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Protocol for assessing students suspected of having influenza-like illness

The New York State Department of Labor Public Employees Safety and Health Bureau (NYSDOL PESH) published an H1N1 enforcement directive to protect public sector employees, including those who work in the New York City public school system, from infection by H1N1. This PESH directive requires the employer to develop and implement a pandemic flu program, provide training on H1N1, conduct workplace assessments to identify those employees who have high risk of exposure to H1N1 and provide high-risk employees with personal protective equipment including N95 respiratory protection. School nurses are considered at high risk for exposure to H1N1 because they must assess students suspected of having influenza-like illness (ILI).

This fact sheet addresses infection control and respiratory protection for school nurses and incorporates protocols specified by the New York City Department of Health and Mental Hygiene (DOH) and the New York City Department of Education (DOE) Office of School Health in the Dec. 2009 document “Infection Control Protocol for Assessing Students Suspected of Having Influenza-Like Illness.”

What is considered an Influenza-Like Illness (ILI)?

The New York City Department of Health and Mental Hygiene (NYCDOHMH) has defined an ILI case as:

  • Fever greater than or equal to 100.0°F and cough or sore throat
    • Oral or aural temperature of greater than or equal to 100.0°F
    • Auxiliary temperature of greater than or equal to 99.0°F

What steps are required to isolate infected persons to prevent transmission of influenza (seasonal and H1N1)? What is the proper triage of students presenting with fever, cough or sore throat?

Warning signs should be placed at the entrance to the medical room advising students who have fever, cough or sore throat to inform the nurse upon arrival.

School staff should instruct students sent for evaluation to notify the nurse if they have ILI symptoms.

Students complaining of fever, cough or sore throat should be asked to wear surgical masks while waiting for evaluation and during screening in the medical office.

If possible, isolate any student complaining of fever, cough or sore throat. Attempts should be made to keep such students away from other students and out of commonly used areas such as hallways until screening is completed.

What protocols has the DOE/DOH Office of School Health implemented to protect school nurses from potential influenza exposure?

Nurses in medical rooms with a high volume of students with ILI should wear N95 disposable respirator continuously while in the medical room.

In addition, nurses should wear N95 disposable respirators any time they are evaluating an individual student with ILI.

Nurses should wash hands before and after evaluating each student.

Flat surfaces in the medical room should be cleaned frequently with CaviWipes.

After washing hands, nurses should put on an N95 respirator and wear it while taking the temperature, providing direct care or being within three feet of any student with fever, cough or sore throat.

Nurses should wear exam gloves if direct contact with secretions, mucous membranes, blood or body fluids is unavoidable.

Nurses should ask students to wash hands with soap and water or use an alcohol-based hand sanitizer before putting on surgical masks. Students should be asked to wear the surgical masks while being evaluated except when their temperature is being taken.

What should be done with students with ILI?

Students with fever and cough or sore throat should be sent home immediately. Students without fever may be sent back to class if in the nurse’s clinical judgment the student is well enough to return to class.

Students waiting to be picked up should continue to wear surgical masks and remain in the medical office or designated waiting area. These students must not go back to the classroom or the general office.

Exclusion of students with ILI

Students with ILI should remain out of school for 24 hours after complete resolution of fever.

Students do not need a doctor’s note to return to school.

Nurses may request a doctor’s note for students with symptoms that persist for seven days or more after onset.

What is the difference between an N95 respirator and a surgical mask? Why are nurses wearing the N95 disposable respirators and students with ILI wearing surgical masks?

Respirators are designed to reduce the employee’s exposure to airborne contaminants including very small airborne contaminants (e.g. aerosols). Respirators come in various sizes and must be individually selected to fit the wearer’s face and to provide a tight seal. The N95 respirator is made with an N-series filter material that is at least 95% efficient in removing particles that are 0.3 microns in size. The N95 respirator should have N95 written on the respirator and be approved by the National Institute for Occupational Safety and Health (NIOSH-certified).

Placing a surgical mask on a student with ILI protects other people from infection by limiting the spread of infectious respiratory secretions from the student. Surgical masks trap large droplets of body fluids that may contain flu viruses. Only surgical masks that are cleared by the US Food and Drug Administration to be legally marketed in the US have been tested for their ability to resist blood and body fluids.

A surgical mask is not a respirator. Surgical masks are not designed or certified to prevent the inhalation of small airborne contaminants including aerosols. These particles are not visible to the naked eye but may still be capable of causing infection. Surgical masks are not designed to seal tightly against the user’s face.

OSHA/PESH Respiratory Protection Standard

As required by the OSHA/PESH Respiratory Protection Standard, components of the DOE/DOH Office of School Health respiratory protection program include:

  • A written respiratory program
  • A program administrator (Diana Rodela from the NYCDOHMH is the current program administrator/coordinator for school nurses)
  • Proper selection of respirators
  • Individual physical medical clearance
  • Fit testing
  • Training about the respiratory hazards and proper use, care and storage of respirators
  • Annual evaluation of program effectiveness

Medical Clearance, Fit-testing and Training

Before school nurses can wear the N95 disposable respirators, they must be medically cleared, fit-tested and trained. The NYCDOH conducts the fit testing and training. The training takes place at each fit-testing session and school nurses can view a video on respiratory protection at the fit-testing session.

The medical evaluation consists of completing a confidential medical questionnaire that is then reviewed by a licensed health care professional. The licensed health care professional will send a written clearance to the DOH/DOE Office of School Health stating that the nurse can or cannot wear a specific respirator, in this case the N95 disposable respirator.

Fit testing

If a respirator does not form a tight seal around the face, contaminated air may leak around the edges of the face seal. The only way to determine if a respirator fits and is capable of protecting the wearer properly is to fit-test the respirator.

Nurses must be fit-tested prior to initial use and annually thereafter. They should also be fit-tested every time a new model, manufacture type/brand or size respirator is worn, if their weight fluctuates or facial/dental alterations occur.

Qualitative Fit Test

It is important to have a respirator fit test because it is a way to determine if the respirator is properly protecting the wearer.

The fit test involves creating a fine mist of an agent that is harmless — either a sweet or bitter tasting aerosol while the nurse is wearing the respirator. The mist is created inside a hood placed over the person’s head while he or she is wearing the respirator. During the test the person performs a number of exercises including talking, deep breathing and movement of the head in various directions. If the respirator wearer does not observe a sweet or bitter taste during the test the respirator is considered passing.

Putting on and Taking off the Respirator

  • Make sure your respirator is clean, undamaged, and the straps have elasticity.
  • Place over nose, mouth and chin.
  • Fit flexible nosepiece over the nose bridge.
  • Secure on head with the elastic straps.
  • Adjust to fit.
  • Perform a seal check.
  • Inhale — the respirator should collapse.
  • Exhale — check for leakage around the face.

When removing the respirator avoid touching the inside of the respirator if you plan to reuse it.

Storage, Care and Use

In medical rooms with a high daily volume of ILI students (more than eight students with ILI), school nurses must discard N95 respirators at the end of each day.

The school nurse may reuse N95 respirators in medical rooms with low or intermediate volume of ILI students (less than eight students with ILI). If a nurse decides to reuse the N95 respirator, the reuse period must not exceed five consecutive school days; respirators should also not be used past the weekend. Disposable respirators must only be used and re-used by a single wearer. Nurses should always wash their hands before and after touching a used respirator.

The N95 disposable respirators should be stored in a brown paper bag or plastic bag that has been labeled with the nurse’s name. Nurse should take care not to touch and contaminate the inside of the respirator when inserting or removing it from the paper bag.

Respirators should be discarded immediately if they are visibly soiled, damaged, and damp or if it is difficult to breathe when wearing them.

Respirators should be discarded immediately if they are contaminated with blood, respiratory or nasal secretions or other bodily fluids from students/patients.