3.2.3.4: Prevention of Exposure to Blood and Body Fluids

Child care facilities should adopt the use of Standard Precautions developed for use in hospitals by The Centers for Disease Control and Prevention (CDC). Standard Precautions should be used to handle potential exposure to blood, including blood-containing body fluids and tissue discharges, and to handle other potentially infectious fluids.

In child care settings:

1. Use of disposable gloves is optional unless blood or blood containing body fluids may contact hands. Gloves are not required for feeding human milk, cleaning up of spills of human milk, or for diapering;
2. Gowns and masks are not required;
3. Barriers to prevent contact with body fluids include moisture-resistant disposable diaper table paper, disposable gloves, and eye protection.

Caregivers/teachers are required to be educated regarding Standard Precautions to prevent transmission of bloodborne pathogens before beginning to work in the facility and at least annually thereafter. Training must comply with requirements of the Occupational Safety and Health Administration (OSHA).

Procedures for Standard Precautions should include:

1. Surfaces that may come in contact with potentially infectious body fluids must be disposable or of a material that can be disinfected. Use of materials that can be sterilized is not required.
2. The staff should use barriers and techniques that:
   1. Minimize potential contact of mucous membranes or openings in skin to blood or other potentially infectious body fluids and tissue discharges; and
   2. Reduce the spread of infectious material within the child care facility. Such techniques include avoiding touching surfaces with potentially contaminated materials unless those surfaces are disinfected before further contact occurs with them by other objects or individuals.
3. When spills of body fluids, urine, feces, blood, saliva, nasal discharge, eye discharge, injury or tissue discharges occur, these spills should be cleaned up immediately, and further managed as follows:
   1. For spills of vomit, urine, and feces, all floors, walls, bathrooms, tabletops, toys, furnishings and play equipment, kitchen counter tops, and diaper-changing tables in contact should be cleaned and disinfected as for the procedure for diaper changing tables in Standard 3.2.1.4, Step 7;
   2. For spills of blood or other potentially infectious body fluids, including injury and tissue discharges, the area should be cleaned and disinfected. Care should be taken and eye protection used to avoid splashing any contaminated materials onto any mucus membrane (eyes, nose, mouth);
   3. Blood-contaminated material and diapers should be disposed of in a plastic bag with a secure tie;
   4. Floors, rugs, and carpeting that have been contaminated by body fluids should be cleaned by blotting to remove the fluid as quickly as possible, then disinfected by spot-cleaning with a detergent-disinfectant. Additional cleaning by shampooing or steam cleaning the contaminated surface may be necessary. Caregivers/teachers should consult with local health departments for additional guidance on cleaning contaminated floors, rugs, and carpeting.

Prior to using a disinfectant, clean the surface with a detergent and rinse well with water. Facilities should follow the manufacturer’s instruction for preparation and use of disinfectant (3,4). For guidance on disinfectants, refer to Appendix J, Selecting an Appropriate Sanitizer or Disinfectant.

If blood or bodily fluids enter a mucous membrane (eyes, nose, mouth) the following procedure should occur. Flush the exposed area thoroughly with water. The goal of washing or flushing is to reduce the amount of the pathogen to which an exposed individual has contact. The optimal length of time for washing or flushing an exposed area is not known. Standard practice for managing mucous membrane(s) exposures to toxic substances is to flush the affected area for at least fifteen to twenty minutes. In the absence of data to support the effectiveness of shorter periods of flushing it seems prudent to use the same fifteen to twenty minute standard following exposure to bloodborne pathogens (5).

RATIONALE

Some children and adults may unknowingly be infected with HIV or other infectious agents, such as hepatitis B virus, as these agents may be present in blood or body fluids. Thus, the staff in all facilities should adopt Standard Precautions for all blood spills. Bacteria and viruses carried in the blood, such as hepatitis B, pose a small but specific risk in the child care setting (3). Blood and body fluids containing blood (such as watery discharges from injuries) pose a potential risk, because bloody body fluids contain the highest concentration of viruses. In addition, hepatitis B virus can survive in a dried state in the environment for at least a week and perhaps even longer. Some other body fluids such as saliva contaminated with blood or blood-associated fluids may contain live virus (such as hepatitis B virus) but at lower concentrations than are found in blood itself. Other body fluids, including urine and feces, do not pose a risk for bloodborne infections unless they are visibly contaminated with blood, although these fluids may pose a risk for transmission of other infectious diseases.

Touching a contaminated object or surface may spread illnesses. Many types of infectious germs may be contained in human waste (urine, feces) and body fluids (saliva, nasal discharge, tissue and injury discharges, eye discharges, blood, and vomit). Because many infected people carry infectious diseases without having symptoms, and many are contagious before they experience a symptom, staff members need to protect themselves and the children they serve by adhering to Standard Precautions for all activities.

Gloves have proven to be effective in preventing transmission of many infectious diseases to health care workers. Gloves are used mainly when people knowingly contact or suspect they may contact blood or blood-containing body fluids, including blood-containing tissue or injury discharges. These fluids may contain the viruses that transmit HIV, hepatitis B, and hepatitis C. While human milk can be contaminated with blood from a cracked nipple, the risk of transmission of infection to caregivers/teachers who are feeding expressed human milk is almost negligible and this represents a theoretical risk. Wearing of gloves to feed or clean up spills of expressed human milk is unnecessary, but caregivers/teachers should avoid getting expressed human milk on their hands, if they have any open skin or sores on their hands. If caregivers/teachers have open wounds they should be protected by waterproof bandages or disposable gloves.

Cleaning and disinfecting rugs and carpeting that have been contaminated by body fluids is challenging. Extracting as much of the contaminating material as possible before it penetrates the surface to lower layers helps to minimize this challenge. Cleaning and disinfecting the surface without damaging it requires use of special cleaning agents designed for use on rugs, or steam cleaning (3). Therefore, alternatives to the use of carpeting and rugs are favored in the child care environment.

COMMENTS

The sanctions for failing to comply with OSHA requirements can be costly, both in fines and in health consequences. Regional offices of OSHA are listed at http://www.epa.gov/aboutepa/index.html#regional/ and in the telephone directory with other federal offices.

Either single-use disposable gloves or utility gloves should be used when disinfecting. Single-use disposable gloves should be used only once and then discarded immediately without being handled. If utility gloves are used, they should be cleaned after every use with soap and water and then dipped in disinfectant solution up to the wrist. The gloves should then be allowed to air dry. The wearing of gloves does not prevent contamination of hands or of surfaces touched with contaminated gloved hands. Hand hygiene and sanitizing of contaminated surfaces is required when gloves are used.

Ongoing exposures to latex may result in allergic reactions in both the individual wearing the latex glove and the individual who contacts the latex glove. Reports of such reactions have increased (1).

Caregivers/teachers should take the following steps to protect themselves, children, volunteers, and visitors from latex exposure and allergy in the workplace (6):

1. Use non-latex gloves for activities that are not likely to involve contact with infectious materials (food preparation, diapering, routine housekeeping, general maintenance, etc.);
2. Use appropriate barrier protection when handling infectious materials. Avoid using latex gloves BUT if latex gloves are chosen, use powder-free gloves with reduced protein content;
   1. Such gloves reduce exposures to latex protein and thus reduce the risk of latex allergy;
   2. Hypoallergenic latex gloves do not reduce the risk of latex allergy. However, they may reduce reactions to chemical additives in the latex (allergic contact dermatitis);
3. Use appropriate work practices to reduce the chance of reactions to latex;
4. When wearing latex gloves, do not use oil-based hand creams or lotions (which can cause glove deterioration);
5. After removing latex gloves, wash hands with a mild soap and dry thoroughly;
6. Practice good housekeeping, frequently clean areas and equipment contaminated with latex-containing dust;
7. Attend all latex allergy training provided by the facility and become familiar with procedures for preventing latex allergy;
8. Learn to recognize the symptoms of latex allergy: skin rash; hives; flushing; itching; nasal, eye, or sinus symptoms; asthma; and (rarely) shock.

Natural fingernails that are long or wearing artificial fingernails or extenders is not recommended. Child care facilities should develop an organizational policy on the wearing of non-natural nails by staff (2).

For more information on safety with blood and body fluids, consult Healthy Child Care Pennsylvania’s “Keeping Safe When Touching Blood or Other Body Fluids” at http://www.ecels-healthychildcarepa.org/content/Keeping Safe 07-27-10.pdf.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.1.4 Diaper Changing Procedure
7.6.1.3 Staff Education on Prevention of Bloodborne Diseases
Appendix D: Gloving
Appendix L: Cleaning Up Body Fluids

REFERENCES

1. De Queiroz, M., S. Combet, J. Berard, A. Pouyau, H. Genest, P. Mouriquand, D. Chassard. 2009. Latex allergy in children: Modalities and prevention. Pediatric Anesthesia 19:313-19.
   
2. Siegel, J. D., E. Rhinehart, M. Jackson, L. Chiarello, Healthcare Infection Control Practices Advisory Committee. 2007. 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov/hicpac/pdf/Isolation/Isolation2007.pdf. 
   
3. Kotch, J. B., P. Isbell, D. J. Weber, et al. 2007. Hand-washing and diapering equipment reduces disease among children in out-of-home child care centers. Pediatrics 120: e29-e36.
   
4. Rutala, W. A., D. J. Weber, HICPAC. 2008. Guideline for disinfection and sterilization in healthcare facilities. Center for Disease Control and Prevention. https://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf.
   
5. Email communication from Amy V. Kindrick, MD, MPH, Senior Consultant, National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline), UCSF School of Medicine at San Francisco General Hospital to Elisabeth L.M. Miller, BSN, RN, BC, PA Chapter American Academy of Pediatrics, Early Childhood Education Linkage System – Healthy Child Care Pennsylvania. November 11, 2009.
   
6. American Latex Allergy Association. Creating a safe school for latex-sensitive children. 1996-2016. http://latexallergyresources.org/articles/web-article-creating-safe-school-latex-sensitive-children.