Haunting Danger, Unseen Enemy:
An Introduction To Blood Borne Pathogens For Martial Artists - Part
By Len Sclafani, DDS
A microscopic view of the Hepatitis B virus
Editor’s Note: This is the first of a two part
article on blood borne pathogens in the martial arts. This article defines
several major pathogens and their dangers. A following article will discuss
infection control, prevention, “universal precautions” and
what you should do if you are exposed.
“Out of sight; out of mind.” “Ignorance is bliss.” “What
you don’t know won’t hurt you.” How many times have
we all heard these little truisms and nodded obligingly in agreement?
Probably, far too often. Fortunately, there are better truisms that can
save us from ourselves, such as, “Forewarned is forearmed,” “It’s
what you learn after you know it all that counts,” and “It’s
what you don’t know that you don’t know that will kill you.” (I
may have made up that last one myself).
As I was wading through the stacks of professional journal articles,
textbooks and lecture notes I used as references for this part 1 and
2 of this article, I encountered two major challenges. One was the temptation
to get overly in depth with the material, and the second was to present
it to completion before you, the reader, went into a boredom induced
coma. Outside of sitting at a lecture that is 95% histologic tissue slides,
the topic of Infection Control and Blood Borne Pathogens is a guaranteed
cure for terminal insomnia. I’ve footnoted and referenced things
that I was not sure of, and I’ve tried to keep personal opinions
to a minimum. Outside of an occasional attempt at some comic relief,
all the didactic material can be easily verified, and if anyone has a
question or comment, my email address is at the bottom of the article.
The first thing we need to do is establish a few definitions and abbreviations:
1) Blood Borne Pathogens (BBP) are pathogenic microorganisms present
in human blood that can cause disease. Viruses are the smallest infectious
agents with very simple structures and methods of replication. (1)
Other potentially infectious materials include human body fluids such
as saliva, or any body fluid which may or may not be contaminated with
blood.(2) Fortunately, sweat does not
qualify as a potentially hazardous body fluid!
The major pathogenic viruses we will be talking about in this article
are Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and Human Immunodeficiency
Virus (HIV) which causes Acquired Immune Deficiency Syndrome (AIDS).
The Occupational Health and Safety Administration (OSHA) has determined
these to be such a concern that in 1991 it published “The Occupational
Exposure to Bloodborne Pathogens Standard.” (3) Although it was
intended to protect employees specifically at risk of exposure to BBP,
the precautions and housekeeping practices are applicable to any martial
arts dojo where exposure to any of the “beasties” mentioned
above is possible.
Since we have already identified the most important bad guys in this
game, we next need to discuss them individually, how they DO and DO NOT
infect us, some current treatments, and finally prevention against infection.
This last aspect is probably the most important.
blood from an injury can cause an exposure to bloodborne
Once again, let me emphasize that my purpose here is not to induce a
generalized panic since there has not to my knowledge ever been a case
of transmission of any of these diseases having an origin in a dojo setting
(but on the other side, for those who have contracted one of these diseases,
they often have no idea where they picked it up). Nonetheless, I would
not want to be the first one on my block to be written up by OSHA, the
Department of Environmental Protection, the Centers for Disease Control
(CDC) and every other professional journal on the planet. It’s
one segment of my “15 minutes of fame” that I’d like
reserved for something less notorious.
1- Human Immunodeficiency Virus (HIV)
HIV, the virus that causes AIDS, is not a major cause for alarm for
most martial arts schools. HIV is a very fragile virus; it does not exist
very long (maybe ½ hour) in air, and is transmitted almost exclusively
by direct blood inoculation, or intimate sexual contact. Hopefully, any
fraternizing that does take place is not done during class time. HIV
is NOT transmitted by sweat (thank goodness) or casual contact. Practices
such as kissing and sharing of drinking cups are considered casual contact.
Isn’t that reassuring?
2-Hepatitis B Virus (HBV)
Hepatitis B (HBV) and C (HCV) attack the liver.
While I’m at a loss for a pithy segue between the two, HIV is
not too easy to contract, but if you do it will eventually kill you.
On the other hand, HBV will probably not kill you, but it is much more
easily and efficiently transmitted and it is a much more resilient organism.
The most frequent route of transmission in the U.S. is by high risk sexual
activity. (4) For our interests though, any contact of mucous membranes
or broken skin with an infected person’s body fluids, especially
saliva (or blood), must be considered an exposure.(5) What that means
in lay terms is that if you punch an HBV positive opponent in the mouth
and you cut your hand on his tooth, you are at risk for infection.
The average incubation period for HBV is 60 - 90 days. Symptoms include
yellowing of the eyes and skin (jaundice), loss of appetite, feeling
extremely tired, nausea, vomiting, and fever. After a bout of acute HBV
infection, most people clear the disease, completely recover and are
then immune to the virus. Chronic infections or “carriers” occur
in about 10% of adults. A “carrier” is a person who is infected
with the virus and who has never fully recovered from the infection;
they carry the virus and can infect others for the rest of their lives.
Chronic HBV sufferers are more likely to develop cirrhosis, liver diseases
and liver cancer.
The bad news about HBV is that it can live outside the human body and
has even been documented to be active for as long as 8 days on a dry
surface. (6) Think for a moment of the implications of this if your dojo
has a rope or cloth covered makiwara and there are some reddish-brown “stains” on
There is a silver lining to the HBV cloud though. This virus has been
thoroughly investigated and the modes of transmission are all well known.
Safe and effective vaccines have been developed, tested, and administered
around the world. A strategy for eliminating HBV transmission in the
US through universal vaccination of new babies is progressing, and global
elimination of HBV through vaccination is a persuable goal.
3- Hepatitis C Virus (HCV)
Well, just when you thought it was safe to go back in the water, last
but certainly not least we have Hepatitis C. HCV has recently been deemed
the most common blood borne disease in America. (7) This is one real
nasty character! One of the problems is that we really don’t know
as much about this virus as we do about the others. Besides normal modes
of transmission (blood - blood), HCV has been transmitted via mucosal
routes, i.e., getting splattered in the face and eyes by blood, and it
has also been detected n the saliva of patients with chronic hepatitis,
which is one of the reasons that HCV is considered the most serious of
the viral hepatitis infections. Its ability to produce infections, hence
a constant risk of being spread, is upward of 85%! HBV if you recall
has a chronicity of only 2-10%. These chronically infected individuals
with HBC also display a long term vulnerability to cirrhosis, liver failure
and hepatocellular carcinoma. It is the leading cause of the need for
liver transplantation in the US.
The clinical course of the disease is also insidious, mild and slow
to develop, and most of those who are infected are unaware that they
are. 80% are asymptomatic and do not develop the typical jaundice of
acute hepatitis. To make matters worse, there are not predictable, reliable,
or efficacious treatments for Hepatitis C, and no vaccines are yet available
for it. There is a genuine fear and concern in the infectious disease
treatment community that HCV will become a far worse epidemic than AIDS.
Kinda gives you something to look forward to, doesn’t it?
There has also been a report of HCV being transmitted by saliva in a
human bite. (8) The concern to us as martial artists should be pretty
immediate. Accidentally, or intentionally, punching someone in the mouth
results in a pretty good chance of blood spillage by both the “puncher” and
the “punchee.” A human bite is bad enough by itself, but
throw in a few potentially life threatening blood borne diseases, and
you are probably not likely to get invited to too many more parties.
How You Can Be Exposed
Although some of the following will be mentioned in part two if this
article, I think it bears discussion here as these things cannot be overemphasized.
How does one go about contracting (or not contracting) these diseases?
The generally recognized “Routes of exposure describe how the
virus can get into your system.
The term, “Inoculation” refers to having infected fluid
injected into your body when something punctures your skin. Although
the most common way for this to happen is from needlesticks or other
cuts from contaminated instruments in the healthcare environment, the
dojo presents its own risks. Inocuclation could occur by being bitten
or by punching someone in the mouth and cutting one’s bare knuckles
on a punchee’s tooth.
Exposure to blood or other infectious materials on healthy, intact skin
usually will not result in infection.
However, if you have any break in the skin such as a cut, scratch, an
open wound, skin tear, abrasion, or lacerations, you could be infected
by exposure to contaminated blood or other infectious materials.
While most are concerned with the concussive injuries that are inevitable
in the karate dojo, there may also be a legitimate concern regarding
the more prolonged contact that occurs in judo, aikido, or other grappling
arts. While ordinary sweat is generally not considered to be an infected
body fluid, but it is potentially hazardous if mixed with blood. If ANY
bleeding is noticed, then those involved should STOP immediately, leave
the deck, determine the source and the severity of the bleeding, and
treat it properly before being allowed to continue.
If your body fluids, such as from a cut, scrape or abrasion, mix with
dried blood there is also the potential for any live agent to be transferred
back to you. This is especially critical in any punching surface, such
as a punching bag or makawara (especially a hard one, such as made of
wood, that is typically wrapped in cord) where the practitioner often
hits the surface repeatedly. If the practitioner has an open would on
his hand, foot or other body part he will leave his own blood on the
striking surface which can also potentially mix and transfer back any
agents that still might be active within the dried blood, already
there. The HBV has been known to remain active on contaminated surfaces
for up to 10 days.
Eyes and Mucous Membranes
Mucous membranes (such as in the eyes or lubricated inner lining of
the mouth and nasal passages) represent a potential risk of exposure,
although they represent a small proportion of reported cases. It is potentially
possible to transmit HIV, HBV and HCV from one person to another through
one person’s blood reaching the mucous membrane of another.
We’ve all seen the slow motion footage of the aerosol created
by a human sneeze. Or who can forget the impact of the action shots of
Rocky Balboa’s face being slammed by a right cross courtesy of
Apollo Creed, and the resultant splash of blood, sweat and tears that
erupted from his glove battered face? These aerosol droplets can enter
the body via our mouths, noses, eyes, and any open cuts we may have.
It normally requires “intimate” contact to transmit bloodborne
pathogens from one person to another. This can be generally defined as
direct person-to-person mixing of blood and/or other infected body fluids.
Needle sticks, sexual contact (in both the Biblical and Clintonian Presidential
senses), or direct inoculation, say, or during grappling direct contact
(even rubbing) of opponent’s open skin abrasions or cuts.
It should be noted here that assisting someone who is injured requires
care to avoid exposure to the injured person's blood or other infectious
materials. Dojo operators should maintain a first aid kit that includes
gloves and other protective equipment and employees should be trained
how to use them properly. More on this in Part 2.
Generally, bloodborne pathogens are not transmitted by casual contact.
I’m not personally sure if there are any hard and fast rules for
distinguishing which kinds of contact go into which class but such things
as sharing drinking water bottles and kissing are considered “Casual
Contact.” Bloodborne pathogens have not been shown to be transmitted
by contact with saliva, towels, cups, or water bottles, but respiratory
and other illnesses can be transmitted by contact with these items so
care should be taken.
In sum, the sources of potential infection include:
For purposes of this article, let’s consider blood and saliva
as the principal body fluids that can be “infected” and therefore
a direct source of concern. Once again, sweat, by itself, is not a problem.
Part two of this article will discuss how to protect yourself and what
you can do if you are exposed to someone else’s blood.
The medical information provided in the article is of a
general nature and while the author and others who have worked on or
contributed to this article in some way have done their best to insure
the accuracy of the information given, the author, contributors and FightingArts.com
can not guarantee the complete accuracy of all factual information given,
and also acknowledge that new relevant information is or might be discovered
which could change, add to, or invalidate some information provided herein.
If you are interested in developing a bloodborne pathogen prevention
program you should seek advice of professionals trained in this field.
The lead photo and the diagram of the human body and
its liver were provided compliments of the Center For Disease Control. Other
photos used in this article were provided by Christopher Caile. The three
martial arts shots were of Christopher Caile and Shirham Hejazi trading
kicks, Ultimate fighter Joel Sutton and Christopher Caile on the mat,
and Aikido Sensei Roy Suenaka throwing Shihan Chad Taylor. The author
would also like to thank Sterling Smith for his expertise and suggestions
on Bloodborne Pathogens routes of exposure and modes of transmission.
About The Author:
Lenny Sclafani, DDS is a dentist in private practice since 1979. He
works and lives in Parsippany, NJ with his wife, Monica, and daughters
Katie, age 12, and Jenny, age 10. He has be training in Isshinryu Karate
since 1971 and Matayoshi Kobudo since 1995. He may be reached via email