Reference Manual for

Health Care Facilities with Limited Resources

Infection
Prevention
and Control.
Module 4. Patient and Health Care Worker Safety
Authors
Melanie S. Curless, MPH, RN, CIC
Patricia Lawson, MS, MPH, RN, CIC
Clare Rock, MD, MS
The authors have made every effort to check the accuracy of all information, the dosages of any drugs, and
instructions for use of any devices or equipment. Because the science of infection prevention and control is rapidly
advancing and the knowledge base continues to expand, readers are advised to check current product information
provided by the manufacturer of:

• Each drug, to verify the recommended dose, method of administration, and precautions for use
• Each device, instrument, or piece of equipment to verify recommendations for use and/or operating
instructions

In addition, all forms, instructions, checklists, guidelines, and examples are intended as resources to be used and
adapted to meet national and local health care settings’ needs and requirements. Finally, neither the authors,
editors, nor the Jhpiego Corporation assume liability for any injury and/or damage to persons or property arising
from this publication.

Jhpiego is a nonprofit global leader in the creation and delivery of transformative health care solutions that save lives.

In partnership with national governments, health experts, and local communities, we build health providers’ skills,
and we develop systems that save lives now and guarantee healthier futures for women and their families. Our
aim is revolutionizing health care for the planet’s most disadvantaged people.

Jhpiego is a Johns Hopkins University affiliate.

Jhpiego Corporation
Brown’s Wharf
1615 Thames Street
Baltimore, MD 21231-3492, USA
www.jhpiego.org

© 2018 by Jhpiego Corporation. All rights reserved.

Editors: Melanie S. Curless, MPH, RN, CIC

Chandrakant S. Ruparelia, MD, MPH
Elizabeth Thompson, MHS
Polly A. Trexler, MS, CIC

Editorial assistance: Karen Kirk Design and layout: AJ Furay

Dana Lewison Young Kim
Joan Taylor Bekah Walsh

Module 4 Jhpiego technical reviewers: Martha Appiagyei, Ghana

May Htin Aung, Myanmar
Yodit Kidanemariam, Ethiopia
Farid Midhet, Pakistan
Module 4. Patient and Health Care Worker Safety
Chapter 1. Injection Safety ................................................................................................................... 3
Key Topics ................................................................................................................................................. 3
Key Terms .................................................................................................................................................. 3
Background ............................................................................................................................................... 4
Single-Use Vials ......................................................................................................................................... 5
Needles and Syringes ................................................................................................................................ 5
Unsafe Injection Practices: Transmission Pathways ................................................................................. 6
Safe Injection Practices ............................................................................................................................. 6
Summary ................................................................................................................................................. 12
References .............................................................................................................................................. 13
Chapter 2. Infection Prevention and Control Aspects of Occupational Health in Health Care Settings . 15
Key Topics ............................................................................................................................................... 15
Key Terms ................................................................................................................................................ 15
Background ............................................................................................................................................. 15
Occupational Health Activities for Preventing Infections among Health Care Workers ........................ 16
Major Occupational Health Activities ..................................................................................................... 17
Occupational Health Activities for Management of Job-Related Illnesses
and Occupational Exposures ................................................................................................................... 20
Occupational Health Activities for Specific Groups of Health Care Workers.......................................... 22
Monitoring Prevention of Occupational Exposures and Injuries ............................................................ 29
Summary ................................................................................................................................................. 31
Appendix 2-A. Risk and Work Restriction for Health Care Workers Exposed to or Infected
with Infectious Diseases of Importance in Health Care Settings ............................................................ 32
References .............................................................................................................................................. 46
Chapter 3. Sharps Injuries and Management of Exposure to Bloodborne Pathogens .......................... 49
Key Topics ............................................................................................................................................... 49
Key Terms ................................................................................................................................................ 49
Background ............................................................................................................................................. 50
Risk of Exposure to Bloodborne Pathogens ............................................................................................ 51
Strategies to Prevent Needle Sticks and Other Sharps Injuries .............................................................. 53
Management of Bloodborne Pathogen Exposures ................................................................................. 56
Summary ................................................................................................................................................. 60
Appendix 3-A. Engineering Controls for Preventing Sharps Injuries ...................................................... 61
Appendix 3-B. Neutral and Safe Zone Using Hands-Free Technique ...................................................... 64
Appendix 3-C. Operating Theater Sharps Safety Checklist ..................................................................... 65

Infection Prevention and Control: Module 4 1

 Appendix 3-D. Safe Assisting and Operating Checklist ........................................................................... 67
References .............................................................................................................................................. 68

2 Infection Prevention and Control: Module 4

 Injection Safety

Chapter 1. Injection Safety

Key Topics
 Risks to patients and health care workers (HCWs) from unsafe injection practices
 Transmission pathways from unsafe injection practices
 Safe injection practices

Key Terms
 Administrative controls, also known as “work practice controls,” are changes in work procedures
such as written policies, rules, protocols, supervision, schedules, and training, with the goal of
reducing the duration, frequency, and severity of exposure to hazardous situations and substances
(e.g., blood, body fluids, chemicals).
 Bloodborne pathogens are infectious microorganisms (bacteria, viruses, and other microorganisms)
contained in blood and other potentially infectious body fluids (including urine, respiratory
secretions, cerebrospinal, peritoneal, pleural, pericardial, and synovial amniotic fluids, semen,
vaginal secretions, breast milk, and saliva). The pathogens of primary concern are hepatitis B virus
(HBV), hepatitis C virus (HCV), and HIV.
 Health care worker (HCW), in this manual, is someone who works in a health care facility and
provides health care and services to people, either directly or indirectly as a clinician, nurse,
midwife, aide, helper, laboratory or x-ray technician, cleaner, or waste handler.
 Multi-dose vial is a vial of liquid medication intended for parenteral administration (injection or
infusion) that the manufacturer has prepared to contain more than one dose of a medication. Multi-
dose vials are labeled as such by the manufacturer and typically contain an antimicrobial
preservative to help prevent the growth of bacteria. The preservative has no effect on viruses and
does not protect against contamination when HCWs fail to follow safe injection practices.
 Post-exposure prophylaxis (PEP) is a preventive medical treatment for which a person may qualify
following potential exposure to a disease-causing pathogen, such as a HIV or HBV, to prevent
becoming infected.
 Safe injection is one that does not harm the recipient, does not expose the HCW to any avoidable
risks, and does not result in waste that is dangerous for the community.
 Sharps are instruments, needles, and any other objects that can easily penetrate through the skin.
 Sharps injuries are injuries from a “sharp” penetrating the skin. “Sharps” include syringe needles,
scalpels, broken glass, and other objects that may be contaminated with blood or body fluids. These
injuries potentially expose HCWs to infections from bloodborne pathogens.
 Sharps injury prevention strategies are measures taken to prevent injuries while handling sharps.
These measures include elimination of hazards and the use of engineering controls, administrative
controls, work space practices, and personal protective equipment.
 Single-use or single-dose vial is a vial of liquid medication intended for parenteral administration
(injection or infusion) that is meant for use in a single patient for a single case/procedure/injection.
Single-use or single-dose vials are labeled as such by the manufacturer and do not contain
antimicrobial preservative.

Infection Prevention and Control: Module 4, Chapter 1 3

Injection Safety

 Standard Precautions are a set of infection control practices used for every patient encounter to
reduce the risk of transmission of bloodborne and other pathogens from both recognized and
unrecognized sources. They are the basic level of infection control practices to be used, at a
minimum, in preventing the spread of infectious agents to all individuals in the health care facility.

Background
The goal of safe health care services is to protect HCWs, patients, and the community from harm,
including exposure to infection. Unsafe injection practices put patients at increased risk of infection and
other hazards. Additionally, inappropriate handling of syringes and needles puts HCWs, patients,
visitors, and the community at increased risk of exposure to bloodborne pathogens. Safe injection
practices, which are a component of Standard Precautions, include using a new, single-use disposable
syringe and needle for each patient, using single-use vials for only one patient, and managing multi-dose
vials correctly.

Risk to Patients
Unsafe injections can result in transmission of a wide variety of pathogens, including viruses, bacteria,
fungi, and parasites. The World Health Organization (WHO) estimates that in low- and middle-income
countries, 16 billion health care injections are administered each year, translating to approximately
three injections per person per year, many of which are unnecessary. Reuse of syringes or needles,
which is common in many settings, exposes patients to pathogens either directly (via contaminated
equipment) or indirectly (via contaminated medication vials). The risks of unsafe injection practices have
been well-documented for the three primary bloodborne pathogens: HIV, HBV, and HCV. Worldwide,
each year, the overuse of injections and unsafe injection practices combine to cause an estimated:
 8–16 million HBV infections
 2.3–4.7 million HCV infections
 80,000–160,000 HIV infections
(Hutin et al. 2003; Wilburn and Eijkemans 2007; WHO 2015)

Risk to Health Care Workers

Globally, in the course of their duties, HCWs are at an increased risk from bloodborne pathogens
because they handle sharps, including needles and syringes. It is estimated that 39% of HCV, 37% of
HBV, and 4.4% of HIV infection among HCWs worldwide are attributable to occupational exposure to
sharps injuries. (Prüss-Üstün et al. 2005)

Both patients and HCWs are at risk of bloodborne disease from unsafe injection practices. Eliminating
unnecessary injections and using safe injection practices are the best ways to protect patients and staff
from the risks.

Multi-Dose Vials
Multi-dose vials are vials of liquid medication intended for parenteral administration (injection or
infusion) that contain more than one dose of a medication. Multi-dose vials are labeled as such by the
manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria.
The preservative has no effect on viruses and does not protect against contamination when HCWs do
not follow safe injection practices. Thimerosal, a mercury-containing compound, has been used as a

4 Infection Prevention and Control: Module 4, Chapter 1

 Injection Safety

preservative in multi-dose vials including vaccines since 1930. It has antiseptic and antifungal properties.
Thimerosal does not have antiviral activity.

There are many documented incidences of contamination of injection vials due to improper practices in
settings with all levels of resources. In a study at a Brazilian teaching hospital, the overall microbial
contamination rate was 5.36%; the highest rate—14.28%—was found in vials used in the interventional
bronchoscopy unit. (Baniasadi et al. 2013)

In a study on isolation of HIV-1 from experimentally contaminated multi-dose local anesthetic vials, it
was observed that needles and syringes retained small volumes of fluid after use (mean, 25 microL; in
syringe alone, mean 16 microL), which could be transferred to multi-dose vials of local anesthetic. A 10-
mL vial of anesthetic solution contaminated with 8 microL of HIV-infected solution (equivalent to 1%
infected lymphocytes in vivo) contained active virus 1 hour later and, in some settings, HIV could be
isolated 4 hours after exposure. The authors demonstrated that multi-dose vials could be a potential
source of transmissible virus and cause inadvertent contamination with HIV. (Druce et al. 1995)

Single-Use Vials
Single-use vials are vials of liquid medication intended for parenteral administration (injection or
infusion) that are meant for use in a single patient for a single procedure or injection. They are labeled
as “single-use” or “single-dose” or “preservative-free” by the manufacturer and lack an antimicrobial
preservative. Using vials designed for single patient doses for more than one patient increases the risk of
infection. The risk for contamination of the vial is the same as described above for multi-dose vials, with
the added risk of the lack antimicrobial preservatives, which increases the vial’s chances of
contamination and becoming a source of infection. (See Table 1-1.)

Table 1-1. Recommendations for Medication Containers

Type of Container Recommendation Reason
Single-dose vial Preferred Low likelihood of contamination
Multi-dose vial Only if unavoidable High likelihood of contamination if
aseptic technique and/or injection
practices are poor
Ampoules Pop-open preferred Breaking a glass ampoule may
result in particulate matter
escaping into the vial, it may also
injure the HCW opening the
ampoule
Fluid or solution bags (100–1,000 Not recommended as s source for High likelihood of contamination
mL) for reconstitution drawing off small volumes for
routine injections (e.g., normal
saline flushes)

Source: WHO 2010.

Needles and Syringes

An adequate supply of single-use disposable syringes and needles for injections is needed at all health
care facilities. Reuse of needles or syringes has been established as a source of transmission of
bloodborne pathogens. Reusing even needles or syringes that have been reprocessed carries a risk since

Infection Prevention and Control: Module 4, Chapter 1 5

Injection Safety

they are difficult to clean and sterilize adequately (tiny lumens of the needles cannot be adequately
cleaned and syringes are prone to melt at high temperatures). Pathogens may remain after
reprocessing. It is no longer acceptable to reprocess needles and syringes for injection.

Needles, syringes, and single-use and multi-dose vials can become transmission routes for infection if
infection prevention and control (IPC) practices are not followed.

Unsafe Injection Practices: Transmission Pathways

Double dipping is the reuse of a syringe that has been used to inject medication into a patient to
withdraw medication from a multi-dose vial using a new needle and injecting another patient with the
medication. This results in contamination of the medication in the vial and the syringe.

Even if a new needle is attached, when this syringe is used on subsequent patients, patients can become
infected with bloodborne pathogens from contamination within the syringe. Even if a new needle and
new syringe are used for subsequent patients, they can become infected with bloodborne pathogens
from the contaminated liquid in the vial. Figure 1-1 shows the pathway of transmission of bloodborne
pathogens, in this case HCV, via unsafe injection practices.

Figure 1-1. Unsafe Injection Practices and Disease Transmission

Source: CDC 2008.

Safe Injection Practices

The reduction of accidental exposure to potentially infected blood and body fluids for patients and
HCWs requires 100% compliance with safe injection practices. A safe injection is one that does not harm
the recipient, does not expose the provider to any avoidable risks, and does not result in waste that is
dangerous for the community (WHO 2015). The components of safe injection practices include the
following:
 Adequate supply of single-use disposable injection devices (needles and syringes)
 Safe handling of vials containing medication (single-use and multi-dose vials)
 Safe preparation of parenteral medication
 Appropriate administration of injections
 Safe disposal of used needles and syringes

6 Infection Prevention and Control: Module 4, Chapter 1

 Injection Safety

Adequate Supply of Safe Injection Devices (Single-Use Disposable Needles and Syringes)
Re-processing of needles and/or syringes is no longer acceptable. This practice should be halted
immediately. Providing sufficient single-use disposable injection devices should be a priority and facility
resources should be prioritized accordingly.

Safe Handling of Vials Containing Medication (Single-Use and Multi-Dose Vials)

Practical guidance on use of safe injection devices
When using a sterile, single-use device (i.e., a syringe and hypodermic needle that are not separated or
manipulated unless necessary):
 Use a new device for every patient, including for Figure 1-2. ONE and ONLY Campaign
withdrawing medication. This practice is considered a very
basic IPC precaution and is promoted by WHO (Safe
Injection Global Network [SIGN]) and the US Centers for
Disease Control and Prevention (CDC), among others.
Figure 1-2 shows the “ONE and ONLY Campaign,” which
advocates for one needle, one syringe, and only one use.
 Inspect the packaging of the device to ensure that the
protective barrier has not been breached.
 Discard the device if the package has been punctured,
torn, or damaged by exposure to moisture, or if the expiry date has passed.
(WHO 2010)

Practical guidance on handling parenteral medication

 When giving medication:
 ALWAYS follow the one needle, one syringe, one injection rule.
 DO NOT use a single-loaded syringe to administer medication to several patients even if you
change the needle every time between patients. See Figure 1-1. Unsafe Injection Practices and
Disease Transmission in this chapter. (Always follow the one needle, one syringe, one injection
rule.)
 DO NOT use the same mixing syringe and needle to reconstitute several vials. See Figure 1-1,
Unsafe Injection Practices and Disease Transmission, in this chapter.
 DO NOT combine leftover medications for later use.
 DO NOT use single-use vials for multiple patients, if at all possible.
 When using single-use vials:
 Vials labeled by the manufacturer as “single-dose,” “single-use,” or “preservative-free” should
be used only for a single patient.
> There may be circumstances when the contents of single-use vials must be used for multiple
patients. In this situation, contents from an unopened single-use vial can be repackaged one
time into multiple single-use syringes for multiple patients. However, this should be
performed only by a trained HCW in an area away from patient care and in accordance with
strict IPC standards. Label as described below. Store for only 24 hours.
 Check that you have the right medication vial for the patient’s prescription.

Infection Prevention and Control: Module 4, Chapter 1 7

Injection Safety

 Double-check the expiration date and if the vial has previously been opened, the current date is
within 24 hours of opening (unless a shorter or longer time frame is otherwise specified by the
manufacturer).
 Follow the principle of one syringe, one needle, one time.
 Discard the single-use vial after use.
 Discard a single-use vial:
> If sterility or content is compromised
> If the expiry date or time has passed
> If found to be undated, improperly stored, inadvertently contaminated, perceived to be
contaminated, or already punctured, regardless of expiration date
 When using multi-dose vials:
 If a multi-dose vial is assigned to a single patient (e.g., insulin pen), check that you have the right
vial for the patient.
 Double-check the expiration date and if previously opened, check that the vial is labeled by the
manufacturer as a multi-dose vial and the current date is within 28 days of opening, unless a
shorter or longer time frame is otherwise specified by the manufacturer.
 Follow the principle of one syringe, one needle, one time.
 When withdrawing medication from a multi-dose vial, avoid double dipping, which may
contaminate the contents of the vial and transmit infection to subsequent patients. See the
Needles and Syringes section in this chapter.
 If newly opened, label the multi-dose vial. See the Labeling section in this chapter.
 DO NOT store multi-dose vials in patient care areas, where they could be inadvertently
contaminated.
 Discard a multi-dose vial:
 If sterility or content is compromised
 If the expiry date or time has passed (even if the vial contains antimicrobial preservatives)
 If it is not properly stored after opening, or within 28 days of opening, unless a shorter or longer
time frame is otherwise specified by the manufacturer, or follow the manufacturer’s
instructions for the time the vial can be used once opened
 If found to be undated, improperly stored, inadvertently contaminated, perceived to be
contaminated, or has a visible hole in the rubber septum, regardless of expiration date, if
thought to be a single-use rather than multi-dose vial

Safe Preparation of Parenteral Medication

Injections should be prepared in a designated clean area, away from patient care, where contamination
by blood and body fluids is unlikely.

8 Infection Prevention and Control: Module 4, Chapter 1

 Injection Safety

Practical guidance on setting up for preparing injections

Three steps must be followed when preparing injections
1. Keep the injection preparation area free of clutter so all surfaces can be easily cleaned.
2. Before starting the injection session, and whenever there is contamination with blood or body
fluids, clean the preparation surfaces with a surface antiseptic such as 0.5% sodium hypochlorite
solution, 70% alcohol (isopropyl alcohol or ethanol), or other suitable surface disinfectant and allow
the preparation to dry.
3. Perform hand hygiene and assemble all equipment needed for the injection: sterile, single-use
needles and syringes; reconstitution solution, such as sterile water or a specific diluent; alcohol
swab or cotton wool; and a sharps container.
(WHO 2010)

Procedure for vials with a rubber septum

Many vials have a rubber septum (stopper).
 Wipe the access rubber septum with 70% alcohol (isopropyl alcohol or ethanol) with a swab or
cotton-wool ball and allow it to dry before piercing the vial or inserting a device into the bottle.
 Use a new, single-use, disposable, sterile syringe and needle for each insertion into a vial.
 Never leave a needle in a multi-dose vial.
 Once the loaded syringe and needle have been withdrawn from a multi-dose vial, administer the
injection as soon as possible.

Reconstitution
 Always use a sterile syringe and a sterile needle to withdraw the reconstitution solution from an
ampoule or a vial, insert the needle into the rubber septum in the single- or multi-dose vial, and
inject the necessary amount of reconstitution fluid.
 Remove the needle and syringe and discard them immediately as a single unit into a sharps
container.
 Mix the contents of the vial thoroughly until all visible particles have dissolved.

Delay in administration
 If a dose has been withdrawn into a syringe and cannot be administered immediately for any
reason, cover the needle with the cap using a one-handed scoop technique. Do not keep the
medication longer than 24 hours unless a shorter or longer time frame is otherwise specified by the
manufacturer. Inject the medication as soon as possible after withdrawing from the vial. See the
section on labeling in this chapter.
(WHO 2010)

Labeling
After reconstitution of a vaccine or medication in a multi-dose vial (e.g., BCG vaccine), label the vial and
the final medication container with:
 Date and time of preparation

Infection Prevention and Control: Module 4, Chapter 1 9

Injection Safety

 Type and volume of diluent (if applicable)

 Final concentration
 Expiry date and time after reconstitution
 Name and signature of the person reconstituting the drug

For multi-dose medications that DO NOT require reconstitution (e.g., lignocaine), label the container
with:
 Date and time of first piercing of the vial
 Expiry date and time after reconstitution
 Name and signature of the person first piercing the vial

Procedure for Pop-Open Ampoules

 Whenever possible, use vials with a rubber septum. If not available, use pop-open ampoules rather
than ampoules that require use of a metal file to open. When opening glass ampoules, always
protect fingers with a clean barrier, such as a small gauze pad (see Figure 1.3).
 Pop-open vials cannot be stored for later use.
(Hutin et al. 2003)

Figure 1-3. Breaking Open an Ampoule

Source: Doyle and McCutcheon 2015.

Safe Administration of Injections

Aseptic techniques should be followed for all injections.

Practical guidance on administering injections

General
 When administering an injection:
 Ensure that the patient is adequately prepared for and informed about the procedure.
 Check the drug chart or prescription for the medication and the five “rights”: right patient, right
drug, right dose, right route, right time.
 Perform hand hygiene.

10 Infection Prevention and Control: Module 4, Chapter 1

 Injection Safety

 Wipe the top of the vial with 70% alcohol (isopropyl alcohol or ethanol) using a swab or cotton-
wool ball. Allow it to dry.
 Open the package in front of the patient to reassure the person that the syringe and needle
have not been used previously.
 Use a sterile syringe and needle to withdraw the medication from the ampoule or vial.

Important points
 DO NOT allow the needle to touch any contaminated surface.
 DO NOT reuse a syringe, even if the needle has been changed.
 DO NOT touch the rubber septum after disinfection with the 70% alcohol (isopropyl alcohol or
ethanol).
 DO NOT re-enter a multi-dose vial with the same needle used for mixing or reconstituting
medications.
 DO NOT re-enter a vial with a needle or syringe used on a patient if that vial will be used to
withdraw medication again (whether it is for the same patient or for another patient).
 DO NOT use bags or bottles of intravenous solution as a common source of supply for injections
(e.g., normal saline flushes) for multiple patients. These are not manufactured as multi-dose and do
not have any preservative (see Table 1-1).

Safe Disposal of Used Needles and Syringes

Use of best practices can help to prevent sharps injuries to HCWs.

Practical guidance on prevention of sharps injuries

 Do not bend, break, manipulate, or manually remove needles before disposal.
 Avoid recapping needles, but if a needle must be recapped, use a single-handed scoop technique
(see Figure 1-4).

Figure 1-4. Single-Handed Scoop Technique for Recapping Needles

1. Place the cap on a flat surface, then remove your hand from the
cap. With one hand, hold the syringe and use the needle to
scoop up the cap.

2. When the cap covers the needle completely, use your other
hand to secure the cap on the needle hub. Handle the cap at the
bottom, near the hub.

Source: Tietjen et al. 2003.

Infection Prevention and Control: Module 4, Chapter 1 11

Injection Safety

 Discard used sharps and glass ampoules into a leak- and puncture-resistant sharps container
immediately after use in the location where they were used.
 Place the sharps container within arm’s reach to allow for easy disposal of sharps.
 Seal and replace the sharps container when it is three-quarters full. Be sure that no sharp items are
sticking out of the container.

Practical guidance on sharps disposal

Used syringes and needles should be disposed of following recommended guidelines. (See Module 5,
Chapter 5, Waste Management in Health Care Facilities.) If used syringes and needles are not properly
disposed of, they can injure patients, HCWs, or members of the community.

To ensure that sharps are dealt with safely:

 Place needles and syringes into containers specifically designed for sharps disposal. The four main
criteria for secure and safe sharps disposal containers are: functionality, accessibility, visibility, and
accommodation (i.e., easy to store and assemble, minimal training required, easy to operate,
flexible in design). (CDC 2010)
 After closing and sealing sharps containers (when three-quarters full), never open, empty, or reuse
them.

Summary
Injections present risks to patients, HCWs, and the community and should be limited where alternative
administration routes are available. Safe injection practices are one of the components of Standard
Precautions. A safe injection is one that does not harm the recipient, does not expose the HCW to any
avoidable risks, and does not result in waste that is dangerous for the community (Rapiti et al.
2005). Safe injection practices include the proper use of single-use and multi-dose vials. It is the
responsibility of each HCW to ensure safe injection practices for every patient.

12 Infection Prevention and Control: Module 4, Chapter 1

 Injection Safety

References
Baniasadi S, et al. 2013. Microbial contamination of single-and multiple-dose vials after opening in a
pulmonary teaching hospital. Braz J of Infect Dis. 17(1):69–73.
Centers for Disease Control and Prevention (CDC). 2008. Acute hepatitis C virus infections attributed to
unsafe injection practices at an endoscopy clinic—Nevada, 2007. MMWR. 57:513–517.
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5719a2.htm.
CDC. 2010. Stop Sticks Campaign. https://www.cdc.gov/niosh/stopsticks/sharpsdisposal.html.
CDC. 2015. Injection Safety: The One & Only Campaign.
http://www.cdc.gov/injectionsafety/1anOnly.html.
CDC. n.d. Injection Safety: What Every Healthcare Provider Needs to Know.
https://www.cdc.gov/winnablebattles/HealthcareAssociatedInfections/pdf/One_and_Only_Campaign_P
roviderBrochure.pdf.
DeGirolamo KM, Courtemanche DJ, Hill WD, Kennedy A, Skarsgard ED. 2013. Use of safety scalpels and
other safety practices to reduce sharps injury in the operating room: what is the evidence? Can J Surg.
56(4):263–269.
Doyle GR, McCutcheon JA. 2015. Clinical Procedures for Safer Patient Care. Vancouver, Canada: British
Columbia Institute of Technology. https://opentextbc.ca/clinicalskills/chapter/safe-injection-
administration-and-preparing-medication-from-ampules-and-vials/.
Druce JD, et al. 1995. Isolation of HIV-1 from experimentally contaminated multi-dose local anesthetic
vials. Med J Aust. 162(10):513–515.
Hanafi MI, et al. 2011. Needle stick injuries among healthcare workers of University of Alexandria
hospitals. East Mediterr Health J. 17(1).
Health Protection Agency. 2005. Eye of the Needle: Surveillance of Significant Occupational Exposure to
Blood-borne Viruses in Healthcare Personnel. London, England: Health Protection Agency.
Hutin YJ, Hauri AM, Armstrong GL. 2003. Use of injections in healthcare settings worldwide, 2000:
literature review and regional estimates. BMJ. 327(7423):1075.
http://www.bmj.com/content/327/7423/1075.long.
http://www.who.int/bulletin/volumes/81/7/en/Hutin0703.pdf.
Motamedifar M, et al. 2009. The prevalence of multi-dose vial contamination by aerobic bacteria in
major teaching hospital, Shiraz, Iran 2006. Am J Infect Control. 37(9):773–777.
Perry J, Jagger J. 2003. EPINet data report: injuries from phlebotomy needles. Adv Expos Prev. 6(4):43–
45.
Prüss-Üstün A, Rapiti E, Hutin Y. 2005. Estimation of the global burden of disease attributable to
contaminated sharps injuries among health-care workers. Am J Ind Med. 48(6):482–490.
http://www.who.int/quantifying_ehimpacts/global/7sharps.pdf.
Rapiti E, Prüss-Üstün A, Hutin Y. 2005. Sharps Injuries: Assessing the Burden of Disease from Sharps
Injuries to Health-Care Workers at National and Local Levels. WHO Environmental Burden of Disease
Series, No. 11. Geneva, Switzerland: WHO.
http://www.who.int/quantifying_ehimpacts/publications/ebd11.pdf?ua=1.
Tietjen L, Bossemeyer D, McIntosh N. 2003. Infection Prevention: Guidelines for Healthcare Facilities
with Limited Resources. Baltimore, MD: Jhpiego.

Infection Prevention and Control: Module 4, Chapter 1 13

Injection Safety

Wilburn S, Eijkemans G. 2007. Protecting health workers from occupational exposure to HIV, hepatitis,
and other bloodborne pathogens: from research to practice. Asian-Pac Newsl Occup Health Safety.
13:8–12.
World Health Organization (WHO). 2005. Sharps Injuries: Assessing the Burden of Disease from Sharps
Injuries to Health-Care Workers at National and Local Levels. Environmental Burden of Disease Series,
No. 11. Geneva, Switzerland: WHO.
http://www.who.int/quantifying_ehimpacts/publications/ebd11.pdf?ua=1.
WHO. 2006. Protecting Healthcare Workers: Preventing Needlestick Injuries Toolkit. Geneva,
Switzerland: WHO. http://www.who.int/occupational_health/activities/pnitoolkit/en/.
WHO. 2010. WHO Best Practices for Injections and Related Procedures Toolkit. Geneva, Switzerland:
WHO. http://apps.who.int/iris/bitstream/10665/44298/1/9789241599252_eng.pdf.
WHO. 2014. Guidelines on Post-Exposure Prophylaxis for HIV and the Use of Co-Trimoxazole Prophylaxis
for HIV-Related Infections among Adults, Adolescents and Children Recommendations for a Public Health
Approach. December 2014 Supplement to the 2013 Consolidated Guidelines on the Use of Antiretroviral
Drugs for Treating and Preventing HIV Infection. Geneva, Switzerland: WHO.
http://apps.who.int/iris/bitstream/10665/145719/1/9789241508193_eng.pdf?ua=1&ua=1.
WHO. 2015. Aide-Memoire for a National Strategy for the Safe and Appropriate Use of Injections.
Geneva, Switzerland: WHO. http://www.who.int/infection-prevention/tools/injections/AideMemoire-
injection-safety.pdf.
WHO. 2016. Injection Safety; Questions and Answers. http://www.who.int/infection-
prevention/publications/is_questions-answers.pdf?ua=1.
WHO. 2017. Injection Safety Tools and Resources. Geneva, Switzerland: WHO. http://who.int/infection-
prevention/tools/injections/communications/en/.

14 Infection Prevention and Control: Module 4, Chapter 1

 Occupational Health

Chapter 2. Infection Prevention and Control Aspects of

Occupational Health in Health Care Settings
Key Topics
 Health care workers’ (HCWs’) occupational risks of infection
 Occupational health activities for the prevention and management of infections in HCWs
 Occupational health activities for specific groups of HCWs
 Monitoring of occupational health activities
 Risks and work restrictions for HCWs exposed to or infected with infectious diseases

Key Terms
 Health care worker (HCW), in this manual, is someone who works in a health care facility and
provides health care and services to people, either directly or indirectly as a clinician, nurse,
midwife, aide, helper, laboratory or x-ray technician, cleaner, or waste handler.
 Occupational exposure is an exposure of an HCW to an infection while providing care and treatment
services to patients in a health care facility.
 Occupational health is the discipline that deals with all aspects of work-related health and safety
and has a strong focus on prevention; it is known also as employee health.
 Occupational health activities include all aspects of work-related health and safety activities,
including prevention. In this chapter, the term refers in particular to activities that address infectious
hazards at health care facilities.
 Occupational health surveillance is the collection, analysis, and dissemination of data on hazards
that have endangered or may endanger HCWs.
 Occupational infection is an infection contracted as a result of an exposure to risk factors arising
from work activity.
 Sharps injuries are injuries from a “sharp” penetrating the skin. “Sharps” include syringe needles,
scalpels, broken glass, and other objects that may be contaminated with blood or body fluids. These
injuries potentially expose HCWs to infections from bloodborne pathogens.
 Vaccine-preventable diseases are infectious diseases for which effective vaccines are available.
They include but are not limited to hepatitis A and B, influenza, measles, mumps, rubella, tetanus,
diphtheria, pertussis, and varicella (chicken pox).

Background
Health care facilities around the world employ over 59 million workers who are routinely exposed to a
variety of health and safety risks (WHO 2016a). These risks include exposure to infectious agents such as
bloodborne pathogens, tuberculosis (TB), viral respiratory infections, vaccine-preventable diseases,
bacterial infections, and gastrointestinal infections, among others. If an infection is contracted as a
result of an exposure to risk factors arising from work activity, it is known as an occupational infection.
In general, HCWs who have contact with patients, body fluids, or specimens have a higher risk of

Infection Prevention and Control: Module 4, Chapter 2 15

Occupational Health

acquiring or transmitting infections than those who have casual contact with patients and the health
care environment.

Occupational exposures to sharps injuries are an example of the substantial impact of occupational
infections among HCWs. It is estimated that 39% of hepatitis C virus (HCV), 37% of hepatitis B virus
(HBV), and 4.4% of HIV infections among HCWs worldwide are attributable to occupational exposure
due to sharps injuries. This amounts to an estimate of 16,000 HCV, 66,000 HBV, and 1,000 HIV
occupational infections annually (Prüss-Üstün et al. 2005). It is thought that more than 90% of these are
in limited-resource countries. (IFIC 2003)

It is notable that infection with HBV is 95% preventable with immunization, and the HBV vaccine has
contributed to a significant reduction of HBV in HCWs. However, less than 20% of HCWs in some regions
of the world have received all three doses of vaccine needed for immunity from HBV infection. (APIC
2014a; IFIC 2003)

In general, occupational health deals with all aspects of work-related health and safety and has a strong
focus on prevention, especially for infectious (such as disease exposures) and non-infectious risks (such
as injury). The goals of infection prevention and control (IPC) intersect with those of occupational health
in preventing and addressing infectious hazards at health care facilities. Therefore, a large portion of
occupational health activities at a health care facility are also IPC activities. (APIC 2014a)

Although the actual risk of infectious exposure for HCWs depends somewhat upon the job description
and the setting, attention to IPC helps protect staff and patients in all settings. Emerging infectious
disease outbreaks, such as severe acute respiratory syndrome (SARS) in 2003, Middle Eastern
respiratory syndrome coronavirus (MERS-CoV) in 2012, and Ebola Virus Disease (EVD) in 2014, have
highlighted the importance of IPC in protecting HCWs, as transmission of these viruses to HCWs
occurred when they cared for infected patients. These outbreaks have demonstrated that strategies to
protect HCWs from exposure to infectious risks in the workplace are critically important and that
facilities must have the infrastructure in place to be able to adapt to changes in emerging infectious
threats. Health care facilities need staff knowledgeable in IPC to conduct and support sound
occupational health activities to minimize the risk of occupational infection in HCWs and provide a safe
environment for patients and staff. (APIC 2014a; WHO 2016a; WHO 2016c)

Occupational Health Activities for Preventing Infections among Health Care

Workers
The goal of occupational health activities is to protect HCWs—and thereby their patients—from
acquiring an infection while working in a health care facility. This goal is achieved by:
 Identifying work-related infection risks and preventing them
 Ensuring prompt and appropriate management of any occupational exposures to infections
 Training all HCWs on IPC practices and how to protect themselves against the risks of occupational
exposures to infections
 Monitoring and investigating potentially harmful exposures and outbreaks among HCWs
 Preventing infections by carrying out occupational health activities
(APIC 2014a; CDC 1998; WHO 2016c)

16 Infection Prevention and Control: Module 4, Chapter 2

 Occupational Health

Protection from acquiring infections through occupational exposure is critical to maintaining and
retaining an adequate workforce of trained and healthy HCWs. Protecting HCWs also helps to contain
costs associated with absenteeism, illness, and attrition as a result of incapacity, death, and fear. In
addition, occupational health activities protect patients through prevention, early identification, and
control of infections among staff. Therefore, protecting HCWs is integral to maintaining a safe
environment for both patients and staff.

Aspects of occupational health should be included in any IPC program; the World Health Organization’s
(WHO’s) (2016c) Core Components of IPC emphasize the importance of collaboration between
occupational health/employee safety activities and the IPC program (CDC 1998; WHO 2016a; WHO
2016c).

It is ideal to have an occupational health department and program in a larger health care facility,
depending on the size of the facility and available staffing. In smaller health care facilities, the IPC team
or other appropriate staff may carry out occupational health activities. All occupational health programs
should be coordinated and overseen by a trained health care professional or team who hold the
responsibility for ensuring that all of the program activities, including IPC aspects are conducted.

A responsible person from various departments, which could include human resources, IPC, outpatient
clinics, administration, and the laboratory, should work in a coordinated manner to implement
occupational health activities such as efficient and prompt screening, immunization, and follow-up of
exposures and outbreaks among HCWs.

Major Occupational Health Activities

The priorities of occupational health activities at any facility will vary depending on factors such as the
type of facility, organizational structure and services provided, geographical location, characteristics of
the patients and HCWs, and diseases that are endemic in the community (APIC 2014a). This section
provides a practical description of the implementation and integration of occupational health activities.

Activities that should be implemented by staff responsible for occupational health can be divided into
the following categories:
 For newly employed HCWs (see Table 2-1)
 For all HCWs on an ongoing basis (see Table 2-2)
 Facility-wide activities (see Table 2-3)

Infection Prevention and Control: Module 4, Chapter 2 17

Occupational Health

Table 2-1. Occupational Health Activities for Newly Employed HCWs

Activity Key Occupational Health Activities: Newly Employed HCWs
Pre-employment • Though not recommended in many settings, a baseline medical history and physical
evaluation examination, if done, can serve as a screening tool and establish a baseline to determine
if any future diseases are work-related.
• Review history of vaccination for hepatitis B in particular and other vaccinations
recommended as per the national guidelines for vaccination of HCWs.
• Assess for immunity: In low-resource settings, documentation of routine immunization
might be the only source to verify immunity if the records are available. Follow the
national vaccination schedule for HCWs when vaccination status is not known. In some
settings blood titers to determine current immunity to vaccine preventable diseases
may be available.
• Assess for presence of chronic and acute infections, including screening for TB.
Education/ • Tailor training to the needs of specific job functions.
training on IPC
• Conduct IPC training for newly employed HCWs following the national training
curriculum. At a minimum, all new employee should receive training in:
− Standard Precautions and Transmission-Based Precautions
− Management of occupational exposure to bloodborne pathogens
• Include topics such as risk and prevention of occupational infections, risk of infection
after exposures, and management of exposures, including availability and effectiveness
of post-exposure prophylaxis (PEP) and potential consequences to family members of
exposed HCWs. Also include updates on occupational health and pregnant HCWs.
Counseling for • Counsel for:
occupational − The risk and prevention of occupational infection
exposure to
− Risk of various infections following exposure
infections
− Management of exposures, including testing and PEP (where indicated)
− Risks and benefits of PEP
− Long-term consequences of infections
− Potential risks for family members, colleagues, and other patients
− The need to be away from the job
• Female HCWs of childbearing age and those who are pregnant should be counseled
on the risks of infections and provided with information on appropriate
Transmission-Based Precautions needed for infections of concern during pregnancy.
• Answer any other questions that the HCW might have.

18 Infection Prevention and Control: Module 4, Chapter 2

 Occupational Health

Table 2-2. Occupational Health Activities for all HCWs

Activity Key Occupational Health Activities: All HCWs
Monitoring • Screen for TB using the WHO TB screening tool.
employee health
status • Ensure that the vaccination status of all HCWs is up to date.
• Update employee health records.
• Perform routine monitoring of HCWs with HBV, HCV, and HIV infection with the
goal of assisting infected HCWs to continue to provide safe health care to patients.
Education/training • Organize periodic refresher training for all HCWs in key IPC practices.
on IPC
• Provide updates on guidelines for monitoring and managing occupational
exposures to bloodborne pathogens and other infections.
Determining work • Make decisions about work restrictions (the need to be away from the job) for ill
restrictions for
HCWs (see Appendix 2-A for disease-specific work restrictions).
employee illness
and exposure

Post-exposure • Follow up immediately those HCWs with job-related exposures and make decisions
follow-up
about work restrictions and post-exposure care (see Appendix 2-A for disease-
specific work restrictions). See the Occupational Health Activities for Management
of Job-Related Illnesses and Occupational Exposures section in this chapter.
Vaccination • Organize vaccination sessions for those staff who need to complete vaccinations
according to national/facility recommendations.

Table 2-3. Facility-Wide Activities

Activity Key Occupational Health Activities: Facility-Wide
Exposure reporting • Conduct a regular review of occupational exposure reporting in the facility.
• Ensure that round-the-clock services are available for post-exposure management
as recommended in Chapter 3, Sharps Injuries and Management of Exposure to
Bloodborne Pathogens, in this module.
• Prepare and transmit documentation of occupational exposures to the authorities
as needed.
Occupational health • Evaluate effectiveness of occupational health activities for preventing occupational
program review exposure to bloodborne pathogens and other risks.
• Make changes in the selection and implementation of occupational health program
activities as needed.

National guidelines, if available, should be followed to vaccinate HCWs against vaccine-preventable

diseases. WHO has provided information on immunization for the general population and HCWs (see
Table 2-4) to help countries develop national policies for vaccination of HCWs.

Infection Prevention and Control: Module 4, Chapter 2 19

Occupational Health

Table 2-4. WHO-Recommended Immunizations for HCWs

Vaccine Recommendations
Hepatitis B • Routine childhood immunization. No booster needed.
• Incompletely vaccinated HCWs should receive additional doses to complete the vaccine
series. The vaccine series does not need to be restarted; however, minimum dosing
intervals should be followed: 4 weeks between the first and second dose, 8 weeks
between the second and third dose, and 16 weeks between the first and third dose.
(CDC 2013)
• Hepatitis B vaccine is affordable and available in many settings and is an appropriate
place to begin when starting a staff immunization program. (CDC 1998)
Polio Routine childhood immunization.
All HCWs should have completed a full course of primary vaccination against polio.
Diphtheria Routine childhood immunization.
Booster for HCWs every 10 years.
Measles Routine childhood immunization.
If required by the national policy, all HCWs should produce proof of immunity or
documentation of immunization at the time of employment.
Rubella If rubella vaccine has been introduced into the national program, all HCWs should be
immunized for rubella and produce proof of immunity or documentation of immunization
at the time of employment.
Meningococcal One booster dose 3–5 years after the primary dose may be given to persons considered to
be at continued risk of exposure, including HCWs.
Influenza Influenza virus changes regularly so annual immunization with a single dose is
recommended if the vaccine is available for HCWs under the national immunization
program.
Varicella Countries should consider vaccination of potentially susceptible HCWs (i.e., unvaccinated
(Chicken pox) and with no history of varicella) with two doses of varicella vaccine.

Immunizations with NO Current WHO Recommendation for HCWs

There are no specific recommendations for vaccination specifically for HCWs for TB, pertussis, tetanus, mumps,
hepatitis A (HAV), typhoid, or cholera. These vaccines should be offered as a part of routine vaccination
programs and as overall strategies for preventing outbreaks (typhoid and cholera).

Adapted from: World Health Organization. WHO Recommendations for Routine Immunization-Summary Tables.
Table 4, Summary of WHO Position Papers-Immunization of Health Care Workers. Updated 2015. © World Health
Organization.

Occupational Health Activities for Management of Job-Related Illnesses and

Occupational Exposures
The occupational health team should respond to all potential and confirmed exposures to bloodborne
pathogens and other infectious diseases immediately and collaborate with IPC staff for follow-up as
necessary. Health care facilities should have systems in place for HCWs to report sharps injuries and
bloodborne pathogen exposures with prompt evaluation and follow-up (see Table 2-5). See Chapter 3,
Sharps Injuries and Management of Exposure to Bloodborne Pathogens, in this module.

20 Infection Prevention and Control: Module 4, Chapter 2

 Occupational Health

Table 2-5. Occupational Health Activities for Management of Job-Related Illnesses and Exposures
Activity Key Occupational Health Activities: Job-Related Illnesses and Exposures
Infectious • Identify infections in HCWs (whether community-acquired or job-related).
disease in HCWs
• Make decisions about the length and type of work restrictions (related to patient care or
food handling) and assignment to other duties (see Appendix 2-A).
• Report to public health authorities if it is a notifiable disease of public health interest.
Sentinel • Suspect a job-related infection in an HCW with an infectious disease known to spread in
infections in health care facilities. Certain occupational infections may be the result of caring for
HCWs patients with an unidentified infection (such as meningococcal meningitis or novel
influenza) or may indicate IPC lapses at the facility. (See Appendix 2-A for disease-
specific risk of transmission to and from HCWs.)
• Ensure infections are managed following clinical guidelines and make decisions about
the length and type of work restrictions (as above).
• Take necessary measures to prevent further spread of the infection through
investigation of possible routes of transmission in the facility and correct any lapses in
IPC.
• Identify and facilitate clinical management and work restrictions of those exposed.
• Monitor closely for additional cases (indicating a hospital or community outbreak).
Post-exposure • Determine what is considered an exposure (exposure definition).
follow-up
• Obtain a list of those who have been exposed.
• Counsel those exposed.
• Offer PEP promptly when appropriate and available.
• Determine any work restrictions.
• Conduct medical surveillance for development of disease.
• Determine when the HCW can return to work.
• Maintain adequate and confidential documentation on the event.
• Coordinate all of the above and any other activities such as ongoing monitoring or
follow-up lab testing.
(See Chapter 3, Sharps Injuries and Management of Exposure to Bloodborne Pathogens,
in this module for more information on post-exposure management for HBV, HCV, and
HIV and Appendix 2-A for disease-specific guidance for management of exposed HCWs.)

Summary of Key Elements of Occupational Health Activities

The following are the key elements for occupational health programs in health care facilities:
 Oversight by a qualified health care professional or team
 Coordination among multiple hospital departments
 Medical evaluation at the start of employment
 Health and safety education and training of all staff
 Immunization programs
 Management of work restrictions and post-exposure treatment for occupational illnesses and
exposures

Infection Prevention and Control: Module 4, Chapter 2 21

Occupational Health

 Counseling on protection from and management of accidental exposure to bloodborne and other
infectious pathogens
 Maintenance of personnel health records
(APIC 2014a; CDC 1998; WHO 2002)

Prevention Strategies for Infections Relevant to Occupational Health in Health Care Facilities
 Prevent occupational exposure of HCWs by the application of Standard Precautions for all patients,
at all times, as well as disease- or syndrome-specific Transmission-Based Precautions, to prevent
exposures to infectious agents. (See Module 1, Chapter 2, Standard and Transmission-Based
Precautions.)
 Protect against vaccine-preventable diseases: Having a mandatory program that requires all HCWs
to receive vaccines to protect themselves against vaccine-preventable diseases has been found to
be more effective than a voluntary program in ensuring that all susceptible staff are vaccinated. In
settings with limited resources, priority should be given to staff who are at high risk of exposure and
those without any existing immunity. Select the vaccines that may provide the most protective
effects, such as hepatitis B or influenza.
 Manage occupational exposures following the national guidelines (e.g., national guidelines for
management of occupational exposure to blood and body fluids) (Refer to Chapter 3, Sharps Injuries
and Management of Exposure to Bloodborne Pathogens, in this module for post-exposure
management of HBV, HCV, and HIV and Appendix 2-A for disease-specific guidance for management
of exposed HCWs.)
 Keep up to date by seeking additional information on specific diseases and local epidemiology:
Details on specific, key infections relevant to limited-resource settings can be found in Appendix 2-A.

Occupational Health Activities for Specific Groups of Health Care Workers

Certain groups of workers at a health care facility may require special attention related to occupational
health activities. They include pregnant staff, laboratory staff, emergency response staff, and HCWs
infected with HIV, HBV, or HCV.

Pregnant Health Care Workers

 Pregnancy does not increase the risk of acquisition of infection for most occupationally acquired
infections, and clinical manifestations are no more severe in pregnant women than in others (APIC
2014b). However, pregnant HCWs may be anxious about potential infection and possible harm to
their babies. The staff supporting occupational health activities should address any questions that
pregnant HCWs may have about occupational exposures, how to avoid them, and the management
of exposures, as well as any implications for the baby. Full compliance with Standard Precautions,
such as hand hygiene and appropriate personal protective equipment (PPE), as well as adherence to
Transmission-Based Precautions, should be adequate for pregnant HCWs in preventing most
infectious diseases (see Table 2-6). (APIC 2014b) (See Module 1, Chapter 2, Standard and
Transmission-Based Precautions.)

22 Infection Prevention and Control: Module 4, Chapter 2

 Occupational Health

Table 2-6. Infectious Agents of Concern for Pregnant HCWs According to the Risk of Transmission Associated
with Providing Health Care Services and Available Preventive Measures

Health Care- Health Care-Associated

Health Care-
Associated Infections for Which Health Care-Associated
Associated
Acquisition Possible Standard and Transmission- Infections for Which
Acquisition Is
and Prevented by Based Precautions Are the PEP Is Effective
Unlikely
Vaccine Only Preventive Measures
Anthrax, hepatitis A Herpes simplex Cytomegalovirus (CMV), viral HIV, N. meningitis, syphilis
virus (HAV), HBV, virus, toxoplasmosis hemorrhagic fever, HCV,
influenza, Neisseria parvovirus B19, TB
meningitis, pertussis,
rubella, measles,
varicella, tetanus,
diphtheria

Source: APIC 2014b.

However, as in the case of non-pregnant HCWs, non-immune pregnant HCWs should not care for
patients with measles, rubella, and varicella (APIC 2014b). Table 2-7 provides information on
occupational exposure to infection among pregnant HCWs, risks to their babies, and prevention
strategies. The information provided in the table will guide the occupational health team members in
making appropriate decisions. Table 2-7 describes additional pertinent facts to assist with management
of relevant occupational exposures in pregnant HCWs.

In settings where adequate infection control precautions (including PPE) are available and
immunizations for vaccine-preventable diseases are maintained, there are few instances in which
pregnant HCWs cannot provide the same care as their non-pregnant colleagues; they should not
routinely be restricted from duties on the basis of pregnancy status. However, pregnant HCWs should
not care for patients with parvovirus B16 and certain vaccine-preventable diseases if they are non-
immune. At times of PPE and vaccine shortage, assign pregnant HCWs to other tasks with no risk for
exposure to infectious agents. (APIC 2014b; CDC 2013)

Infection Prevention and Control: Module 4, Chapter 2 23

Occupational Health

Table 2-7. Management of Occupational Exposure to Common Infections for Pregnant Staff Members

Potential Effect on the Rate of Perinatal

Agent In-Hospital Source Maternal Screening Prevention
Fetus Transmission
Cytomegalo- Urine, blood, semen, Classic cytomegalic inclusion Primary infection Routine screening not Efficacy of CMV immune globulin not
virus vaginal secretion, disease (25–50%) recommended; established.
(CMV) immunosuppressed (5–10%)* Recurrent infants antibody is incompletely No vaccine available
transplant, dialysis, day Hearing loss (52%) protective Standard Precautions
care (10–15%) Symptomatic
(< 5–15%)
Hepatitis A Feces (most common), No fetal transmission None Routine screening not Vaccine is a killed viral vaccine and can
virus blood (rare) described; transmission can recommended safely be used in pregnancy. Contact
(HAV) occur at the time of delivery Precautions during acute phase.
if the mother is still in the The safety of HAV vaccination during
infectious phase and can pregnancy has not been determined;
cause hepatitis however, because the vaccine is produced
from inactivated HAV, the theoretical risk
to the developing fetus is expected to be
low. The risk associated with vaccination,
however, should be weighed against the
risk for HAV in women who might be at
high risk of exposure to HAV.
Hepatitis B Blood, body fluids, Hepatitis, early onset HbsAg + 10% Routine HBsAg testing HBV vaccine during pregnancy
virus vaginal secretions, hepatocellular carcinoma HbeAg + 90% advised Neonate: HBIG plus vaccine at birth
(HBV) semen Standard Precautions
Hepatitis C Blood, sexual Hepatitis 5% (0–25%) Routine screening not No vaccine or immunoglobulin available;
virus recommended post-exposure treatment with antiviral
(HCV) agents being investigated.
Standard Precautions
Herpes simplex Vesicular fluid, Sepsis, encephalitis, Primary genital Antibody testing Chemoprophylaxis at 36 weeks decreases
virus oropharyngeal, and meningitis, mucocutaneous (33–50%) minimally useful, genital shedding.
vaginal secretions lesions, congenital Recurrent genital inspection for lesions if Standard Precautions
malformation (rare) (1–2%) in labor

24 Infection Prevention and Control: Module 4, Chapter 2

 Occupational Health

Potential Effect on the Rate of Perinatal

Agent In-Hospital Source Maternal Screening Prevention
Fetus Transmission

HIV Blood, body fluids No congenital syndrome; if Depends on HIV viral Routine maternal Antiretroviral chemoprophylxis available
fetus infected, AIDS in 2–4 titer and use of ART screening advised for exposures, postnatal/breastfeeding
years If titer < 1,000 virus; If exposed, testing at 3, chemoprophylaxis for HIV+ mothers and
rate 2% 6, and 12 months their infants.
If titer ≥ 10,000; rate Standard Precautions
up to 25%
Influenza Sneezing and coughing, No congenital syndrome: Rare None Non-live vaccine (such as trivalent
respiratory tract influenza in mother could inactivated) for all pregnant HCW during
secretions cause hypoxia in fetus influenza season.
Droplet Precautions
Measles Respiratory secretion, Prematurity, spontaneous Rare Antibody test Vaccine contraindicated during pregnancy.
(rubeola) coughing abortion, no congenital Vaccination recommended prior to
syndrome conception.
Airborne Precautions
Neisseria Respiratory secretion Sepsis Unknown None Chemoprophylaxis with ceftriaxone or
meningitidis of untreated patients No congenital syndrome azithromycin
or those patients who Vaccine if indicated for outbreak control
have received Droplet Precautions, based on syndrome
antimicrobials for and for confirmed cases.
< 24 hours Standard Precautions, especially mask, face
protection for all intubations
Rubella Respiratory secretions Congenital syndrome 90% in first trimester Routine rubella IgG Vaccine contraindicated during pregnancy.
40–50% overall testing in pregnancy Vaccine prior to conception
Preconception screening No congenital rubella syndrome described
recommended for vaccine
Droplet Precautions; Contact Precautions
for contact with congenital rubella
patients.
Syphilis Blood, lesion, fluid, Congenital syndrome Variable 10–90%, VDRL RPR Post-exposure prophylaxis with penicillin
amniotic fluid depends on stage of FTA-ABS Standard Precautions, gloves until 24 hours
maternal disease and of effective therapy completed for infants
trimester of the with congenital syphilis and all patients
infection with skin and mucous membrane lesions

Infection Prevention and Control: Module 4, Chapter 2 25

Occupational Health

Potential Effect on the Rate of Perinatal

Agent In-Hospital Source Maternal Screening Prevention
Fetus Transmission

Tuberculosis Sputum, skin lesions Neonatal TB; liver most Rare TB skin test Post-exposure prevention
(TB) frequently infected Interferon recommendations vary with tuberculin skin
gamma-release assay test reaction size and chest radiograph
(IGRA) blood test; if result.
available. Chest Airborne Precautions
radiograph
Varicella-zoster Droplet or airborne Malformations (skin, limb, Total 25%: congenital Antibody Vaccine contraindicated during pregnancy.
spread of vesicle fluid central nervous system, eye); syndrome Vaccine prior to conception
or secretions of the chicken pox (0–4%) Varicella-zoster immune globulin within 96
respiratory tract (scabs hours’ exposure if susceptible
are not infective) Airborne and Contact Precautions
*Congenital syndrome: varying combinations of jaundice, hepatosplenomegaly, microcephaly, thrombocytopenia, anemia, retinopathy, and skin and bone lesions.
FTA-ABS = fluorescent treponemal absorption test; HbsAg = hepatitis B surface antigen; HbeAg = hepatitis B e-antigen; HBIG = hepatitis B immune globulin; IgG =
immunoglobulin G; RPR = rapid plasma reagin test; VDRL = Venereal Disease Research Laboratory test

Adapted from : APIC 2014b

26 Infection Prevention and Control: Module 4, Chapter 2

Occupational Health

Laboratory Staff
HCWs in laboratories may be at increased risk of occupational exposure to the pathogens with which
they work. Laboratory staff should receive specific training on the risks and how to avoid them (such as
working under a biocontainment hood, using a closed centrifuge, avoiding mouth pipetting) and have
access to PPE, as required, according to the procedures they perform and the pathogens with which
they have contact. (Module 8, Chapter 1, Clinical Laboratory Biosafety, provides details on preventing
infection among laboratory staff.) In addition to the vaccines routinely recommended for all HCWs,
further vaccinations may be appropriate for HCWs working in a clinical or research laboratory (CDC
1998). National recommendations should be consulted and followed if available.

The following vaccines may be relevant for staff working with specific pathogens:
 BCG (Mycobacterium tuberculosis)
 Hepatitis A
 Meningococcal (N. meningitidis)
 Polio
 Rabies
 Typhoid
(CDC 1998)

Emergency Response Staff

HCWs who respond to emergencies and transport patients should not be overlooked during
occupational health activities. These HCWs are at a high risk of exposure to bloodborne pathogens and
should have access to HBV vaccination, have adequate PPE and thorough instruction on proper PPE use,
and be taught to apply Standard Precautions for all patients at all times. Furthermore, they may
transport patients before the infection status of the patient is known (e.g., meningococcal meningitis,
influenza, novel respiratory viruses, viral hemorrhagic fever) and thus should be aware of how to apply
Isolation Precautions based on disease syndromes, be informed about patients who later develop
infections of occupational health concern, and be included in exposure follow-up and relevant PEP and
work restrictions. (CDC 1998) (Information on syndromic Isolation Precautions can be found in Module
1, Chapter 2, Standard and Transmission-Based Precautions.)

Health Care Workers Infected with HIV and/or Hepatitis B or C

HCWs infected with HIV and/or HBV or HCV should inform the facility manager of their status. The
facility IPC team should strive to prevent transmission of infections to patients and at the same time
maintain the livelihood and privacy of the infected staff members. These HCWs should not be prohibited
from providing patient care if they are not performing invasive procedures, the infection is well-
controlled, they fully comply with recommended IPC practices, and there are no other factors that
would prevent them from safely carrying out the patient care activities.

HCWs with these conditions should be closely followed up by a team of clinicians for periodical clinical
monitoring, to assess treatment response and viral suppression, when appropriate, and to revise
recommendations about duty restrictions accordingly. They should avoid performing procedures that
may result in increased risk of contact with large amounts of blood and body fluids. There are no
restrictions for those staff with viral loads less than designated levels. (Henderson et al. 2010)

Infection Prevention and Control: Module 4, Chapter 2 27

 Occupational Health

The Society of Healthcare Epidemiology of America (SHEA) has classified patient care and clinical
procedures into three different categories based on the risk of transmission of bloodborne pathogens:
 Category I: Procedures with minimum risk of bloodborne virus transmission. Clinical procedures
and patient care activities that either do not involve touching patients (e.g., history taking,
counseling) or are limited to touching patients’ intact skin (e.g., performing physical examinations)
and mucous membranes (e.g., performing vaginal examinations, performing some dental
procedures, phlebotomy). It also includes minor surgical procedures with very minimal exposure to
patients’ blood and body fluids (e.g., surface stitches, gastrointestinal endoscopy procedures).
 Category II: Procedures for which bloodborne virus transmission is theoretically possible but
unlikely. Several surgical procedures are examples of such procedures, including ophthalmic
surgery, dental surgery that requires local anesthesia, minor oral surgical procedures, endoscopic
and arthroscopic procedures, provision of contraceptive methods, minor gynecological procedures,
starting of central lines, and medical male circumcisions.
 Category III: Procedures for which there is definite risk of bloodborne transmission of viruses or
that have previously been classified as “exposure-prone.” All major surgical procedures that involve
a high volume of blood and body fluids are Category III procedures with definite risk of exposure.
Examples of Category III procedures are: general surgery; oral surgery with difficult access for
suturing; emergency surgical procedures involving bleeding and exposure to a high volume of blood;
obstetric procedures, including cesarean section; and orthopedic surgeries. Any major surgical
procedure that goes beyond 3 hours and requires changing gloves should not include staff members
infected with bloodborne pathogens.

Managing HCWs infected with HIV and/or hepatitis B or C

HCWs infected with bloodborne pathogens whose viral load is below the minimum designated level
should follow a six-point plan described below to safely provide patient care and be productive.

The HCWs should:

1. Not have transmitted infection to any patient.
2. Obtain advice from a team of clinicians about continuing to care for patients.
3. Undergo testing twice a year to demonstrate the maintenance of a viral burden below designated
levels.
4. Receive follow-up by a clinician with expertise in managing bloodborne pathogen infections and
consent to share their results with the IPC/occupational health team at the facility.
5. Consult closely with experts on the use of optimal IPC procedures:
a. This may include guidance on double gloving, changing gloves during procedures, avoiding
digital palpation of needle tips, and performing all procedures under direct view. It also includes
promptly withdrawing from a procedure if they have any injury that bleeds and informing the
IPC/occupational health team about any injuries.
b. Adhere strictly to recommended procedures, including the routine use of double gloving for
Category II (such as minor surgery) and Category III (such as major surgery) procedures and
frequent glove changes during procedures, particularly if performing technical tasks that have a
potential to compromise glove integrity.

28 Infection Prevention and Control: Module 4, Chapter 2

Occupational Health

6. Agree in writing to comply with recommendations and guidance of the expert clinicians as well as
the facility IPC/occupational health and management team.
Adapted from: Henderson et al. 2010.

Monitoring Prevention of Occupational Exposures and Injuries

Health care facilities should evaluate the effectiveness of occupational health interventions and
practices on a routine basis. They should conduct surveillance to collect, analyze, and disseminate data
on risks to HCWs. There should be a system to report any occupational exposure and injury, which
should be supported by prompt management and PEP. The rates of injuries or exposures among HCWs
should be routinely reviewed and reported back to the staff, and strategies and action plans to prevent
future injuries should be developed and updated. (The principles of surveillance are discussed in Module
9, Chapter 2, Introduction to Surveillance of Health Care-Associated Infections.)

Surveillance activities can be conducted by the staff organizing occupational health activities at the
facility and/or with the assistance of IPC staff. Table 2-8 outlines three examples of how to calculate
rates of reported sharps injuries that can be used to measure performance improvement.

Table 2-8. Calculation of Rates to Measure and Compare Reported Sharps Injuries
Metric How to Calculate
Rate of sharps injuries reported (Number of sharps injuries reported in 1 year/average daily occupied beds
per year during that year) x 100
Application:
Calculate Rates:
1. 2015
(20 sharps injuries reported in 2015/average daily occupied beds during 2015 was 80 per day) x 100
= (20/80) x 100 = Rate of 25 sharps injuries per 100 occupied beds in 2015
2. 2016
(10 sharps injuries reported in 2016/average daily occupied beds during 2016 was 100 occupied beds) x 100
= (10/100) x 100 = Rate of 10 sharps injuries per 100 occupied beds in 2016

Such calculations allow comparisons of yearly rates. The rates for 2016 were much lower than the rates in
2015.
(Number of sharps injuries reported in an occupational category in 1
year/Number of full-time equivalents (FTEs) of the same occupational
Rate of sharps injuries per category employed in that year)
occupational category per year
Note: The category of HCW must be identified when each sharps injury is
reported.

Infection Prevention and Control: Module 4, Chapter 2 29

 Occupational Health

Metric How to Calculate

Application:
Occupational breakdown of sharps injuries: In 2015: surgeons 5; nurses 10; rubbish collectors 5
Calculate Rates for Each:
3. Surgeons
(5 sharps injuries reported by surgeons in 2015/7 FTE surgeons employed in 2015) = 5/7
= Rate of 0.7 sharps injury per FTE surgeon in 2015
4. Nurses
(10 sharps injuries reported by nurses in 2015/100 FTE nurses employed in 2015)
= 10/100
= Rate of 0.1 sharps injury per FTE nurse in 2015
5. Rubbish collectors (5 sharps injuries reported by rubbish collectors in 2015/5 FTE rubbish collectors
employed in 2015)
= 5/5
= Rate of 1 sharps injury per FTE rubbish collectors in 2015
In a comparison of sharps injuries by occupational categories, it is evident that the rubbish collectors had
the highest rate of 1 per FTE rubbish collectors in 2015. The health care facility should prioritize
interventions to reduce sharps injuries among the rubbish collectors.
(Number of sharps injuries from a device type in 1 year/number of the
Rate of sharps injury per device devices iof that type used in that year) x 100
type per year Note: The type of device must be identified when each sharps injury is
reported.
Application:
Breakdown of devices causing sharps injuries: In 2015: removable-blade scalpel 3; disposable fixed-blade
scalpel 1

Calculate Rates for Each:

Removable-blade scalpel
(3 sharps injuries from removable-blade scalpel in 2015/100 removable-blade scalpels used in 2015) x 100
= (3/100) x 100
= Rate of 3 sharps injuries per 100 removable-blade scalpels in 2015

Disposable scalpel
(1 sharps injury from disposable scalpel in 2015/500 disposable scalpels used in 2015) x 100
= (1/500) x 100
= Rate of 0.2 sharps injuries per 100 disposable scalpels in 2015

Compare rates between occupational categories: Comparison of the rates indicates that removable-blade
scalpels are 15 times riskier than disposable scalpels. This will help the health care facility make a strong case for
replacing removable blade scalpels with disposable scalpels.

Sources: APIC 2014a; Jagger 1992.

30 Infection Prevention and Control: Module 4, Chapter 2

Occupational Health

Summary
In the course of their duties, millions of HCWs around the world are routinely exposed to a variety of
health and safety hazards, including infectious agents. Infections can be transmitted to HCWs, who can
in turn transmit the infections to patients and others. The goals of IPC intersect with those of
occupational health activities in preventing and addressing infectious hazards at health care facilities.
Therefore, IPC staff should be involved in occupational health activities at the facility, and occupational
health staff should be knowledgeable about IPC.

IPC elements of an occupational health program include surveillance, education, immunization, and
exposure prevention and response. Protection of staff by the application of Standard Precautions to
every patient, every time, and use of disease- or syndrome-specific Transmission-Based Precautions to
prevent exposures to infectious agents are essential to prevent occupational exposures.
Recommendations for managing specific occupational exposures and infections in staff members are
based on the epidemiology of infectious disease transmission in health care facilities and they should
target HCWs as potential sources or hosts. Special attention may be needed for specific groups of
employees with potential increased risk of exposure (laboratory, pregnant, and emergency response
personnel, and HCWs infected with HBV, HCV, and HIV). Finally, the effectiveness of interventions to
protect HCWs from occupational infection should be evaluated. Monitoring progress and identifying
causes, with feedback to key persons, can enhance prevention activities.

Infection Prevention and Control: Module 4, Chapter 2 31

 Occupational Health

Appendix 2-A. Risk and Work Restriction for Health Care Workers Exposed to or
Infected with Infectious Diseases of Importance in Health Care Settings
This information is to be used in the absence of local regulations.
Transmission Risk Post-
Disease/ Main Risk in Health Exposure
Mode of Incubation Vaccine
Infection/ Staff to Patient to Care Prevention Prophylaxis
Transmission Period Available
Syndrome Patient Staff Facility (PEP)
Available
Yes;
Hours to 5 days,
Hand hygiene, Contact No
Fecal-oral Shedding up to Stool contact,
Cholera Rare Rare Precautions, clean recommend- No
contaminated water 10 days after unwashed hands
environment ation for
cessation
HCWs
Work restrictions: No duty. Restrict from food handling.
Duration of restrictions: Until 48 hours after last episode of diarrhea except for food handlers: 2 consecutive negative fecal specimens at least 48 hours apart and at least 48
hours after stopping antibiotics are required.*
Contact with eye 5–12 days,
Hand hygiene, Contact
secretions and shedding from Surfaces,
Conjunctivitis due Precautions, clean
contaminated High High incubation equipment, No No
to adenovirus instruments and
surfaces and period until 14 unwashed hands
equipment
equipment days after onset
Work restrictions: No contact with patient or patient environment.
Duration of restrictions: Until discharge from eye ceases.
Contact with urine,
saliva, breast milk, Contact with body
cervical secretions, fluids, especially
Cytomegalovirus Hand hygiene,
and semen from Rare Rare Unknown saliva, blood, and No No
(CMV)⁰ Standard Precautions
infected person who urine, possibly
is actively shedding unwashed hands
virus
Work restrictions: No restriction.
Duration of restrictions: None.

32 Infection Prevention and Control: Module 4, Chapter 2

 Occupational Health

Transmission Risk Post-

Disease/ Main Risk in Health Exposure
Mode of Incubation Vaccine
Infection/ Staff to Patient to Care Prevention Prophylaxis
Transmission Period Available
Syndrome Patient Staff Facility (PEP)
Available
Contact with
infected person’s Stool contact,
stool, consumption unwashed hands,
Varies by
of contaminated contaminated Hand hygiene, Contact
pathogen See specific
Diarrheal diseases food or water, Varies Varies environmental Precautions, clean No
causing disease
contact with objects surfaces, environment
diarrhea
or environment contaminated food
contaminated with or water
stool
Work restrictions: Acute (diarrhea with or without other symptoms): No contact with patient or the patient environment, or food handling.
Duration of restrictions: Until symptoms resolve (check the need for negative stool cultures for specific diarrheal etiologies).*
PEP with
Hand hygiene, Droplet antibiotic
By respiratory 2–5 days, Close contact, face- Precautions for Yes, and should be
Diphtheria droplets, contact No data Rare infectious for 2 to-face exposure, pharyngeal lesions, booster every discussed,
with skin lesions weeks cough Contact Precautions 10 years† vaccination if
for skin lesions none within
5 years
Work restrictions: Active disease: No duty; Asymptomatic carriers: No duty.
Duration of restrictions: Until antibiotic therapy completed and 2 negative cultures more than 24 hours apart.
Hand hygiene, Barrier
Exposure of mucous Precautions to
Hemorrhagic fever
membranes or achieve full skin Antivirals
(e.g., Ebola, Bloodborne; possible Moderate
Negligible 5–21 days respiratory tract, coverage to be used No should be
Marburg, Lassa contact transmission to high
through broken skin with training and discussed
virus)
or sharps injury trainer observer to
monitor
Caring for EVD patients with adequate PPE and no known exposure: Active monitoring for fever and symptoms twice per day. Off duty if any symptoms. Work restrictions:
Active suspected or confirmed: Off duty. Post-exposure: Off duty. With active monitoring for fever and symptoms twice per day.
Duration of restrictions: Active: Until cleared by medical staff. Post-exposure: Until 21 days after last exposure.

Infection Prevention and Control: Module 4, Chapter 2 33

 Occupational Health

Transmission Risk Post-

Disease/ Main Risk in Health Exposure
Mode of Incubation Vaccine
Infection/ Staff to Patient to Care Prevention Prophylaxis
Transmission Period Available
Syndrome Patient Staff Facility (PEP)
Available
Person-to-person by
Hand hygiene, Contact Yes; HCWs are
fecal-oral route; Stool contact,
Precautions, not
infected food unwashed hands, Immune
Hepatitis A Rare Rare 15–50 days especially with babies considered at
handlers with poor eating or drinking in globulin
and incontinent
personal hygiene can patient care area increased riskᶧ
patients
contaminate food
Work restrictions: No contact with patient or the patient environment, or food handling.
Duration of restrictions: Until 7 days after the onset of jaundice.
Depends on
HCW
immune
status and
Moderate, source
Via sharps, mucosal, 2–40% patient’s
Sharps injury, blood Hand hygiene,
and non-intact skin, after status;§
45–180 days and serum-derived Standard Precautions, Yes; Recom-
contact with blood, percutan- for non-
Hepatitis B (HBV)⁰ Low (average 60–90 body fluid splashes including prevention mended for
semen, vaginal eous injury immune
days) to mucous of sharps injury, all HCWs†
secretions, and from HCWs with
membranes vaccination
bloody fluids infected HBsAg,
patient positive
source HBIG
and
vaccination
series§
Work restrictions: Acute or chronic HBV: Do not exclude from duty but restrictions apply depending on circulating viral levels and procedures performed by HCW. Requires
review by occupational health/IPC personnel and possibly an expert review panel.#
Duration of restrictions: Different recommendations if HepB antigen is positive or negative and if HBV is < 104 GE/mL (genome equivalents/milliliter plasma) or > 104 GE/mL.#

34 Infection Prevention and Control: Module 4, Chapter 2

 Occupational Health

Transmission Risk Post-

Disease/ Main Risk in Health Exposure
Mode of Incubation Vaccine
Infection/ Staff to Patient to Care Prevention Prophylaxis
Transmission Period Available
Syndrome Patient Staff Facility (PEP)
Available
Moderate,
0–10%
Via sharps, mucosal,
(average
and non-intact skin Sharps injury, Hand hygiene,
1.8%) after
contact with blood, splash on mucous Standard Precautions,
Hepatitis C⁰ Low percutane- 6–7 weeks No No
semen, vaginal membranes or non- including prevention
ous injury
secretions, and intact skin of sharps injury
from
bloody fluids
infected
patient
Work restrictions: Acute or chronic HCV: Do not exclude from duty but restrictions apply depending on circulating viral levels and procedures performed by HCW. Requires
review by occupational health/IPC personnel and possibly an expert review panel.# Post-exposure:§
Duration of restrictions: Different recommendations if HCV is < 104 GE/mL or > 104 GE/mL.#
Person to person by
Contaminated food
fecal-oral route, Hand hygiene,
Hepatitis E — — 2–9 weeks or water, unwashed No No
contaminated water, Standard Precautions
hands
contaminate food
Work restrictions: Off duty.
Duration of restrictions: Duration of illness, viral shedding in stool occurs 7–30 days after onset of jaundice.
Contact with Hand hygiene,
Contact with virus in
infected site or Standard Precautions⁰
saliva of carriers,
Herpes simplex⁰ Rare Low 2–14 days saliva, vaginal (Contact Precautions No No
contact with vesicle
secretions, or in disseminated
fluid
amniotic fluid infection)
Work restrictions: Genital: No restriction. Hands (herpetic whitlow): No contact with patient or the patient environment. Orofacial: No contact with high-risk patients.◊
Duration of restrictions: Genital: None. Hands (herpetic whitlow): Until lesions heal.

Infection Prevention and Control: Module 4, Chapter 2 35

 Occupational Health

Transmission Risk Post-

Disease/ Main Risk in Health Exposure
Mode of Incubation Vaccine
Infection/ Staff to Patient to Care Prevention Prophylaxis
Transmission Period Available
Syndrome Patient Staff Facility (PEP)
Available
Depends on
type of body
fluid, type of
exposure
Primarily via sharps
and source
contact with blood;
Low, 0.2– patient
mucosal or non-
0.4% after Sharps injury, Hand hygiene, status;§
Human intact skin contact
sharps Within 6 splash on mucous Standard Precautions when
immunodeficiency with blood; semen, Rare No
exposure to months membranes or non- including prevention indicated,
virus (HIV)⁰ vaginal secretions,
infected intact skin of sharps injury initiate
and bloody body
person antiretroviral
fluids less likely to
treatment as
transmit
soon as
possible
(within 72
hours)§
Work restrictions: Acute or chronic HIV: Do not exclude from duty but restrictions apply depending on circulating viral levels and procedures performed by HCW. Requires
review by occupational health/IPC personnel and possibly an expert review panel.# Post-exposure:§
Duration of restrictions: Different recommendations if circulating HIV viral burden is < 5x102 GE/mL or > 5x102 GE/mL.#
Droplet spread;
Yes; annual
direct droplet Antivirals
immunization
transmission or Close contact with may be
Hand hygiene, Droplet with a single
droplet-to-contact patient (within 1–2 recom-
Influenza⁰ Moderate Moderate 1–5 days Precautions, annual dose recom-
transmission of meters from mended in
vaccine mended
respiratory coughing/ sneezing) certain
yearly for
secretions of situations
HCWᶧ
infected patients
Work restrictions: No contact with high-risk patients◊ during community outbreaks.
Duration of restrictions: Until acute symptoms resolve.

36 Infection Prevention and Control: Module 4, Chapter 2

 Occupational Health

Transmission Risk Post-

Disease/ Main Risk in Health Exposure
Mode of Incubation Vaccine
Infection/ Staff to Patient to Care Prevention Prophylaxis
Transmission Period Available
Syndrome Patient Staff Facility (PEP)
Available
Yes; all HCWs
Airborne; direct should be
airborne Inhaling droplets immune to
transmission or and airborne virus measles,
Hand hygiene,
airborne-to-contact or contact with the proof of Immune
Measles⁰ High High 5–21 days Airborne and Contact
transmission of patient’s immunity or globulin
Precautions, vaccine
respiratory respiratory immunization
secretions of secretions required pre-
infected person patient
contact†
Work restrictions: Active: Off duty. Post-exposure in non-immune people: Off duty.
Duration of restrictions: Active: 7 days after rash appears. Post-exposure: From 5th day after first exposure through 21st day after last exposure and/or 4 days after rash
appears.
Droplet spread; Close contact (face
Yes; recom-
direct droplet to face) with
mended for
transmission or respiratory
Meningococcal HCWs at risk Antibiotic
droplet-to-contact secretions Hand hygiene, Droplet
infectious — Rare 2–10 days of exposure† after close
transmission of of patients with Precautions
N. meningitides (tetravalent A, contact‡
respiratory meningococcemia
C, W135, and
secretions of or meningococcal
Y)
infected patients meningitis
Work restrictions: Active: No duty. Post-exposure: No restrictions. Recommended prophylaxis includes: rifampin (600 mg twice a day for 2 days), a single dose of ciprofloxacin
(500 mg), or a single dose of ceftriaxone (250 mg) IM.
Duration of restrictions: Active: Until 24 hours after start of effective antibiotic therapy. Post-exposure: No restrictions.

Infection Prevention and Control: Module 4, Chapter 2 37

 Occupational Health

Transmission Risk Post-

Disease/ Main Risk in Health Exposure
Mode of Incubation Vaccine
Infection/ Staff to Patient to Care Prevention Prophylaxis
Transmission Period Available
Syndrome Patient Staff Facility (PEP)
Available
Droplet spread;
direct droplet
Close contact with Yes; HCWs are
transmission or
patient (within 1–2 not indicated
droplet-to-contact Hand hygiene, Droplet
Mumps Moderate Moderate 12–25 days meters from as a group at No
transmission of Precautions
coughing/ increased
respiratory
sneezing) risk†
secretions and saliva
of infected patients
Work restrictions: Active: Off duty. Post-exposure in non-immune people: Off duty.
Duration of restrictions: Active: 9 days after onset of parotitis. Post-exposure: From 12th day after first exposure through 26th day after last exposure or 9 days after onset of
parotitis.
Unwashed hands,
Methicillin- Depends on the contaminated
Direct and indirect Hand hygiene, Contact
resistant S. aureus Rare Rare type of surfaces, No No
contact Precautions
(MRSA) infection infection contaminated
equipment
Work restrictions: Active, draining skin lesions: No contact with patient or the patient environment, or food handling. Carrier: No restriction unless epidemiologically linked
with transmission of the organism.
Duration of restrictions: Until lesions have resolved.
Fecal-oral (direct or
indirect contact with
Stool or vomit
patient’s stool or Hand hygiene, Contact
contact, possibly
vomit), Precautions, clean
Norovirus High High 12–48 hour aerosol No No
contaminated equipment, clean
transmission during
surfaces, environment
vomiting
contaminated food
or water
Work restrictions: Acute: No contact with patient or the patient environment, or food handling.
Duration of restrictions: Until symptoms resolve, viral shedding in stool may occur.

38 Infection Prevention and Control: Module 4, Chapter 2

 Occupational Health

Transmission Risk Post-

Disease/ Main Risk in Health Exposure
Mode of Incubation Vaccine
Infection/ Staff to Patient to Care Prevention Prophylaxis
Transmission Period Available
Syndrome Patient Staff Facility (PEP)
Available
Droplet Precautions
Contact with
Parvovirus B19 for patients with fever
infected persons,
(erythema Respiratory and anemia or aplastic
fomites, or — Rare 6–10 days No No
infectiosum or fifth secretions crisis or chronic B19,
respiratory
disease) others Standard
secretions
Precautions
Work restrictions: Acute: Off duty. Exposed: no restriction.
Duration of restrictions: 7 days after onset of illness.
Droplet spread;
direct droplet
Yes; recom-
transmission or
Respiratory mendation for
Pertussis droplet-to-contact Hand hygiene, Droplet
Moderate Moderate 7–10 days secretions and HCWs Macrolides
(whooping cough) transmission of Precautions
respiratory droplets currently
respiratory
under review†
secretions of
infected patients
Work restrictions: Active: Off duty. Post-exposure asymptomatic: No restriction if PEP received. Post-exposure symptomatic: Off duty.
Duration of restrictions: Active: from beginning of catarrhal stage through 3rd week after onset of paroxysms. Post-exposure: Until 5 days of effective antibiotic therapy.
Yes; all HCWs
3–21 days,
Contact with feces or should have
vaccine-
urine of infected Feces, respiratory completed a
associated polio Hand hygiene, Contact
Poliomyelitis person, respiratory Rare Rare secretions, lab full course of No
(oral vaccine): Precautions
secretions and specimens primary
7–21 days after
fomites vaccination
vaccination
against polio†
Work restrictions: Active: Off duty. Post-exposure: Vaccination series or booster.
Duration of restrictions: Duration of illness.

Infection Prevention and Control: Module 4, Chapter 2 39

 Occupational Health

Transmission Risk Post-

Disease/ Main Risk in Health Exposure
Mode of Incubation Vaccine
Infection/ Staff to Patient to Care Prevention Prophylaxis
Transmission Period Available
Syndrome Patient Staff Facility (PEP)
Available

Animal bite, saliva, Lab samples, saliva Yes; HCWs are

Hand hygiene,
Rabies tissue and organ Rare Rare 1–3 months of infected patients not at Yes
Standard Precautions
transplants (theoretical) increased risk
Work restrictions: Active: Off duty. Post-exposure: No restriction, consider post-exposure treatment.
Duration of restrictions: Rabies is mostly fatal.
Droplet contact or
Respiratory Respiratory
direct contact with Hand hygiene, Contact
syncytial virus Moderate Moderate 2–8 days secretions, hands, No No
respiratory Precautions
(RSV) and fomites
secretions
Work restrictions: No contact with high-risk patients◊ during community outbreaks.
Duration of restrictions: Until acute symptoms resolve.
Yes; adults
Person-to-person via Stool contact, Hand hygiene, Contact including
fecal-oral route; food unwashed hands, Precautions, clean HCWs are not
Rotavirus Moderate Moderate 2–3 days No
handlers may environmental environment, clean at increased
contaminate food surfaces, fomites equipment risk of severe
disease†
Work restrictions: Acute: No contact with patient or the patient environment, or food handling.
Duration of restrictions: Until symptoms resolve.

40 Infection Prevention and Control: Module 4, Chapter 2

 Occupational Health

Transmission Risk Post-

Disease/ Main Risk in Health Exposure
Mode of Incubation Vaccine
Infection/ Staff to Patient to Care Prevention Prophylaxis
Transmission Period Available
Syndrome Patient Staff Facility (PEP)
Available

Yes; all HCWs

should be
Droplet contact or immune to
direct contact with Droplet Precautions rubella and
Respiratory
respiratory (acute infection), proof of
Rubella⁰ Moderate Moderate 12–23 days droplets and No
secretions; airborne Contact Precautions immunity or
secretions
transmission not (congenital rubella) immunization
demonstrated required pre-
patient
contact†
Work restrictions: Active: Off duty. Post-exposure in non-immune people: Off duty.
Duration of restrictions: Active: Until 5 days after rash appears. Post-exposure: From 7th day after first exposure through 21st day after last exposure.
Person-to-person via
Yes (typhoid),
fecal-oral route, via
Hand hygiene, Contact currently no
contaminated food
Salmonella or Stool contact, Precautions for recommen-
or water; food Low Low 1–3 days No
shigella unwashed hands incontinent patients dation
handlers with poor
and babies regarding
personal hygiene can
HCWs†
contaminate food
Work restrictions: Acute: No contact with patient or the patient environment, or food handling. Carrier: No restriction from patient care unless staff member handles food*
or is epidemiologically linked with transmission of the organism.
Duration of restrictions: Until symptoms resolve unless food handler,* in which case a specific number of negative cultures is required.
Small droplets from
Hand hygiene, Droplet
Novel respiratory respiratory
and Contact
viruses (SARS, bird Droplets, contact secretions,
Medium Medium Varies Precautions, use No No
flu, MERS-CoV, (possibly airborne) possibility of
Airborne Precautions
etc.) airborne
if possible
transmission
Work restrictions: Acute: No duty.
Duration of restrictions: Until acute symptoms resolve.

Infection Prevention and Control: Module 4, Chapter 2 41

 Occupational Health

Transmission Risk Post-

Disease/ Main Risk in Health Exposure
Mode of Incubation Vaccine
Infection/ Staff to Patient to Care Prevention Prophylaxis
Transmission Period Available
Syndrome Patient Staff Facility (PEP)
Available
Foodborne: 30
minutes–6 days Unwashed hands,
Staphylococcus
Impetigo: 1–10 contaminated
aureus Direct and indirect Hand hygiene, Contact
Rare Rare days surfaces, No No
infection contact Precautions
Toxic shock contaminated
(see also MRSA)
syndrome: 2 equipment
days
Work restrictions: Active, draining skin lesions: No contact with patient or the patient environment, or food handling. Carrier: No restriction unless epidemiologically linked
with transmission of the organism.
Duration of restrictions: Until lesions have resolved.
Prolonged skin-to-
Low skin contact (typical
Low (typical
(typical scabies), skin-to- Hand hygiene, Contact
Direct skin-to-skin scabies),
scabies) to skin contact during Precautions, clean
Scabies contact with infested moderate 2–6 weeks No No
moderate daily care (crusted environment, clean
person (crusted
(crusted scabies), equipment
scabies)
scabies) infrequently
fomites
Work restrictions: Active: No patient contact. Post-exposure: No restriction.
Duration of restrictions: Active: Until after 1st treatment and cleared by medical evaluation. Post-exposure: Prophylactic treatment not indicated except in outbreak
situations.

42 Infection Prevention and Control: Module 4, Chapter 2

 Occupational Health

Transmission Risk Post-

Disease/ Main Risk in Health Exposure
Mode of Incubation Vaccine
Infection/ Staff to Patient to Care Prevention Prophylaxis
Transmission Period Available
Syndrome Patient Staff Facility (PEP)
Available
Hand hygiene;
precautions depend
on type of infection –
Minor skin and
Droplet contact or Pharyngitis 2–5 endometritis:
Contact with
direct contact with days, impetigo Standard Precautions,
Streptococcus, infected secretions;
oral secretions or Rare No data 7–10 days, Major skin: Contact No No
Group A (GAS) HCWs are rarely
drainage from other infections Precautions,
carriers
infected wounds variable Respiratory tract,
scarlet fever and
invasive disease:
Droplet Precautions

Work restrictions: Active: No contact with patient or the patient environment, or food handling. Carrier: No restriction unless linked with transmission.
Duration of restrictions: Until 24 hours after effective treatment is started.
Airborne
Incomplete Isoniazid
transmission from
implementation of Yes, BCG; (INH) for
sources with active
recommend control There is no treatment of
pulmonary or
measures, including recommenda- latent TB
laryngeal Low to
Tuberculosis (TB)⁰ Low to high Weeks to years patient placement, Airborne Precautions tion for HCWs infection;
tuberculosis; high
facility ventilation, in routine 4-drug
susceptible person
and personal circumstances regimen for
must inhale airborne
respiratory active TB
droplet nuclei to
protection
become infected
Work restrictions: Active pulmonary or laryngeal: Off duty. Active extra-pulmonary: No restriction once pulmonary or laryngeal involvement is excluded. Latent: No
restriction. PPD (tuberculin skin test) conversion (> 10 mm induration): No restriction; consider isoniazid prophylaxis depending on local recommendations.
Duration of restrictions: Active: Until proven non-infectious (by sputum acid-fast bacilli [AFB] culture culture).

Infection Prevention and Control: Module 4, Chapter 2 43

 Occupational Health

Transmission Risk Post-

Disease/ Main Risk in Health Exposure
Mode of Incubation Vaccine
Infection/ Staff to Patient to Care Prevention Prophylaxis
Transmission Period Available
Syndrome Patient Staff Facility (PEP)
Available
Yes; consider
10–21 days (up vaccination of
Contact with to 28 days in Contact with lesions potentially
Varicella, chicken vesicles; droplet or person who and aerosols even susceptible
Airborne and Contact
pox, disseminated airborne spread High High receives without direct HCWs (i.e., VZIG
Precautions
zoster⁰ from respiratory varicella-zoster contact with the unvaccinated
tract immune infected patient and with no
globulin [VZIG]) history of
varicella)ᶧ
Work restrictions: Active: Off duty. Post-exposure in non-immune people: Off duty.
Duration of restrictions: Active: Until all lesions are dry and crusted. Post-exposure: From 10th day after first exposure through 21st day (28th if VZIG is given) after last
exposure.
Contact with
Contact with lesions Yes; see
vesicles; perhaps
and perhaps above;
droplet or airborne Contact Precautions
aerosols from shingles
Localized varicella- spread from Years after and Airborne
Moderate Moderate respiratory tract vaccine not VZIG
zoster (shingles) respiratory tract acute infection Precautions for
from disseminated recommend-
from disseminated disseminated zoster
zoster ed specifically
zoster
for HCWs

Work restrictions: Localized in healthy person: Cover lesions, no contact with high-risk patients.◊ Generalized or localized in immunosuppressed person: No patient contact.
Post-exposure in non-immune people: No patient contact.
Duration of restrictions: Active and generalized: Until all lesions are dry and crusted. Post-exposure: From 10th day after first exposure through 21st day (28th if VZIG is given)
after last exposure or if varicella occurs, until all lesions dry and crusted.

44 Infection Prevention and Control: Module 4, Chapter 2

 Occupational Health

Transmission Risk Post-

Disease/ Main Risk in Health Exposure
Mode of Incubation Vaccine
Infection/ Staff to Patient to Care Prevention Prophylaxis
Transmission Period Available
Syndrome Patient Staff Facility (PEP)
Available
Droplet contact or
direct contact with
Respiratory etiquette,
Viral respiratory respiratory
Respiratory hand hygiene, Droplet Yes (influenza
infections, acute Moderate Moderate 1–7 days secretions, close No
secretions Precautions, annual only)
febrile contact (1–2
vaccine
meters) with
patient
Work restrictions: No contact with high-risk patients◊ during community outbreaks.
Duration of restrictions: Until acute symptoms resolve.
§ PPE—Post-exposure prophylaxis; see Chapter 3, Sharps Injuries and Management of Exposure to Bloodborne Pathogens, in this module for details about PEP for
bloodborne pathogens.
#
See section above on Health Care Workers Infected with HIV and/or Hepatitis B or C.
⁰ For information relevant to exposure of pregnant personnel, see Table 2-7 in this chapter.
◊ Definition of high-risk patient: neonates and immunocompromised persons of any age. For influenza, also those > 65 years, residents of nursing homes, persons with
chronic pulmonary or cardiac conditions, diabetes. (CDC 1998)
‡ Definition of close contact: Direct, mouth-to-mouth contact as in resuscitation attempts, endotracheal intubation, endotracheal tube management, or close examination of
oropharynx of patients. (CDC 1998; WHO 2002)
† For vaccine recommendations for HCWs (WHO 2016b), see Table 2-4.
* For management of illness in food handlers, see Module 5, Chapter 3, Managing Food and Water Services for the Prevention of Health Care-Associated Infections.

Infection Prevention and Control: Module 4, Chapter 2 45

Occupational Health

References
Association for Professionals in Infection Control and Epidemiology (APIC). 2014a. Occupational health
(Chapter 100). In: APIC Text of Infection Control and Epidemiology, 4th ed. Washington, DC: APIC.
APIC. 2014b. Pregnant healthcare personnel (Chapter 104). In: APIC Text of Infection Control and
Epidemiology, 4th ed. Washington, DC: APIC.
Centers for Disease Control and Prevention (CDC). 1998. Guidelines for infection control in the
healthcare worker, 1998. Am J Infect Control. 26:289–354.
CDC. 2005. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care
settings. MMWR. 54(RR-17):1–141. http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.
CDC. 2013. CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for
administering postexposure management. MMWR. 62(RR-10):1–19.
https://www.cdc.gov/mmwr/pdf/rr/rr6210.pdf.
CDC. 2015. Infection Prevention and Control Recommendations for Hospitalized Patients Under
Investigation (PUIs) for Ebola Virus Disease (EVD) in U.S. Hospitals.
http://www.cdc.gov/vhf/ebola/healthcare-us/hospitals/infection-control.html.
Henderson DK, Dembry L, Fishman NO, et al. for the Society for Healthcare Epidemiology of America.
2010. SHEA guideline for management of healthcare workers who are infected with hepatitis B virus,
hepatitis C virus and/or human immunodeficiency virus. Infect Control Hosp Epidemiol. 31(3):203–232.
International Federation of Infection Control (IFIC). 2003. Prevention and management of infectious
diseases in healthcare workers. In: Basic Infection Control Training Programme: Element VI. IFIC.
http://theific.org/basic-ic-training-course-outline/.
Jagger J. 1992. Calculating needle-stick rates. In: BD Safety Compliance Initiative Exposure Prevention
Information Network. Franklin Lakes, NJ: Becton Dickinson.
Prüss-Üstün A, Rapiti E, Hutin Y. 2005. Estimation of the global burden of disease attributable to
contaminated sharps injuries among health-care workers. Am J Ind Med. 48(6):482–490.
Reitsma AM, Closen ML, Cunningham M, et al. 2005. Infected physicians and invasive procedures: safe
practice management. Clin Infect Dis. 40:1665–1672.
Society for Healthcare Epidemiology of America (SHEA). 2014. SHEA Response to Institutions’
Implementation of 2010 Guideline for Healthcare Workers Infected with Bloodborne Pathogens.
https://www.shea-online.org/images/guidelines/10_2014_Bloodborne_Pathogens_Public_Letter.pdf.
World Health Organization (WHO). 2002. Prevention of Hospital-Acquired Infections: A Practical Guide,
2nd ed. Geneva, Switzerland: WHO.
http://www.who.int/csr/resources/publications/drugresist/WHO_CDS_CSR_EPH_2002_12/en/.
WHO. 2009. Hepatitis B vaccines: WHO position paper. Wkly Epidemiol Rec. 40(84):405–420.
WHO. 2010. Infection Control Precautions in Cholera Outbreaks: Aide-Memoire. Pan American Health
Organization. http://www1.paho.org/hq/dmdocuments/2010/Aide_Mem_Cholera-
Eng_4Nov%20.pdf?ua=1.
WHO. 2014. Occupational Health: Ebola Virus Disease: Occupational Safety and Health.
http://www.who.int/occupational_health/publications/ebola_osh/en/.
WHO. 2016a. Health Workers: Health Worker Occupational Health. Introduction.
http://www.who.int/occupational_health/topics/hcworkers/en/.

Infection Prevention and Control: Module 4, Chapter 2 46

 Occupational Health

WHO. 2016b. WHO Recommendations for Routine Immunization: Summary Tables. Table 4: Summary of
WHO Position Papers – Immunization of Health Care Workers, and Table 1: Summary of WHO Position
Papers – Recommendations for Routine Immunization.
http://www.who.int/immunization/policy/immunization_tables/en/.
WHO 2016c. Guidelines on Core Components of Infection Prevention and Control Programmes at the
National and Acute Health Care Facility Level. Geneva, Switzerland: WHO.
http://www.who.int/gpsc/core-components.pdf.

47 Infection Prevention and Control: Module 4, Chapter 2

Occupational Health

Infection Prevention and Control: Module 4, Chapter 2 48

 Sharps Injuries and Exposure to Bloodborne Pathogens

Chapter 3. Sharps Injuries and Management of Exposure

to Bloodborne Pathogens
Key Topics
 Safe and unsafe sharps tasks
 The risk of exposure to bloodborne pathogens
 Prevention of exposure to bloodborne pathogens
 Strategies to reduce sharps injuries
 Management of exposure to bloodborne pathogens

Key Terms
 Bloodborne pathogens are infectious microorganisms (bacteria, viruses, and other microorganisms)
contained in blood and other potentially infectious body fluids (including urine, respiratory
secretions, cerebrospinal, peritoneal, pleural, pericardial, and synovial amniotic fluids, semen,
vaginal secretions, breast milk, and saliva). The pathogens of primary concern are hepatitis B virus
(HBV), hepatitis C virus (HCV), and HIV.
 Hands-free technique is the technique for transferring sharp instruments to reduce the risk of
injuries. It consists of the indirect transfer of instruments between health care workers (HCWs)
performing a procedure so that only one person touches the same sharp item at any time. Items are
usually placed in a designated neutral or safe zone, which can be a section of the surgical field or a
container, from where they can be picked up.
 Neutral (safe) zone is a designated area on the sterile field during procedures where sharps can be
placed by an HCW and then picked up by another HCW.
 Occupational exposure to blood and body fluid is the exposure of an HCW to blood or other
potentially infectious materials during the performance of an employee's duties. Exposure to
bloodborne pathogens involves skin, eye, mucous membrane, or parenteral contact (e.g., a needle
stick).
 Partial or limited hands-free technique is used to hand a sharp instrument directly to the HCW
performing a procedure (e.g., surgeon) and to return the instrument to the assistant HCW via a
neutral zone.
 Post-exposure prophylaxis (PEP) is a preventive medical treatment that a person may take following
exposure to potentially infectious bloodborne pathogens, such as HIV or HBV, to prevent becoming
infected from the exposure. Post-exposure prophylaxis can also be taken following exposure to non-
bloodborne pathogens such as invasive Group A streptococcal infections, invasive meningococcal
infections, and pertussis.
 Sharps are instruments, needles, and any other objects that can easily penetrate through the skin.
 Sharps injuries are injuries from a “sharp” penetrating the skin. “Sharps” include syringe needles,
scalpels, broken glass, and other objects that may be contaminated with blood or body fluids. These
injuries potentially expose HCWs to infections from bloodborne pathogens.

Infection Prevention and Control: Module 4, Chapter 3 49

Sharps Injuries and Exposure to Bloodborne Pathogens

 Sharps injury prevention strategies are measures taken to prevent injuries while handling sharps.
These measures include elimination of hazards and the use of engineering controls, administrative
controls, work space practices, and personal protective equipment.
 Standard Precautions are a set of infection control practices (IPC) used for every patient encounter
to reduce the risk of transmission of bloodborne and other pathogens from both recognized and
unrecognized sources. They are the basic level of infection control practices to be used, at a
minimum, in preventing the spread of infectious agents to all individuals in the health care facility.

Background
Globally, HCWs are at an increased risk of exposure to bloodborne pathogens (HBV, HCV, and HIV)
because they handle sharps during the course of their duties. It is estimated that 39% of HCV, 37% of
HBV, and 4.4% of HIV infection among HCWs worldwide are attributable to occupational exposure to
sharps injuries (Prüss-Üstün et al. 2005). According to estimates in the World Health Organization
(WHO) sharps injuries report (2005), the Eastern Mediterranean region had the highest incidence of
sharps injuries, with 4.86 injuries per HCW; the African regions had an estimated incidence of 2.1. The
regions with the lowest incidence of sharps injuries were the United States, Northern Europe, and the
Western Pacific, with 0.18, 0.64, and 0.74 per HCW respectively. (Rapiti et al. 2005)

Understanding the risk of exposure to blood and body fluids is important for all HCWs. Implementing
recommended IPC practices, technological advances, and a greater emphasis on a culture of safety in
health care facilities have reduced sharps injuries in many settings. While safer practices have been
available for some time, effective implementation of these safety standards has been a challenge for
many low- and middle-income countries. Table 3-1 provides examples of safe and unsafe practices in the
use of sharps. (Also see Module 8, Chapter 1, Clinical Laboratory Biosafety.)

Table 3-1. Unsafe and Safe Sharps Tasks

Sharps Task Unsafe Safe
Suture needle Using fingers to load or reposition Using an instrument to load or reposition
needle needle
Tying suture Exposed needle when tying suture Needle is off/on driver during tying
(not loose) (protected or loose)
Tissue retraction Using hand/fingers to retract wound Using instrument to retract wound edge
edges when using sharps when using sharps
Injection needle Injecting toward hand/fingers; 2- Injecting away from hand/fingers, no 2-
handed needle capping handed needle capping
Placement of sharps in Sharps left in operative field Placing sharps back onto a neutral hands-
sterile field unattended free zone* while not in use
Passage of sharps Passing sharps to another individual Using neutral zone or hands-free zone*
(i.e., hand to hand)
Verbal communication Unclear/no verbal notification when Clear verbal notification when passing
about sharps passing sharps sharps
Disposing of sharps Sharps container not positioned close Sharps container positioned within easy
to procedure reach of procedure

Source: Tso et al. 2012. (*See Appendix 3-B*, Neutral and Safe Zone Using Hands-Free Technique.)

50 Infection Prevention and Control: Module 4, Chapter 3

 Sharps Injuries and Exposure to Bloodborne Pathogens

Risk of Exposure to Bloodborne Pathogens

Certain practices in the health care facility increase the risk of exposure to blood and body fluids. For
example, HCWs often use and pass sharp instruments without looking or letting other HCWs know what
they are doing. The work area is often a confined space requiring HCWs to be aware of their
surroundings at all times during the procedure. Waste disposal containers are often not positioned close
to the areas where procedures are performed. HCWs often have time pressures to complete their
duties. This is especially the case for surgical procedures and emergency medical care. In addition, the
operating theater (OT) presents additional challenges: the ability to see what is going on in the operative
field may be poor for some members of the team. Procedures involving a high volume of blood and
greater length of time (e.g., cardiac, obstetric, and orthopedic surgeries), in general, are more likely to
result in exposure to blood and body fluids. The type of environment in the OT may result in anxiety,
fatigue, and frustration that can impact HCWs’ judgment.

Exposure to blood and body fluids may occur without the HCW’s knowledge and is noticed when the
gloves are removed at the end of the procedure, which prolongs the duration of exposure. Intact skin is
an adequate barrier against bloodborne pathogens such as HBV, HCV, and HIV, but fingers are
frequently the site of minor scratches and cuts, increasing the risk of infection.

Objects That Cause Injuries

The vast majority of sharps injuries in health care facilities occur in the OT. The most common sources of
sharps injuries are suture needles, followed by scalpels. There are many other items that can cause
sharps injuries and glove tears, resulting in exposure to blood and body fluids (see Tables 3-2 and 3-3).
These items include:
 Hypodermic needles
 Wire sutures
 Laparoscopy and surgical drain trocars
 Orthopedic drill bits, screws, pins, wires, and saws
 Needle-point cautery tips
 Skin hooks and towel clips
 Sharp-pointed scissors and sharp-tipped mosquito forceps
 Dissecting forceps
 Sharp-toothed tenacula

Table 3-2. Surgical Staff Injuries, by Instrument and Use

Instrument
Use Suture Needles Scalpel Blades Disposable Syringes
% % %
During use and passing
84% 70% 52%
between steps
Assembly/disassembly 5% 14% 8%
Recapping 0% 0% 11%

Infection Prevention and Control: Module 4, Chapter 3 51

Sharps Injuries and Exposure to Bloodborne Pathogens

Instrument
Use Suture Needles Scalpel Blades Disposable Syringes
% % %

After use/before disposal/

11% 16% 29%
during and after disposal
Total 100.0% 100.0% 100.0%

Adapted from: Jagger et al. 2010.

Table 3-3. Surgical Staff Injuries, by Cadre and Sharps

Surgical Staff
Instrument Surgical Surgical
Surgeons Nurses
Residents Technicians
Suture needles 51.5% 55.1% 35.2% 41.4%
Scalpel blades
12.2% 12.5% 17.2% 21.1%
(reusable/disposable)
Disposable syringes 10.8% 8.5% 16.5% 10.7%
Other (e.g., wire, retractors, IV
25.5% 23.9% 31.1% 26.8%
catheters)
Total 100.0% 100.0% 100.0% 100.0%

Source: Jagger et al. 2010.

Injury Occurrences
Suture needle injuries occur most often when:
 Loading or repositioning the needle in the needle holder
 Passing the needle hand to hand between team members
 Suturing using fingers to hold tissue
 Tying knots with the needle still attached or in the operative field
 Leaving the suture needle in the operative field before and after use
 Accidentally dropping needles and injuring body parts
 Placing needles in an overfilled sharps container or a poorly located container

Scalpel injuries most often occur when:

 Putting on and taking off the disposable blade
 Passing the scalpel hand to hand between team members
 Cutting (e.g., using fingers to hold or spread tissue or cutting toward the fingers of the surgeon or
assistant)
 Leaving the scalpel in the operative field before and after using it
 Accidentally dropping the scalpel and injuring body parts

52 Infection Prevention and Control: Module 4, Chapter 3

 Sharps Injuries and Exposure to Bloodborne Pathogens

 Reaching for a scalpel sliding off a drape

 Placing the scalpel in an overfilled or poorly located sharps container

Surgeons and first assistants (i.e., HCWs assisting with the

Note: Injuries are often self-inflicted.
surgery) have the highest risk of injury during a surgical
The most common body part injured
procedure. Hollow-bore vascular access needles are
is the non-dominant hand.
considered high-risk for transmission of infectious disease
among surgeons and first assistants. However, HCWs do not
always report their injuries and so they are not evaluated or given post-exposure prophylaxis (PEP),
making it challenging to track their risk of infection as well as transmission of the infection to patients.

Strategies to Prevent Needle Sticks and Other Sharps Injuries

General Strategies to Prevent Injuries
General strategies to prevent injuries include using alternative instruments, devices, or methods for the
task, whenever possible:
 Elimination of hazard—the complete removal of the hazard (e.g., substituting blunt-tipped needles
for sharp needles) and use of Standard Precautions (See Module 1, Chapter 2, Standard and
Transmission-Based Precautions, and Appendix 3-A, Engineering Controls for Preventing Sharps
Injuries.)
 Engineering controls—the minimization or removal of bloodborne pathogen hazards from the
workplace (e.g., placing sharp objects into sharps disposal containers, using self-sheathing needles
and needleless systems rather than exposed needles, using blunt suture needles)
 Administrative controls—the plans and policies aimed at limiting exposure to a hazard (e.g., an
exposure control plan, resources, policies, guidelines and protocols)
 Work practice controls—the reduction of the likelihood of exposure by altering the manner in which
a task is performed (e.g., prohibiting recapping of needles, using a two-handed technique or neutral
zone) (See Appendix 3-B, Neutral and Safe Zone Using Hands-Free Technique.)
 Visual Reminders—e.g., color-coding sharps and waste containers, and placing biohazard symbols
on contaminated items
 Barriers—use of personal protective equipment (PPE), which is designed to be used as a barrier
between the worker and the hazard (e.g., gloves, gowns, masks, eye protection, closed-toe shoes)

The following are specific measures the can be used to prevent Note: Educating HCWs on the safe
needle sticks and other sharps injuries (see Appendix 3-C for an handling of sharps reduces the risk
Operating Theater Sharps Safety Checklist and Appendix 3-D of injury.
for a Safe Assisting and Operating Checklist).

Infection Prevention and Control: Module 4, Chapter 3 53

Sharps Injuries and Exposure to Bloodborne Pathogens

Safe Injection Practices

Several studies have documented that unsafe injection practices are responsible for transmitting HIV,
HBV, and HCV to HCWs (Gupta et al. 2013). Safe injection practices include the following guidelines:
 Use each needle and syringe only once.
 Do not disassemble the needle and syringe after use.
 Do not recap, bend, or break needles prior to disposal.
 Place sharps disposal containers as close as possible to the point of use (e.g., within an arm’s reach).
 Dispose of the needle and syringe in a puncture-resistant container. Use improvised sharps
containers made from readily available “throw-away” items (e.g., empty metal containers, plastic
bottles, heavy-duty cardboard boxes) if commercially produced sharps containers are not available.
 Place the universal biohazard symbol on any container used to dispose of sharps.
 See Chapter 1, Injection Safety, in this module for more details.

Double Gloving
The transmission of HBV and HCV from HCWs to patients and vice versa can occur even in the absence
of breaks in proper surgical techniques with intact gloves. Even the best-quality latex rubber surgical and
non-sterile gloves may leak. After testing gloves for defects, the US Food and Drug Administration (FDA)
determined that the acceptable levels of leakage for surgical and non-sterile gloves are 1.5% and 2.5%
respectively. Defects in new gloves would be expected to be higher in gloves from manufacturers with
less stringent quality controls and where poor storage conditions exist. Latex gloves, especially when
exposed to fat in wounds and some alcohol-based handrubs, gradually become weaker and can lose
their integrity. (Davis 2001; FDA 2011; WHO 2009)

Double gloving cannot prevent needle sticks but may lower the risk of blood-hand contact, especially
with procedures that involve large amounts of blood or other body fluids (e.g., vaginal deliveries and
cesarean sections) and orthopedic procedures in which sharp bone fragments, wire sutures, and other
sharps are likely to be encountered. (See Module 3, Chapter 1, Personal Protective Equipment, and
Chapter 2, Infection Prevention and Control Aspects of Occupational Health in Health Care Settings, in
this module.)

Safe Handling of Instruments and Sharps

The goal with any procedure should be to effectively accomplish the procedure using the least
dangerous instruments or devices that will minimize risks to patients and HCWs. (Pyrek 2012)

Many sharps injuries can be easily avoided with little expense by using the following devices (see
Appendix 3-A) and procedures (see Appendix 3-C):
 Use small Mayo forceps (not fingers) when holding a scalpel blade, when putting a blade on or
taking it off, or for loading a suture needle.
 Use disposable scalpels with a permanent blade that cannot be removed.
 Use tissue forceps, not fingers, to hold tissue when using a scalpel or suturing or use blunt-tipped
needles for suturing.

54 Infection Prevention and Control: Module 4, Chapter 3

 Sharps Injuries and Exposure to Bloodborne Pathogens

 Use straight needles to help reduce sharps injuries during surgery. Other examples of instruments or
devices that protect the surgical team without sacrificing patient safety or staff performance are
shown in Table 3-4.
 Use a hands-free technique to pass or transfer sharps (e.g., scalpels, needles, and sharp-tipped
scissors) by establishing a safe or neutral zone in the sterile field. The hands-free technique for
sharps handling is inexpensive, is simple to practice, and ensures that more than one HCW never
touches the same instrument at the same time (see Appendix 3-B). (DeGirolamo et al. 2013; Fox
1992; Stringer et al. 2009)

Table 3-4. Reducing the Risk of Exposure in the Operating Theater

Function Safer Less Safe Avoid
Scalpel with removable
Skin incision Cautery Disposable scalpel
blade
Blunt-tipped scissors, or
Cutting Sharp-tipped scissors Scalpel
cautery probe
Blunt-tipped needles,
Hemostasis Sharp suture needles Wire sutures
staples, or cautery
Sponging with Assistant sponges
Surgeon does sponging; Assistant sponges but only
gauze while spontaneously (no
assistant only retracts by request
using a scalpel communication)
Retraction Blunt retractor Sharp retractor Fingers or hands
Hand to hand Hand to hand (no
Sharps transfer Neutral zone
(communication) communication)
Single pair of reprocessed
Surgical gloves Double gloving Single pair of gloves
gloves
Closing
peritoneum Purse-string closure using
Purse-string closure using
(small, 2- to 3-cm Do not close tissue forceps to grasp
fingers to grasp needle
or 1-inch needle
incision)

Source: Tietjen et al. 2003.

Communication to Reduce Sharps Injuries

 A brief pre-procedure discussion (also known as a time-out or huddle) on how sharps will be
handled by the team can be very helpful.
 The procedure team can review how to safely carry out each step during a procedure—e.g., from
securing the surgical drapes with non-perforating drape clips around the proposed incision to using
blunt-tipped needles for closure of all layers except the skin. (see Appendix 3-C for a list of safety
items that should be reviewed.)
 The risk associated with assisting in a procedure/surgery may be reduced by anticipating the needs
of the surgeon/doctor for each step in the procedure. When procedures are short (≤ 30 minutes)
and/or the steps are straightforward (e.g., dilation and curettage, central line insertion, or cesarean
section), this can be accomplished by developing a procedure checklist with each step or task listed
in the sequence in which it will usually be performed.

Infection Prevention and Control: Module 4, Chapter 3 55

Sharps Injuries and Exposure to Bloodborne Pathogens

 Reviewing the checklist with the surgical team just before starting the procedure and pointing out
where changes may be necessary will make the planned surgery go more smoothly and with less risk
of injury. This review can also help reduce the operation time and therefore protect patients from
injury or increased blood loss. (CDC 1997; Dauleh et al. 1994; Nelson 2008)

Management of Bloodborne Pathogen Exposures

It is easier to prevent accidental exposure to blood and body fluids than to manage accidental
exposures, however exposures still do occur. When an exposure occurs, it is important that HCWs are
aware of the necessary steps, including prompt management and evaluation for PEP. Where indicated,
PEP for HBV and HIV should be initiated as soon as possible, within 72 hours of exposure.

In many low- and middle-income countries, the proportion of HCWs offered PEP after a blood or body
fluid exposure has been poorly documented. Health care facilities should have a non-punitive system to
report occupational exposure. The rates of injuries or exposures among staff should be routinely
reviewed and reported back to the staff, and strategies and action plans to prevent future injuries
should be developed and regularly updated (see Chapter 2, Infection Prevention and Control Aspects of
Occupational Health in Health Care Settings, in this module).

Hepatitis B
Chronic hepatitis B is a global public health problem; 240 million individuals worldwide live with the
disease. Approximately 780,000 individuals (0.3% of infected individuals) die each year from HBV
infection. Guidelines are available for the treatment of HBV infections. A high percentage of patients
who survive become chronic carriers or are disabled and cannot work because of permanent liver
damage (i.e., cirrhosis). HBV is estimated to be 50–100 times more infectious than HIV (WHO 2015). It is
estimated that 37% of HBV infection among HCWs worldwide is attributable to occupational exposure to
sharps injuries. (Prüss-Üstün et al. 2005)

While an effective vaccine for HBV has been available for more than 30 years, many HCWs have not
been immunized against HBV. Health care facilities should prioritize hepatitis B vaccination for all HCWs.
Being vaccinated against HBV protects not only the individual, but also other HCWs, patients, and family
members. PEP is available for HBV exposure in the form of vaccination and immunoglobulin. (See
Chapter 2, Infection Prevention and Control Aspects of Occupational Health in Health Care Settings, in
this module for details on hepatitis B vaccination for HCWs.)

Hepatitis C
Hepatitis C has infected an estimated 130 to 150 million individuals worldwide, resulting in 350,000 to
500,000 deaths annually. Guidelines are available for the treatment of HCV infections. It is estimated
that 39% of HCV infection among HCWs worldwide are attributable to occupational exposure to sharps
injuries. (Prüss-Üstün et al. 2005)

Currently there is no vaccine or PEP available for HCV, and prevention of occupational exposure to blood
and body fluids remains the best option.

HIV
In 2016, 36.7 million people globally were living with HIV; 1.8 million people became newly infected with
HIV; and 1 million people died from AIDS-related illnesses. It is estimated that 4.4% of HIV infection

56 Infection Prevention and Control: Module 4, Chapter 3

 Sharps Injuries and Exposure to Bloodborne Pathogens

among HCWs worldwide are attributable to occupational exposure to sharps injuries. (Prüss-Üstün et al.
2005)

Currently there is no vaccine available for HIV. PEP is available for HIV exposure in the form of
antiretroviral (ARV) drugs.

Post-Exposure Management Steps (HBV, HCV, and HIV)

The aim of post-exposure reporting and follow-up is to start PEP as soon as possible, within 72 hours of
exposure, if indicated. The key components of managing occupational exposure to bloodborne
pathogens are described below.

STEP 1: Time frame—immediately, within 30 minutes. Person responsible: Exposed HCW.

Provide immediate care to the exposure site:
 Wash the exposed skin and any wound with soap and water.
 Flush mucous membranes with water for 15 minutes.
 DO NOT use any antiseptic or caustic agents such as bleach.
 After washing, immediately report the event to the person in charge of PEP management. The
information reported should include identification of the exposed person, date and time of
exposure, type of fluid and nature of exposure, and details about the source person as
recommended by national PEP guidelines.

STEP 2: Time frame—immediately after reporting. Person responsible: Physician, In-Charge of PEP
management.
 Determine the risk associated with exposure (see Table 3-5) by:
 Type of fluid (e.g., blood, visibly bloody fluid, other potentially infectious fluid or tissue)
 Type of exposure (e.g., sharps injury, mucous membrane or non-intact skin exposure, bites
resulting in direct contact with infected blood) (CDC 2001)
 Infectious status of source (presence of HBSAg, HCV antibody, or HIV antibody)
 Susceptibility of exposed person (hepatitis B vaccine and vaccine response status, HBV, HCV
immune status)

Table 3-5. HIV Exposure Risk and Type of Exposure

Risk Type of Exposure
Low-risk exposure Exposure to a small volume of blood or blood-contaminated fluids from
asymptomatic HIV-positive patients
Following an injury with a solid needle
Any superficial injury or mucocutaneous exposure
High-risk exposure Exposure to a large volume of blood or potentially infectious fluids or blood-
contaminated fluid
Exposure to blood or body fluid from a patient with clinical AIDS or early
seroconversion phase of HIV
Injury with a hollow needle and/or deep and extensive injuries

Infection Prevention and Control: Module 4, Chapter 3 57

Sharps Injuries and Exposure to Bloodborne Pathogens

STEP 3: Time frame—as soon as possible, preferably within 24 hours. Person responsible: Physician, In-
Charge of PEP management, HCW.
 Evaluate the exposed HCW:
 Check history of hepatitis B vaccination (currently there is no vaccine for hepatitis C or HIV).
 Determine immune and infection status of the exposed HCW.
 For HBV, if not conducted previously, measure total hepatitis B core antibodies (anti-HBc)1 and
hepatitis B surface antibodies (anti-HBs).2
 For HCV, test for HCV antibodies (anti-HCV—a positive test means current or past infection) and ALT
(alanine aminotransferase).
 If test is positive, test for viremia to confirm current infections.
 For HIV, check status and history of previous HIV testing:
 Provide HIV pretest counseling.
 Offer HIV testing if the exposed HCW provides informed consent.
 Offer HIV post-test counseling per the national counseling and testing guidelines.
 Refer to HIV care and treatment for those who test positive.

STEP 4: Time frame—as soon as possible, preferably within 24 hours, simultaneously with Step 3 above.
Person responsible: In-Charge of PEP management, patient’s treating physician.
 Evaluate the exposure source:
 Obtain detailed information on clinical status of the source person.
 Determine vaccination and immune status of the source person:
> Test known source person for HBsAg.3
> Test known source person for anti-HCV antibodies.
> Check known source person for HIV status and history of previous HIV testing.
> Conduct clinical assessment of known source person for HIV/AIDS.
 Provide HIV pretest counseling.
 Conduct HIV testing if the source person provides informed consent.
 Offer HIV post-test counseling per the national counseling and testing guidelines.
 Refer to HIV care and treatment for those who test positive.

1 Total hepatitis B core antibody (anti-HBc)—indicates previous or ongoing infection with HBV (CDC. Hepatitis).
2 Hepatitis B surface antibody (anti-HBs)—generally indicates recovery and immunity from HBV infection. Anti-HBs also develop
in a person who has been successfully vaccinated against HBV (CDC. Hepatitis).
3 Hepatitis B surface antigen (HBsAg)—indicates that the person is infectious (CDC. Hepatitis).

58 Infection Prevention and Control: Module 4, Chapter 3

 Sharps Injuries and Exposure to Bloodborne Pathogens

Table 3-6. Determinant for Post-Exposure Prophylaxis for Occupational Exposure to HBV
Vaccination and Treatment
Antibody
Response Status
of Exposed Source Unknown or Not
Source HBsAga Positive Source HBsAg Negative
Health Care Available for Testing
Worker
Previously No treatment No treatment No treatment
vaccinated
Unvaccinated HBIGb single dose and full Full HB vaccination Full HB vaccination
HB vaccination
Known responderc No treatment No treatment No treatment
Known non- HBIG single dose and No treatment If known high-risk source,
responderd revaccination or second manage as if source were
dose of HBIG HBsAg positive
Antibody response Test exposed person for No treatment Test exposed person for
unknown anti-HBse: anti-HBs:
If adequate level, no If adequate, no treatment
treatment is necessary; is necessary;
if inadequate level, HBIG if inadequate, vaccine
single dose and HB vaccine booster and check titer in
booster 1–2 months
a
HBsAg: hepatitis B surface antigen
b
HBIG: hepatitis B immunoglobulin
c
Known responder: a person who has an adequate level of serum antibody (anti-HBs ≥ 10 mIU/mL
d
Known non-responder: a person with inadequate response to vaccination (anti-HBs < 10 mIU/mL)
e
Anti-HBs: hepatitis B surface antibody
Source: CDC 2001.

STEP 5: Time frame—as soon as test results return (if any), must be within 72 hours from exposure.
Person responsible: Physician, In-Charge of PEP management, HCW.
 Establish eligibility for PEP:
 Refer to Table 3-6 to determine the PEP required for HBV exposure.
 Parenteral or mucous membrane exposure (e.g., sexual exposure, splashes to the eye, nose, or
oral cavity)
 Exposure to blood, blood-stained saliva, breast milk, genital secretions, or cerebrospinal,
amniotic, peritoneal, synovial, pericardial, or pleural fluids
 PEP is not indicated if:
 The exposed HCW is known to be HIV-positive.
 The source person is HIV-negative.
 Exposure is limited to intact skin.

Infection Prevention and Control: Module 4, Chapter 3 59

Sharps Injuries and Exposure to Bloodborne Pathogens

 Testing the source person and the exposed HCW is helpful but it is not mandatory to have either
test results to initiate HIV PEP. The decision is sometimes based on an individual’s level of concern
as well as background HIV prevalence.

STEP 6: Prescribe PEP: Time frame—initiate PEP as early as possible but within 72 hours.
 Continue ARVs for HIV for 28 days.
 Continue HBV vaccine schedule over 6 months.
 Provide adherence counseling and address any drug interactions.
 Follow national guidelines or WHO recommendations for PEP.

STEP 7: Time frame—72 hours―6 months after exposure. Person responsible: Physician, In Charge of
PEP Management, HCW.
 Follow-up:
 Provide follow-up for adherence and any side effects of ARVs and address questions that the
individual may have.
 Arrange for an HIV test at 3 months after the exposure.
 Arrange for HBV vaccine at 1 and 6 months, if indicated.
 Link HIV care and treatment, including prevention measure for protecting others, in case the HIV
test results are positive.
 Provide additional counseling and other preventive interventions, as needed, and if test results
are negative.
 Document all PEP provided, following facility and national guidelines.
 Monitor PEP provision in the facility.

Summary
Globally, HCWs are at risk of exposure to bloodborne pathogens because they handle sharps and come
into contact with blood and body fluids during the course of their duties. Certain practices and particular
equipment and instruments used in health care increase the risk of exposure to blood and body fluids.
Strategies to prevent injuries include, in general, eliminating hazards, using engineering controls,
developing administrative controls, incorporating work practice controls, placing visual reminders, and
utilizing barriers, whenever possible.

It is better to prevent accidental exposure to blood and body fluids than to manage exposed HCWs.
However, when exposure occurs, it is important that HCWs are aware of the necessary steps, including
prompt management and evaluation for PEP. HCWs often do not report exposures or take advantage of
PEP after occupational exposures. For those who do, adherence can be an issue: the adherence to HIV
PEP was found to be 56% in a systemic review of studies on PEP (WHO 2014a). Understanding the risk is
important for all HCWs. Implementing recommended IPC practices, technological advances, and a
greater emphasis on a culture of safety in health care facilities can reduced occupational exposure in
many settings. Health care facilities should have a non-punitive system for HCWs to report occupational
exposure and obtain access to PEP.

60 Infection Prevention and Control: Module 4, Chapter 3

 Sharps Injuries and Exposure to Bloodborne Pathogens

Appendix 3-A. Engineering Controls for Preventing

Sharps Injuries
Table A-1. Examples of Good Engineering Controls for Preventing Sharps Injuries

1. Blunt-tipped
needle

2. Blunt retractor

3. Scalpel:
disposable,
retractable
safety scalpel

4. Stapler for
closing surgical
skin incision

5. Safe butterfly
needle that can
be drawn in
before
discarding

Blunt-Tipped Needles
More than half of all suture needle injuries occur during the suturing of muscles and fascia. Using blunt-
tipped needles can substantially reduce needle sticks. When used appropriately, these needles are as

Infection Prevention and Control: Module 4, Chapter 3 61

Sharps Injuries and Exposure to Bloodborne Pathogens

effective as sharp-tipped needles; therefore, it is recommended that, where possible, surgeons use
blunt-tipped needles when closing fascia and muscles. (OSHA 2008)

The Technique for Using Blunt-Tipped Needles

STEP 1: Use a strong needle holder and lock it fully.
STEP 2: Position the needle in the holder in the mid-curve rather than three-quarters of the way back to
prevent slippage or bending the needle. (This usually is not necessary when using minimally blunt-tipped
needles.)
STEP 3: Grasp and hold the tissue to be sutured with tissue forceps to make it easier for the needle to go
through the tissue being sutured. In general, the blunter the tip, the more important it is to follow these
steps.
STEP 4: Dispose of sharps in an adequate, leak-proof sharps container (see Module 5, Chapter 5, Waste
Management in Health Care Facilities).

Sharps Containers
Examples of the different types of sharps containers include:
 Ready-made plastic sharps containers are generally bright yellow in color with a biohazard symbol
on the outside.
 Thick cardboard sharps boxes designed by WHO and UNICEF are water-resistant and can hold up to
150 needles and syringes in one container.
 Improvised sharps containers can be used for disposing of used needles (see below). Needles must
be detached from the syringe before being dropped through the hole in the top of the lid.

Improvised Sharps Containers

Obtaining ready-made sharps containers on a regular basis may be challenging in low-resource settings.
In facilities where they are not available, HCWs can make low-cost sharps containers from readily
available leak-proof, puncture-resistant “throw-away” items (e.g., empty metal containers or plastic
bottles).

Improvised containers should be labeled as hazardous, able to be completely closed, used only for
needles (if syringes since may not fit into the opening of the container), and tightly sealed before
disposal to prevent them from being opened.
Recommendations for Using Sharps Containers
 DO put sharps containers as close to the point of use as possible, ideally within an arm’s reach of
the treatment area. Containers should be easy to see, recognize, and use.
 DO attach containers to walls or other surfaces, if at all possible, at a level at which the HCW can
easily see the disposal opening.
 DO mark them clearly so that people will not use them as garbage containers or for discarding
debris.
 DO mark the fill line at the three-quarters-full level.
 DO replace the container when it reaches the fill line (three-quarters full).

62 Infection Prevention and Control: Module 4, Chapter 3

 Sharps Injuries and Exposure to Bloodborne Pathogens

 DO NOT overfill sharps containers.

 DO NOT place non-sharps in the sharps container.
 DO NOT shake a container to settle its contents and make room for more sharps.
 DO NOT place containers in high-traffic areas (e.g., in corridors, thoroughfares, or waiting areas)
where individuals could bump into them or accidently be stuck by someone carrying sharps to be
disposed of.
 DO NOT place containers on the floor or anywhere they could be knocked over or easily reached by
a child.
 DO NOT place containers near light switches, overhead fans, or thermostat controls where people
might accidentally put their hand into them.

Infection Prevention and Control: Module 4, Chapter 3 63

Sharps Injuries and Exposure to Bloodborne Pathogens

Appendix 3-B. Neutral and Safe Zone Using Hands-Free

Technique
The designated neutral or safe zone is where sharps are placed before and immediately after use.4 For
example, the surgical assistant or scrub nurse alerts the surgeon that a sharp instrument has been
placed in or on the safe zone, with the handle pointing toward the surgeon, by saying “scalpel” or
“sharp” while placing it in the safe zone. The surgeon then picks up the instrument and returns it to the
safe-zone container after use, this time with the handle pointing away from the surgeon.

Instruments passed with the hands-free technique include anything sharp enough to puncture a glove
(e.g., trocars, sharp-tipped mosquito forceps, loaded needle holders). The ideal container for a neutral
or safe zone should be large enough to hold sharps, not easy to tip over, preferably mobile in the
operative field, and easy to move between HCWs (e.g., Mayo stand or magnetic pad). Avoid using a
kidney tray as the designated “pass container” because the surgical team member must reach into the
narrow space, causing an increased risk of a sharps injury.

A “partial” hands-free technique may be used when the surgeon must not break eye contact with the
operative field or when a microscope is used. This involves the surgical assistant or scrub nurse directly
handing the sharp instrument to the surgeon. The surgeon later returns the sharp to the scrub nurse by
placing it in a neutral zone.

4 Various items (e.g., basins, mats or trays, parts of a sterile instrument stand) or a designated area in the operative field can be

used as the safe zone.

64 Infection Prevention and Control: Module 4, Chapter 3

 Sharps Injuries and Exposure to Bloodborne Pathogens

Appendix 3-C. Operating Theater Sharps Safety

Checklist
Requirements for Perioperative Health Care Workers
 Obtain hepatitis B vaccination and determination of anti-HBs after completion of the vaccination
cycle.
 Report sharps injuries.
 Use Standard Precautions with all patients.

Personal Protective Equipment

 Protective eyewear (e.g., goggles, mask with face shield)
 Protective face masks (e.g., surgical masks, surgical N95 respirators)
 Gowns resistant to blood and body fluid penetration
 Impervious footwear/shoe covers
 Double gloves

Work Practice Controls

 Surgeon/Assistant: Right-handed ____ Left-handed ____
 Situational awareness (i.e., knowing and communicating the location of sharps)
 Neutral zone identified and in place
 No-touch or “partial” hands-free technique used when handling sharps
 Elimination of unnecessary sharp instrumentation (e.g., towel clips, retractors)
 Procedure plan for sharps management (e.g., unusual shaped and sized trocars and pins)
 Alternative cutting methods (e.g., blunt-tipped cautery) (when appropriate)
 Scalpels with safety features (e.g., disposable, retracting-blade, and shielded-blade scalpels)
 Syringes, needles, and IV catheters with safety engineered features
 Blunt-tipped needles (when appropriate)
 Appropriate retractors to avoid manual tissue retraction (e.g., mechanical retraction devices, blunt
retractors)
 Alternative wound closure methods when appropriate (e.g., blunt-tipped needles, stapling devices,
adhesive strips, tissue adhesives)

Sharps Management and Disposal Devices

 Sharps/needle counter to contain/isolate sharps on the sterile back table
 Needle-capping devices/no recapping of needles
 Scalpel blade removers or forceps to remove blade

Infection Prevention and Control: Module 4, Chapter 3 65

Sharps Injuries and Exposure to Bloodborne Pathogens

 Sharps disposal container that is puncture-resistant, leak-proof, prevents over-filling, has a change
indicator, and is readily accessible
 Separate contaminated, reusable sharps container with biohazard symbols for transport to the
decontamination area

Source: AORN. Sharps Safety Tool Kit.

66 Infection Prevention and Control: Module 4, Chapter 3

 Sharps Injuries and Exposure to Bloodborne Pathogens

Appendix 3-D. Safe Assisting and Operating Checklist

During Preparation for Surgery or Invasive Procedure
 Inspect surgical field for adequate lighting and space.
 Point sharps away from team members.
 Use standardized sterile field setup.
 Include identification of the neutral zone in the pre-operation briefing.

During the Operative Procedure

 Monitor for glove punctures.
 Use blunt-tipped needles unless clinically contraindicated (e.g., scarred fascia).
 Use safety scalpel (when clinically feasible).
 Use alternative wound closure devices (when clinically indicated).
 Use syringes/needles with safety features.
 Take steps to track/account for location of sharps.
 Use forceps to attach or detach scalpel blade to/from handle.
 Avoid handling suture needles manually.
 Do not keep scalpel, loaded needle holder, or any other sharp in the same hand simultaneously with
another instrument.
 Place sharps off the operative field unless in use.
 Employ a proper safe zone for the safe passing of sharps or a modified neutral zone (e.g., use limited
hands-free technique).
 Use verbal warnings to announce transfer of sharps.
 Remove the needle from the suture before tying, park the needle safely, and protect the needle
point with the needle holder or use “control release” sutures to allow the needle to be removed
with a straight pull on the needle holder.
 Load the suture onto the needle holder using the suture packet to position the needle.
 Avoid finger contact with tissue being sutured or cut.
 Keep hands away from the surgical site when sharp items are being used (e.g., suturing or cutting).
 Use retractors rather than manually retracting (whenever possible).
 Avoid reflex sponging of tissue when a sharp is in use.
 Pass long laparoscopic instruments (e.g., sharp-pointed scissors) handle first and tip down.
 Replace the shield on the tip of a drain trocar with an instrument, not the fingers, before pulling the
trocar out of the exit wound.
 Stick the needle in a rolled, sterile towel when not in use, when doing repeat injections with a
hypodermic needle/syringe.
 Use sharps/needle counter devices to contain and isolate sharps on the sterile back table.
 Use gloves and an instrument to pick up sharps that have fallen on the floor.

During Post-Procedure Cleanup

 Inspect the surgical setup used during the procedure for sharps.
 Separate contaminated, reusable sharps (e.g., skin hooks, trocars) from non-sharp instruments after
use for transport to the designated decontamination area in a puncture-resistant, contaminated-
waste container that has a biohazard symbol on it.

Adapted from: Tietjen et al. 2003.

Infection Prevention and Control: Module 4, Chapter 3 67

Sharps Injuries and Exposure to Bloodborne Pathogens

References
Association of periOperative Registered Nurses (AORN). 2014. Recommended practices for sharps
safety. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.
AORN. n.d. Sharps Safety Tool Kit. OR Sharps Safety Checklist. http://www.aorn.org/aorn-
org/guidelines/clinical-resources/tool-kits/sharps-safety-tool-kit.
Centers for Disease Control and Prevention (CDC). 1997. Evaluation of blunt suture needles in
preventing percutaneous injuries among health-care workers during gynecological surgical procedures.
MMWR. 46(2):25–29.
CDC. 2001. Updated U.S. Public Health Service guidelines for the management of occupational
exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR. 50(RR-
11):1–52. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm.
CDC. 2008. Acute hepatitis C virus infections attributed to unsafe injection practices at an endoscopy
clinic—Nevada, 2007. MMWR. 57:513–517.
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5719a2.htm.
CDC. n.d. Hepatitis. Interpretation of Hepatitis B Serologic Test Results.
http://www.cdc.gov/hepatitis/HBV/PDFs/SerologicChartv8.pdf.
CDC. n.d. One Needle, One Syringe, Only One Time. http://www.oneandonlycampaign.org/.
Dagi TF, Berguer R, Moore S, Reines HD. 2007. Preventable errors in the operating room Part 2: retained
foreign objects, sharps injuries, and wrong site surgery. Curr Probl Surg. 44(6):352–381.
Dauleh MI, Irving AD, Townell NH. 1994. Needle prick injury to the surgeon—do we need sharp needles?
J R Coll Surg Edinb. 39(5):310–311.
Davis MS. 2001. Advanced Precautions for Today’s OR: The Operating Room Professional's Handbook for
the Prevention of Sharps Injuries and Bloodborne Exposures, 2nd ed. Atlanta, GA: Sweinbinder
Publications LLC.
DeGirolamo KM, Courtemanche DJ, Hill WD, Kennedy A, Skarsgard ED. 2013. Use of safety scalpels and
other safety practices to reduce sharps injury in the operating room: what is the evidence? Can J Surg.
56(4):263–269.
Food and Drug Administration (FDA), US Department of Health and Human Services. 2011. Compliance
Policy Guide Sec. 335.700 Surgeons’ Gloves and Patient Examination Gloves; Defects – Criteria for Direct
Reference Seizure: Guidance for FDA Staff.
http://www.fda.gov/downloads/ICECI/ComplianceManuals/CompliancePolicyGuidanceManual/UCM255
705.pdf.
Fox V. 1992. Passing surgical instruments, sharps without injury. AORN J. 55(1):264–266.
Gupta E, Bajpai M, Sharma P, Shah A, Sarin SK. 2013. Unsafe injection practices: a potential weapon for
the outbreak of blood borne viruses in the community. Ann Med Health Sci Res. 3(2):177–181.
International Health Care Worker Safety Center, University of Virginia. n.d. Checklist for Sharps Injury
Prevention. http://www.medicalcenter.virginia.edu/epinet/new/chcklst2.pdf.
Jagger J, Berguer R, Phillips EK, Parker G, Gomaa AE. 2010. Increase of sharps injuries in surgical settings
versus nonsurgical settings after passage of national needlestick legislation. J Am Coll Surg. 210(4):496–
502.

68 Infection Prevention and Control: Module 4, Chapter 3

 Sharps Injuries and Exposure to Bloodborne Pathogens

Makary MA, Pronovost PJ, Weiss ES, et al. 2006. Sharpless surgery: a prospective study of the feasibility
of performing operations using non-sharp techniques in an urban, university-based surgical practice.
World J Surg. 30(7):1224–1229.
Manangan LP, Pugliese G, Jackson M, et al. 2001. Infection control dogma: top 10 suspects. Infect
Control Hosp Epidemiol. 22(4):243–247.
Nelson BP. 2008. Making straight suture needles a little safer: a technique to keep fingers from harm’s
way. J Emerg Med. 34(2):195–197.
Occupational Safety and Health Administration (OSHA), US Department of Labor, National Institute for
Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC). 2008. Use of
Blunt-Tip Suture Needles to Decrease Percutaneous Injuries to Surgical Personnel.
https://www.cdc.gov/niosh/docs/2008-101/pdfs/2008-101.pdf.
Pyrek KM. 2012. Occupational health: sharps safety in the OR. Infection Control Today.
http://www.infectioncontroltoday.com/articles/2012/10/occupational-health-sharps-safety-in-the-
or.aspx.
Pyrek KM. 2013. Sharps safety: taking the “unfinished agenda” to completion. Infection Control Today.
http://www.infectioncontroltoday.com/articles/2013/10/sharps-safety-taking-the-unfinished-agenda-
to-completion.aspx.
Rapiti E, Prüss-Üstün A, Hutin Y. 2005. Sharps Injuries: Assessing the Burden of Disease from Sharps
Injuries to Health-Care Workers at National and Local Levels. WHO Environmental Burden of Disease
Series, No. 11. Geneva, Switzerland: WHO.
http://www.who.int/quantifying_ehimpacts/publications/ebd11.pdf?ua=1.
Stringer B, Haines T, Goldsmith CH, et al. 2009. Hands-free technique in the operating room: reduction
in body fluid exposure and the value of a training video. Public Health Rep. 124(Suppl 1):169–179.
Tietjen L, Bossemeyer D, McIntosh N. 2003. Infection Prevention: Guidelines for Healthcare Facilities
with Limited Resources. Baltimore, MD: Jhpiego.
Tso D, Langer M, Blair GK, Butterworth S. 2012. Sharps-handling practices among junior surgical
residents: a video analysis. Can J Surg. 55(4):S178–S183.
WHO. 2007. Standard Precautions in Health Care.
http://www.who.int/csr/resources/publications/standardprecautions/en/.
WHO. 2009. Glove Use Information Leaflet.
http://www.who.int/gpsc/5may/Glove_Use_Information_Leaflet.pdf.
WHO. 2014a. Guidelines on Post-Exposure Prophylaxis for HIV and the Use of Co-Trimoxazole Prophylaxis
for HIV-Related Infections among Adults, Adolescents and Children: Recommendations for a Public
Health Approach; December 2014 Supplement to the 2013 Consolidated Guidelines on the Use of
Antiretroviral Drugs for Treating and Preventing HIV Infection. Supplement. Geneva, Switzerland: WHO.
http://apps.who.int/iris/bitstream/10665/145719/1/9789241508193_eng.pdf?ua=1&ua=1.
WHO. 2014b. WHO Issues Its First Hepatitis C Treatment Guidelines.
http://www.who.int/mediacentre/news/releases/2014/hepatitis-guidelines/en/.
WHO. 2015. Hepatitis B. http://www.who.int/mediacentre/factsheets/fs204/en/.
WHO, International Labour Organization (ILO). 2005. Joint ILO/WHO Guidelines on Health Services and
HIV/AIDS. Geneva, Switzerland: WHO and ILO.
http://www.who.int/hiv/pub/prev_care/ilowhoguidelines.pdf?ua=1.

Infection Prevention and Control: Module 4, Chapter 3 69