Infectious Diseases and Nurses

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Infectious Diseases and Nurses

• Historical Insights Can Guide Future Action

Kate McPhaul, PhD, MPH, RN University of Maryland
Work and Health Research Center June 8,
2007 Massachusetts Nurses Association (MNA)
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Objectives

• List two old and one new infectious disease known
  to be transmitted to healthcare workers today
• Discuss the three classic public health
  interventions for control of infectious disease
  transmission
• Contrast the occupational safety paradigm
  including hierarchy of controls with classic
  pubic health protection and critique the
  implications for protecting healthcare workers
• Describe the elements of the blood borne pathogen
  standard and relate to the hierarchy of controls
  for protecting workers from airborne infectious
  diseases

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• Historical perspectives on TB, SARS, Influenza
  and Healthcare Workers
• Model Standard - Bloodborne Pathogen and
  Needlestick Safety Act
• What do we do NOW to prevent nurses from
  contracting infectious diseases in future
  outbreaks?

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Even super heros can succumb to infectious
diseases.
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• How many infectious agents may be transmitted
  and/or acquired by nurses in healthcare settings?

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Infectious Diseases in Healthcare According to
the CDC, the following may be transmitted and/or
acquired in healthcare settings

• MRSA - Methicillin-resistant Staphylococcus
  Aureus
• Mumps
• Norovirus
• Parvovirus
• Poliovirus
• Pneumonia
• Rubella
• SARS
• S. pneumoniae (Drug resistant)
• Tuberculosis
• Varicella (Chickenpox)
• Viral Hemorrhagic Fever (Ebola)
• VISA - Vancomycin Intermediate Staphylococcus
  aureus
• VRE - Vancomycin-resistant enterococci

• Acinetobacter
• Bloodborne Pathogens
• Burkholderia cepacia
• Chickenpox (Varicella)
• Clostridium Difficile
• Clostridium Sordellii
• Creutzfeldt-Jakob Disease (CJD)
• Ebola (Viral Hemorrhagic Fever)
• Gastrointestinal (GI) Infections
• Hepatitis A
• Hepatitis B
• Hepatitis C
• HIV/AIDS
• Influenza

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Blood borne pathogen transmission to healthcare
workers

• In addition to Hepatitis B and C, and HIV from
  1996 2005 there were published case reports of
  60 pathogens 26 viruses, 18 bacterial/rickettsia,
  13 parasites, and 3 yeast known to
  occupationally infect HCWs. (Tarantola, AJIC,
  2006)

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Occupational Deaths from Infectious Diseases
Hepatitis B

• 1983 10,000 HCWs exposed
• 5-10 (500-1000) develop chronic infection
• 15-25 (75-200) die/year
• Risk of Hep B has diminished gt90 due to Hep B
  Vaccine
• gt30 HCWs decline vaccine resulting 400
  HCWs/year becoming infected

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Occupational Deaths from Infectious Diseases
Hepatitis C

• CDC estimates that Hepatitis C is prevalent in
  1.8 of US population, same for HCWs
• 1-3 of percutaneous exposures result in Hep C
  infection to HCW
• 3-8 HCWs annually die from Hepatitis C (estimate
  based on needlestick rate)

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Occupational Deaths from Infectious Diseases HIV

• 138 HCWs acquired AIDs from a percutaneous
  exposure
• CDC methods do not collect death information
• Personal friend, Meta Snyder, died from AIDS
  acquired via needlestick but did not meet the CDC
  definition

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Occupational Deaths from Infectious Diseases
Internationally

• Hemorrhagic fevers
• TB in Malawi, Ethiopia and South Africa

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The TB Debate TB is good for Nurses
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Early History

• Aristotle in approaching the consumptive one
  breathes his pernicious air, one takes the
  disease because there is in this air something
  disease producing
• Sepkowitz, 1994

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Tuberculosis

• 1699 tuberculosis became a reportable disease in
  Italy
• Some pathologists refuse to do mandated autopsies
  fearing illness
• French MD Laennec dies from TB refusing to
  believe he could acquire it from performing
  autopsies

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Tuberculosis

• 1882 study showed no HCWs infected in a large TB
  Sanatorium TB might not even be contagious
• Clapp of Boston believed in contagion but this
  view was not pervasive

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More data shows risk of TB for HCWs

• Studies of nursing students in Europe and US show
  high rates of tuberculin conversation (79-100)
• Standard 1920s pulmonary text There is no
  danger from the expired air of consumptives. For
  this reason a TB sanatorium is probably the
  safest place one can be so far as the dangers of
  infection is concerned.

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Why was consensus delayed?Sepkowitz, 1994

• Acknowledging risk might scare women away from
  nursing profession
• Some said increased surveillance not increased
  risk
• Middle road view Yes, infections are occurring
  but disease is rare
• Living right prevents disease

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Reducing the risk
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Reducing the Risk

• Mandatory chest x-rays upon admission for all
  patients
• Effective chemotherapy and routine prophylaxis
• TB rates in population declined until 1980s

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Occupational Deaths from Infectious Diseases TB

• At least nine HCWs who were also
  immunocompromised died from TB infection in the
  80s and 90s.
• 6-8 HCWs have also died from TB treatment to
  multi-drug resistant TB

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Occupational Deaths from Infectious Diseases SARS

• 8098 cases
• 774 deaths (9.6)
• 1707 (21)
• cases were HCWs
• 378 (57) of cases in
• healthcare were HCWs
• Number of HCW fatalities
• not known!!!

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Severe Acute Respiratory Syndrome (SARS) -
Timeline

• Mar 2003 HCW with unexplained pneumonia in
  Vietnam dies
• Mar June 2003 - Toronto 2 phase outbreak
  primarily driven by nosocomial infections
• Mar June Taiwan 2 phases 1 in travelers, 1
  in hospitals
• July 2003 WHO declares outbreak over

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SARS and HCWsMcDonald, 2004 Emerging Infectious
Diseases
Characteristics Toronto Taiwan
Total Cases 375 N/A
Probable 247 (66) 668
Suspected 128 (34) N/A
Deaths 44 (12) 72 (11)
Healthcare-related 271 (72) 370 (55)
Healthcare workers 164 (44) 120 (18)
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SARS in Healthcare Facilities
McDonald, 2004 Emerging Infectious Diseases

• Unrecognized SARS Patients
• Minimal infection control practices in ER
• ER high risk
• Virus concentrations highest in patients 10 days
  after infection when symptoms are worsening

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SARS in Healthcare Facilities
McDonald, 2004 Emerging Infectious Diseases

• Transmission appears to be
• Droplet
• Direct contact
• Limited airborne

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SARS in Healthcare Facilities
McDonald, 2004 Emerging Infectious Diseases

• Important Considerations
• Aerosol-generating procedures
• Super spreaders
• Lack of PPE
• Overwhelming hospital resources such as negative
  pressure ventilated rooms
• SARS Tent/SARS Screening station
• No rapid diagnostic test
• Using epidemiologic links

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SARS Ethical FrameworkKey Values

• Individual liberty
• Protection of the public
• Proportionality
• Reciprocity
• Transparency
• Privacy
• Protection from undue stigmatization
• Duty to provide care
• Equity
• Solidarity

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Lawrence Mass 1918
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Why does health care lag behind other sectors in
HS

• False perception that the industry is
  self-regulated (JCAHO)
• Health care traditionally seen as clean
  industry, a place of health
• Focus on curative rather than preventive care
• Primarily a female workforce
• A low unionization rate
  (Lipscomb
  Borwegen, 2000)

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HCW vulnerability

• Socialized to believe that care giving requires
  self sacrifice, even of their own health
• Some hazards considered part of the job
• HCWs become patients (often uninsured) in the
  course of caring for others
• Issues of race, class, gender

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Economic Costs of Staff Injuries/Illnesses

• Medical care and follow-up
• Worker disability
• Staff replacement
• Loss of experienced workers
• Cost of importing workers to replace injured US
  workers
• Reduced productivity
• Poor patient outcomes

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Classic Public Health Interventions

• Handwashing
• Vaccination
• Isolating infected patients

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Health and Safety Programs A Framework for
Prevention

• Management commitment and employee involvement
• Worksite analysis
• Hazard control
• Training
• Evaluation

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H S Program Elements

• All necessary, none sufficient
• Critical for any and all hazards
• Success dependent on genuine team work
• Cant be successful without management commitment
  
• Direct care and support staff expertise are
  essential

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Hazard Control Hierarchy of Controls

• Substitution with a less hazardous chemical or
  device such as antimicrobials that dont cause
  asthma
• Engineering Controls - modify or control the
  hazard at the source, such as ventilation hoods?
• Administrative Controls reduce the amount of
  exposure to hazard via policies and procedures
• Personal Protective Equipment - gloves,
  respirators, protective clothing

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Estimated reduction in adverse outcomes with
improved staffing
Buerhaus, P.I. et al Strengthening Hospital
Nursing. Health Affairs 21(5), 2002
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How do high workload lead to poor patient
outcomes?

• Impaired nurse-physician (and other HCW)
  collaboration,
• Poor nurse-patient communication,
• HCW fatigue, lack of concentration
• HCW burnout, depression, reduced empathy
• Job dissatisfaction
• HCW injury and illness
• HCW disability and/or job change
• Carayon Gurses (2005)

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What do we know about staffing and HCW injuries?

• MNA study found a 9 decrease in RNs was
  associated with a 65 increase in
  injuries/illnesses (Shogren, 1996)
• High workloads associated with 50-200 increase
  in needlestick injuries/near misses, (Clark,
  2002)
• Adverse work schedule and health care system
  changes associated with neck, shoulder, back MSD
  (Lipscomb, 2004).

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Extreme work schedules, injuries and patient care
(JAMA, Sept. 06)

• 84 of interns worked gt than ACGME limits 67
  worked gt 30 consecutive hrs.
• Odds of exposure to sharps or contaminated body
  fluids increase 61 when interns worked gt 20
  consecutive hrs. compared with interns working lt
  12 hrs.
• 24 hrs of continuous wakefulness causes
  impairment of cognitive performance comparable to
  that induced by a blood alcohol concentration of
  100 mg/dl (legal intoxication in most states).

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Blood borne Pathogen Risks

• 2-40 risk of developing Hepatitis B
• 3-10 risk of developing Hepatitis C
• 560-1,120/year
• 85 become chronic carriers
• 0.3 risk of transmission of HIV
• gt1000 workers will contract Hepatitis B,
  Hepatitis C, or HIV/year

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What do we know?

• 300,000 needlesticks continue to occur/year.
• Needlesticks and BB infections are extremely
  costly.
• Safety syringe have reduced incidence (gt 50) but
  much room for improvement.
• Enforcement of Safe Needlestick Act is limited.

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OSHA BBP Standard (1991)

• Require universal precautions
• Required Hep B immunization
• Cases went from 17,000 (1983) to 400/yr
• Engineering controls (safe needles) were to be
  used where available
• Dentists claimed (in the docket) if they were
  forced to where gloves, patients would not see
  them.

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Safe Needle Act of 2000

• Unanimous bipartisan support
• Clarifies the need for employers to use safe
  needles
• Requires front line worker participation in
  product selection committees
• Requires employers to maintain a log of injuries
  from contaminated sharps.

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Airborne Infections

• TB, SARS, influenza
• Seasonal flu - lt40 immunization among HCW
• Pandemic flu preparedness
• Aerosol vs droplet transmission
• Respiratory protection
• Type, fit testing, stockpiles

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What do we know?

• Short staffing leads to sick staff.
• Sick staff lead to sicker patients.
• Current levels of staff immunization inadequate.
• Current levels of available respiratory
  protection (N95s) inadequate for pandemic flu.

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History of Regulations to Prevent HCW Exposure to
Airborne Hazards

• Respiratory Protection Standard (1971, 1998)
• Proposed TB rule (1997) withdrawn (2003)
• Continuation of the Wicker Amendment
  (appropriations rider)
• CA is enforcing the annual fit testing
  requirement.

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Conclusions

• The risks to nurses are historically and
  currently substantial
• Early research is not always accurate
• Educate other RNs and HCWs
• Argue, lobby, insist upon N95 PPE and general
  preparedness of your facility
• Join or get on the agenda of H and S Committee

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Questions and future contact

• mcphaul_at_son.umaryland.edu