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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: 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. 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: 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 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. 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: 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 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: Needlestick or sharp injuries 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 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, 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. 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. 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: 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: 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.