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Canada Communicable Disease Report

 

 

Volume: 23S3 - May 1997

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

Adobe Downloadable Document PDF (667 KB)

Table of Contents

l. Introduction

A. Introductory Comments

B.Historical Perspective of Infection Control Practices Used to Prevent Bloodborne Pathogen Transmission

ll. Epidemiology of the Transmission of Bloodborne Pathogens

A. Significant Exposures to Bloodborne Pathogens

  1. Types of body fluids capable of transmitting HIV, HBV, and HCV
  2. To be considered significant, the type of exposure

B.Prevalence of Infection in the Population

C.Risk of Infection Due to Exposure to Bloodborne Pathogens

  1. Human Immunodeficiency Virus (HIV)
  2. Hepatitis B Virus (HBV)
  3. Hepatitis C Virus (HCV)
  4. Other Bloodborne Pathogens

lll. General Recommendations for Canadian Healthcare and Public Service Settings

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

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

  1. Legislative Protection
  2. Risk Reduction in the Workplace
  3. Risk Reductions for Those with Regular Contact with Blood

C.Hygiene and Sanitation

  1. Hand Washing
  2. Sterilization and Disinfection
  3. Blood Spills
  4. Laundry
  5. Medical Waste

D.Management Issues Related to Occupational Exposure

  1. Education of Workers
  2. Quality Assurance and Improvement

E. Additional Information for Specific Settings

  1. Gross Exposure Potential in Relatively Uncontrolled Circumstances
  2. Gross Exposure Potential in Relatively Controlled Circumstances
  3. Limited Exposure Potential in Relatively Uncontrolled Circumstances
  4. Limited Exposure Potential in Relatively Controlled Circumstances

lV. Bibliography

V. Appendix - Information Resources

1. Introduction

A. Introductory Comments

The potential for transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and other bloodborne pathogens in the health care or public service environments is of concern to patients, clients, health care workers, health care facilities, public health agencies, fire and emergency response personnel, law enforcement and correctional service officers, dental offices, mortuary and autopsy personnel, clinical laboratories, personal service workers, and the general public.

In 1987, Health and Welfare Canada released the first set of Canadian recommendations for the prevention of HIV transmission in health care settings(1). Experts quickly recognized that these recommendations would be useful in preventing the transmission of other bloodborne pathogens (e.g., hepatitis B and C, cytomegalovirus, Epstein-Barr virus). Since 1987, the Laboratory Centre for Disease Control (LCDC) has published three updates or clarifications relating to the prevention of the transmission of bloodborne pathogens in the health care setting(2-4). Specific guidelines with respect to infected health care workers (HCWs) were developed through a series of consensus conferences held by LCDC(4).

This Infection Control Guidelines document consolidates, clarifies and updates the previously published recommendations on the basis of current knowledge regarding bloodborne disease transmission in Canada and elsewhere. Guidelines, by definition, are directing principles and indications or outlines of policy or conduct that should not be regarded as rigid standards.

This Infection Control Guidelines document presents relevant Canadian epidemiologic data. The information and recommendations in Section III are applicable to all situations in which the potential exposure to blood and fluids capable of transmitting bloodborne infection exists. Additional information is provided that will enable application of the recommendations in selected settings (e.g., fire fighting, emergency, law-enforcement, correctional, surgical, dental, hemodialysis, mortuary, autopsy, funeral, laboratory, camp, day care, playground, school, foster care, home health care, long-term care, rehabilitation, personal service).

Recommendations concerning the management of health care workers following an occupational exposure to bloodborne pathogens have recently been published as a supplement to the Canada Communicable Disease Report entitled "An Integrated Protocol to Manage Health Care Workers Exposed to Bloodborne Pathogens"(5).

A future document will contain more recommendations regarding personal care services, such as body piercing, tattooing, electrology and acupuncture.

Prevention of bloodborne pathogen transmission in health care and public service settings requires a comprehensive infection prevention and control and occupational health and education program to limit exposures and reduce transmission if exposures occur. The elements of the program include education of workers, vaccination of people at risk for hepatitis B, identification and restriction of risky practices, design and use of safer medical devices, and targeted interventions based on occupation-specific hazards. A comprehensive infection prevention and control and occupational health program also includes ongoing surveillance and analysis of exposures, with a focus on preventing parenteral exposures and applying risk assessment methods to identify and modify risky procedures. This document embraces the principles of Universal Precautions (UP) to prevent the transmission of bloodborne pathogens in the context of a comprehensive infection prevention and control and occupational health program(6).

Any effective approach to the prevention of the transmission of bloodborne pathogens is based on the assumption that all blood and certain body fluids are potentially infectious. Precautions, applied to all patients at all times, may reduce the incidence and the quantity of blood exposure for health care workers in occupational settings(2-4,7-9).

B. Historical Perspective of Infection Control Practices Used to Prevent Bloodborne Pathogen Transmission

Historically, three forms of body fluid precautions have been practised in Canada. First, facilities used blood labelling precautions(10); then, UP(1,11) and Body Substance Isolation (BSI)(12) were put in place. UP and BSI address the problem of bloodborne pathogens from different perspectives. UP has an occupational health orientation focusing primarily on minimizing HCW exposure to bloodborne pathogens. BSI focuses on minimizing cross-infection risk from all pathogens for both patients and staff. UP and BSI have become confused in practice(13-15). This confusion has led to inconsistent application of terms and of necessary isolation strategies within and between organizations. The following summaries of UP and BSI are provided to help the reader make the necessary links between their agencies' program and the revised practices recommended in this document.

In 1987, the Centers for Disease Control and Prevention (CDC) in the United States published "Recommendations for Prevention of HIV Transmission in Health-Care Settings"(11). The Laboratory Centre for Disease Control (LCDC) and the Canadian Federal Centre for AIDS endorsed these recommendations and published them later the same year(1). The recommendations were based, in part, on the blood and body fluid Infection Control Guidelines previously published in Canada(10) and the United States(16-20). The "Recommendations for Prevention of HIV Transmission in Health-Care Settings"(1,11) incorporated information available in published reports and observations of the epidemiology and prevention of acquired immunodeficiency syndrome (AIDS) from 1982 to 1986. In 1988, 1989, and 1992, LCDC published clarifications on controversial interpretations(2-4) as well as recommendations on related topics(21-23).

The principle of UP, as originally conceived in 1987, was that a single standard of blood and body fluid precaution be used with all patients at all times, i.e., it was assumed that all blood or visibly blood-contaminated body fluids were potentially infectious. UP were specifically intended to prevent transmission of bloodborne pathogens from patients to health care workers (4) . They replaced the traditional isolation category of "blood precautions" used for patients suspected or confirmed with bloodborne pathogen infection. UP were to be used in conjunction with other disease or transmission-specific isolation precautions when patients had a confirmed or suspected infection other than a bloodborne one, e.g., gastroenteritis and tuberculosis(4,6).

UP applied to blood and other body fluids containing visible blood, semen and vaginal secretions, and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids(2,9). See Section II.A., page 4 of this document for a list of body fluids capable of transmitting HIV, HBV and HCV.

In 1992, LCDC recommended that the principles inherent in UP be regarded as the minimum standard of practice for preventing the transmission of bloodborne pathogens in all health care settings(4). Additional interpretive statements published in Canada and the United States expanded the use of UP to occupational groups that work in community settings, such as fire fighters and other emergency responders(24,25); law-enforcement and correctional-facility officers(24,25); research laboratories(26,27); schools, day-care centres and other child care settings(28-31); and home health care(32).

BSI, a strategy intended to prevent transmission of potential pathogens between patients, was introduced in 1987(12). BSI has not been embraced by government bodies in the United States or Canada. BSI expanded the principles of UP to all body fluids. Unlike UP, BSI replaced all other traditional isolation strategies, with the exception of isolation for airborne infections and multiple drug-resistant organisms.

Neither UP nor BSI recommends labelling patients or clinical specimens to identify them as requiring special care because of their potential risk for transmitting infection(4). It is impractical and possibly misleading to attempt to identify infectious blood specimens or selected individuals as infectious(33). Clinical identification of infected individuals is not reliable, and screening of all patients is not practical. Despite the perception by some HCWs that awareness of a patient's infectious status might result in improved safety behaviours, no study has provided objective evidence that identifying an infected patient decreases exposure frequency(34-36). Two studies have shown that HCWs who thought it important to identify high-risk patients were more likely to put themselves at risk by not always wearing gloves when blood contact was likely and by continuing to recap needles. The researchers concluded that the persistent belief that it is possible to identify high-risk patients is actually leading to less safe practice(35,36). This document continues to recommend against labelling of specimens or patients in relation to the prevention of the transmission of bloodborne pathogens.

To date, neither UP nor BSI has undergone in-depth evaluations of efficacy, costs, benefits, or weaknesses. Studies suggest that UP and BSI are costly strategies, and evidence of the effectiveness of either is scarce(34,37-39). Evaluation studies have relied largely upon unstandardized procedures and anecdotal recollections of individuals rather than covert observation of specific procedures. UP and BSI protocols have not consistently shown a decrease in the number of sharps injuries or risky behaviours occurring in health care facilities(33-35,40-54). Studies reporting improved levels of compliance with infection prevention and control precautions have provided variable results with respect to sharps injuries(34,52,55,56). Some studies did show that implementation of universal precautions reduced percutaneous exposures(57,58), risky behaviours(55), and direct contact with blood and body fluids(59,60).

Recent international studies of emergency department and emergency response workers have shown that the workers were unable to accurately predict HIV status from demographic characteristics and other identified risk factors(33,41,61).

Notwithstanding the lack of specific evidence of the effectiveness of UP or BSI protocols, there is significant evidence suggesting that not adhering to bloodborne pathogen protocols results in exposure to bloodborne pathogens from patient to HCW, from patient to patient, and from HCW to patient(7,8,41,61-81).

Infection control protocols are changing in the United States. In 1996, the CDC published an infectious disease isolation guideline, including a strategy entitled Standard Precautions. This strategy has been proposed as a system of isolation to replace UP and BSI(82).

As with UP, application of the recommendations in this present document requires the use of other infection prevention and control and isolation strategies for organisms other than bloodborne pathogens.

 

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