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): 454-466 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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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
- 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
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Ahn YS Peer Reviewers Commentary 466