HEALTH CARE FACILITY INFECTION CONTROL PROGRAM An Employee Health Perspective

1. HEALTH CARE FACILITY INFECTION CONTROL PROGRAM An Employee Health Perspective Kenneth R. Keller, DO Employee Health Physician Medical Director Occupational Health Services McCullough-Hyde Memorial Hospital kkeller@mhmh.org

2. Employee Health & Infection Control Objectives • Minimize communicable disease transmission from employee to patient and patient to employee. • Reduce the need for treatment and absenteeism containing costs • Review immunizationprogram • Review major risks of occupational exposure to Infectious Disease • Review counseling, follow up, and work restriction recommendations for communicable diseases and following exposure • Review strategies to accomplish these functions

3. Immunization Program • Begin with thorough pre-placement evaluation • Assure immunity to minimize employee to patient and patient to employee communicable disease transmission • Must be consistent with the most current ACIP guidelines • Barriers to success

4. Pre-placementEvaluation • Immunization record review • Health history review (pregnancy, current health status, hepatitis, skin condition, TB/ exposure/ skin test conversion, immune deficient conditions) • Physical examination (less important than history for infection control purposes) • Lab tests (other than immune titres) and x-ray are generally of no value) One of our best opportunities to individually explain the benefits of our immunization program, not just for patients, but for the employee, as well.

5. CDC/ACIP Healthcare Personnel Vaccination Recommendations • Hepatitis B – 3 dose series ( now, 1 month, 6 months) IM. Obtain anti- HBs serology 1-2 months after dose 3. (SAFE in pregnancy) • Influenza - 1 dose annually. Inactivated influenza injection IM ( SAFE in pregnancy),Live attenuated vaccine ( LAIV) intranasaly (NOT SAFE in pregnancy) • MMR (measles, mumps, rubella) -without serologic evidence of immunity or prior vaccination, 2 doses, 4 weeks apart SC. NOT SAFE in pregnancy- recommend protected intercourse 4 weeks post vaccination. • Varicella (chickenpox)- no serologic proof of immunity, prior vaccination or PROVIDER documented disease, 2 doses, 4 weeks apart, SC (NOT SAFE in pregnancy ) • Tdap ( tetanus, diphtheria, pertussis) - if not previously given, IM ( SAFE in pregnancy) • Meningococcal– one dose to microbiologists routinely exposed to N. meningitidis, IM, SC. • TB skin test ( PPD)- 2 step ( 7-10 days apart), ID, SAFE in pregnancy. Chest x-ray NOT routinely recommended for prior converters- only if symptomatic ( cough, hemoptysis, fevers, weight loss, other constitutional symptoms ).

6. Major Occupational Infectious Disease Exposure Risks • Bloodborne Pathogens • Tuberculosis • Meningococcus • Selected disease risk to and from patients (Handout) • Selected disease risk from patients to providers (Handout) • Special populations (pregnancy, immunosuppression) (Handout) Ensure your notification follows your policy and any applicable Local or State Health Department Reporting Requirements. For unusual non-major, as well as major, ID concerns - immediately involve Infection Control, Employee Health Officer, Local and State Health Departments.

7. Bloodborne Pathogens • 29 CFR 1910.1030 – OSHA Bloodborne Pathogen Standard • Limits occupational Exposure to blood and other potentially infectious material (OPIM) • Protect workers against exposure that can lead to disease and death

8. Key Elements of the Standard • Record Keeping • Multi-Employer Worksites • Who is covered under the standard • Exposure Control Plan • Compliance • HBV Vaccination, Post-Exposure Evaluation & Follow-Up • Employee Information & Training

9. Record Keeping • Bloodborne Pathogen Exposure is an Injury • Usually recorded in the OSHA 300 Log • Healthcare Employers must Establish a Separate Sharps Log (incident description, location, type and brand of device – at minimum)

10. Multi-Employer Worksites • Agency Contractors (Non-Employees) cannot be Cited in an Exposure • The Contracting Facility (Hospital, etc) is Cited in an Exposure. • Home Health cannot be Cited for Site-Specific Hazards

11. Who is Covered Under the Standard? • Any employee (full time, part, time, temporary) with potential for blood or OPIM exposure • Excluding: students, state, county, municipal, and construction workers. • Also Excluding: “Good Samaritan” (helping co-worker with a nose bleed, etc)

12. Exposure Control Plan • Always reviewed by Compliance Officers • Sample Bloodborne Pathogen Standard Model Exposure Control Plan available on the OSHA Website • Required for any Employer with one ore Employees wit Potential for Exposure • Required Yearly Update • Facility Specific • Must Solicit Input From Non-Management • Must be Readily Available to Employees • Must contain Procedures for Investigation/Evaluation of Exposure Incidents

13. COMPLIANCE • Universal Precautions • Engineering Controls: Sharps Protection • Hand Washing Facilities: Present & Effective • No Cost PPE • Proper Disposal of Contaminated Waste & Sharps

14. HBV Vaccine, Post-Exposure Evaluation & Follow-Up • HBV vaccine (three shot series ) provided at no cost and outlined in the exposure control plan (ECP) • Obtained signed declination if refused, vaccine remains available to them at any time • Beware of current CDC vaccination guidelines • No need to vaccinate if proof of prior vaccination or immunity (positive titer) • Any unvaccinated employee has vaccine availability to them within 24 hours of exposure incident • Every effort should be made (and documented) to test the exposure source

15. Employee Information & Training • Initial & Annual Training on Blood & OPIM Exposure & Protective Measures • Training Conducted & Recorded by Qualified Instructor • Appropriate Biohazard Labeling of Containers & Refrigerators

16. Training Elements Hepatitis B Vaccine Emergency Reporting & Response Exposure Incident Post-Exposure Evaluation & Follow-Up Signs & Labels Live Question & Answer Copy & Explanation of BBP Standard Epidemiology & Symptoms Modes of Transmission Employer & Site-Specific ECP Exposure Determination Hazard Recognition/Risk Identification Engineering Controls, Word Practices & PPE

17. Main Concerns • Hepatitis B Virus • Hepatitis C Virus • HIV Virus

18. Hepatitis B • Potentially Fatal & Preventable by Effective Vaccination • Over 1 Million Americans are Chronically Infected with Hepatitis B • 5,000- 6,000 Deaths Annually due to Liver Disease or Cancer Related to Hepatitis B • At Risk: IV Drug Users, Multiple Sex Partners (A Sexually Transmitted Disease) Hemodialysis Patients • Hearty Virus: Can Live in Dried Blood for up to 2 Weeks • High Transmission Risk • 1/3 of Patients have No Symptoms • CDC Reports 60,000 New HBV Cases a Year

19. HEPATITIS C • Most Common Chronic Bloodborne Infection in the U.S., Nearly 3,000,000 Active Infections • Chronic Infection may not have Symptoms for up to 2 Decades • Symptoms Similar to Hepatitis B • Chronic Liver Disease Occurs in 70% with 8,000-10,000 Deaths Annually • Not as Hearty a Virus as Hepatitis B • Lower Transmission Risk, but No Vaccine

20. HIV Virus • Development of AIDS may take Years from Actual Infection with HIV • 40,000 New Cases of HIV / Year per CDC • Virus is Not Hearty & Does Not Survive Well Outside the Body with Lower Transmission Risk • Less than 100 Reported Cases of Infection due to Occupational Exposure (Nearly all deep needle sticks) • Risk of Transmission even from Needlestick only 1:300

21. Exposure Incident Definition Contact of Blood or other Potentially Infectious Material (OPIM) by SharpsStick, Mucous Membrane Exposure or Non-Intact Skin Exposure

22. What is OPIM? • Practical Definition: All Bodily Fluids • Universal Precautions Refers to Protection from All Bodily Fluids

23. What to Do if an Exposure Occurs? • Wash with Soap & Water • Report Incident to Superior • Medical Evaluation & Arrangement of Follow-Up ASAP

24. What Happens in the Post-Exposure Period? • Documentation of the exposure type • Attempt to obtain source testingif applicable • Testing of exposed employees if applicable • Riskcounseling of the exposed employee in prophylactic treatment as indicated per USPHS and CDC guidelines

25. Exposure Record-Keeping Requirement • Employee Name & SS# • Hepatitis B Immune Status • Applicable Test Results & Post-Exposure Follow-Up • Healthcare Provider Written Opinion • Maintain Confidential Records for Duration of Employment & 30 years

26. The Best Way to Manage BP Exposure in the Work Place? • PREVENTION! • PREVENTION! • PREVENTION!

27. Personal Protective Equipment • Non Latex Gloves • Clothing/Footwear • Eye Protection / Faceshield

28. FIRST AID PRECAUTION • Gloves • Eye/Faceshield if Splash/Spray Hazard • Universal Precautions – Consider all Bodily Fluids OPIM • Wash Hands!

29. Housekeeping Precautions • Gloves for Any Contaminated Object – Including Laundry • Wash Hands ASAP After Removing Gloves • Collect broken Glass, Any Sharp Contaminant with Broom/Dust Pan • Do Not Touch other Surfaces with Contaminated Gloves • No Food/Drink in Contaminated Area • No Smoking • Wash Hands!

30. Disposal & Decontamination • Gloves! • Disinfect with ¾ Cup Bleach to 1 Gallon Water • Spill Clean-Up: Soak Up with Paper Towel, Disinfectant Wipe Down, Red Bag all Wipes • Wash Hands!

31. Summary • An Exposure is Blood or OPIM Contact by Sharps Stick, Mucous membrane or Non-Intact Skin Contact • The Most Important Bloodborne Pathogen is Hepatitis B – Potentially Fatal & Preventable by Effective Vaccine, Hearty Organism with High Transmission Risk & the Only Pathogen Specifically Included in the OSHA ECP • Universal Precautions Requires ConsideringAll Blood & Body Fluids as OPIM & Taking the Appropriate First Aid & Housekeeping Precautions • Personal Protective Equipment is Needed for any Potential Exposure

32. Tuberculosis • At Risk Population • Annual Facility Risk Assessment • Surveillance/Screening • Annual Training • Steps in Exposure • Managing TB Skin Test (TST) Positives/Conversion • Counseling/Treatment

33. At Risk Population for TB • Patient Populations: Foreign Nationals from High Risk Areas, Alcoholic, IV Drug use, Prison Inmates, Homeless, Immunosuppression, HIV History • Healthcare Workers (Especially Respiratory Care, those who Intubate) • Staff Training to Identify those At Risk on Admission for Triage to Negative Pressure Room in the ED or on a Medical Floor

34. Annual Facility TB Risk Assessment • Moderate or High Risk will Require Annual Surveillance • May have up to 3 Year Surveillance Interval if Low Risk

35. Surveillance / Screening • OSHA Requirement • Must Include Employees, Volunteers, Students & Physicians • New Hire: 2 Step TST Mantoux Technique (0.1 ML -5 Tuberculin Units – of Purified Protein Derivative Intermediate Intradermal) – 2 Step Required to Prevent Misinterpretation of a Boosted Response from Recent Infection • If 1 Step 0-9 MM Induration, can Proceed to 2nd Step 1-3 Weeks After • If Negative TST in Last 3 Months, Only Need 1 Step • If Positive TST ( >= to 10 MM Inuration), Obtain Chest X-Ray • If Prior Positive TST, Do Not Do TST, Chest X-Ray only if Symptomatic

36. TB Annual Training • OSHA Required • Epidemiology of TB • Difference Between Latent TB Infection & Disease • Signs, Symptoms & Recognition • Purpose & Interpretation of TST • Multi-Drug Resistant TB & Treatment Problems • PPE & Respiratory Isolation Review (N95, FIT Test, PAPR)

37. Steps Taken in Exposure • Unprotected Exposure (Other than Initial Encounter) Should be Rare • Baseline PPD ASAP After Exposure unless One in Previous 3 Months • 2nd Step at 10 Weeks Post-Exposure • Referral for TB Evaluation if Positive TST Response or Symptoms

38. TB Counseling & Treatment • New TST Converters will Get a Chest X-Ray & Referral (PCP, Pulmonologist, Health Department) for Evaluation • They may not Return to Patient Care Until Cleared by this Evaluation

39. Meningitis Exposure • Neisseria Meningitidis is Spread by Droplet, not Aerosol • Close Contact – Intubation or Nasotracheal Suctioning – Required for Occupational Transmission • Ceftriaxone 125 MG IM X 1 or Rifampin 600 mg every 12 Hours for 4 Doses • Consider No Patient Contact for 24 Hours After Treatment

40. Strategies for Successful Implementation • Annual Training: OSHA required (hand washing, standard/universal precautions, PPE, safe sharps handling, spills, biohazard) but also employee responsibility with communicable disease and any other evolving issues • Cross Talk: Between Employee Health, Infection Control, Health and Safety, Physician Services (Bylaws, Rules and Regulations) and Volunteer Services committees and policies • Reporting & Real Time Action Structure: For TB surveillance, employee or patient communicable or reportable disease. • Secure Employee Health Records: With access on as needed basis. • Preplacement Evaluation: Immunization review • Plan for all Associate Compliance:Thousand mile journey begins with first step • Remember the Primary Objective: You will need it.

41. Questions