ATrain Education

 

Continuing Education for Health Professionals

KY: HIV/AIDS

Module 8

Occupational Exposures

An occupational exposure is defined as a reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials (OPIM) that may result from the performance of an employee’s duties (OSHA, 2013).

Since 1991, when OSHA first issued its Bloodborne Pathogens Standard to protect healthcare personnel from occupational exposure, the focus of regulatory and legislative activity has been on implementing a hierarchy of prevention and control measures. This approach treats every patient as potentially infectious, requires workers to wear protective gear, and trains workers to use syringes properly and sterilize all equipment and surfaces.

Employers are required to create and implement a written exposure control plan (ECP) specific to each workplace setting to eliminate or minimize employee exposures. The plan must be updated annually to reflect technological changes that help eliminate or reduce exposure to bloodborne pathogens. In the plan, employers must include information about the infection control system used in the workplace (OSHA, 2013).

The ECP should contain annual documentation of consideration and implementation of appropriate, commercially available safer medical devices designed to eliminate or minimize occupational exposures. Employers must also document that they have solicited input from non-managerial workers in identifying, evaluating, and selecting engineering controls. The ECP must be available to workers. You may legally ask your employer how you can review it (OSHA, 2013).

The exposure control plan should also include a written exposure determination that includes those job classifications and positions in which employees have the potential for occupational exposures. The exposure determination should be made without taking into consideration the use of personal protective clothing or equipment. Employees who are required or expected to administer first aid must be included (OSHA, 2013).

Standard Precautions

Workplaces are required to adhere to Standard Precautions to prevent occupational exposures to blood and OPIM. If any worker reasonably expects to have contact with blood or body fluids on the job, this law applies to their workplace.

Standard Precautions

Standard Precautions treats all body fluids, except sweat, as potentially infectious and involves the use of protective barriers and safe sharps handling to reduce the risk of exposure to blood and to prevent injuries caused by needles, scalpels, and other sharp instruments or devices.

Correct Use of Standard Precautions

Always

  • Use good hand hygiene.
  • Use gloves for contact with blood, body fluids, non-intact skin (including rash), mucous membranes, used equipment, linen, and trash.
  • Use a gown any time your clothing may become soiled and if a patient has uncontained body substances.
  • Use a mask and eye protection if you may be splashed. OSHA-compliant eye protection must have solid side shields.
  • Change gloves if they become heavily soiled or if you must go from a dirtier area to a cleaner one.

Never

  • Wear artificial fingernails—check your facility’s policy for details.
  • Touch a second patient with the same pair of gloves.
  • Reuse gowns, even for repeated contacts with the same patient.
  • Contaminate the environment with dirty gloves.
  • Wear gloves in the hall unless you can say why you are wearing them.

Bloodborne Pathogens

Bloodborne pathogens are infectious organisms in blood and other body fluids that can cause chronic and life-threatening disease in humans. The bloodborne pathogens of most concern are hepatitis B, hepatitis C, and HIV. Bloodborne exposures can occur when an infectious organism enters the body via a portal of entry such as a cut, dermatitis, or exposure of a mucous membrane. Intact skin is a good barrier against exposures.

The risk of HIV infection to a healthcare worker through a needlestick is less than 1%. 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.

The transmission of bloodborne pathogens can be minimized and even prevented through the use of safer techniques and personal protective equipment. This includes not recapping needles by hand, disposing of used needles in appropriate sharps disposal containers, and using medical devices with safety features designed to prevent injuries. Using appropriate barriers such as gloves, eye and face protection, or gowns when contact with blood is expected can prevent many exposures to the eyes, nose, mouth, or skin. Bloodborne pathogens can be present in both blood and other potentially infectious material (OPIM).

Blood and OPIM That Can Contain Bloodborne Pathogens

  • Human body fluids
  • Semen
  • Vaginal secretions
  • Cerebrospinal fluid, synovial fluid
  • Pleural fluid, pericardial fluid
  • Peritoneal fluid
  • Amniotic fluid
  • Saliva in dental procedures
  • Body fluid visibly contaminated with blood
  • Body fluids in situations where it is difficult or impossible to differentiate between type of body fluids
  • Any unfixed tissue or organ (other than intact skin) from a human (living or dead)
  • HIV-containing cell or tissue cultures, organ cultures
  • HIV- or hepatitis B-containing culture medium or other solutions
  • Blood, organs, or other tissues from experimental animals infected with HIV or hepatitis B

Personal Protective Equipment

Personal protective equipment (PPE) is specialized clothing or equipment worn by an employee for protection against hazards that remain after engineering controls and work practice controls are in place and, as such, is not the first line of defense. Nevertheless, the employer must provide PPE and ensure that the employee uses it, and must clean, repair, and replace this equipment as needed.

General work clothes such as uniforms, pants, shirts, or blouses are not intended to function as protection against a hazard and are not considered to be personal protective equipment. Lab coats and scrubs are generally considered personal clothing. When contamination is reasonably likely, protective gowns should be worn. If lab coats or scrubs are worn as PPE they must be removed as soon as practical and laundered by the employer.

A worker must decide when to wear PPE and if exposure is likely. This is usually easy to determine:

If it is wet and not yours, stay out of it!

If exposure seems reasonably likely, you have the right to protect yourself with PPE. Wearing basic PPE is not optional.

Gloves

Gloves are a type of PPE and should be worn when:

  • It can reasonably be anticipated that the employee may have hand contact with blood, other potentially infectious material, mucous membranes, and non-intact skin
  • Performing all vascular access procedures or procedures involving uncontained blood, such as finger or heel sticks (CDC, 2013e)

Gloves must be changed between patients. Single-use gloves cannot be washed or decontaminated for reuse. Utility gloves may be decontaminated if they are not compromised. They should be replaced when they show signs of cracking, peeling, tearing, puncturing, or deteriorating.

Most gloves in the healthcare workplace are made of latex, although some workers are allergic to latex. In most circumstances, nitrile or other glove alternatives may be used in place of latex gloves. Employers are required to provide non-latex alternatives to employees with sensitivities to latex and other materials.

Hand Hygiene

Hand hygiene is the single most important procedure for preventing the spread of infections. Hand hygiene (soap-and-water washing or a waterless alcohol-based hand rub) must be performed:

  • After removal of gloves or other protective equipment
  • Immediately after hand contact with blood or other infectious materials
  • Upon leaving the work area

Hand hygiene should be performed before and after patient contact and after using restroom facilities. Soap-and-water hand washing must be performed whenever hands are visibly contaminated or there is a reasonable likelihood of contamination. It is advisable to keep fingernails short and to wear minimal jewelry.

Needlesticks and Sharps Disposal

The OSHA Bloodborne Pathogens Standard was amended in 2001 to add the provisions of the Needlestick Safety and Prevention Act of 2001. Since then, safety syringes are required for use whenever possible in healthcare facilities. This legislation mandates that institutions conduct annual product reviews of sharps safety devices and that non-managerial employees must be involved in the decision-making process (OSHA, 2013).

Needlesticks and other sharps injuries carry extra risk of exposure to infectious organisms because they bypass the protection of intact skin. The best way to prevent cuts and sticks is to minimize contact with sharps. That means:

  • Not using a sharp when an alternative method is available
  • Activating safety sharps immediately following completion of use
  • Disposing of used sharps immediately

Recapping, bending, or removing needles should not be done unless there is no feasible alternative or if required for a specific medical procedure. If recapping, bending, or removal is necessary, workers must use either a mechanical device or a one-handed technique. If recapping is required, a one-handed “scoop” technique may be used, using the needle itself to pick up the cap, pushing cap and sharp together against a hard surface to ensure a tight fit.

Puncture-resistant containers must be available nearby to hold contaminated sharps. When reusable sharps must be used, puncture-resistant transport containers must not require employees to reach a hand into the holding container.

Management of Occupational Exposures

The OSHA Bloodborne Pathogens Standard requires employers whose employees may have exposure to body fluids on the job to have a system in place for managing occupational exposures. This system must be available without delay, 24 hours per day, 7 days per week.

Employers must provide free medical evaluation and treatment to employees who experience an exposure incident. A licensed healthcare provider must 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 hepatitis B, hepatitis C, and HIV, with appropriate consent.

Sharps Injuries

If a sharps injury occurs, wash the exposed area with soap and water—do not “milk” or squeeze the wound. There is no evidence that using antiseptics (eg, hydrogen peroxide) reduces the risk of transmission for any bloodborne pathogens; however, the use of antiseptics is not contraindicated. In the event that the wound needs suturing, obtain emergency treatment.

Bite or Scratch Wounds

Exposure to saliva is not considered a substantial risk unless it is visibly contaminated with blood or the saliva is from a dental procedure. If you are exposed to saliva, wash the area with soap and water and cover it with a sterile dressing as appropriate. All bites should be evaluated. 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, Feces, or Sputum

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 up these fluids.

Reporting an Exposure

The OSHA Bloodborne Pathogens Standard requires medical followup for workers who have an exposure incident. Exposures should be reported within 1 hour if possible to allow for prompt intervention to reduce risk of infection if that is indicated.

If an exposure occurs, follow the protocol of your employer. After cleansing the exposed area, report the exposure to the department or individual at your workplace who is responsible for managing exposure. Obtain a medical evaluation as soon as possible and determine the extent of the exposure, treatment, followup care, personal prevention measures, need for a tetanus shot, and other care.

Your employer is required to provide an appropriate post exposure management referral at no cost to you. Your employer must also 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 the employer is responsible to maintain, including vaccination status, relevant to the appropriate treatment of the employee

Post Exposure Prophylaxis

Post exposure prophylaxis (PEP) has been the standard of care for occupationally exposed healthcare workers since 1996. It provides anti-HIV medications to someone who has had an exposure, usually to blood. To be effective, PEP must begin within 2 hours of exposure, before the virus has time to begin to replicate. A first dose of PEP should be offered while evaluation is underway. PEP should not be delayed while awaiting more information about the source patient or results of the exposed worker’s baseline HIV test (HIV Clinical Resource, 2012).

Rapid testing is strongly recommended for the source patient—and for those organizations subject to OSHA regulations, rapid testing is mandated for occupational exposures. If the source patient’s rapid HIV test result is negative but there has been a risk for HIV exposure in the previous 6 weeks, plasma HIV RNA testing of the source patient is also recommended. In this situation, PEP should be initiated and continued until results of the plasma HIV RNA assay are available (HIV Clinical Resource, 2012).

A baseline HIV test of the exposed worker should always be obtained after an occupational exposure, even if the exposed worker declines PEP. Regardless of whether the exposed worker accepts or declines PEP treatment, if the post-exposure evaluation determines that PEP is indicated, repeat HIV testing at 4 weeks and 12 weeks should be obtained. A negative HIV test result at 12 weeks post exposure reasonably excludes HIV infection related to the occupational exposure; routine testing at 6 months post exposure is no longer recommended (HIV Clinical Resource, 2012).

Highly active antiretroviral therapy (HAART) is always recommended for at-risk exposures. Any variance from the recommended regimens should be made in consultation with an HIV specialist or an occupational health clinician experienced in providing PEP. Antiretroviral (ARV) medications for PEP should be readily available to healthcare workers who sustain a known or highly suspect occupational exposure to HIV (HIV Clinical Resource, 2012).

The preferred PEP regimen is tenofovir + emtricitabine* plus raltegravir. Zidovudine is no longer recommended in the preferred PEP regimen. The first dose should be given as soon as possible after exposure, ideally within 2 hours. The recommended duration of PEP is 28 days (HIV Clinical Resource, 2012).

*Lamivudine may be substituted for emtricitabine.

 

HIV PEP Regimen Following Occupational Exposure

Tenofovirb 300 mg PO qd + Emtricitabineb,c 200 mg PO qd

Plus

Raltegravird 400 mg PO bid

Source: HIV Clinical Resource, 2012.

For detailed clinical information about post exposure prophylaxis please see: HIV Prophylaxis Following Occupational Exposure at this source.

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