Take Action to Stay Healthy

The Centers for Disease Control and Prevention (CDC) published infection control guidelines for dental health care settings in 2003.^1,2 This CDC guideline remains the core guidance document for developing infection control policies and procedures and is the recognized standard of care for dental health care personnel (DHCP) and dental health care settings. Other CDC guidelines for health care settings, and federal, state, and local regulations (Occupational Safety and Health Administration [OSHA], Food and Drug Administration [FDA], Environmental Protection Agency [EPA]) also apply.^1,2

The CDC emphasizes the need to establish an infection control program.^1,2 The four core principles of infection control can be used to build an infection control program:

1. Take action to stay healthy.
2. Avoid contact with blood and and other potentially infectious body substances.
3. Make patient care items (dental instruments, devices, and equipment) safe for use.
4. Limit the spread of blood and other infectious body substances.³

The goal of infection prevention and control is to prevent health care-associated infections in patients and injuries and illnesses in health care personnel (HCP).^1,2,4 The principle, “Take action to stay healthy,” addresses personnel health as an integral component of an infection control program. A health care worker in good health is less likely to be vulnerable to emerging infections from patients and less likely to transmit infection. CDC guidelines for health care personnel on taking action to stay healthy were published in 1998.⁴ Recommendations from this 1998 CDC guideline were incorporated into the 2003 dental infection control guidelines.^1,2

The CDC identifies the following elements of a personnel health program:

• Education and training
• Immunization program
• Exposure prevention and management|
• Medical condition management and work-related illnesses and restrictions
• Health record maintenance

Written policies, procedures, and guidelines for all of these elements are necessary for a personnel health program to be successful.^1,4 A policy on confidentiality of information is also important.^1,5 Dental offices should identify and establish a referral policy with a qualified health care professional (physician, occupational medicine clinic, etc.) to ensure prompt and appropriate preventive services and occupationally-related medical services.¹ The CDC recommends and OSHA requires employers to identify a qualified health care provider for post-exposure management and follow-up in accordance with the most current United States Public Health Service recommendations.^1,5

EDUCATION AND TRAINING

All DHCP should be familiar with the written policies and procedures in their facility and with any pertinent guidelines available. New personnel should be educated prior to beginning tasks with a risk of occupational exposure. Education and training are required at least annually or more often if there are any changes in policies, procedures, or if new information becomes available that is relevant to infection control and exposure management.^1,4,5,6,7 The CDC recommends including the following in training personnel at a potential risk of occupational exposure:

• A description of their exposure risks;
• A review of prevention strategies, infection control policies, and procedures;
• Discussion regarding how to manage work related illnesses and injuries, including postexposure prophylaxis (PEP); and
• A review of work restrictions for the exposure or infection. The content of an education and training program needs to be appropriate in language and literacy, remain consistent with state and federal law, and be provided by a qualified individual. Ample opportunity for dialogue and clarification of all material should be provided.^1,5

IMMUNIZATION PROGRAMS

Immunization for vaccine-preventable disease is a primary component of any infection control program. DHCP are at risk of infection—immunization greatly lowers the risk of transmission.^1,4 The immunization history of all personnel should be reviewed in order to determine their documented immunity, if any immunizations are indicated, and to maintain proper records. The Advisory Committee on Immunization Practices (ACIP) of the CDC offers guidelines on immunization that are routinely updated. ACIP provides specific recommendations for HCP.^1,4 The CDC recommends that HCP, including DHCP, know their immune status to vaccine-preventable diseases including hepatitis B, influenza, measles, mumps, rubella, tetanus, diphtheria, pertussis, and varicella. The CDC further recommends that nonimmune personnel be immunized against these vaccine–preventable diseases.^1,4 OSHA addresses the hepatitis B vaccine in the Bloodborne Pathogens Standard.

OSHA regulates employers to provide access to the hepatitis B vaccine for all at-risk personnel who have occupational exposure to blood and other potentially infectious materials.^5-7 OSHA also requires employers to have personnel who refuse the vaccine sign a declination form.^5,7 All HCP must be first educated about the risks associated with their tasks, the risk of transmission and infection, and the benefits of the hepatitis B vaccine before making a decision. Should a HCW change his/her mind, the vaccine should be made available at no cost to the employee.^5,7

ACIP frequently reviews recommendations for adolescent and adult immunization and publishes these in a Morbidity and Mortality Weekly Report through the CDC. Additional information on immunization can be found through the National Center for Immunization and Respiratory Diseases at www.cdc.gov/vaccines. See Table 1 for a summary of immunization recommendations for HCP.

EXPOSURE PREVENTION AND POST-EXPOSURE MANAGEMENT

Avoiding exposure to blood or other potentially infectious material is a primary means of exposure prevention. Adherence to infection control recommendations, standard precautions, engineering, work practice, and administrative controls are the first line of defense. If an exposure does occur, it must be managed effectively and in a timely manner. In order for this to occur, the CDC recommends that health care settings establish a comprehensive post-exposure management and medical follow-up program before exposures occur. The program should include detailed policies and procedures for reporting incidents to the practice setting, first aid management of exposures, and medical evaluation of the exposed person that includes counseling, treatment, and medical follow-up.^1,5,8 All new personnel should be educated and trained about the policies and procedures. Policies and procedures should also be reviewed during annual training.^1,5

Personnel may also have a potential for exposure to tuberculosis (TB).¹ The CDC recommends baseline tuberculin skin testing (TST) using a two-step test at the start of tasks that place a DHCP at risk. Specific guidelines are available from the CDC on TB risk and infection control measures.^1,8

MEDICAL CONDITIONS, WORK-RELATED ILLNESS, AND WORK RESTRICTIONS

DHCP are in the best position to monitor their own health. The CDC recommends that individuals with acute or chronic medical conditions consult with their primary care provider or a specialist to determine if any condition may make them susceptible to opportunistic infections and affect their ability to safely perform their duties.^1,4 A decision to exclude from work/patient contact is made based on the mode of transmission and infectivity period of a given disease. Policies related to exclusion should be written and include the name of the decision maker. These policies should be communicated to all staff and should encourage someone to report illness or exposure without fear of recrimination.⁴ Table 2 reviews work restriction recommendations.

The increased use of latex gloves has generated concerns over allergic reactions among DHCP and their patients. Reports of irritant and allergic dermatitis are increasing. DHCP should be educated to recognize the signs and symptoms associated with any latex sensitivity, the precautions to take, and the necessary actions in the event of a serious reaction.¹

HEALTH RECORD MAINTENANCE

Health records of employees are an important part of a personnel health program. These records need not be stored in the office, but their location should be readily known in case of an emergency. A logical place to keep these is with the designated health care professional chosen by the practice to treat exposure incidents. These records should be kept confidential in accordance with all state and federal laws.^1,5,7 Health records are required to be kept for the duration of employment plus 30 years in accordance with the OSHA Bloodborne Pathogen Standard. OSHA does require that employers ensure employee medical records are kept confidential and not disclosed or reported without a written informed consent outside the workplace.^5,7

Infection control programs that reflect current CDC recommendations and use evidence-based resources to establish and maintain policies and procedures for personnel health can significantly reduce the risk of health care-associated infections in patients and illnesses in personnel. Additional infection control resources, information, and tools are available from the Organization for Safety and Asepsis Procedures (OSAP) at www.osap.org.

The next installment in this series will discuss standard and transmission-based precautions.

REFERENCES

1. Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM, CDC. Guidelines for infection control in dental health-care settings—2003. MMWR Recomm Rep. 2003;19:1-61.
2. Kohn WG, Harte JA, Malvitz DM, Collins AS, Cleveland JL, Eklund KJ. Guidelines for infection control in dental health-care settings—2003. J Am Dent Assoc. 2004;135:33-47.
3. Summers CJ, Gooch BF, Marianos DW, Malvitz DM, Bond WW. Practical infection control in oral health surveys and screenings. J Am Dent Assoc. 1994;125:1213-1217.
4. Boylard EA, Tablan OC, Williams WW, Pearson ML, Shapiron CN, Deitchman SD, Hospital Infection Control Practices Advisory Committee. Guideline for infection control in health care personnel, 1998. Am J Infection Control. 1998:26:289-354.
5. Occupational exposure to bloodborne pathogens; final rule. Available at: www.osha.gov/SLTC/dentistry/index.html. Accessed November 12, 2008.
6. US Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910.1030. Occupational exposure to bloodborne pathogens; needlesticks and other sharps injuries; final rule. Federal Register. 2001;66:5317–25. As amended from and includes 29 CFR Part 1910.1030.
7. US Department of Labor, Occupational Safety and Health Administration. OSHA instruction: enforcement procedures for the occupational exposure to bloodborne pathogens. Washington, DC: US Department of Labor, Occupational Safety and Health Administration, 2001; directive no. CPL 2-2.69.
8. CDC. Updated US Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for post-exposure prophylaxis. MMWR Recomm Rep. 2001;50(No RR-11).

From Dimensions of Dental Hygiene. December 2008; 6(12): 24-27.