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  • Clinic Environment

About EHS
  • We support the University's core mission of
    teaching, research, and service by providing
    comprehensive environmental, health and safety
    services to the University community including
    education through training and consultation
    maintaining a safe environment ensuring
    regulatory compliance and controlling recognized
    health and safety hazards. To achieve this
    mission we must rely on all University employees
    to understand and recognize safety policy and

About EHS
  • The responsibility of the department of
    Environment, Health and Safety is to develop a
    comprehensive program to comply with the
    provisions of each of the following regulations
    Occupational Safety and Health Act (OSHA)
  • Environmental Protection Agency (EPA)
  • NC DENR NC Department of Environment and Natural
  • Joint Commission on Accreditation of Healthcare
    Organization (JCAHO)
  • NC Radiation Protection Section (NCRPS)
  • Office of State Personnel (OSP)
  • NC Fire Prevention Codes
  • NFPA 101 Life Safety Codes

About EHS
  • EHS provides comprehensive support for the
    University community in the areas of
    environmental compliance, occupational health and
    safety. To learn more about each section, please
    visit EHSs website at http//

Workplace Safety Program
  • In accordance to University policy and North
    Carolina General Statute Article 63, each state
    agency must have a written Health and Safety
    program with clearly stated goals or objectives
    that promote safe and healthful working
    conditions. The Environment, Health and Safety
    manual along with other specific manuals, such as
    Radiation Safety Manual, Laboratory Safety
    Manual, and Biological Safety manual serves as
    the University's written Health and Safety
    program. These manuals provide University
    employees with the necessary guidance in
    maintaining a safe work environment. Each of
    these manuals can be viewed in more detail by
    selecting "Manuals" from the EHS web site.
  • Other elements of the Workplace Safety program
  • Conduct new employee training to help with the
    identification of and correction of hazards,
  • Review workplace incidents and develop ways to
    eliminate or minimize hazards, and
  • Employee input through safety committees

Workplace Safety Program
  • UNC's health and safety committees perform
    workplace inspections, review injury and illness
    records, make advisory recommendations to the
    administration, and perform other functions
    determined by the State Personnel Commission. The
    Workplace Safety Committees report through the
    following structure
  • UNC employees should contact EHS or any committee
    member regarding safety concerns.

Workplace Safety Program
  • If you are interested in serving on one of the
    committees please feel free to contact the EHS
    office at (919) 962-5507.

Fire Safety Program
  • UNC's Fire Safety program is based on NFPA 101
    Life Safety Code, N.C. Fire Prevention Code, and
    OSHA 1910 Subpart E. Your understanding and
    contribution to Fire Safety is the key to an
    effective fire protection program for the
    University. Regularly inspecting your area for
  • electrical hazards
  • storage in hallways
  • blocked exit ways
  • adequate lighting of exits
  • general housekeeping
  • can prevent a fire from occurring and provide
    employees with a safe passage in the event of a

Fire Safety Program
  • If a fire or other emergency occurs in your
    building, employees must know two Means of Egress
    (exit). OSHA defines Means of Egress as "A
    continuous and unobstructed way of exit travel
    from any point in a building or structure to a
    public way." The three main components of Means
    of Egress are
  • The way of Exit Access
  • The exit
  • The way of Exit Discharge

Fire Safety Program
Exit Access is the area in which an employee uses
as their means of exiting to an exit.
Exit Discharge is the exit from a building to a
public way.
Exit is the protected way of travel to the exit
Fire Safety Program
  • The Department of EHS has prepared a general
    Emergency Action Plan for the University to
    follow. An Emergency Action Plan is "a plan for
    the workplace describing what procedures the
    employers and employees must take to ensure
    employee's safety from fire and other
    emergencies" (1910.35j). The plan includes
  • posting of planned evacuation routes
  • procedures to follow in the event of a fire or
  • procedures to account for employees after
  • procedures for employees who remain to operate
    critical equipment in an emergency

Fire Safety Program
  • Posting of Planned Evacuation Routes - Building
    evacuation procedure for your department should
    be posted on the office bulletin board and at all
    elevators. Employees should know at least two
    evacuation routes for their designated work area
    and any area that they frequent often. Employees
    are encouraged to evaluate the building
    evacuation areas daily to ensure that there are
    no obstructions. If obstructions are found,
    please report it to the EHS immediately at (919)

Fire Safety Program
  • Procedures to Follow - If a fire emergency was to
    occur in your workplace, it is vital that you be
    prepared to react. The acronym RACE provides the
    basic steps of the Emergency Action Plan to
  • Remove or rescue individuals in immediate danger
  • Activate the alarm by pulling the fire pull
    station located in the corridors and calling 911.
  • Confine the fire by closing windows, vents and
  • Evacuate to safe area (know the evacuation routes
    for your areas).

Fire Safety Program
  • Procedures to Account for Employees The
    University has designated an Emergency
    Coordinator(s) for all occupied buildings. Each
    Emergency Coordinator (EC) is responsible for
    assisting in the safe and orderly emergency
    evacuation of employees. In preparation for an
    emergency, the EC completes an information card
    that includes
  • evacuation monitors' names
  • employee names and phone numbers occupying
  • location of employees needing assistance
  • rooms containing hazardous material,
  • and equipment needing special attention.

Fire Safety Program
  • In an emergency, each Emergency Coordinator is
    responsible for the following in accordance with
    the University Emergency Plan
  • Sweep through assigned area to alert occupants
    that an evacuation is in process.
  • Assist building occupants needing special
  • Report to the University Emergency Command Sector
    with emergency information card
  • Advise emergency personnel regarding building
  • Account for all employees by meeting building
    occupants at the assembly area
  • Advise building occupants regarding situation and
    when re-entry is permitted
  • Advise Facilities Services personnel in cleanup

Fire Safety Program
  • To extinguish a fire requires proper
    identification of the type of fire extinguisher
    to use. There are four classes of extinguishers
    to choose from.
  • Currently University buildings are equipped with
    Type ABC fire extinguishers, except in computer
    labs or mechanical rooms with have CO2

Fire Safety Program
  • Only University employees working in healthcare,
    emergency response, and/or whose job requires
    them to use a fire extinguisher are required to
    receive annual hands on fire extinguisher
    training. EHS Fire Safety section conducts annual
    classes in different locations on campus. For
    other employees it is beneficial to know how a
    fire extinguisher is used. Remembering the
    acronym PASS will assist in the proper use of a
    fire extinguisher.
  • Pull the pin between the handles.
  • Aim the nozzle at the base of the fire.
  • Squeeze the handles together.
  • Sweep the extinguisher from side to side at the
    base of the fire.

Fire Safety Program
  • A few fire safety reminders
  • Everyone is responsible for keeping the work area
    safe from fires.
  • Review your evacuation routes to ensure that
    exits and passageways are unobstructed.
  • Practice good general housekeeping.
  • Store flammable liquids and combustible material
  • Report any fire hazards or other safety concerns
    immediately to the department of Environment,
    Health and Safety at (919) 962-5507.

Workers Compensation Program
  • Workers' Compensation benefits are available to
    any University employee (whether full-time,
    part-time, temporary) who suffers disability
    through accident or illness arising out of, and
    in the scope of, his or her employment, according
    to the North Carolina Workers' Compensation Act.

Workers Compensation Program
  • The benefits provided to University Employees
    include medical and leave. Medical benefits
    include all authorized medical services such as
    physician visit, prescriptions, physical therapy,
    rehabilitation, etc. Leave benefits are provided
    to employees when an authorized medical provider
    places an employee out work.

Workers Compensation Program
  • If you receive an injury or occupational illness,
    go directly to the University Employee
    Occupational Health Clinic (UEOHC) located at 145
    N. Medical Drive. The UEOHC is open from 830 am
    to 430 pm Monday thru Friday, except holidays.
  • For after hours needlestick/human blood or body
    fluid exposures, please call UEOHC at 966-9119.
    The UEOHC line will automatically forward your
    call to Healthlink in order to gather the
    appropriate information and put you in contact
    with the Family Practice physician covering the
    needlestick hotline. For all other after-hour
    work related injuries that require immediate
    medical care, go directly to the UNC Emergency
    Department. If immediate medical care is not
    needed, then please report to the UEOHC the
    following day.
  • For a life-threatening injury or illness, go
    directly to the Emergency Department located in
    the Neurosciences Hospital on Manning Drive.

Workers Compensation Program
  • If you experienced an on-the-job injury or
    illness, you are to report the incident
    immediately to your supervisor no matter how
    minor. Once the injury is reported, an incident
    investigation will occur to determine the cause
    of the incident and corrective action taken to
    prevent the incident from reoccurring. Please
    note Failure to report an injury could result in
    the denial of your claim.

Workers Compensation Program
  • For further information concerning University
    policies on workplace injuries and illnesses,
    refer to the "Workers' Compensation" pages on the
    EHS web site.

Hazard Communication Program
  • The OSHA Hazard Communication standard
    (1910.1200) requires that employees be informed
    of the hazards of chemicals that they may work
    with or are present in their work area. The four
    elements of this program are
  • Labeling
  • Hazardous Chemical Inventories
  • MSDS
  • Training
  • Each of these elements will be reviewed in more

Hazard Communication Program
  • All containers of hazardous chemical must be
    labeled with at least three items
  • the name of the chemical,
  • any hazard warnings associated with the product
  • the name and address of the manufacturer.
  • The name of the chemical must be spelled out
    completely, no molecular formulas are allowed.

Hazard Communication Program
  • All departments must maintain a current Chemical
    Inventory List that is reviewed and updated at
    least annually.

Hazard Communication Program
  • Material Safety Data Sheets must be accessible 24
    hours a day. MSDSs are prepared and distributed
    by the chemical manufacturer or distributor to
    provide important information concerning the
    chemical in question. MSDSs contain the identity
    of the chemical, the manufacturer's name, address
    and phone number and information regarding the
    physical and chemical characteristics of the
    chemical such as toxicity, flammability,
    corrosively physical and health hazards such as
    exposure hazards exposure limits precautions
    and controls and emergency and first aid
    treatment for exposures. A MSDS must be available
    for every chemical on the department's Chemical
    Inventory List.

Hazard Communication Program
  • All University employees who work with chemicals
    or have chemicals in their workplace are required
    to have hazardous materials' training initially
    upon employment and when any new chemical are
    introduced in their workplace thereafter.
  • The Supervisor of employees who will be working
    with hazardous material will provide more
    in-depth training.
  • The training will cover
  • the proper use,
  • handling, and
  • personal protective equipment
  • required for the safe handling of all hazardous
    chemicals. This training is mandatory for all
    employees handling hazardous materials.

Hazard Communication Program
  • EHS is available to assist any department,
    supervisor, and/or employees with information
    concerning the University's Hazard Communication
    Program, Material Safety Data Sheets, etc. Please
    feel free to contact EHS at (919) 962-5507.

Clinical Safety Program
  • The clinical safety program at UNC is designed to
    promote environments that are free of hazards
    specific to clinical environments. Clinical
    environments are classified as areas such as
    healthcare facilities, laboratories that are
    dealing with blood or bodily fluids, or any other
    facility that is dealing with procedures that
    involve hazardous materials and biological
    agents. These areas need special attention to
    hazards to protect both the employees and the

Clinical Safety Issues
  • In the clinic environment safety issues arise
    that are specific to personnel working in a
    healthcare facility. All University healthcare
    workers are expected to conduct their daily
    activities in such a way that they do not expose
    themselves or others to potential injury, such
  • Needlestick or sharp injuries
  • Back injuries
  • Chemical exposures
  • Slips and falls

Needlesticks or Sharp Injuries
  • Needlesticks or sharp injuries are instances
    where an employee was exposed to a needle or
    other sharp tool or object, and were injured.
    These injuries normally break the skin and expose
    the employee to blood or other bodily fluids.
  • Certain measures may be taken to reduce exposure.
    These measures include using appropriate
    engineering controls and using proper personal
    protective equipment (PPE).

Needlesticks or Sharp Injuries, cont.
  • Engineering controls are used to isolate or
    remove the bloodborne pathogens hazards from the
    workplace. Examples may include but are not
    limited to sharps disposal containers,
    self-sheathing needles, and safer medical
    devices, such as sharps with engineered sharps
    injury protectors and needleless systems.
    Personal Protective Equipment (PPE) is
    specialized clothing or equipment worn by an
    employee for protection of a hazard.

Lifting Techniques
  • Proper lifting techniques are also important in
    clinic environments. An employee should maintain
    good body posture, use safe body mechanics (bend
    at the hips and knees, not at the waist), and
    assess the situation of a patient before lifting
    or transferring a patient.
  • An employee may also use lifting devices to aid
    them in achieving proper lifting techniques. In
    the healthcare facilities, there are devices
    which aid employees when lifting a patient.

Chemical Exposures
  • Following appropriate procedures when exposed to
    chemicals or other hazardous materials is
    necessary for preventing incidents. Hazardous
    materials are those substances that are
    potentially hazardous to your safety and health.
    Employees may encounter many hazardous materials
    that are classified as health and/or physical
  • A health hazard is anything that causes acute or
    chronic health effects. A physical hazard is any
    chemical that is flammable, an oxidizer, or

Chemical Exposures, cont.
  • Examples of hazardous materials in the clinic
    environment include infectious waste, flammable
    liquids and gases, toxic chemicals, radioactive
    materials, cancer causing (carcinogens) chemicals
    and drugs, and compressed gas cylinders.
  • All departments using hazardous chemicals are
    responsible for determining if a less hazardous
    chemical may be substituted. The unsafe handling
    of hazardous materials can have an impact on
    ambulatory care or hospital operations.
    Appropriate precautions should always be used in
    handling hazardous materials..

Slips and Falls
  • Another example of incidents that are common in
    the clinic environment is slips and falls.
    Employees should be aware of their surroundings
    and should pay particular attention to areas
    where there could be potential moisture on the
    floor or walking surface that might cause them to
    slip or fall.

Needlestick Safety and Prevention Act
  • The Needlestick Safety and Prevention Act became
    law in 2000. This law revised the Bloodborne
    Pathogens Standard (29 CFR 1910.1030) to include
    safer medical devices, such as sharps with
    engineered sharps injury protections and
    needleless systems, as examples of engineering
    controls designed to eliminate or minimize
    occupational exposure to bloodborne pathogens
    through needlesticks and other percutaneous

  • Requirements of the needlestick safety and
    prevention act include
  • Review and update exposure control plans to
    reflect changes in technology that eliminate or
    reduce such exposure,
  • Document the consideration and implementation of
    appropriate commercially available, safer medical
    devices that eliminate or reduce exposure,
  • Maintain a sharps injury log, noting the type and
    brand of device used, where the injury occurred,
    and an explanation of the incident,
  • Seek input on such engineering and work practice
    controls from the affected healthcare workers.

Needlestick Safety and Prevention at UNC
  • UNC makes every attempt to ensure safety for all
    employees who are exposed to needles and other
    sharps. Needlesticks are one of the most common
    incidents in the workplace. UNC and
    UNC-Healthcare have formed a Needlestick Task
    force that convenes twice a year to examine and
    evaluate techniques and protocols to stay abreast
    of innovative technologies to decrease the number
    of needlestick occurrences. In addition, members
    of the Occupational Health/Clinical Safety
    Committee also address needlestick safety and

Latex Exposure
  • A recently recognized work place hazard for some
    healthcare workers is latex exposure. For some
    individuals exposure to latex products, such as
    powdered latex exam gloves, can cause a mild to
    severe allergic reaction.

Latex Allergy Prevention
  • To prevent latex allergies do the following
  • Use non-latex gloves for activities that are
    likely to involve contact with infectious
  • If you choose latex gloves, use powder-free
  • When using gloves, do not use oil-based hand
    cream or lotions
  • Recognize the symptoms of latex allergy
  • Always wash hands after removing gloves

Latex Allergy
  • If you believe that you may have a latex allergy,
    you should notify your supervisor and contact the
    University Employee Occupational Health Clinic
    (UEOHC) for evaluation at (919) 966-9119.
    Additional information regarding potential
    hazards associated with latex exposure is also
    available by contacting the UEOHC.

Disaster Plan Manuals
  • The UNC Department of Environment, Health and
    Safety, UNC Hospitals and some specific
    departments have Disaster Plan Manuals that
    provide all employees with a written resource to
    accomplish an effective response to disaster
    events. The UNC EHS plan can be found at EHS's
    online manual.
  • The Director-on-Call and the Disaster Commander
    will assess the need for personnel, supplies, and
    equipment. In addition, all departments need to
    have an internal plan on what to do during a

If a Disaster Occurs
  • If a disaster occurs which compromises the
    utilities of the facility, it should be reported
    to the Facilities Services Division (919)
    962-3456 in University buildings and Plant
    Engineering (919) 966-4484 in Hospital buildings.

ID Badges
  • It is imperative that employees wear their ID
    badges at all times. These badges will include
    emergency code announcements and steps to take in
    the event a code is called. ID badges are also an
    essential part of the health and safety system
    due to security issues.

Hazard Assessment and Equipment Selection
  • The department in consultation with the
    Department of Environment Health and Safety will
    assess the workplace to determine if hazards are
    present, or likely to be present, and requires
    the use of Personal Protective Equipment (PPE).
    If such hazards are present, or likely to be
    present, the University will
  • Select and have each affected employee use the
    types of PPE that will protect the affected
    employee from the hazards identified in the
    hazard assessment.

Hazard Assessment and Equipment Selection, cont.
  • Communicate selection decisions to each employee
  • Select PPE that properly fits each affected
  • Verify that the required workplace hazard
    assessment has been performed through a written
    certification that identifies the workplace
    evaluated, the person certifying that the
    evaluation has been performed, and the dates of
    the hazard assessment.

Hazard Assessment and Equipment Selection, con't.
  • Employees working in a clinical facility must
    wear proper personal protective equipment. An
    assessment should be conducted to determine
    proper personal protective equipment. Below you
    will find an example of a hazard assessment for
    employees working in a healthcare environment.
    Also, remember to always use standard precautions
    as all patients are potentially infectious.

Personal Protective Equipment (PPE)
  • Personal Protective Equipment should be
  • Inspected before and after each use
  • Used where there is occupational exposure
  • Used appropriately
  • Used only when its integrity is insured
  • Accessible
  • Removed when contaminated and prior to leaving
    the work area

PPE Training
  •  The University will provide training to each
    employee who is required to use PPE. Each
    affected employee shall demonstrate an
    understanding of the training and the ability to
    use PPE properly, before being allowed to perform
    work requiring the use of PPE. The training
    program must verify that each affected employee
    has received and understood the required training
    through a written certification that contains the
    name of each trained employee, the dates of
    training, and that identifies the subject of the

PPE Training, cont.
  • Each employee is to be trained to know at least
    the following
  • when PPE is necessary
  • what PPE is necessary
  • how to properly don (put on), doff (take off),
    adjust, and wear PPE
  • the limitations of the PPE
  • the proper care, maintenance, useful life and
    disposal of the PPE

PPE Training, con't.
  • The training program must verify that each
    affected employee has received and understood the
    required training through a written certification
    that contains the name of each trained employee,
    the dates of training, and that identifies the
    subject of the certification. Click this link for
    a certification form for Personal Protective

Training and Medical Surveillance Program
  • OSHA and JCAHO regulations require that all
    employees who have duties in or are located in a
    healthcare facility receive medical surveillance
    and attend additional safety training.

Medical Surveillance
  • All healthcare employees are required to complete
    a one-time immunization review through the UEOHC.
    The immunization review consists of
  • A record of 2 Measles, 2 Mumps, and 2 Rubella
    (disease or vaccine for all) OR titers for all OR
    a record of 1 Tdap (Tetanus, diptheria, acellular
  • A record of the Hepatitis B series (for those
    exposed to blood or bodily fluids)
  • Verbal response for Varicella (Chicken Pox)
  • Verbal response for Latex Allergy
  • Annual Tuberculosis Screening

Medical Surveillance, cont.
  • Annually thereafter, employees are to complete a
    Tuberculosis Screening through the UEOHC. UNC
    Environment, Health and Safety will notify
    employees who need to renew his/her TB screening
    via campus mail the month that it is up for
    renewal. Department representatives will also
    receive monthly compliance reports stating the
    current status of their employees.

  • Employees who are classified as working in a
    clinic environment are required to complete
    annual training on JCAHO/General Safety,
    Tuberculosis, and Bloodborne Pathogens for those
    who are potentially exposed to blood or other
    bodily fluid. These training requirements can be
    completed either by utilizing EHS's online
    self-study units or by attending instructor led
    classes which are held every month. For more
    details, select the training section on the EHS

Bloodborne Pathogen Introduction
  • On December 6, 1991, the Occupational Safety and
    Health Administration (OSHA) published their
    standard for occupational exposure to bloodborne
    pathogens in the Federal Register 1910.1030,
    which can be found at the following website A component of this standard
    requires the employer to provide annual education
    regarding the occupational hazard of bloodborne
    pathogens. There are 14 required components of
    this education all of which are incorporated in
    this study module.

Bloodborne Pathogen Intro., cont.
  • These components are listed in the Federal
    Register 1910.1030. It is important to remember
    that OSHA standards are federal law and
    compliance is mandatory. However, it is more
    important to recognize that this standard was
    established to help protect the healthcare worker
    from the serious workplace hazard of bloodborne

Bloodborne Pathogens
  • Bloodborne Pathogens are pathogenic
    microorganisms that are present in human blood or
    other potentially infectious materials (OPIM) and
    can cause disease in humans. These pathogens
    include but are not limited to
  • Human Immunodeficiency Virus (HIV)
  • Hepatitis B (HBV)
  • Hepatitis C (HCV)
  • Non A, non B Hepatitis
  • Syphilis
  • Malaria

Other Potentially Infectious Material (OPIM)
  • OPIMs are body fluids, unfixed tissues or organs,
    and tissue that may cause disease in humans.
    Listed below are some examples
  • cerebrospinal fluid
  • synovial fluid
  • pleural fluid
  • amniotic fluid

Other Potentially Infectious Material (OPIM),
  • pericardial fluid
  • unfixed tissue or body organs other than intact
  • blood, organs, and tissue from experimental
    animals infected with HIV or HBV
  • peritoneal fluid
  • semen
  • vaginal secretions
  • any body fluid contaminated with blood saliva in
    dental procedures
  • body fluids in emergency situations that cannot
    be recognized

Epidemiology of HIV
  • Bloodborne Pathogens are pathogenic
    microorganisms that are Human Immunodeficiency
    Virus (HIV) is the virus that causes AIDS. This
    virus is passed from one person to another
    through blood-to-blood and sexual contact. In
    addition, infected pregnant women can pass HIV to
    their baby during pregnancy or delivery, as well
    as through breast-feeding. People with HIV have
    what is called HIV infection. Most of these
    people will develop AIDS as a result of their HIV
  • According to the CDC, as of 2002, approximately
    65 million people worldwide have been infected
    with HIV. At the end of 2002, an estimated 42
    million people worldwide were living with HIV
    infection or AIDS. In the United States, through
    December 2001, a total of 816,149 cases of AIDS
    had been reported to the CDC.

HIV and AIDS Current Trends
  • According to current trends, these certain
    populations are at a greater risk of contracting
  • Injecting-drug users
  • Women
  • Blacks
  • Hispanics
  • Adolescents/young adults
  • Persons who are involved heterosexually with a
    partner at risk or known to have the infection or

Clinical Manifestation of HIV Infection
The spectrum of HIV infection ranges from an
asymptomatic state to severe immunodeficiency and
associated opportunistic infections, neoplasms,
and other conditions. Initial infection can be
followed by an acute flu-like illness. Features
  • rash
  • malaise
  • sore throat
  • headache
  • fever
  • lymphadenopathy
  • sweats
  • myalgia
  • arthralgia

Clinical Manifestation of HIV Infection, cont.
  • The natural history can vary considerably. The
    risk of disease progression increases with the
    duration of the infection. Most cohort studies
    show that less than 5 of HIV infected adults
    develop AIDS within 2 years of infection. Without
    therapy approximately. 20-25 develop AIDS within
    2 years of infection and 50 within 10 years.

Epidemiology of Hepatitis B Virus
  • Acute viral hepatitis, first reported in 1833, is
    a common and sometimes serious viral infection of
    the liver leading to inflammation and necrosis.
    There are at least five distinct viral agents
    that cause acute viral hepatitis
  • HAV
  • HBV
  • HDV (delta)
  • HCV
  • HEV (an externally transmitted non A, non B
    hepatitis agent)
  • As of 2001, the United States had 78,000 cases of
    Hepatitis B reported to the CDC.

Clinical Manifestation of HIV Infection
  • The clinical presentation of acute HBV ranges
    from asymptomatic, subclinical illness to
    fulminant hepatic failure. The disease has a long
    incubation period from 30 to 180 days. Initial
    symptoms are nonspecific, typically include
  • rash
  • polyarthritis
  • last 3-10 days
  • onset of jaundice or dark urine
  • severe acute liver failure
  • elevations of ALT and AST
  • last 3-10 days
  • onset of jaundice or dark urine
  • severe acute liver failure
  • elevations of ALT and AST

Hepatitis B Vaccine
  • The Hepatitis B vaccine is given as a series of
    three injections. It produces a high antibody
    titer in over 90 of the recipients under the age
    of 40-50 years. Certain factors such as older
    age, obesity, heavy smoking, and immunologic
    impairments can result in lower antibody titers.
  • Hepatitis B is offered to all UNC Employees who
    have reasonably anticipated exposure to blood or
    other potentially infectious material. The
    Hepatitis B vaccine is given to these employees
    to try and reduce the risk of seroconversions due
    to a Hepatitis B exposure. It is given at the
    UEOHC (919-966-9119). If you decline, you must
    sign a declination form, however if you desire it
    at a later time, you may receive it then.

Epidemiology of Hepatitis C Virus
  • Hepatitis C (HCV) is a viral infection of the
    liver. Hepatitis C is a major cause of acute
    hepatitis and chronic liver disease, including
    cirrhosis and liver cancer. Globally an estimated
    170 million persons are chronically infected with
    HCV and 3 to 4 million persons are newly infected
    each year.

Clinical Manifestation of Hepatitis C Virus
  • 80 of the persons infected with Hepatitis C have
    no signs or symptoms. Those that have symptoms
    and signs, may exhibit the following
  • Jaundice
  • Fatigue
  • Dark Urine
  • Abdominal Pain
  • Loss of Appetite
  • Nausea

Chronic infections occur in 75-85 of infected
persons. Chronic liver disease occurs in 70 of
infected persons. Hepatitis C is the leading
indication for liver transplants. There is no
vaccine for Hepatitis C. Employees who acquire
HCV occupationally or suspect an exposure
incident, should contact the University Employee
Occupational Health Clinic (966-9119).
  • In the occupational setting transmission of
    bloodborne pathogens is by needlestick/sharp
    injuries, mucous membrane and non-intact skin
    exposure to contaminated blood/OPIM. In general,
    HIV and hepatitis B virus are transmitted via the
    following routes
  • sexual contact
  • sharing HIV or HBV contaminated needles or
  • from mother to unborn child

Transmission, con't.
  • Hepatitis C is spread primarily by direct contact
    with human blood. The major causes of HCV
    infection include
  • Unscreened blood transfusions
  • Re-use of needles and syringes
  • Injecting drug users
  • From infected mother to baby during birth
  • Sharps exposures or Needlesticks

Rule of Threes
  • Not all the bloodborne pathogens carry the same
    risk of occupational acquisition. Frequency in
    patient population, environmental viability of
    the virus, and viral load all impact your risk of
    acquiring infection, if exposed. The following
    table demonstrates infection risk from a
    percutaneous exposure to HBV, HCV, and HIV.

Exposure Control Plan
  • UNC has two exposure control plans available to
    all employees. One is for the UNC Healthcare
    System and is available at
    and the other you may call the Department of
    Environment, Health and Safety at (919) 962-5507
    to receive a copy or visit The
    Exposure Control Plan contains a list of all job
    categories that have occupational risk to
    bloodborne pathogens. It also outlines management
    of employee exposures and methods to prevent
    exposure in the workplace. A copy of the OSHA
    standard can be referenced directly behind the
    Exposure Control Plan. Every employee should be
    familiar with the Exposure Control Plan and the
    OSHA standard.

Standard Precautions
  • Standard Precautions is a method of infection
    control in which all human blood and other
    potentially infectious materials (OPIM) are
    treated as known to be infectious. Standard
    Precautions apply to blood, all body fluids,
    secretions, and excretions (except sweat),
    non-intact skin, and mucous membranes. They are
    essential in reducing occupational acquisition of
    bloodborne pathogens. This means treating every
    patient as if they were infected with bloodborne
    pathogens, such as HIV or HBV. It also means that
    healthcare workers use personal protective
    equipment to prevent direct contact with blood or
    body fluids. Standard precautions is the best
    method that healthcare workers can use to protect
    themselves from occupational acquisition.

Personal Protective Equipment
  • Personal Protective Equipment (PPE) is
    specialized clothing and equipment worn by
    employees for protection against a hazard, such
    as blood or other potentially infectious
    materials. This equipment should be readily
    available and is provided to the employee at no
  • The employees should never put themselves at risk
    by not using appropriate PPE and should be
    removed after use. The employees should take care
    not to contaminate the skin. Soiled gowns,
    gloves, etc should be disposed of in a Biohazard
    Container immediately after use. Hands should
    always be washed thoroughly after removal of PPE.

Engineering Controls
  • Engineering controls are used to isolate or
    remove the bloodborne pathogen hazards from the
    workplace (e.g. sharps disposal containers,
    self-sheathing needles, and safer medical
    devices). Employers are required to provide
    engineering controls that have been demonstrated
    to significantly reduce occupational hazard.

Administrative Controls
  • Administrative controls are used to reduce the
    likelihood of exposure by altering the manner in
    which a task in performed. Some examples include
    needles not being recapped, specimens transported
    in secondary container. It could also be
    displayed by sharps being immediately disposed in
    a sharps container. Healthcare workers are
    responsible for carefully disposing of all

Transporting Specimens to the Laboratory
  • When transporting specimens, they should not be
    hand carried to the lab. Specimens must be
    transported in a secondary container displaying a
    BIOHAZARD label. The primary specimen container
    and accompanying tags and/or labels must be
    contaminant free.

Universal Biohazard Sign
  • Universal Biohazard Signs are used to alert
    employees that containers, specimen
    refrigerators, or secondary containers used to
    transport specimens may contain infectious
    materials. Individual tubes need not be labeled.
    Secondary containers used for manually
    transporting specimens must display the BIOHAZARD
    sign. Equipment that may have internal
    contamination that cannot be accessed for
    decontamination should also be tagged with a
    BIOHAZARD label. Biohazard signs alert
    maintenance and medical engineering employees to
    use precaution.

Contaminated Equipment
  • Equipment such as blood pressure cuffs and
    stethoscopes must be cleaned if contaminated with
    blood or other potentially infectious materials.
    An EPA approved disinfectant detergent (i.e.
    Vesphene) or a 110 or 1100 dilution of bleach
    and water should be used.

Disposing of Medical Waste
  • Regulated medical waste is infectious waste that
    is to be disposed of according to rules
    established by the North Carolina Solid and
    Hazardous Waste Management Branch. Regulated
    medical waste includes full Sharp Containers,
    microbiological cultures, pathology specimens,
    and gt20ml of blood products which includes
    Blood, serum, plasma, emulsified human tissue,
    spinal fluid, pleural and peritoneal fluid.
  • Medical waste must be disposed in a container
    labeled with the BIOHAZARD label. Certain items
    are required to be incinerated and are referred
    to as regulated medical waste. Blood in
    quantities of greater than 20ml per unit
    container is defined as regulated medical waste.

Disposing of Regulated Waste
  • When transporting specimens, they should not be
    hand carried to the lab. Specimens must be
    transported in a secondary container displaying a
    BIOHAZARD label. The primary specimen container
    and accompanying tags and/or labels must be
    contaminant free.

Disposal of Medical Waste
  • Bandages, dental floss, vacutainer tubes, and
    bags do not require incineration or autoclaving
    are to be disposed in white trash bags labeled
    with the BIOHAZARD SIGN. It is important to
    remember that bags are not puncture-proof and
    sharps are always to be disposed in designated
    sharps containers, not in trash bags.

Wet, Contaminated Laundry
  • Wet contaminated laundry is laundry that is
    soiled with blood or other potentially infectious
    materials and presents a reasonable likelihood to
    soak through or leak from the bag. This laundry
    should not be sorted or handled any more than
    necessary for disposal. It should be disposed in
    fluid resistant linen bags and should be doubled
    bagged when necessary to prevent leaking.

Dermatitis of the Hands
  • Some employees may develop dermatitis of the
    hands. This puts the employee at greater risk of
    infection with bloodborne pathogens. All
    employees who develop or suspect that they may
    have dermatitis of the hands, should be seen at
    the University Employee Occupational Health
    Clinic. This process will provide evaluation and
    treatment prior to work involving exposure to
    blood, to help minimize the risk of infection
    with bloodborne pathogens.

Latex Allergy
  • Latex gloves have proven effective in preventing
    transmission of many infectious diseases,
    however, for some healthcare workers, exposure to
    latex may result in allergic reactions. This
    reaction is to certain proteins in latex rubber.
    The amount of latex exposure needed to produce
    sensitization or reaction is unknown.
  • Symptoms may occur within minutes of exposure or
    may take several hours to appear depending on the
    individual. They may include skin redness,
    hives, itching, respiratory symptoms such as
    runny nose, itchy eyes, scratchy throat, and
    asthma. If an employee has a latex allergy or
    suspects they have had any reaction to latex,
    they should report the incident to the University
    Employee Occupational Health Clinic.

Protection From Latex Allergy
  • There are certain precautions employees can take
    to protect themselves from a latex allergy. Use
    non-latex gloves for activities that are not
    likely to involve contact with infectious
    materials. Appropriate barrier protection is
    necessary when handling infectious materials, so
    if you choose latex gloves, use powder-free
    gloves with reduced protein content. When wearing
    latex gloves, do not use oil-based hand creams or
    lotions. After removing latex gloves, wash hands
    with a mild soap and dry thoroughly. Frequently
    clean areas and equipment contaminated with latex
    dust. Learn to recognize the symptoms and
    procedures for preventing latex allergy.

Exposure Incidents
  • Exposure incidents are events in which there has
    been a
  • percutaneous injury involving a potentially
    contaminated needle or other sharp
  • splash of blood or other potentially infectious
    materials to the eyes, mouth, or mucous membranes
  • blood or other potentially infectious materials
    contacting broken skin
  • At UNC in 2002, there were 72 exposure incidents
    reported. Two of the source patients were HIV
    positive, three were HBV positive, and five were
    HCV positive. There were no seroconversions as a
    result of exposure to HIV, HBV, or HCV positive

Steps to Take in the Event of Exposure
  • In the event of an exposure, employees should
  • Immediately wash the exposed area with soap and
    water. If the eyes are involved, irrigate with
    tap water.
  • Notify your supervisor and complete an incident
  • Go to the University Employees Occupational
    Health Clinic, calling ahead (919-966-9119) to
    alert them of the exposure.
  • If the exposure occurs after regular working
    hours or on weekends, call Health Link
    (919-966-9119) to be instructed on steps
    necessary for further treatment.

Occupational Health Clinic Evaluation
  • The University Employee Occupational Health
    Clinic (UEOHC) staff will evaluate your exposure
    incident. The evaluation may include testing your
    blood and the source patients' blood for HIV,
    HBV, and HCV. This test is only conducted with
    the employees consent and is kept confidential.
    After the results are known, UEOHC will provide
    the employee with written evaluation and
    recommendations regarding the treatment of
    exposure. In some cases a combination therapy for
    HIV exposure may be considered.

Tuberculosis Introduction
  • Healthcare facilities present an environment
    where tuberculosis may be transmitted at an
    increased rate. Patients with active disease may
    expose other patients, some of whom are highly
    susceptible for contracting TB due to immune
    deficiencies. The high risk for transmission of
    TB in healthcare facilities presents an
    occupational health hazard for employees who work
    in healthcare facilities. In 1990 and 1991, CDC
    received 13 reports of outbreaks of MDR-TB in
    hospitals and prisons. These outbreaks resulted
    in the disease being spread to healthcare

OSHA Requirements
  • OSHA does not have specific regulations
    concerning the control of tuberculosis
    infections. However, OSHA has stated that it will
    cite healthcare facilities, under the General
    Duty Clause of the OSHA Act, for non-conformance
    to published CDC guidelines for TB control. These
    guidelines require that healthcare employees
    receive annual training in TB and infection
    control. Successful completion of this training
    module will satisfy those requirements.

Current Trends of TB
  • After decades of decline, the number of cases of
    active tuberculosis has been on the increase
    since the mid 1980s. This increase and the
    concern for occupational exposure for healthcare
    workers has been attributed to
  • HIV epidemic. Individuals who are HIV positive,
    or have other immune deficient conditions, have a
    greater risk of developing active TB disease if
  • Immigration. Foreign-born individuals have come
    from countries with high prevalence of TB, such
    as Asia, Africa, the Caribbean, and Latin
    America. These individuals may also live in
    medically under served areas within the U.S.,
    which further contributes to the increased risk
    for TB transmission.

Current Trends of TB, cont.
  • Transmission in high-risk environments.
    Transmission of tuberculosis accelerates in
    environments where there are
  • persons with active TB, and
  • persons with a higher risk for progression from
    latent TB to active disease.
  • Such environments include homeless shelters,
    prisons, nursing homes, and hospitals.
  • Drug Resistance. Multi-drug-resistant
    tuberculosis (MDR-TB) refers to strains of M.
    tuberculosis that are resistant to isoniazid and
    rifampin, two drugs used to treat TB. Patients
    who become infected with these strains of TB take
    longer to recover and remain infectious for a
    longer period, thus, potentially infecting more

Current Trends of TB, con't.
  • Exposure incidents are events in which there has
    been a
  • percutaneous injury involving a potentially
    contaminated needle or other sharp
  • splash of blood or other potentially infectious
    materials to the eyes, mouth, or mucous membranes
  • blood or other potentially infectious materials
    contacting broken skin
  • At UNC in 2002, there were 72 exposure incidents
    reported. Two of the source patients were HIV
    positive, three were HBV positive, and five were
    HCV positive. There were no seroconversions as a
    result of exposure to HIV, HBV, or HCV positive

Decline in TB Cases
  • The decline in cases during 1992-1997 can be
  • attributed to the following six factors
  • improved laboratory methods to allow prompt
    identification on M. tuberculosis
  • broader use of drug-susceptibility testing
  • expanded use of preventive therapy in high-risk
  • decreased transmission of M. tuberculosis in
    congregative settings (e.g. hospitals,
    correctional facilities)

Decline in TB Cases, cont.
  • improved follow-up of persons with TB initially
    reported to the health department
  • increased federal resources for state and local
    TB-control efforts.
  • In North Carolina the number of cases remains
    stable at approximately 600 cases per year. Less
    than 1 of TB cases that have occurred in North
    Carolina have been MDR-TB. At UNC Hospitals,
    there are approximately 25 cases of TB out of
    27,000 admitted patients each year.

Transmission of TB
  • M. tuberculosis is carried in airborne particles,
    or droplet nuclei, generated when a person with
    pulmonary or laryngeal TB coughs or sneezes.
    Infection occurs when a susceptible person
    inhales droplet nuclei containing M. tuberculosis
    bacilli, which reach the alveoli of the lungs.
    Within 2-10 weeks after initial infection the
    immune response limits further spread of tubercle
    bacilli however, some of the bacilli remain
    dormant and viable for many years. This is known
    as latent TB infection.

Transmission of TB, cont.
  • For a small proportion of infected persons
    (usually lt1 ), initial infection readily
    progresses to clinical illness, or active
    disease. For 5 - 10, illness develops after an
    interval of months, years, or decades, when the
    bacteria begin to replicate and produce disease.
    Progression to active disease is more likely in
    persons with medical conditions that result in
    immune deficiencies, the elderly, and those less
    than 4 years of age. The risk for progression to
    active disease is markedly increased for persons
    with HIV infection.

Transmission of TB, con't.
  • TB infection occurs after prolonged exposure to
    someone who has the infectious form of TB. A
    person has a 50 chance of becoming infected if
    they spend 8 hours a day for 6 months with a
    person with the active form of TB.
  • The site of initial infection is usually the
    alveoli of the lungs where macrophages ingest the
    inhaled bacilli. The body's T-cells are
    stimulated and a cell-mediated or delayed
    hypersensitivity occurs.
  • The T-cells stimulate specialized cells that kill
    the bacilli and wall off infected macrophages,
    producing grayish capsules called tubercles.
    Further multiplication of the TB bacilli are
    usually confined here. In an immunodeficient
    individual the TB bacilli may break out of the
    tubercle and lead to the active form of the

Infection Routes and Symptoms
  • For individuals with active TB, the bacilli will
    spread from the lungs to other parts of the body
    usually the lymph nodes. In 15 of the active TB
    cases, bacilli will infect other sites in the
    body such as the skin, bones, and reproductive or
    urinary systems.
  • Symptoms of the disease include weight loss,
    fever, night sweats and anorexia. If the disease
    is allowed to progress, large cavities may form
    in the lungs, encompassing the bronchi. Symptoms
    also include a persistent (lasting at least three
    weeks) cough with production of bloody sputum.

Diagnosis of TB
  • Persons exhibiting the symptoms and suspected of
    having TB, should be referred for a complete
    medical evaluation, which should include a
    medical history, physical examination, a Mantoux
    tuberculin skin test, a chest radiograph, and
    appropriate bacteriologic or histological

Tuberculin Skin Test
  • The Mantoux or tuberculin skin test is used for
    screening individuals who are at high risk for
    developing tuberculosis, such as persons exposed
    to infectious individuals. The tuberculin skin
    test is the only method of diagnosing TB
    infection before the infection has progressed to
    the active disease. A person who becomes infected
    with TB will show a positive reaction in 2 to 10
  • The Mantoux test is performed by injecting 5
    units of purified protein derivative (PPD)
    intradermally into the volar or dorsal surface of
    the forearm. If the person is infected a
    characteristic welt will form.

Tuberculin Skin Test, cont
  • This welt consists of hardening in the form of a
    raised bump where the PPD was placed and may be
    red in color. The diameter of the induration is
    measured to determine infection status.
  • The reaction to the Mantoux test should be read
    by a trained healthcare worker 48 to 72 hours
    after the injection. A negative reaction must be
    read within 72 hours or the Mantoux test must be

Classification of Tuberculin Reaction
  • There are three different classifications of
    Tuberculin reactions. These vary based upon the
    factors listed below
  • gt5 mm is positive for known or suspected HIV
    patients, close contacts of persons with
    infectious TB, persons with chest x-rays
    suggestive of previous TB, and IV drug abusers.
  • gt10 mm - persons not listed above but are known
    to be of populations at increased risk for having
  • gt15 mm is positive in persons with no known risk

  • Anergy occurs when the delayed hypersensitivity
    reaction to the PPD test is absent or decreased
    in individuals who are immunodeficient, i.e.
    individuals with HIV, persons with severe febrile
    illness, measles or Hodgkin's disease or those on
    immunosuppressive drugs. Approximately one third
    of patients with HIV infection and 60 of those
    with AIDS may have skin reactions of lt5mm even
    though they are infected with TB.
  • Individuals previously infected with TB may also
    show a positive PPD test. A person's exposure
    history and chest x-ray are also used to
    determine infection, however a positive
    bacteriologic culture is needed to confirm
    diagnosis. Sputum collected for culture can be
    produced by having the patient cough deeply so as
    to ensure mucous is collected from diseased lung

Treatment of TB
  • Tuberculosis disease can be effectively treated
    using antibiotic therapy. Isoniazid and rifampin
    are generally used, with pyrazinamide given for
    the first two months. Ethambutol is added when
    drug resistant bacilli are suspected. The length
    of therapy and combination of antibiotics is
    decided by the physician, based upon organism
    antibiotic sensitivity, signs of improvement, and
    patient compliance.
  • While on therapy, patients are monitored for side
    effects that may be caused by the antibiotics.
    Isoniazid (INH) has caused liver toxicity in some
    patients. This occurrence is rare for people
    under the age of 35, but has a somewhat greater
    incidence for people over 35. Liver function
    should be monitored in patients receiving
    treatment with INH. Patients who are taking
    ethambutol should be monitored for potential
    visual changes.

Treatment of TB, con't.
  • It is especially important that patients complete
    the prescribed drug therapy regimen in order to
    effectively kill all bacilli. Drug-resistance can
    develop when medications are taken incorrectly by
    either skipping doses or not taking the
    medication for the prescribed amount of time.
  • Directly Observed Therapy or DOT is used when it
    is suspected that patients may not comply with
    the prescribed treatment. DOT is accomplished by
    designating a person to observe the patient
    swallow each dose of medication.

Preventive Therapy
  • Individuals with positive PPD test results should
    be evaluated for preventive therapy if they
  • are recent converters
  • have close contact with TB patients
  • have an immune deficient medical condition
  • are HIV positive
  • use IV drugs
  • are lt35 years of age.
  • Studies have shown that preventive therapy with
    INH will reduce the risk of active TB by
    approximately 70. Currently, INH taken by mouth
    for 6 to 12 months is the recommended treatment
    for preventive therapy.

Infection Control
  • The main goal of an infection control program is
    to detect TB disease early and to isolate and
    promptly treat persons who have TB. The infection
    control program of any healthcare facility should
    involve three types of controls administrative
    controls isolation facilities and procedures
    personal respiratory protection.
  • Administrative controls include risk assessment
    development of TB infection-control plan
    assignment of infection-control responsibilities
    early identification, isolation, and treatment of
    suspected cases.

Risk Assessment
  • At UNC, the TB Infection-Control Plan requires
    that each healthcare facility and clinic area
    must complete a risk assessment so that
    appropriate infection control interventions can
    be developed based on actual risk of TB
  • The level of risk is based on
  • the number or estimated number of TB infectious
    patients admitted to each area
  • number of personnel PPD conversions
  • and potential for patient transmission.

Assignment of Responsibility
  • The clinic director of each UNC facility is
    responsible for assigning healthcare personnel to
    implement infection control responsibilities.

Early Identification of TB
  • Early identification and isolation of patients
    with TB is necessary to prevent TB transmission
    among patients and personnel. Healthcare workers
    who first come in contact with patients should be
    trained to ask questions which will help identify
    patients with active TB. Designated healthcare
    professionals will evaluate patients immediately
    so as to minimize time spent in waiting areas.

TB Precautions for UNC Clinics
  • TB precautions will be instituted for patients
    suspected of having TB. Patients are instructed
  • wait in separate areas, apart from other
  • wear surgical masks
  • cover their mouths with facial tissues when
    coughing or sneezing.
  • Persons suspected of having TB are referred to
    either the Pulmonary Clinic or the Infectious
    Disease Clinic where isolation facilities are
    available for managing these patients. HIV
    patients are sent to the Infectious Disease

Isolation Facilities
  • Patients with active TB are placed in isolation.
    Engineering controls are used in each isolation
    room to prevent the spread and reduce the
    concentration of infectious droplet nuclei in the
  • Isolation rooms are equipped with at least 6 air
    exchanges per hour sufficient air distribution
    within the room directional airflow from hallway
    to room and direct exhaust of room air to

Isolation Procedures
  • Patients placed in TB isolation will be
    instructed in procedures to prevent TB
    transmission, and the reasons for their being
    placed in isolation.
  • The door to the room must always be kept closed.
    Healthcare workers will be instructed to wear
    respirators. Patients who hav