Blood Borne Pathogens

1. Blood Borne Pathogens Mike Berendsohn FF/Paramedic Leelanau Township Emergency Services

2. Introduction • Blood borne pathogens is something that effects all levels of responders . Healthcare workers also have the potential for a blood borne exposure. Healthcare workers are the most likely to be exposed to blood borne illnesses, but workers form many industries may become exposed to blood borne pathogens. Any occupation or tasks that involves the handling, disposal or transport of blood, feces, medic waste, or any other potentially infectious material has the potential to become exposed. This course is designed to review the Occupational Safety and Health Administrations standards on blood borne pathogens and blood borne diseases. • This Course meets the standards for: • NFPA 1581 • MIOSHA Part 554 • OSHA 29 CRF 1910.1030

3. The Standard • The OSHA standard applies to all employees that have the potential for an exposure to blood borne pathogens. Some of the potential occupation that this standard would apply to includes, Firefighters, Law Enforcement, Medical First Responders, EMT-Baisc’s, EMT-Specialist’s, and Paramedics . It is the responsibility of the Employer to evaluate the work conditions and environment for potential exposure hazards. Some of the OSHA requirements Include: • Developing an Exposure control plan • Having universal precautions available to all employees • Vaccinations and records • Training • Post exposure follow up • Disposal and decontamination

4. What are blood borne pathogens? • Blood borne Pathogens are: • Pathogenic microorganisms that are present in human blood that can cause disease in the body. Some examples of blood borne pathogens include: • Hepatitis B and C • Human Immunodeficiency Virus (HIV) • Tuberculosis Communicable Diseases are: A disease that can be transmitted from one human to another.

5. Who is at risk? • Leelanau Township Emergency Services classifies job tasks and lists there potential for exposure. The job tasks are classified as follows: • Class 1 = Blood/Body fluid exposure possible • Class 2 = No exposure potential • The following is a list of job task that are common among Fire/EMS duties. Assessment (medical) Assessment (trauma) Opening the airway Clearing the airway Suctioning the airway Inserting oral or nasal airway Inserting King airways or Combitube Intubation (ET) Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1

6. Who is at risk? Assisted breathing techniques Mouth to mouth/nose/stoma Mouth to mask Bag valve mask (and through tube) CPR/Rescue breathing/Chest compressions Oxygen administration Nasal cannula Simple mask Non-rebreather mask Venturi mask Humidifier Nebulizers Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1

7. Who is at risk? Direct pressure Tourniquet Closed wound bandaging Open wound bandaging Special wound bandaging MAST Pants Application/Inflation/Removal Managing delivery of obstetric Delivery of infants Abnormal deliveries Care of newborns Manual spinal immobilization Patient handling Cervical motion restriction devices Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1

8. Who is at risk? Spinal motion restriction devices General splinting Rigid splinting Traction splitting All use and assisting with ALS crews Oral medication administration Intravenous medication administration Intramuscular medication administration Use of stethoscope Pulse oximeter/CO oximeter Radio use Portable/mobile Use of sphygmomanometer Lifepak 500/1000/12 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1

9. Who is at risk? Internal temperature probe Glucometer and lancet use Vehicle inspection (exterior) Vehicle inspection (interior) Vehicle cleaning (interior/external) Dispatching Documentation Obtaining patient refusal Cleaning of equipment Use of stretcher/stair chair Lucas 2 application/use/removal Extrication Starting an IV/IO Class 1 Class 1 Class 3 Class 1 Class 1 Class 3 Class 3 Class 1 Class 1 Class 1 Class 1 Class 1 Class 1

10. Who is at risk? • Job tasks that could reasonably anticipate a potential exposure: • Airway suctioning • Airway management • Testing blood glucose • Starting an IV/IO • Administering medications • Wound care • Splinting • Patient Handling • Patient Extrication • Delivery of newborns • Body Removal • Decontamination and disinfecting equipment.

11. How exposures occur • For a blood borne pathogen to be transmitted, the pathogen must enter the individuals bloodstream. Some of the ways that transmissions can occur includes: Breaks in the skin - Anytime there is a break in the skin there is a potential for a transmission. Breaks in the skin can include, scratches, cuts, open wounds, insect bites. • Needle sticks – Needle sticks are one of the most common forms of transmission of blood borne pathogens. For an exposure to happen the needle being used must first be contaminated by the pathogen being transmitted. Sharing of used needles is a very common form of blood borne transmission • Other contaminated object – This may include any other type of object that has come into contact with a transmittable pathogen. Some examples of contaminated object include: Broken glass, used lancets, medication vials, sharp metal, blood soaked clothing, amniotic fluids. • Mucosa membranes – There are many open gateways in the body for the transmission of BBP. Some examples of these membranes include your mouth, eyes, and nose. • Pathogens can be transmitted through sexual activity.

12. How exposures occur • For a transmission to occur: • The pathogen must be present in high a enough concentration. • The infected individual must be susceptible to the pathogen. (Non-vaccinated) • The pathogen must have a viable path of entry into the human body. • All three of the following criteria must be • met for there to have been a potential • Exposure • BBP’s cannot be transmitted by the • following routes: • Casual contact • Hand shakes Once pathogen are introduced into the body there is potential for that pathogens to transmitted to potential offspring.

13. Needle stick Exposures Needle sticks account for approximately 80% of all blood borne exposures. It is not just the person that is doing the IV start that is at risk for any exposure. Often it is the people cleaning up after the incidents that have accidental exposures due to unsecured sharps.

14. Best Protection Engineering Controls: Employers should make every reasonable effort to reduce the chances of a potential exposure. Sharps with Engineered Sharps Injury Protection- a non-needle sharp or a needle device which is used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, and which has a build-in safety feature or mechanism that effectively reduces the risk of an exposure incident. (Needle cover) (needle covered) (Retractable Needle)

15. Best Practices • Needless System- a device that does not use needles for any of the following: • The collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established. • The administration of medication or fluids. • Any other procedure involving the potential for occupational exposure to blood borne pathogens due to percutaneous injuries from contaminated sharps. (blunt tip catheter) (Luer-lock injection cap)

16. Best Practices • It is the responsibility of the employer to provide vaccinations to employees that have a reasonable risk of exposure to patients. • Examples of vaccines provided include: Hepatitis B • These vaccines are too be provided at no cost to the employees. • These vaccines are to be provided to the employees at a reasonable date and time for administration. • The Hepatitis vaccination schedule most often used for adults and children has been three intramuscular injections, the second and third administered 1 and 6 months after the first. • As with all vaccines, there can be minor reactions, including pain and redness at the injection site, headache, fatigue or a vague feeling of discomfort. The hepatitis B vaccine is considered very safe. • the Hepatitis B vaccine is very effective at preventing Hepatitis B virus infection. After receiving all three doses, the Hepatitis B vaccine provides greater than 90% protection to infants, children, and adults immunized before being exposed to the virus.

17. Best Practices • Standard (universal) precautions should be followed. • Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. These practices are designed to both protect healthcare providers and prevent healthcare providers from spreading infections among patients. • Standard Precautions include: 1) hand hygiene, 2) use of personal protective equipment (e.g., gloves, gowns, masks), 3) safe injection practices, 4) safe handling of potentially contaminated equipment or surfaces in the patient environment, and 5) respiratory hygiene/cough etiquette. • Treat all potential infectious material as contaminated.

18. Best Practices • Sharps containers will be stored in a manner to prevent spillage of its contents during use or transit. • There will be no eating, drinking, smoking, make-up, or contact lenses application allowed in the interior of the ambulance(s) when exposure is possible. • No food or drink is allowed to be stored in refrigerators, on shelves, cabinets, counter tops or bench seats where infectious material maybe present. • Hand washing facilities will be readily available to all personnel. Antiseptic (waterless) hand cleaner is available on all department response vehicles. • Crews are recommended to run the exhaust and ventilation fans in the patient compartment while transporting patients.

19. Records keeping • Needle Stick and Prevention Act Mandated that a Sharps Injury Log be kept. • In the event of an Exposure: Name and Social Security Number Shot Record and TB Test Employer’s Copy of Exam, Testing, and Follow-up Procedures Health Care Professionals Written Opinion Copy of Info given to the Health Care Professional Employee’s Records Kept Confidential Unless Written Consent is Given by Employee. • Training: Dates of Training Contents of Training Name and Qualifications of Trainer Names and Job Title of Trainee Kept for a minimum of 3 yrs.

20. What is out there? Hepatitis: There are many strains of hepatitis. The main strains of hepatitis that we will be focus on will be strains B and C. These strains pose the greatest health risk. Hepatitis A: Hepatitis A is a liver disease that results from infection with the Hepatitis A virus. It can range in severity from a mild illness lasting a few weeks to a severe illness lasting several months. Hepatitis A is usually spread when a person ingests fecal matter — even in microscopic amounts — from contact with objects, food, or drinks contaminated by the feces or stool of an infected person. The best way to prevent Hepatitis A is by getting vaccinated

21. What is out there? • Hepatitis B: Hepatitis is a disease cause by the hepatitis B virus. The hepatitis B virus attacks the liver. The liver in impacted by cirrhosis (hardening of the liver) liver cancer, liver failure, and death. Hepatitis B symptoms manifest themselves within 12 weeks. Some of the symptoms include: • Jaundice of the eyes and skin • Loss of appetite • Nausea • Abdominal pains • Stiff joints • Tiredness and weakness • Hepatitis is a preventable disease. Hepatitis B has a vaccine that can prevent a potential infection

22. What is out there? Hepatitis C: Hepatitis C is a liver disease that results from infection with the Hepatitis C virus. It can range in severity from a mild illness lasting a few weeks to a serious, lifelong illness. Today, most people become infected with the Hepatitis C virus by sharing needles or other equipment to inject drugs. Before 1992, when widespread screening of the blood supply began in the United States, Hepatitis C was also commonly spread through blood transfusions and organ transplants. There is no vaccine for Hepatitis C. The best way to prevent Hepatitis C is by avoiding behaviors that can spread the disease, especially injection drug use.

23. What is out there? Hepatitis D: Hepatitis D is a serious liver disease caused by the Hepatitis D virus (HDV). It is uncommon in the United States, and only occurs among people who are infected with the Hepatitis B virus. The transmission of HDV is similar to how HBV is spread and requires contact with infectious blood. There is no vaccine for Hepatitis D. Hepatitis E: Hepatitis E is a serious liver disease caused by the Hepatitis E virus (HEV). While rare in the United States, Hepatitis E is common in many parts of the world. HEV is similar to Hepatitis A, in that it is spread in similar ways and usually results in an acute infection. It is transmitted from ingestion of fecal matter, even in microscopic amounts, and is usually associated with contaminated water supply in countries with poor sanitation. There is currently no FDA-approved vaccine for Hepatitis E

24. What is out there? • Human Immunodeficiency Virus (HIV): HIV stands for human immunodeficiency virus. It is the virus that can lead to acquired immunodeficiency syndrome, or AIDS. Unlike some other viruses, the human body cannot get rid of HIV. That means that once you have HIV, you have it for life. • In the United States, HIV is spread mainly by having sex with or sharing drug injection equipment with someone who is infected with HIV. HIV cannot be spread by casual contact such as hugging or shaking hands. • Post-exposure prophylaxis (PEP) is medicine that is used to prevent HIV after a possible exposure. • Symptoms of HIV infection include: • Fever • Diarrhea • Fatigue • Weight loss • Night sweats

25. What is out there? Methicillin-resistant Staphylococcus aureus (MRSA): is a bacteria that is resistant to many antibiotics. In the community, most MRSA infections are skin infections. In medical facilities, MRSA causes life-threatening bloodstream infections, pneumonia and surgical site infections.

26. What is out there? • Tuberculosis (TB): is caused by a bacterium called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain. If not treated properly, TB disease can be fatal. • TB is spread through the air from one person to another. The TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these bacteria and become infected.Symptoms of TB disease include: • A bad cough that lasts 3 weeks or longer • Pain in the chest • Coughing up blood or sputum • Weakness or fatigue • Weight loss • No appetite • Chills • Fever • Sweating at night

27. What is out there? • Bacterial meningitis: Bacterial meningitis is usually severe. While most people with meningitis recover, it can cause serious complications, such as brain damage, hearing loss, or learning disabilities. In the united states, about 4,100 cases of bacterial meningitis, including 500 deaths, occurred each year between 2003–2007. • The germs that cause bacterial meningitis can be contagious. Some bacteria can spread through the exchange of respiratory and throat secretions (e.G., Saliva or mucus). • Meningitis infection may show up in a person by a sudden onset of fever, headache, and stiff neck. It will often have other symptoms, such as • Nausea • Vomiting • Increased sensitivity to light • Altered mental status (confusion). • The most effective way to protect you against certain types of bacterial meningitis is to complete the recommended vaccine schedule. Antibiotics may be recommended for close contacts of people with meningococcal meningitis.

28. What is out there? • Herpes Zoster (shingles): Shingles is caused by the varicella zoster virus (VZV), the same virus that causes chickenpox. After a person recovers from chickenpox, the virus stays dormant (inactive) in the body. For reasons that are not fully known, the virus can reactivate years later, causing shingles. Shingles is not caused by the same virus that causes genital herpes, a sexually transmitted disease. • Symptoms of shingles can include: • Rash • Fever • Headache • Chills • Upset stomach • The only way to reduce the risk of developing shingles and the long-term pain from post-herpetic neuralgia (phn) is to get vaccinated. CDC recommends that people aged 60 years and older get the shingles vaccine.

29. What is out there? • Clostridium difficile (C-Diff): is a bacterium that causes inflammation of the colon, known as colitis. The bacteria are found in the feces. People can become infected if they touch items or surfaces that are contaminated with feces and then touch their mouth or mucous membranes. Healthcare workers can spread the bacteria to patients or contaminate surfaces through hand contact. • Symptoms include: • Watery diarrhea (at least three bowel movements per day for two or more days) • Fever • Loss of appetite • Nausea • Abdominal pain/tenderness • In about one in four patients, Clostridium difficile infection will resolve within 2-3 days of discontinuing the antibiotic to which the patient was previously exposed.  Clostridium difficile is generally treated for 10 days with antibiotics prescribed by your healthcare provider.

30. What is out there? • Ebola hemorrhagic fever (Ebola HF): is one of numerous Viral Hemorrhagic Fevers. It is a severe, often fatal disease in humans and nonhuman primates. Ebola HF is caused by infection with a virus of the family Filoviridae. • When an infection does occur in humans, there are several ways in which the virus can be transmitted to others. These include: • Direct contact with the blood or secretions of an infected person • Exposure to objects (such as needles) that have been contaminated with infected secretions • Symptoms of Ebola HF typically include: • Fever • Headache • Joint and muscle aches • Weakness • Diarrhea

31. Personal protective equipment Level A PPE Level A - To be selected when the greatest level of skin, respiratory, and eye protection is required. The following constitute Level A equipment; it may be used as appropriate; 1. Positive pressure, full face-piece self-contained breathing apparatus (SCBA), or positive pressure supplied air respirator with escape SCBA, approved by the National Institute for Occupational Safety and Health (NIOSH). 2. Totally-encapsulating chemical-protective suit. 3. Coveralls. 4. Long underwear. 5. Gloves, outer, chemical-resistant. 6. Gloves, inner, chemical-resistant. 7. Boots, chemical-resistant, steel toe and shank. 8. Hard hat 9. Disposable protective suit, gloves and boots (depending on suit construction, may be worn over totally-encapsulating suit).

32. Personal protective equipment

33. Personal protective equipment Level B PPE II. Level B - The highest level of respiratory protection is necessary but a lesser level of skin protection is needed. The following constitute Level B equipment; it may be used as appropriate. 1. Positive pressure, full-facepiece self-contained breathing apparatus (SCBA), or positive pressure supplied air respirator with escape SCBA (NIOSH approved). 2. Hooded chemical-resistant clothing (overalls and long-sleeved jacket; coveralls; one or two-piece chemical-splash suit; disposable chemical-resistant overalls). 3. Coveralls. 4. Gloves, outer, chemical-resistant. 5. Gloves, inner, chemical-resistant. 6. Boots, outer, chemical-resistant steel toe and shank. 7. Boot-covers, outer, chemical-resistant. 8. Hard hat. 9. Face shield.

34. Personal protective equipment

35. Personal protective equipment Level C PPE III. Level C - The concentration(s) and type(s) of airborne substance(s) is known and the criteria for using air purifying respirators are met. The following constitute Level C equipment; it may be used as appropriate. 1. Full-face or half-mask, air purifying respirators (NIOSH approved). 2. Hooded chemical-resistant clothing (overalls; two-piece chemical-splash suit; disposable chemical-resistant overalls). 3. Coveralls. 4. Gloves, outer, chemical-resistant. 5. Gloves, inner, chemical-resistant. 6. Boots (outer), chemical-resistant steel toe and shank. 7. Boot-covers, outer, chemical-resistant. 8. Hard hat. 9. Escape mask. 10. Face shield.

36. Personal protective equipment

37. Personal protective equipment Level D PPE IV. Level D - A work uniform affording minimal protection: used for nuisance contamination only. (Most commonly used PPE level in Rescue and EMS) The following constitute Level D equipment; it may be used as appropriate: 1. Coveralls. 2. Gloves. 3. Boots/shoes, chemical-resistant steel toe and shank. 4. Boots, outer, chemical-resistant. 5. Safety glasses or chemical splash goggles. 6. Hard hat. 7. Escape mask. 8. Face shield.

38. Personal protective equipment

39. N95 Facemasks The N95 respirator is the most common of the seven types of particulate filtering face piece respirators. This product filters at least 95% of airborne particles but is not resistant to oil.

40. EMS PPE Kits Light duty PPE kit (30 second exposure kit) Heavy duty PPE kit

41. Fire Department PPE kits Fire department PPE kit are avail be on every Fire department response vehicle. Kits include: Gloves, N95 masks, 30 Second exposure kits, Red biohazard bags, A liquid solidification powder and PAWS antimicrobial wipes.

42. Cleaning and decontamination •Decontamination- the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe or handling, use, or disposal. •Disinfect- to inactivate virtually all recognized pathogenic microorganisms, but not necessarily all microbial forms, on inanimate objects. •Sterilize- the use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores.

43. Cleaning and decontamination

44. Cleaning and decontamination Cleaning products are located in both ambulances and in the utilities room of the Northport station. Follow the manufactures recommendation for application of cleaning supplies.

45. Cleaning and decontamination Additional cleaning products located in both ambulances and in the utilities room of the Northport station. Follow the manufactures recommendations for application of cleaning supplies.

46. How to dispose of waste “Red Bag” Items- The regulated waste items must be placed in bio-hazard bags are saturated non-sharp materials. They are taken to the emergency department , and placed in the dirty utility room at Munson Medical Center. “Sharps” Containers- Full “Sharps” containers must be sealed, taken to the emergency department, and placed on the counter in the dirty utility room.

47. What to do if exposed •Contact the Medical Director, (s)he will then contact Munson Medical Center. •Fill out an Incident Report and the Exposure Paperwork. •Contact the Charge Nurse at MMC and tell them you are a HCP. –Charge will Contact the Nurse Supervisor in the ER –They will Contact the Infectious Control Officer. •They will Test the Source Individual. •You will Register as a Patient and be tested as needed. •The Information will be returned to the Exposure Liaison and possibly the Exposed.

48. What to do if exposed • Exposure forms are located in the safety books. Safety books are located in every department response vehicle. Safety books are also located in both the Fire and EMS offices. • If exposed, information cards are in both ambulances for exposure reporting instructions.

49. What to do if exposed Leelanau township emergency services incident/safety report

50. What to do if exposed First responders request for testing page 1