Download blood and body fluid exposure management tool

655 West 12th Avenue
Vancouver, BC V5Z 4R4
Tel 604.707.2400
Fax 604.707.2401
Clinical Prevention Services
Tel 604.707.5600
Fax 604.707.5604
www.SmartSexResource.com
www.bccdc.ca
BLOOD AND BODY FLUID EXPOSURE MANAGEMENT TOOL
The purpose of this tool is to assist health professionals in managing patients who have had a
blood and body fluid exposure. A risk assessment should be performed on the exposed
person within two hours of exposure. This is commonly performed at hospital emergency
departments, institutional occupational health departments and public health units for
community exposures.
If the exposure occurred within 36 hours and there was significant risk for exposure to HIV
transmission, clients may be offered post-exposure prophylaxis (PEP) for HIV at the nearest
hospital emergency department. When indicated, it is important to start PEP as soon as
possible after a high risk blood and body fluid exposure. (See the BCCDC Communicable
Disease Control (CDC) Manual: CDC Manual: Blood and Body Fluid Exposure Management for
HIV PEP recommendations). PEP will vary for pregnant women and for those exposed to a
source known to have been on anti-retroviral therapy or a source whose HIV infection is known
to be drug resistant. Refer to BC Centre for Excellence in HIV/AIDS or call 1-888-511-6222.
The risk of developing HBV infection following exposure is extremely low. The majority of the
BC population under the age of 30 has been vaccinated against HBV since the introduction of
grade 6 hepatitis B immunization programs in 1992 and the implementation of a universal infant
program in 2001. If the exposure occurred within the previous 14 days and the client is at
significant risk for exposure to hepatitis B (HBV), HBV prophylaxis, (including hepatitis B
vaccine and potentially hepatitis B immune globulin - HBIG), may be indicated depending on the
clients HBV immune status and hepatitis B vaccination history. When indicated, it is important
to administer HBIG as soon as possible after the exposure. (See the BCCDC CDC manual
Blood and Body Fluid Exposure Management (BBF Exposure Management) for HBV post
exposure prophylaxis recommendations).
Prophylaxis for potential exposure to hepatitis C (HCV) is not available.
DEFINITION
Blood and body fluid exposure is an event where a person is exposed to potentially infectious
blood or bodily fluids through the following:

Percutaneous exposure through puncture of skin by needlestick or another sharp
object;


Permucosal exposure through contact with mucous membranes; or
Non-intact skin exposure through eczema, scratches, and damaged skin.
CAUSES
Post-exposure management must be undertaken when the following conditions are present:
 Exposure is through needlestick/scratches, mucosal contact or contact with
compromised (damaged) skin;
 Exposure is to blood or high-risk body fluids from a source that is either known to be
infectious or might be potentially infectious (high-risk source or in settings where
individuals engage in high-risk activities); and
 The exposed person is known or considered to be at risk for HBV, HCV or HIV.
PREDISPOSING RISK FACTORS
Common Risk Factors for HBV, HCV and HIV include:
 Unprotected sexual activity where there is blood present (e.g. multiple sex partners,
vaginal or anal sex without a condom);
 History of injection drug use;
 History of dialysis;
 Immigration from a high endemic country; and
 Tattoo and body piercing, electrolysis.
TYPICAL FINDINGS
Health History
Assessment of the exposed person includes:
 HBV vaccine history or HBV immune status
 Personal risks for HBV, HCV and/or HIV.
 Obtain verbal informed consent for testing for HBsAg, Anti-HBs, Anti-HBc, Anti-HCV and
HIV Ag/Ab. Also obtain consent for disclosure of their results to their:
o Worksite occupational health department and WorkSafeBC; and
o Follow-up physician.
 Refer to Fluids capable of transmitting bloodborne pathogens (Table 1)
 Inform HIV testing may be done:
o Nominally – in which the test is conducted and reported using the client’s full
name, address and contact information; or
o Non-nominally – in which the test is conducted using initials as per agency
standards
 Positive HIV results will be reported to the Medical Health Officer using the nominal or
non-nominal identifiers. Non-nominal HIV reporting is identified through checking a tick
box on the laboratory requisition form.
 Test results for HBV and HCV, if positive, will be reported to the person’s testing
physician and public health for follow-up.
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Table 1: Fluids capable of transmitting bloodborne pathogens
FLUID
HIV
HBV
HCV
Blood and fluids visibly
contaminated with
blood
Yes
Yes
Yes
Semen
Yes
Yes
Yes if blood present
Vaginal secretions
Yes
Yes
Yes if blood present
Pleural, amniotic,
pericardial, peritoneal,
synovial and
cerebrospinal fluids and
inflammatory exudates
Yes
Yes
Yes
No, unless
contaminated
with blood
Yes
No, unless contaminated
with blood
Yes
Yes
Yes
Saliva
Transplanted tissue or
organs
Breast milk
Yes
Faeces
Nasal secretions
Sputum
Sweat
Tears
Urine
Vomitus
Plausible, particularly if
nipples are cracked or
bleeding. Neonates given
hepatitis B Immune
globulin (HBIG) and HBV
vaccine are not at risk.
Plausible, particularly if
nipples are cracked or
bleeding but the risk of
transmission is very low.
Breastfeeding is
recommended by HCV
infected mothers.
No, unless they contain visible blood
Assessment of the source person includes:
 If the source person is known, test to confirm clinical status
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Physical Assessment
1. Needlestick/wound:
o Allow the wound to bleed freely.
o Do not promote bleeding by squeezing the wound. This may damage the tissues
and increase uptake of any pathogen(s).
2. Mucous membrane or eye:
o Rinse well with water or normal saline.
3. Skin:
o Wash well with soap and water.
o Note: Do not apply bleach to wound or mucosa.
Diagnostic Tests
Blood should be collected from both the exposed and source persons as soon as possible.

At the time of the exposure, the exposed person should be tested for
o HBsAg,
o Anti-HBs,
o Anti-HBc Total,
o Anti-HCV,
o HIV Ag/Ab (detects anti-HIV and P24 antigen). All laboratory based HIV screening
tests in BC detect both antibody and antigen.

If test results are negative, arrange for the following blood tests:
o 3 weeks post exposure: HIV Ag/Ab, HCV RNA (if source HCV+ or high risk group)
o 6 weeks post exposure: HIV Ag/Ab
o 3 months post exposure: HIV Ag/Ab, Anti-HCV, HBsAg, Anti-HBs, Anti-HBc Total
NB: The use of HIV post-exposure prophylaxis (PEP), HBIG, hepatitis B vaccine, or a
positive (reactive) result will alter timelines for testing. Please refer to Appendices 1-4 in
the Blood and Body Fluid Exposure Management Guidelines.



If the source is confirmed HIV-negative and not in a window period, only HIV testing of
the exposed person at baseline is required. Refer to Appendix 1.
If a woman of childbearing age is exposed, consider pregnancy testing when
appropriate.
Refer to Table 2: Follow up Blood Testing after Exposure to Blood and Body Fluids
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Table 2: Follow Up Blood Testing After Exposure to Blood and Body Fluids
Time since
exposure
HIV
Hepatitis C
Virus (HCV)
Hepatitis B Virus (HBV)
ASAP,
usually in
Emergency
Rooms
Yes
Yes
Yes
To check your baseline
status. Negative or nonreactive test results suggest
no prior infection.
3 weeks after
exposure
Yes
Yes
No
If HCV RNA +, early
treatment may prevent
chronic infection.
6 weeks after
exposure
Yes
No
No
3 months after
exposure
Yes
Yes
Refer to Appendices 2 and 3
for HBV management and
testing recommendations
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Rationale for testing
A negative (or non-reactive)
test result at 3 months
following exposure
indicates that you did not
get infected.
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MANAGEMENT AND INTERVENTIONS
Goals of Treatment



Reduce the potential of infection
Prevent complications from undiagnosed and untreated infection
Reduce anxiety
TREATMENT OF CHOICE
*Consultation/referral may be required depending upon the clinician’s professional scope of
practice*
Treatment
Hepatitis B Immunoprophylaxis

Hepatitis B immune globulin and hepatitis B
vaccine series if indicated.
Notes
1. Refer to the BCCDC CDC manual
Blood and Body Fluid Exposure
Management for specific criteria
regarding HBV immunoprohylaxis
and HIV PEP
HIV Post Exposure Prophylaxis (PEP)

Refer to BC Centre for Excellence in
HIV/AIDS for HIV PEP if indicated.
Tetanus Vaccine

2. Refer to Tetanus Prophylaxis in
Wound Management
http://www.bccdc.ca/NR/rdonlyres/
528C4C20-F2F8-4333-9927E8DC455A5E76/0/SectionVII_Biol
ogicalProducts_April20142nd.pdf
Consider with a percutaneous injury
PREGNANT OR BREASTFEEDING WOMEN
Refer all pregnant or breastfeeding clients to a physician or nurse practitioner (NP).
Breastfeeding concerns
HBV:


If the exposure is to a high-risk HBV source, breastfeeding can continue in
circumstances where:
o the mother is immune to HBV
o the mother and infant are vaccinated and treated with HBIG immediately postexposure
Mothers that suspend breastfeeding can preserve breast milk by pumping and freezing
the milk until they are cleared of infection risk.
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HCV:


If the exposure is to an Anti-HCV positive source, breastfeeding is recommended. If the
nipples become cracked or bleed, mothers are to abstain from breastfeeding until they
are healed
To prevent cessation of milk supply, consider expressing and discarding breast milk until
the nipples are healed
HIV:



If the source is infected with HIV, breastfeeding is not recommended.
If the HIV status of the source is unknown, breastfeeding should be temporarily
discontinued. During this time, the mother may pump and freeze breast milk while
awaiting source test results. If a source person has baseline HIV-negative test results
and has no recent high-risk behavior, then breastfeeding can be resumed and the frozen
milk used.
Breastfeeding is contraindicated if the mother is receiving PEP due to a high-risk
exposure. Breastfeeding can be resumed when PEP has been stopped.
PARTNER COUNSELLING AND REFERRAL


Initiate counselling at the site of post-exposure management.
Include discussion regarding window periods and ways of reducing potential infection
transmission to sexual partners and contacts.
If PEP is implemented, refer to the BC Centre for Excellence in HIV/AIDS Therapeutic
Guidelines Accidental Exposure Guidelines available at:
http://www.cfenet.ubc.ca/sites/default/files/uploads/docs/Accidental_Exposure_Therapeutic_
Guidelines_Nov82010.pdf
MONITORING AND FOLLOW-UP
If prophylaxis for HBV and/or HIV are started, it is essential that the exposed person is followed
by a family or an assigned physician as soon as possible as the anti-retroviral starter kits
contain only a five day supply of medication.
POTENTIAL COMPLICATIONS
The toxicity of some antiretroviral drugs is high. The exposed person should be aware of this
and the potential for adverse effects before starting antiretroviral therapy. This information is
provided on the attachments to the antiretroviral package provided in the emergency room. A
small proportion of patients taking prophylaxis will be unable to work during the month of
treatment.
There are many drug interactions with antiretroviral medication, particularly with Protease
inhibitors such as Kaletra®. A careful medication history and use of all alternative therapy
should be reviewed. Non-essential medications and all alternative therapy should be
discontinued during antiretroviral therapy. Questions regarding drug interactions should be
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directed to the Centre for Excellence in HIV Pharmacy (1-888-511-6222). Specific cases
should be discussed with a Centre for Excellence in HIV Physician or Pharmacist.
Refer to the BC Centre for Excellence in HIV/AIDS Therapeutic Guidelines
Accidental Exposure Guidelines are available at:
http://www.cfenet.ubc.ca/sites/default/files/uploads/docs/Accidental_Exposure_Therapeutic_Guidelin
es_Nov82010.pdf
CLIENT EDUCATION
Exposed persons may be anxious when initially assessed. They may not remember the
information provided during the initial counselling session. It is important to repeat and followup with detailed counselling.
While awaiting test results from the source and until the risk assessment is complete, the
exposed person should be advised:











to obtain baseline blood testing and follow-up testing to determine whether transmission
took place
regarding the appropriate use of medications (dosage, side effects).
regarding the potential asymptomatic nature of HBV, HCV and HIV infections.
to use latex condoms during intercourse;
not to donate blood;
not to share toothbrushes, razors, needles and other items potentially contaminated with
bodily fluids;
to keep cuts and abrasions covered until fully healed;
to package any blood containing items separately before disposal;
to clean any blood contamination with a 1:10 solution (9 part water to 1 parts bleach) of
household bleach;
to avoid sharing recreational drug paraphernalia; and
to defer pregnancy. If pregnant, consult the Oak Tree Clinic at BC Women’s Hospital,
Tel # (604) 875-2212 or 1-888-711-3030.
FOLLOW UP AND DOCUMENTATION
Arrange a follow-up with the exposed person’s physician or the physician designated by the
healthcare facility by completing the following form:
Management of Percutaneous or Permucosal Exposure to Blood or Body Fluid Letter for
Follow-Up Physician Form (HLTH 2340)
http://www2.gov.bc.ca/assets/gov/health/forms/2340fil.pdf
 Give the white copy to the client (exposed person)
 Give the yellow copy to Worksite Occupational Health
 Retain the pink copy in the client’s chart
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Complete the following laboratory requisition form for blood testing:
Management of Percutaneous or Permucosal Exposure to Blood and Body
Fluid/Laboratory Requisition Form (HLTH 2339)
http://www2.gov.bc.ca/assets/gov/health/forms/2339fil.pdf
The white and yellow copies (page 1, 2) contain information on the source and/or exposed
person(s).
 Forward the white copy to the laboratory performing the testing
 Forward the yellow copy (page 2) to the occupational health department of the exposed
person’s workplace.
 Forward the pink copy (page 3) to WorkSafeBC.
Fax numbers: (604) 276-3194 [lower mainland] or 1-888-922-3299 [toll-free].

For occupational exposures, the WorkSafeBC guidelines for injury reporting must be
followed.
Attach the golden copy (page 4) to the exposed person’s record.
Risk assessment and management documentation should be recorded in the exposed person’s
health record.
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REFERENCES
BC Centre for Disease Control (2012). British Columbia Annual Summary of
Reportable Diseases. Retrieved from: http://www.bccdc.ca/NR/rdonlyres/F30377E3-D33E-4755-B3F46844E01BD678/0/FinalAR2012.pdf
BC Centre for Disease Control (2009). Communicable Disease Control: Blood and Body
Fluid Exposure Management.
BC Centre for Disease Control (2012). Communicable Disease Control: Chapter 1 –
Management of Specific Diseases Hepatitis C.
BC Centre for Disease Control (2014). Communicable Disease Control Immunization Program
Section VII – Biological Products.
BC Centre for Excellence in HIV/AIDS: HIV Monitoring Quarterly report for BC (2014). Retrieved
from: http://stophivaids.ca/STOP/wpcontent/uploads/monitoring_reports/2014/second_quarter/bc_monitoring_report_14q2_aug19.pdf
BC Centre for Excellence in HIV/AIDS (2009). Therapeutic Guidelines Accidental Exposure
Guidelines. Retrieved from:
http://www.cfenet.ubc.ca/sites/default/files/uploads/docs/Accidental_Exposure_Therapeutic_Guidelines_
Nov82010.pdf
BC Ministry of Health. Management of Percutaneous or Permucosal Exposure to Blood and
Body Fluid/Laboratory Requisition. Retrieved from:
http://www2.gov.bc.ca/assets/gov/health/forms/2339fil.pdf
Beekmann, S. E., & Henderson, D. K. (2005). Protection of healthcare workers from
bloodborne pathogens. Current Opinion in Infectious Diseases, 18(4), 331-336.
Canadian AIDS Society. HIV Transmission: Guidelines for Assessing Risk.(2004). Retrieved
from: www.cdnaids.ca/web/repguide.nsf/Pages/cas-rep-0307
Centers for Disease Control and Prevention (CDC). CDC Guidance for Evaluating Health-Care
Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management. MMWR
2013; 62(RR-10):1-19.
Centers for Disease Control and Prevention (CDC). Immunization of Health-Care Personnel. MMWR
2011;60(RR-07):1-45.
Centers for Disease Control and Prevention (CDC). Updated U.S. public health service guidelines for the
management of occupational exposures to HBV, HCV, and HIV and recommendations for post-exposure
prophylaxis. MMWR 2001;50(RR-11):43-4.
FitzSimons, D., Francois, G., De Carli, G., Shouval, D., Pruss-Ustun, A., Puro, V., Williams, I.,
Lavanchy, D., De Schryver, A., Kopka, A., Ncube, F., Ippolito, G., & Van Damme, P. (2008) Hepatitis B
virus, hepatitis C virus and other blood borne infections in healthcare workers: Guidelines for prevention
and management in industrialized countries. Occup Environ Med, 65, 446-451.
Heathcote, J., & Main, J. (2005). Treatment of hepatitis C. Journal of Viral Hepatology, 12(3), 223-235.
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Kuhar, D, Henderson, D, Struble, K, Heneine, W, Thomas, V, Cheever, L, Gomaa, A, &
Panlilio, A. (2013). Updated U.S. Public health service guidelines for the management of occupational
exposures to HIV and recommendations for postexposure prophylaxis. Atlanta: U.S. National Center for
Emerging and Zoonotic Infectious Diseases.
Maheshwari, A., Ray, S., & Thuluvath, P. (2008). Acute hepatitis C. Lancet, 372,321-32
Taylor D, Durigon M, Davis H, Archibald C, Konrad B, Coombs D, Gilbert M, Cook D, Krajden
M, Wong T, Ogilvie G (2014 In Press). Probability of a false negative HIV antibody test result during the
window period: A tool for pre- and post-test counselling. International Journal of STD&AIDS
Wong, T., & Lee, S. S. (2006). Hepatitis C: A review for primary care physicians. CMAJ, 174(5), 649-659.
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