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.