SARS-Coronaviruses and Highly Pathogenic Influenza Viruses
Section 4: Responding to fever or respiratory symptoms in laboratory workers
Upon onset of fever or respiratory symptoms, the employee will immediately make an initial contact with the Supervisor/Principal Investigator or Laboratory Chief. If at home, the employee will not report to work, pending further evaluation and instruction. If at work, the employee should don a surgical mask, notify the Supervisor and return home without using public transportation. Should onset of fever >100.4 F and severe respiratory symptoms occur while the employee is in travel status, away from the Capital District, the Supervisor will collect supporting information and contact one of the Risk Assessment Group members immediately to gain guidance on response. If a moderate to high risk exposure event has occurred in the 14 days prior to planned travel, the employee will be placed on leave at home, and travel will be cancelled.
When an illness is reported to the Supervisor/Principal Investigator and/or the Risk Assessment Group has been activated, they will use all available information to determine the level of risk of exposure and then follow the appropriate algorithm that may include medical monitoring, laboratory testing and isolation or quarantine.
4.1: Scenario 1: Symptoms with no risk of exposure
Background: An example of this scenario would be an employee who has not worked in the BSL-3 laboratory within the previous 14 days but who has now developed fever of 100.4°F or greater and respiratory symptoms. (The 14 day period is based upon the high likelihood that beyond that period following an exposure, disease would not develop.) The employee calls in indicating he/she has relevant symptoms.
Action taken:
4.1.1 The employee should not report to work, pending further evaluation and instruction.
4.1.2 The laboratory entry log will be reviewed by the Supervisor/Principal Investigator to determine the last day the employee worked in the BSL-3 facility. It should be confirmed that the employee has not worked with either live pathogen within the last 14 days.
4.1.3 Surveillance will be enhanced for other respiratory and/or febrile illness among laboratory workers to determine if the laboratory may have been contaminated. If no other illness is identified, no further action is necessary. Employees who are not well enough to work will remain at home on sick-leave, and will be seen by a personal physician at their own discretion. If illnesses are identified in other laboratory staff working in the BSL-3 laboratory, the Risk Assessment Group should be consulted to determine further action.
4.2: Scenario 2: Symptoms with low risk of exposure
Background: Examples of a low risk of exposure would be an employee who has worked in the BSL-3 laboratory within the previous 14 days without an exposure event and who has now developed specific respiratory symptoms.
In this scenario, given no serious documented laboratory event, a non-work-related respiratory infection should be strongly considered.
Action taken:
4.2.1 The employee will not report to work pending further evaluation and instruction. The Event Log will be reviewed by the Supervisor/Principal Investigator to determine the last day the employee worked in the BSL-3 laboratory, and the Event Log should be checked for documentation of events in the preceding 14 days. The Wadsworth Center senior administration (WC Director, WC Deputy Director or the Division Director) and Biosafety Officer will be notified.
4.2.2 If the employee's symptoms are compatible with SARS-CoV or HPI virus, the Risk Assessment Group will be notified through the Wadsworth Center senior administration.
4.2.3 The Risk Assessment Group may require the employee to remain at home and monitor symptoms using the Daily Monitoring Log of Laboratory Personnel (Attachment 1). The log should be monitored daily by the facility-designated person in consultation with the Infectious Disease Medical Provider.
4.2.4 The Local Health Department and the NYSDOH Regional Epidemiology Central Office will be notified.
4.2.5 If symptoms resolve within 72 hours, the employee, after consultation with the Risk Assessment Group, will return to work (see Section 6). Monitoring will continue for the remainder of the 10-day period.
4.2.6 If symptoms persist or worsen, the Infectious Disease Medical Provider, in consultation with the Risk Assessment Group, will initiate diagnostic testing for respiratory pathogens including SARS-CoV or HPI virus. In this case, CDC Algorithm 2: Algorithm for management of fever or respiratory symptoms when SARS-CoV transmission is occurring in the world (Attachment 2) will be followed using Standard Respiratory Precautions during transportation to and at the Healthcare Facility.
4.2.7 Specifically, the employee should be provided with a surgical mask and instructions on its use and disposal. For patients who cannot wear a mask, tissues and instructions on when to use them (e.g. when coughing, sneezing or controlling nasal secretions) should be provided. The employee should be instructed on how and where to dispose of used tissues and of the importance of hand hygiene after handling this material.
4.2.8 Transport to the Healthcare Facility should be arranged such that the employee does not use public transportation.
4.3: Scenario 3: Symptoms with a documented exposure event
Background: In this scenario a documented exposure event has already occurred (Section 3). The Risk Assessment Group and the Local Health Department have been notified that a potential exposure has occurred. Examples of exposure events would be a spill of virus-containing material outside of the biological safety cabinet, failure of the biological safety cabinet while infectious virus is being handled and a powered air purifying respirator is not being worn, or splashes of infectious materials onto mucous membranes. The development of symptoms has been monitored using the Daily Monitoring Log of Laboratory Personnel (Attachment 1).
Action taken:
4.3.1 If symptoms do appear after an exposure event, the Risk Assessment Group will be consulted and the employee will be referred to the Infectious Disease Medical Provider for further medical evaluation. Algorithm 2: CDC Algorithm for management of fever or respiratory symptoms when SARS-CoV transmission is occurring in the world (Attachment 2) will be followed using Standard Respiratory Precautions during transportation to and at the Healthcare Facility (Section 4.2.7 and 4.2.8 above).
4.4: Medical evaluation for potential SARS Co-V exposure:
4.4.1. Symptoms deemed not significant by the Infectious Disease Medical Provider and public health authority:
a. If symptoms progress, follow Algorithm 2 (Attachment 2) for management of fever or respiratory symptoms.
b. If no significant symptom progression occurs during 10 days following exposure, after consultation with the Risk Assessment Group, discontinue medical evaluation and monitoring (Section 6).
4.4.2. Fever or respiratory symptoms or other symptoms considered significant by the Infectious Disease Medical Provider and the Bureau of Communicable Disease Control:
a. Follow Algorithm 2 (Attachment 2) for management of fever or respiratory symptoms when SARS transmission is occurring in the world.
b. Identify and monitor contacts daily in coordination with the Local Health Department. The laboratory will identify and monitor laboratory contacts. The Local Health Department will identify and monitor community contacts.
c. If not hospitalized, the Local Health Department will assess appropriate placement for home isolation.
4.5: Medical evaluation for potential HPI virus exposure:
4.5.1 For other than fever or respiratory symptoms:
a. If medical findings are deemed significant, follow recommendations outlined for SARS above (Section 4.3, Scenario 3).
b. If medical findings are unrelated or are deemed not significant by the Infectious Disease Medical Provider and public health authority, continue medical follow-up to monitor for symptom progression. If symptoms progress to fever or respiratory symptoms, follow guidance for SARS-CoV above (Section 4.3, Scenario 3). If no symptom progression occurs during the 10 days following the event, in consultation with the Risk Assessment Group, discontinue medical evaluation and monitoring (Section 6).
4.5.2 If not hospitalized:
a. The Local Health Department will assess appropriate placement for home isolation for 14 days after the onset of illness or until an alternative diagnosis is established.
b. Testing for pertinent influenza A strains will be made on a case-by-case basis. This decision will be made by the Infectious Disease Medical Provider, in consultation with the Risk Assessment Group.
c. The laboratory will identify and monitor laboratory contacts.
d. The Local Health Department will identify and monitor community contacts.
4.5.3 If hospitalized with milder illness:
a. Implement infection control precautions as above.
b. The Infectious Disease Medical Provider, in consultation with the Risk Assessment Group, will initiate diagnostic testing for respiratory pathogens including influenza A strains currently used in the laboratory.
4.5.4 If hospitalized with unexplained radiographically confirmed pneumonia, acute respiratory distress syndrome (ARDS) or severe respiratory illness:
a. Implement Standard, Airborne and Contact Precautions, including the use of eye protection when within 3 feet. Continue these precautions for 14 days after onset of symptoms or until an alternative diagnosis is established.
b. The Infectious Disease Medical Provider, in consultation with the Risk Assessment Group, will initiate diagnostic testing for respiratory pathogens including influenza A strains currently used in the laboratory.