1. Sharps Related Infections Olusegun Soge (S.O.) Postdoc, DEOHS sogeo@uw.edu November 13, 2009

2. Scenarios A laboratory manager is contaminated with a large amount of blood on an open cut while trying to help a student who has a deep cut from a pipette failure. The student is a hepatitis B carrier. A physician is splashed in the eye with hepatitis C positive blood while seeing a trauma patient in the ER. A nurse accidentally sticks himself with large bore needle when a psychiatric patient with HIV unexpectedly moves away from him.

3. Learning Objectives Define Bloodborne pathogens (BBPs) Describe the 3 main BBPs and how they are transmitted Describe the symptoms of bloodborne diseases Distinguish between Occupational Exposure and Exposure Incident Explain the main idea of universal precautions Explore ways to prevent occupational exposure to BBPs

4. Bloodborne Pathogens (BBPs) O ther P otentially I nfectious M aterials Blood or BBPs are pathogenic microorganisms that are present in and can cause diseases in humans ‘ Blood’ includes human blood, human blood components, products made from human blood, and also medications derived from blood (e.g., immune globulins, albumin, etc.).”

5. Other Potentially Infectious Materials (OPIM) semen vaginal secretions body fluids such as pleural, cerebrospinal, pericardial, peritoneal, synovial, and amniotic saliva in dental procedures (if blood is present) any body fluids visibly contaminated with blood any unfixed tissue or organ (other than intact skin) from a human (living or dead) HIV- or HBV-containing cultures (cell, tissue, or organ), culture medium, or other solutions blood, organs, & tissues from animals infected with HIV, HBV, or BBPs

6. Other body fluids and materials not considered infectious… ….unless contaminated with blood or OPIM saliva (except during dental procedures) urine feces vomit tears sweat

7. Who is at risk of exposure to BBPs? Lab Technicians Research Scientists Health Care Workers Physicians Blood Bank Workers Police Officers Fire & Rescue Personnel Child care providers Life guards Instructors Security Officers Custodial and house- keeping staff YOU? Those employees who by nature of their tasks have the potential to be exposed to blood, body fluids, or other potentially infectious materials

8. means reasonably anticipated skin, eye, mucous membrane, or parenteral (piercing of the skin) contact with blood or OPIM that may result from the performance of an employee's duties Occupational Exposure Transmission of BBPs is a specific contact with blood or OPIM that is capable of transmitting a bloodborne disease Exposure Incident

9. Transmission of BBPs Risk of infection depends on several factors:  The pathogen involved  The type/route of exposure  The amount of virus in the infected blood at the time of exposure  The amount of infected blood involved in the exposure  Whether post-exposure treatment was taken  Specific immune response of the infected individual Courtesy of Owen Mumford, Inc.

10. Modes of Transmission Percutaneous (through the skin) Being stuck with needles or other sharps Having infected blood or other body fluids splashed onto skin that is cut, scratched, has sores or rashes or other skin conditions Mucocutaneous (via mucous membrane) Having infected blood or other body fluids splashed into eyes, nose or mouth

11. Health Care Workers and BBPs HBV: 30% (6%-30%) HCV: 3.0% (range 0%-7%) HIV: 0.3% Occupational Transmission Risk of infection following needle stick/cut from a positive (infected) source:

12. Most Common Occupational Exposure Needlestick Injuries Over 85% of documented occupational transmissions

13. Bloodborne Pathogen Diseases Main bloodborne pathogens and diseases of concern Hepatitis B Virus (HBV)Hepatitis B Virus (HBV) Hepatitis C Virus (HCV)Hepatitis C Virus (HCV) Human Immunodeficiency Virus (HIV)Human Immunodeficiency Virus (HIV) Some examples of bloodborne pathogens: Malaria Syphilis Brucellosis Leptospirosis Arboviral infections Relapsing fever Creutzfeld-Jakob Disease Viral Hemorrhagic Fever Co-infection is possible.

14. Causes Acquired Immunodeficiency Syndrome (AIDS) HIV destroys cells in the body’s immune system It may take many years before AIDS develops A flu-like illness can occur 1-6 weeks after exposure to the virus: fever diarrhea headache sore throat night sweats enlarged lymph nodes malaisethrush muscle painsfatigue nauseaweight loss HIV

15. In some cases, symptom-free period of 5-10 years can occur SURVIVAL OUTSIDE THE BODY –HIV does not survive well outside the body, making the possibility of environmental transmission remote –But in dry blood, the virus has been shown to survive for up to 6 days in laboratory conditions QUANTITY OF VIRUS IN BLOOD –1 millilitre of blood contains 200-10,000 particles of virus. RISK OF INFECTION FOLLOWING NEEDLE STICK INJURY –Low - 0.3% - 3 people in 1,000. RISK OF INFECTION FOLLOWING EYE SPLASH –Low. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recommendations and Reports, June 29, 2001 / 50(RRll);1-42. Centers for Disease Control and Prevention

16. Occupationally acquired AIDS Updated in a 2007 report, with the same documented 57 cases but an additional 140 “possible” cases http://www.cdc.gov/ncidod/dhqp/bp_hcp_w_hiv.html

17. Global HIV/AIDS Estimates

18. Cases of HIV Infection and AIDS in the United States, 2007 >1.2 million people living with HIV 1/4 th of persons living with HIV do not know the are infected Although African Americans represent about 13% of the population, they accounted for 48% of new HIV or AIDS diagnoses in 2007

19. AIDS in Washington State by County December 31, 2000 - N= 9419 Also, 64% of cumulative HIV cases are from King County

20. Current estimates of the number of HIV/AIDS in King County 7,765 King County residents have been diagnosed with AIDS and 4,254 (55%) have died (1982-2007) An estimated 7,500 residents are currently living with HIV 45% (3,511) diagnosed with AIDS 55% have HIV infection but have not developed AIDS 80% of those living with AIDS in King County were Seattle residents at the time of diagnosis 31% of the King County population lives in Seattle HIV/AIDS Epidemiology Program: Facts about AIDS in King County, June 2009 http://www.kingcounty.gov/health

21. Global Estimates of Hepatitis C

22. Features of Hepatitis C Virus Infection Incubation periodAverage 6-7 weeks Range 2-26 weeks Acute illness (jaundice)Mild (<20%) Case fatality rateLow Chronic infection60%-85% Chronic hepatitis10%-70% Cirrhosis<5%-20% Mortality from CLD1%-5% Leading indication for liver transplant

23. HEPATITIS C IN BLOOD SURVIVAL OUTSIDE THE BODY –Little is known but likely to be the same as hepatitis B, up to 10 days QUANTITY OF VIRUS IN BLOOD –1 millilitre of blood contains 1,000 - 10,000 particles of virus RISK OF INFECTION FOLLOWING NEEDLE STICK INJURY –Medium - 3% - 3 people in 100 RISK OF INFECTION FOLLOWING EYE SPLASH –Low * Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recommendations and Reports, June 29, 2001 / 50(RRll);1-42. Centers for Disease Control and Prevention

24. Hepatitis C Virus Infection, United States New infections per year 1985-89242,000 2001 25,000 Deaths from acute liver failureRare Persons ever infected (1.8%)3.9 million (3.1-4.8)* Persons with chronic infection2.7 million (2.4-3.0)* HCV-related chronic liver disease40% - 60% Deaths from chronic disease/year8,000-10,000 *95% Confidence Interval

25. Occupational Transmission of HCV Inefficient by occupational exposures Average incidence 1.8% following needle stick from HCV-positive source –Associated with hollow-bore needles Case reports of transmission from blood splash to eye; one from exposure to non-intact skin Prevalence 1-2% among health care workers –10 times lower than for HBV infection

26. HCW to Patient Transmission of HCV Rare –In U.S., none related to performing invasive procedures Most appear related to HCW substance abuse –Reuse of needles or sharing narcotics used for self-injection No restrictions routinely recommended for HCV-infected HCWs

27. Perinatal Transmission of HCV Transmission only from women HCV- RNA positive at delivery –Average rate of infection 6% –Higher (17%) if woman co-infected with HIV No association with –Delivery method –Breastfeeding Infected infants do well –Severe hepatitis is rare

28. Source: Sentinel Counties, CDC Sources of Infection for Persons With Hepatitis C Sexual 15% Other 1%* Unknown 10% Injecting drug use 60% Transfusion 10% (before screening) * Nosocomial; iatrogenic; perinatal Occupational 4%

29. HCV Prevalence by Selected Groups in United States Hemophilia Injecting drug users Surgeons, PSWs Hemodialysis Average Percent Anti-HCV Positive Gen population adults Military personnel STD clients Pregnant women

30. Hepatitis B Incidence in U.S., 2001 Statistically poses the greatest risk Estimated incidence – 78,000 cases/year Reported cases – Acute hepatitis B: 7,844 Likelihood of becoming a carrier varies inversely with the age at which infection occurs Pool of carriers in U.S. is 1-1.25 million persons ~5000 persons die/yr. from HBV-related cirrhosis

31. Transmission of HBV (1) Concentration of HBV in various body fluids –High: Blood, serum, wound exudates –Medium: saliva, semen, and vaginal secretions –Low/not detectable: urine, feces, sweat, tears, breast milk Perinatal – transplacental transmission, rare (2-5%) Sexual transmission – unprotected sex

32. Transmission of HBV (2) Percutaneous transmission – sharing of injection drug use equipment, needle stick injury, ear-piercing, body piercing, tattooing, inadequate sterilization of medical equipment, scarification Household and interhousehold transmission – less risk but significant - can occur in settings such as shared toothbrushes, razors, combs, washcloths

33. Transmission of HBV (3) Passed from child to child by biting, shared objects, oozing cuts, impetigo, etc. Virus can exist on environmental surfaces for up to one week and remain infectious Pre-chewing food for babies, or sharing food that has been chewed by someone else (chewing gum)

34. Risk Factors Associated with Reported Hepatitis B, 1990-2000, United States Source: NNDSS/VHSP *Other: Surgery, dental surgery, acupuncture, tattoo, other percutaneous injury

35. HEPATITIS B IN BLOOD SURVIVAL OUTSIDE THE BODY –Very stable, virus can persists in dry blood for up to 10 days QUANTITY OF VIRUS IN BLOOD –1 millilitre of blood contains 100,000,000 particles of virus RISK OF INFECTION FOLLOWING NEEDLE STICK INJURY –Very High - 30% - 3 people in 10 RISK OF INFECTION FOLLOWING EYE SPLASH –High * Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recommendations and Reports, June 29, 2001 / 50(RRll);1-42. Centers for Disease Control and Prevention

36. Hepatitis B: Clinical Features Incubation period ranges from 45-180 days, average is 60-90 days Onset is insidious Clinical illness (jaundice): 5 yrs Acute case-fatality rate:0.5%-1% Chronic infection: 5 yrs old, 2%-6% Premature mortality from chronic liver disease:15%-25%

37. Signs and Symptoms Symptom – there may be none – loss of appetite, malaise, nausea, vomiting, abdominal pain, arthralgias, myalgias Signs – there may be none – jaundice, fever, dark urine Normal eyes Jaundiced eyes

38. Regulatory Risk Reduction Strategies against BBPs 1991, OSHA BBP Standard: Mandates rules for employers to protect workers from occupational exposure to blood and other body fluids that potentially contain bloodborne pathogens 2001, OSHA BBP Standard: Updated with new requirements under Federal Needlestick Safety and Prevention Act WISHA : Washington Industrial and Safety Act

39. Ways to prevent exposure to BBP Universal precautions –Blood and OPIM from ALL persons are considered infectious –Appropriate barriers and procedures must be used when contact with blood or OPIM is anticipated Personal protective equipment (PPE) Gloves, masks, face shields, lab coats, respirators, gowns, resuscitation devices, shoe cover

40. Ways to prevent exposure to BBP (Contd.) Work Practice Controls –Hand washing –Storage and handling of contaminated equipment –No eating, drinking, smoking, handling contact lenses, and applying make-up in work areas

41. Thank you! Recipe for fake blood from Penn and Teller's Bleeding Heart Gelatin Dessert: 1 cup corn syrup 1/2 cup grenadine 0.3 oz. red food coloring 3 drops blue food coloring Jillette, P. and T. Jillette 1992. Penn and Teller's how to play with your food, p.104-109. Villard Books, New York, N.Y.