Chapter 8 Bloodborne Pathogens Universal Precautions and Wound

Chapter 8: Bloodborne Pathogens, Universal Precautions, and Wound Care © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• Healthcare facility must be maintained as clean and sterile to prevent spread of disease and infection • Must take precautions to minimize risk • Coaches must be aware of potential dangers associated with exposure to blood or other infectious materials • Must take whatever measures to prevent contamination © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

Bloodborne Pathogens • Pathogenic organisms, present in human blood and other fluids (cerebrospinal fluid, semen, vaginal secretion, and synovial fluid), can potentially cause disease • Most significant pathogens are HBV and HIV • Others that exist are hepatitis A, C, D, and syphilis © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

Hepatitis B • Major cause of viral infection, resulting in swelling, soreness, loss of normal liver function • Signs and symptoms – Flu-like symptoms include fatigue, weakness, nausea, abdominal pain, headache, fever, and possibly jaundice – Possible that individual will not exhibit signs and symptoms -- antigen always present – Can be unknowingly transferred © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

– 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 – Vaccination against HBV should be provided by employer to those who may be exposed – Athletic trainers and allied health professionals should be vaccinated © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• Prevention (cont. ) – Three dose vaccination over 6 months – Post-exposure vaccination is also available after coming into contact with blood or fluids © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

Human Immunodeficiency Virus • A retrovirus that combines with host cell • Virus that has potential to destroy immune system • According to World Health Organization, 42 million people were living with HIV/AIDS in 2002 © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• 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) © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

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 • After contracting AIDS, people generally die w/in 2 years of symptoms developing © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• 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 • Antiviral drug cocktail • Slows replication of virus, improving prospects for survival © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• 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 © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

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 © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

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 © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• Institutions should take responsibility to educate student athletes • 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 © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

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 • 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 and must take into consideration risk to patient and other participants, and means to reduce risk © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

Testing Athletes for HIV • Should not be used as screening tool • Mandatory testing may not be allowed due to legal reasons • 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 © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• Detectable antibodies may appear from 3 month to 1 year following exposure – Testing should occur at 6 weeks, 3 months, and 1 year • 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 © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

Universal Precautions in Athletic Environment • 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 – Include counseling, education, volunteer testing, and management of bodily fluids © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• 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 • Hyrdrocolloid dressing is considered a superior barrier • Reduces chance that wound will reopen, as wound stays moist and pliable • 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 © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• 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 – Doubling gloves 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 © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• 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 © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

– 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 – 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 © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• Protecting the Coach and 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 and coach have personal responsibility to follow guidelines © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

© 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• 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 © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

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 © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

Caring for Skin Wounds • Skin wounds are extremely common in sports • Soft pliable nature of skin makes it susceptible to injury • Numerous mechanical forces can result in trauma – Friction, scrapping, pressure, tearing, cutting and penetration © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• Types of wounds – Abrasions • Skin scraped against rough surface • Top layer of skin wears away exposing numerous capillaries • Often involves exposure to dirt and foreign materials = increased risk for infection – Laceration • Sharp or pointed object tears tissues – results in wound with jagged edges • May also result in tissue avulsion – Incision • Wounds with smooth edges © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

– Puncture wounds • Can easily occur during activity and can be fatal • Penetration of tissue can result in introduction of tetanus bacillus to bloodstream • All severe lacerations and puncture wounds should be referred to a physician – Avulsion wounds • Skin is torn from body = major bleeding • Place avulsed tissue in moist gauze (saline), plastic bag and immerse in cold water • Take to hospital for reattachment © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

Immediate Care • Should be cared for immediately • All wounds should be treated as though they have been contaminated with microorganisms • To minimize infection, clean wound with copious amounts of soap, water, and sterile solution – Avoid hydrogen peroxide and bacterial solutions initially © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• Dressing – Sterile dressing should be applied to keep wound clean – Occlusive dressings are extremely effective in minimizing scarring – Antibacterial ointments are effective in limiting bacterial growth and preventing wound from sticking to dressing – Utilization of hydrogen peroxide can occur several times daily before reapplication of ointment © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• Are sutures necessary? – Deep lacerations, incisions, and occasionally punctures will require some form of manual closure – Decision should be made by a physician – Sutures should be used within 12 hours – Area of injury and limitations of blood supply for healing will determine materials used for closure – Physician may decide wound does not require sutures and utilize steri-strips or butterfly bandages © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• Signs of Wound Infection – Same as those for inflammation • • • Pain Heat Redness Swelling Disordered function – Pus may form due to accumulation of WBC’s – Fever may develop as immune system fights bacterial infection © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.

• Tetanus – Bacterial infection that may cause fever and convulsions and possibly tonic skeletal muscle spasm for non-immunized athletes – Tetanus bacillus enters wound as spore and acts on motor end plate of CNS – Following childhood vaccination, boosters should be supplied once ever 10 years – If not immunized, athlete should receive tetanus immune globulin (Heper-Tet) immediately following skin wound © 2005 The Mc. Graw-Hill Companies, Inc. All rights reserved.