1. How to Protect Yourself after Body Fluid Exposure
By Andine Davenport, RN, COHN-S, and Frank Myers, CIC, MA
Nursing2009, May 2009
2.5 ANCC contact hours
Online:
© 2009 by Lippincott Williams & Wilkins. All world rights reserved

2. Accidental exposure
To blood or other potentially infectious material (OPIM)
Examples of OPIM - spinal, pleural fluid
Examples of bloodborne and OPIM pathogens - HIV, hepatitis B and C

3. Postexposure prophylaxis (PEP)
Exists for HIV and hepatitis B (HBV)
Not for hepatitis C (HCV)
HCV is the most common chronic bloodborne infection in the U.S. (approx. 3.2 million people)

4. Defining terms
Source - the patient whose blood or OPIM has come in contact with a healthcare worker
Exposed - the healthcare worker
Exposure - contact with OPIM
In some cases, both healthcare worker and patient are considered exposed when blood may “mingle,” such as in sharps injury

5. After an exposure: What’s your risk?
HIV transmission
Contracting HIV from accidental occupational exposure is quite rare, as seen by seroconversion rates:
- sharps injury, 0.3%, or 1 in 300
- mucous membrane exposure, 0.09%, or 1 in 1,000
- exposure to nonintact skin, lower than risk for mucous membrane exposure

6. After an exposure: What’s your risk?
From 1981 to 2006, CDC documented 57 cases of HIV/AIDS among healthcare personnel following occupational HIV exposure and identified additional 140 “possible” cases (included 24 documented and 35 possible cases of occupationally acquired HIV infection among nurses)

7. After an exposure: What’s your risk?
HBV transmission
Risk of susceptible person developing clinical HBV following exposure ranges from 1% to 31%, depending on source person’s HBV status
HBV can remain infectious on environmental surfaces for over a week, even in dried blood

8. After an exposure: What’s your risk?
OSHA regulations require offering HBV vaccine to healthcare workers who may be exposed to blood or OPIM on the job
Some healthcare workers don’t accept vaccine or complete vaccine series; others who are properly vaccinated don’t mount an immune response

9. After an exposure: What’s your risk?
HCV transmission
Risk of HCV transmission after percutaneous exposure is about 1.8%
Virus can remain viable in environment 16 hours to 4 days; HCV transmission via environment isn’t considered significant risk in healthcare settings (possible exception: hemodialysis units)

10. Classifying potentially infectious body fluids
Blood and any visibly bloody body fluids considered potentially infectious under OSHA guidelines. Other OPIM include:
- semen and vaginal secretions
- cerebrospinal fluid
- synovial fluid
- pleural fluid
- peritoneal fluid

11. Classifying potentially infectious body fluids
- pericardial fluid
- amniotic fluid
Materials not considered OPIM include feces, urine, vomitus, nasal secretions, saliva (except during dental procedures), sputum, sweat, tears

12. How to respond
Follow facility policy, based on OSHA, CDC, HIPAA guidelines
Remain calm
If needlestick or puncture injury, or fluids in contact with intact skin, wash area with soap and water

13. How to respond
In case of mucous membrane exposure, rinse area with copious amounts of saline or water
If involves eyes, wash eyes with commercially prepared isotonic solution (eye station) or clean water
Flush splashes to nose, mouth, or skin with water

14. How to respond Seek further care immediately Complete an event report
The source must be identified using two patient identifiers

15. Is PEP indicated?
Determine if true exposure to blood or OPIM has occurred
Determine if blood or OPIM has a portal of entry
Evaluate the source

16. Evaluating the source
If source’s HIV, HBV, HCV status is unknown, testing can be initiated
Your facility policy and CDC guidelines address informed consent issue
CDC recommends eliminating second form requirement for HIV testing (California still requires)

17. HIV testing Rapid HIV test provides results in 20 to 40 minutes
PEP should be administered within 2 hours of exposure
If positive, should be confirmed with more definitive testing

18. HBV and HCV Testing Never require separate consent form
Blood already drawn from source can be tested
Patient may refuse additional blood drawn
Anyone vaccinated against HBV and developed an immune response is considered to have no risk of contracting

19. HBV and HCV testing HBV panel for sources varies among facilities
Surface antigen (HBsAg) is standard
HCV testing: anti-HCV has high false-positive rate
Preferred HCV test is recombinant immunoblot assay HCV RNA

20. Assess and test exposed person
Baseline assessment to include history:
- current pregnancy or breast feeding
- medication reconciliation
- HBV vaccination history
- liver or kidney problems
- depression or insomnia
- pancreatitis or anemia
- any other information that affects risk
of infection

21. Assess and test exposed person
Exposed has right to accept or refuse further testing; refusing could jeopardize worker’s compensation
If immunized with HBV and tested for immunity, no further action required

22. Assess and test exposed person
If not tested for immunity, HBsAb and HbsAg administered; consult occupational health if additional doses needed
Hepatitis C testing should be done with serum liver enzyme levels as soon as possible after exposure

23. Follow-up care for exposed
Anyone exposed to HIV, HCV should have follow-up testing, counseling, and medical evaluation at intervals recommended by CDC
If results negative, no follow-up needed
CDC doesn’t recommend follow-up after PEP for HBV unless exposed develops signs and symptoms of hepatitis

24. PEP for HIV
If rapid HIV test positive, confirming test (remind exposed about false-positives)
Exposed has decision to make regarding receiving PEP for HIV; lasts 30 days and has adverse reactions
Clinicians advised to call National Clinicians’ Postexposure Hotline ( ) for advice before proceeding

25. Teaching about PEP for HIV
Inform of adverse reactions: nausea, diarrhea, abdominal pain, anemia, neutropenia
Help manage adverse reactions
Provide resources to answer questions

26. Teaching about PEP for HIV
Instruct regarding blood tests for toxic drug levels
Instruct testing will include blood cell count, liver and renal functions at 2 weeks
If taking protease inhibitor, teach signs and symptoms of hyperglycemia

27. Teaching about PEP for HIV
Pregnant or breastfeeding women should not take indinavir
Stress importance of completing regimen
Alert patient to contact healthcare provider about adverse reactions

28. PEP for HBV exposure
Exposed persons should be offered hepatitis B immunoglobulin (HBIG) and HBV vaccine
HBIG most effective when given within 24 hours of exposure
Instruct exposed not to donate blood, organs, tissues, semen until 6 month follow-up is complete

29. Testing positive for HCV
CDC guidelines recommend exposed be followed for 4 to 6 months
No PEP regimen available
Immunoglobulin and antiviral drugs not recommended

30. Prevention is best policy
Learn your facility’s infection control standards
Follow them