CDC AND OSHA Guidelines for Clinical Practice

The Centers for Disease Control and Prevention (CDC), along with the Occupational Safety and Health Administration (OSHA) determines the standards to eliminate or minimize occupational exposure to bloodborne pathogens. OSHA has made a determination that healthcare employees face a significant health risk as the result of occupational exposure to blood and other potentially infectious materials because they may contain bloodborne pathogens. The Agency further concludes that this exposure can be minimized or eliminated using a combination of engineering and work practice controls, personal protective clothing and equipment, training, medical surveillance, Hepatitis B vaccination, signs and labels, and other provisions.

OSHA regulations require that anyone with possible exposure to bloodborne pathogens or tuberculosis have yearly education presentations on those topics. This self-study module has been developed to assist you in meeting this requirement. Completion of this module will meet the annual requirement for bloodborne pathogen and tuberculosis education.

After reading the information, you should be able to:

1. Define the term, "bloodborne pathogen".
2. Name the three main diseases caused by bloodborne pathogens.
3. Name symptoms of the three main diseases.
4. List three ways you could be exposed to a bloodborne pathogen while at work.
5. List five ways you can reduce your chance of exposure to blood/body fluids.
6. Name the steps to follow if you have an exposure incident.
7. Explain how pulmonary tuberculosis is spread.
8. List two signs and symptoms of active pulmonary tuberculosis.
9. State where to find hospital policies regarding tuberculosis isolation precautions.
10. Explain the importance of yearly PPD skin testing.

Bloodborne Pathogen Diseases

Hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV) are the three main bloodborne pathogens. A bloodborne pathogen (BBP) is a microorganism that causes disease and is present in human blood. The microorganism could be a virus, bacteria or a fungus. Bloodborne pathogens are spread from person to person or from patient to health care worker. Let’s look at these blood borne pathogens in more detail.

Hepatitis B Virus (HBV)

Hepatitis is an inflammation of the liver caused by an infection of one of five viruses: A, B, C, D, or E. This module will only address hepatitis B and C.

Hepatitis B accounts for about 35% of all hepatitis cases. When the virus enters the bloodstream, it goes to the liver where it destroys liver cells and interferes with liver function. This is also where it will reproduce itself to maintain high levels of circulating virus in the bloodstream. After transmission, symptoms may not appear until 2 to 6 months later. Refer to Table 1 for a full list of symptoms. It is important to keep in mind that over one third of adults that contract hepatitis never show any symptoms and therefore may never be diagnosed as having hepatitis.

Table 1 SYMPTOMS OF HEPATITIS
Fatigue	Joint pain	Change in smell/taste
Loss of appetite	Muscle pain	Jaundice (yellow hue in skin or eyes)
Weight loss	Cough
Headache	Nausea	Generalized itching
Weakness	Vomiting	Pain in right upper abdomen
Fever	Indigestion	Changes in color of stool or urine
No desire for cigarettes if a smoker

Treatment for hepatitis B usually consists of proper diet, rest and close medical follow-up. It may take up to six weeks or longer for a person to clear the virus from the body. Full recovery from acute hepatitis B usually takes about six weeks but can go as long as six months. There are three possible outcomes from hepatitis B:

1. The illness is self-limiting with full recovery and the person will have lifelong immunity to hepatitis B. This usually occurs in 90-95% of cases.
2. A chronic carrier state develops and a person may or may not have symptoms but will have the capacity to spread the disease to other people. A person with chronic hepatitis B is at high risk for developing cirrhosis or primary liver cancer. This outcome occurs in 3-6% of cases.
3. 1% of people with hepatitis B will die during the initial acute phase due to overwhelming liver failure.

Hepatitis C Virus (HCV)

Hepatitis C accounts for about 20% of all hepatitis cases. HCV has only been specifically identified since 1989. Until then, it was commonly referred to as non A non B hepatitis. Hepatitis C was also the most prevalent type of hepatitis associated with post transfusion hepatitis. This is no longer an issue because donor blood is now screened for HBV and HCV.

After exposure to HCV, it may be 2 weeks to 6 months before symptoms appear. Only about 25% of people contracting the disease will have symptoms. Unlike HBV, where less than 10% develop a chronic carrier state, almost all people with HCV will develop into a chronic carrier state. They are also at high risk for primary liver cancer and cirrhosis.

At this time there is not a cure for Hepatitis C.

Human Immunodeficiency Virus (HIV)

Just as the liver is the target for the hepatitis virus, the immune system and specifically the T4 helper cell, is the target for HIV. The immune system protects the body from invading infections and diseases.

Where is my immune system and what does it do??

The IMMUNE SYSTEM is a functional process rather than a specific anatomical organ system like the circulatory system. It could be thought of as an army with specialized troops stationed throughout the body in the form of specialized cells (T4 helper cells, macrophages, etc.). Other body sites, i.e., spleen, lymph nodes, bone marrow, could be viewed as training or support sites.

HIV destroys the T4 helper cells over time and the body is no longer able to fight off infection and disease. There is currently no cure or vaccine for HIV, but treatment is available. Drugs such as Zidovudine (ZVD or AZT), Lamivudine (3TC) and protease inhibitors (Indinavir) have proven to be effective treatment protocols for many HIV infected people and have increased life expectancy to over a decade.

HIV is called a slow invisible killer. Many times the symptoms that may show up soon after exposure are mild and go away soon afterwards. It could then take as long as ten years before symptoms would show again. This is unfortunate because during that period, an infected person is able to spread the disease to other people through sexual, blood or perinatal (mother to unborn baby) contact, besides losing opportunity for treatment. The only sure way to know if HIV is in the body is by a blood test. The blood test will usually be positive 2 weeks to 6 months after exposure (average 2 months). Repeat testing may be necessary. Most people will remain HIV negative if they have not converted by 6 months after exposure.

Table 2. Symptoms of HIV
Early*	Later
Fever	Swollen lymph glands that remain swollen
Sore throat	Unexplained fever
Enlarged lymph glands	Persistent diarrhea
Muscle/joint pain	Unexplained weight loss
Skin eruptions	Night sweats White patches in mouth Skin lesions/sores Hair loss Enlarged liver, spleen Chronic vaginitis

* Similar to flu-like or mononucleosis-like symptoms, usually associated with sero- conversion to HIV antibody, i.e., blood will now test positive for HIV.

The end result of an HIV infection is AIDS, Acquired Immunodeficiency Syndrome. AIDS is usually present when:

1. Positive HIV blood test.
2. T4 cell count 200 or less (normal 600-1400).
3. One or more AIDS indicator conditions present (also called opportunistic diseases). Tuberculosis is one example.

Transmission of Bloodborne Pathogen Diseases to Health Care Workers

Occupational exposure to blood and body fluids could occur in one of the following situations:

1. Puncture injuries from a contaminated sharp object

Example:

·        Needlestick (greatest cause of work place acquired blood borne pathogen diseases)

·        Getting cut from a used scalpel blade

·        Getting cut from broken glass (lab tube)

2. Direct mucous membrane contact with blood or body fluid. (Mucous membrane is the thin, moist tissue lining the nose, mouth and eyes)

Example:

·        Blood gets splashed into the eyes.

 3. Blood or body fluid comes in contact with non-intact skin.

Example:

·        Direct exposure - Hands have open areas due to abraded, chafed skin and you get blood on them when helping a patient with a sudden nose bleed.

HIV/HB are found on environment surfaces for up to 1 week. However, both diseases lose their infectiousness. There are no documented cases that any seroconversion has been accomplished by indirect contact with dry blood.

Incidence of Health Care Workers Acquiring a Bloodborne Pathogen Disease From Occupational Exposure........................It does happen.

Hepatitis B Virus

HBV is acknowledged as being the oldest, the strongest and the most prevalent of the three blood borne pathogen diseases. Its nature was well established in hemodialysis units in the 1970’s. Fortunately, a vaccine for HBV was developed and made available in 1981. As more of the population, and specifically health care workers, have received the vaccine, the total number of HBV cases in general population has decreased by over 50% in the past decade.

In spite of the declining incidence of HBV, 1000 health care workers in 1994 became infected with HBV and an estimated 22 will eventually die from acute or chronic consequences of the disease.

There is a 5-30% risk of an unvaccinated person contacting HBV from a single needlestick exposure from a person diagnosed with HBV. One reason the risk varies is due to the virus concentration in the infected person as the hepatitis disease runs its course.

Hepatitis C Virus

HCV is the most recently identified virus (1989) of the BBP diseases discussed in this packet. Its prevalence among health care workers has not been well established.

The risk of contracting HCV after a single needlestick exposure from a HCV positive person is in the range of 3-10%. The most likely explanation for the low transmission of HCV is due to the low concentration of the virus in the blood of chronically infected patients.

Human Immunodeficiency Virus

HIV was identified in the early 1980’s. Soon after that there was information concerning health care workers becoming infected with HIV in the workplace.

Several studies have been done to establish the transmission risk of HIV from an infected source person to a HIV negative exposed health care worker and all results show around 0.3%. (This means there is about a 3 in 1000 chance of getting HIV).

HOW TO PROTECT YOURSELF AND REDUCE YOUR CHANCE OF EXPOSURE TO BLOOD AND BODY FLUIDS

1. Practice Standard Precautions (previously called Universal Precautions). This standard approach means anyone handling or having possible contact with blood or body fluids will use the same procedures to prevent direct contact each time, regardless of the source person. You must always think that everyone can be a possible carrier of blood borne pathogens.

Besides blood, other body fluids that can contain blood borne pathogens are:

Semen, vaginal secretions, cerebrospinal fluid (from spinal cord and brain), synovial fluid (from the joints), pleural fluid (from the lungs), pericardial fluid (from around the heart), peritoneal fluid (from the abdominal cavity), amniotic fluid (fluid surrounding an unborn baby), saliva in dental procedures, other body fluids with visible blood (bloody urine or sputum).

If there is any doubt about the type of fluid, always treat it as having blood in it.

2. Make engineering controls work for you. Do not ignore or bypass them. Engineering controls are tools, workplace setting, equipment or supplies that have been invented, installed, modified, redesigned or build to reduce the risk of having contact with blood or body fluids.

Examples:

·       
Needleless IV access systems

·        Devices that shield a used needle

·        Needle boxes in patient contact areas

·        Handwashing facilities in patient contact areas

·        Bio-hazardous waste containers

·        One time use, disposable supplies

·        Shield to work behind

3. Examine your work practice skills as you perform job duties that involve blood/body fluids. Are you performing the task in the safest way possible to reduce the chance of exposure to yourself and your co-workers? Are you?

·        Washing your hands when appropriate

·        Not recapping needles

·        Disposing of needles and other sharps immediately after use in the nearest needle box

·        Placing only sharps in sharps containers--not paper or other trash items

·        Placing trash containing blood/body fluids in red biohazardous bags

·        Handling soiled linen with as little contact as possible

·        Cleaning surfaces soiled with blood/body fluids immediately and with an EPA approved disinfectant

·        Cleaning any visible blood off equipment before sending to CSS

·        Not leaving the job site with visible blood on your clothing

4. Get the vaccination for hepatitis B virus. Contact Employee Health or ask your supervisor to find out if you are eligible. The vaccine is given in 3 doses over a 6 month period so it is important to follow through to complete the series. No vaccines are available for HIV or HCV.

5. Wear personal protective equipment (PPE) when necessary to provide a barrier between you and blood and body fluids. The importance cannot be stressed enough. Prior to performing a job duty, plan ahead and choose the appropriate PPE.

GLOVES

• Use to protect your hands having contact with blood or body fluids
• Wash your hands before and after using gloves
• Change gloves whenever there is a tear or puncture in the glove
• Many facilities maintain latex-safe areas for affected patients and workers.

MASKS AND GOGGLES

• Use to protect blood or body fluids from getting sprayed, splashed or splattered into the eyes, nose or mouth
• Always protect all of the face, i.e., cover eyes, nose and mouth

 

GOWNS, APRONS, LAB COATS

• Use to prevent blood or body fluids from soiling clothing
• Do not wear PPE out of the work area.
• Do not wear or take home soiled clothing. Contact your supervisor to arrange for laundering of clothing.

 

 

Occupational Exposure to Blood or Body Fluids

It is defined as:

1. Percutaneous puncture of the skin with a contaminated needle or sharp object.

2. Splatter or splash onto mucous membranes.

3. Significant skin contamination on an open wound or lesion.

4. Prolonged contact with skin, especially when chapped, abraded or afflicted with dermatitis.

Steps to Follow After Exposure to Blood or Body Fluids

1. Wash exposed area with soap and water or flush with water or saline immediately.
2. Notify your preceptor and/or Clinical Instructor of incident.
3. Complete and sign the "Healthcare Student/Faculty or Worker Report of Injury".
4. Report immediately to the Emergency Room after exposure for evaluation. The timing is very important if there is good cause to begin drug treatment to prevent HIV infection. The risk of getting HIV from an infected person can be significantly reduced if medication is started with 1-2 hours of the exposure incident.

If you have questions or desire further information on blood borne pathogens.........

Contact the Infection Control Coordinator listed below for your campus, or for after hours, page the Infection Control Practitioner on call at your Clinical Site.

You can also refer to the following manuals found at all hospitals for information regarding:

Infection Control Manual

Safety Manual

Exposure Control Manual

TUBERCULOSIS

Tuberculosis (TB) is a contagious disease caused by the organism: Mycobacterium tuberculosis or tubercle bacillus. It can cause disease in any organ of the body, but is most commonly (70% of the time) found in the lungs (Pulmonary or Laryngeal). For this educational presentation "TB" will refer to pulmonary or laryngeal tuberculosis.

TB has been around for a long time and was common in the United States prior to the 1940’s. Beginning in 1948, the number of TB cases in the US began to decrease because anti-TB medications became available. During the late 1980’s, the number of TB cases began to increase.

Transmission of TB

Tuberculosis is spread through the air. (It is sometimes referred to as an airborne disease). It is spread by inhaling tiny infectious particles called droplet nuclei. When a person with active TB forcefully exhales by coughing, sneezing, speaking, laughing or singing; they emit tiny particles in droplets of moisture. The droplets remain suspended in the air and can be inhaled by another person in the same air space. Once inhaled, the organisms can move on to the lungs and begin to multiply. TB is not spread by contact with items such as clothing, bedding, food or eating utensils.

TB is not easily spread to another person. The upper airway functions of the nose and throat prevent most inhaled TB droplets from ever reaching the lungs. The risk of transmission depends upon several factors. These factors include:

1. Length of time of exposure - the longer period of time you share airspace with a person with active TB, the greater your chance of becoming infected with TB.
2. Volume of space - you are at increased risk of becoming infected with TB if you are in a small, poorly ventilated space with an infected person.

If the inhaled particles are able to get past the upper airway, they can move deep into the lungs. Within a few weeks, the TB organisms will begin to multiply and spread throughout the body. In most healthy people the immune system will immobilize the organisms and prevent further spread. The organisms become walled off in tiny, hard capsules called tubercles. The tubercles can remain in a dormant or inactive state indefinitely. This condition is called "latent TB".

Latent & Active TB

Latent TB is when a person has the TB organisms in their body but they are not contagious. These persons will have a positive PPD skin test and a normal chest X-ray. They will not have any signs or symptoms of active TB. This represents 90-95% of people who become infected with the tuberculosis organisms. Persons with latent TB may be treated with medication to prevent the TB from later becoming active or contagious. The medication is taken for about 6 months.

Active TB occurs when the TB organisms either progress directly to pulmonary tuberculosis (about 5% of healthy adults), or when the organisms break out of the capsules and begin to multiple (activation of latent infection). This may happen at any time, but it usually occurs when the body’s immune system is weak from fighting other infection and/or diseases. A person with active TB is considered to be contagious or infectious and will have signs and symptoms of TB.

Table 3. SYMPTOMS OF TUBERCULOSIS
Newly developed cough lasting longer than 2 weeks	Unexplained weight loss
Fever	Loss of appetite
Night sweats	Bloody sputum
Fatigue	Hoarseness
Weakness

• most prominent signs/symptoms

Think TB

Early identification, proper isolation and appropriate treatment of TB is the best way to control the spread of TB. It is important to always be on the alert for patients who may have active TB. All patients are screened for signs and symptoms of TB when they are treated at the hospital.

If a patient has signs and symptoms of TB, the patient’s doctor is notified. The doctor will decide if it is necessary to place the patient in isolation and perform further work up to rule out TB. If TB is suspected, then the patient will be placed in "Special Respiratory Isolation".

The isolation policies can be found in the Infection Control Manual, the TB Control Plan or the Safety Manual under the Respiratory Protection Plan depending on the campus where you attend or the Clinical site hosting you.

Isolation of TB Patients

When a patient is suspected of having TB, he/she will be placed in a specially designed isolation room with an "Airborne" sign on the door. Isolation will continue until active TB is ruled out or the patient has been on proper medication for at least two weeks with improvement of symptoms (negative sputum cultures).

The isolation rooms have a special ventilation system that is designed to contain the TB organism and protect other people in the hospital. A warning sign is placed on the door to the room to alert people of the necessary precautions to follow before entering the room. It is important to always keep the door closed tightly after entering or leaving.

Any time a TB patient has to leave the isolation room or is in an out-patient setting, he/she must wear a surgical mask that covers the nose and mouth. That will prevent the spread of TB.

Protection of Health Care Students/Faculty and Workers

As a health care student/faculty, you may have to care for a confirmed or suspected TB patient. Special guidelines and regulations have been developed by the CDC (Center for Disease Control) and OSHA (Occupational Safety and Health Administration) to follow in order to prevent the spread of TB. Remember, these regulations are there to protect you and your fellow students/faculty and other healthcare workers.

When you care for a patient in special respiratory isolation, you must wear a special mask to protect yourself (N95). It is an OSHA regulation that all employees wear these special masks in any of the following conditions:

1. When you enter the room housing a patient with suspected or confirmed TB.
2. When you perform high hazard procedures on a patient with confirmed or active TB. High hazards are defined as:

A) endotracheal intubation

B) suctioning

C) diagnostic sputum induction

D) aerosol treatments

E) bronchoscopy

F) autopsies

3. When transporting a patient with suspected or confirmed TB in a closed vehicle.

Special training and fit testing must be done before anyone can wear these masks. The training is conducted by designated trainers. They will teach you how to wear the mask, what size is right for you, how to check for proper fit. At present we are using the "Technol Duckbill mask". The mask is only used once and then discarded.

It is a requirement that you be re-fit tested if any of the following conditions occur: significant weight loss or gain, change in facial hair, facial reconstruction work, a new wearer of dentures or glasses, and as directed by regulatory agencies.

Policies pertaining to respiratory protection are located in either the Infection Control Manual or the Safety Manual under Respiratory Protection Plan.

Therapy and Treatment

Compared to other infectious diseases, the treatment for TB is long and involves multiple drugs. If treatment is not long enough, the TB organism may survive and the person can have a recurrence of the disease. If the organism survives, it could become resistant to the medication and additional drugs will have to be taken for even a longer period of time.

Generally a person with active TB will have treatment for at least six months. For the first two months the person usually takes four medications, then it is reduced to two medications during the last four months.

For the past several years, drug resistant TB has been showing up in some patients. It is called drug resistant when the TB organism is resistant to the usual drug therapy. It may occur because people with active TB did not finish all their treatment and the organisms then mutate (change) and become resistant to the drug(s). Drug resistant TB is much more difficult to treat and will involve a longer treatment time. Alternative drugs will need to be used which have more potential bad side effects. It is very important to make a patient clearly understand the need to closely adhere to their treatment time.

Skin Testing for TB

The TB skin test used is the PPD, purified protein derivative. A PPD skin test will show if the TB organism is present in the body. A negative PPD means that you probably do not have the TB organism in your body. A positive PPD means that the TB organism is present in your body but additional tests and work up is necessary to show if you have active or latent TB.

PPD skin testing is done by injecting a small amount of fluid just under the skin, usually on the forearm. The test is to be read (inspected) and result recorded 48-72 hours after it has been given. All PPD testing and reading for employees is done by Employee Health.

All hospital employees and nursing students/faculty will have PPD skin testing done as follows:

1. Prior to employment and/or your first clinical assignment, unless you have a history of a positive PPD
2. Every year unless you have a history of a positive PPD
3. If you have been exposed to a patient with active TB

If you have a history of a negative PPD, and you convert to a positive PPD, you will be evaluated for signs of TB, have a chest x-ray and be evaluated by a doctor to determine if medication will be needed to prevent active TB later.

All students/faculty, regardless of current PPD status, must be evaluated for signs/symptoms of TB each year.

Occupational Exposure to TB

If you have been exposed to a patient with active TB at work or in a clinical setting, you will be notified by Infection Control or your manager. If you do not have a history of a positive PPD, then you need to check to see if you have had a PPD within the past 12 months. If it has been longer than 12 months since your last PPD, then you will need to have a PPD done right away to serve as a baseline.

If the baseline PPD is negative, it will be necessary for you to have a repeat PPD about 12 weeks after exposure (this is when the organism will produce a positive skin test result). After the repeat PPD is done and it is negative, then nothing more will need to be done. If it is positive, you will be evaluated as stated above and possibly advised to receive preventative drug therapy. If you have a history of positive PPD and were exposed to an active TB patient at work, you will be evaluated for signs of TB at 12 weeks after exposure.

Everyone must do their part to prevent the spread of TB and stay healthy!!

Key points to remember

• How TB is transmitted and the symptoms it causes
• Follow the guidelines set by OSHA and CDC
• Be fit tested and trained on the special masks
• Always wear your special mask when caring for a patient with TB
• Get your PPD or TB evaluation annually and after any exposure 

You have now completed the reading for this module.