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DISINFECTANTS, OSHA BLOODBORNE PATHOGEN STANDARD AND OTHER TOPICS ON MANAGEMENT OF COMMUNICABLE DISEASES IN SCHOOLS Scott Maag Vice President of Research and Operations Buckeye International, Inc. TOPICS Disinfectants OSHA Bloodborne Pathogen Standard Influenza Viruses (Including Avian Influenza) Norovirus Non-Polio Enterovirus Zika Virus Staphylococcus Aureus/MRSA Head Lice Scabies Giardia DISINFECTANTS Disinfectants Disinfectant Versus Sanitizer How Disinfectants Work Disinfectant Vs. Sanitizer Disinfectant – “a substance, or mixture of substances, that destroys or irreversibly inactivates bacteria, fungi and viruses, but not necessarily bacterial spores, in the inanimate environment.”1 Sanitizer – “a substance, or mixture of substances, that reduces the bacterial population in the inanimate environment by significant numbers, (e.g., 3 log 10 reduction) or more, but does not destroy or eliminate all bacteria.”1 - food contact surface sanitizers are used in food service Disinfectants and sanitizers are also called antimicrobial pesticides, and they are regulated by the U.S. EPA Disinfectant Vs. Sanitizer ORGANISM D S Acinetobacter baumannii X Acinetobacter calcoaceticus X Chlamydia psittaci X Enterobacter aerogenes X Enterobacter cloacae X Enterobacter cloacae - NDM-1 X Enterococcus faecalis - Vancomycin resistant (VRE) X Escherichia coli X Escherichia coli - NDM-1 X Fusobacterium necrophorum X Klebsiella pneumoniae X Klebsiella pneumoniae - NDM-1 X Legionella pneumophila X Listeria monocytogenes X Pasteurella multocida X Proteus mirabilis X Proteus vulgaris X Pseudomonas aeruginosa X Salmonella enterica X Salmonella enteritidis X Salmonella typhi X Salmonella typhimurium X Serratia marcescens X Shigella flexneri X X ORGANISM (cont.) Shigella sonnei Staphylococcus aureus S. aureus - Community Associated Methicillin-Resistant (CA-MRSA) S. aureus Methicillin resistant (MRSA) S. aureus - Vancomycin Intermediate resistant (VISA) Staphylococcus epidermidis (antibioticresistant strain only) Streptococcus faecalis Streptococcus pyogenes Adenovirus type 4 Hepatitis B Virus Hepatitis C Virus Herpes Simplex Virus Type 1 Herpes Simplex Virus Type 2 HIV-1 Human coronavirus Influenza A Virus/Hong Kong Pandemic 2009 H1N1 influenza A virus Respiratory syncytial virus Rotavirus Rubella virus SARS Associated Coronavirus Vaccinia Aspergillus niger Candida albicans Trichophyton mentagrophytes D S X X X X X X X X X X X X X X X X X X X X X X X X X D=Disinfectant (Quat-based, Diluted 1:256) S=Non-food Contact Surface Sanitizer (Citric Acid-based, Diluted 1:4) How Disinfectants Work Can work in a variety of ways involving effects on microorganism components including cell membrane, cell proteins, enzymes, and DNA Quat disinfectants, for example, are known for disrupting the cell membranes of bacteria – quats are able to attach to bacteria to begin with because the quats’ charge is positive and the bacterial cell surface is negative OSHA BLOODBORNE PATHOGEN STANDARD OSHA’s Bloodborne Pathogen Standard History Pathogens Infectious Materials Modes of Transmission Prevention Cleaning Procedures History December 6, 1991 Federal Register 29 CFR 1910.1030 Established in March 1992 “…reasonably be anticipated to come into contact with blood or other OPIM as a result of doing their job duties.”2 (OPIM = Other Potentially Infectious Materials) Limit occupational exposure to blood and other potentially infectious materials since any exposure could result in transmission of bloodborne pathogens which could lead to disease or death. Pathogens Hepatitis B (HBV) “Inflammation of the liver” - can cause cirrhosis and cancer of liver HBV vaccine available - routine for children and healthcare workers No cure for chronic HBV – medications reduce chance of developing severe liver diseases 50-100 times more infectious than HIV3, easily spread by sex or injection drug use Very durable can survive in dried blood for at least seven days Tens of thousands per year are infected (19,200 in 2014)3 Pathogens Hepatitis C (HCV) “Non-A, Non-B Hepatitis.” No vaccine to prevent HCV. Cure may be achievable with medications taken daily for months. Leading cause of cirrhosis & the leading cause of liver transplantation in the US Of 100 persons infected with HCV about4: 75-85 persons develop long-term infection (chronic) 15-25 persons develop acute HCV and recover Virus can survive on environmental surfaces for up to 3 weeks 2.7-3.9 million Americans estimated to have chronic infection4 Pathogens Human Immunodeficiency Virus (HIV) Attacks CD4 cells (T cells) in the immune system Causes AIDS – Acquired Immunodeficiency Syndrome People who are infected carry the virus for many years before AIDS symptoms develop Testing is the only way to know if you are infected 1.2 million people in US are living with the virus – 13% are unaware they are infected (2013 information)5 No cure, treatment is improving Very fragile virus Pathogens Directive Number: CPL 02-02-069 Effective Date: November 27, 2001 Subject: Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens (Purpose: This instruction establishes policies and provides clarification to ensure uniform inspection procedures are followed when conducting inspections to enforce the Occupational Exposure to Bloodborne Pathogens Standard) "Bloodborne Pathogens": While HBV and HIV are specifically identified in the standard, the term includes any pathogenic microorganism that is present in human blood or OPIM and can infect and cause disease in persons who are exposed to blood containing the pathogen. Pathogenic microorganisms can also cause diseases such as hepatitis C, malaria, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, Creutzfeldt-Jakob disease, adult T-cell leukemia/lymphoma (caused by HTLV-I), HTLV-I associated myelopathy, diseases associated with HTLV-II, and viral hemorrhagic fever. Other Potentially Infectious Materials (Aside from blood) semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva, any body fluid visibly contaminated with blood and all body fluids in situations where it is difficult or impossible to differentiate between body fluids… Transmission of Pathogens Normally, unbroken skin forms an impervious barrier against bloodborne pathogens Open sores, cuts, abrasions, acne, sunburn, blisters Mucous Membranes: eyes, nose and mouth (i.e. a splash of contaminated fluid to your eye, nose, mouth or open sore could result in transmission) Prevention Treat all potentially infectious material as if it were contaminated Personal Protective Equipment (PPE) 3 Step Cleaning – contain, clean, decontaminate Handwashing soft, antibacterial soap (if possible) avoid harsh, abrasive soaps Hard Surface Clean - Up Use gloves, gowns and eye protection To clean up the spill: Apply an absorbent to soak up the infectious material. Contaminated broken glassware shall NOT be picked up by hand. Use a brush and dust pan, tongs or forceps. Pick up the moist absorbent. Place the absorbent into a regulated waste container (if it would be capable of releasing infectious material if compressed or during handling). Any brush, dust pan, tongs or forceps must be discarded or decontaminated before reuse. Clean the spill area with a general purpose cleaner or disinfectant cleaner to remove gross filth. Decontaminate area with disinfectant with HIV, HBV& HCV claim, with TB claim or with bleach. Place the towel which was used for cleaning into the regulated waste container. Appropriate Disinfectant Products OSHA letter June 30, 1989 Clarifies use of HIV claimed disinfectant OSHA letter February 28, 1997 Clarifies use of HIV & HBV claimed disinfectants EPA's Registered Sterilizers, Tuberculocides, and Antimicrobial Products Against HIV-1, and Hepatitis B and Hepatitis C Viruses. (Updated March 14, 2016) http://www.epa.gov/pesticide-registration/selected-epa-registereddisinfectants Directive Number: CPL 02-02-069 Subject: Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens Any of the above products are considered effective when used according to the manufacturer's instructions, provided the surfaces have not become contaminated with agents or volumes of or concentrations of agents for which higher level disinfection is recommended. NOTE: Fresh solutions of diluted household bleach made up daily (every 24 hours) are also considered appropriate for disinfection of environmental surfaces and for decontamination of sites following initial cleanup (i.e., wiping up) of spills of blood or other potentially infectious materials. Contact time for bleach is generally considered to be the time it takes the product to air dry. Bleach Strong odor Corrosive to eyes and skin Short shelf life, needs test paper to test concentration Can damage clothes and other fabrics Phenolics Skin depigmentation Possible disposal problems down sanitary sewers High cost Not to be used around neonatal area “Texas public school districts are required to implement bloodborne pathogen exposure control plans.”6 Influenza Viruses Including Avian Influenza Influenza Viruses Types of virus Preventing Avian Influenza The Influenza Virus Virus which infects the respiratory tract (nose, throat and lungs) Three types that infect people Influenza A Influenza B Influenza C Influenza A Tend to cause epidemics of disease almost every winter Divided into subtypes based on two surface proteins H (hemagglutinin) 18 types N (neuraminidase) 11 types Found in many different animals – ducks, chickens, pigs, whales, horses, etc. Birds are thought to be the source of Influenza A viruses in other animals Influenza B Tend to cause epidemics almost every winter No subtypes Circulates widely only among humans Influenza B and A (H1N1 & H3N2) are included in each year’s Influenza vaccine Influenza C Causes mild respiratory illness and not thought to cause epidemics Flu shot does not protect against type C Influenza Preventing Influenza Get vaccinated each fall Avoid close contact with individuals Stay home when you are sick Cover your mouth and nose Wash your hands Avoid touching eyes, mouth & nose Clean and disinfect frequently touched surfaces (influenza virus on a surface may be able to infect for up to 48 hours) Avian Influenza A Known as bird flu Variety of strains with a variety of symptoms – most cause no or mild symptoms Low Pathogenic – may go undetected, cause mild symptoms Highly pathogenic – highly contagious and rapidly fatal (90-100% mortality within 48 hours) Avian Influenza A Spreads through saliva, nasal secretions and feces Avian Influenza viruses don’t usually infect humans Avian Influenza A Strains of Concern Highly Pathogenic Asian Avian Influenza A (H5N1) Virus in Africa, Asia, Europe, and the Middle East and new Avian Influenza A (H7N9) Virus in China – these have caused most human illness worldwide Spread to humans from contact with infected birds and droppings (there has been human-tohuman spread, but it has been rare) Avian Influenza A Symptoms in Humans Flu like – fever, cough, sore throat, muscle aches Eye infections, pneumonia, acute respiratory distress, stomach illness, neurologic changes Avian Influenza A Fear is: virus will change and infect humans easily Spread easily between people Influenza pandemic could begin BUT at this time Asian Avian Influenza A Virus (H5N1) and new Avian Influenza A Virus (H7N9) have not been detected in birds and humans in the U.S. A Few Notes on Pandemic Preparedness Last pandemic was 2009 H1N1 pandemic Most people will not be immune to a pandemic influenza virus, and a vaccine may not be immediately available A preparedness plan may consider communication with public health department, emergency communication with parents/students/staff, sick leave policies, methods for continuing education and services in case of school closures, etc.7,8 Daily influenza prevention measures such as hand washing, cleaning/disinfecting surfaces, etc. should also be relevant for prevention of pandemic flu Having adequate supplies such as soap and tissues would be important during a pandemic NOROVIRUS (PREVIOUSLY CALLED NORWALK-LIKE VIRUS) Norovirus • Symptoms of Norovirus • Spread of Norovirus • Norovirus Prevention Measures Source: CDC/Jessica A. Allen and Alissa Eckert (Illustrator), ID# 21348, https://cdc.gov/phil/home.asp, accessed December 2016. Symptoms of Norovirus • • • • • • Illness is sometimes called “stomach flu,” though norovirus is not related to influenza virus Norovirus causes inflammation of intestines and/or stomach Most common symptoms: diarrhea, vomiting, nausea, stomach pain Less common symptoms: fever, headache, body aches Symptoms usually start 12-48 hours after exposure; people generally feel better in 1-3 days Norovirus illness can lead to dehydration if lost fluids are not replaced Spread of Norovirus Norovirus-containing stool or vomit gets into the mouth of an uninfected person, for example Contaminated food or drinks are consumed A contaminated surface is touched and then fingers are put into mouth Direct contact is had with an infected person Contagious period: before symptoms until 2 weeks after recovery (most contagious while sick plus a few days after) Spread is quick in enclosed facilities Most US outbreaks November-April9 Norovirus Prevention Measures • Wash hands with soap and water • • • • • • • • After changing diapers After using the toilet Before preparing food Before eating Hand sanitizers may be used in addition to soap and water, but they are not substitutes Handle foods correctly (e.g., wash raw produce) Clean and disinfect hard, nonporous surfaces If infected, stay home and do not prepare food when you are most contagious Non-Polio Enterovirus Non-Polio Enterovirus What Non-Polio Enteroviruses Are How to Prevent the Spread What Non-Polio Enteroviruses Are • • • • • Viruses in the Enterovirus genus other than polio virus Can cause mild or no symptoms, especially in adults Can cause illness such as viral conjunctivitis; viral meningitis; and hand, foot, and mouth disease Spread from exposure of eye, nose, or mouth to an infected person’s mouth or nose secretions, stool, or blister fluid Enterovirus D68 caused an outbreak in 2014 How to Prevent the Spread of Non-Polio Enteroviruses • • • • • • Wash hands often with soap and water Avoid touching eyes, nose, and mouth with unwashed hands Avoid close contact with someone who is sick Clean and disinfect frequently touched surfaces Encourage covering coughs and sneezes Stay home when sick ZIKA VIRUS Zika Virus Transmitted primarily through the bite of Aedes species mosquitoes Most infected people have no symptoms or mild symptoms Zika virus infection during pregnancy may lead to microcephaly and other birth defects Schools may take measures to prevent mosquito bites, for example: Removing outside standing water sources where mosquitoes can lay eggs (such as uncovered trash cans) Ensuring that opened windows have functioning screens to keep mosquitoes out of classrooms STAPHYLOCOCCUS AUREUS / METHICILLIN RESISTANT (MRSA) Staphylococcus Aureus/MRSA What is Staph Where is Staph Found What is MRSA How Common is Staph How is Staph Spread How to Prevent Staph Infections What is Staph •Staphylococcus aureus •Bacteria commonly carried on the skin and nose of healthy people •It is one of the most common cause of skin infections in the U.S. •These are simple infections that can cause pimples and boils Staph can also cause serious infections such as surgical wound infections and pneumonia Where is Staph Found In the air On human bodies In their noses On objects What is MRSA Methicillin-Resistant Staphylococcus aureus Antibiotic resistance only! Not resistant to disinfectants Found in serious infections Normally found in hospitals and healthcare facilities Infections occurring in the wider community among healthy people – Community-Associated MRSA (CA-MRSA) Usually shows up as skin infections in healthy people How Common Is Staph/MRSA Tens of thousands of cases of severe MRSA infections are estimated to occur per year nationwide10 How is Staph/MRSA Spread Person-to-person contact Contact with contaminated surfaces such as: Towels, sheets, clothes, workout rooms, gyms, sports equipment, mats, locker rooms Student desks, lunch tables, lockers Restroom fixtures, door handles, sinks, benches Prevention of Staph/MRSA Wash hands frequently with soap and water; use hand sanitizers Keep cuts and wounds clean and bandaged Avoid touching other people’s cuts or wounds Encourage showering and washing clothes/uniforms after exercise Instruct not sharing items such as towels Routinely disinfect hard surfaces of concern HEAD LICE Head Lice Description How Head Lice Are Spread Prevention Description of Head Lice Pediculus humanus capitis (scientific name) Parasitic insects that can be found on the head, eyebrows, and eyelashes of people – live close to the scalp Feed off human blood Do not spread disease Have 3 stages: nit(egg), nymph, adult Source: CDC/Dr. Dennis Juranek, ID# 19067, https://phil.cdc.gov/phil/home.asp, , accessed December 2016. How Head Lice Are Spread • • • • • Movement of head lice is by crawling Head-to-head contact with someone who has head lice is usual means of transmission Less likely, spread may arise from contact with clothing or other personal items of an infested person Lice live only <1-2 days if they cannot feed; nits cannot hatch and will die within a week if not at temperature of scalp Infestation most common among day care/school children and their families11 Prevention of Head Lice • • • • • Treatment of infested person at home with prescribed or OTC medicine (American Academy of Pediatrics urges against excluding children with nonit policies12) Vacuuming, laundering, sealing of non-machine washable items into plastic bags for two weeks, soaking of brushes and combs in hot water (these activities might be most appropriate at infested child’s home) Urging against head-to-head contact If possible, providing each student with a space to keep jackets, hats etc. separate from those of others Avoiding sharing of personal items such as hairbrushes SCABIES Scabies What Is Scabies and How Is It Spread Prevention of Scabies Photomicrograph Showing Changes in a Human Skin Sample from a Scabies Infestation Source: CDC/Reed & Carnrick Pharmaceuticals, ID# 15386, https://phil.cdc.gov/phil/home.asp, accessed December 2016. What Is Scabies and How Is It Spread Human itch mite (Sarcoptes scabiei var. hominis) burrows into the skin Symptoms are itching and a rash Passed usually by direct, prolonged skin-toskin contact with a person who has scabies Less commonly may be transmitted by using an article (e.g., towel) that was used by an infested person Infestations are often seen in crowded facilities or places with frequent skin contact Scabies mites don’t usually survive more than 48-72 hours off a person Prevention of Scabies • • • • • Avoiding direct skin contact with an infested person or with the infested person’s items Keep in mind: symptoms may not appear for up to two months after infestation People in the same household and close contacts are often recommended to be treated along with the diagnosed person Bedding and clothing used by a person during the three days before treatment should be machine washed, dry cleaned, or stored in a plastic bag for up to a week Exclusion from school until treated GIARDIA Giardia Basic Information Prevention of Giardia Infection (Giardiasis) Source: CDC/Janice Haney Carr, ID# 8698, https://cdc.gov/phil/home.asp, accessed December 2016. Basic Information about Giardia Giardia are protozoan parasites (protozoan = a term used to describe certain one-celled, microscopic organisms) Giardiasis (Giardia infection) symptoms can include diarrhea, stomach cramps, vomiting, weight loss, failure to absorb nutrients Giardia are passed in the stool of those infected People get giardiasis when they swallow contaminated food or water or touch contaminated surfaces and then put their fingers in their mouths Illness may not appear until at least one week after exposure, and symptoms may last several weeks Prevention of Giardiasis Frequently wash hands with soap and water Before eating Before preparing food After using the toilet After changing diapers Clean up after ill people (quats are thought to be effective, but this is difficult to test in labs and the products do not have claims to our knowledge – bleach also gets recommended13) Exclude students with diarrhea from school Shower before swimming and exclude people with diarrhea or recent diarrhea from swimming Do not drink water from pools, hot tubs, lakes, etc. Wash with clean drinking water food that is to be eaten raw QUESTIONS? Endnotes 1Environmental Protection Agency Office of Chemical Safety and Pollution Prevention, “Product Performance Test Guidelines OCSPP810.2000 General Considerations for Uses of Antimicrobial Agents (September 2012),” https://www.regulations.gov/document?D=EPA-HQ-OPPT-2009-0150-0019, accessed December 2016. 2Occupational Safety and Health Administration, “OSHA Fact Sheet OSHA’s Bloodborne Pathogens Standard,” https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf , accessed December 2016. 3Centers for Disease Control and Prevention ,“Hepatitis B FAQs for the Public,” https://www.cdc.gov/hepatitis/hbv/bfaq.htm, accessed December 2016. 4Centers for Disease Control and Prevention, “Hepatitis C FAQs for the Public,” https://www.cdc.gov/hepatitis/hcv/cfaq.htm, accessed December 2016. 5Centers for Disease Control and Prevention, “HIV Basics,” https://www.cdc.gov/hiv/basics/, accessed December 2016. 6Texas Department of State Health Services, “Bloodborne Pathogen Control in Texas Schools,” https://www.dshs.texas.gov/schoolhealth/bldbrnpt.shtm, accessed December 2016. 7Centers for Disease Control and Prevention, “Administrators of Childcare and K-12 Schools Flu Prevention at School,” https://www.cdc.gov/nonpharmaceuticalinterventions/school/administrators-childcare-k-12-schools.html. Endnotes cont. 8Centers for Disease Control and Prevention, “Pandemic Flu Checklist: K-12 School Administrators,” https://www.cdc.gov/nonpharmaceutical-interventions/pdf/pan-fluchecklist-k-12-school-administrators-item2.pdf, accessed December 2016. 9Centers for Disease Control and Prevention, “Norovirus,” https://www.cdc.gov/norovirus/, accessed December 2016. 10Centers for Disease Control and Prevention, “Methicillin-resistant Staphylococcus aureus (MRSA),” https://www.cdc.gov/mrsa/, accessed December 2016. 11Centers for Disease Control and Prevention, “Parasites-Lice-Head Lice,” https://www.cdc.gov/parasites/lice/head/index.html, accessed December 2016. 12Barbara L. Fankowski and Joseph A. Bocchini, Jr., “Clinical Report-Head Lice,” Pediatrics 126, no. 2 (August 2010): 399, http://pediatrics.aappublications.org/content/pediatrics/126/2/392.full.pdf, accessed December 2016. 13Centers for Disease Control and Prevention, “Parasites-Giardia,” https://www.cdc.gov/parasites/giardia/, accessed December 2016. Bibliography Centers for Disease Control and Prevention. “Administrators of Childcare and K-12 Schools Flu Prevention at School.” https://www.cdc.gov/nonpharmaceutical-interventions/school/administrators-childcare-k-12-schools.html, accessed December 2016. Centers for Disease Control and Prevention. “Hepatitis B FAQs for the Public.” https://www.cdc.gov/hepatitis/hbv/bfaq.htm, accessed December 2016. Centers for Disease Control and Prevention. “Hepatitis C FAQs for the Public.” https://www.cdc.gov/hepatitis/hcv/cfaq.htm, accessed December 2016. Centers for Disease Control and Prevention, “HIV Basics,” https://www.cdc.gov/hiv/basics/, accessed December 2016. Centers for Disease Control and Prevention. “Influenza (Flu).” https://www.cdc.gov/flu/, accessed December 2016. Centers for Disease Control and Prevention. “Methicillin-resistant Staphylococcus aureus (MRSA).” https://www.cdc.gov/mrsa, accessed December 2016. Centers for Disease Control and Prevention. “MRSA and the Workplace.” https://www.cdc.gov/niosh/topics/mrsa/, accessed December 2016. Centers for Disease Control and Prevention. “Non-Polio Enterovirus.” https://www.cdc.gov/non-polio-enterovirus/, accessed December 2016. Centers for Disease Control and Prevention. “Norovirus.” https://www.cdc.gov/norovirus/, accessed December 2016. Bibliography cont. Centers for Disease Control and Prevention. “Pandemic Flu Checklist: K-12 School Administrators.” https://www.cdc.gov/nonpharmaceutical-interventions/pdf/pan-flu-checklist-k-12-school-administrators-item2.pdf, accessed December 2016. Centers for Disease Control and Prevention. “Parasites-Giardia.” https://www.cdc.gov/parasites/giardia/, accessed December 2016. Centers for Disease Control and Prevention. “Parasites-Lice-Head Lice.” https://www.cdc.gov/parasites/lice/head/, accessed December 2016. Centers for Disease Control and Prevention. “Parasites-Scabies.” https://www.cdc.gov/parasites/scabies/prevent.html, accessed December 2016. Centers for Disease Control and Prevention. “Zika Virus Response Planning : Interim Guidance for District and School Administrators in the Continental United States and Hawaii.” https://www.cdc.gov/zika/schools.html, accessed December 2016. 29 CFR 1910.1030 Clark, Patricia K to Mark Gindling. Memorandum regarding HIV disinfectants, June 30, 1997, Occupational Safety and Health Administration. From OSHA website https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=19815, accessed December 2016. Bibliography cont. Environmental Protection Agency Office of Chemical Safety and Pollution Prevention. “Product Performance Test Guidelines OCSPP 810.2000: General Considerations for Uses of Antimicrobial Agents.” www.regulations.gov/document?D=EPA-HQ-OPPT-2009-0150-0019, accessed December 2016. Fankowski, Barbara L.and Joseph A. Bocchini Jr. “Clinical Report-Head Lice.” Pediatrics 126, no. 2 (August 2010): 392-403. http://pediatrics.aappublications.org/content/pediatrics/126/2/392.full.pdf, accessed December 2016. Mallinger, Stephen to Regional Administrators. Memorandum regarding EPAregistered disinfectants for HIV/HBV, Februrary 28, 1997,, Occupational Safety and Health Administration. From OSHA website https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=22364, accessed December 2016. Mayo Clinic. “Hepatitis B.” https://www.mayoclinic.org/diseases-conditions/hepatitis-b/basics/definition/con-20022210, accessed December 2016. Mayo Clinic. “Hepatitis C.” https://www.mayoclinic.org/diseases-conditions/hepatitis-c/home/ovc-20207365, accessed December 2016. Bibliography cont. Occupational Safety and Health Administration. “Directive Number CPL 02-02-069 Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens.” https://www.osha.gov/pls/oshaweb/owaadisp.show_document?p_table=DIRECTIVES&p_id=2570, accessed December 2016. Occupational Safety and Health Administration,. “OSHA Fact Sheet OSHA’s Bloodborne Pathogens Standard.” https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf , accessed December 2016. Rutala, William A., David J. Weber, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). “CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008.” Downloaded from the CDC website. https://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf, accessed December 2016. Texas Department of State Health Services. “Bloodborne Pathogen Control in Texas Schools.” https://www.dshs.texas.gov/schoolhealth/bldbrnpt.shtm, accessed December 2016.