By Jahangir Moini , M.D., M.P.H. - PowerPoint Presentation

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ByJahangir Moini, M.D., M.P.H.andMorvarid Moini, D.M.D., M.P.H.

Chapter 13

Occupational Safety and Health Administration (OSHA) standards

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OverviewIn workplaces, safety is of critical importanceOccupational Safety and Health Act passed to help prevent diseases and injuries in workplacesIt set up Occupational Safety and Health Administration (OSHA) to regulate: EquipmentMachineryFirst aid

Materials

Hazards

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OSHA Bloodborne Pathogens StandardCreated to reduce occupational exposures:Human immunodeficiency virus (HIV)Hepatitis B virus (HBV)Some health care professionals are: Category I employees (highest risk)

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Bloodborne Pathogens StandardDetermining steps for various exposuresDeveloping exposure control plansFollow-ups after exposuresBiologic waste labeling and disposalFree hepatitis B vaccinations for employeesHousekeeping and laundry standards

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Bloodborne Pathogens StandardPersonal protective equipment standardsRecord-keeping standardsEmployee training about bloodborne pathogens, related practicesUse of universal precautionsWork practice standards

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HIV and AIDSHuman immunodeficiency virus (HIV) Attacks immune system by destroying CD4 positive T-cellsThese cells are vital to fight off infectionHIV-positive patients: Vulnerable to other infections, diseases, complicationsAutoimmune deficiency syndrome (AIDS)

Final stage of HIV infection

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Spreading the HIV virusUnprotected sex (mostly vaginal, anal intercourse)Through blood: Transfusion, needle sticks, sharing needlesTransfusion of HIV-infected blood: 90% chance Transplantation of infected tissue or organsMother-to-child transmissionVia placenta during birth or, rarely, via breastfeeding

1.5 million pregnant women have HIV

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Spreading the HIV virusInitially spread through unprotected sex between homosexual menIn Africa, spread between men and women quicklyIn China, spread via blood transfusionsThen by heterosexual sex and sharing needles

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Effects of HIVAttacks the immune system over timeHalf of patients will have AIDS within 10 yearsOpportunistic infections:Herpes TuberculosisVarious cancers

Toxoplasmosis

Cryptococcal meningitis

Other infections

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Fighting HIV/AIDSIncreased effort promoting condom useTreatments with antiretroviral medicationsWorldwide, 38% of HIV-positive adults receive antiretroviral therapy (ART)Only 24% of HIV-positive children receive it

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Prevalence of HIV/AIDS in AfricaMore prevalent in sub-Saharan AfricaMost common between ages 15 and 594.7% of adults between 15 and 49 are HIV-positiveHigher cause of death of African women than men

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Global HIV/AIDS39% of new infections occur in ages 15 to 24Knowledge, treatment in richer countries is greatly reducing transmissionSixth leading cause of death worldwideSecond leading cause in sub-Saharan Africa

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Stopping HIV/AIDSSurveillance Education, informationCommunication Condom promotionVoluntary circumcisionsVoluntary counseling and testingScreening, treatment for sexually transmitted infectionsART and avoidance of pregnancy in HIV-positive women

Stopping transmission between high- and low-risk groups

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90/90/90 planThe goals of worldwide HIV and AIDS prevention include the 90/90/90 plan, targeted to be achieved by the year 2020:90% of the HIV-positive will know their status90% of the HIV-positive will be receiving ART90% of those being treated = suppressed viral loads

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Viral hepatitisSix forms: A, B, C, D, E, and GMany are extremely communicableBiggest threats to health care employees:Hepatitis B virus (HBV)Hepatitis C virus (HCV)

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Hepatitis A (HAV)Least serious; 98% of patients recoverFecal–oral route (contaminated food, water)Usually occurs in young adultsProphylaxis with immune globulinVaccination is 2 doses For people living in, traveling to areas with Poor sanitation and overcrowding

Also called

acute infective hepatitis

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Viral hepatitis

Type

Incubation period

Transmission

Infectivity

Hepatitis A

15–20 days

Fecal–oral

2

weeks before symptoms;

1

–

2 weeks after symptoms begin

Hepatitis B

45–180 days

Parenteral, mucosal exposure, sex, perinatal transmission

4–6 months

(before and after symptoms);

Carriers infectious throughout life

Hepatitis C

14–180 days

Same as hepatitis B

1–2 weeks before

symptoms, through clinical course;

75%

–

85% develop chronic hepatitis

Hepatitis D

2–26 weeks

HBV must be present; same routes

Blood infectious at

all stages

Hepatitis E

15–64 days

Fecal–oral

Not known; may be similar to HAV

Hepatitis G

Unknown

Blood, sex; rarely,

perinatal transmission

Infection in 10%–20% of those with chronic

HBV, HCV

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Hepatitis B (HBV)Damages the liver; acute or chronicAlong with HCV, leading risk factor for some liver cancers95% clear the infection, develop antibodiesRemainder develop chronic infectionsAlso called serum hepatitisAbout 240 million global chronic infections

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Hepatitis B (HBV)Prevalence highest in South Africa, Eastern Asia780,000+ die annually due to complicationsCan survive outside body 7+ daysBased on temperature, humidity, sunlightIn endemic areasOften spread from mothers to children

Via infected blood

Often between infected, uninfected children below age 5

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Hepatitis B (HBV)If symptoms develop, they include:Jaundice Dark urineExtreme fatigue NauseaVomiting Abdominal painOver 90% of healthy adults recover in 1 year

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Hepatitis B (HBV)Laboratory confirmation is essentialAll blood donations tested for HBVNo specific treatment, but usually lifetime care:Adequate nutritionFluid replacementOral antivirals for chronic cases

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Hepatitis B (HBV)Infants of HBV-positive mothers must receive:Vaccine, immune globulin within 24 hoursAdditional vaccines at 1 and 6 months of ageHBV vaccine recommended for Children, adolescents in countries with Low- or intermediate occurrence of HBV

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High-risk individuals for HBVHealth care workers in contact with infected fluidsThose often needing blood productsDialysis patientsSolid organ transplant recipientsPrisoners and prison workers

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High-risk individuals for HBVInjectable drug usersCasual or sexual contact with HBV-positive peopleThose with multiple sexual partnersPeople exposed to blood productsTravelers who have not been vaccinated

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HBV vaccineDeveloped in 1982Prevented hundreds of thousands of deaths annually, including those from:CirrhosisLiver cancer95% effectiveFirst vaccine protecting against major cause of cancer

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HBV vaccineOSHA requires all health care professionals to be immunized against HBV:They are at risk for exposure to bloodborne pathogensThe vaccine must be available at no cost to them

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Hepatitis C (HCV)Can cause acute and chronic infectionsRanging from mild to severeLast a few weeks to an entire lifetimeUsually transmitted via: Needles TransfusionsInadequate sterilizationNo vaccine currently available

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Hepatitis C (HCV)Carriers are vulnerable to severe infection if they contact HAV or HBVVaccination against both of these forms is recommendedHCV also called Parenterally transmitted non-A non-B hepatitis150 million people have chronic HCVNearly 500,000 die annually from related diseases

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Hepatitis D (HDV)Also known as delta hepatitisCannot replicate with HBV being presentTogether, HBV and HDV can Worsen symptoms, increase risk of chronic hepatitisTransmitted sexually and via needle sharingOnly treatment: prevention of HBV

Uncommon in the U.S.

No vaccine available

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Hepatitis E (HEV)Spread through fecal–oral routeSelf-limitingMostly occurs in Asia and AfricaDoes not cause chronic hepatitisCan be fatal to pregnant womenOutbreaks usually occur after heavy rain or monsoons

Due to disrupted water supplies

No vaccine available

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Hepatitis G (HGV)Mostly linked to transfusions, but also:Intercourse and pregnancyHemodialysisNeedle sharingInfection is widespread but usually mildNot primarily replicated in the liverMay be carried throughout life

No vaccine available

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Components of the OSHA standardUniversal precautionsWritten exposure control planAddresses:How to handle exposure incidentsLabeling requirementsAccurate record-keeping

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Universal precautionsAssume all blood products, tissues, most body fluids are infectious for pathogens (primarily, HIV and HBV):Semen Urine Cerebrospinal fluid Feces

Tears

Vaginal secretions

Amniotic fluid

Pleural fluid

Synovial fluid

Peritoneal fluid

Pericardial fluid

Nasal secretions

Sputum

Saliva

Vomitus

Breast milk

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Standard precautionsUniversal precautions + Body Substance Isolation (BSI) guidelinesDesigned to reduce disease transmissionStandard precautions apply to:Blood Mucous membranesNon-intact skin

All body fluids, secretions, excretions

Except sweat

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Standard precautionsProtect against pathogen transmissionWhen infected blood contacts another’s skin or mucous membranesReduce disease transmission between peopleSafeguards are unique for each procedure

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OSHA safeguardsHand washingGlovesMask and protective eyewear or face shieldLaboratory coat or gownReusable sharps containersSharps disposalBiohazardous waste containersDisinfection

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OSHA standard precautions categoriesCategory I – possible exposure to blood, body fluids, or tissuesSpilling or splashing (such as minor surgeries)Specific protection required:Hand washing Protective clothingGloves Handling sharps

Mask

Decontaminating surfaces

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OSHA standard precautions categoriesCategory II – usually, no special protection; often no visible blood, but possible exposureMay require mouth-to-mouth resuscitation, saliva exposureProtection via: Gloves Resuscitation bagsDisposable airway equipment

Particular concern: transmission of HIV or HBV

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OSHA standard precautions categoriesCategory III – no exposure, no protection neededCheck for open woundsMay require:Taking blood pressureInstilling nasal drugsInstructing patient about equipmentTaking care of a cast

Protective measures may include hand washing

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Written exposure control planRequired for every medical facility by OSHALists treatments after exposure to harmful substancesMinimizes risks; must be updated as necessaryAt-risk employees must have access for annual reviewNew employees must review this plan upon hiringWritten copies must be supplied when requested

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Written exposure control planEmployee exposure determination:Training EquipmentHepatitis immunization Job classifications

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Written exposure control planExposure control method implementation (method of compliance):Engineering controls PPEWork practice controls Universal precautionsHousekeeping

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Written exposure control planVaccination for hepatitis BPost-exposure evaluation, follow-upsExposuresDocumentationInvestigationEmployee hazard communication and trainingRecord-keeping

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Exposure incidentsOccurs when employees believe they have contacted a potentially infectious substanceDespite all precautionsHandled per the OSHA Bloodborne Pathogens StandardMost common: Needlesticks Other types of skin puncture

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Exposure incidentsEmployer must be notified immediatelyPrompt reporting helps prevent repeat incidentsFree medical evaluation offered to employeeHBV testing, vaccination usually occur

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Exposure incidentsExposure to HCV or HIV must also be evaluatedUsually: one or more blood tests plus patient historyRisks:HCV-infected blood exposure: 1 in 50HIV-infected blood exposure: 1 in 300HIV-infected mucous membrane exposure: 1 in 1,000

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Labeling requirementsBiohazard warning labels on: Regulated waste containersFreezersRefrigeratorsStorage containersTransport/shipping containersRed bags, containers can substitute for labels

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Record-keepingAccurate, confidential OSHA medical record: For at-risk employeesContains full employee informationKept for 30 years after employment of each individualSharps injury log: If 10+ at-risk employees

All personal I.D. removed

Helps track injuries, prevent future occurrences

Full information on everything involved in injury cases

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OSHA hazard communicationAll employees must be trained in workplace hazardsMethods to read, understand all documentsHow to handle exposuresEach hazardous material must be labeled correctlyAll employees must have access to documentation

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Biohazard labelsInclude biohazard symbol (bright orange-red)Applied to every container that stores:Waste productsBlood or blood productsOther specimens possibly contaminated with bloodborne pathogensConsidered

biohazardous

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Biohazard labelsWording: “biohazard” and “infectious waste”Must be securely attachedWarning signs posted to alert about presence of these materialsMust list important safeguards:EatingDrinkingSmoking

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Hazard labelsIdentify all hazardous substances in the workplaceThey are simpler than the material safety data sheet (MSDS)Chemical or trade nameShort statement of hazardous effectsHazard labels with color-coding or numbering: Require manufacturer explanation since these factors are not consistently used

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Hazardous waste managementHazardous wastes: GasesLiquidsSolidsSemi-solidsAre not clean, disinfected, or sterilizedClassified by seven different properties

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Hazardous waste classificationsCaustic – cause burns, damage to tissuesCorrosive – can destroy metalCytotoxic – can kill cellsIgnitable – can create firesRadioactiveReactive – can cause explosions or fumesToxic

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Hazardous waste classificationsEnvironmental Protection Agency (EPA) classifications:F-list – no specific sourceK-list – has a specific sourceP-list (or U-list) – discarded commercial chemicals

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Hazardous waste managementProper protective handling equipment requiredRegulations cover:Air emissions Closure of containersGround water monitoring Proper cleanup proceduresLand disposal restrictions

Permitting procedures

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Disposal of hazardous wastesAll materials that contact blood or body fluidsInclude used needles, linen, clothingLeak-proof, puncture-proof containersMarked with the biohazard symbol:Needles Scalpels

Glass slides

Disposable syringes

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Figure 13-1: Sharps container

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Plastic biohazard bagsContain soft materials:Dressings (gauze)GlovesPaper towelsLabeled with the biohazard symbol

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Figure 13-2: Biohazard container for soft items

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Handling hazardous wastesRemoval and disposal usually handled by specialized companiesCleaning staff should not empty containersHandlers must wear PPEBags closed securelyOften placed inside a second secure bagDouble-bagging technique

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Use of personal protective equipmentPPE (barrier precautions) regularly used: Face shields, goggles, masks GlovesGowns, surgical gowns with cuffsHair covers Shoe coversProtect against exposure to pathogens, hazards

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Use of personal protective equipmentNon-intact skinHas a break in its surface:Abrasions BurnsChapping CutsHangnails Acne

Dermatitis

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Use of personal protective equipmentSplashing or splattering of body fluids:Face shieldsGogglesMasksGowns, lab coats, scrubs worn while working Left in special storage areas located thereLatex or non-latex gloves are commonly worn

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Proper glove guidelinesKeep fingernails trimmed shortAlways wear correct glove sizeNever store in very warm or cold areasAvoid oil-based hand lotions or creams

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Fire safety and emergency planClearly detailed building exits, fire doors, escape routesFire alarm pull boxes (up high on walls)Fire alarms, extinguishers must be testedSmoke detectors, testedFire sprinklers mounted on ceilings; tested oftenFire prevention training and fire drills

Emergency phone numbers posted near phones

Hallways kept clear

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Figure 13-3: Clear escape route indicated, as part of a fire safety plan

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Emergency and fire trainingAvoid using elevators – use stairs insteadCorrectly report fires and other emergenciesFire containment must be practiced“All clear” given for employees to return to work

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Fire hazardsRegularly reported and corrected:Electrical wires, overloaded circuitsPaper, waste cans Rags, matches, other flammablesImproperly grounded plugsLighters, smoking in facilityInsufficient protection when oxygen is in use

Smells of smoke or burning

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Three major components of fire preventionA source of ignitionPresence of oxygenEnough heat to ignite a fire

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Extinguishing a fireIf fire is discovered before alarm, try to extinguish itIf not possible, pull the fire alarmEmployees must exit, closing doors behind them to isolate fire

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Types of fire extinguishersCarbon dioxide (types B and C)Regular dry chemical (types B and C)Water (type A)Multi-purpose dry chemical (all 3 types)

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Figure 13-4: A fire extinguisher

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Oxygen hazardsOxygen is highly flammable; Special precautions:Electrical sparksKeep devices awayFlammable liquidsAlcohol, oils, nail polishProper use of oxygen tanks

Secured so they do not fall

Kept away from heat, sun

Valves and stems maintained

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Oxygen hazardsSmokingNever allowedSpecial signs “Oxygen in use” signs postedStatic electricityNo synthetic or wool materials

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Fire preventionKeep flammable liquids away from heatUse material safety data sheetsPractice fire prevention techniquesStore flammable items properlyAvoid smoking; use smoke detectorsExtinguish flames used in procedures quicklyFire extinguishers must be kept nearby

Gas valves must be turned off completely

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Chemical hazards and safetyExposure via direct absorptionSkin Mucous membranesInhalation IngestionAll employees trainedComply with all equipment and conditionsSafety data sheet

for each hazardous chemical

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Safety data sheetTrade, chemical namesChemical family, physical dataSynonyms Manufacturer Protection informationHealth hazards Fire and explosion data Emergency phone number

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Chemical hazardsCarcinogenic – causes cancerCaustic – causes corrosion or burning of body tissuesFlammable – causes firePoisonous – causes illness or deathTeratogenic – causes birth defects

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Storage of hazardous substancesStore below eye level to reduce eye contactWear protective gear when handlingCarry containers with both handsUse only in properly ventilated areas

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Tips for working with hazardous substancesPersonal ventilation deviceNever hold substance directly under your noseWork in a fume hoodNever combine chemicals unsafelyNo mouth pipettingAcids added to other chemicals, not the other way aroundReduces splashing risks

If unknown chemical spills, never pour another one onto it

Never touch unknown substance with hands

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Hazardous substancesChemical hygiene plan in placeOutlines safe handling and disposalEyewash stations available Flush out eyes or mucous membranes with waterLocated in easy-to-access areasChecked monthly for proper operationEmployees must be properly trained

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Figure 13-5: Eyewash station

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Physical safetyUpdated emergency numbers in many locationsKeep floors clear of objectsNo running in the facilityClean up spills immediatelyKeep carpet in good conditionImmediately dispose of dropped medications

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Physical safetyCarefully carry items, especially near cornersKeep everything closed when not in useInspect furniture for sharp corners, edgesTape down and fasten all cables and cordsAvoid using damaged supplies or equipment

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Laboratory safetyAvoid eating, drinking, food storageAvoid putting anything into mouthNo inserting of contact lensesNo application of lip balm or makeupKnow locations of fully-stocked first-aid kitsReplace expired medications in these kitsKnow proper use of eyewash and shower stationsWear protective gear and clothing

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Laboratory safetyAvoid loose clothing, dangling jewelryKeep hair pulled back or coveredOnly open centrifuges after they stopNever grasp containers when wetClose containers immediately after useClean up broken glass or biohazardous material spills appropriately

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Latex allergyLatex gloves not preferred due to allergiesReactions usually involve dermatitisCan be extremely serious (shock, even death)Hypoallergenic low-powder or powderless latex-free gloves preferredOther latex productsBlood pressure cuffs

Catheters

Stethoscopes

Wound drains

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Figure 13-6: Latex-free gloves

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ErgonomicsAlso called human engineeringMeant to increase comfort, performance, and well-being of workersComputer keyboards: lower than level of conventional desksAdjustable chairs should have back support

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Figure 13-7: Keyboard ergonomics

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Steps to decrease injury when liftingPlan how you will lift, and test the loadAsk for help to lift the loadHave a firm footingBend your kneesTighten abdominal musclesUse legs to liftKeep load closeKeep your back straight and upright

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Radiation hazardsRadiopharmaceutical substances can harm body tissues To reduce radiation hazards:Increased distances between source and workersDecreased time working with these substancesUse of film badges to monitor exposureProper material labelingEffective radiation shields

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Workplace violenceMostly related to assaultStrong violence prevention programs, plus:Alarm systemsSecurity camerasAdequate exits, barriers, and “safe” areasAdequate staffPolicies for dealing with problem individuals

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Employee responsibilitiesOSHA penalizes employers for lack of complianceStates also have guidelinesEmployee responsibilities include:Reading OSHA posters and complyingFollowing employer guidelines

Reporting hazards to employers

Reporting injuries/illnesses; seeking treatment

Cooperating with OSHA inspectors

Exercising employee rights responsibly