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: www.nursingcenter.com © 2009 by Lippincott Williams & Wilkins. All world rights reserved

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

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)

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

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

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)

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

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

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)

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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 (888-448-4911) for advice before proceeding

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

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

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

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

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

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