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-----------------------------------------------------------------------------------------------------------------REPORT OF THE MONTH, Volume V, Number 4 – July - August 2001
- - - - from the North Carolina Statewide Program for Infection Control and Epidemiology
-----------------------------------------------------------------------------------------------------------------CONTENTS:
NEWS/REGULATORY
Management of Occupational Exposures to Hepatitis B, Hepatitis C, and HIV
REGULATORY/QUESTION OF THE MONTH
Small Hospitals Complying with New CDC Occupational Exposure Guidelines
NEWS AND ANNOUNCEMENTS
COURSES FOR THE INFECTION CONTROL PROFESSIONAL
-----------------------------------------------------------------------------------------------------------------NEWS FEATURES
Management of Occupational Exposures to Hepatitis B, Hepatitis C, and HIV
The following memorandum is from Kelly T. McKee, Jr., M.D., M.P.H., General Communicable
Disease Control Branch, Epidemiology Section, North Carolina Division of Public Health.
Summary: Management of Occupational Exposures to Hepatitis B, Hepatitis C, and HIV
NC Division of Public Health, Epidemiology Section
July 18, 2001
Recently, the Centers for Disease Control and Prevention (CDC) issued updated guidelines for
the management of occupational exposures to bloodborne pathogens (MMWR 50/RR-11, 29
June 2001 Updated U.S. Public Health Service Guidelines for the Management of Occupational
Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis).
These guidelines represent a synthesis of recommendations published by CDC (and OSHA)
over the past several years in a variety of forums, and reflect the current state of knowledge
regarding risks of contracting Hepatitis B, Hepatitis C, and HIV following percutaneous or
mucous membrane exposure to blood and body fluids. Additionally, these guidelines
summarize current information on, and recommendations for, post-exposure prophylaxis (PEP)
for each of these pathogens. Below is a comparison of the changes from previous
recommendations. Note that this summary is NOT intended to substitute for a careful review
and analysis of the complete CDC document by responsible individuals at the local level. The
complete CDC document can be found at:
http://www.cdc.gov/mmwr//preview/mmwrhtml/rr5011a1.htm
Each local health department should ensure that a plan is in place for management of
occupational exposures to blood and body fluids. Emphasis must be placed on prompt
assessment of incidents by individuals experienced in the management of HIV, familiar with
anti-retroviral therapy, and knowledgeable about drug resistance and its impact on choice of
post-exposure prophylaxis regimens. It is incumbent on each health department to identify
local and/or regional resources capable of responding knowledgeably and in a timely fashion.
Telephone consultation on these matters is available through the Statewide Program for
Infection Control and Epidemiology (SPICE) at 919-966-3242; however, this should not
substitute for local response capability.
_____________________________________________________________________
UPDATES NEW TO 29 JUNE 01 PHS GUIDELINES
_____________________________________________________________________
HIV:
 Last guidelines 1998 (15 May 98; MMWR 47/RR-7).
 Better definition of “less severe” and “more severe” exposure types driving 2 vs. 3 drug PEP
regimens.
 New anti-retroviral agents approved by FDA; modified PEP recommendations.
 More info about the use and safety of PEP.
 For all drugs, much more info on tolerability, toxicities, advantages/disadvantages.
OLD: Basic: 4 weeks (28 days) AZT (600 mg qd-divided doses) PLUS lamivudine (3TC)
(150 mg bid); Expanded: Basic regimen PLUS indinavir (800 mg tid) OR nelfinavir (750
mg tid)
NEW: Basic: 4 weeks (28 days) AZT (600 mg qd-divided doses) PLUS lamivudine
(3TC) (150 mg bid) OR lamivudine (150 mg bid) PLUS stavudine (d4T)(40 mg bid) OR
didanosine (ddI)(400 mg qd) PLUS stavudine (40 mg bid); Expanded: Basic regimen
PLUS indinavir (800 mg tid) OR Nelvinavir (750 mg tid or 1250 mg bid) OR efavirenz
(600 mg qd) OR abacavir (300 mg bid) OR ritonavir OR saquinavir OR amprenavir OR
delavirdine OR lopinavir/ritonavir. Recommended NOT TO USE nevirapine.
HBV:
 Last comprehensive CDC guidelines 1997 (26 December 1997; MMWR 46/RR-18);
included as part of supplement on vaccination of Health Care Professionals (HCPs).
OLD: No significant differences in management of PEP between OLD and NEW.
NEW: Consolidates and packages information previously provided into single
document. More elaboration of factors to consider in assessing need for PEP and
evaluation of exposure source. Emphasis on follow-up and counseling.
HCV:
 Last guidelines 1998 (MMWR 1998 47/RR-17).
 At the present time, the State Laboratory for Public Health is not resourced to support
Hepatitis C diagnostic testing; individual arrangements must be made by local health
departments for this activity.
 Recently, the General Communicable Disease Control Branch in Raleigh contracted with
the Office of Continuing Education at the University of North Carolina-Chapel Hill School of
Medicine to provide a series of CME presentations across the state on Hepatitis C
Awareness. The schedule for these presentations is under development, and will be
distributed soon.
OLD: Post-exposure follow-up of health-care, emergency medical, and public safety
workers for hepatitis C virus (HCV) infection.
For the source, baseline testing for anti-HCV.
For the person exposed to an HCV-positive source, baseline and follow-up testing
including baseline testing for anti-HCV and ALT activity; and follow-up testing for antiHCV (e.g., at 4-6 months) and ALT activity. (If earlier diagnosis of HCV infection is
desired, testing for HCV RNA may be performed at 4-6 weeks).
Confirmation by supplemental anti-HCV testing of all anti-HCV results reported as
positive by enzyme immunoassay.
NEW: Post-exposure follow-up for HCV
For the source, perform testing for anti-HCV.
For the person exposed to an HCV-infected source: perform baseline testing for antiHCV and ALT activity; and perform follow-up testing (e.g., at 4-6 months) for anti-HCV
and ALT activity (if earlier diagnosis of HCV is desired, testing for HCV RNA may be
performed at 4-6 weeks).
Confirm all anti-HCV results reported positive by enzyme immunoassay using
supplemental anti-HCV testing (e.g., recombinant immunoblot assay [RIBA]).
Health care personnel who provide care to persons exposed to HCV in the occupational
setting should be knowledgeable regarding risks for HCV infection and appropriate
counseling, testing, and medical follow-up.
IG and antiviral agents not recommended.
No guidelines exist for administration of therapy during the acute phase of HCV
infection. When HCV identified, prompt referral is appropriate (because antiviral therapy
might be beneficial when started early in course of HCV infection).
BOTH HBV and HCV:
No modifications to an exposed person’s patient-care responsibilities are necessary to prevent
transmission to patients based solely on exposure to HBV or HCV-positive blood. If an exposed
person becomes acutely infected with HBV, the person should be evaluated according to
published recommendations. No recommendations exist regarding restriction of activities of
HCPs with HCV infection. All chronically-infected HCPs (with HBV or HCV) should follow
recommended infection control practices (published).
____________________________________________________________________
For additional information contact:
General Communicable Disease Control
Epidemiology Section
NC Division of Public Health
1902 Mail Service Center
225 N. McDowell Street
Raleigh, NC 27699-1902
Phone: (919)733-3419
Fax:
(919)733-0490
REGULATORY/LEGISLATIVE
QUESTION OF THE MONTH
Small Hospitals Complying with New CDC Occupational Exposure Guidelines
Q:
How can a community hospital without an infectious disease or occupational health
specialist determine which regimen of drugs to give for each individual bloodborne pathogen
exposure?
A:
Acknowledging the increasing complex factors involved in post-exposure prophylaxis for
HIV, the CDC is advising confused clinicians to call for expert consultations before
administering the potentially toxic drugs. In addition, the June 29, 2001 edition of the
MMWR Recommendations and Reports outlines several special circumstances (e.g.,
delayed exposure report, unknown source person, pregnancy in the exposed person, resistance
of the source virus to antiretroviral agents, or toxicity of the PEP regimen) when consultation
with local experts and/or the National Clinicians' Post-Exposure Prophylaxis Hotline ([PEPline]
1-888-448-4911) is advised.
A second means of obtaining expert advice regarding the new PEP regimens is a website. The
following press release issued by the CDC announced a UCLA Emergency Interactive Website
to help healthcare workers exposed to patient bodily fluids.
One of the most frightening experiences for healthcare workers is sustaining an
accidental needlestick or bodily fluid splash and thus facing the possibility of exposure to
HIV, hepatitis or other diseases patients carry.
To help doctors, nurses and other healthcare professionals make decisions about how
to manage such occupational exposures, the UCLA Department of Emergency Medicine
has developed an interactive Website.
The Website, named "Needlestick," was funded by the Centers for Disease Control and
Prevention (CDC). It is based upon new guidelines that CDC released June 29 for
managing and documenting occupational exposures to blood and other body fluids. The
original research leading to the website's development was sponsored by the Agency for
Healthcare Research and Quality (AHRQ). With AHRQ funding, researchers studied
real-time access to clinical guidelines by emergency room healthcare workers exposed
to body fluids.
The site (www.needlestick.mednet.ucla.edu) functions as a smart electronic medical
record. It guides the healthcare provider in acquiring relevant data and selecting
appropriate laboratory tests and treatments. Once the case is complete, the healthcare
provider may print case-specific aftercare instructions to be given to the exposed
healthcare worker and included in the medical record.
Each case is managed anonymously, because the site does not collect identifying
information about the exposed healthcare worker or the source of the body fluid.
Another advantage of this method of healthcare delivery is that when the CDC updates
the occupational exposure guidelines again, modification of a single computer should
change practices much more rapidly than traditional methods of information
dissemination.
from CDC Press Release
NEWS AND ANNOUNCEMENTS
Correction: In the Report of the Month, Volume V, Number 3, May-June 2001, article on
"Prevention and Control of Program Downsizing" the first author of the abstract referenced is
Calfee.
"List of Sterilants and High Level Disinfectants Cleared by Food and Drug Administration in a
510(k) as of June 29, 2001 - Updated" is online at http://www.fda.gov/cdrh/ode/germlab.html
"Control and Prevention of Rubella: Evaluation and Management of Suspected Outbreaks,
Rubella in Pregnant Women, and Surveillance for Congenital Rubella Syndrome" was
published by the Centers for Disease Control and Prevention (CDC) in the July 13, 2001 issue
of MMWR Recommendations and Reports.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5012a1.htm
"Vaccinia (Smallpox) Vaccine Recommendations of the Advisory Committee on Immunization
Practices (ACIP), 2001," which include bioterrorism responses, was published by the Center for
Disease Control and Prevention (CDC) in the June 22, 2001, issue of MMWR
Recommendations and Reports.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5010a1.htm
A Guide to the Clinical Care of Women With HIV: 2001 -- First Edition has been published by
the HIV/AIDS Bureau, Health Resources and Services Administration. It is the first guide
specifically addressing medical treatment of women with HIV. Information about ordering free
copies and downloading online is available at
http://hab.hrsa.gov/womencare.htm
CDC's Division of Global Migration and Quarantine (DQ), National Center for Infectious
Diseases has released the 2001--2002 edition of Health Information for International Travel
(The Yellow Book). The new edition contains updated vaccination information; updated
information on malaria risk and prophylaxis (by country); updated and revised disease-specific
text and tables; new sections on altitude sickness and international adoption; updated country
listings; and improved maps and indexing. The Yellow Book can be purchased from the Public
Health Foundation, telephone (877) 252-1200 or at http://bookstore.phf.org.
specific web site: http://bookstore.phf.org/prod159.htm
download from CDC for free at
http://www.cdc.gov/travel/reference.htm
In July ican, INC. announced that it is ceasing operations of its web site, icanPREVENT,
because the company has been unsuccessful in reaching a break-even point in time to
continue.
COURSES FOR THE INFECTION CONTROL PROFESSIONAL
"Infection Control Part II: The ICP as an Environmentalist" will be held September 10-14, 2001
at the Holiday Inn in Chapel Hill.
"Infection Control in Home Health and Hospice" will be held October 8, 2001 at The Friday
Center in Chapel Hill.
-----------------------------------------------------------------------------------------------------------------Contributors to Report of the Month: Karen K. Hoffmann, RN, MS, CIC; William A. Rutala, PhD,
MPH; David J. Weber, MD, MPH; Eva P. Clontz, MEd.
-----------------------------------------------------------------------------------------------------------------To subscribe to the Report of the Month, send email to
[email protected]
Report of the Month is also available on the home page of the Statewide Program for Infection
Control and Epidemiology at http://www.unc.edu/depts/spice/
The Statewide Program for Infection Control and Epidemiology (SPICE) is funded by the
General Assembly of North Carolina to serve the State. SPICE is not a regulatory agency but
provides education and consultation to North Carolina healthcare facilities.
Copyright 2001 Statewide Program for Infection Control and Epidemiology