The Ryan White Law
The Ryan White HIV/AIDS Treatment Extension Act of 2009 requires that a medical facility respond to the request of an Emergency Response Employee (ERE) and their Designated Infection Control Officer (DICO), of a potential exposure incident such as a needle-stick injury, other contact
with body fluids, or suspicion of exposure to an airborne or aerosolized infectious disease.
You should first consult with your Designated Officer to confirm exposure. Based on your Exposure Control Plan, you may need to report for baseline lab work at a designated location, however it is vital to notify the facility where the patient was transported for source lab work per deemed consent. If a patient is at the University of Virginia, the Designated Officer should request source blood be drawn. The Emergency Department should PIC #1523 to notify of the exposure.
Results of bloodwork (both source patient and provider) will be ONLY be given to provider or DICO by either the ED staff, Nursing Supervisor or Prehospital Coordinator.
Guidelines Pertaining to Infectious Exposures for Public Safety Personnel
Understanding Infectious Exposures:
Public safety professionals are at potential risk of exposure to blood and other infectious bodily fluids during their duties. Emergency response teams, while attending to critical patients, may have to conduct invasive procedures, administer first aid to open wounds, manage bleeding, handle contaminated needles, or even face assault. Such scenarios elevate the probability of transmission of bloodborne pathogens, encompassing but not limited to hepatitis B virus, hepatitis C virus, and human immunodeficiency virus (HIV).
Defining Exposure to Bloodborne Pathogens:
An individual can be deemed exposed to bloodborne pathogens in the professional setting through:
- Direct contact of eyes, nose, mouth, or compromised skin with blood or other potentially infectious materials.
- Injuries from needles or sharp objects imbued with blood or other bodily fluids.
- Incidents involving needles or sharp objects during procedural searches.
- Physical assaults leading to bites, lacerations, or punctures.
Potential Infectious Materials Defined
List of Materials:
Potentially infectious materials encompass:
- Specific human body fluids, including but not limited to semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva during dental procedures, any fluid visibly tainted with blood, and all bodily fluids where differentiation is challenging or unfeasible.
- Any unfixed tissue or organ derived from a human, whether alive or deceased, excluding intact skin.
- HIV-related cell or tissue cultures, organ cultures, as well as HIV- or HBV-tainted culture mediums or solutions, and blood, organs, or tissues taken from experimental animals that are HIV or HBV infected.
Modes of Disease Transmission:
1. Direct Transmission:
This refers to the immediate transfer of microorganisms from one person to another without the involvement of a contaminated intermediate entity or individual.
2. Indirect Transmission:
This method involves the transference of infectious agents via a contaminated intermediate entity or person.
3. Aerosolized Airborne Transmission:
This denotes the transfer of infectious agents by small aerosol particles that can remain airborne for extended durations. Such particles can be transported over expansive distances on air currents, may cause extended contamination of air spaces, and can be aspirated into the trachea and lungs. This mode of transmission is probable when public safety officials share an environment with an infectious individual, and the latter expels small droplets into the air, for instance, through sneezing or coughing. Once these droplets lose their water content, the remaining particles can persist in the air.
4. Aerosolized Droplet Transmission:
This involves the transfer of infectious agents through larger droplets, which stay airborne for brief durations. Typically, they transmit diseases over short distances (around 6 feet) and do not result in extended airspace contamination. This method is possible when public safety officers are in close proximity to an infectious individual.
5. Bioterrorism or Biological Warfare:
The Select Agents registry, overseen by the U.S. Department of Health and Human Services (HHS), categorizes biological elements and toxins that present a heightened threat to human health and are viable for bioterrorist purposes. In situations where these agents might be intentionally modified to enhance their transmissibility or lethality (referred to as "weaponization") and are utilized as bio-weapons, uncharacteristic transmission pathways might be observed. Consequently, public safety officers might be at risk either by entering infected areas to assist victims or through contact with contaminated individuals from those zones.
Guidelines on Managing Exposure to Infectious Materials
Immediate Steps in the Event of Exposure:
If you find yourself subjected to potential contaminants, including blood, bodily fluids, needlestick incidents, or lacerations from sharp instruments, ensure you promptly:
- Cleanse the impacted area, especially in the case of a needlestick or cut, using soap and water.
- Rinse any splashes to the nose, mouth, or skin thoroughly with water.
- For any eye contact, wash with clean water, saline, or other sterile solutions.
- Report the event to the designated infection control personnel, supervisory authority, or the individual tasked with handling exposure in your establishment.
- Immediately seek an assessment from a competent healthcare professional. There may be instances where post-exposure intervention is advised, necessitating timely initiation.
Choosing Healthcare Professionals for Exposure Evaluation:
Healthcare professionals responsible for appraising the exposure of public safety personnel should:
- Be predetermined before there's any risk of exposure to public safety staff.
- Possess experience in the administration of antiretroviral treatment.
- Understand the unique nature of public safety-related injuries to give accurate advice on antiretroviral prophylaxis.
- If the primary evaluator is unfamiliar with antiretroviral therapy, another skilled healthcare professional may be necessary for consultation.
- Professionals can also reach out to the National Clinicians’ Post-exposure Prophylaxis Hotline (PEPline) for recommendations on managing exposures to HIV, and hepatitis B and C viruses. The PEPline operates 24/7 at 1-888-448-4911.
Evaluating Infection Risk Post-Exposure:
Although many exposures don't lead to infections, the risk can vary depending on:
- The specific pathogen encountered.
- The nature of the exposure.
- The volume of blood involved during the exposure.
- The viral load in the patient's blood at the moment of exposure.
- Employers are expected to maintain a robust system to swiftly assess exposure risks, guide you on potential preventive treatments, monitor treatment effects, and ascertain any resultant infections.
Importance of Exposure Reporting:
Swift reporting of potential exposures is paramount as:
- It facilitates timely medical evaluation and treatment.
- It safeguards employees, their kin, and the general populace.
- Exposures through broken skin can lead to infections and should, therefore, be reported.
- Undocumented exposures might result in ineligibility for workers' compensation.
- By recording exposure incidents, employers can pinpoint causes and implement prevention measures.
Understanding the Reluctance to Report Exposures:
While it's paramount for all exposure incidents to be reported, some employees might hesitate due to various reasons, including:
- Underestimating the risk of infection.
- Believing the exposure was a result of their negligence.
- Not using the recommended protective equipment.
- Feelings of embarrassment.
- Concerns about time consumption.
- Fear of negative professional repercussions.
- Job security concerns.
- Misconceptions about exposure management.
- Uncertainty about what constitutes an exposure.
- It's imperative for employers to promote a culture where employees feel safe and encouraged to report any potential exposure incidents promptly.
- Promotion of Exposure Reporting within Organizations:
Strategies to Encourage Reporting:
- Institute a firm policy mandating the reportage of all possible exposures.
- Recognize and address organizational dynamics or obstacles that might deter reporting.
- Educate employees about the definition and implications of an exposure.
- Illuminate the infection risks associated with exposure.
- Deploy a user-friendly mechanism for reporting and scrutinizing exposures.
- Ensure timely and confidential management of exposure reports.
- Guarantee that all personnel, including managerial staff, are acquainted with the organization's reporting guidelines.
- Incorporate reporting guidelines in the inaugural and annual bloodborne pathogens training sessions.
- Regularly reiterate the importance of immediate reporting of potential bloodborne pathogens exposures to employees.
- Affirm to staff that reporting exposures will neither impact their job status nor their performance assessment.
- Maintain a systematic record of exposures to identify trends and instigate preventive measures.
- Exhibit to staff the importance of reporting in exposure prevention.
- Proactively disseminate the policy and associated steps to employees.
- This advisory is inspired by the NIOSH's guidelines on promoting bloodborne pathogen exposure reporting.
Preventative Measures Against Exposures
To safeguard against detrimental exposures, consider the following practices:
- Adhere to Universal/Standard Precautions and pertinent safety protocols.
- Participate in initial and recurrent bloodborne pathogens training sessions.
- Familiarize oneself with the organization's Exposure Control Plan.
- Utilize the safety equipment provided by employers.
- Prioritize safety needle and sharps instruments.
- Properly dispose of needles and sharps.
- Exercise caution during physical searches.
- Wear recommended Personal Protective Equipment (PPE) during potential exposure scenarios.
- Prevent direct skin contact with blood.
- Cleanse skin visibly tainted with body fluids using soap and water.
- In the event of unseen body fluid contact, employ antimicrobial soap and water or an alcohol-based sanitizer.
- Communicate all exposures to organizational leadership.
- Ensure hepatitis B virus immunization.
Recommendations for Employers
- Draft and annually refresh an Exposure Control Plan as mandated by the OSHA Bloodborne Pathogens Standard. An exhaustive prevention program is pivotal for employee safety.
- Impart training on bloodborne pathogens, safe operational practices, proper use of safety devices, and PPE, and other mandated topics under the Bloodborne Pathogens standard (29 CFR* 1910.1030). Allow a Q&A segment with the instructor.
- Supply efficacious medical safety tools and solicit input from frontline employees during their selection.
- Offer suitable PPE and advocate for its consistent use.
- Develop innovative strategies for safely managing patients in restricted spaces or those displaying aggressive behavior.
- Motivate staff to communicate all exposures to blood or body fluids and address potential reporting barriers.
- Evaluate exposure instances to discern patterns and potential prevention avenues. Keep employees informed of your findings.
- Establish procedures for post-exposure assessment and subsequent actions.
- Provide complimentary hepatitis B virus vaccinations and motivate workers to avail themselves of this provision.
- This guidance is derived from the NIOSH's directives on averting bloodborne pathogen exposures among paramedics.
Virginia's Initiative on Exposure Control & Prevention
The peril of infectious disease exposure is of paramount concern for first responders. The General Assembly of Virginia commissioned the creation of a dedicated team to enhance the Commonwealth's preparedness in managing exposure-centric incidents concerning public safety personnel. This team aims to curate and institute consolidated plans, advice, and tools concerning exposure control and prevention for all public safety staff. The team includes delegates from law enforcement units, fire brigades, emergency medical service entities, and other pertinent institutions.