Work Restrictions For Dental Healthcare Personnel
By Kay Carl, RN, BS, Infection Preventionist
After reading this article, the reader should be able to:
- Identify prevention strategies for employees to stay healthy.
- Identify two references for work restrictions for dental healthcare personnel.
- Compare and contrast the differences in work restrictions for various bloodborne diseases.
GUIDELINESFor years, dental healthcare workers (DHCWs) did not have access to suggested work restrictions for healthcare personnel infected or exposed to major infectious diseases in healthcare settings. In the general healthcare field, guidelines have been written for employee health but were not readily available for the dental community. Fortunately, we now have that information from the Centers for Disease Control and Prevention (CDC) 2003 Guidelines for Infection Control in Dental Health-Care Settings—2003 at http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5217a1.htm. Table 1 in this document is a great resource for the dental office. I will not list every disease as the table is so complete. I do wish to elaborate on some diseases listed as they relate to dentistry since it is important to know when to restrict employees from work.
The Society for Healthcare Epidemiology of America (SHEA) is the infectious disease physicians’ association, and their opinions hold great weight in the infection control and prevention community. These specialists are the ones who are responsible for the evaluation of healthcare personnel and when they should be restricted from patient care. SHEA has provided guidelines since 1990 regarding the management of healthcare providers who are infected with HBV, HCV and HIV. This year the guidelines were updated for the third time and are the most comprehensive to date. They can be found at http://www.nechaonline.org/attachments/ File/2010_Handouts/SHEA1.pdf
VACCINATIONSVaccinations will help prevent you from getting sick from vaccine preventable diseases. Without immunity, if exposed or infected, you may be restricted from work to prevent you from passing the illness on to patients and other staff. The more complete the immunization program you provide for your employees, the less risk you have. For a one-page immunization information form for employees, see the OSHA Toolkit I created.
FLUThis year, according to the CDC:
- Everyone 6 months of age and older should get vaccinated against the flu to be protected for the 2010-2011 season. This is the first time this recommendation has been made. The 2010-2011 flu vaccine will protect against an influenza A H3N2 virus, an influenza B virus, and the 2009 H1N1 virus that caused so much illness last season.
- Vaccination of high-risk persons is especially important to decrease their risk of severe flu illness. This includes young children, pregnant women, people with chronic health conditions like asthma, diabetes, or heart and lung disease, and people 65 years and older.
- Vaccination also is important for healthcare workers and other people who live with or care for high-risk people to keep from spreading the flu to high-risk people
Measles, mumps, rubella, and varicella (chicken pox) are all infections that require the DHCW to be excluded from duty. These are all vaccine-preventable diseases. The CDC recommends DHCWs be vaccinated against these diseases. If an employee is exposed to any of these diseases, has not been vaccinated, and does not have a positive antibody titer for the disease, there are work restrictions for the time period in which the employee could be contagious. Most employees already have been vaccinated for these diseases as part of childhood immunization programs.
The Hepatitis B vaccination series is provided by the employer if the DHCW is exposed to bloodborne pathogens at work. After receiving the series, the employee should be tested for immunity to hepatitis B by getting a blood test for antibodies. Once you test positive for the antibody you are considered protected for life.
Tetanus, Diphtheria, and Pertussis: Tetanus, Diphtheria (Td) is a recommended vaccine for DHCPs. But now there is a new vaccine, known as Tdap, that combines Tetanus, Diphtheria, and Pertussis. As we now know that adults can get Pertussis, the Advisory Committee on Immunization Practices (ACIP) from the CDC recommends substituting a one-time dose of Tdap for adults to replace the next booster dose of tetanus and diphtheria toxoids (Td).
VIRAL RESPIRATORY INFECTIONSUsually, this is the most common form of illness that we deal with in the dental setting, both with employees and patients. The majority of the time the respiratory infection is the common cold but rarely is there a confirmed diagnosis. It could be the flu or another serious respiratory virus. Most dental office staffs are small in number, and the loss of one employee for the day can be disruptive. It is a hard call. Analyze the situation. Is the employee in the initial stages, febrile, coughing, sneezing, and easily able to infect others? Restrict from duty. Are there high-risk patients on the schedule who are medically compromised and not able to tolerate a respiratory infection? Restrict from duty. Is there a place in the office where the employee can be restricted from direct patient care? Can the coughing and sneezing be controlled by medication? Take all this into account before a decision can be made to allow the employee to work. With a confirmed diagnosis, the decision is much easier to make.
In addition, I do not recommend treating patients with respiratory infections. We usually do not have a clear understanding of what disease the patient has, and we do not want to be infected or transmit it to other patients. Patient education is key in this situation, and we should remind the patient that he or she would not tolerate a dental procedure very well. Reclining and being subjected to water spray that can be inhaled can make it an unpleasant experience for the patient. Patients can be educated to not present for treatment when ill.
BLOODBORNE DISEASESSince the early 90’s, healthcare personnel have been covered by the Occupational Safety and Health Administration (OSHA) for protection from bloodborne pathogens. In addition, we have the guidelines from the CDC to protect patients from healthcare personnel who have bloodborne diseases, primarily Hepatitis B, Hepatitis C, and Human Immunodeficiency Virus (HIV).
CDC Dental Guidelines 2003:Hepatitis B (HBV) infected personnel, both acute and chronic, are cautioned to not perform invasive procedures until advice from a review panel is sought.
Hepatitis C (HCV) infected personnel are not restricted from work but are cautioned to follow aseptic techniques and standard precautions (author’s note: see SHEA below).
Human Immunodeficiency Virus (HIV) infected personnel should not perform invasive procedures until counsel from a review panel has been sought.
Medical and dental schools in the United Kingdom and other European countries are now requiring proof of immunity to Hepatitis B before admission. In some countries, healthcare workers infected with Hepatitis B are prohibited from performing exposure-prone procedures. Schools in the United States are also testing students preadmission for immunity. Some schools have formed review panels for this. It can be quite a difficult situation because it puts the school in a tenuous risk management position if it allows the student to treat patients, and the risk of transmission to patients would continue for that individual after completion of studies.
SHEA Guidelines 2010:SHEA recommends that each case should be examined individually to determine whether infected providers can participate in patient-care activities. There are different recommendations for HBV, HCV, and HIV because different viral loads of each pathogen require different surveillance measures and different levels of risk. The guide provides an extensive listing of categories of healthcare-associated procedures, according to the level of risk, and couples that with levels of the viral burden of the practitioner to make these determinations. The guideline recommends enhanced precautions such as double-gloving for patient care procedures. For the dental community, dental procedures are listed in the three risk categories of patient procedures. So it is possible, depending on viral load and category of patient procedure, to allow infected dental providers to provide patient care. Infected providers should be followed by an infectious disease physician.
CONJUNCTIVITISMost of us are aware that an employee who has conjunctivitis (pink eye) is restricted from patient contact and their environment. For years we have also been told that 24 hours after medication has been started, an employee can return to work. This is not true. The work restriction is until the discharge ceases. Employee health personnel are seeing more viral conjunctivitis and if the medication prescribed is for a bacterial infection, it will not be effective and the employee is still contagious.
HERPES SIMPLEXGenital herpes infection has no work restriction but use good hand hygiene and aseptic technique. Herpetic whitlow (hands) infection requires restriction from work until lesions heal. We rarely see this infection in dentistry today since wearing gloves during patient treatment has become the standard of care.
Orofacial infection requires evaluation to consider restricting the care of patients at high risk. Again good hand hygiene and aseptic technique are a must. If a patient presents with active orofacial herpes, a decision must be made as to whether the dental procedure can be safely performed. This is another situation in which patient education is key. A patient who routinely has this infection should be medicated before treatment to prevent infection or taught to reschedule timely with an outbreak.