2. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-1 HIV, Hepatitis, and Other Blood-Borne Pathogens PowerPoint® presentation to accompany: Medical Assisting Third Edition Booth, Whicker, Wyman, Pugh, Thompson

3. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-2 Learning Outcomes 21.1Describe ways in which blood-borne pathogens can be transmitted. 21.2Explain why strict adherence to Universal Precautions is essential in preventing the spread of infection. 21.3 Describe the symptoms of hepatitis and AIDS. 21.4List and describe the blood tests used to diagnose HIV infection.

4. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-3 Learning Outcomes (cont.) 21.5Identify chronic disorders often found in patients who have AIDS. 21.6Compare and contrast drugs used to treat AIDS/HIV infection. 21.7Describe the symptoms of infection by other common blood-borne pathogens.

5. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-4 Learning Outcomes (cont.) 21.8Describe the steps involved in reporting a communicable disease. 21.9Explain how to educate patients about minimizing the risks of transmitting blood-borne infections to others. 21.10Describe special issues you may encounter when dealing with patients who have terminal illnesses.

6. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-5 Introduction  Chapter 21 expands on OSHA blood-borne pathogen standards 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

7. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-6 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

8. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-7 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

9. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-8 Transmission (cont.)  Transmission agent only if there is visible blood Feces Nasal secretions Perspiration Sputum Tears Urine Vomitus Saliva

10. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-9 Transmission (cont.)  Blood-borne pathogens may be introduced into a new host by Needlesticks Cuts or abrasions Any body opening Transfusion of infected blood

11. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-10 Transmission: 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

12. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-11  Pathogens Hepatitis B virus (HBV) Hepatitis C virus (HCV) HIV  AIDS Transmission: People at Increased Risk (cont.)

13. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-12 Transmission: Research  Incidence of many infectious diseases Reported to state health departments  Information then sent to CDC Trends in spread Identify control tactics Allocate resources

14. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-13 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 !

15. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-14 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

16. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-15 Universal Precautions  For medical offices, includes all Body fluids Secretions Excretions Moist body surfaces  Assume every patient is contaminated

17. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-16 Apply Your Knowledge ANSWER: In medical offices, Universal Precaution applies 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!

18. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-17 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

19. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-18 Disease Profiles: 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

20. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-19 Disease Profiles: 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

21. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-20 Disease Profiles: 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

22. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-21 Disease Profiles: 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

23. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-22 Disease Profiles: 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.

24. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-23 Disease Profiles: 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

25. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-24 Disease Profiles: 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

26. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-25 Disease Profiles: 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

27. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-26  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 Disease Profiles: AIDS / HIV Infection

28. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-27  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 Disease Profiles: AIDS / HIV Infection (cont.)

29. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-28  Risk in medical community Percutaneous exposure  Exposure through a puncture wound or needlestick Mucocutaneous exposure  Exposure through a mucous membrane Disease Profiles: AIDS / HIV Infection (cont.)

30. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-29  Progress of the infection – t hree main stages Initial infection  Can occur years after exposure  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 Disease Profiles: AIDS / HIV Infection (cont.)

31. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-30  Progress of the infection Incubation period  Virus genetic material incorporated into the genetic material of the helper T cells  Virus trapped in lymph system  Incubation period can be 8 to 15 years  As helper T cells decrease, patients are more prone to opportunistic infections Disease Profiles: AIDS / HIV Infection (cont.)

32. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-31  Progress of the infection Full-blown AIDS  During the incubation period, HIV becomes active again and continues to attack and kill helper T cells  200 or fewer helper T cells/mL blood indicates full- blown AIDS  Opportunistic infections and neurological deterioration Disease Profiles: AIDS / HIV Infection (cont.)

33. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-32  Diagnosis 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 Disease Profiles: AIDS / HIV Infection (cont.)

34. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-33  Symptoms Systemic Respiratory Oral – hairy leukoplakia Gastrointestinal Peripheral nervous system Skin-related Kaposi’s sarcoma Kaposi’s Sarcoma Disease Profiles: AIDS / HIV Infection (cont.)

35. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-34  Preventive measures Sexual contact  Use protection  Avoid multiple partners  Avoid concurrent sexually transmitted infections 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 Disease Profiles: AIDS / HIV Infection (cont.)

36. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-35 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!

37. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-36 AIDS Patients: 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

38. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-37 AIDS Patients: 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 Kaposi’s Sarcoma

39. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-38 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 AIDS Patients: Chronic Disorders of the AIDS Patient (cont.)

40. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-39 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 AIDS Patients: Chronic Disorders of the AIDS Patient (cont.)

41. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-40 AIDS Patients: 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

42. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-41 AIDS Patients: 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

43. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-42 AIDS Patients: 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

44. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-43  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 made by patient and physician AIDS diagnosis or CD4 T cell count is < 200cells/mm 3 AIDS Patients: Drug Treatments (cont.)

45. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-44  Delayed treatment Benefit  Postponement of drug-related adverse affects  Development of drug resistance  Preserving treatment options Risks  Irreversible immune system damage  Increase risk of transmission of disease AIDS Patients: Drug Treatments (cont.)

46. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-45  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 AIDS Patients: Drug Treatments (cont.)

47. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-46  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 AIDS Patients: Drug Treatments (cont.)

48. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-47 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

49. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-48 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.

50. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-49 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

51. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-50 Apply Your Knowledge Which blood-borne pathogen is found in 80% of adults and rarely causes noticeable symptoms? ANSWER: Cytomegalovirus (CMV) Good Job!

52. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-51 Reporting Guidelines  Requirements for reporting HIV infections and AIDS determined by state  Verify the specific guidelines in the state where you are employed

53. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-52 Reporting Guidelines (cont.)  Report forms Different for each disease Information needed  Disease identification  Patient identification  Infection history  Information about reporting institution

54. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-53 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?

55. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-54 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

56. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-55 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 www.ClinicalTrial.gov/ www.ClinicalTrial.gov/

57. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-56 Patient Education: 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

58. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-57 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!

59. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-58 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

60. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-59 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.

61. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-60 In Summary Medical Assistant Helps prevent the spread of HIV, HBV, and HCV by:  Using Universal Precautions  Watching for signs of infectious disease  Educating patients about risk factors associated with blood-borne diseases

62. © 2009 The McGraw-Hill Companies, Inc. All rights reserved 21-61 End of Chapter Thought is an infection. In the case of certain thoughts, it becomes an epidemic. ~ Wallace Stevens