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 reevaluations, 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, 2019)

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, 2023d; NYSDOH, 2018)

Employees who report symptoms of illness should be removed from duty and medically evaluated to determine their ability to work and the duration of work restrictions.

Reporting of suspected or confirmed communicable diseases is mandated under the New York State Sanitary Code (10NYCRR 2.10). Although physicians have primary responsibility for reporting, school nurses, laboratory directors, infection control practitioners, day care center directors, healthcare facilities, state institutions, and any other individuals/locations providing healthcare services are also required to report communicable diseases.

Reports should be made to the local health department in the county in which the patient resides and must be submitted within 24 hours of diagnosis. However, some diseases warrant prompt action and must be reported immediately to local health departments by phone (NYSDOH, 2016). (See “Resources” at the end of this course for a link to New York’s “Communicable Disease Reporting Requirements.”)

STRATEGIES FOR PREVENTION AND CONTROL OF BLOODBORNE PATHOGEN TRANSMISSION

Healthcare workers who have or may be infected with hepatitis B virus (HBV), hepatitis C virus (HCV), or HIV should be evaluated for the ability to work safely. This evaluation is based on the premise that HBV, HCV, or HIV infection 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 (OSHA, 2023a).

Healthcare facilities are required to establish a mechanism for evaluating healthcare workers with HBV, HCV, or HIV infection. However, this does not include involuntary screening of employees for HBV, HCV, or HIV. New York State Public Health Law § 2781 requires verbally advising an individual before an HIV-related test is performed and allows for the individual to object.

Institutional evaluation of individual workers known to be infected with HBV, HCV, or HIV shall be based on New York State DOH criteria and shall involve consultation with experts who can provide a balanced perspective. Such experts can include:

• An infectious disease physician and/or hospital epidemiologist with an understanding of HBV, HCV, or HIV
• A representative from the infected healthcare worker’s practice area
• The personal physician of the infected worker

All matters related to evaluation must be handled confidentially.

All HIV-infected healthcare workers are entitled to protection under the NYS HIV Confidentiality Law. Such workers are not required to disclose their status to patients or employers.

IMMUNIZATIONS

Vaccinating healthcare workers protects both themselves and patients. For those who work directly with patients or handle material that could spread infection, the CDC recommends several vaccines, described in the table below (CDC, 2023i).

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 2022–2023 vaccine reduced the risk by 75% in the pediatric population, with 45% less likely to visit an emergency room with flu symptoms. Among adults, 18–64-year-olds were 43% less likely to be hospitalized with the flu, while those over 65 were 35% less so (CDC, 2023k).

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

From October 2022 through April 2023, between 27–54 million people in the United States were infected with influenza. Between 300,000 and 650,000 individuals were sufficiently ill to require hospitalization, and there were 19,000–58,000 deaths due to influenza. Because the flu is not required to be reported, these numbers are not representative of the total number of cases of flu during this 18-month period. These figures are considered to be lower than usual because people were taking precautions during the COVID-19 pandemic that protected them from contracting the flu (CDC, 2023g).

New York Codes, Rules, and Regulations, Title 10, Section 2.59, requires all healthcare and residential facilities and agencies to document the influenza vaccination status of all personnel for the current influenza season in each individual’s personnel record or other appropriate record. During the influenza season, all healthcare and residential facilities and agencies shall ensure that all personnel not vaccinated against influenza for the current influenza season wear a surgical or procedure mask while in areas where patients or residents are typically present.

This law requires long-term care facilities, adult homes, adult day healthcare facilities, and enriched housing programs to provide or arrange for influenza vaccination for all residents and employees every year. The law also requires these types of facilities to provide or arrange for pneumococcal vaccinations for all residents and employees for whom the vaccine is recommended per guidelines issued by ACIP (NYS, 2014).

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 (CDC, 2023h).

Other Vaccines

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

The New York State of Code of Rules and Regulations currently requires that healthcare workers demonstrate immunity or be vaccinated against measles, rubella, and diseases that can be effectively controlled by one or two doses of a highly efficacious vaccine (NYS, 2023a).

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

Vaccine	Recommendations in Brief
(CDC, 2023i)
Hepatitis B	Healthcare personnel without documented evidence of immunity Healthcare personnel without documented evidence of completed vaccine series Healthcare personnel with a reasonable exposure to the disease
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 Two doses of MMR vaccine 28 days apart
Varicella (chicken pox)	All healthcare personnel who have never had chicken pox, never had a vaccination, or who lack evidence of immunity Two doses of varicella vaccine
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 Especially needed for preteens and teens because of higher incidence
COVID-19	One dose of an updated COVID-19 vaccine to protect against serious illness from COVID-19

Bloodborne Pathogens Training

OSHA (2020b) 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 human T-lymphotropic virus type 1 [HTLV-1])
• HTLV-1-associated myelopathy
• Diseases associated with HTLV-2
• 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 (Denault & Gardner, 2023; NIEHS, 2023).

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
  (NIEHS, 2023)

Exposure Control Plan

OSHA’s Bloodborne Pathogens Standard (OSHA, 2020b) 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 (MFASCO, 2023).

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. Clean the contaminated area thoroughly with soap and water.
2. Wash needlestick injuries, cuts, and exposed skin with soap and water.
3. Flush out any splashes of blood and OPIM to the mouth and nose with water.
4. If the eyes are involved, irrigate with clean water, saline, or sterile irrigants for 20 minutes.
5. Seek immediate follow-up care as identified in the facility’s exposure control plan.

Medical treatment should include an immediate postexposure evaluation, prophylaxis treatment, and appropriate follow-up care, all of which should be conducted by a physician at no cost to the employee.

All incidents should be reported and documentation completed as soon as possible. However, medical treatment should not be delayed in order to fill out paperwork.

An exposure incident report includes the following:

• The time, date, and location of the exposure
• An account of all the people involved, including the exposed person, names of their first aid providers, and, if possible, the name of the source individual
• The circumstances of the exposure, any actions taken after the exposure, and any other information required by your employer
  (ProBloodborne, 2023)

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, 2020b).

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

Below are CDC guidelines for testing source patients and healthcare personnel (HCP) potentially exposed to hepatitis C virus. A source patient or HCP who is positive for HCV RNA should be referred to care.

Postexposure prophylaxis with direct-acting antivirals (DAAs) is not recommended for occupational exposures to hepatitis C. This is due to the low risk of hepatitis C infection after exposure (0%–0.2%), the effectiveness of DAAs in curing hepatitis C infections, the high cost of DAA treatments, and lack of research supporting the use of DAAs for hepatitis C postexposure prophylaxis (Corcoran, 2021).

Source-Patient Testing

• Testing of the source patient may follow option A (preferred), which is testing with a nucleic acid test (NAT) for hepatitis C virus (HCV) RNA, or option B, which is testing for anti-HCV with reflex to an NAT if positive.
• If a source patient is known or suspected to have recent behaviors that increase risk for HCV acquisition (e.g., injection drug use within the previous 4 months) or if risk cannot be reliably assessed, initial testing should include a NAT.
• Follow-up testing of health care personnel (HCP) is recommended if the source patient is HCV RNA positive, anti-HCV positive with RNA status unknown, or cannot be tested.

Healthcare Personnel Testing

• Baseline testing of HCP for anti-HCV with reflex to a NAT if positive should be conducted as soon as possible (preferably within 48 hours) after the exposure and may be simultaneous with source-patient testing.
• If follow-up testing* of HCP is recommended based on the source-patient’s status, test with a NAT at 3–6 weeks postexposure.
• If the HCP is NAT negative at 3–6 weeks postexposure, a final test* for anti-HCV at 4–6 months post exposure is recommended.

* Follow-up testing of HCP is also warranted when concerns exist about specimen integrity, including handling and storage conditions that might have compromised source-patient test results, or if they exhibit any clinical signs of HCV infection (Moorman et al., 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. HIV can be established as soon as 24–36 hours after exposure. PEP is not recommended >72 hours after exposure.

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 (emtricitabine plus tenofovir) 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 (CDC, 2023j).

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. It is considered higher risk if the healthcare worker is not wearing a respirator, or, if wearing a mask, if the person with COVID is not wearing a mask. It is also considered high risk if a healthcare worker is not wearing a face shield and the person with COVID is not wearing a mask. 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 surgical-grade mask
• Wearing all recommended PPE while performing an aerosol-generating procedure

Healthcare workers who are exposed to COVID-positive individuals do not need to implement work restrictions if they exhibit no symptoms and test negative for COVID at 24 and 48 hours after the exposure, unless the healthcare worker is moderately to severely immunocompromised or works with patients who are moderately to severely immunocompromised. If a work restriction is indicated, healthcare workers can return to work after 7 days if they are asymptomatic and test negative. They must be afebrile for 24 hours without the assistance of antipyretic medication. If fever or symptoms develop, they should immediately contact occupational health to arrange for medical evaluation and testing (CDC, 2022e).

A systematic review of 17 resources regarding hydroxychloroquine, lopinavir-ritonavir (LPV/r), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), vitamin D, arbidol, thymosin drugs, and Xin guan no.1 (XG.1, a Chinese formula medicine) showed little if any benefit as PEP agents to treat SARS-CoV-2 (Seyed Alinaghi et al., 2023).

EBOLA VIRUS

There are two developed monoclonal antibody treatments recommended by the WHO to treat Ebola: mAb114 (Ansuvimab, Ebanga) and REGN-EB3 (Inmazeb). It is considered that these have contributed to reducing the fatality from Ebola from 90% to 50% of all cases (WHO, 2023d).

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.

Prevention involves control of the Aedes mosquito, considered to be the primary vector. Although there is ongoing research for prevention and treatment for the Zika virus, there is currently none available. The disease is treated symptomatically for fever, rash, conjunctivitis, malaise, headache, and muscle and joint pain (WHO, 2023e).