INTRODUCTION
PREVENTING TRANSMISSION
BLOODBORNE PATHOGENS EDUCATION
POSTTEST
On December 6, 1991, the Occupational
Safety and Health Administration (OSHA) published their standard
for occupational exposure to bloodborne pathogens in the Federal
Register. A component of this standard requires the employer to
provide annual education regarding the occupational hazard of
bloodborne pathogens. There are 13 required components of this
education all of which are incorporated in this study module.
It is important to remember that OSHA standards are federal law
and compliance is mandatory. However, it is more important
to recognize that this standard was established to help protect
the healthcare worker from the serious workplace hazard of bloodborne
pathogens.
EXAMPLES OF
BLOODBORNE PATHOGENS
OTHER
POTENTIALLY INFECTIOUS MATERIALS (OPIM)
Other body fluids besides blood have demonstrated a viral load sufficient to potentially transmit
infection. These fluids are:
Also considered potentially infectious
are:
HIV and Hepatitis B are transmitted
via the following routes: sexual contact, sharing HIV or HBV contaminated
needles or syringes, and from mother to unborn child. In the occupational
setting transmission is by needlestick/sharp injuries, mucous
membrane and nonintact skin exposure to contaminated blood/OPIM.
Not all the bloodborne pathogens
carry the same risk of occupational acquisition. Frequency in
patient population, environmental viability of the virus, and
viral load all impact your risk of acquiring infection if exposed.
The following table demonstrates infection risk from a percutaneous
exposure to HBV, HCV, and HIV.
EPIDEMIOLOGY
OF HUMAN IMMUNODEFICIENCY VIRUS
As of July 3, 1995, a cumulative
total of 1,169,811 cases of AIDS have been reported to the World
Health Organization (WHO). The majority of cases have originated
from third world countries. Worldwide, it is estimated that 4.5
million people have AIDS and 18.5 million have HIV infection.
In the United States, 68,376 cases
of AIDS were reported in 1995 (as of December 30,1995), bringing
the cumulative total to 509,904. Current trends show cases increasing
in women, blacks, hispanics, and adolescents/young adults. All
areas of the U.S. have had an increase in the number of men and
women with AIDS reportedly infected through heterosexual contact;
the largest increase in the number of these cases occurred in
the South. This trend is associated with a 30% increase in the
South in the number of births to HlVseropositive women from
1989 to 1992, representing the largest increase of any region
of the U.S.
CLINICAL
MANIFESTATIONS OF HIV INFECTION
The spectrum of HIV infection ranges
from an asymptomatic state to severe immunodeficiency and associated
opportunistic infections, neoplasms, and other conditions. Initial
infection can be followed by an acute flulike illness. Features
include fever, lymphadenopathy, sweats, myalgia, arthralgia, rash,
malaise, sore throat, and headache. The natural history of HIV
infection can vary considerably from person to person. The risk
for disease progression increases with the duration of infection.
Most cohort studies that have evaluated the natural history of
HIV infection show that less than 5% of HIVinfected adults
develop AIDS within 2 years of infection; without therapy, approximately
2025% develop AIDS within 6 years after infection, and 50%
within 10 years. AIDS indicators were revised last in 1992 and
include 23 diseases/conditions. Three clinical conditions accounted
for >75% of initial AlDSindicator diseases in 1992: P.
carinii pneumonia, HIV wasting syndrome, and candidiasis
of the esophagus.
EPIDEMIOLOGY
OF HEPATITIS B VIRUS
Acute viral hepatitis is a common
and sometimes serious viral infection of the liver leading to
inflammation and necrosis. There are at least five distinct viral
agents that cause acute viral hepatitis: HAV, HBV, HDV (delta),
HCV, and HEV (an enterally transmitted nonA, nonB
hepatitis agent).
Hepatitis B (HBV) or "serum
hepatitis" was first reported in 1833 following the administration
of smallpox vaccine containing human lymph to shipyard
workers. The frequency of infection in the U.S. population is
not known due in part to underreporting. Use of serologic markers
for evidence of previous HBV infection reveal that by age 50 years,
7% of middleclass white Americans have had HBV infection.
In 1995 (as of December 30,1995), 10,079 cases of hepatitis B
were reported to the CDC.
The clinical presentation of acute
HBV ranges from asymptomatic, subclinical illness to fulminant
hepatic failure. The disease has a long incubation period from
30 to 180 days. Initial symptoms are nonspecific, typically include
malaise, anorexia, vomiting, fever, rash, and polyarthritis. These
symptoms last 310 days. This is followed by the onset of
jaundice and /or dark urine. Fulminant viral hepatitis is defined
as the development of severe acute liver failure with hepatic
encephalopathy within 8 weeks of the onset of symptoms with jaundice.
The most distinctive laboratory finding of viral hepatitis is
dramatic elevations of aminotransferases (ALT and AST). The diagnosis
of HBV rests on specific serologic testing, with the finding of
HBV surface antigen (HBsAg) in the serum during the acute phase.
Recombinant vaccines that consist
of highly purified HBsAg particles expressed in yeast were licensed
in the U.S. in 1986. Given as a series of three injections, the
vaccine produces a high antibody titer in over 90% of recipients
under the age of 4050 years. Older age, obesity, heavy smoking,
and immunologic impairments have been associated with lower antiHBs
responses. The higher the antibody titer after vaccination, the
longer antiHBs persists. When the antiHBs titer falls
below 10 MIU/ml, HBV infections may occur but are always subclinical
and usually without detectable serum HBsAg. The need for a booster
dose of vaccine has not been determined.
All UNC Hospitals' employees who
have reasonably anticipated exposure to blood or other potentially
infectious materials will be offered the hepatitis B vaccine free
of charge through Occupational Health Service. OSHA considered
the hepatitis B vaccine so important that employees will be required
to sign a declination statement if they choose to not receive
the vaccine. However, those declining the vaccine may receive
it at any later time as long as they remain an employee of UNC
Hospitals.
The bloodborne pathogen that has
the greatest risk of occupational acquisition after percutaneous
exposure is: ____________________.
The area of the U. S. that has
had the largest increase in cases of heterosexually transmitted
HIV is: ____________________.
ADMINISTRATIVE
CONTROLS: EXPOSURE CONTROL PLAN
UNC Hospitals' Exposure Control Plan
for Bloodborne Pathogens is located in the Infection Control Manual.
This document contains a complete listing of all job categories
that have been identified as having the risk of occupational exposure
to bloodborne pathogens. Also the plan outlines management of
patients or employees who are infected with a bloodborne pathogen
and methods to prevent exposure in the workplace. Directly behind
the Exposure Control Plan is a copy of the OSHA standard. Every
employee should be familiar with the Exposure Control Plan and
the OSHA standard for bloodborne Pathogens.
Standard Precautions are an essential
component to reducing occupational acquisition of a bloodborne
pathogen. Standard Precautions mean that we treat every patient
as if they are infected with a bloodborne pathogen such as HIV
or HBV. Standard Precautions also mean that healthcare workers
use personal protective equipment to prevent direct contact with
a patient's blood or body fluids. The consistent practice of Standard
Precautions is the best method that healthcare workers can use
to protect themselves from occupationally acquiring a bloodborne
disease.
An engineering control is a device
that removes the hazard from the workplace. Employers are required
to provide engineering controls that have been demonstrated to
significantly reduce an occupational hazard. Examples of engineering
controls used here at UNC Hospitals for bloodborne pathogens are
sharps boxes and resheathing IV catheters.
Work practice controls are designed
to change the way in which a task is performed to reduce the likelihood
of exposure to bloodborne pathogens. Many work practice controls
are practiced by UNC healthcare workers. Needles are not recapped,
specimens are transported in a secondary container and sharps
are disposed of immediately after use by placing them in a sharps
container. Healthcare workers are responsible for carefully disposing
of all sharps (e.g., syringes with needles attached, scalpels,
razors, guidewires) immediately after use.
Procedure trays containing sharps should not be left in a patients room or exam room.
Disposable sharps must be removed
from the tray, deposited in a sharps box, and the tray with any
reusable items returned to Central Sterile Services for resterilization.
Personal protective equipment (PPE)
are specialized clothing and equipment worn by an employee for
protection against a hazard such as blood or other potentially
infectious materials. PPE should be readily available and provided
to the employee at no cost. Most personal protective equipment
at UNC Hospitals are disposable, singleuse items. Clean
exam gloves are located in every patient room. PPE boxes (tan
colored, wallmounted cabinets) containing nonsterile gowns,
protective eyewear, masks, and resuscitation mask with oneway
valve, are located at every nurses station near the code cart.
You can also find PPE in the clean utility rooms on most patient
care units. If you are unable to locate PPE, always ask the nurse
in charge to assist you in finding what you need. Healthcare workers
should never put themselves at risk of exposure to bloodborne
pathogens by not using the appropriate protective equipment.
PPE should be removed prior to exiting
the patients' room, or exam room. Care should be taken not to
contaminate the skin. Soiled gowns, gloves, etc. should be disposed
of in the regular trash (white, plastic bag displaying a BIOHAZARD
label) immediately at the point of use and hands thoroughly washed.
The universal BIOHAZARD sign is used
throughout the hospital to alert employees that containers, specimen
refrigerators, or secondary containers used to transport specimens
may contain infectious materials. Individual tubes of blood or
primary specimen containers do not need to be labeled; however,
secondary containers such as green basins used for transporting
the specimens must display the BIOHAZARD sign. Additionally, equipment
that may have internal contamination that cannot be accessed for
decontamination should be labeled with a BIOHAZARD tag denoting
the area of suspected contamination. This alerts the maintenance
or medical engineering employee to use precautions when handling
the equipment.
CONTAMINATED
PERSONAL CLOTHING
When personal clothing is contaminated
with blood or OPIM, the clothing should be removed as soon as
possible and sent to the hospital laundry room for cleaning. The
item should be placed in a plastic bag and labeled with the employees'
name, department, and phone number. The linen room will issue
scrub clothing to the employee if needed.
Equipment such as blood pressure
cuffs and stethoscopes must be cleaned if contaminated with blood
or other potentially infectious materials. An EPAapproved
disinfectant detergent (i.e., Vesphene) or a 1:10 or 1:100 dilution
of bleach and water should be used.
TRANSPORTING
SPECIMENS TO THE LABORATORY
Specimens should not be hand carried
to the laboratory. All specimens must be transported in a secondary
container displaying a BIOHAZARD label. The primary specimen container
and the specimen requisition slip must be free of any contamination.
If the container or requisition are visibly soiled, the laboratory
will refuse to accept the specimen. No specimens will be accepted
by the laboratory in syringes with a needle attached. Exceptions
to this policy will be considered when the volume is so small
that the entire specimen is contained in the needle.
Most waste generated in the hospital
should be placed in the white trash bags (regular trash) labeled
with the BIOHAZARD sign. These bags are located throughout the
hospital including administrative areas. This waste is disposed
of in our local landfill. Certain items are required by North
Carolina state law to be incinerated and are referred to as regulated
medical waste. Regulated medical waste includes: microbiology
specimens, pathology specimens, >20cc of blood products (includes
blood. serum. Plasma, emulsified human tissue, spinal fluid, pleural
and peritoneal fluid) in containers that cannot be easily opened
and emptied (e.g., pleurevacs and evacuated containers), full
sharps containers. and items used in the preparation and administration
of hazardous drugs/antineoplastic drugs. Regulated medical waste
must be placed in red trash bags bearing a BIOHAZARD label. On
all patient care units, a red bag is inside a large yellow trash
container located in the dirty utility room.
Remember. the trash bags are a
plastic that can easily be punctured. All healthcare workers must
dispose of all sharps in the designated sharps boxes to prevent
sharp injuries to environmental service workers.
Contaminated linen should not be
sorted or handled any more than necessary for disposal. Fluid
resistant linen bags are available for use when disposing of wet,
bloodcontaminated linen. These bags are a pale yellow color
and available on most nursing units. Linen should be doublebagged
when necessary to prevent leaking.
Working with hand dermatitis puts
you at greater risk of infection from bloodborne pathogens. All
employees who develop dermatitis should be seen in Occupational
Health Service for evaluation and treatment prior to providing
patient care.
The following events are considered
an exposure.
At UNC Hospitals in 1995, there were 243 exposure incidents reported to Occupational
Health Service. 27.2% of these exposures
occurred in physicians and 39% occurred in nurses. Ten of the
source patients were HIV positive and 1 was HBsAg positive. No
seroconversions as a result of exposure to HIV or HBV positive
blood occurred.
STEPS
TO TAKE IN THE EVENT OF AN EXPOSURE
OCCUPATIONAL
HEALTH SERVICE EVALUATION
Occupational Health Service staff
will evaluate your exposure incident. This evaluation may include
testing your blood and the source patients' blood for HIV or HBV.
Testing of your blood is only done with your consent and results
are confidential. Occupational Health Service staff will provide
you with a written evaluation and recommendations regarding your
exposure. Zidovidine prophylaxis may be considered when indicated.
An example of a work practice
control is: ____________________.
Pleurevacs and evacuated containers
with >20cc of blood /blood products must be disposed of in
the ____________________ trash bag.
In the event of an exposure to
a patient's blood or other potentially infectious materials, you
should report the exposure by calling the ____________________.
BLOODBORNE PATHOGENS EDUCATION
POSTTEST
INSTRUCTIONS
QUESTIONS
NAME: ______________________________
DATE: _____________________________
1. An example of an important
engineering control used at UNC Hospitals for preventing exposure
to bloodborne pathogens is:
a. sharps boxes
b. handwashing
c. BIOHAZARD warning labels
2. Personal protective equipment
should be disposed of in the:
a. red bag waste (regulated medical waste)
b. white bag waste (regular trash)
c. either a or b above
3. An appropriate disinfectant
to decontaminate equipment soiled with blood is:
a. betadine solution
b. 1:10 or 1:100 dilution of household bleach and water
c. any soap solution
4. Which of the following would
be considered a bloodborne pathogen exposure incident?
a. blood contact with intact skin
b. blood splashed into the eyes
c. blood splashed onto personal clothing
5. Which bloodborne pathogen
has the greatest risk of occupational acquisition for healthcare
workers?
a. hepatitis C
b. HIV
c. hepatitis B
6. Initial infection with HIV
can be followed by which symptoms?
a. flulike illness
b. acute abdominal pain
c. increased hair loss
7. Signs and symptoms of acute
hepatitis B infection include:
a. vomiting, fever, and rash for 3 to 10 days
b. jaundice and or darkening of the urine
c. both a and b
8. The consistent practice of
which of the precautions listed below is the best way to protect
yourself from exposure to bloodborne pathogens?
a. airborne precautions
b. contact precautions
c. standard precautions
9. In the event of an exposure
to a patient's blood, you should call:
a. environmental health and safety at 60749
b. needlestick hotline at 64480
c. hospital police at 63686
10. All sharps should be:
a. recapped and thrown away in the regular (white bag) trash
b. recapped and thrown away in the regulated (red bag) trash
c. never recapped and placed in a
designated sharps container at point of use