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P1
Prevention of blood borne and hospital acquired
infections, including HIV/AIDS
standard work precautions
P2
The chain of infection
Agent
Reservoir
Place of exit
Transmission method
Place of entry
Susceptible host
P3
Bacterial spores
Mycobacteria
Polio virus
Fungi
Other bacteria
Hepatitis B virus
HIV viruses
Descending order of resistance to germicidal chemicals
P4
Important infections associated with exposure to contaminated blood
• Viral hepatitis (HBV most common), HCV, HGV and Delta agent
• HIV
• HCV
• HBV
• Malaria
• Syphillis
P5
Risk procedures
Examination of patients and common OPD procedures (open
wound, PV & PR examination)
Invasive diagnostic and therapeutic procedures
Resuscitation (mouth to mouth)
Wound dressing
Operation theatre procedures
Various ward activities
Handling of blood/serum/body fluids and tissues
Cleaning of hospital/clinic and disposal of waste
Faulty sterilization
Laundry; C.S.S.D and kitchen
Post mortem/embalming
P6
Modes of exposure to blood borne pathogens in the laboratory
Procedure HCW at risk Source/modes of transmission
Collection of blood/body fluids
Laboratory technician
Needle stick injury
Broken specimen vial
Blood contamination of hand with skin lesion/ breach
Transfer of specimen
Laboratory technician and transport worker
Contaminated exterior of the container/ requisition slip
Broken container
Spill/splash of specimen
Processing of specimen
Laboratory personnel
Puncture of skin
Contamination of skin/mucous membrane from contaminated work surface
Spills/splash of specimen
Broken specimens container
Faulty techniques
Perforated gloves
Cleaning/washing Laboratory support staff
Puncture of skin
Contamination of skin fromContaminated
glasswareSpills/splashesContaminated work surface
Disposal of waste Laboratory support staff
Contact with infectious waste specially sharps, broken containers
Specimen transport/mailing
Transport, postal staff
Broken/leaking container or packaging
P7
Risk factors for occupational HBV & HIV infection in health care professionals
•Frequency of occupational exposure (Contact with blood or bloody body fluids, Accidental needle sticks/sharp instrument injuries
•Occupational area in the hospital Gyn & Obst. Dept.HemodialysisPathologySurgery, surgical intensive careEmergency roomBlood bankClinical laboratoryIntravenous teamsDentistry; oral surgery
•Working with at risk populations
•Source infectivityHbs Ag-positive, HIV-positive, HCV positive
P8
HIV and the Environment
HIV was recoverable by tissue culture techniques up to 3 days after drying in laboratory studies (concentration of virus is 100,000 times greater than found in blood of HIV infected person).
CDC, USA studies have shown that drying causes a 90-99% reduction in HIV concentration within several hours.
In tissue culture fluid, cell free HIV could be recovered up to 15 days at room temperature, up to 11 days at 370C and up to 1 day if HIV was cell associated.
No one so far has been HIV infected as a result of contact with an environmental surface.
HIV cannot reproduce outside the living host except under laboratory conditions and cannot spread or maintain infectiousness outside its host.
P9
Characteristics of blood borne viruses during the window period
Window period HIV HCV HBV
Days to antibody detection 22 70 56
Expected reduction with NAT (days) 10-15 41-60 6-15
Viral doubling time (days) 1 0.3 4
WP viral load/ml 102-107 105-107 102-104
NAT = Nucleic acid amplification test
WP = Window period
(Genomic screening for blood borne viruses in transfusion setting. Clin Lab. Haem.. 2000;22:1-10. J.P. Allan Division of Transfusion Medicine, Department of Haematology, University of Cambridge, Cambridge, UK).
P10
Standard work precautions apply to:
Blood Pleural fluid
Semen Peritoneal fluid
Vaginal secretions Pericardial fluid
CSF Amniotic fluid
Synovial fluid Tissues & organs
• Brest milk – bank• Saliva – Dentistry as often mixed with blood• All blood soiled articles• All infectious waste• All contaminated articles
P11
Standard work precautions usually do not apply:
Faeces Tears
Nasal secretions Urine
Sputum Vomitus
Sweat
(Unless mixed with blood)
P12
Essential Dos and Don’ts of biosafey
The essential biosafety measures are as follows:
Dos Don’ts
• Use gloves to prevent manual contact with blood/body fluids, mucous membranes, broken skin
• Use masks, protective eye wears, face shield to prevent droplet infections
• Use gowns, aprons and foot covers to prevent splash of blood/body fluid before testing
• Place all used instruments in disinfectant jar
• Unnecessary risky procedures e.g. mixing, grinding
• Sharp objects use• Allowing persons with broken skin,
weeping skin lesions etc. to work• Recapping needles
P13
Components of Standard Work Precautions(General blood & body fluid precautions)
Hand washing
Careful handling of sharps
Sterilization
Disinfection
Disposal of disposables/reusables as appropriate
Adherence to correct hospital sterilization disinfection protocols
Use of personal barrier precautions (Gloves, masks, gowns/aprons, protective eye wear, foot cover)
HBV immunization of HCW at risk.
P14
Disinfection of surfaces
Soiled instruments and surfaces soiled with blood or other body fluids should be disinfected immediately with a fresh 1% bleach solution or other effective disinfectant.
Disposal of contaminated materials:
Contaminated materials should be placed in distinctively labeled sealed packaging and then incinerated.
Laboratory settings:
The above precautions should take place systematically for all samples; samples should be transported in hermetically sealed tubes or flasks, inside sealed packaging; Mouth pipetting is forbidden.
Safety Precautions
P15
Care when handling potentially infected sharps
•Needles should never be bent back or put back in their original holder•Needles should not be removed by hand from syringes or vacutainers•Needles and other sharps should be disposed off immediately in a special, puncture proof sealed container(sharps box)
Safety Precautions
P16
Limitations of Standard Work Precautions
• The success of Standard work precautions is limited. Gloves do not prevent needle stick or penetrating sharp injuries.
• Gloves can tear and the quality of disposable gloves can be variable. Latex gloves appear preferable to vinyl
• Standard work precautions are expensive both for materials and the educational efforts required.
• However, prudent use and careful handling of sharps, following SWP diligently minimizes the risk of acquiring such infections, transmission of which to HCW is extremely low.
P17
Occupational exposure to HIV is very low; however it may happen
• Needle stick injuries
• Cuts from other sharps
• Contact of eye, nose, mouth or skin with blood
MOST EXPOSURES DO NOT RESULT IN INFECTION
Factors affecting transmission:
• Amount of blood in the exposure• Amount of virus in patient’s blood• Duration of contact• Stage of HIV-infection• Type of exposure • Whether PEP taken or not
P18
Risk of virus transmission in work place HIV vs. HBV
1. Rate of infection following needlestick exposure:
– HIV-0.2%-0.4% (WHO-0.332%)
– HBV – 6%-30%
– HCV – up to 9%
2. Maximum concentration of virus in HIV compared to HBV in blood/body fluids:
10 13 HBV particles/ml of blood
104 HIV particles / ml of blood
3. HIV is more sensitive in environmental conditions compared to HBV.
P19
Is PEP needed for all types of exposures ?
No
Chances of infection must be weighed with side effects of anti-retroviral drugs
How to decide which exposures are to be treated?
P20
Management of accidental occupational exposure to blood and body fluids
Immediate steps after exposure
1.Allow site to bleed2.Cuts to be washed with plenty of soap and running water3.Splashes into nose, mouth, skin to be flushed with water. Irrigate eyes with clean water or saline4.Report the incidence to the designated officer in-charge5.Counseling and medical management6.Take first dose of PEP within 2 hours if status of blood/body fluid is known to be positive or unknown7.Maintain proper report for SACS8.Availability of free drugs for PEP
DO NOT
•Panic•Put pricked finger in your mouth•Squeeze blood from wound, this causes trauma and inflammation –increases the risk of transmission•Do not use bleach, alcohol, betadine or iodine, which may be caustic and cause trauma
P21
Conclusions
HIV transmission to health care workers remains a minimum possibility.
Adoption of standard precautions at work place-ICTCs/hospitals is essential to further minimize this risk.
Very few cases have been reported world over of medical staff being HIV positive due to needle stick injuries.
Responsibility lies with the individual to practice SWP, protect himself from the dangers of this infection and continue caring for the patients without undue fear or apprehension.