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Chapter 8 Advising Travelers with Specific Needs

Health Care Workers

Henry M. Wu, V. Ramana Dhara, Alan G. Czarkowski, Eric J. Nilles

RISKS FOR HEALTH CARE WORKERS PRACTICING DURING TRAVEL OUTSIDE THE UNITED STATES

Health care workers practicing outside the United States may face unique health hazards. Numerous infectious risks are associated with patient contact or handling clinical specimens. Various types of health care workers may be at risk:

  • Physicians, nurses, and other ancillary clinical staff providing care in international settings, including clinics, hospitals, and field locations
  • Medical students and other health care trainees participating in clinical rotations overseas
  • Other people working in clinics, hospitals, or laboratories, including researchers, laboratory technicians, ancillary staff, and public health workers

Health care workers in all settings are at risk for exposure to numerous infectious diseases, including infections spread through blood and bodily fluids (such as HIV or hepatitis B) or through airborne or respiratory droplet routes (such as tuberculosis [TB] or influenza). Risks vary depending on the duties of the worker, the geographic location, and the practice setting. Increased risks are due to multiple factors including the following:

  • Less stringent safety regulations or infection control standards.
  • Limited availability of personal protective equipment (PPE) or safety-engineered devices.
  • Unfamiliar practice conditions or equipment.
  • Challenging practice conditions that can prevent providers from adhering to standard precautions (such as extremely resource-limited settings, natural disasters, or conflict zones) (see Box 8-04, Health care workers in extreme circumstances).
  • Unfamiliar medical procedures.
  • High prevalence of transmissible infections (such as HIV, hepatitis B, hepatitis C, or TB).
  • Potentially high infectious burden and increased transmission risk from source patients (such as high HIV viral loads in untreated patients).
  • Limited resources for evaluation and treatment after exposure to bloodborne pathogens.
  • Potential to encounter uncommon or emerging infectious diseases that are highly transmissible in health care settings (such as Middle East respiratory syndrome [MERS] or Ebola virus disease).
  • Increased psychological stress resulting from practicing in resource-limited settings, isolated areas, and long-term assignments.

These challenges should be taken into account by all health care workers when they consider and prepare for international missions.

Box 8-04. Health care workers in extreme circumstances

Health care workers regularly provide care in a range of extreme circumstances, which may be characterized by limited or absent medical and public health infrastructure, lack of fundamental hygiene supplies (such as soap and water for handwashing), increased infectious disease transmission, extreme environmental conditions, and high levels of violence. Violent attacks on humanitarian workers have increased substantially in the past 20 years, and kidnappings of aid workers increased 400% from 2002 through 2012.

Because of the increased risks and consequences of severe disease or injury, adequate prevention and preparation are essential. Health problems for the health care worker can have serious implications, both for the person and for those who depend on the health care worker for provision of health care. Detailed instructions on how to prepare for travel or work in developing countries or humanitarian environments is covered in detail in other sections, but additional key considerations for the health care worker include the following:

  1. Having reliable communication equipment: usually satellite phone, ensuring service provider contract for duration of the mission. Consider portable solar recharging capabilities unless power supply is guaranteed, which is rare in most extreme circumstances.
  2. Acquiring evacuation insurance and having a plan if ill or injured: depending on the deploying organization, evacuation insurance (see Chapter 2, Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance) and a detailed evacuation contingency plan may or may not be provided. Both are critical, and the health care worker should be familiar with all details.
  3. Considering underlying health conditions: provider’s health should be monitored closely and treatment initiated early, if necessary. Any indication that a potentially serious condition is not responding to treatment should warrant rapid planning for potential medical evacuation.
  4. Being psychologically stable and knowing whom to contact if problems arise: providers in conflict and disaster zones typically work long hours in dangerous conditions and are exposed to profound suffering. These experiences can be intensely stressful, leading to increased rates of depression, posttraumatic stress disorder, and anxiety. Before deployment, providers should think about coping strategies and, as much as possible, stay in contact with a support network of family and friends.
  5. Inquiring about availability of antidotes to chemical warfare: although rare, health care workers may be exposed to chemical warfare agents while caring for patients, as recently documented in Syria. If exposure to these agents is a possibility, antidotes (such as atropine) should be immediately available.

PRETRAVEL VACCINATION AND SCREENING

In addition to vaccinations specifically indicated for the country visited and routine age-appropriate vaccines, all health care workers should be up-to-date on all recommended vaccinations for employment in health care settings. These include vaccinations (or documented immunity) for the following:

  • Measles, mumps, and rubella
  • Influenza
  • Varicella
  • Tetanus, diphtheria, and pertussis
  • Hepatitis B

For hepatitis B, postvaccination serologic testing is recommended for health care workers; of those who do not respond to a primary vaccine series, 25%–50% respond to an additional vaccine dose, and 44%–100% respond to a 3-dose revaccination series. Inactivated polio vaccine (given as an adult booster dose) or meningococcal vaccine may be indicated for specific locations experiencing high incidence or outbreaks of these infections. Providers should consult country-specific recommendations and travel alerts on the CDC Travelers’ Health website (www.cdc.gov/travel) for updated vaccination recommendations.

Regular screening for latent TB infection with tuberculin skin test or interferon-γ release assay is recommended for health care workers, and testing before and after travel is particularly important when the provider is working in a country with a high prevalence of TB infection or in a setting of high TB exposure, such as in prisons (see Chapter 3, Tuberculosis). Routine vaccination of health care workers with bacillus Calmette-Guérin (BCG) is not recommended in the United States; however, BCG vaccination may be considered for some health care workers who will work in settings with high TB transmission risk and a high prevalence of strains resistant to isoniazid and rifampin. Baseline testing for HIV and hepatitis C before travel is not routinely recommended, although it should be considered if risk of exposure will be high and reliable testing will not be available locally in the event of an exposure.

PPE AND INFECTION CONTROL

Health care workers should consistently follow standard precautions whenever possible and apply other precautions (contact, droplet, or airborne) as needed. PPE, including gloves, gowns, aprons, surgical masks, fit-tested N95 respirator masks, and protective eyewear, may be necessary to achieve personal protection. Workers untrained in infection control practices should not participate in clinical activities, handle clinical specimens, or handle contaminated medical equipment. Needlestick injuries are a common mode of percutaneous exposure to bloodborne pathogens, and practices known to increase risk of needlestick injuries, such as recapping syringes or using needles to transfer a bodily fluid between containers, should be avoided whenever possible, even if they are commonly practiced locally. The traveling health care worker should be aware of the local practice environment in advance of travel, since limited use of PPE or even reuse of equipment that would not be acceptable in the United States is common.

For further details, guidelines, and training materials on standard precautions and PPE, see www.cdc.gov/HAI/prevent/ppe.html and www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html. Specific PPE advice may be recommended for certain infections that pose high risk to health care workers (such as MERS, avian influenza, and Ebola virus; see disease-specific websites at www.cdc.gov for further advice).

In preparation, traveling health care workers should:

  • Ensure they are properly trained for all anticipated procedures, considering the locally available equipment.
  • Maintain strict safety standards, even if local standards are less stringent.
  • Bring their own supply of PPE or safety-engineered medical devices if they are unsure of local availability.
  • Assess the local availability of postexposure prophylaxis (PEP) for HIV, and consider bringing a supply for personal use if unavailable (see Postexposure Prophylaxis, below).

INFECTIONS TRANSMITTED BY AIRBORNE OR DROPLET ROUTES

Health care workers are at risk of acquiring numerous airborne and droplet-transmitted infections from patients. Although some of these pathogens are vaccine preventable (such as measles, influenza, and varicella), airborne or droplet isolation precautions for patients suspected of having some respiratory infections are a mainstay of infection control in the United States. These precautions include PPE such as surgical masks for droplet precautions and fit-tested N95 respirator masks and negative-pressure isolation rooms for airborne precautions. Health care workers should inquire about the availability of isolation facilities when working internationally. Bringing a personal supply of PPE for use while working overseas might be prudent (see above, PPE and Infection Control).

TB is a particular concern for health care workers working overseas in high-incidence areas. Although fit-tested N95 respirators are protective for individual providers, identifying the situations where their use is indicated can be difficult when diagnosis and isolation of patients with active tuberculosis is suboptimal.

Traveling health care workers should be aware that they may encounter patients with unusual or emerging respiratory pathogens, such as MERS or avian influenza. Review of the disease-specific CDC websites at www.cdc.gov and the CDC Traveler’s Health website (www.cdc.gov/travel) is important for the most up-to-date information on the epidemiology and infection control recommendations for emerging pathogens.

INFECTIONS TRANSMITTED THROUGH BLOOD OR BODILY FLUIDS

Health care workers are at risk for numerous infections transmitted through exposure to blood or bodily fluids via percutaneous, mucous membrane, or nonintact skin exposures. These include bloodborne pathogens such as HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV). The risk of HIV transmission is approximately 0.3% after a percutaneous exposure to HIV-infected blood and approximately 0.09% after a mucous membrane exposure. Health care workers who have received hepatitis B vaccine and have developed immunity to the virus are at virtually no risk for infection; for an unvaccinated person the risk of HBV transmission from a single needlestick or a cut exposure to HBV-infected blood ranges from 6%–30% and depends on the hepatitis B e antigen status of the source individual. Based on limited studies, the estimated risk for HCV transmission after a needlestick or cut exposure to HCV-infected blood is approximately 1.8%. Other bodily fluids that may transmit HIV and viral hepatitis include cerebrospinal fluid, synovial fluid, pericardial fluid, pleural fluid, peritoneal fluid, amniotic fluid, semen, and vaginal secretions. Saliva, urine, sputum, nasal secretions, tears, feces, vomitus, and sweat are not considered infectious for HIV and HCV unless they are visibly bloody. Typically, exposures occur as a result of percutaneous exposure to contaminated sharps, including needles, lancets, scalpels, and broken glass (from capillary or test tubes). The risk of infection after per-cutaneous exposures is considered increased with exposure to larger blood volumes (visible blood on the injuring device, hollow-bore needles, deeper injuries, or procedures that involved direct cannulation of an artery or vein). Skin exposures to potentially infectious bodily fluids are only considered to be at risk for bloodborne pathogen infection if there is evidence of compromised skin integrity (for example, dermatitis, abrasion, or open wound). Higher circulating viral load in the source patient is also thought to increase the risk of transmission, and this can be of particular concern in resource-poor settings where treatment for HIV and viral hepatitis is limited.

Hepatitis B vaccination, standard precautions, PPE, and safety-engineered devices are important preventative measures (see above sections, Pretravel Vaccination and Screening and PPE and Infection Control). Numerous other infections have also been transmitted to health care workers via blood or bodily fluids, including many that are uncommon or not endemic in the United States, such as viral infections (including Ebola virus, dengue), parasitic infections (including malaria), and brucellosis. Although standard infection control precautions and avoidance of needlestick injuries are effective in preventing most infections that are spread via blood or bodily fluids, enhanced levels of PPE are necessary for some infectious diseases (including Ebola virus disease) that pose high risk for health care workers (see above, PPE and Infection Control).

Health care workers who may have been occupationally exposed to blood or bodily fluids should immediately perform the following steps:

  • Wash the exposed area with soap and water thoroughly. If mucous membrane exposure has occurred, flush the area with copious amounts of water or saline.
  • If possible, assess the HIV and HCV status of the source patient. HBV testing of the source patient may be indicated if the health care worker is not a documented responder to hepatitis B vaccination.
  • Rapid HIV testing of the source patient is preferred. Exposures originating from source patients who test HIV negative are considered not to have HIV transmission risk, unless they have clinical evidence of primary HIV infection or HIV-related disease.
  • Baseline HIV (and potentially HCV and HBV) testing of the exposed health care worker should be performed at the time of the exposure. Seek qualified medical evaluation as soon as possible to guide decisions on HIV PEP (see below).

Postexposure Prophylaxis (PEP)

PEP after percutaneous and mucous membrane exposures to potentially infectious bodily fluids from patients with known or potential HIV infection is recommended to reduce the chance of transmission. A number of medication combinations are available for PEP (see the Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis at http://aidsinfo.nih.gov/guidelines). The decision of whether or not to initiate PEP must weigh numerous factors. These include the timing, nature, and source of the exposure; regimen choice as affected by drug availability; the exposed person’s medical history; potential drug interactions; and the possibility of exposure to a drug-resistant strain. Expert consultation is important when considering PEP. When expert advice is not immediately available, the National Clinicians’ Postexposure Prophylaxis Hotline (PEPline) can be reached toll-free at 888-448-4911 (9 am to 12 am Eastern Time daily) for assistance in managing occupational exposures to HIV and hepatitis B and C (http://nccc.ucsf.edu/clinician-consultation/pep-post-exposure-prophylaxis). Other considerations when initiating HIV PEP include the following:

  • Initiate HIV PEP as soon as possible after exposure.
  • PEP can be stopped if new information changes the decision to treat.
  • PEP recipients should be counseled regarding drug toxicities, drug interactions, and the importance of adherence.

Consider and manage other potentially infectious exposures in the source material. For example, if the health care worker is not a documented serologic responder to hepatitis B vaccination or is incompletely vaccinated, postexposure testing of the source patient and health care worker may be indicated, as well as PEP with hepatitis B immune globulin and vaccination (see www.cdc.gov/mmwr/preview/mmwrhtml/rr6210a1.htm).

Postexposure Testing and Counseling

Postexposure counseling and medical evaluation should be provided, whether or not the exposed person receives HIV or HBV PEP. This may include:

  • Baseline and follow-up testing for HIV at 6 weeks, 3 months, and 6 months (followup to at 6 weeks and 4 months is acceptable if a fourth-generation combination HIV p24 antigen-HIV antibody test is used). Extended HIV follow-up testing for up to 12 months is recommended for those who become infected with HCV after exposure to a source coinfected with HIV and HCV.
  • Baseline and follow-up testing for HCV for those with known or potential exposure to HCV. Perform a baseline test for HCV antibody and if positive perform confirmatory RNA test. Follow-up testing should include either a test for HCV RNA at 3 or more weeks after exposure or a test for HCV antibody at 6 or more months after exposure with a confirmatory RNA test if positive.
  • Baseline and follow-up testing for HBV for those with known or potential exposure to HBV if the health care worker is not a documented serologic responder to hepatitis B vaccination or is incompletely vaccinated. Baseline testing based on hepatitis B surface antigen and total core antibody tests should be performed as soon as possible after exposure with follow-up testing approximately 6 months after exposure.
  • During the first 12 weeks after exposure, health care workers should take precautions to avoid secondary transmission (such as abstaining from sexual contact, using condoms or other barriers to prevent infection, avoiding blood or tissue donations, and breastfeeding, if possible).
  • Monitoring for adverse reactions from HIV PEP (when initiated).
  • Monitoring for other transmissible infections that were diagnosed or suspected in the source patient.
  • Psychological counseling, which should be considered essential since the emotional effect of occupational exposures can be substantial and exacerbated by stressors inherent to the overseas work environment.

BIBLIOGRAPHY

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