Download (WHO), immunization

Module 12 Preventing and Controlling Infectious and
Communicable Diseases in the Workplace
#outcomes
Learning Outcomes
After successfully completing this module, you will be able to:
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Identify the relevant legislative requirements concerning infectious diseases
in the workplace.
Describe the elements of an infectious exposure control plan.
Locate information sources related to infectious disease risk identification
and control.
Identify appropriate immunizations for the workplace and understand the
role of the OHN in workplace immunizations.
Describe the OHN role in preventing and controlling communicable diseases.
Describe the OHN role in the management of blood and body fluid exposures.
/outcomes
Biological Agents
Many of the occupational diseases that are prominent in Canada are caused by
exposure to biological agents. The occupational diseases caused by overexposure to
physical agents such as noise, pressure, heat, and the various types of nonionizing
radiation are generally well understood. The dose-response relationships seem to
be clear and prevention methods have been developed.
Occupational diseases caused by exposure to biological agents are also generally
well understood. However, unlike many other occupational diseases, worker
characteristics factor heavily in our risk assessment. Susceptibility to biological
agents not only depends on our genetic makeup but is also dependent on our health
and immune status. Health care workers and those who work closely with the
general public are at risk for communicable diseases.
The OHN Role in Infectious Diseases
Infectious diseases have a significant impact on occupational health. Annually colds
and influenza cost employers millions of dollars in illness-related absences. Certain
jobs, particularly in the health care field, carry the risk of exposure to more serious
and even fatal infections. Businesses and organizations also need to have emergency
plans in place to be activated in case of pandemics and even bioterrorism.
Unique among members of the occupational health and safety team, occupational
health nurses have the necessary skills to assess workplaces for infectious disease
risks and to propose and deliver programs to mitigate this risk on an ongoing or
event basis. Therefore, it is important that OHNs have a good understanding of
infectious disease assessment and control. This is an area where occupational health
nursing intersects with public health and infection control.
This module begins with a discussion of immunization then moves on to
communicable diseases, and finally the OHN role in post exposure management of
blood and body fluid exposures. The module concludes with case studies of 3
common scenarios you will encounter as an OHN.
This module is not intended to provide comprehensive and detailed information on
every infectious disease that could be potentially encountered in the workplace.
Rather, it is intended as an overview of the most common agents and will provide
resources for further investigation. First let’s start with legislative requirements.
Legislation
All provinces and territories in Canada have legislation that deals with the handling
of hazardous materials (WHMIS). In BC this is found under Part 5 of WorksafeBC
regulations. However, the BC regulations have a much more extensive section
concerning biological substances under Part 6: Substance Specific Regulations,
specifically sections 6.33–6.40 Biological Substances. Take a few minutes to scan
this section now.
#link
Web Resources
WorkSafeBC
Sections 6.33–6.40 Biological Substances
/link
Laboratories have additional regulations under Part 30.
If you do not live in BC, take a few moments to locate the relevant legislation for
your province.
Depending on your workplace there may be few or many infectious diseases of
concern. To begin the process of identification, begin with this general overview:
Employer Requirements
 Identify infectious diseases in the workplace
 Develop and implement an Exposure Control Plan
 Inform workers how they may be exposed
 Educate, train and supervise workers on safe work procedures and personal
protective equipment
 Offer vaccinations recommended by the BCCDC, at no cost to workers
 Purchase safety-engineered medical devices (example safety needles)
 Tell workers to seek medical assessment following BBF exposures
 Encourage workers to report incidents
 Encourage workers to keep personal immunization records and obtain
outstanding recommended immunizations
#link
Web Resources
WorkSafeBC, Controlling Exposure: Protecting Workers from Infectious Disease,
March 2009
https://www.worksafebc.com/en/resources/health-safety/booksguides/controlling-exposure-protecting-workers-from-infectious-disease?lang=en
/link
Immunizations
Background
Immunizations have made a significant contribution to infection control in Canada
and around the world and have been credited with saving more lives than any other
health intervention. The incidence of vaccine-preventable infectious diseases has
been significantly reduced over the past 50 years. Globally, smallpox has been
eradicated and efforts are currently directed at the eradication of polio.
As the incidence of vaccine-preventable diseases decreases, public focus may shift
from the disease and its sequelae to potential post vaccination adverse events. In
some cases, individuals question the need for ongoing immunization, resulting in
decreased vaccination rates with subsequent resurgence of the disease. A recent
resurgence of measles, mumps and pertussis in Canada has highlighted the
continued need for immunization programs. The occupational health nurse (OHN) is
positioned to educate the working population about the importance of adult
immunization and in some settings, may also deliver these immunizations to
workers.
Immunization in Canada
In Canada, the federal, provincial and territorial governments share responsibility
for immunization programs to prevent, control, eliminate, and eradicate vaccinepreventable diseases with provincial/territorial governments and local public
health authorities undertaking the planning and delivery.
#link
Web Resources
Canada’s National Immunization Strategy (2003)
The Public Health Agency of Canada (PHAC) is the principal federal government
agency responsible for immunization, supported by two advisory committees:
National Advisory Committee on Immunization (NACI)
Review the types of recommendations made by this committee.
Committee to Advise on Tropical Medicine and Travel (CATMAT)
Review the CATMAT statements and recommendations.
Health Canada is the federal authority responsible for the regulation of vaccines for
human use and authorizes the sale of vaccine in Canada.
/link
Immunization at the Provincial level
The provincial/territorial (P/T) governments are responsible for the administration
and delivery of health care services, which include immunization programs.
P/T governments:
 Develop immunization policies and schedules
 Establish expert advisory committees
 Identify priorities for publicly funded programs
 Purchase vaccines for publicly funded programs
 Design/maintain immunization registries
 Provide disease and safety surveillance and program monitoring
In British Columbia, this work is done by the BC Centre for Disease Control (BCCDC)
through the Immunization Programs and Vaccine Preventable Disease Service, who
author the Immunization Manual for use by all vaccine providers in the province.
Sections IA to IX of the Immunization Manual can be found here.
#link
Web Resources
Centre for Disease Control (BCCDC)
Section IA Introduction, 2.2 Community Vaccine Provider Responsibilities. Read pages 2-3.
If you do not live in BC, take a few moments to locate the relevant manual and
sections for your province.
The Canadian Immunization Guide s another key reference and can be used by immunization
providers for additional background and information. It is available at
/link
Immunization Competencies
An OHN may decide or be required to administer vaccines at the workplace. Before
beginning such a program, a review of the required competencies is critical.
A vaccine provider must demonstrate the attitudes, knowledge, and clinical skills
necessary to provide safe and effective immunization programs. In 2008. PHAC
published the National Immunization Competencies for Health Professionals
document, which can be found here
#link
Web Resources
PHAC the National Immunization Competencies for Health Professionals
/link
In BC, the BCCDC Immunization Competency Program is available to assist all health
professionals who provide immunization to be knowledgeable vaccine providers,
educators, and advocates for immunization. BCCDC has also developed an online
Immunization Course that is available free to Registered Nurses, Licensed Practical
Nurses, and Pharmacists working in BC. Course content is based on the
Immunization Competencies for BC Health Professionals.
If you are an OHN delivering an immunization program in BC, it is highly
recommended that you complete this online course. This course is mandated in
some practice settings. After successful completion of the online exam, you will be
able to print a certification of achievement. You can access the online course and
obtain enrolment keys from here
#link
Web Resources
BCCDC Immunization Competency Program
/link
Principles of Immunology
The immune system protects the body from infectious agents and other harmful
substances. Immunity is the body’s ability to tolerate the presence of material
indigenous to the body (self), and to eliminate foreign (non-self) material. Immunoprophylaxis is disease prevention using the immune system.
According to the World Health Organization (WHO), immunization "is the process
whereby a person is made immune or resistant to an infectious disease, typically by
the administration of a vaccine. Vaccines interact with the immune system and
produce an immune response similar to that produced by the natural infection, but
they do not subject the recipient to the disease and its potential complications.
Vaccines produce immunological memory similar to that acquired by having the
natural disease. The antigen is the part of the vaccine that stimulates the immune
response.
#link
Web Resources
BC Centre for Disease Control Communicable Disease Control Immunization
Program Section VIII Principles of Immunology September 2009.Pages 12-18
BC Centre for Disease Control
/link
#activity
Learning Activity #1/Perspective
Compare / contrast passive immunizing and active immunizing agents as follows:
Why do live attenuated vaccines produce long-lasting immunity?
#reveal
These vaccines contain whole living virus or bacteria that achieve immunity by
actively replicating within the host. Because these vaccines replicate, the immune
response is both cell mediated and humoral, identical to natural infection–
protection is therefore long term and probably life-long.
/reveal
List vaccine-related factors that can affect the immune response.
#reveal
 Nature of the antigen
 Dose of the antigen
 Presence of an adjuvant
/reveal
List host-related factors that can affect the immune response.
#reveal
 Circulating antibodies
 Age of the client
 Genetics
 Nutritional factors
 Co-existing disease
Previous exposure to antigen/vaccine (anamnestic response)
/reveal
Instructions: Drag the X to identify whether the following vaccines are replicating or
non-replicating:
/activity
Immunization Coverage
Immunization protects both the individual as well as the larger population by
preventing the spread of infectious diseases. It is important to achieve and maintain
a high immunization coverage rate to achieve this protection.
Immunization coverage can be defined as the percent of people who receive one or
more vaccine(s) of interest in relation to the overall population.
Monitoring trends in coverage is important in order to identify the potential for
outbreaks of vaccine-preventable diseases (i.e., when coverage rates drop in a
population, that population has increased chances of having a vaccine-preventable
disease outbreak). In addition, monitoring also guides the BCCDC to recommend
where public health should allocate its resources, such as to improving access to
immunization services or to public education efforts.
In BC, immunization coverage is monitored for:
 Children at the 2nd birthday
 School aged children
 Influenza vaccine recipients aged 65 years or> and 12-64 year olds with high
risk medical conditions
Every year in BC, residential and acute health care facilities report their influenza
immunization coverage numbers for both workers and residents living in these
facilities.
The following reading is an example of how influenza immunization coverage rates
helped to determine the effectiveness of an employer policy.
#link
Web Resources
BC Centre for Disease Control, Influenza vaccination coverage for staff of acute care facilities
British Columbia,
/link
Vaccines: Risks and Safety
As with any medical procedure, vaccine administration carries some risk but these
risks are extremely small. Most vaccine side effects are mild and temporary. Serious
side effects are rare – for example anaphylaxis following vaccination is about one in
a million doses of vaccine given. Yet risks from the disease a vaccine prevents or
complications of the disease can be much greater. These diseases can cause
pneumonia, deafness, brain damage, heart problems, blindness, and paralysis and
can carry a risk of life-long disability and death. An OHN administering vaccines
must be comfortable explaining vaccine risks when gathering informed consent
from the worker.
Vaccines are one of the most monitored and studied items in medicine. Vaccine
production and release takes about 10 years of research and development to ensure
it is both safe and effective for use in Canada.
#link
Web Resources
Immunize BC
/link
Adverse Events
All vaccine providers must have emergency procedures and equipment in place and
readily available in case of adverse reactions to vaccines. Adverse events are
required to be reported.
#reading
BCCDC, Communicable Disease Control Immunization Program Section IX Adverse
Events Following Immunization, January 2014. Read pages 3-8.
/reading
#activity
Learning Activity #2/Perspectives
One of the workers at your workplace complains about a sore arm after receiving
influenza vaccine.
What questions would you ask this worker to assess the situation?
#reveal
 Is the sore arm the same as the injection site?
 Where is the soreness? Is it in the deltoid muscle?
 When was the injection given? When did the soreness start? Has the soreness
been present > 10 days post vaccination?
 How severe is the soreness? Does it extend past the nearest joint?
 Are there any other symptoms?
/reveal
Should this be reported as an adverse event following immunization (AEFI)?
#reveal
Depends on the answers to #1.
Local injection site soreness, which develops within 48 hours of a vaccination,
should NOT be reported as an AEFI as it is an expected reaction.
/reveal
/activity
Adult Immunization Schedule
Ideally, primary immunization begins at 2 months of age. In BC, the BCCDC sets
immunization schedules for both children and adults.
#link
Web Resources
BCCDC, Communicable Disease Control Immunization Program Section IIA Immunization
Schedules, January 2012.
Read page 8, then page 7
http://www.bccdc.ca/resourcegallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20
Manual/Chapter%202%20-%20Imms/SectionIIAImmunizationSchedulesNovember2014.pdf
/link
Special Occupational Populations
Several occupational populations have been identified as having specific
immunization needs. These populations include health care workers, child care
workers, international travelling workers, and workers who are new to Canada.
International travelers are advised to make an appointment with a travel medicine
specialist for a full consultation. An OHN can refer clients to the following websites
for further information:
#link
Web Resources
Canadian Immunization Guide, 7th Edition
http://www.phac-aspc.gc.ca/publicat/cig-gci/p03-10-eng.php
Travel Medicine Program section on the PHAC website
http://www.phac-aspc.gc.ca/tmp-pmv/indexeng.php?utm_source=VanityURL&utm_medium=URL&utm_campaign=travelhealth.gc.
ca
Health Information for International Travel, US Centers for Disease Control and Prevention
International Travel and Health, World Health Organization
http://www.who.int/ith/en/
Travel Clinic, Vancouver Coastal Health
Yellow Fever Vaccination Centres
/link
#reading
Read: BCCDC, Communicable Disease Control Immunization Program Section III
Immunization of Special Populations, January 2009, pages 46-49, 51-55.
/reading
#activity
Learning Activity #3/Perspectives
Are volunteers in a hospital considered health care workers by BCCDC?
#reveal
Yes, BCCDC define HCWs as persons who provide health care to patients. This broad
definition includes hospital volunteers.
/reveal
Can a child care employer ask its workers to provide a copy of their immunization
records?
#reveal
Yes – in fact it is the employer’s responsibility to:
 Assess the immunization status of each worker at the time of initial
employment.
 Obtain full vaccination history, including documentation of the doses
received and dates of administration.
 Offer immunization at the earliest opportunity to persons who cannot
provide acceptable information or evidence of adequate immunity.
 Maintain records of all immunizations and serologic tests. The employee
should also keep these records and institute an immunization recall system.
/reveal
Is a health care worker considered immune to Hepatitis B following a series of 3
Hepatitis B immunizations?
#reveal
No – to be considered immune a health care worker would also need one
documented laboratory test that shows they have developed sufficient antibody
levels.
/reveal
/activity
Communicable Diseases
Background
Communicable diseases spread from one person to another or from an animal to a
person. The spread often happens via airborne viruses or bacteria, but also through
blood or other bodily fluid. The terms infectious and contagious are also used to
describe communicable disease.
It is helpful to understand some of the terms used to describe communicable
diseases:
Communicable Disease: An illness due to a specific infectious agent or its toxic
products that arises through transmission of that agent or its products from an
infected person, animal or inanimate reservoir to a susceptible host; either directly
or indirectly through an intermediate plant or animal host, vector or the inanimate
environment. (Synonym: infectious disease)
Communicable Period: The time during which an infectious agent may be
transferred directly or indirectly from an infected person to another person, from an
infected animal to humans, or from an infected person to animals, including
arthropods.
Contact: A person or animal that has been in such association with an infected
person or animal or a contaminated environment as to have an opportunity to
acquire the infection.
Immune Individual: A person or animal that has specific protective antibodies
and/or cellular immunity as a result of previous infection or immunization, or is so
conditioned by such previous specific experience as to respond in such a way that
prevents the development of infection and/or clinical illness following re-exposure
to the specific infectious agent.
Immunity: That resistance usually associated with the presence of antibodies or
cells having a specific action on the microorganism concerned with a particular
infectious disease or on its toxin.
Incidence Rate: The number of new cases of a specified disease diagnosed or
reported during a defined period of time, divided by the number of persons in a
stated population in which the cases occurred. This is usually expressed as cases per
1,000 or 100,000 per annum.
Incubation Period: The time interval between initial contact with an infectious
agent and the first appearance of symptoms associated with the infection.
Infectivity: Expresses the ability of the disease agent to enter, survive and multiply
in the host.
Infestation: For persons or animals, the lodgment, development and reproduction
of arthropods on the surface of the body or in the clothing. Infested articles or
premises are those that harbor or give shelter to animal forms, especially
arthropods and rodents.
Isolation: As applied to patients, isolation represents separation, for the period of
communicability, of infected persons or animals from others in such places and
under such conditions as to prevent or limit the direct or indirect transmission of
the infectious agent from those infected to those who are susceptible to infection or
who may spread the agent to others.
MHO: Medical Health Officer within the local health authority’s Public Health.
Morbidity Rate: An incidence rate used to include all persons in the population
under consideration who become clinically ill during the period of time stated. The
population may be limited to a specific gender or age group, or to those with certain
other characteristics.
Mortality Rate: A rate calculated in the same way as an incidence rate, by dividing
the number of deaths occurring in the population during the stated period of time,
usually a year, by the number of persons at risk of dying during the period.
Nosocomial Infection: An infection occurring in a patient in a hospital or other
healthcare facility in whom it was not present or incubating at the time of
admission; or the residual of an infection acquired during a previous admission.
Includes infections acquired in the hospital but appearing after discharge, and also
such infections among the staff of the facility. (Synonym: hospital-acquired
infection)
Prevalence Rate: The total number of persons sick or portraying a certain
condition in a stated population at a particular time (point prevalence), or during a
stated period of time (period prevalence), regardless of when that illness or
condition began, divided by the population at risk of having the disease or condition
at the point in time or midway through the period in which they occurred.
Quarantine: Restriction of the activities of well persons or animals who have been
exposed to a case of communicable disease during its period of communicability
(i.e., contacts) to prevent disease transmission during the incubation period if
infection should occur.
Susceptible: A person or animal not possessing sufficient resistance against a
particular pathogenic agent to prevent contracting infection or disease when
exposed to the agent.
Transmission: Any mechanism by which an infectious agent is spread from a
source or reservoir to a person.
Transmission of Infectious Agents
Direct
Direct and essentially immediate transfer of infectious agents to a receptive portal
of entry through which human or animal infection may take place. This may be by
direct contact such as touching, biting, kissing or sexual intercourse, or by the direct
projection (droplet spread) of droplet spray onto the conjunctiva or onto the
mucous membranes of the eye, nose or mouth during sneezing, coughing, spitting,
singing or talking (usually limited to a distance of about 1 m or less).
Indirect
Vehicle-borne – inanimate objects such as toys, soiled clothes, bedding, and surgical
instruments
Vector-borne – an arthropod (crawling or flying insect)
Airborne
Dissemination of microbial aerosols to a suitable portal of entry, usually the
respiratory tract. Microbial aerosols are suspensions of particles in the air
consisting partially or wholly of microorganisms. They may remain suspended in
the air for long periods of time, some retaining and others losing infectivity or
virulence. Particles in the 1- to 5-µg range are easily drawn into the alveoli of the
lungs and may be retained there. Not considered as airborne are droplets and other
large particles that promptly settle out.
Control of Communicable Disease
In BC, the BCCDC produces the Communicable Disease Control Manual to guide the
implementation of communicable disease control and prevention programs.
If you do not live in BC, locate the relevant guidelines for your province.
#link
Web Resources
BC Centre for Disease Control Communicable Disease Control Manual, Introduction, April 2011,
pages 1-3
/link
#activity
Learning Activity #1/Perspectives
Under the Public Health Act, what powers does the Medical Health Officer (MHO)
have?
#reveal
Mandatory reporting of communicable diseases and related matters (PHA section
10 and the Communicable Disease Regulation); issuing of orders to people who may
be infected or to deal with a health hazard (PHA sections 27-33); responding to
communicable disease related public health emergencies (PHA sections 51-57); and
applying for warrants, injunctions, and court orders (PHA sections 47-49).
In addition to MHO general responsibilities to prevent and control communicable
diseases, they have specific statutory responsibilities to determine public health
threats and to direct the response to local public health threats (PHA section 81).
/reveal
What resources would an OHN use to guide her/his response to a communicable
disease threat?
#reveal
Communicable Disease Control Manual
Local Medical Health Officer directions
/reveal
/activity
Management of Specific Communicable Diseases
Exposure to common communicable diseases is common in both community and
occupational settings. Concerns about communicable disease exposure can occur in
any work group and the OHN may be called upon to assess the nature of the
exposure and the individual’s immunity to that specific disease. The OHN may also
be required to recommend exposure prevention strategies for the employer.
Mode of transmission, incubation period, period of communicability, and definition
of immunity vary with each disease. It is important that the OHN has a clear
understanding of the specific disease by consulting the applicable Communicable
Disease Control Manual, Management of Specific Diseases for his/her
province/territory prior to assessing the situation.
#link
Web Resources
BC Centre for Disease Control Communicable Disease Control Manual, Management of Specific
Diseases, Measles, June 2014, pages 1-23
/link
#activity
Learning Activity #2/Perspective
A worker at your health care work site has been diagnosed as having measles. As the OHN at the
workplace, you have been asked by the worker’s manager to provide the following information /
guidance:
How is measles disease spread?
#reveal
Mode of transmission: airborne by aerosol and droplet spread, direct contact with nasal or throat
secretions of infected persons; less commonly by articles freshly soiled with nose and throat
secretions.
/reveal
How long did it take from the time of first exposure until the worker started to show symptoms?
#reveal
Incubation period: average is 8 – 12 days with a range of 7 – 18 days, rarely may be as long as
21 days.
/reveal
How long will the worker be infectious (can spread the disease to others)?
#reveal
Period of communicability: from 1 – 2 days before the beginning of the prodromal period
(usually about 4 days before rash onset) to 4 days after rash appearance in a healthy person and
for the duration of measles illness in an immunocompromised person.
/reveal
The worker diagnosed with measles was at work during part of the communicable period. What
is the definition of immunity for measles?
#reveal
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Birth date before January 1, 1970 (1957 for health care workers)
Documented evidence of vaccination with 2 valid doses of live measles-containing
vaccine after their 1st birthday and given at least one month apart
Laboratory evidence of immunity (i.e., “reactive” or ”positive” anti-measles IgG
antibody or a previous measles antibody level of ≥ 200 mIU per ml).
Laboratory evidence of prior measles infection. Physician diagnosis of measles without
laboratory confirmation is no longer considered proof of immunity in the current
Canadian epidemiologic context.
/reveal
The local Medical Health Officer (MHO) from Public Health has contacted you because measles
is a reportable disease. The MHO has asked you to identify exposed workers who are susceptible
to measles. How would you assess the immunity of these exposed workers?
#reveal

First, the OHN must identify workers who meet the case contact definition for measles.
Definition: Contacts are individuals who have spent any length of time in a room or
enclosed space while the infectious measles case was present or for up to 2 hours after the
case left the room/space.

Individuals who meet this definition, are then assessed. The OHN needs to identify the
birth year for all of these contacts, then review documented proof of vaccination with
MMR vaccine (d/m/y of immunizations). Those who do not meet the definition of
immunity are considered susceptible contacts who may need to be excluded from work
for up to 21 days from the time of the last exposure to the case.
/reveal
One of the exposed susceptible co-workers was born in 1971 and has no records of her baby
shots. Can you give this worker MMR vaccine?
#reveal
As long as this co-worker is not a pregnant female or has any other live measles vaccine
contraindications. 1st dose immediately, then 2nd dose after 28 days.
/reveal
/activity
#activity
Learning Activity #3/Perspective
The following vaccine-preventable communicable diseases can be encountered in Canadian
workplaces: measles; mumps; rubella; varicella (chickenpox); and pertussis.
/activity
#link
Web Resources
BC Centre for Disease Control Communicable Disease Control Manual, Management of Specific
Diseases, Measles, June 2014, pages 1-23
/link
For each of the diseases listed above, identify the following for health care workers (HCWs):
 Mode of transmission
 Incubation period
 Period of communicability
 Definition of immunity
 Exposure Criteria
 Assessment of exposure and guidance
 Exclusion of susceptible contacts in a workplace, school or child care setting
Influenza
Influenza is a highly contagious disease caused primarily by two types of viral strains – Influenza
A or Influenza B. Seasonal influenza causes about 3500 deaths in Canada per year. It is
considered a community acquired rather than an occupationally acquired communicable disease.
It ranges from asymptomatic to mild, uncomplicated illness to severe, complicated illness.
Flu symptoms typically include the sudden onset of:
 high fever
 cough
 muscle aches
 Other common symptoms include:
 headache
 chills
 fatigue
 loss of appetite
 sore throat
 coryza
In some people, especially children, nausea, vomiting and diarrhea may occur. While most people
recover in 7 to 10 days, severe illness can occur. Certain groups are at high risk for complications
or hospitalization, these include adults, pregnant women and children with underlying health
conditions such as:
 cancer
 diabetes
 cardiac disorders
 pulmonary disorders
 morbid obesity (BMI ≥40)
As well as:
 residents of nursing homes and other chronic care facilities
 people aged 65 and older
 Aboriginal peoples
Annual seasonal influenza vaccination is still considered the most effective way to prevent
influenza and its complications.
The OHN may be required to develop a seasonal influenza immunization program for workers.
Further information can be found here:
#link
Web Resources
Government of Canada
PHAC
HealthLinkbc
/link
Tuberculosis (TB)
Tuberculosis disease is caused by any one of the mycobacteria grouped into the Mycobacterium
tuberculosis (MTB) complex. TB bacteria are:
 Rod-shaped
 1 to 5 microns in size
 Aerobic (prefer to grow in high oxygen environments)
 Slow-growing (divide once every 15 to 20 hours)
Transmission:
#link
Web Resources
BC Centre for Disease Control, Disease Control Chapter 4 – Tuberculosis Manual, November
2015, pages 4-7
Canadian Tuberculosis Standards, 7th Edition Chapter 2 Pathogenesis and Transmission of
Tuberculosis, page 5-7
/link
Most of the Canada’s active TB rates occur in the foreign-born population (70 per cent). While
the overall number of foreign-born cases has decreased over the last decade, the recent influx of
immigrants from countries with endemic TB is likely attributable for the province’s higher active
TB rates. It must also be noted that BC has a more inclusive case definition of active TB than that
of the Public Health Agency of Canada (PHAC) which may partially explain the elevated rates
seen in BC.
Current information on the epidemiology of TB in BC can be found in the most recent TB
Surveillance Annual Report.
#link
Web Resources
TB Surveillance Annual Report.
/link
#activity
Learning Activity #4/Perspective
Define Active TB disease:
#reveal
Active clinical disease that is usually symptomatic. Microbiological tests are usually TB bacteria
positive and radiologic tests are usually abnormal: also known as ‘TB disease’.
/reveal
Define Latent TB infection (LTBI):
#reveal
the presence of latent (dormant) infection with TB bacteria. People with LTBI have no evidence
of clinically active TB disease and are not infectious.
/reveal
Following an exposure to an infectious case of TB and initial infection, what percentage of
Canadians develop primary disease?
#reveal
About 5%; 90% develop LTBI
/reveal
Of those who develop Latent TB Infection following an exposure, what percentage will go on to
develop reactivation?
#reveal
About 5%
/reveal
What are the risk factors for the transition of LTBI to active TB?
#reveal
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/reveal
Immune competency of the host
Age – very young and old
Seasons – spring and early summer
Medical conditions affecting immune competency
Crowding, poor ventilation
Poverty
Duration of exposure & proximity to infected case
What are the symptoms of active respiratory TB disease?
#reveal
Fever, cough for 2 to 3 weeks or more with or without fever or phlegm, unexplained weight loss
or failure to thrive, hemoptysis, loss of appetite, night sweats.
/reveal
/activity
Tuberculin Skin Test (TST or Mantoux Test)
TST is used to detect infection with TB bacteria. TST cannot differentiate between latent TB
infection (LTBI) and active TB disease.
The test consists of an intradermal injection of a small volume (0.1 mL) of purified protein
derivative from M. tuberculosis bacteria (PPD, also known as ‘tuberculin’). People infected with
TB bacteria usually respond to tuberculin with a delayed hypersensitivity reaction that manifests
as a discrete area of swelling and firmness (induration) at the site of the injection.
Serial TST’s usually done on an annual basis and are recommended for some at risk groups to
help identify new TB infections, otherwise known as TST conversions. This can help facilitate
the treatment of LTBI.
Health care providers administering TST should be familiar with current recommendations on the
initial management of anaphylaxis in non-hospital settings, provided in Chapter 2, Section V of
the Communicable Disease Control Manual.
Contraindications to TST






Prior allergic response or severe reaction to a TST or any allergy to the components
of Tubersol.
Burns or eczema at skin testing sites (alternate sites may be used).
Previously positive result or previous blistering reaction to a TST (use clinical
judgment to re- administer if the TST is undocumented and the client is unable to
provide a clear description of the positive response).
Previous IGRA reactive.
Previous active TB disease.
Previous treatment for active TB disease or latent TB infection. TST is not
contraindicated for people who have received window period prophylaxis following
contact with infectious TB, provided their 8- week post-exposure TST result was
less than 5 mm.
Special Considerations

Recently acquired TB infection: can take two to eight weeks after infection with TB
bacteria to respond reliably to tuberculin.
 Current or recent (within four weeks) major viral infection: tuberculin
reactivity may be suppressed.
 Live-virus vaccination in the past four weeks: a TST may be performed on
the same day or four weeks after.
 Steroid dose ≥ 15mg prednisone daily for 2-4 weeks: may suppress
tuberculin reactivity.
#link
Web Resources
BC Centre for Disease Control, Disease Control Chapter 4 – Tuberculosis Manual, November
2015, Appendix A pages 96-102
/link
#activity
Learning Activity #5/Perspective
Describe the preferable test site for a TST?
#reveal
Preferably the inner aspect of a forearm, about 5-10 cm (2-4 inches) below the elbow. Avoid
abrasions, lesions, swelling, visible veins, edema, burns, rashes. Can use upper chest (front or
back) if neither forearm is available.
/reveal
Describe the appropriate technique for injecting intradermally.
#reveal
 Position the bevel of the needle so that it opens facing upward.
 While holding the skin at the test site taut, insert the needle at a 5° to 15° angle to the
skin. The tip of the needle should be visible just below the surface of the skin. Insert the
needle just to the point where the entire bevel (opening) is covered.
 Do NOT aspirate. Slowly depress the plunger of the syringe until the entire 0.1 mL of
testing solution has been injected.
 A discrete, pale elevation of the skin (a wheal) 6 to 10 mm in diameter should appear
during the injection (see Figure A-2). The wheal will disappear within 15 minutes.
 If no wheal appears or if a lot of testing solution leaks from the site during the injection,
the TST should be repeated (27). Repeat TSTs can be done immediately. Use the
opposite forearm, or the same forearm, at least 5 cm from site of the previous TST.




Remove the needle and lightly sponge the test site with a dry gauze. Do not press on or
massage the test site. Do not cover the test site with a bandage.
Place used needles and syringes in appropriate puncture-resistant containers immediately
after use.
Discard gloves, if using, and wash hands.
Document in the client record as per agency guidelines (e.g., date, dose, lot number,
testing site)
/reveal
Describe the procedure for reading a TST.
#reveal
Examine the TST site 48 to 72 hours after the TST is administered. If the TST is not read within
72 hours, the result is invalid and must be repeated, unless there is 10 mm or more of induration
present.
Repeat TST can be done immediately. Use the opposite forearm, or the same forearm, at least 5
cm from the site of the previous TST.
Procedure:
 Read the TST site in an area with good lighting.
 Ensure client is seated with his/her forearm supported on a firm surface and slightly
flexed at the elbow.
 Palpate the test site with your fingertips to check for firmness or swelling (induration). If
any induration is felt, ask the client if you may temporarily mark his/her arm with a pen.
Using a pen to locate and mark the edges of the indurated area allows for a more accurate
measurement.
 Mark the left border of the indurated area by moving the tip of a pen at a 45° angle
laterally toward the test site (see Figure A-3). The tip will stop at the edge of the
induration. Repeat the process on the right side of the induration.
 Use a caliper ruler to measure the distance between the pen marks, which will reflect the
induration at its widest point, from side-to-side, across the forearm (see Figure A-4
above). If a caliper ruler is not available, a flexible ruler may be used (shown).
 When a measurement falls between demarcations on the ruler, use the smaller of the two
numbers. For example, if the measurement is between 4 mm and 5 mm, the result is 4
mm.
 Remove pen marks from the client’s arm by rubbing them lightly with an alcohol swab.
/reveal
Is a TST result of 14 mm induration considered positive or negative?
#reveal
Positive.
/reveal
/activity
Contact Investigation
In BC, regional health authorities (Public Health services) are responsible for ensuring contact
investigations are performed for TB cases reported in their jurisdiction. TB Services at BCCDC
are responsible for contact investigations across multiple jurisdictions.
The primary objective of TB contact investigation is to identify people who have been exposed to
infectious TB disease to ensure they receive appropriate screening, and when indicated, treatment
for TB disease or latent TB infection.
An OHN may be asked to assist Public Health by identifying contacts at the workplace and
administering on-site TST post exposure testing of contacts.
Ectoparasitic Infestations
Scabies
Scabies is a very itchy skin condition caused by tiny mites that burrow into your skin. Scabies
mites are spread by close contact with someone who has scabies. They can also be spread by
sharing towels, bed sheets, and clothing. Scabies will not go away without treatment - you need
to use a special cream or lotion that a doctor prescribes.
Scabies is contagious. It often affects several family members at the same time. If you have
scabies, you can spread mites to other people before and after you develop symptoms, for as long
as you remain infested and untreated.
#link
Web Resources
HealthLinkBC Scabies Topic Overview and FAQs
/link
#activity
Learning Activity #6/Perspective
List the common symptoms of scabies infestation.
#reveal
 Severe itching that is usually worse at night. Small children and older adults tend to have
the worst itching.
 A rash with tiny blisters or sores. Children tend to have worse skin reactions than adults.
 Symptoms are more likely to occur:
 Between the fingers and on the palm side of the wrists.






On the outside surfaces of the elbows and in the armpits.
Around the waistline and navel.
On the buttocks.
Around the nipples, the bra line, and the sides of the breasts (in women).
On the genitals (in men).
In babies and small children, itching and skin irritation may also occur on the scalp, neck,
and face and on the palms of the hands and soles of the feet.
/reveal
You are the OHN at a laboratory service company. You receive a phone call from one of the
workers who takes blood samples from clients. This worker has heard that a recent client was
diagnosed with Norwegian scabies and asks “Should I be concerned about getting it from this
client?” What would you tell the worker?
#reveal
Crusted (Norwegian) scabies is a rare, severe form of scabies. It is extremely contagious because of the
large number of mites found in and on the skin.
Mites can be spread by touching someone’s skin. Assess whether the worker touched the client’s skin
without wearing gloves. Review the symptoms of scabies with the worker. Advise the worker to seek
treatment if symptoms develop. Avoid close contact with others and do not share personal items until
treated.
/reveal
/activity
Lice
Lice are tiny insects that live on humans and feed on blood. When a large number of lice live and
multiply on a person, it is called an infestation.
Three different kinds of lice live on humans:



Head lice are usually found in hair, most often on the back of the neck and behind the ears.
Head lice are common in preschool and elementary school-age children. Adults can get them
too, especially adults who live with children.
Pubic lice, also called crabs, are usually found in the pubic area. But they may also be found
on facial hair, on eyelashes, on eyebrows, in the armpits, on chest hair, and, rarely, on the
scalp.
Body lice live and lay eggs (nits) in the seams of clothing. The lice are on the body only
when they feed.
Lice spread easily from one person to another through close contact or through shared clothing or
personal items (such as hats or hairbrushes). A louse cannot jump or fly.
#link
Web Resources
HealthLinkBC Lice Topic Overview, When to Call a Doctor and Prevention
/link
# activity
Learning Activity #7/Perspective
Describe prevention strategies for head lice and body lice.
#reveal
Head lice are easily spread among children because kids commonly share hats, combs, and other
items. If you or your child has head lice, you can help prevent others from getting it if you avoid
head-to-head (hair-to-hair) contact during activities inside the home and outside the home. Also,
don't share clothing, bedding, hair brushes and accessories, pillows, stuffed animals, or towels.
Frequently examining the scalps of your school-age children may help you discover and treat lice
before they spread to the rest of your family. Avoiding prolonged close contact with a person who
has lice will also reduce your risk.
Body lice may be prevented by bathing regularly and changing clothes daily. Body lice live on
clothing, not on the body. Washing clothing in hot water [54.5°C (130°F) or higher] will usually
kill adult lice and prevent eggs from hatching. Body lice that are on the skin usually go away on
their own with daily bathing and wearing clothes that are not contaminated. Medicines to kill
body lice are usually not needed.
To help control the spread of lice, you can also clean combs, brushes, clothing, and other items to
kill lice and their eggs. Placing items in a freezer for a few hours is an effective way to kill lice
and their eggs.
/reveal
Bob has told his co-workers that his school aged son has head lice and Bob has been seen
scratching his head. Now the department is in an uproar and the supervisor asks you to speak to
the workers on the topic. How will you approach Bob? What information will you give to the
workers?
/activity
Measles
Mode of transmission: airborne by aerosol and droplet spread, direct contact with nasal or throat
secretions of infected persons; less commonly by articles freshly soiled with nose and throat
secretions.
Incubation period: average is 8 – 12 days with a range of 7 – 18 days, rarely may be as long as 21
days.
Period of communicability: from 1 – 2 days before the beginning of the prodromal period
(usually about 4 days before rash onset) to 4 days after rash appearance in a healthy person and
for the duration of measles illness in an immunocompromised person.
Definition of Immunity
#table
Number of doses of MMR vaccine recommended by year of birth for BC HCWs
Date of Birth
Measles
Mumps
Rubella
Prior to 1957
1957 to 1969
0 doses
2 doses
0 doses
1 dose
1 dose
1 dose
MMR
Vaccine
1 dose
2 doses
1970+
2 doses
2 doses
1 dose
2 doses
/table
HCWs are considered immune to measles if they fulfill one of the following criteria:
 They were born prior to 1957
 They can produce documentation of receipt of two doses of live measles-containing
vaccine (generally given as MMR)
 They have a letter from their physician confirming a clinical illness compatible with
measles in the past and documented appropriate laboratory confirmation (presence of
measles- specific IgM, rise in convalescent measles-specific IgG, virus detection by PTPCR testing for isolation on cell culture)
 They have documented serological proof of immunity (a measles-specific IgG reactive
result of at least 200mIU/ml, or “positive” results using a test that is equivalent to a
value of at least 200 mIU/ml). A study is underway to compare results from the assay
previously used in BC to measure measles IgG to results from an assay that measures IgG
in mIU/ml. This will allow interpretation of earlier results with respect to the
international standard.
Assessment of exposure and guidance:
If the HCP was born on or after January 1, 1957 and has documented evidence of receiving
one dose of live measles-containing vaccine:
Draw a blood specimen for measles IgG and give a dose of MMR vaccine immediately
thereafter (ideally within three days of exposure, with day of exposure counted as day zero).
If MMR vaccine is contraindicated for medical reasons (e.g. immunocompromised or
pregnant), immune globulin (IG) should be offered within six days of exposure to prevent or
modify measles disease.
When sero-status is unknown or pending or if the HCP is found to be IgG seronegative,
he/she must remain off work between day five (post first exposure) and day 21 (post last
exposure), inclusive, regardless of receipt of MMR vaccine or IG post-exposure.
If the HCP is found to have protective levels of IgG he/she may return to work.
If the HCP was born on or after January 1, 1957 and has no documented evidence of
receiving any live measles-containing vaccine:

Draw a blood specimen for measles IgG and give a dose of MMR vaccine
immediately thereafter (ideally within three days of exposure with day of exposure
counted as day zero). If MMR vaccine is contraindicated for medical reasons (e.g.
immunocompromised or pregnant), immune globulin should be offered within six
days of exposure to prevent or modify measles disease.
When serostatus is unknown or pending or if the HCP is found to be IgG seronegative, he/she
must remain off work between day five (post first exposure) and day 21 (post last exposure),
inclusive, regardless of receipt of MMR vaccine or IG post-exposure.
If the HCP is found to have protective levels of IgG he/she may return to work.
Give a second dose of MMR vaccine at least 28 days after the first.
Exclusion:
If they meet criteria and no doses of Measles send for: Lab req for STAT IGG/ and IGM for
measles; and one dose MMR following blood work then second MMR to be done 28 days
later; if in incubation period employee will need to be excluded from work until lab results
are received and shows immunity
If they meet criteria and one doses of Measles send: Lab req for STAT IGG/ and IGM for
measles; and second dose MMR following blood work; if in incubation period employee will
need to be excluded from work until lab results are received and shows immunity
If employee refuses MMR and is found to be IgG seronegative, he/she must remain off work
between day five (post first exposure) and day 21 (post last exposure)
Mumps
Mode of transmission: airborne transmission droplet contact and direct contact with saliva or
respiratory droplets from the nose or throat, spread through coughing, sneezing, sharing drinks, or
kissing, or from contact with any surface that has been contaminated with the mumps virus.
Incubation period: usually 16 – 18 days to onset; ranges from 12 – 25 days after exposure.
Period of communicability: maximum infectiousness occurs between 2 days before to 5 days
following the onset of parotid swelling. In most circumstances, for the purpose of communicable
disease control, this is considered the period of communicability. However, mumps virus has
been isolated from saliva from 7 days before through 9 days after onset of swelling and may be
detected in urine for up to 14 days after onset of swelling. Inapparent infections can be
communicable.
Definition of Immunity
#table
Number of doses of MMR vaccine recommended by year of birth for BC HCWs
Date of Birth
Prior to 1957
1957 to 1969
1970+
/table
Measles
0 doses
2 doses
2 doses
Mumps
0 doses
1 dose
2 doses
Rubella
1 dose
1 dose
1 dose
HCW are considered immune for mumps if they fulfill one of the following criteria:
 They have a letter from their physician confirming clinical diagnosis of acute mumps and
documented laboratory confirmation of same
 They were born before 1957
 They were born between 1957 through 1969 and documented evidence of one dose of
mumps-containing vaccine
 They were born 1970 or later and documented evidence of two doses of mumpscontaining vaccine.
Assessment of Exposure and Guidance including Exclusions:
If a HCW was born prior to 1957:


No doses of vaccine are required as natural immunity is assumed.
The HCW can continue to work.
If the HCW was born 1957 through 1969 and has documented evidence of having received one
dose of mumps-containing vaccine:


No further doses of vaccine are required.
The HCW can continue to work.
If the HCW was born after 1969 and has documented evidence of having received two doses of
mumps-containing vaccine:


No further doses of vaccine are required.
The HCW can continue to work.
If the HCW was born after 1969 and has documented evidence of having received one dose of
mumps-containing vaccine:



He/she should receive one additional dose of MMR.
The HCW can continue to work.
If the HCW refuses the dose of MMR that person should be furloughed beginning on day 10
after the first exposure to the case through day 26 after the last contact with the case (where
the day of exposure is day one).
If the HCW was born after 1956 and does not have documented evidence of having received any
previous doses of mumps-containing vaccine:


Serology of the exposed HCW drawn before the exposure is acceptable and once immunized
with the appropriate number of doses of MMR vaccine based on year of birth; these HCWs
can continue to remain at work as long as they remain asymptomatic.
He/she should immediately receive one dose of MMR after serology is taken.
If the HCW refuses the dose of MMR that person should be excluded beginning on day 10 after
the first exposure to the case through day 26 after the last contact with the case (where the day of
exposure is day one).

While awaiting the results of mumps serology, the HCW should be off work if the period of
communicability has begun (beginning on day 10 after the first exposure to the case where
the day of exposure is day one).
If the mumps IgG is positive, and he/she has received one dose of MMR, the HCW can then
return to work. Those HCW born after 1969 should receive a second dose of MMR 28 days later
to ensure the individual is protected against measles and rubella.
If the mumps IgG is negative, the HCW should receive a second dose of MMR 28 days after the
first. That person should be excluded beginning on day 10 after the first exposure to the case
through day 26 after the last contact with the case (where the day of exposure is day one).
Rubella
Mode of transmission: Rubella is spread through droplet transmission or direct contact with
nasopharyngeal secretions of an infected person. Infants with CRS shed large quantities of virus
in their pharyngeal secretions and urine.
Incubation period: ranges from 14 – 21 days and is usually 14 – 17 days.
Period of communicability: rubella is most contagious when the rash first appears. Virus may be
shed for up to 7 days before to 7 days or more after rash onset. Infants with CRS may shed the
virus for up to one year in their pharyngeal secretions and urine.
Definition of Immunity
#table
Number of doses of MMR vaccine recommended by year of birth for BC HCPs
Date of Birth
Prior to 1957
Measles
0 doses
Mumps
0 doses
Rubella
1 dose
1957 to 1969
1970+
2 doses
2 doses
1 dose
2 doses
1 dose
1 dose
/table
HCWs are considered immune to rubella if they fulfill one of the following criteria:
 They can produce documentation of receipt of one dose of live rubella virus vaccine
(generally given as MMR)


They have a letter from their physician confirming a clinical illness compatible with rubella
in the past and documented appropriate laboratory confirmation (presence of rubella-specific
IgM, rise in convalescent rubella-specific IgG, virus detection by RT-PCR testing or isolation
on cell culture)
They have documented serological proof of immunity (a rubella-specific IgG reactive result
of at least 10mIU/ml).
Assessment of Exposure and Guidance including Exclusions:
HCWs Who Are Considered Immune to Rubella If the HCW has documented evidence of one
dose of live rubella virus vaccine, or a documented history of laboratory-confirmed rubella
infection:
 No further vaccine required
 The HCW may continue to work
If the HCW has no documented evidence of receiving any live rubella virus vaccine:



Draw a blood specimen for rubella IgG and give a dose of MMR vaccine immediately
thereafter.
When serostatus is unknown or pending or if the HCW is found to be rubella IgG
seronegative, they must remain off work between day seven (post first exposure) and day 21
(post last exposure), inclusive, with day of exposure counted as day zero, regardless of receipt
of MMR vaccine post-exposure.
Post-exposure vaccination is not proven to prevent rubella infection and does not allow for
return to work prior to the maximum incubation period being expired. Vaccination will
protect against rubella infection in future exposures.
If the HCW is found to have protective levels of rubella IgG he/she may return to work.
HCWs who develop a rubella-like illness following exposure should be tested (including by
culture/RT-PCR) to confirm the diagnosis, and not return to work until seven days after onset of
rash.
Varicella Zoster (Chickenpox)
Mode of Transmission: Varicella is transmitted from person to person by direct contact, droplet
or airborne spread of vesicle fluid or secretions of the respiratory tract of chickenpox cases or of
vesicle fluid of patients with herpes zoster and indirectly through articles freshly soiled by
discharges from vesicles or mucous membranes of infected people. Scabs from varicella lesions
are not infective.
Incubation Period: The incubation period is between 10-21 days; however, this may be extended
to 28 days if VZIG is given.
Period of Communicability: Susceptible persons should be considered potentially infectious 8 to
21 days following exposure (28 days if VZIG was given).
Definition of Immunity
Varicella immune individual: Any person with one of the following:
 self reported history of varicella or herpes zoster
 physician-diagnosed varicella or herpes zoster
 documentation of positive VZV IgG
 isolation of varicella virus from an appropriate clinical specimen
 documented receipt of 2 doses of live varicella vaccine, given at least one month apart (for
those ≥ 13 years of age); one dose for those 12 months to ≤ 12 years of age
Assessment of Exposure and Guidance including Exclusions:
 Confirm the diagnosis and nature of exposure of susceptible HCW/student.
 Review the immune status of the HCW/student. If it is unknown, or if only one dose of
vaccine has been received, order serology for VZV IgG.
 If serology negative, start immunization within 3 days of exposure for the susceptible HCW
(providing there are no contraindications to receipt of varicella vaccine).
 If the susceptible HCW is not eligible for immunization, or if serology results can not be
promptly obtained, refer to a physician for clinical management, which may include
prophylaxis with antiviral and VZIG if the HCW is at high risk for complications of varicella
disease.
 Exclude susceptible non-immunized HCW/students from work from days 8 through days 21
post-exposure. Extend the exclusion to 28 days, if VZIG is given.
Pertussis
Mode of transmission:
 face-to-face contact (unless it was only for a short period, e.g.,< 5 minutes)
 sharing of the same confined air space for a prolonged period (e.g., 1 hour)
 direct contact with the respiratory secretions of the infected person (e.g., an explosive cough
or sneeze in the face, sharing food or eating utensils, mouth-to-mouth resuscitation, or
conducting a medical exam which includes nose and throat examination).
Incubation Period:
The period of communicability extends from the beginning of the catarrhal stage (one to two
weeks before the onset of paroxysmal coughing) to three weeks after the onset of the paroxysmal
cough. The individual is most infectious during the catarrhal stage and the first two weeks of the
paroxysmal stage.
Averages 7 - 10 days (range: 5 - 21 days)
Period of Communicability: The period of communicability extends from the beginning of the
catarrhal stage (one to two weeks before the onset of paroxysmal coughing) to three weeks after
the onset of the paroxysmal cough. The individual is most infectious during the catarrhal stage
and the first two weeks of the paroxysmal stage.
Definition of Immunity:-One adult dose
Assessment of Exposure and Guidance including Exclusions:
Assess each employee as per the definition of exposure criteria (High risk contacts are pregnant
women in the 3rd trimester. If they meet the exposure criteria and have not had Tdap give letter to
take to treating physician for prophylaxis)
Recommend treatment and chemoprophylaxis for a pregnant woman who is in the third trimester
at the time of diagnosis or contact. Pregnant women with pertussis near term and other household
contacts with pertussis are an important source of pertussis for newborn infants.
Pregnancy is not a contraindication to azithromycin or erythromycin.
Both azithromycin and erythromycin are classified as Category B drugs, meaning either animalreproduction studies have not demonstrated a fetal risk but there are no controlled studies in
pregnant women, or animal-reproduction studies have shown an adverse effect (other than a
decrease in fertility) that was not confirmed in controlled studies in women in the first trimester
(and there is no evidence of a risk in later trimesters).
#activity
Learning Activity #4/Perspectives
Define Active TB disease:
#reveal
Active clinical disease that is usually symptomatic. Microbiological tests are usually TB bacteria
positive and radiologic tests are usually abnormal: also known as ‘TB disease’.
/reveal
Define Latent TB infection (LTBI).
#reveal
The presence of latent (dormant) infection with TB bacteria. People with LTBI have no evidence
of clinically active TB disease and are not infectious.
/reveal
Following an exposure to an infectious case of TB and initial infection, what percentage of
Canadians develop primary disease?
#reveal
About 5%; 90% develop LTBI
/reveal
Of those who develop Latent TB Infection following an exposure, what percentage will go on to
develop reactivation?
#reveal
About 5%
/reveal
What are the risk factors for the transition of LTBI to active TB?
Immune competency of the host?
#reveal
Age – very young and old
Seasons – spring and early summer
Medical conditions affecting immune competency
Crowding, poor ventilation
Poverty
Duration of exposure & proximity to infected case
/reveal
What are the symptoms of active respiratory TB disease?
#reveal
Fever, cough for 2 to 3 weeks or more with or without fever or phlegm, unexplained weight loss
or failure to thrive, hemoptysis, loss of appetite, night sweats.
/reveal
/activity
#activity
Learning Activity #5/Perspective
Describe the preferable test site for a TST:
#reveal
Preferably the inner aspect of a forearm, about 5-10 cm (2-4 inches) below the elbow. Avoid
abrasions, lesions, swelling, visible veins, edema, burns, rashes. Can use upper chest (front or
back) if neither forearm is available.
/reveal
Describe the appropriate technique for injecting intradermally.
#reveal
Position the bevel of the needle so that it opens facing upward.
 While holding the skin at the test site taut, insert the needle at a 5° to 15° angle to the skin.
The tip of the needle should be visible just below the surface of the skin. Insert the needle just
to the point where the entire bevel (opening) is covered.
 Do NOT aspirate. Slowly depress the plunger of the syringe until the entire 0.1 mL of testing
solution has been injected.
 A discrete, pale elevation of the skin (a wheal) 6 to 10 mm in diameter should appear during
the injection (see Figure A-2). The wheal will disappear within 15 minutes.
 If no wheal appears or if a lot of testing solution leaks from the site during the injection, the
TST should be repeated (27). Repeat TSTs can be done immediately. Use the opposite
forearm, or the same forearm, at least 5 cm from site of the previous TST.
 Remove the needle and lightly sponge the test site with a dry gauze. Do not press on or
massage the test site. Do not cover the test site with a bandage.
 Place used needles and syringes in appropriate puncture-resistant containers immediately
after use.
 Discard gloves, if using, and wash hands.

Document in the client record as per agency guidelines (e.g., date, dose, lot number, testing
site)
/reveal
Describe the procedure for reading a TST.
#reveal
Examine the TST site 48 to 72 hours after the TST is administered. If the TST is not read within
72 hours, the result is invalid and must be repeated, unless there is 10 mm or more of induration
present.
Repeat TST can be done immediately. Use the opposite forearm, or the same forearm, at least 5
cm from the site of the previous TST.
Procedure:
 Read the TST site in an area with good lighting.
 Ensure client is seated with his/her forearm supported on a firm surface and slightly flexed at
the elbow.
 Palpate the test site with your fingertips to check for firmness or swelling (induration). If any
induration is felt, ask the client if you may temporarily mark his/her arm with a pen. Using a
pen to locate and mark the edges of the indurated area allows for a more accurate
measurement.
 Mark the left border of the indurated area by moving the tip of a pen at a 45° angle laterally
toward the test site (see Figure A-3). The tip will stop at the edge of the induration. Repeat
the process on the right side of the induration.
 Use a caliper ruler to measure the distance between the pen marks, which will reflect the
induration at its widest point, from side-to-side, across the forearm (see Figure A-4 above). If
a caliper ruler is not available, a flexible ruler may be used (shown).
 When a measurement falls between demarcations on the ruler, use the smaller of the two
numbers. For example, if the measurement is between 4 mm and 5 mm, the result is 4 mm.
 Remove pen marks from the client’s arm by rubbing them lightly with an alcohol swab.
/reveal
Is a TST result of 14 mm induration considered positive or negative?
#reveal
Positive.
/reveal
/activity
#activity
Learning Activity #6/Perspective
List the common symptoms of scabies infestation.
#reveal
 Severe itching that is usually worse at night. Small children and older adults tend to have the
worst itching.
 A rash with tiny blisters or sores. Children tend to have worse skin reactions than adults.
 Symptoms are more likely to occur:
 Between the fingers and on the palm side of the wrists.
 On the outside surfaces of the elbows and in the armpits.
 Around the waistline and navel.




On the buttocks.
Around the nipples, the bra line, and the sides of the breasts (in women).
On the genitals (in men).
In babies and small children, itching and skin irritation may also occur on the scalp, neck, and
face and on the palms of the hands and soles of the feet.
/reveal
You are the OHN at a laboratory service company. You receive a phone call from one of the
workers who takes blood samples from clients. This worker has heard that a recent client was
diagnosed with Norwegian scabies and asks “Should I be concerned about getting it from this
client?” What would you tell the worker?
#reveal
Crusted (Norwegian) scabies is a rare, severe form of scabies. It is extremely contagious because
of the large number of mites found in and on the skin.
Mites can be spread by touching someone’s skin. Assess whether the worker touched the client’s
skin without wearing gloves. Review the symptoms of scabies with the worker. Advise the
worker to seek treatment if symptoms develop. Avoid close contact with others and do not share
personal items until treated.
/reveal
/activity
#activity
Learning Activity #7/Perspective
Describe prevention strategies for head lice and body lice.
#reveal
Head lice are easily spread among children because kids commonly share hats, combs, and other
items. If you or your child has head lice, you can help prevent others from getting it if you avoid
head-to-head (hair-to-hair) contact during activities inside the home and outside the home. Also,
don't share clothing, bedding, hair brushes and accessories, pillows, stuffed animals, or towels.
Frequently examining the scalps of your school-age children may help you discover and treat lice
before they spread to the rest of your family. Avoiding prolonged close contact with a person who
has lice will also reduce your risk.
Body lice may be prevented by bathing regularly and changing clothes daily. Body lice live on
clothing, not on the body. Washing clothing in hot water [54.5°C (130°F) or higher] will usually
kill adult lice and prevent eggs from hatching. Body lice that are on the skin usually go away on
their own with daily bathing and wearing clothes that are not contaminated. Medicines to kill
body lice are usually not needed.
To help control the spread of lice, you can also clean combs, brushes, clothing, and other items to
kill lice and their eggs. Placing items in a freezer for a few hours is an effective way to kill lice
and their eggs.
/reveal
/activity
Blood and Body Fluid Exposures
Background
Blood and body fluid exposure is an event where a person is exposed to potentially infectious
blood or bodily fluids through the following:
 Percutaneous exposure through puncture of skin by needlestick or another sharp object;
 Permucosal exposure through contact with mucous membranes; or
 Non-intact skin exposure through eczema, scratches, and damaged skin.
Bloodborne viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV) and Human
Immunodeficiency virus (HIV) are commonly detected in both blood and other body fluids. The
possibility of becoming infected with these viruses exists following a BBF exposure.
An OHN working in a health care setting or any setting where first aid attendants have the
potential for being exposed in the course of delivering first aid to workers, needs an
understanding of risk assessment, management and prevention of BBF exposures.
Key elements include:
 Assessment of the risk of exposure;
 Laboratory testing on the exposed person and the source person;
 Administration of post exposure prophylaxis (PEP) treatment when appropriate to prevent the
development of infection;
 Counselling the exposed person to address anxiety, ensure follow-up testing and modify
behaviour to prevent transmission to contacts.
Post-exposure management must be undertaken when the following conditions are present:
 Exposure is through needlestick/scratches, mucosal contact or contact with compromised
(damaged) skin;
 Exposure is to blood or high-risk body fluids from a source that is either known to be
infectious or might be potentially infectious (high-risk source or in settings where individuals
engage in high-risk activities); and
 The exposed person is known or considered to be at risk for HBV, HCV or HIV.
Risk Assessment – Exposed Worker and Source Person
A medical risk assessment by a physician should be performed on the exposed worker within two
hours of exposure. This is commonly performed at hospital emergency departments – workers
should not delay in seeking medical assessment.
Following this medical assessment, the OHN may also assess the risk and guide the worker in
post exposure follow up and management.
#link
Web Resources
BC Centre for Disease Control Clinical Prevention Services, Blood and Body Fluid
Exposure Management Tool, July 2015, page 1-10
http://www.bccdc.ca/resourcegallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20
Manual/Chapter%201%20-%20CDC/CPS_CDManual_BBF_Tool_20150717.pdf
BC Centre for Disease Control, Communicable Disease Manual, Blood and Body Fluid Exposure
Management, July 2015, pages 1-26
http://www.bccdc.ca/resourcegallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20
Manual/Chapter%201%20-%20CDC/CPS_CDManual_BBFExpMangt_20150720.pdf
/link
#activity
Learning Activity #1/Perspective
#accordion
A health care worker reports to the OHN that he received a splash of urine to the face when
emptying a catheter bag. The worker asks the OHN if he should be worried about getting HIV
from this incident. How would you respond?
#reveal
 Did the urine contain visible blood? If no, there is no BBF exposure and no risk of
transmitting a bloodborne disease such as HIV.
 If yes, did the bloody urine splash into your eyes, mouth or nose or on non-intact skin on your
face? If no, there is no BBF exposure.
 If yes, the risk of becoming infected with HIV after an exposure depends on the amount of
virus in the blood or body fluid of the source individual at the time and the type of exposure
(mucocutaneous in this case). The worker should be medically assessed within 2 hours of the
exposure. During this assessment, the physician will be able to tell you whether your
exposure has put you at risk of infection.
 If the source person has a detectable HIV viral load in their blood, the risk of HIV infection
with a muco-cutaneous exposure is about 0.1% (1 in 1000).
/reveal





What risk factors should be assessed for the exposed worker?
#reveal
HBV immunization history and HBV immune status (anti-HBc protected level?)
Personal risk factors for HCV and HIV
Fluids involved
Type of exposure – percutaneous, mucocutaneous
Needlestick – deep puncture? Large bore needle containing blood
/reveal
/activity
Post Exposure Testing
#link
Web Resources
BC Centre for Disease Control, Communicable Disease Manual, Blood and Body Fluid Exposure
Management, July 2015, pages 7-9
http://www.bccdc.ca/resourcegallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20
Manual/Chapter%201%20-%20CDC/CPS_CDManual_BBFExpMangt_20150720.pdf
/link
Post Exposure Treatment
Post exposure prophylaxis is dependent on the virus.
#link
Web Resources
Read BC Centre for Disease Control, Communicable Disease Manual, Blood and Body
Fluid Exposure Management, July 2015, pages 9-11
http://www.bccdc.ca/resourcegallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20
Manual/Chapter%201%20-%20CDC/CPS_CDManual_BBFExpMangt_20150720.pdf
/link
Post Exposure Counseling
Exposed persons may be anxious when initially assessed and not remember all the information
provided in initial counselling. It is important to repeat and follow-up with detailed counselling.
#link
Web Resources
BC Centre for Disease Control, Communicable Disease Manual, Blood and Body Fluid Exposure
Management, July 2015, pages 12-13
http://www.bccdc.ca/resourcegallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20
Manual/Chapter%201%20-%20CDC/CPS_CDManual_BBFExpMangt_20150720.pdf
/link
#activity
Learning Activity #2
The exposed worker tells the OHN that she and her husband had been trying to have a baby just
prior to the exposure. What advice should the OHN provide?
#reveal
Defer pregnancy for the duration of testing. Use latex condoms during intercourse. If she
becomes pregnant, she should consult her physician and BC Women’s Hospital for advice.
/reveal
Can an operating room nurse who experienced a BBF exposure continue to work while awaiting
test results?
#reveal
Yes - if the worker complies with all testing and counselling and seeks immediate assessment if
symptoms appear.
/reveal
Can an operating room nurse who experienced a BBF exposure continue to work while awaiting
test results?
#reveal
Yes - if the worker complies with all testing and counselling and seeks immediate
assessment if symptoms appear.
/reveal
/activity
#activity
Learning Activity #3/Perspective
What infectious diseases can be transmitted to workers through direct or indirect contact?
#reveal

Norovirus

MRSA

VRE

Clostridium difficile
/reveal
What zoonotic diseases can be transmitted to workers?
#reveal





Rabies
Brucellosis
Hantavirus
Campylobacteriosis
Q fever
/reveal
/activity
Applications
Now for the fun part! The following Case Study will give you the opportunity to work through
how the knowledge covered in this module might be applied in practice.
#case
Case Study
Oak Tree Baptist Care Centre (OTBCC) is a contracted service provider for a large provincial
health authority and BC Housing. It offers graduated levels of care that give seniors the choice to
age in place. From support for those who need a little extra assistance, to complex care for those
no longer able to be cared for at home, they strive to ensure all of their residents and tenants
experience the high standard of care they deserve—in a home-like environment. It first opened
its doors in 1962. Today OTBCC offers 110 units of subsidized supportive housing, 84 onebedroom units of assisted living, and 157 units of complex care.
OTBCC strives to be a great place to work with a vision to be one of BC’s top 10 employers by
2018. A traditional management structure is in place which includes an Executive Director who
reports to a Board of Directors, a Director of Care, Professional Practice Leader, Human
Resources Coordinator, and a Finance Director.
There are about 150 employees of OTBCC . The majority are members of a union – most belong
to the nurses’ union, health care professionals union and the health care non-professionals union
Most of the employees are involved in direct care of the residents in Care Aide positions.
Brenda is an occupational health nurse (OHN) with 10 years’ experience. She has a contract with
OTBCC to provide OHN services 8 hours/week and is on-site only one morning per week. The
remainder of the time she is available by telephone. Brenda reports to the Executive Director.
The OHN services were implemented about 3 months ago when the facility was undergoing a
particularly nasty outbreak of gastrointestinal illness in both residents and# employees. The
Director of Care and the Human Resources Coordinator fulfill all of the onsite daily safety
functions. A Joint Health and Safety Committee is well established, as required by WorkSafeBC.
/case
Case 1
Brenda has been asked to review the immunization history of all new employees. She has phoned
Anna, a newly hired 30-year-old Care Aide, who reports receiving her baby shots back home in
the Philippines. Her records indicate she received Tetanus, Diphtheria, Polio and Pertussis
injections as a child and one dose of Measles/Mumps/Rubella vaccine. Anna wants to know
whether she needs any more immunizations and if so, which ones.
1) What resources could Brenda use?
2) What questions might Brenda ask in her assessment of Anna’s immunization needs?
3) What immunizations /infectious disease screening does Anna need now?
What resources could Brenda use?
#link
Web Resources
BC Centre for Disease Control, Communicable Disease Control Manual, Immunization Section
IIA Immunization Schedules, January 2012, page 8
BC Centre for Disease Control, Communicable Disease Control Manual, Immunization Section
VII Biological Products, September 2015
BC Centre for Disease Control, Communicable Disease Control Manual, Chapter 4 Tuberculosis
Manual, November 2015
BC Centre for Disease Control, Communicable Disease Control Manual, Immunization Section
III Immunization of Special Populations, July 2014
HealthLinkBC Immunizations
Public Health Agency of Canada, Canadian Immunization Guide
/link
What questions might Brenda ask in her assessment of Anna’s immunization needs?
#reveal
 d/m/y of the immunizations (if she has records)
 past history of BCG vaccination (Tuberculosis)
 any previous reactions to vaccines
 health status – Immune compromised? Pregnant?
 contact with individuals at risk of vaccine-preventable diseases
 any Ig or blood product administration recently
 any plans for blood donation?
/reveal
What immunizations/infectious disease screening does Anna need now?
#reveal
 Tetanus-Diphtheria every 10 years
 Pertussis – one adult dose is recommended but not publicly funded in BC
 MMR – one dose
 Influenza – if it is influenza season, if not encourage for next season
 Tuberculosis Skin Test – 2-step recommended – licensing requirement for residential
care facilities - ***TST same day as live attenuated vaccines (MMR, Varicella) or
delayed by 4 weeks
 Polio – depends if polio is prevalent in the geographic area or client population, not likely
in this work setting
 Varicella (2 doses) – if no reported history of the disease
 Hepatitis B – 3 doses plus blood test to confirm protective level of antibodies 6 weeks
post vaccination
/reveal
Case 2
One of the registered nurses, Elisha, just poked herself with a contaminated needle after giving an
insulin injection to one of the residents. She is very anxious and calls Brenda immediately for
advice.
What resources could Brenda use?
#reveal
BC Centre for Disease Control, Blood and Body Fluid Exposure Management, July 2015, as
retrieved from
/accordion
#link
Web Resources
BC Centre for Disease Control, Blood and Body Fluid Exposure Management,
http://www.bccdc.ca/resourcegallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD
%20Manual/Chapter%201%20-%20CDC/CPS_CDManual_BBFExpMangt_20150720.pdf
/link
/reveal
What advice should she give?
#reveal
 First Aid for needle stick/wound:
 Allow the wound to bleed freely. Do not promote bleeding by squeezing the wound. This
may damage the tissues and increase uptake of any pathogen(s).



Assessment – go immediately (within 2 hours) to the local hospital emergency room for
medical assessment.
Report the incident using usual workplace injury/illness reporting method. Incident
investigation will follow.
Brenda could ask Elisha to call her back after she has been medical assessed – review the
initial and post exposure testing, liaise with the Clinical Professional Practice Leader to
facilitate source person testing, discuss the need for Elisha to be followed by her family
physician for a period of up to 3 months, answer any questions / concerns. If Elisha is
still anxious, Brenda might suggest she access any counselling benefits available
(example Employee and Family Assistance Program, extended health benefits
psychological services).
/reveal
How much information should the Committee receive?
#reveal
Employers are legally responsible for the investigation of all occupational injuries/illnesses.
An employer must ensure that an incident investigation report required by Division 10 of Part 3
of the Workers Compensation Act contains
(a) the place, date and time of the incident,
(b) the names and job titles of persons injured in the incident,
(c) the names of witnesses,
(d) a brief description of the incident,
(e) a statement of the sequence of events which preceded the incident,
(f) identification of any unsafe conditions, acts or procedures which contributed in any manner to
the incident,
(g) recommended corrective actions to prevent similar incidents, and
(h) the names of the persons who investigated the incident.
The Joint Health and Safety Committee also has a responsibility to participate and review the
results of the incident investigation. Even though the Committee has an obligation to maintain
confidentiality of information as per the Workers Compensation Act, Part 3, Division 7, the
worker’s test results could remain confidential with the OHN. However, if the worker does
contract an infection as a result of the exposure, the employer and the Committee have a right to
know this but have a responsibility for keeping this information confidential.
/reveal
Case 3
Brenda receives a phone call from the Medical Health Officer (the MHO) advising that one of the
OTBCC workers has been diagnosed with mumps. The MHO asks Brenda to do contact tracing
on all coworkers who meet the definition of exposure.
What should Brenda do?
#reveal

Contact Management – page 10 BCCDC Communicable Disease Control Manual,
Mumps, June 2014.


Determine incubation period and period of communicability
Review definition of exposure

Ask supervisor / manager to compile a list of all workers who meet definition of exposure
and had contact with the confirmed case during the period of communicability

Review / obtain immunization records to identify susceptible contacts

Consult with MHO to determine whether susceptible contacts need to be excluded from
work

Ensure susceptible workers receive appropriate immune-prophylaxis and screening tests
 Update the supervisor / manager and the Executive Director

Respond to questions from workers, educate contacts

May be asked to provide a report to the Joint Health and Safety Committee. If workers
were excluded from work, may ask the Director of Finance to assist in quantifying the
cost of this communicable disease exposure

Review MMR immunization uptake rates for OTBCC workers – may need to develop
strategies to increase rates to prevent future exposures - in conjunction with the
management team and the Joint Health and Safety Committee.
/reveal