Blood-borne Diseases Surveillance Protocol For Ontario Hospitals
Transcript Of Blood-borne Diseases Surveillance Protocol For Ontario Hospitals
BLOOD-BORNE DISEASES SURVEILLANCE PROTOCOL
FOR ONTARIO HOSPITALS
Developed by the Ontario Hospital Association and the Ontario Medical Association
Joint Communicable Diseases Surveillance Protocols Committee
Approved by The OHA and the OMA Board of Directors The Ministry of Health and Long-Term Care – The Minister of Health and Long-Term Care
Published and Distributed by the Ontario Hospital Association Published June 1990
Last Reviewed and Revised December 2016
Blood-Borne Diseases Surveillance Protocol for Ontario Hospitals
Published June 1990 Last Reviewed and Revised December 2016
This protocol was developed jointly by the Ontario Hospital Association and the Ontario Medical Association to meet the requirements of the Public Hospitals Act 1990, Revised Statutes of Ontario, Regulation 965. This regulation requires each hospital to have bylaws that establish and provide for the operation of a health surveillance program including a communicable disease surveillance program in respect of all persons carrying on activities in the hospital. The communicable disease program is to include the tests and examinations set out in any applicable communicable disease surveillance protocol. The regulation states that the communicable disease surveillance protocols that hospitals must adopt are those "published jointly by the Ontario Hospital Association (OHA) and the Ontario Medical Association (OMA) and approved by the Minister (of Health and Long-Term Care)."
This Protocol has been reviewed since the previous version; changes have been highlighted in yellow for easy identification. Protocols are reviewed on a regular basis, every two years or as required.
The protocol reflects clinical knowledge, current data and experience, and a desire to ensure maximum cost effectiveness of programs, while protecting health care workers and patients. It is intended as a minimum standard that is practical to apply in most Ontario hospital settings. It does not preclude hospitals from adopting additional strategies that may be indicated by local conditions.
Members of the Joint OHA/OMA Communicable Disease Surveillance Protocols Committee
Representing the Ontario Hospital Association
Dr. Kathryn Suh (Co-chair) Medical Director, Infection Prevention and Control Program The Ottawa Hospital, Ottawa
Kathleen Poole, MScN, COHN(C) Infection Control Practitioner, CIC Providence Care, Kingston
Representing the Ontario Medical Association
Dr. Maureen Cividino (Co-chair) IPAC Physician, Public Health Ontario Occupational Health Physician St. Joseph’s Healthcare, Hamilton
Dr. Irene Armstrong Associate Medical Officer of Health Communicable Disease Control Toronto Public Health, Toronto
Susanne Bjerno Senior Advisor, Hospitals and Health System Funding, Health Policy Ontario Medical Association
Representing the Ministry of Health and Long-Term Care
Melissa Helferty, MIPH Manager, Infectious Disease Policy & Programs Disease Prevention Policy & Programs Branch Population and Public Health Division
Ontario Occupational Health Nurses
Susan Ann McIntyre RN, COHN(C),CRSP Director, Corporate Health & Safety Services St. Michael's Hospital, Toronto
Ontario Hospital Association
Peter Clancy, CRSP, CHRL Manager, Health and Safety
Rachel Bredin Consultant, Health and Safety
EX-OFFICIO
Dr. Deborah Parachin Senior Medical Consultant Occupational Health and Safety Branch – Occupational Medicine Unit Ministry of Labour
Henrietta Van hulle, BN, MHSM, COHN(c), CRSP, CDMP Executive Director, Health and Community Services Public Services Health and Safety Association
OHA/OMA Communicable Disease Surveillance Protocols Blood Borne Diseases
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Rationale for Blood-Borne Diseases Surveillance Protocol
Health care workers (HCWs) who have potential contact with blood and/or body fluids of patients have an occupational risk of acquiring infection with hepatitis B virus (HBV), hepatitis C virus (HCV) and/or human immunodeficiency virus (HIV). This protocol is intended to provide guidance about the prevention of HBV through immunization, and the most appropriate follow-up for HCWs exposed to the blood or body fluids of potentially infected individuals. Because HBV, HCV and HIV are spread by similar means, one protocol will apply to all three diseases.
In developing surveillance policies for blood-borne pathogens, hospitals should include prevention programs to reduce exposure to blood and body fluids, including the use of safety-engineered devices. The Needle Safety Regulation 474/07 made under the Occupational Health and Safety Act came into force September 1, 2008 and mandates the use of safety-engineered needles in Ontario.1 Analysis of incident reports, HCW education and process improvement are critical to reducing exposures.
HBV
HBV is a bloodborne virus that infects the liver and causes acute and chronic infection. HBV is transmitted through percutaneous or mucosal contact with HBV infected blood and body fluids. Occupational transmission of HBV typically occurs through exposure to contaminated sharp instruments (e.g. needle stick injuries), or splash or spray to the mucous membranes. The prevalence of hepatitis B in the general Canadian population is estimated to be less than 1%. In 2011, the overall reported rate of acute hepatitis B infection in Canada was 0.6 reported cases per 100,000.2
The Ontario Burden of Infectious Disease Study (ONBOIDS) identified HBV as the fourth most burdensome infectious disease in Ontario, due to its associated morbidity and mortality.3 The Ontario average annual case count for hepatitis B over a 5 year period (2011 to 2015) was 102.4 About 95 percent of adults will recover within 6 months of becoming infected and as a result will develop lifelong protection against HBV. The remaining 5 percent are unable to clear the virus and will become chronically infected. In 2014, 1,982 new cases of chronic hepatitis B were reported in Ontario, representing a rate of newly reported chronic carriers of 14.6 cases per 100,000 population. This is lower than 2013, when 2,299 cases were reported for a rate of 17.0 cases per 100,000 population.5 Chronic hepatitis B infection is treatable in many cases.
HBV is a vaccine-preventable disease and HBV vaccine has been widely available since 1983. The vaccine is safe and effective, and immunization should be initiated at the earliest opportunity for all persons who may have occupational exposure to HBV.
Transmission of HBV from HCWs to patients has been documented.6,7,8
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HCV
HCV is a bloodborne virus that causes both acute and chronic infection of the liver.
In Ontario, HCV has been associated with the highest burden of any communicable disease.3
Modelled estimates suggest the incidence of new cases is increasing slightly. In 2013, the overall reported rate of hepatitis C infection in Canada was 29.55 cases per 100,000 people. In 2011, it was estimated that over 461,000 Canadians had a history of hepatitis C infection. Of these, an estimated 220,000 to 246,000 people were chronically infected with hepatitis C. About 44% of those chronically infected were not aware of their infection status or were likely undiagnosed.9
In the absence of effective interventions, many infected individuals will go on to develop cirrhosis, liver failure, hepatocellular carcinoma, require liver transplantation, or die as a result of their disease.
Prior to the introduction of blood donor screening, HCV was most commonly related to the receipt of infected blood or blood products. This source of infection is now extremely rare. The majority of new HCV infections in Canada occurs in illicit drug users as a result of sharing injection or inhalation equipment. Occupational exposures primarily occur as a result of a sharps injury; however, there are rare case reports of infection related to a mucosal exposure (eye splash).5
There is no licensed vaccine for HCV, with post-exposure follow-up focusing on early detection and treatment. There are new and effective drug treatment regimens available.
Transmission of HCV to patients by infected HCWs has also been documented.10,11,12,13
HIV
HIV is a bloodborne virus with two major sub-types, HIV-1 and HIV-2; HIV-1 is responsible for most HIV infections in North America. HIV attacks the immune system, resulting in a chronic, progressive illness that leaves people vulnerable to opportunistic infections and cancers.
In 2014 the number of people living with HIV (including AIDS) in Canada was estimated to be 75,500, an increase of 6,700 infections (9.7%) from 2011.14 The prevalence of Canadians living with HIV was estimated to be 0.2%, with just over 20% unaware of their HIV infection.
Several look-back investigations have shown that transmission from an HIV-infected HCW to a patient is extremely unlikely when routine infection control practices are followed. Transmission of HIV from an infected surgeon to a patient and from an
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infected obstetrician to a patient has been documented.15,16
Bloodborne Pathogen (BBP) Occupational Exposure Risk
HBV is transmitted more easily than HIV in the health care setting. After a needle-stick injury from a needle contaminated with HBV, there is a 6-30% chance that an exposed susceptible person will be infected. In a similar situation with HIV, there is a 0.3% risk of infection. Occupational acquisition of HCV infection after exposure is approximately 1.8%.
Effective therapies, including antiviral therapies, are available for HBV, HCV and HIV to reduce viral load to low or undetectable levels, improving patient safety and the medical status of the worker.
This protocol is only one component of an infection prevention and control program; HCWs must consistently adhere to Routine Practices.
OHA/OMA Communicable Disease Surveillance Protocols Blood Borne Diseases
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Blood-Borne Diseases Surveillance Protocol for Ontario Hospitals
Developed by the Ontario Hospital Association and the Ontario Medical Association
Published June 1990 Last Reviewed and Revised December 2016
I. Purpose
The purpose of this protocol is to provide direction to hospitals to prevent the transmission of blood-borne pathogens to health care workers (HCWs) and patients.
II. Applicability
This protocol applies to all persons carrying on activities in the hospital who may have the potential for an occupational exposure to a bloodborne pathogen, including but not limited to employees, physicians, nurses, contract workers, students, post-graduate medical trainees, researchers and volunteers. The term health care worker (HCW) is used in this protocol to describe these individuals. This protocol does not apply to patients or residents of the facility or to visitors.
When training students or hiring contract workers, the hospital must inform the school/supplying agency that the school/agency is responsible for ensuring that their students/contractors are managed according to this protocol.
This protocol is for the use of the Occupational Health Service (OHS) in hospitals. It is expected that OHS collaborate with Infection Prevention and Control (IPAC) and other departments, as appropriate.
III. Pre-placement
Most persons infected with HBV, HCV or HIV can work safely with patients without risk of transmission of the virus, as long as reasonable precautions are taken. No routine screening of persons carrying on activities in the hospital is needed for hepatitis B surface antigen (HBsAg), or antibody to HCV or antibody to HIV.
Transmission of HBV, HCV and HIV from HCWs to patients has been documented. This emphasizes the need for compliance with precautions and primary prevention.
Susceptible HCWs who have the potential for exposure to the blood and/or body fluids of patients must be protected by hepatitis B vaccination. This vaccine must
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be offered at the expense of the hospital or agency. This should include HCWs who may not be in direct contact with patients or gross blood, but may be at risk for sharps injuries (e.g., laundry, housekeeping, central reprocessing staff).
For students and agency workers, the hospital should ensure that the supplying school or agency accepts responsibility for their immunization.
Refusal of immunization should be documented in the HCW's health record. If a HCW is late receiving the second or third dose of the hepatitis B vaccine series, the next dose should be given as soon as possible; it is not necessary to restart the schedule or repeat doses. Post-vaccination testing for antibody to HBsAg should be performed to determine immunity. Testing should be done one month after the vaccine series is complete.
A HCW who has received three vaccine doses and does not have serologic evidence of immunity (i.e. in whom antibody titre to HBsAg is < 10 IU/L) should receive an additional three-dose vaccine series.17 Testing for antibody to HBsAg should be repeated one month after completion of the second series; if antibodies to HBsAg remain < 10 IU/L, the HCW is considered a vaccine nonresponder.
A HCW whose immunization was remote (e.g. immunized in the public school based program) and in whom there is no previous documentation of immunity should be tested for antibody to HBsAg. If antibodies to HBsAg are < 10 IU/L, the HCW should receive one dose of vaccine and be tested one month later; if antibody titre is still < 10 IU/L, the HCW should receive a second vaccine series of three doses.
Routine booster doses of vaccine are not recommended for immunocompetent persons.17 In persons with previously demonstrated antibody to HBsAg, immune memory persists even in the absence of detectable antibody. Immunity may wane in immunocompromised persons; periodic testing of these persons should be considered and booster dosing given with re-testing as necessary.17
Some professional colleges, e.g. the College of Physicians and Surgeons of Ontario,18 have specific policies with regard to pre-appointment screening for HBV, HCV and HIV. HCWs who perform exposure-prone procedures (see Glossary) should seek medical evaluation with respect to the potential for transmission of their infection to patients, which is dependent on the HCW’s type of practice, the infecting virus(es), and the status of their infection and the potential for antiviral therapy to reduce viral load, thereby reducing risk for patients and improving the HCW’s health status.19
IV. Continuing Surveillance
No routine ongoing serologic screening of any persons carrying on activities in the hospital is needed for HBV, HBC or HIV infection.
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HCWs who are at risk for exposure to blood-borne pathogens and who are unimmunized or non-responders to HBV vaccine should be offered annual screening for infection with HBV (i.e., HBsAg, antibody to HB core antigen).20 Some professional colleges (e.g. CPSO) have specific policies with regard to periodic screening for HBV, HCV and HIV of HCWs licensed by the college if they perform exposure-prone procedures (see Glossary); HCWs must be aware of and follow the requirements of their college.
V. Exposure to Blood-Borne Pathogens
Definition
Exposure requires both an injury (i.e. percutaneous injury from a needle or other sharp object, a splash of blood or other body fluid onto a mucous membrane or non-intact skin, or a human bite that breaks the skin) and contact with blood or body fluid capable of transmitting HBV, HCV and/or HIV.
Policies and Procedures
There must be up to date policies and procedures to protect and/or follow-up exposed HCWs; these must be available and easily accessible in OHS and to all exposed HCWs. Although tetanus is not a blood-borne disease, it is included in this protocol because tetanus prophylaxis is part of the first aid for some types of exposures.
There must be a process to effectively provide timely follow-up to exposed HCWs when the OHS is closed or does not formally exist.
A. Initial Procedures for All Cases
When an HCW is exposed to blood or body fluids from a known or unknown source, the HCW should: • allow any wound to bleed freely, then wash it gently but thoroughly with
soap and water; • report to supervisor/manager or delegate and complete an incident report
as per hospital protocol; and • proceed immediately to the OHS (or designated alternate)
When an exposed HCW is assessed, the OHS (or designate) will perform the following procedures:
• thoroughly cleanse and apply an appropriate antiseptic to any wound;
OHA/OMA Communicable Disease Surveillance Protocols Blood Borne Diseases
Page 9 Reviewed and Revised December 2016
• clean minor wound – Td booster if more than 10 years since last booster dose.
• if the wound was caused by a dirty object or is a deep puncture that cannot be adequately cleansed (i.e., tetanus-prone wound) provide Td booster if more than 5 years since last booster dose.
N.B. If the individual has not yet received an adult dose of Tdap (tetanus, diphtheria and acellular pertussis), give Tdap in place of Td booster. Adults who have not previously received Tdap vaccine in adulthood, should receive one dose of Tdap vaccine, regardless of the interval since the last dose of tetanus or diphtheria toxoid-containing vaccine.
• assess hepatitis B immunity:
• if the HCW has documented immunity to HBV (see Glossary), counsel HCW to report to the OHS any symptoms of concern such as nausea, abdominal pain or jaundice (see VII. Reporting);
• if the HCW has begun the hepatitis B vaccine series, continue and complete as originally scheduled; or
• if the HCW has received no doses of hepatitis B vaccine, give the first dose of the vaccine, and arrange for the second and third doses according to the recommended schedule.
• continue with the procedures in parts B to F, below, as appropriate, and
▪ emphasize the importance of follow-up blood testing, if indicated, as infection with HBV, HCV or HIV may be asymptomatic.
B. Unknown Source
If the patient source of the blood is not known, the OHS (or designate) must:
• offer the HCW baseline testing for HBV (if adequate antibodies to hepatitis B are not on file), and for HCV and HIV; without this information, any future claim for compensation for occupationally-acquired HBV, HCV or HIV illness could be jeopardized; and
• arrange follow-up testing at 6 weeks and 4 months for HIV, and at 3 months and 6 months for HBV and HCV
Notes:
1. If there is a high probability that the source of the blood is infective for HBV or the source patient status is unknown, follow the recommended action in section D.
2. If there is a high probability that the source of the blood is infective for HIV, follow the recommended action in section E.
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FOR ONTARIO HOSPITALS
Developed by the Ontario Hospital Association and the Ontario Medical Association
Joint Communicable Diseases Surveillance Protocols Committee
Approved by The OHA and the OMA Board of Directors The Ministry of Health and Long-Term Care – The Minister of Health and Long-Term Care
Published and Distributed by the Ontario Hospital Association Published June 1990
Last Reviewed and Revised December 2016
Blood-Borne Diseases Surveillance Protocol for Ontario Hospitals
Published June 1990 Last Reviewed and Revised December 2016
This protocol was developed jointly by the Ontario Hospital Association and the Ontario Medical Association to meet the requirements of the Public Hospitals Act 1990, Revised Statutes of Ontario, Regulation 965. This regulation requires each hospital to have bylaws that establish and provide for the operation of a health surveillance program including a communicable disease surveillance program in respect of all persons carrying on activities in the hospital. The communicable disease program is to include the tests and examinations set out in any applicable communicable disease surveillance protocol. The regulation states that the communicable disease surveillance protocols that hospitals must adopt are those "published jointly by the Ontario Hospital Association (OHA) and the Ontario Medical Association (OMA) and approved by the Minister (of Health and Long-Term Care)."
This Protocol has been reviewed since the previous version; changes have been highlighted in yellow for easy identification. Protocols are reviewed on a regular basis, every two years or as required.
The protocol reflects clinical knowledge, current data and experience, and a desire to ensure maximum cost effectiveness of programs, while protecting health care workers and patients. It is intended as a minimum standard that is practical to apply in most Ontario hospital settings. It does not preclude hospitals from adopting additional strategies that may be indicated by local conditions.
Members of the Joint OHA/OMA Communicable Disease Surveillance Protocols Committee
Representing the Ontario Hospital Association
Dr. Kathryn Suh (Co-chair) Medical Director, Infection Prevention and Control Program The Ottawa Hospital, Ottawa
Kathleen Poole, MScN, COHN(C) Infection Control Practitioner, CIC Providence Care, Kingston
Representing the Ontario Medical Association
Dr. Maureen Cividino (Co-chair) IPAC Physician, Public Health Ontario Occupational Health Physician St. Joseph’s Healthcare, Hamilton
Dr. Irene Armstrong Associate Medical Officer of Health Communicable Disease Control Toronto Public Health, Toronto
Susanne Bjerno Senior Advisor, Hospitals and Health System Funding, Health Policy Ontario Medical Association
Representing the Ministry of Health and Long-Term Care
Melissa Helferty, MIPH Manager, Infectious Disease Policy & Programs Disease Prevention Policy & Programs Branch Population and Public Health Division
Ontario Occupational Health Nurses
Susan Ann McIntyre RN, COHN(C),CRSP Director, Corporate Health & Safety Services St. Michael's Hospital, Toronto
Ontario Hospital Association
Peter Clancy, CRSP, CHRL Manager, Health and Safety
Rachel Bredin Consultant, Health and Safety
EX-OFFICIO
Dr. Deborah Parachin Senior Medical Consultant Occupational Health and Safety Branch – Occupational Medicine Unit Ministry of Labour
Henrietta Van hulle, BN, MHSM, COHN(c), CRSP, CDMP Executive Director, Health and Community Services Public Services Health and Safety Association
OHA/OMA Communicable Disease Surveillance Protocols Blood Borne Diseases
Page 3 Reviewed and Revised December 2016
Rationale for Blood-Borne Diseases Surveillance Protocol
Health care workers (HCWs) who have potential contact with blood and/or body fluids of patients have an occupational risk of acquiring infection with hepatitis B virus (HBV), hepatitis C virus (HCV) and/or human immunodeficiency virus (HIV). This protocol is intended to provide guidance about the prevention of HBV through immunization, and the most appropriate follow-up for HCWs exposed to the blood or body fluids of potentially infected individuals. Because HBV, HCV and HIV are spread by similar means, one protocol will apply to all three diseases.
In developing surveillance policies for blood-borne pathogens, hospitals should include prevention programs to reduce exposure to blood and body fluids, including the use of safety-engineered devices. The Needle Safety Regulation 474/07 made under the Occupational Health and Safety Act came into force September 1, 2008 and mandates the use of safety-engineered needles in Ontario.1 Analysis of incident reports, HCW education and process improvement are critical to reducing exposures.
HBV
HBV is a bloodborne virus that infects the liver and causes acute and chronic infection. HBV is transmitted through percutaneous or mucosal contact with HBV infected blood and body fluids. Occupational transmission of HBV typically occurs through exposure to contaminated sharp instruments (e.g. needle stick injuries), or splash or spray to the mucous membranes. The prevalence of hepatitis B in the general Canadian population is estimated to be less than 1%. In 2011, the overall reported rate of acute hepatitis B infection in Canada was 0.6 reported cases per 100,000.2
The Ontario Burden of Infectious Disease Study (ONBOIDS) identified HBV as the fourth most burdensome infectious disease in Ontario, due to its associated morbidity and mortality.3 The Ontario average annual case count for hepatitis B over a 5 year period (2011 to 2015) was 102.4 About 95 percent of adults will recover within 6 months of becoming infected and as a result will develop lifelong protection against HBV. The remaining 5 percent are unable to clear the virus and will become chronically infected. In 2014, 1,982 new cases of chronic hepatitis B were reported in Ontario, representing a rate of newly reported chronic carriers of 14.6 cases per 100,000 population. This is lower than 2013, when 2,299 cases were reported for a rate of 17.0 cases per 100,000 population.5 Chronic hepatitis B infection is treatable in many cases.
HBV is a vaccine-preventable disease and HBV vaccine has been widely available since 1983. The vaccine is safe and effective, and immunization should be initiated at the earliest opportunity for all persons who may have occupational exposure to HBV.
Transmission of HBV from HCWs to patients has been documented.6,7,8
OHA/OMA Communicable Disease Surveillance Protocols Blood Borne Diseases
Page 4 Reviewed and Revised December 2016
HCV
HCV is a bloodborne virus that causes both acute and chronic infection of the liver.
In Ontario, HCV has been associated with the highest burden of any communicable disease.3
Modelled estimates suggest the incidence of new cases is increasing slightly. In 2013, the overall reported rate of hepatitis C infection in Canada was 29.55 cases per 100,000 people. In 2011, it was estimated that over 461,000 Canadians had a history of hepatitis C infection. Of these, an estimated 220,000 to 246,000 people were chronically infected with hepatitis C. About 44% of those chronically infected were not aware of their infection status or were likely undiagnosed.9
In the absence of effective interventions, many infected individuals will go on to develop cirrhosis, liver failure, hepatocellular carcinoma, require liver transplantation, or die as a result of their disease.
Prior to the introduction of blood donor screening, HCV was most commonly related to the receipt of infected blood or blood products. This source of infection is now extremely rare. The majority of new HCV infections in Canada occurs in illicit drug users as a result of sharing injection or inhalation equipment. Occupational exposures primarily occur as a result of a sharps injury; however, there are rare case reports of infection related to a mucosal exposure (eye splash).5
There is no licensed vaccine for HCV, with post-exposure follow-up focusing on early detection and treatment. There are new and effective drug treatment regimens available.
Transmission of HCV to patients by infected HCWs has also been documented.10,11,12,13
HIV
HIV is a bloodborne virus with two major sub-types, HIV-1 and HIV-2; HIV-1 is responsible for most HIV infections in North America. HIV attacks the immune system, resulting in a chronic, progressive illness that leaves people vulnerable to opportunistic infections and cancers.
In 2014 the number of people living with HIV (including AIDS) in Canada was estimated to be 75,500, an increase of 6,700 infections (9.7%) from 2011.14 The prevalence of Canadians living with HIV was estimated to be 0.2%, with just over 20% unaware of their HIV infection.
Several look-back investigations have shown that transmission from an HIV-infected HCW to a patient is extremely unlikely when routine infection control practices are followed. Transmission of HIV from an infected surgeon to a patient and from an
OHA/OMA Communicable Disease Surveillance Protocols Blood Borne Diseases
Page 5 Reviewed and Revised December 2016
infected obstetrician to a patient has been documented.15,16
Bloodborne Pathogen (BBP) Occupational Exposure Risk
HBV is transmitted more easily than HIV in the health care setting. After a needle-stick injury from a needle contaminated with HBV, there is a 6-30% chance that an exposed susceptible person will be infected. In a similar situation with HIV, there is a 0.3% risk of infection. Occupational acquisition of HCV infection after exposure is approximately 1.8%.
Effective therapies, including antiviral therapies, are available for HBV, HCV and HIV to reduce viral load to low or undetectable levels, improving patient safety and the medical status of the worker.
This protocol is only one component of an infection prevention and control program; HCWs must consistently adhere to Routine Practices.
OHA/OMA Communicable Disease Surveillance Protocols Blood Borne Diseases
Page 6 Reviewed and Revised December 2016
Blood-Borne Diseases Surveillance Protocol for Ontario Hospitals
Developed by the Ontario Hospital Association and the Ontario Medical Association
Published June 1990 Last Reviewed and Revised December 2016
I. Purpose
The purpose of this protocol is to provide direction to hospitals to prevent the transmission of blood-borne pathogens to health care workers (HCWs) and patients.
II. Applicability
This protocol applies to all persons carrying on activities in the hospital who may have the potential for an occupational exposure to a bloodborne pathogen, including but not limited to employees, physicians, nurses, contract workers, students, post-graduate medical trainees, researchers and volunteers. The term health care worker (HCW) is used in this protocol to describe these individuals. This protocol does not apply to patients or residents of the facility or to visitors.
When training students or hiring contract workers, the hospital must inform the school/supplying agency that the school/agency is responsible for ensuring that their students/contractors are managed according to this protocol.
This protocol is for the use of the Occupational Health Service (OHS) in hospitals. It is expected that OHS collaborate with Infection Prevention and Control (IPAC) and other departments, as appropriate.
III. Pre-placement
Most persons infected with HBV, HCV or HIV can work safely with patients without risk of transmission of the virus, as long as reasonable precautions are taken. No routine screening of persons carrying on activities in the hospital is needed for hepatitis B surface antigen (HBsAg), or antibody to HCV or antibody to HIV.
Transmission of HBV, HCV and HIV from HCWs to patients has been documented. This emphasizes the need for compliance with precautions and primary prevention.
Susceptible HCWs who have the potential for exposure to the blood and/or body fluids of patients must be protected by hepatitis B vaccination. This vaccine must
OHA/OMA Communicable Disease Surveillance Protocols Blood Borne Diseases
Page 7 Reviewed and Revised December 2016
be offered at the expense of the hospital or agency. This should include HCWs who may not be in direct contact with patients or gross blood, but may be at risk for sharps injuries (e.g., laundry, housekeeping, central reprocessing staff).
For students and agency workers, the hospital should ensure that the supplying school or agency accepts responsibility for their immunization.
Refusal of immunization should be documented in the HCW's health record. If a HCW is late receiving the second or third dose of the hepatitis B vaccine series, the next dose should be given as soon as possible; it is not necessary to restart the schedule or repeat doses. Post-vaccination testing for antibody to HBsAg should be performed to determine immunity. Testing should be done one month after the vaccine series is complete.
A HCW who has received three vaccine doses and does not have serologic evidence of immunity (i.e. in whom antibody titre to HBsAg is < 10 IU/L) should receive an additional three-dose vaccine series.17 Testing for antibody to HBsAg should be repeated one month after completion of the second series; if antibodies to HBsAg remain < 10 IU/L, the HCW is considered a vaccine nonresponder.
A HCW whose immunization was remote (e.g. immunized in the public school based program) and in whom there is no previous documentation of immunity should be tested for antibody to HBsAg. If antibodies to HBsAg are < 10 IU/L, the HCW should receive one dose of vaccine and be tested one month later; if antibody titre is still < 10 IU/L, the HCW should receive a second vaccine series of three doses.
Routine booster doses of vaccine are not recommended for immunocompetent persons.17 In persons with previously demonstrated antibody to HBsAg, immune memory persists even in the absence of detectable antibody. Immunity may wane in immunocompromised persons; periodic testing of these persons should be considered and booster dosing given with re-testing as necessary.17
Some professional colleges, e.g. the College of Physicians and Surgeons of Ontario,18 have specific policies with regard to pre-appointment screening for HBV, HCV and HIV. HCWs who perform exposure-prone procedures (see Glossary) should seek medical evaluation with respect to the potential for transmission of their infection to patients, which is dependent on the HCW’s type of practice, the infecting virus(es), and the status of their infection and the potential for antiviral therapy to reduce viral load, thereby reducing risk for patients and improving the HCW’s health status.19
IV. Continuing Surveillance
No routine ongoing serologic screening of any persons carrying on activities in the hospital is needed for HBV, HBC or HIV infection.
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Page 8 Reviewed and Revised December 2016
HCWs who are at risk for exposure to blood-borne pathogens and who are unimmunized or non-responders to HBV vaccine should be offered annual screening for infection with HBV (i.e., HBsAg, antibody to HB core antigen).20 Some professional colleges (e.g. CPSO) have specific policies with regard to periodic screening for HBV, HCV and HIV of HCWs licensed by the college if they perform exposure-prone procedures (see Glossary); HCWs must be aware of and follow the requirements of their college.
V. Exposure to Blood-Borne Pathogens
Definition
Exposure requires both an injury (i.e. percutaneous injury from a needle or other sharp object, a splash of blood or other body fluid onto a mucous membrane or non-intact skin, or a human bite that breaks the skin) and contact with blood or body fluid capable of transmitting HBV, HCV and/or HIV.
Policies and Procedures
There must be up to date policies and procedures to protect and/or follow-up exposed HCWs; these must be available and easily accessible in OHS and to all exposed HCWs. Although tetanus is not a blood-borne disease, it is included in this protocol because tetanus prophylaxis is part of the first aid for some types of exposures.
There must be a process to effectively provide timely follow-up to exposed HCWs when the OHS is closed or does not formally exist.
A. Initial Procedures for All Cases
When an HCW is exposed to blood or body fluids from a known or unknown source, the HCW should: • allow any wound to bleed freely, then wash it gently but thoroughly with
soap and water; • report to supervisor/manager or delegate and complete an incident report
as per hospital protocol; and • proceed immediately to the OHS (or designated alternate)
When an exposed HCW is assessed, the OHS (or designate) will perform the following procedures:
• thoroughly cleanse and apply an appropriate antiseptic to any wound;
OHA/OMA Communicable Disease Surveillance Protocols Blood Borne Diseases
Page 9 Reviewed and Revised December 2016
• clean minor wound – Td booster if more than 10 years since last booster dose.
• if the wound was caused by a dirty object or is a deep puncture that cannot be adequately cleansed (i.e., tetanus-prone wound) provide Td booster if more than 5 years since last booster dose.
N.B. If the individual has not yet received an adult dose of Tdap (tetanus, diphtheria and acellular pertussis), give Tdap in place of Td booster. Adults who have not previously received Tdap vaccine in adulthood, should receive one dose of Tdap vaccine, regardless of the interval since the last dose of tetanus or diphtheria toxoid-containing vaccine.
• assess hepatitis B immunity:
• if the HCW has documented immunity to HBV (see Glossary), counsel HCW to report to the OHS any symptoms of concern such as nausea, abdominal pain or jaundice (see VII. Reporting);
• if the HCW has begun the hepatitis B vaccine series, continue and complete as originally scheduled; or
• if the HCW has received no doses of hepatitis B vaccine, give the first dose of the vaccine, and arrange for the second and third doses according to the recommended schedule.
• continue with the procedures in parts B to F, below, as appropriate, and
▪ emphasize the importance of follow-up blood testing, if indicated, as infection with HBV, HCV or HIV may be asymptomatic.
B. Unknown Source
If the patient source of the blood is not known, the OHS (or designate) must:
• offer the HCW baseline testing for HBV (if adequate antibodies to hepatitis B are not on file), and for HCV and HIV; without this information, any future claim for compensation for occupationally-acquired HBV, HCV or HIV illness could be jeopardized; and
• arrange follow-up testing at 6 weeks and 4 months for HIV, and at 3 months and 6 months for HBV and HCV
Notes:
1. If there is a high probability that the source of the blood is infective for HBV or the source patient status is unknown, follow the recommended action in section D.
2. If there is a high probability that the source of the blood is infective for HIV, follow the recommended action in section E.
OHA/OMA Communicable Disease Surveillance Protocols Blood Borne Diseases
Page 10 Reviewed and Revised December 2016