CalOSHA Aerosol Transmissible Disease Project

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Cal/OSHA Aerosol Transmissible Disease Project

• CTCA 2006
• Deborah Gold, MPH, CIH, dgold_at_hq.dir.ca.gov
• Bob Nakamura, MPH, CIH bnakamura_at_hq.dir.ca.gov
• Senior Industrial Hygienists, Cal/OSHA

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Every Employer shall furnish employment and a
place of employment that is safe and healthful
for the employees therein. California Labor Code
Section 6400
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The Cal/OSHA program

• 1970 Occupational Safety and Health Act
  established OSHA and NIOSH
• Permitted State Plans, but they must be as
  effective as federal OSHA
• 1973 California Occupational Safety and Health
  Act established Cal/OSHA from existing programs.
  There are 26 state plans, although 4 only cover
  public sector workers.
• OSH Act established a health and safety
  regulatory framework similar to wages and hours

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The Cal/OSHA Program

• Division of Occupational Safety and Health (DOSH)
• Enforcement
• Consultation
• Engineering Services -- amusement rides,
  elevators, pressure vessels
• Mining and Tunneling
• OSH Standards Board
• OSH Appeals Board

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Cal/OSHA and Infection Control

• Issued a special order to UCSF in 1970s for Q
  fever
• Issued special orders for HBV vaccine in early
  1990s
• Cited Sanitation standard for sharps and other
  biological waste disposal prior to BBP standard

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Cal/OSHA and Infection Control

• BBP standard (5193) came into effect 1/93,
  amended in 1997, 1999, 2001
• Biosafety cabinet (5154.2), 1994
• TB respirator standard (5147), 1998
• Special orders on TB control to prisons, medical
  facilities, law enforcement, and a card club
• Cal/OSHA PP 47 adddresses TB

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OSHA vs. Other Public Health Approaches

• OSHA
• Mission is to protect individual workers
• Medical surveillance for the protection of the
  employee
• regulatory enforcement mechanism
• Risk at work is often more concentrated than
  risks to the general public
• Employees jobs require them to take risks to
  protect others.

• Public Health
• Mission is to protect the overall publics health
• Medical surveillance to protect the public
• Usually relies on guidelines, and enforces
  through licensing
• Develops risk reduction measures for the general
  public, dont always focus on specific
  occupational risks to individual workers

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What is an ATD

• Aerosol transmissible diseases (ATD) are diseases
  that are spread through the air by droplets
  containing infectious pathogens.
• Infection control professionals distinguish
  between diseases primarily spread by
• larger droplets (near field) gt5 microns (droplet
  precautions)
• Small droplets, droplet nucleii, dusts containing
  the pathogen (airborne isolation)

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Airborne Infectious Diseases

• Airborne spore release (e.g. anthrax) until decon
• Chickenpox (Varicella)
• Highly pathogenic avian influenza
• Herpes zoster (varicella-zoster, disseminated
  disease, per CDC)
• Measles (rubeola)
• Monkeypox

• Novel or Unknown pathogen
• SARS (Severe Acute Respiratory Syndrome)
• Smallpox
• Tuberculosis

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Some Droplet diseases

• Diptheria
• Influenza
• Meningococcal disease
• Mumps
• Mycoplasma pneumonia

• Pertussis
• Plague (pneumonic)
• Rubella
• SARS
• Viral hemorrhagic fevers

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What do ATDs have in common?

• Initial symptoms and signs are often not specific
  
• E.g. TB initially presenting as pneumonia
• Many pose significant risks, particularly to
  health care workers e.g. TB
• There is often an airborne route, even for
  diseases classified as droplet
• It is currently believed that cough etiquette
  (respiratory hygiene) can reduce the spread of
  disease, particularly in the period prior to
  initiation of appropriate treatment.

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Other Important Concepts

• Exposure Incident employees exposed without
  control measures to a confirmed case of a
  Reportable ATD, as listed in Title 17.
• Precautionary Removal when an employee is NOT
  sick, but is required to be removed from the
  workplace during an incubation period because the
  employee may be infectious
• Source Control includes respiratory hygiene/
  cough etiquette
• Novel or Unknown Pathogen e.g. SARS in 2003

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Draft ATD Standard -- Application

• Applies to health care and other high-risk
  environments and occupations
• Law enforcement, corrections, emergency medical,
  homeless shelters, laboratories
• Animal eradication workers for avian flu etc.
• Like new TB guidelines, acknowledges that some
  employers will only provide screening, and then
  pass the patient along to a hospital etc.

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Draft ATD Standard -- Concepts

• Early identification and broad source control
  measures (respiratory hygiene)
• Tracks HICPAC recommendations for specific
  precautions
• Facilities that provide services to airborne
  infectious disease cases must have engineering
  controls, respirators, etc.

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Four Types of Employers

• Hospitals, other work settings which perform
• evaluation, diagnosis, treatment, transport,
  housing or management of persons requiring
  airborne infection isolation
• high hazard procedures performed on suspect or
  confirmed cases
• decontamination or management of persons
  contaminated as a result of a release of
  biological agents
• autopsies or embalming procedures on human
  cadavers potentially infected with aerosol
  transmissible pathogens.

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Four Types of Employers (cont)

• Patients, clients, residents etc. are screened
  for airborne infectious diseases and referred if
  indicated (Referring Employers subsection (b))
• Laboratories (subsection (e))
• Contact with infected animals (subsection (i))

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Referring Employers

• Establish written procedures (may be part of
  Injury and Illness Prevention Program or other
  program)
• Source control (exception for field operations
  where not feasible)
• Identification of suspect airborne cases
• Referral to appropriate facilities, within 5
  hours. Exceptions
• If initial encounter is after 330 p.m. referral
  or transfer by1100 a.m next morning
• If no appropriate facility available and consult
  with LHO
• If medically contra-indicated

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Referring Employers (cont)

• Measures to protect employees during time suspect
  case is in workplace
• Procedures to communicate with other employers
  and to receive info from diagnosing facility
• Vaccinations as recommended by CDC or CDHS
• Procedures for exposure incidents
• Training, record-keeping and annual review of
  procedures

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Employers Providing Services to Airborne
Infectious Disease Cases

• Subsection (c) Written program
• Subsection (d) Control measures
• Initial identification of cases, and referral or
  transfer when necessary
• Use of engineering and work practice controls,
  particularly for high hazard procedures
• Airborne infection isolation when appropriate,
  meeting requirements from building code (OSHPD)
  or CDC
• Personal Protective Equipment based on CDC
  recommendations (includes surgical masks for
  droplet precautions)

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Employers Providing Services to Airborne
Infectious Disease Cases

• Subsection (f) Respiratory protection
• For airborne infectious diseases
• Must meet requirements of section 5144 (and if
  applicable 5192) as well
• N95 is minimum, for high hazard procedures more
  protective respirators unless would interfere in
  successful performance of tasks
• Employees must be medically evaluated (appendix B
  contains reduced questionnaire)
• Fit tests initially, at least annually for high
  hazard
• Permits every 2 years for non-high hazard
  procedures until 2012

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Employers Providing Services to Airborne
Infectious Disease Cases

• Subsection (g) Medical Surveillance
• Vaccinations as recommended by CDC or CDHS
• TB testing at least annually, or as recommended
  by CDC or CDHS (permits blood tests or PPD)
  Conversions referred to PLHCP
• Provisions for exposure incidents
• Report to LHO of Title 17 reportable diseases
• Employers to consult infection control expert or
  LHO on exposure incidents
• Precautionary removal provisions for infection
  control purposes

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Employers Providing Services to Airborne
Infectious Disease Cases

• Subsection (h) Training
• At initial assignment and at least annually
• Train on all applicable elements of the standard
• Additional training for surge and emergencies
• Respirator users must be trained in accordance
  with 5144
• Opportunity for interaction with trainer
• Trainer must be knowledgeable
• Training must be appropriate in language,
  literacy and education to the employees

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Employers Providing Services to Airborne
Infectious Disease Cases

• Subsection (j) Record keeping
• Medical record for each exposed employee,
  maintained confidential, comply with 3204
• Training records maintained for 3 years
• Plan implementation, including
• Ventilation testing and other engineering
  controls
• Exposure incidents
• Annual review of plan and employee involvement
• Respirators in accordance with 5144

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Laboratories Subsection (e)

• Applies where laboratory operations capable of
  aerosolizing ATP-L are performed AND where
  employees do not have direct contract with
  suspect or confirmed cases
• Requires biosafety plan, biosafety officer(s) and
  BSL -3 type control measures
• Ref. BMBL (Biosafety in Microbiological and
  Biomedical Laboratories)

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Role of LHO in Draft Standard

• Employer with suspect or confirmed Airborne case
  may consult with LHO to find placement or for
  advice re interim control measures
• Employers to have effective procedures for
  reporting cases to the LHO
• Employers to consult with infection control
  practitioner or LHO to assess exposure incidents.
• In current draft, may designate a workplace as at
  elevated risk for ATDs.

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Cal/OSHA Rulemaking Process

• Advisory meetings and other pre-rulemaking
  activities
• Proposal goes to Standards Board staff
• After editing and review, Standards Board
  forwards it to the Office of Administrative Law
  for publication
• 45 day public comment period, with a hearing at
  the end
• If there are changes, one or more 15 day notices
  for public comment
• Board votes on standard, if adopted, forwards to
  OAL for review for compliance with the
  Administrative Procedures Act.

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ATD Project Status 5-06

• We are still in pre-rulemaking there is no
  formal proposal
• We are still soliciting and accepting feedback on
  the April 7, 2006 draft, but need it very soon
• Additional advisory meetings are scheduled for
  5/19 (poultry), 5/24 (non-traditional) 5/31(law
  enforcement and corrections)
• We expect to send the proposal to the Standards
  Board by the end of May
• We hope it will be noticed for public comment in
  July or August

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Find Cal/OSHA on the Web

• Advisory committee webpage
• http//www.dir.ca.gov/dosh/DoshReg/advisory_commit
  tee.html
• Respiratory protection regulation
• http//www.dir.ca.gov/Title8/5144.html
• Respiratory Protection in the Workplace
• http//www.dir.ca.gov/dosh/dosh_publications/respi
  ratory.pdf
• DOSH TB PP 47 (Tuberculosis) http//www.dir.ca.go
  v/DOSHPol/PPC-47.HTM

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Thank you TB Controllers for protecting the
health of our communities