Blood-borne Pathogens, Tuberculosis Update, and Infection Control Timothy R. Cassity, Ph. D. Microbiologist October 9, 2007.

Blood-borne Pathogens, Tuberculosis Update, and Infection Control Timothy R. Cassity, Ph. D. Microbiologist October 9, 2007

Objectives Not to bore you – or send you to La- La Land Not to bore you – or send you to La- La Land

Objectives Not to bore you – avoid La-La Land Not to bore you – avoid La-La Land Fulfill OSHA requirements Fulfill OSHA requirements

Objectives Not to bore you – avoid La-La Land Not to bore you – avoid La-La Land Fulfill OSHA requirements Fulfill OSHA requirements Earn some CEUs Earn some CEUs

Objectives Not to bore you – avoid La-La Land Not to bore you – avoid La-La Land Fulfill OSHA requirements Fulfill OSHA requirements Earn some CEUs Earn some CEUs Learn – or be reminded of information that is hopefully useful Learn – or be reminded of information that is hopefully useful

References Most of the information for this presentation was taken from the CDC website at http://www.cdc.gov/ and included references from Morbidity and Mortality Weekly report and Emerging Infectious Diseases Most of the information for this presentation was taken from the CDC website at http://www.cdc.gov/ and included references from Morbidity and Mortality Weekly report and Emerging Infectious Diseaseshttp://www.cdc.gov/

Human Immunodeficiency Virus (HIV)

HIV - Description of the agent

This is the virus that causes AIDS This is the virus that causes AIDS

HIV - Description of the agent This is the virus that causes AIDS This is the virus that causes AIDS HIV finds and destroys CD4 T cells and destroys the immune system. HIV finds and destroys CD4 T cells and destroys the immune system.

HIV - Description of the agent This is the virus that causes AIDS This is the virus that causes AIDS HIV finds and destroys CD4 T cells and destroys the immune system. HIV finds and destroys CD4 T cells and destroys the immune system. HIV is a retrovirus. HIV is a retrovirus. These are RNA viruses, that in order to replicate must make a DNA copy of their RNA. These are RNA viruses, that in order to replicate must make a DNA copy of their RNA.

HIV - Description of the agent HIV and other retroviruses, once inside a cell, use reverse transcriptase to convert their RNA into DNA, which can be incorporated into the host cell's genes. HIV and other retroviruses, once inside a cell, use reverse transcriptase to convert their RNA into DNA, which can be incorporated into the host cell's genes.

HIV History – Where did it come from?

HIV - History Scientists identified a type of chimpanzee in West Africa as the source of HIV infection in humans. Scientists identified a type of chimpanzee in West Africa as the source of HIV infection in humans.

HIV - History AIDS was first identified in the United States in 1981 after a number of homosexual men were diagnosed with Kaposi’s sarcoma. AIDS was first identified in the United States in 1981 after a number of homosexual men were diagnosed with Kaposi’s sarcoma.

HIV - History Although HIV was first identified in 1983, studies of previously stored blood samples indicate that the virus entered the U.S. population sometime in the late 1970s Although HIV was first identified in 1983, studies of previously stored blood samples indicate that the virus entered the U.S. population sometime in the late 1970s

HIV - History During the early 1980s, as many as 150,000 people became infected with HIV each year. During the early 1980s, as many as 150,000 people became infected with HIV each year.

HIV - History By the early 1990s, this rate had dropped to about 40,000 each year. By the early 1990s, this rate had dropped to about 40,000 each year.

HIV - History AIDS cases began to fall dramatically in 1996, when new drugs became available. AIDS cases began to fall dramatically in 1996, when new drugs became available.

HIV - History CDC estimates that about 1 million people in the United States are living with HIV or AIDS CDC estimates that about 1 million people in the United States are living with HIV or AIDS

HIV - History CDC estimates that about 1 million people in the United States are living with HIV or AIDS CDC estimates that about 1 million people in the United States are living with HIV or AIDS About one quarter of these people do not know that they are infected About one quarter of these people do not know that they are infected

Easy questions?

HIV – Scope of Infection Worldwide, an estimated 38 million people were living with HIV/AIDS as of December 2003. Worldwide, an estimated 38 million people were living with HIV/AIDS as of December 2003.

HIV – Scope of Infection Through 2003, cumulative AIDS- associated deaths worldwide numbered more than 20 million. Through 2003, cumulative AIDS- associated deaths worldwide numbered more than 20 million.

HIV – Scope of Infection Globally, approximately 5 million new HIV infections and approximately 3 million AIDS-related deaths, including an estimated 490,000 children under 15 years old, occurred in the year 2003 alone. Globally, approximately 5 million new HIV infections and approximately 3 million AIDS-related deaths, including an estimated 490,000 children under 15 years old, occurred in the year 2003 alone.

HIV - Pathogenesis Untreated HIV disease is characterized by a gradual deterioration of immune function. Untreated HIV disease is characterized by a gradual deterioration of immune function.

HIV - Pathogenesis Untreated HIV disease is characterized by a gradual deterioration of immune function. Untreated HIV disease is characterized by a gradual deterioration of immune function. Most scientists think that HIV causes AIDS by directly inducing the death of CD4+ T cells or interfering with their normal function Most scientists think that HIV causes AIDS by directly inducing the death of CD4+ T cells or interfering with their normal function

HIV - Pathogenesis Infection typically begins when an HIV particle, which contains two copies of the HIV RNA, encounters a CD4+ cell with appropriate receptors. Infection typically begins when an HIV particle, which contains two copies of the HIV RNA, encounters a CD4+ cell with appropriate receptors.

HIV - Pathogenesis The envelope of the virus and the cell membrane then fuse, leading to entry of the virus into the cell. The envelope of the virus and the cell membrane then fuse, leading to entry of the virus into the cell.

HIV - Pathogenesis Cell-to-cell spread of HIV also can occur through the CD4-mediated fusion of an infected cell with an uninfected cell. Cell-to-cell spread of HIV also can occur through the CD4-mediated fusion of an infected cell with an uninfected cell.

HIV - Pathogenesis Once it enters the body, HIV infects a large number of CD4+ cells and replicates rapidly. Once it enters the body, HIV infects a large number of CD4+ cells and replicates rapidly.

HIV - Pathogenesis Once it enters the body, HIV infects a large number of CD4+ cells and replicates rapidly. Once it enters the body, HIV infects a large number of CD4+ cells and replicates rapidly. During this acute or primary phase of infection, the blood contains many viral particles that spread throughout the body, seeding various organs, particularly the lymph system. During this acute or primary phase of infection, the blood contains many viral particles that spread throughout the body, seeding various organs, particularly the lymph system.

HIV - Pathogenesis

Two to 4 weeks after exposure to the virus, up to 70 percent of HIV- infected people suffer flu-like symptoms related to the acute infection. Two to 4 weeks after exposure to the virus, up to 70 percent of HIV- infected people suffer flu-like symptoms related to the acute infection.

HIV - Pathogenesis Their immune system fights back with killer T cells (CD8+ T cells) and B-cell-produced antibodies. Their immune system fights back with killer T cells (CD8+ T cells) and B-cell-produced antibodies.

HIV - Pathogenesis Their immune system fights back with killer T cells (CD8+ T cells) and B-cell- produced antibodies. Their immune system fights back with killer T cells (CD8+ T cells) and B-cell- produced antibodies. These dramatically reduce HIV levels. These dramatically reduce HIV levels.

HIV - Pathogenesis Some HIV invariably escapes the CD8 cells and antibodies and persists. Some HIV invariably escapes the CD8 cells and antibodies and persists.

HIV - Pathogenesis Some HIV invariably escapes the CD8 cells and antibodies and persists. Some HIV invariably escapes the CD8 cells and antibodies and persists. This is due in large part to the high rate of mutations that occur during the process of HIV replication. This is due in large part to the high rate of mutations that occur during the process of HIV replication.

HIV - Pathogenesis Some HIV invariably escapes the CD8 cells and antibodies and persists. Some HIV invariably escapes the CD8 cells and antibodies and persists. The virus may hide within the chromosomes of an infected cell and be shielded from surveillance by the immune system. The virus may hide within the chromosomes of an infected cell and be shielded from surveillance by the immune system.

HIV - Pathogenesis The median time from infection with HIV to the development of AIDS- related symptoms has been approximately 10 years in the absence of antiretroviral therapy. The median time from infection with HIV to the development of AIDS- related symptoms has been approximately 10 years in the absence of antiretroviral therapy.

HIV - Pathogenesis Numerous studies show that people with high levels of HIV in their bloodstream are more likely to develop AIDS-related symptoms or die than those with lower levels of virus. Numerous studies show that people with high levels of HIV in their bloodstream are more likely to develop AIDS-related symptoms or die than those with lower levels of virus.

Preguntas?

HIV - Transmission HIV is a fragile virus. HIV is a fragile virus. It cannot live for very long outside the body. It cannot live for very long outside the body.

HIV - Transmission HIV is a fragile virus. HIV is a fragile virus. Drying of HIV-infected human blood or other body fluids reduces the theoretical risk of environmental transmission to essentially zero. Drying of HIV-infected human blood or other body fluids reduces the theoretical risk of environmental transmission to essentially zero.

HIV - Transmission You cannot get HIV by: You cannot get HIV by: Shaking hands Shaking hands

HIV - Transmission You cannot get HIV by: You cannot get HIV by: Shaking hands Shaking hands Hugging Hugging

HIV - Transmission You cannot get HIV by: You cannot get HIV by: Shaking hands Shaking hands Hugging Hugging Casual kissing (more later) Casual kissing (more later)

HIV - Transmission You cannot get HIV from: You cannot get HIV from: Toilet seats, doorknobs, or drinking fountains Toilet seats, doorknobs, or drinking fountains

HIV - Transmission You cannot get HIV from: You cannot get HIV from: Toilet seats, doorknobs, or drinking fountains Toilet seats, doorknobs, or drinking fountains Dishes, glasses, or food Dishes, glasses, or food

HIV - Transmission You cannot get HIV from: You cannot get HIV from: Toilet seats, doorknobs, or drinking fountains Toilet seats, doorknobs, or drinking fountains Dishes, glasses, or food Dishes, glasses, or food Pets or mosquitoes Pets or mosquitoes

HIV - Transmission There is no known risk of HIV transmission to co-workers, clients, or consumers from food-service establishments There is no known risk of HIV transmission to co-workers, clients, or consumers from food-service establishments

HIV - Transmission HIV has NOT been recovered from the sweat of HIV-infected persons. HIV has NOT been recovered from the sweat of HIV-infected persons.

HIV - Transmission HIV has NOT been recovered from the sweat of HIV-infected persons. HIV has NOT been recovered from the sweat of HIV-infected persons. Contact with saliva, tears, or sweat has never been shown to result in transmission of HIV. Contact with saliva, tears, or sweat has never been shown to result in transmission of HIV.

HIV - Transmission Kissing Kissing Casual contact through closed-mouth kissing is not a risk for transmission of HIV. Casual contact through closed-mouth kissing is not a risk for transmission of HIV.

HIV - Transmission Kissing Kissing Because of the potential for contact with blood during "French" or open-mouth kissing, CDC recommends against engaging in this activity with a person known to be infected with HIV. Because of the potential for contact with blood during "French" or open-mouth kissing, CDC recommends against engaging in this activity with a person known to be infected with HIV.

HIV - Transmission Kissing Kissing However, the risk of acquiring HIV during open-mouth kissing is believed to be very low. However, the risk of acquiring HIV during open-mouth kissing is believed to be very low.

HIV - Transmission Biting Biting There have been other reports in the medical literature in which HIV appeared to have been transmitted by a bite. There have been other reports in the medical literature in which HIV appeared to have been transmitted by a bite.

HIV - Transmission Biting Biting There have been other reports in the medical literature in which HIV appeared to have been transmitted by a bite. There have been other reports in the medical literature in which HIV appeared to have been transmitted by a bite. Severe trauma with extensive tissue tearing and damage and presence of blood were reported in each of these instances. Severe trauma with extensive tissue tearing and damage and presence of blood were reported in each of these instances.

HIV - Transmission Biting Biting There are numerous reports of bites that did NOT result in HIV infection. There are numerous reports of bites that did NOT result in HIV infection.

HIV - Transmission HIV is primarily found in the blood, semen, or vaginal fluid of an infected person. HIV is primarily found in the blood, semen, or vaginal fluid of an infected person.

HIV - Transmission HIV is transmitted in 3 main ways: HIV is transmitted in 3 main ways: Having sex (anal, vaginal, or oral) with someone infected with HIV. Having sex (anal, vaginal, or oral) with someone infected with HIV.

HIV - Transmission HIV is transmitted in 3 main ways: HIV is transmitted in 3 main ways: Having sex (anal, vaginal, or oral) with someone infected with HIV. Having sex (anal, vaginal, or oral) with someone infected with HIV. Sharing needles and syringes with someone infected with HIV. Sharing needles and syringes with someone infected with HIV.

HIV - Transmission HIV is transmitted in 3 main ways: HIV is transmitted in 3 main ways: Having sex (anal, vaginal, or oral) with someone infected with HIV. Having sex (anal, vaginal, or oral) with someone infected with HIV. Sharing needles and syringes with someone infected with HIV. Sharing needles and syringes with someone infected with HIV. Being exposed (fetus or infant) to HIV before or during birth or through breast feeding Being exposed (fetus or infant) to HIV before or during birth or through breast feeding

HIV – Transmission in Health Care Blood is the primary body fluid of concern. Blood is the primary body fluid of concern.

HIV – Transmission in Health Care Cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid are also considered potentially infectious. Cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid are also considered potentially infectious.

HIV – Transmission in Health Care Feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus are not considered potentially infectious unless they are visibly bloody Feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus are not considered potentially infectious unless they are visibly bloody

HIV - Transmission Health-care exposures occur through: Health-care exposures occur through: Needlesticks Needlesticks

HIV - Transmission Health-care exposures occur through: Health-care exposures occur through: Needlesticks Needlesticks Cuts from other sharp instruments contaminated with an infected patient's blood Cuts from other sharp instruments contaminated with an infected patient's blood

HIV - Transmission Health-care exposures occur through: Health-care exposures occur through: Needlesticks Needlesticks Cuts from other sharp instruments contaminated with an infected patient's blood Cuts from other sharp instruments contaminated with an infected patient's blood Contact of the eye, nose, mouth, or skin with a patient's blood. Contact of the eye, nose, mouth, or skin with a patient's blood.

HIV - Transmission Most exposures do not result in infection. Most exposures do not result in infection.

HIV - Transmission Transmission of HIV to patients while in healthcare settings is rare. Transmission of HIV to patients while in healthcare settings is rare.

HIV - Transmission The average risk for HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3%. The average risk for HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3%.

HIV - Transmission The average risk for HIV transmission after a percutaneous exposure to HIV- infected blood has been estimated to be approximately 0.3%. The average risk for HIV transmission after a percutaneous exposure to HIV- infected blood has been estimated to be approximately 0.3%. The average risk for HIV transmission after a mucous membrane exposure, approximately 0.09%. The average risk for HIV transmission after a mucous membrane exposure, approximately 0.09%.

HIV - Transmission Increased risk for HIV infection was associated with exposure to a larger quantity of blood from the source person. Increased risk for HIV infection was associated with exposure to a larger quantity of blood from the source person.

HIV - Transmission The risk also was increased for exposure to blood from source persons with terminal illness, possibly reflecting either the higher titer of HIV in blood late in the course of acquired immunodeficiency syndrome (AIDS). The risk also was increased for exposure to blood from source persons with terminal illness, possibly reflecting either the higher titer of HIV in blood late in the course of acquired immunodeficiency syndrome (AIDS).

Television Timeout?

Diagnostic Testing and HIV

HIV – Principles of Diagnosis You cannot rely on symptoms alone because many people who are infected with HIV do not have symptoms for many years. You cannot rely on symptoms alone because many people who are infected with HIV do not have symptoms for many years.

HIV – Principles of Diagnosis The only way to know whether you are infected is to be tested for HIV. The only way to know whether you are infected is to be tested for HIV.

HIV – Principles of Diagnosis The only way to know whether you are infected is to be tested for HIV. The only way to know whether you are infected is to be tested for HIV. Once HIV enters the body, the body starts to produce antibodies Once HIV enters the body, the body starts to produce antibodies

HIV – Diagnosis Start with a screen Start with a screen HIV 1/2 combined assay HIV 1/2 combined assay Sensitive but not very specific. Sensitive but not very specific.

HIV – Diagnosis If screen is positive, a confirmatory test must be performed If screen is positive, a confirmatory test must be performed Western blot Western blot Indirect immunofluorescence Indirect immunofluorescence Immunblot Immunblot

HIV – Diagnosis HIV nucleic acid (RNA) detection HIV nucleic acid (RNA) detection Reverse transcriptase DNA polymerase chain reaction [RT-PCR] Reverse transcriptase DNA polymerase chain reaction [RT-PCR] Primary use is not diagnostic, but to monitor HIV load in a known positive patient. Primary use is not diagnostic, but to monitor HIV load in a known positive patient. Useful for determining treatment regimen and clinical course. Useful for determining treatment regimen and clinical course.

HIV - Prevention A=Abstinence A=Abstinence

HIV - Prevention A=Abstinence A=Abstinence B=Be Faithful B=Be Faithful

HIV - Prevention A=Abstinence A=Abstinence B=Be Faithful B=Be Faithful C=Condoms C=Condoms

HIV - Prevention Instruments that are intended to penetrate the skin (such as tattooing and acupuncture needles, ear piercing devices) should be used once and disposed of or thoroughly cleaned and sterilized. Instruments that are intended to penetrate the skin (such as tattooing and acupuncture needles, ear piercing devices) should be used once and disposed of or thoroughly cleaned and sterilized.

HIV - Prevention Instruments that are intended to penetrate the skin (such as tattooing and acupuncture needles, ear piercing devices) should be used once and disposed of or thoroughly cleaned and sterilized. Instruments that are intended to penetrate the skin (such as tattooing and acupuncture needles, ear piercing devices) should be used once and disposed of or thoroughly cleaned and sterilized. CDC knows of no instances of HIV transmission through tattooing or body piercing, although hepatitis B virus has been transmitted during some of these practices. CDC knows of no instances of HIV transmission through tattooing or body piercing, although hepatitis B virus has been transmitted during some of these practices.

HIV - Prevention Instruments not intended to penetrate the skin but which may become contaminated with blood (for example, razors) should be used for only one client and disposed of or thoroughly cleaned and disinfected after each use. Instruments not intended to penetrate the skin but which may become contaminated with blood (for example, razors) should be used for only one client and disposed of or thoroughly cleaned and disinfected after each use.

HIV - Vaccine Many have been devised and tested. Many have been devised and tested.

HIV - Vaccine Many have been devised and tested. Many have been devised and tested. It is difficult to prepare a vaccine and test it adequately on human subjects. It is difficult to prepare a vaccine and test it adequately on human subjects.

HIV - Vaccine Many have been devised and tested. Many have been devised and tested. It is difficult to prepare a vaccine and test it adequately on human subjects. It is difficult to prepare a vaccine and test it adequately on human subjects. None have been effective to date. None have been effective to date.

HIV - Vaccine Many have been devised and tested. Many have been devised and tested. It is difficult to prepare a vaccine and test it adequately on human subjects. It is difficult to prepare a vaccine and test it adequately on human subjects. None have been effective to date. None have been effective to date. There are no promising prospects for a vaccine on the horizon. There are no promising prospects for a vaccine on the horizon.

Post-Exposure Testing Test source if possible Test source if possible If source is negative, PEP not a big issue If source is negative, PEP not a big issue

Post-Exposure Testing HIV testing should be performed on the employee immediately after exposure.

Post-Exposure Testing HIV testing should be performed on the employee immediately after exposure. HIV testing should be performed on the employee immediately after exposure. If baseline test is negative, test again at 3 months. If baseline test is negative, test again at 3 months.

Post-Exposure Testing HIV testing should be performed on the employee immediately after exposure. If 3 month test is negative, test again at 6 months. If 3 month test is negative, test again at 6 months.

Post-Exposure Testing HIV testing should be performed on the employee immediately after exposure. HIV testing should be performed on the employee immediately after exposure. If 6 month test is negative, test again at 1 year. If 6 month test is negative, test again at 1 year.

HIV – Post-Exposure Prophylaxis (PEP) If PEP is going to be administered, it should be initiated as soon as possible, preferably within hours of exposure. If PEP is going to be administered, it should be initiated as soon as possible, preferably within hours of exposure.

HIV – Post-Exposure Prophylaxis (PEP) Persons receiving PEP should complete a full 4-week regimen. Persons receiving PEP should complete a full 4-week regimen.

HIV – Post-Exposure Prophylaxis (PEP) Side effects have been reported frequently by persons taking antiretroviral agents as PEP. Side effects have been reported frequently by persons taking antiretroviral agents as PEP.

HIV – Post-Exposure Prophylaxis (PEP) Because of the complexity of selection of HIV PEP regimens, consultation with persons having expertise in antiretroviral therapy and HIV transmission is strongly recommended. Because of the complexity of selection of HIV PEP regimens, consultation with persons having expertise in antiretroviral therapy and HIV transmission is strongly recommended.  PEPline at http://www.ucsf.edu/hivcntr/Hotlines/PEPl ine; telephone 888-448-4911. http://www.ucsf.edu/hivcntr/Hotlines/PEPl ine http://www.ucsf.edu/hivcntr/Hotlines/PEPl ine

HIV – Post-Exposure Prophylaxis (PEP) If PEP is offered and taken and the source is later determined to be HIV- negative, PEP should be discontinued. If PEP is offered and taken and the source is later determined to be HIV- negative, PEP should be discontinued.

HIV – Post-Exposure Prophylaxis (PEP) Health care workers with occupational exposure to HIV should receive follow-up counseling, post- exposure testing, and medical evaluation regardless of whether they receive PEP. Health care workers with occupational exposure to HIV should receive follow-up counseling, post- exposure testing, and medical evaluation regardless of whether they receive PEP.

HIV – Post-Exposure Prophylaxis (PEP) If PEP is used, the HCW should be monitored for drug toxicity by testing at baseline and again 2 weeks after starting PEP. If PEP is used, the HCW should be monitored for drug toxicity by testing at baseline and again 2 weeks after starting PEP.

HIV – Post-Exposure Prophylaxis (PEP) If PEP is used, the HCW should be monitored for drug toxicity by testing at baseline and again 2 weeks after starting PEP. If PEP is used, the HCW should be monitored for drug toxicity by testing at baseline and again 2 weeks after starting PEP. Minimally, laboratory monitoring for toxicity should include a CBC and renal and hepatic function tests. Minimally, laboratory monitoring for toxicity should include a CBC and renal and hepatic function tests.

HIV - Treatment Potent combinations of three or more anti- HIV drugs known as highly active antiretroviral therapy, or HAART, can reduce a person's viral load to very low levels and in many cases delay the progression of HIV disease for prolonged periods. Potent combinations of three or more anti- HIV drugs known as highly active antiretroviral therapy, or HAART, can reduce a person's viral load to very low levels and in many cases delay the progression of HIV disease for prolonged periods.

HIV - Treatment Before the introduction of HAART therapy, 85 percent of patients survived an average of 3 years following AIDS diagnosis. Before the introduction of HAART therapy, 85 percent of patients survived an average of 3 years following AIDS diagnosis.

HIV - Treatment Antiretroviral regimens have delayed the clinical onset of AIDS and prolonged the lives of individuals that have AIDS. Antiretroviral regimens have delayed the clinical onset of AIDS and prolonged the lives of individuals that have AIDS.

HIV - Treatment Antiretroviral regimens, however, have yet to completely and permanently suppress the virus in HIV-infected people. Antiretroviral regimens, however, have yet to completely and permanently suppress the virus in HIV-infected people.

Laws and Ethics

HIV – Legal Issues Source: Adapted from the American Bar Association’s “Model HIV/AIDS Confidentiality Policy.” Source: Adapted from the American Bar Association’s “Model HIV/AIDS Confidentiality Policy.” Confidentiality must be strictly maintained – this means anything that could associate a person with HIV or AIDS or any other related disease must be kept confidential. Confidentiality must be strictly maintained – this means anything that could associate a person with HIV or AIDS or any other related disease must be kept confidential.

HIV – Legal Issues Source: Adapted from the American Bar Association’s “Model HIV/AIDS Confidentiality Policy.” Source: Adapted from the American Bar Association’s “Model HIV/AIDS Confidentiality Policy.” Confidentiality must be strictly maintained – this means anything that could associate a person with HIV or AIDS or any other related disease must be kept confidnetial. Confidentiality must be strictly maintained – this means anything that could associate a person with HIV or AIDS or any other related disease must be kept confidnetial. This may require the use of aliases anonymous testing. This may require the use of aliases anonymous testing.

HIV – Legal Issues Source: Adapted from the American Bar Association’s “Model HIV/AIDS Confidentiality Policy.” Source: Adapted from the American Bar Association’s “Model HIV/AIDS Confidentiality Policy.” Confidentiality must be strictly maintained – this means anything that could associate a person with HIV or AIDS or any other related disease must be kept confidnetial. Confidentiality must be strictly maintained – this means anything that could associate a person with HIV or AIDS or any other related disease must be kept confidnetial. This may require the use of aliases anonymous testing. This may require the use of aliases anonymous testing. Records must be stored securely – both paper and electronic Records must be stored securely – both paper and electronic

HIV – Legal Issues For research – aggregate, not individual data, must be used. For research – aggregate, not individual data, must be used.

HIV – Legal Issues Because it can be easy to inadvertently identify people when small numbers of cases are broken down by age, race/ethnicity, gender, or other factors, most state HIV/AIDS surveillance programs have a restriction policy on small sample size. Because it can be easy to inadvertently identify people when small numbers of cases are broken down by age, race/ethnicity, gender, or other factors, most state HIV/AIDS surveillance programs have a restriction policy on small sample size.

Hepatitis B Virus

Hepatitis B - Description of the agent Hepatitis B virus (HBV), can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death. Hepatitis B virus (HBV), can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death.

Hepatitis B - Description of the agent Humans are the only known host for HBV. Humans are the only known host for HBV.

Hepatitis B - Description of the agent Virions consist of an outer lipid envelope and an icasohedral nucleocapsid core composed of protein. Virions consist of an outer lipid envelope and an icasohedral nucleocapsid core composed of protein.

Hepatitis B - Description of the agent The nucleocapsid encloses the viral DNA and a DNA polymerase that has reverse transcriptase activity. The nucleocapsid encloses the viral DNA and a DNA polymerase that has reverse transcriptase activity.

Hepatitis B - Description of the agent The outer envelope contains embedded proteins which are involved in viral binding. The outer envelope contains embedded proteins which are involved in viral binding.

Hepatitis B - Description of the agent HBV is relatively resilient and, in some instances, has been shown to remain infectious on environmental surfaces for more than 7 days at room temperature. HBV is relatively resilient and, in some instances, has been shown to remain infectious on environmental surfaces for more than 7 days at room temperature.

Hepatitis B - History Originally called serum hepatitis. Originally called serum hepatitis.

Hepatitis B - History The first recorded cases hepatitis B are thought to be those that followed the administration of smallpox vaccine containing human lymph to shipyard workers in Germany in l883. The first recorded cases hepatitis B are thought to be those that followed the administration of smallpox vaccine containing human lymph to shipyard workers in Germany in l883.

Hepatitis B - History The role of blood as a vehicle for virus transmission was further emphasized in 1943. The role of blood as a vehicle for virus transmission was further emphasized in 1943.

Hepatitis B - History Australia antigen, later called hepatitis B surface antigen (HBsAg), was first described in 1965, and the Dane particle (complete hepatitis B virion) was identified in 1970. Australia antigen, later called hepatitis B surface antigen (HBsAg), was first described in 1965, and the Dane particle (complete hepatitis B virion) was identified in 1970.

Hepatitis B - Prevalence In 1987, the CDC estimated the total number of HBV infections in the United States to be 300,000 per year, with approximately 75,000 (25%) of infected persons developing acute hepatitis. In 1987, the CDC estimated the total number of HBV infections in the United States to be 300,000 per year, with approximately 75,000 (25%) of infected persons developing acute hepatitis.

Hepatitis B - Prevalence Of these infected individuals, 18,000- 30,000 (6%-10%) will become HBV carriers, at risk of developing chronic liver disease (chronic active hepatitis, cirrhosis, and primary liver cancer), and infectious to others. Of these infected individuals, 18,000- 30,000 (6%-10%) will become HBV carriers, at risk of developing chronic liver disease (chronic active hepatitis, cirrhosis, and primary liver cancer), and infectious to others.

Hepatitis B - Prevalence Before use of the HBV vaccine – Before use of the HBV vaccine – Approximately 12,000 health-care workers became infected with HBV each year. Approximately 12,000 health-care workers became infected with HBV each year.

Hepatitis B - Prevalence Before use of the HBV vaccine – Before use of the HBV vaccine – Approximately 12,000 health-care workers became infected with HBV each year. Approximately 12,000 health-care workers became infected with HBV each year. 500-600 of them are hospitalized as a result of HBV. 500-600 of them are hospitalized as a result of HBV.

Hepatitis B - Prevalence Before use of the HBV vaccine – Before use of the HBV vaccine – Approximately 12,000 health-care workers became infected with HBV each year. Approximately 12,000 health-care workers became infected with HBV each year. 500-600 of them are hospitalized as a result of HBV. 500-600 of them are hospitalized as a result of HBV. 700-1,200 of those infected become HBV carriers. 700-1,200 of those infected become HBV carriers.

Hepatitis B - Prevalence Before use of the HBV vaccine – Before use of the HBV vaccine – Approximately 12,000 health-care workers became infected with HBV each year. Approximately 12,000 health-care workers became infected with HBV each year. 500-600 of them are hospitalized as a result of HBV. 500-600 of them are hospitalized as a result of HBV. 700-1,200 of those infected become HBV carriers. 700-1,200 of those infected become HBV carriers. Of the infected workers, approximately 250 will die (12-15 from fulminate hepatitis, 170- 200 from cirrhosis, and 40-50 from liver cancer). Of the infected workers, approximately 250 will die (12-15 from fulminate hepatitis, 170- 200 from cirrhosis, and 40-50 from liver cancer).

Hepatitis B - Prevalence The annual number of occupational infections has decreased 95% since hepatitis B vaccine became available in 1982, from >10,000 in 1983 to 10,000 in 1983 to <400 in 2001.

Hepatitis B- Transmission Hepatitis B is not spread through: Hepatitis B is not spread through: Food or water Food or water Sharing eating utensils Sharing eating utensils Breastfeeding Breastfeeding Hugging or kissing Hugging or kissing Coughing or sneezing Coughing or sneezing Casual contact. Casual contact.

Hepatitis B- Transmission HBV is spread through HBV is spread through Having sex with an infected person without using a condom. Having sex with an infected person without using a condom.

Hepatitis B- Transmission HBV is spread through: HBV is spread through: Having sex with an infected person without using a condom. Having sex with an infected person without using a condom. The efficacy of latex condoms in preventing infection with HBV is unknown, but their proper use should reduce transmission. The efficacy of latex condoms in preventing infection with HBV is unknown, but their proper use should reduce transmission.

Hepatitis B- Transmission HBV is spread through: HBV is spread through: Having sex with an infected person without using a condom. Having sex with an infected person without using a condom. Sharing drugs, needles, or drug paraphenalia. Sharing drugs, needles, or drug paraphenalia.

Hepatitis B- Transmission HBV is spread through: HBV is spread through: Having sex with an infected person without using a condom. Having sex with an infected person without using a condom. Sharing drugs, needles, or drug paraphenalia. Sharing drugs, needles, or drug paraphenalia. Needlesticks or sharps exposures on the job. Needlesticks or sharps exposures on the job.

Hepatitis B- Transmission HBV is spread through HBV is spread through Having sex with an infected person without using a condom. Having sex with an infected person without using a condom. Sharing drugs, needles, or drug paraphenalia. Sharing drugs, needles, or drug paraphenalia. Needlesticks or sharps exposures on the job. Needlesticks or sharps exposures on the job. HBV is spread from an infected mother to her baby during birth. HBV is spread from an infected mother to her baby during birth.

Hepatitis B- Transmission For a susceptible person, the risk from a single needlestick or cut exposure to HBV-infected blood ranges from 6-30%. For a susceptible person, the risk from a single needlestick or cut exposure to HBV-infected blood ranges from 6-30%.

Hepatitis B- Transmission Healthcare personnel who have received hepatitis B vaccine and developed immunity to the virus are at virtually no risk for infection. Healthcare personnel who have received hepatitis B vaccine and developed immunity to the virus are at virtually no risk for infection.

Hepatitis B- Transmission Saliva of some persons infected with HBV has been shown to contain HBV- DNA at concentrations 1/1,000 to 1/10,000 of that found in the infected person's serum, but the potential for salivary transmission of HBV is remote. Saliva of some persons infected with HBV has been shown to contain HBV- DNA at concentrations 1/1,000 to 1/10,000 of that found in the infected person's serum, but the potential for salivary transmission of HBV is remote.

Hepatitis B - Diagnosis Frequently a person with HBV infection has no symptoms at all or doesn’t recall any Frequently a person with HBV infection has no symptoms at all or doesn’t recall any Only a blood test can tell for sure. Only a blood test can tell for sure.

Hepatitis B - Diagnosis HBsAg will be detected in an infected person’s blood on the average of 4 weeks (range 1-9 weeks) after exposure to the virus. HBsAg will be detected in an infected person’s blood on the average of 4 weeks (range 1-9 weeks) after exposure to the virus.

Hepatitis B - Diagnosis If symptoms occur, they occur on the average of 12 weeks (range 9-21 weeks) after exposure to hepatitis B virus. If symptoms occur, they occur on the average of 12 weeks (range 9-21 weeks) after exposure to hepatitis B virus. Symptoms occur in about 70% of patients, even though they may be mild and many HBV positive patients don’t recall any. Symptoms occur in about 70% of patients, even though they may be mild and many HBV positive patients don’t recall any.

Hepatitis B - Diagnosis If you have symptoms, they might include: If you have symptoms, they might include: Jaundice Jaundice Fatigue Fatigue Loss of appetite Loss of appetite Nausea Nausea Abdominal discomfort Abdominal discomfort Joint pain Joint pain

Hepatitis B - Diagnosis

Interpretation of the Hepatitis B Panel TestsResults Interpretation HBsAg anti-HBc anti-HBs negative negative negative Susceptible Susceptible HBsAg anti-HBc anti-HBs negative positive positive Immune due to natural infection Immune due to natural infection HBsAg anti-HBc anti-HBs negative negative positive Immune due to hepatitis B vaccination HBsAg anti-HBc IgM anti-HBc anti-HBs positive positive positive negative Acutely infected Acutely infected HBsAg anti-HBc IgM anti-HBc anti-HBs positive positive negative negative Chronically infected Chronically infected HBsAg anti-HBc anti-HBs negative positive negative Recovering from acute HBV infection? Slightly immune - test not sensitive enough to detect anti-HBs Susceptible with a false positive anti-HBc Undetectable level of HBsAg present and the person is actually chronically infected Hepatitis B - Diagnosis

Hepatitis B e Antigen (HBeAg): Hepatitis B e Antigen (HBeAg): A secreted product of the nucleocapsid gene of HBV and is found in serum during acute and chronic hepatitis B. Its presence indicates that the virus is replicating and the infected individual has high levels of HBV. A secreted product of the nucleocapsid gene of HBV and is found in serum during acute and chronic hepatitis B. Its presence indicates that the virus is replicating and the infected individual has high levels of HBV.

Hepatitis B - Diagnosis Hepatitis B e Antibody (HBeAb or anti-HBe): Hepatitis B e Antibody (HBeAb or anti-HBe): Produced by the immune system. Spontaneous conversion from e antigen to e antibody is a predictor of long-term clearance of HBV in patients undergoing antiviral therapy and indicates lower levels of HBV. Produced by the immune system. Spontaneous conversion from e antigen to e antibody is a predictor of long-term clearance of HBV in patients undergoing antiviral therapy and indicates lower levels of HBV.

Hepatitis B - Prevention

Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood, other body fluids to which standard precautions apply. Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood, other body fluids to which standard precautions apply.

Hepatitis B - Prevention Hands should always be washed after gloves are removed, even if the gloves appear to be intact. Hands should always be washed after gloves are removed, even if the gloves appear to be intact.

Hepatitis B - Prevention All spills of blood and blood- contaminated fluids should be promptly cleaned up using an EPA- approved germicide or a 1:10 solution of household bleach while wearing gloves. All spills of blood and blood- contaminated fluids should be promptly cleaned up using an EPA- approved germicide or a 1:10 solution of household bleach while wearing gloves.

Hepatitis B - Prevention All workers should take precautions to prevent injuries caused by needles, scalpel blades, and other sharp instruments or devices during procedures; when cleaning used instruments; during disposal of used needles; and when handling sharp instruments after procedures. All workers should take precautions to prevent injuries caused by needles, scalpel blades, and other sharp instruments or devices during procedures; when cleaning used instruments; during disposal of used needles; and when handling sharp instruments after procedures.

Hepatitis B - Prevention Infectious waste, in general, should either be incinerated or should be decontaminated before disposal in a sanitary landfill. Infectious waste, in general, should either be incinerated or should be decontaminated before disposal in a sanitary landfill.

Hepatitis B - Prevention Sharp items should be placed in puncture-proof containers and other blood-contaminated items should be placed in leak-proof plastic bags for transport to an appropriate disposal location. Sharp items should be placed in puncture-proof containers and other blood-contaminated items should be placed in leak-proof plastic bags for transport to an appropriate disposal location.

Hepatitis B - Prevention Available vaccines stimulate active immunity against HBV infection and provide over 90% protection against hepatitis B for 7 or more years following vaccination. Available vaccines stimulate active immunity against HBV infection and provide over 90% protection against hepatitis B for 7 or more years following vaccination.

Hepatitis B - Prevention In 1987, the Department of Health and Human Services and the Department of Labor stated that hepatitis B vaccine should be provided to all such workers at no charge to the worker. In 1987, the Department of Health and Human Services and the Department of Labor stated that hepatitis B vaccine should be provided to all such workers at no charge to the worker.

Hepatitis B - Prevention Hepatitis B vaccines also are 70%- 88% effective when given within 1 week after HBV exposure. Hepatitis B vaccines also are 70%- 88% effective when given within 1 week after HBV exposure.

Hepatitis B - Prevention Combination treatment with hepatitis B vaccine and HBIG is over 90% effective in preventing hepatitis B following a documented exposure. Combination treatment with hepatitis B vaccine and HBIG is over 90% effective in preventing hepatitis B following a documented exposure.

Hepatitis B - Prevention Who should receive the vaccine? Who should receive the vaccine?

Hepatitis B - Prevention Who should receive the vaccine? Who should receive the vaccine? All infants, at birth All infants, at birth

Hepatitis B - Prevention Who should receive the vaccine? Who should receive the vaccine? All babies, at birth All babies, at birth All children 0-18 years of age who have not been vaccinated All children 0-18 years of age who have not been vaccinated

Hepatitis B - Prevention Who should receive the vaccine? Who should receive the vaccine? All babies, at birth All babies, at birth All children 0-18 years of age who have not been vaccinated All children 0-18 years of age who have not been vaccinated People of any age whose behavior or job puts them at high risk for HBV infection. People of any age whose behavior or job puts them at high risk for HBV infection.

Hepatitis B - Prevention Hepatitis B vaccines have been shown to be safe when administered to both adults and children. Hepatitis B vaccines have been shown to be safe when administered to both adults and children.

Hepatitis B - Prevention Neither pregnancy nor breastfeeding should be considered a contraindication to vaccination of women. Neither pregnancy nor breastfeeding should be considered a contraindication to vaccination of women.

Hepatitis B - Prevention Persons allergic to yeast should not be vaccinated with vaccines containing yeast. Persons allergic to yeast should not be vaccinated with vaccines containing yeast.

Hepatitis B - Prevention Recent studies indicate that immunologic memory remains intact for at least 23 years and confers protection against clinical illness and chronic HBV infection. Recent studies indicate that immunologic memory remains intact for at least 23 years and confers protection against clinical illness and chronic HBV infection.

Hepatitis B - Prevention Who should get post-vaccination testing? Who should get post-vaccination testing?

Hepatitis B - Prevention Who should get post-vaccination testing? Who should get post-vaccination testing? Testing for immunity is advised only for persons whose subsequent clinical management depends on knowledge of their immune status. Testing for immunity is advised only for persons whose subsequent clinical management depends on knowledge of their immune status.

Hepatitis B - Prevention Who should get post-vaccination testing? Who should get post-vaccination testing? When indicated, post-vaccination testing, using the anti-HBs test, should be performed 1 to 2 months after completion of the vaccine series. When indicated, post-vaccination testing, using the anti-HBs test, should be performed 1 to 2 months after completion of the vaccine series.

Hepatitis B – Post-Exposure Management For an exposure to a source individual found to be positive for HBsAg, the worker who has not previously been given hepatitis B vaccine should receive For an exposure to a source individual found to be positive for HBsAg, the worker who has not previously been given hepatitis B vaccine should receive The vaccine series. The vaccine series. A single dose of hepatitis B immune globulin (HBIG), if given within 7 days of exposure. A single dose of hepatitis B immune globulin (HBIG), if given within 7 days of exposure.

Hepatitis B – Post-Exposure Management For exposures from an HBsAg- positive source to workers who have previously received vaccine: For exposures from an HBsAg- positive source to workers who have previously received vaccine: Test for antibody to hepatitis B surface antigen (anti-HBs) Test for antibody to hepatitis B surface antigen (anti-HBs) Given one dose of vaccine and one dose of HBIG if the antibody level in the worker's blood sample is inadequate. Given one dose of vaccine and one dose of HBIG if the antibody level in the worker's blood sample is inadequate.

Hepatitis B – Post-Exposure Management If the source individual is negative for HBsAg and the worker has not been vaccinated, this opportunity should be taken to provide hepatitis B vaccination. If the source individual is negative for HBsAg and the worker has not been vaccinated, this opportunity should be taken to provide hepatitis B vaccination.

Hepatitis B - Treatment There are no medications available for recently acquired (acute) HBV infection. There are no medications available for recently acquired (acute) HBV infection.

Hepatitis B - Treatment There are antiviral drugs available for the treatment of chronic HBV infection. There are antiviral drugs available for the treatment of chronic HBV infection.

Hepatitis D Hepatitis D virus requires Hepatitis B virus for replication. Hepatitis D virus requires Hepatitis B virus for replication. Hepatitis D is prevented with HBV vaccine Hepatitis D is prevented with HBV vaccine

Let’s take a short break!

Hepatitis C - Description of the agent The infection is often asymptomatic, but ensuing chronic hepatitis can result later in cirrhosis and liver cancer. The infection is often asymptomatic, but ensuing chronic hepatitis can result later in cirrhosis and liver cancer.

Hepatitis C - Description of the agent The Hepatitis C virus (HCV) is a small (50 nm in size), enveloped, single- stranded, positive sense RNA virus in the families Flaviviridae. The Hepatitis C virus (HCV) is a small (50 nm in size), enveloped, single- stranded, positive sense RNA virus in the families Flaviviridae.

Hepatitis C - Description of the agent The Flaviviridae are a family of viruses that are primarily spread through arthropod vectors. The Flaviviridae are a family of viruses that are primarily spread through arthropod vectors. West Nile Encephalitis virus West Nile Encephalitis virus Yellow fever virus Yellow fever virus St. Louis Encephalitis virus St. Louis Encephalitis virus

Hepatitis C - History In the 1970’s what is now known as hepatitis C was called non-A, non-B hepatitis (NANBH). In the 1970’s what is now known as hepatitis C was called non-A, non-B hepatitis (NANBH).

Hepatitis C - History In 1987 Michael Houghton, Qui-Lim Choo, and George Kuo at Chiron Corporation utilized molecular methods to identify the unknown organism. In 1987 Michael Houghton, Qui-Lim Choo, and George Kuo at Chiron Corporation utilized molecular methods to identify the unknown organism.

Hepatitis C - History In 1988, the virus was confirmed as a cause of non-A non-B hepatitis by Alter who verified its presence in a panel of NANBH specimens. In 1988, the virus was confirmed as a cause of non-A non-B hepatitis by Alter who verified its presence in a panel of NANBH specimens.

Hepatitis C - History April of 1989, the discovery of the virus, re-named hepatitis C virus (HCV), was published in two articles in the journal Science. April of 1989, the discovery of the virus, re-named hepatitis C virus (HCV), was published in two articles in the journal Science.

Hepatitis C - Prevalence The incidence of hepatitis C has declined steadily since peaking in the late 1980s. The incidence of hepatitis C has declined steadily since peaking in the late 1980s.

Hepatitis C - Prevalence Hepatitis C is the leading cause of liver transplants in the United States. Hepatitis C is the leading cause of liver transplants in the United States.

Hepatitis C - Prevalence Hepatitis C infects an estimated 170 million people worldwide and 4 million in the United States. Hepatitis C infects an estimated 170 million people worldwide and 4 million in the United States.

Hepatitis C - Prevalence There are about 35,000 to 185,000 new cases a year in the United States. There are about 35,000 to 185,000 new cases a year in the United States.

Hepatitis C - Prevalence Co-infection with HIV is common. Co-infection with HIV is common. Approximately 350,000 of patients in the USA infected with HIV are also infected with the hepatitis C virus. Approximately 350,000 of patients in the USA infected with HIV are also infected with the hepatitis C virus.

Hepatitis C - Prevalence There are numerous cases of Hepatitis C in southern Ohio – a higher rate per capita than other areas. There are numerous cases of Hepatitis C in southern Ohio – a higher rate per capita than other areas.

Hepatitis C - Diagnosis Acute hepatitis C refers to the first 6 months after infection with HCV. Acute hepatitis C refers to the first 6 months after infection with HCV.

Hepatitis C - Diagnosis Acute hepatitis C refers to the first 6 months after infection with HCV. Acute hepatitis C refers to the first 6 months after infection with HCV. Between 60% to 70% of people infected develop no symptoms during the acute phase. Between 60% to 70% of people infected develop no symptoms during the acute phase.

Hepatitis C - Diagnosis Acute hepatitis C refers to the first 6 months after infection with HCV. Acute hepatitis C refers to the first 6 months after infection with HCV. Between 60% to 70% of people infected develop no symptoms during the acute phase. Between 60% to 70% of people infected develop no symptoms during the acute phase. In the patients who experience acute phase symptoms, they are generally mild and nonspecific, and rarely lead to a specific diagnosis of hepatitis C. In the patients who experience acute phase symptoms, they are generally mild and nonspecific, and rarely lead to a specific diagnosis of hepatitis C.

Hepatitis C - Diagnosis The hepatitis C virus is usually detectable in the blood within one to three weeks after infection. The hepatitis C virus is usually detectable in the blood within one to three weeks after infection.

Hepatitis C - Diagnosis Approximately 20-30% of persons infected with HCV clear the virus from their bodies during the acute phase. Approximately 20-30% of persons infected with HCV clear the virus from their bodies during the acute phase.

Hepatitis C - Diagnosis Many patients positive for Hepatitis C virus should also be tested for HIV infection. Many patients positive for Hepatitis C virus should also be tested for HIV infection.

Heptatits C – Diagnosis The detection of anti-HCV antibodies in plasma or serum is based on the use of enzyme immunoassays (EIA). The detection of anti-HCV antibodies in plasma or serum is based on the use of enzyme immunoassays (EIA). Anti-HCV antibodies always persist for life in patients who develop chronic infection. Anti-HCV antibodies always persist for life in patients who develop chronic infection.

Hepatitis C - Diagnosis 70-80% of patients infected with HCV develop chronic hepatitis C, (infection lasting more than 6 months). 70-80% of patients infected with HCV develop chronic hepatitis C, (infection lasting more than 6 months).

Hepatitis C - Diagnosis 70-80% of patients infected with HCV develop chronic hepatitis C, (infection lasting more than 6 months). 70-80% of patients infected with HCV develop chronic hepatitis C, (infection lasting more than 6 months). Liver biopsy is the best test to determine the amount of scarring and inflammation. Liver biopsy is the best test to determine the amount of scarring and inflammation.

Hepatitis C - Diagnosis Anti-HCV antibodies can be detected in: Anti-HCV antibodies can be detected in: 80% of patients within 15 weeks after exposure 80% of patients within 15 weeks after exposure >90% within 5 months after exposure >90% within 5 months after exposure >97% by 6 months after exposure. >97% by 6 months after exposure.

Hepatitis C - Diagnosis Anti-HCV antibodies indicate exposure to the virus, but cannot determine if ongoing infection is present. Anti-HCV antibodies indicate exposure to the virus, but cannot determine if ongoing infection is present.

Hepatitis C - Diagnosis Anti-HCV antibodies indicate exposure to the virus, but cannot determine if ongoing infection is present. Anti-HCV antibodies indicate exposure to the virus, but cannot determine if ongoing infection is present. The presence of the virus is tested for using molecular nucleic acid testing methods (PCR, TMA, or branched DNA (b-DNA)) The presence of the virus is tested for using molecular nucleic acid testing methods (PCR, TMA, or branched DNA (b-DNA))

Hepatitis C - Diagnosis Anti-HCV antibodies indicate exposure to the virus, but cannot determine if ongoing infection is present. Anti-HCV antibodies indicate exposure to the virus, but cannot determine if ongoing infection is present. The presence of the virus is tested for using molecular nucleic acid testing methods (PCR, TMA, or branched DNA (b-DNA)) The presence of the virus is tested for using molecular nucleic acid testing methods (PCR, TMA, or branched DNA (b-DNA)) All HCV nucleic acid molecular tests have the capacity to detect not only whether the virus is present, but also to measure the amount of virus present in the blood. All HCV nucleic acid molecular tests have the capacity to detect not only whether the virus is present, but also to measure the amount of virus present in the blood.

Hepatitis C – Chronic infection Among untreated patients, roughly one-third progress to liver cirrhosis in less than 20 years. Among untreated patients, roughly one-third progress to liver cirrhosis in less than 20 years.

Hepatitis C – Chronic infection Among untreated patients, roughly one-third progress to liver cirrhosis in less than 20 years. Among untreated patients, roughly one-third progress to liver cirrhosis in less than 20 years. Another third progress to cirrhosis within 30 years. Another third progress to cirrhosis within 30 years.

Hepatitis C – Chronic infection Among untreated patients, roughly one-third progress to liver cirrhosis in less than 20 years. Among untreated patients, roughly one-third progress to liver cirrhosis in less than 20 years. Another third progress to cirrhosis within 30 years. Another third progress to cirrhosis within 30 years. The remainder of patients appear to progress so slowly that they are unlikely to develop cirrhosis within their lifetimes. The remainder of patients appear to progress so slowly that they are unlikely to develop cirrhosis within their lifetimes.

Hepatitis C - Transmission In 2005, injection-drug use continued to be the most commonly identified risk factor for infection. In 2005, injection-drug use continued to be the most commonly identified risk factor for infection.

Hepatitis C - Transmission Studies conducted to evaluate the role of sexual transmission of HCV have indicated that the virus is spread inefficiently through this route, although it does occur. Studies conducted to evaluate the role of sexual transmission of HCV have indicated that the virus is spread inefficiently through this route, although it does occur.

Hepatitis - Transmission HCV is not spread through: HCV is not spread through: Casual contact Casual contact Hugging or kissing Hugging or kissing Sharing eating or cooking utensils. Sharing eating or cooking utensils.

Hepatitis - Transmission HCV is spread by: HCV is spread by: illicit drug use illicit drug use Occupational expose to blood Occupational expose to blood Body piercing and tatoos Body piercing and tatoos Mother-to-child transmission of hepatitis C occurs relatively infrequently. Mother-to-child transmission of hepatitis C occurs relatively infrequently. Blood transfusions - rare today because blood supply is tested for HCV. Blood transfusions - rare today because blood supply is tested for HCV.

Hepatitis C - Transmission

Hepatitis C - Prevention There is no vaccination that protects against contracting Hepatitis C. There is no vaccination that protects against contracting Hepatitis C.

Hepatitis C - Prevention Avoid high risk activities and contact with blood from infected individuals. Avoid high risk activities and contact with blood from infected individuals.

Hepatitis C – Post-Exposure Determine status of source of exposure, if negative, no additional testing necessary Determine status of source of exposure, if negative, no additional testing necessary

Hepatitis C – Post-Exposure If source is positive: If source is positive: Baseline testing at time of exposure Baseline testing at time of exposure

Hepatitis C – Post-Exposure If source is positive: If source is positive: If baseline is negative, test at 3 months If baseline is negative, test at 3 months

Hepatitis C – Post-Exposure If source is positive: If source is positive: If employee was negative at 3 months, test again at 6 months. If employee was negative at 3 months, test again at 6 months.

Hepatitis C - Treatment There is a very small chance of clearing the virus spontaneously (0.5 to 0.74% per year). There is a very small chance of clearing the virus spontaneously (0.5 to 0.74% per year).

Hepatitis C - Treatment Current treatment is a combination of pegylated interferon alpha (brand names Pegasys and PEG-Intron) and ribaviron for a period of 24 or 48 weeks, depending on genotype. Current treatment is a combination of pegylated interferon alpha (brand names Pegasys and PEG-Intron) and ribaviron for a period of 24 or 48 weeks, depending on genotype.

Hepatitis C - Treatment Those with low initial viral loads respond much better to treatment than those with higher viral loads (greater than 2 million virons/ml). Those with low initial viral loads respond much better to treatment than those with higher viral loads (greater than 2 million virons/ml).

Hepatitis C - Treatment The treatment may be physically demanding, particularly those with a prior history of drug or alcohol abuse. The treatment may be physically demanding, particularly those with a prior history of drug or alcohol abuse. The drop-out rate for treatment of hepatitis C treatment is high. The drop-out rate for treatment of hepatitis C treatment is high.

Fast Break?

Infection Control

Infection Control - Standard Precautions General infection-control procedures are designed to prevent transmission of a wide range of microbiological agents and to provide a wide margin of safety in the varied situations encountered in the health-care environment. General infection-control procedures are designed to prevent transmission of a wide range of microbiological agents and to provide a wide margin of safety in the varied situations encountered in the health-care environment.

Infection Control Policies, Procedure and Documentation Most important Aspect - Common Sense Most important Aspect - Common Sense

Infection Control Policies, Procedure and Documentation Most important Aspect - Common Sense Most important Aspect - Common Sense Standard precautions Standard precautions

Infection Control Policies, Procedure and Documentation Most important Aspect - Common Sense Most important Aspect - Common Sense Standard precautions Standard precautions Specific infection control and isolation requirements fro specific infections Specific infection control and isolation requirements fro specific infections

Standard Precautions Use the appropriate barrier Use the appropriate barrier

Standard Precautions Use the appropriate barrier Use the appropriate barrier Use proper hand hygiene Use proper hand hygiene Alcohol hand sanitizer Alcohol hand sanitizer Soap and water Soap and water

Standard Precautions Use the appropriate barrier Use the appropriate barrier Use proper hand hygiene Use proper hand hygiene Alcohol hand sanitizer Alcohol hand sanitizer Soap and water Soap and water Do not eat, drink, smoke, apply cosmetics, or handle contact lenses in an area where there is a possibility of exposure to an infectious agent. Do not eat, drink, smoke, apply cosmetics, or handle contact lenses in an area where there is a possibility of exposure to an infectious agent.

Standard Precautions Use the appropriate barrier Use the appropriate barrier Use proper hand hygiene Use proper hand hygiene Alcohol hand sanitizer Alcohol hand sanitizer Soap and water Soap and water Do not eat, drink, smoke, apply cosmetics, or handle contact lenses in an area where there is a possibility of exposure to an infectious agent. Do not eat, drink, smoke, apply cosmetics, or handle contact lenses in an area where there is a possibility of exposure to an infectious agent. Careful handling of sharp objects Careful handling of sharp objects

Disinfectants What is the best overall disinfectant? What is the best overall disinfectant?

Disinfectants Sodium hypochlorite – a 1:10 dilution of household bleach with 5% sodium hypochlorite. Sodium hypochlorite – a 1:10 dilution of household bleach with 5% sodium hypochlorite. Must be made fresh daily Must be made fresh daily Dispatch – stabilized Na hypochlorite Dispatch – stabilized Na hypochlorite

Disinfectants What about Sanicloths? What about Sanicloths? Good for electrical equipment and things that bleach would deteriorate. Good for electrical equipment and things that bleach would deteriorate. Not as good of a disinfectant as bleach. Not as good of a disinfectant as bleach.

Gloves Not a replacement for handwashing Not a replacement for handwashing

Gloves Use when exposure to blood or a body fluid is anticipated. Use when exposure to blood or a body fluid is anticipated.

Gloves Not a replacement for handwashing Not a replacement for handwashing Use when exposure to blood or a body fluid is anticipated. Use when exposure to blood or a body fluid is anticipated. Only single-use gloves should be used in patient care. Only single-use gloves should be used in patient care.

Gloves Not a replacement for handwashing Not a replacement for handwashing Use when exposure to blood or a body fluid is anticipated. Use when exposure to blood or a body fluid is anticipated. Only single-use gloves should be used in patient care. Only single-use gloves should be used in patient care. Gloves used in patient care (ie. single use) should not be washed or disinfected and re-used. Gloves used in patient care (ie. single use) should not be washed or disinfected and re-used.

Disposal of Sharps Most sharps injuries are avoidable! Most sharps injuries are avoidable!

Disposal of Sharps Most sharps injuries are avoidable! Most sharps injuries are avoidable! Most people who are injured with sharps were not the persons using the sharp! Most people who are injured with sharps were not the persons using the sharp!

Disposal of Sharps Place sharps immediately into an impervious sharps container. Place sharps immediately into an impervious sharps container. Do not leave needles lying on beds or in linens or put into regular trash Do not leave needles lying on beds or in linens or put into regular trash Do not recap needles (except for some special use needles, then there should not be picked up to recap). Do not recap needles (except for some special use needles, then there should not be picked up to recap).

Disposal of Sharps Place sharp object in sharp container with needle facing down. Place sharp object in sharp container with needle facing down.

Disposal of Sharps Place sharp object in sharp container with needle facing down. Place sharp object in sharp container with needle facing down. Do not overfill a sharps container. Do not overfill a sharps container.

Disposal of Sharps Place sharp object in sharp container with needle facing down. Place sharp object in sharp container with needle facing down. Do not overfill a sharps container. Do not overfill a sharps container. When possible, sharps containers should no be accessible to patients When possible, sharps containers should no be accessible to patients

Infection Control – OSHA Requirements Employers should make protective equipment available to all workers when they are engaged in Category I or II activities. Employers should make protective equipment available to all workers when they are engaged in Category I or II activities.

Infection Control – OSHA Requirements Employers should ensure that the appropriate protective equipment is used by workers when they perform Category I activities. Employers should ensure that the appropriate protective equipment is used by workers when they perform Category I activities.

Infection Control – OSHA Requirements Employers should establish a detailed work practices program that includes standard operating procedures (SOPs) for all activities having the potential for exposure. Employers should establish a detailed work practices program that includes standard operating procedures (SOPs) for all activities having the potential for exposure.

Infection Control – OSHA Requirements Employers should monitor the workplace to ensure that required work practices are observed and that protective clothing and equipment are provided and properly used. Employers should monitor the workplace to ensure that required work practices are observed and that protective clothing and equipment are provided and properly used.

Infection Control – OSHA Requirements In addition, training records, indicating the dates of training sessions, the content of those training sessions along with the names of all persons conducting the training, and the names of all those receiving training should also be maintained. In addition, training records, indicating the dates of training sessions, the content of those training sessions along with the names of all persons conducting the training, and the names of all those receiving training should also be maintained.

Infection Control – OSHA Requirements All workers whose jobs involve participation in tasks or activities with exposure to blood or other body fluids to which universal precautions apply should be vaccinated with hepatitis B vaccine. All workers whose jobs involve participation in tasks or activities with exposure to blood or other body fluids to which universal precautions apply should be vaccinated with hepatitis B vaccine.

Tuberculosis

Tuberculosis - History In 1900 TB was the leading cause of death in the U.S. In 1900 TB was the leading cause of death in the U.S.

Tuberculosis - History Nationwide, from the late 40’s the incidence decreased until 1984. Nationwide, from the late 40’s the incidence decreased until 1984. Cases decreased such that it was thought that TB would be a historic disease by 2005. Cases decreased such that it was thought that TB would be a historic disease by 2005.

Tuberculosis - History Cases began to increase in 1985, mainly due to HIV and MDR strains. Cases began to increase in 1985, mainly due to HIV and MDR strains.

Tuberculosis - Prevalence An estimated 10-15 million Americans are infected with Mycobacterium tuberculosis An estimated 10-15 million Americans are infected with Mycobacterium tuberculosis

Tuberculosis - Prevalence About 10 percent of these infected individuals (that do not receive prophylaxis) will develop TB at some point in their lives. About 10 percent of these infected individuals (that do not receive prophylaxis) will develop TB at some point in their lives.

Tuberculosis - Prevalence Locally, we have a low rate of tuberculosis – 1-3 new cases per year. Locally, we have a low rate of tuberculosis – 1-3 new cases per year.

Tuberculosis – Latent vs. Active Two forms of the disease Two forms of the disease Latent tuberculosis - positive PPD only, no symptoms, cannot spread to others Latent tuberculosis - positive PPD only, no symptoms, cannot spread to others

Tuberculosis – Latent vs. Active Two forms of the disease Two forms of the disease Active tuberculosis – symptoms are present – can spread to others if pulmonary infection. Active tuberculosis – symptoms are present – can spread to others if pulmonary infection.

Infection via inhalation of droplets containing M. tuberculosis Bacteria are engulfed by macrophages, but not killed Initial symptoms – 1-2 weeks following infection Dissemination to other organs via lymphatics Pneumonic symptoms resolve Cellular immunity develops - PPD turns positive Dissemination ceases Immunocompetent host Most bacteria are killed by macrophages Latent disease – bacteria may remain viable for years Immunosuppressed host ACTIVE TUBERCULOSIS Immunosuppression

Tuberculosis Can be (and usually is) carried for a long time before onset of active disease. Can be (and usually is) carried for a long time before onset of active disease.

Tuberculosis Transmitted by inhaling infected droplets from a person with active pulmonary tuberculosis. Transmitted by inhaling infected droplets from a person with active pulmonary tuberculosis.

Tuberculosis With active TB, respiratory isolation and standard precautions are used to prevent spread of infection. With active TB, respiratory isolation and standard precautions are used to prevent spread of infection.

Tuberculosis - Types Causes a wide variety of infections, such as pulmonary infections, skin and sinus tract infections, renal infections, osteomyelitis, nonspecific lymphatic disease. Causes a wide variety of infections, such as pulmonary infections, skin and sinus tract infections, renal infections, osteomyelitis, nonspecific lymphatic disease.

Tuberculosis – Relationship to HIV Because HIV infection weakens the immune system, people infected with HIV and TB have a 100 times greater risk of developing active TB disease compared to people not infected with HIV. Because HIV infection weakens the immune system, people infected with HIV and TB have a 100 times greater risk of developing active TB disease compared to people not infected with HIV.

Tuberculosis – Relationship to HIV TB is the cause of death for one out of every three people with AIDS worldwide. TB is the cause of death for one out of every three people with AIDS worldwide.

Tuberculosis – Relationship to HIV The spread of the HIV epidemic has significantly impacted the TB epidemic. The spread of the HIV epidemic has significantly impacted the TB epidemic.

Tuberculosis – Relationship to HIV Individuals that are HIV positive may not test correctly with PPD. Individuals that are HIV positive may not test correctly with PPD.

Tuberculosis – Relationship to HIV Individuals that have HIV and active TB have more organisms and are a greater threat to spread the disease. Individuals that have HIV and active TB have more organisms and are a greater threat to spread the disease.

Tuberculosis – Relationship to HIV All people infected with HIV should be tested for TB, and, if infected, complete preventive therapy as soon as possible to prevent TB disease. All people infected with HIV should be tested for TB, and, if infected, complete preventive therapy as soon as possible to prevent TB disease.

Tuberculosis - MDR For active TB, treatment usually with 3-4 medications to prevent selection of resistant TB strains. For active TB, treatment usually with 3-4 medications to prevent selection of resistant TB strains. For latent TB, treatment for 6 months with INH alone, if tolerated. For latent TB, treatment for 6 months with INH alone, if tolerated.

Questions or Comment?

References Most of the information for this presentation was taken from the CDC website at http://www.cdc.gov/ and included references from Morbidity and Mortality Weekly report and Emerging Infectious Diseases Most of the information for this presentation was taken from the CDC website at http://www.cdc.gov/ and included references from Morbidity and Mortality Weekly report and Emerging Infectious Diseaseshttp://www.cdc.gov/

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Blood-borne Pathogens, Tuberculosis Update, and Infection Control Timothy R. Cassity, Ph. D. Microbiologist October 9, 2007.

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Presentation on theme: "Blood-borne Pathogens, Tuberculosis Update, and Infection Control Timothy R. Cassity, Ph. D. Microbiologist October 9, 2007."— Presentation transcript:

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Blood-borne Pathogens, Tuberculosis Update, and Infection Control Timothy R. Cassity, Ph. D. Microbiologist October 9, 2007.

Similar presentations

Presentation on theme: "Blood-borne Pathogens, Tuberculosis Update, and Infection Control Timothy R. Cassity, Ph. D. Microbiologist October 9, 2007."— Presentation transcript:

Similar presentations

About project

Feedback