Bloodborne Pathogens: Recognition and Treatment 2011 Occupational Health Services at The Summit Rita M. Lopez, APRN-BC, MSN 751-4189 rlopez@krmc.org
OBJECTIVES DEFINE Bloodborne Pathogen Exposure WHO must be evaluated WHAT actions are required WHY is evaluation important? What are the recommended treatments and related monitoring for exposed?
Viral Pathogens Which are Transmitted in Blood and Other Potentially Infectious Materials Hepatitis B Hepatitis C HIV Hepatitis B causes liver damage. An infected person may turn yellow, have fatigue, nausea, abdomen pain. Hepatitis C causes liver damage too. HIV causes damage to white blood cells, which help fight infection. Infected people develop AIDS, Acquired Immune Deficiency Syndrome, characterized by opportunistic infections and cancers.
Hepatitis B 30 % have no signs or symptoms of acute infection 6% of infected adults will develop chronic infection; 90% of infected infants There is treatment which helps about 40% of infected persons. 15-25% of people with chronic infection will die of chronic liver disease or liver cancer
Hepatitis C 60-70% have no signs or symptoms when first infected 75-85% have chronic infection 70% of those have chronic liver disease which progresses very slowly--20+ years Treatment helps about 40% of infected persons. Leading indication for liver transplant 5% die of chronic liver disease or liver cancer
Occupational Transmission of HCV n n n n n Inefficiently transmitted by occupational exposures Average incidence 1.8% following needle stick from HCV-positive source Associated with hollow-bore needles Case reports of transmission from blood splash to eye No reports of transmission from skin exposures to blood Prevalence 1-2% among health care workers Lower than adults in the general population 10 times lower than for HBV infection Presence of recognized risk factor does not necessarily equate with increased risk
Average Risk of HIV Infection to Healthcare Personnel by Exposure Route Percutaneous 0.3% Mucous membrane 0.09% Non-intact skin <0.1%
Risk of Bloodborne Virus Transmission after Occupational Percutaneous Exposure Source HBV HBeAg + HBeAg - HCV HIV Risk 22.0-30.0% 1.0-6.0% 1%-10% 0.3%
Is it a BBP Exposure? YES Laceration with bloody scalpel or knife Blood splash in eye Bloody urine on skin with open wound Most forms of sexual intercourse Human bite Bloody fist fights NO Puncture wound with sterile needle Blood on intact skin Urine splash in eye Spit on face Feces on skin with open wound Smearing of semen on intact skin
Immediate ACTIONS Protect others First Aide (irrigate) Decontamination Clean people Clean surfaces Wash clothing Solidify liquids Label & dispose Report ASAP Details of exposure Medical Evaluation Within 2 hours!! Bring the source May need medications Immunization record
Decontamination Wear PPE and use tools to avoid contact Solidify liquids towels kitty litter Disinfect surfaces 1:10 bleach quaternary ammonium phenolic leave on 10 minutes Hazardous Waste Double bag, red bag Nothing which drips when squeezed Sharps container Bag & Wash clothing Soap & water May add bleach Hot dryer dry cleaning
Postexposure Management: Wound Care Clean wounds with soap and water Flush mucous membranes with water No evidence of benefit for: application of antiseptics or disinfectants squeezing ( milking ) puncture sites Avoid use of bleach and other agents caustic to skin
Postexposure Management: Assessment of Infection Risk Type of exposure percutaneous mucous membrane non-intact skin bites resulting in blood exposure Body substance blood bloody fluid potentially infectious fluid or tissue Source person presence of HBsAg presence of HCV antibody presence of HIV antibody if source unknown, assess epidemiologic and clinical evidence
Postexposure Management: Unknown or Untestable Source Consider information about exposure where and under what circumstances prevalence of HBV, HCV, or HIV in the population group Testing of needles and other sharp instruments not recommended unknown reliability and interpretation of findings hazard of handling sharp instrument
Hepatitis B Vaccination Required for all employees who have occupational exposure Must be offered free to employee Effective, safe vaccine (3 shot series) Mandatory statement to document if employee declines vaccination Prevents the highest risk transmission!!
OSHA Requirements for Exposure Evaluation Document exposure Injury Report Sharps Injury Report Report of Exposure (MDHES form for EMT, LE, Firefighter, or First Responder) PPE and sharps protection utilized Exposed site of employee (mucous membrane, wound, puncture, bite) Size & location of site Instrument type (hollow, solid, sharp) Use of instrument Body fluid, quantity & dilution factor
OSHA Requirements for Exposure Evaluation NO cost to employee Provide to HCP Copy of 1910.1030 Relevant records Source testing results Description of employee s duties HCP Written Opinion Within 15 days Source Blood Testing (if possible) (HIV HBV) Employee Blood Testing (HIV HBV) PEP for HIV and HBV Records Confidential Keep for duration of employment + 30 yr
Exposure Control Plan Exposure Determination Job classifications which have occupational exposure Engineering and Work Practice Controls Hand hygiene & PPE Housekeeping Engineered protection Hepatitis B vaccine Evaluation of exposure incidents Reviewed and updated at least annually Solicit and document input from nonmanagerial staff Evaluation of sharps
1. Engineered protection Housekeeping Garbage containers with protective lids and/or Large garbage containers Biohazard bags; Sharps containers with signs Laundry chutes and containers with hard sides Sharps protection Needleless devices Guards & disposal
2. Safe Work Practices Hand Hygiene Antimicrobial cleanser Waterless products Housekeeping Blood & OPIM clean-up; disposal ( soaked ) Antimicrobial cleanser for all surfaces Laundry bins empty directly into washer Never put hands into garbage; empty frequently
Standard Precautions All body fluids are potentially contaminated Practice good hygiene (CLEAN hands!!) Soap and water, scrub 30 seconds Waterless alcohol based hand sanitizers Wear Personal Protective Equipment Disinfect contaminated surfaces Dispose of body fluids properly
Recommended Post Exposure Prophylaxis for Exposure to Hepatitis B Virus Exposed Person Status Treatment Source HbsAg positive Source HBsAg negative Source Unknown or Not Tested Unvaccinated Previously infected Previously vaccinated, Known responder** Previously vaccinated, Known nonresponder** Previously vaccinated, antibody response unknown Administer HBIG* x 1 and initiate Hepatitis B vaccine Initiate Hepatitis B vaccine No treatment No treatment No treatment No treatment No treatment No treatment HBIG x 1 plus 1 dose of Hepatitis B vaccine*** Check Anti-HBs titer: 1. If Pos, no treatment 2. If Neg, Administer HBIG* and vaccine booster No treatment No treatment Initiate Hepatitis B vaccine If known high-risk source, may treat as if source were HBsAg positive Check Anti-HBs titer: 1. If Pos, no treatment 2. If Neg, Administer HBIG* and vaccine booster *HBIG dose is 0.06 ml/kg IM **
Exposure to Hepatitis C Virus (HCV) No proven effective PEP for HCV No Recommended PEP for HCV Counsel regarding baseline and follow-up labs Anti-HCV and ALT 4-6 month f/u repeat anti-hcv and ALT Some experts recommend HCV RNA testing at 4-6 weeks for earlier diagnosis. Treatment of persons with very recent acquired HCV has shown to have very high cure rates
DEFINTIONS of Exposures Less Severe= Solid needle or superficial injury More severe= Large-bore, hollow needle; deep puncture; visible blood on device; needle used in artery or vein Small Volume=Few drops blood Large Volume=Large blood splash
Recommended HIV Post exposure Prophylaxis: Percutaneous Injuries Infectious Status of Source Exposure Type Less Severe [4 ] More Severe [5 ] HIV+ Class HIV+ Class Unknown [3] HIV 1 [1] 2 [2] Negativ e 2-drug PEP 3-drug PEP Generally no PEP warranted; consider 2-drug PEP 3-drug PEP 3-drug PEP Generally no PEP warranted; consider* 2-drug PEP No PEP warran ted No PEP warranted
The Good News Through December 2001, only 57 documented cases of occupational HIV transmission to HCP in the US, and only ONE case has been confirmed since 2001!!!
Recommended HIV Postexposure Prophylaxis for Mucous Membrane Exposures and Non-intact Skin Exposure Infectious Status of Source Exposure Type Small Volume [1] Large volume [2] HIV+ Class 1 1 Consider * 2-drug PEP 2-drug PEP HIV+ Class Unknown 3 HIV Negative 2 2 2-drug PEP 3-drug PEP Generally no PEP warranted; consider* 2-drug PEP Generally no PEP warranted; consider* 2-drug PEP No PEP warranted No PEP warranted [1] Small volume splash (i.e. few drops blood) [2] Large volume splash (i.e. major blood splash and/or prolonged contact)
HIV Postexposure Prophylaxis (PEP) Consider PEP indicates that PEP is optional and should be based on an individual decision between the exposed person and the clinician. Baseline Labs including Complete metabolic panel, pregnancy if indicated, CBC with differential, Urinalysis and HIV status. Most HIV exposures that warrant PEP, a basic 4 week, two-drug regime is recommended. Follow-up review of systems, physical exam and labs 2wk, 4wk, 6 wk, 3 mo,6 mo and 1 year.
HIV PEP continued 2-drug PEP: zidovudine (AZT) 300mg bid + lamivudine (3TC) 150 mg bid OR Tenofovir (TDF) 300 mg daily+ Lamivudine (3TC) 300 mg daily 3-drug PEP: Add protease inhibitor (lopinavir/ritonavir 400 mg/100mg po BID (LPV/r). Alternatives are available
PEP Follow-up Hepatitis Exposed HCP HBV exposure follow up testing and counseling->test Anti-HB 1-2 mo after last vaccine dose Advise exposed HCP to refrain from donating blood, plasma, organs or semen and use risk reducation methods including latex barriers during sex, not sharing injection equipment and risk reducution behaviors. Offer mental health counseling
Continued.. HCV exposure follow-up testing and counseling Repeat test for anti-hcv and ALT at least 4-6 months post exposure. Confirm repeatedly positive anit-hcv EIA results and supplemental tests Test HCV RNA @ 4-6 wk for earlier diagnosis >caution must be used to occurrence of false positive results.
HIV Exposed HCP HIV exposure: Avoid breast feeding Offer mental health counseling Counsel about S/Sx of acute retroviral syndrome=flu like syndrome and the need to come in for additional testing at the onset of symptoms If PEP is given, advise and educate about importance of adherence and possible side effects of treatment. Inform regarding possible drug interactions, toxicities and the importance of monitoring for these.
ALL EXPOSURES Advise exposed HCP to refrain from donating blood, plasma, organs or semen and use risk reduction methods including latex barriers during sex, not sharing injection equipment and risk reduction behaviors. Offer mental health counseling
Remember: It s all in your hands
Case Study #1 PA working as surgical assistant is nicked by surgeon s bloody scalpel during a knee replacement. Laceration on his finger requires 3 sutures for closure. Patient is 70 y/o male with hx of severe Osteoarthritis and DJD. PA received HEP series in 1985 with positive titer 4 years ago. Tetanus was 10 years ago. PA is in monogamous relationship with wife of 10 years.
Continued.. Question#1 What lab tests are of concern for source and exposed? Question #2: Exposed care? Question #3: Follow up labs?
Pearls from the Field Voluntary process Anonymous Testing Counseling critical False Positive HIV screens Use resources and experts Timely care is critical care
References http://www.cdc.gov http://www.osha.gov/sltc/bloodbor nepathogens/index.html Hepatitis Hotline 1-888-443-7232 HIV/AIDS Hotline 1-800-342-2437 NATIONAL CLINICIANS HOTLINE (PEPLINE) 1-888-448-4911 www.ucsf.edu.hivcntr/hotlines/pepline.html http://depts.washington.edu/nwaetc/index.html PEP MANUAL