1. BBP Exposure Control and Universal Precautions How you Can Protect Yourself and Others from Occupational Infection

2. What Is A Bloodborne Pathogen? They are blood born diseases designated by the CDC including Hepatitis B, Hepatitis C and HIV (human immunodeficiency virus) They are blood born diseases designated by the CDC including Hepatitis B, Hepatitis C and HIV (human immunodeficiency virus) you can be exposed by an incident that exposes you to body fluid of a person with the disease you can be exposed by an incident that exposes you to body fluid of a person with the disease These policies help prevent those exposures These policies help prevent those exposures

3. A Person May be Exposed By: a needle stick or cut by a sharp instrument that has been exposed to an infected person’s blood a needle stick or cut by a sharp instrument that has been exposed to an infected person’s blood Contact through the mucus membranes- the eye, nose, mouth or skin-by an infected person’s blood or body fluids Contact through the mucus membranes- the eye, nose, mouth or skin-by an infected person’s blood or body fluids

4. To Reduce the Risk of Exposure: Observe universal precautions: 1. Do Not Recap Needles 2. Use Retractable Needles and other safety devices while using sharps 3. Keep a Sharps Disposal Unit next to you and dispose of sharps into the unit directly after use

5. Reducing Risk, cont: Do not recap hypodermic or IV butterfly or catheter needles Do not recap hypodermic or IV butterfly or catheter needles Do not reinsert acupuncture needles or IV butterfly or catheter needles Do not reinsert acupuncture needles or IV butterfly or catheter needles Wear gloves for all medical exams and procedures Wear gloves for all medical exams and procedures If you do not feel competent to perform a procedure, let your supervisor or teacher know before proceeding If you do not feel competent to perform a procedure, let your supervisor or teacher know before proceeding

6. Reducing Risk, Cont. 4.Use appropriate barriers: –Gloves –Eye and Face Protection –Gowns or Jackets 5. Get immunized against Hepatitis B 6. Follow the clinic/campus BBP Procedures in classes and clinical training

7. What To Do After Exposure For Three to Five Minutes: For Three to Five Minutes: Wash Needle sticks, Cuts and broken skin with Soap and Running Water-do not squeeze the exposure site Wash Needle sticks, Cuts and broken skin with Soap and Running Water-do not squeeze the exposure site Flush exposures through the nose, mouth, and unbroken skin with running water Flush exposures through the nose, mouth, and unbroken skin with running water Irrigate Eyes with sterile saline, clean water or sterile irrigants Irrigate Eyes with sterile saline, clean water or sterile irrigants NOTIFY YOUR SUPERVISOR/TEACHER NOTIFY YOUR SUPERVISOR/TEACHER

8. External or Preceptor Site: Does the site have their own BBP incident procedure? Does the site have their own BBP incident procedure? If Yes, follow their procedure If Yes, follow their procedure If No, you or your supervisor contact the physician on call at 206-200-7067. If no answer call back within 10 minutes. If No, you or your supervisor contact the physician on call at 206-200-7067. If no answer call back within 10 minutes. Policy is that high risk exposures must be evaluated as to whether prophylactic treatment is warranted within one hour of occurrence Policy is that high risk exposures must be evaluated as to whether prophylactic treatment is warranted within one hour of occurrence

9. BU Campus or BUNH Clinic Notify your supervisor while you rinse the wound Notify your supervisor while you rinse the wound Your supervisor will contact the physician on call and determine whether your exposure was higher or lower risk Your supervisor will contact the physician on call and determine whether your exposure was higher or lower risk A high risk exposure is when the person is at immediate known risk such as a known positive HIV or high risk of HIV exposure where treatment may reduce the risk of contacting the disease. A high risk exposure is when the person is at immediate known risk such as a known positive HIV or high risk of HIV exposure where treatment may reduce the risk of contacting the disease. The physician on call will contact the source person regarding no cost testing for them. The physician on call will contact the source person regarding no cost testing for them. If high risk, you will be referred to a nearby hospital ER, where you notify them you had a high risk needle stick or BBP incident If high risk, you will be referred to a nearby hospital ER, where you notify them you had a high risk needle stick or BBP incident

10. BU Campus or Clinic, cont At the ER/Hospital you will be tested immediately for HIV, and perhaps for Hepatitis B and Hepatitis C At the ER/Hospital you will be tested immediately for HIV, and perhaps for Hepatitis B and Hepatitis C You may be offered prophylactic treatment for HIV, which is best begun within 2 - 24 hours of exposure, though may still be effective if begun within a few weeks of exposure You may be offered prophylactic treatment for HIV, which is best begun within 2 - 24 hours of exposure, though may still be effective if begun within a few weeks of exposure All costs of testing and treatment will be covered by BU All costs of testing and treatment will be covered by BU

11. High Risk Exposures, cont. Exposure to a known HIV positive patient or patient at high risk of having undiagnosed HIV Exposure to a known HIV positive patient or patient at high risk of having undiagnosed HIV Pregnant exposed person Pregnant exposed person

12. BU Campus or Clinic, cont. If determined to be a lower risk exposure, or following ER evaluation and treatment, follow up with either your own physician or BCNH within 24 hours If determined to be a lower risk exposure, or following ER evaluation and treatment, follow up with either your own physician or BCNH within 24 hours All cost of labs, treatment and care will be covered by BU All cost of labs, treatment and care will be covered by BU If a source person is not known or available for testing, the exposure is considered high risk and options for treatment or prophylaxis will be recommended If a source person is not known or available for testing, the exposure is considered high risk and options for treatment or prophylaxis will be recommended

13. After Exposure, cont. If you are pregnant, the exposure will be considered a high risk exposure and you will be referred to the ER/urgent Care for initial evaluation If you are pregnant, the exposure will be considered a high risk exposure and you will be referred to the ER/urgent Care for initial evaluation

14. After Exposure, Cont. You will complete an incident report form describing the incident and submit that to the BBP officer within 24 hours You will complete an incident report form describing the incident and submit that to the BBP officer within 24 hours You will receive follow up counseling and testing at 6 weeks, 12 weeks and 6 months after exposure You will receive follow up counseling and testing at 6 weeks, 12 weeks and 6 months after exposure Other counseling and support is available on an as-needed basis Other counseling and support is available on an as-needed basis Recommendations for treatment for Hepatitis B will be discussed and testing for immunity if you have been immunized will be performed Recommendations for treatment for Hepatitis B will be discussed and testing for immunity if you have been immunized will be performed

15. After Exposure, cont. preventive measures you need to employ personally will be discussed with your bloodborne pathogen counselor after the incident. preventive measures you need to employ personally will be discussed with your bloodborne pathogen counselor after the incident. All information regarding counseling, testing and treatment is confidential and kept separately from your BU clinic medical record in a locked file cabinet by the BBP officer All information regarding counseling, testing and treatment is confidential and kept separately from your BU clinic medical record in a locked file cabinet by the BBP officer All cost is covered by BU All cost is covered by BU

16. Diseases and Treatment: What you need to know Hepatitis B is a viral infection that occurs in the liver. Hepatitis B is a viral infection that occurs in the liver. If you have been vaccinated and developed immunity, you have no risk of developing this disease If you have been vaccinated and developed immunity, you have no risk of developing this disease If you have no immunity, your risk is 6- 30% from a single blood exposure If you have no immunity, your risk is 6- 30% from a single blood exposure

17. Diseases and Treatment Hepatitis B Hepatitis B may be self-limited or become a chronic infection. Hepatitis B may be self-limited or become a chronic infection. Death from chronic liver disease occurs in 15-25% of chronically infected persons Death from chronic liver disease occurs in 15-25% of chronically infected persons –Chronic infection occurs in: 90% of infants exposed in utero or at birth 90% of infants exposed in utero or at birth 30% of children infected between 1-5 years of age 30% of children infected between 1-5 years of age 5-10% of persons infected after age 5 5-10% of persons infected after age 5

18. Diseases and Treatment, cont. Hepatitis B Transmission of Hepatitis B: Transmission of Hepatitis B: High Risk High Risk –Blood/blood exchange: shared needles, occupational exposure, transfusion, hemodialysis and semen and vaginal secretions, especially if blood is present –Multiple sexual partners, especially with STDs Unprotected Sex Unprotected Sex

19. Diseases and Treatment, cont. Hepatitis B Moderate to High Risk Moderate to High Risk –Across the placenta –Daily or regular household contact with chronically infected person –Living in certain areas of the world (India, Alaska Native Villages, Pacific Islanders, Indochina, Africa, Middle East, Eastern Europe-Romania, Bulgaria)

20. Diseases and Treatment, cont. Hepatitis B Low Risk Low Risk –Saliva, urine, tears, mucus

21. Diseases and Treatment, cont. Hepatitis B If the source person is Hepatitis B positive (HBsAg) and has HBeAg present in their blood, the risk of infection is higher due to the higher levels of the virus circulating their blood If the source person is Hepatitis B positive (HBsAg) and has HBeAg present in their blood, the risk of infection is higher due to the higher levels of the virus circulating their blood The risk is lower from exposures through the eyes, mouth, nose and non-intact skin The risk is lower from exposures through the eyes, mouth, nose and non-intact skin There are no documented cases of exposure to intact skin There are no documented cases of exposure to intact skin The risk may be higher for hollow bore needles than other sharps such as acupuncture needles The risk may be higher for hollow bore needles than other sharps such as acupuncture needles

22. Diseases and Treatment, cont. Hepatitis B Treatment for Hepatitis B exposure The CDC recommends that all health care workers should be vaccinated against Hepatitis B The CDC recommends that all health care workers should be vaccinated against Hepatitis B If you are not vaccinated, and are exposed to HBsAg+ blood a combination of hepatitis vaccination and injection of hepatitis immune globulin may be effective in preventing the disease and should be begun within 24 hours to 7 days after exposure, though may be given 14 days after exposure If you are not vaccinated, and are exposed to HBsAg+ blood a combination of hepatitis vaccination and injection of hepatitis immune globulin may be effective in preventing the disease and should be begun within 24 hours to 7 days after exposure, though may be given 14 days after exposure

23. Diseases and Treatment, cont. Hepatitis B Hepatitis B Immune Globulin is recommended when an exposed person is not immunized or does not have immunity after immunization AND the source person is high risk or Hepatitis B positive Hepatitis B Immune Globulin is recommended when an exposed person is not immunized or does not have immunity after immunization AND the source person is high risk or Hepatitis B positive

24. Disease and Treatment, cont. Hepatitis B Hepatitis B vaccine and immune globulin are evaluated as safe for pregnant and nursing women Hepatitis B vaccine and immune globulin are evaluated as safe for pregnant and nursing women Immunization during pregnancy is recommended as pregnant women are more likely to develop a severe response to the virus and the fetus has a higher probability of developing a chronic infection with negative outcomes Immunization during pregnancy is recommended as pregnant women are more likely to develop a severe response to the virus and the fetus has a higher probability of developing a chronic infection with negative outcomes

25. Disease and Treatment, cont. Hepatitis B If multi-dose Hepatitis B Immune Globulin is begin within 7 days of exposure it is 70- 75% effective in preventing infection after high risk exposure If multi-dose Hepatitis B Immune Globulin is begin within 7 days of exposure it is 70- 75% effective in preventing infection after high risk exposure If the Hepatitis Immunization series is begun within 7 days of exposure it is 65- 70% effective in preventing infection after high risk exposure If the Hepatitis Immunization series is begun within 7 days of exposure it is 65- 70% effective in preventing infection after high risk exposure

26. Disease and Treatment, cont. Hepatitis B If both the immune globulin and the immunization is given within 7 days of exposure it is 80-85% effective in preventing hepatitis B infection If both the immune globulin and the immunization is given within 7 days of exposure it is 80-85% effective in preventing hepatitis B infection

27. Diseases and Treatment, cont. Hepatitis C Hepatitis C is a viral infection occurring in the liver. High Risk Exposures: Blood/blood exposure-IV drug use, transfusion, hemodialysis

28. Disease and Treatment, cont. Hepatitis C Moderate to Low Risk-across the placenta Moderate to Low Risk-across the placenta Low Risk-occupational exposure (needle stick, contaminated sharps breaking skin, splashing of infectious body fluids into mucus membranes or through broken skin; intimate sexual contact with exchange of body fluids Low Risk-occupational exposure (needle stick, contaminated sharps breaking skin, splashing of infectious body fluids into mucus membranes or through broken skin; intimate sexual contact with exchange of body fluids

29. Disease and Treatment, cont. Hepatitis C Chronic Infection occurs in: Chronic Infection occurs in: –75-85% of all infected persons Chronic Liver Disease Occurs in: Chronic Liver Disease Occurs in: –70% of chronically infected persons –Leading indication for liver transplant in US Death from chronic liver disease occur in: Death from chronic liver disease occur in: –1-5% of infected persons

30. Disease and Treatment, cont. Hepatitis C The risk of developing the infection if exposed through a cut or needle stick is 1.8% (98.2% of people do not develop infection). The risk for developing the disease after exposure through the eye, nose or non-intact skin is lower, but has occurred. There is no known risk of development of the disease through intact skin exposure.

31. Disease and Treatment, cont. There is no vaccine against Hepatitis C and no treatment after exposure that will prevent infection. There is no vaccine against Hepatitis C and no treatment after exposure that will prevent infection. Avoidance of exposure is your best option Avoidance of exposure is your best option

32. Disease and Treatment, cont. HIV HIV is a virus that infects cells and impairs immune response of the T-lymphocyte white blood cells The risk of developing HIV after needle stick or cut exposure is.3% (99.7% of exposures do not lead to infection). The risk of developing HIV after needle stick or cut exposure is.3% (99.7% of exposures do not lead to infection). The risk after exposure of the eye, nose and mouth is.1% (99.9 % of infections do not develop disease) The risk after exposure of the eye, nose and mouth is.1% (99.9 % of infections do not develop disease) The risk after exposure to non-intact skin is less than.1% The risk after exposure to non-intact skin is less than.1%

33. Disease and Treatment, cont. HIV There is no documented risk for exposure of HIV infected blood to intact skin. There is no documented risk for exposure of HIV infected blood to intact skin. There is no immunization to prevent HIV infection There is no immunization to prevent HIV infection

34. Disease and Treatment, cont. HIV High Risk Exposures include: High Risk Exposures include: –Exposure to infected blood Needle sharing Needle sharing Blood products received before 1985 Blood products received before 1985 –Sexual contact including exchange of semen and vaginal fluid and/or blood

35. Disease and Treatment, cont. HIV Moderate Risk Exposures include: Moderate Risk Exposures include: –Pregnancy (placental exchange) –Breast milk (moderate to high)

36. Disease and Treatment, cont. HIV Seroconversion to HIV positive status after exposure: Seroconversion to HIV positive status after exposure: –95% test positive within 4 weeks of exposure –3-5% test positive after 3 months There is no risk of disease development if negative test at 6 months There is no risk of disease development if negative test at 6 months

37. Disease and Treatment, cont. HIV Probability of seroconversion (testing HIV positive) is related to the amount of HIV positive blood you are exposed to and the depth of the exposure.

38. Disease and Treatment, cont. HIV Post exposure prophylaxis (PEP) treatment using combination anti-viral drugs for thirty days after known exposure has been shown to reduce the risk of developing disease Post exposure prophylaxis (PEP) treatment using combination anti-viral drugs for thirty days after known exposure has been shown to reduce the risk of developing disease

39. Disease and Treatment, cont. HIV PEP treatment is not recommended for low risk exposures due to the potential for side effects from the drugs PEP treatment is not recommended for low risk exposures due to the potential for side effects from the drugs The PEP treatment shows better efficacy if begun within 2-24 hours of exposure, though treatment begun after that time may also be effective. The PEP treatment shows better efficacy if begun within 2-24 hours of exposure, though treatment begun after that time may also be effective.

40. Disease and Treatment, cont. HIV Safety, efficacy and risks of PEP treatment for pregnant women will be evaluated on a case by case basis by the exposed person and their physician so an informed decision may be made. Safety, efficacy and risks of PEP treatment for pregnant women will be evaluated on a case by case basis by the exposed person and their physician so an informed decision may be made.

41. Follow up After Exposure: After your BBP incident Re-testing is recommended at 6 weeks, 12 weeks and at 6 months Re-testing is recommended at 6 weeks, 12 weeks and at 6 months If Hepatitis B vaccine has been given, testing of the blood to ensure immunity has developed should occur 1-2 months after completion of the vaccination series If Hepatitis B vaccine has been given, testing of the blood to ensure immunity has developed should occur 1-2 months after completion of the vaccination series If PEP treatment is taken, blood tests (CBC, Liver Enzymes, Kidney function tests) are taken at onset and 2 weeks after beginning treatment If PEP treatment is taken, blood tests (CBC, Liver Enzymes, Kidney function tests) are taken at onset and 2 weeks after beginning treatment

42. Precautions During Follow-up If you are exposed to HBV and receive post exposure treatment no precautions need to be taken as you will not be infectious according to the CDC If you are exposed to HBV and receive post exposure treatment no precautions need to be taken as you will not be infectious according to the CDC The risk of exposure or passing on Hepatitis C to others is low, so the CDC recommends no precautions The risk of exposure or passing on Hepatitis C to others is low, so the CDC recommends no precautions

43. Precautions During Follow-Up If you are unaware of exposure risk or there is a risk of Hepatitis or HIV infection, then you should: If you are unaware of exposure risk or there is a risk of Hepatitis or HIV infection, then you should: –Avoid donating blood or serum for 6 months –Avoid donating semen or organs for 6 months –Avoid Intercourse for 6 months If you choose to engage in intercourse, using condoms consistently and correctly is recommended to reduce the risk of passing on the virus If you choose to engage in intercourse, using condoms consistently and correctly is recommended to reduce the risk of passing on the virus

44. Precautions During Follow-Up Women should avoid breast feeding to avoid passing on the virus Women should avoid breast feeding to avoid passing on the virus Utilize birth control in order to ensure pregnancy prevention Utilize birth control in order to ensure pregnancy prevention

45. Finally, The CDC estimates that over 1000 needle sticks occur daily in hospitals across the US. The information from private clinics and doctors offices is not tracked. Universal precautions and awareness need to be integrated by all of us daily to reduce this number. The CDC estimates that over 1000 needle sticks occur daily in hospitals across the US. The information from private clinics and doctors offices is not tracked. Universal precautions and awareness need to be integrated by all of us daily to reduce this number. The CDC also estimates 50% of injuries are not reported due to fear of reprisal. The CDC also estimates 50% of injuries are not reported due to fear of reprisal.

46. Finally, cont. BU has a policy that prohibits reprisals BU has a policy that prohibits reprisals All your care, follow up and outcomes are confidential All your care, follow up and outcomes are confidential We want to know what happens so we can use the information to improve safety and effectiveness of our work place We want to know what happens so we can use the information to improve safety and effectiveness of our work placeAcknowledgements: WWW.CDC.gov Sheryl Berman, PhD, Debra Brammer, ND for their contributions to this presentation