454_466_특집- 안연순

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1 Focused Issue of This Month Yeon-Soon Ahn, MD Department of Occupational Medicine, Dongguk University Ilsan Hospital * Corresponding author : Yeon-Soon Ahn E mail: ysahn@dongguk.ac.kr J Korean Med Assoc 2010; 53(6): Abstract The healthcare industry employs over one million workers in Korea and encompasses a usually broad spectrum of occupations and related exposures. There are so many biological exposures in healthcare settings, including blood-borne pathogens, HIV, hepatitis B and hepatitis C, air-borne pathogens such as tuberculosis, and a wide variety of respiratory viruses. The World Health Organization (WHO) estimates the global burden of disease (GBD) from occupational exposure to be 40% of Hepatitis B and C infections and 2.5% of the human Immunodeficiency virus (HIV) infections among Healthcare workers (HCWs). Some countries have used surveillance systems to monitor national trends and incidence rates of occupational infections among HCWs; identify newly emerging hazards for HCWs; assess the risk of occupational exposures and infections; and evaluate preventive measures including engineering controls, work practices, protective equipment, and post-exposure prophylaxis to prevent occupational infections. Infection control programs such as engineering control in medical facilities, immunization, post exposure prophylaxis, and use of personal protective equipment (PPE) have been widely introduced to reduce occupational infectious disease among HCWs. Thus some developed countries which have actively introduced infection control program have decreased incidences of occupational infectious diseases among HCWs. This study describes the epidemiologic characteristics of occupational infectious diseases among HCWs, the kinds of surveillance system to monitor infectious diseases among HCWs, and infection control measures that apply to healthcare settings. Keywords: Healthcare workers; Infectious diseases; Needle stick injury; Surveillance system; Hepatitis 454

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9 Ahn YS Table 1. Healthcare Personnel Vaccination Recommendations by U.S. Public Health Service (30) Vaccine Hepatitis B Influenza MMR Varicella (Chicken pox) Tetanus, diphtheria, pertussis Meningococcal Recommendations in brief Give 3-dose series (dose #1 now, #2 in 1 month, #3 approximately 5 months after #2). Give IM. Obtain anti-hbs serologic testing 1-2 months after dose #3. Give 1 dose of influenza vaccine annually. Give inactivated injectable influenza vaccine intramuscularly or live attenuated influenza vaccine (LAIV) intranasally. For healthcare personnel (HCP) younger than age 40 or 40 years without serologic evidence of immunity or prior vaccination, give 2 doses of MMR, 4 weeks apart. For HCP older than age 40 years. Give SC. For HCP who have no serologic proof of immunity, prior vaccination, or history of varicella disease, (chickenpox) give 2 doses of varicella vaccine, 4 weeks apart. Give SC. Give all HCP a Td booster dose every 10 years, following the completion of the primary 3-dose series. pertussis Give a 1-time dose of Tdap to all HCP younger than age 65 years with direct patient contact. Give IM. Give 1 dose to microbiologists who are routinely exposed to isolates of N. meningitidis. Table 2. Guideline for infection control in healthcare personnel (22) Disease requiring no patient contact - Infectious conjunctivitis - Acute diarrehea with symptoms* (i.e. fever, cramps, bloody stools) - Group A streptococcal disease - Hepatitis A* - Herpes simplex infection on the hands - Active measles infection - Post-exposure to measles - Active mumps - Post-exposure to mumps - Active pertussis - Active rubella - Post-exposure to rubella - Scabies - Staphylococcus aureus infection of skin - Group A streptococcal infection* - Active tuberculosis - Active varicella (chicken pox) - Post exposure to varicella (chicken pox or shingles) Disease requiring partial restrictions - Acute febrile viral respiratory infection - Diarrhea caused by enteroviral infection - Hepatitis B-e-antigen positive Work restriction - Until the discharge ceases - Until symptoms resolve and infection with salmonella is ruled out, or if caused by salmonella (non-typhoidal), until stool is free of salmonella on 2 consecutive cultures not less than 24 hours apart - Until 24 hours after adequate treatment begun - Until 7 days after onset of jaundice - Until lesions heal - Until 7 days after the rash appears - Susceptible personnel should remain out of the workplace from days 5~21 after exposure, and/or 7 days after rash appears - Until 9 days after onset of parotitis - Susceptible personnel should remain out of the workplace from days 12~26 after exposure, and/or 9 days after onset of parotitis - From beginning of catarrhal stage through the 3rd week after onset of paroxysms of until 7 days after start of effective therapy - Until 5 days after rash appears - Susceptible personnel should remain out of the workplace from days 7~21 after exposure, and/or 5 days after rash appears - Until treated - Until lesions have resolved - Until 24 hours after starting adequate therapy - Until proven non-infectious - Until all lesions dry and crust - Susceptible personnel should remain out of the workplace from days 10~21 after exposure, and/or until all lesion dry and crust Work restrictions - During community outbreaks of influenza&respiratory syncitial virus consider excluding symptomatic personnel from caring for high risk patients - Personnel should not take care of infants and newborns until symptoms resolve - Personnel should be excluded from invasive procedures until recommendations from an expert review panel are made based on the specific job tasks and 462

10 - Orofacial herpes simplex - Human immunodeficiency virus - Staphylococcus aureus respiratory infection - Active varicella zoster their risk for exposing patients - Personnel should not take care of high-risk patients until lesions heal - Personnel should be excluded from invasive procedures until recommendations from an expert review panel are made based on the specific job tasks and their risk for exposing patients - Personnel should not take care of high-risk patients until acute symptoms resolve - Personnel should keep lesions covered and should not take care of high-risk patients until lesions dry and crust Disease not requiring work restrictions - Cytomegalovirus infection - Mild diarrhea lasting less than 24 hours without other symptoms - Hepatitis B-acute or chronic antigenemia: personnel who do not perform exposure-prone procedures should follow standard precautions - Hepatitis C - Genital herpes simplex - Post-exposure pertussis (asymptomatic personnel) * Food handlers should be also remain out of work with these infections. 463

11 Ahn YS 11. World Health Organization (WHO). Global atlas of the Health Workforce, Wickstrom G. The changing working conditions in health care. Journal of UOEH 2004; 28: Korean Medical Association (KMA). Book of health statistics view&strboardid=report&intseq= Wilburn SQ, Eijkemans G. Preventing needlestick injuries among healthcare workers: a WHO-ICN collaboration. Int J Occup Environ Health 2004; 10: Occupational Safety and Health Resarch Institute(OSHRI). Evaluation of infectious disease in health care workers, focusing on management control of occupational safety and health system. OSHRI Publicaton No Incheon: OSHRI, 2006: Ahn YS, Kang SK, Kim KJ. Analysis of occupational diseases compensated with the industrial accident compensation insurance from 2001 to Korean J Occup Environ Med 2004; 16: McDiarmid MA, Kessler E. The health care worker. State of the art reviews. 1997; 12: West DJ. The risk of hepatitis B infection among health professionals in the United States: a review. Am J Med Sci 1984; 287: Centers for Disease Control and Prevention. Updated US Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR 2001; 50: Beltrami EM, Williams IT, Shapiro CN, Chamberland ME. Risk and management of blood-borne infections in health care workers. Clin Microbiol Rev 2000; 13: Alter MJ, Kruszon-Moran D, Nainan OV, McQuillan GM, Gao F, Moyer LA, Kaslow RA, Margolis HS. The prevalence of hepatitis C virus infection in the United States, 1988 through N Engl J Med 1999; 341: Centers for Disease Control and Prevention. Recommendations for follow-up of helathcare workers after occupational exposures to Hepatitis C virus. MMWR 1998; 47: National Institute for Occupational Health and Safety (NIOSH). Worker Health Chart Book, Cincinnati: NIOSH, 2004, Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboul D, Heptonstall J, Ippolito G, Lot F, McKibben PS, Bell DM. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med 1997; 337: Bell DM. Occupational risk of human immunodeficiency virus 464

12 infection in healthcare workers: an overview. Am J Med 1997; 102: Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G, O Sullivan MJ, VanDyke R, Bey M, Shearer W, Jacobson RL. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med 1994; 331: Balsley J. Efficacy of zidovudine in preventing HIV transmission from mother to infant. Am J Med 1997; 102: Russi MB, Howarth MV. Occupational medicine in the healthcareindustry. In: Rosenstock L, ed. Textbook of clinical occupational and environmental medicine. 2nd ed. Philadelphia: Elsevier Saunders. 2005; Occupational Health and Safety Administration (OSHA). Proposed standard for occupational exposure to tuberculosis. Fed Reg 1997; 62: Centers for Disease Control and Prevention. Guidelines for preventing the transmission of mycobacterium tuberculosis in healthcare facilities, MMWR 1994; 43: National Institute for Occupational Safety and Health (NIOSH). TB respiratory protection program in healthcare facilities: administrators guide. DHHS Publication NIOSH No Atlanta: NIOSH, Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deitchman SD, Guideline for infection control in health care personnel, Am J Infection Control 1998; 26: Occupational Safety and Health Resarch Institute (OSHRI). Development of needlestick injury surveillance system for health care personnel. OSHRI Publicaton No Incheon: OSHRI, 2009: International Healthcare Worker Safety Center (IHWSC). EPINet report: 2007 Percutaneous injury rates. Virginia: IHWSC, 2009; Jung SI, Lee CS, Park KH, Kim ES, Kim YJ, Kim GS, Lim DS, Moon JE, Min JJ, Bom HS, Jung MH, Chang YJ, Chae SL, Lee JH. Sero-epidemiology of hepatitis A virus infection among healthcare workers in Korean hospitals. J Hosp Infect 2009; 72: Ahn YS, Lim HS. Occupational Infectious Diseases among Korean Health CareWorkers Who were Compensated with Industrial AccidentCompensation Insurance from 1998 to Ind Health 2008; 46: National Institute for Occupational Health and Safety(NIOSH). Worker Health Chart Book, Cincinnati: NIOSH, 2004; Korea Ministry of Labor (KMOL). The Standard of Occupational Health. Seoul: KMOL, Korean Society of Infectious Diseases. Immunization guideline for healthcare workers sub01.html. 30. Immunization Action Coalition. Healthcare Personnel Vaccination Recommendations, catg.d/p2017.pdf 31. Ciesielski C, Marianos D, Ou CY, Dumbaugh R, Witte J, Berkelman R, Gooch B, Myers G, Luo CC, Schochetman G. Transmission of human immunodeficiency virus in a dental practice. Ann Intern Med 1992; 116: Ou CY, Ciesielski CA, Myers G, Bandea CI, Luo CC, Korber BT, Mullins JI, Schochetman G, Berkelman RL, Economou AN. Molecular epidemiology of HIV transmission in a dental practice. Science 1992; 256: Lot F, Séguier JC, Fégueux S, Astagneau P, Simon P, Aggoune M, van Amerongen P, Ruch M, Cheron M, Brücker G, Desenclos JC, Drucker J. Probable transmission of HIV from an orthopedic surgeon to a patient in France. Ann Intern Med 1999; 130: Bell DM, Shapiro CN, Gooch BF. Preventing HIV transmission to patients during invasive procedures. J Public Health Dent 1993; 53: Centers for Disease Control and Prevention. Recommendations for preventing transmission of HIV and Hepatitis B virus to during exposure-prone invasive procedures. MMWR 1991; 40:

13 Ahn YS Peer Reviewers Commentary 466

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°Ç°�°úÁúº´6-2È£ K O R E A C E N T E R S F O R D I S E A S E C O N T R O L & P R E V E N T I O N PHWR Vol. 6 No. 2 www.cdc.go.kr 2013 1 11 6 2 ISSN:2005-811X Flavivirus surveillance in mosquitoes collected from the quarantine