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Roseann Mulligan DDS, MSRoseann Mulligan DDS, MSUniversity of Southern CaliforniaUniversity of Southern California
Pacific AIDS Education and Training CenterPacific AIDS Education and Training Center
HBV, HCV, and HIV in theHBV, HCV, and HIV in the
Dental Office:Dental Office:Prevention and RecommendationsPrevention and Recommendations
forfor
Postexposure Prophylaxis (PEP)Postexposure Prophylaxis (PEP)
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Preventing Transmission ofPreventing Transmission of
Bloodborne Viruses inBloodborne Viruses inHealthcare SettingsHealthcare Settings
Promote HB VaccinationsPromote HB Vaccinations Treat all patients as potentiallyTreat all patients as potentially
infectiousinfectious
Use barriers to prevent blood or bodyUse barriers to prevent blood or bodyfluid contactfluid contact
Prevent percutaneous injuriesPrevent percutaneous injuries
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Annual Number ofAnnual Number ofPercutaneous Injuries*Percutaneous Injuries*
1987199319871993
1987 1988 1989 1990 1991 1992 19930
2
4
6
8
10
12 11.4
8.8
6.25.4
3.52.9
2.2
Num
ber
*ADA Health Screening, per dentist
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Factors Influencing Risk ofFactors Influencing Risk of
Occupational ExposureOccupational Exposure
Consistent usage of engineeringConsistent usage of engineering
controlscontrols
Proper handling and disposal of sharpsProper handling and disposal of sharps Prevalence of infection among patientsPrevalence of infection among patients
Nature and frequency of exposureNature and frequency of exposure
Type of virusType of virus
Body fluid and level of infectivityBody fluid and level of infectivity
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Prevalence of Bloodborne VirusPrevalence of Bloodborne Virus
Infection Varies in PatientInfection Varies in PatientPopulationsPopulations
GeographyGeography Patient risk behaviorsPatient risk behaviors
Type of care or living arrangementType of care or living arrangement
IncarcerationIncarceration Sex workerSex worker
IV Drug userIV Drug user
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Question: The greatest risk ofQuestion: The greatest risk of
transmission of disease occurs:transmission of disease occurs:
A.A. From the dental healthcare worker toFrom the dental healthcare worker to
the patient.the patient.B.B. From the patient to the dentalFrom the patient to the dental
healthcare worker.healthcare worker.
C.C. From one patient to another patient.From one patient to another patient.D.D. All transmission routes have the sameAll transmission routes have the same
risk.risk.
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Potential Routes ofPotential Routes of
Transmission of BloodborneTransmission of Bloodborne
PathogensPathogens
Patient DHCP
DHCP Patient
Patient Patient
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Transmission of HBV fromTransmission of HBV from
Infected Dentists to PatientsInfected Dentists to Patients Nine clusters of HBV transmissionNine clusters of HBV transmission
from infected dentists and oralfrom infected dentists and oralsurgeons to patients weresurgeons to patients weredocumented between 1970 1987documented between 1970 1987
Lack of documented transmissionsLack of documented transmissionssince 1987since 1987 may reflect increased use of glovesmay reflect increased use of gloves
and hepatitis B vaccinationand hepatitis B vaccination
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Estimated Incidence of HBV InfectionsEstimated Incidence of HBV Infections
Among HCW and General Population,Among HCW and General Population,
United States, 1985-1999United States, 1985-1999
0
50
100
150
200
250
300
350
1985 1987 1989 1991 1993 1995 1997 1999
Year
Incid
ence
per100,000
Health Care Workers
General U.S. Population
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Average Risk of Bloodborne VirusAverage Risk of Bloodborne Virus
Transmission after NeedlestickTransmission after Needlestick
Source Risk
HBVHBsAg+ and HBeAg+ 22 %-31 % clinical hepatitis;
37%-62% serological evidence ofHBV infection
HBsAg+ and HBeAg- 1%-6 % clinical hepatitis;
23% - 37% serological evidence ofHBV infection
HCV 1.8% (0%-7% range)
HIV 0.3% (0.2%-0.5% range)
DC http://www.cdc.gov/OralHealth/infectioncontrol/guidelines/ppt.htm
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1313CDC http://www.cdc.gov/OralHealth/infectioncontrol/guidelines/ppt.htm
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Characteristics ofCharacteristics of
Percutaneous Injuries AmongPercutaneous Injuries Among
DHCPDHCP Reported frequency among generalReported frequency among general
dentists has declineddentists has declined Caused by burs, syringe needles, otherCaused by burs, syringe needles, other
sharpssharps Occur outside the patients mouthOccur outside the patients mouth
Involve small amounts of bloodInvolve small amounts of blood Among oral surgeons, occur moreAmong oral surgeons, occur more
frequently during fracture reductions andfrequently during fracture reductions andprocedures involving wireprocedures involving wire
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Wound CareWound Care
Clean wounds withClean wounds withsoap and watersoap and water
Do not squeezeDo not squeeze Flush mucousFlush mucous
membranes with watermembranes with water Avoid use of bleachAvoid use of bleach
and other agentsand other agentscaustic to skincaustic to skin
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Occupational Exposure to HBVOccupational Exposure to HBV
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Hepatitis B VaccineHepatitis B Vaccine
The vaccine consist of a series of 3 doses via IMThe vaccine consist of a series of 3 doses via IM
injection into the deltoid muscle of the arm.injection into the deltoid muscle of the arm.
Dose # 1 is time zeroDose # 1 is time zero
Dose # 2 given one month after dose #1Dose # 2 given one month after dose #1 Dose # 3 is given 6 months after dose #1Dose # 3 is given 6 months after dose #1
A QUANTITATIVE TITER IS DUE 30-60 DAYSA QUANTITATIVE TITER IS DUE 30-60 DAYS
AFTER THE LAST DOSEAFTER THE LAST DOSE
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Antibody (titer) level determines effectiveness.Antibody (titer) level determines effectiveness.
Titer level 10 or less - entire series needsTiter level 10 or less - entire series needs
repeating (all 3 doses)repeating (all 3 doses) After the second series, titer less than 10, theAfter the second series, titer less than 10, the
person is considered to be a primaryperson is considered to be a primary
nonrespondernonresponder
Nonresponder will need the HBIG if aNonresponder will need the HBIG if a
contaminated puncture/body fluid exposure.contaminated puncture/body fluid exposure.
Hepatitis BHepatitis B
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Hepatitis D depends on Hepatitis B forHepatitis D depends on Hepatitis B for
propagation/transmission.propagation/transmission.
Hepatitis D infections usually injectionHepatitis D infections usually injection
drug users and hemophiliacsdrug users and hemophiliacs
Immunization with HBV vaccine confersImmunization with HBV vaccine confers
immunity to HDVimmunity to HDV
Hepatitis DHepatitis D
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RecommendationsRecommendations
Hepatitis B VaccineHepatitis B Vaccine
Offer vaccination to all personnel who are atOffer vaccination to all personnel who are at
risk of exposure to bloodrisk of exposure to bloodProvide access to qualified health-careProvide access to qualified health-care
professional for administration and follow-upprofessional for administration and follow-up
testingtesting
No need for pre-vaccination testingNo need for pre-vaccination testingfor HBVfor HBV
antibodiesantibodies
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Immunizations for DentalImmunizations for Dental
Healthcare WorkersHealthcare Workers
Hepatitis B vaccineHepatitis B vaccine
must be offered at nomust be offered at no
charge to employeescharge to employeeswho may be exposedwho may be exposed
to body fluids withinto body fluids within
10 days of the10 days of the
potential initialpotential initialexposure. They doexposure. They do
have the right tohave the right to
refuse.refuse.
If the employeeIf the employee
refuses the vaccine,refuses the vaccine,
they must sign thethey must sign theOSHA BloodborneOSHA Bloodborne
Pathogens StandardPathogens Standard
(29 CFR 1910.1030)(29 CFR 1910.1030)
Hepatitis B VaccineHepatitis B VaccineDeclination form.Declination form.
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Hepatitis B Vaccine DeclinationHepatitis B Vaccine Declination
(Mandatory) - 1910.1030 App A(Mandatory) - 1910.1030 App AI understand that due to my occupational exposure to blood orI understand that due to my occupational exposure to blood orother potentially infectious materials I may be at risk ofother potentially infectious materials I may be at risk ofacquiring hepatitis B virus (HBV) infection. I have been givenacquiring hepatitis B virus (HBV) infection. I have been giventhe opportunity to be vaccinated with hepatitis B vaccine, at nothe opportunity to be vaccinated with hepatitis B vaccine, at nocharge to myself. However, I decline hepatitis B vaccination atcharge to myself. However, I decline hepatitis B vaccination at
this time. I understand that by declining this vaccine, I continuethis time. I understand that by declining this vaccine, I continueto be at risk of acquiring hepatitis B, a serious disease. If in theto be at risk of acquiring hepatitis B, a serious disease. If in thefuture I continue to have occupational exposure to blood orfuture I continue to have occupational exposure to blood orother potentially infectious materials and I want to beother potentially infectious materials and I want to bevaccinated with hepatitis B vaccine, I can receive thevaccinated with hepatitis B vaccine, I can receive the
vaccination series at no charge to me.vaccination series at no charge to me.
[56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717,[56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717,April 13, 1992; 57 FR 29206, July 1, 1992; 61 FR 5507, Feb.April 13, 1992; 57 FR 29206, July 1, 1992; 61 FR 5507, Feb.13, 1996]13, 1996]
http://www.osha.gov/pls/oshaweb/owadisp.show_documehttp://www.osha.gov/pls/oshaweb/owadisp.show_docume
nt?p_table=STANDARDS&p_id=10052nt?p_table=STANDARDS&p_id=10052
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Occupational Exposure to HCVOccupational Exposure to HCV
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Hepatitis C - transmitted like HBV.Hepatitis C - transmitted like HBV. Chances of infection following an exposure 10Chances of infection following an exposure 10
times higher for HBVtimes higher for HBV
HCV - RNA virus with at least 6 differentHCV - RNA virus with at least 6 differentgenotypes and 90+ subtypes.genotypes and 90+ subtypes.
U.S. - Most common genotype is type 1 -U.S. - Most common genotype is type 1 -accounts for ~70% of Hepatitis C infectionsaccounts for ~70% of Hepatitis C infections
No vaccine available for Hepatitis CNo vaccine available for Hepatitis C Genotype 1 responds least favorably to alphaGenotype 1 responds least favorably to alpha
interferon and ribavirin treatments.interferon and ribavirin treatments.
Hepatitis CHepatitis C
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Reported Cases of Acute Hepatitis C byReported Cases of Acute Hepatitis C bySelected Risk Factors, United States,Selected Risk Factors, United States,
1982-2001*1982-2001*
0
1 0
2 0
3 0
4 0
5 0
6 0
7 0
8 0
1 9 82 1 9 84 1 9 86 1 9 88 1 9 90 1 9 92 1 9 94 1 9 96 1 9 98 2 0 00 2 0 01
Y e a r
PercentageofCa
ses
Injecting drug use
Sexual
Health related workTransfusion
* 1982-1990 based on non-A, non-B hepatitis
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HCV Infection in DentistryHCV Infection in Dentistry
Frequency of HCV infection among dentistsFrequency of HCV infection among dentistssimilar to that of general population (~ 1-2%)similar to that of general population (~ 1-2%)
No reports of an HCV transmission fromNo reports of an HCV transmission from
infected dental personnel to patientsinfected dental personnel to patients No reports of patient-to-patient transmissionNo reports of patient-to-patient transmission
of HCVof HCV
Risk of HCV transmission is very lowRisk of HCV transmission is very low
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Occupational Exposure to HIVOccupational Exposure to HIV
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(*) 3 dentists, 1 oral surgeon, 2 assistants
*
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Source: Cardo, et al., N England J Medicine 1997;337:1485-90.
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Assessment of Infection RiskAssessment of Infection Risk Source evaluationSource evaluation
Presence of HBsAgPresence of HBsAg
Presence of HBeAgPresence of HBeAg
Presence of HCV antibodyPresence of HCV antibody
Presence of HIV antibodyPresence of HIV antibody
If source unknown, assess epidemiologic evidenceIf source unknown, assess epidemiologic evidence
Susceptibility of the exposed personSusceptibility of the exposed person
Immunity to HBV infection?Immunity to HBV infection?
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Exposure Prevention MethodsExposure Prevention Methods
Standard/Universal PrecautioStandard/Universal Precaution
Engineering controlsEngineering controls
Work place practicesWork place practices
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Post-Exposure ManagementPost-Exposure Management
OSHA requires post exposure protocols to be inOSHA requires post exposure protocols to be in
placeplace
Physician providing counseling , medication, andPhysician providing counseling , medication, and
follow up care.follow up care.
At USC we test for : HBV, HCV, HIV, andAt USC we test for : HBV, HCV, HIV, and
VDRL (syphilis)VDRL (syphilis)
USC protocol states to report the injury within 2-USC protocol states to report the injury within 2-
4 hours of sustaining the injury.4 hours of sustaining the injury. Can only ask source patient to be tested onceCan only ask source patient to be tested once
Post Exposure ManagementPost Exposure Management
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p gp g
ProtocolProtocol
An exampleAn example All exposed faculty, staff and students are testedAll exposed faculty, staff and students are tested
atat 1 month, 3 months and 6 months1 month, 3 months and 6 months from the date offrom the date of
exposureexposure
Employer pays forEmployer pays for all medical exams and blood tests for all employeesall medical exams and blood tests for all employees
and students.and students.
exam and test for source patient if he/she agrees toexam and test for source patient if he/she agrees to
be testedbe tested HBIG and any antiviral medication(s) recommendedHBIG and any antiviral medication(s) recommended
and agreed to.and agreed to.
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HIV Post Exposure TreatmentHIV Post Exposure Treatment
Considers:Considers:
the type of injurythe type of injury
the severity of thethe severity of the
injuryinjury
the infection status ofthe infection status of
the sourcethe source
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Standard PrecautionsStandard Precautions
Apply toApply to allall patientspatients
Expand Universal Precautions to includeExpand Universal Precautions to include
organisms spread by other body fluidsorganisms spread by other body fluids
Apply toApply to
Blood and body fluids, except sweatBlood and body fluids, except sweat
Non-intact skinNon-intact skin
Mucous membranesMucous membranes
Postexposure ManagementPostexposure Management
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Postexposure ManagementPostexposure Management
ProgramProgram
Clear policies/proceduresClear policies/procedures
Education of healthcare personnel (HCP)Education of healthcare personnel (HCP)
Rapid access toRapid access to
Clinical careClinical care
Postexposure prophylaxis (PEP)Postexposure prophylaxis (PEP)
Testing of source patients/HCPTesting of source patients/HCP
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WarmlineNational HIV Telephone ConsultationService
1-800-933-3413
PEPlineNational Clinicians' Post-ExposureProphylaxis Hotline
1-888-HIV-4911
Perinatal HIV HotlineNational Perinatal HIV Consultation andReferral Service
1-888-448-8765
National HIV/AIDSClinician Consultation Center
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www.cdc.gov/oralwww.cdc.gov/oral
healthhealth