Download no PEP

OCCUPATIONAL
EXPOSURES TO BLOOD
AND BODILY FLUIDS
Dr Chow TS
Infectious Disease Unit
Medical Department
HPP
Scope

Bloodborne pathogens
 HIV
 Hep
B
 Hep C
 Others: Malaria, syphilis, HTLV-1 etc.



Assessment
Management per protocol
Prevention
INFECTIOUS

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
Body fluids containing
visible blood
Semen
Vaginal secretions
CSF
Synovial fluid
Pleural fluid
Peritoneal fluid
Pericardial fluid
Amniotic fluid
Tissue
NOT INFECTIOUS
Unless contaminated with
blood
 Feces
 Nasal secretions
 Saliva
 Sputum
 Sweat
 Tears
 Urine
 Vomitus
Needle stick injury occurred ….

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Recapping of needle
Insertion of branulas
Sticking used needles onto mattress (very common in
AE)
Not using sharp bin and blood taking trolley
appropriately
Overflow of sharp bin
Carelessness during procedures e.g. CVL etc
Not using glove during procedure
Needles that were not disposed properly
Overflow of Sharp Bin
Needle andDISPOSAL
sharps being
inappropraitely
IMPROPER
OFdiscarded
WASTE - AVOIDED
Needles being thrown into the sink
Needles being thrown onto the floor
Weird situations…



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Needles in general waste
Needles in tissue box (made into sharp bin by HO)
Needles in boxes (needle being used as scissors to
cut tape on the box in store)
Needles on the mattress of bed (very common)
Needles on the drip set
Is it important to know how it
occurred ?

Yes, study the pattern of injury will give us some
information for remedial measures to be taken.
MANAGEMENT AFTER
Occupational exposures
POST OFFICE HOURS - ED
Post exposure management




First aid
Serological testing
Counseling
Immunoprophylaxis/ vaccine/ antiviral/anti
infectives
FIRST AID after exposure - HCW
IMMEDIATE MEASURES:
Skin: Wash thoroughly with soap & water
Eye: Rinse thoroughly with sterile saline, clean water flush
Mouth, Nose: Clean water rinse/flush
No evidence that using antiseptics/ disinfectant or expressing fluid by squeezing
the wound further reduces risk
SEEK ADVICE EARLY
Preferably prophylaxis should be commenced within 1 –2 hrs of the
exposure
Report the incident- HCW



Sister on call
Consultant / specialist / MO in charge if not sure of
what to do
Fill up incident form HPP/QUA/BR-08-pindaan1
Form IR1 (will be submitted by respective
ward/unit to QA the next working day after HOD
signed)
Report to infection control unit and take forms
from ward/ place of incident



Call Sister Hafizah 019 495 7927 (on call 24 H)
for assistance if in doubt.
Other wise : need to ask the exposed HCW to
notify to IC unit in ACC the next working day
To fill up
 OHU
SIS-1 (exposed HCW),
 OHU-SIS 2a, OHU SIS – 2b (attending ID physician)
 EPINet form (Exposed HCW)
Refer ED MO after office hour



Initial assessment to be done by ED MO,
Call 7030/ 7031 - ID consultant on call to discuss
further if in doubt.
What assessment to be done?
 Serology
testing
 Counseling
 Antiviral / immuno-prophylaxis
 Follow up arrangement
Blood taking – ward of incident

Fill up PER PAT 301 form in 2 :
1
for Source patient (details and diagnosis)
 1 for HCW , write “SHARP INJURY” on both forms


Informed consent to be taken for both source and
HCW (by respective ward Dr)
Take 5 ml blood in red tube each ,
 Source:
HIV, HepBsAg, HCV
 HCW: HIV, HepBsAg, Anti Hep Bs Ab, HCV
 If source or HCW refused HIV testing – no HIV test to
be done.
 VDRL – not routine
Blood sampling- HCV source



If source is known/diagnosed HCV positive:
send source patient and HCW blood for HCV RNA PCR tests
to HSB ( as baseline) in 2 tubes EDTA /purple/FBC tube for
both samples.
Fill up PER PAT 301 form with full history
Serology Testing – send from ED





Send both tubes of samples (HCW and SOURCE)
with PER PAT 301 forms (X2) and the HCW to ED
ED MO need to fill up Sharp injury Form HPP
(HPP/PAT/MM/QP/013-APPENDIX 1)
contact number of the ED MO who attended the
case IS NEEDED
Informed the lab 5153, 5152 after office hour to
run rapid test HIV and Hep B for both source and
HCW immediately
The lab will call you back once result is out.
Information needed: ED MO to take
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HCW details: years of service, unit involved
Date, time and location of the exposure
Details of the procedure being performed and the use of
protective equipment at the time of the exposure
The type, severity, and amount of fluid to which the HCW
was exposed
HCW Vaccination history (Hep B)
Lady HCW: pregnant?
Details about the source patient ( high risk for HIV, HCV or
HBV?) – need the input from respective ward MO
Trace the result within 1 Hour…HIV




If the source is HIV negative by rapid test: no PEP
If the source is HIV negative but has high risk of HIV – may
consider PEP
 High risk: unprotected sexual exposure with multiple partner,
MSM, IVDU, partner of known HIV patient: may start PEP
If HIV status unknown (unknown source or soucre refused to be
tested) : may consider PEP depending on circumstances
If HIV positive : call ID consultant and start
extended regime PEP.
PEP: COMBIVIR 1 tablet 12 hourly
Extended : COMBIVIR + KALETRA 2 tablet 12
hourly
DETAILS OF
HIV EXPOSURES
Main determining factors: HIV exposure
Infective source (HIV Status ):
HIV viral concentration, volume of specimen involved
in exposure, clinical stage, CD4 cell count, current
antiretroviral therapy, etc.

Level of Exposure (Exposure Severity):
Depth of injury, instrument involved, duration of
exposure, integrity of skin/mucous membranes.

Risk of HIV Transmission
1. Bell DM. Am J Med 1997;102(suppl 5B):9-15.
Recommended HIV PEP for percutaneous injury
Exposure
type
Asymptomatic
HIV
Symptomatic
HIV
Low VL
High VL
Less severe
(solid
needle/
superfi inj
2 drug PEP
More severe
(Large bore,
deep
Expanded >
3 drug PEP
Expanded 
3 drug PEP
Status
Source
Unknown
HIV negative
Gen. no PEP. Gen. no PEP. No PEP
Consider 2
drug for
high risk
Expanded 
3 drug PEP
Unknown
source
Consider 2
drug in high
risk setting
Gen. no PEP. Gen. no PEP. No PEP
Consider 2
drug for
high risk
Consider 2
drug in high
risk setting
Recommended HIV PEP for mucous membrane &
non-intact skin
Exposure
type
Asymptomat
ic HIV
Low VL
Symptomatic
HIV
High VL
Status
Unknown
Source
source
Unknown
HIV
negative
Small vol.
(few
drops
only)
Con. 2
drug PEP
R. 2 drug
PEP
Gen. no
PEP.
Gen. no
PEP.
No PEP
R.
Expanded
 3 drug
PEP
Gen. no
PEP.
Gen. no
PEP.
No PEP
Large vol. R. 2 drug
PEP
(Major
blood
splash)
Consider
2 drug for
high risk
Consider 2
drug in
setting
Tolerability of HIV PEP in Health Care
Workers
Percent of HCWs
100
90
80
70
60
50
40
30
20
10
0
Incidence of Common Side Effects
57
38
18
16
14
6
Nausea
Fatigue Headache Vomiting Diarrhea Myalgias
Wang SA. Infect Control Hosp Epidemiol 2000;231:780-5.
WHEN SHOULD PEP BE
STARTED?
Timing of PEP: CDC Guidelines



“PEP should be initiated as soon as possible,
preferably within hours rather than days of
exposure.”
Interval after which there is no benefit for humans is
not known
Obtain expert advice when interval has exceeded
24-36 hours
MMWR 2005;54(No. RR-9).
Duration of PEP

4 weeks (28 days) used in case-control study2 and
recommended by CDC guidelines3
1. Tsai C-C et al. J Virol 1998;72:4265-73.
2. Cardo DM et al. NEJM 1997;337:1485-90.
3. MMWR June 29, 2001:50(RR11);1-42.
PEP Regimens: Basic regimens
Latest guidleines

Two NRTIs


Simple dosing, fewer side effects
Preferred basic regimens:
Combivir (Zidovudine 300 mg+ Lamivudine 150 mg)
1 tab BD for 4 weeks
or
Tenvir –EM ( Tenofovir 300 mg + Emtricitabine 200
mg) 1 Tab OD for 4 weeks
CDC 2009
Expanded PEP Regimens


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Basic regimen plus a third agent
Rationale: 3 drugs may be more effective than 2
drugs, though direct evidence is lacking
Consider for more serious exposures or if resistance
in the source patient is suspected
Adherence more difficult
More potential for toxicity
Expanded PEP Regimens

Preferred Expanded Regimen:
Combivir 1 tab 12H + Kaletra 2 tab 12 H
Tenvir EM 1 tab OD + Kaletra 2 tab 12 H

For 28 days
CDC 2010
*Atazanavir requires ritonavir boosting if used with tenofovir
Adverse Effects:
Basic vs Expanded Regimens
60
2 NRTI
2 NRTI + 1 PI
% of individuals
50
40
30
20
10
0
General
Lower GI Upper GI
elevated hyperbiliTG
rubinemia
Puro V et al. 9th CROI, February 2002, Abstract 478-M
2x ALT
Follow-up of (HCW) exposed to known or suspected
HIV-positive sources


Exposed HCW should be advised to use precautions (e.g., avoid
blood or tissue donations, breastfeeding, or pregnancy) to prevent
secondary transmission, especially during the first 6–12 weeks
post-exposure.
For exposures for which PEP is prescribed, HCW should be
informed regarding:

need for monitoring





(F/U serology tests:HIV serology, HBsAg, HCV serology 0, 6 weeks, 3 and 6 months)
Monitor side-effects if given antiretroviral drugs:
 Symptoms: GI upset, malaise, myalgia

Laboratory: FBC, LFT, RP
possible drug interactions (OCP, anti epileptic, warfarin)
the need for adherence to PEP regimens.
Consider re-evaluation of exposed HCW 72 hours post-exposure,
especially after additional information about the exposure or SP
becomes available.
MMWR 2005;54(No. RR-9).
Follow-up HIV Testing



CDC recommendations: HIV Ab testing for 6 months
post-exposure (e.g., at 6 weeks, 3 months, 6
months)
Extended HIV Ab testing at 12 months is
recommended if health care worker contracts HCV
from a source patient co-infected with HIV and
HCV
VL testing not recommended unless primary HIV
infection (PHI) suspected
MMWR 2005;54(No. RR-9).
PEP for HIV in pregnant HCW




Decision is drawn after discussion with HCW
Do not deny PEP solely on the basis of
pregnancy
Efavirenz not recommended
Combivir +/- Kaletra
OCCUPATIONAL HBV
EXPOSURES
Trace result within 1 hour - HBV


If source blood rapid test for Hep Bs Ag is negative:
no need PEP for HBV
If source blood rapid test is Hep BsAg + ve:
 HCW
vaccinated with 3 doses and sure Hep B s Ab
level tested before was > 10 IU/ml= no need PEP
 HCW not vaccinated or unsure of vaccination/antibody
level: use IM immunoglobulin Ig G (immuno-prophylaxis)
 Then later Hep B booster/revaccination
HBIG
DOSE:
HBIG
A single dose of HBIG (0.06 ml/kg or 5.0 ml for adults) should be given as
soon as possible after exposure and within 24 hours if possible.
HB vaccine
1 ml (20 ug) should be given IM at a separate site as soon as possible, but
within 7 days of exposure, with the second and third doses given 1 month
and 6 months, respectively, after the first
OCCUPATIONAL HCV
EXPOSURES
Trace result HCV 
If source HCV known +ve: need to send HCV RNA
for source and HCW in pair to HSB
 Use

2 bottle EDTA each
If source unknown or negative : nothing to be
offered as PEP, just give FU date.
Hep C exposure

If source is confirmed HCV positive: HCW negative
for HCV
 HCW
and the source blood need to be taken for
 HCV
RNA (detectable in 1-3 weeks post exposure)
 HCV antibody (90% who seroconvert will do so in the first 3
months)


NO reccomended prophylaxis
Monitor early infection
 HCW
who remained HCV RNA detectable 8-12 weeks
post exposure will need a course of Pegylated IFN
Gastro 130: 2006
OTHERS
Other possible pathogens
Malaria:
 1 HO had needle stick injury past 3 weeks ,
exposed to Vivax Malaria patient
 2 weeks later developed high swinging fever, HO
suspected malaria via needle stick transmission
 HO BFMP turned out to have Vivax Malaria!!
 CDC recorded only 1 case transmission (falciparum)
– very rare but could occur
 No post exposure prophylaxis recommended
 Need to watch out and high index of suspicion
Syphilis




If incident of syphilis is high
Source is having active primary or secondary
syphilis (chancre or rash)
Test for VDRL/TPHA only indicated
Exposed HCW : IM 2.4 Benzathine Penicillin stat
may be given.
Don’t Forget...Emotional impact!
Can be severe and long lasting even when serious infection is not
transmitted
 impact is particularly severe when the injury involves exposure to
HIV, HCV.
 Not knowing the infection status of the source patient can accentuate
the HCWs stress.


(HIV and Hep B rapid test play important role)
In addition to the exposed HCW, colleagues and family members
may suffer emotionally.
Reference

National Institute for Occupational Safety and
Health bloodborne pathogens website
 http://www.cdc.gov/niosh/bbppg.html

Occupational Safety and Health Administration
bloodborne pathogens website
 http://www.osha-
slc.gov/SLTC/bloodbornepathogens/index.html
THANK YOU!!