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Bloodborne and Airborne Pathogens

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1 Bloodborne and Airborne Pathogens

2 Introduction to the Bloodborne Pathogen Standard
Chapter 1 McGraw-Hill/Irwin Copyright ©2009 by the National Safety Council. All rights reserved.

3 Bloodborne Pathogen Standard
OSHA Bloodborne Pathogen Standard Designed to eliminate or minimize employees’ exposure to human blood and other potentially infectious materials (OPIM) in the workplace Went into effect in 1992 1-3

4 Who is covered? All employees who may reasonably expect to be exposed to blood and OPIM that may contain pathogens Anyone whose job involves handling or possibly being exposed to blood or blood products, or OPIM 1-4

5 What are pathogens? Germs transmitted from one person to another through contact with blood or OPIM Germs transmitted from one person to another through contact with blood or OPIM Microscopic Germs 1-5

6 Caution! You do NOT need to directly contact someone carrying a bloodborne pathogen to be at risk for exposure! Risks also come from: Clinical specimens Biohazardous trash Blood- or body fluid-soaked laundry Needles or sharps 1-6

7 Annual Training Required:
How diseases are transmitted and their symptoms Protective measures to prevent exposure Procedures to be followed if exposed 1-7

8 Exposure Control Plan OSHA requirement Must describe:
Exposure prevention Engineering and work practice controls Universal precautions Personal protective equipment OSHA record keeping requirements 1-8

9 Other Regulations Needlestick safety and prevention act
Identify, evaluate, and implement safer medical devices Keep sharps injury log 1-9

10 Bloodborne Pathogens Chapter 2 McGraw-Hill/Irwin
Copyright ©2009 by the National Safety Council. All rights reserved.

11 Infectious Disease Transmission
Stages of Disease Transmission: Stages of Disease Transmission: 1. Someone has the infection. 2. The infectious pathogen leaves the infected person’s body. 2-11

12 Infectious Disease Transmission:
The infectious pathogen reaches another person and enters his or her body. Transmission: - Bloodborne - Airborne - Vector - Direct or indirect contact 4. The second person develops the infection. Transmission: - Bloodborne - Airborne - Vector - Direct or indirect contact 2-12

13 Serious Bloodborne Pathogens
Hepatitis B virus (HBV) Hepatitis C virus (HCV) Human immunodeficiency virus (HIV) HIV Virus 2-13

14 Measures Measures you take to prevent HBV, HCV, and HIV also help prevent diseases caused by other bloodborne pathogens 2-14

15 OPIM Saliva containing blood Semen Vaginal secretions Breast milk
Amniotic fluid Blood in saliva during dental exam 2-15

16 OPIM Cerebrospinal fluid Synovial fluid Pleural fluid 2-16

17 OPIM Peritoneal fluid Pericardial fluid
Any body fluid visibly contaminated with blood (such as vomit or urine) 2-17

18 Do Exposures Always Cause Infection?
NO The risk of infection after an exposure depends on: Whether pathogens are present in the source blood or body fluid The number of pathogens present The type of injury or exposure Your current health and immunization status 2-18

19 Hepatitis B 2-19

20 Hepatitis B Caused by hepatitis B virus (HBV)
Transmitted by blood and OPIM Found in all body fluids Blood and semen are the most infectious 2-20

21 Hepatitis B Major cause of liver damage, cirrhosis, and liver cancer
Infections are declining Still infects about 60,000 people yearly About 3,000-5,000 people die of liver problems associated with HBV infection every year 2-21

22 HBV Incubation period averages 12 weeks Infection can
Cause acute hepatitis or A chronic (long-term) infection Chronic HBV can be infectious for decades 2-22

23 How is HBV Spread? Injection Mucous membranes Sexual activity
Needlesticks Puncture wounds Mucous membranes Eyes and mouth Nonintact skin (abrasions) Sexual activity Infected mother to newborn at birth 2-23

24 HBV Transmission Contaminated environmental surfaces
At room temperature HBV may survive for several days in dried body fluids on surfaces HBV more easily transmitted than HIV: - Lives longer outside the body - Little blood needed to cause infection 2-24

25 HBV not transmitted by:
Food or water Fecal matter Through the air sneeze or cough Casual contact shaking hands, hugging, kissing, or sharing a meal, utensils, or a drinking glass 2-25

26 Symptoms of HBV About 30% have no symptoms at all
Flu-like symptoms may appear gradually Loss of appetite Nausea, vomiting Fatigue Muscle or joint aches Mild fever Stomach pain Occasionally jaundice 2-26

27 How Do I Know If I Have HBV?
Only certain way to know is to have a blood test Blood test may not indicate the virus shortly after being infected 2-27

28 Hepatitis B Vaccine Best protection No risk of developing hepatitis
Three doses given by injection on three different dates Most common reaction is soreness at the injection site 2-28

29 HBV Vaccine Recommended:
Employees at risk Those who have unprotected sex with a partner who has HBV or have sex with more than one partner People who have anal sex 2-29

30 HBV Vaccine Recommended:
Those who use intravenous recreational drugs People with hemophilia Those who frequently travel to or live in countries where HBV is common Those who live with someone with lifelong HBV 2-30

31 HBV Vaccine Effectiveness
Prevents hepatitis B in ~ 95% of people After receiving the three shots, you can be tested to make certain you are protected Important if you have a compromised immune system or your job frequently exposes you to human blood 2-31

32 OSHA Standard and HBV Vaccine
Requires employers to offer the HBV vaccine to employees at risk at no cost, at a convenient time and place, and during their normal work hours You have the right to: Refuse the vaccine (You must sign a declination form) Change your mind and have the vaccination at a later date 2-32

33 OSHA Standard Requires Employers to:
Offer training and HBV vaccine before starting a work assignment Explain to employees that vaccination is voluntary Make certain employees receive proper medical treatment following any exposure 2-33

34 Prevention of HBV Infection
Get the HBV vaccine Use barrier devices to prevent contact with any blood and OPIM Handle sharps carefully Avoid recreational IV drugs, tattooing, and body piercing without sterile tools Do not share personal items 2-34

35 Hepatitis C 2-35

36 Hepatitis C Liver disease caused by the hepatitis C virus (HCV)
Lives in the blood of people with the disease Spread via the blood Incubation period averages 7 weeks 3.2 million people in the U.S. have chronic HCV infection 2-36

37 Hepatitis C About 26,000 new infections occur each year
Many people who carry HCV have some liver damage but do not get sick from it Other people develop cirrhosis of the liver, resulting in eventual liver failure 2-37

38 How is HCV Spread? Most often through drug injections with contaminated needles Unclean tattoo or body piercing tools Sharing contaminated toothbrushes, razors or other personal items 2-38

39 How is HCV Spread? From a pregnant woman to the fetus
Rarely, though sexual contact In healthcare, via direct contact with infectious blood through an accidental needlestick or sharps injury 2-39

40 Symptoms of HCV Most infected people do not have symptoms Some have:
- Fatigue - Loss of appetite - Nausea - Anxiety - Weight loss - Alcohol intolerance - Abdominal pain - Loss of concentration - Jaundice 2-40

41 How Do I Know If I Have HCV?
Blood test A false positive test can occur with HCV tests Positive tests should have a follow-up test False negative test results may also occur with HCV usually shortly after infection when antibodies have not yet developed 2-41

42 HCV Testing Anyone who has: Been exposed to HCV-positive blood
Used intravenous recreational drugs Received a blood transfusion or organ transplant Been on kidney dialysis prior to 1992 Been treated with a blood product prior to 1987 Signs of liver disease 2-42

43 HCV Testing Is Important
Treatment can be given to protect the liver from additional damage HCV carriers can take preventive measures to avoid spreading HCV to others 2-43

44 Prevention of HCV Infection
No vaccine available for HCV and there is No cure Prevention is critical 2-44

45 Preventive Measures Handle needles and other sharps with caution
Use barriers to prevent contact with blood and OPIM (wear gloves) Avoid recreational intravenous drug use Never reuse or share syringes, or drug paraphernalia 2-45

46 Preventative Measures
Don’t share toothbrushes, razors, personal care items Get vaccinated against HBV Remember the health risks associated with tattoos and body piercing if tools are not sterile or sanitary practices are not followed 2-46

47 HIV and AIDS 2-47

48 HIV and AIDS Human immunodeficiency virus (HIV) causes acquired immunodeficiency syndrome (AIDS) There are almost one million HIV-positive people in the U.S. ¼ of people are unaware of their HIV infection 2-48

49 HIV and AIDS AIDS damages cells essential for immune function
People with AIDS are more susceptible to opportunistic infections The disease is eventually fatal 2-49

50 How Is HIV Spread? Through an infected person’s body fluids: Blood
Semen Vaginal secretions Breast milk OPIM if blood is present 2-50

51 Transmission in Healthcare
Some health workers are infected with HIV through work-related exposures involving blood or OPIM 2-51

52 Transmission in Healthcare
Infection is most likely to occur with exposure to HIV-contaminated blood, blood components, or blood products through: Injection through the skin Unprotected mucous membranes An open skin wound 2-52

53 HIV not Transmitted Through Casual Contact:
Sharing a drinking glass, a meal, or fork Kissing, hugging, or touching Sneezes or coughs Sharing a phone or bathroom With mosquitos, fleas, ticks, or other bloodsucking vermin 2-53

54 Symptoms of HIV Many people with HIV have no symptoms
HIV can take many years to develop into AIDS Microscopic HIV Virus 2-54

55 AIDS Symptoms Loss of appetite Weight loss Fever Skin rashes
Swollen lymph nodes Diarrhea Tiredness Night sweats Inability to fight off infection 2-55

56 How Do I Know If I Have HIV?
A blood test The result is usually positive 12 weeks after exposure A confirmation test is recommended 6 months after an exposure 2-56

57 Prevention of HIV Infection
No vaccine available for HIV and there is No cure Prevention is critical 2-57

58 Prevention of HIV Infection
Regular hand washing Use of barriers Universal precautions 2-58

59 Preventing Infection from Bloodborne Pathogens
Chapter 3 McGraw-Hill/Irwin Copyright ©2009 by the National Safety Council. All rights reserved.

60 OSHA Standard Requires employers to use strategies to reduce occupational exposures: Engineering controls Work practice controls Personal protective equipment Universal precautions 3-60

61 Engineering Controls Needleless IV systems Eye wash stations
Handwashing facilities Sharps containers Biohazard labels 3-61

62 Sharps Needles and other sharps are a great risk to healthcare workers
Other systems are needleless, have needle shields, retractable needles, or other protective devices Employers are required to evaluate the feasibility of such devices annually 3-62

63 Sharps Containers Employers must document engineering controls being considered OSHA requires employee input Must be present for safe disposal of used sharps Must be: Leak proof Puncture resistant Securely closeable Labeled with a biohazard warning 3-63

64 Handwashing and Eye Wash Stations
Handwashing facilities must be provided (when possible) Waterless antiseptic hand cleanser may be provided when handwashing is not possible Eye wash stations must be available when appropriate 3-64

65 Warning Labels Must be displayed on: Must be displayed on:
Containers for waste that may contain biohazardous waste Freezers and refrigerators used for blood or OPIM Containers used to transport, ship, or store blood or OPIM 3-65

66 Warning Labels Must be displayed on:
Contaminated equipment until properly cleaned Laundry bags used to hold and transport contaminated clothing Entrances to places containing OPIM 3-66

67 Waste Infectious waste must be disposed of in labeled red containers or in containers clearly marked with a universal biohazard symbol 3-67

68 Work Practice Controls

69 Work Practice Controls
Use of personal protective equipment (PPE) Handwashing Decontamination and sterilization of equipment and areas 3-69

70 Work Practice Controls
Safely handling sharps Correctly disposing of wastes Safely handling laundry Work area restrictions 3-70

71 Handwashing Guidelines
Immediately wash any exposed skin (ideally with antibacterial soap) Be gentle with any scabs or sores 3-71

72 Handwashing Guidelines
Wash all surfaces, including the backs of hands, wrists, between the fingers, and under fingernails Wash hands immediately after removing gloves or other PPE 3-72

73 Waterless Handwashing
Antiseptic towelettes and waterless antibacterial handwashing liquid can be used when soap and running water are not available After a potential exposure, a thorough scrubbing with soap and water is still recommended as soon as possible 3-73

74 Decontamination and Sterilization
Clean and sterilize all reusable sharps after use (i.e., knives, scissors, scalpels) Decontaminate equipment and working surfaces, bench tops, and floors with 10% bleach solution At end of work shift As surfaces become obviously contaminated After any spill of blood or OPIM 3-74

75 Decontamination and Sterilization
Disinfect nail brushes, etc. after handwashing 3-75

76 Handling Sharps Handling Sharps 3-76

77 Handling Sharps: Guidelines: Guidelines:
Employers must put sharps disposal containers in easily accessible areas where sharps are used Needles must not be recapped, removed, bent, sheared, or broken The entire needle/syringe assembly must be disposed of in a sharps container 3-77

78 Handling Sharps: Guidelines: Guidelines:
A mechanical device may be used to recap a contaminated needle or remove it from a disposable syringe when necessary The exposure control plan must specify when, why, and how this is done and by whom 3-78

79 Regulated Waste Special handling: Regulated waste requiring
Blood or OPIM in liquid or semi-liquid state Items contaminated with blood or OPIM that could release liquid or semi-liquid blood or OPIM if squeezed Special handling: 3-79

80 Regulated Waste Special handling: Regulated waste requiring
Items with dried blood that could be spread by handling Contaminated sharps Lab specimens containing blood or OPIM Special handling: 3-80

81 Laundry Uniforms, clothing, and cloth supplies should be kept free from contamination when possible Clothing that becomes contaminated with blood or OPIM must be put in special labeled and color-coded laundry bags 3-81

82 Laundry Must be sent to an approved laundry facility for cleaning
Anyone handling contaminated laundry must be trained to handle bloodborne pathogens Never take contaminated clothing home to wash 3-82

83 Work Area Restrictions
Smoke Put on lip balm, hand lotion, or cosmetics Eat or drink Handle contact lenses Store food In places where blood is stored/handled DO NOT! 3-83

84 Work Area Restrictions
Put objects in your mouth where potentially infectious materials may be present (i.e.. pencils, pens) Use a sink that is used for food preparation DO NOT! 3-84

85 Personal Protective Equipment PPE

86 PPE Gloves Jumpsuits, aprons Eye shields, goggles
Face masks, face shields Caps Booties 3-86

87 OSHA Standard Provide PPE at no cost Train you how to use equipment
Requires that your employer: Provide PPE at no cost Train you how to use equipment Must clean, repair, or replace it as needed 3-87

88 Medical Exam Gloves Made of nitrile vinyl latex or other
Latex allergy risk: ask for latex-free or hypoallergenic gloves 3-88

89 Medical Exam Gloves Check that gloves are intact
If not, replace glove Avoid petroleum-based hand lotions 3-89

90 Medical Exam Gloves Remove contaminated gloves carefully, not touching any part of the outside of the gloves 3-90

91 Medical Exam Gloves Dispose of gloves in a container clearly marked for biohazardous waste 3-91

92 Jumpsuits, Aprons, and Lab Coats
Can protect clothing from contamination Available in different thicknesses and materials 3-92

93 Jumpsuits, Aprons, and Lab Coats
Remove contaminated clothing immediately Avoid contact with skin Put article in a clearly marked biohazardous laundry bag 3-93

94 Goggles and Eye Shields
PPE for eyes includes goggles, safety glasses with side shields, and face shields 3-94

95 Goggles and Eye Shields
A splash in the eyes may allow bloodborne pathogens into the body Eye protection recommended when cleaning spills or performing first aid Use side shields with prescription glasses 3-95

96 Face Shields and Face Masks
Face shields protect eyes, mouth, and nose Face masks protect the mouth and nose With goggles or safety glasses, face masks help protect the whole face 3-96

97 Caps and Booties Cover hair and forehead Cover shoes or boots 3-97

98 PPE Improvise! Be creative to avoid contact, use items including:
plastic bag a sheet towels or clothing Dispose of or decontaminate any articles used as barriers 3-98

99 PPE Dispose of contaminated PPE: Dispose of contaminated PPE
Different protective equipment require different disposal methods Put articles such as used gloves in a designated disposal container Store contaminated clothing in clearly labeled bags until decontaminated, laundered, or properly disposed of 3-99

100 Universal Precautions (Standard Precautions)

101 Universal/Standard Precautions
Handle all blood and OPIM as if they are contaminated 3-101

102 Universal/Standard Precautions
Treat all materials as if they are infected with bloodborne pathogens, including: Blood Semen and vaginal secretions Saliva that may contain blood Cerebrospinal fluid Synovial fluid Pleural fluid 3-102

103 Universal/Standard Precautions
All Body Fluids OSHA now applies universal precautions to all body fluids because it is impossible to know by looking whether other body fluids may contain blood 3-103

104 Universal/Standard Precautions
All Body Fluids Assume that all body fluids may be infectious and always follow universal precautions Body substance isolation (BSI) guidelines also define all body fluids and substances as infectious 3-104

105 For Unexpected Exposure
If blood or OPIM splashes in your eyes or other mucous membranes, flush area with running water for 20 minutes Wash any exposed area well with soap, using an antibacterial soap 3-105

106 For Unexpected Exposure
Gently treat any scabs and sores Report the exposure to your supervisor Save any potentially contaminated object for testing purposes Seek medical care 3-106

107 Employer Responsibilities
Identify and document source of blood or OPIM Obtain consent and arrange to test the source blood Inform you of the test results 3-107

108 Employer’s Responsibilities
Arrange for you to have your blood tested Arrange counseling and medical care for you as needed 3-108

109 Follow-up After Exposure
Treatment and medical care depend on the type of exposure: Substance involved Route of transmission Severity of the exposure 3-109

110 Follow up After Exposure
Treatment may include HBV vaccination or hepatitis B immune globulin (HBIG) Confidential exposure report form kept in the employee’s personnel file 3-110

111 Exposure Control Plan Identify the job positions and individuals to receive training Establish necessary engineering controls and work practice controls Specify PPE to be used 3-111

112 Exposure Control Plans
Require using universal precautions State the opportunity for HBV vaccination Include other measures appropriate for your specific work environment Review at least annually 3-112

113 Additional Employer Requirements
Inform new employees about their plan Conduct training before performing any work that puts you at risk for exposure Provide refresher training annually or whenever changes made to policies and procedures 3-113

114 Airborne Pathogens Chapter 4 McGraw-Hill/Irwin
Copyright ©2009 by the National Safety Council. All rights reserved.

115 OSHA Regulations Airborne Diseases
Specific employee protections not currently mandated OSHA expects employers to protect employees from known hazards Airborne Diseases 4-115

116 Three Types of Airborne Pathogens
Viral Bacterial Fungal 4-116

117 Airborne Pathogens Precautions for tuberculosis also lower the risk for other airborne pathogens Meningitis Influenza Pneumonia Tuberculosis 4-117

118 Airborne Pathogens Spread by inhaling the germ
Coughing or sneezing tiny droplets of moisture into the air containing pathogens Pathogens can remain airborne for several hours 4-118

119 Airborne Transmission
Depends On: How contagious the infectious person is Where the exposure occurs How long the exposure lasts How healthy you are at the time of the exposure 4-119

120 Tuberculosis 4-120

121 Tuberculosis 14,000 cases in 2005 in U.S.
Caused by a specific bacteria Affects the lungs but it can also affect: brain spine kidneys Many people with TB infection are not sick (the body effectively fighting the bacteria) and are not contagious 4-121

122 Those with TB disease are contagious
Tuberculosis Those with TB disease are contagious 5%-10% of people develop the disease at some point Risk is higher for people with HIV, diabetes mellitus, severe kidney disease, low body weight, or certain types of cancer 4-122

123 Tuberculosis HIV infection is most important risk factor for progression from latent TB infection to TB disease Progression to TB disease is rapid among HIV-infected people TB outbreaks can rapidly expand in HIV-infected patient groups CDC recommends HIV testing for all TB patients 4-123

124 Employees at Risk Correctional facilities Drug and treatment centers
Homeless shelters Healthcare facilities Long-term care facilities Morgues 4-124

125 How Is TB spread? Inhaling the TB pathogen after an infected person coughs or sneezes The TB pathogen can live up to 1½ hours outside the body Infection detectable 2-12 weeks after infection Some bacteria lay dormant for years 4-125

126 Many people with TB infection have no symptoms!
Symptoms of TB Many people with TB infection have no symptoms! With TB disease: Weight loss Fever Night sweats Weakness 4-126

127 Symptoms of TB Coughing Production of sputum Chest pain
If TB affects the lungs, the common symptoms include: Coughing Production of sputum Chest pain Coughing up blood 4-127

128 Tests to Determine TB Infection
Tuberculin skin test (Mantoux test) -Performed on the skin in lower arm -Result is checked after 2-3 days A blood test (QFT-G) also reveals if a person is infected 4-128

129 Special Considerations for TB Testing
Generally recommended for employees at risk because of being near people who may have TB: Certain healthcare facilities Drug treatment facilties Homeless shelters Nursing homes Prison and jails Certain healthcare facilities Drug treatment facilities Homeless shelters Nursing homes Prisons and jails 4-129

130 Special Considerations for TB Testing
Testing recommended for at-risk employees Pregnant employees should be tested via TST, not GFT-G Consider booster effect Those with other disease or illness more likely to develop TB Use 2-step testing for those who will take TST periodically 4-130

131 How Do I Know If I Have TB? Skin and blood tests cannot distinguish between TB infection and TB disease Chest x-ray and phlegm sample needed to determine diagnosis 4-131

132 Preventing TB Infection
Administrative controls Environmental controls Respiratory controls 4-132

133 Administrative Controls
Consider the most important control measure: Assign responsibility for TB infection control Work with health department Ensure timely lab processing and reporting Implement effective work practices 4-133

134 Administrative Controls, continued
Consider the most important control measure: Test and evaluate workers at risk Train workers about TB infection control Ensure proper equipment cleaning Use appropriate signage 4-134

135 Environmental Controls
These controls remove or inactive M. tuberculosis: Local exhaust ventilation General ventilation Air cleaning methods - HEPA filtration - UVGI 4-135

136 Respiratory Protection Controls
Used in settings where other controls will not prevent inhalation of infectious droplet nuclei Implement respiratory protection program Conduct annual training in respiratory protection Initial and periodic fit testing Training patients in respiratory hygiene 4-136

137 TB Exposure and Recordkeeping
Exposure to a known TB source should be reported to employer Employees have right to know about exposures After exposure employees may be tested for TB If infected, employer will arrange for appropriate treatment 4-137

138 TB Exposure and Recordkeeping
Employers must maintain records Active TB disease must be reported to public health officials OSHA 300 log used to record work-related exposure and infection 4-138

139 Treatment of TB TB disease can be cured with antibiotics Depends on:
Age Overall health Lifestyle Occupation TB disease can be cured with antibiotics 4-139

140 Flu is a virus that infects the respiratory tract
Definition of Flu Flu is a virus that infects the respiratory tract 4-140

141 How Humans Spread Flu 4-141

142 Transmission Vehicles
How Humans Spread Flu Transmission Vehicles Hands Air Contaminated Objects 4-142

143 How Humans Spread Flu Entry Points Mouth Eyes Nose 4-143

144 Flu Symptoms Cough Running or stuffy nose Thick mucus Muscle pain
Stiffness Fatigue 4-144

145 Flu Symptoms, continued
Headache Sore throat Shaking chills Fever Dehydration Difficulty breathing 4-145

146 Steps to Prevent Flu Hand hygiene 2. Respiratory hygiene
3. Social distancing 4. Flu shot 4-146

147 Hand Hygiene 4-147

148 Cough or sneeze into a tissue, or into upper sleeve
Respiratory Hygiene Cough or sneeze into a tissue, or into upper sleeve 2. Dispose of tissues in waste can 3. Avoid touching your eyes, nose or mouth 4. Wear a surgical mask 4-148

149 1. Avoid crowded settings
Social Distancing 1. Avoid crowded settings 2. If you have to be in a crowd, make the time short 3. Avoid sick people, or keep a distance of six feet 4. If you or your children are sick, stay home 4-149

150 Immunization Protects from seasonal flu Does not prevent bird flu

151 If You Are Sick Stay home! 2. Get plenty of rest
3. Drink lots of fluids 4. Avoid alcohol and tobacco 5. Take medication 6. Call your doctor if you have a high fever 7. Wear a surgical mask 4-151

152 Caring for the Sick One person should give care
2. Avoid mingling items 3. Disinfect objects touched by the sick 4. Wash your hands frequently 5. It is okay to mingle dishes and laundry, but wash them in very hot water 6. Wear disposable gloves 4-152

153 Everyone gets it at some point
Seasonal Influenza Occurs every year Everyone gets it at some point Most people have some immunity and can get a vaccine for more immunity Can cause severe illness and death 4-153

154 Infects wild birds and domestic poultry
Bird Flu Infects wild birds and domestic poultry Can have a high death rate Has jumped species to infect humans Concern that humans can infect one another if virus mutates 4-154

155 An outbreak of a disease in a community or a region
Epidemic An outbreak of a disease in a community or a region 4-155

156 Pandemic An outbreak that spreads beyond a community or region throughout the world 4-156

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