Module 9 Safety and Supportive Care in
the Work Setting
After completing the module, the participant will be able to:
 Describe how Universal Precautions can prevent healthcare
workers (HCWs) from exposure to bloodborne pathogens.
 Outline strategies for preventing HIV transmission in the
healthcare setting.
 Identify key steps in the decontamination, cleaning, disinfection
and sterilization of equipment and materials.
 Discuss risk reduction in obstetric settings.
 Describe the management of occupational exposure to HIV.
 Outline the National PEP regimen.
 Identify personal strategies to manage burnout.
Malawi PMTCT Participant Manual
UNIT 1
Universal Precautions
After completing the unit, the participant will be able to:
 Describe how Universal Precautions can prevent healthcare workers (HCWs) from
exposure to bloodborne pathogens.
Basic concepts of infection prevention
HIV and other bloodborne diseases may be transmitted in healthcare settings from a
client to a HCW, from a HCW to a client, or from a client to a client. HIV can be present
in body fluids particularly where visible blood is present. Therefore, 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 HCWs is almost always associated with needlestick injuries during the
care of a client who is HIV-infected. In practice, transmission occurs during:
 Intravenous injections
 Blood donations
 Dialysis
 Transfusions
Client-to-client transmission of HIV infection can be prevented by disinfecting or
sterilizing equipment and devices used in procedures that puncture the skin or other
equipment that is exposed to blood, tissue, or body fluids.
The context and environment in which health care is provided must be safe for the HCW.
Transmission of infectious agents in the healthcare setting can be prevented by using
infection prevention measures, including washing hands with soap and water; adhering to
Universal Precautions and safe environmental practices; and providing ongoing education
for employees about infection prevention. If such measures are employed, most
healthcare settings should not pose any significant risk of HIV transmission to the HCW.
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.
Definition
Universal Precautions are simple set of effective practices designed to protect HCWs
and clients from infection with a range of pathogens, including bloodborne viruses
such as HIV. These practices are used when caring for all clients regardless of
diagnosis.
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It is not feasible or cost-effective to test all clients 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 client’s actual or assumed HIV status.
Managing the work environment
Proper planning and management of supplies and other resources are essential for
reducing the occupational risks of infection with HIV. 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, PEP follow-up,
and first aid.
 Attain and maintain appropriate staffing levels.
 Ensure staff have appropriate workloads.
 Orient new staff to infection prevention procedures.
 Provide ongoing staff education and supervision.
 Implement supportive measures that reduce staff stress, isolation, and burnout.
 Acknowledge and address the multifaceted needs of HCWs who are HIV-infected.
Ensure that Universal Precautions are implemented, monitored, and evaluated
periodically.
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Have enough protective equipment on hand to decrease HCW stress about accidental
occupational exposure to HIV.
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 and accessibility of puncture-resistant sharps containers.
Ongoing education for employees in infection prevention
 Orient all staff to the site’s infection prevention policies.
 Ensure that all workers who are routinely exposed to blood and body fluids (e.g.,
physicians, midwives, nurses, and support staff) 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.
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UNIT 2
Handling and Decontamination of Equipment and
Materials
After completing the unit, the participant will be able to:
 Outline strategies for preventing HIV transmission in the healthcare setting.
 Identify key steps in the decontamination, cleaning disinfection and sterilization of
equipment and materials.
 Discuss risk reduction in obstetric settings.
Hand washing
The following strategies are strongly recommended for reducing transmission of
bloodborne pathogens and other infectious agents in healthcare settings:
 Soap and water hand washing, using friction under running water for a minimum of
15 seconds.
 Alcohol-based hand rubs for routine decontamination or hand antisepsis for hands
that are not visibly soiled. Note, however, that if hands are visibly soiled, hand rubs
should not be considered a substitute for hand washing.
Hand washing
Hand washing with plain soap and water is one of the most effective methods for
preventing transmission of bloodborne pathogens and limiting the spread of infection.
Wash before:
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Wash after:
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Hand hygiene recommendations
Putting on gloves
Examining a client
Performing any procedure that involves contact with blood or
body fluids
Handling contaminated items such as dressings and used
instruments
Eating
Removing gloves
Examining a client
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
Reducing occupational exposure to HIV infection is achieved by avoiding direct
contact with blood or fluids containing blood.
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Personal protective equipment
Personal protective equipment safeguards clients and staff. Use the following equipment
when possible:
 Gloves
 Aprons or gowns
 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 client helps prevent the transmission of
infection from person to person. Protection with gloves is recommended when:

There is a reasonable chance of hand contact with blood, other body fluids, mucous
membranes, or broken or cut skin.
 Handling items contaminated with blood, body fluids, secretions
 HCW has skin lesions on the hand.
 Sterile gloves are required for surgical procedures.
Gloves are not required for routine care activities in which contact is limited to a client’s
intact skin.
Tips for effective glove use
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Wear gloves that are the correct size.
Use water-soluble hand lotions and moisturizers 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 micro-organisms.
Keep fingernails short (less than 3 mm beyond the fingertip). Long nails may provide
a breeding ground for bacteria, yeast, and other disease-causing micro-organisms.
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.
Personal protective clothing such as waterproof gowns, aprons and/or masks must be
worn only where there is likelihood of exposure to large amounts of blood or body fluids,
such as in operating theatre, labour and delivery ward, or laboratory.
Aprons or gowns
Rubber or plastic aprons provide a protective waterproof barrier along the front of the
HCW. A gown should be worn to protect skin and to prevent soiling of clothing during
procedures and client-care activities that are likely to generate splashes or sprays of
blood, body fluids, secretions, or excretions.
Eyewear
Eyewear, such as plastic goggles, safety glasses, face shields, or visors, protects the eyes
from accidental splashes of blood or other body fluids.
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Footwear
Gum 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, e.g., 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 care without
compromising personal safety.
Handling of equipment and materials
Handling and disposal of sharps
Most HIV transmission to HCWs in work settings is the result of skin puncture with
contaminated needles or sharps. These injuries are more likely to occur when sharps are
being recapped, cleaned, or inappropriately discarded.
Recommendations for use of sterile injection equipment
 Use a sterile syringe and needle for each injection and when reconstituting each unit
of medication. If single-use syringes and needles are unavailable, use equipment
designed for steam sterilization.
 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. (See Figure 9.1 Single-handed recap
method.)
 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 burn needles and syringes so that people cannot access them.
 Wear gloves whenever a laboratory procedure is performed.
 Handle all laboratory specimens with care.
 Use holders for all blades.
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 9.1.
 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 9.1).
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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 yourself and
others. Whenever possible, place the sharp on a table or other flat surface (a tray)
where it can then be picked up by the receiving person.
Pick up sharps one at a time and never pass handfuls of sharp instruments or
needles.
Figure 9.1 Single-handed recap method:
Step 1: Scoop up the cap.
Step 2: Push cap firmly down.
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 (i.e., 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
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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 not in the way. 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 for other purposes.
 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
 Close sharp containers tightly when they are full and incinerate or dispose them
according to IP policy.
Introduction to decontamination, cleaning, high-level disinfection
(HLD), and sterilization
The method used to neutralize or remove harmful agents from contaminated equipment or
supplies should be based on:
 Risk of infection associated with the contaminated instrument or piece of equipment
 Decontamination process the object can tolerate
Routine procedures for decontamination, cleaning, HLD and sterilization of equipment:
 Use heavy gloves.
 Dismantle all equipment before cleaning.
 Wear additional protective clothing such as aprons, gowns, goggles, and masks when
at risk for being splashed with body fluid.
Decontamination of equipment and materials
Definition
Decontamination is a process that makes
inanimate objects safer to be handled by staff
before cleaning (i.e., inactivates HBV, HBC and
HIV and reduces, but does not eliminate, the
number of other contaminating microorganisms).
Decontamination is the first step in
processing soiled (contaminated)
surgical instruments, gloves, and
other items, especially if cleaning
by hand. Decontaminate by
soaking contaminated items for 10
minutes in 0.5% chlorine solution,
or other locally available disinfectants.
Larger surfaces, such as examination and operating tables, laboratory bench tops, and
other equipment that may have come in contact with blood or other body fluids should be
decontaminated by wiping with a suitable disinfectant (e.g., 0.5% chlorine solution or 1–
2% phenol).
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Decontamination should be done at point of use in each department, unit, or ward,
immediately after the procedure.
The following chart shows how to prepare a 0.5% chlorine solution from pre-made
solutions.
Brand of Bleach, % chlorine
To obtain a 0.5% chlorine solution
Household bleach, 5% chorine
1 part household bleach to 9 parts water
Jik, 3.5% chlorine
1 part Jik bleach to 6 parts water
Powder bleach, 35% chlorine
14.2 grams of dry powder to 1 litre of water
The general formula for making a dilute chlorine solution from a commercial preparation
of any given concentration is as follows:*
Total parts of water = [% concentrate/% dilute] -1.
Example: to make a 0.5% dilute solution of chlorine from 5% concentrated liquid
household bleach = [5.0%/0.5%] -1 = 9 parts of water; therefore add one part of
concentrated bleach to nine parts of water.
If using commercially available dry powder chlorine, use the following formula to
calculate the amount (in grams) of dry powder required to make 0.5% chlorine solution:
Grams/litre = [% dilute/% concentrate] x 1000.
For example to make a 0.5% dilute chlorine solution from a dry powder of 35% calcium
hypochlorite = [0.5%/35%] x 1000 = 14.2 g. Therefore add 14.2 grams of dry powder to
1 litre of water or 142 grams to 10 litres of water.
Cleaning of equipment
Definition
Cleaning is a process that physically removes all
visible dust, soil, blood or other body fluids from
inanimate objects as well as removing sufficient
numbers of microorganisms to reduce risks for those
who touch the skin or handle the object. It consists of
thoroughly washing with soap or detergent and water,
rinsing with clean water and drying.†
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Any instrument or
equipment that comes
into contact with intact
skin should be cleaned
before it is used.
Any instrument or
equipment shall be
thoroughly cleaned
before further
processing (sterilization
or disinfection).
Adapted from: Colposcopy and Treatment of Cervical Intraepithelial Neoplasia. A Beginner’s Manual,
Chapt. 14, http://screening.iarc.fr/colpochap.php?lang=1&chap=14.php
†
If tap water is contaminated, use water that has been boiled for 10 minutes and filtered to remove
particulate matter (if necessary), or use chlorinated water—water treated with a dilute bleach solution to
make the final concentration 0.001%.
*
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All cleaning agents should be removed from instruments and equipment by rinsing
prior to further processing.
Appropriate personal protective equipment should be used during cleaning.
Cleaning of instruments can be performed in each department, unit, and ward or in a
central sterilization department/area.
High-level disinfection (HLD)
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Any instrument or equipment that comes into
Definition
contact with non-sterile tissue (i.e., intact mucous
HLD is a process that
membranes or skin) should be high-level
eliminates nearly all
disinfected or sterilized before it is used.
microorganisms, except some
The method of HLD should be compatible with the
bacterial endospores, from
particular type of instrument or equipment.
inanimate objects by boiling,
All instruments and equipment should be
steaming, or using chemical
decontaminated, cleaned and dried prior HLD.
disinfectants.
HLD is not a sterilization process.
HLD should be done by boiling or steaming
instruments and other items for 20 minutes.
Chlorine, glutaraldehydes, formaldehyde and peroxide are routinely used as highlevel disinfectants. HLD is achieved by soaking the instruments and other items for
20 minutes in 2–4% glutaraldehyde solution, 8% formaldehyde solution, or 0.1%
chlorine solution. Instruments and other items should be rinsed with sterile or HLD
water after the process to washout the chemical residues.
Items should never be stored in disinfectants before or after any form of disinfection.
Procedures should be in place to ensure that handling, packaging, and storing
techniques prevent contamination of the item.
Some items and equipment do not require HLD (e.g., thermometers, stethescopes). In
these cases other disinfectants may be used. Ethyl and isopropyl (2-propyl) alcohol
(60–90%) are excellent disinfectants that are commonly available and inexpensive.
Their rapid killing action and lack of chemical residue makes them ideal for
disinfection of many medical items.
HLD should be performed in a central sterilization department or area.
Sterilization
Definition
Sterilization is a process that eliminates
all microorganisms (bacteria, viruses,
fungi and parasites) including bacterial
endospores from inanimate objects by
high-pressure steam (autoclave), dry heat
(oven), chemical sterilants or radiation.
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All instruments and equipment should be
decontaminated, cleaned, and dried prior
to sterilization.
The method of sterilization should be
compatible with the particular type of
instrument or equipment.
Any instrument or equipment used to
enter, or that is capable of entering,
sterile tissue or the vascular system of a
client, should be sterilized before it is used.
Microwaves ovens, pressure cookers, dishwashers, ultraviolet cabinets, ultrasonic
cleaners, and similar devices do not sterilize and therefore should not be used for this
purpose.
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If using steam sterilization:
 Observe recommended temperature, pressure and holding time. For most autoclaves
(unless otherwise recommended by the manufacturer) this would be:
 Temperature should be 121C (250F)
 Pressure should be 106 kPa (15 lbs/in2)
 Time should be 20 minutes for unwrapped items, 30 minutes for wrapped items
Otherwise, follow manufacture’s recommendations.
 Manufacture’s instructions for effective and safe use of the sterilizer should be visible
and followed at all times.
 All packed and wrapped instruments and equipment should be stored in a manner that
ensures sterility is maintained.
If using dry heat sterilization:
 Unless otherwise recommended by the manufacturer, recommended temperature and
times are as follows:
 Sterilize at 170C (340F) for 1 hour (total cycle time—placing instruments in
oven, heating to 170C, timing for 1 hour, and then cooling—is from 2–2.5
hours), OR
 Sterilize at 160C (320F) for 2 hours (total cycle time is from 3–3.5 hours).
 Manufacture’s instructions for effective and safe use of the sterilizer should be visible
and followed at all times.
 All packed and wrapped instruments and equipment should be stored in a manner that
ensures sterility is maintained.
If using chemical sterilization:
 Some high-level disinfectants will kill endospores after prolonged (10–24 hour)
exposure. Common disinfectants that can be used for chemical sterilization include
glutaraldehydes and formaldehyde. Sterilization takes place by soaking for at least 10
hours in 2–4% glutaraldehyde solution or at least 24 hours in 8% formaldehyde.
 Both glutaraldehydes and formaldehyde require special handling and leave a residue
on treated instruments; therefore, rinsing with sterile water is essential if the item
must be kept sterile.
 Manufacturer’s instructions for effective and safe use of the sterilizer should be
visible and followed at all times.
 All packed and wrapped instruments and equipment should be stored in a manner that
ensures sterility is maintained.
Sterilized items should be stored and handled in a manner that maintains the integrity of
packing materials, and prevents contamination of the contents. The content of any
sterilized package should be considered contaminated if the packaging is either damaged
or becomes wet. A stock rotation system, based on the expiration date of the sterilization,
should be implemented for all areas of the facility in which sterile supplies are stored.
Proper handling of soiled linen
Soiled linen should be touched as little as possible and should be collected in bags and
not rinsed or sorted at the patient care area. If possible, linen with large amounts of blood
should be transported in leak-proof containers and, if not available, they should be folded
with the soiled parts inside, and handled carefully with gloves. Soiled linen should be
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soaked in 0.5% chlorine solution for ten minutes, then washed separately in hot soapy
water and air-dried. If the linen is to be used in theatre, it should be sterilized.
Risk reduction in the obstetric setting
The potential for exposure to HIV-contaminated blood and body fluids is highest during
labour and delivery. Module 3, Specific Interventions to Prevent Mother-to-Child
Transmission of HIV (PMTCT), includes recommendations for safer obstetric practices
designed to minimize this risk.
In labour and delivery settings, HCWs 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
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Wash hands.
Cover broken skin or open wounds with watertight dressings.
Wear suitable gloves when exposure to blood or body fluids is likely.
Wear a waterproof plastic apron during delivery.
Cover the cord with gloved hand or gauze before cutting.
Use gloves during manual removal of a placenta.
When possible, wear gloves for all operations.
When possible, wear an eye shield during episiotomy and suturing.
Use needle holders when suturing.
Pass all sharp instruments on to a tray, rather than hand-to-hand.
When episiotomy is necessary, use an appropriate-sized needle (21 gauge, 4 cm,
curved) and needle holder during the repair.
If blood splashes on skin, immediately wash the area with soap and water. If splashed
in the eye, wash the eye with water only. If blood splashes on the floor, wash it using
chlorine solution.
Dispose of solid waste (e.g., blood-soaked dressings and placentas) safely according
to local procedures.
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Exercise 9.1 Promoting a safe work environment resource list: group discussion
Purpose
To discuss the availability of safety resources and materials in our
programmes, and the type of risk reduction practices used
Duration
Instructions
15 minutes
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Refer to the Promoting a Safe Work Environment: Resource List
below.
The trainer will lead a group discussion on the availability of the
items in the resources list (below) as well as strategies when supplies
are short.
Exercise 9.1 “Promoting a safe environment” resource list
Personal protective equipment
 Gloves—various sizes
 Aprons or gowns
 Eyewear
 Footwear
 Waterproof dressings
Materials
 Cleaning and disinfecting agents
 Equipment for sterilization
 Sharps disposal containers
 Waterproof waste containers for contaminated items
 Alcohol-based hand rubs or antimicrobial soap
Safety standards
 Policies on use of Universal Precautions
 Procedures for disposal of infectious or toxic waste
 Procedures for sterilization of equipment
 Policies on handling and disposal of sharps
 Protocols for management of PEP, including antiretroviral (ARV) medications and
hepatitis B immunisation
 Procedures for minimizing exposure to infection in high-risk settings, such as labour
and delivery
Education
 New employee orientation to infection prevention procedures
 Ongoing training to build skills in safe handling of equipment
 Monitoring and evaluation of safety practices to assess implementation and remedy
deficiencies
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Exercise 9.2 Reducing HIV transmission risk in MCH settings: case study
Purpose
To review the application of Universal Precautions in a high-risk setting
Duration
45 minutes
Instructions
The trainer will lead a discussion of the case study (below) focusing on
the Universal Precautions principles that apply.
Case study
Nachisale arrives at the labour and delivery unit of your local hospital. She hands you her
Health Passport 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 vaginal
examination and estimate that Nachisale has at least 2 more hours until delivery.
 What are some Universal Precautions that you, as a HCW, should take when
examining Nachisale?
 Should HCWs use gloves when caring for clients who are HIV-infected?
 Does your clinical protocol require HCWs to use gloves when caring for clients 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 and antiseptics for use in the labour ward in good supply?
 What do we know about the relationship between MTCT and vaginal examinations
for pregnant HIV-infected women?
Nachisale 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 cut the cord, wipe and wrap the baby, then hand
the baby to the mother or a gloved assistant. Then the placenta is delivered.
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Itemize 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?
Nachisale was your 30th 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.
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Why is it important that you not stay and not continue to work tonight?
In your facility, do you have someone who will help you find staffing relief if
needed?
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UNIT 3
Managing Occupational Exposure to HIV
After completing the unit, the participant will be able to:
 Describe the management of occupational exposure to HIV.
 Outline the National PEP regimen.
Managing occupational exposure to HIV infection
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 an HIV-infected client. The data that support this estimate were not
collected in resource-limited settings. It is likely that in resource-limited settings the risk
is higher because there are more clients with undiagnosed HIV infection, more clients
with higher viral loads and with advanced HIV or AIDS, and less protective equipment
available. The risk of HIV transmission from exposure to other infected fluids or tissues
is believed to be lower than from exposure to infected blood.
Risk of exposure from needle-sticks and contact with blood and body fluids exists in
settings where:
 Safe needle procedures and Universal Infection Prevention 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 client population are high.
To minimize the need for PEP, national strategies for education and training in
healthcare waste management are necessary.
Benefits of making PEP available for HCWs:
 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 HCWs
A comprehensive PEP protocol outlines the methods for preventing occupational
exposure to HIV and other bloodborne pathogens.
National PEP protocol
Occupational exposure may place a HCW at risk of HIV infection. Needle-stick injury is
the most common occupational exposure, although exposure to other body fluids such as
pleural, pericardial, ascitic, amniotic, synovial, cerebral spinal fluids, semen, and vaginal
secretions pose a risk for HIV infection as well.
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The overall risk of HIV infection from occupational exposure is relatively low. For
example, from needle-sticks the overall risk of becoming HIV-infected is 1 in 300. From
mucous membrane exposure it is less than 1 in 1000.
PEP: low risk and high risk
“PEP” refers to treatment of the HCW who has experienced an occupational exposure
using ARV drugs. ARV therapy started immediately after exposure to HIV may prevent
HIV infection, although this protection is not 100% effective. Treatment should be
initiated within 1-2 hours of exposure, but if there are delays, PEP can still be started up
to 72 hours after the exposure.
For the purposes of intervention, the HIV exposure is classified as either low risk or high
risk.
 High risk exposures: Percutaneous injuries with hollow needles and a large volume
of blood onto a mucosal surface from a source person who is known to be HIVseropositive, or a strong suspicion that the source is HIV-seropositive.
 Low risk exposures: All other exposures, including percutaneous injuries with solid
needles, exposures to fluids other than blood, and exposures to non-intact skin.
Exposure of blood or other fluids to intact skin is not a risk in this context and does not
require PEP.
Although there are several options for PEP, it is critical that healthcare workers minimize
their risk of exposure to HIV infection. Therefore, all body fluids should be considered
potentially infectious and it is important to follow all Universal Precautions.
What to do after occupational exposure
First aid and other immediate measures:
 The aim of first aid is to reduce contact time with the source person’s blood or body
fluid and to decontaminate the site of the exposure to reduce the risk of infection.
 Use soap and water to rinse any wound or skin site in contact with infected blood or
fluid.
 Rinse exposed mucous membranes thoroughly with water.
 Irrigate generously any open wound with sterile saline or disinfectant solution (2-5
minutes).
 Irrigate eyes with clear water, saline, or sterile eye irrigants.
 Report exposure to the clinician on duty as soon as possible.
Operational considerations:
 Each health facility should keep a bottle of AZT+3TC (Duovir®) (60 tablets) in an
agreed designated unit for easy but secure access.
 Following occupational exposure, a HCW should immediately report the exposure to
the senior member of his/her unit and to the designated PEP location where initial risk
assessment will be done.
 A 3 day supply of AZT+3TC will be given and the HCW should begin the PEP
regimen as soon as possible after the exposure. (See PEP regimen below.)
 HCWs must be counselled about ARV side effects. Side effects should be monitored
clinically, and laboratory tests (e.g., haemoglobin measurements for zidovudine)
conducted if indicated.
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The source client
 The HIV status of the source client should be determined whenever possible. If the
source client is HIV-positive, then PEP is indicated.
 If the source client is HIV-negative, this may be because the source client is in the
“window period” of HIV-infection or may be in hospital because of primary HIV
infection. Specialist advice may be sought about the need to continue or stop PEP,
but in general the advice will be to continue the PEP because of the risk.
The HCW
 The HCW must be strongly encouraged to undergo HIV testing and counselling
immediately or, if that is not possible, within 72 hours of exposure.
 If the HCW is HIV-positive, then PEP is not necessary and should be stopped,
administration of two therapies may lead to the development of drug resistance.
 HCWs diagnosed as HIV-positive need to be assessed for eligibility for ART.
 The HCW who tests HIV-negative should receive follow-up HIV testing 3 and 6
months after the exposure. If the HIV test is negative at 6 months, the HCW can be
counselled that he/she has not been infected with HIV as a result of the exposure.
The PEP regimen
Drug
Zidovudine (AZT) 300mg/Lamivudine
(3TC) 150mg (Duovir)
Dose
One tablet
Frequency
Twice a day
(BD)
Duration
30 days
Duovir (a dual NRTI therapy) should be available at every health facility and at central
medical stores. In cases of high risk exposure or when the source client is already on
ART, lopinavir/ritonavir (a protease inhibitor) three capsules twice a day can be added to
the Duovir therapy: specialist advice is necessary in these cases.
Guidelines for providing PEP
Monitoring and management of PEP toxicity
If PEP is used, HCWs should be monitored for drug
toxicity by laboratory testing at baseline and again 2
weeks after starting PEP. Some HCWs 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.
The scope of monitoring should be based on medical
conditions in the exposed person and the toxicity of drugs
in the PEP regimen. Ideally, laboratory monitoring for toxicity should include a complete
blood count and renal and hepatic function tests.
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.
PMTCT services should support workers while they are taking PEP and help manage any
side effects.
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Exercise 9.3 PEP case study: small-group discussion
Purpose
To review implementation of PEP protocols
Duration
30 minutes
Instructions




Participants will be divided into three groups.
Refer to the PEP case study: Nurse Mary (below).
Each small group will have 20 minutes to read the case study and
record on paper the step-by-step implementation of the PEP
protocol.
Share each step in the process with the larger group as directed by
the trainer.
Case Study
Nurse Mary is working late in the labour and delivery unit. When removing an
intravenous needle from the arm of a client who is in labour, Nurse Mary accidentally
punctures her finger.
After this occupational exposure, what is the very first thing Nurse Mary should do?
List each subsequent step according to protocol.
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UNIT 4
Supportive Care for the Carer
After completing the unit, the participant will be able to:
 Identify personal strategies to manage burnout.
Care for the carer
Burnout
HCWs who provide ongoing care of pregnant women who are HIV-infected (or whose
HIV status is unknown) and their infants, are vulnerable to “burnout.” Burnout syndrome
stems from extended exposure to intense job-related stress and strain. Burnout syndrome
is characterized by:
 Emotional exhaustion: feelings of helplessness, depression, anger, and impatience
 Depersonalisation: detachment from the job and an increasingly cynical view of
clients 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
 Frequent changes in mood
 Eating too much or too little
 Drinking alcohol and/or smoking too
much
 Becoming “accident prone”
Cognitive
 Unable to make decisions
 Forgetful, poor concentration
 Sensitive to criticism
Physical
 High blood pressure
 Palpitations, trembling
 Dry mouth, sweating
 Stomach upset
Occupational
 Taking more days off
 Arguing 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
 Unrealistic goals and job expectations
 Low self-esteem
 Anxiety
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
Caring for clients with a fatal disease
Personal strategies for minimizing or preventing burnout syndrome
 Seek support from others
 Take care of yourself
 Engage in restorative activities, such as reading and exercising
Tips for managing burnout




Find or establish a support group of
peers. This could include establishing a
link with existing networks such as the
VCT centre.
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.
Link with social groups, social
functions or services that can provide
support.
Where possible, delegate some workrelated responsibilities to colleagues.
Exercise 9.4 Burnout in the PMTCT service:
large group discussion
Purpose
To examine factors that contribute to burnout and develop creative
prevention strategies
Duration
30 minutes
Instructions


In the large group, discuss your answers to the questions below.
Feel free to share stories and personal experiences about burnout
with the group and consider ways to address burnout.
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Exercise 9.4 Burnout in the PMTCT service,
Questions for discussion








What is the greatest daily challenge in your clinical setting?
Comment on staffing for testing and counselling at your facility. Are there enough
counsellors? What are the training requirements?
Does your facility orient staff to the workplace?
Does your facility meet staffing requirements?
Does your DHO and/or organization e.g. CHAM provide ongoing education to ensure
adequate, updated skills?
Does your organization ensure that staff have all the necessary supplies and
materials?
Does your facility support and assist staff?
 Is there someone you can turn to help you with your workplace concerns?
 Are you connected to community services that make your job easier?
 Do you have your own source of peer support? Who are your supporters?
 Do you use your own stress-reduction techniques that work well for you?
 What are three things that would make your job easier?
Share your personal experiences about burnout in your clinical setting with the larger
group.
Module 9: Key Points





Creating a safe work environment involves practising:
 Universal Precautions
 Management of the work environment
 Ongoing education of employees in all aspects of infection prevention
Universal Precautions apply to all clients, regardless of diagnosis. Key components
include:
 Hand washing
 Use of personal protective equipment
 Decontamination of equipment
 Safe handling and disposal of sharps
 Safe disposal of infectious waste materials
 Safe environmental practices
Decontaminated, cleaning, high-level disinfection, and/or sterilized of all instruments
used in invasive procedures reduce risk of transmission of infection.
Post-exposure prophylaxis (PEP) is short-term antiretroviral prophylaxis that reduces
the risk of HIV infection after occupational exposure. The regimen (one tablet of
Duovir twice a day for 30 days) should be started within 1-2 hours of exposure.
Burnout is related to intense, prolonged job stress but can be managed, even
prevented through personal strategies, particularly if there is organizational support.
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APPENDIX 9-A Guidelines for decontamination, cleaning, sterilization
and disposal of infectious waste materials
Category
Application
Example
Final Process
Required
Critical
Instruments and equipment
which enter, or are capable of
entering, tissue that would be
sterile under normal
circumstances or the vascular
system
Instruments and equipment
which come into contact with
non-sterile tissue (intact
mucous membranes or
broken skin)
Instruments and equipment
which come in contact with
intact skin
Surgical instruments,
injection needles, dental
hand pieces, surgical
gloves, etc.
Sterilization
Vaginal specula, mouth
shutters, respiratory
therapy equipment,
colonoscopies, etc.
Disinfection
Bedpans, linen, beds,
stethoscopes, etc.
Cleaning
Semi-critical
Non-critical
Decontamination
Process that makes inanimate objects safer to be handled by staff before cleaning (i.e.,
inactivates HBV, HBC and HIV and reduces, but does not eliminate, the number of other
contaminating micro-organisms). Decontamination should be the first step in processing
soiled (contaminated) surgical instruments, gloves and other items, especially if they
should be cleaned by hand.
Decontamination should be done by soaking contaminated items for 10 minutes in 0.5%
chlorine solution, or other locally available disinfectants. Larger surfaces, such as
examination and operating tables, laboratory bench tops and other equipment that may
have come in contact with blood or other body fluids also should be decontaminated by
wiping with a suitable disinfectant (e.g., 0.5% chlorine solution or 1–2% phenol).
Decontamination should be done at point of use in each department, unit or ward,
immediately after the procedure.
Cleaning
Process that physically removes all visible dust, soil, blood or other body fluids from
inanimate objects as well as removing sufficient numbers of micro-organisms to reduce
risks for those handling the object. It consists of thoroughly washing with soap or
detergent and water, rinsing with clean water and drying.‡ Any instrument or equipment
that comes into contact with intact skin should be cleaned before it is used. Any
instrument or equipment should be thoroughly cleaned before further processing
‡
If tap water is contaminated, use water that has been boiled for 10 minutes and filtered to remove
particulate matter (if necessary), or use chlorinated water—water treated with a dilute bleach solution to
make the final concentration 0.001%.
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APPENDIX 9-A Guidelines for decontamination, cleaning, sterilization
and disposal of infectious waste materials (continued)
(sterilization or disinfection) and all cleaning agents should be removed from instruments
and equipment by rinsing prior to further processing. Cleaning of instruments can be
performed in each department, unit, and ward or in a central sterilization department/area.
High Level Disinfection (HLD)
Process that eliminates all micro-organisms except some bacterial endospores from
inanimate objects by boiling, steaming or the use of chemical disinfectants. Any
instrument or equipment that comes into contact with non-sterile tissue should be highlevel disinfected or sterilized before it is used. The method of HLD should be compatible
with the particular type of instrument or equipment. All instruments and equipment
should be decontaminated, cleaned and dried prior to HLD. HLD is not a sterilization
process and should be done by boiling or steaming instruments and other items for 20
minutes.
Chlorine, glutaraldehydes, formaldehyde and peroxide—are routinely used as high-level
disinfectants. HLD takes place by soaking the instruments and other items for 20 minutes
in 2–4% glutaraldehyde solution, 8% formaldehyde or 0.1% chlorine solution.
Instruments and other items should be rinsed with sterile or HLD water after the process,
to washout the chemical residues. Disinfection of instruments can be performed in each
department, unit, or ward.
Sterilization
Process that eliminates all micro-organisms (bacteria, viruses, fungi and parasites)
including bacterial endospores from inanimate objects by high-pressure steam
(autoclave), dry heat (oven), chemical sterilants or radiation. Any instrument or
equipment used to enter sterile tissue or the vascular system of a client should be
sterilized before it is used. The method of sterilization should be compatible with the
particular type of instrument or equipment.
If using dry heat sterilization:
170C (340F) for 1 hour (total cycle time—placing instruments in oven, heating to
170C, timing for 1 hour, and then cooling—is from 2–2.5 hours), or 160C (320F) for 2
hours (total cycle time is from 3–3.5 hours). Otherwise manufacture’s recommendations
should be followed.
If using chemical sterilization:
Some high-level disinfectants will kill endospores after prolonged (10–24 hour) exposure.
Common disinfectants that can be used for chemical sterilization include
glutaraldehydes and formaldehyde. Sterilization takes place by soaking for at least 10
hours in 2–4% glutaraldehyde solution or at least 24 hours in 8% formaldehyde.
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APPENDIX 9-A Guidelines for decontamination, cleaning, sterilization
and disposal of infectious waste materials (continued)
Waste segregation
The doctor, nurse or any other person generating waste should separate hazardous waste
from non-hazardous waste at the ward bedside, operation theatre, laboratory or any other
room in the hospital where waste is generated. Disposable medical equipment and
supplies like syringes, needles, plastic bottles; drips etc should be cut or broken and
rendered non- reusable at the point of use by the person using them. Sharps including the
cut or broken syringes and needles should be placed in safety boxes resistant to
penetration and leakage and these containers should be designed in such a way that the
items can be dropped into them by using one hand. Chemical waste and waste with high
content of mercury or cadmin should not be incinerated but should be placed in chemical
resistant containers and sent to specialized treatment facilities.
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APPENDIX 9-A Guidelines for decontamination, cleaning, sterilization
and disposal of infectious waste materials (continued)
Waste storage
A separate central storage facility should be provided for hazardous waste at each health
facility and be inaccessible to unauthorized persons. A hazardous waste central storage
area should have a sign clearly mentioning that the facility stores hazardous waste. The
waste should be put in an appropriately colour coded container. Containers with chemical
waste that are to be treated at a specialized treatment facility should be stored in a
separate room.
Waste treatment and disposal
Hazardous waste should be disposed of by burning in an incinerator or by burial in a
landfill. Radioactive waste should be disposed by encapsulation. Sharps containers not
placed in yellow bags for incineration should be disposed of by encapsulation or any
other method approved by Malawi Bureau of standards. Disposal methods (burning or
incineration, burial in landfill) should be operated by a hospital after approval of its
Environmental Impact Assessment by MNREA. All hazardous waste delivered to an
incinerator should be burned within 24 hrs. Landfills for health care waste treatment
should be located at sites with minimum risk of pollution of groundwater and rivers.
Access to the site should also be restricted to authorized personnel only. All liquid
hazardous waste should be discharged into a sewerage system only after being properly
treated and disinfected.
Accidents and spillages
In case of accidents or spillage, the following actions should be taken
A. The contaminated area should be immediately evacuated.
B. The contaminated area should be cleared or disinfected.
C. Exposure of the staff should be limited to the extent possible during the clean
up operation and appropriate immunization carried out
D. Any emergency equipment used should be immediately replaced in the same
location from which it was taken.
All health staff members should be properly trained and prepared for emergency response
including procedures for treatment of injuries cleaning up of the contaminated area and
all incidents of accidental spillage reported appropriately.
Source: Ministry of Health, Malawi, October 2004. Infection Prevention and Control Policy: Draft for
Review.
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APPENDIX 9-B Post-exposure prophylaxis after sexual assault
Rape is commonly associated with assault and genital tract trauma, which increases the
risk of HIV transmission. A rapid HIV test must be conducted after counselling, and the
victim should be provided with the test results.
Eligibility criteria for PEP
Eligible
Not eligible
Persons who present with a history of rape
within the previous 72 hours, with a history
of penetration, regardless of ejaculation
Victim tests HIV-negative on initial testing
Person who presents more than 72 hours
after rape
Victim consents to PEP
Victim tests HIV-positive on initial testing
(refer to HIV care & support)
Victim does not consent to PEP
The eligible victim should be given PEP regardless of the sero-status of the assailant, as
the assailant may be in the window period during time of a negative test outcome.
Operational considerations:
1) When managing a rape victim, a HCW should assess eligibility for PEP and provide a
30 day supply of PEP to the victim.
2) The victim must be advised to use condoms until 6-months have elapsed and the
victim is then found to be HIV-negative.
3) If a victim on PEP is experiencing side effects such as dizziness, fatigue or parlour,
she should return to the health facility for further assessment.
4) The victim should return at 3 months and 6 months for repeat HIV testing. If the HIV
test remains negative at 6 months, the victim can be counselled that she has not been
infected with HIV as a result of the exposure. If the victim is found to be HIV
infected during follow up, she should be referred for HIV care & support.
5) It is recommended that a baseline Haemoglobin (HB) reading should be determined
before victims commence PEP therapy, because of the possible occurrence of
anaemia due to AZT. If a victim has a HB ≤ 8 mg/ml, Duovir should be replaced with
Lamivir S.
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APPENDIX 9-B Post-exposure prophylaxis after sexual assault
(continued)
The PEP regimen
Drug
Zidovudine (AZT) 300mg/
Lamivudine (3TC) 150mg
Dose
Frequency
Duration
(Also
known as
Duovir)
One tablet
Twice a day
(BD)
30 days
(Also
known as
Lamivir S)
One tablet
Twice a day
(BD)
30 days
OR ELSE
Stavudine (D4T) 40 mg /
Lamivudine (3TC) 150 mg
PEP therapy should be available at every health facility and at central medical stores.
Recommended HIV serology after exposure
Baseline (Day zero)
Within 72 hours of
exposure
Follow-up 2
Three months
Follow-up 3
Six months
If the victim is found to already be HIV-seropositive, then PEP should not be started
(or discontinued if started already), and appropriate counselling and clinical referral
should made.
Counselling on abstinence, use of condoms and drug compliance should be emphasized,
and victims should be fully equipped with the information on drug side effects.
Follow up visits
Follow-up is always necessary in order to identify issues which might have been missed
on the initial visit and to identify other infections that have long incubation period e.g.
syphilis, hepatitis B, HIV. Follow up visit is recommended at 2 weeks post assault. If the
client has been given PEP, a HIV test; including post test counselling is recommended to
be conducted at three months and 6 months post assault.
Source: Ministry of Health, Malawi, 2006. Sexual Assault and Rape Guidelines.
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References
Ministry of Health, Malawi. April 2006. Treatment of AIDS: Guidelines for the Use of Antiretroviral
Therapy in Malawi.
Ministry of Health, Malawi, October 2004. Infection Prevention and Control Policy: Draft for Review.
Resources
Key Resources:
CDC. 1996. Exposure to blood—what health-care workers need to know. CDC: Atlanta. Retrieved 15
February 2006 from http://www.cdc.gov/ncidod/dhqp/pdf/bbp/Exp_to_Blood.pdf.
Department of Health &Human Services and CDC. 2005. Updated U.S. Public Health Service Guidelines
for Management of Occupational Exposure to HIV and Recommendations for Postexposure
Prophylaxis. CDC: Atlanta. MMWR Morb Mortal Wkly Rep 54(No. RR-9): 1–42 Retrieved 15
February 2006, from http://www.ucsf.edu/hivcntr/Clinical_Resources/PEPGuidelines.html
WHO. 2001. Best infection control practices for intradermal, subcutaneous, and intramuscular needle
injections. WHO: Geneva. Retrieved 15 February 2006 from
http://whqlibdoc.who.int/bulletin/2003/Vol81-No7/bulletin_2003_81(7)_491-500.pdf
CDC. 2001. U.S. Public Health Service Guidelines for the Management of Occupational Exposures to
HBV, HCV and HIV and Recommendations for Postexposure Prophylaxis. CDC: Atlanta. MMWR
Morb Mortal Wkly Rep 50(No. RR-11): 1–42 Retrieved 15 February 2006, from
http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf.
Israel, E and M Kroeger. 2003. Integrating prevention of mother-to-child transmission into existing
maternal, child, and reproductive health programs. Pathfinder International: Watertown, MA,. pp
9–11. Retrieved 15 February 2006, from
http://www.pathfind.org/site/DocServer/Technical_Guidance_Series_3_PMTCTweb_01.pdf?docI
D=242.
Mountain Plains AIDS Education & Training Center in Consultation with the National Clinicians’
Postexposure Prophylaxis (PEP) Hotline. 2002. PEP steps: A quick guide to postexposure
prophylaxis in the health care setting. Mountain Plains AIDS Education & Training Center:
Denver.
Tietjen, L, D Bossemeyer, et al. 2003. Infection Prevention Guidelines for Healthcare Facilities with
Limited Resources. [electronic version]. JHPIEGO Baltimore, MD. Retrieved 15 February 2006,
from http://www.reproline.jhu.edu/english/4morerh/4ip/IP_manual/ipmanual.htm.
UCSF Center for AIDS Prevention Studies. 1997. Fact sheet: What is post-exposure prevention (PEP)?
[electronic version]
UCSF Center for AIDS Prevention Studies: San Francisco. Retrieved 15 February 2006, from
http://www.caps.ucsf.edu/PEP.html.
WHO. 2004. Post-exposure prophylaxis. WHO: Geneva. Retrieved 15 February 2006, from
http://www.who.int/hiv/topics/prophylaxis/en/index.html.
WHO. Draft. Guidelines for the use of HIV post exposure prophylaxis after occupational exposure to blood
or body fluids or tissues, WHO.
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