Healthcare and Social Assistance

Participating core and specialty programs: Authoritative Recommendations, Emergency Preparedness and Response, Exposure Assessment, Personal Protective Technology, and Translation Research.

Employers, workers, professional associations, and manufacturers use NIOSH information to prevent the transmission of pathogens, including drug-resistant organisms, among workers in human and veterinary healthcare settings.

NOTE: Goals in bold in the table below are priorities for extramural research.

  Health Outcome Research Focus Worker Population Research Type
A Bloodborne pathogen infection Sharps injury prevention technology Management, workers who use sharps medical devices Intervention
B Bloodborne pathogen infection Sharps injury prevention (safety culture) Management, workers (human or veterinary settings) Translation
C Bloodborne pathogen infection Sharps injury reporting Management, workers who use sharps medical devices Surveillance research
D Influenza and emerging work-related pathogen infection Understanding modes of transmission Workers in pediatrics, acute care, daycare centers, others as needed to address outbreaks (human or veterinary) Basic/etiologic
E Influenza and other healthcare associated-infections Ultraviolet germicidal irradiation utility, Surface disinfection Workers in pediatrics, acute care, daycare centers, others as needed to address outbreaks (human or veterinary) Intervention
F Influenza and other vaccine-preventable diseases Vaccinations are underutilized All healthcare workers (esp. long-term care, home care), veterinary and animal care (VM/AC) workers Translation
G Influenza and other diseases transmitted by contact/droplet sprays Handwashing best practices underused All healthcare and VM/AC workers Translation
H Influenza and other work-related infectious diseases Personal protective equipment (PPE) (e.g., barrier PPE such as gowns, gloves, eye protection; and respiratory protection) All healthcare and VM/AC workers InterventionTranslation
I Influenza Lack of Industry/ occupation variables in surveillance systems All healthcare and VM/AC workers Surveillance research
J Tuberculosis Rapid identification and isolation of contagious individuals Workers in hospitals, urgent care, homeless shelters, others as needed to address outbreaks (human or veterinary) Basic/etiologic
K Infection by drug-resistant organisms Barriers to implementing existing recommendations Workers in hospitals, urgent care, homeless shelters, others as needed to address outbreaks (human or veterinary) Translation
L Tuberculosis Improved surveillance for work-related transmission All healthcare workers Surveillance research
M Zoonotic diseases Improved surveillance VM/AC Surveillance research

Activity Goal 3.3.1 (Basic/Etiologic Research): Conduct basic/etiologic research to better understand influenza aerobiology and transmission in healthcare settings and develop improved approaches to rapidly identify patients with active tuberculosis.

Activity Goal 3.3.2 (Intervention Research): Conduct studies to develop and assess the effectiveness of interventions to prevent transmission of work-related infectious disease among workers in human and veterinary healthcare settings.

Activity Goal 3.3.3 (Translation Research): Conduct translation research to understand barriers to implementation and aid in implementation of best practices for preventing the transmission of work-related infectious disease in human and veterinary healthcare settings.

Activity Goal 3.3.4 (Surveillance Research): Conduct surveillance research to evaluate and track the burden of work-related infectious disease among workers in human and veterinary healthcare settings.

Burden

Occupational infectious diseases are an important hazard for Healthcare and Social Assistance (HCSA) workers caring for human patients. Examples include bloodborne pathogens such as Hepatitis B virus (HBV), Hepatitis C virus (HCV), and Human Immunodeficiency Virus (HIV); tuberculosis (TB); and seasonal influenza. Sharps injuries are important risk factors for transmission of bloodborne pathogens such as HIV, HBV, and HCV. In 2009, it was estimated that there were about 385,000 percutaneous injuries in U.S. hospital-based healthcare and social assistance (HCSA) workers alone each year [NIOSH 2009]. Several well-known emerging infectious diseases affecting healthcare workers in recent years have included 2009 H1N1 pandemic influenza, Ebola, and Middle Eastern Respiratory Syndrome (MERS). A 2015 report indicated that Ebola had killed about 8% of the healthcare workers in Liberia and about 7% in Sierra Leone [Evans et al. 2015]. A recent meta-analysis of the world literature on infection of healthcare personnel during the 2009 H1N1 influenza pandemic found an approximately two-fold increased risk relative to the general population [Lietz et al. 2016]. Multi-drug resistant organisms present a growing challenge for workers in the HCSA sector, with 88 cases of multidrug resistant TB and one case of extensively drug-resistant TB identified in the U.S. in 2015 [CDC 2017]. Occupational infectious diseases are also an important hazard for veterinary medicine/animal care (VM/AC) workers, who face the hazard of zoonotic (animal-to-human) transmission of infectious diseases such as brucellosis, rabies and other zoonotic diseases.

Need

Surveillance information on sharps injuries is an immediate research need for the HCSA sector. Research is also needed to develop surveillance methods to document the burden of infectious disease transmission in VM/AC workers. Currently, innovation and evaluation of sharps injury prevention technology and safety culture is lacking. This research could produce engineering and administrative controls along with other best practices to reduce sharps injuries. Research gaps regarding the pathways of transmission, environmental persistence, and vulnerability of pathogens to disinfection strategies need to be addressed, specifically for influenza and tuberculosis. Better intervention design to prevent workplace transmission of infectious diseases and documentation of effectiveness of strategies such as use of respiratory protection and air disinfection with ultraviolet germicidal irradiation to prevent influenza transmission would be a significant contribution to the protection of HCSA workers. Identification and elimination of barriers to intervention dissemination such as implementation of effective engineering controls (e.g., environmental controls and safe sharps devices), handwashing, vaccination, providing sick leave for contagious workers, and the appropriate availability and use of personal protective equipment (PPE) is needed.

Employers, workers, professional associations, and others use NIOSH information to prevent chemical exposures that contribute to immune diseases among healthcare and social assistance workers.

NOTE: Goals in bold in the table below are priorities for extramural research.

  Health Outcome Research Focus Worker Population* Research Type
A Dermatitis Exposure characterization to novel agents Home healthcare workers Basic/etiologic
B Asthma Exposure to cleaning agents and disinfectants Environmental workers, nursing assistants, nurses Basic/etiologic
C Effect of chronic low dose exposure Exposure to cleaning agents and disinfectants Environmental workers, nursing assistants, nurses Basic/etiologic
D Asthma Adherence to best practices re: cleaning agents Environmental workers, nursing assistants, nurses Translation
E Asthma Exposure to surgical smoke Workers in inpatient and outpatient surgical facilities Basic/etiologic
F Dermatitis Use of latex gloves and disinfectants Nurses Basic/etiologic
G Immune diseases Exposure characterization aerosolized medication Respiratory therapists Basic/etiologic

Intervention

H Infections Host susceptibility Older workers and other vulnerable workers, workers with chronic disease Basic/etiologic

* See definitions of worker populations

Activity Goal 3.4.1 (Basic/Etiologic Research): Conduct basic/etiologic research to better characterize exposures to hazardous chemicals and understand the relationship between hazardous exposures and immune diseases among healthcare and social assistance workers.

Activity Goal 3.4.2 (Intervention research): Conduct studies to develop and assess the effectiveness of interventions to prevent exposures to aerosolized medications linked to immune diseases among healthcare and social assistance workers.

Activity Goal 3.4.3 (Translation Research): Conduct translation research to understand barriers and aids to implementing best practices regarding cleaning agents and disinfectants linked to immune diseases in healthcare and social assistance workplaces.

Burden

Irritant contact dermatitis is very common in nurses, with prevalence documented by surveys ranging from 25-50% [WHO 2009]. Hand dermatitis resulting from frequent hand hygiene and use of occlusive gloves is especially common. Allergic contact dermatitis can also occur as a result of immune sensitization to agents contacting the skin [WHO 2009]. Healthcare workers have one of the highest prevalences of occupational asthma at 8.8%, compared to 7.2% among all workers [NIOSH 2013]. Healthcare workers account for about 16% of all occupational asthma cases and up to 24% of these cases are due to exposure to cleaning agents [NIOSH 2015]. Chemicals commonly found in healthcare settings that can potentially cause or exacerbate asthma include cleaning and disinfecting agents, high level disinfectants, anesthetic gases, surgical smoke, aerosolized medications, and chemical sterilants [Saito et al. 2015; Steege et al. 2014]. Exposure to antineoplastic or chemotherapy drugs have also been linked to skin rashes and asthma [Skov et al. 1992; Lawson et al. 2012]. Healthcare and social assistance (HCSA) workers are routinely exposed to infectious agents; thus, factors that potentially impair their resistance to infection such as aging or chronic disease may put them at increased risk.

Need

Characterization of the biological mechanisms between hazardous exposures and immune diseases (i.e. asthma and dermatitis) in the Healthcare and Social Assistance sector is needed. Of particular interest is identification of agents that are immune sensitizers and characterizing the immune responses that they induce. Little research has been focused on environmental services staff despite their high-frequency and long-duration exposures to cleaning and disinfecting agents. Recommended practices for cleaning and disinfecting in healthcare settings have been identified, however, infection control practices may not adhere to these guidelines [CDC 2008]. Similarly, respiratory therapists have not been specifically researched despite their exposure to aerosolized medications. Other targeted groups in the HCSA sector include older workers and workers with chronic diseases as little is known regarding their susceptibility to infections and whether this puts them at increased risk for acquisition of work-related infections.

CDC [2017]. Tuberculosis — United States, 2016. MMWR 66:289–294, http://dx.doi.org/10.15585/mmwr.mm6611a2External

CDC [2008]. Guideline for disinfection and sterilization in healthcare facilities, 2008. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, https://www.cdc.gov/hai/pdfs/disinfection_nov_2008.pdfCdc-pdf

Evans DK, Goldstein M, Popova A [2015]. Health-care worker mortality and the legacy of the Ebola epidemic. Lancet Glob Health 3(8), http://dx.doi.org/10.1016/S2214-109X(15)00065-0External

Lawson CC, Rocheleau CM, Whelan EA, Lividoti Hibert EN, Grajewski B, Spiegelman D, Rich-Edwards JW [2012]. Occupational exposures among nurses and risk of spontaneous abortions. Am J Obstet Gynecol 206(4):327, http://dx.doi.org/10.1016/j.ajog.2011.12.030External

Lietz J, Westermann C, Nienhaus A, Schablon A [2016]. The Occupational risk of influenza a (H1N1) infection among healthcare personnel during the 2009 pandemic: a systematic review and meta-analysis of observational studies. PLoS One. 11(8), http://dx.doi.org/10.1371/journal.pone.0162061External

NIOSH [2009]. Bloodborne pathogens and sharps injuries. In: State of the Sector: Healthcare and Social Assistance. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2009-139, https://www.cdc.gov/niosh/docs/2009-139/pdfs/2009-139.pdfCdc-pdf

NIOSH [2013]. Healthcare and social assistance industry profile- Figure 4. Prevalence of current asthma among U.S. adults who worked in the past 12 months by healthcare and social assistance subsector, 2010. Occupational Health Supplement. National Health Interview Survey. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, https://www.cdc.gov/niosh/topics/nhis/healthcareind/hcindfig4.html

NIOSH [2015]. Work-Related Lung Disease Surveillance System (eWoRLD). Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, https://wwwn.cdc.gov/eworld/Data/866

Saito R, Virji MA, Henneberger PK, Humann MJ, LeBouf RF, Stanton ML, Liang X, Stefaniak AB [2015]. Characterization of cleaning and disinfecting tasks and product use among hospital occupations. Am J Ind Med 58(1):101-11, http://dx.doi.org/10.1002/ajim.22393External

Skov T, Maarup B, Olsen J, Rørth M, Winthereik H, Lynge E [1992]. Leukaemia and reproductive outcome among nurses handling antineoplastic drugs. Br J Ind Med 49(12):855-61.

Steege AL, Boiano JM, Sweeney MH [2014]. NIOSH health and safety practices survey of healthcare workers: training and awareness of employer safety procedures. Am J Ind Med 57(6):640-52, http://dx.doi.org/10.1002/ajim.22305External

WHO [2009]. WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. Geneva, Switzerland: World Health Organization, https://www.ncbi.nlm.nih.gov/books/NBK144008/External

Page last reviewed: April 24, 2018