UF Bloodborne Pathogen Training

UF Bloodborne Pathogen Training

University of Florida Bloodborne Pathogen Training Biological Safety Office Environmental Health & Safety 352-392-1591 www.ehs.ufl.edu [email protected] Overview What is the BBP standard and why do I need to be trained? BBP diseases What are they, how are they transmitted, what are the symptoms, what are the treatments?

How do I protect myself and others? What steps do I take if I have an exposure? BBP Standard 1990: OSHA estimates that occupational exposure to BBPs cause >200 deaths & 9000 infections/year BBP standard took effect in March 1992 29 CFR 1910.1030 Needlestick Safety and Prevention Act (April 2001)

Covers all employees with potential exposure to blood or OPIM (at UF, students and volunteers are included) BBP Training Requirement Initial and Annual training required General and site-specific Must have access to: A copy of the regulatory text (29 CFR 1910.1030) and an explanation of its contents (training material is appropriate) http:// www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STAND ARDS&p_id=10051

A copy of the UF Exposure Control Plan http:// webfiles.ehs.ufl.edu/BBP_ECP.pdf Site-specific Standard Operating Procedures (SOPs) http:// webfiles.ehs.ufl.edu/BBPSOPS.pdf Bloodborne Pathogens (BBPs) Pathogenic microorganisms present in blood and other potentially infectious material (OPIM) that can cause disease in humans Hepatitis B virus (HBV, HepB) Hepatitis C virus (HCV, HepC) Human immunodeficiency virus (HIV)

Brucella Babesia Leptospira Plasmodium Arboviruses (WNV, EEE) Human T-lymphotropic virus (HTLV-1) What constitutes OPIM? YES NO (unless visibly contaminated with blood) Cerebrospinal fluid

Tears Synovial fluid Feces Peritoneal fluid Urine Pericardial fluid Saliva Pleural fluid Nasal secretions Semen/Vaginal secretions Sputum

Breast milk Sweat Amniotic fluid Vomit Saliva from dental procedures Unfixed human tissue or organs (other than intact skin) Cell or tissue cultures that may contain BBP agents Blood/tissues from animals infected with BBP agents Human Cell Lines Handle cell lines as if infectious/potentially infectious ATCC started testing newly deposited cell lines for HIV,

HepB, HepC, HPV, EBV, CMV in January 2010 Cell lines may become infected/contaminated in subsequent handling/passaging LCMV infected tumor cells Many infectious agents yet to be discovered and for which there is no test Remember HIV? HIV/Hepatitis Research Labs Work must be registered with EH&S

Biosafety Office (rDNA or BA registration forms online at http ://www.ehs.ufl.edu/programs/bio/forms/ Follow CDC/NIH BSL-2 containment practices at a minimum Baseline serum sample obtained prior to work with HIV Primary routes of occupational exposure to BBPs NaSH Summary Report for Blood and Body Fluid Exposure Data Collected from Participating Healthcare Facilities (June 1995-Dec 2007; n=30,945)

Hepatitis = inflammation of the liver Leading cause of liver cancer and main reason for liver transplantation in the U.S. Symptoms of acute infection: *Many people acutely infected with HepB or HepC are asymptomatic Hepatitis B (HepB, HBV) Risk of becoming infected after a percutaneous exposure ~30% in unimmunized people 5-10% of infected adults will develop chronic infection; ~1.25

million people with chronic HBV in the U.S. 15-25% of those chronically infected will develop cirrhosis, liver failure or liver cancer resulting in 2000-4000 deaths/per year in the U.S. HepB is 100 times more infectious than HIV yet it can be prevented with a safe and effective vaccine! Hepatitis B Vaccine Rate of new infections has declined ~82% since 1991 when routine vaccination of children was implemented 3 intramuscular injections typical schedule is 0, 1, and 6

mos 32-56% people develop immunity after 1st dose, 70-75% after 2nd dose and >90% after 3rd dose UF employees receive vaccine free of charge @SHCC (2945700) Bring completed Acceptance/Declination statement ( http://webfiles.ehs.ufl.edu/TNV.pdf) If you decline, can change mind at any time

Post-vaccination testing available but only recommended for those at high risk of an exposure Hepatitis C (HepC, HCV) Risk of becoming infected after percutaneous exposure ~2% Most infected individuals develop a chronic infection (75-85%) ~3.2 million Americans have chronic infection and at least 50% of these people do not know they are infected

75% of people with chronic Hep C born between 1945-1965 Kills more people annually in the U.S. than HIV (16,627 deaths vs. 15,529 in 2010) Hepatitis C No vaccine available Treatment can have severe side effects, be costly, and can last up to 48 weeks Standard treatment = ribavirin + peg-interferon Protease inhibitors (Victrelis, Incivek, Olysio) + ribavirin + peg-interferon

Nucleotide analog (Sovaldi) approved in Dec. 2013 once daily oral treatment given in combination with ribavirin or ribavirin plus peginterferon Cost of one pill is $1000 treatment lasts 12-24 weeks! Sustained virologic response rates can be as high as 90% Depends on numerous factors genotype, how soon treatment is initiated, drugs used, etc. HIV Attacks & destroys CD4+ T cells; leads to loss of cellmediated immunity and increased susceptibility to opportunistic infections ~1.1 million people living with HIV in the U.S.

New infections have remained steady at ~50,000/year since the height of the epidemic The Epidemic in Florida Population: 19.1 million (4th in the nation) Newly reported HIV infections: 5,388 (2nd in the nation in 2011) 57% White 15% Black 23% Hispanic 5% Other* Newly reported AIDS cases: 2,775 (3rd in the nation in 2011) Cumulative pediatric AIDS cases : 1,544

(2nd in the nation in 2011) Persons living** with HIV disease: 98,530 (3rd in the nation in 2010) HIV prevalence estimate: at least 130,000 (11.3% of the U.S. estimate for 2010) 29% White 49% Black 20% Hispanic 2% Other* HIV Incidence Estimates 2010: 3,454 (There was a 30% decrease from 2007-2010) HIV-related deaths: 923 (2012) (Down 8.2% from 2011. The first time to ever be under 1,000 deaths in a given year.) *Other = Asian/Pacific Islanders; American Indians/Alaskan Natives; multi-racial. Trend data as of 12/31/2012, ** Living data as of 06/30/2013

Occupational HIV Exposures Risk for HIV transmission after: Percutaneous injury 0.3% Mucous membrane exposure 0.09% Nonintact skin exposure low risk (< 0.09%) 57 documented occupational infections and 143 possible between 1981-2010 in U.S. 84% of documented cases resulted from percutaneous exposure Comparing the risks

Risks of becoming infected after a percutaneous injury: 35% 30% 30% 25% 20% 15% 10% 5% 0% 2% HepB *If unimmunized* HepC 0.3%

HIV UF Exposures (2008-2013) 200 Number of exposures 180 Residents accounted for 62% of the reported 161 sharps exposures in 2013 174 156 160

144 148 140 140 120 100 Sharps Exposures Splash Exposures 80 60 40 34 33 19

20 32 22 15 0 2008 2009 2010 2011 2012 2013

UF Sharps Exposures by Department (n=127) Dentistry; 20.47% Urology; 2.36% Radiology; 3.15% 85% from 2012 All others; 6.30% Orthopaedics ; 3.94% Pathology; 3.94% Pediatrics; 4.72% OB/GYN; 4.72% Surgery; 16.54% Emergency Medicine; 5.51% Anesthesiology; 11.02%

Medicine; 8.66% 83% from 2012 Neurosurgery; 8.66% UF-HSCJ Sharps Exposures by Department (n=34) All others; 20.59% 7 departments each had one exposure Surgery; 29.41% Radiology; 5.88% Emergency Medicine; 8.82% m

70% ro f 201 2 OB/GYN; 20.59% Medicine; 14.71% Controls to Protect Against BBP Exposures UNIVERSAL PRECAUTIONS Cornerstone of exposure prevention Treat all human blood and OPIM as if it is infectious.

Standard precautions = universal precautions + body substance isolation. Applies to blood & all other body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes Biohazard Controls Engineering Controls - Devices/equipment that isolate and contain a hazard Work Practice Controls - Tasks performed in a way that reduces the likelihood of exposure Administrative Controls - Policies/procedures designed to reduce risk Personal Protective Equipment - Clothing/equipment worn to reduce exposure

Engineering Controls for BBPs List of safety sharps devices available can be found at: http://www.healthsystem.virginia.edu/internet/epinet/safetydevice.cfm#1 Not all safety devices are equal https://www.osha.gov/SLTC/etools/hospital/hazards/sharps/sharps.html Desirable characteristics of a safety device: Safety feature is an integral part of device and passively enabled. Device is easy to use and performs reliably. Safety feature cannot be deactivated and remains protective through

disposal. Cost is not the main decision factor employee feedback is essential ! Switching from a resheathable needle to a retractable needle for phlebotemy procedures reduced percutaneous injuries by almost half at Mount Sinai Medical Center http:// www.medscape.com/viewarticle/805640 Handle sharps safely! DO NOT RECAP NEEDLES Dont bend, break, or detach from syringe Recapping needles and improper disposal are common causes of sharps injuries in the laboratory. Discard needles directly into sharps container

Do not overfill the sharps box close and replace when full Never attempt to re-open a closed sharps box Estimated Preventability of Percutaneous Injuries Involving Hollow-Bore Needles NaSH June 1995December 2007 (n=13,847) More than half the injuries were believed to be preventable! Hand Washing

Employees shall wash their hands immediately or as soon as feasible after removal of gloves or other PPE Best practice is to also wash hands before leaving laboratory Average person washes their hands for ~10 seconds CDC recommends at least 20 seconds (sing Happy Birthday twice!) Personal Protective Equipment (PPE) Must be supplied by the employer Wear it WHEN and WHERE you are supposed to Do not wear in common areas (offices, hallways, bathrooms, cafeterias, etc) or when

handling common-use items (doorknobs, elevator buttons, telephones) It must fit, be suitable to the task (use common sense), and be cleaned or disposed of properly (this does not mean taking it home to wash!) Gloves Face and Eye Protection Latex or nitrile vinyl does not hold up well! Surgical mask, goggles, glasses w/side shield, face shield Body

Gowns, aprons, lab coats, shoe covers Absolutely no open toed shoes in the lab! Gloves Jewelry, long fingernails & other mechanical stresses can cause holes. Pinholes may be present without noticeable visible defects. Change gloves frequently!

Decontamination/Disinfection HepB and HepC can remain infective in dried blood for long time periods HepB infective in dried blood at RT for at least one week (MacCannell et al., Clin Liver Dis 2010; 14:23-36) HepC for 16 hours (Kamili et al., Infect Control Hosp Epidemiol 2007; 28:519-524) Decontaminate work surfaces daily and after any spills FRESHLY DILUTED (w/in 24 hrs) solution of bleach or any EPA registered tuberculocide product effective against M. tuberculosis

http://www.epa.gov/oppad001/list_b_tuberculocide.pdf Ethanol evaporates too quickly to be an effective disinfectant! How do I dilute my bleach? Regular household bleach = 1:10 dilution Concentrated or germicidal bleach = 1:14 dilution Other safe work practices

No eating, drinking, smoking, handling contacts or applying cosmetics in areas where blood/OPIM is handled or stored No mouth pipetting Work in ways that minimize splashes/aerosols Know how to handle spills and how to properly dispose of contaminated waste (covered in BMW training) Labeling Warning labels must be placed on:

Containers of regulated waste Refrigerators & freezers containing blood or OPIM Containers used to store, transport, or ship blood or OPIM Use red bags for waste containers If you have an exposure: Wash wound with soap & water for 5 minutes; flush mucous membranes for 15 minutes Seek immediate medical attention (1-2 hrs max)

In Gainesville, call 1-866-477-6824 (Needle Stick Hotline) In Jacksonville, 7am-4pm, go to Employee Health Suite 505 in Tower 1; Other hours, go to ER Other areas, go to the nearest medical facility Notify supervisor Contact UF Workers Compensation Office, 352-392-4940 Allow medical to follow-up with appropriate testing & required written opinion Needle Stick Hotline Cards Gainesville Use Only The number for the needle stick hotline has not changed but this number will no longer handle general biohazard exposures only exposures to blood/OPIM. Discard your old cards and replace them with a new one.

Old card New card Factors considered in assessing need for PEP Type/amount of fluid/tissue Infectious status of source Susceptibility of exposed person Percutaneous injury (depth, extent, device) Blood Presence of HepB surface antigen

(HBsAg) and HepB e antigen (HBeAg) HepB vaccine and vaccine response status Mucous membrane exposure Fluids containing blood Presence of HepC antibody Immune status Type of exposure Non-intact skin exposure

Presence of HIV antibody Bites resulting in blood exposure to either person U.S. Public Health Service Guidelines for postexposure management/prophylaxis: http://www.jstor.org/stable/10.1086/672271 (HIV - 2013) http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf (HBV/HCV 2001) Call 392-1591 or email [email protected]

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