New guidelines by the Centers for Disease Control and Prevention (CDC) to protect healthcare workers (HCWs) from infections call for infection preventionists (IPs) to be key collaborators with occupational health departments.

The recently published CDC guidelines1 state, “Explicit communication and collaboration between occupational health service (OHS) and other … departments, particularly infection prevention and control (IPC) services, can improve healthcare personnel safety and the delivery of occupational IPC services.”

Some examples of collaboration cited in the guidelines include assessing and selecting devices designed to prevent sharps injuries and needlesticks. IPs can also assist their employee health partners in documenting HCW vaccine immunization declination policies.

The CDC cites other areas of potential IP collaboration to protect workers that include:

  • respiratory protection programs;
  • occupational infection prevention education and training;
  • medical evaluations;
  • infectious disease screening and surveillance;
  • management and reporting of exposures and illness;
  • work restrictions and clearance for returning to work; and
  • infectious disease emergency planning/management (e.g., pandemic planning).

To achieve this level of cooperation that the CDC calls for, provide resources to protect employee health. “An occupational health service can’t do that effectively without backup from the top of the organization. They need that support; otherwise it is not going to work,” says David Kuhar, MD, who spearheaded the guideline development as the CDC’s liaison with its Healthcare Infection Control Practices Advisory Committee (HICPAC).

The guidelines, which are the first by the CDC on this issue in 21 years, include a section on facility leadership. “That is something that is new with this update, as opposed to the 1998 recommendations,” he says. “There are recommendations aimed at healthcare administration. They are focused on ensuring that these programs have resources and leadership commitment so they can succeed.”

The administrative leadership recommendations by the CDC include the following:

  • Invest in an organizational culture that prioritizes safety and occupational infection prevention and control.
  • Regularly review organizational information about occupational infectious risks, exposures, and illnesses with occupational health services.
  • Dedicate one or more persons with appropriate authority and training to lead occupational infection prevention and control services.
  • Provide sufficient resources (e.g., expertise, funding, staff, supplies, information technology) to implement elements of occupational infection prevention and control.
  • Oversee, and include occupational health services leaders in, performance measurement and continuous quality improvement activities for occupational infection prevention.

Other Sections to Follow

The published guidelines will be followed by other sections, with this first document outlining the infrastructure and routine practices for occupational health services to protect workers from infections.

“The second part of the guideline is going to come out in several sections that are going to address the epidemiology and control of selected infections that can be transmitted among healthcare personnel and patients,” Kuhar says. “It will address the infection prevention issues that are relevant to healthcare personnel and will often focus on postexposure prophylaxis and work restrictions.”

A member of the CDC’s HICPAC shared some this draft guidance on measles exposures at the IDWeek 2019 conference held Oct. 2-6 in Washington, DC.

In addition to being a HICPAC member, Hillary Babcock, MD, MPH, is medical director of occupational health at Barnes-Jewish and St. Louis Children’s Hospitals.

As outlined by Babcock, the HICPAC draft definition of exposure to measles for HCWs is “spending any time while unprotected - not wearing respiratory protection - in a shared airspace with an infectious measles patient; or sharing an air space vacated by an infectious measles patient within the prior two hours - regardless of immune status.”

She conceded that “‘any time’ is a pretty high bar. I think it is not really practicable in a real-life setting, and there is a lot of discussion around that.”

There are also a lot of variables at play, like the air exchange of a given area, and how effective it is to mask a measles patient and for how long.

“There is very little data about the role of source control and the impact of masking,” she said. “We recommend it for patients, but we don’t really know how well that works. There is also no great data on duration.”

Clearly, there is higher risk in providing face-to-face care with neither the measles patient nor clinician masked. “[The CDC] can’t give a cut time, but obviously longer is worse,” Babcock said.

Similarly, quantifying the vagaries of “shared air space” is difficult. Ambulances, exam rooms, and small enclosed waiting areas can be seen as a risk, but it is considerably harder to determine the likelihood of exposure in large open waiting areas with shared air handling systems across different patient rooms, she said. If such a situation arises with measles, it may be best to consult with air handling and engineering at your facility, Babcock added.

In another item from the upcoming HICPAC draft guidelines, postexposure prophylaxis (PEP) and work restrictions are not necessary for healthcare personnel with presumptive evidence of immunity to measles who have had an exposure. However, implement daily monitoring for signs and symptoms of measles infection for 21 days after their last exposure, she said.

“Symptom monitoring is still recommended, as we do know that there are [measles] cases in people with evidence of immunity after an exposure,” she said. “In some places, depending on your comfort level with risk, there may be different decisions made on how to manage this.”

For healthcare personnel without presumptive evidence of immunity to measles who have an exposure, the HICPAC draft recommends the following:

  • Administer post-exposure prophylaxis in accordance with recommendations by the CDC and the Advisory Committee on Immunization Practices.
  • Exclude from work for the fifth day after the first exposure through the 21st day after their last exposure, regardless of receipt of PEP.

HCWs who have received only the first dose of the measles, mumps, and rubella (MMR) vaccine prior to exposure may remain at work, but they should receive the second dose of MMR vaccine within at least 28 days after the first dose. Implement daily monitoring for signs and symptoms of measles infection for 21 days after the last exposure.

For healthcare personnel with known or suspected measles, exclude from work for four days after the rash appears. For immunosuppressed healthcare personnel who acquire measles, consider extending exclusion from work for the duration of their illness.

Dispel MMR Concerns

“Because it is a live virus vaccine that we can’t give to immunocompromised patients, many of our employees were worried that if they got this vaccine they would put highly immunized patients at risk,” Babcock said. They were concerned about “transmitting to a patient or a family member that might be immunocompromised.”

On the contrary, by getting vaccinated, the HCWs were protecting patients and immunized family members who rely on the herd immunity of others to protect them from measles, Babcock emphasized.

“There have been no cases of transmission of vaccinated healthcare workers transmitting [measles] to patients,” she added. “The CDC recommends no work restrictions for people who have been vaccinated. This is true even if someone has been vaccinated - which can happen in a small percentage of people - and develop some symptoms like a rash or a low-grade fever. They are still not infectious. That is an immune response to the vaccine.”

Approximately 5-15% of susceptible persons who receive the MMR vaccine will develop a low-grade fever and/or mild rash 7-12 days after vaccination. Again, they are not infectious, and this does not require exclusion from work.

Of course, exposure avoidance is the main goal through screening, masking, and patient isolation. However, questions also come up about special situations like transporting patients within or between facilities.

“For most of us who are working with people who may be transferred between facilities, that staff in the ambulance or transport service needed to be immune and wear PPE,” she said. “If the patient can be masked, they should be.”

The ambulance should be taken out of service for two hours to allow the virus to dissipate and for the vehicle to be cleaned before use on another patient, she added.

“For transport within the facility, we usually try to mask the patient and not the transporters for most diseases,” she said. “For measles, try to do both - mask the staff and the patient.”

Even if the patient is masked, Babcock recommended clearing the hallways during transport and airing out any elevators that were used.

REFERENCES

  1. Kuhar D, Carrico R, Cox K, et al. CDC HICPAC. Infection Control in healthcare personnel: Infrastructure and routine practices for occupational infection prevention and control services. Oct. 2019. Available at: https://bit.ly/2JbcW3s. Accessed Nov. 8, 2019.
  2. Jiang L, McGeer A, McNeil S, et al. Which healthcare workers work with acute respiratory illness? Evidence from Canadian acute-care hospitals during 4 influenza seasons: 2010-2011 to 2013-2014. Infect Control Hosp Epidemiol 2019;40:889-896. doi:10.1017/ice.2019.141.