Prevention and management of infectious or communicable diseases in healthcare workers.
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 (CDC, 1998).
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 IC and stressing individual responsibility for IC.
- 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 (CDC, 1998, 2019)
Infection Control Training
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.
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 other potentially infectious materials
- 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 follow-up that will be made available
- Information on the post-exposure evaluation and follow-up 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 (OSHA, n.d.)
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 (CDC, 2008, 2019).
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 (CDC, 2008, 2019).
Assessments and Vaccines
Most states require healthcare workers to 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. Requirements may include screening and/or vaccinations (as appropriate) for tuberculosis (TB); measles, mumps, and rubella; hepatitis B Virus (HBV); Hepatitis C Virus (HBC); influenza; varicella (chickenpox); Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis).
Occupational Exposure to Bloodborne Pathogens
The need to protect healthcare workers from bloodborne exposures resulted in OSHA’s publication in 1991 of the Bloodborne Pathogens Standard. The Standard requires employers whose employees have exposure to blood to provide safe work practices, education, and barriers to exposure. The Standard was later amended to add requirements for the safe use of sharps devices.
Important factors that influence the overall risk for occupational exposures to bloodborne pathogens include the number of infected individuals in the patient population and the type and number of blood contacts. Most exposures do not result in infection. Following a specific exposure, the risk of infection may vary, depending upon the:
- Pathogen involved
- Type of exposure
- Amount of blood involved in the exposure
- Amount of virus in the patient’s blood at the time of exposure (CDC, 2003b)
An occupational exposure is defined as a percutaneous injury or contact of mucous membrane or non-intact skin with blood, tissue, or OPIM. The risk of infection varies case by case. Factors influencing the risk of infection include:
- Whether the exposure was from a hollow-bore needle or other sharp instrument
- Whether the exposure was to non-intact skin or mucus membranes
- The amount of blood that was involved
- The amount of virus present in the source’s blood
If a sharps injury occurs, as soon as safely possible,
- Wash the affected area with soap and water.
- Do not “milk” or squeeze the wound.
- Application of antiseptics should not be a substitute for washing. There is no evidence that using antiseptics (like hydrogen peroxide) will reduce the risk of transmission for any bloodborne pathogens; however, the use of antiseptics is not contraindicated.
- The risk of contracting HIV from a sharps injury is estimated to be 0.3%.
If there is exposure to the eyes, nose, or mouth,
- Flush thoroughly with water, saline, or sterile irrigants.
- Remove any potentially contaminated clothing as soon as possible.
- Familiarize yourself with existing protocols and the location of emergency eyewash or showers and other stations within your facility in advance of need.
- The risk of contracting HIV through this type of exposure is estimated to be 0.09%.
Guidelines for Post Exposure Prophylaxis
Organizations that employ health professionals or other persons who are at risk for occupational exposure to blood, body fluids, or OPIM are generally required to establish policies and procedures that guide the management of such exposures. Private employers subject to OSHA must conform to the OSHA Bloodborne Pathogen Standard. These regulations require that a management plan be in place (HIVGuidelines.org, 2010).
The employer should ensure that any employee who sustains an occupational exposure has access to post-exposure services within 1 to 2 hours of a reported event. Services must be available 24 hours a day, every day. Organizations that do not have on-site occupational health services are required to form agreements or contracts with another facility, emergency department, or private practitioner for such services (HIVGuidelines.org, 2010).
Post-exposure services for exposures to all bloodborne pathogens include but are not limited to:
- Post-exposure evaluation and follow-up post-exposure medications and/or vaccinations, as indicated
- A full course of post-exposure prophylaxis medications, at no cost to the employee
- Care provided under the supervision of a licensed physician or other licensed healthcare professional
- The performance of laboratory tests by an accredited laboratory
- Supportive counseling (HIVGuidelines.org, 2010)
The National Needlestick Hotline is available 24 hours per day at 888-448-4911, without cost, for consultation by treating providers. Documentation of consultation may be prudent if PEP is being considered.
Federal law requires covered employers to ensure that all medical evaluations and procedures, vaccines, and post-exposure prophylaxis are made available to the employee within a reasonable time and place and are made available at no cost to the employee.
OSHA’s Bloodborne Pathogen Standard make the covered employer responsible for all costs associated with an exposure incident. An employer may not require the employee to pay any out-of-pocket expenses, such as requiring the employee to use workers’ compensation if prepayment is required, or compelling an employee to use health insurance (unless the employer pays all premiums and deductible costs associated with their employee’s health insurance). In addition to the services listed above, NYS Guidelines, “HIV Prophylaxis Following Occupational Exposure,” state that, when establishing plans for providing PEP for exposures to HIV, the employer must ensure that:
- PEP will be made available within 1 to 2 hours of exposure, ideally within 1 hour.
- A “starter kit,” or three-day supply of the PEP, will be made available to the employee.
- A mechanism is in place to provide the balance of the PEP medications needed to complete the 4-week regimen to the employee at no cost. (HIVGuidelines.org, 2010)
Post-exposure prophylaxis (PEP) provides medications to someone who has had a substantial exposure, usually to blood. PEP has been the standard of care for occupationally exposed healthcare workers with substantial exposures since 1996. Animal models suggest that cellular HIV infection happens within 2 days of exposure to HIV and the virus in blood is detectable within 5 days. Therefore, PEP against HIV should be started as soon as possible—within hours, not days—after exposure and continued for 28 days if indicated. However, PEP for HIV does not provide prevention of other bloodborne diseases like HBV or HCV.
Hepatitis B PEP for susceptible persons would include administration of hepatitis B immune globulin and HBV vaccine. This should occur as soon as possible and no later than 7 days post exposure.
For a susceptible person, the risk from a single needlestick or cut exposure to HBV-infected blood ranges from 6 to 30 percent and depends on the hepatitis Be antigen (HBeAg) status of the source individual. Hepatitis B surface antigen (HBsAg)-positive individuals who are also HBeAg-positive have more virus in their blood and are more likely to transmit HBV than those who are HBeAg-negative. While there is a risk for HBV infection from exposures of mucous membranes or non-intact skin, there is no known risk for HBV infection from exposure to intact skin (CDC, 2003b).
The average risk of HIV infection after a needlestick or cut exposure to HlV-infected blood is 0.3%. Stated another way, 99.7% of needlestick or cut exposures do not lead to infection. The risk after exposure of the eye, nose, or mouth to HIV-infected blood is estimated to be, on average, 0.1%. The risk after exposure of non-intact skin to HlV-infected blood is estimated to be less than 0.1%. A small amount of blood on intact skin probably poses no risk at all. There have been no documented cases of HIV transmission due to an exposure involving a small amount of blood on intact skin (a few drops of blood on skin for a short period of time) (CDC, 2003b).
The average risk for infection after a needlestick or cut exposure to HCV-infected blood is approximately 1.8%. The risk following a blood exposure to the eye, nose, or mouth is unknown, but is believed to be very small; however, HCV infection from blood splash to the eye has been reported. There also has been a report of HCV transmission that may have resulted from exposure to non-intact skin, but no known risk from exposure to intact skin (CDC, 2003b).
As of July 2011, there is no approved PEP against HCV. The benefit of the use of antiviral agents to prevent HCV infection is unknown and antiviral are not currently approved by the Federal Drug Administration (FDA)-approved for prophylaxis. Because of the frequent advances in treatment, doses and medications are not listed here.
Post exposure prophylaxis can only be obtained from a licensed healthcare provider. Your facility may have recommendations and a chain of command in place for you to obtain PEP. After evaluation of the exposure route and other risk factors, certain medications may be prescribed. The national bloodborne pathogen hotline provides 24-hour consultation for clinicians who have been exposed on the job.
Post-exposure prophylaxis is not as simple as swallowing one pill. The medications must be started as soon as possible and continued for 28 days. Many people experience significant side effects. It is essential to report occupational exposure to the department at your workplace that is responsible for managing exposure. If post-exposure treatment is recommended, it should be started as soon as possible. In rural areas, police, firefighters, and other at-risk emergency providers should identify a 24-hour source for PEP.