Download 2.1 Occupational exposure to blood and other body fluids

POST-EXPOSURE PROPHYLAXIS (PEP)
PROCEDURES TO BE FOLLOWED IN CASE OF
ACCIDENTAL EXPOSURE TO BLOOD AND OTHER BODY FLUIDS
Médecins Sans Frontières
Medical Departments
December 2004
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
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TABLE OF CONTENTS
Preface................................................................................................................................................................................................3
Abbreviations ....................................................................................................................................................................................4
1. Introduction ..................................................................................................................................................................................5
2. Risks of transmission .................................................................................................................................................................6
2.1 Occupational exposure to blood and other body fluids ................................................................................................6
2.2 Sexual Exposure .......................................................................................................................................................................7
3. Preventing exposure to and transmission of HIV and other viruses..........................................................................8
4. Procedures to be followed to prevent hiv transmission after an accidental exposure to blood .....................10
4.1. Immediate First aid after an accident ........................................................................................................................... 11
4.2. Risk assesment of HIV transmission ..............................................................................................................................12
4.3. Deciding on therapy ..............................................................................................................................................................15
4.4. Post-exposure prophylactic (PEP) regimen for HIV ...................................................................................................17
5. Post-exposure measures against hepatitis B and C....................................................................................................... 20
6. Psychological support and information ...............................................................................................................................21
7. Follow up of an exposed person ........................................................................................................................................... 23
8. Accidental exposure to HIV through sexual contact................................................................................................... 25
9. Information and notification of the accident ................................................................................................................ 28
10. Practical details ...................................................................................................................................................................... 30
11. References ................................................................................................................................................................................31
Appendix 1: HIV, HBV and HCV prevalence by country ................................................................................................... 33
Appendix 2: Standard medicalAL precautions in health-care settings ....................................................................... 37
Appendix 3: Risk assessment guide for the source patient ............................................................................................ 38
Appendix 4: Accidental Exposure to Blood Notification Form ...................................................................................... 40
Appendix 5: Notification of an AE - HQ form .................................................................................................................... 42
Appendix 6: PEP Treatment Informed Consent/Refusal form ...................................................................................... 43
Appendix 7: Information sheet on prophylaxis and follow-up after an AE ............................................................... 44
Appendix 8: Emergency contraceptive regimen .................................................................................................................. 45
Appendix 9: Medical certificate for Swiss insurances .................................................................................................... 46
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
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PREFACE
MSF provides post-exposure prophylaxis (PEP) to its staff in case of occupational or
accidental sexual exposure. This guideline describes the risks of infection, the
preventive measures and the procedures to follow in case of such exposure.
This document is intended for medical doctors and is meant to assist in deciding when
and how post-exposure prophylaxis should be given.
This guideline has been prepared by the MSF international working group on AIDS, in
consultation with specialists*. This third version has been updated in line with MSF
field experience and the latest scientific advances on the issue; the main modifications
are related to the indications of bi or tritherapy with anti-retrovirals for postexposure prophylaxis to blood or other body fluids.
The international working group on AIDS
Médecins Sans Frontières
December 2004
* We acknowledge the useful comments on specific issues from: Pr Sven A. Danner (Academic Medical Centre,
Amsterdam), Pr Elisabeth Bouvet, Dr M Gerard (Hospital Saint Pierre, Brussels, Belgium), the doctors of the Bichat
Hospital, the doctors involved in the Groupe d'Etude sur le Risque d'Exposition au Sang GERES, Paris, Dr Anne Leentvaar
(GG&GD, Amsterdam), Dr Jim V. Steenbergen (Landelijk Coordinatie Centrum Infectieziektenbestrijding, Netherlands)
and Dr P ustero (Spain).
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ABBREVIATIONS
PEP
AE
AEB
CDC
HIV
HBV
HCV
HQ
HR
AZT
3TC
FDC
NFV
PLWHA
STIs
Post-exposure prophylaxis
Accidental exposure
Accidental exposure to blood
Centre for Disease Control
Human immuno-deficiency virus
Hepatitis B virus
Hepatitis C virus
Headquarters
Human resources
Zidovudine
Lamivudine
Fixed Dose Combination
Nelfinavir
People living with HIV/AIDS
Sexually transmitted infections
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1.
INTRODUCTION
Most countries in which MSF is working face a high prevalence of human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) viruses (see appendix
nº1).
Transmission of these agents occur through:
- sexual contact;
- unsafe blood transfusion;
- injury with a needle or any other sharp instrument contaminated with infected
blood or other body fluids;
- direct contact between infected blood or body fluids and cutaneous cuts or
abrasions.
Field workers are therefore at risk of infection through occupational exposure and
accidental sexual exposure. MSF should assure that prophylactic treatment is available
for MSF field workers (expatriate or nationals) who have experienced an accident
involving exposure to blood or other body fluids as well as in case of involuntary high
risk sexual intercourse (eg sexual abuse).
The combination of 2 or 3 anti-retroviral drugs (according to the magnitude of
exposure), administred during 28 days, is now the standard prophylactic treatment
worldwide.
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2.
RISKS OF TRANSMISSION
2.1 Occupational exposure to blood and other body fluids
An accidental exposure (AE) is defined as :
- any contact with blood or other body fluid as a result of a
percutaneous injury with a needle or any other sharp
instrument;
- any exposure to blood or body fluid via mucous membranes
(eye, mouth) or non-intact skin (wound, dermatitis, abrasion).
Body fluids include : cerebrospinal fluid, semen, vaginal secretions, amniotic liquid or
other body fluids contaminated with visible blood.
The average risk for HIV transmission after a single percutaneous exposure to HIVpositive blood is low and this risk is considerably lower than that arising from hepatitis
B and C viruses.
Table 1: Risk for transmission after occupational exposure to infected blood1,2
Agents
HIV
HIV
HBV
HCV
Exposure mode
Percutaneous
Mucocutaneous contact*
Percutaneous exposure
Percutaneous exposure
Risk of infection
0.3%
0.03-0.09%
10-30%
0-10%
*refers to the exposure of mucous membranes or cutaneous cuts or abrasions
The most common procedures presenting a risk of percutaneous exposure with
contaminated blood include the following:
 taking blood samples from arteries or veins and samples of other body fluids (see
above), inserting and handling drips, particularly in emergency situations;
 activities related to surgery, particularly during major surgical interventions of long
duration or where haemorrhage may occur;
 the handling of blood or infectious body fluids by laboratory staff;
 activities related to the cleaning, handling and destroying of contaminated medical
material and medical waste.
Performing these activities in a rush carries an additional risk.
Personnel at risk does not only include medical staff but also non-medical staff of
health facilities.
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2.2
Sexual Exposure
Sexual exposure includes unprotected sexual intercourse including the case of broken
or slipped condom.
Sexual exposure through a forced intercourse requires special attention, as the risk for
HIV transmission is higher.
Risk of transmission3
-
Proven: vaginal and anal penetration.
-
Possible: oral penetration with ejaculation. (In case of sexual violence: victim has
bitten the rapist or been bitten by him and blood is present in the mouth, refer
to exposure to blood chapter).
-
No risk: kissing; digital penetration or penetration by a foreign object in the
vagina, anus or mouth; ejaculation onto intact skin.
Table 2: Risk of HIV transmission after sexual exposure
Type of exposure
(from a source known HIV positive)
Receptive oral sex
Insertive vaginal sex
Receptive vaginal sex
Insertive anal sex
Receptive anal sex
4-6
Risk of HIV transmission
per exposure
0- 0.04%
0.03-0.09%
0.1-0.3%
0.03%
0.5-3%
The risk of transmission is increased:
-
If blood is present
-
If any of the partners has a STI
-
In case of vaginal, anal or oral lesions (very frequent in case of forced
intercourse)
-
If ejaculation took place
-
In case of multiple penetrations or mass rape
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3.
PREVENTING EXPOSURE TO AND TRANSMISSION OF HIV AND
OTHER VIRUSES
STAFF INFORMATION
All MSF staff (expatriate and national) should be informed about how to protect
themselves against HIV and other pathogens transmitted by blood or sexual contact.
Medical coordinators have the responsibility to inform all new staff about:
 the universal precautions to be followed in health services (see Appendix nº2);
 the use of condoms in private life;
 other preventive measures to be taken against these viruses (including vaccination);
 the procedures to be followed in case of an accidental exposure or sexual abuse.
Staff must be reminded of these precautions on a regular basis. All MSF staff share an
individual and collective responsibility in this regard.
According to the policy in each MSF section, MSF expats will have to follow the
recommendations concerning HIV testing before departure.
In MSFCH testing before departure is strongly advised but not compulsory.
BIOSESAFETY COMPONENT IN EACH MSF PROJECT
Every health care setting where MSF is working should apply effective standard
universal precaution practices. Standard biosafety recommendations, especially for
laboratory workers include:
 prevention of puncture wounds, cuts and abrasions and protection of existing
wounds, skin lesions, the conjunctiva and mucosal surfaces
 protective measures to prevent contamination of the person and his clothing; basic
hygiene practices
 control of surface contamination by containment and disinfection’s procedures
 effective use of sterilisation
 safe disposal of contaminated waste
 safe handling, transfer and shipment of specimens
 safe collection of blood samples (never pipette by mouth, never recap needles)
(see biosafety guidelines for diagnostic and research laboratories working with HIVWHO 1991)
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PROTECTION AGAINST HEPATITIS B AND C
All MSF medical staff (national and expatriate) should be correctly vaccinated against
the hepatitis B virus 1,7 : one dose at month 0, 1, 2 and 12, and boosters every 5 years.i
An anti-HbS antibody control should preferably be carried out after the fourth dose
(min. 1 month later), or if the recommended schedule was not properly applied, to check
whether the level of antibody protection is sufficiently high. If the level of anti-HbS is
lower than 10 IU/L, an additional dose is recommended (before the next scheduled
booster).8
There is no danger in vaccinating someone who is already infected with HBV.
There is no vaccine or prophylaxis available against hepatitis C.
.
Another scheme is widely used and recommended by MSF for staff not considered at risk (see
MSF guidelines on expatriate health): 3 doses at month 0, 1 and 6. The need for boosters is still
debated at scientific level and national recommendations for booster vaccination vary in each
Western country. MSF prefers to stay on the safe side and recommend regular systematic
boosters.
i
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4.
PROCEDURES TO BE FOLLOWED TO PREVENT HIV
TRANSMISSION AFTER AN ACCIDENTAL EXPOSURE TO BLOOD
An AE is a medical emergency. The procedure must be conducted in such a way
that the prophylactic treatment, if needed, is started as soon as possible
- ideally within 1 or 2 hours
- preferably within 4 hours
- within 48 hours, in any case
- in some cases, and at the latest, within 72 hours.
Accidental exposure
4.1. Immediate first aid
4.2. Risk assessment by a medical doctor
4.3. Decision regarding therapy by medical doctor
together with exposed person
Offer of psychological support (Chapter 6)
4.4. Start of prophylactic treatment
Notification
(appendix 4 to 6)
7. Monitoring and follow-up
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4.1. IMMEDIATE FIRST AID AFTER AN ACCIDENT
PERCUTANEOUS EXPOSURE
In case of


injury by material contaminated with blood,
contact between non-intact skin and blood or body fluid
let the wound bleed (without scrubbing or squeezing), immediately wash both wound
and surrounding skin with water and soap (without scrubbing), and then rinse;
disinfect the wound and surrounding skin with:
 povidone iodine 2.5% (Betadine)
during 5 minutes,
or
 a solution of chlorine 12° chlorometric
(diluted to 1/1Oth)
during 10 minutes
or
 alcohol 70%
during 3 minutes.
Avoid irritating solutions like caustic agents such as bleach.
EXPOSURE AFFECTING THE EYES OR MUCOUS MEMBRANES
Rinse the exposed area immediately with an isotonic saline solution during 10 minutes.
Antiseptic eye drops can also be used for eye exposure.
If none of these solutions are available, use clean water.
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4.2. RISK ASSESSMENT OF HIV TRANSMISSION
A medical doctor must assess the risk of HIV transmission following an AE. This
evaluation must be made rapidly, so as to start any treatment, if required, as soon as
possible after the accident.
Table 3: Factors which determine the risk of infection1
 Type of exposure
- percutaneous injury
- mucous membrane exposure
- non-intact skin exposure
- bites resulting in blood exposure to either person involved
 Type and amount of fluid/tissue
- Blood
- Fluids containing blood
- Potentially infectious fluid or tissue (semen; vaginal secretions; and
cerebrospinal, synovial, pleural, peritoneal, pericardial and amniotic fluids)
- Direct contact with concentrated virus
 Status of the source patient
- Presence of HIV antibody
- Viral load of the source patient (acute seroconversion, advanced disease, etc)
4.2.1
-
Assessment of the magnitude of the exposure
In case of percutaneous injuries
High risk exposure
In case two of the following circumstances are present :
- high calibre needle (>18 G);
- a deep injury;
- visible blood in device;
- needle in patient artery or vein
Low risk exposure
-
In case only one of the circumstances mentioned above is present
Injury with low calibre needle ( 18 G)
No visible blood contamination
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-
Injury with solid (suture) needle
Superficial wound
In case the hand is injured, the wearing of gloves during any of these accidents
constitutes a protective factor.
-
In case of mucous membranes, eye and non-intact skin (dermatitis, abrasion, wound)
exposures
High risk: major blood or body fluid splashes
Low risk: small volume (drops) of blood or body fluids
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4.2.2
The HIV status of the source patient
Knowing the HIV status of the source patient will determine whether PEP is going to be
taken or not. Therefore whenever possible, it should always be verified, taking into
account that there are some conditions to be met before testing the source patient:
access to VCT, confidentiality, parallel testing, etc.
HIV testing, if performed, should not delay the start of PEP. Give first dose as
soon as possible; prophylaxis can still be cancelled afterwards if needed.
When his/her HIV status is not known, the source patient has to be examined
clinically and a full history has to be taken (see risk assessment guide in Appendix 3). It
is important to assess whether s/he is likely to be HIV infected and particularly if
she/he is likely to have a high viral load (symptomatic primo-infection or advanced
stages of AIDS).
Table 4: Risk assessment of the source patient9

High Risk Patient
HIV positive:
- symptomatic HIV infection
- acute seroconversion
- high viral load (if known)
- patient under HAART with indications of treatment failure (*)
Unknown status or unknown source:
- Prevalence in general population > 1%
- Symptoms of primary infection
- Source person has risk factors for HIV infection

Low risk patient
HIV positive:
- asymptomatic HIV infection
- low viral load
- patient under HAART without treatment failure
Unknown status or unknown source:
- Prevalence in general population  1%
- clinical examination does not establish HIV-related illnesses or AIDS symptoms
- The patient’s history does not indicate risk factors for HIV infection, nor signs
of HIV primo-infection
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(*) See definition of treatment failure in WHO revised version of “scaling up
antiretroviral therapy in resource-limited settings: treatment guidelines for a public
health approach10.
Try to find out previous treatments and risk of infection by a resistant strain,
especially if bad adherence does not seem the reason for the treatment failure. Need
for the advice of a specialist, for the adaptation of the protocol, to assess the risk as
the standard prophylaxis will not be efficient (consult MSF headquarters in each
section).
In case, the patient is found to be HIV+, cotrimoxazole prophylaxis and curative
treatment if feasible, should be provided.

HIV negative
The source patient may be in the window period. Check if any symptoms compatible
with a primary infection syndrome in the last three months. 90 % of the infections are
symptomatic: fever (96 %), adenopathy (74 %), pharyngitis (70 %), rash (70 %),
myalgias (54 %), etc.
4.3. DECIDING ON THERAPY
The combination of the two factors will allow the medical doctor in charge of PEP to
advise whether or not to start prophylactic treatment and the indications for bi or
tritherapy.
Table 5: Recommendations for PEP after percutaneous injury (adapted from the
Public health Service guidelines CDC- NEJM 348;9 2003)9,11
Magnitude Source
Exposure patient
High
Low
HIV-Positive
High risk
Low risk
3 drugs-PEP
recommended
3 drugs-PEP
recommended
3 drugs-PEP
recommended
2 drugs-PEP
recommended
Unkown Status
High risk
Low Risk
2 drugs-PEP
recommended
2 drugs-PEP
recommended
2 drugs-PEP
possible
No PEP
recommended
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HIV
negative
No PEP
necessary
No PEP
necessary
15
In case of mucous membranes and non-intact skin exposures follow the same
recommendations but prescribing tritheraphy only when the patient is HIV positive and
there is large volume of blood (major blood splash) 12.
If the source patient is unknown (e.g. injury while cleaning contaminated material), the
main parameter to take into account in deciding on therapy is the magnitude of the
exposure. However, if prophylaxis is administered and the source person is subsequently
determined to be HIV negative, the prophylaxis should be discontinued. 16.
The medical doctor advises on PEP and the exposed person will be the one to decide
whether s/he will take PEP or not (see also Appendix 6).
It is essential to ensure clinical, biological and psychological follow-up of the
exposed person whether PEP is taken or not. This is discussed in Chapters 6 and 7.
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4.4. POST-EXPOSURE PROPHYLACTIC (PEP) REGIMEN FOR HIV
In order to work effectively, the treatment must preferably be started within the
first 4 hours after an AE, and certainly within 48-72 hours. Treatment after an
interval greater than 48-72 hours may be considered in case of massive exposure – a
situation that requires the opinion of an AIDS specialist (see chapter 6).
As antiretroviral combinations are proven to be more effective than mono-therapy in
suppressing HIV replication in established HIV infection, the use of a double therapy
(two antiretrovirals) or a triple therapy (three antiretrovirals) has become the standard
PEP treatment in Western countries.12-14
MSF recommends as prophylactic treatment a combination therapy with 2 or 3
antiretrovirals (according to the indications) to be taken daily over a period of one
month when there are evidences of high-risk exposure and confidence that the
treatment is going to be completed.
A triple therapy is known to be more potent than a bi-therapy in suppressing HIV viral
replication (in already infected individuals)2, but presents more frequent side effects
(in otherwise healthy persons) with higher rates of abandon.15
Triple therapy is recommended in high risk situations such as: massive exposure and
HIV positive source. It can also be considered in massive exposure and status of the
source patient unknown in a high prevalence country. In all other situations, when a
prophylaxis is necessary, consider dual PEP.
PROTOCOLS
Dual PEP: first option
AZT (Zidovudine) 300mg bid + 3TC (Lamivudine) 150mg bid (FDC)
(Combivir®, Duovir®,…)
Triple PEP: add
Nelfinavir 1250mg bid
The combination therapy available in the field depends from the possibilities of rapid
supply from the capital of the complete treatment, therefore the Medical Coordinator
should decide between:
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-
a complete treatment for one month
a 7-day kit allowing PEP to be started as soon as possible after the exposure.
In this case, the remaining 3-week treatment is available at capital level or can be sent
from the headquarters by a rapid mail service. The remaining 3 weeks can be
completed in the field if the conditions required for the follow up of the exposed
person are available:
 a medical doctor, who can supervise treatment and follow up;
 the necessary laboratory testing (see Chapter 7): tests for HIV (including
confirmation test, confidentiality and counselling), HBV and HCV serology,
transaminases to detect any hepatitis, control of renal function, full blood count
(specially if AZT is given. This requires that every mission identifies whether such
facilities are available locally or regionally.
When it is decided to complete PEP on the field, the coordinator and headquarters must
be quickly informed so that they can immediately send the remaining treatment.
CONTRAINDICATIONS
Nevirapine is STRICLY FORBIDDEN for toxicity reasons
In pregnancy16 : Efavirenz should be avoided because of its teratogenic effects.
Repatriation (of expatriate staff) or referral to a specialised centre should be
considered if:
 the above conditions cannot be met in the field;
 the exposed person requests it;.
 If the medical doctor recommends it e.g. because adverse effects to treatment
In this case, repatriation or referral should better take place within a week of initiating
treatment for clinical reasons. However, it can take place later on, e.g. if the exposed
person is too anxious.
It is the responsibility of the medical coordinator to assess whether the necessary
conditions are met before allowing continuation of PEP treatment in the field. The
medical department should be informed and agree with the proposed strategy.
In case of repatriation, a medical certificate should be provided (see repatriation
procedures).
TREATMENT OF SIDE-EFFECTS
Possible side effects occur mainly at the beginning of the treatment and include nausea,
diarrhoea, muscular pain and headache. The person taking the treatment should be
informed that these may occur and should be dissuaded from stopping the treatment
as most side effects are mild and transient, though possibly uncomfortable. Drugs for
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adverse effects should be administered if necessary to secure adherence. Anaemia
and/or leucopoenia and/or thrombocytopenia may occur during the month of treatment.
In the long term, the side-effects of this treatment are not yet fully known. Data on
carcinogenic effects, fertility, spermatogenesis and teratogenesis16 are still lacking.
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5. POST-EXPOSURE MEASURES AGAINST HEPATITIS B AND C
HEPATITIS B
All MSF staff, whether expatriate or national, should be correctly vaccinated against
hepatitis B (see Chapter 3).
After an AEB:
 if the anti-HBS antibody level is known and sufficient (anti-HbS level > 10 IU/L), no
particular measure needs to be taken;
 if the antibody level is not known and/or insufficient (below 10 IU/L), a booster
vaccination should be administered (and the antibody level checked later on);.
 if the exposed person was vaccinated (or last booster administered) more than 5
years before, a booster vaccination should be administered;
 if the exposed person was never vaccinated, the hepatitis B vaccine series should be
initiated.1
HEPATITIS C
There is presently no prophylaxis available against hepatitis C.17,18 Neither immune
globulin nor antiviral therapy is recommended after exposure.
Recommendations for post-exposure management are intended to achieve early
identification of established infection and, if present, referral for evaluation of
treatment options.
 Perform baseline and follow-up testing for anti-HCV and alanine aminotransferase (ALT) 4-6 months after exposure
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6. PSYCHOLOGICAL SUPPORT AND INFORMATION
Many people will feel anxious after exposure. Every exposed person needs to be
informed about the risks and the measures that can be taken (see below). This will help
to relieve part of the anxiety, but some may require further psychological support.
In some cases, psychological support can be offered locally. When this is not the case,
repatriation is advised in order to offer specialised psychological services. This can be
decided at any moment after exposure. Development of post-traumatic stress disorder
have been described, therefore long term follow-up must be indicated.
INFORMATION
During a confidential encounter with the exposed person, the doctor should bring up the
following points :

The average risk of HIV transmission after an AEB is estimated at 0.3% if the
source patient is HIV positive after a percutaneous exposure and o.09% after
mucous-membrane exposure1,2.

The prescription of prophylactic treatment after an AEB depends both on the
gravity of the exposure and the supposed HIV status of the source patient.

PEP is not 100% effective.

The possible side effects of double/triple therapy are minor and do not require
specialised medical surveillance. They should not lead to stopping PEP.

The insurance companies covering expatriates require an HIV test within 8 days
of exposure.

Staff who might opt for repatriation or referral for medical reasons should best
do so within the week following the initiation of treatment. However, repatriation
is always possible later on when requested by the person or advised for the
provision of psychological support.

After any AE, the exposed person should not have unprotected sexual intercourse
until it is confirmed, 3 months after the exposure, that s/he is not HIV infected.
It is also advised to avoid pregnancy.

If the exposed person has been advised PEP, but refuses to start it, s/he should
sign a refusal form (see Appendix 6). The medical coordinator should keep this
paper.
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
Once prophylactic treatment has begun, the exposed person must sign a specific
form (see Appendix 6). An information sheet covering the PEP and the biological
follow-up after any AE (see Appendix 7) is given to the person under treatment.
However, this sheet cannot replace verbal explanations.
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7. FOLLOW UP OF AN EXPOSED PERSON
Whether PEP prophylaxis has been started or not, medical follow up to monitor possible
infections (see Table 6) and psychological support are indicated. If this follow up cannot
be done properly in the field, repatriation (of expatriate staff) or referral to a
specialised centre is strongly recommended (see Chapter 4.4).
BIOLOGICAL FOLLOW UP
Table 6: Biological tests indicated after AEB
Timing
Baseline
(within 8 days after AE)
Week 2
Week 6
Month 3
Month 6
In persons taking PEP
HIV, HCV, HBV
Hémoglobin
Transaminases
Hémoglobin
Transaminases
Transaminases
HIV, HCV, HBV, FBC
Transaminases
HIV, HCV, HBV, FBC
Transaminases
In persons not taking PEP
HIV, HCV, HBV
HIV, HCV, HBV
Transaminases
HIV, HCV, HBV
Transaminases
HIV, HCV, HBV
Transaminases

HIV, HBV and HCV testing of exposed expatriate staff is required within 8 days
of an AEB for insurance purposes (baseline sero-status). Pre- and post-test
counselling should be offered. Expatriate staff refusing an HIV test cannot be
covered in case of sero-conversion due to AEB .

Extended HIV follow up (for 12 months) is recommended for personnel who
became infected with HCV following exposure to a source coinfected with HIV and
HCV. 1 Consider specialised follow up.

Most national insurance companies do not cover for HIV, HBV or HCV exposure.
Testing of exposed national staff for these infections is thus not required for
insurance purposes. It is, however, advised to offer an HIV test (external to
MSF) in case of an AEB, as a positive HIV status may indicate the need to
discontinue PEPi (see below). The decision on whether to test for HIV or not
should anyway be taken by the exposed person, after adequate counselling.

A single HIV test cannot be used for diagnosis purposes, and the UNAIDS/WHO
guidelines for HIV testing need to be followed19. This means that a single result is
insufficient to confirm or exclude HIV infection and cannot be used for follow up
after exposure.
i
The administration of PEP in a positive person is not indicated
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
If HIV, HBV and HCV tests are negative, subsequent tests will be necessary in
the third and sixth month after an AEB. For expatriate staff, it is essential that
the tests be carried out within the specific time frame if the incident is to be
considered as an occupational accident. ii

In any of these stages, exposed persons testing HIV positive should be offered
psychological support. Repatriation or referral to a specialized centre for an
appropriate follow-up should be proposed, and PEP discontinued.

Whether PEP is taken or not, transaminases should be checked at week 4 to
detect hepatitis (this can be done at the end of the PEP intake), as well as at 3
months and 6 months after exposure.

For persons taking PEP, a complete blood count (including numeration) and
transaminase levels should preferably be checked to detect any side effects. If
the person is receiving Nelfinavir blood glucose levels should be included.
In case serology cannot be performed locally, blood can be collected on filter paper and
sent to a laboratory. In case coagulated blood is used, refrigeration (4°-8°C) is
preferred.
CLINICAL FOLLOW UP
In addition, in the weeks following an AEB, the exposed person must be monitored for
the eventual appearance of signs indicating an HIV seroconversion: acute fever,
generalised lymphadenopathy, cutaneous eruption, pharyngitis, non-specific flu
symptoms, ulcers of the mouth or genital area. These symptoms appear in 50%-70% of
individuals with an HIV primo-infection and almost always within 3 to 6 weeks after
exposure. When a primo-infection is suspected, repatriation or referral should be
arranged rapidly so that the person may be taken in charge by a competent health
service.
ii
MSF insurance covers the risk of sero-conversion, whether PEP has been taken or not.
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
24
8. ACCIDENTAL EXPOSURE TO HIV THROUGH SEXUAL CONTACT20-22
The risk of HIV transmission after a single vaginal intercourse is approximately of the
same magnitude as the risk after percutaneous exposure (0.1%). Ejaculation during
intercourse and anal sex (specially receptive intercourse) has a higher risk of
transmission (<3%). See table nº 2.
SEXUAL VIOLENCE : DUAL PEP
Rape – as compared to regular sexual intercourse – presents a higher risk of HIV and
STIs transmission because the act is violent and entails traumatic lesions of genital
mucous membranes. Menstruation, bleeding during intercourse, genital ulcers, STIs and
more than one assailants leads to a higher risk of HIV transmission.
Psychological support must always be offered to the victim, considering repatriation if
necessary.
Post-exposure prophylactic regimens are indicated in case of rape for both anal or
vaginal sexual intercourse (with or without ejaculation) and receptive oral sex with
ejaculation.
1. The same measures and procedures described for the provision of PEP after an AE
should be applied. Repatriation or referral to a specialised centre is highly
recommended.
PEP should be given as soon as possible and within 72 hours from the time of
exposure.
If the survivor is too distraught to decide about PEP, offer a first dose of
medication and re-open the discussion about treatment within the next 24 hours21.
Motivation and adequate counselling is specially important to complete treatment
as the rate of lost to follow-up is higher in this group of patients, therefore
scheduling a visit in about 24h is recommended.
When there are no risk factors (see above), the prevalence in the country is low and
the source is likely to be HIV negative, prophylaxis only is recommended in receptive
anal sex with ejaculation.
Choice of triple therapy can be considered in case of exposures to high risk HIV
sources and significant exposures where the risk of transmission is increased (see
above), always taking into account that good adherence to treatment can be assured
and followed.
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
25
2.
Post-coital contraception must be provided not later than 120 hours after the
rape (see Appendix 8).
3.
Other STIs may be transmitted as a result of rape and prophylaxis treatment
may also be indicated (immediately or a few days after PEP and post-coital
contraception to avoid additive gastro-intestinal side effects)3,23 to prevent from
gonorrhea, clamydia and incubating syphilis:
Cefixime single dose 400mg p.o or ciprofloxacine 500mg single dose p.o
PLUS
Azithromycin 1g single dose
PLUS
Benzathine benzylpenicilin IM 2.4 MIU single dose.iii
Countries with high prevalence of Trichomoniasis should include:
Metronidazol 2gr po single dose
Examination for STIs can be done (including cervico-vaginal swab if necessary)
the first day deferring the prophylactic treatment, and repeated within 1-2
weeks of assault, if treatment wasn’t provided20.
4.
Exams for HBV and syphilis should be done for an immediate evaluation, with
serologic tests on successive weeks and complete vaccination of HBV with HBIG if
they were not previously vaccinated20.
5.
Tetanus prophylaxis and /or vaccination if there are wounds and vaccination status
is unknown.
IF A CONDOM TEARS OR SLIPS
The risk of HIV transmission must be assessed in line with the risk that the source
person is infected and the risk factors for the exposed person (lesions of genital
mucous membranes, STIs etc). When the source is of low risk, in low prevalence
countries (<1%) PEP is only recommended for receptive anal sex.20
This regimen is effective against sifilis. Azithromycin in a 2g single dose can also be used when
available (for gonorrhea and chlamydia) but causes frequent gastro-intestinal side-effects. If
azithromycin is not available, use doxycycline 200mg 7 days. In case of pregnancy, use cefixime
400mg PO and erythromycin 500mg QID for 7 days. Clinical MSF Guidelines 2004.
iii
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
26
The same risk evaluation and procedures should be applied as in an AEB and PEP can be
proposed. Other prophylactic regimens can also be proposed (post-coital contraception
and presumptive STI treatment).
It is, of course, out of the question to consider PEP as a “morning-after pill” for
unprotected sexual contact.
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
27
9. INFORMATION AND NOTIFICATION OF THE ACCIDENT
CONFIDENTIALITY must be respected in the notification of an AE, even during
emergencies and stressful situations. This applies to everyone in the field, in the
country capital and at headquarters.
COMMUNICATION AND RESPONSIBILITY
After first aid, the AE must be reported by the exposed person to the medical person
responsible for PEP in order to take a decision as quickly as possible. Whether PEP is
prescribed or not, the accident should also be reported to the country medical
coordinator.
The person responsible for PEP will analyse the risk of HIV transmission, provide
psychological support to the exposed person and will advise whether or not PEP
treatment should be taken. If treatment is advised, the ultimate decision is taken by
the exposed person. In case of doubt about whether or not treatment is indicated, it is
advised to already start PEP - while requesting specialised advice from an AIDS
specialist. Treatment can be discontinued afterwards if the specialist does not
recommend it.
When repatriation or transfer is opted for, it is the responsibility of the medical
coordinator to organize this. An additional medical certificate for repatriation should
be provided (see repatriation procedures). Follow-up by a specialised medical team will
be done in collaboration with the headquarters. Specific procedures from each section
will be followed.
REPORTING THE ACCIDENT
In every case of accidental exposure to blood, different administrative forms have to
be completed as soon as possible (within max. 1 week) and sent to the FIELD HQ
ADMINISTRATOR (Cristiano Canuti) that will be in charge of dispaching them.

A nominative form describing the AE and its management is found in Appendix 4.
This form is confidential and has to be filled in by the medical doctor in charge of
PEP. It is the equivalent of a medical file. It can be used for insurance purposes
and for establishing the initial medical certificate for an occupational accident. It
can also be given to the medical doctor to whom that person would be referred. It
has to be handed over to the field HR administrator in the HQ when an expatriate
is concerned, or to the country administrator when a national staff member is
involved. The exposed person keeps a copy.
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
28

A detailed notification of the AE (see Appendix 5) must be filled in by the
medical doctor in charge of PEP and sent with the others form. This will be given
to the person in charge of PEP at the medical department in headquarters,
whether it concerns an expatriate or a national staff member. It should not name
the exposed person. Details are required in order to update the information given
in this guideline.

All the invoices of expenses related to the accident follow up (drugs and lab
expenses) should be sent to the field HR administrator in the HQ.

A standard medical certificate is requested by the Swiss Insurance (appendix 9),
the medical doctor in charge of the person should fill it.
In case PEP treatment was advised:

An informed consent/refusal form confirming that a named individual has
consented or refused to take PEP can be found in Appendix 6. It should be
completed and signed by the exposed person, and countersigned by the medical
doctor. This form will be passed on in a sealed envelope marked "confidential" to
the field HR administrator at headquarters when it concerns an expatriate, or to
the country administrator when it concerns a national staff member. It will be
kept confidentially in the personal file of the exposed person.
It is important to report to the headquarters (HR administration) the follow
up of the accident up to its end (medical and administrative).
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
29
10. PRACTICAL DETAILS
DRUG STOCKS
PEP has to be available in the field, wether as a 7-DAY kit containing AZT with 3TC
(FDC) and Nelfinavir (see Chapter 4.4) or availlable as part of the stock in HIV/AIDS
projects.
Combivir (AZT+3TC) has a shelf life of two years and Nelfinavir for three years. They
must be kept at an ambient temperature (between 2° and 30°C) in a dry place and must
not be exposed to light. The medical coordinators are responsible for supervising the
stock management of both drugs in each country. It is important to monitor the expiry
dates of the drugs and the conditions under which they are kept.
The medical coordinator at capital level decides whether a 7-day PEP or a stock for
more days should be located in the field. The availability of a PEP kit in the field
depends on the conditions of access between the field project and the capital (where
there is generally a medical person and PEP kits), the nature of the work carried out by
the staff (curative intervention, project management etc.), and whether or not there is
someone responsible for medical aspects in the project.
TRAINING
Every MSF staff should be informed about the procedures to be followed in case of an
AE. At every location, one medical person, preferably a medical doctor, will be assigned
responsibility for PEP.
COSTS / REPATRIATION / INSURANCE

The cost of a 28 days course is estimated at around 40 U$ for Duovir and 60 U$
for Nelfinavir and will be reimbursed by the insurance company if the accident is
correctly reported.

The 7-day kits are placed in the field and paid for by MSF.

Repatriation or referral to a specialised centre is paid for by MSF or covered by
insurance. This includes the costs of treatment, tests etc, if all the invoices are
sent to the HQ. The exposed person could be regarded as being on sick leave.
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
30
11. REFERENCES
1
Update U.s. Public Health Service Guidelines for the Managment of Occupational
Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis.
MMWR. June 29, 2001/Vol.50
2
Henderson DK. Postexposure chemoprophylaxis for occupational exposures to the
human immunodeficiency virus. JAMA: 281 (10), 931-936, 1999.
3
MSF guidelines for Medical care for rape survivors; June 2004.
4
Bamberger J. and al. Am. J. med. 1999 106323-326
Ippolito G. Editorial: Prophylaxis after occupational exposure to HIV. BMJ: 315: 557-8,
1997.
5
Mastro TD, De Vicenzi I. Probabilities of sexual HIV-1 transmission. AIDS 1996;
(suppl A): 575-82
6
CDC. Public health service Management of possible sexual, injecting-drug-use, or other
nonoccupational exposure to HIV, included considerations to antiretroviral therapy
MMWR: Sept 1998/Vol 47.
7
CDC. Immunization of health-care workers. Recommendations of the Advisory
Committee on Immunization Practices (ACIP) and the Hospital Infection Control
Practices Advisory Committee (HICPAC). MMWR, 46, RR-18, 22-3, 1997.
8
European Consensus Group on Hepatitis B Immunity. Are booster immunisations
needed for lifelong hepatitis B immunity? The Lancet 12, 355 (9203), 561-5, 2000.
9
Gerbending JL, M.D, M.P.H, Occupational Exposure to HIV in Health Care Settings. N
Engl J Med 2003;348:826-33.
10
WHO 3x5 Scaling up antiretroviral therapy in resource-limited settings: treatment
guidelines for a public health approach; 2003 revision.
11
Barlett & Gallant. Medical management of HIV Infection, 2004. Johns Hopkins
Medicine, Baltimore. www.hopkins-aids.edu
12
Recomendations for Post-Exposure Prophylaxis against HIV infection in Health Care
Workers in Europe, March 2002. www.inmit.it
13
Ippolito G. Editorial: Prophylaxis after occupational exposure to HIV. BMJ: 315: 5578, 1997.
14
Department of Health. HIV post-exposure prophylaxis. Guidance from the UK Chief
medical officers. Febr. 2004.
15
I.V. Bassets, K.A. Freeberg & R.P. Walensky. Two drugs or three? Balancing efficacy,
toxicity and resistance in post-exposure prophylaxis for occupational exposure to HIV.
HIV/AIDS. CID 2004:39.
16
Parkin JM, Murphy M, Anderson J, et al. Tolerability and side effects of postexposure prophylaxis for HIV infection. The Lancet, 355, 9205, 722, 2000.
17
CDC. Recommendations for prevention and control of hepatitis C virus (HCV) infection
and HCV-related chronic disease. MMWR, 47, RR-19, 1998.
18
Practice guideline review of diagnosis and treatment of HCV. American Association
for liver disease 2004. www.aasld.org/eweb/docs/hepatitisc.pdf
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
31
19
WHO 3x5 Rapid HIV tests : guidelines for use in HIV testing and counselling
services in resource-constrained settings ; 2004.
20
Managment of non-occupational post exposure prophylaxis to HIV (NONOPEP):
SexuaL, Injecting drug user or other exposures. European NONOPEP Project. April
2002.
21
Guía de actuación para la profilaxis postexposición no ocupacional del VIH.
Recmendaciones GESIDA/CEESCAT/PNS. Feb.2003 www.gesidaseimc.com
22
Katz M, Geberding JL. The care of persons with recent sexual exposure to HIV. Ann
Intern Med: 128, 306-12, 1998.
23
MMWR. Sexually transmitted diseases treatment guidelines 2002. May 10, 2002/Vol.
51.
24
CDC. Dept of health & human services. Exposure to blood. What health care personnel
need to know; July 2003.
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
32
APPENDIX 1: HIV, HBV AND HCV PREVALENCE BY COUNTRY
HDI
Rank
Country
HIV prevalence
(% ages 15-49)
2003 1
HCV
prevalence
(Rates %)
1999
1
2
3
4
5
6
7
8
9
10
Norway
Sweden
Australia
Canada
Netherlands
Belgium
Iceland
United States
Japan
Ireland
0.1 [0.0 - 0.2]
0.1 [0.0 - 0.2]
0.1 [0.1 - 0.2]
0.3 [0.2 - 0.5]
0.2 [0.1 - 0.4]
0.2 [0.1 - 0.3]
0.2 [0.1 - 0.3]
0.6 [0.3 - 1.1]
<0.1 [<0.2]
0.1 [0.0 - 0.3]
0.1
0.003
0.3
0.1
0.1
0.9
0.1
1.8
2.3
0.1
11
12
13
14
15
Switzerland
United Kingdom
Finland
Austria
Luxembourg
0.4 [0.2 - 0.6]
0.1 [0.1 - 0.2]
<0.1 [<0.2]
0.3 [0.1 - 0.4]
0.2 [0.1 - 0.4]
0.2
0.02
0.02
0.2
0.5
16
17
18
19
20
France
Denmark
New Zealand
Germany
Spain
0.4 [0.2 - 0.7]
0.2 [0.1 - 0.3]
<0.1 [<0.2]
0.1 [0.1 - 0.2]
0.7 [0.3 - 1.1]
1.1
0.2
0.3
0.1
0.7
0.5 [0.2 - 0.8]
0.1 [0.1 - 0.2]
0.5
0.4
0.5
21
22
23
24
25
Italy
Israel
Hong Kong, China
(SAR)
Greece
Singapore
0.1 [<0.2]
0.2 [0.1 - 0.3]
0.2 [0.1 - 0.5]
1.5
0.5
0.5
0.4
1.7
26
27
28
29
30
Portugal
Slovenia
Korea, Rep. of
Barbados
Cyprus
0.4 [0.2 - 0.7]
<0.1 [<0.2]
<0.1 [<0.2]
1.5 [0.4 - 5.4]
..
31
32
33
34
35
Malta
Czech Republic
Brunei Darussalam
Argentina
Seychelles
0.2 [0.1 - 0.3]
0.1 [<0.2]
<0.1 [<0.2]
0.7 [0.3 - 1.1]
..
36
37
38
39
40
41
42
43
44
45
Estonia
Poland
Hungary
Saint Kitts and
Nevis
Bahrain
Lithuania
Slovakia
Chile
Kuwait
Costa Rica
1.1 [0.4 - 2.1]
0.1 [0.0 - 0.2]
0.1 [0.0 - 0.2]
0.1
0.2
0.6
0.8
1.4
0.9
..
0.2 [0.1 - 0.3]
0.1 [<0.2]
<0.1 [<0.2]
0.3 [0.2 - 0.5]
..
0.6 [0.3 - 1.0]
0.4
0.9
3.3
0.3
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
33
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
Uruguay
Qatar
Croatia
United Arab
Emirates
Latvia
0.3 [0.2 - 0.5]
..
<0.1 [<0.2]
Bahamas
Cuba
Mexico
Trinidad and
Tobago
Antigua and
Barbuda
3.0 [1.8 - 4.9]
0.1 [<0.2]
0.3 [0.1 - 0.4]
Bulgaria
Russian Federation
Libyan Arab
Jamahiriya
Malaysia
Macedonia, TFYR
<0.1 [<0.2]
1.1 [0.6 - 1.9]
Panama
Belarus
Tonga
Mauritius
Albania
Bosnia and
Herzegovina
Suriname
Venezuela
Romania
Ukraine
..
0.6 [0.3 - 1.0]
3.2 [1.2 - 8.3]
0.3 [0.1 - 0.6]
3.0
0.9 [0.5 - 1.5]
0.5 [0.2 - 0.8]
..
..
..
0.1
1.4
1.7 [0.5 - 5.8]
0.7 [0.4 - 1.2]
<0.1 [<0.2]
1.4 [0.7 - 2.3]
5.5
0.9
4.5
1.2
2.6
1.0
0.9
76
77
78
79
80
Thailand
Saudi Arabia
Kazakhstan
Jamaica
Lebanon
1.5 [0.8 - 2.8]
..
0.2 [0.1 - 0.3]
1.2 [0.6 - 2.2]
0.1 [0.0 - 0.2]
81
82
83
84
85
Fiji
Armenia
Philippines
Maldives
Peru
0.1 [0.0 - 0.2]
0.1 [0.1 - 0.2]
<0.1 [<0.2]
..
0.5 [0.3 - 0.9]
88
89
90
2.1
<0.1 [<0.2]
..
0.7 [0.3 - 1.1]
0.7 [0.4 - 1.2]
0.1 [0.0 - 0.2]
..
Turkmenistan
Saint Vincent and
the Grenadines
Turkey
Paraguay
Jordan
1.1
2.0
7.9
0.4 [0.2 - 0.7]
<0.1 [<0.2]
Saint Lucia
Brazil
Colombia
Oman
Samoa (Western)
87
0.8
0.7
4.9
..
71
72
73
74
75
86
0.5
2.8
1.4
0.8
5.6
1.8
0.3
3.6
1.6
<0.1 [<0.2]
..
<0.1 [<0.2]
0.5 [0.2 - 0.8]
..
1.5
0.3
2.1
0.7
1.1
3.0
91
92
93
94
95
Azerbaijan
Tunisia
Grenada
China
Dominica
<0.1 [<0.2]
<0.1 [<0.2]
..
0.1 [0.1 - 0.2]
..
96
Sri Lanka
<0.1 [<0.2]
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
34
97
98
99
100
Georgia
Dominican Republic
Belize
Ecuador
0.2 [0.1 - 0.4]
1.7 [0.9 - 3.0]
2.4 [0.8 - 6.9]
0.3 [0.1 - 0.5]
101
Iran, Islamic Rep. of
Occupied
Palestinian Territories
El Salvador
Guyana
Cape Verde
0.1 [0.0 - 0.2]
102
103
104
105
2.4
0.1
0.7
..
0.7 [0.3 - 1.1]
2.5 [0.8 - 7.7]
..
0.2
1.5
107
108
109
110
Syrian Arab
Republic
Uzbekistan
Algeria
Equatorial Guinea
Kyrgyzstan
0.1 [0.0 - 0.2]
0.1 [<0.2]
..
0.1 [<0.2]
111
112
113
114
115
Indonesia
Viet Nam
Moldova, Rep. of
Bolivia
Honduras
0.1 [0.0 - 0.2]
0.4 [0.2 - 0.8]
0.2 [0.1 - 0.3]
0.1 [0.0 - 0.2]
1.8 [1.0 - 3.2]
11.2
0.1
116
117
118
119
120
Tajikistan
Mongolia
Nicaragua
South Africa
Egypt
<0.1 [<0.2]
<0.1 [<0.2]
0.2 [0.1 - 0.3]
21.5 [18.5 - 24.9]
<0.1 [<0.2]
10.7
0.6
1.7
18.1
1.1 [0.6 - 1.8]
8.1 [4.1 - 15.3]
0.7
6.5
106
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
Guatemala
Gabon
São Tomé and
Principe
Solomon Islands
Morocco
Namibia
India
Botswana
Vanuatu
Cambodia
Ghana
Myanmar
Papua New Guinea
Bhutan
Lao People's Dem.
Rep.
<0.1 [<0.2]
0.2
2.1
6.1
..
..
0.1 [0.0 - 0.2]
0.9
1.1
21.3 [18.2 - 24.7]
[0.4 - 1.3]
37.3 [35.5 - 39.1]
..
2.6 [1.5 - 4.4]
1.8
0.0
0.9
4.0
3.1 [1.9 - 5.0]
1.2 [0.6 - 2.2]
0.6 [0.3 - 1.0]
..
2.8
0.6
0.1 [<0.2]
136
137
138
139
140
Comoros
Swaziland
Bangladesh
Sudan
Nepal
..
38.8 [37.2 - 40.4]
[<0.2]
2.3 [0.7 - 7.2]
0.3 [0.2 - 0.5]
141
142
143
144
145
Cameroon
Pakistan
Togo
Congo
Lesotho
6.9 [4.8 - 9.8]
0.1 [0.0 - 0.2]
4.1 [2.7 - 6.4]
4.9 [2.1 - 11.0]
28.9 [26.3 - 31.7]
12.5
2.4
3.3
146
147
148
149
Uganda
Zimbabwe
Kenya
Yemen
4.1 [2.8 - 6.6]
24.6 [21.7 - 27.8]
6.7 [4.7 - 9.6]
0.1 [0.0 - 0.2]
1.2
7.7
0.9
2.6
1.5
2.4
3.2
0.6
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
35
150
Madagascar
1.7 [0.8 - 2.7]
3.3
151
152
153
154
155
Nigeria
Mauritania
Haiti
Djibouti
Gambia
5.4 [3.6 - 8.0]
0.6 [0.3 - 1.1]
5.6 [2.5 - 11.9]
2.4 [0.7 - 7.5]
1.2 [0.3 - 4.2]
1.4
1.1
2.0
156
157
158
159
160
Eritrea
Senegal
Timor-Leste
Rwanda
Guinea
2.7 [0.9 - 7.3]
0.8 [0.4 - 1.7]
..
5.1 [3.4 - 7.6]
3.2 [1.2 - 8.2]
161
162
163
164
165
Benin
Tanzania, U. Rep. of
Côte d'Ivoire
Zambia
Malawi
166
167
168
169
170
Angola
Chad
Congo, Dem. Rep.
of the
Central African
Republic
Ethiopia
171
172
173
174
175
Mozambique
Guinea-Bissau
Burundi
Mali
Burkina Faso
176
177
Niger
Sierra Leone
2.9
17.0
10.7
1.9 [1.1 - 3.3]
8.8 [6.4 - 11.9]
7.0 [4.9 - 10.0]
16.5 [13.5 - 20.0]
14.2 [11.3 - 17.7]
1.5
0.7
3.9 [1.6 - 9.4]
4.8 [3.1 - 7.2]
1.0
4.8
6.4
4.2 [1.7 - 9.9]
13.5 [8.3 - 21.2]
0.0
4.5
4.4 [2.8 - 6.7]
0.8
12.2 [9.4 - 15.7]
..
6.0 [4.1 - 8.8]
1.9 [0.6 - 5.9]
4.2 [2.7 - 6.5]
2.1
11.1
1.2 [0.7 - 2.3]
..
2.5
2.0
Source :
UNAIDS (Joint United Nations Programme on HIV/AIDS). 2004. Correspondence on HIV prevalence rate. May. Geneva. ; aggregates
calculated for the Human Development Report Office by the UNAIDS.
PREVALENCE OF HEPATITIS B IN VARIOUS AREAS
% of population positive for
Area
HBsAg
anti-HBs
Northern, Western,
and Central Europe,
North America,
0.2-0.5
4-6
Australia
Eastern Europe, the
Mediterranean, Russia
and the Russian
Federation, Southwest
Asia, Central and
2-7
20-55
South America
Parts of China,
Southeast Asia,
tropical Africa
8-20
70-95
infection
neonatal
childhood
rare
infrequent
frequent
frequent
very frequent
very frequent
From: Zuckerman AJ. Hepatitis Viruses. In: Baron S, eds. Medical Microbiology, 4th ed. Galveston, TX, The University of Texas
Medical Branch at Galveston, 1996:849-863,52 with permission.
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
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APPENDIX 2: STANDARD MEDICAL PRECAUTIONS IN HEALTH-CARE
SETTINGS
Universal precautions are intended to prevent the exposure of health-care workers and
patients to blood-borne pathogens. These must be respected in regard to the blood and
body fluids of all patients, regardless of their infection status.iv
Universal precautions include:
 safe handling and safe disposal of sharps: never recap needles; use special
containers for sharp disposals;
 safe decontamination of instruments;
 hand-washing after all medical procedures;
 use of protective barriers as needed to prevent direct contact with blood and body
fluid such as gloves, masks, goggles, aprons, and boots. Whenever a health worker
receives a cut or abrasion, the wound should be covered.
 safe disposal of contaminated waste.
For further details, see:
1.
2.
Bouvet E et al. Politique de prévention des AES. In: Accident d'exposition au VIH.
Bases scientifiques et recommandations pour la prise en charge. Bash éditions
médicales, 1999.
CDC. Perspective in disease prevention and health promotion update: Universal
precautions for prevention of transmission of HIV, HBV and other blood-borne
pathogens in health-care settings. MMWR 37;377-88. 1988.
CDC. Perspective in disease prevention and health promotion update: Universal precautions for
prevention of transmission of HIV, HBV and other blood-borne pathogens in healthcare settings.
MMWR 37;377-88. 1988.
iv
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APPENDIX 3: RISK ASSESSMENT GUIDE FOR THE SOURCE PATIENT
The following points need to be covered when questioning and examining the patient.
These will need to be adapted in line with local epidemiological, clinical and cultural
conditions.
There is no such thing as a "score" in this regard; it is up to the doctor to
interpret the results of the clinical assessment. It is important that questioning be
conducted in a way that reveals relevant events that may have occurred several years
ago.
1. Family history
• Have any family members recently been ill or died. What was the cause?
2. Recent personal history of primo-infection symptoms
Primo-infection symptoms generally appear 3 to 6 weeks after contamination:
• general lymphadenopathy, predominently in the cervical and axillary areas;
• fever of unknown origin;
• muscular cramps, joint pain;
• skin rash, urticaria;
• oral and genital ulcers.
3. Individual’s personal "risk history" of HIV
• Has the patient ever had a blood transfusion? If so, under which conditions?
• Has the patient been exposed to injections or surgical procedures (including any
traditional scarification) with non-sterile material?
• Is the patient an intravenous drug user and does s/he possess injection material?
• Does the patient belong to a population group considered at risk? For example:
- sex worker
- truck driver;
- migrant worker;
- soldier.
• Is the patient involved in high-risk sexual activites?
- practising unsafe sex
- already treated or undergoing treatment for a sexually transmitted disease;
- the sexual partners of a person in any of the above categories.
4. Suspicion or actual presence of symptoms and/or HIV infection within the
previous six months or more
• tuberculosis;
• continuous or intermittent fever;
• chronic diarrhoea;
• weight loss;
• chronic cough lasting longer than a month;
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
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• skin infections (severe and/or recurrent)
• oral thrush;
• night sweats.
5. Clinical examination findings
• Cardinal signs:
-
Kaposi sarcoma;
Pneumocystis carinii pneumonia;
cerebral toxoplasma;
oesophageal candidiasis;
cytomegalovirus retinitis.
• Characteristic signs:
- oral thrush;
- hairy leukaplasia of the tongue;
- cryptococcal meningitis;
- pulmonary or extra-pulmonary tuberculosis;
- herpes zooster, particularly multi-dermatomal;
- severe prurigo;
- high-grade B-cell extranodal lymphoma.
• Associated signs:
- weight loss (recent, unexplained) of more than 10% of initial body weight;
- fever (continuous or intermittent) for longer than a month;
- diarrhoea (continuous or intermittent) for longer than a month;
- ulcers (genital or perianal) for more than a month;
- cough lasting longer than a month;
- neurological complaints or findings;
- generalised lymphadenopathy (extra-inguinal lymphatic areas);
- reactions to drugs (not previously observed);
- skin infections (severe and/or recurrent): e.g. warts, dermatophytes,
folliculitis.
- lymphopenia (known).
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
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APPENDIX 4: ACCIDENTAL EXPOSURE TO BLOOD NOTIFICATION FORM
Confidential form to be filled in by the medical doctor in charge of the PEP and to be
sent to the administration department. Medical file to be used for referral and
insurance purposes.
Exposed person
Surname and first name: ........................................................................................
Date of birth: .......................................................................................
Exposure
Date of the accident :............................................ Local time: ..........................
Place (country) :..............................................................................................................
Contact with:  blood
 any other body fluid (specify):........................
Type of contact (injury with a needle or any other sharp instrument, contact with healthy or
broken skin, or mucous membranes, etc.)
........................................................................................................................................... ...........................................
...................................................................................................................................................................……………
Description of the circumstances of the accident:
......................................................................................................................................................................................
............................................................................................................................. ......................................……………
Description of the wound:
......................................................................................................................................................................................
..................................................................................................................................................................................
If the accident involved a needle, specify:
 hollow needle
 plain needle
size of needle : ............................
Contact with:  blood
 any other body fluid (specify):..........................................
During the accident
• were gloves worn?
 yes  no
• were protective goggles worn?
 yes  no
Health status of the source patient
Is the patient known?
yes no
If patient is known, results of the medical evaluation (including HIV status if testing has been
performed):
....................................................................................................................................................................................
Measures taken after the accident
First aid (specify)................................................................................................
Prophylactic treatment :
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advised
prescribed
yes
yes
no
no
Time elapsed between the exposure accident and the beginning of treatment:
 < 4 hours between 4 and 24 hours  > 24 hours< 48h  longer (specify) : .................
Type of treatment:
....................
...... mg ........ times a day
Any other comments
............................................................................................................................. ..................
.............................................................................................................................. .................
...............................................................................................................................................
The victim of an accidental exposure to blood is unable to work for a minimum period of 8 days
starting from the day of the accident and until the next medical consultation:
yes
no
Date .......................,
Place .............................................................................................
Signature of doctor ......................................................................
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APPENDIX 5: NOTIFICATION OF AN AE - HQ FORM
To be filled in by the medical doctor in charge of PEP and to be sent to the Medical
Department at MSF headquarters.
Type of wound
Date of the accident:............................................ Local time: ..........................
Place (country):..............................................................................................................
Contact with:  blood
 any other body fluid (specify):........................
Type of contact (injury with a needle or any other sharp instrument, contact with healthy or
broken skin, or mucous membranes, etc.)
......................................................................................................................................................................................
........................................................................................................ .................... ................................................…..
Description of the circumstances of the exposure:
............................................................................................................................. .........................................................
............................................................................................................................. .........................................................
................................................................................................................................................................................... ...
............................................................................................................................. .................................................
Exposed person
HIV testing performed 15 days prior to departure on mission: yes no
Vaccination against Hepatitis B (doses and dates):
Level of anti-HbS antibodies known prior to the accident yes (result):.................... no
Health status of the source patient
Is the patient known?
yes no
If patient is known, results of the evaluation of the source patient (including HIV testing if
performed):
............................................................................................................................. .......................................................
What measures were taken immediately after the accident?
............................................................................................................................. .........................................................
................................................................................................................................. .................................................
....................................................................................................................................................................................
Prophylactic treatment
Proposed
yes
no
Prescribed
yes
no
Hours between the exposure accident and the beginning of treatment:
 < 4 hours  between 4 and 24 hours  > 24 hours< 48h  longer (specify) : .........................
Type of treatment:
....................
...... mg ........ times a day
Any other comment
...................................................................................................................................................
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APPENDIX 6: PEP TREATMENT INFORMED CONSENT/REFUSAL FORM
When PEP has been advised this form should be filled in and signed by the exposed
person, and signed by the medical doctor in charge of PEP in the field. It must be sent
to the person in charge of PEP at administration level (in the HQ human resources dept.
for expatriates or the country administrator for national staff) in a sealed envelope
marked confidential. A copy should be given to the exposed person.
Surname and first name: ..............................................................................
Date of birth: ........................................................................... Sex: ................................
Date of the accident: .....................................................
I, the undersigned, ................................................................................., hereby declare:
–
–
–
That I have been informed of MSF recommendations in regard to prophylactic
treatment after accidental exposure to HIV.
That I understand the risk of transmission after accidental exposure.
That I have been informed of the effectiveness and the possible side- -effects of
this treatment;
I was offered prophylactic treatment, and:
 I have decided not to take it.
 I agree to follow this prophylactic treatment for a total period of one month and I agree to
accept medical supervision.
Date:.........................................
Signature of the exposed person: ..........................................................................
Signature of the medical doctor in charge: ........................................................................
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
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APPENDIX 7: INFORMATION SHEET ON PROPHYLAXIS AND FOLLOWUP AFTER AN AE
This is to be given to the exposed person, for information only.
The doctor assessed that there is a risk of transmission of HIV infection as a result of
this accident and that you can start anti-viral prophylaxis, if you agree.
1. You must understand that this preventive medication:
 Must be started, if possible, within 4 hours of the AE (within 48 hours at the
latest);
 Although some failures to post-exposure prophylaxis have been described, a
case control study showed that the administration of AZT reduces the risk of
sero-conversion post-exposure by 79%;
 May cause minor side-effects (as with any medication), especially digestive
problems, headache, fatigue, malaise, myalgia or arthralgia;
 Must be taken regularly in two doses per day for four weeks;
 Must be backed up by regular medical check-ups (see below);
 Requires the use of condoms during the period of treatment until the results
of the sixth’s month’s serology are known;
 Requires the use of efficient contraceptive measures during the period of
treatment until the results of the sixth month’s serology are known;
 Requires your consent.
2. The following is proposed as biological follow up:



HIV and Hepatitis C serology before the eighth day and at the third month
and sixth month, after appropriate counselling. An HIV confirmation test will
be carried out if the result of the test is either positive or indeterminate.
This is a health insurance requirement for expatriates, but is only optional for
national staff.
Before the eighth day, at 4 weeks, 3 months and 6 months, control of
transaminases to detect hepatitis.
Before the eighth day and at the end of PEP intake, a complete blood count
(optional).
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APPENDIX 8: EMERGENCY CONTRACEPTIVE REGIMEN
 When high-dose pills containing 0.5 mg ethinylestradiol and 0.25 mg of levonorgestrel
are available:
 two pills should be taken as the first dose as soon as convenient, but not later
than 120 hours after the rape. These should be followed by two more pills 12
hours later.
 When only low-dose pills containing 0.3 mg ethinylestradiol and 0.15 mg of
levonorgestrel are available:
 four pills should be taken as the first dose as soon as convenient, but not
later than 120 hours after the rape. These should be followed by four more
pills 12 hours later.
Side-effects
Nausea occurs in about 50% of those using combined emergency contraceptive pills
(ECPs). Administration of an anti-emetic can be proposed prophylactically. Taking the
pills with food may reduce nausea. If vomiting occurs within two hours of taking ECPs,
repeat the dose after the administration of an anti-emetic.
Contraindications
There are no known medical contraindications to the use of ECPs. The dose of hormones
used in ECPs is relatively small and the pills are only used for a short time. Contraindications associated with the continuous use of hormonal contraceptives do not apply.
ECPs should not be given if there is a confirmed pregnancy. ECPs may be given when
pregnancy status is unclear and pregnancy testing is not available as there is no
evidence of harm to the woman or to an existing pregnancy.
Source: Reproductive health in refugee situations interagency handbook
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APPENDIX 9: MEDICAL CERTIFICATE FOR SWISS INSURANCES
This form has to be send to the field HR administrator of you desk with an official
letterhead of MSF and has to be filled in by the medical DOCTOR in charge of the
person. The name of the treating doctor has to be clearly stated, as well as the date
of the consultation and the date and duration of the working incapacity (time for
travelling to a place where the tests can be done, where a medical treatment is
possible and if psychological problems of the exposed person require a certain time
of rest). The insurances prefer that a medical doctor from the country you work in
does this certificate, but it can be done in exceptional cases by the treating MSF
doctor, if the country does not have medical practitioners capable of taking in charge
a person under PEP. Usually the working incapacity does not exceed a few days if
the exposed person stays in the country and up to 4 weeks if repatriation is
necessary.
----------------------------------------------------------------------------------------------------------------
MEDICAL CERTIFICATE
Mrs/Mr: …………………………………………………………………..
Born: …………………………….
Currently in mission in: …………………………………………………
I hereby certify that the above mentioned person is under treatment for accidental
exposure to blood since the ………………….
and is unable to work until the …………………
Name of treating doctor: ……………………………………….
Country:…………………………..
Signature
Date
Accidental Exposure to Blood and other body fluids/Médecins Sans Frontières/December 2004
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