Prevention and management of infectious or communicable diseases in healthcare workers.

[This section is taken from OSHA, 2011, 1991.]

Healthcare personnel are all paid and unpaid persons working in healthcare settings who have the potential for exposure to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air. These personnel include those involved in direct patient care, students and trainees, contractual staff, and personnel not directly involved in patient care but potentially exposed to infectious agents.

Protecting healthcare workers should be an integral part of a healthcare organization’s general program for infection control and prevention. The objectives usually include:

• Educating personnel about the principles of infection control and stressing individual responsibility for infection control
• Collaborating with the IC department in monitoring and investigating potentially harmful infectious exposures and outbreaks among personnel
• Providing care to personnel for work-related illnesses or exposures
• Identifying work-related infection risks and instituting appropriate preventive measures
• Containing costs by preventing infectious diseases that result in absenteeism and disability

Infection Control Training

New York State requires that healthcare professionals fulfill all federal and state requirements for infection control training and must repeat bloodborne pathogen control training regularly. All licensed healthcare professionals in New York State (physicians, physician assistants, special assistants, registered professional nurses, licensed practical nurses, podiatrists, optometrists, dentists, and dental hygienists) are required to receive training on infection control and barrier precautions every four years through a NYS-approved provider. Documentation of appropriate training must be maintained both by the course provider and course participant (NYSDOH, 2010a).

The federal government, through OSHA, requires that all new employees, or employees being transferred into jobs involving potential exposure to blood or OPIM, must receive bloodborne pathogen training before assignment to tasks where an occupational exposure may occur. Retraining is required annually, or when changes in procedures or tasks affecting occupational exposure occur. Employees must be provided access to a qualified trainer during the training session to respond as questions arise (NYSDOH, 2010a).

The training program shall contain at a minimum the following elements:

• An accessible copy of the regulatory text of the OSHA Bloodborne Pathogens Standard and an explanation of its contents
• A general explanation of the epidemiology and symptoms of bloodborne diseases
• An explanation of the modes of transmission of bloodborne pathogens
• An explanation of the employer’s exposure control plan and the means by which the employee can obtain a copy of the written plan
• An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and OPIM
• An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment
• Information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment
• An explanation of the basis for selection of personal protective equipment
• Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge
• Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials
• An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical followup that will be made available
• Information on the post-exposure evaluation and followup that the employer is required to provide for the employee following an exposure incident
• An explanation of the signs and labels and/or color coding required
• An opportunity for interactive questions and answers with the person conducting the training session (NYSDOH, 2010a).

Healthcare workers must be informed of the possible health effects of exposure to infectious agents such as hepatitis B and C, HIV, and chemicals such as ethylene oxide (EtO) and formaldehyde. The information should be consistent with OSHA requirements and identify the areas and tasks in which potential exists for exposure (Rutala et al., 2008).

Healthcare workers must receive training in the selection and proper use of PPE, and employers must ensure that workers wear appropriate PPE to prevent exposure to infectious agents or chemicals. The employer is responsible for making such equipment and training available to their employees. Healthcare facilities must establish a program for monitoring occupational exposure to regulated chemicals that adheres to state and federal regulations. Healthcare workers with weeping dermatitis of hands must be excluded from direct contact with patient-care equipment (Rutala et al., 2008).

Assessments and Vaccines

The NYSDOH requires that all healthcare workers in New York be medically evaluated prior to employment in hospitals and diagnostic and treatment centers. The evaluation must include screening for tuberculosis and other common communicable diseases. The medical evaluation should determine immunization status and include a history of any conditions that might predispose personnel to acquiring or transmitting communicable diseases. This information will assist in decisions about immunizations or post-exposure management (NYSDOH, 2010a).

Tuberculosis Screening

Tuberculosis (TB) screening may be done with any approved test to detect M. tuberculosis infection, such as the tuberculin skin test (TST) or one of the whole blood interferon-gamma release assays (IGRAs) approved by the FDA.

Annual TB screening of employees must be performed in hospitals and diagnostic and treatment centers in New York State. If previously negative, the TST or QuantiFERON-TB test (QFT) should be performed. If previously positive, a screen for symptoms should be performed and the employee evaluated as appropriate. Routine annual follow-up chest x-rays are not required. All screening activities should be documented in the employee health record (NYSDOH, 2009).

An employee who is found to be a converter (defined as an individual with a >10 mm increase in the size of TST induration, or with a positive IGRA, after establishing a prior negative baseline TB screening test) must be assessed for active TB disease (clinical evaluation and chest x-ray examination). If active TB disease is suspected or diagnosed, the employee should not return to work until TB disease has been ruled out. If an employee is found to have active TB disease, the employee may not return to work until clinically determined to be noninfectious. Clusters of TST or IGRA conversions or active TB disease in an employee must be reported to the local and state health departments (NYSDOH, 2009).

For employees who work in non-clinical, off-site locations, annual TB screening is not required. However, in all cases in which staff is exempted from the requirement of an annual PPD, the provider must document the specific settings and work titles that have been exempted in written occupational health protocols that must be maintained on file at the facility (NYSDOH, 2009).

Mumps, Measles, and Rubella

[The information in the following sections is derived from NYSDOH, 2007.]

All those who work in healthcare facilities are required to be immune to measles and rubella, according to NYS regulations, which also recommends that healthcare personnel be immune to mumps. Those born in 1957 or later can be considered immune to measles, mumps, or rubella only if they have documentation of either:

• Laboratory evidence of measles, mumps, or rubella immunity (those who have an “indeterminate” or “equivocal” level of immunity upon testing should be considered susceptible); or
• Two doses of live measles and mumps vaccines administered on or after the first birthday and separated by at least 28 days, and at least one dose of live rubella vaccine administered on or after the first birthday.

Birth before 1957 is not considered evidence of immunity against rubella according to NYS regulations. Those born before 1957 must have either laboratory evidence of rubella immunity or one dose of live rubella vaccine administered on or after the first birthday. In addition, it is recommended that a dose of measles, mumps, and rubella (MMR) vaccine be given to unvaccinated healthcare personnel born before 1957 who do not have a history of measles and mumps diagnosed by a physician, nurse practitioner, or a physician’s assistant, or laboratory evidence of measles and mumps immunity.

For unvaccinated healthcare workers born before 1957 who do not have other evidence of mumps immunity (e.g., mumps diagnosed by a physician, nurse practitioner, or a physician’s assistant, or laboratory evidence of mumps), consider giving 1 dose on a routine basis and strongly consider giving a second dose during a mumps outbreak.

Hepatitis B Virus (HBV)

Testing for HBsAg is recommended only for persons who are the source of blood or bodily fluid exposures that might warrant post-exposure prophylaxis, such as needlestick injury to a healthcare worker or exposure of a patient to a worker’s blood.

All employees with occupational exposure to blood or OPIM must be offered hepatitis B vaccination after receiving required training and within 10 days of initial assignment. The vaccine must be provided free of charge. The provision of employer-supplied hepatitis B vaccination may be delayed until after probable exposure for employees whose sole exposure risk is the provision of first aid.

In accordance with the OSHA regulation CPL 2-2.69, healthcare personnel who perform tasks that may involve exposure to blood or bodily fluids should receive a three-dose series of hepatitis B vaccine at 0-, 1-, and 6-month intervals. They should be tested for hepatitis B surface antibody (anti-HBs) to document immunity 1 to 2 months after receiving the third dose.

If the level of anti-HBs is at least 10 mIU/mL (positive) after three immunizations, the patient is immune. No further serologic testing or vaccination is recommended. If the level of anti-HBs is negative after three immunizations, the patient is considered unprotected against hepatitis B virus infection. The recommendation is to revaccinate with a three-dose series. Retest anti-HBs levels 1 to 2 months after the third dose. If anti-HBs is positive, the patient is immune—no further testing or vaccination is recommended. If anti-HBs is negative following 6 doses of vaccine, the patient is a non-responder.

Non-responders should be considered susceptible to HBV and counseled regarding precautions to prevent HBV infection and the need to obtain hepatitis B immune globulin (HBIG) prophylaxis for any known or probable parenteral exposure to hepatitis B surface antigen (HBsAg)-positive blood. It is also possible that non-responders are persons who are HBsAg positive, and testing should be considered. Those found to be HBsAg positive should be counseled and receive a medical evaluation.

Note: Anti-HBs testing is not recommended routinely for previously vaccinated healthcare personnel who were not tested 1 to 2 months after their original vaccine series. These individuals should be tested for anti-HBs when they have an exposure to blood or body fluids. If found to be anti-HBs negative, individuals should be treated as if susceptible.

Immunologic memory remains intact for at least twenty years among healthy vaccinated individuals who initiated hepatitis B vaccination after 6 months of age. The vaccine confers long-term protection against clinical illness and chronic hepatitis B virus infection. Cellular immunity appears to persist even though antibody levels might become low or decline below detectable levels.

Hepatitis C Virus (HCV)

Hepatitis C is transmitted primarily through percutaneous exposure to infected blood. All patients suspected of having HCV infection should be tested for antibody to HCV using an enzyme immunoassay test (EIA). The NYSDOH does not have specific guidelines for the management of occupational exposures to HCV but recommends that healthcare workers follow the guidelines published for hepatitis B and HIV. These include IC training, strict enforcement of IC standards, and protecting workers from infection through the use of engineering and work practice controls.

Influenza

The standard of care in New York State is that all healthcare personnel should receive an annual influenza vaccination. In addition, Public Health Law Article 21A, the Long-term Care Resident and Employee Immunization Act (NYSDOH, 2014), requires that all long-term care facilities, adult homes, adult daycare facilities, and enriched housing programs offer influenza vaccine to all employees and residents. There are two types of influenza vaccine available:

• Trivalent inactivated vaccine (TIV): May be given by injection to any healthcare personnel.
• Live attenuated influenza vaccine (LAIV, or FluMist): May be given by nasal spray to all non-pregnant healthy healthcare personnel age 49 years and younger.

Groups that should be targeted for influenza vaccine include all personnel (including volunteers) in hospitals, outpatient, long-term care facilities, and home-health settings who have any patient contact. Trivalent inactivated vaccine should be used rather than LAIV for healthcare personnel who are in close contact with severely immunosuppressed persons (e.g., stem cell transplant patients) when those patients require a protective environment (NYSDOH, 2014).

Other Recommended or Mandated Requirements

The NYSDOH recommended that all healthcare personnel be vaccinated with one dose of Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) to protect themselves, their patients, other healthcare workers, and the community against tetanus, diphtheria, and pertussis. Priority should be given to vaccination of healthcare personnel who have direct contact with infants less than 12 months of age.

NYSDOH also recommended that all healthcare personnel be immune to varicella. Evidence of immunity includes documentation of two doses of varicella vaccine given at least 28 days apart, history of varicella disease (chickenpox) or herpes zoster based on physician diagnosis, laboratory evidence of immunity, or laboratory confirmation of disease.

Symptoms such as fever, cough, rash, lesions, draining wounds, vomiting, and diarrhea require immediate evaluation, with treatment as needed. Healthcare personnel should have limited contact with patients and other susceptible individuals and should not return to work until they are non-infectious (NYSDOH, 2014).