Transmission & Infection Control

Transmission

Conditions for transmission to occur:

For HIV to infect a person, several conditions need to be present.

1. There must be an HIV source
2. There must be a sufficient amount/dose of virus
3. There must be access to another person’s bloodstream

Unlike some might think, HIV cannot spread through casual contact (e.g. hugging, touching, sharing meals, etc.), thus it is not easily contracted. It’s acquired and is most commonly the result of unprotected sexual intercourse or needle sharing. 

Research has shown that HIV cannot live long outside the body (such as on surfaces) and it cannot reproduce outside a human host. Only in certain conditions would HIV have possibility to live. Such survival factors would be influenced by virus titer, the volume of blood, temperature encompassing the blood, and how much exposure it had to sunlight and humidity.

Experiments have shown that HIV is sensitive to high temperatures but not to extreme cold; it can be killed by heat, but temperatures over 60°C are needed to achieve sufficient killing of HIV. Changes in alkalinity or acidity – pH level – where it falls below 7 or above 8 will also affect the virus so it cannot survive. One theory to why HIV transmission may be less likely in healthy women is due to the acidity level in their vaginal secretions.

Transmission of HIV has not been reported as a consequence of contact with spillages of blood, semen or other body fluids.

Sources of HIV Transmission:

Any infected person with HIV virus is a potential source of HIV infection.

Infected blood, semen, vaginal secretions and breast milk are the primary sources of HIV. Bodily fluids such as sweat, tears, saliva, urine and feces are not capable of transmitting HIV unless contaminated with blood. In hospital settings, such as in operating rooms, fluids that have functions inside the body like cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid and amniotic fluid may be considered infectious if the source is HIV positive. The potential for these fluids outside a hospital setting would be rare.

Viral Load:

The concentration of HIV and the necessary amount of HIV for infection to occur is referred to as “sufficient dose.” When testing for HIV infection, the term “viral load” denotes the amount of HIV in a sample of one’s blood. When the viral load is high, there is more HIV in the body, which means that the immune system is not fighting HIV as well. A higher viral load also means the risk of transmission is raised as well. A low viral load has shown to decrease the risk of transmission greatly through sexual contact. This doesn’t, however, mean that low viral loads are guaranteed not to be transmitted. Even when the viral load in the blood stream is undetectable, HIV can still exist in semen, vaginal and rectal fluids, breast milk and other systemic bodily fluids. To learn more about viral load, see Section 3.

Blood Access:

To access another person’s bloodstream, certain behaviors or circumstances must take place. Only then can infectious fluid enter the bloodstream. The major risk behaviors for the transference of HIV are:

1. Unprotected sexual intercourse (anal, vaginal, and/or oral) with an HIV-infected person.
2. Use of contaminate injection equipment (used in injecting drugs)

Other practices concerning blood access:

1. Tattooing
2. Blood-sharing activities such as "blood brothers" rituals
3. Any kind of ritualistic ceremony where blood is exchanged or unsterilized equipment with contaminated blood is shared.

* The transmission of HIV also occurs in occupational settings. More about this later on in this section.

Transmission of HIV:

Specific risk behaviors make HIV transmission more probable. Needle stick injuries, usually in healthcare settings presents one potential way to become infected with HIV. Any blood contact with mucous membrane or non-intact skin provides other possible, though less probable, ways for transmission.

Strong probabilities for HIV to be transmitted:

1. Unprotected anal, vaginal, and oral intercourse
2. The use of improperly sterilized equipment, or sharing needles or other injection equipment
3. Before or after birth—a mother passing the virus to her baby
4. An infected woman breastfeeding an infant
5. Accidental needle stick injuries (as with healthcare workers), or infected body fluid coming into contact with the broken skin or mucous membranes of another person.
6. A transfusion prior to 1986 of HIV-infected blood or blood products
7. Sharing razors or toothbrushes (extremely rare, but possible if infected blood from one person were deposited on the toothbrush or razor, and then should enter the bloodstream of that other person).

HIV transmission depends upon the following four factors:

1. Sufficient quantity of Infectious agent (HIV)
2. Viability of the infectious agent (how strong it is)
3. Virulence of the infectious agent (how infectious it is)
4. Ability of the infectious agent to reach the blood stream, mucous membranes or broken skin of a potential host (i.e., getting into another person's body)

Blood Products & Transfusions:

March 1985 marked the year when transmission by contaminated blood or blood products ended in the United States. In 1986, testing began for HIV at blood banks and organ transplant centers. The risks for transmission in other developed countries has been nearly completed eliminated.

Due to donor screening, blood testing and other processing measures, the risk of transfusion-caused HIV have reduced from 1 in 450,000 to just one case in 600,000 transfusions in the United States. Donating blood in the U.S. is always safe, as strict use of sterile needles and equipment are used.

Hiv Transmission Probability From One HIV Exposure

Exposure Type	Transmission Probability
Contaminated blood transfusion (prior to 1986)	95%
One intravenous syringe or needle exposure	0.67%
One percutaneous exposure (e.g. a needlestick)	0.4%
One episode of receptive anal sexual intercourse	0.1%-3%
One episode of receptive vaginal intercourse	0.1%-0.2%
One episode of insertive vaginal intercourse	0.03%-0.09%

• 1% risk means one chance in 100 for infection to occur.
• .10% risk means one chance in 1,000.

Hepatitis versus HIV

Hepatitis B (HBV) and C (HCV) are both stronger viruses than HIV. They can remain infectious for longer periods of time outside the body. Much depends on environmental factors (heat, cold, exposure to oxygen, etc.).

All used syringes, needles, blood or body fluid spills should be considered potentially infectious, and should be treated using Standard Precautions—designed to reduce the risk of transmission of blood-borne pathogens and BSI (body substance isolation which has the purpose to reduce the risk of pathogens from moist body substances.

These precautions apply to all receiving care in hospitals, regardless of their diagnosis or presumed infection status. The standards are aimed at reducing the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.

Standard Precautions apply to:

1. Blood
2. All body fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood
3. Non-intact skin
4. Mucous membranes

Universal Precautions:

Universal Precautions is a term introduced in 1985 relating to procedures used for the purpose of preventing transmission of blood-borne pathogens in health care and other settings. Under Universal Precautions, blood or other potentially infectious materials of all patients should always be considered potentially infectious for HIV and other pathogens. Appropriate precautions should be taken by all employees.

The use of personal protective equipment (such as gloves, goggles, face shields, etc.) need to be utilized to prevent contact with blood. In 1996, the term Standard Precautions was adopted and the two terms have been used interchangeably. More detailed information about Standard and Universal Precautions are discussed later in this section under blood-borne pathogens.

Risky Behaviors:

Sexual Intercourse

Mucous membranes, breaks, sores and cuts in the mouth, anus, vagina or penis are all portals for HIV to enter the bloodstream. Anal, vaginal and oral intercourse (both receptive and penetrative) can transmit the virus from person to person. Sharing sex toys also have the ability to transmit HIV.

Anal Intercourse

Of all the risks, unprotected anal intercourse is considered to be the greatest sexual risk for transmitting HIV. It frequently results in tears of mucous membranes, making it easy for the virus to enter the bloodstream. The receptive partner (the one on the bottom) is considered to be at most risk for getting HIV if the virus is present. Risks may vary for the insertive (top) partner.

Vaginal Intercourse

The exchange of semen, pre-ejaculate fluid (pre-cum), menstrual blood or vaginal fluids due to unprotected vaginal intercourse is risk for HIV transmission.

Women are shown to be more likely to become infected with HIV through vaginal sex than men. The probable reason may be due to the larger amount of mucous membrane surface area of the vagina.

Needle Sharing and Drug Injection Equipment

The sharing of injection needles, syringes, etc. with an HIV-infected person is the behavior which most efficiently transmits HIV, HBV and HCV. It places HIV directly into the bloodstream.

Indirect Sharing

When drug injectors share injection paraphernalia and/or divide a shared or jointly purchased drug while preparing and injecting it, this is referred to as “indirect sharing.” The transmission potential is carried through the syringe, needle, "cooker,” cotton, and/or rinse water. Sometimes called “works” – this type of sharing can transmit HIV or other bacteria and viruses. The following are examples of indirect sharing:

• Expelling the drug back from a dirty syringe into the drug cooker and/or someone else's syringe
• Sharing a common filter and/or rinse water

HIV and Pregnancy

Transmission from an HIV-infected mother to her child can happened during pregnancy, the birth process, and/or following pregnancy by breastfeeding. How infectious the woman will be to her baby is determined by her viral load (how much HIV is present in her bloodstream). Higher viral loads tend to be in women with new or recent infections or people in later stages of AIDS, and this makes them more infectious.

With the discovery of using a course of the antiretroviral drug AZT (zidovudine) as therapy in 1994, transmission of HIV was significantly reduced from mother to baby. Today there are other antiretroviral drugs that can protect babies from becoming infected with HIV. Transmission from mother to child has been nearly eliminated when the drugs are used correctly.

Without antiretroviral therapy, an HIV-infected woman has a 25% chance of transmitting HIV to her baby. HIV transmission can drop to 2% if the infected mother receives antiretroviral therapies during pregnancy with a closely monitored health care regimen.

Caesarian section (C-section) may be recommended in some pregnancies to reduce the risk of transmission from mother to newborn. A medical provider experienced with working with HIV+ pregnant women will advise about medications and C-section on a case-by-case basis

Transmission of Multi-Drug Resistant Forms of HIV

Taking HIV medication every day, exactly as prescribed, is important. Its function in the body is to prevent HIV from multiplying more of itself in the bloodstream. When one skips an HIV medication, this allows HIV to multiply (make copies of itself), which then increases the risk that the virus will mutate (change form) and produce drug-resistant HIV. As a result of drug resistance, one or more HIV medicines in a person’s HIV regimen may no longer be effective.

What previously controlled the person’s HIV is now ineffective against the new, drug-resistant HIV. In other words, the HIV medicine can’t prevent the drug-resistant HIV from multiplying.

Drug-resistant HIV has the capacity to spread from person to person. People initially infected with drug-resistant HIV have drug resistance to one or more HIV medicines even before they start taking HIV medicines.

Drug resistance is a big problem because it can cause HIV treatment to fail. That’s why it’s essential for anyone on antiretroviral drug therapy to the drugs as directed.

Other factors that affect transmission:

Sexually Transmitted Infections

The risk for HIV transmission is increased when other sexually transmitted infections (STIs) exist. This is due to the breakdown of skin and mucous membranes occurring as a result of STIs, allowing HIV to have easier access into the body. When a person has an STI, HIV virus will concentrate more in those parts affected by the STI.

Syphilis and symptomatic herpes often cause breaks in the skin; chlamydia results in inflammation. Inflammation tends to increase HIV viral shedding and the viral load in genital secretions. Genital ulcers, sores that bleed easily and make contact with vaginal, cervical, oral, urethral and rectal tissues during sex are all potential entry points for HIV.

Multiple Partners

Chances of being exposed by an infected HIV person increases with multiple partners. Having multiple partners is a risky behavior whether it pertains to drug injection and/or sexual intercourse. The best way to prevent HIV from a sex partner is abstinence. Being in a monogamous relationship will also decrease one’s potential for infection. However,someone who has only one partner is still at risk if a person is HIV-positive and he/she has unprotected sex and/or share needles.

Sexually active people have options to use tools that are available today to prevent HIV, such as taking medicines to prevent and treat HIV, or using condoms with special lubricants. 

Substance Use

Alcohol and non-injected "street drugs" can place a person at risk for HIV. Such substances tend to impair judgment and can raise a person’s chance to take risks, which include such risky behaviors as having unprotected sex, sharing needles, and participating in other unsafe practices one normally would not do. Some substances have physiological and biological effects on the body. The masking of pain and creating sores on the mouth and genitals are potential effects that will raise one’s risk to getting HIV infection and other sexually transmitted diseases.

Equality Issues

Power struggles exist in some relationships and restrict what one partner is able to do or say within a relationship. The partner is either afraid of saying what they want and need to say, else cultural rules don’t permit them to. Culturally, women in some countries are dependent on men and live under certain rules and restrictions. Their dependence may extend to social and economic levels. This may make them feel unable to ask their partner to use sexual protection and leave them at risk for infection.

Another area that poses problems deal with domestic violence. Victims of domestic violence have a difficult time asking or insisting on safer sex practices or other actions that can maintain health. All genders are victims of this type of violence—men over women, women over men, men over men, women over men. Even transgendered people have power issues where prejudices and discrimination play a role.

Differences in age, wealth and gender can create power differentials. The main concern here in relation to gender/equality issues is that any lack of power in a relationship has the ability to affect a person's insistence or practice of preventive measures.

Casual Contact

There have been no cases of HIV transmission linked to casual contact. Casual contact would include anything like sharing computers, food, telephones, paper, water fountains, swimming pools, bathrooms, desks, office furniture, toilet seats, showers, tools, equipment, coffee pots or eating facilities. Since HIV is not transmitted through the air, neither does it transmit through sneezing, breathing and coughing. Any sort of touching, hugging or shaking of hands would not transmit HIV. Nor is any food prepared or served in a restaurant by an HIV-infected employee have a means for transmission. An item contaminated with blood should never be shared in any type of setting.

Children

As stated above, any casual contact would refer to children as well. Children playing with, eating with, sleeping with, kissing, or hugging other children are not transmissible actions. No cases of such as ever been reported.

Unusual Cases of HIV Transmission

Cases of HIV transmission occurring in household settings in the U.S. and other countries are very rare. Less than a dozen incidences have been reported, and these were thoroughly investigated by the CDC. Researcher’s conclusions determined that the transmissions involved the sharing of a razor contaminated with infected blood, the exposure of infected blood to cuts and broken skin, and possibly deep kissing involving a couple who both had bleeding gums and poor dental hygiene. These cases are extremely unusual. Sensible precautions with bleeding wounds and cuts and not sharing personal hygiene items would have prevented these cases of infection.

Also rare is the transmission from health care workers to patients. At least one occurred prior to the implementation of strict equipment disinfection. Others were the result of inappropriate infection control measures by healthcare workers and facilities.

Biting

Unless the person that is biting or being bitten has some form of blood exchange with the other, the chance for transmission poses very little risk. Risks would occur when bleeding gums or open sores in the mouth are present.

Bites do have the ability to transmit other infections, and they should be treated immediately. Washing the bitten skin thoroughly with soap and warm water, and disinfecting with antibiotic skin ointment should be done directly after the incident.

Workplace Situations

Exposures in the workplace occur through accidents that involve needle stick injuries or splash-type incidents where potentially infectious blood or blood-contaminated material is involved.

Methods to reduce transmission:

Sexual Abstinence

The safest and most sure way to prevent sexual transmission of HIV is through sexual abstinence. This means not engaging in anal, vaginal or oral intercourse or other sexual activities where blood, semen or vaginal fluid can enter the body.

Risks can be decreased when there is non-penetrative sex, meaning the penis does not enter the mouth, vagina or anus, and no penetrative sex toys are shared. Of course, this would be preventive only if there is no exchange of blood, semen, vaginal fluids or breast milk in the sexual contact. A risk factor is still present, however, for non-penetrative sexual intercourse when it comes to other sexually transmitted diseases.

Monogamous Relationships

As stated earlier, monogamous long-term relationships (having sex with only one person who only has sex with you) is a good choice in preventing and reducing the risk of HIV infection. No risks exists at all if neither partner is infected with HIV or other STIs, and neither has other sexual or injection equipment-sharing contacts. Monogamy only works in cases where both partners are free of disease and both partners remain monogamous.

Limiting Partners

Though not a guarantee against HIV, limiting the number of sexual or drug-injecting partners may reduce the risk of HIV transmission. It does not, however, eliminate the chances of exposure to HIV.

Practicing Safer Sex

The following are sexual tips that can lower the risk of HIV transmission concerning condom use:

• Latex condoms – these can be highly effective in preventing HIV when used correctly and consistently during sexual intercourse (includes anal, vaginal and oral practices)
• Water-based lubricants – these can be used to prevent tearing of latex condoms. The use of oil-based lubricants like petroleum jelly or cooking oils should not be used as these oils can actually breakdown the condom.
• Polyurethane condoms – for Male, these condoms, made of a soft plastic, look like latex condoms yet are thinner. Lab tests have shown that sperm and viruses like HIV cannot pass through polyurethane.
• Female or Insertive condom – The female/insertive condom fits inside the vagina or anus.Made of polyurethane, they help blocks sperm and viruses like HIV and may be inserted several hours before intercourse.
• Dental dams/other barriers – these type barriers can be large pieces of new, unused, clear, non-microwaveable plastic wrap, or square cuts of latex condoms to provide a barrier to reduce the risk of HIV transmission during oral intercourse on a female. The barrier is used as a dental dam. To cut for use of latex condoms, the tip is cut off and then cut down one side to open into a square. To enhance sensitivity and reduce friction, a water-based lubricant may be used.

Drug Injection Use

Using a clean needle with each injection use and not sharing injection equipment will greatly reduce the risk of HIV transmission. This includes any type of medicine that is used via injection (insulin, vitamins, steroids, prescription, and non-prescription drugs). Abstinence from injections is one way to lower one’s risk. Substance abuse treatment may be helpful in stopping or reducing one’s use of drugs.

A program called “syringe exchange” or “needle exchange” assists in encouraging people who use illegal drugs to exchange their old needles/syringes for clean ones. This reduces the risk for HIV and hepatitis.These syringe exchanges are also referral sources for drug treatment and participants have access to drug treatment through the intervention of the syringe exchange staff.

Washington State supports and operates a syringe exchange program in their communities. This disease prevention program has grown in recent years, supported by the public to tame HIV transmission. More information can be found by contacting your local health department/district's HIV/AIDS Program.

Pre-Exposure Prophylaxis (PrEP)

HIV negative people can prevent from being infected with HIV with medicine therapy called Pre-Exposure Prophylaxis, or PrEP. By taking a pill every day, which contains two medicines that are also used to treat HIV, a person who is exposed to HIV through sex or injection drug use can counteract against the virus. The medicine keeps the virus from taking hold and infecting the body. PrEP, if taken properly, and coupled with other prevention methods like condoms, can prevent HIV infection from occurring.

Only a health care provider can prescribe PrEP. The medicine must be taken as directed to work and has shown to be 92% effective against HIV. People who are HIV negative and have a high risk for HIV infection should take PrEP.

Those in risk of HIV would include the following:

• A person who is in an ongoing relationship with an HIV-infected partner
• A person who is not in a mutually monogamous relationship with a partner who recently tested HIV-negative and is a (1) gay or bisexual man who has had sex without a condom or has been diagnosed with a sexually transmitted infection within the past six months; (2) heterosexual man or woman who does not regularly use condoms when having sex with partners and known to be at risk for HIV (e.g. injecting drug users, or bisexual male partners of unknown HIV status)
• A person who has, within the past six months, injected illicit drugs shared equipment or been in a treatment program for injection drug use.

HIV Medication Treatment

Antiretoviral medication is prescribed to people who are infected with HIV. The treatment therapy can reduce one’s chance of transmitting the virus to others if taken as directed. Antiretroviral is a substance that stops or suppresses the activity of HIV. Those who consistently take these medications as directed by a healthcare provider are likely to be virally suppressed. Lab tests results would show no, or very small amounts, of virus in their blood. When the presence of HIV in bodily fluids are lowered, it becomes much less infectious.Again, to be effective (normally up to 90% or more), one must take the medical regimen correctly and consistently in order to reduce his/her chance of transmission.

Occupational Exposure (Blood-borne Pathogens):

The Department of Labor and Industries (L&I) Division of Occupational Safety and Health (DOSH) enforce certain requirements that are mandated by Washington Administrative Code (WAC) 296-823—Occupational Exposure to Blood-borne Pathogens. Failure to comply with these mandatory procedures could result in citations or penalties, so check with your organization to make sure that it complies with the requirements of this rule.

For additional directions beyond the brief summary described in this course (which is not meant to provide direction on compliance with WAC 296-823), consult The Federal Occupational Safety and Health Administration’s compliance directive on occupational exposure to blood-borne pathogens, CPL 2-2.69, or contact an L&I consultant in your area, which can be found in the blue government section of the phone book. L&I's 24-hour toll-free line: 1-800-4-BE-SAFE, website:www.lni.wa.gov

Rule Scope

Safety standards to protect employees from exposure to blood or other potentially infectious materials (OPIM) that may contain blood-borne pathogens can be found in the Occupational Exposure to Blood-borne Pathogens, Chapter 296-823 WAC. This manual applies to employers who have employees with occupational exposure to blood or OPIM (other potentially infectious materials) even if no actual exposure incidents have occurred.

Health care employees, law enforcement, fire, ambulance, and other emergency response and public service employees are the occupational groups most widely recognized as having potential exposure to HBV/HCV/HIV. Other occupations certainly hold risks as well, and every employer should evaluate for such risks in their work environment. Each employer is responsible to train their employees about their risk of exposure to blood-borne pathogens and provide ways for employees to protect themselves.

Exposure Types

1. Occupational exposure - a reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or OPIM that may result from the performance of an employee's duties.

1. Exposure incident - a specific eye, mouth, other mucous membrane, non-intact skin or parenteral contact with blood or (OPIM) that results from the performance of an employee's duties. Examples of non-intact skin include skin with dermatitis, hangnails, cuts, abrasions, chafing, or acne.

Blood-borne Pathogens

Blood-borne pathogens include a much wider range of pathogens than HIV and Hepatitis B (HBV). Any human pathogen present in human blood or other potentially infectious materials (OPIM) would be considered a blood-borne pathogen. These would include HCV, Hepatitis D, malaria, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, Creutzfeldt-Jakob disease, adult T-cell leukemia/lymphoma (caused by HTLV-I), HTLV-I associated myelopathy, diseases associated with HTLV-II, and viral hemorrhagic fever.

Hepatitis C (HCV) is the most common chronic blood-borne infection in the United States according to the Centers for Disease Control and Prevention. HCV is a viral infection of the liver transmitted primarily by exposure to blood. (See Section 4 for more information about HCV.)

Blood & Other Potentially Infectious Materials (OPIM)

As stated earlier in this course, bodily fluids that are linked to the transmission of HIV, HBV and HCV, and to which Standard Precautions and Universal Precautions apply are: blood, blood products, semen, vaginal secretions, cerebrospinal fluid, synovial (joint) fluid, pleural (lung) fluid, peritoneal (gut) fluid, pericardial (heart) fluid, amniotic (fluid surrounding the fetus) fluid, saliva in dental procedures, and specimens with concentrated HIV, HBV and HCV viruses.

Bodily fluids such as urine, feces, and vomitus are not considered other potentially infectious material (OPIM) unless they are visibly contaminated by blood. Wastewater (sewage) has not been associated in the transmission of HIV, HBV, or HCV and therefore not considered to be either OPIM or regulated waste.

Plumbers, however, who work in health care facilities, or are exposed to sewage originating directly from health care facilities, carry a theoretical risk of occupational exposure to blood-borne pathogens. Plumbers or wastewater workers working elsewhere are likely not at risk for exposure. The ones who are, those employers need to consider this risk when preparing their written exposure determination (see below for more about this requirement). As wastewater contains many other health hazards, workers should use appropriate personal protective equipment and maintain personal hygiene standards while working.

Exposure Control Plan (ECP)

Employers are required to provide a plan to protect their workers from exposures to blood and other body fluids covered under WAC 296-823. By providing one, employers also help control exposure incident costs. This "living" document used as a source of information for answering blood-borne pathogen-related questions as well as to help ensure exposure control activities are in place is known as an Exposure Control Plan (ECP). An ECP must contain the following elements:

1. A written “exposure determination” (includes job classifications and positions in which employees have the potential for occupational exposures. Exposure determination should be made without taking into consideration the use of personal protective clothing or equipment.Employees who are required or expected to administer first aid should be included.)
2. The procedure for evaluating the circumstances that surround exposure incidents, including maintenance of “Sharps Injury Log” to record all incidents.
3. The infection control system used in the workplace
4. Considered and implemented documentation of appropriate, commercially available and safer medical devices designed to eliminate or minimize occupational exposure.
5. An annual review and update of the ECP to reflect changes that effect occupational exposure (such as new worker positions; new technology used to reduce exposures).

Training Requirements

Every employer has the responsibility to train all new employees or employees being transferred into jobs involving tasks or activities with potential exposure to blood/OPIM. This training is in accordance with WAC 296-823-120 and must be presented prior to assignment to tasks where occupational exposure may occur.

The hazards associated with blood/OPIM, the protective measures to be taken to minimize the risk of occupational exposure, and information on the appropriate actions to take if an exposure occurs are all necessary teaching materials to be included in the training. When changes in procedures occur or when a task affects occupational exposure, then re-training is required.

Re-training should occur on an annual basis. Qualified trainers should be available to employees during the training session to ask and have answered questions as needed.

Hepatitis B Vaccination

The Hepatitis B vaccine must be offered to all employees with occupational exposure to blood or OPIM after receiving required training, and this should be done within 10 days of initial assignment. The vaccine must be provided free of charge. To ensure that the shots were effective for those persons with ongoing exposure to sharp medical devices, it is recommended that serologic testing be done after vaccination.

Only for employees whose sole exposure risk is for the provision of first aid can hepatitis B vaccine be delayed until after probable exposure (see WAC 296-823-130).

Infection Control

Universal & Standard Precautions:

• Universal Precautions is an infection control system designed to prevent transmission of blood-borne pathogens in health care and other settings. Under this control system, blood/OPIM of all patients should always be considered potentially infectious for HIV and other pathogens. Appropriate precautions by employees need to be utilized by using protective equipment, such as gloves to prevent contact with blood.
• Standard Precautions is a newer infection control system that applies to all patients receiving care in hospitals, regardless of their diagnosis or presumed infections status. Its intention zeros in on not only the risk of transmission of blood-borne pathogens, but also BSI (body substance isolation, which reduces risk of transmission of pathogens from moist body substances). Recommendations are designed to reduce risks by considering (1) blood; (2) all body fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood; (3) non-intact skin; and (4) mucous membranes. The purpose of this system is to reduce risks of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.

Personal Protective Equipment (PPE)

Universal and Standard Precautions involve the use of protective barriers to reduce the risk of exposure of blood-borne pathogens and OPIM to the employee's skin or mucous membranes. All health care workers are recommended to take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices.

PPE (personal protective equipment) is required to be worn by employees in all instances where there is potential for contact with blood or OPIM. Examples of this wear include gloves, masks, protective eyewear, and chin-length plastic face shields. Some occupations that are required to wear PPE include areas of medicine, nursing, dentistry, phlebotomy, laboratory processing of any bodily fluid specimen, and postmortem (after death) procedures. Latex gloves are advised when dealing with blood or OPIM unless an employee is allergic to latex. Employers are required to provide non-latex alternatives to employees with latex and other sensitivities. Nitrile, vinyl, and other glove alternatives are available and can be used as appropriate gloves when latex is contraindicated. PPE should be clean, and employers are responsible for providing decontaminated or laundered PPE to their employees.

Protective gowns should be worn over lab coats and scrubs when contamination is more likely to be present. If lab coats or scrubs are worn as PPE, they must be removed as soon as possible and laundered by the employer.

Safer Medical Devices

Work practices improve as safer medical devices are being manufactured for use to minimize and eliminate employee exposure. A health care facility should first identify the manufacturers and their products and then physically examine the safer medical device to ensure its appropriateness for their specific clinical setting. No device should be used on a patient before it has been screened by the health care facility to ensure it meets clinical needs. Also, an ongoing evaluation of employees and their work conditions is important to enhance a safer environment for them. Documentation of this evaluation and the implementation of these devices are to be recorded in the Exposure Control Plan. 

To access safer medical device lists maintained by the California Division of Occupational Safety and Health SHARP program, the National Association for the Primary Prevention of Sharps Injuries, and the International Health Care Worker Safety Center, visit: http://www.healthsystem.virginia.edu/pub/epinet/home.html

Hand Hygiene

Appropriate hand hygiene is recommended before and after patient contact, as well as after using restroom facilities. When hands are visibly contaminated or there is a likelihood of contamination, hand washing should include soap or the use of a waterless alcohol-based hand sanitizer.

Hand washing should be performed after removal of gloves and/or other protective equipment; immediately after hand contact with blood or other infectious materials; and, upon leaving the work area.

Proper Soap & Water Handwashing Technique:

1. Under warm water, use soap and good friction. Scrub the top, back, and all sides of the fingers.
2. Lather well and then rinse for at least 10 seconds. Begin at the fingertips so that the dirty water runs down and off the hands from the wrists. A pump liquid soap is preferable to a bar of hand soap.
3. Dry hands on paper towels, using the dry paper towel to turn off the faucet. Avoid touching with clean hands.
4. When leaving the room, use the paper towel to open the door.

Keeping fingernails short and wearing minimum jewelry will make hygiene more convenient and germ-free. See the CDC Guideline for Hand Hygiene in Healthcare Settings, 2002 for more information.

Housekeeping

A regularly scheduled cleaning and disinfection based on the location within a facility should be implemented and maintained for a clean and sanitary environment. An employer is required to determine and implement a written schedule and note the type of surface to be cleaned, type of soil present, and tasks or procedures that need to be or is being performed. After any type of contact with blood or OPIM, all equipment, environmental and working surfaces must be properly cleaned and disinfected. For broken glassware with contamination or with possible contamination, the glassware must be removed using mechanical means, as with a brush, dustpan, or vacuum cleaner.

Disinfectants

To decontaminate environmental surfaces, use chemical germicides and disinfectants with recommended dilutions. The choice of disinfectant, concentration, and exposure time is based on the risk for infection associated with the use of the equipment and other factors. The Environmental Protection Agency (EPA) has a list of registered sterilants, tuberculocidal disinfectants, and antimicrobials with HIV/HBV efficacy claims for verification that the disinfectant used is appropriate. Visit them at https://www.epa.gov.

CDC has a Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) for immediate download at: https://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf

Or visit the webpage for more information at: https://www.cdc.gov/hicpac/Disinfection_Sterilization/6_0disinfection.html

Specimen Handling

Prior to being stored or transported, blood or OPIM specimens must be placed in a closeable, labeled or color-coded leak proof container.

Laundry

All laundry that is soiled or may be soiled with blood or OPIM, and/or may contain contaminated sharps, must be transported in bags that are labeled or color-coded (red-bagged). These should be bagged at the location where it was used and should never be sorted or rinsed in patient-care areas.

Protective gloves and other appropriate personal protective clothing should be worn when handling potentially contaminated laundry. All contaminated laundry must be cleaned or laundered so that any infectious agents are destroyed. See CDC’s Guidelines for Environmental Infection Control in the Healthcare Facilities (2003) at http://www.cdc.gov/hicpac/pubs.html for more information.

Regulated Waste Disposal

As with soiled laundry, all regulated waste must be handled safely. Closeable, leak proof containers or bags that are color-coded (red-bagged) or labeled is required for all regulated waste disposal by WAC 296-823-14060. This is to prevent leakage during handling, storage and transport. 

Disposal of waste shall be in accordance with federal, state and local regulations. (See RCW 70.95K as it addresses biomedical waste management for Washington). Individual county or health jurisdiction waste management regulations may need to be consulted.

Regulated Waste as defined by WAC 296-823-140-60:

1. Liquid or semiliquid blood or other potentially infectious materials (OPIM)
2. Contaminated items that would release blood or OPIM in a liquid or semiliquid state, if compressed
3. Items that are caked with dried blood or OPIM and are capable of releasing these materials during handling
4. Contaminated sharps
5. Pathological and microbiological wastes containing blood or OPIM.

Sharps Disposal

• Needles are NOT to be recapped, purposely bent or broken, removed or otherwise manipulated by hand. After they are used, disposable syringes and needles, scalpel blades and other sharp items are to be immediately placed in puncture-resistant, labeled containers for disposal.
• Phlebotomy needles must not be removed from holders unless required by a medical procedure. The intact phlebotomy needle/holder must be placed directly into an appropriate sharps container.

Tags/Label

Tags or labels protect employees from exposure to potentially hazardous biological agent in accordance to the requirements contained in WACs 296-823-14025, 296-823-14050, and 296-800-11045. Tags are required and must have the following:

• Tags must contain a signal word or symbol and a major message. The signal word shall be "BIOHAZARD" or the biological hazard symbol. The major message must indicate the specific hazardous condition or the instruction to be communicated to the employee.
• The signal word must be readable at a minimum of five feet or such greater distance as warranted by the hazard.
• The tag's major message must be presented in either pictographs, written text, or both.
• The signal word and the major message must be understandable to all employees who may be exposed to the identified hazard.
• All employees will be informed as to the meaning of the various tags used throughout the workplace. Special precautions are noted on the tag and are necessary.

Food, Drink, & Personal Activities

All employees are restricted from eating, drinking, smoking, applying cosmetics or lip balm, or handling contact lenses in areas that carry occupational exposure. No food and drink should ever be stored in refrigerators, freezers, or cabinets where blood is stored or where OPIM is present.

Post-Exposure Management

Every employee exposure incident must be filed by the employer. A confidential post-exposure medical evaluation should be available to employees who report an exposure incident.

The post-exposure medical evaluation must be (1) made immediately available; (2) kept confidential; (3) be provided at no cost to the employee; and (4) provide according to current United States Public Health Service recommendations.

Source individual testing must be provided by the employer in accordance with WAC 296-823-160.

See WAC 296-823-180 for additional requirements for HIV/HBV research laboratories and production facilities.

Managing Exposure in Occupational Settings:

Occupational Exposure & HIV Risks

An occupational exposure is an injury on the job that puts one at risk for infection. Defined more specifically, an occupational exposure is a percutaneous injury (e.g., a needle stick or cut with a sharp object) or contact of mucous membrane or non-intact skin (e.g., exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other potentially infectious materials.

The risk of infection varies from case by case, according to the CDC. Several factors influence the risk. These factors take in account whether the exposure was from a hollow-bore needle or other sharp instrument, or if non-intact skin or mucus membranes were involved (such as the eyes, nose, and/or mouth). Lastly, it would depend on how much blood was involved, and what amount of virus was present in the source's blood at the time of the incident.

For needle stick incidents, or accidents from a sharp instrument, the risk of HIV infection is less than 1%. About 1 in 300 exposures through a needle or sharp instrument result in infection.

Concerning splashes of blood to the eyes, nose, or mouth, the risk of HIV is even smaller. About 1 in 1,000.

No HIV transmission from blood contact with intact skin has ever been reported. Blood contact to an area of skin that is damaged or from a large area of skin covered in blood for a long period of time is a theoretical risk only. In 2010, the CDC reported 57 documented cases and 143 possible cases of occupational exposure to HIV since reporting started in 1985. No confirmed cases of occupational HIV transmission to health care workers have been reported since 1999.

Risk of Hepatitis B (HBV) and C (HCV)

There is virtually no HBV risk for healthcare workers who have had the Hepatitis B vaccine and then developed immunity to the virus. A single needle stick or cut exposure to HBV-infected blood for a susceptible person ranges from 6-30%, depending on the hepatitis B antigen (HBeAg) status of the source individual. Those who have Hepatitis B surface antigen (HBsAg) and are HBeAG positive have more virus in their blood. This means they are more likely to transmit HBV than ABeAG negative are.

While there is a risk for HBV infection from exposures of mucous membranes or noncontact skin, there is no known risk for HBV infection from exposure to intact skin.Less than 400 healthcare workers are infected with HBV per year, according to CDC.

Treatment after a Potential Exposure

Familiarizing yourself with existing protocols and the location of emergency eyewash or showers and other stations in your facility is essential. Once an occupational exposure happens, follow the protocol of your employer. As soon as you possibly and safely can, the affected area(s) should be washed with soap and water. Antiseptics should not be a substitute for washing. Any potentially contaminated clothing should be removed as soon as possible. 

Exposure to Mucous Membrane

All exposures to eyes, nose or mouth should be flushed thoroughly with water, saline, or sterile irrigates.

Sharp Injuries

If the wound needs suturing, seek emergency treatment. Washing with soap and water is recommended, but no milking or squeezing of the wound should be done. Antiseptics like hydrogen peroxide hasn’t been proven to reduce risks of transmission for any blood-borne pathogens, but it’s not contraindicated either. Contracting HIV from this type of exposure is estimated to be 0.3%.

Bite or Scratch Wounds

Unless there is contamination with blood, exposure to saliva is not considered substantial. If the saliva emanates from a dental procedure, the risk is higher. Wash the area with soap and water and cover with a sterile dressing. Evaluation from a health care professional is advised.

NOTE: For human bites, the clinical evaluation must include the possibility that both the person bitten and the person who inflicted the bite were exposed to blood-borne pathogens.

Exposure to Urine, Vomit or Feces

Follow your employer’s procedures for cleaning these fluids. Unless the fluid is visibly contaminated with blood, exposure to urine, feces, vomit or sputum is not considered a potential blood-borne pathogens exposure. 

Reporting the Exposure

Knowing and following your employer’s protocol is essential. Clean the exposed area as recommended above, and report the exposure to the department or individual at your workplace that is responsible for managing exposure.

A medical evaluation should be obtained as soon as possible. The healthcare professional will need to know the extent of the exposure, any treatment prior to visit, follow-up care, personal prevention measures, the need for a tetanus shot and other care. It is your employer’s responsibility to provide you an appropriate post-exposure management referral. This should be at no cost to you. Your employer must provide the following information to the health care professional evaluating your case:

1. A copy of WAC 296-823-160
2. A description of the job duties the exposed employee was performing when exposed
3. Documentation of the routes of exposure and circumstances under which exposure occurred
4. Results of the source person's blood testing, if available
5. All medical records that you are responsible to maintain, including vaccination status relevant to the appropriate treatment of the employee.
6. If the exposure is an HIV and hepatitis related infection, by law, the case will need to be reported to a local health care provider under WAC 246-101.

Post-Exposure Prophylaxis (PEP)

When someone has had a substantial exposure, usually to blood, post-exposure prophylaxis (PEP) is the standard care given to occupational exposed healthcare workers since 1996. These anti-HIV medications provide treatment against HIV and keep it from multiplying in the body. As animal models suggest that cellular HIV infection happens within 2 days of exposure to HIV, the virus in blood can become detectable within 5 days—the reason why PEP should be started as soon as possible, within hours not days, after exposure. The medicine regimen needs to continue for 28 days. PEP, however, does NOT provide prevention of other blood-borne diseases like HBV or HCV.

The administration of hepatitis B immune globulin and HBV vaccine is the HBV PEP regimen for susceptible persons of Hepatitis B. This should begin immediately, or as soon as possible, and no later than 7 days post-exposure.

Antiviral agents are not currently FDA-approved for prophylaxis when it comes to Hepatitis C. The benefit of their use to prevent HCV infection is unknown.

Post-exposure prophylaxis must be obtained from a licensed healthcare provider. Check with your facility who may have recommendations and a process in place for you to obtain PEP. Certain anti-HIV medications can be prescribed after evaluation of the exposure. The care provider will need to know the route and other risk factors pertaining to your case. Anyone exposed to a blood-borne pathogen can contact the national blood-borne pathogen hotline, which provides 24-hour consultation for clinicians who have been exposed on the job. Call 1-888-448-4911 for the latest information on prophylaxis for HIV, hepatitis, and other pathogens.

Occupational exposure must be reported to the department at your workplace responsible for managing exposure. It would be important to know if post-exposure treatment is recommended, as it should be started as soon as possible and strictly taken as directed. There is a 24-hour PEP source in rural areas for emergency providers—police, firefighters and others at risk.

Washington state workers have a right to file a worker's compensation claim for exposure to blood-borne pathogens. Industrial insurance will cover the cost of post-exposure prophylaxis and the follow-up needed for the injured worker.

Post-Exposure HIV/HBV/HCV Testing

Following the initial procedure for an occupational exposure (including being evaluated by a health care professional), a follow-up evaluation should be scheduled for counseling, post-exposure testing, and medical evaluation, regardless of whether or not PEP was indicated. The period after exposure for antibody testing for HIV, HVB, and HCV extends for more than six months following exposure.

Once the baseline testing is completed, follow-up testing is recommended to be performed at 6 weeks, 12 weeks, and 6 months after exposure. Certain cases may require longer periods for HIV follow-up (e.g., for 12 months). This is recommended for those who become infected with HCV after exposure to a source co-infected with HIV. Other circumstances might include those persons with an impaired ability to mount an antibody response to infection.

Source Testing

The employer is required to arrange testing of the source individual—the one whose blood or OPIM was the originating source of the HIV, HBV and HCVexposure. As mandated by WAC 296-823-16010, testing should occur as soon as feasible after getting the source’s consent. If the employer does not get consent, the employer must document such and inform the employee.

The Revised Code of Washington 70.24.340 provides for HIV antibody testing of a "source person” when a law enforcement officer, fire fighter, health care provider or health care facility staff, and certain other professions experience an occupational exposure. Those who work within any of these professions and has experienced a substantial exposure to another person’s blood or OPIM should contact their employer or local health officer to request for HIV testing of the source individual.

A health order for HIV testing of the source individual is issued once it is determined by the health officer whether a substantial exposure has actually occurred and if the exposure occurred on the job. The health officer will determine if source testing is necessary or not, dependent on the type of exposure and the risks involved.

In cases of exposure to health care workers and the permission of the source individual is unobtainable by the employer, the employer can request assistance from the local health officer. This needs to be requested within seven days of the occurrence, however.

Baseline testing of the exposed individual for HIV, HBV, HCV and liver enzymes is always necessary and important, no matter if source testing is done. Since the source person's test results may not be available for days or weeks following the exposure and because PEP should be started as soon as possible following exposure, provision of PEP is not contingent upon source individual’s results.

PEP is standard practice for occupational exposure, its effectiveness documented. However, PEP for sexual exposure (assault or consenting) or for needle sharing is not standard medical practice in many communities. PEP is dependent on your location in Washington State. Some providers may not be familiar with providing PEP to people who have post-sexual exposure to HIV. A PEP clinic has been available for non-occupational exposure since 1997, operated by the University of California at San Francisco. To obtain more information, call (415) 487-5538, or (415) 514-4PEP if after hours.

It is advised to start PEP within 48 hours of exposure. Local emergency rooms often serve as a source for PEP. If the emergency room, physician, or your doctor has questions about PEP, the PEPLine hotline for clinicians (The University of California at San Francisco) can be contacted at 1-888-HIV-4911. (Any basic questions about HIV should be sought elsewhere.)

Non-Occupational Exposure to HIV

PEP is not used for primary prevention of HIV. It can be used for those exposed to a single event unrelated to work, though, such as those dealing with sexual assault. See Section 3 of this course for advice concerning PEP and counseling related to sexual assault.

Protection in the Home & Home-type Settings:

Preparation of food or the handling of body fluids and medical equipment in the home or home-type settings requires good hygiene practices. Cuts, accidents, or other circumstances resulting in spills of blood/OPIM may deposit on carpeting, vinyl flooring, clothing, on a person's skin, or other surfaces. Everyone, including children, should have a basic understanding of the importance of good hygiene in the home. One crucial rule to adhere to never place bare hands in or on another person's blood.

The following are common situations that require good hygiene practices within homes and home-like settings

Gloves (available in latex, nitrile or vinyl)

NOTE: Some people have allergies to latex.

Safe Practices concerning the use of gloves:

1. Wear gloves when caretakers anticipate direct contact with any body substances (blood or OPIM) or non-intact skin.
2. When removing gloves, carefully pull them off inside out. This should be done one hand at a time, so that the contaminated surfaces are inside and you avoid contact with any potentially infectious material.
3. Follow the removal of gloves or a change of gloves with good hand washing. This should done as soon as possible and always between children, patients, etc.
4. Avoid rubbing the eyes, mouth or face while wearing gloves. Never wash and reuse latex gloves.

Correct Handwashing Technique

This is extremely important.

1. Use warm (almost hot) water, soap, and good friction. Scrub the top, back, and all sides of the fingers.
2. Lather well and rinse for at least 10 seconds. Rinsing should begin at the fingertips so that the dirty water runs down and off the hands from the wrists. A pump liquid-type soap is preferable to bar hand soap.
3. Use paper towels to dry hands. Paper towels should be used also for turning off the faucets (avoid touching faucets with clean hands) AND when opening the bathroom door when exiting.

NOTE: When there’s not a suitable sink readily available in the home or work setting, a waterless antibacterial handwashing product can be used for immediate use, however this product does not replace proper handwashing with soap and water. Read manufacturer's directions for use.

Hands should always be washed before using the toilet if one has been exposed to body fluids of any kind and after toilet use as well.

Personal Hygiene Precautions

Sharing of razors, toothbrushes, personal towels or washcloths, dental hygiene tools, vibrators, enema equipment, or other such personal care items open an individual to a potential risk for infection. These items should never be shared.

Cleaning Blood/OPIM

After applying appropriate gloves, use sterile gauze or other bandages and follow normal first-aid techniques to stop the bleeding from a wound. Upon completion with an applied bandage, remove the gloves slowly, one by one, so that fluid particles do not splatter, or become aerosolized. Wash hands using good handwashing technique as soon as possible.

Cleaning Body Fluid Spills on Vinyl Floors

Tips & steps for cleaning spills on vinyl floors:

• Sweep up broken glass first, if glass is involved in a body fluid spill. Never pick up glass with bare hands. All sweeping should be done with a broom/brush and dustpan. Empty the dustpan contents in a well-marked plastic bag or heavy-duty container.
• When cleaning up body fluid spills, a full-strength liquid disinfectant or detergent can be used to pretreat. Use appropriate gloves and paper towels for wiping up the spill. Dispose of the paper towels in the plastic bag. For larger spills, use a mop saturated in hot, soapy water.
• A good disinfectant should follow the wiping up of spills (e.g., household bleach usually 5.25%–6.15% sodium hypochlorite mixed fresh with water 1:10).
• Any mop used for the cleaning should be soaked in a bucket of hot water and disinfectant (use recommended instructions for length of time).
• Be sure to empty the mop bucket water into the toilet rather than a sink. Sponges and mops used to clean up body fluid spills should never be rinsed out in a kitchen sink or in a location where food is prepared.

Cleaning Body Fluid Spills on Carpeting

Steps for cleaning spills on carpet:

1. Dry kitty litter or other absorbent material should be poured onto the spill to absorb the body fluid.
2. A full-strength, carpet-safe liquid detergent is then applied on the carpet, which helps to disinfect the area.
3. Next, if broken pieces of glass are present, use a broom/brush and dustpan to sweep up the kitty litter and visible broken glass.
4. Follow with the use of carpet-safe liquid disinfectant (use this instead of diluted bleach). This should be poured carefully onto the entire contaminated area
5. Allow the disinfectant to remain for the time recommended by the manufacturer.
6. When time as lapsed, absorb the spill with paper towels and sturdy rubber gloves.
7. Vacuum

NOTE: Any debris, paper towels, or soiled kitty litter should be disposed of in a sealed plastic bag that has been placed inside another plastic garbage bag. The second bag should be twisted and sealed like the first bag.

Cleaning Clothes or Other Laundry in Home Settings

Any blood/OPIM stained reusable fabric (such as clothes, washable uniforms, towels and other laundry) should be cleaned and disinfected before further use.

1. Remove clothes as soon as possible. Use appropriate gloves as needed for removal of clothing.
2. For any long distances to the washing machine, transport the soiled clothing items in a strong plastic bag.
3. Place the items in the washing machine and soak or wash in cold, soapy water to remove any blood from the fabric. NOTE: Hot water permanently sets bloodstains.
4. Hot soapy water should be used for the next washing cycle. Include sufficient detergent (acts as a disinfectant in the water).
5. Remove items and use a clothes dryer for drying.
6. The plastic bag used to transport the soiled clothing should be placed into another plastic bag. Be careful not to touch the surface of the bag that was exposed to the clothing.
7. Dispose of the bag in an appropriate waste container.

NOTE: Wool clothing or uniforms may be rinsed with cold soapy water and then dry cleaned to remove and disinfect the stain.

Diaper Changes

Appropriate tips when changing diapers:

• Fresh gloves should be donned with each diaper change.
• Discard diapers in an appropriate receptacle.
• Remove gloves (one at a time, inside out as to not touch contaminated area) and dispose of properly.
• Wash hands thoroughly with soap and water immediately following changing the diaper (post glove disposal).
• Clean diapering surface with a suitable disinfectant.
• For cleaning cloth diapers, wash in very hot water with detergent and a cup of bleach. Dry diapers in hot clothes dryer.

Cleaning Sponges and Mops

Sponges and mops used in kitchen areas should not be used to clean body fluid spills or bathrooms. Cleaning of sponges and mops should be done routinely anddisinfected with a fresh bleach solution or another similar disinfectant. (For mops and sponges used for bodily spills, see previous and final notes under cleaning vinyl floors.)

Toilet/Bedpan Safety

People with open sores on their legs, thighs, or genitals should disinfect a toilet seat after each use. Otherwise, it is considered safe to share toilets/toilet seats without special cleaning. Urinals and bedpans should never be shared between family members, unless they are thoroughly disinfected prior to use.

• To clean a toilet/toilet seat/urinal/bedpan surface contaminated with blood/OPIM, disinfect the surface by spraying on a solution of 1:10 bleach. This should be done wearing gloves and wiping with disposable paper towels.

Thermometers

When using a glass thermometer, wash with soap and warm water between uses. This should be done before and after each use. If shared among family members, the thermometer should be soaked in 70-90% ethyl alcohol for 30 minutes, and then rinsed under a stream of warm water between each use.

Unless visibly soiled, electronic thermometers with disposable covers do not need to be cleaned between users. A disinfectant solution may be used as necessary.

Pet Care Precautions

People with compromised immune systems have special precautions around animals as they can present health hazards for their damaged system. Such animals would include turtles, reptiles, birds, puppies and kittens under the age of eight months, wild animals, pets without current immunizations, and pets with illnesses of unknown origin.

Pet items such as pet cages and cat litter boxes can harbor infectious, sometimes aerosolized organisms. They need to be cared and tended by others who are not immunocompromised.

A mask with a sealable nose clip and disposable latex gloves is an alternative for those who do not have help with their pets. The mask should be worn each time pet care is done if HIV-infected as the risk of exposure to disease-causing agents is high. Good hand hygiene is crucial following all pet care.

An animal licking one’s face or an open wound can spread disease to an immunocompromised person. After stroking or other contact with pets, wash hands thoroughly with soap and water. It’s important to keep the nails of cats and dogs trimmed. Latex gloves should be worn to clean up a pet's urine, feces, vomit, etc. Afterward, the soiled area should be cleaned with a fresh solution of 1:10 bleach.

Routine cleaning of cat litter boxes is important. They should be emptied out regularly and washed at least monthly. Regular washing of pet food and water bowls apply as well. They need to be washed in warm, soapy water, and then rinsed.

Concerning fish tanks, routine cleaning is essential as well. For immune-compromised individuals, disposable latex "calf-birthing" gloves are available from a veterinarian. They offer protection from the organisms that are present in the fish tank.

NOTE:Pets should never drink from the toilet or eat other animal's feces, or any type of dead animal or garbage. This presents potential risks. Cats are best restricted to indoors. Dogs, too, should be kept indoors, or on a leash outdoors to narrow down the potential for bringing in disease-causing organisms.

There are communities that have volunteer groups and veterinarians who will assist people with HIV by offering to take care of their pets when needed. Consult your local veterinarian to help with any questions.

Kitchen Safety and Skills for Proper Food Preparation

People living with HIV are more susceptible to unsterilized or spoiled food products. A clean kitchen and ensuring fresh foods and well-cooked meats lower the risks for an HIV-infected person.

Tips on good food preparation and kitchen hygiene:

• Kitchen hygiene for persons with HIV disease are the same as for healthy individuals. Cleanliness lowers the potential for risks from all kinds of microorganisms.
• Hands should be washed thoroughly with soap and water before preparing food.
• When tasting food, a clean spoon is needed for each taste of the food. Wash the spoon after each tasting.
• If HIV-infected, avoid unpasteurized milk, raw eggs or products that contain raw eggs, raw fish, and cracked or non-intact eggs. All meat, eggs and fish need to be cooked thoroughly to kill any organisms that may be present in them. Fruits and vegetables need to be rinsed/cleaned thoroughly before eating.
• Countertops, stoves, sinks, refrigerators, door handles and floors should be cleaned regularly.
• To prevent insects from entering the room, use window screens.
• Food that has expired or is past a safe storage date should be thrown away. Check for any signs of mold or bad smell.
• Separate cutting boards for meat and for fruits and vegetables should be utilized. Cutting boards should be disinfected frequently. Wooden cutting boards have more potential to hold microorganisms. Avoid them if possible.
• When disposing kitchen garbage, do so in a leak-proof, washable receptacle that is lined with a plastic bag. Garbage liner bags should be sealed up tight when garbage is disposed of. Remove garbage frequently.

Needle Disposal and Safety:

Disposal of Sharps

Regulated sharps include syringes, needles, and lancets and must be disposed of safely and legally. Each sharp has the potential to carry hepatitis, HIV and other germs that cause disease.

To control health risks to others, regulations governing disposal of sharps have been enforced to help protect garbage and other utility workers, as well as the general public from needle sticks and illness. Different rules and disposal options are available for different circumstances. It’s best to contact your local health department to determine which option applies to your situation if in question.

A person should never throw a sharp in the trash or flush it down the toilet.Nor should it be pitched in the woods, a lake, or some other unsafe area. Unfortunately, used syringes have been found tossed aside in parks, along roadsides, in laundromats, and other locations. This presents a potential risk for accidental needle sticks.

The risk of infection from a found syringe depends on a variety of factors. One factors has to do with the amount of time the syringe was left out. Another takes into account the presence of blood and the type of injury (scratch versus puncture).

Since the amount of time an improperly disposed of syringe is in the environment is usually not known, the risk of infection cannot be determined. Some communities have facilities that provide for safe disposal of used syringes. As previously mentioned, there are exchange programs where new syringes are available through health departments or other agencies. This provides safe disposal for used sharps and reduces public exposure to contaminated syringes.

Accidental needle sticks require an assessment by a medical professional. The injured person is first checked for any previous vaccination against Hepatitis B and tetanus. The care provider may also recommend testing for HIV, HCV, and HBV.

Testing is not necessary if the syringe found was handled without the involvement of a needle stick and no bloodstream involvement exists.

Safe Disposal of Found Syringes:

• The use of gloves and tongs, a shovel, or a broom and dustpan should always be used when picking up a found syringe or needle. It should never be picked up with the bare hands. The needle/syringe should be held away from your body.
• Needles should not be broken off the syringe as it may carry infection or germs. Do not flush needles or syringes down the toilet
• A safe container should provide the needle’s/syringe’s disposal. If a sharps container is not available, a container with a one-inch opening and a lid that will seal tightly will suffice. An empty plastic laundry detergent, shampoo, pickle, oil or similar bottle or jar will work. When using a glass jar, be sure to place it into a larger plastic bucket or container that has a tight-fitting lid. Containers that would NOT be appropriate would be soda cans as people often try to recycle discarded cans.
• A tightly sealed lid should follow a carefully placed needle or syringe inside a bottle or jar.
• For added safety, tape the bottle or jar shut and label it with the warning: “Sharps, Do Not Recycle”
• Keep the sealed container out of the reach of children and call your local health department to determine what disposal sites are available for the disposal.