By

Mark A. Ceaser

Prior to the early 80s and the introduction of AIDS into our society, infection control practices were designed almost exclusively to protect the patient from developing a nosocomial infection an infection acquired after admission to the hospital. Protocols were focused on protecting the patient, with little or no emphasis on the health care workers potential to become infected.

Hepatitis B has been a significant occupational hazard for health care workers for decades, and is 100 times more infectious than the AIDS virus, but it was the AIDS epidemic in the early 80s that brought an awareness of their the vulnerability to exposure to bloodborne pathogens to the health care worker. This awareness led to the development of the first protocols designed to protect health care workers, the Guideline for Infection Control in Hospital Personnel published by the Centers for Disease Control (CDC) in 1983.

Most workers are covered by either federal or provincial health and safety legislation and/or regulations with the goal of preventing accidents and injury to health arising out of, linked with, or occurring in the course of employment. Protection from occupational exposure to bloodborne pathogens is provided by a combination of acts and regulations in occupational health and safety. While specific legislation varies by jurisdiction, all jurisdictions have similar labor statutes in place.

These regulations were originally published in the Federal Register in December 1991, as the OSHA Bloodborne Pathogens Standard (29CFR 1910.1030). This regulation was designed to protect the workers from risk of infection during their normal job duties. Complete information on the OSHA directive and educational information is available on OSHAs Web site, www.osha.gov.

Education for the workers is critical to emphasis the risks that exist in the workplace. The factors involved with exposure include the infectious agent (bloodborne pathogen), transportation of the agent (either thru body fluids or aerosol means), and the host of agent. A very common and neglected issue in prevention of transmission is proper disinfection and personal protective equipment for the workers hands. Many of the microbial inhabitants of

the hands are capable of colonizing and infecting wounds, cuts, and other susceptible sites. The single most effective means of preventing the transmission of infection is conscientious hand washing.

New technologies should be introduced promptly to replace less effective or less safe practices if evaluation indicates benefit. Emphasis should be on (a) reduction of exposure to needles or other sharp items; (b) reduction of exposure of cuts or mucous membranes to blood and fluids capable of transmitting bloodborne pathogens ;(c) decreased contamination of working environments; (d) redesign of reusable instruments to enable effective cleaning and disinfection; and (e) implementation of safety devices based on level of risk of various types of exposure incidents.

Equipment designed to decrease potential exposure to sharps, and blood and fluids capable of transmitting bloodborne pathogens in operating rooms (e.g., magnetic pads on which to place needles and other sharp instruments, guards to prevent splatter, blunted surgical implements, thimbles to protect forefinger of non-operating hand) should be made available wherever they could be used to decrease occupational exposures.

Some risk may remain, despite the use of risk-reduction measures. Personal protective equipment serves as a barrier against direct contact with bloodborne pathogens. Personal protective equipment includes gloves, eye protection, face shields, masks, gowns, aprons and protective footwear. One study concluded that among surgical personnel, the use of face shields, waterproof gowns and waterproof boots could have prevented more than half of the observed cutaneous exposures involving sites other than the hand.

Gloves are available in a variety of materials, including latex, vinyl, nitrile, neoprene, copolymer, and polyethylene. Gloves in all of these materials, when intact, will serve as adequate barriers to bloodborne pathogens (except in cases of needle stick injury).

Studies have shown that the barrier quality of new gloves varies from lot to lot. Some investigators have found glove lots with a high proportion of leakage, and others have found consistently good quality gloves that adhere to current standards. Both vinyl and latex glove lots have been found to have leaks when gloves are tested new.

The use of latex has been associated with adverse reactions. Latex allergies are an increasing problem through contact and inhalation routes. Mild adverse reactions occur to latex in about 10% of the occupationally exposed population; some experience severe systemic reactions. In order to minimize exposure to latex allergens, low protein, unpowdered latex gloves should be considered when latex gloves are chosen.

Nitrile gloves have shown to be the most effective to be used in handling the clean up and providing safety from risk exposure. However, another point that commonly overlooked in glove type for a blood spill kit is the potential reaction of the surface disinfectant with the glove material.

Usage of the proper disinfectant during waste clean up can prevent exposure risk and infections from occurring both during the actual cleaning procedure, but afterwards from residual microbial activity from incubation. As with the matter of reaction with the personal protective equipment, there are many other factors to consider when using a disinfectant material, such as actual fluid containment and health risk issues.

When deciding on what product or material to consider for body fluid clean up and disposal, comparison of the products available should be considered. Of foremost consideration is the actual killing agent that is included and used for the product. Most commonly, products available have an aldehyde, phenol, or chlorine killing agent. These various disinfectants have a wide range of antimicrobial activity, and not all will kill what they come in contact with. In addition, reaction to the personal protective equipment, and surrounding surface area that has been exposed to the bloodborne pathogen must be also taken into consideration. Finally, and most important, what the product does to the residual waste once treated is highly important and not to be disregarded. Is it simply absorbed on a granular material or polymer, where it can still be in a fluid state, or is it solidified, as in a cementatious reaction, where no visible liquid is available either visually or while handling of the waste The spilled material should be in a solid form that will not be moldable, pliable or release the fluids back out while handling, either during transportation or from landfill burial. An information request to that company, either directly or via their web site, for their material safety data sheet on said products, should provide satisfactory results.

When a spill of infectious waste occurs, prepacked spill kits should be available in the work place with a minimum of having disposable gloves, protective eyewear, disposable facemask, disposable gown/apron, protective shoe covers, and spill powder available. Additional items needed will be antiseptic towelettes, germicidal solution, collection tools and disposable red medical waste bag with proper labeling. It should be noted, that anytime a spill occurs, to use universal precautions and treat all blood or potentially infectious body fluids as if they are contaminated.

Evacuate the scene of the accident, as to control the risk exposure of outside people to the materials and reduce the spread of infection. If people were physically exposed to the material, removal of all clothing that becomes contaminated with blood should be removed as soon as possible because fluids can seep through the cloth to come into contact with skin. Contaminated laundry should be handled as little as possible, and it should be placed in an appropriately labeled bag or container until it is decontaminated, disposed of, or laundered.

Put on all personal protective equipment (PPE), including doubling of gloves, and making sure no exposed skin areas occur. Containment of the spill is of the utmost importance, from both an airborne issue as well as spreading of the fluid. Apply the solidification powder as to form a perimeter around the spill and contain it. This will allow for the chemical treatment to enact while the threat of exposure has been reduced.

With proper tools, scoop up any sharps that may have been formed by the spillage and breakage of the holding material. Place the materials within a lined, thick walled container to reduce the risk of puncture. Be alert not to create aerosols while collecting the debris.

At this point, the treated fluid waste should have solid properties that will allow for collection of the spill. Remember that a true solidifier will continue to set up even after placed in the disposal bag. Apply any additional powder to the spill to collect and treat any remaining fluid.

Wiping down of the affected area with wipes will require the same attention as the spill powder, in regard to killing agents and potential reaction with the personal equipment. The Centers for Disease Control (CDC) recommends that a 5.25% sodium hypochlorite (standard bleach), diluted in water to a concentration of 0.05% is useable for the decontamination of a blood spill. To avoid causing aerosols, do not apply the liquid solution directly to the spilled area, rather apply to the cloth and wipe, and work into the area. Allow several minutes for disinfection, and repeat procedure.

Upon completion of the clean up and collection of the spilled materials, meticulous attention to the removal and collection of the soiled disposable PPE must be followed. First, removal of the gown/ protective apron, followed by the outer layer of gloves. This now allows the worker to remove the facemask and goggles without having to use soiled gloves. This prevents the introduction of blood or other potentially infectious material to the mucous membranes of the face via a contaminated glove. Once all used PPE, spill control equipment, and other potentially contaminated items are in the red bag, add a mixture of cementatious encapsulation powder to the waste container, as so no fluid will be released, and all materials are encased in a solid mass and seal bag securely for disposal.

Wash your hands with a non-abrasive, preferably germicidal, soap and inspect for any possible exposure. If your skin or mucous membranes come into contact with another person's blood/body fluids, flush with water into the

sanitary sewer system as soon as possible. Immediately contact the medical office if you are involved with any blood or body fluid exposure incident. This organization will conduct a confidential medical evaluation and follow-up that includes the documentation of the route(s) of exposure and the circumstances under which the exposure incident occurred, along with identification and documentation of the source individual. Collection and testing of the exposed person's blood for HBV and HIV, along with consultation and progress reports should be included, along with any post-exposure treatment and any reported illnesses.

Not all cleaning of body fluids is going to be in the workplace or hospital based. Fire fighters and emergency medical services, dental clinics, crime scene clean up specialists, mortuaries and autopsy suites, law enforcement and correctional facility officers and clinical laboratories all fall under the practices of having to deal with infectious waste clean up. While the circumstances maybe different (i.e. dentists dealing with bloody saliva), the same careful handling of the resulting body fluids and steps to dispose of must be followed and enforced. The same procedures should be implemented in a reduction in sharps injuries. With any handling of tainted materials, an exposure plan for procedure in sharps disposal and usage of prevention technology should be spelled out. While injuries of such nature are bound to occur, proper handling of the wastes with available chemical and cementatious-based products, allows for infectious items to be treated and encased, as was previously with the fluid spill.

All health care and public service workers must receive infection prevention and control education regarding bloodborne pathogens and safe practice in the workplace before beginning work and on an ongoing basis thereafter (e.g., annually). Educational programming should be based on practical situations faced by workers in the performance of their specific duties. Content should include general information about infection prevention and control (stressing the importance of hand washing), and information about bloodborne pathogen transmission; assessing risk of exposure; preventing exposures; immunization (HBV vaccine); specific policies and procedures for individual work areas, including protocols following an exposure; and resources for further assistance. Workers need to know how to apply preventive techniques in routine practice and in unusual situations. Time must be given for workers to question, absorb and apply the information. It is critical that educational programs enable workers to express and work through their concerns about caring for individuals with a bloodborne infection. Records of participation should be maintained as needed to satisfy legal requirements.