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What Employers Should Do to Protect RNs from Zika

  • Screen patients with possible Zika virus exposure and provide testing for those with exposure
  • Flag charts or other methods for notification of nurses and other healthcare workers of Zika positive cases, especially in Labor and Delivery units
  • Issue plans and procedures to be followed in providing care to a patient with confirmed or suspected Zika virus, including necessary personal protective equipment (PPE) and other protections that comply with OSHA’s Bloodborne Pathogens Standard (29 CFR 1910.1030) and CDC Guidance and recommendations for healthcare providers
  • Provide education and training for nurses and other healthcare workers on Zika virus, including general background, symptoms and other effects, transmission pathways, protections and PPE, and the hospital’s plans and procedures
  • Provide immediate and follow-up testing for any nurse who, in her or his professional judgment, assesses that she or he has been exposed to Zika

Background on Zika Virus


Aedes Aegypti Mosquito, Sanofi Pasteur/Flickr/CC

Zika virus disease is an emerging mosquito-borne disease that has shown unusual propensity for other transmission pathways, including:

  • Sexual transmission,1,2,3
  • Mother to child transmission during pregnancy and birth,4
  • Blood transfusion,5,6 and
  • A needlestick incident in a laboratory setting7

Zika virus has been found in a variety of bodily fluids, including amniotic fluid and fetal brain tissue,8,9 saliva,10,11 urine,12 breast milk,13 the female genital tract,14 and semen.15

Based on these confirmed transmission pathways and the presence of virus in various bodily fluids, nurses and other healthcare workers are at risk for Zika virus exposure.

Preventing Nurses’ Exposure to Zika: What OSHA and the CDC Require

OSHA’s Bloodborne Pathogens (BBP) Standard (29 CFR 1910.1030) mandates that employers implement exposure control plans to eliminate and prevent employee exposure to blood and other bodily fluids. State OSHA plans may have their own standards which must be at least as protective as federal OSHA’s standard.

The BBP Standard requires the following:

  • Implementing universal precautions to prevent contact with blood and other bodily fluids. Universal precautions is an approach to infection control that treats all blood and certain body fluids16 as if known to be infectious for bloodborne pathogens, like HIV or hepatitis B. (29 CFR 1910.1030(d)(1))
    (Note that CDC recommends protection from “all moist and potentially infectious body substances except sweat even if blood not present.”17)
  • Performing hand hygiene immediately or as soon as feasibly after removal of gloves or other PPE. (29 CFR 1910.1030(d)(2)(v)).
  • Employers must provide, at no cost to the employee, appropriate PPE that does not permit blood or bodily fluids to pass through or reach the employee’s clothes, eyes, mouth, or mucous membranes. (29 CFR 1910.1030(d)(3)(i))
    • PPE includes, but is not limited to, gloves, gowns, eye protection such as face shields or masks, mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. (29 CFR 1910.1030(d)(3)(i)).
    • If splashes, sprays, splatter, or droplets of blood or other bodily fluids may be generated, the employer shall provide masks in combination with eye protection devices, like goggles or glasses with side shields or chin-length face shields. (29 CFR 1910.1030(d)(3)(x))
    • Appropriate protective clothing, including gowns, aprons, lab coats, clinic jackets, or other similar garments, shall be provided in occupational exposure settings. The type and characteristics will depend on the task and the degree of exposure anticipated. (29 CFR 1910.1030(d)(3)(xi))
  • Employers must ensure that the worksite is maintained in a clean and sanitary condition. (29 CFR 1910.1030(d)(4)(i))
  • In the event of an occupational exposure, employees must provide post-exposure prophylaxis when medically indicated and recommended by the U.S. Public Health Service. (29 CFR 1910.1030(f)(3)(iv)).
  • Employers must provide training and education to nurses and other healthcare workers, initially, annually, and when changes affect the employee’s occupational exposure. Training and education must include general information about bloodborne pathogens and modes of transmission, the use and limitation of methods implemented by the employer to reduce or prevent exposure, and information regarding PPE use and storage. (29 CFR 1910.1030(g)(2)(v)).
  • Other elements required by the standard can be found here.

The Centers for Disease Control and Prevention (CDC) have released two publications on preventing occupational exposure for healthcare workers:

  • Recommendations for preventing exposure in Labor and Delivery Settings
  • Guidance for preventing occupational exposure released jointly with the Occupational Safety and Health Administration (OSHA) and the National Institute for Occupational Safety and Health (NIOSH)

These publications outline the importance of using both universal and standard precautions to preventing nurse and other healthcare worker exposure to Zika virus. The table below provides a comparison of Standard Precautions and OSHA’s BBP Standard, which requires Universal Precautions.

Universal vs Standard Precautions and OSHA’s Bloodborne Pathogens Standard

Universal Precautions is defined by OSHA’s BBP Standard as “an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.” (29 CFR 1910.1030(b)) This concept was first introduced in the 1980’s.

Standard Precautions is defined by the CDC to combine universal precautions with body substance isolation. Body substance isolation “emphasized avoiding contact with all moist and potentially infectious body substances except sweat even if blood not present.”18 The CDC describes Standard Precautions as a “group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered (Table 4).”19 Table 4 is titled “Recommendations for Application of Standard Precautions for the Care of All Patients in All Healthcare Settings.”20 We have adapted the CDC’s Table 4 to compare Standard Precautions to the requirements of OSHA’s BBP standard (29 CFR 1910.1030).

ADAPTED from Table 4: RECOMMENDATIONS FOR APPLICATION OF STANDARD PRECAUTIONS FOR THE CARE OF ALL PATIENTS IN ALL HEALTHCARE SETTINGS21

Component (from Table 4) Recommendations (from Table 4) BBP standard 1910.1030
Hand hygiene Hand hygiene fluids, secretions, excretions, contaminated items; immediately after removing gloves; between patient contacts. (d)(2)(v) immediately after removing gloves or other PPE
(d)(2)(vi) immediately after contact with blood OPIM
Personal protective equipment (PPE)
Gloves For touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes and nonintact skin. (d)(3)(ix) when reasonably anticipated that employee may have hand contact with blood, OPIM, mucous membranes, and non-intact skin, when performing vascular access procedures, and when handling/touching contaminated items or surfaces.
Gown During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated. (d)(3)(xi) Appropriate protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic jackets, or similar outer garments shall be worn in occupational exposure situations. The type and characteristics will depend upon the task and degree of exposure anticipated.
Mask, eye protection (goggles), face shield* During procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions, especially suctioning, endotracheal intubation. (d)(3)(x) Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or OPIM may be generated and eye, nose, or mouth contamination can be reasonably anticipated.
Soiled patient-care equipment Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene. (d)(3)(ix) wear gloves when handling/touching contaminated items or surfaces.
Environmental control Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient-care areas. (d)(4)(i) Employers shall ensure that the worksite is maintained in a clean and sanitary condition. The employer shall determine and implement an appropriate written schedule for cleaning and method of decontamination based upon the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed in the area.
Textiles and laundry Handle in a manner that prevents transfer of microorganisms to others and to the environment. (d)(4)(iv)(A) provides much more detail in how to deal with contaminated laundry than Table 4.
Needles and other sharps Do not recap, bend, break, or hand-manipulate used needles; if recapping is required, use a one-handed scoop technique only; use safety features when available; place used sharps in puncture-resistant container. (d)(2)(vii) contaminated needles and other sharps shall be not be bent, recapped or removed (unless employer can demonstrate there is no feasible alternative or action is required (A))
(d)(2)(vii)(B) bending, recapping, or needle removal must be accomplished through use of mechanical device or one-handed technique
(d)(2)(viii) contaminated reusable sharps shall be placed in puncture-resistant, properly labeled, leakproof containers
(d)(4)(iii)(A)(1) contaminated sharps shall be discarded immediately or as soon as feasible in containers that are closable, puncture resistant, leakproof on sides and bottom, labeled.
(more details on sharps disposal)
Patient resuscitation Use mouthpiece, resuscitation bag, other ventilation devices to prevent contact with mouth and oral secretions. (d)(3)(i) resuscitation bags are listed as required PPE.
Patient placement Prioritize for single-patient room if patient is at increased risk of transmission, is likely to contaminate the environment, does not maintain appropriate hygiene, or is at increased risk of acquiring infection or developing adverse outcome following infection. None
Respiratory hygiene/cough etiquette Instruct symptomatic persons to cover mouth/nose when sneezing/coughing; use tissues and dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secretions; wear surgical mask if tolerated or maintain spatial separation, >3 feet if possible. None

* During aerosol-generating procedures on patients with suspected or proven infections transmitted by respiratory aerosols (e.g., SARS), wear a fit-tested N95 or higher respirator in addition to gloves, gown, and face/eye protection.

This is not required by BBP but does fall under OSHA’s respiratory protection standard 1910.134.

Footnotes/Resources:

[1] http://www.cdc.gov/mmwr/volumes/65/wr/mm6508e2.htm

[2] http://www.cdc.gov/mmwr/volumes/65/wr/mm6514a3.htm

[3] http://www.cdc.gov/mmwr/volumes/65/wr/mm6528e2.htm

[4] http://onlinelibrary.wiley.com/doi/10.1002/uog.15831/full

[5] http://www.cdc.gov/zika/transmission/blood-transfusion.html

[6] http://in.reuters.com/article/us-health-zika-brazil-blood-idINKCN0VD22N

[7] http://www.achd.net/pr/pubs/2016release/060916_zika.html

[8] http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(16)00095-5/abstract

[9] http://www.cdc.gov/mmwr/volumes/65/wr/mm6506e1.htm

[10] http://www.journalofclinicalvirology.com/article/S1386-6532(15)00133-X/abstract

[11] http://www.eurosurveillance.org/images/dynamic/EE/V21N10/V21N10.pdf

[12] http://wwwnc.cdc.gov/eid/article/21/1/14-0894_article

[13] http://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(16)30070-6.pdf

[14] http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(16)30193-1/fulltext

[15] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4861539/

[16] Bodily fluids covered by the BBP Standard include semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. (29 CFR 1910.1030(b))

[17] http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf (page 118)

[18] http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf (page 118)

[19] http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf (page 66)

[20] http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf (page 129)

[21] http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf