Occupational
Health Risks for
Healthcare Workers
1. Recognize infection health hazards for
healthcare workers.
2. Explain the use of an occupational infection
risk evaluation.
3. Outline methods of reducing occupational risk
of infection for healthcare workers.
December 1, 2013
Learning Objectives
2
• 40 minutes
December 1, 2013
Time involved
3
• Biological hazard
• Chemical hazard
• Physical hazard
• Ergonomic hazard
• Psychosocial hazard
December 1, 2013
Health Hazards in Healthcare
Facilities
4
• If a separate department, size based on
• Institution size
• Number of staff
• Services offered
December 1, 2013
Occupational Health
• Elements
•
•
•
•
•
Medical evaluations
Education
Immunisation program
Management of illness/exposures
Maintenance of records
5
• Conduct written risk assessment for staff hazards
•
•
•
•
•
Physical
Chemical
Biological
Ergonomic
psychosocial
December 1, 2013
Prevention of Occupational Risk
in Healthcare Facilities
• Assess risk and estimate degree of risk annually
6
• 3 million healthcare workers exposed to
bloodborne pathogens each year
• > 90% of infections occur in developing
countries
• 95% of HIV seroconversions in HCWs
caused by needlestick injuries
December 1, 2013
Bloodborne Infection among
Healthcare Workers
7
Risk group
Description
Examples
1
Biological agent unlikely to cause human disease
Bacteria in yoghurt
Yeast in beer
2
Biological agent that can cause human disease and might be a hazard to workers; it
is unlikely to spread to the community; there is usually effective prophylaxis or
treatment available
Most bacteria
Nearly all moulds
Most viruses
3
Biological agent that can cause severe human disease and present a serious hazard
to workers; it may present a risk of spreading to the community, but there is
usually effective prophylaxis or treatment available
Hepatitis B
Hepatitis C
Human immunodeficiency virus
Tuberculosis
4
Biological agent that causes severe human disease and is a serious hazard to
workers; it may present a high risk of spreading to the community; there is usually
no effective prophylaxis or treatment available
Lassa virus
Severe acute respiratory
syndrome?
December 1, 2013
Biological Agents: Risk of
Infection
8
Infection
Cholera
Conjunctivitis,
viral (e.g.,
adenovirus)
Cytomegalovirus
(CMV)
Diphtheria
Haemorrhagic
fever
(Ebola, Marburg,
Lassa virus)
Hepatitis A
Transmission in
general
Risk of transmission
evaluation
Risk
classification
of biological
agents*
Main risk
Vaccine
available
Post-exposure
prophylaxis
(PEP)
Staff to
patient
Rare
Patient to
staff
Rare
2
Stool contact
Yes
High
High
2
No
No
Rare
Rare
2
Hand contact
and touching
eye
Contact with
body fluids,
especially
saliva, blood,
and urine
No
No
No data
Rare
2
Close face to
Yes
face exposure,
cough
Bloodborne; some
question of contact
transmission
Negligible
Moderate
4
Blood splash
on mucous
membrane
No
Person-to-person by
faecal-oral route;
infected food handlers
with poor personal
hygiene can
contaminate food
Rare
Rare
2
Stool contact
Yes
Faecal-oral,
contaminated water
Contact with eye
secretions and
contaminated objects
Contact with urine,
saliva, breast milk,
cervical secretions, and
semen from infected
person who is actively
shedding virus
By droplets, also by
contact
December 1, 2013
Risk evaluation for infectious
agents - 1
PEP with
antibiotic
should be
discussed
Antivirals
should be
discussed
Immune
globulin
9
Infection
Transmission in
general
Risk of transmission
evaluation
Hepatitis B
Via percutaneous,
mucosal, and
nonintact skin contact
with blood, semen,
vaginal secretions,
and bloody fluids
Via percutaneous,
mucosal, and
nonintact skin contact
with blood, semen,
vaginal secretions,
and bloody fluids
Contact with virus in
saliva of carriers;
contact with vesicle
fluid
Primarily via
percutaneous contact
with blood; mucosal
or nonintact skin
contact with blood;
semen, vaginal
secretions, and bloody
body fluids less likely
to transmit
Low
Moderate
Low
Hepatitis C
Herpes simplex
Human
immunodeficiency
virus (HIV)
Risk
Main risk
classification
of biological
agents*
3
Needlestick
injury
Vaccine
available
Moderate
3
Needlestick
injury
No
No
Rare
Low
2
Contact with
infected site
No
No
Rare
Low
3
Needlestick
injury
Yes
Postexposure
prophylaxis
(PEP)
Hepatitis B
immune
globulin
(HBIG)
December 1, 2013
Risk evaluation for infectious
agents - 2
Antivirals
must be
provided
within hours!
10
Infection
Transmission in
general
Risk of transmission
evaluation
Influenza
Droplet spread; direct
droplet transmission or
droplet to contact
transmission of
respiratory secretions
of infected patients
Airborne; direct
airborne transmission
or airborne to contact
transmission of
respiratory secretions
of infected person
Droplet spread; direct
droplet transmission or
droplet to contact
transmission of
respiratory secretions
of infected patients
Droplet spread; direct
droplet transmission or
droplet to contact
transmission of
respiratory secretions
of infected patients
Direct and indirect
contact
Moderate
Moderate
Risk
classification
of biological
agents*
2
High
High
2
Rare
Moderate
Rare
Measles
Meningococcal
infection
Mumps
Methicillinresistant S. aureus
(MRSA)
Main risk
Vaccine
available
Post-exposure
prophylaxis
(PEP)
Close contact
with patient
(Within 3 feet
from
coughing/
sneezing)
Inhaling or
contact with
the patient’s
respiratory
secretions
Yes
Antivirals
normally not
recommended
Yes
Immune
globulin
2
Close contact;
face to face
Yes
(tetravalent
A, C, W135,
and Y)
Antibiotic
after close
contact
Moderate
2
Yes
Rare
2
Close contact
with patient
(Within 3 feet
from
coughing/
sneezing)
Skin contact
December 1, 2013
Risk evaluation for infectious
agents - 3
11
No
No
Infection
Transmission in
general
Risk of transmission
evaluation
Norovirus
Faecal-oral (direct or
indirect contact with
patient’s stool)
Droplet spread; direct
droplet transmission
or droplet to contact
transmission of
respiratory secretions
of infected patients
Faecal-oral
Animal bite
Droplet contact or
direct contact with
respiratory secretions
Person-to-person via
faecal-oral route
Droplet contact or
direct contact with
respiratory secretions;
airborne transmission
not demonstrated.
High
Pertussis
Polio
Rabies
Respiratory
syncytial virus
(RSV)
Rotavirus
Rubella
Vaccine
available
Post-exposure
prophylaxis
(PEP)
High
Risk
Main risk
classification
of biological
agents*
2
Stool contact
No
No
Moderate
Moderate
2
Cough
Yes
Macrolides
Rare
Rare
Moderate
Rare
Rare
Moderate
2
3
Bites
Yes
Yes
Yes
Moderate
Moderate
2
Stool contact
Moderate
Moderate
2
December 1, 2013
Risk evaluation for infectious
agents - 4
Yes
12
Infection
Transmission in
general
Risk of transmission
evaluation
Salmonella or
Shigella
Person-to-person via
faecal-oral route; via
contaminated food or
water; food handlers
with poor personal
hygiene can
contaminate food
Droplets, contact
Low
Severe acute
respiratory
syndrome (SARS)
Scabies
Streptococcus,
Group A
Syphilis
Tetanus
Postexposure
prophylaxis
(PEP)
Low
Risk
Main risk
Vaccine
classification
available
of biological
agents*
2
Stool contact
Medium
Medium
3
No
Direct skin-to-skin
contact with infested
person
Droplet contact or
direct contact with
oral secretions or
drainage from
infected wounds
Direct contact with
lesions of primary or
secondary syphilis
Low
Low
Rare
No data
2
No data
Rare
2
Bites, skin wounds
No data
No data
Cough
No
December 1, 2013
Risk evaluation for infectious
agents - 5
Skin contact
2
Direct
contact with
skin or
mucous
membrane
lesions
Antibiotics
possible
13
Yes
Immune
globulin
Infection
Transmission in
general
Tuberculosis (TB)
Airborne transmission Low to high
from sources with
active pulmonary or
laryngeal tuberculosis;
susceptible person
must inhale airborne
droplet nuclei to
become infected
Low to
high
Typhus
Faecal-oral
Low
Low
3
Varicella,
Chickenpox,
disseminated
zoster
Contact with vesicles;
droplet or airborne
spread from
respiratory tract of
acute cases and
perhaps from
disseminated zoster
High
High
2
moderate
moderate
Negligible
Rare
Localised
varicella-zoster
(shingles)
Yellow fever
Contact with vesicles
Mosquito bites
Risk of transmission
evaluation
Risk
Main risk
classification
of biological
agents*
3
Cough
Vaccine
available
BCG Bacille
Calmette
Guérin
(Not given
to
healthcare
workers)
Stool contact Yes
(IM, SC,
oral)
Yes
Postexposure
prophylaxis
(PEP)
Isoniazid
(INH) for
treatment of
latent TB
infection;
4 drug
regimen for
active TB
December 1, 2013
Risk evaluation for infectious
agents - 6
Varicellazoster
immune
globulin
(VZIG)
14
Yes
No
• Eliminate the hazard
 Reduce the number of injections by providing oral
medication
 Assign a central hospital for treating highly
infectious patients
December 1, 2013
Risk Reduction - 1
15
• Remove or isolate the hazard
 Use safety needles
 Single-use needles designed to retract or cover the sharp
end immediately after use
December 1, 2013
Risk Reduction - 2
 Transport blood specimens in leak- and punctureresistant boxes
 Use puncture-resistant waste boxes for discarding
sharp items and needles
16
• Organisational measures
 Limit number of staff members caring for a patient
with certain illnesses
 Tuberculosis or MRSA
 Train staff regularly in safe work practices
 Establish an occupational safety committee
 Consider every patient to be potentially infected with
hepatitis B or C or HIV
 Strict adherence to Standard Precautions/Routine
Practices
 Audit compliance with prevention measures
periodically
December 1, 2013
Risk Reduction - 3
17
 Evaluate use of personal protective equipment
• Gloves
• Discard and change between patients
• Use only once or disinfect 2-3 times maximum
December 1, 2013
Risk Reduction - 4
• Gowns
•
•
•
•
Use if spills/splashes are possible
Change between patients
Single-use gowns preferred
If used several times put on and remove it without
touching the outer potentially contaminated side
• e.g., during a shift time
18
 Evaluate use of personal protective equipment
• Eye goggles or face shields
• Use if spills/splashes to the face possible
• Disinfect regularly and if visibly soiled
• Masks and respirators
December 1, 2013
Risk Reduction - 5
• N95/FFP respirators with a tight face seal used if a risk of
exposure to airborne pathogens
• When not available, use surgical masks
 Develop written standard operating procedures
 For medium and high-risk activities
 Include staff protection and vaccination
recommendations
19
• Provide a medical examination for all HCWs
• Examination records and other health information
should be kept confidential
• Store in a secure place
December 1, 2013
Risk Reduction - 6
• Repeat the examination periodically
• All injuries documented in the respective staff
member’s medical record
20
• Provide vaccinations for all non-immune HCWs





Hepatitis B
Influenza
Mumps/Measles/Rubella/Varicella/Pertussis
Poliovirus
Tetanus, Diphtheria (as a routine adult
vaccination)
December 1, 2013
Risk Reduction - 7
21
•
•
•
•
Recapping of needles
Unsafe handling of sharps waste
Overuse of injections
Lack of supplies
December 1, 2013
Causes of Needle-stick Injury
in Low Resource Countries
• disposable syringes, safer needle devices, sharps-disposal
containers
• Failure to place needles in sharps containers immediately
after injection
• Passing instruments from hand to hand(e.g., in the OR)
• Lack of awareness of the problem
• Lack of training for staff
22
• The risk of transmission of bloodborne pathogen
from an infected patient to a HCW by a
needlestick injury:
December 1, 2013
Risk of Blood-borne Pathogen
Transmission
• 30% for hepatitis B
• 3% for hepatitis C
• 0.3% for HIV
23
Post-exposure prophylaxis varies with immune status
of HCW
An unvaccinated HCW
Receive both hepatitis B
immune globulin (HBIG) and
HBV vaccination
Previously vaccinated and
known antibody responder
HCW
No treatment
Previously vaccinated, known
non-responder HCW
Both HBIG and HBV
vaccination (a second vaccine
series) or 2 doses of HBIG one
month apart
HCWs whose antibody
response is unknown
Test the HCW for antibody
and administer HBIG + HBV
vaccination if results are
inadequate (<10mIU/ml)
December 1, 2013
Hepatitis B Prevention: PEP
24
• Currently no recommended PEP for hepatitis C
virus
• Perform baseline and follow-up testing for antiHCV and alanine aminotransferase
December 1, 2013
Prevention of Hepatitis C
• Up to six months after exposure
• Perform HCV RNA testing at 4-6 weeks
• If an earlier diagnosis of HCV infection is desired
• Staff members who develop hepatitis C should
be treated after seroconversion
25
• Start as soon as possible, within 2-24 hours, not after 72
hours
• Consider contraindications (e.g., pregnancy)
• Medication taken for at least 4 weeks
• Seek expert consultation if viral resistance is suspected
• In case no PEP is available
December 1, 2013
Prevention of HIV Infection: PEP
• Perform HIV antibody testing for at least six months post exposure
(e.g., at baseline, 6 weeks, 3 months, and 6 months)
• Perform HIV antibody testing if an illness compatible with
an acute retroviral syndrome occurs
• Advise exposed persons to use precautions to prevent
secondary transmission during the follow-up period
26
• Establish a tuberculosis control committee
• Increase awareness about TB among HIV-positive
patients
• Place patients with suspected TB or with an abnormal
chest radiograph in an isolation room
December 1, 2013
Prevention of TB - 1
• With door closed and a special ventilation system (natural or
artificial)
• Place automatic closing devices on all TB isolation room doors
• Continue isolation of TB patients until at least three negative
acid-fast bacilli sputum smears obtained
• Ensure that all HCWs entering a TB isolation room wear a
N95/FFP mask
• Restrict sputum induction procedures and aerosolised
pentamidine treatments to TB isolation rooms
27
• Assign adequate number of trained staff to perform
routine and urgent acid-fast bacilli smears on a daily basis
• Initial anti-TB treatment regimens should include four
drugs
• TB patients should only be allowed to leave their rooms
when medically necessary and must always wear a surgical
mask when outside the room
• Forbid immunocompromised staff from contact with, or
caring for, TB patients
• Perform routine tuberculin testing for tuberculin negative
staff
• Treat HCWs as soon as active TB is confirmed
December 1, 2013
Prevention of TB - 2
28
• Healthcare workers are exposed to biological,
chemical, physical, ergonomic, and psychosocial
hazards
• HBV, HCV, HIV and TB pose the greatest risk of
infection
• Infection with hepatitis B virus is preventable with
immunisation
December 1, 2013
Summary
• All healthcare workers should be vaccinated against
hepatitis B
• Written standard procedures on how to manage
needlestick injuries should be available and known
to all staff
29
• Health worker occupational health. World Health
Organization. 2010.
http://www.who.int/occupational_health/topics/hcworkers
/en/
• AIDE-MEMOIRE for a strategy to protect health workers
from infection with bloodborne viruses. World Health
Organization. 2011.
http://www.who.int/injection_safety/toolbox/en/AM_HCW
_Safety_EN.pdf
• Simonsen L, Kane A, Lloyd J, Zaffran M, Kane M. Unsafe
injections in the developing world and transmission of
bloodborne pathogens: a review. Bull WHO 1999; 77: 789800. http://www.who.int/bulletin/archives/77(10)789.pdf
December 1, 2013
References
30
1. Mucosal exposures cause 95% of HIV seroconversions in
staff. T/F.
2. Prevention of tuberculosis includes
a.
b.
c.
d.
Placing patient in an isolation room
Patient wears mask when leaving the room
Perform AFB lab tests daily
All of the above
December 1, 2013
Quiz
3. A risk assessment for staff hazards is useful to determine
appropriate prevention strategies. T/F.
31
• IFIC’s mission is to facilitate international networking in
order to improve the prevention and control of
healthcare associated infections worldwide. It is an
umbrella organisation of societies and associations of
healthcare professionals in infection control and related
fields across the globe .
• The goal of IFIC is to minimise the risk of infection within
healthcare settings through development of a network of
infection control organisations for communication,
consensus building, education and sharing expertise.
• For more information go to http://theific.org/
December 1, 2013
International Federation of
Infection Control
32