occupational health update: extended care facilities
TRANSCRIPT
Occupational Health Update:Extended Care Facilities
James J. Hill III, MD MPH FACOEMAssociate Professor & Program Director
Department of Physical Medicine & RehabilitationUniversity of North Carolina School of Medicine
Medical Director, Occupational Health, UNC Chapel HillAssociate Medical Director, Occupational Health, UNC Hospitals
Diplomate, American Board of Physical Medicine & RehabilitationDiplomate, American Board of Preventive Medicine/Occupational Medicine
Certified Strength and Conditioning Specialist (CSCS), NSCA
Goals
• Understand occupational health services in a healthcare facility
• Understand pre-exposure evaluation and vaccine-preventable disease for healthcare personnel
• Understand post-exposure prophylaxis for occupational-acquired infectious diseases
• Understand how to manage exposure to blood or potentially infectious material
• Understand basic workplace accommodations in the setting of the ADA
Disclosures• I am actively seeking various sources of revenue
that will allow me to add substantial bias to the following information – but I have none at this time.
• The original presentation for LTC facilities/SPICE was developed by Dr. David Weber, Medical Director, Hospital Epidemiology and Occupational Health Services, UNC Hospitals
Occupational Health Services
Health care facilities• Top five hazards (OSHA 2015)
» Musculoskeletal Disorders related to patient or resident handling
» Bloodborne Pathogens
» Workplace Violence
» Tuberculosis
» Slips, Trips and Falls
Health care facilities• Infections
» Aerosol/droplet• Viral• Pertussis• Tuberculosis
» Bloodborne pathogens• HIV• HBV• HCV
» Contact• Syphilis• MRSA• Norovirus
Health care facilities• Other hazards
» Chemical• Solvents, cleaning supplies, medical gases
» Radiation• Ionizing radiation, radioisotopes, lasers
» Electrical» Workplace Violence» Stress» Shift work
Workplace Safety
• Goals» To provide a safe environment for patients
and health care personnel (HCP)» To minimize risk of injury» To minimize risk of exposure to infectious
disease• How?
» Commitment to health and safety» Formal organized program to evaluate risks in
the workplace » Formal organized program to provide
effective, efficient care to the affected patient and/or HCP
Traditional View ofWorkplace Safety
Workplace Safety
• Prevention is superior to treatment• A safe work environment reduces workplace
costs while improving patient safety• The tools that we use for reducing
occupationally acquired infections can also reduce the risk of injuries
Occupational Health• Pre-employment screening
» HCP-recommended vaccinations» Employment physical » Drugs/alcohol screening» Allergy screening (gloves)» Baseline TB testing» Fit test medical clearance » Hearing evaluation/audiogram» Fitness-for-duty
• pregnancy, immunocompromised, security-sensitive
Occupational Health• Annual
» TB screening (facility and/or regulatory dependent)
» Influenza vaccination» DOT/FMCSA drug/alcohol testing (facility
dependent)» Policy development» Education » Wellness (facility dependent)
Occupational Health• Event-driven
» Communicable disease exposures» Blood-borne pathogens» Contact investigations» Acute injury» Infection Control» Ergonomic evaluation» Indoor air quality» For cause drug/alcohol testing» ADA/FMLA/Fitness-for-Duty
OSHA
CDC/NIOSH
Legal/Administration
Worker’s Compensation
Infection Control
Workplace Safety
State/Local Health Departments
DHHS
Health Care Personnel
Centers for Medicare Services
Occupational Health
Pre-exposure prophylaxis
Vaccine Preventable Diseases• Anthrax• Diphtheria• Hepatitis A/B/D• H. influenza type• Human
papillomavirus (HPV)
• Influenza A and B• Japanese
encephalitis• Lyme disease• Measles• Monkeypox• Mumps• Rabies
• Meningococcal A,C,Y,W135
• Meningococcal B• Pertussis• Pneumococcal• Poliomyelitis• Rotavirus• Rubella• Smallpox• Tetanus• Tuberculosis• Typhoid fever• Varicella (Zoster)• Yellow fever
Why do I have to get vaccinated? • Vaccine-preventable diseases haven’t gone away.• Vaccination can mean the difference between life
and death.» In the US, vaccine-preventable infections kill
more individuals annually than HIV/AIDS, breast cancer, or traffic accidents. Approximately 50,000 adults die each year from vaccine-preventable diseases in the US.
• Vaccines are safe and effective.• When you get sick, your children, grandchildren,
and parents are at risk, too.
I’ve heard that vaccines don’t work
So, do I have to get vaccinated?• 10A NCAC 13D .2209 INFECTION CONTROL
» (a) A facility shall establish and maintain an infection control program for the purpose of providing a safe, clean and comfortable environment and preventing the transmission of diseases and infection.
I can’t get vaccinated, I’m …….• Pregnant
» Live-attenuated vaccines contraindicated (with some exceptions)
• Immunocompromised» Case-dependent, concern is vaccine efficacy as
well as patient safety• Allergic to eggs
» Vaccine-dependent (may have egg-free formulations available)
• On blood thinners» “Let me see your arm”
• Afraid of needles» “Quick, look over there”
I can’t get vaccinated, I’m …….“Not willing to get vaccinated, despite all the
things you have just told me ”
Disease Herd Immunity ThresholdDiphtheria 85%
Measles 83-94%Mumps 75-86%
Pertussis 92-94%Polio 80-86%
Rubella 80-85%Smallpox 83-85%
”Pick battles that are small enough to win, big enough to be important”
Immunization documentationVaccine Birth before
1957MD 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
Specific Vaccines
Hepatitis B
• Indications» Universal; HCP with potential blood exposure
(OSHA required OR signed refusal)• Administration
» 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 “non-responder”
» If non-immune after 6 (or 3) doses, test for HBsAg
050
100150200250300350
1985 1987 1989 1991 1993 1995 1997 1999
Year
Inci
denc
e pe
r 10
0,00
0
Estimated Incidence of HBV infections among HCP and General Population,
United States, 1985-1999
OSHA mandate (1991)
Influenza vaccines• Standard IM inactivate influenza vaccine (TIV) {>
6 months}• Inhaled live-attenuated influenza vaccine (LAIV)
{ages 2-49}• Other formulations
» High titer influenza vaccine {>65 years}» Intradermal influenza vaccine {18-64 years}» Cell culture-based influenza vaccine^ {>18 years}
(egg-free)» Two 2 quadrivalent influenza (2 A, 2 B strains)
vaccines {>3}» Recombinant influenza (HA only) vaccine^ {18-49}
(egg-free)
Influenza vaccines• ACIP recommendations
» 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
Measles, Mumps, Rubella (MMR)• Measles
» Born before 1957: Consider immune (except during outbreak): Born after 1957: 2 doses
» Immunity = Appropriate immunizations or positive serology
• Mumps» Born before 1957: Consider immune (except
during outbreak): Born after 1957: 2 doses» Immunity = Appropriate immunizations or
positive serology• Rubella
» 1 dose of MMR to susceptible women of childbearing potential
» Immunity: Positive serology or documented vaccine
Varicella
• Special consideration should be given to those who have close contact with» persons at high risk for severe disease (e.g.,
immunocompromised persons)» 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
Zoster Vaccine
• 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
Tetanus-diphtheria-acellularpertussis (/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)» Only one dose of Tdap is required, employees
who are 10 years out from Tdap should be boosted with Td.
Meningococcal Vaccine
• Recommended for adults had high risk of disease (persistent complement deficiency, functional or anatomic asplenia, or HIV infection (adolescents))» 2-dose primary series administered 2-months apart
for persons aged 2-54 MCV4,» persons < 55 years; MPSV4 persons > 56 years
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» When indicated only a single dose is recommended for
adults
Pneumococcal Vaccines
• Adults aged 19-64 with immunocompromising conditions or anatomical/functional asplenia» Similar to adults aged > 65, however, can give
second vaccine 8 weeks after initial vaccine» Adults aged 19-64 years who reside in nursing
home or long-term care facility: Administer PPSV23
Exposure Assessment
Exposure Disease
Dose Host
Exposure Assessment
• You have to be exposed to be at risk for the disease» ex. Blood on intact skin, limited time in patient
room
• The definition of exposure is agent-specific
Exposure Assessment
• Potentially infectious material» Contaminated fluids: blood, CSF, vaginal
secretions, semen, synovial, pleural, peritoneal, pericardial, amniotic
• Route of exposure» Percutaneous» Mucous membrane» Non-intact skin
• Risk» HIV, HBV, HCV
Exposure Assessment
• Droplet» Sneezing (velocity 50 m/s; distance 6 m)» Coughing (velocity 10 m/s; distance 2 m)» Breathing (velocity 1 m/s; distance <1 m)
• Route of exposure» Mucous membrane (hand-oral)» Non-intact skin
• Risk» Influenza, adenovirus, RSV, pertussis, N.
meningitides, group A streptococcus
Exposure Assessment
• Contact» Stool, draining wounds, uncontrolled secretions,
pressure ulcers, or presence of ostomy tubes and/or bags draining body fluids
• Route of exposure» Mucous membrane (hand-oral)» Non-intact skin
• Risk» norovirus, rotavirus, C. difficile, syphilis
Exposure Assessment
• Airborne• Route of exposure
» Respiratory» Contact with infected fluid
• Risk» TB, measles, chickenpox, disseminated zoster,
zoster in immunocompromised patient
Exposure Assessment
• Exposure is agent-specific• Ex. Tuberculosis
» Risk of TB infection is determined by duration of exposures (days to weeks, not minutes to hours)
» Household contacts have different ventilation requirements related to air exchanges per hour
» However, there is no ”safe time” to be exposed to TB
Post-exposure prophylaxis
Plague doctor(Library of Medicine/CDC)
Ebola doctor(UNC School of Medicine)
Post-exposure prophylaxis
• Pertussis» Azithromycin (regardless of vaccine status)
• Meningococcal» Ciprofloxacin
• Influenza» Antivirals (depends on sensitivities)
• Human Bite» Augmentin
• Chickenpox/Shingles» Vaccination
• Norovirus» Supportive, removal from work until
asymptomatic
Bloodborne Pathogens
Bloodborne Pathogens
• Approximately 385,000 needle sticks and other sharps-related injuries to hospital-based healthcare personnel each year.
• 88% (50/57) of the documented cases of occupational HIV transmission from 1985-2004 involved a percutaneous exposure. Of those, 45/57 involved a hollow-borne needle.
• 41% of sharp injuries occur during use; 40% after use/before disposal; 15% during/after disposal
OSHA BloodbornePathogens Standard
• Employers must establish a written exposure control plan and provide annual training
• Mandates use of universal precautions (all body fluids assumed contaminated except sweat)
• Employers must utilize engineering and work practice controls to minimize/eliminate exposure» Needleless devices, single-hand recapping,
handwashing stations, sharps containers, laundry, disposal of contaminated material
(29 CFR 1910.1013)
OSHA BloodbornePathogens Standard
• Requires offering hepatitis B vaccine to persons with the potential for exposure
• Testing of exposed employees for Hepatitis B and HIV
• Post-exposure prophylaxis must be immediately available as per CDC guidelines
(29 CFR 1910.1013)
OSHA BloodbornePathogens Standard
• All work-related needle stick injuries and cuts from sharp objects that are contaminated with another person's blood or other potentially infectious material are OSHA-reportable regardless of the source patient disease status.
Incidence of bloodborne pathogen exposures, UNC Hospitals, 1997-2011
Bloodborne Pathogens• Risk (percutaneous exposure)
» HBV• 22.0 – 30.0% (HBeAG+)• 1.0 – 6.0% (HBeAG-)
» HCV• 1.8%
» HIV• 0.3% (1 in 300)
• Risk (mucous membrane)» HBV
• Yes (rate unknown)» HCV
• Yes (rate unknown but very small)» HIV
• 0.1% (1 in 1000)• < 0.1% (non-intact skin)
CDC, 2003
RISK
Post-exposure pathway
• 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, offer
employee HIV prophylaxis per CDC protocol
Post-exposure pathway
• 10A NCAC 41A .0202• CONTROL MEASURES – HIV
» 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.
» Source patient consent is not required
Current HIV PEP
• Three-drug regiment» Tenofovir-emtricitabine (Truvada) + raltegravir
(Isentress) for 4 weeks» Other regiments are available for known HIV-
source patients with specific drug resistance but these cases are rare.
Hepatitis B
• Universal; HCP with potential blood exposure (OSHA required or HCP may decline)» No need to routinely obtain Hep B titers if an
employee has documented vaccine series and a positive titer
» In practice, we usually titer and give a booster if titer is < 10
» For known non-responders, they should get Hepatitis B Immune Globulin (HBIG) within 24 hours (up to 7 days after exposure)
Hepatitis C
• No post-exposure prophylaxis
Follow-up testing
• Hepatitis B» Not required if employee has immunity
• HIV» Dependent on source patient and available
testing• Hepatitis C
» Dependent on source patient, test for HCV antibodies and HCV RNA
Americans with Disability Act
ADA
• Modifications» making existing facilities accessible;» job restructuring;» part-time or modified work schedules;» acquiring or modifying equipment;» changing tests, training materials, or
policies;» providing qualified readers or interpreters;» reassignment to a vacant position
ADA• Reasonable modifications
• Modifications or adjustments to a job application process that enable a qualified applicant with a disability to be considered for the position such qualified applicant desires; or
• Modifications or adjustments to the work environment, or to the manner or circumstances under which the position held or desired is customarily performed, that enable a qualified individual with a disability to perform the essential functions of that position;
• Modifications or adjustments that enable a covered entity's employee with a disability to enjoy equal benefits and privileges of employment as are enjoyed by its other similarly situated employees without disabilities.
ADA
• The employer does not have to» Eliminate an essential function of the job» Adopt a lower production standard» Provide personal use items for use on or off
the job (may provide job-related items) » Provide personal use amenities (unless they
are provided to employees without disabilities)
ADA
• Undue hardship» No change or modification is required if
significant difficulty or expense will be incurred and focuses on the resources and circumstances of the particular employer in relationship to the cost or difficulty of providing a specific accommodation.
» Undue hardship refers not only to financial difficulty, but to reasonable accommodations that are unduly extensive, substantial, or disruptive, or those that would fundamentally alter the nature or operation of the business.
» This is decided on a case-by-case basis
Take your son to work day
Questions and (hopefully) Answers?
