Post Exposure Prophylaxis, Occupational Exposure

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Occupational Exposure, Post exposure prophylaxis

Text of Post Exposure Prophylaxis, Occupational Exposure


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 optionsin resource poor circumstances.DR.T.V.RAO MD2 3. WHAT IS OCCUPATIONAL EXPOSURE Occupational exposure refers to exposure topotential blood-borne infections (HIV, HBVand HCV) that may occur in healthcare settingsduring performance of job duties. Post exposureprophylaxis (PEP) refers to comprehensivemedical management to minimize the risk ofinfection among Health Care Personnel (HCP)following potential exposure to blood-bornepathogens (HIV, HBV, HCV)DR.T.V.RAO MD 3 4. WHO ARE AT RISK All Health Care Personnel,including emergency careproviders, laboratory personnel,autopsy personnel, hospitalemployees, interns and medicalstudents, nursing staff andstudents, physicians, surgeons,dentists, labour and deliveryroom personnel, laboratorytechnicians, health facilitysanitary staff and clinical wastehandlers and health careprofessionals at all levelsDR.T.V.RAO MD 4 5. WHAT ARE SHARPS?Sharps are devices that are intentionally sharp to puncture orcut skin (needles, scalpels, etc.), or become sharp due toaccident, such as broken glass tubes. Hypodermic needles Scalpels IV devices Capillary tubes Glass containers Pipettes Others DR.T.V.RAO MD5 6. WHAT KIND OF DEVICES USUALLY CAUSE SHARPS INJURIES? Hypodermicneedles Blood collectionneedles Suture needles Needles used in IVdelivery systems ScalpelsDR.T.V.RAO MD 6 7. HOW COMMON ARESHARPS INJURIES? Estimates indicate that 600,000 to800,000 needle stick injuries occur eachyear. Unfortunately, about half of theseinjuries are not reported. ALWAYS REPORT sharps injuries to your employer to ensure that you receive appropriate follow-up care.DR.T.V.RAO MD7 8. 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 suchas a scalpel blade Non-percutaneous or Mucocutaneous exposure(contact of mucous membrane or non-intact skin withblood or body fluids) e.g. blood splash to the eyeDR.T.V.RAO MD 8 9. INCREASING THE RISK OF SHARPS INJURIESPast 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 containersDR.T.V.RAO MD 9 10. WHO ARE AT RISK Health Care Personnel are at risk of blood-borneinfection transmission through exposure of apercutaneous injury (e.g. needle-stick or cut with asharp instrument), contact with the mucousmembranes of the eye or mouth of an infectedperson, contact with non-intact skin (particularlywhen the exposed skin is chapped, abraded, orafflicted with dermatitis or contact with blood orother potentially infectious body fluids. potentiallyinfectious body fluidsDR.T.V.RAO MD 10 11. PROTECTING YOURSELF Report all needle stick andsharps-related injuriespromptly to ensure thatyou receive appropriatefollow-up care. Tell your employer aboutany sharps hazards youobserve. Participate in trainingrelated to infectionprevention. Get a Hepatitis Bvaccination.DR.T.V.RAO MD 11 12. SHARPS MANAGEMENT Who is at risk of an occupational exposure? All healthcare workers who have the potential for exposure to infectiousmaterials (e.g. blood, tissue, and specific body fluids, as well as medicalsupplies, equipment or environmental surfaces contaminated with thesesubstances) e.g: Nurses Doctors Laboratory staff Technicians Therapists Support personnel e.g. housekeeping, maintenance Dental staff Contractual staff Students DR.T.V.RAO MD12 13. SHARPS MANAGEMENT - GENERAL PRINCIPLES Needles should notbe recapped, bent orbroken by hand,removed fromdisposable syringesor otherwisemanipulated byhand.DR.T.V.RAO MD13 14. WHAT INFECTIONS CAN BE CAUSED BY SHARPS INJURIES?Sharps injuries can expose workers to anumber of blood borne pathogens thatcan cause serious or fatal infections. Thepathogens that pose the most serioushealth risks are Hepatitis B virus (HBV) Hepatitis C virus (HCV) Human immunodeficiency virus (HIV) DR.T.V.RAO MD14 15. RISK OF ACQUIRING INFECTION 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, 930% for HBV and 1 10% for HCV) and mucous membrane exposure (0.09% for HIV).DR.T.V.RAO MD 15 16. WHICH FLUIDS ARE POTENTIALLYINFECTIOUS FOR HIV? blood? spinal fluid? saliva? pleural fluid? sweat? pus? feces? urine? DR.T.V.RAO MD 16 17. WHICH FLUIDS ARE POTENTIALLY INFECTIOUS FOR HIV? blood spinal fluid saliva pleural fluid sweat pus feces urine DR.T.V.RAO MD 17 18. NEEDLE STICK AND SHARPSINJURIESProcedures for EffectivelyHandling Sharps InjuriesDR.T.V.RAO MD18 19. HIV PEP Exposures common 56 documentedcases of health careworkers contractingHIV from exposures;138 other possiblecases Area of considerableconcern but little data DR.T.V.RAO MD 19MMWR June 29, 2001 / 50(RR11);1-42 20. RISK OF HIV TRANSMISSION FOLLOWINGPERCUTANEOUS (NEEDLE STICK) EXPOSURE Pooled analysis ofprospective studies onhealth care workerswith occupationalexposures suggestsrisk is approximately0.3% (95% CI, 0.2% -0.5%)1 Presence or absence ofkey risk factors mayinfluence this risk inindividual exposuresDR.T.V.RAO MD 201. Bell DM. Am J Med 1997;102(suppl 5B):9-15. 21. ASSESS EXPOSED INDIVIDUAL The exposed individual should have confidentialcounseling and assessment by an experiencedphysician. Exposed individuals who are known ordiscovered to be HIV positive should not receive PEP.They should be offered counseling and information onprevention of transmission and referred to clinical andlaboratory assessment to determine eligibility forantiretroviral therapy (ART). Besides the medicalassessment,counselling exposed HCP is essential toallay fear and start PEP.DR.T.V.RAO MD 21 22. 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 irrigantsDR.T.V.RAO MD22 23. COUNSELLING FOR PEP Exposed persons(clients) should receiveappropriate informationabout what PEP isabout and the risk andbenefits of PEP in orderto provide informedconsent for taking PEP.It should be clear thatPEP is not mandatory.DR.T.V.RAO MD 23 24. PSYCHOLOGICAL SUPPORT Many people feel anxiousafter exposure. Everyexposed person needs tobe informed about the risks,and the measures that canbe taken. This will help torelieve part of the anxiety.Some clients may requirefurther specializedpsychological support .DR.T.V.RAO MD24 25. DOCUMENT EXPOSURE 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 persons mental state, side effects and requirements.DR.T.V.RAO MD25 26. PRACTICAL APPLICATION IN THE CLINICAL SETTINGSFor 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.DR.T.V.RAO MD26 27. 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 DR.T.V.RAO MD 27 28. PRESCRIBE PEPDeciding on PEP regimenThere are two types ofregimens:Basic regimen: 2-drugcombination Expanded regimen: 3-drugcombination The decision to initiate the type of regimen depends on the type of exposure and HIV serostatus of the source person.DR.T.V.RAO MD28 29. OUTCOMES OF HIV EXPOSURES No infection no immune memory Aborted infection cellular immune response Acute infection seroconversionDR.T.V.RAO MD29 30. HIV CHEMOPROPHYLAXIS 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.DR.T.V.RAO MD 30 31. 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)plus lamivudine (3TC) OR emtricitabine (FTC) DR.T.V.RAO MD31MMWR 2005;54(No. RR-9). 32. EXPANDED PEP REGIMENS Basic regimen plus a thirdagent Rationale: 3 drugs may bemore effective than 2drugs, though directevidence is lacking Consider for more seriousexposures or if resistancein the source patient issuspected Adherence more difficult More potential for toxicityD