Chapter 14: Infectious Diseases, Bloodborne Pathogens, and Universal Precautions

1. Chapter 14: Infectious Diseases, Bloodborne Pathogens, and Universal Precautions © 2011 McGraw-Hill Higher Education. All rights reserved.

2. Bloodborne pathogens are transmitted through contact with blood or other bodily fluids • Hepatitis, especially hepatitis B, human immunodeficiency virus are of serious concern • Healthcare facility must be maintained as clean and sterile to prevent spread of disease and infection • Must take precautions to minimize risk © 2011 McGraw-Hill Higher Education. All rights reserved.

3. Infectious Disease • Invasion of a host (animal or person) by a microorganism (pathogen) • Causes disease by disrupting vital body processes • Stimulate the immune system to react defensively • Immune response = fever, inflammation, or other damaging symptoms • Most common pathogens = bacteria, viruses, parasites or fungi © 2011 McGraw-Hill Higher Education. All rights reserved.

4. Microorganism can live in host and be harmless until an agent and mode of transportation allows for transfer of microorganism  pathogen infection • An infectious disease = contagious if transmission occurs from one individual to another • Direct vs. indirect transmission • 3 Types of direct transmission • Contact of body surfaces (touching, sexual intercourse) • Droplet spread (inhalation or air droplets) • Fecal-oral spread (feces on hands  contact with mouth © 2011 McGraw-Hill Higher Education. All rights reserved.

5. Indirect transmission • Travels via inanimate object • Water, food, towels, clothing, utensils • Via vectors • Insects, birds, animals • Airborne transmission • Infected particles suspended in air – infected via sharing air supply • Pathogen entry into body • Through skin, respiratory system, digestive or reproductive system • Ability to generate infection dependent on: • Acquired immunity • Overall health • Health-related behavior © 2011 McGraw-Hill Higher Education. All rights reserved.

6. Stages of Infection • Incubation stage • From time pathogen enters body to time signs and symptoms of disease appear • Lasting from few hours to months depending on concentration, virulence, level of immune response, presence of other health problems • Prodromal stage • Watery eyes, runny nose, slight fever and malaise may develop briefly • Host can transfer pathogen to other hosts • Host should be isolated to prevent transmission © 2011 McGraw-Hill Higher Education. All rights reserved.

7. Acute stage • Disease reaches point of greatest development while body resists further damage from pathogen • Decline stage • First signs of recovery • Could relapse if patient becomes overextended • Recovery stage • Overcome invading pathogen • Patient remains susceptible • Body may have built up immunity and will be resistant to future exposure (may not be permanent) © 2011 McGraw-Hill Higher Education. All rights reserved.

8. The Immune System • Mechanical defenses • Separates the internal body from the external environment • Skin, mucous membranes, nasal hairs, cilia lined airways • Cellular System (Immune system) • Eliminates microorganisms, foreign proteins and antigens • Consists of T-cells and B-cells • Located in bloodstream lymphatic tissues and interstitial fluid © 2011 McGraw-Hill Higher Education. All rights reserved.

9. Antigens trigger leukocytes and macrophages to locate and destroy antigens • T-cells facilitate macrophages • B-cells transformed into specialized cells (plasma cells) capable of producing antibodies • Antibodies neutralize antigens via lysis and phagocytosis • Memory T-cells are formed to record information regarding antigens and immune response © 2011 McGraw-Hill Higher Education. All rights reserved.

10. Figure 14-1 © 2011 McGraw-Hill Higher Education. All rights reserved.

11. Immunity • After effectively managing invading antigens the system is primed for future encounters • Acquired immunity • Developed artificially through vaccination/immunizations or passively when antibodies are injected • Both can provide important protection against infectious disease © 2011 McGraw-Hill Higher Education. All rights reserved.

12. Immunizations • Available and should be provided for all • Possible vaccinations include: • Diphtheria • Pertussis (whooping cough) • Hepatitis B • Haemophilus influenza type B • Tetanus • Rubella (German measles) & measles • Polio, mumps & chickenpox • Helps to minimize incidence of childhood communicable disease © 2011 McGraw-Hill Higher Education. All rights reserved.

13. Immunizations have eradicated many infectious diseases world wide • Epidemiology is a tool used to study infectious disease in a population • Disease outbreaks • Sporadic (occasional, occurrence) • Endemic (regular cases often occurring in a region) • Epidemic (unusually high number of cases in a region • Pandemic (global epidemic) © 2011 McGraw-Hill Higher Education. All rights reserved.

14. Preventing Spread of Infectious Disease • Must be diligent in efforts to minimize transmission of disease • Most effective practice = washing hands • Ensure that patient immunizations are up to date • Be sure to educate patients on inability of antibodies to impact viruses, and need to taking antibiotics as directed • Encourage healthy lifestyles in patients © 2011 McGraw-Hill Higher Education. All rights reserved.

15. 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 (HBV) , hepatitis C (HBC) and human immunodeficiency virus (HIV) © 2011 McGraw-Hill Higher Education. All rights reserved.

16. Submicroscopic parasitic organism is dependent on nutrients of cell Strand of DNA or RNA dependent on metabolic and reproductive activity of cell Redirect cell activity to create more viruses Virus Reproduction Figure 14-3 © 2011 McGraw-Hill Higher Education. All rights reserved.

17. Hepatitis B • Attacks liver, results in lifelong infection, cirrhosis, liver cancer, liver failure and death • Spread when blood from infected person enters the body of someone who is not infected • Unprotected sex, sharing needles • Individuals who have been vaccinated are at virtually no risk for infection • 350-400 million people are infected world-wide • 8700 healthcare workers contract HBV each year, with 200 of these ending in death © 2011 McGraw-Hill Higher Education. All rights reserved.

18. 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 in these individuals • Can be unknowingly transferred • Chronic active hepatitis may occur because of problem with immune system, preventing complete destruction of virus infected liver cells © 2011 McGraw-Hill Higher Education. All rights reserved.

19. Signs & Symptoms (continued) • 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

20. 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 • After second does 87% of those receiving vaccine will be immune and 96% after the third dose • Post-exposure vaccination is also available after coming into contact with blood or fluids © 2011 McGraw-Hill Higher Education. All rights reserved.

21. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

22. Prevention • Occasionally spread through sexual contact • Spread via contact with blood of infected person, sharing needles • 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

23. Human Immunodeficiency Virus • A retrovirus that combines with host cell • Infects T4 blood cells, B cells and monocytes (macrophages) • Estimated that 11 out of 1000 adults are infected with HIV • 4.1 million new HIV infections occurred world-wide in 2005 © 2011 McGraw-Hill Higher Education. All rights reserved.

24. 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) © 2011 McGraw-Hill Higher Education. All rights reserved.

25. 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 HIV cannot predict when the individual will show symptoms of AIDS © 2011 McGraw-Hill Higher Education. All rights reserved.

26. As of 2007, 1.1 million people in the U.S. were living with HIV infection; 468,000 were living with AIDS • 50% develop AIDS w/in 10 years of HIV infection • After contracting AIDS, people generally die w/in 2 years of symptoms developing © 2011 McGraw-Hill Higher Education. All rights reserved.

27. 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 • Drug which blocks enzyme action responsible for new virus cell components • Drug which blocks copying of viral agents, disabling synthesis of new viruses • Third drug helps protect T cells, slowing progression of HIV © 2011 McGraw-Hill Higher Education. All rights reserved.

28. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

29. Additional Hepatitis Viruses • Hepatitis A • Causes inflammation of liver – does not lead to chronic liver disease • Transmitted by fecal or oral routes through close personal contact or contaminated food/water • Transmitted in milk, shellfish, salads, sliced meat • May show no outward signs or symptoms • Adults may exhibit dark urine, light stools, fatigue, jaundice and fever © 2011 McGraw-Hill Higher Education. All rights reserved.

30. Hepatitis D (HDV) causes inflammation of the liver • Found often in those infected with HBV • Transmitted through contact with infected blood, needles or sexual contact • Symptoms more severe than with HBV • Hepatitis E (HEV) • Causes inflammation of the liver • Rarely found in the United States • Transmitted through fecal and oral routes from contaminated water supplies © 2011 McGraw-Hill Higher Education. All rights reserved.

31. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

32. 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 • Institutions should take responsibility to educate student athletes © 2011 McGraw-Hill Higher Education. All rights reserved.

33. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

34. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

35. HIV and Athletic Participation • 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 • Also must take into consideration risk to patient and other participants and means to reduce risk © 2011 McGraw-Hill Higher Education. All rights reserved.

36. Testing Athletes for HIV • Should not be used as screening tool • Mandatory testing may not be allowed due to legal reasons (American with Disabilities Act and HIPAA) • 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

37. Detectable antibodies may appear from 3 month to 1 year following exposure • Testing should occur at 6 weeks, 3 months, and 1 year • Home test kits are also available which allow you to send blood work to lab for analysis • Home Access test is FDA approved • Lab analyzes dried blood sample and labeled with personal identification number (PIN) • Acquire results and counseling confidentially with PIN © 2011 McGraw-Hill Higher Education. All rights reserved.

38. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

39. Universal Precautions in Athletic Environment • 1991 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 • Should include counseling, education, volunteer testing, and management of bodily fluids © 2011 McGraw-Hill Higher Education. All rights reserved.

40. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

41. 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 • Personal Precautions • Those in direct contact must 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

42. Personal Precautions (continued) • Doubling gloving 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 (germicidal agent) • Hands should be washed between patients © 2011 McGraw-Hill Higher Education. All rights reserved.

43. Latex Sensitivity and Nonlatex Gloves • Nonlatex glove use is recommended for athletic trainers • May cause allergic reactions if use latex gloves • Contact dermatitis • Systemic reaction • Some become more susceptible due to repeated exposure • Management of acute reaction includes removing irritant, cleansing affected area, monitoring vital signs, seeking additional medical assistance as warranted © 2011 McGraw-Hill Higher Education. All rights reserved.

44. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

45. Figure 14-4 Figure 14-5 © 2011 McGraw-Hill Higher Education. All rights reserved.

46. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

47. 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 Figure 14-6 © 2011 McGraw-Hill Higher Education. All rights reserved.

48. Protecting the Athletic Trainer • 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 • Provide necessary supplies and education • Athletic trainer has personal responsibility to follow guidelines • Minimize risks by not eating/drinking, applying cosmetics/lip balm, handling contact lenses, and touching face before washing hands © 2011 McGraw-Hill Higher Education. All rights reserved.

49. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.

50. 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 © 2011 McGraw-Hill Higher Education. All rights reserved.