Bloodborne Pathogens

1
Bloodborne Pathogens

• For Tulane National Primate Research Center
  employees whose work involves a high risk of
  exposure to HIV/SIV/SHIV, HBV, or B-virus
• February 2009

2

• This training serves as a review of
• Bloodborne Pathogens (BBP) in
• relation to the specialized work at
• TNPRC in working with nonhuman
• primates (NHP).

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Bloodborne Pathogens Standard

• 1991- OSHAs Occupational Exposure to Bloodborne
  Pathogens (29 CFR 1910.1030)
• Goal eliminate or minimize occupational
  exposure to bloodborne pathogens
• Revised in 2001 in response to the Needlestick
  Safety and Prevention Act
• Goal clarifies employer requirements to
  identify, evaluate, and make use of safer,
  effective medical devices.

4
How does animal blood fit into the Bloodborne
Standard?

• The standard covers animal blood only for those
  animals purposely infected with HIV or HBV.
• Persons handling any animal blood should follow
  general precautions as recommended by the
  CDC/NIH, Biosafety in Microbiological and
  Biomedical Laboratories (BMBL) 5th edition

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What are Bloodborne Pathogens (BBP)?

• Pathogenic microorganisms that are present in
  blood or other potentially infectious materials
  (OPIM) that can cause disease in humans.
• These pathogens include, but are not limited to
  HBV (hepatitis B virus) and HIV (human
  immunodeficiency virus).

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Bloodborne Pathogens (BBP)

• Other examples of BBP include micro-organisms
  that cause
• hepatitis C virus, malaria, syphilis, babesiosis,
  brucellosis, leptospirosis, arboviral infections,
  relapsing fever, Creutzfeldt-Jakob disease,
  HTLV-1, and viral hemorrhagic fever.
• It is important to know which pathogens (from
  humans or animals) you may be exposed to at work,
  especially in the laboratory or clinical setting.

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• Nonhuman primates, by virtue of their genetic,
  physiologic, and sometimes social similarities to
  humans, are particularly likely sources of
  infectious agents that pose a threat to humans.

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What are we concerned about here at TNPRC?

• HIV (human immunodeficiency virus)
• SIV (simian immunodeficiency virus)
• SHIV (simian-human immunodeficiency virus)
• HBV (hepatitis B virus)
• B-virus

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HIV(Human Immunodeficiency Virus)
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HIV

• HIV is the virus that causes AIDS (Acquired
  Immune Deficiency Syndrome). Once a person has
  been infected with HIV, it may be many years
  before AIDS actually develops.
• HIV kills or damages cells in the bodys immune
  system, gradually destroying the bodys ability
  to fight infection and certain cancers.

computer generated art quality graphics of HIV
was done by Russell Kightley of Canberra,
Australia.
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HIV

• As of December 2001, occupational exposure to HIV
  has resulted in 57 documented cases of HIV
  seroconversion among healthcare personnel (HCP)
  in the United States.
• At the end of 2003, an estimated 1,039,000 to
  1,185,000 persons in the United States were
  living with HIV/AIDS, with 24-27 undiagnosed and
  unaware of their HIV infection.

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HIV

• Some infected with HIV have no symptoms for up to
  ten years.
• Within a month or two after exposure to the virus
  some experience flu-like illness such as
• fever, headache fatigue, weight loss, diarrhea,
  night sweats, enlarged lymph nodes
• These symptoms usually disappear within a week to
  a month and are often mistaken for those of
  another viral infection. During this period, the
  individual is very infectious.

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HIV

• The average risk for HIV transmission after a
  percutaneous (e.g., needlestick) exposure to
  HIV-infected blood has been estimated to be
  approximately 0.3.
• HIV does not survive well outside the body,
  making the possibility of environmental
  transmission remote.

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HIV- no cure or vaccine available

• Treatment protocols from the U.S. Public Health
  Service have been developed using antiretroviral
  agents from five classes of drugs to treat HIV
  infection. These include
• the nucleoside reverse transcriptase inhibitors,
  nucleotide reverse transcriptase inhibitors,
  nonnucleoside reverse transcriptase inhibitors,
  protease inhibitors, and a single fusion
  inhibitor.
• The recommendations provide guidance to
  effectively suppress the virus on the basis of
  HIV transmission risk represented by the exposure.

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HIV

• Side effects associated with the use of antiviral
  drugs can be severe.
• The drug regimen is not a cure for AIDS, but it
  has greatly improved the health of many people
  with AIDS and it reduces the amount of virus
  circulating in the blood to nearly undetectable
  levels.
• Researchers, however, have shown that HIV remains
  present in hiding places such as the lymph nodes
  even in people who have been treated.

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SIV/SHIV(Simian Immunodeficiency
Virus/Simian-Human Immunodeficiency Virus)
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SIV

• Primate-borne retrovirus closely related to HIV-1
  and HIV-2
• Infection in monkeys can lead to chronic wasting
  disease syndrome with depletion of CD4
  lymphocytes and lymphadenopathy
• Can be complicated by various opportunistic
  complications similar to AIDS, making it an
  important animal study model.

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SIV

• Natural seroprevalence in captive rhesus monkeys
  appears to be low (0-1)
• Found in variety of tissue and body fluids of
  infected nonhuman primates
• -including blood, plasma, CSF, and
• parenchyma tissue

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SHIV

• Laboratory-made hybrid of the simian and human
  viruses created by wrapping the SIV core in the
  HIV envelope
• Virus seems to affect monkeys much like HIV
  affects humans
• Created to learn what genes are necessary to
  overcome the species barriers to pathogenesis

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SIV/SHIV

• Risk of human infection has not been defined
• Since SIV/SHIV shares many similar
  characteristics of HIV, many of the same
  biosafety precautions are indicated.
• Specific precautions in handling SIV/SHIV are
• based on recommendations developed
• for HIV and other lentiviruses.

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SIV/SHIV

• In the lab, SIV/SHIV must be presumed to be
  present in all SIV/SHIV cultures, in all
  materials derived from such cultures, in all
  specimens from SIV/SHIV antibody-positive
  nonhuman primates, and in/on all equipment coming
  in contact with these materials.
• Skin and mucous membranes should be considered a
  pathway for virus entry.
• Contact with these sites should be considered an
  exposure to SIV/SHIV.

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HBV(Hepatitis B Virus)
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Hepatitis B Virus (HBV)

• Hepatitis B is caused by a virus that attacks the
  liver and can cause lifelong infection,
  cirrhosis, liver cancer, liver failure, or death.
  
• In 2003, an estimated 73,000 people were infected
  with HBV. People of all ages get hepatitis B and
  about 5,000 die per year of sickness caused by
  HBV.

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Hepatitis B Virus

• The average volume of blood inoculated during a
  needlestick injury with a 22-gauge needle is
  approximately 1 µl, a quantity sufficient to
  contain up to 100 infectious doses of HBV.
• HBV can survive outside the body at least 7 days
  and still be capable of causing infection.

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Hepatitis B Virus

• About 30 of infected persons have no sign or
  symptoms of HBV.
• If symptoms occur, they usually begin to appear
  on the average of 12 weeks (range 9-21 weeks)
  after exposure to hepatitis B virus.
• If you have symptoms, they might include
• jaundice abdominal discomfort
• dark urine clay-colored bowel movements
• joint pain fatigue
• loss of appetite nausea

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HBV IS PREVENTABLE!A safe effective vaccine
is available.

• Hepatitis B vaccine prevents hepatitis B
  infection and its serious consequences.
• If the vaccine is administered before infection,
  it prevents the development of the disease and
  the carrier state in almost all individuals.
• Hepatitis B vaccine consists of a series of three
  injections initial, one a month later, and one
  six months from the first.
• Available FREE of charge from employer

27
What treatment is available for HBV?

• In the occupational setting, multiple doses of
  Hepatitis B Immune Globulin initiated within 1
  week following percutaneous exposure to hepatitis
  B surface antigen-positive blood provides an
  estimated 75 protection from HBV infection.
• There is no cure available for acute HBV
  infection. There are antiviral drugs available
  for the treatment of chronic HBV infection.

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B-virus
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What is B-Virus?

• Other names Cercopithecine herpesvirus-1, Herpes
  B virus, Monkey B virus, Herpes Virus Simiae
• Herpes group of viruses that occurs naturally in
  macaques and produces very mild disease in the
  monkey but can cause fatal encephalitis in humans.

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How Do I get B-Virus?

• Exposure to contaminated monkey saliva,
  secretions, or tissues most commonly through
• Bites or scratches
• Splashes
• Needlesticks
• Indirectly (contact with contaminated cage, etc)

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What are the chances that I will get B-Virus?

• The risk of actually acquiring B-Virus infections
  from macaques is very low. The approximate
  proportion of people who work with primates have
  historically become ill with Herpes B is much
  fewer that 1.
• Only 22 cases of human infection have been
  described. Of these cases, 20 infected developed
  encephalitis and 15 of these patients died as a
  result of their infection.

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Who Is Most at Risk for B-Virus?

• animal caretakers
• laboratory personnel
• anyone who is exposed to monkeys or monkey
  tissues
• immune-suppressed individuals may also face a
  higher risk for infection

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B-virusSigns and Symptoms (for monkeys)

• Most have no obvious sign of infection.
• Some have ulcerations on the mouth, face, lips
  genitals, and/or eye.
• Virus resides permanently in the monkey and can
  be periodically reactivated (usually if stressed
  or immunosuppressed). The virus can be shed by
  monkeys without visible lesions or symptoms.

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B-Virus Signs and Symptoms (for humans)
These generally occur within one month of
exposure.

• Vesicular (small blister) skin lesions at or near
  the site of injury
• Localized neurological symptoms such as pain,
  numbness or itching near the wound site
• Flu-like aches and pains

• Fever and chills
• Headaches lasting more than 24 hours
• Fatigue
• Lack of muscular coordination
• Shortness of breath

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Precautions to Consider

• Exercise caution at all times. Nonhuman primates
  can and will bite.
• Wear appropriate, protective clothing.
• Work together with at least one other person when
  handling nonhuman primates. Minimize direct
  handling.
• Report any observed facial, lip or oral lesions
  in the nonhuman primates to a veterinarian.
• For bite or scratch injuries involving a monkey,
  or scratches with cages or equipment that might
  be contaminated with their secretions, wash
  thoroughly and seek medical care immediately.

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How can I protect myself from B-virus infection?

• Read TNPRC Procedure on Herpes B virus
• Follow all standard procedures for your area
• Wash Hands!!!!

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How could I be exposed to these pathogens at work?
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Chain of Infection
Infection Control Break any link in the chain
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Modes of transmission of BBP

• Percutaneous - the direct inoculation of
  infectious material by piercing through the skin
  barrier (needlestick, bites, scratches from
  animals or cages)
• Non-intact skin - exposure of infectious material
  to pre-existing lesions, cuts, abrasions, or
  rashes provides a route of entry into the body.
• Mucous membrane contact splashes of infectious
  material to an individual's unprotected eyes,
  nose, or mouth in clinical or laboratory
  settings.

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What can I do to prevent occupational exposure
incidents?
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Occupational Exposure Prevention

• The risk of occupational exposure can be
  minimized or eliminated using a combination of
  engineering and work practice controls, personal
  protective clothing and equipment, training,
  medical surveillance, HBV vaccination, warning
  signs or labels, and other provisions described
  in this training section.  

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Standard Precautions

• Guidelines to decrease the risk of occupational
  exposure to blood or body fluids.
• A system of infection control which assumes that
  every direct contact with body fluids is
  infectious and requires every employee exposed to
  direct contact with body fluids to be protected
  as though such body fluids were infected with a
  bloodborne pathogen.
• Provides adequate protection against bloodborne
  infections from both humans and animals.

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Employee Responsibilities

• Completing training/orientation as required
• Following the Standard Precautions Policy and the
  Exposure Control Plan (Written plan provided to
  eliminate or minimize occupational exposure to
  BBP.)
• Using work practices, engineering controls, and
  personal protective equipment as outlined in the
  Exposure Control Plan

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Employee Responsibilities

• Reporting exposure incidents to your supervisor
  and assisting the supervisor in completing First
  Report of Injury/Illness Form
• Knowing in advance what to do if an exposure
  incident occurs
• Pursuing follow-up care at after an exposure
  incident with Employee Health in B-building, Room
  112 (Nurse Janey)

Failure to follow these policies could result in
disciplinary action.
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Engineering Controls

• Sharps with Engineered Sharps Injury Protection
  (SESIP) a non-needle sharp or needle with a
  built-in safety feature or mechanism that
  effectively reduces the risk of an exposure
  incident
• Examples include

Self-sheathing syringe
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More Examples of Engineered Sharps Safety Devices
In use
After use
Retractable needle technology
Retractable lancets
Self-blunting needles
Add-ons (needle covers)
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Engineering Controls

• Needleless Systems Device that does not use a
  needle for
• collection of body fluids
• administration of medication/fluids
• any other procedure with
• potential percutaneous exposure
• to a contaminated sharp
• Squeeze cages
• Transfer boxes

48
Work Practice Controls

• Contaminated needles/sharps shall not be bent,
  recapped or removed unless there is no feasible
  alternative or if required by a specific medical
  procedure
• Such bending, recapping, or removal must be done
  through use of mechanical device or a one-handed
  technique
• Use puncture-resistant sharps
• container for disposal of sharps

49
Work Practice Controls

• No food/drink/smoking, handling of contacts, or
  application of cosmetics in work area where there
  is potential for exposure
• Minimize splashing, spraying, spattering, and
  generation of droplets
• Use secondary containment for transport,
  shipping, or storage of containers
• Decontaminate surfaces and equipment

50
Personal Protective Equipment

• Gloves (latex or nonlatex)
• When to use them
• when there is reasonable anticipation
• of employee hand contact with blood, mucous
  membranes, non-intact skin, or other potentially
  infectious materials
• when performing vascular access procedures
• when handling or touching contaminated surfaces
  or items.
• Remove prior to leaving the work area and discard
  as biohazard waste

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Handwashing

• Employees must wash their hands immediately or as
  soon as feasible after removal of gloves or other
  personal protective equipment.
• Wash as soon as possible if gross contamination
  occurs
• Alternate methods
• Antiseptic towelettes
• Waterless handwashing gels

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Personal Protective Equipment (PPE)

• Gowns, aprons, fluid-resistant clothing
• Face shields, eye protection (safety glasses,
  goggles)
• Surgical mask and/or N-95 respirator
• Surgical caps, shoe covers

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Training

• Training is required
• at the time of initial employment and assignment
• (or transfer) to job tasks where occupational
  exposure may occur
• within one year of the employee's previous
  training and annually thereafter
• when changes such as modification of tasks or
  procedures or institution of new tasks or
  procedures affect the employee's potential for
  occupational exposures, and as new standards for
  safe work practices evolve

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HBV Vaccination

• FREE to employee - paid for by your department
  (available from Employee Health) for high-risk
  employees
• If you initially refuse the vaccine, you may
  change your mind later and still receive it.

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Warning Signs and Labels

• Fluorescent orange or orange-red label
• with word Biohazard and biohazard symbol in
  contrasting color must be provided on
• Containers of regulated waste
• Refrigerators/freezers used to store blood/OPIM
• Containers used to store, transport, or ship
  blood/OPIM
• Contaminated equipment
• Red bags may be substituted for biohazard labels
  on biohazardous waste bags.

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Housekeeping Sharps Disposal

• Keep sharps container upright,
• readily available in the work area
• Never place sharps into the regular trash
• Use a leak-proof, puncture-resistant
• sharps container labeled with the biohazard
  symbol
• Do not overfill - dispose of sharps container as
  biohazard waste when it is 2/3 full

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Housekeeping Decontamination
Work surfaces should be decontaminated with an
appropriate disinfectant such as 10 bleach
solution or an EPA approved disinfectant after
completion of procedures, immediately or as soon
as feasible when surfaces are overtly
contaminated or after any spill, and at the end
of the work shift.
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Where do I go and what must I do if I am exposed?
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What to Do Post-Exposure

• Wash exposed area with soap and water for 15
  minutes if eye or mucous membrane contact, flush
  with water or saline for 15 minutes
• Report the incident to your supervisor so the
  veterinarian can be notified to examine the
  source monkey to see if it is shedding virus.
• Complete First Report of Injury/Illness Form
• Report to Employee Health (Bldg B) for evaluation
  and follow-up visits

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Recordkeeping

• Sharps Injury Log
• Maintained by Office of Environmental Health
  Safety (OEHS) independently from OSHA 300 Log
• Training records 3 years
• Confidential medical records duration
• of employment 30 years

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REMEMBER Don't wait. Immediately report all
exposures. You may have to make a quick
decision about starting an antiretroviral agent
as prophylaxis. The time frame for beginning this
treatment is critical. Reporting is also
essential for establishing a claim for Workers
Compensation benefits.
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Summary of Post-Exposure Employee Responsibilities

• Perform 15 minute scrub procedure using soap and
  water. If mucous membrane contact, flush injured
  area with sterile saline or water for 15 minutes.
• 2. Promptly report the incident to your
  supervisor.
• Report to Employee Health during business hours
  for medical evaluation or page the nurse at (985)
  966-6515 after hours for instructions.
• Complete the First Report of Injury forms.

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• Tulane University encourages you to contact your
  Bloodborne Pathogens Coordinator or supervisor
  for questions, comments, or suggestions.

TNPRC Employee Health
[phone] Bloodborne Pathogens Coordinator
[phone] ext. 6653 Office
of Env. Health Safety (OEHS) [phone]
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You can always reach the Bloodborne Pathogens
Coordinator 24 hours a dayby work cell phone
[phone] or call [phone] and press 1.
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Why was this training so vital?

• Healthcare and research personnel are at a great
• risk for occupational exposure to bloodborne
• pathogens.
• Through information and awareness Tulane
• University aims to minimize any risk to our
• employees and continue the commitment to
• safety in the workplace.

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References

• HIV/SIV
• http//www.cdc.gov/mmwr/preview/mmwrhtml/00001303.
  htm
• http//www.cdc.gov/ncidod/EID/vol11no09/05-0179.ht
  m
• http//www.cdc.gov/ncidod/EID/vol11no07/04-0957.ht
  m
• HBV
• http//www.cdc.gov/ncidod/diseases/hepatitis/b/ind
  ex.htm
• B virus
• http//www.cdc.gov/mmwr/preview/mmwrhtml/00015936.
  htm
• http//www.cdc.gov/ncidod/diseases/BVIRUS.pdf
• http//dcminfo.wustl.edu/occhealth/factsheet_herpe
  sb.html
• BBP
• http//www.osha.gov/SLTC/bloodbornepathogens/index
  .html
• http//www.cdc.gov/niosh/topics/bbp/

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Tulane UniversityOffice of Environmental Health
Safety (OEHS)Kellie C. MayerBloodborne
Pathogens Coordinator(504) 419-1391kmayer_at_tulane
.edu
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