Management of Workplace Exposure to Blood-borne Pathogens

Transcription

1 Management of Workplace Exposure to Blood-borne Pathogens 11/22/2017

2 Management of Workplace Exposure to Blood-borne Pathogens BY SOLYMOLE KURUVILLA, PHD, RN, ACNP-BC DIRECTOR, OCCUPATIONAL HEALTH SERVICES NYC H+H/JACOBI & NORTH CENTRAL BRONX

3 Learning Objectives At the end of the presentation, participants will be able to: Identify the relative risk of transmission of common bloodborne pathogens from occupational exposures Analyze three case studies related to the transmission of blood borne pathogens from occupational exposures Describe replication of HIV with an emphasis on the time frame Discuss DOH, OSHA, & CDC recommendations for postexposure prophylaxis and follow-up Review prevention of sharp injuries and blood & body fluid exposures

4 Case Study 1 Ms. Smith, 28 years old nurse from Emergency Department is sent to OHS after being stuck with a needle 4 hours ago s/p giving IM injection. Source patient is a 42 year old male with history of IV drug abuse, brought in by family for altered mental status.

5 Case Study 2 Mr. Smith, 34 years old NP is sent to OHS by his supervisor. He was stuck with a needle few minutes ago after giving cortisone injection to the right knee. Source Patient is a 50 year old man with history of HIV.

6 Case Study 3 Ms. Meads, 58 years old midwife is splashed on face with blood and amniotic fluid while delivering a baby an hour ago. Source patient is a 41 year old female with unknown HIV/ Hep B/ Hep C status.

7 Risk Assessment 1. What are the risk factors related to the transmission of blood-borne pathogens from these exposures? 2. What additional information needs to be obtained about the source patient? 3. What are the priorities in managing the injured staff in the next two hours?

8 Potentially Infected Body Fluids Blood and visibly bloody fluids Amniotic fluid Pericardial fluid Synovial fluid Cerebral/ spinal fluid Vaginal secretions/ Semen Breast milk *** Tears, saliva, sputum, urine, & feces are not considered as potentially infected

9 Immediate Care Wash site with soap & water and do not squeeze the site Flush mucous membrane profusely Endorse patients care to the responsible staff Report to the supervisor immediately Seek medical care right away OHS or Emergency Department per facility protocol

10 Risk Factors for HIV Seroconversion in HCWs Deep Injury 15.0 Visible Blood on Device 6.2 Terminal Illness in Source Patient 5.6 Needle in Source Vein/Artery 4.3 PEP with Zidovudine (decreased by 81%) 0.2 (From: NEJM 1997;337: )

11 Average Risk of Transmission HIV Percutaneous 0.3% Mucous membrane 0.09% Non-intact skin <0.1% HBV HBsAg-Positive & HBeAg negative Clinical hepatitis:1-6% Serologic evidence: 23-37% HBsAg-Positive & HBeAg-positive Clinical hepatitis: 22-31% Serologic evidence: 37-62% HCV 1.8%

12 Number of confirmed cases (N = 58) of occupationally acquired HIV infection among health care workers reported to CDC United States,

13 Occupationally acquired HIV infection among health care workers reported to CDC United States, Occupation Confirmed (N = 58) Possible (N = 150) No. (%) No. (%) Nurse 24 (41.4) 37 (24.7) Lab Tech, clinical 16 (27.6) 21 (14.0) Physician, nonsurgical 6 (10.3) 13 (8.7) Lab Tech, nonclinical 4 (6.9) Housekeeper/maintenance 2 (3.4) 14 (9.3) Technician, surgical 2 (3.4) 2 (1.3) Embalmer/morgue tech 1 (1.7) 2 (1.3) Hospice caregiver/attendant 1 (1.7) 16 (10.7) Respiratory therapist 1 (1.7) 2 (1.3) Technician, dialysis 1 (1.7) 3 (2.0)

14 Case Study 3 Scenario # 2 45 minutes later, source patient s provider informed that the patient is tested HIV positive and that Hepatitis B and Hepatitis C tests are in progress.

15 Case Study Questions What factors guide you in choosing the postexposure prophylaxis? What baseline tests are needed in treating the injured employee? What other important decisions to be made and explain the rationale? When does this employee return back to OHS/ provider and why?

16 HIV Exposure: Sequence of events After exposure Local replication of virus in tissue macrophages or dendritic cells Host cytotoxic T cells will kill productively infected target cells If infection not contained, replication of HIV in regional lymph nodes within 2-3 days Viremia follows within 3-5 days of inoculation *** Limited viral replication may occur without establishment of infection, thus requiring highly active PEP regimen with three drugs.

17 HIV Virus 11/22/2017

18 HIV Replication: Time matters!

19 Positions in the HIV life cycle affected by each drug class 11/22/2017

20 Indications for PEP Per-cutaneous exposure with contaminated sharps Mucus membrane / non-intact skin exposure to blood and potentially infected body fluid Bite from patient with visible bleeding in the mouth that caused bleeding in the exposed HCW Exposure within the past 36 hours

21 HIV PEP Regimens TRUVADA (daily) ISENTRESS (twice a day) Preferred regimen because of: Excellent tolerability Proven potency in established HIV infection Ease of administration For more information:

22 Post-Exposure Prophylaxis Hepatitis B & C Hepatitis B prophylaxis - As indicated Hepatitis B vaccine series or Hepatitis B booster or Hepatitis B Immunoglobulin No prophylaxis for Hepatitis C For more information: 11/22/2017

23 Case Study Scenario # 3 It is 72 hours since the incident. Ms. Smith is on Truvada and Raltegravir. She c/o nausea, fatigue, and headache. Now, you the provider know that the source patient is HIV Ab positive, HCV Ab positive, and Hepatitis B Ag negative.

24 Case Study Questions: 1. What are the precautions to be taken while on PEP? 2. What additional tests are required? When and why? 3. How will you counsel on prevention of needle-sticks and secondary transmission?

25 Provider Roles Emotional support Education Risk Assessment OHS Record keeping Follow-up Prophylaxis

26 Common Side Effects of HIV PEP GI symptoms Fatigue Headache Allergic Reactions Rhabdomyalysis PEP Side effects Hepatotoxicity Skin reactions Nephrotoxicity

27 Monitoring Recommendations 1. Baseline Hours 3. Weekly while on PEP 4. 4 weeks weeks weeks - If the source patient is positive for HCV / an acute elevation of ALT (SGPT) in the exposed HCW

28 Employer s plan in providing PEP WHO WILL perform the post-exposure evaluation provide counseling be given authority for releasing drugs for this purpose HOW PEP will be made available within 2 hours of an exposure 3- to 5-day supply of PEP for urgent use continuous supply of PEP drugs to complete the 28-day regimen

29 Prevention of Secondary Transmission Cover all wounds Protected sex/ sexual abstinence Avoid pregnancy If pregnant, consult with obstetrician/pcp Avoid breast feeding Abstain from donation of blood, blood products, semen, tissues, & organs for one year

30 Prevention of BBFEs Dual Responsibility! Safe work environment Exposure control plan/ Bloodborne Pathogens and Needlestick Prevention Standard Hepatitis B Vaccine series Post-exposure evaluation and follow up Verification of compliance with safety features Record keeping

31 Prevention of BBFEs: Dual Responsibility! Bloodborne Pathogens and Needlestick Prevention Standard Universal Precautions Personal Protective Equipment Education and training Engineering controls e.g. puncture proof sharps disposal containers, safety devices Workplace practices e.g. no recapping, use of safe zone Record keeping

32 Needle Stick Prevention and Safety Act on 11/06/00

33 Summary NS/ BBFE - manage as an emergency PEP - based on risk assessment DOH/ OSHA/CDC provide guidelines Timely follow-up and prevention of secondary transmission are very important Prevention of NS/ BBFEs responsibility of employers and employees

34 References APIC Text of Infection Control and Epidemiology (2009). 3rd Edition, Associations for Professionals in Infection Control and Epidemiology, Inc. CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management (December 2013). MMMR Committee on Infectious Diseases, American Academy of Pediatrics (2009, 28 th Edition). Red Book. AAP: IL HIV Clinical Resource (October 2014). Retrieved on August 24, 2017 from NIOSH Alert: Preventing needlestick injuries in health care settings. Retrieved on February 24, 2008 from The Joint Commission. Preventing Needlestick and sharp injuries. Retrieved on March 7, 2008 from U. S. Department of Labor. Blood borne pathogens and needlestick prevention. Retrieved on March 1, 2008 from

35 Q & A