key: cord-0701148-oz0fvfwy authors: Shenoy, Erica S.; Weber, David J. title: Occupational Health Update: Approach to Evaluation of Health Care Personnel and Preexposure Prophylaxis date: 2021-08-04 journal: Infect Dis Clin North Am DOI: 10.1016/j.idc.2021.04.008 sha: e66055f37a83de7a7ffa7b64e857815745c0f69f doc_id: 701148 cord_uid: oz0fvfwy An effective occupational health program is a key aspect of preventing exposure to infectious agents and subsequent infection, as well as evaluation and management of postexposure prophylaxis and infections in health care personnel (HCP) by educating HCP regarding proper handling of sharps, early identification and isolation of potentially infectious patients, implementation of standard and transmission-based precautions, and offering counseling of HCP regarding nonroutine prophylaxis. Occupational health services (OHS) must also apply standardized processes for determining when exposures have occurred and providing appropriate management, and provide immediate availability of a medical evaluation following a nonprotected exposure to an infectious disease. airborne-transmitted pathogens through direct patient care (eg, pertussis, meningococcal infections, tuberculosis); and indirect contact through transmission related to the contaminated health care environment (eg, Clostridioides difficile). Cases of nonfatal occupational injury and illness among HCP are among the highest of any industrial sector. 3 Approaches to preventing occupational acquisition of infection by HCP have been reviewed, and include implementation of the Hierarchy of Controls to assess implementation of feasible and effective control solutions. [4] [5] [6] [7] The Hierarchy of Controls (Fig. 1) , developed by the National Institute of Occupational Health and Safety (NIOSH), is a framework to assess the effectiveness of interventions to reduce hazards in the workplace and the risks of injury or illness. 8 Minimizing the risk of communicable disease acquisition is based on 6 key recommended practices: (1) proper training of HCP at initiation of health care practice and annually (eg, infection prevention practices, sharp injury prevention, no eating or drinking in areas where care is delivered); (2) ensuring immunity to vaccine-preventable diseases 4,6,7,9-11 ; (3) evaluation of HCP who were exposed to communicable diseases for receipt of postexposure prophylaxis (PEP) 6, 7, [12] [13] [14] ; (4) adherence to standard precautions when providing patient care, 15 especially the performance of appropriate hand hygiene before and after patient care [16] [17] [18] ; (5) rapid institution of appropriate transmission-based precautions for patients with a known or suspected communicable disease as part of the identify-isolate-inform framework [19] [20] [21] [22] [23] ; and (6) proper use of personal protective equipment, such as surgical or procedural masks, N-95 respirators (including respiratory clearance and fit testing), eye protection, gloves, Fig. 1 . The hierarchy of controls. Interventions at the top of the hierarchy can potentially be more effective than those at the bottom. Elimination and substitution strategies are highly effective but can be difficult to implement. An example of an effective elimination strategy is vaccination. Engineering controls are designed to remove a hazard before the hazard comes in contact with the worker. Use of airborne infection isolation rooms for airborne diseases such as measles is an example of engineering controls. Administrative controls, such as symptom screening of visitors, patients, and HCP, can be challenging to maintain over time. Use of personal protective equipment (PPE), although highly effective when used correctly and consistently, requires effort by HCP to achieve protection. (Adapted from The National Institute for Occupational Safety and Health (NIOSH). Hierarchy of Controls. Available at: https://www.cdc.gov/niosh/topics/hierarchy/default.html. 2015. Accessed November 20, 2020.) and gowns when caring for patients with potentially communicable diseases, based on the mode of transmission (Box 1). 15 Prevention of clinical laboratory-acquired infection requires adherence to recommended administrative protocols (eg, no eating, drinking, or smoking in areas where microbiologic or pathologic samples are processed), engineering controls (eg, containment hoods), personal protective equipment (eg, N-95 respirators when culturing Mycobacterium tuberculosis), and appropriate immunizations. 24, 25 The following definitions are from the Centers for Disease Control and Prevention (CDC). 7 HCP refers to all paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances; contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. These HCP may include, but are not limited to, those listed in Box 2. In general, HCP who have regular or frequent contact with patients, body fluids, or specimens have a higher risk of acquiring or transmitting infections than do HCP who have only brief contact with patients and their environment (eg, beds, food trays, medical equipment). However, all HCP who work within the confines of a health care facility should be covered by the occupational health service (OHS) and receive appropriate screening and preexposure prophylaxis even if they do not provide direct patient care. Recommendations for HCP who work in dental health care settings, autopsy personnel, and clinical laboratory personnel are addressed elsewhere. [25] [26] [27] Health care settings refer to locations where health care is delivered and includes, but is not limited to, acute care facilities, long-term acute care facilities, inpatient rehabilitation services, nursing homes and assisted living facilities, home health care, vehicles where care is delivered (eg, mobile clinics), and outpatient facilities such as dialysis centers and physician offices. OHS refers to the group, department, or program that addresses many aspects of health and safety in the workplace for HCP, including the provision of clinical services for work-related injuries, exposures, and illnesses. In health care settings, OHS addresses workplace hazards, including communicable diseases; slips, trips, and falls; patient handling injuries; chemical exposures; HCP burnout; and workplace violence. Most commonly, OHS are provided on site within the health care facility in which HCP are performing patient care but may also be provided off site. Occupational health programs should include a variety of activities designed to minimize the risk for HCP to acquire an infectious disease, to evaluate HCP with a potential exposure to a communicable disease, and to evaluate HCP with a communicable disease (Box 3). Occupational health programs should be aware of appropriate guidelines from the CDC and professional organizations. They should adhere to appropriate state and federal laws and regulations. Specific regulations promulgated by the US Occupational Safety and Health Administration (OSHA) related to HCP include BBP (1910.1030) 28 and tuberculosis/respiratory protection (1910.134). 29 The Federal Needlestick Safety and Prevention Act (HR5178), which was enacted in 2000, requires the use of safety engineered devices whenever possible to reduce the likelihood of sharp injuries. 30 Commonly used references are provided in Table 1 . OHS either provide or refer newly hired HCP for preplacement medical evaluations before initiation of employment, and periodically as needed during the course of employment. All HCP should undergo a new personnel orientation on hire. As part of the orientation process, HCP should undergo screening and education directed at reducing the risk of acquisition of infection diseases by health care providers (Box 2). All information obtained should be entered into an electronic database. Access to this database may be prescribed by state law because some states treat HCP occupational health records as personnel records. If OHS records are part of the organization's standard patient Persons not directly involved in patient care (for example, clerical, dietary, housekeeping, laundry, security, maintenance, engineering and facilities management, administrative, billing, volunteers, clinical laboratory personnel) Note: HCP does not include dental health care personnel, autopsy personnel, and laboratory personnel, for whom recommendations are provided separately. [25] [26] [27] electronic medical records, unauthorized access of provider's occupational health information by supervisors should be prohibited by the institutions privacy rules and periodically assessed. Components of an occupational health service for health care personnel at initial employment General recommendations regarding vaccination of HCP have been published by the CDC, the Advisory Committee on Immunization Practices (ACIP) for HCP 11, 31 as well as the general public 32 and adults, 33 and the American Academy of Pediatrics (AAP) for children. 34 The most recent ACIP recommendations for adults, which are summarized yearly, should always be consulted. It is recommended that all HCP be immune to mumps, measles, rubella, varicella, influenza, and, in the context of the coronavirus disease 2019 (COVID-19) pandemic, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). 35 Depending on the vaccine-preventable disease, immunity may be ensured by several different measures ( Table 2) . HCP who are not immune should receive appropriate immunizations ( Table 3) . However, even if HCP are considered immune to a vaccine-preventable disease transmitted by the droplet (ie, pertussis, invasive meningococcal infection, mumps, rubella, SARS-CoV-2) or airborne (ie, varicella, measles) route, they should wear appropriate respiratory protection as per transmission-based precautions while providing care to a patient with confirmed or suspected disease because immunization is not 100% effective in preventing infection. Further, failure of any provider to wear the appropriate respiratory protection may lead nonimmune providers (eg, persons with a contraindication to vaccination) to mistakenly believe that the transmission-based precautions have been discontinued. HCP should be provided with all vaccines that are recommended for adults, 33 such as human papillomavirus, herpes zoster, Tdap (tetanus toxoid, diphtheria toxoid, acellular pertussis), and pneumococcal vaccines, or referred to their local medical providers for the same. In special circumstances, HCP should be offered immunization 36 f Obtain anti-hepatitis B surface antibody (anti-HBs) titer, 1 to 2 months after the last vaccine dose; if immunization is remote and anti-HBs titer not available, see text for management. with other vaccines, including polio, rabies, hepatitis A, vaccinia (smallpox), 38 Ebola virus, and anthrax (Box 4). HCP responding to an outbreak of Ebola virus disease (EVD), who work in one of the federally designated Ebola treatment centers in the United States, or work as laboratorians or other staff at biosafety level 4 facilities in the United States, are recommended for vaccination with EVD. 39 In addition, HCP who are traveling outside the United States for work-related activities should be evaluated and provided with CDC-recommended immunizations such as typhoid, cholera, and Japanese encephalitis. 40, 41 Vaccination for SARS-CoV-2 is recommended for HCP, including paid and unpaid personnel working in all health care settings. At this time, 2 vaccines, both messenger RNA (mRNA) vaccines, have been approved under Emergency Use Authorization: Pfizer-BioNTech's COVID-19 vaccine and Moderna's COVID-19 vaccine. Late-stage trials of additional vaccines are underway or planned (AstraZeneca, Janssen, and Novavax). There are few contraindications to vaccination. These contraindications include (1) severe allergic reaction (eg, anaphylaxis) after a previous dose of an mRNA COVID-19 vaccine or any of its components, (2) immediate allergic reaction of any severity to a previous dose of an mRNA COVID-19 vaccine or any of its components (including polyethylene glycol [PEG]), and (3) immediate allergic reaction of any severity to polysorbate (because of potential cross-reactive hypersensitivity with the vaccine ingredient PEG). Individuals in the last 2 categories should not receive mRNA COVID-19 vaccination unless they have been evaluated by an allergist-immunologist who has determined that the vaccine can be safely administered with adequate observation and support. Detailed guidance is provided by the CDC. Individuals with a history of immediate allergic reaction to any other vaccine or injectable therapy can receive mRNA COVID-19 vaccines but must have received counseling in advance regarding potential risk of severe allergic reaction. If vaccination proceeds in these instances, the observation period should be extended from 15 minutes to 30 minutes for individuals with a history of immediate allergic reaction of any severity to a vaccine or injectable therapy and persons with a history of anaphylaxis of any cause. 42 Vaccination centers should have immediate availability of resuscitation equipment. Immunocompromised HCP require special consideration in the provision of immunizations. 32 First, live, attenuated virus vaccines (eg, measles-mumps-rubella; varicella; live, attenuated influenza) may be contraindicated. Second, vaccines not routinely recommended may be indicated (eg, pneumococcal, meningococcal, Haemophilus influenzae type b). Third, higher antigen doses (eg, hepatitis B vaccine in people with end-stage renal disease), additional doses of vaccine (eg, rabies vaccine in immunocompromised persons), or postimmunization serologic evaluation may be indicated (eg, antibody response to rabies vaccine) because immunization of immunocompromised people may elicit a lower antibody response. In addition, such personnel should be individually evaluated for reassignment (with the consent of the employee) depending on their job duties. Of importance, caring for an immunocompromised patient is not a contraindication to receipt of a live, attenuated vaccine, although HCP receiving live, attenuated influenza vaccine (LAIV) should not work in a protected environment (ie, stem cell transplant unit) for 7 days postimmunization. 33, 43 Pregnant Health Care Personnel Pregnant HCP also require special consideration in the provision of immunizations. The risks from immunization during pregnancy are largely theoretic. 32 The benefit of immunization among pregnant women usually outweighs the potential risks for adverse reactions, especially when the risk for disease exposure is high, infection would pose a special risk to the mother or fetus, and the vaccine is unlikely to cause harm. [44] [45] [46] [47] Furthermore, newer information continues to confirm the safety of vaccines given inadvertently during pregnancy. Ideally, women of childbearing age, including HCP, should have been immunized against measles, mumps, rubella, varicella, tetanus, diphtheria, pertussis, meningococcus, polio, COVID-19, hepatitis A, and hepatitis B as children or adolescents before becoming pregnant. Nevertheless, live, attenuated vaccines should be provided only to nonpregnant HCP and deferred during pregnancy. The ACIP has recommended administration of Tdap during all pregnancies, preferably during weeks 27 to 36. If not administered during pregnancy, Tdap should be administered immediately postpartum before discharge from the hospital or birthing center for new mothers who have never received Tdap before or whose vaccination status is unknown. Women who are pregnant during respiratory virus season should receive inactivated influenza immunization. There is no convincing evidence of risk from immunizing pregnant women with other inactivated virus or bacterial vaccines, or toxoids. Susceptible pregnant women at high risk for specific infections should receive, as indicated, the following vaccines: hepatitis A, hepatitis B, pneumococcal polysaccharide, meningococcal, rabies, COVID-19, and poliovirus (inactivated) (see Box 3). Importantly, the indications for use of immunoglobulin preparations are the same in pregnant and nonpregnant women. Breastfeeding does not Shenoy & Weber adversely affect the response to immunization and is not a contraindication for any of the currently routinely recommended routine vaccines. Before the administration of any vaccine, the HCP should be evaluated for the presence of conditions that are listed as a vaccine contraindication or precaution. 32 If such a condition is present, the risks and benefits of vaccination need to be carefully weighed by the health care provider and the patient. The most common contraindication is a history of an anaphylactic reaction to a previous dose of the vaccine or to a vaccine component. Factors that are not contraindications to immunization include the following: household contact with a pregnant woman; breastfeeding; reaction to a previous vaccination, consisting only of mild to moderate local tenderness, swelling, or both, or fever less than 40.5 C; mild acute illness with or without low-grade fever; current antimicrobial therapy (except for oral typhoid vaccine) or convalescence from a recent illness; personal history of allergies, except a history of an anaphylactic reaction to a vaccine component; and family history of allergies, serious adverse reactions to vaccination, or seizures. Despite the benefits of vaccination, challenges remain in ensuring a fully vaccinated health care workforce. In February 2012, the National Vaccine Advisory Committee issued a statement that provided recommendations on how to achieve the Healthy People 2020 annual influenza vaccine coverage goal (ie, 90%) for HCP; for facilities that have implemented the recommended initial strategies but have "not consistently achieved the Healthy People goal for vaccination coverage of HCP in an efficient and timely manner" it was recommended that they should "strongly consider an employer requirement for influenza immunization." 48 In the most recent season for which data are available, 80.6% of HCP reported receiving influenza vaccination during the 2019 to 2020 season. Among those who were required by their employer to receive the vaccination, compliance was higher at 94.4% compared with those without an employer mandate at 69.6%. 49 In 2020, the Society for Healthcare Epidemiology of America (SHEA) recommended that only medical contraindications should be accepted as a reason for not receiving all routine immunizations as recommended by the CDC. 50 EVALUATION OF HEALTH CARE PERSONNEL WITH COMMUNICABLE DISEASES HCP exposed to a communicable disease for which they are susceptible should be considered for work restrictions or furlough. Similarly, HCP ill with a communicable disease should be considered for work restrictions or furlough (Table 4) . Importantly, infectious HCP have been the source for patient infection and the index case for outbreaks. 52,53 HCP-to-patient transmission has been well documented for HIV, HBV, and HCV, but has most commonly been reported with HBV. For this reason, infected HCP who perform invasive procedures should be evaluated by a special panel for the need for education, additional engineering controls, and/or work restrictions per current guidelines from the Society of Hospital Epidemiology of America 54 and CDC. 55 Although HCP are at risk of exposure to communicable diseases, effective occupational health programs can mitigate risk through thorough evaluation of HCP, ensuring appropriate preexposure prophylaxis, and management of HCP with communicable diseases. On hire, HCP should undergo screening and education directed at reducing the risk of acquisition of infection diseases by health care providers. Recommendations for immunization for HCP are provided by CDC and ACIP. Before the administration of any vaccine, the HCP should be evaluated for the presence of conditions that are listed as a vaccine contraindication or precaution. Anthrax: PEP, research, biothreat attack 2. 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