[Table of Contents]

Volume: 23S3 - May 1997

PREVENTING THE TRANSMISSION OF BLOODBORNE PATHOGENS IN HEALTH CARE AND PUBLIC SERVICE SETTINGS

lll. General Recommendations for Canadian Health Care and Public Service Settings

The following recommendations pertain to all health care and public service settings, including acute and long-term care inpatient facilities, outpatient clinics, and all the specific settings in section E.

A. Preventing the Transmission of Bloodborne Pathogens Between Patients/Clients and From HCW to Patient/Client

In 1996 LCDC sponsored a Consensus Conference on Infected Health Care Workers: Risk for Transmission of Bloodborne Pathogens. The results of the Conference will be published as a supplement to the Canada Communicable Disease Report in mid-1997. Of the recommen-dations that follow, c, j, k, l, m, n, o and p are based on currently available information, and may need to be modified as a result of the Consensus Conference.

Workers have a pivotal role in preventing transmission of bloodborne pathogens between patients, clients and workers. Errors in handling and disinfecting or sterilizing needles and other instruments after use have been documented and implicated in the transmission of bloodborne agents in health care and public service settings. Adequate patient identification and procedural safeguards are essential whenever fluids are injected into patients.

Recommendations

a. Labelling of specimens or patients to identify them as requiring special care because of their potential risk for transmitting bloodborne pathogens is not recommended⁽⁴⁾.

b. After treatment of each patient/client and at the end of daily work activities, all potentially contaminated work surfaces should be cleaned, e.g., in hospitals, laboratories, ambulances, mortuaries, personal service settings, dental and outpatient clinics^(203,204) . Clean immediately if contamination or a spill occurs.

c. In the past, it was thought that the routine screening of patients or HCWs for HIV, HBV or HCV would not reduce the incidence of blood exposures and was not recommended^(11,69-71).

d. Patient safety is of primary concern when administering all injectable medications. Special attention must be paid to the initial and subsequent reuse of multi-dose vials.

e. Single-use (disposable) needles and syringes should be discarded after one use^(143,205). Changing needles between patients, but not changing syringes, is not an acceptable practice. However, in special circumstances, disposable needles may be reused on the same patient (e.g., acupuncture needles may be reused on the same client if those needles are maintained in a manner that will ensure no cross-use between clients - for instance, clean, sterilized needles are given to the patient/client for safekeeping). Safeguards must be in place and continually monitored to ensure that no possibility exists for reuse of disposable needles and sharps on different patients/clients.

f. All reusable needles or syringes must be appropriately cleaned and sterilized between patients/clients. Procedures must be in place to ensure safe handling, transport, reprocessing and storage of reusable needles and syringes.

g. The user of the sharp is responsible for ensuring its safe disposal.

h. Prior to any infusion of blood or blood product, full identification of patient and product must be made. Establish formal mechanisms to record identification procedures and quality assurance programs to ensure compliance⁽²⁰⁶⁾.

i. Breast milk must be labelled to ensure full identification of mother and child. Establish formal mechanisms to record identification procedures and quality assurance programs to ensure compliance. The Canadian Paediatric Society does not recommend the use of banked human donor milk⁽²⁰⁷⁾.

For an update of the following recommendations refer to the Recommendations from the Consensus Conference on Infected Health Care Workers: Risk for Transmission of Bloodborne Pathogens held in 1996, scheduled to be published as a supplement to the Canada Communicable Disease Report in mid-1997. See also An Integrated Protocol to Manage Health Care Workers Exposed to Bloodborne Pathogens for more information⁽⁵⁾.

j. Health care workers who have had a previous significant exposure⁽⁵⁾ or who have personal risk factors (e.g., high-risk sexual behaviour, injection drug use) should seek testing for HIV, HBV and HCV. Disclosure of an infected worker's serologic status to an employer or patient is not permissible without the HCW's consent⁽⁴⁾.

k. The patient should be notified when he or she has had a significant exposure to blood or fluid capable of transmitting bloodborne pathogens. Disclosure of the source of the exposure and of the serologic status of the HCW is not permissible without the HCW's consent^(4,170). The patient should be counselled about protective practices to be followed before the results are known (e.g., precautions with intercourse, avoidance of breast-feeding, and not donating blood, plasma, organs, tissue or sperm)⁽²³⁾.

l. Workers who have an infectious disease that could put a patient at risk are encouraged to seek medical evaluation with respect to the potential for transmission of the infection to patients clients. Seeking medical evaluation is a fundamental ethical principle for workers infected with HIV, HBV or HCV^(4,170).

m. An infected worker may choose to be medically evaluated by his/her primary care physician. Such physicians who care for HIV, HBV or HCV-infected workers are encouraged to seek advice on assessing the worker's practice and the potential risk for transmission of infection in the health care setting^(4,170).

n. Supportive non-threatening programs through licensing and professional organizations should be developed to assist seropositive workers whose practices are modified because of their infection status. Career counselling and, if necessary, job retraining should be encouraged to promote the use of the worker's skills and knowledge^(4,170).

o. The criteria used to assess fitness for practice of infected workers should include medical evaluation (including mental condition), knowledge, application of infection prevention and control measures, and risk of injuries from sharp objects in the context of the individual's occupation. Restriction of the HCW's ability to work should be based on mental and physical competence and specific practice, not seropositivity alone^(4,23).

p. HCWs infected with HIV, HBV or HCV are responsible for seeking counselling to assist them in assessing the risk that their infective status poses to their patients clients^(4,23). In any situation in which a worker is uncertain about the potential risks or proper procedures to minimize the risk to patients/ clients, he or she should consult with an employee health/infection control practitioner/ patient safety group responsible for the quality of care or an expert panel established by professional organizations for the purpose of assessing infected HCWs.

B. Preventing the Transmission of Bloodborne Pathogens From the Patient/Client to the Worker

1. Legislative Protection

Most workers are covered by either federal or provincial health and safety legislation and/or regulations with the goal of preventing accidents and injury to health arising out of, linked with, or occurring in the course of employment. Protection from occupational exposure to bloodborne pathogens is provided by a combination of acts and regulations in occupational health and safety. While specific legislation varies by jurisdiction, all jurisdictions have similar labour statutes in place.

For example, federal government employees are covered by legislation in the Canada Labour Code, Part II, Occupational Safety and Health⁽²⁰⁸⁾. Duties of employers begins thus: "Every employer shall ensure that the safety and health at work of every person employed by the employer is protected." Duties of Employees include the following: "While at work, every employee shall (a) use such safety materials, equipment, devices and clothing as are intended for the employees's protection... (b) follow prescribed procedures with respect to the safety and health of employees... (c) take all reasonable and necessary precautions to ensure the safety and health of the employee, the other employees and any person likely to be affected by the employees's acts or omissions." The section regarding safety materials, equipment, devices and clothing in the legislation states that "Where (a) it is not reasonably practicable to eliminate or control a safety or health hazard in a work place within safe limits, and (b) the use of protection equipment may prevent or reduce injury from that hazard, every person granted access to the work place who is exposed to that hazard shall use the protection equipment prescribed by this Part" (of the legislation).

2. Risk Reduction in the Workplace

Workers and employers need to analyse the components of their job in order to determine what procedures and activities put them at greatest risk of exposure. Review of reports and workers' compensation claims may assist in this assessment. Exposures and injuries need to be broken down into levels of risk such as low, moderate and high. When risk levels have been identified, then introduction of products and implementation of policies and procedures can be prioritized. For example, an accidental needle stick injury from a hollow bore, blood-filled needle would constitute a high risk as compared with an accidental stick injury from needles used on an intravenous (IV) line for an injection. See An Integrated Protocol to Manager Health Care Workers Exposed to Bloodborne Pathogens⁽⁵⁾ for more information.

Anecdotal reports of near misses are also an important means of obtaining information. When potential risks have been identified, workers need to be involved in problem solving, implementation and evaluation of the solutions.

Recommendations

a. A surveillance system should be established to identify the causes of exposure.

b. A risk reduction program should critically evaluate all procedures that may involve exposures to blood or other fluids capable of causing bloodborne pathogen transmission, in order to identify ways to reduce or eliminate the risk of exposure.

c. Whenever possible, alternative processes should be instituted that will eliminate the risk of a significant exposure (e.g., the use of automated washing and decontamination systems to eliminate the manual cleaning of contaminated sharp items, modifying surgical procedures to eliminate the need for blind suturing, removing lancet and scalpel blades from holders with clamps rather than with fingers)⁽²⁰⁹⁾.

d. If it is impossible to eliminate the risk, engineering controls should be used to modify work practices and procedures in order to reduce the risk (e.g., do not recap needles, place puncture-proof needle disposal containers as close to the site of use as possible and do not empty these containers, use self-blunting needles, use devices to quick-release sharps into containers, evaluate use of needle-less systems, and substitute needle-less products/safety systems wherever possible).

e. Personal protective equipment must be used to reduce the risk of exposure (to blood and other body fluids) that cannot be eliminated or until the process can be altered (e.g., all health care and public service workers should wear gloves as an additional barrier whenever the potential to contact blood or fluid capable of transmitting bloodborne pathogens exists and should wear goggles/face shields when splashes of blood or fluid capable of transmitting bloodborne pathogens are possible).

f. Educational programs (initial and ongoing) are essential to support the successful implementation of the options. However, programs that simply encourage personal responsibility for wearing appropriate personal protective equipment and do not examine how procedures and practices can be altered to reduce or eliminate risk frequently fail to achieve a reduction in exposures.

g. Refusal to work with HIV, HBV or HCV-infected patients is not justified.

h. When precautions to prevent the transmission of bloodborne pathogens are applied to all blood, all blood specimens, and certain body fluids, there is no need for signs to identify known or suspected cases, or for the use of biologic hazard warning labels on blood specimens⁽³⁾.

i. When blood specimens are transported outside the facility, other federal and provincial regulations may apply⁽²¹⁰⁾.

j. Blood specimens transported from one health care setting to another must be contained in safe packaging that is designed, constructed, filled and closed so that under normal conditions of handling and transport there will be no discharge, emission or escape of the specimens from the packaging.

k. Blood specimens that have been tested and confirmed by laboratory analysis to contain regulated infectious substances such as HBV or HIV must be transported (externally) in compliance with the Transport Canada Regulations in packaging Type 1B⁽²¹¹⁾.

3. Risk Reduction for Those with Regular Contacts with Blood

i. Immunization

An effective vaccine against HBV infection exists that will reduce the incidence of transmission and disease in HCWs^{(75,87,146,150)}. Vaccines are not available to prevent HIV or HCV infection. Recommendations

a. Pre-exposure prophylaxis with hepatitis B vaccine is recommended for those persons who are at increased risk of exposure to blood or fluids capable of transmitting bloodborne pathogens⁽⁵⁾ (also section II.A), or who may be at increased risk of sharps injuries (e.g., in occupational settings including health care, mortuary, laboratory, laundry, waste management, housekeeping, personal service and public safety). Students in these occupations should complete their vaccine series before possible occupational exposure to blood or sharps injuries. Other persons who are considered to be at increased risk and should be vaccinated include clients and staff of facilities for developmentally challenged persons, hemodialysis patients, recipients of blood or blood products, inmates of correctional facilities, household and sexual contacts of HBV carriers, and populations or communities in which HBV is highly endemic⁽¹⁵⁰⁾.

b. Post-vaccination testing for HBV serologic response is advised for persons whose subsequent clinical management depends on knowledge of their immune status (e.g., hemodialysis patients and staff, persons with HIV infection, persons with occupational exposure following vaccination)⁽¹⁵⁰⁾. This is under review by the National Advisory Committee on Immunization (NACI).

c. Booster doses of hepatitis B vaccine are not routinely recommended⁽¹⁵⁰⁾.

ii. Engineering safeguards

Occupational acquisition of bloodborne pathogens occurs most frequently following percutaneous injury from needles and other sharp instruments. The degree of hazard varies for different bloodborne pathogens; for different sharp instruments (e.g., hollow bore needles pose a higher risk than solid bore needles); and for different procedures (e.g., procedures in which blood loss is high, such as vascular and abdominal surgery)^{(1-3,7,40,43,53,83,209,212)}.

While injuries from sharp needles and instruments have shown a general downward trend, the decrease is not consistent, despite many years of emphasis on safety education^{(1,4,7,34,35,44,45,98)}. For example, the 1992 study in five Montreal hospitals revealed that many HCWs still recapped needles or left them loose, which resulted in the majority of injuries. Over 6% of exposures were related to disposal of needles in sharp containers, indicating a need for an improvement in the design and utilization of sharp containers⁽¹⁰⁴⁾.

New technologies and products may offer opportunities for non-invasive or minimally invasive alternatives to invasive procedures, with the associated reduced risk of exposure to sharps contaminated with blood or fluids capable of transmitting bloodborne pathogens. Examples include IV syringes and catheters that preclude the use of needles, protective devices for starting and removing IV lines, IV administration units that allow multiple connections without requiring the use of needles, needle disposal containers, single-hand re-closable needles, and devices that incorporate safety features that automatically shield or blunt needles or blades before removal from the patient^(54,213,214).

Recommendations

a. New technologies and products (e.g., needle-less IV systems, self-blunting blood collection needles) should be evaluated in a standardized fashion to assess applicability, cost-effectiveness, the frequency of exposure to sharps and the potential to reduce the frequency of exposure to, and volume of blood and fluids capable of transmitting bloodborne pathogens.

b. New technologies should be introduced promptly to replace less effective or less safe practices if evaluation indicates benefit. Emphasis should be on (a) reduction of exposure to needles or other sharp items; (b) reduction of exposure of cuts or mucous membranes to blood and fluids capable of transmitting bloodborne pathogens (see next section on Personal Protective Equipment); (c) decreased contamination of working environments; (d) redesign of reusable instruments to enable effective cleaning and disinfection; and (e) implementation of safety devices based on level of risk of various types of exposure incidents.

c. Where possible, alternatives to conventional suture needles should be considered and made available (e.g., blunt suture needles, staples, surgical adhesive, cautery).

d. Equipment designed to decrease potential exposure to sharps, and blood and fluids capable of transmitting bloodborne pathogens in operating rooms (e.g., magnetic pads on which to place needles and other sharp instruments, guards to prevent splatter, blunted surgical implements, thimbles to protect forefinger of non-operating hand) should be made available wherever they could be used to decrease occupational exposures.

e. All equipment should be evaluated for the potential to expose workers to sharps contaminated with blood and fluids capable of transmitting bloodborne pathogens. The safest equipment should be used wherever possible (e.g., in mortuaries, autopsy suites, fire and emergency services).

f. Enhanced equipment safeguards should be used for situations in which there is increased risk of encountering broken glass, sharp edges, hidden needles or other sharp instruments (e.g., body searches, extricating a person from an automobile wreck).

g. Used disposable syringes and needles, scalpel blades, and other sharp items should be placed in appropriate puncture-resistant containers located as close as is practical to the area in which the items are used. Bending or breaking of needles before disposal is not recommended^(2,215). Lancet and scalpel blades should be removed from holders with clamps rather than with fingers.

h. Used needles should never be recapped or otherwise manipulated using both hands, or by any other technique that involves directing the point of a needle toward any part of the body. If recapping cannot be avoided, either a one-handed "scoop" technique or a mechanical device designed for holding the needle sheath should be employed. Needles on non-disposable aspirating syringes should be recapped by one of these two methods before removing from the syringe^{(2,32,215,216)}. If multiple injections must be given to the same individual with a single needle, the needle should be placed in a clean, safe position where it cannot be contaminated or cause accidental injury, or covered with a safe re-sheathing device⁽²¹⁶⁾.

iii. Personal protective equipment

Some risk may remain, despite the use of risk-reduction measures. Personal protective equipment serves as a barrier against direct contact with bloodborne pathogens. Personal protective equipment includes gloves, eye protection, face shields, masks, gowns, aprons and protective footwear. One study concluded that among surgical personnel, the use of face shields, waterproof gowns and waterproof boots could have prevented more than half of the observed cutaneous exposures involving sites other than the hand⁽²¹⁷⁾. See Table 3, page 8, in II.C.1.i. for data from the Health Canada National Surveillance of Occupational Exposures to HIV regarding exposures and protective apparel worn. Gloves are available in a variety of materials, including latex, vinyl, nitrile, neoprene, copolymer, and polyethylene.

Gloves in all of these materials, when intact, will serve as adequate barriers to bloodborne pathogens (except in cases of needle stick injury).

The incidence of HCWs contacting blood is lower among those who wear gloves^(33,72). The volume of blood from a needle stick injury may be reduced by at least 50% when the needle passes through a glove⁽²¹⁸⁾. In some hepatitis B outbreaks, requiring HBV-infected HCWs to wear gloves decreased or eliminated HBV transmission to patients undergoing surgical or dental procedures⁽⁷¹⁾.

Studies have shown that the barrier quality of new gloves varies from lot to lot. Some investigators have found glove lots with a high proportion of leakage^(219-222), and others have found consistently good quality gloves^(223-225) that adhere to current standards^(226,227). Both vinyl and latex glove lots have been found to have leaks when gloves are tested new.

The use of latex has been associated with adverse reactions. Latex allergies are an increasing problem through contact and inhalation routes. Mild adverse reactions occur to latex in about 10% of the occupationally exposed population; some experience severe systemic reactions. In order to minimize exposure to latex allergens, low protein, unpowdered latex gloves should be considered when latex gloves are chosen.

No single type or thickness of glove provides appropriate protection in all settings. Selection of the best glove for a given task should be based on a risk analysis of the type of setting, type of procedure, likelihood of exposure to blood or fluid capable of transmitting bloodborne pathogens, length of use, amount of stress on the glove, presence of latex allergy, fit, comfort, cost, length of cuffs, thickness, flexibility, and elasticity^{(203,217,218,223,228-233)}.

Research is needed to identify appropriate gloves and other personal protective equipment that will provide effective protection for HCWs and that are sufficiently durable to ensure continued protection in use^{(203,217,223,233,234)}. Wire mesh gloves used in autopsy rooms do not prevent needle stick injuries⁽³⁾. Bloodborne viruses can pass through holes in damaged gloves, although HIV seroconversion following passive exposure to body fluids through a hole in a glove has not been reported ⁽²²⁸⁾. Reports of bloodborne pathogen exposure typically involve sharps injuries that penetrate the glove or failure to wear any gloves, rather than use of inappropriate gloves.

The Canadian General Standards Board (CGSB) operates a program to certify examination gloves and surgical gloves to national standards that specify glove quality levels that exceed the minimum set by the Health Protection Branch (HPB)⁽²²⁹⁾. The CGSB certification program may aid purchasers in their evaluation of glove quality (see Appendix). In Canada, the Medical Devices Bureau, HPB, Health Canada, produces information on the quality of gloves and on latex allergies, a compendium of non-latex gloves, and the results of tests on glove protein levels (see Appendix). Recommendations

i. General

a. When exposure to blood or fluids capable of transmitting bloodborne pathogens⁽⁵⁾ (also section II.A.) is anticipated, appropriate personal protective equipment should be worn.

b. Policies for use of personal protective equipment should be based on the risks inherent in each procedure (e.g., care of trauma victims carries a considerable risk whereas bathing individuals or doing routine care has negligible risk for transmission of bloodborne pathogens). Policies will require periodic evaluation to ensure consistency with changing knowledge, epidemiology and experience.

c. Face shields, eye protection, masks, gloves, gowns and aprons should be readily accessible and in sufficient quantity, sizes and types to meet occupational needs.

d. Purchasing decisions about personal protective equipment should be based on the facility's experience with comfort, fit, and durability, on epidemiologic evidence of barrier effectiveness, and on cost-benefit.

e. Masks and protective eye wear (e.g., goggles, safety glasses) or face shields should be worn to protect mucous membranes, non-intact skin and conjunctiva during procedures that are likely to generate splashes of blood or fluids capable of transmitting bloodborne pathogens. Wherever there is possibility for exposure to blood or fluid capable of transmitting bloodborne pathogens, masks and protective eye wear should be worn, e.g., during emergency surgical and dental procedures, forensic laboratory procedures, infant deliveries, during postmortem procedures^(1,3).

f. Emergency responders should resuscitate even if they do not have protective equipment. Risk levels are low and do not justify delay. There have been no documented cases of transmission of bloodborne pathogens through direct mouth-to-mouth resuscitation. Following possible exposure to blood or fluid capable of transmitting bloodborne pathogens, the emergency responder should immediately make an assessment, commence initial cleaning/flushing of the exposure site, obtain medical care and initiate the agency notification protocol⁽²⁵⁾. Mouth-to-mouth contact during resuscitation should be avoided by using mouthpieces, resuscitation bags or other ventilation devices. Resuscitation equipment and devices should be used once and disposed of or, if reusable, thoroughly cleaned and disinfected after each use according to the manufacturer's recommendations. Pocket mouth-to-mouth resuscitation masks (i.e., double lumen systems) designed to isolate emergency response personnel from contact with victims' blood and blood-contaminated saliva, respiratory secretions, and vomitus should be provided to all personnel who provide emergency treatment. For more details, refer to "A National Consensus on Guidelines for Establishment of a Post-Exposure Notification Protocol for Emergency Responders"⁽²⁵⁾.

g. Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or fluid capable of transmitting bloodborne pathogens⁽³⁾. Assessment of the specific risk will determine the type of gown required (e.g., fluid-resistant). An extra change of work clothing should be available in case of blood contamination of clothing. Clothing contaminated with blood or body fluid can be cleaned through regular laundering⁽²⁴⁾.

h. Research and clinical laboratories should post (outside the entrance) requirements for barrier equipment. When entering or working in research or clinical laboratories, protective laboratory clothing (uniforms, coats, and gowns) must be available and worn properly fastened by all personnel and visitors. Protective clothing should be removed and hands washed before leaving the area⁽¹⁾.

ii. For medical glove use

i. Medical gloves should be worn for all procedures that might involve direct skin or mucous membrane contact with blood or fluid capable of transmitting bloodborne pathogens. Use of medical gloves for reasons other than preventing the transmission of bloodborne pathogens may be indicated (e.g., procedures involving other infectious agents, contact with infected laboratory animals, toxins or contaminated equipment).

j. Disposable, good quality, medical gloves made of vinyl, nitrile, neoprene, copolymer and polyethylene serve as adequate barriers to bloodborne pathogens, particularly when latex allergies in workers or patients are a concern^{(203,233,234)}. The chosen gloves must be suited to the task (e.g., emergency care workers may require stronger gloves).

k. Non-sterile medical gloves are appropriate for examinations and some other non-surgical procedures⁽²¹⁵⁾. The decision to use sterile or non-sterile medical gloves will depend on the procedure. Medical gloves are manufactured in both industrial and medical grades. Only gloves labelled for medical use (e.g., sterile surgical gloves, non-sterile medical examination gloves) should be used to protect against the transmission of bloodborne pathogens during patient/client care activities⁽²⁰³⁾.

l. Workers who have dermatitis or non-intact skin should wear medical gloves when direct contact with blood or fluid capable of transmitting bloodborne pathogens might occur. Additional barriers, i.e., occlusive dressings, over non-intact skin in addition to gloves further reduces potential exposure. Persons with intact skin need not wear medical gloves when there is little chance of direct contact with blood.

m. The accepted standard should be that medical gloves be worn for all blood collection procedures. However, if phlebotomists choose not to wear gloves routinely, they must be gloved for performing phlebotomy if they have cuts, scratches or other breaks in their skin, or when hand contamination with blood is anticipated (e.g., phlebotomy on an uncooperative patient, finger or heel sticks)⁽³²⁾ . All students or new trainees must wear medical gloves during their training period and in subsequent practice for venipuncture, or other methods of blood collection.

n. Gloves need not be worn for subcutaneous, intramuscular or intradermal injections unless exposure to blood is anticipated. o. When the risk of percutaneous injury is high, double gloving has been shown to decrease the volume of blood involved in needle stick exposures and, therefore, double gloving may be practised, depending on the level of risk of the procedure (e.g., surgery, autopsies, police searches).

p. Gloves must be changed during lengthy procedures (before the development of punctures or tears, or when tears or perforations are suspected).

q. Stainless steel mesh gloves should be used when extensive use of saws, chisels, bone cutters or similar devices presents an increased hazard of accidental laceration (e.g., fire and emergency services, autopsies)⁽³⁾.

r. Gloves must be changed immediately after use, and after contact with one individual is complete before care is provided to another. Gloves may need to be changed between procedures on one individual (e.g., between catheter care and tracheostomy care).

s. Medical gloves must be discarded after single-patient use and not washed or disinfected. Microorganisms adhere to gloves and are not easily washed off⁽²³⁵⁾. Washing with surfactants (soaps or detergents) may enhance penetration of liquids through undetected holes. Disinfectants can cause deterioration of the glove material⁽³⁾.

t. After use, gloves should be removed carefully and disposed of appropriately. Use of gloves does not eliminate the need for hand washing. Hands should be washed whenever gloves are removed^{(203,235-237)}, since studies suggest that HCWs cannot accurately assess when glove leaks occur.

u. For housekeeping activities, instrument cleaning and decontamination procedures, general-purpose household gloves (e.g., neoprene, rubber, butyl) are appropriate. These can be washed and reused but should be discarded when they become peeled, cracked or discoloured⁽³⁾, before to the development of punctures or tears⁽²⁰³⁾.

C. Hygiene and Sanitation

For detailed information regarding hand washing, sterilization and disinfection, housekeeping, laundry and medical waste management, please refer to Infection Control Guidelines for Cleaning, Disinfection, Sterilization and Antisepsis in Health Care⁽²⁰³⁾.

1. Hand Washing

Hand washing is the most important procedure for preventing the transmission of bloodborne pathogens. There are many other indications for hand washing⁽²⁰³⁾.

Recommendations

a. Hands must be washed immediately after unprotected exposure to blood or fluids capable of transmitting bloodborne pathogens.

b. Hands must be washed after a glove tear or suspected glove leak.

c. Hands must be washed after removing gloves.

d. Hands must be washed after handling materials that may be contaminated with blood or fluids capable of transmitting bloodborne pathogens.

e. Hands must be washed before leaving a work area (e.g., the laboratory).

2. Sterilization and Disinfection

Standard sterilization and disinfection procedures for health and personal care equipment currently recommended for use in a variety of health care settings (i.e., hospitals, medical and dental clinics and offices, haemodialysis centres, emergency care facilities, outpatient settings, continuing care facilities, and home health care) are adequate against bloodborne pathogens when performed correctly to sterilize or disinfect instruments^(1,203).

Recommendations

a. Items contaminated with blood or fluids capable of transmitting bloodborne pathogens should be placed and transported in clearly marked containers that prevent leakage. 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^(1,203).

b. Medical devices must be thoroughly cleaned of all organic debris before reuse or exposure to disinfection or sterilization processes. The manufacturer's instructions for the use of germicides should be followed. It is also important that the manufacturer's specifications for compatibility of the medical device with chemical germicides be closely followed^(1,203).

c. Recommended standards for sterilization methods, sterilization process monitoring, and reprocessing items must be followed in all health care and personal care settings⁽²⁰³⁾. d. Instruments or devices that enter sterile tissue or the vascular system should be sterile and be single-use or sterilized before reuse. Devices or items that contact intact mucous membranes should be sterile or receive high-level disinfection⁽¹⁾.

e. Counter tops and surfaces that may have become contaminated with blood or fluid capable of transmitting bloodborne pathogens should be cleaned using an appropriate cleaning agent and water as necessary (e.g., after each procedure, after treatment of each patient/client, at the completion of daily work activities, and after any spill). Surfaces then should be disinfected with a suitable chemical germicide. Loose or cracked work surfaces should be replaced^{(1,27,203,215)}.

f. Accessible parts of equipment requiring repair should be cleaned and disinfected prior to being shipped to the manufacturer for repair. Commercially available chemical germicides (e.g., 70% isopropyl alcohol, glutaraldehyde, quaternary ammonium compound, iodophor, 1% formalin) are effective and may be more compatible with certain medical devices that might be corroded by repeated exposure to sodium hypochlorite (household bleach), especially at 1:10 dilution^{(1,203,238-241)}.

3. Blood Spills

Studies have shown that HIV is inactivated rapidly after being exposed to commonly used chemical germicides at concentrations much lower than those used in practice. Embalming fluids are similar to the types of chemical germicides that have been tested and found to completely inactivate HIV. HBV is also inactivated by common chemical disinfectants, including 500 ppm sodium hypochlorite (1:100 dilution of household bleach) and some quaternary ammonium compounds^(238-241). Other chemical disinfectants (e.g., iodophors, phenols) may also be effective against HBV.

Recommendations

i. For blood spills in patient care and client service areas

a. Appropriate personal protective equipment should be worn for cleaning up a blood spill. Gloves should be worn during the cleaning and decontaminating procedures. If the possibility of splashing exists, the worker should wear a face shield and gown (section III, B, 3, iii). For large blood spills, overalls, gowns or aprons, as well as boots or protective shoe covers should be worn. Personal protective equipment should be changed if torn or soiled, and always removed prior to leaving the location of the spill, then hands washed.

b. The blood spill area must be cleaned of organic matter before disinfection of the area is effective.

c. Excess blood and fluid capable of transmitting bloodborne pathogens must be removed with disposable towels. Discard the towels into a plastic-lined waste receptacle. The surface must be cleaned of obvious organic material before applying a disinfectant because hypochlorites and other germicides are substantially inactivated by blood and other organic materials^{(203,240,241)}.

d. After the area has been cleaned it should be decontaminated with sodium hypochlorite or chemical germicides that are approved as "hospital disinfectants" when used at recommended dilutions and temperatures. Concentrations 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 or mucus) present on the surface to be cleaned and disinfected. Previous recommendations have suggested that sodium hypochlorite or a chemical germicide should be left on the surface for 10 minutes^{(1,203,238-241)}.

ii. For blood spills in clinical laboratories

a. Regulations for blood spills in laboratories vary⁽²⁷⁾.

b. For large spills of cultured or concentrated infectious agents the contaminated area should be gently flooded with a liquid germicide before cleaning, care being taken not to disseminate the spill; the spill should be removed as already described, and finally the area must be decontaminated with fresh germicidal chemicals⁽²⁶⁾.

4. Laundry

Soiled linen may contain large numbers of pathogenic microorganisms, but the risk of disease transmission with appropriate practices is negligible^(203,242). Recommendations

a. HCWs providing patient care must ensure that sharps are not accidentally discarded in the laundry.

b. Wet linen should be placed in bags that prevent leakage and transferred to the cleaning area.

c. Linen soiled with blood or fluid capable of transmitting bloodborne pathogens should be transported and cleaned by standard procedures for all wet linen⁽²⁰³⁾.

d. Clothing contaminated with blood or body fluids can be cleaned through regular laundering.

5. Medical Waste

There is no epidemiologic evidence to suggest that hospital waste is any more infective than residential waste, or that hospital waste disposal practices have caused disease in sanitary engineers, landfill workers or other persons in the community. Medical waste is comparable to residential waste in microbial content, and can be safely disposed, untreated, in properly managed landfills if appropriate procedures are followed^{(203,243-246)}.

Recommendations

a. After use, disposable syringes and needles, scalpel blades, and other sharp items should be placed in puncture-resistant containers for disposal; these containers should be located as close as practical to the use area^(1,203) . In acute care facilities the puncture-resistant containers must be disposed of according to regulations pertaining to waste disposal in the institution. In home care and other non-institutional settings, the puncture-resistant containers can be disposed of with other waste according to local or provincial regulations⁽²⁰³⁾.

b. Reusable needles and other sharp instruments should be placed in a puncture-resistant container for transport to the reprocessing area⁽¹⁾.

c. Hospital wastes for which special precautions appear prudent include untreated microbiologic cultures and other specimen waste from the microbiology laboratory, unfixed tissue from pathology, blood specimens or blood products, and sharps⁽²⁰³⁾.

d. Waste from microbiology laboratories (i.e., culture and specimen waste) should be autoclaved prior to disposal; pathology waste should be incinerated whenever possible or otherwise disposed of according to local regulations.

e. Bulk blood, suctioned fluids, excretions, and secretions may be carefully poured down drains (avoiding contact and splashes) connected to the sanitary sewer system.

f. Waste should be bagged for transport to autoclaving, incineration or a sanitary landfill in a manner that prevents leakage and that complies with institutional and provincial regulations.

D. Management Issues Related to Occupational Exposures

See An Integrated Protocol to Manage Health Care Workers Exposed to Bloodborne Pathogens⁽⁵⁾ .

1. Education of Workers

Educational programing concerning the prevention of bloodborne pathogen transmission should be based on the characteristics of bloodborne diseases and the practical situations faced by workers in the performance of their specific duties. Recommendations

a. All health care and public service workers must receive infection prevention and control education regarding bloodborne pathogens and safe practice in the workplace before beginning work and on an ongoing basis thereafter (e.g., annually). Educational programing should be based on practical situations faced by workers in the performance of their specific duties⁽²⁴⁷⁾. Content should include general information about infection prevention and control (stressing the importance of hand washing), and information about bloodborne pathogen transmission; assessing risk of exposure; preventing exposures; immunization (HB vaccine); specific policies and procedures for individual work areas, including protocols following an exposure; and resources for further assistance. Workers need to know how to apply preventive techniques in routine practice and in unusual situations. Time must be given for workers to question, absorb and apply the information. It is critical that educational programs enable workers to express and work through their concerns about caring for individuals with a bloodborne infection. Records of participation should be maintained as needed to satisfy legal requirements.

b. Employees must be trained so that they can practise safely in their specific areas, including learning when and how to use personal protective equipment and how to use equipment safely. All workers should be taught the principles of preventing injuries from needles and other sharp instruments (e.g., minimizing the use of needles; not recapping needles or deliberately bending, breaking or otherwise manipulating them by hand; handling scalpels and holding suture needles with instruments rather than fingers; avoiding blind suturing; minimizing the use of hypodermic needles in the laboratory)^(27,48) . Actively involving workers in infection prevention and problem solving may help motivate employees to continue examining their practice for safer approaches. Effective leadership and communication, regular feedback, peer support and reinforcement, proof of benefit to self, and involvement in research may help to motivate workers to comply with preventive protocols^{(55,237,248-256)}.

c. Enhanced training and surveillance should be provided to personnel engaged in high-risk activities.

d. Professional associations and occupational groups are also responsible for developing and promoting to their members continuing educational programs in infection prevention and control. Such training should become a compulsory component of a worker's preparatory (pre-licensure) education and continuing education. Training programs should be evaluated regularly to ensure that information is current and meets the changing needs of the worker and workplace.

2. Quality Assurance and Improvement

A continuous effort to improve safety in the workplace requires several components. Learning from one's own exposure and "near-miss" incidents is essential. To be useful, incident reports must be analysed and returned to workers as meaningful information.

This, in turn, can promote interdisciplinary discussion through education and process improvement project teams. Incidents and injury reporting, data analysis, communication, in-service education and process improvement in a continuing cycle are required components. Review of industry-wide experience, or even similar experience in other industries, may reveal potential for improvement. Recommendations

a. Facilities should assess procedures to determine risk of exposure to blood and fluids capable of transmitting bloodborne pathogens.

b. Facilities should participate in and regularly review accidental blood exposure information from their own pertinent injury reporting programs, and from others (e.g., Workers' Compensation Board).

c. Comprehensive objective approaches to data collection and analysis should be used. Statistical and epidemiologic techniques that examine exposure incidences with respect to variables of time, place and person should be applied in a continuous surveillance program to contribute data that should form the basis of occupational safety programs.

d. Formal mechanisms should be established to ensure that action is taken as required as a result of the analysis of injury reporting programs. Involve employees at each stage of the development of safety programs.

E. Additional Information for Specific Settings

The recommendations made in section III, parts A - D, of this document apply in all health care and public service settings, including those specified in section E. Information in this section is intended to help apply the previous recommen-dations under varying circumstances, including gross exposure in uncontrolled and controlled settings, and limited exposures in uncontrolled and controlled settings.

1. Gross Exposure Potential in Relatively Uncontrolled Circumstances

This section provides additional information for emergency care first responders (e.g., ambulance attendants, police or fire department personnel who provide first aid); emergency department trauma teams, and attendants who deal with belligerent patients/clients or correctional facility residents. Individuals in settings where there is potential for gross exposure in relatively uncontrolled circumstances often have little control over the situation. Limited information is available that documents actual disease transmission in these circumstances. Hepatitis B has been transmitted, rarely, in such settings, but HIV and HCV transmission has been even more rare in spite of this exposure potential^{(65,99,176-180,184)}. For police officers, two-thirds of blood exposure incidents occurred in circumstances in which there was little or no time to put on protective clothing, or in which gloves would not have protected against penetrating injury⁽²⁵⁷⁾. Deliberate exposure to infectious agents is a rare but legitimate concern in correctional facilities⁽²⁵⁸⁾. Exposure of emergency department staff to blood and fluid capable of transmitting bloodborne pathogens is more common^{(7,33,41,46,50-52,61,64,83,98,101,158,259-264)}.

i. Fire fighters and emergency medical services

In addition to the general recommendations from previous sections of this document the following should be considered.

a. Identification of high-risk areas and procedures followed by development and implementation of protocols, surveillance, training and provision of equipment designed to decrease risk of exposures is critical in decreasing occupational exposures to bloodborne pathogens.

b. Enhanced equipment safeguards are indicated for situations in which broken glass and sharp edges are likely to be encountered (e.g., such as extricating a person from an automobile wreck). Gloves that meet the national requirements for use by fire fighters should be worn in any situation in which sharp or rough surfaces are likely to be encountered^(24,265).

c. 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 who may respond to medical emergencies or victim rescues.

d. Masks, eye wear, and gowns should be present in all emergency vehicles that respond to medical emergencies or victim rescues. These protective barriers should be used in accordance with the level of exposure encountered. Presence of small lacerations or small amounts of blood requires the use of gloves as an additional barrier. However, managing victims with massive arterial bleeding requires the use of gowns, masks, eye protection and gloves as barrier protection.

e. Pocket masks could be carried with the worker's basic equipment (for example, in a case on a belt).

f. Disposable gloves, appropriate to the task, should be a standard component of emergency response equipment, and should be put on by all personnel prior to initiating any emergency patient care tasks involving exposure to blood and fluid capable of transmitting bloodborne pathogens.

g. Gloves should be removed immediately after use. Hands must be washed after gloves are removed.

ii. Law enforcement and correctional facility officers

In addition to the general recommendations from previous sections of this document the following should be considered.

a. Identification of high-risk areas and procedures followed by development and implementation of protocols, surveillance, training and provision of equipment designed to decrease risk of exposures is critical in decreasing occupational exposures to bloodborne pathogens.

b. Whenever the possibility exists for exposure to blood or fluids capable of transmitting bloodborne pathogens, the appropriate protection should be worn, if feasible under the circumstances. In all cases, extreme caution must be used in dealing with the suspect or prisoner if there is any indication of assaultive or combative behaviour. When blood is present and a suspect or an inmate is combative or threatening to staff, gloves should always be put on as soon as conditions permit⁽²⁴⁾.

c. Criminal justice personnel are potentially at risk of exposure to bloodborne pathogens when performing searches and handling evidence. Penetrating injuries are known to occur, and puncture wounds or needle sticks, in particular, pose a hazard during searches of persons, vehicles, or cells, and during evidence handling. Variables contributing to increased risk include non-intact skin of personnel, blind searches of hidden areas (pockets, under car seats), blood spills and splashes.

d. Gloves should be removed immediately after use. Hands must be washed after gloves are removed.

e. Wear medical gloves if exposure to blood is anticipated. The following precautionary measures will help to reduce the risk of exposure:

Whenever possible, carry gloves on the belt to facilitate quick application when necessary.

Wear medical gloves for all searches.

Whenever possible, keep hands visible. Use equipment rather than hands to expose hidden areas (e.g., long-handled mirrors, flashlights).

Limit blind searches whenever possible.

Always have hands visible.

If cotton gloves are to be worn when working with evidence of potential latent fingerprint value at the crime scene, wear them over medical gloves when exposure to blood and fluid capable of transmitting bloodborne pathogens may occur.

While processing the crime scene, be alert for the presence of sharp objects, such as hypodermic needles, knives, razors, broken glass, nails or other sharp objects⁽²⁴⁾.

Use puncture-proof containers to store sharp items, and clearly marked impervious plastic bags to store other items potentially contaminated with blood and body fluids capable of transmitting bloodborne pathogens.

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: if there is potential for contact with blood or fluids capable of transmitting bloodborne pathogens, cover all cuts and abrasions to create a barrier and wear gloves. Carefully wash all exposed areas after any contact with blood or fluids capable of transmitting bloodborne pathogens, and wash hands after glove removal. 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 for all blood or fluids capable of transmitting bloodborne pathogens through contact, irrespective of known or suspected infection⁽²⁴⁾.

Sharp instruments used by evidence technicians should be safely used, carried in cases, and disinfected following use.

Correctional facility officers may choose to use personal protective equipment when the potential for exposure to blood and fluids capable of transmitting bloodborne pathogens exists. Prisoners may spit at officers and throw feces; sometimes these substances have been deliberately contaminated with blood or fluids capable of transmitting bloodborne pathogens. There are no documented cases of bloodborne pathogen transmission in this manner, and transmission by this route would not be expected to occur. However, when skin or mucous membranes are contaminated, immediate washing or flushing is recommended. For contamination of clothing, normal laundry handling is sufficient. For other items, decontaminate the article with an appropriate germicide⁽²⁴⁾.

2. Gross Exposure Potential in Relatively Controlled Circumstances

This section provides additional information for surgical facilities (including operating rooms and surgical clinics outside of hospitals), dental clinics, hemodialysis units, mortuaries and autopsy suites, and clinical laboratories.

In spite of the recognized high risk, surgeons report infrequent use of strategies to prevent exposure to blood. In a Toronto study (1995), only 21% of surgeons always double or triple gloved, only 10% always used protective eye wear apart from their own personal glasses, and few handled sharps appropriately. Most had been vaccinated against hepatitis B⁽⁴⁹⁾. A large majority of exposures to blood during surgery could have been prevented by additional barrier precautions^{(42,47,217,266,267)}. Knowledge or suspicion of patients' HIV seropositivity has not been associated with reduced exposures^(35,217). Contact with blood by anesthetists has been reported during 36% of procedures, and 98% of these exposures were felt to be preventable⁽²⁶⁸⁾. Similarly, midwives, obstetricians, and dental, mortuary and laboratory personnel suffer an appreciable number of preventable exposures^{(252,253,269,270)}. i.

Surgical facilities, including operating rooms In addition to the general recommendations from previous sections of this document the following should be considered.

a. Identification of high-risk areas and procedures followed by development and implementation of protocols, surveillance, training and provision of equipment designed to decrease risk of exposures are critical in decreasing occupational exposures to bloodborne pathogens.

b. Risk should be reduced through scheduling and assignment of tasks (e.g., minimize the number of staff participating in an operation).

c. Operating theatre personnel should wear face protection, gloves and fluid-resistant gowns, depending on the specific procedure. Reinforced masks with plastic face shields or masks used with solid side shield glasses, plastic sleeves, double gloves, trauma overalls and knee-high boots offer additional protection⁽²⁷¹⁾. Shoe covers may be considered to protect shoes, but are not useful in reducing infection.

d. Hands-free, no-pass, or no-touch techniques of instrument passing minimize risk. Intentions should be announced and actions coordinated when several individuals are working in the same area with sharp items⁽⁴⁷⁾.

e. Gloves should be removed immediately after use. Hands must be washed after gloves are removed.

ii. Dental clinics

In addition to the general recommendations from previous sections of this document the following should be considered.

a. The risk of exposure to bloody saliva in dental work necessitates special attention since there is high risk of glove puncture (e.g., from teeth, wire bands, ligatures).

b. Blood and saliva should be thoroughly and carefully cleaned from equipment used in the mouth, including irrigation equipment, before high-level disinfection or sterilization^{(1,239-241,273,274)}.

c. Equipment that comes in contact with gloved hands, e.g. mirrors and lamps, should be cleaned and disinfected.

d. Instruments that enter sterile spaces must be cleaned and sterilized between patients. In addition, instruments or equipment that have the potential for transmitting blood or fluids capable of transmitting bloodborne pathogens must be sterilized (e.g., high-speed handpieces and other intraoral devices)^{(73,74,102,136,137,203,215,216,239-241,273,274)}.

e. In addition to wearing gloves for contact with oral mucous membranes of all patients, dental workers should wear surgical masks and protective eye wear or chin-length plastic face shields during procedures in which splashing or spattering is likely^(1,273,274).

f. Gloves should be removed immediately after their intended use. Hands must be washed after gloves are removed

iii. Hemodialysis units

In addition to the general recommendations from previous sections of this document the following should be considered.

a. Disposable dialysers should be discarded after each use. Alternatively, centres may have dialyser-reuse programs, in which a specific dialyser is issued to a specific patient, removed, cleaned, disinfected, and reused several times on the same patient. An individual dialyser must never be used on more than one patient^(1,9,85,92).

b. Strategies for disinfecting the hemodialysis fluid pathways of the hemodialysis machine must be targeted to control viral contamination^{(1,9,88-92,195,196)}.

c. Patients infected with HIV can be dialysed by either hemodialysis or peritoneal hemodialysis and do not need to be isolated from other patients^(1,9,85,94).

d. Infection prevention and control strategies for HBV include separation of HBsAg-positive patients from HBsAg-negative patients, routine serologic screening for HBsAg and anti-HBs, and routine cleaning and disinfection procedures⁽⁸⁴⁾. These strategies include the dedication of specific machines for use only by HBsAg-positive patients. HBV-positive patients should be dialysed in a separate room or, if this is impossible, in an area separate from HBV-negative patients. The important principle is that HBV-positive patients be temporally or geographically separated from HBV-negative patients.

e. All hemodialysis patients not already infected with or immune to HBV should be vaccinated against hepatitis B⁽¹⁵²⁾.

f. Improvements in design to ensure the safest possible haemodialysis equipment would incorporate such features as flow-rate monitors and safeguards against inadvertent breaks in blood circuits.

g. Gloves should be removed immediately after use. Hands must be washed after gloves are removed.

iv. Mortuaries and autopsy suites

In addition to the general recommendations from previous sections of this document the following should be considered.

a. All persons performing or assisting in postmortem procedures must wear gloves, masks, protective eye wear, gowns and waterproof aprons^(1,11).

b. Gloves must be worn when personnel are in contact with an unshrouded body, including during pick-up in the home (unpublished observations, EA Henderson, Alberta).

c. Instruments and surfaces contaminated during postmortem procedures must be decontaminated with an appropriate chemical germicide⁽¹⁾.

d. Arterial and trocar embalming may present lower risk than evisceration⁽²⁶⁹⁾.

e. Embalming of autopsied bodies often takes more time and involves more contact with blood than embalming of intact bodies^(269,270).

f. Adequate time must be provided and the safest method of embalming should be selected.

g. Pre-exposure prophylaxis with hepatitis B vaccine is recommended⁽¹⁵⁰⁾.

h. Gloves should be removed immediately after use. Hands must be washed after gloves are removed.

v. Clinical laboratories

In addition to the general recommendations from previous sections of this document the following should be considered.

a. For information on high-volume laboratories or bloodborne pathogen research laboratories refer to guidelines specific for laboratories⁽²⁷⁾.

b. In the planning, construction and operation of clinical and research laboratories, defined physical and operational requirements for bloodborne pathogens should be fulfilled⁽²⁷⁾. Laboratory practices should be developed and equipment acquired to minimize or prevent exposure^{(1,9,17,26,27,67,68,97,122,206,275)}. Sealed centrifuge cups, biologic safety cabinets, pipette aids and shielded incinerators for bacteriologic loops are examples of the engineering safeguards required in laboratories to control transmission of bloodborne as well as other pathogens. Biologic 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, sonication and vigorous mixing. Mechanical pipette devices must be used for manipulating all liquids. Oral pipettes are prohibited. Specimens of blood must be transported in special packaging in accordance with Transport of Dangerous Goods regulations^(210,211). Care should be taken when collecting each specimen to avoid contaminating the outside of the container and the laboratory form accompanying the specimen⁽¹⁾.

c. Hazard warning signs, indicating the risk level of the agents being used, must be posted outside each laboratory. When infectious agent(s) used in the laboratory require special provisions for entry to the laboratory, the relevant information must be included on the sign. Certain bloodborne pathogens (HIV) require Class II biologic safety cabinets and specialized precautions^(27,206,275).

d. Containment level 2 or 3 standards and special practices, containment equipment, and facilities are recommended for activities involving all clinical specimens, body fluids, and tissues from humans or from infected or inoculated laboratory animals^{(1,27,206,275)}.

e. Gloves should be removed immediately after their intended use. Hands must be washed after gloves are removed.

3. Limited Exposure Potential in Relatively Uncontrolled Circumstances

This section provides additional information for schools, playgrounds, day care, camps, group homes and foster care. Studies of school and residential settings reflect both the inefficiency of transmission of bloodborne pathogens and the extent to which risk is adequately controlled by common hygienic measures^{(124,125,130-133)}. In addition to the general recommendations from previous sections of this document the following should be considered.

a. Bloodborne pathogens may be present in any child. Policies and procedures need to be in place to prevent blood exposures from any child.

b. Children who have bloodborne pathogen infections should not be excluded from day care, group homes or foster care. There is no reason for excluding children who do not exhibit aggressive behaviour and who do not have medical conditions facilitating transmission^(28,78).

c. Persons involved in the care and education of a preschool-aged child infected with HIV, HBV or HCV should be informed of the child's infective status only if such knowledge is necessary to ensure proper care of the child and to detect situations in which there is potential for transmission. Parental consent is required for the disclosure of a child's infective status. Decisions should be made on a case-by-case basis, respecting patient-physician privilege. Informed persons should respect the child's and the family's right to privacy. Records that identify a person's HIV, HBV or HCV status should be kept under strict confidentiality⁽²⁸⁾. There is no obligation to disclose the serologic status of an infected child to nursery school or day-care staff.

d. Asymptomatic adults infected with bloodborne pathogens may care for children in day-care settings provided they follow infection prevention and control practices and they do not have weeping skin lesions or other conditions^(28,161).

e. Children in day-care settings need not be considered for HBV vaccination⁽¹⁵⁰⁾.

f. However, if an HBV-infected child in a child-care setting has behaviour problems, such as biting or scratching, or if special medical conditions exist, such as severe weeping skin disease, vaccination of contacts should be discussed with public health officials⁽¹⁵⁰⁾.

4. Limited Exposure Potential in Relatively Controlled Circumstances

This section provides additional information for home health care, outpatient clinics, long-term care⁽²⁷⁶⁾, skilled nursing facilities and rehabilitation facilities. Comments in this section are also relevant to personal service settings (e.g., hairdressing, barber, electrology, esthetician, cosmetology, manicure, pedicure, massage therapy, acupuncture, tattoo and body piercing services).

Any personal care procedure that involves puncturing the skin should be considered high risk. HBV transmission has been documented in outpatient clinics^(76,77), during acupuncture⁽¹⁶⁴⁾, in chiropractic clinics, during ear piercing, in a weight-loss clinic⁽¹⁶⁵⁾ and in tattoo establishments⁽²⁷⁷⁾. Some of the reported cases were caused by repeated use of inadequately sterilized needles. Basic standards of hygiene, care in handling sharps, and proper decontamination of equipment after each use will protect both providers and consumers of these services. In addition to the general recommendations from previous sections of this document the following should be considered.

a. Needles and other penetrating instruments used with each client must be sterile, and such items must be handled in a manner that guards against contamination. This may be achieved by using disposable needles (e.g., acupuncture or electrolysis needles).

b. All other equipment must be cleaned and disinfected between patients/clients and between procedures on the same patient/client.

c. Proper care and handling of sharps is necessary in all settings⁽¹⁾. Puncture-resistant containers from the home health care and personal care setting may be disposed of with the regular waste, or according to local policies. Disposal of sharps from medical clinics, long-term care facilities, rehabilitation facilities and in home care situations will frequently be subject to the same regulations as local acute care facilities. Check with local authorities for direction.

d. Personal protective equipment must be available for use to protect personnel from exposure to blood and fluids capable of transmitting bloodborne pathogens.

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