In 1992 OSHA issued standards to minimize the risk
of infection to healthcare workers due to bloodborne pathogens. These standards required initial training in
exposure and risk reduction, and also require annual retraining. This section is designed to meet the annual
retraining requirement, and refresh your knowledge of bloodborne pathogens,
specifically Hepatitis B.
1. OBJECTIVES
A. Define and specify requirements for
employer and employee compliance with the OSHA bloodborne pathogens standard.
B. Describe the significance and steps for
implementation of an Exposure Control Plan.
C. List the key clinical and serologic
diagnostic features of Hepatitis A, B, C, D, and E.
D. Explain purpose of personal protective
clothing and equipment.
E. Review the post-exposure evaluation and
follow-up procedure.
F. Define regulated waste and the proper
disposal methods.
G. Discuss the communication of hazards to
employees.
2. VIRAL HEPATITIS
There are at least five
forms of viral hepatitis associated with five different viral agents. All five viruses can lead to acute
hepatitis, but only three can lead to chronic infection.
HEPATITIS A
Hepatitis A is caused by the
Hepatitis A virus, an RNA agent, that causes acute hepatitis only; there is no
chronic Hepatitis A virus. The
fecal-oral route has predominantly identified transmission. Incubation period is 15 to 50 days,
depending on the significance of the exposure, with an average of 28 to 30
days. Diagnosis of acute Hepatitis A
can be made in a patient with clinical features of acute Hepatitis A and IgM
anti-HAV in the serum.
Patients identified with
acute Hepatitis A generally have had a blunt onset of symptoms with fever,
malaise, anorexia, nausea, and abdominal discomfort followed within a few days
by jaundice. Many infections are
asymptomatic, mild and without jaundice, especially in children, and
recognizable only by liver function test.
HEPATITIS B
The Hepatitis B virus causes
Hepatitis B, a DNA virus classified as a hepadnavirus. Hepatitis B can lead to acute or chronic
hepatitis, and it causes much of the morbidity and mortality from acute and
chronic liver disease worldwide.
Approximately 300,000 individuals, mostly young adults, become infected
with the Hepatitis B virus yearly. Twenty-five percent will become jaundiced; over 10,000 patients
require hospitalization, and an average of 250 patient’s die of fulminant
disease. In the United States there are
an estimated 750,000 to 1,000,000 infectious carriers. One quarter of these carriers will develop
chronic active hepatitis; causing many to progress to developing
cirrhosis. In addition, Hepatitis B
virus carriers have a risk of 12 - 300 times higher of developing liver cancer
than that of other patients.
Approximately 4,000 individuals die yearly from Hepatitis B related
cirrhosis, and 800 plus die from Hepatitis B related liver cancer.
Transmission occurs
primarily through percutaneous or permucosal exposure to infected body
fluids. The incubation period is
usually 45 to 180 days, with an average of 60 to 90 days; appearance of
Hepatitis B surface antigen has been documented within two weeks but rarely as
long as 6 - 9 months. Onset is usually
insidious with anorexia, vague abdominal discomfort, nausea and vomiting
sometimes arthralgias and rash, often progressing to jaundice.
The presence of Hepatitis B
surface antigen is indicative of ongoing infection; however, the amount of this
antigen does not correlate with the level of active virus and serum, nor does
it indicate whether the disease is acute or chronic, mild or severe. Some patients circulate Hepatitis B surface
antigen in high concentrations and are completely healthy. False positive reactions for Hepatitis B
surface antigen are common, due mostly to technical error and are suggested by
the finding of borderline or low positive results.
HEPATITIS C
The Hepatitis C virus is a
recently discovered RNA virus. It was
formally called parenterally transmitted non-A, non-B hepatitis, non-B
transfusion-associated hepatitis or post-transfusion non-A, non-B
hepatitis. The Hepatitis C infection
becomes chronic in approximately 50% of cases and can lead insidiously to
cirrhosis in as many as 25% of patients with chronic infection and to
hepatocellular carcinoma in a proportion of those with cirrhosis. The epidemiology of Hepatitis C has not been
completely defined. Hepatitis C can
spread parenterally, but appears to be transmitted only rarely by genealogy,
sexual, or maternal-infant exposure.
Incubation period ranges from two weeks to six months; most commonly,
within six to nine weeks from onset.
Onset is usually insidious, with anorexia, vague abdominal discomfort,
and nausea and vomiting, progressing to jaundice less frequently than Hepatitis
B.
Serologic tests for
Hepatitis C infection have been developed recently and are in a stage of rapid
evolution. At present, the only
examination for the Hepatitis C virus infection that is commercially available
and widely used is an EIA for anti-Hepatitis C virus. Preliminary studies indicate that most patients with acute
Hepatitis C circulate Hepatitis C RNA during the incubation period and
symptomatic phase of disease and that 40 to 70% of patients with chronic
Hepatitis C have viral genome in serum.
HEPATITIS D
The Hepatitis D virus is a
single stranded RNA with an internal protein antigen coated with Hepatitis B
surface antigen as the surface protein.
Hepatitis D is always associated with a coexistence with Hepatitis B. Mode of transmission is thought to be
Hepatitis B. Incubation periods have
been between two to ten weeks in experimental tests. Hepatitis D tends to be a severe disease with a high mortality
rate of the acute disease and a propensity of the chronic disease to lead to
cirrhosis.
Hepatitis D can affect a
person who is already a carrier of Hepatitis B or can be transmitted
simultaneously with Hepatitis B. These
two forms of Hepatitis D infection should be separated both because of the
differences in prognosis and in patterns of serologic events. Both EIA and RIA tests for anti-Hepatitis D
are widely available; similar immuno-examinations for IgM anti-Hepatitis D and
Hepatitis D antigen may soon be available.
HEPATITIS E
The Hepatitis E virus is a
small RNA virus that causes acute epidemic or enteracly transmitted non-A,
non-B hepatitis. Hepatitis E infection
does not lead to chronic hepatitis or a carrier state. The fecal-oral route transmits the virus and
transmission is associated with contaminated food or water sources. Hepatitis E is a common cause of sporadic
and epidemic hepatitis in underdeveloped areas of the world, particularly in
the Indian subcontinent in Asia. In
developed countries, only imported cases of Hepatitis E have been reported.
Currently, the only tests
for Hepatitis E infection are the ponderous examinations of immune electron
microscopy and immunofluorescence, both of which can be used to detect either
antigen or antibody.
3. TRANSMISSION OF BLOODBORNE PATHOGENS AND HEALTH CARE WORKERS
HEPATITIS A
Person to person contact,
through fecal contamination and oral ingestion generally transmits Hepatitis
A. Poor personal hygiene, poor
sanitation, and intimate contact facilitate transmission. Intravenous drug users, most likely due to
person to person contact, have been reported with increased frequency. Common source epidemics from contaminated
food and water also occur. Sharing
utensils, cigarettes or kissing is not believed to transmit the Hepatitis A
virus.
HEPATITIS B
Hepatitis B transmission
occurs through percutaneous or permucosal routes, and infected blood or bodily
fluids can be introduced at birth, through sexual contact, or by contaminated
needles. Infection can also occur in
settings of continuous close personal contact, presumably through unnoticed contact
of infected secretions with skin lesions or mucosal surfaces. Transmission of infection by transfusion of
blood or blood products is rare because of routine screening of blood for
Hepatitis B surface antigens and because of current donor selection
procedures.
HEPATITIS C (NON-A, NON-B HEPATITIS)
Healthcare workers with
occupational exposure to blood, and recipients of whole blood, blood cellular
components or plasma are at risk of acquiring Hepatitis C. Sexual activity and other types of person to
person contact have not been generally recognized as important mechanisms of
transmission for Hepatitis C. Further
definition of the role of sexual, parental, and other possible routes of
transmission for Hepatitis C are needed.
There is no evidence that the Hepatitis C virus is transmitted through
such common exposures as sharing meals or eating utensils, sneezing or
coughing, or other casual contact.
HEPATITIS D (DELTA AGENT)
Routes of transmission of
Hepatitis D are similar to those of Hepatitis B. In the United States, Hepatitis D infection most commonly affects
persons at high risk of Hepatitis B infection, particularly parenteral drug
abusers and persons with hemophilia.
Since Hepatitis D is dependent on Hepatitis B for replication, prevention
of Hepatitis B infection will suffice to prevent Hepatitis D infection for a
person susceptible to Hepatitis B.
HEPATITIS E - Presently the modes of transmission for Hepatitis E are similar to
those of Hepatitis A.
CURRENT GUIDELINES FOR
HEPATITIS B VACCINATION
The recombinant vaccines are
produced by using Hepatitis B surface antigen synthesized by Saccharomyces
cerevisiae (common bakers' yeast), into which a plasmid containing the gene for
Hepatitis B surface antigen has been inserted.
Purified Hepatitis B surface antigen is obtained by lysing the yeast
cells and separating Hepatitis B surface antigen from the yeast components by
biochemical and biophysical techniques.
Hepatitis B vaccines are packaged to contain 10-40 ug of Hepatitis B
surface antigen protein/mL after absorption to aluminum hydroxide (0.5 mg/mL)O;
thimerosal (1:20,000 concentration) is added as a preservative.
Routes and sites of administration
The recommended series of
three intramuscular doses of Hepatitis B vaccine induces a protective antibody
response (anti Hepatitis B surface> 10 milli-international units [mlU]mL) in
> 90% of infants, children, and adolescents.
Hepatitis B vaccine should
be administered only in the deltoid muscle of adults and children or in the
anterolateral thigh muscle of neonates and infants. The immunogenicity of the vaccine for adults is substantially
lower when injections are administered in the buttock.
Compared with three standard
doses administered intramuscularly, three low doses of plasma-derived or
recombinant vaccine administered intradermally to adults result in lower
seroconversion rates (55% - 81%) and lower final titers of anti-Hepatitis B
serum, although four doses of plasma-derived vaccine administered intradermally
have produced responses comparable with vaccine administered
intramuscularly. Plasma-derived vaccine
administered intradermally to infants and children do not induce an adequate
antibody response. At this time,
low-dose intradermal vaccination of adults should be performed only under
research protocol with written informed consent. Persons who have been vaccinated intradermally should be tested
for anti-Hepatitis B serum. Those with
adequate response (anti-Hepatitis B serum 10 ml/ml) should be re vaccinated
with three full doses of vaccine administered intramuscularly. Intradermal vaccination should not be used
for infants or children.
The vaccination schedule
most often used for adults and children has been three intramuscular
injections, the second and third administered 1 and 6 months, respectively,
after the first. In a three-dose
schedule, increasing the interval between the first and second dose of
Hepatitis B vaccine has little effect on immunogenicity or final antibody titer. The third dose confers optimal protection,
acting as a booster dose. Longer
intervals between the last two doses (4-12 months) result in higher titers of
anti-Hepatitis B serum.
The employer shall make the HBV vaccine
and series (boosters, if necessary) available to all employees who have
occupational exposure. Evaluation,
laboratory tests, and follow-up shall be available to all employees who have
had an exposure incident, unless otherwise indicated.
All the above evaluations and procedures
shall be offered at no cost to the employees, at a reasonable time and place,
and performed by or under the supervision of a licensed physician or designee.
After any exposure, a blood sample should be
obtained from the person who was the source of the exposure and should be
tested for Hepatitis B surface antigen.
The Hepatitis B vaccination status and anti-Hepatitis B serum response
status of the exposed person should be reviewed.
4. HISTORY OF BLOODBORNE PATHOGEN STANDARD
In 1983, the Occupational Safety and Health
Administration issued a set of voluntary guidelines designed to reduce the risk
of occupational exposure to the Hepatitis B virus. These guidelines where to be followed by all employers who had
employees with occupational exposure to blood or other potentially infectious
materials. After four years of issuing
voluntary guidelines for reducing the risk of exposure to HBV/HIV, the
Occupational Safety and Health Administration published notice for the proposed
rulemaking on Bloodborne Pathogens Standard on November 27, 1987. For the next four years more than 400 people
consisting of expert witnesses, representing a number of healthcare industries,
including physicians and other health care workers participated at the
hearings. This process was concluded
on December 6, 1991, with publication of issuance of the final rule on the
Bloodborne Pathogen Standard in the Code of Federal Regulations. The Occupational Safety and Health
Administration, through the issuance of the Bloodborne Pathogen Standard, has
concluded that the risk of exposure to HBV/HIV and other bloodborne pathogens
can be reduced, by using both engineering and work practice controls, personal
protective clothing and equipment, medical surveillance, Hepatitis B
vaccination, communicating hazards through warning signs and labels and
training.
All funeral home staff that has occupational
exposure or not, regardless of the risk of exposure, will be trained annually
on the regulations that pertain to the funeral industry and have been set forth
by the Occupational Safety and Health Administration
5. EXPOSURE CONTROL PLAN
All employers that have employees with reasonably
anticipated occupational exposure are required by the Bloodborne Pathogens
Standard to have a written exposure control plan and adhere to the provisions
of the bloodborne pathogens standard.
Reasonably anticipated is defined as the potential
for exposure as well as actual exposure regardless of how often exposure
occurs.
The exposure control plan is a key provision of the
bloodborne pathogens standard since it requires the employer to identify the
individuals who will receive training, personal protective clothing and
equipment, vaccinations and other benefits from the standard.
The exposure control plan is central in documenting
how the employer will eliminate or minimize the risk of occupational exposure
among the employees. Since the exposure
control plan is a requirement under the bloodborne pathogens standard, failure
to comply can be costly.
The employer is responsible for making sure the exposure
control plan is always current (the employer may assign an employee the
responsibility to maintain the exposure control plan). This will be the documentation that the
employer has acted appropriately to reduce the exposure to bloodborne pathogens
in the work place.
The following are some important areas that pertain
to the bloodborne pathogens standard, but are not limited to these areas:
Exposure
Determination
Engineering
Controls
Work
Practice Controls
Housekeeping
Post-Exposure
Evaluation and Follow-up
Hepatitis
B Vaccination
Protective
Clothing and Equipment
6. EXPOSURE DETERMINATION
The exposure control plan must list job
classifications, which require exposure, and the names of all employees whose
job duties fall under one or more of the classifications. A second list which lists all of the job
classifications which do not require exposure and the names of all employees
whose job duties fall under one or more of the classification also must be
made. Exposure determination must be
made without taking into consideration the use of personal protective clothing
or equipment.
A. TASKS/PROCEDURES WITH OCCUPATIONAL
EXPOSURE
Handling
of contaminated sharps
Handling
of deceased person
Handling
of regulated waste
Disinfecting
equipment
Cleaning
works areas
Incision
and drainage procedures
Disposal
of biomedical waste
7. ENGINEERING AND WORK PRACTICE CONTROLS
Engineering and work practice controls are to be
instituted as the primary means of eliminating or minimizing employee
exposure. In those circumstances in
which exposure remains after implementing the engineering and work practice
controls, the employer must provide and ensure employees use protective
clothing and equipment as supplemental protection.
Examples of engineering controls are, but not
limited to the following:
a)
Proper and adequate ventilation system
b)
Puncture resistant sharps container
c)
Biomedical waste removal service
d)
Eyewash and quick drench shower
Examples of work practice controls are, but not
limited to the following:
a)
Washing hands after removing gloves
b)
Placing sharps in provided sharps container
c)
Disinfect work area when finished working
d)
Utilize all protective equipment available
e)
Observe universal precautions
It is the responsibility of the employer to maintain
all engineering controls, so they provide the maximum protection to prevent
unnecessary exposure in the work area.
In order to fulfill this responsibility, the employer shall inspect
himself or herself, or delegate authority to an employee to make sure the
engineering controls are inspected regularly.
This is to ensure they are working properly and serving there intended
purpose. All repairs should be done
immediately.
In reference to the work practice controls, there
are alternatives to washing hands if running water is not available. This would be to use antiseptic hand
cleanser or towellettes, until adequate means of washing hands becomes available.
8. PERSONAL PROTECTIVE CLOTHING AND
EQUIPMENT
Universal precautions, work practice controls and
engineering controls are the primary method for ensuring exposure control in
the funeral home. Fortunately, these
methods can be further strengthened through the use of personal protective
clothing and equipment. OSHA requires
personal protective clothing and equipment to be used to prevent blood or other
infectious materials from passing through to, or contacting the employees work
or street clothes, undergarments, skin, eyes, mouth, or other mucous membranes,
unless engineering and work practice controls have eliminated occupational
exposure. The employer will provide all
necessary personal protective clothing and equipment.
The type and amount of personal protective clothing
employees should utilize should be based upon the exposure anticipated during
the task. The employee shall be
knowledgeable in the types of protective clothing available and the location
where stored and the proper use of the clothing or equipment. Remember proper disposal of all disposable
protective clothing or equipment is mandatory.
This means it must be placed in a red biohazardous red bag and disposed
of by a licensed waste removal service.
In reference to gloves, the appropriate size must be
made available. Gloves help reduce that
chance of exposure but are not 100% impermeable. For this reason it is necessary to wash hands after removal of
gloves. Gloves shall be disposed of
after being used. Gloves shall not be re-used. Gloves will be used when there is a chance
of exposure by hand contact to blood, other potentially infectious materials,
mucous membranes, or contaminated surfaces.
9. HOUSEKEEPING
Employees are usually involved in the cleaning of
their work area. The work area must be
maintained in a sanitary condition. The
employer must make sure the cleaning procedures are done safely and personal
protective clothing is used if there is a possibility of occupational
exposure.
Work surfaces must be cleaned with an appropriate
disinfectant and decontaminated immediately or as soon as possible after the
completion of a task and contamination with blood or other potentially
infectious material.
In order to maintain the required cleaning and
decontamination of equipment, the manufacturer's instructions must be
followed. Tuberculocidal disinfectants
and antimicrobials with HIV efficacy are recommended disinfectants due to their
effectiveness against bacteria and viruses.
Looks can be deceiving, so never take for granted
the cleanliness of a work area. If in
doubt, disinfect it. Maintaining good
health depends on it.
REGULATED
WASTE
Engineering controls, work practice controls and
universal precautions plays a major role in the requirements that pertain to
disposal of regulated waste. Regulated
waste pertains to the following:
a)
Blood or other potentially infectious materials
b)
Any item contaminated with blood
c) Contaminated sharps
d)
Any items containing dried blood
e)
Contaminated protective clothing
f)
Any items exposed to bodily fluids
All regulated waste must be placed in a container
that is puncture resistant, leak proof, sealable and labeled with the
appropriate biological hazard symbol.
The label should be red-orange or orange with the symbol being black
with the wording, Biohazardous Waste, Infectious Waste or Biomedical Waste.
The regulated waste container must be picked up once
every 30 days by a licensed waste removal service. All regulated waste must be disposed of in accordance with all
city, county, state and federal regulations.
LAUNDRY
All contaminated laundry must be placed in the
appropriate container. This container
must be lined with a red bag and labeled with the biological hazard
symbol. If a funeral home contracts
with a laundering company, the pick-up bag must be labeled with the biological
hazard symbol. Universal precautions
must be observed and protective clothing is to be used whenever handling contaminated
laundry.
If contaminated laundry is done on-site, the washing
machine must be labeled with the biological hazard symbol, universal
precautions must be observed and protective clothing is to be used during the
procedure.
10. HEPATITIS B VACCINATION
The bloodborne pathogen standard requires all
employees who have occupational exposure to blood or other potentially
infectious materials, be offered the Hepatitis B vaccination (also the booster
dose if necessary) at no charge. This
includes full-time, part-time or temporary employees regardless of the amount
of exposure.
The Hepatitis B vaccination will be made available
to all new employees with in 10 days of employment. Complete training will also be completed with in these 10
days.
The administration of the vaccination will be done
by a licensed healthcare professional and an accredited laboratory will do all
lab work.
The Hepatitis B vaccination will available after the
employee receives proper training in reference to hepatitis. This training will include information on
its efficacy, safety, method of administration, and the benefits of receiving
the vaccination and that the vaccination will be provided at no charge.
The only reasons that the Hepatitis B vaccination
can be waived is if the employee has already received the shot, if the employee
is immune to hepatitis, the vaccine is contraindicated for medical reasons and
if the employee refuses the vaccine.
All cases must be documented and put in the employee medical record.
11. POST-EXPOSURE EVALUATION AND FOLLOW-UP
In the event an employee reports an exposure
incident, there are procedures that must be followed that are required by the
bloodborne pathogen standard. The
procedures are as follows:
1. Record the route of exposure.
2. If possible, identify the source of
exposure.
3. If possible, test the sources blood.
4. Send the employee to a healthcare
professional. Test employee's blood if the employee requests it.
5. Document all events that took place during
exposure incident.
6. Provide a copy of the Bloodborne Pathogen
standard (1910.1030) to the healthcare
professional.
7. All employee medical records will be made
available.
8. Employer shall obtain a copy of the
healthcare professionals written
opinion and provide the employee a copy with-in 15 days.
9. All of the procedures will be done at no
cost to the employee. This includes counseling if requested by
the employee.
10. An accredited laboratory
will do all lab work.
This information shall be provided to the employee
by the employer and reviewed during the annual training program.
12. COMMUNICATION OF HAZARDS
This pertains to the labeling and training that will
help minimize occupational exposure to blood or other potentially infectious
materials, laundry, biomedical waste and any other item that has the potential
to become contaminated with blood or other potentially infectious
materials.
All work areas that have the potential to become
contaminated shall be clearly marked with the labels that are pertinent to the
exposure. For example, equipment or
instruments that come in contact with regulated waste shall be labeled as
such. If they are confined to a
cabinet, the entire cabinet will be labeled warning of such danger.
According to the bloodborne pathogen standard promulgated
by OSHA, this will help minimize occupational exposure and keep the employee
more alert to their surrounding environment.
This course was designed to bring attention to areas
that might be overlooked in your everyday work habits and to keep you abreast
of the possible dangers that are present in your occupation as a funeral
director. Remember to always observe
universal precautions when the threat of exposure is possible.
ANSWER
QUESTIONS 1-11
1. Hepatitis
B virus is the most common virus out of the five forms of viral hepatitis. TRUE
or FALSE
2. When
should universal precautions be observed?
a) When there is a known communicable
disease
b) When
there is a risk of exposure to bodily fluids
c) When an
employee is cleaning the preproom
d) All of
the above situations
3. The biomedical waste container, which holds
regulated waste, can be used to dispose of sharps. TRUE or FALSE
4. Which of
the following plans will determine the occupational exposure and designate
between exposed and non-exposed employees?
a) Biomedical waste plan
b) Emergency
evacuation plan
c) Exposure
control plan
d) Hazard
communication plan
5. Disposable gloves can be used over and over as
long as they are disinfected and hung up to dry before reusing. TRUE
or FALSE
6. In the event there is an exposure incident
involving a employee the following must be done:
a) Test the source of exposure if possible
b) Determine
the route of exposure
c)
Notify your employer immediately
d) Notify
your physician and make an appointment
e) All of
the above must be done
7. The
Hepatitis B vaccination charge should be deducted from the employee’s paycheck
in equal installments until it is paid in full. TRUE or FALSE
8. According
to the text, what is the average incubation
period for the Hepatitis B virus?
a) 1-2 weeks
b) 5-7 years
c) 4-6 weeks
d) 2-3
months
9. The term
"engineering controls" refers to the following except:
a) Ventilation systems
b) Washing
hands
c) Sharps
container
d)
Biomedical waste removal service
10. Personal
protective clothing and equipment is not required and is up to the discretion
of the employee whether or not it will be used? TRUE or FALSE
11. The "Biomedical waste" label must
be present in what areas:
a) Where there is regulated waste
b) Washing
machines, if they are used
c) Slop
sinks
d)
Instrument trays
e) All of
the areas mentioned would require the "Biomedical waste" label
L.F.D. Name:
Florida License #:
Funeral Home Address:
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