Download post-exposure - APIC-DFW

OBJECTIVES (10 QUESTIONS)
Review and/or develop screening and immunization
programs
 Provide counseling, follow-up, work restriction
recommendations related to communicable disease or
following exposures
 Assist with analysis and trending of occupational
exposure incidents and information exchange between
occupational health and infection prevention and
control departments
 Assess risk for occupational exposure to infectious
diseases (eg, TB, bloodborne pathogens)

EMPLOYEE/OCCUPATIONAL
HEALTH PROGRAMS
PROGRAM OBJECTIVES
(RELATED TO INFECTION PREVENTION)

Educate personnel
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Collaborate with IP
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Work-related illness or exposure
Identify risk and institute preventive measures

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Monitor and investigate exposures and outbreaks
Provide care to personnel

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Principles of IP and personnel’s role in prevention
Work-related infection risks
Contain costs by preventing infectious diseases

Absenteeism and disability
OPERATIONS
Screening
 Education and counseling
 Occupational illness and injury treatment
 Nonoccupational illness treatment
 Preventive health services
 Environmental assessment and control
 Record keeping

COMMUNICATION WITH IP
Personnel exposure
 Personnel infections
 Community and personnel outbreaks
 Policies and procedures
 Educational programs for personnel

HEALTHCARE PERSONNEL
“All paid and unpaid persons working in healthcare
settings who have the potential for exposure to
infectious materials, including body substances,
contaminated medical supplies and equipment,
contaminated environmental surfaces, or
contaminated air.”
http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf
POLICIES & PROCEDURES

Work restrictions

Authority to remove personnel from duty
Criteria for exposure and prophylaxis
 Screening procedures
 Illness reporting system
 Methods of detecting, preventing, & controlling
disease
 Protocols for treatment
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Occupational injuries and illnesses
Nonoccupational illness
EDUCATION
New employee orientation & annual updates
 Postexposure counseling (Bloodborne Pathogens)
 TB screening and positive conversions
 Worker’s comp issues
 Pregnant worker concerns
 Community-acquired infections
 Influenza prevention
 MMR & Varicella protection and prevention
 Screening test results
 Guidelines for illness

ACTION PLAN: DETECTION
History of disease
 Symptoms
 Labs
 Reporting cases to health department

ACTION PLAN: PREVENTION & CONTROL
Isolation precautions for patients
 Work restrictions for personnel
 Prophylaxis of patients and personnel
 Educate patients and personnel
 Screening tests postexposure
 Follow up

Secondary cases
 Delayed outbreak

SCREENING PROGRAMS
DECIDING TO SCREEN
Disease in local population
 Risk of significant exposure
 Cost of screening
 Implication of the screening results

WHEN TO SCREEN

Preemployment
Medical history, immunization status
 Pregnancy, compromised immune status, infectious
disease


Periodical
Changes in health status
 Illness during employment


Outbreak/Exposure
Evaluation of susceptibility
 Type and duration of exposure
 Prophylaxis

WHAT TO DO AT A SCREENING
Medical history
 Health assessment
 Lab work
 TB screening
 Immunizations

This information is confidential!
COMMUNICABLE DISEASES TO SCREEN FOR
Tuberculosis (TB)
 Rubella
 OB & Pediatrics  rubella, varicella, pertussis
 Blood/Body fluid exposures  hepatitis B

TUBERCULOSIS

Includes essentially all healthcare personnel,
even those entering patient or treatment rooms
whether a patient is present or not.

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Full time, part time, PRN, contract
TB testing protocols based on
TB risk assessment
 Recent exposures and/or conversions
 Community population

http://www.cdc.gov/tb/publications/guidelines/infectioncontrol.htm
TB SCREENING METHODS

Purified protein derivative (PPD) skin testing
Before employment and at intervals
 Two-step if no documented negative PPD within past
year
 Interpret according to CDC guidelines

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QuantiFERON-TB (QFT) serum testing

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One-step, either + or -
Chest radiograph
Risk factors identified
 New positive reactors (repeat at intervals)

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History of symptoms

Cough, weight loss, night sweats, etc
BLOODBORNE PATHOGENS
exposure plan and immunization
OSHA REGULATIONS

Bloodborne Pathogen Act
Develop an exposure plan
 Provide Hepatitis B vaccine within 10 days of
employment
 Training on potential hazards, PPE, engineering
controls and work practices (sharps safety)
 Must maintain sharps injury log

https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051
EXPOSURE PROCEDURES
1.
2.
3.
4.
5.
6.
Seek first aid (wash with soap & water, ER)
Notify immediate supervisor
Obtain baseline labs for HIV, Hepatitis B & C
Follow requirements for consent to obtain labs
from source patient HIV, Hepatitis B & C
Document exposure ASAP per reporting
methods
Follow up with occupational health for
postexposure testing and counseling
POSTEXPOSURE COUNSELING
Risk of infection
 Signs and symptoms of infection
 Prophylaxis
 Testing
 Side effects of medications
 Interim precautions
 Risk reduction measures

RESPIRATORY PROTECTION
PROGRAM
OSHA REGULATIONS
Program administrator required
 Fit test and seal check for respirator required for
each worker
 Employer must provide respirators, training, and
medical evaluations.

https://www.osha.gov/SLTC/respiratoryprotection/index.html
FIT TEST

Qualitative
Pass/Fail
 Adequacy of fit

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Quantitative
Adequacy of fit
 Measures amount of leakage

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Not required for PAPR (Powered air-purifying
respirator)
WORK RESTRICTIONS
active infections and post-exposure
WORK RESTRICTIONS

List which illnesses and conditions should be
reported to occupational health in policies and
procedures
Communicate this to personnel and management
 Personnel who impose work restrictions should have
their authority written in P&P


Restriction should no penalize the personnel…or
this will undermine reporting
DECIDING WORK RESTRICTIONS

Consider the following:
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Agent
Mode of transmission
Method of interruption of transmission
Population at risk and susceptibility
Educability and compliance of personnel
Clinical status (signs & symptoms)
Degree and type of patient and staff contact
CDC RECOMMENDATIONS

Disease and symptom-specific guidance
http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf
POST-EXPOSURE
DISEASES WITH NO POST-EXPOSURE
TREATMENT
Herpes simplex
 Cytomegalovirus
 Meningitis other than N. meningitidis
 RSV
 Rotavirus
 Hepatitis C (Controversial)
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POST-EXPOSURE: HEPATITIS C

Refer to specialist

treatment controversial, there is no guideline
Exposure considered for HCV-positive source
 Baseline testing for anti-HCV and ALT
 May test in 4-6 weeks post-exposure for HCV
RNA if desired
 Retest in 4-6 months post-exposure for anti-HCV
and ALT

DISEASES WITH POST-EXPOSURE
INTERVENTION

TB

Evaluate and treat if symptomatic, no prophylaxis
Measles
 Meningitis (Neisseria meningitidis)
 Hepatitis A, B
 Varicella-zoster (Chickenpox)
 Scabies


Evaluate and treat if infested, no prophylaxis
Pertussis
 HIV
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POST-EXPOSURE: TB
Baseline skin testing
 Skin testing at 10 weeks after exposure

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Positive conversion (≥5mm, if baseline was 0mm)
Chest radiograph
 Laboratory tests (liver)
 Referral for medical evaluation

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No change 

Consider retesting immunocompromised personnel every 6
months
POST-EXPOSURE: MEASLES
Check immunization status
 If immunity is in question, check titers
 Administer vaccine if susceptible within 72 hours
of exposure
 Exclude from duty 5 days after first exposure to
21 days after last exposure

POST-EXPOSURE: MENINGITIS (NEISSERIA
MENINGITIDIS)
Exposure considered for personnel with potential
direct droplet contact (mouth-to-mouth, assisting
intubation, endotracheal suctioning)
 Prophylaxis immediately after exposure

Ciprofloxacin oral (adults only, nonpregnant),
 Cefotaxime IM (children, pregnant), or
 Rifampin oral (children or adults)

POST-EXPOSURE: HEPATITIS B
Exposure considered if source is HbsAg positive
or unknown
 Perform baseline anti-HBs only if exposed person
is vaccinated, but titers have not been checked
 If unvaccinated, begin vaccine series at time of
exposure and give HBIG (hepatitis B immune
globulin) within 24 hours of exposure

POST-EXPOSURE: HIV
Immediately test personnel and source for HIVAB status
 Baseline testing and follow up for 6 months


6 weeks, 3 months, and 6 months
Postexposure prophylaxis (PEP) and counseling
ASAP, if source is HIV-negative stop PEP
 Consult OB physician for pregnancy (not
contraindicated but is complex)

http://www.jstor.org/stable/pdfplus/10.1086/672271.pdf?acceptTC=true
IMMUNIZATIONS
VACCINE PREVENTABLE
DISEASES
Hepatitis A and B
 Influenza
 Measles
 Mumps
 Rubella
 Tetanus and diphtheria
 Pertussis
 Polio
 Varicella-zoster (Chickenpox)

CDC RECOMMENDATIONS
http://www.cdc.gov/vaccines/adults/rec-vac/hcw.html
PERFORMANCE IMPROVEMENT
MEASURES