Saturday, September 12, 2009

H1N1 Infection Control in Health Care Settings

We are increasingly receiving questions on the use of masks vs N95 respirators in health care settings. Below is a review of some major health organizations’ recommendations for infection control in health care settings that you may find helpful. Dora

All recommendations generally agree on the following:

Use of standard and droplet precautions for suspected or confirmed cases of novel H1N1 influenza;
Placing surgical masks on patients with suspected or confirmed novel H1N1 infection at the point of contact with the health care facility;
Placing such patients in a single room, if available, or cohorting them with other infected patients;
Strict adherence to hand hygiene, respiratory hygiene and cough etiquette;
Early recognition and identification of suspected novel H1N1-infected patients upon presentation to a health care facility;
Restriction of visitors and health care workers with febrile respiratory illnesses.

Status of infection control guidance for novel influenza A H1N1

Background: Numerous state and local health agencies previously endorsed the April 29, 2009, World Health Organization (WHO) recommendations (see below) on infection control measures. Subsequently, recommendations by the CDC’s Hospital Infection Control Practices Advisory Committee (HICPAC), the Society for Healthcare Epidemiology (SHEA), the Infectious Diseases Society of America (IDSA) and the Association for Professionals in Infection Control and Epidemiology (APIC), endorsed this approach. Recently, the Institute of Medicine (IOM) issued a report supporting the CDC’s current recommendations, however, the IOM report is only one component of CDC’s current review of their guidance. CDC anticipates that their updated recommendations should be available by or in October.

Since the spring 2009 outbreak of novel influenza A H1N1, infection control recommendations for novel influenza 2009 H1N1 in health care settings have been issued by multiple agencies, expert advisory groups and professional societies. The issue of respiratory precautions has generated controversy largely because of the absence of controlled scientific studies in the clinical setting to guide definitive policy. Consequently, some of the recommendations from different organizations vary with respect to respiratory protection guidance (primarily mask vs. respirator use).

We understand the challenges that variation in recommendations from authoritative organizations may pose for health care system policy makers. Below are excerpts of salient recommendations that may be of use to you in reviewing your infection control policies for the upcoming influenza season. The majority of expert recommendations support the use of standard and droplet precautions, with respirators reserved for high-risk aerosol generating procedures. Maine CDC is not planning to issue guidance until after US CDC issues their updated recommendations in October.

Centers for Disease Control and Prevention (CDC), issued May 13th, 2009 (currently under review), available at,

May 13, 2009, guidance states that in addition to standard and contact precautions, “All health care personnel who enter the rooms of patients in isolation with confirmed, suspected, or probable novel H1N1 influenza should wear a fit-tested disposable N95 respirator or better.”

World Health Organization (WHO): Issued 29 April, updated July 10, 2009, available at

April 29 guidance and July 10 revision recommend standard and droplet precautions except for aerosol generating procedures where N95 respirator is recommended. July 10 revision recommends N95 protection as for aerosol generating procedures including obtaining specimens by nasopharyngeal aspirate, nasopharyngeal swab, throat swab or bronchial aspirate.

Society for Healthcare Epidemiology (SHEA) issued June 12, 2009, Infectious Diseases Society of America (IDSA) and the Association for Professionals in Infection Control and Epidemiology (APIC), available at

Recommend implementing the same practices recommended to prevent the transmission of seasonal influenza for the novel H1N1 virus: standard and droplet precautions. Recommends enhanced respiratory protection (I.e., N95 respirator) when performing certain aerosol-generating procedures, specifically: bronchoscopy, open suctioning of airway secretions,

resuscitation involving emergency intubation or cardiac pulmonary resuscitation, and endotracheal intubation.

Collection of nasopharyngeal specimens from patients with suspected or confirmed novel H1N1, closed suctioning of airway secretions and administration of nebulized medications should not be considered aerosol-generating and, therefore, do not require enhanced respiratory protection.

CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) Recommendations for Care of Patients with Confirmed or Suspected 2009 H1N1 Influenza Infection in Healthcare Settings - July 23, 2009, available at:

Use standard and droplet precautions for care of patients with suspected or confirmed 2009 H1N1 influenza infection.

Use fit tested N95 respirator or higher and consider airborne infection isolation room for aerosol-generating procedures (e.g., bronchoscopy, intubation under controlled or emergent situations, cardiopulmonary resuscitation, open airway suctioning and airway induction).

Public Health Agency of Canada, issued July 28th, 2009, available at Recommend contact and droplet precautions when within 2 meters of a case

Recommend respiratory precautions (N95 respirator or higher) when conducting an aerosol-generating medical procedure.

Institute of Medicine report, September 3, 2009, available at

Recommended continuing CDC’s current guidance for respirator use, but notes the limitations on clinical studies and their lack of a charge to consider practical implementation issues.

1 comment:

Anonymous said...

The problem is not the lack of scientific information, but rather the lack of occupational health expertise among infection control organizations. The recent IOM report was the product of experts from both disciplines. This controversy began almost 20 years ago during the rebound of Tb in the US. It is now time for healthcare employers and infection control professionals to accept the science and move on.