Occupational Health Clinics

Program 2019

0
Table of Contents
01 Ministry of Health Message

02 Introduction and Executive Summary

03 Important Definitions

04 Policy
05 Procedure
05.1 Administrative Procedures
05.2 Scope of Service
05.2.1 Record-keeping
05.2.2 Medical and Occupational History
05.2.3 Occupational health services
05.2.3.1 Pre-employment Medical Examinations
05.2.3.1.1 Standard Pre-Employment examinations
05.2.3.1.2 Tuberculin skin testing
05.2.3.1.3 Interferon Gamma Release Assay Testing (IGRA)
05.2.3.2. Periodic Medical Examinations
05.2.3.3. Vaccination
05.2.3.3.1 Hepatitis B vaccine
05.2 3.3.2 Influenza vaccine
05.2.3.3.3 Measles, Mumps, Rubella (MMR)
05.2.3.3.4 Varicella
05.2.3.3.5 Tetanus/Diphtheria/Pertussis (Td/Tdap)
05.2.3.3.6 Meningococcal Vaccination

1
 05.2.3.4. Occupational injuries
i. Policy and procedures in case of exposure to needle stick injuries
(NSIs) & exposure to the blood or other body fluid
ii. Post-exposure management of HIV, Hepatitis B & Hepatitis C Virus
iii. Policy and procedures in case of exposure to none needle stick in-
juries (NSI) as; (musculoskeletal disorders, workplace violence & falls)
05.2.3.5. Disability evaluation and Workers’ compensation
05.2.3.6 Work restriction rules for important infectious diseases
05.2.3.7 Training

06. Occupational Health Hazards among Health Care Workers

07. Management of Certain Occupational Infections
07.1 Airborne and Droplet Infections
07.1.1 Occupational exposure to MERS-CoV patient
07.1.2 Mycobacterium Tuberculosis (TB) Exposure
07.1.3 Meningococcal Disease Exposure
07.2 Management of blood borne pathogens:
 Recommendations for Managing Healthcare Providers Infected with
o Hepatitis B Virus (HBV)
o Hepatitis C Virus (HCV)
o Human Immunodeficiency Virus (HIV)

08. Women in health sector

06.1 Pregnant healthcare workers
06.1.1 Pregnant healthcare workers exposed to infections
06.1.2 Pregnant healthcare workers exposed to radiation
06.1.3 Pregnant healthcare workers exposed to chemotherapeutic agents

09. References

2
Acronyms (Abbreviations):
ACIP: Advisory committee on Immunization Practices.
AFB: Acid Fast Bacilli.
ALT: Alanine transaminase (also, called alanine aminotransferase (ALAT) was formerly called se-
rum glutamate-pyruvate transaminase (SGPT) or serum glutamic-pyruvic transaminase
(SGPT)).
BCG: Bacillus Calmette – Guerin.
CBC: complete blood count. CBC: Complete blood count.
CDC: Centers for Disease Control and Prevention.
CRS: Congenital Rubella Syndrome.
CXR: chest x-ray.
EIA: Enzyme immunoassay.
ELISA: enzyme-linked immunosorbent assay.
EPP: Exposure Prone Procedures.
FDA: Food and Drug Administration.
GI: Gastrointestinal.
HB: Hepatitis B.
HBIG: Hepatitis B immunoglobulin.
HBV: Hepatitis B virus.
HCP: Health care professionals / Health-Care Personnel.
HCV: Hepatitis C virus.
HCW: Healthcare Worker.
HD: Hazardous Drug.
HESN: Health Electronic Surveillance Network.
HGB: Hemoglobin.
HIV: Human Immunodeficiency Virus.
I.M: Intra muscular.
IAEA: International Atomic Energy Agency.

3
ICRP: International Commission on Radiological Protection.
IG: Immunoglobulin.
IgG: Immunoglobulin G.
IGRA: Interferon-gamma release assay.
ILO: International labor of organization
IT: Information technologist.
IV: Intravenous.
KPI: Key performance indicators.
LAIV: Live attenuated influenza vaccine.
LFT: Lever function test.
LTBI: Latent Tuberculosis Infection.
MERS: Middle East Respiratory Syndrome.
MERS-CoV: Middle East Respiratory Syndrome Coronavirus.
MMR: Measles, Mumps, Rubella.
MOH: Ministry of Health.
MTB: Mycobacterium tuberculosis bacteria.
NIOSH: National institute for occupational safety and Health.
OHC: Occupational Health Clinic.
OSHA: Occupational Safety and Health Administration.
PFP: Post exposure Prophylaxis.
PPD: purified protein derivative.
PPE: Personal Protective Equipment.
RBC: Red blood cell count (RBC).
RIBA: Recombinant immunoblot assay.
RSV: Respiratory Syncytial Virus.
S.C.: Subcutaneous.
SHEA: Society for Healthcare Epidemiology of America.
Tdap: Tetanus, diphtheria & pertussis.
TNF: Tumor necrosis Factor.

4
TST: Tuberculin Skin Testing.
TSTs: Tuberculin Skin Tests.
USP: United States Pharmacopeia.
VZIG: Varicella zoster immunoglobulin.
WBC: White blood cell count.
WHO: World health organization.
WPV: Workplace violence.

5
01 Ministry of Health Message:
The Ministry of Health, represented by the General Directorate of Occupational
Health, works hard in all its possibilities and spare no effort through developing the oc-
cupational health clinics program in healthcare facilities, individually or in cooperation with
other parties, to maintain our employees well-being and health, to help them perform in
a safe and healthy environment, and to help them to get their best work, ability and
productivity.

02 Introduction and Executive Summary:

Worldwide, the healthcare workforce represents 12% of the working population. A
health facility is, in general, any location where healthcare is provided. The number and
quality of health facilities in a country or region is one common measure of that area's
prosperity and quality of life.
Healthcare workers operate in an environment that is considered to be one of the
most hazardous occupational settings. In addition to the usual workplace related exposures,
healthcare workers encounter diverse hazards due to their work related activities. Every day,
they exposed to a complex variety of occupational health hazards including biological, phys-
ical, chemical, psychosocial and ergonomics hazards. To protect the health care workers
from these hazards, an occupational health clinic must be developed based on this program,
according to the institution specific needs, location and potential exposures.
Occupational health clinics offer comprehensive medical care for those with work-
related injuries, illnesses, and more. Getting injured on the job is a serious issue. You need
to ensure that you get proper care, and that the care you receive is in compliance with your
employer's requests. Work injuries or sickness also need to have proper documentation.
The director of the clinic should be a physician who is board-certified / specialist in
occupational medicine or a medical doctor who had extensive experience in managing oc-
cupational health services. If such qualifications is not available (due to the shortage of

6
 doctors trained in occupational medicine), the clinic may be managed by a specialized phy-
sicians in family medicine, community medicine, public health, or a general practitioner with
proper training in occupational health from an occupational medicine consultant. These
functions may also be performed by a qualified registered nurse, preferably an occupational
health nurse, under the direction of a suitably qualified physician who has responsibility for
the clinic.

03 Important Definitions:
1. Occupational Health (OH) is the promotion and maintenance of the highest degree of
physical, mental and social well-being of workers in all occupations and not merely the
absence of disease; by preventing departures from health, controlling risks and the ad-
aptation of work to people, and people to their jobs. (ILO / WHO 1950). Or As such,
Occupational Health deals with the impact of work on health and health on work.
2. Occupational safety is your legal right to work in conditions that are free of known
dangers. The requirements of the Occupational Safety and Health Act of 1970 helps
employers prevent the number of workplace injuries, illnesses and deaths. Or is a multi-
disciplinary field concerned with the safety, health, and welfare of people at work.
3. Occupational injury according to ILO (International Labor Organization); An occupational
injury is defined as any personal injury, disease or death resulting from an occupational
accident; an occupational injury is therefore distinct from an occupational disease, which
is a disease contracted as a result of an exposure over a period of time to risk factors
arising from work activity.
4. Occupational accident is an unexpected and unplanned occurrence, including acts of
violence, arising out of or in connection with work which results in one or more workers
incurring a personal injury, disease or death.

7
5. Occupational hazard is a hazard experienced in the workplace. Occupational hazards can
encompass many types of hazards, including chemical hazards, biological hazards (bio-
hazards), psychosocial hazards, and physical hazards, mechanical hazards and ergonomics
hazards.
6. Biological hazards for healthcare workers also called occupational infections among HCW.
7. Occupational disease is an adverse health condition in human being, its occurrence or
severity is related to exposure to factors on the job or on the work environment. Or is
any disease contracted primarily as a result of an exposure to risk factors arising from
work activity.
8. Work-related diseases multi factorial diseases that occur among general population
&workers. Or have multiple causes, where factors in the work environment may play a
role, together with other risk factors, in the development of such diseases.
9. Occupational health service is a service established in or near a place of employment
for the purpose of:
• Protecting the workers against any health hazards which may arise out of the
work, or the conditions in which it is carried on.
• Contributing towards the workers physical and mental adjustment, in particular
by the adaptation of the work to the workers and their assignments to jobs for
which they are suited.
• Contributing to the establishment and maintenance of the highest possible de-
gree of physical and mental well-being of the workers. (3 June 1959 I.L.O).
10. Health-care personnel (HCP) are defined as a person (e.g., employees, students, contrac-
tors, attending clinicians, public-safety workers, or volunteers) whose activities involve
contact with patients or with blood or other body fluids from patients in a health-care,
laboratory, or public-safety setting. HCP might include (but are not limited to) physicians,
nurses, nursing assistants, therapists, technicians, emergency medical service personnel,
dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and
trainees, contractual staff not employed by the health-care facility, and a person (e.g.,
clerical, dietary, housekeeping, laundry, security, maintenance, administrative, billing, and

8
 volunteers) not directly involved in patient care but potentially exposed to infectious
agents that can be transmitted to and from HCP and patients.
11. Exposure Prone Procedures (EPP): Any invasive procedures where there is a risk that injury
to the worker may result in exposure of the pa-taint’s open tissues to the blood of the
worker. There include procedures where the worker’s gloved hands may be in contact with
sharp instruments, needle tips or sharp tissues (e.g. specula of bone or teeth) in-side a
patient’s open body cavity, wound or confined anatomical space where the hands or fin-
gertips may not be completely visible at all times.

04 Policy:
Each healthcare facility must establish an occupational health clinic program to
ensure the wellbeing and safety of all workers in the institution and protect patients from
being exposed to any health hazard in health care facility; and aiding the workers which
suffering from occupational diseases or injuries to post-exposure management, disability
evaluation and compensation.

05 Procedure:
05.1 Administrative procedures:
a. The Occupational Health Clinic Program in each health care facility is supervised by
the occupational health department in the health affairs directorate.
b. Each healthcare facility must dedicate a suitable space for an occupational health clinic.
The clinic could be administratively under the medical director of the hospital, or the
medical director of the outpatient department, or public health unit, or the occupa-
tional health unit in the health care facility.
c. During off-duty hours, weekends and national holidays, the emergency medical ser-
vices department will be responsible for employee health matters that need urgent

9
 attention, e.g. post-exposure management of work related injuries (needle stick inju-
ries/ sharp injury/ blood and body fluids splashes/ falls/ and physical workplace vio-
lence).
d. Clinical staffing should be as the following:
i. Physician, preferably with experience or certification in occupational medi-
cine/ or family medicine/ or public health/ or community medicine.
ii. Nurse, preferably with experience or certification or courses in occupational
health or public health.
iii. Clerk.
e. Clinic equipment:
i. Specific space in outpatient department (OPD).
ii. Clinical examination room equipped with:
1. Examination table and chair.
2. Bedside light source.
3. Bedside table for patient equipment.
4. Ladder for the patient.
5. Examination and treatment requirements (e.g. pulse counter, medical
thermometer, sphygmomanometer for measuring blood pressure,
weight and height scales, injections, etc.).
6. Desk for the physician and chair for the patient.
7. Desktop and internet connection for data entry (e.g. occupational inju-
ries data, Health Electronic Surveillance Network (HESN), etc.).
8. Software for data entry and electronic health record access.
9. Hand washing basin and alcohol-based hand rub dispenser.
10. Cupboard for saving supplies.
11. Vaccination refrigerator.
iii. Administrative room for nurses and administrative clerk equipped with:
a. Desks for nurses and clerk.

10
 b. Two Desktop and internet connection for data entry (e.g. occu-
pational injuries data, Health Electronic Surveillance Network
(HESN), etc.).
c. Software for data entry and electronic health record access.
d. Printer, fax, scanner, and a photocopy machine.
e. Cupboard for keeping staff medical files.
f. Files, papers, pens and pencils, etc.
f. The clinic will generate reports of key performance indicators (KPI) monthly/ yearly as
the following:
I. Percentage of employees with files in OHC (number of employees
with files/total number of the facility employees X100).
II. Percentage of employees who completed pre-employment & periodic
medical examinations.
III. Percentage of each vaccine coverage in employees:
• HBV
• Influenza (yearly)
• MMR
• Chicken pox
• Tdap
• Meningitis
IV. Percentage of employees who received PPD skin testing:
o Number of employees with PPD conversion
o Number of employees treated for TB
V. Sero-conversion rates Hepatitis B (HB), Hepatitis C virus (HCV), Human
Immunodeficiency Virus (HIV).
VI. Total Number of occupational injuries
 Needle stick/ sharp injury/ splashes numbers.
 Needle stick/ sharp injury/ splashes followed up.
 Needle stick/ sharp injury/ splashes treated.

11
  Needle stick/ sharp injury/ splashes turned positive.
 Needle stick/ sharp injury/ splashes completed investigation.
 PPD/IGRA conversion rates.
 Fall injuries.
 Cases of musculoskeletal disorders.
 Cases of occupational violence.
VII. Total number of patients seen in month/ year:

• Then divided into categories (nurses, doctors, administrators,

technicians, dependent/family, others).
• Divide each category into seen as: acute sickness (non-work
related), acute sickness/injury (work-related), screening, sick
leaves numbers.
VIII. Total number or % of staff who received training in health care facility
about occupational health issues in month or / year.

05.2 Scope of service:

The Occupational Health program will perform the following duties through Oc-
cupational Health Clinic (OHC):
i. Record keeping.
ii. Medical and Occupational history.
iii. Occupational health services:
a. Pre-employment medical examinations.
b. Periodic medical examinations (and follow-up examinations when appro-
priate).
c. Vaccination according to most recent and updated international stand-
ards.
d. Management of occupational injuries.

o Management of needle stick injuries and body fluids exposures (Post

exposure prophylaxis, treatment and follow up in cases of incidents,

12
 and in case of incident with potential transmission of infectious dis-
ease; the case should be referred to the infectious diseases de-
partment in the institution).
o Management and follow up cases of none needle stick injuries (NSI)
as fall injuries, cases of musculoskeletal disorders and cases of occu-
pational violence, and referral as needed.
e. Treatment, rehabilitation, disability and compensation evaluation services.
f. Applying work restriction rules according to international references.
g. Participation in the investigation of occupational health incidents.
h. Occupational health hazard risk assessment and management.
i. Referral of the common cases as chronic diseases & non -emergency
cases.
j. Training.

05.2.1 Record-keeping:
Each employee should have a medical file. The file may be as paper or
electronic. All paper files must be changed to electronic form according to the
MOH policy. The files are kept confidential in a secure place and separate from the
hospital patients’ files.
 The healthcare worker (HCW) file contains the following:
a. HCW bio-data.
b. Initial medical history and examination.
c. Occupational history.
d. Vaccination record.
e. Pre-employment medical examinations.
f. Periodic medical examinations.
g. Results of all investigations.
h. Record of each OHC visit, work restrictions, and sick leaves.
i. All occupational or work-related injuries.

13
 j. Any unusual physical or psychological conditions should be brought to
the physician's attention.
k. Annual required investigations.

05.2.2 Medical and Occupational History

A. Complete medical and occupational history and complete physical examination must
be done for all newly hired healthcare workers.
B. Occupational history includes knowledge about current and previous occupations (du-
ration of exposure, type of exposure, department, use of personal protective equip-
ment, job description, satisfaction and previous department work).
C. Review past illnesses and chronic diseases, particularly atopic diseases such as eczema
and asthma, lung diseases, and cardiovascular disease.
D. Review symptoms, especially shortness of breath or labored breathing on exertion,
other chronic respiratory symptoms, chest pain, and high blood pressure.
E. Identify individuals who are vulnerable to particular exposures (e.g. surgeons, gynecol-
ogists and obstetricians, anesthesiologists, and technicians, laboratory and blood bank
workers exposed to blood and other body fluids, radiologists and technicians exposed
to radiations, etc.).

05.2.3 Occupational health services

The personnel of the health service is its most valuable asset, if health care workers
are troubled by their own ill-health, then they will not be able to give their full attention
to their tasks. In addition, no hospital or clinic can function effectively if there is a high
incidence of ill health among their health care workers.
A good OH service will help to minimize health and social problems for staff.
Setting up a well- managed OH service makes good economic sense. The reduction in
costs due to preventing occupationally related injuries and diseases would offset the
budget consequently. In addition, an OH service has a unique potential to generate
revenue to be self-sustaining.

14
05.2.3.1 Pre-employment Medical Examinations
Ideally, the pre-employment (pre-placement) medical examination strives to place
and maintain employees in an occupational environment adapted to their physiological
and psychological capacities. Offered to new employees to identify any health issues that
may require the provide support. There are two main purposes of pre-employment medical
examinations:
1. To provide base-line health data against which subsequent changes after
employment can be evaluated.
2. To ensure medical fitness for work.
Pre-placement (screening) examination is conducted at the time of employment and
generally consists of worker’s medical, family, occupational and social history; a thorough
physical examination and a range of laboratory/radiological examinations (such as chest
X-ray, electro-cardiogram, vision testing, urine or blood examination, and genetic screen-
ing) based on the nature of the work.
During the employment process and before starting the work at any health care
facilities (hospitals and primary care) each new employee must go through the pre-em-
ployment examination according to the following Pre-employment Examination form.

15
 ‫اﺳﺗﻣﺎرة ﻓﺣص ﻣﺎ ﻗﺑل اﻟﺗوظﯾف ‪Pre-employment examination Form /‬‬
‫رﻗم اﻟﻣﻠف اﻟطﺑﻲ‪.................................................................. Medical record No./‬‬ ‫اﺳم اﻟﻣوظف‪.......................................................................................... :Name/‬‬
‫رﻗم اﻟﮭوﯾﺔ ‪ /‬اﻹﻗﺎﻣﺔ‪................................................................... Resident ID No:/‬‬ ‫اﻟﺟﻧﺳﯾﺔ‪....................................................................................... :Nationality/‬‬
‫اﻟﻘﺳم‪.....................................................................................................Depart/‬‬ ‫اﻟوظﯾﻔﺔ اﻟﻣرﺷﺢ ﻟﮭﺎ‪....................................................... The candidate's job /‬‬
‫اﻟﺗﺎرﯾﺦ ‪.....................................................................................................Date/‬‬ ‫اﻟرﻗم اﻟوظﯾﻔﻲ‪............................................................................. Job Number /‬‬

‫اﻟﻧﺗﯾﺟﺔ‬ ‫اﻟﻧﺗﯾﺟﺔ‬
‫‪Result‬‬ ‫‪Result‬‬
‫اﻟﻔﺣص اﻟﻣﺧﺑري ‪Lab. Examination‬‬ ‫اﻟﻔﺣص اﻟﺳرﯾري ‪Examination‬‬
‫ﻏﯾر ﺳﻠﯾم‬ ‫ﻏﯾر ﺳﻠﯾم‬
‫ﺳﻠﯾم ‪Fit‬‬ ‫ﺳﻠﯾم ‪Fit‬‬
‫‪Unfit‬‬ ‫‪Unfit‬‬
‫اﺷﻌﺔ اﻟﺻدر‪Chest X-ray.........................‬‬ ‫(‪Rt. Eye ...............‬‬ ‫‪/‬‬ ‫اﻟﯾﻣﻧﻰ )‬

‫‪eyes‬‬
‫اﻟﻧظر‬
‫اﺧﺗﺑﺎر اﻟدرن‪Manteaux Test....................‬‬ ‫(‪Lt. Eye. ..............‬‬ ‫‪/‬‬ ‫اﻟﯾﺳرى )‬
‫ِ◌‬ ‫ِ◌‬ ‫ﺗﺣﻠﯾل اﻟﺑول‪Urine Analysis .....................‬‬ ‫ﺗﻣﺎﯾز اﻻﻟوان‪Color Discrimination ...........‬‬
‫ﺻورة دم ﻛﺎﻣل‪C.B.C .............................‬‬ ‫اﻷذن اﻟﯾﻣﻧﻰ‪Rt.Ear ................................‬‬

‫واﻟﻧطﻖ‬
‫اﻟﺳﻣﻊ‬
‫ﺑوﻟﯾﻧﺎ واﻣﻼح‪U&E ....................................‬‬ ‫اﻷذن اﻟﯾﺳرى‪Lt.Ear ...............................‬‬

‫‪L.F.T.‬‬ ‫وظﺎﺋف اﻟﻛﺑد‪...............................‬‬ ‫اﻟﻧطﻖ ‪Vocalization(Speech)...............‬‬

‫اﻟطول ‪Length............................................................‬‬
‫ﺳﻛر اﻟدم‪) .‬ﺻﺎﺋم( ‪F.B.S...........................‬‬

‫ﻓﺣوﺻﺎت آﺧري ‪Other Examination‬‬

‫اﻟوزن ‪weight.............................................................‬‬
‫اﻟﻣﺧدرات‪Narcotic ................................‬‬
‫ﺗﺣدد ‪.................................... Define /‬‬ ‫اﻟﻧﺑض ‪Pulse..............................................................‬‬

‫ﻏﯾر ﻣوﺟود‬ ‫ﻣوﺟود‬ ‫(‪B.P.....................‬‬ ‫‪/‬‬ ‫ﺿﻐط اﻟدم )‬

‫اﻟﻌﻣﻠﯾﺎت اﻟﺟراﺣﯾﺔ اﻟﻛﺑرى او اﻟﺻﻐرى‬
‫‪Major surgical & Small Operation‬‬ ‫اﻟﺟﮭﺎز اﻟﻘﻠﺑﻲ اﻟوﻋﺎﺋﻲ‪C.V.S.......................‬‬
‫ﺗﺣدد ‪.................................... Define /‬‬ ‫اﻟﺟﮭﺎز اﻟﺗﻧﻔﺳﻲ ‪Resp.S..........................‬‬
‫ﻏﯾر ﻣوﺟود‬ ‫ﻣوﺟود‬
‫اﻣراض أﺧرى‪Others...............................‬‬
‫اﻟﺟﮭﺎز اﻟﻌﺻﺑﻲ‪C.N.S ...........................‬‬
‫ﺗﺣدد ‪.................................... Define/‬‬
‫اﻟﺟﮭﺎز اﻟﮭﺿﻣﻲ‪G.I.T…….......…..….…..‬‬
‫إﻋﺎﻗﺔ ﺑدﻧﯾﺔ ‪Phy. disability .....................‬‬
‫اﻟﻔﺣص اﻟﻧﻔﺳﻲ‪Psychological Exam...‬‬
‫ﺗﺣدد‪Define…………………...….........‬‬
‫اﻟﻧﺗﯾﺟﺔ‬ ‫ﺗﺿﺎف اﻟﻔﺣوﺻﺎت اﻟﻣﺻﻠﯾﺔ اﻟﺗﺎﻟﯾﺔ ﻟﻠﻣﺗﻘدﻣﯾن ﻟﺷﻐل اﻟوظﺎﺋف اﻟﺻﺣﯾﺔ‪:‬‬ ‫‪‬‬
‫ﻓﺣوﺻﺎت ﻣﺻﻠﯾﺔ‬
‫‪ To be performed for health care applicants only :‬‬
‫ﻏﯾر ﺳﻠﯾم‬ ‫ﺳﻠﯾم ‪Fit‬‬
‫‪Unfit‬‬
‫"‪Viral hepatitis (B) "HBs Ag‬‬ ‫اﻻﻟﺗﮭﺎب اﻟﻛﺑدي اﻟﻔﯾروﺳﻲ )ب(‬
‫"‪Viral hepatitis (C) "HCV Ab‬‬ ‫اﻻﻟﺗﮭﺎب اﻟﻛﺑد اﻟﻔﯾروﺳﻲ )ج(‬
‫‪HIV Test.‬‬ ‫ﻣﺗﻼزﻣﺔ ﻧﻘص اﻟﻣﻧﺎﻋﺔ اﻟﻣﻛﺗﺳﺑﺔ )إﯾدز(‬
‫‪• Additional screening according to occupational exposure:‬‬ ‫‪ ‬ﻓﺣص اﺿﺎﻓﻲ ﺣﺳب اﻟﺗﻌرض اﻟوظﯾﻔﻲ‪:‬‬
‫اﻟﻧﺗﯾﺟﺔ ‪.................................................................... :Result /‬‬ ‫)‪.............................................................................. (1‬‬
‫اﺿﺎﻓﻲ‬
‫ﻓﺣص‬

‫اﻟﻧﺗﯾﺟﺔ ‪.................................................................... :Result /‬‬ ‫)‪............................................................................... (2‬‬

‫اﻟﻧﺗﯾﺟﺔ ‪....................................................................:Result /‬‬ ‫)‪................................................................................. (3‬‬

‫‪After medical examination the above mentioned is:‬‬ ‫ﺑﻌد اﻟﻛﺷف اﻟطﺑﻲ ﻋﻠﻰ اﻟﻣذﻛور اﻋﻼه اﺗﺿﺢ اﻧﮫ‪:‬‬
‫‪Fit‬‬ ‫ﻻﺋﻖ ﺻﺣﯾﺎ ً‬
‫‪Unfit‬‬ ‫ﻏﯾر ﻻﺋﻖ ﺻﺣﯾﺎ ً‬

‫ﺧﺗم اﻟطﺑﯾب ‪:‬‬ ‫اﻟﺗوﻗﯾﻊ ‪..............................:‬‬ ‫اﺳم اﻟطﺑﯾب ‪.......................................................:‬‬

‫‪Table (1) pre- employment examination tests‬‬

‫‪16‬‬
05.2.3.1.1 Standard Pre-Employment Examinations
A. Physical Exam:
A physical examination will be performed as part of the pre-employment medical screen-
ing process. Conduct a comprehensive physical examination of all body organs, focusing on
the pulmonary, cardiovascular, and musculoskeletal systems. Most physical evaluations will
generally consist of:
o Measuring blood pressure
o Measuring heights and weight
o Documenting body mass index (BMI)
o Measuring pulse rate
o Measuring respiration rate
o Reporting on existing medical illnesses
o Reporting on previous medical history
o Reporting on allergies and general social history
B. TB Screening:
 ALL new HCW need to be screened for latent tuberculosis infection (LTBI) either
by:
o Interferon Gamma Release Assay (IGRA) “preferred if available” or

o Two-Step Tuberculosis Skin Testing (TST) or (2 Step PPD)

 If the TST or (PPD) documentation is Positive:

You will need to do an Interferon Gamma Release Assay (IGRA)

o If Results are negative nothing further is needed.

o If results are positive, a chest x-ray is required.

o If results of chest x-ray are negative, nothing further is required.

o If results of the chest x-ray are positive follow up with further testing is
required. Applicant cannot begin employment until documentation of fol-
low up is provided.

17
 C. Documentation of Immunizations:
Healthcare workers, expected to be in contact with patients directly or indirectly, are required
(as per the GCC infection control manual 3rd edition) to be immune to the following infections:

Table 2: Documentation of Immunizations

Infection Category/ timing Requirement

Measles, Mumps, All HCW/ pre-employment Proof of receiving at least two doses of MMR
Rubella vaccine or
Proof of immunity by lab test (IgG)

Chickenpox (Vari- All HCW/ pre-employment Proof of receiving at least two doses of Varicella
cella) vaccine or
Proof of immunity by lab test (IgG)
or
Clinically documented previous infection

Hepatitis B virus All HCW/ pre-employment Proof of receiving at least three doses of HBV
(HBV) vaccine or
Proof of immunity by lab test (HBsAb =/< 10U)

Meningococcal HCW working at Microbiology Proof of receiving at least one doses of a quad-
meningitis lab pre-employment and then rivalent Meningococcal meningitis vaccine
every 5 years

Influenza vaccine All HCW annually Proof of vaccination is required during the in-
fluenza season (usually December through the
end of April)

18
 D. Drug Screening:
 A drug screen in urine will be performed as part of the pre-placement medical
clearance process.
E. Respirator Fitness Testing:
 Respirator fit testing to an N-95 respirator will be performed as part of pre-
employment health screening visit.
F. Lab investigations: e.g.
 Screening for Hepatitis B virus (HBV), Hepatitis C Virus (HCV), and Human Immu-
nodeficiency Virus (HIV).

05.2.3.1.2 Tuberculin skin testing

Administration and interpretation:
All new hires or new volunteers should undergo baseline testing for tuberculosis using
Tuberculin Skin Testing (TST) or Interferon Gamma Release Assay (IGRA). There are two types of
testing for TB in healthcare workers:
a. Initial baseline testing upon hire.
b. Annual or serial screening: determined by risk assessment of the healthcare facility
and activity.

1-Initial baseline testing

i. Question candidates regarding past positive test results prior to the actual plant-
ing of the TST.
ii. Exclude persons who have had the following from testing:
a. Live vaccine administered within the past 3 weeks or on the same day as the
TST because live-virus vaccines may cause a false negative reaction.
b. Current febrile illness.
c. Documented positive PPD.

19
The procedure is as follows:
Testing for Latent TB Infection:
1. The Tuberculin Skin Test (TST) detects individuals infected with Mycobacterium tu-
berculosis. The skin test is administered intradermal using the Mantoux technique by
injecting 1.0 ml containing 5 TU of purified protein derivative (PPD) solution. If a person
is infected, a delayed-type hypersensitivity reaction is detectable 2 to 8 weeks after
infection. The reading and interpretation of TST reactions should be conducted within
48 to 72 hours of administration by trained healthcare professionals.
2. Equipment and materials 1 cc tuberculin syringe, 26- or 27-gauge needle, ½ inch
(16 mm) long, alcohol swabs and a measuring tool marked in millimeters.
3. Administration:
The Mantoux test is the recommended TST. It is administered by injecting 1.0 ml con-
taining 5 TU of purified protein derivative (PPD) solution intradermal into the volar
surface of the forearm using a 27-gauge needle with a tuberculin syringe.
a. Obtain results of all previous TSTs. Ask the patient to describe what the test
area looked like 2 to 3 days after administration; obtain documentation.
b. Avoid areas of skin with veins, rashes, or excess hair.
c. Cleanse hands with alcohol hand rub.
d. Cleanse the area with an alcohol swab, allowing the area to dry.
e. Clean the rubber top of vial before drawing up solution.
f. Inject the entire antigen just below the surface of the skin on the volar surface
of the forearm, forming a 6-10 mm wheal (a pale, raised area with distinct
edges; has orange peel-like appearance and does not disappear immediately).
g. Avoid covering the area with a bandage or applying pressure to the injection
site.
h. If minor bleeding occurs, dab the injection site with a cotton swab.
i. If no wheal forms, or if a wheal forms that is less than 6 mm, the test should
be repeated immediately, approximately 2 inches from the original site or on
the other arm.

20
 j. Record the date, time, and location of the TST.
k. Instruct the patient not to scratch the site but to use a cool compress to
relieve any itching or swelling.
l. Give a written appointment card for TST reading. Inform the patient of the
importance of returning for a reading of the TST within 48 to 72 hours (2 to 3
days).
m. Provide written information about the TST (a pamphlet or brochure).
NB: Consider calculate and monitor PPD conversion rates
4. Measurement:
a. Measure the induration (hard bump) rather than the erythema.
b. Palpate the area with the fingertips, measuring the diameter of induration
perpendicular to the long axis of the arm.
c. Use a ballpoint pen to mark the edges of the induration.
d. Use a tuberculin skin test ruler or a ruler with millimeter marks to measure
the distance between the two points.
5. Recording and documentation:
a. Record the date that the TST was administered.
b. Record the brand name of the PPD solution, lot number, manufacturer, and
expiration date in the patient’s records.
c. Record results in millimeters of induration (0 mm if there is no induration)
rather than as positive or negative.
d. Record the date and time of reading and the name of the person reading
the TST.
e. Provide the patient and ordering physician with written documentation.
6. Storage and handling:
a. PPD solution must be kept refrigerated at 36–46°F.
b. Avoid fluctuations in temperature; do not store in the refrigerator door.
c. Syringes must be filled immediately prior to administration.

21
 d. Store and transport the tuberculin in the dark as much as possible and avoid
exposure to light.
7. Notes:
a. The TST should not be performed on a person who has a documented history
of either a positive TST result or treatment for TB disease.
b. TST is contraindicated only for persons who have had a severe reaction (e.g.
necrosis, blistering, anaphylactic shock, or ulcerations) to a previous TST.
c. TST results should only be read and interpreted by a trained healthcare pro-
fessional. Patients or family members should not be relied upon to measure
TST results.
d. TB disease must be ruled out before initiating treatment for Latent Tubercu-
losis Infection (LTBI) to prevent inadequate treatment of TB disease.
Table 3: TST interpretation

TST reaction
≥15 mm indu-
induration ≥ 5mm induration ≥10 mm of induration
ration
size

Considered 1. HIV-infected persons. 1. Recent immigrants (within last 5 1. Persons with

positive in 2. Recent contacts of infec- years) from high-prevalence countries. no risk factors
tious TB cases. 2. Injection drug users. for TB
3. Persons with fibrotic 3. Residents or employees of high-risk
changes on chest radio- congregated settings (prisons, jails,
graph consistent with prior long term care facilities for the elderly,
TB. hospitals and other healthcare facili-
4. Organ transplant recipi- ties, residential facilities for patients
ents. with AIDS, and homeless shelters).
4. Mycobacteriology laboratory per-
sonnel.

22
 5. Those who are immuno- 5. Persons with the clinical conditions
suppressed for other rea- previously mentioned.
sons (taking an equivalent 6. Children younger than 4 years of
of ≥ 15 age.
7. Infants, children, or adolescents ex-
posed to adults at high risk for TB dis-
Mg/ day of prednisone for ease.
1 month or more or taking
TNF-α antagonists).

8- Chest Radiograph:
Chest radiographs help differentiate between LTBI and pulmonary TB disease in
individuals with positive TST results.
For TST-positive individuals:
1. Clinical evaluation to exclude active tuberculosis:
a. Order chest radiography as part of a medical evaluation for a person who has a
positive TST.
b. Determine baseline CBC and liver function test (LFT).
2. Refer to the primary care consultant for evaluation and possible prophylaxis. After
baseline testing, routine periodic retesting is recommended for persons who had ab-
normal initial results and other persons at risk for hepatic disease.
3. At any time during treatment, whether or not baseline tests were done, laboratory
testing is recommended for patients who have symptoms suggestive of hepatitis (e.g.,
fatigue, weakness, malaise, anorexia, nausea, vomiting, abdominal pain, pale stools, dark
urine, and chills) or those who have signs of jaundice. Patients should be instructed at
the start of treatment and at each monthly visit to stop taking treatment and to seek
medical attention immediately if symptoms of hepatitis develop and not to wait until a
clinic visit to stop treatment.

23
 9- Special Considerations during Pregnancy:
a. Consider immediate treatment for LTBI if the woman is HIV-infected or has had
recent contact with a TB case and monitor the patient.
b. In the absence of risk factors, wait until after the woman has delivered to avoid
administering unnecessary medication during pregnancy.
c. INH administered daily is the preferred regimen.
d. Supplementation with 50 mg pyridoxine (vitamin B6) is recommended.

05.2.3.1.1 Interferon Gamma Release Assay Testing (IGRA)

Overview Prior to 2001, the diagnosis of Latent Tuberculosis Infection (LTBI) was based
on history, chest x-ray (CXR) and Tuberculin Skin Tests (TSTs). Limitations inherent in using these
criteria for diagnosis led to both an over- and under-diagnosis of LTBI in some patient groups
e.g. over-diagnosis in those previously vaccinated with Bacillus Calmette - Guerin (BCG) and un-
der-diagnosis of LTBI in immunocompromised patients.
Although TST is the preferred test for diagnosing LTBI, TSTs do have limited predictive
value for LTBI in BCG vaccinated and immune-compromised individuals.
For over a decade, Interferon Gamma Release Assays (IGRAs) have been in use as adjunct
tests for Mycobacterium tuberculosis (TB) diagnosis.
What are IGRAs?
1. An IGRA is a blood test that can determine if a person has been infected with TB
bacteria.
2. An IGRA measures how strong a person’s immunity reacts to TB bacteria by test-
ing the person’s blood in a laboratory. And it differs from TSTs in that:
They are not influenced by prior (BCG) vaccine or with most non tuberculous
mycobacteria. Consequently, IGRA can aid in LTBI diagnosis in those with prior BCG
vaccine and in those who have been exposed to non-tuberculous mycobacteria. IGRA
testing does not replace the TST but rather, is used in specific populations that require
additional information to better determine LTBI status. IGRAs and TSTs are imperfect

24
 tests which must be interpreted within the context of the risks the individual faces of
TB infection and the risks for progression to active TB disease.
Two IGRAs Approved by the United States Food and Drug Administration (FDA):
1. QuantiFeron-TB Gold In-Tube test (QFT-GIT).
2. T-spot TB test (T-Spot).
Procedure:
1. A physician discusses IGRA recommendation with employee.
2. Health Centre/Unit provides IGRA pre-test counseling and advice the client
about the site for testing.
3. Ensure that patient has received no live vaccines in the 4 previous weeks.
If the patient has, delay testing until 4 weeks after live vaccine was re-
ceived.
4. Samples to be drawn using an incubator to transport IGRA
5. Samples must be maintained at specified temperature during transport.
6. IGRA results are recorded under the Immunization tab in the TB module
(CDC 2010 &CTC, 2010).
Interpretations of IGRA results:
1. Positive IGRA: This means that the person has been infected with Mycobacte-
rium tuberculosis bacteria (MTB).
2. Additional tests are needed to determine if the person has LTBI or MTB disease.
3. A healthcare provider will then provide treatment as needed.
4. Negative IGRA: This means that the person’s blood did not react to the test and
that LTBI of MTB disease is not likely.

Indications for IGRA Testing:

Avoid IGRA if patient:
1) Is suspected to have active TB disease or if confirmed in the past
2) Is on treatment or has been treated for LTBI
3) Requires serial testing for employment
4) Is a returning traveler or immigrant at low risk of exposure

25
 5) Clinical management will not be influenced by result. Epidemiologic evidence exists for
sequential test based on result but not for parallel testing
Indications for IGRA:
A. TST positive and BCG vaccinated and Low risk TB exposure
B. TST positive and BCG vaccinated and High risk TB exposure
C. TST negative, Immuno-compromised and High risk of TB exposure
D. Unlikely to return for TST read and High risk TB exposure
E. Specific medical conditions e.g. New dialysis clients, before renal or bone-marrow
transplants
F. Client for Tumor necrosis Factor (TNF) inhibitors
G. Previous indeterminate IGRA
H. At discretion of TB Physician

05.2.3.2. Periodic Medical Examinations

These are performed at periodic intervals during employment which involves exposure
to potential hazards that could not be entirely eliminated by preventive and control
measures. The purpose of periodic health examinations is to monitor the health of workers
during the course of their employment.
Their objectives include:
o Identifying as early as possible any adverse health effects caused by work practices
or exposures to potential hazards
o Detecting the possible onset of an occupational disease
o Verifying whether the health of an especially vulnerable or chronically ill worker is
being adversely affected by the work or the work environment
o Monitoring personal exposure with the help of biological monitoring
o Checking the effectiveness of preventive and control measures
o Identifying possible health effects of changes in the working practices, technology
or substances used in the enterprise

26
Table 4: Tests required as periodic medical examinations:

Medical Periodic testing Departments Frequency of

Examinations Examinations
General examination, Blood Screening for HBV, HCW in places that require direct Mandatory once every 12 months.
and blood tests HCV, HIV contact with patient’s blood or body
fluids e.g. blood bank; lab workers;
dentists; anesthesiologists, surgeons;
operations workers; medical waste
workers.

General examination, Blood Screening for HBV, Other departments Once every 24 months
and blood tests HCV, HIV

General examination, Complete blood count Physicians and technicians working mandatory once every 12 months
and total blood (CBC)( differential platelet in radio diagnostic or radio thera-
count count; white blood cell peutic departments and Physicians

count (WBC), red blood cell and technicians working in chemo-

count (RBC), and hemoglo- therapeutic departments
bin (HGB)

General examination, TST Two-step or IGRA HCW who are suspected to be ex- After baseline testing for infection
and TB screening posed to acquire T.B infection during with M. tuberculosis (baseline nega-

work e.g. chest hospital workers; and tive test results).

those working in isolation depart- Mandatory once every 12 months.
ments.

Chest X – ray Recommended for workers with pos- - HCWs with a baseline positive or
itive PPD newly positive test result

- Chest radiographs help differenti-

ate between Latent Tuberculosis In-
fection (LTBI) and pulmonary Myco-
bacterium tuberculosis bacteria
(MTB) disease in Individuals with
positive TST results.

General examination, Audiogram for noise expo- Laundry workers, sterilization center, Once every 24 months
and audiometric test sure. food service area, engineering units,
etc.

27
05.2.3.3 Vaccination:
Because of their contact with patients or infective material from patients, many HCW
are at risk for exposure to (and possible transmission of) vaccine-preventable diseases. Employers
and HCW have a shared responsibility to prevent occupationally acquired infections and avoid
causing harm to patients by taking reasonable precautions to prevent transmission of vaccine
preventable diseases. Vaccination programs are therefore an essential part of infection prevention
and control for HCW. Optimal use of recommended vaccines helps maintain immunity and safe-
guard HCW from infection, thereby helping protect patients from becoming infected.

Table 5: Applying pre-employment immunizations as recommended by CDC and GCC manual

2009 recommended immunizations.

Vaccine Indication Route/ Schedule Booster dose/Notes

Hepatitis B All health care staff 3 doses intra muscular Not recommended
(I.M)
0,1 month, 6 month

Influenza All health care staff 1 I.M dose of inacti- Vaccine repeated annu-
vated injectable vac- ally
cine annually

MMR (Measles, HCP without serologic ev- 2 doses of MMR 4 Persons vaccinated be-
Mumps, Ru- idence of immunity or weeks apart are given tween 1963 and 1967
bella) prior vaccination (Docu- Subcutaneous (S.C) with a killed measles
mented immunity) vaccine alone, killed

vaccine followed by live

vaccine, or a vaccine of

unknown type should

be revaccinated with 2
doses of the live mea-
sles vaccine

28
 Varicella HCP who have no sero- 2 doses of varicella
(Chickenpox) logic proof of immunity, vaccine 4 weeks apart
prior vaccination or his- are given S.C
tory of varicella disease

(Documented immunity)

Tdap (tetanus, Persons without docu- 3 doses I.M o Td booster doses

diphtheria & mented immunity. 0, 1-2 months, every 10 years
pertussis) 6 months o If exposed to a dirty
wound regardless of

the last booster dose

Meningococcal -HCWs participating in Single dose Repeated every 3 years

Hajj if polysaccharide type

-Clinical research Or
-Microbiologists who are Repeated every 5 years
routinely exposed to iso- if conjugate type

lates of N. meningitides

CDC (2011)

05.2.3.3.1 Hepatitis B vaccine:

Hepatitis B Unvaccinated healthcare workers (HCW) and/ or those who cannot doc-
ument previous vaccination should receive either a 2-dose series of Heplisav-B at 0 and 1
month or a 3-dose series of either Engerix-B or Recombivax HB at 0, 1, and 6 months.
HCP who perform tasks that may involve exposure to blood or body fluids should be
tested for hepatitis B surface antibody (anti-HBs) 1–2 months after dose #2 of Heplisav-B
or dose #3 of Engerix-B or Recombivax HB to document immunity.
 If anti-HBs is at least 10 mIU/mL (positive), the vaccine is immune. No further sero-
logic testing or vaccination is recommended.
 If anti-HBs is less than 10 mIU/mL (negative), the vaccine is not protected from
hepatitis B virus (HBV) infection, and should receive another 2-dose or 3-dose series

29
 of HepB vaccine on the routine schedule, followed by anti-HBs testing 1–2 months
later. A vaccine whose anti-HBs remains less than 10 mIU/ mL after 2 complete series
is considered a “non-responder.” For non-responders: HCP who are non-responders
should be considered susceptible to HBV and should be counseled regarding pre-
cautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any
known or probable parenteral exposure to hepatitis B surface antigen (HBsAg)-
positive blood or blood with unknown HBsAg status.
It is also possible that non responders are people who are HBsAg positive. HBsAg
testing is recommended.
HCW found to be HBsAg positive should be counseled and medically evaluated. For
HCP with documentation of a complete 2-dose (Heplisav-B) or 3-dose (Engerix-B or
Recombivax HB) vaccine series but no documentation of anti-HBs of at least 10
mIU/mL (e.g., those vaccinated in childhood): HCW who are at risk for occupational
blood or body fluid exposure might undergo anti-HBs testing upon hire or matric-
ulation.
05.2.3. 3.2 Influenza vaccine:
All HCW, including physicians, nurses, paramedics, emergency medical technicians,
employees of nursing homes and chronic care facilities, students in these professions, and
volunteers, should receive annual vaccination against influenza. Live attenuated influenza
vaccine (LAIV) may be given only to non-pregnant healthy HCW age 49 years and younger.
Live attenuated influenza vaccine (LAIV) is preferred over LAIV for HCW who are in close
contact with severely immunosuppressed patients (e.g., stem cell transplant recipients)
when they require protective isolation.
05.2.3.3.3 Measles, Mumps, Rubella (MMR):
HCW who work in medical facilities should be immune to measles, mumps, and
rubella. HCW can be considered immune to measles, mumps, or rubella only if they have
documentation of (a) laboratory confirmation of disease or immunity or (b) appropriate
vaccination against measles, mumps, and rubella (i.e., 2 doses of live measles and mumps
vaccines given on or after. The first birthday and separated by 28 days or more, and at

30
 least 1 dose of live rubella vaccine). Health care professionals (HCP) with 2 documented
doses of MMR are not recommended to be serologically tested for immunity; but if they
are tested and results are negative or equivocal for measles, mumps, and/or rubella, these
HCP should be considered to have presumptive evidence of immunity to measles, mumps,
and/or rubella and are not in need of additional MMR doses. 2 doses of MMR vaccine
should be considered for unvaccinated HCW born before 1957 that do not have laboratory
evidence of disease or immunity to measles and/or mumps. One dose of MMR vaccine
should be considered for HCP with no laboratory evidence of disease or immunity to
rubella. For these same HCP who do not have evidence of immunity, 2 doses of MMR
vaccine are recommended during an outbreak of measles or mumps and 1 dose during
an outbreak of rubella.
05.2.3.3.4 Varicella:
It is recommended that all HCP be immune to varicella Evidence of immunity in
HCW includes documentation of 2 doses of varicella vaccine given at least 28 days apart,
laboratory evidence of immunity, laboratory confirmation of disease, or diagnosis or veri-
fication of a history of varicella or herpes zoster (shingles) by a healthcare provider.
05.2.3.3.5 Tetanus/Diphtheria/Pertussis (Td/Tdap):
All HCWs who have not or are unsure if they have previously received a dose of
Tdap should receive a dose of Tdap as soon as possible, without regard to the interval
since the previous dose of Td. Pregnant HCP should be revaccinated during each preg-
nancy. All HCWs should then receive Td boosters every 10 years thereafter.
05.2.3.3.6 Meningococcal Vaccination:
With MenACWY and MenB is recommended for microbiologists who are routinely
exposed to isolates of N. meningitides. The two vaccines may be given concomitantly but
at different anatomic sites, if feasible Immunization Action Coalition 2017 CDC 2018 - IAC
2018.

31
05.2.3.4. Occupational injuries:
Statistics show that a hospital is one of the most hazardous places to work. The
following types of injuries are most prevalent among healthcare workers:
a. Needle stick injuries “NSIs” (blood borne pathogens):
o The most prevalent, least reported, and largely preventable serious risk health
care workers face comes from continuing use of inherently dangerous conven-
tional needles, such unsafe needles transmit blood borne infections to health
care workers employed in a wide variety of occupations.
o Elimination of unnecessary sharps and use of safer needles can dramatically
reduce needle stick injuries.
b. Musculoskeletal disorders:
o Rank second among all work related injuries, with the greatest number occur-
ring among the health care workers.
o Exposures include the requirements to lift, pull, slide, turn and transfer patients,
more equipment and stand for long hours.
c. Workplace violence:
o Workplace violence (WPV) is a recognized hazard in the healthcare industry.
o WPV is any act or threat of physical violence, harassment, intimidation, or other
threatening disruptive behavior that occurs at the work site.
o WPV ranges from threats and verbal abuse to physical assaults and even hom-
icide.
o According to OHSA, health care and social service workers are at high risk of
being violently assaulted at work.
o Unfortunately, many more incidents probably go unreported.
o NIOSH recommends that all hospitals develop a comprehensive violence pre-
vention program.
d. Falls, (Slip and fall from fluids spilled onto the floor):
o When water or liquids are spilled on the floor of a nursing home or hospital, a
healthcare worker can fall on the slick floor.

32
i. Policy and procedures in case of exposure to needle stick injuries (NSIs) & exposure to
the blood or other body fluid.
1. Emergency management of cases:
HCW who experience a needle stick or sharps injury or are exposed to the blood or other
body fluid of a patient during the course of work, should immediately follow these steps:
a. Do not apply pressure to the wound, or do not suck/ squeeze blood from the
injured site; allow it to bleed freely.
b. Wash the wound with a lots of soap and water. If exposure is to the eyes wash
with eyes solution or running tap water for 1 minute at least. , if such a puncture
comes through a gloves, remove gloves and wash your hands.
c. Identify the patient involved so that they can be evaluated for an infection
d. Immediately report the injury to the supervisor; do not wait until the end of the
shift or the end of the procedure
e. Immediately seek medical treatment. And get a medical assessment.
f. Follow the directions for any necessary blood tests, vaccinations, or medications
to prevent infection.
g. Notification by document the incident on the forms at the Occupational Health
Clinic (OHC) in HESN program (Occupational injury form).
h. A risk assessment should be made based on the significance of the exposure,
the HCW prior immunity to Hepatitis B and the known or likely status of the patient
for blood born viruses. This should be carried out by OHC and/or Emergency.
i. If the source patient is known, every attempt should be made to obtain a blood
specimen for testing for blood borne viruses. Check the source patient blood test-
ing status for HIV, Hep B and Hep C, if the patient have testing done in the last
two weeks, use those test results, if not, order HIV, Hep B and Hep C serology for
the source patient. All source patients should be offered tests for the three main
blood born viruses, Hepatitis B, Hepatitis C and HIV. Appropriate pre-test, counsel-
ing and informed consent is a prerequisite of testing the source; this should be
arranged by the manager.

33
 j. Where the risk is high the recipient should be offered prophylaxis medication as
soon as possible; preferably within an hour of the incident.
k. Bloods from the recipient will also be required for serum save. The taking of
blood specimens and the approach to the source for permission to test should be
managed by a third party, i.e. somebody other than the recipient of the injury.
l. The exposed HCW should always get a baseline testing for HIV, Hep B (HBsAg,
HBsAb), and Hep C. Follow up testing at 4, 12, and 24 weeks should be done if the
source patient is positive for HIV, Hep B or Hep C or if the source patient is un-
known.
2. Perform follow-up anti-HBs testing in persons who receive hepatitis B vaccine.
3. Test for anti-HBs 1 – 2 months after last dose of vaccine.
4. Any positive case must be sent to the Infectious Diseases department for treatment,
and the case should be followed-up by the OHC.
5. If the case do not response to treatment and complications appear; a complete
medical report should be sent by the OHC to the disability committee for evaluations
and compensation.
ii. Post-exposure management of HIV, Hepatitis B & Hepatitis C Virus,:

i. HIV post-exposure management:

Post-exposure prophylaxis and consultation with infectious diseases consultant
or department should be offered and initiated as early as possible to all individuals with
exposure that has the potential for HIV transmission, and ideally within 72 hours.
Summary of Recommendations
o PEP is recommended when occupational exposures to HIV occur.
o Determine the HIV status of the exposure source patient to guide need for HIV
PEP, if possible.
o Start PEP medication regimens as soon as possible after occupational exposure to
HIV and continue them for a 4-week duration.
o PEP medication regimens should contain 3 (or more) antiretroviral drugs (listed in
appendix A) for all occupational exposures to HIV.

34
 o Provide close follow-up for exposed personnel (Box 2) that includes counseling,
baseline and follow-up HIV testing, and monitoring for drug toxicity.
o Follow-up appointments should begin within 72 hours of an HIV exposure.
o If a newer 4th generation combination HIV p24 antigen-HIV antibody test is utilized
for follow-up HIV testing of exposed HCP, HIV testing may be concluded at 4
months after exposure (Box 2).
o Expert consultation is recommended for any occupational exposures to HIV and at
a minimum for situations described in (Box 1).
o If a newer testing platform is not available, follow-up HIV, testing is typically con-
cluded at 6 months after an HIV exposure.
Table 6: HIV Post exposure Prophylaxis Regimens:

PREFERRED HIV PEP REGIMENR

altegravir (Isentress®; RAL) 400mg PO Twice Daily PlusTruvada™,1 PO Once Daily [Tenofovir DF (Viread®; TDF)
300mg + tricitabine (Emtriva™; FTC) 200mg])

ALTERNATIVE REGIMENS

(May combine one drug or drug pair from the left column with 1 pair of nucleoside/nucleotide reverse transcrip-
tase inhibitors from the right column.

Raltegravir (Isentress®; RAL) Tenofovir DF (Viread®; TDF) + emtricitabine

(Emtriva™; FTC); available as Truvada

Darunavir (Prezista®; DRV) + ritonavir Tenofovir DF (Viread®; TDF) + lamivudine

(Norvir®; RTV) (Epivir®; 3TC)

Etravirine (Intelence®; ETR) Zidovudine (Retrovir™; ZDV; AZT) +

lamivudine (Epivir®; 3TC); available as Combivir®

Rilpivirine (Edurant™; RPV) Zidovudine (Retrovir®; ZDV; AZT) +

emtricitabine (Emtriva™; FTC)

35
Atazanavir (Reyataz®; ATV) + ritonavir
(Norvir®; RTV)

Lopinavir/ritonavir (Kaletra®; LPV/RTV)

The following alternative is a complete fixed-dose combination regimen and no additional

antiretrovirals are needed: Stribild™ (elvitegravir, cobicistat, tenofovir DF, emtricitabine).

(CDC, 2013)

BOX 1. Situations for Which Expert Consultation for Human Immunodeficiency Virus (HIV) Postex-
posure Prophylaxis (PEP) is Recommended

Delayed (i.e., later than 72 hours) exposure report

•Interval after which benefits from PEP are undefined

Unknown source (e.g., needle in sharps disposal container or laundry) •Use of PEP to be decided
on a case-by-case basis
•Consider severity of exposure and epidemiologic likelihood of HIV exposure
•Do not test needles or other sharp instruments for HIV

Known or suspected pregnancy in the exposed person

•Provision of PEP should not be delayed while awaiting expert consultation

Breastfeeding in the exposed person

•Provision of PEP should not be delayed while awaiting expert consultation

Known or suspected resistance of the source virus to antiretroviral agents

•If source person’s virus is known or suspected to be resistant to one or more of the drugs considered
for PEP, selection of drugs to which the source person’s virus is unlikely to be resistant recom-
mended
•Do not delay initiation of PEP while awaiting any results of resistance testing of the source person’s
virus

Toxicity of the initial PEP regimen

•Symptoms (e.g. Gastrointestinal (GI) symptoms and others) often manageable without changing
PEP regimen by prescribing antimotility or antiemetic agents
•Counseling and support for management of side effects is very important as symptoms are often
exacerbated by anxiety.

Serious medical illness in the exposed person

•Significant underlying illness (e.g. renal disease) or an exposed provider already taking multiple
medications may increase the risk of drug toxicity and drug-drug interactions

36
BOX 2. Follow-Up of Health-Care Personnel (HCP) Exposed to Known or Suspected Human
Immunodeficiency Virus (HIV)-Positive
Sources
Counseling (At the time of exposure, and at follow-up appointments) Exposed HCP should
be advised to use precautions (e.g., use of barrier contraception, avoid blood or tissue dona-
tions, pregnancy, and if possible, breastfeeding) to prevent secondary transmission, espe-
cially during the first 6–12 weeks Post exposure.

For exposures for which PEP is prescribed, HCP should be informed regarding:
•possible drug toxicities (e.g. rash and hypersensitivity reactions which could imitate acute
HIV seroconversion and the need for monitoring) •possible drug interactions, and
•the need for adherence to PEP regimens.

Early Reevaluation after Exposure

Regardless of whether a healthcare provider is taking PEP, reevaluation of exposed HCP
within 72 hours after exposure is strongly recommended, as additional information about the
exposure or source person may be available

Follow-up Testing and Appointments Follow-up testing at a minimum should include:

•HIV testing at baseline, 6 weeks, 12 weeks, and 6 months postexposure; Alternatively, if the
clinician is certain that a 4th generation combination HIV p24 antigen-HIV antibody test is be-
ing utilized, then HIV testing could be performed at baseline, 6 weeks, and concluded at 4
months postexposure.
•Complete Blood counts, Renal and Hepatic Function Tests (At baseline and 2 weeks post-
exposure; further testing may be indicated if abnormalities were detected)

HIV testing results should preferably be given to the exposed healthcare provider at face to
face appointments

37
 ii. Hepatitis B Virus post-exposure management:
Post-exposure prophylaxis and consultation with infectious diseases consultant
or department should be offered, and initiated as early as possible, to all individuals with
exposure that has the potential for Hepatitis B transmission.

Table 7: Post-exposure management of health-care personnel after occupational percutane-

ous and mucosal exposure to blood and body fluids, by health-care personnel, Hepatitis B
vaccination and response status

Post-exposure testing Post-exposure prophylaxis

Health-care personnel
Source pa- HCP test- (HBIG) Post-vaccination
status Vaccina-
tient ing (anti- Hepatitis B im- serologic testing
tion
(HBsAg) HBs) munoglobulin

Documented re-
sponder after com-
No action needed
plete series
(≥3 doses)

HBIG x2 sepa-
Documented non-re- Positive/
— rated — No
Unknown
sponder after 6 doses by 1 month

Negative No action needed

Positive/ <10mIU/m
Response unknown HBIG x1
Unknown L Initiate
after revac- Yes
<10mIU/m cination
3 doses Negative None
L

38
 ≥10mIU/m
Any result No action needed
L

Unvaccinated/incom-
pletely Positive/ Complete
— HBIG x1 Yes
vaccinated or vaccine Unknown vaccination

refusers

(CDC, 2013)

iii. Hepatitis C post-exposure management:

Neither immunoglobulin nor antiviral agents are recommended for HCV post-ex-
posure prophylaxis. Post-exposure consultation with infectious diseases consultant or de-
partment and/or gastroenterology consultant should be offered, and initiated as early as
possible, to all individuals with exposure that has the potential for Hepatitis C transmission.
When HCV infection is identified, the HCW should be referred for medical manage-
ment to a gastroenterologist or other clinician with experience in treating HCV.
Currently, no effective prophylaxis for HCV has been identified. However, if an in-
dividual becomes acutely infected with hepatitis C and is diagnosed at that time, immedi-
ate referral to a gastroenterologist or other specialist experienced in the treatment of
hepatitis C is strongly recommended. Recent data suggest that early treatment of acute
hepatitis C with interferon is highly effective, perhaps as high as 95%.
SECTION 1: Baseline Management
o Following an exposure to blood or body fluid, the clinician should assess the risk
for exposure to HCV.
o Wounds should be washed with soap and water, and should not be squeezed.
o Mucous membranes should be flushed with water.
o Once the clinician has determined that exposure to blood or body fluid has oc-
curred, the following baseline tests should be obtained (see Table below for follow-
up according to baseline results)

39
 Source Patient:
o HCV antibody test (e.g., Enzyme immunoassay (EIA)/ enzyme-linked immuno-
sorbent assay (ELISA)), and if positive, HCV RNA test or Recombinant immunoblot
assay (RIBA)
Exposed HCW:
o Liver panel including liver enzymes
o HCV antibody, and if positive, HCV RNA test

Table 8: Hepatitis C Post-Exposure Management According to Baseline Test Results

Clinical Scenario Follow-Up

Source patient is HCV-antibody No further testing or follow-up is necessary for

negative source patient or the exposed HCW a

Source patient is unavailable or re-

Follow-up HCV antibody at 3 and 6 months a

fuses testing

Manage the exposed HCW as if the source pa-

Source patient is HCV-antibody
tient has chronic hepatitis C (see Section 2: Post-
positive and HCV RNA negative
Exposure Follow-Up) b

Source patient is positive for both Source patient: Counsel and manage as chronic
HCV antibody and HCV RNA and hepatitis C regardless of status of exposed person
Exposed HCW is HCV-antibody Exposed HCW: Follow up as outlined in Section 2:
negative Post Exposure Follow-Up

Exposed HCW tests positive for

Counsel and manage as chronic hepatitis C
both HCV antibody and HCV RNA

40
 a
If at any time the serum ALT level is elevated in the exposed HCW, the clinician should
test for HCV RNA to assess for acute HCV infection.
b
A single negative HCV RNA result does not exclude active infection.
SECTION 2: Post-Exposure Follow-Up for HCV
If the source patient is known to be positive for HCV antibody and/or HCV RNA, the
follow-up schedule for the exposed HCW should be as follows:
Week 4: HCV RNA and liver panel
Week 12: HCV RNA and liver panel
Week 24: Liver panel and HCV antibody
If at any time the serum Alanine transaminase Level (ALT level) is elevated, the clinician
should repeat HCV RNA testing to confirm acute HCV infection.
At any time that exposed HCWs test positive for HCV RNA, the clinician should refer for
medical management by a gastroenterologist or other clinician with experience in treating
HCV.
In the HCW exposed to a hepatitis C-infected source patient, regular follow-up with HCV
RNA testing is recommended in addition to HCV antibody testing, because HCV RNA
testing can identify acute infection within 2 weeks of exposure, whereas accuracy of the
antibody test can be delayed up to several months after acute infection (i.e., “window
period”).

iii. Policy and procedures in case of exposure to non-needle stick injuries (NSI) as; (muscu-
loskeletal disorders, workplace violence & falls).

1. Document the incident (Notification); by reporting in Occupational Health Clinic (OHC).

2. Assessment of the case by the staff in occupational health clinic.

 Investigation & diagnosis

 Fill the occupational health injury form in HESN program
 The case referred to treated or follow-up by specialist (e. g. orthopedic or sur-
gery or emergency departments).

41
 3. If the case do not response to treatment and complications appear ; refereed to
disability committee for worker's compensations

05.2.3.5. Disability evaluation and Workers’ compensation:

Disability evaluation is carried out according to the Saudi occupational disability scale
and Saudi occupational diseases table.
Workers’ compensation allows a worker to have costs covered after any work injury sus-
tained as a direct result of doing work, whether that injury happened at the normal worksite or
not. Also covered are repetitive stress injuries and illnesses that result from exposure to toxins in
the workplace. The worker does not need to show negligence by the employer or anyone else in
order to recover benefits.

05.2.3. 6. Work restriction rules for important infectious diseases

Table 9 : Summary of suggested work restrictions for health care personnel exposed to or
infected with infectious diseases of importance in health care settings, (modified from ACIP
recommendations) GCC manual 2013.

Disease/ problem Work restriction Duration

Conjunctivitis Restrict from patient Until discharge ceases.

contact and contact
with the patient’s envi-
ronment.

Cytomegalovirus No restriction.

42
Diarrheal diseases
· Acute stage (diarrhea with Restrict from patient Until symptoms resolve.
other symptoms) contact, contact with
the patient’s environ-
ment, or food handling.

· Convalescent stage, Salmo- Restrict from care of Until symptoms resolve; consult with em-
nella spp high-risk patients, for ployee health.
example immunocom-
promized patients.

Diphtheria Exclude from duty. Until antimicrobial therapy completed and

2 cultures obtained > 24 hours apart are
negative.

Enteroviral infections Restrict from care of Until symptoms resolve.

infants, neonates, and
immunocompromised
patients and their envi-
ronments.

Hepatitis A Restrict from patient Until 7 days after onset of

contact, contact with Jaundice.
patient’s environment,
and food handling.

43
Herpes simplex
· Genital No restriction.

· Hands (herpetic whitlow) Restrict from patient Until lesions heal.

contact and contact
with the patient’s envi-
ronment.

· Orofacial Evaluate for need to Consult with employee health.

restrict from care of
high risk patients.

Measles
Active Exclude from duty. Until 4 days after the rash appears

From 5th day after 1st exposure through

Post exposure(susceptible Exclude from duty. 21th day after last exposure or until 4 days
personnel) after rash appears.

Meningococcal meningitis Exclude from duty. Until 24 hours after the start of antibiotic
therapy

44
Mumps
· Active Exclude from duty. Until 9 days after onset of parotitis.

· Post exposure (susceptible Exclude from duty. From 12th day after 1st exposure through
personnel) 25th day after last exposure or until 5 days
after onset of parotitis.

Pediculosis Restrict from patient Until treated and observed to be

contact free of adult and immature lice

Pertussis
· Active Exclude from duty. From beginning of catarrhal stage through
3rd wk after onset of paroxysms or until 5
days after start of effective antimicrobial
therapy.

· Postexposure (asympto- No restriction, prophy-

matic personnel) laxis recommended;
Management of Air-
borne and Droplet In-
fectious Disease Expo-
sure in Healthcare
Workers (Chickenpox,
Measles, Rubella,
Mumps, MTB, N. men-
ingitis, Pertussis).

· Postexposure (symptomatic Exclude from duty. Until 5 days after start effective antimicro-
personnel bial therapy.

45
Rubella
· Active Exclude from duty. Until 7 days after rash appears.

· Post exposure (susceptible Exclude from duty From 7th day after 1st exposure
personnel) through 23th day after last exposure and /
or 7 days after rash appears

Scabies Restrict from patient Until cleared by medical evaluation

contact

Staphylococcus aureus infec-

tion
·Active, draining skin lesions Restrict from contact Until lesions have resolved
with patients and pa-
tient’s
environmental or food
handling

· Carrier state No restriction, unless

personnel are epidemi-
ologically linked to
transmission of the or-
ganism

Streptococcal group A Restrict from patient Until 24 hours after adequate

Infection care, contact with pa- antimicrobial therapy
tient’s
environment, or food
handling

46
Tuberculosis
· Active disease Exclude from duty Until proven noninfectious by
Physician
· PPD converter No restriction Treatment for latent TB infection

Varicella
· Active Exclude from duty Until all lesions dry and crust. If only le-
sions that do not crust (macules and pap-
ules), until no new lesions appears within a
24 hours period

· Post exposure (susceptible Exclude from duty From 10th day after 1st exposure
personnel through 21st day (28th day if VZIG
given) after last exposure

Zoster
·Localized, in healthy person Cover lesions; restrict Until all lesions dry and crust
from care of high-
risk patients +

·Generalized or localized in Restrict from patient Until all lesions dry and crust
immunosuppressed person contact

·Post exposure (susceptible Restrict from patient From 8th day after 1st exposure through 21st
personnel) contact day (28th day if VZIG given) after last exposure
or, if varicella occurs, until all lesions dry and
crus. If only lesions that do not crust (macules
and papules), until no new lesions appears
within a 24 hours period

47
Viral respiratory infections, Consider excluding Until acute symptoms resolve
acute febrile from the care of high
risk
patients ++ or con-
tact with their envi-
ronment during
community outbreak
of Respiratory Syn-
cytial Virus (RSV) and
influenza

MRSA (methicillin-resistant Restrict workers with wound drainage Until the infection has
Staphylococcus aureus) (pus) that cannot be covered and healed.
contained with a clean, dry bandage
or who cannot maintain good hy-
giene practices.

Restrict workers with active infections

from activities where it is likely that
others will contact the affected skin,
until the infection has healed.

Restrict food handlers with a lesion

containing pus (such as a boil) or in-
fected wound that is open and drain-
ing unless it is covered.

48
Vancomycin-resistant enterococ- Exclude from work. Until cleared on a case-by-
cus case basis by Infection Con-
(VRE) trol and Employee Health.

+ Those susceptible to varicella and those who are at increased risk of complications due to
varicella, such as neonates and immunocompromised persons of any age
++ High-risk patients as defined by the Advisory committee on Immunization Practices (ACIP) for
complications due to influenza

05.2.3.7. Training:
Training program for all employees in the facility (include new and old employees) dis-
tributed among all months of the year, includes all departments and staff members with the
following topics are included:-
A. Occupational employee clinics (importance & objectives)
B. Occupational health services.
C. Occupational diseases and work related diseases.
D. Occupational health hazards in health care facilities.
E. Vaccination of health care workers.
F. Work stress and workplace violence among health care workers.
G. Occupational injuries in health care facilities.
H. Policies and procedures in cases of sharps and needle-stick injuries, blood and body
fluid exposure incidents.
I. Policy and Procedures in cases of falls, musculoskeletal injuries, and workplace vio-
lence.
J. Personal protective equipment, indications and proper usage.
K. Standard precautions for proper infection control practices

49
 06 Occupational Health Hazards among Health Care Workers

Hospital staff are exposed to a wide range of health hazards in workplace, including
biological, chemical, physical, ergonomic and psychological hazards. Theses hazards put them at
risk of different injuries and disorders.
To reduce the risk that threatens the health of this working group, it is important to
identify the hazards, and define which hazard are predominant and in priority. Training ap-
proaches should be developed and appropriate prevention strategies should be considered to
reduce the risks and minimize the hazards.

i. Biological Hazards
Human diseases caused by work associated exposure to microbial agents such as bacte-
ria, viruses and fungi. The etiology, pathogenesis, clinical findings, diagnosis and treatment of
occupational & non-occupational infections are the same but there are practical differences in
identification of source of exposure, epidemiologic controls and preventive strategies.
Biological hazards in health care industry include blood borne and air borne pathogens.
Most biologic hazards can be classified as infectious or immunologically active. As an example,
accidental injection or splash of blood borne viruses (HIV, hepatitis B, hepatitis C) is the major
hazard of needle stick injuries especially in laboratory and dialysis staff and medical trainers.
Hospital staff have two to three times the tuberculosis infection rate of non-medical
personnel. Laboratory and necropsy room staff are estimated to be between 100 and 200 times
more likely than the general public to develop tuberculosis.
Health care workers are exposed to many infections disease in workplace including: com-
mon cold, influenza, cytomegalovirus, enteric pathogens, herpes simplex virus, measles, mumps,
rubella, Varicella, pertussis, scabies, and staphylococcus. Center for disease prevention and control
recommend hepatitis B, MMR, influenza, Varicella and tetanus vaccination for hospital staff.

ii. Chemical Hazards

50
 Many chemicals in hospitals are capable of producing adverse health effects through
inhalation or by absorption through the skin, which act on the hematopoietic system and damage
the lungs, skin, eyes or mucous membranes.
Chemical hazards in the workplace for health care workers include exposure to anesthetic
gases, antimicrobial drugs, antineoplastic agents, disinfectant agents, ethylene oxide, formalde-
hyde, glutaraldehyde, latex and solvents. Personnel at operating room, delivery area, recovery
units have potential exposure to anesthetic gases which have known adverse effects on repro-
ductive system. Regular maintenance and inspections of anesthesia delivery equipment, use of
scavenging systems, maintenance of room ventilation rate, and provision of training to staff mem-
bers could be effective in reduction of exposure.
Pharmacists, oncology nurses, housekeepers are at risk of exposure to hazardous drugs,
which are prone to health effects on reproductive system and pregnancy outcomes. Implementing
vertical flow biological safety cabinets and personal protective equipment are capable in control-
ling hazardous effects.
Disinfectants such as formaldehyde and glutaraldehyde are associated with irritant and
allergic effects on skin and respiratory system induced asthma.

iii. Physical Hazards

In hospitals; potential physical exposures are:
a) Excessive noise in sterilization center, operating room, food service area and en-
gineering units.
b) Temperature extremes in kitchen facilities, boiler room and laundry.
c) Non-ionizing radiation such as laser and radiofrequency. For example, in the use
of laser therapies, laser radiation absorption can result in thermal damage when
the laser radiation raises the temperature of body tissue, which can result in eye
injuries, as well as skin burns and electric shock.
d) Ionizing radiation exposure can occur in diagnostic imaging procedure, oncology
treatment area and patients treated with radioactive isotope agents. Bodily pro-
tection with aprons containing lead is effective.

iv. Ergonomic Hazards

51
 Ergonomic hazards include heavy lifting, repetitive and forceful movements, and awkward
postures that arise from improper work methods and improperly designed workstations and
equipment. Some examples of task related risk factor for musculoskeletal injuries are patient
transfers, material handling, frequency of lifting, pushing/pulling of objects, and poorly designed
work area. These ergonomic hazards can lead to musculoskeletal disorders which can affect the
nerves, tendons, muscles and supporting structures of the body. Low back pain and carpal tunnel
syndrome are well recognized work related musculoskeletal disorders.

v. Psychosocial hazards
Psychosocial hazards include but aren’t limited to stress, violence and other workplace
stressors. Including negligence and carelessness of health care workers, lack of adequate protec-
tive aids and equipment, inadequate number of staff, excessive workload, failure to observe basic
safety and hygiene guidelines, and inadequate operational knowledge of modern healthcare
equipment.
Work-related mental stress has been described as the adverse reaction experienced by
workers when workplace demands and responsibilities are greater than the worker can comfort-
ably manage or are beyond the workers’ capabilities. It can affect each worker differently and
originate from different sources.
Violence by both patients and coworkers are one of the psychosocial hazards for health
care workers, all violence that hospital staffs experience isn’t physical. Verbal violence is a common
form of violence, which is due to inadequate staffing, ease of hospital entry, presence of money
& drugs, and frustrated family members.
Shift work is one the well-known and inevitable psychosocial hazards in health care set-
ting, which has different health outcomes such as sleep disturbance, psychological disorders,
gastrointestinal problems, cardiovascular diseases and aggravated the underlying diseases (epi-
lepsy, diabetes, asthma).

07. Management of Certain Occupational Infections:

52
 For management, treatment, and prophylaxis, consult with the infectious diseases de-
partment or the infectious diseases consultant in the hospital and refer the exposed HCW to
the infectious diseases department. OHC should continue to follow up the treatment plan
with the HCW while being treated by the infectious diseases department until resolution.

07.1 Airborne & Droplet infections:

07.1.1 Occupational exposure to MERS-CoV patient:
Middle East Respiratory Syndrome (MERS) is a viral respiratory disease caused
by a novel coronavirus (Middle East Respiratory Syndrome Coronavirus, or (MERS-CoV)
.Typical MERS symptoms include fever, cough and shortness of breath. Pneumonia is
common, but not always present. Gastrointestinal symptoms, including diarrhoea, have
also been reported .The virus does not seem to pass easily from person to person
unless there is close contact, such as occurs when providing unprotected care to a
patient.
1- Incubation period
Incubation period: 2 - 14 days.
2- Exposure criteria
 Healthcare Personnel Not Using Recommended Infection-Control Precautions.
 Recommended infection control measures, including standard, contact, and air-
borne precautions, while managing:
 Symptomatic close contacts, patients under investigation, and pa-
tients who have probable or confirmed MERS-CoV infections.
 They should also use recommended infection control precautions
when collecting specimens.
 These individuals should be evaluated and monitored by a healthcare profes-
sional with a higher index of suspicion.

3- Period of communicability

53
 Patients can shed the virus after resolution of symptoms, but the duration of
infectivity is unknown. Patients are not contagious during the incubation period.
Asymptomatic cases might not be contagious.
4- Infection control Standard, Contact and Airborne Precautions
Standard precautions assume that every person is potentially infected or colonized
with a pathogen that could be transmitted in the healthcare setting:
a- Hand Hygiene
HCP should perform hand hygiene before and after all patient contact, contact with
potentially infectious material, and before putting on and upon removal of PPE, includ-
ing gloves. Hand hygiene in healthcare settings can be performed by washing with
soap and water or using alcohol-based hand rubs. If hands are visibly soiled, use soap
and water, not alcohol-based hand rubs.
b- Personal Protective Equipment
Employers should select appropriate PPE. Workers must receive training on and
demonstrate an understanding of when to use PPE; what PPE is necessary; how to
properly use it:
Gloves
 Put on clean, non-sterile gloves upon entry into the patient room or care
area. Change gloves if they become torn or heavily contaminated.
 Remove and discard gloves immediately upon leaving the patient room or
care area.
Gowns
 Put on a clean disposable gown upon entry into the patient room or area.
Change the gown if it becomes soiled. Remove and discard the gown im-
mediately upon leaving the patient room or care area.
Respiratory Protection
 Use respiratory protection (i.e., a respirator) that is at least as protective as
a fit-tested NIOSH-certified disposable N95 filtering face piece respirator
upon entry to the patient room or care area.

54
  For healthcare workers who have facial hair that comes between the sealing
surface of the face piece and the face of the wearer a Powered Air Purifying
Respirator (PAPR) should be used instead.
 The respirator should be the last part of the PPE ensemble to be removed.
 Staff should be medically cleared and fit-tested if using respirators with
tight-fitting face pieces (e.g., a NIOSH-certified disposable N95) and trained
in the proper use of respirators, safe removal and disposal, and medical
contraindications to respirator use.
Eye Protection
 Put on eye protection (e.g., a disposable face shield) upon entry to the
patient room or care area. Remove and discard eye protection immediately
upon leaving the patient room or care area.
Using More than one Kind of Personal Protective Equipment (PPE)
 The following sequence is a general approach to putting on this PPE com-
bination for respiratory pathogens: first gown; then respirator; then goggles
or face shield; then gloves.
 The following sequence is a general approach to removing PPE for respira-
tory pathogens: first gloves; then goggles or face shield; then gown; then
respirator.
 Except for respirator, remove PPE at doorway or in anteroom. Remove res-
pirator after leaving patient room and closing door.
 Perform hand hygiene as described above immediately before putting on
and after removing all PPE.
A fit-tested
 A fit-tested respirator particulate mask (N95 or higher) is required for all
HCWs who will potentially care for patients in respiratory isolation. This will
ensure the prevention of disease transmission to HCWs through the air-
borne route.
 A fit test, tests the seal between the respirator’s face piece and your face. It
takes about 15 to 20 minutes to complete. After passing a fit test with a

55
 respirator, you must use the exact same make, model, style, and size respi-
rator on the workplace.
5- Employee health:
a- Work restrictions :
1. Exposed:
HCP who care for patients with MERS-CoV should be monitored. They
should immediately report any signs (e.g., fever) or symptoms (e.g., cough,
shortness of breath) of acute illness to their supervisor or a facility desig-
nated person (e.g., occupational health services) for a period of 14 days
after the last known contact with a MERS CoV patient, regardless of their
use of PPE.
2. Infected:
HCP who develop any respiratory symptoms after an unprotected exposure
(i.e., not wearing recommended PPE at the time of contact) to a patient with
MERS-CoV should not report for work or should immediately stop working.
These HCP should notify their supervisor, implement respiratory hygiene
and cough etiquette, seek prompt medical evaluation, and comply with work
exclusion until they are no longer deemed infectious to others.
Asymptomatic HCP:
For asymptomatic HCP who have had an unprotected exposure (i.e., not
wearing recommended PPE at the time of contact) to a patient with MERS-
CoV, exclude from work for 14 days to monitor for signs and symptoms of
respiratory illness and fever.

Important considerations:
 If necessary to ensure adequate staffing of the facility, the asympto-
matic provider could be considered for continuing patient care du-
ties after discussion with local, state, and public health authorities.
 Facilities and organizations providing healthcare should:

56
  Implement sick leave policies for HCP, including contract staff
and part-time personnel, that are non-punitive, flexible and
consistent with public health guidance (e.g., policies should
ensure ill HCP who may have MERS-CoV infection stay home,
unless hospital admission for isolation and treatment is rec-
ommended).
 Ensure that all HCP are aware of the sick leave policies.
 Provide employee health services that ensure that HCP have ready
access, including via telephone, to medical consultation and, if
needed, prompt treatment.
6- Occupational health clinic role
Occupational health clinic should perform the following duties:
 Identify individuals who are vulnerable to particular exposures to pa-
tients with suspected or confirmed MERS-CoV to raise their aware-
ness and train them regarding occupational exposure to patients
with suspected or confirmed MERS-CoV
 Medical evaluation for HCWs who had exposure to patients with
suspected or confirmed MERS-CoV
 Follow up of HCWs who had exposure to patients with suspected or
confirmed MERS-CoV
 Reporting for suspected or confirmed to MERS-Co
 Implement sick leave for HCWs who may have MERS-CoV infection
to stay home, unless hospital admission for isolation and treatment
is recommended
 Applying work restriction rules
 Investigation or participation in the investigation of occupational in-
cidents.
 Record keeping, the files are kept confidential in a secure place and
separate from the hospital patient’s files.

57
Figure (1) Management of health care workers HCWs who had exposure to patients with
suspected or confirmed MERS-CoV

58
07.1.2 MYCOBACTERIUM TUBERCULOSIS (TB):
1. Incubation period
2 to 10 weeks after exposure to detection of positive Tuberculin skin test (TST) or Inter-
feron-gamma release assay (IGRA).
Risk of developing active disease is greatest in the first 2 years after exposure.
2. Exposure criteria
Spending time in a room with a person who has active disease without properly wearing
an N95 respirator.
Packing or irrigating wounds infected with Mycobacterium Tuberculosis (MTB) without
wearing an N95 respirator.
3. Period of communicability
Persons whose smears are Acid Fast Bacilli (AFB) positive are 20 times more likely to cause
secondary infections than persons who are smear negative. Children with primary pulmo-
nary MTB are rarely contagious.
4. Employee health
Obtain baseline TST results by doing 2 step TST if these have not been performed recently
and if the HCW was previously negative; perform post-exposure TST test at 8 to 10 weeks;
if the TST test result comes out positive prescribe MTB prophylaxis. Positive IGRA result is
also an indication for MTB prophylaxis.
a. Work restrictions
1. Exposed
None, for persons whose PPD results are positive
2. Infected (HCWs with active T.B disease):
Restrict HCWs with active MTB from duty until after they have taken 2 to 3 weeks
of effective anti-tuberculosis chemotherapy and they have had 3 AFB-negative spu-
tum samples taken over 8 to 24 hours (one must be an early morning specimen).
3. HCWs with Latent T.B
No restriction.
N.B. prophylaxis for latent TB infection, with continuous follow-up.

59
 b. Prophylaxis
Prescribe Isoniazid 300 mg daily for 9 months (or 12 months for HIV-infected per-
sons) and pyridoxine 20-40 mg daily. Consult with Infectious disease consultant for
verification of the most appropriate prophylaxis regimen.

Table 10: Treatment Regimens of TB

Isoniazide Adult: 5 mg/kg Daily x 9 months

Children: 10-20 mg/kg Maximum
OR dose: 300 mg

Rifampin Adults: 10 mg/kg Children: 10-20 Daily x 4 months

mg/kg Maximum dose: 600 mg

(GCC, 2013)

60
61
07.1.3 MENINGOCOCCAL DISEASE EXPOSURE
1. Incubation period
Usually <4 days; range, 1-10 days.
2. Exposure criteria
Extensive contact with respiratory secretions from an infected person without wearing a
mask, particularly when suctioning, resuscitating, or intubating.
3. Period of communicability
Persons are infectious until they have taken 24 hours of effective antibiotic therapy.
4. Employee health
Prescribe prophylaxis; educate exposed HCWs about the signs and symptoms of meningi-
tis.
A. Work restrictions
Exposed:
None.
Infected:
HCW should be restricted from work until they have taken 24 hours of effective antibiotic
therapy.
B. Prophylaxis
Rifampin 600 mg every 12 hours for 2 days (contraindicated in pregnancy) or Ciprofloxacin
500 mg single dose (contraindicated in pregnancy) or Ceftriaxone 250 mg I.M single dose
(safe during pregnancy).

62
07.2. Management of Healthcare Workers infected with blood borne pathogens:

Table 11: Summary Recommendations for Managing Healthcare Providers Infected with Hep-
atitis B Virus (HBV), Hepatitis C Virus (HCV), and/or Human Immunodeficiency Virus (HIV)
(SHEA 2010).

Circulating viral Categories of clinical

Recommendation Testing
burden activities a

HBV
Categories I, II, and III Twice per year
<104 GE/mL No restrictions b

Categories I and II NA
≥104 GE/mL No restrictions b

Category III NA
≥104 GE/mL Restricted c
HCV
No restrictions b
Twice per year
<104 GE/mL Categories I, II, and III
No restrictions b
NA
≥104 GE/mL Categories I and II
Restricted c NA
≥104 GE/mL Category III
HIV
No restrictions b
Twice per year
< 5×102 GE/mL Categories I, II, and III
No restrictions b
NA
≥ 5×102GE/mL Categories I and II
Restricted d
NA
≥ 5×102 GE/mL Category III

Note. These recommendations provide a framework within which to consider such cases; however, each
such case is sufficiently complex that each should be independently considered in context by the expert
review panel (see text).
GE, genome equivalents; NA, not applicable.
a) See categorization of clinical activities.
b) No restrictions recommended, so long as the infected healthcare provider
(1) Is not detected as having transmitted infection to patients;
(2) Obtains advice from an Expert Review Panel about continued practice;
(3) Undergoes follow-up routinely by Occupational Medicine staff (or an appropriate public health offi-
cial), who test the provider twice per year to demonstrate the maintenance of a viral burden of less than
the recommended threshold (see text);

63
 (4) Also receives follow-up by a personal physician who has expertise in the management of her or his
infection and who is allowed by the provider to communicate with the Expert Review Panel about the
provider’s clinical status;
(5) consults with an expert about optimal infection control procedures (and strictly adheres to the
recommended procedures, including the routine use of double-gloving for Category II and Category III
procedures and frequent glove changes during procedures, particularly if performing technical tasks
known to compromise glove integrity [e.g., placing sternal wires]), and
(6) Agrees to the information in and signs a contract or letter from the Expert Review Panel that char-
acterizes her or his responsibilities.
c) These procedures permissible only when viral burden is < 10 4 GE/mL.
d) These procedures permissible only when viral burden is < 5×10 2 GE/mL.

Table 12: Categorization of Healthcare-Associated Procedures According to Level of risk for

Blood borne Pathogen Transmission (SHEA 2010)

Category I: Procedures with minimal risk of blood borne virus transmission

1. Regular history-taking and/or physical or dental examinations, including gloved oral

examination with a mirror and/or tongue depressor and/or dental explorer and per-
iodontal probe.

2. Routine dental preventive procedures (e.g., application of sealants or topical fluoride

or administration of prophylaxis), diagnostic procedures, orthodontic procedures,
prosthetic procedures (e.g., denture fabrication), cosmetic procedures (e.g., bleaching)
not requiring local anesthesia.

3. Routine rectal or vaginal examination.

4. Minor surface suturing.

5. Elective peripheral phlebotomy.

6. Lower gastrointestinal tract endoscopic examinations and procedures, such as sig-

moidoscopy and colonoscopy.

7. Hands-off supervision during surgical procedures and computer-aided remote or ro-

botic surgical procedures.

8. Psychiatric evaluations.

64
Category II: Procedures for which blood borne virus transmission is theoretically possible
but unlikely

1. Locally anesthetized ophthalmologic surgery.

2. Locally anesthetized operative, prosthetic, and endodontic dental procedures

3. Periodontal scaling and root planning.

4. Minor oral surgical procedures (e.g., simple tooth extraction [i.e., not requiring excess
force], soft tissue flap or sectioning, minor soft tissue biopsy, or incision and drainage
of an accessible abscess).

5. Minor local procedures (e.g., skin excision, abscess drainage, biopsy, and use of laser)
under local anesthesia (often under bloodless conditions).

6. Percutaneous cardiac procedures (e.g., angiography and catheterization).

7. Percutaneous and other minor orthopedic procedures.

8. Subcutaneous pacemaker implantation.

9. Bronchoscopy.

10. Insertion and maintenance of epidural and spinal anesthesia lines.

11. Minor gynecological procedures (e.g., dilatation and curettage, suction abortion, col-
poscopy, insertion and removal of contraceptive devices and implants, and collection
of ova).

12. Male urological procedures (excluding transabdominal intrapelvic procedures).

13. Upper gastrointestinal tract endoscopic procedures.

14. Minor vascular procedures (e.g., embolectomy and vein stripping).Amputations, in-
cluding major limbs (e.g., hemipelvectomy and amputation of legs or arms) and minor
amputations (e.g., amputations of fingers, toes, hands, or feet).

15. Breast augmentation or reduction.

16. Minimum-exposure plastic surgical procedures (e.g., liposuction, minor skin resection
for reshaping, face lift, brow lift, blepharoplasty, and otoplasty).

17. Total and subtotal thyroidectomy and/or biopsy

18. Endoscopic ear, nose, and throat surgery and simple ear and nasal procedures (e.g.,
stapedectomy or stapedotomy, and insertion of tympanostomy tubes).

65
 19. Ophthalmic surgery.

20. Assistance with an uncomplicated vaginal delivery.

21. Laparoscopic procedures.

22. Thoracoscopic procedures.

23. Nasal endoscopic procedures.

24. Routine arthroscopic procedures.

25. Plastic surgery.

26. Insertion of, maintenance of, and drug administration into arterial and central venous
lines.

27. Endo tracheal intubation and use of laryngeal mask.

28. Obtainment and use of venous and arterial access devices that occur under complete
antiseptic technique, using universal precautions, “no-sharp” technique, and newly
gloved hands.

Category III: Procedures for which there is definite risk of blood borne virus transmission
or that have been classified previously as “exposure-prone”

1. General surgery, including nephrectomy, small bowel resection, cholecystectomy, sub-

total thyroidectomy other elective open abdominal surgery.

2. General oral surgery, including surgical extractions hard and soft tissue biopsy (if more
extensive and/or having difficult access for suturing), apicoectomy, root amputation,
gingivectomy, periodontal curettage, mucogingival and osseous surgery, alveoplasty
or alveoectomy, and endosseous implant surgery.

3. Cardiothoracic surgery, including valve replacement, coronary artery bypass grafting,

other bypass surgery, heart transplantation, repair of congenital heart defects, thy-
mectomy, and open-lung biopsy.

4. Open extensive head and neck surgery involving bones, including oncological proce-
dures.

5. Neurosurgery, including craniotomy, other intracranial procedures, and open-spine

surgery.

66
 6. Non elective procedures performed in the emergency department, including open
resuscitation efforts, deep suturing to arrest hemorrhage, and internal cardiac mas-
sage.

7. Obstetrical/gynecological surgery, including cesarean delivery, hysterectomy, forceps

delivery, episiotomy, cone, biopsy, and ovarian cyst removal, and other transvaginal
obstetrical and gynecological procedures involving hand-guided sharps

8. Orthopedic procedures, including total knee arthroplasty, total hip arthroplasty, major
joint replacement surgery, open spine surgery, and open pelvic surgery.

9. Extensive plastic surgery, including extensive cosmetic procedures (e.g., abdomi-

noplasty and thoracoplasty).

10. Transplantation surgery (except skin and corneal transplantation).

11. Trauma surgery, including open head injuries, facial and jaw fracture reductions, ex-
tensive soft-tissue trauma, and ophthalmic trauma.

12. Interactions with patients in situations during which the risk of the patient biting the
physician is significant; for example, interactions with violent patients or patients ex-
periencing an epileptic seizure.

13. Any open surgical procedure with a duration of more than 3 hours, probably necessi-
tating glove change.

Note.

a) Does not include subgingival scaling with hand instrumentation.

b) If done emergently (eg, during acute trauma or resuscitation efforts), peripheral phlebotomy is classified

as Category III.
c) If there is no risk present of biting or of otherwise violent patients.
d) Use of an ultrasonic device for scaling and root planing would greatly reduce or eliminate the risk for
percutaneous injury to the provider. If significant physical force with hand instrumentation is anticipated to
be necessary, scaling and root planing and other
Class II procedures could be reasonably classified as Category III.
e) Making and suturing an episiotomy is classified as Category III.

67
f) If unexpected circumstances require moving to an open procedure (eg, laparotomy or thoracotomy),

some of these procedures will be classified as Category III.

g) If moving to an open procedure is required, these procedures will be classified as Category III.
h) If opening a joint is indicated and/or use of power instruments (eg, drills) is necessary, this procedure is

classified as Category III.

i) A procedure involving bones, major vasculature, and/or deep body cavities will be classified as Category
III.
j) Removal of an erupted or nonerupted tooth requiring elevation of a mucoperiosteal flap, removal of

bone, or sectioning of tooth and suturing if needed.

68
 08. Women in health sector:
Women make up about 42% of the estimated global paid working population. A preg-
nant healthcare worker (HCW) may be at risk of occupational exposure to pathogens, radiation
and chemotherapy drugs associated with increased maternal morbidity and mortality as well as
perinatal complications.
In this guidelines; the recommendations of pregnant healthcare worker discuss toward
infectious diseases; chemotherapy drugs and radiation focusing on prevention and management
of exposures.
08.1 PREGNANT HEALTHCARE WORKERS:
06.1.1 Pregnant healthcare workers exposed to infections
06.1.2 Pregnant healthcare workers exposed to radiation
06.1.3 Pregnant healthcare workers exposed to chemotherapeutic agents

08.1.1 Table 13: Pregnant healthcare workers exposed to infections disease-causing agents
that have reproductive hazards for women in the workplace (Quoted from GCC, 2013).

Observed Potentially exposed Preventive

Agent
effects Workers measures

Cytomegalovirus Birth defects, low birth Health care workers in Good hygienic
(CMV) weight, contact with infants practices such
developmental and children as hand washing
disorders

Hepatitis B Low birth weight Health care workers Vaccination

Virus

Human Low birth weight, Health care workers Practice universal pre-
immuno-deficiency Childhood cancer cautions
virus (HIV)

69
Human Miscarriage Health care Good hygienic
parvovirus workers, workers in practices such
B19 contact with infants as hand washing
and children

Rubella Birth defects, Health care workers in Vaccination before

(German low birth weight contact with infants pregnancy if no prior
measles) and children immunity

Toxoplasmosis Miscarriage, Animal care Good hygiene

birth defects, workers, practices such
developmental veterinarians as hand washing
disorders

Varicella- Birth defects, low birth Health care workers, in Vaccination before
zoster virus weight contact with infants pregnancy if no prior
(chickenpox) and children immunity

Workers with immunity through vaccinations or earlier exposures are not generally at risk
from diseases such as hepatitis B, human parvovirus B19, German measles, or chicken pox. But
pregnant workers without prior immunity should avoid contact with infected children or adults.
Workers should also use good hygienic practices such as frequent hand washing to pre-
vent the spread of infectious diseases among workers in elementary schools, nursery schools, and
daycare centers. In addition, they should use universal precautions. Such as glove wearing and
safe disposal of needles.to protect against disease-causing agents found in blood.

70
08.1.2 Pregnant healthcare workers exposed to radiation
A pregnant worker can continue working in an X-ray department as long as there is
reasonable assurance that the fetal dose can be kept below 1 mGy during the pregnancy. It is
important to ensure that pregnant women are not subjected to unnecessary discrimination. Both
worker and the employer carry responsibility towards safety.
The first responsibility for the protection of the conceptus lies with the woman herself,
who should declare her pregnancy to management as soon as the condition is confirmed. The
following recommendations are taken from International Commission on Radiological Protection
(ICRP Publication 84):
 Restricting dose to the conceptus does not mean that it is necessary for pregnant women
to avoid work with radiation or radioactive materials completely, or that they must be
prevented from entering or working in designated radiation areas. It does, however, imply
that the employer should carefully review the exposure conditions of pregnant women. In
particular, their working conditions should be such that the probability of high accidental
doses and radionuclide intakes is insignificant;
 When a medical radiation worker is known to be pregnant, there are three options that
are often considered in medical radiation facilities: 1) no change in assigned working du-
ties; 2) change to another area where the radiation exposure may be lower; or 3) change
to a job that has essentially no radiation exposure. There is no single correct answer for
all situations, and in certain countries, there may even be specific regulations. It is desirable
to have a discussion with the employee. The worker should be informed of the potential
risks, local policies, and recommended dose limits;
 Changing to a position that may have lower ambient exposure is also a possibility. In
diagnostic radiology, this may involve transferring a technician from fluoroscopy to CT
scanning or some other area where there is less scattered radiation to workers. In nuclear
medicine departments, a pregnant technician can be restricted from spending a lot of time
in the radiopharmacy or working with radioiodine solutions. In radiotherapy with sealed
sources, pregnant technicians or nurses might not participate in manual brachytherapy;

71
  An ethical consideration is involved in both of these last two alternatives since another
worker will have to incur additional radiation exposure because a co-worker became preg-
nant;
 There are many situations in which the worker wishes to continue doing the same job, or
the employer may depend on her to continue in the same job in order to maintain the
level of patient care that the work unit is customarily able to provide. From a radiation
protection point of view, this is perfectly acceptable providing the fetal dose can be rea-
sonably accurately estimated and falls within the recommended limit of 1 mGy fetal dose
after the pregnancy is declared. It would be reasonable to evaluate the work environment
in order to provide assurance that high-dose accidents are unlikely; (International Atomic
Energy Agency (IAEA) 2000).

08.1.3 Table 14: Pregnant healthcare workers exposed to chemotherapeutic agents

Hazardous Drug (HD) Handling Activities in Healthcare Workers that can Result in
Exposure

Workers Potentially Exposed Activity Workers Potentially Exposed Activity

Pharmacists, pharmacy technicians Han- Handling drug-contaminated vials

dling drug-contaminated vials Reconstituting powdered or lyophilized drugs and fur-
ther diluting either the reconstituted powder or con-
centrated liquid forms of hazardous drugs
Expelling air from syringes filled with hazardous drugs
Compounding HD powders into custom-dosage forms
Transferring drug solution to Intravenous (IV) bag or
bottle.

Pharmacists, pharmacy technicians, nursing Counting out individual, uncoated oral doses from mul-
tidose bottles
Unit-dosing uncoated tablets in a unit-dose machine
Crushing tablets or opening capsules to make oral liq-
uid dose

72
 Opening ampoules
Preparing topical drugs
Nursing personnel Administering antineoplastic drugs by injection (intra-
muscular, subcutaneous or intravenous (IV)), by inhala-
tion or by nasogastric tube
Spiking the IV set into an HD-containing IV bag (with-
out a closed system)
Priming the IV set with a drug-containing solution at
the administration location
Connecting and disconnecting the IV set to an IV pump
or patient
Nursing personnel, support staff, house- Handling body fluids or body-fluid-contaminated
keeping personnel, laundry personnel clothing, dressings, linens, bedpans, urinals and other
materials
Handling contaminated wastes generated at any step
of the preparation or administration process
Pharmacists, pharmacy technicians, nursing Contacting hazardous drugs present on drug vial exte-
personnel, housekeeping personnel, envi- riors, work surfaces, floors, and final drug products
(bottles, bags, cassettes, and syringes)
ronmental services personnel
Handling unused antineoplastic drugs or antineo-
plastic drug-contaminated waste
Decontaminating and cleaning drug preparation or
clinical areas
Cleaning hazardous drug spills
Physicians, nursing personnel, operating Performing certain specialized HD administration pro-
room cedures such as intraperitoneal chemotherapy (in the
operating room or other locations), bladder instillation,
isolated limb perfusion
Support staff Transporting hazardous throughout the facility

Nursing personnel, housekeeping person- Transporting hazardous waste containers.

nel, waste disposal personnel

Pharmacists, pharmacy technicians, nursing Removing and disposing of personal protective equip-
personnel, housekeeping personnel ment after handling hazardous drugs or waste.

73
Recommendations
Use of Industrial Hygiene Practices to Reduce Exposure to Hazardous Drugs
1. National institute for occupational safety and Health (NIOSH) recommends that a work-
place be safe for all workers, regardless of their reproductive status
2. Several organization’s [Occupational Safety and Health Administration (OSHA) 1999;
NIOSH 2004; ASHP 2006; United States Pharmacopeia (USP) 2008; ONS 2011] recommen-
dations include:
a) The proper use of engineering controls,
b) Administrative controls, and
c) Personal protective equipment [NIOSH 2009].
d) Training of personnel and other critical work practices are instrumental in protecting work-
ers from exposure [NIOSH 2004, 2013].
Additional information on adverse reproductive effects of these drugs can be found in the
drug package inserts and in the Safety Data Sheets (SDS for the drugs.

Implementation of an Alternative Duty or Temporary Reassignment

One such additional precaution is to offer employees who are pregnant, breast-feeding,
or actively trying to conceive the option of alternative duty. Alternative duty does not mean the
worker is excused from work It does suggest some reassignment of duties, often within the same
job, to avoid handling hazardous drugs. For example, various nursing or pharmacy duties can be
redistributed among a team of workers, or the organization of work can be altered to allow those
needing reassignment to still work in many aspects of their jobs (CDC, 2012).

74
09. References:
1. Ahmadi-Javid, A.; Seyedi, P.; Syam, S. (2017). "A Survey of Healthcare Facility Location".
Computers & Operations Research. 79: 223–263.
2. Goniewicz M., Włoszczak-Szubzda A., Niemcewicz M., Witt M., Marciniak-Niemcewicz A.,
Jarosz M. J. Injuries caused by sharp instruments among healthcare workers—interna-
tional and Polish perspectives. Annals of Agricultural and Environmental Medicine. 2012;
19(3):523–527. [PubMed] [Google Scholar].
3. Moore R. M., Jr., Kaczmarek R. G. Occupational hazards to health care workers: diverse, ill-
defined, and not fully appreciated. American Journal of Infection Control. 1990; 18(5):316–
327. [PubMed] [CrossRef] [Google Scholar].
4. Centers for Disease Control and Prevention. Retrieved 2016-06-24.
5. "About OSHA". United States Department of Labor. Retrieved 2016-06-24.
6. Ramos, Athena; Carlo, Gustavo; Grant, Kathleen; Bendixsen, Casper; Fuentes, Axel; Gam-
boa, Rodrigo; Ramos, Athena K.; Carlo, Gustavo; Grant, Kathleen M. (2018-09-02). "A Pre-
liminary Analysis of Immigrant Cattle Feedyard Worker Perspectives on Job-Related Safety
Training". Safety. 4 (3): 37. doi:10.3390/safety4030037
7. Centers for Disease Control and Prevention. Retrieved 2016-07-07.
8. Occupational injuries statistics from household surveys and establishment surveys” (ILO,
Geneva, 2012); http://www.ilo.org/stat/Publications/WCMS_173153/lang--en/index.htm
9. Salvage J., Rogers R., and Cowell R. Nurses at risk. Nursing times. 1998; 94(33):34–35.
[PubMed] [Google Scholar]
10. Triolo P. K. Occupational health hazards of hospital staff nurses. Part II: physical, chemi-
cal, and biological stressors. AAOHN Journal. 1989; 37(7):274–279. [PubMed] [Google
Scholar]
11. Manyele S. V., Ngonyani H. A., Eliakimu E. The status of occupational safety among
health service providers in hospitals in Tanzania. Tanzania Journal of Health Research.
2008; 10(3):159–165. [PubMed] [Google Scholar]
12. Nsubuga F. M., Jaakkola M. S. Needle stick injuries among nurses in sub-Saharan Africa.
Tropical Medicine and International Health. 2005; 10(8):773–781. [PubMed] [CrossRef]
[Google Scholar].

75
13. https://www.solvhealth.com/faq/what-is-an-occupational-medicine-clinic. It is a snapshot
of the page as it appeared on 30 Mar 2019 10:29:52 GMT.
14. WHO and ILO.; Global Plan of Action on Workers’ Health 2008–2017
15. CDC. Immunization of Health-Care Personnel: Recommendations of the Advisory Com-
mittee on Immunization Practices (ACIP). MMWR, 2011; 60(RR-7).
16. WHO Regional office for Eastern Mediterranean, Cairo 2001; Occupational Health; A
manual for primary health care workers.
17. Occupational Medicine Clinical Snippet Taking an Occupational History ;August 2016
18. Occupational health services for health care workers in national health services of South
Africa; A GUIDELINE BOOKLET (2003).
19. Park K. Occupational health. In: Park K, editor. Textbook of Preventive and Social Medi-
cine. 20th ed. Jabalpur: Banarsidas Bhanot Publishers; 2009. p. 708-17. 2.
20. Palmer KT, Poole J, Rawbone RG, Coggon D. Quantifying the advantages and disad-
vantages of pre-placement genetic screening. Occup Environ Med 2004; 61:448-53.
21. https://middlesexhealth.org/careers-at-middlesex-health/new-employee-portal/employee-
health-screening-requirements
22. https://fitforwork.org/blog/employee-health-screening-why-its-worth-doing/
23. Cox RAF, Edwards FC, Palmer K. Fitness for work: the medical aspects, 3rd ed. Oxford:
Oxford Medical Publications; 2009.
24. Serra C, Rodriguez MC, Delclos GL, Plana M, Gómez López LI, Benavides FG. Criteria and
methods used for the assessment of fitness for work: a systematic review. Occup Environ
Med 2007; 64: 304-12.
25. Joseph Pachman : Evidence base for pre-employment medical screening ;Bulletin of the
World Health Organization 2009.
26. QuantiFERON-TB Gold plus (QFT-Plus) Package Insert, Rev. 04. February 2016.
27. . Hoffmann, H., et al. (2016) Equal sensitivity of the new generation QuantiFERON-TB
Gold plus in direct comparison with the previous test version QuantiFERON-TB Gold IT.
Clin. Microbiol. Infect. 22, 701.
28. Centers for Disease Control and Prevention (CDC, 2010). Updated Guide-lines for Using
Interferon Gamma Release Assays to Detect Mycobacterium tuberculosis Infection.
MMWR 2010; 59(RR05):1-25.

76
29. Canadian Tuberculosis Committee (CTC) 2010. Recommendations on Interferon gamma
release assays for diagnosis of latent tuberculosis infection. An Advisory Committee
Statement (ACS). CCDR 2010; 36 (ACS-5):1-22.
30. CDC 2011: General recommendations on immunization: recommendations of the Advi-
sory Committee on Immunization Practices (ACIP). MMWR 2011; 60(No. RR-2).
31. CDC 2011: Immunization of Health-Care Personnel Recommendations of the Advisory
Committee on Immunization Practices (ACIP) Recommendations and Reports / Vol. 60 /
No. 7. MMWR November 25, 2011.
32. Immunization Action Coalition 2017: “Healthcare Personnel Vaccination Recommenda-
tions”. Saint Paul, Minnesota 651-647-9009 www.immunize.org www.vaccineinfor-
mation.org.
33. WHO (2014) Global strategy on human resources for health: Workforce 2030, WHO Li-
brary Cataloguing-in-Publication Data 1-64.
34. Rosenstock L, Cullen MR, Brodkin CA, Redlich CA (2005) Textbook of Clinical Occupa-
tional and Environmental Medicine. 2nd (Edn.), Elsevier inch.
35. Tuberculosis surveillance protocol for Ontario hospitals (2010) OHA/OMA Communicable
Disease Surveillance Protocols, Tuberculosis.
36. Shefer A, Atkinson W, Friedman C, Kuhar DT, Mootrey G, et al. (2011) Immunization of
Health-Care Personnel: Recommendations of the Advisory Committee on Immunization
Practices (ACIP). Center for disease control and prevention 60(RR07): 1-45.
37. La Dou J (2014) Current Occupational and Environmental Medicine 5th (Edn.), Mc Grew
Hill education.
38. Walton AL, Rogers B (2017) Workplace Hazards Faced by Nursing Assistants in the
United States: A Focused Literature Review. Intl J Environ Res Public Health 14(5): 544.
39. Izadi N, Haghighi KS, Malek M (2015), The Results of Medical Surveillance of Health Care
Workers by the First Hospital Occupational Health Clinic. J Mil Med 17(2): 73-79.
40. CDC 2018: “Prevention of Hepatitis B Virus Infection in the United States”. Recommenda-
tions of the Advisory Committee on Immunization Practices. MMWR, 2018; 67(RR1):1–30.
41. IAC 2018: “Pre-exposure Management for Healthcare Personnel with a Documented
Hepatitis B Vaccine Series Who Have Not Had Post-vaccination Serologic Testing”. Ac-
cessed at: www. immun-ize.org/catg.d/p2108.pdf.

77
42. CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and
for Administering Post exposure Management 2013
43. Facts about Hospital Worker Safety September 2013 U.S. Department of Labor
www.osha.gov • (800) 321-OSHA (6742).
44. Bureau of Labor Statistics. 2013 Survey of occupational injuries and illnesses: nonfatal
(OSHA recordable) injuries, industry incidence rates and counts. Washington, DC: US De-
partment of Labor, Bureau of Labor Statistics, Safety and Health Statistics Program; 2014.
Available at www.bls.gov/iif/oshwc/osh/os/osch0052.pdf.
45. Occupational Safety and Health Administration. Safety and health topics: healthcare.
Washington, DC: US Department of Labor, Occupational Safety and Health Administra-
tion. Available at https://www.osha.gov/SLTC/healthcarefacilities/index.html.
46. CDC. NIOSH Occupational Health Safety Network. Cincinnati, OH: US Department of
Health and Human Services, CDC, National Institute for Occupational Safety and Health;
2015. Available at http://www.cdc.gov/niosh/topics/ohsn/.
47. Arnetz JE, Hamblin L, Essenmacher L, Upfal MJ, Ager J, Luborsky M. Understanding pa-
tient-to-worker violence in hospitals: a qualitative analysis of documented incident re-
ports. J Adv Nurs 2015; 71:338–48.
48. Bureau of Labor Statistics. News release: nonfatal occupational injuries and illnesses re-
quiring days away from work, 2013. Washington, DC: US Department of Labor, Bureau of
Labor Statistics, Safety and Health Statistics Program; 2014. Available at
http://www.bls.gov/news.release/osh2.nr0.htm.
49. CDC, 2013: “CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus
Protection and for Administering Post exposure Management” Morbidity and Mortality
Weekly Report (MMWR). Recommendations and Reports / Vol. 62 / No. 10, Dec.20, 2013.
50. CDC, 2013: Updated U.S. Public Health Service Guidelines for the Management of Occu-
pational Exposures to HIV and Recommendations for Post exposure Prophylaxis
51. Society for Healthcare Epidemiology of America (SHEA) 2013: SHEA Guideline for Man-
agement of Healthcare Workers Who Are Infected with Hepatitis B Virus, Hepatitis C Vi-
rus, and/or Human Immunodeficiency Virus. infection control and hospital epidemiology
march 2010, vol. 31, no. 3

78
52. Spotlight on Statistics is a series of fact files on health workforce statistics produced by
the Department of Human Resources for Health,
53. George A, Human Resources for Health: A Gender Analysis. Review paper prepared for
the WHO Commission on the Social Determinants of Health, July 2007.
[http://www.sarpn.org.za/documents/d0002790/index.php]
54. World Health Organization, Gender Equality, Work and Health: A Review of the Evi-
dence. Geneva: World Health Organization, 2006.
55. International Atomic Energy Agency (IAEA) 2000: International Commission on Radiologi-
cal Protection (ICRP), 2000. Pregnancy and Medical Radiation. ICRP Publication 84. Ann.
ICRP 30
56. OSHA [1999]. OSHA Technical Manual, TED 1− 0.15A, Sec VI, Chapter 2: Categorization of
drugs as hazardous. Washington, DC: Occupational Safety and Health Administration
[http://www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.html].
57. NIOSH [2004]. NIOSH Alert: preventing occupational exposures to antineoplastic and
other hazardous drugs in health care settings. 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. 2004–165
[http://www.cdc.gov/niosh/docs/2004-165/].
58. ASHP (American Society of Health-System Pharmacists) [2006]. ASHP guidelines on han-
dling hazardous drugs. Am J Health Syst Pharm 63:1172−1193.
59. U.S. Pharmacopeia (USP) [2008] Revised Chapter (797) Pharmaceutical Compounding-
Sterile Preparations.
60. ONS (Oncology Nursing Society) [2011]. Safe handling of hazardous drugs. 2nd Ed. M.
Polovich, ed. Pittsburgh, PA: Oncology Nursing Society
61. NIOSH [2009]. Personal protective equipment for health care workers who work with
hazardous drugs. 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. 2009−106 [http://www.cdc.gov/niosh/docs/wp-solu-
tions/2009-106/].

79
62. NIOSH [2013]. NIOSH workplace solution document: Medical surveillance for health care
workers exposed to hazardous drugs. Cincinnati, OH: U.S. Department of Health and Hu-
man Services, Centers for Disease Control and Prevention, National Institute for Occupa-
tional Safety and Health, DHHS (NIOSH) Publication No. 2013-103.
63. CDC) 2012: Reproductive Risks Associated with Hazardous Drug Exposures in Healthcare
Workers and Recommendations for Reducing Exposures. department of health and hu-
man services Centers for Disease Control and Prevention National Institute for Occupa-
tional Safety and Health, DHHS (NIOSH) Publication No. 2012–XXX

80
81