Occupational Health Employee Health for the IP

Occupational Health Employee Health for the IP

Disclosures: I have No conflicts of interest No commercial support No specific product will be endorsed during this presentation

Key Concepts Reasons for developing an Employee Health Program Elements of an Employee Health Program Transmission of infection to and from the HCW

KeY Concepts Common infectious processes with indications for post exposure intervention Work restrictions in the healthcare facility

Key Concepts Worker s Compensation Measuring improvement in preventing occupational exposure

Background Providing a safe environment Double-edged sword: Staff and Patients Increased awareness during the past three decades related to the AIDS epidemic

Background Regulatory Compliance: OSHA (Occupational Safety and Health Administration) Organizational Resources and recommended practices: IPs are called on to provide credible references to support the policies and practices that are in place

Basic Principles IP policies, procedures, and practices in an OH program are designed to interrupt the transmission of infection to and from the healthcare personnel

Principle to Process Some pose a threat and have vaccines for prevention Some require post exposure follow-up Some have no indications for follow-up

HCW Health Care Workers

HCW: A Definition All paid and unpaid persons (i.e. volunteers, lay chaplains) working in healthcare settings who have the potential for exposure to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air.

Design Of An OH/EH Program Communication with other departments is vital Proper isolation of contagion by nursing staff Reporting exposures Proper identification of employee with contagion

Design Pre-employment physical exams have not been demonstrated to be cost effective Medical evaluations performed before placement might identify worker risk for infection and whose placement may need to be considered carefully Periodic evaluations may need to be performed for job assignments or work related problems

Design Staff education may contribute to workers compliance with IP practices through understanding of rationale Existing federal, state, and local regulations for staff education and training Management of job related illnesses and exposures and postexposure follow up is mandated by regulatory agencies

Design Work restrictions may be indicated for workers who have transmissible illnesses. The facility should have a process in place to identify who has the authority to remove the worker from duty Maintenance of records, data management, and confidentiality are major requirements of OH/EH programs (know who can have access to files)

Health counseling should be available about occupational and community infection risks Design

Immunization Programs Recommended immunization practices are addressed by the US Public Health Service s Advisory Committee on Immunization Practices (ACIP) Hepatitis B Influenza MMR Varicella Pertussis Tdap VIS (Vaccine information sheets from CDC)

Hepatitis B Hepatitis B Give 3-dose series (dose #1 now, #2 in 1 month, #3 approximately 5 months after #2). Give IM. Obtain anti- HBs serologic testing 1 2 months after dose #3. Hepatitis B recombinant vaccine For HCWs at risk of exposure to blood and body fluids Test for immunity 1-2 months following 3 rd dose If declines must sign declination statement.

Influenza INFLUENZA Give 1 dose of influenza vaccine annually. Give inactivated injectable influenza vaccine intramuscularly or live attenuated influenza vaccine (LAIV) intranasally. All HCWs with direct patient care Contraindicated if SEVERE egg allergy Declination if not taking flu vaccine (TJC) Begin staff education stressing the importance of immunization annually

MMR MMR For healthcare personnel (HCP) born in 1957 or later without serologic evidence of immunity or prior vaccination, give 2 doses of MMR, 4 weeks apart. Give SC. HCP born in 1957 or later can be considered immune to measles, mumps, or rubella only if they have documentation of (a) laboratory confirmation of disease or immunity, or (b) appropriate vaccination against measles, mumps, and rubella (i.e., 2 doses of live measles and mumps vaccines given on or after the first birthday, separated by 28 days or more, and at least 1 dose of live rubella vaccine). Consider recommending 2 doses of MMR vaccine routinely to unvaccinated HCP born before 1957 who do not have laboratory evidence of disease or immunity to measles and/or mumps, and should consider one dose of MMR for HCP with no laboratory evidence of disease or immunity to rubella.

Varicella Varicella For HCP who have no serologic proof of immunity, prior vaccination, give 2 doses of varicella vaccine, 4 weeks apart. Give SC. Evidence of immunity in HCP includes documentation of 2 doses of varicella vaccine given at least 28 days apart, laboratory evidence of immunity, or laboratory confirmation of disease.

Tdap Tetanus, Diphtheria and Pertussis Give a one-time dose of Tdap as soon as feasible to all HCP who have not received Tdap previously. Give Td boosters every 10 years thereafter. Start with high risk areas such as Pediatrics, Nursery, NICU, and ER.

meningococcal Meningococcal Vaccination is recommended for microbiologists who are routinely exposed to isolates of N. meningitidis. Use MPSV4 only if there is a permanent contraindication or precaution to MCV4. Use of MPSV4 (not MCV4) is recommended for HCP older than age 55. References 1. CDC. Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, 2011; 60(RR-7).

Texas Senate Bill 7 Vaccine Preventable Disease Policy Required Based on level of risk Must specify vaccines required Includes procedures for verification of compliance

and more Includes procedures for HCW to be exempt for medical/religious reasons Includes procedures for exempt employees based on employees level of risk Includes disciplinary actions for employees who fail to comply with procedure

Post Exposure Management Meningitis Neisseria meningitidis H. flu TB Baseline PPD and again at 12 weeks Varicella Days 10-21 post exposure

Post Exposure Management Pertussis Within 21 days post exposure to asymptomatic contacts Incubation 7 10 days Bloodborne Pathogens OSHA CDC / PEP Line APIC Text

Index case- verify the diagnosis Is the patient infectious? Yes Was barrier protection absent or breached? Yes No Identify exposed individuals No action Is individual susceptible? No No action No No action Yes Does disease have potential for further spread? No Yes Do therapeutic measures for treatment exist? No Monitor employee for symptoms/work restrictions Yes Implement intervention measures

Tuberculosis CDC published recommendations for controlling the spread of TB in healthcare facilities OSHA has a compliance directive addressing occupational exposure to TB OSHA s General Duty Clause requires each employer to provide it s employees a place of employment free from recognized hazards

TB evaluation of NEW employees QuantiFERON Gold (blood test) 2 step is mandatory for ALL employees Job description makes NO difference Fit testing a MUST for those with patient contact. Check OSHA risk in job description.

Annual TB evaluation EVERY employee must have an annual evaluation. Depends on job description. Do they have patient contact? Sign a statement stating they have NO CONTACT. Or give QFT/TST/ PPDQ (questionnaire) if +.

Annual TB evaluation TST conversion do CXR and send for treatment. (Health department) Document in Employee file.

Employee fit testing for N-95 respirator OSHA requires fit testing

Fit testing Procedures Quantitative Fit Test (QNFT) Protocols Ambient aerosol condensation nuclei counter (CNC) quantitative fit testing protocol (Portacount TM )

Technique Matters!

Technique

Measure induration only not the redness.

Protocol for Occupational Exposure to Pertussis Supplement A Documented occupational exposure to confirmed Pertussis case If macrolide tolerant If macrolide intolerant Azithromycin 600 mg/day orally for five (5) days TMP-SMX 320/1600 mg /day in two divided doses orally for fourteen (14) days

VARICELLA EVALUATION All new hires Positive history of chicken pox OR Positive history of vaccination Unknown history of chicken pox OR Negative or unknown history of vaccination Consider immune Consider non-immune Draw IGG If positive, consider immune If negative, offer vaccine

Staff Exposed to Varicella Report to Staff Health & Safety (Occupational or Community Exposure) History of Varicella Consider immune Vaccinated or unknown history Draw IGG Positive Consider non-immune Negative IGG Offer vaccine if within 72 hrs or VZIG within 96 hrs 1. Mask employee days 10-21 2. Self assessment daily for symptoms 3. Notify Health Staff if symptoms appear Staff Health to verify as Varicella (IGM, IGG and vesicle culture for VZV)

Sample Assessment Prophylaxis for Occupational Exposure to Meningitis (Neisseria meningitidis ) (Charges to Staff Health) 1. Risk Assessment: Must meet both criteria below Source patient has confirmed case of bacterial meningitis Employee had contact within three feet of the patient without wearing a mask 2. Rifampin tolerant: Yes No (circle one) Rifampin* 600mg orally twice a day for two (2) days *Pregnancy Category C in 2 nd and 3 rd trimesters 3. Rifampin intolerant: Yes Ciprofloxacin* 500 mg orally times one (1) dose *Pregnancy Category C in 1 st, 2 nd and 3 rd trimesters 4. PREGNANT or Rifampin and Ciprofloxacin intolerant: Yes Ceftriaxone 250 mg intramuscular (IM) single dose 5. Pregnant and intolerant to above: NO PROPHYLAXIS TO BE GIVEN; EMPLOYEE TO FOLLOW UP WITH PRIMARY CARE PROVIDER 6. List of exposed staff names is included. Physician signature: Date: / /

Defining Exposure MENINGOCOCCAL MENINGITIS EXPOSURE Definition of Exposure: Contact with or face to face (mouth to mouth resuscitation, intubation, suctioning to infectious person s respiratory secretions Timeframe for Prophylaxis: Within two weeks of date of first exposure Incubation Period-2 to 10 days VARICELLA (CHICKENPOX) EXPOSURE Definition of Exposure: Direct contact with vesicles or airborne ( shared air contact ) with infectious person Timeframe for Prophylaxis: Within 96 hours of exposure for seronegative and unvaccinated, immunocompromised or pregnant staff Incubation Period-10-28 days The following employees have authority to initiate the above prescriptions as needed for occupational exposures:

BBP Exposure Determine HIV status of patient & employee (rapid testing if possible) Determine HEP B status of patient & employee (check employee HBAB) Determine HEP C status of patient & employee Reportable in the OSHA log 300

BBP exposure Follow-Up If all patient labs are negative nothing further need be done. If positive, offer PEP, vaccines, and follow-up lab work. If no patient is identified continue with followup lab work. No PEP is needed.

Post Exposure Interventions Work Restrictions www.cdc.gov APIC Text of Infection Control and Epidemiology

Workman s Compensation IP may be asked to help assess situation to determine if a worker has experienced occupational acquisition of infectious agent or disease Workman s comp programs vary from state to state. TX is under Insurance division. Division of Worker s Compensation(DWC).

Workman s Compensation Components may include medical benefits, weekly compensation, safety and rehab programs Eligible if occupational exposure is sole cause of the disease or accident Burden of proof lies with the workers

Workman s Compensation Most states don t provide compensation for a disease that is an ordinary disease of life Stroke Heart attack TB W/C in Texas must be able to attach employee to actual patient

Measuring Improvement in Occupational Exposure Prevention Epidemiologic approach can be taken to manage occupational exposures Reductions or increases in injuries or exposures are monitored over time Causes can be identified Variations are analyzed Prevention strategies are designed and implemented

Rates measuring performance Average daily census of occupied beds for the year can be used as denominator Total number of needle sticks reported in one year Divided by the total number of occupied beds in one year Equals the number of needle sticks per bed per year

What s Next???? WHO KNOWS!!! It is always interesting in Occupational Health

Sit Back and Relax... it really does all come together Thank You!!!