From the Director's Desk
—John Howard, M.D. Director, NIOSH
December eNews 2009

It is no easy task to be an occupational safety and health practitioner in the healthcare industry. Longstanding and deeply embedded assumptions are always difficult to shake, even when the need to do so becomes increasingly apparent.

People in healthcare — including me — often take offense when we are said to belong to an “industry.” In my career as a physician in an acute-care hospital setting, I have heard the words “profession” or even “calling” used to describe people who work in healthcare. And, depending on how remote, or how dangerous the part of the world where you deliver healthcare, healthcare workers are sometimes described as “noble” or “self-sacrificing.”

Indeed, these descriptions are flattering and are, in some cases, accurate, but we must be careful when society characterizes routine work in any industry as “self-sacrificing.” This characterization places workers engaged in such work outside the protections of the governmental worker safety and health paradigm that we apply to other all other industrial sectors where labor is exchanged for wages.

Providing occupational safety and health protections for healthcare workers is complex. In healthcare, some people have described a tension between caring for the patient and caring for the worker who cares for the patient. Healthcare has a long history of resolving that conflict entirely to the advantage of the patient without a rigorous consideration of all alternative ways to protect both the patient and the worker. The adoption of the Bloodborne Pathogens Standard in 1991 marked a real turning point in efforts to protect healthcare workers and patients.

Hazards in the Work Setting
We have known for years about the hazards that healthcare workers face every day:
• Exposures to formaldehyde, anesthetic gases, and other potentially toxic chemicals
• Risks for acute or chronic injuries from physical exertion such as turning and lifting patients, or standing for hours at a time in the operating room
• Potential for work-related assault and injury from human agents in stressful situations or in public-access work areas, such as belligerent psychiatric patients, irate family members, or even gang members who engage in “shoot-outs” in hospital emergency rooms

All of these hazards, and more, characterize the risks associated with working in the industrial sector called healthcare.

Healthcare workers themselves have become more aware of these hazards. As awareness, education and research on preventing these hazards from maturing into injuries and illnesses have increased, so have the demands of healthcare workers for less “self-sacrifice” rhetoric and more straight talk about hazard identification, risk assessment, and risk management. Self-sacrifice is indeed admirable and many healthcare workers often go far beyond the duties of their job to help patients and their loved ones. However, on a routine basis in a $2 trillion industry, it should not be the operating principle if we are to create a sustainable healthcare workforce for the 21st century.

Lessons from 2009 H1N1 Influenza
And it is important that we use the opportunity of the first influenza pandemic of the 21st century to figure out what attitudes, what policies, what programs and what practical decisions we need to employ to guarantee a sustainable healthcare workforce. To do that successfully, we must confront the last frontier of occupational safety and health in the healthcare industry — the frontier associated with biological hazards.

Biological hazards include those that are transmissible from patient to healthcare worker, and from healthcare worker to the healthcare worker’s unborn child, spouse, partner, children, friends, and others. Transmissible diseases are new to the lexicon of all occupational safety and health professionals, but I encourage all occupational safety and health practitioners to learn about transmissible diseases not only in the healthcare workplace, but also in non-healthcare workplaces.
The list of such agents is long and growing, and yet we in occupational safety and health know very little about such agents. In fact, we have often been led to believe that understanding the transmission of such transmissible agents requires a medical degree. That simply is not the case in the context of carrying out our duties as safety and health professionals.

Influenza — that virus that has plagued mankind since the dawn of the human race — that highly changeable virus with an 8-gene team that frequently trades and acquires new gene players—that virus that has outwitted the smartest virologists in the world — to survive through thousands of years — is upon us again. A fourth-generation relative of the virus that caused the terrible 1918 global pandemic appeared in the spring of 2009 and is now spreading throughout the world. In June, the World Health Organization declared the H1N1 influenza a pandemic.

Pivotal Documents
On October 14, 2009, the U.S. Centers for Disease Control and Prevention (CDC) updated its Interim Guidance on Infection Control in Healthcare Settings. The Guidance recommends that a robust hierarchy of controls — engineering, administrative, and personal protective equipment — be used to protect healthcare workers from the biological hazards associated with exposure to influenza. Regarding personal protective equipment, the guidance continues to recommend that healthcare workers in close contact with patients suspected or confirmed to have H1N1 influenza wear fit-tested disposable N95 respirators.

The recommendation is based on scientific findings that the influenza virus can be spread by small particles or aerosols generated by an infected patient that can remain suspended in the air and that a surgical mask does not provide equivalent protection for the healthcare worker to a fit-tested respirator. The CDC Guidance, together with the recently adopted California Aerosol Transmissible Disease Standard , are pivotal documents in the effort to promote a sustainable 21st-century healthcare workforce.

Currently, it is anticipated that there may be a shortage in the supply of disposable N95 respirators for healthcare settings trying their best to follow the CDC Guidance. NIOSH has developed a Respirator Information Clearinghouse to connect those who need to obtain respirators with those suppliers who have respirators available. As new information is obtained, NIOSH will update the clearinghouse site. I encourage you to visit this site and mark the page for ongoing reference.

Where occupational safety and health practice in the healthcare industry goes from here when the current pandemic has passed us by, remains to be seen. A far more virulent influenza, so-called “avian” influenza or H5N1 influenza, may present us with even greater challenges. For this reason, I do not think we can return to an era when a healthcare worker’s exposure to transmissible diseases such as influenza can be merely considered “diseases of life” for which a healthcare worker “assumes the risk” when he or she offers their labor to a healthcare employer.

We need to care for the sick and at the same time, we need to care for those who care for the sick. Our attitudes, our policies, our laws, and our practices need to more clearly and emphatically reflect this duality in the 21st century delivery of healthcare. become familiar with NIOSH’s research program portfolio in healthcare and social assistance .

As always, we invite your partnership under the National Occupational Research Agenda (NORA) to stimulate, plan, conduct, and support the research necessary for meeting the challenges of the 21st Century.

New NIOSH Respirator ‘One-Stop-Shop’ Web Resource
NIOSH has developed a new respirator web page containing information that should be regarded as a reliable source to identify NIOSH-approved respirators, how to obtain products, and how to use them. The page will be dynamic and information will be added as it becomes available. Please click here.