Appendix 3: Methods

Infection Control in Healthcare Personnel Guideline (2023)

At a glance

Research methods for the Infection Control in Healthcare Personnel (2023), from the Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services guideline (2019).

Overview

This document is an update of four sections of Part I of the Guideline for infection control in health care personnel, 1998, and their corresponding recommendations in Part II:

  • C. Infection Control Objectives for a Personnel Health Service;
  • D. Elements of a Personnel Health Service for Infection Control;
  • H. Emergency-Response Personnel; and
  • J. The Americans With Disabilities Act.

The sections were updated by experts in occupational health, infectious diseases, and infection prevention and control (IPC). Updates were informed by a systematic review of recent articles published in peer-reviewed journals and databases of systematic reviews, guidelines, and regulations. All updates were vetted at public meetings of the Healthcare Infection Control Practices Advisory Committee (HICPAC) (See Appendix 1. Contributors).

Literature Search Questions

The questions developed to guide the literature search were:

  • What service elements are important for occupational health services that aim to prevent transmission of infections among healthcare personnel and patients in the United States?
  • What is known about implementing or delivering the following eight infection prevention and control elements of an occupational health service in the United States?
    1. Leadership and management
    2. Communication and collaboration
    3. Assessment and reduction of risks for infection among healthcare personnel populations
    4. Medical evaluations
    5. Occupational infection prevention and control education and training programs
    6. Immunization programs
    7. Management of potentially infectious exposures and illnesses
    8. Management of healthcare personnel health records
  • What interventions can improve the delivery or quality of one of the eight elements, or reduce transmission of infections among healthcare personnel and patients in the United States?

Literature Search

The infrastructure and delivery of healthcare to patients, and hence the provision of occupational IPC services to healthcare personnel (HCP), have changed since the publication of the Guideline for infection control in health care personnel, 1998. CDC conducted a targeted literature search for recent articles consistent with current approaches in occupational IPC service delivery to HCP. Search strategies were formulated using a combination of Medical Subject Headings (MeSH) terms and key words to identify literature that focused on at least one of the eight OHS IPC elements. Four searches were performed in MEDLINE, EMBASE, and CINAHL, or the Cochrane Database of Systematic reviews.

Searches sought:

  1. Articles published from January 2004 – October 2015 that were indexed in one of three databases (Table A3.1).
  2. Articles published from January 2004 – December 2015 that were indexed in one of three databases using different key words (Table A3.2).
  3. Meta-analyses and systematic reviews published from January 2004 – December 2015 that were indexed in the Cochrane Database of Systematic Reviews (Table A3.3).
  4. Meta-analyses, systematic reviews, and narrative reviews about interventions to increase vaccination coverage among HCP published from January 2004–December 2015 that were indexed in one of three databases (Table A3.4).

In addition to the results of the systematic review, CDC (KI, DK) searched relevant websites and systematic review repositories of government agencies and nongovernmental organizations (Table A3.5) for additional guidelines, regulations, program evaluations, quality improvement initiatives, and systematic reviews.

Article Selection

CDC (MD, KI, DK, AO, KR, DT) conducted the title and abstract screening and the full text review using the below inclusion and exclusion criteria.

Inclusion Criteria: Articles were retrieved if they were:

  • research studies, systematic and narrative reviews, meta-analyses, and other reports;
  • relevant to an occupational health service element of interest; and
  • relevant to prevention of transmission of infections among HCP or between HCP and patients.

Exclusion Criteria: Articles were excluded if they were:

  • conference abstracts or unpublished academic dissertations;
  • reports of OHS programs not related to HCP or related to dental practices, laboratory personnel, morgues, mortuaries, or in settings where healthcare is not provided; or
  • non-U.S.-based studies (except for systematic or narrative reviews on immunization programs).

Figure A3.1 depicts the process of screening and selecting articles. Very few relevant intervention studies were found in indexed databases, and many lacked well-defined interventions, a comparison group, large study size, or longitudinal follow-up.

Recommendation Formulation

The authors formulated recommendations based on current federal regulations, standards, and recommendations, or informed by:

  • guidance of nongovernmental organizations;
  • qualitative assessment of findings about interventions, service delivery, or quality from the indexed and non-indexed sources reviewed; and
  • professional experience and opinions regarding:
    • the benefits, harms, feasibility, and acceptability of interventions to HCO leaders, administrators, OHS staff, and HCP; and
    • the feasibility and applicability of interventions for diverse types of HCP and for varied service delivery models (e.g., provided on-site vs. off-site).

Authors recused themselves from decisions pertaining to the development of recommendations when there was a perceived or actual conflict of interest. HICPAC classified all recommendations as good practice statements based on professional experience and scientific evidence that indicated a high probability that the recommended action would do more good than harm1.

Reviewing and Finalizing the Guideline

Drafts of the updated sections and recommendations were presented at public HICPAC meetings in March 2016, July 2016, and December 2016. Input from HICPAC and the public were incorporated into subsequent drafts. The draft recommendations and narrative were provisionally approved by HICPAC at the December 2016 meeting2. Following further revisions, CDC then submitted the guideline to CDC clearance and subsequent posting to Regulations.gov for public comment. The comments were compiled and reviewed with a revised draft document at the May 2019 HICPAC meeting. The document was approved by HICPAC on May 17, 2019.

Table A3.1 First Search Strategy for Indexed Articles Published January 2004-October 2015, by Database

First search of medical databases showing terms searched and number of results.
Search Term MEDLINE EMBASE CINAHL
1 Healthcare Personnel 949 1,162 479
2 Health Care Personnel 1,976 110,486 975
3 Healthcare Worker 808 1,002 2,944
4 Health Care Worker 1,085 1,323 4,526
5 exp Health Personnel/ or exp Personnel, Hospital/ 396,129 952,375 –
6 1 or 2 or 3 or 4 or 5 399,062 954,578 8,664
7 occupational health 44,941 43,405 26,378
8 personnel health 83 79 50,840
9 occupational health objectives 2 2 74
10 7 or 8 or 9 45,021 43,476 75,197
11 6 and 10 6,040 9,015 4,397
12 preventive services 3,984 4,319 2,496
13 infection prevention 2,639 45,325 37,752
14 infection control 32,631 73,945 51,187
15 12 or 13 or 14 38,149 116,256 54,673
16 administration 1,005,772 1,239,293 280,074
17 coordination 77,795 83,464 6,986
18 16 or 17 1,080,888 1,319,751 286,157
19 6 and 10 and 18 575 359 658
20 medical evaluations 352 380 4,282
21 screening 429,687 654,641 69,955
22 surveillance 160,830 179,458 25,725
23 laboratory tests 21,496 27,701 3,715
24 immuni*ation 137,580 120,244 17,972
25 vaccination 128,709 144,566 10,255
26 exp medical history taking/ 19,050 179,580 89
27 20 or 21 or 22 or 23 or 24 or 25 or 26 830,485 1,204,613 120,859
28 6 and 10 and 27 621 1,060 1,031
29 staff education 1,188 1,840 4,795
30 exp inservice training/ 25,343 11,054 76
31 29 or 30 26,365 12,818 4,869
32 6 and 15 and 31 298 257 26
33 immuni*ation program 1,625 1,700 3,560
34 vaccination program 2,303 2,642 982
35 immuni*ation policy 288 295 157
36 vaccination policy 618 665 238
37 33 or 34 or 35 or 36 4,609 5,037 4,417
38 6 and 37 344 644 265
39 postexposure management 55 60 37
40 occupational counseling 13 13 30
41 infection counseling 20 17 84
42 health counseling 496 519 1,100
43 disease exposure management 2 1 8
44 occupational exposure management 10 9 59
45 counseling services 819 856 834
46 39 or 40 or 41 or 42 or 43 or 44 or 45 1,384 1,445 1,980
47 6 and 46 153 400 56
48 employee health records 22 16 30
49 employee medical records 9 5 23
50 48 or 49 31 21 52
51 6 and 50 18 14 8
52 11 or 19 or 28 or 32 or 38 or 47 or 51 6,764 10,251 4,474
53 limit to 2014 to present 292 760 487
54 limit to english 266 718 480
55 limit to humans 250 709 273
56 Exclude MEDLINE – 84 –
CINAHL USA Only – – 177

Table A3.2 Second Search Strategy for Indexed Articles Published January 2004-December 2015, by Database

Second search of medical databases showing terms searched and number of results.
Search Term MEDLINE EMBASE CINAHL
1 Healthcare Personnel 916 1,177 449
2 Health Care Personnel 1,964 112,789 966
3 Healthcare Worker 712 1,028 2,913
4 Health Care Worker 1,081 1,344 4,498
5 exp Health Personnel/ or exp Personnel, Hospital/ 410,717 972,375 –
6 1 or 2 or 3 or 4 or 5 413,621 974,604 8,592
7 employee health 999 958 2,175
8 6 and 7 213 256 125
9 preventive services 3,941 4,364 2,470
10 infection prevention 2,607 45,757 37,934
11 infection control 30,986 74,936 51,389
12 9 or 10 or 11 36,452 117,631 54,825
13 administration 999,337 1,250,816 280,408
14 coordination 78,129 84,331 6,868
15 13 or 14 1,074,822 1,332,098 286,382
16 6 and 8 and 15 32 24 26
17 medical assessment 1,083 31,221 1,998
18 6 and 8 and 17 0 1 2
19 employee education 86 69 210
20 6 and 12 and 19 3 6 4
21 exposure management 114 149 326
22 communicable disease exposure management 1 1 2
23 21 or 22 114 149 326
24 6 and 23 41 66 26
25 healthcare hazard 3 4 58
26 health care hazard 4 3 111
27 infection control hazard 3 4 16
28 25 or 26 or 27 10 11 183
29 8 or 16 or 18 or 20 or 24 or 28 266 338 354
30 limit to 2004 to present 109 211 222
31 limit to english 100 204 213
32 limit to humans 99 186 118
33 Exclude MEDLINE – 13 –
CINAHL USA Only – – 67

Table A3.3 Third Search Strategy for Articles Published January 2004-December 2015 that were Indexed in Cochrane Database of Systematic Reviews

Third search of medical databases showing terms searched and number of results.
Search Term Results
1 “infection control”:ti,ab,kw in Cochrane Reviews (Reviews and Protocols) and Other Reviews (Word variations have been searched) 82
2 Infection Prevention:ti,ab,kw Publication Year from 2004 to 2015, in Cochrane Reviews (Reviews and Protocols) and Other Reviews (Word variations have been searched) 424
3 “health care worker”:ti,ab,kw Publication Year from 2004 to 2015, in Cochrane Reviews (Reviews and Protocols) and Other Reviews (Word variations have been searched) 100
4 Health Care Personnel:ti,ab,kw Publication Year from 2004 to 2015, in Cochrane Reviews (Reviews and Protocols) and Other Reviews (Word variations have been searched) 162
5 Healthcare Worker:ti,ab,kw Publication Year from 2004 to 2015, in Cochrane Reviews (Reviews and Protocols) and Other Reviews (Word variations have been searched) 62
6 Healthcare Personnel:ti,ab,kw Publication Year from 2004 to 2015, in Cochrane Reviews (Reviews and Protocols) and Other Reviews (Word variations have been searched) 75
7 # 1 or #2 488
8 #3 or #4 or #5 or #6 284
9 #7 and #8 14
10 “occupational health”:ti,ab,kw Publication Year from 2004 to 2015, in Cochrane Reviews (Reviews and Protocols) and Other Reviews (Word variations have been searched) 148
12 #8 and #10 19
13 Vaccination 185
14 Immunization 112
15 #13 or #14 251
16 #8 and #15 20

Table A3.4 Fourth Search Strategy for Indexed Articles about Immunization Programs for Healthcare Personnel Published January 2004-December 2015, by Database

Fourth search of medical databases showing terms searched and number of results.
Search Term MEDLINE EMBASE CINAHL
1 Healthcare Personnel 916 1,177 449
2 Health Care Personnel 1,964 112,789 966
3 Healthcare Worker 712 1,030 2,914
4 Health Care Worker 1,081 1,345 4,498/td>
5 exp Health Personnel/ or exp Personnel, Hospital/ 410,717 974,452 –
6 1 or 2 or 3 or 4 or 5 413,623 976,685 8,593
7 immuni*ation 136,878 121,011 17,990
8 vaccination 130,963 146,145 10,179
9 7 or 8 229,682 226,581 22,537
10 6 and 9 4,657 14,067 865
11 occupational health 45,354 43,292 26,379
12 employee health 999 959 2,175
13 personnel health 81 79 3,402
14 11 or 12 or 13 45,922 43,960 30,919
15 6 and 9 and 14 308 489 182
16 limit 15 to (meta analysis or “review”) 24 72 10
17 limit to 2004 to 2015 16 50 7
18 limit to english 13 46 7
19 limit to humans 13 45 –
20 Exclude MEDLINE – 6 –
CINAHL USA Only – – 6

Table A3.5 Websites Examined for Government Regulations, Standards, Guidelines, and Other Reports about Occupational Infection Prevention and Control among Healthcare Personnel

Agency for Healthcare Research and Quality (AHRQ)

Centers for Disease Control and Prevention (CDC)

Centers for Medicare & Medicaid Services (CMS)

Occupational Safety and Health Administration (OSHA)

US Congress

US Department of Justice (DOJ)

US Department of Labor (DoL)

  • Family and Medical Leave Act Wage and Hour Division

US Food and Drug Administration (FDA)

Private Organizations/ Professional Societies

International Sources

Figure A3.1 Results of the Process to Select Relevant Articles

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4,093 potentially relevant articles were identified from literature searches. 24 articles were suggested by authors. These were combined into 4,117 articles that were included for title and abstract screening. As a result, 3,835 articles were excluded. The remaining 282 articles were included in a full text review. Of those, 122 articles were excluded. The remaining 160 articles were examined for information related to the literature search questions. Of those, 30 articles are cited in the document.
Figure A3.1 Results of the Process to Select Relevant Articles
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Content Source:
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
  1. Guyatt G, Schunemann HJ, Djulbegovic B, et al. Guideline panels should not GRADE good practice statements (https://www.sciencedirect.com/science/article/pii/S0895435614005447?via%3Dihub). J Clin Epidemiol. 2015;68: 597-600. Accessed August 20, 2019.
  2. Record of the Proceedings, Healthcare Infection Control Practices Advisory Committee, December 1-2, 2016 [PDF – 139 pages] (https://www.cdc.gov/hicpac/pdf/archive/2016December-HICPAC-meeting.pdf). Centers for Disease Control and Prevention. Accessed August 20, 2019.