1 of 28

Chapter 6: �Occupational Health

Prepared by:

APIC DFW Professional Advancement Committee

2 of 28

Chapter 6�Pre-Study Session Quiz��

3 of 28

1. You are teaching new employee orientation. What should be the first step after a bloodborne pathogen exposure?

Notify immediate supervisor
Report to Employee Health
Wash/flush the site
Complete exposure form

4 of 28

2. Review the situation below and determine if this is the correct action for the situation.

You receive a call from the ED medical director; he suspects that a patient has meningitis & wants to immediately provide prophylactic meds for all staff who have had contact with the patient. Explain to the physician that since this is most likely a viral meningitis there is no need to give prophylaxis & that you will notify the public health department.

This is the correct action.
This is not the correct action.

5 of 28

3. What is the preferred method for screening HCWs for tuberculosis?

TB skin testing utilizing tine tests
Use of symptom screening forms
Chest xrays
TB testing using PPD or blood tests

6 of 28

EMPLOYEE/OCCUPATIONAL HEALTH

Comprises 11 questions on the CIC exam, testing knowledge regarding:

Employee screening & immunization programs
Counseling, follow-up & work restrictions as they relate to communicable diseases & exposures
Partnering with Occ. Health to evaluate data & make recommendations for improvement
Helping Occ. Health to recognize HCW who may pose an infection transmission risk to patients, other care givers & community
Assessment of exposure risk to communicable diseases, such as TB & bloodborne pathogens, within the facility

Employee/Occ. Health is in the Infection Prevention section of Joint Commission standards

7 of 28

The IP/Occ. Health Connection

Tremendous opportunity to break the chain of infection (HCW to patient & patient to HCW)
The IP/Occ. Health roles may be filled by one person, or IP may serve as major advisor/ consultant to Occ. Health—either way, there needs to be great information-sharing & facilitative relationship with mutual respect for specialties.

8 of 28

The IP/Occ. Health Connection

IP & Occ. Health must work closely together,

Annual risk assessment
Developing plans/policies based on the risk assessment
Implementing that plan with close communication & interventions as indicated
Measuring success of the program
Then doing it all over again

9 of 28

Employee Screening & Vaccination Programs

Occ. Health program not only covers paid employees—also covers volunteers, physicians & other LIPs, students, contractors & vendors
All must be screened for presence of infectious disease (TB) & for level of protection against infectious diseases (hep B, measles, mumps, rubella, tetanus, diphtheria, pertussis, varicella, etc) upon hire & in some cases, upon exposure. Be very familiar with these screenings/vaccines (especially hep B vaccine)!

See APIC Text, Ch. 100, table 1 & APIC Text , Ch. 103

If screening shows deficiency (vacc. records or titers), Occ. Health provides the vaccine or requires individual (such as students or vendors) to get vaccine at another location & provide documentation of such.

Exception: hep B vaccination cannot be made mandatory per OSHA hep B regulations (signed consent/refusal IS required).

It is important to note that a comprehensive occ health program not only covers paid employees, but also volunteers, physicians, and other Licensed Independent Practitioners, students, contractors, and vendors. All groups must be screened for presence of infectious disease, such as TB, and for the level of protection against infectious diseases, including: hepatitis B, measles, mumps, rubella, tetanus, diphtheria, pertussis, and varicella to name a few. Screening is done upon hire, and in some cases, upon exposure. Some screening, such as TB, may also be required annually depending on your organization’s TB policy and risk assessment. For the CIC exam, be very familiar with these screenings and associated vaccines, especially the hep B vaccine! The CIC exam will typically have several questions on this material.

Be sure to review the APIC text, chapter 100 table 1, and chapter 103. You can also review a lot of this information on the CDC and OSHA websites.

If screening shows deficiency in vaccine records or titers, occ health provides the vaccine or requires individuals to get vaccinated at another location and provide documentation. One exception to this is that the hep B vaccine cannot be made mandatory per OSHA standards. A signed consent and refusal is required in that scenario.

(LIP=Licensed Independent Practitioner)

10 of 28

Let’s Talk TB

New hire evaluation—getting more complicated with new testing methodologies; also includes Resp. Protection Program (N-95 respirator mask fitting at hire & annually)

Generally, for new hires, 2 neg. TSTs within past year are required;
Most facilities allow HCP to provide documentation of one neg. test, & 2^nd test is performed at the hiring facility. If hiring facility performs both TSTs, they should be performed at least a week apart.

11 of 28

TB Testing & Follow Up

Interpretation of TB testing (be VERY familiar with CDC’s TST interpretation-can find in APIC Text, Ch. 100, Table 3)

For new hires, PPD induration (raised area) ≥ 10mm=Positive
With new testing methods (QFT, Tspot), 1 pos. test=Positive
Pos. tests require F/U to determine whether active or latent TB (obtaining CXR 1^st step). Both latent (neg. CXR) & active cases need referral for treatment & should be reported to Public Health Dept.
HCP with latent TB may start work; HCP with active TB have to be take therapy & be declared non-infectious prior to starting work

Be very familiar with the CDC’s TST interpretation. You can find this in the APIC text chapter 100, table 3, or you can also check for this information on the CDC’s website. I would have this information memorized for the test, as you will likely get a question on this topic.

For new hires, if the PPD induration, known as the raised area, is greater than or equal to 10mm, the result is positive. With new testing methods, such as the quantiferon gold or Tspot, 1 positive test is considered positive. Positive tests require follow-up to determine whether results indicate active or latent TB. The first step in determining this is to obtain a chest xray. In latent TB, the chest xray is negative. Both latent and active cases need referral for treatment and should be reported to the public health department. Healthcare workers with latent TB may start work, as they are not considered infectious. Healthcare workers with active TB must take therapy and be declared non-infectious prior to starting work.

12 of 28

TB Risk Assessment

TB Risk Assessments are completed for each year, & the plan for the next year is based on the assessment. Higher risk facilities require higher frequency of TB testing (semi-annually), especially in depts. at highest risk of exposure (RT, ED, pulmonary units., etc.)
Post-exposure evaluation (exposure = unprotected exposure to airspace of patient with active TB)

Baseline test (TST or blood test) as soon as possible to time of exposure
Follow-up testing 8-12 weeks post-exposure; appropriate follow-up (starting with chest xray) if conversion to positive
Important to include exposures & conversions in annual evaluation of the TB program, as well as IP annual report & risk assessment

The TB risk assessment is completed each year, and the plan for the next year is based on this assessment. Higher risk facilities require higher frequency of TB testing, especially in departments at highest risk of exposure such as the emergency department.

Post-exposure evaluation should be done when there is unprotected exposure to airspace of a patient with active TB. For example, a nurse in the ED is triaging a patient who is later suspected of having TB. The nurse was not initially wearing an N95 and the patient did not have a mask on. This could be a potential exposure to the nurse and possibly others who came into contact with the patient prior to implementing airborne isolation precautions.

Post-exposure evaluation includes a baseline test as soon as possible to the time of exposure. It is really important that occ health is contacted in a timely manner. Follow-up testing is done 8 to 12 weeks post-exposure, with appropriate follow-up if positive. It is also important to include numbers of exposures and conversions in the annual evaluation of the TB program, as well as the IP annual report and risk assessment.

13 of 28

Bloodborne Pathogen (BBP) Exposure Follow-up

Prevention is the key!!

Make sure there is sufficient info. in new hire & annual education regarding safe practices, wearing of PPE, etc.
Great area for IP & Occ. Health to partner

Know the definition of BBP exposure very well:

Sharp object contaminated with blood or other potentially infectious material (OPIM) breaking skin of HCP, or blood/OPIM or entering the HCP’s body via mucous membrane or break in skin. OPIM does not include fluids like vomit or stool UNLESS visibly contaminated with blood. OPIM does include fluids such as amniotic & synovial fluids

14 of 28

Bloodborne Pathogen (BBP) Exposure Follow-up

When there is a BBP exposure…the clock starts ticking!

First thing HCP should do after BBP exposure is to wash or flush the area!! Then they notify their supervisor & report to department where exposure follow-up will take place
Make sure HCPs KNOW that they need to start on HIV prophylaxis within 2 hours of exposure for best results; the decision regarding HIV prophylaxis is made in consultation with someone knowledgeable on the topic, & is based on HIV status of pt., along with type of exposure, amount of blood/OPIM involved, etc.

HCPs are monitored for HIV conversion for 6 mos. post-exposure

15 of 28

BBP Exposure F/U, cont.

Hepatitis…much more likely to be an issue with BBP exposures due to it being more common & higher infectivity

Hepatitis B

HCP’s protection against hep B should have been determined &/or provided on hire, so usually not an issue. However, there are exceptions, so be VERY familiar with process to address hep B vaccine non-responders (revaccinate/retest/etc).
HCPs who have not completed the vaccine series or who have unknown immune status should start the series & also receive hep B immune globulin at time of exposure if source pt. tests positive for infectious hep B or if hep B status unknown

16 of 28

BBP Exposure F/U, cont.

Hepatitis C

Most post-BBP exposure recommendations for HCP involving HCV pos. patients includes the avoidance of activities which could lead to secondary transmission (such as donating blood, taking sexual precautions, etc.)
New prophylactic med has come on market, but not widely used at this time (severe side effects)

STUDY APIC Text, Ch. 101, for much more in-depth info. on post-exposure follow-up.

17 of 28

Other Communicable Diseases of Concern for HCPs

Neisseria meningiditis

Usually an issue in N. meningiditis meningitis (vs. meningoccemia or resp. infection)

Post-exposure prophylaxis recommended for HCP with unprotected direct contact with patient’s resp. secretions (such as mouth-mouth respirations, intubations, etc.); prophylaxis, per CDC recommendations, should be provided as soon as possible after diagnosis is confirmed.

Varicella

Most HCP will have documented immunity; if they don’t have documented immunity, they should be excluded from duty from day 10 through day 21 post-exposure (or until are lesions are dry/crusty if do develop disease).
Varicella-zoster immune globulin (VZIG) is not generally recommended post-exposure, but may be considered for pregnant or immunocompromised HCPs; if VZIG is given, the time the HCP is excluded from duty should be extended to 28 days.

18 of 28

Other Communicable Diseases of Concern for HCPs

Scabies & lice (pediculosis)

Scabies is spread by prolonged skin-skin contact with the infected individual; contact prec. are important to decrease this risk to the HCP
Healthcare-associated transmission of head & body lice is unlikely, & pubic lice transmission is highly unlikely.
No prophylaxis is available to prevent HCP from obtaining lice/scabies; however, appropriate treatment is provided if HCP exhibit symptoms of the condition.

Measles

Most HCP should have documented immunity
For those who don’t, the measles vaccine should be given within 72 hours of exposure to patient with measles; exclusion from duty 5 days after 1^st exposure to 21 days after the last exposure

19 of 28

Other Communicable Diseases of Concern, cont.

Mumps

Again, most HCP should have documented immunity to mumps
Those without documented immunity should be given 2 doses of MMR vaccine & excluded from duty from the 12^th day after the 1^st exposure to the 25^th day after the last exposure.

Rubella

Finally, most HCP should have documented immunity to rubella
Those without documented immunity need to be excluded from duty from the 7^th day after the 1^st exposure through the 23^rd day after the last exposure.

20 of 28

Other Communicable Diseases of Concern, cont.

Pertussis

HCP exposed to pertussis (exposure is to immediate air space or patient secretions) should receive prophylaxis, per CDC recommendations.
Exposed HCP do not have to be excluded from duty unless they become symptomatic; they should then be excluded until they have taken 5 days of appropriate therapy.

Herpes Zoster

Healthcare organizations may consider excluding HCP with active shingles from duty until lesions are dry & crusty (if allowed to work, any draining lesions should be covered); important to note that shingles is less contagious than Varicella, especially if not disseminated.

21 of 28

Chapter 6�Post-Study Session Quiz��

22 of 28

1. You are teaching new employee orientation. What should be the first step after a bloodborne pathogen exposure?

Notify immediate supervisor
Report to Employee Health
Wash/flush the site
Complete exposure form

23 of 28

1. You are teaching new employee orientation. What should be the first step after a bloodborne pathogen exposure?

Notify immediate supervisor
Report to Employee Health
Wash/flush the site
Complete exposure form

24 of 28

2. Review the situation below and determine if this is the correct action for the situation.

You receive a call from the ED medical director; he suspects that a patient has meningitis & wants to immediately provide prophylactic meds for all staff who have had contact with the patient. Explain to the physician that since this is most likely a viral meningitis there is no need to give prophylaxis & that you will notify the public health department.

This is the correct action.
This is not the correct action.

25 of 28

2. Review the situation below and determine if this is the correct action for the situation.

You receive a call from the ED medical director; he suspects that a patient has meningitis & wants to immediately provide prophylactic meds for all staff who have had contact with the patient. Explain to the physician that since this is most likely a viral meningitis there is no need to give prophylaxis & that you will notify the public health department.

This is the correct action.
This is not the correct action.

Take down the patient info.; advise the med. dir. to wait on HCW prophylaxis until CSF gram stain results are available. If gram stain is positive for gram neg. diplococci, this is most likely meningioccoccal meningitis, & HCPs with intimate resp. contact with the patient would be candidates for prophylaxis. Ask him to place the pt. in droplet precautions until diagnosis is determined.

26 of 28

3. What is the preferred method for screening HCWs for tuberculosis?

TB skin testing utilizing tine tests
Use of symptom screening forms
Chest xrays
TB testing using PPD or blood tests

27 of 28

3. What is the preferred method for screening HCWs for tuberculosis?

TB skin testing utilizing tine tests
Use of symptom screening forms
Chest xrays
TB testing using PPD or blood tests

28 of 28

References

CDC/NIOSH guidelines,
OSHA BBP regulations,
University of North Carolina Occ. Health website: http://ehs.unc.edu
CDC. Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR November 25, 2011; 60(No. RR-07); 1-45.
CDC Manual for the Surveillance of Vaccine-Preventable Diseases