Download Bloodborne Pathogens and the Dental Health Care Worker

Module 12
Bloodborne Pathogens and the
Dental Health Care Worker
Bloodborne Pathogens and
the Dental Health Care Worker
Christine Wisnom, RN, BS
Nurse Educator
Dental School
University of Maryland Baltimore
Helene Bednarsh, RDH, MPH
Director, HIV Dental Ombudsperson Program
Boston Public Health Commission
Kathy Eklund, RDH, MPH
The Forsyth Institute
Boston, Massachusetts
Updated Postexposure Protocols for HBV,
HCV, HIV & Special Circumstances
MMWR, CDC, 6-01,Vol. 50,RR-11
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HIV
Hepatitis C
Hepatitis B
Pregnancy
Delayed exposure report
Unknown donor exposure
Source patient drug resistant
Human bite protocols
Objectives Categories

Prevention

Planning

Identification

Implementation

Evaluation
Objectives-Prevention
 Prevention is best strategy to avoid
infection
 Prevent HBV infection by HBV vaccine
 Prevent HBV transmission by HBV PEP
 Prevent HIV infection by timely HIV PEP
 Prevent injury through utilization of “safe
sharps”, auto-recapping devices
Safe Sharps Management
Objectives- Planning
 Planning prior to occupational exposure
is the key to efficient implementation of
post-exposure protocols
 Establish a protocol for occupational
exposures
 Educate health care workers regarding
the implementation of the plan during job
orientation and ongoing job training.
CDC, MMWR 6-29-01, Vol.50/No. RR-11, 16.
Objectives- Identification
 Identify:
 Potential risk factors for
transmission of HIV, HBV and HCV
 Health Care Professional (HCP) for
medical follow-up
 Various recommendations for PEP
based upon type of exposure for
each
Objectives- Implementation
 Implement :Methods of risk reduction
based on Work Practice Controls
(WPC) & Exposure Controls (EC)
 Emergency first aid for injury
 Post-exposure counseling
 Prophylaxis
 Medical evaluation and follow-up of
exposed individuals
Objectives- Evaluation
 Evaluate:
 The effectiveness of the Occupational
Exposure Monitoring System
 Adapt any necessary modifications for
improvement
 Continue to maintain an evolving system
based upon current scientific findings
Exposure Definition
• “An exposure is a percutaneous
injury (e.g., a needle stick or cut with
a sharp object) or contact of mucous
membrane or nonintact skin (e.g.,
exposed skin that is chapped,
abraded, or afflicted with dermatitis)
with blood, tissue, or other body
fluids that are potentially infectious.”
CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 3.
Infectious Body Fluids
• “In addition to blood and body fluids
containing visible blood, semen and vaginal
secretions are also considered potentially
infectious. Although semen and vaginal
secretions have been implicated in sexual
transmission of HBV, HCV and HIV, they
have not caused occupational
transmission from patient to health
care worker.”
CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 3.
Potentially Infectious Fluids
 The risk for transmission of HIV, HBV and
HCV with the following body fluids is
unknown, caution is recommended when
handling : cerebrospinal fluid, synovial
fluid, pleural fluid, peritoneal fluid,
pericardial fluid, and amniotic fluid. They
are considered to pose a potential risk for
transmission.
CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 3.
Low/No Risk Body Fluids
• “Feces, nasal secretions, saliva,
sputum, sweat, tears, urine and vomitus
are not considered potentially infectious
unless they contain blood. The risk
for transmission of HBV. HCV and HIV
infection from these fluids and
materials is extremely low.” Caution
is recommended when handling these
fluids.
CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 3.
Saliva Infectious for HIV?
 In the absence of visible blood in the
saliva, exposure to saliva from a
person infected with HIV is not
considered a potential risk for HIV
transmission. However, caution is
recommended when handling.
CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 3.
Occupational Transmission
of HCV
• Transmission from mucous membrane exposure
to blood rarely occurs .
• HCV is not transmitted efficiently through
occupational exposure to blood.
• Following percutaneous injury from HCV+
source infection rate is 1.8% (range 0%-7%).
• No transmission has been documented from
nonintact or intact skin contact with HCV+
blood.
CDC, MMWR, 6-29-01, Vol. 50/ No. RR-11, 5
Survival of HBV in the
Environment
• Only 1/2 of all HBV positive HCW’s recall
having an occupational injury. (DIRECT)
• Many infected individuals can recall caring for
HBV+ patients. (INDIRECT)
• HBV can survive in dried blood at room
temperature on environmental surfaces for at
least 1 week. Exposures have occurred via
scratches, abrasions, burns or on mucosal
surfaces with poor infection control. Evidence
of outbreaks have occurred in Hemodialysis
Units.
CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 4
Occupational Transmission
of HBV
• The risk of HBV transmission following
needle stick is directly related to the
amount of blood and the HBeAg status
of the patient.
• Infection from HBeAg+ & HBsAg+ is:
37-62%
• Infection from HBeAg- & HBsAg+ is:
23-37%
CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 3.
Post-Hepatitis B Vaccine
Testing
• “Health Care Professionals who
have contact with patients or blood
and are at ongoing risk for
percutaneous injuries should be
tested 1-2 months after completion
of the 3-dose vaccination series for
anti-HBs.”
• Hepatitis B vaccine may be given
during pregnancy, contains no
infectious particles.
CDC, MMWR 6-29-2001/Vol. 50/No. RR-11, 16.
Nonresponders to HBV Vaccine
• People who do not respond to the first
three vaccine series <10 mIU/ml should
complete a 2nd, 3 vaccine series.
• People who do not respond to the first
HBV series only have a 30-50% chance of
responding to the 2nd series.
• Testing at completion should be done to
determine efficacy/or HbsAg status.
• CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 16.
PEP for HBV Exposures in
Non-vaccinated HCW’s
 Health care workers who
experience occupational
exposure to the blood or
body fluids of an HBsAg +
individual should receive
– 1 dose, 0.06mL/kg., of
Hepatitis B immune
globulin (HBIG), and
– The 1st dose of the HBV
vaccine series.
PEP for HBV Non-responders
 When a person has not responded to
the 1st HBV vaccine series & is exposed
to the blood or body fluids of an HBsAg
positive patient, a single dose of HBIG,
preferably within 24 hrs. after exposure,
and the first dose of the 2nd HBV
vaccine series is preferred.
 CDC, MMWR. Vol. 50/ No. RR-11, 4.
PEP for HBV
for Non-responders
 HCW’s that experience occupational
exposures to the blood or body fluids of
HBsAg positive patients who are nonresponders to both the 1st and 2nd HBV
vaccine series should receive 2 doses of
HBIG.
– One at the time of injury and the 2nd dose 1 month
later.
– HBIG should be given with 24 hrs. if possible.
– When given in less than 7 days the effectiveness is
approximately 75%. When given in > 7days after
exposure effectiveness is uncertain.
CDC, MMWR 6-29-01, Vol50/No. RR-11, 4
Expert Consultation
Advised
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When drug resistance is evident
HCW is pregnant
Source is unknown
Source is high risk for HIV infection
Use of PEP When
Source is Unknown
• Decision made case-by-case
PPE worn, removes 50% of inoculum
• Type: puncture, splash, laceration
• Severity : deep wound vs. superficial
• Body fluid and quantity: blood, saliva,
large amount vs. minimal amount of
body fluid
Use of PEP When
Source is Unknown (Cont)
• Environment : IDU clinic, shelter,
community prevalence, etc.
• To treat: a 2 drug PEP for 4 weeks,
reevaluate if new information is
available, if negative discontinue
medications. Do not test discarded
needles for bloodborne pathogens.
Factors that Increase the
Probability of HIV Infection
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Exposure to a larger quantity of blood
Injury with a device with visible blood
Deep injury
Injury with device placed in vein/artery
Injury to blood from patient with
advanced AIDS
• Host defense, immune response may
prevent infection
Management of Occupational
Blood Exposure
• When an exposure occurs, you
should stop immediately
• Wash wound with soap & water;
flush mucous membranes with
water.
• Antiseptic use and/or bleeding
the wound have not been proven
to reduce infections.
 However, antiseptic use
is not contraindicated.
 Bleach & other caustic
agents should not be poured
directly into the wound.
Evaluation of Occupational
Exposure
• Obtain informed consent.
• Test source for HBsAg, anti-HCV, and HIV
antibody. Consider using a rapid HIV
antibody test if available.
• For patients who refuse testing/or
unknown patients, consider medical
diagnosis, risk behaviors and S/S.
• Do not test discarded needles for
bloodborne pathogens.
HCV Exposures
• Following occupational injury on an HCV+
patient:
• Perform baseline & F/U testing for anti-HCV
and alanine aminotransferase (ALT) 4-6
months after exposure.
• Perform HCV RNA 4-6 weeks after exposure,
to determine active viral replication.
• Confirm repeatedly positive anti-HCV (EIAs)
with additional tests.
• No vaccine or PEP are available for protection
against HCV. IG is not recommended for PEP.
Treating early HCV disease
 While there is currently no vaccine to
prevent HCV infection, or PEP to prevent
infection immediately following exposure,
recent studies suggest that early
treatment of acute HCV may prevent
chronic infection.
 Therefore HCW’s should be vigilant with
recommendations for follow-up and
testing.
Health Care Professional (HCP)
Recommendations for PEP in HIV+ Source
 When an exposure occurs on an HIV+
patient a HCP will:
– Establish patients’stage of infection:
HIV+ or AIDS
– Obtain recent blood tests:
CD4 cells, T-cell count, viral load &
current medications
– Determine if donor patient has a resistant
strain
– If information is not available, initiate PEP
 PEP should be initiated even if the exposure
exceeds 36 hours
Evaluation of HIV Exposure
• Following exposure on an HIV+
patient, assess and treat HCW, ideally
within 2 hours.
• Perform HIV antibody testing for
at least 6 months postexposure.
Baseline
6 weeks
3 months and
6 months.
Evaluation of HIV Exposure
• If symptoms of acute retroviral
syndrome appear test HIV antibody
immediately.
 Advise to use precautions to
prevent secondary transmission.
• Evaluate for side effects at 72 hours
and every 2 week thereafter.
• Treat for 4 weeks.
• Consider the use of rapid testing.
Basic PEP for HIV Exposures
• Basic Regimen (2 drugs):
Zidovudine (AZT) & Lamivudine (3TC)
available as COMBIVIR.
• ZDV: 600 mg/day, in 2 or 3 divided doses & 3TC:
150mg twice daily, or give as one COMBIVIR tab
twice daily for 4 weeks. Serious toxicity is rare,
side effects are manageable, documented to
reduce infection by approximately 81%.
CDC, MMWR, 6-29-01, Vol. 50/No. RR-11, 9.
• Other basic 2 drug regimens include:
3TC & Stavudine (d4T); or d4T & Didanosine
(ddl), and should be considered in areas of the
country where COMBIVIR resistance is
common.
CDC,MMWR, 6-29-01, Vol. 50/No. RR-11, 10.
Expanded PEP for HIV
Exposures
 An expanded 3 drug regimen should be
considered for exposures that pose an
increased risk for infection.
– A 3 drug regimen includes a basic 2 drug
regime plus the addition of a Protease
Inhibitor.
Bartlett J. 2001-2 J. Hopkins Univ. School of Medicine,
Medical Management of the HIV Infection, 66.
HIV PEP for Percutaneous Injuries
Patient Status
Low RiskAsymptomatic
VL
High Risk-AIDS
Symptomatic,
AIDS or VL
Not severe,
superficial or
injury with
solid needle
or instrument
2 drug PEP
3 drug PEP
Usually none,
*consider 2
drug PEP
Severe, blood
on device,
deep wound
3 drug PEP
3 drug PEP
Usually none,
*consider 2
drug PEP
Exposure
VL- Viral load, low <1,500 c/ml, high >1,500c/ml
* Consider if source is high HIV risk
Unknown
HIV PEP for Non-intact Skin &
Mucous Membrane Exposures
Patient Status
Low Risk- VL,
Asymptomatic
High Risk- VL
AIDS, blood on
instrument
Consider 2
drug PEP
2 drug PEP
Usually none,
consider 2
drug PEP*
Large
2 drug PEP
volume,
major spill
3 drug PEP
Usually none,
consider 2
drug PEP*
Exposure
Small
volume
(drops)
VL-Viral load, low <1,500 c/ml., high >1,500 c/ml.
* Consider if source has HIV risk
Unknown
Risk of HIV Infection Following
Percutaneous Exposure to HIV+ Blood
• For a mucous membrane exposure
0.09%
• For a percutaneous exposure risk
0.3%.
• For nonintact skin
< 0.09%
Management of HIV Negative
Exposure
 “If source person is HIV seronegative
and has no clinical evidence of AIDS or
symptoms of HIV infection, no further
testing of the person for HIV infection
is indicated.
 The likelihood of the source person
being in the “window period” of HIV, in
the absence of acute retroviral
syndrome, is extremely small.”
Management of Human Bites
 Evaluation of human bites must
include both the person who is bitten
and the person who inflicted the bite,
since both parties were potentially
exposed to the other persons blood.
 All counseling, testing, PEP and
follow-up must be conducted on both
parties for HIV, HBV & HCV.
Surveillance of Health Care Workers with
HIV/AIDS, June 30, 2001
Ref: CDC Natl. Center for HIV, STD and TB Prevention
 Through 6/30/01, 23,473 adults with AIDS
reported working in health care. This represents
5.1% of the 561,495 reported cases.
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Physicians
1,746
Surgeons
117
Nurses
5,105
Dental workers 482
Paramedics
453
Technicians 3,046
Therapists 1,042
Health Aids 5,222
Maintenance workers &
Administrative staff
http://www.cdc.gov/hiv/pubs/facts/hcwsurv.htm
Surveillance of Health Care Workers
with HIV/AIDS, June 30, 2001
Ref: CDC Natl. Center for HIV, STD and TB Prevention
 Fifty-seven health care workers in the U. S. have
seroconverted to HIV following occupational exposures.
Twenty-six have AIDS.
Laboratory workers
19 (16 clinical labs)
Nurses
24
Physicians
6
Surgical technicians
2
Dialysis technicians
1
Respiratory therapist
1
Health aide
1
Embalmer
1
Housekeepers
2
http://www.cdc.gov/hiv/pubs/facts/hcwsurv.htm
Surveillance of Health Care Workers
with HIV/AIDS, June 30, 2001
Ref: CDC Natl. Center for HIV, STD and TB Prevention
Types of Injuries
 Percutaneous
48
(puncture or cut)
 Mucotaneous
5
(mucous membrane
and/or skin)
 Percutaneous &
Mucotaneous
2
 Unknown
2
Body Fluids
 Blood
49
 Concentrated virus
in a laboratory
3
 Visibly bloody fluid
1
 Unspecified fluids
4
http://www.cdc.gov/hiv/pubs/facts/hcwsurv.htm
Occupational Exposure
Assessment Criteria
Type of exposure Type & Amount of fluid
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Percutaneous

Mucous membrane 
Nonintact skin

Bites with blood
contamination to
either person

Blood
Fluids containing blood
Potentially infectious
fluid/tissue, i.e. semen,
vaginal secretions, etc.
Direct contact with
concentrated virus
CDC, MMWR 6-29-01, Vol. 50/ No. RR-11, 17.
Occupational Exposure
Assessment Criteria
Infectious Status of Source
 HIV antibody status
 HCV antibody status
 HBsAg status
Immune Status of Exposed
HCW
 HBV, HCV & HIV
immune status
 Hepatitis B vaccine &
vaccine response
status
CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 18.
Occupational Exposure Report
 Date & time of injury
 Procedure being performed,
– If sharp device caused injury, include type,
manufacturer & how injury occurred
 Type & amount of fluid, severity (deep vs.
superficial), condition of skin (chapped, intact)
 Source patients HIV, HBV, HCV status & stage
(HIV viral load, resistance & antiretroviral meds)
 Exposed HCW’s HBV vaccine status & response
 Counseling, post-exposure treatment & followup
CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 17
Occupational Exposure Resources
 National Clinicians’ Post-exposure Hotline:
PEPline or 1-888-448-4911
 CDC, STD, AIDS Hotline: 800-342-AIDS
 Hepatitis Hotline: 888-443-7232
 CDC reporting for occupationally HIV infected
HCW’s & PEP failures: 800-893-0485
 HIV antiretroviral pregnancy registry:
800-258-4263
Summary
 Occupational transmission for HIV and HCV is low:
– HIV- .09- .3%, HCV- 0- 7%
 Occupational transmission for HBsAg+ and HBeAg+
source:
– 37-62%.
 Occupational transmission for HBsAg+ and HBeAgsource:
– 23-37%.
 Rapid PEP is effective for HIV and HBV:
– HIV PEP-81%, HBV PEP –70-75%.
 No PEP available for HCV
 Standard Precautions, PEP and vaccination are
critical components in reducing cross-transmission
of bloodborne pathogens.
CDC, MMWR 6-29-01, Vol.50
No. RR-11, pp. 3, 6, 7, 9.