Download Blood-borne viruses in health care workers: Prevention

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ARTICLE IN PRESS
Journal of Clinical Virology xxx (2011) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Virology
journal homepage: www.elsevier.com/locate/jcv
Review
Blood-borne viruses in health care workers: Prevention and management
S. Deuffic-Burban a,b,∗ , E. Delarocque-Astagneau c , D. Abiteboul d,e , E. Bouvet d,e , Y. Yazdanpanah a,b,d,f
a
ATIP-AVENIR, Inserm U995, Université Lille Nord de France, 152 rue du Docteur Yersin, 59120 Loos, France
EA2694, Université Lille Nord de France, 1 place de Verdun, 59045 Lille Cedex, France
c
Institut Pasteur, 25–28 rue du Dr Roux, 75724 Paris Cedex 15, Franceg
d
Groupe d’Etude sur le Risque d’Exposition au Sang (GERES), Université Paris Diderot – Paris 7, UFR de Médecine – site Bichat, 16 rue Henri Huchard, 75890 Paris Cedex 18, Franceh
e
Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75877 Paris, Francei
f
Service des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing, 135 rue du Président Coty, B.P. 619, 59208 Tourcoing, Francej
b
a r t i c l e
i n f o
Article history:
Received 7 January 2011
Received in revised form 15 May 2011
Accepted 18 May 2011
Keywords:
Blood-borne pathogens
Infectious disease transmission
Patient-to-professional
Professional-to-patient
Management risk
Prevention and control
a b s t r a c t
Three pathogens account for most cases of occupationally acquired blood-borne infection: hepatitis B
virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). The highest proportion
of occupational transmission is due to percutaneous injury (PI) via hollow-bore needles with vascular
access. We briefly review prevention and management of blood-borne pathogens in health care workers
(HCWs) in developed countries. HCW compliance with standard precautions is necessary for prevention
of PI. Safety-engineered devices are now being increasingly promoted as an approach to decreasing the
rate of PI. Prevention of HBV transmission requires HCW immunization through vaccination against HBV.
In non-vaccinated HCWs (or HCWs with an unknown antibody response to vaccination) exposed to an
HbsAg-positive or an untested source patient, post-exposure prophylaxis with HBV vaccine, hepatitis B
immunoglobulin or both must be started as soon as possible. Although no available prophylaxis exists for
HCV, it is crucial to identify HCV exposure and infection in health care settings and to consequently propose early treatment when transmission occurs. Following occupational exposure with potential for HIV
transmission, use of antiretroviral post-exposure prophylaxis must be evaluated. Patients need to be protected from blood-borne pathogen-infected HCWs, and especially surgeons performing exposure-prone
procedures (EPPs) with risk of transmission to the patient. However, HCWs not performing EPPs should
be protected from arbitrary administrative decisions that would restrict their practice rights. Finally, it
must be emphasized that occupational blood exposure is of great concern in developing countries, with
higher risk of exposure to blood-borne viruses because of a higher prevalence of the latter than in developed countries, re-use of needles and syringes and greater risk of sustaining PI, since injection routes are
more frequently used for drug administration than in developed countries.
© 2011 Elsevier B.V. All rights reserved.
Contents
1.
2.
3.
4.
5.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Occupational risk of exposure to and transmission of blood-borne pathogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Preventing PI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HBV vaccination of HCWs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Management of HCWs exposed to blood-borne pathogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Abbreviations: ALT, alanine aminotransferase; HCW, health care worker; EPP, exposure-prone procedure; HBV, hepatitis B virus; HCV, hepatitis C virus; HIV, human
immunodeficiency virus; PI, percutaneous injury; PEP, post-exposure prophylaxis; SED, safety-engineered device.
∗ Corresponding author at: ATIP-AVENIR, Inserm U995, Université Lille Nord de France, 152 rue du Docteur Yersin, 59120 Loos, France. Tel.: +33 3 20 44 59 62/35128;
fax: +33 3 20 96 86 62.
E-mail addresses: [email protected] (S. Deuffic-Burban), [email protected] (E. Delarocque-Astagneau), [email protected] (D. Abiteboul),
[email protected] (E. Bouvet), [email protected] (Y. Yazdanpanah) .
g
Tel.: +33 1 40 61 37 66; fax: +33 1 45 68 88 76.
h
Tel.: +33 1 57 27 78 70; fax: +33 1 57 27 77 01.
i
Tel.: +33 1 40 25 80 80; fax: +33 1 40 25 83 05.
j
Tel.: +33 3 20 69 46 16; fax: +33 3 20 69 46 15.
1386-6532/$ – see front matter © 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.jcv.2011.05.016
Please cite this article in press as: Deuffic-Burban S, et al. Blood-borne viruses in health care workers: Prevention and management. J Clin Virol
(2011), doi:10.1016/j.jcv.2011.05.016
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JCV-2221; No. of Pages 7
ARTICLE IN PRESS
S. Deuffic-Burban et al. / Journal of Clinical Virology xxx (2011) xxx–xxx
2
5.1.
HBV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.2.
HCV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.3.
HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.
Preventing transmission from HCWs to patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.1.
HBV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.2.
HCV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.3.
HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction
Twenty-six different viruses have been shown to be responsible
for occupational transmission in the literature.1 Three pathogens
account for most cases due to their prevalence in patients and the
severity of infections they cause: hepatitis B virus (HBV), hepatitis
C virus (HCV) and human immunodeficiency virus (HIV). PrussUstun et al.2 estimated that, in the year 2000, 16,000 HCV, 66,000
HBV and 1000 HIV infections may have occurred worldwide among
health care workers (HCWs) due to their occupational exposure to
percutaneous injuries (PIs).
In the present paper, we review data on management and
prevention of blood-borne viruses in HCWs, focusing on HBV,
HCV and HIV. For this purpose, systematic search was performed of Medline literature databases for papers published
from January 1995 to March 2010 using the following search
terms: health care workers, hepatitis C, hepatitis B/vaccination,
HIV-1, injections/practices/utilization, equipment/re-use, personal
protective equipment, infection control/standards, needle stick
injuries/epidemiology, standard precautions, safety-engineered
devices and post-exposure prophylaxis. We also searched for
national guidelines on management and prevention of blood-borne
viruses in HCWs via websites of public health institutes in specific
countries (Centers for Disease Control, Health Protection Agency,
CCLIN), and international guidelines via the WHO website (specifically, the Safe Injection Global Network).
2. Occupational risk of exposure to and transmission of
blood-borne pathogens
Although case reports have documented transmission of these
viruses as a result of splashes of blood from infected patients onto
HCW mucous membranes, the highest proportion of transmission
occurs through PI with hollow-bore needles for vascular access,
i.e. blood-drawing and intravenous/arterial catheters.3–6 Risk of
transmission is closely related to work practices. Surgeons and laboratory assistants have been identified as having the highest risk of
PI.7–9 When PI occurs, the risk of HBV transmission is estimated as
up to 30% in susceptible HCWs without post-exposure prophylaxis
(PEP) or adequate hepatitis B vaccination.10,11 Average risk of HCV
infection is estimated at 0.5%, but is considered null if exposure
was to non-viremic patients.3,12 Risk of HIV infection is estimated
at <0.3%.13
3. Preventing PI
Preventive methods and standard precautions for protecting both HCWs and patients from infection with blood-borne
pathogens include hand washing after patient contact, use of barrier precautions (e.g. gloves), minimal manual manipulation of
sharp instruments/devices (e.g. avoidance of needle recapping)
and disposal in specific resistant containers.14 Regular training
sessions targeting both long-term HCWs, students and residents
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at high risk of injury15 can help to ensure compliance with
standard precautions. Compliance with these precautions has
reduced the incidence of occupational exposure, and therefore of
PI, over time.16–19 For example, in the French national surveillance network,17–19 the incidence of occupational exposure (80%
of which is due to PI) decreased from 8.9 in 2004 to 7.4 per
100 beds in 2008 (Table 1). At the same time, among overall PIs,
the proportion of PIs preventable by taking standard precautions
also decreased, from 52.5% in 2004 to 45.8% in 2008. However,
a high proportion of PIs continue to occur in persons who do
not adhere to these standard precautions: in 2008, 12.5% of PIs
occurred while recapping needles; 31.2% of PIs occurred in HCWs
who did not have containers for sharp device disposal. From available data, evaluating these trends is not possible in Belgium because
data are pooled over 2003–2009 period.20 In the United States, a
decrease in the incidence of occupational exposure is not noted
over time.21,22 However, the surveillance is based on a few facilities
(Table 1).
Although training and education remain key preventive
measures for improving HCW compliance with improved standard precautions, safety-engineered devices (SEDs) (retractable
syringes, needle-free intravenous systems, winged butterfly needles) are now being increasingly promoted for use in decreasing
the rate of PI.23,24 Use of these devices might partly explain the
decrease in the incidence of occupational exposure over time in
France (Table 1). Several recent studies demonstrated the impact of
SEDs on needle stick injuries.24–26 In one French hospital complex,
the rate of needle stick injuries while using SEDs during phlebotomy was 4-fold lower than that with conventional devices.25
Procedure-specific differences in needle stick injury risk in two
surveys conducted in 1990 and 1999–2000 also support this
hypothesis. In the report of those surveys, the sharpest decrease
in needle stick injury rate between the two surveys was observed
for finger-stick-based collection of capillary blood and collection
of blood for culture, two procedures for which use of SEDs has
most strongly increased. However, SEDs do not exist for all type
of procedures. For example, equipment for arterial blood sampling lack appropriate SEDs for protecting HCWs; thus, the rate
of use of SEDs remained unchanged from 1990 to 2000. This may
be related to the fact that SEDs are not suitable for these procedures, but also to cost issues. Although the cost of SEDs may
represent an obstacle to their use, this drawback must be weighed
against the cost of needle stick injury management and that of
occupational blood-borne infections such as hepatitis B and C
and HIV.
Since some studies had reported the effectiveness of blunt-tip
suture needles in decreasing PIs, the American College of Surgeons issued a statement in 2005 supporting universal adoption
of blunt-tip suture needles for suturing fascia. In 2008, in the US,
the Occupational Safety and Health Administration, the Department of Labor, the National Institute for Occupational Safety and
Health, the CDC and the Department of Health and Human Services strongly encouraged use of blunt-tip suture needles whenever
feasible and appropriate.27 The impact of these recommendations
Please cite this article in press as: Deuffic-Burban S, et al. Blood-borne viruses in health care workers: Prevention and management. J Clin Virol
(2011), doi:10.1016/j.jcv.2011.05.016
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3
Table 1
Evolution of occupational exposure in France (2004–2008), in Belgium (2003–2009) and in United States (2004–2006).
Francea
Number of health facilities participating
Number of extrapolated blood and body fluid exposures occurring in all hospitals
Incidence rate per 100 beds
Type of exposure (%)
PI
Projections
Other, unknown
Main material involved (%)
Needle
Syringe
Catheter
Surgical equipment
Patient source status (%)
HIV-positive
HCV-positive
HBV-positive
Unknown
PIs that could have been prevented by taking standard precautions (%)
PIs in people not wearing gloves
PIs occurring while recapping or disposing of needles
PIs occurring among HCWs not having specific containers for device disposal
Belgiuma
USAa
2004
2006
2008
2003–2009
2004
2006
385
41,276
8.9
518
35,418
8.0
709
32,176
7.4
73
11,210
8.4
41
n.a.
26.7b
33
n.a.
27.9b
81.7%
15.8%
2.5%
81.5%
16.1%
2.5%
80.6%
16.7%
2.7%
87.0%
13.0%
n.a.
n.a.
n.a.
n.a.
n.a.
n.a.
37.1%
18.7%
12.8%
11.5%
36.9%
16.8%
11.3%
11.8%
37.0%
17.5%
9.8%
12.0%
56.0%
10.8%
n.a.
36.1%
39.1%
6.2%
n.a.
37.6%
33.3%
4.5%
n.a.
2.3%
5.0%
1.5%
23.0%
52.5%
37.5%
12.8%
32.6%
1.8%
3.5%
1.2%
24.6%
48.6%
33.9%
13.0%
31.0%
2.7%
4.4%
1.4%
20.8%
45.8%
31.2%
12.5%
29.1%
2.1%
4.4%
1.6%
47.7%
36.0%
17.4%b
7.3%c
24.4%
n.a.
n.a.
n.a.
n.a.
n.a.
14.8%b
2.9%c
n.a.
n.a.
n.a.
n.a.
n.a.
n.a.
11.9%b
2.6%c
n.a.
n.a., non available.
a
Estimates are from the French national surveillance network (Réseau d’Investigation et de Surveillance des Infections Nosocomiales, RAISIN; Groupe d’Etude sur le Risque
d’Exposition des Soignants aux agents infectieux, GERES; Institut de Veille Sanitaire, InVS),17–19 from the Belgian Institute of Public Health,20 and from the EPINet network
for USA.21,22
b
Among percutaneous injuries only.
c
While recapping needles only.
on the incidence of occupational exposures will be evaluated in
coming years.
and should be screened at regular intervals or after significant
exposure.
4. HBV vaccination of HCWs
5. Management of HCWs exposed to blood-borne
pathogens
All HCWs in contact with patients, blood or other body secretions should be vaccinated for HBV. HBV vaccination protects
HCWs not only against HBV infections but also against delta
virus infections occurring only in individuals positive for HBV surface antigen.28,29 However, vaccine coverage remains disparate in
western countries, and poor vaccine coverage has been reported
in some countries despite recommendations.30 To ensure wider
hepatitis B vaccine coverage, vaccination should be carried out,
or immune status verified, very early on in the HCW career,
ideally prior to beginning training, as is currently the case in
France31 and as recommended by European guidelines.28 Wider
vaccine coverage is likely to be achieved by a mandatory vaccination policy, as in France, although such a strategy raises ethical
issues.
The HBV vaccine does not provide protective response in all
fully vaccinated persons. Between 5% and 10% of healthy immunocompetent subjects do not show an antibody response to the
vaccine (non-responders; HBs antibody level <10 IU/l).32 Factors
associated with non-response include male sex, older age, cigarette
smoking, obesity and chronic disease.33 European guidelines for
prevention of HBV and HCV transmission from HCWs to patients
recommend that HCWs vaccinated against HBV should have their
response documented within a month after the final dose. HCWs
with anti-HBs, between 10 and 100 IU, should be tested for HbsAg,
but this is not imperative for administering further doses of vaccine to boost the anti-HBs response.34 Non-responders to the HBV
vaccine should also be tested for HBsAg and Hbc antibodies.35,36
If negative, they should be administered up to three further
doses of HBV vaccine and then have their response re-checked.35
Continuing non-responders are susceptible to HBV infection
The exposed site should be washed with soap and water. The
potential for transmitting HBV, HCV and HIV should be evaluated
based on the type of exposure and body material involved. The risk
of transmission of these viruses increases with deep injuries and
procedures involving hollow-bore needles.3,13 The source patient’s
serostatus for antibodies against HIV, HCV and HBsAg should be
obtained. If the source patient is at risk of recent HIV or HCV
infection on the basis of recent exposure (e.g., in the previous 2–4
weeks), nucleic-acid based testing (e.g., HIV and HCV RNA viral load
testing) should be considered for the patient source to rule out acute
infection, which would confer increased risk of transmission.37 In
addition, baseline HBV, HCV and HIV immune status of the exposed
HCW should be available.
5.1. HBV
In previously vaccinated HCWs with known antibody response,
neither PEP nor serological follow-up is recommended. In other
HCWs, if the source patient is HbsAg-positive or untested, or if
the source is unidentifiable, PEP with HBV vaccine, hepatitis B
immunoglobulin or both must be started as soon as possible, preferably within 24 h after exposure and no later than one week after
exposure (see Table 2 for details).38,39 If the source patient is HbsAgnegative, the HCW HBV status should be tested if unknown and
vaccination should take place if necessary.
5.2. HCV
Although no available prophylaxis exists for HCV, effective treatment is available. Thus, it is important to identify HCV exposure
Please cite this article in press as: Deuffic-Burban S, et al. Blood-borne viruses in health care workers: Prevention and management. J Clin Virol
(2011), doi:10.1016/j.jcv.2011.05.016
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ARTICLE IN PRESS
S. Deuffic-Burban et al. / Journal of Clinical Virology xxx (2011) xxx–xxx
4
Table 2
Post-exposure management of unvaccinated, vaccine-non-responding and incompletely responding HCWs in case of HBsAg+, an untested or unidentifiable source. European
recommendations, 2005. Table adapted from Puro et al.28
HBV vaccine status in the exposed
HCW
Anti-HBs
HB Ig (0.06 ml/kg)
HBV vaccine
Not vaccinated
Obtained rapid results
If anti-HBs >10 mUI/ml: no treatment
As above
If anti-HBs <10 mUI/ml: administer HB Ig
1 dose ASAP and repeat after 1 month
1 dose ASAP
As above
As above
1st dose ASAP and then accelerated
schedule at 1, 2 and 12 months
Complete according to documentation
or restarted at 0, 1, 2 and 12 months
1 booster ASAP
Incompletely vaccinated or does not
recall complete vaccination schedule
Vaccinated via a complete vaccination
schedule but unknown antibody
response
Non-responder to primary vaccination
Previously vaccinated with 4 doses or
two complete vaccine series, but a
non-responder
1 dose ASAP and repeat after 1 month
As above
1st dose ASAP and then accelerated
schedule 1, 2 and 12 months
Alternative vaccine might be
considered
HBsAg: hepatitis B surface antigen; HBV: hepatitis B virus; HCW: health care worker; anti-HBs: antibodies against hepatitis B surface antigen; HB Ig: hepatitis B immunoglobulins; ASAP: as soon as possible.
in health care settings so as to perform screening at the time
of HCV exposure, to monitor all HCWs for HCV40 and to offer
early treatment for cases in which transmission occurs. In HCWs
exposed to viremic HCV source patients, European guidelines recommend monthly monitoring of alanine aminotransferase (ALT)
activity for 4 months after HCV exposure, anti-HCV antibodies at
month 6 and HCV RNA testing to confirm a rise in ALT or positive
anti-HCV antibody results.28 However, French guidelines recently
recommended HCV RNA testing in HCWs exposed to HCV two
weeks after exposure, with a control of anti-HCV antibody and
ALT at 1, 3 and 6 months.41 Early HCV RNA testing may lead
to earlier detection of hepatitis C and therefore to earlier initiation of anti-HCV therapy when compared to strategies based
on ALT and/or HCV antibody detection.42 This strategy leads to
lower risk of progression to chronic hepatitis C and was recently
found to be reasonably cost-effective.42 Currently, the American
Association for the Study of Liver Diseases (AASLD) practice guidelines recommend treatment initiation in patients with acute HCV
if serum HCV-RNA is not eliminated spontaneously within 12
weeks of HCV transmission.43 In a recent model-based analysis,
we showed that early antiviral therapy with pegylated interferon
within the first 2 months following transmission may decrease
the risk of chronic hepatitis C occurrence by 54–68%.44 Nevertheless, results of this model-based analysis must be confirmed in the
future.
including a 4th generation HIV screening assay (antigen p24), may
be useful for diagnosis of HIV infection, limiting unnecessary treatment. A positive HIV test should be confirmed by western blot. If the
source patient is known to be HIV-infected, the risk of transmission
differs according to viral inoculum; a useful threshold for risk stratification when evaluating the potential for transmission might be
a detectable load (i.e. ≥50 copies/ml). However, uncertainty exists
as to whether or not transmission occurs if the source patient viral
load is <50 copies/ml; thus, the question of starting PEP in these
patients is subject to debate. However, in France and Switzerland,
when the viral load is <50 copies/ml, stable for several months and
confirmed after exposure, and if the injury was superficial, PEP is
not considered.47
If initiation of PEP has been decided, then current use of specific antiretroviral drugs, prior drug exposure and drug resistance
of the source person should be evaluated in order to adapt the PEP
regimen. It should be initiated as soon as possible, and administered for 4 weeks.48–50 PEP should be discouraged at over 72 h after
exposure.51,52 PEP should be immediately accessible 24 h/day. All
HCWs occupationally exposed to HIV should be clinically followed
up regardless of whether or not they received PEP. European recommendations for clinical evaluation and HIV serological follow-up
recommend follow-up visits and HIV testing at 6–8 weeks and three
months post-exposure.45 In patients with PEP, compliance and tolerance must be monitored, in particular at 15 days depending on
the toxicity profile of the drugs.
5.3. HIV
6. Preventing transmission from HCWs to patients
Following occupational exposure with potential for HIV transmission, use of antiretroviral PEP should be evaluated based on
the route of exposure, the material involved and evaluation of the
source patient.45,46 For the route of exposure, antiretroviral PEP is
recommended after PI; it should be considered after exposure of
mucous membrane or non-intact skin, but should be discouraged
after exposure of intact skin. Concerning the material involved,
antiretroviral PEP is recommended after exposure to blood, body
materials containing visible blood, cerebrospinal fluid or concentrated virus in a research laboratory; it should be considered after
exposure to semen, vaginal secretions, synovial, pleural, peritoneal,
pericardial or amniotic fluid and tissues; it should be discouraged
after exposure to urine, vomit, saliva, feces, tears, sweat or sputum.
Finally, concerning the source patient, antiretroviral PEP is recommended if the source patient is known to be HIV-infected; it can be
considered if the serological status of the source patient is unknown
or not available, or if there exists consent refusal; it should be discouraged if the source patient is HIV-seronegative.45,46 If the source
patient’s HIV serostatus is unknown, highly sensitive rapid ELISA,
The Society for Healthcare Epidemiology of America (SHEA) has
recently reviewed data on HCW-to-patient transmission.53 Reports
of HBV, HCV and HIV transmission from HCWs to patients exist.54
Occupational transmission of blood-borne viruses to patients
almost exclusively occurs via infected HCWs such as surgeons performing EPPs. EPPs are “those where there is a risk that injury to
the worker may result in exposure of the patient’s open tissues to
the blood of the worker. These procedures include those where the
worker’s gloved hands may be in contact with sharp instruments,
needle tips or sharp tissues (spicules of bone or teeth) inside a
patient’s open body cavity, wound or confined anatomical space
where the hands or fingertips may not be completely visible at
all times”.55 In general, blood-exposed patients should systematically receive the same post-exposure follow-up and management
as HCWs.56 For this, it is important to scrupulously report all exposure, especially that occurring in EPPs. Meanwhile, HCWs should be
protected from arbitrary administrative decisions restricting their
practice rights. The vast majority of HCWs infected with blood-
Please cite this article in press as: Deuffic-Burban S, et al. Blood-borne viruses in health care workers: Prevention and management. J Clin Virol
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borne pathogens do not perform EPPs and pose no risk to patients
even when infected. Restrictions would indeed be senseless and
harmful.
6.1. HBV
In general, national guidelines for management of infected
HCWs state that the HBV status of all medical personnel performing EPPs must be known.57,58 To prevent iatrogenic transmission of
HBV, EPPs should be prohibited in HBV-infected HCWs who have
HBV viremia above a specific threshold. Threshold levels above
which EPPs are prohibited vary from country to country.59 The
European consensus threshold level is 10,000 HBV DNA copies/ml,
while the British threshold level is 1000 copies/ml and the Dutch
threshold level is 1,00,000 copies/ml.60 However, with the availability of inhibitors of HBV polymerase for chronic HBV infection
treatment, HBV DNA may be durably suppressed in HBV-infected
HCWs. Thus, as illustrated by Buster et al.61 prolonged antiviral
therapy for HBV-infected HCWs is a viable option instead of work
restriction, provided that the level of HBV DNA is monitored regularly. This option is also likely to encourage already employed HCWs
to determine their status.
6.2. HCV
Currently, no uniform guidelines exist for identification of
HCV-infected HCWs who perform EPPs, nor for prevention of HCWto-patient HCV transmission.62 A few countries have proposed
guidelines, including the UK55 and the USA.63,64 In the UK, only new
HCWs who will be performing EPPs, and HCWs already involved in
EPPs who have suffered an accidental needle stick, are required
to undergo screening for HCV antibodies. Moreover, guidelines
recommend that HCWs with HCV infection not perform EPPs.
HCV-infected HCWs who have a sustained virological response to
antiviral therapy are allowed to perform EPPs six months after
cessation of treatment.55 Current guidelines concerning prevention of HCW-to-patient transmission of HCV need to be improved.
An alternative option to work restrictions for HCV-infected HCWs
would be a therapeutic option,61 which would also incite HCWs to
learn their status. In light of the fact that new drugs with increased
efficacy will soon be available for patients with chronic hepatitis
C,65 a therapeutic option for HCV-infected HCWs should be strongly
encouraged in the near future.
6.3. HIV
The current CDC policy on infected HCWs, issued in 1991, states
that HIV-positive HCWs should not perform EPPs unless they have
sought counsel from an expert review panel and have been advised
under what circumstances, if any, they may continue to perform
these procedures.66 In addition, that policy states that permitted
procedures should only be performed after informed consent from
the patient. Some authors call for “a less restrictive national health
policy regarding infected health care providers,” maintaining that
the policy currently in effect is too stringent and that infected HCWs
pose an insignificant risk to patients.67 This is probably true in
HCWs receiving combination antiretroviral therapy who have a
viral load <50 copies/ml.
7. Conclusion
Here we have briefly reviewed prevention and management
of blood-borne pathogens in HCWs in developed countries. It is
important to emphasize the fact that occupational blood exposure
is of great concern in developing countries; indeed, a high proportion of worldwide occupationally acquired HCV, HBV and HIV
5
infections occur in these countries. HCWs are exposed to patients
with a higher prevalence of blood-borne viruses than in developed
countries. Moreover, re-use of needles and syringes in the context of a lack of supply is not rare.68 Finally, HCWs are at higher
risk of sustaining PIs69,70 because injection routes are more frequently used for drug administration than in developed countries,
exposing them to greater risk;71,72 in addition, two-handed needle
recapping and improper needle disposal remain frequent in these
countries.69
In response to this threat to both HCWs and patients, efforts have
been made on an international level via WHO implementation of
the Safe Injection Global Network (SIGN), the overall goal of which
is to promote safe injection. In developing countries, in particular,
data on injection practices are essential so as to adapt preventive strategies and refine training programs. It is also important
to improve hepatitis B vaccine coverage; in developed countries as
well, it is important to verify immunization and consequently to
begin vaccination early in the career of HCWs.
Conflict of interest
S. Deuffic-Burban received grants from Roche and Janssen-Cilag.
Y. Yazdanpanah received travel grants, honoraria for presentations at workshops and consultancy honoraria from Bristol-Myers
Squibb, Gilead, Glaxo-SmithKline, Merck, Pfizer, Roche and Tibotec.
None of the authors report any association that might pose a conflict
of interest.
Acknowledgments
The authors thank Céline Ciotti and Gérard Pellissier from the
Groupe d’Etude sur le Risque d’Exposition au Sang (GERES) for their
valuable assistance on research data of occupational exposure in
the world.
Funding: None.
Ethical approval: Not required.
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