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

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

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.

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

---------------------------- Occupational Health Service ------------------------------

FDA Health Department

OSHA

NIOSH CDC

External Stakeholders

Internal Stakeholders

Legal/Administration Safety

Medical Staff Worker’s compensation

Infection Control

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

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)

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

OCCUPATIONAL HEALTH ACTIVITIESWork site evaluationFor cause drug/alcohol testing Education

Fire, chemical, radiation safety Infection control (communicable diseases, TB, bloodborne

pathogens) Ergonomics

Smoking cessation

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

PRE-EXPOSURE PROPHYLAXIS

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

ADULT IMMUNIZATION SCHEDULE, US, 2014

ADULT IMMUNIZATION SCHEDULE, US, 2014

KEY REFERENCES

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

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

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

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

CDC. MMWR 2012;61:816

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

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)

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)

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

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)

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

IMMUNIZATION OF HCP WITHCERTAIN CONDITIONS, ACIP, 2011

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

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

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

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

CDCMMWR2013;62(RR-10)

ASSURING HCP COVERAGEHealthcare facility employees - requirement for employmentMedical staff - include in credentialing processStudents - require for attending classVolunteers - requireContract workers - require in contractEmergency responders

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

PROVIDING VACCINESPatient name and identification numberVaccineDose, Site, Route of AdministrationDate givenManufacturerLot numberName, title & address of person providing vaccineDate next dose due Informed consent

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

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

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

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

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

INCIDENCE OF BLOODBORNE EXPOSURES, 1997-2011

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)

NO POST-EXPOSURE PROPHYLAXIS Hepatitis CMumpsParvovirus B19RubellaSevere acute respiratory distress syndrome (SARS)

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%

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

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

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

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

PEP FOR HBV EXPOSURES

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

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

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

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

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

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

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)

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)

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)

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

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

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

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

CDC. MMWR 2008;57(RR-18):1-59

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

Pandemic influenza1918H1N1 “Spanish”

1977H1N1 “Russian”

2009H1N1 pdm09

1957H2N2 “Asian” flu

1968H3N2 “Hong Kong” flu

1947H1N1

1940Influenza B

……………

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

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

EFFICACY OF HIGH DOSE INFLUENZA VACCINE: INFLUENZA A

PD ILI = protocol-defined influenza-like illness; presented Oct. ACIP meeting

EFFICACY OF HIGH DOSE INFLUENZA VACCINE: INFLUENZA B

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

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)

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

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 (%

)

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%

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

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

THANK YOU!