Helene Kaiser, O.D.; and Connie Chronister, O.D.
You have just finished removing a conjunctival foreign body from your patients eye. While disposing of the needle used for the procedure, you accidentally stick yourself in the finger. Knowing the needle was contaminated with tears and blood, you wonder what your risks are for contracting an infectious disease.
The harsh reality is that you have a 6% to 30% chance of contracting hepatitis B, a 2% chance of contracting hepatitis C and a 0.3% chance of contracting HIV, if your patient is infected with any of these diseases.1
Knowledge about risk of exposure to bloodborne pathogens and infections diseases, as well as nosocomial exposure, the risk of transmission, standard precautions, safe work practices and pre- and post-exposure incident procedures can allow all levels of ophthalmic personnel to work safely without unnecessary fear or anxiety.2,3
Many ophthalmic health-care staff members lack knowledge about exposure risk, the availability of immediate treatment and the urgent need to begin treatment after an exposure incident.2 So, ongoing education about the general prevalence, risk of transmission, and availability of prophylaxis and treatment is crucial.3
Personnel who provide care to patients in an eye clinic should use precautions to avoid transmitting or contracting any infectious disease. The Occupational Safety and Health Administration (OSHA), the Centers for Disease Control and Prevention (CDC) and the National Institute of Safety and Health (NIOSH) are responsible for establishing and publishing clinical patient care protocols. These standards act as guidelines for appropriate patient management.4
The concept of standard precautions is based on the assumption that all patients are potential sources of infection.5,6 Substantial risk for pathogen transmission to the patient may occur when health-care workers do not follow adequate sterile procedures.6 Epidemics of infectious disease originating from the practice of optometry in the absence of surgery may involve the use of contaminated instruments or solutions or failure to wash the hands between patients.5
Risk Reduction Strategies
To modify and improve infection control in the health-care environment, many facilities have attempted to reduce the probability of exposure to pathogens.7,8 Primary risk reduction strategies include:9
Infection control and management. This involves standard precautions, safe work practices and engineering controls (which isolate or remove the bloodborne pathogen hazard from the work place). These include antimicrobial handwashes, hand-washing facilities, gloves, prohibiting recapping of needles, proper labeling and proper equipment decontamination or disposal.
Standard precautions. A properly equipped optometric suite should have disposable gloves, alcohol swabs, protective eyewear,
disposable gowns and masks available. Diluted household bleach should also be readily accessible.5
Practitioners hands and tonometer tips can be vectors for transmission of nosocomial infection.10 Instruments that may transmit adenovirus and other infectious agents include Goldmann tonometer tips, contact diagnostic and treatment lenses, pinhole occluders and any instruments contaminated with eye secretions.9
Disinfection with a germicide or disinfectant is required to eliminate most or all pathogenic microorganisms from inanimate objects, such as equipment or medical devices.11 Soak Goldmann tonometer tips and contact diagnostic and treatment lenses in 0.5% hypochlorite solution for at least 10 minutes, then wash with sterile water and allowing to air dry.12 Change the soaking container frequently, and wipe the tonometer prism mechanically.13
Adequate disinfection or sterilization of instruments cannot be achieved if any organic material impedes contact between the germicide and target micro-organism.14 For tonopens, discard covers after each use, and disinfect the surface of the instrument by wiping with alcohol after each patient use. Metal instruments, such as forceps, spuds and burrs, can be precleaned and soaked in a sterilizing solution, such as Cidex Plus (containing 3.2% glutaraldehyde), rinsed with sterile water and allowed to air dry. Heat sterilization with an autoclave is regarded as the strictest method of sterilization.
Disinfect all surfaces touched by either patients or personnel, such as slit lamp knobs, handles and tables, by wiping with an EPA-regulated germicide at least once daily and after any observed contamination by eye secretions.9 Dont use tap water; it may harbor pathogenic organisms, such as Acanthamoeba. Eliminating the presence of potentially infectious organisms is important in situations where patients have active skin or eye infections, or if a patient is immunosuppressed either systemically or locally with topical steroids.15
Many eye-care practitioners do not view recapping and reuse of diagnostic drop bottles as a potential vector for transmission of infection. However, several published studies found that adenovirus survived and could be recovered from various surfaces for up to 10 days.16 Discard and replace multi-dose dilating and other diagnostic eye drops at least once a month, or whenever you suspect that direct contact with the patients tears or conjunctiva has occurred.9,11
Another recommendation: Prohibit eating, drinking, smoking and applying cosmetics or lip balm in patient care areas.17
Proper hand washing methods. Practitioners hands also can be vectors for transmission of nosocomial infection.10 Hand washing is the single most effective way to avoid transmitting or acquiring infections during an eye exam.11,18 Use a germicidal soap and water, and dry with a fresh disposable towel.5 Keep fingernails short and clean. Inspect your hands and fingers for cuts, abrasions, breaks in the skin and dermatologic lesions; when present, use gloves.11
Personal protective equipment. Wear gloves when dealing with a red eye or open sores on a patients orbital region or ocular adnexa.5,14 Also, use gloves to prevent exposure if you anticipate contact with blood or blood-contaminated fluid. Change gloves after contact with each patient, and wash your hands immediately after you take the gloves off.
Gowns, masks and protective eyewear are unnecessary for the usual ophthalmic examination. But, wear disposable gloves and gowns when you perform minor surgical and diagnostic procedures, such as fluorescein and ICG angiography, in which contact with blood or blood-containing fluids may occur. Masks and protective eyewear should also be worn in the event of splashing of blood or bodily fluids.
Proper waste disposal. Equip exam rooms with puncture-proof sharps containers in red or orange-red with biohazard label affixed for proper disposal of contaminated waste. A sharp is any needle, scalpel blade, glass container or other item that may become sharp when broken.18 Never recap needles.
Bloodborne Pathogen Transmission
Bloodborne pathogens are any pathogenic micro-organism found in blood or other bodily infectious material that can cause disease in humans.3 Those with the potential to cause disease in humans include syphilis, viral hemorrhagic fever, and Creutzfeldt-Jakob disease (CJD).19
The Bloodborne Pathogen Standard covers all employees who could reasonably anticipate as a result of their duties to face contact with blood or other potentially infectious materials.20 The purpose of the standard is to limit occupational exposure to blood or other potentially infectious materials, since exposure could result in the transmission of bloodborne pathogens, which could lead to disease or death.18
The probability that susceptible individuals could be exposed to bloodborne pathogens depends on the prevalence of infectious pathogens in the patient population or health-care environment and the effectiveness of infection control in the health-care environment. The risk of transmission depends on the dose of pathogens transmitted, the infectious characteristics of the pathogen and the frequency or probability of exposure to infectious material.6 Infectious characteristics of pathogens are the usual biological range of pathogen concentration in blood and other body fluids, the resistance of the pathogen to the bodys defenses, and the length of time that the pathogen remains viable in the external environment.
There are three recognized modes of workplace transmission of bloodborne pathogens:
Parenteral exposurepiercing, puncturing or cutting the skin with a potentially contaminated sharp item.
Exposure of non-intact skin (with existing cuts, rashes or abrasions) to potentially infectious material.
Mucous membrane exposuresplashing or spraying of potentially infectious material into unprotected eyes, nose or mouth.
Web Sites and Resources National Institute for Occupational Safety and Health Administration Prevention Weekly Report www.cdc.gov/hiv/topics/basic/index.htm www.cdc.gov/ncidod/dhqp/index.html www.cdc.gov/ncidod/diseases/hepatitis/ 1-888-443-7232 or 1-888-4HEPCDC 1-800-321-OSHA www.aoa.org/documents/OSHA
Occupational exposures to bloodborne pathogens are considered urgent medical concerns; timely management should be administered.21 Post-exposure prophylaxis should be initiated as soon as possible, since it is most effective within 24 to 36 hours after exposure.11
Occupational Safety and Health
Centers for Disease Control and
The CDC Morbidity and Mortality
HIV/AIDS Basic Information
Infection Control in Health Care Settings
Viral Hepatitis
Hepatitis Hotline
World Health Organization
CJD Foundation
OSHA 24 hour hotline
American
AOA Infection Control Guidelines
InfectionControlGuidelines.pdf
Human Immunodeficiency Virus (HIV)
Since the emergence of the Acquired Immunodeficiency Syndrome (AIDS) epidemic in the early 1980s, progressive regulatory strategies have been enacted in an attempt to decrease the risk of bloodborne pathogen exposure in health-care workers.2
HIV is an RNA retrovirus that causes AIDS. It is now considered a chronic disease. Preventative strategies, early recognition of the disease, effective diagnosis, prophylaxis and new antiretroviral medications have contributed to the decline of HIV.22
Even though the transmission of the human immunodeficiency virus (HIV) and other bloodborne pathogens in the health-care setting accounts for only a very small proportion of overall infection and transmission, the potential for such transmission always exists.6
HIV can be transmitted perinatally, sexually or percutaneously. It has been identified in a number of bodily fluids, such as blood, semen, breast milk and vaginal secretions. Blood and bloody bodily secretions remain the greatest risk of HIV transmission to health-care workers.3
The virus is also present in surface epithelia in the eye, tears and ocular fluids of infected individuals. It can possibly be transmitted through mucous membranes, so public health officials recommend that reasonable precautions be taken.11
HIV is a fragile virus that cannot survive outside a warm medium. Dried blood or bodily fluids have virtually no risk of environmental transmission.23 Germicides are the most effective method to kill HIV.3
All persons with occupational exposure to HIV should receive testing, follow-up counseling and a medical evaluation. Testing for the presence of HIV is conducted using the Enzyme-Linked Immunosorbent Assay (ELISA) technique. Confirmation of a positive test is conducted using the Western blot technique. A positive ELISA in conjunction with a Western blot indicate the presence of HIV antibodies and HIV infection.24 Since no vaccine is currently available to prevent HIV, the primary means of prevention for health-care workers are standard precautions and safe work practices. Antiretroviral agents are available both for prophylaxis and treatment.3
Hepatitis
Six types of viral hepatitis have been identified: A, B, C, D, E and G. They have similar clinical symptoms but vary significantly with respect to transmission, prevalence and outcomes.18 The primary type that affects the medical community is hepatitis B virus (HBV).18 HBV is a DNA hepadnavirus that is transmitted by contact with blood through percutaneous exposure, mucous membrane or non-intact skin.3,11
HBV may be transmitted in the same manner as HIV, but the rate of transmission is much greater for HBV. This may be due to its higher biological viral concentrations.6 It has been found in tears, soft contact lenses and on the surface of tonometers, but there is no evidence that disease is actually transmitted through these vehicles.5,25,26 HBV can live on inanimate surfaces, such as tables, for a week or more.3 In health-care workers, non-intact skin may be the most frequent mode of transmission.3
Health-care workers are at risk for contracting hepatitis B, hepatitis C and HIV from exposure to blood or bodily fluids. There must be an entry point for blood or bodily fluids into the individual who is exposed, such as being stuck with a contaminated needle or being cut with a sharp object, the most common modes of transmission in the health-care setting. Exposure may also occur through a splash to mucous membranes, such as the eyes, nose and mouth, or through exposure to non-intact skin, such as chapped, abraded, infected or cut skin.
The Hbs Ag test (hepatitis B surface antigen) is the most effective diagnostic tool to test for the possibility of HB infection.3 Prevention, prophylaxis and treatment are available for HBV. It is the only virulent bloodborne pathogen that can be prevented with a vaccine. The CDC recommends that health-care personnel who have contact with blood and bodily fluids be vaccinated.27 Twenty-four hours is the recommended limit within which to vaccinate anyone who may have come into contact with hepatitis B and begin a course of treatment.2
Depending on the circumstances of the exposure, the HBV vaccine series may be started at the same time as the treatment with hepatitis B immune globulin (HBIG). Primary vaccination with hepatitis B is approximately 90% effective.3
Wiping surfaces with standard germicidal cleaning agents kills the virus. Hepatitis B can be inactivated by heating it at 98 Celsius for approximately two minutes.28 All-purpose disinfectants are not believed to be effective against hepatitis B.
Hepatitis C, an RNA flavivirus, is the most common bloodborne pathogen in the
Other Viruses
Transmission of infectious agents like herpes virus and adenovirus through the adnexa and ocular surface has been documented in eye care. Prevention of such transmission requires good hygiene techniques. Nosocomial transmission of herpes simplex virus (HSV) is rare and occurs primarily through contact with primary or recurrent lesions, or virus-containing secretions. Exposed areas of skin are the most likely sites of nosocomial infectionparticularly when minor cuts, abrasions or other lesions are present.30
Adenovirus is the main cause of nosocomial outbreaks of conjunctivitis; it can survive for long periods on surfaces, which then transmit infection.11 Control the chance of outbreaks by washing hands, using gloves, disinfecting instruments and using unit-dose eye solutions. Additionally, prevent infected personnel from having direct patient contact for up to 14 days following onset of adenoviral conjunctivitis.14
Prions
Prions, short for proteinaceous infectious particles, are small pathogenic particles that do not contain any genetic information (DNA or RNA), but can cause transmissible spongiform encephalopathies (TSE).
Creutzfeldt-Jakob Disease (CJD) is a transmissible and progressive neurological disease with a worldwide incidence of one case per million; yet, it is the most common of all the human TSEs.31 CJD comes in three forms: sporadic (85% of all cases), hereditary or familial (5% to 10%) and iatrogenic or acquired (less than 1%). This last can result from accidental transmission via contaminated surgical equipment or procedures, e.g., corneal transplant.31,32
Since 1985, the population in
There is no evidence that CJD can be transmitted thorough casual contact with a vCJD patient.31 But, those individuals incubating vCJD harbor the possibility of iatrogenic transmission via contaminated surgical or other invasive instruments, which presents a concern, since prions are highly resistant to conventional decontamination and sterilization procedures.32 The brain, dura mater and cornea (grafts) are considered high risk. Tears are considered low to no risk for transmission.31
Personnel Education
When training personnel, include a copy of standard precautions as well as work practices and engineering controls in the office. Remind staff about hazards through signage, labeling and color-coding instructions. Describe the transmission modes of bloodborne pathogens and your exposure control plan.
Demonstrate personal protective equipment and its use. Train staff in the removal, handling and disposal of biohazardous waste. Include any employees who work with blood or any other potentially infectious materials, as well as any hazardous chemicals found in the workplace.18
Offer a hepatitis B vaccine to employees who may come in contact with blood or blood containing bodily fluids. Put your exposure incident, post-exposure evaluation and follow-up procedures in writing.17
Clearly written policies, guidelines and procedures are cardinal elements of an effective and efficient infection control program in an optometric practice.30 The risks of transmission for HIV, HBV and HCV are indisputable in environments where workers are exposed to blood or bodily fluids. So, knowledge about exposure, the risks of transmission in health-care workers and primary prevention strategies available can assist ophthalmic personnel to work safely without unnecessary fear or anxiety.2,3
Quality assurance committees with standards from OSHA, NIOSH and the CDC have created legal, enforceable standards for health and safety within the workplace for all employeesno matter what their job description. Basic precautions, such as hand washing and the use of gloves and personal protective equipment, have been shown to decrease incidence of exposure. Armed with this knowledge, optometric practices can follow quality assurance recommendations to protect their staff and patients from infectious diseases.
Dr. Pagani is an associate professor at the Pennsylvania College of Optometry, as well as the director of internships and the clinical medicine course coordinator. She is also a member of the Quality Assurance Committee at The Eye Institute. Dr. Chronister is an associate professor at PCO as well, and chief of primary care for Module Two. Dr. Kaiser is also an associate professor at PCO, and she is the chairman of the Quality Assurance Committee of The Eye Institute.
1. Centers for Disease Control and Prevention. Exposure to blood: What healthcare personnel need to know. July 2003. http://www.cdc.gov/ncidoc/dhqp/pdf/bbp/Exp_to_Blood.pdf. (Accessed September 2007).
2. Twitchell KT. Bloodborne Pathogens: What you need to know Part I. AAOHN Journal 2003;51(1),38-45.
3. Twitchell KT. Bloodborne Pathogens: What you need to know Part II. AAOHN Journal 2003;51(2),89-97.
4. Hilber DJ, Whitwell KJ, Krumholz DM, et al. The effect of continuous quality improvement on compliance with clinical practice guidelines in an optometric clinic: a retrospective review. Optometry 2000 Feb;71(2):83-90.
5. Tillman A, Klotz SA, Maino JH. Preventing transmission of infectious diseases including the human immunodeficiency virus in the practice of optometry. J Am Optom Assoc 1992 Jan;63(1):18-20.
6. Hu DJ, Kane MA, Heymann DL. Transmission of HIV, Hepatitis B virus, and other Bloodborne pathogens in health care settings: a review of risk factors and guidelines for prevention. Bulletin of the World Health Organization 1991 May;69(5):623-630.
7. Centers for Disease Control and Prevention. Recommendations for prevention of HIV transmission in health-care settings. Morbidity and mortality weekly report 1987;36(supplement).
8. Centers for Disease Control and Prevention. Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis C virus to health-care and public safety workers. Morbidity and mortality weekly report 1989:38(No.S-6).
9. The
medicine.org (Accessed Jan 2, 2006).
10. Aizman A, Stein JD, Stenson SM. A Survey of Patterns of Physician Hygiene in Ophthalmology Clinic Patient Encounters. Eye & Contact Lenses 2003 Apr;29(4):221-222.
11.
12. Nagington J, Sutehall GM, Whipp P. Tonometer disinfection and viruses. Br J Ophthalmol 1983 Oct;67(10):674-6.
13. Amin SZ, Smith L, Luthert PJ, et al. Minimising the risk of prion transmission by contact tonometry. British Journal of Ophthalmology 2003;87:1360-1362. BJO Online.
14. Centers for Disease Control and Prevention (CDC). Epidemiologic Notes and Reports: Epidemic Keratoconjunctivitis in an Ophthalmology Clinic
15. Velazquez-Estades LJ, Wanger A, Kellaway J, et al. Microbial Contamination of Immersion Biometry Ultrasound Equipment. Ophthalmology 2005 May;112(5):e13-e18.
16. Wegman DH, Guinee VF, Millian SJ et al. Epidemic Keratoconjunctivitis. Am J Pub Health 1970; 60:1230-1237.
17.
18. Moore B, Infusion Inc. Course: OSHA. http://www.infusionceus.com/oshacourse.htm (Accessed Jan 2, 2005).
19. Occupational Health and Safety Administration. Plasma derivatives are covered by the bloodborne pathogens standard. 2001/09/10/2001.
20. Occupational Health and Safety Administration. Regulation: Bloodborne Pathogen Standard. 29 CFR 1910.1030, July 1992.
21. Centers for Disease Control Morbidity and Mortality Weekly Report: Updated U.S. Public Health Service Guidelines for the management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis.
22. Centers for Disease Control and Prevention. 1-17 Updated US public health service guidelines for the management of occupation exposures to HIV and recommendations for post-exposure prophylaxis. MMWR September 30, 2005/54(RR09).
23. Centers for Disease Control and Prevention. Fact Sheet: HIV and its transmission. http://www.cdc.gov/hiv/pubs/facts/transmission.htm. (Accessed October 22, 2007).
24. Demeter L, Reichman R. Detection of human immunodeficiency virus infection. In G. Mandell, J. Bennett and R. Dolin (eds.), Principles and practice of infectious diseases.
25. Darrell RW, Jacob GB. Hepatitis B surface antigen in human tears. Arch Ophthalmol 1978;96:674-6.
26. Moniz E, Feldman F, Newkirk M, et al. Removal of hepatitis B surface antigen from a contaminated applanation tonometer. Am J Ophthalmol 1981;91:522-5.
27. Occupational Health and Safety Administration. Regulation: Bloodborne Pathogen Standard. 29 CFR 1910.1030 F. http://www.osha.gov/STLC?bloodbornepathogens/ index.html. (Accessed September 2007).
28. Beltrami E, Williams I, Shapiro C, Chamberland M. Risk and management of blood-borne infections in health care workers. Clinical Microbiology Reviews 2000:13(3),385-407.
29.
30. Centers for Disease Control and Prevention. Guideline for Infection Control in Health Care Personnel. June 1998. http://www.cdc.gov/search.do?action=search&queryText= infection+control+for+health+care+personnel&x=12&y=10 (Accessed January 2, 2007).
31. Barnes R. International Association of Healthcare Central Service Material Management. Technicians exchange: prion diseases what are they? http://www.iahcsmm.com/ tech_exch_1101.htm (Accessed February 8, 2005).
32. Collinge J. Varient Creutzfeldt-Jakob disease. Lancet 1999;354:317-23.
