Wednesday, June 23, 2010

CDC: Proposed Influenza Infection Control Guidance



# 4669



The CDC has published their proposed updated guidance on influenza infection control in the Federal Registry, and will accept written public comments until July 22nd.


Notice: Updated Guidance: Prevention Strategies for Seasonal Influenza in Healthcare Settings

Federal Register: June 22, 2010 (Volume 75, Number 119)       Page 35497-35503

AGENCY: Centers for Disease Control and Prevention (CDC), Department of Health and Human Services (HHS).

ACTION: Notice with comment period.


While there’s a lot to absorb here, of particular interest to many HCWs (Health Care Workers) is the proposed guidance on workplace vaccinations, and the use of surgical facemasks vs. N95 respirators.


The issue of mandatory HCW vaccination has been both contentious and controversial.


New York State attempted to require vaccination as a requirement to work as a HCW, but legal challenges and vaccine shortages forced them to abandon – at least temporarily – that mandate  (see New York Rescinds Mandatory Flu Shots For HCWs).


  • Some hospitals around the nation have adopted mandatory vaccination – or require the wearing of masks by unvaccinated workers during flu season.
  • APIC (Association for Professionals in Infection Control and Epidemiology) has been promoting the idea of mandatory flu shots for HCWs for over a year (see APIC Seeking Mandatory Flu Shot For HCWs)
  • And the New York State Health Department indicates that they will pursue mandatory vaccination again in 2010, assuming adequate vaccine supplies are available.


While strongly advocating HCW influenza vaccination, the CDC has stopped short of mandating them.

Here is the passage from the proposed guidance:

Strategies to improve HCP vaccination rates include providing incentives, providing vaccine at no cost to HCP, improving access (e.g., offering vaccination at work and during work hours), and requiring personnel to sign declination forms to acknowledge that they have been educated about the benefits and risks of vaccination.

While some have mandated influenza vaccination for all HCP who do not have a Contraindication, it should be noted that mandatory vaccination of HCP remains a controversial issue.


Another area of infection control that remains contentious has been the use of surgical facemasks in lieu of N95 respirators for respiratory protection.


For decades the assumption has been that surgical masks do not protect the wearer.  They are used to protect others from the wearer’s germs.

For that reason, N95 respirators have been routinely recommended by the CDC for HCWs in contact with pandemic flu patients.   


Despite that recommendation, many healthcare facilities opted to go with the (presumed) less protective surgical masks last year, citing a short supply of N95s and complaints by some HCWs that they are difficult to work in.


image image

N-95 Respirator         Surgical Facemask


The use of surgical masks during the opening months of the pandemic led to protests by some nurses.


Nurses Protest Lack Of PPE’s
Report: Nurses File Complaint Over Lack Of PPE
California Nurses Association Statement On Lack Of PPE


Last fall we saw conflicting studies, some suggesting that surgical masks were reasonably protective against influenza.


JAMA: Surgical Masks vs N95 Respirators

Study: Efficacy of Facemasks Vs. Respirators


In guidance, updated as recently as March of this year, the CDC continued to recommend N95 respirators for HCWs who came in close contact with suspected or confirmed influenza patients.


This new proposed guidance relaxes those recommendations to using surgical masks for routine care, and reserving N95 masks for aerosol producing procedures (intubation, suctioning, etc).


Again, quoting from the proposed guidance.

HCP should don a facemask when entering the room of a patient with suspected or confirmed influenza. Remove the facemask when leaving the patient's room, dispose of the facemask in a waste container, and perform hand hygiene.


Based on their local needs, facilities and organizations may opt to provide employees with alternative personal protective equipment as long as it offers the same protection of the nose and mouth from splashes and sprays provided by facemasks (e.g., face shields and N95 respirators or powered air purifying respirators which would also protect against inhaling airborne particles). 


For aerosol producing procedures, they recommend:


HCP should wear respiratory protection equivalent to a fitted N95 filtering facepiece respirator (i.e., N95 respirator) or higher level of protection (e.g., powered air purifying respirator) during aerosol-generating procedures (See definition of respirator in Appendix). 


These proposed guidelines are obviously not going to please everyone.   


Those advocating stricter infection control will see the vaccination recommendations as being tepid and short of the mark, while those concerned with individual rights will view this as a victory.


Many hospitals will doubtless find the relaxed guidelines on respiratory protection easier to deal with (and less expensive, as well), while some HCWs will continue to question the efficacy and wisdom of using surgical masks for respiratory protection.


These guidelines are `living documents’, however. Always subject to change when new informationor a new pathogen – emerges.  


Interested parties should read the entire document, and comment if they so desire.

You may submit written comments to the following address:

Influenza Coordination Unit, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Attn: Prevention Strategies for Seasonal Influenza in Healthcare Settings, 1600 Clifton Road, NE., MS A-20, Atlanta, GA 30333.

You may also submit written comments via e-mail to:

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