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Occupational Exposure to Blood Borne Pathogens

Author: Julia Tortorice, Dana Bartlett

 

Occupational Exposure to Blood Borne Pathogens | Copyright © 2013 CEUFast.com


 

Purpose/Goals

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.

 

Objectives

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

1. identify the benefits of using strategies to prevent exposure,
   
2. identify safe injection practices,
   
3. identify the actions to take immediately post exposure,
   
4. discuss disease specific, post exposure treatment recommendations, and
   
5. discuss post exposure follow-up recommendations.

 

Introduction

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):

the pathogen involved,
the depth of the injury
needle was from an artery or a vein
type of sharp, e.g., hollow bore needle, scalpel
visible contamination with blood
   
_ the amount of blood involved in the exposure, and
   
_ the amount of virus in the patient's blood at the time of exposure. It is important
to note that risk of infection is very low if the source's viral load is undetectable
but there is still a risk.

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 ).

 

Prevention of Exposure

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

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).

 

Safe Injection Practice

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);
):

  The device is needleless.
   
  The safety feature is an integral part of the device.
   
  The device preferably works passively (i.e., it requires no activation by the user). If user activation is necessary, the safety feature can be engaged with a single-handed technique and allows the professional's hands to remain behind the exposed sharp.
   
  The user can easily tell whether the safety feature is activated.
   
  The safety feature cannot be deactivated and remains protective through disposal.
   
  The device performs reliably.
   
  The device is easy to use and practical.
   
  The device is safe and effective for patient care.

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:

  Use aseptic technique to avoid contamination of sterile injection equipment.
   
  Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed.
   
  Needles, cannula and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient.
   
  Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use.
   
  Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient's intravenous infusion bag or administration set.
   
  Use single-dose vials for parenteral medications whenever possible.
   
  Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use.
   
  If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile.
   
  Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable.
   
  Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients.
   
  Infection control practices for special lumbar puncture procedures
   
  Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space (i.e., during myelograms, lumbar puncture and spinal or epidural anesthesia.
   
  Employee safety
   
  Adhere to federal and state requirements for protection of healthcare personnel from exposure to bloodborne pathogens.
   

 

Handwashing

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).

  Improved adherence to hand hygiene (i.e. hand washing or use of alcohol-based hand rubs) has been shown to terminate outbreaks in healthcare facilities, to reduce transmission of antimicrobial resistant organisms (e.g. methicillin resistant staphylococcus aureus) and reduce overall infection rates (Chow, Arah, Chan, 2012).
   
  The CDC is releasing guidelines to improve adherence to hand hygiene in healthcare settings. In addition to traditional handwashing with soap and water, CDC is recommending the use of alcohol-based hand cleansers by healthcare personnel for patient care because they address some of the obstacles that healthcare professionals face when taking care of patients.
   
  Handwashing with soap and water remains a sensible strategy for hand hygiene in non-healthcare settings and is recommended by the CDC and other experts.
   
  When healthcare personnel's hands are visibly soiled, they should wash with soap and water instead of an alcohol-based rub.
   
  Gloves are an important part of infection control as hand hygiene itself cannot remove all pathogens from the hands or prevent contamination of the hands. However, gloves must be used correctly or they can be a source of contamination and cross infection (Fuller, Savage, Besser, 2011).
   
  The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves.
   
  Gloves reduce hand contamination by 70% to 80 % (Garus-Pakowska, Sobala, Szatko, 2013), prevent cross contamination and protect patients and healthcare personnel from infection.
   
  Alcohol-based hand rubs have been proven to be an effective method for hand hygiene (Shen, Pan, Sheng, 2013). Alcohol-based hand rubs are preferred for hand hygiene in most situations. They require less time to use than soap and water, they remove more bacteria then soap and water, they are easy to use, and they rapidly reduce bacterial contamination on the hands (Marra, Edmond, 2012). These products have also been shown to be associated with increased compliance by healthcare workers with hand hygiene requirements (Ahmed-Lechebed, Cunat, Hartemann, 2012).
   
  When using an alcohol-based hand rub, apply the product to the palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Note that the volume needed to reduce the number of bacteria on hands varies by product. Alcohol-based hand rubs are available as foams, gels, and rinses and with alcohol concentrations ranging from 60-95%. It does not appear that the formulation influences the effectiveness of these products and a higher alcohol concentration is not necessarily better (Edmonds, Macinga, Mays-Suko, 2012). It is important to follow the manufacturer's instructions for any particular product.
   
  Alcohol-based hand rubs significantly reduce the number of microorganisms on skin, are fast acting and cause less skin irritation than repeated washing with soap and water
   
  Decreasing skin irritation is important and not only to help increase hand hygiene compliance by healthcare workers. An intact skin prevents the entry of microorganisms. Frequent hand washing with soap and water can be very irritating and also rapidly breaks down the stratum corneum, creating a potential entry point for microorganisms. Alcohol-based hand rubs cause this breakdown as well, but there is evidence that this breakdown happens to a lesser degree when using alcohol-based hand rubs (Ahmed-Lechebed, Cunat, Hartemann, 2012).
   
  Healthcare personnel should avoid wearing artificial nails and keep natural nails less than one quarter of an inch long if they care for patients at high risk of acquiring infections (e.g. patients in intensive care units or in transplant units).
   
  When evaluating hand hygiene products for potential use in healthcare facilities, administrators or product selection committees should consider the relative efficacy of antiseptic agents against various pathogens and the acceptability of hand hygiene products by personnel. Characteristics of a product that can affect acceptance and therefore usage include its smell, consistency, color and the effect of dryness on hands.
   
  As part of these recommendations, CDC is asking healthcare facilities to develop and implement a system for measuring improvements in adherence to these hand hygiene recommendations. Some of the suggested performance indicators include periodic monitoring of hand hygiene adherence and providing feedback to personnel regarding their performance, monitoring the volume of alcohol-based hand rub used/1000 patient days, monitoring adherence to policies dealing with wearing artificial nails, and focused assessment of the adequacy of healthcare personnel hand hygiene when outbreaks of infection occur.
   
  Allergic contact dermatitis due to alcohol hand rubs is very uncommon. However, with increasing use of such products by healthcare personnel, it is likely that true allergic reactions to such products will occasionally be encountered.
   
  Alcohol-based hand rubs take less time to use than traditional hand washing. In an eight-hour shift, an estimated one hour of an ICU nurse's time will be saved by using an alcohol-based hand rub.

 

Personal Protective Equipment

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

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

Vaccine
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 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

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)

 

Post-Exposure Evaluation and Management

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)

  Wash wounds and skin with soap and water.
   
  Flush mucous membranes with water.
   
  Irrigate eyes with clean water, saline or sterile irrigants.

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:

  type of fluid (e.g., blood, visibly bloody fluid, other potentially infectious fluid or tissue, and concentrated virus)
   
  type of exposure (i.e., percutaneous injury, mucous membrane or non-intact skin exposure, and bites resulting in blood exposure)
   
  body location of exposure
   
  estimated volume of fluid, and
   
  estimated contact time.

Evaluate exposure source.

  Assess the risk of infection using available information.
   
  Test known sources for HBsAg, anti-HCV, and HIV antibody (consider using rapid testing).
   
  For unknown sources, assess risk of exposure to HBV, HCV, or HIV infection.
   
  Do not test discarded needles or syringes for virus contamination.

Evaluate the exposed person.

  Assess immune status for HBV infection (i.e., by history of hepatitis B vaccination and vaccine response).
   
  Check for previous testing for the presence of hepatitis B, hepatitis C, and HIV.
   
  Check tetanus immunization status.
   
  Perform baseline testing for the presence of hepatitis B, hepatitis C, and HIV.
   
  What current medical problems does the exposed person have?
   
  What medications is the exposed person currently taking?
   
  Is the exposed person pregnant or breast feeding?

 

Risk of Infection after Exposure

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:

  type of body substance involved
   
  route of exposure,
   
  volume of blood or body fluid involved
   
  severity of exposure,
   
  pathogen involved
   
  degree of viremia
   
  the immune status of the healthcare professional at the time of the injury
   
  whether appropriate PEP was used

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).

 

Post-Exposure Prophylaxis (PEP)

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:

  PEPline at http://www.ucsf.edu/hivcntr/Hotlines/PEPline; telephone 888-448-4911;
   
  HIV Antiretroviral Pregnancy Registry at http://www.apregistry.com/index.htm; Address: Research Park, 1011 Ashes Drive, Wilmington, NC 28405. Telephone: 800-258-4263; Fax: 800-800-1052; E-mail: registry@nc.crl.com;
   
  FDA (for reporting unusual or severe toxicity to antiretroviral agents) at http://www.fda.gov/medwatch; telephone: 800-332-1088; address: MedWatch, HF-2, Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20857;
   
  CDC (for reporting HIV infections in HCP and failures of PEP) at telephone 800-893-0485; and
   
  HIV/AIDS Treatment Information Service at http://aidsinfo.nih.gov/.

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.

 

Follow-up after 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.

HCV

  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
AND
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.

 

Post Exposure Precautions

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).

 

Conclusion

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.

 

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