David Jay Weber, M.D., M.P.H.
Professor of Medicine, Pediatrics & Epidemiology
Associate Chief Medical Officer
Medical Director, Occupational Health & Hospital Epidemiology
University of North Carolina at Chapel Hill

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Understand activities of an occupational health service
(OHS) in a healthcare facility
Be able to list vaccines recommended for healthcare personnel (HCP)
Be able to list infectious diseases relevant to HCP for which post-exposure prophylaxis is available
Be able to manage exposure to blood or a contaminated fluid

It is the responsibility of the facility, to the extent possible, to provide a safe working environment.
This includes minimizing the risk of infectious disease exposures and injuries. An organized program should be in place to identify and evaluate both infectious disease exposures and injuries, and to provide care of the exposed or injured employee.

 A casual attitude towards employee health entails a high cost
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Increased patient morbidity
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Increased staff morbidity
Significant financial cost and legal risk
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Prevention is superior to treatment
The tools used to reduce the risk of acquiring infection can be used to reduce the risk of injuries

OSHA
NIOSH CDC
Health Department FDA
External Stakeholders
---------------------------- Occupational Health Service ------------------------------
Internal Stakeholders
Legal/Administration
Medical Staff
Safety
Worker’s compensation
Infection Control

 Pre-employment screening
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Immunization review
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Employment physical (selected; DOT, FAA, police)
Drugs/alcohol screening
Latex allergy screen (history; if positive, blood test)
Screen for active TB (symptoms; if positive CxR, sputums?)
Screen for latent TB (TST or IFGR blood test)
Fit test clearance (questionnaire, medical exam?); N95 fit testing
Hearing evaluation/audiogram (if indicated by noise exposure)
Counseling: pregnant women, immunocompromised

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Annual screening
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Immunization review
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Screen for active TB (symptoms; if positive CxR, sputums?)
Screen for latent TB (TST or IGRA blood test)
Evaluation of injured employees
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First aid
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Long-term care
Communication with Worker’s Compensation
Return to work evaluation (non-occupational diseases and/or injuries)

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Evaluation of employees with a potentially communicable disease
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Need for exposure evaluation
Need for work restriction
Therapy if indicated
Infectious disease exposures
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Determination of exposure & risk of disease transmission
Evaluate for post-exposure prophylaxis
Consider need for work restrictions
Communicate with infection control if patients exposed

 Work site evaluation
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For cause drug/alcohol testing
Education
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Fire, chemical, radiation safety
Infection control (communicable diseases, TB, bloodborne pathogens)
Ergonomics
Smoking cessation

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Employers must establish an Exposure Control Plan (reviewed yearly)
Employers must utilize a hierarchy of methods to prevent exposure to blood or potentially contaminated body fluids
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Engineering controls (e.g., needleless devices)
Work practice controls (e.g., single handed recapping)
Mandates use of universal precautions (all body fluids assumed contaminated except sweat)
Requires offering hepatitis B vaccine to persons with the potential for exposure
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Persons may refuse by signing a declination form
PEP must be immediately available as per CDC guidelines
Yearly training required
Federal Register December 6, 1991;56:64003–64182

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Rule proposed by OSHA 997; withdrawn 2003 [compliance required with 29 CFR 1910.134 – Respiratory Protection; 29 CFR – General Duty Clause
Section 5(a)(1)]
CDC recommendations
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Prompt detection of infectious patients
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Airborne precautions (private room, >12 air exchanges per hour, direct out exhausted air)
Treatment of people with suspected or confirmed TB disease
Hierarchy of control measures
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Administrative measures: TB risk assessment of the setting, TB control plan, timely lab testing, training and educating HCP, screen exposed HCP
Environmental control: Airborne isolation, proper hoods in labs
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Use of respiratory protective equipment (per OSHA - N95 respirator, medical clearance, yearly fit testing)
CDC: http://www.cdc.gov/tb/topic/infectioncontrol/default.htm
OHSA: https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=18050
OHSA: https://www.osha.gov/SLTC/etools/hospital/hazards/tb/tb.html

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Outlaws discrimination based on a “disability”
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Allows employers to exclude persons who pose a “direct threat”
Disability is defined as a physical or mental impairment that substantially limits one or more major life activities
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Does not apply to a transitory impairment (duration <6 months)
Impairment can be episodic or in remission
Employee must request an accommodation
Excludes persons who are engaging in use of illegal drugs or alcohol (covers persons post drug rehabilitation) – permits use of drug testing
Requires employers to make “reasonable accommodations”
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Defined by person’s private physician
Accommodations should place undue hardship on employer
Allows employer to require a medical exam after hiring a job applicant (but employer cannot require an exam before making a job offer) http://www.ada.gov/pubs/adastatute08.htm

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Requires employers to grant eligible employees up to a total of 12 weeks of unpaid leave during any 12-month period for one of the following
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Birth and care of a child, or adoption
Care for an immediate family member (spouse, child, parent) with a serious health problem
Medical leave when employee is unable to work because of serious health problem
Family member on active duty with military with a serious injury or illness
Employers may require employee to take an accrued paid vacation or medical leave concurrently with FMLA
Employees responsibility to request FMLA
Employee’s medical provider must provide a certification form http://www.dol.gov/whd/fmla/index.htm

 Infections
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Viral respiratory diseases
Aerosol transmitted diseases: Tuberculosis, pertussis
Bloodborne pathogens: Percutaneous, mucus membrane
Contact transmitted diseases: Syphilis, MRSA
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Fecal oral: Norovirus, rotavirus

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Injuries
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Work-related (e.g., falls, strain, sprain)
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Ergonomic (e.g., strain, sprain, repetitive motion)
Dermatitis (related to latex gloves, antiseptics)
Hearing loss (noise related)
Indoor air quality

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Chemicals: Anti-neoplastics, disinfectants & sterilants, anesthetic gases, organic solvents, mercury, asbestos
Radiation: Ionizing radiation, radioisotopes
Lasers
Fire and electrical
Violence
Psychosocial stress
Bioterrorist agents (microbial, chemical, nuclear)

Person with LTBI (Infected)
Has a small amount of TB bacteria in his/her body that are alive, but inactive
Cannot spread TB bacteria to others
Does not feel sick, but may become sick if the bacteria become active in his/her body
Usually has a TB skin test or TB blood test reaction indicating TB infection
Person with TB Disease (Infectious)
Has a large amount of active TB bacteria in his/her body
May spread TB bacteria to others
May feel sick and may have symptoms such as a cough, fever, and/or weight loss
Usually has a TB skin test or TB blood test reaction indicating TB infection
Radiograph is typically normal Radiograph may be abnormal
Sputum smears and cultures are negative Sputum smears and cultures may be positive
Should consider treatment for LTBI to prevent TB disease
Needs treatment for TB disease
Does not require respiratory isolation
Not a TB case
May require respiratory isolation
A TB case

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Test methods
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Mantoux tuberculin skin test (TST)
IGRA
IGRA can be used in place of TST
These tests do NOT exclude LTBI or TB disease
Decisions about medical management should include other data and not just rely on TST/IGRA results
Cannot switch back and forth between TST and IGRA
2-Step testing: Recommended for person who have not had TST within previous 12 months (required for staff and patients of LTCF)
NC TB manual = http://epi.publichealth.nc.gov/cd/lhds/manuals/tb/toc.html

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TST of individuals and groups should be undertaken only if the diagnostic evaluation and a course of preventive therapy can be completed
Routine testing of low-risk individuals is NOT recommended
The following adults are legally required to receive a TST:
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Patients and staff in long term care facilities upon admission and employment, using the 2-step skin test method
Household and other close contacts of active cases of pulmonary and laryngeal TB
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Persons reasonably suspected of having TB disease
Persons with HIV infection or AIDS
NC TB Policy Manual, New Edition, 23 January 2012

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TST advantages
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Standard for years
Inexpensive
TST disadvantages
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Requires 2 (or 4 visits)
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Requires proper placement
Requires reading
May be positive due to prior
BCG
PPD in short supply
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IGRA advantages
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Not dependent on experienced users
Single visit
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Not affected by prior BCG
IGRA disadvantages
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Expensive
Wobble

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Inject 0.1 mL of PPD (5-TU) intradermally into forearm between skin layers
Produce wheal (raise area) of 6-10 mm in diameter
Requires 2-8 weeks after exposure to turn positive (CDC, wait 10 weeks)
2-step testing: Place and read PPD, and if negative repeat in 2-4 weeks to check for booster phenomenon
Two-step method not needed if a person has ever had a tw-step skin test OR if the person has had a single skin test within the last 12 months (i.e., If PPD in past year that counts as first step in 2-step testing)
Follow standard precautions for infection control

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Read 48-72 hours after injection
Palpate (feel) injection site to find raised area
Measure diameter of induration across forearm; only measure induration, not erythema
Record size of induration in mm

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>5 mm is classified as positive:
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HIV-infected persons
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Recent contacts of infectious TB
Persosn with fibrotic changes on CxR consistent with prior TB
Patients with organ transplants and other immunocompromised persons
>10 mm is classified as positive:
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Recent arrivals from high-prevalence countries (< 5-years)
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Inject drug users
Residents and personnel (HCP) of high-risk congregate settings
Persons with conditions that increase the risk for progression to active TB
Children <4 years of age
>15 mm is classified as positive:
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Persons with no known risk factors for TB

 False-Positive
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NTM
BCG vaccination
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Problems with TST administration
 False-Negative
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Anergy
Viral, bacterial, fungal infection
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Very youg; advanced age
Live-virus vaccination
Overwhelming TB
Renal failure/disease
Lymphoid disease
Low protein states
Immunosuppressive drugs
Problems with TST administration

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Anthrax ( PEP )
Cervical, vulvar, vaginal cancer (HPV)
Diphtheria ( outbreak )
Genital warts (HPV)
Hepatitis A ( PEP, outbreak )
Hepatitis B ( PEP )
Hepatitis D
H. influenza type b
Human papillomavirus
Influenza A and B
Japanese encephalitis
Liver cancer (hepatitis B)
Lyme disease
Measles ( PEP , outbreak )
Meningococcal ( outbreak )
Monkeypox
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Mumps ( outbreak )
Pertussis ( outbreak )
Pneumococcal disease
Poliomyelitis ( outbreak )
Rabies ( PEP )
Rectal cancer (HPV)
Rotavirus
Rubella ( outbreak )
Smallpox ( PEP , outbreak )
Tetanus ( PEP )
Tuberculosis
Typhoid fever
Varicella ( PEP )
Yellow fever
Zoster (Shingles)
PEP = post-exposure prophylaxis

ADULT IMMUNIZATION SCHEDULE, US, 2014

ADULT IMMUNIZATION SCHEDULE, US, 2014

 Influenza
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Older vaccines
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Standard IM inactivate influenza vaccine (TIV) {>6 mo}
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Inhaled live-attenuated influenza vaccine (LAIV) {2-49}
Newer vaccines
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Licensure of high titer influenza vaccine for persons 65 years and older
(improved immunogenicity and efficacy) {>65 years}
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Licensure of intradermal influenza vaccine {18-64 years}
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Licensure of cell culture-based influenza vaccine*^ {>18 years}
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Licensure of 2 quadrivalent influenza (2 A, 2 B strains) vaccines* {>3}+
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Licensure of recombinant influenza (HA only) vaccine*^ {18-49}
* No ACIP statement available, ^ not produced in eggs, +inactivated vaccine

 Influenza
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1 annual dose for all persons >6 months of age
Required to be offered to residents and HCP in ECFs in NC
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Immunize as soon as vaccine becomes available for the current season

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Polysaccharide vaccine (PPSV23)
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Contains 23 different pneumococcal strains
FDA approved for all person >50 years of age
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FDA approved for high risk persons 19-64 years of age
Conjugate vaccine (PCV13)
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Contains 13 different pneumococcal strains
Conjugation with diphtheria toxin may improve immunogenicity
FDA approved for all person >50 years of age

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Pneumococcal (polysaccharide, PPSV23)
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Age >65: All persons
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Age >19: Medical or other risk indications
Required to be offered to residents in ECFs in NC
Revaccination may be recommended (first dose <65 years AND now >65 years AND >5 years have passed)
Pneumococcal (conjugate, PCV13)
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Age >19: Medical or other risk indications
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No recommendation for revaccination
Immunocompromised persons (see chart, next slide)
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Vaccine naïve: PCV13 following at least 8 weeks later by PPSV23
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Previous receipt of PPSV23: PCV13 >1year after last PPSV23

CDC. MMWR 2012;61:816

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Zoster
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One dose for persons >60 years of age regardless of whether they had a prior episode of zoster
FDA approved for persons >50 years of age - ACIP statement to be delayed (pending resolution of vaccine shortage)
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Live attenuated vaccine; avoid in immunocompromised persons
Meningococcal
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Recommended for adults had high risk of disease
2-dose primary series administered 2-months apart for persons 2-54 with persistent complement deficiency, functional or anatomic asplenia, or HIV infection (adolescents)
MCV4, persons <55 years; MPSV4 persons >56 years

 Tetanus-diphtheria-acellular pertussis (/Tdap)
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Substitute 1 dose Tdap for all adults when Td booster due
May be use to provide tetanus PEP
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Provide to all adults with exposure to young children (no delay after Td)
Recommended for pregnant women (preferably 2 nd or 3 rd trimester)

 Hepatitis B
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Occupation: HCP
Medical: clotting disorder, hemodialysis, ESRD
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Behavioral: Multiple sexual partners, injecting drug users, hx STD
Other: Household/sexual contact with chronic HBV, travel, inmate >6 mo, clients/staff of institution for developmentally disable
Diabetes (new)
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Hepatitis B vaccination should be administered to unvaccinated adults with diabetes who are aged 19 through 59 years (A, 2)
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Hepatitis B vaccination may be administered at the discretion of the treating clinician to unvaccinated adults with diabetes who age aged >60 years (B, 2)

 Mumps, measles, rubella (MMR)
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Mumps
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Born before 1957: Considered immune (except during outbreak)
Born during or after 1957: 1 or more doses
Immunity = Appropriate immunizations or positive serology
Measles
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Born before 1957: Consider immune (except during outbreak)
Born after 1957: 1 or more doses
Immunity = Appropriate immunizations or positive serology
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Rubella
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1 dose of MMR to susceptible women of childbearing potential
Immunity: Positive serology or documented vaccine

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Varicella: 2 doses
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Special consideration should be given to those who have close contact with persons at high risk for severe disease (e.g., immunocompromised persons), are at high risk for exposure or transmission (e.g., teachers of young children, college students, military recruits, international travelers)
Immunity: Birth before 1980 (not HCP or pregnant women), history of varicella or zoster by a HCP, positive serology, or laboratory evidence of infection
HPV: 3 doses (0, 2, 6)
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All women and men <26 years of age (only quadrivalent vaccine from
Merck approved for men)

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Hepatitis B (OHSA required)
Influenza*
Measles (MMR preferred)*
Mumps (MMR preferred)*
Rubella (MMR preferred)*
Varicella (V)*
Tetanus (Tdap)*
Diphtheria (Tdap)*
Pertussis (Tdap)*
* Required at UNC

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Anthrax: Post-exposure
BCG: Pre-exposure (high risk)
Hepatitis A: Post-exposure , outbreak, research, travel
Japanese encephalitis: Research, travel
Meningococcal: Outbreak, laboratory (spinning CSF), travel
Polio: Research, travel
Rabies: Post-exposure , research, travel
Typhoid: Research, travel
Vaccinia: Pre-exposure?, post-exposure , research
Yellow fever: Research, travel

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Indications
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Universal; HCP with potential blood exposure (OSHA required OR signed refusal)
Administration
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IM dose into deltoid; 1-1.5” needle, 20-25 gauge
Schedule: 0, 1, 6 mo (May interchange current vaccines)
Prior to administration do not routinely perform serologic screening for
HB unless cost effective
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After 3rd dose, test for immunity (>10 mIU/mL){OSHA required}; if inadequate provide 3 more doses and test again for immunity; if inadequate test consider as “nonresponder”
If non-immune after 6 (or 3) doses, test for HBsAg

Estimated Incidence of HBV infections among
HCP and General Population,
United States, 1985-1999
350
300
250
200
150
100
50
0
Healthcare Personnel
General U.S. Population
1985 1987 1989 1991 1993 1995 1997 1999
Year

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1970s: HCP had a prevalence of
HBV infection ~10x greater than that of general population
1983: ~17,000 HBV infections among HCP
Currently: ~263 acute HBV infections
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Due to HBV vaccine and
Improvements in infection control practices

CDC
MMWR
2013;62
(RR-10)

 Healthcare facility employees - requirement for employment
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Medical staff - include in credentialing process
Students - require for attending class
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Volunteers - require
Contract workers - require in contract
 Emergency responders

Vaccine Birth before
1957
Mumps  1
Measles
Rubella
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
1
1,2
Varicella
Hepatitis B
Pertussis
Influenza
No
No
No
No
MD Dx + Serology Self Report Documented
Vaccination
Yes 3  No 
Yes 3
No
Yes
No
No
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 4
>10 MIU/mL
No
No
4
No
No
No
No
No
No
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1 Consider immunization of HCP born before 1957, recommend during an outbreak;
2 All HCP of childbearing potential should be immunized; 3 requires lab confirmation ;
4 Obtain 1-6 months post last vaccine dose Weber DJ, Schaffner W. ICHE 2011;32:912-4

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Patient name and identification number
Vaccine
Dose, Site, Route of Administration
Date given
Manufacturer
Lot number
Name, title & address of person providing vaccine
Date next dose due
Informed consent

 Pre-immunization testing for immunity
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Do not obtain serological screening for immunity unless costeffective, desired by employee (may require employee to bear cost), or vaccine contraindicated (e.g., MMRV, hepatitis B)
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Post-immunization testing for immunity
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Indicated for hepatitis B, rabies (high risk exposure)
Consider persons with an with an “indeterminate” antibody level susceptible

 Employee Data
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Name, unit number, job description
Date, incident form completed
Employer, supervisor
 Source Data
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Name, unit number, location, infection(s)
 Exposure Data
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Location, date, type & circumstances of exposure

 Determine if source case has infection and is infectious
 Determine transmission possible (i.e., appropriate exposure without protection)
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Determine if employee is susceptible (may require labs)
Determine if prophylaxis available & indicated
Consider alternative prophylaxis (if available) if employee has contraindications to prophylaxis of first choice
Arrange follow-up

 Information to be provided to HCP who are exposed to an infectious agent
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Recommended follow-up
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Risk (if known) of transmitting the infection to patients, other personnel, or other contacts
Methods of preventing the transmission of infection to other persons

 Information to be provided to HCP who are offered prophylaxis
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Alternative means of prophylaxis
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Risk (if known) of infection if treatment not accepted
Degree of protection provided by therapy
Potential side effects of therapy

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Anthrax
Avian influenza (H5N1)
Diphtheria
Hepatitis A
Hepatitis B
HIV
Human bite wound
Influenza A
Influenza B
Measles
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Meningococcal infection
Monkey bite
Monkeypox
Pertussis (whooping cough)
Rabies
Smallpox
Syphilis
Tuberculosis (TB)
Varicella (chickenpox)
Zoster (shingles)

 Hepatitis C
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Mumps
Parvovirus B19
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Rubella
Severe acute respiratory distress syndrome (SARS)

Source
HBV
HBeAg +
HBeAg -
HCV
HIV
Risk
22.0-30.0%
1.0-6.0%
1.8%
0.3%

 Percutaneous exposure to contaminated body fluid
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Mucous membrane exposure to contaminated body fluid
Non-intact skin expose to contaminated body fluid
 Contaminated fluids: blood, CSF, vaginal secretions, semen, synovial, pleural, peritoneal, pericardial, amniotic

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Test source for hepatitis B (HBsAg), hepatitis C, HIV
(consider rapid test)
Provide hepatitis B prophylaxis, if indicated
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Provide follow-up for hepatitis C, if indicated
If source HIV+ or at “high risk” for HIV, exposure confirmed, offer employee HIV prophylaxis per CDC protocol
 Maintain confidentiality: Separate records, labs & pharmacy requisitions sent with code number

 OSHA requirements
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Employer shall make immediately available a confidential medical evaluation and follow-up
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Identification and documentation of source case; test source case for HBV, HCV and HIV after consent (if required)
Offer to test employee for HBV and HIV (if employee refuses HIV testing hold blood for 90 days)
Offer post-exposure prophylaxis, as medically indicated, per
CDC recommendations; offer counseling
Provide employee with results of evaluation with 15 days

State regulations
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When the source case is known, the attending physician or occupational health provider responsible for the exposed person shall notify the healthcare provider of the source case that an exposure has occurred. This healthcare provider shall arrange HIV testing of the source person (unless known to be HIV+) and notify the
OHS provider of the test results.
In the event consent is refused the local health director may order testing

HIV infections in HCP as a result of exposures (12/2001)
 Documented conversions = 57
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26 have developed AIDS
 Types of exposures
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Percutaneous exposure 48, mucocutaneous 5, both 2, unknown route of exposure 2
 Source of exposure
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HIV-infected blood 49, concentrated virus in lab 3, visibly bloody fluid 1, unspecified fluid 4

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PEP is recommended when occupational exposures to HIV occur
HIV status of exposure source patient should be determined, if possible, to guide need for HIV PEP
PEP medication regimens should be started as soon as possible after exposure to HIV, and should be continued for a 4-week duration
New recommendation: PEP medication regimen should contain 3 (or more) antiretroviral drugs for all occupational exposures to HIV
Close follow-up for exposed person should be provided; follow-up should begin within 72 ours of an HIV exposure
Expert consultation recommended for any occupational exposure to HIV
New recommendation – if newer 4 th generation combination HIV p24 Ag HIV test is used for follow-up of exposed HCP, HIV testing may be concluded 4 months after exposure; in a newer test is not available, follow for 6 months
Kuhnar DT, et al. ICHE 2013;34:875-892

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Primary prevention of occupational exposures
Prompt management of occupational exposures
Selection of PEP regimens that have the fewest side-effects and are best tolerated by prophylaxis recipients
Anticipating and preemptively treating side effects commonly associated with taking anti-retroviral drugs
Attention to potential interactions involving both drugs that could be included in HIV PEP regimens, as well as other medications that PEP recipients could be taking
Consultation with experts on PEP management strategies
HIV testing of source patients (without delay in PEP initiation) using methods that product rapid results
Counseling and follow-up of exposed HCP






HCP = all paid and unpaid persons working in healthcare settings who have the potential for exposure to infectious materials, contaminated medical supplies and equipment, or contaminated environmental surfaces (e.g., ED, dental, lab, autopsy personal; MDs, RNs, technicians, pharmacists, students, trainees, etc.)
Exposure that place HCP at risk = Percutaneous injury, contact of mucous membranes or nonintact skin with blood, tissue, or other potentially infected material (OPIM)
Potentially infectious material = blood, visibly bloody body fluids, semen, vaginal secretions. Also CSF, synovial fluid, pleural fluid, peritoneal fluid, amniotic fluid, pericardial fluid.
No known risk (unless visibly bloody) = feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus
Human bites result in 2-way exposure




Type of exposure

Percutaneous ~0.3%

Mucous membrane = ~0.09%
For percutanous exposure, factors increasing risk of HIV acquisition





A device visibly contaminated with patient’s blood
A procedure that involved a need being placed directly in a vein or artery
Deep injury
Blood from a person with late stage disease
Hollow bore (as opposed to solid bore) needle
Despite lower risk, PEP should still be offered even if the source patient has an undetectable viral load





Obtain expert consultation if source patient is known to harbor drugresistant HIV (but do NOT delay initial therapy to obtain consultation)
If exposed person is pregnant, obtain expert consultation (but in general safe anti-retroviral therapy is available)
Breast feeding is NOT a contra-indication to PEP but lactating HCP should be counseled regarding the high risk of HIV transmission through breast milk (stopping breast feeding is the best method to completely protect the fetus)
Each healthcare facility should develop a plan to assess exposures and provide timely PEP








PEP is NOT recommended if source if HIV negative
Re-evaluate exposed HCP within 72 hours post-exposure
Ideally use a rapid (results in ~ 30 minutes) to test source patient
Ideally use a 4 th generation HIV test (combined antibody/antigen test)
Use of a 4 th generation tests allows identification of most infections during the “window period”
Do not be concerned about the “window period” (i.e., source antibody negative but virus positive)
If source patient not immediately available for testing, begin PEP
(discontinue if source patient is HIV negative)





Initial PEP within hours of exposure
PEP is likely to be less effective when started more than 72 hours post-exposure (but the interval after which no benefit is gained from
PEP in humans is unknown)
Provide PEP for 4 weeks
Provide 3-drug HIV PEP regimen



3 drugs superior in reducing viral burden in HIV infected persons
Decreases concerns about possible drug resistance in source patient
New regimens have improved safety and tolerability

New regimens have fewer side effects (likely therefore improved adherence)

 Preferred PEP


Embricitabine (FTC) plus tenofovir (TDF) – dispensed as Truvada PLUS
Raltegravir (RAL)


Regimen is tolerable, potent, conveniently administered, minimal drug interactions
Likely safe in pregnancy (limited data)








Pathogens: A (most severe; pandemics), B (less severe; epidemics) and C (mild)
Geographic distribution: Global
Reservoir: Humans, swine, birds
Incubation: 1-5 days (average ~2 days)
Transmission: Droplet (airborne?), direct and indirect contact
Communicability


1-2 days before onset of symptoms to 7 days post-onset (adults) or 10 days (children)
Attack rate: Up to 60% in closed setting
No carrier state but inapparent or mild illness may occur

Deaths
25,000 - 72,000
Hospitalizations
114,000 - 257,500
Physician visits
~ 25 million
Infections and illnesses
50 - 60 million
Thompson WW et al. JAMA. 2003;289:179-86. Couch RB. Ann Intern Med. 2000;133:992-8.
Patriarca PA. JAMA. 1999;282:75-7. ACIP. MMWR. 2004;53(RR06):1-40.

Influenza Sign/Symptom Children Adults Elderly
Cough (nonproductive)
Fever
Myalgia
Headache
Malaise
Sore throat
Rhinitis/nasal congestion
Abdominal pain/diarrhea
Nausea/vomiting
++
+
+
+
++
++
+++
+
++
+
++
++
–
–
++++
+++
+
++
+++
+
+
+
+
+++
+
+
+
++++ Most frequent sign/symptom; + Least frequent; – Infrequent
Monto AS et al. Arch Intern Med. 2000;160:3243-47. Cox NJ et al. Lancet. 1999;354:1277-82.

Frequent
Rare
Exacerbations of underlying disease
Children
Sinusitis, bronchitis, bronchiolitis, pneumonia, croup, acute otitis media
Encephalopathy, myositis, rhabdomyolysis, myocarditis, pericarditis, Reye syndrome, sepsis-like syndrome
Cardiovascular, diabetes, asthma, cystic fibrosis
Adults
Primary viral pneumonia, secondary bacterial pneumonia, sinusitis, bronchitis
Myositis, rhabdomyolysis, myocarditis, pericarditis
Cardiovascular, diabetes, asthma, COPD
Loughlin J et al. Pharmocoeconomics. 2003;21:273-283. Treanor JJ. Influenza virus. In: Mandell GL, Bennett
JE, Dolin R, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 5th ed.
Philadelphia, PA: Churchill Livingstone; 2000:1823-1849. ACIP. MMWR 2004;53 (RR06):1-40.

CDC. MMWR 2008;57(RR-18):1-59

Type of Nuclear
Material Hemagglutinin
Neuraminidase
A / Sydney / 184 / 93 (H3N2)
Virus type
Geographic origin
Strain number
Year of isolation
Virus subtype
1. CDC. Atkinson W, et al. Chapter 13: Influenza. In: Epidemiology and Prevention of Vaccine-Preventable Diseases, 4th ed. Department of Health and
Human Services, Public Health Service, 1998, 220

1918
H1N1 “Spanish”
1947
H1N1
1977
H1N1 “ Russian ”
… … … … …
2009
H1N1 pdm09
1957
H2N2 “Asian” flu
1968
H3N2 “Hong Kong” flu
1940
Influenza B







Respiratory hygiene
Hand hygiene
Droplet precautions for ill patients
Furlough for ill HCP
Influenza vaccine for HCP and patients
May use antiviral for pre-exposure (only if vaccine contra-indicated),
PEP (immunocompromised, pregnant), and treatment

80.0%
60.0%
40.0%
20.0%
0.0%
Standard Dose
High Dose
A/H1N1 A/H3N2 B
Falsey AR, et al. JID 2009;200:172-80

PD ILI = protocol-defined influenza-like illness; presented Oct. ACIP meeting



More than 25 outbreaks described in literature in acute care hospitals


Infected staff may initiate outbreak or aid in propagation
HCW infection may lead to absenteeism and disruption of health care

Attack rates in HCWs have ranged from 25% to 80%
More than 15 outbreaks described in literature in extended care facilities

Important morbidity and mortality among residents may result

High rates of immunization (>60%) among staff may lead to decreased attack rate in residents

SUMMARY OF CLUSTER RCTs ASSESSING THE
IMPACE OF HCP IMMUNIZATION
Study
Potter J, 1997
Coverage
Control
4.9%
Coverage
Intervention
61%
Mortality
Control
17%
Mortality
Intervention
10%
Mortality
Difference
7.0%
Carman W, 2000 13.6% 50.9% 22.4% 13.6% 8.8%
Hayward A, 2006 5.9%
Lemaitre M, 2009 31.8%
43.2%
69.9%
15.3%
6.0%
11.2%
5.2%
4.1%
0.8%*
Multivariate analysis for death, vaccination OR 0.80 (p=0.008)

Mortality of residents was significantly reduced (10% vs 17%) in nursing homes where the staff was vaccinated (SV) compared to facilities where they were not (S0)
20
(P=0.0009)
Vaccine groups
SV (n=490)
SO (n=561)
10
0
0 20 40 60 80 100 120 140
Time in days
Potter J et al. J Inf Dis. 1997;175:1-6.



20 long-term care facilities, stratified cluster randomization staff influenza vaccination or not
Resident mortality odds ratio 0.58 (95% CI 0.40, 0.84) p=0.014
25
20
15
13.6
22.4
10
5 n = 749 n = 688
0
Vaccine hospitals No vaccine hospitals
No significant difference in % residents positive for influenza:
‘Vaccine hospitals’ 5.4%; ‘no vaccine hospitals’ 6.7%
Carman WF et al. Lancet. 2000;355:93-7.

Influenza infection
Sick days due to respiratory illness
0%
-10%
-20%
-30%
-40%
-50%
-60%
-70%
-80%
-90%
-100%
88%
Wilde
1999*
28%
Saxen
1999
Attack rate unvaccinated = 13.4%
Days lost from work
41%
Wilde
1999
Patient mortality
41%
Carmen
2000
Patient mortality
39%
Potter
1997
Talbot TT, Weber DJ, et al. ICHE 2005;26:882-890



Access to vaccine, inconvenience



Off-hours clinics
Use of mobile vaccination carts
Vaccination at staff and department meetings
Cost

Provision of vaccine free of charge
 Concerns for adverse events

Targeted education, including specific information to dispel vaccine myths

 Fear of needles

Use of LAIV for eligible HCP
 Other

Strong and visible leadership




Visible vaccination of key leaders
Surveillance of HCP-associated influenza
Accurate tracking of individual and unit-based compliance
Active declination for HCP who do not wish to be or cannot be vaccinated