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FAQ's Postexposure Management

Frequently Asked Questions (FAQs) on Dental Infection Control


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Frequently Asked Questions for Postexposure Management

Q What should one do if a puncture injury occurs, resulting in bleeding?

Q Based on the Centers for Disease Control and Prevention (CDC) recommendations for postexposure prophylaxis, what details must the employer include in an incident report?

Q In an occupational exposure and followup, would the consulting healthcare professional report back to the employer with any limits on job performance to lower the risk of a seroconverted healthcare worker transmitting an infectious disease to future patients?

Q Who is responsible for paying for postexposure management if a student has an exposure incident?

Q Is there any type of liquid cleanser that public safety personnel can use on their hands immediately after a possible exposure incident?

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 I am a dental hygienist who works part-time in more than one dental office. Does each employer have to provide and launder a smock to be worn when working in that particular office?

Q Should needlestick injuries be reported to the dental workers' compensation carrier? I asked the nearest hospital about post-exposure prophylaxis and they did not provide nor know about it. Where should I look for the information?

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Q What should one do if a puncture injury occurs, resulting in bleeding?

A If the injury involves exposure to a patient's blood, saliva, or other potentially infectious materials, the dental worker must report the injury to the designated person in the practice as soon as possible. Steps to follow include administering basic first aid, ensuring the device involved in the injury is not reused on the patient, and referral to an appropriate healthcare provider as soon as possible for evaluation and follow-up. More detailed recommendations are provided in the document Exposures to Blood, What Healthcare Workers Need to Know (1). The healthcare provider (usually an occupational health professional) should be knowledgeable in the current Centers for Disease Control and Prevention (CDC) recommendations for post-exposure prophylaxis (2).

References:
(1) CDC. Exposures to Blood, What Healthcare Workers Need to Know. Available at www.cdc.gov/ncidod/hip/BLOOD/exp_blood.htm
(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 www.cdc.gov/mmwr//preview/mmwrhtml/rr5011a1.htm

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Q Based on the Centers for Disease Control and Prevention (CDC) recommendations for postexposure prophylaxis, what details must the employer include in an incident report?

A Because many factors contribute to the risk of infection after an occupational exposure to blood, it is important that the following information be included in the exposure report, recorded in the exposed person's confidential medical record, and provided to the qualified healthcare professional:
date and time of exposure;
details of the procedure being performed, including where and how the exposure occurred and if the exposure involved a sharp device, the type of device and how and when during its handling the exposure occurred;
details of the exposure, including the type and amount of fluid or material and the severity of the exposure. For a percutaneous injury, this would include the depth of the wound, gauge of the needle, and whether fluid was injected; for a skin or mucous membrane exposure, the estimated volume of material, duration of contact, and the condition of the skin (e.g., chapped, abraded, or intact);
details about the exposure source -- whether the source material contained HIV or other bloodborne pathogens, and, if the source was infected with HIV, the stage of disease, history of antiretroviral therapy, and viral load, if known; and
details about counseling, postexposure management, and follow-up (1)
References:
(1) 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

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Q In an occupational exposure and followup, would the consulting healthcare professional report back to the employer with any limits on job performance to lower the risk of a seroconverted healthcare worker transmitting an infectious disease to future patients?

A The responsibility of the evaluating healthcare provider is limited to counseling exposed workers regarding their exposures, risks, and recommended treatments or prophylaxis. The information provided to the employer should be limited to that required under the OSHA Bloodborne Pathogens Rule: that the employee has been informed of the results of the evaluation and that the employee has been told about any medical conditions resulting from the exposure that might require further evaluation or treatment(1).

References:
(1) OSHA Bloodborne Pathogens Standard, Final Rule. Available at http://www.osha.gov/SLTC/bloodbornepathogens/index.html

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Q Who is responsible for paying for postexposure management if a student has an exposure incident?

A According to OSHA, students are not considered to be employees of an institution. Therefore, the student would be responsible for paying for postexposure management unless the institution had developed a policy that requires students to demonstrate proof of health insurance before acceptance into a program, or that requires students to pay a health center fee for these types of emergencies. Residents that receive a stipend from the institution should be considered employees for the purposes of compliance with the Bloodborne Pathogens Rule. For these individuals, the worker's compensation carrier or teaching institution should cover the costs.

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Q Is there any type of liquid cleanser that public safety personnel can use on their hands immediately after a possible exposure incident?

A Wound and skin sites that have been in contact with blood or body fluids should be washed with soap and water. OSHA acknowledges that circumstances may arise where handwashing facilities may not be available and addresses the issue by allowing "…the use of alternative handwashing methods as an interim measure when soap and water are not a feasible means of washing the hands or other parts of the body. In such cases, the employer must provide either antiseptic hand cleaner and clean cloth/paper towels, or antiseptic towelettes. When these types of alternatives are used, employees must wash their hands (or other affected area) with soap and running water as soon as feasible thereafter.” (1)

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

 

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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
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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.

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Q I am a dental hygienist who works part-time in more than one dental office. Does each employer have to provide and launder a smock to be worn when working in that particular office?

A Your job puts you at risk for exposure to blood and other potentially infectious materials, which, according to the Occupational Safety and Health Administration (OSHA), includes saliva. The OSHA Bloodborne Pathogens Standard requires that appropriate personal protective attire be provided at no cost to you by your employer. If you have more than one employer at different worksites, each employer must provide appropriate protective attire in the proper size. Employers also are responsible for maintaining personal protective equipment, including laundering and replacing as needed.(1).

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

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Q Should needlestick injuries be reported to the dental workers' compensation carrier?

A As a rule, injuries that require medical evaluation, care, and/or treatment to workers must be reported to workers' compensation carriers. However, workers' compensation programs can vary from state to state. Contact your state office of employment or worker's compensation for details of how these injuries should be handled.

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Q
Should needlestick injuries be reported to the dental workers' compensation carrier? I asked the nearest hospital about post-exposure prophylaxis and they did not provide nor know about it. Where should I look for the information?

A The United States Public Health Service updated the Guidelines for Management of Occupational Exposures. The guidelines may be viewed at:

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 2001;50(No. RR-11).

Additional information may be viewed at:

NIOSH Emergency Needlestick Information: http://www.cdc.gov/niosh/topics/bbp/emergnedl.html

CDC Exposure to Blood: What Healthcare Personnel Need To Know:

http://www.cdc.gov/ncidod/dhqp/pdf/bbp/Exp_to_Blood.pdf

The CDC's Infection Control Guidelines for Dental Healthcare Settings, in part, states the following:

Postexposure management is an integral component of a complete program to prevent infection after an occupational exposure to blood. During dental procedures, saliva is predictably contaminated with blood. Even when blood is not visible, it can still be present in limited quantities and therefore is considered a potentially infectious material by OSHA. A qualified health-care professional should evaluate any occupational exposure incident to blood or OPIM, including saliva, regardless of whether blood is visible, in dental settings. (1)

Dental practices and laboratories should establish written, comprehensive programs that include hepatitis B vaccination and postexposure management protocols that 1) describe the types of contact with blood or OPIM that can place DHCP at risk for infection; 2) describe procedures for promptly reporting and evaluating such exposures; and 3) identify a health-care professional who is qualified to provide counseling and perform all medical evaluations and procedures in accordance with current recommendations of the U.S. Public Health Service (PHS), including PEP with chemotherapeutic drugs when indicated. DHCP, including students, who might reasonably be considered at risk for occupational exposure to blood or OPIM should be taught strategies to prevent contact with blood or OPIM and the principles of postexposure management, including PEP options, as part of their job orientation and training. Educational programs for DHCP and students should emphasize reporting all exposures to blood or OPIM as soon as possible, because certain interventions have to be initiated promptly to be effective. Policies should be consistent with the practices and procedures for worker protection required by OSHA and with current PHS recommendations for managing occupational exposures to blood.

After an occupational blood exposure, first aid should be administered as necessary. Puncture wounds and other injuries to the skin should be washed with soap and water; mucous membranes should be flushed with water. No evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of bloodborne pathogen transmission; however, use of antiseptics is not contraindicated. The application of caustic agents (e.g., bleach) or the injection of antiseptics or disinfectants into the wound is not recommended. Exposed DHCP should immediately report the exposure to the infection-control coordinator or other designated person, who should initiate referral to the qualified health-care professional and complete necessary reports. Because multiple factors contribute to the risk of infection after an occupational exposure to blood, the following information should be included in the exposure report, recorded in the exposed person's confidential medical record, and provided to the qualified health-care professional (1):

Date and time of exposure.
Details of the procedure being performed, including where and how the exposure occurred and whether the exposure involved a sharp device, the type and brand of device, and how and when during its handling the exposure occurred.
Details of the exposure, including its severity and the type and amount of fluid or material. For a percutaneous injury, severity might be measured by the depth of the wound, gauge of the needle, and whether fluid was injected; for a skin or mucous membrane exposure, the estimated volume of material, duration of contact, and the condition of the skin (e.g., chapped, abraded, or intact) should be noted.
Details regarding whether the source material was known to contain HIV or other bloodborne pathogens, and, if the source was infected with HIV, the stage of disease, history of antiretroviral therapy, and viral load, if known.
Details regarding the exposed person (e.g., hepatitis B vaccination and vaccine-response status).
Details regarding counseling, postexposure management, and follow-up.
Each occupational exposure should be evaluated individually for its potential to transmit HBV, HCV, and HIV, based on the following (1):

The type and amount of body substance involved.
The type of exposure (e.g., percutaneous injury, mucous membrane or nonintact skin exposure, or bites resulting in blood exposure to either person involved).
The infection status of the source.
The susceptibility of the exposed person.
All of these factors should be considered in assessing the risk for infection and the need for further follow-up (e.g., PEP). (1)

During 1990--1998, PHS published guidelines for PEP and other management of health-care worker exposures to HBV, HCV, or HIV. In 2001, these recommendations were updated and consolidated into one set of PHS guidelines. The new guidelines reflect the availability of new antiretroviral agents, new information regarding the use and safety of HIV PEP, and considerations regarding employing HIV PEP when resistance of the source patient's virus to antiretroviral agents is known or suspected. In addition, the 2001 guidelines provide guidance to clinicians and exposed HCP regarding when to consider HIV PEP and recommendations for PEP regimens. (1)

Note: Some dental employers consult/contract with an Occupational Health/Occupational Medicine Facility knowledgeable in exposure incidents to management their employee postexposure evaluation and follow-up.

Resource:

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


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