Risk of Bloodborne Infection
The need to protect healthcare workers from bloodborne exposures resulted in the publication of the Bloodborne Pathogens Standard by the Occupational Safety and Health Administration (OSHA) in 1991. The Standard requires employers whose employees have exposure to blood to provide safe work practices, education, and barriers to exposure. The Standard was later amended to add requirements for the safe use of sharps devices.
Part of the OSHA Bloodborne Pathogens Standard is the requirement that every healthcare worker who may have contact with body fluids on the job must receive specific annual education. This education includes:
- Instruction in the basics of infection control and prevention
- Bloodborne pathogens training
- Instruction in modes of transmission, needlestick precautions, and contact precautions
An occupational exposure to a bloodborne pathogen is defined as a percutaneous injury (eg, a needlestick or cut with a sharp object) or contact of mucous membrane or non-intact skin (eg, exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or OPIM.
According to the CDC, the risk of infection varies case by case. Factors influencing the risk of infection include: whether the exposure was from a hollow-bore needle or other sharp instrument; to non-intact skin or mucus membrane (such as the eyes, nose, and/or mouth); the amount of blood that was involved, and the amount of virus present in the source’s blood.
Risk of HIV Transmission
The risk of HIV infection to a healthcare worker through a needlestick is less than 1%. Approximately 1 in 300 exposures through a needle or sharp instrument result in infection. The risks of HIV infection though splashes of blood to the eyes, nose, or mouth is even smaller—approximately 1 in 1,000. There have been no reports of HIV transmission from blood contact with intact skin. There is a theoretical risk of blood contact to an area of skin that is damaged, or from a large area of skin covered in blood for a long period of time. Through December 2001, the CDC reported 57 documented cases of occupational HIV transmission to healthcare workers in the United States, and no confirmed cases since 1999 (CDC, 2011a).
Risk of Hepatitis B and C Transmission
The risk of getting hepatitis B (HBV) from a needlestick is 22% to 31% if the source person tests positive for hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg). If the source person is HBsAg-positive and HBeAg-negative there is a 1% to 6% risk of getting HBV unless the person exposed has been vaccinated.
The risk of getting hepatitis C (HCV) from a needlestick is 1.8%. The risk of getting HBV or HCV from a blood splash to the eyes, nose, or mouth is possible but believed to be very small. As of 1999 about 800 healthcare workers a year are reported to be infected with HBV following occupational exposure. There are no exact estimates on how many healthcare workers contract HCV from an occupational exposure, but the risk is considered low.
Treatment After a Potential Exposure
Follow the protocol of your employer. As soon as safely possible, wash the affected area(s) with soap and water. Application of antiseptics should not be a substitute for washing. It is recommended that any potentially contaminated clothing be removed as soon as possible. It is also recommended that you familiarize yourself with existing protocols and the location of emergency eyewash or showers and other stations within your facility.
Mucous Membrane Exposure
If there is exposure to the eyes, nose, or mouth, flush thoroughly with water, saline, or sterile irrigants. The risk of contracting HIV through this type of exposure is estimated to be 0.09%.
Wash the exposed area with soap and water. Do not “milk” or squeeze the wound. There is no evidence that shows using antiseptics (like hydrogen peroxide) will reduce the risk of transmission for any bloodborne pathogens; however, the use of antiseptics is not contraindicated. In the event that the wound needs suturing, emergency treatment should be obtained. The risk of contracting HIV from this type of exposure is estimated to be 0.3%.
Bite or Scratch Wounds
Exposure to saliva is not considered substantial unless there is visible contamination with blood or the saliva emanates from a dental procedure. Wash the area with soap and water, and cover with a sterile dressing as appropriate. All bites should be evaluated by a healthcare professional.
Did you know. . .
For human bites, the clinical evaluation must include the possibility that both the person bitten and the person who inflicted the bite were exposed to bloodborne pathogens.
Exposure to Urine, Vomitus, or Feces
Exposure to urine, feces, vomitus, or sputum is not considered a potential bloodborne pathogens exposure unless the fluid is visibly contaminated with blood. Follow your employer’s procedures for cleaning these fluids.
Reporting the Exposure
Follow the protocol of your employer. After cleaning the exposed area as recommended above, report the exposure to the department (or individual) at your workplace that is responsible for managing exposure.
Obtain medical evaluation as soon as possible. Discuss with a healthcare professional the extent of the exposure, treatment, followup care, personal prevention measures, and the need for a tetanus shot or other care.
Your employer is required to provide an appropriate post exposure management referral at no cost to you. In addition, your employer must provide the following information to the evaluating healthcare professional:
- A description of the job duties the exposed employee was performing when exposed
- Documentation of the routes of exposure and circumstances under which exposure occurred
- Results of the source person’s blood testing, if available
- All medical records that you are responsible to maintain, including vaccination status, relevant to the appropriate treatment of the employee
Remember that HIV and hepatitis infection are notifiable conditions.
Post Exposure Prophylaxis
Post exposure prophylaxis (PEP) provides anti-HIV medications to someone who has had a substantial exposure, usually to blood. PEP has been the standard of care for occupationally exposed healthcare workers with substantial exposures since 1996. Animal models suggest that cellular HIV infection happens within 2 days of exposure to HIV and the virus in blood is detectable within 5 days. Therefore, PEP should be started as soon as possible, within hours not days, after exposure and continued for 28 days. However, PEP for HIV does not provide prevention of other bloodborne diseases like HBV or HCV.
Hepatitis B PEP for susceptible people would include administration of hepatitis B immune globulin and HBV vaccine. This should occur as soon as possible and no later than 7 days post exposure.
The benefit of the use of antiviral agents to prevent HCV infection is unknown and antivirals are not currently FDA-approved for prophylaxis. Because of the frequent advances in treatment, doses and medications are not listed here. Post exposure prophylaxis can only be obtained from a licensed healthcare provider. Your facility may have recommendations and a chain of command in place for you to obtain PEP.
After evaluation of the exposure route and other risk factors, certain anti-HIV medications may be prescribed. The national bloodborne pathogen hotline provides 24-hour consultation for clinicians who have been exposed on the job. Call 888 448-4911 for the latest information on prophylaxis for HIV, hepatitis, and other pathogens.
PEP is not as simple as swallowing one pill. The medications must be started as soon as possible and continued for 28 days. Many people experience significant medication side effects. It is very important to report occupational exposure to the department at your workplace that is responsible for managing exposure. If post exposure treatment is recommended, it should be started as soon as possible. In rural areas, police, firefighters, and other at-risk emergency providers should identify a 24-hour source for PEP.