occupational health update 2014: extended care facilities, spice david jay weber, m.d., m.p.h....
TRANSCRIPT
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OCCUPATIONAL HEALTH UPDATE 2014:EXTENDED CARE FACILITIES, SPICE
David Jay Weber, M.D., M.P.H.Professor of Medicine, Pediatrics & Epidemiology
Associate Chief Medical OfficerMedical Director, Occupational Health & Hospital Epidemiology
University of North Carolina at Chapel Hill
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GOALS OF CURRENT LECTUREUnderstand activities of an occupational health service
(OHS) in a healthcare facilityBe able to list vaccines recommended for healthcare
personnel (HCP)Be able to list infectious diseases relevant to HCP for which
post-exposure prophylaxis is availableBe able to manage exposure to blood or a contaminated
fluid
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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.
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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 treatmentThe tools used to reduce the risk of acquiring infection can
be used to reduce the risk of injuries
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---------------------------- Occupational Health Service ------------------------------
FDA Health Department
OSHA
NIOSH CDC
External Stakeholders
Internal Stakeholders
Legal/Administration Safety
Medical Staff Worker’s compensation
Infection Control
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OCCUPATIONAL HEALTH ACTIVITIESPre-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
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OCCUPATIONAL HEALTH ACTIVITIESAnnual 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)
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OCCUPATIONAL HEALTH ACTIVITIESEvaluation 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
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OCCUPATIONAL HEALTH ACTIVITIESWork site evaluationFor cause drug/alcohol testing Education
Fire, chemical, radiation safety Infection control (communicable diseases, TB, bloodborne
pathogens) Ergonomics
Smoking cessation
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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
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TUBERCULOUS: OSHA & CDC GUIDANCE Rule proposed by OSHA 997; withdrawn 2003 [compliance required
with 29 CFR 1910.134 – 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: http://www.cdc.gov/tb/topic/infectioncontrol/default.htmOHSA: https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=18050OHSA: https://www.osha.gov/SLTC/etools/hospital/hazards/tb/tb.html
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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)
http://www.ada.gov/pubs/adastatute08.htm
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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
http://www.dol.gov/whd/fmla/index.htm
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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
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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
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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)
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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
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
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TESTING FORLATENT 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 = http://epi.publichealth.nc.gov/cd/lhds/manuals/tb/toc.html
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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
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TST VS IGRA
TST 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
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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
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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
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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
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PROBLEMS WITH TST
False-Positive 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
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PRE-EXPOSURE PROPHYLAXIS
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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
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ADULT IMMUNIZATION SCHEDULE, US, 2014
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ADULT IMMUNIZATION SCHEDULE, US, 2014
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KEY REFERENCES
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SUMMARY OF CURRENT FDA APPROVED INFLUENZA VACCINES
Influenza 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
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SUMMARY OF CURRENTACIP 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
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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 19-64 years of age
Conjugate vaccine (PCV13) Contains 13 different pneumococcal strains Conjugation with diphtheria toxin may improve immunogenicity FDA approved for all person >50 years of age
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SUMMARY OF CURRENTACIP 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)
Age >19: Medical or other risk indications 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
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CDC. MMWR 2012;61:816
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SUMMARY OF CURRENTACIP 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
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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)
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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)
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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 Immunity = Appropriate immunizations or positive serology
Rubella 1 dose of MMR to susceptible women of childbearing potential Immunity: Positive serology or documented vaccine
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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)
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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
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IMMUNIZATION OF HCP WITHCERTAIN CONDITIONS, ACIP, 2011
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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
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HEPATITIS B VACCINE Indications
Universal; HCP with potential blood exposure (OSHA required OR signed refusal)
Administration IM dose into deltoid; 1-1.5” needle, 20-25 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
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Estimated Incidence of HBV infections among HCP and General Population,
United States, 1985-1999
0
50
100
150
200
250
300
350
1985 1987 1989 1991 1993 1995 1997 1999
Year
Inci
denc
e pe
r 10
0,00
0
Healthcare Personnel
General U.S. Population
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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
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CDCMMWR2013;62(RR-10)
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ASSURING HCP COVERAGEHealthcare facility employees - requirement for employmentMedical staff - include in credentialing processStudents - require for attending classVolunteers - requireContract workers - require in contractEmergency responders
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PROOF OF IMMUNITY FOR HCP
Vaccine Birth before 1957
MD Dx + Serology Self Report
Documented Vaccination
Mumps 1 Yes3 No Measles 1 Yes3 No Rubella 1,2 No No Varicella No Yes 4 No Hepatitis B No >10 MIU/mL4 No Pertussis No No No No Influenza No No No No
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
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PROVIDING VACCINESPatient name and identification numberVaccineDose, Site, Route of AdministrationDate givenManufacturerLot numberName, title & address of person providing vaccineDate next dose due Informed consent
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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
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DATA RECORDED ON EXPOSURESEmployee 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
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EXPOSURE EVALUATIONDetermine if source case has infection and is infectiousDetermine transmission possible (i.e., appropriate exposure
without protection)Determine if employee is susceptible (may require labs)Determine if prophylaxis available & indicatedConsider alternative prophylaxis (if available) if employee
has contraindications to prophylaxis of first choiceArrange follow-up
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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
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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
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INCIDENCE OF BLOODBORNE EXPOSURES, 1997-2011
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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)
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NO POST-EXPOSURE PROPHYLAXIS Hepatitis CMumpsParvovirus B19RubellaSevere acute respiratory distress syndrome (SARS)
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Risk of Bloodborne Virus Transmission after Occupational Percutaneous Exposure
SourceHBV
HBeAg +HBeAg -
HCV
HIV
Risk
22.0-30.0%1.0-6.0%
1.8%
0.3%
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DEFINITION OF EXPOSUREPercutaneous exposure to contaminated body fluidMucous membrane exposure to contaminated body fluidNon-intact skin expose to contaminated body fluidContaminated fluids: blood, CSF, vaginal secretions,
semen, synovial, pleural, peritoneal, pericardial, amniotic
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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 protocolMaintain confidentiality: Separate records, labs & pharmacy
requisitions sent with code number
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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
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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
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PEP FOR HBV EXPOSURES
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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 AIDSTypes 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
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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;34:875-892
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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
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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
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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
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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
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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)
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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)
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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)
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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
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Deaths25,000 - 72,000
Hospitalizations114,000 - 257,500
Infections and illnesses50 - 60 million
Physician visits~ 25 million
Thompson WW et al. JAMA. 2003;289:179-86. Couch RB. Ann Intern Med. 2000;133:992-8. Patriarca PA. JAMA. 1999;282:75-7. ACIP. MMWR. 2004;53(RR06):1-40.
Influenza Disease Burden to U.S. Societyin an Average Year
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Influenza Sign/Symptom Children Adults ElderlyCough (nonproductive) ++ ++++ +++Fever +++ +++ +Myalgia + + +Headache ++ ++ +Malaise + + +++Sore throat + ++ +Rhinitis/nasal congestion ++ ++ +Abdominal pain/diarrhea + – +Nausea/vomiting ++ – +
++++ Most frequent sign/symptom; + Least frequent; – Infrequent
Monto AS et al. Arch Intern Med. 2000;160:3243-47. Cox NJ et al. Lancet. 1999;354:1277-82.
Clinical Manifestations by Age Group
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Influenza Manifestations & Complications
Loughlin J et al. Pharmocoeconomics. 2003;21:273-283. 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; 2000:1823-1849. ACIP. MMWR 2004;53 (RR06):1-40.
Children AdultsFrequent 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
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CDC. MMWR 2008;57(RR-18):1-59
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Viral Nomenclature
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
A / Sydney / 184 / 93 (H3N2)
Type of Nuclear Material
Virus type
Geographic origin
Strain number
Year of isolation
Hemagglutinin
Virus subtype
Neuraminidase
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Pandemic influenza1918H1N1 “Spanish”
1977H1N1 “Russian”
2009H1N1 pdm09
1957H2N2 “Asian” flu
1968H3N2 “Hong Kong” flu
1947H1N1
1940Influenza B
……………
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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
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STANDARD VERSUS HIGH DOSE INFLUENZA VACCINE, ADULTS >75 YEARS
0.0%20.0%40.0%60.0%80.0%
A/H1N1 A/H3N2 B
Ser
ocon
vers
ion
Standard DoseHigh Dose
Falsey AR, et al. JID 2009;200:172-80
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EFFICACY OF HIGH DOSE INFLUENZA VACCINE: INFLUENZA A
PD ILI = protocol-defined influenza-like illness; presented Oct. ACIP meeting
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EFFICACY OF HIGH DOSE INFLUENZA VACCINE: INFLUENZA B
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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
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SUMMARY OF CLUSTER RCTs ASSESSING THE IMPACE OF HCP IMMUNIZATION
Study CoverageControl
CoverageIntervention
MortalityControl
MortalityIntervention
Mortality Difference
Potter J, 1997 4.9% 61% 17% 10% 7.0%
Carman W, 2000 13.6% 50.9% 22.4% 13.6% 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)
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Indirect Benefits of Influenza Vaccination of Health Care ProvidersMortality 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)
Potter J et al. J Inf Dis. 1997;175:1-6.
Vaccine groups
SV (n=490)
SO (n=561)(P=0.0009)
Tota
l pat
ien
t m
ort
alit
y (%
)
Time in days
0 20 40 60 80 100 120 1400
10
20
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Indirect Benefits of Influenza Vaccination of Health Care Providers
22.4
13.6
0
5
10
15
20
25
Vaccine hospitals No vaccine hospitals
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
Carman WF et al. Lancet. 2000;355:93-7.
No significant difference in % residents positive for influenza: ‘Vaccine hospitals’ 5.4%; ‘no vaccine hospitals’ 6.7%
n = 749 n = 688
Res
iden
t m
ort
alit
y (%
)
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REDUCTION IN OUTCOMES IN HCP RECEIVING INFLUENZA VACCINE
-100%
-90%
-80%
-70%
-60%
-50%
-40%
-30%
-20%
-10%
0%
Talbot TT, Weber DJ, et al. ICHE 2005;26:882-890
Influenzainfection
Sick days due torespiratory
illness
Days lostfrom work
Patientmortality
Patientmortality
Carmen2000
Potter1997
Wilde1999*
Saxen1999
88% 28% 41% 41% 39%
Wilde1999
Attack rate unvaccinated = 13.4%
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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
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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
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THANK YOU!