Download HIV transmission in through occupational exposures

Occupational exposures to
HIV: Prevention and PEP
HAIVN
Harvard Medical School AIDS
Initiative in Vietnam
1
Learning objectives
At the end of this presentation, each trainee
can understand:
• the risk of transmission of HIV, HBV and HCV after a
single percutaneous exposure.
• the one handed or “scoop” technique of recapping
needles
• the way to wash a wound in the event of a needle stick
to possibly HIV infected blood or fluids.
• the indications for using PEP.
• PEP regimens in Vietnam
• 5 steps to prevent TB transmission in HIV care settings
2
Content of Presentation
• Risks of HIV transmission through
occupational exposures
• Principles and practices of Universal
Precautions
• Post exposure prophylaxis: rationale and
recommendations
• Post exposure prophylaxis in Vietnam:
procedures
• Occupational exposures to HBV and TB and
preventions in the healthcare setting
3
Estimated HIV risk for a single
exposure to HIV+ source
Blood Transfusion
Mother to child
90%
25-35%
IDU needle sharing
Occupational needle stick
Receptive anal sex
0.67%
Receptive vaginal sex
Insertive anal sex
Insertive vaginal sex
0.1%
0.065%
Receptive oral sex
0.01%
Insertive oral sex
0.005%
0.3%
0.5%
0.05%
(CDC, MMWR, 2005)
4
HIV transmission in through
occupational exposures
• In general the risk for HIV transmission
depends on the route and the severity of
exposure to the HIV infected fluid
• The most common source of HIV
exposure is blood.
5
Data on occupational
exposures to HIV in Vietnam
• At one hospital in HCMC in 2000, 330/886 (38%) staff
suffered a percutaneous exposure to blood.
Type of exposure
%
Hollow-bore needles
53
Injuries occurred during
suturing
24
Giving medications
19
Recapping needles
16
Sohn. 15th IAC: Abstract ThPeC7512.
6
HIV transmissions from patient to
healthcare workers (HCW) in USA
• 57 confirmed HIV seroconversions in HCWs
following occupational exposures
• 138 cases of HIV/AIDS among HCWs with no
risk factors for HIV infection other than
occupational exposure in which seroconversion
after an exposure was not documented
Centers for Disease Control and Prevention, December 2001
7
HIV transmissions from patient to
HCWs in USA
Documented
Transmission
Possible
Transmission
Nurses
Laboratory Workers
Physicians, non-surgical
Physician, surgical*
Surgical Technicians
24
19
6
-2
35
17
12
6
2
Dialysis Technicians
1
3
Respiratory Therapist
Health Aide
Morgue Technician
Housekeeper
Dental workers / dentists
EMT
1
1
1
2
---
2
15
2
13
6
12
Other technician/therapist
--
9
Other healthcare
occupation
Total
5
57
139
8
Exposure types in 57 occupationally
HIV infected healthcare workers in the
United States
Type of exposure
Number of cases with
seroconversions
Percutaneous
(puncture/cut injury)
48
Mucocutaneous (mucous
membrane and/or skin)
5
Percutaneous and
mucocutaneous
2
Unknown
2
9
Fluid exposures that lead to HIV
seroconversion in 57 healthcare
workers in the United States
Types of fluid
Number of cases with
seroconversions
HIV infected blood
49
Concentrated virus in a
laboratory
3
Visible bloody fluid
1
Unspecified fluid
4
10
Risk of HIV transmission
Blood exposures
Percutaneous
needlesticks
Risk of HIV
Transmission
0.3%
(95% CI=0.2-0.5%)
Mucous membranes
0.09%
(95% CI 0.006% -0.5%)
Intact Skin
0%
(95% CI =0.0%-0.77%)
11
Factors affecting risk of HIV transmission
after percutaneous exposure
Risk factor
Adjusted
Odds Ratio
The needle went deep into the
healthcare worker
1.5
Visible blood was seen on the needle
before the percutaneous exposure
6.2
Source patient was terminally ill
5.6
Needle was in source patient’s
artery or vein
4.3
12
Universal Precautions
#1 Treat ALL blood as potentially infectious
Follow Universal Precautions
#2 Prevent needlesticks
Safely manage sharps
13
Universal Precautions
Universal precautions minimizes exposure to blood
in 5 ways:
1. Use of protective barriers
2. Hand hygiene
3. Safe injection practices
4. Environmental control of blood and bodily fluids
5. Sharps management
14
1. Use of protective barriers
Procedure
Gloves Gown Goggles/Face
Protection
Giving an injection
No
No
No
Drawing blood
Yes
No
No
Irrigating a wound
Yes
Yes
Yes
Performing an operation
Yes
Yes
Yes
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2. Hand hygiene
• Prevents transmission of resistant
organisms and infections
– Before patient care
– After blood/fluid contact, glove removal
• Methods
– Handwashing
• (Water + soap) x >10s  single-use towel
– Use of hand sanitizer
• 50-95% ethyl or isopropyl alcohol
http://www.cdc.gov/handhygiene
16
3. Use of safe injection practices
Best injection safety practices
• Injection should be administered
with a sterile syringe and needle,
using the right medication, etc.
• Needle should be placed in a
puncture-proof container
immediately after use.
• Sharps waste should be discarded
appropriately.
17
4. Environmental control of
blood and body fluids
• Spills in patient-care areas
– Clean visible blood/fluid with towel and discard
– Disinfect area
• 1:100 dilution (500 ppm) of hypochlorite
• Spills in laboratory areas
– Soak towel and blood/fluid spill in disinfectant before
discarding
– Use more potent disinfectant
• 1:10 dilution (5000 ppm) of hypochlorite
18
5. Sharps Management
• Injuries can occur whenever a sharp is
exposed in the work environment
• Organize work areas
– Have sharps containers nearby
• Avoid hand-passage of sharps
• Do not recap needles or, recap using a
one-handed “scoop technique”
19
“One-hand” technique of
recapping needles
20
Post-Exposure Prophylaxis (PEP)
Rationale:
• HIV pathogenesis: systemic infection does not
occur immediately - “window of opportunity”
when giving ARV may prevent HIV infection
21
Rationale for post-exposure prophylaxis
22
Efficacy of antiretroviral therapy
Human data-CDC Needlestick Surveillance Group
• Case Control study: 31 cases and 679 controls
• Cases: acquired HIV following an occupational
exposure; 94% after a needlestick (all hollow
needles)
• 29% of cases received PEP (AZT) vs 36% of
controls
• Risk for HIV infection was reduced by ~81% in
HCWs receiving AZT
Cardo D. NEJM 1997; 337:1485-90
23
Steps for post-exposure
management
1. Treat the exposure site
2. Report the exposure to the manager and
complete the report form
3. Assess the risk of exposure
4. Determine the HIV status of the source of
exposure
5. Determine the HIV status of the exposed
person.
6. Counsel the exposed person.
7. Provide ARV prophylaxis (if indicated)
24
What to do immediately upon an exposure to a
possibly HIV infected bodily fluid and/or blood
• If there was a percutaneous exposure:
– Flush the wound with tap water
– Let the wound bleed for a short time
without squeeze
– Clean the wound with soap and water
– Evaluate the need for PEP
25
What to do immediately upon an exposure to a
possibly HIV infected bodily fluid and/or blood
• If there was an eye exposure:
– Wash the eye(s) with water or NaCl 0.9%
solution continuously for 5 minutes
– Evaluate the need for PEP
• If there was a mouth and/or nose
exposure:
– Rinse with water or NaCl 0.9% solution.
– Gargle with NaCl 0.9% solution for several
times.
– Evaluate the need for PEP
26
Evaluating the need for PEP: Assessing the risk
of HIV transmission by occupational exposure
• Risk presents with:
– Deep wounds with large bleeding, caused by
large-bore needles.
– Deep and large percutaneous wounds with
bleeding, caused by scalpels or broken blood
containing tubes.
– Existing lesions, ulcers or scratch on the skin
or mucus membranes (e.g. eye, nose)
exposed to patient's blood or body fluids.
• No Risk if:
– Contact of normal skin with patient’s blood or
body fluid.
27
Additional PEP issues
• Timing – as soon as possible!!!
– Do not delay to obtain additional information on the
source patient
– Best if given within 2 - 6 hours, not recommended
after 72 hours
• Duration of PEP: 4 weeks
28
National Guidelines on PEP
Regimens
Medications
Indications
2 drugs regimen
(basic regimen)
AZT+ 3TC
or d4t + 3TC
All exposures with risk
3 drugs regimen
AZT+ 3TC
or d4t + 3TC
In case the source of
exposure is known
with or suspected of
ARV resistance
Plus: LPV/r
29
National Guidelines on PEP Regimens
• Dosages:
– AZT: 300mg BID PO
– 3TC: 150mg BID PO
– d4T: 30mg BID PO
– LPV/r: 400mg/100mg BID PO
• Nevirapine is not recommended due to fulminant
liver failure in 4 American HCW taking it for PEP.
30
Suggested postexposure
follow-up & testing
• HIV testing of healthcare worker after 1, 3 and 6
months.
• Laboratory tests to monitor ARV side effects:
– Consider CBC, ALT on the start of treatment and
after 4 weeks
• Education and counseling of the healthcare
worker:
– their risk of infection with HIV, HBV, HCV
– symptoms suggestive of ARV toxicity and/or
primary HIV infection
– prevention of secondary transmission: condom
use with their partners
31
Testing the source patient
• Inform the source patient of the incident,
counsel, & test (with consent) for HIV and
hepatitis B and C
– Use a rapid HIV antibody testing if possible
• If source patient found to be HIV negative on
rapid test or, rapid test not done:
– inquire about source patient’s risk factors for HIV
and risk of being in the “window period” of an
acute HIV infection.
32
Testing the source patient
• If source patient is known to be HIV positive:
– define the patients clinical and immunological
stage of HIV infection through a CD4 count
and/or TLC.
– Obtain HIV viral load data, if available
– Obtain information on current and previous
antiretroviral therapy
– Obtain HIV resistance testing results, if done
33
Risk of seroconversion after
percutaneous occupational
exposure
Virus
Range
Mean
HBV
2 – 40 %
30%
HCV
0–7%
3%
HIV
0.2 – 0.5 %
0.3%
HBV is 100x more transmissible than HIV!
34
Hepatitis B prevention
• The best way to avoid HBV infection is to
vaccinate all health care workers against
Hepatitis B.
• HBV vaccination requires 3 injections at 0,
1 and 6 months.
• This should be encouraged by all
employers in health care settings!
35
TB prevention
• TB is the most common OI in Vietnam.
• In the HIV OPC, a significant percentage of
patients will have TB or on TB treatment at
any one time.
• The waiting area and exam rooms at the
OPC are an environment at high risk for TB
transmission.
36
Five Steps to Prevent Transmission
of TB in HIV Care Settings
Step 1: Screen and test
• Early recognition of patients with suspected
or confirmed TB disease.
• Symptoms that may indicate TB include:
– Cough > 2 weeks, fever, weight loss, night sweats,
lymphadenopathy
• Screen all patients who have any symptoms:
– CXR, sputum BK
– lymph node aspirate (if indicated)
37
Five Steps to Prevent Transmission
of TB in HIV Care Settings
Step 2 : Education
• Instruct patients to wear face masks if
they have active TB or if they are
coughing/sneezing.
38
Five Steps to Prevent Transmission
of TB in HIV Care Settings
Step 3: Separate
• If possible, patients who have active TB
or are TB suspects should wear a mask,
be separated from other patients, and
requested to wait in a separate wellventilated waiting area
39
Five Steps to Prevent Transmission
of TB in HIV Care Settings
Step 4: Provide services quickly
• If possible, triage active TB patients to the
front of the line and quickly provide care to
reduce the amount of time that others are
exposed to them.
40
Five Steps to Prevent Transmission
of TB in HIV Care Settings
Step 5: Environmental Control
• Ventilation
– Natural ventilation relies on open doors and
windows to bring in air from the outside
– Fans may also assist to blow the air out of the
room.
• Prevent active TB in HIV patients : IPT
should be supply for HIV patients meet MOH
criteria
41
Face Masks
• Standard Face Masks
– Prevent TB transmission if worn by the TB patient
– Do not prevent the wearer from acquiring TB
• Special Face Masks: N95 or FFP2
– Protect the wearer
– Only needed in high risk areas:
• spirometry or bronchoscopy rooms, or
• MDRTB treatment centers
WHO Guidelines for the Prevention of Tuberculosis in Health Care Facilities
42
in Resource-Limited Settings
Respirator – has only tiny
pores which block droplet
nuclei and relies on an air tight
seal around the entire edge
Face mask – has large
pores and lacks air tight
seal around edges
43
Key Points
• Universal precautions means treating all blood and
body fluids as if they are infectious.
• The risk of HIV transmission from a single occupational
exposure is 0.3%
• The risk of HBV transmission from a single
occupational exposure is 30%
• PEP in Vietnam is used:
– two drugs (D4T or AZT) + 3TC
are given 4 wks
– or three drugs (D4T or AZT) + 3TC + LPV/r
– NVP should NOT be used for PEP due to high risk for
hepatotoxicity.
• Take steps to prevent TB transmission in the health
care setting.
44
Thank you!
Questions?
45