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OSHA: Occupational Exposure to Bloodborne Pathogens

2 Contact Hours
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Athletic Trainer (AT/AL), Certified Medication Assistant (CMA), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Certified Registered Nurse Practitioner, Clinical Nurse Specialist (CNS), Home Health Aid (HHA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Medical Assistant (MA), Medication Aide, Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Registered Nurse Practitioner, Respiratory Care Practitioner, Respiratory Therapist (RT)
This course will be updated or discontinued on or before Saturday, May 8, 2027

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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.



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CEUFast, Inc. (BOC AP#: P10067) is approved by the Board of Certification, Inc. to provide education to Athletic Trainers (ATs).

FPTA Approval: CE25-536907. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.
Outcomes

≥ 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.

Objectives

After completing this course, the learner will be able to:

  1. Identify bloodborne viral pathogens that healthcare workers are likely to be exposed to.
  2. Identify two factors that increase the risk of transmission of and infection with a bloodborne pathogen.
  3. Recognize components of Standard Precautions.
  4. Outline safe injection practices.
  5. Compare the correct immediate post-exposure treatments for occupational exposure to HBV, HCV, and HIV.
  6. Distinguish at least one specific post-exposure treatment recommendation for HBV, HCV, and HIV exposure.
  7. Describe strategies that prevent exposure to bloodborne pathogens.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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OSHA: Occupational Exposure to Bloodborne Pathogens
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To earn a certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Attest that you have read and learned all the course materials.
    (NOTE: Some approval agencies and organizations require you to take a test and "No Test" is NOT an option.)
Author:    Dana Bartlett (RN, BSN, MA, MA, CSPI)

Introduction

Exposure to bloodborne pathogens, particularly hepatitis B virus ( HBV) (Senoo-Dogbey et al., 2024), hepatitis C virus (HCV) (Liu et al., 2023), and human immunodeficiency virus (HIV) (Abadie et al., 2024), is a constant risk for healthcare workers (HCWs) (Centers for Disease Control and Prevention [CDC], 2019; Liu et al., 2023). Transmission of and infection with HBV after an occupational exposure are common, while transmission of and infection with HCV or HIV after an occupational exposure are not. But in either case, needlestick and sharps injuries and splashes with blood and body fluids, situations that put HCWs at risk for infection with these bloodborne pathogens, are a constant, everyday threat. (Abdelmalik et al., 2023; Mengistu et al., 2022). When referring to sharps, this can relate to objects like intravenous (IV) stylets, scalpels, suture needles, and saw blades (CDC, 2019). This course will discuss the epidemiology and transmission of HBV, HCV, and HIV in healthcare settings and the prevention and treatment of exposure to these pathogens. Throughout this course, occupational exposure refers to exposure in a healthcare setting.

Epidemiology and Risk Factors for HBV, HCV, and HIV Transmission

In healthcare settings, HBV, HCV, and HIV are primarily transmitted by contact with blood or infected body fluids. The contact can occur by a percutaneous injury (e.g., a needlestick or a sharps injury), a splash to a mucous membrane, or by exposure to non-intact skin (Fauci et al., 2022; Sallam & Khalil, 2024; Utku & Ak, 2024).

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.):

  • Amniotic fluid
  • Blood, organs, or tissues from experimental animals that are infected with HBV or HIV
  • Cerebrospinal fluid
  • HBV- or HIV-containing culture medium and other solutions
  • HIV-containing cell cultures, organ cultures, or tissue cultures
  • Pericardial fluid
  • Peritoneal fluid
  • Pleural fluid
  • Saliva during a dental procedure
  • Semen
  • Synovial fluid
  • Unfixed tissue or organs, except for intact skin, from a dead or living human
  • Vaginal secretions

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).

HBV Exposure and Transmission

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).

HCV Exposure and Transmission

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).

HIV Exposure and Transmission

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).

Transmission Risk Factors

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). Transmission and infection are more likely to occur and the risk is increased if the patient has a high viral load; if the needlestick was from a hollow bore needle; if the needle had been in an artery or a vein; if the injury is deep; if there was visible blood on the needle/instrument, or if a large volume of blood was involved (Fauci et al., 2022; Weber, 2022; Zachary, 2023).

Situations that increase the risk of a needlestick injury include, but are not limited to:

  • Recapping (Canadian Centre for Occupational Safety and Health [CCOSH], 2024; CDC, 2021; CDC, 2019; Ibrahim et al., 2024).
  • Improper disposal (Canadian Centre for Occupational Safety and Health [CCOSH], 2024; Ibrahim et al., 2024).
  • Accessing an IV line (Canadian Centre for Occupational Safety and Health [CCOSH], 2024).
  • Needle insertion or removal (Canadian Centre for Occupational Safety and Health [CCOSH], 2024).
  • Using disposable syringes (Weber, 2022).
  • Restraining a patient (CDC, 2019).
  • Passing a sharp to another HCW (Canadian Centre for Occupational Safety and Health [CCOSH], 2024).
  • Transferring a body fluid between containers (CDC, 2021).
  • Suturing (Weber, 2022).
  • Work environment, e.g., distraction/lack of concentration, frequency of exposure to needles and/or sharps, long hours, poor staffing, time pressure, and job-related stress (Ibrahim et al., 2024; Weber, 2022).

graphic showing needle stick injury

Prevention

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:

  • Hepatitis B vaccination
  • Engineering controls
  • Standard Precautions
  • Safe injection practices
  • Post-exposure evaluation, treatment, and follow-up

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.

Hepatitis B Vaccination

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 and Work Practice Controls

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.).

Standard Precautions

The OSHA Bloodborne Pathogens standard recommends using Universal Precautions. Universal Precautions were the original CDC infection guidelines for preventing exposure to and transmission of bloodborne pathogens. Standard precautions, which were developed later, were added to and expanded to universal precautions. Standard Precautions are used by all healthcare facilities today.

Standard Precautions include:

  • Hand hygiene
  • Respiratory hygiene and cough etiquette
  • Use of personal protective equipment (PPE)
  • Safe injection practices

graphic showing standard precautions

Hand Hygiene

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). Alcohol-based hand sanitizers are preferred because they are (CDC, 2024a):

  1. More effective at killing microorganisms on the hands than soap
  2. Simpler to use
  3. Are less likely than soap and water to dry or irritate the skin

An alcohol-based hand sanitizer should be used in these situations (CDC, 2024a):

  • Immediately before and immediately after touching a patient
  • Immediately before performing an aseptic procedure or before handling an invasive device or a piece of invasive equipment
  • Immediately after taking off the gloves
  • After touching anything in the patient's immediate environment
  • After you have contacted blood, body fluids, or a contaminated surface
  • Before touching a clean part of the patient, after you have been working or touching a contaminated or soiled part

To properly use an alcohol-based hand sanitizer (CDC, 2024a):

  • Put the recommended amount on your hands
  • Rub your hands together, covering every part of your hands and fingers until they are dry; this usually requires about 20 seconds
  • Pay particular attention to the thumbs, between the fingers, and the fingertips; these areas are often missed

Soap and water should be used in these situations (CDC, 2024a):

  • When your hands are visibly soiled
  • When you are providing direct care for someone who has or could have infectious diarrhea
  • Before eating and after using the restroom
  • During the care of patients with suspected or confirmed infection during outbreaks of C. difficile or norovirus

To properly wash your hands with soap and water:

  • Wet your hands
  • Apply the recommended amount of soap and then rub your hands together, covering every part of your hands and fingers
  • Do this for 15 to 20 seconds
  • Rinse your hands and fingers
  • Use a paper towel to dry them
  • Use the towel to turn the faucet handle to the off position
  • Discard the towel

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.

My Five Moments for Hand Hygiene (WHO, 2021)
  • Before an aseptic/clean procedure
  • Before touching a patient
  • After touching a patient
  • After touching the patient's surroundings

Respiratory Hygiene and Cough Etiquette

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):

  • Post signs that inform people to cover their mouths and noses with tissues when they cough or sneeze.
  • The facility should provide tissues.
  • The tissue should be discarded after it has been used. The facility should provide a no-touch receptacle for discarding used tissues.
  • Wash your hands with an alcohol-based hand sanitizer or soap and water after touching your mouth or nose.
  • Alcohol-based hand sanitizer or soap and water should be provided.
  • After contact with respiratory secretions or contaminated materials and objects, clean your hands with an alcohol-based sanitizer or soap and water.
  • Offer a mask to anyone who is coughing or sneezing.
  • Practice social distancing.
  • The facility should clean frequently touched surfaces, including countertops, handrails, doorknobs, and chairs/ chair arms.

Personal Protective Equipment

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.)." PPE must be donned and removed correctly to protect patients and HCWs.

Proper Donning of PPE (CDC, n.d)
  1. Identify the PPE that you will need.
  2. Wash your hands with an alcohol-based hand sanitizer.
  3. Put on the isolation gown.
  4. Put on the respirator or face mask.
  5. Put on goggles or a face shield.
  6. Put on the gloves.
Proper Removal of PPE
  1. Take off the gloves. The outside of the gloves is contaminated; do not touch the outside of the gloves with your bare hands. Put the gloves in the proper receptacle.
  2. Remove the gown. The outside is contaminated, and when you take it off, do not touch the outside with your bare hands. Put the gown in the proper receptacle.
  3. Wash your hands.
  4. Take off the goggles or the face shield; do not touch the outside surfaces of the face shield or the goggles.
  5. Remove the face mask or respirator without touching the outside surfaces.
  6. Wash your hands if you are wearing a face mask or a respirator.

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 and Safe Use of Needles and Sharps

Safe injection practices, also called injection safety, are practices and techniques that:

  • Prevent the transmission of bloodborne pathogens to patients and healthcare workers when IV catheters, IV equipment, needles, and sharps are used
  •  Prevent unsafe disposal of potentially harmful medical waste

A good rule to remember is One Needle, One Syringe, Only One Time!(CDC, 2024d)

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 specific techniques of safe injection practices are listed below (CDC, 2024e). They can be usefully separated into six basic categories:

  1. Aseptic technique
  2. Correct and safe use of syringes and needles
  3. Correct and safe use of IV cannulas, IV solution bags and bottles, and IV tubing
  4. Correct and safe use of medication vials
  5. Infection control practices for lumbar puncture procedures
  6. Proper disposal of hazardous waste
  • Always use aseptic technique when using IV catheters, IV delivery systems, or needles.
  • Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed.
  • IV catheters, infusion sets, bags, medications, solutions, needles, syringes, and cannulas are sterile, single-use items that should never be reused for another patient.
  • A cannula, a needle, or a syringe that has been used to enter or connect to an IV tubing, an IV administration set, or an IV bag should be considered contaminated and should not be reused.
  • Single-dose medication vials should be used whenever possible.
  • Do not use a single-dose ampule or vial to give medications to multiple patients; do not combine the leftover contents of single-dose ampules or vials.
  • Use a sterile cannula, needle, or syringe to enter a multiple-dose vial.
  • Do not leave a multi-dose vial in the immediate area where patient care is delivered, and store multi-dose vials as per the manufacturer's instructions.
  • Do not use bags or bottles of intravenous solution as a common supply source for multiple patients.
  • Infection control practices for special lumbar puncture procedures include wearing a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space, e.g., during myelograms, lumbar puncture, and spinal or epidural anesthesia.
  • Needles and sharps should be discarded into a sharps container.
  • Wash hands before and after giving an injection. 

The OSHA Bloodborne Pathogens Standard recommendations for the safe use of needles and sharps are listed below:

  • 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 a specific medical or dental procedure requires such action.
  • Bending, recapping, or needle removal must be done using a mechanical or one-handed technique.
  • Shearing or breaking contaminated needles is prohibited.
  • Contaminated reusable sharps shall be placed in appropriate containers immediately or as soon as possible after use until properly reprocessed.
  • These containers shall be color-coded or labeled, leakproof on the bottom and the sides, and puncture-resistant (OSHA, n.d.).

Post-Exposure Evaluation and Management

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).

photo of laboratory testing paperwork

First Aid

After a needlestick or a sharps injury, immediately wash the wound with soap and water (Weber, 2022; Zachary, 2023). If there has been an ocular, mucous membrane, or non-intact skin exposure, flush the area with water (Weber, 2022; Zachary, 2023). Small wounds that involve HIV exposure can be cleaned with an alcohol-based hand wash (Zachary, 2023). Alcohol has been shown to kill HBV and HCV (Zachary, 2023). Topical antiseptics can be applied to a wound that involves HBV or HCV exposure, but there is no evidence that they are effective at preventing transmission (Weber, 2022). Do not inject anything into the area, do not apply bleach, and do not waste time squeezing the wound to try and express blood or fluid from the wound (Weber, 2022; Zachary, 2023).

graphic showing steps to manage needle stick injury

Reporting an Exposure

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.

Employees should report exposure to blood and body fluids, a needlestick injury, or a sharps injury immediately, or as soon as possible(National Institute for Occupational Safety and Health [NIOSH], 2024; National Clinician Consultation Center, 2021). The importance of immediately reporting an exposure cannot be overstated! If an HCW is exposed to HIV, post-exposure prophylaxis (PEP) MUST be started as soon as possible and preferably within 1 to 2 hours after the exposure (Zachary, 2023).

HBV Exposure: Evaluation and Treatment

The treatment for an HBV exposure or a possible HBV exposure will depend on the HBV status of the source and the employee's HBV immune status (Schillie et al., 2018; Weber, 2022). There are multiple scenarios.

  1. The employee has evidence of a prior HBV infection. No treatment is needed, even if the source has a positive HBsAg (hepatitis B surface antigen) test (Schillie et al., 2018; Weber, 2022).
  2. The employee has completed the HBV vaccination series, and they have an adequate response. An adequate response is an HBsAb (hepatitis B surface antibody) level ≥ 10 mIU/mL; in this case, no treatment is needed even if the source has a positive HBsAg test (Schillie et al., 2018; Weber, 2022).
  3. The source patient has a positive HBsAg test or the HBsAg status can’t be determined, and the employee has completed HBV vaccination, but they are a non-responder, i.e., the HBsAb level is < 10 mIU/mL. In this situation, the employee should be given two doses of hepatitis B immune globulin (HBIG) (National Clinician Consultation Center, 2021; Weber, 2022). The first HBIG dose should be given as soon as possible (National Clinician Consultation Center, 2021). The second dose should be given 28-30 days later (UpToDate Online, n.d.). Depending on the HBV vaccine series the employee received, they may need to be revaccinated (National Clinician Consultation Center, 2021). Six months after the exposure, the employee should have HBsAg and HBsAb testing done (Weber, 2022).
  4. The source patient’s HBsAg is negative. The employee should be vaccinated, and no other treatment is needed (Weber, 2022). One month after the vaccination, the employee should have HBsAb testing done (Hibberd, 2025).
  5. For employees who have not completed the HBV vaccination series, the HBsAg status of the source should be determined, but the employee's HBsAb should not be measured. An HBsAb level > 10 mIU/mL does not indicate immunity (Weber, 2022). If the HBsAg of the source is positive or if it cannot be determined, the employee should be given one dose of HBIG and complete the vaccination series, and if unvaccinated, be given the complete vaccination series (Weber, 2022).

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).

HCV Exposure: Evaluation and Treatment

There is no HCV vaccine. Direct-acting antivirals (DAA) are highly effective for treating acute and chronic HCV infections. However, there is no evidence that DAA treatment is an effective prophylactic (Weber, 2022), and DAA treatment is not recommended or approved for acute occupational exposure to HCV (CDC, 2024f; Moorman et al., 2020; National Clinician Consultation Center, 2021; Weber, 2022). The source should have an HCV RNA test and an HCV antibody test done (National Clinician Consultation Center, 2021; Weber, 2022). Testing should be done as soon as possible, preferably within 48 hours of exposure (Weber, 2022).

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).

HIV Exposure: Evaluation and Treatment

Occupational exposure to HIV should be treated as a medical emergency (Fauci et al., 2022). There is no HIV vaccine. The source should have a rapid HIV antibody-antigen test done. If an acute HIV infection is suspected to be present or the source has an increased risk of HIV infection in the previous four weeks, HIV RNA should be measured (Zachary, 2023). The exposed employee should have a rapid HIV antibody-antigen test or an HIV antibody test (National Clinician Consultation Center, 2021; Zachary, 2023), HCV testing, and, depending on the employee’s immunization status, HBV testing (National Clinician Consultation Center, 2021). The antigen-antibody test is preferred because it detects an infection sooner than the antibody test (Zachary, 2023).

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). A positive rapid antibody-antigen test should be considered a true positive, and the use of PEP should be considered(National Clinician Consultation Center, 2021). A confirmatory test to determine the accuracy of the rapid test should be done, and if that test is negative, PEP, if it was started, can be discontinued (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).

HIV: Post-Exposure Prophylaxis

Post-exposure prophylaxis should be given:

  • If the source is known to be HIV positive
  • While waiting for the results of the source's HIV tests, especially if the source has a high risk of having an HIV infection, and
  • If the source's HIV status cannot be determined and if a high-risk needlestick or sharps injury occurred (Zachary, 2023)

Post-exposure prophylaxis with anti-retroviral drugs should be started as soon as possible, preferably within one to two hours post-exposure (National Clinical Consultation Center, 2021; Kuhar et al., 2013; Zachary, 2023). Do not wait for test results unless the results will be available within 1 to 2 hours (National Clinician Consultation Center, 2021). Delaying the use of PEP is likely to diminish its effectiveness (Kuhar et al, 2013). Authoritative sources recommend that PEP should not be given ˃ 72 hours post-exposure (National Clinician Consultation Center, 2021; Zachary, 2023). However, this recommendation is based on drug testing in animals (National Clinician Consultation Center, 2021; Zachary, 2023), and treatment at > 72 hours post-exposure can be considered (National Clinician Consultation Center, 2021; Zachary, 2023). Zachary (2023) wrote, “For most healthcare professionals, we do not initiate PEP if more than 72 hours have elapsed after the initial exposure. However, we do offer PEP after a longer interval to patients with a very high-risk exposure (e.g., sharps injuries from a needle that was in an artery or vein of an HIV-infected source patient)”. For such healthcare professionals, The United States Public Health Service suggests that PEP can be offered up to one week after the exposure.” 

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.

If the source's rapid HIV test is negative, the employee can discontinue using the PEP (National Clinician Consultation Center, 2021).

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

  • Emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg (Combination tablet), one tablet once a day, plus
  • Raltegravir, 400 mg, one tablet twice a day or
  • Dolutegravir, 50 mg, one tablet once a day

CDC PEP Regimen 2: An alternative regimen for healthy adults and adolescents

  • Emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg (Combination tablet), one tablet once a day, plus
  • Darunavir, 800 mg, one tablet once a day and
  • Ritonavir, 100 mg, one tablet once a day

National Clinician Consultation Center PEP Regimen 

  • Emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg (Combination tablet), one tablet once a day, plus
  • Raltegravir 400 mg, one tablet twice a day, or
  • Dolutegravir, 50 mg, one tablet once a day

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).

The duration of treatment is 28 days, and these drug regimens are safe and well tolerated(CDC, 2025; National Clinician Consultation Center, 2021). Common adverse effects include diarrhea, fatigue, insomnia, nausea, stomach upset, and vomiting. They are usually self-limiting, and the CDC notes that “... the benefits of HIV prevention outweigh any other risks posed by the medications” (CDC, 2025).

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).

HIV: Post-Exposure, Pregnancy, Breastfeeding, and PEP

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).

  • Emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg (combination product) 1 tablet once a day, plus
  • Raltegravir 400 mg, 1 tablet twice a day, or
  • Dolutegravir 50 mg, 1 tablet once a day
  • Zidovudine 300 mg and lamivudine 150 mg (Combination product) 1 tablet twice a day, plus
  • Darunavir 800 mg, 1 tablet once a day, boosted with ritonavir 100 mg, 1 tablet once a day, or
  • Atazanavir 300 mg, 1 tablet once a day, boosted with ritonavir 100 mg, 1 tablet once daily

Breastfeeding is not contraindicated for women taking PEP (National Clinical Consultation Center, 2021). However, a lactating mother and a breastfed infant may have a risk for HIV transmission, and the information on the PEP drugs and breastfeeding is limited (National Clinician Consultation Center, 2021). Two helpful information sources on breastfeeding and antiretrovirals are:

  1. LactMed®, a website maintained by the National Institutes of Health. Visit Source, and
  2. Clinical Info. HIVgov. This website is maintained by the U.S. Department of Health and Human Services and has updated information on HIV, breastfeeding, and antiretrovirals. Visit Source.

HIV: Post-Exposure Testing and Monitoring

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). Non-adherence to PEP is common. Liu et al. reported a 58.4% non-adherence rate (This included healthcare workers and patients who needed PEP for other reasons), and non-adherence reduces HIV suppression (Altice et al., 2019). Most drug side effects of HIV PEP are mild and well tolerated. Patients taking tenofovir disoproxil fumarate should have BUN, creatinine, and LFTs monitored for kidney function(National Clinician Consultation Center, 2021).

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.

National Clinician Consultation Center

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.

Case Study 1: Needle Stick Injury in an Emergency Room

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:

  • Immediate wound cleaning and reporting of the incident.
  • Rapid-result HIV antigen-antibody testing was performed on both the nurse and the patient.
  • Blood samples were drawn from both individuals for HCV antibody and HCV RNA testing.
  • The nurse’s HBV immunity status was reviewed and confirmed to be protective (surface antibody level ≥ 10 IU/mL), so no action was needed for HBV.
  • Since both the nurse and patient were HIV-negative, PEP for HIV was not required.
  • The patient was found to be HCV RNA positive, while the nurse tested negative for HCV.
  • The nurse was referred for follow-up HCV testing at three to six weeks and again at four to six months post-exposure.

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:

  • Immediate wound care and adherence to post-exposure protocols minimized infection risk.
  • Rapid HIV testing facilitated prompt decision-making regarding the need for PEP.
  • The nurse’s up-to-date vaccination status for HBV prevented the need for further intervention.
  • Timely testing and appropriate follow-up ensured safe monitoring and reduced anxiety for the exposed healthcare worker.

Weaknesses:

  • The ER's high-risk environment and the patient's unpredictable nature created a setting where standard safety procedures could not fully prevent injury.
  • There was no use of additional restraint or protection during IV insertion, despite the known behavioral history of the patient, which could have mitigated the risk of sudden movement.
  • The hospital did not appear to have specific protocols for securing unresponsive or semi-conscious patients during invasive procedures, which may need to be addressed.

Case Study 2: Blood Exposure While Managing a Wrestling Match Injury

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:

  • Timely follow-up, institutional support, and systemic changes helped prevent future risks.

Weaknesses:

  • The AT was unnecessarily exposed when gloves were not worn during a high-risk situation. The trainer underestimated the transmission risk from non-intact skin contact with blood.

Case Study 3: Needlestick Injury During Dry Needling

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:

  • Immediate First Aid: Sarah thoroughly washed the wound with soap and water for several minutes. Per evidence-based guidelines, she did not squeeze the wound or apply bleach, and no antiseptics were applied beyond washing.
  • Reporting and Evaluation: Sarah notified her clinic supervisor within 10 minutes and reported to Occupational Health immediately for post-exposure evaluation. A comprehensive occupational exposure protocol was initiated, including:
    • Documentation of the exposure details.
    • Rapid HIV antibody/antigen testing of both the patient and Sarah.
    • Source testing for HCV (RNA and antibody) and HBV (HBsAg).
    • Baseline labs for Sarah: CBC, LFTs, BUN/Cr, HIV, HCV RNA/Ab, and HBsAb.
  • Post-Exposure Prophylaxis Decisions:
    • Hepatitis B: Sarah’s HBsAb level came back at 6 mIU/mL, classifying her as a non-responder. The source patient tested positive for HBsAg. Therefore, she was administered the first hepatitis B immune globulin (HBIG) immediately and scheduled to receive the second dose 28 days later. She was also scheduled for HBV revaccination and follow-up testing in 6 months.
    • Hepatitis C: The patient tested HCV RNA positive. Sarah's baseline HCV RNA was negative. She was scheduled for follow-up HCV RNA testing at 6 weeks and HCV antibody testing at 6 months.
    • HIV: The source’s rapid HIV test was inconclusive, with suspicion of possible acute infection due to his high-risk history. An HIV RNA PCR test was ordered, taking up to 48 hours. PEP was initiated immediately with:
      • Emtricitabine 200 mg / tenofovir disoproxil fumarate 300 mg (once daily).
      • Raltegravir 400 mg (twice daily).

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:

  • Rapid reporting and immediate first aid reduced the risk of delayed intervention.
  • Prompt initiation of PEP for potential HIV exposure, by the CDC and National Clinician Consultation Center guidelines.
  • Thorough source testing and comprehensive baseline labs facilitated appropriate and evidence-based follow-up.
  • Psychological support was offered early, addressing the emotional burden of such incidents.
  • Vaccination follow-up ensured long-term protection against HBV.

Weaknesses:

  • The needlestick was preventable. Sarah failed to follow safe needle-handling techniques (e.g., recapping instead of using a sharps container).
  • The absence of immediate access to a sharps disposal container highlighted a systems issue in the clinic’s layout or safety protocols.
  • Sarah’s unknown HBV immune status indicated a lapse in routine occupational health monitoring for vaccine responders.
  • Although Sarah was compliant, PEP adherence is a common challenge in similar cases, and structured follow-up was essential to ensure compliance.

Conclusion

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.

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Implicit Bias Statement

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.

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