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    PENGENDALIAN

    BLOOD BORNE PATHOGEN

    Osman Sianipar

    Clinical Epidemiology and Biostatistics Unit

    Dr. Sardjito Hospital / Faculty of Medicine,

    Gadjah Mada University, Yogyakarta

    Pengantar

    The Center for Disease Control and Prevention

    (CDC) memperkirakan setiap tahunnya 12.000

    tenaga kesehatan mengalami kecelakaan terinfeksi

    kuman patogen yang ditularkan melalui aliran

    darah.

    Disamping bahaya biologik kecelakaan dapat

    dialami oleh tenaga kesehatan berkaitan dengan

    bahaya bahan kimia, radioaktif, aliran listrik,

    kebakaran, dan ledakan.

    Pengantar. lanjutan

    Perlu pedoman prosedur kesehatan dan

    keselamatan kerja berdasarkan bukti ilmiah

    yang kuat.

    Perlu komitmen semua personel di RS

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    Pengantar. lanjutan

    Sebagai institusi rumah sakit sebaiknya memiliki programkesehatan dan keselamatan kerja yang:

    Diarahkan ke bahaya biologis,

    Menerangkan cara penanganan, penyimpanan danpembuangan bahan kimia dan bahan radioaktif yangaman,

    Menguraikan bagan kebijakan rumah sakit tentangprosedur yang benar dalam penangan kebakaran, bencanaalam, dan ledakan

    Menerangkan teknik yang benar untuk mengangkat danmemindahkan barang yang berat dan/atau pasien.

    Sumber utama bahaya biologik

    Personel rumah sakit dan/atau keluarganyamemiliki risiko kontak dengan mikroorganismeyang bersifat infeksius melalui membranmukosa, inhalasi, secara tidak sengaja menelan,atau tertusuk jarum.

    Mikroorganisme yang sering menimbulkaninfeksi pada personel rumah sakit dan/ataukeluarganya antara lain, virus hepatitis B, virusHIV,M. tuberculosis, Shigella spp.

    Universal Precaution

    (CDC&OSHA)

    1. Mengasumsikan pasien bersifat infeksius untuk HIV dan

    patogen lain yang ditularkan melalui aliran darah.

    2. Menempatkan setiap contoh bahan darah atau cairantubuh dalam wadah dengan penutup yang baik untuk

    mencegah tumpah pada saat pengiriman.

    3. Pada saat memproses darah atau cairan tubuh memakai

    sarung tangan dan masker dan kaca mata jika

    kemungkinan ada percikan dan mencuci tangan bila telah

    selesai memproses.

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    Universal Precaution (CDC&OSHA)

    4. Membatasi penggunaan jarum dan spuit,kecuali tidak ada pilihan lain.

    5. Jangan memipet dengan mulut, gunakan alat

    pemipet.

    6. Dekontaminasi semua permukaan tempat

    dengan germisida kimia yang sesuai setelah

    ada tumpahan darah atau cairan tubuh dan

    manakala pekerjaan telah selesai.

    Universal Precaution (CDC&OSHA)

    7. Selalu mencuci tangan setelah kegiatan

    laboratorium selesai, dan lepaslah pakaian

    pengaman sebelum meninggalkan tempat

    kerja.

    8. Dekontaminasi bahan-bahan yang

    terkontaminasi dan menempatkan dalam

    kantong yang dilabel dengan biohazard untuk

    selanjutnya dibuang.

    Buangan limbah infeksius

    Limbah infeksius harus ditempatkan dalam

    kantong yang berlabel infeksius, dan untukseterusnya ditempatkan dalam kotak sampahmedis yang bersifat infeksius.

    Hal ini penting dilakukan guna mencegah infeksipersonel rumah sakit dan juga pasien ataumasyarakat yang lain.

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    Pelatihan Keselamatan Kerja

    Materi yang harus diberikan dalam pelatihan

    keselamatan kerja meliputi:1. Penanganan kebakaran

    2. Pengelolaan bahan berbahaya

    3. Penyimpanan gas yang baik

    4. Pencegahan infeksi patogen yang ditularkan

    melalui aliran darah

    Infeksi Nosokomial yang didapat

    melalui darah dan produk darah

    Darah dan produk darah termasuk bahan paling

    sering digunakan di rumah sakit untuk mengobati

    atau mempercepat penyembuhan, selain obat-

    obatan dan cairan infus.

    Yang termasuk darah atau produk darah adalah

    darah utuh, packed red cells (PRC), platelet

    concentrate, granulocyte concentrate,fresh frozen

    plasma, cryoprecipitate, dan derivat plasma.

    Infeksi Nosokomial yang didapat melalui darah

    dan produk darah

    Darah dan produk darah memainkan perananpenting dalam upaya penyembuhan penderita.Permintaan terhadap bahan-bahan ini cenderung

    meningkat dari tahun ke tahun. Pemberian bahan-bahan ini dapat menimbulkan

    efek samping yaitu reaksi imkompatibilitas, reaksialergi dan/atau infeksi nosokomial. Infeksinosokomial ini dapat mengenai pasien, petugasrumah sakit, atau pengunjung pasien.

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    Sejarah

    Kesadaran adanya infeksi nosokomial padatransfusi darah telah tumbuh pada perang dunia

    I, sehingga pada waktu itu donor darah potensial

    tetapi menderita malaria, sifilis, dan demam

    dikeluarkan sebagai donor.

    Meningkatnya transfusi darah selama perang

    dunia II menyebabkan timbulnya istilah

    hepatitis pasca transfusi.

    Sejarah

    Penggunaan donor darah sipil dimulai tahun

    1947.

    Virus hepatitis B baru dapat ditentukan secara

    serologis pada tahun 1972.

    Mikroorganisme lain sebagai penyebab infeksi

    nosokomial, yaitu virus hepatitis C, virus

    hepatitis D, virus hepatitis non-A non-B lainnya,

    CMV, EBV dan virus hepatitis A.

    Penyakit dan agen penyebab

    1. Hepatitis

    a. Virus hepatitis A

    b. Virus hepatitis Bc. Virus hepatitis C

    d. Virus hepatitis D

    e. Virus hepatitis non-A non-B non-C

    f. Cytomegalovirus (CMV)

    g. Ebstein-Barr virus (EBV)

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    Penyakit dan agen penyebab

    2. Infeksi virus lainnya

    a. HIV 1 dan HIV 2

    b. HTLV 1 dan HTLV 2

    c. Parvovirus

    d. Virus Colorado

    Penyakit dan agen penyebab

    3. Penyakit protozoa

    a. Malaria

    b. Babesiosis

    c. Trypanosomiasis

    d. Toxoplasmosis

    e. Leishmaniasis

    Penyakit dan agen penyebab

    4. Infeksi Spiroketa

    5. Infeksi bakteri

    a. Salmonellosis

    b. Brucellosis

    c. Yersinosis

    d. Kontaminan gram + atau gram

    6. Ricketsiosis

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    Virus Hepatitis A (HAV)

    Penularan virus ini melalui transfusi darah

    adalah jarang. Infeksi HAV didapat melalui transfusi

    darah/produk darah: fresh frozen plasma ataupacked red cells atau derivat plasma yangterkontaminasi.

    Hepatitis A dilaporkan ditemukan pada pasienkanker yang diterapi dengan lymphokine-activated killer lymphocytes (LAK) daninterleukin-2 (IL-2) yang mengandung HAV.

    Virus Hepatitis A (HAV)

    Pemeriksaan serologis HAV tidak rutin untuk penyaringandarah donor berdasarkan pertimbangan sbb:

    1. Kira-kira 50% orang dewasa telah memiliki antibodi

    (IgG) terhadap HAV.

    2. Antibodi IgM dapat menetap 3-6 bulan setelah infeksi,

    walaupun penderita sudah tidak infeksius.

    3. Seringkali sudah timbul gejala klinis pada waktu pasien

    mengalami viremia sehingga pasien tidak menjadi

    donor.

    4. Hepatitis karena HAV jarang menyebabkan kematian

    Virus Hepatitis B (HBV)

    Pencegahan dilakukan melalui pemeriksaanpenyaring rutin terhadap semua darah dan produkdarah.

    Hepatitis pasca transfusi karena HBV masih dapatterjadi walaupun telah dilakukan penyaring. Hal inidisebabkan kadar HbsAg di dalam darah donorberada dibawah kadar yang masih dapat dideteksioleh metoda radioimmuno assay (RIA),reversed-pasivehemaglutination (RPHA) maupun enzymeimmunoassay (EIA).

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    Virus Hepatitis Delta (HDV)

    Infeksi HDV terjadi dalam 2 kondisi.

    Sebagai infeksi yang simultan (koinfeksi) dengan

    hepatitis B

    Sebagai superinfeksi pada penderita carrierhepatitis B

    kronis.

    Pada koinfeksi walaupun infeksinya berat

    [mortalitas (2-20%)], tetapi yang menjadi kronis

    hanya 5%.

    Virus Hepatitis C dan hepatitis non-A

    non-B non-C

    Hepatitis non-A non B pernah dilaporkan terjadi

    pada pasien agamaglobulinemia setelah diterapi

    dengan immunoglobulin intra vena,

    Dapat ditularkan melalui transfusi PRC segar dari

    donor dengan skrining anti HCV negatif.

    Kebanyakan deskripsi epidemiologi hepatitis non-

    A non-B saat ini sesuai dengan virus yang baru

    ditemukan yaitu Hepatitis C Virus (HCV).

    Virus Hepatitis C dan hepatitis non-A non-

    B non-C

    Tampaknya ada penyebab lain yang bertanggung jawab

    atas 9% kasus HPT yang tidak disebabkan oleh HBV,

    HAV, atau HCV. Dari serum pasien hepatitis non-A non-B non-C yang

    digunakan dalam amplifikasi molekuler dan kloning,

    ditemukan virus baru famili flaviviridae yaitu hepatitis

    G virus, sebagai penyebab HPT yang diindikasikan

    pada 1,7% dari donor darah sukarela. HGV ini ternyata

    terdapat diseluruh dunia dan penyebabnya

    dihubungkan dengan hepatitis kronis.

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    Cytomegalovirus

    Infeksi CMV pasca transfusi biasanya

    terjadi setelah mendapatkan transfusi darah

    segar atau lekosit. Infeksi juga dipengaruhi

    oleh banyaknya darah yang ditransfusikan.

    Infeksi CMV pasca transfusi biasanya

    asimptomatik

    Cytomegalovirus

    Kelompok yang berisiko tinggi

    mendapatkan infeksi CMV pasca transfusi

    adalah:

    1. Wanita hamil yang seronegatif

    2. Bayi-bayi prematur seronegatif

    3. Resipien transplantasi organ seronegatif

    4. Pasien kanker seronegatif yang mendapat

    kemoterapi.

    Peraturan OSHA untuk patogen yang

    ditularkan melalui darah

    1. Semua personel yang memiliki risiko terpapar

    darah dan cairan tubuh harus diidentifikasi

    oleh RS

    2. Personel tersebut harus dilatih dengan baik

    dalam menggunakan alat protektif dan/atau

    kendali mesin yang diperlukan untuk tugasnya

    dan harus mendapat penyuluhan dan

    pengobatan selanjutnya jika terjadi paparan.

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    Peraturan OSHA untuk patogen yang ditularkan

    melalui darah

    3. Semua personal yang memiliki risiko

    harus mendapat pelatihan ulang setiaptahun

    4. Semua personel yang bekerja dengan

    bahan infeksius harus ditawari vaksinasi

    hepatitis B secara gratis.

    Injection Safety

    Each year unsafe injection practices areresponsible for 8 to 16 million personscontracting hepatitis B virus (HBV), 2.3 to4.7 million persons contracting hepatitis Cvirus (HCV), and 80,000 to 160,000 personscontracting HIV worldwide. In most cases,the transmission of these agents goesunrecognized because the infection isinitially subclinical. (mathematic model)

    Injection Safety

    Global estimates of the percentage of unsafe

    injections range from 15% in Eastern

    Europe to 50% throughout Asia.

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    Injection Safety

    Safe Injection Global Network (SIGN)

    recommends: Behavior of health care providers and patients

    must be changed to decrease injection overuse andachieve safety.

    Sufficient quantities of appropriate injectionequipment and infection control supplies shouldbe available.

    A sharps waste management system should be setup to ensure that disposable equipment isdestroyed and not reused

    Injection SafetyBefore SIGN (1999), successful efforts have reduced

    injection overuse and improved safety.

    In Indonesia rates of injections decreased from 73% to14% after group discussions between health careproviders and patients.

    In Tanzania, avoidable injections decreased from 16% to6% after guidelines to improve injection practices.

    In Hafizabad, Pakistan, the proportion of injectionsconducted with a new sterile syringe increased from24% to 60% after a health education program wasconducted in mosques.

    Healthcare workers are potentially at risk for

    acquiring certain infections through occupational

    exposures to blood or certain body fluids &

    tissues.

    This may include: needlesticks

    mucous membrane exposures

    skin exposures to skin that is open

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    1. blood

    2. fluid containing visible blood3. tissues

    4. semen

    5. vaginal secretions

    6. cerebrospinal fluid

    7. synovial fluid

    8. pleural fluid

    9. peritoneal fluid

    10. pericardial fluid

    11. amniotic fluid

    The following are a source of

    exposure ONLY if visible blood is

    apparent:

    urine

    feces

    vomitus

    sputum

    human bites / scratches

    Source materials for blood borne

    pathogens include:

    Diseases of concern in Blood Borne Pathogen

    Exposures

    1. Human Immunodeficiency Virus

    (HIV)

    2. Hepatitis B

    3. Hepatitis C

    RISK OF HIV INFECTION

    Needlestick/sharps injury exposures to HIV

    positive blood carry a risk of 0.3% (three out of

    1,000).

    Mucous membrane exposures to HIV positiveblood carry a risk of 0.09% (about one out of

    1,000).

    Open skin exposures to HIV positive blood

    carry a risk of less than 0.1% (less than one out

    of 1,000).

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    Factors that increase the risk for HIV

    transmission

    Deep injury to the healthcare worker:

    A device that comes directly from source

    patients vein or artery

    Visible blood noted at the time of the

    incident.

    A source patient with late stage HIV

    disease.

    Human Immunodeficiency Virus

    (HIV)

    In December, 1995, the C D C published a

    study regarding Zidovudine (AZT) use in

    healthcare workers after a percutaneous

    exposure to HIV. Results indicated that the use

    of AZT was associated with a decrease in the

    risk for HIV seroconversion

    In May, 1998, the Center for Disease Control

    Recommend multiple anti-HIV drugs for

    Postexposure Prophylaxis.

    Human Immunodeficiency Virus

    (HIV)

    Physician should assess risk and based on thatrisk assessment, post-exposure prophylaxis willeither be recommended, offered, or not offered.

    The post-exposure prophylaxis regime mayinclude up to three anti-HIV drugs. The risksand benefits of taking these drugs need to beexplained to the healthcare worker by thephysician.

    Baseline history, physical exam, and lab studiesneed to be done if an exposed employee takesthe post-exposure prophylaxis.

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    Human Immunodeficiency Virus

    (HIV)

    Healthcare workers require close follow-upafter HIV exposures especially if post-

    exposure prophylaxis is administered

    Results of HIV testing are private and

    confidential. All positive HIV tests are

    reported to the Ministry of Health

    Hepatitis B

    Hepatitis B is a virus that affects the liver.

    Symptoms can include: diminished appetite,

    abnormal liver enzymes, abdominal pain,

    enlarged liver, jaundice, fatigue

    Long term consequences of Hepatitis B can

    include:

    chronic active hepatitis

    cirrhosis

    liver cancer

    Hepatitis B

    The risk of contracting Hepatitis B from a

    single contaminated needlestick is reported as

    high as 30% (300 in 1,000).

    All healthcare workers should be vaccinatedwith the three shot series. After the first shot is

    given, the second shot is given at one month

    and the third shot is given at six months.

    If an unvaccinated healthcare worker is

    exposed to Hepatitis B, protective treatments

    are available.

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    Hepatitis B

    At the time of initial evaluation, a test for

    antibody to hepatitis B surface antigenwill be drawn

    Hepatitis B antigen screen can also be

    obtained at baseline to document that the

    healthcare worker does not have pre-

    existing Hepatitis B disease.

    Hepatitis C

    The majority of blood borne hepatitis (non-A,

    non-B) was identified as Hepatitis C in 1989.

    Acute infection usually does not produce

    symptoms or jaundice. Chronic hepatitis C

    may develop in 70% to 85% of these patients.

    Long term consequences of Hepatitis C can

    include:

    chronic liver disease

    cirrhosis

    liver cancer

    Hepatitis C

    The risk of acquiring Hepatitis C after a

    needlestick from a patient with

    documented Hepatitis C is 1.8% (about

    20 out of 1,000).

    There is no vaccine!

    Immunoglobulin is not recommended for

    post-exposure prophylaxis.

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    Hepatitis C

    The exposed healthcare worker is

    screened for pre-existing Hepatitis C witha test for antibody to Hepatitis C.

    The antibody to Hepatitis C test is

    performed on the source patient.

    If the source is identified as Hepatitis C

    antibody positive, the healthcare worker

    needs additional lab tests.

    Hepatitis C

    At six weeks after the exposure, thehealthcare worker needs a liver enzymetest (ALT) and a specialized test called aPCR. This PCR test determines ifHepatitis C virus is present. Additionallab tests may be needed at three months,six months, and twelve months afterexposure to a source patient withdocumented

    Hepatitis C

    If the healthcare worker has a positive PCR

    result, this may indicate early acute infection

    with Hepatitis C. The exposed healthcare

    worker is then referred to the Hepatologyphysicians for consultation and possible

    treatment.

    A definitive treatment for acute Hepatitis C has

    not been established. Research is ongoing in

    this field.

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    DO NOT EXPOSE THE SOURCE

    PATIENT TO YOUR BLOOD

    If you are performing a procedure and suffer a

    sharps stick from the instrument, STOP. Change to clean gloves. Change to a clean instrument and resume the

    procedure.

    If any equipment involved is broken or is notfunctioning:

    Report it to the supervisor immediately so thatthe quipment can be removed from service forrepair or replacement.

    IMMEDIATE CARE OF EXPOSED AREAFor percutaneous/needlestick/sharp injury:

    1. Wash the wound with soap and water.

    2. Antiseptics are not contra-indicated.

    However, there is no evidence that use of

    antiseptics for wound care further reduces the

    risk of HIV transmission.

    3. There is no evidence that expressing fluid by

    squeezing the wound further reduces the risk

    of HIV transmission.

    4. Remove any foreign materials embedded in

    the wound if possible.

    IMMEDIATE CARE OF EXPOSED AREA

    For non-intact skin exposure

    1. Wash the area immediately with soap

    and water.

    2. Antiseptics are not contra-indicated.

    However, there is no evidence that use

    of antiseptics for wound care further

    reduces the risk of HIV transmission.

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    IMMEDIATE CARE OF EXPOSED AREA

    For mucous membrane exposure (i.e. eye

    or mouth)1. Irrigate continuously for 15 minutes with

    tap water, sterile saline, or sterile water.

    2. If there is an eye splash involving blood

    and/or body fluids, remove any contacts

    before irrigating.

    ACCEPT or DECLINE Post-Exposure

    HIV Prophylaxis

    The procedures at Employee Health and the

    ER are updated to remain consistent with

    current CDC recommendations. The exposed

    healthcare worker should be counseled about

    the risk assessment of the exposure , the

    current data about post-exposure HIV

    prophylaxis, and that there is an option to

    accept or decline post-exposure HIV

    prophylaxis.

    ACCEPT or DECLINE Post-Exposure

    HIV Prophylaxis

    The studies done in animal models indicate thatpost-exposure HIV prophylaxis should bestarted early (i.e. within one hour) followingexposure. Animal studies suggest that post-exposure prophylaxis is probably not effectivewhen started later than 36 hours post-exposure.

    The urgent nature of the decision whether ornot to accept post-exposure HIV prophylaxisdoes not allow time to determine the HIVinfection status of the source patient if it is notalready known.

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    ACCEPT or DECLINE Post-Exposure

    HIV Prophylaxis

    At the initial evaluation:

    Tetanus booster is given if indicated If the Hepatitis B vaccination 3 shot

    series was not previously completed other

    treatments may be needed

    ALL SOURCE PATIENT LAB TESTINGIS ARRANGED THROUGH EMPLOYEE

    HEALTH

    Lab tests that are ordered because of an employee

    exposure are not ordered in the patients chart.

    Neither the patient nor the patients insurance are

    charged for the testing. Informed consent is

    obtained from the source patient by Employee

    Health. A suitable specimen is usually available

    in the lab and it is rare that a source patient has to

    undergo a separate venipuncture to obtain a

    specimen

    ALL SOURCE PATIENT LAB TESTINGIS ARRANGED THROUGH EMPLOYEE

    HEALTH

    Employee Health can only arrange

    source patient testing if the exposed

    employee reports the exposure to

    Employee Health.

    Exposed employee REQUIRED to bring

    the source patient sample and HIV

    consent to Employee Health.

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    EXPOSED EMPLOYEE BASELINE

    LAB TESTING

    All exposed employees should, after

    informed consent, have baseline HIVtesting performed. This step is done atEmployee Health and is important interms of implications for possiblecompensation claims shouldseroconversion occur. Healthcareworker HIV test results are keptconfidential

    EXPOSED EMPLOYEE FOLLOW

    UP LAB TESTING

    Follow up testing is closely tracked when

    confirmed exposure to HIV, Hepatitis B, or

    Hepatitis C is documented

    Source patient testing does not reveal HIV,

    Hepatitis B, or Hepatitis C infection, follow

    up testing is available.

    EXPOSED EMPLOYEE FOLLOW

    UP LAB TESTING

    6 weeks HIV test This marks the beginning of the period

    during which both acute infection and seroconversion

    are most likely to occur.

    3 months HIV test This is performed even if the 6 week

    test was negative since seroconversion may have

    occurred in the interim.

    6 months HIV test It is unlikely that seroconversion will

    occur after this point.

    12 months HIV test A final HIV test at 1 year may

    reassure healthcare workers who so far have had

    negative test results

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    EMPLOYEE ASSISTANCE PROGRAM

    Exposed employees may experience a range of

    emotions after being faced with a series ofdecisions. Exposed employees can have difficultywith anxiety, work performance, or inter-personalrelationships.

    This can occur at the time of the exposure orduring the follow up period.

    Employee Assistance Program services areconfidential and free of charge.

    Contact number is available through EmployeeHealth

    HIV TRANSMISSION PRECAUTIONS

    Exposed employees must take precautionsto avoid potential HIV transmission toothers during the six months of follow up.

    These include: Avoiding blood, semen, or organ

    donations. Adopting safer sex practices. Deferring pregnancy for female

    employees.