Difference between revisions of "AY Honors/Home Nursing/Answer Key"

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[[Image:SchoolchildrenWashingHands.jpg|right|thumb|Schoolchildren washing their hands before eating lunch.]]
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'''Infection control and health care epidemiology'''
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'''Hand washing''' is the act of [[cleaning|cleansing]] the [[hand]]s with [[water]] or other [[liquid]], with or without the use of [[soap]] or other [[detergent]]s, for the purpose of removing [[soil]] or [[microorganism]]s.
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is the discipline concerned with preventing the spread of infections within the health-care setting.
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As such, it is a practical (rather than an academic) sub-discipline of [[epidemiology]].
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It is an essential (though often underrecognized and undersupported) part of the infrastructure of health care.
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Infection control and hospital epidemiology are akin to [[public health]] practice, practiced within the confines of a particular health-care delivery system rather than directed at society as a whole.
  
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==Purpose==
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Infection control concerns itself both with prevention (hand hygiene/hand washing, cleaning/disinfection/sterilization, vaccination, surveillance) and with investigation and management of demonstrated or suspected spread of infection within a particular health-care setting (e.g. outbreak investigation). It is on this basis that the common title being adopted within health care is '''"Infection Prevention & Control".
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[[Image:Fingerprint.jpg|left|thumb|An example of how minuscule particles can be caught between dermal ridges in the hand, yet remain unseen by the naked eye. Washing one's hands removes such contaminants.]]
 
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The main purpose of washing hands is to cleanse the hands of [[pathogen]]s (including [[bacterium|bacteria]] or [[virus]]es) and chemicals which can cause personal harm or disease. This is especially important for people who handle food or work in the medical field. The Centers for Disease Control and Prevention (CDC) has stated that “It is well-documented that the most important measure for preventing the spread of of pathogens is effective handwashing.
 
  
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While hot water may more effectively clean your hands, this is primarily due to its increased capability as a solvent, and not due to hot water actually killing germs. Hot water is more effective at removing dirt, oils and/or chemicals, but contrary to popular belief, it does not kill micro organisms. A temperature that is comfortable for hand washing (about 45 °C) is not nearly hot enough to kill any micro organism.  It would take more than double that temperature to effectively kill germs (100 °C, which is boiling).
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==Infection control in healthcare facilities==
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===Hand hygiene===
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Independent studies by [[Ignaz Semmelweis]] in [[1847]] in [[Vienna]] and [[Oliver Wendell Holmes, Sr.|Oliver Wendell Holmes]] in [[1843]] in [[Boston]] established a link between the hands of health care workers and the spread of [[Nosocomial<ref>Nosocomial was derived from two Greek words Nosos (disease) and Komeion (to take care of)</ref> infection|hospital-acquired]] disease.<ref>[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm CDC Guideline for Hand Hygiene in Health-Care Settings]</ref> The [[Centers for Disease Control and Prevention|Centers for Disease Control and Prevention (CDC)]] has stated that “It is well-documented that the most important measure for preventing the spread of of pathogens is effective handwashing.” <ref>[http://www.cdc.gov/nceh/vsp/cruiselines/hand_hygiene_general.htm CDC General information on Hand Hygiene]</ref> [[Hand washing#Medical hand washing|Hand washing]] is mandatory in most health care settings and required by many different state and local regulations as well as good sense.  
  
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==Personal hand washing==
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[[Occupational Safety and Health Administration|Occupational Safety and Health Administration (OSHA)]] standards<ref>[http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051 OSHA Bloodborne Pathogens Regulations 1910.1030]</ref> require that employers must provide readily accessible hand washing facilities, and must ensure that employees wash hands and any other skin with soap and water or flush mucous membranes with water as soon as feasible after contact with blood or other potentially infectious materials (OPIM).
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To maintain good [[hygiene]], hands should always be washed after using the toilet, changing a diaper or tending to someone who is sick; before eating; before handling or cooking food and after handling raw meat, fish or poultry. Conventionally, the use of soap and warm running water and the washing of all surfaces thoroughly, including under fingernails is seen as necessary. One should rub wet, soapy hands together outside the stream of running water for at least 20 seconds, before rinsing thoroughly and then drying with a clean or disposable towel<ref>[http://www.mayoclinic.com/health/hand-washing/HQ00407 Hand washing] from [[Mayo Clinic]]</ref>. After drying a dry paper towel should be used to turn off water and open exit door.  Moisturizing [[lotion]] is often recommended to keep the hands from drying out, should one's hands require washing more than a few times per day. <ref>[http://www.tufts.edu/med/apua/Patients/handwashing.html Hand washing] from [[Tufts University]]</ref>
 
  
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Antibacterial soaps have been heavily promoted to a health-conscious public.  To date, there is no evidence that using recommended antiseptics or disinfectants selects for antibiotic-resistant organisms in nature.<ref>Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America. (Infect Control Hosp Epidemiol) 2006 Oct; 27(10): 1107-19
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===Cleaning, disinfection and sterilization===
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</ref>  However, antibacterial soaps contain common antibiotics such as [Triclosan], which has an extensive list of resistant strains of organisms.  So, even if antibacterial soaps do not select for antibiotic resistant strains, they might not be as effective as they are marketed to be.  These soaps are quite different from the non-water-based hand hygiene agents referred to below, which also do not promote [[antibiotic resistance]]<ref>[http://www.cdc.gov/cleanhands/ Clean hands] from the [[Centers for Disease Control and Prevention|CDC]]</ref>.
 
  
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==Medical hand washing==<!-- This section is linked from [[Ignaz Semmelweis]] -->
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Cleaning, [[disinfection]] and [[sterilization (microbiology)|sterilization]]...
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The purpose of hand washing in the health care setting is to remove or destroy (disinfect) [[pathogens|pathogenic microorganisms]] ("germs" in common parlance) to avoid transmitting them to a patient.  The application of water alone is ineffective for cleaning skin because water is unable to remove fats, oils, and proteins, which are components of organic soil. Therefore, removal of microorganisms from skin requires the addition of soaps or detergents to water. Plain soap does not kill [[pathogen]]s. However, the addition of antiseptic chemicals to soap ("medicated" or "antimicrobial" soaps) does confer killing action to a hand washing agent.Such killing action may be desired prior to performing surgery or in settings in which antibiotic-resistant organisms are highly prevalent.<ref>[http://www.who.int/patientsafety/events/05/HH_en.pdf WHO Guidelines on Hand Hygiene in Health Care]</ref>
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{{sect-stub}}
  
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The proper washing of hands in a [[medicine|medical]] setting generally consists of the use of generous amounts of soap and water to lather and rub each part of ones hands systematically for 15 to 20 seconds. Hands should be rubbed together with digits interlocking. If there is debris under fingernails, a bristle brush is often used to remove it. Finally, it is necessary to rinse well and wipe dry with a paper towel. After drying, a dry paper towel should be used to turn off water and open exit door.
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===Personal protective equipment===
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[[Image:Disp-med-ppe.jpg|thumb|120px|Disposable PPE]]
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[[Personal protective equipment|Personal protective equipment (PPE)]] is specialized clothing or equipment worn by a worker for protection against a hazard. The hazard in a health care setting is exposure to blood, saliva, or other bodily fluids or aerosols that may carry infectious materials such as [[Hepatitis C]], [[HIV]], or other blood borne or bodily fluid [[pathogen]]. PPE prevents contact with a potentially infectious material by creating a physical barrier between the potential infectious material and the healthcare worker.  
  
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To 'scrub' one's hands for a [[surgery|surgical operation]], one requires a tap that can be turned on and off without touching with the hands, some [[chlorhexidine]] or [[iodine]] wash, sterile towels for drying the hands after washing, a sterile brush for scrubbing and another sterile instrument for cleaning under the fingernails. All jewellery should be removed. This procedure requires washing the hands and forearms up to the elbows, and one must in this situation ensure that all parts of the hands and forearms are well scrubbed several times. When rinsing, it is ensured at all times that one does not allow water to drip back from the elbow to your hands. When done hands are dried with the sterile cloth and the surgical gown is donned.
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The [[Occupational Safety and Health Administration|Occupational Safety and Health Administration (OSHA)]] requires the use of [[Personal protective equipment|Personal protective equipment (PPE)]] by workers to guard against blood borne pathogens if there is a reasonably anticipated exposure to blood or other potentially infectious materials. <ref>[http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051#1910.1030(d)(2)(i) OSHA Bloodborne Pathogens Regulations 1910.1030(d)(2)(i)]</ref> 
  
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In the late 1990s and early part of the 21st century, non-water-based hand hygiene agents (also known as alcohol-based hand rubs, antiseptic hand rubs, or hand sanitizers) began to gain popularity.  Most are based on [[isopropyl alcohol]] or [[ethanol]] formulated together with a humectant such as glycerin into a gel, liquid, or foam for ease of use and to decrease the drying effect of the alcohol. The increasing use of these agents is based on their ease of use, rapid killing activity against microorganisms, and lower tendency to induce irritant contact dermatitis as compared to soap and water hand washing. Despite their effectiveness, the non-water agents do not clean hands of organic material, they simply disinfect them. However, disinfection does prevent transmission of infectious microorganisms.
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Components of [[Personal protective equipment|Personal protective equipment (PPE)]] include [[Medical gloves|gloves]], [[Hospital gown|gowns]], bonnets, shoe covers, [[Face shield|face shields]], [[CPR mask|CPR masks]], [[Goggles|goggles]], [[Surgical mask|surgical masks]], and respirators. How many components are used and how the components are used is often determined by regulations or the infection control protocol of the facility in question. Many or most of these items are [[Disposable|disposable]] to avoid carrying infectious materials from one patient to another patient and to avoid difficult or costly [[Disinfection|disinfection]]. [[Occupational Safety and Health Administration|OSHA]] requires the immediate removal and disinfection or disposal of worker's PPE prior to leaving the work area where exposure to infectious material took place.<ref>[http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051#1910.1030(d)(3)(vii) OSHA 1910.1030(d)(3)(vii)]</ref>
  
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Visible soiling of any sort on the hands must be washed with soap and water because alcohol-based hand rubs are ineffective in the presence of organic material. In addition, alcohols are ineffective against non-lipid-enveloped viruses (e.g., Noroviruses) and the spores of bacteria (e.g., Clostridium difficile) and protozoa (e.g., Giardia lamblia). When such microorganisms are likely to be encountered, soap and water hand washing is preferable.  
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===Vaccination of health care workers===
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Health care workers may be exposed to certain infections in the course of their work.   [[Vaccine|Vaccines]] are available to provide some protection to workers in a healthcare setting. Depending on regulation, recommendation, the specific work function, or personal preference, healthcare workers or first responders may receive vaccinations for [[Hepatitis_B#Prevention|hepatitis B]]; [[Flu vaccine| influenza]]; [[MMR vaccine|measles, mumps and rubella]]; [[TDaP|Tetanus, diphtheria, pertussis]]; [[Neisseria_meningitidis#Vaccines|N. meningitidis]]; and  [[Varicella vaccine|varicella]]. In general, [[Vaccine|vaccines]] do not guarantee complete protection from disease, and there is [[Vaccine#Potential_for_adverse_side_effects_in_general|potential]] for adverse effects from receiving the vaccine. <ref>[http://www.cdc.gov/node.do/id/0900f3ec8005df1f CDC Vaccine Site]</ref>
  
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===Surveillance for emerging infections===
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Surveillance is the act of infection investigation using the CDC definitions.  Determining an infection requires an ICP to review a patient's chart and see if the patient had the signs and symptom of an infection.  Surveillance definition cover infections of the bloodstream, Urinary tract, pneumonia, and sugical sites.
  
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The [[New England Journal of Medicine]] reports that hand washing remains at unacceptable levels in most medical environments, with large numbers of doctors and nurses routinely forgetting to wash their hands before touching patients.<ref>{{cite journal |quotes= |last=Goldmann |first=Donald  |authorlink= |coauthors= |year=2006 |month=July |title=System Failure versus Personal Accountability — The Case for Clean Hands |journal=[[New England Journal of Medicine]] |volume=355 |issue=2 |pages=121-123 |id= |url=http://171.66.123.143/cgi/content/full/355/2/121 |accessdate=2007-01-05 }}</ref> One study has shown that proper hand washing and other simple procedures can decrease the rate of catheter-related bloodstream infections by 66 percent.<ref>{{cite journal |quotes= |last= Pronovost |first=Peter |authorlink= |coauthors=Dale Needham, M.D., Ph.D., Sean Berenholtz, M.D., David Sinopoli, M.P.H., M.B.A., Haitao Chu, M.D., Ph.D., Sara Cosgrove, M.D., Bryan Sexton, Ph.D., Robert Hyzy, M.D., Robert Welsh, M.D., Gary Roth, M.D., Joseph Bander, M.D., John Kepros, M.D., and Christine Goeschel, R.N., M.P.A |year=2006 |month=December |title=An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU |journal=[[New England Journal of Medicine]] |volume=355 |issue=26 |pages=2725-2732 |id= |url=http://content.nejm.org/cgi/content/abstract/355/26/2725 |accessdate=2007-01-05 }}</ref>[http://www.technewsworld.com/story/54899.html]
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Surveillance traditionally involved significant manual data assessment and entry in order to assess preventative actions such as isolation of patients with an infectious disease. Increasingly, integrated computerised software solutions which actively assess each incoming risk message are becoming available. Such software significantly reduces the data workload of Infection Control Practitioners (ICP), freeing them to concentrate on clinical surveillance.  
  
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==Hand washing as compensation==
 
  
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Excessive hand washing is commonly seen as a symptom of [[obsessive-compulsive disorder]] (OCD).
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As approximately [http://www.cdc.gov/ncidod/eid/vol4no3/weinstein.htm one third of healthcare acquired infections are preventable] , surveillance and preventative activities are increasingly a priority for hospital staff. A study on the Efficacy of Nosocomial Infection Control Project (SENIC) by the CDC found that hospitals reduced their nosocomial infection rates by approximately 32 per cent by focusing on surveillance activities and prevention efforts.
  
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It has also been found that people, after having recalled or contemplated unethical acts, tend to wash hands more often than others, and tend to value hand washing equipment more. Furthermore, those who are allowed to wash their hands after such a contemplation are less likely to engage in other "cleansing" compensatory actions, such as volunteering.<ref>Benedict Carey. Lady Macbeth Not Alone in Her Quest for Spotlessness. ''[[The New York Times]]'', 12 September 2006</ref><ref>Chen-Bo Zhong and Katie Liljenquist. [http://www.sciencemag.org/cgi/content/abstract/313/5792/1451?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Liljenquist&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT Washing Away Your Sins: Threatened Morality and Physical Cleansing]. ''[[Science (journal)|Science]], 8 September 2006:
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==Outbreak investigation==
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Vol. 313. no. 5792, pp. 1451 - 1452</ref>
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When an unusual cluster of illness is noted, infection control teams  undertake an investigation to determine whether there is a true outbreak, a pseudo-outbreak (a result of contamination within the diagnostic testing process), or just random fluctuation in the frequency of illness.  If a true outbreak is discovered, infection control practitioners try to determine what permitted the outbreak to occur, and to rearrange the conditions to prevent ongoing propagation of the infection. Often, breaches in good practice are responsible, although sometimes other factors (such as construction) may be the source of the problem.
  
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==Symbolic hand washing==
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==Training in infection control and health care epidemiology==
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[[Image:Tsukubai2.JPG|Tsukubai|thumb|230px|left|[[Tsukubai]], provided at a Japanese temple for symbolic hand washing and mouth rinsing]]
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Practitioners can come from several different educational streams. Many begin as nurses, some as medical technologists (particularly in clinical microbiology), and some as physicians (typically infectious disease specialists). Specialized training in infection control and health care epidemiology are offered by the professional organizations described below. Physicians who desire to become infection control practitioners often are trained in the context of an infectious disease fellowship.
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{{main|ablution}}
 
  
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*[[Ablution]] in the [[Bahá'í Faith]]
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[http://www.cbic.org Certification Board of Infection Control and Epidemiology] is an organization that certifies infection control practitioners based on their educational background and professional experience, in conjunction with testing their knowledge base with standardized exams. The credential awarded is CIC, Certification in Infection Control and Epidemiology.  One must have 2 years of Infection Control experience in order to sit for the boards.  Certification must be renewed every five years.
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*[[Ablution]] in the [[Hebrew Bible]]
 
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*[[Ablution]] in [[Hinduism]]
 
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*[[Ablution in Judaism]]
 
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*[[Lavabo]] in [[Christianity]]
 
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*[[Misogi]] in [[Shintoism]]
 
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*[[Wudu]] in [[Islam]]
 
  
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==Idioms==
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A [http://www.shea-online.org/about/shea_courses.cfm course] in hospital epidemiology (infection control in the hospital setting) is offered jointly each year by the Centers for Disease Control and Prevention (CDC) and the Society for Healthcare Epidemiology of America.
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When someone "washes their hands of" something, this means that they are declaring their unwillingness to take responsibility for it or share complicity in it.  [[Gospel of Matthew|Matthew]] 27:24 gives an account of [[Pontius Pilate]] washing his hands of the decision to crucify [[Jesus]]:  "When Pilate saw that he could prevail nothing, but that rather a tumult was made, he took water, and washed his hands before the multitude, saying, I am innocent of the blood of this just person: see ye to it."
 
  
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==See also==
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http://www.apic.org/ offers a training course for practitioners called EPI 101 and 102.
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* [[Escherichia coli O157:H7|E. coli O157:H7]]
 
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* [[Antibiotic resistance]]
 
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* [[Ignaz Semmelweis]]
 
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* [[Soap dispenser]]
 
  
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==References==
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== Footnotes ==
 
<references/>
 
<references/>
  
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== See also ==
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* [[Infectious disease]]
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* [[Nosocomial infection]]
  
 
==External links==
 
==External links==
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* [http://www.tufts.edu/med/apua/Patients/handwashing.html Alliance for Prudent Use of Antibiotics on hand washing]
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* [http://www.apic.org Association for Professionals in Infection Control and Epidemiology] is primarily composed of infection prevention and control professionals with nursing or medical technology backgrounds
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* [http://www.cdc.gov/handhygiene/ Centers for Disease Control on hand hygiene in healthcare settings]
 
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* [http://www.publichealthgreybruce.on.ca/Communicable/Handwashing/ Hand Washing Video - Grey Bruce Health Unit, Canada ]
 
  
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[[Category:Hygiene]]
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* [http://shea-online.org The Society for Healthcare Epidemiology of America] is more heavily weighted towards practitioners who are physicians or doctoral-level epidemiologists.
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[[Category:Medical hygiene]]
 
  
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[[de:Händedesinfektion]]
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[[Category:Epidemiology]]
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[[fr:Hygiène des mains]]
 
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[[ja:手洗い]]
 
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[[simple:Hand washing]]
 

Revision as of 12:20, 26 July 2007

Infection control and health care epidemiology is the discipline concerned with preventing the spread of infections within the health-care setting. As such, it is a practical (rather than an academic) sub-discipline of epidemiology. It is an essential (though often underrecognized and undersupported) part of the infrastructure of health care. Infection control and hospital epidemiology are akin to public health practice, practiced within the confines of a particular health-care delivery system rather than directed at society as a whole.

Infection control concerns itself both with prevention (hand hygiene/hand washing, cleaning/disinfection/sterilization, vaccination, surveillance) and with investigation and management of demonstrated or suspected spread of infection within a particular health-care setting (e.g. outbreak investigation). It is on this basis that the common title being adopted within health care is "Infection Prevention & Control".

Infection control in healthcare facilities

Hand hygiene

Independent studies by Ignaz Semmelweis in 1847 in Vienna and Oliver Wendell Holmes in 1843 in Boston established a link between the hands of health care workers and the spread of [[Nosocomial& infection|hospital-acquired]] disease.& The Centers for Disease Control and Prevention (CDC) has stated that “It is well-documented that the most important measure for preventing the spread of of pathogens is effective handwashing.” & Hand washing is mandatory in most health care settings and required by many different state and local regulations as well as good sense.

Occupational Safety and Health Administration (OSHA) standards& require that employers must provide readily accessible hand washing facilities, and must ensure that employees wash hands and any other skin with soap and water or flush mucous membranes with water as soon as feasible after contact with blood or other potentially infectious materials (OPIM).

Cleaning, disinfection and sterilization

Cleaning, disinfection and sterilization... Template:Sect-stub

Personal protective equipment

Disposable PPE

Personal protective equipment (PPE) is specialized clothing or equipment worn by a worker for protection against a hazard. The hazard in a health care setting is exposure to blood, saliva, or other bodily fluids or aerosols that may carry infectious materials such as Hepatitis C, HIV, or other blood borne or bodily fluid pathogen. PPE prevents contact with a potentially infectious material by creating a physical barrier between the potential infectious material and the healthcare worker.

The Occupational Safety and Health Administration (OSHA) requires the use of Personal protective equipment (PPE) by workers to guard against blood borne pathogens if there is a reasonably anticipated exposure to blood or other potentially infectious materials. &

Components of Personal protective equipment (PPE) include gloves, gowns, bonnets, shoe covers, face shields, CPR masks, goggles, surgical masks, and respirators. How many components are used and how the components are used is often determined by regulations or the infection control protocol of the facility in question. Many or most of these items are disposable to avoid carrying infectious materials from one patient to another patient and to avoid difficult or costly disinfection. OSHA requires the immediate removal and disinfection or disposal of worker's PPE prior to leaving the work area where exposure to infectious material took place.&

Vaccination of health care workers

Health care workers may be exposed to certain infections in the course of their work. Vaccines are available to provide some protection to workers in a healthcare setting. Depending on regulation, recommendation, the specific work function, or personal preference, healthcare workers or first responders may receive vaccinations for hepatitis B; influenza; measles, mumps and rubella; Tetanus, diphtheria, pertussis; N. meningitidis; and varicella. In general, vaccines do not guarantee complete protection from disease, and there is potential for adverse effects from receiving the vaccine. &

Surveillance for emerging infections

Surveillance is the act of infection investigation using the CDC definitions. Determining an infection requires an ICP to review a patient's chart and see if the patient had the signs and symptom of an infection. Surveillance definition cover infections of the bloodstream, Urinary tract, pneumonia, and sugical sites.

Surveillance traditionally involved significant manual data assessment and entry in order to assess preventative actions such as isolation of patients with an infectious disease. Increasingly, integrated computerised software solutions which actively assess each incoming risk message are becoming available. Such software significantly reduces the data workload of Infection Control Practitioners (ICP), freeing them to concentrate on clinical surveillance.


As approximately one third of healthcare acquired infections are preventable , surveillance and preventative activities are increasingly a priority for hospital staff. A study on the Efficacy of Nosocomial Infection Control Project (SENIC) by the CDC found that hospitals reduced their nosocomial infection rates by approximately 32 per cent by focusing on surveillance activities and prevention efforts.

Outbreak investigation

When an unusual cluster of illness is noted, infection control teams undertake an investigation to determine whether there is a true outbreak, a pseudo-outbreak (a result of contamination within the diagnostic testing process), or just random fluctuation in the frequency of illness. If a true outbreak is discovered, infection control practitioners try to determine what permitted the outbreak to occur, and to rearrange the conditions to prevent ongoing propagation of the infection. Often, breaches in good practice are responsible, although sometimes other factors (such as construction) may be the source of the problem.

Training in infection control and health care epidemiology

Practitioners can come from several different educational streams. Many begin as nurses, some as medical technologists (particularly in clinical microbiology), and some as physicians (typically infectious disease specialists). Specialized training in infection control and health care epidemiology are offered by the professional organizations described below. Physicians who desire to become infection control practitioners often are trained in the context of an infectious disease fellowship.

Certification Board of Infection Control and Epidemiology is an organization that certifies infection control practitioners based on their educational background and professional experience, in conjunction with testing their knowledge base with standardized exams. The credential awarded is CIC, Certification in Infection Control and Epidemiology. One must have 2 years of Infection Control experience in order to sit for the boards. Certification must be renewed every five years.

A course in hospital epidemiology (infection control in the hospital setting) is offered jointly each year by the Centers for Disease Control and Prevention (CDC) and the Society for Healthcare Epidemiology of America.

http://www.apic.org/ offers a training course for practitioners called EPI 101 and 102.

Footnotes

  1. ↑ Nosocomial was derived from two Greek words Nosos (disease) and Komeion (to take care of)
  2. ↑ CDC Guideline for Hand Hygiene in Health-Care Settings
  3. ↑ CDC General information on Hand Hygiene
  4. ↑ OSHA Bloodborne Pathogens Regulations 1910.1030
  5. ↑ OSHA Bloodborne Pathogens Regulations 1910.1030(d)(2)(i)
  6. ↑ OSHA 1910.1030(d)(3)(vii)
  7. ↑ CDC Vaccine Site

See also

External links

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