ATrain Education

 

Continuing Education for Health Professionals

NY: Infection Control and Prevention, including Sepsis

Module 10

Occupational Exposure to Bloodborne Pathogens

The need to protect healthcare workers from bloodborne exposures resulted in OSHA’s publication in 1991 of the Bloodborne Pathogens Standard. The Standard requires employers whose employees have exposure to blood to provide safe work practices, education, and barriers to exposure. As noted earlier, the Standard was later amended to add requirements for the safe use of sharps devices (OSHA, 2012, 1991).

Important factors that influence the overall risk for occupational exposures to bloodborne pathogens include the number of infected individuals in the patient population and the type and number of blood contacts. Most exposures do not result in infection. Following a specific exposure, the risk of infection may vary, depending upon the:

  • Pathogen involved
  • Type of exposure
  • Amount of blood involved in the exposure
  • Amount of virus in the patient’s blood at the time of exposure

An occupational exposure is defined as a percutaneous injury or contact of mucous membrane or non-intact skin with blood, tissue, or OPIM. 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
  • Whether the exposure was to non-intact skin or mucus membranes
  • The amount of blood that was involved
  • The amount of virus present in the source’s blood

If a sharps injury occurs, as soon as safely possible,

  • Wash the affected area with soap and water.
  • Do not “milk” or squeeze the wound.
  • Application of antiseptics should not be a substitute for washing. There is no evidence that using antiseptics (like hydrogen peroxide) will reduce the risk of transmission for any bloodborne pathogens; however, the use of antiseptics is not contraindicated.
  • The risk of contracting HIV from a sharps injury is estimated to be 0.3%.

If there is exposure to the eyes, nose, or mouth,

  • Flush thoroughly with water, saline, or sterile irrigants.
  • Remove any potentially contaminated clothing as soon as possible.
  • Familiarize yourself with existing protocols and the location of emergency eyewash or showers and other stations within your facility in advance of need.
  • The risk of contracting HIV through this type of exposure is estimated to be 0.09%. (CDC, 2008)

NYS Guidelines for Post Exposure Prophylaxis

Organizations in New York State that employ health professionals or other persons who are at risk for occupational exposure to blood, body fluids, or OPIM are required to establish policies and procedures that guide the management of such exposures. Private employers subject to OSHA must conform to the OSHA Bloodborne Pathogen Standard, and public employers are subject to Public Employee Safety and Health Bureau (PESH) regulations. OSHA and PESH standards are identical regarding occupational exposure to bloodborne pathogens. These regulations require that a management plan be in place (NYSDOH, 2012).

The employer should ensure that any employee who sustains an occupational exposure has access to post-exposure services within 1 to 2 hours of a reported event. Services must be available 24 hours a day, every day. Organizations that do not have on-site occupational health services are required to form agreements or contracts with another facility, emergency department, or private practitioner for such services (NYSDOH, 2012).

Post-exposure services for exposures to all bloodborne pathogens include but are not limited to:

  • Post-exposure evaluation and followup post-exposure medications and/or vaccinations, as indicated
  • A full course of post-exposure prophylaxis medications, at no cost to the employee
  • Care provided under the supervision of a licensed physician or other licensed healthcare professional
  • The performance of laboratory tests by an accredited laboratory
  • Supportive counseling (NYSDOH 2012)

The National Needlestick Hotline is available 24 hours per day at 888 448 4911, without cost, for consultation by treating providers. Documentation of consultation may be prudent if PEP is being considered.

Federal law requires covered employers to ensure that all medical evaluations and procedures, vaccines, and post-exposure prophylaxis are made available to the employee within a reasonable time and place and are made available at no cost to the employee.

Both New York State’s PESH regulations and OSHA’s Bloodborne Pathogen Standard make the covered employer responsible for all costs associated with an exposure incident. An employer may not require the employee to pay any out-of-pocket expenses, such as requiring the employee to use workers’ compensation if prepayment is required, or compelling an employee to use health insurance (unless the employer pays all premiums and deductible costs associated with their employee’s health insurance). In addition to the services listed above, NYS Guidelines state that, when establishing plans for providing PEP for exposures to HIV, the employer must ensure that:

  • PEP will be made available within 1 to 2 hours of exposure, ideally within 1 hour.
  • A “starter kit,” or 3-day supply of the PEP, will be made available to the employee.
  • A mechanism is in place to provide the balance of the PEP medications needed to complete the 4-week regimen to the employee at no cost. (NYSDOH, 2012)

Post-exposure prophylaxis (PEP) provides 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 against HIV should be started as soon as possible—within hours, not days—after exposure and continued for 28 days if indicated. However, PEP for HIV does not provide prevention of other bloodborne diseases like HBV or HCV.

Hepatitis B PEP for susceptible persons 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.

For a susceptible person, the risk from a single needlestick or cut exposure to HBV-infected blood ranges from 6% to 30% and depends on the hepatitis Be antigen (HBeAg) status of the source individual. Hepatitis B surface antigen (HBsAg)-positive individuals who are also HBeAg-positive have more virus in their blood and are more likely to transmit HBV than those who are HBeAg-negative. While there is a risk for HBV infection from exposures of mucous membranes or non-intact skin, there is no known risk for HBV infection from exposure to intact skin (CDC, 2014b).

The average risk of HIV infection after a needlestick or cut exposure to HlV-infected blood is 0.3%. Stated another way, 99.7% of needlestick or cut exposures do not lead to infection. The risk after exposure of the eye, nose, or mouth to HIV-infected blood is estimated to be, on average, 0.1%. The risk after exposure of non-intact skin to HlV-infected blood is estimated to be less than 0.1%. A small amount of blood on intact skin probably poses no risk at all. There have been no documented cases of HIV transmission due to an exposure involving a small amount of blood on intact skin (a few drops of blood on skin for a short period of time) (CDC, 2014b).

The average risk for infection after a needlestick or cut exposure to HCV-infected blood is approximately 1.8%. The risk following a blood exposure to the eye, nose, or mouth is unknown, but is believed to be very small; however, HCV infection from blood splash to the eye has been reported. There also has been a report of HCV transmission that may have resulted from exposure to non-intact skin, but no known risk from exposure to intact skin (CDC, 2014b).

As of January 2014 there is no approved PEP against HCV. The benefit of the use of antiviral agents to prevent HCV infection is unknown and antivirals are not currently approved by the Federal Drug Administration (FDA) 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 medications may be prescribed. The national bloodborne pathogen hotline provides 24-hour consultation for clinicians who have been exposed on the job; it is available 24 hours per day at 888 448 4911, without cost.

Post-exposure prophylaxis 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 side effects. It is essential 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.

Workers Infected with HIV or Other Bloodborne Pathogens

New York State Department of Health policy on HIV testing of healthcare workers ensures that public protection is a primary consideration and that healthcare personnel are afforded appropriate and equitable treatment. The DOH has established a uniform process and criteria for evaluating HIV/HBV-infected healthcare workers to determine if practice limitations are warranted. They have issued a risk questionnaire, to be found in this source.

The evaluation of a healthcare worker should be based on the premise that HIV or HBV infection alone is not sufficient justification to limit a healthcare worker’s professional duties. The determination of whether an individual poses a significant risk to patients—which warrants job modification, limitation, or restriction—requires a case-by-case evaluation that considers the multiple factors that can influence risk. Periodic re-evaluation of an HIV-infected healthcare worker may be appropriate if physical or mental functioning changes due to disease progression (NYSDOH, 2011).

Factors that may have a bearing on the ability of healthcare workers, including those with bloodborne infections, to provide quality healthcare include:

  • Physical or mental conditions that may interfere with the worker’s ability to perform assigned tasks or regular duties
  • Lack of compliance with established guidelines to prevent transmission of disease
  • Documentation or evidence of previous transmission of bloodborne pathogens
  • The appropriateness of techniques as related to performance of procedures
  • Any health condition that would pose a significant risk to others (NYSDOH, 2011)

Expert Bloodborne Pathogen Workforce Review Panels

In 1992 the NYSDOH established a voluntary evaluation process to provide guidance to HIV/HBV-infected healthcare workers who seek consultation. Access to state-appointed panel review is available to infected healthcare workers who perform procedures that might increase the risk of worker-to-patient blood exposure. State panels function as a primary evaluation resource for practitioners who are not affiliated with institutions, or as a second opinion for workers affiliated with health facilities who have been evaluated by their institutions (NYSDOH, 2011 rev.).

Each panel includes a public health official, an infectious disease expert, and an expert in infection control or epidemiology. In addition, an individual from the infected practitioner’s area of practice and the individual’s private physician may be asked to serve as members of the panel. The purpose of such panels is to provide timely advice and consultation on individuals’ risk of bloodborne disease transmission through their professional practice, and to recommend practice limitations, modifications, or restrictions where the evidence suggests there is a significant risk to patients (NYSDOH, 2011 rev.).

All citizens, including HIV-infected healthcare workers, are entitled to protections under the New York State HIV Confidentiality Law. Such workers are not required to disclose their HIV status to patients or employers. Healthcare facilities are under no obligation under New York law to disclose to patients the status of an infected healthcare worker in their employ. Disclosure—without the consent of the worker—would likely violate New York’s HIV Confidentiality Law (NYSDOH, 2011 rev.).

Notification of patients that they were exposed to the blood of a healthcare worker should be based on documentation of an injury to a worker that could have resulted in the worker’s blood coming into direct contact with a patient’s bloodstream or mucous membranes. In such circumstances, the patient should be advised to receive testing for potential HIV or HBV exposure. The DOH will be available to assist hospitals in determining if a significant risk of exposure to bloodborne pathogens warrants notification to patients (NYSDOH, 2011 rev.).

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