Online Self-Study. Bloodborne Pathogens. Introduction.
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On December 6, 1991, the Occupational Safety and Health Administration (OSHA) published their standard for occupational exposure to bloodborne pathogens in the Federal Register 1910.1030, which can be found at the following website: www.osha.gov. A component of this standard requires the employer to provide training regarding the occupational hazard of bloodborne pathogens. There are 14 required components of this training; all of which are incorporated in this study module. These components are listed in the Federal Register 1910.1030.
It is important to remember that OSHA standards are federal law and compliance is mandatory. However, it is more important to recognize that this standard was established to help protect the healthcare worker from the serious workplace hazard of bloodborne pathogens.
Bloodborne Pathogens are pathogenic microorganisms that are present in human blood or Other Potentially Infectious Materials (OPIM) and can cause disease in humans. These pathogens include but are not limited to:
Exposure to human blood carries the greatest risk for acquiring a bloodborne pathogen. However, other body fluids besides blood have demonstrated a viral load sufficient to potentially transmit infection. These fluids are:
Also considered potentially infectious are:
It is important for healthcare workers to prevent exposure to any body fluid. However, only exposure to the above fluids or substances are considered potentially capable of transmitting a bloodborne disease.
HIV and Hepatitis B virus are transmitted by sexual contact, sharing contaminated needles or syringes and from mother to unborn child.
In the occupational setting transmission is by percutaneous injuries (needlestick/sharp puncture or cut), mucous membrane and non-intact skin exposure to contaminated blood or other potentially infectious materials (OPIM).
HCV is transmitted by percutaneous exposure to contaminated blood and plasma derivatives. The risk of HCV transmission by household contact and sexual activity has not been well defined, but is believed to be low. Transmission from mother to unborn child appears to be uncommon.
Not all the bloodborne pathogens carry the same risk of infection from an occupational exposure. Frequency in patient population, the ability of the virus to survive on environmental surfaces and the amount of virus present in the body fluid, all impact the risk of acquiring infection.
If exposed. The following table demonstrates infection risk from a percutaneous exposure to HBV, HCV, and HIV.
Risk of Infection From Percutaneous Exposure
In a case-control study conducted by the Centers for Disease Control (CDC), significant risk factors for HIV seroconversion (acquired infection) after a percutaneous exposure were determined to be the following.
The study also found that postexposure prophylaxis with zidovudine (AZT) was associated with a decrease in the risk of HIV seroconversion.
The clinical picture of HIV infection ranges from those who have no symptoms to person with severe immunodeficiency or Acquired Immune Deficiency Syndrome (AIDS). Initial infection can be followed by an acute flu-like illness. Symptoms include:
Without treatment, the natural history of HIV infection can vary considerably from person to person. The risk for disease progression increases with the duration of infection. Most studies have shown that less than 5% of HIV-infected adults develop AIDS within 2 years of infection; however approximately 20-25% will develop AIDS within 6 years after infection, and 50% within 10 years. When an HIV-infected person develops certain diseases or conditions, they are then classified as having AIDS. Three of the most common clinical conditions are P. carinnii pneumonia, HIV wasting syndrome, and candidiasis of the esophagus.
The clinical presentation of acute HBV ranges from asymptomatic illness to fulminant hepatic failure. The disease has a long incubation period from 30 to 180 days. Initial symptoms are nonspecific, typically include:
These symptoms last 3-10 days. This is followed by the onset of jaundice (yellowing of the skin) or dark urine. Fulminant viral hepatitis is defined as the development of severe acute liver failure with hepatic encephalopathy within 8 weeks of the onset of symptoms with jaundice.
Recombinant vaccines for HBV were licensed in the US in 1986. Given as a series of three injections, the vaccine produces a high antibody titer in over 90% of recipients under the age of 40-50 years. Older age, obesity, heavy smoking, and immunologic impairments have been associated with lower antibody responses. The higher the antibody titer after vaccination, the longer protection persists. When the antibody titer falls below 10 MIU/mL, HBV infections may occur but are always subclinical and usually without detectable serum antigen. The need for a booster dose of vaccine has not been determined. The vaccine is safe and well tolerated by recipients. All employees who have reasonably anticipated exposure to blood or other potentially infectious materials will be offered the Hepatitis B vaccine through the University Employee Occupational Health Clinic. OSHA considers the Hepatitis B vaccine so important that employees will be required to sign a declination statement if they choose not to receive the vaccine. However, those declining the vaccine may receive it at a future time as long as they remain an employee of the University.
HCV is similar to Hepatitis B virus in that it is associated with chronic Hepatitis, cirrhosis, and hepatocellular cancer. At least 50% and possibly 60-70% of acute HCV infections lead to chronic infection, approximately 20% lead to cirrhosis, and approximately 10% die of complications. Chronic Hepatitis C is one of the major causes of cirrhosis in the U.S. and is one of the most common indications for liver transplantation in adults. There is no vaccine for prevention of Hepatitis C infection and no post-exposure prophylaxis.
The Exposure Control Plan contains the policies and procedures of the UNC and UNC Health Care System to protect employees from acquiring a bloodborne pathogen. It also contains a complete listing of all job categories that have been identified as having the risk of occupational exposure to blood and body fluids. A copy of the Exposure Control Plan is located in UNC Hospitals' Infection Control Manual and the University's EHS web site at http://ehs.unc.edu/ih/biological/bbp.shtml. Directly behind the Exposure Control Plan in the Infection Control Manual is a copy of the OSHA standard for bloodborne pathogens. Every employee should be familiar with the Exposure Control Plan and the OSHA standard.
Standard Precautions are an essential component to reducing the occupational acquisition of a bloodborne pathogen. Standard Precautions apply to blood, all body fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood, non-intact skin, and mucous membranes. Standard Precautions mean that we treat every patient as if they are infected with a bloodborne pathogen such as HIV, HBV, or HCV. Standard Precautions also mean that healthcare workers practice appropriate handwashing and use personal protective equipment to prevent direct contact with a patient's blood or body fluids. The consistent practice of Standard Precautions is the best method that healthcare workers can use to protect themselves from occupationally acquiring a bloodborne disease.
An engineering control is a device that removes a hazard from the workplace. Employers are required to provide engineering controls that have been demonstrated to significantly reduce an occupational hazard. Examples of engineering controls used by the healthcare system include:
Work practice controls are designed to change the way in which a task is performed to reduce the likelihood of exposure to bloodborne pathogens. Healthcare workers routinely practice many work practice controls. Examples of work practice controls include:
* Certain clinical procedures may require that a needle be recapped. Needles should only be recapped using a recapping device or using a one-handed recapping technique. One-handed technique requires that the cap be placed on a solid surface and using only one hand, carefully slipping the needle back into the cap. Also, remember to never place a glove box or any other item on top of a sharps disposal container. This could interfere with the safe disposal of a sharp.
Personal protective equipment (PPE) is specialized clothing and equipment worn by an employee to prevent direct contact with blood or other body substances. PPE should be readily available and provided to the employee at no cost. Most personal protective equipment used by healthcare workers are disposable, single-use items. Clean exam gloves are located in every patient room. PPE boxes (tan colored, wall-mounted cabinets) containing non-sterile gowns, protective eyewear, masks, and resuscitation mask with one-way valve, are located on patient care units. You can also find PPE in the clean utility rooms of patient care units and outpatient clinics. PPE should be carefully removed immediately after use and hands thoroughly washed. Soiled gowns, gloves, etc. should be disposed of in the regular trash (white, plastic bag displaying a BIOHAZARD label). Employees are responsible for using PPE when instructed and whenever clinically indicated to prevent exposure to blood and body fluids.
The universal biohazard sign is used to alert employees when containers, specimen refrigerators, or secondary containers used to transport specimens contain infectious materials. Additionally, equipment that may have internal contamination should be labeled with a biohazard tag denoting the area of contamination.
As soon as possible, contaminated clothing should be carefully removed, avoiding contact with the garment's outer surface to prevent skin contamination. If heavily soiled, gloves may be necessary. The contaminated garment should be placed in a fluid resistant liner bag. If owned by the employee, the item should be placed in a plastic bag and labeled with the employee's name, department, and phone number. The linen room will issue scrub clothing to the employee if needed.
Medical devices such as blood pressure cuffs and stethoscopes must be cleaned if contaminated with blood or other potentially infectious materials. An EPA-approved disinfectant detergent (i.e., Vesphene) or a 1:10 dilution of bleach and water should be used.
All spills must be safely cleaned up as soon as possible. Healthcare workers should use the following guidelines.
Specimens should not be hand carried to the laboratory. All specimens must be transported in a secondary container displaying a BIOHAZARD label. The primary specimen container and the specimen requisition slip must be free of any contamination. If the container or requisition slip is visibly soiled, the laboratory will refuse to accept the specimen. When transporting specimens via the computerized tube system, be sure to carefully follow the appropriate packaging protocol. Urine specimens should have the top tightened securely and the container placed in two ziplock plastic bags. The laboratory will not accept specimens in syringes with a needle attached. Exceptions to this policy will be considered when the volume is so small that the entire specimen is contained in the needle.
Certain items have special disposal procedures required by North Carolina law and are referred to as regulated medical waste. Regulated medical waste includes:
Regulated medical waste must be placed in red trash bags bearing a BIOHAZARD label. On all patient care units, a red bag is located in the dirty utility room. In research laboratories that autoclave their waste, an orange autoclave bag must line the waste receptacle.
Suction canisters from most patient care areas are not disposed of in the red bag waste since they can be opened and emptied prior to disposal. When emptying a suction canister, gloves should be worn and the contents carefully poured into a hopper or toilet. If splash or splatter is anticipated, an impervious gown and eye protection should also be worn. The empty canister should then be placed in the regular trash (white trash bag with a Biohazard label).
Disposal in white Trash Bags labeled with BIOHAZARD SIGN
Remember: bags are not puncture-proof...sharps are to be disposed in designated sharps containers.
Contaminated linen, linen potentially soiled with blood or body fluids, should not be sorted or handled any more than necessary for disposal. Fluid resistant linen bags are available for use when disposing of used linen. Linen should be double-bagged when necessary to prevent leaking. Linen hampers should have a cover or lid.
Our skin serves as a natural barrier to bacteria and viruses. Unfortunately, the skin on a person's hands sometimes becomes reddened and irritated due to exposure to cold or irritating chemicals. Often small cracks occur in the skin affecting its natural barrier qualities. Working with this condition puts you at greater risk of infection from bloodborne pathogens.
Any latex allergy reaction should be reported to the University Employee Occupational Health Clinic.
You are considered potentially exposed to a bloodborne pathogen if you contact blood or other infectious body substances in any of the following ways:
At UNC in 1998, there were 68 exposure incidents reported. Four of the source patients were HIV positive, six were HBV positive, and five were HCV positive. There were no seroconversions as a result of exposure to HIV, HBV, or HCV positive blood.
Knowing the right steps to take after an exposure incident is critical in reducing the likelihood of acquiring a bloodborne pathogen. Immediately after any exposure incident:
UEOHC clinic staff will evaluate your exposure incident. The evaluation may include testing your blood and the source patients' blood for HIV, HBV, and HCV. Testing of your blood is only done with your consent and results are confidential. UEOHC will provide you with written evaluation and recommendations regarding your exposure. Prophylaxis for HIV exposure will be considered when indicated.
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