H1N1 Influenza in NYC: PPE Experience

H1N1 Influenza in NYC: PPE Experience 1

Background: NYC DOH Pandemic Planning NYC plan done in 2006 Assumptions: Focused on more severe pandemic scenario Likely to be recognized overseas prior to arrival in NYC Called for use of droplet precautions ~2005 HHS strategic pandemic plan Exception being aerosol generating procedures Pandemic strains with evidence of increased transmissibilty

Spring 2009 NYC Timeline April 21: CDC MMWR on CA H1N1 cases MMWR

NYC Timeline April 21: April 23: CDC MMWR on CA H1N1 cases CDC call re: 1 st cases of human to human transmission in CA NYC DOH starts active lab surveillance to look for similar strains Report of school cluster of strep throat

NYC Timeline April 21: April 23: April 24: CDC MMWR on CA H1N1 cases CDC call re: Hu-Hu transmission in CA NYC DOH starts active lab surveillance Report of school cluster of strep throat 1 st confirmation that H1N1 in Mexico Increasing # cases at school outbreak DOH team sent to obtain NP swabs

NYC Timeline April 15: April 23: April 24: April 25: CDC MMWR on CA H1N1 cases CDC call re: Hu-Hu transmission in CA NYC DOH starts active lab surveillance Report of school cluster of strep throat 1 st reports received of H1N1 in Mexico Increasing # cases at school outbreak DOH team sent to obtain NP swabs NYC Lab identifies non-subtypeable flu A NYC DOH Incident Command System activated

NYC Timeline April 21: April 23: April 24: April 25: April 26: CDC MMWR on CA H1N1 cases CDC call re: Hu-Hu transmission in CA NYC DOH sends Lab Alert requesting all flu A isolates be sent to PH Lab Report of school cluster of strep throat 1 st reports received of H1N1 in Mexico Increasing # cases at school outbreak DOH team sent to obtain NP swabs NYC PH Lab identifies non-subtypeable flu A Incident Command System activated CDC confirms novel H1N1 NYC press conference with Mayor and COH

Photo of press conference

Initial Key Public Health Questions given Emergence of New Virus Transmissibility ease and extent of spread? Virulence how severe is it?

Spring 2009 H1N1 Outbreak NYC Response Active/enhanced surveillance to Monitor trajectory of outbreak Estimate infection, hospital and case fatality rates Assess epidemiologic and clinical characteristics Monitor influenza subtypes circulating in city Detect and respond to outbreaks in institutional settings Address healthcare surge capacity needs Develop policy guidance on community and healthcare control measures Public and provider communication

Medical Community Outreach Frequent Health Alerts (n=12) Guidance documents (e.g., antiviral use, infection control, triage algorithms for ED/clinics) Daily conference calls with hospitals, private providers, community health clinics

H1N1 in NYC, Spring 2009 ~1000 hospitalizations; 50 deaths Laboratory Confirmed H1N1 Hospital Admissions and Emergency Department (ED) Visits for Influenza-like Illness (ILI) in NYC April 26 - June 29, 2009 100 3000 H1N1 Confirmed Hospital Admissions 90 80 70 60 50 40 30 20 10 H1N1 Admissions ED ILI Visits 2500 2000 1500 1000 500 ED ILI Visits 0 4/26/2009 4/28/2009 4/30/2009 5/2/2009 5/4/2009 5/6/2009 5/8/2009 5/10/2009 5/12/2009 5/14/2009 5/16/2009 5/18/2009 5/20/2009 5/22/2009 5/24/2009 5/26/2009 5/28/2009 5/30/2009 6/1/2009 6/3/2009 6/5/2009 6/7/2009 6/9/2009 6/11/2009 6/13/2009 6/15/2009 6/17/2009 6/19/2009 6/21/2009 6/23/2009 6/25/2009 6/27/2009 6/29/2009 0 Date of ED Visits or Hospital Admission

NYC Infection Control Guidance in Spring 2009 April 25 May 5: Initially followed CDC guidance for N95 use for suspected/confirmed cases based on exposure risk May 6 th : Revised guidance to use of droplet precautions N95s only recommended for aerosol generating procedures Rationale for change in guidance Community wide transmission (no longer able to use epi risk factors to ID potential cases) H1N1 transmission characteristics similar to seasonal influenza Implications for non-hospital sites (home care, clinics) caring for patients with nonspecific fever and resp sx Consistent with recommendations from NYSDOH, WHO, SHEA, IDSA, HICPAC, and most other state health departments Disclaimer to note differences with CDC guidance

NYC DOH Summer Planning for 2009-10 Influenza Season Sustainable surveillance system Strategies to minimize healthcare surge Ensure availability of antivirals Vaccination campaigns (H1N1/seasonal) Revised approach to school closure Public and provider communications Worker Protection/Infection control planning: City IHASP for non-medical workers in 39 city agencies Contingency planning for H1N1 RPP for DOH staff: Trained 35 staff for Just In Time surge capacity fit testing Assessed respirator stockpiling and equipment needs Awaited CDC s revised infection control guidance

CDC Interim PPE Recommendations for 2009 H1N1 (10/14/09) Recommend use of at least N95 for anyone within 6 feet of patient with suspected/confirmed H1N1 Prioritize N95 s for organisms known to be airborne transmitted (e.g., TB, measles) AND aerosolgenerating procedures Prioritization mode, once supplies are inadequate (including extended use and re-use) Facilities need to demonstrate good faith effort to acquire sufficient N95 s

Infection Control Guidance in Fall/Winter 2009-2010 NYC/NYS decided to adopt CDC guidance Primary rationale for change Although H1N1 transmission characteristics still thought to be similar to seasonal influenza Given OSHA decision to enforce CDC guidance, we did not want to put healthcare facilities and ourselves at risk for citations/ violations

NYC DOH Implementation of CDC Guidance Revised all clinical guidance to reflect CDC recommendations Developed infection control guidance for DOH clinics (TB, STD, Vaccine, School RN) PPE caches for hospitals/clinics reporting shortages Respiratory protection program for DOH staff

Approach to Infection Control Guidance for Healthcare Providers Emphasized Hierarchy of Controls Ensure sufficient supply for highest risk scenarios (TB care, aerosol procedures) Recommended documenting good faith effort to procure N-95s Legally enforceable standard of care by OSHA under the General Duty Clause and General Industry Respiratory Standard

Revision of Clinical Guidance: Challenges to Implementation Concerns re: sufficient N95 supplies and risk of shortages for high risk situations (eg TB care) Hardship for clinical sites that do not normally need to fit test staff (eg outpatient offices) especially given need to do so quickly as guidance released during fall influenza season Difficulty in identifying suspect H1N1 patients Most ILI patients don t require testing; insensitive rapid tests Clinical symptoms are nonspecific and very similar to other common winter respiratory pathogens? When to stop given persistence of low levels of H1N1 even after peak outbreak period Implication that N95s required for care of any patient with fever and cough/sore throat symptoms in any clinical care setting if any H1N1 circulating

Challenges for Implementing CDC Guidance in School Nurse Offices Nurses room walk-in clinic inside the school building with minimal triage capacity Limited space for distancing, isolation, and supply storage

Infection Control Guidance for DOH Clinics: Barrier Efficacy of Patient Masking 2009 CDC H1N1 guidance implied that HCWs required to wear respirators even if patient was masked Not c/w longstanding TB practice We usually recommend that when patient is masked, HCWs do not need N95s *, esp. for: Patient transport In waiting areas * CDC-HICPAC 2007 Guidelines

PPE Cache for NYC Healthcare Facilities NYC/NYS made our PPE cache available to NYC facilities reporting shortages Protocol developed to screen/approve requests Received requests and provided supplies for 3 facilities Challenges: Stockpile didn t always have same manufacturer/ model/size as the facility s fit tested staff (potentially requiring need to redo fit testing)

NYC DOH Implementation of CDC Guidance Revised all clinical guidance to reflect CDC recommendations with emphasis on need for hierarchy of controls and good faith efforts Developed infection control guidance for DOH clinics (TB, STD, Vaccine, School RN) PPE caches for hospitals/clinics reporting shortages Respiratory protection program for DOH staff

Background: DOHMH Respiratory Protection Program Prior to Fall 2009 600 staff with routine job duties that meet criteria for respirator use Most commonly for TB protection: clinical staff, lab and morgue workers

Background: All Hazards Emergency Planning Respiratory Protection Program Emergency Respirator Use Plan: Identify emergency response roles likely to require respiratory protection Ready to Go Emergency Use Only 200 staff {~3%} designated for annual fit test/training Just in Time (JIT) Contingent Role 3000 staff {40%} to receive Medical Clearance only with plans for JIT fit test/training in emergencies

Background: NYC DOH Emergency Respiratory Protection Program 11/2008: Identified and trained Just in Time fit testers from each Incident Command Section (e.g., Surveillance, Med Clinical) 12/2008: Developed on line medical clearance survey 2/2009: Began medical clearance of ~ 800 school nurses as part of general emergency preparedness planning

Fall 2009 H1N1 Response: DOHMH Respiratory Protection Program ~ 2,000 DOH healthcare workers with direct patient contact Programs: School Health (OSH), STD, Immunizations, TB, Lab, OCME OSH medical room staff (1700) at highest risk due to ILI prevalence in student population

Office of School Health (OSH) October 14: CDC guidelines released October 15: Ordered 3 month supply for N95 stockpile November 4: Respiratory Protection Program started On line medical clearance website launched Program planning shared with unions Notification sent to OSH staff by email and mail Dec 5-30: Initial fit testing clinics Conducted at central and regional offices 1192 staff fit tested; 78% compliance Feb June 2010: Continuing to offer fit testing clinics to reach 100% compliance

Outreach to School Health N=1700 Email / Snailmail Blast Fax staff Call Center Calls to home and work numbers Intranet

Fit Testing Lack of Guidance for Surge Fit Test Operation 1. Centralized-Large Scale Weekend at HQ Max 132 tests/hour 55 staff (21 fit testers; other due to medical clearance/ paperwork/payroll/security) Medical Clearance online and on site Assembly Line Qualitative (QLT) Method Quantitative reserved as backup for failed QLT and for sensitive staff

Fit Testing 2. Centralized-Small Scale 6 days- Dec 09- Feb 10 1 QLT Team and QNT on site Staff = 162 total 3. Decentralized Fit Testing (preferred by staff) Regional Offices in Boroughs 8 afternoon/evenings in 5 locations 1 QLT Team and QNT on site Staff = 154 total TOTAL COST: ~$500K (300K due to Overtime)

Compliance (May 2010) Total # Medical Room Staff = 1707 DOHMH (1115) Medical Evaluation Status Approved 1079 Not Approved 17 Total Compliance (n=1687 staff eligible to enroll) Successful Fit Tests 979 of 1098 = 89.2% DOE (592) 557 3 478 of 589 = 81.1% TOTAL 1636 95.8% 20 1.1% 1457 (86.4%)

Compliance Issues New Requirement Required significant negotiations/meetings with City Labor Relations and unions Decentralized population; difficult to reach Communication obstacles; Inconsistent access to intranet/email Re-assignment policy if staff not medicallyapproved or unsuccessfully fit-tested

NYS Public Employees Safety and Health (PESH) Notice of Violation (NOV) Anonymous Complaint re OSH in Fall 2009 Issued NOV in Feb 2010 for failure to comply with RPP standards Employer must medically clear, fit test, train and provide respirators to OSH med room staff 7/22 - Final Abatement Date Penalty Up to $200/day if 100% compliance not demonstrated

Final Thoughts on PPE for Pandemic Influenza/Other Viral Resp. Pathogens Need continued research on influenza transmission and respiratory protection? aerosol precautions needed if primary route of influenza transmission is large droplets Guidance based on best available scientific data, with consideration of logistical concerns: Challenges to implementation in outpatient and home care settings where nonspecific ILI common Fit testing/training capacity for non-hospital based clinical sites (private practices, school clinics) for both routine and urgent situations

Final Thoughts (2) Need for R&D on improved respirators Comfort and compliance Universal fit right out of the box so fit testing not required, especially in times of surge demands Further evaluation/consideration re: appropriateness of CDC s 2009 guidance on re-use/extended use

Primary Prevention is Best! Vaccination is the most effective way to protect HCWs (and their patients) Allows protection against patients with unrecognized or asymptomatic infections Need to improve vaccination rates among HCWs voluntarily or via regulatory mandates Need universal influenza vaccine, and improved vaccine manufacturing technology