CDC's October 14, 2009,"Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, including Protection of Healthcare Personnel" determined that school health personnel need to use respiratory protection and comply with the OSHA respiratory protection standards when the hierarchy of controls cannot prevent employee exposure to a patient with influenza-like illness (ILI). Although the New York State Department of Health (NYSDOH) has no enforcement powers regarding OSHA regulations, it had the knowledge and experience to help school districts overcome the daunting task of developing a respiratory protection program.
Outside of New York City, approximately 3,300 school nurses (RNs), along with LPNs and other school health personnel in New York State, became versed in the hierarchy of controls to minimize exposure to influenza. (New York City receives separate federal funding to conduct health-related activities.) School health personnel also became involved in the development and implementation of a complete respiratory protection program.
The major components of a respiratory protection program include: development of a written respiratory protection plan, medical evaluations for employees who may need respiratory protection, employee training, fit testing, and the necessary recordkeeping. Until the emergence of the 2009 H1N1 virus, most schools had only limited need for respiratory protection and typically little to no need for infection control.
To expedite this process and reach the largest number of schools in a short period of time, NYSDOH developed a compliance package. The package contained an electronic sample of a respiratory protection program that included comments from both an OSHA Area office and the Public Employees Safety and Health (PESH) program. Although these agencies do not formally approve sample programs, they were able to ensure that NYSDOH's program met the requirements of the respiratory protection standard. The compliance package also contained a PowerPoint training for school health personnel, a list of suppliers for N-95s and fit-testing equipment, a link to CDC's October 14, 2009 guidance document, a one-hour training webinar, and a checklist the school administration can follow to ensure they meet all the requirements of the OSHA standard (29 CFR 1910.134).
NYSDOH experienced some difficulty when determining how to provide the information to school health personnel. Barriers included limited travel budgets, the infeasibility of asking school health personnel to take time off since schools typically employ only one health worker, and the large number of school health workers in the state. NYSDOH quickly realized that various outreach methods would be necessary.
NYSDOH worked with the State Education Department (SED) to partner with Health and Safety staff from the Boards of Cooperative Educational Services (BOCES). Many school districts have existing contracts with BOCES for health and safety services, and a "train the trainer" approach for the BOCES staff could reach a large number of school health personnel. In addition, the New York State Department of Labor (NYSDOL) offered to provide compliance assistance for schools that did not contract with BOCES. NYSDOH also worked with Questar III, which provides instructional and support services to 23 school districts in three New York counties.
Partner organizations met with NYSDOH in early November 2009 to discuss how they could best communicate with school health personnel and provide respiratory protection training services. The BOCES Northeastern Regional Information Center (NERIC) suggested producing a training webinar. The webinar is presented in modules and can be viewed either in its entirety or as separate modules (e.g., one could view a continuing education module on how to perform a fit-test). In addition, the Northeastern Regional Information Center (NERIC) offered its facilities and technology to create and edit the video. The webinar was completed December 4, 2009, and has provided free and convenient training to New York State school districts and their health personnel. The webinar can be used at any convenient time to reach any school district that is unable to travel to a training session or host on-site training.
One barrier that schools faced as they tried to comply with the respiratory protection standard was the lack of access to N-95 respirators. NYSDOH evaluated the Strategic National Stockpile (SNS) allotments and found that large amounts of N-95s in the stockpile were NIOSH-approved but not cleared by the FDA. Since these respirators could not be used by acute care facilities, they could besupplied to school districts after a good faith effort to obtain respirators from the standard suppliers. School requests for these supplies were submitted to county emergency managers, who then helped to provide the needed equipment. Information on how to contact county emergency managers was provided by SED to the school districts.
This collaborative effort between schools, NYSDOH, NYSDOL, SED, BOCES, NERIC and county emergency managers is ongoing. The training has already proven to be effective for informing school health personnel on the respiratory protection standard, and it has helped to develop effective and sustainable partnerships among many different state groups.