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Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker NEEDLESTICK AND BLOOD EXPOSURE INJURIES: HEALTH CARE WORKER POLICY © DOCUMENT SUMMARY/KEY POINTS • This policy has been developed to prevent, detect, and initiate management of the blood borne viruses human immunodeficiency virus (HIV,) hepatitis B virus (HBV) and hepatitis C virus (HCV) following needle stick incidents or exposure to blood or (potentially) blood contaminated secretions. • All these blood borne infections may become chronic and carry a significant risk of longterm morbidity and mortality. • This document provides details on the management of staff exposed (or potentially exposed) to blood or blood contaminated secretions. This can include: o Skin puncture o Ingestion o Splashing of mucous membranes o Contact with broken skin • Identifies initial action to take after exposure (Immediate Care) and follow-up management requirements. • Details the risk assessment process and the risk classification of exposures. • Provides links to a range of related NSW Health Directives Related Information • Work Health Safety and Injury Management Policy: http://chw.schn.health.nsw.gov.au/o/documents/policies/policies/2013-9040.pdf Approved by: Date Effective: Team Leader: SCHN Policy, Procedure and Guideline Committee 1st January 2015 WHS & IM Coordinator Review Period: 3 years Area/Dept:: WHS & IM - CHW Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 1 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory. Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker CHANGE SUMMARY • CHW version of the same title has been rescinded & replaced by this SCHN version. • Due for mandatory review – no major changes made. • Removed links to obsolete NSW MoH Policy Directives. READ ACKNOWLEDGEMENT • Managers are to acknowledge the document and refer staff to this document as required. Glossary Abbreviation or Term Definition Anti – HBs antibody to hepatitis B surface antigen Anti - HBc antibody to hepatitis B core antigen Anti - HCV antibody to Hepatitis C virus Anti - HIV antibody to Human immunodeficiency virus HBIG Hepatitis B immunoglobulin HBsAg Hepatitis B surface antigen HBcAb Hepatitis B core antibody HBeAg Hepatitis B e antigen HBV Hepatitis B virus HBV DNA Hepatitis B virus deoxyribonucleic acid HCV Hepatitis C virus HIV Human immunodeficiency virus PCR polymerase chain reaction The time from exposure to seroconversion when the source may be asymptomatic or experiencing seroconversion illness. window period Approved by: Date Effective: Team Leader: SCHN Policy, Procedure and Guideline Committee 1st January 2015 WHS & IM Coordinator Review Period: 3 years Area/Dept:: WHS & IM - CHW Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 2 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory. Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker TABLE OF CONTENTS Glossary ..................................................................................................................................2 1 Introduction.................................................................................................................. 4 1.1 Hepatitis B .....................................................................................................................4 1.2 HIV (AIDS) .....................................................................................................................4 1.3 Hepatitis C .....................................................................................................................5 2 Staff member exposed – What to do? ....................................................................... 5 2.1 Immediate care (First Aid) ............................................................................................. 5 2.2 Report the Incident IMMEDIATELY ............................................................................... 5 For CHW Staff .....................................................................................................................5 For SCH Staff ......................................................................................................................6 3 Initial management taken by WH&S /AMO ................................................................ 6 4 Risk Assessment ......................................................................................................... 7 4.1 Assess the injury ........................................................................................................... 7 4.2 Assess the source ......................................................................................................... 8 4.2 Assess the staff ............................................................................................................. 9 5 Initial Treatment of the Staff member ........................................................................ 9 5.1 If source negative for HBV, HCV and HIV ..................................................................... 9 5.2 If source HBsAg Positive OR anti-HBc Positive and anti-HBs Negative ....................... 9 5.3 If source anti-HCV Positive.......................................................................................... 11 5.4 If Source anti HIV Positive ........................................................................................... 11 5.5 Tetanus........................................................................................................................12 6 Complete Appropriate Documentation .................................................................... 12 At CHW ..............................................................................................................................12 At SCH: ..............................................................................................................................13 7 Follow-up Management............................................................................................. 13 7.1.1 Source Negative for HIV, HBV, and HCV ............................................................. 13 7.1.2 Source of Unknown Infectious Status or Unable to be tested .............................. 13 7.1.3 Source Likely to be in the Window Period for HIV, HBV or HCV ......................... 13 7.1.4 Source Positive or Likely to be Positive for HBV .................................................. 13 7.1.5 Source Positive or Likely to be Positive for HCV. ................................................. 13 7.1.6 Source Positive for HIV ........................................................................................ 14 8 General Advice for Staff Exposed to HIV, HCV or HBV Positive Blood................ 14 9 NSW Health Policy Directives .................................................................................. 15 Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 3 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory. Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker 1 Introduction Certain infectious agents may be transmitted from person to person following accidental percutaneous or mucosal exposure to blood or blood-contaminated secretions. Of particular concern at this hospital is the possible transmission of the viruses Hepatitis B, Hepatitis C and Human Immunodeficiency Virus (HIV) which causes Acquired Immunodeficiency Syndrome (AIDS). All these infections may be chronic and carry a significant risk of longterm morbidity and death. Adherence to infection control practices, particularly safe sharps use and appropriate use of personal protective equipment (PPE) remains the first line of protection against occupational exposure to HIV, HBV, or HCV. • This policy has been developed to prevent or reduce morbidity following needle stick incidents or exposure to blood or potentially blood contaminated secretions. • The risk is infection with a blood-borne virus, hepatitis B virus (HBV), hepatitis C virus (HCV) or Human Immunodeficiency virus (HIV). • The situation should be assessed and any prophylaxis, if indicated, given as soon as possible. • Confidentiality should always be maintained. • These injuries are usually very minor in themselves but engender a very high degree of anxiety and therefore need careful, sensitive and thoughtful evaluation and management. 1.1 Hepatitis B Hepatitis B is an acute or chronic infection caused by the hepatitis B virus. Around 30% of infected patients develop acute symptoms with jaundice, signs and symptoms of liver involvement and raised liver enzymes. Diagnosis is by demonstrating HBsAg in the staff member’s blood, which is usually cleared in 3 - 6 months. Failure to clear HBsAg after 6 months is associated with the chronic carrier state, which can lead to lasting liver damage. Hepatitis B virus is mainly transmitted in developed countries from blood transfusions (now rare in Australia), the use of shared syringes and exposure to infected blood (eg. from needle stick incidents). In the general community, transmission may occur via sexual intercourse or by the sharing of such items as razors, needles, or toothbrushes. 1.2 HIV (AIDS) Infection with this virus may produce no symptoms or an initial glandular - fever like condition (lasting 3 – 14 days). After resolution of this initial “seroconversion illness”, infected people usually remain well for months to years but are still infectious. Untreated HIV infection results in AIDS in up to 50% of all infected individuals within 10 years and may present with pneumonia, chronic diarrhoea, dementia, malignancies, encephalitis, etc. HIV is transmitted by blood transfusions or contaminated blood products, IV drug use involving contaminated needles and syringes, by intimate sexual contact and can be transmitted vertically from mother to child. Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 4 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory. Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker 1.3 Hepatitis C Infections with Hepatitis C virus produce a clinical illness, indistinguishable from that produced by other hepatitis viruses and includes jaundice, other features of liver involvement and elevated liver enzymes levels. However, only 5 - 10% of infections are associated with acute symptoms, and 65 - 80% of patients remain infected with the virus, developing chronic hepatitis, with some progressing to liver failure and/or liver cancer. Hepatitis C is principally a blood borne infection transmitted through blood or blood products, and intravenous drug use. Hepatitis C has epidemiological characteristics similar to those of hepatitis B. Health care workers may be infected by contact with blood, particularly where standard (universal) precautions were not followed. Although Hepatitis C is substantially less infectious than Hepatitis B, it is occasionally transmitted by close personal contact, particularly sexual contact. 2 Staff member exposed – What to do? 2.1 Immediate care (First Aid) After exposure and if appropriate the ‘recipient” should: • Encourage bleeding if the exposure involves a cut or puncture, then wash with soap and water; • • Wash with soap and water where the exposure does not involve a cut or puncture; • If blood or other body substances get into the mouth, spit them out and rinse mouth with water several times; • If clothing is contaminated remove clothing and shower if necessary. If eyes are contaminated, rinse them while they are open, gently but thoroughly with water or normal saline; 2.2 Report the Incident IMMEDIATELY For CHW Staff • Monday to Friday Office Hours: o • report to WHS & IM Department (CHW) If unavailable or Out-of-Hours/Weekend/Public Holidays, perform the following; o Apply First Aid o Collect a Blood and Body Fluid Exposure Pack from the Emergency Department, Operating Suite, or the after-hours NUM o Follow the step by step checklist contained therein, o Take the pack to: the Westmead Adults Hospital Emergency unit . OR Your General Practitioner OR Wentworthville Medical Centre 22 Station St Wentworthville NSW. (8am – 10 pm). Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 5 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory. Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker For SCH Staff • • Apply First Aid Monday to Friday Office Hours: o • After Hours, Public Holidays or Weekends contact: o • • • • Contact CHESS - p42782. Prince of Wales (POW) Needle Stick Injury Assessor on POW switch Ext 9. Follow instructions. Report incident to supervisor. Do not enter in IIMS unless incident involved an act of aggression. A confidential NSW Health Reporting form is used on the intranet or CHESS. 3 Initial management taken by WH&S /AMO The process to follow is: 1. Initial management o Check or implement immediate care of the exposed site if required. 2. Complete a risk assessment (refer to section 4 for more information): o Assessment of the injury, staff and source o Ensure Hepatitis B immune status of injured staff member is known and adequately documented. o Perform appropriate blood tests with written/verbal consent: Obtain consent for baseline testing of the staff member for HBV, HCV and HIV Obtain consent for baseline testing of the source child for HBV, HCV and HIV 3. Perform appropriate initial management (refer to section 5 for more information): o Arrange for appropriate initial vaccination and prophylactic treatment for the staff member. o Arrange follow up for the source and staff member. If it appears likely that HIV prophylaxis is warranted, then the (CHW) WHS & IM Department or (SCH) CHESS/Needlestick Injury Assessor should immediately; o At CHW: contact the Infectious Disease (ID) Registrar at Westmead Hospital (Phone: 9845-5555) for an urgent referral for (CHW staff) o At SCH: the Staff member is to be seen immediately by the Prince Of Wales Emergency Dept. Note: Anti-retroviral prophylaxis, because of possible exposure to HIV, should be commenced as soon as possible after exposure, preferable within 1-2 hours but even up to 36 hours post exposure it is still considered worthwhile. 4. Complete appropriate documentation. (refer to section 6 for more information) Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 6 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory. Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker 4 Risk Assessment Risk assessment includes assessment of the significance of the injury and the status of the source if known. This information is to be carefully documented appropriately. Assessment of risk is given in Table 1 ‘Classification of exposures’. At risk situations (Determine nature of exposure) Those incidents whereby blood or blood contaminated secretions involve: • • • Skin puncture Splashing of mucous membranes Contact with broken skin 4.1 Assess the injury Factors which should be considered are: • The nature of the injury (esp depth of penetration, whether it drew blood) • • • The nature of the item that caused the injury (e.g. gauge of the needle); The nature of the body substance involved; The volume of blood and body substances to which the staff member was exposed. In the case of percutaneous blood exposures, other significant percutaneous exposures, and significant mucous membrane or skin exposures the staff member should be assessed further as detailed in Table 1. In the case of other exposures then no further testing or examination is required, apart from the possibility of further counselling. This should be determined according to individual circumstances. Table 1: Classification of Exposures Exposure Percutaneous exposures to blood Other significant percutaneous exposures Significant mucous membrane exposures Significant skin exposures Other exposures Risk Highest Risk BOTH exposure to a large volume of blood (eg deep injury with a large diameter hollow needle previously in the source patient’s vein or artery, and especially involving injection of patient’s blood) AND exposure to blood containing high titre of HIV, HCV, HBV (eg in the case of HIV, blood from a source with acute seroconversion illness or a terminally ill AIDS patient). Increased Risk EITHER exposure to a large volume of blood OR exposure to blood with a high titre of HIV, HCV, HBV (eg percutaneous injury with a soiled solid needle). No Increased Risk NEITHER exposure to a large volume of blood NOR exposure to blood with a high titre of HIV, HCV, HBV. Percutaneous exposures involving fluids containing visible blood, or other potentially infectious fluids (includes semen, vaginal secretions, cerebrospinal, synovial, pleural, peritoneal, pericardial and amniotic fluids) or tissue. Exposures (usually splashes) to eye or mouth involving blood, fluid containing visible blood or other potentially infectious body fluids. Exposures of non-intact skin or extensive or prolonged skin contact involving blood, blood-stained fluid or other potentially infectious body fluids. Percutaneous, mucous membrane or cutaneous exposures to (non-blood stained) urine or saliva. Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 7 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory. Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker 4.2 Assess the source Identify and assess source, and consider whether immediate referral to Westmead Staff Health/Westmead Emergency (CHW) or CHESS/Prince of Wales Hospital (SCH) is indicated. If source is a patient, the attending Medical Officer/Medical Team must be notified. With significant exposures every effort should be made to ascertain the HIV, HBV and HCV status of the source. The source details need to be documented with the medical record number, name, date of birth and diagnosis. Testing of the source must follow accepted guidelines with pre- and post- test counselling and informed consent must be obtained. • Source tests: o HBsAg, o anti-HBc (HBcAb), o anti-HBs (HBsAb), o anti-HCV o anti-HIV Every effort should be made to ascertain the HIV, HBV, and HCV status of the source, particularly in the case of percutaneous, significant percutaneous, significant mucous membrane, or significant skin exposures. If the status of the source individual is unknown at the time of the accident, then baseline testing should be undertaken to determine the source's infectious status for HIV, HBV, and HCV. Testing of the source child must follow accepted guidelines. Pre and post-test counselling must be given and informed consent obtained before testing can proceed. • At CHW; Refer to the “Consent for Blood Testing” form: http://chw.schn.health.nsw.gov.au/o/forms/ohs/staff_health/testing_a_child_following_blood_exposure.pdf • At SCH, refer to CHESS or the Needle Stick Assessor at Prince of Wales. It is appropriate for the admitting team, when available, to approach the patient and/or parent/guardian to gain written consent for testing of the source for issues of consent associated with HIV antibody testing. Blood should be collected from the source if the patient and/or his/her parents or carers give consent. (Age of consent for HIV testing is 14 years). With infants less than 6 months of age, maternal blood should be tested, in preference to the infant. However, if maternal blood is unavailable, 2mL of clotted blood from the infant should be adequate. If any maternal results are positive, infant testing is indicated. The source patient can be tested for HIV without consent in certain limited circumstances if authorised by the Chief Health Officer, NSW Health Department. • The blood should be taken as soon as possible after the incident from both the staff member and the source and sent for urgent testing. • A positive HIV antibody test, although it would be treated confidentially, would have to be reported to the NSW Health Department in the usual way (identified by the first two initials of the surname and date of birth only). Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 8 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory. Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker 4.2 • Assess the staff Staff tests: o anti-HBs (HBsAg), o anti-HBc o anti-HCV o anti-HIV Staff testing can be done through the hospital or through a doctor of the person’s choice. 5 10mL clotted blood from the staff member should be tested (with explanation and written or verbal consent) for hepatitis B, hepatitis C and HIV. Pre-test counselling for HIV antibody testing may need to encompass, with sufficient information, very detailed, extensive, confidential, personal and legal issues that make it inappropriate to be undertaken by fellow staff members involved in the implementation and management of this policy. If a staff member declines to be tested at the time of the incident, this should be documented. If blood has been taken for HBV and/or HCV testing, this will be stored under standard conditions and can be tested at a later stage for HIV antibodies if the staff member later requests. Counselling may be sought from Doctor of choice including GP; specialists and many government agencies (refer to Health Care Facilities with Clinicians Experienced in Prescribing Drugs for Treatment of HIV and HCV). 5 5.1 • Initial Treatment of the Staff member If source negative for HBV, HCV and HIV Provide counselling and perform anti-HIV and anti-HCV. If the staff member was not hepatitis B immune perform HBsAg, anti-HBc and anti-HBs. Hepatitis B - Notes Since one millilitre of serum can contain up to one thousand million particles of hepatitis B virus, an accident involving even the smallest amount of serum may result in the transmission of infection. The occupational risk of exposure to blood or body fluids that are known to contain, or might contain, the hepatitis B virus requires prophylaxis. An effective vaccine for hepatitis B is available, as well as specific hepatitis B immunoglobulin. If the source is HBsAg positive, then HBeAg and HBV DNA testing will be performed to estimate the risk of transmission. The risk of transmission of HBV from a needlestick injury ranges from 1-6% for e-antigen negative blood to 22-40% for e-antigen and/or HBV DNA positive blood. 5.2 • • If source HBsAg Positive OR anti-HBc Positive and anti-HBs Negative If the source was found to be HBsAg positive or anti-HBc positive and anti–HBs negative, the staff member should be offered prophylaxis and vaccination if nonimmune or if their immunity status cannot be rapidly determined. See Table 2. Follow-up testing of the recipient for HBsAg and anti – HBs after completion of vaccinations should be offered. Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 9 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory. Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker Test staff member for anti-HBs/obtain documented evidence of immunity to hepatitis B. • • If anti HBs >10 lU/mL, no treatment is required. If anti HBs< 10 lU/mL: screen for HBsAg: if HBsAg negative administer 400IU HBIG and/or HB vaccine as appropriate. Refer to Table 2. (For HBIG Phone Red Cross Blood Bank – City: 9229-4444 or Parramatta: 9840-5815) AND • If anti HBs< 10 lU/mL and BsAg negative: and never vaccinated offer 3 doses at 0, 1 and 6 months. If negative and previously vaccinated (non-responders) offer a double dose of vaccine, a rapid course of three doses at monthly intervals, or intradermal vaccination (off-label use of vaccine – requires individual informed consent) Table 2: Recommendations for Hepatitis B Prophylaxis following Percutaneous or Permucosal Exposure N.B. Take blood for testing BEFORE administering HBIG and/or HB vaccine. Exposed Person Previously fully immunised and immunity confirmed (‘known responder’) or immunity from past resolved infection Previously fully immunised and response unknown Partially immunised Previously immunised but nonresponder Unimmunised Source is HBsAg positive, unknown, untested or epidemiologically high risk Test exposed person for anti-HBs Result available within 24 hours: - if ≥ 10 lU/mL no treatment - if < 10 lU/mL and HBsAg negative hepatitis B vaccine booster dose. Test exposed person URGENTLY for antiHBs Contact lab to ensure that result will be available within 24 hours3. - if adequate (≥10 lU/mL) no treatment. - if inadequate (< 10 lU/mL) HBIG4 and HB vaccine booster dose. Check immunity after 3 months. Result not available within 24 hours: HBIG within 24 hours4 + HB vaccine booster dose later if indicated by anti-HBs <10 lU/mL. Check immunity after 3 months. Test exposed person URGENTLY for antiHBs Contact lab to ensure that result will be available within 24 hours. - if adequate (≥ 10 lU/mL) no treatment - if inadequate (<10 lU/mL) HBIG + HB vaccine dose. Result not available within 24 hours: HBIG4 + continue HB vaccine doses. Check immunity 3 months after completion of immunisation course. HBIG within 24 hours3. Repeat dose at 4 weeks and then again at 6 months HBIG within 24 hours3 + commence HB immunisation (HBIG and first HB vaccine at separate sites - one in L deltoid, one in R deltoid). Check immunity 3 months after completion of course. Source is HBsAg negative1 No treatment No urgent action. Test for antiHBs within 7 days. If result shows antibody level (<10 U/mL) offer vaccine booster and check immunity after 3 months. (An antibody level <10 IU/mL is non protective). Continue hepatitis B immunisation course. Check immunity 3 months after completion of course No treatment. Commence hepatitis B immunisation. Check immunity 3 months after completion of course. Note: HBIG (hepatitis B immunoglobulin) 400 IU, by deep IM injection Adult dose available from Red Cross Blood Bank-Phone: City-: 9229 4444 or Parramatta-: 9840 5815. HBIG is most effective at preventing HBV infection if administered immediately after exposure. Effectiveness falls rapidly with delay in commencement & is of doubtful value after 3 days. Effective for approximately 3 months, so retest for antibodies 3 months post HBIG administration and 3 months post course completion. Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 10 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory. Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker 5.3 If source anti-HCV Positive Staff members may be exposed to blood from patients with hepatitis C. Blood from staff and source should be tested for hepatitis C antibody. If the source is known to be anti-HCV positive then a HCV PCR test should be ordered to estimate transmission risk. Check with the microbiologist on duty for collection details. At this stage there is no effective prophylaxis against HCV infection, but antivirals effective against Hepatitis C are in development so discussion with a practicing hepatologist is advised. Immunoglobulin is not effective as it does not contain HCV antibodies. Staff follow up will be initiated by the WHS Coordinator. Referral to a specialist hepatologist is advisable. • If the source is positive for anti–HCV there is around 65% to 80% chance that they are infectious. If the source’s blood tests are positive for anti–HCV, a polymerase chain reaction (PCR) test should be performed if possible. • PCR test positivity is currently the best marker of the potential to transmit HCV infection. As PCR positivity can be intermittent, a PCR negative result in a HCV antibody positive source does not preclude infectivity. However it may be reassuring to the staff member to know that the risk of transmission of HCV is lower if the source blood is HCV PCR negative. • If the source was found to be anti–HCV positive, the staff member should be followed up specifically for liver function tests, anti–HCV testing, and Hepatitis C PCR at 6 weeks and again at 6 months or as ordered by the treating hepatologist, to determine if they have become infected. If any abnormality is detected in this testing, the staff member should be referred to a Hepatologist for further management. 5.4 If Source anti HIV Positive IMMEDIATE referral to Westmead Hospital (CHW) and CHESS or Prince of Wales Hospital (SCH) for counselling and possible anti-retroviral prophylaxis if source is either HIV positive or at high risk for HIV for possible prophylactic treatment. The risk of staff contracting HIV infection from needlestick injuries or contact with blood or other body fluids from patients with HIV infection appears to be small. Nevertheless, occasional cases have occurred, so staff who have been accidentally exposed should seek advice immediately after the incident. If the staff member has been exposed to blood or blood contaminated secretions from a patient with HIV or possible HIV infection; • At CHW: the WHS & IM Department will contact Westmead Emergency or for immediate referral. Ph : 9845 5555 • At SCH: CHESS will refer the staff member to Prince of Wales Hospital for review. If the source was considered low risk for HIV infection but later found to be antibody positive, the exposed Staff Member should be sent to Westmead Emergency for (CHW) or CHESS/Prince of Wales Emergency for (SCH) at the earliest opportunity for appropriate management. If the source was found to be anti–HIV positive, consider degree of risk as determined previously (Table 1) and offer HIV prophylaxis as indicated. Refer to Table 3 - CDC Recommendations for (Occupational) HIV Post exposure Prophylaxis (PEP) Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 11 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory. Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker Table 3: HIV Prophylaxis • Two drug regimen use either tenofovir-emtricitabine (Truvada) OR zidovudinelamivudine (Combivir). Drug Tenofovir-emtricitabine (Truvada) Zidovudine-lamivudine (Combivir) • Dose 300-200mg daily 300-150mg twice daily Dose and presentation 1 tab daily Max dose 300-200mg 1 tab twice daily. Main toxicity Nephrotoxicity Three drug regimen use either tenofovir-emtricitabine (Truvada) OR zidovudinelamivudine (Combivir) PLUS one of the following combinations of protease inhibitors. Drug Lopinavir-ritonivir (Kaletra) Dose >40kg 400-100mg twice daily. Dose and presentation Should be taken with food. 100-25mg tablets Main toxicity Diarrhoea, hepatitis, pancreatitis, headache 200-50mg tablets Atazanavir-ritonivir 300-100 mg once daily Darunavir-ritonivir 800-100 mg once daily Max 400-100mg twice daily. Discuss with virologist or ID physician Discuss with virologist or ID physician Jaundice, renal stones hepatitis Hepatitis Note: If the staff member is HBsAg positive discuss anti-retroviral therapy with the virologist or ID physician. 5.5 Tetanus Tetanus prophylaxis should be considered and instituted if the injury circumstances warrant it (e.g. injuries sustained during the handling of garbage bags, or injuries from discarded needles in a soiled environment such as a garden bed or outside grounds of the hospital). 6 Complete Appropriate Documentation At CHW • Document the incident on Safety at Kids (IIMS). • The "Record of Staff Exposed to Blood/or Potentially Blood Contaminated Secretions" form is to be completed by the attending Medical Officer or WHS & IM staff health nurse for the source and person exposed to blood/ body fluid. • The blood exposure packages containing the forms are available from the: o the WHS & IM Department (Level 1) o Operating Suite (Level 3) o Emergency Department (in Blood Exposure Packages) o The Afterhours NUM (Level 4) Note: All forms on completion must be sent to the WHS & IM Department Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 12 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory. Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker At SCH: • Contact CHESS p 42782 Mon- Fri office hours and follow instructions or Page the Prince of Wales (POW) needle stick Assessor via Switch Ext 9 if after hours. • Report the incident to your supervisor • Complete a confidential NSW Health Reporting form • Report to the POW Emergency Department and the Needle Stick Assessor will be paged for management and reporting. 7 Follow-up Management All staff should be offered follow-up testing if required. 7.1.1 • Provide counselling and perform anti-HIV and anti-HCV. If the staff member was not hepatitis B immune perform HBsAg, anti-HBc and anti-HBs. 7.1.2 • Source Negative for HIV, HBV, and HCV Source of Unknown Infectious Status or Unable to be tested Management will depend on the outcome of the risk assessment. 7.1.3 Source Likely to be in the Window Period for HIV, HBV or HCV • Source should be followed up for 3 months to determine if they develop antibodies. • Staff should be retested at: o 6 weeks and 3 months for HIV post exposure o 3 months and 6 months for HBV post exposure o 6 weeks and 6 months for HCV post exposure. 7.1.4 • Source Positive or Likely to be Positive for HBV Prophylaxis and follow up management as per Table 2. 7.1.5 Source Positive or Likely to be Positive for HCV. If the source is positive for anti-HCV there is around 3% risk of transmitting HCV from a deep needlestick injury with a hollow needle. If source blood tests positive for anti-HCV, a polymerase chain reaction (PCR) test should be performed if possible. PCR test positivity is at present the best marker of the potential to transmit HCV infection. As PCR positivity can be intermittent, a PCR negative result in a HCV antibody positive source does not preclude infectivity, but it may be reassuring to the health care worker to know that the transmission of HCV is very low if the source blood is HCV PCR negative (approximately 1.8% from a deep needlestick injury with a hollow needle). If the source was found to be anti-HCV positive, the staff member should be followed up specifically for liver function tests, PCR, and anti-HCV testing as per treating physician, alternatively, this can be arranged through a Doctor of choice. If an abnormality is detected in Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 13 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory. Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker either test, the staff member should be referred to a Hepatologist for further management. HCV PCR should be offered at 6 weeks post exposure and if negative at that time, the risk of transmission is negligible but a HCV antibody test at 6 months post exposure should still be undertaken to confirm that transmission has not occurred. 7.1.6 Source Positive for HIV If the source was found to be anti-HIV positive, follow up management will be continued at the Staff Health Clinic, (CHW) and CHESS (SCH). 8 General Advice for Staff Exposed to HIV, HCV or HBV Positive Blood If source positive or likely to be positive for HIV, HBV or HCV, during the 6 month period following exposure the staff member should be advised: • Not to donate plasma, blood, body tissue, breast milk or sperm. • To protect sexual partners by adopting safe sexual practices (eg use of condoms). • To seek expert medical advice regarding pregnancy and/or breastfeeding. • To seek expert clinical advice regarding the need to modify work practices involving exposure prone procedures. This will usually only be recommended in the case of highest risk percutaneous exposures (as defined in Table 1). • To seek expert clinical advice and to modify work practices if involved in the performance of exposure prone procedures if he/she develops clinical or serological evidence of HBV. Further Information Resource for Staff: o Health Care Facilities with Clinicians Experienced in Treatment of HIV and HCV: http://chw.schn.health.nsw.gov.au/ou/ohs/resources/staff_health/resources_treatment_of_HIV_and_HCV.pdf Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 14 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory. Policy No: 1/A/14:9123-01:00 Policy: Needlestick and Blood Exposure Injuries: Health Care Worker 9 NSW Health Policy Directives Further Information and Bibliography 1. NSW Health Directive PD2005_311 “HIV, Hepatitis B and Hepatitis C – Management of Health Care Workers Potentially Exposed”. 2. NSW Health Directive PD2005_162 “HIV, Hepatitis B and Hepatitis C - Health Care Workers Infected”. Copyright notice and disclaimer: The use of this document outside Sydney Children's Hospitals Network (SCHN), or its reproduction in whole or in part, is subject to acknowledgement that it is the property of SCHN. SCHN has done everything practicable to make this document accurate, up-to-date and in accordance with accepted legislation and standards at the date of publication. SCHN is not responsible for consequences arising from the use of this document outside SCHN. A current version of this document is only available electronically from the Hospitals. If this document is printed, it is only valid to the date of printing. Date of Publishing: 22 December 2014 6:08 PM Date of Printing: 22 December 2014 K:\CHW P&P\ePolicy\Dec 14\Needlestick and Blood Exposure Injuries - Health Care Worker.docx Page 15 of 15 This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.