Occupational Exposure to Blood Borne Pathogens | Copyright © 2009 CEUFast.com

Course Contents

	Purpose/Goals    Objectives    Introduction    Prevention of Exposure    Standard Precautions    Safe Injection Practice    Handwashing    Personal Protective Equipment    Immunization    Post-Exposure Evaluation and Management    Risk of Infection after Exposure    Post-Exposure Prophylaxis (PEP)    Follow-up after Exposure    Post Exposure Precautions    Conclusion    Reference    Click any section in the index above to browse to the corresponding course section

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:

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 HBV, HCV, HIV, malaria, syphilis, viral hemorrhagic fever, arboviral infections, Creutzfeldt-Jakob disease, and relapsing fever.

One serious bloodborne infection can cost more than a million dollars for medications, follow up laboratory testing, clinical evaluation, lost wages, and disability payments. 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 (Twitchell, 2003).

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. 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 (DHHS, 2003):

	the pathogen involved,
	the amount of blood involved in the exposure, and
	the amount of virus in the patient's blood at the time of exposure.

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 (DHHS, 2003).

Prevention of Exposure

Avoiding occupational blood exposures is the primary way to prevent transmission of hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (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 (CDC, 2008).

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, 2008). 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; therefore, barrier precautions should be used routinely to protect from all sources of potential infection. Standard precautions apply to nonintact skin and mucous membranes, blood, 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.

New elements of standard precautions have been added. These elements include safe injection practices, and the use of masks for insertion of catheters of injections into spinal or epidural spaces via lumbar puncture (Siegel, Rhinehart, Jackson, & Chiarello, 2007).

Safe Injection Practice

Nurses sustained the largest proportion of sharps injuries of all healthcare professionals, but laboratory staff, physicians, housekeepers, and other healthcare professionals are also injured (Perry, Jagger & Parker, 2003). Some of these injuries expose professionals to bloodborne pathogens that can cause infection. The most important of these pathogens are HBV, HCV, 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 decreased dramatically (Perry, et.al. 2003). A number of sources have identified the desirable characteristics of safety devices. These characteristics include the following (NIOSH, 2003):

	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 HBV and HCV amongst patients were traced back to ambulatory care facilities, which identified the need to define and reinforce safe injection practices in outpatient care setting. 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, 2008). The following are safe injection practices recommended by CDC (2008, pg. 1) apply to the use of needles, cannulas that replace needles, and, where applicable intravenous delivery systems.

	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.

	Use single-dose vials for parenteral medications whenever possible.

	If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile.

	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

	Employee safety

Handwashing

Handwashing is the most important measure to reduce the transmission of microorganisms. 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. CDC and Prevention Guideline for Hand Hygiene in Healthcare Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force (CDC, 2003, p. 51).

	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.
	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 CDC and other experts.
	When healthcare personnel's hands are visibly soiled, they should wash with soap and water.
	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 %, prevent cross contamination and protect patients and healthcare personnel from infection. Hand rubs should be used before and after each patient just as gloves should be changed before and after each patient.
	When using an alcohol-based hand rub, apply product to 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 significantly reduce the number of microorganisms on skin, are fast acting and cause less skin irritation.
	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 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.

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.

Immunization

Immunization is one method to reduce the transmission of communicable diseases. The following are recommendations for immunization for healthcare personnel (CDC, 2008).

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 post-exposure prophylaxis (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 (CDC, 2001).

The following are recommendation by the Centers for Disease Control (DHHS, 2003) for immediate activity after exposure.

Provide immediate care to the exposure site.

	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.

Report the exposure to the government agency responsible for managing exposures. Reporting is necessary because PEP treatment may be recommended.

Determine risk associated with exposure by:

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

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).

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 HBV vaccine became available in 1982 (CDC, January 2003). Healthcare professionals who have received hepatitis B vaccine and have developed immunity to the virus are at virtually no risk for infection. The risk of HBV 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 HBV. Amongst healthcare professionals who are susceptible, the risk of infection after one percutaneous exposure is 6%-30% (CDC, January 2003).

Although percutaneous injuries are among the most efficient modes of HBV transmission, these exposures probably account for only a minority of HBV 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 (CDC, 2001).

HBV 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 HBV into cutaneous scratches, abrasions, burns, other lesions, or on mucosal surfaces (CDC, 2001). 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, most body fluids are not efficient vehicles of transmission because they contain low quantities of infectious HBV, despite the presence of HBsAg (CDC, 2001).

HCV is not transmitted efficiently through occupational exposures to blood. Transmission has been reported rarely, but more than half the reported cases had other risk factors (Pearlman, 2004). The risk for HCV infection after a needlestick or sharps exposure to HCV-positive blood is approximately 1.8% (range: 0%–10%) (CDC, Nov., 2008). Transmission rarely occurs from mucous membrane exposures to blood, and no transmission in healthcare professionals has been documented from intact or non-intact skin exposures to blood.

HIV: The average risk of HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3%. The risk after a mucous membrane exposure is approximately 0.09% (Panlilio, Cardo, Grohskophf, Heneine, & Ross, 2005). 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. 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 (Panlilio, et.al. 2005).

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 (DHHS, 1999).

HBV: Recommendations for HBV 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 (DHHS, 2003).

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 (HBIG) is effective in preventing HBV infection after an exposure. The decision to begin treatment is based on several factors, such as (DHHS, 2003):

	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 and antiviral agents like, Interferon, with or without ribavirin, are not recommended for PEP of hepatitis C.

IG is not effective for postexposure prophylaxis of HCV. Antiviral agents (e.g., interferon) are not recommended to prevent HCV infection. The mechanisms of the effect of interferon in treating HCV are not understood, and an established infection might need to be present for interferon to be effective.

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. When HCV infection is identified early, the individual should be referred for medical management to a specialist in this area.

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. 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 (Panlilio, Cardo, Grohskophf, Heneine, & Ross, 2005). The PEP regimen should be started immediately. The optimal duration of PEP is not known.

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 (Panlilio, et.al, 2005, pg 10):

	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 (Panlilio, et.al, 2005).

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 (DHHS, 2003).

HCV:

	Postexposure follow-up of healthcare, emergency medical and public safety professionals for HCV virus (CDC, Nov., 2008):
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, Nov., 2008, pg.1).

HIV: Follow up counseling, postexposure testing, and medical evaluation should be done regardless of whether PEP was used (Panlilio, et.al. 2005). Perform HIV-antibody testing by enzyme immunoassay should be monitored at baseline, six weeks, 12 weeks, and six months. If the exposed person becomes infected with HCV, HIV testing should be done for 12 months (Panlilio, et.al, 2005). 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 (DHHS, 2003).

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.

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.

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.

Reference

CDC. (2008). Healthcare Personnel Vaccination Recommendations. CDC. Retrieved 8/16/09 from http://www.immunize.org/catg.d/p2017.pdf

CDC. (November, 2008). Hepatitis C Virus Infection, Past or Present. Retrieved 8/16/09 from http://www.cdc.gov/ncphi/disss/nndss/casedef/hepatitisccurrent.htm

CDC. (May, 2008). Injection Safety. (May 16, 2008). Retrieved 8/16/09 from http://www.cdc.gov/ncidod/dhqp/injectionSafetyPractices.html

CDC. (May, 2006). Infectious Diseases in Healthcare Settings. May 22, 2006. Retrieved 8/16/09 from http://www.cdc.gov/ncidod/dhqp/id.html.

CDC. (July, 2003). Exposure to Blood, what Healthcare Personnel Need to Know. (July 2003). Retrieved 8/16/09 from http://www.cdc.gov/ncidod/dhqp/pdf/bbp/Exp_to_Blood.pdf.

CDC. (January, 2003). Overview of Hepatitis B in Healthcare Settings. January 27, 2003. Retrieved 8/16/09 from http://www.cdc.gov/ncidod/dhqp/bp_hepatitisb.html.

CDC. (June 29, 2001). Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV. Retrieved 8/16/09 from www.cdc.gov.

DesRoches, P. & Moore, P. (2003). HIV post-exposure prophylaxis (PEP) - Effect on management of bloodborne pathogen exposures in the healthcare environment. AAOHN Journal. 51(9) p 370.

DHHS. (2003). Exposure to Blood: What Healthcare Personnel need to Know. The Public Health Foundation. July 2003. Retrieved 8/16/09 from http://www.cdc.gov/ncidod/dhqp/pdf/bbp/Exp_to_Blood.pdf.

Foster, K., & Clark, A. (2008). Increasing Hand Hygiene compliance: A Mystery? Clinical Nurse Specialist. 22(6), November/December 2008 pp 263-267. Retrieved 8/16/09 from http://ovidsp.tx.ovid.com/spb/ovidweb.cgi?&S=ILEIFPBNDNDDNKNONCGLBFJJMFGGAA00&Link+Set=S.sh.15|6|sl_10

NIOSH. (1999). Alert: Preventing needlestick injuries in healthcare settings. DSSH NIOSH publication 2000-108. Retrieved 8/16/09 from http://www.cdc.gov/niosh/pdfs/2000-108.pdf.

Panlilio, A., Cardo, d., Grohskophf, L., Heneine, W., & Ross, C. (2005). Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis. Center for Disease Control MMWR, September 30, 2005/54(RR09); 1-17. Retrieved 8/16/09 from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm.

Pearlman, B. (2004). Hepatitis C infection: A clinical review. Southern Medical Journal. 97(4), 365-376.

Perry, J. Jagger, J. & Parker G. (2003). Nurses and needlesticks, then and now. Nursing. 33(4), p. 22.

Pinkerton, S., Martin, J., Roland, M., Katz, M. et al. (2004). Cost-effectiveness of post-exposure prophylaxis after sexual or injection-drug exposure to human immunodeficiency virus. Archives of Internal Medicine. 164(1). P 46-56.

Siegel, J., Rhinehart, E., Jackson, M. & Chiarello, L. (2006). Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006. Center for Disease Control. Retrieved 8/16/09 from http://www.cdc.gov/ncidod/dhqp/pdf/ar/MDROGuideline2006.pdf.

Twitchell, K. (2003). Bloodborne pathogens: What you need to know-part I. AAOHN Journal 51(1) p 38-48.