The purposes of this course are to reinforce the importance of using standard precautions and to update the healthcare professional on current treatment post exposure.
After completing this course, the learner will be able to:
Bloodborne pathogens are any pathogenic microorganisms found in the blood or other bodily infectious material that can cause disease in humans. Examples of bloodborne pathogens include hepatitis B virus hepatitis C virus , human immunodeficiency virus (HIV), malaria, syphilis, viral hemorrhagic fever, arboviral infections, Creutzfeldt-Jakob disease, and relapsing fever. The three bloodborne pathogens that are the most commonly involved in occupational exposures in healthcare workers are hepatitis B, hepatitis C, and HIV (Weber, Rutala, Eron, 2013; Deuffic-Burbank, Delaroccque-Astagneau, Abitedoul, 2011).
Healthcare worker exposures and potential exposures to these pathogens are widespread. Some studies have estimated that there are more than 400,000 parental exposures suffered by healthcare workers in the US every year and that every year 1 out of 10 healthcare workers in the US suffers a splash exposure or a needle stick injury (Karmon, Mehta, Brehm, 2013; Henderson, 2012). The exact number of exposures is not known and part of the problem is under reporting: it has been estimated that approximately 50-67% of all needlesticks and exposures to bloodborne pathogens are not reported (Bernard, Dattilo, Laporte, 2013; CDC, 2008).
Almost all healthcare workers are at risk for exposure to bloodborne pathogens, but nurses are the group that is most affected (Camacho-Ortiz, Diaz-Rodriguez, Rodriguez-Lopez, et al, 2013; Yang, Wu, Wang, et al, 2013). It has been estimated that > 50% of nurses will experience at least one needlestick injury in their careers (Rhode, Dupler, Posta, 2013).
One serious bloodborne infection can cost more than a million dollars for medications, follow up laboratory testing, clinical evaluation, lost wages, and disability payments. Exact costs of occupational exposures to hepatitis B and C and HIV are not available, but a 2007 article estimated the one year cost for these incidents to be as high as $400 million (Leigh, Gillen, Franks, 2007). The human costs after an exposure are immeasurable. Employees may experience anger, depression, fear, anxiety, difficulty with sexual relations, trouble sleeping, problems concentrating, and doubts regarding their career choice. The emotional effect can be long lasting, even in a low risk exposure that does not result in infection (Green, Griffiths, 2013; Zhiang, Yu, 2013; Lee, Botteman, Xanthakos, 2005).
An exposure to a bloodborne pathogen is defined as: 1) a percutaneous injury, such as a needlestick or a laceration from a sharp object, or; 2) contact of a mucous membrane or non-intact skin (i.e., skin that is abraded, chapped, or has dermatitis) with blood, tissue, or other body fluids that are potentially infectious (Kuhar, Henderson, Struble, 2013). Also, any direct contact to concentrated HIV, hepatitis B, or hepatitis B (Direct contact meaning the healthcare worker was not using barrier protection) should be considered an exposure. Exposures occur through needlesticks or cuts from other sharp instruments contaminated with an infected patient's blood or through contact of the eye, nose, mouth, or skin with a patient's blood. Percutaneous injuries and splash exposures appear to be equally involved (Richardson, 2011), and the most common cause of a percutaneous injuries appears to be puncture wounds from hollow bore needles (Camacho-Ortiz, Diaz-Rodriguez, Rodriguez-Lopez, 2013; CDC, 2008).
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 (Bartlett, Weber, 2013; Kuhar, Henderson, Struble, 2013; Cosens, 2012):
Employers should have a system for reporting exposures in order to quickly evaluate the risk of infection, inform the employee about treatments available to help prevent infection, monitor the employee for side effects of treatments, and to determine if infection occurs. This may involve testing the employee's blood and that of the source patient, and offering appropriate postexposure treatment ( OSHA, 2011 ).
Avoiding occupational blood exposures is the primary way to prevent transmission of hepatitis B virus hepatitis C virus, and HIV in health-care settings. However, hepatitis B immunization and postexposure management are integral components of a complete program to prevent infection following bloodborne pathogen exposure and are important elements of workplace safety (Heininger, Gambon, Gruber, 2010; MacCannell, Laramie, Gomaa, 2010).
Controls are incorporated into the healthcare work setting to avoid or reduce exposure to potentially infectious materials. Healthcare associated transmission is the transmission of microorganisms that is likely to occur in a healthcare setting that can be reduced by using engineered controls, safe injection practices, and safe work practices. Engineering controls are equipment, devices, or instruments that remove or isolate a hazard. Safe injection practices are equipment and practices that allow the performance of injections in an optimally safe manner for patients, healthcare providers, and others that reduce exposure (CDC, 2012). Work practice controls change practices and procedures to reduce or eliminate risks.
Standard precautions are strategies for protecting healthcare professionals from occupational transmission of organisms. The premise is that all pre-existing patient infections cannot be identified. Given that, all body fluids and secretions with the exception of sweat should be considered potentially infectious and, barrier precautions should be used routinely to protect the healthcare worker from exposure, Standard precautions apply to nonintact skin and mucous membranes, blood, and all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood. Additional precautions are based on highly transmissible or epidemiologically important pathogens. Transmission Based Precautions (isolation) are airborne, droplet, and contact precautions.
New elements of standard precautions have been added. These elements include safe injection practices, and the use of masks and possibly head coverings and gowns for insertion of catheters of injections into spinal or epidural spaces via lumbar puncture (Radcliffe, Meites, Briscoe, 2012; Horlocker, Birnbach, Connis, 2010).
Nurses sustain the largest proportion of sharps injuries of all healthcare professionals, but laboratory staff, physicians, housekeepers, and other healthcare professionals are also injured (Gatto, 2013; Tso, Athreya, 2013; de Perio, 2012; Shiferaw, Abebe, Mihret, 2012; Wu, Wu, Chou, et al, 2012; Amuwo, 2011; CDC, 2008). Some of these injuries expose professionals to bloodborne pathogens that can cause infection. The most important of these pathogens are hepatitis B, hepatitis C, and HIV. Infections with each of these pathogens are potentially life threatening and preventable.
Percutaneous injuries can be avoided by eliminating the unnecessary use of needles, using devices with safety features, and promoting education and safe work practices for handling needles and related systems. Since 1993, the use of safety-engineered sharps devices has increased while the use of conventional sharps devices has decreased. Percutaneous injury rates have decreased dramatically, and many studies have proven that the use of safety-engineered devices has significantly decreased the number of needlestick injuries (Black, 2013. A number of sources have identified the desirable characteristics of safety devices. These characteristics include the following (CDC, 2008);):
Although each of these characteristics is desirable, some are not feasible, applicable, or available for certain healthcare situations. For example, needles will always be necessary where alternatives for skin penetration are not available. Also, a safety feature that requires activation by the user might be preferable to one that is passive in some cases. Each device must be considered on its own merit and ultimately on its ability to reduce workplace injuries. The desirable characteristics listed here should serve only as a guideline for device design and selection.
Needles should NEVER be recapped, bent, broken, or removed from contaminated syringes. Recapping by hand is prohibited under the OSHA bloodborne pathogens standard [29 CFR 1910.1030] unless no alternative exists. Sharps should be disposed into a puncture-proof container.
There is exposure to percutaneous injuries during procedures where there is opportunity for percutaneous exposure, especially where there is poor visualization, blind suturing, non-dominant hand opposing or next to a sharp, and exposure to bone spicules and metal fragments. Sharp equipment should be disassembled using forceps or other devices. Suturing should always be done with a needle holder, forceps, or other tool. Do not use fingers to hold tissue when suturing or cutting. Never leave sharps on a work field. If used needles or other sharps are left in the work area or are discarded in a sharps container that is not puncture resistant, a needlestick injury may result. Injury may occur when a healthcare professional attempts to transfer blood or other body fluids from a syringe to a specimen container (such as a vacuum tube) and misses the target.
Safe injection practice in hospitals is well established. However, outbreaks of infections with hepatitis b and hepatitis C amongst patients have been traced back to ambulatory care facilities and associated with non-compliance with safe injection practices, identifying the need to define and reinforce safe injection practices in outpatient care settings (Branch-Elliman, Weiss, Balter, 2013). The reuse of needles, multidose vials, and work areas containing both sterile and contaminated injection supplies contributed to the problem. There was a lack of understanding of aseptic technique, a lack of oversight, and failure to follow up on infection control breeches (CDC, 2013; CDC, 2007). The following are safe injection practices recommended by the CDC (CDC, 2011, ) that apply to the use of needles, cannulas that replace needles, and, where applicable intravenous delivery systems. Examples of these include safe injection practices include:
It has been estimated that between 20-40% of all hospital acquired infections are caused by cross-infection from the hands of healthcare workers (Chow, Arah, Chan, 2012). Studies have clearly shown that the hands of healthcare workers are often contaminated with microbial flora and that the amount of time spent performing patient care increases the amount of contamination. Handwashing is the most important measure to reduce the transmission of microorganisms (Crews, Whaley, Syblik, et al, 2013), and handwashing reduces infection rates, even in high-risk patient populations (Edmonds, Macinga, Mays-Suko, 2012). Hands should be washed or alcohol-based rubs should be used between patient contacts and after gloves are removed. Hands should be washed after contact with blood, body fluids, secretions, excretions, and contaminated equipment. It may be necessary to wash hands between tasks on the same patient to prevent cross-contamination of different body sites. (Rock, Harris, Reich, et al, 2013; CDC, 2011; WHO, 2009).
The appropriate use of personal protective equipment (PPE) is an important element of standard precautions. Gloves provide a protective barrier between the patient and the healthcare professional and prevent gross contamination of the hands. Gloves may also reduce the transfers of blood from a needlestick (Mast, Woolwine, Gerberding, 1993). Gloves do not replace the need for handwashing because the gloves may have small defects, may be torn during use, and hands may become contaminated during glove removal. In addition, microorganisms such as hepatitis B can pass through the pores of gloves, significant surface contamination of hands is possible, even when healthcare workers wear gloves (Garus-Pakowska, Sobala, Szatko, 2013), and glove use has been associated with lower rates of hand hygiene compliance (Fuller, Savage, Besser, 2011; Flores, Pevalin, 2006).
Masks, goggles, or face shields should be used to protect the mucous membranes of the eyes, nose, and mouth during situations where there is a likelihood of splashes or sprays.
Gowns are worn to prevent contamination of clothing and protect the healthcare professional's skin from blood and body fluid exposure. Impermeable gowns, leg coverings, boots, or shoe covers provide more protection when large quantities of blood or body fluids may be splashed. However, as with any PPE, gowns must be used properly and incorrect use of gowns (and other PPE) has been shown to cause contamination of the gowns, contamination of the hands and/or the environment and potential harm to healthcare workers (Mitchell, Gravel, Roth, 2013: Beam, Gibbs, Boulter, 2011; Weiner-Well, Galuty, Rudensky, 2011).
Immunization is one method to reduce the transmission of communicable diseases. The following are recommendations for immunization for healthcare personnel (MMWR, 2011).
|Healthcare Personnel Vaccination Recommendations|
|Hepatitis B||Hep B (3 doses)|
|Influenza||TIV or LA IV annually|
|MMR||MMR if born 1957 or later if no serologic evidence of immunity or prior vaccination|
|Varicella vaccine (2 doses) if no serologic evidence of immunity|
|Tetanus, Diptheria, Pertussis||Tdap one time if younger than 65, TD every 10 years|
|Meningococcal||1 dose to microbiologist who routinely exposed to N. meningitis|
Healthcare workers who are infected with hepatitis B, C, or HIV should follow certain precautions. Pre-notification of patients is not required. Double gloves should be used in all patient care situations in which gloves would typically be required, and Standard Precautions should always be observed. Some sources recommend that the infected healthcare worker should not perform or participate in certain invasive procedures that pose a higher than normal risk for percutaneous injuries and the transmission of hepatitis B, C, or HIV to a patient, e.g., oral surgery, cardio-thoracic surgery, or neuro-surgery. Some sources say that these procedures can be performed by an infected healthcare worker if certain conditions (e.g., the viral load is below a specified level) are met. It is advisable then to determine what policies/restrictions apply for any particular situation and healthcare facility and the particular healthcare worker.
The healthcare worker who is infected with hepatitis B, C, or HIV is advised to seek the advice of an infection control professional, have his/her infection monitored/treated by a physician, and have periodic measurements of viral loads. For healthcare workers infected with hepatitis B, measurement of HBV DNA serum levels rather than hepatitis B e-antigen status should be used a monitoring tool. (CDC, 2012; Henderson, Dembry, Fishman, 2010; CDC, 2001).
Employers are required to establish exposure control plans that include post-exposure follow up for their employees and to comply with incident reporting requirements mandated by the 1992 OSHA bloodborne pathogen standard. Access to clinicians who can provide post-exposure care should be available during all working hours, including nights and weekends. HBIG, hepatitis B vaccine, and antiretroviral agents for HIV PEP should be available for timely administration, either by providing access on site or by creating linkages with other facilities or providers to make them available off-site (OSHA, 2011).
The following are recommendation by the Centers for Disease Control (CDC, 2001) for immediate activity after exposure.
Provide immediate care to the exposure site. (Bader, McKinsey, 2013)
No scientific evidence shows that using antiseptics or squeezing the wound will reduce the risk of transmission of a bloodborne pathogen. Using a caustic agent such as bleach is not recommended. (Bader, McKinsey, 2013; Samaranayake, Scully, 2013).
Report the exposure to the government agency responsible for managing exposures. Reporting is necessary because PEP treatment may becarded needles or syringes for virus contamination.
Determine risk associated with exposure by:
Evaluate exposure source.
Evaluate the exposed person.
Comprehensive exposure prevention strategies have played a significant role in decreasing the probable risk of infection from bloodborne pathogens. The risks of exposure with appropriate precautions are low, but they are real. Understanding how an exposure occurs and the risks of exposure is imperative for both the occupational health clinician and the healthcare professional. After an occupational exposure to a bloodborne pathogen, the risk of infection depends on a number of factors including:
HBV: The number of occupational infections decreased by 95% after the hepatitis B vaccine became available in 1982 (Mahoney, Stewart, Hu, 1997; Beekman, Henderson, 1992). The number of healthcare workers acutely infected with hepatitis B decreased from 10,000 in 1989 to 100 in 2009 (Kaltsas, Sepkowitz, 2013), and the decline in hepatitis B infections in healthcare workers is 1.5 fold higher than the decline in the general population. (Weber, Rutala, Eron, 2012).
The use of hepatitis B vaccine is considered to be most important intervention for the prevention of infections with hepatitis B (De Schryver, Claesen, Meheus, 2011). Healthcare professionals who have received hepatitis B vaccine and have developed immunity to the virus are at virtually no risk for infection (Werner, Abdalla, Gara, 2013), and the absence/presence of a hepatitis B infection in healthcare workers has been strongly associated with vaccination status (Thomas, Factor, Kellen, 1993). The risk of hepatitis B infection is primarily related to the degree of contact with blood in the workplace and also to the hepatitis B e antigen (HBeAg) status of the source person. 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 hepatitis B (MacCannell, Laramie, Gomaa, 2010: Michelin, Henderson, 2010).. Amongst healthcare professionals who are susceptible, the risk of infection after one percutaneous exposure is 6-31% (Bader, McKinsey, 2103; Cosen 2012 ).
Although obvious percutaneous injuries are among the most efficient modes of hepatitis B transmission, these exposures probably account for only a minority of hepatitis B infections among healthcare professionals. In several investigations of nosocomial hepatitis B outbreaks, most infected healthcare professionals could not recall an overt percutaneous injury, although in some studies, up to one third of the infected recalled caring for a patient who was HBsAg-positive. Additionally, HBV has been demonstrated to survive in dried blood at room temperature on environmental surfaces for at least 1 week (Bond, Favero, Petersen, 1981)).
Hepatitis B infections that occur in healthcare professionals with no history of non-occupational exposure or occupational percutaneous injury might have resulted from direct or indirect blood or body fluid exposures that inoculated hepatitis B into cutaneous scratches, abrasions, burns, other lesions, or on mucosal surfaces (CDC, 2001). In approximately two-thirds of all people infected with hepatitis B, no obvious injury, e.g., needle stick could be identified (Dienstag, 2012). HBsAg is also found in several other body fluids, including breast milk, bile, cerebrospinal fluid, feces, nasopharyngeal washings, saliva, semen, sweat, and synovial fluid. However, aside from blood most body fluids are not efficient vehicles of transmission because they contain low quantities of infectious hepatitis B virus, despite the presence of HBsAg.(CDC, 2001).
Most hepatitis C infections are caused by injection drug use or another obvious cause, but in approximately 10-20% of all cases the cause of the infection cannot be identified (Dhawan, 2013; Pondé, 2011). Hepatitis C virus is not transmitted very often or (seemingly) very efficiently through occupational exposures to blood. Transmission from patients to healthcare workers has been reported rarely, but more than half the reported cases had other risk factors (Pearlman, 2004), Approximately 39% of all hepatitis C infections in healthcare workers are considered to be occupational (Strasser, Aigner, Shmidt, 2013). The risk for hepatitis C infection after a needlestick or sharps exposure to HCV-positive blood is approximately 1.8% (range: 0–10%) (Strasser, Aigner, Schmidt, 2013). Transmission rarely occurs from mucous membrane exposures to blood (Hosoglu, Celen, Akalin, 2003), and no transmission to healthcare professionals has been documented from intact or non-intact skin exposures to blood. Hepatitis C virus has been found in ascites, menstrual fluid, saliva, semen, spinal fluid, and urine. Transmission of the hepatitis C virus from these fluids has not been reported, but if there was a parenteral exposure to ascites, spinal fluid, etc, or someone if was exposed to a large amount of one of these fluids, transmission could possibly occur (Henderson, 2003). Hepatitis C virus has been reported to survive on environmental surfaces for up to 16 hours, (Kamali, Krawczynski, McCaustland, 2007).
HIV: The average risk of HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3%. (Hoffman, Bucholz, Schnitzler, 2013). The risk after a mucous membrane exposure is approximately 0.09% (PEPline). Although episodes of HIV transmission after non-intact skin exposure have been documented, the average risk for transmission by this route has not been precisely quantified but is estimated to be less than the risk for mucous membrane exposures. (Kuhar, Henderson, Struble, 2013). The risk for transmission after exposure to fluids or tissues other than HIV-infected blood also has not been quantified but is probably considerably lower than for blood exposures (Kuhar, Henderson, Struble, 2013).
By calling 1-888-448-4911 from anywhere in the United States 24 hours a day, clinicians can gain access to the National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline). The PEPline has trained physicians prepared to give clinicians information, counseling and treatment recommendations for professionals who have needlestick injuries and other serious occupational exposures to blood borne microorganisms that lead to such serious infections or diseases as HIV or hepatitis.
HBV: Recommendations for hepatitis B post-exposure management include initiation of the hepatitis B vaccine series to any susceptible, unvaccinated person who sustains an occupational blood or body fluid exposure, regardless of the source person's hepatitis B status. Postexposure prophylaxis (PEP) with hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine series should be considered for occupational exposures after evaluation of the hepatitis B surface antigen status of the source and the vaccination and vaccine response status of the exposed person (Bader, McKinsey, 2013; CDC, 2001).
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.
Post-exposure treatment should begin as soon as possible after exposure, preferably within 24 hours, and no later than 7 days. Hepatitis B immune globulin is effective in preventing hepatitis B infection after an exposure. The decision to begin treatment is based on several factors, such as (CDC, 2001):
_ whether the source individual is positive for hepatitis B surface antigen,
_ whether the healthcare professional has been vaccinated, and
_ whether the vaccine provided immunity
HCV: There is no vaccine against hepatitis C and no treatment after an exposure that will prevent infection. Immune globulin, antiviral agents like interferon, with or without ribavirin, and protease inhibitors are not recommended for PEP of hepatitis C. (Bader, McKinsey, 2013).
Limited data indicate that antiviral therapy might be beneficial when started early in the course of HCV infection, but no guidelines exist for administration of therapy during the acute phase of infection. (Boesecke, Wedemeyer, Rockstroh, 2012). When HCV infection is identified early, the individual should be referred to a specialist in this area for medical management.
HIV: There is no vaccine against HIV. PEP 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. Based on the level of risk of HIV transmission of the exposure, a two or more drug PEP may be recommended. The updated U.S. Public Services guidelines for PEP after HIV exposure (Kuhar, Henderson, Struble, 2013) can be found on the PEPline website. A three or more drug regimen may be recommended for an exposure of high risk transmission, but potential toxicity many prevent completion of the regimen, making the regimen ineffective The PEP regimen should be started immediately. The optimal duration of PEP is not known. It has been clearly shown that PEP significantly reduces the risk of developing an infection with HIV (Bartlett, Weber, 2013; Henderson, 2012).
The majority of HIV exposures warrant a two drug regime using two nucleoside reverse transcriptase inhibitors (NRTIs), or one NRTI and one nucleotide reverse transcriptase inhibitors (NtRTIs). Because of the complexity determining PEP, consultation should be sought. The following are resources for consultation:
All of the antiviral drugs for HIV have been associated with side effects. The most common side effects include nausea, vomiting, diarrhea, tiredness, or headache. The few serious side effects that have been reported in healthcare professionals using combination PEP have included kidney stones, hepatitis, and suppressed blood cell production. Interaction with other medicines can cause serious side effects.
Pregnancy should not rule out the use of post-exposure treatment when it is warranted. However, 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. The effect of antiretroviral drugs on developing fetus may be teratogenic, and may also cause neonatal death, pre-term delivery, small gestational age, stillbirths cause (Chen, Ribaudo, Souda, 2012)).
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 professionals who are concerned about possible infection through occupational exposure.
HBV: If the HBV vaccine is given, a follow up test in 1-2 months will determine the response to the vaccine. Other routine follow-up after post-exposure treatment is not recommended, because the prevention is highly effective. Symptoms suggesting hepatitis should be reported.
|Postexposure follow-up of healthcare, emergency medical and public safety professionals for hepatitis C virus exposure (Bader, McKinsey, 2013):|
|For the source||Perform baseline testing for anti-HCV|
|For the person exposed to an HCV-positive source||Perform baseline and follow-up testing, including baseline testing for anti-HCV and ALT activity|
Follow-up testing for anti-HCV (e.g., at 4–6 months) and ALT activity. If earlier diagnosis of HCV infection is desired, testing for HCV RNA may be performed at 4–6 weeks
|Supplemental anti-HCV testing to confirm all anti-HCV results reported as positive by enzyme immunoassay|
"CDC's recommendations for prevention and control of HCV infection specify that persons should not be excluded from work, school, play, child care, or other settings on the basis of their HCV infection status. There is no evidence of HCV transmission from food handlers, teachers, or other service providers in the absence of blood-to-blood contact. (CDC, May 28, 2013).
HIV: Follow up counseling, postexposure testing, and medical evaluation should be done regardless of whether PEP was used. Perform HIV-antibody testing at baseline, six weeks, 3 months and six months post-exposure; a complete blood count should be done at baseline, two weeks, and four weeks post-exposure; renal and hepatic function tests at baseline and at two weeks post-exposure; HIV RNA polymerase chain reaction should be perfumed if the exposed person develops an illness suggestive of an HIV infection, and; a urine test for pregnancy in all women of reproductive age (Bader, McKinsey, 2013; Kumar, Henderson, Struble, 2013). If the exposed person becomes infected with HCV, HIV testing should be done for 12 months (Kuhar, Henderson, Struble, 2013). People on PEP should be monitored closely for toxicity.
HBV: If the exposed healthcare professional receives post-exposure treatment, it is unlikely that infection and exposure to others will occur. No precautions are recommended.
HCV: Because the risk of becoming infected and passing the infection on to others after an exposure to HCV is low, no precautions are recommended. The risk of sexual transmission of HCV is considered to be very low. A recent study estimate the risk of transmission to be 1 in 190,000 sexual conducts (Terrault, Dodge, Murphy, 2013), and the CDC notes that in long-term, monogamous, heterosexual relationships in which one partner is infected with HCV, condoms may not be necessary. Breastfeeding is permitted.
HIV: During the follow-up period, especially the first 6-12 weeks when most infected persons are expected to show signs of infection, the exposed person should follow recommendations for preventing transmission of HIV. These include not donating blood, semen, or organs and not having sexual intercourse. If the healthcare professional chooses to have sexual intercourse, 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. (Kuhar, Henderson, Struble, 2013).
The correct incorporation of work practice controls and engineering controls help to avoid or reduce exposure to potentially infectious materials. Compliance with environmental engineered controls will decrease the risk of exposure to blood borne pathogens.
Ahmed-Lechebed, D., Cunat, L., Hartemann, P., Hautemaniére, A. (2012). Prospective observational study to asses hand skin condition after application of alcohol-based hand rub solutions. American Journal of Infection Control. 40 (2), 160-164.
Amuwo, S., Sokas, R.K., McPhaul, K., Lipscomb, J. (2011). Occupational risk factors for blood and body fluid exposure among home care aides. Home Health Care Services Quarterly. 30 (2), 96-114.
Bader, M.S., McKinsey, D.S. (2013). Post-exposure prophylaxis for common infectious diseases. American Family Physician. 88 (1), 25-33.
Bartlett, J.G, Weber, D.J. (2013). Management of healthcare personnel exposed to HIV. UpToDate, September, 2013. Retrieved 10/18/13.
Beam, E.L., Gibbs, S.G., Boulter, K.C., Beckerdite, M.E., Smith, P.W. (2011). A method for evaluating healthcare workers' personal protective equipment technique. American Journal of Infection Control. 39 (5), 415-420.
Beekman, S.E., Henderson, D.K. (1992). Healthcare workers and hepatitis: risk for infection and management of exposures. Infectious Disease Clinics of North America. 1(6), 424-428.
Bernard, J.A., Datillo, J.R., LaPorte, D.M. (2013). The incidence and reporting of sharps exposure among medical students, orthopedic residents, and faculty at one institution. Journal of Surgical Education. 70 (5), 660-668.
Black, L. (2013), Chinks in the armor: Percutaneous injuries from hollow bore safety engineered sharps devices. American Journal of Infection Control. 41(5), 427-432.
Bond, W.W., Favero, M.S., Petersen, N.J., et al. (1981). Survival of hepatitis B virus after drying and storage for one week. Lancet 1 (8219), 550-551.
Boesecke, C., Wedermeyer, H., Roskstroh, J. K. (2012). Diagnosis and treatment of acute hepatitis C infection. Infectious Disease Clinics of North America. 26 (4), 995-1010.
Branch-Elliman, W., Weiss, D., Balter, S., Bornschlegel, K., Phillips. M. (2013). Hepatitis C transmission due to contamination of multi-dose medication vials: Summary of an outbreak and a call to action. American Journal of Infection Control. 41(1), 92-94.
Camacho-Ortiz, A., Díaz-Rodríguez, X., Rodríguez-López, J.M., Martínez-Palomares, M., Palomares-De la Rosa, A., Garza-Gonzalez E. (2013). A 5-year surveillance of occupational exposure to bloodborne pathogens in a university teaching hospital in Monterrey, Mexico. American Journal of Infection Control, 41 (9), e85-e88.
CDC. (2001). Recommendations for prevention of transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone procedures. Retrieved 10/24/13.
CDC. (July 29, 2001). Updated U.S. Public Health Service guidelines for the management of occupational exposure to HBV, HCV, and HIV and recommendations for post-exposure prophylaxis. Retrieved 10/25/13.
CDC. (2007). 2007 Guidelines for isolation Precautions: Preventing Transmission of Infectious Agents In Healthcare Settings. Retrieved 10/18/13.
CDC. (2008). Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program. Retrieved 10/23/13.
CDC. (April 1, 2011). Safe injection practices to prevent transmission of infections to patients. Retrieved 10/1913.DC. (May 19, 2011). Hand Hygiene in Healthcare Settings. Retrieved 10/17/13.
CDC. (July 6, 2012). Updated CDC recommendations for the management of hepatitis B virus-infected healthcare providers and students. Retrieved 10/19/13.
CDC. (August 24, 2012). Injection Safety. Retrieved 10/18/13.
CDC. (May 21, 2013). Healthcare-associated hepatitis B and C outbreaks reported to the Centers for Disease Control and Prevention (CDC) in 2008-2012. Retrieved 10/22/13.
CDC. (May 28, 2013) Hepatitis C Information for Healthcare Professionals. Retrieved 10/24/13.
Chen, J.Y., Ribaudo, H.J., Souda, S., et al. (2012). Highly active anti-retroviral therapy and adverse birth outcomes among HIV-infected women in Botswana. Journal of Infectious Diseases. 206 (11), 1695-1705.
Chow, A., Arah, O.A., Chan, S.P., et al. (2012). Alcohol hand rubbing and chlorhexidine handwashing protocols for routine hospital practice: A randomized clinical trial of protocol efficacy and time effectiveness. American Journal of Infection Control. 40 (9), 800-805.
Cosens, B. (2012). Needle-stick guideline. eMedicine, November 30, 2012. Retrieved 10/20/13.
Crews, J.D., Whaley, E., Syblik, D., Starke, J. (2013). Sustained improvement in hand hygiene at a children's hospital. Infection Control and Hospital Epidemiology, 34(7). 751-753.
Deuffic-Burban, S., Delarocque-Astagneau, C., Abiteboul, D., Bouvet, E., Yazdanpanah, Y. (2011). Bloodborne viruses in healthcare workers: Prevention and management. Journal of Clinical Virology. 52 (1), 4-10.
de Perio, M.A. (2012). Needlestick injuries among employees of a nationwide retail pharmacy chain. Infection Control & Hospital Epidemiology. 33 (11), 156-158.
de Schryver, A., Claesen, B., Meheus, A., van Sprundel, M., Francois, G. (2011). European survey of hepatitis B vaccination policies for healthcare workers. European Journal of Public Health. 21(3), 338-343.
Dhawan, V. K. (2013). Hepatitis C. eMedicine, September 18, 2013. Retrieved 10/25/13.
Dienstag, J.L. (2012). Acute viral hepatitis. In: Long, D. l., Fauci, A.S., Kasper, D.L., Hauser, S.L., Jameson, J.L., Loscalzo, J., eds. Harrison's Principles of Internal, on-line ed. 18th ed. New York, NY: McGraw-Hill. Retrieved 10/24/13 from UConn Health Center.
Edmonds, S.L., Macinga, D.R., Mays-Suko, P., et al. (2012). Comparative efficacy of commercially available alcohol-based hand rubs and World Health Organization-recommended hands rubs: formulation matters. American Journal of Infection Control. 40 (6), 521-525.
Flores A., Pevalin, D. (2006). Healthcare workers compliance with glove use and the effect of glove use on compliance with hand hygiene. Journal of Infection Prevention. 7(6), 15-18.
Fuller, C., Savage, J., Besser, S., et al. (2011). "The dirty hand in the latex glove." A study of hand hygiene compliance when gloves are worn. Infection Control and Hospital Epidemiology. 32 (12), 1194-1199.
Garus-Pakowska, A., Sobala, W., Szatko, F. (2013). The use of protective gloves by medical personnel. International Journal of Occupational Medicine and Environmental Health. 26 (3), 423-429.
Gatto, M.R., Bandini, L., Montevecchi, M., Checchi L. (2013). Occupational exposure to blood and body fluids in a department of oral sciences: results of a thirteen-year surveillance study. ScientificWorldJournal. 2013;2013:459281. doi: 10.1155/2013/459281. Epub 2013 Feb 14.
Green, B., Griffiths E.C. (2013). Psychiatric consequences of needlestick injury. Occupational Medicine. 63(3), 183-188.
Heininger, U., Gambon, M., Gruber, Margelli, D. (2010). Successful hepatitis B immunization in non- and low-responding healthcare workers. Human Vaccines. 6 (9), 725-728.
Henderson, D. K. (2003). Managing occupational risks for hepatitis C transmission in the healthcare setting. Clinical Microbiology Reviews. 16 (3), 546-568.
Henderson, D.K., Dembry, L. Fishman, N.O., et al. (2010). SHEA guideline for management of healthcare workers who are infected with hepatitis B virus, hepatitis C virus, and/or human immunodeficiency virus. Infection Control and Hospital Epidemiology. 31(3), 203-232.
Henderson, D.K. (2012). Management of needlestick injuries. A house officer who has a needlestick. Journal of the American Medical Association. 37 (1), 75-84.
Hoffman, C, Buchholz, L., Schnitzler, P. (2013). Reduction of needlestick injuries in healthcare personnel at a university hospital using safety devices. Journal of Occupational Medicine and Toxicology. 8 (1), 8-20.
Horlocker T.T., Birnbach, D.J., Connis, R.T., et al. (2012). Practice Advisory for the Prevention, Management, and Diagnosis of Infectious Complications Associated with Neuroaxial Techniques. A Report by the American Society of Anesthesiologists Task Force on Infectious Complications Associated with Neuroaxial Techniques. Anesthesiology. 112 (3), 530-545.
Hosoglu, S., Celen, M.C., Akalin, S., Geyik, M.F., Soyoral, Y., Kara, I.H. (2003). Transmission of hepatitis C by blood splash into conjunctiva in a nurse. American Journal of Infection Control. 31(8), 502-504.
Kaltsas, A., Sepkowitz, K.(2013). Vaccinations for healthcare personnel: updates on influenza, hepatitis B, and pertussis. Current Opinion in Infectious Diseases. 26(4), 366-377.
Kamali, S., Krawczynski, K., McCaustland, K. Li, X., Alter, M. (2007). Infectivity of hepatitis C virus in plasma after drying and storing at room temperature. Infection Control and Hospital Epidemiology. 28 (9), 519-524.
Karmon, S.L., Mehta, S.A., Brehm, A., Dzurenko, J., Phillips, M. (2013). Evaluation of bloodborne pathogen exposures at an urban hospital. American Journal of Infection Control. 41(2), 185-186.
Kuhar, D.T., Henderson, D.K., Struble, K.A., et al. (2013). Updated US Public Health Service Guidelines for the management of occupational exposure to human immunodeficiency virus and recommendations for post-exposure prophylaxis. Infection Control and Hospital Epidemiology. 34(9), 875-892.
Lee, J.M., Botteman. M.F., Xanthakos, N., Nicklasson. L. (2005). Needlestick injuries in the United States. Epidemiologic, economic, and quality of life issues. AAOHN. 53 (3), 117-133.
Leigh, J.P., Gillen, M., Franks. P., Sutherland, S., et al. (2007). Costs of needlestick injuries and subsequent hepatitis and HIV infection. Current Medical Research and Opinion. 23 (9), 2093-2105.
MacCannel, T., Laramie, A.K., Gomaa, A., Perz, J.F. (2010). Occupational exposure of healthcare personnel to hepatitis B and hepatitis C: prevention and surveillance strategies. Clinics in Liver Disease. 14 (1), 23-36.
Mahoney F.J., Stewart, K., Hu, H., Coleman, P. Alter, M.J. (1997). Progress toward the elimination of hepatitis B virus transmission among health care workers. Archives of Internal Medicine. 157 (22) 2601-2605.
Marra, A.R., Edmond, M.B. (2012). Hand hygiene: State-of-the art review with emphasis on new technologies and mechanisms of surveillance. Current Infectious Disease Reports. 14 (6), 585-591.
Mast, S.T., Woolwine, J.D., Gerberding, J.L. (1993). Efficacy of gloves in reducing blood volumes transferred during simulated needlestick injury. Journal of Infectious Diseases. 168(6), 1589-1592.
Michelin, A., Henderson, D.K. (2010).Infection control guidelines for prevention of healthcare-associated transmission of hepatitis B and C viruses. Clinics in Liver Diseases. 14(1), 119-136.
Mitchell R., Roth, R., Gravel, D., et al (2013). Are healthcare workers protected? An observational study of selection and removal of personal protective equipment in Canadian acute care hospitals. American Journal of Infection Control. 41(3), 240-244.
Morbidity and Mortality Weekly Report. (November 25, 2011). Immunization of healthcare personnel. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Retrieved 10/19/13 from the CDC.
National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline). Retrieved 10/25/13 from the National HIV/AIDS Clinicians' Consultation Center Exposures to HIV.
OSHA. (2011). OSHA Fact Sheet. OSHA's Bloodborne Pathogens Standard. Retrieved 10/20/13.
Pearlman, B. (2004). Hepatitis C infection: A clinical review. Southern Medical Journal. 97 (4) 365-376.
Pondé, R.A. (2011). Hidden hazards of HCV transmission. Medical Microbiology and Immunity. 200 (1), 7-11.
Radcliffe, R., Meites E., Briscoe, R., et al. (2012). Severe methicillin-susceptible Staphylococcus aureus infections associated with epidural injections at an outpatient clinic. American Journal of infection Control, 40 (2), 144-149.
Rhode, K.A., Dupler, A.E., Postma, J., Sanders A. (2013).Minimizing nurses' risks for needlestick injuries in the hospital setting. Workplace Health & Safety. 61 (5), 197-202.
Richardson, D. (2011). Reducing blood exposure risks and costs associated with SPIVC insertion. Nurse Manager. 42 (12), 31-34.
Rock, C.R., Harris, A.D., Reich , N.G., Johnson, J.K., Thom, K.A., (2013). Is hand hygiene before putting on non-sterile gloves in the intensive care unit a waste of healthcare worker time? – A randomized, controlled study. American Journal of Infection Control, Jul 24. pii: S0196-6553(13)00848-1. doi: 10.1016/j.ajic.2013.04.007. [Epub ahead of print]
Samaranayake, L., Scully, C. (2103). Needlestick and occupational exposure to infections: a compendium of current guidelines. British Dental Journal. 215(4), 163-166.
Shen N.J., Pan, S.C., Sheng, W.H., et al. (2013) Comparative antimicrobial efficacy of alcohol-based hand rub and conventional surgical scrub in a medical center. Journal of Microbiology, Immunology and Infection, Sep 21. pii: S1684-1182(13)00150-3. doi: 10.1016/j.jmii.2013.08.005. [Epub ahead of print]
Shiferaw, Y., Abebe, T., Mihret, A. (2012). Sharps injuries and exposures to blood and bloodstained body fluids involving medical waste handlers. Waste Management & Research. 30(12), 1299-1305.
Strasser, M., Aigner, E., Schmid, I., et al. (2013). Risk of hepatitis C virus transmission from patient to healthcare worker: A prospective, observational study. Infection Control and Hospital Epidemiology. 34 (7), 759-761.
Terrault, N.A., Dodge, J.L., Murphy, E.L., et al. (2013). Sexual transmission of hepatitis C virus among monogamous heterosexual couples: The HCV Partner Study. Hepatology. 57(3), 881-889.
Thomas, D.L., Factor, S.H., Kellen, G.D., et al. (1993). Viral hepatitis in healthcare personnel at Johns Hopkins Hospital: The seroprevalence of and risk factors for hepatitis B virus and hepatitis C virus infection. Annals of Internal Medicine. 153 (14), 1705-1712.
Tso, D.K., Athreya, S. (2013). Reducing blodborne exposure in interventional radiology. what the IR should know. Cardiovascular and Interventional Radiology. 36 (4), 913-916.
Weber D.J., Rutala, W.A., Eron J. (2012). Management of healthcare workers exposed to hepatitis B virus or hepatitis C virus. UpToDate, October 3. 2012. Retrieved 10/18/13.
Weiner-Well, Y., Galuty, M., Rudenksy, B., Schlesinger, Y., Attias, D., Yinnon, A.M. (2011). Nursing and physician attire as possible source of nosocomial infection. American Journal of Infection Control. 39 (7), 555-559.
Werner, J.M., Abdalla, A., Gara, N, Ghany, M.G., Rehermann, B. (2013). The hepatitis B vaccine protects re-exposed healthcare workers, but does not provide sterilizing immunity. Gastroenterology. 45(5), 1026-1034.
WHO. (2009). WHO Guidelines on Hand Hygiene in Healthcare. Retrieved 10/17/13.
Wu F.F., Wu, M.W., Chou, H.Y., Ting, M.H., & Siebers, R. (2012). Incidence of percutaneous injuries and non-reporting rates among first-aid responders in Taiwan. Journal of Occupational & Environmental Hygiene. 9(9), 535-537.
Yang, Y.H., Wu, S.J., Wang, C, L., et al. (2013). Incidence of needlestick and other sharp object injuries in newly graduated nurses. American Journal of Infection Control. 41 (10), 944-945.
Zhiang, M.X., Yu, Y. (2013). A study of the psychological impact of sharps injuries on healthcare workers in China. American Journal of Infection Control. 41(2), 186-187.
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Athletic Trainer (AT/AL), Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Dietetic Technicians, Registered (DTR), Dietitian/Nutritionalist (RDN), Electrologist (EO), Home Health Aid (HHA), Licensed Nursing Assistant (LNA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Medical Assistant (MA), Midwife (MW), Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Respiratory Therapist (RT)
CPD: Practice Effectively, CPD: Preserve Safety, Infection Control/Disease, Legal & Regulatory, Medical Surgical