Key Issues in Occupational Health

By Elizabeth Srejic

Infection prevention remains a major challenge in healthcare, but adhering to stringent occupational safety protocols in the workplace can thwart the spread of disease among both healthcare workers (HCWs) and patients alike. As the 2014-15 flu season approaches, flu vaccination is an important practice.

HCWs are exposed to multiple occupational hazards, the most common being the spread of infection.(1) Continual exposure to disease-causing microbes along with exhaustion and stress increase the chances of HCWs becoming infected on the job – often with antibiotic-resistant superbugs.(2) And, what’s worse, a HCW colonized with active infectious disease during the incubation period may be unaware that they are sick and potentially transmitting these infections to vulnerable patients, fellow HCWs, visitors, and other stakeholders in the healthcare environment. As such, following strict guidelines developed by health and safety organizations is necessary to ensure well-being within the healthcare environment.

As influenza season approaches, HCWs must take additional precautions in order to remain healthy. Vaccination is currently the most effective means of preventing influenza infection yet, year after year, vaccination coverage among HCWs continues to be inadequate at no more than approximately 70 percent.(3-4) Developing programs and incentives or even mandating vaccination within healthcare institutions may be significant in increasing rates of influenza vaccine uptake among HCWs.

Prevention
Limiting infection in healthcare settings no longer focuses on “controlling” infection once it is established but preventing it before it occurs.(5) Established ways for HCWs to prevent the spread of infection include taking standard precautions in the workplace and becoming immunized with recommended vaccinations.

Pathogens can be spread through the air, from a point source such as contaminated equipment or environment, or via contaminated hands.(6) However, following standard precautions minimizes the risk of healthcare-associated infections (HAIs). These precautions include hand hygiene, personal protective equipment (PPE), and respiratory hygiene/cough etiquette.(7)

Hand Hygiene
Since infectious agents most often transmit with the hands, hand hygiene is the most basic tenet of infection prevention and the cornerstone of successful infection control programs.(8) The Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) and the Occupational Safety and Health Administration (OSHA) publish hand hygiene guidelines for HCWs to follow as well as recommendations for healthcare facilities to foster improved hand hygiene within the workplace.(9-11)

PPE
PPE, as defined by OSHA, is “specialized clothing or equipment, worn by an employee for protection against infectious materials.”(12) WHO recommends appropriate PPE to lower risks associated with specific procedures and suspected pathogens.(13) Appropriate PPE may include a surgical or procedural mask, respirator, gloves, long-sleeved gowns and eye protection such as goggles or face shields. While gloves are particularly important to prevent acquisition of bloodborne viral diseases such as hepatitis B, hepatitis C and HIV through inadvertent puncture with used needles or other sharp implements, masks and respirators are particularly important for aerosol-generating procedures that broadcast airborne agents responsible for acute respiratory infections.(14)

Respiratory Protection
HCWs are at particular risk of contracting and transmitting respiratory illnesses responsible for significant morbidity and mortality.(15-16) These diseases even include devastating large-scale outbreaks such as severe acute respiratory syndrome (SARS), avian influenza, swine flu (H1N1), and pneumonic plague.(17) Masks and respirators discourage inhalation of harmful airborne pathogens broadcast in the air during procedures that release airborne particles or droplets.(18) Using appropriate cough etiquette is another measure against respiratory transmission of disease recommended by health and safety organizations. According to guidelines released by WHO in 2014, HCWs should be trained in donning a particulate respirator as well as how to avoid contaminating it during use, and how to remove and dispose of it.(19) WHO also recommends that patients with known or suspected airborne infections be grouped in an isolated area or in several rooms on a nursing unit.(20)

Hand hygiene, PPE and respiratory hygiene should be followed by HCW as part of the routine infection control protocols set by their employing institutions, according to William Schaffner, MD, associate hospital epidemiologist and professor of preventive medicine at Vanderbilt University Medical Center.

“It’s very impressive that hospital acquired infections can be driven down to very low numbers if you do absolutely everything right,” he says. “An analogy is flying – airline pilots have literally flown thousands of times but they must go through a specific checklist each and every time they fly – no matter how boring it is or mundane it sounds – but occasionally in going through the checklist they find a critical error. Over the past 10 to 12 years, the philosophy has changed from controlling hospital acquired infections to actually trying to eliminate them -- changing from reduction to genuine goals of elimination. Frankly, old-timers, myself included, looked askance at that paradigm shift because we thought it was an unreasonable expectation to set goals that were going to result in our failure to meet them. It turns out, however, in a substantial number of cases sustained documentation practices have supported the near elimination -- the profound reduction – of infections even in intensive care units (ICUs). It has been shown that setting goals through an appropriate checklist of mandatory guidelines that need to be followed routinely each and every time and encourage HCWs to take responsibility – that these are our patients and we are responsible for their infections – and take pride in their elimination and then giving them positive feedback to show them that by doing rigorous surveillance and data feedback, the occurrence of infections can be virtually eliminated.”

Vaccination
Vaccination of HCWs is an efficient way to reduce the risk of acquiring vaccine-preventable diseases and transmitting them to vulnerable patients. CDC, the Advisory Committee on Immunization Practices (ACIP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend that all U.S. HCWs keep up to date on routine vaccinations get vaccinated annually against influenza.21 However, the continually inadequate immunization rates among HCWs is leading many health authorities to recommend mandatory vaccination programs for diseases that can be transmitted to susceptible patients such as measles, mumps, rubella, hepatitis B, pertussis, varicella and influenza.22 The issue of mandatory vaccination is controversial and continues to generate much discussion.

Compared to adults working in non-healthcare settings, HCWs are at significantly higher risk of flu, which can result in lost work days and transmission of the virus to patients.(22) Flu vaccines are the first line of defense against the flu, with a new vaccine being developed and distributed each year to reflect the virus’s changing genetic composition.(23) Flu vaccination has been shown to reduce the risk of flu and absenteeism in vaccinated HCWs and reduce the risk of respiratory illness and deaths in patients.(24)

However, annual influenza vaccination rates among HCWs are generally low despite recommendations from WHO and other public health authorities.(25) Studies show that these insufficient rates – which may arise from factors such as demographics, fears and concerns over vaccine safety and efficacy, perceptions of risk and personal vulnerability, past vaccination behaviors and experience with influenza illness, lack of time, worries of adverse effects or contracting flu from the vaccine, and conviction of not being at risk – underscore the importance of increasing awareness of influenza vaccination among HCWs.(26-27)

The CDC analyzed data from an Internet panel survey conducted from Oct. 30 through Nov. 15, 2013, among HCWs, and found that early season 2013-14 flu vaccination coverage among HCWs was 62.9 percent, similar to coverage by early season 2012-13 (63.4 percent), and was higher among HCWs whose employers required (88.8 percent) or recommended (70.1 percent) that they be vaccinated compared to those HCP who did not have an employer policy regarding flu vaccination (44.3 percent).(28)

Although mandatory vaccination policies are controversial, they are sometimes implemented by healthcare authorities with the reasoning that HCW immunity is a moral imperative for those working with patients.(29) If rates of voluntary uptake of vaccination by HCWs are suboptimal, some authorities believe patients’ welfare, public health and also the HCW’s own health interests should outweigh concerns about individual autonomy.(30)

“Official recommendations, and not personal attitudes and misconceptions, should guide occupational vaccination behavior,” says Schaffner. “When you’re a HCW it has now been decided that annual influenza immunization is a patient safety issue and from my point of view it is both a professional and ethical obligation. We vaccinate HCWs surely to protect themselves – we want them vertical, not horizontal, during influenza season so that they can deliver healthcare – but more importantly, we don’t want them transmitting the virus to their patients. HCWs argue that they’ll stay home if sick. But this argument is a fallacy for two reasons. Firstly, HCWs usually come in to work when sick anyway; that’s what we all do. Secondly, you start transmitting the virus 24 hours before you get sick which is something you can’t prevent unless you’re vaccinated. And another reason – and I’m chuckling here – is that some HCWs are needle-averse – you wouldn’t think so but they are – they just don’t like to get stuck – and my response to that is, ‘get over it.’ Another reason is some HCW believe that you can get sick from getting vaccinated against influenza which is, in short, malarkey.  And a reason that has largely been removed is ease of access. Currently most healthcare facilities have improved on past practices by making it convenient for their personnel to obtain vaccines. So all of these reasons taken together are not sufficient to justify a HCW to not be vaccinated.”

In every healthcare institution a well-designed long-term intervention program that includes a variety of coordinated managerial and organizational elements is required to improve vaccine coverage among HCWs, including ensuring convenient access to free flu vaccine at the workplace for the HCW. (31) These elements may include educating health care workers, providing free vaccines at convenient times, reminders and/or incentives, management or organizational changes, assignment of personnel dedicated to the intervention program, requiring active declination and mandatory immunization policies.(32)

“Short of mandates, healthcare facilities should use education, persuasion, ease of access, making individual units accountable, and following up with HCWs who haven’t been vaccinated to increase vaccine uptake,” says Schaffner. “Obviously, vaccines should be provided at no charge to the HCW. So all those good things further the concept that it is our culture here to protect the patient and we’re all in this together. We want to make our institution an influenza-free zone so that patients and all of our visitors can come here and know that at least in this place it’s very hard to pick up influenza. And both the clinical and the administrative leadership of the hospital must work in concert in a very demonstrable fashion – it’s not enough to send out a memo – get the PR people involved and show the senior administrator and chief of surgery all getting their vaccines each year. Sometimes they are sometimes not given sufficient resources to conduct a rigorous comprehensive institution-wise immunization program. Often they can’t do that with their regular personnel – they have to be able to hire temporary workers, they have to be given enough money to purchase sufficient vaccine, work closely with HR people and the administrative structure – the whole institution has to support the effort and sometimes the occupational health folks are not given the resources.”

Infectious diseases are a global hazard that puts every nation and every person at risk, and the source of past and future struggle to control both the causes and consequences, and HCWs are at heightened risk for exposure to serious, and sometimes deadly, diseases.(33) The best solution currently available is to follow guidelines and stay up-to-date with appropriate vaccines to protect oneself, patients, and family members.(34) After all, the health and well-being of HCWs is fundamental to the maintenance of healthcare services, especially during influenza season.(35)

“Influenza vaccine as we all know is not a perfect vaccine but it’s a good vaccine and the best vaccine that we have,” says Schaffner. “And to paraphrase the old French philosopher Voltaire, ‘waiting for perfection is the great enemy of the current good.’ We can do a lot of good by using a good – but not perfect – vaccine.”
Elizabeth Srejic is a Phoenix-based freelance writer.

References
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15. Dolan GP, Harris RC, Clarkson M, Sokal R, Morgan G, Mukaigawara M, Horiuchi H, Hale R, Stormont L, Béchard-Evans L, Chao YS, Eremin S, Martins S, Tam J, Peñalver J, Zanuzadana A, Nguyen-Van-Tam JS. Vaccination of healthcare workers to protect patients at increased risk of acute respiratory disease: summary of a systematic review. Influenza Other Respir Viruses. 2013 Sep;7 Suppl 2:93-6.
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19. Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Infections in Health Care. Geneva: World Health Organization; 2014. Available from: http://www.ncbi.nlm.nih.gov/books/NBK214359/
20. Ibid.
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23. Resistance Phenomenon in Microbes and Infectious Disease Vectors: Implications for Human Health and Strategies for Containment: Workshop Summary. Washington (DC): National Academies Press (US); 2003.
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25. Hollmeyer H, Hayden F, Mounts A, Buchholz U. Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza Other Respir Viruses. 2013 Jul;7(4):604-21.
26. Bellia C, Setbon M, Zylberman P, Flahault A. Healthcare worker compliance with seasonal and pandemic influenza vaccination. Influenza Other Respir Viruses. 2013 Sep;7 Suppl 2:97-104.
27. Nitsch-Osuch A1, Brydak LB. [Influenza vaccinations of health care personnel]. [Article in Polish] Med Pr. 2013;64(1):119-29.
28. Health Care Personnel and Flu Vaccination, Internet Panel Survey, United States, November 2013. (2013, December 12). Retrieved August 21, 2014, from http://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2013.htm
29. Galanakis E, Jansen A, Lopalco PL, Giesecke J. Ethics of mandatory vaccination for healthcare workers. Euro Surveill. 2013 Nov 7;18(45):20627.
30. Ibid.
31. Hollmeyer H, Hayden F, Mounts A, Buchholz U. Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza Other Respir Viruses. 2013 Jul;7(4):604-21.
32. Ibid.
33. Microbial Threats to Health: Emergence, Detection, and Response. Institute of Medicine (US) Committee on Emerging Microbial Threats to Health in the 21st Century; Smolinski MS, Hamburg MA, Lederberg J, editors. Washington (DC): National Academies Press (US); 2003.
34. Vaccine recommendations for adults. (2014, April 15). Retrieved August 20, 2014, from http://www.cdc.gov/vaccines/adults/rec-vac/hcw.html
35. Bellia C, Setbon M, Zylberman P, Flahault A. Healthcare worker compliance with seasonal and pandemic influenza vaccination. Influenza Other Respir Viruses. 2013 Sep;7 Suppl 2:97-104.