Transcript Slide 1

Occupational Blood and
Bodily Fluid Exposures
Shawn Dowling
PGY-1
• Despite our best
efforts, some
occupational
exposures will be
unavoidable
Objectives
• What are blood and bodily fluid
exposures?
• Which diseases are we concerned with?
• Who gets them?
• Why????
• What can be done?
Definitions
A. Health Care Workers:
–
health-care workers (HCW) are defined as persons
whose activities involve contact with patients or with
blood or other body fluids from patients in a healthcare, laboratory, or public-safety setting
B. Blood and Bodily Fluid:
–
Essentially anything that comes out of the patient
(other than abusive language), but certain ones
(feces, urine, vomitus, saliva) are unlikely to be
infectious unless they contain blood
C. Occupational BBF Exposure
–
–
Any time A) comes in contact with B).
Usually classified as percutaneous or
mucocutaneous or non-intact skin
Epidemiology
• 52% of all HCW report a needlestick injury,
24% had one in the last year
• But, estimates are that only 10% of all
needlestick injuries are reported
Calgary Health Region #’s
Reported blood/bodily fluid exposures in 2003
• FMC - 321
• PLC – 153
• RVH – 134
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Who gets exposed (reports)?
16
14
12
10
8
6
4
2
0
Rates per
100 FTE's
Transmittable Infections
The Big 3:
• HIV
• Hep B
• Hep C
For the internist….Other possible infections:
• Blastomycosis
• Brucellosis
• Cryptococcosis
• Diphtheria
• Cutaneous gonorrhea
• Herpes
• Malaria
• Mycobacteriosis
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Mycoplasma caviae
Rocky Mountain spotted fever
Sporotrichosis
Staphylococcus aureus
Streptococcus pyogenes
Syphilis
Toxoplasmosis
Tuberculosis
Transmission of HIV/HBV/HCV
– Transmitted by semen, vaginal secretions, blood or
blood products, breast milk, transplacental
transmission or any bodily fluid contaminated with
blood
– Saliva, feces, urine, vomitus, sputum and tears are
not considered infectious unless contaminated with
blood
– Exceptions:
• Vaginal secretions or semen are unlikely to transmit HCV
• HBV can be transmitted by saliva
HIV
• In general, HIV exposure is low-risk, high
consequence
• Amount of virus is proportional to risk of
infectivity. Therefore viral loads, type of
bodily fluid and volume of exposure are
important variables to consider
ESTIMATES OF PER-CONTACT RISK OF
HIV INFECTION
•Occupational Mucocutaneous Exposure
0.09%
Important: these numbers are generated via aggregate studies of
retrospective and cohort data.
HIV rates in CHR
• Prevalence is 0.5%, rate w/ IVDU is 5%
HCW and HIV
• From CDC (US data, as of June 2000)
– 54 cases reported to have seroconverted after an
occupational exposure
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46/54 were percutaneous exposures
5/54 were mucocutaneous exposures
2/54 were both
1/54 unknown
– 134 other potential cases (serconverted with no RF,
had occupational exposure, but never had blood work
done)
Surveillance of Health Care Workers with HIV/AIDS, August 2004.
HCW and HIV
• Canadian Needle Stick Surveillance Network
– Numbers are from 12 sites (8 teaching, 4 community)
from April 2000 to March 2002 (ongoing…)
– 2,621 occupational exposures to BBF (3.8/100 FTE’s)
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Needlesticks: 65.7%,
splashes from patients: 13.7%,
cuts with sharp objects: 8.6%,
sticks other than needles: 7.2%,
Others: scratches 1.9%, direct contacts with patients 1.8%
(i.e. touching patients directly) and bites with broken skin
1.2%
– Prevalence of HCV = 7.6%, HIV = 2.6% and HBV =
1.8% amongst source patients
– As a result the rate of exposure to infected BBF was
0.3%
Hep B
• Although percutaneous is the
most efficient route of
transmission, these likely only
account for a minority,
• In several studies, HCW could
not recall an overt
percutaneous injury,
• And since HBV can survive in
at room temp for a week,
transmission is thought to
primarily arise from contact
with cuts, abrasions or
mucosal surfaces
95%
5%
Hep B
Hep C
Transmission 30%(22-31%)
Risk
Less if HBeAG Incubation Pd 4-26 wks
1.8% (0-7%)
Carrier State
0.2-1.0% of
blood donors
85% of acute
infections
Yes
0.1-1.0% of blood
donors
Chronic
5-10% of acute
Hepatitis
infections
Increased risk Yes
of HCC
2-26 wks
Hep C
• Best transmitted via
percutaneous exposure
15%
• Minimal risk w/mucous
membranes or contact with
blood
• Crappy dz (since no PEP,
but fortunately, but risk of
transmission is low)
85%
Case
• 78 yr female, security guard at the PLC, is
waiting to be seen in the MT area. An hour
ago she was involved in an alteration with an
agitated patient. Both were bloodied in the
battle and the security guard is concerned
about getting HIV.
• When you go to see her, she’s still covered in
blood. What do you do?
If you do get poked/exposed
• Remove the contaminated clothes –
undergarments excepted
• Allow immediate bleeding of the wound
• Wash the injured area well with soap and
water, and apply an antiseptic
• If the eyes, nose, or mouth are involved,
flush them well with large amounts of
water
Prevention
• Universal Precautions: Treat everyone as if they may
have HIV/HBV/HCV
– In 1985, 94% of all AIDS patients had a major RF
– In 1996, 20% of all patients had been infected through
heterosexual contact or had no known RF
• Protect your self
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Handwashing
Gloves
Masks
Eye protection
Face shields
Gowns/aprons
• Safety Measures
– Don’t recap needles, avoid being a surgical resident, safety
intravenous catheters, dispose sharps
Report all cases
• Call OH & S Nurse (234-7799)
– Available 24 hrs/day
– Provides patient with appropriate f/u
– Will do Risk Assessment
– Allows for surveillance/monitoring
Southern Alberta Clinic Guidelines
1 Is the source known HIV+?
– Yes: proceed to step 2 of protocol
– No:
• Test source (with consent) using rapid point-of-care HIV test
available through CLS at any Emergency Room or 8th and 8th
health centre
• If negative, and no risk of “window period”, reassure patient
• If source unknown or refuses testing and has risks for or
symptoms of HIV, proceed to step 2 of protocol
• Consider source testing for HBV, HCV – most guidelines
suggest testing for this
Rapid HIV Testing
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Sensitivity and Specificity both 99.9%
Done in the on-site rapid response labs
Current turn around time 1 hr 24 min
Confirmed by Western Blot at Prov Lab
Consider giving dose of PEP before results
arrive (based on your pre-test probability)
• Cost: considerable, but should not play a factor
2 Timing and Type of Exposure:
– Assess fluid type, volume, viral titre, mode of
exposure.
– Assess exact timing of exposure
– If exposure is not considered infectious for
HIV/HBV/HCV (i.e. vomit, feces, etc. without
blood – see slide #10) – reassure and arrange
f/u if patient desires
– If exposure considered potentially infections
go to 3.
3 Decision:
– Make a decision for or against PEP based on
risk assessment (these are debatable)
• HIV + = start PEP
• HIV – and no risk of source pt being in “Window
period” = don’t start PEP
• Unknown (source not tested or refuses testing) =
this is where you earn your money
• HEP B – see slide 54-55 on HBIG and Hep B
vaccine
Unknown HIV status: What to
do?
• Determine:
– Type of exposure (percutaneous v mucous
membrane)
– Source risk/setting: needlestick risk different at 8th and
8th clinic compared to Geriatric assessment unit
• In these scenarios, need to have an in-depth
conversation with patient to determine
management/risk tolerance but…fortunately,
there are some consensus guidelines
Risk Assessment
-In general, Should be done by OH&S
• High risk
– IVDU
– High risk sexual behaviour
(MSM, sex w/IVDU, multiple
sexual partners (3 or more
sexual partners/yr w/I past 5
yrs), prostitution
– Blood transfusion prior to 1985
– Sex w/HIV + person
– Clinical suspicion of HIV
infections by physicians
• Prior HIV test
• HIV as part of a Ddx
• Unexplained opportunistic
infections (i.e. PCP, toxo,
crypto, histo, TB, MAC)
• Low Risk
– HIV – Serology unknown but
answers no to all high risk
questions
• Unknown
– Source is not assessed
4 Drug Selection
• Best to start within 1-2 hrs, consider dose before Rapid
HIV test returns depending on risk of source patient
• Basic Regimen:
– If Low risk exposure (unknown source or mucocutaneous
exposure)
– Combivir: (AZT 300mg + 3TC 150mg) bid
• Expanded Regimen:
– For most percutaneous to known HIV +
– Basic Regimen + Nelfinavir 1250mg bid
• Other:
– consider other drugs if source patient is already on antiretrovirals
or if source patient is known to have resistant HIV
5 Duration of Prophylaxis:
– Start ASAP and continue for 4 weeks
6 Discuss adverse reactions w/patient:
7 Access and Cost:
– Starter kits contain 72 hours of drugs
– Free for occupational exposure and non-voluntary or
violent (assault) exposures
– Non-occupational voluntary exposures (needles or
sex): PEP is available, but cost not absorbed by CHR
– In Calgary, starter kits are available in all hospital
ED’s, and at the 8th & 8th 24-hour walk-in medical
clinic. All antiretroviral drugs are stored in the
Pharmacy at Foothills Medical Centre.
– Cost: approx $1000 for 4 wks of combivir
A Few Words about PEP
• Theoretically, initiation of antiretroviral PEP
soon after exposure might prevent or
inhibit systemic infection by limiting the
proliferation of virus in the initial target
cells or lymph nodes – most studies are
done in animals or in vertical HIV
transmission
HIV PEP - evidence
• Case-Control Study
– Primary outcome:
• Risk Factors for acquiring HIV after a HCW has a
percutaneous exposure
– 712 patients
• 679 retrospective controls (no seroconversion after
exposure @ 6 months)
• 33 prospective Cases (seroconversion after
exposure)
• Factors not Associated w/HIV
transmission
– Large bore needles
– Use of gloves
– Hollow bore vs. suture needles
HIV PEP prophylaxis:
Case pts
Control pts
Use of AZT
30%
41%
Use of AZT
w/I 4 hrs
Continued
AZT x 4 wks
89%
67%
44%
66%
• Study quotes a 80% (CI 43-94%) reduction
rate of HIV transmission with use of AZT
– ARR = 0.24%, NNT= 417
– An nationwide RCT was attempted, but only able to
recruit 84 patients over a year --- I wonder why?
Human Studies
• Generally poor
• NEJM is the best study to look at AZT use
and seroconversion in Human
occupational exposures, but it was small
and used different cohorts,
retro/prospective, inconsistent data
availability, and relied on recall
Human Studies
• Lots of studies looking at vertical HIV
transmission
– Quote reduction rates from 37-67%
(depending on when started)
• Problem of the benefit is secondary to decreasing
mom’s viral load and therefore decreasing
infectivity, therefore numbers are not applicable to
occupational exposures
Animal Studies
• Challenges
– identifying an animal model that is
comparable to humans
– In early studies, differences in controlled
variables (e.g., choice of viral strain [based on
the animal model used], inoculum size, route
of inoculation, time of prophylaxis initiation,
and drug regimen) made results very
heterogeneous
Animal Studies
• Studies among animal models have
demonstrated that larger viral inocula
decrease prophylactic efficacy
• Delaying initiation, shortening the duration,
or decreasing the antiretroviral dose of
PEP decreased prophylactic efficacy
PEP Side Effects/Adverse Events
• Divided into Major and Minor
• Minor: experienced by 50 - 80%
– nausea (57%)
– Vomiting & Diarrhea (14% & 16%)
– Headache (18%)
– Fatigue or Malaise (38%)
– Mean time to onset of symptoms 3 or 4 days
for all of the above
• Major: defined as life threatening,
permanent or requiring hospitalization
– Serious side effects, including nephrolithiasis,
hepatitis, and pancytopenia have been
reported with the use of combination drugs for
PEP
– One case of NVP (NNRTI)-associated
fulminant liver failure requiring liver
transplantation
Compliance
• 33% stopped the PEP prematurely
• s/e and discontinuing PEP are seen more
frequently with triple-therapy (indinavir is
particularly nasty)
• If pt started on triple therapy and
complains of a/e and wants to d/c, stop 3rd
Rx first as this is most likely causing the
worse Sx
• Educating pts about s/e, a/e has been
shown to increase compliance
PEP Failure
• Failure of PEP to prevent HIV infection in HCW has been
reported in at least 21 instances
– In 16 of the cases, ZDV was used alone as a single agent
(currently not recommended)
– In 2 cases, ZDV and didanosine (ddI) were used in combination
– In three cases, 3 drugs were used for PEP
– 13 of the source persons were known to have been treated with
antiretroviral therapy before the exposure. Antiretroviral
resistance testing of the virus from the source person was
performed in seven instances, and in four, the HIV infection
transmitted was found to have decreased sensitivity to ZDV
and/or other drugs used for PEP.
– Other factors come in to play: compliance, viral load, inoculum,
etc
8 Follow-up:
– Baseline HIV, HBV, HCV, CBC, Cr, LFTs and
bHCG should be done in recipient
– Follow-up with ID at HPTP clinic within 72
hours (my understanding is this is only
required if exposed to HIV, HBV, HCV +
source)
– HIV testing at 6 wks, 12 wks, 6 months
9 Other considerations:
– For occupational exposures:
• WCB Physician’s First Report
• Employee Accident Report form #00169
– Prevent transmission while in 6 month window period:
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Abstain from intercourse or use condoms
Avoid pregnancy
Discontinue breastfeeding
Do not donate blood, plasma, organs, tissues...
Do not share toothbrushes, razors, needles etc.
When to Speak to ID
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Pregnant or breast feeding patients
Source patient already on retrovirals
Delayed exposure
Significant renal or hepatic disease
Unknown source
Hep B Tx/Management
-Only consider Tx if HBsAg +
• If immunized and adequate titers (>10IU)
– Do nothing (no need to test either HCW or source pt)
• If immunized and ? Anti HBs-Titers
– Get titer levels (can delay as long as HBIG can be initiated within
at least 72 hrs, 24 hrs preferred)
• If immunized and titers <10IU after 1 series of
vaccination
– HBIG (0.6mL/kg/admin) and 1 dose of vaccine or 2 HBIG
• If immunized and known non-responder (low titers after
two series of vaccination)
– HBIG now and then repeated in 1 month
• If not immunized
– HBIG and give 1st dose of vaccine (repeat vaccine at 1 and 5
mths)
Hep B PEP
• Approx 75% effective
• HBIG is derived from human plasma (but
no risk of HIV, no reported cases of HCV)
• Hep B vaccine and HBIG are safe in
pregnant moms
Hep C PEP
Hep C PEP: studies
• Animal study looking at the use of high
dose anti-HCV IG administered 1 hr after
transmission did not prevent infection
• Use of antivirals: no studies, but not
thought to be effective
• Therefore, aim is early detection of HCV
an early referral for possible Tx options
Take Home Points
• Occupational BBF exposures are common
• Although the risks are generally low, the
consequences are severe
• HIV exposure
– If HIV + = start PEP
– If HIV - = don’t start PEP
– If unknown HIV status = MD and Pt need to make a
decision, generally start PEP if high risk
exposure/patient/setting
• Hep B
– If pt has adequate titers = do nothing
– If titers are not adequate = HBIG +/- vaccine
• Hep C
– No Tx, but goal is early identification in order
to institute appropriate f/u, Tx as needed
Resources
• CDC guidelines (US data from June 2001)
– The best and most extensive resource (references
most pertinent studies and compiled by experts)
– www.cdc.gov/mmwr/pdf/rr/rr5011.pdf
• Canadian guidelines/data (from March 1997)
– Public Health Agency of Canada
– http://www.phac-aspc.gc.ca/publicat/ccdrrmtc/97vol23/23s2/index.html
• Southern Alberta Clinic: HIV/AIDS resource
– www.calgaryhealthregion.ca//clin/sac/postexpr.htm
• MARCH 2002 39:3 ANNALS OF EMERGENCY
MEDICINE
• Needlestick!
– www.needlestick.mednet.ucla.edu: currently not
working, but it’s supposed to provide an online
decision making tool for BBF occupational exposures
• Rosen’s
• Robbins Pathology text
• Dr. Walker/Dr. Djurfors Presentations