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PHC 6314, Unit 9: Part 1 of 2Employee/Occupational Health & Infection Control

Donna Haiduven, PhD, RN, CIC, CPH©DJH 2017

Major role by C. Wolfefor Unit 9

https://upload.wikimedia.org/wikipedia/commons/8

/8d/Nurse_takes_a_patient's_blood_pressure.jpg

What is Occupational/Employee Health (OEH)?

• Overall Definition

• O.S.H.A.

• W.H.O.

–Definition

–Focus

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https://upload.wikimedia.org/wikipedia/commons/thumb/c/cb/ROC_Occupational_Safety_and_Health_Admin

istration_Logo.svg/2000px-ROC_Occupational_Safety_and_Health_Administration_Logo.svg.png

Who practices EOH? • Physicians

• Physician assistants (PAs)

• Registered Nurses

• Nurse Practitioners

• Others

• Combined OEH/IP

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www.ct.gov

Healthcare Worker Occupational Health

• Healthcare facilities employ 59 million

• Potential variety of complex exposures

• Focus on biological exposures

• Focus on infection control’s role in OEH in healthcare facilities

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https://www.flickr.com/search/?text=hospital%20workers&license=4%2C5%2C9%2C10

How are Infection Control & Employee Health Related?

• Category Recommendations for Employee Health I, II, & III

• Cover collaborations between IC & OEH

• Cover pre-employment, periodic evaluation, post-exposure evaluation & work restrictions

©DJH 2017

See transcript for reinforcement

CBIC Exam ContentEmployee/Occupational Health (EH/OH)(11)

A. Review/develop screening & immunization programs

B. Collaborate regarding counseling, follow up, & work restriction recommendations related to communicable diseases &/or following exposures

C. Collaborate with OH to evaluate infection-prevention related data & provide recommendations

D. Collaborate with OH to recognize HCP who may present a transmission risk to patients, coworkers & communities

E. Assess risk of occupational exposure to infectious diseases (TB, bloodborne pathogens)

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Terminology• Healthcare personnel (HCP)

(per CDC):–All paid & unpaid persons–Working in a healthcare setting– Potential for exposure to infectious materials

• body substances• contaminated medical supplies & equipment• contaminated environmental surfaces• contaminated air May provide direct patient care

or may not be involved directly in patient care (e.g. dietary &

housekeeping)

©DJH 2017

http://www.progressive-charlestown.com/2012/09/healing-

our-health-care-system.html

Infection Prevention in an Occupational Health Program

• Goal → Interrupt the transmission of infection to & from healthcare personnel

• Objectives:1. Educate HCP

2. Collaborate in monitoring & investigating

3. Provide care for work-related illnesses/exposures

4. Identify work-related infection risks & preventative measures

5. Contain costs by preventing infectious disease

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Elements that include IPs • Coordinating surveillance, exposure investigation

& preventive measures

• Pre-placement medical evaluations

• HCP health & safety education

• Immunization programs

• Management of job-related illnesses & exposuresPost-exposure follow-up & surveillance

• Work restrictions

• Health counseling for HCP re: risk & prevention

• Maintenance of records, data management, & confidentiality

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Serologic Screening & Immunization: Preplacement Examination

• “Fitness for Duty” exam– Employee’s communicable disease history– Underlying conditions that ↑ risk for

occupationally-related infection

• Baseline TB: 2-step TST or 1-step BAMT• Routine vaccination/immunity: hepatitis B,

seasonal influenza, measles, mumps, rubella, pertussis, & varicella

• Certain circumstances: meningococcal, typhoid, & polio

©DJH 2017

Serologic Screening & Immunization: Preplacement

Hepatitis B

- Prevaccination serologic testing usually not recommended

- Complete ≥ 3 dose series before contact with blood

- Post-vaccination serologic testing (titer) for HCP at high risk

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http://www.who.int/immunization_standards/vaccine_quality/pq_131_hepb_10dose_adult_sii/en/index.html

http://demedicina.com/cirrosis-tratamiento/

Serologic Screening & Immunization: Preplacement

• Rubella• Unvaccinated HCP-1. Laboratory evidence of rubella immunity

OR2. Laboratory confirmation of disease

If NOT→ Consider vaccinating with 1 dose of

MMR vaccine at appropriate interval for rubella

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http://drugline.org/drug/medicament/14266/

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Serologic Screening & Immunization: Preplacement

• Measles & Mumps

– HCP born before 1957, without evidence of measles or mumps immunity or laboratory confirmation of disease

→consider 2 doses of MMR vaccine

• Measles (if vaccine of unknown type 1963-1967) -revaccinate with 2 doses of MMR

• Mumps (vaccine before 1979 with either killed mumps vaccine or unknown type)-consider revaccination with 2 doses of MMR

©DJH 2017

Serologic Screening & Immunization: Preplacement

• Pertussis– Single dose of Tdap

– No interval between last Td & Tdap

– Need to maximize immunization rate

• Varicella– Written documentation of 2 vaccine doses 4 weeks apart

OR

– Lab evidence of immunity or lab confirmation of disease

OR

– Diagnosis of varicella disease or herpes zoster

OR GIVE

– 2 doses of vaccine 4 - 8 weeks apart

©DJH 2017

Occupational Health Hazards: Tuberculosis

• Unidentified case of pulmonary/laryngeal TB → unprotected exposure for HCP

• TB screening program for employees who:

– Enter pt./treatment rooms, even without pt.

– Participate in aerosol-generating/producing procedures

– Install, maintain, or replace environmental control in areas where persons with TB are encountered

©DJH 2017 http://www.arrivealive.co.za/pages.aspx?i=941

TB Infection & Screening• Latent TB Infection (LTBI)

– (+ ) for M. tuberculosis infection

– Asymptomatic

– Non-infectious

• Test for LTBI– Purified Protein Derivative (PPD)

– In vitro cytokine-based immunoassays• Aka Blood assay for M. tuberculosis (BAMT)

• Example: QuantiFERON-TB Gold test (QFT-G)

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https://ufandshands.org/ppd-skin-test

+ ppd

TB Screening Risk Classification

• Low risk - Exposure to persons with TB is unlikely

• Medium Risk - HCP will or possibly exposed to persons with TB or to clinical specimens of M. tuberculosis

• Potential Ongoing Transmission - Temporarilyapplied if evidence suggests person-to-person transmission has occurred in last year

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If uncertain whether to choose low or medium risk, classify as medium risk

©DJH 2017

TB Screening Risk ClassificationNew employees for all

settings receive a 2-step TST or 1-step

BAMT at hire

LOW RISKAfter baseline, no additional testing

unless exposure occurs

MEDIUM RISKAfter baseline, HCP receive TB screening

annually.

POTENTIAL ONGOING TRANSMISSION

Testing may need to be repeated every 8-10 weeks until situation

resolvesThis classification warrants immediate investigation &

corrective steps

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TB ExposureIf unprotected exposure to TB…

– TST at time of exposure

– TST repeated at 12 weeks post-exposure

–Chest x-rays only if prior + TST or currently symptomatic

–Re-test immunocompromised HCPs q. 6 mos.

©DJH 2017

http://en.wikipedia.org/wiki/File:Mantoux_tuberculin_skin_test.jpg

http://ethnomed.org/clinical/tuberculosis/firland/tuberculosis-images/testing.jpg

https://en.wikipedia.org/wiki/Tuberculosis_radiology

TB Screening

If HCP has + TST or BAMT….

–Chest x-ray to check for active disease

–Hx. of exposure to determine if work-related

–Clinical exam & symptom screen

–HCP educated re: signs & symptoms

– If recent converter, consider preventive tx.

©DJH 2017

http://www.stanford.edu/class/humbio103/ParaSites2006/TB_Diagnosis/Current%20Diagnostic%20Techniques.html

https://en.wikipedia.org/wiki/Midwife

TB Work Restrictions• Laryngeal or pulmonary TB

• Excluded from work until:– Receiving adequate therapy

– Cough has resolvedAND

– 3 consecutive sputum smears negative for acid-fast bacilli

• Periodic documentation of ongoing treatment

• If treatment stopped, HCP should be evaluated for infectiousness

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https://www.cdc.gov/tb/education/images/patiented_getthefacts2.jpg

HCWs at Higher Risk for TB

• HCPs with immunocompromising conditions at ↑ risk for active TB (e.g., HIV, diabetes mellitus, certain cancers & drug therapies)

• Education of HCP re: risk

• Assignment to where TB exposure risk low

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Respiratory Protection Program

• HCP protection when TB suspected = N95• OSHA’s Respiratory Protection Standard

– Qualified Program Administrator

– Provide respirators, training, & medical evaluations at no cost

– Select respirators so acceptable to & correctly fits the user

– HCP complete fit test before initial use, at least annually, or whenever fit changes occur

– HCP must complete seal check with each use

©DJH 2017

https://en.wikipedia.org/wiki/Respirator

Written Respiratory Protection Program

Procedures for…– Selecting respirators for workplace

use – Medical evaluations of employees – Fit testing procedures– Procedures for proper use, storing, & discarding – Evaluating program effectiveness

Outline training for…• Potential respiratory hazards during routine &

emergency situations• Proper use of N95, limitations, maintenance

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http://www.freestockphotos.biz/stockphoto/15750

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Occupational Health Hazards: Hepatitis B Exposure

• Exposure to blood/body fluids from HBsAg + or unknown

• If vaccinated with documented immunity, no action needed

• If exposed HCP vaccinated, but response unknown, perform baseline test for anti-HBs

• If exposed HCP unvaccinated or incompletely vaccinated, begin vaccine series at time of exposure & give HBIG ASAP (within 24 hours)

©DJH 2017

https://en.wikipedia.org/wiki/Hepatitis_B

Occupational Health Hazards: Hepatitis C Exposure

• Perform anti-HCV testing on source patient

• For exposed HCP:– Perform baseline anti-HCV & ALT activity

– Repeat at 4-6 months after exposure. For early detection, perform HCV RNA at 4-6 weeks.

• Confirm all anti-HCV results reported + by enzyme immunoassay For ex: RIBA

• IG & antivirals NOT recommended

• No guidelines for therapy during acute phase

©DJH 2017

Occupational Hazards: HIV Exposure

• Exposure = source known HIV + or considered likely +

• Balance between managing risk of transmission vs. efficacy & toxicity of PEP

• Rapid HIV testing on source

• Time sensitive

• 4 weeks duration if tolerated

©DJH 2017

For newest guidelines on

this issue: See http://stacks.cdc.gov/view/cdc/

20711Supplemental

Reading

Occupational Hazards: HIV Exposure – Drug Toxicity

• Testing at baseline & 2 weeks after starting PEP

• Minimum: CBC, renal & hepatic function• If toxicities identified, modify regimen after

expert consultation

• Management of side effects (i.e. antiemetics)• Encourage HCP to complete regimen

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https://pixabay.com/en/photos/sample/

• Follow-up counseling (within 72 hrs.)***

• Post-exposure testing

• Medical evaluation

• HIV antibody testing by enzyme immunoassay after exposure

– 6 weeks, 12 weeks, & 6 months (see exception in transcript)

• Extended follow-up for HCP who convert for HCV after exposure to a co-infected patient

Occupational Hazards: Follow-up HIV

©DJH 2017

Regardless of whether PEP was started

https://en.wikipedia.org/wiki/Blood_test

Occupational Hazards: Follow-up HIV Latest Changes

• New Recommendation- PEP medication regimens should contain 3 (or more) antiretroviral drugs for all HIV exposures

• Expert consultation recommended for any occupational exposures to HIV & at minimum for specific listed situations

• Provide close follow-up for exposed personnel: counseling, baseline & follow-up HIV testing, &monitoring for drug toxicity.

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Bloodborne Pathogen Exposure Plan

• Required by OSHA’s BBP standard

• Provide Hepatitis B vaccine within 10 days of employment

• Training BEFORE initial assignment

• Maintain sharps injury log

• Documentation re: engineering controls & HCP input for device selection

• Reviewed & updated annually

©DJH 2017

Occupational Health Hazards:Varicella Exposure

• Infectious period = 10th-21st day post exposure

• Vaccinated HCP: serotest immediately after exposure to assess antibody presence

–What if sero negative?

• Unvaccinated susceptible HCP: exclude from duty during infectious period or until all lesions crusted & dried. Consider administering vaccine.

©DJH 2017

https://en.wikipedia.org/wiki/Measles

Occupational Health Hazards:Meningococcal Disease

• Neisseria meningitidis

• Nosocomial transmission uncommon

• Transmission via contact with resp. secretions of infected pts. or when handling lab specimens

• Post-exposure prophylaxis for HCP with intensive, unprotected contact with infected pts.

• PEP = Rifampin (for 2 days), Ciprofloxacin (single dose), Ceftriazone (single dose)

• Offer pre-exposure vaccination to lab personnel who handle N. meningitidis

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http://bioweb.uwlax.edu/bio203/s2008/bingen_sama/shape%20of%20neisseria.jpg

Occupational Health Hazards: Rubella Exposure

If not immune to rubella, must be excluded from work from 7th day after the first exposure event through the 21st day after the last exposure event

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https://www.papermasters.com/ru

bella.html

http://www.torange.us/photo/19/16/Syringe

s-1361704079_30.jpg

https://es.wikipedia.org/wiki/Rub%

C3%A9ola

Occupational Health Hazards:Measles

Exposed, susceptible HCP….

–Measles vaccine within 72 hours of exposure

– Excluded from work 5 days after first exposure event-21 days after last exposure event

©DJH 2017

http://hardinmd.lib.uiowa.edu/cdc/measles8.html

http://frontelibero.blogspot.it/2012/09/vaccini-il-comilva-non-ci-sta-e.html

Occupational Health Hazards:Mumps

• If not immune to mumps, HCP must be restricted from work from the 9th day after the first exposure event until the 26th day after the last exposure event.

©DJH 2017

http://ruby.fgcu.edu/courses/ndemers/IDS3303/spr09/AutismPaper/mumpssign.jpg

http://vdsstream.wikispaces.com/Mumps

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Occupational Health Hazards:Pertussis

If exposed…

-14 day course of either Erythromycin 500 mg, 4x/day OR 1 tablet trimethoprim-sulfamethoxazole 2x/day

-Can continue to work-If symptoms develop, exclude from work for 5 days after start of appropriate therapy

©DJH 2017

http://www.chabotcollege.edu/healthcenter/img27.jpg

Other shorter dose therapies

Occupational Health Hazards:Exposures for which there is no PEP

• Cytomegalovirus • Herpes Simplex Virus

• Erythrovirus B19 (aka Parvovirus)

• Respiratory Syncytial Virus (RSV)

• Staphylococcal Infection or Carriage

• MDRO

©DJH 2017

Work restrictions may apply if HCP becomes

symptomatic or is diagnosed. These

restrictions vary by illness.

References• APIC Text of Infection Control & Epidemiology, 3rd Edition (2009). Chapter 26-

Occupational Health by Sue Sebazco, RN, BS, CIC.

• Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR Vol. 54, No. RR-17. http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf

• Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HIV & Recommendations for Post-Exposure Prophylaxis. Infection Control & Hospital Epidemiology, Nov 34(11): 875-892. 2013 http://www.ncbi.nlm.nih.gov/pubmed/23917901

• Immunization of Health Care Personnel: Recommendations of ACIP. November 2011, MMWR Vol. 60, No. 7. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm

• Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, & HIV & Recommendations for Post-Exposure Prophylaxis. June 2001, MMWR Vol. 50, RR-11. http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf

©DJH 2017