1. Occupational exposures to HIV: Prevention and PEP
HAIVN
Harvard Medical School AIDS Initiative in Vietnam
M1-05 Preventing occupational exposure to HIV & PEP-EN
M2-16-Occupational Exposure & PEP-EN
HAIVN Module 1-Revised February 2010

2. Learning objectives
At the end of this presentation, each trainee can understand:
the risk of transmission of HIV, HBV and HCV after a single percutaneous exposure.
the one handed or “scoop” technique of recapping needles
the way to wash a wound in the event of a needle stick to possibly HIV infected blood or fluids.
the indications for using PEP.
PEP regimens in Vietnam
5 steps to prevent TB transmission in HIV care settings
Learning Objectives

3. Content of Presentation
Risks of HIV transmission through occupational exposures
Principles and practices of Universal Precautions
Post exposure prophylaxis: rationale and recommendations
Post exposure prophylaxis in Vietnam: procedures
Occupational exposures to HBV and TB and preventions in the healthcare setting
Lecture Content

4. Estimated HIV risk for a single exposure to HIV+ source
Blood Transfusion
Mother to child
IDU needle sharing
Occupational needle stick
Receptive anal sex
Receptive vaginal sex
Insertive anal sex
Insertive vaginal sex
Receptive oral sex
Insertive oral sex
90%
25-35%
0.67%
0.3%
0.5%
0.1%
0.065%
0.05%
0.01%
0.005%
Review the risk of HIV transmission through each type of exposure. Ask the trainees to estimate the risk for each type of exposure before you show it to them. The risk of HIV transmission from patient to health care worker from a single occupation exposure (needle stick) is only 0.3% or about 1/300.
(CDC, MMWR, 2005)

5. HIV transmission in through occupational exposures
In general the risk for HIV transmission depends on the route and the severity of exposure to the HIV infected fluid
The most common source of HIV exposure is blood.
IN the next slides we will review the factors that can affect the risk for occupational HIV transmission.

6. Data on occupational exposures to HIV in Vietnam
At one hospital in HCMC in 2000, 330/886 (38%) staff suffered a percutaneous exposure to blood.
Type of exposure %
Hollow-bore needles 53
Injuries occurred during suturing 24
Giving medications 19
Recapping needles 16
[ThPeC7512] Occupational blood exposures and perception of HIV transmission risk among Vietnamese hospital personnel Background: The frequency of occupational blood exposures to healthcare personnel (HP) and perceptions of occupational HIV transmission risk in Vietnam are unknown. As greater than 50% of new HIV diagnoses are made in hospitals, it is important to understand the epidemiology of exposures in this setting to ensure appropriate management and guide prevention programs. Methods: In 2001, we conducted an anonymous survey of HP at Cho Ray Hospital, Ho Chi Minh City to assess the frequency and reporting of occupational blood exposures through percutaneous injuries (PI), and HP perceptions of HIV transmission risks from these events. Two-thirds of non-clinical (housekeeping, laboratory) and clinical (nursing, physician) staff were randomly selected to participate. Results: Of 1011 surveys distributed, 866 (86%) were returned. A total of 330 (38%) HP recalled sustaining one or more PIs during 2000; 86 (35%) reported their exposures to supervisors or infection control. Most common reasons for not reporting included not being aware of the importance of reporting (32%), knowing that source patients were HIV-negative (27%), and concerns for confidentiality of testing results (22%). Of the most recent PIs described in the survey, 53% were from hollow-bore needles. Injuries occurred during suturing (24%), giving medications (19%), and recapping needles (16%). Source patient HIV status was known for 25% of these exposures or tested afterwards in 37%. Perceptions regarding risks of HIV transmission varied by occupation. Overall, HP believed the risk of HIV transmission to be 1-10% (median). However, 25% of clinical staff reported they did not know the rate of HIV transmission after PI. Conclusions: Occupational PIs are common in Vietnamese HP and are seldom reported. Improved reporting compliance could be achieved through 1) training on the importance of and procedures for exposure prevention, management, and reporting, and 2) assuring confidentiality for post-exposure testing.
Sohn. 15th IAC: Abstract ThPeC7512.

7. HIV transmissions from patient to healthcare workers (HCW) in USA
57 confirmed HIV seroconversions in HCWs following occupational exposures
138 cases of HIV/AIDS among HCWs with no risk factors for HIV infection other than occupational exposure in which seroconversion after an exposure was not documented
Research from the CDC in the USA of health care workers who became HIV infected.
Centers for Disease Control and Prevention, December 2001

8. HIV transmissions from patient to HCWs in USA
Documented Transmission
Possible Transmission
Nurses 24 35
Laboratory Workers 19 17
Physicians, non-surgical 6 12
Physician, surgical* --
Surgical Technicians 2
Dialysis Technicians 1 3
Respiratory Therapist
Health Aide 15
Morgue Technician
Housekeeper 13
Dental workers / dentists
EMT
Other technician/therapist 9
Other healthcare occupation 5
Total 57
139
Nurses and lab technicians have the highest risk for occupational exposure.

9. Exposure types in 57 occupationally HIV infected healthcare workers in the United States
Type of exposure
Number of cases with seroconversions
Percutaneous (puncture/cut injury) 48
Mucocutaneous (mucous membrane and/or skin) 5
Percutaneous and mucocutaneous 2
Unknown
Percutaneous exposures are higher risk than mucous membrane exposures.

10. Fluid exposures that lead to HIV seroconversion in 57 healthcare workers in the United States
Types of fluid
Number of cases with seroconversions
HIV infected blood 49
Concentrated virus in a laboratory 3
Visible bloody fluid 1
Unspecified fluid 4
Most occupational transmission of HIV is due to exposure to blood. Other body fluids have less risk.

11. Risk of HIV transmission
Blood exposures
Risk of HIV Transmission
Percutaneous needlesticks
0.3%
(95% CI= %)
Mucous membranes
0.09%
(95% CI 0.006% -0.5%)
Intact Skin 0%
(95% CI =0.0%-0.77%)
injuries from blood-contaminated needles and other sharp objects=percutaneous exposure. Exposure to intact (normal) skin has no risk for transmission. Source: CDC

12. Factors affecting risk of HIV transmission after percutaneous exposure
Risk factor
Adjusted Odds Ratio
The needle went deep into the healthcare worker
1.5
Visible blood was seen on the needle before the percutaneous exposure
6.2
Source patient was terminally ill
5.6
Needle was in source patient’s artery or vein
4.3
Source: US CDC

13. Universal Precautions
#1 Treat ALL blood as potentially infectious
Follow Universal Precautions
Universal Precautions means treating all blood and body fluids as if they are infectious. Preventing needle sticks is also important for preventing occupational transmission of HIV, HBV, HCV.
#2 Prevent needlesticks
Safely manage sharps

14. Universal Precautions
Universal precautions minimizes exposure to blood in 5 ways:
Use of protective barriers
Hand hygiene
Safe injection practices
Environmental control of blood and bodily fluids
Sharps management
Universal precautions should be used in all health care settings when there is potential exposure to any blood or body fluids. Remember: treat ALL blood and body fluids as if they are infected.

15. 1. Use of protective barriers
Procedure
Gloves
Gown
Goggles/Face
Protection
Giving an injection No No No
Drawing blood
Yes No No
Guidelines on when to use protective barriers.
Irrigating a wound
Yes
Yes
Yes
Performing an operation
Yes
Yes
Yes

16. 2. Hand hygiene
Prevents transmission of resistant organisms and infections
Before patient care
After blood/fluid contact, glove removal
Methods
Handwashing
(Water + soap) x >10s  single-use towel
Use of hand sanitizer
50-95% ethyl or isopropyl alcohol
Hand hygiene guidelines from the CDC.

17. 3. Use of safe injection practices
Best injection safety practices
Injection should be administered with a sterile syringe and needle, using the right medication, etc.
Needle should be placed in a puncture-proof container immediately after use.
Sharps waste should be discarded appropriately.
A safe injection does not harm the recipient, does not expose the provider to any avoidable risk and does not result in any waste that is dangerous for other people.

18. 4. Environmental control of blood and body fluids
Spills in patient-care areas
Clean visible blood/fluid with towel and discard
Disinfect area
1:100 dilution (500 ppm) of hypochlorite
Spills in laboratory areas
Soak towel and blood/fluid spill in disinfectant before discarding
Use more potent disinfectant
1:10 dilution (5000 ppm) of hypochlorite
Guidelines for cleaning spills of blood or body fluids.

19. 5. Sharps Management
Injuries can occur whenever a sharp is exposed in the work environment
Organize work areas
Have sharps containers nearby
Avoid hand-passage of sharps
Do not recap needles or, recap using a one-handed “scoop technique”
Correct use of sharps reduces the risk of accidental needle sticks.

20. “One-hand” technique of recapping needles
Review the technique for the “one-handed scoop.”

21. Post-Exposure Prophylaxis (PEP)
Rationale:
HIV pathogenesis: systemic infection does not occur immediately - “window of opportunity” when giving ARV may prevent HIV infection
Review the rationale for why PEP may be effective.

22. Rationale for post-exposure prophylaxis
HIV infects CD4 white blood cells. Infection starts in a single cell at the site of HIV entry into the body. It them takes 2-3 days for HIV to replicate and infect WBC in the lymph nodes. During that time there is an opportunity to prevent infection by blocking HIV replication in the one or few cells that are infected. If those cells die then the HIV infection will be eradicated before it starts.

23. Efficacy of antiretroviral therapy Human data-CDC Needlestick Surveillance Group
Case Control study: 31 cases and 679 controls
Cases: acquired HIV following an occupational exposure; 94% after a needlestick (all hollow needles)
29% of cases received PEP (AZT) vs 36% of controls
Risk for HIV infection was reduced by ~81% in HCWs receiving AZT
This is the only study we have of PEP in humans. The result was that PEP with AZT appeared to decrease HIV transmission by 81%.
Cardo D. NEJM 1997; 337:

24. Steps for post-exposure management
Treat the exposure site
Report the exposure to the manager and complete the report form
Assess the risk of exposure
Determine the HIV status of the source of exposure
Determine the HIV status of the exposed person.
Counsel the exposed person.
Provide ARV prophylaxis (if indicated)
Source: Vietnam MOH guidelines, 2009.

25. If there was a percutaneous exposure:
What to do immediately upon an exposure to a possibly HIV infected bodily fluid and/or blood
If there was a percutaneous exposure:
Flush the wound with tap water
Let the wound bleed for a short time without squeeze
Clean the wound with soap and water
Evaluate the need for PEP

26. If there was an eye exposure:
What to do immediately upon an exposure to a possibly HIV infected bodily fluid and/or blood
If there was an eye exposure:
Wash the eye(s) with water or NaCl 0.9% solution continuously for 5 minutes
Evaluate the need for PEP
If there was a mouth and/or nose exposure:
Rinse with water or NaCl 0.9% solution.
Gargle with NaCl 0.9% solution for several times.

27. Evaluating the need for PEP: Assessing the risk of HIV transmission by occupational exposure
Risk presents with:
Deep wounds with large bleeding, caused by large-bore needles.
Deep and large percutaneous wounds with bleeding, caused by scalpels or broken blood containing tubes.
Existing lesions, ulcers or scratch on the skin or mucus membranes (e.g. eye, nose) exposed to patient's blood or body fluids.
No Risk if:
Contact of normal skin with patient’s blood or body fluid.
How to evaluate the need for PEP.

28. Additional PEP issues Timing – as soon as possible!!!
Do not delay to obtain additional information on the source patient
Best if given within hours, not recommended after 72 hours
Duration of PEP: 4 weeks
If the HIV status of exposed person is neg: Give the first dose of PEP as soon as possible. PEP started more than 72 hours after exposure is not likely to be effective. Continue PEP for 4 weeks.

29. National Guidelines on PEP Regimens
Medications
Indications
2 drugs regimen (basic regimen)
AZT+ 3TC
or d4t + 3TC
All exposures with risk
3 drugs regimen
Plus: LPV/r
In case the source of exposure is known with or suspected of ARV resistance
Source: Vietnam MOH guidelines, 2009.

30. National Guidelines on PEP Regimens
Dosages:
AZT: 300mg BID PO
3TC: 150mg BID PO
d4T: 30mg BID PO
LPV/r: 400mg/100mg BID PO
Nevirapine is not recommended due to fulminant liver failure in 4 American HCW taking it for PEP.
Vietnam MOH guidelines, Dosages of ARV for PEP are the same as for treatment.

31. Suggested postexposure follow-up & testing
HIV testing of healthcare worker after 1, 3 and 6 months.
Laboratory tests to monitor ARV side effects:
Consider CBC, ALT on the start of treatment and after 4 weeks
Education and counseling of the healthcare worker:
their risk of infection with HIV, HBV, HCV
symptoms suggestive of ARV toxicity and/or primary HIV infection
prevention of secondary transmission: condom use with their partners
Counseling and follow-up is an important part of PEP.

32. Testing the source patient
Inform the source patient of the incident, counsel, & test (with consent) for HIV and hepatitis B and C
Use a rapid HIV antibody testing if possible
If source patient found to be HIV negative on rapid test or, rapid test not done:
inquire about source patient’s risk factors for HIV and risk of being in the “window period” of an acute HIV infection.
If the source patient has a negative HIV test but has had risk behavior in the past 3 months then it is possible for them to be HIV infected and in the window period. In this situation the health provider can consider giving PEP to the exposed health care worker even though the source patient had a negative test.

33. Testing the source patient
If source patient is known to be HIV positive:
define the patients clinical and immunological stage of HIV infection through a CD4 count and/or TLC.
Obtain HIV viral load data, if available
Obtain information on current and previous antiretroviral therapy
Obtain HIV resistance testing results, if done
Viral load can help determine the risk for HIV transmission.

34. Risk of seroconversion after percutaneous occupational exposure
Virus
Range
Mean
HBV
2 – 40 %
30%
HCV
0 – 7 %
3 %
HIV
0.2 – 0.5 %
0.3%
HBV has the highest risk for transmission after occupational exposure.
HBV is 100x more transmissible than HIV!

35. Hepatitis B prevention
The best way to avoid HBV infection is to vaccinate all health care workers against Hepatitis B.
HBV vaccination requires 3 injections at 0, 1 and 6 months.
This should be encouraged by all employers in health care settings!
Encourage all health care workers to be tested and vaccinated against HBV. HBsAb and HBsAg prevalence in Vietnam are very high, so it is cost-effective to test for both before vaccination.

36. TB prevention TB is the most common OI in Vietnam.
In the HIV OPC, a significant percentage of patients will have TB or on TB treatment at any one time.
The waiting area and exam rooms at the OPC are an environment at high risk for TB transmission.
There is risk of TB transmission from patients to other patients or to health care workers in the HIV OPC.

37. Five Steps to Prevent Transmission of TB in HIV Care Settings
Step 1: Screen and test
Early recognition of patients with suspected or confirmed TB disease.
Symptoms that may indicate TB include:
Cough > 2 weeks, fever, weight loss, night sweats, lymphadenopathy
Screen all patients who have any symptoms:
CXR, sputum BK
lymph node aspirate (if indicated)
Screening ALL HIV patients for signs and symptoms of TB, then performing laboratory testing as indicated, should be done routinely in the HIV OPC. Early diagnosis and treatment of active TB will decrease the number of patients who can transmit TB in the community.

38. Five Steps to Prevent Transmission of TB in HIV Care Settings
Step 2 : Education
Instruct patients to wear face masks if they have active TB or if they are coughing/sneezing.
Patients with active pulmonary TB should wear face masks whenever they are around other people, including at home.

39. Five Steps to Prevent Transmission of TB in HIV Care Settings
Step 3: Separate
If possible, patients who have active TB or are TB suspects should wear a mask, be separated from other patients, and requested to wait in a separate well-ventilated waiting area
Separation of active TB patients from other HIV infected patients will decrease risk of TB transmission.

40. Five Steps to Prevent Transmission of TB in HIV Care Settings
Step 4: Provide services quickly
If possible, triage active TB patients to the front of the line and quickly provide care to reduce the amount of time that others are exposed to them.
Minimize the amount of time that patients with active TB are in the OPC to minimize exposure to other patients and health care workers.

41. Five Steps to Prevent Transmission of TB in HIV Care Settings
Step 5: Environmental Control
Ventilation
Natural ventilation relies on open doors and windows to bring in air from the outside
Fans may also assist to blow the air out of the room.
Prevent active TB in HIV patients : IPT should be supply for HIV patients meet MOH criteria
Ventilation will help clear the air of infectious respiratory droplets. Prevention also will reduce the number of contagious YB cases in the community (and in the OPC!)

42. Face Masks Standard Face Masks Special Face Masks: N95 or FFP2
Prevent TB transmission if worn by the TB patient
Do not prevent the wearer from acquiring TB
Special Face Masks: N95 or FFP2
Protect the wearer
Only needed in high risk areas:
spirometry or bronchoscopy rooms, or
MDRTB treatment centers
Standard face masks prevent transmission by blocking respiratory droplets coughed by the patient with active pulmonary TB (sputum AFB positive). Because air can flow around the mask, they do not prevent the wearer from inhaling respiratory droplets coughed out by others.
WHO Guidelines for the Prevention of Tuberculosis in Health Care Facilities in Resource-Limited Settings

43. Face mask – has large pores and lacks air tight seal around edges
Point out that the standard face mask does not filter all air inhaled: air can flow around the mask because it does not form a seal with the skin. N95 masks, if worn properly, filter out particles from the inhaled air.
Respirator – has only tiny pores which block droplet nuclei and relies on an air tight seal around the entire edge
Face mask – has large pores and lacks air tight seal around edges

44. Key Points
Universal precautions means treating all blood and body fluids as if they are infectious.
The risk of HIV transmission from a single occupational exposure is 0.3%
The risk of HBV transmission from a single occupational exposure is 30%
PEP in Vietnam is used:
two drugs (D4T or AZT) + 3TC
or three drugs (D4T or AZT) + 3TC + LPV/r
NVP should NOT be used for PEP due to high risk for hepatotoxicity.
Take steps to prevent TB transmission in the health care setting.
are given 4 wks
Key points

45. Thank you!
Questions?