Introduction
The Communicable Disease Protocols included in this binder have been developed jointly by the OHA and the Ontario Medical Association (OMA) and approved by the Minister of Health and Long-Term Care (MOHLTC). They were developed in compliance with Regulation 965, Section 4, under the Public Hospitals Act. This regulation requires each hospital to have by-laws that establish and provide for the operation of a health surveillance program including a communicable disease surveillance program in respect of all persons carrying on activities in the hospital. The communicable disease program is to include the tests and examinations set out in any applicable communicable disease surveillance protocol. The regulation states that the communicable disease surveillance protocols that hospitals must adopt are those "published jointly by the Ontario Hospital Association (OHA) and the Ontario Medical Association (OMA) and approved by the Minister (of Health and Long-Term Care)."
Previous surveillance programs for tuberculosis and enteric diseases were written into legislation (Regulation 865 under the Public Hospitals Act). Programs were difficult to revise and update when medical and clinical understanding about the diseases changed. Referencing the OHA/OMA protocols in legislation ensures that they have the force of law, while keeping the details out of legislation makes it easier to keep the protocols in line with current clinical knowledge. The protocols will be reviewed annually by the OHA and OMA and revised as necessary.
Actions Taken by the OHA and OMA
To meet the requirements of this legislation, a Joint OHA/OMA Committee was established to develop the protocols. This Joint Committee consisted of representatives of the OHA and OMA, including physicians and registered nurses, with expertise in infectious diseases, occupational health, medical microbiology and public health, and a Ministry of Health representative(s).
All protocols are approved independently by the OHA, the OMA, and the Provincial Infectious Diseases Advisory Committee (PIDAC) of the Ministry of Health and Long-Term Care and finally, the Minister.
Protocols for other diseases may be developed in the future, if a need is identified.
Principles
The Joint Committee developed each protocol on the basis of current clinical knowledge, with a desire to ensure maximum cost effectiveness while protecting health care workers and patients. They are intended as minimum practical standards for Ontario hospitals, however, hospitals may adopt additional strategies when indicated by local conditions.
These protocols are designed for use by occupational health services. They are intended to complement, not replace, the usual infection control practices carried out by staff performing their duties.
Format
A standard format has been followed for each protocol:
I. Purpose
The purpose of the specific protocol is defined.
II. Applicability
The former legislation prescribed certain tests and examinations for hospital “employees.” Regulation 965, Section 4(1)(e), on the other hand, states that the communicable disease surveillance program applies to “all persons carrying on activities in the hospital.” Thus, its scope is much broader. For each protocol, the “Applicability” section identified the types of persons to whom the specific protocol applies. This differs with the disease, depending on how the disease is transmitted.
Note - the protocols apply to those Contract Worker who provide direct patient care: e.g. agency nurses, food service personnel, etc.
III. Preplacement/Pre-Employment
This section defines what tests, examinations, immunizations, etc. must be done when the person begins work in the hospitals.
IV. Continuing Surveillance
This section describes any ongoing, routine tests and examinations, related to the specific disease, that must be done on the persons identified in the Applicability section.
V. Exposure
Occasionally, workers in a hospital may be exposed to a particular communicable disease. This section outlines what the occupational health service, with the family physician and medical officer of health, must do for follow-up to prevent disease in the worker and/or to monitor the worker’s health.
VI. Acute Disease
A person carrying on activities in the hospital who develops a communicable disease may be subject to some job restrictions. These restrictions and, if applicable, the return-to-work criteria are outlined in this section.
Further, health care workers have a responsibility to their patients and colleagues regarding not working when ill with symptoms that are likely attributable to an infectious disease. This includes staff with influenza-like illness, acute respiratory infection, gastroenteritis and conjunctivitis.
VII. Glossary
Specific terms used in the protocol are defined in the Glossary. Terms such as “exposure” may have different meanings for different diseases, depending on the means of transmission.
Implementation
Normally, the occupational health service is responsible for implementing the protocols. We recommend that all chief executive officers share these protocols with their hospital’s occupational health service and provide them with the necessary resources for implementation.
Considerations for Pregnant Health Care Workers
Certain infectious agents can cross the placenta, causing infection in the foetus and may result in adverse outcomes such as abortion, congenital anomalies or impaired mental development. Physiological depression of cell mediated immunity during pregnancy can increase susceptibility to and severity of certain infections during pregnancy. Further, some drugs used for treatment or prophylaxis of some infections are contraindicated during pregnancy. In spite of this, the routine exclusion of women of childbearing age from care of patients with particular infections is usually not necessary. Women who are pregnant or who are planning to become pregnant should be counselled regarding the risk of transmission and prevention of transmission. Transmission of infection will be prevented by:
• Receiving appropriate immunizations;
• Consistently using Routine Practices, including hand hygiene; and
• Adhering to Additional Precautions when indicated.
Employers should have established policies and procedures for such counselling.
Reporting Obligations Under The Workplace Safety & Insurance Act
Beginning March 1, 2000 the Workplace Safety & Insurance Board (WSIB) implemented a revised Employer’s Initial Accident-reporting Obligations Policy (policy is located in the Operating Policy Manual 15-01-02). The policy establishes guidelines for reporting to WSIB a Health Care Worker (HCW) exposure to communicable diseases.
In cases of accidental exposure, hospitals are not required to report the incident if:
A. First aid is administered and includes:
• Cleaning puncture sites, mucous membrane, mouth or eye(s);
• Application of bandages, dressings; and
• Any follow-up visits made for observation purposes only.
B. Hospital has an adequate surveillance system that includes:
• Policies and procedures for testing source and exposed HCW;
• Method(s) to monitor exposed HCW(s) for signs and symptoms of disease including blood tests and follow-up
assessments. Contract workers and students shall obtain the appropriate follow-up through the supplying
agency/school. If the contract worker or student has no supplying agency/school, then the occupational health
service must inform the worker/student of the need for follow-up. If required the Medical Officer of Health will
provide advice; and
• Documentation and maintenance of records that include:
C. Date and time of incident
D. Location and type of exposure
E. Name, risk factors and laboratory results of source patient
F. Laboratory results of exposed HCW
G. Counseling
H. Treatment
Note: Employers without a surveillance system must report to WSIB all cases of HCWs with suspected or confirmed exposures to communicable diseases.
Reporting to WSIB utilizing a Form 7 is required when:
• The HCW tests positive for a communicable disease post-exposure;
• Treatment is required related to the incident, e.g. Tetanus/Diphtheria Immunization and prescription drugs;
• Prophylactic medication is required, e.g. post-exposure prophylaxis (PEP) for HIV exposure and Hepatitis B
Immune Globulin (HBIG);
• The HCW has lost time related to the incident;
• The HCW tests negative but claims for an emotional or anxiety-related response;
• The HCW has been exposed to a communicable disease but chooses not to participate in the surveillance
protocol; and
• The HCW requests that the exposure be reported to the Board.