pathogens standard: management of …...administration (osha) developed a standard that was designed...

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OSHA BLOOD-BORNE

PATHOGENS STANDARD:

MANAGEMENT OF EXPOSURE TO

BLOOD-BORNE PATHOGENS

Dana Bartlett, RN, BSN, MSN, MA, CSPI

Dana Bartlett graduated from the University of

Massachusetts with a B.S. in nursing in 1976; he has an

M.S. in nursing from Boston University, 1978, and an M.A.

in journalism from Temple University, 1988. He has 17

years of clinical nursing experience, primarily ER, and 25 years of poison control

experience. He is currently employed by the Rocky Mountain Poison Control Center in

Denver Colorado as a Certified Specialist in Poison Information. Mr. Bartlett has

published almost 200 on-line continuing education modules; written for Critical Care

Nurse, Journal of Emergency Nursing, American Nurse Today, Nursing, and other

peer-reviewed journals. In addition, he has written textbook chapters, NCLEX test

material, and done editing and reviewing for publishers such as Elsevier and

Lippincott Williams & Wilkins.

Abstract

Healthcare workers are continuously exposed to hazards of blood-

borne pathogen transmission. Many bacteria and viruses may be

transmitted to healthcare workers by needlesticks, sharps injury, or

splash contact. Hepatitis B, hepatitis C, and the human

immunodeficiency virus account for the greatest number of exposures

and infections. Important aspects of the Occupational Safety and

Health Administration standard and information on the management of

exposure to blood-borne pathogens are discussed.


Policy Statement

This activity has been planned and implemented in accordance with

the policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's

Commission on Accreditation for registered nurses. It is the policy of

NurseCe4Less.com to ensure objectivity, transparency, and best

practice in clinical education for all continuing nursing education (CNE)

activities.

Continuing Education Credit Designation

This educational activity is credited for 2 hours. Nurses may only claim

credit commensurate with the credit awarded for completion of this

course activity. Pharmacy content is 0.5 hours (30 minutes).

Statement of Learning Need

All front-line healthcare workers, physicians, nurses, and assistive

personnel, need to know Occupational Safety and Health

Administration (OSHA) safety protocol to prevent and to report

exposure to blood-borne pathogens, in addition to initial interventions

for exposure.

Course Purpose

To provide health clinicians with basic knowledge of OSHA

recommendations for prevention of, exposure to, diagnosis and

treatment of blood-borne pathogens.


Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses

and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Dana Bartlett, RN, BSN, MSN, MA, CSPI, William S. Cook, PhD,

Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC –

all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge,

on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.


1. The majority of occupational exposures to blood-borne pathogens are:

a. Percutaneous.

b. Air-borne. c. Cutaneous.

d. Percutaneous and cutaneous together.

2. The primary focus on post-exposure management of blood-borne pathogens in occupational exposures for healthcare workers are:

a. hepatitis B, hepatitis A, and MRSA.

b. hepatitis C, HIV, and tuberculosis. c. hepatitis B, hepatitis C, and HIV.

d. hepatitis A, HIV, and gram-negative bacteria.

3. The risk of HIV transmission after a percutaneous exposure is

approximately:

a. 3.0%. b. 0.32%.

c. 30%. d. 13%.

4. True or false: Infection with a blood-borne pathogen can occur

after contact with a contaminated surface.

a. True. b. False.

5. The first step in managing an exposure to a blood-borne pathogen is:

a. testing of the source patient

b. notifying the employee health department. c. testing of the affected healthcare professional.

d. to clean the exposed area.


Introduction

Exposure to blood-borne pathogens is a serious, ongoing hazard for

healthcare workers and the Occupational Safety and Health

Administration (OSHA) developed a standard that was designed to

protect at-risk employees: the blood-borne pathogens standard, which

is identified by the Code of Federal Regulations number CFR

1910.1030.1 The standard was amended in 2001 to include the

Needlestick Safety and Prevention Act, and CFR 1910.1030 provides

definitions of risk situations, recommendations for the prevention of

exposures to blood-borne pathogens, and recommendations for the

management of exposures to blood-borne pathogens. Because

healthcare workers have considerable risk for exposure to blood-borne

pathogens, they are required to have a basic knowledge of, and

comply with, the recommendations of the OSHA blood-borne

pathogens standard.

Epidemiology Of Exposures To Blood-Borne Pathogens

Many bacteria and viruses can be transmitted to healthcare workers by

needlesticks, sharps injury, or splash contact, but hepatitis B, hepatitis

C, and the human immunodeficiency virus (HIV) account for the

greatest number of exposures and infections.2 The majority of

occupational exposures to and infections from these viruses are

caused by percutaneous injury. The term percutaneous injury refers to

any puncture of the surface of the skin such as a needlestick and a

sharps injury, the latter being a puncture of the skin from a scalpel, a

trochar, or any other medical device or instrument.2,3


The exact incidence of needlesticks, sharps injuries, and splash

exposures are not known, but it is clear they are a common

occurrence, as seen by the following reports.

• The Centers for Disease Control and Prevention (CDC) has

estimated that in the United States there are 385,000 needlesticks

every year.4

• The Exposure Prevention and Information Network (EPInet™)

noted in their 2015 report that the number of needlestick injuries

was 31.7 per 100 occupied beds.5

• Henderson (2012) estimated that each year almost 1 of every 10

healthcare workers in the United States has a needlestick

exposure,6 and a 2018 article that had surveyed 358 medical

students and 247 members of the staff of the department of

surgery found that 38.7% of those who responded had had a

needlestick injury.7

A review of the literature shows that the most frequent blood and body

exposures were reported by nurses (48.6 percent), physicians in

resident or fellowship training (7.7 percent) and those attending (7.7

percent), non-lab technologists (4.5 percent), respiratory therapists

(3.6 percent), and certified nursing assistants or home health aides

(3.2 percent).8 A factor contributing to a threefold increase of

accidental needle stick injuries included long work hours and sleep

deprivation.

Under-reporting of needlestick injuries, sharps injuries, and splash

contacts with potentially infectious fluids is not unusual. In a 2015

publication The Centers for Disease Control and Prevention noted that

more than 50% or more of these incidents are not reported,4 and


more recent information (2017, 2018) noted that 33%-66% of these

injuries were not reported.7,9 Nurses, for example, work in a wide

variety of patient care areas, i.e., emergency room (ER), intensive

care unit (ICU), and operating room (OR), they frequently will use

needles and handle sharps, and they are often exposed to blood and

body fluids. These factors increase the nursing risk for exposure and

needlesticks, sharps injuries, and splash exposures.

Risk Of Infection After Occupational Exposure

The risk of infection after an occupational exposure to a blood-borne

pathogen depends on many factors and the viral load of the source

(the patient) is probably the most critical of these. Infection is least

likely from a splash contact (cutaneous exposure), and it is most likely

from a deep puncture by a large-gauge, hollow bore needle that

contains a large amount of blood that has a high viral load.8

Simultaneous transmission of several blood-borne pathogens from a

needlestick has been reported.6

Factors For Infection After A Blood-borne Pathogen Exposure6,8

Amount of blood injected

Availability/efficacy of post-exposure prophylaxis

Depth of the injury

Health status of the source person

Hollow bore needle

Immune system competency

Placement of the injuring device in an artery or a vein

Prevalence of the pathogen in the population

The pathogen

Type of injury, i.e., puncture wound versus splash contact

Viral load

Visible blood on a needle or sharp


The risk of infection after a percutaneous exposure to HIV is estimated

to be 0.3%8 and the risk for infection after a mucous membrane

exposure to HIV, such as splash to an eye, has been estimated to be

one infection per 1000 exposures.8,10 No transmission of HIV through

intact skin has been documented. All known sero-conversions from

occupational exposure to HIV have occurred after exposure to blood,

bloody fluids, or viral cultures.8,10 Semen, vaginal fluids, and body

fluids visibly contaminated with blood can transmit HIV, and amniotic

fluid, cerebrospinal fluid, pericardial fluid, peritoneal fluid, pleural, and

synovial fluid are potentially HIV-infected. Feces, gastrointestinal

fluids, nasal secretions, saliva, sputum, sweat, tears, urine, and

vomitus are not considered to be HIV infectious unless they contain

blood.8,10

The risk for transmission after exposure to fluids or tissues other than

HIV-infected blood has not been quantified but is probably low.8 In

most reported cases of HIV transmission, needlestick injury occurred

within seconds or minutes after the needle was withdrawn from the

source patient. From 1985 to 2013, there were 58 documented cases

of acquired HIV seroconversion reported to the CDC.11

The CDC reported that an estimated 5.6 million healthcare workers

and related occupations are at risk of occupational exposure to blood-

borne pathogens, including hepatitis B virus (HBV) and hepatitis C

virus (HCV).13 The primary focus on post-exposure management of

blood-borne pathogens in occupational exposures for healthcare

workers is on hepatitis B, hepatitis C and HIV, although greater than

30 different pathogens have caused documented occupational infection

following exposure to blood or body fluids.13


Hepatitis B virus (HBV) is known to be highly infectious.13 Infection in

healthcare workers with hepatitis B who have not had a needlestick or

other percutaneous exposure could be due to exposure to the virus

through an abrasion, a burn, a scratch, or a mucous membrane,14 and

in approximately two-thirds of all people infected with hepatitis B, no

needlestick was identified.15 Hepatitis B surface antigen is found in

other body fluids aside from blood such as bile, breast milk,

cerebrospinal fluid, feces, nasopharyngeal washings, saliva, semen,

sweat, and synovial fluid. However, these fluids contain low levels of

the virus and exposure to them would not be likely to cause hepatitis B

infection.14

The risk for infection after percutaneous exposure to hepatitis C has

been estimated to be approximately 1.8 percent (range, 0 to 7

percent) after a needle stick or sharps exposures from an HCV-positive

source.13 Approximately 39% of all hepatitis C infections in healthcare

workers are considered to be occupational.16 Infection with hepatitis C

after mucous membrane exposure is considered to be unlikely, but

infection after conjunctival or ocular exposure has been reported.

Hepatitis C virus has been found in ascites, menstrual fluid, saliva,

semen, spinal fluid, and urine. These fluids have a much lower

hepatitis C viral content than blood and transmission of the virus from

these fluids has not been reported,17 but if they were contaminated

with blood or if there was a large exposure, transmission and infection

could occur.

Blood-borne pathogens can contaminate surfaces and persist in

the environment and contact with these contaminated surfaces

can cause infection. Hepatitis B and HIV in dried blood can


remain on surfaces for a week and hepatitis B is capable of

causing infection during that time. Hepatitis C also can survive

outside the body on environmental surfaces and it can remain

survive at room temperatures on surfaces for up to three

weeks.18

Needlestick Injuries and Other Exposures

Needlestick injuries and other exposures to blood-borne

pathogens are usually caused by human error. These errors

can involve personal and organizational issues, and factors such as

poor staffing, a relative lack of nursing experience, long hours at work,

stress and fatigue, and poor or improper use of equipment have been

identified as causes of needlestick injuries.19,20 The most common

situations involving needlestick injuries and other exposures to blood-

borne pathogens are shown in the following table.

At-Risk Situations for Needle-stick Injuries

Accessing an intravenous (IV) line

Cleanup

Collision with another nurse or another healthcare worker

Manipulating the needle while it is in a patient

Passing a needle or a sharp

Poor or improper disposal technique

Puncturing skin with a needle or a sharp

Suturing

Recapping needles

Transferring blood from one container to another

Equipment that must be manipulated after or during use (such as

disposable syringes, IV catheter stylettes, needles attached to

tubing such as winged infusion sets and suture needles)

Acute care, ER, ICU, or OR settings


The OSHA Blood-Borne Pathogens Standard

The OSHA blood-borne pathogens standard is both general and specific

in its recommendations. Some sections provide detailed guidance while

others provide basic direction. For example, the standard states that

employers must provide hand-washing facilities, but if providing these

is not possible the employer must provide either an appropriate

antiseptic hand cleaner or antiseptic towelettes. The standard,

however, does not specify what type of hand cleaners or towelettes.

The OSHA Fact Sheets for various environmental hazards and

recommendations can be found at their website, including all blood-

borne exposures related to healthcare settings:

https://www.osha.gov/pls/publications/publication.athruz?pType=Type

s&pID=2. There are other fact sheets on the OSHA website that

address topics such as the standard’s recommendations on

handwashing and for the safe use of needles and sharps.

The blood-borne pathogen standard was amended in 2001 to include

the Needlestick Safety and Prevention Act that was passed by

Congress in 2000. This Act amended standard CFR 1910.1030 in

order to require employers to: 1) maintain a sharps injury log, and

2) involve non-managerial personnel in the decision-making process

of selecting safer needle devices.

“All of the requirements of OSHA’s Bloodborne Pathogens standard

can be found in Title 29 of the Code of Federal Regulations at 29 CFR

1910.1030. The standard’s requirements state what employers must

do to protect workers who are occupationally exposed to blood or

other potentially infectious materials (OPIM), as defined in the

standard. That is, the standard protects workers who can reasonably

be anticipated to come into contact with blood or OPIM as a result of

doing their job duties.”22

Other helpful OSHA resources may be found at the website:

https://www.osha.gov/SLTC/healthcarefacilities/.

https://www.osha.gov/pls/publications/publication.athruz?pType=Types&pID=2

https://www.osha.gov/pls/publications/publication.athruz?pType=Types&pID=2

https://www.osha.gov/SLTC/healthcarefacilities/


OSHA Definitions

Familiarity with definitions used by the OSHA blood-borne pathogens

standard can help increase understanding of and compliance with the

standard. The definitions provided here are essentially the same as

those found in the standard.

Blood-borne Pathogens

Pathogenic microorganisms that are present in human blood and can

cause disease in humans. These pathogens include, but are not limited

to, hepatitis B virus and HIV.

Contaminated

The presence or the reasonably anticipated presence of blood or other

potentially infectious materials on an item or surface.

Exposure

Eye, mouth, other mucous membrane, non-intact skin, or parenteral

contact with blood or other potentially infectious materials that results

from the performance of an employee’s duties.

Other potentially infectious material includes:

• Semen, vaginal secretions, cerebrospinal fluid, synovial fluid,

pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva

in dental procedures, any body fluid that is visibly contaminated

with blood, and all body fluids in situations where it is difficult or

impossible to differentiate between body fluids.

• Any unfixed tissue or organ (other than intact skin) from a human

(living or dead).


• HIV-containing cell or tissue cultures, organ cultures, and HIV- or

hepatitis B virus-containing culture medium or other solutions.

• Blood, organs, or other tissues from experimental animals infected

with HIV or hepatitis B virus.

Employer and Employee Compliance

Adherence to the OSHA blood-borne pathogen standard is mandatory

for all hospitals and healthcare facilities. To be in compliance with the

standard employers must establish a written plan for controlling

exposure to blood-borne pathogens. This plan should include 1) an

assessment of risk situations, 2) a determination of which employees

are at risk and when they are at risk, and 3) specific actions the

employer will use to control and manage exposure to blood-borne

pathogens. The plan must be reviewed and updated annually and it

must be accessible to all employees, as outlined below.

• Implement standard precautions, ensure that employees know how

to use standard precautions, and ensure they use standard

precautions.

• Provide personal protective equipment (PPE) at no cost to all

employees who need it. Indicate critical or common times PPE

should be donned.

• Provide initial training and annual training on blood-borne

pathogens to all employees. This training should include 1) a review

of the OSHA Blood-borne pathogens standard, 2) information on

the risks of exposures and how exposures happen, 3) information

on how to prevent exposures to blood-borne pathogens, and

4) information on the benefits and risk of vaccination against

hepatitis B.


• Use engineering controls to control risk. Engineering controls that

control the risk of exposure to blood-borne pathogens would include

providing sharps disposal boxes, using safe medical devices, using

needles that do not need to be re-capped, providing proper waste

disposal containers, and using appropriate signs to warn of danger

and to instruct employees on the proper use of equipment.

• Use work practice controls. The employer must have a plan or plans

in place for the proper handling and disposal of blood and other

specimens, the proper handling and disposal of contaminated

waste, and for the proper cleaning and decontamination of

equipment, patient rooms, and patient care areas.

• Offer vaccination against hepatitis B to all employees who may be

reasonably expected to have an occupational exposure to the

hepatitis B virus.

• Have a plan to handle employee exposure to blood-borne

pathogens. This plan should include provisions for immediate care

(i.e., evaluation, first aid, laboratory screening tests, post-exposure

prophylactic medications) and follow-up care.

All health employees must comply with the requirements of the blood-

borne pathogens standard. The ones that address needlestick injuries

and exposure to a blood-borne pathogen will be discussed separately.

Other requirements of standard 1910.1030 that apply to healthcare

workers include:

1. Understanding and following the engineering and work practice

controls established by the employer such as proper waste

disposal and adhering to the employer’s safety and sanitary rules.


2. Using PPE correctly; the employee is required to wear the

appropriate PPE. The PPE must be removed immediately upon

removing the work area, or as soon as possible, and it must be

placed in a container specifically designated for the purpose of

receiving contaminated waste.

3. Proper handling of blood and other body fluids.

4. Understanding and using Universal Precautions.

5. Proper use of medical equipment; i.e., do not bend, break, or re-

cap needles. Do not re-use disposable medical equipment.

6. Proper disposal of contaminated or potentially contaminated

medical equipment.

7. Disposable gloves must be discarded as soon as possible after they

have become contaminated, punctured, or torn. Gloves are not

required to be worn when giving an injection as long as hand

contact with blood or other potentially infectious material is not

reasonably expected.

8. Employees must wash their hands immediately after removing

gloves or as soon as possible after removing gloves. Employees

must wash their hands after contact with blood or other potentially

infectious material and before and after performing patient care. If

handwashing with soap and running water is not possible, the

employee must use either an antiseptic hand cleaner with clean

cloth or paper towels or antiseptic towelettes. After using an


antiseptic hand cleaner or a towelette, employees must wash their

hands with soap and running water as soon as feasible.

9. Food and drink should not be stored in refrigerators, cabinets,

etc., where blood or other potentially infectious material will be

stored.

10. Double-bagging specimens is required if the outside of the

specimen container is contaminated or if the specimen could

puncture the primary container.

Managing Exposures To Blood-Borne Pathogens

Managing exposures to blood-borne pathogens involves three steps:

1) initial care of the exposed person, 2) reporting the exposure and

investigating the circumstances, and 3) post-exposure prophylaxis, if

needed.

Managing Exposures to Blood-Borne Pathogens

Initial Care ↓

Reporting the Exposure/Investigating the

Circumstances ↓

Post-Exposure Prophylaxis

Ongoing assessment of any long-term effects

Initial care of the exposed person involves basic wound care. The first

step in managing an exposure to a blood-borne pathogen is to clean


the exposed area.8,13 If it is a percutaneous exposure or a skin

exposure, the area should be washed with soap and water. Small

puncture wounds can be washed with an alcohol-based hand-wash;

these are considered to be virucidal for hepatitis B, hepatitis C, and

HIV.8 Squeezing the wound to express blood is not recommended nor

is the use of over-the-counter disinfectants such as bleach.8 Wash the

eyes with saline or water and flush mucous membranes with water.

The blood-borne pathogens standard defines an exposure as eye,

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

with blood or other potentially infectious materials that results from

the performance of an employee’s duties. Expanding this definition, an

exposure can also be described as: 1) a percutaneous injury such as a

needlestick or a sharps injury; 2) mucous membrane contact or non-

intact skin (skin that is abraded, chapped, or has dermatitis) contact

with blood, tissue, or potentially infectious body fluids.

The next step is to report the exposure. This should be done as soon

as possible; healthcare workers should not delay reporting the

incident. Information that should be obtained and documented

includes those listed below.

Documentation of Exposure Circumstances

Documentation of the exposure circumstances should include the date

and time of the exposure, the type of exposure, the location of the

exposure (i.e., finger, hand, eye), the estimated time of contact with

the blood or body fluid, how the exposure occurred, the body fluid that

was involved, any first aid that was done, the PPE that was in use,

documentation of the affected person’s blood-borne pathogens


standard training; and, if it was a percutaneous exposure, an

estimation of the depth of the wound, if the needle or sharp was in a

blood vessel, and the size and type of the needle or sharp.

Healthcare Worker Information

Specific information about the health care worker’s vaccination for

hepatitis B, any previous tests for hepatitis B, hepatitis C, or HIV,

tetanus immunization status, medical history, and the names and

doses of prescription medications currently being taken.

Source Patient Information

The source patient should be evaluated for the presence of hepatitis B,

hepatitis C, and HIV, unless their status regarding these diseases is

known.

The laws that govern testing of source patients will not be discussed

here. Affected healthcare workers must assume that their employer

will comply with these laws.

Hepatitis B Post-Exposure Treatment And Prophylaxis

The need for post-exposure treatment and prophylaxis after exposure

to hepatitis B is determined by an evaluation of the source patient and

the affected healthcare worker.

Source Patient Evaluation

The source patient should be tested for hepatitis B surface antigen

even if they have previously been tested.13 Exceptions would be if it is

known that the source is infectious with hepatitis B, or if the affected


healthcare worker has received hepatitis B vaccination and has a

documented adequate response.13

Healthcare Worker Evaluation

There are five possibilities for post-exposure prophylaxis following

exposure to hepatitis B that needs to be considered during evaluation

of an exposed person; a specific post-exposure prophylaxis plan exists

for each scenario, as outlined here.

1. Completed hepatitis B vaccination with response

2. Evidence of a prior infection with hepatitis B

3. Hepatitis B vaccination has been completed but the hepatitis B

anti-HBs titer (surface antibody concentration) is < 10 mIU/mL

4. Hepatitis B vaccination has been completed but serologic testing

for a response has not been done or serologic testing was done and

the response is not known

5. The affected person has not been vaccinated or the vaccination

series has not been completed

For the first and second situations, there is no need for post-exposure

prophylaxis.13

For the third situation, if the source patient is positive for hepatitis B

or the source patient’s hepatitis B status is not/cannot be known, the

affected healthcare worker should be given two doses of hepatitis B

immunoglobulin, the second one month after the first.13

For the fourth situation, if the anti-HBs titer is ≥10 mIU/mL, post-

exposure prophylaxis is not needed. If the anti-HBs titer is <10


mIU/mL, the management will depend on the hepatitis B status of the

source. If the source is positive or the status of the source cannot be

determined, administer one dose of hepatitis B immunoglobulin and

the first dose of hepatitis B vaccine, at the same time. The remaining

two doses of hepatitis B vaccine can be given as per the recommended

schedule.13

For the fifth situation, if the source patient is positive for hepatitis B or

the source patient’s hepatitis B status is not/cannot be known, the

affected healthcare worker should be given one dose of hepatitis B

immunoglobulin and the first dose of the hepatitis B vaccine series, at

the same time. If the source patient is hepatitis B negative, the

healthcare worker should receive the three-dose hepatitis B vaccine

series and then be checked for response.13

The immune globulin and the first dose of the hepatitis B vaccine can

be given at the same time but at different injection sites. The hepatitis

B immune globulin should be give within 24 hours after the exposure

and it must be given within 7 days of the exposure.13 The second and

third doses of the hepatitis B vaccine are given 1 month and 6 months

after the initial dose even if the source patient is subsequently known

not to be infected. Testing for hepatitis B infection should be done six

months after the exposure. During this six-month period the affected

healthcare professional should not donate blood, organs, plasma,

semen, or tissue, but the healthcare worker can perform normal

duties.13 The need for tetanus vaccination should also be considered.

Hepatitis C Post-Exposure Treatment And Prophylaxis

There is no effective post-exposure prophylaxis for hepatitis C.13



If there has been an exposure, the source patient should be tested for

the presence of hepatitis C, unless it is known that the patient is

infected.


The affected healthcare worker should be tested for the presence of

hepatitis C, as well. If the source patient is not infected, then no

further evaluation of the affected healthcare worker is needed.

If the source patient is positive for hepatitis C or if the hepatitis C

status is unknown, the healthcare worker should be tested for anti-

hepatitis C antibodies within 48 hours of the exposure.13 If the

antibody test is positive, the worker should be tested for hepatitis C

RNA; if the RNA test is positive at that time the healthcare worker has

a pre-existing hepatitis C infection. If the initial hepatitis C RNA test is

negative, a re-test should be done at least three weeks later. If this is

negative, no more testing is needed. If it is positive, a hepatitis C

infection is present.

If the antibody test is negative, a test for hepatitis C RNA should be

done at least three weeks later; a positive test confirms an infection.13

Donation of blood, organs, plasma, semen, and tissue should not be

done before the hepatitis C status has been determined. The need for

tetanus vaccination should also be considered.


HIV Post-Exposure Treatment And Prophylaxis

The need for post-exposure treatment and prophylaxis after exposure

to human immunodeficiency virus is determined by an evaluation of

the source patient and the affected healthcare worker.8


If the HIV status of the source patient is unknown, rapid HIV testing

should be done. Depending on the specific test used, the result will be

available in 5-20 minutes and these tests have excellent sensitivity

and specificity.

If the source patient is known to be HIV-positive testing is not

necessary.


Evaluation of an exposed healthcare worker should be done

immediately after wound care or decontamination has been completed.

The benefits and risks of post-exposure prophylaxis should be

thoroughly discussed. If the source patient is known to have an HIV

infection and the exposure is such that transmission of HIV is likely,

post-exposure prophylaxis should be started within 1-2 hours of the

exposure.8

Animal studies indicate that delaying administration of post-exposure

prophylaxis decreases its effectiveness, and post-exposure prophylaxis

should be started as soon as possible and ideally within 72 hours of

the exposure.8 It is not known at what point after an exposure there

would be no benefit from post-exposure prophylaxis. If the HIV status


of the source patient is unknown post-exposure prophylaxis should be

started and if the result of the rapid testing is negative, treatment

should be discontinued.8 The healthcare worker exposed to injury

should not delay starting treatment while waiting for the test results.

Laboratory evidence and confirmation of an HIV infection can be

delayed for up to 3 months after an exposure; this is commonly

termed the “window period” of HIV infection. However, the U.S., Public

Health Services Guidelines for post-exposure prophylaxis states that

“... investigation of whether a source patient might be in the window

period is unnecessary for determining whether HIV PEP [pre-exposure

prophylaxis] is indicated unless acute retroviral syndrome is clinically

suspected.”21 In most cases, rapid testing alone is sufficient.

The affected healthcare worker should be tested for the presence of

HIV and other blood-borne pathogens, if needed. The need for tetanus

vaccination should also be considered.

Recommended HIV Therapy

The recommended therapy is a three-drug regimen using the

nucleotide analogue reverse transcriptase inhibitor-nucleotide reverse

transcriptase inhibitor tenofovir-emtricitabine (Truvada™) and the

integrase inhibitors dolutegravir (Tivicay™) or raltegravir (Isentress™)

for four weeks.8 Four weeks is recommended as in vitro studies,

animal studies, and occupational studies indicate this is the optimal

duration of treatment.21

These combinations of tofovir-emtricitabine and dolutegravir are

recommended, but there are other regimens that are considered


acceptable.8 As with any drug therapy, medications used for post-

exposure prophylaxis for HIV should be prescribed with consideration

of their effectiveness and tolerability. Tolerability is especially

important as the side effects of tofovir-emtricitabine and raltegravir

and other post-exposure prophylaxis medications can have a negative

influence of compliance with therapy.8

The potential for drug-drug interactions is also very important.

Commonly used drugs such as oral contraceptives, H2 receptor

antagonist, and proton pump inhibitors can cause potentially serious

drug interactions when used with HIV post-exposure prophylaxis

drugs.

Follow-up care is essential for persons receiving post-exposure

prophylaxis. The exposed person who is being treated should be re-

evaluated 72 hours after the incident to determine how well she/he is

tolerating drug therapy.8 Testing for HIV should be done at the time of

the exposure, and 6 weeks, 12 weeks, and 6 months after the

exposure;8 there may be slight variations in this schedule, depending

on the test that is used. A complete blood count and measurement of

hepatic and renal function should be done at the time of exposure and

two weeks later.21

During the six months following the exposure, abstinence from sexual

intercourse or the use of condoms is recommended, and the exposed

healthcare worker should not donate blood, organs, plasma, semen, or

tissues.8 These precautions are especially important in the first 6 - 12

weeks after an exposure.8


Special Considerations

In some circumstances of exposure to HIV an expert consultation

should be sought. The need or considerations for expert consultation is

listed in the table below.

Considerations For Expert Consultation

Breastfeeding

Chronic illness that may increase drug toxicity

Delay is reporting the exposure

Current drug therapy that may increase toxicity of post-exposure

prophylaxis

Drug-resistant HIV

Pregnancy

Unknown source, i.e., a needle that is in a sharps container

Breastfeeding and pregnancy are not contraindications for the use of

post-exposure prophylaxis for HIV,21 and women who are

breastfeeding or pregnant should receive post-exposure prophylaxis if

it is indicated. There is a significant risk of in utero transmission of HIV

and transmission of HIV through breastfeeding and although the data

is limited, it does not appear that the use of post-exposure

prophylactic drugs increases the number of birth defects or is harmful

to breastfeeding infants.21 Efavirenz (Sustiva™) is teratogenic and

should not be used in pregnant women.8 Current information about the

use of antiviral drugs during pregnancy can be found on the website of

the Antiviral Pregnancy Registry, www.apregistry.com. Information can

also be obtained by calling the National Perinatal HIV Hotline, 7 days a

week, 24 hours a day, 1-888-448-8765.

http://www.apregistry.com/


Exposure to, and subsequent infection with drug-resistant strains of

HIV has been reported to occur after occupational exposure to HIV,

despite early use of post-exposure prophylaxis. It is not practical to

perform drug-resistance testing immediately after exposure to HIV,

therefore standard post-exposure prophylaxis should be initiated as

soon as possible.

Treatment should not be delayed

while waiting for drug-resistance

testing.21 If there is a possibility

that the source patient may be

infected with a drug-resistant

strain of HIV, expert consultation

should be sought and without

delay; post-exposure prophylaxis

should be started right away.21

The drug regimen can be changed

later if this is needed.

Exposure to a needle or a sharp from an unknown source should not

occur with good adherence to the blood-borne pathogens standards. If

an exposure of this type occurs the need for post-exposure prophylaxis

should be determined on a case-by-case basis. 21

Case Study: Health Employee Exposure To Blood

A 27-year old resident physician in training was working the night shift

of his 24-hour rotation and covering call for the intensive care unit

(ICU) when a patient arrived through the Emergency Department (ED)

following an accidental overdose of heroine. The patient had been

The Clinicians’ Post-Exposure

Prophylaxis Hotline (PEPline) is

available from 9 a.m., to 2 a.m.,

seven days a week and can

provide consultation about risk

assessment and post-exposure

prophylaxis: 888-448-4911.

Clinical guidelines for risk

assessment and treatment and

post-exposure prophylaxis

recommendations for exposure

to HIV, hepatitis B, and

hepatitis C are available on

their website,

http://nccc.ucsf.edu/clinician-

consultation/post-exposure-

prophylaxis-pep/.

http://nccc.ucsf.edu/clinician-consultation/post-exposure-prophylaxis-pep/




uncooperative in the ED with laboratory draws and the ICU nurse was

also having difficulty obtaining blood to send for testing. The nurse

called the physician for assistance with the blood draw because most

of the peripheral veins were difficult to locate, and the decision was

made to draw blood from the patient’s femoral vein. The patient’s

hepatitis status was unknown.

A needleless intravenous system was used to obtain the blood sample.

Personal protective equipment was donned by all of the nursing staff

however the physician had left the ED to assist in the ICU and needed

to return quickly as it was announced a major vehicle accident had

occurred and ambulances transporting the accident victims in serious

condition had already notified an estimated time of arrival of 20

minutes to the ED. The physician applied gloves however opted to not

wear a face shield or gown while obtaining the blood sample from the

patient’s femoral vein. During the procedure, the patient became

agitated and suddenly jerked the leg where the needle had been

advanced and the physician quickly had to abort the procedure to

avoid injury to the patient. As the needle was removed quickly, the

existing aspirated blood drawn into the syringe under suction pressure

splattered up at the physician’s right eye. The physician washed the

eye area after discarding the needle appropriately into a biohazard

needle container and moved onto the emergency cases due to arrive.

The healthcare facility had provided the PPE, which included the face

shield, head covering, gloves and gowns, which were immediately

located outside every ICU patient room in a convenient cupboard so

that clinicians performing procedures with reasonable anticipation of

exposure to body fluids could protect themselves with impervious


coverings from blood splatters or potentially infectious material.

As noted in the above sections, the health employer followed OSHA

standards that required the employer to “undertake measures to

reduce occupational exposures to blood-borne pathogens”, and the

physician was protected from risk of exposure through “engineering

controls that minimize the risk of sharp injuries (i.e., needleless

intravenous medication systems, blunted suture needles)…”13 Other

key measures required by OSHA that the employer followed to reduce

risk of occupational exposure in this case included annual education on

blood-borne pathogen transmission and ways to reduce the risk of

exposure, and immunization to hepatitis offered at no cost to the

employee.13

The employer had supplied every opportunity to avoid accidental

blood-borne pathogen exposure however the harried physician

(working late and probably tired) bypassed safety while prompted by a

need to return to the ED quickly to attend to another emergency call.

Discussion

Blood is the most important source of HBV and HCV transmission in

healthcare workers.13 The physician in this case should report

exposure immediately because the patient would be at high risk of

hepatitis with a history of heroin drug use.

Exposure occurred through contact with mucous membranes (the

eye). The source patient should be assessed after obtaining informed

consent, even if there had been a prior negative test, however the

patient in this case was unknown to carry the hepatitis virus. The

immunization status of the physician should be followed up.


A report of the exposure should immediately have been done by the

physician, such as the date and time of the exposure, the nature of the

exposure (i.e., non-intact skin, mucosal, percutaneous or human bite),

type of fluid, which was blood in this case, the body location (the

physician’s eye) and time of exposure. Further, all of the information

in an occupational report of exposure should be added to the

physician’s employee health file.13

The alarming reality is that often health clinicians will not report an

injury and in the case of this physician, not only did he hurriedly

bypass the OSHA guided employee safety policy of the hospital but he

moved quickly on to another emergency case where the risk for

exposure with bodily injured patients would be just as high or more.

What could the health team have done when the physician appeared

without PPE to perform a blood draw procedure on an uncooperative

patient? This is a self-reflective question each healthcare worker

should ponder.

In some hospital settings, healthcare workers are required to perform

team safety steps, such as procedural time outs or checklists, which

must be followed in a standardized format no matter the urgency at

hand before a procedure begins.22 Any member of the health team

could educate and ask another team member to properly use PPE

before starting a high risk procedure of exposure. This type of team

approach and care to see safety standards followed might have saved

this physician working late in a 24-hour rotation from hurriedly

arriving to a patient’s bedside and bypassing known hospital protocol

to prevent an occurrence of employee exposure.


Summary

The OSHA blood-borne pathogens standard was developed to help

reduce blood-borne pathogens transmission and infection. The blood-

borne pathogens standard has general and specific recommendations,

and all healthcare workers are required to have a basic knowledge of

and comply with the recommendations of the standard. Adhering to a

health employer’s policies related to employee safety and sanitary

rules, such as the correct use of PPE, proper handling of blood and

other body fluids, medical equipment, i.e., needles, sharps, and

disposable medical equipment, and the disposal of contaminated or

potentially contaminated medical equipment, are important

requirements to prevent blood-borne pathogen transmission. Proper

handwashing technique, including use of gloves, and the use of safety

precautions are standard competencies for all healthcare workers.

Exposure to blood or body fluids in the healthcare setting continues to

occur at alarming rates. Necessary information on how to report an

unsafe exposure, such as a needlestick wound, is both an employer

and employee obligation. The potential medical consequences are

quite serious and research indicates that the psychological burden of a

needlestick can be significant. An exposure to a blood-borne pathogen

should be reported immediately.

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a. Percutaneous.

b. Air-borne. c. Cutaneous.

d. Percutaneous and cutaneous together.

2. The primary focus on post-exposure management of blood-borne pathogens in occupational exposures for healthcare workers are:

a. hepatitis B, hepatitis A, and MRSA.

b. hepatitis C, HIV, and tuberculosis. c. hepatitis B, hepatitis C, and HIV.

d. hepatitis A, HIV, and gram-negative bacteria.


approximately:

a. 3.0%. b. 0.32%.

c. 30%. d. 13%



a. True. b. False.


a. testing of the source patient

b. notifying the employee health department. c. testing of the affected healthcare professional.


6. An exposure to a blood-borne pathogen should be reported:

a. Within 24 hours of the exposure. b. At the end of the shift.

c. Immediately. d. Within seven days of the exposure.


7. Commonly used drugs such as oral contraceptives, H2 receptor antagonist, and proton pump inhibitors can cause potentially

serious drug interactions when used with _____ post-exposure prophylaxis drugs.

a. HIV

b. hepatitis A c. hepatitis B

d. hepatitis C

8. True or false: There is effective post-exposure prophylaxis for Hepatitis C.

a. True.

b. False.

9. If the source patient is known, post-exposure prophylaxis for

HIV should be started:

a. Within 7 days of the exposure. b. After drug-resistance testing is completed.

c. Within 1-2 hours of the exposure. d. After tests for Hepatitis B and C and HIV have been

completed.

10. The OSHA blood-borne pathogens standard requires employers to:

a. Test each employee yearly for infection with blood-borne

pathogens.

b. Provide pre-exposure prophylaxis for HIV. c. Test at-risk patient for blood-borne pathogens.

d. Have a plan for the management of exposures to blood-borne pathogens.


Correct Answers


a. Percutaneous.

“The majority of occupational exposures to and infections from

these viruses are caused by percutaneous injury.”

2. The primary focus on post-exposure management of blood-borne pathogens in occupational exposures for healthcare workers are

c. hepatitis B, hepatitis C, and HIV.

“The primary focus on post-exposure management of blood- borne pathogens in occupational exposures for healthcare

workers are on hepatitis B, hepatitis C and HIV, although greater than 30 different pathogens have caused documented

occupational infection following exposure to blood or body fluids.”


approximately:

b. 0.32%.

“The risk of infection after a percutaneous exposure to HIV reported by Henderson (2012) has been estimated to be

0.32%.”



a. True.

“Blood-borne pathogens can contaminate surfaces and persist in the environment and contact with these

contaminated surfaces can cause infection. Hepatitis B and HIV in dried blood can remain on surfaces for a week

and hepatitis B is capable of causing infection during that time. Hepatitis C also can survive outside the body on

environmental surfaces and it can remain infective at room temperatures on surfaces for up to three weeks .”




“The first step in managing an exposure to a blood-borne

pathogen is to clean the exposed area.”

6. An exposure to a blood-borne pathogen should be reported:

c. Immediately.

“An exposure to a blood-borne pathogen should be reported immediately.”

7. Commonly used drugs such as oral contraceptives, H2 receptor antagonist, and proton pump inhibitors can cause potentially

serious drug interactions when used with _____ post-exposure prophylaxis drugs.

a. HIV

“Commonly used drugs such as oral contraceptives, H2 receptor

antagonist, and proton pump inhibitors can cause potentially serious drug interactions when used with _____ post-exposure

prophylaxis drugs.”

8. True or false: There is effective post-exposure prophylaxis for Hepatitis C.

b. False.

“There is no effective post-exposure prophylaxis for hepatitis C.”

9. If the source patient is known, post-exposure prophylaxis for HIV should be started:

c. within 1-2 hours of the exposure.

“If the source patient is known to have an HIV infection, post-

exposure prophylaxis should be started within 1-2 hours of the exposure.”


10. The OSHA blood-borne pathogens standard requires employers to:

d. Have a plan for the management of exposures to blood-borne

pathogens.

“Adherence to the OSHA blood-borne pathogen standard is mandatory for all hospitals and healthcare facilities. To be in

compliance with the standard employers must establish a written plan for controlling exposure to blood-borne pathogens. This

plan should include 1) an assessment of risk situations, 2) a determination of which employees are at risk and when they are

at risk, and 3) specific actions the employer will use to control and manage exposure to blood-borne pathogens. The plan must

be reviewed and updated annually and it must be accessible to

all employees.”


References Section

The References below include published works and in-text citations of published works that are intended as helpful material for your further

reading.

1. Occupational Safety and Health Administration (nd). Bloodborne

pathogens. Standard CFR 1910.1930. Retrieved online April 12, 2018 at

https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10051.

2. Anderson DJ. (2017). Infection prevention: Precautions for preventing transmission of infection. UpToDate. December 1,

2017. Retrieved online at

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infection?search=Infection%20risks%20following%20accidental%20exposure%20to%20blood%20or%20body%20fluids%20in%

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3. Pedrosa PB and Cardoso TA (2011). Viral infections in workers in hospital and research laboratory settings: a comparative review

of infection modes and respective biosafety aspects. Int J Infect Dis.2011;15(6):e366-e76

4. Centers for Disease Control and Prevention (2015). Sharps Safety for Healthcare Settings. CDC. Retrieved online at

https://www.cdc.gov/sharpssafety/ 5. International Safety Center. (2015). Sharp Object Injury Report

2015. Retrieved online from

https://internationalsafetycenter.org/wp-content/uploads/2017/06/Official-2015-NeedleSummary.pdf.

6. Henderson, DK (2012). Management of needlestick injuries: A house officer who has a needlestick. JAMA. 2012; 307(1) :75-84

7. Hasak JM, Novak CB, Patterson JMM, Mackinnon SE. (2018). Prevalence of needlestick injuries, attitude changes, and

prevention practices over 12 years in an urban academic hospital surgery department. Ann Surg. 2018;267(2):291-296.

8. Bartlett, JG. (2018). Management of healthcare personnel exposed to HIV. UpToDate. September 29, 2017. Retrieved

online at https://www.uptodate.com/contents/management-of-healthcare-personnel-exposed-to-

hiv?search=needle%20stick%20injury&source=search_result&selectedTitle=2~49&usage_type=default&display_rank=2.

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https://www.cdc.gov/sharpssafety/

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9. Deipolyi, AR, Prabhakar, AM, Naidu, S, Oklu, R. (2017). Needlestick injuries in interventional radiology are common and

underreported. Radiology. 2017;285(3):870-875. 10. Cohen, M. (2018). HIV infection: Risk factors and prevention

strategies. UpToDate. Retrieved online at https://www.uptodate.com/contents/hiv-infection-risk-factors-

and-prevention-strategies?search=mucous%20membrane%20exposure%20to%

20hiv&source=search_result&selectedTitle=1~150&usage_type=

default&display_rank=1. 11. Joyce MP, Kuhar D, Brooks JT. (2015). Notes from the field:

occupationally acquired HIV infection among health care workers - United States, 1985-2013. MMWR Morb Mortal Wkly Rep.

2015;63(53):1245-1246. 12. Centers for Disease Control and Prevention (2015).

Healthcare-associated infections. Surveillance of occupationally acquired HIV/AIDS in healthcare

personnel, as of December 2010. Retrieved online at http://www.cdc.gov/HAI/organisms/hiv/Surveillance-

Occupationally-Acquired-HIV-AIDS.html. 13. Weber DJ. Prevention of hepatitis B virus and hepatitis C virus

infection among healthcare providers. UpToDate. September 27, 2017. Retrieved online from

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virus-and-hepatitis-c-virus-infection-among-healthcare-providers#!.

14. Centers for Disease Control and Prevention (2015). Recommendations for prevention of transmission of human

immunodeficiency virus and hepatitis B virus to patients during exposure-prone procedures. Retrieved online at

http://www.cdc.gov/mmwr/preview/mmwrhtml/00014845.htm 15. Dienstag JL. (2012). Acute viral hepatitis. In: Long DI, Fauci AS,

Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal, on-line ed. 18th ed. 2012. New York, NY:

McGraw-Hill. 16. Strasser M, Aigner E, Schmid et al. (2013). Risk of hepatitis C

virus transmission from patients to healthcare workers: a prospective observational study. Infect Control Hosp

Epidemiol.2013;34(7):759-761.

17. Pfaender S, Helfritz FA, Siddharta A, et al. (2018). Environmental stability and infectivity of hepatitis C virus (HCV)

in different human body fluids. Front Microbiol. 2018 Mar 27;9:504. doi: 10.3389/fmicb.2018.00504. eCollection 2018.

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18. Centers for Disease Control and Prevention (2016). Viral Hepatitis. CDC. Retrieved online at

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20. Cho E, Lee H, Choi M, Park SH, Yoo IY, Aiken LH. (2013). Factors associated with needlestick and sharp injuries among hospital

nurses: a cross-sectional questionnaire survey. Int J Nurs Stud. 2013;50(8):1025-1032.

21. Kuhar DT, Henderson DK, Struble KA, et al (2013). Updated US Public Health Service Guidelines for the management of

occupational exposure to human immunodeficiency virus and recommendations for post-exposure prophylaxis. Infect Control

Hosp Epidemiol. 2013;34(9):875-892.

22. Wahr, J.A. (2018). Operating room hazards and approaches to improve patient safety. UpToDate. Retrieved online at

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safety?search=time%20out%20safety&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

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The information is designed to assist healthcare professionals, including nurses, in

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The contents of this publication may not be reproduced without written permission

from NurseCe4Less.com.

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