Caring for the Worker Potentially Exposed to Bloodborne Pathogens

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Caring for the Worker Potentially Exposed to
Bloodborne Pathogens

• Lawrence D. Budnick, MD, MPH
• Associate Professor of Medicine
• Director, Occupational Medicine Service
• New Jersey Medical School
• University of Medicine Dentistry of New Jersey
• December 10, 2001

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Objectives

• Risks of exposure to blood and body fluids (BBFs)
• Current regulatory environment regarding
  bloodborne pathogens (BBPs)
• Prevention methods
• Clinical management
• - Assessment - Treatment
• - Counseling - Follow-up

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Health Care Workers
gt10 million persons in the US

• Paid and unpaid persons whose activities involve
• Working in a health care setting
• Contact with patients
• Contact with potentially infectious materials
  from patients in a health care setting

• May include, but not limited to
• Patient care nurses, physicians, EMS personnel,
  part-time staff, temporary contractors, students
• Non-patient care volunteers, dietary, clerical,
  janitorial, maintenance, housekeeping

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Potential Bloodborne Pathogens

• B virus (Herpesvirus simiae) Blastomycosis
  Brucellosis Creutzfeld-Jakob disease
• Cyptococcosis Cytomegalovirus Diphtheria
  Ebola fever Gonorrhea (cutaneous) Hepatitis B
  Hepatitis C Herpes Human
  immunodeficiency virus Leptospirosis

• Malaria Mycobacteriosis Rocky Mtn Spotted
  FeverMycoplasmosis Prion
  Sporotrichosis Scrub Typhus
  Sporotrichosis Staphylococcus aureusStreptococcu
  s Syphilis Toxoplasmosis
  Tuberculosis

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Hepatitis B Virus

• Hepadnavirus
• 42 nm double-
• stranded DNA
• 27 nm
• nucleocapsid
• core (HBcAg)
• Outer lipoprotein
• coat contains
• surface antigen
• (HBsAg)
• 4 major subtypes

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Hepatitis B - Clinical Features
Incubation period Average 9-13
weeks Range 6-26 weeks Clinical
illness 70 Chronic infection 2-8 Death
from chronic liver disease 15-25 of chronic
inf. Immunity Protective antibody
response identified
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Hepatitis B Epidemiology

• Incidence 80,000 cases/year
• Was 450,000 in the 1980s
• Prevalence 1.25 million are chronically infected
• In 1994, 1000 health care workers developed HBV
  infection
• Approx. 200 HCWs died each year

Source CDC, 1991 1997
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Risk Factors for Acute Hepatitis B, US, 1992-93
Heterosexual (41)
Injecting Drug Use (15)
Homosexual Activity (9)
Household Contact (2)
Health Care Employment (1)
Unknown (31)
Other (1)
Includes sexual contact with acute cases,
carriers, and multiple partners. Source CDC
Sentinel Counties Study of Viral Hepatitis
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Hepatitis C Virus

• Hepapavirus
• Enveloped RNA
• virus
• 90 subtypes

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Hepatitis C - Clinical Features

Incubation period Average 6-9
weeks Range 2-28 weeks Clinical
illness 20-40 Chronic hepatitis 70-85 Death
from chronic liver disease lt3 of chronic
inf. Immunity No protective antibody
response identified
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Hepatitis C Epidemiology

• Incidence 40,000 cases/year
• Was 240,000 in the 1980s
• Prevalence 3.9 million or 1.8 persons have been
  infected with HCV
• 2.7 million are chronically infected

Source CDC, 1991 1997
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Click for larger picture
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Occupational Transmission of HCV via NSI
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Human Immunodeficiency Virus

• Retrovirus
• Core of diploid RNA
• Spherical lipid
• envelope
• 2 major types

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Acute HIV - Clinical Features

• Incubation period Avg 2-4 weeks, range 1-12 wks
• Acute antiretroviral syndrome
• 50, 1-2 weeks duration
• Most common symptoms
• - Fever - Lethargy - Pharyngitis
• - Lymphadenopathy - Maculopapular rash
• - Myalgia - Arthralgia
• Immunity No protective Ab response identified
• AIDS incidence 50 in 10 years without Rx

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HIV Epidemiology in the U.S.

• HIV AIDS
• Incidence 42,156 cases/year
• Prevalence 450,151 persons are living with
  HIV/AIDS

Source CDC,2001
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U.S. HCWs with Occupationally Acquired AIDS/HIV,
to October 2001
Documented N 57
Possible N 138

Other Dental worker, dentist, EMT/paramedic,
housekeeper, health aide, other technician
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Potential for Transmission of HIVAfter
Percutaneous Exposure
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Potential for Transmission of Bloodborne Pathogens
CDC. MMWR 2001.
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Concentrations of Hepatitis B Virus in Various
Body Fluids

Low/Not
High
Moderate
Detectable
blood
semen
urine
serum
vaginal fluid
feces
wound exudates
saliva
sweat
tears

breast milk
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Needlestick Injuries

• 6-800,000 annually in US
• 16,000 (2) of these are likely to be
  contaminated by HIV
• Up to 80 of all unintentional exposures to blood
  are caused by needlestick injuries

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Needlestick/Sharps Reports Among Health Care
Workers

• Exposure Prevention Information Network
• 1993-95
• 77 hospitals
• 10 639 cases
• 91 medical students

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Type of Sharps as Cause of Percutaneous Injuries,
NaSH Hospitals, 6/95-7/99
N4951
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Items Most Frequently Causing Sharp-Object
Injuries, 1995
Adapted from Ippolito et al, 1997
Click for larger picture
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Reported Cause of Percutaneous Injuries, NaSH
Hospitals, 6/95-7/99
N3057
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When Do Needlesticks Happen?
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Centers for Disease Control and Prevention

• 11/99 NIOSH Alert Preventing Needlestick Injuries
  in Health Care Settings
• DHHS (NIOSH) Publ 2000-108
• 6/29/01 Updated USPHS Guidelines for the
  Management of Occupational Exposures to HBV, HCV,
  and HIV and Recommendations for Postexposure
  Prophylaxis
• MMWR v 50, RR-11

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NIOSH Alert - Employers

• Improved engineering controls in a comprehensive
  program involving workers
• Eliminate the use of needles where possible
• Implement the use of devices with safety features
  and evaluate their use for effectiveness and
  acceptability
• Analyze injuries to identify hazards and injury
  trends
• Set priorities and strategies for prevention
• Training
• Modify work practices that pose a hazard
• Promote safety awareness
• Reporting and timely follow-up
• Evaluate program effectiveness and provide
  feedback

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NIOSH Alert -Health Care Workers

• Avoid needles where safe effective alternatives
  available
• Help employer select and evaluate safety devices
• Use safety devices
• Avoid recapping needles
• Plan for safe handling and disposal before
  procedure
• Dispose of used needles promptly in sharps
  disposal containers
• Report all sharps-related injuries promptly
• Tell your employer about hazards
• Participate in training and follow recommended
  infection prevention practices

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OSHA General Duty Clause

• Section 5 (a) (1) of the OSH Act
• Each employer shall furnish to each of his
  employees employment and a place of employment
  which are free from recognized hazards that are
  causing or are likely to cause death or serious
  physical harm to his employees.

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OSHA Guidelines

• Management commitment
• Employee involvement
• Worksite analysis
• Hazard prevention and control
• Engineering design
• Administrative controls
• Personal protective equipment

• Medical management
• Prevention
• Early identification
• Systematic evaluation
• Conservative treatment
• Training and education
• Recordkeeping

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OSHA BloodbornePathogens Actions

• 12/6/91 - Occupational Exposure to BBP Final
  Rule. 29 CFR 1910.1030
• 1988, 1990, 1992, 1999, 2001 - OSHA Instruction
  Enforcement Procedures for the Occupational
  Exposure to BBP, CPL-2-2.69
• 11/6/00 - Needlestick Safety and Prevention Act
• 1/18/01 - Revised BBP Standard
• 1/18/01 - Recording and Reporting Occupational
  Injuries and Illnesses. 29 CFR 1904