Occupational Health: Outbreak Investigation 101
By Gary Evans
In an outbreak situation that affects healthcare workers and patients, occupational health can strike a critical partnership with the infection control department to rapidly resolve the situation.
“If you guys do not already have a good working relationship with your infection control team, I highly recommend it,” said Laura Markman, RN-BC, MS, director of infection prevention at the VA Palo Alto Health Care System. “My team and I work very closely in tandem with our occupational health team.”
Markman reviewed a few infection control basics for an employee health audience at a webinar presented by the Association of Occupational Health Professionals in Healthcare.1
“Not every exposure ends in an outbreak, but every outbreak does start with some type of an exposure,” Markman explained. “You start by defining the exposure. Why would you need a definition? Because that definition will guide how you conduct the investigation. Otherwise, without that, you could be kind of lost, trying to figure out where do you go next and what are your next steps.”
The initial definition is based on who is the most likely to be exposed. This will depend on the type of exposure and the basic mode of transmission.
“You need to know if it’s a respiratory exposure — tuberculosis, influenza, and, of course, COVID-19,” Markman said. “Then, there are skin contact exposures, like scabies. If you are in a facility that has children, you might get chickenpox or measles exposures.”
Pathogens that cause infections have different incubation periods and modes of transmission. For example, Legionella contamination in a hospital water system can become aerosolized in water droplets and infect those who inhale it.
“You need to have a different exposure definition that’s specific for what you’re looking at,” Markman said. “There’s not a one size fits all when you’re talking about what constitutes an exposure.”
Narrowing the definition and determining who is at risk often can be determined by a collaboration between occupational health and infection control.
“Sometimes, we have employees who have gotten sick, and they believe they picked it up from a patient,” Markman explained. “They go to the occupational health person, who then in turn calls us and says, ‘Do you know of anything going on with the patients?’ This works vice versa as well. If we identify a patient who has something that could have been spread to employees, we call up occupational health and work with them.”
Through this process, occupational health may find that employees in a certain unit were exposed by a patient or possibly a sick co-worker.
“Talk to the supervisor of the area in which the exposure took place,” Markman recommended. “Find out how many other employees were there. If it’s an employee who brought in an illness to other employees, who might they have been working with? Who was working at that time? If it’s a patient we’re looking at who might be the source of an exposure, who took care of that patient?”
Once these general parameters come into focus, the default by some clinicians is to simply test everybody in the exposed unit or area.
“Sometimes, it’s easier just to say, ‘OK, let’s just test everybody,’ but is that really a good strategy?” Markman asked. “It really isn’t. Think about resources used — not just for the lab, but also your resources. We usually try to start with who really is the highest risk for exposure, and this is where you’re going to be talking about the time [duration] and distance [from the exposure source].”
A common epidemiological method is to test the most exposed workers and then move out in concentric circles to any close contacts they describe. “You move to your next circle, and then further on out, until you don’t have any more positives,” Markman said.
Using this type of process allowed Markman and her occupational health colleagues to determine that a cluster of COVID-19 in healthcare workers was due to exposures in break rooms when they removed their masks.
REFERENCE
- Association of Occupational Health Professionals in Healthcare. Post-exposure investigation from the infection prevention view. May 23, 2023.
In an outbreak situation that affects healthcare workers and patients, occupational health can strike a critical partnership with the infection control department to rapidly resolve the situation.
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