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Infectious Diseases and Nurses Historical Insights Can Guide Future Action Kate McPhaul, PhD, MPH, RN University of Maryland Work and Health Research Center.

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Presentation on theme: "Infectious Diseases and Nurses Historical Insights Can Guide Future Action Kate McPhaul, PhD, MPH, RN University of Maryland Work and Health Research Center."— Presentation transcript:

1 Infectious Diseases and Nurses Historical Insights Can Guide Future Action Kate McPhaul, PhD, MPH, RN University of Maryland Work and Health Research Center June 8, 2007 Massachusetts Nurses Association (MNA)

2 Objectives List two old and one new infectious disease known to be transmitted to healthcare workers today Discuss the three classic public health interventions for control of infectious disease transmission Contrast the occupational safety paradigm including hierarchy of controls with classic pubic health protection and critique the implications for protecting healthcare workers Describe the elements of the blood borne pathogen standard and relate to the hierarchy of controls for protecting workers from airborne infectious diseases

3 Historical perspectives on TB, SARS, Influenza and Healthcare Workers Model Standard - Bloodborne Pathogen and Needlestick Safety Act What do we do NOW to prevent nurses from contracting infectious diseases in future outbreaks?

4 Even super heros can succumb to infectious diseases….

5 How many infectious agents may be transmitted and/or acquired by nurses in healthcare settings?

6 Infectious Diseases in Healthcare According to the CDC, the following may be transmitted and/or acquired in healthcare settings Acinetobacter Bloodborne Pathogens Burkholderia cepacia Chickenpox (Varicella) Clostridium Difficile Clostridium Sordellii Creutzfeldt-Jakob Disease (CJD) Creutzfeldt-Jakob Disease (CJD) Ebola (Viral Hemorrhagic Fever) Ebola (Viral Hemorrhagic Fever) Gastrointestinal (GI) Infections Hepatitis A Hepatitis B Hepatitis C HIV/AIDS Influenza MRSA - Methicillin-resistant Staphylococcus Aureus MRSA - Methicillin-resistant Staphylococcus Aureus Mumps Norovirus Parvovirus Poliovirus Pneumonia Rubella SARS S. pneumoniae (Drug resistant) S. pneumoniae (Drug resistant) Tuberculosis Varicella (Chickenpox) Viral Hemorrhagic Fever (Ebola) VISA - Vancomycin Intermediate Staphylococcus aureus VISA - Vancomycin Intermediate Staphylococcus aureus VRE - Vancomycin-resistant enterococci VRE - Vancomycin-resistant enterococci


8 Blood borne pathogen transmission to healthcare workers In addition to Hepatitis B and C, and HIV from 1996 – 2005 there were published case reports of 60 pathogens: 26 viruses, 18 bacterial/rickettsia, 13 parasites, and 3 yeast known to occupationally infect HCWs. (Tarantola, AJIC, 2006)

9 Occupational Deaths from Infectious Diseases: Hepatitis B 1983 – 10,000 HCWs exposed 5%-10% (500-1000) develop chronic infection 15%-25% (75-200) die/year Risk of Hep B has diminished >90% due to Hep B Vaccine >30% HCWs decline vaccine resulting 400 HCWs/year becoming infected

10 Occupational Deaths from Infectious Diseases: Hepatitis C CDC estimates that Hepatitis C is prevalent in 1.8% of US population, same for HCWs 1-3% of percutaneous exposures result in Hep C infection to HCW 3-8 HCWs annually die from Hepatitis C (estimate based on needlestick rate)

11 Occupational Deaths from Infectious Diseases: HIV 138 HCWs acquired AIDs from a percutaneous exposure CDC methods do not collect death information Personal friend, Meta Snyder, died from AIDS acquired via needlestick but did not meet the CDC definition

12 Occupational Deaths from Infectious Diseases: Internationally Hemorrhagic fevers TB in Malawi, Ethiopia and South Africa



15 The TB Debate: TB is good for Nurses

16 Early History Aristotle – in approaching the consumptive one breathes [his] pernicious air, one takes the disease because there is in this air something disease – producing Sepkowitz, 1994

17 Tuberculosis 1699: tuberculosis became a reportable disease in Italy Some pathologists refuse to do mandated autopsies fearing illness French MD Laennec dies from TB refusing to believe he could acquire it from performing autopsies

18 Tuberculosis 1882 study showed no HCWs infected in a large TB Sanatorium: TB might not even be contagious Clapp of Boston believed in contagion but this view was not pervasive

19 More data shows risk of TB for HCWs Studies of nursing students in Europe and US show high rates of tuberculin conversation (79- 100%) Standard 1920s pulmonary text: There is no danger from the expired air of consumptives. For this reason a TB sanatorium is probably the safest place one can be so far as the dangers of infection is concerned.

20 Why was consensus delayed? Sepkowitz, 1994 Acknowledging risk might scare women away from nursing profession Some said increased surveillance not increased risk Middle road view: Yes, infections are occurring but disease is rare Living right prevents disease

21 Reducing the risk

22 Reducing the Risk Mandatory chest x-rays upon admission for all patients Effective chemotherapy and routine prophylaxis TB rates in population declined until 1980s

23 Occupational Deaths from Infectious Diseases: TB At least nine HCWs who were also immunocompromised died from TB infection in the 80s and 90s. 6-8 HCWs have also died from TB treatment to multi- drug resistant TB

24 Occupational Deaths from Infectious Diseases: SARS 8098 cases 774 deaths (9.6%) 1707 (21%) cases were HCWs 378 (57%) of cases in healthcare were HCWs Number of HCW fatalities not known!!!

25 Severe Acute Respiratory Syndrome (SARS) - Timeline Mar 2003 – HCW with unexplained pneumonia in Vietnam dies Mar – June 2003 - Toronto – 2 phase outbreak primarily driven by nosocomial infections Mar – June – Taiwan – 2 phases: 1 in travelers, 1 in hospitals July 2003 – WHO declares outbreak over

26 SARS and HCWs McDonald, 2004 Emerging Infectious Diseases CharacteristicsTorontoTaiwan Total Cases375N/A Probable247 (66)668 Suspected128 (34)N/A Deaths44 (12)72 (11) Healthcare-related271 (72)370 (55) Healthcare workers164 (44)120 (18)

27 SARS in Healthcare Facilities Unrecognized SARS Patients Minimal infection control practices in ER ER = high risk Virus concentrations highest in patients 10 days after infection when symptoms are worsening McDonald, 2004 Emerging Infectious Diseases

28 SARS in Healthcare Facilities Transmission appears to be Droplet Direct contact Limited airborne McDonald, 2004 Emerging Infectious Diseases

29 SARS in Healthcare Facilities Important Considerations: Aerosol-generating procedures Super spreaders Lack of PPE Overwhelming hospital resources such as negative pressure ventilated rooms SARS Tent/SARS Screening station No rapid diagnostic test Using epidemiologic links McDonald, 2004 Emerging Infectious Diseases

30 SARS Ethical Framework Key Values Individual liberty Protection of the public Proportionality Reciprocity Transparency Privacy Protection from undue stigmatization Duty to provide care Equity Solidarity

31 Lawrence Mass 1918

32 Why does health care lag behind other sectors in H&S False perception that the industry is self- regulated (JCAHO) Health care traditionally seen as clean industry, a place of health Focus on curative rather than preventive care Primarily a female workforce A low unionization rate (Lipscomb & Borwegen, 2000)

33 HCW vulnerability Socialized to believe that care giving requires self sacrifice, even of their own health Some hazards considered part of the job HCWs become patients (often uninsured) in the course of caring for others Issues of race, class, gender

34 Economic Costs of Staff Injuries/Illnesses Medical care and follow-up Worker disability Staff replacement Loss of experienced workers Cost of importing workers to replace injured US workers Reduced productivity Poor patient outcomes**

35 Classic Public Health Interventions Handwashing Vaccination Isolating infected patients

36 Health and Safety Programs: A Framework for Prevention Management commitment and employee involvement Worksite analysis Hazard control Training Evaluation

37 H & S Program Elements All necessary, none sufficient Critical for any and all hazards Success dependent on genuine team work Cant be successful without management commitment Direct care and support staff expertise are essential

38 Hazard Control: Hierarchy of Controls Substitution – with a less hazardous chemical or device such as antimicrobials that dont cause asthma Engineering Controls - modify or control the hazard at the source, such as ventilation hoods? Administrative Controls – reduce the amount of exposure to hazard via policies and procedures Personal Protective Equipment - gloves, respirators, protective clothing

39 Estimated % reduction in adverse outcomes with improved staffing Buerhaus, P.I. et al Strengthening Hospital Nursing. Health Affairs 21(5), 2002

40 How do high workload lead to poor patient outcomes? Impaired nurse-physician (and other HCW) collaboration, Poor nurse-patient communication, HCW fatigue, lack of concentration HCW burnout, depression, reduced empathy Job dissatisfaction HCW injury and illness HCW disability and/or job change Carayon & Gurses (2005)

41 What do we know about staffing and HCW injuries? MNA study found a 9% decrease in RNs was associated with a 65% increase in injuries/illnesses (Shogren, 1996) High workloads associated with 50-200% increase in needlestick injuries/near misses, (Clark, 2002) Adverse work schedule and health care system changes associated with neck, shoulder, back MSD (Lipscomb, 2004).

42 Extreme work schedules, injuries and patient care (JAMA, Sept. 06) 84% of interns worked > than ACGME limits; 67% worked > 30 consecutive hrs. Odds of exposure to sharps or contaminated body fluids increase 61% when interns worked > 20 consecutive hrs. compared with interns working < 12 hrs. 24 hrs of continuous wakefulness causes impairment of cognitive performance comparable to that induced by a blood alcohol concentration of 100 mg/dl (legal intoxication in most states).

43 Blood borne Pathogen Risks 2-40% risk of developing Hepatitis B 3-10% risk of developing Hepatitis C 560-1,120/year 85% become chronic carriers 0.3% risk of transmission of HIV >1000 workers will contract Hepatitis B, Hepatitis C, or HIV/year

44 What do we know? 300,000 + needlesticks continue to occur/year. Needlesticks and BB infections are extremely costly. Safety syringe have reduced incidence (> 50%) but much room for improvement. Enforcement of Safe Needlestick Act is limited.

45 OSHA BBP Standard (1991) Require universal precautions Required Hep B immunization Cases went from 17,000 (1983) to 400/yr Engineering controls (safe needles) were to be used where available Dentists claimed (in the docket) if they were forced to where gloves, patients would not see them.

46 Safe Needle Act of 2000 Unanimous bipartisan support Clarifies the need for employers to use safe needles Requires front line worker participation in product selection committees Requires employers to maintain a log of injuries from contaminated sharps.

47 Airborne Infections TB, SARS, influenza Seasonal flu - <40% immunization among HCW Pandemic flu preparedness Aerosol vs droplet transmission Respiratory protection Type, fit testing, stockpiles

48 What do we know? Short staffing leads to sick staff. Sick staff lead to sicker patients. Current levels of staff immunization inadequate. Current levels of available respiratory protection (N95s) inadequate for pandemic flu.

49 History of Regulations to Prevent HCW Exposure to Airborne Hazards Respiratory Protection Standard (1971, 1998) Proposed TB rule (1997); withdrawn (2003) Continuation of the Wicker Amendment (appropriations rider) CA is enforcing the annual fit testing requirement.


51 Conclusions The risks to nurses are historically and currently substantial Early research is not always accurate Educate other RNs and HCWs Argue, lobby, insist upon N95 PPE and general preparedness of your facility Join or get on the agenda of H and S Committee

52 Questions and future contact

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