Blood borne pathogens seminar

1. Blood borne pathogens seminar Blood borne infections and tuberculosis: management of occupational exposure and isolation precautions Valerie Fletcher, M.D.

2. Blood borne pathogens • Microorganisms that are present in human blood and can cause disease in humans. • Pathogens include, but are not limited to, hepatitis B virus (HBV) and hepatitis C virus (HCV) and human immunodeficiency virus (HIV). • HBV, HCV and HIV may cause major occupational blood borne infections that are potentially fatal.

3. The risk of infection after exposure depends on several factors including: - the pathogen involved - the type of exposure - the amount of blood or infectious material involved in the exposure - and the amount of virus in the infectious material at the time of exposure. • Risk of acquiring infection after percutaneous injury with a contaminated hollow-bore needle are HBV > HCV > HIV. • Most exposures to infectious material do not lead to infections.

4. Most occupational exposures occur among health care workers (HCWs). • > 8 million US HCWs may be exposed to blood or infectious body fluids. • ~ 800,000 percutaneous injuries occur per year in hospitals and other healthcare facilities. • 44 percutaneous injuries reported at SOMC in 2004, 38 in 2005.

5. Body Fluid Exposure Type – SOMC, 2004 - 2005

6. Body fluid exposures – SOMC, 2004 - 2005

7. Percutaneous injuries – SOMC, 2004 - 2005

8. Distribution of 10,378 reported percutaneous injuries among hospital workers by medical device associated with injury 1995 – 2000 (CDC)

9. Distribution of 6,212 reported percutaneous injuries involving hollow-bore needles in hospital workers by associated medical procedure 1995 – 2000 (CDC)

10. Isolation Precautions • Standard precautions – precautions designed to prevent transmission of HIV, HBV, HCV and other blood borne pathogens when providing first aid or healthcare. • Blood and certain body fluids of ALL patients are considered potentially infectious. • Standard precautions involve the use of protective barriers such as gloves, gowns, masks or protective eyewear which can reduce the risk of exposure of the skin or mucous membranes of HCWs to potentially infectious materials. • Precautions to prevent injuries caused by needles, scalpels and other sharp instruments also included.

11. Potentially infectious materials • blood • semen • vaginal secretions • cerebrospinal fluid • synovial fluid • pleural fluid • peritoneal fluid • amniotic fluid • saliva (if contaminated with blood) • any body fluid that is visibly contaminated with blood

12. Standard precautions(MMWR August 21,1987) • HCWs should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood or body fluid of any patients is anticipated. • Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood or other body fluids. Hands should be washed immediately after gloves are removed. • HCWs should take precautions to prevent injuries caused by needles, scalpels and other sharp instruments or devices during procedures; when cleaning used instruments, during disposal of used needles and when handling sharp instruments after procedures.

13. Mouthpieces, resuscitation bags, or other ventilation devices should be available for use in areas in which the need for resuscitation is predictable. • HCWs who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient care equipment. • Pregnant HCWs are not known to be at greater risk of contracting HIV infection than HCWs who are not pregnant; however if a HCW develops HIV during pregnancy, the infant is at risk of infection resulting from perinatal transmission. Pregnant HCWs should therefore be especially familiar with and strictly adhere to precautions to minimize the risk of HIV transmission.

14. Engineering and Work Practice Controls • Standard precautions are used at all times in caring for all patients. • Handwashing facilities (or alcohol-based hand rub) are readily accessible to all employees. • Eating, drinking, smoking, applying cosmetics and handling contact lenses are prohibited in areas where there is a reasonable likelihood of occupational exposure. • Food and drink should not be kept in refrigerators, freezers, shelves, cabinets or on countertops where blood and body fluids may be present.

15. Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited. • Specimens of blood or other potentially infectious materials should be placed in a container which prevents leakage during collection, handling, processing, storage, transport or shipping. • Personal protective equipment, appropriate to the situation, should be used in all situations in which there is a reasonable likelihood of occupational exposure. • A 1:1 dilution of bleach (sodium hypochlorite) is an appropriate disinfecting agent. • Broken glass is never picked up with hands, even if wearing gloves. Use an appropriate sweeping device and pan to collect pieces of glass.

16. Hand hygiene HANDWASHING IS THE SINGLE MOST IMPORTANT MEANS OF PREVENTING THE TRANSMISSION OF INFECTION.

17. Handwashing • Hands are wet with running water. • Lather with soap for at least 15 seconds. • Rinse hand with running water. • Dry hands with disposable towel. • Turn off tap with disposable paper towel. • Place disposable towel in appropriate container.

18. Waterless alcohol-based hand rub or rinse • Approx. 3 ml of product taken from dispenser and rubbed on dry skin for about 30 sec until alcohol evaporates. • Effective only on areas in contact with rub or rinse. • Does not remove soil or organic material. • Contains 60 -70% alcohol. • Contains a moisturizer to prevent drying of skin.

19. Waterless alcohol-based rubs are recommended for areas in which sinks for hand washing are not readily available. • Alcohol-based rubs have been shown to be superior to plain soap for hand washing because of the antimicrobial effect. • Alcohol-based rub does not replace hand washing for visibly soiled hands.

20. Personal protective equipment (PPE) • Specialized clothing or equipment worn by employee for protection against contamination with blood or body fluids which may transmit infectious agents. • General work clothes not intended to function as ‘protective clothing’ are not considered to be PPE. • PPE can fail. Standard precautions and careful attention while performing all patient care duties will minimize the risk of personal contamination.

21. PPE is considered appropriate if it does not allow blood or other potentially infectious material to pass through it and reach the employee’s clothing, undergarments, skin and mucous membranes under normal condition of use and for the duration of time for which the protective equipment is to be used. • PPE sufficient to provide an appropriate protective barrier should be readily available to all employees. The use of PPE is required in all situations in which there is a reasonable possibility of contamination with blood or other potentially infectious material. • PPE are gloves, masks, isolation gowns, laboratory coats, aprons, face shields, goggles, ventilation devices, shoe covers, hats and hoods.

22. Gloves • Should be worn when it can be reasonably anticipated that an employee may have hand contact with blood, other potentially infectious materials, mucous membranes and non-intact skin, when performing vascular access procedures and when handling or touching contaminated items or surfaces. • Disposable (single use) gloves should be used for all patient care functions and procedures. Hand are washed before putting on gloves and immediately following removal of the gloves. • Gloves must be changed and hands washed between patients. • Following use of gloves, they should be disposed of in an appropriate biohazard container. Used gloves are to be considered contaminated.

23. Disposable gloves are not to be washed or in any way cleaned for reuse. • Utility gloves are preferable for housekeeping tasks. Utility gloves may be decontaminated for reuse. They should be discarded if cracked, peeling, torn, punctured, or show signs of deterioration or excessive wear. • If, during a procedure or task, a glove is punctured, torn or its ability to function as a barrier is in any way compromised, the glove should be removed as soon as feasible. Hands are then washed and inspected for possible puncture or damage to the skin, and a new glove is put on. Punctures or skin breaks should be reported.

24. Gloves are used for touching blood and body fluids requiring universal precautions, mucous membranes, or non-intact skin of all patients. • for handling items and surfaces soiled with blood or body fluids to which universal precautions apply. • for performing phlebotomy when HCW has cuts, scratches, or other breaks in his/her skin, or if hand contamination with blood may occur; when receiving training in phlebotomy. • when performing finger and/or heel sticks on infants or children.

25. Masks, Eye Protection, Face Shields • Masks in combination with eye protection devices (goggles, glasses with solid side shields, or chin-length face shields) should be worn whenever splashes, spray, splatter or droplets of blood or other potentially infectious materials may be generated and eye, nose or mouth contamination can be reasonably anticipated. • Glasses are preferable to contact lenses for heath care workers who have potential exposure to blood borne pathogens. • Masks and eye protection are not necessary for those tasks in which aerosols are not likely to occur such as venipuncture and suture removal. • Mask and eye protection should be used for dental procedures in which aerosols may be created.

26. Surgical masks

27. Protective eyewear

28. Gowns, Aprons, and Protective Body Clothing • Appropriate protective clothing such as, but not limited to, gowns, lab coats, aprons, clinic jackets or similar outer clothing should be worn when it is reasonably anticipated that contamination with blood or other infectious materials may occur. The type of garments will depend on the task and the degree of exposure anticipated. • In general, extreme barrier precautions (surgical caps, shoe covers, and hoods) are necessary in instances in which gross contamination is reasonably anticipated. • In are office setting, impervious disposable gowns are, in general, adequate.

29. Housekeeping • If a surface becomes contaminated, clean IMMEDIATELY. • Use Standard Precautions including appropriate barriers. • Clean gross contamination with disposable towel or larger implement. • Wash contaminated area with detergent and hot water. • Disinfect surface by spraying or flooding with approved disinfectant. • Dry area with disposable towel.

30. At the end of the work day, all surfaces that may have been contaminated should be cleaned and disinfected. • Protective covers should be replaced as soon as feasible after contamination. • Contaminated covers and disposable cleaning agents should be disposed of in suitable containers for contaminated wastes. • All bins and other receptacles for reuse that have a reasonable likelihood of being contaminated should be inspected and decontaminated on a regular basis.

31. Dental Operatories • Dental operatories should be cleaned between patients, and disposable items discarded. • Surfaces should be cleaned and disinfected. • Soiled dressings, packing material, removed sutures, dental wires and appliances, removed teeth and tissue should be considered contaminated, and disposed of appropriately. • Used reusable dental instruments should be cleaned and sterilized. • All needles and disposable sharps should be handled in accordance with Standard Precautions.

32. Disposal of sharps • Appropriate sharps containers must be available in all patient areas. They must have appropriate “BIOHAZARD” labeling. • All sharps are to be placed in these containers IMMEDIATELY following use. • If sharps container is punctured or leaks, it is to be placed in another impervious container which is labeled with the appropriate “BIOHAZARD” label. • SHARPS CONTAINERS SHOULD NOT BE ACCESSIBLE TO PATIENTS, ESPECIALLY CHILDREN.

33. Sharps containers should not be overfilled. • They must be kept in an upright position. • Full sharps container are never to shaken to settle the contents. • Transport of sealed sharps containers is to be done in accordance with polices regarding transport of infectious waste. • Needles are never to be cut, bent, broken, or reinserted by two-handed method (recapped) into their original sheaths.

34. Sharps container

35. Exposure to saliva • Practices to minimize exposure to saliva include use of gloves for digital examination of the mucous membranes and endotracheal suctioning. • Handwashing after exposure to saliva. • Minimizing the need for emergency mouth-to-mouth resuscitation by making mouthpieces and other ventilation devices available for use in areas where the need is predictable.

36. Ventilation masks

37. Pocket ventilation mask

38. Laundry • All laundry that is visibly contaminated, or that has a reasonable likelihood of being contaminated, should be considered contaminated. • Contaminated laundry should be handled as little as possible. • Standard precautions should be observed at all times when handling contaminated laundry. • Contaminated laundry should be placed in impervious containers or bags at the location in which it is used.

39. Contaminated laundry should not be sorted or rinsed in the location of use. • It should be placed and transported in bags or containers that are readily identifiable as containing contaminated items. These bags or containers must be able to prevent leakage of fluid. • BIOHAZARD labeling is not required if standard precautions are used when handling all soiled laundry, provided that all employees can readily recognize containers holding soiled laundry. • Appropriate PPE should be available to all employees who have contact with contaminated laundry.

40. Labeling of Potentially Hazardous Materials • All containers of regulated waste, refrigerators, and freezers containing blood and other potentially infectious material and other containers used to store, transport, or ship blood or other potentially infectious material should be clearly labeled with an international biohazard label symbol or placed in a red bag or red container which meets the requirements of the policies for handling trash or infectious waste.

41. Equipment which has been exposed to possible contamination by blood or other potentially biologically hazardous material should be labeled in an easily visible manner with a biohazard label specifically referencing the area of the equipment which is contaminated. Equipment so labeled should then be handled in accordance with the local housekeeping policy on potentially contaminated equipment.

42. All employees should practice Standard Precautions and comply with the specific requirements of the local policy for handling trash and infectious waste, when exposed to any biological waste or potentially biological contaminated equipment.

44. Management of Occupational Blood Exposure • Provide immediate care to the exposed site - wash wounds and skin with soap and water - flush mucous membranes with water • Determine risk associated with exposure by - type of fluid (eg blood, visibly bloody fluid, other potentially infectious fluid or tissue, and concentrated virus) - type of exposure (ie percutaneous injury, mucous membrane or nonintact skin exposure, and bites resulting in blood exposure)

45. Evaluate exposure source - Assess the risk of infection using available information - Test the known sources for HBsAg, anti-HCV, and HIV antibody - For unknown sources, assess risk of exposure to HBV, HCV or HIV infection - Do not test discarded needles or syringes for virus contamination. • Evaluate the exposed person - Assess immune status for HBV infection (ie by history of hepatitis B vaccination or vaccine response)

46. EXPOSURE REPORT

47. Total Hepatitis A Hepatitis B Hepatitis C/ NANB Acute Viral Hepatitis A, B and C/NANB by Year, United States, 1952-2000

48. Hepatitis B and C in Scioto County

49. Hepatitis • Hepatitis B virus (HBV) and hepatitis C virus (HCV) may cause severe liver disease. • Symptoms of acute infection include nausea, vomiting, abdominal pain and jaundice. • HBV becomes chronic in ~ 20% of infected patients. • HCV becomes chronic in ~ 80% in infected patients. • Chronic infection may be asymptomatic

50. Hepatitis B • The risk of acquiring HBV infection from a single needle-stick contaminated with HBV-infected blood ranges from 6 – 30%. • Risk of transmission depends on the HBeAg status of the source; HBeAg-positive patients have more circulating viruses and are more infectious. • There is a risk of infection after exposure of mucous membranes or non-intact skin. • No known risk of infection from exposure to intact skin.