1. Presented by Riverland Community College
Infection Control and Bloodborne Pathogens
Presented by Riverland Community College

2. Objectives
At the end of this training session, participants will be able to:
Describe what laws and safety regulations cover Bloodborne Pathogens
List and describe the diseases that cause the greatest concerns for providers and their symptoms
Describe how to prevent disease transmission
Describe post-exposure treatments and follow-up that may be provided
Discuss the difference between significant vs reportable exposure

3. Things to Know if there is Risk of Exposure
Counseling specific to exposure incident is available
Post-exposure treatments and follow-up that may be provided.
If you are exposed, confidential medical evaluation is to be made immediately available to you.

4. OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030)
OSHA’s Bloodborne Pathogens standard prescribes safeguards to protect workers against the health hazards from exposure to blood and other potentially infectious materials, and to reduce their risk from this exposure.
29 CFR
“Bloodborne pathogens” means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include among others hepatitis B virus (HBV), which causes hepatitis B; human immunodeficiency virus (HIV), which causes AIDS; hepatitis C virus and other pathogens, such as those that cause malaria.
“Other potentially infectious materials” means:
The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between bodily fluids;
Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and
HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

5. Who Needs OSHA BBP Training?
All employees who could be “reasonably anticipated” as the result of performing their job duties to face contact with blood and other potentially infectious materials
“Good Samaritan” acts such as assisting a co-worker with a nosebleed would not be considered occupational exposure
OSHA’s Bloodborne Pathogens standard, 29 CFR , does not apply to construction, agriculture or maritime.
The term “reasonably anticipated” contact means potential contact as well as actual contact with blood or other potentially infectious materials.

6. Employees Who May Be Exposed
Physicians, nurses and emergency room personnel
Orderlies, housekeeping personnel, and laundry workers
Dentists and other dental workers
Laboratory and blood bank technologists and technicians
Maintenance workers in healthcare facilities
Staff of nursing homes and long-term care facilities
Firefighters/Law enforcement personnel
First Responders/EMTs/Paramedics
Medical waste treatment employees
Employees of funeral homes & mortuaries
Home healthcare workers
The scope of the Bloodborne Pathogens standard is not limited to employees in these jobs. The hazard of exposure to infectious materials affects employees in many types of industries and is not restricted to the health care industry.

7. What are Bloodborne Pathogens?
Bloodborne Pathogens are disease-causing microorganisms that may be present in human blood. They may be transmitted with any exposure to blood or OPIM.
Hepatitis Viruses
Hepatitis B (HBV)
HBV Immunization
Hepatitis C Virus
Human Immunodeficiency Virus (HIV)

8. Other Potentially Infectious Materials (OPIM)
Cerebrospinal Fluid
Saliva (in dental procedures)
Blood
Pleural Fluid
Pericardial Fluid
Peritoneal Fluid
Semen and Vaginal Secretions
Amniotic Fluid
Synovial Fluid
Any fluid Containing visible blood.
The sources of pathogens are, first of all, blood...
…but it also includes other potentially infectious material, or other potentially infectious materials as defined by OSHA.

9. How Exposures Occur Most common: needlesticks
Cuts from other contaminated sharps (scalpels, broken glass, etc.)
Contact of mucous membranes (for example, the eye, nose, mouth) or broken (cut or abraded) skin with contaminated blood

10. How Exposures Occur
Disease transmission is a two-way street. It is just as easy for you to infect a person with whom you come in contact as it is for that person to infect you.
A pathogen is a disease-producing organism that enters the body; basically, a germ.
The immune system relies heavily on the skin to keep the amount of pathogens that enter the body to a minimum.

11. How Infections Occur Chain of Infection Infectious Agent Reservoir
Means of Exit
Mode of Transmission
Means of Entry
Susceptible Host

12. How Infections Occur Chain of Infection Infectious Agent Susceptible
Host
Reservoir
Means of
Exit
Means of
Entry
Mode of
Transmission
Chain of Infection

13. How Infections Occur Routes of Transmission: Direct contact
Indirect contact
Airborne transmission
Vector-borne transmission

14. Direct Contact Reservoir to port of entry. (Person to person)
Touching the body fluids from an infected person
Kissing
Sexual Contact
Oral-Fecal
Blood or other bodily fluids comes in contact with any port of entry.

15. Indirect Contact
Touching objects that have been in contact with the body fluid of an infected person
Door knobs
Countertops
Eating utensils
Steering wheel
Waterborne

16. Airborne Transmission
Breathing in droplets that became airborne when an infected person coughs or sneezes
Carried by current or ventilation systems

17. Airborne Transmission
Large droplets that travel up to 3 feet.
Coughing
Sneezing
Talking
Lands on dust or surfaces
Influenza
Meninigitis
Colds
RSV

18. Vector-Borne Bite from an infected animal or insect Blood transfusions
Organ transplant

19. What are the Infection Concerns?
Both patients and healthcare workers are at an increased risk of infection
Patients
weakened immune systems
injury
Healthcare Personnel
daily duties
Consequences of infection
The OSHA Bloodborne Pathogen Standard was introduced because of the risk of serious infection associated with blood and other potentially infectious material. In the hospital setting, both patients and healthcare workers are at a increased risk of infection. Patients are not covered by OSHA, but healthcare employees are.
Patients in the hospital or long term care are at risk because their immune systems may be weak due to illness, injury or the medication they’ve been given.
Workers are at risk because their daily duties may involve the possibility of exposure to blood and other potentially infectious material.
Exposure to some blood-borne pathogens may result in chronic disease and possible death.

20. How Infections Occur
Most infectious diseases are caused by one of five types of pathogens. The most common are viruses and bacteria.
Viruses
Bacteria
Fungi
Protozoa
Parasites

21. How Infections Occur Viruses Bacteria Fungi Protozoa Parasites
Hepatitis, Chicken Pox, HIV, etc.
Bacteria
Meningitis, Tuberculosis, food poisoning
Fungi
Athlete’s foot, ringworm
Protozoa
Malaria, dysentery
Parasites
Abdominal pain, anemia, etc.

22. Viruses Will use genetic make-up of host cell to replicated self.
Hepatitis, Chicken Pox, HIV, Herpes, etc.
Latent type of infection
Cell reproduces both own and viruses genetic structure. (Herpes)
Persistent Infection
Hepatitis B

23. Bacteria One-celled organisms Meningitis, Tuberculosis, food poisoning
Divide and multiply
Produce enzymes and toxins
Damage surrounding tissue
Impair the body’s ability to defend itself

24. Transmission depends upon:
The virulence of the pathogen.
HBV vs. HIV
The length of the exposure
More time equals greater risk
The route of entry
Blood to blood
Mucosal tissue
Your general health
Healthy & well-rested minimizes risk
Your immunity
Maintain your immunizations

25. The Body’s Means of Fighting off Organisms
Vaccinations/Immunizations
Healthy lifestyle
Strong resistance
High risk individuals
HIV +
Chronic health issues
Surgery

26. The HIV virus can survive outside the host body for up to seven days in dried blood
True False
False--It can only live outside the body for a short time once the blood or fluid it is contained in dries. That means if the virus is directly on a surface and it dries...it will live less than 2 minutes.

27. Diseases that Cause Concern
Human Immunodeficiency Virus (HIV)
immune system
Hepatitis B Virus (HBV)
liver
Other Pathogens
The blood-borne pathogens that OSHA is most concerned with are HIV, which attacks the immune system, and HBV, which causes chronic liver disease. Hepatitis B virus was the most concern with OSHA at the time the standard was drafted because it was the easiest to contract from a blood spill.
There are obviously other pathogens in blood, as well as other pathogens to be concerned with in the CS area. Most recently, the hepatitis C virus is raising a concern because of it is so easily contracted. It is important to remember that at this point in time, OSHA recognizes HIV and HBV as the representative organisms for blood-borne pathogen concern when recommending procedures and products to use.

28. Human Immunodeficiency Virus (HIV)
Blood and other body fluids
AIDS
no cure/no vaccine
Auto-immune system suppressed
Vulnerable to opportunistic diseases
Environmental disinfection
easy to kill
The human immunodeficiency virus, or HIV, is the virus that causes AIDS.
It is transmitted though direct contact with blood and other body fluids.
The virus attacks the immune system, leaving the patient vulnerable to many diseases that they would normally be able to defend. There is no cure, nor vaccine for the disease.
The virus itself is a lipid-enveloped retrovirus that has a high susceptibility to germicides - so it’s relatively easy to kill through environmental disinfection.

29. Human Immunodeficiency Virus Symptoms
Certain symptoms & conditions may be associated with HIV/AIDS
Fever
Weight loss
Swollen lymph nodes
White patches in mouth (thrush)
Certain cancers eg. Kaposi’s sarcoma, certain lymphomas
Infections eg. pneumocystis pneumonia, TB, etc.

30. Hepatitis Viral Disease Turn of the century identified as 2 types
Inflammation of the liver
Turn of the century identified as 2 types
Enteric (food and water)
Parenteral (blood and/or other bodily fluids)
Currently-A, B, C, D, E , F & G

31. Hepatitis A (formerly called Infectious hepatitis)
Foodborne illness
Vaccine preventable
More common in countries with underdeveloped sanitation systems
Does not develop into chronic hepatitis or cirrhosis
Can lead to acute liver failure and death
In the News: outbreak in Illinois McDonalds
During the summer of 2009, public health officials in the Quad-City region of Illinois identified 32 confirmed cases of hepatitis A among patrons of the McDonald’s restaurant in Milan, Illinois.  At least eleven people were hospitalized due to the severity of their hepatitis A symptoms. 
According to news reports, the hepatitis A outbreak timeline is as follows:
June 17, 2009A person who works at the McDonald’s restaurant in Milan, Illinois, is diagnosed with hepatitis A.
July 10, 2009 The Rock Island County Public Health Department (RICPHD) learns that five people, including two from Mercer County, have tested positive for hepatitis A.
July 13, 2009 The RICPHD learns of the McDonald’s worker’s hepatitis A infection via a report delivered by the U.S. Postal Service.
July 14, 2009 Representatives from RICPHD visit the Milan McDonald’s restaurant and instruct McDonald’s employees on proper hand-washing techniques to prevent the spread of hepatitis A.
July 15, 2009 RICPHD becomes aware of four additional hepatitis A cases, and learns that one is a second McDonald’s employee.  The Milan McDonald’s is closed for deep cleaning, and a formal notice regarding the hepatitis A outbreak is issued.  All McDonald’s employees are tested for hepatitis A.
July 21 and 22, 2009 Thousands of people exposed to the hepatitis A virus through the consumption of food prepared at the Milan McDonald’s restaurant receive hepatitis A vaccinations or Immune Globulin injections to prevent hepatitis A infection.
July 23, 2009, the Marler Clark law firm filed a class action lawsuit against McDonald’s on behalf of all individuals who received a hepatitis A vaccination or Immune Globulin injection to prevent becoming ill with hepatitis A infection.  The firm has also filed individual lawsuits on behalf of three people who became ill with hepatitis A infections after consuming food purchased from the Milan, Illinois, McDonald’s restaurant.

32. The Hepatitis B virus can survive outside the host body for days in dried blood.
True False
True--Hepatitis B can remain stable outside the body for days or weeks, even when dry.
Hepatitis B can be spread by casual contact. It can be acquired by close contact within families, or from person to person through contact with open skin lesions. The virus may possibly be spread by exposure of mucous membranes to saliva, but you cannot get it from food or water, sneezing or coughing, breastfeeding, handshakes, hugs or casual contact.

33. Hepatitis B Virus (HBV) (formerly called Serum hepatitis)
Parenteral Infection: blood and body fluids
saliva
Highly infectious
diluted blood 1:100,000,000
viable in dried blood
increase in sexually transmitted cases
Immunization
3 shots
The hepatitis B virus, or HBV, is found in blood and other body fluids, including saliva and semen.
It is highly infectious. HBV in blood diluted one to one hundred million in water may still infect. It is also viable in dried blood - dried blood on a dressing in a janitor’s closet was found to contain viable virus. The reference indicated that the amount of time it was there was unknown, but it was more than a few days. While the virus may survive drying or desiccation, it is a lipid-enveloped hepadnavirus, and highly to moderately susceptible to disinfectants.
Luckily, you can be immunized with a vaccine against this organism. A series of 3 shots can protect you from a lifetime of liver problems. All people who have routine occupational exposure to blood or OPIM have the right to receive the immunization series against Hepatitis B aqta no personal expense. The standard includes temporary and part-time workers and volunteers.

34. Hepatitis B Virus Symptoms
Lethargy
Loss of appetite
Fever
Vomiting
Yellow skin & eyes (jaundice)
Dark-colored urine.
Light colored stool
DID YOU KNOW???
It is estimated that 4.9% of all Americans have been infected with HBV

35. Hepatitis C (HCV) Most common chronic bloodborne infection in the US.
Transmitted through large or repeated direct exposures to blood such as: long term kidney dialysis, tattoos, sexual contact, parenteral infection
In many cases, there are no symptoms until cirrhosis has developed.
No vaccination available
Can last in dried blood up to 3 weeks
The Hepatitis C virus has been a very big concern lately, especially with needlestick and other puncture injuries.
It isn’t at the level of infection that HBV is: your risk of infection is 2% from a needle-stick contaminated with an HCV positive patient; however, there is no vaccine to prevent the disease, therefore - gloving and other protective measures are paramount.
This virus is a lipid enveloped flavivirus, therefore it is assumed it is relatively easy to kill with disinfectants

36. Hepatitis C Symptoms Vomiting Lethargy Yellow skin & eyes (jaundice)
Urine that is dark in color
Lethargy
Loss of appetite
Abdominal pain
Nausea

37. Hepatitis D & E Hepatitis D (Delta Virus) Hepatitis E
Rare in most developed countries, and is mostly associated with intravenous drug use.
Propagates only in the presence of the HBV virus.
Hepatitis E
Fecal-oral transmission route
Seen more developing countries
occur after heavy rainfalls because of their disruption of water supplies

38. Hepatitis F & G Hepatitis F Hepatitis G
Debate continues on its presence
Hepatitis G
Symptoms are non-existent
Found in co-infections with other viruses, such as HCV and HIV

39. The Relative Risks LESS MORE RISK RISK
Blood transfusion (infected blood) *
Sharing the toilet or shower
Blood contact with gloved hands
Blood contact with open wound
Blood contact with intact skin
Open Mouthed Kissing
Unprotected Sex
Sharing eating utinsils
Sharing Drug Needles
Needlestick
LESS
RISK
MORE
RISK
* NOTE: The blood supply in the U.S. is now tested for HIV, and is considered safe.

40. Reportable Incidents
Incidents that involve the failure of barrier protection (glove failure), blood or OPIM contact with intact skin or conditions preventing the use of PPE
Reportable Incident that must be reported to your supervisor before the end of your shift.

41. Significant Exposures
Needlesticks
Blood/OPIM contact with non-intact skin
Blood/OPIM contact with mucosal tissue
Follow your organization’s Exposure Reporting Policy.

42. What to do if an exposure occurs?
Wash exposed area with soap and water
Flush splashes to nose, mouth, or skin with water
Irrigate eyes with water or saline
Report the exposure
Direct the worker to a healthcare professional
Treatment should begin as soon as possible after exposure, preferably within 24 hours, and no later than 7 days.
OSHA Office of Training and Education

43. Post-Exposure Follow-Up
Employer will:
document routes of exposure and how exposure occurred
record injuries from contaminated sharps in a sharps injury log, if required
obtain consent from the source individual and the exposed employee and test blood as soon as possible after the exposure incident
provide risk counseling and offer post-exposure protective treatment for disease when medically indicated in accordance with current U.S. Public Health Service guidelines
(f)(3), (4) & (5)
The requirement to establish and maintain a sharps injury log applies to any employer who is required to maintain a log of occupational injuries and illnesses under 29 CFR 1904.
If the employee consents to baseline blood collection, but does not give consent at that time for HIV serologic testing, the sample must be preserved for at least 90 days.
Current U.S. Public Health Service guidelines: Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposure to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis, June 29, 2001.
Call the National Clinician’s Hotline at

44. The Ryan White Act
Requires Health Care Providers (hospitals, nursing homes, primary care facilities) to notify ALL personnel who may have been exposed to infectious/communicable diseases.

45. Labels and Signs
Hazard communication requires that employees receive warning through labels, signs and training in order to eliminate or minimize their exposure to blood-borne pathogens. Warning labels are to be fluorescent orange or orange-red with lettering or symbols in contrasting color and include the “Biohazard” name, the name of the infectious agent, and the name and phone number of the person responsible for it.
The employer also needs to ensure that all employees with occupational exposure participate in a training program in order to minimize the risk of occupational exposure. This information and training should be provided by employers to all employees at no cost and during work hours. Training must be offered at the time of initial work assignment and needs to take place at least annually thereafter.

46. Labeling Regulated Waste
Refers to the following categories of waste that require special handling at a minimum:
Liquid or semi-liquid blood or OPIM
Items contaminated with blood or OPIM & would release these substances in a liquid if compressed
Caked with dried blood or OPIM
Contaminated sharps
Pathological & microbiological wastes containing blood or OPIM

47. When Labeling Regulated Waste is Necessary
On containers of regulated waste or on refrigerators or freezers that are used for storage
Equipment being sent to another facility for servicing or decontamination
Must be labeled with biohazard label
Even if your facility considers all of its waste to be regulated, it still must bear the label

48. Biohazard Labels
Biohazard labels may be attached to bags containing potentially infectious materials
Labels must be fluorescent orange or orange-red with letters or symbols in contracting color or color-coded for your facility
Attached to any container that is used to store or transport potentially infectious materials

49. Contaminated Sharps
OSHA Definition—any contaminated object that can penetrate the skin, including, but not limited to, needles, scalpels, broken capillary tubes, and exposed ends of dental wires.

50. Contaminated Sharps Reusable sharps Acceptable sharps containers
Must be placed in a clearly labeled puncture-resistant, leakproof container asap after use
Acceptable sharps containers
Closable
Puncture resistant
Leakproof on sides & bottom
Labeled or color-coded in accordance with the Standard

51. Sharps Containers
Must be easily accessible to personnel and located as close to immediate area as possible.
Sharps containers mounted onto walls should be 52” to 56”from the floor.
Maintained in an upright position
Reusable containers (those used to transport contaminated sharps for cleaning) shall not be opened, emptied, or cleaned manually which would expose employees to risk of injury

52. Sharps Injury Log
Employers must maintain a sharps injury log for the recording of injuries from contaminated sharps
The log must be maintained in a way that ensures employee privacy and must contain, at a minimum:
Type and brand of device involved in the incident
Location of the incident
Description of the incident
(h)(5)
The purpose of the sharps injury log is to aid in the evaluation of devices being used in the workplace and to quickly identify problem areas in the facility. It must be reviewed at least annually during the review and update of the Exposure Control Plan.
If the data are made available to other parties (e.g., supervisors, safety committees, employees), any information that could be used to identify the employee must be withheld to protect the employee’s privacy.
The requirement to establish and maintain a sharps injury log applies to any employer who is required to maintain a log of occupational injuries and illnesses under 29 CFR 1904, OSHA’s recordkeeping rule. The sharps injury log must be maintained for the period required by 29 CFR

53. Disinfection
“You can clean without disinfecting or sterilizing but you cannot disinfect or sterilize without cleaning.”
The most important thing to keep in mind is that you can clean without disinfecting or sterilizing, but you cannot disinfect or sterilize without cleaning.

54. Disinfection is a Process
Step 1 - Cleaning
If foreign material/soil is visible (i.e., body fluids), remove by cleaning prior to disinfection
Soil can keep the disinfection process from working
Step 2 - Disinfecting
Disinfection is a process that eliminates many or all microorganisms except spores
Disinfection is a process. The first step in that process is cleaning. Any foreign material or soil (including blood and body fluids), must be removed before the surface can be disinfected. Blood and other organic soils can keep the disinfection process from working by tying up the active ingredients and possibly inactivating the disinfectant.

55. Universal Precautions
Treat all human blood & certain body fluids as if they are known to contain HIV, HBV, HCV or other bloodborne pathogens regardless of the perceived risk of the source.

56. Personal Protective Equipment
Gloves
blood or body fluids
mucous membranes
skin with open cuts or sores
contaminated items or surfaces
Gown or Apron
Mask
Don’t Forget Eye Protection!
Another way designed to protect a worker from exposure to disease is through the use of personal protective equipment, or PPE.
Just as construction workers are required to wear hard hats and steel toed shoes, healthcare workers must wear gloves, gowns, aprons, masks, or eye protection when appropriate - as directed.
Gloves must be worn if there is a possibility of contact with blood or body fluids,and any contaminated items or surfaces.
Gowns or aprons should be worn as directed if there is a chance of soiling clothing with blood or other potentially infectious material.
Masks should be worn as directed if there is a threat of airborne transmission of disease. Masks are also a good idea for healthcare workers to use if they themselves have a respiratory disease that should not be transferred to patients or coworkers.
Don’t forget eye protection - the eye is an area where pathogens can penetrate through, so it’s important to wear a face shield or safety glasses/goggles.

57. Preventing Disease Transmission
Wash hands!
if visibly soiled
before and after restroom
before and after eating
after taking off gloves
Washing hands is one of the most significant ways to reduce infection. You should wash your hands if they are visibly soiled, before and after restroom breaks, before and after eating, and after taking off gloves...
...Many people think that gloves keep their hands clean. In reality, there is always a possibility of tiny pinholes that would allow organisms to get through. The inside of the glove is warm and moist, so that microorganisms grow in higher numbers than on ungloved hands...
…so, always wash your hands after you remove your gloves!
E.coli bagel story...

58. Hand Washing Recommendations
Hand Hygiene Indications
Visibly soiled hands - traditional wash
Hand Hygiene Technique
Traditional Handwash
Wet hands first
3 - 5 mL of product
Wash for at least 15 seconds
Rinse
Dry - use towel to turn off faucet
The new guidelines have specific recommendations for hand hygiene: for visibly soiled hands (and this picture is a HUGE exaggeration!), you need do perform a traditional handwash with soap and water.
You need to wet your hands first, apply mL of the product (or whatever the manufacturer recommends), wash for at least 15 seconds, rinse thoroughly and dry thoroughly. Then you use the paper towel to turn off the faucet.

59. Tips for a Traditional Wash
Proper Handwashing:
Wet hands BEFORE adding soap
Dime-sized amount of soap is plenty
Use warm, not HOT water
Rinse thoroughly
Dry thoroughly
Handwashing technique is extremely important to protect your skin. These are a few tips for proper handwashing:
You should always wet hands before adding soap - it doesn’t seem like a big deal, but it is! Compare it to using a germicide at full strength instead of diluting it - you’re going to probably see some surface damage!
A dime-sized amount of soap is plenty - just one pump from most dispensers will do the job.
Hot water dehydrates the skin, and rinsing all residual product off your hands is very important. The surfactants that are left behind can be very irritating when left to dry.
Evaporation also contributes to drier hands, so make sure you dry them thoroughly after being wet..

60. New Guideline Recommendations
Hand Hygiene Indications
If hands are not soiled, use alcohol:
Before and after gloving
Before and after patient contact
intact skin
non-intact skin, wound dressings (no visible soil)
between contaminated and clean body sites
The exciting new recommendations in the guideline as everyone is aware, is that in those cases where hands are not visibly soiled, including before and after gloving, before and after patient content, and between contaminated and clean body sites - you should use a waterless alcohol product.
Hand hygiene technique is a lot less complicated: Basically, you just need to apply enough product to cover the entire surface of the hand, then rub until dry. I am going to emphasize the last step as a safety reminder - it’s important to keep in mind that you’re dealing with a flammable liquid. It should only take a couple of minutes for your hands to air dry, and the potential for ignition is eliminated once that alcohol has evaporated.

61. Considerations Use caution when handling items that may contain sharps
Do not eat, drink, apply cosmetics or handle contact lenses in areas where exposure is likely to occur
Place soiled linen in an impermeable bag
Clean, disinfect or sterilize contaminated equipment between uses
As part of the OSHA Blood-borne Pathogen standard, the employer needs to determine and put into effect a written schedule for cleaning and decontamination, based upon each specific location in the facility, type of soil present, type of surface to be cleaned, and tasks and procedures being performed in that area.
Contaminated sharps must be discarded and/or contained immediately in closed, puncture-resistant, leak-proof and labeled containers that are easily accessible and maintained in an upright position.
Don’t eat, drink, smoke, apply cosmetics or handle contact lenses in areas where exposure is likely to occur.
Contaminated laundry must be handled as little as possible and with a minimum of agitation. It must be bagged at the location where it was used and not sorted or rinsed - then labeled and color-coded for transportation.
All equipment and work surfaces must be cleaned and decontaminated. The particular disinfectant used depends on the surface, soil, circumstances and location requiring decontamination. All equipment, environmental and work surfaces shall be cleaned and decontaminated with an appropriate disinfectant after completion of procedures. This is basically your day to day job...

62. Blood Spills
Spills of blood or body fluids should be cleaned up promptly
Use an appropriate disinfectant (HIV and HBV effective)
OSHA considers tuberculocidal agents (bleach, phenol) HIV and HBV effective
OSHA now considers quats EPA registered as effective against HIV and HBV effective
Blood and other potentially infectious material should be cleaned up promptly and according to OSHA Bloodborne Standards.
OSHA requires that spills be disinfected with an appropriate disinfectant (i.e.. one that kills HBV and HIV).
At the time the standard was introduced (1992), there were disinfectants registered effective against HIV but not HBV.
This is because there was not an EPA approved test method to show effectiveness against HBV.
Because of this, OSHA felt the safest approach was to require the use of a Tuberculocidal disinfectant since TB was considered one of the most difficult organisms to kill.
Since that time EPA has reviewed data and approved select quaternary disinfectants as HBV effective. This means that quaternary disinfectants with EPA claims against HBV and HIV are appropriate for cleanup of blood or other potentially infectious material spill cleanup. These quats were tested using an endangered species, so there were only a few registrations granted. As a result, many companies subregistered these products.
The EPA has recently accepted a new model for testing HBV. Many companies are now involved in scheduling this testing, and we’ll probably see many more cost-effective HBV quats in the market a year from now. *This presentation was created in November, 2000.

63. Descending Order of Resistance
Prions (vCJD)
Bacterial spores Not High Sterilization
(Bacillus, Clostridium spp.) Numbers
Mycobacterium Intermediate High-Level
(M. tuberculosis) Disinfection Disinfection
Nonlipid or
small viruses Check
(Poliovirus, HAV) Label
Fungi
(Candida sp.)
Vegetative bacteria Low-Level
(S. aureus, MRSA, VRE) Disinfection
Lipid or medium-
sized viruses
(Herpes simplex, HBV, HIV)
Infection control professionals have actually categorized levels of disinfection.
This chart shows the relative resistance of microorganisms to disinfectants.
Low level disinfectants (like most quats) are those disinfectants which will kill vegetative bacteria and lipid viruses - in most cases they also kill select fungi and non lipid viruses (you need to read the label)
Notice that the two representative organisms for blood-borne pathogens, HIV and HBV - are relatively easy to kill with a low level disinfectant.
Intermediate level disinfectants (like most phenolics) will kill Mycobacterium (or TB) on down - it should be noted that there are some exceptions where products that kill Mycobacterium will not kill some non-lipid viruses or fungi
High level disinfectants (such as glutaraldehydes) kill Mycobacterium and low numbers of bacterial spores
Sterilants (such as glutaraldehydes at longer time points) kill spores on down.
Prions are basically at the top of the chart - very difficult to eliminate with traditional chemistries alone.
It is important to note that despite the high level of efficacy, glutaraldehydes are only used for surgical instruments - they are not hard surface disinfectants.

64. Choosing a Disinfectant for Blood Spills
Sodium Hypochlorite (bleach)
Phenolic
HBV Effective Quaternary Ammonium Compound
As seen by the previous slide, an appropriate disinfectant for blood spills is one that is HIV and HBV effective.
Sodium hypochlorite, or bleach, has a long history of disinfection. Because of this history, it’s effectiveness is well known. A 1:10 dilution of a 5.25% sodium hypochlorite concentrate is recommended for the disinfection of blood spills.
Phenolics are categorized as intermediate level disinfectants, meaning that they are tuberculocidal. Because of this higher level of disinfectant efficacy, phenolics are appropriate disinfectants for the clean up of blood spills.
HBV Quaternaries are categorized as low-level disinfectants. The HBV claims set these products apart from other available quaternary formulas.
Each choice has pros and cons - the facility needs to decide which characteristics are important to them.

65. Sodium Hypochlorite Pros Cons history of disinfection economical
surface compatibility
stability
safety
cleaning ability
Sodium hypochlorite, as I mentioned in the previous slide, has a great history of disinfection - it’s been used for years, and we are well aware of its efficacy against microorganisms.
It is a very economical chemical to buy - there’s really nothing fancy in the household or industrial bleach that is purchased.
Disadvantages to using bleach, as many of you are aware, includes surface damage - it can bleach out colors on plastics and corrode metals.
Bleach is also unstable in solution - the activity of a diluted solution of bleach diminishes very quickly - especially in the presence of organic soil, such as blood.
There are safety issues with using bleach. Beyond the fumes and irritation associated with using bleach, if it is accidentally combined with other chemicals such as ammonia or acid, toxic fumes may be given off.
Bleach doesn’t have any surfactants, so it’s not a good cleaner. You need to definitely clean the surface before disinfecting with bleach.

66. Phenol Pros Cons broad kill range, including TB cleaning ability
resistance to hard water and organic soil
Cons
surface compatibility
toxicity
Phenolics have a very broad kill range, including Mycobacterium, the organism that causes tuberculosis.
They have excellent cleaning ability - surfactants are typically built into the formula. They are resistant to both the minerals in hard water and organic soil such as blood and other body fluids. Essentially, they are very stable once diluted.
Disadvantages to using phenol include surface incompatibility - there are some plastics that are degraded by phenolic products (the plastic will discolor and become brittle).
Phenol has also raised some toxicity concerns to the environment as well as to people. In California, a certain chemical form of phenol cannot be used, and many facilities monitor their water supply for high levels of phenol in their waste water.

67. HBV Effective Quaternary Ammonium Compounds
Pros
cleaning ability
broad spectrum of kill
resistance to hard water and organic soil
surface compatibility
safety
Cons
not tuberculocidal, unless combined with another chemical
HBV effective quaternary ammonium compounds have many advantages. Quats have great cleaning ability because quaternaries are surfactants as well as antimicrobials. They have a broad spectrum of kill, and higher generations of quats are resistant to hard water and organic soil interference. They are relatively compatible with almost any surface, and they are very safe to the end user when the label directions are followed.
Quats are not tuberculocidal, unless they are combined with another chemical, such as alcohol or another solvent.

68. Final Points to Remember
Basic Steps to Prevent Infection
use appropriate cleaning and disinfectant procedures
wash your hands thoroughly
practice good skin care
use personal protective equipment
HBV Vaccination
know the exposure control plan
Finally, there are basic steps to remember to prevent infection:
Use appropriate cleaning and disinfectant procedures. For blood spills, include the use of a product that is effective against HIV and HBV, or at least effective against TB.
Wash your hands. Handwashing is the single most important factor in preventing infection.
Practice good skin care. Your skin is your best defense against infection. Protect it by keeping it moisturized and using barriers as directed.
Use personal protective equipment. Gloves are very important in handling potentially infectious material, and masks and gowns may be used in extreme cases where the possibility of infection is unusually high.
The HBV vaccination is an important way to prevent a serious and deadly disease. It is highly recommended for people in occupations with any possibility of blood-borne pathogen exposure.
Knowing your facility’s exposure control plan is very important in the prevention of blood-borne pathogen exposure and knowing what to do if an exposure occurs. Knowledge of this plan can mean the difference between staying healthy or becoming infected with a deadly disease.

69. Tuberculosis
Although Tuburbulosis is not a bloodborne pathogen, it has been added to the training because many employees with occupational exposure to bloodborne pathogens may potentially have occupational exposure to persons with TB disease.

70. Tuberculosis
Infectious disease cause by the bacterium, Mycobacterium tuberculosis.
Spread by airborne droplets, “droplet nuclei,” which may be generated when a person with TB disease coughs, sneezes, speaks or sings.
TB infection occurs when a susceptible person inhales droplet nuclei containing the bacteria and becomes established in the body.
There are various symptoms that may indicate exposure to TB. These include: lethargy, weakness, fatigue, fever, weight loss, persistent productive cough, coughing up blood, loss of appetite, and night sweats.
The Mantoux tuberculin skin test is used to detect TB infection. Positive result indicate TB infection. Other tests are needed to confirm TB disease.
TB is largely a preventable disease. Several drugs are used to treat TB. The most common drugs are isoniazid (INH) and rifampin.

71. Occurrence
Nearly one-third of the world’s population is infected with TB, which kills almost 3 million people per year.
In the mid-1980s, a resurgence of outbreaks in the U.S. brought renewed attention to TB. Since 1985, the incidence of TB in the general population has increased 14% reversing a 30 year downward trend. In 1993, over 25,000 new cases of TB were reported in the U.S. During 1994 and 1995, however, there was a decrease in TB cases in the U.S. likely due to increased awareness and efforts in prevention and control of TB.

72. Why Is TB Increasing? Multiple contributing factors: Homelessness
Intravenous drug use
Overcrowding in institutional settings
HIV infection
Drug-resistant strains of TB
Reduced TB control and treatment resources
Immigration from high TB prevalence areas
These factors contribute to the growing increase in TB cases.

73. Where Is TB Found in the Workplace?
Healthcare Facilities
Correctional Institutions
Homeless Shelters
Long-term Care Facilities for the Elderly
Drug Treatment Centers
The Centers for Disease Control and Prevention (CDC) has identified these workplaces as having high incidences of TB.
Health care facilities include hospitals where patients with confirmed or suspect TB are treated or to which they are transported.
Coverage of non-health care settings (doctors’ offices, clinics, etc.) include only personnel present during performance of high hazard procedures on suspect or active TB patients. Dental health care personnel are covered only if they treat suspect or active patients in a hospital, correctional facility, or as part of their practice.

74. What Does it Mean to You?
Your employer must provide training in recognizing high-risk patients and procedures.
Employers must provide fit-tested and N95 masks for all employees.
Employees must receive free skin test (Mantoux test) upon hiring and at least annually thereafter.

75. What Does it Mean to You?
Employer must provide evaluation and management of symptomatic employees with history of positive skin tests.
Employer must maintain complete records of all training, skin tests and exposures.

76. Tuberculosis signs and symptoms
Persistent productive cough (lasting 2 weeks or more)
Weight loss
Loss of appetite
Night sweats and/or fever
General weakness or lethargy
Hemoptysis (coughing up blood)

77. Tuberculosis Screening
Healthcare Workers have increased risk of TB
Frequency of Screening is dependent on the number of active cases within facility

78. TB Skin Test (Mantoux)
Injection of purified protein derivative (PPD) under skin
Injection is then checked for reaction in 48 to 72 hours

79. TB and Respiratory Protection
The primary means to control occupational diseases caused by breathing contaminated air is through the use of feasible engineering controls such as enclosures, confinement of operations, ventilation or substitution of less toxic materials.
When these controls are not feasible, or while they are being instituted, appropriate respirators shall be used.
Respirators shall be provided by the employer when such: equipment is necessary to protect the health of the employee and equipment is applicable and suitable for the purpose intended.

80. When to Wear the Respirator (N95 masks)
When entering a TB isolation area
During contact with a patient with suspected or confirmed active TB
During high risk procedures on high risk patient groups
The minimal acceptable level of respiratory protection for TB is the Type 95 respirator. NIOSH respirator certification requirements are contained in 42 CFR Part 84.
High risk procedures: characterized by potential to generate airborne secretions; aerosolized medication treatment; bronchoscopy; sputum induction; endotracheal intubation and suctioning; and autopsies conducted in hospitals.
A respirator may be re-used by the same person until it becomes wet or damaged.

81. Respirator Limitations
Do not wear a respirator unless cleared
Do not put respirator on patient
N95 masks or H.E.P.A. respirators do not protect from hazardous chemicals
Do not wear in oxygen deficient atmosphere
Do not share respirators

82. Accident Prevention Signs and Tags
In accordance with (f)(8), a warning shall be posted outside the respiratory isolation or treatment room or a message referring one to the nursing station for instruction may be posted.
(f)(4) requires that a signal word or biological hazard symbol may be presented as well as a major message.
Warning signs must be posted on respiratory isolation or treatment rooms stating “pulmonary isolation,” “respiratory isolation,” or “AFB isolation.” the sign must state specifically the precautions required to interact with patients.

83. Accident Prevention Signs and Tags (Continued)
Employers are also required to use biological hazard tags on air transport components which identify TB hazards to employees associated with working on air systems that transport contaminated air.

84. Questions?

85. References OSHA Office of Training & Education
American Academy of Orthopedic Surgeons, Bloodborne Pathogens Fourth Edition