Exposure prevention and post-exposure prophylaxis (PEP) can improve safety for correctional health care workers in a high-risk work environment. However, a new study by researchers at Columbia University's Mailman School of Public Health reveals that correctional health care workers are being exposed to infectious disease and may not be doing all they can to prevent that exposure.

The study, the first to focus on the practices of correctional health care workers, was funded by the National Institute for Occupational Safety and Health (NIOSH). It surveyed correctional health care workers in Rhode Island, Maryland and Texas -- representing low, medium and high risk for exposure from inmate patients.

"We found 7 percent reporting an exposure in the last six months. This corresponds with our hospital data [for heath care worker exposures.] We wouldn't have thought they would have had as much of a risk because they are not doing as many procedures [as hospitals]," said Robyn Gershon, Dr.P.H., M.H.S. of the Mailman School of Public Health at Columbia University.

Gershon said the research team entered the prisons in the three states with a questionnaire for health care workers to complete with inquiries regarding accidental exposures and hepatitis B vaccines status, among others.

A tube of blood was drawn from consenting health care workers and tested for hepatitis B antibody and antigen, and for markers of hepatitis C virus (HCV) infection. In addition, a skin test was performed for the presence of TB. Gershon said the researchers received information from over 400 participants.

"[The inmate population] is getting older and [there are] more acutely ill inmates. They are pretty sickly and our health care workers are doing a lot of intervention with them and are [therefore] getting exposed [to infectious diseases]," said Gershon.

Exposures Are Happening

The survey results revealed that 4 percent of participants were carriers of the hepatitis B virus yet none of those knew their infected status. "It is almost a public health implication," said Gershon. Additionally, 3 percent of participants said they were aware of a previous positive HCV test, and in fact three percent were HCV infected.

In terms of types of exposure, 7 percent of respondents said they had experienced at least one needle stick, 4 percent had experienced at least one splash to the eyes and 2 percent had been cut with sharps. Also, according to the study, 32 percent of those surveyed never reported an accidental exposure.

Why were they not reporting? The reason many respondents gave is that they did not know to whom to give the information, Gershon reported.

But Gershon also believes that many health care workers, who shared their feelings privately, perceive they would be penalized in some way if they reported an accidental exposure. "They know [what they should do] but a lot of them are in denial," she said. Moreover, for workers in facilities located in a remote spot from a local hospital, seeing a doctor may feel like too much of a burden.

Gershon explained that this under-reporting poses a problem for prevention in correctional health care settings. "How can you prevent it if you don't have the data," she said.

Compliance a Problem

According to Gershon, one of the reasons for the relatively high number of exposures is lack of compliance with prevention measures. "There are some bad behaviors here -- this is why they are getting exposed," Gershon said.

Despite improved safety measures including requirements to use safe needles that do not need to be recapped, some safety issues remain. The study results reveal the following lack of protection: 42 percent of respondents lack protective clothing, 46 percent lack eye protection, and 27 percent participate in improper sharps disposal. Beyond that, Gershon said that in some systems safer devices might be chosen for a whole agency without the consultation of those who work on the "front lines." "My understanding is safety committees don't always have representation from front line workers," she said.

Other issues mentioned by health care workers included no place for a proper break, where staff can eat and drink in a separate area. "They don't have stuff like that and have to go to the cafeteria and they don't want to do that. They eat and drink where they have clinic," Gershon said.

Other problems occur when these workers do not follow up with preventative vaccines. In the study, 55 percent of participants who said they had received hepatitis B vaccine also had an observable titer. "It could mean if [the remainder] had an exposure they would not have a response. It is a heads up to let them know they might want to follow up. They are advised to consult their own practitioner to get another shot," said Gershon. For TB risk, the researchers found that only 37 percent used a mask with HEPA filter, 25 percent used surgical masks and 22 percent used none at all.

On the positive side, Gershon said that 50 percent of respondents had had training on TB prevention in the last year and 97 percent had been tested at work. However, 16 percent of respondents tested positive for TB when in the last year they had tested negative.

So what should be done to reduce this risk for correctional health care workers? Gershon has some ideas.

Recommendations

A safe working environment is an important predictor for compliance with preventative measures. Availability of proper resources, including small details such as making sure workers have gloves that fit properly, can mean the difference between compliance or non-compliance. Agencies should be paying attention to these details to help prevent unnecessary exposures among employees, said Gershon.

Additionally, Gershon suggests that officials conduct a periodic review of employee risk. The data might show across institutions a pattern of exposures or a pattern of safety.

"It has to be a combination of public health and correctional agencies doing [the review]. I think [corrections] would be wise to do it themselves in their accreditation agencies and create a standardized reporting program," Gershon said. "Some facilities have marvelous state of the art programs but some need more direction. It would be nice if there were more uniformity. There's certainly room for improvement."

For more information about the study, contact Gershon via email at rg405@columbia.edu.

Note: OSHA mandates HEPA respirator use and while new standards may not be necessary, compliance with existing standards is. The newly revised OSHA bloodborne pathogen control standard requires annual risk assessment and annual input from front line staff. Also, the existing OSHA 2000 log should record all needle stick injuries, and employee training is required to include what to do after an exposure incident. An employer can be fined if this process is not followed correctly. This study has revealed the need for the implementation of an increased compliance with the existing OSHA standards within corrections. Visit www.osha.gov.

* Nothing to disclose.

Back to the HEPP News November 2001 contents page.