452 - Hepatitis A Prevention, UPF Sun Protection, Psychological Safety

From the Advisory Committee on Immunization Practices

1)  Hepatitis A (HepA) Prevention

Southwestern Virginia has been experiencing an outbreak of hepatitis A for the past few years. This outbreak started in neighboring states – Kentucky and West Virginia – and has moved eastward. According to the Virginia Department of Health (VDH), Virginia is officially in an “outbreak” status for HepA. The populations most affected have been people experiencing homelessness, people who use drugs and men who have sex with men. Recently, however, the Roanoke region has experienced some newsworthy cases of HepA which have resulted in many hospitalizations and several deaths. As healthcare workers, we are at risk for exposure to Hep A from our patients. In addition, we have an opportunity to prevent HepA with improved vaccination.

Hepatitis A is spread by fecal-oral transmission – to careful attention to appropriate precautions – contact precautions, handwashing, cleaning exposed surfaces, etc. - is appropriate when working with patients with signs and symptoms of hepatitis. In addition, HepA can be spread by sexual contact and through sharing contaminated needles. Acute hepatitis symptoms are similar across all viral types – nausea, vomiting, fever, fatigue, abdominal pain, jaundice, pale stools, and dark urine. HepA blood tests (looking for IgM antibodies) are widely available and are necessary to accurately diagnose the type of viral hepatitis.

Importantly, if you diagnose HepA, some states (like Virginia) mandate immediate reporting of all cases. Some states require only immediate reporting of hepatitis A in food service workers. Check your state’s reportable disease requirements.

To prevent HepA, there are very effective vaccination series:

·         Havrix – HepA - 2 doses (0.5 ml for ages 1-18, 1.0 ml for adults) at 0 and 6 months.

·         Vaqta – HepA – 2 doses (0.5 ml for ages 1-18, 1.0 ml for adults) at 0 and 6 months.

·         Twinrix – HepA/HepB - three doses (1.0 ml for ages 19 and older only) at 0, 1, and 6 months. Not to be used for post-exposure prophylaxis.

A universal recommendation for childhood HepA vaccination was placed on the childhood immunization schedule by the Advisory Committee on Immunization Practices starting in 2006 and catch-up vaccination is recommended for all children aged 2-18. 

In adults, Hep A vaccination is indicated for (copied directly from reference 2):

·         Persons at increased risk for HAV infection

o   International travelers

o   Men who have sex with men

o   Persons who use injection or non-injection drugs (i.e., all those who use illegal drugs)

o   Persons with occupational risk for exposure

o   Persons who anticipate close personal contact with an international adoptee

o   Persons experiencing homelessness

·         Persons at increased risk for severe disease from HAV infection

o   Persons with chronic liver disease

o   Persons with human immunodeficiency virus infection

·         Other persons recommended for vaccination

o   Pregnant women at risk for HAV infection or severe outcome from HAV infection

o   Any person who requests vaccination

·         Vaccination during outbreaks

o   Unvaccinated persons in outbreak settings who are at risk for HAV infection or at risk for severe disease from HAV Implementation strategies for settings providing services to adults

o   Persons in settings that provide services to adults in which a high proportion of those persons have risk factors for HAV infection

John’s Comments:

Because of the current regional outbreak, consider offering hepatitis A vaccine to your healthcare workers, sanitation workers, plumbers, food service workers, and anyone else at risk of contact with people with hepatitis A, but be aware that there is no general ACIP recommendation for these groups, and insurers may not cover these patients nor healthy international travelers.

References:

·         Virginia Department of Health. Hepatitis A in Virginia. Immunization. Accessed June 15, 2022. Link

·         Nelson NP. Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020. MMWR Recomm Rep. 2020;69. Link

Question/Reminder From a Colleague

2)  The Effectiveness of UPF Clothing for Sun Protection

Question:  “Thanks for your annual Take 3 sunscreen review last week.  What about SPF clothing?  Is it effective and worth the cost?”    

Answer:  There is actually no such thing as SPF clothing. Clothing/fabrics are tested using a UPF (Ultraviolet Protection Factor) rating system.  The UPF rating indicates how much UV radiation (UV-R) will pass through the fabric – the higher the rating the greater the protection.  A UPF 25 means 1/25 (4%) of UV-R will pass. UPF 50 means 1/50 (2%) will be able to penetrate the fabrics.  The highest UPF protective level is 50+, which means less than 2% of the UV-R may be penetrating the clothes. There is no “official” UPF higher than 50+. 

Currently, manufacturers follow voluntary testing guidelines and use private labs to determine a fabric’s UPF rating.  The most common standard used in the US to “rate” UPF clothing is ASTM (formerly the American Society for Testing and Materials).  Some manufacturers also use the AS/NZS (Australia/New Zealand Standard). They are similar in terms of the measurement process used.  In general, advanced textiles and fabrics score better for UPF ratings.  Polyester & Nylon are best for UV reflection. Wool and silk are moderately effective. Cotton, rayon, flax and hemp are the least effective.   

The Federal Trade Commission monitors UPF advertising claims. If a manufacturer adds a tag with a UPF 15-50+ rating to any product, it must adhere to the testing standards outlined above. No clothing item with an Ultraviolet Protection of less than 15 can be labeled “sun-protective”. 

Interestingly, Consumer Reports did a study in 2015 comparing the UPF of three white shirts, only one of which had a UPF claim.  The UPF 50+ rated rash guard, which was a blend of 84 percent polyester and 16 percent spandex embedded with titanium dioxide, delivered a UPF of 174.  A cotton long-sleeve T-shirt which was thicker than a regular T-shirt had a UPF of 115 and a non-rated long-sleeve compression crew made of the same polyester/spandex blend as the UPF 50+ rash guard had a UPF of 392.  When wet, the 50+ UPF shirt’s UPF actually increased to 211, the blend decreased to 304, and the cotton T-shirt decreased to a UPF of 39.

Mark’s Comments:

Clothing can offer excellent sun protection without having a UPF label. For example, it is estimated that jeans have a UPF of approximately 1700!  However, a normal thickness white t-shirt has a UPF of 5.  Note there is great price variation of UPF products, but one can be purchased for under $20.  My favorite long sleeve one for paddleboarding cost me $9.  Even at a higher price, a sunshirt that will last years (and that you don’t have to worry about “reapplying” 2 hours after swimming or after sweating like sunscreen) begins to look like a good bargain indeed. 

There is a distinction between a shirt made of UPF material and a “rash guard” UPF shirt.  Rash guards are made to fit snugly (think 2^nd skin) and can be used during swimming.  Both are effective, though with rash guards, stretch points (like shoulders) can decrease UPF effectiveness.  Note as well that the most popular “sun hat,” the baseball cap, protects the head and forehead well, but not much else.  That’s why I’m a big fan of the broad-brimmed sunhat, even if I get some good-natured teasing about it.  Sure beats Moh’s surgery!

Reference:

·         American Academy of Dermatology:  What to wear to protect your skin from the sun:  Link. Infographic:  Link

·         Consumer Reports Sun Protection Clothing:  Report

From PeerRxMed ( www.PeerRxMed.org )

3)  Is Your Workplace Psychologically Safe?  

“Psychological safety and courage are simply two sides of the same immensely valuable coin.  Both are – and will continue to be – needed in a complex and uncertain world.”  Amy Edmondson, PhD

What topics in your workplace aren’t talked about even though doing so would be important to you and others?  Or perhaps are talked about but only as part of side conversations?  Some common areas I regularly hear about from colleagues and care team members would include the relentless demands of work, the emotional toll such demands exact from us, the dynamic tension that can exist between “efficiency” or “quality” and patient-centered care, staffing challenges, workplace safety, financial stressors, and the impact of healthcare inequities on patient care, to name but a few. 

In that context, lately I’ve been thinking a lot about the concept of “psychological safety”; what it is, why it is so often missing between colleagues, on teams, and in organizations (or even friendships and marriages!), and what can be done to address that.  Indeed, over the two years and counting of the COVID pandemic, I’ve heard numerous stories from colleagues around the country about a lack of psychological safety for talking about what really matters to them in their organizations and the negative impact this has had on patient care quality/safety, team effectiveness, and individual and group morale.  

Organizational psychologist Amy Edmondson, PhD, has written and spoken extensively on the subject of psychological safety in organizations.  She defines psychological safety as “ … a belief that the context is safe for interpersonal risk-taking – that speaking up with ideas, questions, concerns, or mistakes will be welcomed and valued even when I’m wrong.”  Research by she and others has established the presence of psychological safety as a critical driver of high-quality decision making, healthy group dynamics and interpersonal relationships, greater innovation, and more effective execution in organizations.  It is this sense of safety to engage in open, risk-free dialogue that many colleagues have yearned for but has been missing for them. 

But how can we both help create such cultures and feel free to express ourselves within them?  The Center for Creative Leadership notes some practical steps that each of us can take to help create optimal conditions for psychological safety.  They include making it an explicit priority within your group, facilitating everyone to speak up, establishing norms for how “failure” is addressed, and encouraging and creating space for new ideas (even wild ones).   Perhaps most importantly, groups should strive to embrace productive conflict by explicitly discussing the following questions:  How will we communicate their concerns about a process that isn’t working?  How can reservations be shared with each other in a respectful manner? And, What are our norms for managing conflicting perspectives?

This week, consider how you are contributing to the psychological safety of those you work with by being vulnerable, open, and curious.  Then reflect on those circumstances where you are holding back because you are not feeling safe to do so.  Your working to close that gap for yourself and others will help create conditions where everyone’s “best” can more likely emerge, individually and collectively.  It is only under those circumstances that we will be able to provide both exceptional patient care … and caring.  And that, afterall, is why we’re here ….

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org