1. Prevention of Blood-Borne Virus Infections
Transmission of blood-borne viruses (BBV) or pathogens is an important risk for both patients and healthcare personnel. Studies have shown that the risk of exposure of patients and staff to BBVs can be reduced significantly by using infection prevention and control practices.

2. Learning Objectives List causes of bloodborne pathogen infections
Outline risk reduction measures for healthcare workers
Identify methods for reducing risk of bloodborne infections in patients
December 1, 2013

3. Time involved
40 minutes
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4. Blood-borne Viruses
Main blood-borne viruses transmitted in health care settings:
Human immunodeficiency virus
Hepatitis C virus
Hepatitis B virus
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Bloodborne pathogens are present in the blood and body fluids of some individuals receiving health care and may be transmitted to healthcare workers (HCW) via certain types of exposure. Patients with hepatitis B virus (HBV), hepatitis C virus (HCV), or human immunodeficiency virus (HIV) infection may be known at the time of care. However, many infected individuals are asymptomatic, and their infectious status may be unknown. HBV, HCV, and HIV infections all have the potential for a serious adverse outcome, and handling infected blood and body fluids or contaminated sharp equipment is a feature of health care. Therefore, while the risk of occupational exposure and subsequent seroconversion to a bloodborne pathogen is not encountered frequently, the risk is real.

5. Hepatitis B virus (HBV)
Found in all body secretions and excretions
Only blood (and serum-derived fluids), saliva, semen, and vaginal fluids infectious
May survive on environmental surfaces for more than a week
Indirect exposure to HBV can occur
Risk of transmission of HBV is reduced by immunisation
December 1, 2013
HBsAg can be found in virtually all body secretions and excretions; however, only blood (and serum-derived fluids), saliva, semen, and vaginal fluids have been shown to be infectious. Because HBV may survive on environmental surfaces for more than a week, indirect exposure to HBV can occur via contaminated inanimate objects and appears to have been a factor in HBV outbreaks among patients and staff of hemodialysis units. The risk of transmission of HBV is reduced by immunization against hepatitis B, which is 90% to 95% effective in immunocompetent working-age adults.

6. Hepatitis C virus (HCV)
Primary cause of parenterally transmitted hepatitis
Transmitted via blood
No immunisation available
December 1, 2013
HCV is the primary cause of parenterally transmitted non-A non-B hepatitis. Is transmitted via blood. Injection drug use or infected blood products at hospitals. There is no immunization available against HCV at this time.

7. Human immunodeficiency virus (HIV)
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Transmitted via sexual contact, injection drug use, and from mother to neonate
Percutaneous exposure a more effective means of transmission than mucous membrane exposure
HIV is transmitted to others via sexual contact and injection drug use, and from mother to neonate. Epidemiologic studies have shown that the risk of transmission of HIV to HCWs from HIV infected patients is approximately 0.3% following a needlestick exposure. Percutaneous exposure is a more effective means of transmission than mucous membrane exposure.

8. HCW Exposure
Healthcare workers may be exposed to blood-borne infections from:
Lacerations
Punctures
Non-intact skin exposures to the blood or body fluids of infected patients
Surgical or invasive medical/dental procedures
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Determinants of occupational transmission of a bloodborne pathogen include the following:
the risk of exposure to blood and body fluids,
the prevalence of infection in the client population,
the efficiency of transmission following a significant exposure to infected blood or body fluids, in part determined by the amount of virus circulating in the source patient and the type of injury,
the effectiveness of the post-exposure protocol,
the immune status of the exposed person, and
the control measures in place to prevent the exposure and transmission of infection to HCWs.
These factors are further affected by other variables related to the virus, equipment design, and work practices. The risk is not equal for all viruses, for all work practices, or for all HCWs.

9. Blood/Body Fluid Exposure among Healthcare Workers
December 1, 2013
Puncture wound
Skin contact
Mucous membrane contact
The most common cause of HCW occupational exposure to blood and body fluids is by a percutaneous (e.g. needlestick) injury. Studies indicate that of all percutaneous injuries, those involving a hollow-bore needle are responsible for 59% to 94% of HCW exposures to blood. Other sharp injuries, e.g. a cut with a sharp instrument or suture needle, account for only 8% to 10% of percutaneous injuries.
HCW exposure to blood and body fluids via mucous membranes accounts for 10% to 16% of occupational bloodborne pathogen exposures.

10. Patient Exposure
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Patients may be exposed to blood-borne infections from:
Improperly sterilised equipment
Unsterile injection fluids
Contaminated infusions
Transplantation
Blood of infected HCWs during invasive procedures

11. Healthcare Worker Risk Reduction - 1
December 1, 2013
Always use disposable gloves whenever exposure to blood or body fluids likely
NEVER re-sheath needles
Containers for sharps disposal should be available within arm’s length
When sharp items being used
Always use gloves when in contact with body fluids and blood. Always at least wash or disinfect hands and surroundings between all patients.

12. Healthcare Worker Risk Reduction - 2
Containers sealed with a tamper proof lid
Safely discard when three quarters full
Standard Precautions must be adopted
Immunise high-risk HCWs
Always use available safety devices
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13. Safety Devices: examples
December 1, 2013
Whenever possible, ensure that hazardous devices are replaced with equipment with a safer design. Well-designed equipment includes equipment with the use of active or passive safety devices. An active safety device requires the operator to actively engage the safety feature in order to ensure its proper function, whereas a passive safety device is one that requires no action on the part of a HCW to ensure protection and is usually in effect throughout the use of the device, e.g. once the syringe has been fully engaged, the needle is drawn into the barrel.
Consideration should be given to the following:
passive retractable needles to reduce injuries at the point of use and eliminate the need to recap,
active and passive retractable needles and blunt suture needles to eliminate injuries at point of use,
retractable intravenous catheter needles,
alternatives to butterfly needles,
mechanical devices in the laboratory,
needleless intravenous systems to reduce injuries at point of use and eliminate the need to recap,
sharps disposal containers placed close to the bedside to reduce the need to recap
Safety scalpel
Safety hypodermic needle

14. Safer Needle Devices - 1 Needleless Connector Systems
December 1, 2013
Needleless Connector Systems
Needleless connectors for IV delivery systems
Since needleless connectors for use in intravenous (IV) administration were introduced in the early 1990s, a wide variety of these devices have come onto the market. Although these apparatuses are often referred to as “end caps,” “injection caps,” “luer-activated devices,” “injection ports,” and “mechanical valves,” the term “needleless connector” is the most accurate, as it is the only term that includes all types and designs in this category of products.
See for information on various types of connectors.

15. Safer Needle Devices - 2 Self-Sheathing Safety Feature
December 1, 2013
Self-Sheathing Safety Feature
Sliding needle shields attached to disposable syringes and vacuum tube holders
A needle with a cover that the user can slide back over the needle after use. The cover, or sheath, locks into place.
Before use
After use

16. Safer Needle Devices - 3 Retractable Technology
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Retractable Technology
Needles or sharps retract into a syringe, vacuum tube holder or back into the device

17. Safer Needle Devices - 4 Self Blunting Technology
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Self Blunting Technology
Self-blunting phlebotomy and winged-steel “butterfly” needles
Blunt-Tipped Blood Drawing Needle
A blunt cannula seated inside the phlebotomy needle is advanced beyond the needle tip before the needle is withdrawn from the vein.
After blood is drawn, a push on the collection tube moves the blunt tip needle forward through the needle and past the sharp needle point. The blunt point tip of this needle can be activated before it is removed from the vein or artery.
Winged Steel Needles

18. Safer Needle Devices - 5 Add-on Safety Features
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Add-on Safety Features
Hinged or sliding shields attached to phlebotomy needles, winged steel needles and blood gas needles
A safety syringe having a protective barrel which is movable between a retracted position wherein the needle is exposed and a locked extended position wherein the needle is protected.
Add-on sliding shield

19. One Handed Technique December 1, 2013
If you need to put the cap back on a needle (recap), do not bend or break the needle and never remove a hypodermic needle from a syringe by hand. This may result in accidental needle sticks, cuts or punctures. Recapping should be performed using a mechanical device or a one-handed technique.
One-Handed Needle Recapping Method
Step 1: Place the cap on a flat surface like the table or counter with something firm to "push" the needle cap against. Step 2: Holding the syringe with the needle attached in one hand, slip the needle into the cap without using the other hand. Step 3: Push the capped needle against a firm object to “seat” the cap onto the needle firmly using only one hand.
Needle Clippers
Needle clippers make syringes with attached needle unusable by clipping off the needle. Clippers may be used for needle disposal of small syringes (such as insulin syringes), but not for clipping lancets. After the needle clipper clips off the needle from the syringe, the needle is automatically and safely retained within the clipper. Do not attempt to clip a needle with any tool except a needle clipper designed to safely clip a needle.

20. Sharps Containers - examples
December 1, 2013
A sharps container is a container that is filled with used medical needles (and other sharp medical instruments, such as an IV catheter). They fit into two main types: single use which are disposed of with waste and reusable which are robotically emptied and sterilised before being returned for re-use.

21. Sharps Containers December 1, 2013
Discard used sharps and glass ampoules immediately after use in the location where they were used. Discard them into a sharps container that is leak and puncture resistant. Place the sharps container within arm’s reach (preferably in a secured area) to allow for easy disposal of sharps. Seal and replace sharps container when the container is three quarters full.

22. Personal Protective Equipment
December 1, 2013
Personal protective equipment, or PPE, is designed to protect workers from serious workplace injuries or illnesses resulting from contact with chemical, radiological, physical, electrical, mechanical, or other workplace hazards. Besides face shields, safety glasses, hard hats, and safety shoes, protective equipment includes a variety of devices and garments such as goggles, coveralls, gloves, vests, earplugs, and respirators.

23. Reducing Unnecessary Injections
Educate HCWs, patients, and the public about injection risk by:
Developing teaching materials about injection risk and importance of reducing injection frequency
Enlisting influential institutions to campaign against unnecessary injections
churches, mosques, universities, hospitals, and government agencies
When available, teach how to use safety devices and proper disposal of all single use devices
Eliminate use of unsterile needles, syringes, and solutions for injections
December 1, 2013
The World Health Organization proposes that “national strategies for the safe and appropriate use of injections address behaviour change among healthcare workers and patients, provision of equipment and supplies, and sharps waste management. Such initiatives should not constitute separate programs but should be integrated with other activities, including HIV prevention and care, essential medicines, immunisation, and health system management”.
The Safe Injection Global Network (SIGN) estimated that approximately 16 billion injections are performed annually, many of which are unnecessary. Reducing unnecessary injections may be accomplished by:
Developing national policies for health care facilities regarding appropriate medications and circumstances for injections. It is important to publicise the policy widely within the health care community and the country at large.
Educate HCWs, patients, and the public about injection risk by:
Developing teaching materials (posters, lectures) about injection risk and the importance of reducing injection frequency.
Enlisting influential institutions such as churches, mosques, universities, hospitals, and government agencies to campaign against unnecessary injections.
When available, teach how to properly use safety devices and proper disposal of all single use devices.

24. Monitoring Surveillance for occupational blood exposures
Can provide useful data to focus local prevention efforts
Routine accident reports may not provide adequate information
Focused studies may be required
December 1, 2013
A monitoring system to track occupational exposure to BBVs should be introduced. Surveillance for occupational blood exposures can provide useful data to focus local prevention efforts. An occupational health department can centrally collate trends of incidents and make recommendations for improving practice.
Routine accident reports may not provide adequate information; therefore focussed studies may be required. Studies in departments where the risk for occupational blood exposures is high have shown that personnel could reduce the frequency of HCW exposure more than half by changing practices and increasing barrier precautions.
Personnel could reduce the frequency of HCW exposure more than half by changing practices and increasing barrier precautions.

25. Strategies to Eliminate Injuries1
Eliminate or reduce the use of needles and other sharps 2
Use devices with safety features to isolate sharps 3
Use safe practices to minimize risk for hazards
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Hierarchy of Prevention In Order From Most to Least Effective
Eliminate unnecessary injections or substitute sharps
needleless IV systems
Engineering Controls
Safer needle devices
Administrative and Work Practice Controls
Standard precautions, no recapping, provision & placement & removal of sharps containers
Personal Protective Equipment
Gloves, masks, gowns, eye protection

26. Recommendations for Healthcare Facilities - 1
Surveillance
Training personnel
Personnel immunisation
Always wash or disinfect hands and surroundings between patients
Provide appropriate personal protective equipment
Always use gloves when contact with body fluids and blood
Enforce safe practices through monitoring and supervision
Establish a bloodborne pathogen management policy
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27. Recommendations for Healthcare Facilities - 2
Implement management policies
Exposure reporting, PEP access, etc.
Establish laboratory capacity for bloodborne virus testing
Use appropriate PEP regimens
Provide access to counseling for exposed personnel
Monitor adverse events and seroconversion
Monitor exposure management programs
Time between exposure and evaluation, testing source persons, completion of follow-up
December 1, 2013
Practice recommendations to assist healthcare facilities implement guidelines for managing occupational exposures to bloodborne pathogens include the establishment of a bloodborne pathogen management policy, implementation of such policies (including training, hepatitis B vaccination, exposure reporting, and access to postexposure prophylaxis), establishment of laboratory capacity for bloodborne virus testing and the selection and use of appropriate postexposure prophylaxis regimens.

28. Multi-Component Prevention Approaches
Experts agree that safety devices and work practices alone will not prevent all sharps injuries
Significant declines in sharps injuries also require:
Education
Reduce invasive procedures (as much as possible)
A secure work environment
Adequate staff-to-patient ratio
December 1, 2013

29. Patient Risk Reduction
Prevent contact transmission
Needles and syringes single use
Single use vials of medications, not multiple use vials
To reduce contamination during use
Equipment cleaned and sterilised between patients
Single use disposable items used to avoid need for sterilisation/disinfection
Single use items must never be reused
Blood and blood products used for transfusion screened for blood-borne viruses prior to infusion
December 1, 2013
Using needles and syringes which have been inadequately sterilised poses a risk of transmission of infection. Administration of medication by injection should be avoided if the oral route is possible. Inadequate supplies of equipment may lead to reuse of needles and syringes or to the multiple use of equipment without sterilisation between uses; both of which significantly increase the risk of transmission of BBVs.
Equipment must be effectively cleaned and sterilised between patients to reduce the risk of BBV transmission. Single use disposable items should be used to avoid the need for sterilisation/disinfection; single use items must never be reused.
Blood and blood products being used for transfusion should be screened for BBVs prior to infusion, and for other microorganisms if required by local protocols. This may occur by testing the donor at the time of donation or testing the blood product itself.
If injections are essential, then HCWs should ensure that these do not expose a patient to a BBV. Needles and syringes should be single use. Single use vials of medications are preferable to multiple use vials as they increase the risk of BBV infection transmission due to contamination during use.
Eliminate use of unsterile needles, syringes, and solutions for injections.

30. Summary
BBV transmission is a recognised risk to healthcare workers and patients
Transmission of BBVs may occur by contact transmission, injection, infusion, transplantation, unsterile equipment, or other accidental injury/penetration
Risk can be reduced by
preventing contact transmission
eliminating hazards
providing and using engineering controls
avoiding unsafe practices
using personal protective equipment
immunisation, and
post-exposure prophylaxis
December 1, 2013

31. References
World Health Organisation (2010), Geneva, Best practices for injections and related procedures toolkit
Injection Safety, World Health Organisation, Geneva,
Dolan SA, Felizardo G, Barnes S, Cox TR, Patrick M, Ward KS, Arias KM. APIC position paper: safe injection, infusion, and medication vial practices in health care. Amer J Infect Control 2010; 38(3):
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32. Quiz Replace sharps containers when ¾ full. T/F
Use the following practices to decrease exposure to BBVs except
Standard precautions
Immunisation
Sharps containers
Resheathing needles
Decrease patient risk of exposure to BBVs by
Use of single dose vials
Screening blood
Cleaning equipment
All of the above
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True D

33. International Federation of Infection Control
IFIC’s mission is to facilitate international networking in order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe .
The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise.
For more information go to
December 1, 2013