Infectious Diseases and Nurses

Historical Insights Can Guide Future Action

Kate McPhaul, PhD, MPH, RNUniversity of Maryland Work and Health Research Center

June 8, 2007Massachusetts Nurses Association (MNA)

Objectives

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?

Even super heros can succumb to infectious diseases….

How many infectious agents may be transmitted and/or acquired by nurses in healthcare settings?

Infectious Diseases in Healthcare According to the CDC, the following may be transmitted and/or acquired in healthcare settings Acinetobacter 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 HIV/AIDS Influenza

MRSA - Methicillin-resistant Staphylococcus Aureus

Mumps Norovirus Parvovirus Poliovirus Pneumonia Rubella SARS S. pneumoniae (Drug resistant) Tuberculosis Varicella (Chickenpox) Viral Hemorrhagic Fever (Ebola) VISA - Vancomycin Intermediate

Staphylococcus aureus VRE - Vancomycin-resistant enterococci

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 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 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 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

The TB Debate: TB is good for Nurses

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

Tuberculosis

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

Tuberculosis

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 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

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 risk

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 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

•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 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 and HCW’sMcDonald, 2004 Emerging Infectious Diseases

Characteristics Toronto Taiwan

Total Cases 375 N/A

Probable 247 (66) 668

Suspected 128 (34) N/A

Deaths 44 (12) 72 (11)

Healthcare-related 271 (72) 370 (55)

Healthcare workers 164 (44) 120 (18)

SARS in Healthcare Facilities

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

McDonald, 2004 Emerging Infectious Diseases

SARS in Healthcare Facilities

Transmission appears to beDropletDirect contactLimited airborne

McDonald, 2004 Emerging Infectious Diseases

SARS in Healthcare Facilities

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”

McDonald, 2004 Emerging Infectious Diseases

SARS Ethical FrameworkKey Values Individual liberty Protection of the public Proportionality Reciprocity Transparency Privacy Protection from undue

stigmatization Duty to provide care Equity Solidarity

Lawrence Mass 1918

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

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

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

Handwashing Vaccination Isolating infected

patients

Health and Safety Programs: A Framework for Prevention

Management commitment and employee involvement

Worksite analysis Hazard control Training Evaluation

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

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

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

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?

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) 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?

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)

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

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

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 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

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.

Conclusions

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 mcphaul@son.umaryland.edu