Blood-borne Pathogens
Objectives: Identify what BBPs are and how they are transmitted List why health care workers are a risk Protection strategies
What are BBP? Hepatitis B (Hep B) Hepatitis C (Hep C) HIV/AIDS They are tranported by infected blood of a person Blood borne pathogens are microorganisms such as viruses, bacteria, or parasites which can enter the human blood stream causing diseases.
These microorganisms may be transmitted when mucous membranes or non-intact skin (cuts, abrasions, burns) come in contact with human blood or body fluids. Other modes of transmission include blood splashes, handling contaminated items, needle sticks, or cuts from contaminated sharps.
Hepatitis Viruses Hepatitis is inflammation (pain and swelling) of the liver. Viruses that cause inflammation of the liver are called Hepatitis viruses. Hepatitis means inflammation, redness, swelling and soreness of the liver.
Hepatitis B HBV is transmitted by sharing needles, razors, and toothbrushes. Body fluids, saliva and semen which are exchanged during sexual interactions cause transmission. HBV is also transmitted from mother to infant during her pregnancy. Symptoms: Symptoms may begin as early as 60 days or up to 150 days after exposure to HBV. 95% of the adults recover completely from HBV and do not become chronically infected. In contrast, 90% of infants and 35% of children under the age of 5 years will remain chronically (life -long) ill with HBV. Most of the people newly infected with Hepatitis B do not show any symptoms. Most common symptoms if present include: Fever Fatigue Jaundice (yellowing of the skin and/or eyes) Nausea and vomiting Abdominal pain Dark urine Clay-colored bowel movements Loss of appetite
Who is at risk for Hepatitis B? Intravenous drug users Health care and public safety workers, who have contact with blood or body fluids or blood contaminated products Sexual contact with partner infected with Hepatitis B Living with someone with chronic Hepatitis B Traveling to a country with high rates of Hepatitis B Hemodialysis patients Birth of a child to a Hepatitis B infected mother
Long-term with Hep B: Chronic Hep B can result in liver cirrhosis, liver cancer, or liver failure Treatment options: There are no specific treatments available Many antivirals can be used Protection strategies: Wearing PPE available Use safety precautions available Hep B vaccination
Hep B vaccination 3 vaccinations in the series Hep B vaccination vouchers are available Employee records either need to have Hep B vaccination documentation or a declination statement
Hepatitis C Causes inflammation of the liver Hepatitis C is transmitted by needle stick injury, blood, blood products, sharing needles, razors, toothbrushes, sexual contact with Hepatitis C infected person, and birth of a child to an infected Hepatitis C mother. What are the signs and symptoms of HCV? Most of the people newly infected with Hepatitis C do not show any symptoms. Most common symptoms if present include: Fever Fatigue Jaundice (yellowing of the skin and/or eyes) Nausea and vomiting Abdominal pain Dark urine Clay-colored bowel movements Loss of appetite
HIV/AIDS Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome HIV is the virus that causes AIDS HIV attacked the body and breaks down the body s immune systems making is susceptible for more infections and disease; at that state HIV is then know as AIDS
How is it spread? Blood, body fluids containing blood, breast milk, semen/vaginal secretions Contact with infected fluids Sharing of needles or equipment (drugs, tattoos, piercing) Sex Infected mother can pass to child during pregnancy, childbirth, breastfeeding
Signs/Symptoms: Early (weeks to months after exposure): -Flu-like illness Swollen lymph nodes Late (years after exposure) -Persistent fevers -Night sweats -Prolonged diarrhea -Unexplained weight loss -Purple bumps on skin or inside mouth and nose -Chronic fatigue -Swollen lymph nodes -Recurrent respiratory infections (MDH, 2017)
Testing/Treatment: Testing can be completed to determine HIV antibodies No treatment is available Early detection is helpful: medications are able to help immune systems, decrease risk of mother passing it to baby, treat illnesses that came with AIDS
Prevention/Protection: Personal Protective Equipment: gloves, gown, mask Sharps containers No sharing of needles Immediate care with an BBP exposure Proper handling of possible infected material Latex contraception
What are HCW s at risk: Nursing staff: handling/using needles Housekeeping: handling soiled linens Providing care to residents that could be infected
What is available to keep staff protected? PPE: gloves, mask, gown, gloves Cleaning products that kill BBPs Needle safety covers, sharps containers Education Hep B vaccination vouchers
Tuberculosis
TB An airborne disease caused by the M. tuberculosis bacterium The airborne particles get into circulation when a person with active (respiratory) TB cough, sneeze, shout, sings, etc Depending on the environment, the particles can remain in the air for several hours
How is TB transmitted? When the active particles are in the air and someone inhales the droplets The particles can NOT survive on a surface, so it is NOT spread by contact Probability of transmission depends on: susceptibility (immune system), infectiousness (how sick is the active person), environment (how many droplets, ventilation), exposure (duration, frequency, proximity)
TB in the body The disease can affect more than just the respiratory tract. It can also be found in the brain, lymph node, spine, bone/joints, or kidney Active TB in the respiratory tract is the only one transmitted through airborne particles (larynx, lungs), or in open lesions with a high concentration of active bacteria
TB Disease Large amount of active TB bacteria Contagious Feel sick, signs/symptoms Positive TB test (TST or blood) Positive chest x-ray Positive sputum Needs TB treatment Require airbone isolation (hospital) Qualifies as a reportable TB case
Latent TB Small amount of inactive TB bacteria in body Not contagious Not sick (but can become sick if inactive turns active) Positive TST or blood test Negative sputum, chest x-ray Consider treatment to prevent becoming active No airbone isolation needed Not considered a TB case
Who is at risk to change from Latent to Active? Young children People with HIV Infected with TB within 2 years; hx of TB untreated or poorly treated Immunocompromised Gastric bypass Smokers, drug/alcohol users
Signs/Symptoms: Cough lasting longer than 3 weeks Coughing up blood Loss of appetite Unexplained weight loss Fever Fatigue Night sweats Chest pain
Testing for TB: Due to our risk level as a facility all residents are required to completed a baseline TB testing upon admission and symptom screening annually Staff are required to completed a baseline TB testing upon hire and annually thereafter
TST (skin TB test): Known as a Mantoux Placed on the forarm Read between 48-72 hours of placement 2 nd step required to be placed between 1-3 weeks from the first step Must be placed and read by a licensed professional (at Hayes, that will be a nurse)
When reading a TST, you ONLY feel for a hard induration (lump) Redness, rash, general swelling: do NOT indicate a positive test Positive test can be 5mm or greater (depending on the individuals risk factors/criteria); Always positive in greater than 20mm A positive TST indicates further testing to rule out active TB
TB Blood Tests: Ex: Quantiferon Gold Only requires the blood test once (for resident s admission) or annually (for staff) Can be used instead of the TST Positive blood test: infected with TB and further testing is needed to determine Latent or Active
Diagnosis of TB: History and Physical Symptom screening Testing for TB Chest x-ray Sputum smear or culture
Treatment for TB: Commonly, people diagnosed with Latent TB are also treated to help prevent them from becoming active Active TB usually treated with a 6-9 month course of INH plus 3 others Compliance with treatment is very important to eliminate Latent or Active TB bacteria
Airbone Precautions: Residents with suspected TB should be placed on airbone precautions and isolation until they can be transferred to the hospital for further testing/treatment Active TB requires an negative pressure isolation room to prevent spread (in the hospital) Masks (N-9) are required while in facility isolation until transport
Shelley Bhola RN-BC, BSN, PHN, MSN BREAKING THE CHAIN OF INFECTION
OBJECTIVES Explain the chain of infection Describe how to break the chain of infection Reflect on ways you can help stop the spread of infection
THE CHAIN OF INFECTION Infectious Agent Susceptible host Reservoir Portal of Entry Portal of Exit Mode of Transmission
COMMON SOURCES Infectious Agent Bacteria, Virus, Fungi, or Parasite Reservoir Dirty surfaces and equipment, people, water, animals or insects and soil Portal of Exit open wounds/skin, splatter of body fluids or aerosols Mode of Transmission Contact direct or indirect, ingestion, inhalation Portal of Entry Broken skin/incisions, respiratory tract, mucous membranes, catheters and tubes Susceptible host any person, especially those receiving healthcare.
The hands of healthcare workers continues to be the number 1 way infections are transmitted.
HOW DO WE BREAK THE CHAIN? The way to stop germs from spreading is by interrupting this chain where?
WAYS TO BREAK THE CHAIN Immunizations Treatment of underlying disease Health Insurance Education on illnesses and their effects Proper diagnosis and treatment Antibiotic Stewardship Cleaning and disinfecting Infection Prevention policies
WAYS TO BREAK THE CHAIN Hand hygiene Personal Protective Equipment Personal hygiene First Aid Removal of catheters and tubes Food safety Isolation when needed
WAYS TO BREAK THE CHAIN Control of aerosols and splatter Respiratory etiquette Waste disposal
Hand Hygiene A NON-NEGOTIABLE PART OF ALL OF OUR JOBS
DO S AND DON TS FOR GLOVES Non-sterile gloves are indicated for sitatuions when there is a potential for contact with infectious material, such as blood, other body fluids or microorganisms. They are part of Standard Precautions.
DO WEAR GLOVES To reduce risk of contamination or exposure to blood, other body fluids, hazardous materials, and transmission of infection. Clean hands prior to putting gloves on. Clean hands after removing gloves. Clean hands and change gloves between each task. Make sure that gloves fit you properly. Ensure the correct type of gloves are available. Follow community policy on the use of gloves.
DON T Re-use or wash gloves Substitute glove use for hand hygiene Use gloves if they are damaged or visibly soiled Touch your face when wearing gloves Wear the same pair of gloves from one resident to another Wear gloves in the hall Forget to remove and dispose of properly
Why are we Concerned? WE ARE ALL AT RISK
HEALTHCARE ASSOCIATED INFECTIONS 1.5 1.7 million residents in more than 15,000 long term care settings per year 70% of residents in a nursing home are receiving one or more courses of systemic antibiotics 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate Antibiotics are not without harm especially for our frail elderly
ANTIBIOTIC RESISTANCE Antibiotic resistance is the ability of microbes to resist the effects of drugs that is, the germs are not killed and their growth is not stopped. Although some people are at greater risk than others, no one can completely avoid the risk of antibiotic-resistant infections. Infections with resistant organisms are difficult to treat, requiring costly and sometimes toxic alternatives. (CDC, 2015, About Antibiotic Resistance).
ANTIBIOTIC RESISTANCE Bacteria will inevitably find ways of resisting the antibiotics developed by humans, which is why aggressive action is needed now to keep new resistance from developing and to prevent the resistance that already exists from spreading. (CDC, 2015, About Antibiotic Resistance).
THE FUTURE IS IN OUR HANDS Hands of healthcare workers is consistently the #1 cause of infection transmission. We ARE the key to safer care.
REFERENCES APIC, 2013. Infection Preventionist s Guide to Long-term Care, Washington, D.C. APIC, 2016. Break the Chain of Infection. www.apic.org/professionals.
This slide set Hand Hygiene in Healthcare Settings- Core and accompanying speaker notes provide an overview of the Guideline for Hand Hygiene in Healthcare Settings published in 2002. A second slide set Hand Hygiene in Healthcare Settings-Supplemental which can be obtained at www.cdc.gov/handhygiene provides additional slides that may be used in conjunction with the core slide set. The target audience for this slide set is healthcare workers in acute care hospitals.
Hand Hygiene in Healthcare Settings: An Overview Background Definitions Indications Selection of Agents Techniques Surgical Other Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
So Why All the Fuss About Hand Hygiene? Most common mode of transmission of pathogens is via hands! Infections acquired in healthcare Spread of antimicrobial resistance
Evidence of Relationship Between Hand Hygiene and Healthcare-Associated Infections Substantial evidence that hand hygiene reduces the incidence of infections Historical study: Semmelweis More recent studies: rates lower when antiseptic handwashing was performed Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Hand Hygiene Adherence in Hospitals Year of Study Adherence Rate Hospital Area 1994 (1) 29% General and ICU 1995 (2) 41% General 1996 (3) 41% ICU 1998 (4) 30% General 2000 (5) 48% General 1. Gould D, J Hosp Infect 1994;28:15-30. 2. Larson E, J Hosp Infect 1995;30:88-106. 3. Slaughter S, Ann Intern Med 1996;3:360-365. 4. Watanakunakorn C, Infect Control Hosp Epidemiol 1998;19:858-860. 5. Pittet D, Lancet 2000:356;1307-1312.
Self-Reported Factors for Poor Adherence with Hand Hygiene Handwashing agents cause irritation and dryness Sinks are inconveniently located/lack of sinks Lack of soap and paper towels Too busy/insufficient time Understaffing/overcrowding Patient needs take priority Low risk of acquiring infection from patients Adapted from Pittet D, Infect Control Hosp Epidemiol 2000;21:381-386.
Definitions Hand hygiene Performing handwashing, antiseptic handwash, alcohol-based handrub, surgical hand hygiene/antisepsis Handwashing Washing hands with plain soap and water Antiseptic handwash Washing hands with water and soap or other detergents containing an antiseptic agent Alcohol-based handrub Rubbing hands with an alcohol-containing preparation Surgical hand hygiene/antisepsis Handwashing or using an alcohol-based handrub before operations by surgical personnel Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Indications for Hand Hygiene When hands are visibly dirty, contaminated, or soiled, wash with nonantimicrobial or antimicrobial soap and water. If hands are not visibly soiled, use an alcohol-based handrub for routinely decontaminating hands. Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Specific Indications for Hand Hygiene Before: Patient contact Donning gloves when inserting a CVC Inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don t require surgery After: Contact with a patient s skin Contact with body fluids or excretions, nonintact skin, wound dressings Removing gloves Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Selection of Hand Hygiene Agents: Factors to Consider Efficacy of antiseptic agent Acceptance of product by healthcare personnel Characteristics of product Skin irritation and dryness Accessibility of product Dispenser systems Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Efficacy of Hand Hygiene Preparations in Killing Bacteria Good Better Best Plain Soap Antimicrobial soap Alcohol-based handrub
Ability of Hand Hygiene Agents to Reduce Bacteria on Hands % 99.9 Time After Disinfection log 0 60 180 minutes 3.0 Bacterial Reduction 99.0 90.0 2.0 1.0 Alcohol-based handrub (70% Isopropanol) Antimicrobial soap (4% Chlorhexidine) 0.0 0.0 Plain soap Baseline Adapted from: Hosp Epidemiol Infect Control, 2 nd Edition, 1999.
Effect of Alcohol-Based Handrubs on Skin Condition Dry Healthy Self-reported skin score 6 5 4 3 2 1 0 Baseline Alcohol rub 2 weeks Soap and water Epidermal water content 27 25 23 21 19 17 15 Baseline Alcohol rub 2 weeks Soap and water Healthy Dry ~ Alcohol-based handrub is less damaging to the skin ~ Boyce J, Infect Control Hosp Epidemiol 2000;21(7):438-441.
Time Spent Cleansing Hands: one nurse per 8 hour shift Hand washing with soap and water: 56 minutes Based on seven (60 second) handwashing episodes per hour Alcohol-based handrub: 18 minutes Based on seven (20 second) handrub episodes per hour ~ Alcohol-based handrubs reduce time needed for hand disinfection ~ Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;205-208.
Handrubs Recommended Hand Hygiene Technique Apply to palm of one hand, rub hands together covering all surfaces until dry Volume: based on manufacturer Handwashing Wet hands with water, apply soap, rub hands together for at least 15 seconds Rinse and dry with disposable towel Use towel to turn off faucet Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Surgical Hand Hygiene/Antisepsis Use either an antimicrobial soap or alcoholbased handrub Antimicrobial soap: scrub hands and forearms for length of time recommended by manufacturer Alcohol-based handrub: follow manufacturer s recommendations. Before applying, pre-wash hands and forearms with non-antimicrobial soap Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Infection Rates: Surgical Handscrub vs. Handrub 2 Test of Class of No. SSI/No. Operations (%) Equivalence Contamination Handscrub Handrub (p-value) Clean 29/1485 (1.9) 32/1520 (2.1) 16.0 (<0.001) Clean- Contaminated 24/650 (3.7) 23/732 (3.1) 1.9 (0.09) All 53/2135 (2.5) 55/2252 (2.4) 19.5 (<0.001) Parienti et al. JAMA 2002: 288(6);722-27.
Skin Care Provide healthcare workers with hand lotions or creams Get information from manufacturers regarding effects that hand lotions, creams, or alcohol-based handrubs may have on the effectiveness of antimicrobial soaps Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Fingernails and Artificial Nails Natural nail tips should be kept to ¼ inch in length Artificial nails should not be worn when having direct contact with high-risk patients (e.g., ICU, OR) Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Unresolved Issues Routine use of nonalcohol-based handrubs Wearing rings in healthcare settings Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Gloving Wear gloves when contact with blood or other potentially infectious materials is possible Remove gloves after caring for a patient Do not wear the same pair of gloves for the care of more than one patient Do not wash gloves Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Education/Motivation Programs Monitor healthcare workers (HCWs) adherence with recommended hand hygiene practices and give feedback Implement a multidisciplinary program to improve adherence to recommended practices Encourage patients and their families to remind HCWs to practice hand hygiene Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Administrative Measures to Improve Hand Hygiene Make improved hand hygiene an institutional priority Place alcohol-based handrubs at entrance to patient room, or at bedside Provide HCWs with pocket-sized containers Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Alcohol and Flammability Alcohols are flammable Alcohol-based handrubs should be stored away from high temperatures or flames Europe: fire incidence low U.S.: one report of flash fire Application is key: Let It Dry! Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Performance Indicators Monitor and record adherence to hand hygiene by ward or service Provide feedback to healthcare workers about their performance Monitor the volume of alcohol-based handrub used per 1,000 patient days Monitor adherence to policies on wearing artificial nails Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Summary Alcohol-Based Handrubs: What benefits do they provide? Require less time More effective for standard handwashing than soap More accessible than sinks Reduce bacterial counts on hands Improve skin condition
PREVENTION IS PRIMARY! Protect patients protect healthcare personnel promote quality healthcare!