post exposure management and infection control

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  • HIV/AIDS
  • CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17. Exposed health care workers should first seek prompt local medical attention. The National HIV/AIDS Clinicians’ Consultation Center provides a hotline for clinicians caring for health care workers exposed to bloodborne pathogens. The National Clinicians’ Post-Exposure Prophylaxis Hotline is available 24 hours a day, 7 days a week.
  • Risk of Infection Following a specific exposure, the risk of infection vary with factors such as: The pathogen involved The type of exposure The amount of blood involved in the exposure The amount of virus in the patient's blood at the time of exposure
  • The risks for occupational transmission of HIV have been described; risks vary with the type and severity of exposure ( 2,3,7 ). In prospective studies of HCP, the average risk for HIV transmission after a percutaneous exposure to HIVinfected blood has been estimated to be approximately 0.3% (95% confidence interval [CI] = 0.2%–0.5%) ( 7 ) and after a mucous membrane exposure, approximately 0.09% (CI = 0.006%–0.5%) ( 3 ). Although episodes of HIV transmission after nonintact skin exposure have been documented, the average risk for transmission by this route has not been precisely quantified but is estimated to be less than the risk for mucous membrane exposures. The risk for transmission after exposure to fluids or tissues other than HIV-infected blood also has not been quantified but is probably considerably lower than for blood exposures.
  • PEP should be started as soon as possible, preferably within hours, rather than days, following exposure When uncertain as to which drugs to choose, start the basic regimen rather than delay PEP should be administered for 4 weeks, if tolerated.
  • Reevaluate exposed HCP within 72 hours of exposure, especially as additional information about the exposure or source patient becomes available If the source is found to be negative, PEP should be discontinued Rapid HIV testing of the source patient can facilitate decisions regarding PEP when the source patient’s HIV status is unknown
  • Determining which agents and how many to use or when to alter a PEP regimen is primarily empiric. Guidelines for treating HIV infection, a condition typically involving a high total body burden of HIV, recommend use of three or more drugs; owever, the applicability of these recommendations to PEP is unknown. Among HIV-infected patients, combination regimens with three or more antiretroviral agents have proved superior to monotherapy and dual-therapy regimens in reducing HIV viral load, reducing incidence of opportunistic infections and death, and delaying onset of drug resistance. In theory, a combination of drugs with activity at different stages in the viral replication cycle (e.g., nucleoside analogues with a PI) might offer an additive preventive effect in PEP, particularly for occupational exposures that pose an increased risk for transmission or for transmission of a resistant virus. Although use of a three- (or more) drug regimen might be justified for exposures that pose an increased risk for transmission, whether the potential added toxicity of a third or fourth drug is justified for lower-risk exposures is uncertain, especially in the absence of data supporting increased efficacy of more drugs in the context of occupational PEP. Offering a two-drug regimen is a viable option, primarily because the benefit of completing a full course of this regimen exceeds the benefit of adding the third agent and risking non-completion. In addition, the total body burden of HIV is substantially lower among exposed HCP than among persons with established HIV infection. For these reasons, the recommendations in this report provide guidance for two- and three- (or more) drug PEP regimens on the basis of the level of risk for HIV transmission represented by the exposure.
  • Two-drug PEP regimens improve tolerability and therefore chances of completing full 4 weeks Three- (or more) drug PEP regimens provide potentially greater antiviral activity Guidelines recommend more drugs for higher risk exposures
  • The selection of a drug regimen for HIV PEP must balance the risk for infection against the potential toxicities of the agent(s) used. Because PEP is potentially toxic, its use is not justified for exposures that pose a negligible risk for transmission. The initial HIV PEP regimens recommended in these guidelines should be viewed as suggestions that can be changed if additional information is obtained concerning the source of the occupational exposure (e.g., possible treatment history or antiretroviral drug resistance) or if expert consultation is provided. Given the complexity of choosing and administering HIV PEP, whenever possible, consultation with an infectious diseases consultant or another physician who has experience with antiretroviral agents is recommended, but it should not delay timely initiation of PEP. Consideration should be given to the comparative risk represented by the exposure and information regarding the exposure source, including history of and response to antiretroviral therapy based on clinical response, CD4 + T-cell counts, viral load measurements, and current disease stage. When the source person’s virus is known or suspected to be resistant to one or more of the drugs considered for the PEP regimen, the selection of drugs to which the source person’s virus is unlikely to be resistant is recommended; expert consultation is advised. If this information is not immediately available, initiation of PEP, if indicated, should not be delayed; changes in the regimen can be made after PEP has started, as appropriate. For HCP who initiate PEP, re-evaluation of the exposed person should occur within 72 hours postexposure, especially if additional information about the exposure or source person becomes available.
  • Review Basic Regimens.
  • Review alternate basic regimens.
  • Review preferred expanded regimen.
  • Review Alternate expanded regimens.
  • Antiretroviral agents generally NOT recommended for PEP: Nevirapine Delavirdine Abacavir Zalcitabine Didanosine + stavudine Antiretroviral agents to be used for PEP only with expert consultation: Enfuvirtide
  • As of December 2002, there were no DHCP among the 57 U.S. HCP with documented HIV transmission following a specific exposure to a known HIV-infected source. NO NEW CASES OF OCCUPATIONALLY ACQUIRED HIV/AIDS HAVE BEEN REPORTED SINCE DECEMBER 2001. CDC also has received reports of 139 other HCP considered to have possible occupational HIV transmission; of these, only 6 were DHCP. For each of the 139 persons, no other risk for infection could be identified during follow-up investigation. * Each of the 6 DHCP reported a history of occupational percutaneous or mucous membrane exposure to blood or body fluids in the dental setting, but HIV transmission could not be linked to a specific exposure.
  • The goal of an infection control program is to provide a safe working environment for DHCP and their patients. We can accomplish this by adopting measures that will reduce health care-associated infections among patients and occupational exposures among DHCP.
  • During the provision of dental treatment, both patients and dental health care personnel (DHCP) can be exposed to pathogens through contact with blood, oral and respiratory secretions, and contaminated equipment. Following recommended infection control procedures can prevent transmission of infectious organisms among patients and dental health care personnel.
  • Previous CDC recommendations on infection control for dentistry (1986, 1993) focused on the use of Universal Precautions to prevent transmission of bloodborne pathogens. Universal Precautions were based on the concept that all blood and certain body fluids should be treated as infectious because it is impossible to know who may be carrying a bloodborne virus. Thus, Universal Precautions should apply to all patients. The relevance of Universal Precautions applied to other potentially infectious materials was recognized, and in 1996, CDC replaced Universal Precautions with Standard Precautions. Standard Precautions integrate and expand Universal Precautions to include organisms spread by: Blood. All body fluids, secretions, and excretions except sweat, regardless of whether they contain blood. Non-intact skin. Mucous membranes. Saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between Universal Precautions and Standard Precautions.
  • Standard Precautions include: Handwashing. The use of personal protective equipment, such as gloves, masks, eye protection, and gowns, that are intended to prevent the exposure of skin and mucous membranes to blood and other potentially infectious materials. Proper cleaning and decontamination of patient care equipment. Cleaning and disinfection of environmental surfaces. Injury prevention through engineering controls or safer work practices. Note: OSHA retains the use of the term “Universal Precautions” because they are concerned primarily with transmission of bloodborne pathogens.
  • Each dental office should have a written plan for an infection control program that includes elements to protect personnel. These elements include: Education programs for staff members. Immunization plan for vaccine preventable diseases. Exposure prevention and postexposure management, with follow-up of staff exposed to infectious organisms or potentially harmful materials. Medical condition management and work-related illnesses and restrictions. Maintenance of health records in accordance with all applicable state and federal laws.
  • Bloodborne viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) are of concern to dental health care personnel (DHCP). These viruses: Can be transmitted to patients and health care personnel (HCP) in health care settings. Can produce chronic infection. Are often carried by persons unaware of their infection.
  • This slide shows the average risk of transmission after a single needlestick from an infected patient by type of bloodborne virus. As shown here, risk varies greatly by type of virus. For instance, the risk of HBV transmission after a percutaneous exposure (e.g., needlestick) to HBV-infected blood varies from 1%– 62%, depending on the hepatitis B e-antigen (HBeAg) status of the source patient. If the source patient’s blood is positive for HBeAg (a marker of increased infectivity), the risk of transmission can be as high as 62%. If the patient’s blood is hepatitis B surface antigen (HBsAg) positive but HBeAg negative, the risk varies from 1%– 37%. The average risk of HCV transmission after a percutaneous exposure to HCV-infected blood is 1.8%. The average risk of HIV infection after a percutaneous exposure to HIV-infected blood is 0.3%. To put this in perspective, 1 in 3 needlesticks from an HBeAg+ source patient would result in infection compared to only 1 in 300 needlesticks from an HIV-infected patient.
  • As mentioned earlier, one factor to consider in assessing the risk of infection is the type of body substances to which DHCP are exposed. This slide shows the concentration of HBV in various body fluids. On the left, in red, are the fluids with the highest concentration of virus. Moving from the left to the right side, the concentration decreases. Blood, for instance, has a higher virus concentration than urine or sweat. Saliva alone, without blood, has a moderate concentration of virus.
  • In the early to mid-1980s, health care personnel (HCP) had a much higher incidence (i.e., the number of new infections each year) of HBV infection than the general population. By the early 1990s, however, the incidence among health care personnel had dropped below that found in the general population. This decrease likely is the result of increased use of Universal Precautions and the hepatitis vaccine.
  • Among U.S. dentists, evidence of past HBV infection decreased from prevaccine levels of 14% in 1972 to ~9% in 1989. Since then, levels have remained relatively unchanged. This is because the prevalence (proportion) of HBV infection among all dentists should gradually decrease as older dentists (who are more likely to be infected and unvaccinated than younger dentists) retire.
  • Both Occupational Safety & Health Administration (OSHA) regulations and CDC recommendations state that hepatitis B vaccine should be made available to all DHCP who are exposed to blood or other potentially infectious materials. Employers should provide easy access to a qualified health care professional who can administer the vaccine and provide appropriate follow-up testing. Post-vaccination testing for antibody to hepatitis B surface antigen (anti-HBs) response is indicated for DHCP who have blood or patient contact and are at ongoing risk for injuries with sharp instruments or needlesticks. Post-vaccination testing should be completed one to two months after the 3 rd vaccine dose. Knowledge of antibody response should guide appropriate postexposure prophylaxis.
  • Since the early 1970s, nine clusters involving more than 300 cases of HBV transmission from infected DHCP to patients have been reported. Eight (8) providers tested for hepatitis B e-antigen were positive. Since 1987, however, no cases of DHCP-to-patient transmission of HBV have been reported, probably the result of increased use of Universal or Standard Precautions and increased use of the hepatitis B vaccine. In 2003, the first and only case of patient-to-patient transmission of HBV in a dental office was reported. A later investigation of office procedures indicated that proper infection control precautions were being followed and the exact mechanism of transmission could not be identified.
  • HCV appears not to be efficiently transmitted through occupational exposures. Transmission of HCV generally has been associated with hollow-bore needles and not other sharp instruments. Although studies have not documented transmission associated with mucous membrane or non-intact skin exposure, at least two cases of transmission of HCV from a blood splash to the conjunctiva of the eye have been reported. In 2003, there was a report of simultaneous transmission of HIV and HCV from a nursing home patient to a health care worker. This transmission is thought to have occurred through a non-intact skin exposure. The investigation concluded that consistent use of barrier precautions might have prevented this transmission.
  • Currently, there is little information from which to estimate the occupational risk of HCV infection in dentistry. However, most studies suggest that the prevalence (frequency) of HCV infection among dentists, surgeons, and hospital-based HCP is ~1%–2%, similar to that among the general population. There have been no reports of an HCV transmission from an infected DHCP to a patient or of patient-to-patient transmission of HCV in a dental health care setting. Based on this information, the risk of HCV transmission in dentistry appears very low.
  • To date, transmission of HIV from infected HCP to patients has been documented in only one practice. Investigation of the patients of a Florida dentist with AIDS strongly suggested that HIV was transmitted during dental care to 6 of approximately 1,100 patients tested. Additional evidence supporting the very small risk of HIV transmission to patients comes from investigations conducted in the early 1990s of patients of other HIV-infected HCP. Test results of more than 22,000 patients of 63 HIV-infected HCP, including 33 dentists or dental students, failed to identify any additional cases of transmission.
  • As of December 2002, there were no DHCP among the 57 U.S. HCP with documented HIV transmission following a specific exposure to a known HIV-infected source. CDC also has received reports of 139 other HCP considered to have possible occupational HIV transmission; of these, only 6 were DHCP. For each of the 139 persons, no other risk for infection could be identified during follow-up investigation. * Each of the 6 DHCP reported a history of occupational percutaneous or mucous membrane exposure to blood or body fluids in the dental setting, but HIV transmission could not be linked to a specific exposure.
  • Several factors affect the risk of HIV transmission after an occupational exposure. In a study of health care personnel who had percutaneous exposure to HIV-infected blood, an increased risk for HIV infection was associated with exposure to a relatively large quantity of blood as indicated by deep injury, visible blood on the device, or a procedure involving a needle placed in an artery or vein. The risk was also increased if the exposure was to blood from patients with terminal illness, possibly reflecting the higher titer of HIV in late-stage AIDS.
  • Available information indicates that percutaneous injuries among dentists declined from an average rate of 11 injuries per year in 1987 to <3 injuries per year in 1993. In general, most injuries among general dentists were caused by burs, followed by syringe needles and other sharp instruments. Injuries most often occur while the dentist’s hands are outside the patient’s mouth. Most injuries involve small, rather than large, amounts of blood. The frequency of percutaneous injuries among oral surgeons is similar to that reported among U.S. dentists. Injuries among oral surgeons may occur more frequently during procedures using surgical wire, such as during fracture reductions.
  • Primary methods used to prevent occupational exposures to blood in health care settings include Standard Precautions, engineering controls, work practice controls, and administrative controls. Engineering controls that eliminate or isolate the hazard are the primary strategies for protecting DHCP and patients. Where engineering controls are not available or appropriate, work practice controls that result in safer behavior and personal protective equipment (PPE) can prevent exposure. Administrative controls are policies and procedures that reduce the risk of exposure to certain diseases, such as TB.
  • Engineering controls reduce exposure either by removing, eliminating, or isolating the hazard from the worker. These controls are frequently technology based and often incorporate safer designs of instruments and devices. Examples include the following: Sharps containers. Medical devices with injury protection features, such as self-sheathing needles and scalpels.
  • Work practice controls are behavior based and are intended to reduce the risk of blood exposure by changing the manner in which a task is performed. Examples include the following: Using instruments instead of fingers to retract or palpate tissue during suturing and administration of anesthesia. One-handed needle recapping. Not passing an unsheathed needle to another DHCP.
  • Administrative controls include policies, procedures, and enforcement measures to prevent exposure to disease-causing organisms. The placement of administrative controls in the hierarchy of control measures varies by the problem or disease being addressed. For example, for airborne organisms such as Mycobacterium tuberculosis , these controls rank before engineering controls. In this example, the early identification and referral of dental patients suspected of having TB is the most important prevention strategy.
  • Despite our best efforts, blood exposures will likely continue to occur. Post-exposure management remains an important component of a complete program to prevent infection following exposure to blood. Elements of an effective post-exposure management program include: Policies and procedures that clearly state how to manage exposures. Education of dental health care personnel in prevention strategies (including evaluation of safety devices), principles of post-exposure management, the importance of prompt reporting, and PEP efficacy and toxicity. Resources for rapid access to clinical care, post-exposure prophylaxis, as well as testing of both source patients and exposed health care personnel (preferably with a rapid HIV test). [Comments: Except for institutional settings, coordination with off-site infection control or occupational health services likely will be necessary. A health care professional who is qualified to manage, counsel, and provide medical follow-up should be selected before staff are placed at risk. Ensure that this person is familiar with the dental application of risk assessment and management.]
  • The key elements of post-exposure management include wound management and exposure reporting. The evaluating health care professional should assess the risk of infection by examining the type and severity of exposure, the bloodborne status of the source person, and the susceptibility (immune status) of the exposed person. All of these factors should be considered in assessing the risk of infection and the need for further follow-up (e.g., PEP).
  • Next we turn to the subject of Hand Hygiene. So, is hand hygiene the single most important factor in preventing the spread of pathogens in health care settings? First, hands are the most common mode of pathogen transmission. Hand washing can reduce the spread of antibiotic resistance in health care settings and the likelihood of health care-associated infections. [Additional comments: CDC estimates that each year nearly 2 million patients in the United States acquire infections in hospitals, and about 90,000 of these patients die as a result.]
  • CDC recommends that hands be cleaned: When they are visibly dirty. After touching contaminated objects with bare hands. Before and after patient treatment, that is, before glove placement and immediately after glove removal. Photo credit: Centers for Disease Control and Prevention, Atlanta, GA.
  • Personal protective equipment (PPE), or barrier precautions, are a major component of Standard Precautions. Use of rotary dental and surgical instruments (e.g., handpieces, ultrasonic scalers) and air-water syringes creates a visible spray that contains primarily large-particle droplets of water, saliva, blood, microorganisms, and other debris. This spatter travels only a short distance and settles out quickly, landing either on the floor, operatory surfaces, dental health care personnel (DHCP), or the patient. PPE is essential to protect the skin and the mucous membranes of DHCP from exposure to infectious or potentially infectious materials. PPE should be worn whenever there is potential for contact with spray or spatter and should be removed when leaving treatment areas. Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
  • A standard surgical mask that covers the nose and mouth is worn to protect the mucous membranes from spatter generated during dental procedures. Eye protection with solid side shields or a face shield should also be worn. A mask should be changed between patients or if it becomes wet during patient treatment. Clean reusable face protection with soap and water between patients; if visibly soiled, clean and disinfect.
  • DHCP should wear long-sleeved disposable or reusable gowns, lab coats, or uniforms that cover skin and personal clothing likely to become soiled with blood, saliva, or infectious material (e.g., when spatter and spray of blood, saliva, or other potentially infectious material to the forearms might occur). DHCP should change protective clothing when it becomes visibly soiled or as soon as possible if penetrated by blood or other potentially infectious fluids. All protective clothing should be removed before leaving patient care or laboratory areas. Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
  • Gloves are worn for three reasons: To minimize the risk of health care personnel acquiring infections from patients. To prevent pathogenic organisms from being transmitted from health care personnel to patients. To reduce contamination of health care personnel's hands by organisms that can be transmitted from one patient to another. Wearing gloves does not eliminate or replace the need for hand washing. Hand hygiene should be performed immediately prior to putting on and after removal of gloves. Gloves might have small holes or tears that are not noticeable, or hands can become contaminated as gloves are removed. Such circumstances increase the risk of wound contamination and exposure of the DHCP’s hands to microorganisms from patients.
  • For the protection of DHCP and patients, gloves should always be worn when contact with blood, saliva, and mucous membranes is possible. Gloves should be removed after patient care and hands should be immediately washed. Hands should also be washed before putting gloves on. Photo credit: Centers for Disease Control and Prevention, Atlanta, GA
  • There are three categories of patient-care items depending on their intended use and the potential risk of disease transmission. Critical items penetrate soft tissue or contact bone, the bloodstream, or other normally sterile tissues of the mouth. They have the highest risk of transmitting infection and should be heat-sterilized between patient uses. Alternatively, use sterile, single-use disposable devices. Examples include surgical instruments, periodontal scalers, scalpel blades, and surgical dental burs.
  • Semi-critical items contact only mucous membranes and do not penetrate soft tissues. As such, they have a lower risk of transmission. Because most items in this category are heat-tolerant, they should be heat sterilized between patient uses. For heat-sensitive instruments, high-level disinfection is appropriate. Examples of semi-critical instruments include d ental mouth mirrors, amalgam condensers, and impression trays. Dental handpieces are a special case. Even though they do not penetrate soft tissue, it is difficult for chemical germicides to reach the internal parts of handpieces. For this reason, they should be heat sterilized using a steam autoclave or chemical vapor sterilizer.
  • Noncritical instruments and devices only contact intact (unbroken) skin, which serves as an effective barrier to microorganisms. These items carry such a low risk of transmitting infections that they usually require only cleaning and low-level disinfection. If using a low-level disinfectant, according to OSHA, it must have a label claim for killing HIV and HBV. However, if an item is visibly bloody, it should be cleaned and disinfected using an intermediate-level disinfectant before use on another patient. Examples of instruments in this category include X-ray head/cones, facebows, pulse oximeter, and blood pressure cuff.
  • Cleaning is the basic first step in all decontamination processes. Cleaning involves the physical removal of debris and reduces the number of microorganisms on an instrument or device. If visible debris or organic matter is not removed, it can interfere with the disinfection or sterilization process. Automated or mechanical cleaning equipment, such as ultrasonic cleaners, instrument washers, and washer-disinfectors, are commonly used to clean dental instruments. Automated cleaners increase the efficiency of the cleaning process and reduce the handling of sharp instruments. After cleaning, instruments should be rinsed with water to remove chemical or detergent residue. Photo credit: Chris Miller, PhD, Indiana University School of Dentistry.
  • If manual cleaning is necessary, soak instruments in a rigid container filled with detergent, disinfectant/detergent, or an enzymatic cleaner. This step prevents drying of patient material and makes cleaning easier and less time consuming. Do not use high-level disinfectants/sterilants (e.g., glutaraldehyde) as instrument-holding solutions. To avoid injury from sharp instruments, personnel should wear puncture-resistant, heavy-duty, utility gloves (i.e., not patient care gloves) when handling or manually cleaning contaminated instruments and devices. To protect against splashes, a facemask, eye protection or face shield, and a gown or jacket should be worn. Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
  • After thorough cleaning and drying of instruments, critical and semi-critical instruments that will be stored before use should be wrapped or placed into container systems prior to heat sterilization. This step protects items from contamination after the sterilization cycle and during storage. Open or unlock hinged instruments so that all surfaces are exposed. Place a chemical indicator inside each wrapped package. If the indicator cannot be seen from the outside, place another indicator (e.g., indicator tape) on the outside of the package. Always wear heavy-duty, puncture-resistant utility gloves while inspecting and packaging instruments.
  • There are three types of heat sterilization methods commonly used in dentistry. Steam under pressure (autoclaving). There are two types of tabletop steam autoclaves: In most commonly used gravity displacement sterilizers, steam enters the chamber and unsaturated air is forced out of the chamber through a vent in the chamber wall. In contrast, pre-vacuum sterilizers are fitted with a vacuum pump to create a vacuum in the chamber and ensure air removal from the sterilizing chamber and load before the chamber is pressurized with steam. This method improves the speed and efficiency of the sterilization process. Dry heat sterilizers are either static air (convection or FDA-approved oven type) or forced air (rapid heat-transfer). Unsaturated chemical vapor sterilizers use a proprietary formula of alcohol/formaldehyde. With all of these methods, always use FDA-approved devices and closely follow the manufacturer’s instructions for proper use.
  • Heat-sensitive instruments can be sterilized or high-level disinfected by soaking them in a liquid chemical germicide cleared by the FDA. However, exposure to these powerful and toxic chemicals can be harmful to DHCP and patients if the manufacturer’s instructions for use and safety precautions are not followed precisely. For these reasons, CDC encourages the use of heat-tolerant or disposable alternatives. Photo credit: Col. Shannon Mills, United States Air Force.
  • DHCP have a choice about how they maintain their instrument storage area — either date- or event-related shelf-life practices. In date-related packing, every sterilized package is expiration-dated and the instruments are used on a “first in, first out” basis. In event-related practice, the contents of a sterilized package should remain sterile indefinitely unless some event, for example, torn or wet packaging material, causes it to become potentially contaminated. It is still useful to place the date of sterilization and identify the sterilizer used if multiple sterilizers are utilized in the office. In case of sterilization failure, this information would facilitate retrieval of processed items. Examine each package. If it is damaged in any way, items should be re-cleaned, re-wrapped, and re-sterilized. Even if an event-related approach is used, all packages should be labeled with the date of sterilization and which sterilizer was used, should a sterilization failure occur. Store all sterile and clean items and supplies in dry, closed, or covered cabinets.
  • Environmental surfaces can become contaminated with microorganisms during patient care, although they have not been associated directly with disease transmission to patients or DHCP. Environmental surfaces do not require decontamination procedures as stringent as those used on patient care items.
  • There are two categories of environmental surfaces. Clinical contact surfaces have a high potential for direct contamination from patient materials either by direct spray or spatter generated during dental procedures or by contact with DHCP’s gloved hand. These surfaces can later contaminate other instruments, devices, hands, or gloves. Housekeeping surfaces do not come into contact with patients or devices used in dental procedures. Therefore, they have a limited risk of disease transmission.
  • This slide shows some examples of clinical contact surfaces, including a light handle, countertop, bracket tray, dental chair, and door handle (shown by arrows). Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
  • Use appropriate protective barriers such as heavy-duty utility gloves, masks, and protective eyewear when cleaning and disinfecting surfaces. In general, cleaning and removal of microorganisms is as important as the disinfection process itself. Blood or other patient materials left on surfaces can interfere with the disinfecting process. Follow the manufacturer’s instructions for proper storage, dilution, and use of hospital disinfectants. Because of their toxic nature, the use of sterilants or high-level disinfectants on environmental surfaces is NOT recommended.
  • Because clinical contact surfaces come into direct contact with contaminated gloves, instruments, spray or spatter, their risk of transmitting infection is greater than for housekeeping surfaces. These surfaces can subsequently contaminate other instruments, devices, hands, or gloves. Surface barriers can be used to protect clinical contact surfaces and changed between patients. Surface barriers are particularly useful for surfaces that are hard to clean, such as switches on dental chairs. This practice will also reduce exposure to harmful chemical disinfectants. If surface barriers cannot be used, clean and then disinfect the surface with an EPA-registered hospital disinfectant effective against HIV and HBV (low-level disinfectant). If the surface is visibly contaminated with blood or other patient material, clean and then disinfect the surface with an EPA-registered hospital disinfectant with a tuberculocidal claim (intermediate-level disinfectant).
  • Housekeeping surfaces carry the least risk for transmitting infections in dental settings. On a routine basis, these surfaces should be either cleaned with soap and water or an EPA-registered detergent/hospital disinfectant. Wet mops and cloths may become contaminated with microorganisms, so clean the mop and cloths after use and allow them to dry thoroughly before re-using. Prepare fresh cleaning and disinfecting solutions daily and per manufacturer recommendations.
  • There is no evidence that traditional medical waste management has contributed to increased levels of disease in the community or among health care personnel. The majority of waste generated in a medical or dental office (~98%–99%) is not considered infectious and can be discarded in the regular trash. Examples include used gloves, masks, and lightly bloodied gauze. Some waste, such as used needles, extracted teeth, and gauze soaked in blood, may pose a potential risk of infection, however, and warrants special precautions during handling and disposal. Follow federal, state, and local regulations for proper treatment and disposal.
  • Regulated medical waste requires careful containment for treatment or disposal. A single leak-resistant biohazard bag is usually adequate to contain non-sharp, regulated medical waste. Puncture-resistant containers with a biohazard label, such as sharps containers, are used as containment for scalpel blades, needles, syringes, and unused sterile sharps. Medical waste, both nonregulated and regulated, should be stored and disposed of in accordance with federal, state, and local EPA regulations. Treatment of regulated waste can involve on-site or off-site autoclaving and incineration. Never include extracted teeth with amalgam in regulated waste when disposed by one of these methods. Photo credit: NIOSH Web site.
  • post exposure management and infection control

    1. 1. Theresa G. Mayfield, D.M.D. University of Louisville School of Dentistry Department of Diagnostic Sciences, Prosthodontics and Restorative Dentistry Post-exposure Management and Infection Control
    2. 2. Case <ul><li>Mr. Wright presents for routine restorative care in the University of Louisville School of Dentistry dental clinic. Dr. Blue has just completed a composite restoration on #9. As Dr. Blue is moving the bracket table to get up from his chair, the back of his forearm is stuck with a 7901 bur. The bur was used to finish the facial subgingival margin and is laden with debris and blood. </li></ul>
    3. 3. Questions <ul><li>Has an occupational exposure occurred? </li></ul><ul><li>What are the next steps? </li></ul><ul><li>What strategies might be employed to minimize the risk of future injuries? </li></ul>
    4. 4. Has an occupational exposure occurred?
    5. 5. Occupational Exposure Incident <ul><li>Specific eye, mouth, other mucous membrane, non-intact skin or parenteral contact with blood/OPIM (including saliva in dental settings) resulting from performance duties </li></ul>
    6. 6. 2007 Bloodborne Pathogen Incident Analysis <ul><li>Type of incident How occurred # Percent </li></ul><ul><li>Needle Stick While giving local anesthesia 10 40.0 </li></ul><ul><li>During clean-up 2 8.0 </li></ul><ul><li>Unknown 1 4.0 </li></ul><ul><li>Suture Needle While suturing 1 4.0 </li></ul><ul><li>Scalpel Blade During clean-up 1 4.0 </li></ul><ul><li>Bur/Cavitron tip Stick During treatment While using 1 4.0 </li></ul><ul><li> Reaching past bracket table 2 8.0 </li></ul><ul><li> Walking past bracket table 1 4.0 </li></ul><ul><li> Clean-up 1 4.0 </li></ul><ul><li> During handling in sterilization 1 4.0 </li></ul><ul><li>Instrument Stick During patient treatment 1 4.0 </li></ul><ul><li>During clean up 1 4.0 </li></ul><ul><li>During handling in sterilization 1 4.0 </li></ul><ul><li>Bite While taking radiographs by child 1 4.0 </li></ul><ul><li>Total 25 100.0 </li></ul>
    7. 7. What are the next steps?
    8. 8. PEP Steps <ul><li>Treat the exposure site </li></ul><ul><li>Report and document </li></ul><ul><li>Evaluate the exposure </li></ul><ul><li>Evaluate the exposure source </li></ul><ul><li>Disease-specific PEP management </li></ul>
    9. 9. Occupational Exposures
    10. 10. Wound care 1 Postecxposure Management
    11. 11. <ul><li>Clean wounds with soap and water </li></ul><ul><li>Flush mucous membranes with water </li></ul><ul><li>No benefit to: </li></ul><ul><ul><ul><li>-applying of antiseptics or disinfectants </li></ul></ul></ul><ul><ul><ul><li>-squeezing (“milking”) puncture sites </li></ul></ul></ul><ul><li>Avoid use of bleach and other agents caustic to skin </li></ul>Postecxposure Management
    12. 12. Notify one of the attending faculty of the incident 2 Postecxposure Management
    13. 13. Both you and the attending faculty let the patient know of the incident and educate the patient of the importance for blood testing and follow up 3 Postecxposure Management
    14. 14. <ul><ul><li>Go to the Clinical Affairs Office and get the proper paperwork to fill out and take to the ACB </li></ul></ul>4 Postexposure Management
    15. 15. Postexposure Management: The Exposure Report <ul><li>Date and time of exposure </li></ul><ul><li>Procedure details…what, where, how, with what device </li></ul><ul><li>Exposure details...route, body substance involved, volume/duration of contact </li></ul><ul><li>Exposure management details </li></ul><ul><ul><li>The reports are numbered for accounting purposes and to ensure all follow-up paperwork gets completed </li></ul></ul><ul><li>All reports are kept confidential </li></ul>
    16. 16. Go to the ACB for baseline testing for exposed individual and patient 5 Postecxposure Management
    17. 17. Exposure Incident Reporting <ul><li>We have a referral protocol in place – The ACB </li></ul><ul><li>Refer for testing and follow-up counseling </li></ul>
    18. 18. Prevention Prophylaxis Occupational Exposure
    19. 19. Risk of Infection <ul><li>Following a specific exposure, the risk of infection vary with factors such as: </li></ul><ul><li>The pathogen involved </li></ul><ul><li>The type of exposure </li></ul><ul><li>The amount of blood involved in the exposure </li></ul><ul><li>The amount of virus in the patient's blood at the time of exposure </li></ul>Department of Health & Human Services. CDC. Brochure. Exposure to Blood - What Health-Care Workers Need to Know, 2003 CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17.
    20. 20. <ul><li>Approximately 0.3% following percutaneous exposure </li></ul><ul><li>Approximately 0.09% following mucous membrane exposure </li></ul>Risk of HIV Infection Following Occupational Exposure to HIV-Infected Blood CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17.
    21. 21. Evaluate the Exposure <ul><li>The exposure should be evaluated for potential to transmit HBV, HCV, or HIV based on the type of body substance involved, the route, and the severity of exposure. </li></ul>
    22. 22. Evaluate the Exposure <ul><li>Factors to consider: </li></ul><ul><ul><li>Type of exposure </li></ul></ul><ul><ul><ul><li>Percutaneous injury </li></ul></ul></ul><ul><ul><ul><li>Mucous membrane exposure </li></ul></ul></ul><ul><ul><ul><li>Nonintact skin exposure </li></ul></ul></ul><ul><ul><ul><li>Bites involving blood </li></ul></ul></ul><ul><ul><li>Type and amount of fluid tissue </li></ul></ul><ul><ul><ul><li>Blood </li></ul></ul></ul><ul><ul><ul><li>Fluids containing blood </li></ul></ul></ul><ul><ul><ul><li>Potentially infectious fluid or tissue </li></ul></ul></ul><ul><ul><ul><li>Direct contact with concentrated virus </li></ul></ul></ul>
    23. 23. Evaluate the Exposure <ul><li>Factors to consider: </li></ul><ul><ul><li>Infectious status of the patient </li></ul></ul><ul><ul><ul><li>HBV </li></ul></ul></ul><ul><ul><ul><li>HCV </li></ul></ul></ul><ul><ul><ul><li>HIV </li></ul></ul></ul><ul><ul><li>Susceptibility of exposed HCP </li></ul></ul><ul><ul><ul><li>Hepatitis B vaccine and response status </li></ul></ul></ul><ul><ul><ul><li>HBV,HCV,HIV status- baseline testing as soon as possible </li></ul></ul></ul>
    24. 24. Evaluate the Exposure Source <ul><li>Test patient for: </li></ul><ul><ul><li>HBsAg </li></ul></ul><ul><ul><li>HCV antibody </li></ul></ul><ul><ul><li>HIV antibody </li></ul></ul><ul><li>When source patient is not known evaluate the likelihood of high risk exposure </li></ul>
    25. 25. Average Risk of Transmission after Percutaneous Exposure to Blood HIV Hepatitis C Hepatitis B (only HBeAg+) HBeAg- 0.3 1.8 30.0 6.0 Risk (%) Source
    26. 26. Initiating PEP <ul><li>PEP should be started as soon as possible, preferably within hours, rather than days, following exposure </li></ul><ul><li>When uncertain as to which drugs to choose, start the basic regimen rather than delay </li></ul><ul><li>PEP should be administered for 4 weeks, if tolerated </li></ul>CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17. http://www.aidsetc.org
    27. 27. Initiating PEP <ul><li>Reevaluate exposed HCP within 72 hours of exposure, especially as additional information about the exposure or source patient becomes available </li></ul><ul><li>If the source is found to be negative, PEP should be discontinued </li></ul><ul><li>Rapid HIV testing of the source patient can facilitate decisions regarding PEP when the source patient’s HIV status is unknown </li></ul>CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17. http://www.aidsetc.org
    28. 28. Selecting the PEP regimen <ul><li>Selection of number (2 or ≥ 3) of drugs is based on assessment of risk for HIV infection </li></ul><ul><li>Selection of which agents to use is based largely on potential toxicity of PEP drugs and on likelihood of efficacy (especially in the case of resistant virus) </li></ul><ul><ul><li>few data on efficacy of individual antiretroviral agents in PEP </li></ul></ul>CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17. http://www.aidsetc.org
    29. 29. How Many Drugs to Use? <ul><li>Two-drug PEP regimens improve tolerability and therefore chances of completing full 4 weeks </li></ul><ul><li>Three- (or more) drug PEP regimens provide potentially greater antiviral activity </li></ul><ul><li>Guidelines recommend more drugs for higher risk exposures </li></ul>CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17. http://www.aidsetc.org
    30. 30. Which Drugs to Use? <ul><li>Consultation with an expert is recommended </li></ul><ul><li>Regimens should be chosen to minimize potential drug toxicities and maximize the likelihood of adherence </li></ul><ul><li>Consideration should be given to the history of the source person, including history of and response to antiretroviral therapy and disease stage </li></ul>CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17. http://www.aidsetc.org
    31. 31. Basic and Expanded HIV Postexposure Prophylaxis Regimens <ul><li>Basic Regimens: </li></ul>CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17.
    32. 32. Basic and Expanded HIV Postexposure Prophylaxis Regimens <ul><li>Alternate Basic Regimens: </li></ul>CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17.
    33. 33. Basic and Expanded HIV Postexposure Prophylaxis Regimens <ul><li>Preferred Expanded Regimen: </li></ul><ul><ul><li>Basic Regimen + the following: </li></ul></ul>CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17.
    34. 34. Basic and Expanded HIV Postexposure Prophylaxis Regimens <ul><li>Alternate expanded regimen: </li></ul><ul><ul><li>Basic Regimen + one of the following: </li></ul></ul>CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17.
    35. 35. Basic and Expanded HIV Postexposure Prophylaxis Regimens <ul><li>Antiretroviral agents generally NOT recommended for PEP: </li></ul><ul><li>Nevirapine </li></ul><ul><li>Delavirdine </li></ul><ul><li>Abacavir </li></ul><ul><li>Zalcitabine </li></ul><ul><li>Didanosine + stavudine </li></ul><ul><li>Antiretroviral agents to be used for PEP only with expert consultation: </li></ul><ul><li>Enfuvirtide </li></ul>CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17. http://www.aidsetc.org
    36. 36. Selection of Drugs for PEP: Consultation is Part of the Guideline <ul><li>“Because of the complexity of selecting HIV PEP regimens, when possible, these recommendations should be implemented in consultation with persons having expertise in antiretroviral therapy and HIV transmission” </li></ul>CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 2005;54(No. RR-9):1--17. http://www.aidsetc.org
    37. 37. Healthcare personnel with documented and possible occupationally acquired AIDS/HIV Infection (2002) 139 57 Total 5 - Other healthcare occupation 9 - Other technician/therapist 6 - Physician, surgical 12 - Emergency medical technician/paramedic 6 - Dental worker, including dentist 3 1 Technician, dialysis 2 1 Respiratory therapist 15 1 Health aide/attendant 2 1 Embalmer/morgue technician 2 2 Technician, surgical 13 2 Housekeeper/maintenance worker - 3 Laboratory technician, nonclinical 12 6 Physician, nonsurgical 17 16 Laboratory worker, clinical 35 24 Nurse Possible Documented Occupation
    38. 38. What strategies might be employed to minimize the risk of future injuries?
    39. 39. Guidelines for Infection Control in Dental Health-Care Settings—2003 CDC. MMWR 2003;52(No. RR-17) http://www.cdc.gov/oralhealth/ infectioncontrol/guidelines/index.htm
    40. 40. Infection Control Program Goals <ul><li>Provide a safe working environment </li></ul><ul><ul><li>Reduce health care-associated infections </li></ul></ul><ul><ul><li>Reduce occupational exposures </li></ul></ul>
    41. 41. Why Is Infection Control Important in Dentistry? <ul><li>Both patients and dental health care personnel (DHCP) can be exposed to pathogens </li></ul><ul><li>Contact with blood, oral and respiratory secretions, and contaminated equipment occurs </li></ul><ul><li>Proper procedures can prevent transmission of infections among patients and DHCP </li></ul>
    42. 42. Standard Precautions <ul><li>Apply to all patients </li></ul><ul><li>Integrate and expand Universal Precautions to include organisms spread by blood and also </li></ul><ul><ul><li>Body fluids, secretions, and excretions except sweat, whether or not they contain blood </li></ul></ul><ul><ul><li>Non-intact (broken) skin </li></ul></ul><ul><ul><li>Mucous membranes </li></ul></ul>
    43. 43. Elements of Standard Precautions <ul><li>Handwashing </li></ul><ul><li>Use of gloves, masks, eye protection, and gowns </li></ul><ul><li>Patient care equipment </li></ul><ul><li>Environmental surfaces </li></ul><ul><li>Injury prevention </li></ul>
    44. 44. Personnel Health Elements of an Infection Control Program <ul><li>Education and training </li></ul><ul><li>Immunizations </li></ul><ul><li>Exposure prevention and postexposure management </li></ul><ul><li>Medical condition management and work-related illnesses and restrictions </li></ul><ul><li>Health record maintenance </li></ul>
    45. 45. Preventing Transmission of Bloodborne Pathogens <ul><li>Are transmissible in health care settings </li></ul><ul><li>Can produce chronic infection </li></ul><ul><li>Are often carried by persons unaware of their infection </li></ul>Bloodborne viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV)
    46. 46. Average Risk of Bloodborne Virus Transmission after Needlestick 0.3% (0.2%-0.5% range) HIV 1.8% (0%-7% range) HCV 1.0%-6.0% clinical hepatitis; 23%-37% serological evidence of HBV infection HBsAg + and HBeAg - 22.0%-31.0% clinical hepatitis; 37%-62% serological evidence of HBV infection HBsAg + and HBeAg + HBV Risk Source
    47. 47. Concentration of HBV in Body Fluids <ul><li>High Moderate Low/Not Detectable </li></ul><ul><li>Blood Semen Urine </li></ul><ul><li>Serum Vaginal Fluid Feces </li></ul><ul><li>Wound exudates Saliva Sweat </li></ul><ul><li> Tears </li></ul><ul><li> Breast Milk </li></ul>
    48. 48. Estimated Incidence of HBV Infections Among HCP and General Population, United States, 1985-1999 Health Care Personnel General U.S. Population
    49. 49. Source: Cleveland et al., JADA 1996;127:1385-90. Personal communication ADA, Chakwan Siew, PhD, 2005. Percent HBV Infection Among U.S. Dentists Year
    50. 50. Hepatitis B Vaccine <ul><ul><li>Vaccinate all DHCP who are at risk of exposure to blood </li></ul></ul><ul><ul><li>Provide access to qualified health care professionals for administration and follow-up testing </li></ul></ul><ul><ul><li>Test for anti-HBs 1 to 2 months after 3rd dose </li></ul></ul>
    51. 51. Transmission of HBV from Infected DHCP to Patients <ul><li>Nine clusters of transmission from dentists and oral surgeons to patients, 1970–1987 </li></ul><ul><li>Eight dentists tested for HBeAg were positive </li></ul><ul><li>Lack of documented transmissions since 1987 may reflect increased use of gloves and vaccine </li></ul><ul><li>One case of patient-to-patient transmission, 2003 </li></ul>
    52. 52. Occupational Risk of HCV Transmission among HCP <ul><li>Inefficiently transmitted by occupational exposures </li></ul><ul><li>Three reports of transmission from blood splash to the eye </li></ul><ul><li>Report of simultaneous transmission of HIV and HCV after non-intact skin exposure </li></ul>
    53. 53. HCV Infection in Dental Health Care Settings <ul><li>Prevalence of HCV infection among dentists similar to that of general population (~ 1%-2%) </li></ul><ul><li>No reports of HCV transmission from infected DHCP to patients or from patient to patient </li></ul><ul><li>Risk of HCV transmission appears very low </li></ul>
    54. 54. Transmission of HIV from Infected Dentists to Patients <ul><li>Only one documented case of HIV transmission from an infected dentist to patients </li></ul><ul><li>No transmissions documented in the investigation of 63 HIV-infected HCP (including 33 dentists or dental students) </li></ul>
    55. 55. Health Care Workers with Documented and Possible Occupationally Acquired HIV/AIDS CDC Database as of December 2002 * 3 dentists, 1 oral surgeon, 2 dental assistants Documented Possible Dental Worker 0 6 * Nurse 24 35 Lab Tech, clinical 16 17 Physician, nonsurgical 6 12 Lab Tech, nonclinical 3 – Other 8 69 Total 57 139
    56. 56. Risk Factors for HIV Transmission after Percutaneous Exposure to HIV-Infected Blood CDC Case-Control Study <ul><li>Deep injury </li></ul><ul><li>Visible blood on device </li></ul><ul><li>Needle placed in artery or vein </li></ul><ul><li>Terminal illness in source patient </li></ul><ul><li>Source: Cardo, et al., N England J Medicine 1997;337:1485-90. </li></ul>
    57. 57. Characteristics of Percutaneous Injuries Among DHCP <ul><li>Reported frequency among general dentists has declined </li></ul><ul><li>Caused by burs, syringe needles, other sharps </li></ul><ul><li>Occur outside the patient’s mouth </li></ul><ul><li>Involve small amounts of blood </li></ul><ul><li>Among oral surgeons, occur more frequently during fracture reductions and procedures involving wire </li></ul>
    58. 58. Exposure Prevention Strategies <ul><li>Engineering controls </li></ul><ul><li>Work practice controls </li></ul><ul><li>Administrative controls </li></ul>
    59. 59. Engineering Controls <ul><li>Isolate or remove the hazard </li></ul><ul><li>Examples: </li></ul><ul><ul><li>Sharps container </li></ul></ul><ul><ul><li>Medical devices with injury protection features (e.g., self-sheathing needles) </li></ul></ul>
    60. 60. Work Practice Controls <ul><ul><li>Change the manner of performing tasks </li></ul></ul><ul><ul><li>Examples include: </li></ul></ul><ul><ul><ul><li>Using instruments instead of fingers to retract or palpate tissue </li></ul></ul></ul><ul><ul><ul><li>One-handed needle recapping </li></ul></ul></ul>
    61. 61. Administrative Controls <ul><li>Policies, procedures, and enforcement measures </li></ul><ul><li>Placement in the hierarchy varies by the problem being addressed </li></ul><ul><ul><li>Placed before engineering controls for airborne precautions (e.g., TB) </li></ul></ul>
    62. 62. Post-exposure Management Program <ul><li>Clear policies and procedures </li></ul><ul><li>Education of dental health care personnel (DHCP) </li></ul><ul><li>Rapid access to </li></ul><ul><ul><li>Clinical care </li></ul></ul><ul><ul><li>Post-exposure prophylaxis (PEP) </li></ul></ul><ul><ul><li>Testing of source patients/HCP </li></ul></ul>
    63. 63. <ul><li>Wound management </li></ul><ul><li>Exposure reporting </li></ul><ul><li>Assessment of infection risk </li></ul><ul><ul><li>Type and severity of exposure </li></ul></ul><ul><ul><li>Bloodborne status of source person </li></ul></ul><ul><ul><li>Susceptibility of exposed person </li></ul></ul>Post-exposure Management
    64. 64. Hand Hygiene
    65. 65. Why Is Hand Hygiene Important? <ul><li>Hands are the most common mode of pathogen transmission </li></ul><ul><li>Reduce spread of antimicrobial resistance </li></ul><ul><li>Prevent health care-associated infections </li></ul>
    66. 66. Hands Need to be Cleaned When <ul><li>Visibly dirty </li></ul><ul><li>After touching contaminated objects with bare hands </li></ul><ul><li>Before and after patient treatment (before glove placement and after glove removal) </li></ul>
    67. 67. Personal Protective Equipment
    68. 68. Personal Protective Equipment <ul><li>A major component of Standard Precautions </li></ul><ul><li>Protects the skin and mucous membranes from exposure to infectious materials in spray or spatter </li></ul><ul><li>Should be removed when leaving treatment areas </li></ul>
    69. 69. Masks, Protective Eyewear, Face Shields <ul><li>Wear a surgical mask and either eye protection with solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouth </li></ul><ul><li>Change masks between patients </li></ul><ul><li>Clean reusable face protection between patients; if visibly soiled, clean and disinfect </li></ul>
    70. 70. Protective Clothing <ul><li>Wear gowns, lab coats, or uniforms that cover skin and personal clothing likely to become soiled with blood, saliva, or infectious material </li></ul><ul><li>Change if visibly soiled </li></ul><ul><li>Remove all barriers before leaving the work area </li></ul>
    71. 71. Gloves <ul><li>Minimize the risk of health care personnel acquiring infections from patients </li></ul><ul><li>Prevent microbial flora from being transmitted from health care personnel to patients </li></ul><ul><li>Reduce contamination of the hands of health care personnel by microbial flora that can be transmitted from one patient to another </li></ul><ul><li>Are not a substitute for handwashing! </li></ul>
    72. 72. Recommendations for Gloving <ul><li>Wear gloves when contact with blood, saliva, and mucous membranes is possible </li></ul><ul><li>Remove gloves after patient care </li></ul><ul><li>Wear a new pair of gloves for each patient </li></ul>
    73. 73. Sterilization and Disinfection of Patient Care Items
    74. 74. Critical Instruments <ul><li>Penetrate mucous membranes or contact bone, the bloodstream, or other normally sterile tissues (of the mouth) </li></ul><ul><li>Heat sterilize between uses or use sterile single-use, disposable devices </li></ul><ul><li>Examples include surgical instruments, scalpel blades, periodontal scalers, and surgical dental burs </li></ul>
    75. 75. Semi-critical Instruments <ul><li>Contact mucous membranes but do not penetrate soft tissue </li></ul><ul><li>Heat sterilize or high-level disinfect </li></ul><ul><li>Examples: Dental mouth mirrors, amalgam condensers, and dental handpieces </li></ul>
    76. 76. Noncritical Instruments and Devices <ul><li>Contact intact skin </li></ul><ul><li>Clean and disinfect using a low to intermediate level disinfectant </li></ul><ul><li>Examples: X-ray heads, facebows, pulse oximeter, blood pressure cuff </li></ul>
    77. 77. Automated Cleaning <ul><li>Ultrasonic cleaner </li></ul><ul><li>Instrument washer </li></ul><ul><li>Washer-disinfector </li></ul>
    78. 78. Manual Cleaning <ul><li>Soak until ready to clean </li></ul><ul><li>Wear heavy-duty utility gloves, mask, eyewear, and protective clothing </li></ul>
    79. 79. Preparation and Packaging <ul><li>Critical and semi-critical items that will be stored should be wrapped or placed in containers before heat sterilization </li></ul><ul><li>Hinged instruments opened and unlocked </li></ul><ul><li>Place a chemical indicator inside the pack </li></ul><ul><li>Wear heavy-duty, puncture-resistant utility gloves </li></ul>
    80. 80. Heat-Based Sterilization <ul><li>Steam under pressure (autoclaving) </li></ul><ul><ul><li>Gravity displacement </li></ul></ul><ul><ul><li>Pre-vacuum </li></ul></ul><ul><li>Dry heat </li></ul><ul><li>Unsaturated chemical vapor </li></ul>
    81. 81. Liquid Chemical Sterilant/Disinfectants <ul><li>Only for heat-sensitive critical and semi-critical devices </li></ul><ul><li>Powerful, toxic chemicals raise safety concerns </li></ul><ul><li>Heat tolerant or disposable alternatives are available </li></ul>
    82. 82. Storage of Sterile and Clean Items and Supplies <ul><li>Use date- or event-related shelf-life practices </li></ul><ul><li>Examine wrapped items carefully prior to use </li></ul><ul><li>When packaging of sterile items is damaged, re-clean, re-wrap, and re-sterilize </li></ul><ul><li>Store clean items in dry, closed, or covered containment </li></ul>
    83. 83. Environmental Infection Control
    84. 84. Environmental Surfaces <ul><li>May become contaminated </li></ul><ul><li>Not directly involved in infectious disease transmission </li></ul><ul><li>Do not require as stringent decontamination procedures </li></ul>
    85. 85. Categories of Environmental Surfaces <ul><li>Clinical contact surfaces </li></ul><ul><ul><li>High potential for direct contamination from spray or spatter or by contact with DHCP’s gloved hand </li></ul></ul><ul><li>Housekeeping surfaces </li></ul><ul><ul><li>Do not come into contact with patients or devices </li></ul></ul><ul><ul><li>Limited risk of disease transmission </li></ul></ul>
    86. 86. Clinical Contact Surfaces
    87. 87. General Cleaning Recommendations <ul><li>Use barrier precautions (e.g., heavy-duty utility gloves, masks, protective eyewear) when cleaning and disinfecting environmental surfaces </li></ul><ul><li>Physical removal of microorganisms by cleaning is as important as the disinfection process </li></ul><ul><li>Follow manufacturer’s instructions for proper use of EPA-registered hospital disinfectants </li></ul><ul><li>Do not use sterilant/high-level disinfectants on environmental surfaces </li></ul>
    88. 88. Cleaning Clinical Contact Surfaces <ul><li>Risk of transmitting infections greater than for housekeeping surfaces </li></ul><ul><li>Surface barriers can be used and changed between patients </li></ul><ul><li>OR </li></ul><ul><li>Clean then disinfect using an EPA-registered low- (HIV/HBV claim) to intermediate-level (tuberculocidal claim) hospital disinfectant </li></ul>
    89. 89. Cleaning Housekeeping Surfaces <ul><li>Routinely clean with soap and water or an EPA-registered detergent/hospital disinfectant routinely </li></ul><ul><li>Clean mops and cloths and allow to dry thoroughly before re-using </li></ul><ul><li>Prepare fresh cleaning and disinfecting solutions daily and per manufacturer recommendations </li></ul>
    90. 90. Medical Waste <ul><li>Medical Waste: Not considered infectious, thus can be discarded in regular trash </li></ul><ul><li>Regulated Medical Waste: Poses a potential risk of infection during handling and disposal </li></ul>
    91. 91. Regulated Medical Waste Management <ul><li>Properly labeled containment to prevent injuries and leakage </li></ul><ul><li>Medical wastes are “treated” in accordance with state and local EPA regulations </li></ul><ul><li>Processes for regulated waste include autoclaving and incineration </li></ul>
    92. 92. Special Considerations <ul><li>Dental handpieces and other devices attached to air and waterlines </li></ul><ul><li>Dental radiology </li></ul><ul><li>Aseptic technique for parenteral medications </li></ul><ul><li>Single-use (disposable) Devices </li></ul><ul><li>Preprocedural mouth rinses </li></ul><ul><li>Oral surgical procedures </li></ul><ul><li>Handling biopsy specimens </li></ul><ul><li>Handling extracted teeth </li></ul><ul><li>Laser/electrosurgery plumes or surgical smoke </li></ul><ul><li>Dental laboratory </li></ul><ul><li>Mycobacterium tuberculosis </li></ul><ul><li>Creutzfeldt-Jacob Disease (CJD) and other prion-related diseases </li></ul>
    93. 93. Infection Control Protocols <ul><li>Apply to faculty, staff, and students </li></ul><ul><li>Annual Updates </li></ul><ul><li>Online clinic manual </li></ul>CDC Guidelines – MMWR October 25 2002/51(RR16);1-44
    94. 94. Contact Information <ul><li>Theresa G. Mayfield D.M.D. </li></ul><ul><li>Associate Professor </li></ul><ul><li>University of Louisville School of Dentistry </li></ul><ul><li>[email_address] </li></ul>

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