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Developed by JHPIEGO’s Training in Reproductive Health Project with funding from USAID.

Lesson 9: Infection Prevention for Healthcare Workers
Instructor: Linda Tietjen, Infection Prevention Consultant

Objectives

In this lesson, we will be discussing issues related to infection prevention for healthcare providers in limited-resource settings.

By the end of this lesson, participants will be able to:

1. Discuss the risk of acquiring HIV and other diseases from needle stick injuries.
2. Understand risk factors for HIV transmission in the healthcare setting
3. Describe standard prevention strategies 
4. Discuss post-exposure care

Overview

Direct contact with blood and other body fluids is the most frequent and greatest risk healthcare workers encounter when taking care of patients. Contact can occur when performing an examination, when processing instruments, during a surgical procedure, when cleaning up after an operation, or when disposing of waste.

Risk From Needlestick Injuries

The risk of acquiring HIV after being stuck with a needle from an HIV-positive patient is 0.4% or 4 in 1000. This is not as big a risk as many people might guess, but in areas where there is a high prevalence of HIV and poor infection prevention practices, it should be remembered that the risk of exposure is greater.

The risk of acquiring hepatitis B after being stuck with a needle from a hepatitis B-positive patient is as high as approximately 30 percent, which is significantly greater than for HIV. Each year, approximately 10,000 healthcare providers acquire hepatitis B. Between 150 and 250 of these providers die of complications from this disease. There is an effective vaccine available for hepatitis B and all healthcare workers should receive this immunization if possible.

Globally, an estimated 170 million persons are chronically infected with hepatitis C and 3 to 4 million persons are newly infected each year. The risk of acquiring HCV after being stuck by a needle from a hepatitis C-positive patient is between 3 and 10 percent. As compared to hepatitis B, hepatitis C is more likely to lead to cirrhosis, liver cancer and death. Currently, there is no vaccine for hepatitis C.

How frequently do needlesticks occur? According to a study conducted in Tanzania, of 118 doctors and medical assistants interviewed, 1% had stuck themselves in the preceding week as had 9.2% of 623 nurses. In the preceding month, 22% of nurses working in operating theatres had stuck themselves and 25% of 50 laboratory technicians interviewed had been stuck. 

Risk Factors for HIV Transmission in the Healthcare Setting

The likelihood of HIV infection following exposure is affected by the presence of certain risk factors. These include:

Type of exposure - Needle stick injuries are not the only way that healthcare workers can become exposed to blood and body fluids. There can be splashes to mucous membranes such as eyes and mouth. There can also be exposure to nonintact skin, such as when hands become chapped and cracked. There can be splashes to intact skin such as the face or arms or exposure to blood because of holes in the gloves worn during surgery or other procedures or examinations. HIV risk from mucous membrane exposure is approximately 0.09%. Risk from skin exposure is poorly defined but thought to be significantly lower.

Type of body fluid - Blood, semen and vaginal secretions, and sputum are the body fluids associated with the highest risk of HIV transmission. Exposure to other fluids, including amniotic fluid, cerebrospinal fluid, pleural fluid, peritoneal fluid, or fluids from joints or from around the heart (pericardial fluid) is thought to carry risk of transmission as well, although the degree of risk has not been well-defined. Urine, saliva, feces, tears, breastmilk and sweat have a low risk of transmission, unless they are visibly contaminated with blood.

Quantity of blood - Exposure to larger amounts of blood from an HIV-infected person increases risk of transmission. This may occur with deeper needlesticks, exposure to a needle placed directly into a blood vessel, or visible blood on the injuring instrument.

Disease status of the HIV-infected source patient - Exposure to blood from HIV-infected patients who have AIDS or late-stage HIV infection increases risk. This is likely because later stages of infection with HIV are associated with higher levels of virus in the blood. Very high levels of virus are also present in people who are newly infected with HIV and risk of infection is probably also increased with exposures during this time period. However, in very early infection people generally do not know they are infected and standard HIV tests are negative.

Post-exposure prophylaxis - Although it is not 100% effective, the use of antiretroviral agents, which are started immediately after an exposure has been shown to reduce the risk of HIV transmission in the healthcare setting.

Prevention Strategies

What can you do to protect yourself when you are working with patients? Standard or “universal” precautions (which used to be called barrier precautions or blood and body fluid precautions) should be used with every patient, because we cannot tell by looking at people whether or not they have HIV or another infection that can be transmitted in the health care setting. It is important to consider all blood and body fluids to be potentially infectious.

Standard precautions include:

• Hand washing 
• Using personal protective equipment such as gloves, mask to protect nose and mouth, goggles or face shield to protect eyes
• Handling and processing instruments safely
• Safe disposal of medical waste

Hand washing

Hands should be washed:

• after touching blood body fluids or secretions, or contaminated items
• before and after patient care
• before and after using gloves
• between patient contacts. 

Hands can be washed with plain soap and water. Most healthcare workers wash their hands 20 times or more each day. Protect your hands from dryness and chapping by using a petroleum-free cream or lotion. 

Antiseptic agents, such as chlorhexidine, iodophor or triclosan, or a waterless alcohol-based handrub should be used instead of plain soap under the following circumstances:

• before performing an invasive procedure
• before examining or caring for immunocompromised patients, 
• after leaving the room of patients with diseases that are spread by direct contact (such as hepatitis A) or those with drug-resistant infections (such as methicillin-resistant staph infections). 

These considerations relate to the fact that the healthcare worker can also potentially transmit certain infectious diseases to patients or between patients. 

Wearing Personal Protective Equipment

Use gloves when you are going to touch blood or any other body fluid or items that are contaminated with blood or other body fluids or secretions. Wearing two gloves or “double gloving” has been shown to reduce risks associated with injuries from sharp instruments during surgery. If you reprocess surgical gloves, double gloving is suggested because there is a greater chance that reprocessed gloves will have invisible holes or tears and the second glove will offer additional protection.

Use a mask and goggles or face shield when you anticipate splashing (such as when you are washing instruments, starting an IV or during a delivery). Use a gown or apron to protect your clothing, and therefore the skin underneath, whenever you are going to be in contact with large amounts of blood or body fluid and wear closed shoes.

Everything you need to make personal protective equipment can be purchased or made from materials that are locally available. For example, a face shield can be made with an elastic band, a piece of foam and a piece of clear plastic. Plastic can be purchased in a bookstore, or a processed x-ray film can be used. If goggles are not available, you can purchase a pair of glasses with plain glass or plastic to protect the eyes from splashes. 

Handling and Processing Instruments Safely

Another way that healthcare workers can protect themselves is to handle and process sharp instruments safely. When possible, limit the use of sharp instruments and use oral antibiotics instead of injectable or intravenous (IV) antibiotics. Use a needleless or retractable injection system if it is available. For surgery, you can use blunt needles for suturing. Always use of needle holder (not your fingers) when suturing. Never use a scalpel blade without a handle. During surgery use a safe zone for passing sharp instruments, such as a pan, rather than passing these instruments hand-to-hand. Communicate with other members of the surgical team by saying “knife” or “needle down” etc, so that all members of the team will be aware and careful.

Many injuries occur when disposing of sharp instruments such as needles or knife blades. Knife blades should always be removed using another instrument, not your fingers. Use a puncture-proof container, either cardboard or heavy plastic, to dispose of the sharp instruments immediately after use. These should be available at the point of use. If there is a possibility that someone else may come into contact with used needles and syringes, decontaminate them by flushing three times with bleach before disposal. Do not bend, break or recap a needle before disposal. 

After use, instruments and other items that will be reused should be decontaminated by soaking them in a 0.5% bleach solution for 10 minutes. Decontamination will help protect the person who is cleaning the instruments. Then, physically wash the items until they are visibly clean. Finally, either sterilize or high-level disinfect the instruments. 

Other items you need to process are linens, including scrub clothes from surgery and sheets and towels from patient care. When handling soiled linens, wear gloves, hold linens away from your body and do not shake them. Wash linens in hot, soapy water and dry. The procedures for handling linens are the same in either the hospital or at home.

Safely Disposing Medical Waste

No matter where you are disposing clinical waste, such as dressings or other contaminated items, you want to put the waste and all other contaminated items into a leak-proof container and then either burn or bury the container. Another item that needs proper disposal is the placenta. In many countries, the placenta is sent home with family members for burial. Regardless of where the baby is born, the placenta should be placed in a plastic bag or another leak-proof container. The family should be instructed not to remove the placenta from the plastic bag or container before burial or burning.

Post-Exposure Care

What do you do if an exposure occurs? If a splash or a spill occurs on the skin, wash immediately with soap and water. Do not use a caustic agent or bleach because that will irritate the skin and may increase your risk. If you have a splash or a spill in the eyes, the nose or the mouth, or any mucous membrane contact, rinse with clean water for a minimum of 10 minutes. If you are stuck by a needle or cut by an instrument, wash the area with soapy water, allow the wound to bleed freely and apply normal first aid. If the healthcare worker has not been vaccinated against hepatitis B, the vaccine series should be initiated, if available. 

If there is an exposure, evaluation of the degree of risk helps determine the need for post-exposure prophylaxis with antiretroviral drugs. Considerations include the type of body fluid involved, the type and severity of exposure (quantity of blood and duration of contact), and, if available, the HIV status of the source patient. If testing is available, the exposed healthcare worker should also be tested for HIV to rule out already existing HIV infection. 

To be effective, post-exposure prophylaxis should be started immediately, within 1 to 2 hours after exposure. Currently, the US Centers for Disease Control and Prevention (CDC) recommends a four-week regimen of 2 to 3 antiretroviral drugs based on the level of risk. With most exposures a basic two-drug regimen is recommended. However, for HIV exposures that pose an increased risk for transmission an expanded regimen that includes the addition of a third antiretroviral drug from the protease inhibitor class of drugs is recommended. This usually involves exposure to a large volume of blood or more severe type of exposure, when the healthcare worker knows the source patient is HIV-infected. If the HIV status of the source is unknown and rapid testing is not available or is refused and he or she is from a high HIV prevalence setting, the decision about whether to use the basic or expanded regimen should be made based on an individual basis. When the virus from the source patient is known or suspected to be resistant to one or more of the drugs considered for the post-exposure prophylaxis regimen, consultation with an HIV expert is recommended to help select a drug regimen that is likely to be effective. 

Tuberculosis

A related consideration for infection prevention in areas where HIV/AIDS is common is prevention of transmission of tuberculosis. Throughout the world, there are two billion people with tuberculosis. There are eight million new cases of TB per year and two million deaths from TB. Tuberculosis is the leading cause of death related to HIV throughout the world and the tuberculosis epidemic has been made significantly worse by the HIV epidemic. 

To prevent the spread of TB in a hospital setting, patients with active TB should be placed in a room with good ventilation to lower the concentration of infectious particles in the air. If possible this should be a private room so that other patients without TB are not exposed. Ideally, the room should also receive direct sunlight since the ultraviolet rays in sunlight kill the bacteria. The patient and those who come in contact with him or her (family members, healthcare workers and other potential contacts) should wear a mask covering their nose and mouth until the patient is noninfectious. The wearing of mouth and nose protection by potential contacts alone is NOT sufficient. The patient should be instructed to always cover their mouth when coughing and to use sputum containers with lids. Fortunately, once effective treatment is started, patients become noninfectious within several days.

Summary

In summary, three key points should be remembered: 

1. The risk of acquiring HIV after a needlestick from an infected patient is about 4:1000 (0.4%); the risk of acquiring hepatitis B or hepatitis C from similar exposures is significantly higher. 
2. We can minimize and prevent exposure to HIV and other infections that are spread through contact with infected blood or body fluids by using standard precautions with every patient. 
3. Post-exposure care should be used when necessary and prophylaxis with antiretroviral drugs should be used under appropriate circumstances when available.

Next Week's Lesson: 
Summary and Key Issues

References and Additional Readings

1. Bell DM. Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview. Am J Med 102 (Suppl 5B):9-15, 1997. 
2. Cardo DM et al and the Centers for Disease Control and Prevention Needlestick Surveillance Group. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. N. Engl J Med 337: 1485-90, 1997.
3. CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR 2001; 50: RR-11.
4. CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities. MMWR 1994;43:RR-13
5. Chaisson R, Anderson JA. 2002. Care of women with HIV living in limited resource settings: HIV and tuberculosis tutorial. JHPIEGO Corporation.
6. Gumodoka et al. 1997. Occupational exposure to the risk of HIV infection among healthcare workers in Mwanza region, United Republic of Tanzania. Bulletin of the World Health Organization 77(2):133-40.
7. Lewis R. Occupational Exposure. In: Anderson J (ed) A Guide to the Clinical Care of Women with HIV. U.S. Department of Health and Human Services, Health Resources and Services Administration, Washington, D.C. 2001.
8. Tietjen, L. 2003. Care of women with HIV living in limited resource settings: Infection prevention for healthcare providers and home caregivers. ReproLearn Tutorial. JHPIEGO Corporation.