New CDC infection control guidelines broaden scope of whom to cover
Expands definition of health care personnel and facilities
New draft guidelines released by the U.S. Centers for Disease Control and Prevention provide sweeping recommendations for reducing transmission of infections from patients to health care workers, as well as from HCWs to patients, including immunizations, isolation precautions, exposure management, and work restrictions.1
The guidelines, which heavily emphasize the role of the personnel health service (see related story, p. 137), update and replace previous CDC recommendations published in 1983.2 The document includes a wealth of information that has emerged since then on such infection control issues as tuberculosis screening and prevention, bloodborne pathogens, and vaccination recommendations. Also, because latex gloves are frequently used to protect against infection transmission, the guidelines address issues relating to latex reactions among HCWs.
New data make revisions necessary
Two years in preparation, the draft guidelines are part of a series of infection control documents being revised by the CDC and the Hospital Infection Control Practices Advisory Committee (HICPAC).
"We’re systematically revising all the guidelines we have because scientific data become old, and we want to incorporate new information to keep current," says Elizabeth Bolyard, RN, MPH, CIC, an epidemiologist in the CDC’s hospital infections program. "This should have been done at least five years ago."
The definitions of "health care personnel" and "health care facility" have been changed in the new document, Bolyard points out. Because health care increasingly is being provided outside of hospitals in facilities such as outpatient centers, nursing homes, and patients’ homes, hospital-based employees and those who provide health care outside of hospitals could acquire infections from or transmit them to patients or other employees, household members, or other community contacts.
The CDC also now considers health care personnel to include "all paid and unpaid persons working in health care settings who have the potential for exposure to infectious materials. . . . These personnel may include . . . emergency medical service personnel, dental personnel, laboratory personnel, mortuary personnel, nurses, nursing assistants, physicians, technicians, students and trainees, contractual staff not employed by the health care facility, and persons not directly involved in patient care (e.g., clerical, dietary, housekeeping, maintenance, and volunteer personnel) but potentially exposed to infectious agents."
Expanded definition causes concern
Generally, HCWs inside or outside of hospitals who have contact with patients and body fluids have a higher risk of acquiring or transmitting infections than do other HCWs who have only "brief casual contact" with patients, the document states.
The expanded definition of health care personnel to include students and trainees could be a problem for hospitals, says Martha DeCastro, RN, MS, CIC, director of infection control and employee health services at Tallahassee (FL) Memorial Regional Medical Center and a member of the guidelines committee of the Association for Professionals in Infection Control and Epidemiology (APIC) in Washington, DC.
"Overall, it’s an excellent document. We’ve been waiting for the update and it’s very comprehensive, but our most significant concern is with the definition of health care personnel because it includes everyone who works in our facility, including trainees or students to whom we provide the opportunity to get clinical experience. According to this definition, if we are required by some regulatory agency that decides to mandate this recommendation from the CDC to treat trainees as we treat employees, it would be cost-prohibitive for us to have them here," she says.
DeCastro says Tallahassee Memorial provides some services to students, but not to the extent outlined in the draft guidelines, which would include extensive record-keeping, infection control education and training, immunizations, and illness reporting.
"We would not be able to afford to do this," she says. "Our suggestion to the CDC is that they apply this recommendation to educational institutions as well as to health care employers, and require that they make sure their students have the same follow-up and services available to them."
Hospital Employee Health asked Bolyard about this aspect of the guidelines. "It was not our intent to make hospitals responsible for students in that way," she says. "The schools should really be responsible, but if [hospitals] have a student become exposed, they need to let the school know," she says. "I’ll have to reword that [on the final guideline]."
A final version of the guidelines is due out in spring 1998. Meanwhile, the draft’s comprehensiveness makes full coverage here impossible, but synopses of several pertinent sections follow (please consult the full document for details on preventing and managing specific infections):
• Bloodborne pathogens.
Overall: Use of standard precautions (which incorporate universal precautions), including appropriate handwashing and barrier precautions, as well as techniques and devices that reduce percutaneous injury, will reduce transmission risks.
While the risk to patients from HCWs infected with HIV and HBV "has been the subject of much concern and debate," no data indicate that infected workers who do not perform invasive procedures pose a risk to patients. The CDC currently is reviewing relevant data regarding HCW-to-patient transmission of bloodborne pathogens to determine the extent to which infected HCWs who perform certain types of invasive procedures pose a risk to patients.
Hepatitis B: The risk of acquiring occupational infection depends on the nature and frequency of exposure to blood or body fluids containing blood. Vaccination is strongly recommended for personnel exposed to blood or body fluids. Prevaccination serologic screening for susceptibility is not indicated for persons being vaccinated unless the health care organization considers it to be cost-effective. Postvaccination screening for HBsAg is advised for workers at ongoing risk of blood exposure.
Workers who do not respond to or do not complete the primary vaccination series should be revaccinated with a second three-dose vaccine series or be evaluated to determine if they are HBsAg-positive. Revaccinated persons should be tested for anti-HBs after the second vaccine series. If they do not respond, no further vaccinations should be given, and they should be evaluated for HBsAg.
Hepatitis C: Serologic assays to detect antibody are available but unreliable. Postexposure prophylaxis with immune globulin does not appear to be effective and is not recommended. Health care institutions should consider implementing recommended postexposure follow-up.3
Human immunodeficiency virus: The average risk for infection from percutaneous exposure to HIV-infected blood is about 0.3%. Factors determining HCWs’ risk of HIV infection include prevalence of infection among patients, risk of infection transmission after exposure, and frequency and nature of exposures. In 1996, the CDC published provisional recommendations for postexposure chemoprophylaxis,4 and will publish updated recommendations as necessary.
• Pregnant personnel.
Occupationally acquired infections are of special concern to female HCWs of childbearing age, but in general, pregnant health care personnel do not have an increased risk of acquiring infections in the workplace. Risks and prevention methods are discussed in various sections of the guidelines. (For a summary, see tables on p. 135 and above.)
Female personnel of childbearing age are strongly encouraged to receive immunizations before pregnancy.
Some infections, such as varicella, may be more severe during pregnancy. Transplacental infection with viruses such as parvovirus, varicella, and rubella has been associated with abortion, congenital anomaly, and mental retardation. Other diseases in which infectious agents can be transmitted to the fetus include cytomegalovirus, hepatitis B, herpes simplex, influenza, and measles.
Certain drugs, such as those used to treat tuberculosis, may be contraindicated during pregnancy.
• General immunization recommendations (for specific recommendations, see Hospital Employee Health, October 1997, pp. 113-115, and other sections of the guidelines).
Persons administering immunizations should be familiar with the Advisory Committee on Immunization Practices recommendations, and be knowledgeable about indications, storage, dosage, preparation, side effects, and contraindications. A pertinent health history should be obtained from each worker before an agent is given.
Personnel health services should have a written comprehensive policy on immunizing HCWs, a database of employee-specific information on history of vaccine-preventable diseases and vaccine administration status, and a list of needed immunizations for each employee during screening (including an individual plan to provide necessary vaccines).
• General recommendations for prophylaxis and follow-up after exposure.
When HCWs are offered necessary prophylactic treatment with drugs, vaccines, or immune globulins, ensure that they are informed of options for prophylaxis, risk of infection if treatment is not accepted, degree of protection provided by treatment, and potential side effects of treatment.
When HCWs are exposed to particular infectious agents, ensure that they are informed of recommended follow-up based on current knowledge, risk of transmitting infection to patients and others, and methods of preventing transmission to others.
• Latex hypersensitivity.
Increased use of latex gloves has been accompanied by increasing reports of allergic reactions to natural rubber latex among HCWs. Contributors to latex sensitization include protein levels in gloves and the powder used as a lubricant for gloves. Reactions to latex gloves may be localized or systemic and include dermatitis, conjunctivitis, rhinitis, urticaria, angioedema, asthma, and anaphylaxis. The risk of progression from localized to systemic reactions is unknown.
Prevalence of IgE-mediated allergy to latex among HCWs varies from 2.9% to 17%, and varies by job category and location within a hospital. Some of the higher-risk categories appear to be dental residents/assistants, physicians, and operating room personnel.
Diagnosis relies largely on a clinical history of symptoms elicited by exposure to latex products. Most other methods are experimental and have not been approved for clinical use.
Avoiding latex products is the primary means of preventing sensitization and reactions. Proposed strategies to reduce the risk include: nonlatex products, powder-free latex gloves, powdered latex gloves washed to remove powder, and low-protein latex gloves. None of these interventions has been prospectively studied in controlled trials to assess efficacy.
References
1. Department of Health and Human Services, Centers for Disease Control and Prevention. Draft guideline for infection control in health care personnel, 1997; notice. 62 Fed Reg 47,275 (1997).
2. Williams WW. CDC guideline for infection control in hospital personnel. Infect Control 1983; 4:326-349.
3. Centers for Disease Control and Prevention. Recommendations for follow-up of health-care workers after occupational exposure to hepatitis C virus. MMWR 1997; 46:603-606.
4. Centers for Disease Control and Prevention. Update: Provisional Public Health Service recommendations for chemoprophylaxis after occupational exposure to HIV. MMWR 1996; 45:468-472.
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