What is Pandemic influenza and what makes it different from ordinary flu?
Pandemic influenza is different from ordinary seasonal flu, which for most people is an unpleasant illness but runs its natural course (sometimes referred to as self-limiting) and is not life-endangering. Pandemic flu can occur when a new influenza virus emerges which is markedly different from recently circulating strains and to which humans have little or no immunity. Because of this lack of immunity the virus is able to:
- infect more humans over a large geographical area;
- spread rapidly and efficiently from person to person;
- cause clinical illness in a proportion of those infected.
It is easily passed from person to person when an infected person talks, coughs or sneezes. It can also spread through hand/face contact after touching anything that may become contaminated with the virus. Illness develops a few days (average 2-3) after being infected. Everyone is susceptible, although only about a quarter of the population are expected to become ill. Another 25% may catch the infection without getting any symptoms.1
The Government has dedicated a lot of time to influenza pandemic planning in case there should be a influenza pandemic. This is first and foremost a public health matter, and so the UKs Health Departments have taken the planning lead in close consultation with other Government departments and agencies including the Health and Safety Executive. The English, Scottish and Welsh Health Departments have websites dedicated to pandemic flu:
The Department of Health’s pandemic flu website
The Scottish Government pandemic flu webpages*
* - These pages incorporate planning documents and infection control guidance specific to Scotland.
Welsh Assembly Government Pandemic flu website
These include a guide from the CMO (Chief Medical Officer) entitled Explaining pandemic flu, a leaflet entitled Important information for you and your family, key facts, frequently asked questions (FAQs), and the CMO guide for health professionals and the public. The National Framework for responding to an influenza pandemic can be located at: Pandemic Flu A national framework for responding to an influenza pandemic.
What are the signs and symptoms?
The symptoms are similar to ordinary flu but may be more severe: characteristically sudden onset of fever, headache, severe weakness and fatigue, aching muscles and joints and respiratory symptoms such as cough, sore throat, and runny nose. Complications include bronchitis and pneumonia; deaths can occur.
Is bird flu the same as pandemic flu?
No. They are different things. Bird flu is properly called Avian Influenza and is a disease of birds, not humans. People can become infected but rarely are unless they have particularly close contact with infected birds (as has happened in South East Asia). UK Environment
1 More information on influenza can be found on the Health Protection Agency (HPA) website
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Departments have responsibility for matters affecting the environment. Contingency plans specifically focused on Avian Influenza and explanations of Avian Influenza with Q&A briefs and this can be found on the relevant websites.2
HSE has also drawn up guidance in consultation with Defra and with the poultry industry to advise those employed in the poultry industry. The HSE web site has an avian flu page that gives advice to workers who might be exposed to the disease:
Working with Highly Pathogenic Avian Influenza Virus
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The reason that there is some public and media confusion over bird flu is that the current bird flu virus (H5N1) has the potential to mutate or to recombine genetically with the human flu virus and create a new pandemic human flu strain.
What general advice does HSE have for employers/employees concerned about exposure to pandemic flu at work?
Pandemic flu is first and foremost a public health matter. There are, however, clear health and safety requirements (COSHH i.e. the Control of Substances Hazardous to Health Regulations 2002 as amended - http://www.hse.gov.uk/biosafety/law.htm) to protect workers who come into contact with infectious micro-organisms such as the influenza virus either as a direct consequence of their work e.g. those who carry out research work on the virus, or else may be exposed in the course of their work e.g. healthcare workers caring for infectious patients.
Individuals are at risk from pandemic influenza if they are in close contact with someone who has the disease or with objects that have been contaminated by infectious material e.g. droplets from coughs and sneezes on surfaces, used tissues/clothing etc. This means that there may be other workers (e.g. cleaners; prison staff or residential care workers in direct contact with sick people) to whom COSHH applies. Where such direct contact is foreseeable, employers should carry out a risk assessment and put preventative measures and/or controls in place as appropriate. General advice on assessing and controlling the risks from infection at work can be found at: ACDP Infection at work: Controlling the Risks 2003
COSHH does not cover employees who are exposed to a disease, which is in general circulation and so may happen to be in the workplace as well. However, there may be indirect health and safety consequences of such a pandemic which do impinge on Health and Safety legislation (Health and Safety at Work etc Act 1974 and the Management of Health and Safety at Work Regulations 1999 in particular) e.g. the redeployment of workers to unfamiliar tasks or to lone or remote working as a consequence of a depleted staff resource due to sickness absence. Where there are indirect health and safety effects, it is again important to use the principles of risk assessment as a basis for ensuring the appropriate controls are put in place.
This HSE advice applies the Department of Health’s general public health advice to the workplace and at the same time highlights specific health and safety issues.
General advice for employees
HSE’s general advice is to encourage each individual employee to adopt a common sense approach. If you are feeling unwell with flu-like symptoms and particularly if you are coughing and sneezing then stay at home. This will help to prevent the disease being passed on to colleagues (and also fellow passengers on your way to and from work, if you travel by public transport). In the workplace, practice good personal hygiene measures use a disposable
2 For England - http://www.defra.gov.uk/animalh/diseases/notifiable/disease/ai/index.htm
For Scotland - http://www.scotland.gov.uk/Topics/Agriculture/animal-welfare/Diseases/SpecificDisease/AvianInfluenza/AIIntroduction
For Wales - http://www.countryside.wales.gov.uk/fe/master.asp?n1=1&n2=102&n3=259
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tissue to control coughs/sneezes, dispose of it appropriately and wash your hands before eating, drinking etc.
General advice for employers
Advise your staff to stay at home if they are sick. It would be a wise precaution to send home, at the earliest opportunity, any employees who are displaying flu-like signs/symptoms since retaining sick employees in the confines of a workplace will increase the likelihood of further spread of the disease to the workforce. This general precaution should applies in educational and similar establishments to people other than employees e.g. children/students/attendees who are unwell and are coughing and sneezing.
If you have employees who can safely work from home then this should be identified and encouraged. Opting for video-conferencing or tele-conferencing where possible instead of holding meetings is a practical precaution. Remote electronic working, where feasible, will reduce face-to-face meetings.
Throughout the duration of a pandemic, it is likely that your workforce will be depleted. In these circumstances, it is important to ensure that appropriate training is given to any remaining workers who may be required to carry out unfamiliar tasks. You may also need to review risk assessments and apply the necessary control measures to take account of the reduced workforce and the remaining pool of skills available to maintain your business. Young workers and pregnant workers are particular categories of employee to be borne in mind in any temporary reorganisation of this sort and should not be substituted into inappropriate work.
You may need to think about extra precautions if workers, who normally work in a group, are required to work alone or in a remote location such a scenario might even need to be suspended until you have a sufficient complement of staff. Certainly, the risks should be reassessed and appropriate control measures put in place.
Similarly, employee sickness absences may create a need for other employees, if willing, to work longer hours in order to keep your business going. In this event, you will need to comply with the requirements of the Working Time Regulations 1998 as amended to ensure appropriate length of daytime working hours, night shifts and rest breaks. oung workers are a particular category of employee for whom you must ensure appropriate working hours. For further details see: The Working Time Regulations (1998).
Many people work in large open plan offices or workshops that are equipped with air conditioning systems. Although there may be some advantages in switching off an air conditioning system, the overall effect would be to create more static air which may result in discomfort and ill health effects. The main advantage of air conditioning is that it has a dilution effect on stale/contaminated air and also provides a more comfortable environment overall. HSE’s advice is therefore to continue running any air conditioning system already provided for the workspace.
There may be some situations where it will be advisable for a worker to wear a mask and the following information will help you decide.
Do my employees need to wear a mask at work?
The Department of Healths advice is that if a person is ill, or thinks they are ill then they should stay at home. This will contribute to maintaining a healthy workforce, and therefore it should not be necessary to wear a mask in most workplaces.
What about workers who regularly come into contact with the public?
To help prevent spread of infection, the Department of Health recommend that people who are ill stay at home and suggest that relatives, neighbours etc collect food, medicines etc for them. This measure should help limit the number of symptomatic individuals in public places. Therefore it should not be necessary for workers to wear masks routinely when in contact with the general public. There may though be some situations when it will be advisable for a worker to wear a mask. Such a situation will depend on the nature of the work, where it is to
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be carried out and the outcome of the risk assessment that should, amongst other things, gauge:
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- Whether it is reasonably foreseeable that workers may come into close contact (typically about a metre) with symptomatic members of the public during the course of their work;
- If workers are likely to encounter symptomatic members of the public, whether any measures can be taken to minimise contact. For example, in a healthcare setting it is highly likely that contact with the public (patients) will include persons who have symptoms of influenza. But in a sports/leisure facility for example, people using the facilities are very unlikely to have symptoms of influenza because people with flu do not generally take exercise;
- The duration and frequency of contact with members of the public.
- Influenza viruses spread mainly through droplets of respiratory secretions in the air, typically generated by coughing and sneezing. They also spread through hand/face contact with surfaces contaminated with such secretions. Masks can provide a physical barrier but some precautions need to be observed. They should properly cover the mouth and nose and be used in combination with good personal hygiene.
Whose responsibility is it to provide masks?
Responsibility for providing advice on the use of masks for workers in general, including those in healthcare, rests with the employer or dutyholder. Whether a mask will be required will depend on the nature of the work and the outcome of your risk assessment for the workplace see http://www.hse.gov.uk/risk/ for a guide on how to carry out a risk assessment.
Some of my employees need to wear a mask. What type should it be?
There are many types of mask available that will offer different levels of protection. Whilst the choice of facemask rests ultimately with you as employer, based on the results of your risk assessment, as a general guide, fluid repellent surgical masks will suffice as a barrier to large projected droplets that are regarded as the main route of transmission of influenza virus. They are also a practical and pragmatic measure for workers not normally used to wearing a mask whilst at work.
For high risk situations, where exposure to aerosols is considered significant, FFP3 masks are recommended, in particular for healthcare workers engaged in medical procedures generating aerosols of influenza flu virus that carry greater risks of infection. Specific infection control guidance for healthcare is available on the DH website.
What is the difference between a surgical mask and a FFP3 mask?
Surgical masks are plain masks that cover the nose and mouth and are held in place by straps around the head. In healthcare settings, they are normally worn during medical procedures to protect not only the patient but also the healthcare worker from the transfer of microorganisms, body fluids and particulate matter generated from any splash and splatter. Whilst they will provide a physical barrier to large projected droplets, they do not provide full respiratory protection against smaller suspended droplets and aerosols. That is, they are not regarded as personal protective equipment (PPE) under the European Directive 89/686/EEC (PPE Regulation 2002 SI 2002 No. 1144). A filtering facepiece (FFP3) device is a mask which is certified to the PPE Directive. It provides a high level of filtering capability and face fit. It can be supplied with an exhale valve so that it can be worn comfortably over a fairly long period of time. It will provide an effective barrier to both droplets and fine aerosols and is the type recommended particularly for people in the healthcare sector dealing with symptomatic patients undergoing treatment where aerosols are likely to be generated.
There are also filtering facepieces FFP1 and FFP2 available but these provide less respiratory protection than a properly fitting FFP3 device.
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Do any special measures need to be taken when fitting surgical masks and FFP3 masks?
For surgical masks, the main requirement is that people should ensure that these fit as well as possible onto the face especially around the nose and mouth particularly taking account of the manufacturer???s instructions.
FFP3 masks should be fitted with care to ensure that they fit as well as possible onto the face especially around the nose and mouth particularly taking account of the manufacturers instructions. HSE guidance recommends that these masks are fit tested, in advance, to ensure that they are able to fit the wearer. It may be advisable to have more than one make of mask available as some masks may provide a better fit for some people than others.
How long should masks be worn before they are replaced?
Masks should only be worn once. The frequency with which they are changed will depend on the nature of the duties being undertaken as well as taking account of the manufacturers instructions. In the healthcare setting, the replacement of masks will be governed by the requirements of infection control procedures.
What other protective measures should be taken?
Workers should adopt good working practices and not rely solely on personal protective equipment as a means of protection. They need to adopt sensible hygiene measures by washing their hands thoroughly and more frequently than normal and avoiding unnecessary hand to mouth or hand to eye contact.
Do physical barriers provide protection against influenza virus?
If a worker is working in an area where they are separated from other people by barriers such as glass screens etc, then this will act as a physical barrier to influenza transmission. For example, workers who deal with the public from behind glass screens (e.g. in a Post Office) could not be regarded as being likely to be sneezed or coughed upon by a member of the public, even if they were to have symptoms.
Other sources of information
General advice on assessing and controlling the risks from infection at work as well as guidance on other protective measures can be found at:
Advisory Committee on Dangerous Pathogens: Infection at Work: Controlling the Risks 2003
Guidance for Pandemic Influenza: Infection Control in Hospitals and Primary Care Settings
Hand-washing technique with soap and water: NHS Poster
Fit testing of respiratory protective equipment facepieces
How are the agents that cause influenza and pandemic influenza classified under the Control of Substances Hazardous to Health Regulations 2002 (as amended) (COSHH)?
The Advisory Committee on Dangerous Pathogens (ACDP) met in May 2005 to discuss and review advice on influenza viruses. ACDP has produced a generic assessment of the risks of the different types of influenza virus that can be used as the basis for local risk assessment. It made recommendations about the containment level at which certain types of influenza virus should be handled. Details of the relevant ACDP classification recommendations can be found on the ACDP website at: ACDP Containment and control for work with Influenza viruses ACDP/80/P5.
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What advice does HSE have for laboratory workers?
In addition to the ACDP classification recommendations in 5 above, ACDP has also provided guidance on containment and control measures for work with flu viruses. These recommendations cover workers in laboratories that are knowingly handling influenza viruses; diagnostic work; use of microbiological safety cabinets; and planning for a pandemic. All of this ACDP advice can be found at: HSE Advice on working with Influenza viruses 2005
What advice does HSE have for health care workers?
In the event of an influenza pandemic, the major group of workers (other than laboratory workers), most likely to come into contact with the virus are the wide spectrum of health care workers caring for patients with the disease.
Once the Chief Medical Officer (CMO) has declared an influenza pandemic in the UK, then the Department of Health (England) and Health Protection Agencys detailed guidance entitled Guidance for Pandemic Influenza: Infection control in hospitals and primary care settings is a useful document to help inform your risk assessment. This can be accessed at: Pandemic influenza: Guidance for infection control in hospitals and primary care settings: November 2007.
Until that point, standard health and safety risk assessment and controls should be applied. For example, when the first few cases of pandemic influenza start to appear in the UK, there will be no available vaccine. A local risk assessment should be carried out. Patients may need to be isolated and staff may need to use properly fitting FFP3 respirators together with other personal protective equipment coupled with stringent hygiene precautions to provide the best protection available.
Cleaning staff
Specific advice for cleaning staff in hospital and similar clinical settings is given in section 6 of Pandemic influenza: Guidance for infection control in hospitals and primary care settings: November 2007.
Cleaning staff in other settings, particularly those involved in cleaning areas where there is a large public turnover, should be reminded of the need to ensure a personal hygiene routine of hand washing (i.e. using soap and water and thoroughly drying) after contact with communal objects/surfaces.
Research on one particular influenza virus suggests that the virus can survive on hard surfaces (e.g. stainless steel counter, plastic washing-up bowl) for up to 72 hours and on soft items (e.g. pyjamas, handkerchiefs, magazines) for up to 24 hours. Research looked at the transfer of virus from such contaminated surfaces onto hands and found that this could take place up to 24 hours in the case of a contaminated hard stainless steel surface and up to 2 hours in the case of contaminated soft tissues. Once the virus had transferred to hands, it was found to survive for only 5 minutes. Nevertheless, 5 minutes is sufficient time to spread infection, for instance, by putting fingers into mouth or by touching eyes. The importance of hand washing and good personal hygiene, therefore, cannot be overemphasised.
Damp rather than dry dusting should be carried out to avoid the generation of dust particles. Cleaning of surfaces should be carried out using a freshly prepared solution of detergent and hot water followed, where necessary, by a chlorine based disinfectant solution.
The emptying of bins and waste paper baskets should be followed by hand washing.
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I think many of us were surprised by the degree to which critical infrastructure was affected 