Minimizing risks

Last December, there was a report of a hepatitis C virus (HCV) transmission by patient blood splashing into the conjunctiva of a nurse (Hosoglu S. et al. "Transmission of hepatitis C by blood splash into conjunctiva of a nurse."

Charles John Palenik, MS, PhD

Last December, there was a report of a hepatitis C virus (HCV) transmission by patient blood splashing into the conjunctiva of a nurse (Hosoglu S. et al. "Transmission of hepatitis C by blood splash into conjunctiva of a nurse." Am J Infec Control 2003;31:502-504). The accident occurred while the nurse was taking a blood specimen from a peripheral vein of a patient with chronic renal disease. The patient was positive for anti-HCV and HCV-RNA. Blood splashed onto the nurse's face and eyes. She quickly washed her face and flushed her eyes and immediately reported the incident. The nurse was healthy and had no behavioral risks (IV drug abuse, transfusions, tattoos, or needlestick accidents for the last six months).

Initial serological tests (anti-HCV and HCV-RNA) were negative. Liver enzymes (asparate aminotransferase and alanine aminotransferase, ALT) were normal. All lab findings remained unchanged for two months; but after six months, she presented with sore throat, nausea, vomiting, fatigue, and weight loss, starting 45 days earlier and worsening. Her conjunctiva was icteric and examination revealed hepatomegalia. Liver enzymes and bilirubin were elevated. Anti-HCV and HCV-RNA tests were positive. She was treated with interferon for a year. After one month, lab tests were again normal and no HCV-RNA could be detected.

Occupational acquisition of HCV is an important problem for health-care workers. Transmission by splashing blood into eyes is rare. Infection related to a needlestick incident is much more common.

An obvious question is: "Why wasn't the nurse wearing a face guard, safety glasses, and even a mask?" They likely would have prevented exposure. Unfortunately, the hospital where the nurse worked did not have a firm written policy concerning the use of specific standard precautions while drawing blood.

There is no effective postexposure prophylaxis for HCV. The hospital did follow recommended procedure for occupational exposure to HCV. The source patient and exposed practitioner should undergo baseline testing for antibodies to HCV and ALT levels. Testing for HCV-RNA can be performed four to six weeks after an exposure. Follow-up testing for anti-HCV and ALT is generally done after four to six months.

Personal protective equipment helps prevent many occupational exposures, but not all. For example, gloves do not totally protect against contaminated sharps. More effective are engineering and work-practice controls. OSHA states in its Bloodborne Pathogens Standard — 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 also be used.

Engineering controls are the primary means of eliminating or minimizing exposure, such as sharps-disposal containers, self-sheathing needles, and safer medical devices such as sharps with engineered sharps-injury protections and needleless systems, that isolate or remove bloodborne pathogens hazards. The design of an instrument or equipment can establish a barrier between practitioner and patient body fluids.

Engineering controls must be examined, maintained, or replaced regularly to ensure effectiveness. Dental practices now are required to annually review technologies that eliminate or reduce exposure to bloodborne pathogens. Up for consideration is the use of appropriate, commercially available, and effective safer devices.

No single device is effective for all circumstances. Employers must select devices that will not jeopardize patient or employee safety, and make an exposure incident with a contaminated sharp less likely to occur.

Work-practice controls reduce the likelihood of exposure by altering how a task is performed (e.g., prohibiting recapping needles by a two-handed technique).

Minimizing risks involves the application of engineering and work-practice controls and, if necessary, personal protective equipment. Workers must also receive all necessary information and training. Informed workers are usually safer workers. Implementation of a written exposure-control plan is essential.

OSAP, the Organization for Safety & Asepsis Procedures, is dentistry's prime source for evidence-based information on infection control and prevention and human safety and health. Further information on HCV is available on the OSAP Web site — www.osap.org.

Dr. Charles John Palenik is an assistant director of Infection Control Research and Services at the Indiana University School of Dentistry. Dr. Palenik has authored numerous articles, book chapters, and monographs, and is the co-author of the popular Infection Control and Management of Hazardous Materials for the Dental Team. He serves on the Executive Board of OSAP, dentistry's resource for infection control and safety.Questions about this article or any infection-control issue may be directed to office@osap.org.

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