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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.