SECTION ONE: OSHA/TB/BBP
Bloodborne Pathogen Standard
In 1991, the Occupational Safety and Health administration (OSHA) published the “Occupational Exposure to Bloodborne Pathogens Standard” C.F.R. 1910.1030.
he purpose of the standard is to eliminate or minimize occupational exposure to Hepatitis B (HBV), Human Immunodeficiency Virus (HIV), and other bloodborne pathogens. The intent is to protect employees from potential workplace hazards. All persons, regardless of age, race, gender or perception, are considered infected with HIV/HBV/HCV, and all body fluids are considered infectious, with the exception of sweat.
Scope and Application
The Bloodborne Pathogens Standard applies to all occupational exposure to blood or other potentially infectious materials
The following is a list of definitions contained in the standard.
Pathogenic microorganisms that are present in human blood and can cause disease in humans.
Other Potentially Infectious Materials (OPIM)
Human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural and pericardial fluid, peritoneal fluid, amniotic fluid, and saliva in dental procedures. This also applies to all other body fluids visibly contaminated with blood, such as urine, feces, vomitus, tears, and breast milk. Any unfixed human tissue or organ or HIV or HBV containing cell or tissue cultures.
Labels and signs used to communicate warnings of possible exposure to bloodborne pathogens. These should be red in color and/or carry the biohazardous materials symbol:
The presence or anticipated presence of blood or other potentially infectious materials found on an item or surface. For example, HBV may survive on dried work surfaces for up to 7 days.
A specific eye, mouth, or other mucous membrane, non-intact skin, or parenteral contact with blood or OPIM that results from the performance of an employee’s duties.
Liquid or semi-liquid blood or OPIM-contaminated items that would release blood or OPIM in a liquid or semi-liquid state if compressed; items that are caked with dried blood or OPIM and are capable of releasing these materials during handling; contaminated sharps and pathological and microbiological wastes containing blood or OPIM.
The CDC recommends Standard Precautions for the care of all patients, regardless of their diagnosis or presumed infection status. Standard Precautions apply t o all: 1) blood; 2) body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood; 3) non-intact skin; and 4) mucous membranes. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals. Standard precautions include the use of hand washing, appropriate personal protective equipment such as gloves, gowns, masks, whenever touching or exposure to patients’ body fluids is anticipated.
Body Substance Isolation
An infection control measure that means avoiding contact with any and all human body fluid.
Exposure Control Plan
An exposure control plan is a written plan that spells out exactly what steps a company is taking to comply with the Bloodborne Pathogens Standard. This plan must be reviewed and evaluated annually and updated as needed.
Components of The Exposure Control Plan Include:
- A list of tasks that have the potential to cause exposure to bloodborne pathogens, as well as the employees who perform these tasks.
- Methods and schedule of how compliance is maintained.
- Assurance that Universal Precautions are observed within the facility.
- Use of engineering and work practice controls to eliminate or minimize employee exposure to bloodborne pathogens.
- Free Hepatitis B vaccination of all employees at potential risk for exposure to bloodborne pathogens.
- Establishing a post-exposure evaluation and follow-up program for employees who become exposed to bloodborne pathogens.
- Using specified biohazard warning labels and signs.
- Setting up an information and training program for employees.
- Keeping appropriate medical records so that, in case of exposure, needed information is easily available.
- Maintaining training records attesting to employee participation in facility’s training sessions.
Contaminated reusable sharps, immediately after use, must be placed in containers that are puncture resistant, leak-proof on both sides and bottom, red in color and labeled with biohazard symbol. A sharps container that is ¾ full is considered filled and should be promptly removed from the work area and placed in the proper place in the facility for disposal. Employees should never be required to reach by hand into the container.
Specimen containers must be closed prior to being stored or transported, and appropriately labeled with the biohazard symbol. If the primary container is soiled, place contaminated primary containers within a secondary container that is red or appropriately labeled with the biohazard symbol.
The following is the specific section of the Code of Federal Regulations 1910.1030 dealing with specimens and their handling:
Specimens of blood or other potentially infectious materials shall be placed in a container that prevents leakage during collection, handling, processing, storage, transport, or shipping.
The container for storage, transport, or shipping shall be labeled or color-coded according to paragraph (g)(1)(i) and closed prior to being stored, transported, or shipped. When a facility utilizes Universal Precautions in the handling of all specimens, the labeling/color-coding of specimens is not necessary, provided containers are recognizable as containing specimens. This exemption only applies while such specimens/containers remain within the facility. Labeling or color-coding in accordance with paragraph (g)(1)(i) is required when such specimens/containers leave the facility.
If outside contamination of the primary container occurs, the primary container shall be placed within a second container which prevents leakage during handling, processing, storage, transport, or shipping, and is labeled or color-coded according to the requirements of this standard.
If the specimen could puncture the primary container, the primary container shall be placed within a secondary container that is puncture-resistant in addition to the above characteristics.
Health care workers who use or who may be exposed to needles are at increased risk of needlestick injury. Such injuries can lead to serious or fatal infections with bloodborne pathogens such as hepatitis B virus, hepatitis C virus, or human immunodeficiency virus (HIV).
Employers of health care workers must implement the use of improved engineering controls to reduce the likelihood of needlestick injuries. The following recommendations should be considered when evaluating any needleless system.
The new system will:
- Eliminate the use of needles where safe and effective alternatives are available.
- Implement the use of devices with safety features and evaluate their use to determine which are most effective and acceptable.
Needlestick injuries can best be reduced when the use of improved engineering controls is incorporated into a comprehensive program involving workers. Employers should implement the following program elements:
- Analyze needlestick and other sharps-related injuries in your workplace to identify hazards and injury trends.
- Set priorities and strategies for prevention by examining local and national information about risk factors for needlestick injuries and successful intervention efforts.
- Ensure that health care workers are properly trained in the safe use and disposal of needles.
- Modify work practices that pose a needlestick injury hazard to make them safer.
- Promote safety awareness in the work environment.
- Establish procedures for and encourage the reporting and timely follow-up of all needlestick and other sharps-related injuries.
- Evaluate the effectiveness of prevention efforts and provide feedback on performance.
Health care workers should take the following steps to protect themselves and their fellow workers from needlestick injuries:
- Avoid the use of needles where safe and effective alternatives are available.
- Help your employer select and evaluate devices with safety features.
- Use devices with safety features provided by your employer.
- Avoid recapping needles.
- Plan for safe handling and disposal before beginning any procedure using needles.
- Dispose of used needles promptly in appropriate sharps disposal containers.
- Report all needlestick and other sharps-related injuries promptly to ensure that you receive appropriate follow-up care.
- Tell your employer about hazards from needles that you observe in your work environment.
- Participate in bloodborne pathogen training and follow recommended infection prevention practices, including hepatitis B vaccination.
Work Practice Controls
Readily accessible hand washing facilities with antiseptic hand cleanser and towels must be made available to all employees. Antiseptic towelettes may be used if hand-washing facilities are not readily available. However, employees must wash their hands as soon as possible after any patient contact. Alcohol based gels and solutions are now accepted in hospitals and clinics. The gel contains 60% – 90% ethanol or isopropyl alcohol and is proven to be effective in killing germs. According to the CDC, 10 – 15 seconds of vigorous scrubbing is adequate.
The following is the specific section of the Code of Federal Regulations 1910.1030 dealing with hand washing.
Employers shall provide hand-washing facilities that are readily accessible to employees.
When provision of hand washing facilities is not feasible, the employer shall provide either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers or towelettes are used, hands shall be washed with soap and running water as soon as feasible.
Employers shall ensure that employees wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment.
Employers shall ensure that employees wash hands and any other skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials.
Disposal of Sharps: Sharps containers should be used when disposing of sharp objects. However, they must be disposed of without breaking or bending objects. Recapping of needles is only done with a mechanical device or a one-handed technique. Eating, drinking, smoking, handling contact lenses or applying cosmetics is prohibited in areas where there is possible exposure. The storage of food is also prohibited in areas where blood or OPIM are found. Finally, appropriate decontamination of equipment must be performed before and after each use. If this is not feasible, the equipment must be labeled with the biohazard symbol.
The following sections of the standard apply to the use of these recommended work practice controls:
Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed except as noted in paragraphs (d)(2)(vii)(A) and (d)(2)(vii)(B) below. Shearing or breaking of contaminated needles is prohibited.
Contaminated needles and other contaminated sharps shall not be bent, recapped or removed unless the employer can demonstrate that no alternative is feasible or that such action is required by a specific medical or dental procedure.
Such bending, recapping or needle removal must be accomplished through the use of a mechanical device or a one-handed technique.
Immediately or as soon as possible after use, contaminated reusable sharps shall be placed in appropriate containers until properly reprocessed. These containers shall be:
Labeled or color-coded in accordance with this standard;
Leakproof on the sides and bottom
During use, containers for contaminated sharps shall be:
Easily accessible to personnel and located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found (e.g., laundries);
Maintained upright throughout use; and
Replaced routinely and not be allowed to overfill.
When moving containers of contaminated sharps from the area of use, the containers shall be:
Closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping;
Placed in a secondary container if leakage is possible. The second container shall be:
Constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping; and
Labeled or color-coded accordingly.
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
Food and drink shall not be kept in refrigerators, freezers, shelves, and cabinets or on countertops or bench tops where blood or other potentially infectious materials are present.
All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.
Equipment which may become contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping, and shall be decontaminated as necessary, unless the employer can demonstrate that decontamination of such equipment or portions of such equipment is not feasible.
A readily observable label in accordance with paragraph (g)(1)(i)(H) shall be attached to the equipment, stating which portions remain contaminated.
Personal Protective Equipment (PPE): The “last line of defense.” This equipment must be accessible to employees and available in appropriate sizes. Facilities must make sure that their employees use PPE whenever it is needed. One exception to this rule is if, in the employee’s professional judgment, using PPE would pose an increased hazard to their safety or the safety of a co-worker.
All employees must wear gloves whenever hand contact with blood or OPIM is anticipated. Disposable gloves must be replaced as soon as possible if they are contaminated or torn. Disposable gloves cannot be washed or reused. Goggles/face shields, gowns, and masks must be worn whenever splashes, spray, splatter, or droplets of blood or OPIM may occur. The material must not permit fluids to pass through and reach the wearer.
The following sections of the standard apply to the use of Personal Protective Equipment:
Personal Protective Equipment —
Provision . When there is occupational exposure, the employer shall provide, at no cost to the employee, appropriate personal protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal protective equipment will be considered “appropriate” only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.
Use . The employer shall ensure that the employee uses appropriate personal protective equipmen, unless the employer shows that the employee temporarily and briefly declined to use personal protective equipment when, under rare and extraordinary circumstances, it was the employee’s professional judgment that in the specific instance its use would have prevented the delivery of health care or public safety services or would have posed an increased hazard to the safety of the worker or co-worker. When the employee makes this judgment, the circumstances shall be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future.
Accessibility . The employer shall ensure that appropriate personal protective equipment in the appropriate sizes is readily accessible at the worksite or is issued to employees. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided.
Cleaning, Laundering, and Disposal . The employer shall clean, launder, and dispose of personal protective equipment required by paragraphs (d) and (e) of this standard, at no cost to the employee.
Repair and Replacement . The employer shall repair or replace personal protective equipment as needed to maintain its effectiveness, at no cost to the employee.
If a garment(s) is penetrated by blood or other potentially infectious materials, the affected item shall be removed immediately or as soon as feasible.
All personal protective equipment shall be removed prior to leaving the work area.
When personal protective equipment is removed it shall be placed in an appropriately designated area or container for storage, washing, decontamination or disposal.
Gloves . Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing vascular access procedures except as specified in paragraph (d)(3)(ix)(D); and when handling or touching contaminated items or surfaces.
Disposable (single use) gloves, such as surgical or examination gloves, shall be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.
Disposable (single use) gloves shall not be washed or decontaminated for re-use.
Utility gloves may be decontaminated for re-use if the integrity of the glove is not compromised. However, they must be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.
Make gloves available to all employees who wish to use them for phlebotomy;
Not discourage the use of gloves for phlebotomy; and
Require that gloves be used for phlebotomy in the following circumstances:
When the employee has cuts, scratches, or other breaks in his or her skin;
When the employee judges that hand contamination with blood may occur, for example, when performing phlebotomy on an uncooperative source individual; and
When the employee is receiving training in phlebotomy.
Masks, Eye Protection, and Face Shields . Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated.
Gowns, Aprons, and Other Protective Body Clothing . Appropriate protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic jackets, or similar outer garments shall be worn in occupational exposure situations. The type and characteristics will depend upon the task and degree of exposure anticipated.
Surgical caps or hoods and/or shoe covers or boots shall be worn in instances when gross contamination can reasonably be anticipated (e.g., autopsies, orthopedic surgery).
Housekeeping: A written schedule for cleaning and decontamination of areas and equipment that can become contaminated must be implemented. In addition, regulated waste must be placed in containers that are closeable, leak-proof, red or labeled with biohazardous symbol and disposed of in accordance of applicable federal, state & local regulations.
The following sections of the standard apply to the use of Personal Protective Equipment:
General . Employers shall ensure that the worksite is maintained in a clean and sanitary condition. The employer shall determine and implement an appropriate written schedule for cleaning and method of decontamination based upon the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed in the area.
All equipment and environmental and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials.
Contaminated work surfaces shall be decontaminated with an appropriate disinfectant after completion of procedures; immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of blood or other potentially infectious materials; and at the end of the work shift if the surface may have become contaminated since the last cleaning.
Protective coverings, such as plastic wrap, aluminum foil, or imperviously-backed absorbent paper used to cover equipment and environmental surfaces, shall be removed and replaced as soon as feasible when they become overtly contaminated or at the end of the work shift if they may have become contaminated during the shift.
All bins, pails, cans, and similar receptacles intended for reuse, which have a reasonable likelihood for becoming contaminated with blood or other potentially infectious materials, shall be inspected and decontaminated on a regularly scheduled basis and cleaned and decontaminated immediately or as soon as feasible upon visible contamination.
Sorting or rinsing of laundry in patient care areas should be prohibited. Laundry that is contaminated must be placed in red bags/containers or those labeled with the biohazard symbol unless your facility utilizes Universal Precautions in handling all soiled laundry.
Of those healthcare personnel for whom case investigations were completed from 1981-2006, 57 had documented seroconversion to HIV following occupational exposures. Another 140 are considered to have possibly contracted HIV from exposure at work. The risk of HIV after percutaneous exposure is approximately 0.3%. Antibody testing should be done at the time of exposure, and after 6 weeks, 12 weeks and 6 months. Reevaluation at 72 hours should be considered if new information has come up. Drug treatment includes 2 nucleoside analogues (ZDV&3TC: 3TC&d4T; d4T&ddl). The HCP must complete 4-weeks of drug treatment. About 50% of HCP have side effects (n/v, malaise, headache), and 33% stop taking the treatment.
Occupational Exposures to Blood:
Health-care workers are at risk for occupational exposure to bloodborne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Exposures occur through needlesticks or cuts from other sharp instruments contaminated with an infected patient’s blood or through contact through the eye, nose, mouth, or skin with a patient’s blood . Important factors that may determine the overall risk for occupational transmission of a bloodborne pathogen include: the number of infected individuals in the patient population, the chance of becoming infected after a single blood contact from an infected patient and the type and number of blood contacts.
Most exposures do not result in infection. Following a specific exposure , the risk of infection may vary with factors such as these:
- The pathogen involved
- The type of exposure
- The amount of blood involved in the exposure
- The amount of virus in the patient’s blood at the time of exposure
Your employer should have in place a system for reporting exposures in order to quickly evaluate the risk of infection, inform you about treatments available to help prevent infection, monitor you for side effects of treatments, and determine if infection occurs. This may involve testing your blood and that of the source patient and offering appropriate post-exposure treatment.
How Can Occupational Exposures Be Prevented?
Many needlesticks and other cuts can be prevented by using safer techniques (e.g., not recapping needles by hand), disposing of used needles in appropriate sharps disposal containers, and using medical devices with safety features designed to prevent injuries. Many exposures to the eyes, nose, mouth, or skin can be prevented by using appropriate barriers (e.g., gloves, eye and face protection, gowns) when contact with blood is expected.
If An Exposure Occurs
What should I do if I am exposed to the blood of a patient?
Immediately following an exposure to blood :
- Wash needlesticks and cuts with soap and water
- Flush splashes to the nose, mouth, or skin with water
- Irrigate eyes with clean water, saline, or sterile irrigants
Following Any Blood Exposure You Should:
Report the exposure to the department (e.g., occupational health, infection control) responsible for managing exposures. Prompt reporting is essential, because, in some cases, post-exposure treatment may be recommended, and it should be started as soon as possible. Discuss the possible risks of acquiring HBV, HCV, and HIV, and the need for post-exposure treatment with the provider managing your exposure . You should have already received hepatitis B vaccine, which is extremely safe and effective in preventing HBV infection.
Risk of Infection After Exposure
What is the risk of infection after an occupational exposure ? In the case of HBV, healthcare workers who have received hepatitis B vaccine and have developed immunity to the virus are at virtually no risk for infection. For an unvaccinated person, the risk from a single needlestick or a cut exposure to HBV-infected blood ranges from 6-30%, and depends on the hepatitis B e antigen (HBeAg) status of the source individual. Individuals who are both hepatitis B surface antigen (HBsAg) positive and HBeAg positive have more virus in their blood and are more likely to transmit HBV.
With HCV based on limited studies, the risk for infection after a needlestick or cut exposure to HCV-infected blood is approximately 1.8%. The risk following a blood splash is unknown, but is believed to be very small. However, HCV infection from such an exposure has been reported.
Concerning HIV, the average risk of infection after an exposure to HlV-infected blood is 0.3% (about 1 in 300). Stated another way, 99.7% of needlestick/cut exposures do not lead to infection. The risk after exposure of the eye, nose, or mouth to HIV-infected blood is estimated to be, on average, 0.1% (1 in 1,000).
The risk after exposure of the skin to HlV-infected blood is estimated to be less than 0.1%. A small amount of blood on intact skin probably poses no risk at all. There have been no documented cases of HIV transmission due to an exposure involving a small amount of blood on intact skin (a few drops of blood on skin for a short period of time). The risk may be higher if the skin is damaged (for example, by a recent cut) or if the contact involves a large area of skin or is prolonged (for example, being covered in blood for hours).
How Many Health-Care Workers Have Been Infected With Bloodborne Pathogens?
The annual number of occupational infections has decreased sharply since hepatitis B vaccine became available in 1982 (i.e., there was a 90% decrease in the number of estimated cases from 1985 to1996). Nonetheless, approximately 800 health-care workers become infected with HBV each year following an occupational exposure .
There are no exact estimates on the number of health-care workers occupationally infected with HCV. However, studies have shown that 1% of hospital health-care workers have evidence of HCV infection (about 1.8% of the U.S. population has evidence of infection). The number of these workers who may have been infected through an occupational exposure is unknown.
Surveillance of Healthcare Personnel with HIV/AIDS, as of December 2002
Of the adults reported with AIDS in the United States through December 31, 2002, 24,844 had a history of employment in healthcare. These cases represented 5.1% of the 486,826 AIDS cases reported to CDC for whom occupational information was known (information on employment was missing for 362,954 reported AIDS cases).
*Latest data available from CDC as of December 2007
Documented cases of occupationally acquired HIV/AIDS are those in which HIV seroconversion is temporally related to an exposure to an HIV-positive source and in which the exposed worker has no non-occupational risk factors for acquisition of HIV. Possible cases of occupationally acquired HIV/AIDS are those in which a worker is found to be HIV positive, has no non-occupational risk factors for HIV/AIDS, and has opportunities for occupational exposure to blood, body fluids, or HIV-positive laboratory material. Although seroconversion after exposure was not documented for these personnel, occupational acquisition of their infection might have been possible.
Of those healthcare personnel for whom case investigations were completed from 1981-2006, 57 had documented seroconversion to HIV following occupational exposures. The routes of exposure resulting in infection were: 48 percutaneous (puncture/cut injury); five, mucocutaneous (mucous membrane and/or skin); two, both percutaneous and mucocutaneous; and two were of unknown route. Forty-nine healthcare personnel were exposed to HIV-infected blood; three to concentrated virus in a laboratory; one to visibly bloody fluid; and four to an unspecified fluid. In addition, 140 possible cases of HIV infection or AIDS have occurred among healthcare personnel.
The most recent possible new case of occupationally acquired HIV/AIDS was reported to CDC in 2000; no new documented cases have been reported since that time, although several cases are in various stages of investigation. As yet, none can be classified as documented cases.
More than 90% of healthcare personnel infected with HIV have non-occupational risk factors for acquiring their infection.
Healthcare Personnel with Documented and Possible Occupationally Acquired AIDS/HIV Infection, by Occupation, 1981-2006
|Laboratory worker, clinical||
|Laboratory technician, nonclinical||
|Dental worker, including dentist||
|Emergency medical technician/paramedic||
|Other healthcare occupation||
Treatment For Exposure
Is There a Vaccine or Treatment Available to Prevent Infections with Bloodborne Pathogens?
As mentioned above, hepatitis B vaccine has been available since 1982 to prevent HBV infection. All healthcare workers who have a reasonable chance of exposure to blood or body fluids should receive hepatitis B vaccine. Vaccination ideally should occur during the healthcare worker’s training period. Workers should be tested 1-2 months after the vaccine series, to make sure that vaccination has provided immunity to HBV infection.
Hepatitis B immune globulin (HBIG) is effective in preventing HBV infection after an exposure . The decision to begin treatment is based on several factors, such as:
- Whether the source individual is positive for hepatitis B surface antigen.
- Whether you have been vaccinated.
- Whether the vaccine provided you immunity.
There is no vaccine against hepatitis C, and no treatment after an exposure that will prevent infection. Immune globulin is not recommended. For these reasons, following recommended infection control practices is crucial.
There is no vaccine against HIV. However, results from a small number of studies suggest that the use of zidovudine after certain occupational exposures may reduce the chance of HIV transmission. Post-exposure treatment is not recommended for all occupational exposures to HIV, because most exposures do not lead to HIV infection and because the drugs used to prevent infection may have serious side effects. Taking these drugs for exposures that pose a lower risk for infection may not be worth the risk of possible side effects. You should discuss the risks and side effects with a healthcare provider before starting post-exposure treatment for HIV.
What About Exposures to Blood From an Individual Whose Infection Status Is Unknown?
If the source individual cannot be identified or tested, decisions regarding follow-up should be based on the exposure risk and whether the source is likely to be a person who is infected with a bloodborne pathogen. Follow-up testing should be available to all workers who are concerned about possible infection through occupational exposure .
What Specific Drugs Are Recommended for Post-Exposure Treatment?
If you have not been vaccinated, then hepatitis B vaccination is recommended for any exposure, regardless of the source person’s hepatitis B status. HBIG and/or hepatitis B vaccine may be recommended, depending on your immunity to hepatitis B and the source person’s infection status.
Currently there is no recommended post-exposure treatment that will prevent HCV infection.
The Public Health Service recommends a 4-week course of two drugs (zidovudine and lamivudine) for most HIV exposures, or zidovudine and lamivudine plus a protease inhibitor (indinavir or nelfinavir) for exposures that may pose a greater risk for transmitting HIV (such as those involving a larger volume of blood with a larger amount of HIV or a concern about drug-resistant HIV). Differences in side effects associated with the use of these two drugs may influence which drug is selected in a specific situation.
These recommendations are intended to provide guidance to clinicians and may be modified on a case-by-case basis. Determining which drugs and how many drugs to use or when to change a treatment regimen is largely a matter of judgment. Whenever possible, consulting an expert with experience in the use of antiviral drugs is advised, especially if a recommended drug is not available, if the source patient’s virus is likely to be resistant to one or more recommended drugs, or if the drugs are poorly tolerated.
How Soon After Exposure to A Bloodborne Pathogen Should Treatment Start?
Post-exposure treatment should begin as soon as possible after exposure , preferably within 24 hours, and no later than 7 days.
Treatment should be started promptly, preferably within hours, as opposed to days, after the exposure. Although animal studies suggest that treatment is not effective when started more than 24-36 hours after exposure , it is not known if this time frame is the same for humans. Starting treatment after a longer period (e.g., 1-2 weeks) may be considered for the highest risk exposures; even if HIV infection is not prevented, early treatment of initial HIV infection may lessen the severity of symptoms and delay the onset of AIDS.
Has the FDA Approved These Drugs to Prevent Bloodborne Pathogen Infection Following An Occupational Exposure ?
Yes. Both hepatitis B vaccine and HBIG are approved for this use.
No. The FDA has approved these drugs for the treatment of existing HIV infection, but not as a treatment to prevent infection. However, physicians may prescribe any approved drug when, in their professional judgment, the use of the drug is warranted.
What Is Known About the Safety and Side Effects of These Drugs?
Hepatitis B vaccine is very safe. There is no information that the vaccine causes any chronic illnesses. Most illnesses reported after HBV vaccinations are often related to other causes and not the vaccine. However, you should report any unusual reaction after a hepatitis B vaccination to your health-care provider.
All of the antiviral drugs for HIV have been associated with side effects. The most common side effects include: upset stomach (nausea, vomiting, diarrhea), tiredness or headache. The few serious side effects that have been reported in healthcare workers using combination post-exposure treatment have included kidney stones, hepatitis and suppressed blood cell production. Protease inhibitors (indinaivir and nefinavir) may interact with other medicines and cause serious side effects, and should not be used in combination with certain other drugs, such as prescription antihistamines. It is important to tell the healthcare provider managing your exposure about any medications you are currently taking, if you need to take antiviral drugs for an HIV exposure .
Can Pregnant Health-Care Workers Take the Drugs Recommended for Post-exposure Treatment?
Yes. Women who are pregnant or breastfeeding can be vaccinated against HBV infection and/or get HBIG. Pregnant women who are exposed to blood should be vaccinated against HBV infection, because infection during pregnancy can cause severe illness in the mother and a chronic infection in the newborn. The vaccine does not harm the fetus.
Pregnancy should not rule out the use of post-exposure treatment when it is warranted. If you are pregnant, you should understand what is known and not known regarding the potential benefits and risks associated with the use of antiviral drugs, in order to make an informed decision about treatment.
What Follow-Up Should Be Done After An Exposure ?
Because post-exposure treatment is highly effective in preventing HBV infection, the CDC does not recommend routine follow-up after treatment. However, any symptoms suggesting hepatitis (e.g., yellow eyes or skin, loss of appetite, nausea, vomiting, fever, stomach or joint pain, extreme tiredness) should be reported to your healthcare provider. If you are exposed to HBV and receive post-exposure treatment, it is unlikely that you will become infected and pass the infection on to others. No precautions are recommended.
You should have an antibody test for hepatitis C virus and a liver enzyme test (alanine aminotransferase activity) as soon as possible after the exposure (baseline) and at 4-6 months after the exposure . Some clinicians may also recommend another test (HCV RNA) to detect HCV infection 4-6 weeks after the exposure . Report any symptoms suggesting hepatitis (mentioned above) to your health-care provider. Because the risk of becoming infected and passing the infection on to others after an exposure to HCV is low, no precautions are recommended.
You should be tested for HIV antibody as soon as possible after exposure (baseline) and periodically for at least 6 months after the exposure (e.g., at 6 weeks, 12 weeks, and 6 months). If you take antiviral drugs for post-exposure treatment, you should be checked for drug toxicity by having a complete blood count and kidney and liver function tests just before starting treatment and 2 weeks after starting treatment. You should report any sudden or severe flu-like illness that occurs during the follow-up period, especially if it involves fever, rash, muscle aches, tiredness, malaise, or swollen glands. Any of these may suggest HIV infection, drug reaction, or other medical conditions. You should contact the healthcare provider managing your exposure if you have any questions or problems during the follow-up period.
What precautions should be taken during the follow-up period? During the follow-up period, especially the first 6-12 weeks, when most infected persons are expected to show signs of infection, you should follow recommendations for preventing transmission of HIV. These include not donating blood , semen, or organs and not having sexual intercourse. If you choose to have sexual intercourse despite the recommendation against it, using a condom consistently and correctly may reduce the risk of HIV transmission. In addition, women should consider not breastfeeding infants during the follow-up period to prevent exposing their infants to HIV in breast milk.
Modes of Disease Transmission
Contact:This type of pathogen may be transmitted by direct (skin to skin) or indirect (object to skin) contact with microorganisms. Two specific examples of these pathogens are: Staphylococcus and Herpes simplex virus.
Droplet:Coughing or sneezing may transmit this type of pathogen by releasing infectious droplets into the mucus membranes. These infectious droplets, because they are larger in size than airborne droplets, can only travel 3 feet. The general recommendation for avoiding contact with these pathogens is to wear a mask and stay at least 3 feet away from any person who is possibly infected. The influenza virus is an example of this mode of transmission.
Airborne:Coughing, sneezing, or talking releases droplet nuclei into the air, where they remain suspended until breathed in. An example of this type of pathogen is M. Tuberculosis. Tuberculosis (TB) is caused by a mycobacterium that multiplies in the alveolar sacs of the lungs in 85% of cases. The size of the particulate nuclei is less than 5 microns, which can float in the air. Incidence of this disease is on the rise. Due to the mode of transmission, TB is seen in higher numbers among the poor and institutionalized. Once exposed to active TB, an individual will test positive on the TB skin test that is a screening test only. A chest X-ray is done to determine if the disease is active, i.e., the person is infected, as well as sputum cultures for AFB (acid fast bacillus).
Many individuals are exposed to tuberculosis but do not come down with the disease for years, if ever. This is called “latent” infection. As there are no symptoms associated with latent infection, the problem of compliance with a 9-month medication regimen, as is recommended for these individuals, is complex. The person infected with latent TB should undergo prophylactic treatment with INH plus pyridoxine (vitamin B6) for 9 months to prevent the disease.
The TB organism lies dormant in the body and finds “sanctuaries” where it remains in the dormant state, but it has never really left the body, and can re-activate if the immune system becomes impaired. It is important that a person with latent TB infection take all the pills prescribed in order for the treatment to be effective. If you start taking INH, you will need to see your doctor or nurse on a regular schedule. He or she will check on how you are doing. Very few people have serious side effects to INH. However, if you have any of the following side effects, call your doctor or nurse right away:
- No appetite
- Yellowish skin or eyes
- Fever for 3 or more days
- Abdominal pain
- Tingling in the fingers and toes
What If I Have Been Vaccinated with BCG?
BCG is a vaccine for TB. This vaccine is not widely used in the United States, but it is often given to infants and small children in other countries where TB is common. BCG vaccine does not always protect people from TB.
If you were vaccinated with BCG, you may have a positive reaction to a TB skin test. This reaction may be due to the BCG vaccine itself or to latent TB infection. But your positive reaction probably means that you have latent TB infection if:
- You recently spent time with a person who has TB disease
- You are from an area of the world where TB disease is very common (most countries in Latin America and the Caribbean, Africa, Asia, Eastern Europe, and Russia)
- You spend time where TB is common (homeless shelters, drug-treatment centers, health care clinics, jails, prisons)
Active TB is contagious, and individuals must be isolated for the first two to four weeks of chemotherapy. Observing symptoms of active TB infection such as weakness, malaise, fever, night sweats, weight loss and productive cough typically helps to differentiate active infection from latent infection.
Reported cases of tuberculosis were on the decline in the U.S. until about 1986, when they began to rise. This is due in part to the susceptibility of HIV-infected individuals. Issues related to compliance with chemotherapy regimes are twofold. Untreated active TB patients can die from this disease and are a potential public health hazard, sometimes requiring “Direct Observation Therapy” to assure compliance. The medications must be taken for six months to a year, and patients tend to quit taking them when they feel better. This can lead to super infections and render the patients infectious once again.
When chest X-ray and sputum cultures confirm a diagnosis of TB, patients must begin chemotherapy at once. All patients are started on the following four antibiotics until sputum cultures determine sensitivity. Isoniazid, Rifampin, Pyrazinamide, and Streptomycin are the primary agents for treating infectious TB. Individuals caring for active TB patients must protect themselves with a particulate respirator, such as the N95 mask that must be specially fitted to each person’s face to be effective. Institutionalized patients should be placed in a negative airflow room.
Employers must immediately isolate any case of active TB to the local public health department. In work environments where the risk of TB transmission may be higher than in the general workplace (i.e., hospitals, prisons), employers should have a TB skin testing program in place for their workers.
Common Vehicle Transmission:
This occurs when food or water sources are contaminated with microorganisms. Two examples of these pathogens are cholera and salmonella.
A vector is an organism (such as an insect) that transmits a pathogen. Insects, such as mosquitoes or fleas, can transmit microorganisms through their bite. Three examples of vectorborne illnesses are malaria, typhus and West Nile virus (WNV).
West Nile virus first appeared in humans in the U.S. in 1999. By 2005, WNV had spread to all states in the continental United States. According to the Centers for Disease Control and Prevention (CDC), there were 3000 reported cases in humans, including 119 deaths, in the United States in 2007. Persons over the age of 50 have the highest risk of acquiring the severe form of the disease.
The majority of people infected will not develop any form of the disease. 20% of those infected will develop West Nile fever. Signs and symptoms include headache, fever and body aches, with an occasional skin rash on the trunk and swollen lymph glands. Severe infection may lead to West Nile encephalitis and meningitis. Symptoms include: headache, high fever, neck stiffness, stupor, disorientation, tremors, convulsions, muscle weakness, paralysis and coma. There is a lab test, IgM-antibody, which can detect antibodies produced very early, indicating infection with West Nile virus. There is no specific treatment recommended. The worst infections are aggressively managed.
Three simple actions can help prevent infection: 1) avoiding mosquito bites by using insect repellants with DEET and wearing light, long-sleeved clothing, 2) mosquito-proofing your home by emptying standing water and installing screens, and 3) reporting dead birds to local health authorities (mosquitoes become infected when they feed on infected birds).
In a very small number of cases, WNV also has been spread through blood transfusions, organ transplants, breastfeeding and even during pregnancy from mother to baby. The introduction of routine WNV screening of blood donations should greatly reduce the risk of spread of WNV through transfused blood.
Those pathogens present in human blood or OPIM that transmit disease to another through a portal of entry. Transmission can occur through sexual contact, IV drug abuse with needle sharing, accidental needlestick, and splashes into mucus membranes or contact with non-intact skin.
HBV:Hepatitis B Virus is the virus known to cause the disease Hepatitis B. This potentially life-threatening disease generally manifests after a 17 to 98 day incubation period.
There Are 3 Stages To The Illness:
- Prodromal: Malaise, anorexia, headache, low-grade fever followed by jaundice in a week or so.
- Icteric: Jaundice and liver enlargement lasting four to six weeks.
- Recovery: Return to normal color but persistent fatigue lasting two to six weeks.
HBV has been identified in approximately 4.8% of the U.S. population, with .3% having active disease. Of note is the report from OSHA citing that approximately 8,700 health care workers contract the disease through occupational exposure each year. If exposed, they are tested for HBsAG (hepatitis B surface Antigen). If positive, multiple doses of HBIG (hepatitis B immune globulin) are estimated to protect 75%, if given within 1 week after percutaneous exposure.
A safe, effective, and free HBV vaccine is offered to all employees at risk for occupational exposure. Common side effects of the vaccination include: pain at the injection site and mild to moderate fever. A series of three injections will be given on days 1, 30, 180. After the first series of 3 injections you must have titer done. If the titer is <10m1U/mi you should get another series of 3 injections. A booster of Hepatitis B is not necessary, and getting follow-up titer checks are not recommended.
Human Immunodeficiency Virus is the virus known to cause the disease AIDS (Acquired Immune Deficiency Syndrome). This is a fatal disease, in which the immune system is decimated, leading to multiple opportunistic infections. It generally takes ten years for an HIV- infected individual to develop life-threatening opportunistic infections, depending on lifestyle and general health.
There Are 3 Stages to the Illness:
- Acute retroviral seroconversion syndrome: Two to six weeks after exposure, 50% of individuals will develop an acute mononucleosis-like syndrome.
- Clinical latency: The majority of individuals in this stage remain asymptomatic.
- Symptomatic disease: This is the onset of opportunistic infections that ultimately lead to death. CD4+ lymphocyte (T cell) levels drop below 200/mm.