Chapter 14 Infectious Diseases Bloodborne Pathogens and Universal

• Bloodborne pathogens are transmitted through contact with blood or other bodily fluids • Hepatitis, especially hepatitis B, human immunodeficiency virus are of serious concern • Healthcare facility must be maintained as clean and sterile to prevent spread of disease and infection • Must take precautions to minimize risk © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -2

Infectious Disease • Invasion of a host (animal or person) by a microorganism (pathogen) – Causes disease by disrupting vital body processes – Stimulate the immune system to react defensively • Immune response = fever, inflammation, or other damaging symptoms – Most common pathogens = bacteria, viruses, parasites or fungi © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -3

• Microorganism can live in host and be harmless until an agent and mode of transportation allows for transfer of microorganism pathogen infection • An infectious disease = contagious if transmission occurs from one individual to another – Direct vs. indirect transmission – 3 Types of direct transmission • Contact of body surfaces (touching, sexual intercourse) • Droplet spread (inhalation or air droplets) • Fecal-oral spread (feces on hands contact with mouth © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -4

– Indirect transmission • Travels via inanimate object – Water, food, towels, clothing, utensils • Via vectors – Insects, birds, animals • Airborne transmission – Infected particles suspended in air – infected via sharing air supply • Pathogen entry into body – Through skin, respiratory system, digestive or reproductive system • Ability to generate infection dependent on: – Acquired immunity – Overall health – Health-related behavior © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -5

Stages of Infection • Incubation stage – From time pathogen enters body to time signs and symptoms of disease appear – Lasting from few hours to months depending on concentration, virulence, level of immune response, presence of other health problems • Prodromal stage – Watery eyes, runny nose, slight fever and malaise may develop briefly – Host can transfer pathogen to other hosts – Host should be isolated to prevent transmission © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -6

• Acute stage – Disease reaches point of greatest development while body resists further damage from pathogen • Decline stage – First signs of recovery – Could relapse if patient becomes overextended • Recovery stage – Overcome invading pathogen – Patient remains susceptible – Body may have built up immunity and will be resistant to future exposure (may not be permanent) © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -7

The Immune System • Mechanical defenses – Separates the internal body from the external environment • Skin, mucous membranes, nasal hairs, cilia lined airways • Cellular System (Immune system) – Eliminates microorganisms, foreign proteins and antigens – Consists of T-cells and B-cells • Located in bloodstream lymphatic tissues and interstitial fluid © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -8

– Antigens trigger leukocytes and macrophages to locate and destroy antigens • T-cells facilitate macrophages • B-cells transformed into specialized cells (plasma cells) capable of producing antibodies – Antibodies neutralize antigens via lysis and phagocytosis – Memory T-cells are formed to record information regarding antigens and immune response © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -9

Figure 14 -1 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14

Immunity • After effectively managing invading antigens the system is primed for future encounters – Acquired immunity • Developed artificially through vaccination/immunizations or passively when antibodies are injected • Both can provide important protection against infectious disease © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -11

Immunizations • Available and should be provided for all • Possible vaccinations include: – Diphtheria – Pertussis (whooping cough) – Hepatitis B – Haemophilus influenza type B – Tetanus – Rubella (German measles) & measles – Polio, mumps & chickenpox • Helps to minimize incidence of childhood communicable disease © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -12

• Immunizations have eradicated many infectious diseases world wide • Epidemiology is a tool used to study infectious disease in a population • Disease outbreaks – Sporadic (occasional, occurrence) – Endemic (regular cases often occurring in a region) – Epidemic (unusually high number of cases in a region – Pandemic (global epidemic) © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -13

Preventing Spread of Infectious Disease • Must be diligent in efforts to minimize transmission of disease • Most effective practice = washing hands • Ensure that patient immunizations are up to date • Be sure to educate patients on inability of antibodies to impact viruses, and need to taking antibiotics as directed • Encourage healthy lifestyles in patients © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -14

Bloodborne Pathogens • Pathogenic organisms, present in human blood and other fluids (cerebrospinal fluid, semen, vaginal secretion and synovial fluid) that can potentially cause disease • Most significant pathogens are hepatitis B (HBV) , hepatitis C (HBC) and human immunodeficiency virus (HIV) © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -15

Virus Reproduction • Submicroscopic parasitic organism is dependent on nutrients of cell • Strand of DNA or RNA dependent on metabolic and reproductive activity of cell • Redirect cell activity to create more viruses Figure 14 -3 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -16

Hepatitis B • Attacks liver, results in lifelong infection, cirrhosis, liver cancer, liver failure and death • Spread when blood from infected person enters the body of someone who is not infected – Unprotected sex, sharing needles • Individuals who have been vaccinated are at virtually no risk for infection • 350 -400 million people are infected world-wide • 8700 healthcare workers contract HBV each year, with 200 of these ending in death © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -17

• Signs and symptoms – Flu-like symptoms like fatigue, weakness, nausea, abdominal pain, headache, fever, and possibly jaundice – Possible that individual will not exhibit signs and symptoms -- antigen always present in these individuals – Can be unknowingly transferred – Chronic active hepatitis may occur because of problem with immune system, preventing complete destruction of virus infected liver cells © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -18

• Signs & Symptoms (continued) – May test positive for antigen w/in 2 -6 weeks of symptom development – 85% recover within 6 -8 weeks • Prevention – Good personal hygiene and avoiding high risk activities – Proceed with caution as HBV can survive in blood and fluids, in dried blood and on contaminated surfaces for at least 1 week © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -19

• Management – Vaccination against HBV should be provided by employer to those who may be exposed – Athletic trainers and allied health professionals should be vaccinated – Three dose vaccination over 6 months – After second does 87% of those receiving vaccine will be immune and 96% after the third dose – Post-exposure vaccination is also available after coming into contact with blood or fluids © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -20

Hepatitis C • Both an acute and chronic form of liver disease caused by hepatitis C virus (HCV) • Most common chronic bloodborne infection in United States • Leading indication for liver transplant • Signs & Symptoms – 80% of those infected have no S&S – May be jaundice, have mild abdominal pain, loss of appetite, nausea, fatigue, muscle/joint pain, and/or dark urine © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -21

• Prevention – Occasionally spread through sexual contact – Spread via contact with blood of infected person, sharing needles • Management – No vaccine for preventing HCV – Multiple tests available to check for HCV • Single positive = infection • Single negative = does not necessarily mean no infection – Interferon and ribavirin are 2 drugs used in combination and appear to be the most effective for treatment – Drinking alcohol can make liver disease worse © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -22

Human Immunodeficiency Virus • A retrovirus that combines with host cell • Infects T 4 blood cells, B cells and monocytes (macrophages) • Estimated that 11 out of 1000 adults are infected with HIV • 4. 1 million new HIV infections occurred world-wide in 2005 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -23

• Symptoms and Signs – Transmitted by infected blood or other fluids – Fatigue, weight loss, muscle or joint pain, painful or swollen glands, night sweats and fever – Antibodies can be detected in blood tests within 1 year of exposure – May go for 8 -10 years before signs and symptoms develop – Most that acquire HIV will develop acquired immunodeficiency syndrome (AIDS) © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -24

Acquired Immunodeficiency Syndrome (AIDS) • Collection of signs and symptoms that are recognized as the effects of an infection • No protection against the simplest infection • Positive test for HIV cannot predict when the individual will show symptoms of AIDS © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -25

• As of 2007, 1. 1 million people in the U. S. were living with HIV infection; 468, 000 were living with AIDS • 50% develop AIDS w/in 10 years of HIV infection • After contracting AIDS, people generally die w/in 2 years of symptoms developing © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -26

• Management – No vaccine for HIV, no cure even though drug therapy is available – Research looking for preventive vaccine and effective treatment – Most effective drug combination • Drug which blocks enzyme action responsible for new virus cell components • Drug which blocks copying of viral agents, disabling synthesis of new viruses • Third drug helps protect T cells, slowing progression of HIV © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -27

• Prevention – Greatest risk is through intimate sexual contact with infected partner – Choose non-promiscuous sex partners and use condoms for vaginal or anal intercourse – Latex condom provides barrier against HBV and HIV – Condoms with reservoir tip reduces chance of ejaculate being released from sides – Water-based, greaseless spermicides or lubricants should be avoided – If condom breaks, vaginal spermicide should be used immediately – Condom should be carefully removed and discarded © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -28

Additional Hepatitis Viruses • Hepatitis A – Causes inflammation of liver – does not lead to chronic liver disease – Transmitted by fecal or oral routes through close personal contact or contaminated food/water • Transmitted in milk, shellfish, salads, sliced meat – May show no outward signs or symptoms – Adults may exhibit dark urine, light stools, fatigue, jaundice and fever © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -29

• Hepatitis D (HDV) causes inflammation of the liver – Found often in those infected with HBV – Transmitted through contact with infected blood, needles or sexual contact – Symptoms more severe than with HBV • Hepatitis E (HEV) – Causes inflammation of the liver – Rarely found in the United States – Transmitted through fecal and oral routes from contaminated water supplies © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -30

Bloodborne Pathogens in Athletics • Chance of transmitting HIV among athletes is low • Minimal risk of on-field transmission • Some sports have potentially higher risk for transmission because of close contact and exposure to bodily fluids – Martial arts, wrestling, boxing © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -31

Policy Regulation • Athletes are subject to procedures and policies relative to transmission of bloodborne pathogen • A number of sport professional organizations have established policies to prevent transmission • Organizations have also developed educational programs concerning prevention, and medical assistance • Institutions should take responsibility to educate student athletes © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -32

• At high school level, parents should also be educated • Make athletes aware that greatest risk is involved in off-field activities • Athletic trainer should take responsibility of educating and informing student athletic trainers of exposure and control policies • Institutions should implement policies concerning bloodborne pathogens • Follow universal precautions mandated by OSHA © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -33

HIV and Athletic Participation • No definitive answer as to whether asymptomatic HIV carriers should participate in sport • Bodily fluid contact should be avoided • Avoid exhaustive exercise that may lead to susceptibility to infection © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -34

HIV and Athletic Participation • American with Disabilities Act says athletes infected cannot be discriminated against and may only be excluded with medically sound basis – Must be based on objective medical evidence – Also must take into consideration risk to patient and other participants and means to reduce risk © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -35

Testing Athletes for HIV • Should not be used as screening tool • Mandatory testing may not be allowed due to legal reasons (American with Disabilities Act and HIPAA) • Testing should be secondary to education • Athletes engaged in risky behavior should undergo voluntary anonymous testing for HIV • Multiple tests are available to test for antibodies for HIV proteins © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -36

• Detectable antibodies may appear from 3 month to 1 year following exposure • Testing should occur at 6 weeks, 3 months, and 1 year • Home test kits are also available which allow you to send blood work to lab for analysis – Home Access test is FDA approved – Lab analyzes dried blood sample and labeled with personal identification number (PIN) – Acquire results and counseling confidentially with PIN © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -37

• Many states have enacted laws that protect confidentiality of HIV infected person • Athletic trainer should be familiar with state laws and maintain confidentiality and anonymity of testing © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -38

Universal Precautions in Athletic Environment • 1991 OSHA (Occupational Safety and Health Administration) established standards for employer to follow that govern occupational exposure to blood-borne pathogens • Developed to protect healthcare provider and patient • All sports programs should have exposure control plan – Should include counseling, education, volunteer testing, and management of bodily fluids © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -39

• Preparing the Athlete – Prior to participation, all open wounds and lesions should be covered with dressing that will not allow for transmission – Occlusive dressing lessens chance of crosscontamination • Hydrocolloid dressing is considered a superior barrier • Reduces chance that wound will reopen, as wound stays moist and pliable © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -40

• When Bleeding Occurs – Athletes with active bleeding must be removed from participation and returned when deemed safe – Bloody uniform must be removed or cleaned to remove infectivity • Personal Precautions – Those in direct contact must use appropriate equipment including • Latex gloves, gowns, aprons, masks and shields, eye protection, disposable mouthpieces for resuscitation • Emergency kits should contain, gloves, resuscitation masks, and towelettes for cleaning skin surfaces © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -41

• Personal Precautions (continued) – Doubling gloving is suggested with severe bleeding and use of sharp instruments – Extreme care must be used with glove removal – Hands and skin surfaces coming into contact with blood and fluids should be washed immediately with soap and water (antigermicidal agent) – Hands should be washed between patients © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -42

– Latex Sensitivity and Nonlatex Gloves • Nonlatex glove use is recommended for athletic trainers • May cause allergic reactions if use latex gloves – Contact dermatitis – Systemic reaction • Some become more susceptible due to repeated exposure • Management of acute reaction includes removing irritant, cleansing affected area, monitoring vital signs, seeking additional medical assistance as warranted © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -43

• Availability of Supplies and Equipment – Must also have chlorine bleach, antiseptics, proper receptacles for soiled equipment and uniforms, wound care equipment, and sharps container – Biohazard warning labels should be affixed to containers for regulated waste, refrigerators containing blood and containers used to ship potentially infectious material – Labels are fluorescent orange or red – Red bags or containers should be used for potentially infectious material © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -44

Figure 14 -4 Figure 14 -5 © 2014 The Mc. Graw-Hill Companies, Inc. All

– Disinfectant • Contaminated surfaces should be clean immediately with solution of 1: 10 ratio approved disinfectant to water • Should inactivate HIV • Contaminated towels should be bagged, labeled, and separated from other soiled laundry, then transported in biohazard container – Wash in hot water (159. 8 degrees F for 25 minutes) – Laundry done outside institution should be OSHA certified © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -46

• Sharps – Needles, razorblades, and scalpels – Use extreme care in handling and disposing all sharps – Do not recap, bend needles or remove from syringe – Scissors and tweezers should be sterilized and disinfected regularly Figure 14 -6 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -47

• Protecting the Athletic Trainer – OSHA guidelines are designed to protect coaches, athletic trainers and other employees. – Coaches generally do not come into contact with blood and therefore risk is greatly reduced – Responsibility of institution to protect athletic trainer • Provide necessary supplies and education – Athletic trainer has personal responsibility to follow guidelines • Minimize risks by not eating/drinking, applying cosmetics/lip balm, handling contact lenses, and touching face before washing hands © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -48

• Protecting the Athlete From Exposure – Use mouthpieces in high-risk sports – Shower immediately after practice or competition – Athletes exposed to HIV or HBV should be evaluated and immunized against HBV © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -49

Post-exposure Procedures • Athletic trainer should have confidential medical evaluation that documents exposure route, identification of source/individual, blood test, counseling and evaluation of reported illness • Laws that pertain to reporting and notification of results relative to confidentiality vary from state to state © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 14 -50