BLOOD-BORNE

PATHOGENS AND OSHA

CDM 2280

MICHAEL A. SIEGEL, DDS, MS, FDS RCSEd

PROFESSOR AND CHAIR
ORAL MEDICINE & DIAGNOSTIC SCIENCES
PREVIEW
COLLEGE OF DENTAL MEDICINE

PROFESSOR
INTERNAL MEDICINE (DERMATOLOGY)
COLLEGE OF OSTEOPATHIC MEDICINE • Blood-borne Pathogens
– Hepatitis
NOVA SOUTHEASTERN UNIVERSITY
3200 SOUTH UNIVERSITY DRIVE – HIV And AIDS
FORT LAUDERDALE, FLORIDA 33328-2018 • Tuberculosis
PHONE: 954-262-4309 • OSHA And AWDA
E-MAIL: masiegel@nova.edu

BLOOD-BORNE OCCUPATIONAL
PATHOGENS (BBP) EXPOSURE
• Needles, Blades, Other Sharps
• Splash To Mucosa Of Eye, Nose, Mouth, • Exposure Is A Needlestick Or Cut With A
Skin Contaminated Sharp Object
• Viruses, Prions? • Splash Of Blood Or Body Fluids Into Eyes, Nose,
Mouth
– Hepatitis B,C,D,E,F,G,TT, SENV, YoBin?
• Blood, Body Fluids (Cerebrospinal, Synovial,
– HIV
Pleural, Peritoneal, Pericardial, Amniotic,
• Blood Or Body Fluids Contaminated Vaginal), Semen **Not Saliva**
With Blood

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 VIRAL HEPATITIS
• Symptoms
– Flu-like To Hospitalization
• Signs
– Jaundice Appears In Less Than Half
– Impaired Liver Function
– Tests Are Improving
• Acute vs. Chronic
• Risk Of Transmission
HEPATITIS C
•4 Million Cases In US (4x HIV)
•85% Carrier Or Chronic
•#1 Cause For Liver Transplant
•8,000-10,000 Deaths/Year
HEPATITIS. SO WHAT?
•Normal Liver Functions:
– Clotting Factors, Etc.
– Detox
– Digestion
HEPATITIS B
• About 320,000 New Cases/Year In US
– Blood Supply Safe After 1972
• Estimated 1.25 Million Chronic Cases In US
(Virus In Blood > 6 Months) (Who?)
• Vaccine
– Booster?
• Hepatitis D Superinfection Or Coinfection
HEPATITIS C
• Estimated 36,000 New Cases/Year In US
• 2.7 Million Chronic Cases In US (Who?)
– Blood Supply Safe After 1992
• No Vaccine
• Treatment 30% Successful, Weekly Injections And
Daily Pills, $$$$$$
• LONG Time From Infection To Manifestation Of
Disease
HIV
• 46,000 New Cases/Year In US
• Estimated 1 Million Infected In US; (Who?)
Laws Regarding Disclosure
• Trend Of Infection Becoming More Hetero
And Younger
• Length Of Time To Manifestation Of AIDS Is
Getting Longer: 8-12 Years
– “Cocktail”
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 HIV EPIDEMIOLOGY AIDS CASES DATA FOR
U.N. ESTIMATES AS OF 12/03 2002
New HIV+ Cases* 5.0 Million • Florida #3 In US AIDS Cases
Deaths* 3.1 Million – 90,233 56% Have Died
– Miami #4 Metro Area 24,800
(*In 2003)
• #2 In Pediatric And Female
Total Deaths 29.8 Million • 12% Of New Cases In The US
People Living W/HIV,AIDS 40.0 Million – 5,058 Adults, 34 Pedo
• Approximately 900,000 HIV+ In US

HIV EPIDEMIOLOGY PEDIATRIC HIV

AIDS CASES IN FLA THROUGH 12/02
19%
INFECTION
2%

MSM • Risk Of Transmission From Infected Mother

Hetero Estimated At 20% To 30%
IDU • 96% Of FL Pedo Cases Are Perinatal Transmission
38% Other
• 7,000 Births Per Year In US To HIV Infected Mothers
41% – AZT Prophylaxis Reduces Risk Of Transmission To Fetus

In Florida, 1/4-1/3 Don’t Know Their Status; 1/3 Won’t Tell!

HIV INFECTION IN WOMEN HIV INFECTION IN WOMEN

One Quarter Of U.S. Women With AIDS Were
9% Of First 100,000 Cases Of Aids In Diagnosed In Their 20’s
U.S. Were Women Likely Infected As Teenagers
12% Of Next 100,000 Cases Of AIDS In NYC - 50% Of HIV Infected Women Had <5
U.S. Were Women Sex Partners
Risk Of Transmission Is Greater For Teenagers / Adolescents ⇒ Leading Edge Of
Man⎭woman Than For Woman⎭man Next Wave Of Epidemic

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TRENDS IN HIV TRANSMISSION DYNAMICS OF HIV INFECTION
SPECTRUM OF DISEASE
More Than 90% Of The Transmission Of Time Of Initial
HIV Is By Sexual Intercourse, With A Infection With HIV
Steadily Increasing Proportion Due To
Heterosexual Intercourse
Less Than 10% Of Cases Result From
Blood Transfusion Or Injection Drug Abuse 8 -12 Years AIDS

DYNAMICS OF HIV INFECTION

DYNAMICS OF HIV INFECTION

• ~2 Billion CD4+ Cells Are Created And Destroyed

Daily
– ~5% Of Total Lymphocyte Population
• ~110 Million Virions Are Created – Creation Of CD4+ Cells Continues Even In Late Stage Of
And Cleared Daily Disease

– 30% Of Entire Viral Population • The Vast Majority Of Plasma HIV Is From Newly
Infected Lymphocytes
– Half-life Of Viral Population Is 2 Days

HIV PATHOGENESIS HIV PATHOGENESIS

VIRAL REPLICATION IN LYMPH TISSUE
THE NEW PARADIGM
HIV Is Active At All Stages Of Disease
HIV Becomes Sequestered In Lymph
Continuous Rounds Of Tissues
De Novo Infection Lymph Nodes Are Destroyed By HIV
Replication Subsequent Escape Into Peripheral
Rapid Cell Turnover Tissues
Rapid, Ongoing Virus Expression Is Directly Clinical Latency Does Not Equal Viral
Involved In CD4+ Cell Destruction Latency (Viral Load “Non Detectable”)

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 TESTING FOR HIV CLASSIFICATION OF HIV DISEASE,
ARC, AND AIDS

• Rapid HIV Test Takes 5-30 Minutes CDC System (Modified In 1993)
• EIA (Enzyme Immunoassay Takes 1-2 Weeks
– Test Is Repeated If Positive
Aids-Defining Illness
– Western Blot Test Used To Confirm CD4+ Lymphocyte Count
• ***About 25 Days From Infection To Antibody Production***
Viral Load

MANAGEMENT OF HIV INFECTION MANAGEMENT OF HIV INFECTION

AVAILABLE ANTI-HIV DRUGS

• Progressive Illness • Nucleoside Analogs (For Example)

– Zidovudine - AZT Retrovir
• Manage Infection
– Didanosine - DDI Videx
• Psychosocial Support – Zalcitabine - DDC Hivid
• Education Is Critical • Protease Inhibitors
– Abstinence/Safe Sex – Saquinavir Invirase
– Occupational Exposure – Ritonavir Norvir
– Other Risky Behaviors – Indinavir Crixivan

MANAGEMENT OF HIV INFECTION

COMMON ORAL FINDINGS
CURRENT / FUTURE CONCERNS FUNGAL INFECTIONS

Oral Candidiasis Is Frequently

Combination Drug Regimens Using Observed In The HIV Patient
Agents Targeted At Several Points In
The HIV Life Cycle Need To Be Appearance
Developed To Prevent And Treat Drug Importance In Staging
Resistant HIV Isolates; Side Effects Of Management
Meds Becoming More Problematic

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 COMMON ORAL FINDINGS Common Oral Findings
VIRAL INFECTIONS Oral Ulcers
Hairy Leukoplakia And Herpes HIV Patients May Suffer From
Lesions Are Commonly Found In Painful, Aggressive Oral Ulcers
The HIV Patient Appearance
Appearance Management
Management

COMMON ORAL FINDINGS COMMON ORAL FINDINGS

NEOPLASMS BACTERIAL INFECTIONS
Common Bacterial Infections Include
Linear Gingival Erythema (LGE) And
Kaposi’s Sarcoma Necrotizing Ulcerative Periodontitis
Appearance (NUP)
Management Appearance
Management

TUBERCULOSIS (TB) TB INFECTION VS.

• Mycobacterium Tuberculosis
• Can Be In Lungs (85%), Brain, Spine
• Spread Through Air Droplets
– Cough, Spit, Sneeze, Laugh, Sing, Dentistry?
• Symptoms: Feeling Weak Or Sick, Weight Loss,
Fever And/Or Night Sweats, Productive Cough,
Chest Pain
ACTIVE CASE
• 10-15 Million Infected In US (<5%)
• About 10% Will Become Active
– HIV+ Has 40x Greater Risk Of Infection, And
100x Greater Risk Of Active Case
• 5% Will Become Active In First Year
• 2-10 Weeks After Exposure To Show A
Positive Skin Test (PPD Or Tine Test)

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 TB TREATMENT TB HIGH RISK

• “Prophylaxis” Is INH X 6 Months • High-risk Patients (CDC Definition)

• Treatment Is With Multiple Drugs – The CDC Recommends That The Following Groups Be
– INH, Rifampin, Ethambutol, Pyrazinamide, Streptomycin Screened For TB And TB Infection:
– Poor Compliance Leads To Multiple Drug Resistance (MDR-TB) • Close Contacts (E.G., Those Sharing The Same Household)
Of Persons Known Or Suspected To Have TB;
• Be Suspicious Of High Risk Patients
• Persons Infected With HIV;

TB HIGH RISK TB HIGH RISK

• High-risk patients (CDC Definition)

• High-risk Patients (CDC Definition) Continued:
– Persons Who Inject Illicit Drugs Or Other Locally Identified High Risk
Substance Users;
– Persons Who Have Medical Risk Factors Know To Increase The Risk
Of The Disease If Infection Occurs;
– Residents And Employees Of High Risk Congregate Settings (E.G.,
Prisons, Nursing Homes, Mental Institutions
continued:
• Healthcare workers who serve high risk clients;
• Foreign born persons recently arrived (within 5
years) from countries that have a high TB
incidence or prevalence;
• Some medically under-served, low income
populations

TB HIGH RISK WORLDWIDE

EPIDEMIOLOGY - ‘02

• High-risk patients (CDC Definition) continued:

– High risk racial or ethnic minority populations, as defined
locally; and • About 8 Million New Cases/Year
– Infants, children, and adolescents exposed to adults in high • About 2 Million Deaths
risk categories
• Consultation may include PPD, report of chest x-ray • 1.9 Billion People Are Infected!
• No treatment until more information – Percentage Of Infection Is More Than 30%

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 TB MORBIDITY REPORTED TB CASES
UNITED STATES, 1998-2002 UNITED STATES, 1982-2002

Year Cases Rate* 28000

No. of Cases
26000

1998 18,361 6.8 24000

22000
1999 17,531 6.4 20000
18000
2000 16,377 5.8 16000
14000
2001 15,989 5.6 12000
10000 1982 1986 1990 1994 1998 2002
2002 15,075 5.2 83 85 87 89 91 93 95 97 99 2001

2003 est. 14,871 5.1 Year

*Cases per 100,000

TB CASE RATES, UNITED

REPORTED TB CASES STATES, 2002
IN FLORIDA
D.C.

•1997 1400 new •Highest In Dade County,

•1998 1304 Then Broward, Palm
•1999 1271 Beach, Orange, Tampa Bay
•2000 1171 Area, Jacksonville Area
•2001 1145 •Up To 10% MDR-TB < 3.5 (year 2000 target)
•2002 1086 3.6 - 5.2
> 5.2 (national average)
Rate: cases per 100,000

NUMBER OF TB CASES IN ESTIMATED HIV COINFECTION IN PERSONS

U.S.-BORN VS. FOREIGN-BORN REPORTED WITH TB
PERSONS UNITED STATES, 1993-2001
UNITED STATES, 1992-2002
30
% Coinfection

20000
No. of Cases

20
15000
10000 10
5000
0
0 1993 1994 1995 1996 1997 1998 1999 2000 2001
1992 1994 1996 1998 2000 2002
All Ages Aged 25 - 44
U.S.-born Foreign-born Note: Minimum estimates based on reported HIV-positive status
among all TB cases in the age group. All 2001 cases from California
have an unknown HIV status.

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 OCCUPATIONAL SAFETY AND
HEALTH ADMINISTRATION
OSHA REGULATIONS

• President Nixon In 1970 Use Of Mouth Pieces, Etc.

• To Protect Employees
Use Of Disinfectants
• Dental Office Implications
Labeling And Signs
– Universal Precautions*, Vaccination
– Infectious/Hazmat Waste Inspections
– Msds Training And Education Programs
– Sharps And Needlestick Safety Post-exposure Follow-up
– Ergonomics (Pending)

STANDARD PRECAUTIONS
PROVEN & PRACTICAL INFECTION CONTROL MEASURES STANDARD PRECAUTIONS...
...

Comprehensive Medical History Disposable Facemasks

Hepatitis B Vaccine Protective Eyewear
Antiseptic Mouthrinse Clinic Attire
Antiseptic Handwash Rubber Dam
Disposable Latex Gloves... Sharps Disposal System

...STANDARD PRECAUTIONS... ...STANDARD PRECAUTIONS

Sterilizable Handpieces Glutaraldehydes

Ultrasonic Cleaning Surface Asepsis
Instrument Packaging Waste Disposal System
Heat Sterilization OSHA Poster
Monitoring Training And Education

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 NEW INFORMATION
JANUARY 2004
OCCUPATIONAL RISK
• CDC 2003
• More Scientific Evidence
– Articles Are Referenced
• Patient To HCW
– Weighted Values • HCW To Patient
• Added Hand Washing, Water Lines,
Dental Devices, Immunizations, Etc.
• Occupational Exposure

OCCUPATIONAL OCCUPATIONAL RISK

EXPOSURE Comparison of HIV exposure to
Hepatitis B/C exposure* - Risk from
• Exposure Is A Needlestick Or Cut With A Contaminated
single needlestick:
Sharp Object
HBV 6% to 30%
• Splash Of Blood Or Body Fluids Into Eyes, Nose, Mouth
• Blood, Body Fluids (Cerebrospinal, Synovial, Pleural, HIV 0.04%
Peritoneal, Pericardial, Amniotic, Vaginal), Semen **Not
Saliva** HCV 1.8%
* Without HB vaccination.

OCCUPATIONAL RISK
HIV IN HEALTH CARE
As Of 12/31/2001, The CDC Reported:
CDC - THROUGH 12/31/01
23,951 HCWs With HIV/AIDS Occupation # with AIDS
57 Documented Occupational Physician 1,760
Exposures To HIV Surgeon 119
Nurse 5,211
138 Cases Under Investigation As
Dental worker 486
Possible Occupational Exposures
Paramedic 463
Technician 3,086

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OCCUPATIONAL RISK
57 OCCUPATIONAL EXPOSURES TO HIV:
19 Laboratory Workers
24 Nurses / 6 Physicians (No Surg.)
2 Surgical Techs / 1 Dialysis Tech /
1 Respiratory Therapist / 1 Health
Aide 2 Housekeepers / 0 Dental!
26 Have Developed Aids
OCCUPATIONAL RISK
HIV POST-EXPOSURE PROTOCOL*
Determine Extent Of Exposure
Determine Need Postexposure
Prophylaxis (PEP) / Follow-up
ZDV Plus 3TC ± IDV
Prophylaxis Is For 4 Weeks
* Mmwr 45(22):468-72, 1996
NSU POST-EXPOSURE
PRINCIPLES
• Immediately!
– Wash Needlesticks And Cuts With Soap
And Copius Amounts Of Water
– Flush Splashes To Nose, Mouth, Or Skin
With Water
– Irrigate The Eyes With Clean Water,
Saline, Or Sterile Irrigant
OCCUPATIONAL RISK
57 OCCUPATIONAL EXPOSURES TO HIV:
48 Had Percutaneous Exposure
5 Had Mucocutaneous Exposure
2 Had Both Percutaneous And
Mucocutaneous Exposure
2 Had An Unknown Route Of
Exposure
HEPATITIS POST-
EXPOSURE
• Hepatitis B Immune Globulin In
Non-Vaccinated Individuals
– Start Heptavax Series At The Same
Time
• No Options For Hep C
NSU CDM
• Also:
– Report Exposure To Supervisor (May Only Be An
Injury, Not Exposure)
– Complete Appropriate Paperwork
– Go To COM Medical Clinic Or Westside Regional
Hospital ER As Needed
• Counseling For Rx, Other Follow-up
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 NSU STUDENTS NSU STUDENTS

• Report Incident
– Infection Control Officer
– Faculty
• Follow Up Immediately With
Appropriate Medical Facility
• All NSU HPD Students Are Required To
Have Health Insurance
• All Bills For Post-exposure Follow-up Will
Be The Responsibility Of The Student.
• *Exception Exists

SOURCE/PATIENT TESTING PLAN…

• Report For Counseling • Initial Visit

– Pre-hiv Test – Test For Anti-HIV, HbsAb, HbsAg, Anti-
– Post-exposure HCV
• Consent Form For HIV Test
– If PEP
– The Source Patient May Refuse; No
Documentation Goes Into Their Health • LFTs, CBC W/Differential, UA, Pregnancy
Records. Test, Chemistry

…Testing Plan Continues… …Testing Plan Continues

•6 Weeks •12 Weeks
– Anti-HIV – Anti-HIV
• 2 Weeks (Only If On PEP) – Anti-HCV – Anti-HCV
– If PEP Then •6 Months
– CBC CBC, LFT, – Anti-HIV
– LFT Chemistry
– Anti-HCV, ALT if
source is +
– Chemistry
•12 Months
– UA – -Anti-HIV

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PRIVATE PRACTICE MORAL, ETHICAL & LEGAL ISSUES

ADA Council On Ethics, Bylaws And

• Owner Responsible For Staff Judicial Affairs
– Ethics, Confidentiality
Precedents
– Training
– Vaccinations Americans With Disabilities Act (AWDA)
– PPE, MSDS, Waste State Laws Differ
– Record Keeping
Defer Vs. Deny
• OSHA Inspections

CONFIDENTIALITY
ISSUES
EMPLOYEES…

• Public Health Issues Vary By State • Clean Wound Immediately AND

TB – Report Exposure To Infection Control
HIV Officer/Dentist
• Conduct Of Office Staff – Go To Medical Center Or Hospital ER
Referrals As Needed…
• Counseling For Rx, Other Follow-up
Paperwork
Training!

EMPLOYEES…

• Pre-HIV Test Counseling

• Post-Exposure Evaluation
– HIV
QUESTIONS???
– Hepatitis
– Choice Of Meds
(If Employee Declines Post-Exposure
Evaluation, Must Sign Waiver)

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