CHAPTER © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 34 HIV, Hepatitis, and Other Blood-Borne Pathogens

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Learning Outcomes 34.1Describe ways in which blood-borne pathogens can be transmitted. 34.2Explain why strict adherence to Universal Precautions is essential in preventing the spread of infection Describe the symptoms of hepatitis and AIDS. 34.4List and describe the blood tests used to diagnose HIV infection.

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Learning Outcomes (cont.) 34.5Identify chronic disorders often found in patients who have AIDS. 34.6Compare and contrast drugs used to treat AIDS/HIV infection. 34.7Describe the symptoms of infection by other common blood-borne pathogens.

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Learning Outcomes (cont.) 34.8Describe the steps involved in reporting a communicable disease. 34.9Explain how to educate patients about minimizing the risks of transmitting blood- borne infections to others Describe special issues you may encounter when dealing with patients who have terminal illnesses.

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Introduction Chapter 34 expands on OSHA Blood- Borne Pathogen Standard –How to reduce your risk of exposure HIV, hepatitis, and other blood-borne infections –Reporting guidelines –Educating patients Issues associated with terminal illnesses such as AIDS

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Transmission of Blood-Borne Pathogens Blood-borne pathogens are disease- causing microorganisms carried in the host’s blood. Transmission occurs from one host to another through contact with infected –Blood –Tissue –Body fluids –Mucous membranes

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Transmission (cont.) –Cerebrospinal fluid –Synovial fluid –Pleural fluid –Peritoneal fluid –Pericardial fluid –Amniotic fluid Identified by the Centers for Disease Control and Prevention (CDC)  Transmission agents for blood-borne diseases Blood Blood products Human tissue Semen Vaginal secretions Saliva from dental procedures

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Transmission (cont.) Transmission agent only if there is visible blood –Feces –Nasal secretions –Perspiration –Sputum –Tears –Urine –Vomitus –Saliva

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Transmission (cont.) Blood-borne pathogens may be introduced into a new host by –Needlesticks –Cuts or abrasions –Any body opening –Transfusion of infected blood

© 2011 The McGraw-Hill Companies, Inc. All rights reserved People at Increased Risk Anyone who comes in contact with substances that may harbor the pathogens –Health-care professionals –Law enforcement officers –Mortuary or morgue attendants –Firefighters –Medical equipment service technicians –Barbers and cosmetologists

© 2011 The McGraw-Hill Companies, Inc. All rights reserved People at Increased Risk (cont.) Pathogens –Hepatitis B virus (HBV) –Hepatitis C virus (HCV) –HIV  AIDS

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Research Incidence of many infectious diseases –Reported to state health departments Information then sent to CDC –Trends in spread –Identify control tactics –Allocate resources

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Apply Your Knowledge ANSWER: Transmission occurs from one host to another through contact with infected blood, tissue, body fluids, and mucous membranes. How are blood-borne pathogens transmitted from host to host? Good Answer !

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Universal Precautions The most effective means of preventing the spread of HIV, hepatitis, and other blood-borne pathogens is to avoid contamination Universal Precautions are required by OSHA

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Universal Precautions For medical offices, includes all –Body fluids –Secretions –Excretions –Moist body surfaces Assume every patient is contaminated

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Apply Your Knowledge ANSWER: In medical offices, Universal Precautions apply to body fluids, secretions, excretions, and moist body surfaces. Assume every patient is contaminated and use Universal Precautions with everyone. In a medical office, to what items do Universal Precautions apply, and with which patients should you practice these precautions? Right!

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Disease Profiles Keep up-to-date so you can –Identify symptoms that may indicate that a patient has a blood-borne disease –Identify habits of your patients that increase risk of spreading the disease –Educate patients to limit risks of contracting disease

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Hepatitis Viral infection of the liver that can lead to cirrhosis and death –Hepatitis A – spread by fecal-oral route –Hepatitis B – blood-borne disease that spreads by contact with contaminated blood or body fluids or sexual contact

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Hepatitis (cont.) –Hepatitis C (non-A/non-B) Spread through contact with contaminated blood or body fluids and sexual contact No cure Many people are carriers Flu-like symptoms, if any Damages liver; causing cirrhosis, liver failure, and cancer

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Hepatitis (cont.) –Hepatitis D (delta agent hepatitis) Occurs only in people that are infected with HBV May mimic symptoms of hepatitis B, but more severe Associated with liver cancer –Hepatitis E Caused by hepatitis E virus (HEV) Transmitted by fecal – oral route

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Hepatitis (cont.) Risk factors – same for HBV and HCV –Occupation that requires exposure to blood and body fluids –High-risk sexual activity –IV drug use –Hemophilia –Travel to areas with high incidence –Blood transfusions prior to screen –Hemodialysis –Living with partner with hepatitis B or hepatitis C –Multiple sexual partners

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Hepatitis (cont.) Risk in medical community –HIV Approximately 0.5% from a single needlestick –Hepatitis B 6% to 33% from single needlestick The primary risk factor for HBV and HCV infection is occupational exposure to the virus.

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Hepatitis (cont.) Infection progression –Acute illness lasts about 16 weeks –Prodromal stage – general malaise, maybe nausea or vomiting, or no symptoms –Icteric, or jaundice, stage – yellowing of the skin, eyes, and mucous membranes Appears 5 – 10 days after initial infection –Convalescent (after acute stages) – can last 2 to 3 weeks

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Hepatitis (cont.) Symptoms –Jaundice –Decreased appetite –Fatigue –Nausea and vomiting –Joint pain/tenderness –Stomach pain –General malaise Diagnosis –Investigation of Risk factors Exposure incidents –Blood tests Antigen-antibody systems Determine stage of disease

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Hepatitis (cont.) Preventive measures –Avoid contact with contaminated substances –Use Universal Precautions with all patients –Vaccination is available to prevent HBV infections Will not protect you from other strains of hepatitis CDC recommends routine vaccination for everyone –HBIG for postexposure inoculation

© 2011 The McGraw-Hill Companies, Inc. All rights reserved AIDS/HIV Infection Virus that infects and destroys components of the immune system HIV infection develops into AIDS Pathogen destroys –Helper T cells – white blood cells that are a key component of immune system –Neurons, causing demyelination Patients develop opportunistic infections

© 2011 The McGraw-Hill Companies, Inc. All rights reserved AIDS/HIV Infection (cont.) Risk factors –Unprotected sexual activity –Sharing needles used by IV drug users –Passes from mother to fetus during pregnancy or to infant during delivery or breastfeeding Incubation period of 8 to 15 years

© 2011 The McGraw-Hill Companies, Inc. All rights reserved AIDS/HIV Infection (cont.) Risk in medical community –Percutaneous exposure – exposure through a puncture wound or needlestick –Mucocutaneous exposure – exposure through a mucous membrane

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Progression of AIDS/HIV T hree main stages Initial infection –Can occur years before symptoms appear –Virus enters cell and makes copies –Helper T cells die –Immune system responds Cleans the blood supply of the virus Virus enters an inactive phase

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Progression of AIDS/HIV (cont.) Incubation period –Virus genetic material incorporated into the genetic material of the helper T cells –HIV becomes active again and continues to attack and kill helper T cells –Virus trapped in lymph system –As helper T cells decrease, patients are more prone to opportunistic infections –Incubation period can be 8 to 15 years

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Progression of AIDS/HIV (cont.) Full-blown AIDS –200 or fewer helper T cells/mL blood indicates full-blown AIDS –Opportunistic infections and neurological deterioration

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Diagnosis of AIDS/HIV Enzyme-linked immunosorbent assay (ELISA) –Confirms presence of antibodies in response to HIV –85% accurate – cross-reactivity with other viruses Western Blot Test or immunofluorescent antibody (IFA) –Confirms positive ELISA test –Specific to individual viruses Accurate diagnosis – ELISA plus one of the other two Home tests available – may give false results

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Symptoms of AIDS/HIV Systemic Respiratory Oral – hairy leukoplakia Gastrointestinal Peripheral nervous system Skin-related Kaposi’s sarcoma

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Prevention of AIDS/HIV Sexual contact –Use protection –Avoid multiple partners –Use condoms correctly IV drug users –Avoid sharing or reusing needles Medical procedures –Universal Precautions –Wash hands Education –Dangers of HIV/AIDS –How HIV/AIDS is spread and not spread –Preventive measures

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Apply Your Knowledge Which statements are true and which are false? ____ Risk factors are the same for HBV and HCV. ___ Hepatitis A is spread via contaminated blood or body fluids. ____ Helper T cells are red blood cells and are a key component of immune system. ____ Percutaneous exposure occurs through a puncture wound or needlestick. ANSWER: F T T F Hepatitis A is spread by the fecal-oral route. Helper T cells are white blood cells. Right!

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Patient Profile No one is immune to AIDS 2005: 40.3 million men, women, and children were HIV-infected worldwide. People infected –Homosexual males (rate decreasing) –Young people in large metropolitan areas –IV drug users –Women

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Chronic Disorders of the AIDS Patient Impaired immune system permits opportunistic infections –Pneumocystis carinii pneumonia Protozoal infection Occurs in 75% of AIDS patients –Kaposi’s sarcoma Aggressive malignancy –Non-Hodgkin’s lymphoma Second most common malignancy associated with HIV infection

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Chronic Disorders (cont.) –Tuberculosis Often drug-resistant Mantoux skin test often negative in AIDS patients –Anergic reaction – no response to any substances injected as a skin test –Mycobacterium avium complex (MAC) infections 97% of nontuberculous bacterial infections –Meningitis Can lead to AIDS dementia complex

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Chronic Disorders (cont.) –Candidiasis Oral – thrush Vaginal – females –Herpes simplex Infections caused by HSV can be mild to life-threatening –Herpes zoster Virus that causes chickenpox becomes dormant Returns as herpes zoster, or shingles Lesions last longer in immunocompromised patients – patients with impaired or weakened immune systems

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Treating Opportunistic Infections Drug side effects problematic Patients develop –Allergies to treatment –Intolerance to medications Pathogens become resistant to treatments Treatments may conflict with other treatments

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Testing Regulations CDC does not require mandatory HIV testing for health-care workers Health-care workers’ chances of being infected by a patient are greater than a patient being infected by a health-care worker

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Drug Treatments Drugs –Slow reproduction of virus, no current cure –List of FDA approved drugs – Table 21-2 Treatment goals –Increase the time between infection and symptomatic disease –Improve quality of life –Reduce transmission To uninfected Maternal-infant –Reduce HIV-related deaths

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Drug Treatments (cont.) Treatment guidelines –Panel of Clinical Practices for Treatment of HIV Infections Initial and follow-up testing Drug resistance testing HAART – combination of drug treatment Initiating therapy –Decision made by patient and physician –AIDS diagnosis or CD4 T cell count is < 200cells/mm 3

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Drug Treatments (cont.) Delayed treatment –Benefits Postponement of drug-related adverse affects Delaying development of drug resistance Preserving treatment options –Risks Irreversible immune system damage Increased risk of transmission of disease

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Drug Treatments (cont.) Early treatment –Benefits Suppression of viral replication (preserves immune function) Reduction in chance of transmission Helps patient live symptom-free longer –Disadvantages Drug toxicity Drug resistance Adverse effects on quality of life Loss of treatment options

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Drug Treatments (cont.) Treating complications –Must also treat opportunistic infections –Patients more prone to Bacterial infections Protozoal infections Viral infections Fungal infections Malignancies Continuing research –Global issue –Keep informed of new treatments and prevention methods

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Apply Your Knowledge Identify where these opportunistic infections affect the body. 1.Herpes simplex 2.Pneumocystis carinii 3.Kaposi’s sarcoma 4.Tuberculosis 5.Meningitis 6.Oral candidiasis ANSWER: mouth, lips, genitalia lungs arms, legs, chest, neck, face, conjunctiva, palate lungs brain mouth, tongue

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Other Blood-Borne Infections Cytomegalovirus –Antibodies found in 80% of adults Erythema infectiosum –Parvovirus B19 –Fifth disease Human T-cell lymphotropic virus –HTLV-1 –Appears in IV drug users, among others Listeriosis –Caused by bacteria Listeria monocytogenes –Fever, shock, rash, and aches All are problematic for people with impaired immune systems.

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Other Blood-Borne Infections (cont.) Malaria –Parasite enters bloodstream through mosquito’s bite –Cyclical symptoms Syphilis –Caused by spirochete Treponema pallidum –Three stages –Difficult to identify and treat in HIV-positive persons Toxoplasmosis –Caused by Toxoplasma gondii in cat feces

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Apply Your Knowledge Which blood-borne pathogen is found in 80% of adults and rarely causes noticeable symptoms? ANSWER: Cytomegalovirus (CMV) Good Job!

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Reporting Guidelines Requirements for reporting HIV infections and AIDS determined by state Follow state and employer’s guidelines for reporting

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Reporting Guidelines (cont.) State health department report forms –Different for each disease –Information needed Disease identification Patient identification Infection history Information about reporting institution

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Apply Your Knowledge ANSWER: Information needed includes:  Disease identification  Patient identification  Infection history  Information about reporting institution What information is generally needed when making a report of an infectious disease?

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Patient Education An effective means of preventing disease transmission Assess the patient’s understanding of the risk for infection Provide information about preventions and treatments

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Patient Education (cont.) Clinical drug trials –Recognized research protocols designed to Evaluate the efficacy or safety of drugs Produce scientifically valid results –Information on trials available from

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Patients with Special Concerns Teenagers –Dangers of HIV and AIDS –Establish trust and provide facts Patients about to be discharged –Patient must understand the importance of Returning for follow-up Reporting any adverse reactions Watching for signs and symptoms that need to be reported Multicultural concerns –High-risk groups based on CDC reports –Written information available in appropriate language

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Apply Your Knowledge What guidance could you give a patient with AIDS or hepatitis who requests more information about the disease? ANSWER: Suggest that the patient contact government agencies such as the CDC or the Consumer Information Center by mail or on the Internet. In addition, there may be local support groups and resource organizations available in your area. Impressive!

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Special Issues with Terminal Illness Terminal – fatal Reactions will vary Help by –Supporting and accepting patient regardless of reaction –Encouraging patient to express feelings –Communicating respect through nonverbal communication –Meeting reasonable needs and demands –Providing referrals to hospices

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Apply Your Knowledge Mr. Andrews recently learned his HIV status has progressed to AIDS. When he comes into the office for an appointment, his mood swings from anger to crying. What should you do to help him? ANSWER: You should show support and acceptance of Mr. Andrews regardless of his reactions, encourage him to express feelings, and show respect for him. If his demands are reasonable, attempt to meet them. At this time, you should not refer him to a hospice because there may still be treatment options available.

© 2011 The McGraw-Hill Companies, Inc. All rights reserved In Summary 34.1Blood-borne pathogens can be transmitted by exposure to blood and body fluids, including blood products, human tissue, semen, vaginal secretions, saliva from dental procedures, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid. 34.2Strict adherence to Universal Precautions by treating all individuals as if they are potentially infected with blood-borne pathogens is essential in preventing the spread of infection. Protecting oneself from exposure through the use of appropriate personal protective equipment is the best way to prevent the spread of infection.

© 2011 The McGraw-Hill Companies, Inc. All rights reserved In Summary (cont.) 34.3The general symptoms of hepatitis include jaundice, diminished appetite, fatigue, nausea, vomiting, joint pain or tenderness, stomach pain, and general malaise. The initial symptoms of AIDS are usually severe flu-like symptoms followed later by systemic (weight loss, fatigue, night sweats), respiratory, oral, gastrointestinal, nervous system, and skin complaints. 34.4The tests used to diagnose HIV infection include the Rapid test, enzyme-linked immunosorbent assay (ELISA) test, Western blot, and immunofluorescent antibody (IFA) test.

© 2011 The McGraw-Hill Companies, Inc. All rights reserved In Summary (cont.) 34.5AIDS/HIV patients develop chronic disorders including Pneumocystis carinii pneumonia (PCP), Kaposi’s sarcoma, non-Hodgkin’s lymphoma (NHL), tuberculosis, Mycobacterium avium complex (MAC), meningitis, oral and vaginal candidiasis, herpes simplex, and herpes zoster. 34.6FDA-approved pharmaceutical agents used in the treatment of HIV/AIDS are divided into four classes; fusion inhibitors, nonnucleoside reverse transcriptase inhibitors (NNRTIs), nucleoside reverse transcriptase inhibitors (NRTIs), and protease inhibitors (PIs).

© 2011 The McGraw-Hill Companies, Inc. All rights reserved In Summary (cont.) 34.7Several other common blood-borne pathogens are of importance especially to patients who are immunocompromised. It is important that the medical assistant be able to recognize the symptoms of these infections, which include cytomegalovirus (CMV), erythema infectiosum (fifth disease), human T-cell lymphotrophic virus (HTLV-1), listeriosis, malaria, syphilis, and toxoplasmosis. 34.8The steps involved in reporting a communicable disease include obtaining the correct form, filling in the appropriate blanks on the form, and submitting the form to the physician prior to mailing it to the appropriate agency.

© 2011 The McGraw-Hill Companies, Inc. All rights reserved In Summary (cont.) 34.9Medical assistants can assess patients’ understanding of their risk for infection, the measures patients must take to eradicate an infection, the potential dangers posed by treatments, and the methods for controlling an infection’s spread Patients will have a variety of reactions to the news that they are dying. Some become angry, some will deny that they are dying, and some will get depressed.

© 2011 The McGraw-Hill Companies, Inc. All rights reserved Thought is an infection. In the case of certain thoughts, it becomes an epidemic. ~ Wallace Stevens End of Chapter 34