Download Health Care Workers Screening: A Public Health Strategy

Health Care Workers Screening:
A Public Health Strategy
Dr. Rasha Salama
M.Sc., PhD Public Health- Suez Canal University
Dubai Health Authority
Burden of HCAI
• Health care-associated infections occur worldwide and affect both
developed and resource-limited countries.
• About 5%–10% of patients
admitted to acute care hospitals
in developed countries acquire health
care-associated infections and the risk
of acquiring infection is 5–20 times higher
in developing countries - a growing challenge
to quality of health care in the region.
• The economic cost of health care-associated infections as well as the
opportunity cost to health services is enormous. preventing a case of
health care associated infections saves on an average of US$ 10000
and reduces the patient’s risk of death from 7% to 1.6%..
Introduction
• Health care-associated infections (HCAI) can be acquired anywhere
along the continuum of health care settings.
•
• Affect a large number of patients and health care workers and
frequently result in amplification of epidemics.
• Impact of health care-associated infections includes
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Prolonged hospital stay,
Long-term disability,
Increased resistance of microorganisms to antimicrobials,
Massive additional financial burden for health systems,
High cost for patients and their family
Unnecessary deaths
Low quality of patient care
Basic Facts
Transmission of infectious
agents within a healthcare
setting requires:
Factors affecting Health Associated
Infections
• a source or reservoir of infectious
agents
• a mode of transmission
• a susceptible host.
Patients may be exposed to
infectious agents from
themselves (endogenous
infection) or from
other people, HCWs
instruments and equipment,
or the environment
(exogenous infection
Healthcare workers
may be exposed to
infectious agents
from infected or
colonised patients,
instruments and
equipment, or the
environment
In healthcare settings, the main
modes of transmission of infectious
agents are contact (including
blood-borne), droplet and airborne.
Who are Health Care Workers?
A healthcare worker (HCW) is an individual who may
have the potential to acquire or transmit an infectious
agent during the course of his or her work in the
healthcare setting while providing direct care. It may
include all persons working in the healthcare facility
comprising nursing staff, physicians, lab technicians,
home-care workers, students and others.
Screening of health care workers: is it
worthwhile?
The global burden of hepatitis B (HBV), hepatitis C (HCV), and human
immunodeficiency virus (HIV) infection due to percutaneous injuries
among health care workers (HCWs) is estimated:
• Overall, 16,000 HCV, 66,000 HBV, and 1,000 HIV infections may
have occurred in the year 2005 worldwide among HCWs due to
their occupational exposure to percutaneous injuries. The fraction of
infections with HCV, HBV, and HIV in HCWs attributable to
occupational exposure to percutaneous injuries fraction reaches
39%, 37%, and 4.4% respectively.
• These infections are highly preventable and should be eliminated
•
Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers :Am J
Ind Med. 2005 Dec;48(6):482-90.
Transmission of blood-borne pathogens in health
care settings
• The 2009 global burden of disease study revealed that as
many as 5%–10% of new HIV infections, 30%–32% of
new HBV infections, and around 40% of new HCV
infections in low and middle-income countries may be
attributable to exposure in health care settings, including
unsafe injections, unsafe blood and occupational
exposures (25).
Infection prevention and control is
everybody’s business!
• The current global evidence clearly demonstrates that a
considerable proportion of the burden of disease
attributable to health care-associated infections can be
prevented with low-cost interventions.
• The implementation of evidence-based infection control
measures needs more public health actions and
organizational control for universal application of
evidence-based prevention and control practices,
compliance with those practices, behavioral change, risk
management, standardized surveillance methods, and
quality assurance
The Goal
• Effective infection prevention and control is
central to providing high quality health care for
▫ patients and
▫ a safe working environment for those that work
in healthcare settings.
• GOAL: The creation of safe healthcare
environments through the implementation of
practices that minimize the risk of transmission
of infectious agents.
Policy for Infection Control in Health Care
Facilities
• Personal Hygiene
• Employee Health
▫ Employee health: Initial and periodical physical examination,
communicable diseases screening, vaccination (hepatitis B, influenza,
other vaccinations)
▫ Prevention of occupational exposure to blood borne pathogens (e.g.
HBV, HCV and HIV) and post-exposure prophylaxis
• Prevention, surveillance, control and reporting of health-care acquired
infections
• Surveillance, management and reporting of multi-resistant pathogens or
pathogens with relevant resistance; antimicrobials policy
• Isolation precautions and management of specific infectious diseases
• Cleaning and disinfection
• Sterilization and storage of sterile supplies
• Unit specific infection control
• Infection control in supply and disposal
• Environmental and Engineering Controls
Positive Aspects of Policy Application
• Providing a healthy, safe environment free of
risk of transmission of infection between patient
and health care provider.
• Ensuring means of prevention, such as providing
immunization services and changing the
workplace in some required cases.
• Confirming the application of health care
workers screening policy for all workers in the
public and private health sectors.
Action plan ……………..
• Formation of a team of specialists from different parties
• Current situation analysis
• Review of legislation and laws
• Provide scientific evidence and best practices
• Initial development of the proposed policy
• Discussion of the proposal with relevant authorities and
stakeholders
• Final Edition of the policy
Evidence base
• The policy was based on the best available evidence and
knowledge of the practicalities of clinical procedures.
• They draw from other work in the area, including the
national, international infection control guidelines and
policies, systematic literature reviews conducted to inform
the development of this policy, work on HAI prevention
from CDC, WHO, SHEA guidelines, US preventive Task
force, Canadian Task force on Preventive Healthcare,
national discipline-based infection control guidelines, and
National Standards laws and regulations relevant to
infection prevention and control.
Objectives
• Confirm that HCWs are free of infectious
diseases
• Assure safety of Patients/co-patients
• Provision of preventive services
• Provision of the appropriate early management
The Main Domains
• Diseases that must be screened:
- AIDS
- Hepatitis B and C
- Pulmonary tuberculosis
- Chickenpox
- Syphilis
• Determination of the measures of prevention
Infectious Diseases screening
Disease
Screening test
Confirmatory test (If
screening test
Positive)
HIV/AIDS
Elisa HIV Ab/Ag
Western Blot
Elisa HBsAg
Not required
HBV
HBs Ab
CXR
Rule out activity in the
presence of Radiological
changes
AFB and Culture
3 consecutive Sputum
PTB
Protective
action
Fitness category
No action
Unfit to perform
category III
procedures
Vaccinate if
HBsAg/Ab
Negative.
Unfit to perform
category III
procedures
No action
fit after appropriate
treatment and in
accordance with
country laws
Fit
LTBI
PPD or IGRA
LTBI treatment
Varicella
IgG (if no evidence of
past disease or
immunization)
Varicella
vaccination if
Negative
HCV
Elisa Ab
Syphilis
Elisa Ab
PCR
No action
Unfit for category III
procedures
Fit for Duty, provide
treatment
Category I
Procedures with the minimum risk of blood borne
virus transmission
Regular history-taking and/or physical or dental
examinations,
Routine dental preventive procedures
Routine rectal or vaginal examination
Minor surface suturing
Elective peripheral phlebotomy
Category II
Procedures for which blood borne virus
transmission is theoretically possible but unlikely
Locally anesthetized ophthalmologic surgery
Locally anesthetized operative, prosthetic, and
endodontic dental procedures
Periodontal scaling and root planting
Minor local procedures (e.g., skin excision, abscess
drainage, biopsy)
Percutaneous and other minor orthopedic procedures
Subcutaneous pacemaker implantation
Bronchoscopy
Upper gastrointestinal tract endoscopic procedures
Category III
Procedures for which there is definite risk of blood
borne virus transmission
General surgery
General oral surgery, including surgical extraction, tissue
biopsy
Cardiothoracic surgery
Neurosurgery.
Obstetrical/gynecological surgery, including cesarean
delivery, hysterectomy, forceps delivery
Orthopedic procedures
Trauma surgery, including open head injuries, facial and
jaw fracture
Interventions following Screening
Support,
awareness
and direction
Provide
vaccinations
Transfer to low
risk area or job
1. Counseling for HCWs with positive results
2. Raising awareness:
• Risk and mode of transmission.
• Personal protective measures
• Hepatitis B
• Varicella
• Others: Influenza, Tetanus, Pneumococcal
• From area/job of high risk of transmission
to a low risk one
• Based on type of work and infection
• Standard classification of 3 categories
Evidence for Action
Evidence for Action (cont.)
Hepatitis B, Varicella vaccination,
and optional vaccines
• Hepatitis B vaccination is recommended for all healthcare workers - 3 doses
• Booster doses are not recommended for persons with normal immune status
who were vaccinated.
• A
ll HCWs lacking immunity to varicella should receive two doses of varicella
vaccine, 4 weeks apart, unless contraindicated.
• Flu vaccine is recommend for all HCWs annually. Only the inactivated vaccine if
any immuno-compromised state exists.
• Tetanus and Diphtheria vaccinations are indicated if there is history of
incomplete primary vaccination or if the last booster was more than 10 years
ago.
• Pneumococcal vaccine: Recommended for all HCWs above 65 years -single dose
HCWs with NCDs
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Screening for NCDs is important.
Confirm diagnosis
Provision of counseling
Direction for management and follow-up.
Assure life style modification.
Desired Outcomes
• Reducing transmission rates through health
facilities.
• Ensuring the quality of health services provided
by the healthy care workers in the health sector
• Reducing the cost of treatment for workers in
case of exposure to infection - the indirect cost
Thank You