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Infectious Diseases and Nurses. Historical Insights Can Guide Future Action. Kate McPhaul, PhD, MPH, RN University of Maryland Work and Health Research Center June 8, 2007 Massachusetts Nurses Association (MNA). Objectives.

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infectious diseases and nurses

Infectious Diseases and Nurses

Historical Insights Can Guide Future Action

Kate McPhaul, PhD, MPH, RN

University of Maryland Work and Health Research Center

June 8, 2007

Massachusetts Nurses Association (MNA)

  • List two old and one new infectious disease known to be transmitted to healthcare workers today
  • Discuss the three classic public health interventions for control of infectious disease transmission
  • Contrast the occupational safety paradigm including hierarchy of controls with classic pubic health protection and critique the implications for protecting healthcare workers
  • Describe the elements of the blood borne pathogen standard and relate to the hierarchy of controls for protecting workers from airborne infectious diseases
Historical perspectives on TB, SARS, Influenza and Healthcare Workers
  • Model Standard - Bloodborne Pathogen and Needlestick Safety Act
  • What do we do NOW to prevent nurses from contracting infectious diseases in future outbreaks?
How many infectious agents may be transmitted and/or acquired by nurses in healthcare settings?

Bloodborne Pathogens

Burkholderia cepacia

Chickenpox (Varicella)

Clostridium Difficile

Clostridium Sordellii

Creutzfeldt-Jakob Disease (CJD)

Ebola (Viral Hemorrhagic Fever)

Gastrointestinal (GI) Infections

Hepatitis A

Hepatitis B

Hepatitis C



MRSA - Methicillin-resistant Staphylococcus Aureus








S. pneumoniae (Drug resistant)


Varicella (Chickenpox)

Viral Hemorrhagic Fever (Ebola)

VISA - Vancomycin Intermediate Staphylococcus aureus

VRE - Vancomycin-resistant enterococci

Infectious Diseases in Healthcare According to the CDC, the following may be transmitted and/or acquired in healthcare settings
blood borne pathogen transmission to healthcare workers
Blood borne pathogen transmission to healthcare workers
  • In addition to Hepatitis B and C, and HIV from 1996 – 2005 there were “published case reports of 60 pathogens: 26 viruses, 18 bacterial/rickettsia, 13 parasites, and 3 yeast” known to occupationally infect HCW’s. (Tarantola, AJIC, 2006)
occupational deaths from infectious diseases hepatitis b
Occupational Deaths from Infectious Diseases: Hepatitis B
  • 1983 – 10,000 HCW’s exposed
      • 5%-10% (500-1000) develop chronic infection
      • 15%-25% (75-200) die/year
  • Risk of Hep B has diminished >90% due to Hep B Vaccine
  • >30% HCW’s decline vaccine resulting 400 HCW’s/year becoming infected
occupational deaths from infectious diseases hepatitis c
Occupational Deaths from Infectious Diseases: Hepatitis C
  • CDC estimates that Hepatitis C is prevalent in 1.8% of US population, same for HCW’s
  • 1-3% of percutaneous exposures result in Hep C infection to HCW
  • 3-8 HCW’s annually die from Hepatitis C (estimate based on needlestick rate)
occupational deaths from infectious diseases hiv
Occupational Deaths from Infectious Diseases: HIV
  • 138 HCW’s acquired AID’s from a percutaneous exposure
  • CDC methods do not collect death information
  • Personal friend, Meta Snyder, died from AIDS acquired via needlestick but did not meet the CDC definition
occupational deaths from infectious diseases internationally
Hemorrhagic fevers

TB in Malawi, Ethiopia and South Africa

Occupational Deaths from Infectious Diseases: Internationally
early history
Early History
  • Aristotle – “in approaching the consumptive one breathes [his] pernicious air, one takes the disease because there is in this air something disease – producing”

Sepkowitz, 1994

  • 1699: tuberculosis became a reportable disease in Italy
  • Some pathologists refuse to do mandated autopsies fearing illness
  • French MD Laennec dies from TB refusing to believe he could acquire it from performing autopsies
  • 1882 study showed no HCW’s infected in a large TB Sanatorium: “TB might not even be contagious”
  • Clapp of Boston believed in contagion but this view was not pervasive
more data shows risk of tb for hcw s
More data shows risk of TB for HCW’s
  • Studies of nursing students in Europe and US show high rates of tuberculin conversation (79-100%)
  • Standard 1920’s pulmonary text: “There is no danger from the expired air of consumptives. For this reason a TB sanatorium is probably the safest place one can be so far as the dangers of infection is concerned.”
why was consensus delayed sepkowitz 1994
Why was consensus delayed?Sepkowitz, 1994
  • Acknowledging risk might scare women away from nursing profession
  • Some said increased surveillance not increased risk
  • Middle road view: Yes, infections are occurring but disease is rare
  • Living right prevents disease
reducing the risk22
Reducing the Risk
  • Mandatory chest x-rays upon admission for all patients
  • Effective chemotherapy and routine prophylaxis
  • TB rates in population declined until 1980’s
occupational deaths from infectious diseases tb
Occupational Deaths from Infectious Diseases: TB
  • At least nine HCW’s who were also immunocompromised died from TB infection in the 80’s and 90’s.
  • 6-8 HCW’s have also died from TB treatment to multi-drug resistant TB
occupational deaths from infectious diseases sars
Occupational Deaths from Infectious Diseases: SARS
  • 8098 cases
  • 774 deaths (9.6%)
  • 1707 (21%)
    • cases were HCW’s
  • 378 (57%) of cases in
    • healthcare were HCW’s
  • Number of HCW fatalities
  • not known!!!
severe acute respiratory syndrome sars timeline
Severe Acute Respiratory Syndrome (SARS) - Timeline
  • Mar 2003 – HCW with unexplained pneumonia in Vietnam dies
  • Mar – June 2003 - Toronto – 2 phase outbreak primarily driven by nosocomial infections
  • Mar – June – Taiwan – 2 phases: 1 in travelers, 1 in hospitals
  • July 2003 – WHO declares outbreak over
sars in healthcare facilities
SARS in Healthcare Facilities

McDonald, 2004 Emerging Infectious Diseases

  • Unrecognized SARS Patients
  • Minimal infection control practices in ER
  • ER = high risk
  • Virus concentrations highest in patients 10 days after infection when symptoms are worsening
sars in healthcare facilities28
SARS in Healthcare Facilities

McDonald, 2004 Emerging Infectious Diseases

  • Transmission appears to be
    • Droplet
    • Direct contact
    • Limited airborne
sars in healthcare facilities29
SARS in Healthcare Facilities

McDonald, 2004 Emerging Infectious Diseases

  • Important Considerations:
    • Aerosol-generating procedures
    • “Super spreaders”
    • Lack of PPE
    • Overwhelming hospital resources such as negative pressure ventilated rooms
    • SARS Tent/SARS Screening station
    • No rapid diagnostic test
    • Using “epidemiologic links”
sars ethical framework key values
Individual liberty

Protection of the public





Protection from undue stigmatization

Duty to provide care



SARS Ethical FrameworkKey Values
why does health care lag behind other sectors in h s
Why does health care lag behind other sectors in H&S
  • False perception that the industry is self-regulated (JCAHO)
  • Health care traditionally seen as “clean industry”, a place of health
  • Focus on “curative” rather than “preventive” care
  • Primarily a female workforce
  • A low unionization rate (Lipscomb & Borwegen, 2000)
hcw vulnerability
HCW vulnerability
  • Socialized to believe that care giving requires self sacrifice, even of their own health
  • Some hazards considered “part of the job”
  • HCWs become patients (often uninsured) in the course of caring for others
  • Issues of race, class, gender
economic costs of staff injuries illnesses
Economic Costs of Staff Injuries/Illnesses
  • Medical care and follow-up
  • Worker disability
  • Staff replacement
  • Loss of experienced workers
  • Cost of importing workers to replace injured US workers
  • Reduced productivity
  • Poor patient outcomes**
classic public health interventions


Isolating infected patients

Classic Public Health Interventions
health and safety programs a framework for prevention
Health and Safety Programs: A Framework for Prevention
  • Management commitment and employee involvement
  • Worksite analysis
  • Hazard control
  • Training
  • Evaluation
h s program elements
H & S Program Elements
  • All necessary, none sufficient
  • Critical for any and all hazards
  • Success dependent on genuine team work
  • Can’t be successful without management commitment
  • Direct care and support staff expertise are essential
hazard control hierarchy of controls
Hazard Control: Hierarchy of Controls
  • Substitution – with a less hazardous chemical or device such as antimicrobials that don’t cause asthma
  • Engineering Controls - modify or control the hazard at the source, such as ventilation hoods?
  • Administrative Controls – reduce the amount of exposure to hazard via policies and procedures
  • Personal Protective Equipment - gloves, respirators, protective clothing
estimated reduction in adverse outcomes with improved staffing
Estimated % reduction in adverse outcomes with improved staffing

Buerhaus, P.I. et al Strengthening Hospital Nursing. Health Affairs 21(5), 2002

how do high workload lead to poor patient outcomes
How do high workload lead to poor patient outcomes?
  • Impaired nurse-physician (and other HCW) collaboration,
  • Poor nurse-patient communication,
  • HCW fatigue, lack of concentration
  • HCW burnout, depression, reduced empathy
  • Job dissatisfaction
  • HCW injury and illness
  • HCW disability and/or job change

Carayon & Gurses (2005)

what do we know about staffing and hcw injuries
What do we know about staffing and HCW injuries?
  • MNA study found a 9% decrease in RNs was associated with a 65% increase in injuries/illnesses (Shogren, 1996)
  • High workloads associated with 50-200% increase in needlestick injuries/near misses, (Clark, 2002)
  • Adverse work schedule and health care system changes associated with neck, shoulder, back MSD (Lipscomb, 2004).
extreme work schedules injuries and patient care jama sept 06
Extreme work schedules, injuries and patient care (JAMA, Sept. 06)
  • 84% of interns worked > than ACGME limits; 67% worked > 30 consecutive hrs.
  • Odds of exposure to sharps or contaminated body fluids increase 61% when interns worked > 20 consecutive hrs. compared with interns working < 12 hrs.
  • “24 hrs of continuous wakefulness causes impairment of cognitive performance comparable to that induced by a blood alcohol concentration of 100 mg/dl (legal intoxication in most states).”

Blood borne Pathogen Risks

  • 2-40% risk of developing Hepatitis B
  • 3-10% risk of developing Hepatitis C
    • 560-1,120/year
    • 85% become chronic carriers
  • 0.3% risk of transmission of HIV
  • >1000 workers will contract Hepatitis B, Hepatitis C, or HIV/year
what do we know
What do we know?
  • 300,000 + needlesticks continue to occur/year.
  • Needlesticks and BB infections are extremely costly.
  • Safety syringe have reduced incidence (> 50%) but much room for improvement.
  • Enforcement of Safe Needlestick Act is limited.
osha bbp standard 1991
OSHA BBP Standard (1991)
  • Require “universal precautions”
  • Required Hep B immunization
    • Cases went from 17,000 (1983) to 400/yr
  • Engineering controls (safe needles) were to be used where available
  • Dentists claimed (in the docket) if they were forced to where gloves, patients would not see them.
safe needle act of 2000
Safe Needle Act of 2000
  • Unanimous bipartisan support
  • Clarifies the need for employers to use safe needles
  • Requires front line worker participation in product selection committees
  • Requires employers to maintain a log of injuries from contaminated sharps.
airborne infections
Airborne Infections
  • TB, SARS, influenza
  • Seasonal flu - <40% immunization among HCW
  • Pandemic flu preparedness
  • Aerosol vs droplet transmission
  • Respiratory protection
    • Type, fit testing, stockpiles
what do we know48
What do we know?
  • Short staffing leads to sick staff.
  • Sick staff lead to sicker patients.
  • Current levels of staff immunization inadequate.
  • Current levels of available respiratory protection (N95s) inadequate for pandemic flu.
history of regulations to prevent hcw exposure to airborne hazards
History of Regulations to Prevent HCW Exposure to Airborne Hazards
  • Respiratory Protection Standard (1971, 1998)
  • Proposed TB rule (1997); withdrawn (2003)
  • Continuation of the Wicker Amendment (appropriations rider)
    • CA is enforcing the annual fit testing requirement.
  • The risks to nurses are historically and currently substantial
  • Early research is not always accurate
  • Educate other RN’s and HCW’s
  • Argue, lobby, insist upon N95 PPE and general preparedness of your facility
  • Join or get on the agenda of H and S Committee
questions and future contact
Questions and future contact