Bloodborne diseases: developing a training curriculum.

Every day, law enforcement personnel around the Nation respond to thousands of situations ill-equipped and poorly prepared. Even worse, many department administrators remain unaware of how to train their officers to protect themselves adequately in these situations.

To what new foe has the law enforcement community been so slow to respond? Unfortunately, it is not new at all, but one that has assumed a dramatically more dangerous character within the past decade--bloodborne diseases (BBD).

The increasing spread of AIDS, as well as various strains of hepatitis and other bloodborne diseases, presents the public safety community with a formidable enemy. Furthermore, two dangerous allies--ignorance and unsubstantiated fear--often accompany this adversary.

Accurate information and effective precautionary procedures represent the best response strategies for law enforcement. However, increasingly frequent media stories and a recent survey indicate that the public safety community as a whole may not be reacting quickly enough to this threat.

The results of inaction could be devastating--unnecessary threats to law enforcement personnel, lawsuits, and a loss of credibility within communities. These factors, combined with emerging Federal regulation, make it imperative that agency administrators work to develop effective training programs that address the transmission of bloodborne diseases.

SURVEY

An informal survey of 70 law enforcement administrators, managers, and trainers conducted during a recent session of the FBI National Academy revealed some rather startling statistics.(1) Of the 70 supervisors questioned:

* 43 did not have a comprehensive departmental policy in place regarding bloodborne diseases

* 42 stated that their departments had not provided at least 4 hours of BBD training to each employee within the past 4 years

* 50 were unaware of recent Occupational Safety and Health Administration (OSHA) regulations that require employers to provide all vulnerable employees with protective equipment (such as gloves) and to offer free hepatitis B vaccinations to those who desire them

* 50 were not aware that the Centers for Disease Control (CDC) designed a curriculum guide to address the training and education needs of public safety workers who may be exposed to hepatitis B and the human immunodeficiency virus (HIV)--the virus that causes AIDS.

Although admittedly limited in scope, this survey indicates that despite new OSHA health precaution rules, urging by Federal agencies, and readily available information resources, many law enforcement agencies fail to address bloodborne diseases adequately from policy and training standpoints. This failure reinforces a warning issued by policy researchers nearly 5 years ago, "Too many organizations simply have not prepared for the consequences of a case--or many cases--of AIDS among their workforce, and many of these organizations will regret their unpreparedness."(2)

How should law enforcement agencies prepare? The ideal approach is to establish training curriculums and operating procedures that reduce the threat to officers, thereby helping to limit agency liability.

Each department should develop its own bloodborne disease training program--one designed to accommodate the needs of each individual workforce. In addition, a written policy directive should be the cornerstone of frequent, ongoing training. Because research continues to uncover important information, education in this area should be considered a process, not merely a one-time event.

DEVELOPING A CURRICULUM

In 1989, the Centers for Disease Control prepared a curriculum guide to meet the training and educational needs of public safety workers who may be exposed to bloodborne pathogens on the job. "A Curriculum Guide for Public Safety and Emergency Response Workers" is based on Federal guidelines for preventing occupational transmission of HIV and HBV (the hepatitis B virus).(3)

This curriculum serves as a model that any public safety agency can adopt. The course covers:

* Means of HIV and HBV transmission * Suggested personal prevention practices * Universal precaution strategies * Protective equipment * Specific workplace prevention practices * Exposure management procedures.

Individual agencies may choose to modify the contents of the curriculum or design one that addresses departmental needs. Agencies that include these elements in some form, however, will provide employees with a comprehensive training program.

SPECIAL TRAINING CONSIDERATIONS

A successful training program must also incorporate a sensitive, yet direct, approach to providing information. To that end, program planners should stress special considerations to keep in mind when addressing this issue.

Emotions and Attitudes

Certain diseases--particularly those with controversial methods of transmission--arouse intense emotions in people. Therefore, it is important that training in this area not only convey factual information but also address emotional responses.

When discussing AIDS, program instructors should focus on the facts and should not attempt to change individuals' basic attitudes concerning morality or cultural values. At the same time, instruction should stress the importance of distinguishing personal beliefs from professional responsibilities.(4) Through proper training, individuals should come to accept AIDS as a dangerous disease without any religious or moralistic overtones.

Goals and Objectives

To guarantee that training accomplishes its stated purpose, program administrators should first establish overall training goals. Then, trainers should establish specific instructional objectives to ensure that the goals are met. The following sample objectives are adapted from the CDC curriculum guide. Employees who complete this program should be able to:

* Define HIV, HBV, and AIDS

* Identify high-risk workplace situations, exposure protection/management measures, and decontamination procedures

* Know and understand laws and departmental policies governing treatment, testing, confidentiality, and reporting procedures.(5)

While these objectives may be adapted to fit the needs of individual agencies, all performance-based objectives should reflect the established general goals set by administrators.

Definitions

To clarify how bloodborne diseases are transmitted, instructors should provide definitions of certain key terms. The following basic definitions provide a basis for discussing these issues as they relate to law enforcement.

HIV and AIDS: The human immunodeficiency virus (HIV) causes the acquired immunodeficiency syndrome (AIDS). AIDS results from the progressive destruction of an individual's immune system--the body's defense against disease. The virus that causes AIDS is transmitted through sexual contact, exposure to infected blood (or blood components), and perinatally from mother to neonate. Epidemiologic evidence implicates only blood, semen, vaginal secretions, and possibly, breast milk as a means of transmission.

Hepatitis B: Hepatitis B is caused by the hepatitis B virus (HBV). This disease results in liver damage, which may range in severity from mild or even inapparent to severe or fatal. HBV is transmitted through blood, semen, vaginal secretions, and saliva.

High-Risk Exposure Situations

Training should describe workplace situations and address issues that relate to public safety workers. This training should be tailored to the learning group in order to make the curriculum relevant. To increase the impact of the training, instructors should introduce hypothetical case studies, coupled with discussions of actual situations. Copies of these case studies should be distributed to each class member, and discussion questions should be prepared in advance to promote group interaction.

Scenarios used in case studies may include traffic accidents with injuries, drug raids, demonstrations and rallies, autopsies, and evidence handling, among many others. Instructors may use this opportunity to provide specific information relating to viral transmission, departmental procedures, and applicable laws.

Exposure Protection

In the medical sense, the "universal precautions" concept assumes all patients to be infected with bloodborne pathogens. For law enforcement, training should emphasize that when personnel encounter body fluids under uncontrolled, emergency circumstances, they should treat all body fluids as potentially hazardous.

During training, standard personal protective equipment (PPE) should be displayed and its use demonstrated. Trainers should provide detailed instruction regarding disposable gloves, masks, protective eyewear, gowns, and resuscitation equipment. However, trainers should stress that PPE is not limited to these items. In situations where gross contamination can be reasonably anticipated--during an autopsy or the processing of an extremely contaminated crime scene--additional protective equipment, such as shoe coverings, would be required.

Decontamination Methods

Training programs should also discuss specific decontamination processes, including disinfection procedures and disposal equipment. Instructors should present current information on needle disposal, handwashing, sterilization methods, cleaning and decontaminating blood spills, packaging evidence, handling infective waste, and laundering processes for protective clothing.

Managing Exposures

Trainers should explain that exposure results from contact with blood or potentially infectious body fluids through various means, including needle sticks, contacting blood or blood-contaminated body fluids with chapped skin, open wounds or mucous membranes, and saliva. Training should stress that any incident involving contact with blood or body fluids should be treated as an exposure.

The curriculum should then address procedures for treating exposed workers, including referral to proper medical authorities, counseling, and preventive treatment. Instructors should also discuss internal procedures for reporting and documenting cases in detail.

Ethical Issues

Each year, State and Federal legislators review over 1,000 AIDS-related bills. Numerous jurisdictions have enacted ordinances preventing discrimination against persons infected with AIDS.

This makes it imperative that bloodborne diseases training address ethical issues. These include:

* Discrimination * Duty to provide care * HIV testing and confidentiality * Prevention of occupational exposure * Treatment after exposure.

While criminal justice personnel may have legitimate concerns when providing care to those they suspect have a contagious disease, these workers also have a professional responsibility to perform their jobs. Generally, public safety employees cannot refuse to render assistance to persons in need.

Any legal claim supporting officers' refusal to perform duties based on fear of contracting a bloodborne disease would be difficult to sustain on two grounds. First, research points to the unlikelihood of viral transmission through the types of contacts likely to be experienced by police officers, assuming officers take standard precautions. Second, officers assume certain risks in accepting their positions.(6)

Health Precautions

The training curriculum should also address new health precaution rules and their impact on law enforcement agencies. Federal regulations were recently developed to protect against occupational exposure to infectious bloodborne agents.

OSHA compels certain employers to provide protective equipment and to institute other precautions to safeguard public safety workers and the public.(7) OSHA also mandates that agencies make a copy of the 1992 standard available to all affected or potentially affected employees, along with information regarding:

* Epidemiology and symptoms of bloodborne diseases

* Transmission modes of bloodborne diseases

* Employers' exposure control plan

* Signs, labels, and color-coding associated with bloodborne diseases

* Methods for recognizing tasks/activities that may involve exposure to bloodborne pathogens

* Comprehensive guidelines for the use and disposal of personal protective equipment

* Procedures to follow when exposure occurs.

The OSHA standard further requires these employers to make available hepatitis B vaccinations and related information to those employees who desire them.

RESOURCES

The Centers for Disease Control curriculum guide contains 22 pages of resources. In addition to general information on HIV, AIDS, and HBV, the guide includes resources specially tailored to law enforcement officers, correctional personnel, emergency medical technicians/paramedics, and firefighters.

Among the most referenced resources is AIDS and the Law Enforcement Officer: Concerns and Policy Responses. This book specifies 13 relevant subjects that should be addressed in AIDS education programs and suggests 7 key elements for providing effective training.(8)

EVALUATION

After training sessions, instructors and attendees should be allowed to evaluate the content and quality of the instruction provided. Because proper evaluation forms the basis for improving future training, it represents a valuable component of the process.

Evaluations should determine if the course attained its stated objectives. Attendees should also comment on the physical environment, audiovisual equipment, and amount of time allocated and make specific suggestions for improving course content and presentation.

Instructors may also want to use pre- and post-tests to evaluate attendees' learning. When examinations are used, written measurable objectives should determine what constitutes acceptable levels of performance.

The training unit manager should maintain all relevant written material on file. This information provides a record of class attendance, course content, and test results. This documentation may prove invaluable during litigation should an agency need to produce evidence of training.

CONCLUSION

Bloodborne diseases represent increasingly serious health problems in this Nation. As with today's health care workers, law enforcement officers are constantly exposed to deadly diseases. Despite this fact, many agencies have yet to develop training policies in this area.

However, rising rates of infection among the general population clearly point to the need for bloodborne disease training in all public safety agencies. Administrators who have not acted on Federal recommendations in this area delay at the peril of their employees, agencies, and communities. But those who develop effective training programs reduce the threats to officers, limit agency liability, and constructively address a potentially divisive issue within their communities. In this case, the choice is clear.

Endnotes

1 Study conducted during the 169th Session of the FBI National Academy, Quantico, Virginia, May 1992.

2 Sam B. Pucket and Alan R. Emery, Managing AIDS in the Workplace (Reading, Massachusetts: Addison-Wesley, 1988), 13.

3 A Curriculum Guide for Public-Safety and Emergency-Response Workers (Atlanta, Georgia: Centers for Disease Control, 1989).

4 Supra note 2, 114-115.

5 Robert F. Mager, Preparing Instructional Objectives (Belmont, California: Fearson/Lear Siegler, Inc.).

6 Theodore Hammett, "AIDS and the Law Enforcement Officer: Concerns and Policy Responses," National Institute of Justice--Issues and Practices, 1987, 31.

7 OSHA 1910.1030, Bloodborne Pathogens.

8 Supra note 6.

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