Bloodborne Pathogens
Meadowlands Hospital Medical Center
Learning Objectives
Describe the epidemiology, symptoms, and infection risks of select bloodborne pathogens.
Recognize potentially infectious material, tasks with occupational exposure, hazards, and exposure incidents.
Employ controls—including engineering controls, work practices, labeling, and personal protective equipment (PPE).
Summarize components of postexposure management.
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OSHA’s Bloodborne Pathogens Standard
Exposure determination
Exposure control plan Training Labels and signs
Standard precautions
Engineering and work-practice
controls
Disposal of sharps and regulated medical waste,
cleaning, laundry
PPE
Hepatitis B virus (HBV) vaccination
Postexposure evaluation and
follow-upRecord keeping
Requirements for HIV, HBV research
laboratories and production facilities
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Bloodborne Pathogens: What Are They?“Pathogenic microorganisms that are present in human blood and can cause disease in humans”
HIV
Hepatitis B, C, D
Syphilis
Creutzfeldt-Jakob disease
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Sources: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS; University of the Sciences. Q&A on OSHA’s bloodborne pathogens standard [online]. [cited 2014 May 13]. http://www.usciences.edu/safety/infotrain/qablood.htm
HIV Infection: Stages
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Early stage
• Many but not all get symptoms
• May feel like "worst flu ever"
• 2–4 weeks after exposure
• Lasts a few days to several weeks
Clinical latency stage
• No or mild symptoms
• Often lasts a decade in the untreated
• Lasts longer in treated patients
Progression to AIDS
• Potential for opportunistic infections, related cancers
• Treatment may prevent progression to AIDS
2014 ECRI Institute
Sources: Centers for Disease Control and Prevention. About HIV/AIDS [online]. 2014 Feb 12 [cited 2014 May 13]. http://www.cdc.gov/hiv/basics/whatishiv.html; U.S. Department of Health and Human Services (U.S. HHS); HIV/AIDS 101: signs and symptoms [online]. 2013 Dec 19 [cited 2014 May 13]. http://aids.gov/hiv-aids-basics/hiv-aids-101/signs-and-symptoms; U.S. HHS. Stages of HIV infection [online]. 2013 Dec 19 [cited 2014 May 13]. http://aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/hiv-in-your-body/stages-of-hiv
HIV Infection: Signs and Symptoms
Early stage
• Fever• Swollen glands• Sore throat• Rash• Fatigue• Muscle, joint aches• Headache
Clinical latency stage
• No or mild symptoms
Progression to AIDS
• Rapid weight loss• Fever, night sweats• Extreme tiredness• Lymph gland swelling• Long-lasting diarrhea• Oral, anal, genital
sores• Pneumonia• Blotches on skin,
mucous membranes• Memory loss,
depression, etc.
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Sources: Centers for Disease Control and Prevention. About HIV/AIDS [online]. 2014 Feb 12 [cited 2014 May 13]. http://www.cdc.gov/hiv/basics/whatishiv.html; U.S. Department of Health and Human Services (U.S. HHS); HIV/AIDS 101: signs and symptoms [online]. 2013 Dec 19 [cited 2014 May 13]. http://aids.gov/hiv-aids-basics/hiv-aids-101/signs-and-symptoms; U.S. HHS. Stages of HIV infection [online]. 2013 Dec 19 [cited 2014 May 13]. http://aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/hiv-in-your-body/stages-of-hiv
HBV Infection: Stages, Signs, and Symptoms
Acute infection
• 70% of adults get symptoms
• Symptoms can appear 6 weeks to 6 months after exposure
• Symptoms usually last a few weeks but can last as long as 6 months
Chronic infection
• Most have no symptoms for decades
• Some have symptoms like those of acute infection
• 15%–25% get serious liver conditions• Some have no
symptoms even as liver becomes diseased
• Fever• Fatigue• Loss of appetite• Nausea• Vomiting• Abdominal pain• Dark urine• Clay-colored bowel
movements• Joint pain• Jaundice
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Source: Centers for Disease Control and Prevention. Hepatitis B FAQs for the public [online]. 2009 Jun 9 [cited 2014 May 13]. http://www.cdc.gov/hepatitis/b/bfaq.htm
HCV Infection: Stages, Signs, and Symptoms
Acute infection
• 20%–30% of people get symptoms
• Symptoms can appear 2 weeks to 6 months after exposure
Chronic infection
• Most have no symptoms
• In many cases, no symptoms until liver problems have developed
• Can lead to liver damage, liver failure, liver cancer, even death
• Fever• Fatigue• Loss of appetite• Nausea• Vomiting• Abdominal pain• Dark urine• Clay-colored bowel
movements• Joint pain• Jaundice
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Source: Centers for Disease Control and Prevention. Hepatitis C FAQs for the public [online]. 2014 Feb 10 [cited 2014 May 13]. http://www.cdc.gov/hepatitis/c/cfaq.htm
How Common Are Bloodborne Pathogens in the United States?
1.1
milli
on
800,
000
to .
. .
1.4
milli
on
3.2
milli
on
* Age 13 or older
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Sources: Centers for Disease Control and Prevention (CDC). HIV in the United States: at a glance [online]. 2013 Dec 3 [cited 2014 May 13]. http://www.cdc.gov/hiv/statistics/basics/ataglance.html; CDC. Hepatitis B FAQs for the public [online]. 2009 Jun 9 [cited 2014 May 13]. http://www.cdc.gov/hepatitis/b/bfaq.htm; CDC. Hepatitis C FAQs for the public [online]. 2014 Feb 10 [cited 2014 May 13]. http://www.cdc.gov/hepatitis/c/cfaq.htm
Standard Precautions: Approach All Blood and OPIM As If They Were Infectious
16% of people with HIV infection are unaware of their infection.
19% of people with HIV infection are age 55 or older.
Chronic HCV infection is most prevalent among baby boomers.194
5
1965
OPIM = other potentially infectious material
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Sources: Centers for Disease Control and Prevention (CDC). HIV in the United States: at a glance [online]. 2013 Dec 3 [cited 2014 May 13]. http://www.cdc.gov/hiv/statistics/basics/ataglance.html; CDC. HIV among older Americans [online]. 2013 Dec 20 [cited 2014 May 13]. http://www.cdc.gov/hiv/risk/age/olderamericans/index.html; CDC. Hepatitis C FAQs for the public [online]. 2014 Feb 10 [cited 2014 May 13]. http://www.cdc.gov/hepatitis/c/cfaq.htm.
Who May Have Occupational Risk?
Anyone who works in healthcare and has potential for exposure to infectious materials Infectious body substances Contaminated medical supplies and equipment Contaminated surfaces
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Source: Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol 2013 Sep;34(9):875-92. Also available at http://www.jstor.org/stable/10.1086/672271
Blood and OPIMPotentially infectious
BloodBody fluids with visible bloodAll body fluids in situations in which it is difficult or impossible to differentiate between body fluids
Semen*Vaginal secretions*Cerebrospinal fluidSynovial fluidPleural fluidPeritoneal fluidPericardial fluidAmniotic fluidSaliva (dental procedures)
Unfixed human tissue or organ (except skin)HIV-containing cell, tissue, or organ culturesHIV- or HBV-containing culture media or other solutionsBlood, organs, other tissues from experimental animals infected with HIV or HBV
* Potentially infectious but not implicated in occupational transmission
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
What Incidents Should Be Evaluated?
Evaluation
Injury that pierces the skin (e.g.,
needlestick, cut with a sharp object)
Contact between potentially infectious
body fluid and mucous membrane or nonintact skin
Direct contact with concentrated virus in a research laboratory
Human bite
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Source: Centers for Disease Control and Prevention. 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. Also available at http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf
Sharps: Not Just NeedlesA contaminated sharp is “any contaminated object that can penetrate the skin.”
“Contaminated” means “the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.”
These are only examples.
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
How Common Are Injuries?
Each year, almost one in five healthcare workers experiences a needlestick injury.
Only 54% of injuries are reported.
Your health and safety are important!
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Sources: Premier Safety Institute. Prevent needlestick injuries [online]. 2011 [cited 2014 May 14]. https://www.premierinc.com/quality-safety/tools-services/safety/topics/needlestick/downloads/SharpsBRO_SEPT-2011-HR.pdf; Schillie S, Murphy TV, Sawyer M, et al. CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR Recomm Rep 2013 Dec 20;62(RR-10):1-19. Also available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6210a1.htm
Likelihood of Getting Infected from Percutaneous Exposure to Infected Blood
1 in 333 1 in 4
1 in 56
1 in 100 - 1 in 17
HIV HBV (if unvaccinated)
HCV
HBeAg+
HBeAg-
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Source: Centers for Disease Control and Prevention. 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. Also available at http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf
Documented Cases of HIV Transmission to Healthcare PersonnelCDC investigates voluntarily reported cases of HIV transmission to healthcare personnel. Cases may be underreported.
CDC analyzes cases in those with no nonoccupational risk factors, but over 90% of HIV-infected healthcare personnel have nonoccupational risk factors.
From 1981 to 2010, CDC identified only 57 cases of documented HIV seroconversion after occupational exposure.
Another 143 cases were identified as “possible” cases of transmission.
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Source: Centers for Disease Control and Prevention. Surveillance of occupationally acquired HIV/AIDS in healthcare personnel, as of December 2010 [online]. 2011 May 23 [cited 2014 May 15]. http://www.cdc.gov/HAI/organisms/hiv/Surveillance-Occupationally-Acquired-HIV-AIDS.html
Get Involved
engineering and work-practice controls.
• identification, • evaluation, and• selection of
for input regarding . . .
• responsible for direct patient care
• who are potentially exposed to injuries from contaminated sharps . . .
nonmanagerial employees . . .
OSHA requires employers to ask . . .
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
Our Exposure Control Plan
Our exposure control plan . . .
Our plan is located on our intranet in the Policy and Procedure Manual.
Describes how we implementEngineering controlsWork-practice controlsPPEHousekeepingSharps disposal
HBV vaccinationBiohazard labelsTraining
Is required by OSHA’s bloodborne pathogens standard
Describes how exposure incidents will be evaluated
Outlines what records we keep regarding your occupational exposure
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
HBV Vaccination: Efficacy and Dosing
Costs you nothing See employee health nurse
Can prevent HBV infection and serious consequences
Offers long-term protection, possibly lifelong
Usual dosing schedule
2nd1st
3rd4 weeks after 1st dose
5 months after 2nd dose
Blood testing for immunity 1–2 months after last dose
More vaccine doses and testing are indicated if not immune
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Source: Centers for Disease Control and Prevention. Hepatitis B vaccine: what you need to know [online]. 2012 Feb 2 [cited 2014 May 16]. http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.pdf
HBV Vaccination: Safety
HBV vaccine cannot cause HBV infection.
Most people have no problems.
Mild ProblemsInjection site soreness Up to 1 in 4 people
Fever Up to 1 in 15 people
Severe ProblemsSevere allergic reaction
1 in 1.1 million doses
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Source: Centers for Disease Control and Prevention. Hepatitis B vaccine: what you need to know [online]. 2012 Feb 2 [cited 2014 May 16]. http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.pdf
Elimination and Substitution
Elimination or substitution may be used only when clinically appropriate.
Examples are: Oral rather than intravenous administration Use of a needleless device (e.g., needleless IV system)
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Engineering Controls: Sharps with Engineered Sharps Injury Protections Intended to reduce the risk of a sharps injuryMust be used appropriately to reduce injury riskWe have the Vanish pint needle system (the needle retracts
directly from the skin)
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Engineering Controls: How We Select Protective DevicesBy seeking input from
direct care staff Determine availability of
devices for applications that pose exposure risk
Review available devices at least annually, including changes in technology
Some factors to consider • User’s hands always behind needle• Integration of safety features• Ease of use• Use by right- and left-handed staff• Obvious engagement of safety feature• Locking of safety feature after activation• Safety feature activation before removal from
patient• One-handed activation• Permanent protection after activation• Standardization issues
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Sources: Occupational Safety and Health Administration (OSHA). Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS; ECRI Institute. Needlestick-prevention devices. Disposable syringes and injection needles. Health Devices 2007 Aug;36(8):241-73; ECRI Institute. Sharps safety and needlestick prevention. 2nd ed. Plymouth Meeting (PA): ECRI Institute; 2003; Premier Safety Institute. Prevent needlestick injuries [online]. 2011 [cited 2014 May 14]. https://www.premierinc.com/quality-safety/tools-services/safety/topics/needlestick/downloads/SharpsBRO_SEPT-2011-HR.pdf
Engineering Controls: Use of Sharps Disposal ContainersDiscard sharps
immediately or as soon as feasible.
Place reusable sharps in appropriate containers until reprocessed. If reprocessing, don’t reach
by hand into the container.
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
Engineering Controls: Replacement of Sharps Disposal ContainersDon’t overfill.Replace routinely.
When moving containers of used sharps: Close immediately before
removal.
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
Containers for Disposal of Other Regulated WasteUse appropriate containers.Close before removal. If outside of container is contaminated, place in second
container.
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
Some Other Times to Clean and Disinfect
Replace equipment or surface coverings: As soon as feasible if
overtly contaminated At end of shift if they may
have become contaminated during the shift
Disinfect . . .
• Contaminated work surfaces
After procedures
• Overtly contaminated surfaces
• Blood or OPIM spills
Immediately or as soon as feasible
• Surfaces that may have become decontaminated since last cleaning
At end of shift
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
Contaminated Laundry
Minimize agitation when handling. If wet and reasonably likely to soak or leak through the bag or
container, place in bag or container that prevents soak-through and leakage.
Wear gloves and other appropriate PPE.
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
Administrative Controls: Work Practices
Ask for help if patient is uncooperative.
Ensure stable surface and available sharps container.
Limit butterfly use use safety ones if necessary.
Don’t pass by hand set sharp down and pick it up.
Use neutral zone for minor non-OR surgeries.
Avoid recapping use one-hand technique if required.
Dispose of sharps immediately after use.
Clean broken glass using brush and dustpan.
Inform other personnel if patient is uncooperative.
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Source: Premier Safety Institute. Safer work practices to prevent sharps injuries [online]. [cited 2013 Dec 5]. https://www.premierinc.com/needlestick/downloads/16_workpractices.doc
Administrative Controls: Signs and Labels
Things that contain blood or OPIM are labeled with this symbol.
There are exceptions. For example, the following may also contain blood or OPIM: Red bags, red containers Containers of blood or blood products
released for clinical use Individual containers placed in a labeled
container for storage, transport, disposal
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
PPE: Types and Locations
PPE is available at no cost to you. Located on each unit isolation carts
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PPE for Standard Precautions
Also wear PPE as indicated by transmission-based precautions.
• The task and degree of exposure warrant.
• Gross contamination can be reasonably anticipated.
• Splashes, spray, spatter, or droplets of blood or OPIM may be generated AND
• eye, nose, or mouth contamination can be reasonably anticipated.
• Hand contact with blood, OPIM, mucous membranes, or nonintact skin can be reasonably anticipated.
• You’re performing vascular access procedures.• You’re touching contaminated items or surfaces.Gloves Masks
and eye protection
Protective body
clothingHead and/or
foot protection
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
PPE: DonningSee the complete sequence with detailed steps on the Centers for Disease Control and Prevention’s (CDC) website.
1. Gown
2. Mask or respirator
3. Goggles or face shield
4. Gloves
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Source: Centers for Disease Control and Prevention. Sequence for donning and removing personal protective equipment [poster online]. [cited 2014 May 23]. http://www.cdc.gov/HAI/pdfs/ppe/ppeposter1322.pdf
PPE: Safe Glove Use
Replace disposable gloves: As soon as practical if contaminated As soon as feasible if their ability to serve as a barrier is compromised
(e.g., they are torn or punctured)Don’t reuse disposable gloves.
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
PPE: RemovalSee the complete sequence with detailed steps on CDC’s website.
3. Gown
4. Mask or respirator
2. Goggles or face shield
1. Gloves
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Source: Centers for Disease Control and Prevention. Sequence for donning and removing personal protective equipment [poster online]. [cited 2014 May 23]. http://www.cdc.gov/HAI/pdfs/ppe/ppeposter1322.pdf
PPE: Removal
Remove before leaving patient room/ or work area.Place in designated area or container.Perform hand hygiene immediately or as soon as feasible after
removal.
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
Limitations of Controls
What can you do?Understand the risks.Vaccinate against HBV.Use standard precautions.Use controls properly.Report hazards and incidents
promptly.Give feedback.
Engineering controls, work-practice controls, labeling, and PPE can help reduce the risk of exposure to bloodborne pathogens.
But they do not eliminate the risk.
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What to Do in an Event Involving Blood or OPIM ExposureWash wounds, exposed
skin with soap and water.Flush mucous membranes.Immediately notify your
supervisor and go to the ED (and fill out employee incident report)
Postexposure prophylaxis for HIV, if indicated, should be started “as soon as possible, preferably within hours of exposure.”
Report right away!
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Sources: Centers for Disease Control and Prevention. 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. Also available at http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf; Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol 2013 Sep;34(9):875-92. Also available at http://www.jstor.org/stable/10.1086/672271
Report an Exposure Incident
Postexposure evaluation and follow-up will be done.
•at no cost to you•available at a reasonable time and place•performed by or under the supervision of
a licensed healthcare professionalAll medical evaluations,
procedures, and postexposure
prophylaxis will be
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
Postexposure Evaluation: What It Involves
Documentation of exposure route, circumstances
Identification of source person (unless infeasible or prohibited by law)• Testing of source’s blood (if
consent obtained or if permitted by law)
Testing of your blood (with your consent) for HBV and
HIV serologic status
Postexposure prophylaxis for HIV and/or HBV (if
indicated and accepted)Counseling Evaluation of reported
illnesses
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2014 ECRI Institute
Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS
Postexposure Evaluation: Documentation
Depending on the circumstances, information about the exposure incident and resulting illnesses may be recorded in our
OSHA 300 log
and
Sharps injury log
Information about postexposure examinations, medical testing, and follow-up procedures will be placed in your
Employee medical record
All have measures to protect your confidentiality.
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Source: Occupational Safety and Health Administration. Bloodborne pathogens [standard online]. 29 CFR § 1910.1030. 2012 Apr 3 [cited 2014 May 14]. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS