Management of Management of Occupational Exposure Occupational Exposure

to BBVto BBV

Dr. Faisal Al HadadConsultant of Family Medicine & Occupational HealthABFM, SBFM, MSc Occupational Health (UK)Incharge of Occupational HealthPSMMC

OutlineOutline

Primary Prevention of Blood-borne infections

Management of exposure to blood or body fluid

Management of exposure to blood or body fluid infected with BBV

Employment Implications of blood-borne infections

Primary Prevention of Blood-Primary Prevention of Blood-borne Infectionsborne Infections

Vaccination

Standard Precautions:1)Hand hygiene 2)Use of personal protective equipment (e.g.,

gloves) 3)Safe injection practices 4)Safe handling of potentially contaminated

equipment or surfaces in the patient environment

5)Respiratory hygiene/cough etiquette.

Hepatitis B VaccinationHepatitis B Vaccination

Any person who performs tasks involving contact with blood, blood-contaminated body fluids, other body fluids, or sharps should be vaccinated against hepatitis B.

HCP who have contact with patients or blood and are at ongoing risk for percutaneous injuries should be tested 1–2 months after completion of the 3-dose vaccination series for anti-HBs

Booster doses of hepatitis B vaccine are not necessary, and periodic serologic testing to monitor antibody concentrations after completion of the vaccine series is not recommended.

Hepatitis B VaccinationHepatitis B Vaccination

Non-responders to vaccination who are HBsAg-negative:

- Considered susceptible to HBV infection - Should be counseled regarding precautions to

prevent HBV infection - Should obtain HBIG prophylaxis for any known or

probable parenteral exposure to HBsAg-positive blood.

Case StudyCase Study

Nora is a 35 year-old Registered Nurse experienced a needle-stick injury during night shift.

What is the risk of HBV, HCV and HIV transmission?

What should Nora do in respect to this event?

Risk of HBV, HCV and HIV Risk of HBV, HCV and HIV Transmission after Occupational Transmission after Occupational Percutaneous ExposurePercutaneous Exposure

• HBV risk varies depending on e-antigen status of source person

– If e-antigen positive, risk is up to 30%– If e-antigen negative, risk is 1-6%

• HCV risk is 1.8% (range of 0 - 7%)

• HIV risk is 0.3% (range of 0.2 - 0.5%)

Management of Management of Occupational Exposure to Occupational Exposure to Blood or Body fluidBlood or Body fluidTreatment of exposure site : wash exposure site

with water ± soap. No evidence exists that using antiseptics or squeezing the wound reduces the risk of BBV transmission.

Inform supervisor about the incident

Complete the exposure incident report

Report the incident to Preventive Medicine during working hours and the A/E out of working hours.

Exposure Incident Exposure Incident ReportReport

Date and time of exposure

Details of the procedure being performed including where and how the exposure occurred.

Details of the exposure including type and amount of fluid and the severity of exposure (e.g. depth of injury, whether fluid was injected, skin integrity)

Details about the exposure source - Infectious status - Stage of the disease, HX of antiretroviral therapy and viral

load if the source is HIV-infected, Details about the exposed person (Hepatitis B vaccination and

vaccine response status) Details about counseling, post-exposure management, and

follow-up.

Management of Exposure in Management of Exposure in Preventive MedicinePreventive Medicine

Reviewing the exposure incident report

Evaluation of the exposure incident

Evaluation of the exposure source

Baseline screening of the exposed person for BBV

Follow up testing of the exposed person

Post-exposure prophylaxis

Counseling

Evaluation of the Exposure Evaluation of the Exposure IncidentIncidentFactors to consider in assessing the need for follow up

ofoccupational exposures:

Type of body substance: - Blood - Fluids containing blood - Potentially infectious fluid or tissue (semen; vaginal secretions; and

cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids) - Direct contact with concentrated virus

Route of exposure: - Percutaneous injury - Mucous membrane exposure - Nonintact skin exposure - Bites resulting in blood exposure

Amount of exposure

Evaluation of the Exposure Evaluation of the Exposure SourceSource

The person whose blood or body fluid is the source of an occupational exposure should be evaluated for BBV infection.

Information available in the medical record at the time of exposure or from the source person, might confirm or exclude BBV infection.

If the infectious status of the source is unknown, the source person should be informed of the incident and tested for serologic evidence of BBV infection.

Informed consent must be obtained and confidentiality of the source person should be maintained at all times.

Evaluation of the Exposure Evaluation of the Exposure SourceSourceKnown exposure source

Test known sources for HBsAg, anti-HCV, and HIV antibody

Direct virus assays (e.g. tests for HIV RNA or HCV RNA) for routine screening of source patients are not recommended

For sources whose infection status remains unknown, consider medical diagnoses, clinical symptoms, and history of risk behaviors

Do not test discarded needles for bloodborne pathogens

Unknown exposure source

Evaluate the likelihood of exposure to a source at high risk for infection

Management of Exposure to Management of Exposure to HBVHBV

Baseline screening of exposed person for HBV (HBsAg) and immune status (anti-HBs).

Follow up testing if exposed person is not immune at

time of exposure:

- LFT at 6 weeks and 12 weeks

- HbsAg 12 weeks and 6 months

If exposed person is immune at time of exposure, follow-up for Hepatitis B is not indicated.

Post-exposure prophylaxis if indicated

Management of Exposure to Management of Exposure to HBVHBV

Management of Exposure to Management of Exposure to HCVHCV

For the person exposed to an HCV-positive source: - Perform baseline testing for anti-HCV and ALT activity - Perform follow-up testing (e.g., at 4–6 months) for anti-HCV

and ALT activity. If earlier diagnosis is desired, testing for HCV RNA may be performed at 4–6 weeks.

If the source person is not infected with HCV, baseline testing or further follow-up of the exposed person is not necessary.

Confirm all anti-HCV results reported positive by enzyme immunoassay using supplemental anti-HCV testing (e.g. RIBA)

IG and antiviral agents are not recommended for PEP after exposure to HCV-positive blood.

Management of Exposure to Management of Exposure to HIVHIV HCP exposed to HIV should be evaluated within

hours after their exposure and should be tested for HIV at baseline.

HIV-antibody testing should be performed for at least 6 months postexposure.

If the source person is seronegative for HIV, baseline testing or further follow-up of the exposed person normally is not necessary.

HIV testing should be performed on any exposed person who has an illness compatible with an acute retroviral syndrome.

Management of Exposure to HIV

Management of Exposure to HIV

HIV Post-exposure ProphylaxisHIV Post-exposure Prophylaxis

If indicated, start PEP as soon as possible after an exposure.

Reevaluation of the exposed person should be considered within 72 hours postexposure, especially as additional information about the exposure or source person becomes available.

Administer PEP for 4 weeks, if tolerated.

If a source person is determined to be HIV-negative, PEP should be discontinued.

Preferred Basic & Expanded Preferred Basic & Expanded RegimenRegimen

Basic 2-drugs PEP - Zidovudine + lamivudine - Tenofovir DF + emtricitabine

Expanded 3-drugs PEP Basic regimen plus Lopinavir/ritonavir

Counseling for HCP Exposed to Counseling for HCP Exposed to HBV- or HCV-infected bloodHBV- or HCV-infected blood

Do not need to take any special precautions to prevent secondary transmission during the follow-up period.

The exposed person does not need to modify sexual practices or refrain from becoming pregnant.

If an exposed woman is breast feeding, she does not need to discontinue.

They should refrain from donating blood, plasma, organs, tissue, or semen.

Counseling for HCP Exposed to Counseling for HCP Exposed to HIV infected bloodHIV infected blood

Exposed HCP should be advised to use precautions to prevent secondary transmission during the follow-up period:

- Exercise sexual abstinence or use condoms to prevent sexual transmission and to avoid pregnancy

- Refrain from donating blood, plasma, organs, tissue, or semen.

- If an exposed woman is breast feeding, discontinuation of breast feeding should be considered. 

For exposures for which PEP is prescribed, HCP should be informed about possible drug toxicities and the need for monitoring, and possible drug interactions.

Exposed HCP should be advised to seek medical evaluation for any acute illness suggestive of HIV infection during the follow-up period.

 

Employment Implications of Employment Implications of Blood-borne Infection in RMHBlood-borne Infection in RMH

Those who are anti HCV+ve and PCR+ve should be transferred to a non-high risk area.

Those who are anti HCV+ve but PCR-ve can continue their work since they are not dangerous .

Those who are PCR-ve for two (2) consecutive tests, one month apart, are considered free from Hepatitis C

Those who received treatment for Hepatitis C and declared cured with PCR-ve for six (6) months from stopping the treatment are considered free from Hepatitis C.

Employment Implications of Employment Implications of Blood-borne Infection in RMHBlood-borne Infection in RMH

Employees with positive HBsAg

If PCR is positive and viral load is more than 100,000 copies/ml the employee should be prohibited from work in high-risk area and transferred to a non-high risk area.

If PCR is negative or viral load is less than 100,000 copies/ml twice one (1) month apart, the employee can continue working in high-risk area, but should be followed up by PCR yearly.

Employees with positive HIV

Staffs who are HIV positive should be dealt with according to the Government/RMH Policy .

THANK YOU

QUESTIONS?