`Borne free

     Personal safety is always the EMS provider's first priority. Because of bloodborne pathogens, every patient contact is a threat to EMS provider safety. This article reviews the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard, bloodborne pathogens encountered by EMS providers, use of personal protective equipment and reporting exposure incidents.

     The OSHA bloodborne pathogens standard, which was developed to reduce and prevent workplace exposures to infectious diseases among healthcare workers, has several important and relevant components for EMS providers. It outlines the elements for an exposure control program to protect healthcare workers, workplace engineering practices to reduce exposures, provisions for employers to offer hepatitis B vaccinations, elements of employee training in preventing bloodborne pathogen exposure, and record-keeping for exposure incidents. To view the standard, search the Internet for OSHA bloodborne pathogens standard. The standard applies to all employees who could be "reasonably anticipated" to have contact with blood or other potentially infectious materials while performing their duties.

     Bloodborne pathogens are pathogenic microorganisms present in human blood that can cause disease in humans. They include the hepatitis B and C viruses, syphilis and human immunodeficiency virus (HIV).

     EMS providers also want to limit their exposure to other potentially infectious materials, defined as "human body fluids; any body fluid that is visibly contaminated with blood; all body fluids in situations where it is difficult or impossible to differentiate between body fluids; any unfixed tissue or organ from a human and HIV-containing cell or tissue cultures, organ cultures and HIV- or HBV-containing culture medium or other solutions; and blood, organs or other tissues from experimental animals infected with HIV or HBV."¹ Gloves, instruments, cots, linens, clothing and other equipment can become contaminated during patient assessment, treatment and transport. "Contaminated," the standard says, "means the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface."¹

     If blood or other potentially infectious material is present or potentially present on a surface or item, decontamination is needed. Decontamination is the "physical or chemical means to remove, inactivate or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles, and the surface or item is rendered safe for handling, use or disposal."¹

     EMS providers have many potential exposures that may result from performance of their duties. They can be exposed to bloodborne pathogens and other infectious materials by needlesticks, rescue breathing, bleeding control and airway management, as well as through cleaning up blood after an incident.

     The most common occupational exposure to bloodborne pathogens comes through needlesticks. It is estimated that 600,000–800,000 needlesticks happen every year in the U.S. Other exposures involve cuts from contaminated sharps and contact with mucous membranes or broken skin by contaminated blood. An exposure incident is "a specific eye, mouth, other mucous membrane, nonintact skin or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties."¹

     Standard precautions teach us to treat all human blood and certain body fluids as if we know they're infectious. This section reviews common bloodborne pathogens encountered by EMS.

     Hepatitis B is the primary bloodborne pathogen hazard for EMS providers. Hepatitis B is a serious disease that attacks the liver. It can cause lifelong infection, cirrhosis or scarring of the liver, liver cancer, liver failure and death. The hepatitis B virus "is efficiently transmitted by percutaneous or mucous membrane exposure to infectious blood or body fluids that contain blood."⁶ Populations at high risk for hepatitis B infection include:

• Persons with multiple sex partners or diagnosis of a sexually transmitted disease;
• Men who have unprotected sex with men;
• Sex partners of infected persons;
• Injection drug users;
• Household contacts of chronically infected persons;
• Infants born to infected mothers;
• Infants/children of immigrants from areas with high rates of hepatitis B infection;
• Hemodialysis patients.

     In the United States the number of new hepatitis B infections is about 73,000 a year. That represents a significant decline from the rate of 260,000 cases a year in the 1980s. The highest rate of disease occurs in 20–49-year-olds. The most significant decline has been in children and adolescents due to routine hepatitis B vaccinations. It is estimated that there are between 1–1.4 million chronically infected Americans, of whom 20%–30% acquired their infections in childhood. Between 15%–25% of patients with chronic hepatitis disease will die from chronic liver diseases. Each year 620,000 people worldwide die from illness caused by the hepatitis B virus.

     Hepatitis B is transmitted in blood or other potentially infectious material, including saliva and semen.⁶ Transmission occurs when blood or body fluids from an infected person enter the body of a nonimmune person through the skin or a mucous membrane. Hepatitis B is not spread by:

• Food or water
• Sharing eating utensils
• Breast-feeding
• Hugging
• Kissing
• Coughing
• Sneezing
• Casual contact.⁷

     Thirty percent of infected adults show no symptoms; that percentage is even higher in children.⁵ Common symptoms, if present, present 9–21 weeks after exposure and include:

• Jaundice
• Fatigue
• Abdominal pain
• Loss of appetite
• Nausea and vomiting
• Joint pain.^6,7

     The hepatitis B vaccination is the best protection for healthcare workers.⁶ EMS providers should ensure they have received the full hepatitis B vaccination series; use barrier devices (gloves, BVM, pocket mask, goggles, face mask) whenever there is a potential exposure to blood or other potentially infectious materials; and safely handle and dispose of needles and other sharps.⁶ Remember, the hepatitis B virus can survive on surfaces outside the body for more than a week, making it a serious risk to healthcare providers because exposure can come not only from contact with patients, but also with their contaminated belongings.

     Hepatitis C is a liver disease caused by the hepatitis C virus. It accounts for 20% of acute viral hepatitis cases. The effects of hepatitis C include:

• Chronic infection in 75%–85% of patients;
• Chronic liver disease in 70% of chronically infected persons;
• Death in 1%–5% of chronic liver disease patients.

     Hepatitis C is the leading indication for liver transplant. In 2006, approximately 19,000 hepatitis C infections occurred, again representing a steep decline since the 1980s.⁸ Most new infections result from the injection of illegal drugs. At-risk individuals include blood recipients from hepatitis C-positive donors, recipients of blood and organ transfusions prior to July 1992, and long-term kidney dialysis patients. It is estimated that 4.1 million (1.8%) Americans have been infected with HCV, of whom 3.2 million are chronically infected.⁸

     Hepatitis C is spread through direct contact with blood. For EMS providers the most likely exposure source is a needlestick. After a needlestick or sharps exposure to blood with the hepatitis C virus, 1.8% of healthcare workers become infected. Hepatitis C can live outside the human body for at least 16 hours, reinforcing the importance of hand-washing and decontamination of equipment and treatment areas.⁹ Signs and symptoms of hepatitis C include jaundice, fatigue, dark urine, abdominal pain, loss of appetite and nausea.⁸

     Yet 80% of infected patients have no signs or symptoms. There is no vaccination for hepatitis C. EMS providers should always follow routine barrier precautions and safely handle needles and other sharps to avoid hepatitis C exposure.⁸

     Hepatitis D is spread when blood or body fluid from an infected patient enters the body of a person who has no immunity.¹⁰ Hepatitis D can only exist with hepatitis B virus coinfection. The best protection against hepatitis D is to receive the hepatitis B vaccination series. The signs and symptoms of hepatitis D are similar to those of hepatitis A, B and C: jaundice, fatigue, dark tea-colored urine, abdominal pain, loss of appetite, nausea, vomiting and joint pain.

     The numbers of persons with hepatitis D and annual new cases are not known. The populations at risk are the same as for hepatitis B.¹⁰ EMS providers should follow routine barrier precautions and safely handle needles and other sharps to avoid hepatitis D exposure and infection.¹⁰

     HIV, human immunodeficiency virus, is the virus that causes AIDS. People with HIV have an HIV infection, and some infected patients will develop AIDS. The incidence of HIV is most common in the high-risk populations:

• IV drug users;
• Men who have unprotected sex with men;
• Those having unprotected sex with multiple partners.¹¹

     HIV can infect any person of any age, race, gender or sexual orientation. At the end of 2006, about 1.1 million persons in the United States were living with HIV, with 21% undiagnosed and unaware of their infections.

     HIV may be passed from one person to another when infected blood, semen or vaginal secretions during sexual contact come in contact with an uninfected person's broken skin or mucous membranes. Infected pregnant women can pass HIV to their babies during pregnancy or delivery, as well as through breast-feeding. HIV does not survive well outside the body, remaining viable for only few seconds, which makes the possibility of transmission from a toilet seat or ambulance cot remote.¹¹

     The only way to confirm HIV infection is a blood test. These signs and symptoms, however, may warn of an HIV infection:¹¹

• Rapid weight loss;
• Dry cough;
• Recurring fever or profuse night sweats;
• Profound and unexplained fatigue;
• Swollen lymph glands in the armpits, groin or neck;
• Diarrhea that lasts for more than a week;
• White spots or unusual blemishes on the tongue, in the mouth or in the throat;
• Pneumonia;
• Red, brown, pink or purplish blotches on or under the skin or inside the mouth, nose or eyelids;
• Memory loss, depression and other neurological disorders.

     Many patients will not have any signs or symptoms for years after becoming HIV-infected. The risk of EMS providers being infected with HIV on the job is very low, especially if you follow routine barrier precautions. Casual, everyday contact with an HIV-infected person does not expose healthcare workers to HIV. The primary risk for EMS providers is a needlestick or sharps exposure from a contaminated patient, but even this risk is small. Scientists estimate the risk of transmission from a HIV-contaminated needle to be 0.3%.

     The OSHA standard requires that the hepatitis B vaccine be made available, free of charge, to all employees who have occupational exposure to blood. The hepatitis B vaccination has been routinely given to all children since 1982. EMS providers who did not receive childhood hepatitis B vaccinations should be offered them within 10 days of initial assignment. A healthcare provider can decline the hepatitis B vaccine; if the vaccine is initially declined, it can be administered at any time, even post exposure. A provider who declines the hepatitis B vaccine must complete a mandatory declination form. Declining the vaccine may result in a hospital not allowing clinical rotations, because of risk management issues.

     Numerous studies have evaluated the efficacy of the hepatitis B vaccine series. Pre-exposure vaccination has been shown to be 80%–95% effective in preventing hepatitis B infection and clinical hepatitis among susceptible children and adults. Additionally, the vaccine provides lifelong protection. If a protective antibody response develops after vaccination, vaccine recipients are virtually 100% protected against clinical illness from hepatitis B exposure.¹³ If initiated within a week of a percutaneous exposure to hepatitis B virus, the vaccine series is estimated to provide 75% protection from infection. EMS providers who receive the hepatitis B vaccine post exposure should receive the entire series.¹⁴

     Laboratory titer testing can measure the presence of antibodies in the blood. Blood is drawn to check the antibody titer to determine if the hepatitis B vaccine caused a strong enough response from the body's immune system to protect against hepatitis B. In addition, the test can assess whether the recipient has recently had viral hepatitis.

     The hepatitis B vaccine is a series of three intramuscular injections. The second injection is administered one month after the first, and the third is administered six months after the first. Studies indicate hepatitis B vaccination is effective against chronic hepatitis B virus infection for at least 15 years. Boosters are not needed because immune memory remains intact indefinitely following immunization.⁷

     Through 2000 hepatitis B vaccines had been safely administered to more than 100 million American infants, children and adults.¹⁴ Serious side effects are extremely rare, and there is no evidence that the vaccine can cause chronic illness. Common side effects are pain at the injection site and mild to moderate fever.¹⁴ People with known allergies to baker's yeasts or any other components of the vaccine should not be vaccinated. In addition, those who experienced life-threatening allergic reactions with their initial doses should not receive subsequent doses. The CDC reports that severe allergic reactions to the vaccine occur in only one of every 1.1 million doses given.

     Engineering controls, work practice controls and personal protective equipment are used to prevent or reduce the risk of exposure to bloodborne pathogens and other potentially infectious materials.

     Hand-washing is the single most effective work practice control to reduce the transmission of bloodborne pathogens. Gloves do not eliminate the need for hand-washing. After any patient contact, wash your hands with hot water and soap for at least 15 seconds. Alcohol-based hand rubs are an acceptable alternative. If your hands are visibly soiled, always wash them with soap and water. Follow your workplace hand-washing guidelines before and after every patient contact.

     Most exposures to bloodborne pathogens can be avoided by use of personal protective equipment (PPE). In general, PPE is the specialized clothing or equipment worn as barrier between potential contaminants and susceptible parts of the body, and also encompasses needlesafe devices.¹

     Your employer has an obligation, as set by OSHA and the CDC, to provide PPE appropriate to the hazards you are likely to face, including bloodborne pathogens. Employers are also responsible for having all PPE available in appropriate sizes.³ If you do not use the PPE provided by your employer, you are unnecessarily putting yourself at risk. PPE for EMS providers includes gloves, eye protection and pocket masks. All are barriers against contamination.

     PPE is selected based on potential workplace hazards. In EMS our PPE selection is based on standard precautions. Under the concept of standard precautions, all human blood and certain body fluids are treated as if known to be infectious for HIV, HBV and other bloodborne pathogens. Therefore, the minimum PPE for every patient response is gloves. Then, using scene size-up clues, the EMS provider selects other appropriate PPE, like eye protection, face mask and gown. It's better to have PPE on and not need it than to not have it on and wish you did.

     Use gloves for touching blood and body fluids, mucous membranes or nonintact skin of all patients, and for handling items or surfaces soiled with blood or body fluids to which universal precautions apply. Change gloves after each patient contact. If you are allergic to gloves, your employer must make available glove liners, powderless gloves or other similar alternatives.³ After removing gloves, immediately wash your hands, regardless of whether the gloves were visibly contaminated. As necessary, wash any other skin, such as your lower arms, that may have come in contact with blood.

     Use masks, goggles, face shields or glasses to prevent exposure of the mucous membranes of the mouth, nose and eyes during procedures likely to generate spraying or splashing of blood or body fluids.¹⁸ As soon as possible wash your face, neck and any other body surfaces exposed or potentially exposed to splashed body fluids. Gowns or aprons should be worn during procedures likely to generate splashes.

     EMS providers should take precautions to prevent injuries from needles, lancets, broken glass and other sharp instruments and objects. Providers can encounter sharps during procedures, when disposing of needles and on accident scenes.¹⁸ To prevent needlestick injuries:

• Do not recap a needle;
• Do not purposely bend or break a needle;
• Do not remove a needle from a disposable syringe or auto-injector;
• After use discard all sharps in a puncture-resistant container.¹⁸

     PPE should be readily available in locations near likely workplace hazards. For example, exam gloves are best located in the ambulance and jump kit, not in the break room or cafeteria. Remove PPE after patient contact, after cleaning contaminated equipment and surfaces, or if it becomes damaged or inoperable. Always assume used PPE is contaminated. Remove it to avoid contaminating clean surfaces.

     Contaminated personal protective equipment, clothing and linens should only be handled while wearing appropriate PPE. Protect new and unused PPE from damage by properly storing it until it is needed. Most PPE used by EMS providers is single-use, like examination gloves. Follow service policies and manufacturer guidelines for decontamination and reuse of reusable PPE items like bag-valve masks, eye protection, rescue helmets and turnout or bunker gear. Duty uniform items—pants, shirt or shoes—may also become contaminated. As soon as possible, remove contaminated clothing and thoroughly wash underlying skin with soap and water. Use proper PPE while handling contaminated clothing and wash it separately from noncontaminated clothing. Alternatively, commercial dry-cleaning processes also destroy bloodborne pathogens.

     Follow state medical waste laws as well as local policy and procedures for disposing of personal protective equipment. General disposal principles for single-use PPE items include disposal of gloves, pocket masks, oral and nasal airways, and bag-valve masks in regular trash; disposal of dressings, bandages and clothing that has a small amount of blood, such as a used Band-Aid, in regular trash; and disposal of blood-soaked and dripping dressings, bandages or clothing in a red biohazard bag. Containers of body fluids such as emesis should also be disposed of in the latter manner.

     Engineering controls are the primary means to isolate or remove the bloodborne pathogens hazard from the workplace. The standard requires that "employers must gather input from non-managerial employees responsible for direct patient care in the identification, evaluation and selection of engineering and work practice controls."³ Needleless medication administration systems and spring-loaded retracting needles are examples of engineering controls. A sharps disposal container is another. An engineering control is only effective if it is available and used properly.

     Work practice controls reduce the likelihood of exposure by altering the manner in which a task is performed. For example, prohibiting recapping of needles by a two-handed technique is a work practice control. So is requiring immediate hand-washing after removing gloves. Another work practice control is decontamination of contaminated surfaces. After delivering your patient to the hospital, use a 1-to-100 bleach-to-water solution or other approved disinfectant to decontaminate the patient cot, ambulance seats and counters, handrails, door handles and any other equipment or surface that may have been contaminated with blood or other potentially infectious material.

     Warning labels must be attached to containers, refrigerators and freezers used to store or transport blood or other potentially infectious materials. Red bags or containers, like a sharps container, may be substituted for labels.

     In summary, OSHA's bloodborne pathogens standard prescribes safeguards to protect workers against bloodborne pathogens and other potentially infectious materials. The standard also attempts to reduce exposure risk. Implementation of the bloodborne pathogens standard not only will prevent cases of hepatitis B, but also will significantly reduce the risk of workers contracting HIV, hepatitis C or other bloodborne diseases. For questions about any of the content in this article or your organization's exposure control plan, contact your organization's exposure control program administrator, infection control officer or designee.

     What do you do if an exposure occurs? The OSHA standard requires your employer to have a written exposure control plan that includes these key components:

• Identification of jobs and procedures with occupational exposure to blood and other potentially infectious substances;
• Identification of who will receive training;
• A schedule for implementing provisions of the plan;
• A description of vaccine availability;
• A description of the required use of personal protective equipment, engineering controls and work practice controls;
• A procedure for investigation and follow-up of exposures.

     The exposure control plan must be accessible to all employees and reviewed annually. It is developed by the employer and non-managerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps.

     If you are exposed to blood or other potentially infectious material, follow your local exposure control plan response guidelines. In general, after an exposure you should immediately dispose of any offending sharp to prevent additional exposures; wash needlesticks and cuts with soap and water; copiously flush splashes to the nose, mouth or skin with water; and irrigate eyes with water or saline.

     Employers are required to provide post-exposure evaluation and follow-up after an exposure incident. Report any exposure to your manager, occupational health nurse or infection-control specialist—whomever is responsible for managing exposures. Prompt reporting is critical, as some post-exposure treatments should be started as soon as possible, preferably within 24 hours, and no later than seven days. Follow exposure control plan directions for documenting the exposure, assessment and treatment. If you do not know your exposure control plan program director, seek direction from your supervisor.

     During your report you should discuss the following with the exposure control plan program administrator:

• Evaluating the risk of infection;
• Obtaining consent from the source individual and the exposed employee to test blood samples as soon as possible after an exposure incident;
• Available treatments to help prevent infection;
• The need for post-exposure treatment, including receiving the hepatitis B vaccine if you have not;
• How to monitor yourself for side effects of treatments;
• How to determine if infection occurs.²⁰

     Monitoring may involve testing your blood and that of the source patient and offering appropriate post-exposure treatment.

     The OSHA standard mandates that any employer required to maintain a log of occupational injuries also maintain a sharps injury log. Its purpose is to aid in the evaluation of devices used in the workplace and to quickly identify problem areas. It must be reviewed at least annually, during review and update of the exposure control plan. Fortunately most exposures do not result in infection. The risk of infection depends on the pathogen, type of exposure, amount of blood involved and amount of the virus in the patient's blood at the time of exposure.²⁰

     Bloodborne pathogens training must be provided to employees during work hours at no cost. Provide training at the time of job assignment and at least annually thereafter, or when tasks are added or modified. Training records must be maintained for three years and include dates of training sessions; contents or a summary of training sessions; names and qualifications of persons conducting training; and names and job titles of all persons attending training sessions.

1. OSHA Standard 1910.1030, Bloodborne Pathogens. www.osha.gov.

2. OSHA Instruction, Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens. www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=DIRECTIVES&p_id=2570#XIII.

3. OSHA Directorate of Training and Education. Bloodborne Pathogens PowerPoint Presentation, June 2007. www.osha.gov/dcsp/ote/materials_library.html.

4–9. CDC. Viral hepatitis. www.cdc.gov/hepatitis/index.htm.

10. CDC. HIV/AIDS Questions and Answers. www.cdc.gov/hiv/resources/qa/index.htm.

11. CDC. HIV/AIDS Basic Statistics. www.cdc.gov/hiv/stats.htm.

12. CDC. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR 50(RR11): 1–42, June 29, 2001.

13. CDC. Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States Through Universal Childhood Vaccination: Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 40(RR13): 1–19, Nov 22, 1991.

14. Op cit, CDC. MMWR 50(RR11): 1–42, June 29, 2001.

15. MedlinePlus. Antibody Titer. www.nlm.nih.gov/MEDLINEPLUS/ency/article/003333.htm.

16. CDC. Hepatitis B Vaccine: What You Need to Know. www.cdc.gov/vaccines/Pubs/vis/downloads/vis-hep-b.pdf.

17. CDC. Hand Hygiene Guidelines Fact Sheet. www.cdc.gov/od/oc/media/pressrel/fs021025.htm.

18. CDC. Universal Precautions for Prevention of Transmission of HIV and Other Bloodborne Infections. www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html.

19. CDC. Laundry: Washing Infected Material. www.cdc.gov/ncidod/dhqp/bp_laundry.html.

20. CDC. Exposure to Blood: What Healthcare Personnel Need to Know. www.cdc.gov/ncidod/dhqp/pdf/bbp/exp_to_blood.pdf.

     Greg Friese, MS, NREMT-P, WEMT, is president of Emergency Preparedness Systems LLC. EPS helps clients create, design, distribute and facilitate rapid e-learning for emergency responders. Greg is a paramedic, Wilderness Medical Associates lead instructor, conference speaker and author. Contact him and read his rapid e-learning blog at www.eps411.com.

     Martha Bonnie, MSE, is the lead writer and editor for Emergency Preparedness Systems LLC. Martha has worked in many settings as a classroom and outdoor educator. She develops, writes and edits continuing education lessons for emergency response personnel.

     Erin Boness, BA, is a research and production assistant for Emergency Preparedness Systems LLC. Erin's interests include online education for emergency responders, literacy education for working adults and workplace education and communications.