1. OCCUPATIONAL HEALTH UPDATE 2014: EXTENDED CARE FACILITIES, SPICE
David Jay Weber, M.D., M.P.H.
Professor of Medicine, Pediatrics & Epidemiology
Associate Chief Medical Officer
Medical Director, Occupational Health & Hospital Epidemiology
University of North Carolina at Chapel Hill

2. GOALS OF CURRENT LECTURE
Understand activities of an occupational health service (OHS) in a healthcare facility
Be able to list vaccines recommended for healthcare personnel (HCP)
Be able to list infectious diseases relevant to HCP for which post-exposure prophylaxis is available
Be able to manage exposure to blood or a contaminated fluid

3. PREVENTING HCP INFECTIONS & INJURIES
It is the responsibility of the facility, to the extent possible, to provide a safe working environment. This includes minimizing the risk of infectious disease exposures and injuries. An organized program should be in place to identify and evaluate both infectious disease exposures and injuries, and to provide care of the exposed or injured employee.

4. PREVENTING HCP INFECTIONS & INJURIES
A casual attitude towards employee health entails a high cost
Increased patient morbidity
Increased staff morbidity
Significant financial cost and legal risk
Prevention is superior to treatment
The tools used to reduce the risk of acquiring infection can be used to reduce the risk of injuries

5. OSHA
NIOSH CDC
FDA Health Department
External Stakeholders
Occupational Health Service
Internal Stakeholders
Legal/Administration Safety
Medical Staff Worker’s compensation
Infection Control

6. OCCUPATIONAL HEALTH ACTIVITIES
Pre-employment screening
Immunization review
Employment physical (selected; DOT, FAA, police)
Drugs/alcohol screening
Latex allergy screen (history; if positive, blood test)
Screen for active TB (symptoms; if positive CxR, sputums?)
Screen for latent TB (TST or IFGR blood test)
Fit test clearance (questionnaire, medical exam?); N95 fit testing
Hearing evaluation/audiogram (if indicated by noise exposure)
Counseling: pregnant women, immunocompromised

7. OCCUPATIONAL HEALTH ACTIVITIES
Annual screening
Immunization review
Screen for active TB (symptoms; if positive CxR, sputums?)
Screen for latent TB (TST or IGRA blood test)
Evaluation of injured employees
First aid
Long-term care
Communication with Worker’s Compensation
Return to work evaluation (non-occupational diseases and/or injuries)

8. OCCUPATIONAL HEALTH ACTIVITIES
Evaluation of employees with a potentially communicable disease
Need for exposure evaluation
Need for work restriction
Therapy if indicated
Infectious disease exposures
Determination of exposure & risk of disease transmission
Evaluate for post-exposure prophylaxis
Consider need for work restrictions
Communicate with infection control if patients exposed

9. OCCUPATIONAL HEALTH ACTIVITIES
Work site evaluation
For cause drug/alcohol testing
Education
Fire, chemical, radiation safety
Infection control (communicable diseases, TB, bloodborne pathogens)
Ergonomics
Smoking cessation

10. OSHA: BLOODBORNE PATHOGEN RULE
Employers must establish an Exposure Control Plan (reviewed yearly)
Employers must utilize a hierarchy of methods to prevent exposure to blood or potentially contaminated body fluids
Engineering controls (e.g., needleless devices)
Work practice controls (e.g., single handed recapping)
Mandates use of universal precautions (all body fluids assumed contaminated except sweat)
Requires offering hepatitis B vaccine to persons with the potential for exposure
Persons may refuse by signing a declination form
PEP must be immediately available as per CDC guidelines
Yearly training required
Federal Register December 6, 1991;56:64003–64182

11. TUBERCULOUS: OSHA & CDC GUIDANCE
Rule proposed by OSHA 997; withdrawn 2003 [compliance required with 29 CFR – Respiratory Protection; 29 CFR – General Duty Clause Section 5(a)(1)]
CDC recommendations
Prompt detection of infectious patients
Airborne precautions (private room, >12 air exchanges per hour, direct out exhausted air)
Treatment of people with suspected or confirmed TB disease
Hierarchy of control measures
Administrative measures: TB risk assessment of the setting, TB control plan, timely lab testing, training and educating HCP, screen exposed HCP
Environmental control: Airborne isolation, proper hoods in labs
Use of respiratory protective equipment (per OSHA - N95 respirator, medical clearance, yearly fit testing)
CDC:
OHSA:
OHSA: 11

12. AMERICANS FOR DISABILITY ACT (ADA)
Outlaws discrimination based on a “disability”
Allows employers to exclude persons who pose a “direct threat”
Disability is defined as a physical or mental impairment that substantially limits one or more major life activities
Does not apply to a transitory impairment (duration <6 months)
Impairment can be episodic or in remission
Employee must request an accommodation
Excludes persons who are engaging in use of illegal drugs or alcohol (covers persons post drug rehabilitation) – permits use of drug testing
Requires employers to make “reasonable accommodations”
Defined by person’s private physician
Accommodations should place undue hardship on employer
Allows employer to require a medical exam after hiring a job applicant (but employer cannot require an exam before making a job offer)

13. FAMILY MEDICAL LEAVE ACT (FMLA)
Requires employers to grant eligible employees up to a total of 12 weeks of unpaid leave during any 12-month period for one of the following
Birth and care of a child, or adoption
Care for an immediate family member (spouse, child, parent) with a serious health problem
Medical leave when employee is unable to work because of serious health problem
Family member on active duty with military with a serious injury or illness
Employers may require employee to take an accrued paid vacation or medical leave concurrently with FMLA
Employees responsibility to request FMLA
Employee’s medical provider must provide a certification form

14. COMMON OCCUPATIONAL HAZARDS
Infections
Viral respiratory diseases
Aerosol transmitted diseases: Tuberculosis, pertussis
Bloodborne pathogens: Percutaneous, mucus membrane
Contact transmitted diseases: Syphilis, MRSA
Fecal oral: Norovirus, rotavirus

15. COMMON OCCUPATIONAL HAZARDS
Injuries
Work-related (e.g., falls, strain, sprain)
Ergonomic (e.g., strain, sprain, repetitive motion)
Dermatitis (related to latex gloves, antiseptics)
Hearing loss (noise related)
Indoor air quality

16. OTHER OCCUPATIONAL HAZARDS
Chemicals: Anti-neoplastics, disinfectants & sterilants, anesthetic gases, organic solvents, mercury, asbestos
Radiation: Ionizing radiation, radioisotopes
Lasers
Fire and electrical
Violence
Psychosocial stress
Bioterrorist agents (microbial, chemical, nuclear)

19. Person with LTBI (Infected) Person with TB Disease (Infectious)
LTBI vs. TB Disease
Person with LTBI (Infected)
Person with TB Disease (Infectious)
Has a small amount of TB bacteria in his/her body that are alive, but inactive
Has a large amount of active TB bacteria in his/her body
Cannot spread TB bacteria to others
May spread TB bacteria to others
Does not feel sick, but may become sick if the bacteria become active in his/her body
May feel sick and may have symptoms such as a cough, fever, and/or weight loss
Usually has a TB skin test or TB blood test reaction indicating TB infection
Radiograph is typically normal
Radiograph may be abnormal
Sputum smears and cultures are negative
Sputum smears and cultures may be positive
Should consider treatment for LTBI to prevent TB disease
Needs treatment for TB disease
Does not require respiratory isolation
May require respiratory isolation
Not a TB case
A TB case

20. TESTING FOR LATENT TUBERCULOUS INFECTION
Test methods
Mantoux tuberculin skin test (TST)
IGRA
IGRA can be used in place of TST
These tests do NOT exclude LTBI or TB disease
Decisions about medical management should include other data and not just rely on TST/IGRA results
Cannot switch back and forth between TST and IGRA
2-Step testing: Recommended for person who have not had TST within previous 12 months (required for staff and patients of LTCF)
NC TB manual =

21. CANDIDATES FOR TST
TST of individuals and groups should be undertaken only if the diagnostic evaluation and a course of preventive therapy can be completed
Routine testing of low-risk individuals is NOT recommended
The following adults are legally required to receive a TST:
Patients and staff in long term care facilities upon admission and employment, using the 2-step skin test method
Household and other close contacts of active cases of pulmonary and laryngeal TB
Persons reasonably suspected of having TB disease
Persons with HIV infection or AIDS
NC TB Policy Manual, New Edition, 23 January 2012

22. TST VS IGRA TST advantages TST disadvantages IGRA advantages
Standard for years
Inexpensive
TST disadvantages
Requires 2 (or 4 visits)
Requires proper placement
Requires reading
May be positive due to prior BCG
PPD in short supply
IGRA advantages
Not dependent on experienced users
Single visit
Not affected by prior BCG
IGRA disadvantages
Expensive
Wobble

23. ADMINISTERING THE TST
Inject 0.1 mL of PPD (5-TU) intradermally into forearm between skin layers
Produce wheal (raise area) of 6-10 mm in diameter
Requires 2-8 weeks after exposure to turn positive (CDC, wait 10 weeks)
2-step testing: Place and read PPD, and if negative repeat in 2-4 weeks to check for booster phenomenon
Two-step method not needed if a person has ever had a tw-step skin test OR if the person has had a single skin test within the last 12 months (i.e., If PPD in past year that counts as first step in 2-step testing)
Follow standard precautions for infection control

24. READING THE PPD Read 48-72 hours after injection
Palpate (feel) injection site to find raised area
Measure diameter of induration across forearm; only measure induration, not erythema
Record size of induration in mm

25. INTERPRETING THE TST REACTION
>5 mm is classified as positive:
HIV-infected persons
Recent contacts of infectious TB
Persosn with fibrotic changes on CxR consistent with prior TB
Patients with organ transplants and other immunocompromised persons
>10 mm is classified as positive:
Recent arrivals from high-prevalence countries (< 5-years)
Inject drug users
Residents and personnel (HCP) of high-risk congregate settings
Persons with conditions that increase the risk for progression to active TB
Children <4 years of age
>15 mm is classified as positive:
Persons with no known risk factors for TB

26. PROBLEMS WITH TST False-Positive False-Negative NTM BCG vaccination
Problems with TST administration
False-Negative
Anergy
Viral, bacterial, fungal infection
Very youg; advanced age
Live-virus vaccination
Overwhelming TB
Renal failure/disease
Lymphoid disease
Low protein states
Immunosuppressive drugs
Problems with TST administration

27. PRE-EXPOSURE PROPHYLAXIS

28. VACCINE PREVENTABLE DISEASES
Anthrax (PEP)
Cervical, vulvar, vaginal cancer (HPV)
Diphtheria (outbreak)
Genital warts (HPV)
Hepatitis A (PEP, outbreak)
Hepatitis B (PEP)
Hepatitis D
H. influenza type b
Human papillomavirus
Influenza A and B
Japanese encephalitis
Liver cancer (hepatitis B)
Lyme disease
Measles (PEP, outbreak)
Meningococcal (outbreak)
Monkeypox
Mumps (outbreak)
Pertussis (outbreak)
Pneumococcal disease
Poliomyelitis (outbreak)
Rabies (PEP)
Rectal cancer (HPV)
Rotavirus
Rubella (outbreak)
Smallpox (PEP, outbreak)
Tetanus (PEP)
Tuberculosis
Typhoid fever
Varicella (PEP)
Yellow fever
Zoster (Shingles)
PEP = post-exposure prophylaxis

29. ADULT IMMUNIZATION SCHEDULE, US, 2014

30. ADULT IMMUNIZATION SCHEDULE, US, 2014

31. KEY REFERENCES

32. SUMMARY OF CURRENT FDA APPROVED INFLUENZA VACCINES
Older vaccines
Standard IM inactivate influenza vaccine (TIV) {>6 mo}
Inhaled live-attenuated influenza vaccine (LAIV) {2-49}
Newer vaccines
Licensure of high titer influenza vaccine for persons 65 years and older (improved immunogenicity and efficacy) {>65 years}
Licensure of intradermal influenza vaccine {18-64 years}
Licensure of cell culture-based influenza vaccine*^ {>18 years}
Licensure of 2 quadrivalent influenza (2 A, 2 B strains) vaccines* {>3}+
Licensure of recombinant influenza (HA only) vaccine*^ {18-49}
* No ACIP statement available, ^ not produced in eggs, +inactivated vaccine

33. SUMMARY OF CURRENT ACIP RECOMMENDATIONS
Influenza
1 annual dose for all persons >6 months of age
Required to be offered to residents and HCP in ECFs in NC
Immunize as soon as vaccine becomes available for the current season 33

34. SUMMARY OF CURRENT FDA APPROVED PNEUMOCOCCAL VACCINES
Polysaccharide vaccine (PPSV23)
Contains 23 different pneumococcal strains
FDA approved for all person >50 years of age
FDA approved for high risk persons years of age
Conjugate vaccine (PCV13)
Contains 13 different pneumococcal strains
Conjugation with diphtheria toxin may improve immunogenicity

35. SUMMARY OF CURRENT ACIP RECOMMENDATIONS
Pneumococcal (polysaccharide, PPSV23)
Age >65: All persons
Age >19: Medical or other risk indications
Required to be offered to residents in ECFs in NC
Revaccination may be recommended (first dose <65 years AND now >65 years AND >5 years have passed)
Pneumococcal (conjugate, PCV13)
No recommendation for revaccination
Immunocompromised persons (see chart, next slide)
Vaccine naïve: PCV13 following at least 8 weeks later by PPSV23
Previous receipt of PPSV23: PCV13 >1year after last PPSV23 35

36. CDC. MMWR 2012;61:816

37. SUMMARY OF CURRENT ACIP RECOMMENDATIONS
Zoster
One dose for persons >60 years of age regardless of whether they had a prior episode of zoster
FDA approved for persons >50 years of age - ACIP statement to be delayed (pending resolution of vaccine shortage)
Live attenuated vaccine; avoid in immunocompromised persons
Meningococcal
Recommended for adults had high risk of disease
2-dose primary series administered 2-months apart for persons 2-54 with persistent complement deficiency, functional or anatomic asplenia, or HIV infection (adolescents)
MCV4, persons <55 years; MPSV4 persons >56 years

38. SUMMARY OF CURRENT ACIP RECOMMENDATIONS
Tetanus-diphtheria-acellular pertussis (/Tdap)
Substitute 1 dose Tdap for all adults when Td booster due
May be use to provide tetanus PEP
Provide to all adults with exposure to young children (no delay after Td)
Recommended for pregnant women (preferably 2nd or 3rd trimester)

39. SUMMARY OF CURRENT ACIP RECOMMENDATIONS
Hepatitis B
Occupation: HCP
Medical: clotting disorder, hemodialysis, ESRD
Behavioral: Multiple sexual partners, injecting drug users, hx STD
Other: Household/sexual contact with chronic HBV, travel, inmate >6 mo, clients/staff of institution for developmentally disable
Diabetes (new)
Hepatitis B vaccination should be administered to unvaccinated adults with diabetes who are aged 19 through 59 years (A, 2)
Hepatitis B vaccination may be administered at the discretion of the treating clinician to unvaccinated adults with diabetes who age aged >60 years (B, 2)

40. SUMMARY OF CURRENT ACIP RECOMMENDATIONS
Mumps, measles, rubella (MMR)
Mumps
Born before 1957: Considered immune (except during outbreak)
Born during or after 1957: 1 or more doses
Immunity = Appropriate immunizations or positive serology
Measles
Born before 1957: Consider immune (except during outbreak)
Born after 1957: 1 or more doses
Rubella
1 dose of MMR to susceptible women of childbearing potential
Immunity: Positive serology or documented vaccine 40

41. SUMMARY OF CURRENT ACIP RECOMMENDATIONS
Varicella: 2 doses
Special consideration should be given to those who have close contact with persons at high risk for severe disease (e.g., immunocompromised persons), are at high risk for exposure or transmission (e.g., teachers of young children, college students, military recruits, international travelers)
Immunity: Birth before 1980 (not HCP or pregnant women), history of varicella or zoster by a HCP, positive serology, or laboratory evidence of infection
HPV: 3 doses (0, 2, 6)
All women and men <26 years of age (only quadrivalent vaccine from Merck approved for men) 41

42. RECOMMENDED VACCINES FOR HCP: CDC, ACIP, HICPAC
Hepatitis B (OHSA required)
Influenza*
Measles (MMR preferred)*
Mumps (MMR preferred)*
Rubella (MMR preferred)*
Varicella (V)*
Tetanus (Tdap)*
Diphtheria (Tdap)*
Pertussis (Tdap)*
* Required at UNC 42

43. IMMUNIZATION OF HCP WITH CERTAIN CONDITIONS, ACIP, 2011

44. SPECIAL USE VACCINES IN HCP
Anthrax: Post-exposure
BCG: Pre-exposure (high risk)
Hepatitis A: Post-exposure, outbreak, research, travel
Japanese encephalitis: Research, travel
Meningococcal: Outbreak, laboratory (spinning CSF), travel
Polio: Research, travel
Rabies: Post-exposure, research, travel
Typhoid: Research, travel
Vaccinia: Pre-exposure?, post-exposure, research
Yellow fever: Research, travel 44

45. HEPATITIS B VACCINE Indications Administration
Universal; HCP with potential blood exposure (OSHA required OR signed refusal)
Administration
IM dose into deltoid; 1-1.5” needle, gauge
Schedule: 0, 1, 6 mo (May interchange current vaccines)
Prior to administration do not routinely perform serologic screening for HB unless cost effective
After 3rd dose, test for immunity (>10 mIU/mL){OSHA required}; if inadequate provide 3 more doses and test again for immunity; if inadequate test consider as “nonresponder”
If non-immune after 6 (or 3) doses, test for HBsAg

46. Estimated Incidence of HBV infections among HCP and General Population, United States, 1985-1999
Healthcare Personnel
General U.S. Population
This graph shows a 90% decline in the incidence of HBV infections in healthcare personnel from the year 1985 to In the early to mid 1980’s, the incidence of HBV infection in healthcare personnel was much higher than in the general population. However, following the 1987 publication of universal precaution guidelines and the 1991 Occupational Safety and Health Administration requirement that employers provide HBV vaccination to healthcare personnel, the incidence in healthcare personnel has dropped below that in the general population.

47. HBV AMONG GENERAL PUBLIC AND HCP
1970s: HCP had a prevalence of HBV infection ~10x greater than that of general population
1983: ~17,000 HBV infections among HCP
Currently: ~263 acute HBV infections
Due to HBV vaccine and
Improvements in infection control practices

48. CDC
MMWR
2013;62
(RR-10)

49. ASSURING HCP COVERAGE
Healthcare facility employees - requirement for employment
Medical staff - include in credentialing process
Students - require for attending class
Volunteers - require
Contract workers - require in contract
Emergency responders

50. PROOF OF IMMUNITY FOR HCP
Vaccine
Birth before 1957
MD Dx
+ Serology
Self Report
Documented Vaccination
Mumps 1
Yes3  No
Measles
 1
Rubella
 1,2
Varicella
Yes 4
Hepatitis B
>10 MIU/mL4
Pertussis
Influenza
1Consider immunization of HCP born before 1957, recommend during an outbreak;
2All HCP of childbearing potential should be immunized; 3requires lab confirmation;
4Obtain 1-6 months post last vaccine dose Weber DJ, Schaffner W. ICHE 2011;32:912-4 50

51. PROVIDING VACCINES Patient name and identification number Vaccine
Dose, Site, Route of Administration
Date given
Manufacturer
Lot number
Name, title & address of person providing vaccine
Date next dose due
Informed consent

52. PROVIDING VACCINES: SEROLOGIC TESTING
Pre-immunization testing for immunity
Do not obtain serological screening for immunity unless cost-effective, desired by employee (may require employee to bear cost), or vaccine contraindicated (e.g., MMRV, hepatitis B)
Post-immunization testing for immunity
Indicated for hepatitis B, rabies (high risk exposure)
Consider persons with an with an “indeterminate” antibody level susceptible

53. DATA RECORDED ON EXPOSURES
Employee Data
Name, unit number, job description
Date, incident form completed
Employer, supervisor
Source Data
Name, unit number, location, infection(s)
Exposure Data
Location, date, type & circumstances of exposure

54. EXPOSURE EVALUATION
Determine if source case has infection and is infectious
Determine transmission possible (i.e., appropriate exposure without protection)
Determine if employee is susceptible (may require labs)
Determine if prophylaxis available & indicated
Consider alternative prophylaxis (if available) if employee has contraindications to prophylaxis of first choice
Arrange follow-up

55. EMPLOYEE COUNSELING
Information to be provided to HCP who are exposed to an infectious agent
Recommended follow-up
Risk (if known) of transmitting the infection to patients, other personnel, or other contacts
Methods of preventing the transmission of infection to other persons

56. EMPLOYEE COUNSELING
Information to be provided to HCP who are offered prophylaxis
Alternative means of prophylaxis
Risk (if known) of infection if treatment not accepted
Degree of protection provided by therapy
Potential side effects of therapy

57. INCIDENCE OF BLOODBORNE EXPOSURES, 1997-2011

58. POST-EXPOSURE PROPHYLAXIS
Anthrax
Avian influenza (H5N1)
Diphtheria
Hepatitis A
Hepatitis B
HIV
Human bite wound
Influenza A
Influenza B
Measles
Meningococcal infection
Monkey bite
Monkeypox
Pertussis (whooping cough)
Rabies
Smallpox
Syphilis
Tuberculosis (TB)
Varicella (chickenpox)
Zoster (shingles)

59. NO POST-EXPOSURE PROPHYLAXIS
Hepatitis C
Mumps
Parvovirus B19
Rubella
Severe acute respiratory distress syndrome (SARS)

60. Risk of Bloodborne Virus Transmission after Occupational Percutaneous Exposure
Source
HBV
HBeAg +
HBeAg -
HCV
HIV
Risk % %
1.8%
0.3%
The risk of HBV transmission after a percutaneous exposure to HBV-infected blood, without postexposure treatment, varies, depending on the e-antigen status of the source. If the source is e-antigen positive, the risk of transmission will be up to 30%, whereas if the source is e-antigen negative, the risk is from 1-6%. The average risk of HCV transmission after a percutaneous exposure to HCV-infected blood is 1.8%, with a range of 0-7%. The average risk of HIV infection after a percutaneous exposure to HIV-infected blood is 0.3%, or 1 in 300 exposures (with a 95% confidence interval of 0.2%-0.5%). The average risk is based on aggregate data, and may not apply to specific exposure events.

61. DEFINITION OF EXPOSURE
Percutaneous exposure to contaminated body fluid
Mucous membrane exposure to contaminated body fluid
Non-intact skin expose to contaminated body fluid
Contaminated fluids: blood, CSF, vaginal secretions, semen, synovial, pleural, peritoneal, pericardial, amniotic

62. NEEDLESTICK INJURIES: MANAGEMENT
Test source for hepatitis B (HBsAg), hepatitis C, HIV (consider rapid test)
Provide hepatitis B prophylaxis, if indicated
Provide follow-up for hepatitis C, if indicated
If source HIV+ or at “high risk” for HIV, exposure confirmed, offer employee HIV prophylaxis per CDC protocol
Maintain confidentiality: Separate records, labs & pharmacy requisitions sent with code number

63. NEEDLESTICK INJURIES: MANAGEMENT
OSHA requirements
Employer shall make immediately available a confidential medical evaluation and follow-up
Identification and documentation of source case; test source case for HBV, HCV and HIV after consent (if required)
Offer to test employee for HBV and HIV (if employee refuses HIV testing hold blood for 90 days)
Offer post-exposure prophylaxis, as medically indicated, per CDC recommendations; offer counseling
Provide employee with results of evaluation with 15 days

64. NEEDLESTICK INJURIES: MANAGEMENT
State regulations
When the source case is known, the attending physician or occupational health provider responsible for the exposed person shall notify the healthcare provider of the source case that an exposure has occurred. This healthcare provider shall arrange HIV testing of the source person (unless known to be HIV+) and notify the OHS provider of the test results.
In the event consent is refused the local health director may order testing

65. PEP FOR HBV EXPOSURES

66. The upper curve on the line graph represents the estimated number of stage 3 (AIDS) classifications among adults and adolescents diagnosed with HIV infection in the United States and dependent areas, by year of diagnosis from 1985 through 2010; the lower curve represents the estimated number of deaths of adults and adolescents with HIV infection ever classified with stage 3 (AIDS), by year of death from 1985 through The peak in stage 3 (AIDS) in 1993 can be associated with the expansion of the HIV surveillance case definition implemented in January The overall declines in stage 3 (AIDS) and deaths of persons with stage 3 (AIDS) are due in part to the success of highly active antiretroviral therapies, introduced in 1996.
In recent years, stage 3 (AIDS) classifications and deaths of persons with stage 3 (AIDS) have remained stable.
All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting.
Deaths of persons with stage 3 (AIDS) may be due to any cause (may not be HIV-related). Deaths of persons with stage 3 (AIDS) are classified as adult or adolescent based on age at death. 66

67. In the United States and dependent areas, the estimated rate of adults and adolescents living with diagnosed HIV infection ever classified as stage 3 (AIDS) was per 100,000 population at the end of The rate for adults and adolescents living with stage 3 (AIDS) ranged from an estimated 2.4 per 100,000 population in American Samoa to an estimated 1,685.2 per 100,000 in the District of Columbia. The District of Columbia (i.e., Washington, DC) is a city; please use caution when comparing the rate of persons living with stage 3 (AIDS) in DC with the rates in states.
All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting.
Persons living with stage 3 (AIDS) are classified as adult or adolescent based on age at end of 2010.

68. HIV INFECTION AS A RESULT OF OCCUPATIONAL EXPOSURE IN HCP
HIV infections in HCP as a result of exposures (12/2001)
Documented conversions = 57
26 have developed AIDS
Types of exposures
Percutaneous exposure 48, mucocutaneous 5, both 2, unknown route of exposure 2
Source of exposure
HIV-infected blood 49, concentrated virus in lab 3, visibly bloody fluid 1, unspecified fluid 4

69. US PHS HIV POSTEXPOSURE GUIDELINES: NEW RECOMMENDATIONS
PEP is recommended when occupational exposures to HIV occur
HIV status of exposure source patient should be determined, if possible, to guide need for HIV PEP
PEP medication regimens should be started as soon as possible after exposure to HIV, and should be continued for a 4-week duration
New recommendation: PEP medication regimen should contain 3 (or more) antiretroviral drugs for all occupational exposures to HIV
Close follow-up for exposed person should be provided; follow-up should begin within 72 ours of an HIV exposure
Expert consultation recommended for any occupational exposure to HIV
New recommendation – if newer 4th generation combination HIV p24 Ag HIV test is used for follow-up of exposed HCP, HIV testing may be concluded 4 months after exposure; in a newer test is not available, follow for 6 months
Kuhnar DT, et al. ICHE 2013;34:

70. US PHS HIV POSTEXPOSURE GUIDELINES: GUIDELINE EMPHASIS
Primary prevention of occupational exposures
Prompt management of occupational exposures
Selection of PEP regimens that have the fewest side-effects and are best tolerated by prophylaxis recipients
Anticipating and preemptively treating side effects commonly associated with taking anti-retroviral drugs
Attention to potential interactions involving both drugs that could be included in HIV PEP regimens, as well as other medications that PEP recipients could be taking
Consultation with experts on PEP management strategies
HIV testing of source patients (without delay in PEP initiation) using methods that product rapid results
Counseling and follow-up of exposed HCP

71. US PHS HIV POSTEXPOSURE GUIDELINES: DEFINITIONS
HCP = all paid and unpaid persons working in healthcare settings who have the potential for exposure to infectious materials, contaminated medical supplies and equipment, or contaminated environmental surfaces (e.g., ED, dental, lab, autopsy personal; MDs, RNs, technicians, pharmacists, students, trainees, etc.)
Exposure that place HCP at risk = Percutaneous injury, contact of mucous membranes or nonintact skin with blood, tissue, or other potentially infected material (OPIM)
Potentially infectious material = blood, visibly bloody body fluids, semen, vaginal secretions. Also CSF, synovial fluid, pleural fluid, peritoneal fluid, amniotic fluid, pericardial fluid.
No known risk (unless visibly bloody) = feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus
Human bites result in 2-way exposure

72. US PHS HIV POSTEXPOSURE GUIDELINES: RISK OF HIV
Type of exposure
Percutaneous ~0.3%
Mucous membrane = ~0.09%
For percutanous exposure, factors increasing risk of HIV acquisition
A device visibly contaminated with patient’s blood
A procedure that involved a need being placed directly in a vein or artery
Deep injury
Blood from a person with late stage disease
Hollow bore (as opposed to solid bore) needle
Despite lower risk, PEP should still be offered even if the source patient has an undetectable viral load

73. US PHS HIV POSTEXPOSURE GUIDELINES: PEP I
Obtain expert consultation if source patient is known to harbor drug-resistant HIV (but do NOT delay initial therapy to obtain consultation)
If exposed person is pregnant, obtain expert consultation (but in general safe anti-retroviral therapy is available)
Breast feeding is NOT a contra-indication to PEP but lactating HCP should be counseled regarding the high risk of HIV transmission through breast milk (stopping breast feeding is the best method to completely protect the fetus)
Each healthcare facility should develop a plan to assess exposures and provide timely PEP

74. US PHS HIV POSTEXPOSURE GUIDELINES: PEP II
PEP is NOT recommended if source if HIV negative
Re-evaluate exposed HCP within 72 hours post-exposure
Ideally use a rapid (results in ~ 30 minutes) to test source patient
Ideally use a 4th generation HIV test (combined antibody/antigen test)
Use of a 4th generation tests allows identification of most infections during the “window period”
Do not be concerned about the “window period” (i.e., source antibody negative but virus positive)
If source patient not immediately available for testing, begin PEP (discontinue if source patient is HIV negative)

75. US PHS HIV POSTEXPOSURE GUIDELINES: PEP III
Initial PEP within hours of exposure
PEP is likely to be less effective when started more than 72 hours post-exposure (but the interval after which no benefit is gained from PEP in humans is unknown)
Provide PEP for 4 weeks
Provide 3-drug HIV PEP regimen
3 drugs superior in reducing viral burden in HIV infected persons
Decreases concerns about possible drug resistance in source patient
New regimens have improved safety and tolerability
New regimens have fewer side effects (likely therefore improved adherence)

77. US PHS HIV POSTEXPOSURE GUIDELINES: PEP IV
Preferred PEP
Embricitabine (FTC) plus tenofovir (TDF) – dispensed as Truvada PLUS
Raltegravir (RAL)
Regimen is tolerable, potent, conveniently administered, minimal drug interactions
Likely safe in pregnancy (limited data)

81. US PHS HIV POSTEXPOSURE GUIDELINES: PEP V
Toxicity monitoring
Symptoms, focused physical exam
CBC with differential, ALT, AST, Amylase, BUN, Creat, glucose (if on PI)
Monitor at baseline and 2 weeks (and if any acute symptoms develop)
Follow-up HIV testing
At 6 weeks and 4 months (if using 4th generation HIV test)
At 6 weeks, 12 weeks, 6 months (if using 3rd generation HIV test)
If HCP exposed to source with HIV and HCV, follow for 1 year

82. INFLUENZA: EPIDEMIOLOGY
Pathogens: A (most severe; pandemics), B (less severe; epidemics) and C (mild)
Geographic distribution: Global
Reservoir: Humans, swine, birds
Incubation: 1-5 days (average ~2 days)
Transmission: Droplet (airborne?), direct and indirect contact
Communicability
1-2 days before onset of symptoms to 7 days post-onset (adults) or 10 days (children)
Attack rate: Up to 60% in closed setting
No carrier state but inapparent or mild illness may occur

83. Influenza Disease Burden to U.S. Society in an Average Year
Deaths
25, ,000
Hospitalizations
114, ,500
Physician visits
~ 25 million
Influenza Disease Burden to U.S. Society in an Average Year 
A recent study by Thompson et al concluded that the number of influenza-related deaths has increased significantly in the past 2 decades [Thompson 2003].
The number of pneumonia and influenza deaths rose by 83% from the through influenza seasons.
For the through seasons, the greatest average numbers of deaths were associated with influenza A (H3N2) viruses, followed by influenza B, and influenza A (H1N1).
Influenza viruses were associated with annual averages of 8,097 underlying pneumonia and influenza deaths, 36,155 underlying respiratory and circulatory deaths, and 51,203 all-cause deaths.
The authors attributed the increase in influenza-related deaths during the past 2 decades at least partially to the aging of the population.
They noted that people aged 85 years of age and older are 32 times more likely to die from an influenza-associated underlying pneumonia and influenza death than people between 65 and 69 years old.
Because it is a highly contagious, acute respiratory disease, influenza is responsible for an average of 50 to 60 million infections annually, resulting in 25 million health care visits [Couch 2000].
An estimated 114,000 to 142,000 excess hospitalizations occur each year secondary to influenza [ACIP 2004], although others suggest it may be over 0.25 million [Couch 2000].
The annual direct medical costs of influenza are estimated at between $1 and $3 billion [Patriarca 1999].
Economic losses are likely higher: $3 to $5 billion [Patriarca 1999].
Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and
respiratory syncytial virus in the United States. JAMA. 2003;289:
Couch RB. Influenza: prospects for control. Ann Intern Med. 2000;133: Advisory
Committee on Immunization Practices. Prevention and control of influenza. MMWR.
2004;53(RR06):1-40.
Patriarca PA. New options for prevention and control of influenza. JAMA. 1999;282:75-77.
Infections and illnesses
million
Thompson WW et al. JAMA. 2003;289: Couch RB. Ann Intern Med. 2000;133: Patriarca PA. JAMA. 1999;282:75-7. ACIP. MMWR. 2004;53(RR06):1-40.

84. Clinical Manifestations by Age Group
Influenza Sign/Symptom
Children
Adults
Elderly
Cough (nonproductive) ++
++++
+++
Fever +
Myalgia
Headache
Malaise
Sore throat
Rhinitis/nasal congestion
Abdominal pain/diarrhea –
Nausea/vomiting
Clinical Manifestations by Age Group
In general, influenza may include these symptoms [
High fever
Headache
Tiredness/weakness (can be extreme)
Nonproductive cough
Sore throat
Runny nose
Body or muscle aches
Diarrhea and vomiting also can occur, but are more common in children
Common physical signs of influenza infection include the appearance of being ill, skin that is hot and moist to the touch, flushed face, hyperemic mucus membranes, and clear nasal discharge [Cox 1999].
This slide identifies the symptoms that occur most or least frequently in persons of varying age with influenza and, therefore, that have the more or less value in diagnosing influenza infection in specific age groups.
Monto et al reported that, in patients aged 12 years and older, the best multivariate predictors of influenza during confirmed community influenza outbreaks are cough and fever, with a significant positive predictive value of 79% (P<.001) [Monto 2000].
In children, gastrointestinal symptoms such as nausea, vomiting, abdominal pain, and diarrhea are frequently observed [Cox 1999].
Febrile convulsions are the initial sign of influenza infection in many children [Cox 1999].
Adults and adolescents may have abrupt onset of fever and chills with headache, sore throat, myalgia, malaise, anorexia, and a dry cough [Cox 1999].
Elderly patients may not develop a low-grade fever, thereby its absence does not rule out the flu. However, shortness of breath is a common presenting symptoms in elderly persons [Cox 1999].
Monto AS, Gravenstein S, Elliott M, et al. Clinical signs and symptoms predicting influenza infection Arch Intern
Med. 2000;160:
Cox NJ, Subbarao K. Influenza. Lancet. 1999;354:
++++ Most frequent sign/symptom; + Least frequent; – Infrequent
Monto AS et al. Arch Intern Med. 2000;160: Cox NJ et al. Lancet. 1999;354:

85. Influenza Manifestations & Complications
Children
Adults
Frequent
Sinusitis, bronchitis, bronchiolitis, pneumonia, croup, acute otitis media
Primary viral pneumonia, secondary bacterial pneumonia, sinusitis, bronchitis
Rare
Encephalopathy, myositis, rhabdomyolysis, myocarditis, pericarditis, Reye syndrome, sepsis-like syndrome
Myositis, rhabdomyolysis, myocarditis, pericarditis
Exacerbations of underlying disease
Cardiovascular, diabetes, asthma, cystic fibrosis
Cardiovascular, diabetes, asthma, COPD
Influenza Manifestations & Complications
Loughlin J, Napalkov P, Wegmueller Y et al. A study of influenza and influenza-related complications among children in a large US health insurance plan database. Pharmacoeconomics 2003;21:
Treanor JJ. Influenza virus. In: mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and Bennetts Principles and Practice of Infectious Diseases. 5th ed. Philadelphia, PA: Churchill Livingstone; 2000:
ACIP. MMWR 2004;53(RR06):1-40.
Loughlin J et al. Pharmocoeconomics. 2003;21: Treanor JJ. Influenza virus. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 5th ed. Philadelphia, PA: Churchill Livingstone; 2000: ACIP. MMWR 2004;53 (RR06):1-40.

86. CDC. MMWR 2008;57(RR-18):1-59

87. Type of Nuclear Material
Viral Nomenclature
Type of Nuclear Material
Hemagglutinin
Neuraminidase
A / Sydney / 184 / 93 (H3N2)
Virus type
Geographic origin
Strain number
Year of isolation
Virus subtype
1. CDC. Atkinson W, et al. Chapter 13: Influenza. In: Epidemiology and Prevention of Vaccine-Preventable Diseases, 4th ed. Department of Health and Human Services, Public Health Service, 1998, 220

88. Pandemic influenza …………… 1918 1977 H1N1 “Spanish” H1N1 “Russian” 1947
2009
H1N1 pdm09
1957
H2N2 “Asian” flu
1968
H3N2 “Hong Kong” flu
1940
Influenza B

89. INFLUENZA: PREVENTION
Respiratory hygiene
Hand hygiene
Droplet precautions for ill patients
Furlough for ill HCP
Influenza vaccine for HCP and patients
May use antiviral for pre-exposure (only if vaccine contra-indicated), PEP (immunocompromised, pregnant), and treatment

90. STANDARD VERSUS HIGH DOSE INFLUENZA VACCINE, ADULTS >75 YEARS
Falsey AR, et al. JID 2009;200:172-80

91. EFFICACY OF HIGH DOSE INFLUENZA VACCINE: INFLUENZA A
PD ILI = protocol-defined influenza-like illness; presented Oct. ACIP meeting

92. EFFICACY OF HIGH DOSE INFLUENZA VACCINE: INFLUENZA B

93. INFLUENZA IN HEALTHCARE FACILITIES
More than 25 outbreaks described in literature in acute care hospitals
Infected staff may initiate outbreak or aid in propagation
HCW infection may lead to absenteeism and disruption of health care
Attack rates in HCWs have ranged from 25% to 80%
More than 15 outbreaks described in literature in extended care facilities
Important morbidity and mortality among residents may result
High rates of immunization (>60%) among staff may lead to decreased attack rate in residents

94. SUMMARY OF CLUSTER RCTs ASSESSING THE IMPACE OF HCP IMMUNIZATION
Study
Coverage
Control
Intervention
Mortality
Difference
Potter J, 1997
4.9%
61%
17%
10%
7.0%
Carman W, 2000
13.6%
50.9%
22.4%
8.8%
Hayward A, 2006
5.9%
43.2%
15.3%
11.2%
4.1%
Lemaitre M, 2009
31.8%
69.9%
6.0%
5.2%
0.8%*
Multivariate analysis for death, vaccination OR 0.80 (p=0.008)

95. Indirect Benefits of Influenza Vaccination of Health Care Providers
Mortality of residents was significantly reduced (10% vs 17%)
in nursing homes where the staff was vaccinated (SV) compared to facilities where they were not (S0) 20
Vaccine groups
SV (n=490)
SO (n=561)
(P=0.0009)
Total patient mortality (%) 10
Indirect Benefits of Influenza Vaccination of Health Care Workers
In the season, the effects of vaccination of healthcare workers on morbidity and mortality of the patient population was studied in a randomized, controlled study in Glasgow.
N = 1059 patients in 12 geriatric medical long-term care facilities; 653 (61%) of 1078 healthcare workers were vaccinated
Vaccination of healthcare workers was associated with a reduction in total patient mortality from 17% to 10% (odds ratio 0.56; 95% CI 0.40, 0.80). ILI odds ratio was 0.57 (95% CI 0.34, 0.94).
Vaccination of residents was not associated with significant effects on mortality; odds ratio 1.15 (95% CI 0.81, 1.64).
Potter J, Stott DJ, Elder RAG et al. Influenza vaccination of health care workers in long-term-care
Hospitals reduces the mortality of elderly patients. J Infect Dis 1997;175:1-6. 20 40 60 80
100
120
140
Time in days
Potter J et al. J Inf Dis. 1997;175:1-6.

96. Indirect Benefits of Influenza Vaccination of Health Care Providers
20 long-term care facilities, stratified cluster randomization staff influenza vaccination or not
Resident mortality odds ratio 0.58 (95% CI 0.40, 0.84) p=0.014
Resident mortality (%)
Indirect Benefits of Influenza Vaccination of Health Care Workers
20 long-term care facilities in UK ( patients).
Randomly offered vaccine or not.
All deaths were recorded over 6 months in winter of 1996/97.
Random sample of 50% of patients selected for virological surveillance combined with nasal and throat swabs every 2 weeks during the epidemic period. Swabs tested by tissue culture and PCR for influenza A and B.
Influenza uptake in healthcare workers was 50.9% in hospitals in which they were routinely offered vaccine, compared with 4.9% in those in which they were not.
Uncorrected rates of mortality are given in the slide.
Mortality of residents (n =102/749) in ‘vaccine hospitals’ was 13.6%
Mortality of residents (n=154/688) in ‘no vaccine hospitals’ was 22.4%
At necropsy, PCR was positive in 0 of 17 patients from vaccine hospitals and 6 of 30 from no vaccine hospitals (p=0.055).
Vaccination of healthcare workers was associated with a substantial decrease in mortality among LTCF residents.
Virological surveillance showed no associated decrease in non-fatal influenza infection in patients.
Carman WF, Elder AG, McAulay K et al. Effects of influenza vaccination of healthcare workers
on mortality of elderly people in long-term care: a randomised controlled trial. Lancet
2000;355:93-7.
n = 749
n = 688
No significant difference in % residents positive for influenza:
‘Vaccine hospitals’ 5.4%; ‘no vaccine hospitals’ 6.7%
Carman WF et al. Lancet. 2000;355:93-7.

97. REDUCTION IN OUTCOMES IN HCP RECEIVING INFLUENZA VACCINE
infection
Sick days due to
respiratory illness
Days lost
from work
Patient
mortality
Patient
mortality
28%
41%
41%
39%
88%
Saxen
1999
Carmen
2000
Potter
1997
Wilde
1999
Wilde
1999*
Attack rate unvaccinated = 13.4%
Talbot TT, Weber DJ, et al. ICHE 2005;26:

98. BARRIERS AND SOLUTIONS TO HCW INFLUENZA VACCINE CONCERNS
Access to vaccine, inconvenience
Off-hours clinics
Use of mobile vaccination carts
Vaccination at staff and department meetings
Cost
Provision of vaccine free of charge
Concerns for adverse events
Targeted education, including specific information to dispel vaccine myths

99. BARRIERS AND SOLUTIONS TO HCW INFLUENZA VACCINE CONCERNS
Fear of needles
Use of LAIV for eligible HCP
Other
Strong and visible leadership
Visible vaccination of key leaders
Surveillance of HCP-associated influenza
Accurate tracking of individual and unit-based compliance
Active declination for HCP who do not wish to be or cannot be vaccinated

100. THANK YOU!