Occupational Health Update: Extended Care Facilities

Transcription

1 Occupational Health Update: Extended Care Facilities James J. Hill III, MD MPH FACOEM Associate Professor & Vice Chair Department of Physical Medicine & Rehabilitation University of North Carolina School of Medicine Medical Director, Occupational Health, UNC Chapel Hill Associate Medical Director, Occupational Health, UNC Hospitals Diplomate, American Board of Physical Medicine & Rehabilitation Diplomate, American Board of Preventive Medicine/Occupational Medicine

2 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

3 Disclosures No financial relationships to disclose No off-label or investigational use of medications and/or devices The information and views set out in this presentation are those of the author and do not necessarily reflect the official opinion of the University of North Carolina at Chapel Hill or UNC Hospitals

4 Pneumococcal Vaccines

5 Pneumococcal Vaccines Polysaccharide vaccine (PPSV23)» Vaccine administration schedule is determined by age and disease status of the patient One dose of PPSV23 is recommended for all adults aged 65 or older, regardless of previous vaccine history.*» Once a dose of PPSV23 has been given at age 65 or older, no additional doses of PPSV23 should be administered. One dose of PPSV23 is recommended for adults with certain medical conditions.» A second PPSV23 vaccine should be given > 5 years after initial vaccine in adults with one additional dose given when they turn 65

6 Pneumococcal Vaccines Conjugate vaccine (PCV13)» When indicated only a single dose is recommended for adults One dose of PCV13 is recommended for» all adults > 65 years of age unless they have already received the vaccine» 19 years or older with certain medical conditions

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8 Pneumococcal Vaccines wnloads/pneumo-vaccine-timing.pdf

9 Occupational Health Services

10 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

11 Health care facilities Infections» Aerosol/droplet Viral Pertussis Tuberculosis» Bloodborne pathogens HIV HBV HCV» Contact Syphilis MRSA Norovirus

12 Health care facilities Other hazards» Chemical Solvents, cleaning supplies, medical gases» Radiation Ionizing radiation, radioisotopes, lasers» Electrical» Workplace Violence»Stress» Shift work

13 Goals Workplace Safety» 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

14 Traditional View of Workplace Safety

15 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

16 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, securitysensitive

17 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)

18 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

19 CDC/NIOSH OSHA State/Local Health Departments DHHS Centers for Medicare Services Occupational Health Legal/Administration Workplace Safety Health Care Personnel Worker s Compensation Infection Control

20 Pre-exposure prophylaxis

21 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

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23 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.

24 I ve heard that vaccines don t work

25 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.

26 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

27 I can t get vaccinated, I m. Not willing to get vaccinated, despite all the things you have just told me Disease Herd Immunity Threshold Diphtheria 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

28 Immunization documentation Vaccine Birth before 1957 MD Dx + Serology Self Report Documented Vaccination Mumps 1 Yes 3 No Measles 1 Yes 3 No Rubella 1,2 No No Varicella No Yes 4 No Hepatitis B No >10 MIU/mL 4 No Pertussis No No No No Influenza No No No No 1 Consider immunization of HCP born before 1957, recommend during an outbreak; 2 All HCP of childbearing potential should be immunized; 3 requires lab confirmation; 4 Obtain 1-6 months post last vaccine dose Weber DJ, Schaffner W. ICHE 2011;32:912-4

29 Specific Vaccines

30 2018 ACIP Changes Use of a third dose of MMR for persons identified as an increased risk for mumps due to an outbreak Shingrix for prevention of herpes zoster» Adults > 50 years of age and older» Vaccinate adults who have previously received Zostavax» Preference for Shingrix over Zostavax» Removal of MPSV4 (meningococcal polysaccharide vaccine) no longer available

31 Indications Hepatitis B» 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); 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

32 Hepatitis B HEPLISAV-B approved in late 2017 Adults > 18 years of age Two doses one month apart Not studied on hemodialysis patients rovedproducts/ucm pdf

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34 Incidence per 100, OSHA mandate (1991) Year Estimated Incidence of HBV infections among HCP and General Population, United States,

35 Influenza vaccines Standard IM inactivated influenza vaccine (IIV3, IIV4) (most > 6 months) Other formulations» High-dose influenza vaccine (IIV3) (> 65 years)» Adjuvanted influenza vaccine (IIV3) (> 65 years)» Intradermal influenza vaccine (IIV4) (18-64 years)» Cell culture-based influenza vaccine (IIV4) (> 4 years) (egg-free)

36 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

37 CDC National Summary and Season

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39 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

40 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

41 Zostavax (ZVL) Zoster Vaccine Shingrix (RZV) Approved 2006 Approved 2017 Live, attenuated virus Recombinant, inactivated varicella antigen Adults > 50 years and older Adults > 50 years and older One dose Two doses, 2 6 months apart 51% reduction in risk of zoster in subjects > 60 years old (41% in 70 90% effective, 85% for at least four years after vaccination 79yrs, 18% in > 80 yrs) Reduced efficacy if given with PNEUMOVAX 23 (wait 4 weeks) Adults over 60 may be given RZV or ZVL (RZV is preferred) Should be given even if patient has had shingles, had Zostavax, unsure if they had chickenpox Wait 8 weeks after Zostavax administration. Can give with inactivated flu vaccine

42 Tetanus-diphtheria-acellular pertussis (/Tdap) Substitute 1 dose Tdap for all adults when Td booster due» May be used to provide tetanus PEP» Provide to all adults with exposure to young children (no delay after Td)» Recommended for pregnant women (preferably weeks gestational age)» Only one dose of Tdap is required, employees who are 10 years out from Tdap should be boosted with Td.

43 Meningococcal Vaccine Recommended for adults had high risk of disease (persistent complement deficiency, functional or anatomic asplenia, or HIV infection (adolescents)) MenACWY» Immunosupressed 2 doses of MenACWY and boosters every 5 years» Microbiologists 1 dose, booster every 5 years» 1 st -year college/military recruits 1 dose

44 Exposure Assessment

45 Exposure Disease Dose Host

46 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

47 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

48 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

49 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

50 Exposure Assessment Airborne Route of exposure» Respiratory» Contact with infected fluid Risk» TB, measles, chickenpox, disseminated zoster, zoster in immunocompromised patient

51 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

52 Post-exposure prophylaxis

53 Plague doctor (Library of Medicine/CDC) Ebola doctor (UNC School of Medicine)

54 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

55 Bloodborne Pathogens

56 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 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

57 OSHA Bloodborne Pathogens 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 )

58 OSHA Bloodborne Pathogens 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 )

59 OSHA Bloodborne Pathogens 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.

60 Incidence of bloodborne pathogen exposures, UNC Hospitals,

61 Bloodborne Pathogens Risk (percutaneous exposure)»hbv % (HBeAG + ) % (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 R I S K

62 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

63 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

64 Three-drug regiment Current HIV PEP» Tenofovir-emtricitabine (Truvada) + raltegravir (Isentress) for 4 weeks» Other regiments are available for known HIVsource patients with specific drug resistance but these cases are rare.

65 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)

66 Hepatitis C No post-exposure prophylaxis

67 Hepatitis B HIV Follow-up testing» Not required if employee has immunity» Dependent on source patient and available testing Hepatitis C» Dependent on source patient, test for HCV antibodies and HCV RNA

68 Take your son to work day Questions and (hopefully) Answers?

69 Contact Information Thanks!