1. Occupational Health Risks for Healthcare Workers

2. Learning Objectives 1.Recognize infection health hazards for healthcare workers. 2.Explain the use of an occupational infection risk evaluation. 3.Outline methods of reducing occupational risk of infection for healthcare workers. December 1, 2013 2

3. Time involved 40 minutes December 1, 2013 3

4. Health Hazards in Healthcare Facilities Biological hazard Chemical hazard Physical hazard Ergonomic hazard Psychosocial hazard December 1, 2013 4

5. Occupational Health If a separate department, size based on Institution size Number of staff Services offered Elements Medical evaluations Education Immunisation program Management of illness/exposures Maintenance of records December 1, 2013 5

6. Prevention of Occupational Risk in Healthcare Facilities Conduct written risk assessment for staff hazards Physical Chemical Biological Ergonomic psychosocial Assess risk and estimate degree of risk annually December 1, 2013 6

7. Bloodborne Infection among Healthcare Workers 3 million healthcare workers exposed to bloodborne pathogens each year > 90% of infections occur in developing countries 95% of HIV seroconversions in HCWs caused by needlestick injuries December 1, 2013 7

8. Biological Agents: Risk of Infection Risk groupDescriptionExamples 1Biological agent unlikely to cause human disease Bacteria in yoghurt Yeast in beer 2 Biological agent that can cause human disease and might be a hazard to workers; it is unlikely to spread to the community; there is usually effective prophylaxis or treatment available Most bacteria Nearly all moulds Most viruses 3 Biological agent that can cause severe human disease and present a serious hazard to workers; it may present a risk of spreading to the community, but there is usually effective prophylaxis or treatment available Hepatitis B Hepatitis C Human immunodeficiency virus Tuberculosis 4Biological agent that causes severe human disease and is a serious hazard to workers; it may present a high risk of spreading to the community; there is usually no effective prophylaxis or treatment available Lassa virus Severe acute respiratory syndrome? 8 December 1, 2013

9. Risk evaluation for infectious agents - 1 InfectionTransmission in general Risk of transmission evaluation Risk classification of biological agents* Main riskVaccine available Post-exposure prophylaxis (PEP) Staff to patient Patient to staff CholeraFaecal-oral, contaminated water Rare 2Stool contactYes Conjunctivitis, viral (e.g., adenovirus) Contact with eye secretions and contaminated objects High 2Hand contact and touching eye No Cytomegalovirus (CMV) Contact with urine, saliva, breast milk, cervical secretions, and semen from infected person who is actively shedding virus Rare 2Contact with body fluids, especially saliva, blood, and urine No DiphtheriaBy droplets, also by contact No dataRare2Close face to face exposure, cough YesPEP with antibiotic should be discussed Haemorrhagic fever (Ebola, Marburg, Lassa virus) Bloodborne; some question of contact transmission NegligibleModerate4Blood splash on mucous membrane NoAntivirals should be discussed Hepatitis APerson-to-person by faecal-oral route; infected food handlers with poor personal hygiene can contaminate food Rare 2Stool contactYesImmune globulin 9 December 1, 2013

10. Risk evaluation for infectious agents - 2 10 InfectionTransmission in general Risk of transmission evaluation Risk classification of biological agents* Main riskVaccine available Post- exposure prophylaxis (PEP) Hepatitis BVia percutaneous, mucosal, and nonintact skin contact with blood, semen, vaginal secretions, and bloody fluids LowModerate3Needlestick injury YesHepatitis B immune globulin (HBIG) Hepatitis CVia percutaneous, mucosal, and nonintact skin contact with blood, semen, vaginal secretions, and bloody fluids LowModerate3Needlestick injury No Herpes simplexContact with virus in saliva of carriers; contact with vesicle fluid RareLow2Contact with infected site No Human immunodeficiency virus (HIV) Primarily via percutaneous contact with blood; mucosal or nonintact skin contact with blood; semen, vaginal secretions, and bloody body fluids less likely to transmit RareLow3Needlestick injury Antivirals must be provided within hours! December 1, 2013

11. Risk evaluation for infectious agents - 3 11 InfectionTransmission in general Risk of transmission evaluation Risk classification of biological agents* Main riskVaccine available Post-exposure prophylaxis (PEP) InfluenzaDroplet spread; direct droplet transmission or droplet to contact transmission of respiratory secretions of infected patients Moderate 2Close contact with patient (Within 3 feet from coughing/ sneezing) YesAntivirals normally not recommended MeaslesAirborne; direct airborne transmission or airborne to contact transmission of respiratory secretions of infected person High 2Inhaling or contact with the patient’s respiratory secretions YesImmune globulin Meningococcal infection Droplet spread; direct droplet transmission or droplet to contact transmission of respiratory secretions of infected patients Rare2Close contact; face to face Yes (tetravalent A, C, W135, and Y) Antibiotic after close contact MumpsDroplet spread; direct droplet transmission or droplet to contact transmission of respiratory secretions of infected patients Moderate 2Close contact with patient (Within 3 feet from coughing/ sneezing) Yes Methicillin- resistant S. aureus (MRSA) Direct and indirect contact Rare 2Skin contactNo December 1, 2013

12. Risk evaluation for infectious agents - 4 12 InfectionTransmission in general Risk of transmission evaluation Risk classification of biological agents* Main riskVaccine available Post-exposure prophylaxis (PEP) NorovirusFaecal-oral (direct or indirect contact with patient’s stool) High 2Stool contactNo PertussisDroplet spread; direct droplet transmission or droplet to contact transmission of respiratory secretions of infected patients Moderate 2CoughYesMacrolides PolioFaecal-oralRare 2 Yes RabiesAnimal biteRare 3BitesYes Respiratory syncytial virus (RSV) Droplet contact or direct contact with respiratory secretions Moderate RotavirusPerson-to-person via faecal-oral route Moderate 2Stool contact RubellaDroplet contact or direct contact with respiratory secretions; airborne transmission not demonstrated. Moderate 2 Yes December 1, 2013

13. Risk evaluation for infectious agents - 5 13 InfectionTransmission in general Risk of transmission evaluation Risk classification of biological agents* Main riskVaccine available Post- exposure prophylaxis (PEP) Salmonella or Shigella Person-to-person via faecal-oral route; via contaminated food or water; food handlers with poor personal hygiene can contaminate food Low 2Stool contact Severe acute respiratory syndrome (SARS) Droplets, contactMedium 3CoughNo ScabiesDirect skin-to-skin contact with infested person Low Skin contact Streptococcus, Group A Droplet contact or direct contact with oral secretions or drainage from infected wounds RareNo data2 SyphilisDirect contact with lesions of primary or secondary syphilis No dataRare2Direct contact with skin or mucous membrane lesions Antibiotics possible TetanusBites, skin woundsNo data 2 YesImmune globulin December 1, 2013

14. Risk evaluation for infectious agents - 6 14 InfectionTransmission in general Risk of transmission evaluation Risk classification of biological agents* Main riskVaccine available Post- exposure prophylaxis (PEP) Tuberculosis (TB)Airborne transmission from sources with active pulmonary or laryngeal tuberculosis; susceptible person must inhale airborne droplet nuclei to become infected Low to high 3CoughBCG - Bacille Calmette Guérin (Not given to healthcare workers) Isoniazid (INH) for treatment of latent TB infection; 4 drug regimen for active TB TyphusFaecal-oralLow 3Stool contactYes (IM, SC, oral) Varicella, Chickenpox, disseminated zoster Localised varicella-zoster (shingles) Contact with vesicles; droplet or airborne spread from respiratory tract of acute cases and perhaps from disseminated zoster Contact with vesicles High moderate High moderate 2 YesVaricella- zoster immune globulin (VZIG) Yellow feverMosquito bitesNegligibleRare YesNo December 1, 2013

15. Risk Reduction - 1 Eliminate the hazard  Reduce the number of injections by providing oral medication  Assign a central hospital for treating highly infectious patients 15 December 1, 2013

16. Risk Reduction - 2 Remove or isolate the hazard  Use safety needles  Single-use needles designed to retract or cover the sharp end immediately after use  Transport blood specimens in leak- and puncture- resistant boxes  Use puncture-resistant waste boxes for discarding sharp items and needles December 1, 2013 16

17. Risk Reduction - 3 Organisational measures  Limit number of staff members caring for a patient with certain illnesses  Tuberculosis or MRSA  Train staff regularly in safe work practices  Establish an occupational safety committee  Consider every patient to be potentially infected with hepatitis B or C or HIV  Strict adherence to Standard Precautions/Routine Practices  Audit compliance with prevention measures periodically 17 December 1, 2013

18. Risk Reduction - 4  Evaluate use of personal protective equipment Gloves Discard and change between patients Use only once or disinfect 2-3 times maximum Gowns Use if spills/splashes are possible Change between patients Single-use gowns preferred If used several times put on and remove it without touching the outer potentially contaminated side e.g., during a shift time December 1, 2013 18

19. Risk Reduction - 5  Evaluate use of personal protective equipment Eye goggles or face shields Use if spills/splashes to the face possible Disinfect regularly and if visibly soiled Masks and respirators N95/FFP respirators with a tight face seal used if a risk of exposure to airborne pathogens When not available, use surgical masks  Develop written standard operating procedures  For medium and high-risk activities  Include staff protection and vaccination recommendations December 1, 2013 19

20. Risk Reduction - 6 Provide a medical examination for all HCWs Examination records and other health information should be kept confidential Store in a secure place Repeat the examination periodically All injuries documented in the respective staff member’s medical record December 1, 2013 20

21. Risk Reduction - 7 21 Provide vaccinations for all non-immune HCWs  Hepatitis B  Influenza  Mumps/Measles/Rubella/Varicella/Pertussis  Poliovirus  Tetanus, Diphtheria (as a routine adult vaccination) December 1, 2013

22. Causes of Needle-stick Injury in Low Resource Countries Recapping of needles Unsafe handling of sharps waste Overuse of injections Lack of supplies disposable syringes, safer needle devices, sharps-disposal containers Failure to place needles in sharps containers immediately after injection Passing instruments from hand to hand(e.g., in the OR) Lack of awareness of the problem Lack of training for staff December 1, 2013 22

23. Risk of Blood-borne Pathogen Transmission The risk of transmission of bloodborne pathogen from an infected patient to a HCW by a needlestick injury: 30% for hepatitis B 3% for hepatitis C 0.3% for HIV December 1, 2013 23

24. Hepatitis B Prevention: PEP Post-exposure prophylaxis varies with immune status of HCW 24 An unvaccinated HCWReceive both hepatitis B immune globulin (HBIG) and HBV vaccination Previously vaccinated and known antibody responder HCW No treatment Previously vaccinated, known non-responder HCW Both HBIG and HBV vaccination (a second vaccine series) or 2 doses of HBIG one month apart HCWs whose antibody response is unknown Test the HCW for antibody and administer HBIG + HBV vaccination if results are inadequate (<10mIU/ml) December 1, 2013

25. Prevention of Hepatitis C Currently no recommended PEP for hepatitis C virus Perform baseline and follow-up testing for anti- HCV and alanine aminotransferase Up to six months after exposure Perform HCV RNA testing at 4-6 weeks If an earlier diagnosis of HCV infection is desired Staff members who develop hepatitis C should be treated after seroconversion December 1, 2013 25

26. Prevention of HIV Infection: PEP Start as soon as possible, within 2-24 hours, not after 72 hours Consider contraindications (e.g., pregnancy) Medication taken for at least 4 weeks Seek expert consultation if viral resistance is suspected In case no PEP is available Perform HIV antibody testing for at least six months post exposure (e.g., at baseline, 6 weeks, 3 months, and 6 months) Perform HIV antibody testing if an illness compatible with an acute retroviral syndrome occurs Advise exposed persons to use precautions to prevent secondary transmission during the follow-up period December 1, 2013 26

27. Prevention of TB - 1 Establish a tuberculosis control committee Increase awareness about TB among HIV-positive patients Place patients with suspected TB or with an abnormal chest radiograph in an isolation room With door closed and a special ventilation system (natural or artificial) Place automatic closing devices on all TB isolation room doors Continue isolation of TB patients until at least three negative acid-fast bacilli sputum smears obtained Ensure that all HCWs entering a TB isolation room wear a N95/FFP mask Restrict sputum induction procedures and aerosolised pentamidine treatments to TB isolation rooms December 1, 2013 27

28. Prevention of TB - 2 Assign adequate number of trained staff to perform routine and urgent acid-fast bacilli smears on a daily basis Initial anti-TB treatment regimens should include four drugs TB patients should only be allowed to leave their rooms when medically necessary and must always wear a surgical mask when outside the room Forbid immunocompromised staff from contact with, or caring for, TB patients Perform routine tuberculin testing for tuberculin negative staff Treat HCWs as soon as active TB is confirmed December 1, 2013 28

29. Summary Healthcare workers are exposed to biological, chemical, physical, ergonomic, and psychosocial hazards HBV, HCV, HIV and TB pose the greatest risk of infection Infection with hepatitis B virus is preventable with immunisation All healthcare workers should be vaccinated against hepatitis B Written standard procedures on how to manage needlestick injuries should be available and known to all staff December 1, 2013 29

30. References Health worker occupational health. World Health Organization. 2010. http://www.who.int/occupational_health/topics/hcworkers /en/ http://www.who.int/occupational_health/topics/hcworkers /en/ AIDE-MEMOIRE for a strategy to protect health workers from infection with bloodborne viruses. World Health Organization. 2011. http://www.who.int/injection_safety/toolbox/en/AM_HCW _Safety_EN.pdf http://www.who.int/injection_safety/toolbox/en/AM_HCW _Safety_EN.pdf Simonsen L, Kane A, Lloyd J, Zaffran M, Kane M. Unsafe injections in the developing world and transmission of bloodborne pathogens: a review. Bull WHO 1999; 77: 789- 800. http://www.who.int/bulletin/archives/77(10)789.pdfhttp://www.who.int/bulletin/archives/77(10)789.pdf December 1, 2013 30

31. Quiz 1.Mucosal exposures cause 95% of HIV seroconversions in staff. T/F. 2.Prevention of tuberculosis includes a.Placing patient in an isolation room b.Patient wears mask when leaving the room c.Perform AFB lab tests daily d.All of the above 3.A risk assessment for staff hazards is useful to determine appropriate prevention strategies. T/F. December 1, 2013 31

32. International Federation of Infection Control IFIC’s mission is to facilitate international networking in order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe. The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise. For more information go to http://theific.org/http://theific.org/ December 1, 2013 32