Impacto epidemias respiratorias en trabajadores de la salud.

Respiratory Epidemic Impact on workers health

Dra. Laura Flores

1- Respiratory Epidemic

2- Review about Impacts, risk, use of PPE, Vaccination

3- Recommendations

Las infecciones respiratorias virales agudas se encuentran entre las enfermedades más comunes del ser humano y se estima que constituyen la mitad o más de todas las enfermedades agudas.

Acute viral infections respiratory are the most common diseases in human being and estimated that they are half of acute diseases.

En Estados Unidos, la incidencia de la infección respiratoria aguda (IRA) es de 3 a 5,6 casos por persona por año. Las cifras más elevadas se observan en niños menores de cinco años (6,1 a 8,3 casos por año). Los adultos presentan tres a cuatro casos por persona al año. La morbilidad por enfermedades respiratorias agudas justifica un 30 a50% de ausentismo laboral en los adultos y un 60 a 80% de las ausencias escolares en los niños .

USA, Incidence is 3 a 5,6 cases per person per year.Most common in children less tan 5 years (6,1 to 8,3)Adults have 3 to 4 cases per person per year.Morbidity justifies 30 to 50% to absenteeism and 60-80% of school absences in children.

Marco Soto-Barba.Epidemiologic features of deaths from influenza A (H1N1) 2009 in EsSalud insuredpopulation-2009An Fac med. 2009;70(4):235-40

Sesenta millones (60) millones de personas a nivel mundial, lo que equivale

a un 12 por ciento de la fuerza laboral.

Salud de los Trabajadores v.15 n.2 Maracay dic. 2007.

Human Resources In Health Care

Sixty (60) millions people worldwide.

Twelve (12%) of the workforce.

Fuente: OMS.Global Atlas of the Health Workforce. Perfil Mundial de los Trabajadores Sanitarios. 2006

How impacts these epidemics on health of the health workers

Inauguración Hospital de Clínicas-Año 2012.

Syndrome (SARS) in 2003 with attack rates of more than 50% in HCW. Taiwan: 63% of cases. Hong Kong, at 46% of cases. In Singapore, surveillance indicated that 76% of infections.

New epidemic of the 21st century resulted in tremendous economic and psychological impact with its high rates of mortality and nosocomial transmission

Reviews of nosocomial outbreaks estimate the HCW attack rate to be as high as 60%.

Many affected HCWs with subclinical or even full clinical syndromes continue to report to work while unwell and become a source of influenza transmission for their patients.

Mortality rates during nosocomial outbreaks varied according to the patient population and circulating strains. The highest mortality was seen in transplant or intensive care unit (ICU) settings, with mortality rates as high as 60%.

Influenza Epidemics

The socio-economic impact of nosocomial influenza is also tremendous because of prolonged hospitalisation, cost of diagnostic and therapeutic interventions and HCW absenteeism.

Registered annual sick-leave incidence for influenza-like illnesses (ILI) per 100,000 workers was 1,260.6 in 2007, 915.2 in 2008 and 2,377.2 in 2009.

Flu and other acute respiratory infections in the working population. the impact of influenza A (H1N1) epidemic].[Article in Spanish]. Albertí C, Orriols R, Manzanera R, Jardí J. Arch Bronconeumol. 2010 Dec;46(12):634-9

Economic impact of pandemic Influenza in Mexico, 2009

Attacak rate: 16,2 per 100.000 people

9.110 millions $

1% GDP

14% Prevalence in HCW

Evaluación preliminar del Impacto en Mexico de la Influenza A H1N1. CEPAL-OMS, 2010.

Risk Factors for Influenza among Health Care Workers during 2009 Pandemic, Toronto, Ontario, Canada. Emerg Infect Dis. 2013 April; 19(4): 606–615

Compared with other HCWs, those with symptomatic influenza infection were more likely to be present during aerosol-generating medical procedures >1× per week (38.5% vs. 12.7%; p = 0.02) and reported lower adherence to hand hygiene recommendations (77.5% vs. 95%; p = 0.02). After adjustment for changing risks for influenza infection over time, risk factors for influenza infection among HCWs were: contact with a family member with ARI in the previous week, performing or assisting with aerosol-generating medical procedures, and lower adherence to hand hygiene recommendations .

563 HCWs, 169 non-HCWs using PCR to test nasal swab samples collected during acute respiratory illness.

Pandemic influenza A(H1N1)pdm09: risk of infection in primary healthcare workers.

Hudson B, Toop L, Mangin D, Brunton C, Jennings L, Fletcher L. Br J Gen Pract. 2013 Jun;63(611):416-22.

1027 participants

Receipt of seasonal influenza vaccine (odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.2 to 3.3), recall of influenza (OR = 1.9, 95% CI = 1.3 to 2.8), and age ≤45 years (OR = 1.4, 95% CI = 1.0 to 1.9) were associated with seropositivity. Conclusion A total of 22% of primary care healthcare workers were seropositive. Younger participants, those who recalled having influenza, and those who had been vaccinated against seasonal influenza were more likely to be seropositive. Working in a dedicated influenza centre was not associated with an increased risk of seropositivity.

Department of Public Health and General Practice, University of Otago, Christchurch, New Zealand.

Impact of the 2009 influenza A (H1N1) pandemic on Canadian health care workers: a survey on vaccination, illness, absenteeism, and personal protective equipment.

Mitchell R, Ogunremi T, Astrakianakis G, Bryce E, Gervais R, Gravel D, Johnston L, Leduc S, Roth V, Taylor G, Vearncombe M, Weir C; Canadian Nosocomial Infection Surveillance Program.Am J Infect Control.2012 Sep;40(7):611-6.

Experience working in health care improves PPE use and HCWs in emergency departments should be targeted for interventions to improve PPE compliance. pH1N1 influenza vaccine coverage was high, but seasonal influenza vaccine coverage was low, and significant HCW illness and absenteeism were reported.

Influenza-like illness was reported by 236 (24%) HCWs, 170 of whom (72%) reported missing work.

Surveys were returned from 986 HCWs (80% nurses, 14% respiratory therapists, and 6% physicians).

Differences in the compliance with hospital infection control practices during the 2009 influenza H1N1 pandemic in three countries.

Chor JS, Pada SK, Stephenson I, Goggins WB, Tambyah PA, Medina M, Lee N, Leung TF, Ngai KL, Law SK, Rainer TH, Griffiths S, Chan PK J Hosp Infect.2012 Jun;81(2):98-103

A total of 2100 HCWs in the three countries participated. They reported high compliance (>80%) with infection control procedures regarded as standard for droplet-transmitted infections including wearing and changing gloves, and washing hands before and after patient contact. However, the reported use of masks with indirect or direct patient contact (surgical or N95 as required by their hospital) varied considerably (96.4% and 70.4% for Hong Kong; 82.3% and 87.7% for Singapore; 25.3% and 62.0% for the UK). Reported compliance was associated with job title, number of patient contacts and perceived severity of pandemics. There was no association between the uptake for seasonal or 2009 H1N1 vaccines and compliance.CONCLUSIONS:Compliance with infection control measures for pandemic influenza appears to vary widely depending on the setting.

Impact of severe acute respiratory syndrome care on the general health status of healthcare workers in taiwan.

Rate of transmission among HCWs at 63% of cases and in Hong Kong, at 46% of cases. In Singapore, surveillance indicated that 76% of infections were acquired in a healthcare facility and a similarly high rate of transmission was observed in Toronto.

Chen NH, Wang PC, Hsieh MJ, Huang CC, Kao KC, Chen YH, Tsai YH. Infect Control Hosp Epidemiol. 2007 Jan;28(1):75-9.

The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk.

Wu P, Fang Y, Guan Z, Fan B, Kong J, Yao Z, Liu X, Fuller CJ, Susser E, Lu J, Hoven CW. Can J Psychiatry. 2009 May;54(5):302-11.

About 10% of the respondents had experienced high levels of posttraumatic stress (PTS) symptoms since the SARS outbreak. Respondents who had been quarantined, or worked in high-risk locations such as SARS wards, or had friends or close relatives who contracted SARS, were 2 to 3 times more likely to have high PTS symptom levels, than those without these exposures. Respondents' perceptions of SARS-related risks were significantly positively associated with PTS symptom levels and partially mediated the effects of exposure.Altruistic acceptance of work-related risks was negatively related to PTS levels.

In 2006, randomly selected employees (n = 549) of a hospital in Beijing were surveyed concerning their exposure to the 2003 SARS outbreak, and the ways in which the outbreak had affected their mental health.

Which is the evidence for cough-generated aerosol?

N95 respirators or surgical masks to protect healthcare workers against respiratory infections: are we there yet?

Am J Respir Crit Care Med. 2013 May 1;187(9):904-5

Prior to 1990, respirators were infrequently used in healthcare delivery. If exposure to an infection was anticipated, the exposed healthcare worker would occasionally don a surgical mask, although this practice was infrequent as well.

U.S. practices began to change when the incidence of tuberculosis surged in the 1980s, during the early years of the AIDS epidemic, substantially increasing the number of hospitalized cases.

Dispersion and exposure to a cough-generated aerosol in a simulated medical examination room.

Lindsley WG, King WP,  Thewlis RE, Reynolds JS, Panday K, Cao G, Szalajda JVJ Occup Environ Hyg. 2012;9(12):681-90

Results show that cough-generated aerosol particles spread rapidly throughout the room, and that within 5 min, a worker anywhere in the room would be exposed to potentially hazardous aerosols. Aerosol exposure is highest with no personal protective equipment, followed by surgical masks, and the least exposure is seen with N95 FFRs. These differences are seen regardless of breathing rate and relative position of the coughing and breathing simulators. These results provide a better understanding of the exposure of workers to cough aerosols from patients and of the relative efficacy of different types of respiratory PPE, and they will assist investigators in providing research-based recommendations for effective respiratory protection strategies in health care settings.

National Institute for Occupational Safety and Health, Health Effects Laboratory Division. USA

Detection of infectious influenza virus in cough aerosols generated in a simulated patient examination room

Noti JD, Lindsley WG, Blachere FM, Cao G, Kashon ML, Thewlis RE, McMillen CM, King WP, Szalajda JV, Beezhold DH. Clin Infect Dis. 2012 Jun;54(11):1569-77.

National Institute for Occupational Safety and Health aerosol samplers collected size-fractionated aerosols for 60 minutes at the mouth of the breathing manikin, beside the mouth, and at 3 other locations in the room. Total recovered virus was quantitated by quantitative polymerase chain reaction and infectivity was determined by the viral plaque assay and an enhanced infectivity assay.

These results support a role for aerosol transmission and represent the first reported laboratory study of the efficacy of masks and respirators in blocking inhalation of influenza in aerosols. The results indicate that a poorly fitted respirator performs no better than a loosely fitting mask.

RESULTS:Infectious influenza was recovered in all aerosol fractions (5.0% in >4 μm aerodynamic diameter, 75.5% in 1-4 μm, and 19.5% in <1 μm; n = 5). Tightly sealing a mask to the face blocked entry of 94.5% of total virus and 94.8% of infectious virus (n = 3). A tightly sealed respirator blocked 99.8% of total virus and 99.6% of infectious virus (n = 3). A poorly fitted respirator blocked 64.5% of total virus and 66.5% of infectious virus (n = 3). A mask documented to be loosely fitting by a PortaCount fit tester, to simulate how masks are worn by healthcare workers, blocked entry of 68.5% of total virus and 56.6% of infectious virus (n = 2).

Health Effects Laboratory Division (HELD), National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), USA

MacIntyre CR, Wang Q, Seale H, Yang P, Shi W, Gao Z, Rahman B, Zhang Y, Wang X, Newall AT, Heywood A, Dwyer DE.Am J Respir Crit Care Med. 2013 May 1;187(9):960-6

A randomized clinical trial of three options for N95 respirators and medical masks in health workers.

A cluster randomized clinical trial of 1,669 hospital-based HCWs in Beijing, China in the winter of 2009-2010.

Participants were randomized to medical masks, N95 respirators, or targeted use of N95 respirators while doing high-risk procedures or barrier nursing. Outcomes included clinical respiratory illness (CRI) and laboratory-confirmed respiratory pathogens in symptomatic subjects.

Continuous use of N95 respirators was more efficacious against CRI than intermittent use of N95 or medical masks. Most policies for HCWs recommend use of medical masks alone or targeted N95 respirator use. Continuous use of N95s resulted in significantly lower rates of bacterial colonization, a novel finding that points to more research on the clinical significance of bacterial infection in symptomatic HCWs. This study provides further data to inform occupational policy options for HCWs.

A randomized clinical trial of three options for N95 respirators and medical masks in health workers.

MacIntyre CR, Wang Q, Seale H, Yang P, Shi W, Gao Z, Rahman B, Zhang Y, Wang X, Newall AT, Heywood A, Dwyer DE.Am J Respir Crit Care Med. 2013 May 1;187(9):960-6

Headaches and the N95 face-mask amongst healthcare providers.

RESULTS:In the survey, 212 (47 male, 165 female) healthcare workers of mean age 31 years (range, 21-58) participated.Of the 79 (37.3%) respondents who reported face-mask-associated headaches, 26 (32.9%) reported headache frequency exceeding six times per month. Six (7.6%) had taken sick leave from March 2003 to June 2004 (mean 2 days; range 1-4 days) and 47 (59.5%) required use of abortive analgesics because of headache. Four (2.1%) took preventive medications for headaches during this period. Multivariate logistic regression showed that pre-existing headaches [P = 0.041, OR = 1.97 (95% CI 1.03-3.77)] and continuous use of the N95 face-mask exceeding 4 h [P = 0.053, OR = 1.85 (95% CI 0.99-3.43)] were associated with development of headaches.

CONCLUSIONS:Healthcare providers may develop headaches following the use of the N95 face-mask. Shorter duration of face-mask wear may reduce the frequency and severity of these headaches.

Lim EC, Seet RC, Lee KH, Wilder-Smith EP, Chuah BY, Ong BK.Acta Neurol Scand. 2006 Mar;113(3):199-202.

Lessons learned: protection of healthcare workers from infectious disease risks

Weber DJ, Rutala WA, Schaffner W.Crit Care Med. 2010 Aug;38(8 Suppl):S306-14

MEASUREMENTS AND MAIN RESULTS:Key components of an effective infection control program include the following: 1) pre-exposure immunization with vaccines to prevent mumps, measles, rubella, varicella, pertussis, hepatitis B, and viral influenza; 2) adherence to standard precautions when providing patient care, especially the performance of hand hygiene before and after patient care; 3) rapid evaluation and initiation of appropriate isolation precautions for patients with potentially communicable diseases; 4) proper use of personal protective equipment such as masks,N95 respirators, eye protection, and gowns when caring for patients with potentially communicable diseases; and 5) evaluation of personnel with exposure to communicable diseases for receipt of postexposure prophylaxis.CONCLUSIONS:Risks of acquisition of infectious diseases by healthcare workers can be minimized by adherence to current infection control guidelines.

Vaccination

Annual influenza vaccination has been recommended by the Advisory Committee on Immunization Practices in the United States for high-risk persons and their contacts, including HCWs, since 1981. However, its use has not been universally accepted. Among HCWs, the immunisation rates range from 2% to 60%.

Some of the most commonly cited reasons for non-acceptance of the vaccine among HCWs were fear of side effects, avoidance of medications, previous reactions to vaccines, an impression of being at low risk of acquiring influenza and dislike of injections.

Factors influencing pandemic influenza vaccination of healthcare workers--a systematic review

Prematunge C, Corace K, McCarthy A, Nair RC, Pugsley R, Garber GVaccine. 2012 Jul 6;30(32):4733-43.

20 publications sampling HCW from different geographic regions are included in this review. H1N1 vaccine coverage was found to be variable (9-92%) across HCW populations, and self-reported vaccine status was the most frequently utilized predictor of pandemic vaccination. HCW were likely to accept the H1N1 vaccine if they perceived, (1) the H1N1 vaccine to be safe, (2) H1N1 vaccination to be effective in preventing infection to self and others (i.e. loved ones, co-workers and patients), and (3) H1N1 was a serious and severe infection. Positive cues to action, such as the access of scientific literature, trust in public health communications and messaging, and encouragement from loved ones, physicians and co-workers were also found to influence HCW H1N1 uptake. Previous seasonal influenza vaccination was found to be an important socio-demographic predictor of vaccine uptake. Factors unique to HCW pandemic vaccine behaviour are (1) lack of time and vaccine access related barriers to vaccination, (2) perceptions of novel and rapid pandemic vaccine formulation, and (3) the strong role of mass media on vaccine uptake.

Many of the factors that influenced HCW pandemic vaccination decisions have previously been reported in seasonal influenza vaccination literature, but some factors were unique to pandemic vaccination. Future influenza vaccine campaigns should emphasize the benefits of vaccination and highlight positive cues to vaccination, while addressing barriers to vaccine uptake in order to improve vaccine coverage among HCW populations. Since pandemic vaccination factors tend be similar among different HCW groups, successful pandemic vaccination strategies may be effective across numerous HCW populations in pandemic scenarios.

Comprehensive systematic review of healthcare workers' perceptions of risk and use of coping strategies towards emerging respiratory infectious diseases

Koh Y, Hegney DG, Drury V. Int J Evid Based Healthc. 2011 Dec;9(4):403-19.

It appears that healthcare workers' risk perceptions can influence their behaviour towards patients with emerging acute respiratory infectious diseases as well as their use of risk-mitigating strategies. Institutions need to ensure that appropriate infection control safeguards are in place to protect workers and their families. Institutions can also offer incentives to encourage healthcare workers to comply with the policies and procedures introduced to mitigate risk.

Infectious respiratory disease outbreaks and pregnancy: occupational health and safety concerns of Canadian nurses.

Phillips KP,,O'Sullivan TL, Dow D, Amaratunga CAPrehosp Disaster Med. 2011 Apr;26(2):114-21

This paper is a report of a qualitative study of emergency and critical care nurses' perceptions of occupational response and preparedness during infectious respiratory disease outbreaks including severe acute respiratory syndrome (SARS) and influenza.

RESULTS:Occupational health and safety issues anticipated by Canadian nurses for future infectious respiratory disease outbreaks were grouped into four major themes: (1) apprehension about occupational risks to pregnant nurses; (2) unknown pregnancy risks of anti-infective therapy/prophylaxis; (3) occupational risk communication for pregnant nurses; and (4) human resource strategies required for pregnant nurses during outbreaks. The reproductive risk perceptions voiced by Canadian nurses generally were consistent with reported case reports of pregnant women infected with SARS or emerging influenza strains. Nurses' fears of fertility risks posed by exposure to infectious agents or anti-infective therapy and prophylaxis are not well supported by the literature, with the former not biologically plausible and the latter lacking sufficient data.

CONCLUSIONS:Reproductive risk assessments should be performed for each infectious respiratory disease outbreak to provide female healthcare workers and in particular pregnant women with guidelines regarding infection control and use of anti-infective therapy and prophylaxis.

Recommendations

1- Hospital surveillance should be expanded to all respiratory diseases to facilitate early detection of nosocomial outbreaks, and this should also include surveillance of all HCW.

2- Active fever surveillance of all HCWS. HCWs are encouraged to report respiratory symptoms, HCWs are screened for influenza, and sent home if unwell, have attack rates <2%.

3- Strict adherence to infection control practices. Infection control practices include pre-exposure infection control training, droplet and contact precautions (masks, gowns, gloves and eye protection); these were shown to effectively reduce transmission in hospitals and in the community.

4- To increase substantially the acceptance of respiratory protective equipment and improve compliance rates, respirators should be modified to meet the specific needs of HCWs.

6- Carry a health directive stating that all HCWs who are exposed to micro-organisms for which a vaccine is available should be vaccinated.

5- More education amongst HCWs is urgently needed toraise the awareness that many of these diseases are vaccine preventable.Vaccines against influenza and pertussis have proven to be efficacious in reducing the incidence of disease outbreaks.

7- Preemployment health screenings should incorporate education on vaccine-preventable diseases amongst HCWs.

8- Training for all HCWs on infection control precautions should be revisited on a regular basis.

9- Institutions and government need to ensure that policies and procedures are communicated and adequate institutional measures (i.e. personal protective equipment; education and training; and personal support) are implemented to safeguard healthcare workers during and after pandemic outbreaks.

10- Future research needs to examine how perception of risk related to acute emerging respiratory infectious diseases.

11- Guideline about reproductive risk assessments and use of anti-infective therapy and prophylaxis.

12- Administrative, personal and engineering measures to control respiratory infection are effective and should be implemented in healthcare facilities.

13- Ultraviolet germicidal irradiation is underused at present, despite good evidence of safety and efficacy in elimination of airborne respiratory infectious agents including TB.

14- New line of research: Psychosocial Factor, Risk perception.

New challenges