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146 HIV, viral hepatitis and STIs: a guide or primary care

The aim of this chapter is to provide: Detail about standard precautions and inection

control guidelines or health care settings Guidance on the management o blood and body

substance exposures and incidents

IntroductionThe potentially inectious nature o all blood andbody substances necessitates the implementationo inection control practices and policies. InAustralia, inection control guidelines have beendeveloped based on the United States Centers orDisease Control and Prevention model, in termso 'standard precautions' and transmission basedprecautions. Standard precautions ensure a highlevel o protection against transmission o blood-borne viruses in the health care setting and theuniversal application reduces the potential orstigma and discrimination. Standard precautionsare the minimum level o inection control required

in the treatment and care o all patients to preventtransmission o blood-borne inections includingHIV, HBV and HCV. Standard precautions should beimplemented universally, regardless o inormationor assumptions about a patient's inection status.Additional precautions are urther measures requiredto protect against transmission o inections such astuberculosis.

This chapter provides a summary o the most recentAustralian inection control guidelines endorsed bythe Communicable Diseases Network o Australia(CDNA), National Public Health Partnership (NPHP)and Australian Health Ministers' Advisory Council

(AHMAC): Inection control guidelines or the preventiono transmission o inectious diseases in the healthcare setting1. The CDNA guidelines describe in detailthe practices and procedures necessary to preventtransmission o blood-borne inections, includingHIV, HBV and HCV. Review o these guidelines isstrongly recommended or clinicians and otherhealth care workers implementing inection controlprocedures.

Implementation o standard precautions minimisesthe risk o transmission o blood-borne and otherinections rom health care worker to patient,rom patient to health care worker and rompatient to patient. Inection control guidelines arerelevant in social and domestic contexts as well asoccupational settings. The clinician should be readyto answer patients' questions about their clinic'sinection control policies and provide advice orpatients in relation to inection control in their dailyenvironment.

Transmission of blood-borne virusesThe modes o transmission or blood-borne virusesare outlined in Table 13.1 and risk o transmissionis discussed in more detail in Chapters 2 and 3.

146 HIV, viral hepatitis and STIS: guid for primry cr

13Standard precautions and

infection control

Ky points

The potentially inectious nature o all blood and body substancesnecessitates the implementation o inection control practices andpolicies in the health care setting.

The universal application o standard precautions is the minimumlevel o inection control required in the treatment and care oall patients to prevent transmission o HIV, HBV and HCV. Theseinclude personal hygiene practices particularly hand-washing, use opersonal protective equipment such as gloves, gowns and protectiveeye wear, aseptic technique, sae disposal systems or sharps andcontaminated matter, adequate sterilisation o reusable equipmentand environmental controls.

Vaccination is an important inection control strategy or HBV andHAV; all health care workers should be aware o their immune statusand be vaccinated i appropriate.

Clinicians and other health care workers who regularly perormexposure-prone procedures have a responsibility to be regularlytested or HIV, HCV and HBV i not immune. Health care workers whoare aware that they are inected with HIV, HBV or HCV should notperorm exposure-prone procedures.

The current best practice guidelines or inection control proceduresin Australian health care settings are outlined in Inection ControlGuidelines or the Prevention o Transmission o Inectious Diseases in

the Health Care Setting (2004).

Jnnifr Hoy Inectious Diseases Physician, Alred Hospital, Melbourne, Victoria.Jcqui Richmond Victorian Viral Hepatitis Educator, St Vincent's Hospital, Melbourne, Victoria.


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HIV, viral hepatitis and STIs: a guide or primary care 147

Transmission o HBV is approximately 100 times moreecient than transmission o HIV and approximately10 times more ecient than HCV.

The ri sk o bloo d-borne vi rus transmis sion isdependent on a number o actors. Incidents involvingblood-to-blood contact with inectious blood areassociated with a high risk o inection when: There is a large quantity o blood, indicated by

visible contamination There is insertion o a needle directly into a vein or

artery or deep cavity The pat ient has advanced HIV disease and/or

high HIV viral load; high levels o HBV DNA anddetectable HBeAg; HCV RNA detected by PCR

Transmission o blood-borne viruses in the healthcare setting is generally associated with ailure tocomply with recommended inection controlguidelines and/or cleaning and disinection protocols.In the case o HCV, patient-to-patient transmissionhas been associated with endoscopic procedures,

The risk o transmission o HIV is estimated to beapproximately 0.3% ater a percutaneous needlestickinjury with HIV-inected blood and 0.09% ater amucous membrane exposure. Transmission o HBVin the health care setting can be prevented throughhealth care worker, patient and community hepatitisB vaccination programs.

Standard precautionsStandard precautions ensure a high level oprotection against transmission o inection includingblood-borne viruses in the health care setting andare recommended or the care and treatment o allpatients and in the handling o: Blood including dried blood All other body substances, secretions and

excretions (excluding sweat) regardless o whetherthey contain visible blood

Non-intact skin Mucous membranes.

The universal application o standard precautionsis the minimum level o inection control requiredin the treatment and care o all patients to preventtransmission o blood-borne viruses. These includepersonal hygiene practices, particularly hand-washing; use o personal protective equipmentsuch as gloves, gowns and protective eyewear;aseptic technique; sae disposal systems or sharpsand contaminated matter; adequate sterilisation oreusable equipment and environmental controls.

Standard precautions should be implementeduniversally, regardless o inormation or assumptionsabout a patient's blood-borne virus status, andthereore assist to reduce potential stigma anddiscrimination in the health care setting.

Hand hygieneHand-washing is generally considered the mostimportant hygiene measure in preventing the spreado inection. Clinicians should wash their handsbeore and ater signicant contact with any patientand ater activities that may cause contamination.

Hand-washing should occur: Beore and ater each clinical contact with a

patient Beore and ater eating

Ater using the toilet

Beore and ater using gloves Ater contact with used equipment Immediately ollowing contact with body

substances

It is important to note that gloves are not asubstitute or eective hand-washing. A routinehand-wash should include removal o jewellery anduse o a cleaning solution (detergent with or withoutdisinectant) and water or 15 to 20 seconds, ollowedby drying with a single-use towel.

Table 13.1 Prcutions for prvnting trnsmission of ood-orn viruss1

Diss Mod of trnsmission Rcommndd prcutions Immunistion

HAV Contact (oral-aecal route)Standard precautionsAdditional precautions or

incontinent patients

Immunise health care workers at

high risk

HBVBlood-borne (directcontact with blood or bodysubstances)

Standard precautionsImmunise all health care workers.

Test or seroconversion 48 weeksater 3rd dose o vaccine

HCVBlood-borne (direct contactwith blood)

Standard precautions No vaccine available

HIVBlood-borne (directcontact with blood or bodysubstances)

Standard precautions.Additional precautions maybe required in the presence ocomplicating condition (e.g.

Tuberculosis)

No vaccine available


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Skin care is important because healthy, unbrokenskin provides a valuable, natural barrier to inection.Skin breaks should be covered with a water-resistantocclusive dressing. Alcohol-based hand rubs can beused in the absence o appropriate washing acilities.

GlovesGloves are a orm o personal protective equipment.Clinicians and other health care workers should weargloves whenever there is a risk o exposure to bloodor body substances, and should change their glovesand wash their hands ater contact with each patientand during procedures with the same patient i thereis a chance o cross contamination. Gloves must beused when: Handling blood and/or body substances Perorming venepuncture Touching mucous membranes Touching non-intact skin Handling contaminated sharps

Perorming invasive procedures Cleaning body substances spills or any equipment(instruments) or materials (linen) or surace thatmay have been contaminated by body substances

For urther inormation about the appropriate useo sterile, non-sterile and general purpose glovesreer to Inection control guidelines or the preventiono transmission o inectious diseases in the health caresetting.

Other personal protective equipmentPersonal protective equipment should be readilyavailable and accessible in all health care settings.

The type o protective equipment required dependson the nature o the procedure, the equipment usedand the skill o the operator. For example, the useo protective equipment is recommended in theollowing circumstances: Protective eyewear and ace shields must be worn

during procedures where there is potential orsplashing, splattering or spraying o blood or otherbody substances

Impermeable gowns and plastic aprons shouldbe worn to protect clothing and skin romcontamination with blood and body substances

Footwear should be enclosed to protect againstinjury or contact with sharp objects

Needlestick or sharps injury preventionInappropriate handling o sharps is a major cause oaccidental exposure to blood-borne viruses in healthcare settings. To minimise the risk o a needlestickor sharps injury, needles, sharps and clinical wasteshould be handled careully at all times. Specically,clinicians and other health care workers should: Minimise their handling o needles, sharps and

clinical waste Not bend or recap needles or remove needles rom

disposable syringes

Use sae needle-handling systems including rigidcontainers or disposal, which should be kept outo the reach o toddlers and small children

Ensure 'sharps' containers are available at the pointo use or in close proximity to work sites to aideasy and immediate disposal

Importantly, the person who has used a sharpinstrument or needle must be responsible or theimmediate and sae disposal o the sharp ollowingits use.

Health care workersVaccinationVaccination is an important inection controlstrategy to prevent the transmission o HBV and HAV.

The Aust rali an Immunisa tion Handboo k2 providesguidelines on the vaccination o health care workers.All clinicians and other health care workers who may

come into contact with blood or body substancesshould be aware o their HBV vaccination statusand be vaccinated i appropriate. Post-vaccinationserological testing is recommended our to eightweeks ater completion o the primary course , orpeople in the ollowing categories: People at signiicant occupational risk (e.g.

Clinicians and other health care workers whosework involves requent exposure to blood andbody substances)

People at risk o severe or complicated disease (e.g.people with impaired immunity and people withpre-existing liver disease not related to HBV)

People in whom a poor response to HBV

vaccination is expected (e.g. patients undergoinghaemodialysis) Sexual partners and household contacts o people

with hepatitis B

I an individual's anti-HBs level is


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Individuals at signiicant occupational risk whohave a documented history o a primary course ohepatitis B vaccine, but unknown seroconversionstatus, and now have an anti-HBs level


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Post-exposure prophylaxis for HIV inthe health care settingPost-exposure prophylaxis or HIV is a complex area.Currently HIV PEP consists o a combination o two tothree drugs depending on the level o risk associatedwith the exposure and it is recommended that HIV

PEP should be started between one and two hoursater an exposure. Post-exposure prophylaxis or HIVis: Recommended or signiicant percutaneous

exposure to blood or body substances involving ahigh risk o HIV transmission

Oered (but not actively recommended) or ocularmucous membrane or non-intact skin exposure toblood or body substances

Not oered or exposure to any non-bloody urine,saliva or aeces

Post-exposure prophylaxis for HBV

in the health care settingI the exposed person is not immune to HBV, or isunaware o their immune status, then HBIG should begiven within 4872 hours o exposure. For example: I the exposed person is not immune to HBV, or

is o unknown immune status, HBIG should beadministered within 72 hours o exposure

I the exposed person is a non-responder to theHBV vaccine, HBIG should be given within 72hours

There is currently no PEP available to prevent HCVinection.

Infected health care workersClinicians and other health care workers have a legalobligation to care or the saety o others in theworkplace, which includes colleagues and patients.Clinicians and other health care workers inectedwith a blood-borne virus should consult State or

Territory regulations to determine what restrictionsare placed on their clinical practice. In general, it isrecommended they do not perorm procedures thatcarry a high risk o transmission o the virus romhealth care worker to patient, such as exposure-prone procedures (reer to Table 13.2).

Health care workers must not perorm exposure-

prone procedures i they are: Anti-HIV positive HBeAg positive and/or HBV DNA positive with high

titres Anti-HCV positive and HCV RNA positive (by

polymerase chain reaction).

Infection control in the primarycare settingInection control guidelines or the prevention otransmission o inectious diseases in the health caresetting1 provides detailed inormation relating tothe application o inection control in an oiceor primary health care setting including: routine

cleaning; disinectants and antiseptics; design andmaintenance o health care premises; managemento clinical waste and linen; and reprocessing oinstruments and equipment. Speciic proceduresrelating to the oice practice and home andcommunity care are included in the guidelines.

The genera l princ ipl es o inection contro l thatapply to large health care settings also apply tooice practices. Issues that relate to preventingtransmission o blood-borne viruses include: All clinical waste such as dressings containing

expressible blood, human matter (excluding hair,nails, urine and aeces) and blood sharps must beappropriately packed or transport and disposalaccording to local regulations

Sharps are to be disposed o in yellow, rigid-walledcontainers containing the 'Biological Hazard' labeland symbol

Injecting equipment (including hypodermicsyringes, needles, vials o local anaestheticagent, dental local anaesthetic cartridges, dentalneedles, intravenous lines and giving sets) mustbe discarded ater single use. Syringes used tohold single-use anaesthetic cartridges must besterilised between patients

Dressings, suture material, suture needles, scalpels,intracranial electrodes, pins or needles used orneurosensory testing, spatulas, electric clips andrazor blades must also be discarded ater singleuse

Linen must be managed using standardprecautions. Contaminated linen should havebody substances removed with paper towelsand cold running water, beore being washed in

cold or hot water. Drying at high temperatureaids disinection. Linen which is to be treated o-site must be packed in labelled, water-resistant,regulation bags

Re-usable equipment and instruments shouldbe re-processed and sterilisation/disinectionprocedures ollowed in accordance withmanuacturers' and national guidelines

Sterile equipment must be used on critical sites(sterile tissue)

Sterile equipment is generally recommended orsemi critical sites (intact mucous membrane),except in the case o single-use clean tonguedepressors and vaginal specula, which are used in

procedures unlikely to penetrate the mucosa When steam or dry heat sterilisation is not suitable,

other sterilisation systems such as ethyleneoxide or automated, low-temperature chemicalsterilisation may be used i acceptable to theinstrument manuacturer

Management of blood and body

substance spills in the health care settingManagement o blood and body substance spillsdepends on the nature o the spill, likely pathogens,type o surace and the area involved. The basicprinciples o spills management are:

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Standard precautions including use o personalprotective equipment apply where there is a risko contact with blood or body substances

Spills should be cleaned up beore the area isdisinected

Generation o aerosols rom spilled material shouldbe avoided

All spills must be dealt with as soon as possible. Ingeneral cleaning blood and body substance spillsshould take into account the ollowing actors: The nature o the spill (e.g. sputum, vomit, aeces,

urine, blood or laboratory culture) The pathogens most likely to be involved in the

spill The size o the spill (spot, small or large spill) The type o sur ace (e.g. carpet or imperv ious

fooring) The area involved (i.e. whether the spill occurs in a

contained area such as a microbiology laboratoryor in a public area such as a hospital ward oroutpatient area)

The likelihood o bare skin contact with the soiledsurace.

In the case o a small spill, wipe the area clean usinga paper towel and then clean with detergent andwarm water. A disposable alcohol wipe also may beused. Quarantine areas where sot urnishings areinvolved (carpet, curtains or seating) until dry. In thecase o larger spills mop up with paper towel or use'kitty litter' or granular chlorine, picking up the largeramount with cardboard.

In general, it is unnecessary to use sodiumhypochlorite or managing spills because there isno evidence o any benet rom an inection controlperspective. However, it is recognised that somehealth care workers may eel more reassured thatthe risk o inection is reduced through the use osodium hypochlorite.

Legal and ethical issuesLegal liability may occur i inadequate carehas been taken to prevent the transmission oinection in the health care setting. Regulatoryauthorities, including environmental protectionservices and Commonwealth, State/Territory and

local governments, enorce laws and regulationsrelating to inection control and waste disposal.

These regulations can vary considerably throughoutAustralia and such regulations should takeprecedence over the general inormation presentedin this chapter. For urther inormation contact Stateand Territory health departments and medical andother proessional boards (reer to ASHM Director yavailable at www.ashm.org.au/ashm-directory). Legalissues are considered in greater detail in Chapter 14.

SummaryStandard precautions and inection controlprocedures protect against transmission o blood-borne viruses including HIV, HBV and HCV in thehealth care setting. Regardless o the perceived riskor assumptions about a patient's inection status,

inection control procedures must be ollowed in allclinical settings to minimise the risk o transmissiono blood-borne viruses.

References1 Communicable Diseases Network of Australia

(CDNA), National Public Health Partnership (NPHP),and Australian Health Ministers Advisory Council(AHMAC). Infection control guidelines for theprevention of transmission of infectious diseases inthe health care setting. Canberra: CommonwealthDepartment of Health and Ageing; 2004. Availablefrom http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/icg-guidelines-index.htm

2 Australian Government Department of Health andAgeing. Australian Immunisation Handbook, 9th Ed.Canberra; Commonwealth Department of Healthand Ageing; 2008.

Further readingThe Royal Australian College o General Practice,Inection Control Standards or Ofce-based Practices(4th Edition) can be obtained rom the RACGPPublications Department on (03) 8699 0495, or bydownloading the order orm at www.racgp.org.au/publications/orders and axing back to (03) 86990400. The cost is $88 or RACGP members and $132

or non-members. For urther inormation contactRACGP Publications on [email protected] [email protected]

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