EXPOSURE CONTROL PLAN
FOR
OCCUPATIONAL EXPOSURE TO BLOODBORNE PATHOGENS (BBP)
FOR THE
U.S. ENVIRONMENTAL PROTECTION AGENCY
NATIONAL ENFORCEMENT INVESTIGATIONS CENTER
(NEIC)
PREPARED BY
U.S. PUBLIC HEALTH SERVICE
DIVISION OF FEDERAL EMPLOYEE OCCUPATIONAL HEALTH
REGION VIII
FEBRUARY 23, 1993
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EXPOSURE CONTROL PLAN
FOR
NEIC OCCUPATIONAL EXPOSURE TO BLOODBORNE PATHOGENS
TABLE OF CONTENTS
SECTIONS : PAGE
INTRODUCTION 1
EXPOSURE DETERNINATION
METHODS OF COMPLIANCE 8
EXPOSURE INCIDENT 16
TRAINING 17
RECORDKEEPING 19
BIOHAZARD WASTE 21
APPENDICES :
A. OSHA Bloodborne Pathogens Standard (1910.1030).
B. Exposure Incident and Treatment Packet
C. Hepatitis B.Availability Vaccination Information
D. Reference Information on Hepatitis B Infections from MMWR.
E. Optional Post-Exposure Testing for Human Ixnmunodeficiency
Virus (HIV): Information and Consent/Declination Forms
F. Reference Information on HIV Infections from MNWR.
G. Training Packet
H. Information for Ordering Approved Sharps Containers.
I. California Morbidity Report - Information on Exposure Risk
From Waste Water and Sewage
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NEIC Exposure Control Plaxv Bloodborne Pathogen Exposures Page 1
SECTION I:
INTRODUCTION
This Exposure Control Plan for Occupational Bloodborne Pathogen
(BBP) Exposure has been developed for the U.S. Environmental
Protection Agency, National Enforcement Investigations Center
(NEIC), by the U.S. Public Health Service (PHS), Division of
Federal Occupational Health (FOH). The document has been
developed in accordance with the CDC guidelines and the OSHA
Bloodborne Pathogens Standard (1910.1030) to protect all NEIC
employees from occupational exposure to blood or other
potentially infectious materials. A copy of the Standard is
included in Appendix A.
The document is presented in seven main sections:
I. Introduction
II. Exposure Determination
This section presents a method for determining bloodborne
pathogen exposure risks for NEIC employees. A list of NEIC
job classifications has been compiled in which employees may
be potentially exposed to bloodborne pathogens. In some
instances, specific tasks and procedures have also been
identified in which occupational exposure may reasonably be
expected to occur. In addition, there may be other
potential occupational exposure settings not covered by
these lists.
III. Methods of Compliance
This section discusses work practice controls which shall be
used to minimize or eliminate employee exposure. Included
in this section is the use, accessibility, cleaning, repair
and replacement, and disposal of personal protective
equipment (PPE).
IV. Handling Exposure Incidents
This section discusses NEIC procedures once an exposure
occurs. Exposure incident means a specific eye, mouth,
other mucous membrane, non-intact skin, or parenteral
contact with blood or other potentially infectious
materials.
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V. Training
This section discusses the required information needed for
training.
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SECTION II:
EXPOSURE DETERMINATION
Contents of this section :
A. Need for Identifying Increased Risk Groups
B. Definitions
C. Work Activities with Increased Risk
D. Estimating Exposure Risks for Specific Jobs/Tasks
A. NEED FOR IDENTIFYING INCREASED RISK GROUPS
This section presents a mechanism to determine which NEIC
employees may be at increased risk for occupational exposure
to bloodborne pathogens (BBP), as required by the OSHA
Bloodborne Pathogens Standard. Such employees at increased
risk need to be included in special programs designated by
the Standard including special training, issuance of
personal protective gear (i.e., gloves and airway masks for
CPR) and the availability of immunization for Hepatitis B
and gamma globulin for treatment after exposure.
Employees determined to not be at increased risk for
exposure are not covered by the Standard. However, the PHS
recommends that all employees receive limited information
about certain aspects of the Standard, whether or not they
are considered in the increased risk group. Such
information should include availability of protective
equipment at first aid stations and post-exposure
treatment/monitoring procedures if a BBP exposure occurs.
B. DEFINITIONS
1. Occupational exposure means reasonably anticipated skin,
eye, mucous membrane, or parenteral contact with blood or
other potentially infectious materials that may result from
the performance of an employee’s duties. The determination
of potential exposure is made without regard to whether the
employee uses personal protective equipment such as gloves.
2. Other potentially infectious materials means human body
fluids: semen, vaginal secretions, cerebrospinal fluid,
synovial fluid, pleural fluid, pericardial fluid,
peritoneal fluid, amniotic fluid, saliva in dental
procedures, body fluid that is visibly contaminated with
blood, and all body fluids in situations where it is
difficult or impossible to differentiate between body
fluids.
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C. WORK ACTIVITIES WITH INCREASED RISK
It is reasonable to assume that some NEIC workers will be at
increased (i.e., moderate or high) risk for these exposures
based on the nature of their jobs. There appear to be four
general types of job tasks or exposure settings where NEIC
employees MIGHT be at SOME risk for exposure to bloodborne
pathogens. NEIC employees who should be considered at
increased risk for such BBP exposures are identified below
in each of the four categories.
1. First Aid Providers
a. First aid providers for co-workers (an increased
risk group):
Some employees may be part of work groups which are
at times remote from emergency medical services
and/or may do tasks which pose a significantly
increased risk for injury. In such work groups or
settings these employees would be formally
designated to serve as “first responders” in
performing first aid on injured co—workers. In
these instances, first aid training and the
providing of such first aid to injured co—workers
are a required or expected part of job duties. For
the purposes of the Standard, such an expectation
might be felt to exist unless it is explicitly and
formally excluded in the written part of the job
description or as an explicit policy clarification
is issued to all employees. These employees would
be in the increased risk group.
b. Voluntary or “Good Samaritan” first aid providers (a
low risk group):
A distinction should be made between: (1) employees
described in parts 2.a. above, who are required or
expected to provide first aid as a part of their
jobs and are in the increased risk group, versus (2)
employees who receive first aid training primarily
for their own benefit and are not designated or
expected to perform first aid as part of their job,
who are at low risk. Such employees may at times
perform first aid on a voluntary basis as “Good
Samaritans.” Since they are not required to do this
as part of their jobs, they would not be considered
in the increased occuDational risk group. However,
if these employees should become exposed at work
because of voluntary or “Good Samaritan” actions,
they would still be covered by parts of the Standard
dealing with exposure treatment and post-exposure
monitoring. In addition, first aid training for all
groups should cover the issue of BBP exposure and
preventive measures.
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2. Workers Engaged in Field Activities
Employees engaged in field activities (e.g., hazardous waste
disposal sites or sanitary landfills) might have occasional
exposure to potentially infectious materials. This would be
particularly true with sites at which employees directly
handle biohazard wastes or wastes from health care
facilities. General landfills and illegal garbage dumps
might also contain potentially infected materials. In
general, since the contents of hazardous waste sites and
landfills are usually not known with certainty, the most
prudent policy may be to consider all employees who may work
at such sites and who directly handle materials to be
included in the increased risk group.
Alternately, workers assigned only to overview or
supervisory tasks at these sites, who have no direct contact
with waste material, would be at low risk . In addition,
well—characterized and regulated hazardous waste land fills
which only contain known chemical wastes are probably also
low risk settings for BBP exposures.
Employees who may work- at waste water treatment facilities
or with waste water effluent are probably at low risk unless
they directly handle raw sewage. (See Appendix I).
3. Laboratory Exposures
Employees in laboratory settings should be considered at
increased risk for BBP exposures they handle any human
specimens (i.e., blood or other body fluids or tissues).
Because of the possibility of glass sample container
breakage, laboratory workers iay also be at increased risk
if they handle other materials which are potentially
contaminated by BBP (e.g., solid samples of unknown
materials from hazardous waste sites or any samples from
crime labs, etc.)
4. Other Exposure Settings
There may other circumstances not noted above when a NEIC
employee might be at increased risk for exposure to
bloodborne pathogens. These may need to be determined on a
case-by—case basis. Therefore some general educational
information or brief training on the risks of bloodborne
pathogeris will probably need to be given to all NEIC
employees.
0. ESTIMATING EXPOSURE RISKS FOR SPECIFIC JOBS/TASKS
After assessment of all NEIC activities, job titles, and
potential for exposure, PHS has determined that only
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NEIC Exposure Control Plan: Bloodborne Pathogen Exposures Page 6
employees engaged in field activities in the Criminal
Enforcement Branch with the following titles constitute an
increased risk group:
Supervisory Environmental Scientist,
Environmental Protection Specialist,
Environmental Investigation Specialist,
Environmental Scientist,
Environmental Engineer, and
Physical Science Technician.
However, supervisors and employees should review all job
duties and tasks to assess whether any of the previously
identified increased risk activities are part of the
employee’s job description. Those employees not included in
the increased risk group above, but who feel they are at
increased risk for occupational exposure to BBP, should be
encouraged to discuss this with their supervisor or safety
officer. In addition, managers and safety officers should
be asked to identify increased risk worker groups or
individuals not included in the categories above. These
situations should be discussed with the appropriate public
health personnel and individual decisions should be made on
whether such employees should be considered in the increased
risk group.
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SECTION III:
METHODS OF COMPLIANCE
Engineering and work practice controls shall be used to eliminate
or minimize employee exposure. Where occupational exposure
remains after institution of these controls, personal protective
equipment shall be used.
A. DEFINITIONS
1. BLOODBORNE PATHOGENS
Bloodborne pathogens are defined as pathogenic
microorganisms present in human blood which can cause
disease in humans. These bloodborne pathogens include, but
are not limited to, Hepatitis B virus (HBV) and human
iinirtunodeficiency virus (HIV or AIDS virus).
2. OTHER POTENTIALLY INFECTIOUS MATERIALS
Other potentially infectious materials are defined as the
other types of body fluids and tissues besides blood which
are potentially capable of causing disease. The OSHA
Standard specifically defines other potentially infectious
materials to include: semen, vaginal secretions, fluids from
internal body spaces (such as spinal fluid or joint fluid),
any body fluid visibly contaminated with blood, and all body
fluids where it is difficult or impossible to differentiate
between body fluids. Also included are any human tissues
other than intact skin (unless the tissue has been fixed by
histology procedures) and tissue culture and potentially
infected experimental animals used in medical research.
The Standard does not specifically include tears, vomit,
urine, or fec es on this list unless visibly contaminated
with blood. However, from a practical point of view, tears,
vomit, urine, and feces should be regarded by employees as
if they were potentially infectious, and the same
precautions should be used as when dealing with blood and
the other potentially infectious material specifically
mentioned in the Standard. In disposing of tears, vomit,
urine, and feces, these need not be treated as hazardous
materials (see below) as long as they are not visibly
contaminated with blood. It should be mentioned here that a
number of serious human diseases can be transmitted by
urine, feces, etc., even in the absence of blood. While
such transmissions are not covered by the Standard unless
contaminated with blood, they should still be regarded as
potentially dangerous.
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3. ENGINEERING CONTROLS
Engifleerina controls means control measures that isolate or
remove the bloodborne pathogens front the workplace. These
might include such things as special containers for disposal
of contaminated needles or self—sheathing needles, or -
automated handling of contaminated materials.
4. ExPOSURE INCIDENT
Exposure incident is defined as a specific contact of blood
or other potentially infectious materials with a person’s
eye, mouth, other mucous membrane, non—intact skin, or by
parenteral contact (i.e., by a puncture wound or cut with a
contaminated object such as a hypodermic needle).
5. PERSONAL PROTECTIVE EQUIPMENT
Personal protective eauipment includes items an individual
employee may use to prevent contamination by potentially
infectious material. In the case of bloodborne pathogens,
such personal protective equipment might include gloves, eye
protection or face shields, masks covering the mouth, and
protective clothing. (See specific information below.)
6. SHARPS
Sharps are defined as all sharp items which may become
contaminated with potentially infectious materials (this is
primarily relevant to health care or lab settings). Sharps
include all hypodermic needles, scalpel blades, glass lab
pipettes or other sharp instruments considered as
potentially infective and must be handled with extreme care
to prevent accidental injuries.
7. UNIVERSAL PRECAUTIONS
Universal precautions are defined as the standard
precautions all persons should use to prevent contact with
blood or other potentially infectious materials whenever
these situations occur or are anticipated. These may
involve standard work practices and the use of personal
protective equipment such as gloves, protective clothing,
eye protection, and/or masks. (See more information in
Section III.B.l., below).
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B. APPROVED GENERAL WORK PRACTICES
1. UNIVERSAL PRECAUTIONS
universal precautions should be used by all employees
whenever the potential for exposure to bloodborne pathogens
exists. Employees should adhere rigorously to the infection
control precautions noted in this section in order to
minimize the risk of exposure to blood and other body
fluids. All body fluids shall be considered potentially
infectious materials. All protective equipment needed to
protect workers will be supplied, cleaned, disposed of,
repaired, or replaced by NEIC.
Eating, drinking, smoking, applying cosmetics or lip balm,
and handling contact lenses are prohibited in areas where
there is a reasonable likelihood of occupational exposure to
bloodborne pathogens.
Food and drink shall not be kept in refrigerators, freezers,
shelves, cabinets, or on counters where blood or other
potentially infectious materials are present.
2. USE OF GLOVES
Gloves are to be worn when it can be reasonably anticipated
that an employee’s hands may be in contact with blood or
other potentially infectious materials, including touching
contaminated items or surfaces. Gloves should be located at
appropriate sites for easy access. Hands shall be washed
thoroughly and inunediately after possible contact with blood
and/or body fluids as well as before putting on and after
taking off of the gloves.
Gloves must be of appropriate material, latex, vinyl, or
rubber and of appropriate size for each worker. In a health
care setting when doing procedures where gloves are needed,
the gloves should be changed each time a new patient is
being dealt with. Anytime the gloves are contaminated with
blood and/or other body fluids, the gloves must be changed
and disposed of as noted below. For field settings, thick
non—disposable gloves of the materials identified above are
acceptable so long as their surface is not cracked or
abraded and the gloves are sterilized after each potential
exposure. (See Section III.B.4. below on cleaning
contaminated materials.)
3. USE OF RESPIRATORS, EYE PROTECTION, AND FACE SHIELDS
Respirators or eye protection and face shields shall be worn
whenever splashes, spray, spatter, or droplets of blood or
other potentially infectious materials may be generated and
eye, nose, or mouth contamination can be reasonably
anticipated.
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C -
4. USE OF BODY CLOTHING
Coveralls, lab coats, aprons, and other protective body
clothing shall be worn in occupational exposure situations.
If contaminated, these clothing should be discarded (if
disposable) or placed in a special receptacle to be cleaned
(see Section III.B.7. below on handling contaminated linen).
Plastic and rubberized aprons or gloves should be cleaned
first by rinsing with soap and water, and then disinfected
using a bleach solution (as noted below) or similar
disinfectant recommended by the manufacturer.
5. HANDLING AND DISPOSAL OF SHARPS
a. All used or potentially contaminated sharps should be
disposed of in puncture-resistant Approved Sharps
Containers located as close as practical to the area of
use. Needles or glass pipettes are not to be recapped,
purposefully bent, broken, removed from disposable
syringes, or otherwise manipulated by hand . The sharps
containers shall be located in all areas where needles
and sharps are commonly used. (See Appendix H for
approved and suggested sharp containers).
b. When an Approved Sharps Container is full, it should be
labelled as BIOHAZARD, sealed, disinfected using the
bleach solution described below by pouring the solution
into the container, label as BIOHAZARD, and sealed. The
container should then be allowed to sit for 24 hours
before being disposed of.
6. USE OF RESUSCITATION (CPR) EQUIPMENT
Pocket masks and resuscitation bags will be provided in all
First Aid Kit or emergency boxes intended for resuscitation.
Resuscitation bags or pocket masks shall be used for all
resuscitation where emergency mouth-to—mouth resuscitation
is indicated.
“-
Pocket cardiopulmonary resuscitation (CPR) masks and gloves
should also be available in all non-CPR first aid kits, and
should be used by any individual adrn:nistering CPR or first
aid. In addition, individuals who are required to be first
aid certified as part of their jobs may wish to carry their
own small packet containing gloves and a pocket mask for
CPR.
7. HANDLING CONTAMINATED LINEN
Linen contaminated with blood and/or other body fluids shall
be placed in a laundry bag and labelled. If the bag is
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NEIC Exposure Control Plan Bloodborne Pathogen Exposures Page 1.1.
punctured or if outside contamination of the bag is likely,
a second bag shall be used. Gloves shall be worn when
working with linen contaminated with blood and/or other body
fluids.
8. CLEANING BLOOD AND/OR BODY FLUID SPILL
The following procedures should be utilized for cleaning up
blood or body fluid spills:
a. Area of the spill shall be cordoned of f to prevent the
accidental spread of body fluids.
b. Vinyl or latex gloves are donned if not already in
place.
c. An appropriate germicide or bleach solution should be
prepared. A germicide solution is the cleaning solution
of choice. If a bleach solution is used it can be
prepared with 800 ppm NaC1O solution (i.e., standard
household chlorine bleach) by mixing a quarter cup (60
ml) with one gallon of water. The bleach solution
should only be used on hard floors. Do not use this
solution on carpet . Bleach solution should be made
fresh; never hold more than one day’s worth at a time
unless it is stored in an air-tight container in a cool
dark place.
d. Remove any large pieces of glass or other particulate
material. Do not pick up material, with hands . Use a
plastic scoop to remove this matter. A tongue depressor
may be employed to maneuver items onto the scoop. Care
should be taken not to flip material with the tongue
depressor. Particulate material and tongue depressors
are placed in a puncture-resistant and splatter-proof
container. The scoop is placed in a clean place after
being cleaned (see 8.h., below).
e. Carefully remove the body fluids from the spill surface
with gauze sponges. When the sponge is saturated,
replace it with a new one. Do not wring out fluids .
All soiled sponges are placed in the puncture-resistant
and splatter-proof container.
f. Once body fluids have been removed from the area, the
bleach solution is used to decontaminate the area. This
is done by starting two (2) inches outside the spill and
moving into the center of the spill by making a series
of overlapping concentric circles with a sponge. The
area is allowed to air dry and the process is repeated.
The soiled sponges are placed into the puncture-
resistant splatter—proof container.
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g. All material used in the cleanup are placed in a safe
holding area until they can be disposed of in accordance
with Section C.3., below.
h. All material in the container is disinfected in
accordance with usual procedure for sharp containers.
The germicide or bleach solution may be disposed of in a
sanitary sewer; large quantities may be harmful to
septic tank systems. The scoop may be allowed to air
dry. NOTE: If it is desired to neutralize via the NaClO
solution, there should be a minimum contact time of 10-
minutes in the solution.
C. SPECIFIC PROCEDURES FOR HANDLING POTENTLY EXPOSURES
1. General Exposures:
a. Cleaning Spills
See specific instructions in Section III.B.8.
b. Emesis
Gloves must be worn when handling, cleaning, and/or
disposing of emesis fluid.
c. Iniuries
Gloves are to be worn whenever blood and/or other body
fluids are present.
d. CPR
Follow instructions in Section III.B.6. regarding CPR
and cleaning of resuscitation equipment.
e. Disposal of Syringes/Need1es/ Pipettes
Please follow the instructions for sharps in Section
III.B.5.
f. Reusable Instruments
Gloves must be worn in handling any contaminated
instruments.
g. Special Note on Exposures of Pregnant Women
Pregnant women are not known to be at greater risk of
contracting HBV or HIV infections than workers who are
not pregnant. However, if a worker develops HIV
infection during pregnancy, the infant is at increased
risk of infection resulting from perinatal transmission.
Because of this risk, pregnant women should be
especially familiar with the above precautions.
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SECTION IV:
EXPOSURE INCIDENT
A. DEFINITION OF EXPOSURE INCIDENT
“Exposure Incident” refers to a specific eye, mouth, other
mucous membranes, non—intact skin, or parentera]. contact
with blood or other potentially infectious material that
results from the performance of an employee’s duties.
B. WHAT TO DO IF AN EXPOSURE INCIDENT OCCURS
If an exposure incident occurs, the employee should be given
the “Exposure Incident and Treatment Packet” (Appendix B).
This packet contains all necessary instructions. It should
be completed by the employee and taken with them to the
designated medical clinic: federal employees to the FEOH
Health Unit physician or insurance provider; for
contractors, to their private health care provider (this is
at the cost of the contractor). The health care provider
seeing the employee at that clinic is to complete
appropriate portions of the packet and use the information
provided in the packet to determine appropriate treatment.
The completed packet is to be returned to the NEIC where it
will be kept as a permanent part of the employee’s
occupational health record. This report only states that
the employee was (1) evaluated and treated if appropriate
for a bloodborne pathogen exposure incident and (2) was
offered Hepatitis B vaccine if appropriate. All other
information is considered medically confidential and is
available only to the employee, their designees, health
professionals, and others as designated in the OSHA
Standard. These provisions are in accordance with OSHA
standards with respect to exposure incident procedures and
record keeping.
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SECTION V:
TRAINING
A. GENERAL TRAINING REQUIREMENTS
The OSHA Bloodborne Pathogen Standard requires initial
training with annual updates for employees who are at
increased risk for bloodborne pathogen exposure.
As described in Section II on exposure determination,
employees can probably be classified in terms of their BBP
exposure risk based on their specific job/task assignments.
Therefore, two levels of training will occur as described
below:
B. SPECIFIC LEVELS OF TRAINING
1. Training Level I: For NEIC Employees
a. Groups to be Included : NEIC Employees
All NEIC employees will receive some basic information
about BBP exposure risks and should have an idea of what
the agency’s BBP Exposure Plan covers. This type of
training is not required by the OSHA Standard for groups
with no increased risk; however, it seems prudent since
employees may hear about the program from others and
this may raise concerns or questions. Also, all
employees may occasionally come across blood or a body
fluid spill, at work or at home, and they should know
how to handle these situations.
b. Content of Training
This will include at minimum a memo sent to all federal
employees stating that the NEIC is instituting a BBP
Exposure Control Plan as per the OSHA Standard. It
should be stated that employees felt to be at increased
risk from occupational BBP exposure will be contacted by
their supervisor or designee. The memo should also
state gloves and CPR face masks should be in all first
aid kits and should be used in performing any first aid.
If an employee notes a blood or body fluid spill they
should be told who to contact to assure proper cleaning.
A small pamphlet on occupational BBP exposure could be
included. If appropriate, a brief description of the
BBP Exposure Control Plan might be presented at a
regular staff or safety meeting. Alternately, all NEIC
employees can be included in the initial training for
employees in the increased risk group.
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2 raifliflq Level II: NEIC Employees with Increased Work
Exposure Risk
a Groups Included : All employees determined to be in the
I creased risk group should receive this level of
training.
b. Content of the Training : This will be an overview of all
the material in the BBP Exposure Control Plan.
The format of this training should be a classroom
setting primarily focusing on Sections II, III (Sections
A.l. through C.l.), IV, and VI of this document.
c. Anticipated training time: 1—2 hours.
Additional information such as record forms, brief training
outlines, etc., are included in Appendix G.
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SECTION VI:
RECORD KEEPING
A. MEDICAL RECORDS
1 • General Requirements for Medical Record Maintenance
The U.S. Public Health Service, division of Federal Employee
Occupational Health and NEIC are required to establish and
maintain an accurate record for each federal employee at
increased risk for occupational exposure in accordance with
the Standard. All medical records are to be kept
confidential and not disclosed or reported to any person
within or outside the workplace without the employee’s
express written consent except as required by law. Each
record is to be maintained for at least the duration of
employment, plus 30 years, in accordance with the Standard.
2. Specific Components of Medical Records to be Kept by NEIC
for Potentially Exposed Employees
These records shall include:
a. The name and social security number of the employee.
b. A copy of the employee’s Hepatitis B vaccination status
if accepted by the employee including the dates of all
the Hepatitis B vaccinations and any medical records
relative to the employee’s ability to receive
vaccination. (See Appendix C on Hepatitis B
Vaccination). If the employee declines vaccination, a
copy of the signed declination statement will be
included.
c. The employer’s copy of the health care professional’s
written opinion if actually exposed.
d. A copy of the information provided to the health care
professional during the evaluation of an exposure
incident (such as the document included as Appendix C.)
B. TRAINING RECORDS
1. General Requirements of Training Record Maintenance
Training records shall be maintained by NEIC for three years
from the date on which the training occurred.
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SECTION VII:
BIOHAZARD WASTE
A. GENERAL REQUIREMENTS FOR HANDLING BIOHAZARD WASTE
All regulated waste shall be disposed of in accordance with
applicable regulations of the United States, as well as the
States and Territories and their political subdivisions.
The OSHA Bloodborne Pathogens Standard does not appear to
require any measures which are not already mandated by these
regulations. However, general guidelines for handling
biohazard waste are given below. The OSHA standard, in
Appendix A, can be consulted for more information.
B. SPECIFIC GUIDELINES FOR HANDLING BIOHAZARD WASTES
1. The containers for storage, transport, or shipping shall
be labelled or color-coded and closed prior to being
stored, transported, or shipped.
2. If contamination of the outside of the primary container
occurs, the primary container shall be placed within a
second container which prevents leakage during handling,
processing, storage, transport, or shipping and is
labeled or color-coded.
3. If the specimen could puncture the primary container,
the primary container shall be placed within a secondary
container which is puncture-resistant in addition to the
above characteristics. Equipment which may become
contaminated with blood or other potentially infectious
materials shall be examined prior to servicing or
shipping and shall’ be decontaminated ‘as necessary,
unless the employer can demonstrate that decontamination
of such equipment or portions of such equipment is not
feasible.
4. Regulated waste need not be handled as biohazard waste
if it has been properly disinfected, except for “sharps”
as described in Section III.
5. Communication of the hazards of potential exposure must
be made to all individuals who deal with biohazard
wastes.
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APPENDIX A
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APPENDIX A
OSHA BLOODBORNE PATHOGENS STANDARD (1920.1030)
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Federal Register / VoL 56 No 235 / Friday. December 6. 1991 / Rules and Regulations 64175
Xl. Tb. Standard
Geneiel Lndustr,’
Part 1910 of title 36 of the Code of
Federal Regulations is amended u
Foilow
PART 1910—(AMENDEDJ
Subp*rt Z—{Am.nd.dl
I The general authority citation for
subpart Z of 36 CFP. part 1910 conneue,
to read as follows and a new atation for
§ 1910.1030 Ii added
Autherlir Seea.i and a. O p.ne i
S.dety end Health Act. 36 U.S.C. 655. 657.
Se tlary of Labors Order, Nos. 12-71(36 FR
&S11. B— 9(41 FR o5e). orO -63(46 FR
337361. as apphcable and 36 ‘R past liii.
• . . . .
SecOon iaio.imu also heard under 36
U.S.C. 653.
• • . . .
2. Section 1910.1030 ii added to read
as follows.
1910.1030 Bloo oeso Pauiogans .
(a) Scope and Apphcotion. This
sec*i applies to all occupational
exposwe to blood or other potentially
tnfectioea materials as ii.d by
paragraph (b) of this saction.
(b) Definitions. For purposes of this
section. the following shall appiy
Awatant Seaetar,’ n ins the
Assistant Seoretary of Labor far
Occupational Safety and Health, or
designated iepresentath’e.
Bood , np hu iian blood. human
blood components. and products made
from human blood.
Bloodbwna Pathogen, means
pathogenic oorganisma that axe
present in human blood and can cause
disease in hu’n .s, These pathogen,
induce. but are not limited to. hepatitis
B virus (F V) and human
lmnunodefl eucy virus (1•U ’v).
C :nzcaJ Laborator means a
workplace where dlageostlc or other
eenang procedures axe performed an .,
blood or other potentially infectious
materials.
Contaminated means the presence or
the reasonably anticipated presence of
blood or other potentially infectious
enalj on an item or surface.
Contaminated Lcwrthy mans
liiimdiy which has been soiled with
blood or other potentially iofect oui
materials or may contain sharps.
Contammatad Sharps muses any
Contaminated object that can penetiete
the s including but not limited to.
needle,, scaip.I broken glass. broken
Capillary tubes. and exposed end, of
denial wires.
Decontamination means the use of
ptiysical or chemical means to remove.
inactivate, or destroy bloodbonie
pathogen, on a surface or item to the
point where they are no longer capable
of transmitting infectious particles and
the surface or item ii rendered site for
handling use, or disposaL
Director means the Director of the
National Institute for Occupational
Safety and Health. U.S. Depar eni of
Health and Human Services. or
designated representative.
Engineering Controls means controls
(e.g.. sharps disposal containfra, self.
sheathing needles) that isolate or
remove the bloodborne pathogens
hazard from the workplace.
Exposwe incident means a specific
eye. mouth. other mucous membrane.
Don-intact skth. or parenterul contact
wnh blood or other potentially
infectious materials that results from the
performance of so employee’s duties.
Handwashjr,g Facilities means a
facility providing an adequate supply of
ri mrig potable water, soap and single
use towels or hot air drying machines.
Licensed Healthcwe Professional is a
person who,, legally permitted scope of
practice allows lamar her to
Independently p 1 rf the activities
required by paragraph (I) Hepatitis B
Vaccination and Post-exposure
Evaluation and Follow-up.
11EV means hepatitis B virus.
!IIV means human immunodeflctency
means
reasonably anticipated skin, eye.
mucous membrane, or parentersi
contact with blood or other potentially
Infectious materials that may r siilt from
the perforinei , of an employee’.
duties.
Other Potentially infectious Materials
means
(1) The following human body fluids .
semen. vaginal secietrona, cerebrosainal
fluid, synoviel fluid, pleural fluid.
pencarthel fluid. peritoneal fluid.
amniotic fluid, saliva in dental
procedures, any body fluid that is
visibly contn’pted wtth blood. and alt
body fluids in situtia s where it is
difficult or impossible to differentiate
between body fluids,
(2) Any unfixed tissue or organ (other
than intact skin) from a human (living or
dead): sod
(3) HIV -onntaliung cell or tissue
cultures, organ cultures. and )‘DV. or
HBV.cont u tng culture medium or other
solutions: and blood. organs. or other
tissues from experimental em,n k
Infected with I’IIV or } V.
Pu,enteral means piercing mucous
membranes or the skin barrier through
such events as needlestidin, human
bites, cuts. and abrasion,,
Pe.’sor7ol Protective Equipment is
specialized clothing or equipment worn
by an employee lot protection against a
hazard. General work clothes (e.g..
uniforms, pans, shirts or blouse,) not
intended to function as protection
against a hazard are not considered to
be personal protective equipment.
Production Facility means a facility
engaged in industr.al.scale. large’
volume or high concentration production
of HIV or V.
Regulated Waste means liquid or
semi-liquid blood or other potentially
infectious materials: cont vu ln ted items
that would release blood or other
potentially infectious materials in a
liquid or semi4iqwd state if compressed.
items that are caked with dried blood or
other potentially infectious material,
and are capable of releasing these
mat.nal, during h IIl!n,r contaminated
sharps. and pathological and
micioiclogrcai wastes contnrni’ig blood
or other po .fthoIly infectious materials.
Research Laboratory means a
laboratory producing or uning research-
laboratory-scale amounts of HiVor
l’IBV. Research laboratories may
produce high concentrations of IOV or
HBV but not In the volume found c i
production facilities.
Source indiVidual means any
individual. living or dead. whose blood
or other potentially infe’c ’ous materials
may be a source at oompational
expoo to the employee Examples
Include. but are not limited to, hospital
and clinic patients. ‘ “ • in Institutions
for the developmentally disabled.
trauma victims. clients of drug and
alcohol treaneent facilities. residents of
hospicas and nursing homes. human
remains. and individuals who donate or
sell blood or blood components.
Sterilize means the use of a physical
or chemical procedure to destroy all
maci ’obisl life tv... 1 1u 4 !?lg highly resistant
bacterial endospores.
UrnversoJPrecoutions 1, an approach
to infection control. According to the
concept of Universal Precautions, all
human blood and certain human body
fluids are treated as if own to be
infectious for I’flV. HBV. and other
bloodliorite pathogens.
Woik Practice Controls mean,
controls that reduce the likelihood of
exposure by altering the manner in
which a task is performed (e.g.,
prohibiting recapping of needles bye
two-handed technique).
fc) Lrporurr contra/— fl) Łaposuze
Control Plan. (i) Each employer having
an employee(s) with occupational
exposure as defined by paragraph (b) of
this section shall establish a written
Exposure Control Plan designed to
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64176 Federal Register / VoL 56. No. 235 I Friday. December 6. 1991 I Rules arid Regulations
eliinlflate or minimize employee
exsUre Exposure Cou ol Plan shall
contain at least the following elemeritsi
(A) The exposure determination
required by paraçuph(c)(2),
(B) The schedule and method of
implementation for paragraphs (di
Methods of Compliance. (e) j and
i mv Research Laboratories and
production Facilities. (f) Hepatitis B
Vaccination and Post-Exposure
Evaluation and Foliow.up. (g)
Counication of Hazards to
Employees. and (h) Recozdkeeping. of
this standard. and
(C) The procedure for the evaluation
of cir atances surrounding exposure
incidents as required by paragraph
(fl(3)(i) of this standard.
(iii) Each employer shall ensure that a
copy of the Exposure Conti ol Plan is
accessible to employees in accordance
with 29 R 191O. (e).
(iv) The Exposure Con ol Plan shall
be reviewed and updated at lust
nrinnally and whenever necessary to
reflect new or modified tasks and
procedures which affect occupational
exposure and to reflect new or revised
employee positions with ocinipatlonal
exposure.
(v) The Exposure Control Plan shall
be made available to the Assistant
Seoretary and the Director upon request
for exsmin bon and copytng.
(2) Lrposure determznog,on. ( I) Each
employer who baa an employee(s) with
occupational expo. as defined by
paragraph (b) of this section shall
prepare an exposw det muziabos. This
exposure determination shall contain
the following:
(A) A list of all job classifications in
which all employees in those job
classifications have occupational
exposure:
(B) A list of job classifications ic
which some employees have
accupaUon j exposure, and
(C) A list of all tasks and procedure,
or groups of closely related task and
procedures in which occupational
exposure occurs and that are perf ed
by employee, in job classifications
listed in accordan with the provisions
of pararraph (cl(2)(i)(B) of this standard.
(ii) This exposure determination shall
be made without regard to the use of
personal protective equipment.
(d) Methods of compl,once....(1)
Geflem/—..tJmve , precautions shall be
observed to prevent contact with blood
or other potentially infectious materials.
tinder 5thnre, which
differentiation between body fluid types
is difficult or impossible. all body fluids
shall be considered potentially
infectious materials.
(2) Engineering and work practice
controls. (I) Engineering and work
practice controls shall be used to
phmn!t te or itnu’use employee
exposure. Where occupational exposure
remains after institution of these
controls, personal protective equipment
shall also be used.
(ii) Engineering controls shall be
examined arid maintained or replaced
on a regular schedule to ensure their
effectiveness.
(iii) Employer, shall provide
handwashing facilities which are readily
accessible to employees.
(iv) When provision of handwaihing
facilities is not feasible. the employer
shall provide either an appropriate
antiseptic hand cleanser in conjunction
with clean cloth/paper towels or
antiseptic towelettes. When antiseptic
hand cleanser, or towelettes are used.
hands shall be washed with soap and
rimntng water as soon as feasible.
(v) Employer, shall ensure that
employees wash their hands
immediately or as soon as feasible after
removal of gloves or other personal
protective equipment
(vi) Employer, shall ensure that
employees wash hands and any other
skin with soap and water, or flush
mucous membranes with water
immediately or as soon as feasible
following contact of such body areas
with blood or other potentially
infectIons materials.
(v ii) Conr ml’ inted needles and other
con’-. ’mnted sharps shall riot be bent.
recapped, or removed except as noted in
paragraphs (d)(2)(vii)(A) and
(d)(2)(vlI)(B) below. Shearing or
breaking of con’ ”’a ted needjes is
prohibited.
(A) Contsmhuited needles and other
conth ntn ted sharps shall not be
recapped orremoved unless the
employer can demonstrate that no
alternative is feasible or that such
action I. required by a specific medical
(B) Such recapping or needle removal
must be accomplished through the use of
a mechanical device or a one-handed
technique.
(viii) Immediately or as soon as
possible after use. conre unAted
reusable sharps shall be placed in
appropriate container, until properly
reprocessed. These containers shall be:
(A) Puncture resistant
(B) Labeled or color-coded an
accordance with this standard
(C) Leakproof on the aides and
bottoini and
CD) In accordance with the
requirements set forth In paragraph
(d)(4)(tl)(E) for reusable sharps.
(ix) Eating, drinking, smoking.
applying cosmetics or lip balm, and
handling contact lenses are prohibited an
work areas where there is a reasonable
likelihood of occupational exposure.
(x) Food and drink shall not be kept in
refrigerators, freezers, shelves, cabinets
or on countertops or benchtops where
blood or other potentially infectious
materials are present.
(xi) All procedures Involving blood or
other potentially infectious materials
ahall be performed in such a mn’in.r as
to m n ure spl.s.hing spraying.
spattering, and generation of droplets of
these subst ni ’ ..
(all) Mouth plperting/suctioning of
blood or other potentially infectious
materials is prohibited.
(sill) of blood or other
potentially infectious materials shall be
placed in a container which prevents
leakage during collection, h rtdling ,
processing. storage, transport or
(A) ’ e container for storage.
transport or shipping shall be labeled or
color-coded according to paragraph
(g)(1)(i) and closed prior to being stored.
transported, or shipped. When a facility
utilizes Umversai Precautions In the
h iidlmg of all specimens, the labeling!
color-coding of spe mens is not
necessary provided containers are
recognizable as containing specimens.
This exemption only applies while such
specimens/containers remain within the
facility. Labeling orcalor .coding an
accordance with paragraph (g )(1)(i) is
required when such specimens!
containers leave the facility.
(B) If outside con’ ”.ton of the
primary container o rs , the primary
container shall be placed within a
second container which prevents
leakage during h Iing . processing.
storage. transport or shipping and is
labeled or color-coded according to the
requirements of this standard.
(C) If the specimen could puncture the
primary container, the primary container
shall be placed within a secondary
container which as puncture-resistant in
addition to the above characteristics.
(xiv) Equipment which may become
conta , nated with blood or other
potentially infectious materials shall be
e ?iIt ed prior to servicing or shipping
and shall be decontimrn. ted as
necessary. anless the employer can
demonstrat, that deconte,,un bon of
such equipment or portions of such
equipment as not feasible.
(A) A readily observable label in
accordance with paragraph (gIIINLUH)
shall be attached to the equipment
stat_ag which portions resn*tn
cont.mmnted.
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Federal Register I Vol. 56. No. 235 I Friday. December 6. 1991 I Rules and Regulations
64177
(B) employer shall ensure that
this information is conveyed to all
gflected employees, the servicing
represent3ti and/or the manufacturer
as approp1 8t . prior to handling.
servicing. or shipping so that
appropriate precautions wilJ be taken.
(3) Personal protective eqwpmant—{i)
Provision. When there is occupational
e’cposure. the employer shall provide, at
no cost to the employee. appropriate
personal protective equipment such as.
but not limited to. gloves, gowns.
laboratory coats face shields or masks
and eye protection, and mouthpieces.
resuscitation bags. pocket masks, or
other ventilation devices. Personal
protective equipment will be considered
‘appropriate” only if it does not permit
blood or other potentially infectious
materials to pass through to or reach the
employees work clothes, street clothes.
undergarments. skin, eyes. mouth, or
other mucous membranes under norm_ni
conditions of use and for the duration of
time which the protective equipment
will be used
(ii) Use. The employer shall ensure
that the employee uses appropriate
personal protective equipment unless
the employer shows that the employee
temporarily and briefly declined to use
personal protective equipment when.
under rare and extraordinary
circumstances, it was the employee’,
professional judgment that in the
specific instance its use wouid have
prevented the delivery of health care or
public safety services or would have
posed an increased hazard to the safety
of the worker or co-worker. When the
employee makes this judgement. the
circumstances shall be investigated and
documented in order to determine
whether changes can be instituted to
prevent such occurence , in the future.
(:ii) Accessibility The employer shall
ensure that appropriate personal
protecut e ecuipinent in the appropriate
size, is readiiy accessible at the
worksite or is issued to employees.
Hypoallergeruc gloves. glove hneh.
powder(ess gloves. or other itmila _ r
alternatives shall be readily accessible
to those employees who are allergic to
the glo%es normally provided
(iv) Clear.ing, Laundering. and
Disposal The employer shall clean.
launder, and dispose of personal
prote tite equipment required by
Paragraph, (d) and (e) of this standard,
at no cost to the employee.
(v) Repair and Replacement. The
employer shall repair or replace
Personal protective equipment as
needed to maintain its effectiveness, at
no cost to the employee.
(vi) l a garment(s) is penetrated by
blood or oti’ier potentially infectious
materials, the garment(s) shall be
removed immediately or as soon as
feasible
(vu) All personal protective
eqwpment shall be removed prior to
leaving the work area
(viii) When personal protective
equipment is removed it shall be placed
in an appropriately desigeated area or
container for storage. washing.
deconthmin tiou or disposaL
(ix) Gloves. Gloves shall be worn
when it can be reasonably anticipated
that the employee may have hand
contact with blood, other potentially
infectious materials, mucous
membranes, and non ’intact skin. when
performing vascular access procedures
except as specified in paragraph
(d)(3)(ix)ID) and when h ‘ 1 ing or
touching contaminated items or
surfaces.
(A) Disposable (single use) gloves
such is surgical or exemlnat ion gloves.
shall be replaced as soon as practical
when contaminated or as soon U
feasible If they are torn, punctured. or
when their ability to function as a
barrier is compromised.
(B) Disposable (single use) gloves
shall not be washed or decontaminated
for ie use.
(C) Utility gloves may be
decontaminated for re-use if the
integrity of the glove is not
compromised. However, they must be
discarded if they are cracked, peeling.
torn, punctured, or exhibit other signs of
deterioration or when their ability to
function as a barrier is compromised
(DJ If an employer in a volunteer
blood donation center judges that
routine gloving for all phlebotonues is
not necessary then the employer shall.
(1) Periodically reevaluate this policy:
(2) Make gloves available to all
employee, who wish to use them for
phlebotomy:
(3) Not discourage the use of glove,
for phlebotomy: and
(4) Require that gloves be used for
phlebotomy in the following
(1) When the employee has cuts.
scratches, or other breaks in his or her
ak
(“1 When the employee judges that
hand contamination with blood may
occur, for example. when performing
phlebotomy on an uncooperative source
individuak and
( v i) When the employee is receiving
training in phlebotomy.
(x) Masks, Eye Protection. and Face
Shields. Masks in combination with eye
protection devices. such as goggles or
glasses with solid side shields. or chin-
length face scalds. shall be worn
whenever splashes. spray, spatter. or
droplets of blood or other potentially
infectious materials may be generated
and eye. nose, or mouth contamination
can be reasonably anticipated.
(x i) Gowns. Aprons, and Other
Protective Body Clothing. Appropriate
protective clothing such as. but not
Limited to. gowns, aprons, lab coats.
clinic jackets. or similar outer garments
shall be worn in occupational exposure
situations. The type and characteristics
will depend upon the task and degree of
exposure anticipated.
(xii) Surgical caps or hoods and/or
shoe covers or boots shall be worn in
instances when gross contamination can
reasonably be anticipated (e.g..
autopsies. orthopaedac surgery).
(4) Housekeeping (,) General.
Employers shall ensure that the worksite
is maintained in a clean and sanitary
conthnon. The employer shall determine
and implement an appropriate written
schedule for cleaning and method of
decontamination based upon the
location within the facility, type of
surface to be cleaned, type of soil
present, and tasks or procedures being
performed in the area
(ii) All equipment and environmental
and working surfaces shall be cleaned
and decontammated after contact with
blood or other potentially infectious
materials
(A) Contaminated work surfaces shall
be cecontaminated with an appropriate
disinfectant after completion of
prncedures immediately or as soon as
feasible when surfaces are overtly
contaminated or after any spill of blood
or other potentially infectious materials.
and at the end of the work shaft if the
surface may have become contaminated
since the last cleaning.
(B) Protective coverings, such as
plastic wrap. aluminum foil, or
imperviously-backed absorbent paper
used to cover equipment and
environmental surfaces. shall be
removed and replaced as soon as
feasible when they become overtly
contaminated or at the end of the
workshzft if they may have become
contaminated during the shaft.
(C) All bins, pails, cans. and similar
receptacles intended for reuse which
have a reasonable likelihood for
becoming contaminated wit’n blood or
ocher potentially infectious materials
shall be inspected and decontaminated
on a regulany scheduled basis and
cleaned and decontaminated
immediately or as soon as feasible upon
visible contamination.
(Di Broken glassware which may be
containin ted shall not be picked up
directly with the hands. It shall be
cleaned up using mechanical means.
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4178 Fader.! Register I VoL 58. No. 235 / Pridav . December 6. 1991 I Rules and Regulations
such u a brush and dust pan. to . or
forceps.
(E) Reusable sharps that are
contaminated with blood or other
potentially infectious materials shall not
be stored or processed in $ manner that
requueS employees to reach by hand
into the ccntainm where these sharps
have been placed.
(iii) Regulated Waste.
(A) Can__ ted Sharps Discarding
and Containment (2) Cont ,i ina ted
sharps shall be discarded immediately
or as SCCfl as feasible to containers that
are:
(/) aauble
(ii) Punn resistant
(ii:) Leakproof an sides and battonu
and
( iv) Labeled or color.ccded in
accordance with paragraph (g)(1)(i) of
this standard.
(2) Doing use. 000taine,i for
cont2mm ted sharps shall be
(I) Easily accessible to personnel and
located as close as is feasible to the
immediate area where sharps are used
or can be reasonabiy antiapated to be
found (e.g.. laucdnes):
(ii) Maintained upright throi out ussi
and
(ii:) Replaced routinely and not be
allowed to uver l 13.
(3) When moving containers of
cont nninatad sharps from the area of
use, the containers shall be
(1) Closed immediately prior to
removal or repIa . t to j vcflt
spillage or prouuasion of contents during
handling, storage. tiunspcrt. or shipping:
(ii) Placed in a secondary container if
leakage is possible. The second
container ahafl be
(A) Closable
(B) Consu ’ucted to contain all contents
und prevent leakage during handling .
storage. Uanrport. or shipping: and
(C) Labeled or color.coded according
to pa.-agraph (gj(i)(i) of this standard.
(4) Rnusable containers shall not be
opened. emptied. or cleaned manually or
In any other manner which would
expose employees to the risk of
perc ’Jtsneous m ury.
(B) Other Rerulated Waste
Ccnta!nment ,(7) Regulated waite shall
be.p laced n containers which are’
(,) Closable:
(i/) Consti,icted to contain all contents
and prevent leakage of fluids during
handling. storage. tiensport or shipping:
(ii i) Labeled or color.coded si
scuardance with parapaph (gXl)(I) this
standardi and
(iv) Closed prior to removal to pieent
spillag, or protrusion of contents during
handling. storage. transport, or shipping.
(2) If outside nt.Mln.tion of the
regulated waste container o s . It
shall be placed to a second container.
The second container shall be’
(1) Closable’
(ii) Constructed to contain all contents
and pre t leakage of fluids during
handling. storage. transport or shipping:
(i ii) Labeled or color .coded in
accordance with parapaph (g)(1)(f) of
this standard: and
(iv) Closed prior to removal to prcvunt
spillage or pro usion of contents dw g
h ndhng . storage. transport, or shipping.
(C) Disposal of all regulated waste
shall bern accordance with applicable
regulations of the United Slates. Slates
and Territories. and political
subdivisions of States and Territories.
(iv) Laundry.
(A) Ctmt m ted lawu&y shall be
handled as little as possible with a
mtTnom ofagitation. (1) Contiu ii,ioted
laundry shall bebagged or containerized
at the location where it was used and
shall not be sorted or rinsed in the
location of use.
(2) t Iinth!, uI ted laundry shall be
placed and transported in bags or
containers labeled or color.coded in
accordance with paragraph (gJ(1)(i) of
this standard. When a facility utilizes
Universal Precautions in the handling of
all soiled laundry. alternative labeling or
color-coding Is sn urent lilt permits all
employees to recognine the containers
as requiring ca mp l ’ . ” , with Universal
(3) Whenever cont m ted laundry Is
wet and presents a reasonable
likntthoo 4 of soak-through of or leakage
from the bag or container, the laundry
shall be placed end transported in bags
or containers which prevent soak-
through and/or leakage of fluids to the
(B) The employer shall emure that
employees who have contact with
cont. ! in ted Laundry wear protective
gloves and other u ,pnate personal
protective equipment.
(C) When a facility ships
contaI,i,i ted laundry offitte to a
second facility which does not utihee
Universal Precautions in the h dling of
all laundry. the facility generating the
cont m ted laundry must place such
launchym bags or containers which are
labeled or color-coded to accordance
with parsgrsph (gfllXI).
(a) HlVondHBVResea,ch
Lobozctcnes and Prothict. on FaciIit,.on
(1) This paragraph applie, to research
laboratories and production facilities
engaged in the sulture. production.
conomtratlon. experimentation, and
mpuladen of 10V and ISV. It does
not apply to H il I or diagnostic
laboratories engaged solely to the
analysis of blood, tissues. or organs.
These r u. inents apply in addition to
the other re us ments of the standard.
(2) Research laboratories and
production facilitie, shall meet the
following erutena:
(i) Standard microbiologicel practices.
All regulated waste shall either be
incinerated or decontaminated by a
method such as autoclavurug keown to
effectively destroy bloodborne
pathogens.
(11) Special practices.
(A) Laboratory doors shall be kept
closed when work involvuig IfiVor
HBV Is in
(B) Contaminated materials that are to
be decont m ted at a site away from
the work area shall be placed in a
durable. &ealcproof. labeled or color-
coded container that is closed before
being removed from the work area.
(C) A to the work area shall be
limited to authorized persons. Written
policies and procedures shall be
established whereby only persons who
have been advised of the potential
biohazard. who meet any specific enoy
req tmants. and who comply with all
entry and esit procedures shall be
allowed to enter the work areas sad
•nti i I rooms.
(D) When other potentially infectious
ma ials or infected m Iu are
present in the work area or cont 9in .,%t
module. a hazard warning sign
incorporating the universal biohazard
symbol shall be posted on all access
doors. The hazard warning sign shall
comply with paragraph (gJ(lXll) of this
(E) All activities involving other
potentially Infectious materials shall be
conducted in biological safety cabinets
or other devices
within the coet.i . lt module. No
work with these other potentially
infectious materials shall be conducted
on the open ben
(F) Laboratory coats. gowns. smocks.
uniforms, or other a 4 ate protective
clothing shall be used in the work area
and rooms. Protective clothing
shall not be worn outside of the work
area and shall be decontaminated
before being laundered.
(G) Special care shall be taken to
avoid skin contact with other potentially
infectious materials. Gloves shall be
worn when handling infected animals
and when making hand contact with
other potentially infectious materials Is
unavoidable.
(H) Before disposal all waste from
work areas and from animal rooms shall
sidisi be incinerated or
by a method such as autoclaving own
to effectively destroy bloodbosne
pathogens.
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Federal Register / Vol. 56. No. 235 I Friday. December 6. 1991 I Rules arid Regulations 64179
(I) Vacuum Lines shall be protected
with liquid disinfectant traps and high-
efficiency particulate air (} A) filters
or filters of equivalent or superior
efficiency and which are checked
routinely and maintained or replaced as
(J)Hypodermic needles and syringes
shall be used only for parenteral
irnection and aspiration of fluids from
laboratory n,mgI . and diapbra
bottles. Only needle-locking syringes or
disposable syringe-needle units (i.e.. the
needle in integiul to the syringe) shall be
used for the injection or aspiration of
other potentially infectious materials.
Extreme caution shall be used when
h i’ 4brig needles and syringes. A needle
shall not be bent, sheared, replaced in
the sheath or guard. or removed from the
syringe following use The needle and
syringe shall be promptly placed in a
puscnure-resistant container and
autoclaved or decontamt ated before
reuse or disposal.
( IC ) All spills shall be immediately
contained and cleaned up by
appropriate professional staff or others
properly trained and equipped to work
with potentially concentrated infectious
materials.
(U A spill or aecident that results in
in exposure incident shall be
immediately reported to the laboratory
director or other responsible person.
(M) A bioufery mAT !I2l shall be
prepared or adopted and periodically
reviewed and updated at least annually
or more often If necessary. Personnel
shall be advised of potential hazards.
shall be required to read Instructiots on
practices and procedures. and shall be
required to follow them.
(uij Containment equ ipmenL (A)
Certified biological safety cabinets
(Class L I I. or UI) or other appropriate
combinations of personal protection or
physmnal containment devices, such as
special protective clothing, respirators.
centrifuge safety cups. sealed centrifuge
rotor,, and containment caging for
‘ Ls . shall be used for all act1v1tie
with other potentially infectious
materials that pose a threat of exposure
to droplets,, splashes. spills, or aerosols
(B) Biological safety cabinets shall be
certified when installed. whenever they
are moved and at least annually
(3) HIV and V research
laboratories shall meet the following
criter ia
(i) Each laboratory shall contain a
facility for hand washing and an eye
wash facility which is readily available
within the work area.
(ii) An autoclave for decontamination
of regulated waste shall be available.
(4) MW and HBV production facilities
shall meet the following ciiteria
(1) The work areas shall be separated
from areas that are open to unrestricted
traffic flow within the building Passage
through two sets of door, shall be the
basic requirement far entry into the
work area from acces, corridors or other
contiguous areas. Physical separation of
the high-containment work area from
access corridors or other areas or
activities may also be provided by a
double-doored clothes-change room
(showers may be meluded). airlock, or
other access facility that requires
passing through two sets of doors before
entering the work area.
(i i) The surfaces of doors. walls, floor,
and ceilings in the work area shall be
water resistant so that they can be
easily cleaned. Penetrations in these
surface, shall be sealed or capable of
being sealed to facilitate
deconta”t,na bon.
(iii) Each work ares shall contain a
sink for washing hands and a readily
available eye wash facllity. The sink
shill be foot, elbow, or automatically
operated and shall be located near the
exit door of the work area.
(iv) Access doors to the work area or
contain t module shall be self-
closing.
(v) An autoclave for decontamination
of regulated waste shall be available
wfthinoru near as possible to the work
area.
(vi) A ducted exhaust-air ventilation
system shall be provided. This system
shall oreate directional airflow that
draws air into the work area through the
anny area. The exhaust air shall not be
recirculated to any other area of the
building. shall be discharged to the
outside, and shall be dispersed away
from occupied areas and air intakes.
The proper direction of the airflow shall
be verified (La.. into the work area).
(5) Training Requirement,. Additional
training requirements for employees in
MW and HBV research laboratories and
MW and I9V production facthtzes are
specified in paragraph (g)(2)(ix).
(0 Hepatitis B vaccznotion and post-
exposure evaluation and fellow.up—(i)
General (i) The employer shall make
available the hepatitis B vaccine and
vaccination series to all employees who
have occupabons.l exposure, and post.
exposure evaluation and follow-up to all
employees who have had an exposure
incident
(ii) The employer shafl ensure that all
medical evaluations and procedure,
including the hepatitis B vaccine and
vaccination series and poat-exposu_re
evaluation and follow-op. including
prophylaxis. are
(A) Made available at no cost to the
employesi
(B) Made a ailable to the employee at
a reasonable time and place.
(C) Performed by or under the
supervision of a licensed physician or
by or under the supervision of another
licensed healthcare professionaL and
(D) Provided according to
recommendations of the U.S. Public
Health Service current at the time these
evaluations and procedure, take place.
except as specified by this paragraph (I).
(iii) The employer shall ensure that all
laboratory tests are conducted by an
acciedited laboratory at no cost to the
employee.
(2) Hepatitis B Vaccz,otion. (i)
Hepatitis B vaccination shall be made
available after the employee has
received the training required in
paragraph (g)(2)(vu)(I) and within 10
working days of initial assignment to all
employees who have occupational
exposure unless the employee has
previously received the complete
hepatitis B vaccination series, antibody
testing has revealed that the employee is
immune. or the vaccine is
contraindicated for medical reasons.
(L) The employer shall not make
participation in a presoreening program
a prerequisite far receiving hepatitis B
vacumabon.
(iii) If the employee initially declines
hepatitis B vaccination but at a later
date while still covered under the
standard decides to accept the
vionnanon, the employer shall make
available hepatitis B vaccination at that
time.
(iv) The employer shall assure that
employee, vho decline to accept
hepatitis B vaccination offered by the
employer sign the statement in appendix
A.
(v) If a routine booster dose(s) of
hepatitis B vaccine is recommended by
the U.S. Public Health Service at a
future date, such booster dose(s) shall
be made available in accordance with
section (f)(1)(u)
(3) Pbst-expasure Eraluat,on and
Follow-up Following a report of an
exposure incident. the employer shall
make immediately available to the
exposed employee a confidential
medical evaluation and follow-up.
including at least the following
elements
(I) Documentation of the route(s) of
exposure, and the circumstance, under
which the exposure incident occurredi
(ii) Identification and documentation
of the source individual, unless the
employer can establish that
identification is infeasible or prohibited
by state or local law
(A) The source individual’s blood
shall be tested as soon as feasible and
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g gj Federal Register I Vol. 56. No. 235 I Friday. December 6. 1991 / Rules and Rvoulations
after consent is obtained in order to
determine F V and H1V infectivity. If
consent is not obtained, the employer
shall establish that legally required
consent cannot be obtained. When the
source individual’s consent is not
required by law, the source individuals
blood. if available, shall be tested and
the results documented.
(B) When the source individual is
already known to be infected with HBV
or } ‘V, testing for the source
individual’, known I V or }flV states
need act be repeated.
(C) Results of the source individual’,
testing shall be made available to the
exposea employee. and the employee
shall be informed of applicable laws and
regulations concerning disclosure of the
identity and nfectious status of the
source individual.
(iii) Collection and testing of blood for
HBV and J’CV serological status
(A) The exposed employee’s blood
shall be collected as soon as feasible
and tasted after consent is obtained.
(B) If the employee consents to
baseline Wood collection, but does not
give consent at that time for M W
serologic tasting. the sample shall be
preserved for at least 90 days. If. wtthan
ao days of the exposure incident, the
employee elects to have the baseline
sample tested. such testing shall be done
as soon as feasible.
(iv) Post-exposure prophyjaxis, when
medically indicated,., recommended
by the U.S. Public Health Service
(v) Counselingi and
( vi) Evaluation of reported illnties .
(4) Lrxformotion Provided to the
Heolthcn,e ProfessionaL (I) The
employer shall ensure that the
healthcare professional responsible for
the employee’s Hepatitis B vaccination
is provided a copy of this regulation.
(ii) The employer shall ensure that the
healthcare professzo al evaluating an
employee after an ex os incident is
provided the following information:
(A) A copy of this regulation,
(B) A desoription of the exposed
employees duties as they relate to the
exposure incident
(C) Documentation of the route(s) of
exposure and ci stance , der
which exposure occigred.
(D) Results of the source individual’,
blood testing. if available. and
fE) All medical records relevant to the
appropriate nea ent of the employee
u ’.clud ing vaccination status which axe
the employers respousibthty to
ciamlain.
(5) Heclthcore Professional’s Written
Opinwa. The employer shall obtain and
provide the employee with a copy of the
eveluatii 4 healthcare professional’,
written opinion within IS days of the
completion of the evaluation.
(i) The healthcaie professional’,
written opinion for Hepatitis B
vaccination shall be limited to whether
Hepatitis B vaccination is indicated for
an employee, and if the employee has
received such vaccination.
(ii) The healthcare professional’s
written opinion for post-exposure
evaluation and follow-up shall be
limited to the following information:
(A) That the employee has been
informed of the results of the evaluation:
and
(B) That the employee has been told
about any medical conditions resulting
from exposure to blood or other
potentially infectious materials which
require further evaluation or tiea ent.
(iu) All other findings or diagnoses shall
r am confidential and shall not be
included in the written report.
(6) Medical zecozdkeepmg. Medical
records reqaired by this standard shall
be maintained in accordance with
para apb (hfli) of this section.
(g) Communication of hazwds to
employee,— (I) Labels and signs (I)
Labels. (A) Warning labels shall be
a,thxed to containers of regulated wute,
refrigerators and freezers contamrng
blood or other potentially infectious
material: and other containers used to
store. ti’,nsport or ship blood or other
potentially infectious materials, except
as provided in paru?eph (g)(1)(i)(E). (F)
and (C).
(B) Labels requrred by this section
shall include the following legend:
WOHAz RD
(C) These labels shall be fluorescent
orange or orange-red or predo”tantly
so. with lettering or symbols in a
cononsting color.
(D) Labels required by a xed as
close as feasible to the container by
sting, wire, adhesive, or other method
that prevents thai lou or unintentional
removal.
(E) Red bags or red container, may be
substituted for labels.
(F) Containers of blood, blood
components, or blood products that are
labeled u to their contents and have
been released for ti’ansfusion or othsr
clinical use are exempted from the
labeling requirements of p.r*gieph (g)
(C) Individual containers of blood or
other potentially infectious materials
that are placed in a labeled container
during storage. uensport. shipment or
disposal are exempted from the labeling
req ement ,
(H) Labels required for conteminated
equipment shall be in accordance with
this para aph and shall also state
which portions of the equipment remain
cont amm ted.
(I) Regulated waste that has been
decontam ted need not be labeled or
color-coded.
(ii) Signs (A) The employer shall post
signs at the ennence to work areas
specified in paragieph (e). MW and HBV
Research Laboratory and Production
Facilities, which shall bear the following
BIOE .ZARD
BIOHAZARD
(Nans of the Infectious Agmt)
(Special ieq ent (or ent.nn the area)
(Nuns. talephuna nienber of the tsborstoxy
dasou or other vssp sxble person.)
(B) These signs shall be fluorescent
orange -red or predoiv m ntly so. with
Lettenag or symbols in a contesting
color.
(2) lnf oneouon and Trnzni g. (1)
Employers shall ensure that all
employees with occupational exposure
participate in a taming program which
must be provided at no cost to the
emoloyee and during working hours.
(ml) Training shall be provided as
foilowe:
(A) At the time of initial assignment to
tasks where occupational exposure may
take place
(B) Within 90 days after the effective
date of the standard: and
(C) At least annually thereafter.
(iii) Far employees who have received
taming on bloodhorne pathogens in the
year preceding the effective date of the
standard, only fr m,Iig with respect to
the provisions of the standard which
ware not included need be provided.
(iv) Annul taming for all employees
shall be provided within one year of
their previous t .I m1
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Federal Register / Vol 56 No. 235 / Friday. December 6. 1991 I Rules and Regulations
(v) Employer, shall provide additional
tiaining when shanges such as
modification of tasks or procedures or
t stituDofl of sew tasks or procedures
affect the employee, occupational
ecpoaure. The additional training may
be limited to addressing the new
e’ posuees meated.
(vi) Material appropriate in content
and vocabulary to educational leveL
literacy, and language of employees
sb iall be used.
(vii) The training program shall
contain at a mimum the following
e!ementsi
(A) Anaccessible copy of the
regulatory text of this standard and an
e’cplanation of its contents:
(B) A general explanation of the
eptdemiolo ’ and symptoms of
bloodborne diseases:
(C) An explanation of the modes of
transmission of bloodhorne pathogenn
(D) An explanation of the employer’s
exposure control plan and the means by
which the employee can obtain $ copy
of the wr tt lani
(E) An explanation of the aporopriate
methods for recognimng tasks and other
actaslbes that may involve exposure to
blood and other potentially infectious
matenalg
(F) An explanation of the use and
limitations of methods that will prevent
or reduce exposure including
appropriate engineering controls, work
practices, and personal protecti ’e
equipment
(C) Information on the types. proper
use. Location, removal, handling .
decontn,nznstion and disposal of
personal protective eqnipment
(H) An explanation of the basis for
se lec tion of personal protective
eqwpme n
(I) Information on the hepatitis B
vaccine, including information on its
efflcac . safety. methcd of
acu isu’euon, the beni fi ., fbauig
.accina(en, and thai tLe va ne and
viccinzbon will be offered tree of
cltarge:
U) lniormc cn on the appropriate
actor.s to take and persona to cor. act in
an eme aency Ln olving blood or other
potentially infectious materiaL,.
( Xl An expianation of the procedure
to foiow if an ex’osure incident occurs.
uicludw.g the method of repor ing the
incident and the edical foUo ’up that
will be made available:
I L) !nIormat on on the post-exposure
evaluation and follow-up that the
employer is requ - to pro ’ ’ide for the
employee following an exposure
incident
(M) An expLar.ation of the signs arid
labe ls and/or color coding required by
paragraph (g)(i) and
(N) An opportunity for interactive
questions and answers with the person
cor.ducting the training session.
(viii) The person conducting the
trairung shall be knowledgeable in the
sub;ect matter covered by the elements
contained in the training program as it
relates to the workplace that the training
will address
(ix) Additional Initial Training for
Employees in MW and HBV
Laboratories and Production Facilities
Employees in l ’BV or ) ‘ V research
laboratories and l ’UV or 11EV production
facilities shall receive the following
initial training in addition to the above
training requirements.
(A) The .mp oyer shall assure that
employees demonstrate proficiency in
standard microbiological practices and
techniques and in the practices and
operations specific to the facility before
being allowed to work with HIV or 11EV.
(B) The employer shall assure that
employees have prior experience in the
handling of human pathogens or tissue
cultures before working with HIV or
1 V.
(C) The employer shall provide a
training program to employees who have
no prior experience in h ndhrig human
pathogen.. Initial work activities shall
not include the handling of infectious
agents. A progression of work acbv i es
snaIl be assigned as techniques are
learned and proficiency is developed.
The employer shall assure that
employees participate in work activ’.ties
involving infectious agents only after
proficiency has been demonstrated,
(h) Recordkeep.:.’rg—(z) .‘ (ethca/
Records. (I) The employer shall establish
an maintain an accurate record for
each employee with occupational
exposure, in accordance with 29 CFR
19rn29.
(:i) This record shall include:
(A; The name and social seciiri’y
n.imoer c’ the epli, cc
(B) A copy of the emplc ee s hepat.us
B vaccination s:atus inc ndng the dates
of all the hepatitis B vacunations and
any medicai records rela ve to the
emoioyee $ abiLty to rece ve
vac:ina n as required cy paragraph
(fl j
tC) A coov of all reo t, cf
examinations, mecica! testing. and
futlow-up procedures as required ‘cy
paragraph U (3):
(Dl The emoloyar s copy of the
healthcare professionals written
opinion as required by paregrape (fl(5 1.
and
(E) A copy of the information
provided to the healthwe professional
as required by paragraphs (f)(4)(ii)(B)(C)
and (D).
(iii) Confidentiality The employer
shall ensure that employee medical
records required by paragraph (h)(t) are’
(A) Kept confidentiaL and
(B) Are not disclosed or reported
without the employee s express written
consent to any person within or outside
the workplace except as required by this
section or as may be required by law.
(iv) The employer shall maintain the
records required by paragraph (h) for at
least the duration of employment plus 30
years in accordance with 29 CFR
1910,29.
(2) Tro:.iing Records. (ii T.-czn:oy
records shc!I include the following
rnformctwr
(A) The dates of the training sessions’
(B) The contents or a summary of the
training sessions.
(Cyrhe names and qualifications of
persons conducting the training and
(Di The names and job titles of all
persons att.’ding the training sessions.
(ii) Training records shall be
maintained for 3 years from the date on
which the training occurred.
(3) Avnilobsthy. (I) Ibe employer
shall ensure that all records required to
be maintained by this section shall be
made available upon request to the
Assistant Secretary and the Director for
er i I I.tion and copying.
(ii) Employee training records
required by this paragraph shall be
provided upon request for exkmIr . tion
and copying to employees, to employee
representatives, to the Director. and to
the Assistant Secretary in accordance
with 29 ‘R i io.m
( Ii :) Employee medical records
required by this paragrsph shall be
provided upon request tar exn n1nR don
and copying to the subject employee, to
anyone having written consent of the
subject employee, to the Director and to
the Assistant Secretary in accordance
w:th 29 CFR 1910_29
(..) T.’arsfer of Records (‘) The
employer shall compl) with the
requirements involving transfer of
records set forth in 29 1910.29th)
(i.) 11 the employer ceases to do
business and there :s no successor
employer to recetve and retain the
records for the prescribed period, the
employer shall notify the Director. at
leas: thiet months prior to their disposal
and transmit them to the Director. if
required by the Director to co so. within
that t ee month period.
(i) Dates—fl) Effective Date The
standard shall become e ecDve on
March 6. 1992,
(j The E.*posure Control Plan
required by paragraph (c)12) of this
section shall be completed on or before
May 5. 1992.
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64182 Federal Register / Vol. 56. N3. 235 I Friday. December 6. 1991 I Rules and Reg i1ations
(3) Paraçaph (g)(2) Information and
Training and (hi Recordkeeping shall
take effect an or before june 4. 1992.
(4) Paragraphs (d)(2) En neertag and
Work Practice Con ols. (d)(3) Personal
Protective Eçwptner.t. (d)(4)
Housekeeping. (e) IUV and I V
Reeeaxch Laboratones and Frodtictian
FacilIties. (fl Hepatitis B Vaccination
and Post-Expasore Evaluation and
Follow-up, and (g) (1) Labels and S: s.
shall take effect juy 6.1992.
Appendix A to Sc o 1110 313O—Hspaa a
B Va (Mandatory)
I onderstand that nn to y op. oaaI
v a e to blood or othor potentta 1y
infections inaterials I inay be at tak of
$ 4 ..M.4 hepatitis B vwius (I t) infection. I
have been ven the opportunty to be
vacunazsd with hepatitis B at no
sip to inywlL Huwwv . I dedine bapatina
B vac nation at this tine I cndeinsnd that
by declining Lbs vac n* I continue to be at
n ih of sc utnng hepatitis B. a serous
oiuue. If in the future I continue to have
owational exposure to blood or other
potentially infectious materials and I want to
be vaccinated with hepatitis 3 vae. I cen
receive the vaccination series at no thar e to
ma
[ FR Dcc. 9I- M6 Filed U--9t &43 anl
eeI onni ř
-------
APPENDIX B
-------
APPENDIX B
EXPOSURE INCIDENT AND TREATMENT PACKET
-------
EXPOSURE INCIDENT RECORD
FOR BLOODBORNE PATHOGEN EXPOSURE
EMPLOYEE INSTRUCTIONS
You are completing this form because you have experienced an
actual or a potential exposure to blood or other potentially
infectious material. An evaluation of this exposure is required
by the Bloodborne Pathogen Standard of the Occupational Safety
and Health Administration.
Please complete all the information below. Take this form with
you when you go to a physician or other health care provider for
the evaluation of the exposure. The information contained on
this form is crucial to a proper evaluation of the exposure.
Please take the time and care in completing the form to insure
that the information is clear and accurate.
If you need information on where to have this medical evaluation
performed, please contact your supervisor.
The medical evaluation for a suspected exposure to blood or other
potentially infectious material should be done soon as possible
after the exposure. The effectiveness of certain vaccines or
other medication which might prevent any illness resulting from
these exposures is greatest if given shortly after the exposure.
Complete the appropriate accident report for your supervisor.
Page 1 of 6
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EMPLOYEE’S STATEMENT: (PLEASE PRINT)
A. Employee Identification.
Name: _______________________________________
Social Security Number: _________________
Job Title: ____________________________
Work Location: __________________________
Work Phone: _____________________________
Supervisor: ________________________________
B. Description of Exposure Incident.
Date: ___________ Time: _______ am/pm (circle one)
City/Town: _____________________ State: ______________
Describe Incident (Please include the type of infectious material to which
you were exposed and the circumstances of the exposure):
Page 2 of 6
-------
SUPERVISOR’S STATEMENT: (PLEASE PRINT)
Employee’s Name:
A. Supervisor Identification.
Name: _______________________________________
Work Phone: ______________________________
B. Description of Incident
Please describe the employee’s duties as they relate to the
exposure incident:
C. Hepatitis B Status
The employee named above 0 has /0 has not received a three dose
series of Hepatitis B Vaccine. If yes, the series was completed
on __________ (date).
D. Investigation of Source
Please describe what information is known about the source
(person) of the exposure (especially name, address, telephone
number, or other contact point), the result(s) of the blood
testing of the source (if known), or why blood testing of the
source is not feasible. Also, if the source is known to have or
test positive for Hepatitis B or Human Immunodeficiency Virus
(HIV), please indicate this fact. The OSHA standard requires
that the source be tested for these agents unless such testing is
not legally possible.
Page 3 of 6
-------
EXPOSURE INCIDENT RECORD
FOR BLOODBORNE PATHOGEN EXPOSURE
HEALTH CARE PROVIDER INSTRUCTIONS
This employee is being referred for your evaluation of an
exposure incident to blood or another potentially infectious
material. This referral is to be performed under the provisions
of the OSHA Bloodborne Pathogen Standard (29 CFR 1910.1030). A
copy of this standard is attached. Several items included in the
OSHA standard deserve your close attention.
• Under the OSHA standard, the following bodily fluids are
considered potentially infectious: blood, semen, vaginal
secretions, cerebrospinal fluid, synovial fluid, pleural
fluid, pericardial fluid, peritoneal fluid, amniotic fluid,
saliva (in dental procedures), and any body fluid visibly
contaminated with blood.
• The exposed employee’s blood should be collected as soon as
feasible after consent is obtained and tested for HBV and HIV
status.
• If the employee gives consent for baseline blood collection,
but does not give consent for HIV serological testing at the
time of collection, the blood sample should be stored for 90
days. If within 90 days of the exposure incident, the
employee elects that the baseline sample be tested, such
testing should be performed.
• Post-exposure prophylaxis is to be given according to the
guidelines of the U.S. Public Health Service, which are
attached. Optimal use of these recommendations requires
knowledge of the HBV status of the source and the exposed
individual.
• OSHA requires that you submit a report of the post-exposure
evaluation. A form for this purpose is attached.
Page 4 of 6
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EXPOSURE INCIDENT RECORD
FOR BLOODBORNE PATHOGEN EXPOSURE
HEALTH CARE PROVIDER REPORT OF POST-EXPOSURE EVALUATION
Employee name:
Date of office visit: __________________________________________
Health Care Facility Address: _________________________________
Health Care Facility Telephone: _______________________________
As required under the OSHA Bloodborne Pathogen Standard:
o The employee named above has been informed of the results of
the post-exposure medical evaluation.
O The employee named above has been told about any medical
conditions resulting from exposure to blood or other
potentially infections materials which require further
evaluation or treatment.
(Printed Or Typed Name of Health Care Provider)
(Signature of Health Care Provider)
(Date of Signature)
Page 5 of 6
-------
Treatment Protocol Table.
Recommendations for hepatitis B prophylaxis following exposure incident)
Trea nent when source Is found to be
Exposed person HBsAG po bve HBSAG nega ve Unknown or not tested
unyaccinated Administer HB!G x 1 and initiate Initiate hepatitis B nitiate hepatitis B vaccine’
hepatitis B vaccine’ vaccine’
Previously vaccinated
known responder Test exposed person for No treatment No treatment
ar iti-HBs
1 II adequate, no treatment
2 Il inadequate, hepatitis B
vaccine booster dose
Known non-responder HBIG x 2 or HBIG x 1, pIus 1 No treatment No treatment
dose of hepatitis B vaccine
Response unknown Test exposed person for anti-HB’ No treatment Test exposed person for anti-HBs
1 If inadecuate HBIG x 1, pIus 1 If inadequate, hepatitis B
hepatitis B vaccine booster vaccine booster dcse
dose
2 If adecuate, no treatment 2 Il adecuate, no treatment
riepatitis B immune giooulin (HBIG) dose 006 mI/kg intramuscu arIy
- -lepatitis B vaccine cose—see Table 1
Adequate anti-HBs is 10 millt-internationai unrts
U.S. Public Health Servtce, Center for Disease Control, Morbidity and Mortality Weekly ,
November 22, 1991, 40:(RR-13) 22.
Page 6 of 6
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APPENDIX C
-------
APPENDIX C
HEPATITIS B VACCINATION INFORMATION AND
CONSENT/DECLINATION FORMS
-------
NEIC Exposure Control Plan Bloodborne Pathogen Exposures Page 1
Appendix C. Hepatitis Vaccination Information and Consent/Declination Forms
APPENDIX C
HEPATITIS B VACCINATION INFORMATION AND
CONSENT/DECLINATION FORMS
NEIC offers free vaccinations against Hepatitis B virus for all
employees who are at increased risk for bloodborne pathogens
(BBP) at work. Employees are at increased risk and should
consider vaccination if they (1) have direct contact with human
blood or other body tissues or (2) are at risk of trauma, needle
sticks, cuts, or abrasions that may result in percutaneous
exposure to materials infected with Hepatitis B virus.
The Disease
Hepatitis B, formerly called serum , hepatitis is a disease
caused by the Hepatitis B virus (HBV). There is no specific
treatment for Hepatitis B infection other than supportive
measures. Most persons who become infected with Hepatitis B
recover completely and are immune to subsequent exposures.
However, of all those who develop Hepatitis B infection, about
0.1% die of fulminating hepatitis. The prognosis depends on age,
dose, and severity of underlying disease. Five to 10% of cases
become chronic lifetime carriers who are capable of transmitting
the disease to others and are at risk of developing chronic
active Hepatitis B, cirrhosis (2%) or liver cancer (0.4%).
Risks of Hepatitis B Infection for Health Care Workers
Health care workers who have contact with blood, infected tissue
or secretions, and regular exposure to trauma, needle sticks,
cuts, and abrasions are most at risk for acquiring Hepatitis B.
In the United States, about 5% of the general population show
evidence of past or present Hepatitis B infection, while up to
30% or more health care workers in high risk areas show evidence
of past Hepatitis B infection.
The Vaccine
A genetically engineered Hepatitis B vaccine was first licensed
by the Food and Drug Administration in July of 1986. Genetically
engineered vaccine is the vaccine offered to NEIC employees. The
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NEIC Exposure Control Plan loodborne Pathogen Exposures Page 2
Appendix C: Hepatitis B Vaccination Information and Consent/Declination Forms
vaccine, referred to as recombinant HB vaccine, (“Recoinbivax HB”,
or “Engerix—B”) is very comparable, immunologically, to the
earlier “Heptovax B” vaccine which was introduced in 1981. The
difference between the two vaccines relates to their methods of
derivation. Recombinant HB vaccine is genetically engineered
from common baker’s yeast into which a plasmid containing the
gene for the Hepatitis B surface antigen (HBsAg) and has been
inserted. The first available plasma derived Hepatitis B vaccine
(“Heptovax B”) is derived from highly purified plasma of chronic
HBV carriers and then inactivated so that it is not infectious.
The plasma derived vaccine is no longer produced in the United
States.
The full vaccination series for Hepatitis B includes an initial
vaccination followed by repeat doses one month and six months
later. Over 95 percent of susceptible healthy adults (20-39
years of age) who receive the full vaccination series achieve
high levels (titers) of Hepatitis B surface antibody (anti-HBs)
and are considered to be immune from Hepatitis B infection. The
vaccine produces somewhat lower antibody responses in older
adults than in younger adults.
The dose is lOLg (1 ml) injected into the deltoid muscle. There
is no evidence that the vaccine has ever caused Hepatitis B.
Administration of the vaccine to persons already positive has no
effect, good or bad. Administration of Hepatitis B hyper-immune
globulin (HBIG) given prophylactically does not interfere with
the development of antibodies to the vaccine. Persons already
incubating Hepatitis B prior to receiving the vaccine may go on
to develop clinical hepatitis in spite of the immunization
although the vaccination may reduce the severity of the illness.
Vaccine Risks and Possible Side Effects
The incidence of side effects is very low, usually limited to
soreness at the injection site, and mild systemic symptoms
(fever, headache, fatigue, and nausea).
There is no dancer of acauiring any blood borne disease from the
Hepatitis B vaccine Itself . Early concerns about safety of
plasma-derived HB vaccine (no longer in use here), especially the
concern that infectious agents such as human immunodeficiency
virus (HIV) present in donor plasma pools might contaminate the
final product, have proven to be unfounded. The recombinant HB
vaccine does not contain infectious materials.
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NEIC Exposure Control Plan. Bloodborne Pathogen Exposures Page 3
Appendix C Hepatitis B Vaccination Information and Consent/Declination Forms
post vaccination antibody testin for immune response
it is currently recommended that titers of anti—HBs (Hepatitis B
antibody) be tested 1-2 months after the completion of the full
vaccination series for Hepatitis B. Those with a positive
antibody titer* (i.e., a titer of 10 inilli—internationa]. units
per milliliter of blood) at that time are considered to be
immune. It is not known how long this immunity will last but the
current thinking is that immunity will last for at least five to
seven years and may be lifelong. At this time, the CDC is not
recommending any booster shots for these and it is hoped that
this immunity will be permanent. Further data on the need for
booster shots may be available in coming years.
Individuals who have a low antibody titer when tested (i.e., < 10
MIU/ml) 1-2 months after completion of the full vaccination
series should receive further vaccinations and testing as noted
below: They should receive a fourth injection (at the same dose
as the original injection) just after the negative test results
are received, and 1-2 months later should be tested again for
ariti—HBs titers. If the titers are positive, the person should
be considered immune. If the titers are still low, a fifth
vaccination should be given at that time and anti-HBs titers
tested once more 1-2 months later. If these titers are positive,
the individual is considered immune. If antibody titers remain
low after five injections, it is presumed the individual will not
be able to develop an immune response and no further injections
are indicated. In these cases the individual is considered a
non—responder to Hepatitis B vaccinations and a physician should
be consulted regarding the need for medical work restrictions.
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NEIC Exposure Control Plan: Bloodborne Pathogen Exposures Page 4
Appendix C: Hepatitis B Vaccination Information and Consent/Declination Forms
HEPATITIS B VACCINATION: CONSENT FORM
I have read the information about Hepatitis B and the Hepatitis B vaccine.
have had the opportunity to ask questions and understand the benefits and
risks of Hepatitis B immunization. I agree to receive the three doses
required for the optimum immune response. However, as with all medical
treatment, I understand there is no guarantee that I will become immune or
that I will not experience adverse side effects from the vaccine. Please
print.
Name of person to receive vaccine Social Security Number
Signature of person receiving vaccine Witness
Date Date
HEPATITIS B VACCINATION RECORD
1 DATE
GIVEN BY
LOT #
Primary dose
1 Month after Primary Dose
6 Months after Primary Dose
HEPATITIS B VACCINATION: DECLINATION FORM
I understand that, due to my occupational exposure to blood or other
potentially infectious materials, I may be at risk of acquiring Hepatitis B
virus (H.BV) infection. I have been given the opportunity to be vaccinated
with Hepatitis B vad ine, at no cost to me. However, I decline Hepatitis B
vaccination at this time. I understand that by declining this vaccine, I
continue to be at risk of acquiring Hepatitis B, a serious disease. If in the
future I continue to have occupational exposure to blood or other potentially
infectious materials and I want to be vaccinated with Hepatitis B vaccine, I
can receive the vaccination series at no cost t me.
Print Name Signature
Social Security Number Address
Date City/State
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APPENDIX D
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APPENDIX D
REFERENCE INFORMATION ON HEPATITIS B INFECTIONS
FROM MMWR
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MMWR CEMEPS FOP DISEASE CONIROL Novembe, 22 1991 1 Vol 401 No AR 13
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and
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ha dii. In the weakly MMWR a,s piovislon.) basso on *eakly sports to COC by slat. ha.Iih
Reports
d.p.sirnmta Hi. uepo ,tlng weak conctudsa .1 close of business on Filday cornpll.d data one n allon.l basis
as. ollklaly ,ets.,sd to th, public on the succeeding Filday Inquliles aboul the MMWA Sari,. Including
n ,ala,Ial to ha cois,kfa..d I.. piubItcallois, should be dkscted to Eutlto,. MMWA Sails,. Medstop C Cs
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I
I Hepatitis B Virus:
A Comprehensive Strategy
for Eliminating Transmission in the
z I
United States Through Universal
5 , .
Childhood Vaccination
Recommendations of the Immunization
Practices Advisory Committee (ACIP)
a
I 1
I I
‘ I
I I U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
I .• Public Health Service
4 Centess for Disease Control
/
j I
I I National Center for Inlect,ous Diseaces
I I Atlanta. Georgia 30333
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I I MMWJ I
Nowemb,, 22. 1991 Vol 40 I No RR- 13
MMWR 1
Immunization Practices Advisory Committee
Membership LIst. September 1991
EXECUTIVE SECRETARY
Claire V Broome. M 0
Centers for Disease Control
MEMBERS
Stanley E Broadnax. M D
Cincinnati Health Department
Mary Lou Clement.. M D
Johns Hopkins University
(Baltimore. Maryland)
David W. Fraser, M V
Swaithniore College
(Pennsylvania)
Carotine B Hall, M 0
University of Rochester
School of Medicine and
Dentiatry (New York)
Carlos H Ramiiez Ronda. M 0
University of Puerto Rico
School of Medicine (San Juan)
Mary E Wilson. M 0
Mount Auburn Hospital
(Cambridge. Massachusetts)
Canadian National Advisory Committee
on Immunization
Susan E Tamblyn, M 0. Dr P H
Stratford. Ontario
Canada
Hepatitis B Virus: A Comprehensive Strategy
for Eliminating Transmission in the
United States Through Universal
Childhood Vaccination
Recommendations of the Immunization Practices
Advisory Committee (ACIP)
The following statement updates all previous recommendations on psotec-
hon against hepatitis B virus infection, including use of hepatitis B vaccine and
hepatitis B immune globulin for prophylaxis against hepatitis B virus infection
(MMWR I 985.34 313 24.329-35, MMWR 7987,36 353 66, and MMWR 1990.39
INo R n 2! 8 79) and universal SC O8flifl9 of pregnant women to prevent pen-
natal hepatitis B virus transmission (MMWR I 988.37 347 46,51. and MMWR
1990,39INo RR-2! 8- 79! Recommendations concerning the prevention of of her
types of vua hepatitis are found in MMWR 1990,39(No RR 2! 1 8, 22-26
This document provides the rationale for a comprehensive strategy to
eliminate transmission of hepatitis B virus in the United States This prevention
strategy includes making hepatitis B vaccine a part of routine vaccination
schedules for all infants
INTRODUCTION
The acute and chronic consequences of hepatitis B virus (HBV) infection are niaior
health problems in the United States The reported incidence of acute hepatitis B
increased by 37% from 1979 to 1989, and an estimated 200.000 300.000 now
Infections occurred annually during t he period 1980—1991 The estimated 1 million-
1 25 million persons with chronic HBV infection in the United States are potentially
infectious to others In addition, many chronically infected persons are at risk of
long term sequelae, such as chronic liver disease and primary hepolocellular
carcinoma, each year approximately 4.000-5.000 of these persons die from chronic
liver disease (I)
Immunization with hepatitis B vaccine is the most elleclive means of proveiiliiig
HBV infection and Its consequences in the United States, most infections occur
among adults and adolescents (2,3) The recommended strategy for preventing these
infections has been the seleclive vaccination of persons wiih ideritilied risk factors
(1,2) However, this strategy has not lowered the incidence of hepatitis B primarily
because vaccinating persons engaged in high-risk behaviors, life styles, or occupa-
tions before they become infected generally has not been feasible In addition, many
infecied persons have no identifiable source for their infections and thus cannot be
targeted for vaccination (2)
Preventing IIBV transmission during eoriy childhood is irnpoilamit because of the
high liketihood of chronic HBV imifectiori and chronic liver disease that occurs when
children less luau 5 years of age become infected (3) Testing to identity pregnant
CHAIRMAN
Samuel I, Katz. M D
Duke University Medical Center
iames 0 Cherry. M 0
University of California School
of Medicine (Los Angeles)
EX OFFICIO MEMBERS
John La Montagne. Ph 0
Nstional Institutes of Health
Carolyn Hardegree. M D
Food and rug Administration
LIAISON REPRESENTATIVES
American Academy of Family Physicians
Ronald C Van Bureri, M 0
Columbus. Ohio
American Academy of Pediatrics
Georges Peter, M 0
Providence, Rhode island
Caroline 8 HaIl, M 0
Rochester, New York
American College of Physicians
Pierce Gardner, M D
Stonybrook. New York
American Hospital Association
William Schaffner, M 0
Nashville, Tennessee
American Medical Association
Edward A Morlime,, Jr. M 0
Cleveland. Ohio
Carlos E Hernandez. M 0
Kentucky Department for
Health Services
Gregory H Istre. M D
Medical City Hospital
(Dallas, Texas)
Department of Defense
Michael Peterson, DV M
MPH,Or PH
Wasliiiigton. 0 C
National Vaccine Program
Kenneth J Ban. M V
Rockville, Maryland
•Terms oinpired 6130/91
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Nov.mber 22. 1991
MMWR
The MMWR series of publications is publishod by the Epidemiology Program Office,
Centers foe Disease Control. Public HealIli Service. U S Department of Health and
Human Services. Atlanta, Georgia 30333
Centers for Disease Control William I Roper. M 0. M P H
Director
The recoiiimendatlons on hepatitis B virus ware developed by the Immunization
Practices Advisory CommIttee (ACIPI. in collaboration with
National Center lot Infectious Diseases James M Hughes, M D
Acting Director
Division of Viral and Rlckettsial Diseases Brian W J Mahy. Ph 0, Sc 0
Director
HepatitIs Branch Harold S Margolis, M 0
Chief
The production of this report as en MMWA serial publication was coordinated in
Epidemiology Progmein Office Slephen B Thacker, M 0. M Sc
Director
Richard A Goodman, M 0, M P H
Editor; MMWR Series
Scieniillc CommunIcations Program
Public Health Publications Branch
Ava W Navin. M A
Project Editor
Ruth C Greenberg
Editorial Assrstant
Contents
Introduction
Epidemiology and Prevention of Hepatitis B Virus Infection
Infections among Infants and Children
Infections among Adolescents and Adults
Epidemiology and Prevention of hepatitis Delia Virus Inlectioii
Strategy to Eliminate Hepatitis B Virus Transmtssion
Prophyla is against Hepatitis B Inlection
Hepatitis B Immune Globulin
Hepatitis B Vaccine
Vaccine Usage
Vaccine Efficacy and Booster Doses
Vaccine Side Effects and Adverse Reactions
Recommendations
Prevention of Perinatal Hepatitis B Virus tnfection
Universal Vaccination of Infants Born to HHsA 9 Negative Mothers
Vaccination of Adolescents
Vaccination of Selected High Risk Groups
EvolvIng Issues in Hepatitis B Immunization Programs
References
Appendix Postexposure Prophylaxis for Hepatitis B
Introduction
Acute Exposure to Blood that Contains (or Might Contain) HBsAg
Sea Partnere of Persons with Acute Ilepatitis B Virus Infection
Household Contacts of Persons with Acute Hepatitis B Virus liifection
SUGGESTED CITATION
Centers (or DIsease Control Hepatitis B virus a comprehensive strategy (or
elimInating transmissIon In the United Slates through universal childhood
vaccination recommendattons of the Immunization Practices Advisory Commit-
tee (ACIP) MMWR 1991 40(No RA 13) linciusive pa4e numbers)
2
2
3
4
4
5
5
5
6
9
10
11
11
13
13
14
16
16
21
21
21
24
24
Suzanne M Hewitt
Chief
Use of trade names is for identification only and does not imply endorsement by
Pie Public Health Service or the U S Oeparlmeiit of Health and Human Services
Copies can be purchased from Superintendent of Documents. U S Government
Printing Office. Washington. DC 20402 9325 Telephone (202) 783 3238
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2 MMWR
Nov,nib., 22. 1991 Vol 401 No 11 1 113
MMWR 3
women who are hepatitis B surface antigen(HBsA 9 ) positive and providing their
infants with Immunoprophylaxis effectively prevents HBV transmission during the
perinalal period (4,5) Integrating hepatitis B vaccine into Childhood vaccination
schedules in populations with high rates of childhood infection (e g , Alaskan Natives
and Pacilic Islanders) has been shown to interrupt IIBV transmission (6)
This document provides the rationale for a comprehensive strategy to eliminate
transmission of HBV and ultimately reduce the incidence of hepatitis B and hepatitis
U-associated chronic liver disease in the United States The recommendations for
Implementing this str.legy include making hepatlhis B vaccine a part of routine
vaccination schedules (or infants
EPIDEMIOLOGY AND PREVENTION OF HEPATITIS B VIRUS
INFECTION
Infection, among Infants and Children
In the United States, children become infected with HBV through a variety of
means The risk of perinatai HBV infection among infants born to HBV-infected
mothers ranges from 10% to 85%, depending on each mother’s hepatitis U e antigen
(HBeAg) status (3.7,8) Infants who become infected by perinetal transmission have
a 90% risk of chronic infection, and up to 25% will die of chronic liver disease a. adults
191 Even when not infected during the perinatat period, children of HBV-infected
mothers remain at high risk of acquiring chronic HOV infection by person to-person
(horizontal) transmission during the first 5 years of life (90) More than 90% of these
infections can be prevented if HBsA 9 positive mothers are identrlied so that their
infants can receive hepatitis B vaccine and hepatitis B immune globulin (HBiG) soon
alter birth (4,5)
Because screening selected pregnant women for HBaAg has failed to identify a
high proportion of HBV-infocted mothers (11.92). prenatal HB8Ag testing of all
pregnant women Is now recommended (1, I 3.941 Universal prenatal testing would
Identify an estimated 22,000 1-IBeAg positive women end could prevent at least 6,000
chronic NOV Infections annually (3) Screening and vaccination programs for women
and infants receiving care in the public sector have already been initiated through
state immunization projects
Horizontal transmission of NOV during lIre first 5 years of tile occurs frequently in
populations in which HOV infection is endemic The risk of chronic infection is age
dependeni. ranging from 30% to 60% for children 1-5 years of age (15) Worldwide,
it has been recommended that, in populations in which HBV infection is acquired
during childhood, hepatitis B vaccine should be integrated into routine vaccination
schedules (or infants, usually as a part of the World Health Organization’s Expanded
Programme on Immunization (16) in the United States, racial/ethnic groups shown
to have high rates of childhood NOV infection include Alaskan Natives (6,97). Pacific
Islanders (18). and infants of first generation immigrant mothers from parts of the
world whole NOV infection is eiidernic, especially Asia (19,20) Vaccination programs
to prevent perinatal. childhood, and adult I - ISV infections among Alaskan Nativea
were begun in late 1982. as a result, the incidence of acute hepatitis B in this
population lies declined by over 99% (6) Hepatitis B vaccine was integrated into
vaccination schedules for infants in American Samoa beginning in 1986 and by 1990
was incorporated into the schedules of tIre remaining Pacilmc Islands under U S
jurisdiction
Each year. approximately 150.000 infants are born to women who trove mmmi
grated to the United States from areas of the world wheme HBV infection is highly
endemic (3) Children born to HBsA 9 positive mothers can be identified through
prenatal screening programs However. chitdren horn to HBsA 9 negative immigrant
mothers are still at high risk of acquiring HOV infection, usually from other HSV
carriers in their families or communities (3. 99.20) Infections among these children
can be prevented by making hepatitis B vaccine part of their routine infant vaccine
tions (I)
Infections among Adolescents and Adults
In the United States most persons with hepatitis B acquire the infeclion as
adolescents or adults Several specific modes of transmission have been identified
Including sexual contact, especially among homosexual men and persons with
multiple heterosexual partners. parenteral drug use, occupational exposurE’s. tionise
hold contact with a person who has an acute infection or with a chronic carrier,
receipt of certain blood products, and hemodialysis However, over one third of
patients with acute hepatitis B do not have readily identifiable risk factors (9,2)
The rates of NOV infection differ significantly among various racial and ethnic
groups (2,21) For example, the prevalence of infection among adolescents and
adulte has been shown to be threefold to fourfold greater for blacks then for whites
and to be associated with serologic evidence of previous infection with syphilis
(21,221
Efforts to vaccinate persons in the major risk groups trove had limited success For
example, programs directed at iniecting drug users failed to motivate thorn to receive
three doses of vaccine (CDC. unpublished data) Health care providers aie often not
aware of groups at high risk of HBV infection and frequently do not uleinlily
candidales for vaccination during routine health care visits (COC. unpublished data)
In addition, there has been limited vaccination of susceptible household and sexual
contacts of HBsA 9 carriers identified in screening progrerlis for blood donors (23)
Hepatitis B vaccination of health-care workers appears to have resulted in a substan-
tial decrease in tire rate of disease in this group, but lies had little effect on overall
rates of hepatitis 0 (2) Moreover, to achieve widespread vaccination of persons at
occupational risk, regulations have had to be developed to ensure implementation of
vaccination programs (24)
Educational programs to reduce parenteret drug use and unprotected sexual
activity are important components of the strategy to prevent infection with the truman
lmmunode(iciency virus (HIV). which causes acquired immunodeticrency syndrome
These programs appear to have reduced the risk of HBV infections among homosex-
ual men but have not had err impact on hepatitis B attributeble to parenterai drug use
or heterosexual transmission (2) Educational efforts alone are not likely to fully
elimninate tire high risk behaviors responsible for IIBV traiisrniissron
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4 MMWR
Vol 401 No RR 13
November 22. 1991
MMWR 5
EPIDEMIOLOGY AND PREVENTION OF HEPATITIS DELTA
VIRUS INFECTION
Hepatitis delta virus (HDV) is a defective virus that causes infection only in the
presence of active HBV infection (25 HDV infection occurs as either coinfection with
HBV or superinfection of an HBV carrier Coirifectron usually resolves, superinfection,
however, frequently causes chronic HDV infectiore and chronic active hepatitis Both
types of infection may cause fulminant hepatitis
Routes of transmission are similar to those of HBV In the United States, HDV
•nf ction most commonly afiects persons at high risk of HBV infection, particularly
iniecting drug users and persons receiving clotting (actor concentrates (26) Prevent
lug acute and chronic HBV infection of susceptible persons will also prevent HDV
Infection
STRATEGY TO ELIMINATE HEPATITIS B VIRUS TRANSMISSION
A comprehensive strategy to prevent HBV infection, acute hepatitis B, and the
sequelae of HBV infection in the United Slates must eliminate transmission that
occurs during infancy arid childhood, as well as during adolescence and adulthood In
the United States it has become evident that HBV transmission cannot be prevented
through vaccinating only the groups at high risk of infection No current medical
treatment will reliably eliminate chronic HBV Infection and thus eliminate the source
of new infections in susceptible persons (27) Therefore, new infections can be
prevented only by immunizing susceptible persons with hepatitis B vaccine Routine
visits (or prenatal and well-child care can be used to target hepatitis B prevention A
comprehensive prevention strategy includes a) prenatal testing of pregnant women
for HBsAg to Identify newborns who require immunoprophytaxis for the prevention
of peruiatal infection and to identify household conlact who should be vaccinated, bi
routine vaccination of children born to HBsA 0 negative mothers, c) vaccination of
certain adolescents and d) vaccination of adults at high risk of infection
infants anal children can receive liepatilis B vaccine during routine health care
visits, no additional visits would be required Coats Include that of the vaccine and the
incremental expense associated with delivering an additional vaccine during a
scheduled health care visit implementation of this immunization strategy would be
greatly facilitated by the development and use of multiple antigen vaccines (e g.
diphtheria-telanus-pertU sslslDTPllhePatitia B, Haemophslus ,nfluenzae type b con-
jugale/tiepatitis B) These vaccines would reduce the number of injections received by
the infant, reduce the cost of administration, and greatly facilitate widespread vaccine
delivery
Since most l- (BV infections occur among adults, disease control could be acceler-
ated by vaccinating emerging at-risk populations, such as adolescents and suscepti’
ble contacts of chronic HBV carriers The recommendation for universal infant
vaccinstion neIther precludes vaccinating adults identified to be at high risk of
infection nor altars previous recommendations for postexposure prophytaxis for
hepatitis B (I)
The reduction in acute hepatitis B and hepatitis B associated chronic liver disease
resulting lrom universal infant vaccination may not become apparent for a number of
yea’s Ifowever universal HBsA 9 screening of pregnant women to prevent perinatal
HBV infection has been shown to be cost saving (28, CDC, unpublished data). and the
estimated cost of universal hepatitis B vaccination for Infants is less than the direct
medical end work loss costs associated with the estimated 5% lifetime risk of
Infection (CDC. unpublished data) Currently, tIne cost of era infant’s dose of hepatitis
B vaccine delivered in the public sector is about the same as each of the oilier
childhood vaccinations Vaccinating adolescents and adults is substantially more
expensive because of the higher vaccine cost and the higher implementation costs of
delivering vaccine to target populations In the long term, universal infant vaccination
would eliminate the need for vaccinating adolescents and high-risk adults
PROPHYLAXIS AGAINST HEPATITIS B VIRUS INFECTION
Two types of products are available for prophylaxis against HBV infection
Hepatitis B vaccine, which provides long term protection against HBV infection, is
recommended for both preexposure and postexposure prophylaxis HBiG provides
temporary protection (i a, 3 8 months) and is indicated only in certain postoxposure
setting,
Hepatitis B Immune Globulin
HUIG is prepared from plasma known to contain a high titer of antibody against
HBsAg (anti HBs) In the United States, HOIG ties an anti HOs titer of >100.000 by
radloimmunoessay The human plasma from which HBIG is prepared is screened for
antibodies to HIV, in addition, the process used to prepare IIBIG inactivates and
eliminates HIV from the final product There is no evidence thai HIV can be
transmitted by HBIG (29,30)
HepatitIs B Vaccine
Two types of hepatitis B vaccine have i’eon licensed ira the United States One,
which was manufactured (morn the plasnraa of chronically uii(ecio(l persoiis, is rio
longer produced in the United States The currently available vaccines are produced
by recombinant DNA technology
The recombinant vaccines are produced by using HBsAg synthesized by Saccha
romyces ce,ev,s,ee (common bakers’ yeast), into which a piasinid containing the
gene for HBsA 9 has been inserted Purified HBsA 9 is obtained by lysing the yeast
cells and separating HBsAg from the yeast components by biochemical and biophys’
Ical techniques Hepatitis B vaccines are packaged to contain 10 40 pg of HB5Ag
protein/mi after adsorption to aluminum hydroxide (05 mg/nil), thirnerosal (1
20,000 concentration) is added as a preservative
Routes and sites of administration
The recommended series of three intramuscular doses of hepatitis B vaccine
induces a protective antibody response (anti HBs 10 math international units (miUll
ml) in >90% of healthy adults and in >95% of infants, children arail adolescents
(31-33) Hepatitis B vaccine should be administered Only in lIre deltoid niuscie of
adults end children or ira the ariterolaterai thigh muscle of neonates and rnfant the
irnrnuraogenicity of tIre vaccine for adults is substantially lower when inlectroris are
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6 MMWR
November 22, 1931 Vol 40 No HR 13
MMWR 7
erlministe,ed in the buttock (34) When hepatitis B vaccine is administered to Infants
at the same time as other vaccines, separate sites in the enterolateral thigti may be
used for the multiple in ecttons This method is prelerabie to administering vaccine at
sites such as the buttock or deltoid
Compared with three standard doses admistered intramuscularly, three low doses
of plasma derived or recombinant vaccine administered intradermatiy to adults result
in lower seroconversion rates (55%-B1%) and lower (mat titers of ant.-HBs 135-38).
although four doses of plasma derived vaccine administered intradermally have
produced responses comparable with vaccine administered intramuscularly (39)
Plasma derived vaccine administered intradermaiiy to infants and children does not
induce an adequate antibody response (40) At this time, low dose initadermal
vaccination of adults should be performed only under research protocol with written
informed consent Parsons who have been vaccinated intredermally should be tested
for anti HBs Those with en inadequate response (anti HHs 10 mlU/mL) should be
revaccinated with three lull doses of vaccine administered intramuscularly intrader-
mel vaccination should not be used for infants or children
Vaccination during pregnancy.
On the basis of limited experience, there is no apparent risk of adverse effects to
developing fetuses when hepatitis B vaccine is administered to pregnant women
(CDC. unpublished data) The vaccine conisins noninfectious HBsAg particles and
should cause no risk to the fetus HBV infection affecting a pregnant woman may
result in severe disease for the mother and chronic infection for the newborn
Iherelora. neither pregnancy nor lactation should be considered a contraindication to
vaccination of women
Vaccine Usage
Preexposute prophylaitis
Vaccination schedule and dose The vaccination schedule most often used for
adults and children has been three intramuscuiaf iniections. the second and third
administered 1 and 6 months. respecliveiy, after the first An alternate schedule of
four doses has been approved for one vaccine that would allow more rapid induction
of immunity However, for preexposure prophylaxia. there is no clear evidence that
this regimen provides greater protection than that obtained with the standard
three dose schedule
Eecli vaccine has beet, evaluated to determine (he age specific dose at which an
optimum antibody response Is achieved The recommended dose varies by product
and the recipient’s age and, for infants, by the mother’s HBsAg serologic status (Table
1) In general, the vaccine dose for children and adolescents Is 60%-75% lower than
that required for adults (Table 1)
Incorporating hepatitis B vaccine into childhoOd vaccination schedules may
require modifications of previously recommended schedules However, a protective
level of anti-liBs (“10 mlU/mt-) was achieved when hepatitis B vaccine was
adinim ,istered in a variety of schedules. including tttose in which vaccination was
begin’ soon after birth (5.8.41)
In a three dose schedule, increasing the interval between the first and second
doses of hepatitis B vaccine has little of fact on immnunOgeniCitY or I i, ,al antibody tiler
The third dose confers optimal protection, acting as a booster dose Longer intervals
between the last two doses (4 12 niontlis) result in higher final liters of aiiii ItOs
(42.43) Sevemal studies have shown that the currently licerisoil vaccines produce
high rates of seroconversion (>95%) and induce adequate levels of anti I- lBs when
administered to infants at bIrth. 2 months. and 6 months of age or at 2 months. 4
months, and 6 months of age (COC, Merck Sharpe & Oohme. Smmthkline Beecham.
unpublished dale) When the vaccine is administered in four doses at 0. 1, 2. and 12
months, the last dose is necessary to ensure the highest fimial antibody titer
When hepatitis B vaccine has been administered at the some time as other
vaccines, no interference with the antibody response of the other vaccines has been
demonstrated (44)
If the vaccination series is interrupted after the first dose, the second dose should
be administered as soon as possible The second and third doses should be separated
by an Interval of at least 2 months If only the third dose ma delayed, it should be
administered when convenient
The immune response when one or two doses of a vaccine produced by one
manufacturer are followed by subsequent doses from a different manufacturer has
been shown to be comparable with that resulting from a full course of vaccination
with a single vaccine
Larger vaccine doses or an increased number of doses are required to induce
protective antibody in a high proportion of hemodmalysis patients 145.46) and may
also he necessary for other immunocompromised persons te g, those who take
immunosuppressive drugs or who are HIV positive), although few data are available
concerning response to higher doses of vaccine by these patients (47)
Prevaccination testing for susceptibility Susceptibility testing is not indicated (or
immunization programs for children or for most adolescents because of the low rate
of HBV infection and the relatively low cost of vaccine For adults, the decision to do
Recomblv.s H8 Enge
rio B
Group Dose lug) (m l) Dose li ’g)
of HOsAg’
(niL)
mothers end children
< Ii years 25 1025) 10
Intents of positive
(05)
mothers, prevention of 5 (051 tO
peri,ioiel niection
and adolescents
(05)
1119 years 5 (05) 20
20
10 (1 0) 20
ii 0)
ii 0)
years
and
Dialysis patients
other immunocompiomised
persons 40 (1 0)’ 40
floth vaccines are routinely administered in a three dose series [ migerma B lie,
also
120)’
been
licensed for a four dose series administered at 0, I. 2. ond 12 months
‘HUsAg — llepaiiiis B aur(ace antigen
‘Special formulation
‘Iwo 1 0 ml doses ad,nmniste,ed at one sHe. do a four dose schedule or 0 1 2 and
mo
,ili ,s
-------
S MMWR
Novsmbsr 22, 1991
Vol 4OlNo RR-13
MMWR 9
nevaccination testing sliotilil include an eui8tysis of cost effectiveness because of the
higher cost of the vaccine Testing for prior infection should be considered for adulle
In risk groups with high rates of HBV infection (e g . infecting drug users. homosexual
men, and household contacts of HBV carriers) The decision for testing should be
based on whether the costs of testing balance the costs of vaccine saved by not
vaccinating already-infected persons Estimates of the cost effectiveness of testing
depend on three variables the cost of vaccination. the cost of testing for suscapti.
bilily. and the expected prevalence of immune persons II susceplibility testing is
being considered, careful attention should also be givqn to the likelihood of patient
follow up and vaccine delivery
ror routine testing, only one antibody test is necessary antibody either to the core
antigen lariti HBcl or anti-HBsI Aiiti HOc testing identifies all previously infected
persons. including HBV centers, but does not differentiate carriers end non-carriers
The presence of anti HBs Identifies previously Infecled persons, except for HRV
carriers Neither test has a particular advantage for groups expected to have HBV
carrier rates <2%, such as health care workers Anti-HBc may be preferable so that
unnecessary vaccination of HBV carriers can be avoided In groups with high carrier
rates
Postvacclnstlon t..tlng for s.rotoglc r.spona. Such testing is not necessary
alter routine vaccination of infants, children, or adolescents Testing for immunity is
advised only for poisons whose subsequent clinical management depends on
knowledge of their immune Status (e g, infants born to HBsAg positive mothers,
dialysis patients and stall, and persons with H1V Infection) Postvaccinalion testing
houtd also be considered for persona at occupational risk who may have exposures
from injuries with sharp instruments, because knowledge of their antibody response
will aid in determining appropriate postexposure prophytaxis When necessary.
postvaccination testing should be performed from 1 to 8 months after completion of
the vaccine series Testing after immunoprophytexis of infants born to HBsAg-
positive mothers ehould be performed from 3to 9 months after the completion of the
vaccination series ( see section on Postexposure prophylaxis)
Revaccination of nonr.spondeis When persons who do not respond to the
primary vaccine series are rovaccinated. 15% 25% produce an adequate antibody
response alter one additional dose and 30%-50% alter three additional doses ( 48)
Therefore. revaccinalion with one or more additional doses should be considered for
persons who do not respond to vaccination initially
Poatexposurl prophylaxls
After a person has been exposed to HBV. appropriate immunoprophylectic
treatment can effectively prevent infection The mainstay of postexpoaure immurro ’
prophylaxis Is hepatitis B vaccine, but in some settings the addition of HBIG will
provide some Increase in protection Table 2 provides a guide to recommended
treatment for various HBV exposures
Transmission of perinatal HBV infection can be effectively prevented if the
HOsAg positive mother is identified and if her infant receives appropriate immuno-
prophylaxie Hepatitis B vaccination and one dose of H8IG. administered within 24
hours after birth, are 85% 95% effective in preventing both HBV infection end the
chronic carrier state (4,5,8) Hepatitis 8 vaccine administered atone in either a
three dose or four-dose schedule (Table 1). beginning within 24 hours after birth, is
70% 95% effective in preventing perinatal HBV infections (841) The infants of
women admitted for delivery who have not had prenatal HOsAg testing pose
problems in clinical management Initiating hepatitis B vaccination at birth for infants
born to these women will provide adequate postexposure prophylaxis if the mothers
are indeed HOsAg positive The few infections not prevented by either of these
treatment regimens were most likely acquired tn utero or may be due to very high
levels of maternal HBV-DNA (49)
SerologIc testing of infants who receive lmmunoprophylaxis to prevent perinatat
infection should be considered as an aid in the long tern) medical management of the
few infants who become HBV carriers Testing for anti HAs and Ht3sAg at 9 15 months
of age will determine the success of the therapy and, in the case of failure, will identify
HBV carriers or infants who may require revaccination
Recommendations for postexposure prophylaxis in circumstances other than the
perinatal period (Table 2) have been addressed in a previous statement and are
reprinted as Appendix A to this document
Vaccine Efficacy and Booster Doses
Clinical trials of the hepatitis B vaccines licensed in the United States have shown
that they are 80% 95% effective in preventing HOV infection and clinical hepatitis
among susceptible children and adults (5,33,4 1,50) If a protective antibody response
develops after vaccination, vaccine recipients are virtually 100% protected against
clinical illness
The duration of vaccine induced Immunity has been evaluated in long term
follow up studies of both adults and children (48,51 ) Only the plasma derived
hepatitis B vaccine has been evaluated because it has had the longest clinical rise.
however, on the basis of comparable immunogenicily and short term efficacy, similar
TABLE 2 Guide to postexposure immunoprophylaxis for exposure to hepatitis B
virus
Type of .xposur.
Immunoprophylasts
Referenc.
Pednatal
Vaccination I liBlG’
11 12
Sexual—acute Infection
I I BIG Vaccination
Appendix
Sexual—chronic carrier
Vaccination
p 12 15
Household coniact—
chronic carrier
Vaccination
p 12 15
Household contact—
acute case
None unies
known exposure
Appendix
Houeehoid coniaci-acuie
case, known exposure
I-WIG ± vaccination
Appendix
Infant f’ 12 months)—
acute case in primary
care giver
HBIG i vaccination
Appendix
Inadverlent-perCutafleOUS!
permucosal
Vaccination ‘ ttRiG
Ap ieriiin n
‘HBiG Hepatitis B ininiunre giobuli
n
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10 MMWR
November 22. 1991 Vol 40! No AR 13
MMWR 11
results would be expected with recombinant vaccines The magnitude of the antibody
response induced by the primary vaccination series is predictive of antibody persis-
tmrro. and a logarithmic decline of antibody levels occurs over time Among young
adults homosexual men end Alaskan Eskimos) who initially responded to a three-
dose vaccine series, loss of detectable antibody has ranged from 13% to 60% alter 9
years of follow up For children vaccinated alter tire first year of life, tire rate of
antibody decline has been lower than for adults (51) The peak antibody titers for
infants are lower their those for clrildroir immunized after 12 months of age, but the
rate of antibody decline is comparable with that observed for adults in the seine
population
Long term studies of healthy adults and children Indicate that immunologic
memory remains intact (or at least 9 years and confers protection against chronic HDV
infection, even though anti-HBs levels may become low or decline below detectable
levels (48.51.52) In these studies, the I- WV Infections were detected by the presence
of anti HBc. No episodes of clinical hepatitis were reported and HBsA 0 was not
detected, although brief episodes of viremia may not have been detected because of
infrequent testing The mild, inapparent infections among persons who have been
previously vaccinated should not produce the eequelae associated with chronic HBV
infection and should provide lasting immunity In general, follow.up studies of
children vaccinated at birth to prevent perinatal HBV infection have shown that a
continued high level of protection from chronic HBV infections persists at least 5
years (52.53)
For children and adults whose immune status is normal, booster doses of v8ccine
are not recommended, nor Is serologic tesiing to assess antibody levels necessary
Tire possible need for booster doses will be assessed as additional information
becomes available For hemodialysis patients, vaccine-induced protection may be
less complete and may persist only as long as antibody levels are 10 mlU/nil For
these patients, the need for booster doses should be assessed by annual antibody
testing, and a booster dose should be administered when antibody levels decline to
<10 miUlmi.
Vaccine Side Effects and Adverse Reactions
Hepatitis B vaccines have been shown to be safe when administered to both adults
and children Over 4 million adults have been vaccinated in the United States, and at
least that many children have received hepatitis 8 vaccine worldwide
V.cclne.ssoci.ted side sffscts
Pain at the ln(action site (3%-29%) and a temperature greater than 37 7 C (1%-6%)
have been among the most frequently reported side effects among adults and
children receiving vaccine (5,31-33,50). in placebo-controlled studies, these side
effects were reported no more frequently among vaccinees than among persons
receiving a placebo (33.50) Among children receiving both hepatitis B vaccine and
DTP vaccine, these mild aide effects have been observed no more frequently than
among children receiving DTP vaccine alone.
Serious adverse events
In the United Slates, surveillance of adverse reactions has shown a possible
association between Guillalir-Barré syndrome (GBS) and receipt oh the first dose of
plasma derived hepatitis B vaccine (54, CDC unpublished datal GUS was reported at
a very low rate (05/100,000 vaccinees), no deaths were reported, and all reported
cases were amoirg adults An estimated 2 5 million adults receivr’d omro or more dosrs
of recombinant hepatitis B vaccine during the period 1966 1990 Available data from
reporting systems for adverse events do not indicate air association between receipt
of recombinant vaccino arid GBS (COC, unpublished data)
Until recently, large-scale hepatitis B vaccination programs for infants leg.
Taiwan. Alaska, and New Zealand) have primarily used plasma-derived hepatitis B
vaccine No association has been found between vaccination end tire occurrence of
severe adverse events, including seizures and GBS (55. B McMahon and A Milire,
unpublished data) However, systematic surveillance for adverse reactions has beau
limited in these populations, and only a small number of children have received
recombinant vaccine Any presumed risk of adverse events possibly associated with
hepatitis B vaccination must he balanced against the expected risk of acute end
chronic liver disease associahed with tire current 5% lifetimo risk of IWV infpi-tioii in
the United States it is estimated that, for each U S birth cohort, 2000 5,000 persons
will die from HBV-reiated liver disease
As hepatitis B vaccine is introduced for routine vaccination of infants, surveillance
for vaccine-associated adverse events will conlirwe to be en important part of the
program in spite of the current record of safety Any adverse event suspected to be
associated with hepatilis B vaccination should be reported to lire Vaccine Adverse
Event Reporting System (VAERS) VAERS forms can be obtairred by calling 1-
800 822-7967
RECOMMENDATIONS
Pzevention of Perinatal Hepatitis B Virus Infection
1 All pregnant women should be routinely tested for HBsA 9 during an early prenatal
visit in each pregnancy, preferably at the same time other routine prenatal
laboratory testing is done HBsAg testing should be repeated late in tire pregnancy
for women who are HBsAg negative but who are at high risk of IIBV infection (a g,
injecting drug users, those with intercurrent sexually transmitted diseases) or who
have had clinically apparent hepatitis Tests for other HBV markers are not
necessary for the purpose of maternal screening However, HBsA 9 positive
women identified during screening may have HBV-related liver disease and should
be evaluated (56)
2 Infants born to motirers who are 1-IBsAg positive should receive the appropriate
doses of hepatitis B vaccine (Table 1) and HUIG (05 ml) within 12 hours of birth
Both should be administered by intramuscular injection Hepatitis 8 vaccine
should be administered concurrently with FIBIG but at a different site Subsequent
doses of vaccine should be administered according to the recommended schedule
(Table 3)
3 Women admitted for delivery who have not had prenatal HBsAg testing should
have blood drawn for testing Wlrile test results are pending, tire irrfant should
receive hepatitis B vaccine within 12 hours of birth, in a dose appropriate for
infants born to 1 -IBsAg positive mothers (Table 1)
-------
12 MMWR
Novemb., 22. 1991 Vol 401 No RB 13
MMWR 13
• lithe mother is later found to be HBsA 9 positive, her inlant should receive the
additional protection of HBIG as soon as possible end within 7 deys of birth.
although the efficacy of HBIG administered alter 48 hours of age is not known
(57) I I HBIG has not been administered, it is important that the infant receive
the second dose of hepatitis B vaccine eli month end not later then 2 months
of age because of the high risk of infection The last dose should be adminis’
tered at age 8 months (Table 3)
b If the mother is found to be HBsAg negative, her infant should continue to
receive hepatitis B vaccine as pall of his or her tbutine vaccinations (Tables 3
end 4), in the dose appropriate for infants born to HBsAg-negatsve mothers
(Table I)
4 In populations in which screening pregnant woman for HBsAg is not feasible. all
infants should receive their first dose of hepatitis 8 vaccine within 12 hours of birth,
their second does at 1 2 months of ego. and their third dose at 8 months of age ap
• pelt of their childhood vaccinations end wall-child care (Table 3)
5 Household contaCtS and ses partners of HBsAg positive women identified through
prenatal screening should be vaccinated The decision to do prevaccinetion testing
of these contacts to determine susceptibility to HBV infection should be made
according to the guidelines in the section “Prevaccinetion testing for
‘if . fou, dose ichedute is used ltabtas I and 31. the second and third doses should be
.dmanIsieied stl end 2 months of age respectively, end the fourth dose at 12 18 months of age
TABLE 3 R.commendud schedul. of hepatitis B Immunoprophylasis to prsvent
perinetal transmission of hepatitis B virus infection
infant born to mother known to be HBA9 poslttv.
V.ccln• do..’ Ag. of
12 hours)
First Biith (within
12 hours)
HBIG’ Bi,ih (within
month
Second 1
Third 8 months’
tnfant born to mothsr not .cr.sn .d for HBsAg
Vaccln• doa. Ag. of
12 hours)
First Birth (within
be HBeAg
HBtG’ if mother i.
positive, sdrninister dose to
infant as soon as possible. not
1 week slier bi.ih
isier than
Second 1 2 months”
Third 8 months’
•ltRsA H*pslitis B surface antigen
‘See table I for appropriate vaccine dose
1 Hepstitis B immune globulin tHBtG)—O 5 ml administered iniremuscuterty at a site different
from that used for vaccine
‘if four dose schedule (Engerix B) is used, the third dose is administered at 2 months of age and
the fourth dose at 12 lB months
‘First dose dose (or infant of HBeAg positive,mother (see Table ii If mother is found to be
HBsAg posItive, continue that dose, if mother is found to be HBsAg negative. use approprIate
dose from Table I
“infants of woman who are HBsAg negative can be vaccinated at 2 months of age
susceptibility “ Hepatitis B vaccine should be administered at the age-appropriate
dose (Table I) to those determined to be susceptible or ludged likely to be
susceptible to infection
Universal Vaccination of Infants Born to HBsAg-Negatlve Mothers
1 Hepatitis B vaccination is recommended for all infants, regardless of the HBsA 9
status of the mother Hepatitis B vaccine should be incorporated into vaccination
schedules for children The first dose can be administered during the newborn
period, preferably before the infant is discharged from the hospital, but no later
than when the Infant is 2 months of age (Table 4) Because the highest titers of
•nti-HBs are achieved when the last two doses of vaccine are spaced at least 4
months apart, schedules that achieve this spacing may be preferable (Table 4)
However, schedules with 2-month intervals between doses, which conform to
schedules for other childhood vaccines, have been shown to produce a good
antibody response (Table 4) and may be appropriate in populations In which ills
difficult to ensure that infants will be brought back for all their vaccinations The
development of combination vaccines containing HOsAg may lead to other
schedules that will allow optimal use of combined antigens
2 Special efforts should be made to ensure that high levels of hepatitis B vaccination
are achieved in populations in which HUV infection occurs at high rates among
children (Alaskan Nelives, Pacific Islanders, and infants of immigrants from
countries in which HBV is endemic)
TABLE 4 Recommended schedules of hepatitis B vaccination for infants born to
HBsAg-nsgatlvl mothers
H.pstitis
OptIon 1
Dose 1
Birth—before hospitat discharge
Dose 2
Dose 3
I 2 rno,,ihs’
6 lB months’
Option
Dose 1
Dose 2
1 2 months’
4 months’
Dose 3
6 18 months’
Hepatitis H surface antigen
‘Hepatitis
Uaomophs
the same
B vaccine can be adn,unistemed
Iua lnfluenzee type b confugaia.
visit
simultaneously with, diphtluenie tetanus pentiussis.
meastes mumps rubetia and onat poiio vaccines at
Vaccination of Adolescents
At) adolescents at high risk of infection because they are in)ecting drug users or
have multiple sex partners (more than one partnerl6 months) should receive hepatitis
B vaccine Widespread use of hepatitis B vaccine is encouraged Because risk factors
are often not identified directly among adolescents. univei sat hepatitis B vaccination
of teenagers should be implemented in communities where Injecting drug use.
pregnancy among teenegers. and/or sexually transmitted diseases are common
-------
14 MMWR
November 22, 1991 Vol 401 No RH 13
MMWR 15
Adolescents can be vaccinated in school based clinics, community health centers.
(amity planning clinics, clinics for the treatment of sesuelly transmitted diseases, and
special adolescent clinics
The 0, 1-, and 6 month schedule is preferred for vaccinating adolescents wilh the
age appropriate dose of vaccine (Table 1) However, tIre choice of vaccination
schedule should take into account the feasibility of delivering three doses of vaccine
over a given period of time The use of alternate schedules (a g, 0, 2. and 4 months)
may be advisable to achieve Complete vaccination
Vaccination of Selected High-Risk Groups
Efforts to vaccinate persons at high risk of HBV infection should follow the vaccine
doses shown In Table 1 High risk groups for whom vaccination is recommended
include
I Persons with occupational risk HBV infection is an occupational hazard for
heallh care workers and for public safely workers who have exposure to blood
in the workplace (24.58) The risk of acquiring HBV infections from occupa-
tional exposures depends on lhe frequency ol percutaneous and permucosel
exposwe to blood or blood Contaminated body fluids Any health-care or
public Safety worker may be at risk for HBV exposure, depending on the tasks
he or she performs Workers who perform tasks involving contact with blood
or blood contaminated body fluid should be vaccinated (24.58,59) For public-
safety workers whose exposure to blood is infrequent, timely postexposure
prophylexig should be considered rather than routine preoxposure vaccina
lion
For persons in health care fields, vaccination should be completed during
training in schools of medicine, dentistry, nursing, laboratory technology, and
other allied health professions, before trainees have their first contact with
blood
2 Clients and stall of Institutions for the developmentally disabled Susceptible
clients in institutions for lhe developmentally disabled, as well as staff who
work closely with clients, should be vaccinated Susceptible clients and staff
who live or work in smaller residential settings with known HBV carriers
should also receive hepatitis B vaccine Clients discharged from residential
institutions mb community programs should be screened for HBsAg so that
appropriate measures can be taken to prevent HBV transmission Those
measures should include both environmental controls and appropriate use of
vaccine
Staff of nonresidential day-care programs for the developmentally disabled
(e g. schools. sheltered workshopsl attended by known HBV carriers have a
risk of infection comparable Will) Ihat of health care workers and therefore
should be vaccinated (60) The risk of infection for other clients appears to be
lower than the risk for staff Vaccination of clients in day care programs may be
considered Vaccination of classroom contacts is strongly encouraged if a
classmate who is an HBV carrier behaves aggressively or has special medical
problems le g , exudative dermatitis, open skin iesions) that increase the risk of
exposure to his or tier blood or serous secretions
3 Hemodialysls patients Hepatitis B vaccination is recommended for suscepti-
ble hemodialysis patients Vaccinating palienis early in the course of their
renal disease is encouraged because patients with uremia who are vaccinated
before they require dialysis are more likely to respond to the vaccine (61
Although their seroconversion rates and enti HBs titers are lower than those of
healthy persons, patients who respond to vaccination will be protected from
infection, and the need for frequent serologic testing will be reduced (62)
4 Reclpi.nts of certain blood products Patients who receive clotting factor
concentrates have en increased risk of HBV infection and should be vaccinaied
as soon as their specilic clotting disorder is identified Prevaccination testing is
recommended for patients who have already received multiple infusions of
these products
5 Household contacts end sex partners of HBV carrIa s All household and
sexual contacts of persons identified as HBaAg positive should be vaccinated
The decision to do prevaccination testing to deternuiie susceptibility to IIBV
infection should be made according to the guidelines described earlier in the
section “Prevaccinetion testing for susceptibility” Hepatitis B vaccine should
be administered at the age appropriate dose flable 1)10 those determined to
be susceptible or judged likely to be susceptible to infection
6 Adoptees from countries where HBV Infection is endemic Adopted or
fostered orphans or unaccompanied minors from countries where I -ISV inlec
hon is endemic should be screened for HH5A 9 (3) If the children are 1 -IBsAg
positive, oIlier family members should be vac inaied (63)
7 International travelers Vaccination should be considered br persons who
plan to spend more than 6 months in areas wilh high rates of HBV infection
and who will have close contact with the local population Short term travelers
who are likely to have contact with blood (e g, in a medical setting) or sexual
contact with residents of areas with high or intermediate levels of endemic
disease should be vaccinated Vaccination should begin at least 6 months
before travel to allow for completion of the full vaccine series, aluliough a
partial series will offer some protection The alternate four dose schedule Isee
Table 1) should provide protection ii the first three doses can be delivered
beloie departure
a ln ecting d,ug users All injecting drug users who are susceptible to HBV
should be vaccinated as soon as their drug use begins Because of the high
rate of HBV infection in this population. pievaccination screening should be
considered as outlined in the section “Prevaccination tesliiig (or susceptitnl-
ity” Injecting drug users known to have I-IIV infection should be tested br
anti HBs response after compietion of the vaccine series Those who do riot
respond to vaccination should be counseled accordingly
9 Sexually active homosexual and bisexual men Susceptilile sexually active
homosexual and bisexual men should be vaccinated Because of the high rate
ol HBV infection in this population. prevaccination screening should be
considered as described in the section “Prevaccinration testing for susceptrbil
ity” Men known to have HIV infection should be tesled for anti i-1 s response
after completion of tire vaccine series Those who do not respond io vaccine
lion should he counseled accordingly
10 Sexuallyactive heterosexual men and women Vaccination is recornrinenidrid
for men and women who are diagnosed 8s havir recoiiiiy acquired oilier
sexually treneriritted diseases for prostituies and for persons who have a
-------
16 MMWR
Nov.mbsr 22. 1991 Vol 401 No RH 13
MMWR I?
hisloly of sexual activity with more than one partner in the previous 6 months
12) Most patients seeis in clinics for sexually iiansn itled diseases should be
considered candidates for vaccination
11 Inmates a! Iong-t.,m co ectIonaI !acIIW.s Prison officials should consider
undertaking screening and vaccination programs directed at inmates with
histories of hIgh risk behavIors
EVOLVING ISSUES IN HEPATITIS B IMMUNIZATION
PROGRAMS
Hepatitis B vaccine has now been used extensively throughout the world and is
currently being incorporated into the Expanded Programme on Immunization of the
Wotid Heallh Organization ( 16) New information, vaccines, and technology will have
implications for this effort, end adjustments and changes eve expected to occur over
the years Some of the issues that can be expected to be addressed in clinical and
operational studies include the following’
I In most dřveloplng countries with hřpatiti B irnmtiniration programs, the first
dose of vaccine is adtniiiistered to all itifaitta soon after birth to prevent
perinatel infections, pregnant women are not screened for HBsAg. and HBIG is
not used (8,16.45) The feasibility and effectiveness of Incorporating thIs
approach into the hepatitis B prevention strategy for the United Stales must be
evaluated
2 Booster doses of hepatitis B vaccine have not been recommended because of
the persistence of protective efficacy 9 years alter vaccination (48,5 11 The
duration of protective efficacy for adolescents who were vaccinated during
infancy or childhood must be evaluated, Ihe results will determine future
recommendations concerning booster doses
3 FlexIble dosage schedules are required to effectively integrate hepatitis B
vaccine into current and future immunization programs for infants Schedules
may change as optImum dosage and timing are studied and new information
becomes available
4 Multiple-antigen vaccines that incorporate HB5Ag as one component are
currently being evalualed The routine use of these vaccines may alter child
hood vaccination schedules or may result in the administration of additional
doses of certain antigens However, these vaccines should greatly facilitate
vaccine delivery and minimize the number of injections
flele,encei
I COC Protection egainst viral hepaiitis recommendations ol the Immunization Practices
Advisory Committee IACIPI MMWR 1990,39 5 22
2 Alter Mi, Hadlor SC Margohs HS, at at The changing epidemiology of hopatilis B in the
United States need (Or alternative vaccination strategies JAMA 1990,263 1218 22
3 Margohs HS. Alto, Mi, Hadler SC Hepatitis B evolving epidemiology end implications for
control Semin Liver Di, 1991,11 8492
4 Siovens CE Toy PT. Tong Mi. et a) Perinatal hepatiiis B virus transmission in the United
Sisie. prevention by passive active immunization JAMA 1985,253 1740 S
S Stevens CE Taylor PE. Tong MJ. et al Yeast recombinant hepatitis B vaccine efficacy with
hepatiiis B immune giobulin in preveniion oi perinaisi hepatiiis B virus transmissIOn JAMA
1907 251 26126
6 McMahon BJ. Rhoades ER Heyward WL 01 at A comprehensive prograririne to reduce tire
incidence of hepaiiiis B virus intection and its sequeiae in Alaskan Natives tancet
1987.2 11346
7 Stevens CE. Neurath HA. Beasiey HP Szmunesg W HBeA 9 and anti HOe deiection by
radioimmunoaasay correlation with vertical transmission of hepaiiiis B virus in Taiwan J
Med Virol 1919,3 237 41
8 Xu 1 V. Liu C B. Francis OP. oi al Prevention of perin tbi acquisition of hepaiili B virus
carriage using vaccine preliminary report of a randomized double blind placebo controlled
snd comparative trial Pediatrics 1985.76 7138
9 Be.sley HP Hwang I. V Epidemiology of hepatoceiiular carcinoma in Vyas ON. Dienstag
JL. l loolnaçile itt. ads Viral hepaiitis •nd liver disease New York Grime & Straiton
1984 209 24
10 Beasley HP. Hwang I. V Postnatal infectivity of hepatitis B surface antigen carrier mothers
J infeci Dis 1983.147 185 90
II Jonas MM, Schif I ER. O’Sullivan Mi. etal Failure of itie Centers for Disease Controi c,iteria
to identify hepatitis B infeclion in a large municipal obsietrical population Ann Intern Med
1987.107 335 7
12 Kumar ML. Dawson NV McCuiiough AJ. at al Should oil pregneni women be screened for
hepatitis 81 Ann Intern Med 1987. 107 273 7
13 American Academy of Pediairics Hepatilis B in Peter 0. Lepow ML McCracken OH. Phiitips
CF. ads Report of the Commiltee on Infectious Diseases 22nd ed Elk Grove Village. IL
American Academy of Pediatrics. 1991 238 55
14 Aiurericari Acamioiiiy oi roilinirics nimul Aiiinrirrir, CiiilntiR nI Oiisir’nir nnrt (lyricroloqy
Guidelines for preinaiai care 3rd ed Eik Grove Viilage IL Aineurcan Acautonny of Pedmaiiics.
1991 tin pressi
15 McMahon BJ, Alwerd WIM Hali OH. at al Acute hepatitis B virus infection reiation of age
to the clinicai expression of disease and subsequent development of the carrier stale J
infect Dis 1985.151 599 603
16 World Heaith Organization Progress in tIme control of viral hepatitis inenrioranduni Ironi a
WHO meeting Bull WItO 1988.66 443 55
17 Schroeder MT. Bender IR, McMahon Hi. olaf Prevalence of hepatitis B in seiected Alaskan
Eskimo villages Am J Ipidemiol 1983 1185439
18 Wong DC. Purceil flIt. Rosen I. Prevalence of enlihody to hepatitis A and hepatitis H viruses
in selected popuiaiions of the South Pacific Aini J Etiidemrol 1919 110 221 36
19 Franks AL, Berg Ci. Kane MA. et al Hepatitis B virus infection arnourg children born iii the
United Slates to Southeasi Asian refugees N EngI i Med 1989 321 1301 5
20 Hurl. MB Mast EE. Davis JP Horizonial transmission of hepatitis B virus infection 10 United
States born children of Hmong refugees Pediatrics 1992 tin press)
21 McOuilten GM. Townsend TR. Fieids HA et al The seroepidenriotogy ol hepatitis B virus in
the United States. 1976 io 1980 Am J Med 1989 BllSuppl 3A) 5 10
22 COC Raciai differences in rates of hepatitis B virus infection-United States 1976 1900
MMWR 1989,38 81821
23 Moyer LA Shapiro CN. Shulman G. Orugliera P A survey of hepatitis B surface antigen
positive blood donors degree of understanding and action taken alter notification In
Hollinger FO. Lemon SM. Margolis HS. eds Viral hepatitis and iiver disease Batlimore
WillIams & Wilkins. 1991 728 9
24 US Department of Labor. US Deparirneni of Heatih and Human Services Joint Advisory
Notice Protection aqainsi exposure to hepatitis B virus ( ( ISV) arid hunian irninunodaficienicy
virus iHiV) Federal Register 1987.52 41818 24
25 Ruzzetto M The delta agent Hepatology 1983.3 729 37
28 Hadler SC Fields HA Hepelitis delia virus In Belslie RB. ad Textbook of human virology
SI Louis Mosby Year Book, 1991 749 66
27 Perriiio HP. Schilf ER. Davis FL. et ai A randomized. controlled trial of interferon aifa 2h
alone and after predrsisone withdrawal for the treatment of chronic hepatitis B N Engi J Med
1990.323 295 301
29 Arevalo JA. Washington E Cost effectiveness of prenatal screening and immunization for
hepatitis B virus JAMA 1988 259 365 9
29 COC Safety of itienapeuric immune globulin preparaiions with raspeci in iransirrislinir for
human I tyniphotroirhic virus type iitiiyirptiadniniopaitry a ociarerl virus iirtet,iiriii MMWII
1986,35 231 ‘I
-------
I. MMWR
November 22, 1991 Vol 401 No R B - f l
MMWH 19
30 Walls MA Writek AL (J iStein iS at al Iriactivaliriri end perluliori of human I cell lym
ptiolrophic virus, type tIl, during ethanol fractionation of plasma Transfusion 1988,
26 210 3
31 Zaiac BA West Di. McAleer Wi, Srolnlck EM Overview of clinical Studies with hepalitis 8
vaccine made by recombinant DNA J InlecI 1986.i3lSuppl Al 3945
‘I? ftrurlro E Siunuiuuy ul afoly attn efllu.aty dale on a yeast derived hepatitis B vaccine Am
i Med I 989 .OlfSuuppl 3A) 14, 70,
33 S:muness W. Slevena CE. Harley Li, at at Hepalitis B vaccine demonstration of efficacy in
• couulrolled clinical trial in a high risk population in the United Stales N Engi J Med
1980. 303 833 41
34 Shaw FE Jr. Guess HA. Boats JM at .1 FIfed of anatomic inlectuon site age, and smoking
on the immune response to hepatitis B vaccination Vaccine 1989.7 425 30
35 edlietd RH, Innis 81. Scott AM, Cannon HG. Bancroft WH Clinical evaluatIon bf low dose
lnlradermaliy administered hepalilis B vaccine, a cosl reduction strategy JAMA 1985.
254 3203 6
36 Coleman Pi. Shaw FE J,. Serovich J. Hadier SC. Maigolls KS Intradermal Piepatllis B
vaccination in a large hospital employee population Vaccine 1991.9 7237
31 Gonzalez ML. Usandliaga M. Alomar P. at .1 Intradermal and Intramuscular roule for
vaccination against hepatitis 0 Vaccine 1990,0 402 5
30 Lancaster 0, 11am S. Kaiser AB Immunogenicily of the Intradermal route of hepati Ii. 8
vaccination with use of recombinant hepatitis B veccihe Am J Infect Control 1989,11 126 9
39 King JW, Taylor EM, Crow SD. et .1 Comparison of the immunogenicity of hepatitis 0
vaccine administered intradarmsliy and intramuscularly Rev Infacl Ols 1990,12 1035 43
40 Ku 2 V. Margotis ItS Determinant, at hepatitis B vaccIne elficacy and ImplIcations for
vaccination slrategles Monogr Vlrol 1991 Ito press)
41 Poovorawan V. Sanpavat S. Pongpuniert W, Chumdarmpsdetauk S. Sentrakul P. Safary A
Protective efficacy of a recombinant DNA hepalllls 0 vaccIne In neonate, of ItO. antigen
positive mothers JAMA 1989.261 3278 81
42 Jug W SchmIdt M, Dienhardt F Vaccination against hepatitis B comparison of three
diflerent vaccination schedules J Intact Dna 1989 160 786 9
43 Hadler SC, Monion MA. Lugo DR Parer M Effect of timing of hepalttis B vaccine dose on
rrsluiunso In vaccuisri in Viuclia iriuiinrui Vaccine 1989,1 106 tO
44 Cnuraaget P. Yvontiet B, Rolyvefrl (H. Barnes .11. Duop Mar I, Chiron .JP SImultaneous
administration of diphtheria tetanus pertuasis polio arid hepalilis B vaccines in a simplified
immunization program Immune response to diphtheria toxoId, tetanus toxoid. perlussis
and hepatitis B surface antigen Infect Immun 1986.151 784 7
45 Stevens CE. After Hi. Taylor PE. 01 at Hepatitis B vaccine In patients receiving hemodialysls
Immunogenlctty and efficacy N Engl J Med 1984.311 498 601
48 Jilg W. Schmidt M, Welnel B. et at Immunogenlcity of recombinant hepatitis B vaccine in
dialysis patients J Hapatol 1988. 3 190 5
4? LiiIlror AC, Corey 1, Murphy VI, Hau,dsfuold HI-I Antibody to human irnmunodoluciency virus
IltiVi and subopttmal response to hepatitis B vaccination Ann Inlern Med 1998. 109 lOt S
48 Hadler SC, Francis OP. Maynard iF. at al Long term Immunogenicity and efficacy of
hepatitis B vaccine In homosexual men N EngI J Med 1986,315 209 14
49 Lee S 0, Lo K J, Wu J C. at al Prevention of maternal infant hepatitis B virus transmission
by urnmunuaiinn role of serum hepatitis B virus DNA Ifepatology 1986,8 369 73
50 Francic or. Hauler SC. Thompson SE. el at Prevention of hepalitis B with vaccine report
from the Coolers for Disease Control multi center efficacy trial among homosexual men
Ann Intern Med 1982,97 382 6
51 Wainwright RB. McMahon Bi. Bulkow LA. et al Duration of irnmunogenicity and efficacy of
hepatitis B vaccine in a Vupik Eskimo population JAMA 1989:261 2362 6
52 Lo K J. Lee S 0. Isal V T. et al Long lerrn Immunogenicity and efficacy of hepatitis B vaccine
In Iniants born to HBeAg positive HOsA 9 carrier mothers Hepatology 1988.8 1647 50
53 Hwang L V, Lee C V. Beesley HP Five year follow up of HBV vaccination with plasma
derived vaccine in neonates Evaluation of immunogenicily and efficacy against perinatal
transmission in Hollinger FR. Lemon SM Margolis HS. ada Viral hepatitis and liver
disease Baltimore Williams Si Wilkins. 1991 75961
54 Shaw FE Jr. Graham Di Guess HA at al Postinarkeling surveillance br neurologic adverse
events reported after hepatitis B vaccination experience of the first three years Am J
Epidenuiol 1988 121 331 52
55 Chen 0 S Control of hepatitis B in Asia mass immunization program iii Taiwan In
Hollinger FB. Lemon SM Margolis I I S. ads Viral hepatitis amid liver disease Baltimore
William, & Wilkins. 1991 1)69
66 COC Public Health Service Inte, agency guidelines for screening donors ol blood, plasma.
organs. tIc ues miil srrmwmu for evirtriwe of liei)atttts B and liepatitic C MMWR 1991,40 56
5? Beesley ftP, ltweurg I V. Stevens CE, et al Eflucecy of hepatitis B immune globulin for
prevention of perimialal transmissIon of the hepatitis B vi,us Carrier stale final report of a
randomized double blind, placebo controlled trial Hepatology 1903.3 135 41
58 CLIC Guidelines for prevention of transmission of human ininrurnodeticrerucy vinus and
hepatitis B virus to health care end public safety worker, MMWR 1989.3BISuppl 6) 5 IS
59 Department of Labor Occupational exposure to bioodbonne pathogens proposed rule and
notice of hearing Federal Register 1989.54 23042 139
60 O,euer B. Friedman SM. Muilner ES. Kane MA, Snyder RH. Maynard iF Transmission of
hepatitis B virus In classroom contacts of mentally retarded carriers JAMA 1985,254 3190 5
61 Seaworlh 0. Drucker J, Starling J. Drucker H, Stevens C. Hamilton J Hepatitis 8 vaccines in
patients with chronic renal failure before dialysis J Infect Dus 1988.167 332-7
62 Moyer LA, Alter Mi. Favero MS Hemodiatysls.associated hepaliti, B revised reconumen
dalions ho, serologic screening Semin Dialysis 1990,3 201 4
63 Hershow BC. Hadter SC. Kane MA Adoption of children from Countries with endemic
hepatitis B transmission risks end medical issues Pediatr Infect Dis J 1987,6 43) 7
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Vol 4OINo RR13 MMWR
APPENDIX A
Postexposure Prophylaxis for Hepatitis B
Adapted horn COC Protecuron agauiisl viral hepatitis reco,,,mendalio,is of the
lnimu,iizatioii Practices Advisory Coin,inttee (ACIP ) MMWH 1990,39(No HR 2) 17
22
INTRODUCTION
Prophylactic treatment to prevent infection after exposure to HBV should be
considered in the following situations perinaial exposure of an ln(a,il born to an
HBsA 9 positive mother, inadvertent percutaneous or permucosat exposure to
HBsAg positive blood, sexual exposure to an HBsAg positive parson, and household
exposure of an infant 12 months of age to a primary ca,e giver who has acute
hepatitis B
Various studies huve established the relative efficacies of HBIG and/or hepatitis 8
vaccine in different exposure situations For an infant with perinatal exposure to an
H8sA 9 positive and 1 -IBeAg positive mother, a regimen conibmning one dose of FIBIG
at birth with the hepatitis B vaccine series started soon after birth is 85% 95% effective
in preventtng development of the H BV carrier state IA ? A3) Regimens involving
either multiple doses of HBIG alone or the vaccine series alone have 70% 90% efficacy
(A4,A5 I
For inadvertent perrcutaneous exposure, only regimens including HOIG arid/or
Immune globulin (IGI have bean studied A regime,i of two doses of 116 1G. one given
after exposure and one a month later, is about 75% effective in preventing hepatitis
B in this Betting 1A6.A7) For sexual exposure to a person with acute hepatitis B, a
single dose of HOIG is 75% effective if administered within 2 weeks of last sexual
exposure 1A8) The efficacy of IG for postexposure prophytaxis is uncertain, IG no
longer has a role in postexposure prophylaxis of hepatitis B because of the availability
of HBIG and the wider use of hepatitis B vaccine
Recommendations on postexposure prophylaxis are based on available efficacy
data and on the likelihood of future HHV exposure for the person requiring treatment
In all exposures, a regimen combining H8I(. with hepatitis B vaccine will provide both
short- and long term protection, will be less costly than the two (lose HOIG treatineiit
alone, end Is the treatment of choice
Acute Exposure to Blood that Contains (or Might Contain) HBsA 9
For Inadvertent percutaneous Ineedlestick. laceration, or bite) or permucosal
(ocular or mucous membrane) exposure to blood, the deciston to provide prophylaxis
must include consideration of several factors a) whether the source of the blood is
available. b) the HBsAg Status of the source, and cI the hepatitis B vaccination and
vaccine response status of the exposed person Such exposures usually affect
persons for whom hepatitis H vaccine is recommended For any exposure of a person
not previously vaccinated, hepatitis H vaccination is recoflimeiinfed
After army such exposure a 1)100(1 sample should be obtai,ied lronm tho person who
was the source of the exposure and should be tested Ion URsAg lime hepatitis H
-------
MMWR
Novsmb.r 22. 1991 Vol 40! No BR 13
MMWR 23
vaccination status and anti HBs response status (if known) of the exposed person
should he reviewed The outline 1)010w and Table Al summarize prophylexis for
percutaneous or peimucosal exposure to blood according to the HBsA 9 status of the
source of exposure and the vaccination Status and vaccine response of lhe exposed
person For greatest effectiveness, passive prophylexis with HOIG, when indicated,
should be administered as soon as possible slier exposure since its value beyond 7
days alter exposure is unclear
1 Source of exposure known and H8sAg positive
a Exposed person has not been vaccinated or has not completed vaccination
Hepatitis B vaccination ahould be initiated A single dose of HBIG (006 mlikg)
should be adrnirusteied as soon as possible after exposure end withrn 24 hours,
if possible Tb. first dose of hepatilie B vaccine should be administered
intramuscularly at a separate silO (deltoid for sdulle) and can be administered
simultaneously with HBIG or within 7 days of exposure, subsequent doses
should be adrninistered as recommended for the specific vaccine lithe exposed
person has begusi but has not completed vaccination, one dose ol HHlG should
be administered immediately and vaccination should be completed as schecl
iiled
b Exposed person lieS already been vaccinated against hepatitis B. and anti HBs
response status is known
TABLE Al
exposure
for hepatitis B prophylexi. following percutaneous
Ti..tm.nt when source
is found to b.
Unknown or
Eaposed p.rson
HB.Ag po.Itiv.
HHsA 9 nsg.tiv.
not t.st.d
Unvscctr taisd
Administer ilHiG I • and
initiate hepatitis B vaccine’
inii,ai hepatitis B
vaccine’
inltiaie hepaiiti , B
vaccine’
Pnsvlouil v.ccin t .d
Known responder
Test exposed person
for anti 118,
I If adequate.
no treatment
2 Il inadequate,
hepatitis B
vaccine hoosier dose
No treai,nerit
‘
No ireat,nent
Known non
responder
11816 a 7 on
HBtG a I, plus 1 dose
of hepatitis B vaccine
No treatment
If known high risk
source, may treat a,
if source were
IIBeAg positive
Response
unknown
Test exposed person
for anti HB
I II inadequate
11816 x 1. plus hepatitIs
B vaccine booster dose
2 II adequate no treatment
No treatment
Test exposed parson
br anti 118, 1
1 If Inadequate.
hepatitis B vaccine
hoosier dose
2 ii adequate.
no treatment
liepei ,Ius B ii,,rirune globulin fitBiOl dose 008 intikg intraitiuscuierly
llepetiirs B vaccine dose see labia 1
‘Adequate anti liRe i , ‘ 10 ri,Iiti litter neiio, ,eI units
(1) lithe exposed person is known to have had adequate response in the past.
the anti HBs level should he tested unless an adequate level has been
demonstrated within the last 24 months Although Current data show that
vaccine induced protection does not decrease as anttbody level wanes.
most experts consider the following approach to be prudent
(a) lithe anti HBs level is adequate, no treatment is necessary
(b) lIthe anti HBs level is Inadequate, • a booster dose of hepatitis B vaccine
should be administered
(2) If the exposed person is known not to have responded to the primary
vaccine series, he or she should receive either a single dose of HBIG and a
dose of hepatitis B vaccine as soon as possible abler exposure, or two doses
of HBIG 1006 mI/kg), o,w as soon as possible after exposure and the second
1 month taler The lalter treatment is preferred for those who have not
responded to at leasl four doses of vaccine
c Exposed person has already been vaccinated against hepatitis B. attd the
anti HBs response is unknown The exposed person should be tested for
anti liBs
(1) Ii fIts exposed person lies adequate antibody, ito addiiional treatineiit is
necessary
(2) lithe exposed person has inadequate antibody on testing, one dose of HB1G
(0 06 niL/kg) should be administered imniiediatelv arid a standard booster
dose of vaccine administered at a different site
2 Source of exposure known and l-fflsAg-negative
a Exposed person has not been vaccinated or has riot completed vaccination If
unvaccineted, the exposed person should he edrniiiistered the first dose of
hepatitis B vaccine within 7 days of exposure, and vaccination should be
completed as recommended tithe exposed person lies not completed vacci
nation. vaccination series should be completed as sclieriuled
b Exposed person has already been vaccinated against hepatitis B No treattisenit
is necessary
3 Source of exposure unknowns or not available for testing
a Exposed person has riot been vaccinated or lies not conipleted vaccination Ii
unvaccirsated. the exposed person should be administered the first dose of
hepatitis B vaccine wIthin 7 days of exposure and vaccination should be
completed as recommended If the exposed person has not completed vacci
nation, vaccination should be completed as scheduled
b Exposed person lies already been vaccinated against hepatitis B, and anti HOs
response status is known
(1) If the exposed person is known to have had adequale response in the past.
no treatment is necessary
(2) If the exposed person is known not to have responded to the vaccine,
prophylaxis as described earlier in seclion 1 b (2) under “Source of expo.
sure known and HBsAg .positive” may be considered if the source of the
exposure is known to be at high risk of HBV infection
c Exposed person lies already been vaccinated against hepatitis B, arid the
anti HHs response is unknown The exposed person should be tested for
anti HUs
A a e juai enitrbody level us 10 mlIJ/nnl
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24 MMWR
November 22. 1991 Vol 401 No RH 13
MMWR 25
(1) II the exposed 1)015011 has a(le(lriale anti fiRs. 110 lreatiiieril Is necessary
121 If the exposed person has inadequate 8011 HOs. a standard booster dose of
vaccine should be administered
Sex Partners ol Persons with Acute Hepatitis B Virus Infection
Sex partners of HBsA 9 positive persons are at increased risk of acquiring HBV
infection, arid HBIG has been shown to be 75% effective in preventing such infections
(A8 I Because data are limited, the period after sexual exposure during which HB1G
is effective is unknown, but extrapolation from other s ttings makes it unlikely that
this period would exceed 14 days Before treatment, testing sex partners (or
susceptibility is recommended if it does not delay treatment beyond 14 days after last
exposure Testing for antl-HBc is the most efficient prescreening procedure to use in
this population
All susceptible persona whose sex partners have acute hepatitis B infection should
receive a single dose of HBIG (006 niLlkgl and should begin the hepatitis B vaccine
series if prophylaxis can be started within 14 days of the last sexual contact or if
sexual contact with the infected per son will continue Administering the vaccine with
HBIG may improve the efficacy of postexposure treatment The vaccine has the added
advantage of conferring long lasting protection
An alternate treatment for persons who are not from a high risk group for whom
vaccine is routinely recommended and whose regular sex partners have acute HBV
infection is to administer one dose of HBIG (without vaccine) and retest the sex
partner for HB5Ag 3 months later No further treatment is necessary if the sex pariner
becomes HBsAg negative If the sex partner remains HBsAg positive, a second dose
of HBIG should be given end the hepatitis B vaccine series starled
Household Contacts of Persons with Acute Hepatitis B Virus Infection
Since infants have close contact with primary care givers and they have a higher
risk of becoming HBV carriers after acute I-IBV infection, prophylaxis of an infant less
than 12 rnoiithie of age with HBIG (05 nil) end hepatitis B vaccine is indicated if the
mother or primary care giver has acute IWV infection Prophylaxis for other house-
hold contacts of persons with acute HBV infection is not Indicated unless they have
had identifiable blood exposure to the index patient, such as by sharing toothbrushes
or razors Such exposures should be treated like sexual exposures If the index patient
becomes an HBV carrier, all household contacts should receive hepatitis B vaccine
References
Al Stevens CE, Taylor PE. Tong Mi, or al Yeast recombinant hepatitis B vaccine efficacy with
hepalilis B immune globulin in prevention of perinatal hepatitis B virue transmission JAMA
*997,257 2612 6
A? Besstey RP, Hwang I. V. lee 6 C. or at Prevention oh perinatalty transmitied hepatitis B virus
Infections with hepatitis B immune globulin arid hepatitis B vaccine Lancel 1983 2
1099 102
A3 Stevens CE. Toy P. Tong Mi. et at Perinatat hepatitis B virus *ransmi,sion in the United
States prevention by passive active immunization JAMA 1985,253 1740 5
A4 Beastey HP. Hwang L-V. Stev8ns CE. 01 at Efficacy of hepatitis B immune globulin (or
prevention of periiiaixl transmission of the hepatitis B virus carrier siate boat reponi of a
randomized double blind pt8Cat)0 controlled filet Hepatotogy 1983 3 135 41
AS Xu Z Y tiu C B Francis oP. et el P,eveniioin of peririetal ecqulalilon of hapailile 0 virus
car i isqi. Iis linq varc,irn’ ti. rliriiinar y r i. ini I of n i a.uitoniii,ed dot ,I,fe lili,id 1 it aceimo coniiroilcil
and comparelive Irial Pediairics 1985 76 7138
A6 Seeff LB Wright (C Zimmerman Hi at at Type B hepeillis alter rieedlestick exposure
Prevention with hepatitis B iniinuiie globulin hinal report ol itia Veterans Administration
Cooperative Study Ann triter,, Med 1970.89 205 93
Al Grady GF. Lee VA. Prince AM et at Hepatitis B immune globulin for accidental exposures
among medical personnel final report of a mulliceriter conirotted Iruel J Infect Die
1978,13862530
A9 Redekes AG. Mosley JW Gocke DJ McKee AP Pollack W llepaiiiis I I immune globulin as
a prophylactic n ,easiire for spouses exposed to acure iype 8 lier)aiiIiS N Enigl J Med
1975 293 lOSS 9
-------
APPENDIX E
-------
APPENDIX E
OPTIONAL POST-EXPOSURE TESTING FOR HUMAN
IMMUNODEFICIENCY VIRUS (HIV): INFORMATION AND
CONSENT/DECLINATION FORMS
-------
NEIC Exposure Control Plan: Eloodborne Pathogen Exposures Page 1
Appendix E: Optional Post—Exposure Testing for Human Inmiunodeficiency Virus (HIV):
Information and Consent Declination Forms
APPENDIX E
OPTIONAL POST-EXPOSURE TESTING FOR HUMAN
IMMUNODEFICIENCY VIRUS (HIV): INFORMATION AND
CONSENT/DECLINATION FORMS
A. BACKGROUND INFORMATION ON HIV (AIDS) INFECTIONS
Following job related exposure, the NEIC may be required to offer HIV
antibody testing without cost to a federal employee. The blood test
for antibodies against the HIV determines if someone has had exposure
to this virus. A positive test (one that shows the presence of
antibodies) does not necessarily mean that you now have or will
develop Acquired linmunodeficiency Syndrome (AIDS). A positive test
does mean that you should have further medical evaluation by your
physician or usual source of medical care. A positive test also means
that you may spread the virus by intimate sexual contact or by
exposure to infected blood or other body fluids. Individuals who have
a positive test must never be blood donors and should seek information
from their usual source of medical care on ways to avoid spreading the
virus. The virus can also be spread by an infected mother to her
developing child.
There is presently no permanently effective treatment for AIDS and the
disease has thus far been uniformly fatal.
The populations which have experienced the highest prevalence of AIDS
in the United States include homosexual and bisexual men, people who
use intravenous drugs, hemophiliacs, and people who received blood
transfusions subsequent to 1977 and prior to the adoption of proper
HIV antibody testing of donor blood in 1985. It is unsafe sex and
abuse of illegal drugs which have been identified as the major risk
factors which place individuals at greatest risk to AIDS through
exposure to infected blood and/or other body fluids.
-------
NEIC Exposure Control Plan: Bloodborne Pathogen Exposures Page 2
Appendix E: Optional Post—Exposure Testing for Human Immunodeficiency Virus (HIV):
Information and Consent Declination Forms
B. PROCEDURES FOR VOLUNTARY HIV ANTIBODY SCREENING
If the source patient has AIDS, is positive for HIV antibody, or
refuses the test, an employee or contractor will be counseled
regarding the risk of infection and evaluated clinically and
serologically for evidence of HIV infection as soon as possible after
the exposure.
Testing will be done:
immediately after exposure,
_______ 6 weeks after exposure,
_______ 12 weeks after exposure, and
_______ 6 months after exposure.
Counselling must be done both before and after HIV testing.
All testing for HIV following blood exposure is strictly voluntary.
Results will be confidential and will be given only to the employee,
in person. Due to the extremely sensitive nature of these test
results, and to insure absolute confidentiality,these results will
only be presented in person and will not be provided over the phone or
by mail.
A copy of the results will be stored in a confidential medical file at
the clinical facility.
It is important for you to be acquainted with the above information
before you consider having your blood drawn for this test.
-------
NEIC Exposure Control Plan: Bloodborne Pathogen Exposures Page 3
C. STATEMENT OF CONSENT FOR HIV ANTIBODY SCREENING
I have read and understand the information on voluntary post-exposure
HIV anti-body screening. I have also had an opportunity to ask any
questions I may have concerning this screening. I consent to have the
blood test for antibodies to the HIV virus, which will be paid for by
my employer. I understand that a screening test will be performed
first. If this test result is positive, the screening test will be
repeated on the same specimen. If the repeat test is positive, a more
specific test will be performed on the same specimen. My results will
be reported to me in person. Individual test results will be kept
confidential in my medical record.
Signed Date
Social Security Number
Witness Date
D. DECLINATION OF HIV ANTIBODY SCREENING
I have decided not to have the MIV blood screening at this time but
understand that my blood will be stored for 90 days in the event that
I change my mind and later consent to the test.
Signed Date
Social Security Number
Witness Date
-------
APPENDIX F
-------
APPENDIX F
REFERENCE INFORMATION ON HIV INFECTIONS FROM I4MWR
-------
MMWfl CENJIRS EOQ DISEASE CONIROt Jun. 23 $9991 Vol Jo INo S 6
Recommendations
and
ku Reports
MORBIDItY AND MOR AIIIY WUKLY REPORI
Guidelines for Prevention of
Transmission of
Human Immunodeficiency
Virus
__ and
U I Gsi i Pi i 01111. I 9 Oil I IOiSII 11 . 1s. I V
Hepatitis B Virus to
AtIN & IAIMAN UNV II
P M.c 111.1111 S ., .
Health —C are and
Au. .. GA 333
1111 1 1 Su$ 1.S
Public-Safety Workers
U S Depadment of Health and Human Services
Public Health Seivica
Centers for Disease Coi;tioI
National Institute for Occupational Safely and health
Atlanta Geoigia 30333
II$IS PubIstSIlOfl No (COCI 990012
-------
VoIlISNoI MMWA
Serial .uWIc.ikim ki she MMWR are p .Ni Iied by the Epidemininpy P np,an, Duke.
( g l)ke. e Cre,tml PuNk lleabh Sender. U S Ibparnneas ui Nealib NOTICE
II.,uiam %uv.cr . Alisnia. tkmp .a m i i i
Ibis issue of MMWR Re ommvndagu,n, and Repotis (Vol 38. No S 6) is a repi.uil of
an adminisiralive documenl circutaled and reviewed tidier in 1989 I i is being psoviskd
SUGGESTED CITATION
I fre fo ( T mlss 4 l1 as a. an Issue in she MMWR series as a service so ihe readership
I linmuandellckiscy Vim, asid Ikpehk R Vinis io Ikahh Cite aud PuIuiIc.SaIety I
Wnuhers MNWR I9* N4no S A) lh’clu 1ve pipe aunthrr , I
Cenius for Disease Coimul . WaIst, ft Thi*dk. Pb 0
A thug Di ’etinr
This ,rpnn wa. piqwred by
Nub..) lnstUvw fat (keupuilonat Safesy and UuIih I Onsiald MIII .,. M 0
Dlre .-s.w
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Cen ter ln,In laci lcssD lqasws FtededckA Muqrliy.DVM.PIsD
Dl,asuw
flu piuducilon .1 thIs sepast was cacidjialed In
Ep ldeiabulnpy Prop.... . O(flci Michael (ht,,. N D
Acting Dl,aiMr
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Revesly Holland
Progras Specialist
I Copies can hr purchased 1mm Suprilniendini of Document,. U S Oovenimeni I
P .bntlrip 0 10cc W.üenplon DC 20402-921S Trkplsnne 120H 1P1 i1I
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Guidelines for Prevention of
Transmission of
Human Immunodeficiency Virus
and
Hepatitis B Virus
to Health-Care and
Public-Safety Workers
A Rcspoiisc to I’.L. 100-607
The Health Omnibus rrograrns Extension
Act of 1988
U.S. Deparlmtnl of Iltaith and liwnan Servke3
Public Health Service
Centers for Disease Control
Atlanta, Georgia
February 1989
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TABLE OF CONTENTS
Introduction 3
A Background
B Purpose and Organiration of Document ... . 3
C Modes and Risk of Virus Traiwnibsion In the Workplace . .. . 4
1). 1 tausmlesion of hepatitis B VIrus to Workers . 3
I health care wuskesi 5
2 Emergency medkal und publlc-salety workers 6
3 VaccinatIon lot hepatitis B virus 6
E Ttammbsk’n of Human Immunodeflciency Virus to Woskeri . . 6
I health case workefl with AIDS 6
2 Human lmmunodefkiency virus t,mambskrn In the workplace ... 7
3 Emergency medical service and pubik-ulety workers 8
Ii. Principle. of Infection Control irid Their Application to Emergency and
Publk.Safety Worlera 9
A General Infectio n Control 9
B. Ilniversill Blood and Body Fluid Precautlona to Prevent Occupational
lilV and IWV Transmission 9
III. Employer Reaponslbllllim II
A General
B. Medical 12
I hepatitis B vaccination 12
2. Management of percutaneous esposure to blood and other Infectious
body fluk 12
a. Hepatitis B virus po.tespo.ure management 12
b. Human Immunodelklency virus postelposure management.. Ii
3. Management of human bites 14
4 Documentation of espoaure and reporting 14
5. Management of I IBV . or HIV .Inlected workers 15
C. Disinfection. Decontaminalion. and Disposal IS
I. Needle and sharp. disposal 16
2 hand washing 16
3 (leanIng. disln lcctlng. and aterilleing 16
4 CleanIng and decontentlnatlng spills of blood 16
5 Laundry 17
6 i)ccontaminatiOn and laundering of protective clothing .. 17
7 InfectIve waste . . . . i7
IV. Fire and Ernulency Medkal Service. . . 19
A Personal Protective Equipment 19
I Glove’ 19
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2 M ks. eye eet, snd owt . . 20
3. Re.uscllalkrn equipment. 20
V. I ..w.!n(ora,menl .nd Cosv,disusSI-Fc0h 17 Oflkm . 22
A. [ aw-EnIo.ctment .,ui Coued nsI Facliliks Co, lderet . 22
I Fights end ,.ulIs • 22
2. cEdk)pulmonsq , adtsIkn 23 Guidelines for Pre’r ntiOfl of
a Ls*’ cement Coindde,at 23 Trnnsmj 5 5jofl of
I. Sesiches end e4denc hendllii$ 23
2, HandlIng end body t 51OVII Human ImmunodeficiencY Virus
3. Auio ks 25 and
4. Fo.eindc laborstoiks 25
C Couedkmsl FacUlty Cooddersilot. 26 IIcpřIi(is II Virus
2. m :::::::::::::::::::::::::: to IlealthCare and
Public-Safety Workers
VI. Rd ianc
VII. T.bIes
The CDC iaIl members lsvted below 5 civcd as .uthms (or ibis publication
Robe,’ I Mullan. M I)
Edwaid I Bases. M U . M P II James M Hughes M U
David M Bell. M I) Ilaiohi W hue. M U
Wallel W hood. I, Ma,k A Kane. M I) M r ii
M iiy C Clm.ol ilIiiiil M I) . M r I I Ruih.iiine Marcus M r It
Maflin S Faveto Pt. I) William i Maitsitic. M U
Julia S Gainer. M N Maik I Sc.lly
Stephen C tiadler. M I) Phillip W St,.nc
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I. lnd
A. Background
This document is. resporwe to recently enacted legislation. Public Law *00 607. The
Health Omnibus Progranw Eztemkm Act of 1988. iltIe II. Programs with Respect to
Aequlied Immune Deficiency Syndrome (AIDS Amendments of *988”) SubtItle E,
Oeneral p,ovbkjna. Section 253(a)of Title II specliks that “the Secretary of Health .nd
Human Services, acting lhwugh the Director of the Centers for Disease Control, shall
develop. issue, and disseminate guldeUnes to ill health workers, public a.iety workers
tl,iriudlna emer,encv response employees) In the United States concerning —
(I) ,,elhodatoredueetherbklnthewO1kplacCOfbCU1fl1IflglnfeCted lts
the cilologie agent (or aequired Immune deficiency syndrome; and
(2) circumstances under which eaposwe to such ctkkrgk sFnt may
occur.—
It is further noted that beSectetary lol Health and human Scrvkrsl shalltr.nsmlt the
guidelines issued under subsection (a) to the Secretary of Labor br we by the Secretary
of Labor InthedeveiopmentObstSfldaUisIObo 1t1edu11&1 theOceupatlonalSafetyand
Health Act of *970,” and that “the Secretary, actIng through the DIrector of the Centers
with respect to the prevention olexposwe to the etlologic agent for aequl red Immune
deficiency syndrome during the proceas of responding to emergencies -
Following development of these guidelines and curriculum. “Itihe Secretary shall —
(A) transmit toSatepublicheIlthoIf rs00pS01the$U Uu 5rai he
niodelcurrkulumdeve l oped under pars gnsph( I )wlth the request that
such of (leers disseminate such copies as appropriate throughout the
State; and
(B) make such copies available to the public.”
B. Purpose and Organization of Document
The purpose of this document is to provide snoverview of the modes of transmission of
human Immunodelkkncy vhw (lflV) in the woriptact. an assessment of the risk of
transmission under various assumptions. principles underlying the control of risk, and
apedulc risk-control recommendations for employers and workers uris document also
Includes lnfornIatlononmedkslmaflagemefltotPe11omwhohave1wtau 51td1Pohhmte
at the workplace to these viruses (e g • an emergency medical technicians who Incur a
....Ate itick lnlurvwhile nerformlni professkinaldutks). These guidelines are intended
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for tsebyatechnkally Info,medaudlencc. Mnotcdebove.asep.ratemodeieurrkulum
b.sed on the principles cm l practices discussed in this document is being developed for
use in training workers and wUl contain less Sechnkal wording
Inlorinatlon concerning the protection of workei against acquisition of the human
Immimodelkiency virus (lIIVj whik pcrformlngjobdutle., the virus that cause. AIDS,
is presented here. tnlo,siatkmon hepatitis Betom (lID V I k.bo presented In this docu-
meni on the bh of the following mownptlom:
• the mode. o( trarwai ksn(oi hepatitis B virus (HDV) are similar to those of IIIV.
• the potential (or HDV trsmmisskrn in the oecupslk)hal setting is greater than for
“IV.
.
workplace, and
• general practices to present the trsrnm kmof 1IDV will siso minimize the risk of
transmission of IIIV
Blood borne *rammissk,n of other psthorm not specifically addressed here will be
Interrupted by.dherence to the precautions notedbeiow It is Important to nose that the
Implementation of control measures for IIIV .nd HBV does nut obviate the need for
continued adherence to general infection-control prlndpks and general hygiene mea-
sures fe g • hand wsshlng ) for preventing transmission of other infectious disesses to
both worker and dient. (leneral guidelines for control of these disemea have been pub.
lished (1.2.3).
This document wdevelopedpibnltlty to provide guidelines for fire-service personnel.
emergency medical technicians. paramedlus (see section IV. page 19). and law enloror-
mentandaurecilonhl fadutypenonflel(seeaect lonV.Pal efl) lbroughouttherepotl,
pa,.medka and emergency t’ e ’ technicians see called emergency medical wotkers
and Ike-service, law enforcement, and correctional facility personneL publk safely
worker. - Previously issued guidelines address the necib ol hospital . laboratory • and
clinic basedhcatlh-eare w inkers(4.5) Acondens .tk)nOl generalguldellneafor protec-
tknt ol workers horn tratomisalon of blood-borne pathogens. derived from the Joint
Advisory Notice of she Departments of Labor and Health and Human Services (6). is
provldcdlnectk)fl Ill (see page I I) .
C. Mode. nd Risk of Virus Transmission in the Workplace
wound. nonintact (e g,ch.pped,sbr.drd.w ep lng.ordeimathl lc)1 1 1 t1.0r mucous niem-
brand to blood, blood contaminated body fluI . or concentrated virus Blood Is the
single most Imposlant source of WV and IIBV In lbs worbptsct setting. Protection
mcuusea against IliV and IIBV for woekers should focus prienaillyon preventing these
types of exposure’ to blood so well — on delivery of I WV vaccination.
The risk of hepatitis B lnfectlonfollowlflghPar eflt erat(l e • needle stick or cut) exposure
to blood is directly proportional to the prob.blllty that the blood contains hepatItis B
surface antigen llBsAg). the immunity stetus of the recipient, and on the efficiency ol
transmisslon(l). Theprobabitityof thesourceol lhebloodbdlflgHllsAg positive varies
from ItoS per thousand In the general population to 5%-lS% In groups at high risk for
HBV Infection. such as Immigrant. from areas of high endemicity (China and Southeast
Ailasub SaharanAftlCa,rnOst paclflcislan& andthe Amazon IlasIn);ctlents Ininstitu
tions for the mentally .ct.,ded intravenous drug users, homosexually .ctlve male., and
household (sexual and non sexual) contacts of IIBV carriers 01 persons who have not
had prior hepatitis B vwxtnationot postelposwe prophylaib. 6%-3O% of persons who
receives needle stick exposure (roman lUDaAg-poaltlse individual wilibecome Infected
(7)
The risk of Infection with HIV following one needle stick esrosu,e to blood from a
patient known to be Infected with lily is approxImately 0 5% (4.5) This rate of hans-
mbslonbconskldiatrly lower than that for HBV. probably ma result of the signhllcantly
lowerconcent,atlom0fvir ad thehPbood0f l-ilV lnfectedpei.ons Tablet (seepage 31)
presents theoretical data concerning the likelihood of iniection given repeated needle-
IllVsetoatatusis unknown Thoughlnadequateiy
quentilled. the risk from exposure of nonlntacl skinor mucous membranes is likely tobe
far less than that from percutaneous inoculation.
U. Transmission of hepatitis B Virus to Wo,kers
I. health-care workers
In 19*7, the CDC estimated the total number of I IBV infections In the United States
10 30,O0pCry1,witppro1 tdly75.O 25 0 l infrcledpersonldevel0P-
ing acute hepatitis 01 these infected Indlviduab. lI.000-30.OtXI (6%-iU%) will
become IIBV canlen. at risk of developing cluonic liver disease tchronic active
hepatitis. cirrhosis, and primary liver cancer), and infectious to others
CDC ha. estimated that 12,000 health care workers whose )obs entail exposure to
blood become infected with tiHY each year, that 500-600 of them ate hospitalized
as a result of that Infection, and that 700-1,2(X) of tho,e infected become IIHV
carriers 01 the Infected woikers, spproilmatety 250 wIll dIe ( 12-1 5 from fulminant
hepatitis. l7O_2UUfromcIrrhosis,aM40- 50 fr0m re.1 r) Studies lndlcatethat
Atthoughthe potentialfor I WV tr.n.mbsionin the workptacesettIflIisgrdtthar f0r
HIV, the modes of transmission for these two viruses are similar. Both have been trans
misted inoccupatlunal s ettinpoitlyby percutaneous inoculatlonor contact with anopen
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lO%-30% of health care or dental worke,s show serologic evidence of pest or pie.
sent IIBV Infection.
2. Emergency medical and publlc safesy workers
Fmergencymedkatwoike,s hsveanh,crearedrhk forhepatith BInleclkin(8,9,1O).
Thedegreeolrhkco,relstes wiIhthefrequnqandeJtentofbloodeaposuredu,
She conduct of work activities. A few studies are available concerning thkof HBV
lnfccl i onI o rothergeoupsofpabilcsafe t,wo,ke,s(Isw.eflfO,ctmentpefsoflnep 5
coriecltnnisi Iacfflivw ,hCfl),bu 5 reports that Icnpubftiheddonnidocuni,ni
any increased ilk for HBVInfedkm(I j2IJ) I4eve,thelesa, In occupational
settings In which workers sarybe routhielyesposedto blood or other body (tulsis
described below, an Increased ibis lot oncupatlonsi acquisition of HBV Infection
mint be esstimad to be preseaL
3. Vacetnatk. for hepatitis B vicmn
A safe and effective vaccine to piewnt hepatitis B tme been avaIlable lime 1952.
Vaccination is. been recommended for health care workers regularly esposed to
bloodandotherbody Ilukie potenthltycontasn lnatcdwfth VlBV(7,l4,1 ). In 1987,
the Depaitmentof IleahhandHum.nSe vkesandtheDepartment oflaborstated
that hepatitis B vaccine should be provided to aS such workers at no charge to the
worker (dJ.
Avblevsstlmulatect lvelmmunh yaga lnatllflV lnfecsk,nandp,ov ldeo v er
90% ptotedkm against hepathis B lot 7 or more years following vaccInation (7).
Hepatitis B vaccines ahoa,e 70-88% effectlvawhenglvenwhhln I week after IIDV
eaposure. HepatItis Birmtmuneglobultn(HBIG ) .aprep.rationofhmnunoginbufln
w4thh lghkveholanlibodytoHBV(.n ll-lIBs), provides temporary passive prolec.
lion following esposure to HBV. Combination treatment with hepatitis B vaccine
and HB 1O hover 90% effectIve In preventing hepatitis B following a documented
elposure (7).
E. Transmission of human Immw iodeflclency Virus to Workers
I. Heahh.care workers with AIDS
Asof September 19, 195$, a total of 3.182(5 t%)of6I .929adults with AIDS, who
had keen irnorted to the CDC national aurvrillanrr . 5 1 5 cm .nd for whom occun..
incomplete for 2$(17%) because of death or refusal lobe Interviewed; 97 157%)are
still being Investigated. The remaining 44 (26%) health care workers were inter.
viewed directly or had other follow-up inlormatlon available The occupations of
these 44 were nine nursing assistants (20%); eight physicIans 115%). four of whom
weresusgeom;eighthoisaekeeplngormalntenanoewotkerat I$%);thnurses( 14%);
(2%); one paramedIc (2%); one embalmer (2%); and (our others who did not have
contact with patients (9%). Eighteen of these 44 health care workers reported
psrentersland/o ,othernon-needle-stkkespoauretobloodorothcrbodyfluidalrom
patients in the tOyea.s preceding their diagnosis of AIDS l4oneof these elpeaures
Involved. patient with AIDS or known IIIV infection, sod I IIV serocxmvcrvion of
the health care workcs war not documented followings specific esposure.
2. human Immunodeficlency vinsa transmission In the workplace
Aaof July31, 1988,1,201 heahh-cate workers had been enrolled and tested for IIIV
.nt lbodyinongo lngCDCsurve lllanceofheahh-ca rewo rkcrseiposedv laneed lestkk
or splashes to akin or mucous membranes to blood from patients known to be
HIV.infccted (16). Of 860 workeis who had received needle-stick Injuries or cute
with sharp objects (Le , parenteralespoaurea) and whoseserum had been tested for
HlVantlbodyst least i5odaysafterespcsaure. 4 were positive, ylekiingaseropieva-
knee rate of 047%. Three of these individual eaperienced an acute rctrovlrat
syndrome associated with documented seroconversion Investigation revealed no
nonoccupatkrnalrbkfactonfortheaethreeworkers. Serunicotkctedwlthtn3odays
of esposure was not available from the fourth person. This worker had an
I -Il V-seroposltlve sejual partner, and heterosexual acquisition of infection cannot
beesciuded Noneof She IO3wo,kerswhohadconlamlnalionofmucousmembsanea
or nonlntact skin and whose serum had been tested at least I SO days after exposure
developed serologIc evidence of HiV InfectIon.
Two other ongoing prospectIve studies assess the risk of nosoconmlat acquisItion of
lllVlnlecttonamonghealth-c .reworkerslfltheUnttedStstel Ajof April 1988,the
National Institutes of Health had tested 983 health care workers 131*11k &,cu-
mentedneedk.stkklnjurkasnd345kealth -c*re *orkerswhOhadsUslaincdmUC nl n-
membrane esposures to blood or other body fluisk of III V-Infected patients; none
had seroconverted (I?) (one health care worker who sut,scquentty c.pcrknccd an
occupational HIV .eroconverslon lies since been reported from MIt 1181) As of
March IS, 98$, a similar study at the IJnlvcralty of California of 212 health care
workers with 625 documented accidental parenteral esposures Involving ltlV-ln-
fected patknla had identified one seroconversion following a needle stick (19)
Prospective studies In the United kingdom and Canada show no evidence of ISV
tional Information w available, reported being employed in. health care settIng.
Of the health-care workers wish AIDS. 95% reported hIgh-rIsk behavior; for the
remaIning 5% (i69 workers), the means of ISV acquisition was undetermined.
Of these 169 health care workers with AIDS with undetermined risk, information is
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srammhlkrn.mong22oheafth carceorkeri wlthparcntersl, mucor membrane,o,
cutlneot eipo.we. (20.21).
in addltkrn to the hesltheese woiker. enrolled In these kniglludlnal surveillance
studies, case biSons. tgve been publhhed In She scientific literature for 19 liv.
Infected hesith-eate workers (13 wIth documented scroconversion .nd6 without
documcnledseroconver.loa) l4oncof these rkersrcportednonoccupatlona l,lsk
lactoes (see T.ble 2, psgca 32. 33)
3. Emergency medical sender and public safety worker.
In sddlikrn So the one paramedic with undetermined rirk dlsca*scd above three
publIc-safety worker. lsw.enforcrmcnt oflke,s).re clarsilledlnthe undetermined
s l am group Follow-up Investigations of these worker. could not determine con.
chaively If lily Infection wm ac u1red dunlni the performance of job duties.
II. Prtnetph.ol Infection Control and Their Application to !mergency and Publk.Satety
Woebere
A. Oeneral infection Control
Wlthtnthehealth caresettlnLFneralbncofltroiprOcedUre.hevebcendeve lopod
to ntltdmlie the rbk of patient acquiltionol Infection from contact with cont.mlnated
devices, objects, or surfaces or of tr.mmhekm of an Infections agent from health care
worker. to patients (1,2.3). Such procedure. abo protect workeri from the uk of
t,eoondng Infected General InfectIon-control procedures are designed to prevent trans.
nthalonof a wide range of nrlcrobloiogkal agent, ant to provide .wkie margin of safety
In the varied situations ennountered In She health-care environment.
General infectlon-conurol principles are applicable to othcn work environments where
workenconlaclother Indlvlduabandwhere trammbsbno( Infectionsagenti mayoecur.
The modes of tranambalon noted In the hospital and medical office environment are
observed In the work situations of emergency and public safety worker., as well There-
fore, the principles of InfectIon control developed for hospital and other health-care
settings are sho applicable to these work sItuations Use of general Infection Control
measures. adaptodtothe workenvlronmentaofemergencyandPubllc safety worker.,
b important to protect both workers and indlvlduabwfthwhomtheyworkhOmavsrlety
of Infections agents not juat IIIV and ISV.
Becanse emergency and public-safety worker. work In environments that provide in-
herently unpredictable iii.. of eaposurea, general InJection-control procedures should
be adapted to these work sItuations Exposures are unpredictable, and protective mea-
sures may often be med In situations that do not appear to present ilak. Emergency and
public safety workers perform their duties In the community under estremely variable
conditions; thin. control mamures tint are sImple and uniform across all sItuations have
the greatest likelIhood of worker compliance. Admlnlsttative procedures to ensure
compliance sko can be more readily developed then when procedures are complex and
Hghty variable.
B. Universal Blood and Body Fluid Precautions to Prevent Oceupatkrnal H1V and IIBV
Trammialon
In 1983. CDC developed thestrategyof “tuihersal blood and body fluid precautions” to
address concerns regarding tran,mbslon of IIIV In the health care settIng (4) The
concept, now referred to simply as unlversal precautions” stresses that all satlenla
should he assumed to he InfectiouS fur fflV and other blood-borne pathoantil In the
ho.pltslandothcr health caleaettlng.”ufllvcrulpreCaUtiofls” shoul.Jbcluilowed when
worker. are exposed to blood, certain other body flukie (smnlotk fluid, per Icardisi fluid,
peritoneat fluid, pleural fluid, synovisi fluid, cerebrospinal fluid, semen, sod vaginal
secretions), or any body fluid vblbty contaminated with blood Since thy and IIBV
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timwmtasion ha. not been documented from elposure to other body liukie (feces, mail
aecretk,n., sputum, sweat, tears, urine, and vomilto), unlve,..l precautiona” do not
apply So these flulč. Universal precautkuw abe do not apply to saliva, except in the
dental setting, where sally. h likely So be contaminated with blood (7).
For She purposeof thiedocument, human elposwebdellnedasarntec l wtthbloodor
other body fluke to whkhw i lve rsa l pr ecsutk m aspp l y through percutanco tatlon
oe contact with n open wound, nonlntact skin, or murow membraneduring She pester.
m.iice of normal Job duties. An “exposed worker” I defined, for the purposes of thh
document as an Individual exposed , as described above, while performing noimat Job
duties.
The unpredklsble and emergent nature of exposures encountered by emergency and
public
which are not Isazsrdma very difficult midoftenlmposalble. For example, poor lighting
mayllmlt thewosker’ssbilitytodetectvbibleblo din nitiworfeces Therefore,
smaredncs ci matinees in flies daffoubeiworn fluWtv a ea isdif flc idLi l nut
._________l.._ __ — a-— as s__s _.• a__ta a - — - — - S -
spplk.tion prhidpksof 5.1 pracaulkiru to ihealtimtk,nunmuntered
by these workers results In the development of guidelines (lined below) for work proc.
ticea, use of personalprotectlveequlpment, sMother protective measures. Tomlnbnlze
the rIb of acquiring HiV and HBV dwing peciormance of Job duties, emergency and
puirk-safetyworkenhoueprotededlromeiposuretobk,odandother body fluids
drcunwtanmsdkute P tecllonennbeach ievedth,ouah.dherer ice towo,bnractkex
designed to mininthe or eliminate exposure and through use of personal protective
equipment (Lc.,g l oves,mmbs.andpmtsetlvedothlng) ,whkh provideabarrier between
the worker and the exposure source, In some sltuatiom, redesign of selected aspects of
the Job through equipment modificatloiw or environmental control can further reduce
viek. These approaches to prbnary prevention should be mcd together to achieve mail.
mat reduction of the ilk of exposure.
lfeiposursof.nlndlvidualwoskeroccurs, medlcalmanagement ,conshllngofcolledk,n
of pertinent medical and oecupstlonsl hietory, pro,bkm of treatment, and osumdling
regarding future work and personal behaviors, may reduce riek of develophigdbcase as
• result of the exposure epbode (22) Following epbodk (or continuous) exposure,
dea,ntaminatk,n and di.lnfecikrn of the work environment, devices, equipment, and
doihins or other Intia. of ntiaonat niotective eauinnirnt can reduce subscuucnt ilk of
Ill. Employer Respoualbllltiee
A. General
Detailed recommendations for employer responsibIlItIes in protecting workers from
.cquhitlonof blood bornedbea.eslntheworkplaet havebeenpublished inthebepart.
mdntofEborandDeDaftn l entofHe 5ithafldHUmanSe s10ifltAdchor 0 an1d
follows series of steps: I) classification of work activity. 2) development of st.ndard
operating procedures. 3) provlknof traingandeducation. 4) development of proce.
dines toerisureand monitoroompllsnce,andS)worklllace redesign. Ajelint .tep.eveiy
see Table 3, page 34). I inployeis should make protective equipment available to all
worker . when they are engsgcd In Category I or Il .cllvitks. Employers should ensure
that the .pproprlate protective equipment bused by workers when they perform Cate-
goryl activities.
As . e nd step, employers should establbh $ detailed work practices program that
includes standard operating procedures (SOPs) for all activities having the potential lot
exposure Once these SOP. are developed, an initial and periodic worker education
program to assure Iamill . rlIy with work practices should be provided to potentially
exposed worker.. No worker should engage In such tasks or activities before receiving
training pertaining to the SOP., work ptact , sod protective equipment required for
thattask. anrpkio1pcrsonalp,otedivcequipnientforthep1eh01Plt5l5cttmf$( i0ed
ass setting where delivery of emergency health care tales place away from a hospital or
other health care seating) are provided In Table 4 (page 33j (A curriculum for such
training progranw I being developed in conJur ictkm with these guidelines and should be
corwulled for further Information concerning such training programs)
To facilitate and monitor complience with SOP., sdmlnbtratlve procedures should be
developed and records kept as described In the Joint Advbory Notice (6). Employers
should monitor the workplace to cosine that required work practices are observed and
that protective clothing and equipment are provided and property wed The employer
should maintain records documenting the admlniatraiive procedures used to classify Job
activities and copies of all SOP. for tasks or activities involving predictable or unpredic-
table exposure to blood or other body fluids to which universal precautions apply In
addition, training records, Indicating the dates of training sessions, the content of those
training sessions along with the names of .11 persons conducting the training, and the
names of .11 those receiving training should also be maintained.
ing the work environment which will reduce exposure rIL Such approaches are desira-
ble, since they don’t require individual worker action or management activity For
..i.mnl, irikandcnrlrctionslladhitk ShOUWhaVeda SSi IiCatlOflPrOcett Iu1d1 that require
exposures. Proper dhpos.l of contaminated waste ha. similar benefIts.
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— . s
•flc 1 .t 5 .Iwu. ,. .,.— —
to attack correctional facility stall with the Intent of traiwmllling IliVot I WV
B Medk.l
In addition to the geeral ,e onalbliullos note4 above, the employer h the specific
reapomlbwly to make available to the worker a program of medkal management. 11th
program b designed so provide (or the reduction of rbk of infection by HBV and for
aruiwefing woiken a,nctmtng hsuea regardIng lily and HOV. These services should
be provided by. Ikemed health professionaL All phmes of medical management and
c,ounseUnishouldenaure thaItheiidelUia ,Ofthewotke1, fh5n *W5ta
bpsoiectd.
I. llepsthhBv.cdrmtk’fl
AU workers whose jobs involve participation hi m b or .ctlvlllcs with eiposwe to
bloodorothei bodyflukiatOwhkhUflhoflalP Iapply tmdelinedabOveOfl
page 9) should be .acehwted with hepalIth B vaccine.
2. Management of percutmmot eaposur. to blood and other Inlacliour body flukia
Onceanelposute hat xvrtesi(.deflncdabovcoflpar IO).abloodsam ple sho uid
bedrawnaIteIameflth0bbom 1 u 5 0o nbd
eliclency virus (IIIV antibody) Local lawn regarding coment for testing source
Individoab should be followed. Polkics should be available for testing source ln
dI,kiuah In situatiotw where cement cannot be obtained ag • an uncoosdous
patient) Teasing of the souros Individual should be dons as. location where ap
propriate pretest wumctlng b avsllsbk poatteal coumeflng and referral (or treat.
ment should be provided. Is h estremely Important that all IndMduals who seek
iomultallofl lot any I II V.related concerns receive coumefing as outlined In the
‘Public I lealthServke Ouldelinea for Counseling and Antibody Testing to Prevent
IIIV Infection and AiDS” (22).
a. Hepatith B virus posle .poaure msnsgement
For aneapoturs toa source Individual found lobe positive for HBIAg. the
worker w 0 h flotprevi beengivenhePauith Bvscdne,houMreceh’c
the vbcclne scales A single dose of hepatith B immune globulin (IIBIG) b
.bo recommended. If thb can be given wIthin? days of caporule For c i.
polules (roman lIBsAg positive source to workers who have previously
recelvedvaclflc.thet1P001r5h0 be1ested lo,snilbodytohepati
lb Bsurlaceafltlgen(anti IIB.,.andglvCflOflCdOICOf vaccine andonedoic
IOSRUbyRIA,negatlvebyE lA) (7). - - -
If the source individual I negative for liBsAg and the worker has not been
vaccinated, thir opportunity should be taken to provide hcpatltb B vacelna-
haiL
lithe source Individual ref ure, testing or he/she cannot be kientilled. the
unvacdnaicd worker should receive the hepatllb B vaccine perk. IlItiO
administration should be considered on an Individual bash when the source
Individual I known or surpected lobe at high ilk of IWV infection Man
agementandtrealmenl. If anyoiprevloualyvscdnated workeis who receive
an eapeawe from .souice who reluses testing orb not identifiable should
be IndIvidualized (7).
b Human bnmunodelklency vIta posteiposure management
For any eaposule los source Individual who has AIDS, who I found lobe
positive for IIIV Infection (4), or who relines testing, the worker should be
counseirdregardlngthe rbkoflnfectlonandevslualeddlnkailyandscrolo-
gkally for evidence of HIV Iniectionessoon as possible after she eiposurc.
Inv lewoflheevolvtngnalureollllVpoalcipoauiemaflagement.the health.
care provider should be well liformed of current PHS guidelines on
subject. Thcwo,kctshouldbeadvbedtoreportsndieek niedlcalevatuatlon
(or any acute febrile illness that occurs wIthin 12 weeka alter the eaposure.
Suchsnwnns.p .rlk i arlyofledrdei lzedbyre vei.r s sh.OiIyiflPhaden O-
pathy. may be Indicative of reotnt HIV Infection Following the initial tess
at the timed eiposuse.seronegalive workcrsshouldbe retcsted6 weeks, Il
weeks, antl6montlo alter eiposuze ho determine whethet tran,mbakin has
oecwred Du,tngthkl000w-uppcrlod(eapedally the (1. 16- l2weekiaftcr
eiposwe,whcnmost fectcdpersoiwareeipechedtoscrocunvert ).eipoied
worke,sshouldlollow U S Pubtlclle.IthServlce (PuS) recommendations
for preventing tranambilon of IIIV (22). These Include rdraInlng from
blood donation and taing approprhle protection duilngsciual lniercouisc
(23) Dwlngailphascsof(OIIOW-Up,I1 hvltalthat workerconlidentlallsybe
protected.
If the source IndIvidual wes tested and found so he seronegailve. baselIne
testing of the eaposed worker wi;h follow-up testing 12 weeks later may be
peilormed U dralred by the worker or recommended by the health case
provider
-------
I I MMWR
Vol hub SI
MMWR Is
follow up should be kalividualked Serologic testing should be node avail
•bk by the employer to at) wo,kei. who may be concerned they have been
Infected with lilY Ihiough an occupational erpoaure as defined above (see
page 10)
3 Management of human bites
On occasion, police and correctional facility officers are inientlona lly bitten by
stwpectaor prisoners When such bile. occur, routine medical and surgical lher.py
lincluding an assessment of tetsnua vwxlnation stal in) should be Implemented as
soonas possible, since such bites frequently result in Infection wlthorganbnnothes
than tliV and 1IBV. Victims of bites should be evaluated as deicilbed above (see
page Il) for erposure to blood or other Inlec tloi n body flukie.
Sallvaof some penornlnfectedwlthHBV hasbeenshowntoconisln HBV.DNA at
concentrations 1/1.000 to 1/10,000 of that found in the Infected person’s serum
(3,24) IIbaAg positive saliws has been shown lobe infcctknm when injected into
esperimentat .nimais and In human bite eipuaures (23-27) However. HOIA5.
positive uiiva has not been shown to be inleciloin when applied to oral mucous
membranes In esperimentalprimate studies (27)or ihroughwntsmln.lionof musi-
cat Instruments or cardiopulmonary resuscitation dummies med by HBV carriers
(28.29). Epidemiologic studies of nomeau.l boinehold contacts of Ill V-Infected
patknt..lnc ludingseveralsms i laedesinwhlchH lVtrammh h lOnfa lkdto occ llratter
bile. or (ler percutaneots Inoculation or contamination of cuts and open wounda
with s.ltv.froin Hi V.Infected patients, suggest thai the potenlial for salivary tram.
mbskmof HIV is remote (3.30-13). One case report from Germany has suggeated
the possibility of transmbslonof HIV na hotsehold setting from an infected child
toe sibling through a human bile (34). The bite did not break she skin or result In
bleeding Since the date of aeroconversion to HiV w not known for either child In
4 DocumentatkmOf esposure and reporting
As pert of the anti Identlal medical record, the clrcunwtances of espolure should be
recorded Relevant Information includes the activity In which the worker was en-
gaged at she time of eaposuse. the extent to which appropriate work practices end
protective equipment were med. and. description of the soucoc of exposure.
Employers haves ,espomnlbiUty under various Federal end state laws end regulations
so report occupational Illnesses and injuries Existing program’ in the i4atlonal
institute for Occupational Safety and Heaith (NiOSIt), Department of Ikalth end
Human Services, the tiurenuof labor Stat btka, Department of Labor (1)01); and
theOccupatlonaiSafcl,sfldIle a IthAdmIfl i str l 0I)r 5ud i1d0mm 5tboh i
for the purposes of surveillance and other objectives. Cases of Infectious disease,
Inciuding AIDS and IIBV Inf ectkni , eze reported to the Centers for Disease Control
through State health departments. -
3 Management of HBV. or HIV-Infected workers
Transmission of HBV from hesith-care workers to patients has been documented.
Suchtr.mmbslonhasoccurreddwhigcertalfltfltcsoflttvslveproCedUfes(e.I ,orai
arid gynecokigle surgery) In which health-care workers, when tested, had very high
conorntr.tknsof IIBV In their blood (at least 100 millIon Infectious viris particles
per mllhtllter,aoonosntratkmn much hlg$ier than occurs with HiV Infection), and the
health care workers sustained a puncture wound while performing invasive proce.
dwes or had exudative or weeping lesions or mk,oiaceratlona that aflowedvlna to
contaminate ltwtnunents or open wounda of patients (33,36) A worker who is
liBsAg positive and who has transmitted hepatitis B vInn lo another Individual
during the performance of hh or bet job duties should be eududed from the perfor-
mance of those job duties which place other individuab at risk for aa uisitlon of
hepatitis B infection.
Workerswithtnlpairedimmunesyltemsrc sUtttflg fromHlVlntectkinorotbercauscs
are at increased rukof acqulrlngorelperkndngaeilouscomptlcatk)naOl Inlectlotn
disease. Of particular concern is the risk of severe Infection following exposure to
other persona with infectious diseases that arc easily transmitted If appropriate
precautions sic not taken (e g • measles. vericella). Any woiker with an Impaired
immune system should be counseled about the potential risk associated with provi-
ding health care to persona with any transmissible Infection and should continue to
follow existing recommendatlomn for inlectloncontrol to minimize risk of exposure
to other Infectious agents (2,3) Recommendations of the immunization Practices
for
vaccinating workers with llvc.virus vaccines (e.g, measles. rubella) should aiso be
considered
The question of whether workers infected with IllV can adequately and safely be
allowed to perform patlent-caredutlea or whether their work assignments .houldbc
changed must bedetermined on en kidlvidual basis. These decisions should be made
by the worker’s personal physician(s) In conjunction wIth the employer’s medk*l
advisors.
C Disinfection. Decontainlnatkrn, and Disposal
Asdescflbedk%Sectlonl C. (see pagel).theofllydocumentedOocUpatlOflhirl 5kiof lllV
arid I- WV infection are associated with parenteral (Including open wound) arid mucous
membmaneelposUre So blood andother potentially Infectious body flukb Neve,thcless,
the precautions described below should be routinely followed.
-------
J u N 53 ) Vat 5SINoS
I,
MM*
I. NeedkandShatPsdhPohht
MNWw
All workeis should take precsulknw to prevent injuries cained by needles, scalpel
imtrwnenta . during disposal 01 med needki, and when tiandilng sharp Instruments
alter procedures To prevent needle stick Injuries, needles should not be recapped.
purposely bent orbmkenby hand. removed (rdm disposable syringes, or otherwise
manipulated by hand. After they arc med. disposable syn*ngea .nd needles, scalpel
blades, end other sharp itemashould be placed In pundute-teibtat t container, lot
disposat the pun e.resnfltaisuh0 k,cstedmclose — practical to
the we area leg, lathe ambul.nce or, if sharps are carried to the scene of victim
Sothescene.wefl). Remnshie needle shou ldbeleftoflthtsyrlnhl shOuhd
be placed na puncture4Csistaflt container (as transport to the teproctssing r
2. Hand washing
lands ami other skin surfaces should be wedied Immediately and thoroughly II
contaminated wlthbk,Od. other body fluids towtdchuntvtml prec .utkun apply. Or
potentially contaminated .rtkirs Hands should sinayl be wedied after glo as are
,emoved .cVefl If the gloves appear lobe intact. hand washing shouldbealmPleted
wing the.pp.oprlate fadUbim.surhUtIlityOrtutr00msI k Watelkllafltbeptle
hand cleanser should be provided on responding units lowe when hand washing
lacllhki s ic not .vsllable. When hand washing facilities are available, wash hands
with warm water and soap. When hand.washlflg facIlIties arc not svallsbk. mae a
asterlma antiseptic hand cleanser. The manufacturer’s recommendations For the
product should be followed
3. CleanIng. dislnfcctlfl$. and aterilising
TableS (see pages 36,37) present’ the nscthods and applications (or cleaning. disin-
fecthig. .inI sterilIrkil equipment and surfaces In the prehospltal setting These
thods abo apply to homaekeepiflg and other cleaning tasks 1’,evlotnly Issued
guidelines for heahh4ate workeis contain mote detailed descrIptions (4).
4. Cleaning .nddrcont .mhl atlflg splib of blood
ANspUb i oodntamt b5h PP
an EPA.SPprOr cdVI cora I.I sol onofhoUsCholdb 1 dh1the following
manner while wearing glares Visible material should lint be ,emoved with dis-
posable toa’ Is or other appropriate means that will ensure against direct contact
althblood i (splashiflgia.fltlClpat proteccyeweMsho m11vlthm
an tmperviomd gown or spron which provides an effective barrier to splashes The
area should then be decontaminated with an appropriate germicide I lands should
SoiledclcsningcqulPmentsbouldsest%ed
andmiecontamlflatedot plscedlnaflaPPfOPtieteWnt 5 hsPo1ed0otO1 18
to agency policy Plastic bags should be available for removal of contaminated Demo
(tons the site of the spill
Shoes and boots can beuune contaminated with blood in certain Instances Where
coverings should be comlde,cd. Protective gloves should be worn to remove con.
t.mlnated shoe coverIngs The coverings and gloves shouldbe dIsposed of In plastic
bags AplastiebagshOUldbe the mesctnekibot thecarwhichbtobe
wed for the disposal of contaminated ltenn. Eats. plastic bags should be stored In
the police auber or emergency vehicle.
5. Laundry
oIactual0neasCir5Ian iuu3 ’ e ’
catlons. hygienic storageand proceuingof clean end soiled linen are recommended.
L au,yfaCllit i eand/ 0 fseMce, 5h0ul m 5&routindl7aval YtbeP0Y
Soiled linen should be handled little as possible and with minimum agitation to
prevent gross mic,oblslcontsmtflatlOli0f the sir and of persona handling the linen
Misolledlinenshouldbe baggedat the location where it waS wed EJnensollcd with
bloodshoUldbe placedsndtransportediflbaP that prevent leakage F’Iormst laundry
cycles should be wed according to the washer and detergent manufacturers’ recom
mendatiota.
6 i)econtatnlnatk)n and Iaw,derlng of protective clothing
Protective work clothing coniaminated with blood or other body fluids to which
universal precautions apply should Lie placed and transported in bags or contains
that prevent leakage Personnel Involved in the begging. transport. and laundering
of contaminated clothing should wear gloves Protective clothing and station end
work uniforna shouldbe washed and dried according to the manuladuier’s Instruc
lions Boots and leather goods may be brwh scrubbed with soap and hot water so
remove contamination
7. infectIve waste
The selection of procedures For disposal of infective wnite is determined by the
rcIatlvc risk of disease transmission end applkstk)flOf local regulations, which vary
widely in all cases, local regulations phould be consulted prior to dlapar.l proce-
dures and followed. Infective waste, in general, should either be Incinerated or
ahouldbedec ofltamin ate 0re poie ass ts,yl andfill lluikbioud, suCIIOfled
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Is MMWn
5 ). I S I S Vol 15 1W. SI
MMWR I.
fluids. eretetlona. andsecretions may be carefully poureddowna drain connected to
• sanitary sewer, where permitted. Sanitary sewers etay also be used to dbposc of
other infectious wastes c .p . U . of being ground and iliohed into the sewer, whets
permitted. Sharp itenw uhould be placed in puncture-proof containers and other
blood-contamInated beam should be placed in leak-proof plastic bap for transport
to so appropriate disposal location.
the pstknt has been eared for titouidcsselullyseaichf ot and remove contaminated
materIals. Debib should be disposed of a noted above.
IV. flr, sod emergency Medical S., . k
The guidelines that appear in this section spply to lire and emergency
This
support personneL Firefighters often provide emergency medical seniors and therefore
enmtmter the eaposurn common to paramedics and emergency medical technicians Job
duties are often performed in uncontrolled environments, which. doe to a lack of time and
other laclora,donot show for auotkatlonof acompleadeclsion -makbig process tothe emer-
rncvat hand.
The general prlnclpks presented here have beendevelopedfromesbtingprlndpksofoocu-
pational safety and health In conjunction with data from studies of health-care workers In
hospital settings The basic premise is that worker, must be protected from esposure to
bloodsndother poientlaltyinfectlorwbodyflukbinthccourseofthelrworkaCllvitles There
bapaudtyoidstaconorrnht gthe,bkstheseworkerg roU psla ce.hOwever,whlChCOmPlk* 1e 5
development of control prinelpies. Thus, She guidelines presented below are based on prin.
ciples of prudent public health practice.
Fire and emergency mrdkalservkt personnel are engaged In delivery of medical care In the
prehospitalsettlng Thefollowlnggukleiinesareintendedtoasslst thesepersonncilnmaklng
decisloca conoernins we of personal protective equipment and resuscitation equipment, as
well as lot decontamination, dlshifectlon,.nd disposal procedures.
A. Personal Protective Equipment
Appropriate personal protective equipment should be made availeble routinely by the
employer to reduce the risk of especure as defined above For many situations, the
chance that the rescuer will be esposed to blood and othe, body fluidi to which universal
prec*utloea apply can be determined in advance. Therelore. lithe chances of being
esposed to blood is hIgh (e g .CPR. IV insertion, trauma, delivering babies), the worker
should put on protective attire before beginning patient care. Table 4 sce page 13) sets
Iorthesampksofrecommendationlforpelsonaiprotectlveequipment inthe prchospitai
setting; the list is not Intended to be aU-Inclusive.
I. Oloves
Disposable gloves should be a standard cumponent of emergency response equip.
ment,andshou)dbedonnedbyallpersOflfleiplIoI tolnltiatingsnyemergencypat lent
care asks involvingesposure tobloodorother bodyiluids to which unlversalprecsu-
lions apply. Eatra pairs should always be available Considerations In the choice of
disposabie gloves should include desterity, durability, lit, and the taik bcinF per-
formed. Thus,there is no.lngk typeor thickness of glove appropriate for protection
in allsltuatlons For situations where large aniountsof blood tue llkeiy to beencoun-
tcred,it isimportant thstgloveslitttghltyst the w,ist toprevent hloodcontaminatiofl
-------
aS MMWn
Junfl.iN 5 Vc IflINSS
MM ii
of handa around the cull For multiple trauma victims. gloves should be changed
between patient contacts, If she emergency situation allows
theater pcr.on.l protective equipment measures are Indicated for situations where
btokenglmeandsharpcdgaserebkel,sobeenoun lered.such.sc xt, i c a s i ngaper,on
from an automobile wreck. Structural I I,. lighting gloves that meet the Federal
OSlIA requirements lot lire lighten gloves as contained In 29 CFR 1910156 or
llstkmnal Fire Protection Aaaodsikm Stans ard *973, Oloves lot Structural Fire
Ftghtenpsbooldbeworninanyshuatkmwheassbazpo. toughawlacasare Ilkelyto
beenoounle,ed(37).
While wearing gloves, avoid handling personal brew, suchmcombs and pens, that
could become soiled or contamlimled. Oloves thai have become contaminated with
blood or other body Ilulde to which wthcnal peecautkriw apply should be removed
• soon as possible, taking ease to avoid skin contact with the esierior surface
Contaminated gloves should be piaced and transported In h . p that prevent leakage
mid should be diaposed ole., In the ems of tamable gloves, cleaned and dblnfected
properly.
2. Mmba,p....ar,ndgowrw
Mwha,eyeweat ,andgowmshouldbepresentonallemergencyvehkksthat respond
or potentially respond to medical emergencies or victim rescues These protective
barrlersshoublbe wed ina rdanceMththelevelofeape.weencountered. Minor
loceratlom or small amounts of blooddo not mciii the same extent of barrier r ae as
tequimdtorensanguInatingvictltnsormemIvea talalbkedIng Msnagementolthc
patient who it not bleeding, and who has no bloody body liulda present, should met
rouinquheweofbatrlerprecsutkuw. Masks .ndcyewear (eg safety glasses)
should be worn tugeiher,or a lamahield should be med by all personnel prior to any
slsuat l onwtsern.phot.csotbkrodorosherbodyllukittow*skhunlve iaalprecaui i om
apply are likely tooecue. (loans or aprons should be worn to protect clothing from
sphehor with blood. If inrge aphahea or qrantltles of blood arc present or anikip..
ted, Imp omagowiwor aprons should be worn. Aneitrachangeof work clothing
sisouk ibe avallabteat all times.
3 Resracftatlon equipment
Notrsmmhslonol HBVos HtVlnfectiondurlngmouih to mouthre,uscltstionhas
been documented. however, become of the irk of salivary trsmmimlon of other
Inlectiomadbeascs (eg, herpes simplex and Nthude mesrin 1 tt idir P and the theore
•frmt.kInlIIIVandI iRViianimhalnndu,In..tl llklslventUatk)flOltraUfl%avkuInw,
thoroughly cleaned and dbmnfected after each inc according to the manufacturer’s
recommendations
Mechanical respiratory assirt devices leg, bag-valve masks, oxygen demand valve
,csmadtstors) should be avaIlable on all emergency vehicles and to all emergency
response personnel that respond or potentially respond to medkal emergencIes or
vIctim rescues.
Pocketmouth to rnouth,csusdtationmaskadeslgfledtObOiateemergtn cyrespome
personnel lie • double lumen 5 )1 5mw) from contact with vid Inn’ blood and blood-
contaminated saliva, respiratory secretions, and vomifta should be provided to all
personnel who provide or potentially provide emergency treatment
dnlevl(ca be wed once and dbposed of or,lf reusable,
-------
Jun. 21. ime
vol IN. S•
23
be put on soon N amditlom permit. In e of blood contamination of clothing.
sneMra change of clothing should be available at all times
2. cardIopulmonary resuscitation
LenforccmentandenfleetioflaIpeiOflfletme5bOco e bd 5tbout infectionwith
lily and IIDV through administration of csrdiopuimonasy resuscitation (CPRI.
Although there have been tm documented cases of I-IIV irammisrion through this
mechanhm,thepossibllllyOftrsmmbslOnOfOlheI lnfectiousdiscaacseibli There-
fore. agencies should make protective masks or airwaya available to office’s and
provide training In their proper me Devices with one-way valves to prevent the
patient? saliva or vomitus from entering the caregiver’s mouth are prelerabie
B. law-Enforcement Co,nljerstloin
I. Srdmeaanduvide&C handling
Crlmhaljmnlkr personnel have potential risk. of aciuirlng liDVor lily infcction
througheIposureswbkhoeeWd%flthI5esresan 1 cc handling Penetrating
injuries are known tooceur.and puncture wountis or needle sticks in particular pose
a h izard during searches of persor .vehklea.o b. and during evidence handling
The following precautionary measure. will help to reduce the risk of Infection-
• An officer should use greet caution in searching the clothing of suspects
lndlvldu.ldiscrctiOfl,baaed on the ckcunntancea at hand.shoulddetcrmine
ilasuspecto l prisoner shouldempty his own pockets or ii the officer should
use his own skits in determining the contents of a suspect’s clothing
• A safe distance should always be maintained between the officer arid the
suspect
• Wear protective gloves If elposure to blood is likely to be encountered
• Wear protective gloves by .Il body cavity searches
• lb cation gloves are to be worn when working with evidence of potential
latent fingerprint vaiueat the aimescene. theycun be wornover protective
disposable gloves when eaposure to blood may occur.
• shifts, toaearch hlddenareas
Whenever possible, use long-handled nmhrors and flashlights to search such
areas (C g • under cut seats,
22 MMWn
V. L aw.Inf ,JUNLCt and C.rr,dIetesl.FadhItIOf hh1
Law enforcement and correctional facility office’s may face the risk of eaposure to blood
during the conduct of their duties. For eisnmpk, at the crime scene or during processing of
suspects. law loreement off b e ets may e ‘ som rbb o tmminated oderm ic needles
oiweapolS.Ofbe(mIkd upon to assist with body removal o,rectionml -fsc1lby officers may
similarly be required to search prisoners or their eelS for hypodermic needles or wcsporn.or
subdue violent and combative inmates.
The following section present. inlor matbon for reducing the risk of acquiring HiV and HBV
infectionby law-.nIolCemenI ann correctional facUlty officers acursequence of cmnylng
out their duties. However, there is an eatremely diverse range of potential situatborts which
fore, medjgle*it0(th Untivarual ou r
or event. arise. These recommendat should serve an adjunct to rational decision
action is required to preserve We or prevent significant Injury.
The following guideline. .rc arranged into three aectiona: .sectlon addressing conceriss
shared by both law enforcement and correctional facility officers, and two sectknts dealing
separately with lawenlotcelnent office’s .nd c rr tlonalfadlhy officers. respectively.
Table 4(5cc page 33)contsirn Kkdedelampksof personal protective equipment that may
be employed by lawenfotetment and correctional facility officers
A Law Enforcement and Correctional F.dlltlea Comiderstbont
I Fights and assaults
Iaw.enlo,ccmeI%t andcorrection5tf5cllltyo ce ’ s are elposell iou uu.. .
tive and disruptive behavior through which they may potentially become eaposed to
blood or other body flul containing blood. Behaviors of particular concern arc
biting. attacks resulting In blood esposure and attacks with sharp objects Such
bchsvlO ’ s may occur In a range of lawenfOrcement situations Including arrests.
routine inte,rogatinns.domestkdisPutes,5nd p0rtloM._ 0r
tbonal facility activities. Hand to hand combat may result in bleeding and may thus
incur agreaterchaflee for
blood-boll’s disease t,anambak,n.
Whenever the possibility for elposure to blood or blood contaminated body flukis
In all easel. estreme caution must be used in dealing with the suspect or prisoner If
there is any Indication of assaultive or combative behavior. When blood is present
andaaidpectOr an lnmatclsconlbmtive or threatefllflgtOstafl. giovcssh0uklml 5
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24 MUW
Jwisfl. 1 5S 1 V ol SPIN.
MMWR 2S
• I I searchings purse.are(ufl,emptycoflt efltsdilectly Iiompu,sc,by .wnmg
ft upside down over .tsbie.
• liar puncture prooi cont wrs to store sberp hutrumenta mid dmely masked
p 1.5 1k begs to stoic other poschly miptanthwded Itenn.
• To avoid tearing gloves. use evidence tqc instead ol metal staples to seal
• LoesIpioccdureslore4meh5ndUflhht
should be air dried before sealing in photk.
h.n
Not all types of gloves are sultsble lot conducting searches VInyl or late. rubber
provide Nt 1 octionsgslnstsbarpht strumts,afldt h elatet lot puncture.
proof There badlrect lrade-oUbetweenleveIof protectkmsnd manipulability In
other words, the thicker the gloves, the more protection they provide, but the less
eUectlve they .rc hi locating objects Thus, there ft no single type or thickness of
gloveapproptiate lot protecilon ln.llsltuatkflw Ofikee.ahouldsclect the type and
thickness of gk)ve which provides the best balance of protection and search clii.
ckncy.
OlikenandahnesCene technklanamsya)flfrOflt unusual hara,ds,eapeclally when
the crime scene Involves violent behavior, such as a homicide where large amounts
• of blood are present Protective gloves should be .vsllsble and worn hi thb setting
In addition, lot very large spur. conskierstbn should be given to other protective
clothing, such as oversile. aprons. boots, or protective shoe covers They should be
changed II torn or soiled, and siwsyl removed prkw to leaving she scene While
wearing gloves, avoid handling penonal Itenn, such — combs and pens, that could
become soiled or contaminated
Face masks sod eye protection ora lam shield sic required lot laboratory and cvi
dence sechniclam whose jobs which entail potential e po,utes to blood via ssplash
to the face, mouth, nose, or eyes.
Airborne particles of dried blood may be generated when a stain ft sciaped It ft
recommended that protective masks and eyewear or lace shields be worn br labor.
toryor evidence technicians when removing she blood stain (or laboratory analyses.
objects
e,personnelshOuidbeakrtbor thepzescflceOlUhsrP
i ,...i ..n.ti aanalb.ornthershatP
2 Handling deceased peruorn and body removal
Fordctcctlvcs. invcstlgstors,evldcnce technkisna,andothcrswhomayhavc to touch
or removes body, the response should be the same as (or situations requiring CPR
or first aid: wear gloves andoover aficuta arid abrasions tocrcate a barrier and care-
lutly wsshslieiposed sreslteranycont .ct wish blood. The p,ecautions to be used
with blood and deceased person. should abe be used when handling amputated
limbs, hands, or other body parts. Such procedures should be followed after contact
with the blood ol anyone, regardless of whether they are known or suspected lobe
infected with lIiV or HBV.
3 AutopsIes
Protective nwaks end eyewear (or (ace shields), laboratory coats, gloves, and water.
proof apmmshouldbewornwhenperfosmingoraltendlngall.utopsles Atlautopsy
materlslshou$becomldered lnfectkunlor both HIVsndHBV Onlookeriwithan
opportunity (or eaposure to blood splashes should be similarly protected instru
meAts and surlsces contaminated during postmortem procedures should be decon.
tamlnaledwlthanappropsiatechemicllgermkide(4) Manyiaboraiories havemore
detailed standard operating procedures lot conducting autopsies; where available,
these should be followed. More detailed recommendations (or health-care workers
in this setting have been published (4)
4. Forensic laboratories
fflood Irom all individusk should be considered Infective To supplement other
worksiie precautions, the following precautions are recommended (or workers In
forensic laboratories
a. All specimens of blood should be put In a well constructed, appropriately
labelled container with a secure lid to prevent leaking during transport Care
should be taken when collecting each specimen to avoid contaminsling the
outikleol thecontalnersndo( the laboratory lorm . mpanylng the specimen
b All persona processing blood apedmern should west gloves Maskiand protec-
tive eyewear or lace shields should be worn If mucous membrane contact with
blood ft snilcipated (e g ,removing tops from vacuum tubes) I lands should be
wbcd alter completion of specimen processing
C-
—— a--— — — flS_.__I___I___S __.I__ _ _I_ _,.._M_._ ——
gical culturing.. biological safety cabinet is not necessary however, biological
safety cabinets (Class I or Ii) should be used whenever procedures arc
conducted that have a high potential for generating dropleti These indude
activities such as bkndlng, sonicating, and vigorous miring
-------
MMwa
Jun. fl imo
V Ol 3I II. S.•
‘7
d. Mechanical plpettlngdevkiea should be used (or manipulating all liquids In the
laboratory. Mouth plpetllng must Aol be done.
C.
I.
U.e ol needle. and syilngc should be limited to .Ituatkins in which there is
alternatIve, and the recommendations (or preventing injuries with needles out-
lined under wilve,ul precautions should be followed.
Laboialorvwo,kawfscessbouldbeckanedo (vblbIe mate ,Iabandthendecon.
laminated with an apjwopriate chemical germicide sfterasplllof blood, semen,
or binod-axdandnated body fluid and when work activities .rc completed.
• Contaminated snaterlab wed In laboratory teal, should be decontaminated
• bdoe reprocessing or be placed in hap and disposed of In accordance with
Insthutlooal and local tegulelosy policies (or disposal of Infective waste.
Penetrating Injuries are known to occur in the correctional facility setting, and
puncture wounds or needle stick. In psiticuler pose a hazard during searches of
prisoneraorthelrcelis. Thefollow1ngp,ecautlonarmeasureswIflheIPt0Kd tha
risk of Infection:
• A correcilonal-facdlty officer should use great caution In searching the
clothing of prisoners. Individual discretion, based on the circumstance’ at
hand, ahouki dctennlne lie prisoner should empty Id. own pockets or It the
officer should tar itis own skis In determining the contents of a prisoner’.
clothing.
• A safe distance should slwaye be maintained between the officer and the
prisonel.
• Alwayscarrysflashllght.evendurlngdayllghl shlfts,touearchhlddenareiia
Whenever possible, we long handkd mlrro,. and flashlights toaearchsuch
areas (eg • under commodes, bunks, and In vents in jail celis).
• Wear protective gloves If elposwe to blood Is likely lobe encountered.
• Wear protective gloves (or all body cavity searches.
Not all types of glove. are suitable for conducting searches. Vinyl or late, rubber
glovescanprovldeflule,lfany.prolectlon.gslnataha,p lmtrumenia.andtheyare not
puncture-proof. lbereis•d lrecttrsde.of(betwecnkvelofprotedionandmanlpula.
bully. In other words, the thicker the glove.. the more protection they provide, but
the less effective they are In locating object.. Thia, there is noalngk type or thick.
nessol glove appropriate (or protection in all situations. Officers should lelect the
typeandthkknesaofg l ovcwh lchplov i desthebe.t b atanceo(proteci i onandam,ch
elficlency.
2. Decontamination s-wi disposal
Prisoner, nasyspit atoflkenanduhmw(ecea; sometimes thesesubilanoes have been
purposefullyo,ntaminated with blood. Although there are no documented cases of
IUV or HBV transmission In this mannerand transmission by this route would not
becapected Iooccur,othe ,dbeasescouldbei ,ammltted. These mate.labshouldbe
removedwith. paper towelafterdonnlngglovea,andtheareathen Ieoontamlnste4
with en appropriate germicide. Following clean-up, soiled toweb and glovci should
be disposed of properly.
is. Scientific equipment that is. been atatanthiated with blood should be cleaned
to the macufactusci.
I. AU persons should wash their hands after completing laboratory activities and
should remove protective clothing before leaving the laboratory.
Area posting of warning signs should be considered to remind employees of
continuing hazard of htlcctlois disease transmission In the laboratory setting
C. Correctional Facility Considerations
I. Searches
-------
MMW
2i
anI fl tNS
VI. leisrencan
(1a,ner iS. Fevero MS OuldeIlnelOt
19*5. Atlanta Public Heshh ServIce. Centers for Dbeasc Conttol, 19*5 BUS
publIcation no. 99- I I I?.
2 OarneriS.SimmonaBP flflefO,h0I tionp opitala. Infect Control
19*3,4 (suppl) 245-325.
3 WilIlaim WW. OuldeUne (or Infection control In hospital personnel. Infect Control
19*3. 4(auppl)326- 49
4 Center. for Diae.ae Control. kecommend atkflw (Or preventIon of IIIV transmhakfl in
he.ltb.C*rSKttlIlP MMWR 19*7; 36 suppl2S).
S Centers for Diseme Control. Update: Universal prec.utkna (or preventIon of
aranambal0nOlhU ’ ’ t ’ Bvlrua.afld0ther0 0t
pathogena In health care eUlnp MMWR *9*8; 37:377-382,387
6 U S Department of Labor. U S Department of Health and human ServIces. Joint
AdvNory Notkc: protectk)fl spinal occupStk)nb* eaposure 10 hepatItis B vina IHBV)
and human lmmunOdeIlcIeIKY ,t,ta (HIV). Federal Register 19*7; 52:41*18-24.
7. Centers for Discue ControL , ccommendstkrna Inc prote lion q u a t viral hepatitis.
MMWR 19*5; 34:313-324,329-335.
& Kunches LM.Craven DE. Werner RCI.JscX)b$ LM Hepatitis BelpolUre Inemerlencl
medical persoruseF prcvslenct of serologic markers and need for inununIiatk 1 . Amer
J M cd 19$); 75:269—272.
9. Pepe PP.. HollInget FR. T,obl CL, Helberl D. Viral hepatitis risk In uiban emergency
medical services personnel. Anak Emergency Med *9*6; lS(4):434-45
Ift VaktUUeIST . Hook EW. Copus MK. Corey L OccupatIonal eaposure to hepatitis
B In paremedlol. Arch Intern M cd *9*5; 143.1976-1977.
I I. Morgsn-CeP 1 P. I lurbon P. 1 -lepatllb B markers In Lancashire police off kers.
EpIdemlol 101 *9*8. 100:145-151
12 I’etetklil M.CrSWIOId RI. Hepatitis B vaccine for police forces lLetterP Lancet 1986;
2 *458-59.
I) Radvan Oil. IIewsot% P0. Berenger S. Rrookman Di The NewCaStle hepatitis B
outbicak ob.ervetk)na on car.C. management, and prevention Med I AWt,alla *9*6;
v .a 881N0 S•
14446 1-464.
II Center’ for Disease ControL InactIvated hepatitis B virus vaccine MMWR 1982;
263*7-322.327-326
Ii. Center’ for Disease Control. Update on hepatitis B prevenuion MMWR 19*7;
36-333-360,366
16. Marcus Rand the CDC Cooperative Needkstkk Surveillance Oroup SurvclUanc’eof
health eare worker’ eaposed to blood from pstlenta Infected with the human
immnunodelkiency virija N EngI I Med *9*8.319 11*8-23
*7 Henderson Uk. Fahey RI. Sash Al. Schmitt JM, Lane IIC Longitudinal assessment of
rkkforoecupatlonaI/n0mlaltran’m 1b0f hunranImmunodefkkflCY 1IiU5. type
* In health care worker’. Abstract p634; presented at the 1988 ICAAC Conference,
New Orleam
*8 flamesDM IlealthwovkerlSndAlDS Questlo rwpelsbt Science 1988.241161-2
*9. Oerberding IL UtteflCO, Chamber’ hF, Moss AR, Carbon I. Drew W. Levy I, Sende
MA. Rbkofoccupation.li1iVtr 5mm nt7 th careworkeri
FoHow-up Abstr.ct S 343; presented at the *9*8 ICAAC Conference. New Orleans
20. Heehh.ndWel la,eCSflada Natlonalsu,velIlstlCe programonoccupittIOnaICIPOaUtes
to HIV among health care workers In Canada Canada Dis Weekly Rep *987;
13-37:163-6.
2*. McE oyM.POftCf K,MofllmerP,SimmOM N,ShenaonD prospectiveatudyof clinical.
Inboratory, and ancillary stall with accidental esposures to blood or body fluids (rum
patients Infected with lily, Br M cd 1*987; 294 *595-7.
22. Centers for Disease Control Public health Service guidelines for counseling and
antIbody testing to prevent HIV Infection and AIDS MMWR 1987; 36.509-315
23 Centers for Disease Control Additional recommendations to teduce aerual and drug
abuae.relatcdtran’mis*IofloIh ii T.tymphotropIC virur type lil/lymphadcnopathly.
associated visa. MMWR *986; 35.152-35.
24. Jenison SA, Lemon SM. Baker IN. Newbold JE. Quantitative analysis of hepatitis B
visa DNA In saliva end semen of cluonicaUy Infected homosesual men I Infect Uls
*987; I56 299-306.
25 Canclo Bello TI’, de Medlna M. Shoreyi. V,illedor MD. Schill 1R An lnriiiiitlonal
outbreak of hepatitis B related toe human biting cattier I infect I )sr l9 1t2, 146652 6
-------
MM
. 1 fiN.
MMW SS II
31.
26. MscQ anlr MB,Foi 1 haMB,WofocbowDA. HeputlthBirimmltiedbyahunmnbhe.
lANA 1974; 23&723-4.
27. Sazts RN. Snhbhan R. Hancroft W1 AIter HI, IlnipsI.pong N Eapethnental
i,aasmbsloo of hepatith B vIne by eeaeoandssitva. I Infect Db 191% 142.67-71.
21. Glue, iS, N.dle, JP. Hepatlib B v*na In. cradiopulmonary resiacftatk,n training
une: RMk of •iuwmiskm (romasuzf.cean*Igenposlilvc pulkipani. Asc I i Intern
Med 1965; 145:1633-S.
29. OsleiholmMT. Bra .oER.CrossonJT.ciaL tacIioIimbsIonof ii.IhepatIthtype
B after oral cqosvre so HBsAg.posltlve saliva. Br Mcdi l979 2:1263-4.
30. LUson AR. Do akeranie uiodes (or ime,m 1on of human hemunodrfkkncy vtna
eat? A uvie.. , . lANA 191% 239:1333-6
P ,kdlnGH.SahsmanBR,RogenME et.L LackofIraasmbslonol lfltV.lII/LAV
k,Iectkrn to hoiehoM rantactiol patknts with AIDS or A1DS-rc iedrampki with
oralrandidlub. N En 6 IJ Med *916; 314:3449.
32. Cusr.n JW. Jaffe HW, Hardy AM. dii Epkkmlology of IIIV hifectkrn and AIDS In
the United SIatra Sclenor 1911,239610-4.
33. Jason iN, McDoupIJS. DIxon 0. cii i. 1f1LV.IU/LAV azithody and knmune.tatn
of hoinehold nentacti and semml psflne,i of peisom with bemoptW JAMA *91%
255:2 *2—3.
34. Wahn V, Kramer HH, Volt 1, Bdkier HI’, Sccaznplcal B, Scheld A. Hoilsontal
i,ansnthslon of HIV Infectirn between two sflIInp Iteticil . LaneS 1966; 2.694.
35. Kane MA. Lattau LA. Ti.umlulonofHBV from dental penonnel So psilenIL JAm
Dent Aisoc 1915; I 10.634-4.
36. Leti .uLA,SmIthJD, Williamas DetaL Transmbakmofhepsillb Bvkn whhrcsultant
,cstrktlonofsurglral practice. JAMA *964 235:934—7.
37. InternatIonal Aaaodatkm of Fire Fighters. Guidelines So pievent Scensmbslon of
c*nnmunknble diteMe during emergency raze for Ike Ilghtcrs. pasamedim. and
emergency medical technicians. Intern.tkmal Association of Fire Fighters. New York
City, New York. 1911.
VII. Tablu
I
11
t!I
II
!J liii i
-
ti i 4111 i !!
d
9 g9 9 9
A
d
.1
-------
U MMW
Jw ,.2). I SS S Vol IISN. 5•
MUWR I)
Table 2
III Vial eded health care workers with no reported nonoccupsOonal
Ilek (actors and ( i whom e h%storles have been
publhhed hi the sdentilic Iheistwe
Csees wIth Documented Seroçunver.Ion
• AID1 .
No(spt ’ kd
• Mothu . Lw hei HIV W eawwhs o 1 with he chUlibloud afl
body sea,t s TCt ihe othIt dM not wc and o(Ita d m l mlb he. hm
_ Iy alIt .-.‘a .
Table Z continued.
lily Infected health care woikeis with no reported nonoccupatk.nai
rha iactors and (or whom e histories have been published
In the aclentilic literature
Cnoes without Documented Seroconverskrn
Case Occupation
Country Type of Esposuic
Source
Country Type of Espolure
Case Oeeupatkrn
19 NS
20 NS
21 Itescarchlab
worker
22 Home health-
care provider
23 Dentist
Source
United States
United Slates
United Slates
England
Puncture wound
2 Needkslkks
Nonintact skin
Nonintact skin
I•
2
3
4
115’
1 1$
1 19
113
UnhedStstea
United States
UnIted Slates
UnIted States
Needleitiek
I leedlestick
I lecdlestkk
2 Ilcedleatlcha
AlDSpatient
AIDS patient
AIDS patient
AIDS patient,
Ill V-Infected
patient
3
6
7
NS
Nurse
Nurse
United States
England
France
Ileedlestiek
I leedkstkk
lleed l e st lck
AIDS patient
AIDS patient
H IV.lnfected
patient
S
9
10
Nurse
Research
lab worker
Home health-
MartInique
Uniled states
United States
Needkstlck
Cut with sharp
object
Cutaneous
AIDS patient
Concentrated
virus
AIDS patient
Ii
12
care worker
149
PMebotonikt
Unt tedStates
UnitedStates
Non lnt.ctakIn
Mucous-membrane
AlD spat lent
IIIV.in(ectcd
patient
13
Tecbnok)$bt
UnhedStates
Nonlntadsk ln
I IIVinfected
patient
14
is
115
Nurse
UnitedSistea
Italy
Needlestlck
Mucous membrane
AIDS patient
IIIV infected
patient
16
I?
iS
Ilutse
Navy medic
Clinical
lab wo rkec
Fiance
UnttedStates
U nltedStat e s
Needlestick
Needkstlck
Cut wIthshaip
object
AIDS patient
AIDS patient
AIDS patient
AIDS patient
2 AII)S patients
Concentrated
virus
AIDS patient
Unknown
Unknown
Unknown
United State. Multiple needle-
sticks
24 Technician Meiko Multiple needle.
stkk . and
mucous membrane
25 lab worker United Stales Netdkitkk.
puncture wound
• AIDS case
-------
TIbis 3. Su. , Of T k
Tmp1 cI ih for Fr .i u t Eq i4 mro1
Jo t Mv ory P -.1 prot ve sbou bt
Nou Cazejo,,* Natwe of T.k/Aozcd A ab 7 Woio ?
Db i..ct ijh b od
or ot body O
iwveiia1 p --’—”.’ qp y
I I. Acthuy p.U 4 weboi Ya No
b od b ip w
, o m
Thk/ydoa Ie No No
or
to b od
U.S. Dtp rt ut of Labor. U.S. D n tof H th H0= Servi . Jo z . 4 wy ww L O
ap t oorupa& i t p rwiL to kipttit I B v (HBV) a . .um -’ VW (} V).
Wto ogton. DC: US D pan L of Labor, US D .ri eoa of Health s H0= Ser s. 19S7. r
U ‘11
‘ ! Illit’! !IIUJHI [ fl 1’! ‘1
‘I’k t’lI ti I i!J it 1’
‘If
Ii . .
I ’ is
a’
I.;ii ti I
11111 i ii ‘ ‘ i r ii
I ‘ I i
I
I t I I . ,
i i ‘I d
I I
I II ‘liii
I 1 i1 11
‘4
“
S I II Ii
I s r2 ’
I i
IS II Iflfl
11
I
I U
-------
MMW
JwslI. i • Vol IIINoR•
MMW 3p
lUSh 1e,.elOh sdloot
Tablet P., .sb Mesha fat Eqs4 .eai Used lo the
p,,hcsphsV Heihh Cs,. Sesibi
Doelic s AU lo, of .kioblsl Ifs lodu hĽh isuods,, of bsctsdol
spo t.
Meihoč. 3le . .um t piweots lo.totlesel.g. I Si k .eoe f .čy ho. ..
as s,b loOPA lasrste , selo,peoluiised
peilod of s .e 5 • 6 II) hoses as seeo, So .o.uladu ,ei$
hoH.ICUO Ifols isetlho lsbsweds.l7
Foe those hoUeoli at dev She . peseli.l.ablo a, o.atscl
oiweIp $s, Snot of lbs body. es s .lpeh needhe el
)bposabls losoths sq.lp.tas slotissicu the wed to aspect..
thess 5,,e, of I .i Who. h kstsd . ho s.s,. aasayssease
sIio be s .hh s hush... lscUhp foe aspe000albi of
eeotsbk lo,.h. heHuweots.
AIfoe .sof_k . s* l eI I fsu ,eI$hISh ou elI o fhstt1 l ot1P01
Hal oslo. pooeuiSisllo. (SO-IOOC. t0.lostoe)o espouse to
51IPPA ,eShSe,edsle,lesl€kotbsfotlt.P41015lb011
apias,t thu (0- d i sweas .*ulof bp the eweud.d, .u
Foe ,eso.bls heusuotentt at deekee thel cosot Into conlsd .IIh
se *....L5 (s(.. heyni.ecpe bo nctsnt ha..
etc)
lablet m ’r 1 4 histhode toe Equipsesil Used lo the
P..L.,kd Uhak cots Sdthi -
D .l,o,s Mast b.eleth.osse tfrwo...osuie (wigS. bus sot Mpeobocfevnir.s
ai3orrslosb a. bscte,loI spot..
Methnde PM eegbteted hospltsi dlslofectsnii 5 as beI doSs, lot
l &,.Ii. l s e1Mt )
Use: Thus 55 1551 see s,c flesl deane,, sad otn be wed to. toolbie
hakeepls$oesessov.lof .lNshi .heeSsewsol eblileblood
o.iM swfs o*kh hose boos.. used oSmull be
tinned and dbbdeded otbi so, clesne, se dbhsfectsnl .gent
sblth b Istended foe eosin.....entol see Sash sutton Include
floats. .d .eb. _ od...le . . . sasu. sauntellops. etc
t licps MF 51tiwus atksesots. ueet.iise lees . ’.. —. —— .
sad .051 ls.L hal dee. mal b becte,Nl spoe
Methade EPA eqbleud hospbsi dbmS etasul d.euofc .l peu .k51es that
hew s d lu, tab. declhlpo..’I.Sy sss le
hsed sisSies 51 ,.kld . a, salutloss c o& .blb i ii Inns tOO pp.
I, .. .seflsblo chlosho • I IOO dIhillo . of soonosihootchald
b le ijcb - . ppeushu*elp b eo, blesek pee plasof sap ores).
Use: Faslhoseosl.nthMIOi5ebeOnt t0m5515Mat S.
.teltrnscopel. blood puss.. cuffs. splInts. etc • sad hew bees
ihhIp eoa l.ndnsled olih blood as bloody body Ibil SwIped
s, be peeckaned .1 ebLIc ..ste,W befoes the 5e.s iId
ehendsel h applIed I.. dhlslecIIo
Sue, Shs sk ,.
l.n. Le,eIDbMfedloa
IMPORTANT
Destoojo
Meshode
U..
Sote,.edhite Lcael
wee
holiunansi .sei this be lhosouhlj cksned of ii sIeSk atit
-------
APPENDIX G
-------
APPENDIX G
TRAINING PACKET
-------
NEIC Exposure Control Plan: Bloodborne Pathogen Exposures Page 1
APPENDIX G: TRAINING PACKET
(SAMPLE)
TRAINING RECORD
(Note: Fill out separate form for each training session)
Date of Training Session: ________________________
Number of Hours of Training: _________________________
Location of Training Session: ____________________________
Level of Training Session:
Level I: Brief Overview for All Employees
Level II: All Employees at Increased Risk
Total Number in Training Session: ________
Trainer: ____________________________
Printed Name: ______________________ Phone: ______________
Signature: _________________________ Date: _______________
Please attach content or summary of training session and names
and qualifications of persons conducting the training. (See
“Trainer Information Sheet.”)
Complete one line below for each person attending the training
session.
Work Location
NAME
Job Title
Number
-------
NEIC Exposure Control Plan: Bloodborne Pathogen Exposures Page 2
Appendix G: Training Packet
QUALIFICATION VITAE FORM FOR TRAINERS
TRAINER NAME: _______
ADDRESS: _____________
TELEPHONE NUMBER: ____
PRESENT POSITION: ____
PROFESSIONAL EDUCATION:
Institution Major Degree Year
PROFESSIONAL LICENSURE AND/OR CERTIFICATION:
RELEVANT PROFESSIONAL EXPERIENCE OR SPECIAL PREPARATION
WHICH QUALIFIES YOU FOR TEACHING THIS COURSE:
Signature: Date:
-------
NEIC Exposure Control Plan: Bloodborne Pathogen Exposures Page 3
Appendix C: Training Packet
SAMPLE TRAINING OUTLINE FOR OCCUPATIONAL EXPOSURE TO
BLOODBORNE PATHOGENS (BBP) 29 CFR 1910.1030
Level I Training (approximately 30 minutes, or via a memorandum
and/or brochure)
This training is not required under the Standard but is highly
recommended. It briefly highlights the general concepts in the
Bloodborne Pathogen Standard for those people who will probably
not be occupationally exposed to BBP and includes:
1. Where an employee can find a copy of the regulatory text
of this Standard.
2. A brief explanation of the Standard:
a. Who is covered under the Standard,
b. Definitions of:
1. Blood and body fluids.
2. Bloodborne pathogen.
3. Exposure incident.
4. Occupational exposure.
5. Potentially infectious material.
6. Universal precautions.
3. A brief explanation of the employer’s Exposure Control
Plan and means by which the employee can obtain a copy
of the written plan.
4. Information on the appropriate actions to take and
person(s) to contact in an emergency involving blood or
other potentially infectious materials.
5. Information about Hepatitis B and Human Immunodeficiency
Virus (HIV).
6. Question and answer period.
-------
NEIC Exposure Control Plan: 8loodborne Pathogen Exposures Page 4
Appendix C: Training Packet
SAMPLE TRAINING OUTLINE FOR OCCUPATIONAL EXPOSURE TO
BLOODBORNE PATHOGENS (BBP) 29 CFR 1910.1030
Level II Training (approximately 2 hours)
This training highlights the general concepts in the Standard for
those people who will probably be exposed to BBP, and includes:
1. Where an individual can find a copy of the regulatory
text of this Standard.
2. A general explanation of the epidemiology (incidence,
distribution, and control of disease in population) mode
of transmission, and symptoms of bloodborne disease.
Emphasis will be placed on Hepatitis B (HBV) and Human
Immunodeficiency Virus (HIV).
3. A general explanation of:
a. Who is covered under the Standard,
b. Definitions of:
1. Blood and body fluids.
2. Bloodborne pathogen.
3. Exposure incident.
4. Occupational exposure.
5. Potentially infectious material.
6. Universal precautions.
C. Engineering controls
d. Work practices
e. Personal protective equipment, including types, use,
handling, and disposal.
4. A brief explanation of the employer’s Exposure Control
Plan and means by which the employee can obtain a copy
of the written plan, including methods of recognizing
work tasks and other activities that may result in
exposure.
5. Information on Hepatitis B Vaccine (HBV), and that the
vaccine and vaccination will be offered free of charge.
6. Information on Human linmunodeficiency Virus (HIV), and
that the screening will be provided free of charge under
certain conditions.
7. Information on the appropriate actions to take,
procedures to follow, and person(s) to contact in an
emergency or exposure incident involving blood or other
potentially infectious materials.
8. Information on the post-exposure evaluation and follow-
up.
9. Discussion of record keeping requirements for the
agency.
10. An explanation of signs and labels and/or color coding
required for biohazardous waste.
11. Question and answer period.
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APPENDIX H
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APPENDIX H
INFORMTION FOR ORDERING
APPROVED SHARPS CONTAINERS
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APPENDIX H
APPROVED SHARPS CONTAINERS
Approved sharps containers for disposal of syringes/needles are puncture-r istant and
splatter-proof.
Perry Point
Perry Point is the HRSA Supply Service Center located in Perry Pomt. Maryland
21902. (All federal agencies, including federally funded projects, can use Pen-v Point
once an account is established.)
The following are approved sharps containers that can be ordered through Perry
Point
3.5 qt. (24/case) 6515011885345
7.5 qt. (12/case) 6530011832863
For more information on approved sharps containers, call an FEOH re ional office which
will also likely be able to provide advice on local disposal regulations.
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APPENDIX I
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APPENDIX I
STATE OF CALIFORNIA- HEALTH AND WELFARE AGENCY
CALIFORNIA MORBIDITY REPORT
DATED SEPTEMBER 4, 1992
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ste. W - Hsslih aist Wui ,, As
p 7E SO GDvww
California
Morbidity
2151 AjJka.M. , esleesy 54754.1011
______ Hac.i (510) 0’O-
_ . IWlCon ______
The Dm an of Commie cable Disease Control Řormeily, d bdectious
Disease 8r ’) pravicx ly publidied rexnvnendaflcns for preveruing
mess in sewage workers (Callf irn a Morbidity, Auguat 24,1964).
Que O(is nthue to be received, not only lorthe 4 es discussed tasi
e bt 5 ao because newer cericems thoid d’ iara. HIV. and
Hepad 1s
it should be emphasized that there are NO state Immunization
recpiremen maidated I c r sewage workers. Any eioli reqisreinerns that
exist a’s made atthe local loyal, by employers or by local health agenoes.
A ug t CaUOSHA otholats. sewage workers as not cevered by the
•CatOSMA 8ioo orne PaPiogens Standard urdess those workers work
dire yin cuw ge fleS w)Ihu M th r, $ c c before those lines
jon ier (e.g.. vTuT1apa ) sewerage fnes.
It stictid also be th ha ized that there axe no n ior uiddines or formal
re mendabons in this area (as enunc zed by the Advisory Committee
on Inwrsirizabon Pr cesotthe USPHS) nor is there universal agreement
on what fIVTUlIZin9 agents sho d be recommended. Tt s is a dutf it
aea. where the very small risk of disease (Irom pooled human sewage)
must be b J aganst the very small risk of adverse effects (and St)
ol on. Though pubrishea data do not eatst for all at the disease-
ieof r imendabons oiniined below, there is Deportment of Health
Services consensus on the following re mmendadcns:
1. Freqi,wnt, routine handwashing is the jimoortant sitoauard in
preverwng infection by agents prss.nt in sewage.
2. Pveai v. clothing (Li., work clothes, covereUs, boots. gloves.-.
nf _ re ep,rupriu . and plastie face shields—where appropn.ete) is
rsc.unuundd , and such work clothes shOufd b. worn home or
outsIde the Innii.dlase work environment.
3. Im.mnexaiian recomm.nd. ons can be cstegur .d as follows:
a. Su’srietv Ricuuunendsd
1. T. -diphtherfe (rd)_Ml adu s. aid eupeaally sewage
workers. shia.Ad be up -to-dale on Td inTmJr on. For those who
havecornpleted the bawc sines of vee litvntsi ations, a booster
shotddbegrven every sin years.
2. Noceiur vw1iursz ns as strongly recanuiiendedatthe present
tine, but Hepatitis A vecone. recendy sised in Europe (by
SnethX ne Beetham). may become licensed and available in the
-. Urited S tes 1 ’ dn ’ w I ext severaz y rs. The need fci sewagu
waters to receive 0 s v ie will be revIewed at that brrio
b. Ootaon
1. Poliomyeftths - This ts a complex iseue. Sewage workers are
probably at some risk of exposure to v.cthte polio wus but very
raWyb wild polio virus. ki coreiv es with aibeensat twters
of recent irrvmwants fran’ Southeast Asia, the nsli of wild virus
exposure from pooled sewage may be somewhat greater.
no cases of orx Jpesonally ared po omyeUlis have
been repoiled in United States sewage workeism the va ne era.
Further. unmuru tion with oral (San) poäo vaccine is riot
rai nely recommended (or Uriied S es ilts (age 18 and over)
of the smaU risk (perhaps one in a nilion) of developing
paralytic polio altar meca ng oral po’o ne . This risk is
for those who have received no prior doses at polio
va ne of any t Wa: the risk extends to urinvasezad household
of these va iees. as weL
September 4, 1902
Deeanmaie at Nth si . vwam
Moliy . sl Coys, M.D . .PJI., Dr r
eves doses.
c) Pa suns who have never received any Oral polio v me or
inactivated polio vacome should receive Inactivateti polio
yawns (IPV), exolusively. The m ary sense consIsts of two
doses 4-8 weeks ai and a thud dose 6-12 nionthe after the
second . The need arid interval for booster doses of IPV li
have not been e ialted. Probably, at least one booster dose
be taken five years after completion of the primary wws.
2. Typhud Fever - The risk of this disease for sewage workers In
Cailfornie is exceodmgly small. Only one case has ever been
reported ma Cafilornia sewage worker arid this was sian Ir vid i
who had received at toast one dose of typhoid vacolne rine rrcrths
previously. - Typhoid immunization Is no: g.nereny
r&.o..m.nded . If iutuzaiion is considered, eIther of two
va nes i be used:
a) Inlectabi. vaccine: The inactivated v ne is only 70 -80
percent effective. The primary sines is two doses, gwen four
weeks apart. Pan at the injection site, fever, and malaise we
iemr . One fatal reaction has been recordecf in Ca crri A
booster dose is needed at least every three yeas tar coninriued
protection. The ineadermal 0.1 co dosage can be used for
boosters (but not for the primary sines) and Is assooiatec with
fewer edo effects. The uraradermal n,jectlon is best given at ttie
mceps or deltoid area, not the vofar aspect at the forearm.
b) Oral vaccine: The live bacterial vanone, given ii four ca si.4es
on alternate days. is at feast as effective as the inactivated
va ne and has tower side effects. The lou’- ule series
be repeated every five yeas for continued protection.
Nol Recommended
1. Irrvre ns glabubri (IG). also called Gamma Globilin (GG) tar
Hepatitis A prophylaxis is not recommended because:
a) It is relatively expensIve. painkil. and tnt rare Instances is
associated with allergic reactions.
b) IG injections must be repeated every 4-6 months for oorrn iued
protecaon.
2. HepatitIs 8 Vaccine- While blood and other body fluids (a g..
men uaI discharges. etc.) enter the sewage stream. Hepatitis B
virus is present in very dilute concentrations. No cases of
Hepatitis B have ever been linked to sewage exposure. Moreover,
- 1r H ,uJd B i i i u Ib nL4w0’by the fa1 .d1- iaI r Iw, mere is
no risk from sewage by this route Hepatitis B v ne rs now
mzwveroally recommended tar all inlaits born in the United S es
wid for car n high-risk persons. far example, to protect zigasist
sexuet transmission, exposures in health care se ngs. a -id
benariüsiori by u ected drugs, etc.
3. io$era - The n k of cholera for sewage workers is extremely
remote. Only a few cases of imported cholera are reported eadi
yea- lii Caillornia aid titers has been no soixindary trans.mssmon.
W ’io of eae onneentratlan in Caltorrea sewage is so d ltze as
to probably be no -mnfe aus. (Whereas 1 Q2 St’igella are needed
iocausedisease.asmanyasio’to 10’ V. o’iolerae ateneecled)
Even If cholera did result. specific treatment is readily av slable
Cholera yawns is not recommend.d: it Is only about 50 percent
effective. requres booster doses every six months. and frequer y
produces porn and redness at the injection site, fever, arid malaise.
P mst auon is not routinely recommended for sewage Finafy, a word about POV and the nak of AIDS from sewage. The r nnwts
waters. If it a to be considered, we eqgsst thw made above about Hepatitis B. and its extreme d ution in sewage, apçiy to
ILLNESS IN SEWAGE WORKERS/RECOMMENDATIONS FOR PREVENTION
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va ne of aiiy type; the n extends to urinTnLsllzed household
s o these va ees. as weL
P snmun %n nof rovtlnhly recommended tar sewage
wakers. if ii to be amsidered. we suggest th
a Persons with a history c4 three or more doses at oral (Sabn)
polo v ne at any pńor time do not need additional doses.
b) P onswthahss cyci l-2dose loralpov neatany
or time i talie ad borial doses of either oral polio va rie
or ma ivaied (Salk) polio va ine to br g the litadme totol to
produces pain and redness at the inie ion site, fever, and malaise.
Rna y, a word ab t HIV and the nsk of AIDS from sewage. The r naiuis
made above about H a1lbs B. and its extieme di1 tjon in sewage, apply to
HIV weILaxce that the level ci HIV in sewage woi4d be even several
ci magnitude less than that at Hepatth5 B. Moreover, Ike Hu athis
B. HIV is not ansmitted by the fece -arai route. In summery, the nsk at
Hepatitis B tram sewage Is virtually nonexistenr and the rIsit of I V
transmission tram sewage is even less.
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