FOR THE MASSAGE THERAPIST Florida Board of Massage CE Broker Provider #50-1997 CE Broker Course Tracking # 20-135583 NCBTMB Approved Provider #154019-00
The Institute for Advanced Therapeutics, Inc. P.O. Box 848152
Pembroke Pines, Florida 33084 1-954-441-9553
INFECTION CONTROL FOR THE MASSAGE THERAPIST
Consultant and Editor
Mark Blum, D.D.S.
Research and Development:
Charles Edwin Cook, L.M. T., C.R. T.
By:
Renee J. Demmery, C.R.T.
©2006 Renee J. Demmery All Rights Reserved
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INFECTION CONTROL FOR THE MASSAGE THERAPIST
Published By:
The Institute for Advanced Therapeutics, Inc. P.O. Box 848152
Pembroke Pines, Florida 33084 1-954-441-9553 tel 1-954-432-1824 fax
This course was developed to help expand the knowledge and skills of massage therapist with respect to the subject of infection control. It is the responsibility of the massage therapist to determine which principles and theories contained herein are appropriate with respect to his/her personal limitations and scope of practice. The information in this course has been carefully researched and is generally accepted as factual at the time of publication. The Institute for Advanced Therapeutics, Inc. disclaims responsibility for any contradictory data prior to the publication of the next revision of this course. The images used herein were obtained from IMSI's MasterClips® and MasterPhotos™ Premium Image Collection, 1895 Francisco Blvd. East, San Rafael, CA 94901-5506, USA.
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TABLE OF CONTENTS COURSE DIRECTIONS MAILING INSTRUCTIONS COURSE OBJECTIVES INTRODUCTION COMPONENTS OF AN INFECTION CONTROL PROGRAM STAFF EDUCATION AND TRAINING STAFF IMMUNIZATION EXPOSURE PREVENTION DISPOSABLE PATIENT CARE ITEMS WORK RESTRICTIONS POSTEXPOSURE PROPHYLAXIS STAFF RECORD MANAGEMENT HAND HYGIENE HAND WASHING USE OF LOTIONS FINGERNAILS JEWELRY PROTECTIVE BARRIERS GLOVES SURGICAL FACE MASKS DISINFECTION LEVELS OF DISINFECTION ENVIRONMENTAL DISINFECTION INSTRUCTIONS FOR COMPLETING THE TEST INFECTION CONTROL FOR THE MASSAGE THERAPIST TEST TEST ANSWER CARD/COURSE EVALUATION GLOSSARY REFERENCES
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COURSE DIRECTIONS
HOW TO BEST PROCEED WITH THIS COURSE Each chapter should be approached systematically in a careful and objective manner. It is important to master each chapter before going on to the next. Relax, take your time, and go at your own pace. As 4 credits of continuing education are rewarded after successfully completing this course, the reading of this manual and completion of the test questions should not take less than 4 hours. Only after you have successfully mastered all the material in the course should you proceed to the test questions.
COMPLETING THE TEST Before beginning, please clearly write your name, address, zip code, and license number on your test answer card. Read each question carefully before answering. Please use a ballpoint pen to fill-in your answers on the answer card by completely shading your choice. Keep in mind that each question has only one correct answer. The test consists of 25 questions. For a passing grade, you must correctly answer 20 questions. We encourage your input and would welcome any suggestions to improve our course or test questions. Please feel free to note your suggestions or comments on the course evaluation found at the bottom of the test answer card.
INFORMATION FOR CERTIFICATION In order to receive your 4 hours of continuing education credit, you must be a registered purchaser of this course. Please notify us of any address or name changes as we keep permanent records for certification and licensure.
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MAILING INSTRUCTIONS Please send your completed test answer card and course evaluation to:
The Institute for Advanced Therapeutics, Inc. P.O. Box 848152
Pembroke Pines, Florida 33084
If you have any questions regarding this course, please contact our Customer Service Department at 1-954-441-9553 or fax us at 1-954- 432-1824.
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COURSE OBJECTIVES Upon completion of this course, you will be able to:
1. List the conditions that must be met in order for infection to be transmitted.
2. Identify ways to reduce transmission of disease. 3. Describe prophylactic measures that can be taken following
accidental exposure to hepatitis B and HIV.
4. Discuss methods of disinfection.
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INTRODUCTION
The reason for infection control in massage therapy is to prevent transmission of disease from patient to massage therapist, from massage therapist to patient, and from patient to patient during massage treatment. Adhering strictly to guidelines developed in collaboration with the Centers for Disease Control and other public agencies, academia, and private and professional organizations, patients and massage therapists can be protected from most pathogenic microorganisms in the massage setting. These bacteria or viruses can be transmitted through the following:
direct or indirect contact with blood or bodily fluids indirect contact with contaminated surfaces contact with droplets containing microorganisms
through an infected person sneezing, coughing, or talking reaching the oral mucosa, nasal membranes, or conjunctivae
contact with microorganisms suspended in the air for long periods through inhalation
The following conditions must be met in order for infection to be transmitted.
a means of access through which the pathogenic microorganism can enter the host
a host that is not immune to the pathogenic microorganism
a method of transmission a source that allows the pathogenic
microorganism to survive and reproduce a pathogenic microorganism hardy enough and in
sufficient quantities to cause disease
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An effective infection control program aims at preventing transmission of disease by breaking the chain of cross-infection above. Some of the diseases that present the greatest risk for massage therapists include the following.
hepatitis B virus hepatitis C virus cytomegalovirus herpes simplex viruses 1 and 2 HIV Staphylococci Mycobacterium tuberculosis Streptococci
In 1996, the Centers for Disease Control and Prevention developed a standard of care designed to prevent transmission of pathogens that can be spread by blood or body fluids, excretion, or secretion called standard precautions.
NOTES
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COMPONENTS OF AN INFECTION CONTROL PROGRAM
STAFF EDUCATION AND TRAINING
All massage therapy practices should develop a written plan to prevent or reduce the risk of transmission of infectious diseases. This program should include ways to implement procedures to identify and help prevent work-related cross-contamination among staff and patients and work-related injuries. A person to coordinate the infection control program and provide instruction to staff regarding these procedures should be assigned. Staff at risk for occupational exposure to pathogens should be educated in infection control measures upon initial employment and periodically throughout the employment history. STAFF IMMUNIZATION
An essential component of a massage therapy practice’s infection control program should be a staff immunization policy. Massage professionals are considered high risk for acquiring vaccine-preventable diseases such as:
hepatitis B influenza rubella varicella measles mumps
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Vaccinations against these diseases can provide immunity and break the chain of infection by eliminating a susceptible host. Massage employees should be offered immunization upon initial employment. Administrative staff can be offered vaccinations as well. Immunization schedules should take into consideration state and federal regulations and U.S. Public Health Service recommendations. The Advisory Committee on Immunization Practices (ACIP) has issued national guidelines for health care professionals regarding immunization including massage professionals. These guidelines can be utilized to create a staff immunization policy. EXPOSURE PREVENTION
As massage therapy professionals, there are precautions that can be taken to reduce the risk of infection. First, treat every patient as if they have an infectious disease. Many persons with infectious diseases do not exhibit obvious symptoms and may appear to be healthy. Precautions should be taken with patients who deny having an infectious disease as they may not realize they have an infectious disease or they may be concealing their disease for fear of discrimination or being denied treatment. Exposure to infection can occur through percutaneous injury such as when a sharp object punctures the skin or through nonintact skin such as chapped hands. Infection can also occur when infected blood, tissues, or bodily fluids come in contact with the mucous membranes of the eyes, nose, and mouth.
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Although the risk of occupational exposure to infection can never be completely eliminated, the following strategies can help prevent exposure and should be part of a massage practice’s infection control policy.
Avoid coming in contact with blood, bodily fluids, or tissues.
Consistently adhere to use of gloves during contact with nonintact skin and masks to prevent spread of viral illness.
Comply with the massage practice’s infection control policy.
Vaccinate all eligible employees. Facilitate prompt reporting and management of
exposure incidents. Employ a strict policy of work restrictions. Train staff in infection control measures. Wash hands thoroughly between each patient. Cover your mouth and nose with a tissue when
coughing or sneezing. Do not touch your eyes, nose, or mouth unless
your hands have just been washed or disinfected with an alcohol-based hand rub.
DISPOSABLE PATIENT CARE ITEMS
Disposable single-use patient care items should not be cleaned, disinfected, or sterilized for reuse at a later time. Such items should be used only once then discarded. Some examples include:
Table paper Face rest covers gloves masks disposable wear implements
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WORK RESTRICTIONS
Massage therapy practice employees with certain contagious illnesses pose a risk to patients as well as other staff members while they are infectious. These employees should not be allowed to be in the workplace until they are asymptomatic and/or a medical physician deems them non-contagious. POSTEXPOSURE PROPHYLAXIS
All massage practices where massage therapy personnel might experience exposures should have a written policy for management of exposures. The policy should be based on the U.S. Public Health Service guidelines. It should be reviewed periodically to ensure that it is consistent with Public Health Service recommendations. Procedures should be in place to promptly report, medically evaluate, and record all cases of accidental occupational exposure. Percutaneous injuries should be washed with soap and water. If the exposure was to the eyes, nose, or mouth, the mucous membranes should be flushed with copious amounts of water.
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A qualified health care professional should be assigned to perform a medical evaluation and provide first aid and counseling if necessary. The medical evaluator should include in the chart:
the date and time of the exposure details of where and how the exposure occurred the type, brand, and size of the massage device
involved in the exposure the amount of contaminant involved and what
type of injury details regarding the depth of the wound and
whether any potentially-infectious fluid was injected into the body
an estimate of the amount of potentially-infectious fluid involved
how long the potentially-infectious material remained on the skin or mucous membranes before washing or flushing of the area
the infectious medical history of the patient from which the exposure occurred
the vaccination history of the exposed massage therapist
details of any counseling, treatment, or prophylaxis performed
For diseases such as hepatitis B and HIV, there are prophylactic measures that can be taken following accidental exposure. In certain cases, anti-retroviral agents can be administered prophylactically. Guidelines published by the U.S. Public Health Service outline management of occupational exposures. Recommendations for hepatitis B virus postexposure management include initiation of the hepatitis B vaccine series to any susceptible, unvaccinated person who sustains an occupational blood or body fluid exposure.
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Postexposure prophylaxis with hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine series should be considered for occupational exposures after evaluation of the hepatitis B surface antigen status of the source and the vaccination and vaccine-response status of the exposed person. Guidance is provided to clinicians and exposed health-care personnel for selecting the appropriate hepatitis B virus postexposure prophylaxis. Immune globulin and antiviral agents (e.g., interferon with or without ribavirin) are not recommended for postexposure prophylaxis of hepatitis C. For hepatitis C virus postexposure management, the hepatitis C virus status of the source and the exposed person should be determined, and for health care personnel exposed to a hepatitis C virus positive source, follow-up hepatitis C virus testing should be performed to determine if infection develops.
Recommendations for HIV postexposure prophylaxis include a basic 4-week regimen of two drugs (zidovudine [ZDV] and lamivudine [3TC]; 3TC and stavudine [d4T]; or didanosine [ddI] and d4T) for most HIV exposures and an expanded regimen that includes the addition of a third drug for HIV exposures that pose an increased risk for transmission. When the source person's virus is known or suspected to be resistant to one or more of the drugs considered for the postexposure prophylaxis regimen, the selection of drugs to which the source person's virus is unlikely to be resistant is recommended. STAFF RECORD MANAGEMENT
The health status of each massage therapist should be recorded in a medical chart and properly maintained according to state and federal laws regarding confidentiality and duration of maintenance.
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This medical chart should contain information relating to:
immunizations work-related medical examinations initial screening tests exposure incident reports postexposure management work restrictions
NOTES
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HAND HYGIENE
HAND WASHING Strict adherence to hand hygiene has been demonstrated to both terminate outbreaks and reduce overall infection rates. There are three methods of improving hand hygiene in the dental office – traditional hand washing, hand asepsis, and surgical hand asepsis. The desired method of hand washing should depend on the level of contamination of the hands as well as the type of procedure being performed. Traditional hand washing involves the use of plain soap and water. Hand asepsis involves the use of an antimicrobial soap and water or alcohol-based hand rub. Surgical hand asepsis involves the use of an antimicrobial soap that has a broad-spectrum of activity and long-lasting antimicrobial effect. Massage therapy practices should take into consideration a couple of factors when choosing which antiseptic agent to use in their facility:
the efficacy of the product against the pathogens likely to be encountered in the workplace
the persistence of antiseptic activity the speed at which the product takes effect the likelihood of acceptance and compliance by
employees.
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A pleasing color, smell, and moisturizing properties all can positively influence acceptance. Massage therapy professionals should be expected to wash their hands:
Upon arrival to the massage facility If the gloves are noted to have a tear or defect If the hands come in contact with saliva or blood Before a patient is seen and gloves are put on After a patient is seen and gloves are taken off Anytime gloves are removed If the hands are visibly soiled Before leaving the facility for the day
Two methods of improving massage therapist hand hygiene are outlined below.
1. Traditional Hand Washing – Purpose is to remove dirt, organic material, and most transient microorganisms. Wet hands with running water and apply soap or detergent. Rub hands together vigorously for at least 10 to 15 seconds. Rinse hands thoroughly and dry.
2. Hand Asepsis – The purpose is to remove or destroy transient
microorganisms. Wet hands with running water and apply antimicrobial soap or detergent that contains an antiseptic. Rub hands together vigorously for at least 10 to 15 seconds. Rinse hands thoroughly and dry. An alternative when the hands are not soiled with dirt or organic material is to use an alcohol-based antiseptic hand rub to achieve hand antisepsis. Apply a sufficient amount of the product to the palm of one hand to completely cover the surfaces of both hands and fingers when the hands are rubbed together. Continue to rub the hands together until dry. No rinsing or towel drying is required.
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USE OF LOTIONS Frequent hand washing and use of antiseptic products can lead to dry, chapped hands which can provide easy entry for pathogens. Moisturizing lotion to the hands can ease dryness associated with frequent hand washing. However, it is important to avoid petroleum or oil-based lotion since it can break down latex gloves and increase permeability. FINGERNAILS Fingernail length should be kept short since most of the bacterial flora on the hands is found under and around the fingernails. Having shorter fingernails can reduce infection rates by:
allowing easier cleaning underneath the nails. decreasing the likelihood of glove punctures.
The use of artificial fingernails is discouraged because of the increased incidence of fungal and bacterial infections associated with their use. Chipped nail polish can also harbor bacteria. JEWELRY Although it is not known whether wearing rings while working in a massage therapy setting increases the risk of acquiring an infection, it may make hand washing more difficult to perform and may increase the likelihood of glove tears.
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PROTECTIVE BARRIERS
Today, massage professionals can use protective barriers to reduce the risk of disease transmission. Some examples of protective gear include:
1. Gloves. 2. Surgical face masks.
GLOVES
Wearing gloves prevents contamination of the hands during massage and can prevent potentially infectious microorganisms on the hands from transmitting to patients. Gloves can also prevent the transmission of potentially infectious microorganisms on patients nonintact skin from transmitting to the massage therapist . Gloves should be used only once on a single patient then discarded. Contamination of the hands is reduced by 70-80% by using gloves. Washing gloves can cause micropunctures invisible to the naked eye which can compromise the integrity of the gloves. This can allow contaminated fluids to pass through the gloves.
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Hands should be washed thoroughly before putting on each pair of gloves and washed again once gloves are removed. If using an alcohol-based hand rub, hands must be completely dry before putting on gloves since alcohol-based liquid on gloved hands can increase the risk of glove perforation. To optimize glove performance and reduce infection rates:
Wear gloves in the appropriate size.
Apply gloves to completely dry hands after using alcohol-based hand rubs.
Keep fingernails short.
Do not wear hand jewelry.
Replace visibly torn or damaged gloves
immediately. There are two forms of contact dermatitis common among massage therapists:
Irritant contact dermatitis - characterized by an itchy, dry skin rash around the area of contact that is generally a result of frequent hand washing with soaps and antiseptic products.
Allergic contact dermatitis - characterized by a hypersensitivity reaction due to chemicals used in the manufacturing of gloves. The allergic rash usually becomes apparent a few hours after contact.
Contact dermatitis can increase the risk of infection and transmission of pathogens because any damage to the skin can result in more frequent colonization by certain types of bacteria.
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Some massage therapists develop a hypersensitivity to the natural rubber proteins in latex. This condition is characterized by a systemic hypersensitivity reaction and is far more serious than irritant or allergic contact dermatitis. Symptoms range in severity and include:
itchy burning skin itchy eyes scratchy throat sneezing runny nose hives difficulty breathing wheezing coughing gastrointestinal tract irregularities heart irregularities anaphylaxis or death (rarely)
Latex protein attaches to the powder in gloves and can reach the skin or be inhaled. When this happens, people who are allergic can develop adverse symptoms. To reduce the risk of allergy to latex while using latex gloves, reduced protein/powder-free gloves can be worn. SURGICAL FACE MASKS
Surgical face masks can be worn to reduce the risk of transmission of the cold or flu.
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To optimize surgical face mask performance and reduce infection rates:
♦ Wash hands before putting on a mask. ♦ Wash hands before taking off a mask. ♦ Make sure the surgical face mask fits snugly over the face. ♦ Make sure the elastic bands or strings are positioned properly
to keep the mask securely in place. ♦ Make sure the mask completely covers the nose, mouth and
chin. ♦ When taking off the mask, avoid touching the outside part of
the mask as it may be contaminated. ♦ Replace the mask if it becomes damaged, wet or visibly soiled. ♦ Do not wear the same surgical mask for longer than a day.
NOTES
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DISINFECTION LEVELS OF DISINFECTION There are two levels of disinfection for environmental surfaces.
intermediate low
ENVIRONMENTAL DISINFECTION
Surfaces or equipment in the massage therapy office that do not touch patients directly are known as environmental surfaces. The surfaces of items such as knobs, switches, and handles can become contaminated with microorganisms. For the purposes of disinfection, there are two categories of environmental surfaces:
clinical contact – (ex. countertops, switches, door knobs).
housekeeping – (ex. walls, floors). Clinical contact surfaces should be disinfected with more rigorous methods than housekeeping surfaces because they are touched more frequently. Following treatment of each patient and at the end of the work day, environmental surfaces that may have been contaminated by patient debris should first be cleaned with paper towels and a cleaning agent then disinfected appropriately.
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Environmental surfaces that may have been contaminated with patient’s saliva, blood or other patient debris should be disinfected with an intermediate-level, EPA-registered germicide with mycobacterial activity. An alternative would be to use a solution of sodium hypochlorite (household bleach) and water at a concentration of 1:100. Housekeeping surfaces such as walls and floors that have not been contaminated with patient debris can be disinfected with a low-level, EPA-registered germicide that does not have mycobacterial activity.
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GLOSSARY
Alcohol-based hand rub: an alcohol-containing preparation designed for application to the hands for reducing the number of viable microorganisms on the hands.
Allergic contact dermatitis: a type IV or delayed-hypersensitivity reaction resulting from contact with a chemical allergen (e.g. certain components of patient care gloves), generally localized to the contact area. Reactions occur slowly over 12-48 hours.
Anaphylaxis (immediate anaphylactic hypersensitivity): a severe and sometimes fatal Type 1 reaction in a susceptible person after a second exposure to a specific antigen (e.g., food, pollen, proteins in latex gloves, or penicillin) after previous sensitization. Anaphylaxis is characterized commonly by respiratory symptoms, itching, hives, and rarely by shock and death (anaphylactic shock).
Antimicrobial soap: a detergent containing an antiseptic agent.
Antiseptic: a germicide that is used on skin or living tissue for the purpose of inhibiting or destroying microorganisms.
Antiseptic handwash: washing hands with water and soap or detergents containing an antiseptic agent. Antiseptic hand rub. The process of applying an antiseptic hand-rub product to all surfaces of the hands to reduce the number of microorganisms present.
Asepsis: prevention from contamination with microorganisms. Includes sterile conditions on tissues, on materials, and in rooms, as obtained by excluding, removing, or killing organisms.
Asymptomatic: Without symptoms.
Cleaning: the removal of visible soil, organic and inorganic contamination from a device or surface, using either the physical action of scrubbing with a surfactant or detergent and water or an energy-based process (e.g., ultrasonic cleaners) with appropriate chemical agents. Contaminated: state of having been in contact with microorganisms. As used in health care, it generally refers to microorganisms capable of producing disease or infection.
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Disinfectant: a chemical agent used on inanimate objects to destroy virtually all recognized pathogenic microorganisms, but not necessarily all microbial forms.
Disinfection: the destruction of pathogenic and other kinds of microorganisms by physical or chemical means. Disinfection is less lethal than sterilization, because it destroys most recognized pathogenic microorganisms, but not necessarily all microbial forms, such as bacterial spores. Disinfection does not ensure the margin of safety associated with sterilization processes.
Hand hygiene: a general term that applies to handwashing, antiseptic handwash, antiseptic hand rub, and surgical hand antisepsis.
Hypersensitivity: an immune reaction (allergy) in which the body has an exaggerated response to a specific antigen (e.g., food, pet dander, wasp venom). See allergic contact dermatitis, anaphylxis, latex allergy.
Immunization: The process by which a person becomes immune, or protected, against a disease. This term is often used interchangeably with vaccination or inoculation. However, the term “vaccination” is defined as the injection of a killed or weakened infectious organism in order to prevent the disease. Thus, vaccination, by inoculation with a vaccine, does not always result in immunity.
Intermediate-level disinfectant: a liquid chemical germicide registered by the EPA as hospital disinfectant and with a label claim of potency as a tuberculocidal.
Irritant contact dermatitis: the development of dry, itchy, irritated areas on the skin, which can result from frequent handwashing and gloving as well as exposure to chemicals. This condition is not an allergic reaction. Latex: a milky white fluid extracted from the rubber tree Hevea brasiliensis that contains the rubber material cis-1,4 polyisoprene. Low-level disinfectant: a liquid chemical germicide registered by the EPA as a hospital disinfectant. OSHA requires low-level disinfectants also to have a label claim for potency against HIV and HBV if used for disinfecting clinical contact surfaces.
Percutaneous injury: an injury that penetrates the skin.
Postexposure prophylaxis: the administration of medications following an occupational exposure in an attempt to prevent infection.
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Semi-critical: the category of medical devices or instruments that come into contact with mucous membranes and do not ordinarily penetrate body surfaces.
Sterilization: the use of a physical or chemical procedure to destroy all microorganisms including large numbers of resistant bacterial spores.
Vaccine: a product that produces immunity therefore protecting the body from the disease. Vaccines are administered through needle injections, by mouth and by aerosol.
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REFERENCES CDC. Exposure to Blood: What Health Care Workers Need to Know. Available at: http://www.cdc.gov/ncidod/hip/Blood/Exp_to_Blood.pdf (PDF–363K). Accessed February 2005.
CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR 2001;50(No.RR-11).
Chiarello LA, Bartley JB. Prevention of blood exposure in health care personnel. Seminars in Infection Control 2001;1:30–43.
CDC. National Institutes of Occupational Safety and Health (NIOSH). Latex Allergy: A Prevention Guide. Questions and Answers about identifying and preventing latex allergy. Cincinnati, OH: US Department of Health and Human Services, Public Health Service, CDC, National Institute for Occupational Safety and Health DHHS NIOSH Publication No. 98-113. Available at http://www.cdc.gov/niosh/98-113.html. Accessed February 2005.
CDC. Guideline for hand hygiene in health care settings: Recommendations of the Health Care Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR-16). De Haan P, Meester HHM, Bruynzeel DP. Irritancy of alcohols. In: van der Valk, PGM, Mailbach HI, eds. The Irritant Contact Dermatitis Syndrome. New York: CRC Press, 1996:65–70.
US Department of Labor, Occupational Safety and Health Administration. OSHA instruction: enforcement procedures for the occupational exposure to Bloodborne pathogens. Washington, DC: US Department of Labor, Occupational Safety and Health Administration, 2001; directive no. CPL 2 2.69.
Goldmann DA. The role of barrier precautions in infection control. J Hosp Infect 1991;18:515-523.
Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recomm Rep 2001 Jun 29;50(RR-11):1-52.
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