OHS Canada 25th Anniversary Best Editorial

The Silent Enemy

September 2004

In the aftermath of SARS, the health care sector needs to evaluate if existing protective measures are still enough. But as stakeholders take aim at new and emerging disease, it is essential not to lose sight of “older” diseases still lurking in their midst.

By: Nicolette Beharie

It's a chilling thought, but an infection can cross entire continents in just a few days. "Organisms don't have to have passports," says Shirley Paton, chief of the nosocomial and occupational infections section at Health Canada. And as we prepare to do battle with new, microscopically small enemies, it's essential that we not lose sight of the "older", established diseases not yet conquered.

Dr. Lynora Saxinger, assistant professor in the infectious diseases division of the University of Alberta in Edmonton, says most experts would agree that infectious diseases are emerging more frequently than in the past. In a 1995 article in the journal, Emerging Infectious Diseases, Stephen S. Morse of New York's Rockefeller University wrote of the spread of disease: "Opportunities in recent years have become far richer and more numerous, reflecting the increasing volume, scope and speed of traffic in an increasingly mobile world."

The ever-changing roster of infectious disease can often be most clearly felt in health care where the ill come to "get all better." And the threats from so-called superbugs, antibiotic-resistant organisms, bloodborne diseases, and respiratory conditions that pass through hospital doors with every infected individual has demanded that the health care sector evaluate safety protections for front-line staff to determine if they still measure up.

In Ontario, the Workplace Safety and Insurance Board (WSIB) allowed 1,013 claims for infectious disease in the health care sector from 1999 to 2003. Among others, there were 421 claims for intestinal infectious disease, 171 for infestation by head lice and scabies, four for hepatitis C, and one each for tuberculosis and rubella. More recent claims have seen the WSIB allow 221 for diseases related to Norwalk-like viruses and 129 for SARS.

Of course, there are many more diseases and infections -- each posing a threat to health care workers. Health Canada's guideline, "Prevention and Control of Occupational Infections in Health Care", outlines infections and what protective measures should be in place.

Gastroenteric infections

Examples: E. coli, salmonella, and shigella

Transmission: Direct or indirect ingestion of feces or by ingestion of contaminated water or food. Airborne transmission has been suggested in some Norwalk-like viruses.

Symptoms: Diarrhea, abdominal pain, malaise, fever, nausea and vomiting, among others.

Real life: A Norwalk-like agent was responsible for a hospital-wide outbreak that affected 27 per cent of the 2,379 health care workers. Of those infected, the greatest number worked in the emergency department.

Respiratory Infections

Examples: Parainfluenza virus, respiratory syncytial virus (RSV), and rhinovirus

Transmission: Droplet contact of the oral, nasal or conjunctival mucous membranes of an infected individual. It can also be indirectly transmitted from hands and articles freshly soiled with the nose/throat discharges of an acutely ill and coughing individual.

Symptoms: Sore throat, fever, pneumonia and conjunctivitis, among others.

Real life: RSV infection has repeatedly been acquired by health care workers, says the prevention and control guideline, and primarily in those working in pediatrics. However, the guideline adds that the use of disposable eye-nose goggles has been associated with a significant decrease in patient and staff RSV infections.

Bloodborne Pathogens

Examples: HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV)

Transmission: Body fluids capable of transmitting pathogens from an infected individual include blood, serum, plasma and all biological fluids visibly contaminated with blood; uterine/vaginal secretions or semen; and saliva. Bloodborne pathogens are primarily transferred by percutaneous injury with contaminated equipment, but also by mucous membrane or non-intact skin contact with blood or body fluids.

Real life: The most common cause of health care worker exposure to blood and body fluids is by percutaneous -- for example, needlestick -- injury. HBV can survive on environmental surfaces for more than a week, meaning indirect exposure can occur. This appears to have been a factor in HBV outbreaks among patients and staff of hemodialysis units, the guideline notes.

A hospital environment, says Paton, is "a wonderful environment as a training ground for organisms to learn how to survive against the big guns." Organisms become stronger by learning how to survive against the high-powered antibiotics given to patients -- drugs to which they would not otherwise be exposed, she explains. The organisms that health care workers are exposed to, in turn, are "likely to be more resistant."

Beyond changes to the environment is a "new consciousness among health care workers about the risks to themselves that are posed by infectious diseases, unfortunately born of the experience of SARS," says Nancy Johnson, a labour relations officer for the Ontario Nurses' Association (ONA) in Toronto.

Add the two together and you have a work force that is more aware -- and possibly more fearful -- of those silent enemies that make their way through the door.

Last April, British Columbia's Occupational Health & Safety Agency for Healthcare (OHSAH) released an inter-agency report, "Protecting the Faces of Healthcare Workers," that identified several areas requiring greater attention. Focus group participants, as noted below, expressed many concerns over the SARS outbreak, but added that lessons learned may provide guidance for health care settings in future.

The OHSAH study found that, with different institutions using different methods, the benefits of fit-testing were not universally accepted. Workers often regarded the inconsistencies as a source of concern that tainted the whole process.

During the SARS outbreak, Paton says, "changes were coming so fast that nothing got to be routine. So the opportunity for error was huge in terms of [the] use of personal protective equipment [PPE]."

Dr. Alison McGeer, medical director of infection control at Mount Sinai Hospital in Toronto, observes that if people consider safety measures to be too difficult and too inconvenient, they simply begin to work their way around it. "Health care workers, in general, are a very highly dedicated group of people," says Dr. McGeer. "It's hard to get them to protect themselves sometimes. They see their jobs as taking care of patients."

Dr. McGeer notes that "it's a really difficult balancing issue trying to make sure that you recommend precautions enough so that you protect people, but not too much so that people don't start ignoring the recommendation and putting themselves at risk."

A Toronto support staff worker who took part in the OHSAH focus group found that the discomfort of her protective gear dramatically increased her workload. Moving from one room to the next had become a laborious task. "You can't just go back and get a drink," she said, "because just coming out you have to strip and then you have to regown, double of everything, and you have to go back in. And the time that it takes to put all these layers on is just so much that you can't be bothered."

Dr. Saxinger suggests that already-established standards offer sufficient protection. "I don't think it's reasonable to have full precautions on all the time because if they were easy we would be doing that already," she says. The OHSAH report notes, "If staff are asked to wear this equipment too often when it is not necessary, then it is quite likely that the 'new normal' of hyper-vigilance with respect to infectious precautions will be eroded."

Dr. Saxinger says she has witnessed common infectious disease miscues. It's very common to see people undo a dressing wearing the same gloves they used when they did the last patient's dressing, she says. "From an infectious disease point of view, it's horrendous because it's kind of cross-contaminating patients in a high-risk body locale."

Gear such as gloves, gowns, masks and eye protection may be recommended, depending on the hazard to which a health care worker is exposed.

Gloves, for example, are not required for routine patient care in which contact is limited to a patient's intact skin. If there is a risk of exposure to blood, body fluids, secretion and excretions, mucous membranes or while draining wounds or non-intact skin, however, gloves should be worn. A supplement to Health Canada's guideline, "Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care," cautions that it is possible for hands to become contaminated through glove defects or during removal.

Long-sleeved gowns that protect forearms and clothing should be worn when health care workers are at risk of being splashed or soiled with body substances. There is little evidence that routine use of gowns is beneficial in the control of nosocomial infections, the routine practices guideline says, but it is believed that using gowns may help to increase hand-washing by serving as a reminder.

Last, masks and eye protection (such as face shields and goggles) should be considered when a risk exists of exposure to large droplets. For airborne infections, the routine practices guideline says special masks with high-filtration capacity, good fit, and that are known to meet specific performance criteria are recommended.

Jean Candy, labour relations representative for the Nova Scotia Nurses' Union in Dartmouth, says health care workers are starting to realize that using various types of protective equipment will likely "become a trend in working in health care institutions." Their only concern, Candy says, is that the equipment provided is safe and does what it is intended to do.

ONA's Johnson is particularly concerned over equipment deficiencies because nurses have a limited right to refuse unsafe work. "You don't expect a firefighter to run into a fire without his protective equipment," she says.

While the OHSAH report found that there was extensive literature on the performance of PPE, how that performance translates into protecting health care workers from infectious disease is not clear. Researchers note that two observational studies have shown that "using any mask regularly is more protective than not using a mask regularly."

Health care workers already know what they can expect from needles and sharps -- everything from transmission of hepatitis C to HIV. That's why unions and organized labour are pushing for government help to reduce, and hopefully eliminate, needlestick injuries and their potentially deadly consequences.

In Manitoba, the Service Employees International Union (SEIU) Canada and other area unions recently came together to launch an awareness campaign they hope will lead to a legislative requirement to use safety-engineered medical devices (SEDs). Every year, 3,500 health care workers in Manitoba are stuck with used needles and medical sharps, SEIU Canada reports.

Jackie Bourdages, a registered nurse in British Columbia, has experienced firsthand the fear of not knowing what a needlestick injury may ultimately mean, says information from Fraser Health. Over her 25-year career, Bourdages has received two accidental needlestick injuries. "Fortunately for me, my needlesticks came before the days of AIDS, so my worry was limited to the possibilities of hepatitis C and hepatitis B," she says.

Not all health care workers, however, have managed to escape harm. Health Canada's prevention and control guideline notes one occupational HIV percutaneous transmission documented in Canada. The incident occurred when a health care worker sustained a shallow puncture wound from a small-gauge needle. Although there was a small amount of blood at the wound site, the guideline notes, it appeared trivial and the worker did not seek antiretroviral drugs. Unfortunately, the source person was in the late stages of AIDS and the health care worker seroconverted to HIV.

Ted Mansell, national health and safety coordinator for SEIU Canada, says needlestick injuries can be prevented with the use of SEDs. Dr. McGeer notes, however, that any change -- including something like adopting SEDs -- demands careful consideration. "One of the things that happened when we engineered safety devices for staff was that in some circumstances we increased the risk to patients," she points out.

Health Canada's Paton believes not enough attention has been paid to creating an overall safe environment within health care facilities. "We have tended to focus on personal behaviour to protect health care workers," she says, with individual precautions like wearing gloves, gowns, and masks serving as the lead item on prevention lists. But rather than being first, says Paton, PPE should be the last thing on which health care workers depend.

"We're not downgrading the use of personal protective equipment, " Paton emphasizes. "But what we're trying to underline is that is the last plank in a true safe environment. And too often we've focused on that as the only plank." Taking a closer look at air handling systems, administrative procedures and work practices, among other environmental factors, will help balance the scale and ensure there is as little exposure to infectious agents as possible.

Keeping everyone on their toes may benefit from checks. Belinda Sutton, a spokesperson for Ontario's Ministry of Labour (MOL), says the frequency of inspections for all sectors -- including health care -- is determined by a risk assessment model that identifies high-risk workplaces. Following the SARS outbreak, Sutton notes, "there was a commitment to visit all acute care facilities to audit infection control." By the end of July of this year, says Sutton, the MOL made visits to the 192 acute care facilities across Ontario and issued 1,950 orders.

"We've not been happy with disciplinary measures for people who do not comply with precautions," says Dr. McGeer. In the aftermath of SARS, however, some hospitals may now be taking a closer look at monitoring and compliance with policies and procedures.

The OHSAH focus group revealed that there was a lack of safety consciousness among health care workers. Although good peer support and follow-up training were suggested, the report says, participants generally felt that better supervision on hospital wards would help bolster compliance with infection control measures.

The source of infections passed onto health care workers while on the job, in general, is the patients, says Dr. McGeer. "You can make the environment relatively safe," she notes, but it is also important to determine which patients require special precautions. "In SARS, for instance, almost all the health care workers who got SARS were taking care of somebody who they didn't think had SARS."

Dr. Bonnie Henry, associate medical officer of health for Toronto Public Health, says health care workers in the city should be particularly concerned about tuberculosis (TB). In June, the health department released a 10-year review summarizing the communicable disease trends in the city between 1992 and 2002. The TB rate in Toronto is four times greater than the rest of Ontario -- and twice as high as the Canadian rate.

Dr. Rita Shahin, acting director of communicable disease control with Toronto Public Health, said in a statement that the risks associated with large urban settings must be considered. "The data reflect the reality of a large urban environment and underscore the need for a comprehensive urban health strategy that includes prevention and control of communicable diseases," Dr. Shahin said.

Information from Health Canada's Canada Communicable Disease Report notes that, in 2002, 1,555 cases of new active and relapsed TB were reported to the Canadian Tuberculosis Reporting System. Ontario, Quebec and British Columbia accounted for 75 per cent of the reported cases.

"I think we've become complacent over the years because we think tuberculosis isn't a problem anymore," Dr. Henry says. "We have the idea that adults don't transmit respiratory diseases and I think SARS certainly changed all that."

Another significant threat, although underestimated for years, is influenza. This, suggests Dr. Saxinger, poses one of the biggest risks to health care workers.

Adds Dr. Henry, "We hope that what we learned last year will do for respiratory illnesses what things like HIV did for blood-borne illnesses."

Researchers at the University of Toronto recently analyzed the responses of 129 people -- most of whom were health care workers -- who completed a Web-based survey and who had been quarantined during that city's SARS crisis in 2003. Published in the July issue of Emerging Infectious Diseases the findings note that most respondents exhibited a high prevalence of psychological distress. In all, 28.9 per cent showed symptoms of post-traumatic stress disorder and 31.2 per cent showed signs of depression.

There was also some anger over what was seen as inconsistent and incomplete information on infection control measures and quarantine. Respondents expressed frustration over how difficult it was to contact employers (health care institutions) and public health officials, disappointment over the perceived insufficient support, and anxiety over the lack of information on the modes of transmission and prognosis of SARS.

Although the events of SARS were exceptional, Dr. Saxinger recalls an outbreak of meningoccocal meningitis in Alberta hospitals a few years back that fed similar fears.

"I think it caused quite a bit of concern for health care workers because during the first 24 hours that people are on treatment they are still considered infectious," Dr. Saxinger says. And although workers were given the facts, some were worried even if their contact with a patient was minimal, she reports.

Until you receive confirmation that an exposure has not resulted in an infection, the SEIU's Mansell says workers should assume the worst case scenario -- and expect the mental unease of possibly infecting a loved one.

As an infectious disease doctor, says Dr. Saxinger, "you often find yourself feeling defensive when talking to health care workers who are worried." Stating the facts and figures about the potential risks, she has found, is sometimes far from comforting. "You can't just show the person that their individual risk is really null," she adds, "because it's not."

SARS delivered a harsh reminder that infection control and occupational health need to go hand-in-hand in hospital settings. Now, says the ONA's Johnson, "there's a heightened awareness that infection is an occupational hazard."

But that connection has not always been an easy one to make -- or to maintain. "One of the things that we discovered just before SARS and during SARS," says Dr. McGeer, "is that as communicable diseases sort of faded and became less common, we removed a lot of the teaching about infections and infection prevention from our professional schools."

Toronto's Mount Sinai Hospital recently partnered with Oxegen Inc., a risk management software company, to develop a series of electronic infection control training modules. The courses, to be developed by staff within the hospital's microbiology department, will cover topics such as SARS protection, routine practices, airborne precautions, aseptic techniques and disinfection procedures.

Hospitals in Ontario's Niagara region have also made efforts to beef up infection control. The Niagara Health System recently adopted an infection prevention program developed by 3M Canada in six of its eight hospital sites.

"While people are giving very serious thought to what needs to go into undergraduate curriculums, the position that we're all in at the moment is having a lot of health care professionals who didn't have adequate education to deal with SARS," says Dr. McGeer.

Despite having to play catch-up, Dr. Henry says there's evidence that an overall shift in thinking has taken place over the past 15 years. Things as simple as alcohol hand sanitizers are now readily available in most hospitals to encourage what Dr. Henry calls a critical infection control measure: hand-washing (see sidebar on page 50). Yet, studies have demonstrated that "less than half of people do it after an exposure where they were in contact with somebody's blood or body fluid," she says.

During the SARS outbreak, the OHSAH study says, much of the communication issues involved distributing constantly changing directives. Although the opinions of focus group participants varied with respect to the best means of communication, most people agreed that face-to-face meetings were effective. Having a hospital representative deliver messages was not only seen as credible, but important in terms of bolstering staff morale.

"I think the good thing to come out of SARS was that it really heightened everyone's sensitivity to the thought of infectious disease in a hospital setting again," says Dr. Saxinger.

Should some other unnamed enemy come along, Dr. Saxinger is thankful the systems now in place in hospitals are better than what was there before. "I actually think something will come up," she says. "That's the world we live in now."

Nicolette Beharie is assistant editor of ohs canada.

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Awash with infection control

Keeping the hands of health care workers clean is the first line of defence when it comes to infection control. Hospital staff are always using their hands when they work with patients and within the hospital environment -- making them the surface most at risk of contamination. But observational studies have, time and again, showed that health care workers frequently fail to wash their hands, says Health Canada's routine practices guideline. Time constraints, understaffing and a lack of access to sinks are among the barriers to consistent hand-washing practices.

The guideline recommends that hands be washed in the following circumstances:

• - after any direct contact with a patient and before contact with the next patient;

• - after contact with blood, body fluids, secretions and excretions and exudates from wounds;

• - immediately after removing gloves;

• - before preparing, handling, serving or eating food; and,

• - when hands are visibly soiled.

Hand-cleansing products should be gentle enough to protect the hands during repeated washings, but strong enough to eliminate microorganisms.