2011 UF Bloodborne Pathogen Training

1. 2011 UF BloodbornePathogen Training Biological Safety Office Environmental Health & Safety 352-392-1591 www.ehs.ufl.edu bso@ehs.ufl.edu Sharon Judge, PhD Assistant Biosafety Officer

2. Bloodborne Pathogens (BBPs) • Pathogenic microorganisms present in blood and other potentially infectious material (OPIM) that are able to cause disease in humans • Hepatitis B virus (HBV, HepB) • Hepatitis C virus (HCV, HepC) • Human immunodeficiency virus (HIV) • Less commonly, human T-lymphotropic virus (HTLV-1), Epstein-Barr virus (EBV), malaria, brucellosis, rabies, leptospirosis, babesiosis, syphilis, Creutzfeld-Jakob disease, arboviral infections (WNV, EEE), etc.

3. BBP Standard • Implemented in 1991 by the Occupational Safety & Health Administration (OSHA) • 29 CFR 1910.1030 http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051 • Revised in 2001 – safe sharps devices, maintain a log of injuries from contaminated sharps • UF follows OSHA requirement • General and workplace-specific training • Completed BEFORE individual is assigned to tasks with the potential for BBP exposure and ANNUALLY thereafter

4. BBP Standard • In addition to training, individuals with potential exposure must also have: • Access to the regulatory text and an explanation of its contents http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051 • Access to a copy of the UF Exposure Control Plan http://www.ehs.ufl.edu/Bio/BBP/ECP2011.pdf • Access to site-specific Standard Operating Procedures (SOPs) http://www.ehs.ufl.edu/Bio/BBP/BBPSOPS.pdf

5. UF BBP Program • Chairs/Directors Ensure dept. compliance • Faculty/Supervisors Ensure appropriate exposure control plan is in place and being followed • Employees, students, volunteers, etc Follow exposure control plan, report problems/exposure • SHCC/Occ. Med Immunizations & post-exposure follow-up • EH&S Biosafety Develop/coordinate program, track participants

6. UF BBP Program • ALL employees, staff, students, volunteers, affiliates with potential exposure to BBP from human blood/OPIM Custodians, medical providers, dentists/dental staff, autopsy staff, clinical laboratory staff, research lab staff & students, biomedical engineers, athletic trainers, event staff, police, emergency responders, physical plant workers…etc

7. What constitutes OPIM? *unless visibly contaminated with blood

8. Common transmission modes • Cuts or punctures with contaminated sharp objects • Splashes to mucous membranes • Contamination of broken/non-intact skin

9. From the bizarre but true files… • A woman in KY was arrested and charged with public intoxication (March 2010) • While changing into an inmate uniform, she squirted a stream of breast milk into the face of a female deputy • The press release sparked a debate when it was noted that the deputy was able to “clean the biohazard off of her” • Does this constitute an occupational exposure? • Yes, breast milk is considered OPIM

10. UF Exposures (2008-2010)

11. 2010 Reported Sharps Exposures by Department

12. 2010 Reported Sharps ExposuresUFHSC-Jax

13. Cornerstone of exposure prevention“UNIVERSAL PRECAUTIONS” • All human blood or OPIM is treated as infectious Use: Safety Equipment Safe Work Practices Personal Protective Equipment (PPE) • Standard precautions = universal precautions + body substance isolation. Applies to blood & all other body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes

14. Use universal precautions to handle… • Human blood and OPIM • Objects/items contaminated by blood or OPIM • Unfixed human tissues/organs (other than intact skin) • Cell or tissue cultures that may contain BBP agents • Blood/tissues from animals infected with BBP agents

15. Research using human cell lines… • Use Universal Precautions for all human cell lines • ATCC started testing newly manufactured/deposited cell lines for common viral pathogens (HIV, HepB, HepC, HPV, EBV, and CMV) in January 2010 • Many infectious agents yet to be discovered and for which there is no test • Remember HIV? • What about XMRV?

16. Hepatitis B (HepB, HBV) • Spread through direct contact with infectedbody fluids (blood, semen, vaginal fluids) • Infection may be acute or chronic • ~4.3-5.6% of Americans have been infected with HepB • 5-10 % of adults will develop chronic infection; ~1.2 million people with chronic HBV • 15-25% develop cirrhosis , liver failure, or liver cancer (~ 3000 deaths/year) • Many people (~50%) are asymptomatic; if symptoms occur they include:

17. Occupational HepB Exposures • Percutaneous • ~30% of these exposures results in infection • Mucosal exposure to blood/body fluids • Exposure to nonintact skin from contaminated surfaces and equipment – HBV can remain infective in dried blood at RT for at least 1 week (MacCannell et al., Clin Liver Dis 2010; 14:23-36)

18. Preventing Occupational HepB Exposures • Get vaccinated! • Universal Precautions • Cleaning/disinfection

19. HepB Vaccine • Safe • Given to newborns, 120 million people in U.S. have received at least one dose • Effective • >95% develop immunity after full series (3 doses given at 0, 1, 6 mos) • In Gainesville, free @UF SHCC (392-0627) • Bring completed Acceptance/Declination statement with you http://www.ehs.ufl.edu/Bio/BBP/TNV.pdf • If you decline, can change mind at any time

20. Postvaccination testing • Health-care workers or public safety workers at high risk for continued percutaneous or mucosal exposure to blood or body fluids, HBV research lab workers • Performed 1-2 months after dose #3 • HepB surface antibody (anti-HBs) ≥ 10 mIU/mL - immune • Anti-HBs < 10 mIU/mL – revaccinate (3 doses) and retest anti-HBs • Still negative – nonresponder, need HBIG after exposure • Previously vaccinated but not tested? Test for anti-HBs after an exposure; if negative, treat as susceptible.

21. Hepatitis C (HepC, HCV) • Transmitted primarily through contact with infected blood • Many people asymptomatic (symptoms similar to HepB) • ~1.8 % of Americans have been infected with HepC, 3.2 million chronically infected • ~ 12,000 deaths/year • Leading indication for liver transplant in U.S.

22. Occupational HepC Exposures • Percutaneous injury, esp. with deep punctures or extensive blood exposures • ~2% develop infection • Mucosal/nonintact skin exposures rarely documented • Proper cleaning/disinfection of surfaces important • HCV in dried blood samples remains infective for at least 16 hours (Kamili et al., Infect Control Hosp Epidemiol 2007; 28:519-524) • Universal Precautions for Prevention! • NO VACCINE • Antivirals (interferon/ribavirin) can have serious side effects, treatment lasts 24-48 weeks

23. HIV • Transmitted through contact with infected blood/OPIM • 1° infection • transient, non-specific illness (fever, malaise, muscle pain, sore throat) • Asymptomatic phase • Symptomatic phase • ↑ susceptibility to opportunistic infections, nonspecific constitutional symptoms (night sweats, weight loss, anorexia, fever) • Advanced (AIDS) • one or more opportunistic infections, CD4<200 cells/µl

24. HIV/AIDS - U.S. and Florida • > 1 million living with HIV/AIDS • ~56,000 new infections/year • ~20% don’t know they are infected • Florida ranks 3rd among states in the number of reported HIV/AIDS cases

25. Occupational HIV Exposures • Risk for HIV transmission after: • Percutaneous injury – 0.3% • Mucous membrane exposure – 0.09% • Nonintact skin exposure – low risk (< 0.09%) 57 documented occupational infections in U.S. (139 possible infections) 84% resulted from percutaneous exposure!

26. If HIV is such low risk, why worry? • No cure • No vaccine • Antiretroviral therapy – cocktail of 3 or more drugs, costly, side effects, drug resistance • Always use Universal Precautions!

27. Comparing the risks… • Risks of becoming infected after a needle stick injury: 30% 2% 0.3% *If unvaccinated*

28. Controls to Protect Against BBP Exposures

29. Primary Controls • Engineering (safety equipment) • Safety needles, sharps box, biosafety cabinet • Work Practices • Cleaning work surfaces, not recapping needles • Personal Protective Equipment (PPE) • Gloves, lab coat, face shield Maximum protection when these controls overlap

30. Engineering Controls • Sharps container • Biosafety cabinet • Cleanable work surfaces/chairs • Leak-proof transport containers • Safety needles/syringes

31. List of safety sharps devices available can be found at: http://www.healthsystem.virginia.edu/internet/epinet/safetydevice.cfm#1

32. Work Practices • Know what they are and follow them! • Minimize splashes • Don’t recap needles • Know how to handle spills • Wash your hands! • No eating/drinking in areas where blood/OPIM is handled or stored

33. DO NOT RECAP NEEDLESDon’t bend, break, or detach from syringe NO!! NO!! • Discard needles directly into sharps container • Do not overfill the sharps box – close and replace when ¾ full • Never attempt to re-open a closed sharps box

34. Circumstances Associated with Hollow-Bore Needle Injuries NaSH June 1995—December 2003 (n=10,239) 35% disposal related

35. Decontamination/Disinfection • FRESHLY DILUTED (w/in 24 hrs) 1:10 solution of household bleach • EPA listed tuberculocidal disinfectant • http://www.epa.gov/oppad001/chemregindex.htm • Clorox, amphyl, lysol, sporicidin • Ethanol evaporates too quickly to be an effective disinfectant!

36. Do you know how to clean this? • Notify people in the area • Don appropriate PPE (gloves, safety glasses) • Place absorbent material on spill • Apply appropriate disinfectant – allow sufficient contact time (30 min) • Pick up material (watch for glass – use tongs or dust pan); dispose of as biowaste • Reapply disinfectant and wipe For large/problematic spills, call EH&S Biosafety Office (392-1591)

37. Do you have a bio-spill kit? • Container of undiluted household bleach • Several pairs of gloves • Safety glasses • Absorbent material • Biohazardous waste (autoclave) bags • Dust pan & scoop or tongs for broken glass Place in a labeled bag or bucket and keep in areas where biohazards are used

38. Hand washing Pay attention to frequently missed areas – fingertips, between fingers, under jewelry Wash hands after removing gloves & before leaving the work area If no sink nearby, use hand sanitizer and then wash with soap and water ASAP

39. Personal Protective Equipment (PPE) • Wear it WHEN and WHERE you are supposed to • PPE should never be worn in common areas (offices, hallways, bathrooms, cafeterias, etc) or when handling common-use items (doorknobs, elevator buttons, telephones) • It is also common courtesy – others don’t know what you may have touched/where you have been

41. PPE • PPE must be supplied by the employer • It must fit, be suitable to the task (use common sense), and cleaned or disposed of properly (this does not mean taking it home to wash!) • Gloves • Face and Eye Protection • Surgical mask, goggles, glasses w/side shield, face shield • Body • Gowns, aprons, lab coats, shoe covers Absolutely no open toed shoes in the lab!

42. Gloves • Never re-use or wash gloves! • Some chemicals may breakdown the glove – use glove compatibility chart • http://www.ehs.ufl.edu/Lab/CHP/gloves.htm

43. Pay attention to how you remove your gloves! WASH HANDS!

44. Exposure Control Plan and Standard Operating Procedures (SOPs) • Site-specific! • Equipment, practices, and PPE used AT YOUR SITE to protect you and others • Written down, reviewed, accessible, updated annually or as needed • Template for SOPs: http://www.ehs.ufl.edu/Bio/BBP/BBPSOPS.pdf

45. HIV/Hepatitis Research Labs • More stringent control measures • Work must be registered with EH&S Biosafety Office (rDNA or BA registration) • Enrollment in medical surveillance program • Follow CDC/NIH BSL-2 containment practices at a minimum

46. If you have an exposure: • Wash wound with soap & water for 5 minutes; flush mucous membranes for 15 minutes • Seek immediate medical attention (1-2 hrs max) • In Gainesville, call 1-866-477-6824 (Needle Stick Hotline) • In Jacksonville, 7am-4pm, go to Employee Health Suite 505 in Tower 1; Other hours, go to ER • Other areas, go to the nearest medical facility • Notify supervisor • Contact UF Worker’s Compensation Office, 352-392-4940 • Allow medical to follow-up with appropriate testing & required written opinion

47. Call this number 24 hours a day, 7 days a week for all needle sticks and biological exposures!

48. Factors considered in assessing need for PEP CDC PEP Guidelines: http://www.cdc.gov/mmwr/PDF/rr/rr5409.pdf http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf

49. Record Keeping Requirements • Training records: • Retain a minimum of 3 years • Medical records for immunization or post-exposure follow up: • Retain for duration of employment + 30 yrs (includes HepB vaccination records, vaccination declination statement) • Confidential sharps injury log (type of device involved, where and how injury occurred): • Retain for 5 years from date of exposure

50. BBP standard requires that a labeling system be in place to warn people about the potential for BBPs • Warning labels must be placed on: • Containers of regulated waste • Refrigerators & freezers containing blood or OPIM • Containers used to store, transport, or ship blood or OPIM • Use red bags for waste containers