This interactive Florida Funeral Ebook contains 12 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.
FLORIDA Funeral Continuing Education
Elite Learning
The courses in this book fulfill 12 hours of home study. Also included is the mandatory HIV/AIDS course required for license renewal.
12-Hour Continuing Education Package $64.95
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WHAT’S INSIDE
THIS COURSE MEETS YOUR HIV/AIDS REQUIREMENT Chapter 1: HIV/AIDS and Other Bloodborne Pathogens for Funeral Professionals - 1 hour (Mandatory) [1 CE hour] Microorganisms carried in the blood that can cause disease are called bloodborne pathogens. Various types of microorganisms can be transmitted through contact with blood, but this course will focus primarily on human immunodeficiency virus (HIV)—the cause of acquired immunodeficiency syndrome (AIDS)—and the virus that causes hepatitis B (HBV). These two diseases are specifically addressed by the Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogens Standard. The course will also touch on hepatitis C virus (HCV), which has dramatically increased in the United States. Of the bloodborne pathogens, funeral professionals are most likely to be exposed to HIV, HBV, and HCV (Davidson & Benjamin, 2006). Chapter 2: Advanced Funeral Planning, 2nd Edition [4 CE hours] Advanced funeral planning is a general term with many facets. It is a decision that must be fine-tuned to the individuality, lifestyle, and religious base of each person. Many people plan for life events, such as weddings and vacations, well in advance. However, most do not plan for something that is certain to happen: their funeral. Further, many people are unaware of how expensive laying a loved one to rest can be. Assisting individuals in their quest to plan ahead significantly reduces the risk of leaving family members not only emotionally unprepared but also financially unprepared. This course is developed as a guide to help you, as a professional [2 CE hours] This course takes laws from the website of United States government’s Occupational Safety and Health Administration’s formaldehyde standards and informs and updates the reader of what checks and balances are in place to keep laborers who require exposure to formaldehyde as part of their vocation safe, healthy, and protected from negligent overexposure or misuse of the helpful yet toxic colorless liquid preservative. Chapter 4: Modern Restorative Arts and Embalming Techniques, 2nd Edition provider or agent, navigate the options that best suit all parties. Chapter 3: Formaldehyde Monitoring Update, 2nd Edition
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[3 CE hours] This course is an intermediate course that is designed to provide some updated information on the new trends and advanced procedures for embalming, restorative art, and burial in the funeral profession. Let’s face the fact that much of the funeral industry has been stuck in the past with limited exposure to advancement and ideas of modern modalities to create a better environment. The past has been passed on for generations and what has been done has been passed on from one generation to another with limited training on the new advances and what could be done. With every changing world and new blood coming into the funeral industry, we start to see these ideas coming up, but still hold habits that are hard to break to introduce these new technological advances. This course isn’t created to force these ideas on you, but to share what is available and to better share what might be working and what might not to better help you grow in this era. Chapter 5: Opioids: Contributing to Both Health and Death, 2nd Edition 50 [2 CE hours] Opioids are pain relievers accessed through prescriptions. When someone takes too many opioids or reaches a tolerance threshold, an overdose occurs. With the increase of opioid deaths in the U.S., it is imperative for the death-care industry to recognize and respect the hidden dangers. The funeral arrangements, visitation, and funeral can be complicated because of the circumstances surrounding the death. Opioids can affect the vessels and tissues of the body and cause embalming issues for embalmers. Funeral directors and embalmers need to be aware of safety procedures before embalming and to incorporate strict personal protective equipment protocols. There are different embalming techniques for embalming an individual who was using opioids at the time of death as well as those who have overdosed on opioids. This course will also describe strategies to help combat overdoses in the funeral home. Final Examination Answer Sheet 60
©2025: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials. i FUNERAL CONTINUING EDUCATION Book Code: FFL1225
What are the requirements for license renewal? Licenses Expire Frequently Asked Questions
CE Hours Required
Mandatory Subjects
Funeral Directors and Embalmers Biennial renewals are due on August 31 odd years.
12 (All hours are allowed through home-study)
1 hour HIV/AIDS
How much will it cost? If you are only completing individual courses in this book, use the code that corresponds to the course when completing online.
COURSE TITLE
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HIV/AIDS and Other Bloodborne Pathogens for Funeral Professionals - 1 hour (Mandatory)
1 4 2 3 2
$14.95 $31.95 $19.95 $25.95 $19.95
FFL01HA FFL04AF FFL02FM FFL03MR FFL02OP
Chapter 1:
Chapter 2:
Advanced Funeral Planning, 2nd Edition
Chapter 3:
Formaldehyde Monitoring Update, 2nd Edition Modern Restorative Arts and Embalming Techniques, 2nd Edition Opioids: Contributing to Both Health and Death, 2nd Edition
Chapter 4:
Chapter 5:
Best Value - Save $47.80 - All 12 Hours
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How do I complete this course and receive my certificate of completion? See the following page for step-by-step instructions on how to complete and receive your certificate. Are you an Florida board-approved provider? Colibri Healthcare, LLC’s courses are approved by the Florida Department of Financial Services, Board of Funeral, Cemetery, and Consumer Services (Provider #113). Are my hours reported to the Florida board? Yes. Colibri Healthcare, LLC will report your hours electronically within two business days. What information do I need to provide for course completion and certificate issuance? Please provide your license number on the test sheet to receive course credit. Your state may require additional information such as date of birth and/or last 4 of Social Security number; please provide these, if applicable. Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Funeral you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, email us at office@elitelearning.com, or call us toll-free at 1-888-857-6920, Monday - Friday 9:00 am - 6:00 pm and Saturday 10:00 am - 4:00 pm EST. Important information for licensees: Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Disclosures Resolution of conflict of interest Sponsorship/commercial support and non- endorsement
Colibri Healthcare, LLC implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity.
It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
Licensing board contact information: Florida Department of Financial Services | Division of Funeral, Cemetery, and Consumer Services 200 East Gaines Street | Tallahassee, FL 32399-0361 | Phone: (850) 413-3039 or (800) 323-2627 Website: https://www.myfloridacfo.com/division/funeralcemetery
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Book Code: FFL1225
FUNERAL CONTINUING EDUCATION
How To Complete This Book For Credit
Please read these instructions before proceeding.
• Go to EliteLearning.com/Book and enter code FFL1225 in the book code box, then click GO . • Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your exam and finalize your purchase. Upon completion, you’ll receive access to your completion certificate. ONLINE FASTEST AND EASIEST!
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CODE TO ENTER
COURSE TITLE
HOURS PRICE
ALL HOURS IN THIS CORRESPONDENCE BOOK
12
$64.95 FFL1225
If you are only completing individual courses in this book, enter the code that corresponds to the course below online.
HIV/AIDS and Other Bloodborne Pathogens for Funeral Professionals - 1 hour (Mandatory)
1
$14.95
FFL01HA
Advanced Funeral Planning, 2nd Edition
4
$31.95
FFL04AF
Formaldehyde Monitoring Update, 2nd Edition
2
$19.95
FFL02FM
Modern Restorative Arts and Embalming Techniques, 2nd Edition
3
$25.95
FFL03MR
Opioids: Contributing to Both Health and Death, 2nd Edition
2
$19.95
FFL02OP
Complete the answer sheet and evaluation found in the back of this book. Include your payment information and email address. Mail to: Elite Learning, PO Box 997432, Sacramento, CA 95899
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iii
FUNERAL CONTINUING EDUCATION
Book Code: FFL1225
Chapter 1: HIV/AIDS and Other Bloodborne Pathogens for Funeral Professionals - 1 hour (Mandatory) 1 CE Hour
By: Staff Writer
Course Approval Number: 383096
Learning outcomes After completing this course, the learner will be able to: Know the difference between HIV infection and AIDS. Describe how HIV is transmitted. Recognize popular misconceptions and stigma surrounding HIV/AIDS. Recall rules and regulations regarding HIV/AIDS status disclosure. Paraphrase protections afforded to HIV-positive funeral personnel under the Americans with Disabilities Act. Course overview Microorganisms carried in the blood that can cause disease are called bloodborne pathogens . Various types of microorganisms can be transmitted through contact with blood, but this course will focus primarily on human immunodeficiency virus (HIV)—the cause of acquired immunodeficiency syndrome (AIDS)—and the virus that causes hepatitis B (HBV). These two diseases are specifically
Understand the dangers of bloodborne pathogens, including hepatitis B and hepatitis C. Identify and define standard precautions that apply to mortuary and funeral procedures. Understand OSHA’s Bloodborne Pathogens Standard. Describe the precautions that should be taken to limit
exposure to bloodborne pathogens. Describe an exposure control plan.
addressed by the Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogens Standard. The course will also touch on hepatitis C virus (HCV), which has dramatically increased in the United States. Of the bloodborne pathogens, funeral professionals are most likely to be exposed to HIV, HBV, and HCV (Davidson & Benjamin, 2006).
INTRODUCTION
Microorganisms carried in the blood that can cause disease are called bloodborne pathogens . Various types of microorganisms can be transmitted through contact with blood, but this course will focus primarily on human immunodeficiency virus (HIV)—the cause of acquired immunodeficiency syndrome (AIDS)—and the virus that causes hepatitis B (HBV). These two diseases are specifically addressed by the Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogens Standard. The course will also touch on hepatitis C virus (HCV), which has dramatically increased in the United States. Of the bloodborne pathogens, funeral professionals are most likely to be exposed to HIV, HBV, and HCV (Davidson & Benjamin, 2006). HIV AND OTHER BLOODBORNE PATHOGENS: MODES OF TRANSMISSION
● Amniotic fluid. ● Any body fluid that is visibly contaminated with blood. (OSHA, n.d.b) These fluids can transmit HIV and other bloodborne pathogens only if they come into contact with mucous membranes or damaged tissue or are directly injected into the bloodstream (CDC, 2021a).
Bloodborne pathogens such as HIV, HBV, and HCV can be transmitted through contact with infected body fluids other than human blood. These body fluids include: ● Semen.
● Vaginal secretions. ● Cerebrospinal fluid.
● Synovial fluid. ● Pleural fluid.
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
What is HIV? The human immunodeficiency virus, HIV, is the virus that causes AIDS. This virus is transmitted from one person to another through blood-to-blood and sexual contact. Pregnant women can pass HIV to their children during pregnancy, delivery, and breastfeeding. HIV is a retrovirus. It forces CD4 white blood cells to convert the virus’s RNA into DNA and instructs the cell to make more retroviruses. These new retroviruses attack other cells (Ganguly, 2023).
CD4 cells, also called CD4 T lymphocytes , or helper T cells, are part of the human immune system. The HIV virus, in hijacking these cells, damages the body’s ability to fight off infection. A CD4 cell count can help determine whether a person is infected with HIV and also how far the disease has progressed. Infection with HIV and a CD4 count at or below 200 per cubic millimeter, along with an AIDS-defining illness, is indicative of AIDS (Cleveland Clinic, 2022b). In the presence of HIV, a low CD4 cell count indicates a high virus load (MedlinePlus, n.d.). In the United States, antiretroviral therapies mean that people who are infected with HIV rarely go on to develop AIDS (HIV.gov, 2023b).
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What is AIDS? AIDS stands for acquired immunodeficiency syndrome. An HIV-infected person receives a diagnosis of AIDS after developing one of the AIDS-defining illnesses (e.g., Kaposi’s sarcoma, pneumocystis pneumonia, or histoplasmosis; Cleveland Clinic, 2021; U.S. Department of Veterans Affairs, 2019). These infections are known as opportunistic The history and origins of HIV and AIDS In the early 1980s, U.S. physicians noticed that a new disease was attacking patients’ immune systems. The cause was a mystery (Sepkowitz, 2001) until 1984, when scientists discovered HIV (History.com, 2021). The earliest apparently indisputable tissue samples containing HIV were taken in 1959 and 1960 in what is now HIV and AIDS statistics Approximately 1,189,700 people in the United States were living with HIV at the end of 2019, with approximately 30,635 new diagnoses in 2020. Of those people, about 87% knew they had HIV (CDC, 2022c; KFF, 2021). New infections According to the CDC (2022c), in 2020, 68% of all new U.S. HIV diagnoses were accounted for by men having sex with men, as compared with 22% resulting from heterosexual contact. Injection drug use alone accounted for 7%, and male-to-male sexual contact plus injection drug use accounted for the rest. The 2020 race/ethnicity breakdown for new HIV cases was approximately 42% Black/African American (though as of 2021 Black/African American people represent only 14.2% of the population; Moslimani et al., 2023), 27% Hispanic/ Latino, 26% Caucasian, 3% multiracial, 2% Asian, 1% American Indian/Alaska Native, and less than 1% Native Hawaiian and other Pacific Islander. The most affected subpopulation was Black/African American gay and bisexual men. Symptoms of HIV infection The first stage of HIV infection is acute infection. About two to four weeks after infection, two-thirds of people will experience flu-like symptoms caused by the body’s immune system’s attempt to fight off the virus. The individual may experience chills and fever, muscle aches, and a sore throat. Other symptoms are night sweats, fatigue, swollen lymph nodes, and mouth ulcers. Symptoms can last from days to several weeks, or a person may experience no symptoms at all (HIV.gov, 2022e). Symptoms of AIDS The third stage of HIV infection is AIDS, a stage that most patients in the United States no longer experience because of the treatments available. During this stage, people may experience: ● Rapid weight loss. ● Recurring fever or profuse night sweats. ● Extreme or unexplained fatigue. ● Prolonged swelling of lymph nodes. Transmission HIV is most commonly transmitted through: ● Sexual contact. ● Sharing of hypodermic needles. ● Pregnancy and childbirth, from mother to child. ● Accidental puncture from contaminated needles, broken glass, or other sharps.
infections because they take the opportunity of a weakened immune system to cause illness. Today, medical treatments can stop HIV from developing into AIDS. Other treatments can prevent or cure some of the illnesses associated with AIDS. Early detection offers more options for treatment and preventative care. known as the Democratic Republic of Congo. However, the genetic diversity in the virus at that time indicates that the disease had probably already been in the human population for a while. The virus has existed in the United States since at least the mid to late 1970s (CDC, 2022a; Worobey et al., 2008). In 2020, people aged 13 to 24 were especially affected by HIV, accounting for 20% of all new diagnoses. Young gay and bisexual men accounted for 84% of all new cases in that age group. The highest rates of new infection have continued to occur in the South. Since the beginning of this epidemic, more than 700,000 AIDS-related deaths have been reported in the United States (HIV.gov, 2022a). In 2019, HIV was the 10th leading cause of death for Americans aged 25 to 34 (CDC, 2023a). In 2020, 38.4 million people were living with HIV worldwide. In 2021, approximately 1.5 million people acquired HIV, which was a decline of 32% in new infections since 2010 (HIV.gov, 2022b). Worldwide, AIDS-related deaths have declined by 68% since 2004. In 2021, 650,000 people died of AIDS-related illnesses, as compared with 2,000,000 in 2004 (HIV.gov, 2023a). According to a 2019 report, sub-Saharan Africa had two thirds of all people in the world who were living with HIV. The next hardest hit areas were Asia and the Pacific (KFF, 2022). While one part of the immune system (the innate immune response) is causing flu-like symptoms, another part (the adaptive immune system) is gearing up and beginning to produce antibodies. These are proteins that bind to the invaders to neutralize them (National Genome Research Institute, 2023). When a detectable number of antibodies begin circulating in the patient’s blood, the person is said to have experienced seroconversion (Wysong, 2022). During the second stage, clinical latency, which may last for a decade or more without treatment, people experience no symptoms. ● Chronic diarrhea. ● Sores of the mouth, anus, or genitalia. ● Pneumonia. ● Neurological disorders. (HIV.gov, 2022e) Many of the symptoms are caused by opportunistic infections.
● Contact between broken or damaged skin and infected body fluids. ● Contact between mucous membranes and infected body fluids.
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Unbroken skin forms an impervious barrier against HIV and other bloodborne pathogens. However, infected blood can enter the system through: ● Open sores. ● Cuts. ● Abrasions. ● Acne. ● Any sort of damaged or broken skin, such as sunburn or blisters. one pill per day (FDA, 2019; NIAID, 2018) or an injection every other month (Williamson, 2022). The mid-1990s saw the development of new, less expensive drugs (NIAID, 2018). In 2007, a drug called maraviroc , which targets the primary receptor that HIV uses to gain entry into an immune cell, was developed. Also in 2007, a new class of drugs that inhibit one of the steps in the process of HIV’s incorporation into the host cell’s genome was introduced (Scarsi et al., 2020). One current weapon against HIV is post-exposure prophylaxis (PEP). Taken within 72 hours of possible exposure to HIV, this combination of antiretroviral drugs is highly effective in preventing seroconversion (CDC, 2022d). Also available is pre-exposure prophylaxis (PrEP), which reduces the risk of acquiring HIV from sexual activity by 99% (CDC, 2022e) and from injection drug use by at least 74% (HIV.gov, 2022d). These medications may be right for people who engage in risky behaviors. The HIV/AIDS drugs lamivudine and adefovir can help patients with hepatitis B who have no other options. Protease inhibitors have been developed to combat infections such as hepatitis C, influenza, and even COVID-19 (FDA, 2022; Pfizer, n.d.). A modified version of a drug called cidofovir , used to treat eye infections in AIDS, is now being developed to treat and possibly prevent smallpox infection (CDC, 2021c). (Naturally occurring smallpox is considered eradicated, but bioterrorists could weaponize the disease.) The antiretroviral drugs adefovir (used for HBV) and tenofovir can eradicate the banana streak virus, which endangers banana crops (CORDIS, 2003). The ADA also requires employers to provide “reasonable accommodations” for employees with disabilities. Reasonable accommodations are changes or adjustments in the job or work environment that permit individuals with disabilities to perform the essential functions of a job. An employer may choose to go beyond the ADA and provide an accommodation that would not be required under the law. For example, removing an essential function from an employee’s job description and providing HIV education for all employees are not examples of reasonable accommodations. Similarly, while allowing an employee to work part-time is a type of reasonable accommodation, continuing to pay that employee a full-time salary is not required by the law. The ADA establishes a baseline—a floor, not a ceiling. Specific legal boundaries of reasonable accommodation Many people with HIV or AIDS will need minimal or no accommodations (HIV.gov, 2017a). Employers should consider the ADA implications of any decisions involving an employee with HIV infection or AIDS, including any decisions about disclosing an employee’s HIV status.
Rarely, in work situations, transmission occurs through accidental puncture from contaminated needles, broken glass, or other sharps; contact between broken or damaged skin and infected body fluids; or contact between mucous membranes and infected body fluids. Whenever there is blood-to-blood contact with infected blood or body fluids, there is a slight potential for transmission. Advances in treatment of HIV/AIDS Research has led to dramatic improvements in length and quality of life for people with HIV. In the early days of the AIDS epidemic, the average life expectancy after a person developed AIDS was 1 year (NIAID, 2018). Now life expectancy with HIV is close to normal (Hanes, 2020). In the 1980s, a drug called azidothymidine (AZT, also called zidovudine) was found to suppress replication of HIV. At first, AZT was used only to treat AIDS, but research showed that the drug could also delay the onset of AIDS in people with HIV infection (NIAID, 2018). The rapid mutation of HIV often conferred resistance to a one-drug treatment. For this reason, another, similar drug was added to the AZT regimen. In 1996, yet another drug was added. This new triple-drug therapy became known as highly active antiretroviral therapy (HAART) . The new, third drug was a protease inhibitor (NIAID, 2018). With two kinds of drugs in use, viral loads started to drop to undetectable levels. The next step was to simplify the regimen, so that now many people with HIV may take only HIV research and other diseases HIV/AIDS research is helping solve other medical mysteries (Goodenow, 2018; Schwetz & Fauci, 2019). Scientists have learned, for example, that Kaposi’s sarcoma is caused by a herpesvirus. Also, the development of antiviral medications for HIV helped to lead to effective antiviral therapies for hepatitis C. The research has led to insights into immune activation and inflammation in other diseases and may help improve treatment of Alzheimer’s disease (Guengerich, 2020).
Workplace accommodations for employees with HIV/AIDS Today, people living with HIV infection and even AIDS can work productively for many years. HIV/AIDS raises difficult medical, legal, and emotional issues—fear, stigma, death, and dying. Employment provisions under the Americans with Disabilities Act of 1990 The Americans with Disabilities Act (ADA) prohibits discrimination against all people with disabilities or
perceived disabilities, including people with HIV infection and AIDS. A detailed explanation of the ADA is beyond the scope of this course but can be found at https://www. ada.gov. In most cases, unless an employee is requesting accommodations, the employee is not required to disclose HIV status (HIV.gov, 2017b). However, the employer does have the right to ask if a potential employee has any health conditions that would affect his or her ability to do the job or pose a serious risk to others. Similar legal requirements have been in place for employers covered by the Rehabilitation Act of 1973 and by certain state and municipal ordinances covering disability discrimination in employment.
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accommodation. A manager’s message about how an employee with HIV infection or AIDS will be treated is critical because it sets a clear standard. Balancing the costs and benefits of accommodation How a company treats one employee with a chronic illness is a clear indicator of the standard it will use in managing other employees. Witnessing support, accommodation, and respect for a coworker with a chronic illness strengthens worker morale, loyalty, and productivity. Disclosing HIV status An employee with HIV/AIDS must manage the overwhelming emotions of facing a chronic and often stigmatizing illness while continuing to be a productive worker. Like employees with many other chronic illnesses, those with HIV infection must adhere to a strict drug schedule and sometimes grapple with side effects and changes in medications. HIV-positive employees must decide who to inform about their health status, how much information to reveal, and when to reveal it. The stigma still associated with HIV/AIDS makes such decisions even more difficult. The decision to disclose HIV status belongs to the HIV- positive individual. It is illegal for an employer to ask a current or prospective employee about HIV status. Nonetheless, the HIV-positive employee may have to disclose some health information to managers or supervisors when seeking an accommodation. Accommodations can be made without the supervisor’s knowing that the individual is HIV-positive or has AIDS; the supervisor may know only that the individual is ill. Intensive workplace HIV/AIDS education may precede or follow a disclosure. Employees may inform managers of their health condition but request that the information be kept confidential; by law, the employer must comply with that request. Coworkers unaware of the circumstances may become suspicious of perceived preferential treatment and become resentful. When the performance of their work groups is called into question by superiors, managers may find themselves unable to adequately explain the situation. In such circumstances, the employee may be uncomfortable as well, knowing that rumors are circulating and feeling the unwanted attention from others. At that point, it may be helpful for the manager to discuss with the employee what, if anything, he or she wants to do to address the situation. The decision to disclose rests with the employee, but the employee may be willing to risk disclosure if the manager is not forcing the issue but, instead, offers support for whatever decision is made. Work can hold deep ethical, economic, and personal significance. The importance of work and the workplace for people with HIV infection and AIDS should be honored.
Employers should be careful not to violate the ADA’s strict rules about maintaining confidentiality of such information. As awareness of the ADA and its employment provisions increases, more employees are disclosing their HIV status to their employers, managers, coworkers, and friends. Disclosure takes courage and needs an environment of cooperation and support. The stigma still associated with HIV means that this disclosure—especially in the workplace setting—too often occurs only when a crisis forces the issue out into the open. Many employers believe that encouraging disclosure may create obligations that might not have otherwise existed. An environment that discourages or is hostile to disclosure, however, may present altogether different problems, legal and otherwise, like those a company experiences when it does not encourage employees with harassment complaints to come forward. Providing an environment where complaints or situations (such as the existence of a disability and the need for an accommodation) can be discussed and remedied without the fear of retaliation is a sound legal as well as business policy. Balancing accommodations with expectations The dual goals of accommodation are to ensure that work assignments are accomplished and that the individual with HIV infection or AIDS continues working as long as possible. Accommodation is a process of ongoing problem solving between an employee with HIV infection or AIDS and his or her supervisor. Because the manifestations of HIV infection and AIDS are different in different people, accommodation is not a one-time alteration of a job or physical structure. Just as each person with HIV infection or AIDS experiences the disease differently, each person will also require different accommodations. An accommodation that is effective for an earlier phase of HIV infection may not be effective for a later phase; an accommodation is an ongoing process requiring ongoing evaluation, in part because the manifestations of HIV infection and AIDS can change over time, and in part because some attempted accommodations may not work for either the employer or the employee. Accommodations as a team effort and their impact on a company’s workforce, managers, and policies Because of the fear and stigma still associated with HIV/ AIDS, accommodating people with HIV infection and AIDS affects virtually everyone in the workplace. A fearful work environment discourages productivity. When providing accommodation for employees with HIV infection or AIDS, an employer might consider addressing coworker attitudes. To dispel unwarranted fears and to ensure cooperation in the accommodation process, managers need accurate information about HIV infection and AIDS. Coworkers and managers can respond constructively in a supportive environment where emotional responses to HIV can be addressed. Leadership is important to effective
OTHER BLOODBORNE PATHOGENS
HIV is one among many bloodborne pathogens, including other viruses, as well as bacteria, parasites, and possibly even prions (which, though usually transmitted through brain material, have been transferred via blood transfusions; CDC, 2022b).
Of most concern, however, are hepatitis B and C (HBV and HCV). Although preventable by vaccination, HBV still infects many people in the United States. HCV, for which no vaccine yet exists, is most commonly spread through sharing needles (CDC, 2020b). HBV and HCV are leading causes of liver cancer (CDC, 2023c).
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The basic facts on hepatitis Viral hepatitis
HAV, which is spread sometimes by contact with blood but mainly by contact with feces (Mayo Clinic, 2022a), is not considered a threat on the same level as HBV or HCV. It will therefore not be discussed in detail in this course. Hepatitis B (HBV) In the United States, in 2019, an estimated 20,700 people were acutely infected with HBV. That same year saw 1,662 HBV-associated deaths. An estimated 580,000 to 2.4 million persons in the United States are living with HBV infection, and two thirds of them may be unaware that they are infected (Conners et al., 2023). Despite the vaccine and public awareness campaigns, progress toward the elimination of this disease has been slow (HHS.gov, 2022a). “Hepatitis” means “inflammation of the liver,” and as its name implies, hepatitis B is a virus that infects the liver. This disease is transmitted through blood-to-blood contact and initially causes inflammation of the liver. Ultimately, it can lead to more serious conditions, such as cirrhosis and liver cancer (Mayo Clinic, 2022b; NIDDK, 2020). There is no “cure” or specific treatment for HBV, but many people who contract the disease will develop antibodies, which help them get over the infection and protect them from getting it again. (Infection with HBV will not stop someone from getting another type.) Treatment can involve antiviral medications and interferon injections. Other drugs are currently in development. The HBV virus is very durable, and it can survive in dried blood for up to seven days (CDC, 2023b). For that reason, this virus is the primary concern for employees such as housekeepers, funeral directors, custodians, laundry personnel, and other employees who may come into contact with blood or potentially infectious materials in a non-first-aid or medical care situation. Symptoms HBV symptoms begin with a sense of fatigue, possible stomach pain, loss of appetite, and even nausea (Cleveland Clinic, 2022a; Mayo Clinic, 2022b). As the disease continues to develop, jaundice (a distinct yellowing of the skin and eyes) and darkened urine often appear. However, people who are infected with HBV will often show no symptoms for some time. Symptoms begin an average of 90 days after exposure, with a range of 60 to 150 days. However, many people have no symptoms at all (CDC, 2022f). Hepatitis B vaccine For 5% to 10% of adults who contract HBV, infection is lifelong. Among infants, 90% of those infected develop chronic HBV. Up to 50% of children between the ages of 1 and 5 who have HBV develop chronic infection. The vaccine should be given to infants between 12 and 24 hours after birth (Hepatitis B Foundation, n.d.a). The OSHA Bloodborne Pathogens Standard requires that employers “offer the vaccination series to all workers who have occupational exposure” to HBV. Morticians are listed among the examples of workers who may have occupational exposure. The standard goes on to say that “the vaccine and vaccination must be offered at no cost to the worker and at a reasonable time and place” (OSHA, 2011a). The vaccination is to be offered after the worker is trained and within 10 days of beginning to work on the job that might involve exposure to HBV. The vaccination is not required if the worker has already been vaccinated, or if antibody testing has shown that the worker is immune, or if the vaccine is medically contraindicated. A worker may decline vaccination but must sign a declination form. If the worker
Hepatitis is an inflammation that can have many causes. However, when health professionals talk about viral hepatitis, they usually mean hepatitis caused by the hepatitis A, hepatitis B, or hepatitis C virus. When they talk about bloodborne hepatitis, they usually mean HBV and HCV (CDC, 2019). The differences between hepatitis A, B, and C Although HAV, HBV, and HCV have similar symptoms, the viruses themselves are quite different. HAV is most commonly spread through the ingestion of stool and is much more rarely spread through contact with blood. Acute symptoms are not followed by the chronic problems that HBV and HCV can cause. HBV and HCV can infect a person whose mucous membranes or blood are exposed to an infected person’s blood, saliva, wound exudates, semen, or vaginal secretions. Like HIV, HBV and HCV can be spread by sharing hypodermic needles. HCV can be acquired from improperly sanitized tattooing needles. Symptoms appear more gradually than in HAV. Unlike HAV, HBV and HCV can stay in the body—sometimes for a lifetime—and eventually cause chronic, serious liver diseases. The symptoms of viral hepatitis Early symptoms of viral hepatitis include: ● Fatigue. ● Tenderness in the upper right abdomen. ● Sore muscles and joints. ● Loss of appetite. ● An altered sense of taste and smell. ● Nausea, vomiting, and diarrhea. ● Low-grade fever. ● Malaise. Other symptoms can include jaundice—abnormally yellow skin and eyes caused by bile entering the blood—as well as darkened urine and light-colored or gray stool (Kahn, 2021; Mayo Clinic, 2022b). Diagnosis of hepatitis Although health providers use information about symptoms, health history, and behaviors to help in diagnosis, only blood tests can confirm the diagnosis and pinpoint which type of hepatitis a person has (CDC, 2020d; Hepatitis B Foundation, n.d.b). Treatments for viral hepatitis There is no medication that can treat the initial illness that viral hepatitis causes. Health professionals manage symptoms and try to help the body’s immune system fight the infection. A patient may be told to: ● Avoid alcohol and other drugs, large doses of vitamins, and prescription drugs metabolized by the liver (sometimes including birth control pills). ● Drink high-calorie fluids such as fruit juices and eat a balanced diet; to control nausea, several smaller meals are advisable. ● Limit activity if hepatitis is symptomatic; this typically means bed rest at first, progressing to normal activity as symptoms disappear. A patient may be hospitalized in cases of severe vomiting or in the absence of improvement after several weeks. Researchers are making gains in treating the chronic liver disease associated with HBV and HCV. New oral treatment regimens offer cure rates in more than 90% of patients with HCV (FDA, 2017; Mayo Clinic, 2021). Effective treatments also exist for patients with chronic HBV, although in most cases the treatments will need to be lifelong (Mayo Clinic, 2022b).
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later decides to be vaccinated and is still in a job where exposure is possible, the employer must make vaccination available (OSHA, 2011a). The HBV vaccination is given to adults in a series of two, three, or four shots, depending on the vaccine or condition. The series gradually builds up the body’s immunity to HBV (Dorwart, 2022). Once vaccinated, a person does not need to receive the series again. People who might be carriers of hepatitis B ● An infected person can begin infecting several weeks before symptoms appear and can continue infecting others as long as the person’s body harbors the virus. ● About 1 in 10 people infected with HBV become chronic carriers and can spread the disease even if they have no symptoms. Some of these people eventually die of liver diseases, including cirrhosis—a serious scarring of the liver—and liver cancer. Infected infants and small children are very likely to become carriers of HBV. (Oakland County, Michigan, n.d.) Risk behaviors for contracting hepatitis B Practicing unsafe sex The more partners with whom a person has vaginal, anal, or oral contact, the higher the risk of becoming infected with HBV. Abstinence is the most effective way to prevent sex-related transmission. It is advisable always to use barrier protection when having vaginal, anal, or oral contact. People who have sex with multiple partners should be sure to get the HBV vaccination. Sharing needles No matter what drug is injected, sharing needles is risky. Only reputable professionals should be sought for acupuncture or tattoos. Close, frequent contact with bodily fluids Funeral professionals, like healthcare workers, should be vaccinated. People who live long-term with others who have HBV occasionally become infected. On the other hand, receiving a blood transfusion or other blood products no longer carries the threat of HBV that it once did. Today, all blood is screened for HBV before it is used. Prevention of hepatitis B The best way to avoid contracting HBV is to get vaccinated. Approximately 90% of persons who receive the injections obtain full immunity lasting more than 30 years (Dorwart, 2022). People should avoid high-risk behaviors and practice good personal hygiene when sharing food, handling human remains, and using bathrooms. They should not share razors, toothbrushes, or pierced earrings with anyone. Exposure to hepatitis B People who have not been vaccinated against HBV but are exposed to the virus can be vaccinated and, in some circumstances, treated with HBV immune globulin (HBIG) as well (CDC, 2020e). It is important to be treated and vaccinated as soon as possible after exposure. Preventing the Spread of Hepatitis B. People who have been exposed to HBV: ● Should not engage in sexual contact without a condom. ● Should not donate blood. ● Should bandage all cuts and open sores. ● Should not share anything—such as needles, razors, or toothbrushes—that could be contaminated with their blood, semen, vaginal secretions, or saliva. ● Should wash their hands well after using the toilet or handling human remains.
A pregnant patient with HBV, along with the baby, must receive HBIG and HBV vaccine within 12 hours of birth (CDC, 2020e). All pregnant women should be screened for HBV, and all babies should begin a series of HBV vaccinations within 24 hours of birth. Babies who contract HBV are likely to develop chronic HBV. Hepatitis C (HCV) HCV is the most common bloodborne infection in the United States (FDA, 2017). Between 2010 and 2018, the opioid epidemic (with its increase in injection drug use) brought about a quadrupling of acute HCV infections among people aged 18 to 39 (Maness et al., 2021). The HCV virus spreads primarily through contact with infected blood and can cause cirrhosis, liver cancer, or liver failure. HCV was formerly the major reason for liver transplants in the United States (Cleveland Clinic, 2020; Noureddin et al., 2018). The development of new drugs sent this reason for transplantation into a steep decline, with a primary diagnosis of HCV accounting for 858 (approximately 10%) of the 8,250 procedures in 2018 (HRSA, n.d.; Noureddin et al., 2018). The year 2019 saw 14,242 HCV-associated deaths in the United States (CDC, n.d.). The number of HCV-infected people may be four times the number of those infected with HIV. HCV is less likely than the other hepatitis viruses to cause serious illness at first (only one quarter of the people infected develop symptoms), but about 75% to 85% of those infected develop chronic disease (Cleveland Clinic, 2020). As of 2021, only 52% of the 3.7 million people in the United States with chronic HCV infection were aware that they had the disease, and only 37% of those infected had received treatment (Maness et al., 2021). Like HBV, HCV can be spread by contact with infected blood, and possibly semen, vaginal secretions, and saliva. In the United States, the most common means of transmission is injection of drugs. In 2019, there were an estimated 57,500 new hepatitis C infections (CDC, n.d., 2021d). Between 2013 to 2016, there may have been more than 2 million Americans living with chronic HCV. Between 2010 and 2020, the number of reported HCV infections increased fivefold, mainly because of injection drug use (HHS.gov, 2022b). HCV treatment is expensive. As of 2020, one pill could cost more than $1,000 (Myhre & Sifris, 2022). Even so, this represents a decline in costs over the past few years (CDC, 2021b). According to the CDC (2021b), the number of people with HCV who seek treatment has declined in spite of decreasing costs. Some reasons for people’s reluctance or difficulty in pursuing treatment may be Medicaid’s restrictions on provider types, patient sobriety requirements, and complicated authorization processes. The COVID-19 pandemic may have placed barriers with stay-at-home orders, reduced operation of clinics, and self-isolation. One problem with the new, highly effective, direct-acting antiviral medications (DAA) for HCV is that they can reactivate an HBV coinfection (Mavilia & Wu, 2018). Who is at risk? People are at risk who share needles; received blood during a blood transfusion or organ transplant before 1992; work with blood as a funeral director or embalmer (Hoffman & Healing, 2022); or have vaginal, oral, or anal contact without barrier protection (CDC, 2020c). All donated blood is now screened for HCV (American Red Cross, n.d.).
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Prevention of hepatitis C Similar precautions to those used for HBV can help to prevent infection with HCV. It is important always to use barrier protection during vaginal, anal, or oral contact;
practice good personal hygiene; and never share needles, razors, toothbrushes, or pierced earrings with anyone. Although no HCV vaccine is available, research is ongoing (HIV.gov, 2022c; Rizza, 2020). UNIVERSAL AND STANDARD PRECAUTIONS WHEN DEALING WITH HIV AND OTHER BLOODBORNE PATHOGENS
Universal precautions Universal precautions (UP) describe the practice of avoiding contact with bodily fluids by means of wearing nonporous articles, such as gloves, goggles, and face shields. In this approach to infection control, all human blood and some body fluids are treated as though they are infectious. Standard precautions In 1996, the CDC added more infection prevention elements to universal precautions to protect healthcare workers from bodily fluids that had not been included in universal precautions. The new term was “standard OSHA Bloodborne Pathogens Standard To protect healthcare workers (and their patients), OSHA developed the Bloodborne Pathogens Standard. The CDC includes mortuary and funeral personnel under the category of healthcare workers. The universal precautions guidelines were the foundation for OSHA’s 1991 development of precautions to prevent occupational exposure to bloodborne pathogens in healthcare settings, including the funeral industry. OSHA (2011b) defines bloodborne Exposure control plan In keeping with paragraph 1910.1030(c)(1)(i) in OSHA’s Bloodborne Pathogens Standard, employers need to establish an exposure control plan and update the plan annually (OSHA, 2011b). This written plan is designed to eliminate or at least minimize occupational exposure to bloodborne pathogens. In the plan: ● The employer prepares an exposure determination containing a list of job classifications in which all workers have occupational exposure, a list of job classifications in which workers have some exposure, and a list of tasks and procedures that result in exposure.
In the early 1990s, OSHA mandated the use of universal precautions, which were particularly meant to protect against potentially infectious blood and other bodily fluids. Although OSHA’s Bloodborne Pathogens Standard incorporates universal precautions, they are no longer used on their own (OSHA, n.d.b). precautions” (SP; Gamma Compliance Solutions, 2021; OSHA, n.d.b). These precautions cover bloodborne and airborne transmission and assume that all patients are potentially infectious. pathogens as infectious microorganisms present in human blood that can cause disease in humans. These pathogens include, but are not limited to, HIV, HBV, and HCV. OSHA covers bloodborne pathogens under Standard Number 1910.1030 (OSHA, n.d.a). The OSHA Bloodborne Pathogens Standard can be accessed at https://www.osha. gov/laws-regs/regulations/standardnumber/1910/1910.1030 ● The employer includes annual updates reflecting changes in tasks, procedures, and positions that affect occupational exposure, along with technological changes that reduce or eliminate occupational exposure. ● The employer documents having solicited input from frontline workers in identifying, evaluating, and selecting effective engineering and work practice controls. (OSHA, 2011b) State requirements may be more stringent than those of OSHA, and it is therefore important to be aware of state regulations (Denault & Gardner, 2022).
CDC recommendations concerning universal versus standard precautions Although the OSHA Bloodborne Pathogens Standard incorporates universal precautions into its mandates for dealing with such threats as HIV, HBV, and HCV, the Centers
for Disease Control and Prevention prefers that funeral professionals incorporate the extra protection offered by standard precautions (NFDA, n.d.).
PERSONAL PROTECTIVE EQUIPMENT (PPE)
PPE refers to a variety of barriers and respirators, used alone or in combination, to protect mucous membranes, airways, skin, and clothing from contact with infectious agents. The selection of PPE is based on the nature of the interaction or Gloves Gloves are used to prevent contamination when anticipating direct contact with blood or body fluids, mucous membranes, nonintact skin, and other potentially infectious material, as well as for handling or even touching visibly or potentially contaminated equipment and environmental surfaces (Siegel et al., 2007 [updated in 2022]).
the likely mode of transmission. Hand hygiene is always the final step after removing and disposing of PPE. The following sections highlight the primary uses and methods for selecting PPE equipment: For contact with blood and body fluids during nonsurgical procedures, a single pair of gloves generally provides adequate barrier protection. Vinyl gloves have higher failure rates than latex or nitrile gloves (Siegel et al., 2007/2022). Either latex or nitrile gloves are preferable for procedures that require manual dexterity or that will involve more than brief contact with potentially infectious materials. For embalmers, nitrile gloves are in any case preferred because of nitrile’s higher chemical resistance against formaldehyde (NFDA, 2010).
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