Transcript Sharps and BBP

Sharps Related Infections
Olusegun Soge (S.O.)
Postdoc, DEOHS
[email protected]
November 13, 2009
Scenarios
• A laboratory manager is contaminated with a large
amount of blood on an open cut while trying to help a
student who has a deep cut from a pipette failure. The
student is a hepatitis B carrier.
• A physician is splashed in the eye with hepatitis C
positive blood while seeing a trauma patient in the ER.
• A nurse accidentally sticks himself with large bore
needle when a psychiatric patient with HIV
unexpectedly moves away from him.
Learning Objectives
• Define Bloodborne pathogens (BBPs)
• Describe the 3 main BBPs and how they are
transmitted
• Describe the symptoms of bloodborne
diseases
• Distinguish between Occupational Exposure
and Exposure Incident
• Explain the main idea of universal precautions
• Explore ways to prevent occupational exposure
to BBPs
Bloodborne Pathogens (BBPs)
BBPs are pathogenic microorganisms that
are present in
Blood
or
Other
Potentially
Infectious
Materials
and can cause diseases in humans
‘Blood’ includes human blood, human blood components, products made from human
blood, and also medications derived from blood (e.g., immune globulins, albumin, etc.).”
Other Potentially Infectious
Materials (OPIM)
• semen
• vaginal secretions
• body fluids such as
pleural, cerebrospinal,
pericardial, peritoneal,
synovial, and amniotic
• saliva in dental
procedures (if blood is
present)
• any body fluids visibly
contaminated with blood
• any unfixed tissue or
organ (other than intact
skin) from a human
(living or dead)
• HIV- or HBV-containing
cultures (cell, tissue, or
organ), culture medium,
or other solutions
• blood, organs, & tissues
from animals infected
with HIV, HBV, or BBPs
Other body fluids and materials
not considered infectious…
….unless contaminated with blood or OPIM
• saliva (except during dental procedures)
• urine
• feces
• vomit
• tears
• sweat
Who is at risk of exposure to
BBPs?
Those employees who by nature of their tasks
have the potential to be exposed to blood, body
fluids, or other potentially infectious materials
•
•
•
•
•
•
•
Lab Technicians
Research Scientists
Health Care Workers
Physicians
Blood Bank Workers
Police Officers
Fire & Rescue Personnel
•
•
•
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•
Child care providers
Life guards
Instructors
Security Officers
Custodial and housekeeping staff
• YOU?
Transmission of BBPs
Occupational
Exposure
• means reasonably anticipated skin, eye,
mucous membrane, or parenteral
(piercing of the skin) contact with blood or
OPIM that may result from the
performance of an employee's duties
Exposure Incident
• is a specific contact with blood
or OPIM that is capable of
transmitting a bloodborne
disease
Transmission of BBPs
Risk of infection depends on several factors:
 The pathogen involved
 The type/route of exposure
 The amount of virus in the
infected blood at the time of
exposure
 The amount of infected
blood involved in the
exposure
 Whether post-exposure
treatment was taken
 Specific immune response
of the infected individual
Courtesy of Owen Mumford, Inc.
Modes of Transmission
Percutaneous (through the skin)
• Being stuck with needles or other sharps
• Having infected blood or other body
fluids splashed onto skin that is cut,
scratched, has sores or rashes or other
skin conditions
Mucocutaneous (via mucous membrane)
• Having infected blood or other body fluids
splashed into eyes, nose or mouth
Health Care Workers and
BBPs
Occupational Transmission
Risk of infection
following needle stick/cut
from a positive (infected)
source:
• HBV: 30%
(6%-30%)
• HCV: 3.0%
(range 0%-7%)
• HIV:
0.3%
Most Common Occupational
Exposure
Needlestick Injuries
Over 85% of documented
occupational transmissions
Bloodborne Pathogen Diseases
Some examples of bloodborne pathogens:
•
•
•
•
Malaria
Syphilis
Brucellosis
Leptospirosis
•
•
•
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Arboviral infections
Relapsing fever
Creutzfeld-Jakob Disease
Viral Hemorrhagic Fever
Main bloodborne pathogens and diseases of
concern
• Hepatitis B Virus (HBV)
• Hepatitis C Virus (HCV)
• Human Immunodeficiency
Virus (HIV)
Co-infection is possible.
HIV
• Causes Acquired Immunodeficiency Syndrome
(AIDS)
• HIV destroys cells in the body’s immune
system
• It may take many years before AIDS develops
• A flu-like illness can occur 1-6 weeks after
exposure to the virus:
fever
headache
night sweats
malaise
muscle pains
nausea
diarrhea
sore throat
enlarged lymph nodes
thrush
fatigue
weight loss
HIV
• In some cases, symptom-free period of 5-10
years can occur
• SURVIVAL OUTSIDE THE BODY
– HIV does not survive well outside the body, making the
possibility of environmental transmission remote
– But in dry blood, the virus has been shown to survive for
up to 6 days in laboratory conditions
• QUANTITY OF VIRUS IN BLOOD
– 1 millilitre of blood contains 200-10,000 particles of virus.
• RISK OF INFECTION FOLLOWING NEEDLE STICK
INJURY
– Low - 0.3% - 3 people in 1,000.
• RISK OF INFECTION FOLLOWING EYE SPLASH
– Low.
Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR
Recommendations and Reports, June 29, 2001 / 50(RRll);1-42. Centers for Disease Control
and Prevention
Occupationally acquired AIDS
Updated in a 2007 report, with the same documented 57 cases but an additional
140 “possible” cases
http://www.cdc.gov/ncidod/dhqp/bp_hcp_w_hiv.html
Global HIV/AIDS Estimates
Cases of HIV Infection and AIDS in the
United States, 2007
• >1.2 million people
living with HIV
• 1/4th of persons living
with HIV do not know
the are infected
• Although African
Americans represent
about 13% of the
population, they
accounted for 48% of
new HIV or AIDS
diagnoses in 2007
AIDS in Washington State by
County
December 31, 2000 - N= 9419
Pierce
n=837
9%
Clark
n=326
3%
Kitsap
n=166
2%
All Others
n=1143
12%
Snohomish
n=465
5%
Spokane
n=386
4%
King
n=6096
65%
Also, 64% of cumulative HIV
cases are from King County
Current estimates of the number
of HIV/AIDS in King County
• 7,765 King County residents have
been diagnosed with AIDS and 4,254
(55%) have died (1982-2007)
• An estimated 7,500 residents are
currently living with HIV
• 45% (3,511) diagnosed with AIDS
• 55% have HIV infection but have
not developed AIDS
• 80% of those living with AIDS in
King County were Seattle residents at
the time of diagnosis
• 31% of the King County population
lives in Seattle
HIV/AIDS Epidemiology Program: Facts about AIDS in King County, June 2009
http://www.kingcounty.gov/health
Global Estimates of Hepatitis C
Features of Hepatitis C Virus Infection
Incubation period
Acute illness (jaundice)
Case fatality rate
Chronic infection
Chronic hepatitis
Cirrhosis
Mortality from CLD
Average 6-7 weeks
Range 2-26 weeks
Mild (<20%)
Low
60%-85%
10%-70%
<5%-20%
1%-5%
Leading indication for liver transplant
HEPATITIS C IN BLOOD
• SURVIVAL OUTSIDE THE BODY
– Little is known but likely to be the same as hepatitis B, up to
10 days
• QUANTITY OF VIRUS IN BLOOD
– 1 millilitre of blood contains 1,000 - 10,000 particles of virus
• RISK OF INFECTION FOLLOWING NEEDLE STICK
INJURY
– Medium - 3% - 3 people in 100
• RISK OF INFECTION FOLLOWING EYE SPLASH
– Low
* Updated U.S. Public Health Service Guidelines for the Management of Occupational
Exposures to HBV, HCV, and HIV and Recommendations for Postexposure
Prophylaxis. MMWR Recommendations and Reports, June 29, 2001 / 50(RRll);1-42.
Centers for Disease Control and Prevention
Hepatitis C Virus Infection,
United States
New infections per year 1985-89
2001
242,000
25,000
Deaths from acute liver failure
Rare
Persons ever infected (1.8%)
3.9 million (3.1-4.8)*
Persons with chronic infection
2.7 million (2.4-3.0)*
HCV-related chronic liver disease
40% - 60%
Deaths from chronic disease/year
8,000-10,000
*95% Confidence Interval
Occupational Transmission of
HCV
• Inefficient by occupational exposures
• Average incidence 1.8% following
needle stick from HCV-positive source
– Associated with hollow-bore needles
• Case reports of transmission from blood
splash to eye; one from exposure to
non-intact skin
• Prevalence 1-2% among health care
workers
– 10 times lower than for HBV infection
HCW to Patient Transmission of
HCV
• Rare
– In U.S., none related to performing
invasive procedures
• Most appear related to HCW substance
abuse
– Reuse of needles or sharing narcotics
used for self-injection
• No restrictions routinely recommended
for HCV-infected HCWs
Perinatal Transmission of
HCV
• Transmission only from women HCVRNA positive at delivery
– Average rate of infection 6%
– Higher (17%) if woman co-infected with HIV
• No association with
– Delivery method
– Breastfeeding
• Infected infants do well
– Severe hepatitis is rare
Sources of Infection for
Persons With Hepatitis C
Injecting drug use 60%
Sexual 15%
Transfusion 10%
(before screening)
Occupational 4%
Other 1%*
Unknown 10%
* Nosocomial; iatrogenic; perinatal
Source: Sentinel Counties, CDC
HCV Prevalence by Selected Groups
in United States
Hemophilia
Injecting drug users
Hemodialysis
STD clients
Gen population adults
Surgeons, PSWs
Pregnant women
Military personnel
0
10
20 30
40 50 60
70 80
Average Percent Anti-HCV Positive
90
Hepatitis B Incidence in U.S., 2001
• Statistically poses the greatest risk
• Estimated incidence
– 78,000 cases/year
• Reported cases
– Acute hepatitis B: 7,844
• Likelihood of becoming a carrier varies inversely
with the age at which infection occurs
• Pool of carriers in U.S. is 1-1.25 million persons
• ~5000 persons die/yr. from HBV-related
cirrhosis
Transmission of HBV (1)
• Concentration of HBV in various body fluids
– High: Blood, serum, wound exudates
– Medium: saliva, semen, and vaginal secretions
– Low/not detectable: urine, feces, sweat, tears, breast milk
• Perinatal – transplacental transmission, rare (2-5%)
• Sexual transmission – unprotected sex
Transmission of HBV (2)
• Percutaneous transmission – sharing of injection
drug use equipment, needle stick injury,
ear-piercing, body piercing, tattooing,
inadequate sterilization of medical equipment,
scarification
• Household and interhousehold transmission –
less risk but significant - can occur in settings
such as shared toothbrushes, razors, combs,
washcloths
Transmission of HBV (3)
• Passed from child to child by biting, shared
objects, oozing cuts, impetigo, etc.
• Virus can exist on environmental surfaces for
up to one week and remain infectious
• Pre-chewing food for babies, or sharing food
that has been chewed by someone else
(chewing gum)
Risk Factors Associated with
Reported Hepatitis B, 1990-2000,
United States
Other*
Injection drug use
14%
15%
Sexual contact with
hepatitis B patient
13%
Household contact of
hepatitis B patient
2%
Men who have
sex with men 6%
Unknown 32%
Blood transfusion
0%
Source: NNDSS/VHSP
Medical
Employee 1%
Multiple sex partners
Hemodialysis 0%
17%
*Other: Surgery, dental surgery, acupuncture, tattoo, other percutaneous injury
HEPATITIS B IN BLOOD
• SURVIVAL OUTSIDE THE BODY
– Very stable, virus can persists in dry blood for up to 10
days
• QUANTITY OF VIRUS IN BLOOD
– 1 millilitre of blood contains 100,000,000 particles of virus
• RISK OF INFECTION FOLLOWING NEEDLE STICK
INJURY
– Very High - 30% - 3 people in 10
• RISK OF INFECTION FOLLOWING EYE SPLASH
– High
* Updated U.S. Public Health Service Guidelines for the Management of Occupational
Exposures to HBV, HCV, and HIV and Recommendations for Postexposure
Prophylaxis. MMWR Recommendations and Reports, June 29, 2001 / 50(RRll);1-42.
Centers for Disease Control and Prevention
Hepatitis B: Clinical Features
• Incubation period ranges from 45-180 days, average is
60-90 days
• Onset is insidious
• Clinical illness (jaundice): <10% for <5 yr olds
30%-50% for >5 yrs
• Acute case-fatality rate:
0.5%-1%
• Chronic infection:
<5 yrs old, 30%-90%
>5 yrs old, 2%-6%
• Premature mortality from
chronic liver disease:
15%-25%
Signs and Symptoms
• Symptom
–
–
there may be none
loss of appetite,
malaise, nausea,
vomiting, abdominal
pain, arthralgias,
myalgias
Normal eyes
• Signs
–
–
there may be none
jaundice, fever, dark
urine
Jaundiced eyes
Regulatory Risk Reduction
Strategies against BBPs
• 1991, OSHA BBP Standard: Mandates rules
for employers to protect workers from
occupational exposure to blood and other
body fluids that potentially contain
bloodborne pathogens
• 2001, OSHA BBP Standard: Updated with
new requirements under Federal
Needlestick Safety and Prevention Act
• WISHA: Washington Industrial and Safety Act
Ways to prevent exposure to BBP
• Universal precautions
– Blood and OPIM from ALL persons are
considered infectious
– Appropriate barriers and procedures must
be used when contact with blood or OPIM is
anticipated
• Personal protective equipment (PPE)
Gloves, masks, face shields, lab coats,
respirators, gowns, resuscitation devices,
shoe cover
Ways to prevent exposure to
BBP (Contd.)
• Work Practice Controls
– Hand washing
– Storage and handling of contaminated
equipment
– No eating, drinking, smoking, handling
contact lenses, and applying make-up in
work areas
Thank you!
Recipe for fake blood from Penn and Teller's
Bleeding Heart Gelatin Dessert:
•1 cup corn syrup
•1/2 cup grenadine
•0.3 oz. red food coloring
•3 drops blue food coloring
Jillette, P. and T. Jillette 1992. Penn and Teller's how to play with your food, p.104-109. Villard
Books, New York, N.Y.