*Information in this unit was provided by UNC Health Care Hospital Epidemiology and was adapted for use at UNC-CH.

Note: This self-study unit is intended for University employees. Employees who have duties in UNC Hospitals should also refer to the Bloodborne Exposure Control Plan and other policies and procedures described in the UNC Health Care Infection Control Manual.

INTRODUCTION

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

• HEPATITIS B (HBV)



• HEPATITIS C (HCV)



• NON A, NON B HEPATITIS



• HUMAN IMMUNODEFICIENCY VIRUS (HIV)



• SYPHILIS



• MALARIA

OTHER POTENTIALLY INFECTIOUS MATERIALS (OPIM)

Other body fluids besides blood have demonstrated a viral load sufficient to potentially transmit infection. These fluids are:

• cerebrospinal fluid


• synovial fluid


• pleural fluid


• amniotic fluid


• pericardial fluid


• peritoneal fluid


• semen


• vaginal secretions


• any body fluid contaminated with blood saliva in dental procedures


• body fluids in emergency situations that cannot be recognized

Also considered potentially infectious are:

• unfixed tissue or body organs other than intact skin


• blood, organs, and tissue from experimental animals infected with HIV or HBV

TRANSMISSION

HIV and hepatitis B virus 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 non-intact skin exposure to contaminated blood/OPIM.

RULE OF THREES

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, cumulative totals 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 that 18.5 million adults and 1.5 million children have been infected with HIV.

The total individuals living with HIV infection and with AIDs through December 1998 in the United States and territories is 372,586. Current trends show cases increasing in injecting-drug users, women, blacks, Hispanics, adolescents/young adults, and among persons infected through heterosexual contact with a partner at risk for or known to have HIV infection or AIDS.

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 flu-like 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 of 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 HIV-infected adults develop AIDS within 2 years of infection; without therapy, approximately 20-25% 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 AIDS-indicator 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 non A, non B 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 middle class white Americans have had HBV infection. In 1995 (as of December 30,1995), 10,079 cases of hepatitis B were reported to the CDC.

CLINICAL MANIFESTATIONS

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 3-10 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.

HEPATITIS B VACCINE

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 40-50 years. Older age, obesity, heavy smoking, and immunologic impairments have been associated with lower anti HBs responses. The higher the antibody titer after vaccination, the longer anti HBs persists. When the anti HBs titer falls below 10 MlU/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 employees who have reasonably anticipated exposure to blood or other potentially infectious materials will be offered the hepatitis B vaccine free of charge through University Employees Occupational Health Clinic (UEOHC). OSHA considers 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.

ADMINISTRATIVE CONTROLS: EXPOSURE CONTROL PLAN

The Exposure Control Plan for Bloodborne Pathogens is available to all employees. To receive a copy, please call the Health and Safety Office at 962-5507. 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 employee exposures 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

Standard Precautions (formerly referred to as Universal Precautions) are essential to reducing the occupational acquisition of a bloodborne pathogen. Standard Precautions mean that we treat every patient as if they are infected with bloodborne pathogens, 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.

ENGINEERING CONTROLS

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 and UNC Health Care for bloodborne pathogens are sharps boxes and resheathing IV catheters.

WORK PRACTICE CONTROLS

Work practice controls are designed to change the way in which a task is performed to reduce the likelihood of exposure to bloodborne pathogens. Examples of work practice controls are: 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.

PERSONAL PROTECTIVE EQUIPMENT

Personal protective equipment (PPE) is 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. Employees should never put themselves at risk of exposure to bloodborne pathogens by not using the appropriate protective equipment.

PPE should be removed after use. Care should be taken not to contaminate the skin. Soiled gowns, gloves, etc. should be disposed of in a BIOHAZARD container immediately at the point of use and hands thoroughly washed.

UNIVERSAL BIOHAZARD SIGN

The universal BIOHAZARD sign is used 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 used for manually transporting 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 EQUIPMENT

Equipment such as blood pressure cuffs and stethoscopes must be cleaned if contaminated with blood or other potentially infectious materials. An EPA approved 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 accompanying tags and/or labels must be free of any contamination.

DISPOSING OF MEDICAL WASTE

The OSHA Bloodborne Pathogens Standard definition of regulated medical waste includes liquid or semi-liquid blood that must be disposed in a container labeled with the BIOHAZARD label. Certain items are required by North Carolina state law to be incinerated and are referred to as regulated medical waste. NC Medical Waste rules define regulated medical waste as blood in quantities greater than 20 ml per unit container. Regulated medical waste includes: microbiological cultures, pathology specimens, >20ml of blood products (includes blood, serum, plasma, emulsified human tissue, spinal fluid, pleural and peritoneal fluid), full sharps containers. The following table indicates the method of disposal for each type of waste.

In clinic areas, blood contaminated waste, such as bandages, dental floss, and vacutainer tubes should be placed in the white trash bags labeled with the BIOHAZARD sign. The bags do not require treatment, such as autoclaving or incineration, before disposal. These bags are located in all clinics. This waste is disposed of in our local landfill, according to NC Medical Waste rules.

Remember the trash bags are a plastic that can easily be punctured. All healthcare and laboratory workers must dispose of all sharps in the designated sharps containers to prevent sharp injuries to housekeeping workers.

WET, CONTAMINATED LINEN

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, contaminated linen. Linen should be double bagged when necessary to prevent leaking.

DERMATITIS OF THE HANDS

Working with hand dermatitis puts you at greater risk of infection from bloodborne pathogens. All employees who develop dermatitis should be seen in University Employees Occupational Health Clinic for evaluation and treatment prior to work involving exposure to blood.

LATEX ALLERGY

Latex gloves have proven effective in preventing transmission of many infectious diseases to health care workers. But for some workers, exposure to latex may result in allergic reactions. Latex allergy is a reaction to certain proteins in latex rubber. The amount of latex exposure needed to produce sensitization or an allergic reaction is unknown. In sensitized persons, symptoms usually begin within minutes of exposure; but they can occur hours later and can be quite varied. Mild reactions to latex involve skin redness, hives, or itching. More severe reactions may involve respiratory symptoms such as runny nose, sneezing, itchy eyes, scratchy throat, and asthma. Any latex allergy reaction should be immediately evaluated by the University Employees Occupational Health Clinic.

PROTECTION FROM LATEX ALLERGY

• Use nonlatex gloves for activities that are not likely to involve contact with infectious materials
• Appropriate barrier protection is necessary when handling infectious materials. If you choose latex gloves, use powder-free gloves with reduced protein content.
• When wearing latex gloves, do not use oil-based hand creams or lotions
• After removing latex gloves, wash hands with a mild soap and dry thoroughly
• Frequently clean areas and equipment contaminated with latex dust
• Learn to recognize the symptoms and procedures for preventing latex allergy

EXPOSURE INCIDENTS

The following events are considered an exposure.

• percutaneous injury involving a potentially contaminated needle or other sharp
• splash of blood or other potentially infectious materials to the eyes, mouth, or mucous membranes
• blood or other potentially infectious materials contacting broken skin

At UNC in 1998, there were 68 exposure incidents reported. Four of the source patients were HIV positive, six were HBV positive, and five were HCV positive. There were no seroconversions as a result of exposure to HIV, HBV, or HCV positive blood.

STEPS TO TAKE IN THE EVENT OF AN EXPOSURE

• Immediately wash the exposed area with soap and water. If the eyes are involved, irrigate with tap water
• Notify your supervisor and complete an incident report
• Go to the University Employees Occupational Health Clinic, calling ahead (966-9119) to alert them of the exposure. If the exposure occurs after regular working hours or on weekends, call Health Link (966-7890) to be instructed on how to seek treatment.

OCCUPATIONAL HEALTH CLINIC EVALUATION

The University Employees Occupational Health Clinic staff will evaluate your exposure incident. This evaluation may include testing your blood and the source patients' blood for HIV, HBV, and HCV. Testing of your blood is only done with your consent and results are confidential. The UEOHC staff will provide you with a written evaluation and recommendations regarding your exposure. Combination therapy for HIV exposure may be considered when indicated.

You have completed this self-study unit. Please see your OSHA educator or call the Health and Safety Office for questions and discussion.

We would like to assess your learning and also document your participation in this self-study. To do this, we have provided a short multiple choice test. To take this test, you may click on the highlighted Post-test now.