![](media/image1.png){width="1.0263888888888888in"
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**Module 8** Safety and Supportive Care in the Work Environment

**SESSION 1** Universal Precautions and Creating a Safe Work Environment

**Session 2** Handling and Decontamination of Equipment and Materials

**Session 3** Managing Occupational Exposure to HIV Infection

**Session 4** Supportive Care for the Caregiver

**After completing the module, participants will be able to:**

-   Describe strategies for preventing HIV transmission in the
    healthcare setting.

-   Define universal precautions in the context of the prevention of
    mother-to-child transmission (PMTCT) of HIV.

-   Identify key steps and principles involved in the decontamination of
    equipment and materials.

-   Assess occupational risk and identify risk-reduction strategies in
    maternal and child health (MCH) settings.

-   Describe the management of occupational exposure to HIV.

-   Identify measures to minimise stress and support healthcare workers
    and caregivers.

+-----------------------------------------------------------------------+
| **Relevant Policies for Inclusion in National Curriculum**            |
+-----------------------------------------------------------------------+
| Session 1                                                             |
|                                                                       |
| -   National guidelines, policies, standards of procedure on          |
|     universal precautions in MCH/ANC settings                         |
|                                                                       |
| Session 2                                                             |
|                                                                       |
| -   National guidelines, policies, standards of procedure on handling |
|     and decontamination of equipment and materials if not included    |
|     previously in Session 1                                           |
|                                                                       |
| -   National policy on risk reduction in the obstetric setting        |
|                                                                       |
| Session 3                                                             |
|                                                                       |
| -   National post-exposure prophylaxis (PEP) policy                   |
+-----------------------------------------------------------------------+

  ---------------------------------------------------- -----------------------------------------------------------
  ![](media/image2.png){width="0.7597222222222222in"   The *Pocket Guide* contains a summary of each session in
  height="0.6263888888888889in"}                       this module.

  ---------------------------------------------------- -----------------------------------------------------------

SESSION 1 Universal Precautions and Creating a Safe Work Environment

Basic concepts of HIV infection prevention

HIV infection can be transmitted through contact with blood or body
fluids, either by direct contact with an open wound or by needle-stick
injury.

Blood is the primary fluid known to be associated with HIV transmission
in the healthcare setting; small quantities of blood may be present in
other body fluids.

HIV transmission to healthcare workers is almost always associated with
needle-stick injuries during the care of a patient who is HIV-infected.
In practice, transmission occurs when administering

-   Intravenous injections

-   Blood donations

-   Dialysis

-   Transfusions

    *Patient-to-patient* transmission of HIV infection can be prevented
    by disinfecting or sterilising equipment and devices used in
    percutaneous procedures.

    Transmission of infectious agents in the healthcare setting can be
    prevented by using infection control measures, including adherence
    to universal precautions, safe environmental practices, and ongoing
    education of employees in infection prevention.

Bloodborne pathogens are viruses, bacteria, or other disease-causing
microorganisms carried in blood. There are many different bloodborne
pathogens such as the hepatitis B virus, hepatitis C virus, syphilis
spirochete, brucellosis bacteria and the human immunodeficiency virus
(HIV). This training module will focus on HIV.

Universal precautions

*Universal precautions are practices designed to protect healthcare
workers and patients from exposure to bloodborne pathogens.*

It is not feasible or cost-effective to test *all* patients for all
pathogens before providing care. Therefore, the level of precautions
employed should be based on the nature of the procedure involved, not on
the patient's actual or assumed HIV status.

[]{.mark}

**Definition**

> **Universal precautions**: A simple set of effective practices
> designed to protect health workers and patients from infection with a
> range of pathogens including bloodborne viruses. These practices are
> used when caring for all patients regardless of diagnosis.

Creating a safe work environment

Creating a safe work environment involves practising universal
precautions, managing the work environment, and providing ongoing
infection prevention education for employees.

**In practice, actions to implement universal precautions include the
following:**

-   Washing hands before and after direct contact with patients

-   Disinfecting or sterilising all devices and equipment used during
    invasive procedures

-   Avoiding needle recapping; especially two-handed needle recapping

-   Using needles or scalpel blades on one patient only

-   Safely disposing of needles (hypodermic and suture) and sharps
    (scalpel blades, lancets, razors, and scissors) in puncture- and
    leak-proof safety boxes

-   Using gloves when in contact with body fluids, non-intact skin, or
    mucous membranes

-   Using masks, eye protection, and gowns (or plastic aprons) when
    blood or other body fluids could splash

-   Applying waterproof dressing to cover all cuts and abrasions

-   Promptly and carefully cleaning spills involving blood or other body
    fluids

-   Using systems for safe waste collection and disposal

Managing the work environment

Ensure that universal precautions are implemented, monitored, and
evaluated periodically.

-   Establish and implement policies and procedures for reporting and
    treating occupational exposure to HIV infection.

-   Attain and maintain appropriate staffing levels.

-   Implement supportive measures that reduce staff stress, isolation,
    and burnout (eg, ensure the availability of protective equipment).

-   Acknowledge and address the multifaceted needs of healthcare workers
    who are HIV-infected.

-   Provide protective clothing and equipment, including gloves, plastic
    aprons, gowns, goggles, and other protective devices.

-   Provide and use appropriate disinfectants to clean up spills
    involving blood or other body fluids.

-   Increase availability of---and staff access to---puncture-resistant
    sharps containers.

Ongoing education for employees in infection prevention

-   Orient all staff, including peer and lay counsellors, to the site's
    infection control policies.

-   Ensure that all workers who are routinely exposed to blood and body
    fluids (eg, physicians, midwives, nurses, and housekeeping
    personnel) receive preliminary and ongoing training on safe handling
    of equipment and materials.

-   Require that supervisors regularly observe and assess safety
    practices and remedy deficiencies as needed.

+-----------+----------------------------------------------------------+
| *         |                                                          |
| *Exercise |                                                          |
| 8.1       |                                                          |
| Reducing  |                                                          |
| HIV       |                                                          |
| tra       |                                                          |
| nsmission |                                                          |
| risk in   |                                                          |
| MCH       |                                                          |
| settings: |                                                          |
| case      |                                                          |
| study**   |                                                          |
+-----------+----------------------------------------------------------+
| **        | To review the application of universal precautions as    |
| Purpose** | described in this session, focusing on high-risk         |
|           | settings.                                                |
+-----------+----------------------------------------------------------+
| **D       | 20 minutes                                               |
| uration** |                                                          |
+-----------+----------------------------------------------------------+
| **Instr   | -   Read the case study below. As each paragraph is read |
| uctions** |     aloud by a volunteer participant, consider your      |
|           |     answers to the questions.                            |
|           |                                                          |
|           | -   Review the key points written on the flipchart.      |
|           |                                                          |
|           | -   Comment on how these situations are dealt with in    |
|           |     your clinical setting.                               |
|           |                                                          |
|           | -   Share the challenges and obstacles you face in       |
|           |     applying the universal precautions in your work      |
|           |     setting.                                             |
+-----------+----------------------------------------------------------+

Case study

Margaret arrives at the labour and delivery unit of your local hospital.
She hands you a small card that identifies her as someone who has
received care at the neighbouring ANC clinic. This card is coded to let
you know that she is HIV-infected. She explains that her contractions
are steady now and about four minutes apart. You perform a cervical
examination and estimate that Margaret has at least 2 more hours until
delivery. You give her nevirapine prophylaxis at this time.

*Does your clinical protocol require healthcare workers to use gloves
when caring for patients who are HIV-infected? According to universal
precautions, would the same gloving requirements apply for all labour
and delivery patients, regardless of HIV status?*

*In your facility, are gloves in good supply and available in a variety
of sizes?*

*What do we know about the relationship between MTCT and cervical
examinations for pregnant women who are HIV-infected?*

It has now been several hours since Margaret's waters broke (rupture of
membranes). She is exhausted. After checking her partogram a decision is
made to use oxytocin to shorten her labour.

*Why is it important to shorten the time between the rupture of
membranes and delivery by a woman who is HIV-infected?*

Margaret is now fully dilated and ready to deliver. As the head is
delivered, you use gauze to carefully free the infant's mouth and
nostrils of fluids. Then, with one final push, the infant is delivered
completely. You hand the newborn to a gloved assistant, who wipes him
dry and continues with neonatal care. Then the placenta is delivered.

*Itemise the protective clothing that would be appropriate in a labour
and delivery setting.*

*Consider the need for proper disposal of sharps used in labour and
delivery. Does your facility have conveniently located containers for
the disposal of sharps?*

*At your facility, what are the policies for disposing of waste
materials? What should be done with the placenta and other contaminated
materials?*

Margaret was your 12^th^ delivery in the past 24 hours. You need to get
home and tend to your family but your replacement has not yet arrived.
You speak with your supervisor and she is able to locate someone else to
take your place.

*Why is it important that you not stay and continue to work tonight?*

*In your facility, do you have someone who will help you find staffing
relief if needed?*

SESSION 2 Handling and Decontamination of Equipment and Materials

Handling and disposal of sharps

Most HIV transmission to healthcare workers in work settings is the
result of skin puncture with contaminated needles or sharps. These
injuries occur when sharps are recapped, cleaned, or inappropriately
discarded.

**Recommendations for use of sterile injection equipment**

-   Use a sterile syringe and needle for each injection and to
    reconstitute each unit of medication. If single-use syringes and
    needles are unavailable, use equipment designed for steam
    sterilisation.

-   Use new, quality-controlled disposable syringes and needles.

-   Avoid recapping and other manipulations of needles by hand. If
    recapping is necessary, use a single-handed scoop technique.

-   Collect used syringes and needles at the point of use in a sharps
    container that is puncture- and leak-proof and that can be sealed
    before completely full.

-   Completely destroy or bury needles and syringes so that people
    cannot access them and so that groundwater contamination is
    prevented.

**When it is necessary to recap, use the single-handed scooping
method:**

-   Place the needle cap on a firm, flat surface.

-   With one hand holding the syringe, use the needle to "scoop" up the
    cap, as shown in Step 1, Figure 8.1.

-   With the cap now covering the needle tip, turn the syringe upright
    (vertical) so the needle and syringe are pointing toward the
    ceiling.

-   Use the forefinger and thumb on your other hand to grasp the cap
    just above its open end and push the cap firmly down onto the hub
    (the place where the needle joins the syringe under the cap) (Step
    2, Figure 8.1).

Figure 8.1 One-handed recap method

> ![](media/image4.png){width="4.083333333333333in"
> height="4.675694444444445in"}**Step 1:** Scoop up the cap
>
> **Step 2:** Push cap firmly down

Tips for careful handling of sharps

-   Always point the sharp end away from yourself and others.

-   Pass scalpels and other sharps with the sharp end pointing away from
    staff; or place the sharp on a table or other flat surface (a
    receiver) where it can then be picked up by the receiving person.

-   Pick up sharps one at a time and do not pass handfuls of sharp
    instruments or needles.

Sharps containers

Using sharps disposal containers helps prevent injuries from disposable
sharps. Sharps containers should be fitted with a cover, and should be
puncture-proof, leak-proof, and tamper-proof (ie, difficult to open or
break). If plastic or metal containers are unavailable or too costly,
use containers made of dense cardboard (cardboard safety boxes) that
meet WHO specifications. *If cardboard safety boxes are unavailable,
many easily available objects can substitute as sharps containers:*

-   Tin with a lid

-   Thick plastic bottle

-   Heavy plastic box

-   Heavy cardboard box

Recommendations for safe use of sharps containers

-   All sharps containers should be clearly marked "SHARPS" and/or have
    pictorial instructions for the use and disposal of the container.

-   Place sharps containers away from high-traffic areas and as close as
    possible to where the sharps will be used. The placement of the
    container should be practical (ideally within arm's reach) but
    unobtrusive. Do not place containers near light switches, overhead
    fans, or thermostat controls where people might accidentally put one
    of their hands into them.

-   Attach containers to walls or other surfaces if possible. Position
    the containers at a convenient height so staff can use and replace
    them easily.

-   Never reuse or recycle sharps containers.

-   Mark the containers clearly so that people will not unknowingly use
    them as garbage receptacles.

-   Seal and close containers when ¾ full. Do not fill safety box beyond
    ¾ full.

-   Avoid shaking a container to settle its contents to make room for
    more sharps.

Handwashing

The following strategies settings are strongly recommended for reducing
transmission of bloodborne pathogens and other infectious agents to
patients and personnel in healthcare settings:

-   Soap and water handwashing, using friction, under running water for
    at least 15 seconds.

-   Use of alcohol-based hand rubs (or antimicrobial soap) and water for
    routine decontamination or hand antisepsis.

+-------------------+--------------------------------------------------+
| Hand hygiene      |                                                  |
| recommendations   |                                                  |
+===================+==================================================+
| **Wash before:**  | -   Putting on gloves                            |
|                   |                                                  |
|                   | -   Examining a patient                          |
|                   |                                                  |
|                   | -   Performing any procedure that involves       |
|                   |     contact with blood or body fluids            |
|                   |                                                  |
|                   | -   Handling contaminated items such as          |
|                   |     dressings and used instruments               |
|                   |                                                  |
|                   | -   Eating                                       |
+-------------------+--------------------------------------------------+
| **Wash after:**   | -   Removing gloves                              |
|                   |                                                  |
|                   | -   Examining a patient                          |
|                   |                                                  |
|                   | -   Performing any procedure that involves       |
|                   |     contact with blood or body fluids            |
|                   |                                                  |
|                   | -   Handling contaminated items such as          |
|                   |     dressings and used instruments               |
|                   |                                                  |
|                   | -   Making contact with body fluids, mucous      |
|                   |     membranes, non-intact skin, or wound         |
|                   |     dressings                                    |
|                   |                                                  |
|                   | -   Handling soiled instruments and other items  |
|                   |                                                  |
|                   | -   Using a toilet                               |
+-------------------+--------------------------------------------------+

**Handwashing**

> Handwashing with plain soap and water is one of the most effective
> methods for preventing transmission of bloodborne pathogens and
> limiting the spread of infection.

Personal protective equipment

Personal protective equipment safeguards patients and staff. Use the
following equipment when possible:

-   Gloves

-   Aprons

-   Eyewear

-   Footwear

When resources for purchasing protective equipment are limited,
purchasing gloves should receive priority over other protective
equipment.

Gloves

The use of a separate pair of gloves for each patient helps prevent the
transmission of infection from person to person. Protection with gloves
is recommended when:

-   There is reasonable chance of hand contact with blood, other body
    fluids, mucous membranes, or broken or cut skin

-   An invasive procedure is performed

-   Contaminated items are handled

**Tips for effective glove use**

-   Wear gloves that are the correct size.

-   Use water-soluble hand lotions and moisturisers often to prevent
    hands from drying, cracking, and chapping. Avoid oil-based hand
    lotions or creams because they will damage latex rubber surgical and
    examination gloves.

-   Do not wear rings because they may serve as a breeding ground for
    bacteria, yeast, and other disease-causing microorganisms.

-   Keep fingernails short (less than 3 mm (1/8 inch) beyond the
    fingertip). Long nails may provide a breeding ground for bacteria,
    yeast, and other disease-causing microorganisms. Long fingernails
    are also more likely to puncture gloves.

-   Store gloves in a place where they are protected from extreme
    temperatures, which can damage the gloves.

Aprons

Rubber or plastic aprons provide a protective waterproof barrier along
the front of the healthcare worker.

Eyewear

Eyewear, such as plastic goggles, safety glasses, face shields, or
visors, protect the eyes from accidental splashes of blood or other body
fluids.

Footwear

Rubber boots or leather shoes provide extra protection to the feet from
injury by sharps or heavy items that may accidentally fall. They must be
kept clean. When possible, avoid wearing sandals, thongs, or shoes made
of soft materials.

Strategies for resource-constrained settings

Universal precaution measures are difficult to practise when supplies
are low and protective equipment is not available. *Use resources
cost-effectively* by prioritising the purchase and use of supplies, eg,
if gloves are in short supply, use them for childbirth and suturing
instead of routine injections and bed-making.

The most important way to *reduce occupational exposure to HIV* is to
decrease contact with blood. Facilities should develop and use safety
procedures that allow them to deliver effective patient care without
compromising personal safety.

Decontamination of equipment

The method used to neutralise or remove harmful agents from contaminated
equipment or supplies should be based on:

-   Risk of infection associated with the instrument or piece of
    equipment

-   Decontamination process the object can tolerate

**Definitions**

> **Decontamination:** The first step in making equipment safe to
> handle. This requires a 10 minute soak in a 0.5% chlorine
> solution.[^1] This important step kills both hepatitis B and HIV.
>
> **Cleaning:** Efficient cleaning with soap and hot water is essential
> prior to disinfection or sterilisation.

-   Removes a high proportion of microorganisms.

-   Removes contaminants such as dust, soil, salts, and the organic
    matter that protects them.

> **Disinfection:** A chemical procedure that eliminates most recognised
> pathogenic microorganisms. Does not destroy all microbial forms (eg,
> bacterial spores).
>
> **Sterilisation:** Destroys all microorganisms

Disinfection and sterilisation

Detailed information to assist with procedures for decontaminating
infectious waste materials and equipment is found in Appendix 8-A.
Routine procedures for decontamination of equipment include:

-   Use heavy gloves.

-   Dismantle all equipment before cleaning.

-   Clean with soap and hot water prior to disinfection or
    sterilisation.

-   Wear additional protective clothing such as aprons, gowns, goggles,
    and masks when at risk for splashing with body fluid.

-   Rinse equipment thoroughly after chemical disinfection.

Safe work practices

Proper planning and management of supplies and other resources are
essential in reducing the occupational risks of HIV infection. To reduce
occupational risks:

-   Assess risks in the work setting.

-   Explore different strategies for meeting resource needs.

-   Develop standards and protocols that address safety, risk reduction,
    post-exposure prophylaxis (PEP) follow-up, and first aid.

-   Maintain an optimal workload.

-   Institute measures to prevent or reduce healthcare worker stress.

-   Orient new staff to infection control procedures.

-   Provide ongoing staff education and supervision.

Risk reduction in the obstetric setting

The potential for exposure to HIV-contaminated blood and body fluids is
greatest during labour and delivery. *Module 3, Specific Interventions
to Prevent MTCT*, includes recommendations for safer obstetric practices
designed to minimise this risk.

In labour and delivery settings, healthcare workers should:

-   Provide appropriate and sensitive care to all women regardless of
    HIV status.

-   Work in a manner that ensures safety and reduces the risk of
    occupational exposure for themselves and their colleagues.

**Tips for reducing the risk of occupational exposure in the obstetric
setting**

-   Cover broken skin or open wounds with watertight dressings.

-   Wear suitable gloves when exposure to blood or body fluids is
    likely.

-   Wear an impermeable plastic apron during the delivery.

-   Pass all sharp instruments on to a receiver, rather than
    hand-to-hand.

-   Use long, cuffed gloves during manual removal of a placenta.

-   Modify surgical practice to use needle holders to avoid using
    fingers for needle placement.

-   Workers with dermatitis should not work in obstetrics.

-   When episiotomy is necessary, use an appropriate-size needle (21
    gauge,\
    4 cm, curved) and needle holder during the repair.

-   When possible, wear gloves for all operations.

-   When possible, wear an eye shield during caesarean section and
    episiotomy suturing.

-   If blood splashes on skin, immediately wash the area with soap and
    water. If splashed in the eye, wash the eye with water only.

-   Dispose of solid waste (eg, blood-soaked dressings and placentas)
    safely according to local procedures.

+-----------------+----------------------------------------------------+
| **Exercise 8.2  |                                                    |
| Promoting a     |                                                    |
| safe            |                                                    |
| environment     |                                                    |
| resource list:  |                                                    |
| group           |                                                    |
| discussion**    |                                                    |
+-----------------+----------------------------------------------------+
| **Purpose**     | To compare and contrast the availability of safety |
|                 | resources, practices, and materials in our         |
|                 | programmes                                         |
+-----------------+----------------------------------------------------+
| **Duration**    | 15 minutes                                         |
+-----------------+----------------------------------------------------+
| *               | -   Review the "Promoting a Safe Environment"      |
| *Instructions** |     resource list below.                           |
|                 |                                                    |
|                 | -   Share in the large group discussion the use of |
|                 |     each category of resources in your clinical    |
|                 |     setting. Share innovative ideas that your      |
|                 |     clinical setting has developed to address      |
|                 |     shortages of resources.                        |
|                 |                                                    |
|                 | ```{=html}                                         |
|                 | <!-- -->                                           |
|                 | ```                                                |
|                 | -   Review the key points written on the           |
|                 |     flipchart.                                     |
|                 |                                                    |
|                 | ```{=html}                                         |
|                 | <!-- -->                                           |
|                 | ```                                                |
|                 | -   Comment on the challenges and obstacles you    |
|                 |     face in your practice.                         |
+-----------------+----------------------------------------------------+

Exercise 8.2 "Promoting a safe environment" resource list

+-----------------------------------------------------------------------+
| Personal protective equipment                                         |
+-----------------------------------------------------------------------+
| -   Gloves---various sizes                                            |
|                                                                       |
| -   Aprons                                                            |
|                                                                       |
| -   Eyewear                                                           |
|                                                                       |
| -   Footwear                                                          |
|                                                                       |
| -   Waterproof dressings                                              |
+-----------------------------------------------------------------------+
| Materials                                                             |
+-----------------------------------------------------------------------+
| -   Cleaning and disinfecting agents                                  |
|                                                                       |
| -   Equipment for sterilisation                                       |
|                                                                       |
| -   Sharps disposal containers                                        |
|                                                                       |
| -   Waterproof waste containers for contaminated items                |
|                                                                       |
| -   Alcohol-based hand rubs or anti-microbial soap                    |
+-----------------------------------------------------------------------+
| Safety standards                                                      |
+-----------------------------------------------------------------------+
| -   Policies on use of universal precautions                          |
|                                                                       |
| -   Procedures for disposal of infectious or toxic waste              |
|                                                                       |
| -   Procedures for sterilisation of equipment                         |
|                                                                       |
| -   Policies on handling and disposal of sharps                       |
|                                                                       |
| -   Protocols for management of post-exposure prophylaxis (PEP),      |
|     including ARVs and hepatitis B immunisation                       |
|                                                                       |
| -   Procedures for minimising exposure to infection in high-risk      |
|     settings, such as labour and delivery                             |
+-----------------------------------------------------------------------+
| Education                                                             |
+-----------------------------------------------------------------------+
| -   New employee orientation to infection control procedures          |
|                                                                       |
| -   Ongoing training to build skills in safe handling of equipment    |
|                                                                       |
| -   Monitoring and evaluation of safety practices to assess           |
|     implementation and remedy deficiencies                            |
+-----------------------------------------------------------------------+

SESSION 3 Managing Occupational Exposure to HIV Infection

Post-exposure prophylaxis

Either of the following exposures could put a healthcare worker at risk
of HIV infection if the exposure involves blood, tissue, or other body
fluids containing visible blood:

-   Percutaneous injury (eg, a needlestick or cut with a sharp object)

-   Contact with mucous membrane or non-intact skin (eg, exposed skin
    that is chapped, abraded, or affected by dermatitis)

After occupational HIV exposure, a short-term course of ARV drugs (eg,
one month) may be used to reduce the likelihood of infection. This is
referred to as post-exposure prophylaxis (PEP), and is a key part of a
comprehensive universal precautions strategy for reducing staff exposure
to infectious agents in the workplace.

In healthcare settings the occupational risk of becoming HIV-infected
due to a

needlestick is low (less than 1%). Most cases involve injuries from
needles or sharps that have been used on a patient who is HIV-infected.
The risk of HIV transmission from exposure to infected fluids or tissues
is believed to be lower than from exposure to infected blood.

Risk of exposure from needlesticks and contact with blood and body
fluids exists in settings where:

-   Safe needle procedures and universal precautions are not followed

-   Waste management protocols are inadequate or not consistently
    implemented

-   Protective gear is in short supply

-   Rates of HIV infection in the patient population are high

To minimise the need for PEP, national strategies for education and
training of key partners in healthcare waste management is necessary.

Benefits of making PEP available for healthcare workers:

-   Promotes retention of staff who are concerned about the risk of
    exposure to HIV in the workplace

-   Increases staff willingness and motivation to work with people who
    are HIV-infected

-   Reduces the occurrence of occupationally-acquired HIV infection in
    healthcare workers

A comprehensive PEP protocol outlines the methods for preventing
occupational exposure to HIV and other bloodborne pathogens including:

-   Summary of the system for supervising and monitoring the
    implementation of universal precautions

-   Discussion of safe practices for the disposal of infectious waste

-   Outline of strategies for ensuring that protective materials are in
    sufficient supply (with examples of potential substitutes for these
    materials if necessary)

    A sample PEP protocol is found in Appendix 8-B.

**The PEP protocol should:**

-   Establish guidelines for PEP for the healthcare setting.

-   Be used to educate staff and managers at designated intervals.

-   Ensure that HIV counselling, testing, and ARV drugs are available
    for PEP.

-   Ensure an HIV test is done when starting and after completing PEP.

-   Ensure HIV antibody testing if illness compatible with an acute
    retroviral syndrome occurs.

-   As part of counselling, encourage exposed persons to use precautions
    to prevent secondary transmission during the follow-up period.

-   Evaluate exposed persons taking PEP within 72 hours after exposure
    and monitor for drug toxicity for at least 2 weeks.

-   Maintain a facility register of occupational exposures.

-   Educate healthcare workers to report all occupational accidents so
    that they are recorded on the facility register of occupational
    incidents.

Guidelines for providing PEP

Healthcare workers should report occupational exposure to HIV
immediately after it occurs. Early rapid testing of the source patient
(the patient involved in the incident) can help determine the need for
PEP---and may avert the unnecessary use of ARV drugs, which may have
adverse side effects. If necessary, PEP should begin as soon as possible
after exposure, ideally within 2 hours.

Staff who are at risk for occupational exposure to bloodborne pathogens
need to be educated about the principles of PEP management during job
orientation and on an ongoing basis. Currently there is no single
approved PEP regimen; however, dual or triple drug therapy is
recommended and believed to be more effective than a single agent.

Drug selection for PEP depends on the following factors:

-   Type of injury and transmission device

-   Source patient's HIV viral load and treatment history

-   ARV drugs available at the facility

**Importance of ARV treatment for post-exposure prophylaxis on-site**

Due to the need to start PEP as soon as possible after exposure
(ideally, within

2 hours), a minimum of two doses of ARV treatment should be available
and accessible at the facility at all times.

ARV treatment should be provided in accordance with national or
institutional protocol. A minimum treatment of 2 weeks and maximum of 4
weeks is recommended. If possible, consulting with a HIV specialist is
recommended, particularly when exposure to drug-resistant HIV may have
occurred.

It is important that healthcare workers have ready access to a full
month's supply of ARV treatment once PEP is initiated.

Some healthcare workers taking PEP experience adverse symptoms including
nausea, malaise, headache, and anorexia. Pregnant workers or women of
childbearing age who may be pregnant may receive PEP, but must avoid
efavirenz, which has harmful effects on the foetus. PMTCT programmes
should support workers while they are taking PEP and help manage any
side effects.

+----------------+-----------------------------------------------------+
| # Exercise     |                                                     |
| 8.3 PEP case s |                                                     |
| tudy: small gr |                                                     |
| oup discussion |                                                     |
+----------------+-----------------------------------------------------+
| **Purpose**    | To review implementation of PEP protocols.          |
+----------------+-----------------------------------------------------+
| **Duration**   | 30 minutes                                          |
+----------------+-----------------------------------------------------+
| **             | -   Review the case study below.                    |
| Instructions** |                                                     |
|                | -   In your group, record on paper the steps needed |
|                |     to implement a PEP protocol.                    |
|                |                                                     |
|                | -   Share each step in the process with the larger  |
|                |     group as requested by the facilitator.          |
+----------------+-----------------------------------------------------+

Case study

Nurse Andrews is working late in the labour and delivery unit. When
removing an intravenous needle from the arm of a patient who is in
labour, Nurse Andrews accidentally punctures her finger.

After this occupational exposure, what is the very first thing Nurse
Andrews should do?

*List each subsequent step according to the PEP protocol.*

SESSION 4 Supportive Care for the Caregiver

Compassion fatigue

Healthcare workers who provide ongoing care of pregnant women who are
HIV-infected (or whose HIV status is unknown) and their infants are
vulnerable to compassion fatigue or "burnout."

Burnout syndrome stems from extended exposure to intense job-related
stress and strain. Burnout syndrome is characterised by:

-   Emotional exhaustion: feelings of helplessness, depression, anger,
    and impatience

-   Depersonalisation: detachment from the job and an increasingly
    cynical view of patients and co-workers

-   Decreased productivity: due to a real or perceived sense that their
    efforts are not worthwhile and do not seem to have an impact.

+----------------------------------------+-----------------------------+
| > Signs and symptoms of burnout        |                             |
+----------------------------------------+-----------------------------+
| Behavioural                            | **Physical**                |
|                                        |                             |
| -   Frequent changes in mood           | -   High blood pressure     |
|                                        |                             |
| -   Eating too much or too little      | ```{=html}                  |
|                                        | <!-- -->                    |
| -   Drinking alcohol and/or smoking    | ```                         |
|     too much                           | -   Palpitations, trembling |
|                                        |                             |
| -   Becoming "accident prone"          | -   Dry mouth, sweating     |
|                                        |                             |
| **Cognitive**                          | -   Stomach upset           |
|                                        |                             |
| -   Unable to make decisions           | **Occupational**            |
|                                        |                             |
| -   Forgetful, poor concentration      | -   Taking more days off    |
|                                        |                             |
| -   Sensitive to criticism             | -   Fighting with           |
|                                        |     co-workers              |
|                                        |                             |
|                                        | -   Working more hours but  |
|                                        |     getting\                |
|                                        |     less done               |
|                                        |                             |
|                                        | -   Having low energy,      |
|                                        |     being less motivated    |
+----------------------------------------+-----------------------------+

Institutional or job-related risk factors for burnout

-   Work overload, limited or no breaks

-   Long working hours

-   Poorly structured work assignment (worker not able to use skills
    effectively)

-   Inadequate leadership and support

-   Lack of training and skill-building specific to your job

Personal risk factors for burnout include

-   Unrealistic goals and job expectations

-   Low self-esteem

-   Anxiety

-   Caring for patients with a fatal disease

Personal strategies for minimising or preventing burnout syndrome

Seeking support from others, taking care of yourself, and engaging in
restorative activities, such as reading and exercising may reduce or
minimise burnout syndrome.

**Tips for managing burnout**

-   Find or establish a support group of peers.

-   Search out a mentor---someone who can confidentially support you,
    listen to you, and guide you.

-   Read books or listen to tapes that provide strategies for coping
    with stress.

-   Take a course to learn about a subject relevant to your work (or
    take a refresher course on a previously-studied subject).

-   Take structured breaks during work hours.

-   Make time for yourself and your family.

-   Exercise, eat properly, and get enough rest.

+------------+---------------------------------------------------------+
| # Exe      |                                                         |
| rcise 8.4  |                                                         |
| Compassion |                                                         |
|  fatigue/b |                                                         |
| urnout in  |                                                         |
| PMTCT prog |                                                         |
| rammes: la |                                                         |
| rge group  |                                                         |
| discussion |                                                         |
+------------+---------------------------------------------------------+
| *          | To examine the factors that contribute to burnout and   |
| *Purpose** | develop creative prevention strategies                  |
+------------+---------------------------------------------------------+
| **         | 45 minutes                                              |
| Duration** |                                                         |
+------------+---------------------------------------------------------+
| **Inst     | Participate in the discussion about factors that        |
| ructions** | contribute to compassion fatigue or burnout in the      |
|            | PMTCT setting as well as creative strategies for        |
|            | preventing burnout. The trainer may get the discussion  |
|            | going by asking the group questions about policies and  |
|            | practices in their facilities that may, in the long     |
|            | term, affect job commitment. The trainer may also ask   |
|            | about stress-reduction techniques that work for you as  |
|            | well as what would make your job easier.                |
+------------+---------------------------------------------------------+

> Module 8: Key Points

-   Universal precautions apply to all patients, regardless of
    diagnosis.

-   Key components of universal precautions include:

    -   Handwashing

    -   Safe handling and disposal of sharps

    -   Use of personal protective equipment

    -   Decontamination of equipment

    -   Safe disposal of infectious waste materials

    -   Safe environmental practices

-   Needle-stick injuries from patients who are HIV-infected are the
    most common source of HIV transmission in the workplace.

-   Cleaning, disinfection, and sterilisation of all instruments used in
    invasive procedures reduce risk of patient-to-patient transmission
    of infection.

-   During labour and childbirth, safe care reduces the risk of
    occupational exposure.

-   Short-term ARV treatment reduces the risk of HIV infection after
    occupational exposure.

-   Burnout syndrome is related to intense, prolonged job stress but can
    be managed and the effects minimised by individual and
    organisational supports.

Appendix 8-A Guidelines for cleaning, sterilisation, and disposal of
infectious waste materials

+---------------+------------------+----------------------------------+
| **Level of    | **Items**        | **Decontamination Method**       |
| Risk**        |                  |                                  |
+---------------+------------------+----------------------------------+
| **High risk   | Equipment and\   | Sterilisation is a process that  |
| or\           | instruments that | destroys all microorganisms,     |
| critical**    | penetrate the    | including HIV. Use the following |
|               | skin or body     | methods:                         |
|               |                  |                                  |
|               |                  | -   Use of steam under pressure  |
|               |                  |     is the preferred method.     |
|               |                  |                                  |
|               |                  | -   Use ethylene oxide gas or    |
|               |                  |     other low-temperature        |
|               |                  |     process for heat-sensitive   |
|               |                  |     equipment.                   |
|               |                  |                                  |
|               |                  | -   Use chemical sterilants with |
|               |                  |     adequate pre-cleaning and    |
|               |                  |     follow proper protocols.     |
+---------------+------------------+----------------------------------+
| **Moderate    | Equipment and\   | Sterilise with heat or steam.    |
| risk or\      | instruments that |                                  |
| se            | touch non-intact | Use high-level disinfection.     |
| mi-critical** | skin or mucous   | This method destroys all         |
|               | membranes        | microorganisms with the          |
|               |                  | exception of high numbers of     |
|               |                  | bacterial spores. Use the        |
|               |                  | following methods:               |
|               |                  |                                  |
|               |                  | -   Boil for 20 minutes, or      |
|               |                  |     longer if above sea level.   |
|               |                  |                                  |
|               |                  | -   Perform chemical             |
|               |                  |     disinfection with            |
|               |                  |     glutaraldehyde, stabilised   |
|               |                  |     hydrogen peroxide, chlorine, |
|               |                  |     or peracetic acid, followed  |
|               |                  |     by a sterile water rinse or  |
|               |                  |     a tap water and alcohol      |
|               |                  |     rinse; dry with forced air,  |
|               |                  |     when possible.               |
|               |                  |                                  |
|               |                  |     **Note**: Intermediate-level |
|               |                  |     disinfectants for certain    |
|               |                  |     semi critical items do not   |
|               |                  |     kill all viruses, fungi, or  |
|               |                  |     bacterial spores.            |
+---------------+------------------+----------------------------------+
| **Low risk    | Equipment and\   | Perform low-level disinfection   |
| or\           | instruments that | with diluted germicidal          |
| n             | touch intact     | detergent solution, isopropyl    |
| on-critical** | skin             | alcohol, or 1:500 dilution of    |
|               |                  | household bleach.                |
+---------------+------------------+----------------------------------+

When possible, high-risk or critical equipment and instruments should be
pre-packaged, disposable, and designed for single use.

Cleaning

Cleaning removes all foreign material (dirt, body fluids, and
lubricants) from objects by washing or scrubbing the object using water
and detergents or soaps. Detergents and hot water are generally adequate
for the routine cleaning of floors, beds, toilets, walls, and rubber
draw sheets.

To clean a spill involving body fluids

-   Use heavy-duty rubber gloves and remove body fluid with an absorbent
    material

-   Discard the material in a leak-proof container.

Appendix 8-A Guidelines for cleaning, sterilisation, and disposal of
infectious waste materials *(continued)*

Note the following when handling soiled linen:

-   Use gloves, but avoid handling as much as possible.

-   Do not sort or rinse in patient care areas.

-   Transport linen soiled with large amounts of body fluid in
    leak-proof bags.

-   Fold linen so that the soiled parts are on the inside.

Safe disposal of infectious waste materials

The purpose of waste management is to:

-   Protect people who handle waste items from injury, and

-   Prevent the spread of infection to healthcare workers and the local
    community.

To dispose of solid waste contaminated with blood, body fluids,
laboratory specimens, or body tissue:

-   Place in leak-proof containers and burn, or

-   Bury in a pit 2.5 meters (about 8 feet) deep, at least 30 meters
    (about 98 feet) from a water source.

To dispose of liquid waste, such as blood or body fluids, pour liquid
waste down a drain connected to an adequately treated sewer or pit
latrine.

Recommendations on disposal of sharps

Disposable sharp items, such as hypodermic needles, require special
handling because they are the items most likely to injure healthcare
workers. If these items are disposed of in the municipal landfill, they
are a danger to the community.

Note the following to dispose of sharps containers safely:

-   Wear heavy-duty gloves.

-   When the sharps container is three-quarters full, completely seal
    the opening of the container using a cap, a plug, or tape.

-   Be sure that no sharp items are sticking out of the container.

-   Dispose of the sharps container by burning, encapsulating, or
    burying it.

-   Remove the heavy-duty gloves.

-   Wash your hands and dry them with a clean cloth or air dry.

Burning waste containers

High-temperature burning destroys waste and kills microorganisms. This
method reduces the bulk volume of waste and ensures that the items are
not scavenged and reused.

Encapsulating waste containers

Encapsulation is recommended as the easiest way to dispose of sharps
safely. In this method, collect sharps in puncture-resistant and
leak-proof containers. When the container is three-quarters full, pour a
material such as cement (mortar), plastic foam, or clay into the
container until completely filled. After the material has hardened, seal
the container and dispose it in a landfill, store it, or bury it.

Appendix 8-A Guidelines for cleaning, sterilisation, and disposal of
infectious waste materials *(continued)*

Burying waste

In healthcare facilities with limited resources, safe burial of waste on
or near the facility may be the only option available for waste
disposal. Take the following precautions to limit health risks:

-   Restrict access to the disposal site. Build a fence around the site
    to keep animals and children away.

-   Line the burial site with a material of low permeability (for
    example, clay or cement), if available.

-   Select a site at least 30 meters (about 98 feet) away from any water
    source to prevent contamination of the water table.

-   Ensure that the site has proper drainage, is located downhill from
    any wells, is free of standing water, and is not in a flood-prone
    area.

-   The bottom of the burial pit should be at least 1.5 meters above the
    groundwater level during the wet season.

This appendix includes original material and material adapted from the
following:

-   Tietjen, Bossemeyer, McIntosh. *Prevention: Guidelines for
    Healthcare Facilities with Limited Resources.* JHPIEGO Corporation,
    Baltimore, March 2003.
    http://www.reproline.jhu.edu/english/4morerh/4ip/IP_manual/ipmanual.htm

-   International Council of Nurses, World Health Organization (WHO) and
    the Joint United Nations Programme on HIV/AIDS (UNAIDS). 2000. *Fact
    Sheet 11 HIV and the workplace and Universal Precautions (Fact
    sheets on HIV/AIDS for nurses and midwives)*,
    http://www.who.int/health-services-delivery/hiv_aids/English/fact-sheet-11/index.html

-   World Health Organization (WHO) and the Joint United Nations
    Programme on HIV/AIDS (UNAIDS). 1999. *HIV in Pregnancy: A Review*.
    Pp 39--42. Retrieved 3 June 2004, from
    http://www.who.int/reproductive-health/publications/rhr_99_15/rhr99-15.pdf

Appendix 8-B Managing occupational exposure to HIV:\
a sample protocol

Immediate steps

Any healthcare worker accidentally exposed to blood or body fluids must
take the following steps:

-   Wash the wound and skin sites exposed to blood and body fluids with
    soap and water.

-   For percutaneous injuries (those that break the skin) where bleeding
    occurs, allow bleeding for a few seconds before washing with soap
    and water.

-   Flush mucous membranes exposed to blood and body fluids with water.

-   Topical use of antiseptics is optional.

-   Do not apply caustic agents, such as bleach, onto the wound or
    inject antiseptics or disinfectants into the wound.

-   Immediately inform the supervisor, or person in charge, of the
    exposure type and the action taken.

Once informed, the supervisor should take the following actions:

-   Assess the exposure to determine the risk of transmission.

-   Inform the patient about the exposure and request permission for HIV
    testing.

-   Inform the healthcare worker about the exposure and request
    permission for HIV testing.

-   Perform rapid testing on both specimens following testing
    procedures. If rapid testing is not available, send both samples to
    the closest designated laboratory for HIV testing.

-   Immediately arrange for the healthcare worker to visit the nearest
    physician who manages this type of injury.

-   Provide immediate support and information on post-exposure
    prophylaxis (PEP) to the healthcare worker.

-   Record the exposure in the facility register or the appropriate form
    and forward the information to the individual or department assigned
    to manage such exposures.

-   Maintain the confidentiality of all related records.

PEP

-   In all cases of accidental exposure, start PEP within 2 hours of the
    exposure, whether or not patient's HIV status is known.

-   Discontinue PEP after you have confirmed that the patient's HIV test
    is negative.

-   If the patient is HIV-infected (with a positive test result),
    continue PEP.

-   ARV therapy should be provided according to national or facility
    protocol. A minimum of two weeks and a maximum of four weeks
    treatment is recommended. When possible, consultation with a HIV
    specialist, particularly when exposure to drug resistant HIV may
    have occurred, is recommended.

-   If the healthcare worker's initial HIV test is positive, counsel the
    person on the test result and refer to a HIV/AIDS programme for care
    and treatment.

Appendix 8-B Managing occupational exposure to HIV:\
a sample protocol *(continued)*

-   Always have a minimum of two doses of the approved PEP ARV regimen
    available and accessible at your facility at all times.

-   If the healthcare worker's initial HIV test is negative, repeat the
    HIV test at the following post-exposure intervals: 6 weeks, 3
    months, and 6 months.

-   Healthcare worker should receive follow-up care for 6 months.

-   If the healthcare worker converts from a negative to a positive test
    result, which is rare, refer the worker to an HIV/AIDS programme for
    treatment, care, and support.

Post-exposure counselling for the healthcare worker

-   Healthcare worker must be counselled to either abstain from sexual
    intercourse or use condoms for 6 months after the exposure or until
    receiving the third negative test result.

-   Healthcare worker should not donate blood, plasma, organs, tissues,
    or semen for

    6 months after the exposure or until receiving the third negative
    test result.

-   Breastfeeding should be discouraged during this period.

-   Offer counselling support to the healthcare worker and, if
    requested, to the healthcare worker's spouse or sexual partner, to
    help them manage the implications of and stress related to the
    exposure.

*Source*: Adapted from CDC. 2001. Updated US public health service
guidelines for the management of occupational exposure to HBV, HCV and
HIV and recommendations for postexposure prophylaxis. *MMWR* 50(No.
RR-11): 1--42. Retrieved 30 July 2004, from
http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf and World Health Organization.
Post-exposure prophylaxis Retrieved 30 July 2004, from
http://www.who.int/hiv/topics/prophylaxis/en/index.html

[^1]: If making a 0.5% chlorine solution from liquid household bleach
    which is 3.5% chlorine concentrate, mix 1:7 dilution of household
    bleach to water. A 1:7 dilution is the same as 1 part bleach to 6
    parts water. A \"part\" can be used for any unit of measure (eg,
    ounce, gram, cup, litre or even a bottle). For more information,
    refer to http://www.engenderhealth.org/ip/instrum/inm7.html.