Occupational Health Update: Extended Care Facilities

1. Occupational Health Update:Extended Care Facilities James J. Hill III, MD MPH FACOEM Associate Professor & Program Director Department of Physical Medicine & Rehabilitation University of North Carolina School of Medicine Medical Director, Occupational Health, UNC Chapel Hill Associate Medical Director, Occupational Health, UNC Hospitals Diplomate, American Board of Physical Medicine & Rehabilitation Diplomate, American Board of Preventive Medicine/Occupational Medicine

2. Goals • Understand occupational health services in a healthcare facility • Understand pre-exposure evaluation and vaccine-preventable disease for healthcare personnel • Understand post-exposure prophylaxis for occupational-acquired infectious diseases • Understand how to manage exposure to blood or potentially infectious material • Understand basic workplace accommodations in the setting of the ADA

3. Disclosures • None

4. Pneumococcal Vaccines

5. Pneumococcal Vaccines • Polysaccharide vaccine (PPSV23) • Contains 23 different pneumococcal strains • FDA approved for all person > 50 years of age • FDA approved for high risk persons 19-64 years of age • One dose of PPSV23 is recommended for all adults aged 65 or older, regardless of previous vaccine history.* • Once a dose of PPSV23 has been given at age 65 or older, no additional doses of PPSV23 should be administered.

6. Pneumococcal Vaccines • One dose of PPSV23 is recommended for adults 19-64 with certain medical conditions. • Once a dose of PPSV23 has been given at age 65 or older, no additional doses of PPSV23 should be administered. • A second PPSV23 vaccine should be given > 5 years after initial vaccine in adults 19-64 with one additional dose given when they turn 65

8. Pneumococcal Vaccines • Conjugate vaccine (PCV13) • Contains 13 different pneumococcal strains • Conjugation with diphtheria toxin may improve immunogenicity • FDA approved for all person > 50 years of age • When indicated only a single dose is recommended for adults • One dose of PCV13 is recommended for all adults > 65 years of age unless they have already received the vaccine • If a patient needs both the PPSV23 and the PCV13, give the PCV13 first and the PPSV23 after > 8 weeks

9. Pneumococcal Vaccines • https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf

10. Occupational Health Services

11. Health care facilities • Top five hazards (OSHA 2015) • Musculoskeletal Disorders related to patient or resident handling • Bloodborne Pathogens • Workplace Violence • Tuberculosis • Slips, Trips and Falls

12. Health care facilities • Infections • Aerosol/droplet • Viral • Pertussis • Tuberculosis • Bloodborne pathogens • HIV • HBV • HCV • Contact • Syphilis • MRSA • Norovirus

13. Health care facilities • Other hazards • Chemical • Solvents, cleaning supplies, medical gases • Radiation • Ionizing radiation, radioisotopes, lasers • Electrical • Workplace Violence • Stress • Shift work

14. Workplace Safety • Goals • To provide a safe environment for patients and health care personnel (HCP) • To minimize risk of injury • To minimize risk of exposure to infectious disease • How? • Commitment to health and safety • Formal organized program to evaluate risks in the workplace • Formal organized program to provide effective, efficient care to the affected patient and/or HCP

15. Traditional View of Workplace Safety

16. Workplace Safety • Prevention is superior to treatment • A safe work environment reduces workplace costs while improving patient safety • The tools that we use for reducing occupationally acquired infections can also reduce the risk of injuries

17. Occupational Health • Pre-employment screening • HCP-recommended vaccinations • Employment physical • Drugs/alcohol screening • Allergy screening (gloves) • Baseline TB testing • Fit test medical clearance • Hearing evaluation/audiogram • Fitness-for-duty • pregnancy, immunocompromised, security-sensitive

18. Occupational Health • Annual • TB screening (facility and/or regulatory dependent) • Influenza vaccination • DOT/FMCSA drug/alcohol testing (facility dependent) • Policy development • Education • Wellness (facility dependent)

19. Occupational Health • Event-driven • Communicable disease exposures • Blood-borne pathogens • Contact investigations • Acute injury • Infection Control • Ergonomic evaluation • Indoor air quality • For cause drug/alcohol testing • ADA/FMLA/Fitness-for-Duty

20. OSHA State/Local Health Departments CDC/NIOSH Centers for Medicare Services DHHS Occupational Health Health Care Personnel Legal/Administration Worker’s Compensation Workplace Safety Infection Control

21. Pre-exposure prophylaxis

22. Vaccine Preventable Diseases • Anthrax • Diphtheria • HepatitisA/B/D • H. influenza type • Human papillomavirus (HPV) • Influenza A and B • Japanese encephalitis • Lyme disease • Measles • Monkeypox • Mumps • Rabies • Meningococcal A,C,Y,W135 • Meningococcal B • Pertussis • Pneumococcal • Poliomyelitis • Rotavirus • Rubella • Smallpox • Tetanus • Tuberculosis • Typhoid fever • Varicella(Zoster) • Yellow fever

24. Why do I have to get vaccinated? • Vaccine-preventable diseases haven’t gone away. • Vaccination can mean the difference between life and death. • In the US, vaccine-preventable infections kill more individuals annually than HIV/AIDS, breast cancer, or traffic accidents. Approximately 50,000 adults die each year from vaccine-preventable diseases in the US. • Vaccines are safe and effective. • When you get sick, your children, grandchildren, and parents are at risk, too.

25. I’ve heard that vaccines don’t work

26. So, do I have to get vaccinated? • 10A NCAC 13D .2209 INFECTION CONTROL • (a) A facility shall establish and maintain an infection control program for the purpose of providing a safe, clean and comfortable environment and preventing the transmission of diseases and infection.

27. I can’t get vaccinated, I’m ……. • Pregnant • Live-attenuated vaccines contraindicated (with some exceptions) • Immunocompromised • Case-dependent, concern is vaccine efficacy as well as patient safety • Allergic to eggs • Vaccine-dependent (may have egg-free formulations available) • On blood thinners • “Let me see your arm” • Afraid of needles • “Quick, look over there”

28. I can’t get vaccinated, I’m ……. “Not willing to get vaccinated, despite all the things you have just told me ” ”Pick battles that are small enough to win, big enough to be important”

29. Immunization documentation 1Consider immunization of HCP born before 1957, recommend during an outbreak; 2All HCP of childbearing potential should be immunized; 3requires lab confirmation; 4Obtain 1-6 months post last vaccine dose Weber DJ, Schaffner W. ICHE 2011;32:912-4

30. Specific Vaccines

31. Hepatitis B • Indications • Universal; HCP with potential blood exposure (OSHA required OR signed refusal) • Administration • Prior to administration do not routinely perform serologic screening for HB unless cost effective • After 3rd dose, test for immunity (>10 mIU/mL){OSHA required}; if inadequate provide 3 more doses and test again for immunity; if inadequate test consider as “non-responder” • If non-immune after 6 (or 3) doses, test for HBsAg

33. OSHA mandate (1991) Estimated Incidence of HBV infections among HCP and General Population, United States, 1985-1999

34. Influenza vaccines • Standard IM inactivate influenza vaccine (TIV) {> 6 months} • Inhaled live-attenuated influenza vaccine (LAIV) {ages 2-49} (NOT for 2016-2017 influenza season) • Other formulations • High titer influenza vaccine {>65 years} • Intradermal influenza vaccine {18-64 years} • Cell culture-based influenza vaccine^ {>18 years} (egg-free) • Two 2 quadrivalent influenza (2 A, 2 B strains) vaccines {>3} • Recombinant influenza (HA only) vaccine^ {18-49} (egg-free)

35. Influenza vaccines • ACIP recommendations • 1 annual dose for all persons > 6 months of age • Required to be offered to residents and HCP in ECFs in NC • Immunize as soon as vaccine becomes available for the current season

36. CDC National Summary 2016-2017 Season

37. Measles, Mumps, Rubella (MMR) • Measles • Born before 1957: Consider immune (except during outbreak): Born after 1957: 2 doses • Immunity = Appropriate immunizations or positive serology • Mumps • Born before 1957: Consider immune (except during outbreak): Born after 1957: 2 doses • Immunity = Appropriate immunizations or positive serology • Rubella • 1 dose of MMR to susceptible women of childbearing potential • Immunity: Positive serology or documented vaccine

38. Varicella • Special consideration should be given to those who have close contact with • persons at high risk for severe disease (e.g., immunocompromised persons) • persons are at high risk for exposure or transmission (e.g., teachers of young children, college students, military recruits, international travelers) • Immunity • birth before 1980 (not HCP or pregnant women), history of varicella or zoster by a HCP, positive serology, or laboratory evidence of infection

39. Zoster Vaccine • One dose for persons > 60 years of age regardless of whether they had a prior episode of zoster • FDA approved for persons > 50 years of age - ACIP statement to be delayed (last update in 2014) • Live attenuated vaccine; avoid in immunocompromised persons

40. Tetanus-diphtheria-acellular pertussis (/Tdap) • Substitute 1 dose Tdap for all adults when Td booster due • May be use to provide tetanus PEP • Provide to all adults with exposure to young children (no delay after Td) • Recommended for pregnant women (preferably 2nd or 3rd trimester) • Only one dose of Tdap is required, employees who are 10 years out from Tdap should be boosted with Td.

41. Meningococcal Vaccine • Recommended for adults had high risk of disease (persistent complement deficiency, functional or anatomic asplenia, or HIV infection (adolescents)) • 2-dose primary series administered 2-months apart for persons aged 2-54 MCV4, • persons < 55 years; MPSV4 persons > 56 years

42. Exposure Assessment

43. Exposure Disease Dose Host

44. Exposure Assessment • You have to be exposed to be at risk for the disease • ex. Blood on intact skin, limited time in patient room • The definition of exposure is agent-specific

45. Exposure Assessment • Potentially infectious material • Contaminated fluids: blood, CSF, vaginal secretions, semen, synovial, pleural, peritoneal, pericardial, amniotic • Route of exposure • Percutaneous • Mucous membrane • Non-intact skin • Risk • HIV, HBV, HCV

46. Exposure Assessment • Droplet • Sneezing (velocity 50 m/s; distance 6 m) • Coughing (velocity 10 m/s; distance 2 m) • Breathing (velocity 1 m/s; distance <1 m) • Route of exposure • Mucous membrane (hand-oral) • Non-intact skin • Risk • Influenza, adenovirus, RSV, pertussis, N. meningitides, group A streptococcus

47. Exposure Assessment • Contact • Stool, draining wounds, uncontrolled secretions, pressure ulcers, or presence of ostomy tubes and/or bags draining body fluids • Route of exposure • Mucous membrane (hand-oral) • Non-intact skin • Risk • norovirus, rotavirus, C. difficile, syphilis

48. Exposure Assessment • Airborne • Route of exposure • Respiratory • Contact with infected fluid • Risk • TB, measles, chickenpox, disseminated zoster, zoster in immunocompromised patient

49. Exposure Assessment • Exposure is agent-specific • Ex. Tuberculosis • Risk of TB infection is determined by duration of exposures (days to weeks, not minutes to hours) • Household contacts have different ventilation requirements related to air exchanges per hour • However, there is no ”safe time” to be exposed to TB

50. Post-exposure prophylaxis