Download Occupational exposure and PEP

Occupational Exposure to HIV:
Universal Precautions and PEP
HAIVN
Harvard Medical School
AIDS Initiative in Vietnam
1
Learning Objectives
By the end of this session, participants
will be able to:
 Explain the risk of HIV transmission
after a single per-cutaneous exposure
 Demonstrate “scoop” technique of
recapping needles
 List the steps involved in post-exposure
prophylaxis (PEP)
 Describe PEP regimens in Vietnam
2
Overview of
Occupational Exposure to HIV
3
Body Fluids and Risk for HIV
Exposure
Potential Risk
 Blood
 Cerebrospinal fluid
(CSF)
 Pleural fluid
 Peritoneal fluid
 Any body fluid visibly
contaminated with
blood
Negligible Risk*
 Urine
 Saliva
 Sputum
 Sweat
 Feces
 Vomitus
* If not visibly contaminated
with blood
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Risk of HIV Transmission
Blood exposures
Risk of HIV
Transmission
Percutaneous
needle-sticks
0.3%
Mucous membranes
0.09%
Intact Skin
0%
5
Factors that Increase
Risk of Transmission

Factors that increase the risk of HIV
transmission from a needle stick injury
include exposure:
•
•
•
•
through a visibly bloody device
through a device used in an artery or vein
via a deep injury
from a source individual with more advanced
HIV disease and a high HIV viral load
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Factors Affecting Risk of HIV Transmission
after Percutaneous Exposure
Risk factor
The needle went deep into the
healthcare worker
Visible blood was seen on the
needle before the percutaneous
exposure
Source patient was terminally ill
Needle was in source patient’s
artery or vein
Adjusted
Odds Ratio
1.5
6.2
5.6
4.3
Occupational Exposure to HIV
in Vietnam
In 2000, at a hospital in HCMC,
330 /886 (38%) health workers experienced
percutaneous exposure
Type of Exposure
%
Hollow needles
53
Surgical needles
24
When injecting medications
19
Re-cap needles
16
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Sohn. 15th IAC: Abstract ThPeC7512.
Steps of
Universal Precautions
9
Key Definitions:
Universal Precautions (1)
#1 Treat ALL blood and body fluids as if they
are potentially infectious
Follow Universal
Precautions
#2 Prevent needle sticks
Safely manage
sharps
Universal Precautions (2)
Following universal precautions means
minimizing exposure to blood and
body fluids through:
1.
2.
3.
4.
Use of protective barriers
Hand hygiene
Safe injection practices
Environmental control of blood and
bodily fluids
5. Sharps management
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1. Use of Protective Barriers
Procedure
Goggles/
Gloves Gown Face
Protection
Intravenous
injection, blood
drawing, blood and
fluid transfusion
YES
NO
NO
Intravenous
injection, blood
drawing, blood and
fluid transfusion
NO*
NO
NO
Irrigating a wound
YES
YES
YES
Performing an operation
YES
YES
YES
Giving an
injection
2. Hand Hygiene

Prevents transmission of resistant
organisms and infections
• Before patient care
• After blood/fluid contact, glove removal

Methods:
• Hand washin:


Water+soap  10 seconds
 disposal towels
• Use hand sanitizer

60-95% ethyl or isopropyl alcohol
http://www.cdc.gov/handhygiene
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3. Safe Injection Practices



Use a sterile syringe and needle for
every infection; use the correct
intended medication
Place needle in a puncture-proof
container right after use
Discard sharps waste appropriately
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4. Environmental Control of Blood
and Body Fluids
Spills in patient-care
areas
Spills in laboratory
areas
 Wearing gloves to visible blood/fluid with
towels
 Soak towel and blood/fluid spill in
disinfectant before discarding
Disinfect area:
1:100 dilution (500
ppm) of hypochlorite
Disinfect area:
1:10 dilution (5000
ppm) of hypochlorite
5. Sharps Management

Organize work areas:
• Have sharps containers nearby


Avoid hand-passage of sharps
Not recap needles,
• or: recap using a one-handed “scoop
technique”
16
“One-hand” Technique of
Recapping Needles
17
Post-Exposure
Prophylaxis (PEP)
18
Steps for Post-Exposure
Management
Bước 1
• Treat the exposure site
Bước 2
• Report the exposure to the manager and
complete the report form
Bước 3
• Assess the risk of exposure
Bước 4
• Determine the HIV status of the source of
exposure
Bước 5
• Determine the HIV status of the exposed
person
Bước 6
• Counsel the exposed person
Bước 7
• Provide ARV prophylaxis (if indicated)
Exposure to Bodily Fluid
and/or Blood (1)
If there was a percutaneous exposure:
 Flush the wound with tap water
 Let the wound bleed for a short time
 Clean the wound with soap and water,
treat the wound with an antiseptic
solution, appropriately bandage the
wound
 Evaluate the need for PEP
20
Exposure to Bodily Fluid
and/or Blood (2)
If there was an eye exposure:
 Wash the eye(s) with water or NaCl
0.9% solution continuously for 5
minutes
 Do not rub your eyes
 Evaluate the need for PEP
21
Exposure to Bodily Fluid
and/or Blood (3)
If there was a mouth and/or nose
exposure:
 Rinse with NaCl 0.9% solution
 DO NOT BRUSH TEETH
 Gargle with NaCl 0.9% solution for
several times
 Evaluate the need for PEP
22
Evaluating the need for PEP (1)

High Risk exposures:
• Percutaneous wounds:


Deep with large bleeding, caused by largebore needles.
Deep and large with bleeding, caused by
scalpels or broken blood containing tubes
• Large lesions on the skin or mucus
membranes (e.g. eye, nose, mouth)
exposed to patient's blood or body fluids
23
Evaluating the need for PEP (2)

Low Risk exposures:
• Shallow wounds with minor bleeding or
no bleeding
• Intact mucosa exposed to patient’s
blood or body fluids.

No Risk exposures:
• Contact of normal skin with patient’s
blood or body fluid.
24
PEP Rationale (1)
25
PEP Rationale (2)

ARVs given soon after exposure may
prevent infection by:
• blocking HIV replication in the few cells
that are initially infected
• if those cells die then the HIV infection
will be eradicated before it starts
26
Post-Exposure Prophylaxys

Timing: as soon as possible
• Do not delay to obtain additional
information on the source patient
• Best if given within hours following
exposure
• PEP started more than 72 hours after
exposure is not likely to be effective.

Duration of prophylaxys: 4 week
27
National Guidelines on
PEP Regimens
Regime
Medications
Indications
2 drug
AZT+ 3TC
OR
d4t + 3TC
All exposures
with risk
AZT+ 3TC
OR
d4t + 3TC
In case source
of exposure is
known to have
or suspected of
ARV resistance
(basic regimen)
3 drug
Plus: LPV/r
Suggested Post-Exposure
Follow-up and Testing (1)
Testing:
 Test health care worker for HIV after
4-6 weeks, 3 months, and 6 months
 Conduct laboratory tests to monitor
ARV side effects (CBC, ALT):
• at baseline and
• after 4 weeks
29
Suggested Post-Exposure
Follow-up and Testing (2)
Education and Counseling for
HCW:
 their risk of infection with HIV, HBV,
HCV
 symptoms suggestive of ARV toxicity
and/or primary HIV infection
 prevention of secondary transmission
• Use condom with sex-partners
30
Determine the HIV Status
of the Source Patient (1)

Inform the source patient of the
incident, counsel, & test (with consent)
for HIV, HBV and HCV
• Use a rapid HIV antibody testing if possible

Inquire about source patient’s risk
factors for HIV and risk of being in the
“window period” of an acute HIV
infection.
• If source patient found to be HIV negative:
• Or if it is impossible to take the HIV test for
the source patient
31
Determine the HIV Status
of the Source Patient (2)

If source patient is known to be HIV
positive:
• Define the patient’s clinical and
immunological stage of HIV infection
through:


a CD4 count
and/or TLC.
• Obtain:



HIV viral load data, if available
Obtain information on current and previous
antiretroviral therapy
Obtain HIV resistance testing results, if done
32
Prophylaxis with
other Etiologies
33
Risk of Seroconversion after
Percutaneous Occupational Exposure
Virus
Range
Mean
HBV
2 – 40 %
30%
HCV
0–7%
3%
HIV
0.2 – 0.5 %
0.3%
HBV is 100x more transmissible
than HIV!
34
HBV Prevention

The best way to prevent HBV
infection is to vaccinate all health
care workers:
• 3 times at 0, 1 and 6 months
• The
Every
health care workers working at
health settings should take
HBV Vaccination
35
TB prevention


TB is the most common OI in Vietnam
In the HIV OPC:
• There is a significant percentage of patients
will have TB or on TB treatment at any one
time
• The waiting area and exam rooms are an
environment at high risk for TB
transmission

Five steps to prevent transmission
of TB in HIV care settings (WHO)
should be practiced at any health
settings
36
Key Points



Universal Precautions helped
minimizing exposure to blood/bodily
fluids
PEP should be taken as soon as
possible, within 72 hours
AZT/d4T+ 3TC is the first line regime
for PEP
37
Thank you!
Questions?
38