Bloodborne Pathogens

1. Next page Bloodborne Pathogens Welcome To our OSHA Bloodborne Pathogens Course Presented by: Safety and Risk Services UNM Health Sciences Center Epidemiology Instructions This course was designed for you in an electronic book format. It offers you convenience and the most current information available. • Simply “read” through the electronic pages by clicking on Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu When you complete this module return to Learning Central and complete the on-line Bloodborne Pathogens Exam

2. Next page Introduction On December 6, 1991, the Occupational Safety and Health Administration (OSHA) finalized a federal regulation to protect employees against exposure to bloodborne pathogens. This regulation is known as the Bloodborne Pathogen Standard and requires the use of Standard Precautions to prevent exposure to bloodborne pathogens. This regulation was revised in November 1999 to increase the emphasis on prevention of employee exposure to bloodborne pathogens through engineering controls. The Needlestick Safety and Prevention Act of 2000 set out in greater detail the requirement for employers to identify, evaluate and implement safer medical devices. This act also mandated additional requirements for maintaining a sharps injury log and for the involvement of non-managerial healthcare workers in evaluating and choosing devices. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

3. Next page Introduction • What are bloodborne pathogens? • Bloodborne Pathogens are microorganisms found in human blood, blood components and body fluids and known to cause diseases in humans. The Hepatitis B and C viruses and Human Immunodeficiency Virus are the bloodborne pathogens of greatest importance in clinical settings. • Who is at risk? • Anyone who handles human blood, blood components, blood products or body fluids is at risk. This includes: • Health Care Workers • Laboratory and Research Personnel • Correctional Facility Personnel • Police Officers • Infectious Waste Personnel • Morticians • Custodial Personnel • Medical Equipment Personnel • Fire Fighters Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

4. Next page Introduction How are bloodborne pathogens transmitted in the healthcare setting? The most efficient mode of transmission for bloodborne diseases is from contaminated needle-stick injuries. Bloodborne pathogens are also transmitted from blood or body fluid (BBF) contamination of eye, mouth or other mucous membranes, or from BBF contact to non-intact skin, e.g. cuts scrapes, burns, and dermatitis. What job duties may involve potential exposure to bloodborne pathogens? Job duties involving possible exposure to bloodborne diseases include: Drawing blood First aid Dental procedures Blood spill clean-up CPR Giving injections Bathing patients Surgery Sterilizing instruments Handling soiled linen Autopsies Gathering infectious waste Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

5. Next page part 1 Hepatitis B • What is Hepatitis B? (HBV) HBV is a virus that infects liver cells, resulting in acute, and sometimes chronic, liver disease. In the U.S, there are an estimated 750,000-1,000,000 chronic HBV carriers who transmit infection to others primarily through sexual contact and contact with blood and body fluids of infected individuals. Perinatal transmission of Hepatitis B may also occur. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

6. Next page Hepatitis B What are the symptoms of HBV infection? Acute Hepatitis B with complete resolution This is the most frequent response to HBV infection in adults. Persons with a history of infection become immune against re-infection. Some infected individuals show no symptoms, some will have mild flu-like illness not diagnosed as hepatitis, and 25% will have severe symptoms such as fatigue, anorexia, nausea, dark urine, abdominal pain, fever, joint pain and jaundice (yellowing of skin and eyes). Progression to chronic hepatitis B infection following acute episode Chronic HBV is the outcome of 1-10% of all HBV infections in adults (rates differ in different populations and are much higher in infants). Viral infection of the liver remains persistent. A “hepatitis carrier” may be infectious to others. Patients with chronic HBV may develop chronic active hepatitis (ongoing liver inflammation), cirrhosis of the liver or primary liver cancer. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

7. Next page Hepatitis B HBV Vaccine Pre-exposure vaccination is the most effective preventive measure. Healthcare workers should note that patients with chronic HBV may be highly infectious and that many exposures may not be apparent to the healthcare worker. All healthcare workers should be vaccinated for HBV before any possible contact with blood and body fluids occurs. Vaccinations are free for employees with occupational exposure to blood/body fluids. Contact Employee Occupational Health Services (272-8043) to receive vaccination. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

8. Next page Hepatitis B The HBV Vaccine Series The HBV vaccine series involves a series of three doses over a period of 4-6 months to induce protective antibody levels in 85-97% of healthy adults. Measurable antibodies in vaccinees usually persist for more than 8 years, provided the employee responds to the vaccine with a measurable titer initially. All employees receiving the HBV vaccine must be tested for proof of immunity with a follow-up serology after the third dose of vaccine. Employees who fail to develop immunity after the first series often respond to a second series of HBV vaccine. In the rare instance that a non-immune employee is exposed to HBV, infection can be prevented by use of HBV immune globulin. Employees uncertain of their immune status should contact Employee Occupational Health Services at 272-8043 Boosters The CDC has no recommendation concerning boosters of HBV vaccine in vaccine responders because it is unknown whether routine boosters will be required to prevent symptomatic disease. So far, vaccine responders, appear to be protected from clinical Hepatitis B disease for at least 20 years, even if antibody levels decline to undetectable levels. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

9. Next page part 2 Hepatitis C What is Hepatitis C? (HCV) Hepatitis C is the most common blood-borne pathogen in the U.S. Approximately 1.4% of the U.S. population is infected with HCV. Most of these persons (around 85%) are chronically infected and many are unaware of their infection because they are not clinically ill. HCV is transmitted primarily through large or repeated direct percutaneous exposures to blood. Blood transfusion accounted for a large proportion of HCV infections acquired prior to 1990, but is now rarely a source of new infection. Injection drug use now accounts for 60% of new cases. Multiple sexual partners, occupational exposure, and perinatal exposure are risk factors that are thought to account for most of the remaining cases. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

10. Next page Hepatitis C • Acute HCV • Most cases of acute HCV are asymptomatic. Some patients have jaundice or symptoms of malaise, poor appetite or abdominal pain. A small proportion of patients with acute HCV, 15-25%, appear to resolve their acute infection. • Chronic HCV • Most patients with HCV remain chronically infected, and some progress to cirrhosis of the liver or primary liver cancer. Concurrent alcohol use is a significant risk factor for progression of liver disease in patients with HCV. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

11. Next page Hepatitis C There is no vaccine for HCV HCV infection in healthcare workers is best prevented through following Standard Precautions. All persons with exposure, regardless of source HCV status, should have a follow-up. For persons with high-risk exposure to a known HCV-seropositive patient, a follow-up HCV RNA test by PCR is recommended at 4-6 weeks. Any healthcare worker with a positive PCR and/or seroconversion after exposure will be referred to Gastroenterology Services for discussion of treatment. • Studies of healthcare workers with nosocomial exposure to HCV suggest early antiviral treatment may result in higher rates of resolved infections. The average incidence of anti-HCV seroconversion after unintentional needlesticks or sharps exposures from an HCV-positive source is 1.8% (range in studies: 0-10%). Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

12. Next page part 3 HIV What is Human Immunodeficiency Virus? (HIV) HIV is the human retrovirus which causes Acquired Immunodeficiency Syndrome or AIDS, first reported in the U.S. in 1981. HIV is now estimated to infect around 900,000 people in the US. HIV is transmitted primarily through sexual contact, injection drug use, and perinatally. In most cases, HIV causes progressive immunodeficiency marked by declines in CD4 lymphocyte counts. Infected persons with advanced immunodeficiency are vulnerable to multiple infections. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

13. Next page HIV • What are the symptoms of HIV? • HIV infection progresses in stages: Acute seroconversion syndrome may occur 6-12 weeks after infection with flu-like symptoms. After seroconversion, infected patients may have no further signs or symptoms for months or years. However, they are infectious to others through sexual contact and blood and body fluid contact. Progressive disease in untreated patients is characterized by a steady decline in the CD4 lymphocyte count and increasing susceptibility to infection. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

14. Next page HIV How can HIV infection in exposed health care workers be prevented? The average risk of HIV seroconversion after a percutaneous exposure to HIV-infected blood is approximately 0.3%, and after a mucous membrane exposure is 0.09% Post-exposure treatment should be given immediately to prevent or inhibit infection Antiretroviral medications given immediately after exposure have been shown to prevent HIV infection. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

15. Next page part 4 Standard Precautions • Standard Precautions prevent exposure to bloodborne pathogens All blood or body fluids are treated as potentially infectious. This applies to all patients. Standard Precautions prevent the healthcare worker from coming into contact with blood and other potentially infectious material (OPIM) of all patients by using the correct Personal Protective Equipment (PPE) • Summary of Standard Precautions • Perform hand hygiene before and after patient care and after glove removal • Wear gloves if blood or OPIM contact with hands is likely • Wear gowns if blood or OPIM contact with clothing is likely • Wear goggles & mask if blood or OPIM splash is likely (or face shield) Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

16. Next page Standard Precautions • Disposable Single Use Gloves Surgical or examination type gloves.If exposure to a large quantity of blood is likely, or if gloves might be damaged,wearing two pairs (double gloving) is recommended. • Heavy Duty Utility Gloves Household utility gloves are used for some tasks, e.g. cleaning up blood spills. May be decontaminated and re-used if they are not cracked, peeling, torn, punctured, discolored or deteriorating • Eye and Face Protection • Eye protection is required whenever blood or infectious materials can splash, spray, spatter or contaminate the eyes, nose, or mouth.A mask may be used with goggles/glasses with solid side shields.A chin-length face shield may be used. • Outer Protective Gear • A gown, apron, or booties may be required to keep contamination away from the body or personal clothing. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

17. Next page Employee Work Practices • When is hand hygiene recommended? • Before and after every patient contact and after glove removal • After handling potentially infectious material, even if you have been wearing gloves. • Before eating, smoking, or touching your face • Note: in addition to protecting healthcare workers from exposure to bloodborne pathogens, hand hygiene before and after every patient contact is the single most effective way to prevent healthcare-associated infections in patients Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

18. Next page Employee Work Practices How is hand hygiene performed? Note: alcohol hand disinfection is the preferred technique unless hands are visibly soiled or contaminated with blood or OPIM Alcohol hand disinfection (AHD) technique: • Apply enough alcohol-based product to cover both hands thoroughly • Rub over all surfaces until hands are dry • Use a CHW every 5-6 AHDs to get rid of emollient residue • Conventional hand wash (CHW) technique: • Wet hands, apply 5cc of anti-microbial soap • Rub all hand surfaces under warm running water to for 15-30 second • Other aspects of hand hygiene: • Avoid skin dryness or irritation Use hospital-supplied lotions that will not compromise the integrity of latex gloves or interfere with the action of antimicrobial soap products. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

19. Next page Employee Work Practices • How can needle sticks be avoided? • Locate the sharps container before beginning any procedure • Ensure that the sharps container is not overfilled (more than ¾ full). If it is, close the container and obtain a new one. • Dispose of sharps immediately into designated sharps containers. • Do not bend, shear or break contaminated needles or sharps. • Never interfere with the operation of a safety device • Make sure safety devices are fully engaged • Never throw a contaminated sharp to the floor or stick a sharp of any kind into a patient mattress or examining table. • Never recap needles! • In the rare instance when a needle needs to be re-sheathed for medical reasons, a device should be used. • Anticipate the need for extra syringes before starting a procedure Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

20. Next page Employee Work Practices • Use good work habits to avoid exposure to bloodborne pathogens and other hazards • What is meant by good personal habits? • Do not eat, drink, smoke, chew tobacco or apply cosmetics or lip balms where you may be exposed to blood and body fluids, e.g. patient care areas. Eating and drinking in patient care areas may also expose healthcare workers to infection with other highly contagious pathogens, such as Hepatitis A • Only eat and drink in designated break areas • Do not keep food and drinks in refrigerators, freezers, cabinets or on shelves, countertops or bench tops where blood or infectious materials may be present Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

21. Next page part 6 Needlestick Safety and Prevention Act • Why do we have another law involving bloodborne pathogens? The Centers for Disease Control and Prevention estimate that healthcare workers in the US sustain nearly 600,000 percutaneous injuries annually involving contaminated sharps. Many of these injuries involve sharps contaminated with blood or other potentially infectious materials containing HIV. An estimated 16,000 of these injuries involve sharps contaminated with blood or OPIM containing HIV. It is thought that use of safer devices could prevent about 80% of these injuries. In response to both the continuous concern over these exposures and the technological developments which may increase employee protection, Congress passed the Needlestick Safety and Prevention Act of 2000. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

22. Next page Needlestick Safety and Prevention Act • Under this law, what must employers do? • Document consideration and use of appropriate, commercially available and effective safer devices. • Solicit input from non-managerial employees responsible for direct patient care regarding the identification, evaluation and selection of effective engineering controls. • Document, in the exposure control plan, how this input was received. • Maintain a detailed sharps injury log. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

23. Next page Needlestick Safety and Prevention Act • What is expected of employees? • Not to interfere with the safety features of any device. • Employees are encouraged to report all exposures immediately. • Participate in the evaluation of effective engineering controls as these are introduced into their area. • Share ideas and opinions concerning safer devices by communicating in writing with the appropriate safety officer, giving specific details of the device and any problems or advantages regarding the use of the device. • How are needlestick data collected? Employee Occupational Health Services (EOHS) collects detailed data on all exposures for trending and analysis. The UNM Health Sciences Center contributes data from UNM employees. All data entries are confidential and are not name-linked at the database level. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

24. Next page part 7 Storage and Disposal • Where are warning labels required? Warning labels are required on: • Containers of waste, refrigerators, microwaves and freezers used for blood or potentially infectious materials. • Containers used to store, transport or ship blood or potentially infectious materials. • Doors to rooms containing potentially infectious materials. • Any contaminated equipment until the equipment is decontaminated. • What do the warning labels look like? Labels must include the Biohazard symbol and legend. The symbol must be either fluorescent orange, orange-red, with a red/orange background, or predominantly so. Biohazard Symbol Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

25. Next page Storage and Disposal • How are sharps disposed of? Discard all needles and contaminated sharps as soon as possible in a labeled or color-coded container which is puncture-proof, able to be tightly closed, and leak-proof. • How are non-sharps disposed of? In soak-proof or leak-proof bags or containers which are labeled and color-coded if waste is considered biohazardous. Non-sharp medical waste is considered biohazardous only if it consists of: • Liquid or semi-liquid blood or other potentially infectious material (OPIM) • Contaminated items, e.g. gauze pads that could release blood or OPIM in a liquid or semi-liquid state when compressed • Items that are caked with dried blood or OPIM and are capable of releasing these materials during handling • Pathological or microbiological wastes containing blood or OPIM Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

26. Next page part 8 Housekeeping/ Decontamination What is good housekeeping? The work area is kept clean and sanitary. Equipment and working surfaces are decontaminated after contact with infectious materials. Decontamination is accomplished with appropriate disinfectants. Reusable bins pails or cans are inspected and decontaminated regularly or after contamination. Reusable sharps are not stored so employees must reach by hand into containers where sharps are stored. Protective coverings (plastic wrap, aluminum foil, and absorbent paper) are removed and replaced after contamination. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

27. Next page Housekeeping/ Decontamination • What is a safe decontamination procedure? • Wear appropriate PPE. • Use approved hospital disinfectant in clinical areas. • Laboratory workers may use bleach according to their lab protocol. Fresh 1:10 dilution of ordinary household bleach and water is effective (One and one-half cups of bleach to one gallon of water). • If possible, cover contaminated area with paper towels (or absorbent cloth). • Pour bleach solution over paper towels. • Allow bleach solution to soak through paper towels. • Wipe area. • Pour more bleach solution over area. • Use fresh paper towels to wipe clean and dry. • Some equipment may be damaged by bleach: other disinfectant may be required or 1:100 bleach and water solution may be used. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

28. Next page part 9 Post-Exposure Protocols After exposure, what are the chances of infection? The risk of infection depends on specific type of exposure, type of body substance involved, route of entry and severity of exposure Estimated risks of becoming infected after injury with contaminated hollow bore needle (highest risk exposure): Hepatitis B 19-37% Hepatitis C 1.8% HIV 0.3% Fewer than 20% of Hepatitis B infected HCWs in past studies reported a known injury. Therefore, much of the transmission of Hepatitis B from patient to HCW occurred from inapparent exposure. Vaccination before possible exposure is essential. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

29. Next page Post-Exposure Protocols What are appropriate emergency first aid procedures? • Thoroughly wash area with soap and warm water as soon as possible. • Do not use abrasive soap or scrubbing devices that could break intact skin. • Using caustic fluids, e.g. bleach, on injuries is not recommended and could increase risk of infection through tissue damage. • The use of antiseptic agents has not been shown to reduce the rate of infection. • If material has splashed into eyes, immediately use an emergency eyewash or clean running water to flush eyes for at least 15 seconds. • Report exposure to your supervisor and seek post exposure evaluation immediately. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

30. Next page Post-Exposure Protocols • Where do we report for evaluation? 8:00 a.m. to 4:00 p.m. • UNM employees report to Employee Occupational Health Services 272-8043 (in Family Practice Building on Tucker behind HSC library) • UNM employees working in the main hospital building may report to the Occupational Health Clinic 272-2517 (5th floor UH)for an initial evaluation and treatment, then follow up at Employee Occupational Health Services • UNM housestaff rotating at the VA hospital should report first to the VA Employee Health Clinic and then follow up at Employee Occupational Health Services • University Hospital employees report to the Occupational Health Clinic • Students report to Student Health Center, UNM Main Campus (see Student Health website on UNM website www.unm.edu for more details) • UNM students rotating at the VA hospital should report first to the VA Employee Health Clinic on the first floor and then follow up at the Student Health Center After hours, holidays or weekends • UNM/ UH employees and students report to UH ER • UNM employees (housestaff) rotating at the VA Hospital should report first to the VA Emergency Room and then follow up at Employee Occupational Health Services • UNM students rotating at the VA Hospital should report first to the VA Emergency Room and then follow up at the Student Health Center Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

31. Next page Post-Exposure Protocols Medical Evaluation and Treatment A medical evaluation and treatment is no cost to UNM or UH employees, and is covered by mandatory student insurance for all Health Sciences Center students. Test results and medical records are kept confidential and are available to the employee or student. Treatments: Effective prophylactic treatment is available for Hepatitis B exposure if an employee is not immune to Hepatitis B. No prophylactic treatment is available for Hepatitis C, but follow-up and early disease treatment in the event of infection has had good outcomes. Early prophylactic treatment with antiretroviral drugs reduces the risk of HIV seroconversion. Exposure to an Outpatient Special procedures are needed if an employee or student is exposed to the blood and body fluids of an outpatient. Ask the patient to STAY IN THE MEDICAL CENTER until arrangements are made to draw a “source panel” (HIV, Hepatitis B and Hepatitis C serologies) on that patient. This will be done through the provider seeing the exposed employee or student. Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu

32. part 10 Take the Test Instructions When you are ready to take the test: Return to Learning Central. Then, click on “Return to Content Structure.” Then, click on “Bloodborne Pathogens Exam.” This will take you to the assessment test for this course. There are 13 questions on the test. You must score at least 75% to obtain credit. When you have successfully completed the test, go to the main Learning Central homepage. Click on the “Reports” folder and then click on “Learning History.” Next, enter the appropriate timeframes in the “Completed Date From:” and the “Completed Date To:” spaces. Finally, click on “Run Report.” Your transcript of learning sessions should appear and you can print this page out to submit to your credentialing agency for proof of your annual OSHA Bloodborne Pathogens training. Thank you for visiting this site. Comments or questions about the design of this course may be sent to: skellie@salud.unm.edu Any questions that arise during the course of this training may be directed immediately to the UNM epidemiologist, Susan Kellie, MD, at 272-1670, pager 951-1067 or e-mail skellie@salud.unm.edu