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Prevention Strategy of

Infectious Diseases for


Health Care Workers
Evy Yunihastuti, Samsuridjal Djauzi
Division of Allergy and Clinical Immunology
Adult Immunization Clinic
Internal Medicine Department Faculty of Medicine
University of Indonesia/Cipto Mangunkusumo Hospital
Background
Health care workers (HCWs) are at
occupational risk for a vast array of
infections that cause substantial illness
and occasional deaths
Families Patients

HCW
Other HCWs Patients
Who are HCWs?

HCW can be very broadly defined as:


Any employee or volunteer, working
in a healthcare setting
with potential exposure to patients
or infectious material
including :
body substances,
contaminated medical supplies or equipment,
contaminated environmental surfaces,
contaminated air

[1] Bolyard EA et al. Guideline for infection control in healthcare personnel. Hospital Infection
Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1998;19 (6):407-63
HCWs who reported possibly occupational HIV
exposure
42.5 42.16%
40
37.5
35 medical
32.5 32.37% students
30 physicians
27.5
25 nurses
22.5 lab workers
20 18.58% outreach
17.5
15
workers
12.5 cleaning
10 service
7.5
5 3.90%
2.5 2.00%
1.00%
0
profession

Yunihastuti, et al. Health Care Workers’ Behaviour during HIV Occupational


Exposure Reported to Pokdisus AIDS Jakarta 2004-2006
Occupationally acquired infections in HCWs
Bloodborne infections
Hepatitis B: needle stick injury depends
on e Ag status
HBeAg +: 20-40%
HBeAg - : 2%
Hepatitis C: needle stick injury
1.2% to 10%

Sepkowitz, K. A. Ann Intern Med 1996;125:826-834


Occupationally acquired infections in HCWs
Bloodborne infections
HIV:
Percutaneous exposure: 0.3%
Membranous exposure: 0.09%
Non intact skin < 0.1%
CMV
Ebola virus

Ippolito, et al. Clin Infect Dis 1999;28:365-83; MWR 2001;50(RR11):1-52; Sepkowitz, K. A.


Ann Intern Med 1996;125:826-834
Needle Stick Injury
300 injuries/100 beds/year (EPInet 1999)
21.5% during the procedure
78.5% after the procedure
Recapping
Moving the needle/sharp
knife

Yunihastuti, et al. Health Care Workers’ Behaviour during HIV Occupational Exposure Reported to Pokdisus AIDS
Jakarta 2004-2006
Occupationally acquired infections in HCWs
Airborne infections
Tuberculosis Influenza
Varicella Parvovirus B12
Mumps RSV infection
Measles Adenovirus
Rubella

Sepkowitz, K. A. Ann Intern Med 1996;125:826-834


Occupationally acquired infections in HCWs
Fecal-oral infections
Salmonellosis
Hepatitis A
Shigellosis
Cryptosporodiosis
H. pylori infection
Clostridium difficile infection

Sepkowitz, K. A. Ann Intern Med 1996;125:917-928


Prevention of infectious
diseases
Universal Precaution
Post Exposure Prophylaxis
Vaccination
Post
exposure
prophylaxis
Post exposure prophylaxis
HIV
Window of opportunity <36-72 hours
Reduced risk of transmission up to 81%
Standard regimen:
AZT + 3TC
28-30 days

MMWR2005 ;54(RR09):1-17
Post exposure prophylaxis
Hepatitis B
IVIg Hepatitis B
Followed by Hepatitis B vaccination
Varicella MMWR2005 ;54(RR09):1-17

Varicella vaccine
IVIg varicella (if indicated before vaccine)
MMWR 2007 / 56(RR04);1-40
Recommended PEP for HBV

1 Hepatitis B surface antigen


2 Hepatitis B immune globulin; dose 0.06 mL/kg intramuscularly
3 Hepatitis B vaccine
4 Responder is defined as a person with adequate levels of serum antibody to hepatitis B surface antigen (i.e., anti-HBs 10 mIU/mL);
inadequate response to vaccination defined as serum anti-HBs <10 mIU/mL
5 Antibody to hepatitis B surface antigen
MMWR 2001 / 50(RR11);1-42
Recommended Adult Immunization Schedule
Approved by Advisory Committee on Immunization Practices (ACIP), American
Academy of Family Physicians & American College of Obstetricians and Gynecologists

http://www.cdc.gov/nip/recs/adult-schedule.pdf
Factors that would influence unvaccinated high-risk
individuals to accept vaccination

If my doctor suggested it -
If I knew about its effectiveness -
If I received a reminder letter -
If I was provided with free vaccine -
If I saw information about vaccination -
If I heard information about vaccination -
If my pharmacist suggested it -
If I knew someone who has it yearly -
If I became at risk -
None -
Don’t know -
Other -
0 10 20 30 40 50 60 70
% respondents
Recommended Vaccines for HCWs
Diseases for which immunization is
strongly recommended:
Hepatitis B
Influenza
Mumps, Measles, Rubella
Varicella

MMWR 1997 / Vol. 46 / No. RR-18


HBV Vaccine among HCWs
HBV prevalence among HCWs 2-4fold higher
than general population
Higher prevalence:
Dentist
Physicians
Nurses
Dialysis workers
Laboratory workers
Cleaning service
5100 HCWs infected by HBV every year
200-300 HCWs died to HBV related disease/year

Sepkowitz, K. A. Ann Intern Med 1996;125:917-928; American liver foundation. http:/www.liverfoundation.org


HBV Vaccine among HCWs
Should be strongly recommended
before contact with patients
Prevaccination serologic screening is not
indicated
Adult immunization clinic experience
2006:
Enrolled 1099 HCWs, 7 already infected
Completed 3 vaccines<900
HBV Vaccine among HCWs
HCWs known their protective antibody
status after reported percutaneous
injury
after vaccination 18%
never been vaccinated 0.28%

Yunihastuti, et al. HIV Occupational Exposure Reported to Pokdisus AIDS Jakarta 2004-2005
Role of HCW in Influenza Disease
Transmission
■ Health care workers are frequently implicated
as the source of influenza transmission in
health care settings:
Employees continue to work while sick with
influenza
Unvaccinated workers who are infected but not
sick can still spread the virus
Up to ¼ of HCW contract influenza during the
winter

Source: APIC Member Initiative Protect your patients. Protect yourself. 2004
Influenza Transmission in
Health Care Facilities
 In 1957, an influenza outbreak infected 39% of
patients and incapacitated all but one physician on
the neurology ward of a VA hospital.

 In the 1990s, a nursing home outbreak led to


infection in 19% of residents.
 Thirty-four pneumonia cases: 19 residents hospitalized, two deaths
 Only 10% of health care workers were immunized

 In 2000, an outbreak in a NICU affected 19 infants, killing


one; HCP were the suspected cause of illness because
none of the mothers were infected.

Source: APIC Member Initiative Protect your patients. Protect yourself. 2004
HCWs offered vaccination versus HCWs offered no vaccination –
experimental study

Thomas RE. Cochrane Database of Systematic Reviews 2006, Issue 3.


HCWs offered vaccination versus HCWs offered no vaccination –
cohort study, Outcome Influenza Like Influenza

Thomas RE. Cochrane Database of Systematic Reviews 2006, Issue 3.


Factors Influencing HCWs
Decisions to Receive Vaccine
Vaccinees (%) Non-Vaccinees (%)
Don’t want to get sick 83 Concern re: side effects 36
Protect patients 62 Not in target group 15
Convenience 68 Disagree with recommend. 10
Free 58 Inconvenience 10
National recommend. 25 No high-risk patient contact 6
Physician recommend. 8 Dislike needles 5
Forgot 5

Odds ratio for very strongly recommending to elderly if HCW


vaccinated = 1.91
Nichol KL. ICHE 1997; 18: 189.
Recommended Vaccines for HCWs
Diseases for which immunization is or
may be indicated:
Hepatitis A
Typhoid fever
Esp. lab workers work on feces sample
Meningococcal disease

MMWR 1997 / Vol. 46 / No. RR-18


Recommended Vaccines for HCWs
Other vaccine-preventable disease:
Tetanus
Diphteria
Pneumococcal infection

MMWR 1997 / Vol. 46 / No. RR-18


Vaccines for Pregnant HCWs
Safe Contraindicated
Influenza MMR
Hepatitis B Varicella
Difteri BCG
tetanus

Sur DK. Am Fam Physician 2003;68:E299-309


Obstacles in vaccination for HCWs

1. Less information
2. Unavailable Indonesian guidelines
3. Limited services
4. Limited financial support
5. Expensive
“First do no harm”
Adult Immunization Clinic
Division of Allergy and Immunology Department of
Internal Medicine Cipto Mangunkusumo Hospital
4th floor, URM building, phone: 021-3904546