Curbing the Spread of Respiratory Viral HAIs by Healthcare Workers

In a session at the Society for Healthcare Epidemiology of America (SHEA) Spring 2017 Conference, on March 30, 2017, co-chair of Scientific Spring Program at the SHEA Spring Meeting, Matthew Linam, MD, MS, associate professor, Department of Pediatrics at the University of Arkansas, and medical director of Hospital Epidemiology and Infection Control at Arkansas Children’s Hospital (ACH), examined methods to prevent the spread of respiratory viral healthcare-associated infections (HAIs) by healthcare workers in healthcare settings.

Respiratory viral HAIs are a growing threat in healthcare facilities. At ACH, the second highest cause of HAIs was found to be respiratory viral HAIs, which accounted for approximately 20% of the total HAIs at the facility. These infections occurred most often in the Neonatal Intensive Care Unit, Cardiovascular Intensive Care Unit, and Intensive Therapy Unit. In addition, these infections occurred mostly in long-term care patients who “had cardiopulmonary issues that placed them at increased risk for morbidity related to these infections.”

A special infection prevention team was formed at ACH specifically to reduce respiratory viral HAIs in the hospital by 25% over the course of the year, according to Dr. Linam. The team focused on several primary sources of transmission of respiratory viral HAIs, including healthcare workers, family members, and visitors.

“Within preventing healthcare worker transmission, we’ve really been focused on four areas: hand hygiene, using syndrome-based isolation precautions, healthcare worker influenza vaccination, and getting our healthcare workers to not come to work when they are ill,” Dr. Linam said.

In a surveillance study of respiratory viral shedding at another healthcare facility, researchers enrolled 170 healthcare workers who were employed at the hospital during the time of the study. The study was designed to focus on the spread of influenza in a year with relatively low case prevalence. Using a multiplex polymerase chain reaction (PCR) panel, the researchers tested for other respiratory viruses. They then collected 119 specimens from 83 symptomatic healthcare workers. These specimens were compared with 200 specimens from 160 healthcare workers “obtained at a time when various healthcare workers were asymptomatic.”

The results showed that, of the specimens collected from the symptomatic healthcare workers, 39 were positive for a virus, while a smaller number of specimens from asymptomatic healthcare workers were found to be positive for a virus. These findings show that, on occasion, healthcare workers who do not present with symptoms are still shedding viruses, said Dr. Linam. “The majority of these specimens were positive for human rhinovirus,” he continued. Rhinovirus is the usual cause of the common cold, and while it is not harmful to healthcare workers, it does have a “significant impact on high-risk patients.”

Approximately half of the healthcare workers enrolled in the study “admitted coming to work in the past year with an influenza-like illness.” In those who were positive for a virus, these healthcare workers were “significantly more likely to have symptoms of any kind,” although fever was not significant between the symptomatic or asymptomatic groups.

According to Dr. Linam, proper hand-hygiene practices for healthcare workers are “the most important behavior to prevent HAIs.” Although guidelines defining proper hand hygiene have been provided by the Centers for Disease Control and Prevention and the World Health Organization, “we don’t do near as good a job as we should.”

Guidelines for hand hygiene among healthcare workers focus on an institutional approach that provides proper education and training, ensures the availability of supplies at the point of care, provides workplace reminders such as signs, and provides feedback to the healthcare workers so that they are aware of what they are doing well in addition to what they should improve on.

“What we’ve seen, through a number of different studies, is that groups that have implemented some combination of these interventions have seen significant improvement in their hand hygiene [compliance rates]. But, often, that improvement is below 90% [compliance].” However, he added, additional studies have shown that goal setting, incentivizing hand hygiene, direct accountability of healthcare workers, and providing real-time feedback “may further increase hand-hygiene compliance.”

Although most children who are admitted into hospitals are hospitalized due to respiratory infections such as bronchiolitis, most guidelines do not require testing to specify the cause of infection. This allows for an umbrella designation of “respiratory syndrome.” Therefore, Dr. Linam recommends taking syndrome-based isolation precautions.

Another imperative practice that can hinder the transmission of respiratory viruses from healthcare workers across the facility is influenza vaccination. Whole facility vaccination can be accomplished through several strategies, including educational campaigns, by providing different vaccination choices—such as FluMist for those who do not like needles for years this method of influenza vaccination is deemed acceptable—or by mandating that healthcare workers who are unvaccinated wear masks at all times. Some healthcare facilities, however, require all hospital personnel, including contract workers, to be vaccinated for influenza. These hospitals have seen an increase of up to 90% vaccination rates among workers. “But, this strategy, as you can imagine, is controversial,” Dr. Linam said.

The final manner by which Dr. Linam suggested healthcare facilities can prevent infection transmission by healthcare workers is to prevent ill personnel from going to work. A mixed-method study published several years ago, said Dr. Linam, looked at why clinicians and advanced practice clinicians choose to go to work sick. The study found that 94% of healthcare workers included in the study “believed that working while sick placed patients at risk.” Nonetheless, this did not stop 83% of these same individuals from showing up to work sick at least once in the past year, and approximately 10% from working while sick at least five times in the past year.

Expanding on why these healthcare workers chose to show up to work while sick, Dr. Linam said that many believed they would let their patients or colleagues down otherwise, and they believed to be abiding by the “cultural norm.” Some shared that they were not aware of what is considered “too sick” to work, “especially as it relates to respiratory viral illness.”

In this same study, more than half of the respondents claimed they would continue to go to work if they exhibited “acute onset of significant respiratory tract symptoms,” while approximately 75% would continue working with a “cough or rhinorrhea only.” However, as noted in the study alluded to above, about one third of symptomatic workers shed virus.

Ultimately, Dr. Linam recommended a “tiered strategy to address healthcare worker illness.” First and foremost, the focus should be at the hospital-level, he said. “[We should work] with our [human resources] departments, leadership, infection prevention, and occupational health, in trying to make as clear as possible the definitions of what is considered too ill to work. This is pretty easy if you’re talking about fever and [gastrointestinal] illnesses. It becomes more challenging when you’re talking about respiratory symptoms and what’s too ill.” Paid sick-leave, relaxing doctors’ notes requirements, and creating nonpunitive sick leave policies are all strategies Dr. Linam believes may contribute to decreasing the rate at which healthcare workers spread infections throughout healthcare facilities. He stressed that we should “make it easier for healthcare workers to do the right thing. They already feel bad about not coming to work, we shouldn’t make it harder.”

Most importantly, leadership—both at the senior level and unit-leadership level—should be supportive, and should provide resilient staffing during infection seasons, such as the flu season. This may make those sick days easier to manage for the institution. “What’s interesting is that residency programs have been doing this for years. Most residencies have a jeopardy program, [which means] when you’re sick, there’s a pool of people to step-in and cover your shift.” This strategy can help institutions better plan for infection seasons, “instead of standing around on a burning platform.” At the individual level, healthcare workers should support their colleagues by providing assistance in the times of illness.

While infection prevention strategies focus on healthcare-associated infections originating from patients, one should not forget that healthcare workers can also unknowingly spread infections throughout healthcare facilities. Practicing proper hand hygiene, getting vaccinated for preventable infections, and staying home while ill are all actions that healthcare workers can take to prevent transmitting infections to susceptible patients.

DISCLOSURES: None

SOURCE: SHEA Spring 2017 Conference

PRESENTATION: Preventing Respiratory Viral Healthcare Associated Infections in Children