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HEALTHCARE WORKERS: PROTECTING THOSE WHO PROTECT OUR HEALTH
Volume 18 (6) * June 1997 * Editorial
(full text)
http://www.slackinc.com/general/iche/stor0697/edit.htm
Jane Lipscomb, RN, PhD; Linda
Rosenstock, MD, MPH
The nation's healthcare system is in a
transition of potentially historic proportions, driven by the need for
cost-effectiveness under pressures of cost containment and competition,
but also made possible by scientific and technological breakthroughs.1
This transition presents new challenges and opportunities for protecting
the health and safety of our nation's healthcare workers. Toward the
goal of maximizing future opportunities for the primary prevention of
illnesses and injuries among healthcare workers, a brief review of
history in relationship to this work force should assist us in
identifying successful models for future action.
In the United States, the practice of
occupational health dates back to the late 1800s. National professional
societies in occupational medicine and nursing were established in 1916
and 1942, respectively. The hospital and healthcare environments did not
become a focus of study and prevention strategies until much later. In
fact, as recently as the 1950s, there still was no consensus regarding
the occupational risk of tuberculosis (TB) exposure. It has been
suggested that a number of factors drove this lack of consensus,
including the fear that young women would avoid nursing if they knew the
risks involved and that liability might surface. It was not until TB
declined significantly in the general public but remained elevated in
the medical profession that TB was recognized fully as an occupational
hazard.2
Professional associations and the
federal government began to address healthcare-worker health and safety
in subsequent years. In 1958, the American Medical Association (AMA) and
American Hospital Association (AHA) issued a joint statement in support
of worker health programs in hospitals; the Centers for Disease Control
and Prevention (CDC)'s National Institute for Occupational Safety and
Health (NIOSH) published criteria for effective hospital occupational
health programs in 1977; and, in 1982, the CDC published the "Guideline
for Infection Control in Hospital Personnel." This last document focused
on infections transmitted between patient-care personnel and patients,
not exclusively on healthcare workers' risk of infectious diseases. The
CDC guidelines for blood and body fluid precautions (1982) and universal
precautions (1987) were published to provide guidance to healthcare
workers. In 1987, the Departments of Labor and Health and Human Services
issued a Joint Advisory Notice entitled "Protection Against Occupational
Exposure to HBV and HIV." In 1988, NIOSH published comprehensive
guidelines for protecting the safety and health of healthcare workers.
In late 1991, the Occupational Safety and Health Administration (OSHA)
promulgated the Bloodborne Pathogens Standard, which required the
observance of Universal Precautions, the offering by the employer of
hepatitis B (HBV) vaccine, and the implementation of engineering
controls to protect workers from the health hazards related to
bloodborne pathogens. OSHA is scheduled to publish a proposed TB
standard in the Federal Register in mid-1997.
In spite of impressive activities in
the 1980s and 1990s, healthcare-worker protection has lagged behind that
afforded other workers with similarly increased risks. Possible
explanations for the delay in focusing on occupational hazards faced by
healthcare workers are many and likely include the focus of curative
rather than preventive medicine in the hospital environment; the focus
on patient health over worker health; and the focus within occupational
health on traditionally male occupations and hazards rather than female
workers. Hopefully, recognition of historical barriers to prevention
will inform future prevention strategies.
NIOSH, the only federal research agency
mandated to conduct occupational health and safety research, is
concerned with physical, chemical, psychosocial, and biologic hazards
facing healthcare workers in a variety of settings. Within this broad
context, it is easy to point to a number of research and prevention
successes, such as the identification and control of exposures to waste
anesthetic gases, ethylene oxide, and cytotoxic drugs. In the area of
infectious disease over the past several years, the combination of
healthcare-worker immunization, the use of safer needle devices, and the
early recognition and control of exposure to infectious patients have
contributed to reduced transmission of occupationally related HBV, TB,
and human immunodeficiency virus (HIV). Excellent reviews of the scope
of the problem and progress to date in controlling occupationally
acquired infectious diseases have been published recently.3,4 Much work,
however, remains to be done. Historical hazards such as back injuries
and exposure to a number of infectious diseases continue to pose a
substantial risk to the approximately 6 million persons who work in more
than 6,000 US hospitals and the nearly 1 million workers providing care
in a variety of community health settings, including patient homes,
where available control measures are more limited than in the hospital
setting. Female nursing aides and licensed practical nurses are
approximately 2˝ times more likely to experience a work-related low-back
disorder than all other female workers. Workplace assaults, work
organization issues such as adequate staffing, poor indoor air quality,
and exposure to newly identified infectious agents and drug-resistant
strains of long-recognized infections such as TB all pose new challenges
to occupational health and infection control professionals, healthcare
workers, and the institutions in which they work.
Healthcare workers continue to be at
elevated risk of occupational exposure to a number of airborne and
bloodborne infectious diseases relative to the general population. For
example, urban healthcare workers have a rate of seropositivity on
tuberculin skin tests that is approximately eight times that of the US
population.5 Of greater concern is the experience of healthcare workers
in hospital-based outbreaks of multidrug-resistant TB, with 17
documented cases among workers. Similarly, in prevaccine surveys, the
annual incidence of HBV among physicians and dentists was 5 to 10 times
higher than among blood donors.6 The CDC estimated that, in 1994, there
were approximately 1,100 occupationally acquired HBV infections in
healthcare workers in the United States, causing 250 to 1,000 cases of
clinical acute hepatitis and 50 hospitalizations (CDC, unpublished
data). In spite of these sobering statistics, HBV vaccination of
healthcare workers remains incomplete. Although the incidence of
occupational hepatitis C virus infection among healthcare workers is
unknown, "occupational exposure" accounts for approximately 2% of all
cases of hepatitis C.7 Dentists, in particular oral surgeons, have been
found to have a significantly higher seropositivity rate than blood
donors.8
Any discussion of the recent history of
infection control in the healthcare setting would be incomplete without
addressing the occupational risk of HIV infection. As of December 1996,
the CDC reported 163 US healthcare workers with documented or possible
occupational transmission of HIV as a consequence of the approximately
800,000 needlestick injuries that occur each year.
The first case of occupational
transmission of HIV infection to a healthcare worker, documented in
1984, caused an epidemic of fear among healthcare workers and their
families and, as a consequence, great advances in occupational health
and infection control practices. The final passage of OSHA's Bloodborne
Pathogens Standard in 1991 has provided important protection for
healthcare workers at risk of HIV, HBV, and other bloodborne infections.
In addition, the CDC recently advised that chemoprophylaxis should be
recommended to exposed workers after those occupational exposures
associated with the highest risk for HIV transmission.
However, for all of the successes
associated with the Bloodborne Pathogens Standard and related guidance
from the CDC and professional associations, a very significant health
problem has emerged that can be attributed in part to the increased use
of examination and surgical gloves. An epidemic of latex allergy is now
plaguing healthcare and other exposed workers. The prevalence of latex
allergy among healthcare workers is between 7% and 10%, with atopic
workers at even greater risk.9,10 Manifestations of this exposure range
from type IV delayed hypersensitivity to rubber additives, which
presents as contact dermatitis, to type I immunologic responses to
residual proteins in gloves and other medical devices. Later in 1997,
NIOSH will release an "Alert" document requesting assistance in
preventing allergic reactions to natural rubber latex in the workplace
and recommending measures to control exposure.
Nonetheless, primary prevention has
been effective and needs to be the focus of future actions. Substitution
of a nonhazardous substance for a hazardous one, isolation of workers
from a hazardous exposure, engineering controls such as local and
dilution ventilation, administrative controls including work practices,
and personal protective equipment, referred to as the "hierarchy of
controls," should be the approach to controlling all hazards facing
healthcare workers. For example, recent reports have demonstrated the
success of safety devices for preventing percutaneous injuries during
phlebotomy and surgical suturing.11,12 Similar innovations are needed in
the area of administrative controls. Ongoing work examining compliance
with safety work practices among healthcare workers has identified
several psychosocial and organizational factors that are important
correlates of these practices, namely risk-taking personality profiles,
perceived poor safety climate at the workplace, and perceived conflict
of interest between providing optimal patient care and protecting
oneself from exposure.13 Another type of administrative control,
adequate staffing and appropriate staff mix to meet the increasing
acuity of hospitalized patients, has been examined for its relationship
with work-related injuries among nurses in a recent Institute of
Medicine study.1 Additional research is sorely needed to elucidate the
relationship between these work organization factors and workplace
injury and illness.
NIOSH is addressing the challenges
facing healthcare workers and workers in general through the National
Occupational Research Agenda (NORA) developed to guide occupational
safety and health research in the next decade. NIOSH, in collaboration
with 500 organizations and individuals (including infection control
professionals and front-line healthcare workers) who provided input into
the agenda, is now in the process of directing and stimulating research
in the 21 identified NORA priority areas. A number of these priorities
will have a substantial impact on healthcare workers, including
infectious diseases, allergic and irritant dermatitis, asthma and
chronic obstructive pulmonary disease, low-back disorders, indoor
exposures, and organization of work. In addition, each of the eight
research priorities characterized as research tools and approaches has
the potential to improve research into healthcare-worker health and
safety. Teams of individuals representing many perspectives and
disciplines are working together to address the specific research needs
of each of these areas. We believe that this activity will provide a
forum for enhancing work between occupational health and infection
control professionals.
Healthcare work is a critical and
rewarding occupation. It is incumbent on all of us to apply our various
perspectives and expertise to assure our fellow healthcare workers that
their health and safety is of primary importance. To deliver on this
assurance, we must work more closely than we have in the past, with a
greater emphasis on primary prevention strategies well known in the
field of public health.
REFERENCES
1.Institute of Medicine. Nursing Staff
in Hospitals and Nursing Homes—Is It Adequate? Washington, DC: National
Academy Press; 1996. 2.Sepkowitz KA. Tuberculosis and healthcare
workers: an historical perspective. Ann Intern Med 1994;120:71-79.
3.Sepkowitz KA. Occupationally acquired infections in healthcare
workers, Part I. Ann Intern Med 1996;125:826-834. 4.Sepkowitz KA.
Occupationally acquired infections in healthcare workers, Part II. Ann
Intern Med 1996;125:917-928. 5.Sepkowitz KA. AIDS, tuberculosis, and the
healthcare worker. Clin Infect Dis 1995;20:232-242. 6.Gibas A, Blewett
DR, Schoenfeld DA, Dienstag JL. Prevalence and incidence of viral
hepatitis in health workers in the prehepatitis B vaccination era. Am J
Epidemiol 1992;136:603-610. 7.Alter MJ. The detection, transmission, and
outcome of hepatitis C virus infection. Infect Agents Dis
1993;2:155-166. 8.Klein RS, Freeman K, Taylor PE, Stevens CE.
Occupational risk for hepatitis C virus infection among New York City
dentists. Lancet 1991;338:1539-1542. 9.Turjanmas K. Incidence of
immediate allergy to latex gloves in hospital personnel. Contact
Dermatitis 1987;17:270-275. 10.Arellano R, Bradley J, Sussman G.
Prevalence of latex sensitization among hospital physicians
occupationally exposed to latex gloves. Anesthesiology 1992;77:905-908.
11.Centers for Disease Control and Prevention. Evaluation of safety
devices for preventing percutaneous injuries among health-care workers
during phlebotomy procedures—Minneapolis-St. Paul, New York City, and
San Francisco, 1993-1995. MMWR 1997;46:21-25. 12.Centers for Disease
Control and Prevention. Evaluation of blunt suture needles in preventing
percutaneous injuries among health-care workers during gynecologic
surgical procedures—New York City, March 1993-June 1994. MMWR
1997;46:25-29. 13.Gershon R. Facilitator report: bloodborne pathogens
exposure among healthcare workers. Am J Ind Med 1996;29:418-420.
AUTHORS
From the National Institute for
Occupational Safety and Health, Washington, District of Columbia.
The authors would like to acknowledge
Dr. Linda Martin and Dr. David Bell for their technical assistance and
thoughtful review of this editorial.
Address reprint requests to Linda
Rosenstock, MD, MPH, Director, NIOSH, Hubert H. Humphrey Bldg, Room
715H, 200 Independence Ave SW, Washington, DC 20201.
97-ED-037. Lipscomb J, Rosenstock L.
Healthcare workers: protecting those who protect our health. Infect
Control Hosp Epidemiol 1997;18:397-399.
Copyright 1997, SLACK Incorporated.
Revised 6 June 1997.
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