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GDS 211
Course Overview
Why Infection Control ? Practical Infection Control OSHA Requirements Hazard Communication Competency Examination Questions and Answers
!www.cdc.gov/OralHealth/guidelines.html
www.osap.org
Manufacturers Clinicians Academics
In the beginning...
Man and microbes
Guns, Germs, and Steel Jared Diamond
WARS
1976!
American Legion Convention Philadelphia, PA Independence Hall
Emerging Diseases
75 - Lyme disease 76 - Ebola hemorrhagic fever - Legionnaires disease 78 - Toxic shock syndrome 81 GRID / 82 - AIDS 82 - E.coli 0157:H7 food poisoning 93 - Hantavirus pulmonary syndrome 02 - West Nile Fever 03 SARS 04 Asian Bird Flu (Avian Flu) 09 - H1N1
Lyme Disease
E. coli O157:H7
1982 - First recognized as a pathogen 1985 - Associated with hemolytic uremic syndrome 1990/91 - Outbreak from drinking water, apple cider 1993 - Multi-state outbreak from fast food hamburgers 1995 - Outbreak from fresh produce 1996 - Multistate outbreak from unpasteurized apple juice 1997 25 million pounds of beef recalled 2002 18 million pounds of beef recalled 2006 Outbreak from spinach 09/2007- 21.7 million pounds of beef recalled
Cryptosporidiosis
1976 - First human case recorded 1984 - First well water outbreak 1987 - First river water outbreak 1992 - Multiple municipal water supply outbreaks 1993 - Largest recorded waterborne outbreak in U.S. history (Milwaukee, WI) 1993 - fresh pressed apple cider outbreak (Maine) 1994 - First outbreak in community with state of the art water treatment (Las Vegas)
Theyre Back
Yellow fever Dengue fever Malaria Staphylococcus Cholera Tuberculosis (MDR TB and XDR TB)
Source?
Ebola Virus - Suspected sources: bats, rodents, monkeys HIV - virus from African Chimps? 62 human diseases found in other animals Insect vectored - malaria, dengue fever, yellow fever, Rift Valley fever, encephalitis, West Nile Blood spills or bites
Why Now?
Human assault on the natural world Air / water pollution Soil erosion Reduction in biodiversity Examples: elimination of large predators Lyme disease pampas to corn - Junin virus in new mouse Aswan Dam - new habitat for
Superbugs
Natural Selection Antibiotic -resistant forms: TB and Staph aureus Horizontal gene transfer: picking up new DNA from mating or other bacteria in the environment New strains of E.coli have a deadly toxin gene picked up from Shigella which lives alongside it in the guts of cattle
Human Action
Widespread use of antibiotics in lessthan-critical situations Viral infections Live stock 30 times as many antibiotics are used on farm animals as on humans in USA
October, 1990
Cytomegalovirus Hepatitis B (HBV) Hepatitis C (HCV) Herpes Simplex Virus 1 and 2 Human Immunodeficiency Virus (HIV) M. Tuberculosis Staph, strep, and viruses in the oral cavity
168, 000 Dentists 112,000 RDH 218,000 Dental Assistants 53,000 Dental Laboratory Technicians
All are necessary for the spread of infection. If one is missing, the chain is broken and the possibility of infection is eliminated.
Causative Agents
Pathogens: any microorganism capable of causing disease may include viruses, bacteria, protozoa, fungi Bloodborne pathogens - present in human blood
Hepatitis B virus (HBV) Hepatitis C virus (HCV) Human Immunodeficiency virus (HIV)
Susceptible Host
Lacking effective resistance to a particular pathogen. Factors that influence susceptibility:
Heredity, nutritional status, medications, therapeutic procedures, underlying disease, and immunization status Immunization status
Vaccination Acquired
Modes of Transmission
The mechanism by which an infectious agent is transferred to a susceptible host. By contact, inhalation, or through a vehicle (food, water, blood)
Contact may be direct or indirect Inhalation of airborne suspension, e.g. TB, measles Vehicle - blood is single most important vehicle for HIV, HBV and HCV
Standard Precautions
Combines components of: Universal Precautions
All human blood and all body fluids are to treated as if known to be infectious for HIV, HBV, and other Bloodborne pathogens
with
Moist body substances isolation (mucous membranes, and non-intact skin) Used for the care of all patients, regardless of infection status
Occupational Exposure
Direct contact with infectious lesions or infected blood or saliva Splatter of blood or saliva directly onto broken or intact skin or mucosa Aerosolization, the airborne transfer of microbes Parenteral exposure - piercing the skin barrier
Parenteral Exposure
Risk of acquiring disease after needlestick
HIV : 0.3% HCV : 3.0 % (3-10%) HBV : 30 % (6 -30%)
Personal Protection
Standard Precautions Vaccinations
Work practice controls reduce chance of exposure by changes in the way a task is performed
Handwashing Sharps Personal habits and eating
Handwashing
Hand Hygiene
Austrian Physician Attributed maternity deaths in hospital to cadaveric particles on hands of physicians who performed autopsies and then delivered babies without washing hands
Ignaz Semmelweiss 1818-65
Handwashing
Skin harbors resident and transient flora Microbes can infect through dermal defects Fingernails can harbor bacteria >5 days Removes transient bacteria & decreases number of microbes Mechanically Chemically Substantivity- residual effects of chemical
Handwashing Protocol
Remove visible debris Avoid abrading skin Use cool/warm water, not hot Use antimicrobial handwash
4% Chlorhexadine gluconate 3% Parachlormetaxylenol (PCMX) .25% - 3% Triclosan
Handwashing Protocol
(Contd.)
Dry thoroughly Turn off faucet with paper towel Wash any other skin contacting OPIM immediately MANDATORY
Before treatment Between patients After glove removal Needle stick or cut
3% Triclosan
Hand Hygiene
!CDC
Alcohol (60-95%) gels, sprays, or foams between patients in lieu of washing with water
!Goal:
Gloves
Purpose: To prevent cross contamination To protect hands Types: (dictated by task) Patient exam Surgical (best fit, most expensive) Non-medical Utility (puncture resistant for cleanup)
Glove Materials
Natural-rubber latex Nitrile Nitrile & chloroprene (neoprene) Polyvinyl chloride (vinyl) Polyurethane Styrene-based coploymers Butyl-rubber fluoroelastomers
Gloves
(Contd.)
Gloving does not replace handwashing ADA recommends routinely wear for all treatment Do not reuse or wash gloves Cover cuffs, avoid long nails, jewelry Avoid contaminating unprotected skin during removal Latex hypersensitivity
Latex Allergies
Natural Rubber Latex (NRL)- natural product from rubber trees Hevea brazilienis ! Tapping trees produces rubber and proteins ! Increased exposure to allergenic proteins accounts for increased incidence of allergies. ! Incidence: 6-17% healthcare workers 6.2% Type I (JADA, Jan. 1998) up to 65% spina bifida patients
LATEX PRODUCTION
1992 2002 28-30 billion 1800 ug 100 mg
Latex Allergies
! Hand
Dermatitis - irritation of the skin Irritant Contact Dermatitis Allergic Contact Dermatitis (Delayed or Type IV hypersensitivity) Immediate or Type I hypersensitivity
- Heat & perspiration - Metals & jewelry - Improper drying - Detergents & soaps
! Symptoms
Causes
- Accelerators - Antioxidants - Emulsifiers - Disinfectants - Fungicides - Stabilizers - Odorants - Bonding agents - Erythema - Edema - Itching - Swelling
Symptoms
- Dryness - Fissures - Hyperkeratosis - Scabbing
! Symptoms:
Recommendation: Be Prepared
! Recognize
patient chart and records ! Establish latex-safe areas, equipment, and emergency procedures ! Educate staff and patients about latex
Face Masks
! Worn
whenever aerosol or splatter generated ! Reduce inhalation of potentially infectious aerosol particles
Created by handpiece and ultrasonic scalers
! Protect
mask itself
! Filtration:
Surgical > Dome ! Splatter Control: Surgical < Dome ! Duration of Effectiveness
Dry Environment: 5 - 6 hours Water Spray: less than 1 hour
Protective Eyewear
Purpose To prevent infection to eyes To prevent physical / chemical damage to eyes ! Types Goggles Side shields Face shields ! Worn by both patients and providers
!
Gowns
! Purpose To avoid contamination of street clothing To prevent cross-contamination of family
members
! Worn
/ removed only in treatment area ! Laundered separately from street clothes ! Changed daily, and when visibly soiled ! Cover arms and fit snugly around neck
Black Death
1347-1352 25 million people died in Europe ! Transmitted by fleas on rats ! Recurred throughout the next 200 years ! Outbreak in San Francisco at turn of this century
!
Sharps
Sterile syringe, new needle, and solution for each patient ! Handle all sharp instruments carefully ! Avoid manual handling of needles ! Never leave needles unsheathed ! Avoid two-handed recapping of needles ! Use scoop, one-handed, or holder to recap ! Never break, cut or bend after use ! Discard in puncture resistant containers
!
Recapping Device
Scoop Technique
DECONTAMINATION
Disinfection / Sterilization
Asepsis
a!sep!sis (noun)
1.The state of being free of pathogenic microorganisms. 2. The process of removing pathogenic microorganisms or protecting against infection by such organisms.
Decontamination Processes
CLEANING DISINFECTING STERILIZING
Cleaning
Physical removal of debris (BIOBURDEN) and reduction in microorganisms Basic FIRST step in decontamination Performed before disinfection or sterilization
Ultrasonic cleaners
Reduced handling/touching Elimination of aerosols from ultrasonics and hand scrubbing Reduced potential for injuries Increased efficacy of cleaning and disinfection Decreased staff time $7,850 vs $600-$1000 for ultrasonics
Disinfection
The destruction of pathogenic microorganisms on inanimate objects Not ALL microbes killed, particularly the more resistant forms, e.g. spores Three levels of disinfection LOW
Kills HIV, HBV
INTERMEDIATE
Kills HIV, HBV, and TB
HIGH
Kills HIV, HBV, TB, and some, but not all, spores
Low-level Disinfection
Least effective, but will kill HIV and HBV Does not kill bacterial spores or Mycobacterium tuberculosis var. bovis (MTB)
Very resistant microbe used to test killing power of chemical agents Used to classify strength of chem. disinfectants
Intermediate-level Disinfection
Kills M. tuberculosis var. bovis (MTB) Tuberculocidal activity label claim Kills microbes that cause HBV and HIV Hospital Disinfectant EPA classification Kills three species of test bacteria
Staphylococcus aureus Salmonella typhimurium Pseudomonas aeriginosa
High-level Disinfection
Kills some, not all , bacterial spores Kills MTB, other bacteria, fungi, and viruses Sterilant/Disinfectant - EPA registered Must use for recommended contact time ( longer for sterilization )
IDEAL Disinfectant *
Broad spectrum Fast acting Long use life Non-toxic Economical Simple to use Residual effect Odorless Surface compatible Unaffected by debris
Disinfectants vs Antiseptics
Disinfectants are regulated and registered by EPA For use on environmental, inanimate objects Antiseptics are regulated by FDA For use on living tissue DO NOT interchange the use of the two
Environmental Surfaces
Clinical Contact directly contacted by contaminated instruments, devices, gloves light handles, switches, x-ray equipment, drawer handles, countertops, pens, telephone, doorknobs Housekeeping surfaces that require regular cleaning and removal of soil and dust Floors, walls, sinks
Housekeeping Surfaces
No evidence HBV, HIV, HCV has ever been transmitted from housekeeping surfaces Should be cleaned and decontaminated after any spill of blood or OPIM
Wear PPE Remove organic material Clean and disinfect with intermediate level disinfectant
Chlorines
ADVANTAGES Economical Rapid broad spectrum activity Tuberculocidal Effective in dilute solutions DISADVANTAGES Diluted solutions must be prepared fresh daily Corrosive to some metals May destroy fabrics Irritates skin Chlorine dioxide is a poor cleaner
Complex Phenols
!
ADVANTAGES
DISADVANTAGES
Broad spectrum
Not sporicidal Tuberculocidal Many must be prepared fresh daily Residual biocidal action Degrades certain plastics and etches Useful on metal, glass, glass rubber, and plastic Film accumulation Economical Skin and eye irritation Effective cleaner Contact time 10 min/ 200C or 250C* * Varies by active ingredient/brand
Iodophors
ADVANTAGES DISADVANTAGES Tuberculocidal Unstable at high temps Broad spectrum Dilution and contact time are critical Effective in dilute Must prepare fresh daily solution Few side reactions Discolors some surfaces Residual biocidal action Rust inhibitor necessary Effective cleaner Inactivated by hard water, alcohol Contact time 10 min/ 200C
Phenol-alcohol combinations
ADVANTAGES Tuberculocidal Fast acting Residual activity Some inhibit growth of mold, fungi DISADVANTAGES May cause porous surfaces to dry and crack Poor cleaning capabilities
Other Halogens
(sodium bromide and chlorine)
ADVANTAGES DISADVANTAGES Fast acting Use on hard surfaces only Tuberculocidal Chlorine smell Supplied in tablet form for simple dilution Minimal storage space Contact time 5 min/ 200C or 250C* * Varies by active ingredient/brand
Alcohols
NOT RECOMMENDED FOR SURFACE DISINFECTION ADVANTAGES Rapidly bactericidal DISADVANTAGES Not sporicidal Diminished activity with bioburden Damages rubber and plastics Rapid evaporation
Sterilization
Definition The destruction or removal of all forms of life, with particular reference to microbial organisms Basic Criterion Destruction of bacterial and mycotic spores, which are the most heat resistant microbial forms
Decontamination Decision
How an item is used is the major factor determining whether it must be sterilized, disinfected, or simply cleaned Critical - Tissue or bone -- sterilize Semicritical - Mucosa -- sterilize/high level disinfection Noncritical - Intact skin -intermediate to low level disinfection DO NOT DISINFECT WHEN YOU CAN STERILIZE
Sterilization Methods
Steam under pressure (2500F) Dry Heat (320-3400F) Chemical Vapor (2700F) Ethylene Oxide Liquid Chemicals Glutaraldehydes Hypochlorites Chlorine Dioxide
Steam Sterilization
Temp: 1210 C (2500 F) Pressure: 15 psi Cycle time: 30 min (gravity displacement) 4 min. ( pre-vacuum sterilizer) @ 2700F Use small bundles so steam can freely circulate
Dry Heat
The time needed to sterilize with dry heat depends on the temperature A typical dry heat cycle is 6o min @ 1700C (3400F ) plus time required to bring load up to sterilization temperature. Important: Follow manufacturer instructions.
Dry Heat
Static air
1 hour @ 1700 C (3400F) 2 hours @ 1600C (3200F) 2 " hours @ 1500C (3000F)
Forced air
12 min. @ 1900C ( 3750C)
Chemical Vapor
Deodorized alcohol-formaldehyde /H2O solution under pressure at 1320C (2700F) @ 20 psi for 20-40 min (unwrapped or bagged) Vapor should be discharged thru an aircooled coil into container beneath sterilizer (not reused)
Chemical Vapor
Ethylene Oxide
Room temperature for 10-16 hours Limitations Degrades plastics with repeated exposure Not reliable for unwrapped goods or towels Toxic Expensive Requires additional time for gas
Hydrogen Peroxide
Category Ortho-pthalaldehyde
Bead Sterilizers
Inconsistent heating Significant temperature variation FDA has deemed them not safe or effective
Cold Sterilization
Immersion in high-level disinfectants for less than the required sterilization time (minimum of 10 hours) One of the most abused aspects of infection control Cannot verify sterilization Often rinsed with tap water NOT an accepted method of sterilization
Cold Sterilization
Steam Autoclave
ADVANTAGES
Quick and easy Allows for sterile packaging Penetrates fabric and paper wrapping Very reliable
DISADVANTAGES
Wet instruments /rust Requires packaging Damages plastics Dulls unprotected cutting edges Corrodes carbon steel
Dry Heat
ADVANTAGES
Dry instruments No rusting Cheap and easy Little maintenance Very reliable
DISADVANTAGES
Slow Longer processing time Careful loading Damages plastics Melts or destroys some metal or solder joints Chars fabric Unsuitable for handpieces
Chemical Vapor
ADVANTAGES
Short cycle time No rusting or corroding Does not dull cutting edges Used with packaged items Very reliable
DISADVANTAGES
Instruments must be dry Requires good ventilation Cannot handle large loads Cannot sterilize liquids Damages certain plastics Costly solution
Chemical Disinfectant/Sterilant
ADVANTAGES
Sterilizes items damaged by heat Cheap initially
DISADVANTAGES
Has a limited life Is expensive in the long run; may rust instruments No effectiveness monitors Special ventilation req.... Protective clothing req.... Not used with pkg.... item Rinse with sterile water
Glutaraldehydes
ADVANTAGES
EPA registered as chem. sterilant Most potent chem. germicide Sporicidal at room temp. after 6-10 hrs. Noncorrosive Penetrates organic debris
DISADVANTAGES
Not an antiseptic Not a surface disinfectant Severe tissue irritation Allergenic Discolors some metals Biologically non verifiable Reuse life varies with biourden Cannot package items
Glutaraldehydes (Cont'd.)
ADVANTAGES
Useful for rubber and plastic items Instrument sterilant or disinfectant Prolonged activated life
DISADVANTAGES
Reuse life varies with bioburden Cannot package items Corrosive activity can increase with dilution
DISADVANTAGES
Sporicidal only at high concentrations Cannot be reused Must be prepared fresh daily Activity diminished by organic matter Unpleasant, persistent odor Corrodes metals
Chlorine Dioxide
ADVANTAGES Immersion or surface disinfectant/sterilant Rapid acting: 3min for disinfection / 6 hrs for sterilization DISADVANTAGES Discard daily 24 hrs sterilant use-life Does not readily penetrate organic debris Protective eyewear / gloves required Closed containers Adequate ventilation for surface disinf Corrodes aluminum
Monitoring Sterilization
Mechanical: observing pressure, temperature gauges, and printouts Chemical: Process Indicators
Exposed to heat, color changes Placed in or on all packs Does NOT verify sterilization
Spore Testing
Proper functioning of sterilization cycles should be verified by the periodic use (at least once weekly) of biologic indicators
CDC 2003 recommendations
Weekly sporicidal tests provide biological verification and control of sterilization process
Biological Indicators
Steam/Chemical autoclave: B. stearothermophilis Dry Heat / ETO: B.Subtilis Combination: B. stearothermophilis and B.Subtilis
Process Indicators
Exposure to a heat as indicated by several types of color-change tapes Placed prior to sterilize on a few inst. in unwrapped loads, or on outside of packs & trays Verifies items have undergone processing Does not prove sterilization
Alliance, NE
Somewhere in England
Clinical Applications
Clinical Applications
Pre-treatment Phase Treatment Phase Post-treatment Phase
Pre-treatment Phase
Preplan the materials needed Remove unnecessary items Use pre-set trays for routine procedures Use individualized, sterilized bur blocks If indicated , have rubber dam setup on tray
Pre-treatment Phase
Pre-treatment (Contd.)
Identify those items that will become contaminated Disinfect Barriers Place radiographs on viewbox Flush water lines on unit to limit microbial contamination Prepare personnel involved in care
SPRAY
WIPE
SPRAY
Surface Barriers
Time-saving alternative to betweenpatient cleaning and disinfection of operatory surfaces. Fluid impervious cover on surfaces prone to contamination. As long as the barrier remains intact , the surface it protects remains free of patient material, and thus does not need to be disinfected after each patient.
Benefits of Barriers
Reduced chemical use Protects equipment & furniture Simple, easy technique Reliable, consistent efficacy Visible to patient
Barrier Placement
Treatment Phase
Seat Patient Place eyewear, mask, wash hands, gloves Mouthwash rinse Use care when handling sharp instruments Take special precaution with needles Use rubber dam whenever possible
Treatment Phase
Sharps/ waste disposal Dismiss patient Keep eyewear, mask on Remove treatment gloves Wash hands
(Contd.)
Post-treatment Phase
Continue to wear PPE during cleanup Remove all disposable barriers Clean and disinfect all items not protected by barriers Wash all instruments that have solids adhering to them Use utility gloves
Cleaning
Heavy duty utility gloves Clean any hard deposits, eg. cements, composite resins, etc. Wash gloves, disinfect work area Scrub brush or ultrasonic cleaner
Wrapping
Paper, muslin, nylon Cover tips of pointed instruments Sterilize hinged instruments in open position If unwrapped, must store in clean area Wrap according to sterilizing method Event related packaging
Steam Autoclaves
Storing
Avoid aerosols / dust 12-14 inches from floor Disinfect drawers & shelves Remove only with clean hands Package seldom-used items If pkg. becomes torn or wet, repackage and sterilize again
Followed by Disinfection
Occupational Exposure to Bloodborne Pathogens; Final Rule Federal Register, Dec. 6, 1991 Standard applying to occupational exposure to blood and other potentially infectious material (OPIM) saliva in dentistry is considered OPIM Revisions: Federal Register, Jan 18, 2001 Needlestick Safety and PreventionAct
OSHA Requirements
Exposure Control Plan Training Program Record Keeping
Exposure Determination
Occupational Exposure: Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious material (OPIM) that may result from the performance of an employees duties
Determined without regard to the use of personal protective equipment
Exposure Determination
(Contd.)
Job Classifications
ALL - job classifications in which all employees on the list have occupational exposure, e.g. dentist, dental hygienist, dental assistant
(Contd.)
Standard Precautions Engineering and Work Practice Controls* Handwashing Personal Protective Equipment (PPE) Housekeeping Procedures Cleaning and Decontamination Regulated Waste Containment *Needlestick Safety
(Contd.)
Laundry for PPE HBV Vaccination for all employees at risk Postexposure Evaluation Labeling Procedures Information and Training
Record Keeping
Employee Medical Record Employee Training Record Hepatitis B Vaccine Declination Informed refusal by employee of postexposure medical evaluation and follow-up (not an OSHA requirement) Posters and Regulations Annual evaluation of new devices to prevent needlesticks
Needlestick Safety
Solicit employee input in any manner appropriate to the workplace Documentation includes: Listing employees involved Describing the process by which the input was requested Other documents, such as meeting minutes, copies of requests for input, records of responses received from employees
Steps for Selecting and Evaluating Dental Safety Programs and Devices*
Assign responsibility to someone for coordinating the process
Identify available devices Organize education and training Coordinate product evaluation Monitor safety performance Document in exposure cintrol plan
Safety Products
www.Safe-Mate.com
www.milesci.com
Steps for Selecting and Evaluating Dental Safety Programs and Devices*
Set a reasonable time period Provide adequate training Monitor patient safety Involve staff in decisions Solicit ongoing feedback Review safety performance periodically Document annually www.cdc.gov/oralhealth/infectioncontrol/forms.htm
29 CFR 1910.1200
Hazard Communication Standard
29 CFR 1910.1030
OSHA Bloodborne Pathogens Standard
29 CFR 1910.1020
Access to Employee Exposure and Medical Records
For offices with 11 or more employees: OSHA Form 101 Log of Individual Injury or Illness OSHA Form 200 Yearly Log of Occupational Illness and Injury As of Jan 2002, private dental offices exempt from the above
Must be affixed to container so there is no possibility of loss Red bags or containers can be substituted for labels Placed on containers of regulated waste, contaminated laundry
Medical Record
Contents
(Contd.)
Name and social security number HBV vaccination status, including dates received If exposure occurs, copies of all examinations, medical testing, followup procedures and written opinion of the health care professional (HCP) Copies of info provided to HCP regarding HBV vaccination and/or
9 Ohio veterans test positive for hepatitis March 3, 2011 8:50 p.m.
STORY HIGHLIGHTS Hepatitis tests for hundreds follow dental treatment VA dentist voluntarily retires Dentist admitted to not washing hands or changing gloves between patients during 18-year period
Hepatitis A (HAV)
Enterically transmitted Spread by fecal-oral route
Soiled hands/objects Consumption of contaminated food, water
Mild disease, does not lead to chronic infection Infection leads to lifelong immunity Isolated cases and widespread epidemics occur
Hepatitis A (HAV)
Incubation is 30 days 1/3 of Americans have serological evidence of previous infection Disease severity increases with age Symptoms last about 2 months HAV vaccine (1995) has resulted in 85% decrease from 1975 NOT an occupational hazard for dental healthcare workers
Hepatitis D (HDV)
Requires HBV to replicate Takes up residence within the HBV particle Modes of transmission and risk groups same as HBV Can infect simultaneously with HBV or superinfect chronic HBV HBV VACCINATION PREVENTS HDV INFECTION
Hepatitis E (HEV)
Common outside U.S. Domestic cases involve travelers returning from endemic areas Transmission and symptoms similar to HAV No vaccine exists for HEV Avoidance of contaminated food and drinks, including ice
Transfer of contaminated blood on inanimate objects or environmental surfaces has been shown to cause infection in health care workers
HBV Symptoms
1/3 have NO symptoms 1/3 have relatively mild flu-like illness 1/3 have severe disease: jaundice, dark urine, extreme fatigue, anorexia, nausea, abdominal pain, joint pain, rash, fever, vomiting incubation ranges from 45 -160 days
Hepatitis B Vaccination
Two types of vaccine Plasma derived, only for those allergic to yeast DNA recombinant Series of three injections (0, 1, and 6 months) Induces protective antibody levels If do not develop antibodies after first series: 15-25% develop antibodies after 1 injection Up to 50% develop after second series
HBV Vaccination
(Contd.)
Highly effective in preventing HBV and its complications 50 million children, 30 million adults vaccinated (OSAP , Feb 2007) Pregnancy not a contraindication noninfectious Hepatitis B surface antigen particles Contraindicated in individuals with previous anaphylactic reaction to common bakers yeast
HBV Vaccination
(Contd.)
Must be offered to all employees with occupational exposure , at employers expense If decline, must sign HBV Vaccine Declination form for Medical Record Employer may not require prescreening prior to vaccination
HBV Vaccination
(Contd.)
Booster not recommended (CDC, 2003) If booster doses recommended in the future, employer must provide these at no cost If employee wishes to be evaluated before vaccination, employer must obtain HCP written opinion, and give to employee within 15 days of its completion
states if vaccine indicated & if received
HEPATITIS C
Identified in 1988 as parenterally acquired non-A, non-B hepatitis
20,000 infections per year (2008) leading reason for liver
transplantation in U.S.
chronically infected
170 million infected worldwide
HCV Transmission
Spreads through direct contact with blood Risk related to type and size of inoculum and route of transmission Social practices using percutaneous procedures and non-sterile instruments
body-piercing, tattooing, ornamental scarring, circumcision
HCV Symptoms
65-75% have no symptoms 25 -35% will have jaundice, fatigue, abdominal pain, loss of appetite, intermittent nausea, and vomiting. Incubation of 6 - 7 weeks 15-20% resolve without lasting sequelae.
70% develop chronic liver disease.
Chronic hepatitis may be unrecognized until symptoms of advanced liver disease appear (20 - 30 years).
HIV Epidemiology
57 healthcare workers have seroconverted after occupational exposure (CDC 12/2004) 22 developed AIDS No documented seroconversions associated with dentistry
HIV Transmission
Sexual intercourse with an infected person Contaminated needles Parenteral, mucous membrane, or nonintact skin contact with HIV-infected blood, blood components, or blood products Transplants of HIV-infected organs/tissues Transfusions of HIV-infected blood Perinatal ( mother to child at birth)
HIV Symptoms
Within a month after exposure, may develop flu-like illness fever, lymphadenopathies, myalgias, arthralgias, diarrhea, fatigue, and rash self-limiting, and develop antibodies may be symptom-free for up to 10 years AIDS - Acquired Immune Deficiency Syndrome
AIDS
An HIV-infected person is considered to have AIDS when one or more indicator diseases has been diagnosed:
Pneumocystis carninii pneumonia Esophageal candidiasis Neurologic disorders or dementia Cancers such as Kaposis sarcoma and non-Hodgkins lymphoma Less than 200 T-helper lymphocytes / mm3
Bacterium carried in airborne particles, called droplet nuclei, aerosolized from patients 1-5 particles can be suspended in air for hours Infection in lungs by inhalation Within 2-12 weeks immune system prevents spread, and becomes latent (LTBI)
Positive tuberculin skin test (TST) Not infectious Can become active if not treated 90% of US patients do not progress to active TB
Symptoms of Active TB
Productive cough Night sweats Fatigue Malaise Fever Unexplained weight loss
Risk of TB Transmission
Standard precautions not sufficient to prevent transmission Risk to DHCP is quite low (only one reported case in a dental office, 1982) Community risk assessment Medical History of TB If suspected, referred promptly
TB
Elective dental care should be deferred until confirmed not infectious If emergency dental care required, refer to facility with engineering controls such as isolation rooms, and air filtration Respirators should be used, face masks inadequate
1 case/million population Linked to BSE, mad cow disease Resistant to conventional decontamination procedures
Transmission during dental procedures low to nil
Workplace Emergency
If an emergency occurs that has potential for exposure to blood don appropriate PPE: Gloves, mask, clinic attire, and protective eyewear for a blood spill and its decontamination If patients life at risk, may deviate from Standard Professional judgment of employee Pocket masks and resuscitation bags
Postexposure Procedures
Following a report of an exposure incident, employer shall make available a confidential medical evaluation and follow-up to include: Exposure information: routes and circumstances of the incident Identify of source individual Test source for HIV and HBV ASAP after consent is obtained
document if consent not obtained
Postexposure Procedures
(Contd.)
Make results available to employee, respect confidentiality of source status Test employees blood, with consent, as soon as feasible Provide postexposure prophylaxis, when medically recommended Provide counseling Evaluate illnesses that are reported in the first 12 weeks after exposure
Postexposure Prophylaxis
HBV
Test source blood for HBsAg Provide HBIG if required
Postexposure Prophylaxis
CDC recommendations for HCW exposed to HIV Exposure : a percutaneous injury, contact of mucous membranes or nonintact skin, or contact with intact skin when duration of contact is prolonged or involves an extensive area, with blood, tissue, or other body fluids In the absence of visible blood in saliva, exposure to saliva from a person infected with HIV is NOT considered a risk for HIV transmission
MMWR, May 15,1998
Postexposure Prophylaxis
(Cont'd.) Postexposure evaluation for HBV and possibly HCV still required after exposure to non-bloody saliva or after contamination of mucous membranes Low incidence of seroconversion to HCV (1.8%, range 0-7%)
Antiretroviral Agents
Three Classes: Nucleoside analogue reverse transcriptase inhibitors Zidovudine (ZDV) - Only agent shown to prevent HIV transmission in humans Lamivudine (3TC) Non-nucleoside reverse transcriptase inhibitors Protease inhibitors Combination regimens : reduce viral load in HIV infected patients active at different stages in viral replication
OSHA Inspections
Oct 2004-Sept 2005 Inspected 21 dental offices Issued 97 citations Total penalties $20,000 Covers those states that do not have their own OSHA program (about half of all states) Bloodborne Pathogens source of most citations (67 of 97)
CDC Guidelines
Consolidates recommendations
for preventing and controlling infectious diseases for managing personnel health and safety concerns related to infection control
Updates and revises previous CDC recommendations Incorporates relevant measures from other CDC guidelines Discusses concerns not addressed previously
Program Evaluation
Systematic approach to ensure procedures are useful, ethical, feasible and accurate Develop SOPs Evaluate Document Includes checklists, calendars, observations, reviews COACH
Microbial counts of <500 cfu/ml (CDC 2003) A good coolant mist (atomization) Adjustable low flow rates for handpiece coolant - 1 droplet/second Low water volume for restorative work, higher volume for hygiene
Water Water
Control
Air In
Foot Control
No Pressure
Static
Control
Air In
Foot Control
Microfiltration
Output
Water Water
Control
Foot Control
At each outlet Proven technology Installation requires waterline surgery Daily or weekly change 89-$2.00/day/outlet; $2.67-$6.00/day/oper.
Chairside Technology
Output
Silver ion Iodine Glutaraldehyde Hydrogen Peroxide Proprietary Chemicals U/V Light Reverse Osmosis Micro Filtration Turbulent flow Ozone
Water
Control
Foot Control
Chairside Technology
Output
Silver ion Iodine Glutaraldehyde Hydrogen Peroxide Proprietary Chemicals U/V Light Reverse Osmosis Micro Filtration Turbulent flow Ozone
Water
Control
Foot Control
Sterisil Ag Ion
Dentapure Iodine
Centralized
Chair #1
Chair #3
Chair #4
Control
Water Bottle
Foot Control
Cost for each assistant Annual cost (3600 visits) Cost for each assistant 28% increase since 1999
Sharps Containers
Disposal by USPS
Select a vendor through state dental society Ask to see permits and proof of insurance coverage Collect all manifests of waste transported from the office and maintain for 3 years
50% of Hg in the environment comes from human activity 53% from combustion of fuels 34% from combustion of wastes Less than 1% from dentistry
Collects in waterways, methylated by bacteria, enters food chain EPA estimates that 3,426,244 acres are impaired
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Recap empty capsules, place in noncontact container Place disposable chairside traps in contact container Empty contents of reusable traps in contact container
Amalgam Waste
DOs
Amalgam Waste
DONTs
Strategies For Proper Amalgam Waste Management Grey bag It.Never dispose in a red bag Recycle It.Select a responsible amalgam
recycler
Heavy material, accumulates in P traps and longer horizontal runs. Precaution needed:
Plumbing being done in areas where waste likely to adhere In work is such that it is likely to dislodge adhered waste elsewhere Demolition or major operatory renovations Whenever pipes are cleaned out
Plumbing Guidelines
Hire Licensed plumber, provide guidelines Place bucket on non-porous tarp to catch waste Avoid prolonged use of torch (heat) Gloves, impervious gown (apron) Assume sludge is hazardous if significant waste amalgam exists Place waste in recycling container Licensed waste hauler Receipt that waste will be disposed or recycled
Container labeling
Identity of hazardous chemical Name of manufacturer Appropriate hazard warning
Overview of MSDSs
Provided by the manufacturer, comes with shipment Provides detailed information on hazards and properties Many can be accessed via Internet Updates mandated when composition changes, or new information obtained
Excluded Products
Ordinary consumer products if their use is same as that of typical consumer, e.g. household cleaners Cosmetics Tobacco Hazardous wastes Wood products Biohazards Drugs in solid final form (tablets) Office supplies
Sections of MSDSs
I II III IV V VI VII VIII Manufacturers Information Hazardous ingredients, exposure times Physical/Chemical Characteristics, e.g., boiling, melting points Fire and Explosion Hazard Data Reactivity Data Health Hazard Data, First Aid Precautions for safe handling Control measures
Employee Training
When: at time of initial assignment Whenever a new hazard is introduced May be at one setting, or several small sessions Lectures, videos, self-instruction materials Must include question and answer
Training Topics
Copy of the Standard and explanation of contents Location of written Hazard Communication Program Chemicals present in workplace Physical and health effects of chemical on the inventory
Method and observation techniques used to determine presence or release of hazardous chemicals
Source reduction Recycling Amalgam, lead foil, silver from x-ray processors, batteries, alcohol containing fluids, fluorescent lights Use a licensed Treatment, Storage and Disposal (TSD) company Cradle-to-grave responsibility The generator is ultimately responsible
QUIZ ?
Group Effort
Course Content
Emerging Diseases OSHA Inspections Costs of Infection Control Dental Unit Waterlines Waste Management Best Management Practice: Dental Amalgam HAZCOM Question and Answers
Legal Issues
ADA policy bars dentists from denying treatment because of HIV/AIDS status.
Maine dentist refused to treat HIV positive patient in his private dental office. offered to treat her in hospital dental clinic
unable to bear children for fear of transmitting disease to offspring. inability to reproduce constitutes disability because reproduction qualifies as a major life activity.
Appeal to Supreme Court
Returned to appeals court Follow the policy of acknowledged expert organizations: American Dental