# : § : # U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE Centers for Disease Control • Center for Prevention Services • Public Hedlth Proctice Program Office Food and Drug Administration • Center for Devices dnd Rodiological Hedlth - ". . . --.. * º," ſº, tº A *-** * - 4 *.**** ** * -.” & - - - ; .-, y a', - - - - {t x "-ºvº; * * • * . L. r ... - * * * * , w **- . . . * } -- **. ...' -> -- * : * .* x-y CONTENTS “If you provide dentol services . . .” (Introduction to the File) “Hepotitis B; A Mojor Hedlth Risk in Dentistry” “Whof About AIDS?” “Procticol Infection Control; A Workbook for the Dentol Tedm” “Hove You Noticed . . . Your Dentist Becoming Less Visible???" (Somple ledflet for potients with comerd-reddy copy for reproduction) “Understonding AIDS" (An informationdl flyer suitdble for potients) Reprint: “Recommended Infection Control Proctices for Dentistry” Reprint: “Recommendotions of the Immunization Proctices Advisory Committee; Updote on Hepotitis B Prevention" Reprint: "Updote: Universdl Precdutions for Prevention of Tronsmission of Humon Immunodeficiency Virus, Hepotitis B Virus, dnd Other Bloodborne Pothogens in Hedlth-Cdre Settings" Reprint: “Guidelines for Prevention of Tronsmission of Humon Immunode- ficiency Virus dnd Hepotitis B Virus to Hedlth-Core ond Public-Sofety Workers” Reprint: “Recommendotions for Prevention of HIV Tronsmission in Hedlth- Core Settings” Wollohort: “Steps in Hedt Sterilization” Wollohdrf: “Mondgement of Persons Exposed to Blood; Hepdfitis B Virus Postexposure Mondgement" - Wollohort: “Mondgement of Persons Exposed to Blood; Humon Immuno- deficiency Virus Postexposure Mondgement” Practical Infection Control in the Dental Office PUB RK 52 • I53 1989 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE Centers for DisedSe Control Food ond Drug Administration December 1989 Contents PREFACE INTRODUCTION Your disease risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Principles for infection control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 PRINCIPLE 1. Take action to stay healthy Protect yourself with immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Have certain tests, when advisable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Wash your hands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 PRINCIPLE 2. Avoid contact with blood Wear protective coverings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Avoid injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 PRINCIPLE 3. Limit the spread of blood *-- a-- . . . Limit the spread of blood and blood-contaminated saliva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Cover Surfaces that can’t be decontaminated easily . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Handle waste and soiled linens préperly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 PRINCIPLE 4. Make objects safe for use . . . - Know how decontamination prºſesses differ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Choose the right way to decontaminate . . . . . . . . . . . . . . . . . . . . . , , - e º e º 'º - © e º º e º 'º - e º ºs e º 'º - c s e 40 When you decontaminate, do it right: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Check to be sure you've done it sight ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 { - * , , . - -": - APPENDIX. SUPPLEMENTARY MATERIALS . . . * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 ANSWERS TO EXERCISES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Preface If you are a dentist, a dental hygienist, a dental assistant, or a dental laboratory technician, this workbook has been written for you. What is the purpose of the workbook? This workbook is intended to help everyone on your dental team learn about infection control practices that can work for you. It and the other materials in the Infection Control File provide information on your disease risks and offer guidance in protecting yourself and your patients from infection. HOW to USe this WOrkbOOk The workbook is written like a conversation. When we think you might have a question, we ask it for you in a Subheading. We may use the word I in these questions. For example, at one point the following “conversation” takes place: When should I wear gloves? Wear gloves whenever you must put your hands into any patient's mouth or on instruments, equipment, or surfaces that may be contaminated with blood. You — whether you are a dentist, a dental assistant, a dental hygienist, or a dental laboratory technician — are the “you” and the “I” in this conversation. This workbook is designed to be used by everyone on the dental team. Use the workbook to review and if necessary to revise your infection control practices. Each member of the team should read the Workbook and do the exercises. Some exercises are group exercises, which the team does together after everyone has read the workbook to that point. As new persons are added to the team, they can use the workbook to learn the Office infection control practices. You may also wish to incorporate the practices you adopt from this workbook into your office procedures handbook. Introduction Your disease risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Principles for infection control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 YOUr disease riskS As someone who works in dentistry, you are exposed to more disease-causing microorganisms, especially those found in blood, than you would be in some other occupations. Your exposure increases your risk of getting a disease. This workbook and the other materials in the Infection Control File tell you how to reduce your disease risks at work. What does “risk” mean? If you are not immune to a microorganism, it can cause you to become ill if (1) you become infected with the microorganism, and (2) the microorganism survives and mul- tiplies in your body. Your chance of either of these events happening is called a “risk.” Why does my work increase my risk? The more you are exposed to blood, the more your risk of becoming infected with a bloodborne microorganism is increased. Although your risk of becoming infected from a single exposure to a microorganism may be quite Small, your Work exposes you repeatedly to blood that may contain micro- organisms. These repeated exposures increase your risk of eventually becoming infected, if you are not immune. You may be exposed to microorganisms in other ways as well. However, you should be most concerned about protecting yourself from the microorganisms carried through blood. What microorganisms am I most likely to be exposed to in blood? Your greatest risk is hepatitis B virus (HBV). Your risk of being exposed to HBV is greater than your risk for other blood- borne microorganisms. A brochure in the Infection Control File gives more information on hepatitis B. Am I at high risk for being exposed at work to the organism that causes AIDS? No, you are not at high risk. Your risk of being exposed to blood infected with the human immunodeficiency virus (HIV), which causes AIDS, depends on a number of factors explained in a brochure on AIDS that is included in the Infection Control File. Your chances of becoming infected with HIV can be made even lower by following procedures which protect you from all bloodborne microorganisms. How are microorganisms spread in the dental operatory? Microorganisms vary in how they are trans- mitted. In general, transmission is either direct or indirect. In the dental operatory, direct transmission can be by person-to- person contact or by droplets which are produced in Sneezing or coughing, or by Spatter during dental procedures. Indirect transmission can be vehicle-borne or air- borne. What is vehicle-borne transmission? In vehicle-borne transmission, micro- organisms are first transferred to an intermediate object, such as an instrument, and then transferred from that to another person. Infection through a needlestick injury would be an example of vehicle-borne transmission. What is airborne transmission? With airborne transmission, microorganisms from an infected person become suspended in air, where they can be inhaled by others breathing the air. A few kinds of microor- ganisms, such as those that cause measles or chickenpox, can be spread through airborne transmission. Most microorganisms, includ- ing those that cause AIDS and hepatitis B, are not transmitted in this way. Don't droplets of blood in spatter become airborne? No. Spatter is heavy and the droplets do not stay suspended in air. This means that they are not inhaled. However, if spattered drop- lets land on the mucous membranes of the eye, nose, or mouth, or on breaks in the skin there may be a risk of infection. When transmission of microorganisms occurs in this way the transmission is direct — from one person to another – not airborne. How are bloodborne viruses transmitted? Bloodborne viruses—your more serious Occupational infection risks—are transmit- ted by blood and blood-contaminated items. In the dental operatory, this transmission may occur through injury with sharp objects, Splashes to mucous membranes, or con- tamination of broken Skin with blood. How can I protect myself from bloodborne microorganisms? Two major ways to protect yourself are (1) avoid contact with blood and (2) get vacci- nated against hepatitis B. Studying this workbook and practicing the four infection control principles it describes will help pro- tect you from getting a bloodborne infection while at work. Two brochures in the Infection Control File— “Hepatitis B: A Major Health Risk in Den- tistry” and “What About AIDS?”—give detailed information on those diseases. BEFORE YOU GO ON . . . Answer the questions below to find out how much you already know about your risk of becoming infected with a bloodborne microorganism. These questions are challenging ones. You will probably not know the answers to all of them. That's okay. They are asked to help you decide whether you need to learn more about your disease risks. Write your answers on a separate sheet of paper. 1. What is the major occupational infection hazard for dentists and other dental health care WOrkers? 2. While working in a dental office, how can you become infected with a bloodborne infection? 3. How does your risk of becoming infected with the hepatitis B virus compare with the risk of someone in the general population? 4. What is the most effective method available for reducing the transmission of the hepatitis B Virus? 5. How is the human immunodeficiency virus (HIV), the virus that causes AIDS, most commonly spread? 6. What are the chances of becoming infected with HIV if a health care worker is accidentally stuck with a needle contaminated with the blood of an AIDS patient? 7. What are some problems associated with the testing of dental patients for HIV antibodies? Answers are given on page 70. Principles for infection control These principles are the basis for the practices described in this workbook. Understanding and using them will give you a Sound basis for making infection risk management decisions when faced with situations not discussed here. 1. Take action to stay healthy. 3. Limit the spread of blood. This principle is given first to emphasize the You can spread blood in many ways— need for you to be healthy and to take posi- causing spatter during treatment and tive steps to keep yourself healthy. Splashes during cleanup, touching equip- ment with contaminated hands, or soiling the Outside of specimen containers. Areas that you contaminate with blood may then become potential sources of exposure. By taking care not to spread blood you will help yourself and others avoid contact with blood. th blood. A number of potentially serious diseases are spread through blood. Since there is no way 2. Avoid contact w 4. Make objects safe for use. to know which patients are infected with Even though you control the spread of these diseases, avoid direct contact with the blood, Some instruments, equipment, and blood of every patient. Apply the concept of surfaces do become contaminated during universal precautions — that is, protect your- patient treatment. These must be cleaned self from the blood of every patient, not just and sterilized or disinfected before they are those you know or suspect are infected. touched with bare skin or used again. BEFORE YOU GO ON . . . Learn the four principles. Write them on a separate sheet of paper and state what they mean to you. Then, Compare what you wrote with the explanation given above. When you are confident that you know the four principles, go on to the next section. There you will learn how to put the first principle into practice. PRINCIPLE 1. Take action to stay healthy Protect yourself with immunizations . • Get immunized against hepatitis B . • Get a tetanus booster every 10 years • Get a flu shot every year . . . . . . . . . . • If not immune, get immunizations against childhood diseases Have certain tests, when advisable . . . . . . . . . Wash your hands . . . . . . . . . . . . - e tº e º e s - - e º 0 ° tº 10 11 Protect yourself with immunizations Immunizations will reduce your risk of becoming infected and can also protect your patients and family. Get immunized against hepatitis B. Your immunization against hepatitis B is essential—both because of the seriousness of the infection and the likelihood that some of your patients are infected with the virus. If you have not been immunized, get vac- cinated with hepatitis B vaccine. Two types of hepatitis B vaccine are avail- able. Both vaccines are effective and safe. Get a tetanus booster every 10 years. Because you work with sharp instruments, you can get cuts and puncture wounds. Deep cuts and puncture wounds provide ideal con- ditions for the growth of the tetanus bacillus. You should be immunized against tetanus and should maintain that protection with boosters every 10 years. Get a flu shot every year. Influenza (flu) is not usually a serious dis- ease for healthy adults. For older individuals, however, or for persons with chronic respira- tory illnesses or compromised immune systems, flu may lead to a life-threatening bacterial infection. Getting a flu shot can help you avoid loss of work, as well as discomfort. More important, it can help you avoid giving your patients flu. Immunity produced by the flu vaccine is not permanent. You should be immunized each fall with the current vaccine, which is formu- lated to immunize against the current form of the virus. IF NOT IMMUNE, get immunizations against childhood diseases. Immunization against measles, mumps, rubella (German measles), and polio is rec- ommended for adults who are not already immune. If you have had these diseases or have been immunized against them, you should be immune. If you are not immune, you could get these infections from an infected patient. - Pregnancy or other health conditions may mean that these recommendations should be modified. Talk with your physician about what immunizations you need. Have Certain tests, When advisable You can develop immunity to many diseases. Tests can provide valuable information about whether or not you are immune. Some tests can also show current or previous infection by certain organisms. Your local health department or physician can advise you on testing. They can tell you what tests you should have. Ask about being tested for tuberculosis, bloodborne infections, and rubella or other diseases which could affect an unborn child. Do I need to be tested if I injure myself? If you cut or injure yourself with a contaminated instrument, you may need to be tested for certain bloodborne infections. As described on page 24, you should report any such injury to the person on your dental team who is designated to follow up on injuries. That person will be responsible for making Sure that you and the patient whose blood you have been exposed to receive appropriate tests. Pages 66 and 67 in the appendix provide guidance on what tests are necessary. You do not need to seek follow-up testing or medical care for Small cuts and abrasions that do not expose you to a patient's blood. For example, you may get a scrape while polishing a new denture or nick your finger with a bur while polishing a crown before try-in. Do try to avoid these injuries, however, because they provide pathways for microorganisms to enter. More information on injuries is given on page 23. Before an injury occurs, get hepatitis B vaccine and other immunizations to protect yourself, your patients, and your family. BEFORE YOU GO ON . . . Make a copy of this page and mark your answers On it. 1. Indicate with a checkmark in the appropriate Column(s) what your status is for each disease listed below. (1) (2) Immunized (and up to date) Disease Gisease Have had the (3) (4) (5) Not immunized| Have not had | DO not know (or not up to date) the disease Hepatitis B Influenza Measles Mumps POliO Rubella Tetanus If you did not check either column 1 or column 2 for hepatitis B, GETVACCINATED NOW. If you did not check either column 1 or column 2 for any of the other diseases listed, ask your physician about being immunized for them at your next appointment. 2. If you and your physician have not discussed what tests and vaccinations you should have because of your occupation, make a note to do so at your next appointment. Wash your hands Your hands can spread microorganisms that cause disease. Handwashing removes microorganisms and helps you avoid spreading them. You pick up organisms from patients and from contaminated environmental surfaces. Ordinary handwashing will easily remove these organisms from your skin, but may not remove them from around rings and under long fingernails. Make sure your handwash- ing is effective by keeping your nails cut short and well manicured. Don't wear rings, fingernail polish, or false fingernails at work. When should I wash my hands? You should always wash your hands • Before treatment • Between patients • After glove removal • During treatment, if you touch an object that might be contaminated by another patient's blood or saliva • Before leaving the operatory Is there a special handwashing technique? For most procedures, the following tech- nique is adequate: 1. Lather your hands well with soap and water and rub them vigorously together for at least 10 seconds so that all surfaces are scrubbed. When your hands are visibly soiled, rub the lather over them for longer than 10 seconds or wash and rinse them 2 or 3 times. 2. Rinse under a stream of water. N- ^\ - If you use a hand-operated faucet, don't touch the handle with bare skin. Instead, use a clean paper towel to avoid contaminat- ing the handle or your hands. TAKE ACTION TC STAY HEALTHTY Should I use the same technique for a surgical scrub? No, use the following technique for a surgi- cal scrub: º º 1. Scrub your hands and arms to the elbows with an antimicrobial liquid product for several minutes. 2. Rinse thoroughly to remove soap. 3. Dry on sterile towels. Do I need a special soap for ordinary handwashing? No. A special soap is not necessary. It is important, however, that you choose a soap that will not irritate your skin when used frequently. You may find that liquid soap is easier to use than bar soap. Use the plain soap you choose for ordinary handwashing before • examinations • restorative procedures • Suture removal Do I ever need a special soap? A special antimicrobial product is needed any time you use a surgical scrub. An anti- microbial product can kill microorganisms left on the surface of your skin after hand- washing. More important than any soap is your handwashing procedure. Each part of the handwashing process is necessary for remov- ing microorganisms: • Rubbing gets the microorganisms out of the skin's crevices. • Lathering holds them suspended away from the skin's surface. • Rinsing washes them off the hands. 12 BEFORE YOU GO ON . . . Make a copy of this page and mark your answers on it. 1. Evaluate the handwashing area in your operatory: • DO you have disposable paper towels? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO • Can you reach the paper towels without touching anything else? . . . . . . . . . . Yes NO º • Do you have a nonirritating soap for routine use? . . . . . . . . . . . . . . . . . . . . . . . . Yes NO 2. Examine your hands: • Are your nails Short? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO • Are your hands free of rings, fingernail polish, and false fingernails where microorganisms can grow? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO 3. Wash your hands for routine care and have someone evaluate your technique: • DO you avoid touching the Soap dispenser and faucet with a bare hand? . . . Yes No • DO you lather Well and wash for at least 10 seconds? . . . . . . . . . . . . . . . . . . . . Yes NO • Do you rub all parts of your hands vigorously? . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO • Do you rinse your hands thoroughly? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO Scoring: Count the number of “No” answers. If you answered “no” to any question under part 3, add 3 points to your Score. If your total is 0-1 – You are able to use good handwashing techniques. 2-3 – You need to make a few improvements but on the whole seem to be able to keep your hands free of harmful microorganisms. 4 + – You may be carrying harmful microorganisms on your hands. Act immediately to make whatever improvements are needed. REMEMBER . . .WASH YOUR HANDS FREQUENTLY º .* PRINCIPLE 2. AVOid COntact With blood Wear protective coverings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 • Wear gloves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 • Wear a mask and glasses, or a face Shield . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 - e e - - * - e s - - g • - e - - e e - e º • e º - - º - - º • Wear a uniform or cover your street clothes . Avoid injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 º º g e º º º -> º * º * º º - e - º e e - e e - e e - e & º e e º e º - º e - • Handle sharp instruments with care . e º º º - g º - tº º - º e - - e • - e e - e e - e s º e e e • Have a written policy for injuries . . . * Treat injuries properly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 - e e - e o - - º • - e - - e - - e - - º - - º º - e º - - º - e • Have tests when injured, if advisable . 15 Wear protective coverings Special coverings act as a barrier, protecting you from contact with blood and saliva contaminated with blood. AVOD CONTACT WITH BLOOD | Wear gloves contaminated with blood. Use a new pair of - - loves for every patient. You are most likely to contact blood with 9. y p your hands. If the skin of your hands is intact, it provides good protection from What type of gloves should I wear? microorganisms that may be in blood. Most of the time, however, you probably have breaks in the skin on your hands. For exam- ple, you may have small cuts, or your hands Three types of gloves are available: may be chapped or scratched from outdoor activities. The type of gloves you should wear will depend on what you are doing. Wearing gloves will protect you by providing an extra barrier against the entry of micro- organisms through any breaks in your skin. They also protect your patients from becom- ing infected with microorganisms that may be present on your hands. Remember, how- ever, that handwashing after any possible contact with blood is your best protection. Gloves and handwashing may not provide enough protection, however, if you have open Sores, oozing dermatitis, or similar lesions. These conditions increase your risk of becoming infected and of passing micro- organisms to your patients. If you have one of these conditions, you should avoid patient contact until your skin has healed. 1. Disposable examination gloves for pro- cedures involving contact with oral mucous membranes. These gloves can be When should I wear gloves? made of either vinyl or latex. There are no reported differences in the effective- Wear gloves whenever you put your hands ness of intact latex and intact vinyl when into any patient's mouth or touch instru- used as a barrier against contact with ments, equipment, or surfaces that may be blood. 17 Can gloves be washed and reused? NEVER reuse surgical or examination gloves. Washing these gloves may damage the gloves and actually cause “wicking,” increasing the flow of liquid through undetected holes in the gloves. Utility gloves may be reused if they are not punctured or torn. They should be properly decontaminated before reuse. Information on decontamination is given under Prin- ciple 4, beginning on page 37. 2. Sterile disposable gloves for use when sterility is necessary, such as during surgi- cal procedures. What if my gloves tear? 3. General purpose utility gloves for use If your gloves are torn, cut, or punctured, when cleaning instruments, equipment, remove them immediately and dispose of and contaminated surfaces. Rubber them properly. Then wash your hands thor- household gloves are suitable, and can be oughly with soap and water and put on a decontaminated and reused. new pair. BEFORE YOU GO ON . . . Make a copy of this page and mark your answers on it. You may not realize you have little cuts on your hands. This exercise will help you find where the skin of your hands is not intact. 1. Examine your hands. Count and write the number of cuts, scratches, or chapped areas you see. 2. Apply rubbing alcohol to your hands. Does it sting anywhere that you didn't notice before? Count and write the number of places. Scoring: Add your answers together to get the number of breaks you have in your skin. These are openings where microorganisms can enter. Now you know why it's a good idea to wear gloves and to wash your hands well. 18 Wear a mask and glasses, or a face shield Research has shown that there is extensive spatter of blood and saliva during many den- tal procedures. Spattered material may get into your eyes, nose, and mouth where mucous membranes may provide easy entrance for microorganisms. For example, tiny amounts of blood containing HBV (hep- atitis B virus) can cause infection if it gets into your eyes. What should I wear? Wear either a mask and protective glasses or goggles, or a chin-length face shield that protects your eyes, nose, and mouth from spatter. When should I wear facial protection? Wear facial protection whenever blood or fluids contaminated by blood may be spattered – during patient treatment, while cleaning instruments, or when disposing of contaminated fluids. For example, wear your facial protection whenever you • prepare a tooth with a high-speed hand- piece • polish teeth with a slow-speed handpiece • polish a crown • wash contaminated instruments • empty a suction trap • use an air/water syringe Should I take any special precautions with this equipment? When wearing a mask or handling a used one, always keep in mind that it is contami- nated even though it may look clean. It is contaminated on the inside by your own microorganisms and on the outside by blood or other material spattered on it. How often should I replace a disposable mask? Use a new surgical mask for every patient. Always replace a mask when it becomes wet during a single treatment. A wet mask will tend to collapse against your face and may not provide a barrier to microorganisms. How can I handle a used mask safely? You can handle it either by the body while still wearing gloves or by the ties or elastic with clean hands. Immediately discard any gloves that come into contact with the body of the mask. What should I do with used glasses, goggles, or face shield? Decontaminate your protective glasses, gog- gles, or face shield between patients. If you need to put them down before you have decontaminated them, put them on a dispos- able towel out of the way. Don't handle them with unprotected hands until they have been decontaminated. How should I decontaminate this equipment? Wash nondisposable facial protective equip- ment with detergent and water between patients and disinfect it with a tuberculoci- dal “hospital disinfectant” that is registered with the Environmental Protection Agency (EPA). More detailed information on decon- tamination of all types of instruments, equipment, and surfaces is discussed under Principle 4, beginning on page 37. AVOD CONTACT WITH BLOOD Wear a uniform or cover your street clothes Protect your street clothes from contamina- tion by wearing a uniform or covering them with a gown or coat. Long sleeves and a high neck will provide the most protection. Change these work clothes at least daily, or more often if soiled, especially if they become visibly contaminated with blood. When removing visibly contaminated clothing, fold the Soiled area inside, being careful not to contaminate your hands. Put Soiled clothing into a laundry or plastic bag and keep it in that bag until it is laundered. Remove your protective clothing any time you leave the office. That is, before you go to lunch, on breaks, or home. Although risk of exposure from contaminated clothing is small, it is unhygienic to wear blood- spattered clothes out of the office. BEFORE YOU GO ON . . . Apply what you have just read by answering the questions below. Mark your answers On a copy of this page or on a separate sheet of paper. What protective coverings, if any, should you wear while 1. Polishing a patient's teeth? Gloves Glasses/goggles or face Shield Mask or face Shield Uniform or gown/coat over Street clothes None needed 2. Doing an oral soft tissue exam? Gloves Glasses/goggles or face Shield Mask or face Shield Uniform or gown/coat over street clothes None needed 3. Suctioning while a tooth is being prepared? Gloves Glasses/goggles or face Shield Mask or face Shield Uniform or gown/coat over street clothes __NOne needed 4. Taking a patient's medical history? Gloves Glasses/goggles or face Shield Mask or face Shield Uniform or gown/coat over street clothes NOne needed Check your answers on page 71. Then use the checklist on the next page to evaluate your use of protective coverings. 20 CHECKLIST ON THE PERSONAL USE OF PROTECTIVE COVERINGS Make copies of this checklist and complete a copy after each of the next five patients whose treatment exposes you to blood. Column Column With the patient you just saw, did you . . . 1 2 1. Wear disposable gloves? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO 2. Put on a new pair of gloves for this patient? . . . . . . . . . . . . . . . . . . . . . . . Yes NO 3. Touch unnecessarily—while wearing contaminated gloves – either yourself or instruments, equipment, and surfaces in the operatory? . . No Yes 4. Remove your gloves when treatment was completed and Contaminated instruments had been removed? . . . . . . . . . . . . . . . . . . . Yes NO 5. Put your gloves directly into a trash receptacle after you removed them? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO 6. Wash your hands immediately after removing your gloves? . . . . . . . . . Yes NO 7. Wear sturdy utility gloves while cleaning instruments and decontaminating equipment and surfaces in the operatory? . . . . . . . . Yes NO 8. Avoid contaminating your hands with blood during treatment? . . . . . . Yes NO 9. Wear facial protection? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO 10. Avoid touching the contaminated surface of your mask and glasses Or face Shield? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO 11. Decontaminate your glasses or face shield after patient treatment? . . Yes NO 12. Protect yourself and your street clothes by wearing a gown, coat, or uniform? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO Scoring: Count the number of answers in Column 2. If your total is 0-1 – You are using protective coverings effectively to reduce your risk of infection. Continue these practices with every patient. 2-3 – Your use of protective coverings was almost ideal with this patient. Try to have all your answers in column 1 with the next One. 4+ – You need to make better use of protective coverings. Read the preceding section again and try to put more of the recommendations into practice. AVOID CONTACT WITH BLOOD 2] Many dental instruments are sharp and can easily pierce or cut your skin. If you are injured by a contaminated instrument, you may become infected. Use extreme care to avoid injuries. AVOD CONTACT WITH BLOOD Any event that exposes you to blood in a way that could infect you with microorganisms is an injury. For example, all of the following events would be injuries: • Sticking or cutting yourself with a used needle or with an instrument that has been contaminated with blood • Splashing blood into your eyes, nose, or mouth • Getting blood on broken skin Handle sharp instruments with care Be VERY careful with all instruments that are capable of breaking the skin. These include: • needles • Scalpels • explorers • Scalers • rotating burs • endodontic files • rotating pumice and stone wheels How should I handle sharp instruments? Take the following precautions: • Point the sharp end of an instrument away from yourself. • Pass scalpels and Syringes with the sharp ends pointing away from anyone, including yourself. • Avoid picking up sharp instruments by the handful. • Keep your fingers out of the way of rotat- ing instruments. • Dispose of used needles and other dispos- able sharp items promptly. • Wear Sturdy utility gloves during cleanup. 23 Are there any other special precautions for needles? In general, DO NOT RECAP NEEDLES BY HAND. Do not bend, break, or other- wise manipulate needles by hand. Put used needles and other disposable sharp items into a puncture-resistant container. Keep the container where it is convenient to use. One exception to the rule against recapping is aspirating syringes, which are not fully disposable. You can injure yourself with one of these if you remove the disposable needle without recapping it. Until aspirating syringes are fully disposable or some new technology develops, recap them using one of the one-handed techniques shown here. Never recap them by using both hands or by any other technique that involves moving the point of a used needle toward any part of your body. When giving multiple injections with a single needle, place the unsheathed needle out of your way in a safe, clean area where it can- not become contaminated. If you decide to recap a needle between injections to avoid injuring yourself or others, use a one-handed technique. Have a written policy for injuries Even if you take great care to avoid injury, you probably will injure yourself occasion- ally. It is almost impossible to work in dentistry without injuring yourself. Every dental office needs a written policy for the management of injuries. The policy should include the following: • A person who is designated to receive reports of injuries and who is responsible for follow-up • A person who is designated to interview patients whose blood may be involved in an injury • A written log for recording injuries similar to the two-page log shown here in reduced size. (A full-sized version of the log is given in the appendix, pages 62 and 63, for your use.) Your log should include the following information: Date Who was injured What caused the injury Name of the patient How it happened Names of any witnesses What action was taken What follow-up, if any, is necessary What the outcome was Log of Injuries, Including Exposures to Blood Date of Person Cause of Patient I- Description In Injured In Name of Events Jury I Jury I - H –l - Log of Injuries, Including Exposures to Blood Witnesses action Taken Outcome Follow-up Needed –H --- - - - - Document in the log every injury that exposes you to blood. Look for ways to avoid similar injuries in the future. The log and the information in it should be kept strictly confidential. 24 Treat injuries properly What should I do if I’m injured? If you are exposed to blood in a way that could infect you with microorganisms, wash the contaminated area with soap and water. I | If your eyes are exposed, flood them with plain water. Have tests when injured, if advisable If you are injured, report it to the person on your dental team who is responsible for follow-up. That person will evaluate your risk of having been exposed to a bloodborne microorganism and help you assess your need for laboratory tests and for immu- noglobulin and hepatitis B vaccination. Laboratory tests might include testing for HIV and/or HBV. All such tests should be performed with appropriate counseling and follow-up, if necessary. Any testing should be done in consultation with a personal physi- cian or appropriate health care provider. Pages 66 and 67 in the appendix give addi- tional information on the management of the type of exposures to blood that could transmit infection. For further information on what to do in case of exposure to blood, see the following reprints from the Morbidity and Mortality Weekly Report in the Infection Control File: • “Recommended Infection-Control Practices for Dentistry” • “Recommendations for Prevention of HIV Transmission in Health-Care Settings” • “Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in Health-Care Settings” • “Update on Hepatitis B Prevention” AVOD CONTACT 25 BEFORE YOU GO ON . . . 1. For two days, pay attention to how you handle the instruments and equipment that might injure you. Ask other members of the dental team to watch you as well. Look for practices that could lead to injury. If you find you have some habits that could lead to injury, take action to change them. Watch yourself and ask other members of the dental team to remind you if you forget. If you have several habits you want to change, work on one at atime. Continue to watch yourself until you are sure you do the right thing automatically. When everyone on your dental team has reached this point in the workbook, as a team review your office policy on injuries. Does it meet the recommendations given in the preceding section? Is there a log for injuries? If not, the sheets on pages 62 and 63 in the appendix show what a log might look like. 26 PRINCIPLE 3. Limit the spread of blood 29 • Set up the Operatory before beginning treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 & e * g * & tº tº tº © & tº & & & e e * t e & g & & e g & Limit the spread of blood and blood-contaminated saliva . . . . • Minimize Splashes and Spatter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 30 30 • Use care in handling biopsy specimens and extracted teeth . • Be careful not to Splash contaminated solutions during cleanup Cover surfaces that can’t be decontaminated easily . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Handle waste and soiled linens properly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 ° Medical waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 33 * Solid Waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 e tº * & g & * & tº * sº gº & e s * e e & g º * t e & g e * * e e * sº & e & * e e * * e g & sº & e * £º º º tº g e e e º • Disposable sharp objects • Liquid waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 34 e e {e & * e e e {º e & º e e e & tº e e e e e e † & º * e e e e # e * † e tº $ e * # * e g & e * e * * & e e e * º e • Nondisposable linens . . . 27 Limit the spread of blood and blood-COntaminated Saliva Blood, and saliva contaminated with blood, can be spread during treatment and during cleanup by anything that has been in a patient's mouth. Use techniques that prevent the unnecessary contamination of any area. LIMIT THE SPREAD OF BLOOD | Set up the operatory before beginning treatment Plan ahead and anticipate the needs for treatment of each patient. If you have to get out supplies and equipment after you have contaminated your hands, you may spread microorganisms to surfaces that should be kept clean. Know what instruments, equipment, and supplies are needed for each dental pro- cedure and make sure everything that will be needed is at hand before you begin treat- ment. Put out instruments, medications, and impression materials you will need. Use disposable items and unit dose materials whenever possible. Minimize splashes and spatter Splashes and spatter may directly contaminate items with blood and saliva contaminated with blood. This may occur both during and after treatment, and in the laboratory. During treatment, you can minimize spatter of blood and blood-contaminated saliva by using • a rubber dam • high-velocity evacuation • proper patient positioning In the laboratory, you can avoid spattering blood by • decontaminating items before processing • using a splash guard when operating the rag wheel or lathe 29 using an EPA-registered tuberculocidal Use care in handling biopsy specimens and extracted teeth Anyone who collects biopsy specimens should take the following precautions: • Use a sturdy container that will not leak. • Be careful not to contaminate the outside of the container with blood when collecting the specimen. • Seal the lid securely. • If the outside of the container is visibly soiled, first clean it, and then disinfect it “hospital disinfectant.” Be careful not to get any disinfectant inside the container or on the specimen itself. Detailed information on disinfection pro- cedures is given under Principle 4, beginning on page 37. Wear gloves to handle extracted teeth. Put them into a leakproof container which you seal and dispose of as you would any infec- tive solid waste. Disposal of infective waste is discussed under Principle 3, beginning on page 27. Be careful not to splash contaminated solutions during cleanup When you clean instruments, don't spatter blood-contaminated water outside the sink area. When you rinse instruments, don’t use a stream of water forceful enough to cause Splashing. Hold the instruments at an angle that doesn't cause water to splash onto you, the counters, walls, or floors. Ultrasonic cleaners create spatter. When you use an ultrasonic cleaner, cover it during operation to prevent spatter. 30 BEFORE YOU GO ON . . . 1. Perform two typical procedures and note every instance in which you touch something with contaminated hands because you did not anticipate your needs beforehand. Develop a checklist to help you avoid such instances in the future. 2. Use the checklist for a week. Revise it as necessary to further improve the pretreatment setup of the operatory. 3. Follow the instructions below to evaluate the amount of spatter produced when you polish teeth. You will need plaque-disclosing tablets, a camera with a flash attachment and color film, and three people: • a volunteer to act as “patient” • a person to polish the “patient's" teeth • a person to take photographs What To Do”: a. Have the “patient” chew the disclosing tablet without rinsing. b. Have the “polisher” use a prophy brush or cup to polish the volunteer's teeth. If the disclosing tablet becomes diluted with saliva during this procedure, have the “patient” Chew a Second tablet. - c. Have the “photographer” record what becomes contaminated during the procedure: the “polisher's" gloved hands, facial covering, and clothing; the instruments; the equipment (such as the handles on the overhead light); and any other contaminated Surfaces. d. Discuss the photographs. What surfaces became contaminated? Did this exercise show why you need to wear protective clothing? Discuss how you can reduce the amount and area of contamination. (You may wish to practice your new techniques and then evaluate them by repeating steps a-c, above.) 4. Discuss how to reduce contamination during other procedures. Use these new practices until they are automatic. *The procedure described here was developed by Dr. James J. Crawford, University of North Carolina, and adapted for use in this Workbook. LIMIT THE SPREAD OF BLOOD 3] COver Surfaces that Can't be decontaminated easily Surfaces that are likely to become contaminated can be covered while they are still clean. How do I decide whether to cover a surface? You can either cover a surface before it becomes contaminated or leave it uncovered and disinfect it after treatment. To decide, consider how likely it is to become contaminated, the cost of disposable coverings, and the time saved. Some surfaces, such as light handles, hand- operated chair controls, and cloth-covered suction hoses, are time-consuming and difficult to disinfect adequately. Consider covering these surfaces. Whether to cover before treatment or to disinfect afterward is up to you. If you decide not to cover a surface, make sure that you can disinfect it thoroughly and adequately. Disinfection is described under Principle 4, beginning on page 37. What kind of covering should I use? Use a disposable waterproof covering. Clear plastic wrap, aluminum foil, or paper with an impervious backing are all types of coverings that can be used for this purpose. When should I change the covering? Change the covering after each patient if it has been touched during treatment or has been contaminated by spatter. When changing the covering, do the following: • remove the soiled covering while you are still gloved • remove your gloves and wash your hands • recover the surface with clean material 32 Handle waste and soiled linens properly Handle waste in a way that will protect you, your patients, and persons outside the operatory from potentially infectious hazards and from being offended by unsightly waste. º Medical waste You should consider bulk blood and materials that are soaked with blood, oral tissues, extracted teeth, suctioned fluids, and used sharp items as potentially infective medical waste. In general, if the waste is Solid, it should be either incinerated or autoclaved before disposal in a sanitary landfill. If the waste is liquid, it can be poured down a drain that is connected to a sanitary sewer system. Local laws may vary, however, and you should follow your State and local regulations for disposal of medical WaSte. Both solid and liquid medical waste are discussed in more detail below. Disposable sharp objects Put all used disposable sharp items, such as needles and disposable scalpels, into a puncture-resistant container. When it is full, seal the intact container and dispose of it according to State and local regulations. Should I break needles before disposing of them? No. You should handle used needles as little as possible. Do not break, bend, or otherwise manipulate used needles by hand. Put intact needles into a puncture-resistant container with other used disposable sharp items. Avoid any other unnecessary handling. What kind of container should I use for sharp items? Suitable containers should be sturdy and puncture resistant. They can be metal or rigid plastic. Select containers according to how they will be handled for disposal. - LIMIT THE SPREAD OF BLOOD 33 Solid waste Other solid waste, such as blood- contaminated gauze, cotton rolls, disposable gowns, and masks, should be well-secured in a sturdy leakproof plastic bag. When putting waste into a bag, take care not to contaminate the outside of the bag. If you do accidentally contaminate the outside, seal the bag in a second, clean bag. How should solid waste be disposed of? Waste should be disposed of according to the requirements of local or State environmental regulatory agencies. Consult with these agencies before disposing of such material. If you work in an institution, follow the policies of your institution. Nondisposable linens Risk of transmission of any microorganism from clothing is extremely low. Therefore, good cleaning, rather than sterilization, is the goal for nondisposable linens. Wash soiled linens in hot or cold water with detergent and, if possible, chlorine bleach. Use normal washing and drying cycles. Washing and drying will remove or kill potentially harmful microorganisms, including viruses. The heat in ironing can also kill microorganisms. Handle linens (coats, gowns, or uniforms) contaminated with blood as little as possible before laundering and wash your hands after you do handle them. Liquid waste Whenever you are handling blood, suctioned fluids, or other liquid waste, wear gloves. How should I dispose of liquid waste? Liquid that is collected by blood-collection and high-velocity evacuation systems is contaminated with blood. Liquids contaminated with blood may be poured into a drain or toilet that is connected to a sanitary sewer system. How should I empty the suction trap? To empty the suction trap, first clean the suction system with a solution recommended by the manufacturer. Then, while wearing gloves, remove the suction trap. Being careful not to spill or splash, pour any liquid into a drain. Put the solids into a leakproof bag with other solid waste. 34 BEFORE YOU GO ON . . . Copy this page and use your copy to answer the following questions that evaluate the handling of waste and soiled linens in your dental office. Column Column 1 2 L|M|T THE SPREAD 1. Do you cover surfaces which are difficult or impossible to clean if OF BLOOD they will become contaminated during treatment? . . . . . . . . . . . . . . . . . NO Yes Do you ever bend or break needles by hand? . . . . . . . . . . . . . . . . . . . . . Yes NO 3. Do you put used needles and other sharp items into a puncture- resistant container immediately after use? . . . . . . . . . . . . . . . . . . . . . . . . NO Yes 4. Do you ever handle an extracted tooth in a way that unnecessarily contaminates areas of the Operatory? . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO Do you put extracted teeth into a leakproof container for disposal? . . No Yes Do you know the requirements of local or State environmental regulatory agencies for the disposal of contaminated waste? . . . . . . . . NO Yes 7. Do you pour liquid waste into a drain that is connected to a sanitary Sewer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NO Yes Do you wear gloves when cleaning a suction trap? . . . . . . . . . . . . . . . . NO Yes Do you seal all blood-contaminated solid waste into a sturdy leakproof plastic bag? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NO Yes When everyone on the dental team has answered these questions, discuss any office practices that need to be changed. Scoring: • If none of your answers are in column 1, you probably handle waste and contaminated linens in a way that protects you and others from infection. Continue your good practices. • If your answer to question 6 is in column 1, take steps to find out what the requirements are and make sure that your practices meet them. • If your answers to any other questions are in column 1, consider how you might improve your infection control practices in this area. 35 PRINCIPLE 4. Make objects safe for use Know how decontamination processes differ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Choose the right way to decontaminate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 When you decontaminate, do it right . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 • How to decontaminate critical items . . . . . . . . “. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 • How to decontaminate Semicritical items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 • How to decontaminate noncritical items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 • How to read labels of chemical germicides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 • What to do when you can’t apply the “rules” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Check to be sure you’ve done it right . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 * Does it work? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 * Am I doing it properly? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 • Am I buying equipment that can be decontaminated properly? . . . . . . . . . . . . . . . . . . . . . . . . . 55 37 Know how decontamination processes differ Cleaning, sterilization, and disinfection are all decontamination processes. These processes differ in the number and types of microorganisms killed. By knowing the differences between the processes, you will know how to choose the right way to make contaminated items safe to touch and UlSC. MAKE OBJECTS SAFE FOR USE What is cleaning? When you clean, you physically remove debris and reduce the number of microor- ganisms present. Cleaning is the basic first step of all decontamination. You always need to clean before you disin- fect or sterilize. Cleaning before sterilization or disinfection is sometimes called “precleaning.” For items that do not require disinfection or sterilization, thorough clean- ing with soap and water is all that is neces- sary. Cleaning is described in more detail on page 42. What is sterilization? Sterilization is a process that kills all microbial life. It kills bacterial spores, which are the most difficult form of microorganism to kill. This is significant because if you use a process that kills large numbers of bac- terial spores, you will also kill all other types of microorganisms. You will kill the organ- isms that cause tuberculosis, hepatitis B, AIDS, and a variety of other infections. After you have sterilized properly, no micro- organisms will be alive. What is disinfection? Disinfection is a process that kills disease- causing microorganisms, but not necessarily all microorganisms. Nonpathogenic microorganisms may remain on an object after you have disinfected it. How many and what kind of microorganisms you can kill with disinfection depends on what level of disinfection you use. What are the different levels of disinfection? There are three levels of disinfection: low, intermediate, and high. 1. Low-level disinfection is the least effective disinfection process. It does not kill bacterial spores or Mycobacterium tuberculosis var. bovis, a laboratory test microorganism that is used to classify the strength of disinfectant chemicals. 2. Intermediate-level disinfection is a disinfection process that does kill M. tuberculosis var. bovis. This is significant because it is almost as difficult to kill this microorganism as it is to kill spores. If you use a process that kills M. tuberculosis var. bovis, you will also kill organisms that are easier to kill, such as the ones that cause hepatitis B and AIDS. 3. High-level disinfection is a disinfection process that kills some, but not neces- sarily all, bacterial spores. This powerful process will also kill M. tuberculosis var. bovis, as well as other bacteria, fungi, and viruses. What is the difference between sterilization and high-level disinfection? Sterilization kills every microorganism on the object that is sterilized. High-level disinfection kills the same types of micro- organisms—including spores—but isn't as thorough. It will kill some spores, but not large numbers of them. 39 Choose the right way to decontaminate The choice of how to decontaminate anything should be based on how it will be used. Everyone on the dental team should know how to choose the correct decontamination process. How do I choose the right way? To know which decontamination process you should use, apply the following “rules”; • If an instrument will penetrate tissue or • For equipment and surfaces that will touch touch bone, STERILIZE it. only intact skin, USE INTERMEDIATE- OR LOW-LEVEL DISINFECTION. Which level of disinfection you use depends on whether or not the items are visibly contaminated with blood. Remembering these “rules” will help you choose the proper decontamination process for any item. Unfortunately, the choice is not always easy. Some items cannot be decon- taminated as called for by the “rules.” These exceptions to the “rules” are discussed on pages 49-51. • If an instrument will touch mucous mem- branes but will not penetrate tissue or touch bone, STERILIZE it if it will not be damaged by heat. If it will be damaged, USE HIGH-LEVEL DISINFECTION. 40 Can the “rules” be shortened to help me remember them? Yes. The names critical, semicritical, and noncritical have been given to the three ways items contact patients. • Instruments that will touch bone or pene- trate tissue are called CRITICAL. Forceps, scalpels, and scalers are examples of criti- cal items. • Instruments that will touch mucous mem- branes but will not touch bone or penetrate tissue are called SEMICRITICAL. Mirrors and amalgam condensers are examples of Semicritical items. • Equipment and environmental Surfaces that will come into contact only with intact Skin are called NONCRITICAL. Chairs and countertops are examples of noncritical items. With these shorthand names — CRITICAL, SEMICRITICAL, and NONCRITICAL– you can state the rules more simply: • Sterilize all critical instruments and those semicritical instruments that are not damaged by heat. Heat sterilization methods are preferable. • Use high-level disinfection on semicritical instruments that are damaged by heat. • Use intermediate- or low-level disinfection on noncritical environmental Surfaces. Cleaning alone will be sufficient for most noncritical items that are not contaminated with blood. You could also use low-level dis- infection for these. However, if an item is visibly contaminated with blood, choose intermediate-level disinfection. BEFORE YOU GO ON . . . Answer the following questions to review what you have learned about decontamination processes. Write your answers on another sheet of paper. 1. What is the first step in any decontamination process? 2. What are the three levels of disinfection? 3. Compare the numbers and types of microorganisms killed by sterilization and high-level disinfection: a. Sterilization kills b. High-level disinfection kills 4. What is the definition of instruments that are classified as critical? How should they be decontaminated? 5. What is the definition of instruments and equipment that are classified as semicritical? How should they be decontaminated? 6. Classify each item below as CRITICAL, SEMICRITICAL, or NONCRITICAL, and indicate how it should be deCOntaminated: DECONTAMINATION |TEM CLASSIFICATION FORCEPS USed to extract teeth PROCESS BUR used to reshape bone AMALGAM CONDENSER GLASS SLAB used in mixing cement Check your answers on page 72. MAKE OBJECTS SAFE FOR USE 4 | When you decontaminate, do it right To make contaminated items safe for use, you must not only choose the right process, you must also make sure that you do it properly. How to decontaminate critical items Anything that will touch bone or penetrate tissue—or anything that will come into con- tact with an item that will touch bone or penetrate tissue—is a critical item. Forceps, Scalpels, and scalers, for example, are critical items. To decontaminate critical items—and semi- critical items that are not damaged by heat-do the following: 1. CLEAN by rinsing under a stream of water and scrubbing thoroughly with detergent and water. You can also use an ultrasonic cleaner. Rinse and dry cleaned items completely. Remember that cleaning is the first step in every decon- tamination process. 2. STERILIZE. Are there different ways to sterilize? In dentistry, instruments and equipment are usually sterilized by one of the following: • Steam under pressure (steam autoclave) • Dry heat • Chemical under pressure (chemical auto- clave) • An EPA-registered “disinfectant/sterilant” The first three methods, which use heat to sterilize, are preferred. The fourth sterilization method listed above – using an EPA-registered “disinfec- tant/sterilant”—is sometimes called “cold sterilization.” You may use a “disinfectant/ sterilant” for instruments that are damaged by heat, but sterilization by heat is always preferred. How do I sterilize using heat methods? Your main source of information on how to Sterilize should be the instructions that the manufacturer of your sterilizer provided. Keep those instructions—or a copy of them—in a convenient place. Study them until you completely understand them and then follow them exactly. If you do not fol- low the manufacturer's recommendation for time, temperature, or pressure, your method may not sterilize. The general steps in heat sterilization are described in Table 1, on the next page. This table has been produced as a wall chart which you may post near your sterilizer. 42 TABLE 1 Steps in Heat Sterilization 1. PACKAGE CLEANED ITEMS. • If possible, wrap or package everything that must be kept sterile and that will not be used immediately. MAKE OBJECTS SAFE FOR USE • Put a heat-sensitive process indicator on each pack and each unwrapped item to verify that they have been processed. • Write the date of processing on the process indicator. 2. PROCESS ITEMS. • Load the sterilizer so that hot air, steam, or chemical vapor will be able to circulate freely around every item or pack. • Bring the sterilizer up to the temperature recommended by the manufacturer. Allow time for all parts of the load to reach that temperature, and then process for the recom- mended time. 3. STORE STERILIZED ITEMS. • If any unwrapped items will not be used immediately, wrap them in sterile packaging (or sterile toweling) before storing. • Keep sterilized items wrapped until they are used. • Store the packages where they will not become torn or wet. If a package does become punctured, torn, or wet, repackage the contents and sterilize them again. How would I use a “disinfectant/sterilant” 2. Read the label to see that the chemical for sterilization?” kills spores (that it is sporicidal). --- - - 3. Put cleaned items into the chemical, To sterilize using an EPA-registered - covering them completely, and leave them “disinfectant/sterilant,” do the following: immersed for the prolonged time 1. Thoroughly clean the items to be recommended by the manufacturer to kill Sterilized. spores. (This can be as long as 10 hours.) 43 4. Remove items from the chemical Solution Why is sterilization using heat preferred? with a sterile instrument and rinse them with Sterile water. Heat methods are preferred for sterilization because you can monitor (check) them with 5. Dry with sterile towels. a spore test to see whether the process was 6. Store under Sterile conditions. adequate. (Use of spore tests is discussed on Most people find this technique impractical pages 54-55.) Table 2 compares the for routine sterilization. You may have to use advantages and disadvantages of all four it, however, to Sterilize critical items that are methods of Sterilization. damaged by heat. TABLE 2 Advantages and Disadvantages of Sterilization Methods Advantages Disadvantages • Is Guick and easy • May leave instruments wet, causing them • Allows for sterile packaging to ruSt • Penetrates fabric- and paper-wrapped • Requires packaging packs • Damages plastics • Is very reliable • May dull certain sharp items CHEMICAL VAPOR Advantages Disadvantages • Is quick • Requires good ventilation • Can be used with packaged items • Can't handle large loads • Penetrates paper-wrapped packs • Won't penetrate fabric-wrapped packs • DOesn't rust instruments • Damages Certain plastics • Leaves instruments dry • Replacing special Solution increases cost • Is very reliable DRY HEAT Advantages Disadvantages • Is Cheap and easy • Is slow, requires a longer processing time • Leaves instruments dry • Requires careful loading • Doesn't rust instruments • Damages plastics • Requires little maintenance • Melts or destroys some metal or solder • Is very reliable joints • CharS fabric CHEMICAL DISINFECTANT/STERILANT Advantages Disadvantages • Is cheap initially • Has a limited life • Can Sterilize items that WOuld be • Is expensive in the long run damaged by heat • Cannot be checked for effectiveness • Toxic fumes require special ventilation • Protective clothing required during use • Cannot be used with packaged items • Must be rinsed Off With Sterile Water • May rust instruments 44 BEFORE YOU GO ON . . . Answer the questions below on a separate sheet of paper 1. What four methods are commonly used in dentistry to sterilize instruments and equipment? What are four disadvantages to using a "disinfectant/sterilant” for sterilization? 2 3. If a package of sterilized instruments is torn during storage, what should you do? 4 MAKE OBJECTS SAFE FOR USE . Do you have the manufacturers' instructions on how to sterilize the different instruments you use? 5. Do you look at the gauges on your heat sterilization during the cycle to make sure that the load is processed at the right temperature for the right amount of time? 6. Do you use heat sterilization for all critical items that can withstand heat? Answers are given on page 73. How to decontaminate semicritical items Anything that will touch mucous mem- branes, but not penetrate tissue or come into contact with bone, is a semicritical item. A mouth mirror is an example of a semicritical Item. To decontaminate semicritical items, do the following: 1. CLEAN by rinsing under a stream of water and scrubbing thoroughly. You can also use an ultrasonic cleaner. Rinse and dry the items completely. Remember that cleaning is the first step in all decontamination. 2. STERILIZE items not damaged by heat and use HIGH-LEVEL disinfection on other items. Sterilization has already been discussed on pages 42-44. High-level disinfection can be carried out by boiling cleaned items in water or soaking them in a liquid chemical germicide regis- tered with the Environmental Protection Agency (EPA) as a “disinfectant/sterilant.” (CAUTION: This class of chemical germi- cide is toxic and requires special ventilation. Be certain to follow precautions on the product label.) How do I carry out high-level disinfection by boiling? To disinfect using boiling water, put cleaned items in the water, wait until the water boils again, and then boil for 10 minutes. If semicritical items will withstand the heat of boiling, they can probably withstand the heat of sterilization. Therefore, sterilize them with heat whenever heat methods of sterilization are available. How do I carry out high-level disinfection using a “disinfectant/sterilant”? You should follow these steps: 1. Read the label to see that the chemical kills spores (that it is sporicidal). 2. Put cleaned items into the chemical, covering them completely, and leave them immersed for the shorter time recommended by the manufacturer. (The shorter contact time is for high-level disinfection and the longer contact time is for sterilization.) 3. Remove items and rinse thoroughly with sterile water to remove all chemical residue. 4. Dry with sterile towels. 5. Use items immediately or store in a Sterilized container. 45 How to decontaminate noncritical items Anything that will touch only intact skin is a noncritical item. Chairs and countertops are examples of noncritical items. How do I clean noncritical items? You can clean noncritical items using absorbent towels, water, and either soap or a disinfectant product registered by the Environmental Protection Agency (EPA) for cleaning. Scrubbing itself removes microorganisms very well, however, and is probably as important as the cleaning agent used. Noncritical surfaces, such as floors, walls, and windows, have not been identified as being responsible for the transmission of any type of infection to patients or health care workers. Nevertheless, these surfaces should routinely be kept visibly clean. How do I carry out low-level disinfection? Cleaning alone is sufficient for items not contaminated with blood. If you choose to use low-level disinfection, however, you can do the following: 1. Prepare an EPA-registered “hospital disinfectant” according to the manufacturer's instructions. It is not necessary for the “hospital disinfectant” to have tuberculocidal activity. 2. Wipe or spray the solution on the surfaces of the cleaned items and allow to air dry. 46 º º º º R. º º º º : . How do I carry out intermediate-level disinfection? If a noncritical item is contaminated, do the following: 1. Remove any visible contamination with a paper towel or moist cloth. 2. Clean the item well with detergent and Water. 3. If there is visible blood in the contam- ination, carry out intermediate-level disinfection using a solution of bleach or of a liquid chemical germicide registered with the EPA as a tuberculocidal “hospital disinfectant.” How do I use bleach for intermediate-level disinfection? To disinfect using bleach do the following: MAKE OBJECTS 1. Mix a fresh solution daily, using SAFE FOR USE household bleach and water. Use a bleach dilution that has at least 500 parts per million of free available chlorine. Either 1 part bleach to 100 parts water OR /4 cup bleach in 1 gallon of water will provide a solution that is strong enough. Higher concentrations of bleach are very corrosive (especially to aluminum), unpleasant to use, and not necessary for effective disinfection. 2. Wipe the cleaned item with the bleach solution and allow to air dry. How do I use a tuberculocidal “hospital disinfectant” for intermediate-level disinfection? To disinfect using a tuberculocidal “hospital disinfectant,” do the following: 1. Prepare the chemical solution according to the manufacturer's instructions. 2. Wipe or spray the cleaned surfaces of the items with the solution. 3. Allow to air dry and then rinse with water to remove chemical residue if recommended by the manufacturer. What about alcohol? Alcohol is not recommended for disinfecting contaminated environmental surfaces because it evaporates quickly and allows insufficient contact time for effective action. BEFORE YOU GO ON . . . Answer the following questions to review how to sterilize and how to disinfect. Write your answers on a separate sheet of paper. 1. What four methods of sterilization are commonly used in dentistry? Which is/are used in your Office? 2. Where can you find information about the time, temperature, and pressure to use when sterilizing items in a heat sterilizer? 3. Why are sterilization methods that use heat preferred? 4. What is the first step in sterilization and in high-, intermediate-, and low-level disinfection? 5. If a noncritical Surface is not contaminated with blood, what should be done to deContami- nate it? 6. If a noncritical surface is contaminated with blood, what should be done to decontaminate it? Answers are given on page 73. 47 TABLE 3 Class of Chemicals To Use for Each Disinfection Process USE THIS EPA CLASSIFICATION:* FOR THIS PROCESS; Sterilization Disinfectant/sterilant (with a prolonged contact time) High-level disinfection Disinfectant/sterilant (with a short contact time) Intermediate-level disinfection Hospital disinfectant with tuberculocidal activity label claim LOW-level disinfection Nontuberculocidal hospital disinfectant *The names of the EPA classes of chemicals are controlled by law. The manufacturer of a disinfectant cannot use these terms without EPA approval. They appear on the label of any chemical registered with the EPA. How to read labels of chemical germicides How can I remember the chemicals to use for each level of disinfection? The Environmental Protection Agency (EPA) registers chemicals used as disinfec- tants or sterilants. The EPA puts chemicals into the following four classes of use: • Disinfectant/sterilants • Hospital disinfectants with tuberculocidal activity • Hospital disinfectants • Sanitizers The table above shows how the EPA classes of use are related to sterilization and disinfection. Any chemical you use should have a label that shows the following: • EPA classification • EPA registration and establishment num- bers • Directions for use and disposal º He § ep 3 ºr c wn § # 3 ### , ; ºn - E. - 3 5 * ** E ºn tº 3. º º E ſe tº E ºr F º º º: ... º ºil. a E 32 : Hi ºn E 535 g ; : * ## * : # 42 and 21 day repeated reuse in manual E ºf ºi; ; #3 º # = #3 HH (bucket and tray) systems E o #### iii.33 p. ~ - - º . . º ºx * : * a # E g : - ;3 ; :##: § 2 #3 # Sporicidal, virucidal, Bactericidal, Tuberculocidal, Fungicidal 5 : #### - # : tº 3 2 5 HT + 3 35 ; ; ; * :: – tº E = 5 # E3 & ##### U) # #" # DISINFECTING/STERILIZINGSOLUTION gö ºf £3 - - - - - - R.R. on- º # = #: For immersible items, not for environmental E #: § #####: 5 # surface decontamination º 3 : E #####5 5 º E < ; : º, .35% $5.5 - E. º use only in well-ventilated areas 3: ºr - 5 --- º avoid contact with skin or mucous membranes º º For turther instructions on use refer to package insert How can I tell which chemical to use? If “disinfectant/sterilant” and the word “sporicidal,” (kills spores) are on the label, you can use the chemical for either steriliza- tion or high-level disinfection. The same concentration of the chemical is used for both processes. The contact time is the important difference to notice. Follow the instructions on the label. Below is the label for a disinfectant/sterilant we “invented.” The name KILZALL emphasizes that it kills spores and could be used for sterilizing or high-level disinfection. How can I tell that a chemical could be used for intermediate-level disinfection? Look for the term “tuberculocidal” and “hospital disinfectant” on the label of any chemical you use for intermediate-level dis- infection. 48 (Virucidal Bactericidal, Fungicida Y Tuberculocidal, Pseudomonacidal zºº HOSPITAL DISINFECTANT A disinfecting solution for dental offices that can be used for dental operatory surfaces and impressions DILUTE AS RECOMMENDED Recommended for: Rubber, aluminum, and plastic objects WARNING: Harmful if swallowed Caustic to skin Active Ingredient Iodophore ........................... 1.6% Inert ingredients ............... 98.4% Inert ingredients contain other chemicals EPA Reg. No. 000-00 EPA Est. No. 00000-XX00 SAMPLE A solution for dental offices that can be used routinely as a floor cleaner/disinfectant º HOSPITAL DISINFECTANT Virucidal, Bactericidal, Fungicidal Recommended for environmental surfaces only Do not use on instruments WARNING: Harmful iſ swallowed Caustic to skin i Note: In the presence of spore organisms, Mycobacterium tuberculosis, or etiologic agent for viral hepatitis, quaternary ammonium compounds cannot be relied upon to produce thorough disinfection For rubber, aluminum, and plastic surfaces Directions: Dilute 2 ounces of Kiizafew with sufficient water to obtain 32 oz. of ready to use solution Active ingredient ...................................... 2.24% Cetyl dimethyl ethyl ammonium bromide 1.12% n-Alkyl (50%. C., 40% Cz, 10% Chs) dimethyl benzyl ammonium chloride 1.12% Inert ingredients ..................................... 97.76% Inert ingredients contain other chemicals Rinse empty container thoroughly with water and discard it EPA Reg. No. 000-0 EPA Est. No. 00000-XX00 SAMPLE At the left is the label for a tuberculocidal hospital disinfectant we “invented.” We named our fictitious chemical KILZALOT to emphasize what to look for when reading a label of this class of chemical. KILZALOT could be used for intermediate-level disin- fection. MAKE OBJECTS SAFE FOR USE How can I tell that a chemical could be used for low-level disinfection? Notice that our fictitious KILZAFEW label (on bottom left) shows its EPA registration as a “hospital disinfectant,” but does not indicate that it is tuberculocidal (that it inactivates M. tuberculosis var. bovis). In fact, the label states that it may not produce thor- ough disinfection in the presence of M. tuberculosis var. bovis. KILZAFEW could be used for low-level disinfection. What to do when you can't apply the “rules” The design of some dental equipment and laboratory items makes it difficult or imposs- ible to decontaminate them adequately. Both the material an item is made of and the tex- ture of its surface can make it difficult to apply the “rules.” Some laboratory devices are difficult to dis- infect because materials used in their man- ufacture can be altered by exposure to a chemical or heat. For example, an appliance may be made of both acrylic and metal. Heat may melt the acrylic and chemicals may corrode the metal. There may be ways to avoid having to decon- taminate items with irregular surfaces which cannot be cleaned and disinfected easily. Some, such as saliva ejectors, are available in a disposable form and can be thrown away after a single use. Others, such as light han- dles and hand-operated chair controls, can be covered to avoid contamination altogether. Still others, however, such as light-curing wands, are not disposable and cannot be covered. Your dental supplier and the manufacturer of a particular piece of equipment or material are the best sources of information for decontaminating these items. What about dental unit waterlines, handpieces, and ultrasonic scalers? Check the manufacturer's instructions for information on • the use and maintenance of waterlines, including check valves 49 • the proper sterilization or high-level disin- fection of handpieces, ultrasonic scalers, or air-water syringes and other items con- nected to the dental unit waterlines • the types of disinfectant that can be used without damaging the equipment Because handpieces come into contact with mucous membranes, they are semicritical. THEY SHOULD BE STERILIZED OR GIVEN HIGH-LEVEL DISINFECTION BETWEEN PATIENTS. Unfortunately, most handpieces are not engineered to be easily and effectively cleaned and then sterilized or disinfected between patients. If a handpiece cannot be sterilized, there is no effective way to clean and disinfect the inside of it after each patient treatment has been completed. If a handpiece cannot be autoclaved, clean- ing and disinfecting the outside of it by the following compromise procedure is the best that can be done at this time. It is empha- sized that this compromise procedure is unique for dental handpieces which cannot be autoclaved and is presented as an alter- native ONLY until you can replace your handpiece with one that can be autoclaved. The procedure is NOT capable of steriliza- tion or high-level disinfection. 1. Flush the handpiece thoroughly with Water. 2. SCRUB the handpiece thoroughly with a detergent and water to remove any debris. 3. WIPE it with clean absorbent material that you have saturated with an EPA-registered tuberculocidal “hospital disinfectant,” wetting the surfaces thoroughly. 4. KEEP IT WET with the disinfectant for the time stated on the label: Spray disin- fectant on the handpiece repeatedly or wrap it with saturated absorbent material and cover with plastic wrap. 50 5. RINSE the handpiece thoroughly with water to remove chemical residues, which might irritate your hands or harm patients. Use the same procedure for ultrasonic scalers, air/water syringe tips, and other items that touch mucous membranes, but that cannot be sterilized or immersed. (First, always check the manufacturer's recommen- dations on decontamination procedures.) To reemphasize, this procedure is a compro- mise and is NOT high-level disinfection. At best, it is intermediate level. Use this pro- cedure only if you cannot sterilize your handpiece without damaging it, or if the manufacturer does not recommend steriliza- tion. Whenever you buy a new handpiece – or other equipment—evaluate it to see if you can sterilize or disinfect it properly. How can I decontaminate impressions and appliances? Clean and decontaminate anything that has been in a patient's mouth, or that has touched anything that has been in a patient's mouth, before you handle it without gloves. - * I' * | MAKE OBJECTS SAFE FOR USE Before disinfecting these patient items, care- fully clean any blood and saliva from them, if possible. Apply the “rules” in deciding how to disin- fect. Items such as retainers, dentures, and other appliances will be put back into the patient's mouth and are semicritical: Disinfect them using at least high-level dis- infection as described on page 45. After disinfecting items that will be put back into a patient's mouth, rinse them well. 5] Items that will not be put back into the patient's mouth, such as casts, are noncriti- cal, but are probably contaminated with blood: Use at least intermediate-level disin- fection as described on page 47. Because a variety of materials are used to construct these items, check with the manufacturer of a particular material for information on how to disinfect it. Disinfect impressions before you send them to a laboratory, and let the laboratory know that you have disinfected them. You can write this information on the lab prescrip- tion form. If you work in a lab and receive these items from a dentist, wear gloves when handling them or disinfect them before you work on them unless you are sure they have already been disinfected. Also, when impressions and appliances are returned from a dental lab, disinfect them before putting them into the patient's mouth, unless the lab notifies you that they have been disinfected. BEFORE YOU GO ON . . . 1. Classify items used in your dental office: • Have one person make a list of items that you use. Set up the page like the list on page 41. Put in the headings for showing classification and decontamination process, but don't fill them in yet. Pages 64 and 65 in the appendix show an inventory of items found in many operatories which may help with making your list. Give a copy of your list to everyone on the dental team. • Each person on the team should classify each item as CRITICAL, SEMICRITICAL, or NONCRITICAL, depending on how it is used in your operatory. Then write how it should be decontaminated: cleaning, sterilization, or high-, intermediate-, or low-level disinfection. • When everyone on your dental team has filled in the list, discuss your answers and the reasons for your choices together. Make a copy of the list you all agree on and post it where you can refer to it easily when you decontaminate. 2. Complete a copy of the checklist on the next page to review and evaluate the decontamina- tion procedures used in your dental office. When everyone on the staff has answered these questions, discuss your answers. 52 Checklist for Evaluating Decontamination Practices Column Column 1 2 1. Do you clean items that cannot be sterilized before you disinfect them? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO MAKE OBJECTS SAFE FOR USE 2. Do you use a method of heat sterilization for all semicritical items that Can Withstand heat? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO 3. When you use a “disinfectant/sterilant” for high-level disinfection, do you use the concentration and contact time needed to kill M. tuberculosis Var. bovis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO 4. Do you know how to disinfect all laboratory items? . . . . . . . . . . . . . . Yes NO 5. Do you flush handpieces and maintain waterlines as recommended by the manufacturer? . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO 6. If you can sterilize the handpiece, do you sterilize it after patient treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO 7. If you cannot sterilize the handpiece, do you clean and disinfect the outside of it after every patient treatment? . . . . . . . . . . . . . . . . . . Yes NO 8. Do you know how materials you use for impressions and appliances Can be disinfected? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO 9. Do you use high-level disinfection on patient items such as dentures that will go back into a patient's mouth? . . . . . . . . . . . . . . . Yes NO 10. Do you ever use an ungloved hand to handle contaminated impressions, retainers, or dentures that have not been disinfected? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NO Yes 11. When you disinfect items such as impressions and appliances, do you clean them first? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO 12. When items that must be put into a patient's mouth are received from a dental lab, do you know whether they have already been disinfected? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NO Scoring: • If none of your answers are in column 2, you are probably using good decontamination procedures. • If the answer to question 8 is “No,” find out if the materials are compatible with high-level disinfection processes. • If your answers to any questions are in column 2, consider how you might improve your infection control practices in this area. Discuss this with others on the dental team. 53 Check to be sure you've done it right To be confident that you are decontaminating effectively, you must constantly evaluate what you do. By checking yourself frequently, you will reduce the risk that your patients will be exposed to microorganisms. There are three questions to answer to make sure you are decontaminating as well as possible: 1. Does it work? 2. Am I doing it properly? 3. Am I buying equipment that can be decontaminated properly? Does it work? Heat sterilization is the only decontamina- tion process that can be easily and reliably checked to see that it works. You should check your heat sterilization process once a week with a spore test. By using spore tests, you can see that your process kills spores. Why do I need to use a weekly spore test if I use a process indicator for every pack? |ECK STERILECHEC 250 t. STEAM ACCEPT only if both bars are YELLOW STERILECHECK 250; STEAM Accept only if both bars are YEL LOW Only a spore test shows whether or not your sterilization process is effective in killing all types of microorganisms. A process indicator is a chemical device that changes color when exposed to heat. It may be tape that you Stick to packs and individual items before you sterilize them, or it may be printed on the packaging material. The change in color only shows that the chemical process indica- tor has been exposed to heat, not that your process actually sterilizes. How do I test my heat sterilization methods? Do the following when you test: 1. Check with the manufacturer of your sterilizer for the proper spore test. The spore Bacillus stearothermophilus is used for chemical vapor and steam sterilizers, and Bacillus subtilis var. niger, for dry heat sterilizers. 2. Put the correct type of test spores inside a pack and put that pack near the center of a typical load. What do I do after I process the spore test in a typical load? Either mail the exposed test spores to an appropriate microbiology laboratory or check them yourself in a special incubator made specifically for this purpose. These incubators are commercially available. 54 What do positive results mean? If the results are positive, that means that not all the spores were killed and the items processed in that load may not be sterile. You can get positive results when: • packs are improperly prepared • the sterilizer is improperly loaded • the sterilizer doesn't work properly • the process time is too short What should I do if I get positive results? Repeat the spore test, examining your pro- cedure to see that: • you load the sterilizer properly and don't Overfill it • your packs are not too large • you are following all manufacturer's instructions What if I get positive results a second time? If the results are positive again, do not use the sterilizer until it has been inspected or repaired, or until the exact reason for the positive test has been found. Use another sterilizer and/or another method. Also, reprocess any items sterilized since the last negative spore test. What if results are negative? If the results are negative, it means that no spores are left. If no spores are left, your sterilizer is working properly and items pro- cessed in that load were sterilized. Repeat the test again in a week. - - Record your weekly results in a log to be kept near the sterilizer. Page 68 of the º tº - º appendix is an example of a log which can be used for this purpose. Am I doing it properly? It is especially important to ask this question about decontamination processes other than heat sterilization because there is no way to test those processes to be sure they are kill- ing microorganisms. MAKE OBJECTS SAFE FOR USE The dental team should have written instructions for all decontamination pro- cedures. You should periodically compare your technique with the written instructions. Always think about what you are doing. For example, even though the manufacturer's instructions say that a solution can be used for up to 28 days, you may not be able to use it that long. Because many chemicals are inactivated in the presence of gross amounts of contamination, pay attention to how you use the solution and what it looks like. If it becomes murky, cloudy, or develops a jellylike substance in the bottom, it may no longer be effective. Throw it away. Should I look at anything else to find out if I'm decontaminating properly? The chemicals used in decontamination are toxic to microorganisms. Examine your pro- cedures to make sure they will not be toxic to you or your patients. For example, • Do you wear protective clothing when han- dling chemicals? • Do you label containers if you move chemi- cals from their original containers? • Do you rinse patient-care items well? • Do you and the other team members know what to do if someone is unintentionally exposed to a chemical? You might consider the following: Is the poison control phone number posted? Do you know antidotes? Are eyewash solutions kept handy? There may be other questions you should ask. To avoid serious injury, think about what you need to know before an unintentional chemical exposure occurs. Am I buying equipment that can be decontaminated properly? To answer this question look at critical, semicritical, and noncritical items. Can the critical and semicritical equipment you use be cleaned and sterilized? Can you easily clean and disinfect noncritical equip- ment that is likely to be spattered with blood? 55 If you find that you cannot clean and steril- In addition, when you buy new equipment ize critical and Semicritical items properly, find out how you can clean and sterilize crit- you may want to consider using more dispos- ical items or disinfect noncritical items that ables. In general, to make that decision you are likely to be spattered with blood. Buy have to weigh the cost and ease of use with equipment that can be decontaminated risk of transmission. easily. BEFORE YOU GO ON . . . 1. Make a list of items of equipment that are difficult to clean. Anything that is difficult to clean cannot be disinfected adequately. Examine the equipment looking for grooves and cracks. Also look for porous or textured material or fabric. 2. When everyone on your dental team has made a list, discuss what to do about each item of equipment. Decide which items can be replaced with disposable ones, which can be covered to avoid contamination, and which you must consult the manufacturer on. 56 Infection Control is not difficult, but it does require planning in Order to be SUCCeSSful. The time you take will be rewarded with the knowledge that you have created an environment that protects you and your patients from the risk of infection. 57 BEFORE YOU FILE THIS AWAY. . . Take a few minutes to review what you have learned on the preceding pages. Try to answer the questions below without looking back in the workbook. Write your answers on a separate sheet of paper. 1. What bloodborne microorganism should you be most concerned about becoming infected With at Work? 2. What are the four principles for infection control? 3. When should you wear household-type utility gloves? 4 11. 12. 13. 14. 15. 16. 17. . When washing your hands, how long should you rub them together after you lather them if they are not especially dirty? . When should you wear disposable vinyl or latex examination gloves? What should you do if you tear a glove during patient treatment? When should you wear facial protection? . What are three ways to minimize spatter of blood during patient treatment? How should a biopsy specimen be packaged before it is to be sent to a laboratory? How should you handle extracted teeth and how should you dispose of them? What Waste Should be treated as infective? Where should you empty a suction trap? What three processes does decontamination include? Which decontamination process kills all microorganisms? What are the three levels of disinfection? What are the “rules” for choosing the right way to decontaminate instruments, equipment, and environmental Surfaces? What should be written on the label of a chemical that you use for high-level disinfection? Correct answers are given on page 74. 59 PHOTO CREDITS Bob Duncan, Centers for Disease Contol - photographs credited on pages 40, 42, 45, 46, and 47 Jim Gathany, Centers for Disease Control - photographs credited on pages 30 and 33 Allen Polansky, Baltimore, Maryland - all photographs not otherwise credited Special appreciation is extended to the Veterans' Administration Hospital, Washington, D.C., for pro- viding the facilities used in the photographs, and to all those who appear in the photographs for their generous assistance. 60 APPENDIX Supplementary materials ONQ 6 , materials, and Some commonly used items . . . . . . . . . . . . . 64 * ple log of injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sam Class 1pment f dental equ ification o B itis hepat postexposure management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 2 Management of persons exposed to blood Iciency Virus def postexposure management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 III] ITTUII) O human 3 Management of persons exposed to blood IZatl On te il Sample log of ster 6 | Log of Injuries, Including Exposures to Blood Date Of PerSOn Cause of Patient Description Iniu Injured Iniu Name Of Events 62 Log of Injuries, Including Exposures to Blood Witnesses Action Taken OutCOme Follow-up Needed 63 Classification and Proper Method of Decontaminating Dental Equipment, Instruments, Materials, and Some Commonly Used Items |TEM CLASSIFICATION METHOD OF DECONTAMINATION Dental Equipment Air-water syringe Angle attachments Dental light Dental Chair Dental Carts Handpieces Low-Speed handpiece Scalers Tubings Light curing units Instruments and Items Used in Treatment Amalgam pluggers Amalgam carving instruments Burs: Fissure Surgical Bur blockS Condensers Dappen dishes Endodontic instruments Explorer Fluoride gel trays Glass Slabs Hand instruments Mirrors Mouth props Napkin chain Orthodontic pliers Polishing wheels and disks Prophylaxis cups Saliva evacuators, ejectors Scalpels Stones: Diamond Polishing Sharpening Surgical instruments Ultrasonic scaling tips Ó4 Classification and Proper Method of Decontaminating Dental Equipment, Instruments, Materials, and Some Commonly Used Items (continued) |TEM CLASSIFICATION METHOD OF DECONTAMINATION Rubber Dam Equipment Carbon steel clamps Metal frames Plastic frames Punches Stainless steel clamps Laboratory and Prosthetic Devices Articulators Blades and knives BOWIS CrOWns: Acrylic Porcelain Porcelain-fused to gold Cerestore Crucibles Dentures Impression trays Impressions: Alginate Polyvinyl Silicon Lathes: PanS Brushes Stones Wheels Prostheses, removable Stone Casts X-ray Equipment Bite tabs Collimating tube of X-ray Switches of X-ray X-ray holders 65 Management of Persons Exposed" to Blood Once an exposure has occurred, the blood of the individual from whom exposure occurred should be tested for hepatitis B Surface antigen (HBSAg) and antibody to human immunodeficiency virus (HIV antibody). Local laws regarding Consent for testing Source individuals should be followed. Testing of the source individual should be done at a location where appropriate pretest Counseling is available; posttest counseling and referral for treatment should be provided. Hepatitis B Virus Postexposure Management? AND THEN The SOUrce individual is found positive for HBSAg. The exposed worker has not been Vaccinated against hepatitis B. 1. The WOrker Should receive the vaccine series for hepatitis B. 2. The WOrker Should receive a single dose of hepatitis B immune globulin if it can be given within 7 days of exposure. The exposed worker has been Vaccinated against hepatitis B. The exposed worker should be tested for antibody to hepatitis B surface antigen (anti-HBS), and given one dose of vaccine and one dose of HBIG if the antibody level in the worker's blood sample is inadequate (i.e., * 10 SRU by RIA, negative by EIA). The SOUrCe individual is found negative for HBSAg. The exposed worker has not been Vaccinated against hepatitis B. The worker should be encouraged to receive hepatitis B vaccine. The exposed worker has been Vaccinated against hepatitis B. NO further action is needed. The SOUrce individual refuses testing or Cannot be identified. The exposed worker has not been Vaccinated against hepatitis B. 1. The WOrker Should receive the hepatitis B series. 2. HBIG administration Should be COnSidered On an individual basis When the source individual is known or suspected to be at high risk of HBV infection. The exposed worker has been Vaccinated against hepatitis B. Management and treatment of the exposed worker should be individualized. 1 Being "exposed to blood" means having blood, blood-contaminated saliva, or a blood-contaminated object come into contact with broken skin or mucous membranes, or pierce the skin as through a needlestick injury. 2 The information given in the table is based on recommendations in Guidelines for Prevention of Transmission of HIV and HBV to Health-Care and Public-Safety Workers. DHHS (NIOSH) Publication No. 89-107; Cincinnati, Ohio, February 1989. 66 Management of Persons Exposed" to Blood Once an exposure has occurred, the blood of the individual from whom exposure occurred should be tested for hepatitis B surface antigen (HBSAg) and antibody to human immunodeficiency virus (HIV antibody). Local laws regarding consent for testing source individuals should be followed. Testing of the source individual should be done at a location where appropriate pretest counseling is available; posttest counseling and referral for treatment should be provided. Human Immunodeficiency Virus Postexposure Management? THEN AND The SOUrce individual has AIDS. OR The SOurce individual is positive for HIV infection. OR The SOUrce individual refuses to be tested. 1. The exposed worker should be COUnSeled about the risk of infection. 2. The exposed worker should be evaluated clinically and serologically for evidence Of HIV infection as SOOn as possible after the exposure. 3. The exposed worker should be advised to report and seek medical evaluation for any febrile illness that occurs within 12 weeks after the exposure. 4. The exposed worker should be advised to refrain from blood donation and to use appropriate protection during sexual intercourse during the follow-up period, especially the first 6-12 weeks after exposure. An exposed worker who tests negative initially should be retested 6 Weeks, 12 Weeks, and 6 months after exposure to determine Whether transmission has OCCurred. The SOurce individual is tested and found Seronegative. Baseline testing of the exposed worker with follow-up testing 12 weeks later may be performed if desired by the worker or recommended by the worker's health care provider. The SOurce individual Cannot be identified. Decisions regarding appropriate follow-up should be individualized. Serologic testing ShOuld be done if the WOrker is COncerned that HIV transmission has OCCurred. 1 Being “exposed to blood" means having blood, blood-contaminated saliva, or a blood-contaminated object come into contact with broken skin or mucous membranes, or pierce the skin as through a needlestick injury. 2 The information given in the table is based on recommendations in Guidelines for Prevention of Transmission of HIV and HBV to Health-Care and Public-Safety Workers. DHHS (NIOSH) Publication No. 89-107; Cincinnati, Ohio, February 1989. 67 Log of Sterilization Tests Date Of Sterilizer Date Results Results Actions Taken/Remarks Test Tested Received 68 Řšķ &.* ¿× 、 &&&& A™) ✉ ₪ R : |× §§§ şºx}}--· §$$$$$·ŠĶſ，-- -*-sae， ž.š.-§§:$$$$$ģ&&3&&ğ* -§ ^&&&|- && $§. & № && && $ $$$$$$$$$$$$$$$$$$$$- ¿? >§§§§§§§§-·-- --~~~~ ·-·ş z- -.* ‘’*'.xx§§§, * 3. §§§）.5;&& -（* * *^$%&&. ，-§ :¿??¿:: 3. §§&&-;...}}:$------·ģķğģ&& $$$$$§§§$$$$$$$ģĞ 、、。}-§§ §§§§};; “¿- -%&ş:33, * ;·|-----.*¿¿.* * … ►--- && ！ ;$$$$$$ -&& 、。 .*-º £3.-ķ} ×?§§ §§- % %: $$$$$$$（'.';} |- & && §§ $$$$$- §§§§-§§,‘; $ $ $$$$$;': , & ' ?... - < … --§... ;&→---→·: z.- -|--|-- -· 69 Answers to the questions on page 4. 1. 2. 3 5 The major occupational health hazard for dentists and other dental health care workers is hepatitis B. You can become infected with a bloodborne virus if the blood of an infected person gets into your bloodstream, for example, by sticking yourself with a used needle. . A member of the general population has a lifetime risk of 3% to 5% of becoming infected with hepatitis B virus (HBV). If you are not immune and you stickyourself with a needle contaminated with the blood of someone infected with HBV, your chances of becoming infected from that exposure range from 6% to 30%. A dentist has at least one chance in four (25%) of becoming infected with HBV during a lifetime career. . Immunization is the most effective method available for reducing transmission of the hepatitis B virus. HIV is most commonly spread through sexual contact and sharing needles. 6. In 1988, a health care worker who was accidentally stuck with a needle contaminated with the blood of an AIDS patient had less than a 1% chance (0.5%) of becoming infected with HIV. Routine testing of dental patients for antibodies to HIV may not be recommended for the following reasons: • The test tells a person's status only at the time the blood is drawn, and the status can change at any time. A person who is tested during the period between being exposed and the development of antibodies will test negative, but still may be able to transmit the virus. Negative test results can give a false sense of Security leading to an increased chance of becoming infected with a number of bloodborne diseases. Testing will significantly increase the cost of dental services without significantly reducing the risk of infection. • The test results are not available immediately. More than one visit is required. • In most states, testing for HIV without consent may not be permitted by law. Therefore, it makes most sense to handle the blood of every patient as if it contains infectious microorganisms. 7O Answers to the exercise on page 20. Compare your answers with ours. If you missed any, go back and review the section where that information is discussed. What protective coverings, if any, should you wear while 1. Polishing a patient's teeth? X Gloves X Glasses/goggles or face shield X Mask or face shield X Uniform or gown/coat over street clothes __NOne needed 2. Doing an oral soft tissue exam? X Gloves Glasses/goggles or face Shield Mask Or face Shield X Uniform or gown/coat over street clothes NOne needed 3. Suctioning while a tooth is being prepared? X Gloves X Glasses/goggles or face shield X Mask or face shield X Uniform or gown/coat over street clothes NOne needed 4. Taking a patient's medical history? Gloves Glasses/goggles or face Shield Mask Or face Shield X Uniform or gown/coat over street clothes” X None needed” *Although no protective Covering is needed, you would probably wear your uniform, or a gown or coat over your street clothes, because you would not change out of these just to take a medical history. 7| Answers to the questions on page 41. 1. 2. Cleaning is the first step in every decontamination process. The three levels Of disinfection are • high-level disinfection • intermediate-level disinfection • |OW-level disinfection , a. Sterilization kills all microorganisms present on the object Sterilized (every one of every kind of microorganism). b. High-level disinfection kills every kind of microorganism, including Some Spores, but cannot kill large numbers of Spores. Instruments that will touch bone or penetrate tissue are classified as critical. They must be Sterilized. Instruments and equipment that will touch mucous membranes but will not touch bone or penetrate tissue are classified as semicritical. They should be sterilized if possible. If they cannot be sterilized, high-level disinfection should be used to decontaminate them. DECONTAMINATION |TEM CLASSIFICATION PROCESS FORCEPS USed to extract teeth Critical Sterilization BUR used to reshape bone Critical Sterilization AMALGAM CONDENSER Semicritical Sterilization or high-level disinfection GLASS SLAB used in mixing cement nonCritical cleaning alone if not visibly COntaminated With blood 72 Answers to questions on page 45. 1. 3. The four methods used in dentistry to sterilize instruments and equipment are • Steam under pressure (steam autoclave) • Dry heat • Chemical under pressure (chemical autoclave) • An EPA-registered "disinfectant/sterilant” Disadvantages to using a “disinfectant/sterilant” for sterilization are • It has a limited Shelf life. • It is expensive in the long run. • It Cannot be Checked for effectiveness. • Its toxic fumes require special ventilation. • Its use requires that protective clothing be worn. • It cannot be used with packaged items. • It must be rinSed Off With Steriſe Water • It may rust instruments. If a package of Sterile instruments is torn, you should package and sterilize them again. 4, 5, and 6. If you answered "no" to any of these questions, you may not be sterilizing properly Answers to questions on page 47. 1. The four methods of sterilization that are commonly used in dentistry are • Steam under pressure (Steam autoclave) • dry heat • Chemical vapor under pressure (chemical autoclave) • an EPA-registered “disinfectant/sterilant” Compare your answer about the method(s) used in your office with what others on your Cental team anSWered. . The manufacturer's instructions will tell you the propertime, temperature, and pressure to use when sterilizing items in a heat sterilizer Be sure to follow them exactly . Sterilization methods that use heat are preferred because they can be checked with a spore test to see whether they do sterilize. 4. Cleaning is the first Step in Sterilization and in high-, intermediate-, and low-level disinfection. 5. If a noncritical surface is not contaminated with blood, cleaning alone is all that is needed to decontaminate it. If you choose, you can also wipe or spray a solution of an EPA-registered "hospital disinfectant” on the cleaned surface, but this may not be necessary. Allow the surface to air dry If a noncritical surface is contaminated with blood, the following decontamination procedure is needed: • Remove blood and other visible contamination with a paper towel or moist cloth. • Clean the surface well with detergent and water • Wipe or Spray the surface with a solution of bleach or of a liquid chemical germicide registered with the EPA as a tuberculocidal "hospital disinfectant.” Allow surface to air dry 73 Answers to questions on page 59. 1. 10. 11. 12. 13. The hepatitis B virus (HBV) is the bloodborne microorganism you should be most con- cerned about becoming infected With at Work. . The four principles for infection control are: • Take action to Stay healthy • AVOid COntact With blood. • Limit the spread of blood. • Make objects safe for use. . You should wear household-type utility gloves when Washing instruments and cleaning equipment and environmental Surfaces. . You should rub your lathered hands together for at least 10 Seconds when you are Washing your hands and they are not especially dirty . You should wear disposable vinyl or latex examination gloves whenever you put your hands into any patient's mouth when sterility is not required. . If you tear a glove during treatment you should • remove your gloves immediately • Wash your hands thoroughly with Soap and Water • put on a new pair of gloves You should wear facial protection whenever blood or Saliva contaminated with blood may be Spattered. . Three ways to minimize spatter during patient treatment are by using • a rubber dam • high-velocity evacuation • proper patient positioning . A biopsy specimen should be packaged in a Sturdy leakproof container and its lid Sealed securely before the specimen is sent to a laboratory; if the outside of the container becomes visibly soiled during the collection procedure, the container Should be cleaned and then disinfected using an EPA-registered tuberculocidal “hospital disinfectant” before it is sent. When handling extracted teeth you should wear gloves and be careful not to contaminate any area with blood from the teeth; you should dispose of them with other Solid medical WaSte. Contaminated Sharp items, blood, oral tissues, and extracted teeth Should be considered infective Waste. You should empty a suction trap into a drain or toilet that is connected to a Sanitary Sewer System. DeContamination includes • Cleaning • Sterilization • disinfection 74 14. 15. 16. 17. Sterilization kills all microorganisms. The three levels Of disinfection are • high-level disinfection • intermediate-level disinfection • |OW-level disinfection The “rules” for choosing the right decontamination process are • Sterilize all instruments that will penetrate tissue or come into contact with bone (critical instruments) and all instruments not damaged by heat that will touch mucous membranes (semicritical instruments) • Use high-level disinfection on semicritical instruments that are damaged by heat • Use intermediate- or low-level disinfection on equipment and surfaces that will come into contact only with intact skin The label of a chemical that is used for high-level disinfection should show • An EPA registration number • An EPA establishment number • That it is sporicidal • That it is an EPA-registered "disinfectant/sterilant” 75 PUG 5 2. , I 33 14.9% AIDS Understanding What Do You Really Know About AIDS? Are You At Risk? AIDS And Drugs. IDS is a serious health problem. It is important that we all understand this disease. AIDS stands for acquired immunodeficiency syndrome. It is a disease caused by the Human Immunodeficiency Virus, HIV — the AIDS virus. The AIDS virus may live in the human body for years before it shows. It makes you unable to fight other diseases. These other diseases can kill you. Many people feel that only certain “high risk groups” of people are infected by the AIDS virus. This is untrue. Who you are has nothing to do with whether you are in danger of being infected with the AIDS virus. What matters is what you do. People are worried about getting AIDS. Some should be worried and need to take some serious precautions. But many are not in danger of contracting AIDS. HOW DO You Get AIDS? Tº are two main ways you can get AIDS. First, you can become infected by having sex — oral, anal, or vaginal — with some- one who has already been infected with the AIDS virus. Second, you can be infected by sharing drug needles and syringes with an infected person. Babies of women who have been infected with the AIDS virus may be born with the infection because it can be transmitted from the mother to the baby before or during birth. What Behavior Puts You At Risk? Y ou are at risk of being infected with the AIDS virus if you have sex with someone who is infected, or if you share drug needles and syringes with someone who has been infected by the AIDS virus. Since you can’t be sure who is infected, your chances of coming into contact with the virus increase with the number of sex partners you have. Any exchange of infected blood, semen, or vaginal fluids can spread the virus and place you at great risk. RISKY BEHAVIOR Sharing drug needles and syringes. Anal sex, with or without a condom. Vaginal or oral sex with someone who shoots drugs or engages in anal sex. Sex with someone you don’t know well (a pickup or prostitute) or with someone you know has several sex partners. Unprotected sex (without a con- dom) with an infected person. SAFE BEHAVIOR Not having sex. Sex with one mutually faithful, uninfected partner. Not shooting drugs. This sheet has been prepared by the United States Government. I feel it is important that you have the best information now available for fight- ing the AIDS virus, -> * a health problem that the President has called “Public Enemy Number One.” Stopping AIDS is up to you, your family, and your loved ones. – C. Everett Koop, M.D., Sc.D. Surgeon General How Do You Get AIDS From Sex? Tº AIDS virus can be spread by sexual intercourse whether you are male or female, heterosexual, bisexual, or homosexual. This happens because a person infected with the AIDS virus may have the virus in semen or vaginal fluids. The virus can enter the body through the vagina, penis, rectum, or mouth. Anal intercourse, with or without a condom, is risky. The rectum is easily injured during anal intercourse. Remember, AIDS is passed on through sex, and the AIDS virus is not the only infection that is passed through intimate sexual COntact. Other sexually transmitted diseases, such as gonorrhea, syphilis, herpes, and chlamydia, can also be caught through oral, anal, and vagi- nal intercourse. If you should be infected with one of these diseases, you are at greater risk of becoming infected with the AIDS virus. This fact sheet has been prepared by the Surgeon General and the Centers for Disease Control, U.S. Public Health Service. The Centers for Disease Control is the government agency responsible for the prevention and control of diseases, including AIDS, in the United States. Drugs And AIDS Tºº, in some cities, the sharing of drug needles and syringes by those who shoot drugs is the fastest growing way that the virus is being spread. No one should shoot drugs. It can result in addiction, poor health, family and emotional prob- lems, and death. Many drug users are addicted and need to enter a drug treatment program as SOOn as possible. In the meantime, these people must avoid AIDS by not sharing any of the equipment used with illegal drugs. Sharing drug needles, even once, is a very easy way to become infected with the AIDS virus. Blood from an infected person can be trapped in the needle or Syringe, and then injected directly into the bloodstream of the next person who uses the needle. Other kinds of drugs, including alcohol, can also cause problems. Under their influence, your judgment becomes impaired. You could be exposed to the AIDS virus while doing things you would not otherwise do. For information about drug abuse treatment programs, contact your physician, local public health agency, or community AIDS or drug assistance group. What About Condoms? F or those who are sexually active and not limiting their sexual activity to One partner, condoms have been shown to help prevent the spread of sexually transmitted diseases. That is why the use of condoms is recommended to help reduce the spread of AIDS. Condoms are the best measure against AIDS besides not having sex and practicing safe behavior. But condoms are far from being foolproof. You have to use them properly. And you have to use them every time you have sex, from start to finish. If you use a condom, you should remember are a man who h of these things these rules: (l) Use condoms made of latex rubber. Latex serves as a barrier to the virus. “Lambskin” or “natural membrane” condoms are not as good because of the pores in the material. Look for the word “latex” on the package. (2) A condom with a spermicide may help protect you. Spermicides have been shown in laboratory tests to kill the virus. Use the spermicide in the tip and outside the condom. (3) Condom use is safer with a lubricant. Check the list of ingredients on the back of the lubricant package to make sure the lubricant is water-based. Do not use petroleum-based jelly, cold cream, baby oil, or cooking shorten- ing. These can weaken the condom and cause it to break. AIDS And Babies n infected woman can give the AIDS virus to her baby before it is born, or during birth. If a woman is infected, her child has about one chance in two of being born with the virus. If you are thinking of having a baby, and you might have been at risk of being infected with the AIDS virus, you should get counseling and be tested before you get pregnant. You must have a long talk with the person with whom you’re A M F. R. I C A R E S P O N D S T O A I DS planning to have a child. He or she needs to think hard and decide if an AIDS test might be a good idea. Talking With Kids About AIDS hildren hear about AIDS, just as we all do. But they don’t really understand it, so they become frightened. They are worried that they or their friends might get very sick and die. Children need to be told they can’t get AIDS from everyday contact in the classroom, cafeteria, or bathrooms. They don’t have to worry about getting AIDS even if one of their schoolmates is infected. Basic health education should be started as early as pos- sible. Local schools have the job of seeing that their students know the facts about AIDS. It is very impor- tant that middle school students — those entering their teens — learn to protect themselves from the AIDS virus. Children must also be taught what is right and wrong and how to resist pressure from their friends that might lead to risky behavior. These skills can be strengthened by religious and com- munity groups. However, the final duty is with the parents. As a parent, you should read and discuss this brochure with your children. YOUR DENTIST BECOMING LESS VISIBLE2?? NS7 #. ** sº &# :S)? º:3 fº S § S$ § r § S. §§ C SS A Message from your dentist Dentists dre becoming less Visiblell Are they hiding from something? No, not of dll . . .they're procticing the preventive dentistry of the 90's The Prevention of Disedse Tronsmission For the post 20 years you hove hedro the dentol profession folk dbout preventive dentistry. Then, dentists were usudlly referring to brushing dnd flossing, the use of fluorides, dnd pit dnd fissure Sedlonts. Toddy, dentistry is reexomining Woys to protect your hedlth through preventing disedSe frons- mission. Clednliness dnd proper sterilization techniques hove been d port of dentol proctices for mony yedrs, but recently d number of disedSe Orgon- isms hove mode these techniques more impor- font. We dre referring specificolly to the AIDS, hepotitis B, dnd herpes viruses. The dentol profession is extremely concerned dbout the possibility of disedse fronsmission dnd is moking severdl visible chdnges in the Woy dentol Services Cire provided. What Changes Are Being Made? 1. Dentists, hygienists, dnd dssistonts dre rou- finely wedring Surgicol gloves, eye gldSSes, ond mosks to prevent microorgonisms from being fronsferred. Using these dnd other methods con prevent fronsmission of micro- organisms thot moy occur through droplets spottered during dentol procedures. 2. Dentists dre using these some procedures for dll potients. 3. Dentol personnel dre being encourdged to become voccinoted dgoinst the hepotitis B Virus. 4. Dentists dre becoming more educated dbout the best methods to protect you, their volued potient. Are These Changes for the Profection of the Potient or f/he Denfish? BOTH! Everyone benefits from these sofeguards... Potients. . .FCInnilies. . . Denfo| Personnel. . .YOU! Will These Changes Incredise My Denfal Bills? The infection control techniques being used dre not costly dnd dred gredt volue considering the dmount of protection thot is provided. Most of these techniques hove been done in the dentol office for yedrs. Are These Changes Recommended by Major Hedlth Organizations? The Centers for DisedSe Confrol of the Public Hedlth Service, the Americon Dentol ASSociotion, stote bodros of hedlth, Schools of dentistry, dnd mony other hedlth dgencies dnd professional dssociotions dre strongly supportive of these IſleCISUſeS. What Can Patients Do To Help? At edch dentol visit help your dentist by report- ing dny chdnges in your hedlth stotus. This will help your dentist provide the best freqtment bosed on your hedlth needs. And if you wish to know more obout infection control issues your dentist should be dble to provide you with dClditiondſ informotion. For Further Information Confocf: Centers for DisedSe Control M600 Clifton Rodd, N.E. Atlanto, Georgid 30333 AmericOn Dentol ASSOCiCition 214 Edst Chicogo Avenue Chicago, Illinois 60614 Addpted with permission from d publication of the Division of Dentd. Hedlth, Indidnd Sfcite BOCrd of Hedlth by the Centers for Disedse Control HAVE YOU NOTICED . . . YOUR DENTIST BECOMING LESS VISIBLE2?? Rºssº - S º §§ Ç §§ s - | * W :. º A Message from your dentist Dentists dre becoming less Visiblell Are they hiding from something? No, not of dll . . .they're procticing the preventive dentistry of the 90's The Prevention of Disedse Tronsmission For the post 20 years you hove hedro the dentol profession folk dbout preventive dentistry. Then, dentists were usudlly referring to brushing dnd flossing, the use of fluorides, dnd pit dnd fissure SedlonfS. Toddy, dentistry is reexamining Woys to protect your hedlth through preventing disedse frons- mission. Cleonliness dnd proper sterilizdfion techniques hove been d port of dentol proctices for mony yedrs, but recently d number of disedse organ- isms hove mode these techniques more impor- font. We dre referring specifically to the AIDS, hepotitis B, dnd herpes viruses. The dentol profession is extremely concerned dbout the possibility of disedse fronsmission dnd is moking severdl visible chdnges in the woy dentol Services dre provided. What Changes Are Being Made? 1. Dentists, hygienists, dnd dssistonts dre rou- finely wedring surgicol gloves, eye glosses, ond mosks to prevent microorgonisms from being fronsferred. Using these dnd other methods con prevent fronsmission of micro- organisms thof mdy occur through droplets Spoffered during denfol procedures. 2. Dentists dre using these some procedures for oll potients. 3. Dentdl personnel dre being encourdged to become voccinoted dgClinst the hepatitis B Virus. 4. Dentists dre becoming more educated dbout the best methods to protect you, their Volued potient. Are These Changes for the Profection Of the POIfienf Or he Denfisf? BOTH! Everyone benefits from these Sofegudrds... PCitients. . .FCImilies. . . Denfo| Personnel. . .YOU! Will These Changes Incredise My Denfal Bills? The infection control techniques being used dre not costly dmd dred gredt volue considering the dmount of protection thot is provided. Most of these techniques hove been done in the dentol office for yeors. Are These Changes Recommended by Major Hedlth Organizations? The Centers for DisedSe Control of the Public Hedlth Service, the Americon Dentol ASSocidfion, stote boords of hedlth, Schools of dentistry, dnd mony other hedlth dgencies dnd professiondl dSSocidfions dre Strongly supportive of these ſhe CSU ſeS. Whdf Can Patients Do To Help? At edch dentol visit help your dentist by report- ing dny chdnges in your hedlth stdfus. This will help your dentist provide the best freqtment bosed on your hedlth needs. And if you wish to know more dbout infection control issues your dentist should be oble to provide you with CICICitionCll informotion. For Further Information Confo.cf: Centers for DisedSe COntrol M600 Clifton Rodd, N.E. Atlanto, Georgid 30333 Americon Denfol ASSOCiCition 214 Edst Chicogo Avenue Chicogo, Illinois 60614 Addpted with permission from d publication of the Division of Denfoi Hedlth, IndidnC, Stolte BOCrd Of Hedlth by the Centers for Disedse Control You moy be concerned thof potients Will CISk Guestions Cibout your new infection control proctices. We hove prepored the Offdched ledflet for them. We encourdge you to copy if dnd give it to them, whether they dSk Guestions or not. You will find thof they ore pledsed to know of your concern for their hedlth ond Sofety. How To Print More Copies Comerd-reddy copy for the leoflet is printed on the bock side of this sheet. Copy if on your office copier, ond then fold the sheets so thof they motoh the offdched leoflet. Or, for d more profes- SiOndl Cippedronce, hove C printer use the camera-ready copy on the back of this sheet to reproduce the leoflet. ſ If you provide CentOl Services, this brochure hCIS been Written for you. Whof iS AIDS? AIDS is the abbreviation for acquired immunodeficiency syndrome. With this disease, there is a defect in natural immu- nity. As a result, a person with AIDS becomes ill with diseases that would not be a threat to anyone whose immune system was functioning normally. Whof COUSeS AIDS? AIDS is caused by a virus that can infect certain cells of the immune system. It can also infect nerve cells in the brain and other parts of the central nervous system. This virus has been named the human immuno- deficiency virus (HIV). How do people get HIV infection? HIV infection has been spread by sexual contact and by needle sharing. Infected women have transmitted it to their infants during pregnancy or birth, and through breast feeding. Whot dre the symptoms of HIV infection? Persons infected with HIV may go for years without showing any symptoms. Even though they feel well, they are still at risk of developing AIDS, and can pass the virus to others. Symptoms of HIV infection may include tiredness, fever, loss of appetite and weight, night Sweats, diarrhea, and Swollen glands, usually in the neck, under the arms, or in the groin. When CCIn infection With HIV be defected? Blood tests can detect antibodies to HIV in 6 to 12 weeks after infection. After antibodies are detected, there may be no other indica- tion of infection for two or more years. Symptoms of HIV infection may appear 2 to 10 years or later after the time of infection. Each year after infection, an aver- age of 5% of adults who are infected have developed AIDS. No group of infected persons has been studied long enough to document how long risk persists or what percentage will eventually develop AIDS. How is AIDS didgnosed? The diagnosis of AIDS depends on the pres- ence of opportunistic diseases that indicate a loss of immunity. The presence of one or more opportunistic diseases, plus a blood test that detects antibodies to HIV, can establish a diagnosis of AIDS. Certain tests which can detect evidence of damage to certain parts of the immune system, such as special types of white blood cell tests, Sup- port the diagnosis. HOW is AIDS frected? No cure for AIDS is currently available, although some drugs have been found to inhibit the growth of the AIDS virus. One of these is zidovudine, formerly called azido- thymidine (AZT). An ultimately successful treatment for AIDS must eventually include three strategies: 1. Aggressive diagnosis and therapy for op- portunistic diseases 2 . Control of HIV infection and elimination of the Virus 3 . Restoration of the immune system and other organ systems damaged by HIV With AZT there has been Some Success in forestalling and controlling opportunistic diseases. No lasting success, however, has been documented with restoration of the immune and other organ Systems damaged by HIV. Are there ordl signs to HIV infection? Persons with deficient immune systems may be at high risk for infections from a variety of microorganisms. Figures 1-4 show the most common oral manifestations of HIV infection. The condition shown in Figure 4, hairy leukoplakia, presents as a raised white thick- ening of the tongue. It may be a precursor of AIDS in persons who are infected with HIV. Are there ony Specidl risks for me CIS C. Cienfol Worker? In 1988, health care workers who were Stuck with a needle contaminated with the blood of patients infected with HIV had less than a 1% (0.5%)* chance of becoming infected with HIV. Although your risk of becoming in- fected with HIV through your work is very low, you have a much higher risk (up to 30%) of becoming infected with hepatitis B virus (HBV). Whot con I do to reduce my occupdfiond risk of HIV? Protect yourself from coming into direct contact with blood. Apply the concept of universal precautions—that is, protect your- self from the blood of every patient, not just those you know or suspect are infected. Routinely wear gloves, eye glasses, and a mask when treating all patients. Avoid inju- ries with contaminated needles and scalpels. Read ‘Practical Infection Control for the Dental Office’’ in the Infection Control File. Specific practices for preventing the transmission of HIV are described in this workbook. *Centers for Disease Control. Update: Acquired Immu- nodeficiency Syndrome and Human Immunodeficiency Virus Infection Among Health-Care Workers. MMWR 1988:37:229-239 Should denfol potients be Screened for HIV? Routine testing of dental patients for anti- bodies to HIV is not recommended for the following reasons: • Although the presently available tests are Very accurate, they do not detect antibod- ies until 6-12 weeks after a person is infected. If a person is tested during that period, the infection will not be detected, but the person will still be able to transmit the virus. • Negative test results might give a false Sense of Security, causing you to become careless when exposed to blood. This might increase your chances of becoming infected with HIV, hepatitis B virus, or Some other bloodborne disease. • The test results are not available immedi- ately. More than one visit is required. • It is not practical to test a patient before every dental visit. The test can ascertain a person’s antibody status only at the time the test is done. A person who has not developed antibodies on the day of the test could become infected between the time of the test and the next dental appoint- 1Thent. • Testing will increase the cost of dental Services without significantly reducing the risk of infection. • In some States, screening for HIV infec- tion without appropriate counseling or consent may be restricted by statute or regulation. Whot should I do if q potient hos signs or symptoms of HIV infection Or AIDS? Patients with signs or symptoms should be handled like patients with any other undiag- nosed finding. The patient should be informed of what you have observed and be referred to a physician for definitive diagno- sis and treatment. Whot should I do if q potient does hove HIV infection or AIDS? You should be aware of the patient’s medical conditions and current medications. As with other patients who have serious medical conditions, you may wish to discuss planned dental procedures with the patient’s physi- Clan. Whot should I fell my potients? If patients ask about AIDS, tell them what it is, what causes it, and how it is transmitted. Describe the infection control practices you have in your practice. Point out what you and your staff are routinely doing to prevent the spread of infections, such as wearing gloves, eye glasses, and masks when per- forming dental procedures. The Infection Control File contains two leaf- lets for patients which you may find useful. One is on infection control practices used in dentistry; the other is on AIDS and HIV infections. Where con I get more informotion on AIDS? You and your patients can call the AIDS national toll-free Information Line: 1-800- 342-AIDS. It is answered 24 hours a day, 7 days a week. Spanish-speaking persons can call 1-800-344-SIDA. Persons who are deaf can call 1-800-AIDS-TTY. These toll-free telephone numbers are sponsored by the U.S. Public Health Service, Centers for Disease Control. Figure M Condidiosis Figure 2 Kaposi's sorcoma Figure 3 Chronic herpetic gingivostomatitis Figure 4 Hoiry leukoplakia U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE Centers for DisedSe Control Food dnd Drug Administration December 1989 HEPATO B A MAJOR HEALTH RISK |N DENTISTRY i Whot is hepatitis B? Hepatitis B is one type of inflammation of the liver which is sometimes called serum hepatitis because it is transmitted by blood or serum. It is caused by the hepatitis B virus (HBV). How Serious is hepotitis B? Infection with hepatitis B virus is a major health problem—major both in terms of the consequences of infection and number of persons who become infected. In the United States, about 300,000 people become in- fected with HBV every year. About 10% become chronic carriers of the virus. These chronic carriers may eventually develop liver disease and cancer. In fact, except for to- bacco, HBV causes more cancer worldwide than anything else we know about. About 80% of all liver-cell cancer is a result of infection with HBV. HOW is infection with hepotitis B spredd? The hepatitis B virus (HBV) is usually trans- mitted during an activity in which there is contact with blood, as when drug users share needles; contact with Semen, as during sex- ual intercourse; or at birth, from infected women to their infants. Health care workers, including those who work in dentistry, can also become infected when they are exposed to an infected pa- tient’s blood. Are there ony Specidl risks for me CIS C. Cienfo| Worker? Dental workers are three to five times more likely to become infected with HBV than most people. Studies have shown that den- tists have at least one chance in four of becoming infected before they retire; oral surgeons are even more likely to become infected. Dental hygienists, assistants, and laboratory technicians also have higher rates of infection with HBV than the general public. Even a Secretary in a dental office who occasionally helps with patient treat- ment is more likely to become infected than a member of the general population. Why is my risk of HBV infection So gredf? HBV is present in extremely large numbers in the blood of an infected person and can Survive in dried blood for a number of days. For this reason, a drop of blood containing HBV can transmit infection to you much more easily than a drop of blood infected With other bloodborne viruses, such as those that cause other types of hepatitis and AIDS. HOW CCIn become infected from d potient? Your greatest risk of infection in your work is from Sticking or cutting yourself with a needle, Scalpel, or other sharp instrument that has been contaminated by the blood of an infected patient, or by spattering infected blood into your mouth, nose, or eyes. Stud- ies show that up to 30% of health care workers who stick themselves with sharp items contaminated with HBV become infected themselves. Your most frequent exposure to HBV, however, is probably by getting patient blood on cuts and cracks on your ungloved hands. Would I know if I become infected? Not necessarily. Only 30% of the people with hepatitis B develop jaundice. You can become infected without becoming ill. Very likely, your symptoms would be mild and common to flu; headache, slight fever, mild gastrointestinal upset, or general fatigue. If you become infected with HBV, you (like everyone who becomes infected) have a l in 10 chance of becoming a chronic carrier. Also, if infected you may transmit the infec- tion to your spouse, because Semen and vaginal fluids can also transmit the infection. If | become infected, could | poss it on to d potient? Yes. You could transmit the infection with- out even being aware that you were infected. There are more opportunities, however, for the transmission to occur in the other direc- tion: from the patient to you. HOW CCIn reduce my chonces of becoming infected With HBV'? =l ||||||I|| H Immunization is your best profection. Everyone who works in d denfal hedlth care setting should be immunized. There are two vaccines. One derived from plasma and one from yeast. Studies have shown that both are safe and highly protec- tive. Either can be used. Three doses, given in the arm, are needed to produce immunity: an initial dose followed by a second dose month later, and a third dose 5 months after the Second. You must have all three doses for lasting immunity. Your physician can Vaccinate you against HBV and tell you whether you should have any follow-up or booster doses. If you haven't already had hepatitis B or been Vaccinated, make an appointment today. Whof else CCIn | CO to reduce my occupotionol risk Of HBV2 Protect yourself from coming into direct contact with the blood of your patients. Use universal precautions—that is, protect your- self from the blood of every patient, not just those you know or suspect are infected. Routinely wear gloves, eyeglasses, and a mask when treating all patients. Avoid inju- ries with contaminated Sharp instruments Such as needles and scalpels. If I get the voccine, Should | Still be COncerned dbout hepotitis B? Yes. Even if you are immune to HBV, you can still carry the infection from one patient to another on your hands or on instruments or other items contaminated with blood. Avoid contact with blood, and use the infec- tion control methods recommended in the Workbook, Practical Infection Control for the Dental Office’’ in the Infection Control File. Where con I get more informotion on hepotitis B? Two excellent sources for additional information are © The most recent Hepatitis Surveillance Report from the Centers for Disease Control, Atlanta, Georgia 30333 • The pullout from the April 1985 issue of the Journal of the American Dental ASSOciation U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE Centers for DisedSe Control Food dnd Drug Administration December 1989 PL/3 KK & Z. Tº 3 | 734 If you provide services to dental patients. . . --~~~. All-P-A-S- You need to know the answers to these questions: injured with an instrument that is contaminated with blood? Why is infection control 6. How can you reduce your risk essential for you and your of injury from contaminated patients? needles and sharp items? . How can you protect yourself 7. How should you dispose of and your patients from dental waste materials? diseases that could be spread during dental treatment? 8. As a dental health care Worker, are you at risk of . Why should you avoid direct becoming infected with the contact with blood? human immunodeficiency virus (HIV)? . What bloodborne micro- organism should you be most 9. What is your most effective concerned about becoming protection against the infected with at Work? hepatitis B virus? . What should you do if you are 10. What precautions should you take when treating all patients? To learn the answers to these questions, as well as information on infection control principles . . . l Practical infection Control in the Dental office i|> Read the material in the Infection Control File. To learn about your disease risks, read the brochures: • ‘‘Hepatitis B: A Major Health Risk in Dentistry” O ‘‘What About AIDS?’” To learn how to reduce the risk of diseases being transmitted to your Operatory, Read the workbook “Practical Infection Control for the Dental Office.’’ If you want to know more Scientific detail about your disease risks and the recommendations for reducing them, Read the reprints of scientific articles included in the Infection Control File. And to remind yourself and other members of the dental team to follow the recommended infection control practices, Post the wallcharts where you can refer to them easily. Steps in Heat Sterilization 1. PACKAGE CLEANEO ITEMS. • If possible, wrap or package everything that must be kept sterile and that will not be used immediately. Put a heat-sensitive process indicator on each pack and each unwrapped item to verify that they have been processed. • Write the date of processing on the process indicator 2. PROCESS ITEMS. Load the sterilizer so that hot air, steam, or chemical vapor will be able to circulate freely around every item or pack. Bring the sterilizer up to the temperature recommended by the manufacturer. Allow time for all parts of the load to reach that temperature, and then process for the recom. mended time. 3 STORE STERILIZED ITEMS If any unwrapped items will not be used Immediately, wrap them in sterile packaging (or sterile toweling) before storing • Keep sterilized items wrapped until they are used. Store the packages where they will not become torn or wet. If a package does become punctured, torn, or wet. repackage the contents and sterilize them again, Infection Control File Developed By U.S. Department of Health and Human Services Centers for Disease Control (CDC) Center for Prevention Services (CPS) Public Health Practice Program Office (PHPPO) Food and Drug Administration (FDA) Center for Devices and Radiological Health Acknowledgements Instructional design and development: Betty S. Segal, Division of Media and Training Services, PHPPO, CDC Technical development: Walter W. Bond, Jr., M.S., Hospital Infections Program, Center for Infectious Diseases, CDC Mary Beth Kinney, R.D.H., M.P.H., Dental Disease Prevention Activity, CPS, CDC Margaret I. Scarlett, D.M.D., Dental Disease Prevention Activity, CPS, CDC Technical direction: Lawrence J. Furman, D.D.S., M.P.H., Dental Disease Prevention Activity, CPS, CDC Technical consultation and review: Betty A. Ballinger, Dental Disease Prevention Activity, CPS, CDC David M. Bell, M.D., Center for Infectious Diseases, CDC Peter D. Drotman, M.D., M.P.H., Center for Infectious Diseases, CDC Jerre E. Jensen, Center for Devices and Radiological Health, FDA Lireka P. Joseph, Dr.P.H., Center for Devices and Radiological Health, FDA Mark A. Kane, M.D., M.P.H., Center for Infectious Diseases, CDC Jacquelyn A. Polder, B.S.N., M.P.H., Center for Infectious Diseases, CDC Gary West, M.P.A., AIDS Program, CPS, CDC Technical review panel: James J. Crawford, M.A., Ph.D., University of North Carolina Col. Bruce Matis, D.D.S., M.S., USAF, Brooks Air Force Base, San Antonio John A. Molinari, Ph.D., University of Detroit School of Dentistry Elizabeth Ochoa, M.A.T., Medical University of South Carolina U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE Centers for DisedSe Control Food ond Drug Administration December 1989 CENTERS FOR DISEASE CONTROL June 19, 1987 / Vol. 36 / No. 23 353 ACIP: Update on Hepatitis B Prevention 366 Nutritional Status of Minority Children — United States, 1986 370 Premature Mortality Due to Congenital Anomalies — United States, 1984 371 Self-Study Training Offered by CDC MORBIDITY AND MORTALITY WEEKLY REPORT Recommendations of the Immunization Practices Advisory Committee Update on Hepatitis B Prevention INTRODUCTION Hepatitis B virus (HBV) infection is a major cause of acute and chronic hepatitis, cirrhosis, and primary hepatocellular carcinoma in the United States and worldwide. Since 1982, a safe and effective hepatitis B (HB) vaccine manufactured from human plasma has been available in the United States. This vaccine has been recommended as preexposure prophylaxis for persons at high or moderate risk of HBV infection (1). In addition, the combination of HB vaccine and hepatitis B immunoglobulin (HBIG) has been recommended for postexposure prophylaxis in susceptible persons who have perinatal or needle-stick exposure to known HBV-positive persons or their blood. This statement provides an update on HB vaccine usage and on its impact on disease incidence in the 5 years following its licensure. In addition, it provides both recommendations for using a new HB vaccine produced in yeast by recombinant DNA technology and an assessment of the need for HB vaccine booster doses for persons who have received the initial three-dose regimen. Basic recommendations on preexposure and postexposure usage of HB vaccine and on prevaccination serologic testing for susceptibility to hepatitis B are unchanged. Previous recommendations should be consulted for a complete discussion of the usage of HB vaccine (1). PLASMA-DERIVED HB VACCINE Patterns of Usage to Date Since the plasma-derived HB vaccine became available in June 1982, 4,400,000 doses have been distributed in the United States, and an estimated 1,400,000 persons have completed the three-dose series (Merck Sharp & Dohme, unpublished data). During this 5-year period, vaccination programs and overall vaccine usage have focused primarily on three risk groups—persons who work in health-care professions and have exposure to blood, staff and clients of institutions for the developmentally disabled, and staff and patients in hemodialysis units. Although no precise figures are available, it is estimated that more than 85% of distributed vaccine has been used for these groups. Development of vaccination programs for health-care workers has progressed steadily since vaccine licensure. Several surveys of hospitals in 1985 showed that U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES / PUBLIC HEALTH SERVICE 354 MMWR June 19, 1987 ACIP: Hepatitis B – Continued between 49% and 68% of hospitals had established HB vaccination programs and that the number has increased steadily each year (CDC, unpublished data). Large hospitals (>500 beds) were most likely to establish programs (90%). However, by June 1985, 60% of hospitals with fewer than 100 beds also had begun vaccination programs. In 75% of the programs, vaccination was recommended for high-risk health-care workers (as defined by the hospital), and, in 77%, the hospital paid for these vaccinations. In addition, 70% of states had established programs for vaccinating health-care workers under state jurisdiction (CDC, unpublished data). In spite of these programs, the actual use of vaccine in high-risk health-care professions has been modest. One statewide survey showed that, in hospitals with HB vaccine programs, only 36% of persons at high risk had actually received vaccine (CDC, unpublished data). In one survey in three large cities, only 24% of physicians had received vaccine (CDC, unpublished data). National surveys have shown higher rates of vaccination among dentists (44% in early 1986) and hemodialysis staff (an estimated 44% in 1985); however, even these rates fall well short of optimal coverage (CDC, unpublished data). Development of vaccination programs has also progressed for several other groups at high risk of HBV infection. By mid-1985, 94% of states had established vaccination programs for the developmentally disabled in institutions under state jurisdiction, and 75% had programs for staff of such facilities (CDC, unpublished data). By 1986, an estimated 27% of the developmentally disabled had received HB vaccine (Merck Sharp & Dohme, unpublished data). In addition, wide-scale programs directed at vaccinating all susceptible persons were established in 1981 for Alaskan Natives and in 1985 for the population of American Samoa. Nevertheless, there has been little progress in developing vaccination programs for other major risk groups, including parenteral drug abusers, homosexual men, and heterosexually active persons with multiple sexual partners. Few states have estab- lished programs for offering vaccine to any of these groups, and private usage of vaccine among these groups is believed to be limited. Impact on Disease Incidence The incidence of reported hepatitis B has increased steadily over the last decade. Hepatitis B is now the most commonly reported type of hepatitis in the United States. In 1978, 15,000 cases of clinical hepatitis B were reported to CDC, for an incidence rate of 6.9/100,000 population. At that time, CDC estimated that there were actually 200,000 persons with HBV infection and that 50,000 of these had clinically confirmed cases with jaundice. The incidence rate of reported disease increased 33%, to 9.2/100,000, in 1981, the year prior to vaccine availability. It continued to increase during the initial 4 years of vaccine availability, reaching a rate of 11.5/100,000 in 1985 (2). Based on a comparison with the overall infection rate estimated in 1978, the incidence of HBV infection in the United States is now estimated at over 300,000 cases per year. The apparent lack of impact of HB vaccine on the incidence of hepatitis B is attributable to several factors. First, the majority of acute hepatitis B cases now occur in three groups: homosexual men, parenteral drug abusers, and persons acquiring disease through heterosexual exposure (3). None of these groups is being reached effectively by current HB vaccine programs. In contrast, fewer than 10% of cases occur in health-care workers, the institutionalized developmentally disabled, and other groups currently accounting for the bulk of vaccine usage. Finally, up to 30% of Vol. 36 / No. 23 MMWR 355 ACIP: Hepatitis B – Continued patients deny any of the recognized risk factors, even after careful questioning. No effective strategy has been devised to prevent disease among this group, although some are probably undisclosed members of the three major risk groups. A reduction in the incidence of hepatitis B can be expected only if significant proportions of persons at high risk receive vaccine. Increased efforts are needed to develop programs to vaccinate persons in all high-risk groups and to increase compliance among those who are susceptible in areas where programs are estab- lished. To have any effect on the incidence of hepatitis B, use of HB vaccine in the United States must extend beyond the current groups of recipients. NEW RECOMBINANT DNA HB VACCINE Formulation In July 1986, a new, genetically engineered HB vaccine (Recombivax HB(B); Merck Sharp & Dohme) was licensed by the U.S. Food and Drug Administration. This vaccine, as formulated, has an immunogenicity comparable to that of the currently available plasma-derived vaccine (Heptavax B(B); Merck Sharp & Dohme). The two vaccines are also comparably effective when given with HBIG to prevent perinatal HBV transmission. The new vaccine provides an alternative to the plasma-derived HB vaccine for almost all groups at risk of HBV infection. The recombinant vaccine is produced by Saccharomyces cerevisiae (common baker's yeast) into which a plasmid containing the gene for the Hepatitis B surface antigen (HBSAg) subtype adv has been inserted (4). HBSAg is harvested by lysing the yeast cells and is separated from yeast components by hydrophobic interaction and size-exclusion chromatography. The purified HBSAg protein undergoes sterile filtra- tion and treatment with formalin prior to packaging. The vaccine is packaged to contain 10pg HBs.Ag protein per ml, adsorbed with 0.5 mg/ml aluminum hydroxide; a 1:20,000 concentration of thimerosal is added as a preservative. The recombinant HBs.Ag takes the form of 17-25 nm spherical particles, similar in appearance to human plasma-derived HBs.Ag. The recombinant particles differ in that the HBs.Ag is not glycosylated, whereas up to 25% of plasma-derived HBs.Ag is glycosylated. The vaccine contains more than 95% HBs.Ag protein. Yeast-derived protein can constitute up to 4% of the final product, but no yeast DNA is detectable in the vaccine. Immunogenicity and Efficacy The immunogenicity of the recombinant HB vaccine is comparable to that of the plasma-derived product (5). When given in a three-dose series (10pg per dose), recombinant HB vaccine induces protective antibodies (anti-HBs”) in over 95% of healthy adults 20–39 years of age. Studies comparing antibody responses of healthy adults show equal rates of seroconversion following the three doses of either the recombinant vaccine (10pg per dose) or the plasma-derived vaccine (20pg per dose). However, the geometric mean titers (GMT) of antibodies developed by recipients of the recombinant vaccine have ranged from equal to to 30% as high as those developed by recipients of the plasma-derived vaccine. The recombinant vaccine, like the plasma-derived vaccine, produces a somewhat lower antibody response in older adults than in younger adults (5). In studies using three 5-pºg doses of recombinant vaccine for children.<12 years of age, over 99% of the recipients have developed protective levels of antibodies. Hemodialysis patients develop a poorer response to the recombinant vaccine than do *Greater than 10 milli-International Units (ml U)/ml of anti-HBs, approximately equal to 10 sample ratio units by radioimmunoassay or positive by enzyme immunoassay. 356 MMWR June 19, 1987 ACIP: Hepatitis B – Continued healthy adults. For example, in one study using three 40-pºg doses of recombinant HB vaccine, only 64% of vaccine recipients developed protective levels of antibodies. The recombinant HB vaccine has been shown to prevent HBV infection of vaccinated chimpanzees challenged intravenously with HBV of either adv or ayr subtypes. In studies of infants born to HBSAg- and HBeAg-positive mothers, the combination of HBIG (0.5 cc at birth) and recombinant HB vaccine (5pg in each of three doses) protected 94% of infants from developing the chronic carrier state, an efficacy equalling that of HBIG plus plasma-derived HB vaccine (6). The simultaneous administration of HBIG did not interfere with induction of anti-HBs antibody response by the recombinant HB vaccine. There have been no large-scale efficacy trials of recombinant vaccine in adults. Nevertheless, the immunogenicity studies, the challenge studies using chimpanzees, and the efficacy trials of the HB vaccine and HBIG in infants born to mothers who are carriers of HBV strongly suggest that the efficacy of recombinant HB vaccine in adults is comparable to that of the plasma-derived product. Safety Because only the portion of the HBV viral genome that codes for the surface coat of the virus (HBSAg) is present in the recombinant yeast cells, no potentially infectious viral DNA or complete viral particles can be produced. No human or animal plasma or other blood derivative is used in the preparation of recombinant HB vaccine. During prelicensure trials, approximately 4,500 persons received at least one dose, and 2,700 persons completed the vaccine series (5). Reported side effects were similar in extent and variety to those following administration of the plasma-derived vaccine. Seventeen percent of those vaccinated experienced soreness at the injection site, and 15% experienced mild systemic symptoms (fever, headache, fatigue, and nausea). To date, no severe side effects have been observed, nor have significant allergic reactions been reported. Although yeast-derived proteins may constitute up to 4% of the protein in the vaccine, no adverse reactions that could be related to changes in titers of antibodies to yeast-derived antigens occurred during clinical trials. Early concerns about safety of plasma-derived HB vaccine, especially the concern that infectious agents such as human immunodeficiency virus (HIV) present in donor plasma pools might contaminate the final product, have proven to be unfounded (7). There are no data to indicate that the recombinant vaccine is potentially or actually safer than the currently licensed plasma-derived product. Dosage and Schedule The recombinant HB vaccine is given in a series of three doses over a 6-month period. The second dose is administered 1 month after the first, and the third dose, 5 months after the second. For normal adults and children.>10 years of age, the recommended dose is 10pg (1 ml) intramuscularly in each of the three inoculations. Children.<11 years of age should receive a 5-pig dose (0.5 ml) by the same schedule. Newborns of mothers who are carriers of HBs.Ag should receive the three-dose series (5pg per dose) by the same schedule; however, the first dose, which is given at birth, should be combined with a single dose of HBIG (0.5 ml) given intramuscularly at another site. The recommended dose of recombinant HB vaccine for hemodialysis patients or other immunosuppressed persons is 40p.g, which is identical to the dose of plasma- derived vaccine recommended for these groups. A specially formulated preparation Vol. 36 / No. 23 MMWR 357 ACIP: Hepatitis B – Continued (40pg HBSAg protein/ml adsorbed with 0.5 mg aluminum hydroxide) is being developed for these patients. At present, it is not advisable to administer the standard formulation of recombinant HB vaccine to these patients because this would require a large volume (4.0 cc), which is inconvenient for injection in the deltoid muscle, and would contain more aluminum hydroxide (2.0 mg) than currently recommended as an adjuvant in vaccines (1.25 mg per dose). Only plasma-derived vaccine should be used for these patients. As with plasma-derived vaccine, recombinant HB vaccine should only be given to older children and adults in the deltoid muscle and to neonates or infants in the anterolateral thigh muscle. The vaccine should be stored at 2C to 6 C (36 F to 43 F) and should not be frozen; freezing destroys the potency of this vaccine. The response to vaccination by the standard schedule using one or two doses of plasma-derived vaccine followed by the remaining doses of recombinant vaccine has not been studied. However, because the immunogenicities of the two vaccines are similar, it is likely that the response will be comparable to that induced by three doses of either vaccine alone. The response to revaccination with the recombinant vaccine following nonresponse to an initial series of plasma vaccine has not been evaluated. Indications for Use The indications for use of the recombinant HB vaccine are identical to those for the plasma-derived product, except that the present formulation of the recombinant HB vaccine should not be used for hemodialysis patients or other immunosuppressed persons (Table 1) (1). For other groups, including persons with Down's syndrome, there are no data indicating that the recombinant HB vaccine is either superior or inferior to the plasma-derived HB vaccine for any preexposure or postexposure indication. Precautions The recombinant HB vaccine contains only noninfectious HBSAg particles; there- fore, vaccination of a pregnant woman should entail no risk to either the woman or the fetus. Furthermore, HBV infection in a pregnant woman can result in severe disease for the mother and chronic infection of the newborn. Pregnancy should not be TABLE 1. Persons for whom hepatitis B vaccine is recommended or should be considered” Preexposure Persons for Whom vaccine is recommended: • Health-care workers having blood or needle-stick exposures Clients and staff of institutions for the developmentally disabled Hemodialysis patients Homosexually active men Users of illicit injectable drugs Recipients of certain blood products Household members and Sexual contacts of HBV Carriers • Special high-risk populations Persons for whom vaccine should be considered: • Inmates of long-term correctional facilities • Heterosexually active persons with multiple sexual partners • International travelers to HBV endemic areas Postexposure • Infants born to HBV positive mothers • Health-care workers having needle-stick exposures to human blood *Detailed information on recommendations for HB vaccination is available (1). 358 MMWR June 19, 1987 ACIP: Hepatitis B – Continued considered a contraindication for women in high-risk groups who are eligible to receive this vaccine. NEED FOR VACCINE BOOSTER DOSES Long-Term Protection by Plasma-Derived HB Vaccine In short-term efficacy studies, the plasma-derived HB vaccine provided protection against HBV infection for 85%-95% of vaccine recipients, including virtually all those who developed adequate levels of antibodies (see footnote on pg. 355) (8,9). A recent evaluation of the long-term protection afforded by this vaccine (>5 years) provides a basis for recommendations concerning the need for booster doses in previously vaccinated persons (10). Currently available data indicate that vaccine-induced antibody levels decline significantly (10). Antibody may decrease to low levels for 30%-40% of vaccinated adults who initially develop adequate levels of antibody during the 5 years after vaccination, and it may become undetectable in 10%-15% of them. The duration of antibody persistence is directly related to the peak level achieved after the third dose of vaccine (11). The longer persistence of detectable levels of antibody observed in children and young adults (<20 years of age) is consistent with the higher peak response in these age groups. - Studies of the licensed plasma-derived HB vaccine in adults have demonstrated that, in spite of declining levels of antibody, protection against clinical (or viremic) HBV infection persists for >5 years (10). Although the risks of HBV infection appear to increase as antibody levels become low or undetectable, the resultant infections are almost always innocuous and do not cause detectable viremia, liver inflamma- tion, or clinical illness. These infections are detected by serologic evidence of an increase of anti-HBs levels associated with the appearance of antibody to the hepatitis B core antigen (anti-HBc). To date, only one transient viremic infection has been recognized in a vaccine responder within 72 months after vaccination. This infection produced mild alanine aminotransferase elevation, but no clinical illness (10). Thus, among adults who have responded to the vaccine, protection against clinically significant HBV infection appears to outlast the presence of detectable anti-HBs and can persist for =2 years among vaccine recipients whose antibodies have declined to low or undetectable levels. For infants born to mothers who are carriers of HBV, there are insufficient data to assess duration of antibody persistence and protection against clinically significant HBV infection with the U.S. plasma-derived vaccine. One study, in a developing country (Senegal) and using a different plasma-derived HB vaccine, has demon- strated that protection against viremic HBV infection can decline within 6 years in infants vaccinated between 6 months and 2 years of age (12). Firm data on the duration of protection among infants receiving the vaccines licensed in the United States will be necessary before recommendations on booster doses can be made for this group. Postvaccination Testing of Response to Vaccine When properly administered, HB vaccine produces anti-HBs in more than 90% of healthy persons. Testing for immunity following vaccination has been recommended only for persons in whom suboptimal response to vaccine is anticipated, including persons who received vaccine in the buttock or persons, such as hemodialysis patients, whose subsequent management depends on knowing their immune status (1). Revaccination, which has produced adequate antibody in only 30%-50% of persons who have not responded to primary vaccination in the deltoid, is not routinely recommended (1,10). Vol. 36 / No. 23 MMWR 359 ACIP: Hepatitis B – Continued Vaccine program coordinators in hospitals may decide to test vaccine recipients serologically to assess their antibody responses, even though such postvaccination testing is not routinely recommended. Persons electing to do postvaccination testing should be aware of potential difficulties in interpreting the results. Serologic testing within 6 months of completing the primary series will differentiate persons who respond to vaccine from those who fail to respond. However, the results of testing undertaken more than 6 months after completion of the primary series are more difficult to interpret. A vaccine recipient who is negative for anti-HBs between 1 and 5 years after vaccination can be 1) a primary nonresponder who remains susceptible to hepatitis B or 2) a vaccine responder whose antibody levels have decreased below detectability but who is still protected against clinical HBV disease (10). There is no need for routine anti-HBs testing 1 to 5 years after vaccination unless there has been a decision to provide booster doses for persons who are anti-HBs negative. This strategy is medically acceptable, but costly, and will prevent few additional cases of disease because of the excellent long-term protection already provided by the primary series of vaccine. Recommendations for Booster Doses Adults and children with normal immune status. For adults and children with normal immune status, the antibody response to properly administered vaccine is excellent, and protection lasts for at least 5 years. Booster doses of vaccine are not routinely recommended, nor is routine serologic testing to assess antibody levels in vaccine recipients necessary during this period. The possible need for booster doses after longer intervals will be assessed as additional information becomes available. Hemodialysis patients. For hemodialysis patients, in whom vaccine-induced pro- tection is less complete and may persist only as long as antibody levels remain above 10 ml U/ml, the need for booster doses should be assessed by semiannual antibody testing (13). Booster doses should be given when antibody levels decline below 10 ml U/ml. Postexposure Prophylaxis of Persons Exposed to HBSAg Positive Needle Sticks In vaccinated persons who experience percutaneous or needle exposure to HBSAg- positive blood, serologic testing to assess immune status is recommended unless testing within the previous 12 months has indicated adequate levels of antibody. If the exposed person is tested and found to have an inadequate antibody level, treatment with HBIG and/or a booster dose of vaccine is indicated, depending on whether vaccination has been completed and whether the person is known to have previously responded to HB vaccine. Detailed recommendations on prophylaxis in this situation are provided in the previous recommendations for HB vaccine (1). Dosage When indicated, HB vaccine recipients can be given booster doses of either plasma-derived or recombinant HB vaccine. Booster doses of either vaccine induce prompt anamnestic responses in over 90% of persons who initially respond to vaccine but subsequently lose detectable antibody (14,15). The booster dose for normal adults is 20pg of plasma-derived vaccine or 10pg of recombinant vaccine. For newborns and children.<10 years of age, the dose is half that recommended for adults. For hemodialysis patients, a dose of 40p.g of plasma-derived vaccine is recommended; a formulation of recombinant HB vaccine is not yet available for this 360 MMWR June 19, 1987 ACIP: Hepatitis B – Continued group. Vaccine should be given in the deltoid muscle. Buttock injection does not induce adequate levels of antibody. Precautions Reported adverse effects following booster doses have been limited to soreness at the injection site. Data are not available on the safety of the vaccine for the developing fetus, but there should be no risk because both plasma-derived and recombinant HB vaccines are inactivated and do not contain live virus particles. Booster doses need not be withheld from pregnant women who are at ongoing risk of HBV infection. References 1. ACIP. Recommendations for protection against viral hepatitis. MMWR 1985;34:313-24, 329-35. 2. CDC. Annual summary 1984; reported morbidity and mortality in the United States. MMWR 1986;33(54); 125. 3. CDC. Hepatitis surveillance report no. 50. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, 1986:16-25. (Continued on page 366) TABLE 1. Summary — cases specified notifiable diseases, United States 23rd Week Ending Cumulative, 23rd Week Ending Disease June 13, June 7, | Median June 13, June 7, Median 1987 1986 1982-1986 1987 1986 1982–1986 Acquired Immunodeficiency Syndrome (AIDS) 493 148 N 7,947 5,437 N Aseptic meningitis 145 107 131 2,141 1,987 1,852 Encephalitis: Primary (arthropod-borne & unspec) 16 11 19 356 342 399 Post-infectious 6 8 4 42 54 49 Gonorrhea: Civilian 15,276 16,201 16,201 347,885 366,576 366,576 Military 273 257 437 7,238 6,922 9,414 Hepatitis: Type A 447 363 366 10,866 9,623 9,623 Type B 483 425 467 11,131 11,107 10,848 Non A, Non B 68 74 N 1,354 1,548 N Unspecified 44 64 129 1,404 2,124 2,405 Legionellosis 19 9 N 337 251 N Leprosy 2 8 7 92 125 118 Malaria 8 33 15 310 355 330 Measles: Total * 62 387 66 2,225 3,627 1,385 Indigenous 57 366 N 1,958 3,441 N Imported 5 21 N 267 181 N Meningococcal infections: Total 46 30 61 1,546 1,381 1,528 Civilian 46 30 61 1,545 1,379 1,513 Military - - - 1 2 6 Mumps 197 54 76 8,575 1,937 1,937 Pertussis 22 88 27 744 1,183 807 Rubella (German measles) 7 19 19 178 268 368 Syphilis (Primary & Secondary): Civilian 551 454 493 14,625 11,284 12,198 Military 2 1 4 78 90 152 Toxic Shock syndrome 8 2 N 133 156 N Tuberculosis 418 444 472 8,855 8,922 9,141 Tularemia 1 2 11 48 33 64 Typhoid Fever 4 4. 4 126 111 140 Typhus fever, tick-borne (RMSF) 26 31 32 113 140 159 Rabies, animal 94 111 120 2,238 2,509 2,509 TABLE ll. Notifiable diseases of low frequency, United States Cum. 1987 Cum. 1987 Anthrax - Leptospirosis 8 Botulism: Foodborne 3 Plague 2 Infant (Calif. 3) 23 Poliomyelitis, Paralytic -- Other - Psittacosis (Mich. 1) 42 Brucellosis (Iowa 1, Tenn. 1, Calif. 1) 47 Rabies, human - Cholera - Tetanus 13 Congenital rubella syndrome 3 Trichinosis 25 Congenital syphilis, ages < 1 year - Typhus fever, flea-borne (endemic, murine) 10 Diphtheria 1 rerºrs: reported cases for this week were imported from a foreign country or can be directly traceable to a KnOWF internationally imported case within two generations. 366 MMWR June 19, 1987 ACIP: Hepatitis B – Continued 4. Emini EA, Ellis RW, Miller WJ, McAleer WJ, Scolnick EM, Gerety R.J. Production and immunological analysis of recombinant hepatitis B vaccine. J Infection 1986; 13 (suppl A):3-9. 5. Zajac BA, West DJ, McAleer WJ, Scolnick EM. Overview of clinical studies with hepatitis B vaccine made by recombinant DNA. J Infection 1986; 13(suppl A):39-45. 6. Stevens CE, Taylor PE, Tong MJ, et al. Yeast-recombinant hepatitis B vaccine; efficacy with hepatitis B immune globulin in prevention of perinatal hepatitis B virus transmission. JAMA 1987;257:2612-6. 7. Francis DP, Feorino PM, McDougal S, et al. The safety of hepatitis B vaccine: inactivation of the Alſ)S virus during routine vaccine manufacture. JAMA 1986;256:869-72. 8. Szmuness W, Stevens CE, Harley EJ, et al. Hepatitis B vaccine: demonstration of efficacy in a controlled clinical trial in a high-risk population in the United States. N Engl J Med 1980;303:833-41. 9. Francis DP, Hadler SC, Thompson SE, et al. The prevention of hepatitis B with vaccine: report of the Centers for Disease Control multi-center efficacy trial among homosexual men. Ann Intern Med 1982;97:362-6. 10. Hadler SC, Francis DP, Maynard JE, et al. Long-term immunogenicity and efficacy of hepatitis B vaccine in homosexual men. N Engl J Med 1986;315:209-14. 11. Jilg W, Schmidt M, Deinhardt F, Zachoval R. Hepatitis B vaccination: how long does protection last [Letter]? Lancet 1984;2:458. 12. Coursaget P, Yvonnet B, Chotard J, et al. Seven-year study of hepatitis B vaccine efficacy in infants from an endemic area (Senegal). Lancet 1986;2:1143-5. 13. Stevens CE, Alter HJ, Taylor PE, et al. Hepatitis B vaccine in patients receiving hemodialysis: immunogenicity and efficacy. N Engl J Med 1984;311:496-501. 14. McLean AA, Hilleman MR, McAleer WJ, Buynak EB. Summary of worldwide clinical experience with H-B-Vax(B) (B, MSD). J Infection 1983;7 (supply:95-104. 15. Davidson M, Krugman S. Recombinant yeast hepatitis B vaccine compared with plasma- derived vaccine: immunogenicity and effect of a booster dose. J Infection 1986; 13 (suppl A):31-8. PL/3 K.K. 52. r 52 sº. | ** 3º A ºf ºr * * * * * Reprinted by the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE from MMWR, April 18, 1986, Vol. 35, No. 15, pp. 237–242 Recommended Infection-Control Practices for Dentistry Dental personnel may be exposed to a wide variety of microorganisms in the blood and saliva of patients they treat in the dental operatory. These include Mycobacterium tuberculosis, hepatitis B virus, staphylococci, streptococci, cytomegalovirus, herpes simplex virus types I and ll, human T-lymphotropic virus type Ill/lymphadenopathy-associated virus (HTLV-Ill/ LAV), and a number of viruses that infect the upper respiratory tract. Infections may be trans- mitted in dental practice by blood or saliva through direct contact, droplets, or aerosols. Al- though not documented, indirect contact transmission of infection by contaminated instru- ments is possible. Patients and dental health-care workers (DHCWs) have the potential of transmitting infections to each other (1). A common set of infection-control strategies should be effective for preventing hepatitis B, acquired immunodeficiency syndrome, and other infectious diseases caused by bloodborne viruses (2-4). The ability of hepatitis B virus to survive in the environment (5) and the high titers of virus in blood (6) make this virus a good model for infection-control practices to pre- vent transmission of a large number of other infectious agents by blood or saliva. Because all in- fected patients cannot be identified by history, physical examination, or readily available laboratory tests (3), the following recommendations should be used routinely in the care of all patients in dental practices. MEDICAL HISTORY - Always obtain a thorough medical history, Include specific questions about medications, current illnesses, hepatitis, recurrent illnesses, unintentional weight loss, lymphadenopathy, oral soft tissue lesions, or other infections. Medical consultation may be indicated when a his- tory of active infection or systemic disease is elicited. USE OF PROTECTIVE AT TIRE AND BARRIER TECHNIO UES 1. For protection of personnel and patients, gloves must always be worn when touching blood, saliva, or mucous membranes (7-10). Gloves must be worn by DHCWs when touching blood-soiled items, body fluids, or secretions, as well as surfaces contaminated with them. Gloves must be worn when examining all oral lesions. All work must be completed on one pa- tient, where possible, and the hands must be washed and regloved before performing proce- dures on another patient. Repeated use of a single pair of gloves is not recommended, since such use is likely to produce defects in the glove material, which will diminish its value as an effective barrier. 2. Surgical masks and protective eyewear or chin-length plastic face shields must be worn when splashing or spattering of blood or other body fluids is likely, as is common in deri- tistry (1 1, 12). 3. Reusable or disposable gowns, laboratory coats, or uniforms must be worn when cloth- ing is likely to be soiled with blood or other body fluids. If reusable gowns are worn, they may be washed, using a normal laundry cycle. Gowns should be changed at least daily or when visibly soiled with blood (13). 4. Impervious-backed paper, aluminum foil, or clear plastic wrap may be used to cover surfaces (e.g., light handles or x-ray unit heads) that may be contaminated by blood or saliva and that are difficult or impossible to disinfect. The coverings should be removed (while DHCWs are gloved), discarded, and then replaced (after ungloving) with clean material be- tween patients. 5. All procedures and manipulations of potentially infective materials should be performed carefully to minimize the formation of droplets, spatters, and aerosols, where possible. Use of rubber dams, where appropriate, high-speed evacuation, and proper patient positioning should facilitate this process. HAND WASHING AND CARE OF HANDS Hands must always be washed between patient treatment contacts (following removal of gloves), after touching inanimate objects likely to be contaminated by blood or saliva from other patients, and before leaving the operatory. The rationale for handwashing after gloves have been worn is that gloves become perforated, knowingly or unknowingly, during use and allow bacteria to enter beneath the glove material and multiply rapidly. For many routine dental procedures, such as examinations and nonsurgical techniques, handwashing with plain Soap appears to be adequate, since soap and water will remove transient microorganisms ac- quired directly or indirectly from patient contact (13). For surgical procedures, an antimicro- bial Surgical handscrub should be used (14). Extraordinary care must be used to avoid hand injuries during procedures. However, when gloves are torn, cut, or punctured, they must be re- moved immediately, hands thoroughly washed, and regloving accomplished before comple- tion of the dental procedure. DHCWs who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling dental patient-care equipment until the condition resolves (15). USE AND CARE OF SHARP INSTRUMENTS AND NEEDLES 1. Sharp items (needles, scalpel blades, and other sharp instruments) should be consid- ered as potentially infective and must be handled with extraordinary care to prevent uninten- tional injuries. 2. Disposable syringes and needles, scalpel blades, and other sharp items must be placed into puncture-resistant containers located as close as practical to the area in which they were used. To prevent needlestick injuries, disposable needles should not be recapped; purposefully bent or broken; removed from disposable syringes; or otherwise manipulated by hand after US8. - 3. Recapping of a needle increases the risk of unintentional needlestick injury. There is no evidence to suggest that reusable aspirating-type syringes used in dentistry should be handled differently from other syringes. Needles of these devices should not be recapped, bent, or broken before disposal. 4. Because certain dental procedures on an individual patient may require multiple injec- tions of anesthetic or other medications from a single syringe, it would be more prudent to place the unsheathed needle into a “sterile field" between injections rather than to recap the needle between injections. A new (sterile) syringe and a fresh solution should be used for each patient. INDICATIONS FOR HIGH-LEVEL DISINFECTION OR STERILIZATION OF INSTRUMENTS Surgical and other instruments that normally penetrate soft tissue and/or bone (e.g., forceps, scalpels, bone chisels, scalers, and surgical burs) should be sterilized after each use. Instruments that are not intended to penetrate oral soft tissues or bone (e.g., amalgam con- densers, plastic instruments, and burs) but that may come into contact with oral tissues should also be sterilized after each use, if possible; however, if sterilization is not feasible, the latter instruments should receive high-level disinfection (3, 13, 16). METHODS FOR HIGH-LEVEL DISINFECTION OR STERILIZATION Before high-level disinfection or sterilization, instruments should be cleaned to remove debris. Cleaning may be accomplished by a thorough scrubbing with soap and water or a deter- gent, or by using a mechanical device (e.g., an ultrasonic cleaner). Persons involved in cleaning and decontaminating instruments should wear heavy-duty rubber gloves to prevent hand inju- ries. Metal and heat-stable dental instruments should be routinely sterilized between use by steam under pressure (autoclaving), dry heat, or chemical vapor. The adequacy of sterilization cycles should be verified by the periodic use of spore-testing devices (e.g., weekly for most dental practices) (13). Heat- and steam-sensitive chemical indicators may be used on the out- side of each pack to assure it has been exposed to a sterilizing cycle. Heat-sensitive instruments may require up to 10 hours' exposure in a liquid chemical agent registered by the U.S. Environ- mental Protection Agency (EPA) as a disinfectant/sterilant; this should be followed by rinsing with sterile water. High-level disinfection may be accomplished by immersion in either boiling water for at least 10 minutes or an EPA-registered disinfectant/sterilant chemical for the expo- sure time recommended by the chemical's manufacturer. DECONTAMINATION OF ENVIRONMENTAL SURFACES At the completion of work activities, countertops and surfaces that may have become con- taminated with blood or saliva should be wiped with absorbent toweling to remove extrane- ous organic material, then disinfected with a suitable chemical germicide. A solution of sodium hypochlorite (household bleach) prepared fresh daily is an inexpensive and very effec- tive germicide. Concentrations ranging from 5,000 ppm (a 1:10 dilution of household bleach) to 500 ppm (a 1:100 dilution) sodium hypochlorite are effective, depending on the amount of organic material (e.g., blood, mucus, etc.) present on the surface to be cleaned and disinfected. Caution should be exercised, since sodium hypochlorite is corrosive to metals, especially aluminum. DECONTAMINATION OF LABORATORY SUPPLIES AND MATERIALS Blood and saliva should be thoroughly and carefully cleaned from laboratory supplies and materials that have been used in the mouth (e.g., impression materials, bite registration), espe- cially before polishing and grinding intra-oral devices. Materials, impressions, and intra-oral appliances should be cleaned and disinfected before being handled, adjusted, or sent to a dental laboratory (17). These items should also be cleaned and disinfected when returned from the dental laboratory and before placement in the patient's mouth. Because of the ever- increasing variety of dental materials used intra-orally, DHCWs are advised to consult with manufacturers as to the stability of specific materials relative to disinfection procedures. A chemical germicide that is registered with the EPA as a “hospital disinfectant" and that has a label claim for mycobactericidal (e.g., tuberculocidal) activity is preferred, because myco- bacteria represent one of the most resistant groups of microorganisms; therefore, germicides that are effective against mycobacteria are also effective against other bacterial and viral pathogens (15). Communication between a dental office and a dental laboratory with regard to handling and decontamination of supplies and materials is of the utmost importance. USE AND CARE OF ULTRASONIC SCALERS, HANDPIECES, AND DENTAL UNITS 1. Routine sterilization of handpieces between patients is desirable; however, not all hand- pieces can be sterilized. The present physical configurations of most handpieces do not readi- ly lend them to high-level disinfection of both external and internal surfaces (see 2 below); therefore, when using handpieces that cannot be sterilized, the following cleaning and disin- fection procedures should be completed between each patient: After use, the handpiece should be flushed (see 2 below), then thoroughly scrubbed with a detergent and water to remove adherent material. It should then be thoroughly wiped with absorbent material saturated with a chemical germicide that is registered with the EPA as a “hospital disinfec- tant" and is mycobactericidal at use-dilution (15). The disinfecting solution should remain in contact with the handpiece for a time specified by the disinfectant's manufacturer. Ultrasonic scalers and air/water syringes should be treated in a similar manner between patients. Follow- ing disinfection, any chemical residue should be removed by rinsing with sterile water. 2. Because water retraction valves within the dental units may aspirate infective materials back into the handpiece and water line, check valves should be installed to reduce the risk of transfer of infective material (18). While the magnitude of this risk is not known, it is prudent for water-cooled handpieces to be run and to discharge water into a sink or container for 20-30 seconds after completing care on each patient. This is intended to physically flush out patient material that may have been aspirated into the handpiece or water line. Additionally, there is some evidence that overnight bacterial accumulation can be significantly reduced by allowing water-cooled handpieces to run and to discharge water into a sink or container for several minutes at the beginning of the clinic day (19). Sterile saline or sterile water should be used as a coolant/irrigator when performing surgical procedures involving the cutting of soft tissue or bone. HANDLING OF BIOPSY SPECIMIENS In general, each specimen should be put in a sturdy container with a secure lid to prevent leaking during transport. Care should be taken when collecting specimens to avoid contamina- tion of the outside of the container. If the outside of the container is visibly contaminated, it should be cleaned and disinfected, or placed in an impervious bag (20). DISPOSAL OF WASTE MATERIALS All sharp items (especially needles), tissues, or blood should be considered potentially in- fective and should be handled and disposed of with special precautions. Disposable needles, Scalpels, or other sharp items should be placed intact into puncture-resistant containers before disposal. Blood, suctioned fluids, or other liquid waste may be carefully poured into a drain connected to a sanitary sewer system. Other solid waste contaminated with blood or other body fluids should be placed in sealed, sturdy impervious bags to prevent leakage of the contained items. Such contained solid wastes can then be disposed of according to require- ments established by local or state environmental regulatory agencies and published recom- mendations (13,20). Developed by Dental Disease Prevention Activity, Center for Prevention Svcs, Hospital Infections Pro- gram, Center for Infectious Diseases, CDC. Editorial Note: All DHCW's must be made aware of sources and methods of transmission of infectious diseases. The above recommendations for infection control in dental practices in- corporate procedures that should be effective in preventing the transmission of infectious agents from dental patients to DHCWs and vice versa. Assessment of quantifiable risks to dental personnel and patients for specific diseases requires further research. There is no cur- rent documentation of patient-to-patient blood- or saliva-borne disease transmission from procedures performed in dental practice. While few in number, reported outbreaks of dentist- to-patient transmission of hepatitis B have resulted in serious and even fatal consequences (9). Herpes simplex virus has been transmitted to over 20 patients from the fingers of a DHCW (10). Serologic markers for hepatitis B in dentists have increased dramatically in the United States over the past several years, which suggests current infection-control practices have been in- sufficient to prevent the transmission of this infectious agent in the dental operatory. While vaccination for hepatitis B is strongly recommended for dental nersonnel (21), vaccination alone is not cause for relaxation of strict adherence to accepted methods of asepsis, disinfec- tion, and sterilization. Various infection-control guidelines exist for hospitals and other clinical settings. Dental facilities located in hospitals and other institutional settings have generally utilized existing guidelines for institutional practice. These recommendations are offered as guidance to DHCW's in noninstitutional settings for enhancing infection-control practices in dentistry; they may be useful in institutional settings also. References 1. Ahtone J, Goodman RA. Hepatitis B and dental personnel: transmission to patients and prevention issues. J Am Dent Assoc 1983; 1 06:219–22. 2. Crawford J.J. State-of-the-art: practical infection control in dentistry. J Am Dent Assoc 1985; 110: 629-33. 3. Cottone JA, Mitchell EW, Baker CH, et al. Proceedings of the National Symposium on Hepatitis B and the Dental Profession. J Am Dent Assoc 1985; 1 10:614-49. 4. CDC. Acquired immunodeficiency syndrome (AIDS); precautions for health-care workers and allied professionals. MMWR 1983;32:450-1. 5. Bond WW, Favero MS, Petersen NJ, Gravelle CR, Ebert JW, Maynard JE. Survival of hepatitis B virus after drying and storage for one week [Letter]. Lancet 1981;1:550-1. 6. Shikata T. Karasawa T, Abe K, et al. Hepatitis Be antigen and infectivity of hepatitis B virus. J Infect Dis 1977; 136:571-6. 7. Hadler SC, Sorley DL, Acree KH, et al. An outbreak of hepatitis B in a dental practice. Ann Intern Med 1981;95:133-8. 8. Occupational Safety and Health Administration. Risk of hepatitis B infection for workers in the health care delivery system and suggested methods for risk reduction. U.S. Department of Labor 1983; (CPL 2-2.36). 9. CDC. Hepatitis B among dental patients—Indiana. MMWR 1985;34:73-5. 10. Manzella JP, McConville JH, Valenti W. Menegus MA, Swierkosz EM, Arens M. An outbreak of herpes simplex virus type 1 gingivostomatitis in a dental hygiene practice. JAMA 1984:252: 2019-22. 11. Petersen NJ, Bond WW, Favero MS. Air sampling for hepatitis B surface antigen in a dental opera- tory. JAm Dent Assoc 1979;99:46.5-7. 12. Bond WW, Petersen NJ, Favero MS, Ebert JW, Maynard JE. Transmission of type B viral hepatitis B via eye inoculation of a chimpanzee. J Clin Microbiol 1982; 15:533-4. 17. 18. 19. 20. 21. Garner JS, Favero MS. Guideline for handwashing and hospital environmental control, 1985. Atlan- ta, Georgia: Centers for Disease Control, 1985; publication no. 99-11 17. Garner JS. Guideline for prevention of surgical wound infections, 1985. Atlanta, Georgia: Centers for Disease Control, 1985; publication no. 99-2381. CDC. Recommendations for preventing transmission of infection with human T-lymphotropic virus type Ill/lymphadenopathy-associated virus in the workplace. MMWR 1985;34:682-6, 691-5. Favero MS. Sterilization, disinfection, and antisepsis in the hospital. In: Lennette EH, Balows A, Hauslen WJ, Shadomy H.J. Manual of clinical microbiology. Washington, D.C.: American Society of Microbiology, 1985:129-37. Council on Dental Therapeutics and Council on Prosthetic Services and Dental Laboratory Relations, American Dental Association. Guidelines for infection control in the dental office and the commer- cial laboratory. J Am Dent Assoc 1985; 110:969-72. Bagga BSR, Murphy RA, Anderson AW, Punwani I. Contamination of dental unit cooling water with oral microorganisms and its prevention. J Am Dent Assoc 1984; 109:712-6. Scheid RC, Kim CK, Bright JS, Whitely MS, Rosen S. Reduction of microbes in handpieces by flush- ing before use. JAm Dent Assoc 1982; 105:658-60. Garner JS, Simmons BP. CDC guideline for isolation precautions in hospitals. Atlanta, Georgia: Cen- ters for Disease Control, 1983; HHS publication no. (CDC) 83-83.14. ACIP. Inactivated hepatitis B virus vaccine. MMWR 1982:31:317-22, 327-8. Reprinted by the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE CENTERS FOR DISEASE CONTROL from MMWR, June 24, 1988, Vol. 37, No. 24, pp. 377-382, 387-388 Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in Health-Care Settings Introduction The purpose of this report is to clarify and supplement the CDC publication entitled “Recommendations for Prevention of HIV Transmission in Health-Care Settings" (1).” In 1983, CDC published a document entitled “Guideline for Isolation Precautions in Hospitals” (2) that contained a section entitled “Blood and Body Fluid Precautions." The recommendations in this section called for blood and body fluid precautions when a patient was known or suspected to be infected with bloodborne pathogens. In August 1987, CDC published a document entitled “Recommendations for Prevention of HIV Transmission in Health-Care Settings" (1). In contrast to the 1983 document, the 1987 document recommended that blood and body fluid precautions be consis- tently used for all patients regardless of their bloodborne infection status. This extension of blood and body fluid precautions to all patients is referred to as “Universal Blood and Body Fluid Precautions" or “Universal Precautions.” Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other bloodborne pathogens. Universal precautions are intended to prevent parenteral, mucous membrane, and nonintact skin exposures of health-care workers to bloodborne pathogens. In addi- tion, immunization with HBV vaccine is recommended as an important adjunct to universal precautions for health-care workers who have exposures to blood (3,4). Since the recommendations for universal precautions were published in August 1987, CDC and the Food and Drug Administration (FDA) have received requests for clarification of the following issues: 1) body fluids to which universal precautions apply, 2) use of protective barriers, 3) use of gloves for phlebotomy, 4) selection of gloves for use while observing universal precautions, and 5) need for making changes in waste management programs as a result of adopting universal precautions. Body Fluids to Which Universal Precautions Apply Universal precautions apply to blood and to other body fluids containing visible blood. Occupational transmission of HIV and HBV to health-care workers by blood is documented (4,5). Blood is the single most important source of HIV, HBV, and other bloodborne pathogens in the occupational setting. Infection control efforts for HIV, *The August 1987 publication should be consulted for general information and specific recommendations not addressed in this update. Copies of this report and of the MMWR supplement entitled Recommendations for Prevention of HIV Transmission in Health-Care Settings published in August 1987 are available through the National AIDS Information Clearinghouse, P.O. Box 6003, Rockville, MD 20850. HBV, and other bloodborne pathogens must focus on preventing exposures to blood as well as on delivery of HBV immunization. Universal precautions also apply to semen and vaginal secretions. Although both of these fluids have been implicated in the sexual transmission of HIV and HBV, they have not been implicated in occupational transmission from patient to health-care worker. This observation is not unexpected, since exposure to semen in the usual health-care setting is limited, and the routine practice of wearing gloves for perform- ing vaginal examinations protects health-care workers from exposure to potentially infectious vaginal secretions. Universal precautions also apply to tissues and to the following fluids: cerebrospi- nal fluid (CSF), synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid. The risk of transmission of HIV and HBV from these fluids is unknown; epidemiologic studies in the health-care and community setting are currently inade- quate to assess the potential risk to health-care workers from occupational exposures to them. However, HIV has been isolated from CSF, synovial, and amniotic fluid (6–8), and HBs.Ag has been detected in synovial fluid, amniotic fluid, and peritoneal fluid (9–11). One case of HIV transmission was reported after a percutaneous exposure to bloody pleural fluid obtained by needle aspiration (12). Whereas aseptic procedures used to obtain these fluids for diagnostic or therapeutic purposes protect health-care workers from skin exposures, they cannot prevent penetrating injuries due to contaminated needles or other sharp instruments. Body Fluids to Which Universal Precautions Do Not Apply Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine, and vomitus unless they contain visible blood. The risk of transmission of HIV and HBV from these fluids and materials is extremely low or nonexistent. HIV has been isolated and HBSAg has been demonstrated in Soiſie of these fluids; however, epidemiologic studies in the health-care and community setting have not implicated these fluids or materials in the transmission of HIV and HBV infections (13,14). Some of the above fluids and excretions represent a potential source for nosocomial and community-acquired infections with other pathogens, and recom- mendations for preventing the transmission of nonbloodborne pathogens have been published (2). Precautions for Other Body Fluids in Special Settings Human breast milk has been implicated in perinatal transmission of HIV, and HBSAg has been found in the milk of mothers infected with HBV (10,13). However, occupational exposure to human breast milk has not been implicated in the trans- mission of HIV nor HBV infection to health-care workers. Moreover, the health-care worker will not have the same type of intensive exposure to breast milk as the nursing neonate. Whereas universal precautions do not apply to human breast milk, gloves may be worn by health-care workers in situations where exposures to breast milk might be frequent, for example, in breast milk banking. Saliva of some persons infected with HBV has been shown to contain HBV-DNA at concentrations 1/1,000 to 1/10,000 of that found in the infected person's serum (15). HBs.Ag-positive saliva has been shown to be infectious when injected into experi- mental animals and in human bite exposures (16–18). However, HBs.Ag-positive saliva has not been shown to be infectious when applied to oral mucous membranes in experimental primate studies (18) or through contamination of musical instru- ments or cardiopulmonary resuscitation dummies used by HBV carriers (19,20). Epidemiologic studies of nonsexual household contacts of HIV-infected patients, including several small series in which HIV transmission failed to occur after bites or after percutaneous inoculation or contamination of cuts and open wounds with saliva from HIV-infected patients, suggest that the potential for salivary transmission of HIV is remote (5, 13, 14,21,22). One case report from Germany has suggested the possi- bility of transmission of HIV in a household setting from an infected child to a sibling through a human bite (23). The bite did not break the skin or result in bleeding. Since the date of seroconversion to HIV was not known for either child in this case, evidence for the role of saliva in the transmission of virus is unclear (23). Another case report suggested the possibility of transmission of HIV from husband to wife by contact with saliva during kissing (24). However, follow-up studies did not confirm HIV infection in the wife (21). Universal precautions do not apply to saliva. General infection control practices already in existence — including the use of gloves for digital examination of mucous membranes and endotracheal suctioning, and handwashing after exposure to saliva – should further minimize the minute risk, if any, for salivary transmission of HIV and HBV (1,25). Gloves need not be worn when feeding patients and when wiping saliva from skin. Special precautions, however, are recommended for dentistry (1). Occupationally acquired infection with HBV in dental workers has been documented (4), and two possible cases of occupationally acquired HIV infection involving dentists have been reported (5,26). During dental procedures, contamination of saliva with blood is predictable, trauma to health-care workers' hands is common, and blood spattering may occur. Infection control precautions for dentistry minimize the potential for nonintact skin and mucous membrane contact of dental health-care workers to blood-contaminated saliva of patients. In addition, the use of gloves for oral examinations and treatment in the dental setting may also protect the patient's oral mucous membranes from exposures to blood, which may occur from breaks in the skin of dental workers' hands. Use of Protective Barriers Protective barriers reduce the risk of exposure of the health-care worker's skin or mucous membranes to potentially infective materials. For universal precautions, protective barriers reduce the risk of exposure to blood, body fluids containing visible blood, and other fluids to which universal precautions apply. Examples of protective barriers include gloves, gowns, masks, and protective eyewear. Gloves should reduce the incidence of contamination of hands, but they cannot prevent penetrating injuries due to needies or other sharp instruments. Masks and protective eyewear or face shields should reduce the incidence of contamination of mucous membranes of the mouth, nose, and eyes. Universal precautions are intended to supplement rather than replace recommen- dations for routine infection control, such as handwashing and using gloves to prevent gross microbial contamination of hands (27). Because specifying the types of barriers needed for every possible clinical situation is impractical, some judgment must be exercised. The risk of nosocomial transmission of HIV, HBV, and other bloodborne pathogens can be minimized if health-care workers use the following general guidelines:" 1. Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles. Do not recap used needles by hand; do not remove used needles from disposable syringes by hand; and do not bend, break, or otherwise manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in puncture-resistant containers for disposal. Locate the puncture-resistant con- tainers as close to the use area as is practical. "The August 1987 publication should be consulted for general information and specific recommendations not addressed in this update. 2. Use protective barriers to prevent exposure to blood, body fluids containing visible blood, and other fluids to which universal precautions apply. The type of protective barrier(s) should be appropriate for the procedure being performed and the type of exposure anticipated. 3. Immediately and thoroughly wash hands and other skin surfaces that are contam- inated with blood, body fluids containing visible blood, or other body fluids to which universal precautions apply. Glove Use for Phlebotomy Gloves should reduce the incidence of blood contamination of hands during phlebotomy (drawing blood samples), but they cannot prevent penetrating injuries caused by needles or other sharp instruments. The likelihood of hand contamination with blood containing HIV, HBV, or other bloodborne pathogens during phlebotomy depends on several factors: 1) the skill and technique of the health-care worker, 2) the frequency with which the health-care worker performs the procedure (other factors being equal, the cumulative risk of blood exposure is higher for a health-care worker who performs more procedures), 3) whether the procedure occurs in a routine or emergency situation (where blood contact may be more likely), and 4) the prevalence of infection with bloodborne pathogens in the patient population. The likelihood of infection after skin exposure to blood containing HIV or HBV will depend on the concentration of virus (viral concentration is much higher for hepatitis B than for HIV), the duration of contact, the presence of skin lesions on the hands of the health-care worker, and — for HBV — the immune status of the health-care worker. Although not accurately quantified, the risk of HIV infection following intact skin contact with infective blood is certainly much less than the 0.5% risk following percutaneous needlestick exposures (5). In universal precautions, all blood is assumed to be potentially infective for bloodborne pathogens, but in certain settings (e.g., volunteer blood-donation centers) the prevalence of infection with some bloodborne pathogens (e.g., HIV, HBV) is known to be very low. Some institutions have relaxed recommen- dations for using gloves for phlebotomy procedures by skilled phlebotomists in settings where the prevalence of bloodborne pathogens is known to be very low. Institutions that judge that routine gloving for all phlebotomies is not necessary should periodically reevaluate their policy. Gloves should always be available to health-care workers who wish to use them for phlebotomy. In addition, the following general guidelines apply: 1. Use gloves for performing phlebotomy when the health-care worker has cuts, scratches, or other breaks in his/her skin. 2. Use gloves in situations where the health-care worker judges that hand contami- nation with blood may occur, for example, when performing phlebotomy on an uncooperative patient. 3. Use gloves for performing finger and/or heel sticks on infants and children. 4. Use gloves when persons are receiving training in phlebotomy. Selection of Gloves The Center for Devices and Radiological Health, FDA, has responsibility for regulating the medical glove industry. Medical gloves include those marketed as sterile surgical or nonsterile examination gloves made of vinyl or latex. General purpose utility (“rubber") gloves are also used in the health-care setting, but they are not regulated by FDA since they are not promoted for medical use. There are no reported differences in barrier effectiveness between intact latex and intact vinyl used to manufacture gloves. Thus, the type of gloves selected should be appropriate for the task being performed. The following general guidelines are recommended: 1. Use sterile gloves for procedures involving contact with normally sterile areas of the body. 2. Use examination gloves for procedures involving contact with mucous mem- branes, unless otherwise indicated, and for other patient care or diagnostic procedures that do not require the use of sterile gloves. 3. Change gloves between patient contacts. 4. Do not wash or disinfect surgical or examination gloves for reuse. Washing with surfactants may cause "wicking," i.e., the enhanced penetration of liquids through undetected holes in the glove. Disinfecting agents may cause deterioration. 5. Use general-purpose utility gloves (e.g., rubber household gloves) for housekeep- ing chores involving potential blood contact and for instrument cleaning and decontamination procedures. Utility gloves may be decontaminated and reused but should be discarded if they are peeling, cracked, or discolored, or if they have punctures, tears, or other evidence of deterioration. Waste Management Universal precautions are not intended to change waste management programs previously recommended by CDC for health-care settings (1). Policies for defining, collecting, storing, decontaminating, and disposing of infective waste are generally determined by institutions in accordance with state and local regulations. Information regarding waste management regulations in health-care settings may be obtained from state or local health departments or agencies responsible for waste manage- ment. Reported by: Center for Devices and Radiological Health, Food and Drug Administration. Hospital Infections Program, AlBS Program, and Hepatitis Br, Div of Viral Diseases, Center for Infectious Diseases, National Institute for Occupational Safety and Health, CDC. Editorial Note: Implementation of universal precautions does not eliminate the need for other category- or disease-specific isolation precautions, such as enteric precau- tions for infectious diarrhea or isolation for pulmonary tuberculosis (1,2). In addition to universal precautions, detailed precautions have been developed for the following procedures and/or settings in which prolonged or intensive exposures to blood occur: invasive procedures, dentistry, autopsies or morticians' services, dialysis, and the clinical laboratory. These detailed precautions are found in the August 21, 1987, “Recommendations for Prevention of HIV Transmission in Health-Care Settings" (1). In addition, specific precautions have been developed for research laboratories (28). References 1. Centers for Disease Control. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36(suppl no. 2S). 2. Garner JS, Simmons BP. Guideline for isolation precautions in hospitals. Infect Control 1983:4; 245–325. 3. Immunization Practices Advisory Committee. Recommendations for protection against viral hepatitis. MMWR 1985;34:313-24,329–35. 4. Department of Labor, Department of Health and Human Services. Joint advisory notice: protection against occupational exposure to hepatitis B virus (HBV) and human immuno- deficiency virus (HIV). Washington, DC: US Department of Labor, US Department of Health and Human Services, 1987. 5. Centers for Disease Control. Update: Acquired immunodeficiency syndrome and human immunodeficiency virus infection among health-care workers. MMWR 1988;37:229–34,239. 6. Hollander H, Levy JA. Neurologic abnormalities and recovery of human immunodeficiency virus from cerebrospinal fluid. Ann Intern Med 1987; 106:692–5. 7. Wirthrington RH, Cornes P, Harris JRW, et al. Isolation of human immunodeficiency virus from synovial fluid of a patient with reactive arthritis. Br Med J 1987;294:484. 8. Mundy DC, Schinazi RF, Gerber AR, Nahmias AJ, Randall HW. Human immunodeficiency virus isolated from amniotic fluid. Lancet 1987;2:459–60. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. . Onion DK, Crumpacker CS, Gilliland BC. Arthritis of hepatitis associated with Australia antigen. Ann Intern Med 1971;75:29–33. Lee AKY, Ip HMH, Wong VCW. Mechanisms of maternal-fetal transmission of hepatitis B virus. J Infect Dis 1978; 138:668–71. Bond WW, Petersen NJ, Gravelle CR, Favero MS. Hepatitis B virus in peritoneal dialysis fluid: A potential hazard. Dialysis and Transplantation 1982; 11:592–600. Oskenhendler E, Harzic M, Le Roux J-M, Rabian C, Clauvel JP. HIV infection with Serocon- version after a superficial needlestick injury to the finger [Letter]. N Engl J Med 1986;315:582. Lifson AR. Do alternate modes for transmission of human immunodeficiency virus exist? A review. JAMA 1988;259:1353–6. Friedland GH, Saltzman BR, Rogers MF, et al. Lack of transmission of HTLV-III/LAV infection to household contacts of patients with AIDS or AIDS-related complex with oral candidiasis. N Engl J Med 1986;314:344–9. Jenison SA, Lemon SM, Baker LN, Newbold JE. Ouantitative analysis of hepatitis B virus DNA in saliva and semen of chronically infected homosexual men. J Infect Dis 1987; 156:299–306. Cancio-Bello TP, de Medina M, Shorey J, Valledor MD, Schiff ER. An institutional outbreak of hepatitis B related to a human biting carrier. J Infect Dis 1982; 146:652–6. MacQuarrie MB, Forghani B, Wolochow DA. Hepatitis B transmitted by a human bite. JAMA 1974; 230:723–4. Scott RM, Snitbhan R, Bancroft WH, Alter HJ, Tingpalapong M. Experimental transmission of hepatitis B virus by semen and saliva. J Infect Dis 1980; 142:67–71. Glaser JB, Nadler JP. Hepatitis B virus in a cardiopulmonary resuscitation training course: Risk of transmission from a surface antigen-positive participant. Arch Intern Med 1985; 145: 1653–5. Osterholm MT, Bravo ER, Crosson JT, et al. Lack of transmission of viral hepatitis type B after oral exposure to HBs.Ag-positive saliva. Br Med J 1979;2:1263–4. Curran JW, Jaffe HW, Hardy AM, et al. Epidemiology of HIV infection and AIDS in the United States. Science 1988;239:610–6. Jason JM, McDougal JS, Dixon G, et al. HTLV-III/LAV antibody and immune status of household contacts and sexual partners of persons with hemophilia. JAMA 1986;255:212–5. Wahn V, Kramer HH, Voit T, Brüster HT, Scrampical B, Scheid A. Horizontal transmission of HIV infection between two siblings [Letter]. Lancet 1986;2:694. Salahuddin SZ, Groopman JE, Markham PD, et al. HTLV-III in symptom-free seronegative persons. Lancet 1984;2:1418–20. Simmons BP, Wong ES. Guideline for prevention of nosocomial pneumonia. Atlanta: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, 1982. Klein RS, Phelan JA, Freeman K, et al. Low occupational risk of human immunodeficiency virus infection among dental professionals. N Engl J Med 1988;318:86–90. Garner JS, Favero MS. Guideline for handwashing and hospital environmental control, 1985. Atlanta: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, 1985; HHS publication no. 99-1117. Centers for Disease Control. 1988 Agent summary statement for human immunodeficiency virus and report on laboratory-acquired infection with human immunodeficiency virus. MMWR 1988;37(suppl no. S4:1S-22S). 00-5490 CENTERS FOR DISEASE CONTROL June 23, 1989 / Vol. 38 / No. S-6 Recommendations and Reports . - ... * * § º º s - s w - - * . - º d 1. D º º - . - l - º *: r &. - 5: º º: * *. º * º - - - c ſ º . * * ~ * s º l g MORBIDITY AND MORTALITY WEEKLY REPORT Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers Reprinted by U.S. Department of Health and Human Services Public Health Service Centers for Disease Control Vol. 38 / No. S-6 MMWR i NOTICE This issue of MMWR Recommendations and Reports (Vol. 38, No. S-6) is a reprint of an administrative document circulated and reviewed earlier in 1989. It is being provided as an issue in the MMWR series as a service to the readership. Serial publications to the MMWR are published by the Epidemiology Program Office, Centers for Disease Control, Public Health Service, U.S. Department of Health and Human Services, Atlanta, Georgia 30333. SUGGESTED CITATION Centers for Disease Controi. Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers. MMWR 1989;38(no. S-6): [inclusive page numbers]. Centers for Disease Control ......................................... Walter R. Dowdle, Ph.D. Acting Director This report was prepared by: National Institute for Occupational Safety and Health ......... J. Donald Millar, M.D. Director in collaboration with: Center for Infectious Diseases................. Frederick A. Murphy, D.V.M., Ph.D. Director The production of this report was coordinated in: Epidemiology Program Office .................................... Michael B. Gregg, M.D. Acting Director Richard A. Goodman, M.D., M.P.H. Editor, MMWR Series Editorial Services ............................................... R. Elliott Churchill, M.A. Chief and Production Editor Beverly Holland Program Specialist Copies can be purchased from Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402-9235. Telephone: (202) 783-3238. Vol. 38 / No. S-6 MMWR iii Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers A Response to P.L. 100-607 The Health Omnibus Programs Extension Act of 1988 U.S. Department of Health and Human Services Public Health Service Centers for Disease Control Atlanta, Georgia February 1989 Vol. 38 / No. S-6 MMWR II. III. IV. TABLE OF CONTENTS Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Purpose and Organization of Document . . . . . . . . . . . . . . . . . . . . . . Modes and Risk of Virus Transmission in the Workplace . . . . . . . . . . Transmission of Hepatitis B Virus to Workers . . . . . . . . . . . . . . . . . . 1. Health-care workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Emergency medical and public-safety workers . . . . . . . . . . . . . . . 3. Vaccination for hepatitis B virus . . . . . . . . . . . . . . . . . . . . . . . . . E. Transmission of Human Immunodeficiency Virus to Workers . . . . . . . 1. Health-care workers with AIDS . . . . . . . . . . . . . . . . . . . . . . . . . 2. Human immunodeficiency virus transmission in the workplace . . . 3. Emergency medical service and public-safety workers . . . . . . . . . . : Principles of Infection Control and Their Application to Emergency and Public-Safety Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A. General Infection Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Universal Blood and Body Fluid Precautions to Prevent Occupational HIV and HBV Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Employer Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e s e e A. General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Medical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. Hepatitis B vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Management of percutaneous exposure to blood and other infectious body fluids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a. Hepatitis B virus postexposure management . . . . . . . . . . . . . b. Human immunodeficiency virus postexposure management . . . 3. Management of human bites . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Documentation of exposure and reporting . . . . . . . . . . . . . . . . . . 5. Management of HBV- or HIV-infected workers . . . . . . . . . . . . . . C. Disinfection, Decontamination, and Disposal . . . . . . . . . . . . . . . . . . . 1. Needle and sharps disposal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Hand washing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Cleaning, disinfecting, and sterilizing . . . . . . . . . . . . . . . . . . . . . . 4. Cleaning and decontaminating spills of blood . . . . . . . . . . . . . . . . 5. Laundry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Decontamination and laundering of protective clothing . . . . . . . . . 7. Infective waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fire and Emergency Medical Services . . . . . . . . . . . . . . . . . . . . . . . . . . . A. Personal Protective Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. Gloves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi MMWR June 23, 1989 VI. VII. 2. Masks, eyewear, and gowns . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 3. Resuscitation equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Law-Enforcement and Correctional-Facility Officers . . . . . . . . . . . . . . . . . 22 A. Law-Enforcement and Correctional-Facilities Considerations . . . . . . . . 22 1. Fights and assaults . . . . . . . . . . * e o e º e s e s s e º e e o e o e o e o e o e o o 22 2. Cardiopulmonary resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . 23 B. Law-Enforcement Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1. Searches and evidence handling . . . . . . . . . . . . . . . . . . . . . . . . . . 23 2. Handling deceased persons and body removal . . . . . . . . . . . . . . . 25 3. Autopsies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 4. Forensic laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 C. Correctional-Facility Considerations . . . . . . . . . . . . . . . . . . . . . . . . . 26 1. Searches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 2. DeContamination and disposal . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Vol. 38 / No. S-6 MMWR Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers The CDC staff members listed below served as authors for this publication. Robert J. Mullan, M.D. Edward L. Baker, M.D., M.P.H. James M. Hughes, M.D. David M. Bell, M.D. Harold W. Jaffe, M.D. Walter W. Bond, Jr. Mark A. Kane, M.D., M.P.H. Mary C. Chamberland, M.D., M.P.H. Ruthanne Marcus, M.P.H. Martin S. Favero, Ph.D. William J. Martone, M.D. Julia S. Garner, M.N. Mark J. Scally Stephen C. Hadler, M.D. Phillip W. Strine Vol. 38 / No. S-6 MMWR 3 Introduction A. Background This document is a response to recently enacted legislation, Public Law 100-607, The Health Omnibus Programs Extension Act of 1988, Title II, Programs with Respect to Acquired Immune Deficiency Syndrome (“AIDS Amendments of 1988”). Subtitle E, General Provisions, Section 253(a) of Title II specifies that “the Secretary of Health and Human Services, acting through the Director of the Centers for Disease Control, shall develop, issue, and disseminate guidelines to all health workers, public safety workers (including emergency response employees) in the United States concerning— (1) methods to reduce the riskin the workplace of becoming infected with the etiologic agent for acquired immune deficiency syndrome; and (2) circumstances under which exposure to such etiologic agent may occur.” It is further noted that “The Secretary [of Healthand Human Services] shall transmit the guidelines issued under subsection (a) to the Secretary of Labor for use by the Secretary of Labor in the development of standards to be issued under the Occupational Safety and Health Act of 1970,” and that “the Secretary, acting through the Director of the Centers for Disease Control,shalldevelopamodelcurriculumforemergency responseemployees with respect to the prevention of exposure to the etiologic agent for acquired immune deficiency syndrome during the process of responding to emergencies.” Following development of these guidelines and curriculum, “[t]he Secretary shall— (A) transmit to State publichealth officers copies of the guidelines and the modelcurriculum developedunderparagraph.(1) with therequest that such officers disseminate such copies as appropriate throughout the State; and (B) make such copies available to the public.” . Purpose and Organization of Document The purpose of this document is to provide an overview of the modes of transmission of human immunodeficiency virus (HIV) in the workplace, an assessment of the risk of transmission under various assumptions, principles underlying the control of risk, and specific risk-control recommendations for employers and workers. This document also includes information on medicalmanagement of persons who havesustainedanexposure at the workplace to these viruses (e.g., an emergency medical technicians who incur a needle-stick injury while performing professional duties). These guidelines are intended MMWR June 23, 1989 for use by a technically informed audience. As noted above, aseparate model curriculum based on the principles and practices discussed in this document is being developed for use in training workers and will contain less technical wording. Information concerning the protection of workers against acquisition of the human immunodeficiency virus (HIV) while performing job duties, the virus that causes AIDS, is presented here. Information on hepatitis B virus (HBV) is also presented in this docu- ment on the basis of the following assumptions: • the modes of transmission for hepatitis B virus (HBV) are similar to those of HIV, • the potential for HBV transmission in the occupational setting is greater than for HIV, • there is a larger body of experience relating to controlling transmission of HBVinthe workplace, and • general practices to prevent the transmission of HBV will also minimize the risk of transmission of HIV. Blood-borne transmission of other pathogens not specifically addressed here will be interrupted by adherence to the precautions noted below. It is important to note that the implementation of control measures for HIV and HBV does not obviate the need for continued adherence to general infection-control principles and general hygiene mea- sures (e.g., hand washing) for preventing transmission of other infectious diseases to both worker and client. General guidelines for control of these diseases have been pub- lished (1,2,3). This document was developed primarily to provide guidelines for fire-service personnel, emergency medical technicians, paramedics (see section IV, page 19), and law-enforce- mentandcorrectional-facility personnel (seesection V, page:22). Throughout the report, paramedics and emergency medical technicians are called “emergency medical workers” and fire-service, law-enforcement, and correctional-facility personnel, “public-safety workers.” Previously issued guidelines address the needs of hospital-, laboratory-, and clinic-based health-care workers (4,5). A condensation of general guidelines for protec- tion of workers from transmission of blood-borne pathogens, derived from the Joint Advisory Notice of the Departments of Labor and Health and Human Services (6), is provided in section III (see page 11). Modes and Risk of Virus Transmission in the Workplace Although the potential for HBV transmission in the workplace setting is greater than for HIV, the modes of transmission for these two viruses are similar. Both have been trans- mitted in occupationalsettings only by percutaneous inoculation or contact withan open Vol. 38 / No. S-6 MMWR - 5 wound, nonintact (e.g., chapped, abraded, weeping, or dermatitic) skin, or mucous mem- branes to blood, blood-contaminated body fluids, or concentrated virus, Blood is the single most important source of HIV and HBW in the workplace setting. Protection measures against HIV and HBV for workers should focus primarily on preventing these types of exposures to blood as well as on delivery of HBV vaccination. The risk of hepatitis B infection followingaparenteral (i.e., needlestick or cut) exposure to blood is directly proportional to the probability that the blood contains hepatitis B surface antigen (HBSAg), the immunity status of the recipient, and on the efficiency of transmission (7). The probability of the source of the blood being HBs.Ag positive varies from 1 to 3 per thousand in the general population to 5%–15% in groups at high risk for HBV infection, such as immigrants from areas of high endemicity (China and Southeast Asia, sub-Saharan Africa, most Pacificislands, and the Amazon Basin); clients in institu- tions for the mentally retarded; intravenous drug users; homosexually active males; and household (sexual and non-sexual) contacts of HBV carriers. Of persons who have not had prior hepatitis B vaccination or postexposure prophylaxis, 6%–30% of persons who receive a needle-stick exposure from an HBs.Ag-positive individual will become infected (7). The risk of infection with HIV following one needle-stick exposure to blood from a patient known to be infected with HIV is approximately 0.5% (4,5). This rate of trans- mission is considerably lower than that for HBV, probably as a result of the significantly lower concentrations of virus in the blood of HIV-infected persons. Table 1 (seepage31) presents theoretical data concerning the likelihood of infection given repeated needle- stickinjuries involving patients whose HIVserostatus is unknown. Though inadequately quantified, the risk from exposure of nonintactskin or mucous membranes is likely to be far less than that from percutaneous inoculation, D. Transmission of Hepatitis B Virus to Workers 1. Health-care workers In 1987, the CDC estimated the total number of HBV infections in the United States to be 300,000peryear, with approximately 75,000(25%) of infected persons develop- ing acute hepatitis. Of these infected individuals, 18,000–30,000 (6%–10%) will become HBV carriers, at risk of developing chronic liver disease (chronic active hepatitis, cirrhosis, and primary liver cancer), and infectious to others. CDC has estimated that 12,000 health-care workers whose jobs entail exposure to blood become infected with HBV each year, that 500–600 of them are hospitalized as a result of that infection, and that 700–1,200 of those infected become HBV carriers. Of the infected workers, approximately 250 will die (12–15 from fulminant hepatitis, 170–200from cirrhosis, and 40–50from liver cancer). Studies indicate that MMWR June 23, 1989 10%–30% of health-care or dental workers show serologic evidence of past or pre- sent HBV infection, Emergency medical and public-safety workers Emergency medical workers have an increased risk for hepatitis Binfection (8,9,10). The degree of riskcorrelates with the frequency and extent of bloodexposure during the conduct of work activities. A few studies are available concerning risk of HBV infection forcther groups of public-safety workers (law-enforcement personneland correctional-facilityworkers), but reports that have beenpublisheddonotaocument any increased risk for HBV infection (11,12,13). Nevertheless, in occupational settings in which workers may be routinely exposed to blood or other body fluids as described below, an increased risk for occupational acquisition of HBV infection must be assumed to be present. Vaccination for hepatitis B virus A safe and effective vaccine to prevent hepatitis B has been available since 1982. Vaccination has been recommended for health-care workers regularly exposed to blood and other body fluids potentially contaminated with HBV (7,14, 15). In 1987, the Department of Health and Human Services and the Department of Labor stated that hepatitis B vaccine should be provided to all such workers at no charge to the worker (6). Available vaccinesstimulateactive immunityagainst HBVinfectionandprovideover 90% protection against hepatitis B for 7 or more years following vaccination (7). Hepatitis B vaccines also are 70–88% effective when given within 1 week after HBV exposure. Hepatitis B immune globulin (HBIG), a preparation of immunoglobulin with high levels of antibody to HBV (anti-HBs), provides temporary passive protec- tion following exposure to HBV. Combination treatment with hepatitis B vaccine and HBIG is over 90% effective in preventing hepatitis B following a documented exposure (7). E. Transmission of Human Immunodeficiency Virus to Workers 1. Health-care workers with AIDS As of September 19, 1988, a total of 3,182 (5.1%) of 61,929 adults with AIDS, who had been reported to the CDC national surveillance system and for whom occupa- tional information was available, reported being employed in a health-care setting. Of the health-care workers with AIDS, 95% reported high-risk behavior; for the remaining 5% (169 workers), the means of HIV acquisition was undetermined. Of these 169 health-care workers with AIDS with undetermined risk, information is Vol. 38 / No. S-6 MMWR 7 incomplete for 28(17%) because of death or refusal to be interviewed;97 (57%) are still being investigated. The remaining 44 (26%) health-care workers were inter- viewed directly or had other follow-up information available. The occupations of these 44 were nine nursing assistants (20%); eight physicians (18%), four of whom weresurgeons;eighthousekeepingormaintenanceworkers (18%);six nurses (14%); fourclinicallaboratorytechnicians (9%); tworespiratorytherapists (5%);onedentist (2%); one paramedic (2%); one embalmer (2%); and four others who did not have contact with patients (9%). Eighteen of these 44 health-care workers reported parenteraland/orothernon-needle-stickexposuretobloodorotherbodyfluids from patients in the 10 years preceding their diagnosis of AIDS. None of these exposures involved a patient with AIDS or known HIV infection, and HIV seroconversion of the health-care worker was not documented following a specific exposure. 2. Human immunodeficiency virus transmission in the workplace As of July 31, 1988, 1,201 health-care workers had been enrolled and tested for HIV antibodyinongoing CDCsurveillanceofhealth-careworkersexposed vianeedlestick or splashes to skin or mucous membranes to blood from patients known to be HIV-infected (16). Of 860 workers who had received needle-stick injuries or cuts with sharp objects (i.e., parenteral exposures) and whose serum had been tested for HIV antibody at least 180 days after exposure, 4 were positive, yielding a seropreva- lence rate of 0.47%. Three of these individuals experienced an acute retroviral syndrome associated with documented seroconversion. Investigation revealed no nonoccupational risk factors for these three workers. Serumcollected within30days of exposure was not available from the fourth person. This worker had an HIV-seropositive sexual partner, and heterosexual acquisition of infection cannot be excluded. None of the 103 workers who had contamination of mucous membranes or nonintact skin and whose serum had been tested at least 180 days after exposure developed serologic evidence of HIV infection. Two other ongoing prospective studies assess the risk of nosocomial acquisition of HIV infectionamong health-care workers in the United States. As of April 1988, the National Institutes of Health had tested 983 health-care workers, 137 with docu- mented needle-stickinjuries and 345health-careworkers who had sustained mucous- membrane exposures to blood or other body fluids of HIV-infected patients; none had seroconverted (17) (one health-care worker who subsequently experienced an occupational HIV seroconversion has since been reported from NIH [18]). As of March 15, 1988, a similar study at the University of California of 212 health-care workers with 625 documented accidental parenteral exposures involving HIV-in- fected patients had identified one seroconversion following a needle stick (19). Prospective studies in the United Kingdom and Canada show no evidence of HIV MMWR June 23, 1989 transmissionamong220health-care workers with parenteral, mucous-membrane, or cutaneous exposures (20,21). In addition to the health-care workers enrolled in these longitudinal surveillance studies, case histories have been published in the scientific literature for 19 HIV- infected health-care workers (13 with documented seroconversion and 6 without documented seroconversion). None of these workers reported nonoccupational risk factors (see Table 2, pages 32,33). Emergency medical service and public-safety workers In addition to the one paramedic with undetermined risk discussed above, three public-safety workers (law-enforcement officers) are classified in the undetermined risk group. Follow-up investigations of these workers could not determine con- clusively if HIV infection was acquired during the performance of job duties. II. A. Vol. 38 / No. S-6 MMWR 9 Principles of Infection Control and Their Application to Emergency and Public-Safety Workers General Infection Control Within the health-caresetting, general infectioncontrol procedures have beendeveloped to minimize the risk of patient acquisition of infection from contact with contaminated devices, objects, or surfaces or of transmission of an infectious agent from health-care workers to patients (1,2,3). Such procedures also protect workers from the risk of becoming infected. General infection-control procedures are designed to prevent trans- mission of a wide range of microbiological agents and to provide a wide margin of safety in the varied situations encountered in the health-care environment. General infection-control principles are applicable to other work environments where workers contactother individuals and where transmission of infectious agents mayoccur. The modes of transmission noted in the hospital and medical office environment are observed in the work situations of emergency and public-safety workers, as well. There- fore, the principles of infection control developed for hospital and other health-care settings are also applicable to these work situations. Use of general infection control measures, as adapted to the workenvironments of emergency and public-safety workers, is important to protect both workers and individuals with whom they work from a variety of infectious agents, not just HIV and HBV. Because emergency and public-safety workers work in environments that provide in- herently unpredictable risks of exposures, general infection-control procedures should be adapted to these work situations. Exposures are unpredictable, and protective mea- sures may often be used in situations that do not appear to present risk. Emergency and public-safety workers perform their duties in the community under extremely variable conditions; thus, control measures that are simple and uniform across all situations have the greatest likelihood of worker compliance. Administrative procedures to ensure compliance also can be more readily developed than when procedures are complex and highly variable. Universal Blood and Body Fluid Precautions to Prevent Occupational HIV and HBV Transmission In 1985, CDC developed the strategy of “universal blood and body fluid precautions” to address concerns regarding transmission of HIV in the health-care setting (4). The concept, now referred to simply as “universal precautions” stresses that all patients should be assumed to be infectious for HIV and other blood-borne pathogens. In the hospital and other health-care setting, “universal precautions” should be followed when workers are exposed to blood, certain other body fluids (amniotic fluid, pericardial fluid, peritoneal fluid, pleural fluid, synovial fluid, cerebrospinal fluid, semen, and vaginal secretions), or any body fluid visibly contaminated with blood. Since HIV and HBV 10 MMWR June 23, 1989 transmission has not been documented from exposure to other body fluids (feces, nasal secretions, sputum, Sweat, tears, urine, and vomitus), “universal precautions” do not apply to these fluids. Universal precautions also do not apply to saliva, except in the dental setting, where saliva is likely to be contaminated with blood (7). For the purpose of this document, human “exposure” is defined as contact with blood or other body fluids to which universal precautions apply through percutaneous inoculation or contact with an open wound, nonintactskin, or mucous membrane during the perfor- mance of normal job duties. An “exposed worker” is defined, for the purposes of this document, as an individual exposed, as described above, while performing normal job duties. The unpredictable and emergent nature of exposures encountered by emergency and public-safety workers maymake differentiation between hazardous body fluids and those which are not hazardous very difficult and often impossible. For example, poor lighting may limit the worker's ability to detect visible bloodinvomitus or feces. Therefore, when emergency medicalandpublic-safetyworkersencounterbodyfluidsunderuncontrolled, emergency circumstances in which differentiation between fluidtypes is difficult, if not impossible, they should treat all body fluids as potentially hazardous. The application of the principles of universal precautions to the situations encountered by these workers results in the development of guidelines (listed below) for work prac- tices, use of personal protective equipment, and other protective measures. To minimize the risks of acquiring HIV and HBV during performance of job duties, emergency and public-safety workers should be protected from exposure to blood and other body fluids as circumstancesdictate. Protectioncanbeachieved throughadherence toworkpractices designed to minimize or eliminate exposure and through use of personal protective equipment (i.e., gloves, masks, and protective clothing), which provide a barrier between the worker and the exposure source. In some situations, redesign of selected aspects of the job through equipment modifications or environmental control can further reduce risk. These approaches to primary prevention should be used together to achieve maxi- mal reduction of the risk of exposure. If exposure of an individual worker occurs, medical management, consisting of collection of pertinent medical and occupational history, provision of treatment, and counseling regarding future work and personal behaviors, may reduce risk of developing disease as a result of the exposure episode (22). Following episodic (or continuous) exposure, decontamination and disinfection of the work environment, devices, equipment, and clothing or other forms of personal protective equipment can reduce subsequent risk of exposures. Proper disposal of contaminated waste has similar benefits. Vol. 38 / No. S-6 MMWR 11 III. Employer Responsibilities A. General Detailed recommendations for employer responsibilities in protecting workers from acquisition of blood-borne diseases in the workplace have been published in the Depart- mentof Laborand Department of Healthand Human Services Joint Advisory Noticeand are summarized here (6). In developing programs to protect workers, employers should follow a series of steps: 1) classification of work activity, 2) development of standard operating procedures, 3) provision of training and education, 4) development of proce- dures to ensure and monitor compliance, and 5) workplace redesign. As a first step, every employershould classify work activities into one of threecategories of potentialexposure (see Table 3, page 34). Employers should make protective equipment available to all workers when they are engaged in Category I or II activities. Employers should ensure that the appropriate protective equipment is used by workers when they perform Cate- gory I activities. As a second step, employers should establish a detailed work practices program that includes standard operating procedures (SOPs) for allactivities having the potential for exposure. Once these SOPs are developed, an initial and periodic worker education program to assure familiarity with work practices should be provided to potentially exposed workers. No worker should engage in such tasks or activities before receiving training pertaining to the SOPs, work practices, and protective equipment required for that task. Examples of personalprotective equipment for the prehospitalsetting(defined as a setting where delivery of emergency health care takes place away from a hospital or other health-care setting) are provided in Table 4 (page 35). (A curriculum for such training programs is being developed in conjunction with these guidelines and should be consulted for further information concerning such training programs.) To facilitate and monitor compliance with SOPs, administrative procedures should be developed and records kept as described in the Joint Advisory Notice (6), Employers should monitor the workplace to ensure that required work practices are observed and that protective clothing and equipment are provided and properly used. The employer should maintain records documenting the administrative procedures used to classify job activities and copies of all SOPs for tasks or activities involving predictable or unpredic- table exposure to blood or other body fluids to which universal precautions apply. In addition, training records, indicating the dates of training sessions, the content of those training sessions along with the names of all persons conducting the training, and the names of all those receiving training should also be maintained. Whenever possible, the employershould identifydevicesandotherapproaches to modify- ing the workenvironment which will reduce exposure risk. Such approaches are desira- ble, since they don't require individual worker action or management activity. For example, jailsandcorrectional facilitiesshould have classification procedures thatrequire 12 MMWR June 23, 1989 the segregation of offenders who indicate through their actions or words that they intend to attack correctional-facility staff with the intent of transmitting HIV or HBV. Medical In addition to the general responsibilities noted above, the employer has the specific responsibility to make available to the worker a program of medical management. This program is designed to provide for the reduction of risk of infection by HBV and for counseling workers concerning issues regarding HIV and HBV. These services should be provided by a licensed health professional. All phases of medical management and counselingshouldensure that the confidentiality of the worker's and client's medical data is protected. 1. Hepatitis B vaccination All workers whose jobs involve participation in tasks or activities with exposure to blood or other body fluids to which universal precautions apply (as defined above on page 9) should be vaccinated with hepatitis B vaccine, Management of percutaneous exposure to blood and other infectious body fluids Once an exposure has occurred (as defined above on page 10), a blood sample should bedrawn after consentisobtained from the individual from whomexposureoccurred and tested for hepatitisBsurfaceantigen (HBSAg)andantibody to humanimmunod- eficiency virus (HIV antibody). Local laws regarding consent for testing source individuals should be followed, Policies should be available for testing source in- dividuals in situations where consent cannot be obtained (e.g., an unconscious patient). Testing of the source individual should be done at a location where ap- propriate pretest counseling is available; posttest counseling and referral for treat- ment should be provided. It is extremely important that all individuals who seek consultation for any HIV-related concerns receive counseling as outlined in the “Public Health Service Guidelines for Counseling and Antibody Testing to Prevent HIV Infection and AIDS” (22). a. Hepatitis B virus postexposure management For an exposure to a source individual found to be positive for HBSAg, the worker who has not previously been given hepatitis B vaccine should receive the vaccine series. A single dose of hepatitis B immune globulin (HBIG) is also recommended, if this can be given within 7 days of exposure. For ex- posures from an HBSAg-positive source to workers who have previously received vaccine, the exposed workershould be tested for antibodytohepati- tisBsurface antigen (anti-HBs), and given one dose of vaccine and one dose Vol. 38 / No. S-6 MMWR 13 of HBIG if the antibody level in the worker's bloodsample is inadequate (i.e., < 10 SRU by RIA, negative by EIA) (7). If the source individual is negative for HBs.Ag and the worker has not been vaccinated, this opportunity should be taken to provide hepatitis B vaccina- tion, If the source individual refuses testing or he/she cannot be identified, the unvaccinated worker should receive the hepatitis B vaccine series, HBIG administration should be considered on an individual basis when the source individual is known or suspected to be at high risk of HBV infection. Man- agementand treatment, if any, of previously vaccinated workers who receive an exposure from a source who refuses testing or is not identifiable should be individualized (7). b. Human immunodeficiency virus postexposure management For any exposure to a source individual who has AIDS, who is found to be positive for HIV infection (4), or who refuses testing, the worker should be counseled regarding the risk of infection and evaluated clinically and serolo- gically for evidence of HIV infection as soon as possible after the exposure. Inviewof theevolving natureof HIV postexposure management, the health- care provider should be well informed of current PHS guidelines on this subject. The workershould be advised to reportandseek medical evaluation for any acute febrile illness that occurs within 12 weeks after the exposure. Suchanillness, particularly one characterized by fever, rash, or lymphadeno- pathy, may be indicative of recent HIV infection. Following the initial test at the time of exposure, seronegative workers should be retested 6 weeks, 12 weeks, and 6 months after exposure to determine whether transmission has occurred. During this follow-up period (especially the first 6-12 weeks after exposure, whenmost infected personsareexpected to seroconvert), exposed workers should follow U.S. Public Health Service (PHS) recommendations for preventing transmission of HIV (22). These include refraining from blood donation and using appropriate protection during sexual intercourse (23). During all phases of follow-up, it is vital that worker confidentiality be protected. If the source individual was tested and found to be seronegative, baseline testing of the exposed worker with follow-up testing 12 weeks later may be performed if desired by the worker or recommended by the health-care provider. 14 MMWR June 23, 1989 If thesource individualcannot be identified, decisions regarding appropriate follow-up should be individualized. Serologic testing should be made avail- able by the employer to all workers who may be concerned they have been infected with HIV through an occupational exposure as defined above (see page 10). 3. Management of human bites On occasion, police and correctional-facility officers are intentionally bitten by suspects or prisoners. When such bites occur, routine medical and surgical therapy (including an assessment of tetanus vaccination status) should be implemented as soon as possible, since such bites frequently result in infection with organisms other than HIV and HBV, Victims of bites should be evaluated as described above (see page 12) for exposure to blood or other infectious body fluids. Saliva of some persons infected with HBV has been shown to contain HBV-DNA at concentrations 1/1,000 to 1/10,000 of that found in the infected person's serum (5,24). HbsAg-positive saliva has been shown to be infectious when injected into experimental animals and in human bite exposures (25–27). However, HBs.Ag- positive saliva has not been shown to be infectious when applied to oral mucous membranes inexperimental primate studies (27) or through contamination of musi- cal instruments or cardiopulmonary resuscitation dummies used by HBV carriers (28,29). Epidemiologic studies of nonsexual household contacts of HIV-infected patients, includingseveralsmallseries in which HIV transmission failed to occur after bites or after percutaneous inoculation or contamination of cuts and open wounds with saliva from HIV-infected patients, suggest that the potential for salivary trans- mission of HIV is remote (5,30–33). One case report from Germany has suggested the possibility of transmission of HIV in a household setting from an infected child to a sibling through a human bite (34). The bite did not break the skin or result in bleeding. Since the date of seroconversion to HIV was not known for either child in this case, evidence for the role of saliva in the transmission of virus is unclear (34).) Documentation of exposure and reporting As part of the confidential medical record, the circumstances of exposure should be recorded. Relevant information includes the activity in which the worker was en- gaged at the time of exposure, the extent to which appropriate work practices and protective equipment were used, and a description of the source of exposure. Employers have a responsibility under various federaland state laws and regulations to report occupational illnesses and injuries. Existing programs in the National Institute for Occupational Safety and Health (NIOSH), Department of Health and Human Services; the Bureau of Labor Statistics, Department of Labor (DOL); and the OccupationalSafetyand Health Administration(DOL) receivesuchinformation Vol. 38 / No. S-6 MMWR 15 for the purposes of surveillance and other objectives. Cases of infectious disease, including AIDS and HBV infection, are reported to the Centers for Disease Control through State health departments. 5. Management of HBV- or HIV-infected workers Transmission of HBV from health-care workers to patients has been documented. Such transmission has occurred during certain types of invasive procedures (e.g., oral and gynecologic surgery) in which health-care workers, when tested, had very high concentrations of HBV in their blood (at least 100 million infectious virus particles per milliliter, a concentration much higher than occurs with HIV infection), and the health-care workers sustained a puncture wound while performing invasive proce- dures or had exudative or weeping lesions or microlacerations that allowed virus to contaminate instruments or open wounds of patients (35,36). A worker who is HBs.Ag positive and who has transmitted hepatitis B virus to another individual during the performance of his or her job duties should be excluded from the perfor- mance of those job duties which place other individuals at risk for acquisition of hepatitis B infection. Workers withinpaired immunesystems resulting from HIV infection orother causes are at increased risk of acquiring or experiencing serious complications of infectious disease. Of particular concern is the risk of severe infection following exposure to other persons with infectious diseases that are easily transmitted if appropriate precautions are not taken (e.g., measles, varicella). Any worker with an impaired immune system should be counseled about the potential risk associated with provi- ding health care to persons with any transmissible infection and should continue to follow existing recommendations for infection control to minimize risk of exposure to other infectious agents (2,3). Recommendations of the Immunization Practices Advisory Committee (ACIP) and institutional policies concerning requirements for vaccinating workers with live-virus vaccines (e.g., measles, rubella) should also be considered. The question of whether workers infected with HIV can adequately and safely be allowed to perform patient-care duties or whether their workassignments should be changed must be determined on an individual basis. These decisions should be made by the worker's personal physician(s) in conjunction with the employer's medical advisors. C. Disinfection, Decontamination, and Disposal As described in Section I.C. (see page 4), the only documented occupational risks of HIV and HBV infection are associated with parenteral (including open wound) and mucous membrane exposure to blood and other potentially infectious body fluids. Nevertheless, the precautions described below should be routinely followed. 16 MMWR June 23, 1989 Needle and sharps disposal All workers should take precautions to prevent injuries caused by needles, scalpel blades,andothersharpinstrumentsordevices during procedures; whencleaning used instruments; during disposal of used needles; and when handling sharp instruments after procedures. To prevent needle-stick injuries, needles should not be recapped, purposely bent or broken by hand, removed from disposable syringes, or otherwise manipulated by hand. After they are used, disposable syringes and needles, scalpel blades, and other sharp items should be placed in puncture-resistant containers for disposal; the puncture-resistant containers should be located as close as practical to the use area (e.g., in the ambulance or, if sharps are carried to the scene of victim assistance from theambulance,asmallpuncture-resistant containershould becarried to the scene, as well). Reusable needlesshould be left on the syringe body and should be placed in a puncture-resistant container for transport to the reprocessing area. Hand washing Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood, other body fluids to which universal precautions apply, or potentially contaminated articles. Hands should always be washed after gloves are removed, even if the gloves appear to be intact. Hand washing should be completed using the appropriate facilities, such as utility.orrestroomsinks. Waterless antiseptic hand cleanser should be provided on responding units to use when hand-washing facilities are not available. When hand-washing facilities are available, wash hands with warm water and soap. When hand-washing facilities are not available, use a waterless antiseptic hand cleanser. The manufacturer's recommendations for the product should be followed. Cleaning, disinfecting, and sterilizing Table 5 (see pages 36,37) presents the methods and applications for cleaning, disin- fecting, and sterilizing equipment and surfaces in the prehospital setting. These methods also apply to housekeeping and other cleaning tasks. Previously issued guidelines for health-care workers contain more detailed descriptions (4). Cleaning and decontaminating spills of blood Allspillsofbloodandblood-contaminated fluids should be promptlycleaned up using an EPA-approved germicideora 1:100solution of householdbleachin the following manner while wearing gloves. Visible material should first be removed with dis- posable towels or other appropriate means that will ensure against direct contact with blood. If splashing is anticipated, protective eyewear should be worn along with an impervious gown or apron which provides an effective barrier to splashes. The Vol. 38 / No. S-6 MMWR 17 area should then be decontaminated with an appropriate germicide, Hands should be washed following removal of gloves. Soiled cleaning equipmentshould be cleaned and decontaminated or placedinanappropriate container and disposed of according to agency policy. Plastic bags should be available for removal of contaminated items from the site of the spill. Shoes and boots can become contaminated with blood in certain instances. Where there is massiveblood contamination onfloors, the useof disposable impervious shoe coverings should be considered. Protective gloves should be worn to remove con- taminated shoe coverings. The coverings and gloves should be disposed of in plastic bags. A plastic bag should be included in the crime scene kit or the car which is to be used for the disposal of contaminated items. Extra plastic bags should be stored in the police cruiser or emergency vehicle. 5, Laundry Althoughsoiled linen maybe contaminated with pathogenic microorganisms, the risk of actual disease transmission is negligible. Rather than rigid procedures and specifi- cations, hygienic storage and processing of clean and soiled linen are recommended, Laundryfacilities and/orservicesshould be made routinelyavailable by the employer. Soiled linen should be handled as little as possible and with minimum agitation to prevent gross microbial contamination of the air and of persons handling the linen. All soiled linenshould be bagged at the location where it was used. Linensoiled with bloodshould be placed and transported in bags that prevent leakage. Normallaundry cycles should be used according to the washer and detergent manufacturers' recom- mendations. 6. Decontamination and laundering of protective clothing Protective work clothing contaminated with blood or other body fluids to which universal precautions apply should be placed and transported in bags or containers that prevent leakage. Personnel involved in the bagging, transport, and laundering of contaminated clothing should wear gloves, Protective clothing and station and work uniforms should be washed and dried according to the manufacturer's instruc- tions. Boots and leather goods may be brush-scrubbed with soap and hot water to remove contamination. 7. Infective waste The selection of procedures for disposal of infective waste is determined by the relative risk of disease transmission and application of local regulations, which vary widely. In all cases, local regulations should be consulted prior to disposal proce- dures and followed. Infective waste, in general, should either be incinerated or should be decontaminated before disposalinasanitarylandfill. Bulkblood, suctioned 18 MMWR June 23, 1989 fluids, excretions, and secretions may be carefully poured down adrain connected to a sanitary sewer, where permitted. Sanitary sewers may also be used to dispose of other infectious wastes capable of being ground and flushed into the sewer, where permitted. Sharp items should be placed in puncture-proof containers and other blood-contaminated items should be placed in leak-proof plastic bags for transport to an appropriate disposal location. Prior to the removalofprotective equipment, personnel remainingon thescene after the patient has been cared for should carefully search for and remove contaminated materials. Debris should be disposed of as noted above. Vol. 38 / No. S-6 MMWR 19 IV. Fire and Emergency Medical Services The guidelines that appear in this section apply to fire and emergency medical services. This includesstructuralfirefighters, paramedics, emergency medical technicians, and advanced life support personnel. Fire fighters often provide emergency medical services and therefore encounter the exposures common to paramedics and emergency medical technicians. Job duties are often performed in uncontrolled environments, which, due to a lack of time and other factors, do not allow for application of a complexdecision-making process to the emer- gency at hand. The general principles presented here have been developed from existing principles of occu- pational safety and health in conjunction with data from studies of health-care workers in hospital settings. The basic premise is that workers must be protected from exposure to blood and other potentially infectious body fluids in the course of their work activities. There is a paucity of data concerning the risks these worker groups face, however, which complicates development of control principles. Thus, the guidelines presented below are based on prin- ciples of prudent public health practice. Fire and emergency medical service personnel are engaged in delivery of medical care in the prehospitalsetting. The following guidelines are intended to assist these personnel in making decisions concerning use of personal protective equipment and resuscitation equipment, as well as for decontamination, disinfection, and disposal procedures. A. Personal Protective Equipment Appropriate personal protective equipment should be made available routinely by the employer to reduce the risk of exposure as defined above. For many situations, the chance that the rescuer will be exposed to blood and other body fluids to which universal precautions apply can be determined in advance. Therefore, if the chances of being exposed to blood is high (e.g., CPR, IV insertion, trauma, delivering babies), the worker should put on protective attire before beginning patient care. Table 4 (see page 35) sets forthexamples of recommendations for personal protective equipment in the prehospital setting; the list is not intended to be all-inclusive. 1. Gloves Disposable gloves should be a standard component of emergency response equip- ment, and should be donned by all personnel prior to initiatinganyemergency patient care tasks involving exposure to bloodorother body fluids to which universal precau- tions apply. Extra pairs should always be available. Considerations in the choice of disposable gloves should include dexterity, durability, fit, and the task being per- formed. Thus, there is no single type or thickness of glove appropriate for protection in all situations. For situations where large amounts of bloodare likely to be encoun- tered, it is important that gloves fittightly at the wrist to prevent blood contamination 20 MMWR June 23, 1989 of hands around the cuff. For multiple trauma victims, gloves should be changed between patient contacts, if the emergency situation allows. Greater personal protective equipment measures are indicated for situations where brokenglass and sharpedges are likely to be encountered, such as extricating aperson from an automobile wreck, Structural fire-fighting gloves that meet the Federal OSHA requirements for fire-fighters gloves (as contained in 29 CFR 1910,156 or National Fire Protection Association Standard 1973, Gloves for Structural Fire Fighters) should be worn in any situation where sharp or rough surfaces are likely to be encountered (37). While wearing gloves, avoid handling personal items, such as combs and pens, that could become Soiled or contaminated. Gloves that have become contaminated with blood or other body fluids to which universal precautions apply should be removed as soon as possible, taking care to avoid skin contact with the exterior surface. Contaminated gloves should be placed and transported in bags that prevent leakage and should be disposed of or, in the case of reusable gloves, cleaned and disinfected properly, Masks, eyewear, and gowns Masks, eyewear, and gowns should be presentonallemergency vehicles that respond or potentially respond to medical emergencies or victim rescues. These protective barriers should be used inaccordance with the levelof exposure encountered. Minor lacerations or small amounts of blood do not merit the same extent of barrier use as required for exsanguinating victims or massive arterial bleeding. Management of the patient who is not bleeding, and who has no bloody body fluids present, should not routinely require use of barrier precautions. Masks and eyewear (e.g., safety glasses) should be worn together, or a faceshield should be used by all personnel prior to any situation where splashes of bloodorother body fluids to whichuniversal precautions apply are likely to occur, Gowns or aprons should be worn to protect clothing from splashes with blood. If large splashes or quantities of blood are present or anticipa- ted, impervious gowns or aprons should be worn. An extra change of work clothing should be available at all times. Resuscitation equipment No transmission of HBV or HIV infection during mouth-to-mouth resuscitation has been documented. However, because of the risk of salivary transmission of other infectious diseases (e.g., herpes simplex and Neisseria meningitidis) and the theore- tical risk of HIV and HBV transmissionduringartificialventilationof traumavictims, disposableairway equipmentor resuscitation bags should be used. Disposable resus- citation equipment and devices should be used once and disposed of or, if reusable, Vol. 38 / No. S-6 MMWR 21 thoroughly cleaned and disinfected after each use according to the manufacturer's recommendations. Mechanical respiratory assist devices (e.g., bag-valve masks, oxygen demand valve resuscitators) should be available on all emergency vehicles and to all emergency response personnel that respond or potentially respond to medical emergencies or victim rescues. Pocketmouth-to-mouth resuscitationmasks designed to isolate emergency response personnel (i.e., double lumen systems) from contact with victims’ blood and blood- contaminated saliva, respiratory secretions, and vomitus should be provided to all personnel who provide or potentially provide emergency treatment. 22 MMWR June 23, 1989 V. Law-Enforcement and Correctional-Facility Officers Law-enforcement and correctional-facility officers may face the risk of exposure to blood during the conduct of their duties. For example, at the crime scene or during processing of suspects, law-enforcement officers may encounter blood-contaminated hypodermic needles or weapons, or be called upon to assist with body removal. Correctional-facility officers may similarly be required to search prisoners or their cells for hypodermic needles or weapons, or subdue violent and combative inmates. The following section presents information for reducing the risk of acquiring HIV and HBV infection by law-enforcement and correctional-facility officers as a consequence of carrying out their duties. However, there is an extremely diverse range of potential situations which mayoccur in the controlofpersons with unpredictable, violent, or psychoticbehavior. There- fore, informed judgment of the individual officer is paramount when unusual circumstances or events arise. These recommendations should serve as an adjunct to rational decision makingin thosesituations wherespecific guidelinesdonotexist, particularlywhere immediate action is required to preserve life or prevent significant injury. The following guidelines are arranged into three sections: a section addressing concerns shared by both law-enforcement and correctional-facility officers, and two sections dealing separately with law-enforcement officers and correctional-facility officers, respectively, Table 4 (see page 35) contains selected examples of personal protective equipment that may be employed by law-enforcement and correctional-facility officers. A. Law-Enforcement and Correctional-Facilities Considerations 1. Fights and assaults Law-enforcement and correctional-facility officers are exposed to a range of assaul- tive and disruptive behavior through which they may potentially become exposed to blood or other body fluids containing blood. Behaviors of particular concern are biting, attacks resulting in blood exposure, and attacks with sharp objects. Such behaviors may occur in a range of law-enforcement situations including arrests, routine interrogations, domesticdisputes, andlockup operations, as wellas incorrec- tional-facility activities. Hand-to-hand combat may result in bleeding and may thus incur a greater chance for blood-to-blood exposure, which increases the chances for blood-borne disease transmission. Whenever the possibility for exposure to blood or blood-contaminated body fluids exists, theappropriateprotectionshouldbeworn, iffeasible underthecircumstances. In all cases, extreme caution must be used in dealing with the suspect or prisoner if there is any indication of assaultive or combative behavior. When blood is present and a suspector an inmate is combative or threatening to staff, gloves should always Vol. 38 / No. S-6 MMWR 23 be put on as soon as conditions permit. In case of blood contamination of clothing, an extra change of clothing should be available at all times. 2. Cardiopulmonary resuscitation Law-enforcementandcorrectionalpersonnelarealsoconcernedaboutinfectionwith HIV and HBV through administration of cardiopulmonary resuscitation (CPR). Although there have been no documented cases of HIV transmission through this mechanism, the possibility of transmission of other infectious diseases exists. There- fore, agencies should make protective masks or airways available to officers and provide training in their proper use. Devices with one-way valves to prevent the patients’ saliva or vomitus from entering the caregiver's mouth are preferable. B. Law-Enforcement Considerations 1. Searches and evidence handling Criminal justice personnel have potential risks of acquiring HBV or HIV infection through exposures which occur during searches and evidence handling, Penetrating injuries are known to occur, and puncture wounds or needlesticks in particular pose a hazard during searches of persons, vehicles, or cells, and during evidence handling. The following precautionary measures will help to reduce the risk of infection: • An officer should use great caution in searching the clothing of suspects. Individual discretion, based on the circumstances at hand, should determine if a suspector prisonershould empty his own pockets or if the officer should use his own skills in determining the contents of a suspect's clothing. • A safe distance should always be maintained between the officer and the suspect. • Wear protective gloves if exposure to blood is likely to be encountered. • Wear protective gloves for all body cavity searches. • If cotton gloves are to be worn when working with evidence of potential latent fingerprint value at the crime scene, they can be worn over protective disposable gloves when exposure to blood may occur, • Always carry a flashlight, even during daylightshifts, to search hidden areas. Whenever possible, use long-handled mirrors and flashlights to search such areas (e.g., under car seats). 24 MMWR June 23, 1989 • Ifsearchingapurse, carefullyempty contents directly from purse, by turning it upside down over a table. • Use puncture-proof containers to store sharp instruments and clearly marked plastic bags to store other possibly contaminated items. • To avoid tearing gloves, use evidence tape instead of metal staples to seal evidence. • Local procedures forevidence handlingshould be followed. In general, items should be air dried before sealing in plastic, Not all types of gloves are suitable for conducting searches. Vinyl or latex rubber gloves providelittle protection against sharpinstruments, and they are not puncture- proof. There is a direct trade-off between levelof protection and manipulability. In other words, the thicker the gloves, the more protection they provide, but the less effective they are in locating objects. Thus, there is no single type or thickness of glove appropriate for protectionin all situations. Officers should select the type and thickness of glove which provides the best balance of protection and search effi- ciency. Officers and crime scene technicians may confront unusual hazards, especially when the crime scene involves violent behavior, such as a homicide where large amounts of blood are present. Protective gloves should be available and worn in this setting. In addition, for very large spills, consideration should be given to other protective clothing, such as overalls, aprons, boots, or protective shoe covers. They should be changed if torn or soiled, and always removed prior to leaving the scene. While wearing gloves, avoid handling personal items, such as combs and pens, that could become soiled or contaminated. Face masks and eye protection or a face shield are required for laboratory and evi- dence technicians whose jobs which entailpotential exposures to blood via a splash to the face, mouth, nose, or eyes. Airborne particles of dried blood may be generated when a stain is scraped. It is recommended that protective masks and eyewear or face shields be worn by labora- tory or evidence technicians when removing the bloodstain for laboratory analyses. While processing the crimescene, personnelshouldbealert for the presence of sharp objects such as hypodermic needles, knives, razors, brokenglass, nails, or other sharp objects. Vol. 38 / No. S-6 MMWR 25 2. Handling deceased persons and body removal For detectives, investigators, evidence technicians, and others who may have to touch or remove a body, the response should be the same as for situations requiring CPR or first aid; wear gloves and cover all cuts and abrasions to create a barrier and care- fully washallexposed areas after any contact with blood. The precautions to be used with blood and deceased persons should also be used when handling amputated limbs, hands, or other body parts. Such procedures should be followed after contact with the blood of anyone, regardless of whether they are known or suspected to be infected with HIV Or HBV. 3. Autopsies Protective masks and eyewear (or face shields), laboratory coats, gloves, and water- proofaprons should be wornwhen performingorattendingallautopsies. Allautopsy material should be considered infectious for both HIV and HBV. Onlookers with an opportunity for exposure to blood splashes should be similarly protected. Instru- ments and surfaces contaminated during postmortem procedures should be decon- taminated with anappropriate chemical germicide(4). Many laboratories have more detailed standard operating procedures for conducting autopsies; where available, these should be followed. More detailed recommendations for health-care workers in this setting have been published (4). 4. Forensic laboratories Blood from all individuals should be considered infective. To supplement other worksite precautions, the following precautions are recommended for workers in forensic laboratories. a. All specimens of blood should be put in a well-constructed, appropriately labelled container with a secure lid to prevent leaking during transport. Care should be taken when collecting each specimen to avoid contaminating the outside of the container and of the laboratory formaccompanying the specimen. b. All persons processing blood specimens should wear gloves. Masks and protec- tive eyewear or face shields should be worn if mucous-membrane contact with blood is anticipated (e.g., removing tops from vacuum tubes). Hands should be washed after completion of specimen processing. c. For routine procedures, such as histologicandpathologicstudies or microbiolo- gical culturing, a biological safety cabinet is not necessary. However, biological safety cabinets (Class I or II) should be used whenever procedures are conducted that have a high potential for generating droplets. These include activities such as blending, sonicating, and vigorous mixing, MMWR June 23, 1989 d. Mechanical pipetting devices should be used for manipulating all liquids in the laboratory. Mouth pipetting must not be done. e. Use of needles and syringes should be limited to situations in which there is no alternative, and the recommendations for preventing injuries with needles out- lined under universal precautions should be followed. f. Laboratory worksurfaces should be cleaned of visible materials and thendecon- taminated with an appropriate chemical germicide after aspill of blood, semen, or blood-contaminated body fluid and when work activities are completed. g, Contaminated materials used in laboratory tests should be decontaminated before reprocessing or be placed in bags and disposed of in accordance with institutional and local regulatory policies for disposal of infective waste, h. Scientific equipment that has been contaminated with blood should be cleaned and then decontaminated before being repaired in the laboratory or transported to the manufacturer, i. All persons should wash their hands after completing laboratory activities and should remove protective clothing before leaving the laboratory. j. Area posting of warning signs should be considered to remind employees of continuing hazard of infectious disease transmission in the laboratory setting, C. Correctional-Facility Considerations 1. Searches Penetrating injuries are known to occur in the correctional-facility setting, and puncture wounds or needle sticks in particular pose a hazard during searches of prisoners or their cells. The following precautionary measures will helptoreduce the risk of infection: • A correctional-facility officer should use great caution in searching the clothing of prisoners, Individual discretion, based on the circumstances at hand, should determine if a prisoner should empty his own pockets or if the officer should use his own skills in determining the contents of a prisoner's clothing, • A safe distance should always be maintained between the officer and the prisoner. Vol. 38 / No. S-6 MMWR 27 • Always carry a flashlight, even during daylight shifts, to search hidden areas. Whenever possible, use long-handled mirrors and flashlights to search such areas (e.g., under commodes, bunks, and in vents in jail cells), • Wear protective gloves if exposure to blood is likely to be encountered. • Wear protective gloves for all body cavity searches. Not all types of gloves are suitable for conducting searches. Vinyl or latex rubber gloves can providelittle, if any, protectionagainst sharpinstruments, and they are not puncture-proof. Thereisadirect trade-off between levelof protectionandmanipula- bility. In other words, the thicker the gloves, the more protection they provide, but the less effective they are in locating objects. Thus, there is no single type or thick- ness of glove appropriate for protection in all situations. Officers should select the type and thickness of glove which provides the best balance of protection and search efficiency. 2. Decontamination and disposal Prisoners may spitat officers and throw feces; sometimes these substances have been purposefully contaminated with blood. Although there are no documented cases of HIV or HBV transmission in this manner and transmission by this route would not be expected to occur, other diseases could be transmitted. These materials should be removed with a paper towel after donning gloves, and the area then decontaminated with an appropriate germicide. Following clean-up, soiled towels and gloves should be disposed of properly. 28 MMWR June 23, 1989 VI. References 1. 10, 11. 12, 13, GarnerJS, Favero MS, Guideline for handwashing and hospitalenvironmentalcontrol, 1985. Atlanta; Public Health Service, Centers for Disease Control, 1985. HHS publication no. 99-1117. GarnerJS,Simmons BP, Guideline for isolationprecautions inhospitals. Infect Control 1983; 4 (supply:245–325. Williams WW. Guideline for infection control in hospital personnel. Infect Control 1983; 4(supply:326–49. Centers for Disease Control. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987; 36 (suppl2S). Centers for Disease Control. Update: Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR 1988; 37:377–382,387–88. U.S. Department of Labor, U.S. Department of Health and Human Services. Joint Advisory Notice: protection against occupational exposure to hepatitis B virus (HBV) and human immunodeficiency virus (HIV). Federal Register 1987; 52:41818–24. Centers for Disease Control. Recommendations for protection against viral hepatitis. MMWR 1985; 34:313–324, 329–335. Kunches LM, Craven DE, Werner BG, Jacobs LM. Hepatitis Bexposure in emergency medical personnel: prevalence of serologic markers and need for immunization, Amer J Med 1983; 75:269–272. Pepe PE, Hollinger FB, TroisiCL, Heiberg D. Viral hepatitis risk in urban emergency medical services personnel. Annals Emergency Med 1986; 15(4):454–457. Valenzuela TD, Hook EW, Copass MK, Corey L. Occupational exposure to hepatitis B in paramedics. Arch Intern Med 1985; 145:1976–1977. Morgan-Capner P, Hudson P. Hepatitis B markers in Lancashire police officers. Epidemiol Inf 1988; 100:145–151. Peterkin M, Crawford R.J. Hepatitis B vaccine for police forces [Letter]? Lancet 1986; 2:1458–59, Radvan GH, Hewson EG, Berenger S, Brookman DJ. The Newcastle hepatitis B outbreak: observations on cause, management, and prevention. Med JAustralia 1986; Vol. 38 / No. S-6 MMWR 29 14. 15. 16, 17. 18. 19. 20. 21. 22. 23. 24. 25. 144:461–464. Centers for Disease Control. Inactivated hepatitis B virus vaccine. MMWR 1982; 26:317–322, 327–328, Centers for Disease Control. Update on hepatitis B prevention. MMWR 1987; 36:353–360,366. Marcus R, and the CDC Cooperative Needlestick Surveillance Group. Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus. NEngl J Med 1988; 319:1118–23. Henderson DK, Fahey BJ, Saah AJ, Schmitt JM, Lane HC. Longitudinal assessment of risk for occupational/nosocomial transmission of human immunodeficiency virus, type 1 in health care workers, Abstract #634; presented at the 1988 ICAAC Conference, New Orleans. Barnes DM. Health workers and AIDS: Questions persist. Science 1988; 241:161–2. Gerberding JL, Littell CG, Chambers HF, Moss AR, Carlson J, Drew W. Levy J, Sande MA. Riskofoccupational HIV transmissionin intensively exposed health-careworkers: Follow-up. Abstract #343; presented at the 1988 ICAAC Conference, New Orleans. Health and Welfare Canada. National surveillance programon occupationalexposures to HIV among health-care workers in Canada. Canada Dis Weekly Rep 1987; 13–37:163–6. McEvoy M, Porter K, Mortimer P, Simmons N, Shanson D. Prospectivestudy of clinical, laboratory, and ancillary staff with accidental exposures to blood or body fluids from patients infected with HIV. Br Med J 1987; 294:1595–7. Centers for Disease Control. Public Health Service guidelines for counseling and antibody testing to prevent HIV infection and AIDS, MMWR 1987; 36:509–515. Centers for Disease Control. Additional recommendations to reduce sexual and drug abuse-related transmission of human T-lymphotropic virus type III/lymphadenopathy- associated virus, MMWR 1986; 35:152–55. Jenison SA, Lemon SM, Baker LN, Newbold JE. Quantitative analysis of hepatitis B virus DNA in saliva and semen of chronically infected homosexual men. J Infect Dis 1987; 156:299–306. Cancio-Bello TP, de Medina M, Shorey J, Valledor MD, Schiff ER. An institutional outbreak of hepatitis B related to a human biting carrier. J Infect Dis 1982; 146:652–6. 30 MMWR June 23, 1989 26, 27. 28, 29. 30. 31. 32, 33. 34, 35. 36. 37. MacQuarrie MB, Forghani B, Wolochow DA. Hepatitis B transmitted by a humanbite, JAMA 1974; 230:723–4. Scott RM, Snitbhan R, Bancroft WH, Alter HJ, Tingpalapong M. Experimental transmission of hepatitis B virus by semen and saliva. J Infect Dis 1980; 142:67–71. Glaser JB, Nadler JP, Hepatitis B virus in a cardiopulmonary resuscitation training course: Risk of transmission from a surface antigen-positive participant. Arch Intern Med 1985; 145:1653–5. Osterholm MT, Bravo ER, Crosson JT,etal. Lackof transmission of viral hepatitis type B after oral exposure to HBSAg-positive saliva, Br Med J 1979; 2:1263–4. Lifson AR. Do alternate modes for transmission of human immunodeficiency virus exist? A review, JAMA 1988; 259:1353–6. Friedland GH, Saltzman BR, Rogers MF, etal, Lackof transmissionof HTLV-III/LAV infection to household contacts of patients with AIDS or AIDS-related complex with oral candidiasis. NEngl J Med 1986; 314:344–9. Curran JW, Jaffe HW, Hardy AM, et al. Epidemiology of HIV infection and AIDS in the United States. Science 1988; 239:610–6, Jason JM, McDougal JS, Dixon G, et al. HTLV-III/LAV antibody and immune status of household contacts and sexual partners of persons with hemophilia. JAMA 1986; 255:212–5, Wahn V, Kramer HH, Voit T, Brüster HT, Scrampical B, Scheid A. Horizontal transmission of HIV infection between two siblings [Letter]. Lancet 1986; 2.694. Kane MA, Lettau LA. Transmission of HBV from dental personnel to patients. JAm Dent Assoc 1985; 110:634–6. Lettau LA, Smith JD, Williams D, et al. Transmission of hepatitis B virus with resultant restriction of surgical practice. JAMA 1986; 255:934–7. International Association of Fire Fighters. Guidelines to prevent transmission of communicable disease during emergency care for fire fighters, paramedics, and emergency medical technicians. International Association of Fire Fighters, New York City, New York, 1988. Table 1. The Risk of HIV Infection Following Needlestick Injury: Hypothetical Model Probability of Infection Given Probability of Probability of Probability of Prevalence Needlestick Injury Infection Given Infection Given Infection Given Of HIV with Blood Random Needlestick 10 Random 100 Random Infection Containing HIV (Unknown Serostatus) Needlesticks Needlesticks (A) (B) A * B = (C) 1-(1-C)” 1-(1-C)” 0.0001 0.001 0.0000001 0.000001 0.00001 0.0001 0.005 0.0000005 0.000005 0.00005 0.001 0.001 0.000001 0.00001 0.0001 0.001 0.005 0.000005 0.00005 0.0005 0.01 0.001 0.00001 0.0001 0.001 0.01% 0.005 0.00005 0.0005 0.005 0.05 0.001 0.00005 0.0005 0.005 0.05 0.005 0.00025 0.0025 0.025 * For example, if the prevalence of infection in the population is 0.01 (i.e., 1 per 100) and the risk of a seroconversion following a needlestick with blood known to contain HIV is 0.005 (i.e., 1 in 200), then the probability of HIV infection given a random needlestick is 0.00005 (i.e., 5 in 100,000). If an individual sustains 10 needlestick injuries, the probability of acquiring HIV infection is 0.0005 (i.e., 1 in 2,000); if the individual sustains 100 needlestick injuries, the probability of acquiring HIV infection is 0.005 (i.e., 1 in 200). ; : ; *: 32 MMWR June 23, 1989 Table 2. HIV-infected health-care workers with no reported nonoccupational risk factors and for whom case histories have been Case Occupation 1+ NS! 2 NS 3 NS 4 NS 5 NS 6 Nurse 7 Nurse 8 Nurse 9 Research lab worker 10 Home health- care worker 11 NS 12 Phlebotomist 13 Technologist 14 NS 15 Nurse 16 Nurse 17 Navy medic 18 Clinical lab worker * AIDS case f Not specified Country published in the scientific literature Cases with Documented Seroconversion Type of Exposure Source United States Needlestick United States Needlestick United States Needlestick United States 2 Needlesticks United States Needlestick England Needlestick France Needlestick Martinique Needlestick United States Cut with sharp object United States Cutaneous # United States Nonintact skin United States Mucous-membrane United States Nonintact skin United States Needlestick Italy Mucous membrane France Needlestick United States Needlestick United States Cut with sharp object AIDS patient AIDS patient AIDS patient AIDS patient, HIV-infected patient AIDS patient AIDS patient HIV-infected patient AIDS patient Concentrated virus AIDS patient AIDS patient HIV-infected patient HIV-infected patient AIDS patient HIV-infected patient AIDS patient AIDS patient AIDS patient # Mother who provided nursing care for her child with HIV infection; extensive contact with the child's blood and body secretions and excretions occurred; the mother did not wear gloves and often did not wash her hands immediately after exposure. Vol. 38 / No. S-6 MMWR 33 Table 2, continued. HIV-infected health-care workers with no reported nonoccupational risk factors and for whom case histories have been published in the scientific literature Cases without Documented Seroconversion Case Occupation Country Type of Exposure Source 19 NS United States Puncture wound AIDS patient 20 NS United States 2 Needlesticks 2 AIDS patients 21 Research lab United States Nonintact skin Concentrated worker virus 22 Home health- England Nonintact skin AIDS patient care provider 23 Dentist United States Multiple needle- Unknown sticks 24* Technician Mexico Multiple needle- Unknown sticks and mucous-membrane 25 Lab worker United States Needlestick, Unknown puncture wound * AIDS case $: ; ; Joint Advisory Notice Category' I. II. III. Table 3. Summary of Task Categorization and Implications for Personal Protective Equipment Personal protective equipment should be: Nature of Task/Activity Available? WOrn? Direct contact with blood Yes Yes or other body fluids to which universal precautions apply Activity performed without - Yes NO blood exposure but exposure may occur in emergency Task/activity does not entail NO NO predictable or unpredictable exposure to blood *U.S. Department of Labor, U.S. Department of Health and Human Services. Joint advisory notice: protection against occupational exposure to hepatitis B virus (HBV) and human immunodeficiency virus (HIV). Washington, DC: US Department of Labor, US Department of Health and Human Services, 1987. Vol. 38 / No. S-6 Task or Activity Bleeding control with with spurting blood Bleeding control with minimal bleeding Emergency childbirth Blood drawing Starting an intravenous (IV) line Endotracheal intubation, esophageal obturator use Oral/nasal suctioning, manually cleaning airway Handling and cleaning instruments with microbial contamination Measuring blood pressure Measuring temperature Giving an injection Table 4. Examples of Recommended Personal Protective Equipment for MMWR 35 Worker Protection Against HIV and HBV Transmission' in Prehospital’Settings Disposable Gloves Yes Yes Yes At certain times 4 Yes No No Gown Yes No No No, unless solling is likely No No No Mask? Yes No Yes, if splashing is likely No No No, unless splashing is likely No, unless splashing is likely No No No No Protective Eyewear Yes No Yes, if splashing is likely No No No, unless splashing is likely No, unless splashing is likely No No No No "The examples provided in this table are based on application of universal precautions. Universal precautions are intended to supplement rather than replace reef -* - a (e.g., contact with urine or feces). for routine infection control, such as handwashing and using gloves to prevent gross microbial contamination of hands *Defined as setting where delivery of emergency health care takes place away from a hospital or other health-care facility. 3r-e---- a – – a 1 r masks toprevent devices, some of which are also referred to as "masks," is discussed on page 23. r frnucous 1- * - 1-1--- “For clarification see Appendix A, page 7, and Appendix B, page 7. A 1- A ul vulvi pu y vº ted body fluids. The useof resuscitation *While not clearly necessary to prevent HIV or HBV transmission unless blood is present, gloves are recommended to prevent transmission of other agents (e.g., Herpes simplex). 36 MMWR June 23, 1989 Sterilization: High-LevelDisinfection: Intermediate-Level Disinfection: Table 5. Reprocessing Methods for Equipment Used in the Destroys: Methods: Use: Destroys: Methods: Use: Destroys: Methods: Use: Prehospital' Health-Care Setting All forms of microbial life including high numbers of bacterial spores. Steam under pressure (autoclave), gas (ethylene oxide), dry heat, orimmersionin EPA-approvedchemical"sterilant”forprolonged period of time, e.g., 6–10 hours or according to manufacturers' instructions. Note: liquidchemical"sterilants"should be used only on those instruments that are impossible to sterilize or disinfect with heat. For those instruments or devices that penetrate skin or contact normally sterile areas of the body, e.g., scalpels, needles, etc. Disposable invasive equipment eliminates the need to reprocess these types of items. When indicated, however, arrangements should be made with a health-care facility for reprocessing of reusable invasive instruments. All forms of microbiallife except high numbers of bacterialspores. Hot water pasteurization (80–100C, 30 minutes) or exposure to an EPA-registered “sterilant"chemicalasabove, except for ashort exposure time (10–45 minutes or as directed by the manufacturer). For reusable instruments or devices that come into contact with mucous membranes (e.g., laryngoscope blades, endotracheal tubes, etc.). Mycobacterium tuberculosis, vegetative bacteria, most viruses, and most fungi, but does not kill bacterial spores. EPA-registered “hospital disinfectant” chemical germicides that have a label claim for tuberculocidal activity; commercially available hard-surface germicides or solutions containing at least 500 ppm free available chlorine (a 1:100 dilution of common household bleach—approximately 9% cup bleach per gallon of tap water). For thosesurfaces thatcome into contactonly withintactskin, e.g., stethoscopes, blood pressure cuffs, splints, etc., and have been visibly contaminated with blood or bloody body fluids. Surfaces must be precleaned of visible material before the germicidal chemical is applied for disinfection. Vol. 38 / No. S-6 MMWR 37 Table 5. Reprocessing Methods for Equipment Used in the Prehospital' Health-Care Setting – Continued Low-Level Disinfection: Destroys: Methods: Use: Environmental Disinfection: Most bacteria, some viruses, some fungi, but not Mycobacterium tuberculosis or bacterial spores. EPA-registered “hospital disinfectants” (no label claim for tuberculocidal activity). These agents are excellent cleaners and can be used for routine housekeeping or removal of soiling in the absence of visible blood contamination. Environmental surfaces which have become soiled should be cleaned and disinfected using any cleaner or disinfectant agent which is intended for environmental use, Such surfaces include floors, woodwork, ambulance seats, countertops, etc. IMPORTANT: Toassure the effectiveness of anysterilization ordisinfection process, equipment and instruments must first be thoroughly cleaned of all visible soil. ‘Defined assetting where delivery of emergency health-care takes place prior to arrival at hospital or other health- care facility, Reprinted by the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE CENTERS FOR DISEASE CONTROL August 21, 1987 / Vol. 36 / No. 2S Supplement MORBIDITY AND MORTALITY WEEKLY REPORT Recommendations for Prevention of HIV Transmission in Health-Care Settings U. S. Department of Health and Human Services Public Health Service Centers for Disease Control Atlanta, Georgia 30333 Supplements to the MMWR are published by the Epidemiology Program Office, Centers for Disease Control, Public Health Service, U.S. Department of Health and Human Services, Atlanta, Georgia 30333. SUGGESTED CITATION Centers for Disease Control. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36 (suppl no. 2S) :[inclusive page numbers]. Centers for Disease Control ......................................... James O. Mason, M.D., Dr.P.H. Director The material in this report was developed (in collaboration with the Center for Prevention Services, the National Institute for Occupational Safety and Health, and the Training and Laboratory Program Office) by: Center for Infectious Diseases............................. Frederick A. Murphy, D.V.M., Ph.D. Acting Director Hospital Infections Program............................................... James M. Hughes, M.D. Director AIDS Program........................................................................ James W. Curran, M.D. Director Publications and Graphics................................................. Frances H. Porcher, M.A. Chief Karen L. Foster, M.A. Consulting Editor This report was prepared in: Epidemiology Program Office ................................................ Carl W. Tyler, Jr., M.D. Director Michael B. Gregg, M.D. Editor, MMWR Editorial Services ............................................................... R. Elliott Churchill, M.A. Chief Ruth Greenberg Editorial Assistant MMWR Supplement – August 21, 1987, Vol. 36, No. 2S Recommendations for Prevention of HIV Transmission in Health-Care Settings Introduction Human immunodeficiency virus (HIV), the virus that causes acquired immuno- deficiency syndrome (AIDS), is transmitted through sexual contact and exposure to infected blood or blood components and perinatally from mother to neonate. HIV has been isolated from blood, semen, vaginal secretions, saliva, tears, breast milk, cerebrospinal fluid, amniotic fluid, and urine and is likely to be isolated from other body fluids, secretions, and excretions. However, epidemiologic evidence has impli- cated only blood, semen, vaginal secretions, and possibly breast milk in transmission. The increasing prevalence of HIV increases the risk that health-care workers will be exposed to blood from patients infected with HIV, especially when blood and body- fluid precautions are not follovved for all patients. Thus, this document emphasizes the need for health-care workers to consider all patients as potentially infected with HIV and/or other blood-borne pathogens and to adhere rigorously to infection-control precautions for minimizing the risk of exposure to blood and body fluids of all patients. The recommendations contained in this document consolidate and update CDC recommendations published earlier for preventing HIV transmission in health-care settings: precautions for clinical and laboratory staffs (1) and precautions for health-care workers and allied professionals (2); recommendations for preventing HIV transmission in the workplace (3) and during invasive procedures (4); recom- mendations for preventing possible transmission of HIV from tears (5); and recom- mendations for providing dialysis treatment for HIV-infected patients (6). These recommendations also update portions of the "Guideline for Isolation Precautions in Hospitals" (7) and reemphasize some of the recommendations contained in "Infection Control Practices for Dentistry” (8). The recommendations contained in this docu- ment have been developed for use in health-care settings and emphasize the need to treat blood and other body fluids from all patients as potentially infective. These same prudent precautions also should be taken in other settings in which persons may be exposed to blood or other body fluids. Definition of Health-Care Workers Health-care workers are defined as persons, including students and trainees, whose activities involve contact with patients or with blood or other body fluids from patients in a health-care setting. 95 August 21, 1987 — Supplement Health-Care Workers with AIDS As of July 10, 1987, a total of 1,875 (5.8%) of 32,395 adults with AIDS, who had been reported to the CDC national surveillance system and for whom occupational information was available, reported being employed in a health-care or clinical laboratory setting. In comparison, 6.8 million persons—representing 5.6% of the U.S. labor force—were employed in health services. Of the health-care workers with AIDS, 95% have been reported to exhibit high-risk behavior; for the remaining 5%, the means of HIV acquisition was undetermined. Health-care workers with AIDS were significantly more likely than other workers to have an undetermined risk (5% versus 3%, respectively). For both health-care workers and non-health-care workers with AlDS, the proportion with an undetermined risk has not increased since 1982. AlDS patients initially reported as not belonging to recognized risk groups are investigated by state and local health departments to determine whether possible risk factors exist. Of all health-care workers with AIDS reported to CDC who were initially characterized as not having an identified risk and for whom follow-up information was available, 66% have been reclassified because risk factors were identified or because the patient was found not to meet the surveillance case definition for AIDS. Of the 87 health-care workers currently categorized as having no identifiable risk, information is incomplete on 16 (18%) because of death or refusal to be interviewed; 38 (44%) are still being investigated. The remaining 33 (38%) health-care workers were interviewed or had other follow-up information available. The occupations of these 33 were as follows: five physicians (15%), three of whom were surgeons; one dentist (3%); three nurses (9%); nine nursing assistants (27%); seven housekeeping or maintenance workers (21%); three clinical laboratory technicians (9%); one therapist (3%); and four others who did not have contact with patients (12%). Although 15 of these 33 health-care workers reported parenteral and/or other non-needlestick exposure to blood or body fluids from patients in the 10 years preceding their diagnosis of AIDS, none of these exposures involved a patient with AIDS or known HIV infection. Risk to Health-Care Workers of Acquiring HIV in Health-Care Settings Health-care workers with documented percutaneous or mucous-membrane expo- sures to blood or body fluids of HIV-infected patients have been prospectively evaluated to determine the risk of infection after such exposures. As of June 30, 1987, 883 health-care workers have been tested for antibody to HIV in an ongoing surveillance project conducted by CDC (9). Of these, 708 (80%) had percutaneous exposures to blood, and 175 (20%) had a mucous membrane or an open wound contaminated by blood or body fluid. Of 396 health-care workers, each of whom had only a convalescent-phase serum sample obtained and tested =90 days post- exposure, one — for whom heterosexual transmission could not be ruled out — was seropositive for HIV antibody. For 425 additional health-care workers, both acute- and convalescent-phase serum samples were obtained and tested; none of 74 health-care workers with nonpercutaneous exposures seroconverted, and three (0.9%) of 351 96 August 21, 1987 — Supplement with percutaneous exposures seroconverted. None of these three health-care workers had other documented risk factors for infection. Two other prospective studies to assess the risk of nosocomial acquisition of HIV infection for health-care workers are ongoing in the United States. As of April 30, 1987, 332 health-care workers with a total of 453 needlestick or mucous-membrane exposures to the blood or other body fluids of HIV-infected patients were tested for HIV antibody at the National Institutes of Health (10). These exposed workers included 103 with needlestick injuries and 229 with mucous-membrane exposures; none had seroconverted. A similar study at the University of California of 129 health-care workers with documented needlestick injuries or mucous-membrane exposures to blood or other body fluids from patients with HIV infection has not identified any seroconversions (11). Results of a prospective study in the United Kingdom identified no evidence of transmission among 150 health-care workers with parenteral or mucous-membrane exposures to blood or other body fluids, secretions, or excretions from patients with HIV infection (12). In addition to health-care workers enrolled in prospective studies, eight persons who provided care to infected patients and denied other risk factors have been reported to have acquired HIV infection. Three of these health-care workers had needlestick exposures to blood from infected patients (13-15). Two were persons who provided nursing care to infected persons; although neither sustained a needlestick, both had extensive contact with blood or other body fluids, and neither observed recommended barrier precautions (16,17). The other three were health- care workers with non-needlestick exposures to blood from infected patients (18). Although the exact route of transmission for these last three infections is not known, all three persons had direct contact of their skin with blood from infected patients, all had skin lesions that may have been contaminated by blood, and one also had a mucous-membrane exposure. A total of 1,231 dentists and hygienists, many of whom practiced in areas with many AlDS cases, participated in a study to determine the prevalence of antibody to HIV; one dentist (0.1%) had HIV antibody. Although no exposure to a known HIV-infected person could be documented, epidemiologic investigation did not identify any other risk factor for infection. The infected dentist, who also had a history of sustaining needlestick injuries and trauma to his hands, did not routinely wear gloves when providing dental care (19). Precautions To Prevent Transmission of HIV Universal Precautions Since medical history and examination cannot reliably identify all patients infected with HIV or other blood-borne pathogens, blood and body-fluid precautions should be consistently used for all patients. This approach, previously recommended by CDC (3,4), and referred to as "universal blood and body-fluid precautions" or "universal precautions," should be used in the care of all patients, especially including those in emergency-care settings in which the risk of blood exposure is increased and the infection status of the patient is usually unknown (20). 97 August 21, 1987 — Supplement 1. All health-care workers should routinely use appropriate barrier precautions to prevent skin and mucous-membrane exposure when contact with blood or other body fluids of any patient is anticipated. Gloves should be worn for touching blood and body fluids, mucous membranes, or non-intact skin of all patients, for handling items or surfaces soiled with blood or body fluids, and for performing venipuncture and other vascular access procedures. Gloves should be changed after contact with each patient. Masks and protective eyewear or face shields should be worn during procedures that are likely to generate droplets of blood or other body fluids to prevent exposure of mucous mem- branes of the mouth, nose, and eyes. Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or other body fluids. 2. Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood or other body fluids. Hands should be washed immediately after gloves are removed. 3. All health-care workers should take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices during procedures; when cleaning used instruments; during disposal of used needles; and when handling sharp instruments after procedures. To prevent needlestick injuries, needles should not be recapped, purposely bent or broken by hand, removed from disposable syringes, or otherwise manipulated by hand. After they are used, disposable syringes and needles, scalpel blades, and other sharp items should be placed in puncture-resistant containers for disposal; the puncture- resistant containers should be located as close as practical to the use area. Large-bore reusable needles should be placed in a puncture-resistant container for transport to the reprocessing area. 4. Although saliva has not been implicated in HIV transmission, to minimize the need for emergency mouth-to-mouth resuscitation, mouthpieces, resuscitation bags, or other ventilation devices should be available for use in areas in which the need for resuscitation is predictable. 5. Health-care workers who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient-care equipment until the condition resolves. 6. Pregnant health-care workers are not known to be at greater risk of contracting HIV infection than health-care workers who are not pregnant; however, if a health-care worker develops HIV infection during pregnancy, the infant is at risk of infection resulting from perinatal transmission. Because of this risk, pregnant health-care workers should be especially familiar with and strictly adhere to precautions to minimize the risk of HIV transmission. Implementation of universal blood and body-fluid precautions for all patients eliminates the need for use of the isolation category of "Blood and Body Fluid Precautions" previously recommended by CDC (7) for patients known or suspected to be infected with blood-borne pathogens. Isolation precautions (e.g., enteric, “AFB" [7]) should be used as necessary if associated conditions, such as infectious diarrhea or tuberculosis, are diagnosed or suspected. Precautions for Invasive Procedures In this document, an invasive procedure is defined as surgical entry into tissues, cavities, or organs or repair of major traumatic injuries 1) in an operating or delivery 98 August 21, 1987 — Supplement room, emergency department, or outpatient setting, including both physicians' and dentists' offices; 2) cardiac catheterization and angiographic procedures; 3) a vaginal or cesarean delivery or other invasive obstetric procedure during which bleeding may occur; or 4) the manipulation, cutting, or removal of any oral or perioral tissues, including tooth structure, during which bleeding occurs or the potential for bleeding exists. The universal blood and body-fluid precautions listed above, combined with the precautions listed below, should be the minimum precautions for all such invasive procedures. 1. All health-care workers who participate in invasive procedures must routinely use appropriate barrier precautions to prevent skin and mucous-membrane contact with blood and other body fluids of all patients. Gloves and surgical masks must be worn for all invasive procedures. Protective eyewear or face shields should be worn for procedures that commonly result in the generation of droplets, splashing of blood or other body fluids, or the generation of bone chips. Gowns or aprons made of materials that provide an effective barrier should be worn during invasive procedures that are likely to result in the splashing of blood or other body fluids. All health-care workers who perform or assist in vaginal or cesarean deliveries should wear gloves and gowns when handling the placenta or the infant until blood and amniotic fluid have been removed from the infant's skin and should wear gloves during post-delivery care of the umbilical cord. 2. If a glove is torn or a needlestick or other injury occurs, the glove should be removed and a new glove used as promptly as patient safety permits; the needle or instrument involved in the incident should also be removed from the sterile field. Precautions for Dentistry” Blood, saliva, and gingival fluid from all dental patients should be considered infective. Special emphasis should be placed on the following precautions for preventing transmission of blood-borne pathogens in dental practice in both institu- tional and non-institutional settings. 1. In addition to wearing gloves for contact with oral mucous membranes of all patients, all dental workers should wear surgical masks and protective eyewear or chin-length plastic face shields during dental procedures in which splashing or spattering of blood, saliva, or gingival fluids is likely. Rubber dams, high- speed evacuation, and proper patient positioning, when appropriate, should be utilized to minimize generation of droplets and spatter. 2. Handpieces should be sterilized after use with each patient, since blood, saliva, or gingival fluid of patients may be aspirated into the handpiece or waterline. Handpieces that cannot be sterilized should at least be flushed, the outside surface cleaned and wiped with a suitable chemical germicide, and then rinsed. Handpieces should be flushed at the beginning of the day and after use with each patient. Manufacturers' recommendations should be followed for use and maintenance of waterlines and check valves and for flushing of handpieces. The same precautions should be used for ultrasonic scalers and air/water syringes. *General infection-control precautions are more specifically addressed in previous recommen- dations for infection-control practices for dentistry (8). 99 August 21, 1987 — Supplement 3. Blood and saliva should be thoroughly and carefully cleaned from material that has been used in the mouth (e.g., impression materials, bite registration), especially before polishing and grinding intra-oral devices. Contaminated materials, impressions, and intra-oral devices should also be cleaned and disinfected before being handled in the dental laboratory and before they are placed in the patient's mouth. Because of the increasing variety of dental materials used intra-orally, dental workers should consult with manufacturers as to the stability of specific materials when using disinfection procedures. 4. Dental equipment and surfaces that are difficult to disinfect (e.g., light handles or X-ray-unit heads) and that may become contaminated should be wrapped with impervious-backed paper, aluminum foil, or clear plastic wrap. The coverings should be removed and discarded, and clean coverings should be put in place after use with each patient. Precautions for Autopsies or Morticians' Services In addition to the universal blood and body-fluid precautions listed above, the following precautions should be used by persons performing postmortem procedures: 1. All persons performing or assisting in postmortem procedures should wear gloves, masks, protective eyewear, gowns, and waterproof aprons. 2. Instruments and surfaces contaminated during postmortem procedures should be decontaminated with an appropriate chemical germicide. Precautions for Dialysis Patients with end-stage renal disease who are undergoing maintenance dialysis and who have HIV infection can be dialyzed in hospital-based or free-standing dialysis units using conventional infection-control precautions (21). Universal blood and body-fluid precautions should be used when dialyzing all patients. Strategies for disinfecting the dialysis fluid pathways of the hemodialysis machine are targeted to control bacterial contamination and generally consist of using 500-750 parts per million (ppm) of sodium hypochlorite (household bleach) for 30-40 minutes or 1.5%-2.0% formaldehyde overnight. In addition, several chemical germicides formulated to disinfect dialysis machines are commercially available. None of these protocols or procedures need to be changed for dialyzing patients infected with HIV. Patients infected with HIV can be dialyzed by either hemodialysis or peritoneal dialysis and do not need to be isolated from other patients. The type of dialysis treatment (i.e., hemodialysis or peritoneal dialysis) should be based on the needs of the patient. The dialyzer may be discarded after each use. Alternatively, centers that reuse dialyzers—i.e., a specific single-use dialyzer is issued to a specific patient, removed, cleaned, disinfected, and reused several times on the same patient only— may include HIV-infected patients in the dialyzer-reuse program. An individual dialyzer must never be used on more than one patient. Precautions for Laboratories' Blood and other body fluids from all patients should be considered infective. To Supplement the universal blood and body-fluid precautions listed above, the follow- ing precautions are recommended for health-care workers in clinical laboratories. 'Additional precautions for research and industrial laboratories are addressed elsewhere (22.23). 100 August 21, 1987 — Supplement 1. All specimens of blood and body fluids should be put in a well-constructed container with a secure lid to prevent leaking during transport. Care should be taken when collecting each specimen to avoid contaminating the outside of the container and of the laboratory form accompanying the specimen. 2. All persons processing blood and body-fluid specimens (e.g., removing tops from vacuum tubes) should wear gloves. Masks and protective eyewear should be worn if mucous-membrane contact with blood or body fluids is anticipated. Gloves should be changed and hands washed after completion of specimen processing. 3. For routine procedures, such as histologic and pathologic studies or microbio- logic culturing, a biological safety cabinet is not necessary. However, biological safety cabinets (Class I or ll) should be used whenever procedures are con- ducted that have a high potential for generating droplets. These include activities such as blending, sonicating, and vigorous mixing. 4. Mechanical pipetting devices should be used for manipulating all liquids in the laboratory. Mouth pipetting must not be done. 5. Use of needles and syringes should be limited to situations in which there is no alternative, and the recommendations for preventing injuries with needles outlined under universal precautions should be followed. 6. Laboratory work surfaces should be decontaminated with an appropriate chemical germicide after a spill of blood or other body fluids and when work activities are completed. - 7. Contaminated materials used in laboratory tests should be decontaminated before reprocessing or be placed in bags and disposed of in accordance with institutional policies for disposal of infective waste (24). 8. Scientific equipment that has been contaminated with blood or other body fluids should be decontaminated and cleaned before being repaired in the laboratory or transported to the manufacturer. 9. All persons should wash their hands after completing laboratory activities and should remove protective clothing before leaving the laboratory. Implementation of universal blood and body-fluid precautions for all patients eliminates the need for warning labels on specimens since blood and other body fluids from all patients should be considered infective. Environmental Considerations for HIV Transmission No environmentally mediated mode of HIV transmission has been documented. Nevertheless, the precautions described below should be taken routinely in the care of all patients. Sterilization and Disinfection Standard sterilization and disinfection procedures for patient-care equipment currently recommended for use (25,26) in a variety of health-care settings—including hospitals, medical and dental clinics and offices, hemodialysis centers, emergency- care facilities, and long-term nursing-care facilities—are adequate to sterilize or disinfect instruments, devices, or other items contaminated with blood or other body fluids from persons infected with blood-borne pathogens including HIV (21,23). 101 August 21, 1987 — Supplement Instruments or devices that enter sterile tissue or the vascular system of any patient or through which blood flows should be sterilized before reuse. Devices or items that contact intact mucous membranes should be sterilized or receive high- level disinfection, a procedure that kills vegetative organisms and viruses but not necessarily large numbers of bacterial spores. Chemical germicides that are regis- tered with the U.S. Environmental Protection Agency (EPA) as "sterilants" may be used either for sterilization or for high-level disinfection depending on contact time. Contact lenses used in trial fittings should be disinfected after each fitting by using a hydrogen peroxide contact lens disinfecting system or, if compatible, with heat (78 C-80 C (172.4 F-176.0 F]) for 10 minutes. Medical devices or instruments that require sterilization or disinfection should be thoroughly cleaned before being exposed to the germicide, and the manufacturer's instructions for the use of the germicide should be followed. Further, it is important that the manufacturer's specifications for compatibility of the medical device with chemical germicides be closely followed. Information on specific label claims of commercial germicides can be obtained by writing to the Disinfectants Branch, Office of Pesticides, Environmental Protection Agency, 401 M Street, SW, Washington, D.C. 20460. Studies have shown that HIV is inactivated rapidly after being exposed to commonly used chemical germicides at concentrations that are much lower than used in practice (27-30). Embalming fluids are similar to the types of chemical germicides that have been tested and found to completely inactivate HIV. In addition to commercially available chemical germicides, a solution of sodium hypochlorite (household bleach) prepared daily is an inexpensive and effective germicide. Con- centrations ranging from approximately 500 ppm (1:100 dilution of household bleach) sodium hypochlorite to 5,000 ppm (1:10 dilution of household bleach) are effective depending on the amount of organic material (e.g., blood, mucus) present on the surface to be cleaned and disinfected. Commercially available chemical germicides may be more compatible with certain medical devices that might be corroded by repeated exposure to sodium hypochlorite, especially to the 1:10 dilution. Survival of HIV in the Environment The most extensive study on the survival of HIV after drying involved greatly concentrated HIV samples, i.e., 10 million tissue-culture infectious doses per milliliter (31). This concentration is at least 100,000 times greater than that typically found in the blood or serum of patients with HIV infection. HIV was detectable by tissue-culture techniques 1-3 days after drying, but the rate of inactivation was rapid. Studies performed at CDC have also shown that drying HIV causes a rapid (within several hours) 1-2 log (90%-99%) reduction in HIV concentration. In tissue-culture fluid, cell-free HIV could be detected up to 15 days at room temperature, up to 11 days at 37 C (98.6 F), and up to 1 day if the HIV was cell-associated. When considered in the context of environmental conditions in health-care facilities, these results do not require any changes in currently recommended sterilization, disinfection, or housekeeping strategies. When medical devices are contaminated with blood or other body fluids, existing recommendations include the cleaning of these instruments, followed by disinfection or sterilization, depending on the type of medical device. These protocols assume "worst-case" conditions of 102 August 21, 1987 — Supplement extreme virologic and microbiologic contamination, and whether viruses have been inactivated after drying plays no role in formulating these strategies. Consequently, no changes in published procedures for cleaning, disinfecting, or sterilizing need to be made. Housekeeping Environmental surfaces such as walls, floors, and other surfaces are not associated with transmission of infections to patients or health-care workers. Therefore, extra- ordinary attempts to disinfect or sterilize these environmental surfaces are not necessary. However, cleaning and removal of soil should be done routinely. Cleaning schedules and methods vary according to the area of the hospital or institution, type of surface to be cleaned, and the amount and type of soil present. Horizontal surfaces (e.g., bedside tables and hard-surfaced flooring) in patient-care areas are usually cleaned on a regular basis, when soiling or spills occur, and when a patient is discharged. Cleaning of walls, blinds, and curtains is recommended only if they are visibly soiled. Disinfectant fogging is an unsatisfactory method of decontaminating air and surfaces and is not recommended. Disinfectant-detergent formulations registered by EPA can be used for cleaning environmental surfaces, but the actual physical removal of microorganisms by scrubbing is probably at least as important as any antimicrobial effect of the cleaning agent used. Therefore, cost, safety, and acceptability by housekeepers can be the main criteria for selecting any such registered agent. The manufacturers' instructions for appropriate use should be followed. Cleaning and Decontaminating Spills of Blood or Other Body Fluids Chemical germicides that are approved for use as "hospital disinfectants" and are tuberculocidal when used at recommended dilutions can be used to decontaminate spills of blood and other body fluids. Strategies for decontaminating spills of blood and other body fluids in a patient-care setting are different than for spills of cultures or other materials in clinical, public health, or research laboratories. In patient-care areas, visible material should first be removed and then the area should be decontaminated. With large spills of cultured or concentrated infectious agents in the laboratory, the contaminated area should be flooded with a liquid germicide before cleaning, then decontaminated with fresh germicidal chemical. In both settings, gloves should be worn during the cleaning and decontaminating procedures. Laundry Although soiled linen has been identified as a source of large numbers of certain pathogenic microorganisms, the risk of actual disease transmission is negligible. Rather than rigid procedures and specifications, hygienic and common-sense storage and processing of clean and soiled linen are recommended (26). Soiled linen should be handled as little as possible and with minimum agitation to prevent gross microbial contamination of the air and of persons handling the linen. All soiled linen should be bagged at the location where it was used; it should not be sorted or rinsed in patient-care areas. Linen soiled with blood or body fluids should be placed and transported in bags that prevent leakage. If hot water is used, linen should be washed 103 August 21, 1987 — Supplement with detergent in water at least 71 C (160 F) for 25 minutes. If low-temperature(s/0 C (158 FI) laundry cycles are used, chemicals suitable for low-temperature washing at proper use concentration should be used. infective Waste There is no epidemiologic evidence to suggest that most hospital waste is any more infective than residential waste. Moreover, there is no epidemiologic evidence that hospital waste has caused disease in the community as a result of improper disposal. Therefore, identifying wastes for which special precautions are indicated is largely a matter of judgment about the relative risk of disease transmission. The most practical approach to the management of infective waste is to identify those wastes with the potential for causing infection during handling and disposal and for which some special precautions appear prudent. Hospital wastes for which special precau- tions appear prudent include microbiology laboratory waste, pathology waste, and blood specimens or blood products. While any item that has had contact with blood, exudates, or secretions may be potentially infective, it is not usually considered practical or necessary to treat all such waste as infective (23,26). Infective waste, in general, should either be incinerated or should be autoclaved before disposal in a sanitary landfill. Bulk blood, suctioned fluids, excretions, and secretions may be carefully poured down a drain connected to a sanitary sewer. Sanitary sewers may also be used to dispose of other infectious wastes capable of being ground and flushed into the sewer. Implementation of Recommended Precautions Employers of health-care workers should ensure that policies exist for: 1. Initial orientation and continuing education and training of all health-care workers—including students and trainees—on the epidemiology, modes of transmission, and prevention of HIV and other blood-borne infections and the need for routine use of universal blood and body-fluid precautions for all patients. 2. Provision of equipment and supplies necessary to minimize the risk of infection with HIV and other blood-borne pathogens. 3. Monitoring adherence to recommended protective measures. When monitoring reveals a failure to follow recommended precautions, counseling, education, and/or re-training should be provided, and, if necessary, appropriate discipli- nary action should be considered. Professional associations and labor organizations, through continuing education efforts, should emphasize the need for health-care workers to follow recommended precautions. 104 August 21, 1987 — Supplement Serologic Testing for HIV infection Background A person is identified as infected with HIV when a sequence of tests, starting with repeated enzyme immunoassays (EIA) and including a Western blot or similar, more specific assay, are repeatedly reactive. Persons infected with HIV usually develop antibody against the virus within 6-12 weeks after infection. The sensitivity of the currently licensed EIA tests is at least 99% when they are performed under optimal laboratory conditions on serum specimens from persons infected for = 12 weeks. Optimal laboratory conditions include the use of reliable reagents, provision of continuing education of personnel, quality control of proce- dures, and participation in performance-evaluation programs. Given this perform- ance, the probability of a false-negative test is remote except during the first several weeks after infection, before detectable antibody is present. The proportion of infected persons with a false-negative test attributed to absence of antibody in the early stages of infection is dependent on both the incidence and prevalence of HIV infection in a population (Table 1). The specificity of the currently licensed EIA tests is approximately 99% when repeatedly reactive tests are considered. Repeat testing of initially reactive specimens by Ela is required to reduce the likelihood of laboratory error. To increase further the specificity of serologic tests, laboratories must use a supplemental test, most often the Western blot, to validate repeatedly reactive EIA results. Under optimal laboratory conditions, the sensitivity of the Western blot test is comparable to or greater than that of a repeatedly reactive El/A, and the Western blot is highly specific when strict criteria are used to interpret the test results. The testing sequence of a repeatedly reactive EIA and a positive Western blot test is highly predictive of HIV infection, even in a population with a low prevalence of infection (Table 2). If the Western blot test result is indeterminant, the testing sequence is considered equivocal for HIV infection. TABLE 1. Estimated annual number of patients infected with HIV not detected by HIV-antibody testing in a hypothetical hospital with 10,000 admissions/year.” Approximate Approximate number of Beginning Annual number of HIV-infected prevalence of incidence of HIV-infected patients HIV infection HIV infection patients not detected 5.0% 1.0% 550 17-18 5.0% 0.5% 525 11-12 1.0% 0.2% 110 3-4 1.0% 0.1% 105 2-3 0.1% 0.02% 11 O-1 0.1% 0.01% 11 0-1 *The estimates are based on the following assumptions: 1) the sensitivity of the screening test is 99% (i.e., 99% of HIV-infected persons with antibody will be detected); 2) persons infected with HIV will not develop detectable antibody (seroconvert) until 6 weeks (1.5 months) after infection; 3) new infections occur at an equal rate throughout the year; 4) calculations of the number of HIV-infected persons in the patient population are based on the mid-year prevalence, which is the beginning prevalence plus half the annual incidence of infections. 105 August 21, 1987 — Supplement When this occurs, the Western blot test should be repeated on the same serum sample, and, if still indeterminant, the testing sequence should be repeated on a sample collected 3-6 months later. Use of other supplemental tests may aid in interpreting of results on samples that are persistently indeterminant by Western blot. Testing of Patients Previous CDC recommendations have emphasized the value of HIV serologic testing of patients for: 1) management of parenteral or mucous-membrane exposures of health-care workers, 2) patient diagnosis and management, and 3) counseling and serologic testing to prevent and control HIV transmission in the community. In addition, more recent recommendations have stated that hospitals, in conjunction with state and local health departments, should periodically determine the prevalence of HIV infection among patients from age groups at highest risk of infection (32). Adherence to universal blood and body-fluid precautions recommended for the care of all patients will minimize the risk of transmission of HIV and other blood-borne pathogens from patients to health-care workers. The utility of routine HIV serologic testing of patients as an adjunct to universal precautions is unknown. Results of such testing may not be available in emergency or outpatient settings. In addition, some recently infected patients will not have detectable antibody to HIV (Table 1). Personnel in some hospitals have advocated serologic testing of patients in settings in which exposure of health-care workers to large amounts of patients' blood may be anticipated. Specific patients for whom serologic testing has been advocated include those undergoing major operative procedures and those undergoing treat- ment in critical-care units, especially if they have conditions involving uncontrolled bleeding. Decisions regarding the need to establish testing programs for patients should be made by physicians or individual institutions. In addition, when deemed appropriate, testing of individual patients may be performed on agreement between the patient and the physician providing care. In addition to the universal precautions recommended for all patients, certain additional precautions for the care of HIV-infected patients undergoing major surgical operations have been proposed by personnel in some hospitals. For example, Surgical procedures on an HIV-infected patient might be altered so that hand-to-hand passing of sharp instruments would be eliminated; stapling instruments rather than TABLE 2. Predictive value of positive HIV-antibody tests in hypothetical populations with different prevalences of infection Prevalence Predictive value of infection of positive test" Repeatedly reactive - 0.2% 28.41% enzyme immunoassay (EIA)" | 2.0% 80.16% 20.0% 98.02% Repeatedly reactive EIA l 0.2% 99.75% followed by positive 2.0% 99.97% Western blot (WB)* | 20.0% 99.99% *Proportion of persons with positive test results who are actually infected with HIV. "Assumes Ela sensitivity of 99.0% and specificity of 99.5%. *Assumes WB sensitivity of 99.0% and specificity of 99.9%. 106 August 21, 1987 — Supplement hand-suturing equipment might be used to perform tissue approximation; electro- cautery devices rather than scalpels might be used as cutting instruments; and, even though uncomfortable, gowns that totally prevent seepage of blood onto the skin of members of the operative team might be worn. While such modifications might further minimize the risk of HiW infection for members of the operative team, some of these techniques could result in prolongation of operative time and could potentially have an adverse effect on the patient. Testing programs, if developed, should include the following principles: • Obtaining consent for testing. • Informing patients of test results, and providing counseling for seropositive patients by properly trained persons. • Assuring that confidentiality safeguards are in place to limit knowledge of test results to those directly involved in the care of infected patients or as required by law. • Assuring that identification of infected patients will not result in denial of needed care or provision of suboptimal care. • Evaluating prospectively 1) the efficacy of the program in reducing the inci- dence of parenteral, mucous-membrane, or significant cutaneous exposures of health-care workers to the blood or other body fluids of HIV-infected patients and 2) the effect of modified procedures on patients. Testing of Health-Care Workers Although transmission of HIV from infected health-care workers to patients has not been reported, transmission during invasive procedures remains a possibility. Trans- mission of hepatitis B virus (HBV)—a blood-borne agent with a considerably greater potential for nosocomial spread — from health-care workers to patients has been documented. Such transmission has occurred in situations (e.g., oral and gynecologic surgery) in which health-care workers, when tested, had very high concentrations of HBV in their blood (at least 100 million infectious virus particles per milliliter, a concentration much higher than occurs with HIV infection), and the health-care workers sustained a puncture wound while performing invasive procedures or had exudative or weeping lesions or microlacerations that allowed virus to contaminate instruments or open wounds of patients (33,34). The hepatitis B experience indicates that only those health-care workers who perform certain types of invasive procedures have transmitted HBV to patients. Adherence to recommendations in this document will minimize the risk of transmis- sion of HIV and other blood-borne pathogens from health-care workers to patients during invasive procedures. Since transmission of HIV from infected health-care workers performing invasive procedures to their patients has not been reported and would be expected to occur only very rarely, if at all, the utility of routine testing of such health-care workers to prevent transmission of HIV cannot be assessed. If consideration is given to developing a serologic testing program for health-care workers who perform invasive procedures, the frequency of testing, as well as the issues of consent, confidentiality, and consequences of test results—as previously outlined for testing programs for patients — must be addressed. 107 August 21, 1987 — Supplement Management of Infected Health-Care Workers Health-care workers with impaired immune systems resulting from HIV infection or other causes are at increased risk of acquiring or experiencing serious complica- tions of infectious disease. Of particular concern is the risk of severe infection following exposure to patients with infectious diseases that are easily transmitted if appropriate precautions are not taken (e.g., measles, varicella). Any health-care worker with an impaired immune system should be counseled about the potential risk associated with taking care of patients with any transmissible infection and should continue to follow existing recommendations for infection control to minimize risk of exposure to other infectious agents (7.35). Recommendations of the Immunization Practices Advisory Committee (ACIP) and institutional policies concerning require- ments for vaccinating health-care workers with live-virus vaccines (e.g., measles, rubella) should also be considered. The question of whether workers infected with HIV — especially those who perform invasive procedures—can adequately and safely be allowed to perform patient-care duties or whether their work assignments should be changed must be determined on an individual basis. These decisions should be made by the health-care worker's personal physician(s) in conjunction with the medical directors and personnel health service staff of the employing institution or hospital. Management of Exposures If a health-care worker has a parenteral (e.g., needlestick or cut) or mucous- membrane (e.g., splash to the eye or mouth) exposure to blood or other body fluids or has a cutaneous exposure involving large amounts of blood or prolonged contact with blood—especially when the exposed skin is chapped, abraded, or afflicted with dermatitis—the source patient should be informed of the incident and tested for serologic evidence of HIV infection after consent is obtained. Policies should be developed for testing source patients in situations in which consent cannot be obtained (e.g., an unconscious patient). If the source patient has AIDS, is positive for HIV antibody, or refuses the test, the health-care worker should be counseled regarding the risk of infection and evaluated clinically and serologically for evidence of HIV infection as soon as possible after the exposure. The health-care worker should be advised to report and seek medical evaluation for any acute febrile illness that occurs within 12 weeks after the exposure. Such an illness—particularly one characterized by fever, rash, or lymphadenopathy – may be indicative of recent HIV infection. Seronegative health-care workers should be retested 6 weeks post-exposure and on a periodic basis thereafter (e.g., 12 weeks and 6 months after exposure) to determine whether transmission has occurred. During this follow-up period—especially the first 6-12 weeks after exposure, when most infected persons are expected to seroconvert–exposed health-care workers should follow U.S. Public Health Service (PHS) recommendations for preventing transmis- sion of HIV (36.37). No further follow-up of a health-care worker exposed to infection as described above is necessary if the source patient is seronegative unless the source patient is at high risk of HIV infection. In the latter case, a subsequent specimen (e.g., 12 weeks following exposure) may be obtained from the health-care worker for antibody 108 August 21, 1987 — Supplement testing. If the source patient cannot be identified, decisions regarding appropriate follow-up should be individualized. Serologic testing should be available to all health-care workers who are concerned that they may have been infected with HIV. If a patient has a parenteral or mucous-membrane exposure to blood or other body fluid of a health-care worker, the patient should be informed of the incident, and the same procedure outlined above for management of exposures should be followed for both the source health-care worker and the exposed patient. References 1. CDC. Acquired immunodeficiency syndrome (AIDS): Precautions for clinical and laboratory staffs. MMWR 1982:31:577-80. 2. CDC. Acquired immunodeficiency syndrome (AIDS): Precautions for health-care workers and allied professionals. MMWR 1983:32:450-1. 3. CDC. Recommendations for preventing transmission of infection with human T-lymphotropic virus type Ill/lymphadenopathy-associated virus in the workplace. MMWR 1985;34:681-6, 691-5. 4. CDC. Recommendations for preventing transmission of infection with human T-lymphotropic virus type Ill/lymphadenopathy-associated virus during invasive proce- dures. MMWR 1986;35:221-3. 5. CDC. Recommendations for preventing possible transmission of human T-lymphotropic virus type Ill/lymphadenopathy-associated virus from tears. MMWR 1985;34:533-4. 6. CDC. Recommendations for providing dialysis treatment to patients infected with human T-lymphotropic virus type Ill/lymphadenopathy-associated virus infection. MMWR 1986:35:37.6-8, 383. 7. Garner JS, Simmons BP. Guideline for isolation precautions in hospitals. Infect Control 1983;4 (suppl) :245-325. . CDC. Recommended infection control practices for dentistry. MMWR 1986:35:237-42. . McCray E, The Cooperative Needlestick Surveillance Group. Occupational risk of the acquired immunodeficiency syndrome among health care workers. N Engl J Med 1986;314:1127-32. 10. Henderson DK, Saah AJ, Zak BJ, et al. Risk of nosocomial infection with human T-cell lymphotropic virus type Ill/lymphadenopathy-associated virus in a large cohort of inten- sively exposed health care workers. Ann Intern Med 1986; 104:644-7. 11. Gerberding JL, Bryant-LeBlanc CE, Nelson K, et al. Risk of transmitting the human immunodeficiency virus, cytomegalovirus, and hepatitis B virus to health care workers exposed to patients with AIDS and AIDS-related conditions. J Infect Dis 1987; 156:1-8. 12. McEvoy M, Porter K, Mortimer P, Simmons N, Shanson D. Prospective study of clinical, laboratory, and ancillary staff with accidental exposures to blood or other body fluids from patients infected with HIV. Br Med J 1987;294:1595-7. 13. Anonymous. Needlestick transmission of HTLV-III from a patient infected in Africa. Lancet 1984;2:1376-7. 14. Oksenhendler E, Harzic M, Le Roux JM, Rabian C, Clauvel JP. HIV infection with serocon- version after a superficial needlestick injury to the finger. N Engl J Med 1986;315:582. 15. Neisson-Vernant C, Arfi S, Mathez D, Leibowitch J, Monplaisir N. Needlestick HIV serocon- version in a nurse. Lancet 1986;2:814. 16. Grint P, McEvoy M. Two associated cases of the acquired immune deficiency syndrome (AIDS). PHLS Commun Dis Rep 1985; 42:4. 17. CDC. Apparent transmission of human T-lymphotropic virus type Ill/lymphadenopathy- associated virus from a child to a mother providing health care. MMWR 1986;35:76-9. 18. CDC. Update: Human immunodeficiency virus infections in health-care workers exposed to blood of infected patients. MMWR 1987:36:285-9. 19. Kline RS, Phelan J, Friedland GH, et al. Low occupational risk for HIV infection for dental professionals (Abstract). In: Abstracts from the Ill International Conference on AIDS, 1-5 June 1985. Washington, DC: 155. 20. Baker JL, Kelen GD, Sivertson KT, Ouinn TC. Unsuspected human immunodeficiency virus in critically ill emergency patients. JAMA 1987;257:2609-11. 21. Favero MS. Dialysis-associated diseases and their control. In: Bennett JV, Brachman PS, eds. Hospital infections. Boston: Little, Brown and Company, 1985:267-84. : 109 August 21, 1987 — Supplement 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 35. 36. 37. Richardson JH, Barkley WE, eds. Biosafety in microbiological and biomedical laboratories, 1984, Washington, DC : US Department of Health and Human Services, Public Health Service. HHS publication no. (CDC) 84-8395. CDC. Human T-lymphotropic virus type III/lymphadenopathy-associated virus: Agent sum- mary statement. MMWR 1986:35:540-2, 547-9. Environmental Protection Agency. EPA guide for infectious waste management. Washing- ton, DC : U.S. Environmental Protection Agency, May 1986 (Publication no. EPA/530-SW-86-014). Favero MS. Sterilization, disinfection, and antisepsis in the hospital. In: Manual of clinical microbiology. 4th ed. Washington, DC: American Society for Microbiology, 1985;129-37. Garner JS, Favero MS. Guideline for handwashing and hospital environmental control, 1985. Atlanta: Public Health Service, Centers for Disease Control, 1985. HHS publication no. 99-11 17. Spire B, Montagnier L, Barré-Sinoussi F, Chermann JC. Inactivation of lymphadenopathy associated virus by chemical disinfectants. Lancet 1984;2:899-901. Martin LS, McDougal JS, Loskoski SL. Disinfection and inactivation of the human T lymphotropic virus type Ill/lymphadenopathy-associated virus. J infect Dis 1985; 152:400-3. McDougal JS, Martin LS, Cort SP, et al. Thermal inactivation of the acquired immunodefi- ciency syndrome virus-Ill/lymphadenopathy-associated virus, with special reference to antihemophilic factor. J Clin Invest 1985;76:875-7. Spire B, Barré-Sinoussi F, Dormont D, Montagnier L, Chermann JC. Inactivation of lymphadenopathy-associated virus by heat, gamma rays, and ultraviolet light. Lancet 1985; 1:188-9. Resnik L, Veren K, Salahuddin SZ, Tondreau S, Markham PD. Stability and inactivation of HTLV-III/LAV under clinical and laboratory environments. JAMA 1986;255:1887-91. CDC. Public Health Service (PHS) guidelines for counseling and antibody testing to prevent HIV infection and AIDS. MMWR 1987;3:509-15. Kane MA, Lettau LA. Transmission of HBV from dental personnel to patients. J Am Dent Assoc 1985; 110:634-6. . Lettau LA, Smith JD, Williams D, et. al. Transmission of hepatitis B with resultant restriction of surgical practice. JAMA 1986;255:934-7. Williams WW. Guideline for infection control in hospital personnel. Infect Control 1983;4 (suppl.) :326-49. CDC. Prevention of acquired immune deficiency syndrome (AIDS): Report of inter-agency recommendations. MMWR 1983:32:101-3. CDC. Provisional Public Health Service inter-agency recommendations for screening do- nated blood and plasma for antibody to the virus causing acquired immunodeficiency syndrome. MMWR 1985;34:1-5. 110 • t) H (" ") sº & Uyº. . . A 7" -: 3 } | ! § º r) Steps in Heat Sterilization . PACKAGE CLEANED ITEMS. • If possible, wrap or package everything that must be kept sterile and that will not be used immediately. • Put a heat-sensitive process indicator on each pack and each unwrapped item to verify that they have been processed. • Write the date of processing on the process indicator. . PROCESS ITEMS. • Load the sterilizer so that hot air, steam, or chemical vapor will be able to circulate freely around every item or pack. • Bring the sterilizer up to the temperature recommended by the manufacturer. Allow time for all parts of the load to reach that temperature, and then process for the recom- mended time. . STORE STERILIZED ITEMS. • If any unwrapped items will not be used immediately, wrap them in sterile packaging (or sterile toweling) before storing. • Keep sterilized items wrapped until they are used. • Store the packages where they will not become torn or wet. If a package does become punctured, torn, or wet, repackage the contents and sterilize them again. Management of Persons Exposed' to Blood Once an exposure has occurred, the blood of the individual from whom exposure occurred should be tested for hepatitis B surface antigen (HBSAg) and antibody to human immunodeficiency virus (HIV antibody). Local laws regarding consent for testing source individuals should be followed. Testing of the source individual should be done at a location where appropriate pretest counseling is available; posttest counseling and referral for treatment should be provided. - o Human Immunodeficiency Virus Postexposure Management? THEN AND The Source individual has AIDS. OR The Source individual 6 Weeks, is positive for HIV 3. The exposed worker should be 12 Weeks, and infection. advised to report and seek medical 6 months OR The Source individual refuses to be tested. 1. The exposed worker should be Counseled about the risk of infection. 2. The exposed worker should be evaluated clinically and serologically for evidence Of HIV infection as SOOn as possible after the exposure. evaluation for any febrile illness that occurs within 12 weeks after the exposure. 4. The exposed worker should be advised to refrain from blood donation and to use appropriate protection during sexual intercourse during the follow-up period, especially the first 6-12 weeks after exposure. An exposed worker who tests negative initially should be retested after exposure to determine whether transmission has OCCurred. The Source individual is tested and found seronegative. Baseline testing of the exposed worker with follow-up testing 12 weeks later may be performed if desired by the worker or recommended by the worker's health care provider. The SOUrce individual cannot be identified. Decisions regarding appropriate follow-up should be individualized. Serologic testing Should be done if the WOrker is Concerned that HIV transmission has OCCurred. 1 Being “exposed to blood” means having blood, blood-contaminated saliva, or a blood-contaminated object come into contact with broken skin or mucous membranes, or pierce the skin as through a needlestick injury. - 2The information given in the table is based on recommendations in Guidelines for Prevention of Transmission of HIV and HBVto Health Care and Public-Safety Workers. DHHS (NIOSH) Publication No. 89-107: Cincinnati, Ohio, February 1989. . . . --> r. ºyº）, ſ ſy Management of Persons Exposed' to Blood Once an exposure has occurred, the blood of the individual from whom exposure occurred should be tested for hepatitis B surface antigen (HBSAg) and antibody to human immunodeficiency virus (HIV antibody). Local laws regarding consent for testing source individuals should be followed. Testing of the source individual should be done . at a location where appropriate pretest Counseling is available; posttest counseling and referral for treatment should be provided. Hepatitis B Virus Postexposure Management? The SOUrce individual is found positive for HBSAg. has not been Vaccinated against hepatitis B. |F AND THEN 1. The WOrker should receive the The exposed worker vaccine series for hepatitis B. 2. The WOrker Should receive a single dose of hepatitis B immune globulin if it can be given within 7 days of exposure. The exposed worker has been vaccinated against hepatitis B. The exposed worker should be tested for antibody to hepatitis B surface antigen (anti-HBs), and given one dose of vaccine and one dose of HBIG if the antibody level in the worker's blood sample is inadequate (i.e., * 10 SRU by RIA, negative by EIA). The Source individual is found negative for HBSAg. The exposed worker has not been vaccinated against hepatitis B. The worker should be encouraged to receive hepatitis B vaccine. The exposed worker has been vaccinated against hepatitis B. No further action is needed. The SOurce individual refuses testing or cannot be identified. The exposed worker has not been Vaccinated against hepatitis B. 1. The WOrker Should receive the hepatitis B series. - 2. HBIG administration should be Considered On an individual basis when the source individual is known or suspected to be at high risk of HBV infection. The exposed worker has been Vaccinated against hepatitis B. Management and treatment of the exposed worker should be individualized. 1 Being “exposed to blood” means having blood, blood-contaminated saliva, or a blood-contaminated object come into contact with broken skin or mucous membranes, or pierce the skin as through a needlestick injury. 2 The information given in the table is based on recommendations in Guidelines for Prevention of Transmission of HIV and HBV to Health-Care and Public-Safety Workers. DHHS (NIOSH) Publication No. 89-107: Cincinnati, Ohio, February 1989. UNIVERSITY O Lili 3 901 5 04 iii. 225 5540