Bloodborne pathogens: HIV and HBV contagion risks at camp.

At your camp, who is responsible for ensuring the proper and safe handling of accidents involving campers and staff? Who is responsible for seeing to it that anyone involved in giving care or cleaning up after an incident is protected from risks of becoming infected with human immunodeficiency virus (HIV) or Hepatitis B virus (HBV)? The answer: you, the camp director.

Ten years ago, a band-aid and a quick wipe-up often solved first aid problems. Now, giving immediate care is only part of the larger area of concern regarding contagion from bloodborne pathogens. As the person responsible for the safety of everyone in your camp, you need to know that your responsibility extends to bloodborne pathogen contagion risks, risks due to HIV (the causative virus of AIDS) and HBV (the causative virus of Hepatitis B).

The problem

HIV and HBV are disease-causing viruses (pathogens). The diseases are spread primarily in blood and body fluids including urine, saliva, vaginal secretions, breast milk, and semen. Evidence of these viruses has been found in tears and sweat, and HBV has been isolated in feces (Mandell, et al., 1990). For both HIV and HBV, blood is the primary means of spreading disease. Because of the dilution associated with urine, tears, saliva, and sweat, these substances pose less of a threat for contagion, but potential for infection still exists. HIV can only be spread by means of human to human contact, whereas HBV can be contracted from contaminated objects (Mandell, 1990). To date there is no cure for either disease.

Risk of infection

HIV

The risk of infection with HIV is less than one in 10,000 (.01 percent) among non-risk-taking individuals, even after needle stick exposure (Sande, 1986), so it is unlikely that campers and staff will contract this disease through usual casual contact. Nationwide estimates of the prevalence of HIV indicate one in 250 persons is infected with the virus (Hall, 1993).

HBV

The scenario for HBV is considerably different. HBV is tremendously more infectious than HIV; even casual, inadvertent contact can be risky. Since camps serve a wide population, and since people engaging in high risk behaviors are from all aspects of society and all cultures, constant vigilance must be maintained regarding bloodborne pathogen contagion risks.

HBV is 100 times more contagious than HIV (Levine, 1991), with approximately 300,000 new cases being reported to the Centers for Disease Control annually (Hall, 1993). Hepatitis B symptoms usually appear within 2 to 6 weeks after exposure and disappear 2 to 4 weeks later, except for a very small percentage of people who develop a rapidly fatal course. Unfortunately, many persons who contract HBV develop no symptoms and their illness goes unrecognized. These people present an insidious risk to others because of their ability to transmit the disease unknowingly.

Transmission

The primary ways of becoming infected with these diseases are:

* unprotected sexual intercourse, especially with multiple partners

* illicit intravenous drug use 

* mother to fetus transmission

* living with infected individuals

* undergoing dialysis.

Failure to use appropriate protective equipment and procedures and, in the case of HBV, immigrants from certain Third World countries also contribute significantly to the contagion risks (Mandell, 1990).

HIV is ultimately, and at times rapidly, fatal. The virus is only capable of surviving in human tissue. HBV, while not universally fatal, can be very debilitating and is significantly more contagious. It can live as long as a month in dried blood, and possibly longer (Hall, 1993).

Potential for exposure

Contagion risks are present in the course of routine activities, with potential for exposure increasing with the risk of injury. Exposure is not limited to blood; it can also include saliva contact during an altercation involving a bite, either intentional or as the result of a body part inadvertently striking an opponent's teeth. This incident carries a high risk of transmitting both HIV and HBV if an infected individual is involved.

In some activities, such as contact sports, the handling of dirty towels and clothing and the handling or sharing of equipment such as swim masks, snorkels, and other athletic gear that is worn in the mouth or exposed to blood, are contagion risks. Performing general first aid or CPR places an individual at increased risk of becoming infected with HBV.

General clean up chores such as handling trash which may be contaminated (used tissue, residual debris from injury care, sanitary napkins, and tampons), cleaning up blood after an injury, and handling "sharps" such as razor blades and broken glass, all carry the likelihood of exposure (Grosse and Skaros, in print). Even the sharing of eating utensils, toothbrushes, or cups may pose risks of infection with HBV.

Camp concerns

Camps, and ultimately camp administrators, have a key responsibility in addressing problems of bloodborne pathogen contagion. Four areas of concern are identified:

* strict implementation of Occupational and Safety Health Act (OSHA) guidelines for managing potential bloodborne pathogen contagion situations, (see sidebar, page 30)

* encouraging and facilitating vaccination of staff and campers,

* developing ongoing camper education, and

* developing ongoing staff education.

Vaccination

According to OSHA standard 1910.1030 for bloodborne pathogens, as of March 1, 1992 all employees with job descriptions that include primary responsibilities that could involve possible exposure to blood or other potentially infectious substances (camp nurses, lifeguards, first aiders, tripping staff, off-season program leaders, maintenance staff charged with waste clean-up, etc.) must be offered HBV vaccination, at no cost to the employee, within 10 working days of their initial placement in that position. Employees may initially refuse the vaccine and may later accept it and receive it at no cost (Hall, 1993). There is no exemption for seasonal employees or tax-exempt status of the employer.

Staff who give first aid as a secondary responsibility are not required to be offered the vaccine unless they have a significant exposure as defined by OSHA. Should unvaccinated, non-immune employees receive significant exposure, they must be offered HBIG and the initiation of the full immunization series within 24 hours of exposure (OSHA addendum, 1992). However, it is to your benefit, as well as that of each staff member and camper, to have everyone vaccinated against HBV. The initial cost of providing the vaccination may be high, but as more people are vaccinated because of prior jobs, athletics, or routine immunizations, these costs will drop. It is imperative to consider these costs as part of the annual budget.

Ideally, blood from the person who creates a contamination situation can be obtained and tested for HIV and HBV after the significant exposure (Hall, 1993). Unfortunately, this seldom occurs and when it does, results of these tests are not known for at least 24 hours and, often, up to a week later. Current recommendations are to check the HBV antibody level of people who have had significant exposure after each exposure, whether or not they have received the total HBV vaccine series (OSHA, 1991). The HIV status of exposed individuals needs to be checked initially after the exposure incident and periodically over the next six months to one year because of the slow conversion rate of this virus (Mendelson, 1991).

Camper education

Camper education must focus on responsibility. Altering irresponsible behaviors, including, but not limited to, behaviors involving sexual intimacy and substance abuse, is key to stemming spread of both HIV and HBV. Personal hygiene, including proper disposal of used tissues, bandages, and sanitary items, must be taught and encouraged, and behavior which could spread disease such as spitting, biting, and fighting should be strongly condemned (Committee on School Health, 1993). Drinking from a common cup and sharing eating utensils, while of minimal risk, should be discouraged. This is especially true when tripping and wilderness camping. Personal hygiene items (combs, toothbrushes, razors) should not be shared at anytime because of the risk of small amounts of blood being on them. These are camper, as well as staff, responsibilities.

Staff education

Staff education is critical. It begins with development of an exposure control plan specific to the camp and activity setting. This plan identifies where bloodborne pathogen contagion risks could occur and the steps the employer and employees must take to guard against exposure (OSHA, 1991).

Staff must become knowledgeable about and responsible for using personal protective equipment (gloves, masks, eye protection, resuscitation devices, gowns, etc.) and universal precautions (proper apparel, handling of, and disposing of contaminated materials) in every potential contagion situation. All staff from activity and unit areas should wear fanny packs containing gloves and gauze pads. Maintenance staff should have and use appropriate coveralls and equipment when cleaning up areas that may have contamination potential. This includes cooks and kitchen staff.

No staff is exempt. Education of all staff about where risks are found and how to handle them according to OSHA guidelines, as well as information about the diseases themselves, should be conducted on an annual basis. In addition, you should educate staff regarding immunization options so they can make an informed immunization decision (OSHA, 1991).

Cost versus benefit

The question of cost often arises when discussions about implementation of the bloodborne pathogen guidelines occur. The initial outlay for every at-risk staff member, the cost of personal protective equipment, training time, and the expense involved with developing and initiating exposure control plans can be burdensome. Most staff will not complete their six-month vaccination program while at camp. Some camp owners and administrators have even given thought to ignoring the standard and hoping they are lucky. However, the real costs come with non-compliance.

Treatment for HBV can run anywhere from $90,000 to $250,000 or more for persons who remain actively contagious or have a complicated illness. The post-exposure HBIG costs a minimum of $900 plus the $150 for the vaccine for exposed individuals not previously immune (Bukata, 1991). Costs involved in treating HIV are even greater. Failure to abide by OSHA standards for bloodborne pathogens could result in fines of $10,000 per incident (OSHA, 1991). This does not take into consideration the personal and emotional costs involved with becoming infected with HIV or HBV.

Conclusion

Bloodborne pathogen contagion risks are here, and they are real. Only diligent implementation of universal precautions, an exposure control plan, use of personal protective equipment, a vaccination program, and ongoing staff and camper education can assure that everything is being done to limit contagion risks.

References

Bukata, W.R. (1991). Hepatitis B and health-care workers. Emergency Medicine and Acute Care Essays, 15(4).

Centers for Disease Control. (July 22, 1988). Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. Morbidity and Mortality Weekly Report, JAMA, 260(4), 462.

Committee on School Health. (April, 1993). Prevention of hepatitis B in school settings. Pediatrics, American Academy of Pediatrics, 91(4).

Committee on Sports Medicine and Fitness. (May, 1992). HIV and sports. The Physician and Sports Medicine, 20(5).

Grosse, S.J. (March, 1994). Warning! First aid can be hazardous to your health (editorial). JOPERD, 65(3).

Grosse, S.J. and Skaros, S. (Nov., 1994). Contagion: know the risks, take precautions! Scholastic Coach, 64(4).

Hall, K. et. al. (1993). Bloodborne Pathogens. National Safety Council. Boston, MA: Jones and Bartlett.

Mandell, G.L., Douglas Jr., R.G, & Bennett, J.P. (Eds.) (1990). Infectious diseases and their etiologic agents. Principles and Practice of Infectious Diseases. (pp. 1038-1231). Churchill Livingstone, N.Y.

Mendelson, M.H. (September, 1991). HIV infection in healthcare workers: risk and prevention. Mt. Sinai Journal of Medicine, 57(4), 216.

Occupational Safety and Health Administration. (December 6, 1991). Bloodborne Pathogens Standard, 1910.1030. Federal Register 56(235), 64175-64182.

Occupational Safety and Health Administration. (1992). Supplement to bloodborne pathogens standard 1910.1030.

Owens, D.K, et al. (May, 1992). Occupational exposure to human immunodeficiency virus and hepatitis B virus: a comparative analysis of risk. American Journal of Medicine, 92(5), 503.

Sande, M.A (February 6, 1986). Transmission of AIDS: the case against casual contagion. New England Journal of Medicine, 314(6), 380.

Stein, R. (June, 1993). ABC's of hepatitis. American Health, 12(3), 65-69.

RELATED ARTICLE: OSHA Guidelines

Implementation of OSHA bloodborne pathogen guidelines is based on a single premise: everyone is contagious and capable of infecting others. Since the number of individuals infected with HIV and/or HBV is significant, trying to exclude them from camp activities is not reasonable, cost-effective, or legal (Committee on Sports Medicine and Fitness, 1992). Therefore, steps must be taken to limit exposure opportunities. These steps include:

* developing and implementing an exposure control plan

* knowledge of and strict adherence to implementation of universal precautions as defined by OSHA

* educating staff and campers regarding the identity and proper disposal of contaminated materials

* removing from any activity any individual who has evidence of bleeding or blood on themselves or their clothes until it can be cleaned up

* ensuring any area used for first aid is not used for eating, smoking, applying cosmetics, inserting contact lenses, or any other activity that could increase the risk of infection

* ensuring an adequate supply of disposable personal protective equipment (PPE) is available in multiple, easily accessible places, including fanny packs or jump kits for first responders, unit staff, activity leaders, life guards, health care personnel, maintenance workers, and other staff

* cleaning up, rapidly, all potentially contagious spills using either a 10 percent bleach (hypochlorite) solution or other virus-killing agent recognized by OSHA

* stressing good hygiene, especially hand washing at all times, even if PPE has been used

* having red or biohazard labeled bags available for proper disposal of contaminated materials

* picking up sharp objects or broken glass with a broom and dustpan or tweezers, never with the hands, even if wearing gloves

* holding annual in-services to ensure up-to-date understanding and compliance with bloodborne pathogen standards

* ensuring immediate reporting of every significant exposure so that appropriate immunity intervention can be initiated

* establishing a thorough record keeping of every significant exposure as well as initiating a post-incident evaluation to prevent further exposure incidents

* encouraging HBV vaccination of all at-risk employees and preferably, encouraging HBV immunization for all staff and campers

* ensuring all contaminated refuse is carried out of wilderness areas and disposed of appropriately.

Susan Skaros is a physician assistant at Sinai Samaritan Medical Center. She has 20 years of camp counseling experience and continues to train staff in water safety and canoeing.