COURSE PRICE: $10.00
CONTACT HOURS: 1
This course will expire or be updated on or before September 1, 2014.
ABOUT THIS COURSE
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.
ACCREDITATION / APPROVAL
This course covers the requirements for annual bloodborne pathogen training as outlined by the Occupational Safety and Health Administration of the U.S. Department of Labor (OSHA).
Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Wild Iris Medical Education, Inc. (CBRN Provider #12300) is approved as a provider of continuing education for RNs and LVNs by the California Board of Registered Nursing.
Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. See our disclosures for more information.
This course covers the requirements for annual bloodborne pathogen training as outlined by the Occupational Safety and Health Administration of the U.S. Department of Labor (OSHA).
Copyright © 2011 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to provide information on bloodborne diseases and the OSHA Bloodborne Pathogens Standard.
Upon completion of this course, you will be able to:
The Occupational Safety and Health Administration of the U.S. Department of Labor (OSHA) first published the Occupational Exposure to Bloodborne Pathogens Standard in 1991 in Title 29 of the Code of Federal Regulations 1910.1030. In 2001, in response to the Needlestick Safety and Prevention Act, OSHA revised the Bloodborne Pathogens Standard. The standard details what employers must do to protect workers whose jobs put them at risk for exposure to blood and other potentially infectious materials. OSHA regularly inspects healthcare agencies for compliance and may fine employers if infractions are identified.
In general, the standard requires employers to do the following:
Bloodborne pathogens are microorganisms present in human blood or other potentially infectious materials (OPIM) that can cause disease in individuals who are exposed to the blood containing the pathogen. Many are relatively rare, such as malaria and syphilis. Others are common, such as the hepatitis virus and the human immunodeficiency virus (HIV), which causes acquired immune deficiency (AIDS).
In addition to blood, potentially infectious materials include any body fluid that might be infected, such as:
Two bloodborne pathogens are specifically addressed by OSHA standards because they are the most common and pose the greatest threat to employees who may be exposed. They are hepatitis B (HBV) and human immunodeficiency virus (HIV).
Hepatitis means inflammation of the liver. Several strains of the hepatitis virus have been identified; hepatitis A, hepatitis B, and hepatitis C are the most common. (Hepatitis A is not a bloodborne pathogen and will not be discussed here.)
The liver is an organ located at the top of the abdomen, just below the diaphragm. The liver performs several vital functions that serve to detoxify the blood cells, inactivate many chemical compounds, store glucose as glycogen, synthesize triglycerides and cholesterol, and produce plasma proteins. Diseases that inflame or damage the liver adversely affect the body’s ability to perform these vital functions, leading to acute or chronic illness and sometimes death.
Hepatitis B is an infection of the liver caused by the hepatitis B virus. Acute hepatitis B refers to the first 6 months after someone is exposed to the hepatitis B virus. The illness can range in severity from very mild with few or no symptoms to a serious condition requiring hospitalization. Some people are able to fight the infection and clear the virus. For others, the infection remains and leads to a chronic, or lifelong, illness. Chronic hepatitis B refers to the illness that occurs when the hepatitis B virus remains in a person’s body. Over time, the infection can cause serious health problems.
In the United States, approximately 1.2 million people have chronic hepatitis B. Unfortunately, many people do not know they are infected. The number of new cases of hepatitis B has decreased more than 80% over the last 20 years. An estimated 40,000 people now become infected each year. Many experts believe this decline is a result of widespread vaccination of children.
Approximately 15%–25% of people with chronic hepatitis B develop serious liver problems, including liver damage, cirrhosis, liver failure, and liver cancer. Every year, approximately 3,000 people in the United States and more than 600,000 people worldwide die from hepatitis B–related liver disease (CDC, 2010a).
Hepatitis B is transmitted through activities that involve percutaneous (i.e., puncture through the skin) or mucosal contact with infectious blood or body fluids (e.g., semen or saliva), including:
Hepatitis B is not spread through breastfeeding, sharing eating utensils, hugging, kissing, holding hands, coughing, or sneezing. Unlike some forms of hepatitis, hepatitis B is not spread by contaminated food or water.
The hepatitis B virus is very resilient, and it can survive in dried blood for up to 7 days (CDC, 2011a). For this reason, the virus is a concern for medical personnel such as nurses and paramedics, as well as custodians, laundry personnel, and other employees who may come in contact with blood or potentially infectious materials.
People who are infected with HBV often show no symptoms for a period of time. After exposure it can take up to 9 months before symptoms become noticeable. The symptoms of hepatitis B are often much like a mild flu. Initially there is fatigue, possible stomach pain, fever, loss of appetite, and nausea. As the disease continues to develop, jaundice (a distinct yellowing of the skin and eyes) and darkened urine usually occurs.
Hepatitis B is diagnosed with specific blood tests that are not part of blood work typically done during regular physical exams. The hepatitis B surface antigen (HBsAg), a protein on the surface of HBV, can be detected in high levels in serum during acute or chronic HBV infection. The presence of HBsAg indicates that the person is infectious. The body normally produces antibodies to HBsAg as part of the normal immune response to infection. HBsAg is the antigen used to make hepatitis B vaccine.
HBsAg will be detected in an infected person’s blood from 1 to 9 weeks after exposure to the virus. About half will no longer be infectious by 7 weeks after onset of symptoms, and all persons who do not remain chronically infected will be HBsAg-negative by 15 weeks after onset of symptoms (CDC, 2011a).
There is no cure for HBV, but there are medications available to treat long-lasting HBV infection. Adefovir dipivoxil, interferon alfa-2b, pegylated interferon alft-2a, lamivudine, entecavir, and telbivudine are six medications used for the treatment of persons with chronic hepatitis B (CDC, 2011a). Many people who contract the disease develop antibodies that help them get over the infection and protect them from getting it again. It is important to note that infection with HBV will not prevent someone from getting another type of hepatitis.
The hepatitis B vaccine is the best protection from the disease.
All employees who are exposed to blood or other potentially infectious materials as part of their job duties are eligible to be vaccinated against the hepatitis B virus. The OSHA Bloodborne Pathogen Standard requires employers to offer the vaccination series to all workers who have occupational exposure. Examples of workers who may have occupational exposure include, but are not limited to, healthcare workers, emergency responders, morticians, first-aid personnel, correctional officers, and laundry workers in hospitals and commercial laundries that service healthcare or public safety institutions. The vaccine and vaccination must be offered at no cost to the employee and at a reasonable time and place (OSHA, 2011b).
The hepatitis B vaccine is a noninfectious, yeast-based vaccine that is usually given in a series of three intramuscular injections in the arm. It is prepared from recombinant yeast cultures rather than human blood or plasma. Thus, there is no chance of developing HBV from the vaccine.
The vaccination consists of a series of three injections. The second injection should be given 1 month after the first, and the third injection 6 months after the initial dose. To ensure immunity, it is important to receive all three injections. The vaccine causes no harm to those who are already immune or to those who may be HBV carriers.
Although employees may opt to have their blood tested for antibodies to determine need for the vaccine, their employers may not make such screening a condition of receiving vaccination, nor are employers required to provide screening. For employees at risk for exposure, an antibody titer can be drawn 1 to 2 months after the vaccination series is completed to determine vaccine effectiveness. If a second vaccine series is indicated, it must be offered free of charge.
Employees who decide to decline vaccination must complete a declination form. An employee may opt to take the vaccine at any time even after initially declining it.
Hepatitis C is a serious infection of the liver caused by the hepatitis C virus, a bloodborne pathogen. An estimated 3.2 million people in the United States have chronic hepatitis C. Most are unaware of their infection. Each year, about 17,000 Americans become infected with hepatitis C (CDC, 2010b).
Transmission of the virus occurs when blood or body fluids from an infected person enter the body of a person who is not infected. Today, most people become infected with hepatitis C by sharing needles or other equipment to inject drugs. Before widespread screening of the blood supply began in 1992, hepatitis C was also commonly spread through blood transfusions and organ transplants. Although uncommon, outbreaks of hepatitis C have occurred from blood contamination in medical settings (CDC, 2010b).
Hepatitis C is a progressive disease that varies from person to person. It is characterized as either acute or chronic. Acute hepatitis C is a short-term illness that occurs within the first 6 months after someone is exposed to the hepatitis C virus. The acute infection can range in severity from a very mild illness with few or no symptoms to a serious condition requiring hospitalization. For reasons that are not known, some of those infected recover from the virus without treatment and show no signs of further disease.
Approximately 75%–85% of people who become infected with the Hepatitis C virus develop chronic infection. Chronic hepatitis C is a long-term illness that occurs when the hepatitis C virus remains in a person’s body. Over time, it can lead to serious liver problems, including liver damage, cirrhosis, liver failure, or liver cancer (CDC, 2010b).
Many people with hepatitis C do not have symptoms and do not know they are infected. Symptoms for both acute and chronic hepatitis C can include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, grey-colored stools, joint pain, and jaundice.
Treatment is not always effective for HCV, and all infected persons are not candidates for treatment. The therapy for chronic hepatitis C has evolved steadily since alpha interferon was first approved for use in this disease more than 15 years ago. At the present time, the optimal regimen appears to be a 24- or 48-week course of the combination of pegylated alpha interferon and ribavirin (NIH, 2010a).
Although there is currently no vaccine to prevent Hepatitis C, research is being conducted to develop one. At this time, there is no recommendation for the use of antiviral agents upon exposure to HCV. Adherence to Universal Precautions and Body Substance Isolation (BSI) is the most effective way for healthcare workers to prevent exposure to the virus.
As noted earlier, the human immunodeficiency virus (HIV) causes acquired immune deficiency syndrome, or AIDS. HIV attacks the body's immune system, weakening it so that it cannot fight other deadly diseases. Though a person has been infected with HIV, it may be many years before AIDS develops. AIDS is a fatal disease, and while treatment for it is improving, there is no known cure.
The CDC estimates that more than 1 million people are living with HIV in the United States. One in five (21%) of those people living with HIV are unaware of their infection. An estimated 56,300 Americans become infected with HIV each year (CDC, 2010c).
HIV is spread by sexual contact with an infected person; by sharing needles and/or syringes with someone who is infected; and less commonly, through transfusions of infected blood or blood clotting factors. Babies born to HIV-infected women may become infected before or during birth or through breastfeeding after birth. HIV is not spread through contaminated food or by casual contact.
In the healthcare setting, personnel have been infected with HIV after being stuck with needles containing HIV-infected blood or, less frequently, after infected blood gets into a worker’s open cut or a mucous membrane such as the eye, mouth, or nostril. Through December 2001, there were 57 documented cases of occupational HIV transmission to healthcare workers in the United States, and only one reported case has been confirmed since 2001 (CDC, 2011b).
The symptoms of HIV infection vary but often include weakness, mild viral illness within 6 weeks, fever, sore throat, nausea, headaches, diarrhea, a white coating on the tongue, weight loss, and swollen lymph glands.
HIV/AIDS infection occurs in three broad stages. In the first stage, the person is actually infected with HIV. After the initial infection, the infected individual may show few, or no, signs of illness for many years. During the second stage, the individual may suffer swollen lymph glands or other lesser diseases that begin to take advantage of the body’s weakened immune system. The second stage is believed to lead eventually to AIDS. In the third and final stage, that of AIDS itself, the body becomes completely unable to fight off life-threatening diseases and infections.
The HIV virus is fragile and does not survive long outside the human body. It is primarily of concern to employees providing first aid or medical care in situations involving fresh blood or other potentially infectious materials. It is estimated that the chances of contracting HIV in a workplace environment are minimal. However, because it is such a devastating disease, all precautions must be taken to avoid exposure.
There is no vaccine to prevent HIV infection. Adherence to Universal Precautions is the most effective means of protection.
A plan for post-exposure management of healthcare personnel is an important element of workplace safety. The Centers for Disease Control has issued guidelines for the management of healthcare worker exposures to HIV and recommendations for post-exposure prophylaxis (PEP). The guidelines outline a number of considerations in determining whether healthcare workers should receive PEP and in choosing the type of PEP regimen. For most HIV exposures that warrant post-exposure prophylaxis, a basic 4-week, two-drug regimen is recommended (CDC, 2011b).
Bloodborne pathogens such as hepatitis B and HIV can be transmitted through contact with infected blood and other potentially infectious body fluids such as semen and vaginal secretions, cerebrospinal fluid, pleural and peritoneal fluid, amniotic fluid, saliva in dental procedures, and any body fluid that is visibly contaminated with blood.
Transmission of a bloodborne pathogen can occur through:
Unbroken skin forms an impervious barrier against bloodborne pathogens. However, infected blood and body fluids can enter one’s system through open sores, cuts and abrasions; acne; any damaged or broken skin; or the mucous membranes of eyes, nose, or mouth if splashed with contaminated fluid.
Healthcare personnel are at high risk due to routine exposure to blood and other potentially infectious body fluids. Thus, it is important to know the ways exposure and transmission are most likely to occur in a work situation. Any time there is blood-to-blood contact with infected blood or body fluids, there is a risk. In most situations, transmission likely occurs because of accidental puncture from contaminated needles or other sharps, contact between broken skin and infected body fluids, or contact between mucous membranes and infected body fluids.
Employers are required to develop and make available an exposure control plan (ECP). The plan is in place to protect employees from health hazards associated with bloodborne pathogens and provide appropriate treatment and counseling if an exposure incident occurs. Employees should know where their facility’s exposure control plan is located and what it includes.
The exposure control plan includes detailed information about ways an employer provides a safe and healthful work environment, including:
Employers are required to implement these preventive measures to reduce or eliminate the risk of exposure to bloodborne pathogens.
Universal Precautions is the term used to describe a prevention strategy in which all blood and potentially infectious materials are treated as if they are actually infectious, regardless of the perceived status of the source individual. In other words, whether or not one thinks the blood/body fluid is infected with bloodborne pathogens, treat it as if it is. This approach is used in all situations where exposure to blood or potentially infectious materials is possible. In addition, it means that certain engineering and work practice controls shall always be utilized in situations where exposure may occur.
OSHA’s Bloodborne Pathogen Standard allows for healthcare facilities to use acceptable alternatives to Universal Precautions. Alternative concepts in infection control are called Body Substance Isolation (BSI) and Standard Precautions. These methods define all body fluids and substances as infectious. These methods incorporate not only the fluids and materials covered by the Bloodborne Pathogens Standard but expand coverage to include all body fluids and substances (OSHA, 2011c).
Wearing gloves, gowns, masks, and eye protection can significantly reduce health risks for employees exposed to blood and other potentially infectious materials. Employers are required to provide, clean, and maintain appropriate personal protective equipment (PPE) and clothing free of charge to employees. Latex-free PPE must be made available on request.
Personal protective equipment must be readily accessible to employees and available in appropriate sizes. It is important to know what type of personal protective equipment is available at work and where it is stored. To protect oneself, a healthcare provider must have a barrier between them and any potentially infectious material.
|Gloves||Nonsterile, disposable; worn when soiling of the hands with blood or body fluids is likely|
|Utility gloves||To prevent injuries during extrication or when working in other hazardous environments where broken glass or sharps may be present|
|Gowns||Outerwear impervious to fluids; worn when soiling of exposed skin or clothing is likely|
|Tyvek suit||One-piece, impervious outerwear with zipper; may have hood and booties attached; worn when gross contamination with blood and body fluids is anticipated|
|Face shield||One-piece face protection; worn while performing invasive techniques, including IV therapy, suctioning, and intubations, or any time there is an opportunity for blood or body fluids to be splashed, sprayed, or splattered; not to be used for TB protection|
|Goggles||Eye protection that includes shielding front, sides, and top; goggles/safety glasses with side and top shields as well as full-face shielding are all acceptable; prescription glasses are acceptable if side shields are added|
|Mask (surgical)||Disposable; to be placed over the mouth and nose; worn when splashing of blood or body fluids is likely; worn with eye protection|
|Head coverings||Cap that covers hair; worn when splashing of blood or body fluids is likely|
|Booties||Outerwear used to cover shoes/boots when exposed to blood and body fluids|
|Turnout gear||Fire-resistant coat and pants; may provide protection during extrication|
|Steel-toed shoes/boots||Protective footwear|
|Hard hats||Protective head covering; worn during extrication|
|Body armor||Bulletproof vest; worn for protection in potentially hostile situations|
Gloves are to be worn when contact with blood or other potentially infectious materials or contaminated surfaces is anticipated. Gloves should be made of latex or other water-impervious materials. If the glove material is thin or flimsy, double gloving can provide an additional layer of protection. Those who allergic to standard gloves must be provided with an alternative at no charge.
Cuts or sores on one’s hands should be covered with a bandage or similar protection as an additional precaution before donning gloves. Always inspect gloves for tears or punctures before putting them on. If a glove is damaged, don't use it.
When taking contaminated gloves off, do so carefully. Make sure not to touch the outside of the gloves to bare skin, and be sure to dispose of the gloves in a proper container so that no one else will come in contact with them.
The order in which personal protective equipment is removed is not as important as the principle behind choosing such an order. The key principle is that, when removing personal protective equipment, one should avoid contact with blood, body fluids, secretions, excretions, and other contaminants. When hands become contaminated, they should be washed or decontaminated.
HOW TO REMOVE PPE
Work practice controls refer to the processes and procedures used to ensure that work is conducted in a safe and healthy manner. Work practice controls are an essential component of a safe work environment.
Work practices to learn and follow include: proper and timely handwashing; minimizing splashing or spraying of any potentially infectious material; proper decontamination and sterilization of equipment and supplies; cleanup, care, and maintenance of supplies and equipment; proper disposal of used supplies and equipment; keeping all food and drink away from areas where blood or potentially infectious materials are present; and no eating, drinking, smoking, applying cosmetics or lip balm, or handling contact lenses where there is a risk of contamination.
To minimize exposure to bloodborne pathogens, effective decontamination is essential. Use either a 10% household bleach solution, Lysol, or another EPA-registered disinfectant. Check the label of all disinfectants to be sure they meet this requirement.
When cleaning up a blood spill, carefully cover the spill with rags or paper towels. Pour disinfectant solution over the rags or towels and let it sit for 10 minutes, or follow the manufacturer’s recommendations.
Handwashing is one of the most important—and easiest—practices used to prevent transmission of bloodborne pathogens. Hands or other exposed skin should be thoroughly washed as soon as possible following an exposure incident. Hands should also be washed immediately or as soon as feasible after removing gloves or other PPE.
Use soft antibacterial soap, if possible. Avoid harsh abrasive soaps, as these may open fragile scabs or other sores. Because handwashing is so important, it is wise to be familiar with the nearest handwashing facilities. Public restrooms, janitor closets, and so forth may be used for handwashing if they are normally supplied with soap.
When one is working in an area without access to such facilities, an antiseptic cleanser may be used in conjunction with clean cloth/paper towels or antiseptic hand wipes. If these alternative methods are used, hands should be washed with soap and running water as soon as feasible (OSHA, 2003).
Engineering controls isolate or remove bloodborne pathogens hazards from the workplace. They include any physical device or equipment used or installed to prevent occupational hazard exposure, illness, or injury. Examples of engineering controls include sharps disposal containers, self-sheathing needles, and safer medical devices, such as needleless systems.
Employers must select and implement appropriate engineering controls to reduce or eliminate employee exposure. It is important for workers to learn and use the engineering controls available in the work environment.
Sharps are anything that can puncture the skin, such as needles, blades, scissors, or broken glass. A needle stick or a cut from a contaminated sharp can lead to infection from a bloodborne pathogen. Proper handling and disposal of sharps greatly reduces this risk. Sharps containers should be closable, puncture-resistant, and leak-proof on the sides and the bottom. They must be labeled or color-coded.
HOW TO HANDLE SHARPS
Warning labels need to be affixed to containers of regulated waste; refrigerators and freezers containing blood or OPIM; and other containers used to store, transport, or ship blood or OPIM. These labels are fluorescent orange, red, or orange-red. Bags used to dispose of regulated waste must be red or orange-red, and they too must have the biohazard symbol readily visible upon them.
Biohazard warning label.
Regulated waste refers to any liquid or semi-liquid blood or other OPIM, contaminated items that would release blood or OPIM in a liquid or semi-liquid state if compressed, items that are caked with dried blood or OPIM and are capable of releasing these materials during handling, and contaminated sharps.
If you experienced a needle stick or other sharps injury or were exposed to the blood or other body fluids of a patient during the course of your work, immediately follow these steps:
Your employer must provide you with a written report telling you how a bloodborne pathogen might have entered your body and a description of what happened when you were exposed. Your employer must identify the source individual (the person who might have infected you) unless the source individual is unknown or state or local law prohibits disclosure. If the source person is known, many states require that the person be tested for HBV and HIV and notified of the results. Your blood must also be collected and tested after you have agreed to the test.
Medical care will be provided by your employer at no charge to you. All test records are confidential. You must be given a copy of the healthcare professional's written opinion with 15 days after your medical evaluation is finished. You will be given postexposure prophylaxis if medically necessary, as recommended by the U.S. Public Health Service. If you wish, you will be given counseling that includes recommendations for transmission and prevention of HIV.
Q:If I accidentally get a patient’s blood on my hands, do I need to treat the incident as an exposure?
A:Yes. Wash the area with soap and water and report the occurrence to your supervisor as soon as possible. Your supervisor will determine the type of follow-up needed.
Q:How great is my risk for hepatitis B?
A:One out of 20 people living in the United States will get infected with HBV at some time during their lives. Your risk is higher if you have a job that involves contact with human blood.
Q:How do I know if I have hepatitis?
A:A blood test is the only way to diagnose hepatitis.
Q:When should I get the hepatitis B vaccine?
A:The vaccination must be offered within 10 days of initial assignment to a job where exposure to blood or other potentially infectious materials can be anticipated.
Q:If I decline to take the vaccination, can I change my mind later?
A:Yes, you can decide to begin the vaccination series at any time.
Q:If I think I’ve been infected with HIV, how soon can I find out?
A:You will usually develop antibodies against the HIV virus within 6 to 12 weeks after becoming infected. Tests will not reveal whether you had been infected before that time.
Q:Can I get HBV, HIV, or AIDS from being bitten by an infected mosquito?
A:No. There is no evidence that the HBV or HIV virus is transmitted through insects such as mosquitoes.
Q:If dried blood were to get wet, could the HIV virus become active again?
A:No. Once a virus is no longer active, it cannot be “reconstituted” by adding water.
Q:Can I catch HIV from being in the same room or vehicle with someone who has the infection if they cough or sneeze?
A:No. HIV cannot be transmitted through sneezing or coughing (you cannot catch it like the common cold), or by shaking hands, hugging, sharing the water fountain, or sharing the rest room or work equipment.
Q:If the chances of being exposed to a patient with a contagious disease are low, why do I need to take precautions all the time?
A:Universal Precautions are the most effective way to safeguard against exposure to bloodborne pathogens. It is not always possible to predict when an exposure will occur. Bloodborne pathogens are not visible, and you don’t know whether the patient you are working with is infected.
Q:Can I refuse to do a job that will expose me to potential infection?
A:No. Universal Standards do not allow you to refuse to take an assignment. However, your employer is required to provide you with the appropriate personal protective equipment and training to minimize your risk.
Centers for Disease Control and Prevention (CDC), Viral Hepatitis
Centers for Disease Control and Prevention (CDC). HIV
Occupational Safety and Health Administration (OSHA), Bloodborne Pathogen Standard
Centers for Disease Control and Prevention (CDC). (2011a). Hepatitis B FAQs for health professionals. Retrieved April 4, 2011, from http://www.cdc.gov/hepatitis/HBV/HBVfaq.htm#overview.
Centers for Disease Control and Prevention (CDC). (2011b). Fact sheet: Occupational HIV transmission and prevention among health care workers. Retrieved April 6, 2011, from http://www.cdc.gov/hiv/resources/factsheets/PDF/hcw.pdf.
Centers for Disease Control and Prevention (CDC). (2010a). Hepatitis B fact sheet, Publication No. 21-1073. Retrieved April 3, 2011, from http://www.cdc.gov/hepatitis/HBV/PDFs/HepBGeneralFactSheet.pdf.
Centers for Disease Control and Prevention (CDC). (2010b). Hepatitis C fact sheet, Publication No. 21-1075. Retrieved April 3, 2011, from http://www.cdc.gov/hepatitis/HCV/PDFs/HepCGeneralFactSheet.pdf.
Centers for Disease Control and Prevention (CDC). (2010c). HIV in the United States. Retrieved April 6, 2011, from http://www.cdc.gov/hiv/resources/factsheets/PDF/us.pdf.
National Institutes of Health (NIH). (2010a). Chronic hepatitis C: Current disease management, NIH Publication No. 10–4230. Retrieved April 5, 2011, from http://digestive.niddk.nih.gov/ddiseases/pubs/chronichepc/chronichepc.pdf.
National Institutes of Health (NIH). (2010b). The ABCs of hepatitis, NIH Publication No. 21-1076. Retrieved April 6, 2011, from http://www.cdc.gov/hepatitis/Resources/Professionals/PDFs/ABCTable.pdf.
Occupational Safety and Health Administration (OSHA), U.S. Department of Labor. (2011a). OSHA fact sheet: OSHA’s Bloodborne Pathogen Standard. Retrieved on April 4, 2011, from http://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf.
Occupational Safety and Health Administration (OSHA). (2011b). OSHA fact sheet: Hepatitis B vaccination protection. Retrieved April 6, 2011, from http://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact05.pdf.
Occupational Safety and Health Administration (OSHA). (2011c). Hospital e-Tool: (Lack of) Universal Precautions. Retrieved April 6, 2011, from http://www.osha.gov/SLTC/etools/hospital/hazards/univprec/univ.html.
Occupational Safety and Health Administration (OSHA). (2008). Bloodborne Pathogen Standard. Retrieved April 4, 2011, from http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051.
Occupational Safety and Health Administration (OSHA). (2003). Standard interpretations: Acceptable use of antiseptic hand cleansers for bloodborne pathogen decontamination and as an appropriate handwashing practice. Retrieved April 4, 2011, from http://www.osha.gov/pls/oshaweb/
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. (2007). Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare setting. Retrieved April 5, 2011, from http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf.
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