The CalOSHA Aerosol Transmissible Disease Regulation and Indoor

The Cal/OSHA Aerosol Transmissible Disease Regulation and Indoor Air Deborah Gold, dgold@dir. ca. gov Bob Nakamura, bnakamura@dir. ca. gov IAWG September 2009

The ATD Project • Early 1990’s Cal/OSHA worked on draft TB standard • 1994 Fed/OSHA announced rulemaking so CA dropped • 2003 Feds dropped TB, put respirators under general industry • 2004 CA equivalent, request for rulemaking

Why can’t we just adopt CDC guidelines? • CDC Guidelines aren’t enforceable – Nonmandatory language – Lots of recommendations • Many in public health do not understand why recommendations to protect employees should be different from those to protect the public. – E. g. how can we recommend respirators for employees and not for the public

OSHA vs. Other Public Health • • • 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 public’s health Medical surveillance to protect the public Usually relies on guidelines, and enforces through licensing Develops risk reduction measures for the general public, don’t always focus on specific occupational risks to individual workers

Our Advisory Process • • • • • American Federation of State County and Municipal Employees American Medical Response Association of Professionals in Infection Control B-SAFE California Association of Health Facilities California Conference of Local Health Officers California Hospital Association California Nurses Association California Professional Firefighters California Tuberculosis Controllers Association Cities and Counties – San Francisco, San Bernardino, San Diego, Los Angeles, Alameda, Contra Costa, Lake, California Department of Public Health – Emergency Preparedness Office, Immunization Branch, Occupational Health Branch, TB Control Branch, Health Care organizations including Kaiser Permanente, Sutter Health Care International Brotherhood of Teamsters Service Employees International Union Stanford University State of California – Departments of Food and Agriculture, Fish and Game, Corrections and Rehabilitation University of California at San Diego, Los Angeles, San Francisco, Berkeley, Davis

What is an Aerosol Transmissible Disease? • A disease • That is transmitted by aerosols (A gaseous suspension of fine solid or liquid particles)

From Milton Panel 2 IOM

Issues • Scope – Which diseases, include droplet or limit to Airborne – Which occupations/environments – What is the default for novel diseases • • Routes of transmission – airborne vs. droplet Communication Engineering Controls Personal protective equipment and respirators – Surgical masks vs. respirators – Fit-testing and fit-test interval • Vaccination, exposure incidents, med services

Zoonotics • Started as a section in ATD – History with Q fever, bovine TB • Split off as separate section because it became too complicated • Most employers just referred to IIPP • Sets up system based on fish and game or agricultural agencies for higher precautions

OSHA Risk Pyramid HCW – Aerosol Generating Procedures HCW High Frequency Contact with General Population Minimal contact with general public and other co-workers How Do You Know it’s a pyramid?

Scope • Applies in health care and certain other high risk environments – Corrections – Homeless shelters – Drug treatment programs – First receiver • Applies to diseases classified by HICPAC as either droplet or airborne – Novel or unknown pathogens considered airborne

“One example was the debate during SARS over whether SARS was transmitted by large droplets or through airborne particles. The point is not who was right and who was wrong in this debate. When it comes to worker safety in hospitals, we should not be driven by the scientific dogma of yesterday or even the scientific dogma of today. We should be driven by the precautionary principle that reasonable steps to reduce risk should not await scientific certainty. ” SARS Commission Final Report, Volume 3, p. 1157

Types of employers • 4 types of employers – Referring: don’t provide care beyond initial to cases and suspected cases of AII, and don’t do high hazard procedures on them – Full standard: hospitals and others that are not referring – Laboratories – Conditionally exempt – dentists and outpatient medical specialty practices that don’t treat ATDs and have screening procedures

5199 Elements • Administrator • Medical services – Annual TB testing • Written – Vaccinations (flu for procedures/plans everyone, others HCW • Source control only) • Engineering, work – Post exposure follow practice, up administrative controls – Precautionary Removal and PPE • Training • Respirators • Recordkeeping • Communication

ATD and Indoor Air • Establishes enforceable requirements for airborne infection isolation rooms • Encourages other engineering controls – Local exhaust ventilation • Applies to employees who service equipment reasonably anticipated to be contaminated – Biosafety cabinets, ducts and HEPA filters from AIIR

Airborne Infection Isolation Rooms Create inward flow (negative pressure) to protect outside the room Flow rate must be large enough to dilute contaminants Employees may be downstream of source Exhaust must be filtered or discharged to a safe location

Our first month… • 5199 and 5199. 1 adopted unanimously on May 21, effective August 5 Table 2. Total number of hospitalized and/or fatal cases reported and incidence rate of pandemic (H 1 N 1) 2009 in California, April 3 - August 18, 2009

Early Effects of ATD Standard • Employers are beginning to come into compliance with written programs • Closer communication with health care programs at CDPH • Hospitals reviewing policies about respirator use • Many calls from law enforcement and other environments • Provides a framework to address H 1 N 1 • Lots of pressure on CDPH to change recommendations to droplet

H 1 N 1 and Cal/OSHA • Approximately 8 inspections have been opened, – 4 in hospitals, including one fatality, one serious illness (both H 1 N 1 and MRSA) – 1 in a prison • Hospitals perceive that 5199 created a “new” requirement to use respirators • CDPH recommendation for AII for H 1 N 1 is now clearly enforceable – Many hospitals had reduced protection level based infection control organizations recommendations

Public Contact • Schools • Grocery checkers, bank tellers, etc. • Public offices such as social services, DMV • Some public transit and terminals

Outdoor Air Supply Trend nationally and in California is to decrease ventilation in congregate spaces, Required Demand Control Ventilation. HVAC systems with the following characteristics shall have demand ventilation controls complying with 121(c)4: A. They have an air economizer; and B. They serve a space with a design occupant density, or a maximum occupant load factor for egress purposes in the CBC, greater than or equal to 25 people per 1000 ft 2 (40 square foot person); and C. They are either: i. Single zone systems with any controls; or ii. Multiple zone systems with Direct Digital Controls (DDC) to the zone level. EXCEPTION 1 to Section 121(c)3: Classrooms, call centers, office spaces served by multiple zone systems that are continuously occupied during normal business hours with occupant density greater than 25 people per 1000 ft 2 per Section 121(b)2 B, healthcare facilities and medical buildings, and public areas of social services buildings are not required to have demand control ventilation.

Effect of Ventilation • Myatt (2004) – Varied outdoor air supply – Correlated 100 ppm CO 2 increase with increased collection of virus particles • DCV permits 600 ppm increase • Blachere (2009) found influenza virus in hospital emergency department

Engineering Controls • To what extent do AIIR reduce risk? – Need better evaluation methods • How to assess negative pressure hoods, tents, booths • Would increasing general dilution ventilation reduce risk in waiting rooms, schools, etc. (e. g. Myatt) • What other controls are appropriate for schools etc. ?

Air Cleaning Technologies • Upper Room Ultraviolet Germicidal Irradiation (UVGI) – 1957 -58 Livermore VA found reduced transmission of Influenza (Mc. Lean RL 1961) • HEPA filters

How Effective Is Source Control? • Studies looking at filtration materials tell part of the story • Surgical masks have gaps, sometimes very low filtration • What particle sizes are important to source control, as compared to inhalation? • What role does reducing source emissions play in preventing transmission? • For diseases that are widespread in the community, with multiple routes of transmission, how effective is any given intervention?

Respirators • What is the relevant particle size for evaluating respirators against infectious aerosols? • Do electrostatic filtering material degrade over time in real-world health care scenarios (e. g. Janssen and Bidwell, Diesel Particulate) • Is there an infection risk to patient if employee uses respirator with exhalation valve or uses PAPR with head covering? • Does CO 2 buildup in N 95 respirator pose a health risk to HCWs?

Find Cal/OSHA on the Web • Cal/OSHA regulations: – http: //www. dir. ca. gov/samples/search/query. htm • Standards Board Proposed Regulations: http: //www. dir. ca. gov/oshsb/atdapprvdtxt. pdf • Advisory committee webpage: – http: //www. dir. ca. gov/dosh/Dosh. Reg/advisory _committee. html