1. 2012 UF Bloodborne Pathogen Training
Biological Safety Office
Environmental Health & Safety

2. BBP Standard
1990: Occupational Safety & Health Administration (OSHA) estimates >200 deaths & 9000 infections/year from occupational BBP exposure
BBP standard implemented in 1991 to protect workers from occupational exposure
29 CFR able=STANDARDS&p_id=10051
Revised in 2001 – safe sharps devices, maintain a log of injuries from contaminated sharps
1990 – OSHA estimated more than 200 deaths and 9000 infections/year from occupational BBP exposure. BBP standard issued to protect workers from occupational exposure.
CDC 2004 – estimated 385,000 needlestick and sharps injuries each year to health care workers in hospital settings, more than 1000/day!

3. BBP Training Requirement
UF follows OSHA requirement
ALL employees, staff, students, volunteers, affiliates with potential exposure to BBP from human blood/OPIM
General and workplace-specific training
Completed BEFORE individual is assigned to tasks with the potential for BBP exposure and ANNUALLY thereafter
In addition to training, individuals with potential exposure must also have:
Access to the regulatory text and an explanation of its contents
Access to a copy of the UF Exposure Control Plan
Access to site-specific Standard Operating Procedures (SOPs)
Exposure control plan and SOPs are site-specific and detail equipment, practices & PPE used at your site. Update annually or as needed. Should be available in the lab and all members should have reviewed the documents.

4. Bloodborne Pathogens (BBPs)
Pathogenic microorganisms present in blood and other potentially infectious material (OPIM) that are able to cause disease in humans
Hepatitis B virus (HBV, HepB)
Hepatitis C virus (HCV, HepC)
Human immunodeficiency virus (HIV)
Less commonly, human T-lymphotropic virus (HTLV-1), Epstein-Barr virus (EBV), malaria, brucellosis, rabies, leptospirosis, babesiosis, syphilis, Creutzfeld-Jakob disease, arboviral infections (WNV, EEE), etc.
The “big 3” account for most cases of occupationally acquired blood-borne infection

5. NO (unless visibly contaminated with blood)
What constitutes OPIM?
YES
NO (unless visibly contaminated with blood)
Cerebrospinal fluid
Tears
Synovial fluid
Feces
Peritoneal fluid
Urine
Pericardial fluid
Saliva
Pleural fluid
Nasal secretions
Semen/Vaginal secretions
Sputum
Breast milk
Sweat
Amniotic fluid
Vomit
Saliva from dental procedures
Unfixed human tissue or organs (other than intact skin)
Cell or tissue cultures that may contain BBP agents
Blood/tissues from animals infected with BBP agents

6. Research using human cell lines…
Cell lines may be infected or become infected/contaminated in subsequent handling/passaging
ATCC started testing newly manufactured/deposited cell lines for common viral pathogens (HIV, HepB, HepC, HPV, EBV, and CMV) in January 2010
Many infectious agents yet to be discovered and for which there is no test
Remember HIV?
Use Universal Precautions for all human cell lines
HIV detected in a plasma sample dating back to 1959 – not officially identified until early 80’s
Lymphocytic choriomeningitis virus in cell lines

7. HIV/Hepatitis Research Labs
More stringent control measures
Work must be registered with EH&S Biosafety Office (rDNA or BA registration – forms online at Forms.htm)
Enrollment in medical surveillance program
Follow CDC/NIH BSL-2 containment practices at a minimum

8. How are BBPs commonly transmitted in the workplace?
Cuts or punctures with contaminated sharp objects (needles, glass, scalpels, etc)
Splashes to mucous membranes (eyes, nose, mouth)
Contamination of broken/non-intact skin

9. “UNIVERSAL PRECAUTIONS” Cornerstone of exposure prevention
All human blood or OPIM is treated as infectious
Standard precautions = universal precautions + body substance isolation. Applies to blood & all other body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes

10. Hepatitis B (HepB, HBV)
Spread through direct contact with infected blood or OPIM; times more infectious than HIV
Infection may be acute or chronic
5-10 % of infected adults will develop chronic infection; ~1.2 million people with chronic HBV
15-25% develop cirrhosis, liver failure, or liver cancer (~ deaths/year)
Symptoms of acute infection can appear 6 wks - 6 mos after exposure & include:
Younger age when infected increases risk of chronic infection > 90% of infants, 25-50% in 1-5 years, 5-10% older children and adults
~70% of adults will develop symptoms after acute infection
Many people have no symptoms but can still spread the virus
Fever
Abdominal pain
Fatigue
Loss of appetite
Nausea
Vomiting
Jaundice
Joint pain
Dark urine

11. Occupational HepB Exposures
Needlestick/sharp injury from HepB contaminated source
~30% of these exposures results in infection
Mucosal exposure to blood/body fluids
Exposure to nonintact skin from contaminated surfaces and equipment
HBV can remain infective in dried blood at RT for at least 1 week (MacCannell et al., Clin Liver Dis 2010; 14:23-36)
What besides Universal Precautions & appropriate cleaning & disinfection can be used to prevent HepB infection….. ?

12. HepB Vaccine Safe Effective
Given to newborns, 120 million people in U.S. have received at least one dose
Effective
>95% develop immunity after full series (3 doses given at 0, 1, 6 mos)
In Gainesville, free to UF employees @SHCC ( )
Bring completed Acceptance/Declination statement
If you decline, can change mind at any time
Became available in Routine childhood vaccination started in Incidence of acute HepB among children and adolescents dropped by more than 95% and by 75% in all age groups.
Inverse correlation with age and risk of chronic infection - 90% of infants, 25-50% in 1-5 years, 6-10% older children and adults
Alternative schedules available: 0, 1, and 4 mos or 0,2, and 4 mos

13. Postvaccination testing
Health-care workers or public safety workers at high risk for continued percutaneous or mucosal exposure to blood or body fluids, HBV research lab workers
Performed 1-2 months after dose #3
HepB surface antibody (anti-HBs) ≥ 10 mIU/mL - immune
Anti-HBs < 10 mIU/mL – revaccinate (3 doses) and retest anti-HBs
Still negative – nonresponder, need HBIG after exposure
Previously vaccinated but not tested? Test for anti-HBs after an exposure; if negative, treat as susceptible.

14. Hepatitis C (HepC, HCV)
Transmitted primarily through contact with infected blood
~3.2 million Americans chronically infected; many do not know they are infected b/c they are asymptomatic (if symptoms do occur, similar to HepB)
~ 12,000 deaths/year
Leading indication for liver transplant in U.S.

15. Occupational HepC Exposures
Percutaneous injury, esp. with deep punctures or extensive blood exposures
~2% develop infection
Mucosal/nonintact skin exposures rarely documented
Proper cleaning/disinfection of surfaces important
HCV in dried blood samples remains infective for at least 16 hours (Kamili et al., Infect Control Hosp Epidemiol 2007; 28: )
Universal Precautions for Prevention!
NO VACCINE
Antivirals (peginterferon/ribavirin) can have serious side effects, treatment lasts weeks
New HCV protease inhibitors – boceprevir & telaprevir (approved 5/11). Given in combination with traditional therapy, many side effects, drug resistance, only effective for genotype 1
Side effects – fatigue, fever, nausea, diarrhea, insomnia, irritability, depression…
Interferon – injected
NS3/4A serine protease req’d for RNA replication and virion assembly

16. HIV Transmitted through contact with infected blood/OPIM
Attacks & destroys CD4+ T cells
Can be asymptomatic for many years
AIDS - occurrence of opportunistic infections or HIV-related cancers & a decline in CD4+ T cell (<200/µl blood)
50 cases of HIV reported in Alachua county in 2010
1° infection - transient, non-specific illness (fever, malaise, muscle pain, sore throat)
Symptomatic phase - ↑ susceptibility to opportunistic infections, nonspecific constitutional symptoms (night sweats, weight loss, anorexia, fever)
1.2 million Americans living with HIV
135,000 (11%) in FL (ranks 3rd among states in # of reported infections)
20% don’t know they are infected
~50,000 new infections/year

17. Occupational HIV Exposures
Risk for HIV transmission after:
Percutaneous injury – 0.3%
Mucous membrane exposure – 0.09%
Nonintact skin exposure – low risk (< 0.09%)
Lab workers includes both clinical (16; 28%) and non-clinical (3; 5%)
Other: embalmer/morgue attendant, health aide/attendant, respiratory therapist, dialysis technician
48 percutaneous, 5 mucocutaneous, 2 both percutaneous/mucocutaneous, 2 unknown
Documented-seroconversion after occupational exposure
Possible-no identifiable behavioral/transfusion risks and history of occupational exposures but seroconversion specifically resulting from occupational exposure not documented
57 documented occupational
infections in U.S. (139 possible infections)
84% resulted from percutaneous exposure!

18. If HIV is such low risk, why worry?
No cure
No vaccine
Antiretroviral therapy – cocktail of 3 or more drugs, costly, side effects, drug resistance
Always use Universal Precautions!

19. Comparing the risks…
Risks of becoming infected after a needle stick injury:
30% 2%
0.3%
*If unvaccinated*

20. UF Exposures ( )
Number of exposures
Residents – 93/150 (62%)

21. Sharps Exposures by Department (UF)
All others includes 1 exposure each in the following departments:
ACS
EH&S
Nursing
Pharmacy
Psychiatry
Rec Sports
3 departments accounted for 52% of the exposures.

22. Sharps Exposures by Department (UFHSCJ)
All others includes 1 exposure each in the following departments:
Cardiology
CMFM IM
Neurology
UFHSCJ accounted for 27% of all exposures

23. Controls to Protect Against BBP Exposures

24. Know and use prudent practices, protective devices and PPE needed to minimize risk
Engineering Controls
- Safety needles, sharps containers, BSC’s
Work Practices
- Waste disposal, spill cleanup
Administrative Controls
- Training, vaccinations
Personal Protective Equipment
- Gloves, lab coat, eye protection

25. Engineering Controls Sharps container Biosafety cabinet
Cleanable work surfaces/chairs
Leak-proof transport containers
Safety needles/syringes

26. List of safety sharps devices available can be found at:
Requirement for employers to identify, evaluate, and implement safer medical devices (2001 BBP revision) – lots of choices!
List of safety sharps devices available can be found at:

27. Safe Work Practices Know what they are and follow them!
Minimize splashes/aerosols
Safe handling of sharps
Proper hand washing
Decontaminate work surfaces daily and after spills
Know how to handle spills (covered in BMW training)
Proper disposal of contaminated items
No eating, drinking, smoking, handling contacts or applying cosmetics in areas where blood/OPIM is handled or stored
Many injuries attributed to improper work practices

28. Hand washing is critical!
Hand transmission important route of infection
Hands easily contaminated during lab procedures
Usually no barrier between hands and face
Hand-to-face contact common → times/half hour (Collins & Kennedy, 1999)
Wash hands frequently & thoroughly
After handling infectious/potentially infectious materials
After removing gloves
Before leaving the lab
If no sink nearby, use hand sanitizer and then wash with soap and water ASAP
Pay attention to frequently missed
areas – fingertips, between fingers,
under jewelry

29. DO NOT RECAP NEEDLES Don’t bend, break, or detach from syringe
Discard needles directly into sharps container
Do not overfill the sharps box – close and replace when ¾ full
Never attempt to re-open a closed sharps box

30. Circumstances Associated with Hollow-Bore Needle Injuries
NaSH June 1995—December 2003 (n=10,239)
35% disposal
related
Why do people recap needles? 614 injuries due to recapping in this study
NaSH – National Surveillance System for Health Care Workers

31. Decontamination/Disinfection
FRESHLY DILUTED (w/in 24 hrs) 1:10 solution of household bleach
EPA listed tuberculocidal disinfectant
Clorox, amphyl, lysol, sporicidin
Ethanol evaporates too quickly to be an effective disinfectant!

32. Personal Protective Equipment (PPE)
Must be supplied by the employer
Wear it WHEN and WHERE you are supposed to
Do not wear in common areas (offices, hallways, bathrooms, cafeterias, etc) or when handling common-use items (doorknobs, elevator buttons, telephones)
It must fit, be suitable to the task (use common sense), and be cleaned or disposed of properly (this does not mean taking it home to wash!)
Gloves
Latex or nitrile – vinyl does not hold up well!
Face and Eye Protection
Surgical mask, goggles, glasses w/side shield, face shield
Body
Gowns, aprons, lab coats, shoe covers
Must be supplied by employer.
Wear gloves for anticipated hand contact w/blood or OPIM; eye/face protection for splashes, sprays, spatters, droplets
Absolutely no open toed
shoes in the lab!

33. Labeling BBP standard requires that warning labels are placed on:
Containers of regulated waste
Refrigerators & freezers containing blood or OPIM
Containers used to store, transport, or ship blood or OPIM
Use red bags for waste containers

34. If you have an exposure:
Wash wound with soap & water for 5 minutes; flush mucous membranes for 15 minutes
Seek immediate medical attention (1-2 hrs max)
In Gainesville, call (Needle Stick Hotline)
In Jacksonville, 7am-4pm, go to Employee Health Suite 505 in Tower 1; Other hours, go to ER
Other areas, go to the nearest medical facility
Notify supervisor
Contact UF Worker’s Compensation Office,
Allow medical to follow-up with appropriate testing & required written opinion

35. Factors considered in assessing need for PEP
Type of exposure
Type/amount of fluid/tissue
Infectious status of source
Susceptibility of exposed person
Percutaneous injury (depth, extent, device)
Blood
Presence of HepB surface antigen (HBsAg) and HepB e antigen (HBeAg)
HepB vaccine and vaccine response status
Mucous membrane exposure
Fluids containing blood
Presence of HepC antibody
Immune status
Non-intact skin exposure
Presence of HIV antibody
Bites resulting in blood exposure to either person
CDC PEP Guidelines:

36. This completes the PowerPoint segment of the Bloodborne PathogenTraining
Please exit the session and click on the link for Tests & Quizzes on the left hand side of the screen. You must take the quiz & score at least 75% to fulfill the training requirement.