Healthcare and Social Assistance
Participating core and specialty programs: Authoritative Recommendations, Center for Occupational Robotics Research, 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 and climate) | Management, workers (human or veterinary settings) | Translation |
| C | Bloodborne pathogen infection | Sharps injury reporting | Management, workers who use sharps medical devices | Surveillance research |
| D | Viral and other 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, COVID-19, healthcare associated infections, and emerging work-related pathogens | Ultraviolet germicidal irradiation utility, surface disinfection, and use of robotic technologies in disinfection | All HCSA workers including those in pediatrics, acute care, daycare centers, others as needed to address outbreaks (human or veterinary) | Intervention
Translation |
| F | Inhalable 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 | Inhalable 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 | Intervention Translation |
| I | Respiratory infectious diseases | Lack of Industry/ occupation variables in surveillance systems | All healthcare and VM/AC workers | Surveillance research |
| J | Respiratory infectious diseases | 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 | Respiratory infectious diseases | Improved surveillance for work-related transmission and adverse personal and economic consequences of infection | All healthcare workers | Surveillance research |
| M | Zoonotic diseases | Improved surveillance | VM/AC | Surveillance research |
| N | COVID-19 | Mitigate impact of long-term sequelae | All healthcare and social assistance workers | Intervention, Surveillance |
| O | Work-related pathogen infection | Use of robots and artificial-intelligence-based procedures for preventing worker exposure to pathogens, e.g. by increasing physical distance/separation between healthcare workers and infectious patients | All healthcare and social assistance workers | Intervention |
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 current infection.
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 and assist those with long-term sequelae in returning to work.
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 and its long-term sequelae 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 a major hazard for Healthcare and Social Assistance (HCSA) workers caring for human patients. Since the drafting of the NIOSH Strategic Plan goals in 2017, the Nation has faced a global pandemic of COVID-19. As essential workers provide direct care to patients with confirmed and suspected SARS-CoV-2, healthcare workers perform their duties with a high risk of SARS-CoV-2 transmission. To date, reports of COVID-19 among healthcare workers reached 510,759 cases, including 1,670 deaths [CDC 2021]. A prospective cohort study of over 2 million people and 99,795 healthcare workers found that the likelihood of testing positive for COVID-19 was 12 times higher for healthcare workers [Nguyen et al. 2020]. Further, an analysis of 42,647 COVID-19 cases in Washington State with employment information found that the HCSA sector had the highest percentage of cases at 24% [WA DOH 2020]. Other well-known emerging infectious diseases affecting healthcare workers in recent years include 2009 H1N1 pandemic influenza, Ebola, and Middle Eastern Respiratory Syndrome (MERS). A 2015 report indicated that Ebola 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]. In addition, bloodborne pathogens such as Hepatitis B virus (HBV), Hepatitis C virus (HCV), and Human Immunodeficiency Virus (HIV) remain as healthcare hazards. Sharps injuries are major risk factors for transmission of bloodborne pathogens such as HIV, HBV, and HCV. In 2009, a NIOSH report 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]. Occupational infectious diseases are also a major hazard for veterinary medicine/animal care (VM/AC) workers, who face the risk of zoonotic (animal-to-human) transmission of infectious diseases such as brucellosis, rabies, and other zoonotic diseases.
Need
The COVID-19 pandemic is generating numerous areas for research in the HCSA industry sector. To protect healthcare personnel, there is a significant need for basic/etiologic, surveillance, translation, and intervention research related to SARS-CoV-2 transmission and infection prevention, as well as the long-term impact of the pandemic on workers and workplaces. During the past year, multiple agencies, organizations, and industrial entities called for or supported emerging technologies and procedures to reduce worker exposures to pathogens [ARM 2020; Cresswell and Sheikh 2020; Diab-El Schahawi et al. 2021; Yang et al. 2020]. Surveillance information on sharps injuries is an immediate research need for the HCSA sector. Research is also necessary for developing 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 prevalence’s 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.
Advanced Robotics in Manufacturing (ARM) Institute [2020]. Learn more and get involved with ARM’s efforts to mitigate the COVID-19 pandemic. Pittsburgh, PA: The Advanced Robotics in Manufacturing (ARM) Institute, https://arminstitute.org/covid-19/external icon.
CDC [2017]. Tuberculosis — United States, 2016. MMWR 66:289–294, http://dx.doi.org/10.15585/mmwr.mm6611a2external icon
CDC [2021]. COVID Data Tracker: Cases & Deaths among Healthcare Personnel. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention, https://covid.cdc.gov/covid-data-tracker/#health-care-personnel
Cresswell K, Sheikh A. [2020]. Can disinfection robots reduce the risk of transmission of SARS-CoV-2 in health care and educational settings? J Medical Internet Res 22(9): e20896, https://doi.org/10.2196/20896external icon
Diab-El Schahawi M, Zingg W, Vos M, Humphreys H, Lopez-Cerero L, Fueszl A, Zahar JR, Presterl E. [2021]. Ultraviolet disinfection robots to improve hospital cleaning: Real promise or just a gimmick? Antimicrob Resist Infect Control, 10: article 33 . https://doi.org/10.1186/s13756-020-00878-4external icon
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 icon
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 icon
Nguyen LH, Drew DA, Graham MS, Joshi AD, Guo CG, Ma W, Mehta RS, Warner ET, Sikavi DR, Lo CH, Kwon S, Song M, Mucci LA, Stampfer MJ, Willett WC, Eliassen AH, Hart JE, Chavarro JE, Rich-Edwards JW, Davies R, Capdevila J, Lee KA, Lochlainn MN, Varsavsky T, Sudre CH, Cardoso MJ, Wolf J, Spector TD, Ourselin S, Steves CJ, Chan AT, Coronavirus Pandemic Epidemiology Consortium [2020]. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet Public Health 5(9):e475-e483. doi: 10.1016/S2468-2667(20)30164-X
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.pdfpdf icon
WA DOH [2020]. COVID-19 Confirmed Cases by Industry Sector. Shoreline, WA: Washington State Department of Health and Washington State Department of Labor, https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/data-tables/IndustrySectorReport.pdfpdf iconexternal icon
Yang G, Lv H, Zhang Z, Yang L, Deng J, You S, Du J, Yang H [2020]. Keep healthcare workers safe: Application of a teleoperated robot in isolation ward for covid-19 prevention and control. Chinese J of Mech Eng 33, 47. https://cjme.springeropen.com/articles/10.1186/s10033-020-00464-0external icon
Note: Goal 3.3 was revised in September 2021 to address the impact of COVID-19 and other infectious diseases.