Special populations of health care workers who may be at increased risk for acquiring/ transmitting certain infectious diseases in the workplace.

Strategies for prevention of infectious diseases in health care workers who may be immunocompromised or pregnant, and their implementation.

Case histories as examples.
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II.Ý Outline

A.Ý Introduction
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1.Ý Bidirectional Spread of Infection (classic concept):Ý infection diseases in health care are transmitted in in both directions
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ÝPatientÝ <---------> health care worker

2.Ý Changes in the health care environment from hospitals only to vertically-integrated health care systems changes some of our prevention strategies.Ý Infection control was practice in hospitals only.Ý Today, as hospitals become health care systems, we need to address these issues for HCWs in home care agencies, physician offices, long-term care, hospice, etc).

B.Ý Laying the groundwork

1.Ý Statement of the problem

Certain disease states/ clinical situations in HCWs require special attention of employee health program.

Some of these clinical situations may put health care workers at increased risk of infection transmission (see A1 above).
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2. Possible solutions

a. There are many; there is no one right answer.Ý Infection Control (IC) and Employee Health (EH) Professionals need to understand, plan, and manage these situations.

b. Additional components of the solution are:
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Ýï administrative comittment from the hospital or health system
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Ýï involvement of the employee health physician or consultant, particularly when dealing with peers (ie other physicians, esp the physicians of health care workers who are either cimmunocompromised or pregnant.

Ýï accountability.Ý Solutions are rarely black or white.Ý Whichever solution you choose, requires monitoring and assessing your strategy.ÝÝ Whenever possible, build preventive strategies and quality assurance acitivites into policies, procedures and strategies to minimize risk to employees in any given situation.

C.Ý Key Clinical Situations in Which Employees May be Immunocompromised

1. Immunosuppression
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ÝïÝÝÝ Malignancy (solid tumors, disseminated cancer)
Ý chemotherapy
Ý radiation therapy
Ý other immunosupression (eg steroids)

ÝïÝÝÝ Other immunosupressed states
Ý transplant recipients on immunosupressive therapy
Ý asplenia, alcoholism, cirrhosis, dialysis

ÝïÝÝÝ HIV/ AIDS
Ý greatest risk of immunosupression is in patients with advanced AIDS or symptomatic disease with low CD4 counts (<50-100).

2. Other chronic illness and/ or treatment
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Ýï diabetic employees who use insulin:Ý disposal of needles.Ý This points out the need to educate employees with chronic illnesses.Ý In one recent case in which I consulted, a diabetic employee using insulin disposed of the syringe in the trash.....this was followed by a needlestick injury in a housekeeping employee who emptied the trash.
ÝThis results in another potential mode of bidirectional transmission; rare, but real.
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ÝÝ employee <--------------> employee

Ýï employees taking corticosteroids (eg asthma, rheumatologic/ connective tissue diseases).

D.Ý Vaccination Programs for Health Care Workers

1. Vaccine priorities for HCWs according to CDC...there are 2 categories of vaccines to consider
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a.Ý Vaccine Table

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b.Ý Considerations for Vaccination of Immunosupressed Employees

Is there:

ï increased risk of acquiring virus from live vaccines that can then enter the chain of transmission and go the bidirectional route from patient <-----> employee?

ï increased risk of progression of illness or immunosuppressionÝ to the employee from live vaccines?

ï suboptimal (blunted or inadequate) reponse to vaccine in immunocompromised HCWs?

2.Ý Vaccine Preventable Disease:  (See table below)
ÝÝ
3.Ý Other disease states of concern; not vaccine preventable

Ýa. Tuberculosis:
Ý Surveillance: primary infection control strategy
Ý BCG: in high risk settings; secondary strategy
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Ýb. HIV
Ý Surveillance: standard in most settings

E.Ý Adapting Vaccination Strategies to Immunosupressed People

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F.Ý Definitions:Ý Immunosupression

1.Ý Steroid use:Ý Prednisone
Ýa.Ý >20 mg/ day or alternate days
ÝÝÝÝ > 14 days of treatment
Ýavoid MMR for 1 month after steroid cessation

Ýb.Ý > 20 mg prednisone/ day or QOD for < 14 days of steroid treatment
Ývaccinate without waiting although some experts wait 2 weeks

2.Ý HIV/ AIDS

Ýa.Ý asymptomatic without immune suppression
ÝMMR recommended

Ýb.Ý symptomatic without immune suppression
ÝMMR recommended

Ýc.Ý symptomatic with immune suppression (ìadvanced AIDS)
Ýlive vaccines not recommended
Ýmeasles pneumonia reported
Ýblunted antibody response to vaccine

G.Ý Other Clinical Situations

1.Ý Tuberculosis and BCG Recipients
ï Tuberculin reactivity caused by BCG vaccination wanes with time
ï unlikely to persist >10 years after vaccination in absence of M.
tuberculosis exposure and infection.
ï BCG-induced reactivity that has weakened might be boosted by administering a tuberculin skin test 1 week to 1 year after the initial postvaccination skin test;
ï ongoing periodic skin testing also might prolong reactivity to tuberculin in vaccinated persons

ï TB skin testing not contraindicated for persons who have been vaccinated with BCG,
ï skin-test results of such persons are used to support or exclude the diagnosis of M. tuberculosis infection
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Definitions of (+) PPD in BCG vaccinated persons

ï HIV (-)Ý * 10 mm of induration
ï HIV (+)ÝÝ * 5mm induration
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Key points from above table:

ï definitions of (+) PPD are same regardless of whether or not they received BCG.

ï the definition of PPD (+) requires less induration in immunosuppressed people.Ý In other words, more severe immune compromise will result in a more sluggish response to PPD and a smaller size of induration is acceptable to call the skin test reaction a positive reaction.

2. Use of BCG in Health Care Workers

About BCGÝÝÝ Bacille-Calmette-Guerin Vaccine

ï is a live attenuated vaccine.
ï it is of low protective efficacy
ï appears to be more protective in children than adults
ï it is a secondary strategy for TB prevention in health care

a.Ý Settings with high risk for transmission of M.TB strains resistant to INH/RIF

ï may be useful as a secondary strategy
ï not recommended for HCWs who are
Ý ï infected with HIV
Ý ï otherwise immunocompromised.
Ýï pregnant

HIV (+) employees/ volunteers or otherwise immunosupressed
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ïÝ should be informed of risks associated with the
development of active TB disease because of immunosuppression
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ï employers should offer, but not compel, a change in work assignment in
which the HCW would have the lowest possible risk for infection with M. tuberculosis.
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b.Ý Settings Associated With Low Risk for M. tuberculosis Transmission

ï BCG vaccination is not recommended in these settings

c.Ý Pregnancy:Ý not recommended
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2. Pregnancy

Strategies for pregnant women in health care should be based on scientific data
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The problem of course is the very rational tendency to do as little intervention as possible during pregnancy to maximize good outcome for both mother and baby.

In the course of doing this, there may be a tendency to overreact to certain situations lose site of the objective approach.

There is a tendency to overreact to certain diseases of low transmissability (eg CMV) and underreact to diseases that are more transmissable, such as multidrug-resistant M. tuberculosis.

a.Ý Cytomegalovirus

Problems/ Issues:

Ý ï CMV is a cause of congenital malformations in infants

Ýï 60-80% of health care workers are women of childbearing age

Ýï Many immunosuppressed patients in health care settings shed CMV (HIV/ AIDS, transplant patients, congenitally infected neonates)

Ýï transmission primarily by close intimate contact (sexual contact),Ý transplanted organ.Ý Rarely by blood transfusion now.

Ýï Health care workers are not at increased risk of CMV compared to general population.Ý If 2 groups of healthy women are compared:Ý health care workers in pediatrics settings and women in the community who are not HCWs, there is no difference is the rate of acquisition of CMV between the 2 groups.

In other words, since CMV is primarily sexually transmitted, working in health care does not increase the risk of Cmv acquisition.

The recommendation coming from these data is:

Ýï Restriction or reassignment is not recommended

H.Ý Additional Strategies:

1.Ý Vaccination of patients throughout the health care system, especially for hospitalized patients.
ÝCatching up in adults and children, especially in patients with chronic illness who may be discharged to home care and have less frequent contact with the physicianís office.

2. Refer to new CDC Employee Health Guidelines
Ýa.Ý Need to know employees at risk
Ý ïÝÝÝ pre-employment health evaluation
Ý ïÝÝÝ periodic re-evaluation
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Ýb.Ý Role of the Employee Health Physician
Ý ï Communication with employeeís physician
Ý ï Employee health provider: physician, PA or NP
Ý ï If EH services are done by contractor, are infection control policies and procedures spelled out clearly?

Ýc.Ý More frequent surveillance
Ý ïÝÝÝ employee awareness
Ý ïÝÝÝ continued surveillance for sentinal infections: TB, influenza
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Ý ïÝÝ continued monitoring of incident reports and use of data: categorized infection control incidents.

Ý5.Ý Workplace accomodations
ÝÝ ïÝÝÝ restriction/ transfer
Ý ïÝ if no restriction/ transfer, what is your plan for ensuring workplace safety.
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6. Vaccine Catch Up & The Employee Health Service

Two groups for consideration here:
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a.Ý An important group to help with catch up is the group of employees who are already working within your health care system who, for one reason or another, have not been brought up to date on immunizations.

These employees will fall into 3 major subgroups

ï employees who have already had their pre-employment health evaluation and are not up to date because they have not met your b aseline requirements.

Ýï employees who have already had their pre-employment health evaluation and are not up to date because your immunization requirements have changed since their pre-employment evaluation.

ï employees who have come into your system as your hospital has acquired physician practices or other programs and have not been brought up to date.

b.Ý HCWs who come to work with incomplete immunization histories and need to catch up.

The employee health service can be instrumental in helping with this catch up.

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I.Ý Case studies

Case 1:Ý CMV, Pregnancy and HIV

Problem: How would you handle the following letter from the obstetrician of a nurse on your inpatient general medical unit?
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To the supervisor of (First Name Last Name)

Mrs. (Last Name) is 4 months pregnant and should not have contact with CMV patients until she delivers in about 5 months.

Ý(First Name Last Name) MD

Solutions/ Analysis

ï Pregnancy does not increase risk of CMV transmission.
ï What does your policy say about CMV, its mode of transmission, and the need for restriction?
ï Communicating with the employeeís physician is a good job for the employee health physician.

Case 2:Ý Would your response be any different if the employee was a child life specialist, working in a day care program for developmentally challenged children, in a satellite program at a facility in your health care system?

Case 3:Ý A 52 year old retired policeman is hired by your health care system as a public safety officer.Ý His job will involve travelling from one satellite office to another during his 8 hour shift to monitor safety issues outlined in his job description.Ý He will also work in your hospital emergency room every other weekend as the safety officer.

As your physicianís assistant is reviewing the employeeís health inventory, the employee gives the following history:
Ýï he has a long standing history of ashtma for which he uses a non-steroidal bronchodilator inhaler.
Ýï his asthma is well-controlled
Ýï he quit smoking 2 years ago
Ýï at least once a year, he needs an occassional course of steroids (prednisone 60mg/ day tapered over 3-4 weeks, usually during the winter months.
Ýï His last course of prednisone was 10 months ago.
Vaccination history is as follows:
Had polio vaccine as a child.Ý Had chickenpox, measles, and mumps disease as a child.Ý His doctor at the HMO where he gets his health care talked to him about a ìpneumonia shotî but it was never given.

Your job:Ý Outline a vaccination plan for this employee.

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VaccineÝÝÝ YesÝÝ NoÝÝ Comments

Hepatitis B
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Influenza
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Measles/ mumps/ rubella
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Varicella/ Zoster
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HIV
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Tuberculosis
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Pneumovax
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other
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Case 4.Ý What if the same job were filled by a 24 year old man with same history of asthma.Ý In addition, he is taking prednisone 20 mg/ day now; started 2 weeks ago and he is tapering from 40 mg a day for asthma.

History:Ý had oral polio vaccine (OPV) as a child, no history of varicella, measles or mumps.

When you ask him about pneumovax, he says ìCool, whatís pneumovax?î

Design an immunization program for him.
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ÝÝÝÝ YesÝ NoÝÝ Comments

Hepatitis B
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Influenza
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Measles/ mumps/ rubella
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Varicella/ Zoster
Ý
HIV
Ý
Tuberculosis
Ý
Pneumovax
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other
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Case 5

The coordinator of the newly-acquired home care program, recently acquired by your hospital calls and asks how to handle the following case:

A 35 year old new hire, a native of the Carribean, has HIV.Ý He says he has never had poliovaccine.Ý He has some documentation of vaccination:Ý a sheet from the local health department of his Carribean country that indicates he was vaccinated with MMR and tentaus/ diphtheria.

He is being treated for his HIV with a combination of antiretriviral therapy, has an undetectable viral load and is considered asymptomatic and otherwise heatlhy.Ý He has never had an opportunisitic infection.

The question:Ý the home care program would like to hire him to work in the pediatrics home care program, but they are concerned about his being susceptible to polio.

What do you tell them?

References

1.Ý Centers for Disease Control and Prevention. Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR 1997;46(No. RR-18].

2.Ý Screening for Tuberculosis and Tuberculosis Infection in High-Risk Populations Recommendations of the Advisory Council for the Elimination of Tuberculosis MMWR 44(RR-11);18-34.Ý Publication date: 09/08/1995

3. The Role of BCG Vaccine in the Prevention and Control of Tuberculosis in the United States A Joint Statement by the Advisory Council for the Elimination of Tuberculosis and the Advisory Committee on Immunization Practices.
MMWR 45(RR-4);1-18.Ý Publication date: 04/26/1996

4.Ý Valenti, WM.Ý Infection Control and the Pregnant Health Care Worker.Ý Nursing Clinics of North America.Ý (September) 1993; 28: 673.

5.Ý Valenti, WM.Ý Selected Viruses of Nosocomial Importance in Hospital Infections, Fourth edition. Bennet and Brachman (eds). Chapter 42. p. 637, 1998.

6.Ý Murph, JR et al.Ý The occupational risk of CMV among day care providers.Ý JAMA 1991; 265; 603-608.

7.Ý Balcarek KB et al.Ý Cytomegalovirus infection among employees of a childrenís hospital:Ý no evidence for increased risk associated with patient care.Ý JAMA 1990: 263: 840-843.

8. CDC Web Site:Ý http://www.cdc.gov
l
l . CDC Employee Health Guidelines
? Federal Register: September 8, 1997 (Vol 62, # 173, Page 47275-47327)
? Internet: wais.access.gpo.gov
ÝDOCID: fr08se97-87
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