County of Marin – H&HS ATD Compliance Program Guidelines
ATD Standard Overview……………………………………….3
ATD Standard Application to County Ops & Services….10
ATD Exposure Control Plan Overview……………………..20
Facility Classification Flowchart…………………………….27
County of Marin
Cal-OSHA
Aerosol Transmissible Diseases
Regulation Overview
Aerosol Transmissible Diseases - New Cal/OSHA Regulation
Cal/OSHA recently adopted a new standard, Title 8 CCR § 5199 - Aerosol Transmissible Diseases, regulating employee exposure to aerosol transmissible diseases (ATDs). These diseases can be spread through the air in the form of small particles or droplets. Influenza, tuberculosis, and severe acute respiratory syndrome (SARS) are just a few examples of aerosol transmissible diseases. The standard became effective August 5, 2009.
An Aerosol Transmissible Disease (ATD) or Aerosol Transmissible Pathogen (ATP) is a disease or pathogen for which droplet or airborne precautions are recommended. These are listed in Appendix A of the standard and this document.
Aerosol Transmissible Pathogen -- Laboratory (ATP-L) is a pathogen that meets one of the following criteria: (1) the pathogen appears on the list in Appendix A, (2) the Biosafety in Microbiological and Biomedical Laboratories (BMBL) recommends biosafety level 3 or above for the pathogen, (3) the biological safety officer recommends biosafety level 3 or above for the pathogen, or (4) the pathogen is a novel or unknown pathogen.
Title 8 CCR § 5199 Aerosol Transmissible Diseases has ten sections.
(a) Scope and Application – The standard covers four types of employers:
1. Hospitals, or other work settings which perform (subsections d, e, f, g, h, I, j):
Ø Evaluation, diagnosis, treatment, transport, housing or management of persons requiring Airborne Isolation (AII);
Ø High hazard procedures performed on suspect or confirmed cases;
Ø Decontamination or management of persons contaminated as a result of biological agents;
Ø Autopsies or embalming procedures on human cadavers potentially infected with aerosol transmissible pathogens.
2. Patients or clients are screened for airborne infectious diseases and referred if indicated (Referring Employers – subsection c, h, j)
3. Laboratories (subsections f, h, I, j)
4. Contact with infected animals (Section 5199.1)
Health care facilities: hospitals, skilled nursing facilities, clinics, medical offices, and other outpatient medical facilities, home health care, public health services, long term health care facilities and hospices, medical outreach services, paramedic and emergency medical services including these services when provided by firefighters and other emergency responders, medical transport, and facilities where high hazard procedures are performed.
Additionally, facilities, services, or operations that:
Ø Receive persons arriving from the scene of an uncontrolled release of hazardous substances involving biological agents
Ø Are at increased risk for transmission of an ATD infection: correctional facilities, homeless shelters, drug treatment programs
Ø Perform aerosol-generating procedures on cadavers
Ø Transport or detain cases or suspected cases of aerosol transmissible diseases and police services provided in conjunction with health care or public health operations
Ø Laboratories that perform procedures with materials that contain ATPs-L or zoonotic aerosol transmissible pathogens (see appendices)
Ø Public health services provided to cases or suspected cases of aerosol transmissible diseases
Ø Any other facility, service or operation that has been determined in writing by the Chief of the Division of Occupational Safety and Health through the issuance of an Order to Take Special Action
Ø Maintenance, renovation, service, or repair operations involving air handling systems or equipment or building areas that may be contaminated with ATPs or ATPs-L
Occupational exposure to animals infected by aerosol transmissible pathogens is covered by a separate, newly adopted standard, T8 CCR § 5199.1 Aerosol Transmissible Diseases – Zoonotic.
The following are not covered:
Ø Outpatient dental clinics or offices are not required to comply with this standard if they do not perform dental procedures on patients identified to them as ATD cases or suspected ATD cases; the Injury and Illness Prevention Program includes a written procedure for screening patients for ATDs and employees are trained in this procedure.
Ø Outpatient medical specialty practices whose policy is not to diagnose or treat ATDs are not required to comply with this standard if they do not perform aerosol-generating procedures on cases or suspected cases of ATD; the Injury and Illness Prevention Program includes written screening procedures, and employees have been trained in the procedures.
(b) Definitions: The standard contains 59 definitions
(c) Referring Employers: A Referring Employer provides initial treatment only, does not treat people with ATDs, but only screens them. A Referring Employer does not transport, house or provide airborne infection isolation to patients infected with suspected ATDs, but only refers them to facilities that do treat them. (See the County of Marin - Aerosol Transmissible Diseases – Referring Employers overview)
(d) Aerosol Transmissible Diseases Exposure Control Plan: County of Marin departments and programs covered under the ATD standard are required to write an ATD Exposure Control Plan [except certain laboratories may write a Biosafety Plan].
(e) Engineering and Work Practice Controls and Personal Protective Equipment:
County of Marin departments and programs covered under the ATD standard must use feasible engineering and work practice controls to minimize employee exposures to ATPs. Engineering and work practice controls are also detailed in the following documents:
Ø Cal-OSHA Title 8 CCR § 5199 – Aerosol Transmissible Diseases – August 2009
Ø County of Marin Aerosol Transmissible Disease Exposure Control Plan – September 2009
Ø CDPH Pandemic (H1N1) Updated Recommendations for Health Care Settings – August 2009
Ø IOM Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A: A Letter Report – September 2009
Ø County of Marin – Public Health Notice, Update on H1N1 Influenza – July 2009
Ø County of Marin – H&HS TB Exposure Control Plan – July 2006
Where engineering and work practice controls do not provide sufficient protection, the County of Marin will provide respiratory protection and/or other personal protective equipment. Guidance regarding the use of respiratory protection and other personal protective equipment can be found in the following documents:
Ø Cal-OSHA Title 8 CCR § 5199 – Aerosol Transmissible Diseases – August 2009
Ø CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings
Ø County of Marin – H&HS TB Exposure Control Plan – July 2006
Ø IOM Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A: A Letter Report – September 2009
Ø County of Marin – H&HS Respiratory Protection Program – July 2006
Ø CDC Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus Transmission – August 2009
(f) Laboratories: The standard applies to laboratory operations where employees perform procedures capable of aerosolizing ATPs-L or zoonotic aerosol transmissible pathogens as defined in Section 5199.1. (See Aerosol Transmissible Diseases – Laboratories - Cal-OSHA Title 8 CCR § 5199.1)
(g) Respiratory Protection: The standard specifies which respirators must be used. A minimum of an N95 filtering respirator must be used for routine occupationally exposed tasks. As of September 1, 2010, high hazard procedures with possible ATD exposure must be done using a powered air-purifying respirator (PAPR) with a High Efficiency Particulate Air (HEPA) filter(s), or a respirator that provides equivalent or greater protection unless there are effective engineering controls. There is an exception to the PAPR requirement when the employer determines that the use of a PAPR would interfere with the procedure being performed. The justification for the exception must be documented in writing. Paramedics and EMTs may use a P100 respirator.
When respirators are required, the employer must establish and implement a written respiratory protection program in accordance with T8 CCR § 5144 Respiratory Protection. (In some instances, an alternate medical questionnaire to the one in Section 5144 can be used). Also, until January 1, 2014, in some cases, fit testing may be conducted every two years after the initial fit-testing has been done.
(h) Medical Services: County of Marin employees with occupational exposure to ATDs or infection with ATPs or ATPs-L will be provided with medical services in accordance with applicable public health guidelines for the type of work setting and disease. These services may include vaccinations, tests, post-exposure follow-up (including treatment), latent tuberculosis infection testing, and precautionary removal.
(i) Training: The ATD standard outlines the training that County of Marin employees with occupational exposure must receive, including training on the employer’s ATD Exposure Control Plan and/or Biosafety Plan. Training must be provided at least annually. Dental clinics and outpatient medical specialty practices (Referring Employers), not covered by the entire ATD standard, must be trained in screening procedures in accordance with their Injury and Illness Prevention Program (IIPP) and as outlined in the ATD standard.
(j) Recordkeeping: The County of Marin must keep medical records, training records and other records related to the implementation of the ATD Plan and/or Biosafety Plan.
County of Marin departments and employees are encouraged to refer to the regulations and any guidance documents Cal/OSHA may have available at www.dir.ca.gov/dosh. They may also contact the County Safety Officer or County Division of Public Health for additional guidance.
References:
Ø Centers for Disease Control and Prevention (CDC) Infection Control Guidelines http://www.cdc.gov/ncidod/dhqp/
Ø Cal-OSHA Title 8 CCR § 5199 – Aerosol Transmissible Diseases – August 2009 http://www.dir.ca.gov/oshsb/atdapprvdtxt.pdf
Ø Infection Control in Dental Settings http://www.cdc.gov/OralHealth/infectioncontrol/
Ø Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm
Ø CDC Swine Flu (H1N1) page http://www.cdc.gov/h1n1flu/
Ø CDC Avian Flu (H5N1) page http://www.cdc.gov/flu/avian/
Ø Government Pandemic Flu page http://www.pandemicflu.gov/
Appendix A
Aerosol Transmissible Diseases/Pathogens (Mandatory)
This appendix contains a list of diseases and pathogens which are to be considered aerosol transmissible pathogens or diseases for the purpose of Section 5199. Employers are required to provide the protections required by Section 5199 according to whether the disease or pathogen requires airborne infection isolation or droplet precautions as indicated by the two lists below.
Diseases/Pathogens Requiring Airborne Infection Isolation
Ø Aerosolizable spore-containing powder or other substance that is capable of causing serious human disease, e.g. Anthrax/Bacillus anthracis
Ø Avian influenza/Avian influenza A viruses (strains capable of causing serious disease in humans)
Ø Varicella disease (chickenpox, shingles)/Varicella zoster and Herpes zoster viruses, disseminated disease in any patient. Localized disease in immunocompromised patient until disseminated infection ruled out
Ø Measles (rubeola)/Measles virus
Ø Monkeypox/Monkeypox virus
Ø Novel or unknown pathogens (H1N1)
Ø Severe acute respiratory syndrome (SARS)
Ø Smallpox (variola)/Varioloa virus
Ø Tuberculosis (TB)/Mycobacterium tuberculosis – Extrapulmonary, draining lesion; Pulmonary or laryngeal disease, confirmed; Pulmonary or laryngeal disease, suspected
Ø Any other disease for which public health guidelines recommend airborne infection isolation
Diseases/Pathogens Requiring Droplet Precautions
Ø Diphtheria pharyngeal
Ø Epiglottitis, due to Haemophilus influenzae type b
Ø Haemophilus influenzae Serotype b (Hib) disease/Haemophilus influenzae serotype b - Infants and children
Ø Influenza, human (typical seasonal variations)/influenza viruses
Ø Meningitis
§ Haemophilus influenzae, type b known or suspected
§ Neisseria meningitidis (meningococcal) known or suspected
Ø Meningococcal disease sepsis, pneumonia (see also meningitis)
Ø Mumps (infectious parotitis)/Mumps virus
Ø Mycoplasmal pneumonia
Ø Parvovirus B19 infection (erythema infectiosum)
Ø Pertussis (whooping cough)
Ø Pharyngitis in infants and young children/Adenovirus, Orthomyxoviridae, Epstein-Barr virus, Herpes simplex virus,
Ø Pneumonia
§ Adenovirus
§ Haemophilus influenzae Serotype b, infants and children
§ Meningococcal
§ Mycoplasma, primary atypical
§ Streptococcus Group A
Ø Pneumonic plague/Yersinia pestis
Ø Rubella virus infection (German measles)/Rubella virus
Ø Severe acute respiratory syndrome (SARS)
Ø Streptococcal disease (group A streptococcus)
Ø Viral hemorrhagic fevers
Ø Any other disease for which public health guidelines recommend droplet precautions
Ø County of Marin
Cal-OSHA Aerosol Transmissible Disease (ATD) Standard
Application to County of Marin Operations and Services
Subsection (a)(1)(A) through (a)(1)(I) – ATD Scope and Application
County of Marin operations and services that fall within these categories and definitions must comply with the entirety of the ATD standard.
(a) Scope and Application.
(1) Scope. This section applies to work in the following facilities, service categories, or operations:(A) Each of the following health care facilities, services, or operations:
1. Hospitals
2. Skilled nursing facilities
3. Clinics, medical offices, and other outpatient medical facilities
4. Facilities where high hazard procedures, as defined in subsection (b), are performed
5. Home health care
6. Long term health care facilities and hospices
7. Medical outreach services
8. Paramedic and emergency medical services including these services when provided by firefighters and other emergency responders
9. Medical transport
(B) Facilities, services, or operations that are designated to receive persons arriving from the scene of an uncontrolled release of hazardous substances involving biological agents, as defined in Section 5192, Hazardous Waste Operations and Emergency Response, of these orders.
(C) Police services, provided during transport or detention of persons reasonably anticipated to be cases or suspected cases of aerosol transmissible diseases; and police services provided in conjunction with health care or public health operations.
(D) Public health services, such as communicable disease contact tracing or screening programs that are reasonably anticipated to be provided to cases or suspected cases of aerosol transmissible diseases, and public health services rendered in health care facilities or in connection with the provision of health care.
(E) The following facilities, services or operations that are identified as being at increased risk for transmission of aerosol transmissible disease (ATD) infection:
1. Correctional facilities and other facilities that house inmates or detainees
2. Homeless shelters
3. Drug treatment programs
(F) Facilities, services or operations that perform aerosol-generating procedures on cadavers such as pathology laboratories, medical examiners' facilities, coroners' offices, and mortuaries.
(G) Laboratories that perform procedures with materials that contain or are reasonably anticipated to contain aerosol transmissible pathogens - laboratory (ATP-L) or zoonotic aerosol transmissible pathogens as defined in Section 5199.1.
(H) Any other facility, service or operation that has been determined in writing by the Chief of the Division of Occupational Safety and Health through the issuance of an Order to Take Special Action, in accordance with Section 332.3 of these orders, to require application of this standard as a measure to protect employees.
(I) Maintenance, renovation, service, or repair operations involving air handling systems or equipment or building areas that may reasonably be anticipated to be contaminated with aerosol transmissible pathogens (ATPs) or ATPs-L, including:
1. Areas in which Airborne Infectious Disease (AirID) cases and suspected cases are treated or housed.
2. Air handling systems that serve airborne infection isolation rooms or areas (AIIRs).
3. Equipment such as laboratory hoods, biosafety cabinets, and ventilation systems that are used to contain infectious aerosols.
Specific Public Health Services covered by the standard: