by Noel Brandon Kelsch, RDHAP
I'm continually in awe of people who are willing to cradle other people in their laps and share a smile in order to increase the other people's health. Thousands voluntarily give of their time, talent, and treasure to provide for those who can receive care no other way. I recently attended a free dental clinic, and as the staff arrived, many of them commented about the staggering number of people who had lined up since dawn to receive something many Americans take for granted -- dental care. As we become part of the solution, we must make sure that we're not creating another problem.
There is so much to be aware of when we give through something such as a free dental clinic. The services we render need to be at the same level of quality and with the same standard of care in infection control that is present in any other setting . Having limited supplies or quality materials means that we have to limit treatment rather than deliver substandard care.
Other articles by Kelsch:
- Disinfectants and the EPA
- Five Moments of Hand Hygiene in Dentistry
- Vaccinations are a pain in the ...
A recent article in the Journal of the American Dental Association about a portable dental clinic made that very clear.1
In this case there was a cluster of acute hepatitis B virus (HBV) infections among attendees of a two-day portable dental clinic in West Virginia. The clinic was held in a gymnasium and staffed by 750 volunteers. In those two days, 1,137 adult patients were treated. Of this group, five developed HBV within the window of the incubation period.
Here are a few interesting facts:
- Four of the patients available for genotyping all had genotype D.
- The three patients did not share treatment providers but attended the clinic on the same day.
- Three patients underwent extractions, and one patient also received restorations and a prophylaxis.
- Two were volunteers that were not health-care professionals. They were not vaccinated. One worked maintenance and the other directed patients from triage to the treatment waiting area.
- None of them reported behavior risk factors for HBV infections (e.g., multiple sex partners, IV drug use, etc.).
It was found that transmission was likely to have occurred in this setting.1 This was a very difficult assessment of the transmission because it was conducted after almost a year post-event. Because it was a temporary clinic, investigators could not assess the clinic or staff and observe infection control practices. They had to do a retrospective investigation and review.
There may be many more than five people who have HBV as a result of this clinic. Of the 1,887 involved in this clinic, 389 were tested, or 20% of those who may have been exposed. One additional person was positive but could not be linked because of the delay in notification and testing. Typically 50% to 70% of adults with acute HBV will not have any symptoms. This makes it very difficult to identify those who were exposed to and contracted the disease and link it to this event.2
It is also very difficult to assess the transmission process in the medical setting. Allos and Schaffner, in their article, "Transmission of hepatitis B in the health care setting: the elephant in the room ... or the mouse?" suggest that "the current burden of health-care acquired bloodborne infection is largely unknown because only modest efforts have been made to identify such cases and quantify the risk."3 Many times when traditional risk factors are not found, the investigation stops there. The cases that have been identified went beyond the traditional methods of identification.
So what went wrong?
As the study went on to evaluate the missing links, many issues came to light. Here are a few of the top concerns:
1. Information gathering--One of the most vital parts of any event is the gathering of information to serve the patients' needs and health-care providers' needs during and after an event. A log of all volunteers, their stations, time of volunteering, licenses, vaccination history, and more needs to be in place before the volunteers hit the floor or patients are seen. Information for contacting patients is equally important so any necessary follow-up can occur as quickly as possible.
West Virginia--When health-care providers signed up for this event, contact information and date of birth were not obtained for all volunteers. There was also a lack of information for contacting the patients. This made it difficult to notify attendees and volunteers. Because of the delay in notification, some of the positive results could not conclusively be linked to the clinic. This could also have delayed the diagnosis and treatment of patients who did contract the disease.1,3
2. Infection control and quality assurance -- It is important to include someone who is well versed in infection control to oversee the event from start to finish. They need to not only make sure infection control standards are met, but that every person is educated and trained in the procedures for the event and has the opportunity for vaccination. A person or committee should be in charge of overseeing compliance and correcting any errors immediately. State laws, OSHA regulations, and CDC recommendations must be addressed.
West Virginia -- Though there was a safety officer for sharps injury, etc., there was no person assigned to oversee the infection control practices and quality assurance of those practices. Levels of understanding will differ, and it is vital to have someone to make sure that all precautions are adhered to.
3. Educating the staff on infection control -- When preparing for a mobile event, the first order of business should be infection control. Training must occur before the event. This can be done through an online seminar or an educational module. All staff is required to be educated in bloodborne pathogens/infection control before they see patients. OSHA has now included both employees and volunteers. All staff who may be at risk of exposure, from the janitor to the staff who enter the operatory to chart, must be trained.i
West Virginia -- No one was instructed in the infection control process, and no one's past history of training was confirmed. Those with no background in dentistry were not trained. No training was conducted on infection control before the event. One of the HBV-positive volunteers reported that he had not been trained in infection control. He was working with equipment that was blood contaminated (compressor, etc.), and he frequently wiped sweat from his brow and blew his nose while wearing the same gloves that he used to work with equipment.
4. Hand hygiene -- Hospital-grade hand sanitizers are very effective at killing bacteria when the hands are debris free. Before and after patient care and when the hands have debris on them, it is vital to wash hands.5 It is imperative to have hand-washing stations available for these events. There are units available from rental companies, and there are many methods of setting up hand-washing stations that are very inexpensive. This needs to be built into the budget. There are several online demonstrations of how to build your own. If you cannot afford hand-washing stations, you should not be having an event.
West Virginia -- Though there were gel sanitizers at stations, there were only a few sinks to wash the debris from hands. These sinks were far away from the patient care areas and were difficult to access.
5. Supplies -- When you run out of infection control supplies, you should stop seeing patients. You cannot make do with infection control. You should see only as many patients as you can serve safely and with the same standards as at any other setting.
West Virginia -- At the end of the two-day clinic, supplies became scarce so barrier protection was not changed between patients.
6. Transporting instruments -- Contaminated instruments should be transferred from place to place in a method that minimizes the risk of exposure to staff, patients, and the environment. A closed, rigid, leak-proof container is the safest method of facilitating movement from room to room. Patients should not be doing this for themselves since there is no way of assuring that the field is kept clear of cross-contamination.
West Virginia -- The patients were to transport uncovered carpules and syringes from the anesthesia area to the treatment area. There is no way to assure that this was done safely and properly. This not only put the patients at risk, but also anyone who was around the patients was put at risk if the tray dropped or a patient put a tray down on a surface. One patient reported seeing the doctor use instruments off another patient's tray.
7. Outside instruments and supplies -- All instruments used in the medical setting must be confirmed as sterile before use.
West Virginia -- Clinicians were allowed to bring outside instruments in without confirming the sterile status of the instruments.
8. Separation -- It is vital to have a separation between where surgical procedures are being performed, the sterilization area, and other patient care areas. Barriers such as curtains should be used to separate operational areas, especially when patients are in close proximity.1 These barriers can be created with rental units or borrowed from state agencies.
West Virginia -- The design of the clinic included multiple treatment areas in close proximity to the surgical area. This created an increased potential for overspray and spatter to contaminate the unwrapped instruments, supplies, and equipment in other areas. The gym did not have an air conditioner and temperatures were reported to be 100 degrees. The heat and lack of air circulation could also have been a contributing factor.
9. Vaccination -- Everyone at risk for exposure to bloodborne pathogens should be given the opportunity for vaccination. Confirmation of vaccination is the responsibility of the organization conducting the event.
West Virginia -- It was not confirmed that the volunteers dealing with bloodborne pathogens were vaccinated. None of the volunteers were made aware of the need for vaccination before the event.
10. Sterilization -- All instruments that are not for immediate use after the sterilization process must be wrapped before sterilization and kept in the package until used for patient care. There must be an internal and external indicator. Sterilized instruments must be kept in a closed container if they are not put away in a drawer or cupboard. All dental handpieces must be heat sterilized between patients. Instruments should not be taken out of the sterilizer until dry to prevent wicking contamination.6
West Virginia -- The instruments were processed unpackaged with no chemical indicator. They were placed on a tray to dry with no covering. While unwrapped instruments can be sterilized for immediate use, this system cannot be used with instruments that will be stored or dispensed at a different time. Instruments were set out on a table uncovered and clinicians picked them up with "clean" gloves. Chemical indicators were not used. None of the sterilization units were known to be tested or verified for their ability to sterilize. Handpieces were not sterilized between patients. They were wiped down with a disinfectant wipe.
11. Single-use items -- Many supplies that are used in dentistry are Food and Drug Administration-approved medical devices. They must be treated according to CDC guidelines, OSHA regulations, and manufacturer instructions. All single-use items must be disposed of after a single use and cannot be reused.
West Virginia -- Items such as disposable mirrors were not disposed of after use. They were reprocessed with a disinfectant wipe and returned to service without being heat sterilized. These single use items where not meant to be sterilized or reprocessed.
Anything with the number 2 with a line through on the box must be disposed of after. There is no way to assure they were not contaminated since they were not intended for reuse or sterilization.
As we all become part of the solution to end the disparity in dental health care, we have to take stock and make sure we are not creating another problem because of an oversight in infection control. Sharing our time and talent in dentistry does make a difference. Doing it in the right manner will make a bigger difference.
NOEL BRANDON KELSCH, RDHAP, is a syndicated columnist, writer, speaker, and cartoonist. She serves on the editorial review committee for the Organization for Safety, Asepsis and Prevention newsletter and has received many national awards. Kelsch owns her dental hygiene practice that focuses on access to care for all and helps facilitate the Simi Valley Free Dental Clinic. She has devoted much of her 35 years in dentistry to educating people about the devastating effects of methamphetamines and drug use. She is a past president of the California Dental Hygienists’ Association.
1 Hepatitis B virus transmissions associated with a portable dental clinic, West Virginia, 2009 Rachel A. Radcliffe, Danae Bixler, Anne Moorman, et al. JADA 2013;144(10):1110-1118.
2 Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. Weinbaum CM, Williams I, Mast EE, et al. Centers for Disease Control and Prevention. MMWR Recomm Rep 2008;57(RR-8):1-20.
3 Transmission of hepatitis B in the health care setting: the elephant in the room ... or the mouse? Ban Mishu Allos and William Schaffner The Journal of Infectious Disease 2007 195: 1245-1247.
4 Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings: 2003 Kohn WG, Collins AS, Cleveland JL, et al. MMWR Recomm Rep 2003;52(RR-17):1-61.
5 http://www.cdc.gov/handhygiene/ accessed 9/2013
6 Association for the Advancement of Medical Instrumentation. ANSI/AAMI ST79: 2006 Comprehensive guide to steam sterilization and sterility assurance in health care facilities. 2006. Arlington, VA: AAMI.
8 Infection control and management of hazardous materials for the dental team. Chris H. Miller, Charles John Palenik. 4th Edition 2010.
i Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings: 2003 Kohn WG, Collins AS, Cleveland JL, et al. MMWR Recomm Rep 2003;52(RR-17):1-61.
Want to start a program or evaluate what you are doing in your program?
The first place to start is infection control. There is a great resource page with checklists, resources, and even a manual to get started. The nonprofit organization for safety, asepsis, and prevention has done a lot of the work for you!
An event that never happened: Preventing disease
It is vital to always be prepared when planning a temporary mobile clinic event. During the 2009 California Dental Hygienists' Association meeting, the Public Health Committee developed a fluoride varnish project to be performed in conjunction with their House of Delegates. Hundreds of hygienists signed up for the project to see 1,500 children in one day. Prior to the event, several cases of the swine flu were identified, and some schools in the area of the planned project were closed. Though the schools reopened by the time of the planned event, it was vital to check on the possibility of a mode of transmission across the state. Working with the Public Health Department, it was determined it was in the best interest of the public not to conduct any preventive clinic until the epidemic had passed. One of the main concerns was spreading the virus via the health-care providers who would be coming in from all over the state. The course on fluoride was still conducted and the infection control guidelines were given for future clinics. Hygienists took the supplies back to their communities and conducted varnish clinics after the epidemic was over. Anytime a clinic is being planned, it is vital to work with area agencies that oversee such projects. The added benefit is that many times they will assist with the event and may even help fund the supplies. All epidemiologic considerations must be the first priority.
So what do I need to know about HBV?
One of the viruses we all need to know about is hepatitis B virus (HBV), an occupational risk in dentistry. It is a virulent virus that can survive outside the body up to seven days and still be capable of causing infection.ii Once you're exposed to HBV, the incubation period can last from 45 to 180 days. This can make it very difficult to determine where the exposure occurred in some cases. Five to 10% will have a carrier state. To compound the incubation period challenge, HBV has different concentrations in different parts of the body. The highest concentration is in blood, which hygienists are exposed to daily. The lower concentrations include wound exudate, semen, vaginal secretions, and saliva.8
In adults, approximately half of newly acquired HBV infections are symptomatic, and approximately 1% of reported cases result in acute liver failure and death. Risk for chronic infection is inversely related to age at infection -- approximately 90% of infected infants and 30% of infected children aged 5 years or younger become chronically infected, compared with 2% to 6% of adults. Among persons with chronic HBV infection, the risk for premature death from cirrhosis or hepatocellular carcinoma is 15% to 25%. HBV is efficiently transmitted by percutaneous or mucous membrane exposure to infectious blood or body fluids that contain blood. The primary risk factors that have been associated with infection are unprotected sex with an infected partner, being born to an infected mother, unprotected sex with more than one partner, men who have sex with other men, history of other STDs, and illegal injection drug use.iii
In the dental setting the greatest occupational risks are:
- Injuries from contaminated sharps
- Blood and saliva contamination of cuts on skin or ungloved hands or hands with torn gloves
- Spraying of blood and saliva onto open lesions on the skin or onto the mucous membranes
There are very few cases of dental health-care providers spreading the disease to a patient -- 11 cases between 1974 and 1987. In these cases the dentist was in a highly infectious state and did not routinely wear gloves. The drop in contamination from dentists coincides with when infection control became a major emphasis in dentistry due to the transmission of HIV/AIDS around 1984. There have been a few cases of HBV spread from patient to patient, and in those cases no conclusion was reached on the actual mode of transmission. It is speculated that environmental surfaces could be the mode. This is why it is vital to use barrier protection or to clean and disinfect after every patient. Adherence to infection control guidelines and vaccinations are both effective methods of reducing the risk.
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