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Halloween Special: Chicken-Go-Round

Occupational Health and Safety Administration (OSHA)

OSHA's final rule for Occupational Exposure to Bloodborne Pathogens [29 CFR 1910.1030(f)]:

requires dental employer to make immediately available confidential medical evaluation and follow-up to employee reporting exposure incident.

OSHA Definition for Dental Exposure

Exposure incident is any:

eye, mouth, mucous membrane, non-intact skin or other parenteral contact with blood or

Other Potentially Infectious Material (OPIM)

Puncture from contaminated sharps such as:

Injection needle or cut from scalpel blade

or suture needle

CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 3

Infectious Body Fluids

In addition to blood and body fluids containing visible blood, semen and vaginal secretions are also considered potentially infectious.

have been implicated in sexual transmission of HBV, HCV and HIV, or occupational transmission from patient to health care worker.

cerebrospinal fluid synovial fluid pleural fluid

peritoneal fluid pericardial fluid amniotic fluid.

Fluids Containing Blood

Considered a potential risk for transmission

CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 3

Low Risk/No Risk Body Fluids

Feces, nasal secretions, saliva, sputum, sweat, tears, urine and vomitus are not considered potentially infectious unless they contain blood.

The risk for transmission of HBV. HCV and HIV infection from these fluids and materials is extremely low.

Saliva Low Risk

Caution handling these fluids

CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 3

OSHA Definition for Dental Exposure

Saliva in dental procedures is treated as OPIM (other potential infectious material)

Exposure Risk Management Policies

Include hepatitis B vaccination Are consistent with

OSHA worker protection requirements

PHS exposure management recommendations

CDC exposure management recommendations

Infection Risk Variables

Pathogen
HBV HCV HIV

Type of exposure
Percutaneous injury (needle stick or cut) Splash onto mucous membrane or skin

Amount of source blood

Concentration of virus in source blood

Percutaneous Injuries: Job & Instrument

Dentists among other 33%

Injection needles Suturing needles Draw venous blood

Percutaneous Injuries: Instrument Timing

Manipulate needle in pt.

85% During and after device use

Transmission Risk

Hepatitis B Virus

Infection risk from needle stick or cut is 6%30%

risk near zero for vaccinated HCW

HBeAg-positive individuals much more infectious

Higher concentration of virus in blood

Survival of HBV in the Environment

Only 1/2 of all HBV positive HCWs recall having an

occupational injury. (DIRECT)

Many infected individuals can

recall caring for HBV+

patients. (INDIRECT)

CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 4

Survival of HBV in the Environment

HBV can survive in dried blood at room temperature on environmental surfaces for at least 1 week. Exposures have occurred via:
scratches abrasions burns on mucosal surfaces with poor infection control. in Hemodialysis Units.

CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 4

Occupational Transmission of HCV

Transmission from mucous membrane exposure to blood rarely occurs . HCV is not transmitted efficiently through occupational exposure to blood.

Rare
Following percutaneous injury from HCV+ source infection rate is 1.8% (range 0%-7%) similar to general population No transmission has been documented from non-intact or intact skin contact with HCV+ blood.

Risk HCV > HIV

CDC, MMWR, 6-29-01, Vol. 50/ No. RR-11, 5

Human Immunodeficiency Virus

Infection risk from needle stick or cut is 0.3%

Blood splash to eye, nose, or mouth is 0.1%

No confirmed DHCP occupational infections 2005 update to post-exposure prophylaxis (PEP)

Needle stick, cut = 0.3% Blood splash = 0.1%

Factors that Increase the Probability of HIV Infection

Exposure to a larger quantity of blood Injury with a device with visible blood Deep injury Injury with device placed in vein/artery Injury with blood from patient with advanced AIDS Host defense, immune response may prevent infection

Saliva Infectious for HIV?

In the absence of visible blood in the saliva,

exposure to saliva from a person infected with

HIV is not considered a potential risk for HIV transmission. However, caution is recommended when handling.

CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 3

Question 1
In health care workers immunized against hepatitis B, occupational exposure incidents involving which bloodborne pathogens have the greatest risk of resulting in infection?

A) Hepatitis A virus
B) Hepatitis B virus C) Hepatitis C virus D) HIV, class 1 infection status source E) HIV, class 2 infection status source

Answer
In health care workers immunized against hepatitis B, occupational exposure incidents involving which bloodborne pathogen have the greatest risk of resulting in infection?

C) Hepatitis C virus
Individuals who have developed immunity to HBV by vaccination have virtually no risk of infection. Hepatitis A is not considered a bloodborne pathogen because it is readily transmitted without exposure to blood.

HCV is more transmissible than HIV, although class 2 (high viral load)
HIV+ sources pose greater risk than class 1.

Risk of Infection from Needle Stick

Virus Comparison

Virus

Risk from Needle Stick or Cut

HBV
HCV HIV

6-30%
1.8% (range 0-7%) 0.3%

Risk Reduction Measures

Hepatitis B vaccination Engineering controls sharps safety devices and disposal

Work practice controls safe procedures Personal protective equipment Training & education

Safety Anesthetic Devices and Scalpels

Scoop Technique for Needle Recapping

Needle Recapping Methods and Devices

Personal Protective Equipment

Gloves Masks Eyewear with side shields Gowns

Written Policy for Handling Exposures

Provide written policies & procedures Identify risks & institute preventive measures

Educate HCP about infection control

Identify qualified HCP for postexposure

care

Alleviate DHCP misconceptions & fears

Student Exposure Event LSUSD-New Orleans

There may be variations in reporting and managing incidents at off-campus sites

POST-EXPOSURE PROTOCOL AND INJURY REPORT

Applies to all students and employees New Orleans Campus And Other Extra-mural Sites

POST-EXPOSURE PROTOCOL

Exposure Incident

A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials Results from the performance of student activities or employee's duties. Piercing mucous membranes or the skin barrier through such events as: needlesticks, human bites, cuts, and abrasions.

Parenteral

POST-EXPOSURE PROTOCOL
FIRST! STOP the procedure WASH the area with soap and water DO NOT use bleach or squeeze the area

For Eye Exposure Rinse the eye at the Eye Wash station (located in each clinic)

For Unexpected Exposure

If blood or OPIM splashes in your eyes or other mucous membranes, flush area with running water for 20 minutes
Wash any exposed area well with soap, using an antibacterial soap, not bleach!

3-36

For Unexpected Exposure

Gently treat any scabs and sores
Report the exposure to your supervisor Save any potentially contaminated object for testing purposes Seek medical care
3-38

POST-EXPOSURE PROTOCOL
INSTRUCTIONS AND RAPID HIV TEST LOCATION NEW ORLEANS -Instrument dispensary on each clinic floor (second, third and fourth floors)

Consent forms must be signed: by the source patient by the student or employee

PERFORM RAPID HIV TEST

Document if the source patient, student or employee refuses testing

Employer Responsibilities
Identify and document source of blood or OPIM
Obtain consent and arrange to test the source blood Inform you of the test results

3-40

POST-EXPOSURE PROTOCOL
TIME CRITICAL!!! 10 minutes for results Prophylactic Drug Protocol must be started within 2 Hours

RAPID HIV TEST

Review and answer questions in the exposure packet. Review each page and follow the directions. Send the completed packet to Linda Smith, RN.

HIV Post-exposure Prophylaxis

OraQuick Rapid HIV test for Oral Fluid

Provides results in 20 minutes

Begun preferably within hours Based on risk factors Rapid testing of source patient

Multidrug regimens Adverse side effects

Post Exposure Check List Notified faculty and Linda Smith, RN Employee exposure packet and quick HIV test obtained form the dispensary/BR CSR Student exposure packet and quick HIV test obtained from the dispensary/ BR CSR Student and Patient Source consents signed Have patient or student sign refusal if indicated. Immediately do Quick HIV test on Patient Source Results of test in 10 min neg____ pos_______ Notify Dr. McLean if Patient Source is positive for Student Exposure to determine if PEP is recommended Notify Concentra if Patient Source is positive for Employee Exposure. Send employee to Concentra to have blood drawn. Positive result, immediately have blood drawn from student and patient source by Linda or Labcorp. Negative result, blood to be drawn by Linda Smith or Labcorp- may be done a few days from exposure. Source should follow the student to Labcorp, not be driven by student. Fill out all forms and send packet to Linda Smith

POST-EXPOSURE PROTOCOL
POSITIVE RAPID HIV TEST Go immediately to have blood work drawn and to see if prophylactic combination drug regimen is indicated.

NEGATIVE RAPID HIV TEST Go the same day for the blood work.

POST-EXPOSURE PROTOCOL Students New Orleans Campus Labcorp

1716 St. Charles Ave. NO, LA 70130 525-8033 Mon-Fri 8-5pm Lunch 12-1 3.81 mi. from school

4330 Loveland St. Ste C Metairie, La 70006 455-5268 7:30-12 1-4:30 5.78 mi.from school

The school will be billed for the cost of the source patients blood work.

POST-EXPOSURE PROTOCOL Students

Student fills out LSUHSC injury/incident report within 24 hours and sends the completed packet to Linda Smith, RN via campus mail, box 145 or room 4312K

Counseling and follow up will be done by LSUHSC Student Health

The student must provide a copy of his/her UnitedHealth Care insurance card and drivers license

Follow-up After Exposure

Treatment and medical care depend on the type of exposure:

Substance involved Route of transmission Severity of the exposure

3-48

Follow up After Exposure

Treatment may include HBV vaccination or hepatitis B immune globulin (HBIG) Confidential exposure report form kept in the employees personnel file

3-49

Occupational Exposure Risk Evaluation

Occupational Exposure Risk Evaluation

Type & amount of body substance

Details of incident & wound

Infection status & viral load of

source

Epidemiologic prevalence if unknown

Susceptibility of exposed person

Occupational Transmission of HBV

The risk of HBV transmission following needle stick is directly related to the:
amount of blood HBeAg status of the patient.

Infection from HBeAg+ & HBsAg+

Infection from HBeAg- & HBsAg+ i

37-62%

23-37%

CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 3

HBV: Post-exposure Prophylaxis

Unvaccinated or inadequate anti-HBs response

Begun as soon as possible, preferably within 24 hours (No later than 7 days)

Hepatitis B immune globulin

and/or Hepatitis B vaccine

PEP for HBV Exposures Non-vaccinated HCWs

For occupational exposure to the blood or body fluids of an HBsAg + individual should receive

1 dose, 0.06mL/kg., of Hepatitis B immune globulin (HBIG)

1st dose of the HBV vaccine series.

PEP for HBV Exposures Non-responder HCW

Non-responder - person, who has not responded to the 1st HBV vaccine series

Occupational exposures body fluids of HBsAg

positive patients:
1 dose HBIG (within 24 hrs)

1st dose of 2nd HBV vaccine series.

CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 4

PEP for HBV Exposures Non-responder HCW

Non-responders to both the 1st and 2nd HBV vaccine series Occupational exposures to body fluids of HBsAg positive patients:

2 doses HBIG One within 24 hrs Second dose 1 month later

CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 4

Medical Consult Advised

When drug resistance is evident HCW is pregnant

Source is unknown
Source is high risk for HIV

infection

When Source is Unknown: Use of PEP: Case by Case Decision

Condition
If PPE worn Type of injury Severity of wound

Criteria
removes 50% of inoculum puncture, splash, laceration deep wound vs. superficial

Body fluid involved Quantity of body fluid Environment of patient

blood, saliva large amount minimal amount IDU clinic, shelter, community prevalence, etc.

When Source is Unknown: Use of PEP

2 drug PEP
(HBIG + HBV vaccine series)

Reevaluate

4 weeks

Negative discontinue

HCV: Post-exposure Prophylaxis

Following occupational injury on an HCV+ patient:
Perform baseline testing for exposure now & after 4-6 months anti-HCV and alanine aminotransferase (ALT)

Perform HCV RNA 4-6 weeks after exposure, to determine

active viral replication. Confirm repeatedly positive anti-HCV (EIAs) with additional

tests.

Treating early HCV disease

There is currently no vaccine to prevent HCV

infection, or PEP to prevent infection immediately following exposure

Recent studies suggest that early treatment of acute

HCV may prevent chronic infection.

HCV: Post-exposure Prophylaxis

Following exposure by an HIV+ patient:

Establish patients stage of infection:

HIV+ AIDS

Obtain recent blood tests: CD4 cells T-cell count viral load

HCV: Post-exposure Prophylaxis

Following exposure by an HIV+ patient (cont.):

Determine current medications

Determine if donor patient has a resistant strain

If information is not available, initiate PEP

PEP should be initiated even if the exposure exceeds 36 hours

HCV: Post-Exposure Prophylaxis (PEP)

Following exposure by an HIV+ patient (cont.):

assess and treat HCW, ideally within 2 hours.

perform HIV antibody testing for at least 6 months post-exposure.

Baseline

6 weeks

3 months

6 months

Evaluation of HIV Exposure

If symptoms of acute retroviral syndrome appear test HIV antibody immediately. Advise to use precautions to prevent secondary transmission. Evaluate for side effects at 72 hours and every 2 week thereafter. Treat for 4 weeks. Consider use of rapid HIV testing.
Source: Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm

HIV Transmission Risk

Basic PEP for HIV Exposure

Antiretroviral medications (ARVs)
ZDV: 600 mg/day, in 2 or 3 divided doses & 3TC: 150mg twice daily, or give as one COMBIVIR tab twice daily for 4 weeks.
Serious toxicity is rare, side effects are manageable, documented to reduce infection by approximately 81%.

Basic Regimen (2 drugs) available as COMBIVIR: Zidovudine (AZT) Lamivudine (3TC)

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm

Basic PEP for HIV Exposure

Antiretroviral medications (ARVs)
Other basic 2 drug regimens include: should be
considered in areas of the country where COMBIVIR resistance is common

3TC & Stavudine (d4T)

or d4T & Didanosine (ddl)

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm

PEP for High Risk HIV Exposure

Expanded PEP for HIV Exposures

An expanded 3 drug regimen should be considered

for exposures that pose an increased risk for infection.

Basic Regimen (2 drugs) +:

plus Protease Inhibitor

Zidovudin e (AZT)

Lamivudin e (3TC)

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm

PEP for HIV Exposure Related to: Patient Status

Exposure
Low Risk- VL Asymptomatic High Risk-AIDS Symptomatic, AIDS or VL

Unknown

Not severe, superficial or injury with solid needle or instrument

2 drug PEP

3 drug PEP

Usually none, *consider 2 drug PEP

Severe, blood 3 drug PEP on device, deep wound

VL- Viral load, low <1,500 c/ml, high >1,500c/ml * Consider if source is high HIV risk

3 drug PEP

Usually none, *consider 2 drug PEP

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm

PEP for HIV Exposure Related to: Patient Status

Exposure
Low RiskVL, Asymptomatic High Risk- VL AIDS, blood on instrument

Unknown

Small volume Consider 2 drug (drops) PEP Large volume, major spill 2 drug PEP

2 drug PEP

Usually none, consider 2 drug PEP* Usually none, consider 2 drug PEP*

3 drug PEP

VL-Viral load, low <1,500 c/ml., high >1,500 c/ml. * Consider if source has HIV risk
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm

Risk of HIV Infection Following Percutaneous Exposure to HIV+ Blood

EXPOSURE For a mucous Membrane exposure

RISK LEVEL
0.09%

For a percutaneous exposure risk For non-intact skin

0.3% < 0.09%

Management of HIV Negative Exposure

Source person is HIV seronegative, has no clinical

evidence of AIDS or symptoms of HIV infection

no further testing for HIV infection is indicated.

likelihood of the source person being in the window period of

HIV, in the absence of acute retroviral syndrome, is extremely small.

Question 2
Factors in determining appropriate prophylaxis after a potential occupational HIV exposure include
A. B. C.

Susceptibility of person exposed Mail-in HIV antibody testing of source individual

Testing of needle or sharp involved in the incident if the source

patient is unknown

D. E.

Expert judgment

All of the above

Answer
Factors in determining appropriate prophylaxis after a potential occupational HIV exposure include
D) Expert judgment

Determining PEP is largely a matter of judgment based on many clinical & epidemiologic factors. Because there is no vaccine & rare natural immunity, all persons are considered susceptible to HIV. The CDC encourages source patient rapid testing; immediate results are required. Testing of needles could provide indeterminate results & endanger personnel.

24 hour Needlestick Hotline (888) 448-4911

FREE
Established by the CDC and manned by the physicians of San Francisco General Hospital Available for consultation

Student At Risk Event on Campus

During hours when the Student Health Clinic is

not open, students should seek emergency care at:

Contact at after hour number 412-1366 Fast Track emergency room at the Medical Center of Louisiana, Charity Campus

Present needle stick insurance card at ER visit

Student At Risk Event on Campus

The student is entitled to seek his/her health care of choice. Health care will be made available if requested by the student at either:

LSUHSC-NO Student Health Clinic, or if contracted to another facility or location, from that satellite location following their policy for "at risk incidents. Injured students may also seek treatment from their personal health care provider.

Student At Risk Event on Campus

Counseling for LSUHSC-NO students is available through the LSUHSC-NO Student Health Mental Health Counselors or the Campus Assistance Program. The Student Health Clinic can also provide access to the Expert Review Panel (ERP) on behalf of students.

Summary of steps to be taken when and "at risk" incident occurs: 1. Report incident to supervisor 2. Provide immediate attention, testing 3. File required paperwork 4. Seek counseling and access to ERP, if

necessary.

LA State Board Policy

A seropositive dental health care provider shall not thereafter perform or participate directly in an exposure-prone procedure and shall be required to give notice of such seropositivity to the board.

II. HIV/HBV/HCV Infected Individuals

Expert Review Panel (ERP) Campus Assistance Program (CAP)

The purpose of the ERP

Provide review of cases Provide advice and make recommendations to the Chancellor Provide advice to HIV/HBV/HCV infected students, faculty, and employees

Certify extent and limitation on an individual's

involvement with exposure prone procedures;

Recommend modification of training curriculum and/or job re-assignment, where appropriate

The purpose of the Expert Review Panel (ERP)

Provide advice to HIV/HBV/HCV infected students, faculty, and employees, at their request, or by way of referral from an instructor, supervisor, department head, or dean.

Certify extent and limitation on an individual's involvement with exposure prone procedures;

Recommend modification of training curriculum and/or

job re-assignment, where appropriate

Campus Assistance Program (CAP)

24 hour crisis line Problem assessment Referral Confidential HIV/HBV/HCV testing; Pre/Post test counseling for those unable to obtain such services through other means

Crisis and short term emotional counseling

LSUHSC Reporting Standards

Faculty, staff, and students who are HIV/HBV/HCV infected, and who perform exposure prone procedures are encouraged to self-identify

Question 3
What should be considered the primary method to reduce HCP exposures to bloodborne pathogens from sharps?
A.
B. C.

D.
E.

Engineering controls Work practice controls Needle & sharp instrument handling techniques Gloves, masks & protective eyewear Patient screening & testing

Answer
What should be considered the primary method to reduce HCP exposures to bloodborne pathogens from sharps?
A)

Engineering controls

Whenever possible, engineering controls should be used. Work practice controls (i.e., techniques) are subject to human error & noncompliance. Gloves are minimally protective against cuts & sticks & relatively few percutaneous injuries are sustained to the face. Standard precautions obviate patient screening & postincident testing can rule out, rather than reduce, exposures.

Principles of Infection Control

Proper Barrier Techniques Follow CDC Guidelines for Infection Control
Use Appropriate Gloves For Cleaning Instruments

HBV Vaccination