Occupational Considerations

'IN THIS TOGETHER'

OCCUPATIONAL CONSIDERATIONS

Healthcare
Occupational Exposure --- Although there have been no confirmed cases of occupational transmission of TSE to humans, cases of CJD in healthcare workers have been reported in which a link to occupational exposure is suggested. Therefore, it is prudent to take a precautionary approach. In the context of occupational exposure, the highest potential risk is from exposure to either high or low infectivity tissues through direct inoculation (e.g. needle-sticks, puncture wounds, 'sharps' injuries, or contamination of broken skin) must be avoided. Exposure by splashing of the mucous membranes (notably the conjunctiva) or unintentional ingestion may be considered a hypothetical risk and must also be avoided. Healthcare personnel who work with patients with confirmed or suspected TSEs, or with their high or low infectivity tissues, should be appropriately informed about the nature of the hazard, relevant safety procedures, and high level of safety provided by the proposed procedures described throughout this document.

Post-exposure Management --- Appropriate counseling should include the fact that no case of human TSE is known to have occurred through occupational accident or injury. A number of strategies to minimize the theoretical risk of infection following accidents have been proposed, but their usefulness is untested and unknown. For the present the following common-sense actions are recommended:

Contamination of unbroken skin with internal body fluids or tissues: wash with detergent and abundant quantities of warm water (avoid scrubbing), rinse, and dry. A brief exposure (1 min) to 0,1N NaOH or a 1:10 dilution of bleach can be considered for maximum safety.

Needle sticks or lacerations: gently encourage bleeding; wash (avoid scrubbing) with warm soapy water, rinse, dry and cover with a waterproof dressing. Further treatment (e.g., sutures) should be appropriate to the type of injury. Report the injury according to normal procedures for your hospital or health care facility/laboratory.

Splashes into the eye or mouth: irrigate with either saline (eye) or tap water (mouth); report according to normal procedures for your hospital or health care facility/laboratory.

Health and safety guidelines mandate reporting of injuries and records should be kept for no less than 20 years.

Patient Care --- Normal social and clinical contact, and non-invasive clinical investigations (e.g. x-ray imaging procedures) with TSE patients do not present a risk to healthcare workers, relatives, or the community. There is no reason to defer, deny, or in any way discourage the admission of a person with a TSE into any health care setting. Based on current knowledge, isolation of patients is not necessary; they can be nursed in the open ward using Universal Precautions.

As the disease is usually rapidly progressive, the patient will develop high dependency needs and require ongoing assessment. It is essential to address the emotional, physical, nutritional, psychological, educational, and social needs of the patient and the associated needs of his or her family. Coordinated planning is vital in transferring care from one environment to another.

Private room nursing care is not required for infection control, but may be appropriate for compassionate reasons. Patient waste should be handled according to country, regional or federal regulations. Contamination of body fluids (categorized as no detectable infectivity tissues) poses no greater hazard than for any other patient. No special precautions are required for feeding utensils, feeding tubes, suction tubes, bed linens, or items used in skin or bed sore care in the home environment.

Psychiatric Manifestations --- Caregivers both in the home and health care setting should be made aware and anticipate the possibility of labile psychiatric symptoms e.g. mood swings, hallucinations, or aggressive behavior. For this reason, training and counseling of professional and non-professional caregivers is recommended.

Confidentiality -- Current heightened awareness requires special sensitivity to confidentiality of written and verbal communications. Special measures to safeguard the privacy of the patient and family are essential.

Dental Procedures
Although epidemiological investigation has not revealed any evidence that dental procedures lead to increased risk of iatrogenic transmission of TSEs among humans, experimental studies have demonstrated that animals infected by intraperitoneal inoculation develop a significant level of infectivity in gingival and dental pulp tissues, and that TSEs can be transmitted to healthy animals by exposing root canals and gingival abrasions to infectious brain homogenate. The consultant agreed that the general infection control practices recommended by national dental associations are sufficient when treating TSE patients during procedures not involving neurovascular tissue. The committee was unable to come to a consensus on the risk of transmission of TSEs through major dental procedures; therefore, extra precautions such as those listed have been provided for consideration without recommendation.

Use single-use items and equipment e.g. needles and anesthetic cartridges. Do not re-use dental broaches and burrs that may have become contaminated with neurovascular tissue. Destroy them after use by incineration, or alternatively, decontaminate. Schedule procedures involving neurovascular tissue at the end of the day to permit more extensive cleaning and decontamination.

Diagnostic Procedures
During the earlier stages of disease, patients with TSE who develop intercurrent illnesses may need to undergo the same kinds of diagnostic procedures as any other hospitalized patient. These could include opthalmoscopic examinations, various types of endoscopy, vascular or urinary catheterization, and cardiac or pulmonary function tests. In general, these procedures may be conducted without any special precautions, as most tissues with which the instruments come in contact contain no detectable infectivity. A conservative approach would nevertheless try to schedule such patients at the end of the day to allow more strict environmental decontamination and instrument cleaning. When there is known exposure to high or low infectivity tissues, the instruments should be subjected to the strictest form of decontamination procedure that can be tolerated by the instrument.