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Occupational HIV Exposure Prophylaxis Dr Truong Anh Tan June 30th , 2010 Infected post-exposure rate/1000 Blood infusion IDU (shared needle) Anal sex receiver Needlestick Vaginal sex female Anal sex giver Vaginal sex male Oral sex receiver Oral sex giver 900 6,7 5,0 3,0 1,0 0,65 0,5 0,1 0,05 Estimated Pathogen-Specific Seroconversion Rate Per Exposure for Occupational Needlestick Injury 3 . AETC http://depts.washington.edu/hivaids Type of Exposure Way Involved in Transmission of HIV to Health Care Workers AETC http://depts.washington.edu/hivaids 4 Source of HIV Involved in HIV Transmission to Health Care Worker 5 AETC http://depts.washington.edu/hivaids Risk Factors for HIV Transmission with Occupational Exposure to HIVInfected Blood Odds Ratio Confidence Interval Deep Injury Visibly Bloody Device 15 6.2 6.0-41 2.2-21 Device Used in Artery or Vein 4.3 1.7-12 Terminally Ill Source Patient Use of Zidovudine for PEP 5.6 0.19 2.0-16 0.06-0.52 Risk Factor P<0.01 for all associations 6 Other Possible Risk Factors Hollow bore vs solid bore Glove use No documented cases to date of seroconversion from suture needles 50% decrease in volume of blood transmitted Mucous membrane exposure Mosquitoes bite? 7 Standard Precautions Definition Standards developed to prevent exposure and transmission of disease in occupational setting Provide guidance for the safe handling of infectious material 8 Components of Standard Precautions Hand washing Use protective barriers when indicated Gloves: mucus membranes, body fluids, broken skin Goggles: procedures Masks: procedures 9 Components of Standard Precautions (2) Sharps and waste - handle with gloves and dispose in designated containers Needles Scalpels Suture material Bandages Dressings Anything contaminated with any body fluid 10 Handling with Disposing Sharps Do not recap needles! Put containers within arms reach Use adequate light source when treating patients Wear heavy-duty gloves when transporting sharps Incinerate used needles to a sufficient temperature to melt Keep sharps out of reach of children 11 Components of Standard Precautions (3) Re-usable instruments must be thoroughly disinfected Speculums Surgical tools Thermometers Immunizations for Healthcare Workers Hepatitis A and B 12 Recommended Antiseptic Solutions Alcohol 70% Chlorhexidine, 2-4% (e.g. Hibtane, Hibiscrub) Iodine 3% Iodophores 7.5-10% (e.g. Betadine) 13 Recommended Disinfectants Chlorine, 0.5% (Barkina) Sedex and Ghion brands contain 5% Chlorine, dilute for use Glutaraldehyde, 2-4% (e.g. Cidex) Formaldehyde, 8% Hydrogen peroxide, 6% Soak the instrument for 20 minutes after decontamination and cleaning 14 Management of Occupational Exposure HIV AB: for both (giver and receiver) Hepatitis : B & C CBC SGOT/SGPT Blood Glucose 136th month 1 mil 100,000 + _ 10,000 Ab 1,000 100 HIV RNA Exposure HIV-1 Antibodies HIV RNA Diagnostic Testing Symptoms 10 0 7 14 21 Days 28 Image courtesy of The Center for AIDS Information & Advocacy, www.centerforaids.org 16 The Early Stages of HIV Infection Cell free HIV T-cell Immature Dendritic cell Skin or mucosa PEP 24 hours 1. Burst of HIV replication Via lymphatics or circulation HIV co-receptors, CD4 + chemokine receptor CC5 48 hours 2. Selective of macrophagetropic HIV 3. Mature Dendritic cell in regional LN undergoes a single replication, which transfers HIV to Tcell 17 Wound Care Gently wash wounds with soap and water/ 5 minutes alchol 70% 5 minutes (don’t scrub vigorously) Allow wounds to bleed freely Irrigate exposed mucosal surfaces with sterile saline 19 Post Exposure Prophylaxis (PEP) Definition: Use of therapeutic agent to prevent establishment of infection following exposure either occupationally or non-occupationally to pathogen Roles in Occupational Exposure: HIV prevention HBV prevention Tests before ARVs therapy 20 Step 1: Does This Patient Need HIV PEP? Source patient HIV - HIV + Unknown / Unwilling to get tested* High background risk No PEP PEP Low background risk No PEP 21 *CDC recom: usually PEP unnecessary; consider use if source patient is high risk Step 2: Determine HIV Status Code of Source (HIV SC) HIV Negative HIV Positive Asymptomatic/high CD4 = HIV SC 1 No PEP HIV Status Unknown or Source Unknown = HIV SC Unknown Advanced disease, primary infection or low CD4 =HIV SC 2 PEP No PEP or + PEP with 2 drugs CDC Sep 2005 Occupational HIV PEP 2 drug regimen Zidovudine plus lamivudine (combivir) Stavudine plus Lamivudine Tenofovir plus lamivudine 3 drug regimen LPV/r or Indinivr or Nelfinavir plus NRTI backbone Efavirez plus NRTI backbone Consider resistance potential of source patient Don’t use NVP (hepatotoxic) When to start ASAP PEP no efficacy after 72 hours 25 PEP Guideline from MOH - PEP 1: AZT + 3TC AZT: 300mg bid & 3TC: 150 mg bid. - PEP 2: 3TC + d4T 3TC: 150mg bid & d4T: 30-40mg bid. < 60 kg, d4T: 30 mg bid. > 60 kg, d4T: 40 mg bid. AZT(Zidovudine);3TC(Lamivudine);D4T(Stavudine) Advanced PEP(for high risk) PEP 1 or 2 plus 1of following agents: - NFV: 1,25 g bid. - EFV: 300 mg bid - LPV/r: 500 mg bid (recommended) 28 days duration (MOH guideline for PEP updated on 9/2009) Follow-up HIV Testing -CDC: HIV Ab at 6th week, 3rd month, 6th month -Extended HIV Ab testing at 12 months recommended if a source patient co-infected HCV -VL testing not recommended unless Primary HIV Infection (PHI) suspected -Early diagnosis: HIV RNA PCR at 3th week - MMWR June 29, 2001 / 50(RR11);1-42. 28 Thank you for your attention!