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An occupational exposure is defined as a percutaneous (through the skin) injury such as a needle stick or cut with a sharp object or contact of mucous membrane or non-intact skin with blood, tissue, or OPIM. Non-intact skin may be chapped, abraded, or afflicted with dermatitis. Intact skin is a good barrier against these viruses. For exposure to occur there must be some sort of break in the skin, a “portal of entry,” such as a needle stick, cut, dermatitis, or exposure of a mucous membrane. The skin is the primary “suit of armour” against pathogens and to avoid a “pathogen party” the host must protect skin by using a barrier, such as gloves when coming in contact with potential pathogens, and then wash off after exposure.
Factors influencing the risk of infection include:
- Whether the exposure was from a hollow-bore needle or other sharp instrument
- Whether the exposure was to non-intact skin or mucous membranes such as the eyes, nose, or mouth
- The amount of blood that was involved
- The amount of virus present in the source's blood
- Which virus is involved—hepatitis B can be much more infectious than hepatitis C or HIV.
The OSHA Bloodborne Pathogens Standard requires medical follow-up for workers who have an exposure incident. Exposures should be reported within 1 hour if possible to allow for prompt intervention to reduce the risk of infection. Follow the protocol of your employer. Wash the exposed area with soap and water, or use an eye-wash station in the event of an eye-splash. Then report the exposure to the department or individual at your workplace who is responsible for managing exposure, which is often the occupational health nurse or infection control department/worker. Your employer should let you know how to do this as part of your orientation. If you do not know or are not sure, ask.
If you know the name of the individual who was the source of the exposure, take it and any information of the device involved when you report the exposure. For example, the brand of the safety sharp in use should be brought to the attention of the person receiving the report as a supply success or failure can be evaluated and lead to improvements in supplies carried by the facility. You will be asked about the situation that led to the exposure. These facts are needed for follow-up and prevention of similar exposures to others.
Reporting is important because part of the follow-up includes testing the blood of the individual source to determine HBV and HIV infectivity, if this is unknown and if permission for testing can be obtained. There are now at least four FDA-approved tests available for rapid HIV antibody testing that can confirm negative HIV status within an hour after blood is drawn from a source individual.
An employer’s failure to use rapid HIV antibody testing of the individual source could be considered a violation of paragraph 1910.1030(f)(3)(ii)(A) in the OSHA standard (OSHA, 2019a). The exposed employee must be informed of the results of these tests. Employers must tell the employee what to do if an exposure incident occurs.
Medical Evaluation and Follow-up
The Bloodborne Pathogens Standard requires employers whose employees may have exposure to body fluids on the job have a system in place for managing occupational exposures. This system must be available without delay, 24 hours per day, 7 days per week. This requirement may be challenging for employers who are not health-care providers, such as correctional facilities, firefighters, and first-aid providers. It is often managed by contractual arrangement.
Knowledge of the way to access this system is required as part of your orientation to the job and as part of your annual update education. If you do not know how to do it on your job, ask. Employers must provide free medical evaluation and treatment to employees who experience an exposure incident. A licensed healthcare provider will evaluate the exposure and advise on how to prevent further spread of any potential infection. If known, the source patient’s blood will be tested for HBV, HCV and HIV, with appropriate consent.
The blood of the exposed employee will be tested with their consent, or the employee may choose to have blood drawn but may not delay testing later than 24 hours or be tested until later. The employer must hold this specimen for at least 90 days. This baseline specimen is needed to determine if any later disease is related to the exposure or may have been present before the exposure.
The healthcare provider will share information from testing with the employee and will prescribe appropriate treatment in line with current U.S. Public Health Service recommendations. If the source individual was HBV- or HIV-positive or in a high-risk category, the exposed employee may be offered post exposure prophylaxis (PEP), medication that can be taken following exposure to reduce risk of infection. There is no available PEP against hepatitis C. Hepatitis B vaccine should always be offered following any exposure incident unless the employee is already immune as confirmed with a blood titer.
Because of the complexity of selecting an HIV/PEP regimen, consultation with people having expertise in antiretroviral therapy and HIV transmission is strongly recommended. The National PEP Hotline is available 24/7 at no cost to treating professionals at 888-448- 4911 (Clinical Consultation Center, 2019).
In addition to counseling the employee, the healthcare provider will provide a written report to the employer. This report simply identifies whether hepatitis B vaccination was recommended for the exposed employee and whether the employee received vaccination. The employer must provide a copy of the report to the employee within 15 days of the completion of the evaluation. The healthcare provider also must note that the employee has been informed of the results of the evaluation and told of any medical conditions resulting from exposure to blood which require further evaluation or treatment. Any added findings must be kept confidential.
Medical records must remain confidential. Employee health and medical records are not available to the employer, without the written consent of the employee. The employee must give specific written consent for anyone to see the records. Records must be maintained for the duration of employment plus 30 years in accordance with OSHA's standard on access to employee exposure and medical records.
The OSHA Bloodborne Pathogens Standard specifies recordkeeping requirements for employers that include confidential medical records for employees with occupational exposures, records of training provided, and a sharps injury log that documents every sharps injury in detail.
If you were to be stuck with a needle at your facility, do you know who to go to for reporting, testing, and treatment? How can you find out who that is?