OCCUPATIONAL HEALTH UPDATE, 2014 - PowerPoint PPT Presentation


Title: OCCUPATIONAL HEALTH UPDATE, 2014


1
OCCUPATIONAL HEALTH UPDATE, 2014
  • David Jay Weber, M.D., M.P.H.
  • Professor of Medicine, Pediatrics Epidemiology
  • Medical Director, Occupational Health Hospital
    Epidemiology
  • University of North Carolina at Chapel Hill

2
GOALS OF CURRENT LECTURE
  • Understand activities of an occupational health
    service (OHS) in a healthcare facility
  • Be able to list vaccines recommended for
    healthcare perconnel (HCP)
  • Be able to list infectious diseases relevant to
    HCP for which post-exposure prophylaxis is
    available
  • Understand selected OHSA/CDC guidelines
  • Bloodborne pathogens
  • Tuberculosis

3
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.

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PREVENTING HCP INFECTIONS INJURIES
  • A casual attitude towards personnel health
    entails a high cost
  • Increased patient morbidity
  • Increased staff morbidity
  • Significant financial cost and legal risk
  • Prevention is superior to treatment
  • The tools used to reduce the risk of acquiring
    infection can be used to reduce the risk of
    injuries

5
OSHA
NIOSH CDC
FDA Health
Department
External Stakeholders
---------------------------- Occupational Health
Service ------------------------------
Internal Stakeholders
Legal/Administration Safety
Medical Staff Workers compensation
Infection Control
6
OCCUPATIONAL HEALTH ACTIVITIES
  • Pre-employment screening
  • Immunization review
  • Employment physical (selected DOT, FAA, police)
  • Drug/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 IGRA blood test)
  • Fit test clearance (questionnaire, medical
    exam?) fit testing
  • Hearing evaluation/audiogram (if indicated by
    noise exposure)
  • Counseling pregnant women, immunocompromised

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OCCUPATIONAL HEALTH ACTIVITIES
  • Annual 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 Workers Compensation
  • Return to work evaluation (non-occupational
    diseases and/or injuries)

8
OCCUPATIONAL HEALTH ACTIVITIES
  • Evaluation of personnel 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

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OCCUPATIONAL HEALTH ACTIVITIES
  • Work site evaluation
  • For cause drug/alcohol testing
  • Education
  • Fire, chemical, radiation safety
  • Infection control (communicable diseases, TB,
    bloodborne pathogens)
  • Ergonomics
  • Smoking cessation

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OSHABLOODBORNE 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, 1991566400364182
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OSHATUBERCULOUS RULE
  • Requires a Tuberculosis Control Plan (reviewed
    yearly)
  • Airborne isolation for patients with known or
    suspected disease
  • Private room, gt12 air exchanges per hour, direct
    out exhausted air
  • Personal protective equipment
  • Medical evaluation prior to fit testing
  • N95 respirator (or PAPR)
  • Yearly fit testing
  • Risk assessment of facility required
  • Testing for tuberculosis required to be offered
    (initially, annually)
  • Yearly training required

http//www.osha.gov/pls/oshaweb/owadisp.show_docum
ent?p_tableFEDERAL_REGISTERp_id13717
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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 lt6 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 persons 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
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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
  • Employees medical provider must provide a
    certification form

http//www.dol.gov/whd/fmla/index.htm
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COMMON OCCUPATIONAL HAZARDS
  • Infections
  • Viral respiratory diseases
  • Influenza, RSV
  • Bacterial respiratory diseases
  • Tuberculosis, pertussis
  • Bloodborne pathogens (Percutaneous, mucus
    membrane)
  • HIV, HBV, HCV
  • Contact transmitted diseases
  • Direct contact Syphilis, MRSA
  • Fecal-oral Norovirus, rotavirus

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OCCUPATIONAL ACQUIRED VIRAL INFECTIONS FOLLOWING
BBF EXPOSURE
  • Argentinian VHF
  • Bolivian VHF
  • Brazilian VHF
  • Crimean Congo VHF
  • Dengue
  • Ebola VHF
  • Hendra virus
  • Hepatitis B
  • Hepatitis C
  • Hepatitis D
  • Hepatitis G
  • Herpex simplex 1
  • HIV 1
  • Kyasanus virus
  • Lassa VHF
  • Marburg VHF
  • Rift Valley fever virus
  • SIV
  • Varicella zoster virus
  • Venezuelan VHF
  • Virus B (Herpes I)
  • West Nile Virus
  • Yellow Fever virus

Needlestick, health care nonintact skin,
health care Tarantola A, AJIC 200634367
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OCCUPATIONAL ACQUIRED BACTERIAL PARASITIC
INFECTIONS FOLLOWING BBF EXPOSURE
  • Brucella abortus
  • Burkholderia mallei
  • Corynebacterium diphtherie
  • C. striatum
  • Leptospira icterohaemarragiae
  • Mycobacterium leprae
  • M. marinum
  • M. tuberculosis
  • M. caviae
  • Neisseria gonorrhoeae
  • Richettsia tsutsuguchi
  • Pasteurella multocida
  • RMSF
  • Richettsia typhi
  • Staphylococcus aureus
  • S. pyogenes
  • Treponema pallidum
  • Leishmania sp.
  • Plasmodium faliciparum
  • Plasmodium malariae
  • Plasmodium vivax
  • Trypanosoma brucei

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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

21
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)

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COMMUNICABLE DISEASE EXPOSURES, UNC HEALTH CARE,
2009-213
2009 FTE Rate 2010 FTE Rate 2011 FTE Rate 2012 FTE Rate 2013 FTE Rate Total Mean Median

Pertussis 40 6897 5.80 11 7305 1.51 13 7862 1.65 134 8102 16.54 10 8705 1.15 208 5.33 1.65

Mening 9 6897 1.30 7 7305 0.96 10 7862 1.27 0 8102 0.00 53 8705 6.09 79 1.92 1.3

Syphils 2 6897 0.29 0 7305 0.00 0 7862 0.00 2 8102 0.25 26 8705 2.99 30 0.70 0.25

Parvo 5 6897 0.72 0 7305 0.00 6 7862 0.76 19 8102 2.35 10 8705 1.15 40 1.00 0.76

TB 72 6897 10.44 17 7305 2.33 62 7862 7.89 17 8102 2.10 15 8705 1.72 183 4.89 1.72

HIV 15 6897 2.17 15 7305 2.05 15 7862 1.91 17 8102 2.10 15 8705 1.72 77 1.99 2.05

HBV 1 6897 0.14 2 7305 0.27 3 7862 0.38 1 8102 0.12 1 8705 0.11 208 0.21 0.14

HCV 18 6897 2.61 15 7305 2.05 25 7862 3.18 30 8102 3.70 31 8705 3.56 119 3.02 3.18

BBF 292 6897 42.34 317 7305 43.39 348 7862 44.26 345 8102 42.58 353 8705 40.55 1655 42.63 42.58
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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
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ADULT IMMUNIZATION SCHEDULE, US, 2014
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ADULT IMMUNIZATION SCHEDULE, US, 2014
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KEY REFERENCES
27
SUMMARY OF CURRENT FDA APPROVED INFLUENZA VACCINES
  • Influenza
  • Older vaccines
  • Standard IM inactivate influenza vaccine (TIV)
    gt6 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 efficacy not yet studied) gt65
    years
  • Licensure of intradermal influenza vaccine 18-64
    years
  • Licensure of cell culture-based influenza
    vaccine gt18 years
  • Licensure of 2 quadrivalent influenza (2 A, 2 B
    strains) vaccines gt3
  • Licensure of recombinant influenza (HA only)
    vaccine 18-49

No ACIP statement available, not produced in
eggs, inactivated vaccine
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SUMMARY OF CURRENTACIP RECOMMENDATIONS
  • Influenza
  • 1 annual dose for all persons gt6 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

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SUMMARY OF CURRENT FDA APPROVED PNEUMOCOCCAL
VACCINES
  • Polysaccharide vaccine (PPSV23)
  • Contains 23 different pneumococcal strains
  • FDA approved for all person gt50 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 gt50 years of age

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SUMMARY OF CURRENTACIP RECOMMENDATIONS
  • Pneumococcal (polysaccharide, PPSV23)
  • Age gt65 All persons
  • Age gt19 Medical or other risk indications
  • Required to be offered to residents in ECFs in NC
  • Revaccination may be recommended (first dose lt65
    years AND now gt65 years AND gt5 years have passed)
  • Pneumococcal (conjugate, PCV13)
  • Age gt19 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 gt1year after
    last PPSV23

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CDC. MMWR 201261816
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SUMMARY OF CURRENTACIP RECOMMENDATIONS
  • Zoster
  • One dose for persons gt60 years of age regardless
    of whether they had a prior episode of zoster
  • FDA approved for persons gt50 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 lt55 years MPSV4 persons gt56 years

33
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 at each pregnancy
    (preferably during 27 to 36 weeks gestation)
    regardless of interval since last Td or Tdap
    immunization

34
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 gt6 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
    gt60 years (B, 2)

35
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 immunization(s) 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

36
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 lt26 years of age (only
    quadrivalent vaccine from Merck approved for men)

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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
38
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

39
PROVIDING VACCINES
  • Patient name and identification number
  • Vaccine
  • Dose, Site, Route of Administration
  • Date given
  • Manufacturer
  • Lot number
  • Name, title address of person providing vaccine
  • Date next dose due
  • Informed consent

40
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
  • Written documentation required

41
IMMUNIZATIONS FOR HCP
  • Measles (provide as MMR)
  • 2 doses in susceptible persons (1 month apart)
  • Demonstration of immunity Appropriate
    immunizations, positive serology, MD diagnosed
    disease with lab confirmation
  • Birth before 1957 Consider immune (except during
    an outbreak)
  • Rubella (provide as MMR)
  • 1 dose in susceptible persons
  • Demonstration of immunity Immunization, positive
    serology
  • Birth before 1957 Consider immune (except during
    an outbreak or woman of childbearing potential)

42
IMMUNIZATIONS FOR HCP
  • Mumps (provide as MMR)
  • 2 doses
  • Demonstration of immunity Appropriate
    immunizations, positive serology, MD diagnosed
    disease with lab confirmation
  • Birth before 1957 Consider immune (except during
    an outbreak)
  • Varicella
  • 2 doses
  • Demonstration of immunity MD diagnosed disease,
    immunization, positive serology

43
MUMPS, MEASLES, RUBELLAISSUES FOR HEALTHCARE
FACILITIES
  • Mumps
  • Droplet transmission
  • No post-exposure prophylaxis
  • Recent outbreaks in US
  • Measles
  • Airborne transmission
  • Post-exposure prophylaxis Ig
  • Most cases imported (most commonly from Europe)
  • Rubella
  • Droplet transmission
  • No post-exposure prophylaxis
  • Concern about congenital infection

44
Vaccine licensed, 1967. MMWR 201360(53)
45
MUMPS OUTBREAK, IOWA, 2006
Loreen Herwaldt, personal communication
46
Vaccine licensed, 1963. MMWR 201356(53)
47
MEASLES OUTBREAKS
  • More than 30 reports in the literature of
    outbreaks in healthcare facilities
  • Between 1985 and 1989, 3.5 of all case acquired
    in a medical facility (Atkinson Wl, et al. Am J
    Med 199191(S 3B)320-24S
  • Investigation of individual outbreaks has
    revealed that 17 to 53 were acquired in a
    medical facility
  • Nosocomial outbreaks have led to hospitalization
    of medical staff and severe complications in
    infected patients including death
  • Cost of outbreaks has ranged from 28,000 to more
    than 100,000

48
SEROLOGIC TESTS OF NEW HIRES BORN BEFORE 1957,
UNC, 2006-2008
  • Non-immune by serology
  • Measles 1.3 (6/469)
  • Mumps 3.7 (14/381)
  • Rubella 2.9 (14/477)
  • Costs of testing
  • Number of new employees 6,597
  • Number of persons tested 488
  • Number of tests 1,327
  • Total cost of serologic tests 78,768
  • Cost per non-immune person detected 2,317

Weber DJ, et al. ICHE 201031655-657
49
VZVISSUES FOR HEALTHCARE FACILITIES
  • Communicable (1-2 days) before rash appears
  • Multiple outbreaks reported in hospitals
  • Airborne transmission
  • Highly communicable
  • Life threatening disease in immunocompromised
    persons and neonates
  • Infection in pregnant woman may lead to
    congenital malformations
  • Seropositivity lower in persons born in tropical
    countries
  • For near future, how to manage HCP with remote
    immunization

50
Vaccine licensed 1996
MMWR
201259(53)
51
Vaccine licensed 1996
MMWR
201360(53)
52
CHICKENPOX FROM AN IMMUNO-SUPPRESSED INDEX CASE
WITH ZOSTER
Faizallah R, et al. BMJ 19822851022-1023
53
Gustafson TL, et al. Pediatr 198270550-6
54
VARICELLAIMMUNIZATION IN HCP
  • To prevent disease and nosocomial spread of VZV,
    healthcare institutions should ensure that all
    HCP have evidence of immunity to varicella
  • Birth before 1980 is NOT considered evidence of
    immunity
  • Serologic screening before vaccination of
    personnel who have a negative or uncertain
    history of varicella and are unvaccinated is
    likely to be cost effective
  • Institutions may elect to test all HCP regardless
    of disease history because a small proportion of
    persons with a positive history might be
    susceptible
  • Institutions should consider precautions for
    personnel in whom rash occurs after vaccination.
    HCP in who a vaccine related rash occurs should
    avoid contact with persons without evidence of
    immunity who are at risk for severe disease

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VIRAL HEPATITIS,INCIDENCE,BY YEAR, US, 1981-2011
56
IMMUNIZATIONS FOR HCP
  • Hepatitis B
  • 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 (gt10
    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

57
Estimated Incidence of HBV infections among HCP
and General Population, United States, 1985-1999
Healthcare Personnel
General U.S. Population
58
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

59
NEW ACIP GUIDELINES FOR HBV VACCINE USE IN HCP
  • HCP and trainees at high risk for chronic
    hepatitis B (e.g., born in high endemicity
    countries) should be tested for HBsAg and
    anti-HBc/anti-HBs
  • New algorithm for evaluation of HCP who have
    remote history of HBV vaccine and who have not
    had an ant-HBsAg titer
  • HBV PEP recommendations essentially unchanged

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CDC MMWR 201362 (RR-10)
61
IMMUNIZATIONS FOR HCP
  • Pertussis
  • Provide at Tdap
  • 1 dose for all HCP (unless contra-indicated)
  • Revised recommendations
  • No upper age limit
  • May provide regarding of time of last Td
  • Other comments
  • May be used to provide tetanus immunity
  • Provide antibiotic PEP regarding of Tdap receipt
  • No current recommendation for revaccination

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PERTUSSIS EPIDEMIOLOGY
  • Worldwide distribution
  • Humans sole reservoir
  • Droplet transmission
  • Incubation period 7-10 days (range, 4-21 days)
  • Communicable period
  • High (1st two weeks)
  • Low (weeks 2-3)
  • Very low (gt3 weeks)
  • Huovila, 1982 48 culture after 3 weeks, 23
    after 4 weeks

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MMWR 201360 (No. 53)
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Pertussis Complications by Age
Percent
Supplementary Pertussis Surveillance System data,
1992-1994 (N13,615)
CDC. Atkinson W, et al. Chapter 4 Pertussis. In
Epidemiology Prevention of Vaccine-Preventable
Diseases, 4th ed. Department of Health and Human
Services, Public Health Service, 1998, 67
15
66
Pertussis Stages, Symptoms, Communicability
period of communicability
Catarrhal runny nose, sneezing, low-grade
fever, mild cough Paroxysmal cough (97),
severe spasms of cough (73) , thick mucus,
whoops (69), vomiting 65), exhaustion Convales
cent gradual recovery with less frequent and
less severe cough
paroxysmal cough onset
exposure
2
4
-1
1
3
5
6
8
9
10
11
12
-2
0
7
weeks of cough
catarrhal stage
paroxysmal stage
convalescent stage
CDC. Epidemiology and Prevention of
Vaccine-Preventable Diseases. PHF 2004 Adults
Symptoms gt3 weeks
67
CAVEATS IN TREATMENT
  • All patients with pertussis should be treated to
    hasten clearance of the organism and limit
    transmission to susceptible contacts
  • Treatment within first week reduces severity
    and/or duration of symptoms
  • Treatment renders the patient noninfectious
    within 5 days (treatment recommended even 6-8
    weeks after onset of illness)
  • Treatment
  • Azithromycin x 5 days (treatment of choice)
  • Trimethoprim-sulfamethoxazole x 14 days
    (alternative)

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OUTBREAK MAYO CLINIC, ROCHESTER
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IMMUNIZATIONS FOR HCP
  • Influenza
  • 1 dose annually (inactivated, live-attenuated/nasa
    l, ID, etc.)
  • Attenuated influenza vaccine (FluMist)
    contra-indicated only in HCP working with highly
    immunocompromised patients housed in a protected
    environment
  • Meningococcal
  • Recommended for lab workers who spin CSF
  • Pneumococcal (polysaccharide)
  • 1 dose (booster may be indicated)
  • No specific indication for HCP

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INFLUENZA EPIDEMIOLOGY
  • Pathogen Single-stranded, enveloped RNA virus
  • Geographic distribution Global
  • Reservoir Humans, swine, birds
  • Incubation period 1-5 days (average, 2 days)
  • Transmission
  • Droplet (lt6 feet)
  • Contact Direct and indirect
  • Communicability
  • 1-2 days before onset of symptoms to 7 days
    post-onset (adults) or 10 days (children) no
    carrier state but inapparent illness may occur
  • Attack rate Up to 60

71
Influenza Disease Burden to U.S. Societyin an
Average Year
Deaths 25,000 - 72,000
Hospitalizations 114,000 - 257,500
Physician visits 25 million
Infections and illnesses 50 - 60 million
Thompson WW et al. JAMA. 2003289179-86. Couch
RB. Ann Intern Med. 2000133992-8. Patriarca PA.
JAMA. 199928275-7. ACIP. MMWR.
200453(RR06)1-40.
72
CDC. MMWR 200857(RR-18)1-59
73
Viral Nomenclature
Type of Nuclear Material
Hemagglutinin
Neuraminidase
A / Sydney / 184 / 93 (H3N2)
Virus subtype
Virus type
Geographic origin
Year of isolation
Strain number
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
74
Pandemic influenza
1977 H1N1 Russian
1918 H1N1 Spanish

2009 H1N1 pdm09
1947 H1N1
1957 H2N2 Asian flu
1968 H3N2 Hong Kong flu
1940 Influenza B
75
SUMMARY OF CLUSTER RCTs ASSESSING THE IMPACE OF
HCP IMMUNIZATION
Study Coverage Control Coverage Intervention Mortality Control Mortality Intervention 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 (p0.008)
76
REDUCTION IN OUTCOMES IN HCP RECEIVING INFLUENZA
VACCINE
Influenza infection
Sick days due to respiratory illness
Days lost from work
Patient mortality
Patient mortality
28
41
41
39
88
Saxen 1999
Carmen 2000
Potter 1997
Wilde 1999
Wilde 1999
Talbot TT, Weber DJ, et al. ICHE 200526882-890
Attack rate unvaccinated 13.4
77
INFLUENZA VACCINE COVERAGE, HCP, 2010-11,
2011-12, AND 2012-13
MMWR 201362781-786
78
ARGUMENTS IN FAVOR AND AGAINST CONDITIONAL
(MANDATORY) USE OF INFLUENZA VACCINE IN HCP
  • In favor of conditional vaccine use
  • Key principle First do no harm (nosocomial
    transmission linked to infected staff)
  • Protects the staff and their families
  • Institutional benefit Decreased absenteeism,
    cost effective
  • Against conditional vaccine use
  • Feasibility Difficult to capture all employees
    each year
  • May result in staff dissatisfaction
  • Union concerns

79
IMPACT OF MANDATORYINFLUENZA REQUIREMENTS
Miller BL, et al. Vaccine 2011299398-9403
80
INFLUENZA PROPHYLAXIS AND THERAPIES
  • Oseltamivir (Tamiflu) Influenza A B
  • Treatment 75 mg PO 2x/day x 5d
  • Post-exposure prophylaxis 75 mg PO 1x/day x 10
    days
  • Seasonal prophylaxis 75 mg PO 1x/day x 4-8 weeks
  • Zanamivir (Relenza) Influenza A B
  • Treatment 10 mg (2 nasal inhalations 2x/d x 5d)
  • Post-exposure prophylaxis 10 mg (2 nasal
    inhalations 1x/d x 10d)
  • Seasonal prophylaxis 10 gm (2 nasal inhalations
    1x/day x 4-8 weeks)

Must begin therapy within 2 days of onset of
illness Reduce dose if creatinine clearance
lt30mL/min, or lt10mL/min
81
INFLUENZA - ANTIVIRAL THERAPIESTOXICITIES
  • Zanamivir
  • Brochospasm (avoid in asthmatics)
  • Headache (prophylaxis 13-24, treatment 2)
  • Throat/tonsil discomfort/pain (prophylaxis 8 to
    19)
  •  Cough (prophylaxis 7 to 17)
  • Oseltamivir
  • GI nausea (3-10), vomiting (2-5)
  • Pregnancy class C
  • Use with caution in patients with cardiac, liver,
    or renal dysfunction
  • FDA alert Reports of self-injury (with
    fatalities), confusion, and delirium (primarily
    in pediatric patients from Japan)

82
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 ? No ?
Hepatitis B No gt10 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 201132912-4
83
POST-EXPOSURE PROPHYLAXIS
84
DATA RECORDED ON EXPOSURES
  • Employee 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

85
EXPOSURE EVALUATION
  • Determine if source case has infection and is
    infectious
  • Determine transmission possible (i.e.,
    appropriate exposure without protection)
  • Determine if employee is susceptible (may require
    labs)
  • Determine if prophylaxis available indicated
  • Consider alternative prophylaxis (if available)
    if employee has contraindications to prophylaxis
    of first choice
  • Arrange follow-up

86
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
  • 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

87
POST-EXPOSURE PROPHYLAXIS
  • Anthrax
  • Diphtheria
  • Hepatitis A
  • Hepatitis B
  • HIV
  • Human bite wound
  • Influenza A (novel, H5N1)
  • Influenza B
  • Measles
  • Meningococcal infection
  • Monkey bite
  • Monkeypox
  • Pertussis (whooping cough)
  • Plague
  • Rabies
  • Rat bite (rodent bite)
  • Smallpox
  • Syphilis
  • Tuberculosis (TB)
  • Tularemia
  • Varicella (chickenpox)
  • Zoster (shingles)

88
NO POST-EXPOSURE PROPHYLAXIS
  • Arboviruses (encephalitis)
  • Hepatitis C
  • Mumps
  • Parvovirus B19
  • Rubella
  • Severe acute respiratory distress syndrome (SARS)

89
VACCINES INDICATED FORPOST-EXPOSURE PROPHYLAXIS
  • Mumps No post-exposure prophylaxis available
  • Measles lt3 days post-exposure (alternative Ig)
  • Rubella No post-exposure prophylaxis available
  • Varicella lt4 days post-exposure (alternative
    VZIG or acyclovir)
  • Hepatitis B lt7 days post-exposure /- HBIG
    (alternative HBIG)
  • Influenza Vaccine not indicated may use
    oseltamivir or zanamivir x 5 days
  • Pertussis Vaccine not indicated (use
    antibiotics azithromycin, TMP-SMX)
  • Tetanus Post-wound /- TIG (no time limit
    Tdap preferred)
  • Rabies Prior to symptoms plus RIG (avoid RIG
    if previously vaccinated)
  • Vaccinia lt4 days post-exposure (may also be
    indicated for monkey pox)
  • Outbreak control Hepatitis A, pertussis,
    meningococcal

May need to be provided with an immunoglobulin
preparation
90
Risk of Bloodborne Virus Transmission after
Occupational Percutaneous Exposure
  • Source
  • HBV
  • HBeAg
  • HBeAg -
  • HCV
  • HIV
  • Risk
  • 22.0-30.0
  • 1.0-6.0
  • 1.8
  • 0.3

91
DEFINITION OF EXPOSURE
  • Percutaneous exposure to contaminated body fluid
  • Mucous membrane exposure to contaminated body
    fluid
  • Non-intact skin expose to contaminated body fluid
  • Contaminated fluids blood, CSF, vaginal
    secretions, semen, synovial, pleural, peritoneal,
    pericardial, amniotic

92
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 protocol
  • Maintain confidentiality Separate records, labs
    pharmacy requisitions sent with code number

93
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 postexposure prophylaxis, as medically
    indicated, per CDC recommendations offer
    counseling
  • Provide employee with results of evaluation with
    15 days

94
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

95
PEP FOR HBV EXPOSURES
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98
HIV INFECTION AS A RESULT OF OCCUPATIONAL
EXPOSURE IN HCP
  • HIV infections in HCP as a result of exposures
    (12/2004)
  • Documented conversions 57
  • 26 have developed AIDS
  • Types 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

99
Risk Factors for HIV Transmission After
Percutaneous Exposure to HIV-Infected Blood CDC
Case-Control Study
  • Risk Factor Adjusted OR ratio (95 CI)
  • Deep injury 15 (6.0-41)
  • Visible blood on device 6.2 (2.2-21)
  • Procedure involving needle 4.3 (1.7-12)
  • placed in artery or vein
  • Terminal illness in source patient 5.6 (2.0-16)
  • Postexposure use of zidovudine 0.19 (0.06-0.52)
  • Cardo et al., New Engl J Med
    19973371485-90.

100
US PHS HIV POSTEXPOSURE GUIDELINESNEW
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 201334875-892
101
US PHS HIV POSTEXPOSURE GUIDELINESGUIDELINE
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

102
US PHS HIV POSTEXPOSURE GUIDELINESDEFINITIONS
  • 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

103
US PHS HIV POSTEXPOSURE GUIDELINESRISK 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 patients
    blood
  • A procedure that involved a needle 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

104
US PHS HIV POSTEXPOSURE GUIDELINESPEP 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

105
US PHS HIV POSTEXPOSURE GUIDELINESPEP 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)

106
US PHS HIV POSTEXPOSURE GUIDELINESPEP 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)

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US PHS HIV POSTEXPOSURE GUIDELINESPEP 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)

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US PHS HIV POSTEXPOSURE GUIDELINESPEP V
  • Toxicity monitoring
  • Symptoms, focused physical exam
  • CBC with differential, ALT, AST, Amylase, BUN,
    Creat, glucose (if on PI)
  • Monitor at baseline and 2 weeks (and if any acute
    symptoms develop)
  • Follow-up HIV testing
  • At 6 weeks and 4 months (if using 4th generation
    HIV test)
  • At 6 weeks, 12 weeks, 6 months (if using 3rd
    generation HIV test)
  • If HCP exposed to source with HIV and HCV, follow
    for 1 year

113
SUMMARY PEP PROGRAM
  • Establish bloodborne pathogen policy
  • Implement management policies
  • Establish laboratory capacity for bloodborne
    pathogen testing
  • Provide access to counseling
  • Monitor adverse reactions
  • Monitor exposure management program (e.g.,
    evaluate time between exposures and evaluation,
    monitor completion of follow-up)

114
THANK YOU!!
Edward Jenner, 1749-1823
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Title: OCCUPATIONAL HEALTH UPDATE, 2014


1
OCCUPATIONAL HEALTH UPDATE, 2014
  • David Jay Weber, M.D., M.P.H.
  • Professor of Medicine, Pediatrics Epidemiology
  • Medical Director, Occupational Health Hospital
    Epidemiology
  • University of North Carolina at Chapel Hill

2
GOALS OF CURRENT LECTURE
  • Understand activities of an occupational health
    service (OHS) in a healthcare facility
  • Be able to list vaccines recommended for
    healthcare perconnel (HCP)
  • Be able to list infectious diseases relevant to
    HCP for which post-exposure prophylaxis is
    available
  • Understand selected OHSA/CDC guidelines
  • Bloodborne pathogens
  • Tuberculosis

3
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.

4
PREVENTING HCP INFECTIONS INJURIES
  • A casual attitude towards personnel health
    entails a high cost
  • Increased patient morbidity
  • Increased staff morbidity
  • Significant financial cost and legal risk
  • Prevention is superior to treatment
  • The tools used to reduce the risk of acquiring
    infection can be used to reduce the risk of
    injuries

5
OSHA
NIOSH CDC
FDA Health
Department
External Stakeholders
---------------------------- Occupational Health
Service ------------------------------
Internal Stakeholders
Legal/Administration Safety
Medical Staff Workers compensation
Infection Control
6
OCCUPATIONAL HEALTH ACTIVITIES
  • Pre-employment screening
  • Immunization review
  • Employment physical (selected DOT, FAA, police)
  • Drug/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 IGRA blood test)
  • Fit test clearance (questionnaire, medical
    exam?) fit testing
  • Hearing evaluation/audiogram (if indicated by
    noise exposure)
  • Counseling pregnant women, immunocompromised

7
OCCUPATIONAL HEALTH ACTIVITIES
  • Annual 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 Workers Compensation
  • Return to work evaluation (non-occupational
    diseases and/or injuries)

8
OCCUPATIONAL HEALTH ACTIVITIES
  • Evaluation of personnel 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

9
OCCUPATIONAL HEALTH ACTIVITIES
  • Work site evaluation
  • For cause drug/alcohol testing
  • Education
  • Fire, chemical, radiation safety
  • Infection control (communicable diseases, TB,
    bloodborne pathogens)
  • Ergonomics
  • Smoking cessation

10
OSHABLOODBORNE 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, 1991566400364182
11
OSHATUBERCULOUS RULE
  • Requires a Tuberculosis Control Plan (reviewed
    yearly)
  • Airborne isolation for patients with known or
    suspected disease
  • Private room, gt12 air exchanges per hour, direct
    out exhausted air
  • Personal protective equipment
  • Medical evaluation prior to fit testing
  • N95 respirator (or PAPR)
  • Yearly fit testing
  • Risk assessment of facility required
  • Testing for tuberculosis required to be offered
    (initially, annually)
  • Yearly training required

http//www.osha.gov/pls/oshaweb/owadisp.show_docum
ent?p_tableFEDERAL_REGISTERp_id13717
12
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 lt6 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 persons 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
13
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
  • Employees medical provider must provide a
    certification form

http//www.dol.gov/whd/fmla/index.htm
14
COMMON OCCUPATIONAL HAZARDS
  • Infections
  • Viral respiratory diseases
  • Influenza, RSV
  • Bacterial respiratory diseases
  • Tuberculosis, pertussis
  • Bloodborne pathogens (Percutaneous, mucus
    membrane)
  • HIV, HBV, HCV
  • Contact transmitted diseases
  • Direct contact Syphilis, MRSA
  • Fecal-oral Norovirus, rotavirus

15
OCCUPATIONAL ACQUIRED VIRAL INFECTIONS FOLLOWING
BBF EXPOSURE
  • Argentinian VHF
  • Bolivian VHF
  • Brazilian VHF
  • Crimean Congo VHF
  • Dengue
  • Ebola VHF
  • Hendra virus
  • Hepatitis B
  • Hepatitis C
  • Hepatitis D
  • Hepatitis G
  • Herpex simplex 1
  • HIV 1
  • Kyasanus virus
  • Lassa VHF
  • Marburg VHF
  • Rift Valley fever virus
  • SIV
  • Varicella zoster virus
  • Venezuelan VHF
  • Virus B (Herpes I)
  • West Nile Virus
  • Yellow Fever virus

Needlestick, health care nonintact skin,
health care Tarantola A, AJIC 200634367
16
OCCUPATIONAL ACQUIRED BACTERIAL PARASITIC
INFECTIONS FOLLOWING BBF EXPOSURE
  • Brucella abortus
  • Burkholderia mallei
  • Corynebacterium diphtherie
  • C. striatum
  • Leptospira icterohaemarragiae
  • Mycobacterium leprae
  • M. marinum
  • M. tuberculosis
  • M. caviae
  • Neisseria gonorrhoeae
  • Richettsia tsutsuguchi
  • Pasteurella multocida
  • RMSF
  • Richettsia typhi
  • Staphylococcus aureus
  • S. pyogenes
  • Treponema pallidum
  • Leishmania sp.
  • Plasmodium faliciparum
  • Plasmodium malariae
  • Plasmodium vivax
  • Trypanosoma brucei

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20
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

21
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)

22
COMMUNICABLE DISEASE EXPOSURES, UNC HEALTH CARE,
2009-213
2009 FTE Rate 2010 FTE Rate 2011 FTE Rate 2012 FTE Rate 2013 FTE Rate Total Mean Median

Pertussis 40 6897 5.80 11 7305 1.51 13 7862 1.65 134 8102 16.54 10 8705 1.15 208 5.33 1.65

Mening 9 6897 1.30 7 7305 0.96 10 7862 1.27 0 8102 0.00 53 8705 6.09 79 1.92 1.3

Syphils 2 6897 0.29 0 7305 0.00 0 7862 0.00 2 8102 0.25 26 8705 2.99 30 0.70 0.25

Parvo 5 6897 0.72 0 7305 0.00 6 7862 0.76 19 8102 2.35 10 8705 1.15 40 1.00 0.76

TB 72 6897 10.44 17 7305 2.33 62 7862 7.89 17 8102 2.10 15 8705 1.72 183 4.89 1.72

HIV 15 6897 2.17 15 7305 2.05 15 7862 1.91 17 8102 2.10 15 8705 1.72 77 1.99 2.05

HBV 1 6897 0.14 2 7305 0.27 3 7862 0.38 1 8102 0.12 1 8705 0.11 208 0.21 0.14

HCV 18 6897 2.61 15 7305 2.05 25 7862 3.18 30 8102 3.70 31 8705 3.56 119 3.02 3.18

BBF 292 6897 42.34 317 7305 43.39 348 7862 44.26 345 8102 42.58 353 8705 40.55 1655 42.63 42.58
23
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
24
ADULT IMMUNIZATION SCHEDULE, US, 2014
25
ADULT IMMUNIZATION SCHEDULE, US, 2014
26
KEY REFERENCES
27
SUMMARY OF CURRENT FDA APPROVED INFLUENZA VACCINES
  • Influenza
  • Older vaccines
  • Standard IM inactivate influenza vaccine (TIV)
    gt6 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 efficacy not yet studied) gt65
    years
  • Licensure of intradermal influenza vaccine 18-64
    years
  • Licensure of cell culture-based influenza
    vaccine gt18 years
  • Licensure of 2 quadrivalent influenza (2 A, 2 B
    strains) vaccines gt3
  • Licensure of recombinant influenza (HA only)
    vaccine 18-49

No ACIP statement available, not produced in
eggs, inactivated vaccine
28
SUMMARY OF CURRENTACIP RECOMMENDATIONS
  • Influenza
  • 1 annual dose for all persons gt6 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

29
SUMMARY OF CURRENT FDA APPROVED PNEUMOCOCCAL
VACCINES
  • Polysaccharide vaccine (PPSV23)
  • Contains 23 different pneumococcal strains
  • FDA approved for all person gt50 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 gt50 years of age

30
SUMMARY OF CURRENTACIP RECOMMENDATIONS
  • Pneumococcal (polysaccharide, PPSV23)
  • Age gt65 All persons
  • Age gt19 Medical or other risk indications
  • Required to be offered to residents in ECFs in NC
  • Revaccination may be recommended (first dose lt65
    years AND now gt65 years AND gt5 years have passed)
  • Pneumococcal (conjugate, PCV13)
  • Age gt19 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 gt1year after
    last PPSV23

31
CDC. MMWR 201261816
32
SUMMARY OF CURRENTACIP RECOMMENDATIONS
  • Zoster
  • One dose for persons gt60 years of age regardless
    of whether they had a prior episode of zoster
  • FDA approved for persons gt50 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 lt55 years MPSV4 persons gt56 years

33
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 at each pregnancy
    (preferably during 27 to 36 weeks gestation)
    regardless of interval since last Td or Tdap
    immunization

34
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 gt6 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
    gt60 years (B, 2)

35
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 immunization(s) 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

36
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 lt26 years of age (only
    quadrivalent vaccine from Merck approved for men)

37
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
38
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

39
PROVIDING VACCINES
  • Patient name and identification number
  • Vaccine
  • Dose, Site, Route of Administration
  • Date given
  • Manufacturer
  • Lot number
  • Name, title address of person providing vaccine
  • Date next dose due
  • Informed consent

40
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
  • Written documentation required

41
IMMUNIZATIONS FOR HCP
  • Measles (provide as MMR)
  • 2 doses in susceptible persons (1 month apart)
  • Demonstration of immunity Appropriate
    immunizations, positive serology, MD diagnosed
    disease with lab confirmation
  • Birth before 1957 Consider immune (except during
    an outbreak)
  • Rubella (provide as MMR)
  • 1 dose in susceptible persons
  • Demonstration of immunity Immunization, positive
    serology
  • Birth before 1957 Consider immune (except during
    an outbreak or woman of childbearing potential)

42
IMMUNIZATIONS FOR HCP
  • Mumps (provide as MMR)
  • 2 doses
  • Demonstration of immunity Appropriate
    immunizations, positive serology, MD diagnosed
    disease with lab confirmation
  • Birth before 1957 Consider immune (except during
    an outbreak)
  • Varicella
  • 2 doses
  • Demonstration of immunity MD diagnosed disease,
    immunization, positive serology

43
MUMPS, MEASLES, RUBELLAISSUES FOR HEALTHCARE
FACILITIES
  • Mumps
  • Droplet transmission
  • No post-exposure prophylaxis
  • Recent outbreaks in US
  • Measles
  • Airborne transmission
  • Post-exposure prophylaxis Ig
  • Most cases imported (most commonly from Europe)
  • Rubella
  • Droplet transmission
  • No post-exposure prophylaxis
  • Concern about congenital infection

44
Vaccine licensed, 1967. MMWR 201360(53)
45
MUMPS OUTBREAK, IOWA, 2006
Loreen Herwaldt, personal communication
46
Vaccine licensed, 1963. MMWR 201356(53)
47
MEASLES OUTBREAKS
  • More than 30 reports in the literature of
    outbreaks in healthcare facilities
  • Between 1985 and 1989, 3.5 of all case acquired
    in a medical facility (Atkinson Wl, et al. Am J
    Med 199191(S 3B)320-24S
  • Investigation of individual outbreaks has
    revealed that 17 to 53 were acquired in a
    medical facility
  • Nosocomial outbreaks have led to hospitalization
    of medical staff and severe complications in
    infected patients including death
  • Cost of outbreaks has ranged from 28,000 to more
    than 100,000

48
SEROLOGIC TESTS OF NEW HIRES BORN BEFORE 1957,
UNC, 2006-2008
  • Non-immune by serology
  • Measles 1.3 (6/469)
  • Mumps 3.7 (14/381)
  • Rubella 2.9 (14/477)
  • Costs of testing
  • Number of new employees 6,597
  • Number of persons tested 488
  • Number of tests 1,327
  • Total cost of serologic tests 78,768
  • Cost per non-immune person detected 2,317

Weber DJ, et al. ICHE 201031655-657
49
VZVISSUES FOR HEALTHCARE FACILITIES
  • Communicable (1-2 days) before rash appears
  • Multiple outbreaks reported in hospitals
  • Airborne transmission
  • Highly communicable
  • Life threatening disease in immunocompromised
    persons and neonates
  • Infection in pregnant woman may lead to
    congenital malformations
  • Seropositivity lower in persons born in tropical
    countries
  • For near future, how to manage HCP with remote
    immunization

50
Vaccine licensed 1996
MMWR
201259(53)
51
Vaccine licensed 1996
MMWR
201360(53)
52
CHICKENPOX FROM AN IMMUNO-SUPPRESSED INDEX CASE
WITH ZOSTER
Faizallah R, et al. BMJ 19822851022-1023
53
Gustafson TL, et al. Pediatr 198270550-6
54
VARICELLAIMMUNIZATION IN HCP
  • To prevent disease and nosocomial spread of VZV,
    healthcare institutions should ensure that all
    HCP have evidence of immunity to varicella
  • Birth before 1980 is NOT considered evidence of
    immunity
  • Serologic screening before vaccination of
    personnel who have a negative or uncertain
    history of varicella and are unvaccinated is
    likely to be cost effective
  • Institutions may elect to test all HCP regardless
    of disease history because a small proportion of
    persons with a positive history might be
    susceptible
  • Institutions should consider precautions for
    personnel in whom rash occurs after vaccination.
    HCP in who a vaccine related rash occurs should
    avoid contact with persons without evidence of
    immunity who are at risk for severe disease

55
VIRAL HEPATITIS,INCIDENCE,BY YEAR, US, 1981-2011
56
IMMUNIZATIONS FOR HCP
  • Hepatitis B
  • 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 (gt10
    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

57
Estimated Incidence of HBV infections among HCP
and General Population, United States, 1985-1999
Healthcare Personnel
General U.S. Population
58
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

59
NEW ACIP GUIDELINES FOR HBV VACCINE USE IN HCP
  • HCP and trainees at high risk for chronic
    hepatitis B (e.g., born in high endemicity
    countries) should be tested for HBsAg and
    anti-HBc/anti-HBs
  • New algorithm for evaluation of HCP who have
    remote history of HBV vaccine and who have not
    had an ant-HBsAg titer
  • HBV PEP recommendations essentially unchanged

60
CDC MMWR 201362 (RR-10)
61
IMMUNIZATIONS FOR HCP
  • Pertussis
  • Provide at Tdap
  • 1 dose for all HCP (unless contra-indicated)
  • Revised recommendations
  • No upper age limit
  • May provide regarding of time of last Td
  • Other comments
  • May be used to provide tetanus immunity
  • Provide antibiotic PEP regarding of Tdap receipt
  • No current recommendation for revaccination

62
PERTUSSIS EPIDEMIOLOGY
  • Worldwide distribution
  • Humans sole reservoir
  • Droplet transmission
  • Incubation period 7-10 days (range, 4-21 days)
  • Communicable period
  • High (1st two weeks)
  • Low (weeks 2-3)
  • Very low (gt3 weeks)
  • Huovila, 1982 48 culture after 3 weeks, 23
    after 4 weeks

63
MMWR 201360 (No. 53)
64
(No Transcript)
65
Pertussis Complications by Age
Percent
Supplementary Pertussis Surveillance System data,
1992-1994 (N13,615)
CDC. Atkinson W, et al. Chapter 4 Pertussis. In
Epidemiology Prevention of Vaccine-Preventable
Diseases, 4th ed. Department of Health and Human
Services, Public Health Service, 1998, 67
15
66
Pertussis Stages, Symptoms, Communicability
period of communicability
Catarrhal runny nose, sneezing, low-grade
fever, mild cough Paroxysmal cough (97),
severe spasms of cough (73) , thick mucus,
whoops (69), vomiting 65), exhaustion Convales
cent gradual recovery with less frequent and
less severe cough
paroxysmal cough onset
exposure
2
4
-1
1
3
5
6
8
9
10
11
12
-2
0
7
weeks of cough
catarrhal stage
paroxysmal stage
convalescent stage
CDC. Epidemiology and Prevention of
Vaccine-Preventable Diseases. PHF 2004 Adults
Symptoms gt3 weeks
67
CAVEATS IN TREATMENT
  • All patients with pertussis should be treated to
    hasten clearance of the organism and limit
    transmission to susceptible contacts
  • Treatment within first week reduces severity
    and/or duration of symptoms
  • Treatment renders the patient noninfectious
    within 5 days (treatment recommended even 6-8
    weeks after onset of illness)
  • Treatment
  • Azithromycin x 5 days (treatment of choice)
  • Trimethoprim-sulfamethoxazole x 14 days
    (alternative)

68
OUTBREAK MAYO CLINIC, ROCHESTER
69
IMMUNIZATIONS FOR HCP
  • Influenza
  • 1 dose annually (inactivated, live-attenuated/nasa
    l, ID, etc.)
  • Attenuated influenza vaccine (FluMist)
    contra-indicated only in HCP working with highly
    immunocompromised patients housed in a protected
    environment
  • Meningococcal
  • Recommended for lab workers who spin CSF
  • Pneumococcal (polysaccharide)
  • 1 dose (booster may be indicated)
  • No specific indication for HCP

70
INFLUENZA EPIDEMIOLOGY
  • Pathogen Single-stranded, enveloped RNA virus
  • Geographic distribution Global
  • Reservoir Humans, swine, birds
  • Incubation period 1-5 days (average, 2 days)
  • Transmission
  • Droplet (lt6 feet)
  • Contact Direct and indirect
  • Communicability
  • 1-2 days before onset of symptoms to 7 days
    post-onset (adults) or 10 days (children) no
    carrier state but inapparent illness may occur
  • Attack rate Up to 60

71
Influenza Disease Burden to U.S. Societyin an
Average Year
Deaths 25,000 - 72,000
Hospitalizations 114,000 - 257,500
Physician visits 25 million
Infections and illnesses 50 - 60 million
Thompson WW et al. JAMA. 2003289179-86. Couch
RB. Ann Intern Med. 2000133992-8. Patriarca PA.
JAMA. 199928275-7. ACIP. MMWR.
200453(RR06)1-40.
72
CDC. MMWR 200857(RR-18)1-59
73
Viral Nomenclature
Type of Nuclear Material
Hemagglutinin
Neuraminidase
A / Sydney / 184 / 93 (H3N2)
Virus subtype
Virus type
Geographic origin
Year of isolation
Strain number
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
74
Pandemic influenza
1977 H1N1 Russian
1918 H1N1 Spanish

2009 H1N1 pdm09
1947 H1N1
1957 H2N2 Asian flu
1968 H3N2 Hong Kong flu
1940 Influenza B
75
SUMMARY OF CLUSTER RCTs ASSESSING THE IMPACE OF
HCP IMMUNIZATION
Study Coverage Control Coverage Intervention Mortality Control Mortality Intervention 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 (p0.008)
76
REDUCTION IN OUTCOMES IN HCP RECEIVING INFLUENZA
VACCINE
Influenza infection
Sick days due to respiratory illness
Days lost from work
Patient mortality
Patient mortality
28
41
41
39
88
Saxen 1999
Carmen 2000
Potter 1997
Wilde 1999
Wilde 1999
Talbot TT, Weber DJ, et al. ICHE 200526882-890
Attack rate unvaccinated 13.4
77
INFLUENZA VACCINE COVERAGE, HCP, 2010-11,
2011-12, AND 2012-13
MMWR 201362781-786
78
ARGUMENTS IN FAVOR AND AGAINST CONDITIONAL
(MANDATORY) USE OF INFLUENZA VACCINE IN HCP
  • In favor of conditional vaccine use
  • Key principle First do no harm (nosocomial
    transmission linked to infected staff)
  • Protects the staff and their families
  • Institutional benefit Decreased absenteeism,
    cost effective
  • Against conditional vaccine use
  • Feasibility Difficult to capture all employees
    each year
  • May result in staff dissatisfaction
  • Union concerns

79
IMPACT OF MANDATORYINFLUENZA REQUIREMENTS
Miller BL, et al. Vaccine 2011299398-9403
80
INFLUENZA PROPHYLAXIS AND THERAPIES
  • Oseltamivir (Tamiflu) Influenza A B
  • Treatment 75 mg PO 2x/day x 5d
  • Post-exposure prophylaxis 75 mg PO 1x/day x 10
    days
  • Seasonal prophylaxis 75 mg PO 1x/day x 4-8 weeks
  • Zanamivir (Relenza) Influenza A B
  • Treatment 10 mg (2 nasal inhalations 2x/d x 5d)
  • Post-exposure prophylaxis 10 mg (2 nasal
    inhalations 1x/d x 10d)
  • Seasonal prophylaxis 10 gm (2 nasal inhalations
    1x/day x 4-8 weeks)

Must begin therapy within 2 days of onset of
illness Reduce dose if creatinine clearance
lt30mL/min, or lt10mL/min
81
INFLUENZA - ANTIVIRAL THERAPIESTOXICITIES
  • Zanamivir
  • Brochospasm (avoid in asthmatics)
  • Headache (prophylaxis 13-24, treatment 2)
  • Throat/tonsil discomfort/pain (prophylaxis 8 to
    19)
  •  Cough (prophylaxis 7 to 17)
  • Oseltamivir
  • GI nausea (3-10), vomiting (2-5)
  • Pregnancy class C
  • Use with caution in patients with cardiac, liver,
    or renal dysfunction
  • FDA alert Reports of self-injury (with
    fatalities), confusion, and delirium (primarily
    in pediatric patients from Japan)

82
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 ? No ?
Hepatitis B No gt10 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 201132912-4
83
POST-EXPOSURE PROPHYLAXIS
84
DATA RECORDED ON EXPOSURES
  • Employee 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

85
EXPOSURE EVALUATION
  • Determine if source case has infection and is
    infectious
  • Determine transmission possible (i.e.,
    appropriate exposure without protection)
  • Determine if employee is susceptible (may require
    labs)
  • Determine if prophylaxis available indicated
  • Consider alternative prophylaxis (if available)
    if employee has contraindications to prophylaxis
    of first choice
  • Arrange follow-up

86
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
  • 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

87
POST-EXPOSURE PROPHYLAXIS
  • Anthrax
  • Diphtheria
  • Hepatitis A
  • Hepatitis B
  • HIV
  • Human bite wound
  • Influenza A (novel, H5N1)
  • Influenza B
  • Measles
  • Meningococcal infection
  • Monkey bite
  • Monkeypox
  • Pertussis (whooping cough)
  • Plague
  • Rabies
  • Rat bite (rodent bite)
  • Smallpox
  • Syphilis
  • Tuberculosis (TB)
  • Tularemia
  • Varicella (chickenpox)
  • Zoster (shingles)

88
NO POST-EXPOSURE PROPHYLAXIS
  • Arboviruses (encephalitis)
  • Hepatitis C
  • Mumps
  • Parvovirus B19
  • Rubella
  • Severe acute respiratory distress syndrome (SARS)

89
VACCINES INDICATED FORPOST-EXPOSURE PROPHYLAXIS
  • Mumps No post-exposure prophylaxis available
  • Measles lt3 days post-exposure (alternative Ig)
  • Rubella No post-exposure prophylaxis available
  • Varicella lt4 days post-exposure (alternative
    VZIG or acyclovir)
  • Hepatitis B lt7 days post-exposure /- HBIG
    (alternative HBIG)
  • Influenza Vaccine not indicated may use
    oseltamivir or zanamivir x 5 days
  • Pertussis Vaccine not indicated (use
    antibiotics azithromycin, TMP-SMX)
  • Tetanus Post-wound /- TIG (no time limit
    Tdap preferred)
  • Rabies Prior to symptoms plus RIG (avoid RIG
    if previously vaccinated)
  • Vaccinia lt4 days post-exposure (may also be
    indicated for monkey pox)
  • Outbreak control Hepatitis A, pertussis,
    meningococcal

May need to be provided with an immunoglobulin
preparation
90
Risk of Bloodborne Virus Transmission after
Occupational Percutaneous Exposure
  • Source
  • HBV
  • HBeAg
  • HBeAg -
  • HCV
  • HIV
  • Risk
  • 22.0-30.0
  • 1.0-6.0
  • 1.8
  • 0.3

91
DEFINITION OF EXPOSURE
  • Percutaneous exposure to contaminated body fluid
  • Mucous membrane exposure to contaminated body
    fluid
  • Non-intact skin expose to contaminated body fluid
  • Contaminated fluids blood, CSF, vaginal
    secretions, semen, synovial, pleural, peritoneal,
    pericardial, amniotic

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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 protocol
  • Maintain confidentiality Separate records, labs
    pharmacy requisitions sent with code number

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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 postexposure prophylaxis, as medically
    indicated, per CDC recommendations offer
    counseling
  • Provide employee with results of evaluation with
    15 days

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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

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PEP FOR HBV EXPOSURES
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HIV INFECTION AS A RESULT OF OCCUPATIONAL
EXPOSURE IN HCP
  • HIV infections in HCP as a result of exposures
    (12/2004)
  • Documented conversions 57
  • 26 have developed AIDS
  • Types 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

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Risk Factors for HIV Transmission After
Percutaneous Exposure to HIV-Infected Blood CDC
Case-Control Study
  • Risk Factor Adjusted OR ratio (95 CI)
  • Deep injury 15 (6.0-41)
  • Visible blood on device 6.2 (2.2-21)
  • Procedure involving needle 4.3 (1.7-12)
  • placed in artery or vein
  • Terminal illness in source patient 5.6 (2.0-16)
  • Postexposure use of zidovudine 0.19 (0.06-0.52)
  • Cardo et al., New Engl J Med
    19973371485-90.

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US PHS HIV POSTEXPOSURE GUIDELINESNEW
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 201334875-892
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US PHS HIV POSTEXPOSURE GUIDELINESGUIDELINE
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

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US PHS HIV POSTEXPOSURE GUIDELINESDEFINITIONS
  • 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

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US PHS HIV POSTEXPOSURE GUIDELINESRISK 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 patients
    blood
  • A procedure that involved a needle 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

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US PHS HIV POSTEXPOSURE GUIDELINESPEP 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

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US PHS HIV POSTEXPOSURE GUIDELINESPEP 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)

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US PHS HIV POSTEXPOSURE GUIDELINESPEP 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)

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US PHS HIV POSTEXPOSURE GUIDELINESPEP 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)

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US PHS HIV POSTEXPOSURE GUIDELINESPEP V
  • Toxicity monitoring
  • Symptoms, focused physical exam
  • CBC with differential, ALT, AST, Amylase, BUN,
    Creat, glucose (if on PI)
  • Monitor at baseline and 2 weeks (and if any acute
    symptoms develop)
  • Follow-up HIV testing
  • At 6 weeks and 4 months (if using 4th generation
    HIV test)
  • At 6 weeks, 12 weeks, 6 months (if using 3rd
    generation HIV test)
  • If HCP exposed to source with HIV and HCV, follow
    for 1 year

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SUMMARY PEP PROGRAM
  • Establish bloodborne pathogen policy
  • Implement management policies
  • Establish laboratory capacity for bloodborne
    pathogen testing
  • Provide access to counseling
  • Monitor adverse reactions
  • Monitor exposure management program (e.g.,
    evaluate time between exposures and evaluation,
    monitor completion of follow-up)

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THANK YOU!!
Edward Jenner, 1749-1823
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