Bloodborne Pathogens and B virus

1. Bloodborne Pathogens and B virus For Tulane National Primate Research Center employees whose work involves a high risk of exposure to HIV/SIV/SHIV, HBV, or B virus January 2012 Tulane University - Office of Environmental Health & Safety (OEHS)

2. This training serves as a review of Bloodborne Pathogens (BBP) in relation to the specialized work at TNPRC in working with nonhuman primates (NHP). Tulane University - Office of Environmental Health & Safety (OEHS)

3. Bloodborne Pathogens Standard • 1991- OSHA’s “Occupational Exposure to Bloodborne Pathogens” (29 CFR 1910.1030) Goal: eliminate or minimize occupational exposure to bloodborne pathogens • Revised in 2001 in response to the Needlestick Safety and Prevention Act Goal: clarifies employer requirements to identify, evaluate, and make use of safer, effective medical devices. Tulane University - Office of Environmental Health & Safety (OEHS)

4. How does animal blood fit into the Bloodborne Standard? • The standard covers animal blood only for those animals purposely infected with HIV or HBV. • Persons handling any animal blood should follow general precautions as recommended by the CDC/NIH, Biosafety in Microbiological and Biomedical Laboratories (BMBL) 5th edition Tulane University - Office of Environmental Health & Safety (OEHS)

5. What are Bloodborne Pathogens (BBP)? • Pathogenic microorganisms that are present in blood or other potentially infectious materials (OPIM) that can cause disease in humans. • These pathogens include, but are not limited to HBV (hepatitis B virus) and HIV (human immunodeficiency virus). Tulane University - Office of Environmental Health & Safety (OEHS)

6. Bloodborne Pathogens (BBP) • Other examples of BBP include micro-organisms that cause: • hepatitis C virus, malaria, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, Creutzfeldt-Jakob disease, HTLV-1, and viral hemorrhagic fever. • It is important to know which pathogens (from humans or animals) you may be exposed to at work, especially in the laboratory or clinical setting. Tulane University - Office of Environmental Health & Safety (OEHS)

7. Nonhuman primates, by virtue of their genetic, physiologic, and sometimes social similarities to humans, are particularly likely sources of infectious agents that pose a threat to humans. Tulane University - Office of Environmental Health & Safety (OEHS)

8. What are we concerned about here at TNPRC? • HIV (human immunodeficiency virus) • SIV (simian immunodeficiency virus) • SHIV (simian-human immunodeficiency virus) • HBV (hepatitis B virus) • B virus Tulane University - Office of Environmental Health & Safety (OEHS)

9. HIV(Human Immunodeficiency Virus) Tulane University - Office of Environmental Health & Safety (OEHS)

10. HIV • HIV is the virus that causes AIDS (Acquired Immune Deficiency Syndrome). Once a person has been infected with HIV, it may be many years before AIDS actually develops. • HIV kills or damages cells in the body’s immune system, gradually destroying the body’s ability to fight infection and certain cancers. computer generated art quality graphics of HIV was done by Russell Kightley of Canberra, Australia. Tulane University - Office of Environmental Health & Safety (OEHS)

11. HIV Through December 2001, there were 57 documented cases of occupational HIV transmission to health care workers in the United States, and no confirmed cases have been reported since 1999. At the end of 2008, an estimated 1,178,350 persons aged 13 and older were living with HIV infection in the United States. Of those, 20% had undiagnosed HIV infections and were unaware of their HIV infection. Tulane University - Office of Environmental Health and Safety (OEHS)

12. HIV • Some infected with HIV have no symptoms for up to ten years. • Within a month or two after exposure to the virus some experience flu-like illness such as: • fever, headache fatigue, weight loss, diarrhea, night sweats, enlarged lymph nodes • These symptoms usually disappear within a week to a month and are often mistaken for those of another viral infection. During this period, the individual is very infectious. Tulane University - Office of Environmental Health & Safety (OEHS)

13. HIV • The average risk for HIV transmission after a percutaneous (e.g., needlestick) exposure to HIV-infected blood has been estimated to be approximately 0.3%. • HIV does not survive well outside the body, making the possibility of environmental transmission remote. Tulane University - Office of Environmental Health & Safety (OEHS)

14. HIV- no cure or vaccine available • Treatment protocols from the U.S. Public Health Service have been developed using antiretroviral agents from five classes of drugs to treat HIV infection. These include: • the nucleoside reverse transcriptase inhibitors, nucleotide reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, protease inhibitors, and a single fusion inhibitor. • The recommendations provide guidance to effectively suppress the virus on the basis of HIV transmission risk represented by the exposure. Tulane University - Office of Environmental Health & Safety (OEHS)

15. HIV • Side effects associated with the use of antiviral drugs can be severe. • The drug regimen is not a cure for AIDS, but it has greatly improved the health of many people with AIDS and it reduces the amount of virus circulating in the blood to nearly undetectable levels. • Researchers, however, have shown that HIV remains present in hiding places such as the lymph nodes even in people who have been treated. Tulane University - Office of Environmental Health & Safety (OEHS)

16. SIV/SHIV(Simian Immunodeficiency Virus/Simian-Human Immunodeficiency Virus) Tulane University - Office of Environmental Health & Safety (OEHS)

17. SIV • Primate-borne retrovirus closely related to HIV-1 and HIV-2 • Asian macaques are susceptible to SIV infection. SIV is not a naturally occurring infection of wild macaques in their countries of origin. • Various strains of SIV are highly pathogenic in macaques and produce a severe immune deficiency disease (similar to AIDS), making it an important animal study model. Tulane University - Office of Environmental Health & Safety (OEHS)

18. SIV • Found in variety of tissue and body fluids of infected nonhuman primates -including blood, plasma, CSF, and parenchyma tissue Tulane University - Office of Environmental Health & Safety (OEHS)

19. SHIV • Laboratory-made hybrid of the simian and human viruses created by wrapping the SIV core in the HIV envelope • Virus seems to affect monkeys much like HIV affects humans • Created to learn what genes are necessary to overcome the species barriers to pathogenesis Tulane University - Office of Environmental Health & Safety (OEHS)

20. SIV/SHIV • Risk of human infection has not been clearly defined • Since SIV/SHIV shares many similar characteristics of HIV, many of the same biosafety precautions are indicated. Specific precautions in handling SIV/SHIV are based on recommendations developed for HIV and other lentiviruses. Tulane University - Office of Environmental Health & Safety (OEHS)

21. SIV/SHIV • In the lab, SIV/SHIV must be presumed to be present in all SIV/SHIV cultures, in all materials derived from such cultures, in all specimens from SIV/SHIV antibody-positive nonhuman primates, and in/on all equipment coming in contact with these materials. • Skin and mucous membranes should be considered a pathway for virus entry. • Contact with these sites should be considered an exposure to SIV/SHIV. Tulane University - Office of Environmental Health & Safety (OEHS)

22. HBV(Hepatitis B Virus) Tulane University - Office of Environmental Health & Safety (OEHS)

23. Hepatitis B Virus (HBV) • Hepatitis B is caused by a virus that attacks the liver and can cause lifelong infection, cirrhosis, liver cancer, liver failure, or death. • In 2009, an estimated 38,000 people were newly infected with HBV. 800,000 - 1.4 million Americans are chronically infected with HBV. Tulane University - Office of Environmental Health and Safety (OEHS)

24. Hepatitis B Virus • The average volume of blood inoculated during a needlestick injury with a 22-gauge needle is approximately 1 µl, a quantity sufficient to contain up to 100 infectious doses of HBV. • HBV can survive outside the body at least 7 days and still be capable of causing infection. Tulane University - Office of Environmental Health & Safety (OEHS)

25. Hepatitis B Virus • About 30% of infected persons have no sign or symptoms of HBV. • If symptoms occur, they usually begin to appear on the average of 12 weeks (range 9-21 weeks) after exposure to hepatitis B virus. • If you have symptoms, they might include: • jaundice • abdominal discomfort • dark urine • clay-colored bowel movements • joint pain • fatigue • loss of appetite • nausea Tulane University - Office of Environmental Health & Safety (OEHS)

26. HBV IS PREVENTABLE!A safe & effective vaccine is available. • Hepatitis B vaccine prevents hepatitis B infection and its serious consequences. • If the vaccine is administered before infection, it prevents the development of the disease and the carrier state in almost all individuals. • Hepatitis B vaccine consists of a series of three injections – initial, one a month later, and one six months from the first. • Available FREE of charge from employer Tulane University - Office of Environmental Health & Safety (OEHS)

27. What treatment is available for HBV? • In the occupational setting, multiple doses of Hepatitis B Immune Globulin initiated within 1 week following percutaneous exposure to hepatitis B surface antigen-positive blood provides an estimated 75% protection from HBV infection. • There is no cure available for acute HBV infection. There are antiviral drugs available for the treatment of chronic HBV infection. Tulane University - Office of Environmental Health & Safety (OEHS)

28. B Virus Tulane University - Office of Environmental Health & Safety (OEHS)

29. What is B Virus? • B virus infection is caused by the zoonotic agent Macacine herpesvirus (formerly Cercopithecine herpesvirus 1) • Other names: Herpes B virus, Monkey B virus, Herpes Virus Simiae • It is an alphaherpesvirus that occurs naturally in macaques and produces very mild disease in the primate but can cause a fatal encephalitis in humans. Tulane University - Office of Environmental Health & Safety (OEHS)

30. How Do I get B virus? • Exposure to contaminated monkey saliva, secretions, or tissues most commonly through: • Bites or scratches • Splashes • Needlesticks • Indirectly (contact with contaminated cage, etc) Tulane University - Office of Environmental Health & Safety (OEHS)

31. What are the chances that I will get B virus? • Reported cases of infection in humans are very rare. • Since the identification of the virus in 1932, there have only been 31 documented human infections by B virus, 21 of which were fatal. • Most of these infections have resulted from animal bites or scratches or from percutaneous inoculation with infectious materials. • However, in 1997 a researcher died from B virus infection following a mucosal splash exposure. Tulane University - Office of Environmental Health & Safety (OEHS)

32. Who Is Most at Risk for B virus? • animal caretakers • laboratory personnel • anyone who is exposed to monkeys or monkey tissues • immune-suppressed individuals may also face a higher risk for infection Tulane University - Office of Environmental Health & Safety (OEHS)

33. B virusSigns and Symptoms (for monkeys) • Most have no obvious sign of infection. • Some have ulcerations on the mouth, face, lips genitals, and/or eye. • Virus resides permanently in the monkey and can be periodically reactivated (usually if stressed or immunosuppressed). The virus can be shed by monkeys without visible lesions or symptoms. • . Tulane University - Office of Environmental Health & Safety (OEHS)

34. Vesicular (small blister) skin lesions at or near the site of injury Localized neurological symptoms such as pain, numbness or itching near the wound site Flu-like aches and pains Fever and chills Headaches lasting more than 24 hours Fatigue Lack of muscular coordination Shortness of breath B virus: Signs and Symptoms (for humans) *These generally occur within one month of exposure. Tulane University - Office of Environmental Health & Safety (OEHS)

35. Precautions to Consider • Exercise caution at all times. Nonhuman primates can and will bite. • Wear appropriate, protective clothing. • Work together with at least one other person when handling nonhuman primates. Minimize direct handling. • Report any observed facial, lip or oral lesions in the nonhuman primates to a veterinarian. • For bite or scratch injuries involving a monkey, or scratches with cages or equipment that might be contaminated with their secretions, wash thoroughly and seek medical care immediately. Tulane University - Office of Environmental Health & Safety (OEHS)

36. How can I protect myself from B virus infection? • Read TNPRC Procedure on Herpes B virus • Follow all standard procedures for your area • Wash Hands!!!! Tulane University - Office of Environmental Health & Safety (OEHS)

37. How could I be exposed to these pathogens at work? Tulane University - Office of Environmental Health & Safety (OEHS)

38. Chain of Infection Infection Control = Break any link in the chain Tulane University - Office of Environmental Health & Safety (OEHS)

39. Modes of transmission of BBP • Percutaneous - the direct inoculation of infectious material by piercing through the skin barrier (needlestick, bites, scratches from animals or cages) • Non-intact skin - exposure of infectious material to pre-existing lesions, cuts, abrasions, or rashes provides a route of entry into the body. • Mucous membrane contact – splashes of infectious material to an individual's unprotected eyes, nose, or mouth in clinical or laboratory settings. Tulane University - Office of Environmental Health & Safety (OEHS)

40. What can I do to prevent occupational exposure incidents? Tulane University - Office of Environmental Health & Safety (OEHS)

41. Occupational Exposure Prevention The risk of occupational exposure can be minimized or eliminated using a combination of engineering and work practice controls, personal protective clothing and equipment, training, medical surveillance, HBV vaccination, warning signs or labels, and other provisions described in this training section.   Tulane University - Office of Environmental Health & Safety (OEHS)

42. Standard Precautions • Guidelines to decrease the risk of occupational exposure to blood or body fluids. • A system of infection control which assumes that every direct contact with body fluids is infectious and requires every employee exposed to direct contact with body fluids to be protected as though such body fluids were infected with a bloodborne pathogen. • Provides adequate protection against bloodborne infections from both humans and animals. Tulane University - Office of Environmental Health & Safety (OEHS)

43. Employee Responsibilities • Completing training/orientation as required • Following the Standard Precautions Policy and the Exposure Control Plan (Written plan provided to eliminate or minimize occupational exposure to BBP.) • Using work practices, engineering controls, and personal protective equipment as outlined in the Exposure Control Plan Tulane University - Office of Environmental Health & Safety (OEHS)

44. Employee Responsibilities • Reporting exposure incidents to your supervisor and assisting the supervisor in completing First Report of Injury/Illness Form • Knowing in advance what to do if an exposure incident occurs • Pursuing follow-up care at after an exposure incident with TNPRC Occupational Health Failure to follow these policies could result in disciplinary action. Tulane University - Office of Environmental Health & Safety (OEHS)

45. Engineering Controls • Sharps with Engineered Sharps Injury Protection (SESIP)– a non-needle sharp or needle with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident • Examples include: Self-sheathing syringe Tulane University - Office of Environmental Health & Safety (OEHS)

46. More Examples of Engineered Sharps Safety Devices In use After use Retractable needle technology Retractable lancets Add-ons (needle covers) Self-blunting needles

47. Engineering Controls • Needleless Systems = Device that does not use a needle for: • collection of body fluids • administration of medication/fluids • any other procedure with potential percutaneous exposure to a contaminated sharp • Squeeze cages • Transfer boxes Tulane University - Office of Environmental Health & Safety (OEHS)

48. Work Practice Controls • Contaminated needles/sharps shall not be bent, recapped or removed unless there is no feasible alternative or if required by a specific medical procedure • Such bending, recapping, or removal must be done through use of mechanical device or a one-handed technique • Use puncture-resistant sharps • container for disposal of sharps Tulane University - Office of Environmental Health & Safety (OEHS)

49. Work Practice Controls • No food/drink/smoking, handling of contacts, or application of cosmetics in work area where there is potential for exposure • Minimize splashing, spraying, spattering, and generation of droplets • Use secondary containment for transport, shipping, or storage of containers • Decontaminate surfaces and equipment Tulane University - Office of Environmental Health & Safety (OEHS)

50. Personal Protective Equipment • Gloves(latex or nonlatex) • When to use them: • when there is reasonable anticipation of employee hand contact with blood, mucous membranes, non-intact skin, or other potentially infectious materials • when performing vascular access procedures • when handling or touching contaminated surfaces or items. • Remove prior to leaving the work area and discard as biohazard waste Tulane University - Office of Environmental Health & Safety (OEHS)