Print Page   |   Contact Us   |   Your Cart   |   Sign In
Search
Sign In


Forgot your password?

Haven't registered yet?

Breaking News
Calendar
FAQ's Diseases and Disease Agents

Frequently Asked Questions (FAQs) on Dental Infection Control

Top|Diseases and Disease Agents

 


 

Frequently Asked Questions for Diseases and Disease Agents

Q

How long does a virus live outside a body?
 

Q

Where can I get the vaccine for spinal meningitis?

Q

Why is it that people who had hepatitis B, and are cured, cannot donate blood? Can those who have had the vaccine donate blood?

Q

What is the estimated risk for contracting HIV through a percutaneous exposure?

Q

Are there any states or institutions that require notification to patients if the healthcare worker is positive for viral hepatitis, HIV, or other infectious diseases?
Q What are the risks involved with having dental work done following a recent illness?
Q Is the employer required to provide post-vaccination testing for hepatitis B antibody?
Q Is it appropriate for employers to administer vaccines against the hepatitis B virus to his/her employees?
Q Is the tuberculosis (TB) vaccine recommended or required?
Q How long is the incubation time for tuberculosis (TB)?
Q How do you clean a nitrous oxide unit after a patient with chronic hepatitis C has used it?
Q In regard to hepatitis B vaccination, does the employer have to pay for the antibody response check, which occurs after 10 years?
Q What is the best injection site for the hepatitis B vaccine?
Q Is there any vaccine for Hepatitis C?
Q How do you handle the sterilization of instruments used on known hepatitis patients? Can you put them in the ultrasonic cleaner or separate them and handscrub them? If you use the ultrasonic cleaner, do you have to then empty it and sterilize it?
Q What does OSHA require in annual training for bloodborne pathogens?
Q

Which states allow employees to decline their hepatitis B vaccine?

 Q  We were all trained in the 1990s to avoid using Cavitrons and Prophy jets on patients with active diseases (i.e., HIV, HBV, HCV) because of the likelihood of blood aerosolization. Most of the recent research I've checked has been unclear as to whether anything other than typical standard precautions are needed (plus pre-procedure mouthrinse, high speed evacuation, etc.). As far as you know, is this still the case? I can't find anything really definitive.

Q

How long does a virus live outside a body?

A

The survival of a virus can depend on the individual virus characteristics, the condition of the environment, and other factors. Some resources provide specific information on various viruses(1). The Centers for Disease Control and Prevention (CDC) has information on multiple health topics, including viral disease(2).

References:
(1) Block SS, ed. Disinfection, Sterilization and Preservation, 4th ed; Lea & Febiger, Philadelphia, 2000.
(2) Centers for Disease Control and Prevention. Health Topics A to Z. Available at http://www.cdc.gov/health/default.htm
Top

Q

Where can I get the vaccine for spinal meningitis?

A

Call the CDC National Immunization Program at 1-800-232-2522 or visit http://www.cdc.gov/nip. General information on meningitis and available vaccines may be found on the CDC website(1).

References:
(1) Centers for Disease Control and Prevention, Center for Bacterial and Mycotic Disease. Meningococcal Disease. Available at http://www.cdc.gov/ncidod/dbmd/diseaseinfo/meningococcal_g.htm
Top

Q Why is it that people who had hepatitis B, and are cured, cannot donate blood? Can those who have had the vaccine donate blood?
A Those who have had hepatitis B are often considered carriers, even if they no longer exhibit signs or symptoms of the disease. It is highly likely that blood banks feel that anyone at risk for hepatitis B, as indicated by past infection, are at risk for other bloodborne diseases and as a precaution do not accept their blood. Those who have had the vaccine, on the other hand, may give blood because they are not considered a risk. The Centers for Disease Control and Prevention (CDC) has numerous resources on a variety of topics related to hepatitis B and the other known forms of viral hepatitis(1). A search of the Food and Drug Administration (FDA) database http://www.fda.gov/ can provide some resources on blood donation policies and restrictions.

References:
(1) CDC. National Center for Infectious Diseases. Viral Hepatitis. Available at http://www.cdc.gov/ncidod/diseases/hepatitis/index.htm
Top

Q What is the estimated risk for contracting HIV through a percutaneous exposure?
A Prospective hospital-based studies indicate that the estimated risk for HIV infection after percutaneous exposure to HIV-infected blood is approximately 0.3%(1). To date, there are no confirmed occupationally acquired cases of HIV in dentistry.

References:
(1) CDC/Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV and HIV and Recommendations for Postexposure Prophylaxis. MMWR Morbid Mortal weekly Rep 2001;50(RR-11). Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm
Top

Q Are there any states or institutions that require notification to patients if the healthcare worker is positive for viral hepatitis, HIV, or other infectious diseases?
A In 1991, the Centers for Disease Control and Prevention (CDC) recommendations on this issue were published.(1) Subsequently, Congress mandated that each state implement the CDC guidelines or equivalent as a condition for continued federal public health funding to that state. Although all states have complied with this mandate, there is a fair degree of state-to-state variation regarding specific provisions. Local or state public health officials should be contacted to determine the regulations or recommendations applicable in a given area. A Hospital Infection Control practices Advisory Committee (HICPAC) document titled "Guideline for infection control in health care personnel, 1998" can provide more information.(2)

References:
(1) CDC. Recommendations for Preventing Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Patients During Exposure-Prone Invasive Procedures. MMWR Mordbi Mortal Weekly Rep 1991;40(RR-8). Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/00014845.htm
(2) Bolyard EA, Tablan OC, Williams WW, Pearson ML,a Shapiro CN, Deitchman SD,c and The Hospital Infection Control Practices Advisory Committee. Guideline for infection control in health care personnel, 1998. Available at http://www.cdc.gov/ncidod/dhqp/gl_hcpersonnel.html
Top

Q What are the risks involved with having dental work done following a recent illness?
A If patients or practitioners have concerns regarding dental care for recently ill individuals or individuals with chronic health conditions, the patient's physician should be consulted before undertaking any dental treatment. Conditions requiring premedication, interruption of existing medications, or avoidance of certain medications to prevent adverse interactions may be present. Such considerations should be ruled out or accommodated prior to dental treatment. The Hospital Infections Practice Action Committee (HICPAC) has published guidelines that provide suggested work restrictions for healthcare personnel exposed to, or infected with diseases important in the healthcare setting. These guidelines could also provide a rationale basis for deferring treatment on infected patients.(1)

References:
(1) Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deithman SD. HICPAC. Guideline for infection control in health care personnel, 1998. Am J Infec Control 1998;26(3):289-354. Available athttp://www.cdc.gov/ncidod/dhqp/gl_hcpersonnel.html
Top

Q Is the employer required to provide post-vaccination testing for hepatitis B antibody?
A OSHA requires employers to follow the CDC guidelines current at the time of the evaluation or procedure.”(1) This includes the recommendation for antibody testing 1 to 2 months after completion of the vaccination series.(2)

References:
(1) OSHA. Compliance Directive CPL 2-2.69 - Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens. Available at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=DIRECTIVES&p_id=2570&p_text_version=FALSE
(2) CDC. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Morbid Mortal Weekly Rep 2001;50(RR-11). Available at http://www.cdc.gov/mmwr//preview/mmwrhtml/rr5011a1.htm
Top

Q Is it appropriate for employers to administer vaccines against the hepatitis B virus to his/her employees?
A For most dentists, administering vaccinations falls outside the scope of their license and therefore should not be done. For employers who are licensed healthcare professionals for whom administering vaccines is within the scope of their licenses, there is nothing in the OSHA regulations that would prevent them from providing this service to employees.
Top

Q

Is the tuberculosis (TB) vaccine recommended or required?
A In the United States, the use of BCG vaccination is rarely indicated. BCG vaccination is not recommended for inclusion in immunization or TB control programs, and it is not recommended for most HCWs. In countries where TB is endemic, however, it is often administered to infants and small children.

References:
(1) CDC. Division of Tuberculosis Elimination. Questions and Answers About TB. Available at http://www.cdc.gov/tb/publications/faqs/default.htm.
Top

Q How long is the incubation time for tuberculosis (TB)?
A According to the Centers for Disease Control and Prevention (CDC), "Usually within 2-10 weeks after initial infection with M. tuberculosis, the immune response limits further multiplication and spread of the tubercle bacilli; however, some of the bacilli remain dormant and viable for many years. This condition is referred to as latent TB infection. Persons with latent TB infection usually have positive purified protein derivative (PPD)-tuberculin skin-test results, but they do not have symptoms of active TB, and they are not infectious.”(1) About 10% of individuals with latent TB infection will develop active disease at some later point in life.

References:
(1) CDC. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, 1994. MMWR Morbid Mortal Weekly Rep 1994;43(RR13), 1-132. Available at http://www.cdc.gov/mmwr//preview/mmwrhtml/00035909.htm
Top

Q How do you clean a nitrous oxide unit after a patient with chronic hepatitis C has used it?
A Following the concept of universal precautions, process the unit as recommended for all patients. The use of an intermediate-level or low-level disinfectant (depending upon the degree of contamination) after cleansing should be adequate. Some nitrous oxide masks are intended to withstand heat sterilization processes and may be sterilized. Single use disposable nitrous masks should be discarded.
Top

Q In regard to hepatitis B vaccination, does the employer have to pay for the antibody response check, which occurs after 10 years?
A There is currently no U.S. Public Health Service recommendation for testing the presence of surface antibodies to hepatitis B virus 10 years post-vaccination. This is a decision that must be made between the individual and their physician. If the physician recommends testing as a routine precaution, the cost of that testing would not be the responsibility of the employer.
Top

Q What is the best injection site for the hepatitis B vaccine?
A The hepatitis B vaccine should always be administered in the deltoid muscle of the upper arm.
Top

Q Is there any vaccine for Hepatitis C?
A To date, no vaccine against hepatitis C virus has been developed.
Top

Q How do you handle the sterilization of instruments used on known hepatitis patients? Can you put them in the ultrasonic cleaner or separate them and handscrub them? If you use the ultrasonic cleaner, do you have to then empty it and sterilize it?
A Instruments used on known hepatitis patients do not require special reprocessing procedures. The same sterilization and other infection control precautions should be used regardless of a patient's HIV, hepatitis, or other disease status.

The Centers for Disease Control and Prevention's guidelines for infection control in dentistry state: "Universal precautions were based on the concept that all blood and body fluids that might be contaminated with blood should be treated as infectious because patients with bloodborne infections can be asymptomatic or unaware they are infected … Standard precautions integrate and expand the elements of universal precautions into a standard of care designed to protect HCP and patients from pathogens that can be spread by blood or any other body fluid, excretion, or secretion . Standard precautions apply to contact with 1) blood; 2) all body fluids, secretions, and excretions (except sweat), regardless of whether they contain blood; 3) nonintact skin; and 4) mucous membranes. Saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between universal precautions and standard precautions."(1)

In other words, the same sets of instrument processing, personal protection equipment, and engineering and work practice control precautions can be expected to protect against all bloodborne disease agents.(1) As such, instruments used on a known hepatitis patient need not be segregated from other contaminated instruments, can be cleaned in an ultrasonic cleaner, and do not require special post-cycle maintenance or cleaning of ultrasonic equipment.

References:
1) CDC. Guidelines for Infection Control in Dental Health-Care Settings --- 2003. December 19, 2003 MMWR 52(RR17);1-61 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm
Top

Q What does OSHA require in annual training for bloodborne pathogens?
A The Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard requires that all employees with occupational exposure receive training at the time of initial assignment and at least annually thereafter. Employees must also receive additional training when changes such as modification of tasks or procedures or institution of new tasks or procedures affect the employee's occupational exposure.

The elements of the training program must include, at a minimum:
  1. An accessible copy of the regulatory text of the current standard  and an explanation of its contents;
  2. A general explanation of the epidemiology and symptoms of bloodborne diseases;
  3. An explanation of the modes of transmission of bloodborne pathogens;
  4. An explanation of the employer's exposure control plan and the means by which the employee can obtain a copy of the written plan;
  5. An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials;
  6. An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment;
  7. Information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment;
  8. An explanation of the basis for selection of personal protective equipment;
  9. Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge;
  10. Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials;
  11. An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available;
  12. Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident;
  13. An explanation of the signs and labels and/or color coding required by paragraph (g)(1); and
  14. An opportunity for interactive questions and answers with the person conducting the training session.
The standard also requires that the person conducting the training be knowledgeable in the subject matter, and how the information relates to that workplace. The trainer also must provide an opportunity for questions and answers.

In addition to these OSHA requirements, OSAP recommends contacting your state's Board of Dental Examiners(2) to determine if it has any additional requirements for relicensure.

References:
1) OSHA. 29CFR 1910.1030. Bloodborne Pathogens, Final Rule. Available at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051
2) The Dental Student Dental Students: The Dental Students Network. State and Regional Dental Practice Boards. Available at http://forums.studentdoctor.net/forumdisplay.php?f=55.
Top

Q Which states allow employees to decline their hepatitis B vaccine?
A

Under the federal Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard 1910.1030, employers must explain the risks of exposure, state the benefits of the hepatitis B vaccine, and offer the vaccine, at no charge, to all employees at risk of exposure to blood or potentially infectious materials. Any employee, in any state, may choose to decline the vaccine.

Employees must understand the risks of disease transmission and the risks and benefits of receiving the vaccination before the employer offers the vaccine. Once they understand these risks and that the vaccine is available to them at the employer's expense, they reserve the right to decline. If they later change their mind, the employer is still obligated to provide the vaccine at not cost to any employee in a job category that involves exposure.

Top

QWe have had some recent cases of patients labeled MRSA at our facility. Are Standard Procedures sufficient to properly care for thesepatients? Any information would be appreciated.

A OSAP is not aware of special infection control practices for dentistry, in the United States, with regard to MRSA.

CDC's Infection Control Guidelines for Dental Healthcare Settings (December 2003) does not specifically address MRSA. However, dental healthcare workers should always practice Standard Precautions. Standard Precautions integrate and expand the elements of universal precautions into a standard of care designed to protect healthcare providers and patients from pathogens that can be spread by blood or any other body fluid, excretion, or secretion. (1)  

 

In addition to standard precautions, other measures (e.g. expanded or transmission-based precautions might be necessary to prevent potential spread of certain diseases that are transmitted through airborne, droplet, or contact transmission. (1)  

 

The main mode of transmission of MRSA is via hands which may become contaminated by contact with colonized or infected patients; colonized or infected body sites of the personnel themselves; devices, items, or environmental surfaces contaminated with body fluids containing MRSA. Standard Precautions (e.g. proper handwashing; gloves; mask; gown; eyewear; careful handling of all sharps; appropriate care, handling, disinfection of equipment, and sterilization of instruments, etc.) should control the spread of MRSA in most instances (2)  

 

For specific dental related concerns about MRSA patients, the dentist should consult with the patient's physician (physician treating the MRSA patient) prior to dental care.  

 

 

Resources:  

 

1) CDC's Infection Control Guidelines for Dental Healthcare Settings (December 2003) may be
viewed at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm  

 

2) CDC's Issues In Healthcare Settings: MRSA (A great deal of information on MRSA may be
viewed in CDC's Issues In Healthcare Settings)

http://www.cdc.gov/ncidod/hip/ARESIST/mrsa.htm  


QWe were all trained in the 1990s to avoid using Cavitrons and Prophy jets on patients with active diseases (i.e., HIV, HBV, HCV) because of the likelihood of blood aerosolization. Most of the recent research I've checked has been unclear as to whether anything other than typical standard precautions are needed (plus pre-procedure mouthrinse, high speed evacuation, etc.). As far as you know, is this still the case? I can't find anything really definitive.

A First and foremost, if a patient presents with any active, infectious disease, dentists should consult with the patient's treating physician prior to dental care. Modifications to the treatment plan may be necessary.

OSAP can provide general information regarding infection control guidelines. However, it is often a personal choice as to whether or not a dental healthcare worker chooses hand scalers or ultrasonic scaling. According to dental infection control experts, there shouldn't be a need to refrain from use of ultrasonic scalers with HIV/Hep. B & C positive patients. As with the use of ultrasonic scalers on any patient, proper PPE, HVE, engineering controls, work practice controls, etc. should be followed.Following Standard Precautions means all patients should be treated the same regardless of their status (e.g. HIV, Hep. B & C). In other words, all patients should be treated as if they are carrying an infectious disease. Therefore, if a clinician would not ultrasonic an HIV/HBV/HCV positive patient, then following Standard Precautions means you should not use it for any patient.  

 

The Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental Health Care Settings (December 2003), in part, states the following:

 

Preprocedural Mouth Rinses:

 

Antimicrobial mouth rinses used by patients before a dental procedure are intended to reduce the number of microorganisms the patient might release in the form of aerosols or spatter that subsequently can contaminate DHCP and equipment operatory surfaces. In addition, preprocedural rinsing can decrease the number of microorganisms introduced in the patient's bloodstream during invasive dental procedures. (1)

 

No scientific evidence indicates that preprocedural mouth rinsing prevents clinical infections among DHCP or patients, but studies have demonstrated that a preprocedural rinse with an antimicrobial product (e.g., chlorhexidine gluconate, essential oils, or povidone-iodine) can reduce the level of oral microorganisms in aerosols and spatter generated during routine dental procedures with rotary instruments (e.g., dental handpieces or ultrasonic scalers). Preprocedural mouth rinses can be most beneficial before a procedure that requires using a prophylaxis cup or ultrasonic scaler because rubber dams cannot be used to minimize aerosol and spatter generation and, unless the provider has an assistant, high-volume evacuation is not commonly used. (1)  

 

 

The science is unclear concerning the incidence and nature of bacteremias from oral procedures, the relationship of these bacteremias to disease, and the preventive benefit of antimicrobial rinses. In limited studies, no substantial benefit has been demonstrated for mouth rinsing in terms of reducing oral microorganisms in dental-induced bacteremias (400,401). However, the American Heart Association's recommendations regarding preventing bacterial endocarditis during dental procedures provide limited support concerning preprocedural mouth rinsing with an antimicrobial as an adjunct for patients at risk for bacterial endocarditis. Insufficient data exist to recommend preprocedural mouth rinses to prevent clinical infections among patients or DHCP. (1)

 

Although transmission of bloodborne pathogens (e.g., HBV, HCV, and HIV) in dental health-care settings can have serious consequences, such transmission is rare. Exposure to infected blood can result in transmission from patient to DHCP, from DHCP to patient, and from one patient to another. The opportunity for transmission is greatest from patient to DHCP, who frequently encounter patient blood and blood-contaminated saliva during dental procedures. (1)

 

Since 1992, no HIV transmission from DHCP to patients has been reported, and the last HBV transmission from DHCP to patients was reported in 1987. HCV transmission from DHCP to patients has not been reported. The majority of DHCP infected with a bloodborne virus do not pose a risk to patients because they do not perform activities meeting the necessary conditions for transmission. For DHCP to pose a risk for bloodborne virus transmission to patients, DHCP must 1) be viremic (i.e., have infectious virus circulating in the bloodstream); 2) be injured or have a condition (e.g., weeping dermatitis) that allows direct exposure to their blood or other infectious body fluids; and 3) enable their blood or infectious body fluid to gain direct access to a patient's wound, traumatized tissue, mucous membranes, or similar portal of entry. Although an infected DHCP might be viremic, unless the second and third conditions are also met, transmission cannot occur. (1)

 

The risk of occupational exposure to bloodborne viruses is largely determined by their prevalence in the patient population and the nature and frequency of contact with blood and body fluids through percutaneous or permucosal routes of exposure. The risk of infection after exposure to a bloodborne virus is influenced by inoculum size, route of exposure, and susceptibility of the exposed HCP. The majority of attention has been placed on the bloodborne pathogens HBV, HCV, and HIV, and these pathogens present different levels of risk to DHCP. (1)

 

DHCP should be familiar also with the hierarchy of controls that categorizes and prioritizes prevention strategies. For bloodborne pathogens, engineering controls that eliminate or isolate the hazard (e.g., puncture-resistant sharps containers or needle-retraction devices) are the primary strategies for protecting DHCP and patients. Where engineering controls are not available or appropriate, work-practice controls that result in safer behaviors (e.g., one-hand needle recapping or not using fingers for cheek retraction while using sharp instruments or suturing), and use of personal protective equipment (PPE) (e.g., protective eyewear, gloves, and mask) can prevent exposure. In addition, administrative controls (e.g., policies, procedures, and enforcement measures targeted at reducing the risk of exposure to infectious persons) are a priority for certain pathogens (e.g., M. tuberculosis), particularly those spread by airborne or droplet routes. (1)

 

Dental practices should develop a written infection-control program to prevent or reduce the risk of disease transmission. Such a program should include establishment and implementation of policies, procedures, and practices (in conjunction with selection and use of technologies and products) to prevent work-related injuries and illnesses among DHCP as well as health-care--associated infections among patients. The program should embody principles of infection control and occupational health, reflect current science, and adhere to relevant federal, state, and local regulations and statutes. An infection-control coordinator (e.g., dentist or other DHCP) knowledgeable or willing to be trained should be assigned responsibility for coordinating the program. (1)

 

The effectiveness of the infection-control program should be evaluated on a day-to-day basis and over time to help ensure that policies, procedures, and practices are useful, efficient, and successful (see Program Evaluation). (1)

 

Standard precautions include use of PPE (e.g., gloves, masks, protective eyewear or face shield, and gowns) intended to prevent skin and mucous membrane exposures. Other protective equipment (e.g., finger guards while suturing) might also reduce injuries during dental procedures. (1)

 

Engineering controls are the primary method to reduce exposures to blood and OPIM from sharp instruments and needles. These controls are frequently technology-based and often incorporate safer designs of instruments and devices (e.g., self-sheathing anesthetic needles and dental units designed to shield burs in handpieces) to reduce percutaneous injuries. (1)

 

Work-practice controls establish practices to protect DHCP whose responsibilities include handling, using, assembling, or processing sharp devices (e.g., needles, scalers, laboratory utility knives, burs, explorers, and endodontic files) or sharps disposal containers. Work-practice controls can include removing burs before disassembling the handpiece from the dental unit, restricting use of fingers in tissue retraction or palpation during suturing and administration of anesthesia, and minimizing potentially uncontrolled movements of such instruments as scalers or laboratory knives. (1)

 

Again, it is often a personal choice as to whether or not a dental healthcare worker chooses hand scalers or ultrasonic scaling.  

 

You may also contact CDC's Oral Health Resource Division for further guidance regarding ultrasonic scaling. They may have additional research data regarding the use of ultrasonic scalers that OSAP would not be aware of. Contact information is available at: http://www.cdc.gov/oralhealth/contact.htm  

 

 

Resource:  

 

1) Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental
Healthcare Settings. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm  

Top


OSAP Disclaimer | Please notify ourwebmaster of any problems with this website.
OSAP thanks its Super Sponsors for their support in 2014. Sponsorship does not imply endorsement by OSAP of a company's products or services.