Chapter 8: Bloodborne Pathogens, Universal Precautions and Wound Care

1. Chapter 8: Bloodborne Pathogens, Universal Precautions and Wound Care

2. Healthcare facility must be maintained as clean and sterile to prevent spread of disease and infection • Must take precautions to minimize risk • Coaches must be aware of potential dangers associated with exposure to blood or other infectious materials • Must take whatever measures to prevent contamination

3. Bloodborne Pathogens • Pathogenic organisms, present in human blood and other fluids (cerebrospinal fluid, semen, vaginal secretion and synovial fluid) that can potentially cause disease • Most significant pathogens are Hepatitis B, C and HIV • Others that exist are hepatitis A, D, E and syphilis

4. Hepatitis B • Major cause of viral infection, resulting in swelling, soreness, loss of normal liver function • Signs and symptoms • Flu-like symptoms like fatigue, weakness, nausea, abdominal pain, headache, fever, and possibly jaundice • Possible that individual will not exhibit signs and symptoms -- antigen always present • Can be unknowingly transferred

5. May test positive for antigen w/in 2-6 weeks of symptom development • 85% recover within 6-8 weeks • Prevention • Good personal hygiene and avoiding high risk activities • Proceed with caution as HBV can survive in blood and fluids, in dried blood and on contaminated surfaces for at least 1 week

6. Management • Vaccination against HBV should be provided by employer to those who may be exposed • Athletic trainers and allied health professionals should be vaccinated • Three dose vaccination over 6 months • Post-exposure vaccination is also available after coming into contact with blood or fluids

7. Hepatitis C • Both an acute and chronic form of liver disease caused by hepatitis C virus (HCV) • Most common chronic bloodborne infection in United States • Leading indication for liver transplant • Signs & Symptoms • 80% of those infected have no S&S • May be jaundice, have mild abdominal pain, loss of appetite, nausea, fatigue, muscle/joint pain, and/or dark urine

8. Prevention • Occasionally spread through sexual contact • Spread via contact with blood of infected person, sharing needles, or sharing items that may carry blood (razors, toothbrush) • Consider the risks of getting a tattoo or body piercing • ATC should always follow routine barrier precautions

9. Management • No vaccine for preventing HCV • Multiple tests available to check for HCV • Single positive = infection • Single negative = does not necessarily mean no infection • Interferon and ribavirin are 2 drugs used in combination and appear to be the most effective for treatment • Drinking alcohol can make liver disease worse

10. Human Immunodeficiency Virus • A retrovirus that combines with host cell • Virus that has potential to destroy immune system • According to World Health Organization 42 million people were living with HIV/AIDS in 2002

11. Symptoms and Signs • Transmitted by infected blood or other fluids • Fatigue, weight loss, muscle or joint pain, painful or swollen glands, night sweats and fever • Antibodies can be detected in blood tests within 1 year of exposure • May go for 8-10 years before signs and symptoms develop • Most that acquire HIV will develop acquired immunodeficiency syndrome (AIDS)

12. Acquired Immunodeficiency Syndrome (AIDS) • Collection of signs and symptoms that are recognized as the effects of an infection • No protection against the simplest infection • Positive test for HIC cannot predict when the individual will show symptoms of AIDS • After contracting AIDS, people generally die w/in 2 years of symptoms developing

13. Management • No vaccine for HIV, no cure even though drug therapy is available • Research looking for preventive vaccine and effective treatment • Most effective drug combination • Antiviral drug cocktail • Slows replication of virus, improving prospects for survival

14. Prevention • Greatest risk is through intimate sexual contact with infected partner • Choose non-promiscuous sex partners and use condoms for vaginal or anal intercourse • Latex condom provides barrier against HBV and HIV • Condoms with reservoir tip reduces chance of ejaculate being released from sides • Water-based, greaseless spermicides or lubricants should be avoided • If condom breaks, vaginal spermicide should be used immediately • Condom should be carefully removed and discarded

15. Bloodborne Pathogens in Athletics • Chance of transmitting HIV among athletes is low • Minimal risk of on-field transmission • Some sports have potentially higher risk for transmission because of close contact and exposure to bodily fluids • Martial arts, wrestling, boxing

16. Policy Regulation • Athletes are subject to procedures and policies relative to transmission of bloodborne pathogen • A number of sport professional organizations have established policies to prevent transmission • Organizations have also developed educational programs concerning prevention, and medical assistance

17. Institutions should take responsibility to educate student athletes • At high school level, parents should also be educated • Make athletes aware that greatest risk is involved in off-field activities • Athletic trainer should take responsibility of educating and informing student athletic trainers of exposure and control policies • Institutions should implement policies concerning bloodborne pathogens • Follow universal precautions mandated by OSHA

18. HIV and Athletic Participation • No definitive answer as to whether asymptomatic HIV carriers should participate in sport • Bodily fluid contact should be avoided • Avoid exhaustive exercise that may lead to susceptibility to infection • American with Disabilities Act says athletes infected cannot be discriminated against and may only be excluded with medically sound basis • Must be based on objective medical evidence and must take into consideration risk to patient and other participants and means to reduce risk

19. Testing Athletes for HIV • Should not be used as screening tool • Mandatory testing may not be allowed due to legal reasons • Testing should be secondary to education • Athletes engaged in risky behavior should undergo voluntary anonymous testing for HIV • Multiple tests are available to test for antibodies for HIV proteins

20. Detectable antibodies may appear from 3 month to 1 year following exposure • Testing should occur at 6 weeks, 3 months, and 1 year • Many states have enacted laws that protect confidentiality of HIV infected person • Athletic trainer should be familiar with state laws and maintain confidentiality and anonymity of testing

21. Universal Precautions in Athletic Environment • OSHA (Occupational Safety and Health Administration) established standards for employer to follow that govern occupational exposure to blood-borne pathogens • Developed to protect healthcare provider and patient • All sports programs should have exposure control plan • Include counseling, education, volunteer testing, and management of bodily fluids

22. Preparing the Athlete • Prior to participation, all open wounds and lesions should be covered with dressing that will not allow for transmission • Occlusive dressing lessens chance of cross-contamination • Hydrocolloid dressing is considered a superior barrier • Reduces chance that wound will reopen, as wound stays moist and pliable • When Bleeding Occurs • Athletes with active bleeding must be removed from participation and returned when deemed safe • Bloody uniform must be removed or cleaned to remove infectivity

23. Personal Precautions • Those in direct contact should use appropriate equipment including • Latex gloves, gowns, aprons, masks and shields, eye protection, disposable mouthpieces for resuscitation • Emergency kits should contain, gloves, resuscitation masks, and towelettes for cleaning skin surfaces • Non-latex gloves can be used when long term exposure to blood and bodily fluids is not likely • Doubling gloves is suggested with severe bleeding and use of sharp instruments • Extreme care must be used with glove removal • Hands and skin surfaces coming into contact with blood and fluids should be washed immediately with soap and water (antigermicidal agent) • Hands should be washed between patients

24. Availability of Supplies and Equipment • Must also have chlorine bleach, antiseptics, proper receptacles for soiled equipment and uniforms, wound care equipment, and sharps container • Biohazard warning labels should be affixed to containers for regulated waste, refrigerators containing blood and containers used to ship potentially infectious material • Labels are fluorescent orange or red • Red bags or containers should be used for potentially infectious material • Gloves and bandages should be placed in sealed white bags prior to disposal in regular trash receptacles

25. Disinfectant • Contaminated surfaces should be clean immediately with solution of 1:10 ratio approved disinfectant to water • Should inactivate HIV • Contaminated towels should be bagged, labeled, and separated from other soiled laundry, then transported in biohazard container • Wash in hot water (159.8 degrees F for 25 minutes) • Laundry done outside institution should be OSHA certified • Sharps • Needles, razorblades, and scalpels • use extreme care in handling and disposing all sharps • Do not recap, bend needles or remove from syringe • Scissors and tweezers should be sterilized and disinfected regularly

26. Protecting the Caregiver • OSHA guidelines are designed to protect coaches, athletic trainers and other employees. • Coaches generally do not come into contact with blood and therefore risk is greatly reduced • Responsibility of institution to protect athletic trainer and other staff • Provide necessary supplies and education • All staff have personal responsibility to follow guidelines and to enforce them

28. Protecting the Athlete From Exposure • Use mouthpieces in high-risk sports • Shower immediately after practice or competition • Athletes exposed to HIV or HBV should be evaluated and immunized against HBV

29. Post-exposure Procedures • Athletic trainer should have confidential medical evaluation that documents exposure route, identification of source/individual, blood test, counseling and evaluation of reported illness • Laws that pertain to reporting and notification of results relative to confidentiality vary from state to state

30. Caring for Skin Wounds • Skin wounds are extremely common in sports • Soft pliable nature of skin makes it susceptible to injury • Numerous mechanical forces can result in trauma • Friction, scrapping, pressure, tearing, cutting and penetration

31. Types of wounds • Abrasions • Skin scraped against rough surface • Top layer of skin wears away exposing numerous capillaries • Often involves exposure to dirt and foreign materials = increased risk for infection • Laceration • Sharp or pointed object tears tissues – results in wound with jagged edges • May also result in tissue avulsion

32. Puncture wounds • Can easily occur during activity and can be fatal • Penetration of tissue can result in introduction of tetanus bacillus to bloodstream • All severe lacerations and puncture wounds should be referred to a physician • Avulsion wounds • Skin is torn from body = major bleeding • Place avulsed tissue in moist gauze (saline), plastic bag and immerse in cold water • Take to hospital for reattachment • Incision • Wounds with smooth edges

33. Immediate Care • Should be cared for immediately • All wounds should be treated as though they have been contaminated with microorganisms • To minimize infection clean wound with copious amounts of soap, water and sterile solution • Avoid hydrogen peroxide and bacterial solutions initially

35. Dressing • Sterile dressing should be applied to keep wound clean • Occlusive dressing are extremely effective in minimizing scarring • Antibacterial ointments are effective in limiting bacterial growth and preventing wound from sticking to dressing • Utilization of hydrogen peroxide can occur several times daily before reapplication of ointment

36. Are sutures necessary? • Deep lacerations, incisions and occasionally punctures will require some form of manual closure • Decision should be made by a physician • Sutures should be used within 12 hours • Area of injury and limitations of blood supply for healing will determine materials used for closure • Physician may decide wound does not require sutures and utilize steri-strips or butterfly bandages

37. Signs of Wound Infection • Same as those for inflammation • Pain • Heat • Redness • Swelling • Disordered function • Pus may form due to accumulation of WBC’s • Fever may develop as immune system fights bacterial infection

38. Most wound infections can be treated with antibiotics • Staphylococcus aureus has become resistant to some antibiotics • Methicillin-resistant staphylococcus aureus (MRSA) is more difficult to treat and infection is extremely difficult to treat • If cause of infection is not discovered early and improper antibiotics are used initially infection that starts in skin could spread into more serious infection

39. Tetanus • Bacterial infection that may cause fever and convulsions and possibly tonic skeletal muscle spasm for non-immunized athletes • Tetanus bacillus enters wound as spore and acts on motor end plate of CNS • Following childhood vaccination, boosters should be supplied once ever 10 years • If not immunized, athlete should receive tetanus immune globulin (HyperTET) immediately following skin wound