Occupational Safety and Employee Health

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					                       Occupational Safety and Employee Health

       Occupational Safety and
          Employee Health

In Egypt, there are about 1 million people employed in the health care field. The
great majority of health care personnel (HCP) are employed in the formal (public
or private) health care sector; however, a significant number of people in the
community provide care in informal settings.
HCP are at particular risk for occupational exposure to blood-borne pathogens
including hepatitis B virus (HBV), hepatitis C virus (HCV), and human
immunodeficiency virus (HIV). A seroprevalence survey of 765 HCP in health
facilities in Cairo indicated an overall prevalence of antibody against HBV (anti-
HBs) of 28% before the availability of Hep B vaccine. 53 Another seroprevalent
survey for HCV infection revealed 7.7% of HCP tested had evidence of exposure
to HCV. 54 Exposures can occur through needlesticks or through cuts from other
sharp instruments that are contaminated with blood from an infected patient.
Important factors that may determine the overall risk for occupational
transmission of a blood-borne pathogen include:
         The nature and type of sharps injury (e.g., blood filled, hollow bore
          needle carries greater risk than contaminated scalpel blade);
         The prevalence of blood-borne infection in the patient population;
         Concentration of blood-borne pathogen circulating in the patient who is
          the source of the sharps injury (e.g. may be higher during acute or later
          stages of disease).
         The number of blood exposures to which a health care worker is
          exposed (e.g. new personnel or personnel in training may be less
          familiar with medical devices and experience greater frequency of
The frequency of needlestick injuries among HCP is high in Egypt. In surveys
conducted in Upper and Lower Egypt in 2001, approximately 30% of HCP
reported a needlestick injury within the past 3 months. There was an average of
5 needlestick injuries per year per HCP. The frequency of needlestick injuries
was similar across a broad category of HCP that included dental personnel,
laboratory workers, nurses and nursing assistants, housekeeping personnel,
sanitarians, physicians, technicians, and other allied health professionals.

                        Occupational Safety and Employee Health

Underreporting of needlestick injuries in studies published outside of Egypt is
estimated to be between 30-96 percent, suggesting that the actual rate of such
injuries is much higher. 55- 57 In general, HCP who have more intense contact with
patients or more opportunity for exposure to blood and body fluids (nurses,
physicians, dentists, laboratory technicians) have an increased risk of blood-
borne pathogen infection than do HCP who have only brief or casual contact with
patients. Studies of sharps injuries elsewhere indicate that nurses experience the
greatest proportion of these; however, others, such as environmental services
(housekeeping) personnel, also rank high (third behind nurses and physicians). 58
An effective occupational health program in the healthcare setting should help to
protect patients and HCP. It should:
          Ensure and maintain a health standard that is required for all
           employees before they are allowed to perform their assigned duties.
          Ensure that employees are not at risk of acquiring communicable
           diseases and are not potentially disseminating infectious agents to
           other hospital personnel or patients.

Any occupational health program should include:
 Pre-employment screening and employee health screening of staff.
   Training in personal health and safety precautions.
   Immunization of health care personnel.
   Management of occupational exposures.
   Monitoring of injuries and of infectious diseases among HCP.

Services Provided by the Occupational
Health Program
Pre-employment Screening and Employee Health
The primary aim of occupational health screening is to prevent disease in the
individual. A second function is to prevent transmission of infectious agents to
patients. It is important that all staff in the health care setting be screened by the
Occupational Health Department on their first day of employment.
The screening process includes assessment by:
          Completion of a health questionnaire by the employee that covers
           questions related to general health, pregnancy, past infectious
           diseases (e.g. chickenpox), and immunization status of all prior
           vaccinations such as measles/rubella.

                        Occupational Safety and Employee Health

           Determination of skin disorders such as eczema or a history of an
            underlying immunosuppressive disorder that might require a
            reassessment of the staff member’s work assignments.
           Offering of hepatitis B vaccine to HCP who have not yet been
            immunized and who are at occupational risk of exposure to blood or to
            body fluids as part of their regular duties.

The employee must be given assurance of the complete confidentiality of the
health questioning and of their occupational health record.

The health of all personnel should be supported by policies that address the
following elements of the program:
           Maintenance of records related to occupationally acquired infections,
            needlesticks and/or sharps injuries, and notification of the designated
            Occupational Health/IC personnel of work-related infections and/or
            sharps injuries for appropriate follow-up and prevention activities.
           Clinical and laboratory evaluation of HCP who report work related
            injuries or illnesses.
           Evaluation of personnel who report to work with communicable
            diseases for fitness to work.
           Clearance of employees to resume work assignments after reporting
            an episode of a communicable disease to their supervisor.
           Periodic review of key employee health indicators used as
            performance measures of the program, such as hepatitis B vaccination
            status, frequency of needlestick injuries, and work-related illnesses or

Infection control programs should have a system to monitor medical conditions
among staff and to provide guidance on work restrictions. The employee health
physician should evaluate health care personnel with selected communicable
diseases and should recommend work restrictions according to the following
guidelines: 59

                         Occupational Safety and Employee Health

  Table 14: Guidelines for work restrictions for HCP with infectious diseases
                         Relieve from
                                                     Partial work
 Disease problem         direct patient                                            Duration
                                                                            Until discharge from eye
   Conjunctivitis              Yes
                          Yes; include
     Diarrhea           restriction of food                                 Until symptoms resolve
                                                                              Until 24 hours after
  Group A Strep                Yes                                           adequate treatment is
                                                                            Until 7 days after onset
    Hepatitis A                Yes
  Hepatitis B or C                                Strict adherence to
     (chronic)                                   standard precautions

Herpes on the hands
                               Yes                                             Until lesions heal
 (herpetic whitlow)
                                                                             Until 7 days after the
  Measles/Rubella              Yes
                                                                                rash appears
                          Yes; include
Staphylococcal skin
                        restriction of food                                       Until treated
     infection               handlers
                                                                            Until receiving adequate
                                                                            therapy including proof
                               Yes                                          with 3 negative sputum
    pulmonary                                                                smears and resolved
                                                Personnel with a upper
                                                    respiratory tract
                                                  infection should not
                                                                            Until acute symptoms
                                                 take care of high risk
 Upper respiratory                                                            are resolved HCP
                               No               patients (i.e., intensive
  tract infection                                                           should stay away from
                                                   care unit, immuno-
                                                                              high-risk patients
                                                compromised patients,
                                                or patients with chronic
                                                     lung disease)
                                                                            Until all lesions dry and
  Varicella, active            Yes
                                                                            From the 10th through
                                                                              the 21st day after
                               Yes                                          exposure or if varicella
   postexposure                                                             occurs, until all lesions
                                                                                dry and crust
                      Relieve from contact
                                                  Strict adherence to
     HIV/Aids         with highly infectious
                                                 standard precautions

                        Occupational Safety and Employee Health

Training in Personal Health and Safety Precautions
All health care facilities should provide training to personnel who are at risk of
occupational exposure to blood and to infectious body fluids. This training should
include the use of standard precautions for personal protection.

All health care personnel should be trained in the following essential health
and safety precautions:
 Hand hygiene;
   Use of gloves and protective clothing during contact with patients’ blood or
    body fluids;
   Proper disposal (do not recap needles) of sharps and infectious waste;
   Reporting of sharps/needlestick injuries;
   Reporting of certain conditions such as jaundice, rash-like illness, skin
    infections that are vesicular or pustular, and illnesses that do not resolve
    within a designated period (fever more than 2 days, cough > 2 weeks,
    diarrheal disease).

Immunization of Health Care Personnel
Occupational health programs should maintain immunization records on all
employees. HCP may be exposed to infectious disease agents that may be
transmitted through the airborne route, through direct contact with patients and
through the blood-borne route by way of sharps/needlestick injuries.
For example:
   Airborne: Many airborne infectious agents are vaccine preventable (e.g.,
    rubella, chickenpox), and determining HCP immunization status for such
    infections is an essential element in the employee health program.

   Blood-borne: Hepatitis B is one of the three major blood-borne pathogens of
    concern to HCP that can be prevented by immunization. All medical, nursing,
    and ancillary staff who have potential for exposure to patient blood and body
    fluids as part of their assigned tasks should be offered hepatitis B vaccine. It
    is critically important to ensure that they are protected through immunization
    and as early as possible, prior to potential blood exposures or sharps injuries.

                         Occupational Safety and Employee Health

Table 15: Table of Vaccines that are recommended for HCP
      Vaccine          Indication      Vaccine/Route/Schedule Booster dose

                    All Health care    3 doses i.m.                Not
    Hepatitis B
                    workers            0, 1 month, 6 months;       recommended

                                                                   Every 10
                                                                   If exposed to
                    Persons without
                                       3 doses i.m.                a dirty wound
    Td (Tetanus)    a history or an
                                       0, 1-2 months, 6 months     and last
                    unknown history
                                                                   booster dose
                                                                   is > 5 years,
                                                                   give booster
      Rubella       women of child-    Single dose i.m. or s.c.
                    bearing age

Tips about hepatitis B vaccination of HCP:
 All Health care staff should be offered hepatitis B vaccine prior to beginning
   assigned tasks.
     Ensure that all students and trainees are vaccinated.
     There is no need to provide booster doses or to revaccinate HCP who have
      previously received hepatitis B vaccine.
     If a HCP has not completed the series, do not restart the series but do
      complete the series.*
     If the vaccine supply is limited, then offer the vaccine to HCP who are
      exposed to blood or who have potential for sharps or needlestick injuries as
      part of their routine duties.
     Do not perform serologic testing before vaccination.
     Perform serologic testing 2 months after the 3rd dose to ensure adequate
      immune response (HbsAb +ve). Non-responders should repeat the
      vaccination schedule again (3 doses).
     Provide hepatitis B vaccine according to a routine schedule as post-exposure
      prophylaxis for unvaccinated HCPs who receive needlestick injuries.
     Seroconversion (HbsAb +ve) occurs 1-2 months after the 3rd dose.

                       Occupational Safety and Employee Health

On Vaccine series interruption:
 If the series of HB vaccine is interrupted after the first dose, administer the
   second as soon as possible. The second and third dose should be separated
   by an interval of at least 2 months.
 If only the 3rd dose of vaccine is delayed, administer when convenient.

Management of Occupational Exposure
HCP in contact with patients may be exposed to infectious agents. Pregnant
HCP are not at greater risk that other HCP from acquiring infections from
patients, but if they do, the infection could affect their newborn.
Infection control programs should have written procedures to monitor and to
manage exposures to health care staff. Preventative measures include routine
precautions to prevent exposure and post-exposure prophylaxis in the event of
needlestick or other sharp injuries.

Management of needlestick injuries
1. Immediately following an exposure to blood or body fluids with visible blood:
      Wash needlesticks/sharps injury site and cuts with soap and water.
      Irrigate eyes with clean water, saline, or sterile irrigates. There is no
       scientific evidence that using antiseptics prevents infection or that by
       squeezing the injured site can remove contaminants.

2. Report to a designated person (e.g., supervisor).

3. Procedures should describe where the injured HCP should seek initial
assessment and counseling for follow-up testing and appropriate treatment.

4. The occupational safety program should provide post-exposure prophylaxis
based on the hepatitis B vaccination status of the HCP and on the serology
status of the source patient according the following table.

                        Occupational Safety and Employee Health

Table 16: HB Post Exposure Prophylaxis
                          Hepatitis B vaccination
     Source patient                                               Treatment
                              status of HCP
                         Not vaccinated                  Start vaccine immediately*
                         1 dose vaccine                  Complete series*
        HBsAg +
                         2 doses vaccine                 Complete series*
                         3 doses vaccine                 No treatment
                         Not vaccinated                  Vaccinate
    HBsAg negative
                         Vaccinated                      No treatment
                         Not vaccinated                  Vaccinate**
                         Vaccinated                      No treatment
    Anti-HCV positive    No vaccine for HCV              No treatment***
                         No vaccine for HIV              1.Four week course of 3
                                                         antiretroviral drug therapy
                                                         (e.g., zidovudine and
      HIV-positive                                       lamivudine) ***
                                                         2. Start treatment
                                                         immediately (within

*    If available, unvaccinated persons exposed to a HBsAg-positive patient
     should receive a dose of hepatitis B immune globulin (HBIG) within 24 hours
     of exposure in addition to hepatitis B vaccine.
** All HCPs exposed to a needlestick injury should be offered hepatitis B
*** Consult with an infection control specialist for further assessment.

    There is no vaccine against HIV and post exposure treatment is only
     recommended for exposures that may cause a greater risk for transmitting
    There is no vaccine against HCV and no treatment after an exposure that will
     prevent infection. Immune globulin is not recommended.

                        Occupational Safety and Employee Health

Tips on prevention of needlestick injuries in HCPs
   Educate HCP on the proper disposal of needles.
   Place needle without manipulation into MOHP-approved sharps container.
   Do not recap/bend/break used needles.
   Do not overfill sharps containers.
   Ensure availability of sharps containers in all settings where injections are

Monitoring Injuries among Health Care Personnel
One of the most important ways that infection control programs can help maintain
the safety of the facility environment is by reporting incidents and by monitoring
disease occurrences that have the potential for disseminating infections to staff
or to patients. All injuries or conditions that predispose HCP to injuries should be
reported to the infection control program including:
          Needlestick and sharps injuries;
          Conditions that exist in the facility that increase the risk of disease
           transmission such as a shortage of needles for injections (which may
           increase likelihood of reuse);
          Shortage of sharps boxes and hazardous waste containers;
          Conditions that exist in the facility that increase the risk of injury to the
           community at large such as improper disposal of waste.
          Based upon the analysis of these reports, the infection control team
           should implement appropriate measures to minimize the risk to the
           clinician, to fellow staff, to patients, to visitors, and to the community at

Sharps Injury Prevention Program
Prevention of occupational sharps injuries among personnel is an important
component of the Infection Control program. Personnel in Egypt are at risk of
occupational exposure to blood-borne pathogens during the course of their
duties. A Sharp Injury Prevention Program therefore should be developed that
balances availability of resources and devices with care activities that have been
identified as placing personnel at risk. For example, there is evidence that
inappropriate sharps disposal containers or the absence of puncture-resistant
sharps disposal containers place waste disposal personnel at risk of exposure. 60-
   An intervention to reduce this risk could include implementation of puncture-
resistant containers for disposal of contaminated sharps. One of these studies
identified use of cardboard shipping containers being converted to use as sharps
containers. This material is not puncture resistant. Instead alternatives such as
empty containers previously used for bleach could be thoroughly rinsed and

                        Occupational Safety and Employee Health

distributed to points throughout the facility where sharps are being generated.
The cap would need to be attached to the container to assure it could be sealed
once ¾ full.
Background on sharps injuries: Whenever a needle or other sharp device is
exposed, injuries can occur. Data from a recent study conducted in 98 health
care facilities in Egypt 100 show that approximately 36% of percutaneous injuries
occur due to two hand recapping. Behaviors associated with needlestick injuries
are presented in the figure below.

                          Fig. 20: Sharps Injuries in Egypt

The circumstances leading to a needlestick injury depend partly on the type and
design of the device used. For example, needle devices that must be taken apart
or manipulated after use (e.g., prefilled cartridge syringes and phlebotomy
needle) are an obvious hazard and have been associated with increased injury
rates. In addition, needles attached to a length of flexible tubing (e.g., winged-
steel needles and needles attached to IV tubing) are sometimes difficult to place
in sharps containers and thus present another injury hazard. Injuries involving
needles attached to IV tubing may occur when health care personnel insert or
withdraw a needle from an IV port or tries to temporarily remove the needlestick
hazard by inserting the needle into a drip chamber, IV port or bag, or even
bedding. In addition to risks related to device characteristics, needlestick injuries
have been related to certain work practices such as:

                        Occupational Safety and Employee Health

          Recapping.
          Transferring a body fluid between containers.
          Failing to properly dispose of used needles in puncture-resistant
           sharps containers.

Examples of Strategies for Health Care Facility Sharp
Injury Prevention Program

Some interventions that facilities should consider based on available
resources include:
      Eliminate the use of needles where safe and effective alternatives are
      Implement the use of devices with safety features and evaluate their use
       to determine which are most effective and acceptable.
      Sharps injuries can best be reduced when the use of improved
       engineering controls (modifications in devices needed for patient care that
       protect the sharp once used from potential contact with personnel) is
       incorporated into a comprehensive program involving personnel.
       Examples of engineering controls include a sheath that can slide over a
       needle once an injection is given, an angiocatheter which offers a
       retractable needle once the catheter is in the vein, and needleless
       connectors for IV systems.

Health care facilities should also consider implementation of the following
prevention program elements:
      Analyze needlestick and other sharps-related injuries in the facility to
       identify hazards and injury trends.
      Set priorities and strategies for prevention by examining local, national,
       and international information about risk factors for sharps injuries and
       successful intervention efforts.
      Ensure that health care personnel are properly trained in the safe use and
       disposal of needles. This is particularly important for less experienced or
       new personnel as the frequency of injuries tend to be higher when
       learning to use invasive devices.
      Modify work practices that pose a needlestick injury hazard to make them
      Promote safety awareness in the work environment.
      Establish procedures for and encourage the reporting and timely follow-up
       of all needlestick and other sharps-related injuries.

                         Occupational Safety and Employee Health

      Evaluate the effectiveness of prevention efforts and provide feedback on
       performance to personnel.

Moving the Sharp Injury Prevention Program from
Concept to Reality:

Depending on available resources the next tier of intervention after addressing
sharps disposal issues, etc., is to consider use of safer devices. The major
elements of a process for selecting and evaluating needle devices with safety
features are listed here briefly:
1. Form a multidisciplinary team that includes personnel to:
       (a) develop, implement, and evaluate a plan to reduce sharps injuries in
       the institution and
       (b) evaluate needle devices with safety features.

2. Identify priorities based on assessments of how sharps injuries are occurring
   and patterns of device use in the institution. Give the highest priority to needle
   devices with safety features that will have the greatest impact on preventing
   occupational infection.

3. When selecting a safer device, identify its intended scope of use in the health
   care facility and any special technique or design factors that will influence its
   safety, efficiency, and user acceptability. Seek published, Internet, or other
   sources of data on the safety and overall performance of the device.

4. Conduct a product evaluation, making sure that the participants represent the
   scope of eventual product users. The following steps will contribute to a
   successful product evaluation:
    Train health care personnel in the correct use of the new device.
    Establish clear criteria and measures to evaluate the device with regard to
       both personnel safety and patient care.
    Conduct onsite follow-up to obtain informal feedback, identify problems,
       and provide additional guidance.

Recommended reading:
 Centers for Disease Control & Prevention (CDC). Exposure To Blood - What Health-Care
  Workers Need to Know. 1999.
  Available at: http://www.cdc.gov/ncidod/hip/Blood/exp_blood.htm
 U.S. Public Health Service. Updated U.S. Public Health Service Guidelines for the
  Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for
  Postexposure Prophylaxis. MMWR 2001; 50(RR11). Available at:

Occupational Safety and Employee Health