DR.T.V.RAO MD 1
Dr.T.V.Rao MD
OCCUPATIONAL EXPOSURE
& POST-EXPOSURE PROPHYLAXIS
DR.T.V.RAO MD 2
• This presentation is designed to assist with the training of staff on sharps
management including safety devices• The drug regime should be followed according to the best available options
in resource poor circumstances.
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WHAT IS OCCUPATIONAL EXPOSURE
• Occupational exposure refers to exposure to potential blood-borne infections (HIV, HBV and HCV) that may occur in healthcare settings during performance of job duties. Post exposure prophylaxis (PEP) refers to comprehensive medical management to minimize the risk of infection among Health Care Personnel (HCP) following potential exposure to blood-borne pathogens (HIV, HBV, HCV)
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• All Health Care Personnel, including emergency care providers, laboratory personnel, autopsy personnel, hospital employees, interns and medical students, nursing staff and students, physicians, surgeons, dentists, labour and delivery room personnel, laboratory technicians, health facility sanitary staff and clinical waste handlers and health care professionals at all levels
WHO ARE AT RISK
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WHAT ARE “SHARPS”?Sharps are devices that are intentionally sharp to puncture or cut skin (needles, scalpels, etc.), or become sharp due to accident, such as broken glass tubes.
• Hypodermic needles
• Scalpels
• IV devices
• Capillary tubes
• Glass containers
• Pipettes
• Others
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• Hypodermic needles
• Blood collection needles
• Suture needles
• Needles used in IV delivery systems
• Scalpels
WHAT KIND OF DEVICES USUALLY CAUSE SHARPS INJURIES?
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HOW COMMON ARE SHARPS INJURIES?
• Estimates indicate that 600,000 to 800,000 needle stick injuries occur each year.
• Unfortunately, about half of these injuries are not reported.
• ALWAYS REPORT sharps injuries to your employer to ensure that you receive appropriate follow-up care.
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SHARPS MANAGEMENT• What is an occupational exposure?
• A blood or body fluid exposure that occurs as a consequence of a work-related activity
• There are two types of blood and body fluid exposure:
• Percutaneous exposure (penetrates the skin) e.g. needle stick injury (NSI) or cut with a sharp object such as a scalpel blade
• Non-percutaneous or Mucocutaneous exposure (contact of mucous membrane or non-intact skin with blood or body fluids) e.g. blood splash to the eye
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INCREASING THE RISK OF SHARPS INJURIES
Past studies show sharps injuries are often associated with these activities:
• Recapping needles or other devices
• Transferring a body fluid between containers
• Failing to dispose of used needles or other devices properly in puncture-resistant sharps containers
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WHO ARE AT RISK• Health Care Personnel are at risk of blood-borne
infection transmission through exposure of a percutaneous injury (e.g. needle-stick or cut with a sharp instrument), contact with the mucous membranes of the eye or mouth of an infected person, contact with non-intact skin (particularly when the exposed skin is chapped, abraded, or afflicted with dermatitis or contact with blood or other potentially infectious body fluids. potentially infectious body fluids
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• Report all needle stick and sharps-related injuries promptly to ensure that you receive appropriate follow-up care.
• Tell your employer about any sharps hazards you observe.
• Participate in training related to infection prevention.
• Get a Hepatitis B vaccination.
PROTECTING YOURSELF
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SHARPS MANAGEMENT
• Who is at risk of an occupational exposure?
• All healthcare workers who have the potential for exposure to infectious materials (e.g. blood, tissue, and specific body fluids, as well as medical supplies, equipment or environmental surfaces contaminated with these substances) e.g:
• Nurses
• Doctors
• Laboratory staff
• Technicians
• Therapists
• Support personnel e.g. housekeeping, maintenance
• Dental staff
• Contractual staff
• Students
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• Needles should not be recapped, bent or broken by hand, removed from disposable syringes or otherwise manipulated by hand.
SHARPS MANAGEMENT -GENERAL PRINCIPLES
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WHAT INFECTIONS CAN BE CAUSED BY SHARPS INJURIES?
Sharps injuries can expose workers to a number of blood borne pathogens that can cause serious or fatal infections. The pathogens that pose the most serious health risks are• Hepatitis B virus (HBV)
• Hepatitis C virus (HCV)
• Human immunodeficiency virus (HIV)
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• The average risk of acquiring HIV infection from different types of occupational exposure is low compared to risk of infection with HBV or HCV. In terms of occupational exposure the important routes are needle stick exposure (0.3% risk for HIV, 9–30% for HBV and 1–10% for HCV) and mucous membrane exposure (0.09% for HIV).
RISK OF ACQUIRING INFECTION
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WHICH FLUIDS ARE POTENTIALLY INFECTIOUS FOR HIV?
• blood?
• saliva?
• sweat?
• feces?
• spinal fluid?
• pleural fluid?
• pus?
• urine?
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WHICH FLUIDS ARE POTENTIALLY INFECTIOUS FOR HIV?
• blood
• saliva
• sweat
• feces
• spinal fluid
• pleural fluid
• pus
• urine
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NEEDLE STICK AND SHARPS INJURIES
Procedures for Effectively Handling Sharps Injuries
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HIV PEP• Exposures common• 56 documented
cases of health care workers contracting HIV from exposures; 138 other possible cases
• Area of considerable concern but little data
MMWR June 29, 2001 / 50(RR11);1-42
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• Pooled analysis of prospective studies on health care workers with occupational exposures suggests risk is approximately 0.3% (95% CI, 0.2% - 0.5%)1
• Presence or absence of key risk factors may influence this risk in individual exposures
RISK OF HIV TRANSMISSION FOLLOWING PERCUTANEOUS (NEEDLE STICK) EXPOSURE
1. Bell DM. Am J Med 1997;102(suppl 5B):9-15.
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ASSESS EXPOSED INDIVIDUAL
• The exposed individual should have confidential counseling and assessment by an experienced physician. Exposed individuals who are known or discovered to be HIV positive should not receive PEP. They should be offered counseling and information on prevention of transmission and referred to clinical and laboratory assessment to determine eligibility for antiretroviral therapy (ART). Besides the medical assessment,counselling exposed HCP is essential to allay fear and start PEP.
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IMMEDIATE MEASURES• Percutaneous:
• wash needle sticks and cuts with soap and water
• remove foreign materials
• Non-intact skin exposure:• wash with soap and water or antiseptic
• Mucous membrane• flush splashes to the nose, mouth or skin with water
• irrigate eyes with clean water, sterile saline or sterile irrigants
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• Exposed persons (clients) should receive appropriate information about what PEP is about and the risk and benefits of PEP in order to provide informed consent for taking PEP. It should be clear that PEP is not mandatory.
COUNSELLING FOR PEP
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• Many people feel anxious after exposure. Every exposed person needs to be informed about the risks, and the measures that can be taken. This will help to relieve part of the anxiety. Some clients may require further specialized psychological support.
PSYCHOLOGICAL SUPPORT
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• Documentation of exposure is essential. Special leave from work should be considered initially for a period of two weeks. Subsequently, it can be extended based on the assessment of the exposed person’s mental state, side effects and requirements.
DOCUMENT EXPOSURE
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PRACTICAL APPLICATION IN THE CLINICAL SETTINGS
• For prophylactic treatment the exposed person must sign consent form.
• · Informed consent also means that if the exposed person has been advised PEP, but refuses to start it, this needs to be recorded. This document should be kept by the designated officer for PEP.
• · An information sheet covering the PEP and the biological follow-up after any AEB must be given to the person under treatment. However, this sheet cannot replace verbal explanations.
•
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SHARPS MANAGEMENT -GENERAL PRINCIPLES
• Policies and procedures including NSI management • Standard Precautions including personal protective equipment (PPE)• Hepatitis B vaccination• Education programs• Modifications to work practices including alternatives to using needles• Safe handling of sharps • Sharps disposal systems i.e. puncture-resistant containers• Injury prevention features/safety devices
• Active
• Passive
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Deciding on PEP regimen
There are two types of regimens:
Basic regimen: 2-drug combination
Expanded regimen: 3-drug combination
• The decision to initiate the type of regimen depends on the type of exposure and HIV serostatus of the source person.
PRESCRIBE PEP
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OUTCOMES OF HIV EXPOSURES
• No infection
• Aborted infection
• Acute infection
no immune memory
cellular immune response
seroconversion
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• Because post-exposure prophylaxis (PEP) has its greatest effect if begun within two hours of exposure, it is essential to act immediately. The prophylaxis needs to be continued for four weeks. Exposure must be immediately reported to designated authority and therapy administered. Never delay start of therapy due to debate over regimen. Begin with basic 2-drug regimen, and once expert advice is obtained, change as required.
•
HIV CHEMOPROPHYLAXIS
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PEP REGIMENS: BASIC REGIMENS• Two NRTIs • Simple dosing, fewer side effects• Preferred basic regimens:
Zidovudine (AZT) OR tenofovir (TDF) plus lamivudine (3TC) OR emtricitabine (FTC)
• Alternative basic regimens:stavudine (d4T) OR didanosine (ddI)
pluslamivudine (3TC) OR emtricitabine (FTC)
MMWR 2005;54(No. RR-9).
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• Basic regimen plus a third agent
• Rationale: 3 drugs may be more effective than 2 drugs, though direct evidence is lacking
• Consider for more serious exposures or if resistance in the source patient is suspected
• Adherence more difficult
• More potential for toxicity
EXPANDED PEP REGIMENS
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EXPANDED PEP REGIMENS• Preferred Expanded Regimen:
• Basic regimen plus lopinavir/ritonavir (Kaletra)
• Alternate Expanded Regimens:
• Basic regimen plus one of the following:
• Atazanavir* +/- ritonavir
• Fosamprenavir +/- ritonavir
• Indinavir +/- ritonavir
• Saquinavir (hgc; Invirase) + ritonavir
• Nelfinavir
• Efavirenz
MMWR 2005;54(RR-9)*Atazanavir requires ritonavir boosting if used with tenofovir
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• Delay in reporting exposure (> 72 hours).
• · Unknown source
• · Known or suspected pregnancy, but initiate PEP
• · Breastfeeding mothers, but initiate PEP
• · Source patient is on ART
• · Major toxicity of PEP regimen.
SEEK EXPERT OPINION IN CASE OF
TOLERABILITY OF HIV PEP IN HEALTH CARE WORKERS
0
1020
30
4050
6070
80
90100
Nausea Fatigue Headache Vomiting Diarrhea Myalgias
Per
cen
t of
HC
Ws
Wang SA. Infect Control Hosp Epidemiol 2000;231:780-5.
Incidence of Common Side Effects
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CDC POST-EXPOSURE PROPHYLAXIS GUIDELINES
MMWR 2005;54(No. RR-9).http://www.aidsinfo.nih.gov
DR.T.V.RAO MD 37MMWR 2005;54(No. RR-9).
CDC POST-EXPOSURE PROPHYLAXIS GUIDELINES
DR.T.V.RAO MD 38MMWR 2005;54(No. RR-9).
CDC Post-Exposure Prophylaxis Guidelines
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• CDC recommendations: HIV Ab testing for 6 months post-exposure (e.g., at 6 weeks, 3 months, 6 months)
• Extended HIV Ab testing at 12 months is recommended if health care worker contracts HCV from a source patient co-infected with HIV and HCV
• VL testing not recommended unless primary HIV infection (PHI) suspected
FOLLOW-UP HIV TESTING
MMWR 2005;54(No. RR-9).
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INSTITUTIONAL PROCEDURES
• HAVE A PLAN for immediate evaluation of employees
• HAVE A PLAN for financial provision of PEP
• HAVE A PLAN to protect employee confidentiality about exposure, treatment and test results
• Review and Update annually
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• For the unimmunized:• prophylactic
HBIG
• initiate the vaccine series
RECOMMENDATIONS HEPATITIS B
DR.T.V.RAO MD
DR.T.V.RAO MD 42
GENERAL PRINCIPLES IN HEPATITIS B
VACCINATION
• Hepatitis B Vaccination
• A primary course of hepatitis B vaccinations over six months
• Mandatory for all staff in contact with patients and patient-contaminated material
• Titre level (HBsAb) four to six weeks after last dose
• Booster doses not required if titre level >10 mIU/mL
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PROTECTING YOURSELF FROM NEEDLE STICK INJURIES
A SELF RESPONSIBILITY ???
• Avoid the use of needles where safe alternatives are available.
• Help your employer select and evaluate devices with safety features that reduce the risk of injury.
• Use devices with safety features provided by your employer.
• Do not recap needles or scalpels.
• Plan for safe handling and disposal of sharps before using them.
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RECOMMENDATIONS HEPATITIS C
• No effective prophylaxis
• Immunoglobulin and antiviral agents are NOT recommended
• Determine status of source
• Establish baseline serology and serum ALT of employee and repeat testing at 4-6 months post-exposure
• Early treatment if infection occurs
• Refer to Hepatologist
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• CDC guidelines: follow-up HCV Ab and ALT at 4-6 months1
• Consider periodic HCV RNA screening (monthly?) if earlier detection desired
• Note that unlike acute HIV infection, most patients are not symptomatic with acute HCV infection2
HEPATITIS C: FOLLOW-UP TESTING
1. MMWR June 29, 2001 / 50(RR11);1-42.2. Mandell: Principles and Practice of Infectious Diseases, 5th ed., p. 1279.
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MAJOR REFERENCES • MMWR reviews
• CDC guidelines • Post-Exposure Prophylaxis
an evidence-based review Christopher Behrens, MD Hillary Liss, MD Northwest AIDS Education & Training Center University of Washington
• NACO guidelines on Post exposure prophylaxis
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• Programme created by Dr.T.V.Rao MD for Medical and Paramedical Professionals in
the Developing world.• Email
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