Transcript Slide 1

Infectious Diseases
and Nurses
Historical Insights Can Guide Future Action
Kate McPhaul, PhD, MPH, RN
University of Maryland Work and Health
Research Center
June 8, 2007
Massachusetts Nurses Association (MNA)
Objectives
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List two old and one new infectious disease known to be transmitted
to healthcare workers today
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Discuss the three classic public health interventions for control of
infectious disease transmission
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Contrast the occupational safety paradigm including hierarchy of
controls with classic pubic health protection and critique the
implications for protecting healthcare workers
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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….
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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
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Acinetobacter
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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
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Influenza
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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
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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
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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
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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)
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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
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Occupational Deaths from
Infectious Diseases: Internationally
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Hemorrhagic fevers
TB in Malawi,
Ethiopia and South
Africa
The TB Debate:
TB is good for Nurses
Early History
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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
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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
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More data shows risk of TB for
HCW’s
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Studies of nursing students in Europe and US
show high rates of tuberculin conversation (79100%)
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
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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
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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
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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 multidrug 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
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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’s
McDonald, 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
McDonald, 2004 Emerging Infectious Diseases
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
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SARS in Healthcare
Facilities
McDonald, 2004 Emerging Infectious Diseases
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Transmission appears to be
 Droplet
 Direct
contact
 Limited airborne
SARS in Healthcare
Facilities
McDonald, 2004 Emerging Infectious Diseases
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Important Considerations:
 Aerosol-generating
 “Super
procedures
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”
SARS Ethical Framework
Key Values
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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
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False perception that the industry is selfregulated (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
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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
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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
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Handwashing
Vaccination
Isolating infected
patients
Health and Safety Programs: A
Framework for Prevention
Management commitment and employee
involvement
 Worksite analysis
 Hazard control
 Training
 Evaluation
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H & S Program Elements
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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
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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?
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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?
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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)
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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
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 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
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What do we know?
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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)
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Require “universal precautions”
Required Hep B immunization
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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
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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
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 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.
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History of Regulations to Prevent
HCW Exposure to Airborne
Hazards
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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
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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
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[email protected]