Flu Season Best Practices

Follow these recommendations to provide "state of the art" protection for your employees from seasonal flu and the eventual pandemic flu.

This article is written to provide some assistance to employers in the event of a severe 2007-08 flu season by providing guidelines for employee protection. Many will think the recommendations to be extreme until a cost-benefit analysis is done on the cost to individual companies; this analysis will prove that the actions recommended are very cost effective once implemented. A quick review of flu history is in order to make this point:

20th Century influenza pandemics:
1918, "Spanish" flu, 550,000 excess deaths in the United States
1957, "Asian" flu, 70,000 excess deaths in the United States
1968, "Hong Kong" flu, 30,000 excess deaths in the United States

At least 20 million people, including 500,000 U.S. citizens, died in the 1918 influenza pandemic. Today, as many as 36,000 Americans continue to die each year of what's commonly known as the flu and more than 200,000 are hospitalized. Most outbreaks in North America occur between October and May. The peak season is usually late December to early March.

Human influenza is transmitted from person to person, primarily via virus-laden large droplets (particles >5 µm in diameter) that are generated when infected persons cough or sneeze. These large droplets can then be directly deposited onto the mucosal surfaces of the upper respiratory tract of susceptible persons who are near (i.e., within 3 feet) the droplet source. Transmission also may occur through direct and indirect contact with infectious respiratory secretions. They are carried in respiratory secretions as small-particle aerosols (less than 10 micrometers in diameter). The influenza virus spreads through droplets that have been coughed or sneezed into the air by someone who has the flu. You can get the flu by breathing in these droplets through your nose or mouth or by the droplets landing directly on your eyes. The flu virus is also found on the hands of people with the flu and on surfaces they have touched. You can become infected if you shake hands with infected persons or touch contaminated surfaces and transfer the virus to your own eyes, nose, or mouth.

Anyone can get influenza, a viral infection that attacks your respiratory system, including your nose, throat, bronchial tubes, and lungs. You're especially at risk if you are an older adult or have diabetes, chronic heart or lung disease, or an impaired immune system. If you're at high risk of getting the flu, your first line of defense is an annual flu vaccine.

Recommendation 1. Employees should take the annual flu shots in October and November.
Rationale: Additional strategies should be considered in addition to vaccinating the "at risk" and the elderly. Many studies have shown that socially active people have the highest rates of flu infection each year and are the major spreaders of flu in the community and introducers into households. This is in part due to their high level of socialization and their participation in group activities. Immunization of socially active employees, therefore, would reduce exposure of highly vulnerable individuals to flu.
"One of the problems with current vaccination strategy is that high-risk persons are often relatively inaccessible; and no improvement in vaccine coverage has occurred since 1997. Children could be accessible through school-based vaccine clinics allowing rapid administration of vaccine to large numbers, representing all socioeconomic groups, within a short period of time." (Arch Intern Med. 2005; 165:265-272. Available post-embargo at www.archinternmed.com)

Recommendation 2. Develop an employee learning module and short certification exam for dealing with flu and infectious material exposure.
Rationale: Your employees are the first line of interface with the general population. Their offices and meeting areas are the prime locations from which the virus will spread.

Recommendation 3. Design an "exception" policy to work attendance that encourages employees not to attend work or travel, and to cease social activities if they have a fever of 101 F or higher.
Rationale: Employees often come to work ill and are the prime source of spread of the flu virus. They need to realize that both their supervisors and co-workers would rather they not come work while ill. Disposable fever thermometers or the very inexpensive paper sensors could be available in the workplace for employees to check themselves during flu season.

Recommendation 4. Encourage proper hand washing with hot and cold running water, a soap dispenser, and paper towels.
Rationale: Typically, people carry between 10,000 and 10 million bacteria on each hand. Hand transfer of the virus is one of its prime modes of spread. To properly wash the hands, use warm, soapy water and rub vigorously for at least 20 seconds -- about the amount of time it takes to sing "Happy Birthday" twice, suggests Dr. Paul Horowitz, medical director of pediatric clinics at Legacy Health System in Portland, Ore. "We can't stress this enough when it comes to keeping colds and flu away," he says. "Avoid eating or touching your eyes, nose, and mouth without washing your hands first."

All employees or service personnel should wear disposable gloves for direct contact with blood or bodily fluids of any ill individual. However, gloves are not intended to replace proper hand hygiene. Immediately after activities involving contact with bodily fluids, gloves should be carefully removed using a "cuff first" removal technique and discarded and hands should be cleaned. Gloves must never be washed or reused.

The use of antimicrobial soaps would appear to be advised, however, they raise some concerns, as well. Antimicrobial soaps contain an antiseptic agent to help lower the number of microbial flora. Triclosan is the most commonly used chemical ingredient in antimicrobial soaps. A key factor in its effectiveness is that it must be left on the skin long enough to work, as in a good 30-45 second scrub. Companies have not published information on which combination of triclosan concentrations and washing times are most effective, so it is difficult to know which brands work best. Also, there is concern that use of some antimicrobial soap may lead to bacterial resistance.

Hot-air hand dryers have increasingly proven not to be preferable to paper towels due to time required for use and temperature and velocity adjustment problems. Noise levels also make them unattractive for use in office buildings. In a comparison of hot-air hand dryers, cloth towels, and paper towels, researchers in the United Kingdom found that paper towels were the most effective and inexpensive choice. (The Applied Ecology Research Institute at the University of Westminster in London carried out the research in 1994.) They also found that paper towels reduced bacterial counts on the hands, while hot-air dryers increased them and emitted bacterially contaminated air. At least six species of gut bacteria were isolated from the airflows of almost two-thirds of dryers, indicating possible fecal contamination.

Recommendation 5. Provide each office suite with tissues, a hand sanitizer, and dispenser.
Rationale: The federal Food and Drug Administration develops regulations and standards concerning food services and recommends that hand sanitizers not be used in place of soap and water, but only as an adjunct. A hand sanitizer cannot and should not take the place of proper cleansing procedures with soap and water.
In alcohol-based hand sanitizers, the active ingredient is ethyl alcohol. Alcohol is a natural antiseptic that has been used in the medical field for more than 100 years because it kills germs in seconds without water and evaporates quickly, leaving no residue on the skin. It physically destroys the germs. The use of alcohol-based hand sanitizers has been shown to reduce illness and absence rates in places where germs are commonly spread, such as in schools. The Centers for Disease Control and Prevention (CDC) recommends the use of alcohol or alcohol-based products in hospitals, home, work, and schools to stop the spread of germs. For more information about the CDC’s recommendations, please visit its Web site, www.cdc.gov.

The antibacterial products that are not alcohol based usually require water to work. They also contain different synthetic chemical active ingredients, such as triclosan and quaternary ammonium, to kill germs.

Some confusion has occurred as a result of the 2002 CDC guidelines "recommending alcohol-based gel as a suitable alternative to hand washing for health-care personnel in health-care settings." Because many health care workers routinely must clean their hands multiple times per hour, the use of alcohol gels while moving between patients has been shown to favorably impact hand-cleansing adherence by staff because of the time saved versus traditional hand-washing methods. However, the guidelines apply only to hospitals and clinics. These are not appropriate for and do not apply to those in non-health care settings.

Recommendation 6. Provide a cleaning agent and disinfectant for sanitizing the desk, phone receivers, and doorknobs or provide disinfectant-treated wipes and suggest to employees that they use the agents when time permits.
Rationale: The length of time that cold and flu viruses can survive outside the body on an environmental surface varies greatly, but the suspected range is from a few seconds up to 48 hours, depending on the specific virus and the type of surface.

Flu viruses tend to live longer on surfaces than cold viruses. Also, it is generally believed that cold and flu viruses survive for longer periods on nonporous surfaces, such as plastic, metal, or wood, than they do on porous surfaces, such as fabric or paper.

Although cold and flu viruses primarily spread from person-to-person contact, they also can spread from contact with contaminated objects or surfaces. The best way to avoid becoming infected with the cold or flu virus is to wash your hands frequently. A study conducted by researchers at the University of Arizona in Tucson of the presence of Influenza a virus, the virus most commonly associated with the flu, in day-care centers and in the homes of families with children enrolled in the programs found Influenza A on 53 percent of surfaces tested during the spring. In homes where one child had the flu during March 2003, the percentage was higher: 59 percent of all surfaces tested positive for the virus.

If we are looking at other organisms than virus that cause disease, six items commonly handled by the public were tested for their bacterial content using e ATP method:
1. Shopping cart handles: 1,100 colony-forming units of bacteria per 10 square centimeters
2. Mouse used on computers in Internet cafes: 690 units
3. Hand straps on buses: 380 units
4. Public restroom doorknobs: 340 units
5. Elevator buttons: 130 units
6. Hand straps on subways: 86 units

In other studies, phone receivers were found to be a major problem area: 80 percent tested positive for the virus. In day-care centers, kitchen dishcloths were most likely to test positive for the virus (58 percent), followed by diaper-changing areas (57 percent). In both homes and centers, bathroom surfaces were among the least contaminated surfaces because these surfaces are more likely to be cleaned regularly.

Recommendation 7. Institute a "cover your cough" campaign.
Rationale: The second important prevention practice for flu is respiratory hygiene. According to CDC, serious respiratory illnesses like influenza, respiratory syncytial virus (RSV), whooping cough, and severe acute respiratory syndrome (SARS) are spread by:
• Coughing or sneezing
• Unclean hands

To help stop the spread of germs:
• Cover your mouth and nose with a tissue when you cough or sneeze.
• If you don't have a tissue, cough or sneeze into your upper sleeve, not your hands.
• Put your used tissue in the waste basket.
Source: www.cdc.gov/flu/protect/covercough.htm

Recommendation 8.The employer may want to make respiratory masks available to employees to be used for coughs in severe flu seasons.
Rationale: Droplet precautions are designed to reduce the risk of droplet transmission of infectious agents. Droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets (larger than 5 µm in size) containing microorganisms generated from a person who has a clinical disease or who is a carrier of the microorganism. Droplets are generated from the source person primarily during coughing, sneezing, or talking. Transmission via large-particle droplets requires close contact between source and recipient persons because droplets do not remain suspended in the air and generally travel only short distances, usually 3 feet or less, through the air. Because droplets do not remain suspended in the air, special air handling and ventilation are not required to prevent droplet transmission. Droplet precautions apply to any patient known or suspected to be infected with epidemiologically important pathogens that can be transmitted by infectious droplets.

Common Cold
Sudden onset, often high, lasts 3-4 days
Aches and Pains
Usual, often quite severe
Moderate to extreme, may last up to one month
Frequent, may last up to 5-10 days
Sore Throat
Sometimes, mild to moderate
Usual, can become severe
Sinus or ear infection
Pneumonia, kidney failure, heart failure; can be life-threatening
Sources: CDC, FDA, World Health Organization

During periods of increased respiratory infection activity in the community, masks should be offered as part of a respiratory hygiene/cough etiquette strategy to individuals who are coughing or have other symptoms of a respiratory infection when they are present in a public area. Masks should be worn by these patients until it is determined the cause of symptoms is not an infectious agent that requires isolation precautions to prevent respiratory droplet transmission or the individual has been appropriately isolated, either by placement in a private room or by placement in a room with other individuals with the same infection (cohorting). Once isolated, the individual does not need to wear a mask unless transport outside the room is necessary.

Recommendation 9. Post signs near or in each office area that tells the differences between the symptoms of the common cold and the symptoms of the flu.
Rationale: Such information will assist employees and clients in determining the need for self-isolation until the period of infection passes.

This article originally appeared in the December 2007 issue of Occupational Health & Safety.

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