1. Bloodborne Pathogens Training USC Environmental Health and Safety University of Southern California **For annual refresher training ONLY (initial training must be taken in class)

2. Outline Objective Objective Introduction to Bloodborne Pathogens Introduction to Bloodborne Pathogens Epidemiology and Symptoms Epidemiology and Symptoms Modes of transmission Modes of transmission Case Reports Case Reports Preventive methods Preventive methods Summary Summary

3. Objective To inform USC healthcare workers (HCW), students, staff and other personnel about: To inform USC healthcare workers (HCW), students, staff and other personnel about: Occupational risk, vaccination program, exposure control plan, etc. Occupational risk, vaccination program, exposure control plan, etc. Comply with OSHA Bloodborne Pathogen Standard Comply with OSHA Bloodborne Pathogen Standard 29 CFR 1910.1030 & CCR Title 8, section 5193 29 CFR 1910.1030 & CCR Title 8, section 5193 Cal-OSHA BBP Std. Guide Cal-OSHA BBP Std. GuideBBP Std. GuideBBP Std. Guide Comply with CA Medical Waste Management Act Comply with CA Medical Waste Management Act Safety Code, Sections 117600-118360 Safety Code, Sections 117600-118360

4. Bloodborne Pathogens Microorganisms that are present in human and non-human primate blood and can cause disease in human: Microorganisms that are present in human and non-human primate blood and can cause disease in human: HBV, HCV, HIV most prevalent (Herpes B, Malaria & Syphilis) HBV, HCV, HIV most prevalent (Herpes B, Malaria & Syphilis) Transmitted by blood or other bodily fluids/tissue via: Transmitted by blood or other bodily fluids/tissue via: contaminated sharps, contaminated sharps, mucosal exposure, mucosal exposure, or exposure with non-intact skin or exposure with non-intact skin Needlestick – HBV ~30% risk of transmission, HCV 1-10%, HIV ~.3% Needlestick – HBV ~30% risk of transmission, HCV 1-10%, HIV ~.3% Hepatitis B has been the most frequent laboratory-acquired viral infection, with a rate of 3.5–4.6 cases per 1000 workers. Any laboratory personnel who collects or handles tubes of blood is vulnerable Hepatitis B has been the most frequent laboratory-acquired viral infection, with a rate of 3.5–4.6 cases per 1000 workers. Any laboratory personnel who collects or handles tubes of blood is vulnerable Exposure to Blood: What Healthcare Personnel Need to Know, http://www.cdc.gov/ncidod/dhqp/pdf/bbp/Exp_to_Blood.pdf http://www.cdc.gov/ncidod/dhqp/pdf/bbp/Exp_to_Blood.pdf

5. Disease characteristics Hep B – Acute: liver inflammation, cold/flu-like symptoms and vomiting. Chronic: cirrhosis, liver cancer, death Hep B – Acute: liver inflammation, cold/flu-like symptoms and vomiting. Chronic: cirrhosis, liver cancer, death Hep C – many cases asymptomatic, mostly chronic infection, liver transplant Hep C – many cases asymptomatic, mostly chronic infection, liver transplant HIV – once immunocompromised, succumb to opportunistic infections(CMV, Pneumocystis pneumonia) HIV – once immunocompromised, succumb to opportunistic infections(CMV, Pneumocystis pneumonia)

6. Occupationally acquired HIV among healthcare personnel 1981-2006 OccupationDocumentedPossible Nurse2435 Clinical Laboratory Worker 1617 Nonsurgical Physician 612 Non-Clinical Laboratory Technician 3- Housekeeping or Maintenance 213 Dentist or Dental Worker -6 Other healthcare occupation -6 Surveillance of Occupationally Acquired HIV/AIDS in Healthcare Personnel, as of December 2006, http://www.cdc.gov/ncidod/dhqp/bp_hcp_w_hiv.html http://www.cdc.gov/ncidod/dhqp/bp_hcp_w_hiv.html

7. Needlesticks ~85% occupationally acquired HIV ~85% occupationally acquired HIV 600K-800K injuries annually 600K-800K injuries annually Half are estimated to be unreported. Half are estimated to be unreported. Most needlesticks due to poor work practices Most needlesticks due to poor work practices  Preventable Panlilio AL, et al. Infect Control Hosp Epidemiol, 2004

8. Tasks that may put you at risk Phlebotomy Phlebotomy Handling containers of blood, fluid, tissue, or cultures Handling containers of blood, fluid, tissue, or cultures Pipetting, mixing, or handling blood, fluid, tissue Pipetting, mixing, or handling blood, fluid, tissue Using finger stick device for blood testing Using finger stick device for blood testing Using capillary tube Using capillary tube Providing injections Providing injections Cleaning blood or broken contaminated glass Cleaning blood or broken contaminated glass Handling medical waste Handling medical waste Assisting diabetic patient with blood glucose monitoring Assisting diabetic patient with blood glucose monitoring Performing first aid or CPR Performing first aid or CPR Finding improperly discarded needle Finding improperly discarded needle An introduction to Bloodborne Pathogens in the Pharmacy, https://webapp.walgreens.com/cePharmacy/viewpdf?fileName=blood_borne_pathogens.pdf https://webapp.walgreens.com/cePharmacy/viewpdf?fileName=blood_borne_pathogens.pdf

9. Case Report

10. Controlling Risk Risk Assessment Risk Assessment Universal precautions Universal precautions Engineering controls, work practice controls, personal protective equipment Engineering controls, work practice controls, personal protective equipment Proper Waste Disposal Proper Waste Disposal Disinfection Disinfection

11. Risk Assessment Process What is Risk? What is Risk? A measure of the likelihood that a loss will occur (probability) and its potential seriousness (severity) A measure of the likelihood that a loss will occur (probability) and its potential seriousness (severity) Risk Assessment Process (I.A.M) Risk Assessment Process (I.A.M) I dentify the hazards I dentify the hazards A ssess the potential impact of the hazards A ssess the potential impact of the hazards M anage the potential impact of the hazards through risk reduction strategies: M anage the potential impact of the hazards through risk reduction strategies: (Engineering, Administrative, PPE) (Engineering, Administrative, PPE)

12. Engineering controls Biosafety Cabinet (BSC) Biosafety Cabinet (BSC) Safety-engineered sharps must be used, such as self-retracting needle, hinged cap needle Safety-engineered sharps must be used, such as self-retracting needle, hinged cap needle Proven to reduce number of needlestick injuries Proven to reduce number of needlestick injuries Plastic capillary tubes/ aspirating pipettes Plastic capillary tubes/ aspirating pipettes

13. Biosafety Cabinets (Engineering Controls) BSC work practices: 1.Disinfect working area with appropriate disinfectant and contact time. 2.Do not block front or back grilles 3.Divide BSC’s working area into: clean, working and dirty areas. 4.Work from clean to dirty area 5.Have only items needed for procedures *Do not overcrowd BSC 6.Minimize rapid movements inside BSC: *Move arms in and out slowly (minimize sweeping motion) 7.Disinfect thoroughly at the end of experiment. * UV light is not recommended

14. Potential Risk of Using Glass Pasteur Pipettes

15. Work practice controls No recapping of needles No recapping of needles Place sharps container as close to you as possible, don’t exceed fill line Place sharps container as close to you as possible, don’t exceed fill line Immediately dispose of medical waste Immediately dispose of medical waste When using sharps, focus on task at hand When using sharps, focus on task at hand Practice before using device on patients Practice before using device on patients Practice good hand hygiene (soap and water, alcohol based hand sanitizer) Practice good hand hygiene (soap and water, alcohol based hand sanitizer)

16. Hand Hygiene Frequently missed areas

17. Personal Protective Equipment Gloves for any vascular access(latex alternatives), remove carefully to minimize contamination of hands, wash hands afterwards Gloves for any vascular access(latex alternatives), remove carefully to minimize contamination of hands, wash hands afterwards Lab coat/scrubs Lab coat/scrubs Eye and face protection Eye and face protection when splash potential Closed-toe shoes Closed-toe shoes

18. Hepatitis B core antigen Hepatitis B surface antigen Hepatitis C virus HIV 1 & 2 A, B, O and Rh Working with commercial blood bank samples? Samples are tested for Samples are NOT tested for Eastern Equine encephalitis virus (EEEV) St. Louis encephalitis virus (SLEV) West Nile Virus (WNV) Brucellosis Others

19. Hazardous Waste Disposal - Biomed PATHOLOGICAL PHARMACEUTICAL SOLID SHARPS Chemotherapy

21. Decontamination of Biohazardous Liquid Waste Decontaminate tissue and media with 10% bleach solution with a 30 minute contact time Decontaminate tissue and media with 10% bleach solution with a 30 minute contact time Flasks must be emptied and surfaces must be decontaminated at the end of a shift Flasks must be emptied and surfaces must be decontaminated at the end of a shift

22. Disinfection 1-10% household bleach 1-10% household bleach Make 10% solution weekly for effectiveness Make 10% solution weekly for effectiveness 70% Ethanol 70% Ethanol Not suitable for non-enveloped viruses Not suitable for non-enveloped viruses Sani-wipes Sani-wipes Must be EPA approved Must be EPA approved

23. Labeling Place International biohazard symbol on: Place International biohazard symbol on: Biohazardous waste Biohazardous waste Door signs Door signs Incubators Incubators Freezers Freezers Refrigerators Refrigerators Shipping boxes Shipping boxes Any equipment use for biological samples Any equipment use for biological samples

24. Handling, storage, transport procedures Specimens must be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping (use secondary container), container must be labeled with biohazard symbol Specimens must be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping (use secondary container), container must be labeled with biohazard symbol

25. Hep B Vaccination Recombinant vaccine Recombinant vaccine Anti-cancer Anti-cancer Anaphylaxis rare Anaphylaxis rare Contact EH&S for more information and forms: 323-442-2200 or IBC@admin.usc.eduIBC@admin.usc.edu **In-class training required to obtained vaccination form

26. Handling Exposures Wash affected area with soap and water, if mucosal exposure, rinse with water/saline Wash affected area with soap and water, if mucosal exposure, rinse with water/saline Report immediately and seek medical evaluation (Internal Medicine, White Memorial after-hours) Report immediately and seek medical evaluation (Internal Medicine, White Memorial after-hours) Counseling, baseline testing, test source if possible, possibly initiate PEP, schedule follow-up testing various timepoints up to 1 year Counseling, baseline testing, test source if possible, possibly initiate PEP, schedule follow-up testing various timepoints up to 1 year

27. Post exposure prophylaxis HBV: HBIG + vaccine if unvaccinated HBV: HBIG + vaccine if unvaccinated HIV: Standard Antiretroviral Therapy (ART) HIV: Standard Antiretroviral Therapy (ART) antiretrovirals, 2 or 3 drug expanded regimen depending on type of exposure (percutaneous vs. mucosal), status of the source, bodily fluid antiretrovirals, 2 or 3 drug expanded regimen depending on type of exposure (percutaneous vs. mucosal), status of the source, bodily fluid HCV: Rivavirin & pegylated-interferon alpha-2b. HCV: Rivavirin & pegylated-interferon alpha-2b.

28. In summary Practice safe techniques Use safety-engineered sharps Use safety-engineered sharps Dispose of needles into sharps containers Dispose of needles into sharps containers Don’t recap needles Don’t recap needles Wear gloves, lab coat/scrubs, closed-toe shoes Wear gloves, lab coat/scrubs, closed-toe shoes Good hand hygiene Good hand hygiene Follow post-exposure procedures Follow post-exposure procedures

29. Exposure control plan Cal-OSHA BBP & Exposure Control Plan info: http://www.dir.ca.gov/dosh/dosh_publications/bbpbest1.pdf

30. Internal Medicine (HCC II) and White Memorial Hospital

31. References Cal OSHA Bloodborne Pathogen Standard, http://www.dir.ca.gov/title8/5193.HTML http://www.dir.ca.gov/title8/5193.HTML Surveillance of Occupationally Acquired HIV/AIDS in Healthcare Personnel, as of December 2006, http://www.cdc.gov/ncidod/dhqp/bp_hcp_w_hiv.html http://www.cdc.gov/ncidod/dhqp/bp_hcp_w_hiv.html Panlilio AL, et al. Infect Control Hosp Epidemiol, 2004 Exposure to Blood: What Healthcare Personnel Need to Know, http://www.cdc.gov/ncidod/dhqp/pdf/bbp/Exp_to_Blood.pdf http://www.cdc.gov/ncidod/dhqp/pdf/bbp/Exp_to_Blood.pdf An introduction to Bloodborne Pathogens in the Pharmacy, https://webapp.walgreens.com/cePharmacy/viewpdf?fileName=blood_borne_pathogens.pdf https://webapp.walgreens.com/cePharmacy/viewpdf?fileName=blood_borne_pathogens.pdf Aoun, H.: When a house officer gets AIDS. N Eng J Med 321(10):693-696, 1989. FDA Safety Alert: Hepatitis B Transmission via Spring-loaded Lancet Devices http://www.fda.gov/downloads/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm063124.pdf NIOSH Alert: Preventing Needlestick Injuries in Health Care Settings, 1999