Health-care Exposure Health-care Exposure to Hepatitis & HIVto Hepatitis & HIV

DR. ABDULRAHMAN LOTFYDR. ABDULRAHMAN LOTFYPREVENTIVE MEDICINE -- JAHRAPREVENTIVE MEDICINE -- JAHRA HOSPITALHOSPITAL

13 September 200513 September 2005

Health-Care Personnel

persons whose activities involve contact with patients or with blood or other body fluids from patients in a health-care, laboratory, or public-safety setting.

EXPOSURE EXPOSURE

a percutaneous injury (e.g., a needle stick or cut with a sharp object) or contact of mucous membrane or non intact skin (e.g., exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious

POTENTIALLY POTENTIALLY INFECTIOUS SECRETIONSINFECTIOUS SECRETIONS

, semen and vaginal secretions also are considered potentially infectious. Although semen and vaginal secretions have been implicated in the sexual transmission of HBV, HCV, and HIV, they have not been implicated in occupational transmission from patients to HCP.

The following fluids also are considered

potentially infectious: – cerebrospinal fluid, synovial fluid, pleural fluid,

peritoneal fluid, pericardial fluid, and amniotic fluid. But the risk for transmission of HBV,HCV, and HIV infection from these fluids is unknown;

HEPATITIS B HEPATITIS B OCCUPATIONAL HAZARDOCCUPATIONAL HAZARD

HEPATITIS BHEPATITIS B

MOST COMMON INFECTIOUS MOST COMMON INFECTIOUS HAZARD FOR HCW’S. HAZARD FOR HCW’S.

KILLS DAILY MORE THAN KILLS DAILY MORE THAN AIDS KILLS YEARLY.AIDS KILLS YEARLY.

2 MILLION DEATHES / YEAR. 2 MILLION DEATHES / YEAR.

350 MILLION CARRIERS 350 MILLION CARRIERS WORLDWIDE.WORLDWIDE.

SECOND IN IMPORTANCE TO SECOND IN IMPORTANCE TO TOBACCO SMOKING AMONG TOBACCO SMOKING AMONG HUMAN CARCINOGENS.HUMAN CARCINOGENS.

HEPATITIS BHEPATITIS B HEPATITIS CHEPATITIS C RUBELLARUBELLA T.B.T.B. MENINGITISMENINGITIS INFLUENZAINFLUENZA HIV INFECTIONSHIV INFECTIONS SCABIESSCABIES MUMPSMUMPS STAPH. INFECTIONSSTAPH. INFECTIONS

CARRIER RATECARRIER RATE

..

0%

2%

4%

6%

8%

10%

12%

14%

16%

GENERAL POPULATION HCW

20

80

WHITES

BLACKS

MODES OF MODES OF TRANSMISSIONTRANSMISSION

..PARENTRAL

SEXUAL

VERTICAL

HORIZONTAL

BLOOD

SALIVA

PLACENTA&B.MILK

SEMEN&VAG.DISCHARGE

RISKY MODES RISKY MODES

..

0%

10%

20%

30%

40%

RISK

HETEROSEX HOMOSEX

INJECTIONS UNKNOWN

HB

HB

Sequelae of Sequelae of infectioninfection

..Infection

Clinical Sub-Clinical

65% 35%

FulminantRecovery &immunity

1% 9% 90%

Chronic carrier

Death •Chronic persistent

•Chronic active•Cirrhosis

•Carcinoma

ACUTE SEROLOGICAL RESPONCEACUTE SEROLOGICAL RESPONCE

HBsAgAnti-HBc

HBeAg

Anti-HBsAnti- HBe

INCUBATION3 months

ACUTE INFECTION6 MONTHS

CONVALESCENCE RECOVERY

+12 MONTHS

HBsAgHBcAb

HBeAg

HBeAb

HBsAb

CHRONIC SEROLOGICAL RESPONCECHRONIC SEROLOGICAL RESPONCE

HBsAg HBeAg Anti-HBc

INCUBATION4-12 WEEKS

ACUTE INFECTION6 MONTHS

CHRONIC INFECTIONYEARS

Interpretation of the Hepatitis B Panel

Tests Results  Interpretation

HBsAganti-HBcanti-HBs

negativenegativenegative

   susceptible

  

HBsAganti-HBcanti-HBs

negativepositivepositive

   immune due to natural infection

   

HBsAganti-HBcanti-HBs

negativenegativepositive

immune due to hepatitis B vaccination

HBsAganti-HBc

IgM anti-HBcanti-HBs

positivepositivepositivenegative

  acutelyinfected

  

HBsAganti-HBc

IgM anti-HBcanti-HBs

positivepositivenegativenegative

   chronically infected 

HBsAganti-HBcanti-HBs

negativepositivenegative

  1

1. recovering from acute HBV infection.    2. distantly immune and test not sensitive enough to detect very low level of anti-HBs in serum.    3. susceptible with a false positive anti-HBc.    4. undetectable level of HBsAg present in the serum and the person is actually a carrier

PREVALENCE OF HBV PREVALENCE OF HBV MARKERSMARKERS

0

10

20

30

40

CLEANERS PHYSICIANS

NURSES ADMINSTRATION

AUXILLARY

FREQUENCY OF POTENTIAL HEPATITIS B EXPOSURE INCIDENTSFREQUENCY OF POTENTIAL HEPATITIS B EXPOSURE INCIDENTS

79

8 5 4 1.5 1.70

20

40

60

80

1st Qtr

NEEDLE PUNCTURE SCALPELS

BROKEN GLASSWARE BLOOD SPILLS

SECRETION SPILLS HUMAN BITES

Risk for Occupational Transmission of HBV

The risk of HBV infection is primarily related to the degree of contact with blood in the work place and also to the hepatitis B e antigen (HBeAg) status of the source person.

Source Source personperson

Clinical hepatitisClinical hepatitis Serological Serological evidenceevidence

(HBsAg)- and HBeAg-positive

22-31%22-31% 37-62%37-62%

HBsAg-positive, HBeAg-negative 1-6%1-6% 23-37%23-37%

DIRECT AND INDIRECT DIRECT AND INDIRECT TRANSMISSIONTRANSMISSION

HBV has been demonstrated to survive in dried blood at room temperature for at least 1 week.

Thus, HBV infections have resulted from direct or indirect blood or body fluid exposures that inoculated HBV into cutaneous scratches, abrasions, burns, other lesions, or on mucosal surfaces

LOCATION OF INCIDENTSLOCATION OF INCIDENTS

3900

%

1400%

10 8 5 3 2 1 4 3 1 50%

2000%

4000%

SURGICAL ICU

OT LAB

CASUALITY OB GYN

PEDIATRICS DIALYSIS

CENTRAL SUPPLY RADIOLOGY

RECOVERY OTHERS

WHO WILL BE AT RISK ?WHO WILL BE AT RISK ?

NURSESNURSES HOUSEKEEPERSHOUSEKEEPERS CENTRAL SUPPLY CENTRAL SUPPLY

WORKERSWORKERS LABORATORY LABORATORY

TECHNICIANSTECHNICIANS SURGICAL SURGICAL

TECHNICIANSTECHNICIANS X- RAY TECHNICIANSX- RAY TECHNICIANS PHYSICIANSPHYSICIANS

HEPATITIS B VACCINEHEPATITIS B VACCINE

THE FIRST ANTI-CANCER THE FIRST ANTI-CANCER VACCINE.VACCINE.

SAFE & EFFECTIVE.SAFE & EFFECTIVE. NO ADVERSE NO ADVERSE

REACTIONSREACTIONS..

THE ACTION -- THE THE ACTION -- THE VACCINEVACCINE YEAST DERIVED -- YEAST DERIVED --

RECOMBINANT DNA RECOMBINANT DNA TECHNOLOGY.TECHNOLOGY.

ADULT DOSE IS 20 ADULT DOSE IS 20 UNITS ( 10 U FOR UNITS ( 10 U FOR

CHILDRENCHILDREN)). . Given I.M. in deltoid Given I.M. in deltoid

muscle with a muscle with a needle 1-1.5 inches needle 1-1.5 inches longlong..

VACCINE SCHEDULEVACCINE SCHEDULE

Vaccine can be given as 0,1,6 months schedule.

If the vaccination series is interrupted after the first dose, the second dose should be administered as soon as possible. The second and third doses should be separated by an interval of at least 2 months.

If only the third dose is delayed, it should be administered when convenient

BOOSTER DOSEBOOSTER DOSE

Vaccine-induced (anti-HBs) levels may decline Vaccine-induced (anti-HBs) levels may decline overtime;overtime; BUT BUT, , immune memory response immune memory response remains intact indefinitely following remains intact indefinitely following immunizationimmunization. Persons with declining antibody . Persons with declining antibody levels are still protected against clinical illness levels are still protected against clinical illness and chronic disease.and chronic disease.

SO , booster doses of vaccine are not SO , booster doses of vaccine are not recommended recommended

POST VACCINATION POST VACCINATION SCREENSCREEN After routine vaccination of infants, children, After routine vaccination of infants, children,

adolescents, or adults adolescents, or adults post-vaccination testing for post-vaccination testing for adequate antibody response is not necessaryadequate antibody response is not necessary..

Post-vaccination testing IS recommended forPost-vaccination testing IS recommended for persons persons whose medical management will depend on whose medical management will depend on knowledge of their immune status. This includes :knowledge of their immune status. This includes :– Immunocompromised (e.g., hemodialysis patients)Immunocompromised (e.g., hemodialysis patients)– Persons received the vaccine in the buttockPersons received the vaccine in the buttock– Infants born to HBsAg (hepatitis B surface antigen)-Infants born to HBsAg (hepatitis B surface antigen)-

positive motherspositive mothers– Healthcare workers who have contact with bloodHealthcare workers who have contact with blood– Sex partners of persons with chronic hepatitis B virus Sex partners of persons with chronic hepatitis B virus

infectioninfection

Post-vaccination testing should be completed Post-vaccination testing should be completed 1-2 1-2 monthsmonths after the third dose. A protective antibody after the third dose. A protective antibody response is (>=10mIU/mL). response is (>=10mIU/mL).

No Response No Response

Persons who do not respond to the primary vaccine series should complete a second 3-dose vaccine series or be evaluated to determine if they are HBsAg-positive.

Revaccinated persons should be retested at the completion of the second vaccine series.

Persons who do not respond to an initial 3-dose vaccine series have a 30%–50% chance of responding to a second 3-dose series ..

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.

POST- EXPOSURE POST- EXPOSURE PROPHYLAXISPROPHYLAXIS

EXPOSED TO

HbsAg +ve Patient or carrier

HbsAg -ve unknown

UNVACCINATED HBIG+ 3HBV

3HBV 3HBV

VACCINATED

WITH K NOWN RESPONCE 1HBV X X WITH K NOWN NONRESPONCE 2HBIG OR

1HBIG + 1HBV

X HBIG+ 3HBV

WITH UNK NOWN RESPONCE 1HBIG+ 1HBV

X 1HBV

HBIG administrationHBIG administration

When HBIG is indicated, it should be administered as soon as possible after exposure (preferably within 24 hours). The effectiveness of HBIG when administered >7 days after exposure is unknown.

When hepatitis B vaccine is indicated, it should also be administered as soon as possible (preferably within 24 hours) and can be administered simultaneously with HBIG at a separate site (vaccine should always be administered in the deltoid muscle).

For exposed persons who are in the process of being vaccinated but have not completed the vaccination series, vaccination should be completed as scheduled, and HBIG should be added as indicated.

Persons exposed to HBsAg-positive blood or body fluids who are known not to have

responded to a primary vaccine series should receive a single dose of HBIG and reinitiate the hepatitis B vaccine series with the first dose of the hepatitis B vaccine as soon as possible after exposure.

Alternatively, they should receive two doses of HBIG, one dose as soon as possible after exposure, and the second dose 1 month later

Survei

llance

shee

t use

d in h

ospita

l

PROTECTIVE PROTECTIVE EFFICIENCYEFFICIENCY

SCHEDULE HBIG EFFICIENCY

0,1,2,12 - 94.8

0,1,2,12 + 97.6

0,1,6 - 94.8

0,1,6 + < 97.4

Hepatitis C ExposureHepatitis C Exposure

Occupational Transmission of HCV

HCV is not transmitted efficiently through occupational exposures to blood. The average incidence of anti-HCV seroconversion after accidental percutaneous exposure from an HCV-positive source is 1.8% (range: 0%–7%)

Transmission rarely occurs from mucous membrane exposures to blood, and no transmission in HCP has been documented from intact skin exposures to blood.

Data are limited on survival of HCV in the environment.

Post-exposure Management for HCV

The use of IG as PEP for hepatitis C was not The use of IG as PEP for hepatitis C was not supportedsupported

No clinical trials have been conducted to assess post exposure use of antiviral agents to prevent HCV infection.

In the absence of PEP for HCV, recommendations for post exposure management are intended to achieve early identification of chronic disease and, if present, referral for evaluation of treatment options.

Management of Exposures to HCV

For the source, perform testing for anti-HCV. For the person exposed to an HCV-positive

source:1. perform baseline testing for anti-HCV

and ALT activity;2. perform follow-up testing (e.g., at 4–

6 months) for anti-HCV and ALT activity .• Confirm all anti-HCV results reported positive

by enzyme immunoassay using supplemental anti-HCV testing (e.g., recombinant immuno blot assay [RIBA™])

HIV ExposureHIV Exposure

Risk for Occupational Transmission of HIV

The average risk of HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3%.

factors affecting risk of HIV transmission after an

occupational exposure Exposure to a larger quantity of blood

from the source person as indicated by:– a device visibly contaminated with the

patient’s blood. – a procedure that involved a needle being

placed directly in a vein or artery. – a deep injury

exposure to blood from source persons with terminal illness.

Recommendations for HIV PEP

a basic 4-week regimen of two drugs (zidovudine [ZDV] and lamivudine [3TC]; 3TC and stavudine [d4T]; or didanosine [ddI] and d4T) for most HIV exposures and an expanded regimen that includes the addition of a third drug for HIV exposures that pose an increased risk for transmission. When the source person’s virus is known or suspected to be resistant to one or more of the drugs considered for the PEP regimen.

RECOMMENDATIONS FOR THE MANAGEMENT OF HCP POTENTIALLY EXPOSED TO HBV,

HCV, or HIV

HCP should report occupational exposures immediately after they occur to infection control personnel at hospital, particularly because HBIG, hepatitis B vaccine, and HIV PEP are most likely to be effective if administered as soon after the exposure as possible.

Treatment of an Exposure Site

Wounds and skin sites that have been in contact with blood or body fluids should be washed with soap and water; mucous membranes should be flushed with water.

No evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of blood borne pathogen transmission;

however, the use of antiseptics is not contraindicated. The application of caustic agents (e.g., bleach) or the injection of antiseptics or disinfectants into the wound is not recommended.

Evaluation of the Exposure Source

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

If the HBV, HCV, and/or HIV infection status of the source is unknown, the source person should be informed of the incident and tested for serologic evidence of blood -borne virus infection.

THANK YOUTHANK YOU