1. Occupational Blood and Bodily Fluid Exposures
Shawn Dowling
PGY-1

2. Despite our best efforts, some occupational exposures will be unavoidable

3. Objectives What are blood and bodily fluid exposures?
Which diseases are we concerned with?
Who gets them?
Why????
What can be done?

4. Definitions Health Care Workers: Blood and Bodily Fluid:
health-care workers (HCW) are defined as 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
Blood and Bodily Fluid:
Essentially anything that comes out of the patient (other than abusive language), but certain ones (feces, urine, vomitus, saliva) are unlikely to be infectious unless they contain blood

5. Occupational BBF Exposure
Any time A) comes in contact with B).
Usually classified as percutaneous or mucocutaneous or non-intact skin

6. Epidemiology
52% of all HCW report a needlestick injury, 24% had one in the last year
But, estimates are that only 10% of all needlestick injuries are reported

7. Calgary Health Region #’s
Reported blood/bodily fluid exposures in 2003
FMC - 321
PLC – 153
RVH – 134

8. Who gets exposed (reports)?

9. Transmittable Infections
The Big 3:
HIV
Hep B
Hep C
For the internist….Other possible infections:
Blastomycosis
Brucellosis
Cryptococcosis
Diphtheria
Cutaneous gonorrhea
Herpes
Malaria
Mycobacteriosis
Mycoplasma caviae
Rocky Mountain spotted fever
Sporotrichosis
Staphylococcus aureus
Streptococcus pyogenes
Syphilis
Toxoplasmosis
Tuberculosis

10. Transmission of HIV/HBV/HCV
Transmitted by semen, vaginal secretions, blood or blood products, breast milk, transplacental transmission or any bodily fluid contaminated with blood
Saliva, feces, urine, vomitus, sputum and tears are not considered infectious unless contaminated with blood
Exceptions:
Vaginal secretions or semen are unlikely to transmit HCV
HBV can be transmitted by saliva

11. HIV In general, HIV exposure is low-risk, high consequence
Amount of virus is proportional to risk of infectivity. Therefore viral loads, type of bodily fluid and volume of exposure are important variables to consider

12. ESTIMATES OF PER-CONTACT RISK OF HIV INFECTION
Occupational Mucocutaneous Exposure %
Important: these numbers are generated via aggregate studies of retrospective and cohort data.

13. HIV rates in CHR
Prevalence is 0.5%, rate w/ IVDU is 5%

15. HCW and HIV From CDC (US data, as of June 2000)
54 cases reported to have seroconverted after an occupational exposure
46/54 were percutaneous exposures
5/54 were mucocutaneous exposures
2/54 were both
1/54 unknown
134 other potential cases (serconverted with no RF, had occupational exposure, but never had blood work done)
Surveillance of Health Care Workers with HIV/AIDS, August 2004.

16. HCW and HIV Canadian Needle Stick Surveillance Network
Numbers are from 12 sites (8 teaching, 4 community) from April 2000 to March 2002 (ongoing…)
2,621 occupational exposures to BBF (3.8/100 FTE’s)
Needlesticks: 65.7%,
splashes from patients: 13.7%,
cuts with sharp objects: 8.6%,
sticks other than needles: 7.2%,
Others: scratches 1.9%, direct contacts with patients 1.8% (i.e. touching patients directly) and bites with broken skin 1.2%
Prevalence of HCV = 7.6%, HIV = 2.6% and HBV = 1.8% amongst source patients
As a result the rate of exposure to infected BBF was 0.3%
Body fluids deemed likely to transmit bloodborne infections include blood, serum, plasma, saliva, sperm, vaginal secretions, amniotic fluid, cerebrospinal fluid, pleural fluid, pericardial fluid, peritoneal fluid, synovial fluid and other fluids visibly stained with blood. Exposures include percutaneous (needlestick, cut, scratch, bite) or mucocutaneous (contact with mucous membranes or with non-intact skin) injuries.

18. Hep B
Although percutaneous is the most efficient route of transmission, these likely only account for a minority,
In several studies, HCW could not recall an overt percutaneous injury,
And since HBV can survive in at room temp for a week, transmission is thought to primarily arise from contact with cuts, abrasions or mucosal surfaces
95% 5%

19. Hep B
Hep C
TransmissionRisk
30%(22-31%) Less if HBeAG -
1.8% (0-7%)
Incubation Pd
4-26 wks
2-26 wks
Carrier State
% of blood donors
% of blood donors
Chronic Hepatitis
5-10% of acute infections
85% of acute infections
Increased risk of HCC
Yes

20. Hep C Best transmitted via percutaneous exposure
Minimal risk w/mucous membranes or contact with blood
Crappy dz (since no PEP, but fortunately, but risk of transmission is low)
15%
85%

21. Case
78 yr female, security guard at the PLC, is waiting to be seen in the MT area. An hour ago she was involved in an alteration with an agitated patient. Both were bloodied in the battle and the security guard is concerned about getting HIV.
When you go to see her, she’s still covered in blood. What do you do?

22. If you do get poked/exposed
Remove the contaminated clothes – undergarments excepted
Allow immediate bleeding of the wound
Wash the injured area well with soap and water, and apply an antiseptic
If the eyes, nose, or mouth are involved, flush them well with large amounts of water

23. Prevention
Universal Precautions: Treat everyone as if they may have HIV/HBV/HCV
In 1985, 94% of all AIDS patients had a major RF
In 1996, 20% of all patients had been infected through heterosexual contact or had no known RF
Protect your self
Handwashing
Gloves
Masks
Eye protection
Face shields
Gowns/aprons
Safety Measures
Don’t recap needles, avoid being a surgical resident, safety intravenous catheters, dispose sharps

24. Report all cases Call OH & S Nurse (234-7799) Available 24 hrs/day
Provides patient with appropriate f/u
Will do Risk Assessment
Allows for surveillance/monitoring

25. Southern Alberta Clinic Guidelines
Is the source known HIV+?
Yes: proceed to step 2 of protocol
No:
Test source (with consent) using rapid point-of-care HIV test available through CLS at any Emergency Room or 8th and 8th health centre
If negative, and no risk of “window period”, reassure patient
If source unknown or refuses testing and has risks for or symptoms of HIV, proceed to step 2 of protocol
Consider source testing for HBV, HCV – most guidelines suggest testing for this

26. Rapid HIV Testing Sensitivity and Specificity both 99.9%
Done in the on-site rapid response labs
Current turn around time 1 hr 24 min
Confirmed by Western Blot at Prov Lab
Consider giving dose of PEP before results arrive (based on your pre-test probability)
Cost: considerable, but should not play a factor

27. Timing and Type of Exposure:
Assess fluid type, volume, viral titre, mode of exposure.
Assess exact timing of exposure
If exposure is not considered infectious for HIV/HBV/HCV (i.e. vomit, feces, etc. without blood – see slide #10) – reassure and arrange f/u if patient desires
If exposure considered potentially infections go to 3.

28. Decision:
Make a decision for or against PEP based on risk assessment (these are debatable)
HIV + = start PEP
HIV – and no risk of source pt being in “Window period” = don’t start PEP
Unknown (source not tested or refuses testing) = this is where you earn your money
HEP B – see slide on HBIG and Hep B vaccine

29. Unknown HIV status: What to do?
Determine:
Type of exposure (percutaneous v mucous membrane)
Source risk/setting: needlestick risk different at 8th and 8th clinic compared to Geriatric assessment unit
In these scenarios, need to have an in-depth conversation with patient to determine management/risk tolerance but…fortunately, there are some consensus guidelines

30. Risk Assessment -In general, Should be done by OH&S
High risk
IVDU
High risk sexual behaviour (MSM, sex w/IVDU, multiple sexual partners (3 or more sexual partners/yr w/I past 5 yrs), prostitution
Blood transfusion prior to 1985
Sex w/HIV + person
Clinical suspicion of HIV infections by physicians
Prior HIV test
HIV as part of a Ddx
Unexplained opportunistic infections (i.e. PCP, toxo, crypto, histo, TB, MAC)
Low Risk
HIV -
Serology unknown but answers no to all high risk questions
Unknown
Source is not assessed

33. Drug Selection
Best to start within 1-2 hrs, consider dose before Rapid HIV test returns depending on risk of source patient
Basic Regimen:
If Low risk exposure (unknown source or mucocutaneous exposure)
Combivir: (AZT 300mg + 3TC 150mg) bid
Expanded Regimen:
For most percutaneous to known HIV +
Basic Regimen + Nelfinavir 1250mg bid
Other:
consider other drugs if source patient is already on antiretrovirals or if source patient is known to have resistant HIV

34. Duration of Prophylaxis:
Start ASAP and continue for 4 weeks
Discuss adverse reactions w/patient:

35. Access and Cost: Starter kits contain 72 hours of drugs
Free for occupational exposure and non-voluntary or violent (assault) exposures
Non-occupational voluntary exposures (needles or sex): PEP is available, but cost not absorbed by CHR
In Calgary, starter kits are available in all hospital ED’s, and at the 8th & 8th 24-hour walk-in medical clinic. All antiretroviral drugs are stored in the Pharmacy at Foothills Medical Centre.
Cost: approx $1000 for 4 wks of combivir

36. A Few Words about PEP
Theoretically, initiation of antiretroviral PEP soon after exposure might prevent or inhibit systemic infection by limiting the proliferation of virus in the initial target cells or lymph nodes – most studies are done in animals or in vertical HIV transmission

37. HIV PEP - evidence

38. Case-Control Study Primary outcome: 712 patients
Risk Factors for acquiring HIV after a HCW has a percutaneous exposure
712 patients
679 retrospective controls (no seroconversion after 6 months)
33 prospective Cases (seroconversion after exposure)

40. Factors not Associated w/HIV transmission
Large bore needles
Use of gloves
Hollow bore vs. suture needles

41. HIV PEP prophylaxis: Case pts Control pts Use of AZT 30% 41%
Use of AZT w/I 4 hrs
89%
67%
Continued AZT x 4 wks
44%
66%

42. Study quotes a 80% (CI 43-94%) reduction rate of HIV transmission with use of AZT
ARR = 0.24%, NNT= 417
An nationwide RCT was attempted, but only able to recruit 84 patients over a year --- I wonder why?

43. Human Studies Generally poor
NEJM is the best study to look at AZT use and seroconversion in Human occupational exposures, but it was small and used different cohorts, retro/prospective, inconsistent data availability, and relied on recall

44. Human Studies Lots of studies looking at vertical HIV transmission
Quote reduction rates from 37-67% (depending on when started)
Problem of the benefit is secondary to decreasing mom’s viral load and therefore decreasing infectivity, therefore numbers are not applicable to occupational exposures

45. Animal Studies Challenges
identifying an animal model that is comparable to humans
In early studies, differences in controlled variables (e.g., choice of viral strain [based on the animal model used], inoculum size, route of inoculation, time of prophylaxis initiation, and drug regimen) made results very heterogeneous

46. Animal Studies
Studies among animal models have demonstrated that larger viral inocula decrease prophylactic efficacy
Delaying initiation, shortening the duration, or decreasing the antiretroviral dose of PEP decreased prophylactic efficacy

47. PEP Side Effects/Adverse Events
Divided into Major and Minor
Minor: experienced by %
nausea (57%)
Vomiting & Diarrhea (14% & 16%)
Headache (18%)
Fatigue or Malaise (38%)
Mean time to onset of symptoms 3 or 4 days for all of the above

48. Major: defined as life threatening, permanent or requiring hospitalization
Serious side effects, including nephrolithiasis, hepatitis, and pancytopenia have been reported with the use of combination drugs for PEP
One case of NVP (NNRTI)-associated fulminant liver failure requiring liver transplantation

49. Compliance 33% stopped the PEP prematurely
s/e and discontinuing PEP are seen more frequently with triple-therapy (indinavir is particularly nasty)
If pt started on triple therapy and complains of a/e and wants to d/c, stop 3rd Rx first as this is most likely causing the worse Sx
Educating pts about s/e, a/e has been shown to increase compliance

50. PEP Failure
Failure of PEP to prevent HIV infection in HCW has been reported in at least 21 instances
In 16 of the cases, ZDV was used alone as a single agent (currently not recommended)
In 2 cases, ZDV and didanosine (ddI) were used in combination
In three cases, 3 drugs were used for PEP
13 of the source persons were known to have been treated with antiretroviral therapy before the exposure. Antiretroviral resistance testing of the virus from the source person was performed in seven instances, and in four, the HIV infection transmitted was found to have decreased sensitivity to ZDV and/or other drugs used for PEP.
Other factors come in to play: compliance, viral load, inoculum, etc

51. Follow-up:
Baseline HIV, HBV, HCV, CBC, Cr, LFTs and bHCG should be done in recipient
Follow-up with ID at HPTP clinic within 72 hours (my understanding is this is only required if exposed to HIV, HBV, HCV + source)
HIV testing at 6 wks, 12 wks, 6 months

52. Other considerations:
For occupational exposures:
WCB Physician’s First Report
Employee Accident Report form #00169
Prevent transmission while in 6 month window period:
Abstain from intercourse or use condoms
Avoid pregnancy
Discontinue breastfeeding
Do not donate blood, plasma, organs, tissues...
Do not share toothbrushes, razors, needles etc.

53. When to Speak to ID Pregnant or breast feeding patients
Source patient already on retrovirals
Delayed exposure
Significant renal or hepatic disease
Unknown source

54. Hep B Tx/Management -Only consider Tx if HBsAg +
If immunized and adequate titers (>10IU)
Do nothing (no need to test either HCW or source pt)
If immunized and ? Anti HBs-Titers
Get titer levels (can delay as long as HBIG can be initiated within at least 72 hrs, 24 hrs preferred)
If immunized and titers <10IU after 1 series of vaccination
HBIG (0.6mL/kg/admin) and 1 dose of vaccine or 2 HBIG
If immunized and known non-responder (low titers after two series of vaccination)
HBIG now and then repeated in 1 month
If not immunized
HBIG and give 1st dose of vaccine (repeat vaccine at 1 and 5 mths)

56. Hep B PEP Approx 75% effective
HBIG is derived from human plasma (but no risk of HIV, no reported cases of HCV)
Hep B vaccine and HBIG are safe in pregnant moms

57. Hep C PEP

58. Hep C PEP: studies
Animal study looking at the use of high dose anti-HCV IG administered 1 hr after transmission did not prevent infection
Use of antivirals: no studies, but not thought to be effective
Therefore, aim is early detection of HCV an early referral for possible Tx options

59. Take Home Points Occupational BBF exposures are common
Although the risks are generally low, the consequences are severe
HIV exposure
If HIV + = start PEP
If HIV - = don’t start PEP
If unknown HIV status = MD and Pt need to make a decision, generally start PEP if high risk exposure/patient/setting

60. Hep B Hep C If pt has adequate titers = do nothing
If titers are not adequate = HBIG +/- vaccine
Hep C
No Tx, but goal is early identification in order to institute appropriate f/u, Tx as needed

61. Resources CDC guidelines (US data from June 2001)
The best and most extensive resource (references most pertinent studies and compiled by experts)
Canadian guidelines/data (from March 1997)
Public Health Agency of Canada
Southern Alberta Clinic: HIV/AIDS resource

62. MARCH 2002 39:3 ANNALS OF EMERGENCY MEDICINE Needlestick!
currently not working, but it’s supposed to provide an online decision making tool for BBF occupational exposures
Rosen’s
Robbins Pathology text
Dr. Walker/Dr. Djurfors Presentations