CDC issuing new HCW infection control guidelines to protect staff and patients
Needle safety devices, latex allergies debated in HICPAC revisions
New infection control guidelines for health care workers in a wide variety of medical settings are expected to be issued in February by the Centers for Disease Control and Prevention, providing infection control and employee health professionals with the first comprehensive CDC update on the issue in 15 years.
Final revisions that addressed two of the draft document’s most controversial aspects needle safety devices and latex allergy issues were completed at a recent meeting of the CDC Hospital Infection Control Practices Advisory Committee (HICPAC) in Atlanta.
Designed to protect both patients and health care workers, the "Infection Control in Health Care Personnel" guideline calls for a multifaceted strategy to prevent nosocomial and occupational infections.1 The document maps out several lines of defense against infection and transmission, including immunizations, postexposure prophylaxis, and detailed work restrictions for infected workers. (See highlights and charts, pp. 3-4 and insert.) The employee health recommendations, which are the fourth completed infection control guideline update released by HICPAC since its inaugural meeting in 1992, are expected to be jointly published in final form in February in two infection control professional journals: the American Journal of Infection Control and Infection Control and Hospital Epidemiology.
Pushing the envelope of HICPAC’s charter
Perhaps more than any other guideline issued by HICPAC, this document reflects a growing effort to develop recommendations applicable to non-hospital settings without violating the committee’s charter to dispense guidance only to hospitals. (See related story, p. 7.)
"We are trying to push the envelope of our charter," says Elaine Larson, RN, PhD, HICPAC chairperson and dean of the School of Nursing at Georgetown University in Washington, DC.
In that regard, the guidelines note that nearly a third of the nation’s estimated 9 million health care workers are employed in non-hospital settings. To address the issue, the guidelines cast a wide net, including all health care employees and volunteers with the potential for exposure to infectious materials such as body substances and contaminated medical supplies and equipment. Such personnel may include, for example, medical students and trainees, as well as those employed in emergency medical services, dentistry, laboratories, and mortuaries, the guidelines state. By the same token, hospital-based personnel may acquire or transmit infections at work, home, or in the community, the guidelines remind. The breadth of the approach has raised some question about cost and compliance should the voluntary CDC guidelines become the basis for some future regulatory standard, but the CDC and HICPAC deemed the scope appropriate given today’s health care system.
"I think it is a reflection that health care is moving from just acute care facilities to dialysis centers, outpatient centers, long-term care, and home care," says William Jarvis, MD, acting director of the CDC hospital infections program.
Updating the 1983 CDC employee health guidelines, the new version frequently references the updated CDC patient isolation guidelines and addresses latex allergy problems in an era of ubiquitous glove use for universal/standard precautions.2,3 The guidelines also represent something of a HICPAC milestone in that they formally recommend ICPs consider developing policies to follow up workers exposed to hepatitis C virus. The issue sparked some debate at past HICPAC meetings when committee members took exception to the CDC position that no recommendation for follow-up of exposed workers could be made due the lack of an effective postexposure prophylaxis and incomplete data on the epidemiology of HCV. (See Hospital Infection Control, January 1996, pp. 1-4.) Indeed, the draft recommendations on HCV advise infection control and employee health professionals not to administer immune globulin to personnel who have exposure to blood or body fluids positive for HCV. However, they should "consider implementing policies for postexposure follow-up for health care personnel who have had a percutaneous or mucosal exposure to blood containing antibody to hepatitis C virus at baseline and six months," the guidelines recommend.
In addition to addressing specific diseases and infections, the guidelines recommend that the infection control objectives of the personnel health service should include the following:
• educating personnel about the principles of infection control and stressing individual responsibility for infection control;
• collaborating with the infection control department in monitoring and investigating potentially harmful infectious exposures and outbreaks among personnel;
• providing care to personnel for work-related illnesses or exposures;
• identifying work-related infection risks and instituting appropriate preventive measures;
• containing costs by preventing infectious diseases that result in absenteeism and disability.
Needle safety, latex allergy
While the guidelines provide a detailed update on many issues, comments on the draft version criticized it for a perceived glaring omission. Bill Borwegen, health and safety director at the Service Employees International Union in Washington, DC, cited the failure of the draft guidelines to underscore the availability of safer medical devices to prevent the vast majority of an estimated 800,000 needlesticks that occur annually in health care workers.
"The document does mention that these needlesticks continue to cause far too many cases of HIV, hepatitis B, hepatitis C, and other bloodborne illnesses and deaths," Borwegen stated in written comments. "However, nowhere does the document mention that the leading way to prevent needlesticks is through the use of widely available and widely marketed safer needle technologies. . . . It is critical that healthcare employers purchase and supply safer devices to their employees if our nation is to stem this epidemic of preventable needlestick injuries among healthcare workers. The CDC must assume the main leadership role in this arena."
As a result of such comments, the final version will include a revised section on the issue that references needle safety studies and cites the benefits of the devices without recommending specific models. The new section, as approved at the HICPAC meeting held Nov. 17-18, 1997, reads as follows:
"The use of engineering controls (e.g., safety devices) and changes in work practices (e.g., techniques to reduce handling of sharp instruments) can reduce the frequency of percutaneous injuries. In settings such as the operating room, changes in instrument design and techniques for performing surgeries and modified personal barriers have been shown to reduce blood contacts. Despite adherence to standard precautions, and implementation of some new techniques and devices, percutaneous injuries continue to occur. This is of concern because percutaneous injuries represent the greatest risk of transmission of bloodborne pathogens to health care personnel. Only a few studies evaluating a limited number of safety devices have demonstrated a reduction in percutaneous injuries among health care workers. This document will not address the use of safety devices as the public health service is assessing the need for further guidance on selection, implementation and evaluation of such devices in health care settings."
CDC is planning to tackle the needle safety device issue in separate guidelines that will include involvement of CDC branches on HIV and other bloodborne pathogens, says Michelle Pearson, MD, medical epidemiologist in the CDC hospital infections program and HICPAC executive secretary.
"Some of these devices have been evaluated; others have not," she tells HIC. "We really do not feel comfortable at this point endorsing certain products and not endorsing others. There is a plan to address that in the more global setting of HIV and bloodborne pathogens in the workplace. That will be addressed in another document."
In addition, the CDC’s first attempt to address the latex allergy issue in an infection control guideline was found lacking by nurses as well as glove manufacturers but for distinctly different reasons. For example, the American Nurses Association in Washington, DC, praised the CDC for addressing the issue, but urged the agency to go further in emphasizing latex alternatives and powder-free gloves as effective strategies against latex allergies. On the other hand, comments submitted by a major glove manufacturer questioned whether latex allergies are truly an occupationally acquired syndrome. Industry representatives also stated that data do not support the contention that powdered gloves are more allergy-producing than non-powdered. (See related story, at right.)
The CDC guidelines recommend the development of an institutional protocol for evaluating and managing personnel with suspected or known latex allergy, including establishing surveillance for latex reactions within the facility. The guidelines also advise consideration of targeted substitution of nonlatex gloves and/or powder-free latex gloves in areas of the facility where personnel have developed latex allergy.
"[The latex allergy issue] is new ground being broken by these guidelines that we think is very important," Jarvis says. "It will provide a basis for occupational health and infection control personnel to gain knowledge about this subject and to have some guidance on how they should approach latex allergy. I’m hopeful that as time moves on we can improve education about this issue and move more aggressively toward primary prevention, where we can try to eliminate sensitization, and not just severe reactions after sensitization. It’s a step at a time, but it is a very important first step."
References
1. Centers for Disease Control and Prevention. Draft guideline for infection control in health care personnel, 1997; notice. 62 Fed Reg 47,276-47,327.
2. Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996; 17:53-80.
3. Williams WW. CDC Guideline for infection control in hospital personnel. Infect Control 1983; 4:326-349.
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