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Caring for the Worker Potentially Exposed to Bloodborne Pathogens

Caring for the Worker Potentially Exposed to Bloodborne Pathogens. Lawrence D. Budnick , MD, MPH Associate Professor of Medicine Director, Occupational Medicine Service New Jersey Medical School University of Medicine & Dentistry of New Jersey December 10, 2001. Objectives.

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Caring for the Worker Potentially Exposed to Bloodborne Pathogens

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  1. Caring for the Worker Potentially Exposed to Bloodborne Pathogens Lawrence D. Budnick, MD, MPH Associate Professor of Medicine Director, Occupational Medicine Service New Jersey Medical School University of Medicine & Dentistry of New Jersey December 10, 2001

  2. Objectives • Risks of exposure to blood and body fluids (BBFs) • Current regulatory environment regarding bloodborne pathogens (BBPs) • Prevention methods • Clinical management - Assessment - Treatment - Counseling - Follow-up

  3. Paid and unpaid persons whose activities involve: Working in a health care setting Contact with patients Contact with potentially infectious materials from patients in a health care setting May include, but not limited to: Patient care: nurses, physicians, EMS personnel, part-time staff, temporary contractors, students Non-patient care: volunteers, dietary, clerical, janitorial, maintenance, housekeeping Health Care Workers >10 million persons in the US

  4. B virus (Herpesvirus simiae) Blastomycosis Brucellosis Creutzfeld-Jakob disease Cyptococcosis Cytomegalovirus Diphtheria Ebola feverGonorrhea (cutaneous) Hepatitis B Hepatitis C Herpes Human immunodeficiency virus Leptospirosis Malaria Mycobacteriosis Rocky Mtn Spotted FeverMycoplasmosis Prion Sporotrichosis Scrub Typhus Sporotrichosis Staphylococcus aureusStreptococcus Syphilis Toxoplasmosis Tuberculosis Potential Bloodborne Pathogens

  5. Hepatitis B Virus • Hepadnavirus • 42 nm double- • stranded DNA • 27 nm • nucleocapsid • core (HBcAg) • Outer lipoprotein • coat contains • surface antigen • (HBsAg) • 4 major subtypes

  6. Hepatitis B - Clinical Features Incubation period:Average 9-13 weeks Range 6-26 weeks Clinical illness: 70% Chronic infection: 2-8% Death from chronic liver disease: 15-25% of chronic inf. Immunity: Protective antibody response identified

  7. Hepatitis B Epidemiology • Incidence 80,000 cases/year • Was 450,000 in the 1980’s • Prevalence 1.25 million are chronically infected • In 1994, 1000 health care workers developed HBV infection • Approx. 200 HCWs died each year Source: CDC, 1991; 1997

  8. Risk Factors for Acute Hepatitis B, US, 1992-93 Heterosexual* (41%) Injecting Drug Use (15%) Homosexual Activity (9%) Household Contact (2%) Health Care Employment (1%) Unknown (31%) Other (1%) * Includes sexual contact with acute cases, carriers, and multiple partners. Source: CDC Sentinel Counties Study of Viral Hepatitis

  9. Hepatitis C Virus • Hepapavirus • Enveloped RNA • virus • 90 subtypes

  10. Hepatitis C - Clinical Features Incubation period:Average 6-9 weeks Range 2-28 weeks Clinical illness:20-40% Chronic hepatitis: 70-85% Death from chronic liver disease: <3% of chronic inf. Immunity:No protective antibody response identified

  11. Hepatitis C Epidemiology • Incidence 40,000 cases/year • Was 240,000 in the 1980’s • Prevalence 3.9 million or 1.8% persons have been infected with HCV • 2.7 million are chronically infected Source: CDC, 1991; 1997

  12. Click for larger picture

  13. Occupational Transmission ofHCV via NSI

  14. Human Immunodeficiency Virus • Retrovirus • Core of diploid RNA • Spherical lipid • envelope • 2 major types

  15. Acute HIV - Clinical Features • Incubation period: Avg 2-4 weeks, range 1-12 wks • Acute antiretroviral syndrome • 50%, 1-2 weeks duration • Most common symptoms • - Fever - Lethargy - Pharyngitis • - Lymphadenopathy - Maculopapular rash • - Myalgia - Arthralgia Immunity: No protective Ab response identified AIDS incidence:50% in 10 years without Rx

  16. HIV Epidemiology in the U.S. HIV + AIDS • Incidence 42,156 cases/year • Prevalence 450,151 persons are living with HIV/AIDS Source: CDC,2001

  17. U.S. HCWs with Occupationally Acquired AIDS/HIV, to October 2001 Documented N = 57 Possible N = 138 Other = Dental worker, dentist, EMT/paramedic, housekeeper, health aide, other technician

  18. Potential for Transmission of HIVAfter Percutaneous Exposure

  19. Potential for Transmission of Bloodborne Pathogens CDC. MMWR 2001.

  20. Concentrations of Hepatitis B Virus in Various Body Fluids Low/Not High Moderate Detectable blood semen urine serum vaginal fluid feces wound exudates saliva sweat tears breast milk

  21. Needlestick Injuries • 6-800,000 annually in US • 16,000 (2%) of these are likely to be contaminated by HIV • Up to 80% of all unintentional exposures to blood are caused by needlestick injuries

  22. Needlestick/Sharps Reports Among Health Care Workers • Exposure Prevention Information Network • 1993-95 • 77 hospitals • 10 639 cases • 91 medical students

  23. Type of Sharps as Cause of Percutaneous Injuries, NaSH Hospitals, 6/95-7/99 N=4951

  24. Items Most Frequently Causing Sharp-Object Injuries, 1995 Adapted from Ippolito et al, 1997 Click for larger picture

  25. Reported Cause of Percutaneous Injuries, NaSH Hospitals, 6/95-7/99 N=3057

  26. When Do Needlesticks Happen?

  27. Centers for Disease Control and Prevention • 11/99 NIOSH Alert Preventing Needlestick Injuries in Health Care Settings • DHHS (NIOSH) Publ 2000-108 • 6/29/01 Updated USPHS Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis • MMWR v 50, RR-11

  28. NIOSH Alert - Employers Improved engineering controls in a comprehensive program involving workers • Eliminate the use of needles where possible • Implement the use of devices with safety features and evaluate their use for effectiveness and acceptability • Analyze injuries to identify hazards and injury trends • Set priorities and strategies for prevention • Training • Modify work practices that pose a hazard • Promote safety awareness • Reporting and timely follow-up • Evaluate program effectiveness and provide feedback

  29. NIOSH Alert -Health Care Workers • Avoid needles where safe & effective alternatives available • Help employer select and evaluate safety devices • Use safety devices • Avoid recapping needles • Plan for safe handling and disposal before procedure • Dispose of used needles promptly in sharps disposal containers • Report all sharps-related injuries promptly • Tell your employer about hazards • Participate in training and follow recommended infection prevention practices

  30. OSHA General Duty Clause Section 5 (a) (1) of the OSH Act “Each employer shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees.”

  31. Management commitment Employee involvement Worksite analysis Hazard prevention and control Engineering design Administrative controls Personal protective equipment Medical management Prevention Early identification Systematic evaluation Conservative treatment Training and education Recordkeeping OSHA Guidelines

  32. OSHA BloodbornePathogens Actions • 12/6/91 - Occupational Exposure to BBP; Final Rule. 29 CFR 1910.1030 • 1988, 1990, 1992, 1999, 2001 - OSHA Instruction: Enforcement Procedures for the Occupational Exposure to BBP, CPL-2-2.69 • 11/6/00 - Needlestick Safety and Prevention Act • 1/18/01 - Revised BBP Standard • 1/18/01 - Recording and Reporting Occupational Injuries and Illnesses. 29 CFR 1904

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