1. 1 Roseann Mulligan DDS, MS University of Southern California Pacific AIDS Education and Training Center HBV, HCV, and HIV in the Dental Office: Prevention and Recommendations for Postexposure Prophylaxis (PEP)

2. 2 Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV) Bloodborne viruses Bloodborne viruses Can produce chronic infection Can produce chronic infection Transmissible in healthcare settings Transmissible in healthcare settings

3. 3 Preventing Transmission of Bloodborne Viruses in Healthcare Settings Promote HB Vaccinations Promote HB Vaccinations Treat all patients as potentially infectious Treat all patients as potentially infectious Use barriers to prevent blood or body fluid contact Use barriers to prevent blood or body fluid contact Prevent percutaneous injuries Prevent percutaneous injuries

4. 4 Annual Number of Percutaneous Injuries* 1987–1993 1987198819891990199119921993 0 2 4 6 8 10 12 11.4 8.8 6.2 5.4 3.5 2.9 2.2 Number * ADA Health Screening, per dentist

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6. 6 Factors Influencing Risk of Occupational Exposure Consistent usage of engineering controls Consistent usage of engineering controls Proper handling and disposal of sharps Proper handling and disposal of sharps Prevalence of infection among patients Prevalence of infection among patients Nature and frequency of exposure Nature and frequency of exposure Type of virus Type of virus Body fluid and level of infectivity Body fluid and level of infectivity

7. 7 Prevalence of Bloodborne Virus Infection Varies in Patient Populations Geography Geography Patient risk behaviors Patient risk behaviors Type of care or living arrangement Type of care or living arrangement Incarceration Incarceration Sex worker Sex worker IV Drug user IV Drug user

8. 8 Question: The greatest risk of transmission of disease occurs: A. From the dental healthcare worker to the patient. B. From the patient to the dental healthcare worker. C. From one patient to another patient. D. All transmission routes have the same risk.

9. 9 Potential Routes of Transmission of Bloodborne Pathogens Patient DHCP Patient

10. 10 Transmission of HBV from Infected Dentists to Patients Nine clusters of HBV transmission from infected dentists and oral surgeons to patients were documented between 1970 – 1987 Nine clusters of HBV transmission from infected dentists and oral surgeons to patients were documented between 1970 – 1987 Lack of documented transmissions since 1987 Lack of documented transmissions since 1987 may reflect increased use of gloves and hepatitis B vaccinationmay reflect increased use of gloves and hepatitis B vaccination

11. 11 Estimated Incidence of HBV Infections Among HCW and General Population, United States, 1985-1999 Health Care Workers General U.S. Population

12. 12 Average Risk of Bloodborne Virus Transmission after Needlestick SourceRisk HBV HBsAg + and HBeAg + 22 %-31 % clinical hepatitis; 37%-62% serological evidence of HBV infection HBsAg + and HBeAg - 1%-6 % clinical hepatitis; 23% - 37% serological evidence of HBV infection HCV 1.8% (0%-7% range) HIV 0.3% (0.2%-0.5% range) CDC http://www.cdc.gov/OralHealth/infectioncontrol/guidelines/ppt.htm

13. 13 CDC http://www.cdc.gov/OralHealth/infectioncontrol/guidelines/ppt.htm

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15. 15 Characteristics of Percutaneous Injuries Among DHCP Reported frequency among general dentists has declined Reported frequency among general dentists has declined Caused by burs, syringe needles, other sharps Caused by burs, syringe needles, other sharps Occur outside the patient’s mouth Occur outside the patient’s mouth Involve small amounts of blood Involve small amounts of blood Among oral surgeons, occur more frequently during fracture reductions and procedures involving wire Among oral surgeons, occur more frequently during fracture reductions and procedures involving wire

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18. 18 Wound Care Clean wounds with soap and water Clean wounds with soap and water Do not squeeze Do not squeeze Flush mucous membranes with water Flush mucous membranes with water Avoid use of bleach and other agents caustic to skin Avoid use of bleach and other agents caustic to skin

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24. 24 Occupational Exposure to HBV

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27. 27 Hepatitis B Vaccine The vaccine consist of a series of 3 doses via IM injection into the deltoid muscle of the arm. The vaccine consist of a series of 3 doses via IM injection into the deltoid muscle of the arm. Dose # 1 is time zero Dose # 1 is time zero Dose # 2 given one month after dose #1 Dose # 2 given one month after dose #1 Dose # 3 is given 6 months after dose #1 Dose # 3 is given 6 months after dose #1 A QUANTITATIVE TITER IS DUE 30-60 DAYS AFTER THE LAST DOSE A QUANTITATIVE TITER IS DUE 30-60 DAYS AFTER THE LAST DOSE

28. 28 Antibody (titer) level determines effectiveness. Antibody (titer) level determines effectiveness. Titer level 10 or less - entire series needs repeating (all 3 doses) Titer level 10 or less - entire series needs repeating (all 3 doses) After the second series, titer less than 10, the person is considered to be a “primary nonresponder” After the second series, titer less than 10, the person is considered to be a “primary nonresponder” Nonresponder will need the HBIG if a contaminated puncture/body fluid exposure. Nonresponder will need the HBIG if a contaminated puncture/body fluid exposure. Hepatitis B

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30. 30 Hepatitis D depends on Hepatitis B for propagation/transmission. Hepatitis D depends on Hepatitis B for propagation/transmission. Hepatitis D infections – usually injection drug users and hemophiliacs Hepatitis D infections – usually injection drug users and hemophiliacs Immunization with HBV vaccine confers immunity to HDV Immunization with HBV vaccine confers immunity to HDV Hepatitis D

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36. 36 Recommendations Hepatitis B Vaccine  Offer vaccination to all personnel who are at risk of exposure to blood  Provide access to qualified health-care professional for administration and follow-up testing  No need for pre-vaccination testing for HBV antibodies

37. 37 Immunizations for Dental Healthcare Workers Hepatitis B vaccine must be offered at no charge to employees who may be exposed to body fluids within 10 days of the potential initial exposure. They do have the right to refuse. Hepatitis B vaccine must be offered at no charge to employees who may be exposed to body fluids within 10 days of the potential initial exposure. They do have the right to refuse. If the employee refuses the vaccine, they must sign the “OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030) Hepatitis B Vaccine Declination” form. If the employee refuses the vaccine, they must sign the “OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030) Hepatitis B Vaccine Declination” form.

38. 38 Hepatitis B Vaccine Declination (Mandatory) - 1910.1030 App A I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me. I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me. [56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717, April 13, 1992; 57 FR 29206, July 1, 1992; 61 FR 5507, Feb. 13, 1996] http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table =STANDARDS&p_id=10052

39. 39 Occupational Exposure to HCV

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41. 41 Hepatitis C - transmitted like HBV. Hepatitis C - transmitted like HBV. Chances of infection following an exposure 10 times higher for HBV Chances of infection following an exposure 10 times higher for HBV HCV - RNA virus with at least 6 different genotypes and 90+ subtypes. HCV - RNA virus with at least 6 different genotypes and 90+ subtypes. U.S. - Most common genotype is type 1 - accounts for ~70% of Hepatitis C infections U.S. - Most common genotype is type 1 - accounts for ~70% of Hepatitis C infections No vaccine available for Hepatitis C No vaccine available for Hepatitis C Genotype 1 responds least favorably to alpha interferon and ribavirin treatments. Genotype 1 responds least favorably to alpha interferon and ribavirin treatments. Hepatitis C

42. 42 Reported Cases of Acute Hepatitis C by Selected Risk Factors, United States, 1982-2001* Injecting drug use Sexual Health related work Transfusion * 1982-1990 based on non-A, non-B hepatitis

43. 43 HCV Infection in Dentistry Frequency of HCV infection among dentists similar to that of general population (~ 1-2%) Frequency of HCV infection among dentists similar to that of general population (~ 1-2%) No reports of an HCV transmission from infected dental personnel to patients No reports of an HCV transmission from infected dental personnel to patients No reports of patient-to-patient transmission of HCV No reports of patient-to-patient transmission of HCV Risk of HCV transmission is very low Risk of HCV transmission is very low

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46. 46 Occupational Exposure to HIV

47. 47 (*) 3 dentists, 1 oral surgeon, 2 assistants *

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50. 50 Source: Cardo, et al., N England J Medicine 1997;337:1485-90.

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55. 55 Assessment of Infection Risk Source evaluation Source evaluation Presence of HBsAgPresence of HBsAg Presence of HBeAgPresence of HBeAg Presence of HCV antibodyPresence of HCV antibody Presence of HIV antibodyPresence of HIV antibody If source unknown, assess epidemiologic evidenceIf source unknown, assess epidemiologic evidence Susceptibility of the exposed person Susceptibility of the exposed person Immunity to HBV infection?Immunity to HBV infection?

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64. 64 Exposure Prevention Methods Standard/Universal Precautions Standard/Universal Precautions Engineering controls Engineering controls Work place practices Work place practices

65. 65 Post-Exposure Management OSHA requires post exposure protocols to be in place OSHA requires post exposure protocols to be in place Physician providing counseling, medication, and follow up care.Physician providing counseling, medication, and follow up care. At USC we test for : HBV, HCV, HIV, and VDRL (syphilis) At USC we test for : HBV, HCV, HIV, and VDRL (syphilis) USC protocol states to report the injury within 2- 4 hours of sustaining the injury. USC protocol states to report the injury within 2- 4 hours of sustaining the injury. Can only ask source patient to be tested once Can only ask source patient to be tested once

66. 66 Post Exposure Management Protocol An example All exposed faculty, staff and students are tested at All exposed faculty, staff and students are tested at 1 month, 3 months and 6 months from the date of exposure 1 month, 3 months and 6 months from the date of exposure Employer pays for Employer pays for all medical exams and blood tests for all employees and students. all medical exams and blood tests for all employees and students. exam and test for source patient if he/she agrees to be testedexam and test for source patient if he/she agrees to be tested HBIG and any antiviral medication(s) recommended and agreed to.HBIG and any antiviral medication(s) recommended and agreed to.

67. 67 HIV Post Exposure Treatment Considers: Considers: the type of injury the type of injury the severity of the injury the severity of the injury the infection status of the source the infection status of the source

68. 68 Standard Precautions Apply to all patients Apply to all patients Expand Universal Precautions to include organisms spread by other body fluids Expand Universal Precautions to include organisms spread by other body fluids Apply to Apply to Blood and body fluids, except sweatBlood and body fluids, except sweat Non-intact skinNon-intact skin Mucous membranesMucous membranes

69. 69 Postexposure Management Program Clear policies/procedures Clear policies/procedures Education of healthcare personnel (HCP) Education of healthcare personnel (HCP) Rapid access to Rapid access to Clinical careClinical care Postexposure prophylaxis (PEP)Postexposure prophylaxis (PEP) Testing of source patients/HCPTesting of source patients/HCP

70. 70 Warmline National HIV Telephone Consultation Service 1-800-933-3413 PEPline National Clinicians' Post-Exposure Prophylaxis Hotline 1-888-HIV-4911 Perinatal HIV Hotline National Perinatal HIV Consultation and Referral Service 1-888-448-8765 National HIV/AIDS Clinician Consultation Center

71. 71 www.cdc.gov/oral health www.cdc.gov/oral health