An exposure to an infectious disease can happen if an ESW comes into contact with blood or bodily fluids of an infected individual. Below you will find information on the notification process, assessment and post-exposure management.
- Notification Process for ESWs Exposed to Infectious Diseases
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In the event of a potential occupational exposure, notification may occur in two ways, either initiated by Public Health or initiated by an Emergency Service Worker (ESW).
Notification Initiated by Public Health
Public Health follows up reports of infectious diseases and potential contacts (people exposed). This notification may come to Public Health from several different sources (e.g., physicians, hospitals, laboratories or other public health departments). If an Emergency Service Worker (ESW) has been potentially exposed during the care or transportation of a person suspected or confirmed to have an infectious disease, Public Health notifies the Designated Officer (DO) who will then notify the ESW of the exposure, as well as the recommendations for follow-up as determined by the Medical Officer of Health.
Notification Initiated by an Emergency Service Worker (ESW)
Emergency Service Workers are often required to react and perform their job functions in uncontrolled environments where they may be exposed to an infectious disease. An ESW who believes that they may have been exposed to an infectious disease should take the following steps:
- Obtain first aid, if necessary.
- If the exposure involves blood, be examined in an Emergency Department immediately. Treatment, if recommended should start within two hours of exposure.
- Report the incident immediately to their Designated Officer (DO).
Resources (to be added soon)
- Bloodborne Infections Fact Sheet
- Reporting Process for ESWs Exposed to Bloodborne Illness Algorithm
- Reporting Process for ESWs Exposed to Diseases of Public Health Significance Algorithm
- Notification Process by Public Health After Exposure to an ESW Algorithm
- Assessment of the Exposure
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Following an exposure, the below actions will be taken:
- The ESW and their Designated Officer (DO) will review the details of the exposure, including:
- What precautions were taken (use of equipment, PPE)
- Any failure in PPE, or lack of PPE
- Immunization history of the ESW
Documentation of the potential exposure should be completed, and copies retained by both the ESW and the workplace.
- After investigating the exposure and risks associated with the incident, the DO will provide recommendations for follow-up, arrange for medical follow-up if required, advocate for the ESW with the healthcare personnel in the emergency department if necessary and complete any workplace documentation and WSIB forms if indicated.
- This process should never interfere with or delay immediate medical follow-up.
- There is no requirement to forward a copy of the report to Public Health. If the DO would like to discuss the exposure incident, the potential risks to the ESW and recommendations for post-exposure follow-up, they may contact Public Health for consultation.
- Public Health will review the details of the occupational exposure and may investigate further by contacting the infection control practitioner at the hospital, the attending physician or the Emergency Service Worker.
- Public Health will inform the DO of any recommendations for follow-up as soon as possible. Recommendations may include specific medical care for the exposed ESW, as well as advice regarding standards of practice, appropriate use of PPE and training of ESWs to prevent future exposures.
Resources
- Assessing High-risk Exposures to Infectious Diseases
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An exposure is defined as any event that may result in the ESW coming in contact with an infectious disease. A high-risk exposure occurs when there is potential for the worker to be infected, and specifically infected with an infectious disease that may be life-threatening. The risk of some high-risk exposures such as human immunodeficiency virus (HIV), hepatitis B (HBV), hepatitis C (HCV), meningococcal meningitis, invasive group A streptococcus, and rabies can be mitigated through timely post-exposure management and the administration of post-exposure prophylaxis and/or immunization.
Occupational exposures, in addition to the health concerns that result, can cause tremendous stress, anxiety and fear for the exposed worker. All exposures should be treated as critical incidents requiring both medical and emotional support. It is important to note that most exposures do not result in infection. Several factors may influence the overall risk of infection such as:
- The infectious agent involved. Some pathogens infect at lower doses than others (e.g. measles).
- The type of exposure. The infectious agent must be able to get into the body though an unprotected portal of entry (e.g., mucous membrane, inhalation, or non-intact skin).
- The type of body fluid. Blood and any body fluids with visible blood are higher risk for transmission.
- The amount of blood/body fluids involved in a splash/spray or sharps injury.
- The concentration of the virus/infectiousness of the source at the time of exposure. For example, low levels of HIV virus in the source client’s blood or “scarce” tuberculosis bacteria seen in a client’s sputum means the client is less infectious than clients with many bacteria.
- The length of time exposed. For example, infection to measles or chickenpox may take as little as five minutes in susceptible workers while exposure to tuberculosis can take 8 to 12 hours of continuous contact with an infectious client.
- The susceptibility/vaccine status of the worker. A worker who is immunized will not be susceptible to those diseases.
- The health of the worker. A worker whose immune system is compromised due to illness, such as diabetes or cancer, may be more susceptible to an infectious disease than a worker who has a healthy immune system.
Evaluating the Significance of the Exposure
Exposures to blood and/or body fluids are only considered significant/high risk if there is potential for infection. An assessment of the above factors (if known) that influence the overall risk of infection will assist in evaluating whether the exposure is significant.
High-risk Body Fluids:
- Blood
- Any body fluids with visible blood
- Semen or vaginal fluids (low risk for HCV)
Risk Unknown:
- Pleural, amniotic, pericardial, peritoneal, synovial, and cerebrospinal fluids
Not Infectious Unless Visibly Bloody:
- Saliva, feces, nasal secretions, sputum, tears, urine, and vomitus
High-risk Exposures:
- Exposures to blood and/or body fluids visibly contaminated with blood
- Puncture wounds with contaminated needle or sharp object
- Splash of body fluids into the mouth, eyes, or nose
- Human bite that breaks the skin with bleeding, or
- Prolonged body fluid contact with non-intact skin (e.g., open wounds, cuts, cracked hands, abrasions, and rashes)
- Unprotected exposure to respiratory secretions from a client with known or suspected meningitis if those secretions have direct contact with the mucous membranes (nose and/or mouth) of the worker
- Unprotected exposure to drainage from a wound, contaminated skin, or contact with respiratory droplets from a client diagnosed with invasive Group A Streptococcus
- Unprotected prolonged exposure in a confined air space with a client diagnosed with tuberculosis (TB)
- A bite, lick, or scratch from an animal known or suspected to have rabies
Source Risk Factors (Past or Present):
- High-risk sexual behaviour (e.g., men who have sex with men, multiple sexual partners, unprotected vaginal or anal sex)
- Injection or street drug use
- Tattooing/piercing with non-sterile equipment
- Blood transfusion or organ transplant prior to 1992, known to have haemophilia
- Incarcerated, lived in a shelter, homeless, resident of an institution or group home
- Immigrated or moved from a country or area with a high rate of HBV or HIV in the population
- Known to have HBV, HCV, HIV
- Stage of disease (risk of transmission is higher in the first 6 months)
- Most recent viral load
- Antiretroviral/antiviral use
- Post-exposure Management
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The below steps should be followed for post-exposure management.
- Immediate first aid
- Remove any contaminated clothing.
- Allow injury/wound to bleed freely.
- Do not promote bleeding by cutting, scratching, squeezing, or puncturing the skin. This may damage the tissues and increase uptake of the pathogen.
- Gently clean the wound with an antiseptic or soap and warm water as soon as possible. If the site is not deep, and soap and running water are not available, alcohol-based hand rub (ABHR) may be used.
- If the exposure happens to a mucous membrane including the eyes, nose, or mouth, flush well with cold water and/or normal saline for 10 to 15 minutes.
- Report injury to the Designated Officer or supervisor when it happens.
- Immediately go to the nearest Emergency Department for medical assessment by a physician.
All exposures to blood and/or high-risk body fluids should be assessed immediately at the nearest emergency department. Post-exposure prophylaxis (PEP) medications, if indicated, should be started within two hours of exposure.
- Baseline testing
- Hepatitis B, C, and HIV; liver function tests (if medications for HIV are started).
- Baseline testing helps establish the ESW’s current hepatitis B, C, and HIV status (e.g., whether he/she had any of these bloodborne infections prior to exposure). It also determines if the ESW is protected against hepatitis B. If blood tests are negative, they should be repeated as directed by infectious disease physician (Refer to the section about repeat bloodwork).
- Tuberculosis (TB)
- If required and recommended, testing for TB may include 2 skin tests: one after exposure and repeated at least 8 weeks after exposure. Each test must be read 48-72 hours later by a healthcare provider. If the skin test is positive, a chest x-ray is performed to assess for active TB disease. If the ESW has a positive skin test, antibiotics may be recommended.
- If the ESW has had a previous positive skin test, a TB skin test will not be repeated. A chest x-ray and referral to a healthcare provider is recommended.
- Post-exposure Prophylaxis (PEP) – preventative treatment
- Hepatitis B, C, HIV
- Depending on the significance of the risk, the attending physician may recommend post-exposure prophylaxis (PEP) for hepatitis B and HIV to prevent infection from occurring. Hepatitis B vaccine may also be provided. There is no post–exposure prophylaxis treatment for hepatitis C.
- Invasive Group A Streptococcus (iGAS)
- People identified by public health as close contacts of a confirmed, active case may require antibiotics to prevent infection.
- Invasive Meningococcal Disease (IMD)
- People identified by public health as close contacts of a confirmed case require antibiotics to prevent infection. This includes:
- Health care workers (HCWs) who have had intensive unprotected contact (without wearing a mask) with an infected person such as in intubation, mouth-to-mouth resuscitation, or closely examining the oropharynx
- Persons who have direct contact with the case’s oral/nasal secretions
- Household contact of a case
- Post-exposure counselling for the ESW
Counselling is an essential component of care for the exposed ESW. It helps to reduce anxiety, promotes adherence to PEP protocol, and reduces secondary transmission to others. All exposed ESWs should receive initial counselling in the emergency department by the attending physician; however, follow-up with a family physician or infectious disease physician can help reinforce post-exposure recommendations. Counselling should include:
- The impact of positive results
- The benefits and risks of PEP
- Information about the PEP medications, their side effects, and how to manage side effects
- Signs and symptoms to watch for and reporting illness to a healthcare provider
- Further medical follow-up
- Personal protection guidelines to prevent secondary transmission to others
Post-exposure recommendations ensure others are not exposed to your blood or body fluids until final testing has ruled out infection at six months:
- Practice safe sex with all sexual partners. This means not having sex, or always using condoms during vaginal and anal sex, and using a barrier or condom during oral sex.
- Do not share razors, toothbrushes, needles, scissors, nail files, or other items which may be contaminated with blood or body fluid.
- Breastfeeding may not be advisable under some circumstances. Discuss this with your healthcare professional.
- Do not donate blood, organs, tissues, or sperm.
- Avoid pregnancy or have further consultation especially if high risk for HIV and taking PEP for HIV. If the ESW is pregnant a referral to an infectious disease specialist is recommended.
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Repeat blood work
It is important to repeat blood work at established intervals as certain infections may take longer to show up. For example, hepatitis B can take up to six months to show up in a blood test.
Recommended intervals for repeat blood testing following a bloodborne exposure Bloodborne Pathogen Intervals for Repeat Blood Testing
Hepatitis B (HBV) Retest at six months after exposure if baseline test is negative. Hepatitis C (HCV) Retest at three months and six months after exposure if baseline test is negative. HIV Retest at three weeks and six weeks.
Please contact 1-800-265-7293 ext. 4752 if you have questions about exposures.
