Universal precations for health care workers

Are we at risk of HIV?

Dr Madhu OswalSAMVAD HIV HELPLINE

Muktaa Charitable Foundation

Procedures we perform in the clinic set-up

- General Examination of patients PV exam, P/A exam, oral cavity- Giving IM injection- Giving IV injection- Drawing blood for lab investigation• Minor Procedures – Catheterization, pap smear, IUD insertion, ascitis fluid tapping, etc. • Minor Surgeries – Suturing, I& D, removing corn,lipoma, taking biopsy, etc.

Procedures we perform in the Hospital set-up

• All as above, plus (all that we do in clinic)- Ryles tube insertion- Plural tapping- CSF tapping- Suction- Intubation

• In operation Theatres- Invasive procedures- Vaginal delivery

Duties your assistant/Nurses/Aaya/mama perform

• Handling bio-medical waste• Cleaning soiled surfaces• Washing soiled linen – clothes, bed

sheets, etc.• Handling vomitus, urine, stools, suction

material• Handling lab specimen – sputum, blood,

urine, etc.• Cleaning toilets, bathrooms, urinals, bed

pan, suction jar, etc.

What Extra-precautions should we take when we deal with HIV

+ve patients?

NONE

Universal precautionsUP means-EVERYONE, EVERYWHERE,ALWAYS,

UP applies to – blood, semen, vaginal secretons, cerebro-spinal fluid, ascitic fluid, pericardial fluid & amniotic fluid

UP does not apply to urine, stools, saliva, tears, sputum, vomitus – if not blood stained or contaminated with blood

How much is the risk?

• HBV- 4%• HCV- 1.8%• HIV - 0.4%

HIV is an very fragile virus. Then why ‘phobia’ about HIV?

5.

Estimated Pathogen-Specific Seroconversion Rate Per Exposure for Occupational Needlestick Injury

AETC http://depts.washington.edu/hivaids

6

AETC http://depts.washington.edu/hivaids

Type of Exposure Involved in Transmission of HIV to Health Care Workers

8

P<0.01 for all associations

0.06-0.520.19Use of Zidovudine for PEP

2.0-165.6Terminally Ill Source Patient

1.7-124.3Device Used in Artery or Vein

2.2-216.2Visibly Bloody Device

6.0-4115Deep Injury

Confidence IntervalOdds RatioRisk Factor

Risk Factors for HIV Transmission with Occupational Exposure to HIV-Infected Blood

UNIVERSAL PRECAUTIONS- 4 components

• Hand Hygiene• Barriers• Care of sharps and needles• Sterilization and disinfection

Hand Washing

Before- Examining patient Removal of glove Before wearing glove

After- Examining a patient Contact potentially contaminated body secretions/excretions, instruments routine surgical scrub After removing glove

Too simple to be important but Most Important

Gloves, apron, goggles, etc

• For protection of HCW from infection from the patient.

• For protection of patient from infection from HCW or other source.

• Be judicious in use of gloves.• Utility gloves, sterile gloves, non-

sterile gloves.

Handling needles and sharps

- Disposable needles- Do not RECAP – 80%- Do not BEND- Do not BREAK- Cut the needle in a puncture resistant

container- Use hands- free technique while

passing ‘sharp’ instruments.

Things/Instruments we need to reuse or dispose off safely

• Decontamination

• Disinfection – removing and reducing some agents of infection

• Sterilization – Killing all organisms including spores

Dis-infection- Cleaning with soap and water- Heat – boiling for a minute kills all

organism. For spores – 20 - Chemical - Sodium Hypochlorle 1%

- Glutaarlderyde 2%(Sterylium) - Ethyl alcohol – 70%

(Hospital spirit) - Chlorhexidine – 3%(Savlon) -Iodine tinc-3%

-Iodophores 7.5-10%(Betadine)

Sterilization

Dry Heat – (Incirinators) – destroy soiled dressings, biomedical, waste, equipments

Autoclave – For equipment which can tolerate heat – clothes, dressing, instruments, apparatus, etc.

Ethylene oxide- Respirator, HL machine

Gamma radiation – Suture material, catheters, gloves, etc.

What to do if one gets a pinprick/exposure?

Do not Panic!!!- Do not squeeze the wound or suck.- Allow the wound to bleed freely. - Wash the puncture site with soap & water- Confirm the serostatus of the source case

If negative – do nothingIf positive – know your sero-status at baseline

- Assess the risk(with the help of an HIV expert)

- Seek for PEP, if necessary with 6 hrs, not later than 72 hrs

Decision-making Tools for PEP

• Source code (SC)– Risk assessment of the source patient– SC 1, SC 2, SC Unknown

• Exposure code (EC)– Risk assessment of exposure type– EC 1, EC 2, EC 3

Step 1: Does This personNeed HIV PEP?

Source patient

HIV +HIV - Unknown / Unwilling to get tested*

PEP

High back-ground risk

Low back-ground risk

No PEP No PEP

*CDC recom: usually PEP unnecessary; consider use if source patient is high risk

HIV Negative HIV Positive

Asymptomatic/high CD4 = HIV SC 1

Advanced disease, primary infection or low

CD4 =HIV SC 2

HIV Status Unknown or Source Unknown

= HIV SC Unknown

No PEP

Step 2: Determine HIV Status Code of Source (HIV SC)

28

Expanded (3 Drugs)Expanded (3 Drugs)More Severe

Expanded (3 Drugs)Basic (2 Drugs)Less Severe

HIV+ Class 2HIV+ Class 1

Source Infection StatusExposure Type

Step 4: Determine PEP Regimen (2)

Less Severe: Solid needle, superficial injury More Severe: Large-bore hollow needle, deep punture,

visible blood on device, or needle used in patient's artery or vein

HIV Class 1: Asymptomatic or HIV RNA less than 1500 copies/ml

HIV Class 2: Symptomatic HIV infection, AIDS, acute seroconversion, or known high HIV RNA

Step 4: Determine PEP Regimen

HIV SC EC PEP Recommendation

1 1 PEP may not be warranted

2 1 Consider basic regimen

1 2 Recommend basic regimen

2 2 Expanded regimen recommended

1 or 2 3 Expanded regimen recommended

Unknown If EC is 2 or 3 and a risk exists, consider PEP basic regimen

29

HIV Post Exposure Prophylaxis

2 drug regimenZidovudine plus lamivudine (combivir)

Stavudine plus Lamivudine

Tenofovir plus lamivudine

3 drug regimenLPV/r or Indinivr or Nelfinavir plus NRTI backbone

Efavirez plus NRTI backbone

Consider resistance potential of source patient

Don’t use NVP (hepatotoxicity)

ARE WE AT RISK?

YESIF WE DISCRIMINATE

THANKS

Contact InfoDr Madhu Oswal9890044477madhu.oswal@mcf.org.in