INDIAN JOURNAL OF DENTAL ADVANCEMENTS

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1 INDIAN JOURNAL OF DENTAL ADVANCEMENTS Journal homepage: CASE REPORT Prophylaxis Following Occupational Exposure To HIV Manika 1, Shashikant M C 2, Shailaja S 3 Sr. Lecturer 1 & 3 Dept of Oral Medicine and Radiology, Panineya Mahavidyalaya Institute of Dental Sciences, Hyderabad, A.P. Prof & HOD 2 Dept of Oral Medicine & Radiology, U. P. Dental College, Lucknow, U.P. Article Info Received: April 10, 2010 Review Completed: May 15, 2010 Accepted: June 15, 2010 Available Online: July, 2010 NAD, All rights reserved ABSTRACT: Dental Health care providers are at risk of acquiring HIV-1 infection through occupational exposure. Exposure to HIV-1 is worrisome because of its high mortality rate and lack of current treatment. The risk from percutaneous exposure is approximately 0.3%. The knowledge about HIV infection indicates that systemic infection does not occur immediately after exposure, leaving a brief "window of opportunity" during which Post Exposure Prophylaxis (PEP) can modify disease progression. As HIV infected patients are increasing, dentists are at an increased risk of infection. So, this presentation is to ascertain the knowledge, attitude and behavior of dentists with respect to occupational exposure to HIV. Key words: PEP, Zidovudine, Seroconversion, Dental health care personnel. INTRODUCTION: In Dental setting, the transmission of blood borne pathogens, such as HIV is a rare event. Exposure to HIV-1 is worrisome because of high morbidity and mortality rate. Exposure that might place Dental Health Care Personnel (DHCP) at risk of HIV infection include percutaneous injuries(e.g. a needle stick or cut with a sharp object) or contact with potentially infectious blood, tissues or other body fluids etc. The average risk of HIV transmission after a percutaneous exposure to HIV infected blood has been estimated to be approximately 0.3 % 1. The current data shows that incidence of HIV infection is increasing, 2.31million people are living with HIV and as a result the number of infected patients seeking dental treatment are also increasing. Prevention of blood exposure, through safer practice, barrier precaution, safer needle devices, etc are the best ways to prevent infection with HIV. for correspondence: manika20@yahoo.com, jainmanika@gmail.com Despite constant effort to prevent occupational exposure and emphasis on infection control, Accidents Do Happen! There are several modes of transmission of infection to health care workers such as puncture or cut (bur, explorer, scaler, curette, scalpel, wire etc) needle prick, splash (eye, face, finger) and bite. WINDOW OF OPPORTUNITY: Local host defenses appear to be critical in deciding the outcome of transcutaneous exposure. Skin dendritic cell may also play a role in the initiation of HIV infection. Cutaneous dendritic cells normally take up viruses and present antigen to T- lymphocytes, natural killer cells, and other immune effector cells; these cells are also believed to be the initial target cells in transcutaneous HIV exposure (1). Information about primary HIV infection indicates that systemic infection does not occur immediately, leaving a brief window of opportunity during which post exposure antiretroviral intervention may modify disease progression. In a primate model of simian IJDA, 2(3), July-September,

2 immunodeficiency virus (SIV)infection, infection of dendritic-like cells occurred at the site of inoculation during the first 24 hours following mucosal exposure to cell-free virus. During the subsequent hours, migration of these cells to regional lymph nodes occurs, and virus was detectable in the peripheral blood within 5 days. Theoretically, initiation of antiretroviral PEP soon after exposure may prevent or inhibit systemic infection by limiting the proliferation of virus in the initial target cells or lymph nodes. 2 Post exposure prophylaxis (PEP) is a course of antiretroviral drugs given after exposure to infection. Anti retroviral drugs can be classified into following groups, nucleoside reverse transcriptase, nucleotide reverse transcriptase, non-nucleoside reverse transcriptase protease inhibitor and single fusion inhibitor. 3 It should be given as soon as possible; if given in time it interferes via two mechanisms. First is, it inhibits the uptake of virion particle by the dendrite cell. (2) The reverse transcriptase inhibitors and protease inhibitors, act via protection of uninfected cells from becoming infected and, therefore demonstrate a profound effect on plasma viral burden within days of initiation of therapy. 4 Other is it inhibits replication of the virion particle in the initial target cells or lymph nodes. 2 Reverse transcriptase inhibitors can interfere with the ability of the attached virus to infect the targeted cell; however, protease inhibitors can only work after the initial cell has become infected. Moreover, in order for nucleoside reverse transcriptase inhibitor to prevent the target cell from becoming infected, the drugs need to be inside the cell in an activated (phosphorylated) state, to have any protective effect. 4 PRECAUTIONS FOR OCCUPATIONAL EXPOSURE: The routine application of precautions such as multiple aseptic procedure, instruments decontamination, efficient sterilization modalities and chemical disinfectants should be performed for effective sterilization. Methods used to prevent occupational exposure in dental setting include hand washing; use of barrier precautions, and careful handling and disposal of sharp instruments e.g. gloves, mask, and protective eyewear. 5 The practice of wearing two pairs of gloves offers a high degree of protection from acquiring infection. Berguer & Heller (2004) in their article reported that double gloving reduces risk of exposure to patient blood by as much as 87% when the outer glove is punctured. The volume of blood on a solid suture needle is reduced by 95% when passing through two gloves layer, thereby reducing viral load in the event of a contaminated percutaneous injury. 6 MANAGEMENT AND RECOMMENDATION FOR PEP: Immediately after an exposure, first aid should be administered and the exposure wound should be washed first with soap and water, and then irrigated with sterile saline or a disinfectant solution. Bleeding should be encouraged from puncture wound. Eyes should be irrigated with clean water, saline, or sterile eye irrigant. As promptly as is feasible the health care worker should report the exposure to her/his institution s occupational medical department. Studies have shown substantial underreporting of occupational blood exposures by DHCP because they do not consider them to pose significant risk. Reporting mechanisms must be easy to access, nonpunitive & communicated to all personnel at risk. If an occupational HIV exposure has occured, the health care worker should be counselled thoroughly. 7 EVALUATION OF EXPOSURE AND SOURCE: Evaluation of source needle or instrument & patient is very important. The risk of transmission increases if there is visible blood on the device causing the injury, deep injury to DHCP, device previously placed in the source patient s vein or artery (Tabble-1). For skin exposure, clinical evaluation for human bites, possible exposure of both the person bitten & the person who inflicted the bite must be considered. If a bite results in blood exposure to either person involved, PEP follow-up should be provided. 7 TIMING AND DURATION FOR POST EXPOSURE PROPHYLAXIS: 1. Start as soon as possible preferably with in 1-2 hrs. 2. Some studies suggest that PEP probably is substantially less effective when started after more than hours (2). 310 IJDA, 2(3), July-September, 2010

3 3. Reevaluation of the exposed person should be considered with in 72hrs. 4. PEP should be administered for 4 weeks. 7 ations for HIV PEP apply to situation in which a person has been exposed to a source person with HIV infection or in which information suggests that there is a likelihood that the source person is HIV infected (Table-II).These recommendations are based on the risk for HIV infection after different types of exposure and limited data regarding efficacy and toxicity of PEP. Because most occupational HIV exposures do not result in the transmission of HIV, potential toxicity must be considered carefully when prescribing PEP. In selecting drug regimen for HIV PEP, clinician must strive to balance the risk of infection against the potential toxicity of the agents used, because PEP is potentially toxic, its use is not justified for an exposure that possesses a negligible risk for transmission. Therefore, two regimens for PEP are provided: 1) Basic 2-drug regimen that should be appropriate for most HIV exposures. 2) Expanded 3-drug regimen is the basic two drug regimen plus addition of any one drug mentioned in three drug regimen. It should be used for an exposure that poses an increased risk for transmission 7 (Table-III). The emphasis is on the consultation within few hours after exposure.a screening test for the presence of anti-hiv antibodies should also be performed, preferably on the same day. EFFICACY OF ANTIRETROVIRAL THERAPY FOR POSTEXPOSURE PROPHYLAXIS: There is little information regarding the efficacy of PEP in humans. In retrospective case control study of DHCP, use of zidvoudine (ZDV) as PEP was associated with reduced risk of HIV infection by approximately 81%. 8 In a multicentre trial in which ZDV was administered to HIV infected pregnant women and their infants, the administration of ZDV during pregnancy, labor and delivery and to the infant, reduced transmission by 67%. A reduction in risk has been shown to correlate in part with the degree of suppression of HIV RNA in mother s serum 9 and diminished the viral exposure of the foetus. 10 Zidovudine is usually tolerated well by DHCP, short term toxicity associated with higher doses primarily include gastrointestinal symptoms, fatigue, and headache. 11 Almost 50% of DHCP experience one or more adverse effects (e.g. nausea, malaise, anorexia, and headache) while taking PEP and as a result about one third stop taking the drugs. Serious events are rare, but they do occur and can be life threatening. Nephrolithiasis, impaired ocular muscle movement, hepatitis, hyperglycemia and pancytopenia have been reported. Efavirenz is not recommended during pregnancy because of teratogenic effects. 8 Among HIV infected patients combination regimens reduces HIV viral load, incidence of opportunistic infections, & delaying onset of drug resistance. 11 Lamivudine, is particularly attractive for use with zidovudine. These drugs in combination appear to have synergistic antiviral activity, decrease the emergence of zidovudine resistance, and retain activity against many strains of HIV that are otherwise resistant to zidovudine & does not increase the incidence of side effects. 1 Empiric decision about the presence of antiretroviral drug resistance is often difficult because source patient generally take more than one antiretroviral agent. Resistance should be suspected in source persons where there is clinical progression of disease or a persistently increasing viral load or decline in CD4 T-cell count despite a therapy or lack of virologic response to therapy. 8 FOLLOW UP: Health care workers with occupational exposure to HIV should receive follow-up counseling, postexposure testing, and medical evaluation, regardless of whether they receive PEP. HIV antibody testing should be performed for at least 6 months after exposure (e.g. At 6 weeks, 12 weeks and 6 months). Extended HIV follow up(e.g. for 12 months) is recommended for DHCP who become co- infected. HIV antibody tests using enzyme immunoassay (EIA) should be used to monitor for sero-conversion.the routine use of direct virus assay (e.g., HIV p24 antigen EIA or test for HIV RNA) to detect infection in exposed DHCP generally is not recommended. If PEP is used, DHCP should be monitored for drug toxicity by testing at baseline and again 2 weeks after starting IJDA, 2(3), July-September,

4 PEP.HIV exposed DHCP should be advised to use appropriate measures to prevent secondly transmission during the follow-up period, especially the first 6 to 12 weeks after the exposure when most HIV-infected persons are expected to seroconvert. (7) CONCLUSION: According to surveillance 2002 possible reported DHCP were 6 (Table-4). 12 So, we conclude by highlighting some important points: 1. PEP should be readily available in hospital or any health care establishments. 2. Needle stick injuries should not be ignored. 3. Correct and timely use of PEP is recommended. 4. Side effects should be assessed properly. 5. Exposed DHCP who choose to take PEP should be advised of the importance of completing the prescribed regimen. REFERENCES: 1. Gerberding JL. Prophylaxis for occupational Exposure to HIV. Ann Intern Med: vol 125: CDC. Public Health services Guidelines for the management of Health Care worker. Exposure to HIV & recommendations for PEP. MMWR: 1998 : 47(RR-7): CDC. Prepared by Adelisa L. Panlilio, Denise M. Cardo, Lisa A. Grohskopf, Walid Heneine, Clara Sue Ross. Updated U.S. Public health Service Guidelines for the Management of Occupational Exposures to HIV and ations for postexposure prophylaxis. MMWR 2005:54(RR-09): 1-17:. 4. Saag MS. Candidate Antiretroviral Agents for Use in Postexposure Prophylaxis. Am J Med: 1997:102(5B): 25-31:. 5. Cleveland JL and Cardo DM. Occupational exposures to human immunodeficiency virus, hepatitis B virus, and hepatitis C virus: risk, prevention, and management. Dent Clin N Am:2003:47: Berguer R and Heller P J. Preventing sharps injuries in the Operating Room. J Am Coll Surg 2004:199(3): CDC. Updated U.S. Public Health Services Guidelines for the management of occupational exposure to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR: (RR-11): Gerberding JL. Occupational Exposure to HIV in health Care Settings. N Engl J Med: 2003:348: Hamlyn E and Easterbrook P. Occupational exposure to HIV and the use of post-exposure prophylaxis. Occup.Med:2000:50(6): Connor EM et al. Reduction of Maternal-Infant Transmission of Human Immunodeficiency Virus Type 1 with Zidovudine Treatment. 1994: 331(18): Notice to the reader Update: Provisional Public Health Service ations for Chemoprophylaxis after occupational exposure to HIV. MMWR: 1996:45(22): CDC, fact sheet, Sep Surveillance of Occupaionally Acquird HIV/AIDS in Healthcare Personnel, as of December fact_sheet_clearence_evised_090507dec2006.pdf Table-1 Evaluation of exposure and source 7 : PATIENT'S STATUS Known To Have HIV Seronegative Unknown or cannot be tested Unknown at the time of exposure ASSESSMENT OF THE CASE Information CD4+ T-cell count, viral load testing, current& previous antiretroviral Therapy, any genotypic or phenotypic viral resistance No clinical evidence of Sign and symptoms and investigations are negative. Epidemiological Assessment (high risk geographic area where injection drug use is prevalent) Use of PEP should be decided case by case CONSIDERATION FOR PEP If information not available PEP should be initiated immediately, and after results of investigation it should be reconsidered. No PEP Considered as high risk and PEP should be initiated Use of PEP should be decided case by case 312 IJDA, 2(3), July-September, 2010

5 Table-2: ed HIV PEP for percutaneous injuries, mucous membrane and non intact skin exposures: INFECTION STATUS OF SOURCE Exposure Type HIV positive Class I a HIV positive Class II b Source of unknown HIV status c Unknown Source d HIV negative Less Severe g Small volume e basic 2- drug PEP expanded 3-drug PEP Basic 2-drug PEP Generally, No PEP warranted, However consider basic 2-drug PEP* for source with HIV risk factor** Generally, no PEP warranted, however consider 2-drug PEP* in setting in which exposure to HIV-infected persons is likely No PEP warranted More Severe h Large volume f expanded 3- drug PEP Basic 2-drug PEP expanded 3-drug PEP Generally, No PEP warranted, However consider 2-drug PEP* for source with HIV risk factor** Generally, no PEP warranted, however consider 2-drug PEP* in setting in which exposure to HIV-infected persons is likely No PEP warranted a b c d e f HIV positive class1: asymptomatic HIV infection or known low viral load (e.g., <1500 RNA copies/ml). HIV positive Class 2: symptomatic HIV infection, AIDS, acute seroconversion, or known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of PEP cannot substitute face to face counseling, resources should be available to provide immediate evaluation and follow up care for all exposures. Source of unknown HIV status (e.g., deceased source person with no samples available for HIV testing). Unknown source ( e.g., a needle from a sharps disposable container) Small volume(i.e. a few drops) Large volume (i.e. major blood splash * The designation "consider PEP" indicate that PEP is optional and should be based on an individual decision between the exposed person and the treating clinician ** if PEP is offered & taken & the source is later determined to be HIV negative, PEP should be discontinued. If PEP is offered and taken, and the source is later determined to be HIV negative, PEP should be discontinued. g h Less severe (e g, solid needle and superficial injury) More severe(e.g. large bore hollow needle, deep puncture, visible blood on device, or needle used in patient's artery or vein) IJDA, 2(3), July-September,

6 Table-3: Basic and Expanded Regimens of Post-exposure Prophylaxis against Human Immunodeficiency Virus Infection. 7 Regimen Doses Primary Adverse Effects BASIC Zidovudine (Retrovir) plus lamivudine (Epivir) Lamivudine plus stavudine (Zerit) Didanosine, available as a chewable or ispersable buffered tablet (Videx) or as adelayed-release capsule (Videx EC), plus stavudine Regimen Doses Primary Adverse Effects 600 mg of zidovudine daily in two or three divided doses; 150 mg of lamivudine twice daily 150 mg of lamivudine twice daily; 40 mg of stavudine (if bodyweight is <60 kg, 30 mg) twice daily 400 mg of didanosine daily, taken on an empty stomach if a buffered tablet is used (if bodyweight is <60 kg, 125 mg twice daily if a buffered tablet is used), or 250 mg daily if a delayed-release capsule is used; 40 mg of stavudine twice daily Regimen Doses Primary Adverse Effects Zidovudine: anemia, eutropenia,nausea, headache, insomnia,muscle pain, weakness; lamivudine:abdominal pain, nausea,diarrhea, rash, pancreatitis Lamivudine: as above; stavudine: peripheral neuropathy, headache, diarrhea, nausea, insomnia, anorexia, pancreatitis, elevated liver-function values, anemia, neutropenia Didanosine: pancreatitis, lactic acidosis, neuropathy, diarrhea, abdominal pain, nausea; stavudine: as above EXPANDED (basic regimen plus one of the following) Indinavir (Crixivan) Nelfinavir (Viracept) Efavirenz (Sustiva) Abacavir (Ziagen) 800 mg every 8 hr, taken on an empty stomach 750 mg three times daily, with a meal or snack, or 1250 mg twice daily, with a meal or snack 600 mg daily, at bedtime 300 mg twice daily Nausea, abdominal pain, nephrolithiasis, indirect hyperbilirubinemia Diarrhea, nausea, abdominal pain,weakness, rash Rash (including Stevens-Johnson syndrome), insomnia, somnolence, dizziness, trouble concentrating, abnormal dreaming Nausea, diarrhea, anorexia, abdominal pain, fatigue, headache,insomnia, hypersensitivityreactions 314 IJDA, 2(3), July-September, 2010

7 TABLE 4: Health care personnel with documented and possible occupationally acquired AIDS / HIV infection by occupation, (12) HEALTH CARE OCCUPATION Documented Possible Dental health-care worker 0 6 Embalmer/morgue technician 1 2 Emergency medical technician/paramedic 0 12 Health aide/attendant 1 15 Housekeeper/maintenance worker 2 13 Laboratory, Worker, clinical Technician, non-clinical 3 0 Nurse Physician, Non-surgical 6 12 Surgical 0 6 Respiratory therapist 1 2 Technician, Dialysis 1 3 Surgical 2 2 Other 0 9 Other 0 5 Documented cases of occupationally acquired HIV /AIDS are those in which HIV seroconversion is temporally related to an exposure to an HIV- positive source and in which the exposed worker has no non-occupational risk factor for acquisition of HIV. Possible cases of occupationally acquired HIV/AIDS are those in which a worker is found to be HIV positive, has no non-occupational risk factors for HIV/AIDS, and has opportunity for occupational exposure to blood, body fluids, or HIV-positive laboratory material. Gain quick access to our journal online View our journal at IJDA, 2(3), July-September,