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OSHA BLOOD-BORNE
PATHOGENS STANDARD:
MANAGEMENT OF EXPOSURE TO
BLOOD-BORNE PATHOGENS
Dana Bartlett, RN, BSN, MSN, MA, CSPI
Dana Bartlett graduated from the University of
Massachusetts with a B.S. in nursing in 1976; he has an
M.S. in nursing from Boston University, 1978, and an M.A.
in journalism from Temple University, 1988. He has 17
years of clinical nursing experience, primarily ER, and 25 years of poison control
experience. He is currently employed by the Rocky Mountain Poison Control Center in
Denver Colorado as a Certified Specialist in Poison Information. Mr. Bartlett has
published almost 200 on-line continuing education modules; written for Critical Care
Nurse, Journal of Emergency Nursing, American Nurse Today, Nursing, and other
peer-reviewed journals. In addition, he has written textbook chapters, NCLEX test
material, and done editing and reviewing for publishers such as Elsevier and
Lippincott Williams & Wilkins.
Abstract
Healthcare workers are continuously exposed to hazards of blood-
borne pathogen transmission. Many bacteria and viruses may be
transmitted to healthcare workers by needlesticks, sharps injury, or
splash contact. Hepatitis B, hepatitis C, and the human
immunodeficiency virus account for the greatest number of exposures
and infections. Important aspects of the Occupational Safety and
Health Administration standard and information on the management of
exposure to blood-borne pathogens are discussed.
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Policy Statement
This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses. It is the policy of
NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all continuing nursing education (CNE)
activities.
Continuing Education Credit Designation
This educational activity is credited for 2 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this
course activity. Pharmacy content is 0.5 hours (30 minutes).
Statement of Learning Need
All front-line healthcare workers, physicians, nurses, and assistive
personnel, need to know Occupational Safety and Health
Administration (OSHA) safety protocol to prevent and to report
exposure to blood-borne pathogens, in addition to initial interventions
for exposure.
Course Purpose
To provide health clinicians with basic knowledge of OSHA
recommendations for prevention of, exposure to, diagnosis and
treatment of blood-borne pathogens.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses
and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Dana Bartlett, RN, BSN, MSN, MA, CSPI, William S. Cook, PhD,
Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC –
all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge,
on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.
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1. The majority of occupational exposures to blood-borne pathogens are:
a. Percutaneous.
b. Air-borne. c. Cutaneous.
d. Percutaneous and cutaneous together.
2. The primary focus on post-exposure management of blood-borne pathogens in occupational exposures for healthcare workers are:
a. hepatitis B, hepatitis A, and MRSA.
b. hepatitis C, HIV, and tuberculosis. c. hepatitis B, hepatitis C, and HIV.
d. hepatitis A, HIV, and gram-negative bacteria.
3. The risk of HIV transmission after a percutaneous exposure is
approximately:
a. 3.0%. b. 0.32%.
c. 30%. d. 13%.
4. True or false: Infection with a blood-borne pathogen can occur
after contact with a contaminated surface.
a. True. b. False.
5. The first step in managing an exposure to a blood-borne pathogen is:
a. testing of the source patient
b. notifying the employee health department. c. testing of the affected healthcare professional.
d. to clean the exposed area.
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Introduction
Exposure to blood-borne pathogens is a serious, ongoing hazard for
healthcare workers and the Occupational Safety and Health
Administration (OSHA) developed a standard that was designed to
protect at-risk employees: the blood-borne pathogens standard, which
is identified by the Code of Federal Regulations number CFR
1910.1030.1 The standard was amended in 2001 to include the
Needlestick Safety and Prevention Act, and CFR 1910.1030 provides
definitions of risk situations, recommendations for the prevention of
exposures to blood-borne pathogens, and recommendations for the
management of exposures to blood-borne pathogens. Because
healthcare workers have considerable risk for exposure to blood-borne
pathogens, they are required to have a basic knowledge of, and
comply with, the recommendations of the OSHA blood-borne
pathogens standard.
Epidemiology Of Exposures To Blood-Borne Pathogens
Many bacteria and viruses can be transmitted to healthcare workers by
needlesticks, sharps injury, or splash contact, but hepatitis B, hepatitis
C, and the human immunodeficiency virus (HIV) account for the
greatest number of exposures and infections.2 The majority of
occupational exposures to and infections from these viruses are
caused by percutaneous injury. The term percutaneous injury refers to
any puncture of the surface of the skin such as a needlestick and a
sharps injury, the latter being a puncture of the skin from a scalpel, a
trochar, or any other medical device or instrument.2,3
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The exact incidence of needlesticks, sharps injuries, and splash
exposures are not known, but it is clear they are a common
occurrence, as seen by the following reports.
• The Centers for Disease Control and Prevention (CDC) has
estimated that in the United States there are 385,000 needlesticks
every year.4
• The Exposure Prevention and Information Network (EPInet™)
noted in their 2015 report that the number of needlestick injuries
was 31.7 per 100 occupied beds.5
• Henderson (2012) estimated that each year almost 1 of every 10
healthcare workers in the United States has a needlestick
exposure,6 and a 2018 article that had surveyed 358 medical
students and 247 members of the staff of the department of
surgery found that 38.7% of those who responded had had a
needlestick injury.7
A review of the literature shows that the most frequent blood and body
exposures were reported by nurses (48.6 percent), physicians in
resident or fellowship training (7.7 percent) and those attending (7.7
percent), non-lab technologists (4.5 percent), respiratory therapists
(3.6 percent), and certified nursing assistants or home health aides
(3.2 percent).8 A factor contributing to a threefold increase of
accidental needle stick injuries included long work hours and sleep
deprivation.
Under-reporting of needlestick injuries, sharps injuries, and splash
contacts with potentially infectious fluids is not unusual. In a 2015
publication The Centers for Disease Control and Prevention noted that
more than 50% or more of these incidents are not reported,4 and
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more recent information (2017, 2018) noted that 33%-66% of these
injuries were not reported.7,9 Nurses, for example, work in a wide
variety of patient care areas, i.e., emergency room (ER), intensive
care unit (ICU), and operating room (OR), they frequently will use
needles and handle sharps, and they are often exposed to blood and
body fluids. These factors increase the nursing risk for exposure and
needlesticks, sharps injuries, and splash exposures.
Risk Of Infection After Occupational Exposure
The risk of infection after an occupational exposure to a blood-borne
pathogen depends on many factors and the viral load of the source
(the patient) is probably the most critical of these. Infection is least
likely from a splash contact (cutaneous exposure), and it is most likely
from a deep puncture by a large-gauge, hollow bore needle that
contains a large amount of blood that has a high viral load.8
Simultaneous transmission of several blood-borne pathogens from a
needlestick has been reported.6
Factors For Infection After A Blood-borne Pathogen Exposure6,8
Amount of blood injected
Availability/efficacy of post-exposure prophylaxis
Depth of the injury
Health status of the source person
Hollow bore needle
Immune system competency
Placement of the injuring device in an artery or a vein
Prevalence of the pathogen in the population
The pathogen
Type of injury, i.e., puncture wound versus splash contact
Viral load
Visible blood on a needle or sharp
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The risk of infection after a percutaneous exposure to HIV is estimated
to be 0.3%8 and the risk for infection after a mucous membrane
exposure to HIV, such as splash to an eye, has been estimated to be
one infection per 1000 exposures.8,10 No transmission of HIV through
intact skin has been documented. All known sero-conversions from
occupational exposure to HIV have occurred after exposure to blood,
bloody fluids, or viral cultures.8,10 Semen, vaginal fluids, and body
fluids visibly contaminated with blood can transmit HIV, and amniotic
fluid, cerebrospinal fluid, pericardial fluid, peritoneal fluid, pleural, and
synovial fluid are potentially HIV-infected. Feces, gastrointestinal
fluids, nasal secretions, saliva, sputum, sweat, tears, urine, and
vomitus are not considered to be HIV infectious unless they contain
blood.8,10
The risk for transmission after exposure to fluids or tissues other than
HIV-infected blood has not been quantified but is probably low.8 In
most reported cases of HIV transmission, needlestick injury occurred
within seconds or minutes after the needle was withdrawn from the
source patient. From 1985 to 2013, there were 58 documented cases
of acquired HIV seroconversion reported to the CDC.11
The CDC reported that an estimated 5.6 million healthcare workers
and related occupations are at risk of occupational exposure to blood-
borne pathogens, including hepatitis B virus (HBV) and hepatitis C
virus (HCV).13 The primary focus on post-exposure management of
blood-borne pathogens in occupational exposures for healthcare
workers is on hepatitis B, hepatitis C and HIV, although greater than
30 different pathogens have caused documented occupational infection
following exposure to blood or body fluids.13
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Hepatitis B virus (HBV) is known to be highly infectious.13 Infection in
healthcare workers with hepatitis B who have not had a needlestick or
other percutaneous exposure could be due to exposure to the virus
through an abrasion, a burn, a scratch, or a mucous membrane,14 and
in approximately two-thirds of all people infected with hepatitis B, no
needlestick was identified.15 Hepatitis B surface antigen is found in
other body fluids aside from blood such as bile, breast milk,
cerebrospinal fluid, feces, nasopharyngeal washings, saliva, semen,
sweat, and synovial fluid. However, these fluids contain low levels of
the virus and exposure to them would not be likely to cause hepatitis B
infection.14
The risk for infection after percutaneous exposure to hepatitis C has
been estimated to be approximately 1.8 percent (range, 0 to 7
percent) after a needle stick or sharps exposures from an HCV-positive
source.13 Approximately 39% of all hepatitis C infections in healthcare
workers are considered to be occupational.16 Infection with hepatitis C
after mucous membrane exposure is considered to be unlikely, but
infection after conjunctival or ocular exposure has been reported.
Hepatitis C virus has been found in ascites, menstrual fluid, saliva,
semen, spinal fluid, and urine. These fluids have a much lower
hepatitis C viral content than blood and transmission of the virus from
these fluids has not been reported,17 but if they were contaminated
with blood or if there was a large exposure, transmission and infection
could occur.
Blood-borne pathogens can contaminate surfaces and persist in
the environment and contact with these contaminated surfaces
can cause infection. Hepatitis B and HIV in dried blood can
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remain on surfaces for a week and hepatitis B is capable of
causing infection during that time. Hepatitis C also can survive
outside the body on environmental surfaces and it can remain
survive at room temperatures on surfaces for up to three
weeks.18
Needlestick Injuries and Other Exposures
Needlestick injuries and other exposures to blood-borne
pathogens are usually caused by human error. These errors
can involve personal and organizational issues, and factors such as
poor staffing, a relative lack of nursing experience, long hours at work,
stress and fatigue, and poor or improper use of equipment have been
identified as causes of needlestick injuries.19,20 The most common
situations involving needlestick injuries and other exposures to blood-
borne pathogens are shown in the following table.
At-Risk Situations for Needle-stick Injuries
Accessing an intravenous (IV) line
Cleanup
Collision with another nurse or another healthcare worker
Manipulating the needle while it is in a patient
Passing a needle or a sharp
Poor or improper disposal technique
Puncturing skin with a needle or a sharp
Suturing
Recapping needles
Transferring blood from one container to another
Equipment that must be manipulated after or during use (such as
disposable syringes, IV catheter stylettes, needles attached to
tubing such as winged infusion sets and suture needles)
Acute care, ER, ICU, or OR settings
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The OSHA Blood-Borne Pathogens Standard
The OSHA blood-borne pathogens standard is both general and specific
in its recommendations. Some sections provide detailed guidance while
others provide basic direction. For example, the standard states that
employers must provide hand-washing facilities, but if providing these
is not possible the employer must provide either an appropriate
antiseptic hand cleaner or antiseptic towelettes. The standard,
however, does not specify what type of hand cleaners or towelettes.
The OSHA Fact Sheets for various environmental hazards and
recommendations can be found at their website, including all blood-
borne exposures related to healthcare settings:
https://www.osha.gov/pls/publications/publication.athruz?pType=Type
s&pID=2. There are other fact sheets on the OSHA website that
address topics such as the standard’s recommendations on
handwashing and for the safe use of needles and sharps.
The blood-borne pathogen standard was amended in 2001 to include
the Needlestick Safety and Prevention Act that was passed by
Congress in 2000. This Act amended standard CFR 1910.1030 in
order to require employers to: 1) maintain a sharps injury log, and
2) involve non-managerial personnel in the decision-making process
of selecting safer needle devices.
“All of the requirements of OSHA’s Bloodborne Pathogens standard
can be found in Title 29 of the Code of Federal Regulations at 29 CFR
1910.1030. The standard’s requirements state what employers must
do to protect workers who are occupationally exposed to blood or
other potentially infectious materials (OPIM), as defined in the
standard. That is, the standard protects workers who can reasonably
be anticipated to come into contact with blood or OPIM as a result of
doing their job duties.”22
Other helpful OSHA resources may be found at the website:
https://www.osha.gov/SLTC/healthcarefacilities/.
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OSHA Definitions
Familiarity with definitions used by the OSHA blood-borne pathogens
standard can help increase understanding of and compliance with the
standard. The definitions provided here are essentially the same as
those found in the standard.
Blood-borne Pathogens
Pathogenic microorganisms that are present in human blood and can
cause disease in humans. These pathogens include, but are not limited
to, hepatitis B virus and HIV.
Contaminated
The presence or the reasonably anticipated presence of blood or other
potentially infectious materials on an item or surface.
Exposure
Eye, mouth, other mucous membrane, non-intact skin, or parenteral
contact with blood or other potentially infectious materials that results
from the performance of an employee’s duties.
Other potentially infectious material includes:
• Semen, vaginal secretions, cerebrospinal fluid, synovial fluid,
pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva
in dental procedures, any body fluid that is visibly contaminated
with blood, and all body fluids in situations where it is difficult or
impossible to differentiate between body fluids.
• Any unfixed tissue or organ (other than intact skin) from a human
(living or dead).
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• HIV-containing cell or tissue cultures, organ cultures, and HIV- or
hepatitis B virus-containing culture medium or other solutions.
• Blood, organs, or other tissues from experimental animals infected
with HIV or hepatitis B virus.
Employer and Employee Compliance
Adherence to the OSHA blood-borne pathogen standard is mandatory
for all hospitals and healthcare facilities. To be in compliance with the
standard employers must establish a written plan for controlling
exposure to blood-borne pathogens. This plan should include 1) an
assessment of risk situations, 2) a determination of which employees
are at risk and when they are at risk, and 3) specific actions the
employer will use to control and manage exposure to blood-borne
pathogens. The plan must be reviewed and updated annually and it
must be accessible to all employees, as outlined below.
• Implement standard precautions, ensure that employees know how
to use standard precautions, and ensure they use standard
precautions.
• Provide personal protective equipment (PPE) at no cost to all
employees who need it. Indicate critical or common times PPE
should be donned.
• Provide initial training and annual training on blood-borne
pathogens to all employees. This training should include 1) a review
of the OSHA Blood-borne pathogens standard, 2) information on
the risks of exposures and how exposures happen, 3) information
on how to prevent exposures to blood-borne pathogens, and
4) information on the benefits and risk of vaccination against
hepatitis B.
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• Use engineering controls to control risk. Engineering controls that
control the risk of exposure to blood-borne pathogens would include
providing sharps disposal boxes, using safe medical devices, using
needles that do not need to be re-capped, providing proper waste
disposal containers, and using appropriate signs to warn of danger
and to instruct employees on the proper use of equipment.
• Use work practice controls. The employer must have a plan or plans
in place for the proper handling and disposal of blood and other
specimens, the proper handling and disposal of contaminated
waste, and for the proper cleaning and decontamination of
equipment, patient rooms, and patient care areas.
• Offer vaccination against hepatitis B to all employees who may be
reasonably expected to have an occupational exposure to the
hepatitis B virus.
• Have a plan to handle employee exposure to blood-borne
pathogens. This plan should include provisions for immediate care
(i.e., evaluation, first aid, laboratory screening tests, post-exposure
prophylactic medications) and follow-up care.
All health employees must comply with the requirements of the blood-
borne pathogens standard. The ones that address needlestick injuries
and exposure to a blood-borne pathogen will be discussed separately.
Other requirements of standard 1910.1030 that apply to healthcare
workers include:
1. Understanding and following the engineering and work practice
controls established by the employer such as proper waste
disposal and adhering to the employer’s safety and sanitary rules.
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2. Using PPE correctly; the employee is required to wear the
appropriate PPE. The PPE must be removed immediately upon
removing the work area, or as soon as possible, and it must be
placed in a container specifically designated for the purpose of
receiving contaminated waste.
3. Proper handling of blood and other body fluids.
4. Understanding and using Universal Precautions.
5. Proper use of medical equipment; i.e., do not bend, break, or re-
cap needles. Do not re-use disposable medical equipment.
6. Proper disposal of contaminated or potentially contaminated
medical equipment.
7. Disposable gloves must be discarded as soon as possible after they
have become contaminated, punctured, or torn. Gloves are not
required to be worn when giving an injection as long as hand
contact with blood or other potentially infectious material is not
reasonably expected.
8. Employees must wash their hands immediately after removing
gloves or as soon as possible after removing gloves. Employees
must wash their hands after contact with blood or other potentially
infectious material and before and after performing patient care. If
handwashing with soap and running water is not possible, the
employee must use either an antiseptic hand cleaner with clean
cloth or paper towels or antiseptic towelettes. After using an
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antiseptic hand cleaner or a towelette, employees must wash their
hands with soap and running water as soon as feasible.
9. Food and drink should not be stored in refrigerators, cabinets,
etc., where blood or other potentially infectious material will be
stored.
10. Double-bagging specimens is required if the outside of the
specimen container is contaminated or if the specimen could
puncture the primary container.
Managing Exposures To Blood-Borne Pathogens
Managing exposures to blood-borne pathogens involves three steps:
1) initial care of the exposed person, 2) reporting the exposure and
investigating the circumstances, and 3) post-exposure prophylaxis, if
needed.
Managing Exposures to Blood-Borne Pathogens
Initial Care ↓
Reporting the Exposure/Investigating the
Circumstances ↓
Post-Exposure Prophylaxis
Ongoing assessment of any long-term effects
Initial care of the exposed person involves basic wound care. The first
step in managing an exposure to a blood-borne pathogen is to clean
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the exposed area.8,13 If it is a percutaneous exposure or a skin
exposure, the area should be washed with soap and water. Small
puncture wounds can be washed with an alcohol-based hand-wash;
these are considered to be virucidal for hepatitis B, hepatitis C, and
HIV.8 Squeezing the wound to express blood is not recommended nor
is the use of over-the-counter disinfectants such as bleach.8 Wash the
eyes with saline or water and flush mucous membranes with water.
The blood-borne pathogens standard defines an exposure as eye,
mouth, other mucous membrane, non-intact skin, or parenteral contact
with blood or other potentially infectious materials that results from
the performance of an employee’s duties. Expanding this definition, an
exposure can also be described as: 1) a percutaneous injury such as a
needlestick or a sharps injury; 2) mucous membrane contact or non-
intact skin (skin that is abraded, chapped, or has dermatitis) contact
with blood, tissue, or potentially infectious body fluids.
The next step is to report the exposure. This should be done as soon
as possible; healthcare workers should not delay reporting the
incident. Information that should be obtained and documented
includes those listed below.
Documentation of Exposure Circumstances
Documentation of the exposure circumstances should include the date
and time of the exposure, the type of exposure, the location of the
exposure (i.e., finger, hand, eye), the estimated time of contact with
the blood or body fluid, how the exposure occurred, the body fluid that
was involved, any first aid that was done, the PPE that was in use,
documentation of the affected person’s blood-borne pathogens
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standard training; and, if it was a percutaneous exposure, an
estimation of the depth of the wound, if the needle or sharp was in a
blood vessel, and the size and type of the needle or sharp.
Healthcare Worker Information
Specific information about the health care worker’s vaccination for
hepatitis B, any previous tests for hepatitis B, hepatitis C, or HIV,
tetanus immunization status, medical history, and the names and
doses of prescription medications currently being taken.
Source Patient Information
The source patient should be evaluated for the presence of hepatitis B,
hepatitis C, and HIV, unless their status regarding these diseases is
known.
The laws that govern testing of source patients will not be discussed
here. Affected healthcare workers must assume that their employer
will comply with these laws.
Hepatitis B Post-Exposure Treatment And Prophylaxis
The need for post-exposure treatment and prophylaxis after exposure
to hepatitis B is determined by an evaluation of the source patient and
the affected healthcare worker.
Source Patient Evaluation
The source patient should be tested for hepatitis B surface antigen
even if they have previously been tested.13 Exceptions would be if it is
known that the source is infectious with hepatitis B, or if the affected
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healthcare worker has received hepatitis B vaccination and has a
documented adequate response.13
Healthcare Worker Evaluation
There are five possibilities for post-exposure prophylaxis following
exposure to hepatitis B that needs to be considered during evaluation
of an exposed person; a specific post-exposure prophylaxis plan exists
for each scenario, as outlined here.
1. Completed hepatitis B vaccination with response
2. Evidence of a prior infection with hepatitis B
3. Hepatitis B vaccination has been completed but the hepatitis B
anti-HBs titer (surface antibody concentration) is < 10 mIU/mL
4. Hepatitis B vaccination has been completed but serologic testing
for a response has not been done or serologic testing was done and
the response is not known
5. The affected person has not been vaccinated or the vaccination
series has not been completed
For the first and second situations, there is no need for post-exposure
prophylaxis.13
For the third situation, if the source patient is positive for hepatitis B
or the source patient’s hepatitis B status is not/cannot be known, the
affected healthcare worker should be given two doses of hepatitis B
immunoglobulin, the second one month after the first.13
For the fourth situation, if the anti-HBs titer is ≥10 mIU/mL, post-
exposure prophylaxis is not needed. If the anti-HBs titer is <10
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mIU/mL, the management will depend on the hepatitis B status of the
source. If the source is positive or the status of the source cannot be
determined, administer one dose of hepatitis B immunoglobulin and
the first dose of hepatitis B vaccine, at the same time. The remaining
two doses of hepatitis B vaccine can be given as per the recommended
schedule.13
For the fifth situation, if the source patient is positive for hepatitis B or
the source patient’s hepatitis B status is not/cannot be known, the
affected healthcare worker should be given one dose of hepatitis B
immunoglobulin and the first dose of the hepatitis B vaccine series, at
the same time. If the source patient is hepatitis B negative, the
healthcare worker should receive the three-dose hepatitis B vaccine
series and then be checked for response.13
The immune globulin and the first dose of the hepatitis B vaccine can
be given at the same time but at different injection sites. The hepatitis
B immune globulin should be give within 24 hours after the exposure
and it must be given within 7 days of the exposure.13 The second and
third doses of the hepatitis B vaccine are given 1 month and 6 months
after the initial dose even if the source patient is subsequently known
not to be infected. Testing for hepatitis B infection should be done six
months after the exposure. During this six-month period the affected
healthcare professional should not donate blood, organs, plasma,
semen, or tissue, but the healthcare worker can perform normal
duties.13 The need for tetanus vaccination should also be considered.
Hepatitis C Post-Exposure Treatment And Prophylaxis
There is no effective post-exposure prophylaxis for hepatitis C.13
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Source Patient Evaluation
If there has been an exposure, the source patient should be tested for
the presence of hepatitis C, unless it is known that the patient is
infected.
Healthcare Worker Evaluation
The affected healthcare worker should be tested for the presence of
hepatitis C, as well. If the source patient is not infected, then no
further evaluation of the affected healthcare worker is needed.
If the source patient is positive for hepatitis C or if the hepatitis C
status is unknown, the healthcare worker should be tested for anti-
hepatitis C antibodies within 48 hours of the exposure.13 If the
antibody test is positive, the worker should be tested for hepatitis C
RNA; if the RNA test is positive at that time the healthcare worker has
a pre-existing hepatitis C infection. If the initial hepatitis C RNA test is
negative, a re-test should be done at least three weeks later. If this is
negative, no more testing is needed. If it is positive, a hepatitis C
infection is present.
If the antibody test is negative, a test for hepatitis C RNA should be
done at least three weeks later; a positive test confirms an infection.13
Donation of blood, organs, plasma, semen, and tissue should not be
done before the hepatitis C status has been determined. The need for
tetanus vaccination should also be considered.
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HIV Post-Exposure Treatment And Prophylaxis
The need for post-exposure treatment and prophylaxis after exposure
to human immunodeficiency virus is determined by an evaluation of
the source patient and the affected healthcare worker.8
Source Patient Evaluation
If the HIV status of the source patient is unknown, rapid HIV testing
should be done. Depending on the specific test used, the result will be
available in 5-20 minutes and these tests have excellent sensitivity
and specificity.
If the source patient is known to be HIV-positive testing is not
necessary.
Healthcare Worker Evaluation
Evaluation of an exposed healthcare worker should be done
immediately after wound care or decontamination has been completed.
The benefits and risks of post-exposure prophylaxis should be
thoroughly discussed. If the source patient is known to have an HIV
infection and the exposure is such that transmission of HIV is likely,
post-exposure prophylaxis should be started within 1-2 hours of the
exposure.8
Animal studies indicate that delaying administration of post-exposure
prophylaxis decreases its effectiveness, and post-exposure prophylaxis
should be started as soon as possible and ideally within 72 hours of
the exposure.8 It is not known at what point after an exposure there
would be no benefit from post-exposure prophylaxis. If the HIV status
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of the source patient is unknown post-exposure prophylaxis should be
started and if the result of the rapid testing is negative, treatment
should be discontinued.8 The healthcare worker exposed to injury
should not delay starting treatment while waiting for the test results.
Laboratory evidence and confirmation of an HIV infection can be
delayed for up to 3 months after an exposure; this is commonly
termed the “window period” of HIV infection. However, the U.S., Public
Health Services Guidelines for post-exposure prophylaxis states that
“... investigation of whether a source patient might be in the window
period is unnecessary for determining whether HIV PEP [pre-exposure
prophylaxis] is indicated unless acute retroviral syndrome is clinically
suspected.”21 In most cases, rapid testing alone is sufficient.
The affected healthcare worker should be tested for the presence of
HIV and other blood-borne pathogens, if needed. The need for tetanus
vaccination should also be considered.
Recommended HIV Therapy
The recommended therapy is a three-drug regimen using the
nucleotide analogue reverse transcriptase inhibitor-nucleotide reverse
transcriptase inhibitor tenofovir-emtricitabine (Truvada™) and the
integrase inhibitors dolutegravir (Tivicay™) or raltegravir (Isentress™)
for four weeks.8 Four weeks is recommended as in vitro studies,
animal studies, and occupational studies indicate this is the optimal
duration of treatment.21
These combinations of tofovir-emtricitabine and dolutegravir are
recommended, but there are other regimens that are considered
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acceptable.8 As with any drug therapy, medications used for post-
exposure prophylaxis for HIV should be prescribed with consideration
of their effectiveness and tolerability. Tolerability is especially
important as the side effects of tofovir-emtricitabine and raltegravir
and other post-exposure prophylaxis medications can have a negative
influence of compliance with therapy.8
The potential for drug-drug interactions is also very important.
Commonly used drugs such as oral contraceptives, H2 receptor
antagonist, and proton pump inhibitors can cause potentially serious
drug interactions when used with HIV post-exposure prophylaxis
drugs.
Follow-up care is essential for persons receiving post-exposure
prophylaxis. The exposed person who is being treated should be re-
evaluated 72 hours after the incident to determine how well she/he is
tolerating drug therapy.8 Testing for HIV should be done at the time of
the exposure, and 6 weeks, 12 weeks, and 6 months after the
exposure;8 there may be slight variations in this schedule, depending
on the test that is used. A complete blood count and measurement of
hepatic and renal function should be done at the time of exposure and
two weeks later.21
During the six months following the exposure, abstinence from sexual
intercourse or the use of condoms is recommended, and the exposed
healthcare worker should not donate blood, organs, plasma, semen, or
tissues.8 These precautions are especially important in the first 6 - 12
weeks after an exposure.8
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Special Considerations
In some circumstances of exposure to HIV an expert consultation
should be sought. The need or considerations for expert consultation is
listed in the table below.
Considerations For Expert Consultation
Breastfeeding
Chronic illness that may increase drug toxicity
Delay is reporting the exposure
Current drug therapy that may increase toxicity of post-exposure
prophylaxis
Drug-resistant HIV
Pregnancy
Unknown source, i.e., a needle that is in a sharps container
Breastfeeding and pregnancy are not contraindications for the use of
post-exposure prophylaxis for HIV,21 and women who are
breastfeeding or pregnant should receive post-exposure prophylaxis if
it is indicated. There is a significant risk of in utero transmission of HIV
and transmission of HIV through breastfeeding and although the data
is limited, it does not appear that the use of post-exposure
prophylactic drugs increases the number of birth defects or is harmful
to breastfeeding infants.21 Efavirenz (Sustiva™) is teratogenic and
should not be used in pregnant women.8 Current information about the
use of antiviral drugs during pregnancy can be found on the website of
the Antiviral Pregnancy Registry, www.apregistry.com. Information can
also be obtained by calling the National Perinatal HIV Hotline, 7 days a
week, 24 hours a day, 1-888-448-8765.
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Exposure to, and subsequent infection with drug-resistant strains of
HIV has been reported to occur after occupational exposure to HIV,
despite early use of post-exposure prophylaxis. It is not practical to
perform drug-resistance testing immediately after exposure to HIV,
therefore standard post-exposure prophylaxis should be initiated as
soon as possible.
Treatment should not be delayed
while waiting for drug-resistance
testing.21 If there is a possibility
that the source patient may be
infected with a drug-resistant
strain of HIV, expert consultation
should be sought and without
delay; post-exposure prophylaxis
should be started right away.21
The drug regimen can be changed
later if this is needed.
Exposure to a needle or a sharp from an unknown source should not
occur with good adherence to the blood-borne pathogens standards. If
an exposure of this type occurs the need for post-exposure prophylaxis
should be determined on a case-by-case basis. 21
Case Study: Health Employee Exposure To Blood
A 27-year old resident physician in training was working the night shift
of his 24-hour rotation and covering call for the intensive care unit
(ICU) when a patient arrived through the Emergency Department (ED)
following an accidental overdose of heroine. The patient had been
The Clinicians’ Post-Exposure
Prophylaxis Hotline (PEPline) is
available from 9 a.m., to 2 a.m.,
seven days a week and can
provide consultation about risk
assessment and post-exposure
prophylaxis: 888-448-4911.
Clinical guidelines for risk
assessment and treatment and
post-exposure prophylaxis
recommendations for exposure
to HIV, hepatitis B, and
hepatitis C are available on
their website,
http://nccc.ucsf.edu/clinician-
consultation/post-exposure-
prophylaxis-pep/.
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uncooperative in the ED with laboratory draws and the ICU nurse was
also having difficulty obtaining blood to send for testing. The nurse
called the physician for assistance with the blood draw because most
of the peripheral veins were difficult to locate, and the decision was
made to draw blood from the patient’s femoral vein. The patient’s
hepatitis status was unknown.
A needleless intravenous system was used to obtain the blood sample.
Personal protective equipment was donned by all of the nursing staff
however the physician had left the ED to assist in the ICU and needed
to return quickly as it was announced a major vehicle accident had
occurred and ambulances transporting the accident victims in serious
condition had already notified an estimated time of arrival of 20
minutes to the ED. The physician applied gloves however opted to not
wear a face shield or gown while obtaining the blood sample from the
patient’s femoral vein. During the procedure, the patient became
agitated and suddenly jerked the leg where the needle had been
advanced and the physician quickly had to abort the procedure to
avoid injury to the patient. As the needle was removed quickly, the
existing aspirated blood drawn into the syringe under suction pressure
splattered up at the physician’s right eye. The physician washed the
eye area after discarding the needle appropriately into a biohazard
needle container and moved onto the emergency cases due to arrive.
The healthcare facility had provided the PPE, which included the face
shield, head covering, gloves and gowns, which were immediately
located outside every ICU patient room in a convenient cupboard so
that clinicians performing procedures with reasonable anticipation of
exposure to body fluids could protect themselves with impervious
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coverings from blood splatters or potentially infectious material.
As noted in the above sections, the health employer followed OSHA
standards that required the employer to “undertake measures to
reduce occupational exposures to blood-borne pathogens”, and the
physician was protected from risk of exposure through “engineering
controls that minimize the risk of sharp injuries (i.e., needleless
intravenous medication systems, blunted suture needles)…”13 Other
key measures required by OSHA that the employer followed to reduce
risk of occupational exposure in this case included annual education on
blood-borne pathogen transmission and ways to reduce the risk of
exposure, and immunization to hepatitis offered at no cost to the
employee.13
The employer had supplied every opportunity to avoid accidental
blood-borne pathogen exposure however the harried physician
(working late and probably tired) bypassed safety while prompted by a
need to return to the ED quickly to attend to another emergency call.
Discussion
Blood is the most important source of HBV and HCV transmission in
healthcare workers.13 The physician in this case should report
exposure immediately because the patient would be at high risk of
hepatitis with a history of heroin drug use.
Exposure occurred through contact with mucous membranes (the
eye). The source patient should be assessed after obtaining informed
consent, even if there had been a prior negative test, however the
patient in this case was unknown to carry the hepatitis virus. The
immunization status of the physician should be followed up.
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A report of the exposure should immediately have been done by the
physician, such as the date and time of the exposure, the nature of the
exposure (i.e., non-intact skin, mucosal, percutaneous or human bite),
type of fluid, which was blood in this case, the body location (the
physician’s eye) and time of exposure. Further, all of the information
in an occupational report of exposure should be added to the
physician’s employee health file.13
The alarming reality is that often health clinicians will not report an
injury and in the case of this physician, not only did he hurriedly
bypass the OSHA guided employee safety policy of the hospital but he
moved quickly on to another emergency case where the risk for
exposure with bodily injured patients would be just as high or more.
What could the health team have done when the physician appeared
without PPE to perform a blood draw procedure on an uncooperative
patient? This is a self-reflective question each healthcare worker
should ponder.
In some hospital settings, healthcare workers are required to perform
team safety steps, such as procedural time outs or checklists, which
must be followed in a standardized format no matter the urgency at
hand before a procedure begins.22 Any member of the health team
could educate and ask another team member to properly use PPE
before starting a high risk procedure of exposure. This type of team
approach and care to see safety standards followed might have saved
this physician working late in a 24-hour rotation from hurriedly
arriving to a patient’s bedside and bypassing known hospital protocol
to prevent an occurrence of employee exposure.
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Summary
The OSHA blood-borne pathogens standard was developed to help
reduce blood-borne pathogens transmission and infection. The blood-
borne pathogens standard has general and specific recommendations,
and all healthcare workers are required to have a basic knowledge of
and comply with the recommendations of the standard. Adhering to a
health employer’s policies related to employee safety and sanitary
rules, such as the correct use of PPE, proper handling of blood and
other body fluids, medical equipment, i.e., needles, sharps, and
disposable medical equipment, and the disposal of contaminated or
potentially contaminated medical equipment, are important
requirements to prevent blood-borne pathogen transmission. Proper
handwashing technique, including use of gloves, and the use of safety
precautions are standard competencies for all healthcare workers.
Exposure to blood or body fluids in the healthcare setting continues to
occur at alarming rates. Necessary information on how to report an
unsafe exposure, such as a needlestick wound, is both an employer
and employee obligation. The potential medical consequences are
quite serious and research indicates that the psychological burden of a
needlestick can be significant. An exposure to a blood-borne pathogen
should be reported immediately.
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1. The majority of occupational exposures to blood-borne pathogens are:
a. Percutaneous.
b. Air-borne. c. Cutaneous.
d. Percutaneous and cutaneous together.
2. The primary focus on post-exposure management of blood-borne pathogens in occupational exposures for healthcare workers are:
a. hepatitis B, hepatitis A, and MRSA.
b. hepatitis C, HIV, and tuberculosis. c. hepatitis B, hepatitis C, and HIV.
d. hepatitis A, HIV, and gram-negative bacteria.
3. The risk of HIV transmission after a percutaneous exposure is
approximately:
a. 3.0%. b. 0.32%.
c. 30%. d. 13%
4. True or false: Infection with a blood-borne pathogen can occur
after contact with a contaminated surface.
a. True. b. False.
5. The first step in managing an exposure to a blood-borne pathogen is:
a. testing of the source patient
b. notifying the employee health department. c. testing of the affected healthcare professional.
d. to clean the exposed area.
6. An exposure to a blood-borne pathogen should be reported:
a. Within 24 hours of the exposure. b. At the end of the shift.
c. Immediately. d. Within seven days of the exposure.
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7. Commonly used drugs such as oral contraceptives, H2 receptor antagonist, and proton pump inhibitors can cause potentially
serious drug interactions when used with _____ post-exposure prophylaxis drugs.
a. HIV
b. hepatitis A c. hepatitis B
d. hepatitis C
8. True or false: There is effective post-exposure prophylaxis for Hepatitis C.
a. True.
b. False.
9. If the source patient is known, post-exposure prophylaxis for
HIV should be started:
a. Within 7 days of the exposure. b. After drug-resistance testing is completed.
c. Within 1-2 hours of the exposure. d. After tests for Hepatitis B and C and HIV have been
completed.
10. The OSHA blood-borne pathogens standard requires employers to:
a. Test each employee yearly for infection with blood-borne
pathogens.
b. Provide pre-exposure prophylaxis for HIV. c. Test at-risk patient for blood-borne pathogens.
d. Have a plan for the management of exposures to blood-borne pathogens.
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Correct Answers
1. The majority of occupational exposures to blood-borne pathogens are:
a. Percutaneous.
“The majority of occupational exposures to and infections from
these viruses are caused by percutaneous injury.”
2. The primary focus on post-exposure management of blood-borne pathogens in occupational exposures for healthcare workers are
c. hepatitis B, hepatitis C, and HIV.
“The primary focus on post-exposure management of blood- borne pathogens in occupational exposures for healthcare
workers are on hepatitis B, hepatitis C and HIV, although greater than 30 different pathogens have caused documented
occupational infection following exposure to blood or body fluids.”
3. The risk of HIV transmission after a percutaneous exposure is
approximately:
b. 0.32%.
“The risk of infection after a percutaneous exposure to HIV reported by Henderson (2012) has been estimated to be
0.32%.”
4. True or false: Infection with a blood-borne pathogen can occur
after contact with a contaminated surface.
a. True.
“Blood-borne pathogens can contaminate surfaces and persist in the environment and contact with these
contaminated surfaces can cause infection. Hepatitis B and HIV in dried blood can remain on surfaces for a week
and hepatitis B is capable of causing infection during that time. Hepatitis C also can survive outside the body on
environmental surfaces and it can remain infective at room temperatures on surfaces for up to three weeks .”
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5. The first step in managing an exposure to a blood-borne pathogen is:
d. to clean the exposed area.
“The first step in managing an exposure to a blood-borne
pathogen is to clean the exposed area.”
6. An exposure to a blood-borne pathogen should be reported:
c. Immediately.
“An exposure to a blood-borne pathogen should be reported immediately.”
7. Commonly used drugs such as oral contraceptives, H2 receptor antagonist, and proton pump inhibitors can cause potentially
serious drug interactions when used with _____ post-exposure prophylaxis drugs.
a. HIV
“Commonly used drugs such as oral contraceptives, H2 receptor
antagonist, and proton pump inhibitors can cause potentially serious drug interactions when used with _____ post-exposure
prophylaxis drugs.”
8. True or false: There is effective post-exposure prophylaxis for Hepatitis C.
b. False.
“There is no effective post-exposure prophylaxis for hepatitis C.”
9. If the source patient is known, post-exposure prophylaxis for HIV should be started:
c. within 1-2 hours of the exposure.
“If the source patient is known to have an HIV infection, post-
exposure prophylaxis should be started within 1-2 hours of the exposure.”
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10. The OSHA blood-borne pathogens standard requires employers to:
d. Have a plan for the management of exposures to blood-borne
pathogens.
“Adherence to the OSHA blood-borne pathogen standard is mandatory for all hospitals and healthcare facilities. To be in
compliance with the standard employers must establish a written plan for controlling exposure to blood-borne pathogens. This
plan should include 1) an assessment of risk situations, 2) a determination of which employees are at risk and when they are
at risk, and 3) specific actions the employer will use to control and manage exposure to blood-borne pathogens. The plan must
be reviewed and updated annually and it must be accessible to
all employees.”
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References Section
The References below include published works and in-text citations of published works that are intended as helpful material for your further
reading.
1. Occupational Safety and Health Administration (nd). Bloodborne
pathogens. Standard CFR 1910.1930. Retrieved online April 12, 2018 at
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10051.
2. Anderson DJ. (2017). Infection prevention: Precautions for preventing transmission of infection. UpToDate. December 1,
2017. Retrieved online at
https://www.uptodate.com/contents/infection-prevention-precautions-for-preventing-transmission-of-
infection?search=Infection%20risks%20following%20accidental%20exposure%20to%20blood%20or%20body%20fluids%20in%
20healthcare%20workers&source=search_result&selectedTitle=6~150&usage_type=default&display_rank=6.
3. Pedrosa PB and Cardoso TA (2011). Viral infections in workers in hospital and research laboratory settings: a comparative review
of infection modes and respective biosafety aspects. Int J Infect Dis.2011;15(6):e366-e76
4. Centers for Disease Control and Prevention (2015). Sharps Safety for Healthcare Settings. CDC. Retrieved online at
https://www.cdc.gov/sharpssafety/ 5. International Safety Center. (2015). Sharp Object Injury Report
2015. Retrieved online from
https://internationalsafetycenter.org/wp-content/uploads/2017/06/Official-2015-NeedleSummary.pdf.
6. Henderson, DK (2012). Management of needlestick injuries: A house officer who has a needlestick. JAMA. 2012; 307(1) :75-84
7. Hasak JM, Novak CB, Patterson JMM, Mackinnon SE. (2018). Prevalence of needlestick injuries, attitude changes, and
prevention practices over 12 years in an urban academic hospital surgery department. Ann Surg. 2018;267(2):291-296.
8. Bartlett, JG. (2018). Management of healthcare personnel exposed to HIV. UpToDate. September 29, 2017. Retrieved
online at https://www.uptodate.com/contents/management-of-healthcare-personnel-exposed-to-
hiv?search=needle%20stick%20injury&source=search_result&selectedTitle=2~49&usage_type=default&display_rank=2.
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9. Deipolyi, AR, Prabhakar, AM, Naidu, S, Oklu, R. (2017). Needlestick injuries in interventional radiology are common and
underreported. Radiology. 2017;285(3):870-875. 10. Cohen, M. (2018). HIV infection: Risk factors and prevention
strategies. UpToDate. Retrieved online at https://www.uptodate.com/contents/hiv-infection-risk-factors-
and-prevention-strategies?search=mucous%20membrane%20exposure%20to%
20hiv&source=search_result&selectedTitle=1~150&usage_type=
default&display_rank=1. 11. Joyce MP, Kuhar D, Brooks JT. (2015). Notes from the field:
occupationally acquired HIV infection among health care workers - United States, 1985-2013. MMWR Morb Mortal Wkly Rep.
2015;63(53):1245-1246. 12. Centers for Disease Control and Prevention (2015).
Healthcare-associated infections. Surveillance of occupationally acquired HIV/AIDS in healthcare
personnel, as of December 2010. Retrieved online at http://www.cdc.gov/HAI/organisms/hiv/Surveillance-
Occupationally-Acquired-HIV-AIDS.html. 13. Weber DJ. Prevention of hepatitis B virus and hepatitis C virus
infection among healthcare providers. UpToDate. September 27, 2017. Retrieved online from
https://www.uptodate.com/contents/prevention-of-hepatitis-b-
virus-and-hepatitis-c-virus-infection-among-healthcare-providers#!.
14. Centers for Disease Control and Prevention (2015). Recommendations for prevention of transmission of human
immunodeficiency virus and hepatitis B virus to patients during exposure-prone procedures. Retrieved online at
http://www.cdc.gov/mmwr/preview/mmwrhtml/00014845.htm 15. Dienstag JL. (2012). Acute viral hepatitis. In: Long DI, Fauci AS,
Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal, on-line ed. 18th ed. 2012. New York, NY:
McGraw-Hill. 16. Strasser M, Aigner E, Schmid et al. (2013). Risk of hepatitis C
virus transmission from patients to healthcare workers: a prospective observational study. Infect Control Hosp
Epidemiol.2013;34(7):759-761.
17. Pfaender S, Helfritz FA, Siddharta A, et al. (2018). Environmental stability and infectivity of hepatitis C virus (HCV)
in different human body fluids. Front Microbiol. 2018 Mar 27;9:504. doi: 10.3389/fmicb.2018.00504. eCollection 2018.
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18. Centers for Disease Control and Prevention (2016). Viral Hepatitis. CDC. Retrieved online at
https://www.cdc.gov/hepatitis/hcv/cfaq.htm. 19. Lauer AC, Reddemann A, Meier-Wronski CP, et al. (2014).
Needlestick and sharps injuries among medical undergraduate students. Am J Infect Control. 2014;42(3):235-239
20. Cho E, Lee H, Choi M, Park SH, Yoo IY, Aiken LH. (2013). Factors associated with needlestick and sharp injuries among hospital
nurses: a cross-sectional questionnaire survey. Int J Nurs Stud. 2013;50(8):1025-1032.
21. Kuhar DT, Henderson DK, Struble KA, et al (2013). Updated US Public Health Service Guidelines for the management of
occupational exposure to human immunodeficiency virus and recommendations for post-exposure prophylaxis. Infect Control
Hosp Epidemiol. 2013;34(9):875-892.
22. Wahr, J.A. (2018). Operating room hazards and approaches to improve patient safety. UpToDate. Retrieved online at
https://www.uptodate.com/contents/operating-room-hazards-and-approaches-to-improve-patient-
safety?search=time%20out%20safety&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.
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