BBP Exposure Control and Universal PrecautionsHow you Can Protect Yourself and Others from Occupational

Infection

What Is A Bloodborne Pathogen?• They are blood born diseases designated

by the CDC including Hepatitis B, Hepatitis C and HIV (human immunodeficiency virus)

• you can be exposed by an incident that exposes you to body fluid of a person with the disease

• These policies help prevent those exposures

A Person May be Exposed By:• a needle stick or cut by a sharp

instrument that has been exposed to an infected person’s blood

• Contact through the mucus membranes-the eye, nose, mouth or skin-by an infected person’s blood or body fluids

To Reduce the Risk of Exposure:Observe universal precautions:1. Do Not Recap Needles2. Use Retractable Needles and other

safety devices while using sharps3. Keep a Sharps Disposal Unit next to

you and dispose of sharps into the unit directly after use

Reducing Risk, cont:• Do not recap hypodermic or IV butterfly or

catheter needles• Do not reinsert acupuncture needles or IV

butterfly or catheter needles• Wear gloves for all medical exams and

procedures• If you do not feel competent to perform a

procedure, let your supervisor or teacher know before proceeding

Reducing Risk, Cont.4. Use appropriate barriers:

– Gloves– Eye and Face Protection– Gowns or Jackets

5. Get immunized against Hepatitis B6. Follow the clinic/campus BBP

Procedures in classes and clinical training

What To Do After Exposure• For Three to Five Minutes:• Wash Needle sticks, Cuts and broken skin

with Soap and Running Water-do not squeeze the exposure site

• Flush exposures through the nose, mouth, and unbroken skin with running water

• Irrigate Eyes with sterile saline, clean water or sterile irrigants

• NOTIFY YOUR SUPERVISOR/TEACHER

External or Preceptor Site:• Does the site have their own BBP incident

procedure?• If Yes, follow their procedure• If No, you or your supervisor contact the

physician on call at 206-200-7067. If no answer call back within 10 minutes.

• Policy is that high risk exposures must be evaluated as to whether prophylactic treatment is warranted within one hour of occurrence

BU Campus or BUNH Clinic• Notify your supervisor while you rinse the wound• Your supervisor will contact the physician on call

and determine whether your exposure was higher or lower risk

• A high risk exposure is when the person is at immediate known risk such as a known positive HIV or high risk of HIV exposure where treatment may reduce the risk of contacting the disease.

• The physician on call will contact the source person regarding no cost testing for them.

• If high risk, you will be referred to a nearby hospital ER, where you notify them you had a high risk needle stick or BBP incident

BU Campus or Clinic, cont• At the ER/Hospital you will be tested

immediately for HIV, and perhaps for Hepatitis B and Hepatitis C

• You may be offered prophylactic treatment for HIV, which is best begun within 2 - 24 hours of exposure, though may still be effective if begun within a few weeks of exposure

• All costs of testing and treatment will be covered by BU

High Risk Exposures, cont.• Exposure to a known HIV positive

patient or patient at high risk of having undiagnosed HIV

• Pregnant exposed person

BU Campus or Clinic, cont.• If determined to be a lower risk exposure,

or following ER evaluation and treatment, follow up with either your own physician or BCNH within 24 hours

• All cost of labs, treatment and care will be covered by BU

• If a source person is not known or available for testing, the exposure is considered high risk and options for treatment or prophylaxis will be recommended

After Exposure, cont.• If you are pregnant, the exposure will

be considered a high risk exposure and you will be referred to the ER/urgent Care for initial evaluation

After Exposure, Cont.• You will complete an incident report form

describing the incident and submit that to the BBP officer within 24 hours

• You will receive follow up counseling and testing at 6 weeks, 12 weeks and 6 months after exposure

• Other counseling and support is available on an as-needed basis

• Recommendations for treatment for Hepatitis B will be discussed and testing for immunity if you have been immunized will be performed

After Exposure, cont.• preventive measures you need to employ

personally will be discussed with your bloodborne pathogen counselor after the incident.

• All information regarding counseling, testing and treatment is confidential and kept separately from your BU clinic medical record in a locked file cabinet by the BBP officer

• All cost is covered by BU

Diseases and Treatment: What you need to know • Hepatitis B is a viral infection that

occurs in the liver. • If you have been vaccinated and

developed immunity, you have no risk of developing this disease

• If you have no immunity, your risk is 6-30% from a single blood exposure

Diseases and TreatmentHepatitis B• Hepatitis B may be self-limited or

become a chronic infection.• Death from chronic liver disease

occurs in 15-25% of chronically infected persons– Chronic infection occurs in:

• 90% of infants exposed in utero or at birth• 30% of children infected between 1-5 years

of age• 5-10% of persons infected after age 5

Diseases and Treatment, cont.Hepatitis B• Transmission of Hepatitis B:• High Risk

– Blood/blood exchange: shared needles, occupational exposure, transfusion, hemodialysis and semen and vaginal secretions, especially if blood is present

– Multiple sexual partners, especially with STDs• Unprotected Sex

Diseases and Treatment, cont.Hepatitis B• Moderate to High Risk

– Across the placenta – Daily or regular household contact with

chronically infected person– Living in certain areas of the world

(India, Alaska Native Villages, Pacific Islanders, Indochina, Africa, Middle East, Eastern Europe-Romania, Bulgaria)

Diseases and Treatment, cont.Hepatitis B• Low Risk

– Saliva, urine, tears, mucus

Diseases and Treatment, cont.Hepatitis B• If the source person is Hepatitis B positive

(HBsAg) and has HBeAg present in their blood, the risk of infection is higher due to the higher levels of the virus circulating their blood

• The risk is lower from exposures through the eyes, mouth, nose and non-intact skin

• There are no documented cases of exposure to intact skin

• The risk may be higher for hollow bore needles than other sharps such as acupuncture needles

Diseases and Treatment, cont.Hepatitis BTreatment for Hepatitis B exposure• The CDC recommends that all health care

workers should be vaccinated against Hepatitis B

• If you are not vaccinated, and are exposed to HBsAg+ blood a combination of hepatitis vaccination and injection of hepatitis immune globulin may be effective in preventing the disease and should be begun within 24 hours to 7 days after exposure, though may be given 14 days after exposure

Diseases and Treatment, cont.Hepatitis B• Hepatitis B Immune Globulin is

recommended when an exposed person is not immunized or does not have immunity after immunization AND the source person is high risk or Hepatitis B positive

Disease and Treatment, cont.Hepatitis B• Hepatitis B vaccine and immune globulin

are evaluated as safe for pregnant and nursing women

• Immunization during pregnancy is recommended as pregnant women are more likely to develop a severe response to the virus and the fetus has a higher probability of developing a chronic infection with negative outcomes

Disease and Treatment, cont.Hepatitis B• If multi-dose Hepatitis B Immune

Globulin is begin within 7 days of exposure it is 70-75% effective in preventing infection after high risk exposure

• If the Hepatitis Immunization series is begun within 7 days of exposure it is 65-70% effective in preventing infection after high risk exposure

Disease and Treatment, cont.Hepatitis B• If both the immune globulin and the

immunization is given within 7 days of exposure it is 80-85% effective in preventing hepatitis B infection

Diseases and Treatment, cont.Hepatitis CHepatitis C is a viral infection occurring

in the liver. High Risk Exposures:

Blood/blood exposure-IV drug use, transfusion, hemodialysis

Disease and Treatment, cont.Hepatitis C• Moderate to Low Risk-across the

placenta• Low Risk-occupational exposure

(needle stick, contaminated sharps breaking skin, splashing of infectious body fluids into mucus membranes or through broken skin; intimate sexual contact with exchange of body fluids

Disease and Treatment, cont.Hepatitis C• Chronic Infection occurs in:

– 75-85% of all infected persons• Chronic Liver Disease Occurs in:

– 70% of chronically infected persons– Leading indication for liver transplant in

US• Death from chronic liver disease

occur in:– 1-5% of infected persons

Disease and Treatment, cont.Hepatitis CThe risk of developing the infection if

exposed through a cut or needle stick is 1.8% (98.2% of people do not develop infection). The risk for developing the disease after exposure through the eye, nose or non-intact skin is lower, but has occurred. There is no known risk of development of the disease through intact skin exposure.

Disease and Treatment, cont.• There is no vaccine against Hepatitis

C and no treatment after exposure that will prevent infection.

• Avoidance of exposure is your best option

Disease and Treatment, cont.HIVHIV is a virus that infects cells and impairs

immune response of the T-lymphocyte white blood cells

• The risk of developing HIV after needle stick or cut exposure is .3% (99.7% of exposures do not lead to infection).

• The risk after exposure of the eye, nose and mouth is .1% (99.9 % of infections do not develop disease)

• The risk after exposure to non-intact skin is less than .1%

Disease and Treatment, cont.HIV• There is no documented risk for

exposure of HIV infected blood to intact skin.

• There is no immunization to prevent HIV infection

Disease and Treatment, cont.HIV• High Risk Exposures include:

– Exposure to infected blood• Needle sharing• Blood products received before 1985

– Sexual contact including exchange of semen and vaginal fluid and/or blood

Disease and Treatment, cont.HIV• Moderate Risk Exposures include:

– Pregnancy (placental exchange)– Breast milk (moderate to high)

Disease and Treatment, cont.HIV• Seroconversion to HIV positive status

after exposure:– 95% test positive within 4 weeks of

exposure– 3-5% test positive after 3 months

• There is no risk of disease development if negative test at 6 months

Disease and Treatment, cont.HIVProbability of seroconversion (testing

HIV positive) is related to the amount of HIV positive blood you are exposed to and the depth of the exposure.

Disease and Treatment, cont.HIV• Post exposure prophylaxis (PEP)

treatment using combination anti-viral drugs for thirty days after known exposure has been shown to reduce the risk of developing disease

Disease and Treatment, cont.HIV• PEP treatment is not recommended

for low risk exposures due to the potential for side effects from the drugs

• The PEP treatment shows better efficacy if begun within 2-24 hours of exposure, though treatment begun after that time may also be effective.

Disease and Treatment, cont.HIV• Safety, efficacy and risks of PEP

treatment for pregnant women will be evaluated on a case by case basis by the exposed person and their physician so an informed decision may be made.

Follow up After Exposure:After your BBP incident• Re-testing is recommended at 6 weeks, 12

weeks and at 6 months• If Hepatitis B vaccine has been given,

testing of the blood to ensure immunity has developed should occur 1-2 months after completion of the vaccination series

• If PEP treatment is taken, blood tests (CBC, Liver Enzymes, Kidney function tests) are taken at onset and 2 weeks after beginning treatment

Precautions During Follow-up• If you are exposed to HBV and

receive post exposure treatment no precautions need to be taken as you will not be infectious according to the CDC

• The risk of exposure or passing on Hepatitis C to others is low, so the CDC recommends no precautions

Precautions During Follow-Up• If you are unaware of exposure risk or

there is a risk of Hepatitis or HIV infection, then you should:– Avoid donating blood or serum for 6 months– Avoid donating semen or organs for 6 months– Avoid Intercourse for 6 months

• If you choose to engage in intercourse, using condoms consistently and correctly is recommended to reduce the risk of passing on the virus

Precautions During Follow-Up• Women should avoid breast feeding

to avoid passing on the virus• Utilize birth control in order to ensure

pregnancy prevention

Finally,• The CDC estimates that over 1000 needle

sticks occur daily in hospitals across the US. The information from private clinics and doctors offices is not tracked. Universal precautions and awareness need to be integrated by all of us daily to reduce this number.

• The CDC also estimates 50% of injuries are not reported due to fear of reprisal.

Finally, cont.• BU has a policy that prohibits reprisals• All your care, follow up and outcomes are

confidential• We want to know what happens so we can

use the information to improve safety and effectiveness of our work place

Acknowledgements:WWW.CDC.govSheryl Berman, PhD, Debra Brammer, ND for their

contributions to this presentation