INFECTIOUS DISEASES AND OCCUPATIONAL HEALTH STRATEGIES

Because healthcare workers have contact with patients and infectious material, and because vulnerable patients will be exposed to healthcare workers, healthcare organizations utilize various occupational health strategies to assess, prevent, and control infections and communicable diseases.

Occupational health services provide or refer potential healthcare employees for preplacement medical evaluation prior to taking on job duties and for periodic and episodic medical evaluations during the course of employment.

Preplacement assessments are done in order to:

• Document the employee’s baseline health status
• Implement measures to reduce the employee’s risk of acquiring or transmitting infections in the healthcare settings, such as:
  • Ensuring the individual has evidence of immunity to vaccine-preventable diseases, as recommended by the Advisory Committee on Immunization Practices
  • Conducting tuberculosis screening, as required by OSHA
  • Offering hepatitis B immunization before starting work, as required by the OSHA Bloodborne Pathogens Standard
  • Providing or referring for medical clearance for respirator fit-testing, training, and medical re-evaluations, as required by the OSHA Respiratory Protection Standard
• Assess job placement and provide “clearance for duty”
• Inform the healthcare worker about occupational health services and expectations and confidentiality of health information

Periodic medical evaluations are done in order to:

• Provide additional doses of recommended vaccines
• Perform or refer for indicated follow-up testing
• Conduct periodic screening for tuberculosis as recommended by CDC
• Provide or refer for periodic respirator fit testing

Episodic medical evaluations are done in order to:

• Evaluate and manage potentially infectious exposures and illnesses
• Evaluate and manage new health conditions that may affect risk of acquiring or transmitting infections or ability to perform job functions
• Provide preplacement medical evaluation for those who are changing job duties
• Survey healthcare personnel for exposures and/or illness during outbreaks of infectious diseases in healthcare settings
  (CDC, 2019g)

Healthcare Workers and Communicable Diseases

Healthcare workers are responsible for reporting to their supervisor or occupational health service when they have any signs or symptoms of a communicable disease. Symptoms requiring immediate evaluation by a licensed medical professional and possible restriction from patient care activities and return-to-work clearance may include:

• Fever or chills
• Sore throat
• Cough
• Shortness of breath or difficulty breathing
• Rash
• Vesicular lesions
• Draining wounds
• New loss of taste or smell
• Vomiting
• Diarrhea
  (CDC, 2020i; NYDOH, 2018)

STRATEGIES FOR PREVENTION AND CONTROL OF BLOODBORNE PATHOGEN TRANSMISSION

Healthcare workers who have or may have HBV, HCV, or HIV should be evaluated for the ability to work safely. This evaluation is based on the premise that HBV, HCV, or HIV alone is not sufficient justification to limit the worker’s professional duties.

Factors that may bear on the ability of the healthcare worker to provide healthcare include:

• Physical or mental condition that may interfere with ability to perform assigned tasks or regular duties
• Lack of compliance with established guidelines for prevention of disease transmission and/or documentation or evidence of previous transmission of bloodborne pathogens
• Lack of infection prevention and control techniques related to performance of procedures (e.g., poor hand hygiene or failure to follow Standard Precautions)
• Any health condition that would pose a significant risk to others

Notification of patients exposed to the blood of a healthcare worker should be based on documentation of an injury to a healthcare worker or negligent practice. In such cases, the patient should be advised to receive testing for potential bloodborne pathogen exposure.

IMMUNIZATIONS

Vaccinating healthcare workers protects both themselves and patients.

Influenza

The CDC conducts studies each year to determine how well the influenza vaccine protects against flu illness. While effectiveness can vary, recent studies show that the vaccine reduces the risk by between 40% and 60% among the overall population during seasons when most circulating flu viruses are well-matched to the flu vaccine (CDC, 2020m).

The CDC, the Advisory Committee on Immunization Practices (ACIP), and the Healthcare Infection Control Practices Advisory Committee recommend that all U.S. healthcare workers get vaccinated annually against influenza.

Beginning in 2015, the Affordable Care Act linked failure to meet certain percentages of a healthcare facility’s employees vaccinated for influenza to federal reimbursement of Medicare and Medicaid funds. The goal was to have 90% compliance for healthcare workers by 2020 (CDC, 2019h). In 2018–19 flu vaccination coverage among healthcare personnel was 81.1%, similar to coverage during the past four seasons. As in previous seasons, coverage in the 2018–19 season was highest among healthcare workers in hospital settings (95.2%), followed by those working in ambulatory care (79.8%).

Hepatitis B

Federal law requires that all employees whose jobs involve participation in tasks or activities with potential exposure to blood or OPIM be offered hepatitis B vaccination. The vaccination is free, safe, and highly protective. This vaccine is given in three doses. Serologic testing after vaccination (to verify that the vaccination was effective) is recommended.

The vaccination schedule most often used is three intramuscular injections, the second and third doses administered 1 and 6 months, respectively, after the first dose. In 2018 a new formulation (Heplisav-B) was approved for two doses, one month apart (CDC, 2018).

Other Vaccines

Vaccinations recommended by the CDC for healthcare workers who do not have evidence of immunity are shown below.

CDC HEALTHCARE PERSONNEL VACCINATION RECOMMENDATIONS
(For healthcare workers who do not have evidence of immunity)

Vaccine	Recommendations in Brief
(CDC, 2020n)
Hepatitis B	Healthcare personnel without documented evidence of immunity Healthcare personnel without documented evidence of completed vaccine series
Influenza	All healthcare personnel, including volunteers and students
MMR (measles, mumps, and rubella)	Healthcare personnel without documented evidence of immunity Healthcare personnel born in or after 1957 without documentation of MMR vaccine
Varicella (chickenpox)	All healthcare personnel who have never had chickenpox, never had a vaccination, or who lack evidence of immunity
Tetanus, diphtheria, and pertussis (Td/Tdap)	All healthcare personnel who have not or are unsure if they have received a dose of Tdap (boosters needed every 10 years) Pregnant healthcare workers (dose of Tdap needed during each pregnancy)
Meningococcal	One dose for those who are routinely exposed to isolates of N. meningitides

Bloodborne Pathogens Training

OSHA requires employers to provide bloodborne pathogens training for all workers who may come into contact with blood and OPIM in their jobs.

• This training includes information on bloodborne pathogens and diseases, methods used to minimize risk and control occupational exposure, hepatitis B vaccine, and medical evaluation and postexposure follow-up procedures.
• Employers must offer this training on initial assignment, at least annually thereafter, and when new or modified tasks or procedures affect a worker’s occupational exposure.
• HIV and HBV laboratory and production facility workers must receive specialized initial training in addition to the training provided to all workers with occupational exposure. Workers must have the opportunity to ask the trainer questions. Training must be presented at an educational level and in a language that workers understand.

Although HBV and HIV are specifically identified in the OSHA Bloodborne Pathogens Standard, bloodborne pathogens include any pathogen present in human blood or OPIM that can infect and cause disease in people exposed to the pathogen. There are approximately 20 additional pathogens that can be transmitted by blood, including:

• HCV
• Malaria
• West Nile virus
• Syphilis
• Babesiosis
• Brucellosis
• Leptospirosis
• Arboviral infections
• Relapsing fever
• Creutzfeldt-Jakob disease (although not a microorganism)
• Adult T-cell leukemia/lymphoma (caused by HTLV-I)
• HTLV-I-associated myelopathy
• Diseases associated with HTLV-II
• Ebola (also known as Ebola hemorrhagic fever)
• Zika viral infection

It is yet unknown whether other nonrespiratory body fluids from an infected person, including blood, vomit, urine, breast milk, or semen, can contain viable infectious SARS-CoV-2 (NIEHS, 2020).

To prevent transmission of bloodborne pathogens to healthcare workers, the CDC recommends:

• Strict adherence to sharps safety guidelines and Standard Precautions
• Hepatitis B vaccination of healthcare workers
• Postexposure prophylaxis and counseling in the event of exposure incident

Exposure Control Plan

OSHA’s Bloodborne Pathogens Standard (OSHA, 2012) requires employers to:

1. Establish a written exposure control plan designed to eliminate or minimize employee exposure to bloodborne pathogens. Employers must:
   • Prepare an exposure determination that contains a list of job classifications in which all workers have occupational exposure and a list of job classifications in which some workers have occupational exposure, along with a list of the tasks and procedures performed by those workers that could result in exposure
   • Ensure that a copy of the exposure control plan is accessible to employees
2. Update the exposure control plan at least annually to reflect changes in tasks, procedures, and positions that affect occupational exposure, and also technological changes implemented to eliminate or reduce occupational exposure. Employers must:
   • Annually document in the plan that they have considered and begun using appropriate, commercially available, and effective safer medical devices designed to eliminate or minimize occupational exposure
   • Document that they have solicited input from frontline workers in identifying, evaluating, and selecting effective engineering and work practice controls

The exposure control plan is a key document to assist in implementing and ensuring compliance with OSHA standards, detailing information about the ways an employer provides a safe and healthy work environment, including:

• Who is responsible for implementing the plan
• Determination of employee exposure incidents
• Methods of exposure control, such as Standard Precautions; environmental, engineering, and work practice controls; PPE; and housekeeping methods
• Hepatitis B vaccination programs
• Postexposure evaluation and follow-up, as well as the procedures for evaluating the circumstances surrounding an exposure incident
• Communication of hazards to employees
• Training and recordkeeping

Employers are required to implement these preventive measures to reduce or eliminate the risk of exposure to bloodborne pathogens.

EMERGENCY STEPS FOLLOWING AN OCCUPATIONAL EXPOSURE

If an occupational exposure to blood or other body fluids occurs, the following steps must immediately be taken:

1. Wash needlestick injuries and open wounds with soap and water.
2. Flush splashes to nose, mouth, or skin with water.
3. If exposed, irrigate eyes with clean water, saline, or sterile irrigant.
4. Report the incident to the supervisor.
5. Immediately seek medical treatment.
   (CDC, 2016b)

EMPLOYER FOLLOW-UP

Following an exposure incident, the employer is required to:

• Perform a timely evaluation of the circumstances surrounding the exposure incident to find ways of preventing such a situation from occurring again
• Identify the source individual (unless the employer can establish that identification is not possible or prohibited by state or local law), and determine the source’s HBV and HIV infectivity status
• If the status of the source individual is not already known, test the source’s blood as soon as possible, provided the source individual consents
• If the source individual does not consent, establish that legally required consent cannot be obtained
• If state or local law allows testing without the source person’s consent, test the individual’s blood if it is available
• Make the results of the tests available to the exposed worker and inform the worker of the laws and regulations concerning disclosure of the source’s identity and infectivity status
• Provide a timely written report of the above information

Medical care as the result of an exposure is provided by the employer at no charge to the healthcare worker. All test records are confidential. The healthcare worker must be given a copy of the healthcare professional’s written opinion within 15 days after the medical evaluation is finished. Postexposure prophylaxis may be administered if medically necessary, as recommended by the U.S. Public Health Service. The healthcare worker should also be offered counseling that includes recommendations for transmission and prevention of HIV (OSHA, 2012).

Postexposure Prophylaxis (PEP)

The CDC and the Clinician Consultation Center offer guidelines for occupational postexposure prophylaxis.

HEPATITIS B

Following an exposure to HBV, prophylaxis can prevent HBV infection and subsequent development of chronic liver infection. The central component of postexposure prophylaxis is hepatitis B vaccine. In certain circumstances, hepatitis B immune globulin is recommended in addition to vaccine for added protection.

HEPATITIS C

There is no postexposure prophylaxis currently available or approved for HCV prevention. Following exposure, initial management recommendations are:

• The exposed individual should receive initial follow-up testing for HCV viral load (HCV RNA) at 6 weeks postexposure if the source person is HCV positive or has potential HCV risk factors.
• The exposed individual should have baseline HCV antibody (HCV Ab) testing with final follow-up testing at 6 months or later if the source person’s HCV status is unknown or if the source person’s status is known and has no known HCV risk factors. Optional testing can be done at 6 weeks for HCV viral load.
  (NCCC, 2020)

HIV

Occupational exposures require urgent medical evaluation. Baseline HIV testing of the exposed worker should be done even if the exposed worker refuses PEP treatment.

PEP should be initiated as soon as possible, ideally within 2 hours of exposure. A first dose of PEP should be offered while evaluation is underway and should not be delayed while awaiting information about the source person or results of the exposed worker’s baseline HIV test.

Whether the exposed worker accepts or declines PEP treatment, if postexposure evaluation shows that PEP is indicated, repeat HIV testing should be done at 4 and 12 weeks. If test results at 12 weeks are negative, HIV can reasonably be excluded in relation to an occupational exposure.

The preferred HIV three-drug occupational PEP regimen is Truvada orally once a day plus raltegravir orally twice a day or dolutegravir once a day for a duration of 28 days. If source person testing is found to be negative for HIV, PEP can be discontinued before 28 days (NCCC, 2020).

SARS-CoV-2/CORONAVIRUS

Higher-risk exposures generally involve exposure of the healthcare worker’s eyes, nose, or mouth to material potentially containing SARS-CoV-2. Close contact of 15 minutes or longer is considered a prolonged exposure, but any duration should be considered prolonged if the exposure occurs during performance of an aerosol-generating procedure.

A record of healthcare workers exposed to the virus should be maintained and should include whether or not the worker was:

• Wearing a respirator or mask
• Wearing eye protection if the source person was not wearing a cloth face covering or mask
• Wearing all recommended PPE while performing an aerosol-generating procedure

Healthcare workers who experience prolonged close contact should be excluded from work for 14 days after last exposure and be advised to self-monitor for fever or symptoms consistent with COVID-19. If fever or symptoms develop, they should immediately contact occupational health to arrange for medical evaluation and testing (CDC, 2020o).

EBOLA VIRUS

There are no FDA-approved vaccines or therapeutics available for Ebola virus disease prevention or postexposure.

ZIKA VIRUS

Healthcare workers who believe an occupational exposure to Zika virus has occurred should report it immediately to their supervisor and follow their employer’s procedures. This usually involves contacting the occupational health office for an assessment of the exposure with consideration of all bloodborne pathogens.

If it is determined that an occupational exposure did occur, testing might be indicated; however, this needs to be determined individually along with public health authorities and will depend on the type of exposure, infectious status of the source patient, and individual healthcare personnel factors, including pregnancy status (CDC, 2019b).