OSHA/Infection Control
Annual Update Training 2014
IC/EC, Inc.
1
Objectives
Update disease information
List new training responsibilities
Conduct refresher training on key department
issues of compliance
Understand the use of surgical masks
Clarify use of declination forms
Review new flu vaccines
2
Disease Numbers 2012-2013
2013
HIV –
HBV – 2,666
HCV – 1,655
Syphilis – 15,639
TB – 8,080
2012
HIV Dx – 35,361
HBV – 2,895
HCV – 1,782
Syphilis – 15,667
TB – 9,945
•CDC, MMWR, Jan.3, 2014 – provisional
3
Other Diseases - 2013
Measles
Mumps
Rubella
Chickenpox
184
438
9
9,987
Pertussis (whooping
cough)
24,231
CDC, MMWR, 1/3/14- provisional
4
County Disease Numbers
HIV Dx. - 20 (down from previous year)
HBV – 6 new 48 chronic (up from previous year)
HCV – 6 new 528 chronic (same as previous year)
Syphilis - 16 (up from previous year)
TB - 8 (same as previous year)
5
Ryan White Notification Update
This means that medical facilities have expanded
notification responsibilities
This means that departments have extended
vaccine/immunization responsibilities
6
Education & Training to
Include
Bloodborne
Airborne
HCV
HBV
HIV
Vaccinia virus
Cutaneous Anthrax
Rabies
Viral hemorrhagic fevers
Measles (Rubeola)
Chickenpox
Tuberculosis
7
Federal Register, 11/2/11
List Published
Droplet Transmitted
N. Meningitis
Diphtheria
Mumps
Pertussis
Plague
Rubella
SARS-CoV
Novel Influenza A viruses
8
Federal Register, 11/2/11
Prevention
Travel history on
patient
assessment
especially with
respiratory
symptoms
9
Prevention
Place surgical mask on patient
If can not, place surgical mask on yourself
Good handwashing
Use good airflow in vehicle
10
IOM
meeting June 3, 2010/ CDC
Masks & Influenza
Surgical mask and droplet precautions even if H1N1
CDC reverted to this in 2010
N95s for hospital use for aerosol-generating
procedures
Personal communication, Dr. Uyeki, CDC July 19, 2012
11
Immunizations/Vaccinations
Hepatitis B vaccine
Tdap booster x1
MMR
Chickenpox
Flu vaccine
TB Testing
CDC,1997,
2011
12
CDC Statement on Records
HICPAC and CDC have recommended that secure,
preferably computerized, systems should be used to
manage vaccination records for HCP so records can
be retrieved easily as needed
Each record should reflect immunity status for
indicated vaccine-preventable diseases, as well as
vaccinations administered during employment
13
CDC, November, 2011
Did You -Obtain Your Records
From –
Your schools
High school
College
Training programs
Previous employer
14
Declination Forms
If you do not wish to give your medical information,
you must sign a declination form
15
MMR Vaccine
If received between 1963 – 1967
Revaccinate with 2 doses one month
apart
Measles Status Unknown
No need to titer
Just vaccinate
CDC, 11/25/12
17
Chickenpox Vaccine
Unable to document immunity
Just vaccinate
CDC, Nov. 25, 2011
18
Shingles Vaccine - Clarification
Recommended for persons 50 and older
Can take if you have had an outbreak of shingles
Employer does not need to offer
19
CDC
Healthcare Worker Duty
To protect patients from infection
To protect yourself
To protect co-workers
20
Clarification
Declination Forms
Document that the employer met his/her obligation to
offer
Does not eliminate employee rights
21
Department Exposures - 2013
Bloodborne - 0
Airborne/droplet - 0
22
HBV Infection Rate- US
Universal vaccination
1983 - 1995 occupational infections decreased by
95%
Healthcare worker infection infrequent
CDC, September, 2009, Nov.. 2011
23
Vaccine - HBV
Need to complete all 3 shots
1 dose = 30% - 55% protection
2 dose = 75% protection
3 dose = >90% protection
CDC, MMWR, Nov. 2011
HCV Increased
Due to improper infection control practices
Outbreaks
Ambulatory care clinics
Free dental clinic
Dialysis centers
Dental Practices
25
HCV Outbreaks
Since 2001, over 157,000 persons have
been called back for testing for HIV,HBV and
HCV due to breaks in basic infection control
practices
CDC, 2012
26
CDC- Baby Boomers
All persons born between 1945-1965 should
have a one time screening for HCV infection
27
New Rapid HCV Test
OraQuick ®HCV
FDA approved
Takes 20 mins.
No lab equipment required
Very accurate- 99.8%
Waiver granted 11/28/11**
Screens for multiple genotypes
28
FDA. June 25, 2010
Remember
A positive test for HCV by antibody testing does
NOT mean current infection
Source patient to have viral load test for
confirmation
(HCV-RNA)
29
CDC, Hep C Symposium Dec.. ,2011
Reminder -
If you are exposed to a hepatitis C positive patient,
you should have a blood test in 2 weeks
HCV-RNA (blood test)
Cost - $65.00 - $100.00
Am. Assoc. for the Study of Liver
30 Disease, Practice Guidelines, 2009
Hepatitis C – Early Treatment
HCV-RNA positive
begin treatment
12 -24 weeks –
31
New Treatment Drug
Boceprevir – Merck
Telaprevir- Vertex
“cured 75%-79% of patients with
Genotype 1 HCV in 24 weeks
of treatment”
FDA approval granted – April
2011
FDA approved 5/13/11
Given as 3 drug cocktail
32
Newer Drugs
Olysio
Solvadi
Treatment Genotype 1
Treatment Genotype 1 & 4
Cure more often and in less time 0 12 weeks
80% - 95+%
33
2014
Solvadi
Treatment Genotype 2 & 3
Given with Ribavirin
NO interferon
2014
34
Infected Healthcare WorkersOccupational Infection-HIV
1978 – December, 2010
57* documented cases
0 in fire/EMS personnel
49 were sharps related exposures
CDC, May, 2012(CDC), NIOSH
35
CDC Surveillance of Occupationally
Acquired HIV
CDC reported that –
“More than 90% of healthcare personnel infected with
HIV have non-occupational risk factors reported for
acquiring their infection.”
36
CDC, 2012 Report
No new cases since 1999
37
Risk group – HIV infection
Cases increase in ages 13-24
2010 -12,000 infected
1,000 per month
38
CDC, 2012
Update - 2011
Aids “cocktail” drugs = 96% unable to transmit the
disease
HIV/AIDS – living 50 years
39
Dr. Fauci, NIH, May 2011
Result 3 Drug Cocktail= 0 virus
Atripla – 84%- 0 HIV virus in blood in 48 weeks
Stribild – 88% - 90% in 48 weeks
Truvada – 87% in 48 weeks
40
CDC, Oct. 2012
Rapid HIV Tests- Post Exposure
Rapid HIV Test - currently available – using blood
OraQuick
Reveal
Uni-Gold
Multispot
Clearview
CDC January 2007
41
Reminder - Testing Issues Post Exposure
If source patient is negative with rapid testing
= no further testing of health-care worker
Use of rapid testing will prevent staff from
being placed on toxic drugs for even a short
period of time
•CDC, May , 421998, CDC June 29, 2001, September 2005
Change in Post Exposure to HIV
Updated CDC Guidelines – September, 2013
If source is HIV positive and has viral load=
Baseline, 6 weeks and rapid test at 4 months using
rapid test
43
Point of Care Testing - POCT
Since rapid tests are waivered, they can be
performed in the ED
Point of Care Testing is the current standard of care
44
Point of Care Testing
HIV
HCV
Syphilis
Lyme disease
Herpes Simplex
Influenza A&B
Strep A
45
Syphilis Cases
Part of post exposure
testing
Part of point of care testing
Post exposure follow up if
source is HIV positive or
Hepatitis C positive
More testing under new
Sexually transmitted
disease (STD) guidelines
(2010)
46
Highest States for cases 2013
California
Texas
New York City
Florida
CDC, MMWR , 2013
47
CDC - Plan
Update plan to
eliminate syphilis by
2015?
Not looking good!
48
Tuberculosis
49
Tuberculosis
2012 lowest case number since 1953
10,528 in 2011- now 8,080 for 2013
Goal to eliminate by 2015 - worldwide
CDC,50MMWR, 2012;61:181-185
Multi-drug Resistant TB
MDR-TB – 84% in foreign-born persons
109 cases in 2010
XDR-TB – 2 cases reported in 2007
XDR-TB 1993 -2007 = 83 cases reported
2008 = 0
2009 = 0
2011= 4 cases in foreign-born persons
Both are treatable !
51
Short Term Course of Treatment
New 12 Dose Regimen for latent TB
infection
(positive test)
Rifapentine and INH once a week for 12
weeks
CDC, 2012
No alcohol
52
Decrease in TB Cases
National and global decrease due to Direct Observed Therapy- DOT
53
Risk Assessment - CDC
Based on number
of active-untreated
TB patients
transported in the
past year
54
CDC, 2005
Risk Assessment - TB
Low Risk
Medium Risk
Transported less than 3 TB
patients
Transported more than 3 TB
patients
55 Guidelines, 2005, pg. 134
CDC TB
Department TB Risk
Assessment
2013 –
0
56
New Version TB Blood Test
QFT-T (In-tube)
FDA approved – October 2007
Less time consuming to perform
More accurate
Cost effective - $33.67
57
T-Spot
Second blood test available for TB testing
FDA approved
Cost – approximately $45.59
58
TST Testing Solution
Currently there is a national shortage
Use the Blood test for new hires
59
Reminder -Transmission Plane
“ TB is generally not spread by casual contact, but
typically requires relatively prolonged contact in
shared air space. The environment on long flights in
commercial aircraft, particularly those of 8 or more
hours in length, has been previously implicated in
TB transmission, especially to passengers seated in
close proximity”
Dr. Cetron, US Public Health, July,2007
60
Flu Vaccine - Annual
“Direct patient care”
All healthcare workers
61
CDC Flu Vaccine Program
Employers must offer
Employers must pay
Employees who
decline - sign a
declination form
CDC, February 24, 2006/- current NFPA 1581
62
Department Flu Vaccine Participation
- 2013
Percent =
41%
63
Why Important
Used to identify which new vaccines may be
offered to increase compliance
Currently lowest rate of compliance is in EMS
groups
64
New Influenza Vaccines
65
Vaccine for 2013/14
A- California/H1N1
A- H3N1
B - Massachusetts
CDC, March. 28, 2013
66
Quadrivalent Flu Mist or
Injection
2 B Strains
A/ H1N1
A/H3N2
B/Yamagata
B/Victoria
2013
MedImmune/CDC
67
Over 65 Vaccine
4 times higher antigen level
68
Vaccine –
New
Flucelvax
No thimerosal or antibiotics
Not egg based
New Flu Vaccine
Flublok
No virus
No eggs used in production
No antibiotics/mercury
DNA technology
FDA, 1/16/13
70
Employee with allergies
Accommodation with new vaccine
Flushot.healthmap.org
72
Universal Vaccine?
New antibody identified inhibits many strains of
influenza
CH65
Infectious Disease News,
Aug. 24,2011
73
Flu Vaccine EMS Participation
Lower than any other HCW group in 3 studies
74
Work Restriction
Restrict ill workers from
the workplace
use sick time
protect co-workers
protect patients
75
ENFORCEMENT
General Duty Clause – OSHA
Employee with a communicable disease poses a
direct threat
Can require reporting
Maintain confidentiality
SHRM, 2013
MDRO’s – Update Issues
77
MRSA/VRE Exposure
There is NO recommended follow up or
treatment needed for exposure to MRSA,
VRE
CDC,
78 2010
Reminder
For C-diff and Norovirus a chlorine –based
cleaning agent is needed
Handwashing post care of patient with C-diff
is warm soap & water
waterless agent not effective
79
CRE – New Resistant Organism
High mortality rate
Difficult to treat
15 cases in US in 2013
Contact Precautions
Not acquired by healthy people
Travel History & CRE
81
Compliance
Monitoring
Check for compliance
82
Compliance Monitoring
What issues need to be addressed in your
department
83
Insulin Pens
Single patient use only
HIV testing of patients in NY VA Hospital
CDC,
84 January 5, 2010
Glucose Monitors
Need to be cleaned after each patient use
Recently implicated in outbreak investigation
85
Cleaning Issues
There is no disease that requires airing of a
vehicle or putting a vehicle out of service
Focus high touch items!
Non-critical items
Clean and go!
86
Pre-Mixed Cleaning Wipes
Only need a 1 min. contact time
Very effective
CDC, 2010 COCA Conference/ CDC Guidelines for Disinfection and Sterilization, 2008
87
Handwashing
88
Handwashing -
No antibacterials
Use hand sanitizers !
No artificial nails !
CDC
89
Handwash Study - EMS
Study from Robert Woods Johnson University
Hospital
1,500 EMS providers surveyed
13% compliance
First responders
EMS providers
Paramedics
11/12/13
90
Hand Hygiene Agents
Soap & water – removes dirt from hands; associated
with skin irritation after repeated use
Alcohol based solutions: active against gram- and
gram + bacteria, but not against spores
Quaternary Ammonium Compounds: weak activity
against gram- bacteria- not recommended in
healthcare
Triclosan: broad range of activity but relatively non
– effective against gram- 91bacteria- not
OSHA Most Common BBP Citations
- 2013
Not having a compliant
Exposure Control Plan
Not offering HBV vaccine to
unprotected staff at risk and not
offering post exposure evaluation &
follow up
No initial or annual training
offered to staff and at no
cost to staff
No employee input to selection of
needlesafe devices
Not having declination forms
No annual update of Plan
Not maintaining a sharps injury log
Hepatitis B vaccine not
offered within 10 days of
hire and after education &
training
OSHA Jan.,2014
No effective engineering
Not offering annual update training
within 1 year of previous training
92
Reminder -
Program Goal
Protect the patient
Protect the care provider
Accomplish in a cost effective manner whenever
possible using evidence-based practice
93
Questions &
Answers
94