Care of Women Living with HIV in LimitedResource Settings Infection Prevention for Healthcare Provid

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Care of Women Living with HIV in Limited-Resource
SettingsInfection Prevention for Healthcare
Providers

• Linda Tietjen, RN, BS, MPH
• Infection Prevention Consultant

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Objectives

• Discuss the risk of acquiring HIV and other
  diseases after a needle stick injury
• Describe standard precautions
• Describe methods for disposal of clinical waste
• Discuss post-exposure care
• Describe ways to make the workplace safer
• Recommend infection prevention practices for home
  care

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What is the most common or frequent risk
healthcare workers encounter while caring for
patients?
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Direct contact with blood and other body fluids.
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Surgical Procedures
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Surgical Procedures
Cleaning after Procedures
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Some Biological Hazards

• Bacterial
• E. coli
• Tuberculosis
• Streptococcus Group A
• Fungal
• Yeast
• Parasitic
• Malaria

• Viral
• HIV
• Hepatitis B virus
• Hepatitis C virus
• Rotavirus
• Ebola
• Papillomavirus

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How Risky is Working in Any Healthcare Setting?
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HIV Risk

• Risk of acquiring HIV after being stuck with a
  needle from an HIV-positive patient
• 0.4

Source Gerberding 1990.
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Hepatitis B Virus Risk

• Risk of acquiring HBV after being stuck with a
  needle from an HBV-positive patient

Source Seeff et al 1978.
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Hepatitis B Virus Risk

• Risk of acquiring HBV after being stuck with a
  needle from an HBV-positive patient
• 2737

Source Seeff et al 1978.
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Hepatitis B Virus Risk continued

• As little as 10-8 ml (.00000001 ml) of
  HBV-positive blood can transmit HBV to a
  susceptible host.
• Even in the US, approximately 10,000 healthcare
  providers acquire hepatitis.

Source Bond et al 1982.
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Hepatitis C Virus Risk

• Risk of acquiring HCV after being stuck with a
  needle from an HCV-positive patient
• 3-10

Source Lanphear 1994.
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Needle Stick Injuries

• 800,000 needle sticks are reported by healthcare
  workers each year in the US

Source Rogers 1997 Gumodoka et al 1997.
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Needle Stick Injuries continued

• Needle sticks occur
• While giving an injection
• While drawing blood
• During IV insertion/removal
• While disposing of sharps
• During waste disposal
• While suturing during surgery

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Other Exposures to Skin and Mucous Membranes

• Nonintact skin (tear in glove)
• Abraded
• Chapped
• Splashes to mucous membrane
• Intact skin

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HIV/AIDS Infection

• Worldwide
• 40 million people in the world are living with
  HIV/AIDS
• Many also have TB
• Local
• Do you know?

Source UNAIDS 2001. Chaisson 2002.
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Precaution Strategies

• Precaution strategies must address the fact that
• Most infectious agents are transmitted by contact
  with body substances (blood, vaginal secretions,
  semen, feces or sputum).
• Most infections are communicable for some period
  of time when symptoms are absent.

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Precaution Strategies continued

• Standard precautions
• Used during the care of all patients
• Developed to reduce the risk of transmission of
  microorganisms
• Apply to all blood and body secretions,
  excretions, non-intact skin and mucous membranes
• Transmission-based precautions
• Airborne
• Droplet
• Contact

Source CDC Isolation Guidelines 1996.
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Standard Precautions

• Hand hygiene
• Personal protective equipment
• Handling and processing of instruments and other
  items

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Hand Hygiene

• Handwashing
• Hand antisepsis
• Antiseptic handrub
• Surgical scrub

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Handwashing

• When
• Before and after patient care
• Before and after using gloves
• Between patient contact
• When visibly soiled
• Protect hands from dryness with petroleum-free
  creams
• No artificial nails, wraps, etc.
• Clear nail polish okay

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Handwashing continued

• Thoroughly wet hands.
• Apply soap.
• Rub all areas of hands and fingers for 10-15
  seconds.
• Rinse hands thoroughly with clean running water
  from a tap or bucket.
• Dry hands with clean, dry towel, if available. If
  not available, air dry hands.
• Use a paper towel when turning off water to avoid
  recontaminating hands.

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Handwashing continued

• If bar soap is used, provide small bars and soap
  racks that drain.
• Avoid dipping hands into basins containing
  standing water.
• Do not add soap to a partially empty liquid soap
  dispenser.
• When no running water is available, use a bucket
  with a tap that can be turned off while lathering
  hands and turned on again for rinsing or use a
  bucket and a pitcher.

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Hand Antisepsis

• Similar to plain handwashing except involves use
  of an antimicrobial agent
• Use before performance of any invasive
  procedures, (e.g., placement of an intravascular
  catheter)
• Use when caring for immunocompromised patients
  (premature infant or AIDS patients)
• Use when leaving the room of patients with
  diseases spread via direct contact

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Antiseptic Handrub

• Make alcohol / glycerin solution by combining
• 2 ml glycerin
• 100 ml 60-90 alcohol solution
• Use 3-5 ml of solution for each application
• Rub the solution vigorously into hands until dry

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Surgical Scrub

• Supplies
• Antiseptic
• Running water
• Stick for cleaning the fingernails
• Soft brush or sponge for cleaning the skin
• Towels

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Surgical Scrub continued

• If no antiseptic soap is available
• Wash hands and arms with soap / detergent and
  water.
• Clean fingernails thoroughly.
• Scrub with a soft brush or sponge and rinse.
• Dry hands thoroughly.
• Apply handrub to hands and forearms until dry.
• Repeat handrub two more times.

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Personal Protective Equipment

• Gloves
• Mask / goggles / face shields
• Gown / apron
• Closed shoes

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Personal Protective Equipment continued

• Gloves
• Utility gloves
• Exam gloves
• Surgical gloves
• Double gloving

Source Gerberding 1993.
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Personal Protective Equipment continued

• Goggles
• Face masks
• Aprons

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Personal Protective Equipment continued

• Closed shoes

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Immunization for Adults

• Hepatitis A
• Hepatitis B
• Influenza
• Pneumococcus

• Tetanus, diphtheria
• Chicken pox
• Measles, mumps, Rubella (German measles)

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Immunization for Adults continued

• Hepatitis A
• Hepatitis B
• Influenza
• Pneumococcus

• Tetanus, diphtheria
• Chicken pox
• Measles, mumps, Rubella (German measles)

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Prevention of Sharps Injuries

• Limit use of sharps whenever possible. Use
• Oral antibiotics / medicine instead of injectable
  or IVs
• Needleless or retractable injection systems
• Blunt needles for suturing
• Disposal of sharps (e.g., needles, scalpels,
  capillary tubes, biopsy glass)
• Immediately after use
• Puncture proof container at point of use

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Handling Needles and Sharps

• Use a safe zone for passing sharps
• Say pass or sharps when passing sharps

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Handling Needles and Sharps continued

• Use a needle driver or holder, not your fingers.
• Use blunt needles when available.
• Do not blind suture.

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Handling Needles and Sharps continued

• Always remove blades with another instrument

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Handling Needles and Sharps continued

• Use a puncture-proof container for storage and/or
  disposal
• Do not recap a needle before disposal unless
  using the one-hand technique

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Instrument Processing
Decontaminate
Clean

• High-Level Disinfect
• Boil
• Steam
• Chemical

• Sterilize
• Chemical
• High pressure steam
• Dry heat

Dry/Cool and Store
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Linen Processing

• Wash in hot, soapy water and dry
• Same in hospital or home

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Disposal of Clinical Waste

• Place contaminated items in leak-proof container
  or plastic bag.
• Dispose by incineration or burial.

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Disposal of Placenta

• If disposing
• Place in plastic bag and incinerate or bury
• Wash hands after disposal or burial
• If sending home
• Place in plastic bag or leak-proof container
  (such as clay pot) brought by family
• Instruct family not to remove from plastic bag or
  container when burying

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Post-Exposure Management

• If exposure occurs
• Skin
• Wash with soapy water
• Do not use caustic agent or bleach
• Eye, nose, mouth
• Rinse with water for 10 minutes
• Needle stick or cut
• Wash with soapy water
• Allow to bleed freely
• Apply first aid

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Body Fluids and Risk of HIV Exposure
Poorly Defined Risk Amniotic fluid, cerebrospinal
fluid, pleural fluid, periotoneal fluid,
pericardial fluid, synovial fluid
Low risk Cervical mucus, emesis, feces, saliva,
sweat, tears, urine, breastmilk Unless visibly
contaminated with blood
Source CDC MMWR 1998.
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Body Fluids and Risk of HIV Exposure
Poorly Defined Risk Amniotic fluid, cerebrospinal
fluid, pleural fluid, periotoneal fluid,
pericardial fluid, synovial fluid
Low risk Cervical mucus, emesis, feces, saliva,
sweat, tears, urine, breastmilk Unless visibly
contaminated with blood
Source CDC MMWR 1998.
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Body Fluids and Risk of HIV Exposure
Poorly Defined Risk Amniotic fluid, cerebrospinal
fluid, pleural fluid, periotoneal fluid,
pericardial fluid, synovial fluid
Low risk Cervical mucus, emesis, feces, saliva,
sweat, tears, urine, breastmilk Unless visibly
contaminated with blood
Source CDC MMWR 1998.
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Body Fluids and Risk of HIV Exposure
Poorly Defined Risk Amniotic fluid, cerebrospinal
fluid, pleural fluid, periotoneal fluid,
pericardial fluid, synovial fluid
Low risk Cervical mucus, emesis, feces, saliva,
sweat, tears, urine, breastmilk Unless visibly
contaminated with blood
Source CDC MMWR 1998.
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Post-Exposure Management

• Post-exposure prophylaxis (PEP) considerations
• Evaluate risk.
• Source of fluid or material
• Type of exposure
• Evaluation of exposure source patient
• HIV status
• Stage of infection
• Test healthcare worker for HIV after exposure as
  baseline, if available.

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Post-Exposure Prophylaxis

• Treatment, if started, should be initiated
  immediately after exposure, within 1-2 hours.
• Decisions regarding which and how many
  antiretroviral agents to use are largely empiric.
• CDC recommendations
• Zidovudine (ZDV) and lamivudine (3TC)
• Lamivudine (3TC) and stavudine (d4T)
• Didanosine (ddI) and stavudine (d4T)
• Continue treatment for 4 weeks
• Medical followup

Source CDC MMWR 2001.
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Infection Control for Tuberculosis (TB)

• Place patient in room with good ventilation
• Place patient in room receiving direct sunlight
• Patient should wear mask over mouth and nose
  until noninfectious, if possible
• Patient should cover mouth when coughing and use
  sputum containers with lids
• TB patients become noninfectious within several
  days of beginning effective treatment

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Making the Workplace Safer

• Continue identifying risk.
• Continue to use standard precautions.
• Teach patients it is okay to remind healthcare
  workers to wash hands and use gloves.
• Actively role model and support IP practices

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Supporting a Safer Workplace

• Support from hospital administrator
• Positive feedback from supervisor

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Recommendations for IP in the Home

• Use standard precautions
• Hand wash or handrub
• Personal protective equipment when exposure to
  blood and bodily fluids is anticipated
• Reduce risk
• Wash dishes and laundry in hot soapy water.
• Use utility gloves to handle bed and bath linens
  if they are soiled with blood/body fluids.
• Do not share toothbrush or razor.
• Teach patients and family to wash their hands
  before and after giving care.

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Summary

• Minimize and prevent exposure to infection by
• Using standard precautions with every patient
• Disposing of clinic waste properly
• Using post-exposure care when necessary
• Work together to make the workplace safer.
• Teach patients and their families how to reduce
  risk of exposure in the home.