Infection Control: New York State Mandatory Training

Element VI: The prevention and management of infectious or communicable disease in healthcare workers.


Introduction

Element I

Element II

Element III

Element IV

Element V

Conclusion

Resources

References

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This colorized transmission electron micrograph (TEM) revealed some of the ultrastructural morphology displayed by an Ebola virus virion. Photo courtesy of CDC/Cynthia Goldsmith.

Because of their contact with patients or infective material from patients, environmental services and facility visitors, healthcare workers and healthcare organizations utilize multiple interventions to prevent and/or manage infections in healthcare workers.

Initially, new employees are generally required to have a pre-employment physical; presumably any infection can be identified at that time and treatment initiated or management strategies employed prior to contact with patients or coworkers. Because healthcare workers are at risk for exposure to and possible transmission of vaccine-preventable diseases, maintenance of immunity is an essential part of prevention and infection control programs for healthcare workers. Optimal use of immunizing agents safeguards the health of workers and protects patients from becoming infected through exposure to infected workers.

On the basis of documented transmission, healthcare workers are considered to be at significant risk for acquiring or transmitting (CDC, 1997):

  • Hepatitis B,
  • Influenza,
  • Measles,
  • Mumps,
  • Rubella, and
  • Varicella.

All of these diseases are vaccine-preventable. The Advisory Committee on Immunization Practices (ACIP) has developed the following adult immunization schedule for October 2007 - November 2008 (ACIP, 2007).

View the Adult Immunization Schedule.

In addition to pre-employment screening or testing for infection and illness, vaccinations for vaccine-preventable illnesses, maintenance of good health, and the utilization of engineering and work practice controls are all methods to minimize the risk of acquiring or transmitting an infectious disease.

The estimated number of occupational HBV infections among U.S. healthcare workers has decreased significantly over the last 20 years. Data from surveillance systems indicated a 96% decline in HBV infections among healthcare workers over a 17-year period-from nearly 11,000 cases in 1983 to fewer than 400 in 1999. This reduction is largely due to the adoption of universal precautions in the mid-1980s by healthcare facilities and the 1992 OSHA Bloodborne Pathogen Standard (29 CFR 1910.1030), which required employers to offer HBV vaccinations to exposed workers (NIOSH, 2004).

During the time frame from 1981 through December 2002, 57 cases of documented occupational transmission of HIV to healthcare workers occurred. In that same time frame, 139 cases of occupational transmission of HIV to healthcare workers were possible (NIOSH, 2004).

Most documented cases of occupational HIV transmission occurred among nurses (24 cases or 42.1%) and laboratory workers (19 cases or 33.3%). These cases were reported to the HIV/AIDS Reporting System. Among the documented cases of HIV following occupational exposure, 84% resulted from percutaneous exposure (NIOSH, 2004).

Healthcare workers must be educated concerning the risk of and prevention for bloodborne pathogens, including the need to be vaccinated against HBV. Employers are required to establish exposure control plans that include post-exposure follow-up for employees and to comply with the incident reporting requirements of the 1992 OSHA Bloodborne Pathogens Standard.

Exposure prevention remains the primary strategy for reducing occupational bloodborne pathogen infections. However, occupational exposures will continue to occur, and post exposure prophylaxis (PEP) is an important element of exposure management (CDC, 2005).

Access to clinicians who can provide post-exposure care should be available during all working hours, including nights and weekends. Hepatitis B immunoglobulin (HBIG), HBV vaccine and antiretroviral agents for post-exposure prophylaxis (PEP) should be available in a timely manner, either by providing access onsite or by developing linkages with providers or facilities that can provide such service off-site. Those individuals who are responsible to provide post-exposure management must be knowledgeable about the evaluation and treatment protocols and the facility's plans for accessing post-exposure medications (CDC, 2005).

The recommendations provided by the CDC (See Tables 3 and 4) apply to situations in which healthcare providers have been exposed to a source person who either has or is considered likely to have HIV infection. These recommendations are based on the risk for HIV infection after different types of exposure and on limited data regarding efficacy and toxicity of PEP. If PEP is offered and taken and the source is later determined to be HIV-negative, PEP should be discontinued (CDC, 2005).

Although concerns have been expressed regarding HIV-negative sources being in the window period for seroconversion, no case of transmission involving an exposure source during the window period has been reported in the United States. Rapid HIV testing of source patients can facilitate making timely decisions regarding use of HIV PEP after occupational exposures to sources of unknown HIV status. Because the majority of occupational HIV exposures do not result in transmission of HIV, potential toxicity must be considered when prescribing PEP. Because of the complexity of selecting HIV PEP regimens, when possible, these recommendations should be implemented in consultation with persons having expertise in antiretroviral therapy and HIV transmission. Reevaluation of exposed healthcare providers should be strongly encouraged within 72 hours postexposure, especially as additional information about the exposure or source person becomes available (CDC, 2005).

Healthcare workers must be informed to report occupational exposures immediately after they occur because prophylactic treatment is most effective when administered as soon after the exposure as possible. PEP is preferably within hours rather than days of exposure (CDC, 2005).

Healthcare facilities will have policies and procedures for the prevention of occupational exposure in place as part of their administrative controls related to infection control, however, these facilities will also have policies and procedures in place regarding reporting, evaluation, counseling, treatment and follow-up of occupational exposure (CDC, 2005).

In the event that wounds or skin sites have been in contact with blood or body fluids, the sites must immediately be washed with soap and water; mucous membranes should be flushed with water. No evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of transmission; however, the use of antiseptics is not contraindicated (CDC, 2005).

In the event of an occupational exposure, the exposure and post-exposure management should be recorded in the exposed person's medical record. A facility may have a specific form for such an exposure. Employers must follow all federal and state requirements for recording and reporting occupational injuries and exposures (CDC, 2005).

The CDC (2005) recommends that the following information be recorded in the exposed person's confidential medical record:

  • Date and time of exposure;
  • Details of the procedure being performed, including where and how the exposure occurred; if related to a sharp device, the type and brand of device, and how and when in the course of handling the device the exposure occurred;
  • Details of the exposure, including type and amount of fluid or material and the severity of the exposure (e.g., for a percutaneous exposure, depth of injury and whether fluid was injected; for a skin or mucous membrane exposure, the estimated volume of material) and the condition of the skin (e.g., chapped abraded, intact).
  • Details about the exposure source (e.g., whether the source material contained HBV, HCV or HIV; if the source is HIV-infected, the stage of disease, history of antiretroviral therapy, viral load, antiretroviral resistance information, if known).
  • Details about the exposed person (e.g., HBV vaccination and vaccine response status).
  • Details about counseling, post-exposure management and follow-up.

Basic and Expanded HIV Postexposure Prophylaxis Regimens can be found in the Appendix of Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Post Exposure Prophylaxis (2005) available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm

Table 3. Recommended HIV postexposure prophylaxis (PEP) for percutaneous injuries
Infection Status of Source
Exposure Type
HIV-Positive,
class 1*
HIV-positive,
class 2*
Source of
unknown HIV
status†
Unknown source§
HIV-negative
Less severe¶ Recommend basic 2-drug PEP Recommend expanded >/= 3-drug PEP Generally, no PEP warranted; however, consider basic 2-drug PEP** for source with HIV risk factors†† Generally, no PEP warranted; however, consider basic 2-drug PEP** in settings in which exposure to HIV-infected persons is likely No PEP warranted
More severe§§ Recommend expanded 3-drug PEP Recommend expanded >/= 3-drug PEP Generally, no PEP warranted; however, consider basic 2-drug PEP** for source with HIV risk factors†† Generally, no PEP warranted; however, consider basic 2-drug PEP** in settings in which exposure to HIV-infected persons is likely No PEP warranted

* HIV-positive, class 1 _ asymptomatic HIV infection or known low viral load (e.g., <1,500 ribonucleic acid copies/mL). HIV-positive, class 2 - symptomatic HIV infection, acquired immunodeficiency syndrome, acute seroconversion, or known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of PEP should not be delayed pending expert consultation, and, because expert consultations alone cannot substitute for face-to-face counseling, resources should be available to provide immediate evaluation and follow-up care for all exposures.
† For example, deceased source person with no samples available for HIV testing.
§
For example, a needle from a sharps disposal container.
¶ For example, solid needle or superficial injury.
** The recommendation "consider PEP" indicates that PEP is optional; a decision to initiate PEP should be based on discussion between the exposed person and the treating clinician regarding the risks versus benefits of PEP.
†† If PEP is offered and administered and the source is later determined to be HIV-negative, PEP should be discontinued.
§§ For example, large-bore hollow needle, deep puncture, visible blood on device or needle used in patient's artery or vein.

 

Table 4. Recommended HIV postexposure prophylaxis (PEP) for mucous membrane exposures and nonintact skin* exposures
Infection status of source
Exposure type
HIV-positive,
class 1†
HIV-positive
class 2†
Source of
unknown HIV
status§
Unknown
source¶
HIV-negative
Small volume** Consider basic 2- drug PEP†† Recommend
2-drug PEP
Generally, no PEP warranted§§ Generally, no PEP warranted No PEP warranted
Large Volume Recommend basic 2-drug PEP Recommend expanded >/= 3-drug PEP Generally, no PEP warranted; however, consider basic 2-drug PEP†† for source with HIV risk factors§§ Generally, no PEP warranted; consider basic 2-drug PEP†† in settings in which exposure to HIV-infected persons is likely No PEP warranted

* For skin exposures, follow-up is indicated only if evidence exists of compromised skin integrity (i.e., dermatitis, abrasion, or open wound).
† HIV-positive, class 1 - asymptomatic HIV infection or known low viral load (e.g., <1,500 ribonucleic acid copies/ml). HIV-positive, class 2 - symptomatic HIV infection, AIDS, acute seroconversion, or known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of PEP should not be delayed pending expert consultation, and, because expert consultation along cannot substitute for face-to-face counseling, resources should be available to provide immediate evaluation and follow-up care for all exposures.
§ For example, deceased source person with no samples available for HIV testing.
¶ For example, splash from inappropriately disposed blood.
**For example, a few drops.
§§ If PEP is offered and administered and the source is later determined to be HIV-negative, PEP should be discontinued.
¶¶ For example, a major blood splash.

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