OHS Catalogue of Infection Prevention

The OHS Catalogue of Infection Prevention has not yet been approved by the Inspectorate SZW.

Biological agents is the generic term for micro-organisms (bacteria, viruses, fungi, parasites and prions) and products of those micro-organisms, such as
endotoxins, exotoxins and mycotoxins, which can lead to (serious) health problems, such as an allergic reaction or a toxic effect.

Biological agents are everywhere in the environment, in the air and on and in the bodies of all living organisms, including humans. They are essential to our existence. Because of the wide variety of biological agents, there is a natural balance, so that more aggressive biological agents, which can potentially cause disease, rarely have the opportunity for unrestricted growth. Therefore, biological agents generally do not make us ill.

The situation in a hospital is, however, different. In hospitals, there is a concentration of ill people often with a reduced resistance, in whom the natural balance of biological agents can be readily disrupted. People with various infectious diseases are also being treated. This may result in exposure of hospital staff to biological agents. A distinction is made between a non-targeted and a targeted way of working with biological agents. Non-targeted work involves risks that occur (unintentionally). For example, by working with patients or potentially contagious bodily materials. Targeted work is defined as working with an identified risk, for example in a laboratory where biological agents are examined.

This OHS Catalogue is limited to the non-targeted way of working with biological agents in the hospital. This OHS Catalogue does not apply to laboratory situations, nor to working with genetically modified organisms (GMOs).

If a staff member is exposed to a biological agent, an infection can occur, which can lead to an infectious disease in the short or long term. The risk of disease depends on the amount and infectious potential of the biological agent, the transmission route, ambient factors and the immune system of the infected person(e.g. immunity to the microorganism in question).

For the purposes of this OHS catalogue, we distinguish two groups of staff:

1. Potential infectees:
These are staff who may be exposed to and possibly contaminated with (infectious) biological agents originating from patients, colleagues and visitors.

2. Potential infectors:
These are infected staff who can spread biological agents unnoticed, thereby infecting colleagues (and beyond the scope of this OHS catalogue, of course, patients and visitors as well).

The OHS Catalogue of Infection Prevention has been developed for everyone who is employed at a UMC that can come into contact with (infectious) biological agents. The target group also includes students and interns. Special attention is paid to vulnerable groups, such as pregnant women, staff with reduced resistance and young people (<18 years).
The infection charts further specify the target groups and medically vulnerable groups for each infectious disease.

The European directives form the basis for legislation in the Netherlands. For biological agents, this is the EC Directive 2000/54/EC 'Directive on the protection of workers from risks related to exposure to biological agents at work'.

This Directive has been implemented in Dutch legislation in Sections 9 and 10 of Chapter 4 of the Working Conditions Decree. The following articles are important for this OHS Catalogue:

• Further regulations on risk assessment (Article 4.85 of the Working Conditions Decree)
  If a worker is exposed or is likely to be exposed to biological agents, the nature, degree and duration of exposure must be assessed in the context of the risk assessment provided for in Article 5 of the Act in order to determine the hazard to the worker.
   
• Prevention or limitation of exposure (Article 4.87a of the Working Conditions Decree)
  Where there is a risk to workers' health or safety and where, owing to the nature of the work, it is impracticable to replace biological agents with biological agents that are not dangerous, other measures must be taken, insofar as technically possible, to prevent workers from being exposed to biological agents and to limit the risks.
   
• Hygienic protective measures (Article 4.89 of the Working Conditions Decree)
  In places where there is a risk of exposure to biological agents, smoking, eating and/or drinking are not permitted. Appropriate protective measures must also be taken, such as hygiene measures and personal protective equipment.
   
• Registration (Article 4.90 of the Working Conditions Decree)
  If workers are likely to be exposed to category 3 and 4 biological agents, this must be recorded.
   
• Medical health studies and vaccines (Article 4.91 of the Working Conditions Decree)
  Insofar as possible, effective vaccines must be made available to any worker who is not yet immune to the biological agents to which they are or may be exposed. Every employee who has been or may be exposed to biological agents should be given the opportunity to undergo a Preventive Medical Examination when they start work.
   
• Reporting incidents and notification (Art. 4.94 and 4.95 of the Working conditions Decree)
  The Netherlands has one national labour regulator, the Health and Safety Inspectorate (Inspectorate SZW).
  The Inspectorate SZW must be notified of the first use of category 2, 3 and 4 biological agents. Incidents and accidents which have (possibly) led to the release of biological agents of risk categories 3 and/or 4 must be reported to the Inspectorate SZW.
   
• Special stipulations (Articles 4.97 and 4.98 of the Working Conditions Decree)
  Taking effective measures to protect the safety and health of the workers due to the uncertainty surrounding the presence of biological agents in patients' samples and materials. This pertains to disinfection procedures, waste disposal and the prevention of needle stick accidents. For needle stick accidents, a medical device with built-in safety and protective mechanism should be provided if there is a risk of injury or infection from a sharp medical device and there is a prohibition on recapping needles.
   
• Information and instruction (Article 4.102 of the Working Conditions Decree)
  Workers who may be exposed to biological agents at work must be given information and training in such things as potential health hazards, precautions and the protective measures to be taken.
   

• Work bans (Articles 4.105 and 4.109 of the Working Conditions Decree)
  Young workers and pregnant workers are prohibited from performing work that is likely to expose them to the biological agents Toxoplasma and Rubella virus, unless they have been shown to be immune.

• Reporting occupational diseases (Section 9 of the Working Conditions Act)
  If an (infectious) disease has (probably) been contracted during work or as a result of work, a company doctor must report this to the Netherlands Center for Occupational Diseases (NCvB).

The UMCs seek to establish a permanent and, as much as possible, uniform prevention programme to minimise exposure and the effects of exposure to (infectious) biological agents. The infection charts (appendices, which are part of this OHS Catalogue) are used as a basis for this.
All UMC staff (as described in the target group) are aware of the risks of infectious biological agents, know what risks they run and know how to manage the risks.

A worker can check this in the following ways:

• the department's risk assessment and information at www.Dokterhoe.nl
• familiarity with the policy for the prevention of infections within the UMCs through access to protocols/guidelines of the hospital hygiene department (e.g. with regard to insolation instructions, hygiene measures, etc.)
• training programme repeating instruction as often as necessary
• access to the OHS service for advice in the event of incidents and individual cases

In order to optimise patient safety and staff protection, there is close cooperation between the Infection Prevention Committee, the hospital hygiene department and the UMC's OHS service.

Every UMC has an infection prevention policy in place to protect the target group of this OHS catalogue. The local infection prevention committee, the hospital hygiene department and the OHS service are involved in drawing up and implementing this policy. The policy is based on the risk assessment and the Biological Occupational Hygiene Control Measures (BAH). The policy pays minimal attention to:

1. Source measures:
   • To keep the source away (keeping the source away is difficult in a hospital setting).
   • combating the source by disinfecting. This means working hygienically and good cleaning protocols and control measures (see WIP guidelines).
   • See also professional and personal hygiene.
2. Technical measures, such as:
   • use of safe needles
   • (if possible) shielding of the infectious agent
   • workplace extraction
   • creating air pressure differences between rooms
3. Organisational measures, such as:
   • separating employee and patient flows as much as possible
   • setting up clean/dirt areas
   • limiting number of staff at a certain location
   • information and instruction (and supervision). so that staff are aware of the health risks, the hygiene protocols and controls and what to do in the event of an incident.
4. Hygiene measures (professional and personal hygiene), such as hand washing and coughing hygiene.
5. Personal protective equipment. If exposure cannot be prevented by other means, the
6. employer has to offer the worker personal protective equipment (PPE). It is important that PPE is provided with good user instructions and monitoring.
   6. Vaccination. A person who has been vaccinated against a certain biological agent runs a lower risk of being infected or of infecting a patient with this agent.
7. Therapy in the case of occupational exposure to biological agents. If a worker is unexpectedly infected or exposed to a harmful biological agent or if there is a significant risk of it, the worker must be treated as soon as possible. This also includes: post-exposure policy in the case of accidental blood contact (based on the national guideline on how to act in the case of needle stick, cut, splash and bite incidents).
8. Separate policy for vulnerable groups.
9. Periodic medical examinations, screening.

• Every UMC has a policy in place so that the organisation can be scaled up in the event of an emergency involving infectious biological agents.
• The UMC ensures that arrangements are made with external companies about the information and instruction of their staff (described in the target group as contractors) with respect to working safely with biological agents.
• Every two to three years, every UMC evaluates the policy it has pursued.

• Easily accessible information on the risk of exposure to infectious biological agents is available at all UMCs. Go to www.Dokterhoe.nl (the infection prevention cards are available there) or to the UMC intranet.
• The infection prevention charts prepared by the Working Group provide information on the relevant infectious diseases and are the guiding principle for policy on infectious diseases. The infection prevention charts are structured as follows:

1. Description of biological agents and clinical picture
2. Infection route (e.g. via air, bodily fluids or via needle stick incidents)
3. Contagious period (how long is a potential source contagious to others)
4. Incubation time (if someone is infected, how long does it take to infect others and to develop symptoms)
5. Potential infectees
6. Medically vulnerable groups
7. Prevention (this can cover the various aspects of the Biological Occupational Hygiene Control Measures principle, such as banning the source, vaccination, technical, organisational and personal controls.
8. Post-exposure policy (including any treatment)
9. Potential infectors (especially relevant to health care and patient safety)
10. UMC staff can use these charts to obtain information about the relevant infectious disease

• Matrix table showing source, occupation, risk situation/action (KIZA website)
• Infection Prevention Working Group guidelines
• National needle stick incidents directive (protocol)
• OHS information sheet 9 Biological Agents, SDU
• CCDR: Prevention and Control of Occupational Infections in Health Care
• directive of LCI and RIVM for reporting and recording infectious diseases and/or occupational diseases
• RIVM Infectious diseases A to Z
• Working Conditions Decree
• Reporting occupational diseases under the Working Conditions Act under Article 9 EC Directive 2000/54/EC