Hepatitis B Vaccination and Post-Exposure Follow-Up Procedures

Q. Who must be offered the hepatitis B vaccination?

A. The hepatitis B vaccination series must be made available to all employees who have occupational exposure. The employer does not have to make the hepatitis B vaccination available to employees who have previously received the vaccination series, who are already immune as their antibody tests reveal, or who are prohibited from receiving the vaccine for medical reasons.

Q. When should the hepatitis B vaccination be offered to employees?

A. The hepatitis B vaccination must be made available within 10 working days of initial assignment, after appropriate training has been completed. This includes arranging for the administration of the first dose of the series. In addition, see page 17 for vaccination of designated first aiders.

Q. Can pre-screening be required for hepatitis B titer? Post-screening?

A. No. The employer cannot require an employee to take a pre-screening or post-vaccination serological test. An employer may, however, decide to make pre-screening available at no cost to the employee. Routine post-vaccination serological testing is not currently recommended by the CDC unless an employee has had an exposure incident, and then it is also to be offered at no cost to the employee.

Q. If an employee declines the hepatitis B vaccination, can the employer make up a declination form?

A. If an employee declines the hepatitis B vaccination, the employer must ensure that the employee signs a hepatitis B vaccination declination. The declination’s wording must be identical to that found in Appendix A of the standard. A photocopy of the Appendix may be used as a declination form, or the words can be typed or written onto a separate document.

Q. Can employees refuse the vaccination?

A. Employees have the right to refuse the hepatitis B vaccine and/or any post-exposure evaluation and follow-up. Is important to note, however, that the employee needs to be properly informed of the benefits of the vaccination and post-exposure evaluation through training. The employee also has the right to decide to take the vaccination at a later date if he or she so chooses. The employer must make the vaccination available at that time.

Q. Can the hepatitis B vaccination be made a condition of employment?

A. OSHA does not have jurisdiction over the issue.

Q. Is a routine booster does of hepatitis B vaccine required?

A. Because the U.S. Public Health Service (USPHS) does not recommend routine booster doses of hepatitis B vaccine, they are not required at this time. However, if a routine booster dose of hepatitis B vaccine is recommended by the USPHS at a future date, such booster doses must be made available at no cost to those eligible employees with occupational exposure.

Q. Whose responsibility is it to pay for the hepatitis B vaccine?

A. The responsibility lies with the employer to make the hepatitis B vaccine and vaccination, including post-exposure evaluation and follow-up, available at no cost to the employees.

Q. What information must the employer provide to the healthcare professional following an exposure incident?

A. The healthcare professional must be provided with a copy of the standard, as well as the following information:

•A description of the employee’s duties as they relate to the exposure incident;

•Documentation of the route(s) and circumstances of the exposure;

•The results of the source individual’s blood testing, if available; and

•All medical records relevant to the appropriate treatment of the employee, including vaccination status, which are the employer’s responsibility to maintain.

Q. What serological testing must be done on the source individual?

A. The employer must identify and document the source individual if know, unless the employer can establish that identification is not feasible or is prohibited by state or local law. The source individual’s blood must be tested as soon as feasible, after consent is obtained, in order to determine HIV and HBV infectivity. The information on the source individual’s HIV and HBV testing must be provided to the evaluating healthcare professional. Also, the results of the testing must be provided to the exposed employee. The exposed employee must be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.

Q. What if consent cannot be obtained from the source individual?

A. If consent cannot be obtained and is required by state law, the employer must document in writing that consent cannot be obtained. When the source individual’s consent is not required by law, the source individual’s blood if available shall be tested and the results documented.

Q. When is the exposed employee’s blood tested?

A. After consent is obtained, the exposed employee’s blood is collected and tested as soon as feasible for HIV and HBV serological status. If the employee consents to the follow-up evaluation after an exposure incident, but does not give consent for HIV serological testing, the blood sample must be preserved for 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested for HIV, testing must be done as soon as feasible.

Q. What information does the healthcare professional provide to the employer following an exposure incident?

A. The employer must obtain and provide to the employee a copy of the evaluating healthcare professional’s written opinion within 15 days of completion of the evaluation. The healthcare professional’s written opinion for hepatitis B is limited to whether hepatitis B vaccination is indicated and if the employee received the vaccination. The written opinion for post-exposure evaluation must include information that the employee has been informed of the results of the evaluation and told about any medical conditions resulting from exposure that may further require evaluation and treatment. All other findings or diagnoses must be kept confidential and not included in the written report.

Q. What type of counseling is required following an exposure incident?

A. The standard requires that post-exposure counseling be given to employees following an exposure incident. Counseling should include USPHS recommendations for prevention of HIV. These recommendations include refraining from blood, semen, or organ donation; abstaining from sexual intercourse or using measures to prevent HIV transmission during sexual intercourse; and refraining from breast feeding infants during the follow-up period. In addition, counseling must be made available regardless of the employee’s decision to accept serological testing.

Q. What information about exposure incidents is recorded on the OSHA 300 Log?

Revision 10/02 A. All work-related needlestick injuries and cuts from sharp objects that are contaminated with another person’s blood or other potentially infectious materials must be recorded. Enter the case on the 300 Log as an injury. To protect the employee’s privacy, do not enter the employee’s name. Enter the case on the sharps injury log or enter comparable data on the OSHA 300 Log.

NIOSH Update: Aging Workers at Higher Risk of Death, Severe Injury, Conference Report Suggests Ways to Keep Workers Healthy and Productive

Policy Shifts on Work Environment, Health Promotion, Continued Research Needed to Maintain Healthy U.S. Workforce

A report of conference presentations and discussions among participants from the National Academies of Science, universities and research institutions, and representatives of professional associations, industry and labor, recommends attention to workplace environments to maintain “work ability” as workers age, along with legislative fixes and research to fill in knowledge gaps for keeping workers healthy and productive.

According to researchers using U.S. Bureau of Labor Statistics (BLS) data, older workers are more severely injured and die with greater frequency from work-related injuries than younger workers. Older workers also have longer recovery periods than younger workers. These findings raise health care delivery and economic issues for the nation, as more workers are choosing to delay retirement due to collapsed 401(k) plans and savings. BLS uses workers age 55 and older in its calculations, although the rates rise sharply for those workers over age 65. Other agencies and organizations define the term as age 50 or 55 and up. The Department of Labor uses age 40 as a starting point for “older worker.”

“The issue of healthy aging is critically important as the U.S. economy is revitalized. As we go forward in time, the demand for workers will grow but fewer workers will be entering the workforce and a larger proportion of the workforce will be older. This is a simple reality of demographics,” said National Institute for Occupational Safety and Health (NIOSH) Director John Howard, M.D. “Having a healthy, productive workforce will help sustain economic growth in the decades ahead. We must take steps now to help all workers stay safe and healthy at work as they age. We must also take steps to address the special needs of older workers who, more and more, will be staying on the job past traditional retirement age.”

The conference, held Feb. 17-18, 2009, at the National Labor College in Silver Spring, Md., paid particular attention to workers in physically demanding jobs, such as construction and health care. Health care cost-containment has meant longer work hours and increased stress among health care workers, which has led to a shortage of nurses. Thirty-nine percent of RNs were 45 years or older in 2002.

Construction workers already suffer the highest number of fatalities in any U.S. industry.  But the death rate among construction workers 55 years and older was nearly 80% higher than that of construction workers under 35 in 2007. And like the rest of the workforce, the average age of a construction worker is rising; it was 40.4 in 2008, which is 4.4 years older than in 1985. The average retirement age among construction workers is 61.

“Our nation loses an average of four construction workers every workday to a job-related incident – and that’s been consistent for more than a decade,” said Pete Stafford, executive director of CPWR – The Center for Construction Research and Training, one of the conference’s co-sponsors. “As we start to rebuild our nation’s crumbling infrastructure and venture into green jobs, we want to make sure jobsites do not become a source of pain and death for older workers who have so much to contribute, especially in mentoring younger workers.”

Howard believes the conference confirms and expands on a 2004 report from the National Academies of Science that recognized the deteriorating conditions facing an aging workforce, to the detriment of workers, their families, and businesses. “Health and Safety Needs of Older Workers” made clear recommendations to increase research efforts toward preventing work-related injury, illness and fatality among aging workers.   These recommendations have yet to be adopted.

“The discussions and recommendations from the conference point to steps that can be taken to address needs identified in the 2004 report  that were never acted upon,” said Jordan Barab, acting Assistant Secretary of Labor for  the Occupational Safety and Health Administration (OSHA). “As those discussions make clear, a sustainable workforce will be a critical component of a secure and prosperous 21st century economy. The work we do now is an investment in a stronger workforce for tomorrow.”

The Healthy Aging for Workers conference was funded through grants from NIOSH and CPWR. The Association of Occupational and Environmental Clinics and the Society for Occupational and Environmental Health were conference sponsors. Additional co-sponsors were AARP, OSHA, the American Public Health Association, the Veterans Administration, and the University of Maryland Work and Health Research Center.

The full conference report and presentations from national and international researchers on occupational health and safety issues can be found on the Society for Occupational and Environmental Health’s Web site.

Nonfatal workplace injuries and illnesses among private industry employers in 2008 occurred at a rate of 3.9 cases per 100 equivalent full-time workers — a decline from 4.2 cases in 2007, the Bureau of Labor Statistics reported Oct. 29th. Similarly, the number of nonfatal occupational injuries and illnesses reported in 2008 declined to 3.7 million cases, compared to 4 million cases in 2007. The total recordable case (TRC) injury and illness incidence rate among private industry employers has declined significantly each year since 2003, when estimates from the Survey of Occupational Injuries and Illnesses (SOII) were first published using the 2002 North American Industry Classification System (NAICS).

National public sector estimates covering nearly 19 million State and local government workers — for example, police protection and fire protection — are available for the first time from the SOII for reference year 2008.  Nonfatal workplace injuries and illnesses among state and local government workers combined occurred at a higher rate (6.3 cases per 100 full-time workers) than among private industry workers in 2008.

Key findings of the 2008 Survey of Occupational Injuries and Illnesses:

• Incidence rates for injuries and illnesses combined among private industry establishments declined significantly in 2008 for all case types, with the exception of job transfer or restriction cases whose rate remained unchanged from 2007.  The number of cases of injuries and illnesses combined declined significantly in 2008 for all case types.
• For injuries only, both the incidence rate and the number of cases in private industry establishments declined significantly in 2008 compared to 2007 — each falling 8 percent from the year earlier.
• Looking at illnesses, both the incidence rate and the number of cases declined significantly in 2008 compared to 2007 — mainly the result of a decline among the ‘All other illnesses’ category, which accounted for nearly 84 percent of the decline in illness cases among private industry establishments.
• Manufacturing was the only private industry sector in 2008 in which the rate of job transfer or restriction cases exceeded the rate of cases with days away from work, continuing an 11 year trend.
• The total recordable case injury and illness incidence rate was highest in 2008 among mid-size private industry establishments (those employing between 50 and 249 workers) and lowest among small establishments (those employing fewer than 11 workers) compared to establishments of other sizes.

Slightly more than one-half of the 3.7 million private industry injury and illnesses cases reported nationally in 2008 were of a more serious nature that involved days away from work, job transfer, or restriction — commonly referred to as DART cases.  These occurred at a rate of 2.0 cases per 100 workers, declining from 2.1 cases in 2007.   Among the two components of DART cases, the rate of cases involving days away from work fell from 1.2 to 1.1 cases per 100 workers, while the rate for cases resulting in job transfer or restriction remained unchanged at 0.9 cases in 2008. Other recordable cases — those not involving days away from work, job transfer, or restriction–accounted for the remaining injury and illness cases nationally and occurred at a lower rate in 2008 (1.9 cases per 100 workers) compared to 2007 (2.1 cases per 100 workers).

Private Industry Injuries and Illnesses

Injuries. Approximately 3.5 million (94.9 percent) of the 3.7 million nonfatal occupational injuries and illnesses in 2008 were injuries — of which 2.5 million (71.2 percent) occurred in service-providing industries, which employed 80.1 percent of the private industry workforce covered by this survey.  The remaining 1.0 million injuries (28.8 percent) occurred in goods-producing industries, which accounted for 19.9 percent of private industry employment in 2008.

Illnesses. Workplace illnesses accounted for slightly more than 5 percent of the 3.7 million injury and illness cases in 2008. Private industry employers reported 18,900 fewer illness cases in 2008 — down to 187,400 cases compared to 206,300 in 2007. This resulted in a decline in the rate of workplace illnesses in 2008 from 21.8 to 19.7 cases per 10,000 full-time workers.

Goods-producing industries as a whole accounted for approximately 38 percent of all occupational illness cases and were responsible for more than two-thirds of the decline in illnesses reported among private industry workplaces in 2008. Consequently, both the number and rate of illnesses declined significantly for goods-producing industries as a whole in 2008. The manufacturing sector accounted for 31.5 percent of all occupational illnesses cases and reported 12,000 fewer illnesses in 2008 compared to 2007. Both the number and rate of illness cases among service-providing industries as a whole remained statistically unchanged in 2008, compared to 2007.

National Public Sector Estimates

National public sector estimates covering nearly 19 million State and local government workers — for example, Police protection (NAICS 922120) and Fire protection (NAICS 922160) — are available from the SOII for the first time for 2008.

Nearly 940,000 injury and illness cases were reported among State and local government workers combined in 2008, resulting in a rate of 6.3 cases per 100 workers — significantly higher than the rate among private industry workers (3.9 cases per 100 workers). Approximately 4 in 5 injuries and illnesses reported in the public sector occurred among local government workers, resulting in an injury and illness rate of 7.0 cases per 100 workers — significantly higher than the 4.7 cases per 100 workers in State government.

In addition to the industry-level estimates available for the first time with this release, more detailed national public sector estimates will be available in the future covering case and worker demographics for cases that involved days away from work.

First aid in the era of biohazards

by Lisa J. Burns, Q.S.S.P.

10 best practices to keep responders safe

Everyone sees the need for trained responders, first-aid kits and automated external defibrillators at the workplace. But what about the simple cut that bleeds enough to require a gauze bandage? Does the responder — or just a nearby helpful employee — see the need to wear disposable gloves? Bloodborne pathogens and other biohazards command little attention from most people, yet can cause critical illnesses and sometimes eventual death.

Defining the danger
Bloodborne pathogens are microorganisms (bacteria or viruses) carried in the blood that can be transmitted and cause disease in other people. Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) are two examples that are addressed by the OSHA Bloodborne Pathogen standard 29 CFR 1910.1030. Malaria and syphilis also are caused by bloodborne pathogens. Other body fluids also may transmit these and other diseases.

Infectious disease such as the H1N1 flu virus is a workplace concern that employers must address.

Transmission
Unbroken skin generally acts as a barrier to bloodborne pathogens. However, microorganisms can enter through any damaged or broken skin such as acne, sunburn, blisters, open sores, cuts or abrasions. They also may be transmitted through mucous membranes, including those of the eyes, nose or mouth.

Infectious diseases such as the H1N1 flu virus are primarily transmitted through airborne body fluids emitted with coughs and sneezes, and breathed in by others in the immediate vicinity. They also are transmitted when a hand used to cover the mouth then touches faucets, doorknobs and other surfaces from which it is later picked up by others.

OSHA first-aid regulations
Emergency medical services and first aid that general industry employers must provide are described in OSHA standard 29 CFR 1910.151. The standard recommends kits and supplies that are compliant with the minimum guidelines established by the American National Standards Institute (ANSI) in Z308.1-2009. It also incorporates other standards and measures by reference, such as 29 CFR 1910.1030, which deals with bloodborne pathogens.

OSHA’s 29 CFR 1910.1030 standard requires limiting employee exposure to blood and other potentially infectious materials. It specifies that training and personal protective equipment must be provided for employees who can be “reasonably anticipated” to face possible contact with blood or other potentially infectious materials on the job.

The standard, issued in 1991, was updated in 2001 in response to the Needlestick Safety and Prevention Act, and can be found at http://www.osha.gov, along with FAQs and various letters of interpretation issued over the years since then.

Best practices
Following the best PPE practices recommended below will help keep first responders safe from bloodborne pathogens and other infectious material.

1. “Universal precautions.” Treat every situation as potentially dangerous. OSHA’s universal precautions require that all human blood or other potentially infectious materials be considered hazardous.

2. Hand protection. Before donning gloves, cover any cuts or sores on your own hands with a bandage. Inspect the gloves and if the material is thin, doubleglove to provide another layer of protection. Do not use torn or punctured gloves, no matter how miniscule the damage might be. When removing used gloves, pull them off from the cuff, turning them inside out so the outside of the gloves do not touch your bare skin. Dispose of them in a designated biohazard bag. Immediately scrub your hands thoroughly, including under nails — and any other potentially contaminated skin — with nonabrasive soap and running water at hand-washing facilities that employers must provide in readily accessible areas.

3. Eye and face protection. While providing first aid or other medical assistance as well as working in labs or while cleaning up a spill, there may be a risk of splashing or vaporization of contaminated fluids. Use goggles to protect against transmission of pathogens through your eye membranes. Use a face shield in addition to goggles to protect against splashes to your nose and mouth.

4. Body protection. In some cases, you may need to wear aprons or body shields to protect your clothing and keep blood or other contaminated fluids from soaking through to your skin. Wear shoe covers to avoid contamination of your footwear.

5. Clean up. For clean-up of blood or other body fluids from sick or injured employees, use gloves and, depending on the situation, some or all of the above-mentioned PPE. In addition, you should have available a small shovel and scraper, appropriate absorbent materials, biohazard bags, ties, germicidal towelettes — and for large areas, a mop or sponge and bucket with a solution of 1/4 cup bleach to 1 gallon of water. Some manufacturers supply complete biohazard clean-up kits that contain all the necessary supplies, including special absorbent materials that deodorize as well as bind the hazardous body substances together.

6. Deposit waste. Once clean-up is complete, deposit the waste material first in a labeled, red biohazard bag and tie it tightly. Use germicidal towelettes or bleach solution to clean the contaminated area. Then put the first bag into a second biohazard bag, and add the used towelettes or sponges, your shoe covers, gown, face mask with eye shield and, lastly gloves in the same bag, and seal it with a tie. Discard the red bag in an appropriate container for infected solid waste as required by local regulations.

7. Sharps. For any broken glass or other sharp material, use a broom with shovel or dustpan, and deposit them in appropriate boxes. Never touch them with your gloved or ungloved hands and do not put them in a biohazard bag.

8. Decontamination. Finally, wipe your hands with antiseptic hand wipes that provide rapid bactericidal action and allow them to air dry. Next, go to the nearest handwashing area and wash your hands and all potentially exposed skin thoroughly with non-abrasive soap and running water.

9. Equipment decontamination. A person trained in the appropriate procedures must decontaminate and sterilize all non-disposable equipment and tools used, such as mops, buckets and re-usable gloves, as soon as possible.

No complacency
Factory or construction site, chemical, plastics or food and beverage processing plant — no matter what the workplace — there should be no toleration of complacency when there is potential for exposure to bloodborne pathogens and other infectious disease. The effects of exposure may not be immediate, but there is a definite potential for serious illness and eventual death.

Lisa J. Burns, Q.S.S.P. Lisa is associate product manager-personal protection- Americas at North by Honeywell. She is a member of the International Safety Equipment Association and a Qualified Safety Sales Professional. Lisa can be reached at (401) 275-2608 or by e-mail at Lisa.J.Burns@Honeywell.com.

In general, health care management emphasizes the prevention of impairment and disability through early detection, prompt treatment, and timely recovery. Medical management responsibilities fall on employers, employees, and health care professionals (HCPs). A medical management program can help to either eliminate or substantially reduce the risk of development of ergonomics-related problems and symptoms through early identification and treatment.

Musculoskeletal disorders are caused or aggravated by repetitive motions, forceful exertions, vibration, mechanical compression (hard and sharp edges), and sustained or awkward postures that occur over extended periods of time. MSDs can affect nearly all tissues, the nerves, tendons, tendon sheaths, and muscles, with the upper extremities being the most frequently affected. These injuries range from disorders of the back, the neck, the arms and legs, or the shoulders and involve strains, sprains, or tissue inflammation, and dislocation.

Workers suffering from MSDs may experience less strength for gripping, less range of motion, loss of muscle function, and inability to do everyday tasks. These painful and sometimes crippling injuries develop gradually over periods of weeks, months, and years as the result of the repeated actions required to perform their jobs.

Awareness is the key to preventing serious MSD injuries. It is important for employers and employees alike to know the signs and symptoms of MSDs. These signs and symptoms are often ignored, because they seem slight at first and go away when the employee is not at work. However, as time goes on, the symptoms increase and last longer until finally it’s impossible to perform simple tasks such as holding a drinking glass or keyboarding. Early intervention is essential to recovery.

That’s why it’s important to train employees about MSD signs and symptoms and encourage them to report symptoms as soon as they become aware of them. They also need to understand what may happen if they continue to perform their regular job and don’t report the symptoms. Early reporting is essential to lessen the severity of the injury. The longer warning signs are ignored, the more damage is done, the longer recovery takes, and in some cases, the damage can’t be repaired.

Signs and Symptoms

The presence of MSD signs and/or symptoms is usually the first indication that an employee may be developing an MSD. The signs are objective physical findings that an MSD may be developing. The symptoms, on the other hand, are physical indications that an employee may be developing an MSD.

Symptoms can vary in severity, depending on the amount of exposure to MSD hazards and often appear gradually, for example, as muscle fatigue or pain at work that disappears during rest. Usually symptoms become more severe as exposure continues. If the employee continues to be exposed, symptoms may increase to the point that they interfere with performing the job. Finally, pain may become so severe that the employee is unable to perform physical work activities).

Signs that may indicate an MSD include deformity, decreased grip strength, decreased range of motion, and loss of function. Common symptoms of MSDs include:

• Painful joints,
• Pain, tingling, or numbness in the hands or feet,
• Shooting or stabbing pains in the arms or legs,
• Swelling or inflammation,
• Burning sensation,
• Pain in wrists, shoulders, forearms, or knees,
• Fingers or toes turning white,
• Back or neck pain, and
• Stiffness

The U.S. Centers for Disease Control and Prevention has launched CDC-TV, a new online video resource on a variety of health, safety and preparedness topics.

The premiere series on CDC-TV is “Health Matters.” The first segment of the series, “Break the Silence: Stop the Violence,” addresses the topic of teen dating violence. In this video, parents and teens discuss the problem of dating violence and how to prevent it.

The library of available videos through CDC-TV will expand to include single-topic presentations as well as series for children, parents and public health professionals. Most are short and all include captioning for the hearing-impaired.
The videos are part of CDC’s efforts to increase access to information that can help people prevent illness and injury. “Online video is one of the best tools we have to reach a large number of people and help them make informed health decisions by providing accurate health information,” said Jay Bernhardt, Ph.D., director of CDC’s National Center for Health Marketing. “CDC-TV marks an exciting new chapter in our continuing efforts to provide CDC’s health information to the public when, where, and how they want it.”

The videos are available at http://www.cdc.gov/CDCtv.