Transcript Slide 1

ONLINE ORIENTATION
Clinic Environment
About EHS
We support the University's core mission of teaching,
research, and service by providing comprehensive
environmental, health and safety services to the
University community including: education through
training and consultation; maintaining a safe
environment; ensuring regulatory compliance; and
controlling recognized health and safety hazards.
To achieve this mission we must rely on all University
employees to understand and recognize safety
policy and procedures.
About EHS
The responsibility of the department of Environment, Health and Safety
is to develop a comprehensive program to comply with the
provisions of each of the following regulations: Occupational Safety
and Health Act (OSHA)
 Environmental Protection Agency (EPA)
 NC DENR NC Department of Environment and Natural Resources
 Joint Commission on Accreditation of Healthcare Organization
(JCAHO)
 NC Radiation Protection Section (NCRPS)
 Office of State Personnel (OSP)
 NC Fire Prevention Codes
 NFPA 101 Life Safety Codes
About EHS
EHS provides comprehensive support for the University
community in the areas of environmental
compliance, occupational health and safety. To
learn more about each section, please visit EHS’s
website at http://ehs.unc.edu.
Workplace Safety Program
In accordance to University policy and North Carolina General Statute Article
63, each state agency must have a written Health and Safety program with
clearly stated goals or objectives that promote safe and healthful working
conditions. The Environment, Health and Safety manual along with other
specific manuals, such as Radiation Safety Manual, Laboratory Safety
Manual, and Biological Safety manual serves as the University's written
Health and Safety program. These manuals provide University employees
with the necessary guidance in maintaining a safe work environment. Each
of these manuals can be viewed in more detail by selecting "Manuals" from
the EHS web site.
 Other elements of the Workplace Safety program include:
 Conduct new employee training to help with the identification of and
correction of hazards,
 Review workplace incidents and develop ways to eliminate or minimize
hazards, and
 Employee input through safety committees
Workplace Safety Program
UNC's health and safety committees perform workplace inspections, review
injury and illness records, make advisory recommendations to the
administration, and perform other functions determined by the State
Personnel Commission. The Workplace Safety Committees report through
the following structure:
UNC employees should contact EHS or any committee member regarding
safety concerns.
Workplace Safety Program
If you are interested in serving on one of the
committees please feel free to contact the EHS
office at (919) 962-5507.
Fire Safety Program
UNC's Fire Safety program is based on NFPA 101 Life Safety
Code, N.C. Fire Prevention Code, and OSHA 1910 Subpart
E. Your understanding and contribution to Fire Safety is the
key to an effective fire protection program for the
University. Regularly inspecting your area for
 electrical hazards
 storage in hallways
 blocked exit ways
 adequate lighting of exits
 general housekeeping
can prevent a fire from occurring and provide employees with
a safe passage in the event of a fire.
Fire Safety Program
If a fire or other emergency occurs in your building,
employees must know two Means of Egress (exit).
OSHA defines Means of Egress as "A continuous
and unobstructed way of exit travel from any point
in a building or structure to a public way." The three
main components of Means of Egress are:
 The way of Exit Access
 The exit
 The way of Exit Discharge
Fire Safety Program
Exit Access is the
area in which an
employee uses as
their means of
exiting to an exit.
Exit Discharge
is the exit from
a building to a
public way.
Exit is the protected
way of travel to the
exit discharge.
Fire Safety Program
The Department of EHS has prepared a general Emergency
Action Plan for the University to follow. An Emergency Action
Plan is "a plan for the workplace describing what
procedures the employers and employees must take to
ensure employee's safety from fire and other emergencies"
(1910.35j). The plan includes:
 posting of planned evacuation routes
 procedures to follow in the event of a fire or emergency
 procedures to account for employees after evacuation
 procedures for employees who remain to operate critical
equipment in an emergency
Fire Safety Program
Posting of Planned Evacuation Routes - Building
evacuation procedure for your department should
be posted on the office bulletin board and at all
elevators. Employees should know at least two
evacuation routes for their designated work area
and any area that they frequent often. Employees
are encouraged to evaluate the building evacuation
areas daily to ensure that there are no obstructions.
If obstructions are found, please report it to the EHS
immediately at (919) 962-5507.
Fire Safety Program
Procedures to Follow - If a fire emergency was to
occur in your workplace, it is vital that you be
prepared to react. The acronym RACE provides the
basic steps of the Emergency Action Plan to follow:
 Remove or rescue individuals in immediate danger
 Activate the alarm by pulling the fire pull station
located in the corridors and calling 911.
 Confine the fire by closing windows, vents and doors
 Evacuate to safe area (know the evacuation routes
for your areas).
Fire Safety Program
Procedures to Account for Employees – The
University has designated an Emergency
Coordinator(s) for all occupied buildings. Each
Emergency Coordinator (EC) is responsible for
assisting in the safe and orderly emergency
evacuation of employees. In preparation for
an emergency, the EC completes an
information card that includes:
 evacuation monitors' names
 employee names and phone numbers
occupying building
 location of employees needing assistance
 rooms containing hazardous material,
 and equipment needing special attention.
Fire Safety Program
In an emergency, each Emergency Coordinator is
responsible for the following in accordance with the
University Emergency Plan:
 Sweep through assigned area to alert occupants that
an evacuation is in process.
 Assist building occupants needing special assistance
 Report to the University Emergency Command Sector
with emergency information card
 Advise emergency personnel regarding building
contents
 Account for all employees by meeting building
occupants at the assembly area
 Advise building occupants regarding situation and
when re-entry is permitted
 Advise Facilities Services personnel in cleanup
operations.
Fire Safety Program
To extinguish a fire requires proper identification of the type of fire
extinguisher to use. There are four classes of extinguishers to choose from.
Class
Fire Type
Extinguisher Contains
Class A
Ordinary combustible products such
as paper, cloth or wood
Water
Class B
Flammable Liquids such as petroleum
base oil, solvents, greases, and
gasses
Dry chemicals such as carbon
dioxide or halogenated agents
Class C
Electrical
Dry chemicals such as carbon
dioxide or halogenated agents
Class D
Combustible Metals (ex: magnesium
sodium)
Special liquid or dry powder agent
Currently University buildings are equipped with Type ABC fire extinguishers,
except in computer labs or mechanical rooms with have CO2 extinguishers.
Fire Safety Program
Only University employees working in
healthcare, emergency response, and/or
whose job requires them to use a fire
extinguisher are required to receive annual
hands on fire extinguisher training. EHS Fire
Safety section conducts annual classes in
different locations on campus. For other
employees it is beneficial to know how a fire
extinguisher is used. Remembering the
acronym PASS will assist in the proper use of
a fire extinguisher.
 Pull the pin between the handles.
 Aim the nozzle at the base of the fire.
 Squeeze the handles together.
 Sweep the extinguisher from side to side
at the base of the fire.
Fire Safety Program
A few fire safety reminders:
 Everyone is responsible for keeping the work area safe
from fires.
 Review your evacuation routes to ensure that exits and
passageways are unobstructed.
 Practice good general housekeeping.
 Store flammable liquids and combustible material
properly.
 Report any fire hazards or other safety concerns
immediately to the department of Environment, Health
and Safety at (919) 962-5507.
Workers’ Compensation Program
Workers' Compensation benefits are available to any
University employee (whether full-time, part-time,
temporary) who suffers disability through accident
or illness arising out of, and in the scope of, his or
her employment, according to the North Carolina
Workers' Compensation Act.
Workers’ Compensation Program
The benefits provided to University Employees include
medical and leave. Medical benefits include all
authorized medical services such as physician visit,
prescriptions, physical therapy, rehabilitation, etc.
Leave benefits are provided to employees when an
authorized medical provider places an employee
out work.
Workers’ Compensation Program
If you receive an injury or occupational illness, go directly to the
University Employee Occupational Health Clinic (UEOHC) located at
145 N. Medical Drive. The UEOHC is open from 8:30 am to 4:30 pm
Monday thru Friday, except holidays.
For after hours needlestick/human blood or body fluid exposures,
please call UEOHC at 966-9119. The UEOHC line will automatically
forward your call to Healthlink in order to gather the appropriate
information and put you in contact with the Family Practice physician
covering the needlestick hotline. For all other after-hour work
related injuries that require immediate medical care, go directly to
the UNC Emergency Department. If immediate medical care is not
needed, then please report to the UEOHC the following day.
For a life-threatening injury or illness, go directly to the Emergency
Department located in the Neurosciences Hospital on Manning Drive.
Workers’ Compensation Program
If you experienced an on-the-job injury or illness, you
are to report the incident immediately to your
supervisor no matter how minor. Once the injury is
reported, an incident investigation will occur to
determine the cause of the incident and corrective
action taken to prevent the incident from
reoccurring. Please note: Failure to report an injury
could result in the denial of your claim.
Workers’ Compensation Program
For further information concerning University policies
on workplace injuries and illnesses, refer to the
"Workers' Compensation" pages on the EHS web
site.
Hazard Communication Background
What is OSHA’s Hazard Communication Standard?
OSHA’s Hazard Communication standard (29 CFR
1910.1200), promulgated 1994, requires that
employees be informed of the hazards of chemical(s)
that they work with or are present in their work area.
OSHA Hazard Communication
Standard (continued)
The four elements of the program include:
 Ensuring chemicals are labeled
 Maintaining departmental/work unit/laboratory
chemical inventories
 Maintaining Material Safety Data Sheets (MSDS)
 Training of personnel by Supervisor on the
chemicals that are used or in the workplace
OSHA collaborates with United Nation
Understanding the need for
consistent classifications of
hazards chemicals, OSHA
decided to better align with the
United Nations’ Globally
Harmonized System by adopting
a common classification and
labeling of chemicals.
To view details of this
report, double click picture.
Benefits of Adopting GHS
There are several benefits for OSHA in adopting the
Globally Harmonized system. In particular, it will
provide a common and coherent approach to
classifying chemicals and communicating hazard
information on labels and safety data sheets. Thus
resulting in:
• Consistency of information provided
• Increase comprehension of hazards
• Help address literacy problems
• Facilitation of international trade of chemicals
OSHA Publishes Revised Standard
In March 2012, the revised Hazard Communication Standard
became law and included an established timeframe for
implementation. The table below outlines the effective dates,
requirements and responsible parties.
Effective Completion Date
Requirement(s)
Who
December 1, 2013
Train employees on the new label elements and SDS
format.
Employers
June 1, 2015*
Comply with all modified provisions of this final rule,
except:
December 1, 2015
Distributors may ship products labeled by
manufacturers under the old system until December 1,
2015.
Chemical
manufacturers,
importers, distributors
and employers
June 1, 2016
Update alternative workplace labeling and hazard
communication program as necessary, and provide
additional employee training for newly identified
physical or health hazards.
Employers
Transition Period
Comply with either 29 CFR 1910.1200 (this final
standard), or the current standard, or both
All chemical
manufacturers,
importers, distributors
and employers
Benefit of HazCom2012
With the University’s mission to “serve North Carolina,
the United States, and the World through teaching,
research, and public service,” the new requirements
under HazCom 2012 will enhance clarity for
University employees positioned on campus as well as
abroad.
HazCom2012 Requirements
By December 2013, all University employees are to
have received general training regarding
“definitions”, “label” and “Safety Data Sheet” for
chemicals under new HazCom 2012 standard.
Supervisors are still required to provide job specific
training to employees on the chemicals used in their
area at least once and every time a new chemical is
added. The training must cover proper use, handling,
and personal protective equipment required for the
safe handling of the hazardous chemicals.
Definitions
HazCom 2012 will use a “specification” approach
rather than a “performance-oriented” approach.
Hazards will be classified thus providing a specific
criteria for classification of health and physical
hazards, as well as classification of mixtures.
Specifically:
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Appendix A defines health and physical hazards
Appendix B includes additional parameters to evaluate health
hazard data
Appendix F pertains to Carcinogens
Labels
HazCom 2012 requires
chemical manufacturers and
importers to provide a
label that includes a
harmonized product
identifier, pictogram, signal
word, and hazard
statement for each hazard
class and category.
Precautionary statements
must also be provided.
Labels - Pictograms
Pictograms are required on labels to alert users of the chemical
hazards to which they may be exposed. Each pictogram consists
of a symbol on a white background framed within a red border
and represents a distinct hazard(s), such as health, physical, and
environmental . The pictogram on the label is determined by the
chemical hazard classification. There are nine pictograms with
only the environmental pictogram being optional.
Labels – Distinct Hazards
As previously stated, “Distinct hazards” are chemicals
in which there is scientific evidence that a health,
physical, and/or environmental hazards may occur.
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Health Hazard - acute or chronic health affects may occur if
exposed.
Physical Hazard - a combustible liquid, a compressed gas,
explosive, flammable, an organic peroxide, an oxidizer,
pyrophoric, unstable (reactive) or water-reactive
Environmental Hazard – pose risk or danger to the
environment
Labels – Pictograms (Health)
Skull and Cross Bones will appear on the most severely toxic
chemicals. Depending on the toxicity of the chemical, the skull
and crossbones indicates that the chemical may be toxic or
fatal. Specifically it can mean:
 Acute Toxicity (fatal and toxic)
 Fatal in contact with skin
 Fatal if inhaled
 Fatal if swallowed
 Toxic if swallowed
 Toxic in contact with skin
Examples: Carbon Monoxide, Ammonia,
Acrylonitrile, Arsenic
Labels – Pictograms (Health)
Corrosive will appear on chemicals that have
corrosive properties. Depending on the properties
of the chemical(s) in the product, the corrosion
pictogram can mean:

May be corrosive to metals

Causes severe skin burns

Causes serious eye damage
Examples: Sodium Hydroxide (lye) and Sulfuric Acid
Labels – Pictograms (Health)
Exclamation Mark will appear on chemicals with less severe toxicity. This
symbol will never be used with “skull and crossbones” symbol. Depending
on the health hazard, it can mean:
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Harmful if swallowed
Acute Toxicity (harmful)
Harmful in contact with skin
Skin Sensitizer
Harmful if inhaled
Respiratory Tract Irritant
Causes skin irritation
Irritant (skin and eye)
Causes serious eye irritation
May cause allergic skin reaction
Hazardous to Ozone Layer
Examples: Isopropyl Alcohol, Ethyl Alcohol, Acetone
Labels – Pictograms (Health)
Health Hazard will appear on chemicals with less severe toxicity. This
symbol will never be used with “skull and crossbones” symbol. Depending
on the health hazard, it can mean:

Carcinogen

Mutagenicity

Reproductive Toxicity

Respiratory Sensitizer

Target Organ Toxicity

Aspiration Toxicity
Examples: Carbon Monoxide, Hexanes
Labels – Pictograms (Health/Physical)
Gas Cylinder can cause fires, explosions, oxygen
deficient atmospheres, toxic gas exposures as well as the
innate physical hazard associated with cylinders under
high pressure
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Gases under pressure
Compressed gases
Liquefied gases
Refrigerated liquefied gases
Dissolved gases
Examples: Butane and Propane
Labels – Pictograms (Physical)
Exploding Bomb symbol will appear on chemicals that
have explosive properties.
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Unstable Explosives
Self-reactive substances and mixtures
Organic peroxides
Examples: Nitroglycerine and TNT, Gunpowder, Rocket
propellants, and Pyrotechnic mixtures (fireworks).
Labels – Pictograms (Physical)
Flame symbol will appear on chemicals that are flammable.
Depending on the properties of the chemical(s) and the
product, the flame can mean:
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Extremely flammable gas
Extremely flammable aerosol
Self-Heating
Flammable aerosol
Extremely flammable liquid and vapor
Highly flammable liquid and vapor
Flammable liquid and vapor
Flammable solid
Examples: Butane, Pyrophorics, Organic Peroxides
Labels – Pictograms (Physical)
Flame over circle symbol will appear on chemicals that are:


Oxidizers
Oxidizing gases, liquids, and solids
Examples: Hydrogen Peroxide and Nitrous Oxide
Labels – Pictograms (Environment)
Environment symbol will appear on chemicals which
are acutely hazardous to fish, crustacean, or aquatic
plants. This is the only symbol that is not mandatory.

Aquatic Toxicity

Acute hazards to the aquatic environment

Chronic hazards to the aquatic environment
Label – Signal Word
A Signal Word is used to indicate
the relative level of severity of
hazard and alert the reader to a
potential hazard on the label. The
signal words used are:


"Danger" - used for the more
severe hazards
“Warning" - used for less
severe hazards.
Labels- Hazard Statement
A Hazard Statement describes the nature of the
hazard(s) of a chemical, including where appropriate
the degree of hazard.
All of the applicable hazard
statements must appear on
the label.
Labels – Precautionary Statement
A Precautionary Statement
is a statement that describes
recommended measures that
should be taken to minimize
or prevent adverse effects.
Label –
What do UNC Employees need to do?
Effective June 1 2015, all chemicals received
at the University should have the required
label. Any material transferred to another
container must also have the same label
versus just chemical/product name.
Safety Data Sheets
HazCom 2012 requires Safety Data Sheets - SDS
(formerly known as Material Safety Data Sheets –
MSDS) to use a specified 16-section standardized
format.
Under the new format, employees wanting information
regarding Exposure Controls/Personal Protection will
always refer to Section 8 of the Safety Data Sheets.
Safety Data Sheets
To improve employee understanding, information
listed on the label, like Precautionary Statement, will
be same information the employee will find on the
Safety Data Sheet.
The standardize 16 sections is broken down as
follows:
Safety Data Sheet – 16 Sections
1.
2.
3.
Identification of the substance
or mixture and of the supplier
11.
12.
Hazards identification
Composition/information on
ingredients Substance/Mixture
4.
First aid measures
5.
Firefighting measures
6.
Accidental release measures
7.
Handling and storage
8.
Exposure controls/personal protection
9.
Physical and chemical properties
10.
Stability and reactivity
13.
14.
15.
16.
Toxicological
Ecological information
(non mandatory)
Disposal considerations
(non mandatory)
Transport information
(non mandatory)
Regulatory information
(non mandatory)
Other information including information
on preparation and revision of the SDS
Safety Data Sheets –
What do UNC Employees need to do?
By December 2015, distributors must provide the new
format of Safety Data Sheets. Supervisors need to
update the Safety Data Sheet notebooks and/or
computer links in their job specific area to the newly
format sheets.
Remember SDS(s) must be accessible to employees at
all times.
NC OSHA– Enforcement
By June 2016, NC OSHA will begin to enforce
compliance with HazCom 2012 by conducting site
evaluations.
Environment, Health and Safety will continue to assist
University departments with the implementation of the
specific requirements covered in this training.
Resources OSHA’s HazCom2012 Web Page
OSHA has
developed an
extensive web
page to provide
additional
resources for
employees at
http://www.osha.gov/dsg/hazcom/index.html
Resources Guidance & Outreach
Supervisors can find printable
guidance material that can be utilized
when training employees.
• Guidance
»
»
»
OSHA Briefs
Fact Sheet
Quick Cards
Asbestos on Campus
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As an employee of UNC, EHS is informing you of the presence of asbestoscontaining materials in residence halls and campus buildings. Provided the materials
are in good condition, they pose no health risk to the building occupants.
http://www.ehs.unc.edu/ih/asbestos.shtml
UNC has an Asbestos Control Policy and Program to manage asbestos on UNC's
campus.
Materials containing asbestos may include flooring, ceilings, walls, thermal system
insulation on tanks, pipes and other miscellaneous materials.
UNC maintains asbestos-containing materials so they do not release asbestos fibers
into the air. When asbestos containing materials become damaged, isolation, repair
and/or removal are implemented immediately.
The University has a staff of accredited professionals that conduct building
inspections, coordinate and supervise asbestos related construction activities,
perform air monitoring and provide employee training.
If you have any questions concerning asbestos in a specific building on campus,
please feel free to contact EHS at 919-962-5507 to make an appointment to
review the building inspection reports.
Clinical Safety Program
The clinical safety program at UNC is designed to promote environments
that are free of hazards specific to clinical environments. Clinical
environments are classified as areas such as healthcare facilities,
laboratories that are dealing with blood or bodily fluids, or any other
facility that is dealing with procedures that involve hazardous materials
and biological agents. These areas need special attention to hazards to
protect both the employees and the patients.
Clinical Safety Issues

In the clinic environment safety issues arise that are specific to
personnel working in a healthcare facility. All University healthcare
workers are expected to conduct their daily activities in such a way
that they do not expose themselves or others to potential injury, such
as:
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Needlestick or sharp injuries
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Back injuries

Chemical exposures

Slips and falls
Needlesticks or Sharp Injuries
Needlesticks or sharp injuries are instances where an
employee was exposed to a needle or other sharp
tool or object, and were injured. These injuries
normally break the skin and expose the employee to
blood or other bodily fluids.
Certain measures may be taken to reduce exposure.
These measures include: using appropriate
engineering controls and using proper personal
protective equipment (PPE).
Needlesticks or Sharp Injuries, cont.
Engineering controls are used to isolate or remove the
bloodborne pathogens hazards from the workplace.
Examples may include but are not limited to sharps
disposal containers, self-sheathing needles, and safer
medical devices, such as sharps with engineered
sharps injury protectors and needleless systems.
Personal Protective Equipment (PPE) is specialized
clothing or equipment worn by an employee for
protection of a hazard.
Lifting Techniques
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Proper lifting techniques are also important in clinic
environments. An employee should maintain good
body posture, use safe body mechanics (bend at the
hips and knees, not at the waist), and assess the
situation of a patient before lifting or transferring a
patient.
An employee may also use lifting devices to aid them
in achieving proper lifting techniques. In the
healthcare facilities, there are devices which aid
employees when lifting a patient.
Chemical Exposures
Following appropriate procedures when exposed to
chemicals or other hazardous materials is necessary
for preventing incidents. Hazardous materials are
those substances that are potentially hazardous to
your safety and health. Employees may encounter
many hazardous materials that are classified as
health and/or physical hazards.
A health hazard is anything that causes acute or chronic
health effects. A physical hazard is any chemical that
is flammable, an oxidizer, or corrosive..
Chemical Exposures, cont.
Examples of hazardous materials in the clinic environment
include infectious waste, flammable liquids and gases,
toxic chemicals, radioactive materials, cancer causing
(carcinogens) chemicals and drugs, and compressed gas
cylinders.
All departments using hazardous chemicals are responsible
for determining if a less hazardous chemical may be
substituted. The unsafe handling of hazardous materials
can have an impact on ambulatory care or hospital
operations. Appropriate precautions should always be
used in handling hazardous materials..
Slips and Falls
Another example of incidents that are common in the
clinic environment is slips and falls. Employees should
be aware of their surroundings and should pay
particular attention to areas where there could be
potential moisture on the floor or walking surface that
might cause them to slip or fall.
Needlestick Safety and Prevention Act
The Needlestick Safety and Prevention Act became law
in 2000. This law revised the Bloodborne Pathogens
Standard (29 CFR 1910.1030) to include safer
medical devices, such as sharps with engineered
sharps injury protections and needleless systems, as
examples of engineering controls designed to
eliminate or minimize occupational exposure to
bloodborne pathogens through needlesticks and other
percutaneous exposures.
Requirements
Requirements of the needlestick safety and prevention act include:

Review and update exposure control plans to reflect changes in
technology that eliminate or reduce such exposure,

Document the consideration and implementation of appropriate
commercially available, safer medical devices that eliminate or
reduce exposure,
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Maintain a sharps injury log, noting the type and brand of device
used, where the injury occurred, and an explanation of the incident,

Seek input on such engineering and work practice controls from the
affected healthcare workers.
Needlestick Safety and Prevention at UNC
UNC makes every attempt to ensure safety for all
employees who are exposed to needles and other
sharps. Needlesticks are one of the most common
incidents in the workplace. UNC and UNC-Healthcare
have formed a Needlestick Task force that convenes
twice a year to examine and evaluate techniques and
protocols to stay abreast of innovative technologies
to decrease the number of needlestick occurrences. In
addition, members of the Occupational
Health/Clinical Safety Committee also address
needlestick safety and prevention.
Latex Exposure
A recently recognized work place hazard for some
healthcare workers is latex exposure. For some
individuals exposure to latex products, such as
powdered latex exam gloves, can cause a mild to
severe allergic reaction.
Latex Allergy Prevention
To prevent latex allergies do the following:
 Use non-latex gloves for activities that are likely to
involve contact with infectious substances
 If you choose latex gloves, use powder-free gloves
 When using gloves, do not use oil-based hand cream
or lotions
 Recognize the symptoms of latex allergy
 Always wash hands after removing gloves
Latex Allergy
If you believe that you may have a latex allergy, you
should notify your supervisor and contact the
University Employee Occupational Health Clinic
(UEOHC) for evaluation at (919) 966-9119.
Additional information regarding potential hazards
associated with latex exposure is also available by
contacting the UEOHC.
Disaster Plan Manuals
The UNC Department of Environment, Health and
Safety, UNC Hospitals and some specific departments
have Disaster Plan Manuals that provide all
employees with a written resource to accomplish an
effective response to disaster events. The UNC EHS
plan can be found at EHS's online manual.
The Director-on-Call and the Disaster Commander will
assess the need for personnel, supplies, and
equipment. In addition, all departments need to have
an internal plan on what to do during a disaster.
If a Disaster Occurs
If a disaster occurs which compromises the utilities of the
facility, it should be reported to the Facilities Services
Division (919) 962-3456 in University buildings and
Plant Engineering (919) 966-4484 in Hospital
buildings.
ID Badges
It is imperative that employees wear their ID badges at
all times. These badges will include emergency code
announcements and steps to take in the event a code
is called. ID badges are also an essential part of the
health and safety system due to security issues.
Hazard Assessment and Equipment
Selection
The department in consultation with the Department of
Environment Health and Safety will assess the
workplace to determine if hazards are present, or
likely to be present, and requires the use of Personal
Protective Equipment (PPE). If such hazards are
present, or likely to be present, the University will:
 Select and have each affected employee use the
types of PPE that will protect the affected employee
from the hazards identified in the hazard assessment.
Hazard Assessment and Equipment
Selection, con’t.
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

Communicate selection decisions to each employee
Select PPE that properly fits each affected employee
Verify that the required workplace hazard
assessment has been performed through a written
certification that identifies the workplace evaluated,
the person certifying that the evaluation has been
performed, and the dates of the hazard assessment.
Hazard Assessment and Equipment
Selection, con't.
Employees working in a clinical facility must wear
proper personal protective equipment. An assessment
should be conducted to determine proper personal
protective equipment. Below you will find an example
of a hazard assessment for employees working in a
healthcare environment. Also, remember to always use
standard precautions as all patients are potentially
infectious.
Personal Protective Equipment (PPE)
Personal Protective Equipment should be:
 Inspected before and after each use
 Used where there is occupational exposure
 Used appropriately
 Used only when its integrity is insured
 Accessible
 Removed when contaminated and prior to leaving
the work area
PPE Training
The University will provide training to each employee
who is required to use PPE. Each affected employee
shall demonstrate an understanding of the training
and the ability to use PPE properly, before being
allowed to perform work requiring the use of PPE.
The training program must verify that each affected
employee has received and understood the required
training through a written certification that contains
the name of each trained employee, the dates of
training, and that identifies the subject of the
certification.
PPE Training, con’t.
Each employee is to be trained to know at least the
following:
 when PPE is necessary
 what PPE is necessary
 how to properly don (put on), doff (take off), adjust,
and wear PPE
 the limitations of the PPE
 the proper care, maintenance, useful life and
disposal of the PPE
PPE Training, con't.
The training program must verify that each affected employee has
received and understood the required training through a written
certification that contains the name of each trained employee, the dates
of training, and that identifies the subject of the certification. Click this
link for a certification form for Personal Protective Equipment.
Training and Medical Surveillance
Program
OSHA and JCAHO regulations require that all
employees who have duties in or are located in a
healthcare facility receive medical surveillance and
attend additional safety training.
Medical Surveillance
All healthcare employees are required to complete a one-time





immunization review through the UEOHC. The immunization
review consists of:
A record of 2 Measles, 2 Mumps, and 2 Rubella (disease or
vaccine for all) OR titers for all OR a record of 1 Tdap
(Tetanus, diptheria, acellular pretusis)
A record of the Hepatitis B series (for those exposed to blood
or bodily fluids)
Verbal response for Varicella (Chicken Pox)
Verbal response for Latex Allergy
Annual Tuberculosis Screening
Medical Surveillance, con’t.
Annually thereafter, employees are to complete a
Tuberculosis Screening through the UEOHC. UNC
Environment, Health and Safety will notify employees
who need to renew his/her TB screening via campus
mail the month that it is up for renewal. Department
representatives will also receive monthly compliance
reports stating the current status of their employees.
Training
Employees who are classified as working in a clinic
environment are required to complete annual training
on JCAHO/General Safety, Tuberculosis, and
Bloodborne Pathogens for those who are potentially
exposed to blood or other bodily fluid. These training
requirements can be completed either by utilizing
EHS's online self-study units or by attending instructor
led classes which are held every month. For more
details, select the training section on the EHS Website.
Bloodborne Pathogen Introduction
On December 6, 1991, the Occupational Safety and Health Administration
(OSHA) published their standard for occupational exposure to bloodborne
pathogens in the Federal Register 1910.1030, which can be found at the
following website: www.osha.gov. A component of this standard requires the
employer to provide training regarding the occupational hazard of
bloodborne pathogens. There are 14 required components of this training;
all of which are incorporated in this study module. These components are
listed in the Federal Register 1910.1030.
It is important to remember that OSHA standards are federal law and
compliance is mandatory. However, it is more important to recognize that
this standard was established to help protect the healthcare worker from
the serious workplace hazard of bloodborne pathogens.
Examples of Bloodborne
Pathogens
Bloodborne Pathogens are pathogenic microorganisms that are
present in human blood or Other Potentially Infectious Materials
(OPIM) and can cause disease in humans. These pathogens
include but are not limited to:
 HUMAN IMMUNODEFICIENCY VIRUS (HIV)
 HEPATITIS B (HBV)
 HEPATITIS C (HCV)
 NON A, NON B HEPATITIS
 SYPHILIS
 MALARIA
Potentially Infectious Body
Fluids/Materials
Exposure to human blood carries the greatest risk for acquiring a bloodborne
pathogen. However, other body fluids besides blood have demonstrated a viral
load sufficient to potentially transmit infection. These fluids are:

cerebrospinal fluid

semen

synovial fluid

vaginal secretions

pleural fluid

any body fluid contaminated with blood

amniotic fluid

saliva in dental procedures

pericardial fluid


peritoneal fluid
body fluids in emergency situations that cannot
be recognized
Also considered potentially infectious are:

unfixed tissue or body organs other than intact skin

blood, organs, and tissue from experimental animals infected with HIV or HBV
It is important for healthcare workers to prevent exposure to any body fluid. However,
only exposure to the above fluids or substances are considered potentially capable
of transmitting a bloodborne disease.
Transmission and Risk of
Infection
HIV and Hepatitis B virus are transmitted by sexual contact, sharing
contaminated needles or syringes and from mother to unborn child.
In the occupational setting transmission is by percutaneous injuries
(needlestick/sharp puncture or cut), mucous membrane and non-intact skin
exposure to contaminated blood or other potentially infectious materials
(OPIM).
HCV is transmitted by percutaneous exposure to contaminated blood and
plasma derivatives. The risk of HCV transmission by household contact and
sexual activity has not been well defined, but is believed to be low.
Transmission from mother to unborn child appears to be uncommon.
Not all the bloodborne pathogens carry the same risk of infection from an
occupational exposure. Frequency in patient population, the ability of the
virus to survive on environmental surfaces and the amount of virus present in
the body fluid, all impact the risk of acquiring infection.
Risk of Infection After
Occupational Exposure
If exposed. The following table demonstrates infection risk from a percutaneous
exposure to HBV, HCV, and HIV.
Risk of Infection From Percutaneous Exposure
Virus
Viral particles/mL of
serum/plasma
Infection Risk
HBV
102 - 108
30%
HCV
100 - 106
3%
HIV
100 - 103
0.3%
Human Immunodeficiency Virus
(HIV)
In a case-control study conducted by the Centers for Disease
Control (CDC), significant risk factors for HIV seroconversion
(acquired infection) after a percutaneous exposure were
determined to be the following.
 Deep Injury
 Visible blood on the device
 Procedure involving needle placed directly into a vein or
artery
 Terminal illness in the source patient
The study also found that postexposure prophylaxis with
zidovudine (AZT) was associated with a decrease in the risk of
HIV seroconversion.
Clinical Manifestation of HIV
Infection
The clinical picture of HIV infection ranges from those who have
no symptoms to person with severe immunodeficiency or
Acquired Immune Deficiency Syndrome (AIDS). Initial infection
can be followed by an acute flu-like illness. Symptoms include:
 fever
 swollen neck glands
 sweats
 rash
 malaise
 sore throat
 headache
Disease Progression
Without treatment, the natural history of HIV infection can vary
considerably from person to person. The risk for disease
progression increases with the duration of infection. Most
studies have shown that less than 5% of HIV-infected adults
develop AIDS within 2 years of infection; however
approximately 20-25% will develop AIDS within 6 years after
infection, and 50% within 10 years. When an HIV-infected
person develops certain diseases or conditions, they are then
classified as having AIDS. Three of the most common clinical
conditions are P. carinnii pneumonia, HIV wasting syndrome,
and candidiasis of the esophagus.
Clinical Manifestations of
Hepatitis B Virus
The clinical presentation of acute HBV ranges from asymptomatic illness to
fulminant hepatic failure. The disease has a long incubation period from 30
to 180 days. Initial symptoms are nonspecific, typically include:

malaise,

anorexia,

vomiting,

fever,

rash, and

joint pain.
These symptoms last 3-10 days. This is followed by the onset of jaundice
(yellowing of the skin) or dark urine. Fulminant viral hepatitis is defined as
the development of severe acute liver failure with hepatic encephalopathy
within 8 weeks of the onset of symptoms with jaundice.
Hepatitis B Vaccine
Recombinant vaccines for HBV were licensed in the US in 1986. Given as a
series of three injections, the vaccine produces a high antibody titer in over
90% of recipients under the age of 40-50 years. Older age, obesity,
heavy smoking, and immunologic impairments have been associated with
lower antibody responses. The higher the antibody titer after vaccination,
the longer protection persists. When the antibody titer falls below 10
MIU/mL, HBV infections may occur but are always subclinical and usually
without detectable serum antigen. The need for a booster dose of vaccine
has not been determined. The vaccine is safe and well tolerated by
recipients. All employees who have reasonably anticipated exposure to
blood or other potentially infectious materials will be offered the Hepatitis
B vaccine through the University Employee Occupational Health Clinic.
OSHA considers the Hepatitis B vaccine so important that employees will be
required to sign a declination statement if they choose not to receive the
vaccine. However, those declining the vaccine may receive it at a future time
as long as they remain an employee of the University.
Clinical Manifestations of
Hepatitis C
HCV is similar to Hepatitis B virus in that it is
associated with chronic Hepatitis, cirrhosis, and
hepatocellular cancer. At least 50% and possibly
60-70% of acute HCV infections lead to chronic
infection, approximately 20% lead to cirrhosis, and
approximately 10% die of complications. Chronic
Hepatitis C is one of the major causes of cirrhosis in
the U.S. and is one of the most common indications
for liver transplantation in adults. There is no
vaccine for prevention of Hepatitis C infection and
no post-exposure prophylaxis.
Exposure Control Plan
The Exposure Control Plan contains the policies and procedures of
the UNC and UNC Health Care System to protect employees
from acquiring a bloodborne pathogen. It also contains a
complete listing of all job categories that have been identified
as having the risk of occupational exposure to blood and body
fluids. A copy of the Exposure Control Plan is located in UNC
Hospitals' Infection Control Manual and the University's EHS
web site at http://ehs.unc.edu/ih/biological/bbp.shtml.
Directly behind the Exposure Control Plan in the Infection
Control Manual is a copy of the OSHA standard for
bloodborne pathogens. Every employee should be familiar
with the Exposure Control Plan and the OSHA standard.
Standard Precautions
Standard Precautions are an essential component to reducing the
occupational acquisition of a bloodborne pathogen. Standard
Precautions apply to blood, all body fluids, secretions, and
excretions except sweat, regardless of whether or not they
contain visible blood, non-intact skin, and mucous membranes.
Standard Precautions mean that we treat every patient as if
they are infected with a bloodborne pathogen such as HIV,
HBV, or HCV. Standard Precautions also mean that healthcare
workers practice appropriate handwashing and use personal
protective equipment to prevent direct contact with a patient's
blood or body fluids. The consistent practice of Standard
Precautions is the best method that healthcare workers can use
to protect themselves from occupationally acquiring a
bloodborne disease.
Engineering Controls
An engineering control is a device that removes a
hazard from the workplace. Employers are required
to provide engineering controls that have been
demonstrated to significantly reduce an
occupational hazard. Examples of engineering
controls used by the healthcare system include:
 needleless IV infusion system
 protective (resheathing) IV catheters that reduce the
likelihood of a needlestick injury.
 single-use lancets with a retractable needle
Work Practice Controls
Work practice controls are designed to change the way in which a task
is performed to reduce the likelihood of exposure to bloodborne
pathogens. Healthcare workers routinely practice many work
practice controls. Examples of work practice controls include:



needles/sharps are not recapped and are disposed of immediately
after use*
specimens are transported in a secondary container
sharps used during surgical procedures are not passed by hand but
instead placed in a basin or on a tray
* Certain clinical procedures may require that a needle be recapped.
Needles should only be recapped using a recapping device or using
a one-handed recapping technique. One-handed technique requires
that the cap be placed on a solid surface and using only one hand,
carefully slipping the needle back into the cap. Also, remember to
never place a glove box or any other item on top of a sharps
disposal container. This could interfere with the safe disposal of a
sharp.
Personal Protective Equipment
Personal protective equipment (PPE) is specialized clothing and equipment
worn by an employee to prevent direct contact with blood or other body
substances. PPE should be readily available and provided to the employee
at no cost. Most personal protective equipment used by healthcare workers
are disposable, single-use items. Clean exam gloves are located in every
patient room. PPE boxes (tan colored, wall-mounted cabinets) containing
non-sterile gowns, protective eyewear, masks, and resuscitation mask with
one-way valve, are located on patient care units. You can also find PPE in
the clean utility rooms of patient care units and outpatient clinics. PPE should
be carefully removed immediately after use and hands thoroughly washed.
Soiled gowns, gloves, etc. should be disposed of in the regular trash (white,
plastic bag displaying a BIOHAZARD label). Employees are responsible for
using PPE when instructed and whenever clinically indicated to prevent
exposure to blood and body fluids.
Universal Biohazard Sign
The universal biohazard sign is used
to alert employees when
containers, specimen refrigerators,
or secondary containers used to
transport specimens contain
infectious materials. Additionally,
equipment that may have internal
contamination should be labeled
with a biohazard tag denoting the
area of contamination.
Contaminated Personal Clothing
As soon as possible, contaminated clothing should be
carefully removed, avoiding contact with the
garment's outer surface to prevent skin
contamination. If heavily soiled, gloves may be
necessary. The contaminated garment should be
placed in a fluid resistant liner bag. If owned by the
employee, the item should be placed in a plastic
bag and labeled with the employee's name,
department, and phone number. The linen room will
issue scrub clothing to the employee if needed.
Contaminated Medical Devices
Medical devices such as blood pressure cuffs and
stethoscopes must be cleaned if contaminated with
blood or other potentially infectious materials. An
EPA-approved disinfectant detergent (i.e.,
Vesphene) or a 1:10 dilution of bleach and water
should be used.
Spills of Blood/Body Fluid
All spills must be safely cleaned up as soon as possible. Healthcare workers
should use the following guidelines.





Wear gloves and other appropriate PPE as indicated
A solution of 1:10 bleach and water or an EPA-approved disinfectant
detergnt (i.e. Vesphene) should be used.
If broken glass is involved, it shold be carefully removed using a mechanical
device such as tongs or forceps and the broken glass placed in the sharps
container. Never pick up broken glass by hand.
Small spills are cleaned by first wiping the spill then cleaning the area with
the disinfectant.
Large spills should first be flooded with the disinfectant, the spill wiped or
mopped up then the area cleaned with the disinfectant.
Transporting Specimens to the
Laboratory
Specimens should not be hand carried to the laboratory. All
specimens must be transported in a secondary container
displaying a BIOHAZARD label. The primary specimen
container and the specimen requisition slip must be free of any
contamination. If the container or requisition slip is visibly
soiled, the laboratory will refuse to accept the specimen.
When transporting specimens via the computerized tube
system, be sure to carefully follow the appropriate packaging
protocol. Urine specimens should have the top tightened
securely and the container placed in two ziplock plastic bags.
The laboratory will not accept specimens in syringes with a
needle attached. Exceptions to this policy will be considered
when the volume is so small that the entire specimen is
contained in the needle.
Regulated Medical Waste
Certain items have special disposal procedures required by North Carolina law and are referred
to as regulated medical waste. Regulated medical waste includes:

microbiology specimens

pathology specimens

>20cc of blood or blood products in containers that cannot be easily opened and emptied
(e.g., pleurevacs and evacuated containers)

full sharps containers

items used in the preparation and administration of hazardous drugs/antineoplastic drugs
Regulated medical waste must be placed in red trash bags bearing a BIOHAZARD label. On all
patient care units, a red bag is located in the dirty utility room. In research laboratories that
autoclave their waste, an orange autoclave bag must line the waste receptacle.
Suction canisters from most patient care areas are not disposed of in the red bag waste since they
can be opened and emptied prior to disposal. When emptying a suction canister, gloves
should be worn and the contents carefully poured into a hopper or toilet. If splash or splatter
is anticipated, an impervious gown and eye protection should also be worn. The empty canister
should then be placed in the regular trash (white trash bag with a Biohazard label).
Disposing of Medical Waste




Regulated medical waste includes liquid or semiliquid blood
Must be disposed in a container labeled with the
BIOHAZARD label
Certain items are required to be incinerated and
are referred to as regulated medical waste
Blood in quantities of greater than 20 mL per unit
container is defined as regulated medical waste
Disposal of Medical Waste
Disposal in white Trash Bags labeled with BIOHAZARD
SIGN
 Bandages
 Dental Floss
 Vacutainer Tubes
 Bags do not require incineration or autoclaving
Remember: bags are not puncture-proof...sharps are
to be disposed in designated sharps containers.
Wet, Contaminated Linen
Contaminated linen, linen potentially soiled with blood
or body fluids, should not be sorted or handled any
more than necessary for disposal. Fluid resistant
linen bags are available for use when disposing of
used linen. Linen should be double-bagged when
necessary to prevent leaking. Linen hampers should
have a cover or lid.
Dermatitis of the Hands
Our skin serves as a natural barrier to bacteria and
viruses. Unfortunately, the skin on a person's hands
sometimes becomes reddened and irritated due to
exposure to cold or irritating chemicals. Often small
cracks occur in the skin affecting its natural barrier
qualities. Working with this condition puts you at
greater risk of infection from bloodborne
pathogens.
Latex Allergy






Latex gloves have proven effective in preventing transmission of many
infectious diseases
For some healthcare workers, exposure to latex may result in allergic
reactions
It is a reaction to certain proteins in latex rubber
Amount of latex exposure needed to produce sensitization or reaction is
unknown
Symptoms range from occurring within minutes of exposure to hours later
and vary
Symptoms include:

Skin redness, hives, itching, respiratory symptoms such as runny nose, itchy eyes,
scratchy throat, and asthma
Any latex allergy reaction should be reported to the University Employee
Occupational Health Clinic.
Protection from Latex Allergy






Use nonlatex gloves for activities that are not likely to involve
contact with infectious materials
Appropriate barrier protection is necessary when handling
infectious materials. If you choose latex gloves, use powderfree gloves with reduced protein content.
When wearing latex gloves, do not use oil-based hand creams
or lotions
After removing latex gloves, wash hands with a mild soap and
dry thoroughly
Frequently clean areas and equipment contaminated with
latex dust
Learn to recognize the symptoms and procedures for
preventing latex allergy
Exposure Incidents
You are considered potentially exposed to a bloodborne
pathogen if you contact blood or other infectious body
substances in any of the following ways:
 Needlestick/sharp injury that punctures the skin
 Splash to the mucous membranes of the eyes and mouth
 Potentially infectious fluid that contacts broken or abraded skin
At UNC in 1998, there were 68 exposure incidents reported.
Four of the source patients were HIV positive, six were HBV
positive, and five were HCV positive. There were no
seroconversions as a result of exposure to HIV, HBV, or HCV
positive blood.
Exposure Follow-Up
Knowing the right steps to take after an exposure incident is critical in reducing the
likelihood of acquiring a bloodborne pathogen. Immediately after any exposure
incident:





Wash the exposed area with soap and water; if the exposure involves the eyes, you
should flush with tap water
Report the incident to your supervisor and complete an incident report.
Call the University Employee Occupational Health (UEOHC) at 919-966-9119
during their operational hours of 8:30 AM to 4:30 PM
After–hours/weekend exposures to human blood or body fluid exposures: please
call UNC HealthLink at 919-966-7890
For all other after-hour work related injuries that requires immediate medical care,
go directly to the UNC Emergency Department. If immediate medical care is not
needed, then please report to the UEOHC the following day.
Occupational Health Service
UEOHC clinic staff will evaluate your exposure
incident. The evaluation may include testing your
blood and the source patients' blood for HIV, HBV,
and HCV. Testing of your blood is only done with
your consent and results are confidential. UEOHC
will provide you with written evaluation and
recommendations regarding your exposure.
Prophylaxis for HIV exposure will be considered
when indicated.
Tuberculosis Introduction
Healthcare facilities present an environment where
tuberculosis may be transmitted at an increased rate.
Patients with active disease may expose other patients,
some of whom are highly susceptible for contracting TB
due to immune deficiencies. The high risk for transmission
of TB in healthcare facilities presents an occupational
health hazard for employees who work in healthcare
facilities. In 1990 and 1991, CDC received 13 reports of
outbreaks of MDR-TB in hospitals and prisons. These
outbreaks resulted in the disease being spread to
healthcare workers.
OSHA Requirements
OSHA does not have specific regulations concerning the
control of tuberculosis infections. However, OSHA has
stated that it will cite healthcare facilities, under the
General Duty Clause of the OSHA Act, for nonconformance to published CDC guidelines for TB
control. These guidelines require that healthcare
employees receive annual training in TB and infection
control. Successful completion of this training module
will satisfy those requirements.
Current Trends of TB
After decades of decline, the number of cases of active tuberculosis
has been on the increase since the mid 1980s. This increase and
the concern for occupational exposure for healthcare workers has
been attributed to:

HIV epidemic. Individuals who are HIV positive, or have other
immune deficient conditions, have a greater risk of developing
active TB disease if infected.

Immigration. Foreign-born individuals have come from countries
with high prevalence of TB, such as Asia, Africa, the Caribbean,
and Latin America. These individuals may also live in medically
under served areas within the U.S., which further contributes to
the increased risk for TB transmission.
Current Trends of TB, con’t.
Transmission in high-risk environments. Transmission of tuberculosis
accelerates in environments where there are:


persons with active TB, and
persons with a higher risk for progression from latent TB to active
disease.
Such environments include homeless shelters, prisons, nursing homes, and
hospitals.
Drug Resistance. Multi-drug-resistant tuberculosis (MDR-TB) refers to strains
of M. tuberculosis that are resistant to isoniazid and rifampin, two drugs
used to treat TB. Patients who become infected with these strains of TB
take longer to recover and remain infectious for a longer period, thus,
potentially infecting more people.
Current Trends of TB, con't.
Exposure incidents are events in which there has been a:

percutaneous injury involving a potentially contaminated
needle or other sharp

splash of blood or other potentially infectious materials to
the eyes, mouth, or mucous membranes

blood or other potentially infectious materials contacting
broken skin
At UNC in 2002, there were 72 exposure incidents reported.
Two of the source patients were HIV positive, three were
HBV positive, and five were HCV positive. There were no
seroconversions as a result of exposure to HIV, HBV, or
HCV positive blood.
Decline in TB Cases
The decline in cases during 1992-1997 can be
attributed to the following six factors:
1. improved laboratory methods to allow prompt
identification on M. tuberculosis;
2. broader use of drug-susceptibility testing;
3. expanded use of preventive therapy in high-risk groups;
4. decreased transmission of M. tuberculosis in congregative
settings (e.g. hospitals, correctional facilities);
Decline in TB Cases, con’t.
improved follow-up of persons with TB initially
reported to the health department;
6. increased federal resources for state and local TBcontrol efforts.
In North Carolina the number of cases remains stable at
approximately 600 cases per year. Less than 1% of
TB cases that have occurred in North Carolina have
been MDR-TB. At UNC Hospitals, there are
approximately 25 cases of TB out of 27,000
admitted patients each year.
5.
Transmission of TB
M. tuberculosis is carried in airborne particles, or droplet
nuclei, generated when a person with pulmonary or
laryngeal TB coughs or sneezes. Infection occurs when
a susceptible person inhales droplet nuclei containing
M. tuberculosis bacilli, which reach the alveoli of the
lungs. Within 2-10 weeks after initial infection the
immune response limits further spread of tubercle
bacilli; however, some of the bacilli remain dormant
and viable for many years. This is known as latent TB
infection.
Transmission of TB, con’t.
For a small proportion of infected persons (usually <1%
), initial infection readily progresses to clinical illness,
or active disease. For 5% - 10%, illness develops
after an interval of months, years, or decades, when
the bacteria begin to replicate and produce disease.
Progression to active disease is more likely in persons
with medical conditions that result in immune
deficiencies, the elderly, and those less than 4 years
of age. The risk for progression to active disease is
markedly increased for persons with HIV infection.
Transmission of TB, con't.
TB infection occurs after prolonged exposure to someone who has the
infectious form of TB. A person has a 50% chance of becoming
infected if they spend 8 hours a day for 6 months with a person
with the active form of TB.
The site of initial infection is usually the alveoli of the lungs where
macrophages ingest the inhaled bacilli. The body's T-cells are
stimulated and a cell-mediated or delayed hypersensitivity occurs.
The T-cells stimulate specialized cells that kill the bacilli and wall off
infected macrophages, producing grayish capsules called tubercles.
Further multiplication of the TB bacilli are usually confined here. In
an immunodeficient individual the TB bacilli may break out of the
tubercle and lead to the active form of the disease.
Infection Routes and Symptoms
For individuals with active TB, the bacilli will spread from
the lungs to other parts of the body usually the lymph
nodes. In 15% of the active TB cases, bacilli will infect
other sites in the body such as the skin, bones, and
reproductive or urinary systems.
Symptoms of the disease include weight loss, fever, night
sweats and anorexia. If the disease is allowed to
progress, large cavities may form in the lungs,
encompassing the bronchi. Symptoms also include a
persistent (lasting at least three weeks) cough with
production of bloody sputum.
Diagnosis of TB
Persons exhibiting the symptoms and suspected of
having TB, should be referred for a complete medical
evaluation, which should include a medical history,
physical examination, a Mantoux tuberculin skin test,
a chest radiograph, and appropriate bacteriologic or
histological examinations.
Tuberculin Skin Test
The Mantoux or tuberculin skin test is used for screening
individuals who are at high risk for developing tuberculosis,
such as persons exposed to infectious individuals. The
tuberculin skin test is the only method of diagnosing TB
infection before the infection has progressed to the active
disease. A person who becomes infected with TB will show a
positive reaction in 2 to 10 weeks.
The Mantoux test is performed by injecting 5 units of purified
protein derivative (PPD) intradermally into the volar or dorsal
surface of the forearm. If the person is infected a
characteristic welt will form.
Tuberculin Skin Test, con’t
This welt consists of hardening in the form of a raised
bump where the PPD was placed and may be red in
color. The diameter of the induration is measured to
determine infection status.
The reaction to the Mantoux test should be read by a
trained healthcare worker 48 to 72 hours after the
injection. A negative reaction must be read within 72
hours or the Mantoux test must be repeated.
Classification of Tuberculin Reaction
There are three different classifications of Tuberculin reactions.
These vary based upon the factors listed below:



>5 mm is positive for known or suspected HIV patients, close
contacts of persons with infectious TB, persons with chest xrays suggestive of previous TB, and IV drug abusers.
>10 mm - persons not listed above but are known to be of
populations at increased risk for having TB.
>15 mm is positive in persons with no known risk factors.
Anergy
Anergy occurs when the delayed hypersensitivity reaction to the PPD
test is absent or decreased in individuals who are immunodeficient,
i.e.: individuals with HIV, persons with severe febrile illness, measles
or Hodgkin's disease or those on immunosuppressive drugs.
Approximately one third of patients with HIV infection and 60% of
those with AIDS may have skin reactions of <5mm even though they
are infected with TB.
Individuals previously infected with TB may also show a positive PPD
test. A person's exposure history and chest x-ray are also used to
determine infection, however a positive bacteriologic culture is
needed to confirm diagnosis. Sputum collected for culture can be
produced by having the patient cough deeply so as to ensure
mucous is collected from diseased lung tissue.
Treatment of TB
Tuberculosis disease can be effectively treated using antibiotic therapy.
Isoniazid and rifampin are generally used, with pyrazinamide given
for the first two months. Ethambutol is added when drug resistant
bacilli are suspected. The length of therapy and combination of
antibiotics is decided by the physician, based upon organism
antibiotic sensitivity, signs of improvement, and patient compliance.
While on therapy, patients are monitored for side effects that may be
caused by the antibiotics. Isoniazid (INH) has caused liver toxicity in
some patients. This occurrence is rare for people under the age of
35, but has a somewhat greater incidence for people over 35. Liver
function should be monitored in patients receiving treatment with
INH. Patients who are taking ethambutol should be monitored for
potential visual changes.
Treatment of TB, con't.
It is especially important that patients complete the prescribed
drug therapy regimen in order to effectively kill all bacilli.
Drug-resistance can develop when medications are taken
incorrectly by either skipping doses or not taking the
medication for the prescribed amount of time.
Directly Observed Therapy or DOT is used when it is suspected
that patients may not comply with the prescribed treatment.
DOT is accomplished by designating a person to observe the
patient swallow each dose of medication.
Preventive Therapy
Individuals with positive PPD test results should be evaluated for
preventive therapy if they:

are recent converters;

have close contact with TB patients;

have an immune deficient medical condition;

are HIV positive;

use IV drugs;

are <35 years of age.
Studies have shown that preventive therapy with INH will reduce the risk
of active TB by approximately 70%. Currently, INH taken by mouth for
6 to 12 months is the recommended treatment for preventive therapy.
Infection Control
The main goal of an infection control program is to detect TB
disease early and to isolate and promptly treat persons who
have TB. The infection control program of any healthcare
facility should involve three types of controls: administrative
controls; isolation facilities and procedures; personal
respiratory protection.
Administrative controls include: risk assessment; development of TB
infection-control plan; assignment of infection-control
responsibilities; early identification, isolation, and treatment of
suspected cases.
Risk Assessment
At UNC, the TB Infection-Control Plan requires that each
healthcare facility and clinic area must complete a risk
assessment so that appropriate infection control interventions
can be developed based on actual risk of TB transmission.
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The level of risk is based on:
the number or estimated number of TB infectious patients
admitted to each area;
number of personnel PPD conversions;
and potential for patient transmission.
Assignment of Responsibility
The clinic director of each UNC facility is responsible for assigning
healthcare personnel to implement infection control
responsibilities.
Early Identification of TB
Early identification and isolation of patients with TB is necessary
to prevent TB transmission among patients and personnel.
Healthcare workers who first come in contact with patients
should be trained to ask questions which will help identify
patients with active TB. Designated healthcare professionals
will evaluate patients immediately so as to minimize time spent
in waiting areas.
TB Precautions for UNC Clinics
TB precautions will be instituted for patients suspected of having
TB. Patients are instructed to:

wait in separate areas, apart from other patients;

wear surgical masks;

cover their mouths with facial tissues when coughing or
sneezing.
Persons suspected of having TB are referred to either the
Pulmonary Clinic or the Infectious Disease Clinic where isolation
facilities are available for managing these patients. HIV
patients are sent to the Infectious Disease Clinic.
Isolation Facilities
Patients with active TB are placed in isolation. Engineering controls
are used in each isolation room to prevent the spread and
reduce the concentration of infectious droplet nuclei in the air.
Isolation rooms are equipped with: at least 6 air exchanges per
hour; sufficient air distribution within the room; directional
airflow from hallway to room; and direct exhaust of room air
to outside.
Isolation Procedures
Patients placed in TB isolation will be instructed in procedures to
prevent TB transmission, and the reasons for their being placed in
isolation.
The door to the room must always be kept closed. Healthcare
workers will be instructed to wear respirators. Patients who have
active TB will be scheduled to avoid contact with
immunocompromised patients. Cough inducing procedures should
be avoided if possible, and if necessary, done in TB isolation
facilities. Thirty minutes should pass before the room is utilized for
other patients.
TB isolation may be discontinued when the patient: is on effective
therapy; is improving clinically; and has 3 consecutive negative
sputum AFB smears.
Respiratory Protection
Administrative controls and isolation facilities and procedures may not
fully protect healthcare workers from infectious droplet nuclei in
settings where high risk procedures are performed. TB respirators
are required for healthcare workers who enter rooms where patients
with active TB are being isolated.
 Respirator devices will meet the following criteria:
 ability to filter particles 1 um in size with a filter efficiency of
>95%
 ability to be qualitatively or quantitatively fit tested for faceseal leakage of no greater than 10%
CAUTION: Respirators with exhalation valves do not filter exhaled air
and therefore are not to be used by operating room personnel or
patients with TB.
Respiratory Protection Program
The respiratory protection program will include medical screening, fit testing,
and training. Medical screening is conducted to determine whether the
employee is physically able to wear a respirator. The employee must
complete the "Medical Clearance for Respirator Use" form found in the
Tuberculosis Control Plan (Appendix F). Completed forms should be taken
to University Employees Occupational Health Clinic at time of fit-testing
appointment. A fit test is used to determine whether the respirator wearer
is able to obtain a satisfactory fit. A respirator cannot be worn by
healthcare workers with facial hair that comes between the sealing
surface of the mask and face, or if facial hair interferes with valve
function. Bearded healthcare workers should contact Environment, Health
and Safety to obtain alternative respiratory protection. Training will be
provided to personnel who receive respirators and will include selection,
use and storage of respirators as well as their limitations.
Medical Surveillance of Healthcare
Personnel
All new employees must complete a TB history as described in the
Tuberculosis Control Plan. The history will provide the following
information:

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
history of PPD placement;
history of treatment for positive PPD;
history of active tuberculosis;
and any presence of signs and symptoms of active TB.
TB Testing of Healthcare Personnel
All healthcare personnel will receive the Mantoux test upon employment.
Excluded are those individuals who have had a previous positive reaction
or who have completed therapy for active TB. The results of the PPD
testing of healthcare personnel will be used in the risk assessment for the
facility. Healthcare personnel are to be retested annually.
If an employee is exposed to a potentially infectious patient and infection
control procedures were not followed, he/she will be given the Mantoux
test. A negative test is to be repeated after 12 weeks. If PPD >5mm or
symptoms of TB are present, the employee will receive a chest
radiograph.
Exposed employees who have had a previous positive PPD will not be given
a chest radiograph or PPD test, but will monitored for symptoms of TB.
Work Restrictions
Healthcare workers with current tuberculosis pose a risk to patients
and other personnel while they are infectious. These healthcare
workers will be restricted from duty until:

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they have received appropriate documented therapy for at least
two weeks;
they show clinical improvement;
they have three consecutive negative sputum smears from
Mycobacteria;
and they have a stable or improved chest radiograph.
Work Restrictions, con’t.
Personnel will be cleared to return to work by the University
Employees Occupational Health Clinic.
Healthcare workers who are receiving preventive therapy and are
otherwise healthy may continue working. If personnel who
require preventive therapy refuse or cannot complete the
prescribed treatment, they will have their work assignments
reevaluated. They should receive counseling regarding the risk
of contracting the disease and instructed to report any symptoms
of TB promptly.
Infection Control Goal
The goal of infection control is to prevent infections among patients
and personnel. To accomplish this goal, every employee needs to
have an understanding of the basic principles of disease
transmission and methods to prevent infections.
Elements of the Infectious Process
In order for an infection to take place, certain elements must be
present. These elements include:




an infectious agent such as a virus, bacteria, or fungus;
a method of travel or transmission such as carriage on
respiratory droplets or by transient carriage on hands;
a susceptible host or person at risk or acquiring the infection;
a means of entering and exiting the human body such as the
respiratory tract and the gastrointestinal tract.
Handwashing
Simple and effective.
Handwashing is the simplest but most important means of preventing
the spread of infection.
Every healthcare worker should wash their hands for ten seconds
using an antimicrobial soap (Bactoshield or Alcare): before and
after patient contact; after removing gloves; upon arriving and
departing work; and whenever skin contamination is suspected.
Isolation Precautions
Isolation precautions are designed to prevent the transmission of
infection based upon the recognized method of transmission for
the infecting organism. The precaution categories are Standard
Precautions, Contact Precautions, Droplet Precautions, and
Airborne Precautions.
Standard Precautions
Standard Precautions are followed for all patients regardless of
their diagnosis or presumed infectious status. Standard
Precautions apply to: blood; all body fluids; secretions, and
excretions (except sweat); non intact skin; and mucous
membranes.
Healthcare workers must recognize that all body fluids may be
potentially infectious and learn to protect themselves from direct
contact with these fluids.
Contact Precautions
Contact Precautions are followed to prevent infections that are
transmitted by direct body surface to body surface contact or via
indirect contact with a contaminated object. Examples of infections
transmitted via the contact route include rotavirus and infections
cause by antibiotic-resistant bacteria.
Contact precautions are followed when: the patient must be placed in
a private room; gloves are worn by those entering the room and
removed with hands washed thoroughly with an antimicrobial soap
upon exiting; and a gown is required to be worn if contact with
potentially contaminated surfaces (e.g., direct contact with patient,
bed linen, beside table) is anticipated.
Droplet Precautions
Droplet Precautions are used to prevent transmission of infections
spread by respiratory droplets. Infectious droplets are released
when the infected person sneezes or coughs. These droplets are
heavy and usually fall rapidly within 3 feet of the patient.
Examples of infections transmitted via the droplet route are
pertussis (whooping cough) and meningococcal meningitis.
Droplet precautions are followed when: the patient must be placed
in a private room; all people entering the room must wear a
surgical mask to prevent the infectious droplets from impacting
mucous membranes.
Airborne Precautions
Airborne Precautions are used to prevent the transmission of
infections spread by the airborne route. These infectious particles
are so small that they can remain suspended in the air for long
periods of time and carried on air currents. Examples of
infections spread by the airborne route include varicella
(chickenpox), tuberculosis and measles. When following airborne
precautions: the patient must be placed in a private room with
special ventilation.
Airborne Precautions, con’t
Respirators are worn by personnel if the patient has or is suspected
of having tuberculosis. Respirators are worn for chickenpox or
measles only if the employee entering has not had the disease
or has not be immunized. Visitors should wear a tight fitting
surgical mask if the patient has or is suspected of having
tuberculosis. Surgical masks are worn for chickenpox or measles
only if the visitor has not had the disease or has not been
immunized.
Immunizations
Immunizations serve as a tool to protect a person from being a
"susceptible host". All employees are required to have
documented immunity to measles, mumps, rubella, and varicella.
Tetanus and diphtheria are recommended at 10 year intervals.
Hepatitis B vaccine is strongly encouraged for employees with
occupational exposure to blood and body fluids. All of these
vaccines are available from the University Employees
Occupational Health Clinic.
Infection Control Manual
The Infection Control Manual contains numerous infection control
policies and serves as an important resource for employees in
the prevention of nosocomial infection. The Exposure Control Plan
for Bloodborne Pathogens and Tuberculosis can be found in the
Infection Control Manual. Infection Control Manuals are
available in all patient care areas of the Hospitals and
University clinics.