Infection control is an integral part of pediatric practice in outpatient settings as well as in hospitals. All employees should be educated regarding the routes of transmission and techniques used to prevent transmission of infectious agents. Policies for infection control and prevention should be written, readily available, updated annually, and enforced. The Centers for Disease Control and Prevention standard precautions for hospitalized patients with modifications from the American Academy of Pediatrics are appropriate for most patient encounters. As employers, pediatricians are required by the Occupational Safety and Health Administration (OSHA) to take precautions to protect staff likely to be exposed to blood or other potentially infectious materials while on the job. Key principles of infection control include the following: hand-washing before and after every patient contact, separation of infected, contagious children from uninfected children, safe handling and disposal of needles and other sharp medical devices, appropriate use of personal protection equipment such as gloves, appropriate sterilization, disinfection and antisepsis, and judicious use of antibiotics.
Infection control practices have long been recognized as an important means of preventing transmission of infectious agents. Infection control is important in every patient encounter. Recommendations for infection control practices in hospitals are well-documented and updated on a regular basis.1,,2 Because most patient encounters occur in outpatient settings, the availability of established guidelines for control of transmission of infection in office settings is critical.3,,4 There are no comprehensive, national guidelines, however, for the practice of infection control in the outpatient setting.
The risk of developing infection after an outpatient clinic or office visit has been evaluated.5 In all instances, children who visited physicians' offices had better outcomes than children who did not receive regular care, but an office waiting area often presents opportunities for transmission of infectious agents among patients. Multiple outbreaks of measles,6,,7tuberculosis,8 and other infectious diseases have been traced to physicians' offices or clinics.3,,9
Most of the outbreaks reported in the outpatient setting were associated with noncompliance with infection control procedures.9 To understand infection control issues, modes of transmission of infectious agents should be considered.10–14 Transmission can result from contact with contaminated hands, objects, and body material including blood, urine, stool, and respiratory tract secretions. Contaminated hands are the predominant mode of transmission, underscoring the importance of appropriate hand-washing before and after contact with each patient. Fomites, such as toys and office equipment, have been implicated in the transmission of some pathogens. Blood-borne pathogens can be spread if proper precautions with needles and other sharps (sharp instruments) are not followed. Standard precautions, as recommended for hospitalized patients (Table 11), should be followed at all times.
As employers, pediatricians are required by the Occupational Safety and Health Administration (OSHA) to take precautions to protect staff likely to be exposed to blood or other potentially infectious materials while on the job. OSHA has published guidelines for the protection of all health care workers from blood-borne agents.15 Each office is required to have a written plan to decrease the risk of transmission of blood-borne agents to employees. Furthermore, all employees who might be exposed to blood should be immunized against hepatitis B virus and regularly educated about risks of all blood-borne agents. The hepatitis B vaccine should be available, at no cost, to all employees who have occupational exposure to blood. Employees should sign a declination form if they choose not be vaccinated, but vaccine should be provided free of charge if the employee later opts to receive it. Failure to comply with OSHA regulations can result in severe penalties and fines. Each office must be aware of current OSHA regulations and directives (see Table 2).
This review provides practical information regarding infection control in the office setting. The goal is to prevent transmission of infectious agents to patients and visitors, health care workers, and other employees in the office setting. Additional infection control recommendations may be necessary for other outpatient settings including dialysis centers, chemotherapy centers, procedure suites (eg, endoscopy), emergency centers, and outpatient surgery suites.3
GUIDELINES FOR HEALTH CARE DELIVERY
Hand-washing is the single most important method to prevent transmission of infectious agents.1,,216–18 Hands should be washed before and after each contact with patients, body fluids, and contaminated or soiled materials; between dirty and clean procedures on the same patient, after removing gloves; before and after performing invasive procedures; after using the rest room; and whenever hands are visibly soiled. Liquid soap in pump dispensers is ideal; the dispenser should be disposable or should be rinsed and washed before refilling to avoid contamination. Antibacterial soaps are not necessary for routine use.16 Soaps containing alcohol are drying and damaging to skin. Bar soaps are not recommended because bars frequently are wet and easily contaminated with potential pathogens. Use of sinks is preferred to waterless hand cleansers, especially if the hands are soiled. Paper towels are preferred for hand drying and always should be available and reached easily by the health care professional. Hand lotions should be available in pump-type containers that are replaced or cleaned at regular intervals.16 Hand lotions should not be petroleum-based as this may cause deterioration of latex material and thus reduce the effectiveness of gloves.
The method of hand-washing depends on the task to be performed. Routine hand-washing should be done by thoroughly covering the hands with soap and vigorously rubbing the hands under running water for at least 10 seconds. Washing with antimicrobial soaps, such as chlorhexidine or povidone-iodine, is recommended before performing invasive procedures. In these cases, nails are cleaned with disposable manicure sticks and hands and wrists are included in a 1-minute scrub.
All employees at the time of orientation should receive and review information regarding infection control policies and procedures. Furthermore, regularly scheduled educational sessions for all staff are important to ensure that the level of hand-washing and infection control awareness remain high.19,,20 Policies for infection control should be written, readily available, and enforced. All staff members should be aware of and motivated to follow these policies.21
Communication With Local and State Health Authorities
State and local health authorities determine which diseases should be reported. Office physicians must be aware of the rules and regulations in their municipality. Policies and procedures for communication with local and state health authorities regarding reportable diseases and suspected outbreaks should be established.
Minimize the Likelihood of Liability to Third Parties
A number of third-party liability cases involve infectious diseases (ie, cases alleging that the physician is liable for injury to parties that came in contact with his/her patient). Although some courts have discussed these cases, holding that there can be no liability absent the physician-patient relationship, other courts have held that the physician owes a duty to third parties if contact with the infected patient is “reasonably foreseeable.” Therefore, physicians should be aware that the sphere of physician duty to third parties may be expanding and should take appropriate steps to minimize such risks (see Table 3).
Standard precautions, as recommended for hospitalized patients1 (Table 1), should be used in the care of every child because it cannot be determined which child harbors an infectious agent. Gloves should be available for use by all health care professionals. Gloves should be worn when contact with blood, body fluids, secretions, excretions, and items contaminated with these fluids is reasonably anticipated. Gloves do not need to be worn for routine well-child care, such as wiping a nose or changing a diaper. When gloves are used, hands should be washed after they are removed because contamination can occur during removal or from a break in the glove.22 Masks, face shields, and protective eyewear should be worn if splashing of body fluids is anticipated. When soiling of clothes with blood, body fluids, secretions, or excretions is highly likely, gowns can be worn. Water impermeable gowns are needed if splashes of blood or blood-containing body fluids might occur.
The OSHA and National Institute for Occupational Safety and Health (NIOSH) guidelines require use of special masks—NIOSH-certified N-95 respirators—when caring for patients with contagious tuberculosis23; use of these masks requires education to ensure proper fit. Rarely is there a need for use of such masks in pediatric offices because most children with tuberculosis are not contagious.24 Final OSHA rules on protecting health care workers from tuberculosis exposure are expected later this year. Adults suspected to be contagious for tuberculosis should not be permitted in the office because they pose a hazard to patients and staff.
Skin surfaces that are contaminated with blood or other body fluids should be washed immediately and thoroughly. Environmental surfaces should be cleaned with a detergent, then treated with freshly prepared bleach solution (diluted 1:64; ¼ cup of bleach to 1 gallon of water, bleach contact time must be at least 30 seconds), with gloves worn during cleaning. Immunization with hepatitis B vaccine is mandated by OSHA for all persons whose job might involve exposure to blood or blood-containing body fluids.15
Impermeable and puncture-proof needle disposal containers, or sharps containers, should be available in areas where injections are given. The containers should not be overfilled and should be out of reach of young children. Policies consistent with state and local regulations for removal and incineration or sterilization should be in place. Policies for management of needlestick injuries should be readily available and understood by employees (example, Table 4). OSHA requires that employees receive education on the management of sharps injuries, that procedures not only be available and understood, but followed. As of November 5, 1999, OSHA requires that all percutaneous sharps injuries be recorded on the OSHA 200 log.
General Health Considerations of Office Staff
Individuals who work in health care are exposed frequently to persons with infectious diseases. Health care workers also pose a risk to patients and other personnel if they develop a communicable disease. Written policies, therefore, should exist regarding exclusion of staff members with contagious illnesses (Table 5). Respiratory tract infections may not be a reason to exclude office personnel, but precautions should be taken with an emphasis on hand-washing before all patient contacts.
In adults, screening for tuberculosis using the Mantoux skin test should be done before employment to ensure active tuberculosis is detected early and treated. When necessary, employees should be excluded from the office until they are no longer infectious.9 A test is considered positive in a healthy health care professional if an area of induration of at least 10 mm is detected. For persons with underlying conditions or known household exposure to tuberculosis, 5 mm of induration is considered positive. If the Mantoux test is positive, the employee is referred for evaluation and appropriate management.25 The frequency of repeat skin testing for PPD-negative employees should be based on the risk of exposure to people with active tuberculosis. Risk factors will vary from employee to employee; yearly testing should be considered in practices where there has been a high rate of documented tuberculosis or skin test conversion among families and patients or among health care professionals. Consultation with local health departments is useful to determine the prevalence of tuberculosis in the local area.
Properly functioning sinks with adjacent soap dispensers and disposable towels should be conveniently located in all patient care areas. Faucet aerators are discouraged because they are often contaminated by Pseudomonas species and other bacteria.
Waiting rooms and reception areas offer the opportunity for child-to-child interaction, and, unfortunately, child-to-child transmission of infectious agents. Waiting rooms can be compared with child care settings, where contamination of the environment and transmission of infectious agents occur at an increased rate compared with the home setting. Efforts should be made to limit transmission of infectious agents by avoidance of crowding, shortening waiting times, and minimizing the sharing of toys. Infected children who are symptomatic should be segregated from well children as quickly as possible. There are no studies documenting the need for, or benefit of, separate waiting areas for well and ill children.5 Sick adults should be discouraged from spending time in waiting areas. Triage should begin at the time the office visit is scheduled. Parents of a contagious child should register with the receptionist immediately; in some cases, the child may be asked to use a separate entrance to avoid the waiting area. Ideally, immunocompromised children should not wait in the general waiting area but be escorted immediately to an examining room.
Toys in the office should be disposable or washable and of appropriate sizes and shapes to avoid aspiration or other injuries. Ideally, toys should be cleaned between use to avoid transfer of infectious agents.28 Toys contaminated with body fluids should be removed until cleaned. The value of antibacterial soaps for cleansing and antibacterial agents within the toys is unproven. These agents also add expense. Regular cleansing of toys in a dishwasher at the end of each day decreases microbial contamination and eliminates organic material on the toy.
Floors in the waiting area and office are often soiled with body secretions as well as dirt. These surfaces should be cleaned regularly. After spills involving blood or body fluids contaminated with blood, floors should be first cleaned with detergent, then disinfected promptly using a freshly prepared bleach solution (¼ cup of bleach in 1 gallon of water, bleach contact time at least 30 seconds). Linoleum or wood floors are optimal surfaces to keep clean.
Equipment should be cleaned after each use. Although furniture in the room generally is not a major concern for transfer of infectious agents, contamination of the examining table can be a problem. Covering the table with disposable paper or linen, which is changed between patients, decreases the risk for transmission of microbes. More thorough cleaning should be done if contamination is visible. Where diaper changing has occurred, more thorough cleaning should be done to remove visible soil. This is followed by sanitizing the surface using a freshly prepared solution of 1:64 household bleach (¼ cup diluted in 1 gallon of water) applied for 2 minutes, rinsed, and dried.
Rest rooms for staff and patient use should be provided and cleaned daily and whenever visibly soiled. A diaper changing area should be provided in at least 1 rest room with disposable paper and a receptacle for soiled diapers and paper.
Certain infections, including varicella, measles, and tuberculosis, are transmitted by the air-borne route. Unfortunately, the number of air exchanges in buildings that house outpatient facilities often is low, and the air is frequently recirculated.
Physicians should be aware of air flow patterns to limit transmission of air-borne pathogens. Special arrangements are recommended for patients considered to be contagious including the following: 1) making efforts to see these patients at the end of the day; 2) quickly triaging these patients out of common waiting areas; and 3) closing the door of the examining room and limiting access to the patient by visitors and staff members who are not immune to the suspected disease. The duration of time that air-borne viruses remain in a room depends on air exchange rates; for example, in hospitals where air exchange rates are 6 to 8 per hour, several air exchanges occur within 30 minutes. Recommended air exchange rates depend on the stated use of a room. Recommendations and guidelines are made by the American Society of Heating, Refrigerating and Air Conditioning Engineers located in Atlanta, Georgia. The current recommended air exchange rate for a medical office examination room is 6 air changes per hour with 2 outside air exchanges per hour.
Personal and Diagnostic Equipment
The role of stethoscopes and other examining devices in transmitting infectious agents is unclear; however, stethoscopes can be contaminated with multi–drug-resistant bacteria. A reasonable means of decreasing contamination is to wipe the bell and diaphragm of the stethoscope as well as the handle and body of otoscopes or ophthalmoscopes regularly and whenever they become soiled; a paper towel with soap and water or an alcohol wipe is effective. Ear curettes should be cleaned after each use and, if contaminated by blood, should be disinfected with a bleach solution or alcohol.
Ballpoint pens, patient charts, computer keyboards, and the mouse can be contaminated with infectious agents that can be transmitted by hands to other environmental sources. Because these items rarely are cleaned, hand-washing before and after patient contact is necessary to minimize the potential transfer of bacteria and viruses from equipment to patients.
In most cases, blood pressure cuffs are placed on intact skin so the risk of transmission of infectious agents is minimal. These cuffs should not be placed in direct contact with damaged or nonintact skin.
Whenever economically and medically feasible, disposable supplies should be used. Plastic sleeves are available for use with glass thermometers. Any contaminated thermometer should be disinfected. Electronic thermometers have single-use shields, but care must be taken to avoid contaminating the housing of the thermometer. The “box” should be wiped whenever soiled and after measuring the temperature of an infected child; paper towels with soap and water or alcohol wipes can be used.
Care should be taken to avoid contamination of pulse oximetry and tympanometry equipment with any body secretions, and equipment should be cleaned carefully after each use. Pieces of other office equipment, such as electrocardiogram machines and Denver Developmental Testing kits (Denver Developmental Materials Incorporated, Denver, CO), should be cleaned whenever contaminated by patient secretions.
STERILIZATION, DISINFECTION, AND ANTISEPSIS
Sterilization completely eliminates or destroys all forms of microbial life. Disinfection reduces, but does not eliminate, the microbial burden. The extent of disinfection depends on the type of disinfectant and its concentration, the resistance of the microbes, and the contact time. Cleaning removes foreign material from objects. Antisepsis refers to the process used to decontaminate the skin of the patient or health care professional.
All equipment should be cleaned regularly and stored where it will not become contaminated. Equipment having contact with mucous membranes requires high-level disinfection, whereas instruments that penetrate skin or mucosal membranes must be sterile (Table 7).29,,30
Sterilization is accomplished by autoclave, dry heat, or gas.30 Items must be cleaned manually with soap and water to remove organic debris before autoclaving. Steam autoclaving uses distilled water that must reach a temperature of 121° to 132°C. Recommended time for exposure of items is 20 minutes for unwrapped instruments and 30 minutes for small packs. Unwrapped instruments should be used immediately or aseptically transferred to a sterile container. Hot air oven sterilization is used only for items that cannot be sterilized by autoclaving. The oven temperature should be 170°C for an exposure time of 1 hour.
The sterilization equipment should be monitored by the use of various indicators to ensure that the process has been effective. Manual indicators ensure that a machine reaches the correct temperature and pressure. Chemical indicators are useful in showing that the wrapped package has been sterilized. Biological indicators are necessary to ensure sterility. A variety of indicator systems are available. The procedure recommended by the manufacturer to document sterility should be done at least weekly and results should be recorded.
Packs that have been sterilized should be dated and stored in clean, dry areas to minimize recontamination. Muslin wrapped materials cannot be stored for more than a few months, whereas plastic wrapped packs can be stored safely for 1 year.
For this statement, the terms for disinfection are taken from standards for sterilization, disinfection, and antisepsis in hospitals.29 High-level disinfection is used for instruments having contact with mucous membranes. Two types of procedures may be used. 1) Boiling. Instruments are placed in boiling water for at least 20 minutes. The vessel used for boiling should be cleaned daily. 2) Chemical disinfection. Chemical disinfection is accomplished with glutaraldehyde, hydrogen peroxide, or sodium hypochlorite (bleach). Two percent glutaraldehyde solutions are most commonly used; however, these products have potential toxicity if proper ventilation is not ensured. The solution should be prepared according to manufacturer's instructions. A 6% solution of hydrogen peroxide is safe and effective to use with most medical instruments. A 1:64 dilution of sodium hypochlorite is effective for disinfection. The only disinfectant approved for use in hospitals is 2% glutaraldehyde. After disinfection, instruments are rinsed with sterile water, dried, and stored aseptically to avoid recontamination.
Intermediate-level disinfection is accomplished with ethanol and isopropanol, iodine and iodophors, phenols and phenolics, and 1:64 dilutions of sodium hypochlorite.
Low-level disinfection is appropriate for instruments that do not touch mucous membranes; examples include bedpans, blood pressure cuffs, crutches, and table tops. Low-level disinfectants include phenols and phenolics, quaternary ammonium compounds, 1:500 dilutions of sodium hypochlorite, and iodine and iodophors.
Written policies for sterilization and disinfection in the office will ensure that these procedures are performed properly, and regular reviews should be conducted to be sure that policies are being followed.
Antiseptics are chemical agents intended for use on skin or tissue. Skin preparation agents include isopropyl alcohol, chlorhexidine gluconate, iodine, and iodophors. Alcohol is the preferred skin preparation for immunizations and venipuncture for routine blood collection. Most skin preparation agents must be allowed to dry before surface bacteria are killed. Tincture of iodine is active on contact and thus could be considered the preferred skin preparation agent for invasive procedures, such as insertion of indwelling intravenous catheters and when obtaining blood for culture. Povidone iodine is an acceptable alternative. Contamination of antiseptics has been associated with outbreaks of infections and pseudoepidemics attributable to false-positive blood cultures.31,,32 To prevent contamination, bottles of antiseptics should be dated, should not be refilled, and should be inspected and discarded if not used within 3 months. Alcohol pads and iodine products prepared for single use are available and eliminate the need for bottles of antiseptics.
Offices and office equipment should be cleaned daily. Surfaces should be cleaned with a low-level disinfectant. Phenolics, iodophors, and quaternary ammonium compounds are appropriate for use in daily cleaning and disinfection of surfaces. Blood spills should be cleaned, using disposable gloves. The area should be disinfected with a freshly prepared solution of 1:10 household bleach applied for at least 30 seconds and wiped after the minimum contact time. Gloves should be worn during cleanup of any blood or body fluid.
DISPOSAL OF MEDICAL WASTES
The federal OSHA standard as well as local and state regulations dictate the proper disposal of medical wastes, including dressings, needles, sharps, and body fluid samples.33,,34 All physicians should be aware of the policies in their municipality and ensure that regulated wastes are disposed of appropriately. Basic principles include defining which items constitute infectious waste and which do not; appropriately separating, labeling, storing, and transporting items in these 2 categories; instructing staff on how to handle infectious wastes; and developing plans for managing waste, spills, and inadvertent exposures.
JUDICIOUS USE OF ANTIMICROBIALS
Another aspect of infection control is diagnosis of infection and institution of antibiotic therapy when indicated. Inappropriate use of antimicrobial agents in hospitals and in physician offices has contributed to the emergence of antibiotic-resistant organisms. The Centers for Disease Control and Prevention and the American Academy of Pediatrics have provided guidelines for the judicious use of antibiotics.35–40
Guidelines have been published for isolation and precautions for hospitalized children and adults who acquire resistant flora.41 Patients may continue to harbor resistant bacteria as part of their respiratory or gastrointestinal tract flora. These organisms include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin intermediate susceptible S aureus (glycopeptide intermediate S aureus or GISA), vancomycin-resistant Enterococcus species (VRE), and extended-spectrum β-lactamase-producing or multiply-resistant Gram-negative bacteria. Hand-washing before and after contact with these colonized children is appropriate; no guidelines for management of these patients in office settings have been published.
SUMMARY OF INFECTION CONTROL POLICIES
All health care workers should wash their hands before and after patient contact. Parents and children should be taught the importance of hand-washing.
Standard precautions should be used in dealing with all patients.
Contact between infected, contagious children and uninfected children should be minimized. Policies to deal with children who present with infections, such as varicella or measles, should be implemented. Prompt triage of immunocompromised children should be performed routinely.
Alcohol is preferred for skin preparation before immunization and routine venipuncture. Skin preparation for incision, suture, and collection of blood for culture, requires iodine; solutions of choice are 1% or 2% tincture of iodine or povodine iodine.
Needles and sharps should be handled with great care. Needle disposal units that are impermeable and puncture-proof should be available next to the areas used for injection or venipuncture. The containers should not be overfilled and should be kept out of the reach of young children. Policies should be established for removal and incineration or sterilization of contents.
Policies for management of needlestick injuries should also be in place.
Standard guidelines for sterilization, disinfection, and antisepsis should be followed.
Judicious use of antimicrobial agents is essential to limit the emergence and spread of drug-resistant bacteria.
Outpatient offices and clinics should develop policies and procedures for communication with local and state health authorities regarding reportable diseases and suspected outbreaks.
Ongoing educational programs that encompass appropriate aspects of infection control should be implemented, reinforced, and evaluated on a regular basis.
Jon S. Abramson, MD, Chairperson
Carol J. Baker, MD
Margaret C. Fisher, MD
Michael A. Gerber, MD
H. Cody Meissner, MD
Dennis L. Murray, MD
Gary D. Overturf, MD
Charles G. Prober, MD
Margaret B. Rennels, MD
Thomas N. Saari, MD
Leonard B. Weiner, MD
Richard J. Whitley, MD
Committee on Infectious Diseases, 1999–2000
Georges Peter, MD
Larry K. Pickering, MD
Noni E. MacDonald, MD
Anthony Hirsch, MD
Pediatric Practice Action Group
Richard F. Jacobs, MD
American Thoracic Society
Gilles Delage, MD
Canadian Paediatric Society
Scott F. Dowell, MD, MPH
Centers for Disease Control and Prevention
Walter A. Orenstein, MD
Centers for Disease Control and Prevention
Peter A. Patriarca, MD
Food and Drug Administration
N. Regina Rabinovich, MD
National Institutes of Health
Martin G. Myers, MD
National Vaccine Program Office
Edgar O. Ledbetter, MD
Joann Kim, MD
Jack T. Swanson, MD, Chairperson
Edward O. Cox, MD
F. Lane France, MD
Katherine C. Teets Grimm, MD
Norman “Chip” Harbaugh, Jr, MD
James W. Herbert, MD
Allan S. Lieberthal, MD
Kyle E. Yasuda, MD
Committee on Practice and Ambulatory Medicine, 1999–2000
Todd Davis, MD
Ambulatory Pediatric Association
Adrienne A. Bendel
Medical Group Management Association
Winston Price, MD
National Medical Association
Philip Itkin, MD
Section on Administration and Practice Management
Susan Rogers, MD
Section on Residents
Junelle Fletcher, BA
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
- OSHA =
- Occupational Safety and Health Administration
- ↵Herwaldt LA, Smith SD, Carter CD. Infection control in the outpatient setting. In: Herwaldt LA, ed. The Society for Healthcare Epidemiology of America: A Practical Handbook for Hospital Epidemiologists. Thorofare, NJ: Slack, Inc; 1998:357–402
- ↵Jackson MM. Ambulatory care facilities. In: Abrutyn E, ed. Saunders Infection Control Reference Service. Philadelphia, PA: WB Saunders Co; 1998:99–108
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- ↵Bennett JV, Brachman PS, eds. Hospital Infections. 3rd ed. Boston, MA: Little, Brown & Co; 1992
- ↵Mayhall CG, ed. Hospital Epidemiology and Infection Control. Baltimore, MD: Williams & Wilkins; 1996
- ↵Wenzel RP, ed. Prevention and Control of Nosocomial Infections. 3rd ed. Baltimore, MD: Williams & Wilkins; 1997
- ↵Abrutyn E, ed. Saunders Infection Control Reference Service. Philadelphia, PA: WB Saunders Co; 1998
- ↵Herwaldt LA, ed. The Society for Healthcare Epidemiology of America: A Practical Handbook for Hospital Epidemiologists. Thorofare, NJ: Slack, Inc; 1998
- ↵Department of Labor, Occupational Safety and Health Administration. (Codified at 29 CFR 1920.1030). Occupational exposure to bloodborne pathogens, final rule. Federal Register. December 6, 1991, Volume 56-64004264182
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- ↵American Academy of Pediatrics. Tuberculosis. In: Peter G, ed. 1997 Red Book: Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:541–562
- ↵Centers for Disease Control and Prevention. Guidelines for Prevention of TB Transmission in Hospitals. Atlanta, GA: Department of Health, Education, and Welfare; 1979. Publication No. CEC 79-8371
- ↵Centers for Disease Control and Prevention. Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Morb Mortal Wkly Rep. 1997;46(RR-18):1–42
- Geyer SA
- ↵Favero MS, Bond WW. Sterilization, disinfection, and antisepsis in the hospital. In: Manual of Clinical Microbiology. 5th ed. Washington, DC: American Society for Microbiology; 1991:183–200
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- ↵Keene JH. Regulated medical waste. In: Abrutyn E, ed. Saunders Infection Control Reference Service. Philadelphia, PA: WB Saunders Co; 1998:727–750
- ↵Reinhardt PA, Gordon JG, Alvarado CJ. Medical waste management. In: Mayhall CG, ed. Hospital Epidemiology and Infection Control. Philadelphia, PA: Williams &Wilkins; 1996:1099–1108
- ↵Centers for Disease Control and Prevention. Public Health Service guidelines for management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis. MMWR Morb Mortal Wkly Rep. 1998;47(RR-7):1–33
- ↵American Academy of Pediatrics. Materials to Assist the Pediatric Office in Implementing the Bloodborne Pathogen, Hazard Communication, and Other OSHA Standards. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 1994
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- Copyright © 2000 American Academy of Pediatrics