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OSHA/Infection Control Annual Update Training - 2014

IC/EC, Inc.

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Update disease information List new training responsibilities Conduct refresher training on key

department issues of compliance Understand the use of surgical masks Clarify use of declination forms Review new flu vaccines

Objectives

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Disease Numbers 2012-2013

2012 HIV Dx – 35,361 HBV – 2,895 HCV – 1,782 Syphilis – 15,667 TB – 9,945

2013 HIV – HBV – 2,666 HCV – 1,655 Syphilis – 15,639 TB – 8,080

•CDC, MMWR, Jan.3, 2014 – provisional

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Other Diseases - 2013

Measles Mumps Rubella Chickenpox

Pertussis (whooping cough)

184 438 9 9,987

24,231

CDC, MMWR, 1/3/14- provisional

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County Disease Numbers

HIV Dx. - 20 (down from previous year)

HBV – 6 new 48 chronic (up from previous year)

HCV – 6 new 528 chronic (same as previous year)

Syphilis - 16 (up from previous year)

TB - 8 (same as previous year)

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This means that medical facilities have expanded notification responsibilities

This means that departments have extended vaccine/immunization responsibilities

Ryan White Notification -Update

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Education & Training to Include

Bloodborne

HCV HBV HIV Vaccinia virus Cutaneous Anthrax Rabies Viral hemorrhagic fevers

Airborne

Measles (Rubeola) Chickenpox Tuberculosis

Federal Register, 11/2/11

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Droplet TransmittedN. MeningitisDiphtheriaMumpsPertussisPlagueRubellaSARS-CoVNovel Influenza A viruses

List Published

Federal Register, 11/2/11

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Prevention

Travel history on patient assessment especially with respiratory symptoms

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Place surgical mask on patient If can not, place surgical mask on yourself

Good handwashing Use good airflow in vehicle

Prevention

IOM meeting June 3, 2010/ CDC

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Surgical mask and droplet precautions even if H1N1

CDC reverted to this in 2010 N95s for hospital use for aerosol-generating

procedures

Masks & Influenza

Personal communication, Dr. Uyeki, CDC July 19, 2012

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Hepatitis B vaccine Tdap booster x1 MMR Chickenpox Flu vaccine TB Testing

Immunizations/Vaccinations

CDC,1997, 2011

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HICPAC and CDC have recommended that secure, preferably computerized, systems should be used to manage vaccination records for HCP so records can be retrieved easily as needed

Each record should reflect immunity status for indicated vaccine-preventable diseases, as well as vaccinations administered during employment

CDC Statement on Records

CDC, November, 2011

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From – Your schools

High school College

Training programs Previous employer

Did You -Obtain Your Records

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If you do not wish to give your medical information, you must sign a declination form

Declination Forms

If received between 1963 – 1967 Revaccinate with 2 doses one

month apart

MMR Vaccine

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No need to titer

Just vaccinate

Measles Status Unknown

CDC, 11/25/12

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Unable to document immunity

Just vaccinate

Chickenpox Vaccine

CDC, Nov. 25, 2011

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Recommended for persons 50 and older Can take if you have had an outbreak of

shingles

Employer does not need to offer

Shingles Vaccine - Clarification

CDC

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To protect patients from infection To protect yourself To protect co-workers

Healthcare Worker Duty

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Declination Forms

Document that the employer met his/her obligation to offer

Does not eliminate employee rights

Clarification

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Bloodborne - 0

Airborne/droplet - 0

Department Exposures - 2013

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Universal vaccination 1983 - 1995 occupational infections

decreased by 95%

Healthcare worker infection infrequent

HBV Infection Rate- US

CDC, September, 2009, Nov.. 2011

Need to complete all 3 shots

1 dose = 30% - 55% protection 2 dose = 75% protection 3 dose = >90% protection

Vaccine - HBV

CDC, MMWR, Nov. 2011

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Due to improper infection control practices Outbreaks

Ambulatory care clinics Free dental clinic Dialysis centers Dental Practices

HCV Increased

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Since 2001, over 157,000 persons have been called back for testing for HIV,HBV and HCV due to breaks in basic infection control practices

HCV Outbreaks

CDC, 2012

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All persons born between 1945-1965 should have a one time screening for HCV infection

CDC- Baby Boomers

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OraQuick ®HCV FDA approved Takes 20 mins. No lab equipment required Very accurate- 99.8% Waiver granted 11/28/11** Screens for multiple genotypes

New Rapid HCV Test

FDA. June 25, 2010

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A positive test for HCV by antibody testing does NOT mean current infection

Source patient to have viral load test for confirmation

(HCV-RNA)

Remember

CDC, Hep C Symposium Dec.. ,2011

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If you are exposed to a hepatitis C positive patient, you should have a blood test in 2 weeks

HCV-RNA (blood test) Cost - $65.00 - $100.00

Reminder -

Am. Assoc. for the Study of Liver Disease, Practice Guidelines, 2009

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Hepatitis C – Early Treatment

HCV-RNA positive begin treatment

12 -24 weeks –

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New Treatment Drug

Telaprevir- Vertex

“cured 75%-79% of patients with Genotype 1 HCV in 24 weeks of treatment”

FDA approval granted – April 2011

Boceprevir – Merck

FDA approved 5/13/11 Given as 3 drug cocktail

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Newer Drugs

Olysio

Treatment Genotype 1

Solvadi

Treatment Genotype 1 & 4

Cure more often and in less time 0 12 weeks80% - 95+%

2014

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Treatment Genotype 2 & 3

Given with Ribavirin NO interferon

Solvadi

2014

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1978 – December, 2010 57* documented cases

0 in fire/EMS personnel 49 were sharps related exposures

Infected Healthcare Workers- Occupational Infection-HIV

CDC, May, 2012(CDC), NIOSH

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CDC reported that – “More than 90% of healthcare personnel

infected with HIV have non-occupational risk factors reported for acquiring their infection.”

CDC Surveillance of Occupationally Acquired HIV

CDC, 2012 Report

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No new cases since 1999

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Cases increase in ages 13-24

2010 -12,000 infected 1,000 per month

Risk group – HIV infection

CDC, 2012

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Aids “cocktail” drugs = 96% unable to transmit the disease

HIV/AIDS – living 50 years

Update - 2011

Dr. Fauci, NIH, May 2011

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Atripla – 84%- 0 HIV virus in blood in 48 weeks

Stribild – 88% - 90% in 48 weeks

Truvada – 87% in 48 weeks

Result 3 Drug Cocktail= 0 virus

CDC, Oct. 2012

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Rapid HIV Tests- Post Exposure

Rapid HIV Test - currently available – using blood

OraQuick Reveal

Uni-Gold Multispot

Clearview

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CDC January 2007

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If source patient is negative with rapid testing = no further testing of health-care worker

Use of rapid testing will prevent staff from being placed on toxic drugs for even a short period of time

Reminder - Testing Issues - Post Exposure

•CDC, May , 1998, CDC June 29, 2001, September 2005

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Updated CDC Guidelines – September, 2013

If source is HIV positive and has viral load= Baseline, 6 weeks and rapid test at 4 months

using rapid test

Change in Post Exposure to HIV

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Since rapid tests are waivered, they can be performed in the ED

Point of Care Testing is the current standard of care

Point of Care Testing - POCT

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Point of Care Testing

HIV HCV Syphilis Lyme disease Herpes Simplex Influenza A&B Strep A

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Syphilis Cases

Part of post exposure testing

Post exposure follow up if source is HIV positive or Hepatitis C positive

More testing under new Sexually transmitted disease (STD) guidelines

(2010)

Part of point of care testing

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Highest States for cases - 2013

California

Texas

New York City

Florida

CDC, MMWR , 2013

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CDC - Plan

Update plan to eliminate syphilis by 2015?

Not looking good!

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Tuberculosis

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2012 lowest case number since 1953

10,528 in 2011- now 8,080 for 2013

Goal to eliminate by 2015 - worldwide

Tuberculosis

CDC, MMWR, 2012;61:181-185

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MDR-TB – 84% in foreign-born persons 109 cases in 2010

XDR-TB – 2 cases reported in 2007 XDR-TB 1993 -2007 = 83 cases reported

2008 = 0 2009 = 0 2011= 4 cases in foreign-born persons

Both are treatable !

Multi-drug Resistant TB

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New 12 Dose Regimen for latent TB infection (positive test)

Rifapentine and INH once a week for 12 weeks

No alcohol

Short Term Course of Treatment

CDC, 2012

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National and global decrease due to -

Direct Observed Therapy- DOT

Decrease in TB Cases

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Risk Assessment - CDC

Based on number of active-untreated TB patients transported in the past year

CDC, 2005

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Risk Assessment - TB

Low Risk Transported less than 3

TB patients

Medium Risk Transported more than 3

TB patients

CDC TB Guidelines, 2005, pg. 134

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2013 – 0

Department TB Risk Assessment

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QFT-T (In-tube) FDA approved – October 2007 Less time consuming to perform More accurate Cost effective - $33.67

New Version TB Blood Test

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Second blood test available for TB testing FDA approved Cost – approximately $45.59

T-Spot

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Currently there is a national shortage

Use the Blood test for new hires

TST Testing Solution

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“ TB is generally not spread by casual contact, but typically requires relatively prolonged contact in shared air space. The environment on long flights in commercial aircraft, particularly those of 8 or more hours in length, has been previously implicated in TB transmission, especially to passengers seated in close proximity”

Reminder -Transmission - Plane

Dr. Cetron, US Public Health, July,2007

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Flu Vaccine - Annual

“Direct patient care”

All healthcare workers

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CDC Flu Vaccine Program

Employers must offer

Employers must pay

Employees who decline - sign a declination form

CDC, February 24, 2006/- current NFPA 1581

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Percent = 41%

Department Flu Vaccine Participation - 2013

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Used to identify which new vaccines may be offered to increase compliance

Currently lowest rate of compliance is in EMS groups

Why Important

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New Influenza Vaccines

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Vaccine for 2013/14

A- California/H1N1 A- H3N1 B - Massachusetts

CDC, March. 28, 2013

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2 B Strains

A/ H1N1 A/H3N2 B/Yamagata B/Victoria

Quadrivalent Flu Mist or Injection

2013 MedImmune/CDC

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4 times higher antigen level

Over 65 Vaccine

New Flucelvax

No thimerosal or antibiotics Not egg based

Vaccine –

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Flublok No virus No eggs used in production No antibiotics/mercury DNA technology

New Flu Vaccine

FDA, 1/16/13

Employee with allergies

Accommodation with new vaccine

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Flushot.healthmap.org

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New antibody identified inhibits many strains of influenza CH65

Universal Vaccine?

Infectious Disease News, Aug. 24,2011

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Lower than any other HCW group in 3 studies

Flu Vaccine EMS Participation

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Work Restriction

Restrict ill workers from the workplace use sick time

protect co-workers protect patients

ENFORCEMENT

General Duty Clause – OSHA

Employee with a communicable disease poses a direct threat Can require reporting Maintain confidentiality

SHRM, 2013

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MDRO’s – Update Issues

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There is NO recommended follow up or treatment needed for exposure to MRSA, VRE

MRSA/VRE Exposure

CDC, 2010

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For C-diff and Norovirus a chlorine –based cleaning agent is needed

Handwashing post care of patient with C-diff is warm soap & water waterless agent not effective

Reminder

High mortality rate

Difficult to treat 15 cases in US in 2013

Contact Precautions

Not acquired by healthy people

CRE – New Resistant Organism

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Travel History & CRE

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Compliance Monitoring

Check for compliance

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What issues need to be addressed in your department

Compliance Monitoring

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Single patient use only HIV testing of patients in NY VA Hospital

Insulin Pens

CDC, January 5, 2010

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Need to be cleaned after each patient use Recently implicated in outbreak investigation

Glucose Monitors

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There is no disease that requires airing of a vehicle or putting a vehicle out of service

Focus high touch items! Non-critical items

Clean and go!

Cleaning Issues

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Only need a 1 min. contact time Very effective

Pre-Mixed Cleaning Wipes

CDC, 2010 COCA Conference/ CDC Guidelines for Disinfection and Sterilization, 2008

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Handwashing

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No antibacterials Use hand sanitizers ! No artificial nails !

Handwashing -

CDC

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Study from Robert Woods Johnson University Hospital 1,500 EMS providers surveyed 13% compliance

First responders EMS providers Paramedics

Handwash Study - EMS

11/12/13

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Soap & water – removes dirt from hands; associated with skin irritation after repeated use

Alcohol based solutions: active against gram- and gram + bacteria, but not against spores

Quaternary Ammonium Compounds: weak activity against gram- bacteria- not recommended in healthcare

Triclosan: broad range of activity but relatively non – effective against gram- bacteria- not recommended in healthcare

Hand Hygiene Agents

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OSHA Most Common BBP Citations - 2013

Not having a compliant Exposure Control Plan

No initial or annual training offered to staff and at no cost to staff

No annual update of Plan

Hepatitis B vaccine not offered within 10 days of hire and after education & training

No effective engineering controls

Not offering HBV vaccine to unprotected staff at risk and not offering post exposure evaluation & follow up

No employee input to selection of needlesafe devices

Not having declination forms

Not maintaining a sharps injury log

Not offering annual update training within 1 year of previous training

OSHA Jan.,2014

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Program Goal

Protect the patient

Protect the care provider

Accomplish in a cost effective manner whenever possible using evidence-based practice

Reminder -

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Questions & Answers

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