≥ 92% of participants will know how HBV, HCV, and HIV can be transmitted in occupational settings, how transmission can be prevented, and how occupational exposures to HBV, HCV, and HIV are managed.
CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.
≥ 92% of participants will know how HBV, HCV, and HIV can be transmitted in occupational settings, how transmission can be prevented, and how occupational exposures to HBV, HCV, and HIV are managed.
After completing this course, the learner will be able to:
The Occupational Safety and Health Organization (OSHA) defines blood as blood, human blood components, and other products made from human blood (OSHA, n.d.).
In addition to blood, OSHA considers these body fluids potentially infectious (OSHA, n.d.):
OSHA states that body fluids visibly stained with blood should be considered potentially infectious. Additionally, body fluids should be considered potentially infectious if it is difficult or impossible to determine whether they are contaminated (OSHA, n.d.).
Occupational exposures to bloodborne pathogens are common. Each year in the United States, 300,000 healthcare workers get a needlestick or sharps injury (Fauci et al., 2022). Mengistu et al. (2022) did a systematic review and meta-analysis of the published literature. The authors found that worldwide, the career and the previous year's prevalence of needlestick injuries in healthcare workers were 56.2% and 32.4%, respectively. While these statistics are sobering, they are not exact. The true number of needlesticks is likely much higher, as ≥ 50% of needlesticks and sharps injuries are not reported (Bahat et al., 2021; CDC, 2019; Keicher et al., 2024).
Transmission of and subsequent infection with HBV after occupational exposure to HBV is common. The risk of developing serologic evidence of HBV infection after an occupational, percutaneous exposure is 37% to 62%, and the risk of developing clinical hepatitis is 22%-31% (Shenoy & Weber, 2021; Weber, 2022). A splash contact can transmit hepatitis B to a mucous membrane (Schillie et al., 2018). There are no reported incidents of transmission of HBV through intact skin (Chilaka et al., 2020).
Transmission of and infection with HCV after percutaneous exposure is uncommon (Egro et al., 2017; Weber, 2022). The CDC has estimated that the incidence of HCV seroconversion (the production of antibodies to a specific pathogen) after an HCV exposure is 0% to 7%, with an average of 0.7% (Weber, 2022). Egro et al. (2017) examined data from 13 years of HCW occupational exposure to HCV-contaminated body fluids. The authors reported that the estimated risk of HCV infection from percutaneous exposure to anti-HCV-positive blood was 0.2%. There were 458 mucocutaneous exposures, and no HCW developed an infection (Egro et al., 2017).
The risk of HIV transmission after a needlestick or a sharps injury where the object was contaminated with blood from someone who has an HIV infection is approximately 0.23%. The risk of HIV transmission after a mucous membrane exposure to blood from someone who has an HIV infection is approximately 0.09% (Fauci et al., 2022). These estimates assume that the exposed HCW does not receive antiretroviral therapy within 24 hours after the exposure (Fauci et al., 2022; Shenoy & Weber, 2021). Transmission of HIV through non-intact skin has occurred, but the level of risk for this type of exposure is unknown (Fauci et al., 2022). There are currently no reported incidents of transmission of HIV through intact skin (Chilaka et al., 2020; Fauci et al., 2022).
The risk of transmission of and infection with HBV, HCV, or HIV to HCWs depends on the HBV vaccination status of the employee, how common these viruses are in the patient population, the viral load of the source, and how the exposure occurred (Weber, 2022; Zachary, 2023).
Situations that increase the risk of a needlestick injury include, but are not limited to:
Avoiding occupational blood exposure is the primary way of preventing the transmission of bloodborne pathogens in healthcare settings. The OSHA Standard 1910.1030, Bloodborne Pathogens, mandates that the employer develop a written exposure control plan designed to eliminate or minimize employee exposure in a workplace where employees could be exposed to bloodborne pathogens (OSHA, n.d.). An exposure control plan has many parts; the ones that directly concern healthcare professionals include:
The HBV vaccination recommendations in Standard 1910.1030 differ slightly from the infection control advice of the CDC and other authoritative sources. These differences are not critically important; the essential content and the basic recommendations are the same.
Standard 1910.1030 states that employers must offer hepatitis B vaccination to at-risk employees at no cost (OSHA, n.d.). Employees are exempt if they have been vaccinated, if antibody testing shows that they are immune, or if the vaccine is contraindicated (OSHA, n.d.).
Hepatitis B vaccination is effective. Approximately 95% of vaccinated, immunocompetent adults are seroprotected (Mironova & Ghany, 2024; Nikolopoulou et al., 2023).
There are no hepatitis C and HIV vaccines.
Engineering controls are devices, equipment, and procedures that help reduce the risk of exposure to bloodborne pathogens (OSHA, n.d.). Examples of engineering controls mentioned in Standard 1910.1030 are disposal containers for needles and sharps, needleless systems for self-sheathing needles, and sharps with built-in injury protection (OSHA, n.d.). Example: Sharps with engineered sharps injury protections means that a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids has a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident (OSHA, n.d.).
Hand hygiene has been identified as the most important method of preventing and reducing the transmission of pathogens from one patient to another and from an infected site on a patient to a clean site on the same patient (Anderson, 2025; Gammon & Hunt, 2020). Unfortunately, HCW compliance with hand hygiene protocols is often sub-optimal (Hoffmann et al., 2020). Poor compliance is a source of iatrogenic infections (Kovacs-Litman et al., 2021). The OSHA Bloodborne Pathogens standard states that employers must provide handwashing equipment and facilities (OSHA, n.d.), and employees must know when and how to wash their hands (OSHA, n.d.).
Hand hygiene can be done with an alcohol-based hand sanitizer or soap and water (CDC, 2024a).
An alcohol-based hand sanitizer should be used in these situations (CDC, 2024a):
To properly use an alcohol-based hand sanitizer (CDC, 2024a):
Soap and water should be used in these situations (CDC, 2024a):
To properly wash your hands with soap and water:
The recommended 15 to 20 seconds is a guideline only, and the CDC notes that the length of time is less important than ensuring you clean all areas of your hands (CDC, 2024a).
The World Health Organization (WHO) Save Lives: Clean Your Hands program has a simple way to remember when to use hand hygiene.
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Respiratory hygiene and cough etiquette were added to Standard Precautions in 2003 in response to the severe acute respiratory syndrome (SARS) outbreak (Siegel et al., 2007).
Viruses like the coronaviruses SARS-CoV-2003 and SARS-CoV-2 and the influenza virus are transmitted by infected droplets that are spread when someone coughs, sneezes, talks, and to a lesser degree, by airborne transmission (CDC, 2024b; Gandi, 2025). Respiratory hygiene and cough etiquette can help prevent the transmission of viruses that cause respiratory infections, and this infection control technique includes the following measures (CDC, 2024c):
Personal protective equipment is designed to prevent direct contact and/or inhalation transmission of pathogens. Personal protective equipment includes eye shields, face shields, foot/shoe covers, gloves, goggles, gowns, head covers, and respirators. Employers must provide employees with the PPE they need to protect themselves and provide training on how to use PPE (OSHA, n.d.).
Choose the PPE to use by assessing a situation and determining what you may be exposed to and how you may be exposed. Healthcare facilities must train employees in the proper use of PPE, but healthcare professionals must use their judgment to decide what PPE they need. For example, the OSHA Bloodborne Pathogens Standard states, “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 (OSHA, n.d.)."
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It is important to note that handwashing and the proper use of gloves are effective infection control techniques. However, healthcare workers often do not follow handwashing recommendations (Hoffmann et al., 2020; Moore et al., 2021. Gloves are a necessary part of infection control (Anderson, 2025). However, gloves can tear and be penetrated (Zhang et al., 2021). Using gloves does not eliminate the need for hand hygiene (Anderson, 2025). Likewise, hand hygiene does not eliminate the need for gloves (Anderson, 2025). Gloves should be changed when they are damaged, when you move from a contaminated body site to a clean body site, and when the gloves are bloody, dirty, or contaminated by body fluids (Anderson, 2025).
Safe injection practices, also called injection safety, are practices and techniques that:
Safe injection practices were added to Standard Precautions after four large outbreaks of HBV and HCV infection occurred in patients who had been treated in ambulatory care centers (an endoscopy clinic, a hematology/oncology clinic, a pain clinic, and a private physician's office) (CDC, 2024e). The outbreaks were caused by these specific failures to use safe injection practices (CDC, 2024e). These unsafe practices included the reinsertion of used needles into a multiple-dose vial or a container of a solution, using a single needle/syringe to give IV medication to multiple patients, and preparing medications in the same place where used needles/syringes were dismantled.
The OSHA Bloodborne Pathogens Standard recommendations for the safe use of needles and sharps are listed below:
Infection from occupational exposure to a bloodborne pathogen can cause substantial monetary, emotional, and psychological consequences (Cooke & Stevens, 2017; Hambridge, 2022; Hambridge et al., 2021). The human costs after exposure can be significant and are immeasurable. Employees who have suffered a needlestick or a sharps injury may experience anxiety, depression, diminished professional confidence, fear, flashbacks, post-traumatic stress disorder, and stress (Hambridge, 2022; Hambridge et al., 2021).
The OSHA Bloodborne Pathogens Standard defines exposure as specific eye, mouth, other mucous membranes, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from performing an employee's duties.
An employee exposed to an HBsAg-positive source or a source whose HBsAg status is unknown should not donate blood, organs, plasma, semen, or tissues during the six-month follow-up period (Schille et al., 2018; Weber,2022). Sexual practices do not need to be changed, becoming pregnant is not contraindicated, and breastfeeding can be continued (Schillie et al., 2018). Also, the employee can continue their normal work responsibilities (Schillie et al., 2018).
If the antibody test is positive, the exposed employee should have an HCV antibody test and an HCV RNA test (Weber, 2022). Testing should be done as soon as possible, preferably within 48 hours of the exposure (Weber, 2022).
If the source does not have HCV RNA, no further testing of the source or the employee needs to be done (National Clinician Consultation Center, 2021). If the source has a positive HCV RNA test and/or a positive HCV antibody test, they should be referred for evaluation and (possible) treatment (National Clinician Consultation Center, 2021).
An employee who has been exposed to a source whose HCV tests, either one, were positive or whose HCV status cannot be determined should be evaluated three to six weeks after the exposure (National Clinician Consultation Center, 2021). If the HCV RNA is positive at that time, the employee should be referred to a specialist for care (National Clinician Consultation Center, 2021).
If the HCV RNA at that time is negative, the employee should return in four to six months for HCV antibody testing. If the test is negative, further testing is unnecessary; if it is positive, refer the employee to a specialist for care (National Clinician Consultation Center, 2021). If an exposed employee has signs/symptoms of a viral illness within the six-month follow-up period, they should contact a healthcare provider (National Clinician Consultation Center, 2021).
The result of a rapid combined HIV antigen-antibody test will typically be available within 30 minutes (Cachay, 2025). These tests are very sensitive and specific. A negative test should be considered definitive unless the source may have an acute HIV infection (National Clinician Consultation Center, 2021; Zachary, 2023).
There is a lag between an initial, acute HIV infection and the production of detectable HIV antibodies (National Clinician Consultation Center, 2021; Kuhar et al., 2013; Zachary, 2023). This lag, referred to as a window period, is concerning, but in the United States, no cases of occupational HIV transmission during the window period have been detected (Kuhar et al., 2013; National Clinician Consultation Center, 2021). If the source could have an acute HIV infection or if in the previous 1 to 2 months the source engaged in high-risk behaviors, an HIV RNA PCR test (aka a viral load test), should be done to see if the source is in the window period and to determine if PEP is needed (National Clinician Consultation Center, 2021).
Post-exposure prophylaxis should be given:
It is recommended that clinicians get a consultation if they intend to prescribe PEP > 72 hours post-exposure (National Clinician Consultation Center, 2021). Call the National Clinician Consultation Center at 1-888-448-4911 for advice about this situation.
Worldwide, recommendations for PEP protocols vary considerably (Maisano et al., 2025). The recommended PEP drug regimens are described below (CDC, 2025; National Clinician Consultation Center, 2021).
CDC PEP Regimen 1: This is the preferred regimen for healthy adults and adolescents
CDC PEP Regimen 2: An alternative regimen for healthy adults and adolescents
National Clinician Consultation Center PEP Regimen
Serum BUN and creatinine, a CBC (complete blood count), and hepatic function tests (LFTs) should be done before starting PEP (CDC, 2025; National Clinician Consultation Center, 2021).
Tenofovir disoproxil fumarate can be nephrotoxic. Its use should be avoided in patients with an eGFR < 60 mL/min/1.73 m2(Zachary, 2023), and an alternative should be used.
Abacavir sulfate should not be used in any PEP regimen (CDC, 2025). It has been linked to potentially fatal hypersensitivity reactions. These are more likely to occur in people with the HLA-B*57:01 allele (Mounzer et al., 2019), and because PEP must be started as soon as possible, there is no time for genetic testing (CDC, 2025).
The risk of vertical HIV transmission is high (National Clinician Consultation Center, 2021; Whiteley, 2019), and perinatal transmission can occur, as well (National Clinician Consultation Center, 2021; Whiteley, 2019). For a pregnant patient, the benefits of anti-retroviral therapy are much higher than the known risks (Abrams, 2024), and the PEP drugs are effective (Hughes & Cu-Uvin, 2021; Rogers & Roberts, 2020). Using PEP during the first trimester does not appear to cause congenital disabilities (Abrams, 2024; National Clinician Consultation Center, 2021), and the prevalence of congenital abnormalities in pregnant women who are taking antiretroviral therapy is equivalent to the prevalence of congenital abnormalities in the United States (Abrams, 2024). The toxic effects of PEP drugs do not appear to be amplified or changed by pregnancy.
All pregnant patients who are beginning PEP with antiretrovirals should be entered into the Antiretroviral Pregnancy Registry. This is a database that collects information on the outcomes of pregnancies in which anti-retroviral drugs were used, regardless of the HIV status. Clinicians can reach the Antiretroviral Pregnancy Registry at 1-800-258-4263 or on their website.
The PEP regimens that are recommended for treating pregnant patients are like the ones used for non-pregnant patients (Zachary, 2023).
The National Clinician Consultation Center recommends either of these two PEP regimens (National Clinician Consultation Center, 2021). The duration of the treatment is 28 days Zachary, 2023).
If PEP is continued, the patient should be reminded of the need to adhere to the treatment regimen, they should see their provider if they have signs and symptoms of an infection, and they should be asked about and examined for the presence of drug side effects (Zachary, 2023).
Patients taking zidovudine should have their CBC and LFTs monitored (National Clinician Consultation Center, 2021; Zachary, 2023).
If the source is HIV positive, the patient should have HIV testing in 6 weeks and 3 months (National Clinician Consultation Center, 2021). If the HCW develops an HCV infection and the source is HIV and HCV positive, the HCW should have HIV testing done in 12 months (National Clinician Consultation Center, 2021; Zachary, 2023). This recommendation is made because one case was reported in which an HCW had delayed HIV seroconversion after developing HIV infection and HCV infection from a single needlestick injury (Zachary, 2023). (Note: The recommendations for post-exposure HIV testing can differ, depending on the PEP drugs that are used and the source (Zachary, 2023). The recommendations of the National Clinician Consultation Center are in basic agreement with other available recommendations.
The National Clinician Consultation Center provides telephone consultations by physicians and other healthcare professionals for occupational and non-occupational exposures to bloodborne pathogens.
The Center is open for consultation on occupational exposures from 11:00 a.m. to 8:00 p.m., ET, seven days a week.
The Center is open for consultation on non-occupational exposures from 9:00 a.m. to 8:00 p.m. ET Monday through Friday and 11:00 a.m. to 8:00 p.m. ET on weekends and holidays.
The Center's website has detailed instructions for treating an exposure to a bloodborne pathogen if the exposure happens outside of its operating hours. 1-888-448-4911. The Center’s website address is Visit Source.
Scenario/Situation/Patient Description:
A 29-year-old emergency room (ER) nurse was caring for a patient brought in by EMS after being found unresponsive on the street from a suspected fentanyl overdose. The patient had a history of repeated opioid overdoses and presented with classic signs of opioid poisoning, including drowsiness, miosis, and a severely depressed respiratory rate. Upon arrival at the ER, the patient’s condition had worsened—he was minimally responsive, had a respiratory rate of six breaths per minute, and oxygen saturation of 81%.
While inserting an IV catheter to administer naloxone, the patient suddenly pulled his arm away. This caused the needle to dislodge and puncture the nurse’s finger. The needle had visible blood contamination, and the nurse had parenteral contact with potentially infectious material, meeting OSHA’s criteria for a significant exposure incident. The nurse immediately washed the wound with soap and water and completed the necessary initial clinical care for the patient, including registering them into the ER system.
Intervention/Strategies:
Post-exposure, the nurse underwent the following interventions:
Discussion of Outcomes:
The nurse remained asymptomatic throughout the follow-up period. Serial HCV RNA testing at the recommended intervals showed no evidence of seroconversion. The nurse’s test remained negative at the six-month follow-up, and no treatment was necessary. The hospital’s occupational health service documented the incident and reinforced needlestick prevention protocols in the ER, particularly with unpredictable or agitated patients.
Strengths and Weaknesses of the Approach Used in the Case:
Strengths:
Weaknesses:
Scenario/Situation/Patient Description:
During a high school wrestling match, an athlete sustained a facial laceration. The athletic trainer (AT) applied direct pressure and cleaned and dressed the wound without gloves due to the situation's urgency. Blood splashed onto the AT’s hand, which had a small, healing cut from earlier in the day.
Intervention/Strategies:
After completing care, the AT washed hands thoroughly and reported the incident. The athlete involved later disclosed being HCV-positive, prompting risk assessment and baseline HCV testing for the AT. The institution provided access to occupational health services and mental health support.
Discussion of Outcomes:
The AT tested negative for HCV at the initial and 6-month follow-up screenings. No infection occurred. The incident triggered the school’s athletic department to conduct mandatory bloodborne pathogen training and provide better access to PPE at all sporting events.
Strengths and Weaknesses of the Approach:
Strengths:
Weaknesses:
Scenario/Situation/Patient Description:
Sarah, a 34-year-old licensed physical therapist with 10 years of clinical experience, was performing dry needling therapy on a 56-year-old male patient with chronic lower back pain and myofascial trigger points. During the session, she accidentally pricked her right index finger. The needle had just been withdrawn from the patient's paraspinal region, and visible blood was present.
The patient had a known history of intravenous drug use and hepatitis C in the past, but his current HCV status was unknown. Sarah had completed her hepatitis B vaccine series over a decade ago, but her immunity status (HBsAb titer) was not recently confirmed. The incident occurred around 2:00 PM in an outpatient orthopedic clinic on a weekday.
Intervention/Strategies:
Sarah was educated about medication adherence, potential side effects (e.g., nausea, fatigue), and the importance of completing the 28-day regimen. She was referred for psychological counseling due to acute anxiety, and weekly check-ins were scheduled with her occupational health provider.
Discussion of Outcomes:
Over the next six weeks, Sarah experienced mild side effects from PEP (primarily gastrointestinal discomfort and insomnia) but completed the regimen. Her HIV RNA and antigen-antibody tests remained negative at 6 weeks and 3 months. Her HCV RNA also remained negative at the 6-week follow-up, and she tested negative for HCV antibodies at 6 months, indicating no seroconversion. Her HBV follow-up showed rising antibody titers post-revaccination, suggesting improved immune response.
Psychologically, Sarah initially struggled with anxiety and reported intrusive thoughts and sleep disturbances. She utilized employee support services and counseling, which helped her manage the psychological toll. Professionally, she resumed dry needling after a 2-week self-imposed break, following a refresher in sharps safety protocols.
Strengths and Weaknesses of the Approach:
Strengths:
Weaknesses:
Healthcare workers are continually at risk for exposure to HBV, HCV, and HIV. Needlestick injuries and other exposures are common. Although the transmission of a bloodborne pathogen and infection is uncommon to rare, the consequences can be costly and emotionally and psychologically devastating.
Fortunately, HBV vaccination, engineering and workplace controls, Standard Precautions with hand hygiene, respiratory hygiene and cough etiquette, PPE, and safe injection practices can significantly reduce the risk of exposure to and transmission of bloodborne pathogens. Also, post-exposure treatment can effectively reduce the risk of developing HBV or HIV infection from occupational exposure to these pathogens.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.