Health Care Workers Screening: A Public Health Strategy

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Health Care Workers Screening A Public Health
Strategy

• Dr. Rasha Salama
• M.Sc., PhD Public Health- Suez Canal University
• Dubai Health Authority

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Burden of HCAI

• Health care-associated infections occur worldwide
  and affect both developed and resource-limited
  countries.
• About 510 of patients
• admitted to acute care hospitals
• in developed countries acquire health
• care-associated infections and the risk
• of acquiring infection is 520 times higher
• in developing countries - a growing challenge
• to quality of health care in the region.
• The economic cost of health care-associated
  infections as well as the opportunity cost to
  health services is enormous. preventing a case of
  health care associated infections saves on an
  average of US 10000 and reduces the patients
  risk of death from 7 to 1.6..

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Introduction

• Health care-associated infections (HCAI) can be
  acquired anywhere along the continuum of health
  care settings.
• Affect a large number of patients and health care
  workers and frequently result in amplification of
  epidemics.
• Impact of health care-associated infections
  includes
• Prolonged hospital stay,
• Long-term disability,
• Increased resistance of microorganisms to
  antimicrobials,
• Massive additional financial burden for health
  systems,
• High cost for patients and their family
• Unnecessary deaths
• Low quality of patient care

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Basic Facts

• Transmission of infectious agents within a
  healthcare setting requires
• a source or reservoir of infectious agents
• a mode of transmission
• a susceptible host.

• Factors affecting Health Associated Infections

Patients may be exposed to infectious agents from
themselves (endogenous infection) or from other
people, HCWs instruments and equipment, or the
environment (exogenous infection
Healthcare workers may be exposed to infectious
agents from infected or colonised
patients, instruments and equipment, or the
environment
In healthcare settings, the main modes of
transmission of infectious agents are contact
(including blood-borne), droplet and airborne.
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Who are Health Care Workers?
A healthcare worker (HCW) is an individual who
may have the potential to acquire or transmit an
infectious agent during the course of his or her
work in the healthcare setting while providing
direct care. It may include all persons working
in the healthcare facility comprising nursing
staff, physicians, lab technicians, home-care
workers, students and others.
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Screening of health care workers is it
worthwhile?

• The global burden of hepatitis B (HBV), hepatitis
  C (HCV), and human immunodeficiency virus (HIV)
  infection due to percutaneous injuries among
  health care workers (HCWs) is estimated
• Overall, 16,000 HCV, 66,000 HBV, and 1,000 HIV
  infections may have occurred in the year 2005
  worldwide among HCWs due to their occupational
  exposure to percutaneous injuries. The fraction
  of infections with HCV, HBV, and HIV in HCWs
  attributable to occupational exposure to
  percutaneous injuries fraction reaches 39, 37,
  and 4.4 respectively.
• These infections are highly preventable and
  should be eliminated
• Estimation of the global burden of disease
  attributable to contaminated sharps injuries
  among health-care workers Am J Ind Med. 2005
  Dec48(6)482-90.

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Transmission of blood-borne pathogens in health
care settings

• The 2009 global burden of disease study revealed
  that as many as 510 of new HIV infections,
  3032 of new HBV infections, and around 40 of
  new HCV infections in low and middle-income
  countries may be attributable to exposure in
  health care settings, including unsafe
  injections, unsafe blood and occupational
  exposures (25).

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Infection prevention and control is everybodys
business!

• The current global evidence clearly demonstrates
  that a considerable proportion of the burden of
  disease attributable to health care-associated
  infections can be prevented with low-cost
  interventions.
• The implementation of evidence-based infection
  control measures needs more public health actions
  and organizational control for universal
  application of evidence-based prevention and
  control practices, compliance with those
  practices, behavioral change, risk management,
  standardized surveillance methods, and quality
  assurance

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The Goal

• Effective infection prevention and control is
  central to providing high quality health care for
  
• patients and
• a safe working environment for those that work in
  healthcare settings.
• GOAL The creation of safe healthcare
  environments through the implementation of
  practices that minimize the risk of transmission
  of infectious agents.

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Policy for Infection Control in Health Care
Facilities

• Personal Hygiene
• Employee Health
• Employee health Initial and periodical physical
  examination, communicable diseases screening,
  vaccination (hepatitis B, influenza, other
  vaccinations)
• Prevention of occupational exposure to blood
  borne pathogens (e.g. HBV, HCV and HIV) and
  post-exposure prophylaxis
• Prevention, surveillance, control and reporting
  of health-care acquired infections
• Surveillance, management and reporting of
  multi-resistant pathogens or pathogens with
  relevant resistance antimicrobials policy
• Isolation precautions and management of specific
  infectious diseases
• Cleaning and disinfection
• Sterilization and storage of sterile supplies
• Unit specific infection control
• Infection control in supply and disposal
• Environmental and Engineering Controls

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Positive Aspects of Policy Application

• Providing a healthy, safe environment free of
  risk of transmission of infection between patient
  and health care provider.
• Ensuring means of prevention, such as providing
  immunization services and changing the workplace
  in some required cases.
• Confirming the application of health care workers
  screening policy for all workers in the public
  and private health sectors.

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Action plan ..

• Formation of a team of specialists from different
  parties
• Current situation analysis
• Review of legislation and laws
• Provide scientific evidence and best practices
• Initial development of the proposed policy
• Discussion of the proposal with relevant
  authorities and stakeholders
• Final Edition of the policy

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Evidence base

• The policy was based on the best available
  evidence and knowledge of the practicalities of
  clinical procedures.
• They draw from other work in the area, including
  the national, international infection control
  guidelines and policies, systematic literature
  reviews conducted to inform the development of
  this policy, work on HAI prevention from CDC,
  WHO, SHEA guidelines, US preventive Task force,
  Canadian Task force on Preventive Healthcare,
  national discipline-based infection control
  guidelines, and National Standards laws and
  regulations relevant to infection prevention and
  control.

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Objectives

• Confirm that HCWs are free of infectious diseases
• Assure safety of Patients/co-patients
• Provision of preventive services
• Provision of the appropriate early management

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The Main Domains

• Diseases that must be screened  - AIDS -
  Hepatitis B and C - Pulmonary tuberculosis -
  Chickenpox - Syphilis
• Determination of the measures of prevention

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Infectious Diseases screening Infectious Diseases screening Infectious Diseases screening Infectious Diseases screening Infectious Diseases screening
Disease Screening test Confirmatory test (If screening test Positive) Protective action Fitness category
HIV/AIDS Elisa HIV Ab/Ag Western Blot No action Unfit to perform category III procedures
HBV Elisa HBsAg Not required Vaccinate if HBsAg/Ab Negative. Unfit to perform category III procedures
HBV HBs Ab Vaccinate if HBsAg/Ab Negative. Unfit to perform category III procedures
PTB CXR Rule out activity in the presence of Radiological changes No action fit after appropriate treatment and in accordance with country laws
PTB AFB and Culture 3 consecutive Sputum No action fit after appropriate treatment and in accordance with country laws
LTBI PPD or IGRA LTBI treatment Fit
Varicella IgG (if no evidence of past disease or immunization) Varicella vaccination if Negative
HCV Elisa Ab PCR No action Unfit for category III procedures
Syphilis Elisa Ab Elisa Ab Fit for Duty, provide treatment
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Category I

• Procedures with the minimum risk of blood
  borne virus transmission
• Regular history-taking and/or physical or dental
  examinations,
• Routine dental preventive procedures
• Routine rectal or vaginal examination
• Minor surface suturing
• Elective peripheral phlebotomy

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Category II

• Procedures for which blood borne virus
  transmission is theoretically possible but
  unlikely
• Locally anesthetized ophthalmologic surgery
• Locally anesthetized operative, prosthetic, and
  endodontic dental procedures
• Periodontal scaling and root planting
• Minor local procedures (e.g., skin excision,
  abscess drainage, biopsy)
• Percutaneous and other minor orthopedic
  procedures
• Subcutaneous pacemaker implantation
• Bronchoscopy
• Upper gastrointestinal tract endoscopic procedures

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Category III

• Procedures for which there is definite risk of
  blood borne virus transmission
• General surgery
• General oral surgery, including surgical
  extraction, tissue biopsy
• Cardiothoracic surgery
• Neurosurgery.
• Obstetrical/gynecological surgery, including
  cesarean delivery, hysterectomy, forceps delivery
  
• Orthopedic procedures
• Trauma surgery, including open head injuries,
  facial and jaw fracture

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Interventions following Screening

• 1. Counseling for HCWs with positive results
• 2. Raising awareness
• Risk and mode of transmission.
• Personal protective measures

• Hepatitis B
• Varicella
• Others Influenza, Tetanus, Pneumococcal

• From area/job of high risk of transmission to a
  low risk one
• Based on type of work and infection
• Standard classification of 3 categories

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Evidence for Action
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Evidence for Action (cont.)
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Hepatitis B, Varicella vaccination,and optional
vaccines

• Hepatitis B vaccination is recommended for all
  healthcare workers - 3 doses
• Booster doses are not recommended for persons
  with normal immune status who were vaccinated.
• ?All HCWs lacking immunity to varicella should
  receive two doses of varicella vaccine, 4 weeks
  apart, unless contraindicated.
• Flu vaccine is recommend for all HCWs annually.
  Only the inactivated vaccine if any
  immuno-compromised state exists.
• Tetanus and Diphtheria vaccinations are indicated
  if there is history of incomplete primary
  vaccination or if the last booster was more than
  10 years ago.
• Pneumococcal vaccine Recommended for all HCWs
  above 65 years -single dose

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HCWs with NCDs

• Screening for NCDs is important.
• Confirm diagnosis
• Provision of counseling
• Direction for management and follow-up.
• Assure life style modification.

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Desired Outcomes

• Reducing transmission rates through health
  facilities.
• Ensuring the quality of health services provided
  by the healthy care workers in the health sector
• Reducing the cost of treatment for workers in
  case of exposure to infection - the indirect cost
  

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Thank You