Presentation on theme: "Occupational Blood and Bodily Fluid Exposures"— Presentation transcript:
1Occupational Blood and Bodily Fluid Exposures Shawn DowlingPGY-1
2Despite our best efforts, some occupational exposures will be unavoidable
3Objectives What are blood and bodily fluid exposures? Which diseases are we concerned with?Who gets them?Why????What can be done?
4Definitions 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 settingBlood 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
5Occupational BBF Exposure Any time A) comes in contact with B).Usually classified as percutaneous or mucocutaneous or non-intact skin
6Epidemiology52% of all HCW report a needlestick injury, 24% had one in the last yearBut, estimates are that only 10% of all needlestick injuries are reported
7Calgary Health Region #’s Reported blood/bodily fluid exposures in 2003FMC - 321PLC – 153RVH – 134
9Transmittable Infections The Big 3:HIVHep BHep CFor the internist….Other possible infections:BlastomycosisBrucellosisCryptococcosisDiphtheriaCutaneous gonorrheaHerpesMalariaMycobacteriosisMycoplasma caviaeRocky Mountain spotted feverSporotrichosisStaphylococcus aureusStreptococcus pyogenesSyphilisToxoplasmosisTuberculosis
10Transmission of HIV/HBV/HCV Transmitted by semen, vaginal secretions, blood or blood products, breast milk, transplacental transmission or any bodily fluid contaminated with bloodSaliva, feces, urine, vomitus, sputum and tears are not considered infectious unless contaminated with bloodExceptions:Vaginal secretions or semen are unlikely to transmit HCVHBV can be transmitted by saliva
11HIV 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
12ESTIMATES OF PER-CONTACT RISK OF HIV INFECTION Occupational Mucocutaneous Exposure %Important: these numbers are generated via aggregate studies of retrospective and cohort data.
13HIV rates in CHRPrevalence is 0.5%, rate w/ IVDU is 5%
15HCW and HIV From CDC (US data, as of June 2000) 54 cases reported to have seroconverted after an occupational exposure46/54 were percutaneous exposures5/54 were mucocutaneous exposures2/54 were both1/54 unknown134 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.
16HCW 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 patientsAs 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.
18Hep BAlthough 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 surfaces95%5%
19Hep BHep CTransmissionRisk30%(22-31%) Less if HBeAG -1.8% (0-7%)Incubation Pd4-26 wks2-26 wksCarrier State% of blood donors% of blood donorsChronic Hepatitis5-10% of acute infections85% of acute infectionsIncreased risk of HCCYes
20Hep C Best transmitted via percutaneous exposure Minimal risk w/mucous membranes or contact with bloodCrappy dz (since no PEP, but fortunately, but risk of transmission is low)15%85%
21Case78 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?
22If you do get poked/exposed Remove the contaminated clothes – undergarments exceptedAllow immediate bleeding of the woundWash the injured area well with soap and water, and apply an antisepticIf the eyes, nose, or mouth are involved, flush them well with large amounts of water
23PreventionUniversal Precautions: Treat everyone as if they may have HIV/HBV/HCVIn 1985, 94% of all AIDS patients had a major RFIn 1996, 20% of all patients had been infected through heterosexual contact or had no known RFProtect your selfHandwashingGlovesMasksEye protectionFace shieldsGowns/apronsSafety MeasuresDon’t recap needles, avoid being a surgical resident, safety intravenous catheters, dispose sharps
24Report all cases Call OH & S Nurse (234-7799) Available 24 hrs/day Provides patient with appropriate f/uWill do Risk AssessmentAllows for surveillance/monitoring
25Southern Alberta Clinic Guidelines Is the source known HIV+?Yes: proceed to step 2 of protocolNo:Test source (with consent) using rapid point-of-care HIV test available through CLS at any Emergency Room or 8th and 8th health centreIf negative, and no risk of “window period”, reassure patientIf source unknown or refuses testing and has risks for or symptoms of HIV, proceed to step 2 of protocolConsider source testing for HBV, HCV – most guidelines suggest testing for this
26Rapid HIV Testing Sensitivity and Specificity both 99.9% Done in the on-site rapid response labsCurrent turn around time 1 hr 24 minConfirmed by Western Blot at Prov LabConsider giving dose of PEP before results arrive (based on your pre-test probability)Cost: considerable, but should not play a factor
27Timing and Type of Exposure: Assess fluid type, volume, viral titre, mode of exposure.Assess exact timing of exposureIf 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 desiresIf exposure considered potentially infections go to 3.
28Decision:Make a decision for or against PEP based on risk assessment (these are debatable)HIV + = start PEPHIV – and no risk of source pt being in “Window period” = don’t start PEPUnknown (source not tested or refuses testing) = this is where you earn your moneyHEP B – see slide on HBIG and Hep B vaccine
29Unknown 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 unitIn these scenarios, need to have an in-depth conversation with patient to determine management/risk tolerance but…fortunately, there are some consensus guidelines
30Risk Assessment -In general, Should be done by OH&S High riskIVDUHigh risk sexual behaviour (MSM, sex w/IVDU, multiple sexual partners (3 or more sexual partners/yr w/I past 5 yrs), prostitutionBlood transfusion prior to 1985Sex w/HIV + personClinical suspicion of HIV infections by physiciansPrior HIV testHIV as part of a DdxUnexplained opportunistic infections (i.e. PCP, toxo, crypto, histo, TB, MAC)Low RiskHIV -Serology unknown but answers no to all high risk questionsUnknownSource is not assessed
33Drug SelectionBest to start within 1-2 hrs, consider dose before Rapid HIV test returns depending on risk of source patientBasic Regimen:If Low risk exposure (unknown source or mucocutaneous exposure)Combivir: (AZT 300mg + 3TC 150mg) bidExpanded Regimen:For most percutaneous to known HIV +Basic Regimen + Nelfinavir 1250mg bidOther:consider other drugs if source patient is already on antiretrovirals or if source patient is known to have resistant HIV
34Duration of Prophylaxis: Start ASAP and continue for 4 weeksDiscuss adverse reactions w/patient:
35Access and Cost: Starter kits contain 72 hours of drugs Free for occupational exposure and non-voluntary or violent (assault) exposuresNon-occupational voluntary exposures (needles or sex): PEP is available, but cost not absorbed by CHRIn 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
36A Few Words about PEPTheoretically, 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
38Case-Control Study Primary outcome: 712 patients Risk Factors for acquiring HIV after a HCW has a percutaneous exposure712 patients679 retrospective controls (no seroconversion after 6 months)33 prospective Cases (seroconversion after exposure)
40Factors not Associated w/HIV transmission Large bore needlesUse of glovesHollow bore vs. suture needles
41HIV PEP prophylaxis: Case pts Control pts Use of AZT 30% 41% Use of AZT w/I 4 hrs89%67%Continued AZT x 4 wks44%66%
42Study quotes a 80% (CI 43-94%) reduction rate of HIV transmission with use of AZT ARR = 0.24%, NNT= 417An nationwide RCT was attempted, but only able to recruit 84 patients over a year --- I wonder why?
43Human 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
44Human 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
45Animal Studies Challenges identifying an animal model that is comparable to humansIn 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
46Animal StudiesStudies among animal models have demonstrated that larger viral inocula decrease prophylactic efficacyDelaying initiation, shortening the duration, or decreasing the antiretroviral dose of PEP decreased prophylactic efficacy
47PEP Side Effects/Adverse Events Divided into Major and MinorMinor: 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
48Major: 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 PEPOne case of NVP (NNRTI)-associated fulminant liver failure requiring liver transplantation
49Compliance 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 SxEducating pts about s/e, a/e has been shown to increase compliance
50PEP FailureFailure of PEP to prevent HIV infection in HCW has been reported in at least 21 instancesIn 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 combinationIn three cases, 3 drugs were used for PEP13 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
51Follow-up:Baseline HIV, HBV, HCV, CBC, Cr, LFTs and bHCG should be done in recipientFollow-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
52Other considerations: For occupational exposures:WCB Physician’s First ReportEmployee Accident Report form #00169Prevent transmission while in 6 month window period:Abstain from intercourse or use condomsAvoid pregnancyDiscontinue breastfeedingDo not donate blood, plasma, organs, tissues...Do not share toothbrushes, razors, needles etc.
53When to Speak to ID Pregnant or breast feeding patients Source patient already on retroviralsDelayed exposureSignificant renal or hepatic diseaseUnknown source
54Hep 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-TitersGet 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 vaccinationHBIG (0.6mL/kg/admin) and 1 dose of vaccine or 2 HBIGIf immunized and known non-responder (low titers after two series of vaccination)HBIG now and then repeated in 1 monthIf not immunizedHBIG and give 1st dose of vaccine (repeat vaccine at 1 and 5 mths)
58Hep C PEP: studiesAnimal study looking at the use of high dose anti-HCV IG administered 1 hr after transmission did not prevent infectionUse of antivirals: no studies, but not thought to be effectiveTherefore, aim is early detection of HCV an early referral for possible Tx options
59Take Home Points Occupational BBF exposures are common Although the risks are generally low, the consequences are severeHIV exposureIf HIV + = start PEPIf HIV - = don’t start PEPIf unknown HIV status = MD and Pt need to make a decision, generally start PEP if high risk exposure/patient/setting
60Hep B Hep C If pt has adequate titers = do nothing If titers are not adequate = HBIG +/- vaccineHep CNo Tx, but goal is early identification in order to institute appropriate f/u, Tx as needed
61Resources 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 CanadaSouthern Alberta Clinic: HIV/AIDS resource
62MARCH 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 exposuresRosen’sRobbins Pathology textDr. Walker/Dr. Djurfors Presentations