. A written program is needed because

health and safety programs can be more effectively

implemented and evaluated if the procedures are

available in a written form for study and review.

Also, a written respiratory protection program is

the best way to ensure that the unique characteristics of the worksite are taken into account. Developing the written program encourages the employer

to thoroughly assess and document information

pertaining to the respiratory hazards to which their

employees will potentially be exposed, both during

normal operating conditions and during reasonably

foreseeable emergencies.

A respiratory protection program is required to

include the following elements (as applicable):

• Procedures for selecting appropriate respirators for use in the workplace.

• Fit testing tight-fitting respirators.

• Cleaning, disinfecting, storing, inspecting,

repairing, removing from service or discarding, and otherwise maintaining respirators.

Also, you must establish schedules for these

elements.

• Ensuring adequate air supply, quantity, and

flow of breathing air for atmosphere supplying respirators.

• Provisions for medical evaluation of employees

who must use respirators.

• Training employees in the proper use of respirators (including putting them on and removing them), the limitations on their use, and

their maintenance.

• Regularly evaluating the effectiveness of the

program.

Respiratory Protection Program Administrator

The employer must designate a program administrator to run the program and evaluate its effectiveness. An individual is qualified to be a program

administrator if he or she has appropriate training

or experience in accord with the program’s level of

complexity. This training or experience is appropriate if it enables the program administrator to fulfill

the minimum standard requirements of recognizing, evaluating, and controlling the hazards in the

workplace. For example, if the program requires

air-supplying respirators for use in immediately

dangerous to life or health environments, the program administrator must have training and experience pertaining to the use of this type of equipment. Similarly, if air-supplying respirators are not

used and there are no significant respiratory hazards at the workplace, someone with less sophisticated experience or training might be able to effectively serve in this position.

Ultimately, the appropriate qualifications for the

respiratory protection program administrator must

be determined based on the particular respiratory

hazards that exist, or that are reasonably anticipated, at the workplace.

Medical Evaluations

Employers must medically evaluate their employees’ ability to wear a respirator. Medical evaluations

are required for both positive pressure and negative pressure respirators. Medical evaluation can

be performed by using a medical questionnaire or

by performing an initial medical examination that

obtains the same information as the medical questionnaire. Employers must allow the employee to

be evaluated during the employee’s normal working hours or at a time that is convenient to the

employee, and employers are responsible for paying for this service (even if the employee has coverage under an insurance plan).

6 2

Occupational Safety and 

Health Administration

Appendix C 

Implementation and Planning for Respiratory Protection

Programs in Healthcare Settings
Employers must identify a physician or another

licensed healthcare professional (PLHCP) to perform the medical evaluations. Physicians are not

the only healthcare professionals allowed to perform medical evaluations for respirator use. The

Respiratory Protection standard allows any PLHCP

to administer the medical questionnaire (described

below) or to conduct the medical examination if

doing so is within the scope of the PLHCP’s license.

Employers may check with PLHCPs in their local

area to see if performing the medical evaluation is

within the scope of their professional license, or

employers may check with the state’s licensing

board.

The Medical Questionnaire 

The medical questionnaire is designed to identify

general medical conditions that place employees

who use respirators at risk of serious medical consequences. If employers choose to use the medical

questionnaire to conduct the medical evaluation,

they must use the questionnaire contained in the

Respiratory Protection standard (Appendix C of the

standard, Part A., Sections 1 and 2). The PLHCP

determines whether or not Part B of the questionnaire needs to be administered, and the PLHCP can

alter the questions in Part B in any manner he or

she thinks is appropriate. Employers may choose to

use medical examinations in place of the questionnaire, but they are not required to do so. Medical

examinations must be provided for an employee

who gives a positive response to any question

among questions 1-8 of Part A, Section 2 in

Appendix C of the standard. Although the questionnaire does not have to be administered during the

medical examination, the PLHCP must obtain the

same information from the employee that is contained in the questionnaire.

Fit Testing

The Respiratory Protection standard requires

employers to conduct fit testing on all employees

who are required to wear a respirator that includes

a tight-fitting facepiece. Fit testing is a procedure

used to determine how well a respirator “fits”—

that is, whether the respirator forms an adequate

seal on the user’s face. If a good facepiece-to-face

seal is not achieved, the respirator will provide a

lower level of protection than it was designed to

provide. For example, without a good seal, the respirator can allow contaminants to leak into the facepiece and be inhaled by the user.

There are two types of fit testing: quantitative

and qualitative. Quantitative fit testing is a method

of measuring the amount of leakage into a respirator. It is a numeric assessment of how well a respirator fits a particular individual. To quantitatively fit

test a respirator, sampling probes or other measuring devices must be placed to measure aerosol

concentrations both outside and on the inside of

the respirator facepiece. Qualitative fit testing is a

non-numeric pass/fail test that relies on the respirator wearer’s response to a substance (“test agent”)

used in the test to determine respirator fit. In qualitative fit testing, after performing user seal checks,

the respirator wearer stands in an enclosure and

a test agent is introduced, such as banana oil

(isoamyl acetate), saccharin, Bitrex, or irritant

smoke (without a test enclosure). If the individual

can smell or taste the test agent (or is irritated by

the smoke), this indicates that the agent leaked into

the facepiece and that the respirator has failed the

test because a good facepiece-to-face seal has not

been achieved. If the employee cannot successfully

complete the qualitative test with a particular respirator, the employee must then be tested with

another make, size, or brand of respirator.

Fit testing must be conducted for all employees

required to wear tight-fitting facepiece respirators

as follows:

• Prior to initial use.

• Whenever an employee switches to a different

tight-fitting facepiece respirator (for example, a

different size, make, model, or style).

• At least annually.

Employers must ensure that an additional fit test

is conducted if an employee experiences a change

in physical condition that could affect the seal on

the tight-fitting facepiece respirator. This requirement is triggered by a physical change:

• Reported by the respirator user.

• Observed by the employer, a physician or

other licensed healthcare professional, the

supervisor, or the program administrator.

• Physical changes in the employee that might

affect the facepiece-to-face seal could include,

for example, an obvious change in body

weight, facial scarring, dental work, or cosmetic surgery.

If, after fit testing, an employee reports that his

or her respirator does not fit properly, you must

allow the employee a reasonable opportunity to

select a different tight-fitting facepiece respirator.

After another respirator is selected, you must conduct a new fit test on the employee’s replacement

equipment. An employee might determine that the

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

6 3
facepiece does not establish an effective facepieceto-face seal, for example, upon smelling a worksite

contaminant while wearing the respirator with new

cartridges. Or an employee might hear or feel air

leaking around the facepiece-to-face seal. The

employee’s determination also can be based on

factors unrelated to the particular worksite. For

example, the employee might find that he or she

cannot wear the respirator for extended periods

without experiencing irritation or pain.

Employers must ensure that all fit testing conducted for employees required to wear tight-fitting

facepiece respirators follows the OSHA approved

protocols. Detailed protocols for qualitative and

quantitative fit testing are provided as part of the

standard (see Appendices A and B of the standard).

These protocols specify that you must have on

hand during fit testing all types and sizes of respirators that are available for use at the worksite. This

allows you to ensure that each employee is tested

with the same type of respirator (make, model, style,

and size) that he or she will wear at the worksite.

Tight-Fitting and Loose-fitting Respirator

Facepieces

A tight-fitting facepiece is intended to form a complete seal with the respirator wearer’s face. This

seal must be sufficiently tight to prevent any contaminants in the work environment from leaking

around the edges of the facepiece into the user’s

breathing air.

In contrast, a loose-fitting facepiece is specifically designed to form a partial seal with the user’s

face. Such a facepiece typically covers at least the

head and includes a system through which clean

air is distributed into the breathing zone. For example, hoods and helmets are loose-fitting facepieces.

Such equipment does not rely on a tight facepieceto-face seal to protect the wearer, and is useful for

employees with facial hair or other physical characteristics that make it difficult to wear a tight-fitting

facepiece.

Preventing Leaks in the Facepiece Seal

Facepiece seals and valves are important in tightfitting respirators. Tight-fitting respirators have a

complete seal to the face. If there is a leak in the

seal of a tight-fitting respirator or valve, then the

respirator cannot reduce the wearer’s exposures to

respiratory hazards. You must be sure that nothing

interferes with the seal of the respirator to the

employee’s face or with the valves. Conditions that

can interfere with the seal or valve include:

• Facial hair

• Facial scars

• Jewelry or headgear 

• Missing dentures

• Corrective glasses or goggles or other PPE

such as:

• Face shields

• Protective clothing

• Helmets 

• Eyeglass insert or spectacle kits

Employees may use the equipment in the above

list with tight-fitting respirators if the employer

ensures that the equipment is worn in a way that:

• Does not interfere with the face-to-facepiece

seal.

• Does not distort the employee’s vision.

• Does not cause physical harm to the employee

(e.g., if the eyeglass insert did not fit properly

so that the tight fit of the respirator caused the

insert to press against his or her forehead,

eyes, or temples). 

If an employee wears corrective glasses or goggles or other personal protective equipment, the

employer shall ensure that such equipment is worn

in a manner that does not interfere with the seal of

the facepiece to the face of the user.

Conducting User Seal Checks

To conduct a user seal check, the employee performs a negative or positive pressure fit check.

For the negative pressure check, the employee:

• Covers the respirator inlets (cartridges, canisters, or seals)

• Gently inhales, and

• Holds breath for 10 seconds.

The facepiece should collapse on the employee’s face and remain collapsed.

For the positive pressure check, the employee:

• Covers the respirator exhalation valve(s); and

• Gently exhales.

The facepiece should hold the positive pressure

for a few seconds. During this time, the employee

should not hear or feel the air leaking out of the

face-to-facepiece seal. Appendix B-1 of the OSHA

Respiratory Protection standard provides detailed

instructions on how to conduct the user seal check.

The manufacturer’s recommended procedures for

checking the facepiece seal may be used if the

employer demonstrates that the manufacturer’s

procedures are as effective as those described in

Appendix B-1 of the OSHA Respiratory Protection

standard.

6 4

Occupational Safety and 

Health Administration
Maintenance and Care of Respirators

Employers must provide respirator users with

equipment that is clean, sanitary, and in good working order. To accomplish this, employers must have

a system of respirator care and maintenance as a

component of their respiratory protection program.

Regular care and maintenance is important to

ensure that the equipment functions as designed

and protects the user from the threat of illness or

death.

Your system of respirator care and maintenance

must provide for:

• Cleaning and disinfection procedures

• Proper storage

• Regular inspections

• Repair methods

Cleaning and Disinfection

Respirator equipment must be regularly cleaned

and disinfected according to specified procedures

(see Appendix B-2 of the standard) or according to

manufacturer specifications that are of equivalent

effectiveness.

Cleaning and disinfection procedures are divided into the following:

• Disassembly of components

• Cleaning and disinfecting

• Rinsing, drying, and reassembly

• Inspection 

The frequency of cleaning and disinfecting or

sanitizing respirators will depend in part on

whether your employees share the equipment or

are issued respirators for their exclusive use.

Worksite conditions also will dictate cleaning frequency, e.g., working in a dirty environment. In

addition, if individual employees are required to

clean their own respirators, you must allow time

during work hours for users to perform this function.

Proper Storage Procedures for Respirators

Employers must store respirators in a manner that:

• Protects them from contamination, dust, sunlight, extreme temperatures, excessive moisture, damaging chemicals, or other destructive

conditions.

• Prevents the facepiece or valves from becoming deformed.

• Follows all storage precautions issued by the

respirator manufacturer.

In addition, if a respirator is intended for emergency use, it must be:

• Kept accessible to the work area, but not in an

area that may itself become involved in an

emergency and become contaminated or inaccessible.

• Stored in a compartment or cover (e.g., on a

fire truck) that is clearly identified as containing

emergency equipment.

Training and Information

Employee training is a critical part of a successful

respiratory protection program and is essential for

correct respirator use. Employers must provide

training to their employees who are required to

wear respirators and must ensure that each employee can demonstrate knowledge of at least the following:

1. Why the respirator is necessary and how

improper fit, usage, and maintenance can make

the respirator ineffective.

Training must address the identification of hazards, the extent of employee exposure to those

hazards, and the potential health effects of exposure. The training that is required under the

Hazard Communication standard (29 CFR

1910.1200) can satisfy this requirement for

chemical hazards. Employees must understand

that proper fit, usage, and maintenance of respirators is critical to ensure that they can perform

their protective function.

2. The limitations and capabilities of the selected

respirator.

Training must cover how the respirator operates. Included must be an explanation of how

the respirator provides protection by filtering the

air, absorbing the gas or vapor, or by supplying

a clean source of air. Limitations on the use of

the equipment, such as prohibitions against

using an air-purifying respirator in an immediately dangerous to life and health atmosphere,

and why not, must also be explained.

3. How to inspect, put on and remove, and check

the seals of the respirator.

Employers must train employees how to recognize problems that may decrease the effectiveness of the respirator and what steps to follow if

a problem is detected, such as the person to

whom problems should be reported and where

replacement equipment can be obtained if needed. If specialized personnel conduct inspections,

individual respirator wearers only need to be

taught about the portions of the inspection

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

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6 5
process that are their responsibility. Training

must also cover how to properly put on and

remove the respirator to ensure that respirator

fit in the workplace is as close as possible to the

fit obtained during fit testing. 

4. The proper respirator maintenance and storage

procedures.

The extent of training required may vary according to workplace conditions. If employees are

individually responsible for storing and maintaining respirators, detailed training may be necessary. If specialized personnel perform these

functions, employees only need to be informed

of the maintenance and storage procedures.

5. The general requirements of the Respiratory

Protection standard.

Employers must ensure that employees are

aware, in general, of the employer’s obligations

under the standard. This discussion need not

focus on the standard’s provisions but could, for

example, simply inform employees that employers are obligated to develop a written program,

properly select respirators, evaluate respirator

use, correct deficiencies in respirator use, conduct medical evaluations, provide for the maintenance, storage and cleaning of respirators,

and retain and provide access to specific

records.

Employers must ensure that, before an employee is required to use a respirator in the workplace,

he or she understands the information provided

and can use the respirator properly. This can be

done by reviewing the training with the employee

either orally or in writing, and by reviewing the

employee’s hands-on use of respirators. Training

must be conducted in a manner that is understandable to the employees. This means that your program should be tailored to your employees’ education level and language background. Employers

must provide the required training prior to requiring an employee to use a respirator in the workplace.

If employers can demonstrate that a new employee has received training within the last 12 months

and that the new employee has the necessary

knowledge, employers are not required to repeat

this training. In cases where training in some elements is lacking or inadequate, employers are

required to provide training in those elements.

Previous training not repeated initially must be provided no later than 12 months from the date of the

previous training.

Retraining

Employers must retrain employees in the proper

use of respirators annually. They must also retrain

employees when:

• Changes in the workplace or the type of respirator make previous training obsolete.

• The knowledge and skill necessary to use the

respirator properly has not been retained by

the employee.

• Any other situation arises in which retraining

appears necessary to ensure safe respirator

use.

6 6

Occupational Safety and 

Health Administration
Appendix C-2 

Readiness Plan for Epidemic Respiratory Infection: 

A Guideline for Operations for Use by the Dartmouth-Hitchcock Medical CenterLebanon Campus and the Dartmouth College Health Service

Reproduced with permission

Readiness Plan for Epidemic Respiratory Infection: 

A Guideline for Operations for Use by the Dartmouth-Hitchcock Medical CenterLebanon Campus and the Dartmouth College Health Service

DHMC, 2005

Developed by Kathy Kirkland, MD, Hospital 

Epidemiologist, and the DHMC Readiness Committee

Background: The Readiness Plan for Epidemic Respiratory Infection (ERI) evolved from our initial response

and planning for the prevention and control of Severe Acute Respiratory Syndrome (SARS) which began in

the spring of 2003. During those planning activities it became clear that DHMC needs to maintain a level of

readiness at all times for a variety of contagious respiratory infections with epidemic potential. Potential

threats include SARS or a new strain of influenza that becomes pandemic. Many elements of the plan will

make us more prepared to identify and contain other contagious respiratory infections as well, including

pertussis, mycoplasma, and parainfluenza, for example.

The DHMC plan builds on guidelines from state and federal health authorities which recommend

aggressive implementation of respiratory hygiene practices and universal administration of influenza vaccine to healthcare workers and high-risk patients for all healthcare facilities regardless of the presence of

an epidemic.

This document outlines a plan for responding to various levels of threat posed by ERIs, and an

approach to stepping up prevention and control activities as the threat increases. It is based on the premises that we should be vigilant at all times for syndromes that may represent contagious respiratory infection, and that we should maintain a group of people prepared to actively respond to changing situations

by implementing appropriate parts of this plan, when indicated.

The document is divided into:

• a matrix that defines parameters that will be the critical determinants of the level of risk at DHMC

• a summary of the elements of the baseline state of readiness that should be maintained at all times

• a summary of the ways in which our surveillance, prevention and control activities may need to

change at each level of increasing risk to DHMC 

• an appendix that includes standard operating procedures for the management of patients who have

suspected ERI as outpatients, as inpatients, and for resuscitation of these patients. 

This document is intended for use by the DHMC Readiness Committee or an Incident Command team

to determine actions that should be taken to prevent the spread of ERI among our patients, staff, volunteers, students, and visitors. The intent is that this document will be used in the context of advisory documents and guidance provided by NH DHHS and the CDC. It may be used as a template by other New

Hampshire healthcare facilities as they prepare themselves for the threat of epidemic respiratory infection.

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

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6 7
6 8

Occupational Safety and 

Health Administration

What type of transmission is confirmed?

None or sporadic 

cases only

Person-to-person 

transmission

Person-to-person 

transmission 

Person-to-person 

transmission 

Does not matter

Person-to-person 

transmission 

Person-to-person 

transmission 

Where are the cases? 

Anywhere in the world

Anywhere outside the

U.S. and bordering

countries (Canada,

Mexico)

In the U.S., Canada 

or Mexico

In region: NH/VT or

close to borders

At DHMC or DC

At DHMC or DC

At DHMC or DC

Epidemic Respiratory Infection ALERT MATRIX 

Six levels of alert corresponding to the type of transmission, the location of the cases, and the presence

and type of cases at DHMC or DC. 

Are there cases at

DHMC? 

No

No

No

Does not matter

Yes, but no nosocomial

transmission

Yes, with nosocomial

transmission, from

known sources only

Yes, with nosocomial

transmission, sources

not clear

Alert Level

Ready

Green

Yellow

Orange

“Controlled Orange”

Orange

Red

The alert level will be determined by the Readiness Committee, using this matrix and data collected

through surveillance activities. It can be upgraded (or downgraded) by the committee depending on the

number of cases, or for other compelling circumstances.

At each level of alert, the Readiness Committee will consider implementing certain actions. As the level of

alert becomes higher, additional actions are added to the actions initiated at the lower level.
Level: READY

Baseline activities to ensure preparedness in

the absence of known active epidemic of 

ERI in the world

Goals

• To prevent cases of vaccine-preventable contagious respiratory infection (e.g., influenza) at

DHMC and in the community.

• To promote early detection of initial cases of

contagious respiratory infection (including, but

not limited to influenza, SARS).

• To prevent nosocomial spread of contagious

respiratory infections. 

• To create systems for real-time data collection

flexible enough to be adapted for use in an epidemic setting.

Influenza Vaccination

• For patients and the public

• Nursing will carry out standing orders for all

eligible patients to be offered and receive

influenza vaccine in all clinics and prior to discharge from all inpatient units.

• DHMC will continue to collaborate with other

community health organizations to hold public clinics to provide influenza vaccine to all

eligible community members of any age.

• Public Affairs, with input from the Readiness

Committee, will develop educational and promotional materials to promote availability and

desirability of influenza vaccine for all.

• The administering provider of flu vaccine in

the inpatient and outpatient setting will document administration of influenza vaccine in

CIS.

• For staff, volunteers, and students

• Administrative, educational, and clinical leaders will promote maximum participation of

staff, volunteers, and students in influenza

vaccine program. 

• Occupational Medicine will provide multiple

opportunities for staff, volunteers, and students to receive influenza vaccine conveniently and efficiently.

• Occupational Medicine will present regular

updates of physician compliance with flu vaccine by section for review by Board of

Governors.

• DHMC will report flu vaccine rates among

direct care providers on public reporting website.

Access Control

• The Security Office will develop a plan and a

timeline for implementing a policy that enables

them to control access to the medical center

through the use of mandatory ID badges for all

staff, volunteers, students, vendors, and other

people coming to DHMC to work, and a plan to

lock down certain entrances and exits, and to

monitor use of others, if necessary.

Surveillance, Screening and Triage

• For patients

• Receptionists will screen all outpatients at the

time of registration at selected DHMC clinics,

the ED, and the Dartmouth College Health

Service with the following question: Do you

have a new cough that has developed over

the last 10 days?, and will:

◆ Provide patients who have a new cough

with a surgical mask and/or tissues.

◆ Document data at time of screening and

transmit clinic-specific data to Infection

Control each week for review and analysis

of trends.

• Clinical staff at these clinics will:

◆ Evaluate patients who have a new cough or

fever.

◆ Place all patients who have fever and a new

cough on droplet precautions, pending further evaluation.

• The admitting office staff will screen all

patients at the time of admission for “fever

and cough” and will:

◆ Admit patients with fever and cough to a

private room with droplet precautions.

◆ Document data at time of screening and

transmit inpatient admitting diagnoses to

Infection Control daily for review of appropriate use of precautions for inpatients.

• For staff, volunteers, and students

• Receptionists will screen all staff, volunteers,

or students who present to Occupational

Medicine clinic with the following question:

Do you have a new cough that has developed

over the last 10 days?, and will:

◆ Provide patients who have a new cough

with a surgical mask and/or tissues.

◆ Document data at time of screening and

transmit clinic-specific data to Infection

Control each week for review and analysis

of trends.

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

6 9
• Clinical staff in Occupational Medicine clinic

will:

◆ Evaluate patients who have a new cough or

fever.

◆ Place all patients who have fever and a new

cough on droplet precautions, pending further evaluation.

• Occupational Medicine staff, clinical and administrative leaders will advise staff, volunteers and students who have fever and a new

cough not to come to work.

• Occupational Medicine will: 

◆ Screen staff, volunteers, and students who

report pneumonia or respiratory infection to

identify possible clusters of pneumonia or

respiratory infection in healthcare providers 

◆ Report possible clusters to Infection Control.

• For visitors, vendors, registrants at conferences

• Public Affairs will maintain “Ask for a Mask”

signs at all entrances, and at all meeting

rooms, to encourage all persons entering

DHMC to self-screen (rotating the posters

periodically to maintain impact).

• Via posters, ask persons who have new

cough to wear a surgical mask or use tissues

to cover their mouth and nose when coughing, and to use good hand hygiene during the

time they need to be at DHMC.

• All staff will advise persons who have fever

and cough to defer visiting DHMC until their

illness has resolved.

• Monitoring surveillance data

• The Infection Control Unit will monitor national, regional, and local data related to ERI and

report changing trends to the Readiness

Committee on a regular basis.

Infection Control/Precautions

• All staff, volunteers, and students will use

Droplet Precautions (private room and surgical

mask within 3 feet of patient) for all contact

with any outpatient who has a new cough and

fever, until a diagnosis of a non-contagious

respiratory illness, or an infection requiring a

higher level of precautions, is made.

• All staff, volunteers, and students will use

Droplet Precautions (private room and surgical

mask within 3 feet of patient) for all contact

with any patient being admitted to the hospital

who has a new cough and fever until a diagnosis of a non-contagious respiratory illness, or

an infection requiring a higher level of precautions, is made.

• Clinic and inpatient staff will use a visible doorway “precautions sign” system to allow persons entering the room to know what type of

protective equipment is needed.

• Clinic Administrative services and

Housekeeping will maintain adequate supplies

at all times of surgical masks, waterless hand

rub, and tissues throughout public areas, clinic

waiting rooms, and meeting rooms. Clinic and

inpatient unit staff will maintain these supplies

in clinical areas.

• The Safety Office will identify key areas

throughout the hospital which need to maintain core groups of N95 respirator fit-tested

personnel.

• Each director is responsible for maintaining

the appropriate number of trained and fit-tested staff

• The Safety Office will ensure that an adequate

number of PAPRs are maintained for use by

personnel who cannot use N95 respirators.

• Engineering will maintain negative pressurecapable rooms on 3 West. 

• Nursing will develop plans for moving patients

out of these rooms on 3 West if needed.

Communication/Education

• Public Affairs will develop a sustainable and

effective plan for communication and promotion of messages relating to ERI to internal and

external audiences.

• Public Affairs and Communications will coordinate with the Emergency Preparedness Committee to develop an internal communication

plan to allow immediate access to predefined

groups of people, including “on call” staff, via

e-mail, Intranet, paging system, telephone.

• The Center for Continuing Education in the

Health Sciences will develop a sustainable plan

to orient and educate staff regarding basic

readiness activities at DHMC, and a strategy for

“just-in-time” educational activities to provide

timely information to providers in the event of

ERI.

Additional Preparedness Activities

• The Readiness Committee will meet approximately once a month.

• The Readiness Committee will designate an

Incident Command core team including senior

administration, infection control, ACOS, communications, nursing, safety, engineering,

security, College Health Service with 7-day a

7 0

Occupational Safety and 

Health Administration
week availability to respond to a potential outbreak of contagious respiratory infection.

• The Infection Control Unit will monitor the

Health Alert Network and other communications from public health officials to review

changes in recommendations from NH

DHHS/CDC about screening criteria and will

communicate changes to clinicians via some

combination of e-mail, Intranet, or radiographic

or laboratory reporting. 

Level: GREEN

Confirmed efficient human-to-human transmission of potentially epidemic contagious

respiratory infection present outside the U.S.

and bordering countries (Canada and Mexico)

Summary: At the “GREEN” level, our basic activities remain similar to the “READY” level, except

that there may be more focused surveillance and

screening based on specific geographic and epidemiologic risk factors, and more aggressive forms

of isolation may be required for suspected cases.

Vigilance of all staff is required to identify potential

cases of ERI remains critical. At the GREEN level,

the following additional actions will be considered

for implementation by the Readiness Committee.

Access Control

• The Readiness Committee will consider the

need to activate the policy on requiring staff,

volunteers, students, and vendors to wear

identification while in the medical center.

Surveillance, Screening and Triage

• “Ask for a Mask” signs will be placed at all

entrances, and in all meeting rooms, which

may be modified to include specific risk factors

for a specific ERI, to encourage all persons

entering DHMC to self-screen.

• Persons who self-identify as at risk for the

designated infection are instructed to don a

surgical mask and may be asked to go to a

designated location for clinical evaluation.

• Receptionists in selected areas (which may

expand) will continue to screen all patients at

registration for new cough, and additional

questions may be added if appropriate.

Receptionists will:

• Provide patients who have a new cough who

have specific risk factors for the targeted

infection with a surgical mask and ask clinical

staff to place them immediately in a private

exam room.

• Provide patients who have a new cough but

no specific risk factors for the targeted infection with a surgical mask and/or tissues.

• Clinical staff will evaluate:

• Patients who answer “yes” to new cough and

specific risk factors for fever and other symptoms, using N95 masks, gowns, gloves and

eye protection.

• Patients who answer yes to new cough but

do not have specific risk factors, using droplet

precautions.

• Clinicians who suspect, after initial clinical evaluation that a patient may have an ERI should

immediately consult with the Infectious

Disease Service and the Infection Control Unit,

who will involve the state health department

as appropriate. (IF A PATIENT IS DETERMINED

TO BE A SUSPECT CASE OF ERI, GO TO

LEVEL: “CONTROLLED ORANGE”)

• No patient can be admitted or accepted in

transfer to DHMC with a suspected diagnosis

of the ERI in question, without the approval of

the Infectious Disease Service.

• Staff, volunteers, and students traveling to designated high risk areas must register with

Occupational Medicine upon return and report

any symptoms of fever or cough that occur

during a specified time period. Occupational

Medicine will maintain a list of people under

surveillance for this reason.

Infection Control/Precautions

• Airborne, droplet, and contact precautions are

required for all contact with any outpatient

who has screened as a possible ERI case, until

an alternate diagnosis is made.

• Droplet precautions are required for all contact

with any outpatient who has a new cough and

fever, but no risk factors for the ERI, until a

diagnosis of a non-contagious respiratory illness, or an infection requiring a higher level of

precautions, is made.

• Any patient who has screened as a possible

ERI case and requires admission to DHMC,

must be admitted to a negative pressure room

on 3 West, where airborne and contact precautions are required for all contact. (IF A PATIENT

IS DETERMINED TO BE A SUSPECT CASE OF

ERI, GO TO LEVEL: “CONTROLLED ORANGE”).

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

7 1
Communication/Education

• At each committee meeting, the Readiness

Committee will review the need for communication with, or educational programs for staff,

volunteers, and students, and the public.

Preparedness

• The Readiness Committee meets once or twice

a month, depending on the stability of the situation.

Level: YELLOW

Confirmed human-to-human transmission of

potentially epidemic contagious respiratory

infection documented in the U.S. or bordering countries (Canada or Mexico)

Summary: At the “YELLOW” level, the ERI is closer to home, and may pose a more real threat.

Vigilance of all to identify potential cases of ERI

remains critical. At the YELLOW alert level, rapid

changes in the epidemiology of disease and the

level of threat to DHMC may be expected. The

major change is that the Readiness Committee

becomes more active so that a rapid change to a

higher level of alert is possible. The following additional activities will be considered.

Access Control

• Review need to require staff, volunteers, students, and vendors to wear ID badges at all

times.

Surveillance, Screening and Triage

• Expand screening and triage of patients and

employees to all clinics, with regular review of

need to modify or add specific risk factors.

• Continued use of posters to promote screening

visitors and vendors.

Infection Control/Precautions

• No changes

Communication/Education

• No changes

Preparedness

• The Readiness Committee meets at least once

a week to review surveillance data and new

recommendations from DHHS/CDC.

• Evaluate the availability and appropriateness of

disease-specific vaccine or preventive treatment.

Level: CONTROLLED ORANGE

A case of ERI has been diagnosed at DHMC

or Dartmouth College or is an inpatient at

DHMC but there has been no documented

nosocomial or community spread from this

person to others.

Summary: When there is a patient with suspected

ERI at DHMC, because of the potential for transmission in the hospital setting, the alert level immediately is raised to a form of ORANGE. (i.e., with a

single imported case, we immediately would go

from READY or GREEN to CONTROLLED ORANGE.)

At the “CONTROLLED ORANGE” level, more caution is needed, and our activities shift from more

passive to more active control measures. The goal

is to prevent nosocomial spread to employees and

patients within DHMC. At this level, activation of a

number of new measures is considered, relating to

access, screening, and clinical care, but there is an

effort to maintain relatively normal operations at

DHMC except in the area where a potentially infected patient is being cared for. The emphasis is on

personal protection of staff and patients, and a

readiness to raise the alert level quickly if there is

any indication of spread.

Access Control

• Limit visitors and admissions to 3 West.

• Review need to restrict vendors, visitors, conferences.

• Require staff, volunteers, students, vendors,

and other people coming to DHMC to work to

wear their badges/identification at all times.

Surveillance, Screening and Triage

• Modified “Ask for a Mask” signs remain at all

entrances, and at all meeting rooms, which

include specific risk factors for the targeted

infection, to encourage all persons entering

DHMC to self-screen.

• A knowledgeable staff member may need to

be present at all entrances to assist people

with self-screening, answer questions, and

direct them to evaluation centers if needed.

• Screening questions for patients and employees at registration, admission will be reviewed

and modified as needed at each Readiness

Committee meeting.

7 2

Occupational Safety and 

Health Administration
• Staff, volunteers, and students who have had

contact with suspected patients must register

with Occupational Medicine and be screened

daily for fever or respiratory symptoms.

• Surveillance data will be transmitted to

Infection Control for review daily. 

Infection Control/Precautions

• No changes

Communication/Education

• Regular updates to all staff via Intranet as

determined by the Readiness Committee.

Preparedness

• Readiness Committee will meet daily to review

situation and strategies.

• Nursing and ACOS will review plans for moving non-epidemic patients out of negative pressure-capable rooms on 3 West; Engineering

will review plan to add HEPA filters and negative pressure to additional rooms on 3 West

and ensure that the plan could be operationalized within 4 hours if needed.

• Infection Control will notify microbiology laboratory director of relevant information.

Level: ORANGE

There is evidence of nosocomial transmission

of ERI from known infected patients to other

patients, employees, or visitors at DHMC, OR

there is human-to-human transmission in the

Upper Valley region, or nearby.

Summary: “ORANGE” indicates a high level of

alert, with restrictions on access to DHMC, much

more active screening, and a shift away from normal operations throughout the institution. At the

ORANGE level, the Readiness Committee will consider implementing each of the following additional

actions.

Access Control

• All entrances to medical center will be locked

except the Main Entrance, the entrance from

Parking Garage, and the Emergency

Department entrance.

• Security guards will be stationed at open

entrances.

• Entry into facility will be restricted to the following:

• Staff, and students with valid ID 

• Patients with appointments

• A single adult accompanying a patient

• A single parent of hospitalized child

• Those allowed into the facility must be

screened for fever or cough (see Surveillance,

screening and triage below) and have their

temperature taken and if cleared, given something to indicate that they have been cleared to

enter the facility (e.g., a sticker, a card, a stamp

on their hand).

• Activities of Food Court eateries and shops,

hair salon, optical shop, etc. will be suspended. 

• Activities of vendors, volunteer activities, continuing education programs, except those

related to the epidemic disease will be suspended.

• There will be some degree of suspension of

elective surgeries, elective admissions, elective

outpatient appointments as determined by the

Readiness Committee.

• There will be some level of suspension of medical student rotations, construction as determined by the Readiness Committee.

Surveillance, Screening and Triage

• Patients calling for same day appointments will

be screened for new cough developing over

the last 10 days.

• Patients who answer yes will be phone

triaged to a clinician who can do further

screening for epidemic infection risk factors

and determine the need for the patient to be

evaluated in person.

• Patients being called with appointment

reminders will be screened for new cough and

phone triaged to a clinician for further screening prior to coming to DHMC.

• All people entering DHMC will be actively

screened by trained staff for cough or fever at

open entrances 

• Patients and visitors who are identified to

have fever and/or cough will be instructed to

don a surgical mask, use waterless handrub,

and go to a designated evaluation location

(NB: risk factors at this alert level may be simply living in the Upper Valley, or having been

at DHMC).

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

7 3
• Employees who have fever and/or cough will

be considered possible cases: 

◆ If at home, they should call Occupational

Medicine for evaluation prior to coming to

work.

◆ If at work, they should call Occupational

Medicine and be instructed regarding the

need for evaluation. 

◆ Occupational Medicine will develop a tool to

screen employees regarding need for evaluation, need for home isolation, etc.

• After evaluation, no patient or employee who

has fever or cough will be allowed to remain

at DHMC unless the person requires hospitalization.

◆ The name and phone number/address of all

patients or employees sent home with suspected epidemic infection should be recorded and reported to the NH DHHS.

• Occupational Medicine will continue to maintain a log of which employees have contact

with epidemic patients, whether there are

unprotected exposures, and the employee’s

health and work status daily.

Infection Control/Precautions

• An N95 mask and contact precautions are

required for all HCWs having contact with any

outpatient who has fever and/or a new cough,

until an alternate diagnosis is made. (This

includes staff who conduct screening at DHMC

entrances.)

• Adequate supplies of personal protective

equipment, waterless hand rub, tissues will

be maintained throughout the hospital by

Housekeeping and Clinic Administrative

Services, as well as clinical staff.

• Everyone providing patient care will be N95

respirator fit-tested.

Communication/Education

• Daily or more frequent updates to staff and the

public/press will be provided as determined by

the Readiness Committee.

Preparedness

• The Readiness Committee will meet twice daily

to review infection control surveillance data,

clinic operations (i.e., number of screening

evaluations being done) and adequacy of new

controls and revise alert level as needed.

• The Readiness Committee will reassess daily

the need to create special epidemic inpatient

unit off site (e.g., Armory).

• Staff may be redeployed from areas where

clinical activities have been suspended or limited to screening, infection control, Occupational

Medicine, epidemic patient care and other

areas of need, as determined by Readiness

Committee in collaboration with hospital leaders.

Level: RED

There is evidence of untraceable or uncontrolled nosocomial transmission of ERI OR

there is widespread human-to-human transmission in the Upper Valley region, or nearby

Summary: “RED” indicates the highest level of

alert, with extreme restrictions on access to DHMC

and a major shift away from normal operations

throughout the institution. The following additional

actions will be considered.

Access Control

• All entrances to medical center will be locked

except one entrance designated for employees

and Emergency Dept entrance.

• Security guards will be stationed at open

entrances.

• Entry into facility will be restricted to the following:

• Employee with valid ID 

• Patient arriving by ambulance [a parent may

remain with a hospitalized child but cannot

come and go from the medical center]

• Patients who must receive regular, life-sustaining treatments at DHMC (e.g., dialysis

patients, transfusion-dependent patients)

• Those allowed into the facility must be

screened for cough and other criteria (as outlined in ORANGE) and have their temperature

taken and if cleared, given something to indicate that they have been cleared to enter the

facility.

• Suspension of elective surgeries, elective

admissions, elective outpatient appointments,

non-emergency transfers as determined by the

Readiness Committee.

• Suspension of on-site student rotations, construction activities.

• Possible redeployment of clinical students to

areas of need.

7 4

Occupational Safety and 

Health Administration
Surveillance, Screening and Triage

• Required daily for all persons entering facility

(see ORANGE).

Infection Control/Precautions

• All staff will wear surgical masks and use frequent hand hygiene at all times while in the

facility.

Communication/Education

• There will be daily or more frequent updates to

staff and the public/press as determined by the

Readiness Committee.

Preparedness

• The Readiness Committee will meet twice daily

to review situation.

• The Readiness Committee will reassess daily

the need to create special epidemic inpatient

unit off site (e.g., Armory).

• Staff may be redeployed from areas where

clinical activities have been suspended or limited to screening, infection control, Occupational

Medicine, epidemic patient care and other

areas of need, as determined by Readiness

Committee in collaboration with hospital leaders.

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

7 5
Appendix 1

Epidemic Respiratory Infections Patient Flow

Patient Response to Risk 

Factor Screening Questions?

7 6

Yes

Proceed with appointment 

as scheduled.

Receptionist gives surgical mask to

patient and notifies nurse.

Nurse places pt in room, door 

closed, implements airborne/contact

precautions with N95 masks.

Evaluation by scheduled provider

Confirms symptoms & risk factors

Initial disposition

No

ID Consult - confirm symptoms & risk

factors, review disposition, discuss

with Infection Control & NH DHHS

Suspect Case?

No Yes

Continue with 

scheduled appt

Does patient need 

to be admitted?

No

Complete evaluation

Not sure Yes in clinic

ED for Evaluation

Admission to Negative

Pressure Room

Home

ICU 3W
The following protocol will be followed when a

patient has a new cough and risk factors associated

with a specific epidemic respiratory infection (ERI).

Principles to follow in care of ERI patient.

• Minimize Health Care Workers (HCW) contact

with the patient.

• Protect HCWs during contact with patient.

• Minimize opportunities for exposure to other

patients or visitors.

Key points

1. The receptionist should give the patient a mask

to put on covering their nose and mouth and immediately inform the nurse who will immediately place

the patient in a private exam room, the door to the

exam room must be kept closed. We want to minimize the amount of time that the patient is in the

waiting area or other common areas. 

2. Personnel Protective Equipment (PPE) is required

for anyone going in the room to see the patient.

This includes gown, gloves, goggles and N95 mask

or PAPR hood. N95 masks and the PAPR hoods will

be available from the Safety Office (ext. 57233) during the day or the ACOS after hours.

3. The health care provider who was scheduled to

see the patient will evaluate them to confirm that

they have a fever >38, respiratory symptoms and

risk factors for ERI. If the provider confirms this

information s/he should contact the Infectious

Disease physician by calling the DHMC operator

and asking for the ID physician on call.

4. The ID physician will consult with the patient’s

provider to confirm the suspect case and plan further evaluation. They will also notify the Infection

Control Team and the NH Department of Health. If

possible, a disposition decision should be made at

this time.

5. If the patient is in a clinic without a negative

pressure room and is considered to be a suspect

case of ERI and needs further evaluation, including

lab work and/or X-rays, to determine the need for

hospital admission they will be moved as soon as

possible to the negative air pressure room in the

Emergency Department. The clinic nurse caring for

the patient must call the ED (ext 57000) and notify

them of this. When the patient is moved to the ED,

they should be wearing a surgical mask. The

patient should be taken to the ED via a route that

avoids crowded public areas. The clinic nurse who

has been caring for the patient will transport the

patient to the ED and should continue to wear PPE.

If the patient is no longer considered to be a

suspect case they may continue with their appointment as scheduled. People no longer need to follow contact and airborne isolation, only appropriate

Standard Precautions.

6. The patient will remain in the negative pressure

room in the ED until a decision regarding admission is made. The patient will only leave for urgent

medically necessary tests that can not be done in

the negative pressure room. If the patient needs to

leave the ED, the charge nurse is responsible for

notifying the department that they will be going to

that the patient requires airborne and contact precautions. The PPE will go with the patient when

they leave the ED. Employees who have contact

with the patient should be kept to a minimum. 

7. If the patient is stable and does not need admission the provider should coordinate appropriate

medical follow-up and surveillance from the NH

Department of Health prior to discharge from the

clinic or ED. 

8. If the patient requires admission to DHMC the

Infectious Disease physician will activate the ERI

plan and notify Admitting of the need to admit the

patient to a negative pressure room. N95 masks

and PAPR hoods will be sent with the patient. The

patient will travel from the clinic or ED to the unit

wearing a surgical mask via a route that avoids

crowded public areas. The nurse who has been caring for the patient will transport the patient to the

inpatient room and should continue to wear PPE

during transport.

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

7 7

Appendix 2

Suspected or Confirmed Epidemic Respiratory Infection (ERI) 

Outpatient Management Protocol
This plan will be put into effect when a patient is

believed to meet the criteria for an epidemic respiratory infection by one of the Infectious Disease

physicians and needs hospitalization.

Principles to follow in care of ERI patient

• Minimize Health Care Workers (HCW) contact

with the patient.

• Protect HCWs during contact with patient.

• Minimize opportunities for exposure to other

patients or visitors.

Criteria for Admission

• Patient will be admitted only when medically

necessary.

• Patients will not be admitted solely for the purpose of isolation.

• The Infectious Disease service must approve all

admissions for ERI and is responsible for activating the ERI plan in collaboration with

Infection Control.

Admitting Service/Medical Responsibility

The ERI patient will be admitted to the Hospitalist

service, adult or pediatric, with mandatory consultation with Infectious Disease and Critical Care Service

on admission. Transfer to the Critical Care Service

should be made as soon as a patient shows signs of

respiratory distress, i.e., increasing O2 requirement,

FI02 > 50, respiratory therapy assessment.

Patient Placement 

All patients, adult and pediatric, will be admitted to

3W. The first case will be admitted to room 301. (If

the first patient is critically ill, requiring immediate

intensive care they should be admitted to a negative pressure room in the ICU for an adult or the

PICU for a child.)

• Planning and activity will begin to prepare

room 303 as a potential intensive care location.

Engineering will install special ventilation unit

to create negative pressure (Engineering

Services Policy 6.207b; Temporary Negative

Pressure Rooms).

Second case will be admitted to room 302.

• 3W- Pod 1 now restricted to only ERI patients.

ACOS, Admitting, and nursing directors will

make arrangements to move the non-ERI

patients on Pod 1 to another area of the hospital. 

• Engineering will install special ventilation units

to create negative pressure in rooms 327, 328,

and 329. Contact State of NH to get more

portable HEPA filter units.

• Plan for provision of adequate staff initiated.

This may require cancellation of elective cases

and re-allocation of nursing staff.

ERI patients 3, 4, & 5 will be admitted to rooms 327,

328, & 329.

• When these rooms are full, 3W will be closed

to all other patient types.

• Non-ERI patients will be moved to other areas

of the hospital.

• Plans initiated to open an alternate site for care

of ERI patients outside of MHMH.

• ERI patients will continue to be admitted to

3West until alternate care site is opened. Other

units of the hospital may need to accept patients

(non ERI) from 3W. Other areas of the hospital

may need to close some beds in order to provide extra staff to 3W.

Any patient requiring critical care support will be

placed in Room 303. Nursing staff from ICU will

provide critical care in this location.

Pediatric patients will be admitted to the rooms

on 3West (not the Pedi/Adolescent unit). Nursing

staff from the Pedi/Adolescent unit will provide care

to the pediatric patient on 3West.

If the number of ERI patients exceeds the number of available private negative pressure rooms

patients with known ERI can be cohorted together.

The following patients will be given priority for the

private negative pressure rooms; these decisions

will be made in collaboration with the ACOS,

Infectious Disease, Infection Control, and

Admitting.

• ERI patients who are known to have transmitted ERI to others. 

• Patients who are being assessed for ERI (do

not want to put someone who does not ultimately have ERI in with known ERI patients).

As soon as the Admissions Department is aware

of ERI patient admission they will notify the ACOS

(ext 5-8245 or beeper # 9732) of the admission. 

7 8

Occupational Safety and 

Health Administration

Appendix 3 

Suspected or Confirmed Epidemic Respiratory 

Infections (ERI) Inpatient Management Protocol
The ACOS will work with Admitting and the 3W

staff to expedite the admission. (The patient will

remain where s/he has been evaluated until the

inpatient room is ready.) The ACOS will:

• Expedite transferring current patient to another

room

• Notify engineering of the admission, engineering will ensure negative pressure is functioning

in the room (This can be done by holding a

small strip of tissue paper at the closed door

and observing to be sure that it is pulled

toward the room, not blown out away from the

room. Engineering can assist with this if needed.)

• Ensure the room’s pressure monitor alarm has

been turned on and is working. Use the key to

turn the room pressure monitor to “Infectious

Isolation - Negative Pressure”. This only turns

the room alarm on, the room is always on negative pressure and does not need to be turned

on. The alarm should go on when the door is

left open for more than 1 minute or the seal is

not adequate to maintain negative pressure in

the room. Before the patient arrives to the

room, check the room pressure monitor to be

sure it is working by opening door, the alarm

should go off after 1 minute. If there are questions about the monitor or room call Engineering. Monday through Friday 0800-1600 Ext. 5-

7150. At other times use Engineering Pager

#9234.

• Ensure unnecessary equipment (extra chairs,

cot) is removed from the room 

• Ensure that protective equipment is available

in the anteroom (masks, gowns, goggles,

gloves, PAPR units); Masks and goggles can be

obtained from Stores, gowns from Linen

Service ext. 57136, and PAPR units are in the

Emergency Department. If rooms without an

anteroom are used for a ERI patient the necessary equipment will need to be set up on a cart

outside the room.

Patient Transport

Guidelines for moving ERI patients in DHMC

• The nurse caring for the patient will transport

the patient with the assistance of transportation personnel as needed.

• If an elevator is needed, use a service elevator

and be sure there are no other people in it. 

• The patient must wear a surgical mask over

their nose and mouth during transport through

the institution. 

• Security (ext. 5-7896) can help with providing

an empty elevator available and other logistics

if needed. 

• Employees who are transporting the patient

should wear gloves, N95 mask (or PAPR hood

and motor unit), goggles, and gown.

Protective Equipment

Anyone entering the room must wear respiratory

protection appropriate to the disease. If the disease

is transmitted via the airborne route then the following is required.

• N95 mask (employee must have been fitted

and trained by an administrator of the

Respiratory Protection Program) and goggles

(face shields are not felt to provide adequate

protection). 

• If the employee cannot be fitted for an N95

mask they must wear a PAPR unit when entering the room. (People wearing a PAPR hood do

not need goggles; the hood provides protection for the eyes.) 

• Everyone must wear gloves and a gown. 

When leaving the room the PPE will be removed

in the anteroom, if there is one, or just outside the

door if the room does not have an anteroom.

Remove PPE in the following order.

• Untie the gown’s waist tie 

• Remove gloves and dispose of them in trash 

• Remove goggles handling them by the side

pieces and place in sink

• Remove mask handling it by the head straps

and dispose of in trash

• Untie neck ties of gown and carefully remove

gown turning sleeves inside out as arms are

pulled out, place gown in linen bag

• Put new gloves on and disinfect goggles with

alcohol or Dimension III

• Remove gloves and dispose

• WASH HANDS before doing anything else.

People who have used a PAPR unit should

remove PPE in the following order:

• Remove hood and motor unit and place on

chux pad

• Remove gloves, dispose of them in trash and

put new gloves on, clean hood, hose and

motor with Dimension III, place unit in clean

area and dispose of chux pad

• Untie the gown’s waist tie

• Remove gloves and dispose of them in trash

• Untie neck ties of gown and carefully remove

gown turning sleeves inside out as arms are

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

7 9
pulled out, place gown in linen bag. 

• WASH HANDS before doing anything else.

All of the PPE, except for the PAPR units, are

either disposable or single use and should not be

reused.

N95 masks will not be reused. They will be disposed in the trash of as soon as they are removed. 

PAPR units must be disinfected as soon as they

are removed. The person who used the equipment

is responsible for cleaning it and plugging in the

motor unit to recharge while it is not in use. The

hood and hose must be wiped with a disinfectant

before being handled and used again. The motor

unit should be wiped with a disinfectant if it has

been in contact with respiratory secretions.

Room Setup

Both doors to rooms 301 and 302 must be kept

closed. When other rooms are used, the single

door to the room must be kept closed.

Only essential equipment should be in the room.

Equipment brought into the room should be left in

the room for use only by that patient. Thermometer,

stethoscope glucometer, pulse oyx, should remain

in the room. A thermometer can be obtained from

CSR, a glucometer can be obtained from Point of

Care Testing, ext 57198, in the lab, pulse oyx can be

obtained from respiratory therapy. Equipment that

cannot be left in the room must be disinfected

before it is used for any other patient. Most equipment can be disinfected by cleaning thoroughly

with Dimension III. 

Linen requires no special precautions. Used

linen should be handled as little as possible. It

should be carefully rolled together in a manner that

avoids shaking, and placed in the yellow linen bags.

Trash requires no special precautions. Routine

waste should be placed in the regular trash bags.

Any waste that is saturated with blood or body fluids should be disposed of in the tan bags.

Regular dishes will be used. The dietary aide

will give the tray to the nurse who will bring it into

the room. The nurse will also bring the tray out of

the room when the meal is finished. 

Blood and other specimens may be sent to the

lab via normal mechanisms. Be sure the outside of

the biohazard bag does not become contaminated.

The patient room should be cleaned daily and

as needed by housekeeping. While the patient is in

the room the housekeeping staff must wear N95

mask and goggles or a PAPR unit and gloves and

gowns while in the room. Routine cleaning with a

disinfectant is adequate. When the patient is discharged the room should be left closed for an hour,

then people may enter without masks to clean.

Staffing

Nursing staff from Pediatrics and the Critical Care

units will provide care to pediatric or critical care

patients on 3W.

The registered nurse taking care of a ERI

patient will not care for any other patients. Other

staff members such as LNAs who may be needed

to assist with care may care for other patients.

The goal is to limit the number of employees

who enter the room while providing appropriate

safe care for the patient. 

All employees will be expected to participate in

the care of ERI patients as needed.

Pregnant employees will not be excused from

caring for ERI patients.

Staff who are taking care of ERI patients may

wear hospital supplied scrub uniforms. (There is a

cabinet in Stores that has a few scrubs available for

emergency use, a larger supply will need to be

ordered from the linen department.)

Staff who have cared for a ERI patient may

shower in their locker room before leaving work.

Employee Surveillance

A list of all employees who enter the room or have

had close contact with the patient will be started by

Infection Control as soon as the ERI plan is activated and maintained by the RN who is assigned to

the patient. All employees entering the room or

who have contact with the ERI patient must add

their name and contact information to the list. The

unit secretary will FAX the prior day’s list to

Occupational Medicine (FAX 650-0928) between

8:00 and 9:00 a.m. each day. These employees will

be followed by Occupational Medicine for symptoms of the disease. Occupation Medicine will

develop a disease-specific protocol for close monitoring of all employees who have had contact with

the ERI patient.

Visitors

No visitors. People can talk to the patient via telephone. 

For pediatric patients, one parent may be

allowed in the room. They will need to use PPE and

follow policies as above. They may not sleep in the

room.

Special Situations

Cough inducing or aerosol producing procedures

(intubation, sputum induction, nebulizer treatment,

CPAP, BiPAP, suctioning) should not be done unless

8 0

Occupational Safety and 

Health Administration
absolutely necessary. If they must be done the

patient should be medicated if possible to limit

aerosol production (sedate, paralyze). The absolute

minimum number of employees should be in the

room. Employees who are in the room during such

a procedure must wear PAPR units.

To the extent possible all tests and procedures

will be done in the patient’s room. Medically necessary tests that cannot be done in the patient’s room

need to be planned and coordinated with the

department doing the test so that the patient does

not wait in the department’s waiting area, as few

staff as possible are present and they have appropriate PPE, as few other patients as possible are in

the area. The room and equipment must be appropriately cleaned after the patient leaves and before

another patient is seen.

If surgery is needed it should be done at a time

when as few other patients as possible are in the

OR. The patient should be brought directly into the

OR, not wait in the holding area. As few staff as

possible should be in the room. The OR staff in the

room should all wear N95 masks and goggles as

well as other appropriate PPE.

If the patient needs dialysis, this will be done in

the patient’s room. The patient will not go to the

dialysis unit.

In the event of cardiopulmonary arrest a

Protected Code Blue will be called. Only 6 members of the code team will be in the room. They

must all wear the appropriate PPE; PAPR unit,

gloves and gown. Equipment and supplies must go

in only one direction (equipment and supplies that

are taken off the code cart are not put back on the

cart).

Cohorting of Patients and Staff

If there is significant ERI transmission in the facility

or frequent unprotected exposures then patients

and staff may need to be cohorted in separate

areas of the facility according to their exposure status;

• No exposure

• Unprotected exposure but no symptoms

• Unprotected exposure with symptoms but do

not meet the ERI case definition

• Symptoms meet the ERI case definition

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

8 1

This policy has been reviewed and accepted by

Hospitalist Service 

Critical Care Service 

Pediatric Service 

Infectious Disease Service 

Occupational Medicine Department 

Emergency Department 

GIM Clinic 

Admitting Department 

ACOS 

Nursing Director for 3W 

Nursing Director for Pediatrics 

Nursing Director for Critical Care 

Housekeeping Department 

Engineering 

Perioperative Services 

CPR Committee 

Respiratory Therapy 

Security 

Transportation 

Laboratory 

Risk Management
Appendix D-1 

Sample Self-Triage Algorithm for Persons with Influenza Symptoms

Reproduced with permission from the Department of Veterans Affairs, VA Pandemic Influenza Plan

Appendix E-5: SAMPLE Self-Triage Algorithm for Persons with Influenza Symptoms.

You may have influenza (flu).

When should you seek additional help from a healthcare provider?

The symptoms of influenza are:

• Fever—low (99 ̊F) to high (104 ̊F), usually for 3 days, but may persist for 4 to 8 days. Sometimes fever

will go away and return a day later. 

• Aching muscles 

• Cough 

• Headache 

• Joint aches 

• Eye pain 

• Feeling very cold or having shaking chills 

• Feeling very tired 

• Sore throat, runny or stuffy nose 

8 2

Appendix D 

Self-Triage and Home Care Resources for Healthcare

Workers and Patients

If you have some of these symptoms:

Stay Home

• Rest

• Drink Fluids

• Take fever reducers (acetaminophen or ibuprofen)

But IF you

• Are unable to drink enough fluids

(urine becomes dark; you may feel

dizzy when standing)

• Have fever for more than 3 to 5 days

• Feel better, than develop a fever again

Or IF you

• Become short of breath or you develop

wheezing

• Cough up blood

• Have pain in your chest with breathing

• Have heart disease (like angina, or congestive heart failure) and you develop

chest pain

• Become unable to walk or sit up, or

function normally (others might be the

ones to notice this-especially in elderly

persons)

CALL your healthcare provider GO RIGHT AWAY for healthcare
Appendix D-2 

Home Care Guide for Influenza

Reproduced with permission from the Department of Veterans Affairs, VA Pandemic Influenza Plan Appendix

E-6, Home Care Guide for Influenza: Symptom and Care Log, Infection Control Measures for the Home.

A person with influenza will often become ill very suddenly. Fever and the worst symptoms often last three

days, but sometimes last as many as eight days. The person may feel weak, tired, or less energetic than

normal for weeks afterward, and may have a long-lasting hacking cough. 

Common symptoms:

Fever—low (99 ̊F) to high (104 ̊F), usually for 3 days, but may persist for 4 to 8 days. Sometimes fever will

go away and return a day later. 

• Extreme fatigue 

• Muscle and body aches 

• Feeling very cold or having shaking chills 

• Joint aches 

• Headache (may be severe) 

• Eye pain 

• Sore throat 

• Stuffed nose or runny nose 

• Dry cough initially, may become a deep, hacking, and painful cough over the course of several days 

• No appetite for food or desire to drink fluids 

Supplies to have on hand:

• Thermometer 

• Acetaminophen

• Cough suppressants/cough syrup 

• Drinks—fruit juices, sports drinks

• Light foods—clear soups, crackers, applesauce

• Blankets; warm covers 

Caring for a person with influenza:

• Comfort measures 

• Have the patient rest in bed.

• Allow the sick person to judge the amount of bed covers needed; when fever is high the person may

feel very cold and want several blankets. 

• Give acetaminophen or ibuprofen according to the package label or a health care provider’s direction

to reduce fever, headache, and muscle, joint or eye pain.

• Fluids—give frequently, extremely important to replace body fluids that are lost as a result of fever.

• Feeding 

• Give light foods as the person wants: fluids are more important than food, especially in the first days

when the fever may be highest. 

When to seek additional medical advice:

• If the person is short of breath or breathing rapidly at rest

• If the person’s skin is dusky or bluish in color 

• If the person is disoriented (“out of it”) 

• If the person is so dizzy or weak that standing is difficult (in a person who was able to walk before the

illness)

• If the person has not urinated in 12 or more hours 

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

8 3
Symptom and Care Log for Home Care

(Copy, fill out, and bring log sheets to healthcare provider visits)

Name of patient

Name of healthcare provider

Date Time Observations* Temperature Medication

8 4

* How the person looks; what the person is doing; fluids or foods taken since the last observation.
Appendix E-1. Influenza Diagnostic Table

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

8 5

Appendix E 

References for Diagnosis and Treatment of Staff 

During an Influenza Pandemic

Please refer to www.pandemicflu.gov or http://www.pandemicflu.gov/vaccine/#testing for current information and recommendations. Reproduced from the CDC Influenza (Flu) Laboratory Diagnostic Procedures for

Influenza webpage, http://www.cdc.gov/flu/professionals/labdiagnosis.htm. Last accessed March 6, 2007.

Procedure

Viral culture 

Immunofluorescence DFA

Antibody Staining 

RT-PCR5

Serology 

Enzyme Immuno Assay

(EIA) 

Rapid Diagnostic Tests 

Directigen Flu A7

(Becton-Dickinson) 

Directigen Flu A+B7,9

(Becton-Dickinson) 

Directigen EZ Flu A+B7,9

(Becton-Dickinson) 

FLU OIA4,7 

(Biostar) 

FLU OIA A/B 7, 9

(Biostar) 

XPECT Flu A&B7,9

(Remel) 

NOW Influenza A8,9

(Binax)

NOW Influenza B8,9

(Binax) 

NOW Influenza A&B8,9

(Binax)

OSOM® Influenza A&B9

(Genzyme)

QuickVue Influenza Test4,8

(Quidel) 

Influenza

Types

Detected

A and B

A and B 

A and B 

A and B 

A and B

A 

A and B 

A and B 

A and B

A and B 

A and B 

A 

B

A and B

A and B

A and B

Acceptable Specimens

NP swab2

, throat swab, nasal wash,

bronchial wash, nasal aspirate, sputum

NP swab2, nasal wash, bronchial wash,

nasal aspirate, sputum 

NP swab2

, throat swab, nasal wash,

bronchial wash, nasal aspirate, sputum 

paired acute and convalescent serum

samples6

NP swab2, throat swab, nasal wash,

bronchial wash

NP wash and aspirate 

NP swab2

,aspirate, wash; lower nasal

swab; throat swab; bronchioalveolar

lavage 

NP swab2

, aspirate, wash; lower nasal

swab; throat swab; bronchioalveolar

lavage 

NP swab2

, throat swab, nasal aspirate,

sputum 

NP swab2

, throat swab, nasal aspirate,

sputum 

Nasal wash, NP swab2

, throat swab 

Nasal wash/aspirate, NP swab2

Nasal wash/aspirate, NP swab2

Nasal wash/aspirate, NP swab2

Nasal swab

NP swab2

, nasal wash, nasal aspirate 

Time for

Results

3-10 days 3

2-4 hours 

2-4 hours 

>2 weeks 

2 hours

<30 minutes 

<30 minutes 

<30 minutes 

<30 minutes 

<30 minutes 

<30 minutes 

<30 minutes

<30 minutes

<30 minutes

<30 minutes

<30 minutes 

Rapid 

result 

available

No 

No 

No 

No 

No 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes

Yes

Yes

Yes

Yes 
8 6

Occupational Safety and 

Health Administration

QuickVue Influenza A+B

Test8,9

(Quidel) 

SAS Influenza A Test7,8,9

SAS Influenza B Test7,8,9

ZstatFlu4,8

(ZymeTx)

A and B

A

B

A and B

NP swab2

, nasal wash, nasal aspirate 

NP wash2, NP aspirate2

NP wash2, NP aspirate2

throat swab 

<30 minutes 

<30 minutes

<30 minutes

<30 minutes

Yes 

Yes

Yes

Yes 

1. List may not include all test kits approved by the U.S. Food and Drug Administration. 

2. NP = nasopharyngeal. 

3. Shell vial culture, if available, may reduce time for results to 2 days. 

4. Does not distinguish between influenza A and B virus infections. 

5. RT-PCR = reverse transcriptase polymerase chain reaction. 

6. A fourfold or greater rise in antibody titer from the acute- (collected within the 1st week of illness) to the 

convalescent-phase (collected 2-4 weeks after the acute sample) sample is indicative of recent infection. 

7. Moderately complex test – requires specific laboratory certification. 

8. CLIA-waived test. Can be used in any office setting. Requires a certificate of waiver or higher laboratory. 

certification. 

9. Distinguishes between influenza A and B virus infections. 

Disclaimer: Use of trade names or commercial sources is for identification only and does not imply endorsement by the Centers for Disease Control and Prevention or the Department of Health and Human Services.
1. Hospital Preparedness Checklist (Department of Health and Human Services) 

http://www.hhs.gov/pandemicflu/plan/sup3.html#app2

2. Long-term Care and Other Residential Facilities Pandemic Influenza Planning Checklist 

(Department of Health and Human Services)

http://www.pandemicflu.gov/plan/LongTermCareChecklist.html

3. Medical Offices and Clinics Pandemic Influenza Planning Checklist 

(Department of Health and Human Services)

http://www.pandemicflu.gov/plan/medical.html

4. Emergency Medical Services and Non-emergent (Medical) Transportation Organizations 

Pandemic Influenza Planning Checklist 

(Department of Health and Human Services)

http://www.pandemicflu.gov/plan/emgncy medical.html

5. Home Health Care Services Pandemic Influenza Planning Checklist 

(Department of Health and Human Services)

http://www.pandemicflu.gov/plan/healthcare.html

6. Department of Veterans Affairs (VA) 

VA Pandemic Influenza Plan Appendix D-2: Sample Emergency Management Program 

Standard Operating Procedure (SOP)

http://www.publichealth.va.gov/flu/pandemicflu_plan.htm#

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

8 7

Appendix F 

Pandemic Planning Checklists and Example Plans
Appendix F-1 

Sample Emergency Management Program

Standard Operating Procedure (SOP)

Reproduced with permission from the Department

of Veterans Affairs Pandemic Plan, Appendix D-2:

Sample Emergency Management Program

Standard Operating Procedure (SOP). 

Pandemic Influenza Affecting A VA Healthcare

Facility (Modify for your facility)

Emergency Management Program Guidebook

Department of Veterans Affairs 

THE DEPARTMENT OF VETERANS AFFAIRS 

MEDICAL CENTER 

(LOCATION) 

EMERGENCY MANAGEMENT PROGRAM (DATE) 

STANDARD OPERATING PROCEDURE NO. ( ) 

SUBJECT: VA Health Care Facility’s Preparation and

Response to an Influenza Pandemic 

Description of the Threat/Event.

a.Agent. A pandemic occurs when a new strain

of influenza virus emerges that has the ability

to infect and be passed between humans.

Because humans would have little immunity to

the new virus, a worldwide epidemic, or pandemic, can ensue. Influenza viruses have

threatened the health of human populations

for centuries. The diversity and propensity of

influenza viruses for mutation have thwarted

efforts to develop both a universal vaccine and

highly effective antiviral drugs. As a result, and

despite annual vaccination programs and modern medical technology, even seasonal influenza in the United States results in approximately

36,000 deaths and 226,000 hospitalizations

each year. A pandemic strain of influenza could

cause manyfold more. Transmission of influenza is aided by the fact that infected people may

shed virus and spread the infection for one-half

day to one day before symptoms begin. 

b.Clinical Disease. Symptoms of influenza typically begin two days after exposure, often

starting with a sudden onset of fever, severe

fatigue or muscle pain, sore throat, and a dry

cough. Uncomplicated seasonal influenza commonly leads to three to five days of acute illness, including fever and prostration, leaving

the sufferer feeling weakened and with a residual cough for two or more weeks longer. A

new strain may present a different clinical

course and be much more serious, causing

severe morbidity and mortality from influenza

pneumonia or pneumonitis and secondary

bacterial infections. 

c. Public Health Response. Public health measures to slow or stop a pandemic influenza

will likely include a number of actions that

will have a range of success. A monovalent

influenza vaccine made for the specific pandemic strain will be manufactured, but this will

take several months. An antiviral medication,

oseltamivir, that can be given to exposed persons to prevent illness and help limit transmission is available but supplies are limited and

manufacturing is a complex process.

Oseltamivir may be effective against the H5N1

avian influenza that has infected humans in

Asia and Europe; VA holds a 500,000 treatment

course stockpile of oseltamivir. Other public

health measures include commonsense

actions, like hand washing, respiratory

hygiene, staying home when sick, and using

telework or telecommuting options when able.

Health care facility actions involve isolating the

sick, having staff wear appropriate personal

protective equipment (PPE), and screening for

influenza illness or exposure before permitting

entry to a facility. Community, regional, and

nationally-mandated measures may include

declaration of “snow days”, postponing of

large public gatherings, quarantine of the

exposed, and restrictions on travel. 

Impact on Mission Critical Systems.

• An influenza pandemic can quickly overwhelm

a VA medical center’s or community-based outpatient clinic’s normal capacity to provide timely and accessible medical care. Because of the

ease with which influenza is transmitted,

healthcare facilities can quickly become sites of

intensive exposure for staff and non-infected

patients. Breaks in procedure or unanticipated

exposures may overwhelm a whole Medical

Center, for example, by exposing personnel

and requiring quarantine of the Medical Center.

For this reason it is incumbent that VHA facilities prepare for the possibility of an influenza

pandemic. 

• An influenza pandemic can quickly overwhelm

a hospital’s or CBOC’s mission critical systems,

causing such problems as: 

• Staffing shortages from community quarantine

and competing family interests. 

8 8

Occupational Safety and 

Health Administration
• Depleted supplies of vaccines and antivirals. 

• Stretched bed capacity and operational space

required for patient care or quarantine. 

• A pandemic, by definition, will be a widespread—even national—event, so close coordination and cooperation with local, county, state

public health agencies; and private sector

healthcare facilities will be necessary and vital.

It will also be necessary for VA medical centers

to anticipate VA’s mission to back up the

Department of Defense (and provide care to

designated members of the military) and VA’s

responsibilities to the National Response Plan

(and provide care and resources for care to

non-enrolled veterans and non-veterans). 

Operating Units and Key Personnel with

Responsibility to Manage this Threat.

• Facility Director – Responsible for assuring

the organization implements the necessary

preparatory measures for a potential influenza

pandemic. The Director is also responsible for

initiating the organization’s disaster plan. 

• Infection Control Team/Epidemiology – Key role

in: tracking potential and confirmed cases;

infection control management of patients

using airborne precautions (private room, negative airflow, N95 respirator use by staff) or,

when the Medical Center is overwhelmed,

using droplet precautions and cohorting (isolation of infectious patients together, but away

from non-exposed); working with and reporting to local and state public health agencies;

serving as a VA medical center information

resource on changing public health recommendations and on the community/outbreak;

assisting with vaccination decisions affecting

staff and patients; and advising on mass distribution systems for vaccine and antivirals. 

• Engineering Service – Key role in: assessment

of negative airflow rooms and negative airflow

systems; identification of areas suitable for

cohorting patients both in waiting areas and

after hospitalization. 

• Clinical Laboratory – Key role in: obtaining and

performing diagnostic tests for the pandemic

strain; knowing availability of reference laboratories for diagnosis (like the CDC’s Laboratory

Response Network [LRN] or state laboratories);

advising on specimen collection; safe handling,

storage, and shipping of specimens. 

• Safety/Industrial Hygiene – Key role in: support

of N95 respirator usage (fit testing) program.

• Police and Security – Key role in: crowd control, managing the flow of patients and visitors.

If the situation warrants, police have key role in

perimeter control, site access. Police may be

called upon to protect the supply of influenza

vaccines and supplies like oseltamivir, vaccine,

N95 masks, and surgical or procedure-type

masks. Perimeter access and site control may

pertain to staff, staff relatives/family, and

patients and require ingress and egress control. Site control may include assisting with

drive-through triage stations or drive-through

clinic sites, and mass distribution of vaccine

and antivirals.

• Medical Service – Key role in: clinical diagnosis

of cases; treatment of cases; providing healthcare advice via telephone; staffing innovative

care delivery sites, advising/assisting with

mass delivery of vaccine and antivirals. 

• Nursing Service – Key roles in: staffing and bed

support for inpatient, outpatient, and innovative care delivery sites; assisting with restriction of non-essential personnel from patient

rooms (i.e., environmental management service, nutrition and food service personnel); providing healthcare advice via telephone; advising/assisting with mass delivery of vaccine and

antivirals. 

• Emergency Department – Key role in: monitoring incoming patients suspected of exposure

or disease; making decisions on maintaining

separate clinical activities. 

• Pharmacy – Key role in managing the supply of

vaccines and antivirals. 

• Employee/Occupational Health – Key role in:

employee vaccination/clinical care (identification of vaccine contraindications), information

flow/risk communication to staff; advising/

assisting with advice to staff about their ability

to work, maintaining healthcare records for

staff, including immune status. 

• EMS/Safety – Key role in: advising on cleaning

of rooms; equipment; communication of advice

on cleaning measures. 

• Volunteer Service – Key role in: coordinating

volunteers (existing and community members)

willing to assist. Volunteers also should assist

in establishing an area for child care and

respite for healthcare facility staff unable to

leave the facility. 

• Public Affairs – Key role in: keeping staff and

patients informed, updating website, working

with VSOs, media. 

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

8 9
Mitigation/Preparedness Activities of the

Threat/Event.

The mode(s) of transmission, degree of morbidity and mortality, and amount of societal disruption that a pandemic influenza might cause will

be uncertain until the specific influenza strain is

identified and observed. From applying what 

is known about seasonal influenza, it might be

expected that a pandemic influenza would follow

some of the same transmission patterns: ready

transmission by respiratory droplets (and perhaps by aerosolized particles) from person to

person; shedding and transmission of virus

before persons are ill, a short incubation period

of approximately 2 days, and thus a potential

doubling of cases every 2 to 3 days.

a. Hazard Reduction.

• Notification/risk communications plan. 

• Activation of hospital emergency plan. 

• Perimeter control potential: need for

increased security staffing, heightened security requirements for access control. 

• Building systems assessment for cohorting

potential and confirmed patients. 

• Implementation of measures to provide

added capacity for a potential surge of inpatient and ambulatory care. 

• Exposure control/Infection control: Airborne

Infection Isolation and Contact Precautions

are advised for a potentially lethal strain of

pandemic influenza, in order to maximally

protect staff. Patients should be placed in

room with negative airflow and HEPA

exhaust; and should wear surgical masks

when transported through the Medical Center.

If facilities are unable to exercise this degree

of isolation, cohorting of patients in common,

exposed areas with HVAC isolation and exhaust

(if possible) and use of respiratory droplet

precautions by staff are advised. 

• Separation of new, unexposed patients from

potential pandemic influenza cases. 

• Use of Airborne Infection Isolation and

Contact Precautions, if possible, or Droplet

Precautions. 

• Visitor restriction policies. 

• If necessary, control of the perimeter: need

for increased security staffing, heightened

security requirements for access control. 

b. Preparedness Strategies and Resources.

• Establishment of Pandemic Response Team

that will be prepared to work during a pandemic. 

• Vaccination (if available). 

• Antiviral medications prescribed to prevent

illness in the exposed or unvaccinated (if

available). 

• Public health measures of hand washing,

respiratory hygiene, staying home when ill,

respecting quarantine, isolation, “snow day”

and travel, and public gathering limitations. 

• Education (on public health measures, infection control guidelines, home care, self-triage

[to determine when medical care is necessary]). 

• Plan for Airborne Infection Isolation and

Contact Precautions for all personnel with

patient contact. 

• Anticipation of need to manage a large number of fatalities. 

Response/Recovery from the Event/Threat.

a. Hazard Control and Monitoring Strategies.

• First case identified at a VAMC. 

1. Should be immediately reported: any

suspected case(s) of pandemic influenza

to Infection Control for confirmation.

Infection Control would then brief the

Chief of Medicine and the Chief of Staff.

If case is confirmed, the Director, Safety

Officer, Police and Occupational Health

would be notified (this will most likely

occur when a known pandemic virus is

circulating elsewhere in the world and a

VA medical center suspects it has the first

U.S. or regional case). 

2. Activate Infection Control Team for initiation of patient/exposed staff tracking system, patient/staff educational information. 

3. Clear all patients and employees from

the vicinity of the suspected case. 

4. Document details of incident and names

of all persons within the immediate “at

risk” area (i.e., who have become contacts and may require quarantine, antiviral medications). 

5. Contact local/state public health contacts

for diagnostic sample collection and

shipping instructions. 

9 0

Occupational Safety and 

Health Administration
6. Contact local/state public health agencies, Pharmacy Benefits Management, or

VACO Office of Public Health and

Environmental Hazards to obtain vaccine,

depending on guidance provided at the

time (if pandemic vaccine is available). 

7. Contact Pharmacy Benefits Management,

or VACO Office of Public Health and

Environmental Hazards for access to VA’s

oseltamivir (antiviral medication) stockpile. 

8. Activate Infection Control Team for initiation of patient/exposed employee tracking system, patient/employee educational information. 

9. Initiate antiviral medication for all potential exposed persons as appropriate after

discussion with local/state public health

agencies, if appropriate. 

10. Notify internal personnel, as appropriate,

including Chief of Staff, Health Care

Providers, Nursing Service, Pharmacy,

Microbiology Laboratory, and Engineering

for immediate inventory of critical

resources. 

11. Immediately assess potential impact of

actual event on mission-critical systems

to include staffing, critical supplies, operational space, potential for patient and

staff exposures and HVAC system. 

• Cases already identified among existing

enrolled veterans. 

1. VA personnel must maintain communications and awareness with local and state

public health agencies of progression of

the pandemic in the community. Information must be shared with internal VA

personnel, including VAMC Director,

Chief of Staff, Police and Security, Chief

Nurse Executive, Safety Officer/Industrial

Hygienist, Employee/Occupational

Health, Emergency Room Personnel,

Health Care Providers, Pharmacy, and

Microbiology Laboratory for immediate

inventory of critical resources. 

A. Perform active surveillance for pandemic influenza appearing among

hospitalized inpatients, or outpatients

according to the prevailing case definition. 

B. Notify the Clinical Microbiology

Laboratory of potential for use of

rapid diagnostic tests or sending of

specimens to reference laboratories. 

C. Immediately assess potential impact of

reported community events on mission critical systems to include

staffing, critical supplies and operational space. 

D. Await follow-up information from local

authorities and prepare for potential

presentation of patients. 

b. Resource Issues. 

• Staffing needs will be monitored and addressed by Chief of Staff, Chief of Nursing,

VAMC Director, and other involved Service

Chiefs. 

• Critical Supplies – Vaccine (if available at the

time) will likely be distributed through state

health departments or through VA Central

Office Pharmacy Benefits Management

Strategic Healthcare Group. Additional timely

information about vaccine may be expected

from VACO. Other critical supplies to assess

in the event of pandemic influenza include

respiratory support equipment (oxygen, and

oxygen-delivery equipment, ventilators), personal protective equipment, antimicrobial

soap and alcohol-based hand cleaners, antibiotics to treat secondary bacterial pneumonias,

morgue kits. 

• Resource Allocation – Develop criteria and

transparent processes for allocation decisions

regarding resources that may not be available

in sufficient quantities during a pandemic:

antivirals, respirators, vaccines, staff. 

• Space Management – Assess negative airflow

room and cohorting bed and space availability; refrigerated space to store bodies. 

• Emergency Room capabilities, acute care clinic capabilities and current/projected bed availability should be immediately assessed. 

• Exposed patients and staff might expect

short-term quarantine on site or relocation to

alternate care sites or alternate healthcare

facilities. 

• Consideration should be given to providing

pandemic influenza countermeasures that are

in short supply to staff members’ families

(vaccine, antivirals, personal protective equipment), depending on availability and on the

facility’s responsibilities and assignments

under the National Response Plan. If staff

members’ families can be protected, staff will

be more available to take care of patients. 

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

9 1
c. Clinical Response.

• Treatment protocols will be based upon prevailing knowledge of the pandemic influenza

strain and will include supportive care (respiratory support, hemodynamic support) and

use of antivirals. 

• Clinical admission/treatment decisions will be

made by the health care providers. 

• All quarantine and visitor restriction decisions

will be made by the VAMC Director based

upon recommendations of the Infection

Control Team or pandemic influenza response

team following local/state public health guidance and decisions, and advice of regional VA

counsel, if needed. Such decisions will be

proportional to the disease impact, necessary,

relevant, and applied equitably, and will

employ the least restrictive means if options

are available. 

• All patients treated and evaluated for potential pandemic influenza must be reported to

the Infection Control Team or designated pandemic influenza response team for data collection. 

• Patient and staff recordkeeping must be

maintained according to usual standards, if

possible. 

• The Infection Control Team or designated

pandemic influenza response team will monitor all potential cases and make appropriate

reports to the VAMC Director and state and

local public health agencies. 

Notes:

1.Vaccination of Health Care Providers: Vaccine

for a pandemic influenza strain will be developed once the strain is known. This vaccine

will most likely be distributed to states and

then to public and private medical centers.

Changes and updates on vaccine availability

will be communicated to VISNs and VAMCs

from VACO. 

i. The Infection Control Team, or designated pandemic influenza response

team, working with the Chief of Staff

and VAMC Director will notify Health

Care Providers when treatment/exposure guidelines are updated or as new

resources are made available. The

Infection Control Team can monitor

the VA pandemic influenza websites

for these updates. Note that VA guidance may differ from CDC guidance. 

d. Recovery Strategies.

• Periodic critical supply inventories with resupply or supplementation from outside facilities, as needed. 

• Periodic staffing census with workload redistribution, as needed. 

• Close monitoring of patient census and bed

status. 

• Monitoring of staff and patient mental health. 

External Notification Procedures.

a. Within VA. VISN, VACO. 

b. Other State and Federal Agencies. Local and

state public health departments who will notify

CDC. 

• OSHA – follow prevailing rules for notification

of employee fatalities and hospitalizations. 

c. Community Entities. Neighboring hospitals,

emergency response systems (police, firefighters, emergency medical services, 911 operators). 

Specialized Staff Training.

• Health Care Provider Training – Recognition of

clinical syndromes associated with influenza,

treatment protocols, guidelines for personal

protective equipment. 

• Infection Control Team Training – Passive and

active surveillance systems for monitoring

reportable infectious disease pathogens. 

• Safety Specialist/Industrial Hygienist – N95 respirator usage. 

• Clinical Laboratories – Diagnostic tests, specimen collection, handling, and shipping. 

• Social Work Service – Introductory training on

pandemic influenza, risks, treatments, family

implications, and follow-up. 

• Police and Security – Introductory training on

pandemic influenza, PPE recommendations. 

• Environmental Management Service Personnel

– Introductory training on pandemic influenza

risks, decontamination of environments, bedclothing management, PPE recommendations. 

References and Further Assistance.

• The VA Pandemic Influenza Plan. 

• The VA Respiratory Infectious Diseases

Emergency Plan (an amendment to the VHA

Emergency Management Guidebook).

9 2

Occupational Safety and 

Health Administration
PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

9 3

pandemicflu.htm 

• Federal websites on pandemic influenza

www.pandemicflu.gov 

• Phone Numbers. 

• VACO Office of Public Health and

Environmental Hazards - 202-273-8575, 8567 

• VACO Pharmacy Benefits Management - 708-

786-7886 

Review Date

(NAME) 

Chief, (SERVICE NAME) 

Attachment: 

Key Activity Management Tool/Structure 

Available at http://www.publichealth.va.go/

watch/respiratoryID.htm 

• VHA Under Secretary for Health Influenza

Advisories. Available at http://www.

publichealth.va.gov/flu/advisory.htm 

• Local, County, State Health Departments (24/7

contact information must be part of your emergency plans for pandemic influenza). 

• VA guidance and websites on pandemic

influenza www.publichealth.va.gov/infection

dontpassiton

http://www.publichealth.va.gov/flu/
9 4

Occupational Safety and 

Health Administration

1. Department of Health and Human Services

http://www.pandemicflu.gov/rcommunication/

“Message maps” are risk communication tools used to convey complex information, and to make it

easier to understand. Each primary message has three supporting messages that can be used to provide context for the subject of the primary message.

http://www.pandemicflu.gov/rcommunication/ pre_event_maps.pdf 

2. Association of State and Territorial Health Officials

http://www.astho.org/?template=risk_ communication.html

3. Substance Abuse and Mental Health Services Administration

http://www.riskcommunication.samhsa.gov/ index.htm

4. World Health Organization

http://www.who.int/csr/resources/publications/ WHO_CDS_2005_31/en/

http://www.who.int/infectious-disease-news/IDdocs/whocds200528/whocds200528en.pdf

http://www.who.int/csr/don/Handbook_ 

influenza_pandemic_dec05.pdf

Appendix G 

Risk Communication Resources
Appendix G-1 

Risk and Crisis Communication: 

77 Questions Commonly Asked by

Journalists During a Crisis 

(Reproduced with permission from: Covello, V.T.,

“Risk Communication and Message Mapping: A

New Tool for Communicating Effectively in Public

Health Emergencies and Disasters,” Journal of

Emergency Management, Vol.#4 No.#3, 25-40

(2006)).

Journalists are likely to ask six questions in a crisis

(who, what, where, when, why, how) that relate to

three broad topics: (1) What happened?; (2) What

caused it to happen?; (3) What does it mean?

Specific questions include:

1. What is your name and title?

2. What are your job responsibilities?

3. What are your qualifications?

4. Can you tell us what happened?

5. When did it happen?

6. Where did it happen?

7. Who was harmed?

8. How many people were harmed?

9. Are those that were harmed getting help?

10. How certain are you about this information?

11. How are those who were harmed getting help?

12. Is the situation under control?

13. How certain are you that the situation is under

control?

14. Is there any immediate danger?

15. What is being done in response to what happened?

16. Who is in charge?

17. What can we expect next?

18. What are you advising people to do?

19. How long will it be before the situation returns

to normal?

20. What help has been requested or offered from

others?

21. What responses have you received?

22. Can you be specific about the types of harm

that occurred?

23. What are the names of those who were

harmed?

24. Can we talk to them?

25. How much damage occurred?

26. What other damage may have occurred?

27. How certain are you about damages?

28. How much damage do you expect?

29. What are you doing now?

30. Who else is involved in the response?

31. Why did this happen?

32. What was the cause?

33. Did you have any forewarning that this might

happen?

34. Why wasn’t this prevented from happening?

35. What else could go wrong?

36. If you are not sure of the cause, what is your

best guess?

37. Who caused this to happen?

38. Who is to blame?

39. Could this have been avoided?

40. Do you think those involved handled the situation well enough?

41. When did your response to this begin?

42. When were you notified that something had

happened?

43. Who is conducting the investigation?

44. What are you going to do after the investigation?

45. What have you found out so far?

46. Why was more not done to prevent this from

happening?

47. What is your personal opinion?

48. What are you telling your own family?

49. Are all those involved in agreement?

50. Are people overreacting?

51. Which laws are applicable?

52. Has anyone broken the law?

53. How certain are you that mistakes have not

been made?

54. Have you told us everything you know?

55. What are you telling us?

56. What effects will this have on the people

involved?

57. What precautionary measures were taken?

58. Do you accept responsibility for what happened?

59. Has this ever happened before?

60. Can this happen elsewhere?

61. What is the worst case scenario?

62. What lessons were learned?

63. Were those lessons implemented? Are they

being implemented now?

64. What can be done to prevent this from happening again?

65. What would you like to say to those who have

been harmed and to their families?

66. Is there any continuing danger?

67. Are people out of danger? Are people safe? 

68. Will there be inconvenience to employees or

to the public?

69. How much will all this cost?

70. Are you able and willing to pay the costs?

71. Who else will pay the costs?

72. When will we find out more?

73. What steps need to be taken to avoid a similar

event?

74. Have these steps already been taken?

75. If not, why not?

76. Why should we trust you?

77. What does this all mean?

PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

9 5
9 6

Occupational Safety and 

Health Administration

Appendix H-1 

Examples of Consumable and Durable

Supply Needs

Reproduced and modified from the HHS Pandemic

Influenza Plan Supplement 3 Health Care Planning,

Box 2. 

• Consumable resources 

• Hand hygiene supplies (antimicrobial soap

and alcohol-based, waterless hand hygiene

products) 

• Disposable N95 respirators, surgical and procedure masks 

• Face shields (disposable or reusable) 

• Gowns 

• Gloves 

• Facial tissues 

• Central line kits 

• Morgue packs 

• Durable resources 

• Ventilators 

• Respiratory care equipment 

• Beds 

• IV pumps

http://www.hhs.gov/pandemicflu/plan/sup3.html

Appendix H-2 

Suggested Inventory of Durable and

Consumable Supplies for Veterans

Administration Health Care Facilities 

during a Pandemic Influenza

Reproduced with permission from Department of

Veterans Affairs, VA Pandemic Plan

Durable resources

• Mechanical ventilators 

• Manual resuscitators (bag-valve mask) 

• Beds 

• Stretchers/gurneys 

• IV pumps 

• Positive air purifying respirators (PAPRs) or

other equivalent respirators 

Consumable resources (consider stockpiling a 4-

week supply)

• Hand hygiene supplies (antimicrobial soap and

alcohol-based [>60%], waterless hand hygiene

gels or foams) 

• Disposable fit-testable N95 respirators 

• Elastomeric respirators with P100 filters 

• Surgical and procedure-type masks 

• Goggles 

• Gowns 

• Gloves 

• Facial tissues

• Central line kit

• Morgue packs 

• IV equipment 

• Syringes and needles for vaccine administration

• Respiratory care equipment 

• Portable oxygen 

• Regulators and flow meters

• Oxygen and ventilator tubing, cannulae,

masks

• Endotracheal tubes, various sizes 

• Suction kits 

• Tracheotomy

• Vacuum gauges for suction and portable suction machines

• Intensive care unit (ICU) monitoring equipment 

Medications (consider stockpiling a 4-week supply)

• Nonsteroidal anti-inflammatory drugs

(NSAIDs), pill and liquid forms

• Acetaminophen (pill, suppository, liquid) 

• Antibiotics (consider ciprofloxacin, levofloxacin

po and iv, vancomycin, piperacillin/tazobactam,

ceftriaxone)

• Antivirals (oseltamivir) 

• Vaccines (pandemic and seasonal influenza,

pneumococcal)

• Vasopressors

• Benzodiazepines, propofal 

• Proton pump inhibitors

• Bronchodilators 

Items to consider including in home care kits 

• Thermometers 

• NSAIDs or acetaminophen 

• Cough suppressants 

• Oral rehydration mix packs 

• Surgical or procedure-type masks for the

patient to wear around others and for care

providers to wear around the patient 

• Printed home care instructions, including VA

facility contact information and information

about symptoms that should prompt the

patient to see a healthcare provider 

Appendix H 

Sample Supply Checklists For Pandemic Planning
PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE FOR 

HEALTHCARE WORKERS AND HEALTHCARE EMPLOYERS

9 7

OSHA Assistance

OSHA can provide extensive help through a variety of

programs, including technical assistance about effective safety and health programs, state plans, workplace consultations, voluntary protection programs,

strategic partnerships, training and education, and

more. An overall commitment to workplace safety and

health can add value to your business, to your workplace, and to your life.

Safety and Health Program Management Guidelines

Effective management of employee safety and health

protection is a decisive factor in reducing the extent

and severity of work-related injuries and illnesses and

their related costs. In fact, an effective safety and

health program forms the basis of good employee

protection and can save time and money (about $4

for every dollar spent) and increase productivity and

reduce employee injuries, illnesses, and related workers’ compensation costs.

To assist employers and employees in developing

effective safety and health programs, OSHA published recommended Safety and Health Program

Management Guidelines (54 Federal Register (16):

3904-3916, January 26, 1989). These voluntary guidelines can be applied to all places of employment covered by OSHA.

The guidelines identify four general elements critical to the development of a successful safety and

health management system:

• Management leadership and employee involvement,

• Worksite analysis,

• Hazard prevention and control, and

• Safety and health training.

The guidelines recommend specific actions, under

each of these general elements, to achieve an effective safety and health program. The Federal Register

notice is available online at www.osha.gov. 

State Programs

The Occupational Safety and Health Act of 1970 (OSH

Act) encourages states to develop and operate their

own job safety and health plans. OSHA approves and

monitors these plans. Twenty-four states, Puerto Rico

and the Virgin Islands currently operate approved

state plans: 22 cover both private and public (state

and local government) employment; Connecticut,

New Jersey, New York and the Virgin Islands cover

the public sector only. States and territories with their

own OSHA-approved occupational safety and health

plans must adopt standards identical to, or at least as

effective as, the Federal OSHA standards.

Consultation Services

Consultation assistance is available on request to

employers who want help in establishing and maintaining a safe and healthful workplace. Largely funded

by OSHA, the service is provided at no cost to the

employer. Primarily developed for smaller employers

with more hazardous operations, the consultation

service is delivered by state governments employing

professional safety and health consultants. Comprehensive assistance includes an appraisal of all mechanical systems, work practices, and occupational safety and health hazards of the workplace and all aspects

of the employer’s present job safety and health program. In addition, the service offers assistance to

employers in developing and implementing an effective safety and health program. No penalties are proposed or citations issued for hazards identified by the

consultant. OSHA provides consultation assistance to

the employer with the assurance that his or her name

and firm and any information about the workplace will

not be routinely reported to OSHA enforcement staff.

Under the consultation program, certain exemplary

employers may request participation in OSHA’s Safety

and Health Achievement Recognition Program

(SHARP). Eligibility for participation in SHARP includes receiving a comprehensive consultation visit,

demonstrating exemplary achievements in workplace

safety and health by abating all identified hazards, and

developing an excellent safety and health program.

Employers accepted into SHARP may receive an

exemption from programmed inspections (not complaint or accident investigation inspections) for a period of 1 year. For more information concerning consultation assistance, see OSHA’s website at

www.osha.gov.

Voluntary Protection Programs (VPP)

Voluntary Protection Programs and on-site consultation services, when coupled with an effective enforcement program, expand employee protection to

help meet the goals of the OSH Act. The VPPs motivate others to achieve excellent safety and health

results in the same outstanding way as they establish a cooperative relationship between employers,

employees, and OSHA.

For additional information on VPP and how to

apply, contact the OSHA regional offices listed at the

end of this publication.

Strategic Partnership Program

OSHA’s Strategic Partnership Program, the newest

member of OSHA’s cooperative programs, helps

encourage, assist, and recognize the efforts of partners to eliminate serious workplace hazards and

achieve a high level of employee safety and health.

Whereas OSHA’s Consultation Program and VPP entail

one-on-one relationships between OSHA and individual worksites, most strategic partnerships seek to

have a broader impact by building cooperative relationships with groups of employers and employees.

These partnerships are voluntary, cooperative relation-
9 8

Occupational Safety and 

Health Administration

ships between OSHA, employers, employee representatives, and others (e.g., trade unions, trade and professional associations, universities, and other government agencies). 

For more information on this and other cooperative programs, contact your nearest OSHA office, or

visit OSHA’s website at www.osha.gov.

Alliance Program

Through the Alliance Program, OSHA works with

groups committed to safety and health, including

businesses, trade or professional organizations,

unions and educational institutions, to leverage

resources and expertise to develop compliance assistance tools and resources and share information with

employers and employees to help prevent injuries,

illnesses and fatalities in the workplace.

Alliance Program agreements have been established with a wide variety of industries including

meat, apparel, poultry, steel, plastics, maritime, printing, chemical, construction, paper and telecommunications. These agreements are addressing many safety and health hazards and at-risk audiences; including

silica, fall protection, amputations, immigrant workers,

youth and small businesses. By meeting the goals of

the Alliance Program agreements (training and education, outreach and communication, and promoting the

national dialogue on workplace safety and health),

OSHA and the Alliance Program participants are

developing and disseminating compliance assistance

information and resources for employers and employees such as electronic assistance tools, fact sheets,

toolbox talks, and training programs.

OSHA Training and Education

OSHA area offices offer a variety of information services, such as compliance assistance, technical advice,

publications, audiovisual aids and speakers for special

engagements. OSHA’s Training Institute in Arlington

Heights, IL, provides basic and advanced courses in

safety and health for Federal and state compliance

officers, state consultants, Federal agency personnel,

and private sector employers, employees, and their

representatives.

The OSHA Training Institute also has established

OSHA Training Institute Education Centers to address

the increased demand for its courses from the private

sector and from other federal agencies. These centers

are nonprofit colleges, universities, and other organizations that have been selected after a competition for

participation in the program.

OSHA also provides funds to nonprofit organizations, through grants, to conduct workplace training

and education in subjects where OSHA believes there

is a lack of workplace training. Grants are awarded

annually. Grant recipients are expected to contribute

20 percent of the total grant cost.

For more information on grants, training, and education, contact the OSHA Training Institute, Office of

Training and Education, 2020 South Arlington Road,

Arlington Heights, IL 60005, (847) 297-4810, or see

Outreach on OSHA’s website at www.osha.gov. For

further information on any OSHA program, contact

your nearest OSHA regional office listed at the end of

this publication.

Information Available Electronically

OSHA has a variety of materials and tools available on

its website at www.osha.gov. These include electronic

compliance assistance tools, such as Safety and

Health Topics, eTools, Expert Advisors; regulations,

directives and publications; videos and other information for employers and employees. OSHA’s software

programs and compliance assistance tools walk you

through challenging safety and health issues and

common problems to find the best solutions for your

workplace.

A wide variety of OSHA materials, including standards, interpretations, directives and more can be

purchased on CD-ROM from the U.S. Government

Printing Office, Superintendent of Documents, toll-free

phone (866) 512-1800.

OSHA Publications

OSHA has an extensive publications program. For a

listing of free or sales items, visit OSHA’s website at

www.osha.gov or contact the OSHA Publications

Office, U.S. Department of Labor, 200 Constitution

Avenue, NW, N-3101, Washington, DC 20210:

Telephone (202) 693-1888 or fax to (202) 693-2498. 

Contacting OSHA

To report an emergency, file a complaint, or seek

OSHA advice, assistance, or products, call (800) 321-

OSHA or contact your nearest OSHA Regional or Area

office listed at the end of this publication. The teletypewriter (TTY) number is (877) 889-5627.

Written correspondence can be mailed to the nearest OSHA Regional or Area Office listed at the end of

this publication or to OSHA’s national office at: U.S.

Department of Labor, Occupational Safety and Health

Administration, 200 Constitution Avenue, N.W.,

Washington, DC 20210.

By visiting OSHA’s website at www.osha.gov, you

can also:

• file a complaint online,

• submit general inquiries about workplace safety

and health electronically, and

• find more information about OSHA and occupational safety and health.
SAFEGUARDING EQUIPMENT AND PROTECTING EMPLOYEES FROM AMPUTATIONS 9 9

OSHA Regional Offices

Region I

(CT,* ME, MA, NH, RI, VT*) 

JFK Federal Building, Room E340

Boston, MA 02203

(617) 565-9860

Region II

(NJ,* NY,* PR,* VI*)

201 Varick Street, Room 670

New York, NY 10014

(212) 337-2378

Region III

(DE, DC, MD,* PA, VA,* WV)

The Curtis Center

170 S. Independence Mall West

Suite 740 West

Philadelphia, PA 19106-3309

(215) 861-4900

Region IV 

(AL, FL, GA, KY,* MS, NC,* SC,* TN*)

61 Forsyth Street, SW

Atlanta, GA 30303

(404) 562-2300

Region V

(IL, IN,* MI,* MN,* OH, WI)

230 South Dearborn Street 

Room 3244

Chicago, IL 60604

(312) 353-2220

Region VI

(AR, LA, NM,* OK, TX)

525 Griffin Street, Room 602

Dallas, TX 75202

(972) 850-4145

Region VII

(IA,* KS, MO, NE)

City Center Square

1100 Main Street, Suite 800

Kansas City, MO 64105

(816) 426-5861

Region VIII

(CO, MT, ND, SD, UT,* WY*)

1999 Broadway, Suite 1690

PO Box 46550

Denver, CO 80202-5716

(720) 264-6550

Region IX 

(American Samoa, AZ,* CA,* HI,* NV,* 

Northern Mariana Islands)

90 7th Street, Suite 18-100

San Francisco, CA 94103

(415) 625-2547

Region X

(AK,* ID, OR,* WA*)

1111 Third Avenue, Suite 715

Seattle, WA 98101-3212

(206) 553-5930

* These states and territories operate their own

OSHA-approved job safety and health programs

and cover state and local government employees

as well as private sector employees. The

Connecticut, New Jersey, New York and Virgin

Islands plans cover public employees only. States

with approved programs must have standards that

are identical to, or at least as effective as, the

Federal standards.

Note: To get contact information for OSHA Area

Offices, OSHA-approved State Plans and OSHA

Consultation Projects, please visit us online at

www.osha.gov or call us at 1-800-321-OSHA.