Occupational health & infection control

Occupational Health &

Infection Control

Dr Faisal Al Haddad

Consultant of Family Medicine & Occupational Health

PSMMC

Outlines

Occupational Health (OH)

Role of OH in Infection Control

Prevention of Blood-borne virus infections in Healthcare setting

What is occupational health?

The promotion and maintenance of the highest degree of physical, mental and social wellbeing of workers in all occupations.

(ILO/WHO, 1950)

Why Occupational Health?

To prevent occurrence of occupational injury or illness

and their costs on workers and employers

Costs on workers

Pain and suffering of the injury or illness

Possible loss of income

Possible loss of a job

Health-care costs

Costs on employers

Payment for work not performed

Medical and compensation payments

Possible reduction in the quality of work Replacement of the injured/ill worker

Time

Concern of fellow workers

Poor public relations

Occupational Health Services

Risk assessment and risk control

Pre-employment assessments

Periodic medical examinations including HS

Post-sickness absence review

Immunization

Occupational Health Services

Health education and counseling

Treatment of occupational injury or illness

Advice on compensation

Advice on environmental issues

Occupational Hazards in healthcare

Physical

Chemical

Microbiological

Ergonomic Psychosocial

Role of OH in Infection Control

Microbial Risk Assessment

Microbial Risk Control

Education of Health Care Workers (HCWs)

Microbial Risk Assessment

Steps:

Identification of microbiological hazards in workplace

Assessment of the risk of exposure to the microbiological hazards

Information:

Workplace surveillance (walk-through visit)

Pre-employment assessment (history, testing)

Ongoing interactions between OH and the HCW

Microbial Risk Control

Microbial Risk control is the eradication or minimization of the risk

of exposure to microbiological hazards .

Includes:

Risk control measures to prevent HCW exposure to or infection with disease

Risk control measures to manage HCWs exposed to or infected with disease

Control measures to prevent exposure to or infection with disease

1) Engineering Controls

2) Administrative Controls

3) OH Work Practices

4) Personal Protective Equipment (PPE)

OH Work Practices

Regular workplace microbial risk assessment

Pre-employment and periodic screening

Vaccination and post-exposure prophylaxis

Managing HCWs (infected, immunocompromised, dermatitis)

*OH should establish and maintain communication with appropriatedepartments (Admin, IC, Lab, Operation and Maintenance, Safety..)

Routine vaccination for HCWs

HBV: 3 doses given at 0, 1, and 6 months

DTP: primary series of 3 doses and booster doses of Td/10 y

MMR: 2 doses one month apart

Varicella: 2 doses on month apart

BCG: one dose

Meningococcal: one dose /3 y

Influenza: one dose annually

Control measures to manage HCWs exposed to or infected with disease

1. Assessment of the incident: The method of transmission Type of exposure Use of PPE Compliance with precautions

2. Assessment of the source of exposure: Communicability Diagnosis of infection

3. Assessment of the HCW exposed to or infected with disease: Determining immune status of HCW Diagnosis of infection

Management of HCWs exposed to or infected with disease

Post-exposure prophylaxis

Treatment of infected HCW

Counseling

Work restriction/reassignment/return to work Tracing close contacts

Assessing worker for fitness to work

Education of HCWs

Prevention and management of exposure to and infection with disease

Universal and additional precautions

Action recommended following potential exposure

The consequences of non-compliance

Prevention of Blood-borne virus infections in healthcare setting

Dr. Faisal Al Hadad

Outlines

BBV-specific exposure definition

Occupations at increased risk of exposure

Risk of transmission

Prevention of exposure/transmission

Employment implications

HIV, HBV, HCV - Vaccination - Post-exposure prophylaxis - Fitness for work

Occupational infections in Healthcare

1. Airborne Transmission: Adenovirus Diphtheria Influenza Measles Meningococcus Mumps Mycoplasma infection Parvorvirus Pertussis Rubella SARS Tuberculosis Varicella

2. Bloodborne Transmission AIDS Hepatitis B Hepatitis C Cytomegalovirus Hepatitis D virus Human parvovirus Human T-cell lymphotropic virus

3. Oral-Fecal Transmission Hepatitis A Typhoid fever

4. Direct-contact Herpes simplex Scabies and pediculosis

Exposure definition (CCDR)

A percutaneous injury from equipment contaminated with blood or body fluids, or mucous membrane or non-intact skin contact with blood or body fluids. Blood on intact skin is not an exposure.

The types of body fluids capable of transmitting BBVs: Blood, serum, plasma, and all biologic fluids visibly contaminated with

blood. Lab specimens, samples or cultures that contain concentrated BBVs. Organ and tissue transplants. Pleural, amniotic, pericardial, peritoneal, synovial, and CS fluids. Uterine/vaginal secretions or semen (HCV unlikely) Saliva for HBV only, unless contaminated with blood.

Occupations at risk of exposure to BBVs

Healthcare workers

Laboratory staff

Staff of residential for those with learning difficulties

Those handling human remains

Prison service staff in regular contact with inmates

Emergency frontline responders

The risk of transmission after exposure

After parenteral exposure to infected blood:

HIV 0.3%

Hepatitis C 3%-10% Hepatitis B 30%

Transmission is more likely where the worker has been exposed to infected blood through NSI injury than through exposure of MM.

Prevention of exposure to BBVs

Reduction in the number of blood samples taken from a patient

Safer-needle devices

Needleless drug administration

Reduce work duration and night work

Advice on bloodborne pathogen precautions and action recommended following potential exposure to blood

Bloodborne pathogen precautions

Wear gloves

Wash hands

Cover existing wounds and skin lesions

Avoid sharps

Safe handling and disposal of contaminated waste

Contd;

Avoid wearing open footwear

Clean up spillage of blood and disinfect surfaces

Protect mucus membrane of eyes with protective eyewear

Never resheath needles and never put hands in a used sharps box.

Action recommended following potential exposure to blood

Encourage bleeding

Wash the site of bleeding

Cover the bleeding site

If splashed in eye, nose or mouth wash immediately

Note the name and location of the patient concerned

Contact occupational health department

Report the accident and complete an incident-report form

Employment implications

Restriction from EEP Sickness absence

Discrimination

Loss of skilled workers

Staff shortage

Hepatitis B virus

Vaccination Strongly recommended before employment. Hepatitis B vaccines are not 100% effective in all workers.

The normal course of vaccination comprises 3 doses of vaccine over a 6month period.

HCWs with postvaccinal anti-HBs levels, one to two months after vaccine completion, ≥10 mIU/ml are considered as responders and immune against HBV infection.

In responders, booster doses of vaccine or periodic antibody concentration testing are not recommended

Non- responders can be given another course of vaccines followed by retesting. If the HCW fail to respond they need to be informed of the implications of this.

Non-responding HCWs involved in a high risk incident should be offered PEP with IG.

Hepatitis B virus

Post-exposure management

Hepatitis B vaccine + hepatitis IG within 24 hours of exposure.

HBsAg status of the source (HBsAg-positive)

Immune status of exposed person (non-immune)

Hepatitis B virus

Fitness of HBsAg-positive HCWs for work

HBeAg-positive HCWs Not allowed to carry out exposure-prone procedures (EPP) Undergoing antiviral treatment have to show that their viral load

has been reduced to <1000 GEq/ml 1 year after finishing their therapy.

HBeAg-negative HCWs Viral load >1000 GEq/ml are restricted from performing EPP Viral load <1000 GEq/ml need not have their working practices

restricted

Exposure-Prone Procedures (EPP)

Insertion of hands or fingers inside the body cavity

Hands or fingers may disappear from view

Hands or fingers may come into contact with a sharp instrument or tissue

The operator may bleed into the patient

Hepatitis C virus

Vaccination

No vaccine available

Post-exposure management

IG and antiviral agents are not recommended for PEP after exposure to HCV-positive blood.

HCWs exposed should be tested for HCV-Ab at baseline and after 6 months.

Hepatitis C virus

Fitness to work

HCV RNA-positive HCWs should not be allowed to perform EPP

HCV RNA-positive HCWs who have responded successfully to

treatment with antiviral therapy should be allowed to resume EPP

Successful response is defined as remaining HCV RNA negative six months after cessation of treatment.

HIV

VaccinationNo vaccine available

Post exposure management

Prophylaxis 300mg zidovudine + 150mg lamivudine (one Combivir tab) 28 days 200mg lopinavir + 50mg ritonavir (two Kaletra tab) 28 days HIV testing at baseline at 6-8 weeks at least 6 months post exposure

HIV (indications of PEP)

1. Type of injury: Percutaneous injury (recommended) Exposure of mucus membrane or non-intact skin (considered) Exposure of intact skin (discouraged)

2. Type of source material: Blood, body fluid containing visible blood, CSF, concentrated virus in a lab

setting (recommended) Semen, vaginal secretions, synovial, pleural, peritoneal, amniotic fluids and

tissues (considered) Urine, vomit, saliva, tears, faeces, sweats, sputum (discouraged)

3. Source patient: Known to be HIV-positive (recommended) HIV status unknown, consent refused or unavailable (considered) HIV-negative (discouraged)

HIV-positive HCWs

HIV-positive HCWs must not undertake EPP and they must receive appropriate guidance from an occupational physician.

There is little evidence of HCWs passing HIV to their patients

through normal medical procedures.

Efficient and confidential reporting channels are required to ensure that HCWs who know or suspect that they could be HIV-positive can report to the OH department.

Testing source patients

It is considered unethical to test a source patient for BBV infection without their fully informed consent.

The clinician who has received the needlestick injury should never seek the consent from the source patient.

Source patients should be counseled on the implications of the test and results including possible need to discuss any positive test with his/her sexual partner.

It is unacceptable to seek preoperative consent for source-patient testing in order to guard against an exposure incident occurring during surgery.

.

Thank You