ONLINE ORIENTATION

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ONLINE ORIENTATION

• Clinic Environment

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About EHS

• We support the University's core mission of
  teaching, research, and service by providing
  comprehensive environmental, health and safety
  services to the University community including
  education through training and consultation
  maintaining a safe environment ensuring
  regulatory compliance and controlling recognized
  health and safety hazards. To achieve this
  mission we must rely on all University employees
  to understand and recognize safety policy and
  procedures.

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About EHS

• The responsibility of the department of
  Environment, Health and Safety is to develop a
  comprehensive program to comply with the
  provisions of each of the following regulations
  Occupational Safety and Health Act (OSHA)
• Environmental Protection Agency (EPA)
• NC DENR NC Department of Environment and Natural
  Resources
• Joint Commission on Accreditation of Healthcare
  Organization (JCAHO)
• NC Radiation Protection Section (NCRPS)
• Office of State Personnel (OSP)
• NC Fire Prevention Codes
• NFPA 101 Life Safety Codes

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About EHS

• EHS provides comprehensive support for the
  University community in the areas of
  environmental compliance, occupational health and
  safety. To learn more about each section, please
  visit EHSs website at http//ehs.unc.edu.

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Workplace Safety Program

• In accordance to University policy and North
  Carolina General Statute Article 63, each state
  agency must have a written Health and Safety
  program with clearly stated goals or objectives
  that promote safe and healthful working
  conditions. The Environment, Health and Safety
  manual along with other specific manuals, such as
  Radiation Safety Manual, Laboratory Safety
  Manual, and Biological Safety manual serves as
  the University's written Health and Safety
  program. These manuals provide University
  employees with the necessary guidance in
  maintaining a safe work environment. Each of
  these manuals can be viewed in more detail by
  selecting "Manuals" from the EHS web site.
• Other elements of the Workplace Safety program
  include
• Conduct new employee training to help with the
  identification of and correction of hazards,
• Review workplace incidents and develop ways to
  eliminate or minimize hazards, and
• Employee input through safety committees

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Workplace Safety Program

• UNC's health and safety committees perform
  workplace inspections, review injury and illness
  records, make advisory recommendations to the
  administration, and perform other functions
  determined by the State Personnel Commission. The
  Workplace Safety Committees report through the
  following structure
• UNC employees should contact EHS or any committee
  member regarding safety concerns.

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Workplace Safety Program

• If you are interested in serving on one of the
  committees please feel free to contact the EHS
  office at [phone].

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Fire Safety Program

• UNC's Fire Safety program is based on NFPA 101
  Life Safety Code, N.C. Fire Prevention Code, and
  OSHA 1910 Subpart E. Your understanding and
  contribution to Fire Safety is the key to an
  effective fire protection program for the
  University. Regularly inspecting your area for
• electrical hazards
• storage in hallways
• blocked exit ways
• adequate lighting of exits
• general housekeeping
• can prevent a fire from occurring and provide
  employees with a safe passage in the event of a
  fire.

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Fire Safety Program

• If a fire or other emergency occurs in your
  building, employees must know two Means of Egress
  (exit). OSHA defines Means of Egress as "A
  continuous and unobstructed way of exit travel
  from any point in a building or structure to a
  public way." The three main components of Means
  of Egress are
• The way of Exit Access
• The exit
• The way of Exit Discharge

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Fire Safety Program
Exit Access is the area in which an employee uses
as their means of exiting to an exit.
Exit Discharge is the exit from a building to a
public way.
Exit is the protected way of travel to the exit
discharge.
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Fire Safety Program

• The Department of EHS has prepared a general
  Emergency Action Plan for the University to
  follow. An Emergency Action Plan is "a plan for
  the workplace describing what procedures the
  employers and employees must take to ensure
  employee's safety from fire and other
  emergencies" (1910.35j). The plan includes
• posting of planned evacuation routes
• procedures to follow in the event of a fire or
  emergency
• procedures to account for employees after
  evacuation
• procedures for employees who remain to operate
  critical equipment in an emergency

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Fire Safety Program

• Posting of Planned Evacuation Routes - Building
  evacuation procedure for your department should
  be posted on the office bulletin board and at all
  elevators. Employees should know at least two
  evacuation routes for their designated work area
  and any area that they frequent often. Employees
  are encouraged to evaluate the building
  evacuation areas daily to ensure that there are
  no obstructions. If obstructions are found,
  please report it to the EHS immediately at (919)
  962-5507.

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Fire Safety Program

• Procedures to Follow - If a fire emergency was to
  occur in your workplace, it is vital that you be
  prepared to react. The acronym RACE provides the
  basic steps of the Emergency Action Plan to
  follow
• Remove or rescue individuals in immediate danger
• Activate the alarm by pulling the fire pull
  station located in the corridors and calling 911.
• Confine the fire by closing windows, vents and
  doors
• Evacuate to safe area (know the evacuation routes
  for your areas).

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Fire Safety Program

• Procedures to Account for Employees The
  University has designated an Emergency
  Coordinator(s) for all occupied buildings. Each
  Emergency Coordinator (EC) is responsible for
  assisting in the safe and orderly emergency
  evacuation of employees. In preparation for an
  emergency, the EC completes an information card
  that includes
• evacuation monitors' names
• employee names and phone numbers occupying
  building
• location of employees needing assistance
• rooms containing hazardous material,
• and equipment needing special attention.

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Fire Safety Program

• In an emergency, each Emergency Coordinator is
  responsible for the following in accordance with
  the University Emergency Plan
• Sweep through assigned area to alert occupants
  that an evacuation is in process.
• Assist building occupants needing special
  assistance
• Report to the University Emergency Command Sector
  with emergency information card
• Advise emergency personnel regarding building
  contents
• Account for all employees by meeting building
  occupants at the assembly area
• Advise building occupants regarding situation and
  when re-entry is permitted
• Advise Facilities Services personnel in cleanup
  operations.

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Fire Safety Program

• To extinguish a fire requires proper
  identification of the type of fire extinguisher
  to use. There are four classes of extinguishers
  to choose from.
• Currently University buildings are equipped with
  Type ABC fire extinguishers, except in computer
  labs or mechanical rooms with have CO2
  extinguishers.

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Fire Safety Program

• Only University employees working in healthcare,
  emergency response, and/or whose job requires
  them to use a fire extinguisher are required to
  receive annual hands on fire extinguisher
  training. EHS Fire Safety section conducts annual
  classes in different locations on campus. For
  other employees it is beneficial to know how a
  fire extinguisher is used. Remembering the
  acronym PASS will assist in the proper use of a
  fire extinguisher.
• Pull the pin between the handles.
• Aim the nozzle at the base of the fire.
• Squeeze the handles together.
• Sweep the extinguisher from side to side at the
  base of the fire.

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Fire Safety Program

• A few fire safety reminders
• Everyone is responsible for keeping the work area
  safe from fires.
• Review your evacuation routes to ensure that
  exits and passageways are unobstructed.
• Practice good general housekeeping.
• Store flammable liquids and combustible material
  properly.
• Report any fire hazards or other safety concerns
  immediately to the department of Environment,
  Health and Safety at [phone].

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Workers Compensation Program

• Workers' Compensation benefits are available to
  any University employee (whether full-time,
  part-time, temporary) who suffers disability
  through accident or illness arising out of, and
  in the scope of, his or her employment, according
  to the North Carolina Workers' Compensation Act.

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Workers Compensation Program

• The benefits provided to University Employees
  include medical and leave. Medical benefits
  include all authorized medical services such as
  physician visit, prescriptions, physical therapy,
  rehabilitation, etc. Leave benefits are provided
  to employees when an authorized medical provider
  places an employee out work.

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Workers Compensation Program

• If you receive an injury or occupational illness,
  go directly to the University Employee
  Occupational Health Clinic (UEOHC) located at 145
  N. Medical Drive. The UEOHC is open from 830 am
  to 430 pm Monday thru Friday, except holidays.
• For after hours needlestick/human blood or body
  fluid exposures, please call UEOHC at 966-9119.
  The UEOHC line will automatically forward your
  call to Healthlink in order to gather the
  appropriate information and put you in contact
  with the Family Practice physician covering the
  needlestick hotline. For all other after-hour
  work related injuries that require immediate
  medical care, go directly to the UNC Emergency
  Department. If immediate medical care is not
  needed, then please report to the UEOHC the
  following day.
• For a life-threatening injury or illness, go
  directly to the Emergency Department located in
  the Neurosciences Hospital on Manning Drive.

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Workers Compensation Program

• If you experienced an on-the-job injury or
  illness, you are to report the incident
  immediately to your supervisor no matter how
  minor. Once the injury is reported, an incident
  investigation will occur to determine the cause
  of the incident and corrective action taken to
  prevent the incident from reoccurring. Please
  note Failure to report an injury could result in
  the denial of your claim.

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Workers Compensation Program

• For further information concerning University
  policies on workplace injuries and illnesses,
  refer to the "Workers' Compensation" pages on the
  EHS web site.

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Hazard Communication Program

• The OSHA Hazard Communication standard
  (1910.1200) requires that employees be informed
  of the hazards of chemicals that they may work
  with or are present in their work area. The four
  elements of this program are
• Labeling
• Hazardous Chemical Inventories
• MSDS
• Training
• Each of these elements will be reviewed in more
  detail.

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Hazard Communication Program

• All containers of hazardous chemical must be
  labeled with at least three items
• the name of the chemical,
• any hazard warnings associated with the product
  and,
• the name and address of the manufacturer.
• The name of the chemical must be spelled out
  completely, no molecular formulas are allowed.

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Hazard Communication Program

• All departments must maintain a current Chemical
  Inventory List that is reviewed and updated at
  least annually.
• Example HAZARDOUS MATERIALS INVENTORY

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Hazard Communication Program

• Material Safety Data Sheets must be accessible 24
  hours a day. MSDSs are prepared and distributed
  by the chemical manufacturer or distributor to
  provide important information concerning the
  chemical in question. MSDSs contain the identity
  of the chemical, the manufacturer's name, address
  and phone number and information regarding the
  physical and chemical characteristics of the
  chemical such as toxicity, flammability,
  corrosively physical and health hazards such as
  exposure hazards exposure limits precautions
  and controls and emergency and first aid
  treatment for exposures. A MSDS must be available
  for every chemical on the department's Chemical
  Inventory List.

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Hazard Communication Program

• All University employees who work with chemicals
  or have chemicals in their workplace are required
  to have hazardous materials' training initially
  upon employment and when any new chemical are
  introduced in their workplace thereafter.
• The Supervisor of employees who will be working
  with hazardous material will provide more
  in-depth training.
• The training will cover
• the proper use,
• handling, and
• personal protective equipment
• required for the safe handling of all hazardous
  chemicals. This training is mandatory for all
  employees handling hazardous materials.

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Hazard Communication Program

• EHS is available to assist any department,
  supervisor, and/or employees with information
  concerning the University's Hazard Communication
  Program, Material Safety Data Sheets, etc. Please
  feel free to contact EHS at [phone].

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Clinical Safety Program

• The clinical safety program at UNC is designed to
  promote environments that are free of hazards
  specific to clinical environments. Clinical
  environments are classified as areas such as
  healthcare facilities, laboratories that are
  dealing with blood or bodily fluids, or any other
  facility that is dealing with procedures that
  involve hazardous materials and biological
  agents. These areas need special attention to
  hazards to protect both the employees and the
  patients.

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Clinical Safety Issues

• In the clinic environment safety issues arise
  that are specific to personnel working in a
  healthcare facility. All University healthcare
  workers are expected to conduct their daily
  activities in such a way that they do not expose
  themselves or others to potential injury, such
  as
• Needlestick or sharp injuries
• Back injuries
• Chemical exposures
• Slips and falls

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Needlesticks or Sharp Injuries

• Needlesticks or sharp injuries are instances
  where an employee was exposed to a needle or
  other sharp tool or object, and were injured.
  These injuries normally break the skin and expose
  the employee to blood or other bodily fluids.
• Certain measures may be taken to reduce exposure.
  These measures include using appropriate
  engineering controls and using proper personal
  protective equipment (PPE).

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Needlesticks or Sharp Injuries, cont.

• Engineering controls are used to isolate or
  remove the bloodborne pathogens hazards from the
  workplace. Examples may include but are not
  limited to sharps disposal containers,
  self-sheathing needles, and safer medical
  devices, such as sharps with engineered sharps
  injury protectors and needleless systems.
  Personal Protective Equipment (PPE) is
  specialized clothing or equipment worn by an
  employee for protection of a hazard.

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Lifting Techniques

• Proper lifting techniques are also important in
  clinic environments. An employee should maintain
  good body posture, use safe body mechanics (bend
  at the hips and knees, not at the waist), and
  assess the situation of a patient before lifting
  or transferring a patient.
• An employee may also use lifting devices to aid
  them in achieving proper lifting techniques. In
  the healthcare facilities, there are devices
  which aid employees when lifting a patient.

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Chemical Exposures

• Following appropriate procedures when exposed to
  chemicals or other hazardous materials is
  necessary for preventing incidents. Hazardous
  materials are those substances that are
  potentially hazardous to your safety and health.
  Employees may encounter many hazardous materials
  that are classified as health and/or physical
  hazards.
• A health hazard is anything that causes acute or
  chronic health effects. A physical hazard is any
  chemical that is flammable, an oxidizer, or
  corrosive..

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Chemical Exposures, cont.

• Examples of hazardous materials in the clinic
  environment include infectious waste, flammable
  liquids and gases, toxic chemicals, radioactive
  materials, cancer causing (carcinogens) chemicals
  and drugs, and compressed gas cylinders.
• All departments using hazardous chemicals are
  responsible for determining if a less hazardous
  chemical may be substituted. The unsafe handling
  of hazardous materials can have an impact on
  ambulatory care or hospital operations.
  Appropriate precautions should always be used in
  handling hazardous materials..

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Slips and Falls

• Another example of incidents that are common in
  the clinic environment is slips and falls.
  Employees should be aware of their surroundings
  and should pay particular attention to areas
  where there could be potential moisture on the
  floor or walking surface that might cause them to
  slip or fall.

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Needlestick Safety and Prevention Act

• The Needlestick Safety and Prevention Act became
  law in 2000. This law revised the Bloodborne
  Pathogens Standard (29 CFR 1910.1030) to include
  safer medical devices, such as sharps with
  engineered sharps injury protections and
  needleless systems, as examples of engineering
  controls designed to eliminate or minimize
  occupational exposure to bloodborne pathogens
  through needlesticks and other percutaneous
  exposures.

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Requirements

• Requirements of the needlestick safety and
  prevention act include
• Review and update exposure control plans to
  reflect changes in technology that eliminate or
  reduce such exposure,
• Document the consideration and implementation of
  appropriate commercially available, safer medical
  devices that eliminate or reduce exposure,
• Maintain a sharps injury log, noting the type and
  brand of device used, where the injury occurred,
  and an explanation of the incident,
• Seek input on such engineering and work practice
  controls from the affected healthcare workers.

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Needlestick Safety and Prevention at UNC

• UNC makes every attempt to ensure safety for all
  employees who are exposed to needles and other
  sharps. Needlesticks are one of the most common
  incidents in the workplace. UNC and
  UNC-Healthcare have formed a Needlestick Task
  force that convenes twice a year to examine and
  evaluate techniques and protocols to stay abreast
  of innovative technologies to decrease the number
  of needlestick occurrences. In addition, members
  of the Occupational Health/Clinical Safety
  Committee also address needlestick safety and
  prevention.

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Latex Exposure

• A recently recognized work place hazard for some
  healthcare workers is latex exposure. For some
  individuals exposure to latex products, such as
  powdered latex exam gloves, can cause a mild to
  severe allergic reaction.

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Latex Allergy Prevention

• To prevent latex allergies do the following
• Use non-latex gloves for activities that are
  likely to involve contact with infectious
  substances
• If you choose latex gloves, use powder-free
  gloves
• When using gloves, do not use oil-based hand
  cream or lotions
• Recognize the symptoms of latex allergy
• Always wash hands after removing gloves

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Latex Allergy

• If you believe that you may have a latex allergy,
  you should notify your supervisor and contact the
  University Employee Occupational Health Clinic
  (UEOHC) for evaluation at [phone].
  Additional information regarding potential
  hazards associated with latex exposure is also
  available by contacting the UEOHC.

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Disaster Plan Manuals

• The UNC Department of Environment, Health and
  Safety, UNC Hospitals and some specific
  departments have Disaster Plan Manuals that
  provide all employees with a written resource to
  accomplish an effective response to disaster
  events. The UNC EHS plan can be found at EHS's
  online manual.
• The Director-on-Call and the Disaster Commander
  will assess the need for personnel, supplies, and
  equipment. In addition, all departments need to
  have an internal plan on what to do during a
  disaster.

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If a Disaster Occurs

• If a disaster occurs which compromises the
  utilities of the facility, it should be reported
  to the Facilities Services Division (919)
  962-3456 in University buildings and Plant
  Engineering [phone] in Hospital buildings.

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ID Badges

• It is imperative that employees wear their ID
  badges at all times. These badges will include
  emergency code announcements and steps to take in
  the event a code is called. ID badges are also an
  essential part of the health and safety system
  due to security issues.

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Hazard Assessment and Equipment Selection

• The department in consultation with the
  Department of Environment Health and Safety will
  assess the workplace to determine if hazards are
  present, or likely to be present, and requires
  the use of Personal Protective Equipment (PPE).
  If such hazards are present, or likely to be
  present, the University will
• Select and have each affected employee use the
  types of PPE that will protect the affected
  employee from the hazards identified in the
  hazard assessment.

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Hazard Assessment and Equipment Selection, cont.

• Communicate selection decisions to each employee
• Select PPE that properly fits each affected
  employee
• Verify that the required workplace hazard
  assessment has been performed through a written
  certification that identifies the workplace
  evaluated, the person certifying that the
  evaluation has been performed, and the dates of
  the hazard assessment.

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Hazard Assessment and Equipment Selection, con't.

• Employees working in a clinical facility must
  wear proper personal protective equipment. An
  assessment should be conducted to determine
  proper personal protective equipment. Below you
  will find an example of a hazard assessment for
  employees working in a healthcare environment.
  Also, remember to always use standard precautions
  as all patients are potentially infectious.

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Personal Protective Equipment (PPE)

• Personal Protective Equipment should be
• Inspected before and after each use
• Used where there is occupational exposure
• Used appropriately
• Used only when its integrity is insured
• Accessible
• Removed when contaminated and prior to leaving
  the work area

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PPE Training

•  The University will provide training to each
  employee who is required to use PPE. Each
  affected employee shall demonstrate an
  understanding of the training and the ability to
  use PPE properly, before being allowed to perform
  work requiring the use of PPE. The training
  program must verify that each affected employee
  has received and understood the required training
  through a written certification that contains the
  name of each trained employee, the dates of
  training, and that identifies the subject of the
  certification.

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PPE Training, cont.

• Each employee is to be trained to know at least
  the following
• when PPE is necessary
• what PPE is necessary
• how to properly don (put on), doff (take off),
  adjust, and wear PPE
• the limitations of the PPE
• the proper care, maintenance, useful life and
  disposal of the PPE

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PPE Training, con't.

• The training program must verify that each
  affected employee has received and understood the
  required training through a written certification
  that contains the name of each trained employee,
  the dates of training, and that identifies the
  subject of the certification. Click this link for
  a certification form for Personal Protective
  Equipment.

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Training and Medical Surveillance Program

• OSHA and JCAHO regulations require that all
  employees who have duties in or are located in a
  healthcare facility receive medical surveillance
  and attend additional safety training.

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Medical Surveillance

• All healthcare employees are required to complete
  a one-time immunization review through the UEOHC.
  The immunization review consists of
• A record of 2 Measles, 2 Mumps, and 2 Rubella
  (disease or vaccine for all) OR titers for all OR
  a record of 1 Tdap (Tetanus, diptheria, acellular
  pretusis)
• A record of the Hepatitis B series (for those
  exposed to blood or bodily fluids)
• Verbal response for Varicella (Chicken Pox)
• Verbal response for Latex Allergy
• Annual Tuberculosis Screening

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Medical Surveillance, cont.

• Annually thereafter, employees are to complete a
  Tuberculosis Screening through the UEOHC. UNC
  Environment, Health and Safety will notify
  employees who need to renew his/her TB screening
  via campus mail the month that it is up for
  renewal. Department representatives will also
  receive monthly compliance reports stating the
  current status of their employees.

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Training

• Employees who are classified as working in a
  clinic environment are required to complete
  annual training on JCAHO/General Safety,
  Tuberculosis, and Bloodborne Pathogens for those
  who are potentially exposed to blood or other
  bodily fluid. These training requirements can be
  completed either by utilizing EHS's online
  self-study units or by attending instructor led
  classes which are held every month. For more
  details, select the training section on the EHS
  Website.

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Bloodborne Pathogen Introduction

• On December 6, 1991, the Occupational Safety and
  Health Administration (OSHA) published their
  standard for occupational exposure to bloodborne
  pathogens in the Federal Register 1910.1030,
  which can be found at the following website
  www.osha.gov. A component of this standard
  requires the employer to provide annual education
  regarding the occupational hazard of bloodborne
  pathogens. There are 14 required components of
  this education all of which are incorporated in
  this study module.

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Bloodborne Pathogen Intro., cont.

• These components are listed in the Federal
  Register 1910.1030. It is important to remember
  that OSHA standards are federal law and
  compliance is mandatory. However, it is more
  important to recognize that this standard was
  established to help protect the healthcare worker
  from the serious workplace hazard of bloodborne
  pathogens.

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Bloodborne Pathogens

• Bloodborne Pathogens are pathogenic
  microorganisms that are present in human blood or
  other potentially infectious materials (OPIM) and
  can cause disease in humans. These pathogens
  include but are not limited to
• Human Immunodeficiency Virus (HIV)
• Hepatitis B (HBV)
• Hepatitis C (HCV)
• Non A, non B Hepatitis
• Syphilis
• Malaria

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Other Potentially Infectious Material (OPIM)

• OPIMs are body fluids, unfixed tissues or organs,
  and tissue that may cause disease in humans.
  Listed below are some examples
• cerebrospinal fluid
• synovial fluid
• pleural fluid
• amniotic fluid

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Other Potentially Infectious Material (OPIM),
cont.

• pericardial fluid
• unfixed tissue or body organs other than intact
  skin
• blood, organs, and tissue from experimental
  animals infected with HIV or HBV
• peritoneal fluid
• semen
• vaginal secretions
• any body fluid contaminated with blood saliva in
  dental procedures
• body fluids in emergency situations that cannot
  be recognized

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Epidemiology of HIV

• Bloodborne Pathogens are pathogenic
  microorganisms that are Human Immunodeficiency
  Virus (HIV) is the virus that causes AIDS. This
  virus is passed from one person to another
  through blood-to-blood and sexual contact. In
  addition, infected pregnant women can pass HIV to
  their baby during pregnancy or delivery, as well
  as through breast-feeding. People with HIV have
  what is called HIV infection. Most of these
  people will develop AIDS as a result of their HIV
  infection.
• According to the CDC, as of 2002, approximately
  65 million people worldwide have been infected
  with HIV. At the end of 2002, an estimated 42
  million people worldwide were living with HIV
  infection or AIDS. In the United States, through
  December 2001, a total of 816,149 cases of AIDS
  had been reported to the CDC.

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HIV and AIDS Current Trends

• According to current trends, these certain
  populations are at a greater risk of contracting
  HIV/AIDS
• Injecting-drug users
• Women
• Blacks
• Hispanics
• Adolescents/young adults
• Persons who are involved heterosexually with a
  partner at risk or known to have the infection or
  AIDS.

65
Clinical Manifestation of HIV Infection
The spectrum of HIV infection ranges from an
asymptomatic state to severe immunodeficiency and
associated opportunistic infections, neoplasms,
and other conditions. Initial infection can be
followed by an acute flu-like illness. Features
include

• rash
• malaise
• sore throat
• headache

• fever
• lymphadenopathy
• sweats
• myalgia
• arthralgia

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Clinical Manifestation of HIV Infection, cont.

• The natural history can vary considerably. The
  risk of disease progression increases with the
  duration of the infection. Most cohort studies
  show that less than 5 of HIV infected adults
  develop AIDS within 2 years of infection. Without
  therapy approximately. 20-25 develop AIDS within
  2 years of infection and 50 within 10 years.

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Epidemiology of Hepatitis B Virus

• Acute viral hepatitis, first reported in 1833, is
  a common and sometimes serious viral infection of
  the liver leading to inflammation and necrosis.
  There are at least five distinct viral agents
  that cause acute viral hepatitis
• HAV
• HBV
• HDV (delta)
• HCV
• HEV (an externally transmitted non A, non B
  hepatitis agent)
• As of 2001, the United States had 78,000 cases of
  Hepatitis B reported to the CDC.

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Clinical Manifestation of HIV Infection

• The clinical presentation of acute HBV ranges
  from asymptomatic, subclinical illness to
  fulminant hepatic failure. The disease has a long
  incubation period from 30 to 180 days. Initial
  symptoms are nonspecific, typically include

• rash
• polyarthritis
• last 3-10 days
• onset of jaundice or dark urine
• severe acute liver failure

• elevations of ALT and AST
• last 3-10 days
• onset of jaundice or dark urine
• severe acute liver failure
• elevations of ALT and AST

69
Hepatitis B Vaccine

• The Hepatitis B vaccine is given as a series of
  three injections. It produces a high antibody
  titer in over 90 of the recipients under the age
  of 40-50 years. Certain factors such as older
  age, obesity, heavy smoking, and immunologic
  impairments can result in lower antibody titers.
• Hepatitis B is offered to all UNC Employees who
  have reasonably anticipated exposure to blood or
  other potentially infectious material. The
  Hepatitis B vaccine is given to these employees
  to try and reduce the risk of seroconversions due
  to a Hepatitis B exposure. It is given at the
  UEOHC (919-966-9119). If you decline, you must
  sign a declination form, however if you desire it
  at a later time, you may receive it then.

70
Epidemiology of Hepatitis C Virus

• Hepatitis C (HCV) is a viral infection of the
  liver. Hepatitis C is a major cause of acute
  hepatitis and chronic liver disease, including
  cirrhosis and liver cancer. Globally an estimated
  170 million persons are chronically infected with
  HCV and 3 to 4 million persons are newly infected
  each year.

71
Clinical Manifestation of Hepatitis C Virus

• 80 of the persons infected with Hepatitis C have
  no signs or symptoms. Those that have symptoms
  and signs, may exhibit the following

• Jaundice
• Fatigue
• Dark Urine

• Abdominal Pain
• Loss of Appetite
• Nausea

Chronic infections occur in 75-85 of infected
persons. Chronic liver disease occurs in 70 of
infected persons. Hepatitis C is the leading
indication for liver transplants. There is no
vaccine for Hepatitis C. Employees who acquire
HCV occupationally or suspect an exposure
incident, should contact the University Employee
Occupational Health Clinic (966-9119).
72
Transmission

• In the occupational setting transmission of
  bloodborne pathogens is by needlestick/sharp
  injuries, mucous membrane and non-intact skin
  exposure to contaminated blood/OPIM. In general,
  HIV and hepatitis B virus are transmitted via the
  following routes
• sexual contact
• sharing HIV or HBV contaminated needles or
  syringes
• from mother to unborn child

73
Transmission, con't.

• Hepatitis C is spread primarily by direct contact
  with human blood. The major causes of HCV
  infection include
• Unscreened blood transfusions
• Re-use of needles and syringes
• Injecting drug users
• From infected mother to baby during birth
• Sharps exposures or Needlesticks

74
Rule of Threes

• Not all the bloodborne pathogens carry the same
  risk of occupational acquisition. Frequency in
  patient population, environmental viability of
  the virus, and viral load all impact your risk of
  acquiring infection, if exposed. The following
  table demonstrates infection risk from a
  percutaneous exposure to HBV, HCV, and HIV.

75
Exposure Control Plan

• UNC has two exposure control plans available to
  all employees. One is for the UNC Healthcare
  System and is available at www.unchealthcare.org
  and the other you may call the Department of
  Environment, Health and Safety at [phone]
  to receive a copy or visit ehs.unc.edu. The
  Exposure Control Plan contains a list of all job
  categories that have occupational risk to
  bloodborne pathogens. It also outlines management
  of employee exposures and methods to prevent
  exposure in the workplace. A copy of the OSHA
  standard can be referenced directly behind the
  Exposure Control Plan. Every employee should be
  familiar with the Exposure Control Plan and the
  OSHA standard.

76
Standard Precautions

• Standard Precautions is a method of infection
  control in which all human blood and other
  potentially infectious materials (OPIM) are
  treated as known to be infectious. Standard
  Precautions apply to blood, all body fluids,
  secretions, and excretions (except sweat),
  non-intact skin, and mucous membranes. They are
  essential in reducing occupational acquisition of
  bloodborne pathogens. This means treating every
  patient as if they were infected with bloodborne
  pathogens, such as HIV or HBV. It also means that
  healthcare workers use personal protective
  equipment to prevent direct contact with blood or
  body fluids. Standard precautions is the best
  method that healthcare workers can use to protect
  themselves from occupational acquisition.

77
Personal Protective Equipment

• Personal Protective Equipment (PPE) is
  specialized clothing and equipment worn by
  employees for protection against a hazard, such
  as blood or other potentially infectious
  materials. This equipment should be readily
  available and is provided to the employee at no
  cost.
• The employees should never put themselves at risk
  by not using appropriate PPE and should be
  removed after use. The employees should take care
  not to contaminate the skin. Soiled gowns,
  gloves, etc should be disposed of in a Biohazard
  Container immediately after use. Hands should
  always be washed thoroughly after removal of PPE.

78
Engineering Controls

• Engineering controls are used to isolate or
  remove the bloodborne pathogen hazards from the
  workplace (e.g. sharps disposal containers,
  self-sheathing needles, and safer medical
  devices). Employers are required to provide
  engineering controls that have been demonstrated
  to significantly reduce occupational hazard.

79
Administrative Controls

• Administrative controls are used to reduce the
  likelihood of exposure by altering the manner in
  which a task in performed. Some examples include
  needles not being recapped, specimens transported
  in secondary container. It could also be
  displayed by sharps being immediately disposed in
  a sharps container. Healthcare workers are
  responsible for carefully disposing of all
  sharps.

80
Transporting Specimens to the Laboratory

• When transporting specimens, they should not be
  hand carried to the lab. Specimens must be
  transported in a secondary container displaying a
  BIOHAZARD label. The primary specimen container
  and accompanying tags and/or labels must be
  contaminant free.

81
Universal Biohazard Sign

• Universal Biohazard Signs are used to alert
  employees that containers, specimen
  refrigerators, or secondary containers used to
  transport specimens may contain infectious
  materials. Individual tubes need not be labeled.
  Secondary containers used for manually
  transporting specimens must display the BIOHAZARD
  sign. Equipment that may have internal
  contamination that cannot be accessed for
  decontamination should also be tagged with a
  BIOHAZARD label. Biohazard signs alert
  maintenance and medical engineering employees to
  use precaution.

82
Contaminated Equipment

• Equipment such as blood pressure cuffs and
  stethoscopes must be cleaned if contaminated with
  blood or other potentially infectious materials.
  An EPA approved disinfectant detergent (i.e.
  Vesphene) or a 110 or 1100 dilution of bleach
  and water should be used.

83
Disposing of Medical Waste

• Regulated medical waste is infectious waste that
  is to be disposed of according to rules
  established by the North Carolina Solid and
  Hazardous Waste Management Branch. Regulated
  medical waste includes full Sharp Containers,
  microbiological cultures, pathology specimens,
  and gt20ml of blood products which includes
  Blood, serum, plasma, emulsified human tissue,
  spinal fluid, pleural and peritoneal fluid.
• Medical waste must be disposed in a container
  labeled with the BIOHAZARD label. Certain items
  are required to be incinerated and are referred
  to as regulated medical waste. Blood in
  quantities of greater than 20ml per unit
  container is defined as regulated medical waste.

84
Disposing of Regulated Waste

• When transporting specimens, they should not be
  hand carried to the lab. Specimens must be
  transported in a secondary container displaying a
  BIOHAZARD label. The primary specimen container
  and accompanying tags and/or labels must be
  contaminant free.

85
Disposal of Medical Waste

• Bandages, dental floss, vacutainer tubes, and
  bags do not require incineration or autoclaving
  are to be disposed in white trash bags labeled
  with the BIOHAZARD SIGN. It is important to
  remember that bags are not puncture-proof and
  sharps are always to be disposed in designated
  sharps containers, not in trash bags.

86
Wet, Contaminated Laundry

• Wet contaminated laundry is laundry that is
  soiled with blood or other potentially infectious
  materials and presents a reasonable likelihood to
  soak through or leak from the bag. This laundry
  should not be sorted or handled any more than
  necessary for disposal. It should be disposed in
  fluid resistant linen bags and should be doubled
  bagged when necessary to prevent leaking.

87
Dermatitis of the Hands

• Some employees may develop dermatitis of the
  hands. This puts the employee at greater risk of
  infection with bloodborne pathogens. All
  employees who develop or suspect that they may
  have dermatitis of the hands, should be seen at
  the University Employee Occupational Health
  Clinic. This process will provide evaluation and
  treatment prior to work involving exposure to
  blood, to help minimize the risk of infection
  with bloodborne pathogens.

88
Latex Allergy

• Latex gloves have proven effective in preventing
  transmission of many infectious diseases,
  however, for some healthcare workers, exposure to
  latex may result in allergic reactions. This
  reaction is to certain proteins in latex rubber.
  The amount of latex exposure needed to produce
  sensitization or reaction is unknown.
• Symptoms may occur within minutes of exposure or
  may take several hours to appear depending on the
  individual. They may include skin redness,
  hives, itching, respiratory symptoms such as
  runny nose, itchy eyes, scratchy throat, and
  asthma. If an employee has a latex allergy or
  suspects they have had any reaction to latex,
  they should report the incident to the University
  Employee Occupational Health Clinic.

89
Protection From Latex Allergy

• There are certain precautions employees can take
  to protect themselves from a latex allergy. Use
  non-latex gloves for activities that are not
  likely to involve contact with infectious
  materials. Appropriate barrier protection is
  necessary when handling infectious materials, so
  if you choose latex gloves, use powder-free
  gloves with reduced protein content. When wearing
  latex gloves, do not use oil-based hand creams or
  lotions. After removing latex gloves, wash hands
  with a mild soap and dry thoroughly. Frequently
  clean areas and equipment contaminated with latex
  dust. Learn to recognize the symptoms and
  procedures for preventing latex allergy.

90
Exposure Incidents

• Exposure incidents are events in which there has
  been a
• percutaneous injury involving a potentially
  contaminated needle or other sharp
• splash of blood or other potentially infectious
  materials to the eyes, mouth, or mucous membranes
  
• blood or other potentially infectious materials
  contacting broken skin
• At UNC in 2002, there were 72 exposure incidents
  reported. Two of the source patients were HIV
  positive, three were HBV positive, and five were
  HCV positive. There were no seroconversions as a
  result of exposure to HIV, HBV, or HCV positive
  blood.

91
Steps to Take in the Event of Exposure

• In the event of an exposure, employees should
• Immediately wash the exposed area with soap and
  water. If the eyes are involved, irrigate with
  tap water.
• Notify your supervisor and complete an incident
  report
• Go to the University Employees Occupational
  Health Clinic, calling ahead (919-966-9119) to
  alert them of the exposure.
• If the exposure occurs after regular working
  hours or on weekends, call Health Link
  (919-966-9119) to be instructed on steps
  necessary for further treatment.

92
Occupational Health Clinic Evaluation

• The University Employee Occupational Health
  Clinic (UEOHC) staff will evaluate your exposure
  incident. The evaluation may include testing your
  blood and the source patients' blood for HIV,
  HBV, and HCV. This test is only conducted with
  the employees consent and is kept confidential.
  After the results are known, UEOHC will provide
  the employee with written evaluation and
  recommendations regarding the treatment of
  exposure. In some cases a combination therapy for
  HIV exposure may be considered.

93
Tuberculosis Introduction

• Healthcare facilities present an environment
  where tuberculosis may be transmitted at an
  increased rate. Patients with active disease may
  expose other patients, some of whom are highly
  susceptible for contracting TB due to immune
  deficiencies. The high risk for transmission of
  TB in healthcare facilities presents an
  occupational health hazard for employees who work
  in healthcare facilities. In 1990 and 1991, CDC
  received 13 reports of outbreaks of MDR-TB in
  hospitals and prisons. These outbreaks resulted
  in the disease being spread to healthcare
  workers.

94
OSHA Requirements

• OSHA does not have specific regulations
  concerning the control of tuberculosis
  infections. However, OSHA has stated that it will
  cite healthcare facilities, under the General
  Duty Clause of the OSHA Act, for non-conformance
  to published CDC guidelines for TB control. These
  guidelines require that healthcare employees
  receive annual training in TB and infection
  control. Successful completion of this training
  module will satisfy those requirements.

95
Current Trends of TB

• After decades of decline, the number of cases of
  active tuberculosis has been on the increase
  since the mid 1980s. This increase and the
  concern for occupational exposure for healthcare
  workers has been attributed to
• HIV epidemic. Individuals who are HIV positive,
  or have other immune deficient conditions, have a
  greater risk of developing active TB disease if
  infected.
• Immigration. Foreign-born individuals have come
  from countries with high prevalence of TB, such
  as Asia, Africa, the Caribbean, and Latin
  America. These individuals may also live in
  medically under served areas within the U.S.,
  which further contributes to the increased risk
  for TB transmission.

96
Current Trends of TB, cont.

• Transmission in high-risk environments.
  Transmission of tuberculosis accelerates in
  environments where there are
• persons with active TB, and
• persons with a higher risk for progression from
  latent TB to active disease.
• Such environments include homeless shelters,
  prisons, nursing homes, and hospitals.
• Drug Resistance. Multi-drug-resistant
  tuberculosis (MDR-TB) refers to strains of M.
  tuberculosis that are resistant to isoniazid and
  rifampin, two drugs used to treat TB. Patients
  who become infected with these strains of TB take
  longer to recover and remain infectious for a
  longer period, thus, potentially infecting more
  people.

97
Current Trends of TB, con't.

• Exposure incidents are events in which there has
  been a
• percutaneous injury involving a potentially
  contaminated needle or other sharp
• splash of blood or other potentially infectious
  materials to the eyes, mouth, or mucous membranes
  
• blood or other potentially infectious materials
  contacting broken skin
• At UNC in 2002, there were 72 exposure incidents
  reported. Two of the source patients were HIV
  positive, three were HBV positive, and five were
  HCV positive. There were no seroconversions as a
  result of exposure to HIV, HBV, or HCV positive
  blood.

98
Decline in TB Cases

• The decline in cases during 1992-1997 can be
• attributed to the following six factors
• improved laboratory methods to allow prompt
  identification on M. tuberculosis
• broader use of drug-susceptibility testing
• expanded use of preventive therapy in high-risk
  groups
• decreased transmission of M. tuberculosis in
  congregative settings (e.g. hospitals,
  correctional facilities)

99
Decline in TB Cases, cont.

• improved follow-up of persons with TB initially
  reported to the health department
• increased federal resources for state and local
  TB-control efforts.
• In North Carolina the number of cases remains
  stable at approximately 600 cases per year. Less
  than 1 of TB cases that have occurred in North
  Carolina have been MDR-TB. At UNC Hospitals,
  there are approximately 25 cases of TB out of
  27,000 admitted patients each year.

100
Transmission of TB

• M. tuberculosis is carried in airborne particles,
  or droplet nuclei, generated when a person with
  pulmonary or laryngeal TB coughs or sneezes.
  Infection occurs when a susceptible person
  inhales droplet nuclei containing M. tuberculosis
  bacilli, which reach the alveoli of the lungs.
  Within 2-10 weeks after initial infection the
  immune response limits further spread of tubercle
  bacilli however, some of the bacilli remain
  dormant and viable for many years. This is known
  as latent TB infection.

101
Transmission of TB, cont.

• For a small proportion of infected persons
  (usually lt1 ), initial infection readily
  progresses to clinical illness, or active
  disease. For 5 - 10, illness develops after an
  interval of months, years, or decades, when the
  bacteria begin to replicate and produce disease.
  Progression to active disease is more likely in
  persons with medical conditions that result in
  immune deficiencies, the elderly, and those less
  than 4 years of age. The risk for progression to
  active disease is markedly increased for persons
  with HIV infection.

102
Transmission of TB, con't.

• TB infection occurs after prolonged exposure to
  someone who has the infectious form of TB. A
  person has a 50 chance of becoming infected if
  they spend 8 hours a day for 6 months with a
  person with the active form of TB.
• The site of initial infection is usually the
  alveoli of the lungs where macrophages ingest the
  inhaled bacilli. The body's T-cells are
  stimulated and a cell-mediated or delayed
  hypersensitivity occurs.
• The T-cells stimulate specialized cells that kill
  the bacilli and wall off infected macrophages,
  producing grayish capsules called tubercles.
  Further multiplication of the TB bacilli are
  usually confined here. In an immunodeficient
  individual the TB bacilli may break out of the
  tubercle and lead to the active form of the
  disease.

103
Infection Routes and Symptoms

• For individuals with active TB, the bacilli will
  spread from the lungs to other parts of the body
  usually the lymph nodes. In 15 of the active TB
  cases, bacilli will infect other sites in the
  body such as the skin, bones, and reproductive or
  urinary systems.
• Symptoms of the disease include weight loss,
  fever, night sweats and anorexia. If the disease
  is allowed to progress, large cavities may form
  in the lungs, encompassing the bronchi. Symptoms
  also include a persistent (lasting at least three
  weeks) cough with production of bloody sputum.

104
Diagnosis of TB

• Persons exhibiting the symptoms and suspected of
  having TB, should be referred for a complete
  medical evaluation, which should include a
  medical history, physical examination, a Mantoux
  tuberculin skin test, a chest radiograph, and
  appropriate bacteriologic or histological
  examinations.

105
Tuberculin Skin Test

• The Mantoux or tuberculin skin test is used for
  screening individuals who are at high risk for
  developing tuberculosis, such as persons exposed
  to infectious individuals. The tuberculin skin
  test is the only method of diagnosing TB
  infection before the infection has progressed to
  the active disease. A person who becomes infected
  with TB will show a positive reaction in 2 to 10
  weeks.
• The Mantoux test is performed by injecting 5
  units of purified protein derivative (PPD)
  intradermally into the volar or dorsal surface of
  the forearm. If the person is infected a
  characteristic welt will form.

106
Tuberculin Skin Test, cont

• This welt consists of hardening in the form of a
  raised bump where the PPD was placed and may be
  red in color. The diameter of the induration is
  measured to determine infection status.
• The reaction to the Mantoux test should be read
  by a trained healthcare worker 48 to 72 hours
  after the injection. A negative reaction must be
  read within 72 hours or the Mantoux test must be
  repeated.

107
Classification of Tuberculin Reaction

• There are three different classifications of
  Tuberculin reactions. These vary based upon the
  factors listed below
• gt5 mm is positive for known or suspected HIV
  patients, close contacts of persons with
  infectious TB, persons with chest x-rays
  suggestive of previous TB, and IV drug abusers.
• gt10 mm - persons not listed above but are known
  to be of populations at increased risk for having
  TB.
• gt15 mm is positive in persons with no known risk
  factors.

108
  Anergy

• Anergy occurs when the delayed hypersensitivity
  reaction to the PPD test is absent or decreased
  in individuals who are immunodeficient, i.e.
  individuals with HIV, persons with severe febrile
  illness, measles or Hodgkin's disease or those on
  immunosuppressive drugs. Approximately one third
  of patients with HIV infection and 60 of those
  with AIDS may have skin reactions of lt5mm even
  though they are infected with TB.
• Individuals previously infected with TB may also
  show a positive PPD test. A person's exposure
  history and chest x-ray are also used to
  determine infection, however a positive
  bacteriologic culture is needed to confirm
  diagnosis. Sputum collected for culture can be
  produced by having the patient cough deeply so as
  to ensure mucous is collected from diseased lung
  tissue.

109
Treatment of TB

• Tuberculosis disease can be effectively treated
  using antibiotic therapy. Isoniazid and rifampin
  are generally used, with pyrazinamide given for
  the first two months. Ethambutol is added when
  drug resistant bacilli are suspected. The length
  of therapy and combination of antibiotics is
  decided by the physician, based upon organism
  antibiotic sensitivity, signs of improvement, and
  patient compliance.
• While on therapy, patients are monitored for side
  effects that may be caused by the antibiotics.
  Isoniazid (INH) has caused liver toxicity in some
  patients. This occurrence is rare for people
  under the age of 35, but has a somewhat greater
  incidence for people over 35. Liver function
  should be monitored in patients receiving
  treatment with INH. Patients who are taking
  ethambutol should be monitored for potential
  visual changes.

110
Treatment of TB, con't.

• It is especially important that patients complete
  the prescribed drug therapy regimen in order to
  effectively kill all bacilli. Drug-resistance can
  develop when medications are taken incorrectly by
  either skipping doses or not taking the
  medication for the prescribed amount of time.
• Directly Observed Therapy or DOT is used when it
  is suspected that patients may not comply with
  the prescribed treatment. DOT is accomplished by
  designating a person to observe the patient
  swallow each dose of medication.

111
Preventive Therapy

• Individuals with positive PPD test results should
  be evaluated for preventive therapy if they
• are recent converters
• have close contact with TB patients
• have an immune deficient medical condition
• are HIV positive
• use IV drugs
• are lt35 years of age.
• Studies have shown that preventive therapy with
  INH will reduce the risk of active TB by
  approximately 70. Currently, INH taken by mouth
  for 6 to 12 months is the recommended treatment
  for preventive therapy.

112
Infection Control

• The main goal of an infection control program is
  to detect TB disease early and to isolate and
  promptly treat persons who have TB. The infection
  control program of any healthcare facility should
  involve three types of controls administrative
  controls isolation facilities and procedures
  personal respiratory protection.
• Administrative controls include risk assessment
  development of TB infection-control plan
  assignment of infection-control responsibilities
  early identification, isolation, and treatment of
  suspected cases.

113
Risk Assessment

• At UNC, the TB Infection-Control Plan requires
  that each healthcare facility and clinic area
  must complete a risk assessment so that
  appropriate infection control interventions can
  be developed based on actual risk of TB
  transmission.
• The level of risk is based on
• the number or estimated number of TB infectious
  patients admitted to each area
• number of personnel PPD conversions
• and potential for patient transmission.

114
Assignment of Responsibility

• The clinic director of each UNC facility is
  responsible for assigning healthcare personnel to
  implement infection control responsibilities.

115
Early Identification of TB

• Early identification and isolation of patients
  with TB is necessary to prevent TB transmission
  among patients and personnel. Healthcare workers
  who first come in contact with patients should be
  trained to ask questions which will help identify
  patients with active TB. Designated healthcare
  professionals will evaluate patients immediately
  so as to minimize time spent in waiting areas.

116
TB Precautions for UNC Clinics

• TB precautions will be instituted for patients
  suspected of having TB. Patients are instructed
  to
• wait in separate areas, apart from other
  patients
• wear surgical masks
• cover their mouths with facial tissues when
  coughing or sneezing.
• Persons suspected of having TB are referred to
  either the Pulmonary Clinic or the Infectious
  Disease Clinic where isolation facilities are
  available for managing these patients. HIV
  patients are sent to the Infectious Disease
  Clinic.

117
Isolation Facilities

• Patients with active TB are placed in isolation.
  Engineering controls are used in each isolation
  room to prevent the spread and reduce the
  concentration of infectious droplet nuclei in the
  air.
• Isolation rooms are equipped with at least 6 air
  exchanges per hour sufficient air distribution
  within the room directional airflow from hallway
  to room and direct exhaust of room air to
  outside.

118
Isolation Procedures

• Patients placed in TB isolation will be
  instructed in procedures to prevent TB
  transmission, and the reasons for their being
  placed in isolation.
• The door to the room must always be kept closed.
  Healthcare workers will be instructed to wear
  respirators. Patients who hav