The aim of this chapter is to provide:
- detail about standard precautions and infection control guidelines for health-care settings
- advice about hepatitis B prevention in health-care settings, and guidance on the management of blood and body-substance exposures and incidents.
|HBV, hepatitis B virus|
|Myths and facts about infection control|
|MYTH – Wearing gloves means you do not need to wash your hands.
FACT – Gloves are not a substitute for effective hand washing.
|MYTH – Health-care workers should use transmission-based precautions (formerly referred to as additional precautions) when caring for a patient with HBV, to prevent transmission.
FACT – Implementation of standard precautions ensures a high level of protection against transmission of HBV in the health-care setting.
|MYTH – Health-care workers need to have booster dose of hepatitis B vaccine every 5 years.
FACT – Booster doses are no longer recommended in immunocompetent individuals after a primary course of HBV vaccine, because the evidence suggests that a completed course of HBV vaccination provides long-lasting protection.
|MYTH – Health-care workers with HBV must not have contact with patients because of the risk of transmission.
FACT – Health-care workers with HBV are generally advised to avoid performing exposure-prone procedures; however, they can still have non-invasive contact with patients.
It is essential to maintain the safety of the health-care environment for patients and health professionals; this necessitates the implementation of infection control guidelines. The current best-practice guidelines for infection control procedures in Australia are outlined in the Australian guidelines for the prevention and control of infection in healthcare (2010) (1). State and territory health departments in Australia have adopted the principle of standard precautions. Such precautions ensure a high level of protection against transmission of infection in the health-care setting, and are required in the treatment and care of all patients to prevent transmission of blood-borne infections.
Infection control guidelines are relevant in social and domestic contexts, as well as in occupational settings. The implementation of infection control guidelines in social and domestic settings can help patients with hepatitis B virus (HBV) to reduce the risk of transmitting the disease to unvaccinated significant others. Clinicians should be able provide advice for patients in relation to infection control in their daily environment. This chapter provides an overview of the current Australian infection control guidelines and their relevance in treating patients with HBV.
Modes of HBV transmission and risk of transmission are outlined in Chapter 3.
The risk of blood-borne virus transmission depends on a number of factors. Incidents involving blood-to-blood contact with infectious blood are associated with a high risk of infection when:
- there is a large quantity of blood, indicated by visible contamination
- there is insertion of a needle directly into a vein or artery or deep cavity
- the patient has high levels of HBV DNA and detectable hepatitis B e antigen (HBeAg); hepatitis C virus (HCV) RNA detected by polymerase chain reaction (PCR); advanced human immunodeficiency virus (HIV) disease or high HIV viral load
- the immunisation status of the exposed individual (in the case of HBV) is unknown.
Patient-to-patient transmission of HBV, although rare, has been associated with oral surgery, inadequate use or disinfection of medical devices (e.g. blood glucose finger-stick devices), and multidose vials (2-6). Transmission of HBV in the health-care setting can be prevented through hepatitis B vaccination programs for health-care workers, patients and community, and strict adherence to standard precautions.
The universal application of standard precautions is the minimum level of infection control required in the treatment and care of all patients to prevent transmission of blood-borne viruses. These precautions include personal hygiene practices (particularly hand washing) before and after every episode of patient contact, use of personal protective equipment (e.g. gloves, gowns and protective eye wear), aseptic non-touch technique, safe disposal systems for sharps and contaminated matter, routine environmental cleaning, reprocessing of reusable medical equipment and instruments, ensuring that single use items are only used once and disposed of after single use (including single use of multidose vials), respiratory hygiene and waste management.
Standard precautions should be implemented for all patients all of the time, regardless of information or assumptions about a patient’s blood-borne virus status. This practice will help to reduce potential stigma and discrimination in the health-care setting.
12.3.1 Hand hygiene
Hand hygiene practices are generally considered the most important hygiene measure in preventing the spread of infection. However, hand hygiene alone is insufficient to prevent and control infection, it needs to be used as part of a multifactorial approach to infection control. Clinicians should wash their hands or use an alcohol-based hand rub before and after contact with any patient, and after activities that may cause contamination.
Hand hygiene must be performed before and after every episode of patient contact. This includes:
- before touching a patient
- before a procedure
- after a procedure or body-substance exposure risk
- after touching a patient
- after touching a patient’s surroundings.
Hand hygiene must also be performed after the removal of gloves.
Adapted with permission from: Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect. 2007;67(1): 9–1.
Skin care is important because healthy, unbroken skin provides a valuable, natural barrier to infection. Skin breaks should be covered with a water-resistant occlusive dressing. Alcohol-based hand rubs are more effective against most common infectious agents on hands than hand hygiene with plain or antiseptic soap and water.
Gloves are a form of personal protective equipment. Clinicians and other health-care workers should wear gloves whenever there is a risk of exposure to blood or body substances. They should change their gloves and wash their hands after contact with each patient, and during procedures with the same patient if there is a chance of cross contamination. Gloves must be used when:
- handling blood or body substances (or both)
- performing venepuncture
- touching mucous membranes
- touching non-intact skin
- handling contaminated sharps
- performing invasive procedures
- cleaning body-substance spills or any equipment (instruments), materials (linen) or surface that may have been contaminated by body substances.
Gloves do not need to be used for every episode of patient contact unless the above points apply.
Further information about the appropriate use of gloves is given in the Australian guidelines (1).
12.3.3 Other personal protective equipment
Personal protective equipment should be readily available and accessible in all health-care settings. The type of protective equipment required depends on the nature of the procedure, the equipment used and the skill of the operator. For example, the use of protective equipment is recommended in the following circumstances:
- protective eyewear and face shields should be worn during procedures where there is potential for splashing, splattering or spraying of blood or other body substances
- impermeable gowns and plastic aprons should be worn to protect clothing and skin from contamination with blood and body substances
- footwear should be enclosed to protect against injury or contact with sharp objects.
12.4.1 Prevention of occupational exposure (needlestick or sharps injuries)
Inappropriate handling of sharps is a major cause of accidental exposure to blood-borne viruses in health-care settings. To minimise the risk of a needlestick or sharps injury, needles, sharps and clinical waste should be handled carefully at all times. Specifically, clinicians and other health-care workers should:
- minimise their handling of needles, sharps and clinical waste
- not bend or recap needles, or remove needles from disposable syringes
- use safe needle-handling systems, including rigid containers for disposal (these should be kept out of the reach of children)
- ensure that ‘sharps’ containers are available at the point of use or in close proximity to work sites, to aid immediate disposal.
Importantly, the person who has used a sharp instrument or needle must be responsible for its immediate safe disposal following its use.
12.4.2 Management of occupational exposures
All clinicians and health-care workers should have access to infection control guidelines that advise about the management of an occupational injury, including clear written instructions on the appropriate action to take in the event of a needlestick and other blood or body-substance exposures involving either patients or health-care workers. Clinicians and health-care workers should be encouraged to report occupational exposures immediately, and all testing procedures and follow-up treatment should be fully documented. Confidentiality should be maintained.
In general, if an injury or incident occurs where blood or body substances come into contact with non-intact skin or membranes, the following action should be taken:
- Wash exposed membrane or injury with soap and water (an antiseptic could also be used on the skin).
- If eyes have been exposed, thoroughly rinse the eyes with tap water or saline while open.
- If mouth has been exposed, thoroughly rinse the mouth with water and spit out.
- Seek medical advice immediately for assessment of nature of the exposure, the risk of transmission of blood-borne viruses and the need HIV or HBV post-exposure prophylaxis.
- If the exposure is significant and the source patient is known, their consent for HIV, HCV and HBsAg testing should be sought.
12.4.3 Hepatitis B immunoglobulin as post-exposure prophylaxis in the health-care setting
Initiation of hepatitis B immunoglobulin (HBIG) depends on the type of exposure, the source patient’s HBsAg status and the exposed person’s HBV immunisation history.
188.8.131.52 Unvaccinated individual
In the case of an unvaccinated individual who is exposed to HBV infected blood or body substances, HBIG should be administered within 72 hours of the exposure, to prevent HBV infection. The first dose of the HBV vaccine should also be administered as soon as possible.
184.108.40.206 Vaccinated individual
For individuals who have been vaccinated and who have a documented protective response after vaccination (anti-HBs level ≥10 mIU/mL), HBIG is not recommended. If an individual’s response to the vaccine has not been determined, this should be done immediately. If there is no protection, the individual should be offered a dose of HBIG and HBV vaccine.
Vaccination is an important infection control strategy to prevent the transmission of HBV. For further information on the HBV vaccination regime and groups to be vaccinated, see Chapter 5.
The mandatory testing of clinicians and other health-care workers for HBV, HCV and HIV is not warranted, due to the low risk of transmission if standard precautions are followed. Testing for blood-borne viruses should only be undertaken on the basis of clinical assessment or where testing is in the interests of patients and health-care workers (e.g. a needlestick injury) (1). Clinicians and other health-care workers who regularly perform exposure-prone procedures have a responsibility to be regularly tested for HIV, HCV and HBV if they are not immune. The provision of confidentiality, privacy and consent for testing should be applied.
12.5.3 Infected health-care workers
Clinicians and other health-care workers have a legal obligation to care for the safety of others in the workplace, and this includes colleagues and patients. Clinicians and other health-care workers infected with HBV should consult state or territory regulations to determine what restrictions are placed on their clinical practice. In general, it is recommended that they do not perform procedures that carry a high risk of transmission of the virus from health-care worker to patient (i.e. exposure-prone procedures).
Health-care workers must not perform exposure-prone procedures if they are HBeAg positive or hepatitis B DNA positive at high titres. Those who are currently HBsAg positive and HBV DNA negative must obtain ongoing medical advice about their potential infectiousness and the appropriateness of their continued performance of such procedures (1).
12.5.4 Infection control in the primary-care setting
The general principles of infection control that apply to large health-care settings also apply to office practices; specific issues related to office practices are outlined in the The Australian guidelines for the prevention and control of infection in healthcare (2010) (1) and the Royal Australian College of General Practice (RACGP) infection control standards (9).3
12.5.5 Management of blood and body-substance spills in the health-care setting
Management of blood and body-substance spills depends on the nature of the spill, type of surface and the area involved. The basic principles of spills management are:
- standard precautions, including use of personal protective equipment, apply where there is a risk of contact with blood or body substances
- spills should be cleaned up before the area is disinfected
- the spill should be confined and contained, and visible matter should be cleaned with disposable absorbent material, and the used cleaning materials discarded in the appropriate waste container
- generation of aerosols from spilled material should be avoided.
Use of chemical disinfectants such as sodium hypochlorite should be based on assessment of risk of transmission of infectious agents from the spill.
Prompt removal of spots and spills of blood and body substances, followed by cleaning and disinfection of the area contaminated, is sound infection control practice and meets occupational health and safety requirements (1). Further information about management of blood or body fluid spills is given in the Australian guidelines (1).
Legal liability may occur if inadequate care has been taken to prevent the transmission of infection. Regulatory authorities (e.g. environmental protection) and the Australian Government, states or territories, and local governments enforce laws and regulations relating to infection control and waste disposal. These regulations can vary considerably throughout Australia, and should take precedence over the general information presented in this chapter. Further information can be obtained from state and territory health departments, and from medical and other professional boards. Legal issues are considered in greater detail in Chapter 13.
Standard precautions and infection control procedures protect against transmission of blood-borne viruses, including HBV, HCV and HIV, in the health-care setting. Regardless of the perceived risk, infection control procedures must be followed in all clinical settings, to minimise the risk of accidental transmission of blood-borne viruses. Clinicians and other health-care workers should be vaccinated against HBV, and should know their vaccination response. Exposures to blood and body substances should be reported immediately and monitored.
- National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare. Canberra: Commonwealth of Australia, 2010.
- Redd JT, Baumbach J, Kohn W, Nainan O, Khristova M, Williams I. Patient-to-patient transmission of hepatitis B virus associated with oral surgery. The Journal of Infectious Diseases. 2007;195(9):1311–4.
- Polish LB, Shapiro CN, Bauer F, Klotz P, Ginier P, Roberto RR, et al. Nosocomial transmission of hepatitis B virus associated with the use of a spring-loaded finger-stick device. The New England Journal of Medicine. 1992;326(11):721–5.
- Hutin YJ, Goldstein ST, Varma JK, O’Dair JB, Mast EE, Shapiro CN, et al. An outbreak of hospital-acquired hepatitis B virus infection among patients receiving chronic hemodialysis. Infection Control and Hospital Epidemiology. 1999;20(11):731–5.
- Dumpis U, Kovalova Ž, Jansons J, Čupane L, Sominskaya I, Michailova M, et al. An outbreak of HBV and HCV infection in a paediatric oncology ward: epidemiological investigations and prevention of further spread. Journal of Medical Virology. 2003;69(3):331–8.
- Samandari T, Malakmadze N, Balter S, Perz JF, Khristova M, Swetnam L, et al. A large outbreak of hepatitis B virus infections associated with frequent injections at a physician’s office. Infection Control and Hospital Epidemiology. 2005;26(9):745–50.
- World Health Organization (WHO). Guidelines on hand hygiene in healthcare. Geneva: WHO; 2009; Available from: http://www.who.int/patientsafety/information_centre/documents/en/index.html.
- Grayson L, Russo P, Ryan K. Hand Hygiene Australia Manual: Australian Commission for Safety and Quality in Healthcare and World Health Organization; 2009.
- Royal Australian College of General Practitioners (RACGP). Infection control standards for office based practices. Melbourne: RACGP; 2006.
3. The RACGP Infection prevention and control standards for general practices and other office-based and community-based practices (5th Edition) can be accessed electronically at http://www.racgp.org.au/publications/ordering/standards/.