Expect Zika Return, Reinforce HCW Safety
First cases appearing in Florida
Employee health professionals should prepare for the return of Zika virus, as the CDC expects the mosquito-borne infection threat to return to the U.S. as the warmer months arrive. That poses employee health challenges that come down to the same essential message: prevent blood exposures, needlesticks, and alert employees who are pregnant or trying to become so.
Florida is already under fire, as state health officials reported the state had 29 cases as of March 20, 2017. The vast majority were in travelers returning from countries where Zika is spreading, but two cases were locally acquired via mosquitoes and two were of unknown origin. The state reported Zika infections in 13 pregnant women for 2017. All Florida county health departments now offer free Zika risk assessment and testing to pregnant women.
As this issue went to press, the CDC was advising pregnant women to consider postponing travel to Miami-Dade County.
“If you are pregnant and must travel or if you live or work in Miami-Dade County, protect yourself from mosquito bites by wearing insect repellent, long clothing, and limiting your time outdoors,” the state health department advised. According to CDC guidance, providers should test all pregnant women who lived in, traveled to, or whose partner traveled to Miami-Dade County after Aug. 1, 2016.
“This is the first time a mosquito-borne disease has ever caused birth defects in humans,” Lyle R. Petersen, MD, MPH, director of the CDC’s Division of Vector-Borne Infectious Diseases, said at a recent two-day Zika summit at the CDC. “The last time an infectious pathogen — rubella virus — caused an epidemic of congenital defects was more than 50 years ago. … This is also the first mosquito-borne virus that has shown to be sexually transmitted in humans.”
Again, though the primary threat is to pregnant women and unborn children, adherence to standard precautions and injection safety should block occupational transmission to workers if patients with Zika are hospitalized or treated in other healthcare settings.
The CDC recently reported Zika-affected pregnancies with birth defects in the U.S. were about 20 times higher than pregnancies occurring before the virus emerged as an epidemic in the Americas last year. “Defects and other early brain malformations, eye defects, and other central nervous system problems, were seen in about 3 of every 1,000 births in 2013-2014,” the CDC reported.1 “In 2016, the proportion of infants with these same types of birth defects born to women with Zika virus infection during pregnancy was about 6%, or nearly 60 of every 1,000 completed pregnancies with Zika infections.”
The birth defects include microcephaly, with the critical risk period to the fetus occurring in the first trimester of pregnancy, Petersen said. The virus attacks the brain before the cranial plates of the skull are fully set, causing them to collapse in to form the small head, he said.
The prevailing consensus is that most Zika infections are largely asymptomatic and inconsequential unless the infected person is pregnant or has had unprotected sex while the virus was circulating in the blood or persisting in a human reservoir like semen. Thus, we have seen the tragic birth defects, failed or terminated pregnancies, transmission to sexual partners both male and female, and Zika infection following a needlestick.
In addition, 2016 saw the strange case of a 73-year-old patient in the U.S. who apparently transmitted Zika to a visiting acquaintance — possibly through tears — before dying with an incredibly high level of circulating virus in the blood.2 The secondary case developed symptomatic Zika infection, but subsequently recovered. It is possible that hormonal treatment for prostate cancer somehow accelerated viral replication in the index case, investigators concluded.
As employee health professionals are well aware, Zika is just the latest example of bloodborne threats to healthcare workers. This underscores the importance of using sharps designed to prevent injuries, the prompt reporting of any needlesticks, lacerations, and other exposure incidents to supervisors as soon as possible.
Healthcare workers should use standard precautions during patient care regardless of suspected or confirmed Zika infection status, NIOSH and OSHA recommend.3 However, employers should consider enhanced precautions in situations where workers are at increased risk of exposure to Zika virus or other hazards.
“While there is no evidence of Zika transmission through aerosol exposure, minimizing the aerosolization of blood or body fluids as much as possible during patient care or laboratory tasks may help prevent workers from being exposed to other pathogens,” the agencies recommend. “Additional protections, including engineering controls to ensure containment of pathogens or enhanced PPE to prevent or reduce exposure, may be necessary during any aerosol-generating procedures or other such tasks.”
ANA Trains for ‘New Normal’
As emerging, novel viruses seem to have become the “new normal” for employee health professionals, several research and training projects are being undertaken to shed light on how best to protect staff from infectious threats.
The healthcare system has certainly been tested by Ebola, Zika, and MERS, with a common finding that training and consistent, correct use of PPE is an ongoing concern.
The 2014-2015 Ebola outbreak spread to some 28,000 cases and caused more than 11,000 deaths. One of them was a patient admitted to a hospital in Dallas in October 2014. He died, but infected two nurses, who survived. There was considerable confusion about the case, and some initial speculation that the nurses must have had a break in infection control technique or PPE. While the exact route of transmission was never determined, a report by an expert investigative panel described a chaotic scene where any number of factors could have led to the occupational infections. Healthcare workers were confused and “lost confidence” trying to protect themselves with PPE guidelines that were in flux at that critical time, the panel concluded.
As a result of the Ebola outbreak, the American Nurses Association (ANA) has entered into training and resource collaborations with the CDC.
“The ANA has been involved in infection prevention and control for quite some time, ranging from antibiotic stewardships to preventing healthcare-associated infections, but after the Ebola outbreak we wanted a more formalized collaboration between ourselves and the CDC,” says Seun Ross, DNP, MSN, CRNP-F, NP-C, NEA-BC, director of nursing practice and work environment at the ANA.
The nurse-patient relationship is arguably the most critical aspect of care delivery, and the ANA is particularly proud that nurses are consistently ranked as the most ethical of all professions.
“We have ranked No. 1 in that category for the past 15 years and that is a position we don’t want to concede,” Ross says. “We want to continue that trust [in nursing as an ethical profession]. We want to make sure that nurses are knowledgeable to handle anything that comes their way. Certainly, emerging infectious diseases are in that category and may involve at any time a different understanding of [infection control recommendations]. We want to do everything we can to minimize any concern or hesitation on the part of the nurse.”
Thus, the ANA collaborated with the CDC to form the Nursing Infection Control Education (NICE) Network. The plan is to present CDC training materials at conferences and meetings of nursing specialty groups.
“The CDC is developing a basic training program and we are going to take it and gear it more toward nurses for ANA and some 20 other nursing associations,” Ross says. “We will do it in collaboration with them at each of their conferences so we can reach a broader range of [nursing specialties]. After nursing school, once you get your first job, every hospital does basic infection control. With the NICE Network, we plan on teaching hand hygiene, PPE, fundamental principles, and prevention of infection transmission. We will use all of that as a baseline and expand on that and talk more about emerging infections.”
In additional Ebola education efforts, the federal government has awarded $12 million over the next five years for training development at three hospitals that all cared for infected patients in their respective biocontainment units during the outbreak. The facilities participating in the collaborative training and education effort are Emory University in Atlanta; the University of Nebraska Medical Center in Lincoln; and Bellevue Hospital Center in New York City. Training will include rapid suspect or confirmed case identification and immediate isolation as well as appropriate donning and doffing of PPE.
- CDC. Baseline Prevalence of Birth Defects Associated with Congenital Zika Virus Infection — Massachusetts, North Carolina, and Atlanta, Georgia, 2013–2014. MMWR 2017;66(8):219–222.
- Swaminathan S, Schlaberg R, Lewis J, et al. Correspondence: Fatal Zika Virus Infection with Secondary Nonsexual Transmission. New Engl Jrl Med 2016;375(19):1907-1909.
- OSHA, NIOSH. Fact Sheet: Interim Guidance for Protecting Workers from Occupational Exposure to Zika Virus. 2016: http://1.usa.gov/1TvbTJu.
Employee health professionals should prepare for the return of Zika virus, as the CDC expects the mosquito-borne infection threat to return to the U.S. as the warmer months arrive.
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