Download OCCUPATTIONAL SAFETY AND HEALTH ADMINISTRATION

OSHA BLOOD-BORNE
PATHOGENS
STANDARD:
MANAGEMENT OF
EXPOSURE TO BLOODBORNE PATHOGENS
Dana Bartlett, BSN, MSN, MA, CSPI
Dana Bartlett is a professional nurse and author.
His clinical experience includes 16 years of ICU
and ER experience and over 20 years of as a
poison control center information specialist. Dana has published numerous CE and
journal articles, written NCLEX material and textbook chapters, and done editing and
reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written
widely on the subject of toxicology and was recently named a contributing editor,
toxicology section, for Critical Care Nurse journal. He is currently employed at the
Connecticut Poison Control Center and is actively involved in lecturing and mentoring
nurses, emergency medical residents and pharmacy students.
Abstract
Healthcare workers are continuously exposed to hazards of bloodborne pathogen transmission. Many bacteria and viruses may be
transmitted to healthcare workers by needlesticks, sharps injury, or
splash contact. Hepatitis B, hepatitis C, and the human
immunodeficiency virus (HIV) account for the greatest number of
exposures and infections. Important aspects of the Occupational
Safety and Health Administration (OSHA) standard and information on
the management of exposure to blood-borne pathogens are discussed.
Policy Statement
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This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses. It is the policy of
NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all continuing nursing education (CNE)
activities.
Continuing Education Credit Designation
This educational activity is credited for 1.5 hours. Nurses may only
claim credit commensurate with the credit awarded for completion of
this course activity.
Statement of Learning Need
Front-line healthcare workers need to know OSHA safety protocol to
prevent and to report exposure to blood-borne pathogens, in addition
to initial interventions for exposure.
Course Purpose
To provide health clinicians with basic knowledge of OSHA
recommendations for exposure to blood-borne pathogens.
Target Audience
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Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses
and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Dana Bartlett, BSN, MSN, MA, CSPI, William S. Cook, PhD,
Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC –
all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge,
on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge
learned will be provided at the end of the course.
1. The majority of occupational exposures to blood-borne
pathogens are
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a.
b.
c.
d.
percutaneous.
air-borne.
cutaneous.
percutaneous and cutaneous together.
2. The most common blood-borne pathogens in occupational
exposures are:
a.
b.
c.
d.
Hepatitis
Hepatitis
Hepatitis
Hepatitis
B, hepatitis D, and MRSA.
C, HIV, and tuberculosis.
B, hepatitis C, and HIV.
E, HIV, and gram-negative bacteria.
3. The risk of HIV transmission after a percutaneous exposure
is approximately:
a.
b.
c.
d.
3.0%.
0.3%.
30%.
13%
4. True or False: Infection with a blood-borne pathogen can
occur after contact with a contaminated surface.
a. True
b. False
5. The first step in managing an exposure to a blood-borne
pathogen is:
a.
b.
c.
d.
Testing of the source patient.
Notifying the employee health department.
Testing of the affected healthcare professional.
Perform basic wound care or flush the affected area.
Introduction
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Exposure to blood-borne pathogens is a serious, ongoing hazard for
healthcare workers and the Occupational Safety and Health
Administration (OSHA) developed a standard that was designed to
protect at-risk employees: the blood-borne pathogens standard, which
is identified by the Code of Federal Regulations number CFR
1910.1030.1 The standard was amended in 2001 to include the
Needlestick Safety and Prevention Act, and CFR 1910.1030 provides:

Definitions of risk situations.

Recommendations for the prevention of exposures to bloodborne pathogens

Recommendations for the management of exposures to bloodborne pathogens.
Nurses have considerable risk for exposure to blood-borne pathogens,
and they are required to have a basic knowledge of, and comply with,
the recommendations of the OSHA blood-borne pathogens standard.
This module will review important aspects of the standard and provide
information on the management of exposure to blood-borne
pathogens.
Epidemiology Of Exposures To Blood-Borne Pathogens
Many bacteria and viruses can be, and have been transmitted to
healthcare workers by needlesticks, sharps injury, or splash contact,2
but hepatitis B, hepatitis C, and the human immunodeficiency virus
(HIV) account for the greatest number of exposures and infections.2
The majority of occupational exposures to and infections from these
viruses are caused by percutaneous injury.3 The term percutaneous
injury refers to any puncture of the surface of the skin such as a
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needlestick and a sharps injury, the latter being a puncture of the skin
from a scalpel, a trochar, or any other medical device or instrument.
The exact incidence of needlesticks, sharps injuries, and splash
exposures is not known, but it is clear they are a common occurrence,
as seen by the following reports:

The Centers for Disease Control and Prevention (CDC) has
estimated that in the United States there are 385,000
needlesticks every year.4

The Exposure Prevention and Information Network (EPInet)
noted in their 2011 report that the number of needlestick
injuries was 19.46 per 100 occupied beds.5

Karmon, et al. (2013) surveyed healthcare workers in an urban
hospital and they found that in the previous year 9.4% of
nurses, physicians, and other employees had a needlestick, a
sharps injury, or a splash contact with blood or potentially
infectious body fluid.6

Henderson (2012) estimated that almost 1 of every 10
healthcare workers in the United States has a needlestick
exposure each year.7

Under-reporting of needlestick injuries, sharps injuries, and
splash contacts with potentially infectious fluids is not
unusual.8-12 The CDC has estimated that 50% or more of these
incidents are not reported.4
Health clinicians work in a wide variety of patient care areas, i.e.,
emergency room (ER), intensive care unit (ICU), and operating room
(OR), they frequently use needles and handle sharps, and they are
often exposed to blood and body fluids. These factors increase their
risk for exposure and needlesticks, sharps injuries, and splash
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exposures, all of which occur more often to nurses than to other
healthcare workers.12-15
Risk Of Infection After Occupational Exposure
The risk of infection after an occupational exposure to a blood-borne
pathogen depends on many factors7,16,17 and the viral load of the
source (the patient) is probably the most critical of these.7 Infection is
least likely from a splash contact (cutaneous exposure), and it is most
likely from a deep puncture by a large-gauge, hollow bore needle that
contains a large amount of blood that has a high viral load.
Simultaneous transmission of several blood-borne pathogens from a
needlestick has been reported.18
Table Risk 1: Factors for Infection after Exposure to a Blood-borne
Pathogen6,7,16
Amount of blood injected
Availability/efficacy of post-exposure prophylaxis
Depth of the injury
Health status of the source person
Hollow bore needle
Immune system competency
Placement of the injuring device in an artery or a vein
Prevalence of the pathogen in the population
The pathogen
Type of injury, i.e., puncture wound versus splash contact
Viral load
Visible blood on a needle or sharp
The risk of infection after a percutaneous exposure to HIV has been
estimated to be 0.32%7 and the risk for infection after a mucous
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membrane exposure to HIV has been estimated to be 0.03%0.09%.16,19,20 No transmission of HIV through intact skin has been
documented. All known sero-conversions from occupational exposure
to HIV have occurred after exposure to blood, bloody fluids, or viral
cultures.19 Semen, vaginal fluids, and body fluids visibly contaminated
with blood can transmit HIV; and, amniotic fluid, cerebrospinal fluid,
pericardial fluid, peritoneal fluid, pleural, and synovial fluid are
potentially HIV-infected. Feces, gastrointestinal fluids, nasal
secretions, saliva, sputum, sweat, tears, urine, and vomitus are not
considered to be HIV infectious unless they contain blood.
The risk for transmission after exposure to fluids or tissues other than
HIV-infected blood has not been quantified but is probably quite low.21
In most reported instances involving transmission of HIV, the
needlestick injury occurred within seconds or minutes after the needle
was withdrawn from the source patient.22 The CDC surveyed
occupational exposures to HIV that occurred in the years 1981-2010
and found 57 cases of documented HIV sero-conversion; and, 84.2%
of these were percutaneous exposures and in greater than 90% of the
cases there were non-occupational risk factors for HIV exposure.23
The risk of infection after percutaneous exposure to hepatitis B has
been estimated to be between 6%-62%16,19,24 and is especially high if
the source is positive for hepatitis B surface antigen (HbsAg) and
hepatitis B e antigen (HbeAg).16 Infection in healthcare workers with
hepatitis B who have not had a needlestick or other percutaneous
exposure could be due to exposure to the virus through an abrasion, a
burn, a scratch, or a mucous membrane,25 and in approximately twothirds of all people infected with hepatitis B, no needlestick was
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identified.26 Hepatitis B surface antigen is found in other body fluids
aside from blood such as bile, breast milk, cerebrospinal fluid, feces,
nasopharyngeal washings, saliva, semen, sweat, and synovial fluid.
However, these fluids contain low levels of the virus and exposure to
them would not be likely to cause hepatitis B infection.25
The risk for infection after percutaneous exposure to hepatitis C has
been estimated to be approximately 1.8%, the reported range being
0-10%.27-29 Approximately 39% of all hepatitis C infections in
healthcare workers are considered to be occupational.28 Infection with
hepatitis C after mucous membrane exposure is considered to be
unlikely, but infection after conjunctival or ocular exposure has been
reported.30-32 Hepatitis C virus has been found in ascites, menstrual
fluid, saliva, semen, spinal fluid, and urine. These fluids have a much
lower hepatitis C viral content than blood and transmission of the virus
from these fluids has not been reported but if they were contaminated
with blood or if there was a large exposure, transmission and infection
could occur.33
Learning Break:
Blood-borne pathogens can contaminate surfaces and persist in the
environment and contact with these contaminated surfaces can
cause infection. Hepatitis B and HIV in dried blood can remain on
surfaces for a week 3 4 , 3 5 and hepatitis B is capable of causing
infection during that time. 3 4 Hepatitis C also can survive out side
the body on environmental surfaces 3 6 and it can remain infective at
room temperatures on surfaces for up to six weeks. 3 7
How Do Exposures To Blood-borne Pathogens Occur?
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Needlestick injuries and other exposures to blood -borne
pathogens are usually caused by human error. These errors
can involve personal and organizational issues, and factors such as
poor staffing, a relative lack of nursing experience, long hours at work,
stress and fatigue, and poor or improper use of equipment have been
identified as causes of needlestick injuries.38-42 The most common
situations that are involved in needlestick injuries and other exposures
to blood-born pathogens are listed in Table 2.
Table 2: At-Risk Situations for Needle-stick Injuries
Accessing an IV line
Cleanup
Collision with another nurse or another healthcare worker
Manipulating the needle while it is in a patient
Passing a needle or a sharp
Poor or improper disposal technique
Puncturing skin with a needle or a sharp
Suturing
Recapping needles
Transferring blood from one container to another
Equipment that must be manipulated after or during use such as
disposable syringes, IV catheter stylettes, needles attached to
tubing such as winged infusion sets and suture needles
Acute care, ER, ICU, or OR settings
The OSHA Blood-Borne Pathogens Standard
The OSHA blood-borne pathogens standard is both general and specific
in its recommendations. Some sections provide detailed guidance while
others provide basic direction. For example, the standard states that
employers must provide hand-washing facilities but if providing these
is not possible the employer must provide either an appropriate
antiseptic hand cleaner or antiseptic towelettes. The standard,
however, does not specify what type of hand cleaners or towelettes. A
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fact sheet that provides a short overview of the standard is available
at this link: http://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf.
There are other fact sheets on the OSHA website that address topics
such as the standard’s recommendations on hand washing and the
recommendations for the safe use of needles and sharps.
Learning Break:
The blood-borne pathogen standard was amended in 2001 to include the
Needlestick Safety and Prevention Act that was passed by Congress in
2000. This Act amended standard CFR 1910.1030 in order to require
employers to: 1) maintain a sharps injury log, and 2) involve nonmanagerial personnel in the decision-making process of selecting safer
needle devices. The Act also added language to the blood-borne
pathogens standard that redefined engineering controls as "controls (i.e.,
sharps disposal containers, self-sheathing needles, safer medical devices,
such as sharps with engineered sharps injury protections and needleless
systems) that isolate or remove the blood-borne pathogens hazard from
the workplace."
Another helpful OSHA resource that has detailed information about the
standard is: Most Frequently Asked Questions Concerning the BloodBorne Pathogens Standard. It is available at this link:
https://www.osha.gov/pls/oshaweb/owadisp.show_document%3Fp_table=INTERPRE
TATIONS%26p_id=21010.
OSHA Blood-Borne Pathogen Standard: Definitions
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Familiarity with definitions used by the OSHA blood-borne pathogens
standard can help increase understanding of and compliance with the
standard. The definitions provided here are essentially the same as
those found in the standard.
Blood-borne pathogens:
Pathogenic microorganisms that are present in human blood and can
cause disease in humans. These pathogens include, but are not limited
to, hepatitis B virus and HIV.
Contaminated:
Contamination involves the presence, or the reasonably anticipated
presence, of blood or other potentially infectious materials on an item
or surface.
Exposure:
Eye, mouth, other mucous membrane, non-intact skin, or parenteral
contact with blood or other potentially infectious materials that results
from the performance of an employee’s duties.
Other potentially infectious material: 1) semen, vaginal secretions,
cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid,
peritoneal fluid, amniotic fluid, saliva in dental procedures, any body
fluid that is visibly contaminated with blood, and all body fluids in
situations where it is difficult or impossible to differentiate between
body fluids; 2) Any unfixed tissue or organ (other than intact skin)
from a human (living or dead); 3) HIV-containing cell or tissue
cultures, organ cultures, and HIV- or hepatitis B virus-containing
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culture medium or other solutions; and, 4) blood, organs, or other
tissues from experimental animals infected with HIV or hepatitis B
virus.
Compliance With The Blood-Borne Pathogens Standard:
Employers And Employees
Adherence to the OSHA blood-borne pathogen standard is mandatory
for all hospitals and healthcare facilities. To be in compliance with the
standard employers must establish a written plan for controlling
exposure to blood-borne pathogens. This plan should include 1) an
assessment of risk situations, 2) a determination of which employees
are at risk and when they are at risk, and 3) specific actions the
employer will use to control and manage exposure to blood-borne
pathogens. The plan must be reviewed and updated annually and it
must be accessible to all employees, as outlined below.

Implement standard precautions, ensure that employees know
how to use standard precautions, and ensure they use standard
precautions.

Provide personal protective equipment (PPE) at no cost to all
employees who need it.

Provide initial training and annual training on blood-borne
pathogens to all employees. This training should include 1) a
review of the OSHA Blood-borne pathogens standard, 2)
information on the risks of exposures and how exposures
happen, 3) information on how to prevent exposures to blood-
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borne pathogens, and 4) information on the benefits and risk of
vaccination against hepatitis B.

Use engineering controls to control risk:
Engineering controls that control the risk of exposure to bloodborne pathogens would include providing sharps disposal boxes,
using safe medical devices, using needles that do not need to be
re-capped, providing proper waste disposal containers, and using
appropriate signs to warn of danger and to instruct employees
on the proper use of equipment.

Use work practice controls:
The employer must have a plan or plans in place for the proper
handling and disposal of blood and other specimens, the proper
handling and disposal of contaminated waste, and for the proper
cleaning and decontamination of equipment, patient rooms, and
patient care areas.

Offer vaccination against hepatitis B to all employees who may
be reasonably expected to have an occupational exposure to the
hepatitis B virus.

Have a plan to handle employee exposure to blood-borne
pathogens. This plan should include provisions for immediate
care (i.e., evaluation, first aid, laboratory screening tests, postexposure prophylactic medications) and follow-up care.
Nurses must comply with the requirements of the blood-borne
pathogens standard. The ones that address needlestick injuries and
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exposure to a blood-borne pathogen will be discussed separately.
Other requirements of standard 1910.1030 that apply to nurses and
the practice of nursing:

Understanding and following the engineering and work practice
controls established by the employer such as proper waste
disposal and adhering to the employer’s safety and sanitary
rules.

Using PPE correctly:
The employee is required to wear the appropriate PPE. The PPE
must be removed immediately upon removing the work area, or
as soon as possible, and it must be placed in a container
specifically designated for the purpose of receiving contaminated
waste.

Proper handling of blood and other body fluids.

Understanding and using Universal Precautions

Proper use of medical equipment; i.e., do not bend, break, or recap needles. Do not re-use disposable medical equipment.

Proper disposal of contaminated/potentially contaminated
medical equipment.

Disposable gloves:
Disposable gloves must be discarded as soon as possible after
they have become contaminated, punctured, or torn. Gloves are
not required to be worn when giving an injection as long as hand
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contact with blood or other potentially infectious material is not
reasonably expected.

Hand washing:
Employees must wash their hands immediately after removing
gloves or as soon as possible after removing gloves. Employees
must wash their hands after contact with blood or other
potentially infectious material and before and after performing
patient care. If hand washing with soap and running water is not
possible, the employee must use either an antiseptic hand
cleaner with clean cloth or paper towels or antiseptic towelettes.
After using an antiseptic hand cleaner or a towelette, the
employees must wash their hands with soap and running water
as soon as feasible.

Food and drink storage:
Food and drink should not be stored in refrigerators, cabinets,
etc., where blood or other potentially infectious material will be
stored.

Bagging specimens:
Double-bagging specimens is required if the outside of the
specimen container is contaminated or if the specimen could
puncture the primary container.
Managing Exposures To Blood-Borne Pathogens
Managing exposures to blood-borne pathogens involves three steps:
1) initial care of the exposed person, 2) reporting the exposure and
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investigating the circumstances, and 3) post-exposure prophylaxis, if
needed.
Table 3: Managing Exposures to Blood-Borne Pathogens
Initial Care
↓
Reporting the Exposure/Investigating the Circumstances
↓
Post-Exposure Prophylaxis
Initial care of the exposed person involves basic wound care. The first
step in managing an exposure to a blood-borne pathogen is to clean
the exposed area.19 If it is a percutaneous exposure or a skin exposure
wash the area with soap and water. Small puncture wounds can be
washed with an alcohol-based hand-wash; these are considered to be
virucidal for hepatitis B, hepatitis C, and HIV.19 Squeezing the wound
to express blood is not recommended nor is the use of over-thecounter disinfectants such as bleach.27 Wash the eyes with saline or
water and flush mucous membranes with water.
Learning Break:
The blood-borne pathogens standard defines an exposure as eye, mouth,
other mucous membrane, non-intact skin, or parenteral contact with
blood or other potentially infectious materials that results from the
performance of an employee’s duties. Expanding this definition, an
exposure can also be described as: 1) a percutaneous injury such as a
needlestick or a sharps injury; 2) mucous membrane contact or nonintact skin (skin that is abraded, chapped, or has dermatitis) contact with
blood, tissue, or potentially infectious body fluids. 21
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The next step is to report the exposure. This should be done as soon
as possible; do not delay reporting the incident. Information that
should be obtained and documented includes:
1. Exposure circumstances:
Documentation of the exposure circumstances should include the
date and time of the exposure, type of exposure, location of the
exposure (i.e., finger, hand, eye), estimated time of contact with
the blood or body fluid, how the exposure occurred, the body
fluid that was involved, any first aid that was done, PPE that was
in use, documentation of the affected person’s blood-borne
pathogens standard training, and, if it was a percutaneous
exposure, an estimation of the depth of the wound, if the needle
or sharp was in a blood vessel, and the size and type of the
needle or sharp.
2. Information about the affected healthcare professional:
Specific information about his/her vaccination for hepatitis B,
any previous tests for hepatitis B, hepatitis C, or HIV, status of
his/her tetanus immunization, medical history, and the names
and doses of prescription medications currently being taken.
Learning Break:
If the affected healthcare professional has received the complete hepatitis
B vaccination and she/he is known to have a response to the vaccination defined as Hepatitis B surface antibody concentration ≥ 10 mIU/mL - then
the source patient does not need to be evaluated for the presence of
hepatitis B and the affected person does not need post-exposure
prophylaxis.27
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3. Information about the source:
The source patient should be evaluated for the presence of
hepatitis B, hepatitis C, and HIV, unless their status regarding
these diseases is known. The laws that govern testing of source
patients will not be discussed here. Affected healthcare workers
must assume that their employer will comply with these laws.
Post-Exposure Treatment And Prophylaxis For Hepatitis B
The need for post-exposure treatment and prophylaxis after exposure
to hepatitis B is determined by an evaluation of the source patient and
the affected healthcare professional.
1. Evaluation of the source patient.
a. The source patient should be tested for hepatitis B surface
antigen even if they have previously been tested.27
b. If the source patient is known to be infected or if the affected
healthcare professional has received hepatitis B vaccination and
has a documented adequate response, the source patient does
not need to be tested.
2. Evaluation of the affected healthcare professional: There are five
possibilities and there is a specific post-exposure prophylaxis plan
for each one:
a. Complete hepatitis B vaccination with response
b. There is evidence of a prior infection with hepatitis B
c. Hepatitis B vaccination has been completed but the hepatitis B
surface antibody concentration is < 10 mIU/mL
d. Hepatitis B vaccination has been completed but serologic
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testing for a response has not been done or serologic testing
was done and the response is not known
e. The affected person has not been vaccinated or the
vaccination series has not been completed
For a and b there is no need for post-exposure prophylaxis. For c, d,
and e post-exposure prophylaxis may be needed depending on the
Hepatitis B status of the source. If the source patient is known as
being infected, or if the hepatitis B status of the source patient cannot
be determined, post-exposure prophylaxis should be done.27
Table 4: Post-Exposure Prophylaxis for Hepatitis B
One dose of hepatitis B immune globulin
One dose of hepatitis B vaccine
Two more doses of hepatitis B vaccine
The immune globulin and the first dose of the hepatitis B vaccine can
be given at the same time but at different injection sites. The hepatitis
B immune globulin should be give within 24 hours after the exposure
and it must be given within 7 days of the exposure.43 The second and
third doses of the hepatitis B vaccine are given 1 month and 6 months
after the initial dose even if the source patient is subsequently known
not to be infected. Testing for hepatitis B infection should be done six
months after the exposure. During this six-month period the affected
healthcare professional should not donate blood, organs, plasma,
semen, or tissue, but she or he can perform their normal duties.43 The
need for tetanus vaccination should also be considered.
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Post-Exposure Treatment And Prophylaxis For Hepatitis C
There is no effective post-exposure prophylaxis for hepatitis C.27 If
there has been an exposure the source patient should be tested for the
presence of hepatitis C, unless it is known that the patient is infected.
The affected healthcare professional should be tested for the presence
of hepatitis C, as well. If the source patient is not infected then no
further evaluation of the affected healthcare professional is needed. If
the source patient is infected with hepatitis C then the healthcare
professional: 1) should be counseled about the risk for transmission
and infection, 2) he/she should be tested for hepatitis C antibodies and
hepatitis C RNA at the time of exposure and every two months for six
months, and he/she should be referred to a specialist for ongoing
evaluation and, if needed, treatment.27 Donation of blood, organs,
plasma, semen, and tissue should not be done before the hepatitis C
status has been determined. The need for tetanus vaccination should
also be considered.
Post-Exposure Treatment And Prophylaxis For HIV
The need for post-exposure treatment and prophylaxis after exposure
to human immunodeficiency virus is determined by an evaluation of
the source patient and the affected healthcare professional.
1. Evaluation of the source patient.
b. If the HIV status of the source patient is unknown, rapid HIV
testing should be done. Depending on the specific test used, the
result will be available in 5-20 minutes and these tests have
excellent sensitivity and specificity.
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c. If the source patient is known to be HIV-positive testing is not
necessary.
2. Evaluation of the affected healthcare professional.
a. Evaluation should be done immediately after wound care or
decontamination has been completed.
b. The benefits and risks of post-exposure prophylaxis should be
thoroughly discussed.
c. If the source patient is known to have an HIV infection, postexposure prophylaxis should be started within 1-2 hours of the
exposure.19 Animal studies indicate that delaying administration
of post-exposure prophylaxis decreases its effectiveness,44,45 and
post-exposure prophylaxis should be started as soon as possible
and ideally within 72 hours of the exposure.21,46 It is not known
at what point after an exposure there would be no benefit from
post-exposure prophylaxis.21
d. If the HIV status of the source patient is unknown post-exposure
prophylaxis should be started and if the result of the rapid
testing is negative, treatment can be discontinued.21 Do not
delay starting treatment while waiting for the test results.
e. Laboratory evidence and confirmation of an HIV infection can be
delayed for up to 3 months after an exposure; this is commonly
termed the “window period” of HIV infection. However, the U.S.
Public Health Services Guidelines for post-exposure prophylaxis
state “... investigation of whether a source patient might be in
the window period is unnecessary for determining whether HIV
PEP is indicated unless acute retroviral syndrome is clinically
suspected.”21 In most cases, rapid testing alone is sufficient.
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f. The affected healthcare professional should be tested for the
presence of HIV and other blood-borne pathogens, if needed.
The need for tetanus vaccination should also be considered.
The recommended therapy is a three-drug regimen using the
nucleotide analogue reverse transcriptase inhibitor-nucleotide reverse
transcriptase inhibitor tenofovir-emtricitabine (Truvada™) and the
integrase inhibitor raltegravir (Isentress™) for four weeks.19,21 Four
weeks is recommended as in vitro studies, animal studies, and
occupational studies indicate this is the optimal duration of
treatment.21
The combination of tofovir-emtricitabine and raltegravir is a commonly
used regimen for HIV prophylaxis but there are other regimens that
are considered acceptable.21 As with any drug therapy, medications
used for post-exposure prophylaxis for HIV should be prescribed with
considerations of their effectiveness and tolerability. Tolerability is
especially important as the side effects of tofovir-emtricitabine and
raltegravir and other post-exposure prophylaxis medications can have
a negative influence of compliance with therapy.21 The potential for
drug-drug interactions is also very important. Commonly used drugs
such as oral contraceptives, H2 receptor antagonist, and proton pump
inhibitors can cause potentially serious drug interactions when used
with HIV post-exposure prophylaxis drugs.
Follow-up care is essential for persons receiving post-exposure
prophylaxis. The exposed person should be re-evaluated 72 hours
after the incident regardless of whether or not he or she is being
treated.21 Testing for HIV should be done at the time of the exposure,
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and 6 weeks, 12 weeks, and 6 months after the exposure.21 A
complete blood count and measurement of hepatic and renal function
should be done at the time of exposure and two weeks later.21 In the
six months following the exposure abstinence from sexual intercourse
or the use of condoms is recommended, and the exposed healthcare
professional should not donate blood, organs, plasma, semen, or
tissues.19 These precautions are especially important in the first 6-12
weeks after an exposure.
21
Special Situations
In some circumstances of exposure to HIV an expert consultation
should be sought.
Table 5: The Need for Expert Consultation
Breastfeeding
Chronic illness that may increase drug toxicity
Delay is reporting the exposure
Current drug therapy that may increase toxicity of post-exposure
prophylaxis
Drug-resistant HIV
Pregnancy
Unknown source, i.e., a needle that is in a sharps container
Breastfeeding and pregnancy are not contraindications for the use of
post-exposure prophylaxis for HIV,21 and women who are
breastfeeding or pregnant should receive post-exposure prophylaxis if
it is indicated. There is a significant risk of in utero transmission of HIV
and transmission of HIV through breastfeeding and although the data
is limited, it does not appear that the use of post-exposure
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prophylactic drugs increases the number of birth defects or is harmful
to breastfeeding infants.21,47 Efavirenz (Sustiva™) is teratogenic and
should not be used in pregnant women.48 Up-to-date information
about the use of antiviral drugs during pregnancy can be found on the
website of the Antiviral Pregnancy Registry, www.apr.com. Information
can also be obtained by calling the National Perinatal HIV Hotline, 7
days a week, 24 hours a day, 1-888-448-8765.
Exposure to, and subsequent infection with drug-resistant strains of
HIV has been reported to occur after occupational exposure to HIV,
despite early use of post-exposure prophylaxis.49-51 It is not practical
to perform drug-resistance testing immediately after exposure to HIV
so standard post-exposure prophylaxis should be initiated as soon as
possible; treatment should not be delayed while waiting for drugresistance testing.21 If there is a possibility that the source patient may
be infected with a drug-resistant strain of HIV, expert consultation
should be sought and without delay; post-exposure prophylaxis should
be started right away.21 The drug regimen can be changed later if this
is needed.
Exposure to a needle or a sharp from an unknown source should not
occur with good adherence to the blood-borne pathogens standards. If
an exposure of this type occurs the need for post-exposure prophylaxis
should be determined on a case-by-case basis. The needle or the
sharp does not need to be tested.21
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Learning Break:
The Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline) is available
from 9 a.m., to 2 a.m., seven days a week and can provide consultation
about risk assessment and post-exposure prophylaxis: 888-448-4911.
Clinical guidelines for risk assessment and treatment and post-exposure
prophylaxis recommendations for exposure to HIV, hepatitis B, and
hepatitis C are available on their website,
http://nccc.ucsf.edu/clinician-consultation/post-exposure-prophylaxispep/.
Summary
The OSHA blood-borne pathogens standard was developed to help
reduce transmission of and infection with blood-borne pathogens. The
Blood-borne pathogens standard has general and specific
recommendations, and nurses are required to have a basic knowledge
of and comply with the recommendations of the standard. The
recommendations are general and specific and requirements of
standard 1910.1030 that apply to nurses and the practice of nursing
are:

Understanding and following the engineering and work practice
controls such as proper waste disposal and adhering to the
employer’s safety and sanitary rules.

Using PPE correctly.

Proper handling of blood and other body fluids.

Proper use of medical equipment, particularly needles, sharps,
and disposable medical equipment.

Proper disposal of contaminated or potentially contaminated
medical equipment

Hand washing
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
Universal precautions

Proper use of gloves
Familiarity with the plan is required of nurses, but as needle sticks,
sharps injuries, and splash contact with blood and body fluids are
common occupational occurrences for nurses they need more
information, such as:

Transmission of and infection with a blood-borne pathogen is
unusual after a needlestick, sharps injury or cutaneous
exposure, but the potential medical consequences are quite
serious and research indicates that the psychological burden of a
needlestick can be significant.52,53

The risk of transmission of and infection with a blood-borne
pathogen depends on the circumstances of the exposure, the
pathogen, and the characteristics of the exposed individual.
Hepatitis B is highly transmittable, hepatitis C and HIV much less
so, and the risk of infection from a mucous membrane exposure
to any of these viruses is slight.

All exposures to blood-borne pathogens must be reported
immediately. Do not try and evaluate the level of risk yourself.

Clean or flush the affected area.

The need for treatment and post-exposure prophylaxis will
depend on the circumstances of the exposure, the infectivity of
the source patient, and the characteristics of the person who
was exposed.

If there is a risk for infection with HIV post-exposure prophylaxis
should be started as soon as possible after the exposure,
preferably within 1-2 hours.

There is no post-exposure prophylaxis for hepatitis C.
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
Post-exposure prophylaxis for hepatitis B is available.

Expert consultation should be sought if there are special or
unusual circumstances, i.e., potential for exposure to a drugresistant virus.
The OSHA blood-borne pathogens standard also requires employers to
have in place a plan for managing exposures to blood-borne
pathogens. The plan should provide basic information about bloodborne pathogen transmission and guidance about what to do in the
event of an exposure.
Please take time to help NurseCe4Less.com course planners
evaluate the nursing knowledge needs met by completing the
self-assessment of Knowledge Questions after reading the
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1. The majority of occupational exposures to blood-borne
pathogens are
a.
b.
c.
d.
percutaneous.
air-borne.
cutaneous.
percutaneous and cutaneous together.
2. The most common blood-borne pathogens in occupational
exposures are:
a.
b.
c.
d.
Hepatitis
Hepatitis
Hepatitis
Hepatitis
B, hepatitis D, and MRSA.
C, HIV, and tuberculosis.
B, hepatitis C, and HIV.
E, HIV, and gram-negative bacteria.
3. The risk of HIV transmission after a percutaneous exposure
is approximately
a.
b.
c.
d.
3.0%.
0.3%.
30%.
13%.
4. True or False: Infection with a blood-borne pathogen can
occur after contact with a contaminated surface.
a. True
b. False
5. The first step in managing an exposure to a blood-borne
pathogen is:
a.
b.
c.
d.
Testing of the source patient.
Notifying the employee health department.
Testing of the affected healthcare professional.
Perform basic wound care or flush the affected area.
6. An exposure to a blood-borne pathogen should be reported:
a.
b.
c.
d.
Within 24 hours of the exposure.
At the end of the shift.
Immediately.
Within seven days of the exposure.
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7. Post-exposure prophylaxis for Hepatitis B:
a. Is not needed if vaccination is complete and the response is
adequate.
b. Should be given only if the exposure involved a large amount of
blood.
c. Is not needed if the source patient has had Hepatitis B for > 10
years.
d. Should be given only if the source patient is not known.
8. True or False: There is effective post-exposure prophylaxis
for Hepatitis C.
a. True
b. False
9. Post-exposure prophylaxis for HIV should be started:
a.
b.
c.
d.
Within 7 days of the exposure.
After drug-resistance testing is completed.
Within 1-2 hours of the exposure.
After tests for Hepatitis B and C and HIV have been completed.
10. The OSHA blood-borne pathogens standard requires
employers to:
a. Test each employee yearly for infection with blood-borne
pathogens.
b. Provide pre-exposure prophylaxis for HIV.
c. Test at-risk patient for blood-borne pathogens.
d. Have a plan for the management of exposures to blood-borne
pathogens.
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CORRECT ANSWERS:
1. The majority of occupational exposures to blood-borne
pathogens are
a. percutaneous.
“The majority of occupational exposures to and infections from
these viruses are caused by percutaneous injury.”
2. The most common blood-borne pathogens in occupational
exposures are:
c. Hepatitis B, hepatitis C, and HIV.
“Many bacteria and viruses can be, and have been transmitted to
healthcare workers by needlesticks, sharps injury, or splash
contact, but hepatitis B, hepatitis C, and the human
immunodeficiency virus (HIV) account for the greatest number
of exposures and infections.”
3. The risk of HIV transmission after a percutaneous exposure
is approximately:
b. 0.3%.
“The risk of infection after a percutaneous exposure to HIV has
been estimated to be 0.32% and the risk for infection after a
mucous membrane exposure to HIV has been estimated to be
0.03%-0.09%.”
4. True or False: Infection with a blood-borne pathogen can
occur after contact with a contaminated surface.
a. True
“Blood-borne pathogens can contaminate surfaces and
persist in the environment and contact with these
contaminated surfaces can cause infection. ”
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5. The first step in managing an exposure to a blood-borne
pathogen is:
d. Perform basic wound care or flush the affected area.
"Initial care of the exposed person involves basic wound care.
The first step in managing an exposure to a blood-borne
pathogen is to clean the exposed area. If it is a percutaneous
exposure or a skin exposure wash the area with soap and water.
Familiarity with the plan is required of nurses, but as needle
sticks, sharps injuries, and splash contact with blood and body
fluids are common occupational occurrences for nurses they
need more information, such as:... Clean or flush the affected
area.”
6. An exposure to a blood-borne pathogen should be reported:
c. Immediately.
“All exposures to blood-borne pathogens must be reported
immediately. Do not try and evaluate the level of risk yourself.”
7. Post-exposure prophylaxis for Hepatitis B:
a. Is not needed if vaccination is complete and the response is
adequate.
“If the affected healthcare professional has received the
complete hepatitis B vaccination and she/he is known to have a
response to the vaccination - defined as Hepatitis B surface
antibody concentration ≥ 10 mIU/mL - then the source patient
does not need to be evaluated for the presence of hepatitis B
and the affected person does not need post-exposure
prophylaxis.”
8. True or False: There is effective post-exposure prophylaxis
for Hepatitis C.
b. False
“There is no effective post-exposure prophylaxis for hepatitis C.”
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9. Post-exposure prophylaxis for HIV should be started:
c. Within 1-2 hours of the exposure.
“If the source patient is known to have an HIV infection, postexposure prophylaxis should be started within 1-2 hours of the
exposure.”
10. The OSHA blood-borne pathogens standard requires
employers to:
d. Have a plan for the management of exposures to blood-borne
pathogens.
“The OSHA blood-borne pathogens standard also requires
employers to have in place a plan for managing exposures to
blood-borne pathogens.”
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References Section
The References below include published works and in-text citations of
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