Preventing Transmission of Infections Recommended Practices for Preventing Infection Transmission The following are the standard recommended precautions for anyone working in a health-care setting who may come in contact with blood or other body fluids that may contain HIV, HBV, HCV, or other bloodborne pathogens (BBP). Syringe exchanges should develop their own protocols for biohazard handling and disposal. To the extent possible, participants should be responsible for their own returned syringes, needles, and/or injection supplies, including depositing any loose syringes and/or injection supplies in biohazard containers on premises. If necessary, exchange workers should use tongs to deposit used syringes or other supplies in biohazard containers. Please visit the CDC resources, Human Immunodeficiency Virus (HIV) in Healthcare Settings (available at http://www.cdc.gov/HAI/organisms/hiv/hiv.html) and Hepatitis in Healthcare Settings (available at https://www.cdc.gov/hai/organisms/hepatitis.html), for more information. Standard Precautions Since medical history and examination cannot reliably identify all patients infected with HIV or other BBP, blood and body fluid precautions should be consistently used for ALL patients. This approach, referred to as "standard precautions," should be used in the care of ALL patients. Hand hygiene Hands should be cleansed with soap and water or alcohol-based hand sanitizer immediately before and after patient contact, and before gloves are donned and after gloves are removed. Hand hygiene should be performed regardless of signs of obvious contamination. Hands and other skin surfaces should be washed with immediately and thoroughly with soap and water if contaminated with blood or other body fluids, or if there are any visible signs of contamination. For more information, consult the CDC Guideline for Hand Hygiene in Health-Care Settings (available from https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf). Personal protective equipment (PPE) All health-care workers should routinely use appropriate barrier precautions to prevent skin and mucous-membrane exposure when contact with blood or other body fluids from any patient is anticipated. Gloves should be worn for touching blood and body fluids, mucous membranes, or non-intact skin of all patients, for handling items or surfaces soiled with blood or body fluids, and for performing venipuncture and other vascular access procedures. Gloves should be changed after contact with each patient. Masks and protective eyewear or face shields should be worn during procedures that are likely to generate droplets of blood or other body fluids to prevent exposure of mucous membranes of the mouth, nose, and eyes. Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or other body fluids.[K1] Handling of needles and other sharps All health-care workers should take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices, particularly when handling or disposing of used instruments. To prevent needlestick injuries, needles should not be recapped, purposely bent or broken by hand, removed from disposable syringes, or otherwise manipulated by hand. After they are used, disposable syringes and needles, scalpel blades, and other sharp items should be placed in puncture-resistant containers for disposal. Puncture-resistant containers should be located as close as practical to the use area. Other considerations Health-care workers who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient-care equipment until the condition resolves. Any lesions should also be covered and remain covered until they resolve. Pregnant health-care workers should be especially familiar with and strictly adhere to precautions to minimize the risk of BBP transmission. Table 1 summarizes standard precautions for the care of all patients in all health-care settings. Detailed guidelines for preventing transmission of infectious agents in healthcare settings are described in the document, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (available from https://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf). Table 1. Recommendation for application of standard precautions for the care of all patients in all health-care settings. COMPONENT RECOMMENDATIONS Hand hygiene After touching blood, body fluids, secretions, excretions, contaminated items; immediately after removing gloves; between patient contacts Personal protective equipment (PPE) Gloves For touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes and nonintact skin Gown During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated Mask, eye protection (goggles), face shield During procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions, especially suctioning, endotracheal intubation Soiled patient-care equipment Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene Environmental control Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient-care areas Textiles and laundry Handle in a manner that prevents transfer of microorganisms to others and to the environment Needles and other sharps Do not recap, bend, break, or hand-manipulate used needles; if recapping is required, use a one-handed scoop technique only; use safety features when available; place used sharps in puncture-resistant container Patient resuscitation Use mouthpiece, resuscitation bag, other ventilation devices to prevent contact with mouth and oral secretions Patient placement Prioritize for single-patient room if patient is at increased risk of transmission, is likely to contaminate the environment, does not maintain appropriate hygiene, or is at increased risk of acquiring infection or developing adverse outcome following infection Respiratory hygiene/cough etiquette (source containment of infectious respiratory secretions in symptomatic patients, beginning at initial point of encounter e.g., triage and reception areas in emergency departments and physician offices) Instruct symptomatic persons to cover mouth/nose when sneezing/coughing; use tissues and dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secretions; wear surgical mask if tolerated or maintain spatial separation, >3 feet if possible CDC. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Specific Recommendations for Prevention of HIV Transmission in Health-Care Settings[JM2] The following recommendations are described in CDC’s Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis (PEP) (available from https://stacks.cdc.gov/view/cdc/20711). PEP is recommended when occupational exposures to HIV occur. Determine the HIV status of the exposure source patient to guide need for HIV PEP, if possible. Start PEP medication regimens as soon as possible after occupational exposure to HIV and continue them for a 4-week duration. PEP medication regimens should contain 3 (or more) antiretroviral drugs for all occupational exposures to HIV. Refer to appendix A of Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis for a list of antiretroviral drugs. Expert consultation is recommended for any occupational exposures to HIV and at a minimum for the following situations: delayed (i.e. later than 72 hours) exposure report, unknown source (e.g. needle in sharps disposal container or laundry), known or suspected pregnancy in the exposed person, breastfeeding in the exposed person, known or suspected resistance of the source virus to antiretroviral agents; toxicity of the initial PEP regimen, or serious medical illness in the exposed person. Provide close follow-up for exposed personnel that includes counseling, baseline and follow-up HIV testing, and monitoring for drug toxicity and interactions. Follow-up appointments should begin within 72 hours of an HIV exposure. Refer to Box 2 of Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis for more information. If a newer 4th generation combination HIV p24 antigen-HIV antibody test is utilized for follow-up HIV testing of exposed healthcare providers, HIV testing may be concluded at 4 months after exposure. If a newer testing platform is not available, follow-up HIV testing is typically concluded at 6 months after an HIV exposure. Refer to Box 2 of Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis for more information. Specific Recommendations for Prevention of Hepatitis B Transmission in Health-Care Settings The following recommendations are described in CDC’s Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis (available from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm). For percutaneous or mucosal exposures to blood, several factors must be considered when making a decision to provide prophylaxis, including the hepatitis B virus surface antigen (HBsAg) status of the source and the hepatitis B vaccination and vaccine-response status of the exposed person. Such exposures usually involve persons for whom hepatitis B vaccination is recommended. Any blood or body fluid exposure to an unvaccinated person should lead to initiation of the hepatitis B vaccine series. The hepatitis B vaccination status and the vaccine-response status (if known) of the exposed person should be reviewed. A summary of prophylaxis recommendations for percutaneous or mucosal exposure to blood according to the HBsAg status of the exposure source and the vaccination and vaccine-response status of the exposed person is included in Table 3 of Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. When hepatitis B immune globulin (HBIG) is indicated, it should be administered as soon as possible after exposure (preferably within 24 hours). The effectiveness of HBIG when administered >7 days after exposure is unknown. When hepatitis B vaccine is indicated, it should also be administered as soon as possible (preferably within 24 hours) and can be administered simultaneously with HBIG at a separate site (vaccine should always be administered in the deltoid muscle). For exposed persons who are in the process of being vaccinated but have not completed the vaccination series, vaccination should be completed as scheduled, and HBIG should be added as indicated in Table 3 of Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. Persons exposed to HBsAg-positive blood or body fluids who are known not to have responded to a primary vaccine series should receive a single dose of HBIG and reinitiate the hepatitis B vaccine series with the first dose of the hepatitis B vaccine as soon as possible after exposure. Alternatively, they should receive two doses of HBIG, one dose as soon as possible after exposure, and the second dose 1 month later. The option of administering one dose of HBIG and reinitiating the vaccine series is preferred for nonresponders who did not complete a second 3-dose vaccine series. For persons who previously completed a second vaccine series but failed to respond, two doses of HBIG are preferred. Specific Recommendations for Prevention of Hepatitis C Transmission in Health-Care Settings The following recommendations are described in CDC’s Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis (available from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm). Individual institutions should establish policies and procedures for testing health-care workers for HCV after percutaneous or mucosal exposures to blood and ensure that all personnel are familiar with these policies and procedures. Following an occupational HCV exposure, the source should be tested for anti-HCV. For the person exposed to an HCV-positive source, baseline anti-HCV and ALT activity testing and follow-up testing (e.g., at 4-6 months) for anti-HCV and ALT activity should be conducted (if earlier diagnosis of HCV infection is desired, testing for HCV RNA may be performed at 4-6 weeks). All anti-HCV results reported positive by enzyme immunoassay should be confirmed using supplemental anti-HCV testing (e.g., recombinant immunoblot assay [RIBA™]). Health-care workers who provide care to persons exposed to HCV in the occupational setting should be knowledgeable regarding the risk for HCV infection and appropriate counseling, testing, and medical follow-up. Immune globulin (IG) and antiviral agents are not recommended for PEP after exposure to HCV-positive blood. In addition, no guidelines exist for administration of therapy during the acute phase of HCV infection. However, limited data indicate that antiviral therapy might be beneficial when started early in the course of HCV infection. When HCV infection is identified early, the person should be referred for medical management to a specialist knowledgeable in this area. Counseling for Health-care Workers Exposed to Viral Hepatitis Health-care workers exposed to HBV- or HCV-infected blood do not need to take any special precautions to prevent secondary transmission during the follow-up period; however, they should refrain from donating blood, plasma, organs, tissue, or semen. The exposed person does not need to modify sexual practices or refrain from becoming pregnant. If an exposed woman is breast feeding, she does not need to discontinue. No modifications to an exposed person's patient-care responsibilities are necessary to prevent transmission to patients based solely on exposure to HBV- or HCV-positive blood. If an exposed person becomes acutely infected with HBV, the person should be evaluated according to published recommendations for infected health-care workers. No recommendations exist regarding restricting the professional activities of health-care workers with HCV infection. As recommended for all health-care workers, those who are chronically infected with HBV or HCV should follow all recommended infection-control practices, including standard precautions and appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments. References Centers for Disease Control and Prevention. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Available from https://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings. Available from https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf Centers for Disease Control and Prevention. Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. Available from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm Centers for Disease Control and Prevention. Recommendations for prevention of HIV transmission in health-care settings. Available from https://www.cdc.gov/mmwr/preview/mmwrhtml/00023587.htm Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis. Available from https://stacks.cdc.gov/view/cdc/20711 [K1]This may not be relevant to events that commonly occur in the syringe exchange setting. [JM2]The following is primarily related to occupational exposure and PEP.