Transcript Document

Post Exposure Prophylaxis For
Management of Occupational
Exposure
Dr A.K. Gupta MD (Pediatrics)
Additional Project Director
Delhi State AIDS Control Society
Govt of Delhi
Definitions
Occupational exposure refers to exposure to potential
blood-borne infections (HIV, HBV and HCV) during
performance of duties.
Non-occupational exposure refers to exposure to potential
blood-borne infections (HIV, HBV, HCV) outside
work
setting- e.g. sexual assault /rape/sodomy etc
Post exposure prophylaxis (PEP) refers to the
comprehensive management given to minimize the risk of
infection following potential exposure to blood-borne
pathogens (HIV, HBV, HCV).
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Exposures which place health
personnel at risk of blood borne
infection –
• A percutaneous injury e.g. Needle stick injury
(NSI) or cut with a sharp instrument
• Contact with the mucous membrane of eye or
mouth
• Contact with non-intact skin (abraded skin or with
dermatitis)
• Contact with intact skin when the duration of
contact is prolonged with blood or other potential
infected body fluids
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Exposed Person
Exposed person is the person who is at risk of
acquiring HIV/HBV/HCV infection through
exposure to blood or body fluids .
Who is at Risk ? • Nursing Staff
• Emergency Care Providers
• Labor & delivery room personnel
• Surgeons and operation theater staff
• Lab Technicians
• Dentists
• Health cleaning/ mortuary staff / Waste Handlers
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Potentially infectious body fluids Exposure to body fluids
considered at risk
Exposure to body fluids
considered not at risk
unless they contain
visible blood
Blood, Semen, Vaginal
Tears, Sweat, Urine and
secretions, CSF, Synovial,
faeces, Saliva, Sputum and
Pleural and Pericardial fluid, vomitus
Amniotic fluid & other body
fluids contaminated with
visible blood
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Occupational Blood-Borne Exposures
Relative Risk of Sero-conversion with
Percutaneous Injury
Mucous membrane splash
to. eye, oro nasal
0.09%
Work Practices which Increase the Risk of
Needle Stick Injury
• Recapping needles (Most important)
• Performing activities involving needles and
sharps in a hurry
• Handling and passing needles or sharp after
use
• Failing to dispose of used needles properly in
puncture-resistant sharps containers
• Poor healthcare waste management practices
• Ignoring Universal Work Precautions
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Risk Factors for HIV Seroconversion in
HCWs
Risk Factor
Adjusted Odds Ratio*
Deep Injury
Visible Blood on Device
Terminal Illness in Source Patient
Needle in Source Vein/Artery
From: NEJM 1997;337:148590.
15.0
6.2
5.6
4.3
*All Risk Factors were significant (P <
0.01)
Supreme Court Directive To Ensure PEP
Drugs in All Govt Hospitals
1. Universal Work Precautions (UWP) and PEP guidelines
should be followed by HCPs to prevent occupational
transmission of HIV, Hepatitis B and hepatitis C.
2. This will develop confidence in HCPs while working with
patients some of whom might be infected with
HIV/HBV/HCV.
3. PEP drugs should be available in all Govt Hospitals to
enable protection of HCPs dealing with potentially infected
patients to make sure that no patients suffering from HIV be
denied treatment/surgery/ procedures etc
4. Availability of UWP and PEP can minimize the stigma and
discrimination against PLHIVs in Health Care facilities.
Post Exposure Prophylaxis (PEP)
It refers to the comprehensive management to
minimize the risk of infection following potential exposure
to blood borne pathogens (HIV, HBV, HCV ).It includes –





First Aid
Risk Assessment
Counseling
PEP drugs (4Weeks) depending upon risk assessment
Relevant Lab Investigation on informed consent of the
source and exposed person
 Follow up and support
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Management of exposed person
1st step: Management of exposed site - First Aid
 Skin: Do not squeeze the wound to bleed it, do not
put the pricked finger in mouth. Wash with soap &
water, don’t scrub, no antiseptics or skin washes
(bleach, chlorine, alcohol, betadine).
 Eye: wash with water/ normal saline/ don’t remove
contact lens immediately if wearing, no soap or
disinfectant.
 Mouth: spit fluid immediately, repeatedly rinse the
mouth with water and spit / no soap/ disinfectant.
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2nd step: Establish eligibility for PEP
Evaluation must be made rapidly so as to start
treatment as soon as possible-ideally within 2hours but
certainly within 72 hours of exposure. However all
exposed cases don’t require prophylactic treatment.
Factors determining the requirement of PEP Nature/Severity of exposure and risk of transmission
 HIV status of the source of exposure
 HIV status of the exposed individual
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A. Categories of exposure
Category
Definition and Example
Mild
exposure
Mucous membrane/non-intact skin with small
volumes e.g. a superficial wound with a low
caliber needle, contact with eyes or mucous
membrane, subcutaneous injections with a low
caliber needle.
Moderate
exposure
Mucous membrane/non-intact skin with large
volumes or percutaneous superficial exposure
with solid needle e.g. a cut or needle stick injury
penetrating gloves.
Severe
exposure
percutaneous exposure with large volumes e.g.
an accident with a high caliber needle visibly
contaminated with blood, a deep wound, an
accident with material that has been previously
been used intravenously or intra-arterially
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Exposure with discarded sharps / needles ,
contaminated for over 48hrs, the risk for HIV is
negligible but risk for HBV remains significant as
HBV survives longer outside the body.
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B. Assessment of HIV status of the source of
exposure
 A baseline rapid HIV testing should be done before
stating PEP. Further initiation of PEP where indicated
should not be delayed for want of report.
 A + HIV test result can help taking a decision but a
negative test result does not exclude HIV infection as
the source may be in the window period.
 When the status of source is unknown or the sample is
not available for testing the risk is based on the HIV
prevalence in the geographical area.
C. Assessment of the exposed individual
Exposed individual should be tested for pre-existing HIV
infection. HIV + cases should not receive PEP and should be
referred to ART centre for eligibility of ART and further
management.
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3rd step – Counseling for PEP
Information to exposed person includes 1. The risk of acquiring HIV infection from specific exposure.
2. PEP is provided to prevent potential transmission of HIV virus. It is not 100%
effective and should be given preferably within 2 hours but certainly within 72
hours if eligible.
3. Baseline HIV testing is important. PEP medicines will be discontinued if the
initial baseline HIV test is positive. In that case further assessment for initiating
ART would be done.
4.
Duration of course of medicine is 4 weeks. Importance of adhering to
medication once started. Medicines can be stopped at any time but
benefit of PEP will not be obtained.
5. Common side effects of medicines.
6. After exposure the person should not have unprotected sexual
intercourse until it is confirmed 6 months after the exposure that he/she
is not HIV infected. Condom use is essential
7. The PEP drugs are usually safe during pregnancy. If the lady gets HIV
due to exposure during pregnancy, the baby will have some risk of
becoming HIV infected.
8. The PEP drugs are usually safe during breast feeding but the lady may
consider stopping breast feeding if PEP is indicated.
9. Symptoms and signs of early HIV sero conversion
10. Risk of Hepatitis B and Hepatitis C after needle stick exposure and
available prophylaxis for this.
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4th step – Prescribe PEP
There are 2 types of regimen
Basic
- 2 drug combination
Expanded regimen - 3 drug combination
Drug
2 drug regimen 3 drug regimen
Zidovudine(AZT)
Or
Stavudine (d4T)
+
Lamivudine
(3TC)
300 mg twice a day
or
30 mg twice a day
+
150 mg twice a day
300 mg twice a day
or
30 mg twice a day
+
150 mg twice a day
+
Protease
inhibitors
Nil
1st choice: Lopinavir/ ritonavir
400mg/100mg twice a day
or
2nd choice: Nelfinavir
1250 mg twice a day
If Protease
inhibitors is not
available
Nil
Efavirenz (EFV) 600 mg once
a day
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Status of source
Exposure
HIV+ and
HIV+ and
asymptomatic symptomatic
HIV status not known
Consider
2 drug PEP
Start 2 drug
PEP
Usually no PEP or
Consider 2 drug PEP
Moderate Start 2 drug
PEP
Start 3 drug
PEP
Usually no PEP or
Consider 2 drug PEP
Severe
Start 3 drug
PEP
Usually no PEP or
Consider 2 drug PEP
Mild
Start 3 drug
PEP
• HIV testing of source should not delay the decision of starting
PEP. Start 2 drugs first if required then obtain consultation.
• Prophylaxis needs to be continued for 4 weeks.
• For a female under consideration of PEP a pregnancy test is
recommended. Efavirenz is contraindicated in first 3months and
Indinavir during Pre natal time. It is recommended to begin with
basic regimen and if 3rd drug is required then add Nelfinavir.
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Tolerability of HIV PEP in HCWs
Adverse Effects of PEP Regimens
6
Myalgias
14
Diarrhea
Vomiting
16
18
Headache
38
Fatigue
57
Nausea
0
20
40
60
Percent
From: Wang SA. Infect Control Hosp Epidemiology
2000;231:780-5.
80
100
Protection Against Hepatitis B
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5th step - Laboratory Evaluation
Reason for testing soon after exposure is to establish “baseline’
against which to compare future test results.
Timing
In persons on PEP In persons not on PEP
Baseline (with in
8 days of
exposure)
HIV, anti- HCV,
HBsAg, Complete
blood counts
Transaminases
HIV,HCV,HBV
6th step – Follow up
Clinical –
• Monitoring for appearance of signs of HIV sero conversion
• Use precautions to prevent secondary transmission (Blood
donation, Breast feeding ,Pregnancy, Unprotected Sexual
relations especially during 6-12 wks following exposure.
Condom use is essential.
• Drug adherence
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• Psychological support
Lab follow up for HIV and Hepatitis –
Timing
In persons taking PEP
Weeks 2 & 4
Transaminases
Complete blood counts
Week 6
HIV-Ab
Month 3
HIV-Ab, anti - HCV,
HBsAg, Transaminases
Month 6
HIV-Ab, anti –HCV,
HBsAg, Transaminases
Exposed persons should have post PEP HIV test. Testing at end
of PEP may give indication of sero conversion. To diagnose all
persons who sero convert testing at 3 and 6 months is
recommended.
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Availability of PEP at Healthcare facility
It is recommended that PEP drugs be kept available
round-the-clock in any of the three locations Emergency room, Labor room and ICU.
Drug Stock at the Healthcare facility
PEP kit comprises of 2 drug regimen:
Zidovudine(AZT) 300mg + Lamivudine (3TC) 150
mg as a fixed dose combination
3rd Drug (PI) can be purchased from chemist near
RML Hospital, Lok Nayak Hospital or AIIMS &
amount will be reimbursed by DSACS.
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• 24 hour PEP Helpline
• PEP guidelines on web site of DSACS.
www.delhisacs.org
Thanks
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