Health care workers have serious concerns about exposures to bodily fluids. Accidental exposures to bodily fluids present a wide variety of issues to healthcare workers. These issues include transmission of communicable diseases such as human immune deficiency virus (HIV), Hepatitis B Virus (HBV), and hepatitis C virus (HCV). These exposures have led to a significant public health hazard since they have become a known occupational hazard in 1978. Among healthcare workers, nursing staff/students seem to have the highest rate of exposures at 45%, and physicians come next at 17%. Further dividing the physician group, surgeons were the most likely to be at risk of being exposed. Other research has shown that doctors and nurses have a good knowledge of standard safety protocols regarding bodily fluid exposure; nurses have a better practice level than physicians. Another confounding factor regarding these exposures is the fear of infection and/or loss of employment due to the exposure. Multiple studies have shown that some healthcare workers are confused about what to do in case of exposure. Despite almost all healthcare facilities in the world having some sort of protocol regarding exposure, some healthcare workers are unaware of them. Other research has shown that non-percutaneous exposures seem to de dismissed by employers according to their employees. Exposed workers can also suffer other injuries as well, including psychological effects. Recent research has been aimed at improving recognition and proper evaluation of bodily fluid exposures.
Exposure to blood and bodily fluids for healthcare workers is mostly due to needlestick injuries and cuts on the job. These preventable exposures result in approximately 1000 infections a year with exposure to over 20 different bloodborne pathogens. Hepatitis B is the most common pathogen encountered with these events. The increased incidence of these pathogens, along with the frequency of needlestick exposures, is a significant occupational risk to healthcare workers. National Institute of Occupational Safety and Health has identified these issues in regard to risk for needlestick injuries: injection medication over-use, unnecessary sharps, lack of proper personal protective equipment supplies, needle recapping, not utilizing the sharps container as advised, and, poorly trained staff. Also, other sited risks include lack of availability of safe needle devices, the passing of instruments in the operating room, and a general lack of awareness of the hazards in the situation. Other non-percutaneous exposures can lead to the transmission of bloodborne pathogens. Most healthcare workers researched were found to be less compliant with notification of exposure if it was not the result of a needlestick. Most felt there was no need to be tested due to perceived low-risk. Other risk factors included the duration of time on shift. Almost 25% of exposures occurred in workers working 12 hours or more.
Occupational exposures to bodily fluids are one of the most serious public health issues that face health care workers. Approximately 3 million percutaneous exposures occur every year among 35 million health care workers. Health care workers can also be exposed in other ways through urine, vomit, saliva, and feces. Developing countries account for over 90% of these events. After a percutaneous exposure, the risk of Hepatitis C infection is 3%, Hepatitis B 30%, and HIV 0.3%. With other exposures of non-bloody bodily fluids, the risk of transmission is negligible or non-existent. HBV is more 50-100 times more likely to be transmitted and cause infection in comparison to HIV. Among health care workers worldwide, 40% of HBV and HBV, with 2.5% of HIV cases are due to accidental occupational exposures.
History is key in helping to access the risk of disease transmission in bodily fluid exposure. Healthcare workers should be asked about previous immunizations. A thorough investigation into their social history, including tattoos, body piercings, and other body modifications, is recommended. The history-taker needs to ask about sexual, travel, and drug use history. Travel history is especially important as recent pandemics have highlighted the ease of imported infections in the age of across the globe travel. A previous history of blood transfusions and hemodialysis should also be explored. The source patients need to be interviewed as well. A comprehensive history-taking is advised as this affects treatment. All of these factors play into risk stratification for patients exposed to bodily fluids.
On physical exam, patients need to be examined at the site of the percutaneous exposure or the site of exposure. The area needs to be examined for foreign bodies, bleeding, or signs of localized infection. If splashed into an eye, the eye should be examined for any obvious foreign bodies, debris, or signs of trauma. An exam of the heart, lungs, abdomen, and lymph nodes should be done as a baseline for possible infection later on. Most exposures will not exhibit clinical signs until later.
A thorough history and physical is usually the only evaluation necessary in patients presenting with bodily fluid exposure. Management will depend on the type of exposure and the source of exposure. All percutaneous injuries should be assessed for foreign bodies. Some cases may require some form of radiographic imaging. Modality would be dependent on the location of the exposure and clinical suspicion of a foreign body. Labwork consisting of testing for HIV, Hepatitis B, and Hepatitis C is standard. Additional testing may be needed according to local hospital guidelines and regional incidence of other blood-borne pathogens.
Management and treatment can vary greatly from institution to institution. Almost all protocols recommend getting a sample of the affected healthcare worker's blood and as well as recommend getting a sample of blood from the source. Even though healthcare workers are aware of the need for testing, a majority will forego testing and start prophylactic treatment. Most find little value with regard to formal risk assessment and feel it adds little value in primary outcomes. Similar attitudes have been found in African counties as well. As for management, if the source patient is known to be HIV positive, the post-exposure prophylaxis (PEP) regimen is started. If the source patient is HCV-positive, additional testing is carried out for up to 6 months depending on the scenario. HBV-positive source patients require testing of the healthcare worker's hepatitis B immunization status. In the United States, this follow-up is usually performed by the health care facility's occupational health department. One of the biggest concerns among those exposed is great anxiety that they have contracted a serious blood-borne pathogen while testing is completed.
In general, the differential diagnosis of bodily fluid exposure depends on the fluid the healthcare worker was exposed to, as well as the pathogens potentially present in those fluids. Testing for HBV, HCV, and HIV is standard. Other considerations include emerging infections affecting a region that may have been brought in by travelers.
With early recognition of bodily fluid exposure, along with proper follow-up testing, the prognosis is good for healthcare workers following a body fluid exposure. The incidence of transmission of HBV, HCV, and HIV after a needle-stick is declining in industrial nations. However, the emergence of “rare” pathogens in developing countries requires continued vigilance in the healthcare community.
Complications of bodily fluid exposures include the transmission of various types of pathogens. Also, a localized site infection can occur due to exposure. Nerve damage from a needle-stick can occur along with the potential of the needle breaking off in the skin. Significant anxiety and depression can occur after an event and should be considered.
Continued education of the use of protective equipment and safe practices in handling bodily fluids is crucial in reducing risk. Multiple training sessions regarding the use of personal protective equipment are recommended for healthcare workers. The key factor in personal protective equipment is having adequate supplies readily available for healthcare staff. Those who are exposed must not be afraid to report their exposure. Timely testing will lessen anxiety as well as lead to better outcomes if some form of pathogen transmission has occurred. Surveillance of pathogens found in bodily fluids will guide health care providers in treatment following exposure to bodily fluids.
In recent years, Ebola virus disease and severe acute respiratory syndrome have led to renewed research regarding personal protective equipment (PPE). In 2020, the novel coronavirus COVID-19 became a worldwide pandemic that has highlighted the need for proper personal protective equipment. Hospital protocols involving interdisciplinary teams have been revised over the years as novel outbreaks of disease have occurred. These events have been studied, and work on improving personal protective equipment continues today. However, work remains to be done in developing countries as a higher transmission risk of pathogens exist with bodily fluid exposure. Continued training of healthcare workers, along with good team leadership, has been proved to decrease exposures to body fluids. Interprofessional communication is key to preventing and addressing body fluid exposures.
|||Green-McKenzie J,Shofer FS, Duration of time on shift before accidental blood or body fluid exposure for housestaff, nurses, and technicians. Infection control and hospital epidemiology. 2007 Jan [PubMed PMID: 17230381]|
|||Asmr Y,Beza L,Engida H,Bekelcho T,Tsegaye N,Aschale Y, Assessment of Knowledge and Practices of Standard Precaution against Blood Borne Pathogens among Doctors and Nurses at Adult Emergency Room in Addis Ababa, Ethiopia. Emergency medicine international. 2019 [PubMed PMID: 31179129]|
|||Yi Y,Yuan S,Li Y,Mo D,Zeng L, Assessment of adherence behaviors for the self-reporting of occupational exposure to blood and body fluids among registered nurses: A cross-sectional study. PloS one. 2018 [PubMed PMID: 30256805]|
|||Yasin J,Fisseha R,Mekonnen F,Yirdaw K, Occupational exposure to blood and body fluids and associated factors among health care workers at the University of Gondar Hospital, Northwest Ethiopia. Environmental health and preventive medicine. 2019 Mar 9; [PubMed PMID: 30851726]|
|||Zaidi MA,Griffiths R,Beshyah SA,Myers J,Zaidi MA, Blood and body fluid exposure related knowledge, attitude and practices of hospital based health care providers in United arab emirates. Safety and health at work. 2012 Sep; [PubMed PMID: 23019533]|
|||Singru SA,Banerjee A, Occupational exposure to blood and body fluids among health care workers in a teaching hospital in mumbai, India. Indian journal of community medicine : official publication of Indian Association of Preventive [PubMed PMID: 19966992]|
|||Zafar A, Blood and body fluid exposure and risk to health care workers. JPMA. The Journal of the Pakistan Medical Association. 2006 Oct [PubMed PMID: 17144385]|
|||Madiba TK,Nkambule NR,Kungoane T,Bhayat A, Knowledge and Practices Related to Hepatitis B Infection among Dental and Oral Hygiene Students at a University in Pretoria. Journal of International Society of Preventive & Community Dentistry. 2018 May-Jun [PubMed PMID: 29911055]|
|||Schmidt-Chanasit J,Schmiedel S,Fleischer B,Burchard GD, Viruses acquired abroad: what does the primary care physician need to know? Deutsches Arzteblatt international. 2012 Oct [PubMed PMID: 23264811]|
|||King KC,Strony R, Needlestick 2019 Jan; [PubMed PMID: 29630199]|
|||Nouetchognou JS,Ateudjieu J,Jemea B,Mbanya D, Accidental exposures to blood and body fluids among health care workers in a Referral Hospital of Cameroon. BMC research notes. 2016 Feb 15; [PubMed PMID: 26879949]|
|||Koizumi M,Shimizu M,Kobashi K, Enzymatic sulfation of quercetin by arylsulfotransferase from a human intestinal bacterium. Chemical [PubMed PMID: 2347024]|
|||Wicker S,Cinatl J,Berger A,Doerr HW,Gottschalk R,Rabenau HF, Determination of risk of infection with blood-borne pathogens following a needlestick injury in hospital workers. The Annals of occupational hygiene. 2008 Oct; [PubMed PMID: 18664514]|
|||Tarantola A,Abiteboul D,Rachline A, Infection risks following accidental exposure to blood or body fluids in health care workers: a review of pathogens transmitted in published cases. American journal of infection control. 2006 Aug; [PubMed PMID: 16877106]|
|||Verbeek JH,Ijaz S,Mischke C,Ruotsalainen JH,Mäkelä E,Neuvonen K,Edmond MB,Sauni R,Kilinc Balci FS,Mihalache RC, Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. The Cochrane database of systematic reviews. 2016 Apr 19; [PubMed PMID: 27093058]|
|||Verbeek JH,Rajamaki B,Ijaz S,Tikka C,Ruotsalainen JH,Edmond MB,Sauni R,Kilinc Balci FS, Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. The Cochrane database of systematic reviews. 2019 Jul 1; [PubMed PMID: 31259389]|
|||[PubMed PMID: 32195311]|
|||Moore C,Edward KL,King K,Giandinoto JA, USING THE TEAM TO REDUCE RISK OF BLOOD AND BODY FLUID EXPOSURE IN THE PERIOPERATIVE SETTING. ORNAC journal. 2015 Dec; [PubMed PMID: 26790319]|