1. “Help! I stuck myself! Now what?!” Evaluation and Treatment of Body Fluid Exposures in the Health Professional Student Sharon McMullen, RN BSN Vanessa Stoloff, MD

2. Bloodborne Pathogens Transmissible in healthcare settings Can produce chronic infections Hepatitis B Virus (HBV) Hepatitis C Virus (HCV) Human Immunodeficiency Virus (HIV) McMullen/Stoloff, ACHA, 6.2011

3. Factors Influencing Risk of Infection Prevalence of infection among patients Experience of clinician Nature of exposures Risk of infection transmission after exposure McMullen/Stoloff, ACHA, 6.2011

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5. HBV Prevalence http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/hepatitis-b.htm

7. HCV Prevalence Modified from Perz JF, Farrington LA, Pecoraro C, et al. Estimated global prevalence of hepatitis C virus infection. 42nd Annual Meeting of the Infectious Diseases Society of America; Boston, MA, USA; Sept 30–Oct 3, 2004. Data source: World Health Organization

8. HIV Incidence and Prevalence United States, 1977-2006 CDC. HIV prevalence estimates—US, 2006. MMWR 2008;57(39):1073-76 McMullen/Stoloff, ACHA, 6.2011

9. HIV Prevalence http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-5/hiv-aids.htm

10. Elements of an effective post- exposure management program Clear policies/procedures Rapid access to ▫Expert evaluation ▫Post-exposure prophylaxis (PEP) ▫Testing McMullen/Stoloff, ACHA, 6.2011

13. “Help! I stuck myself! Now what?!” McMullen/Stoloff, ACHA, 6.2011

14. Body Fluid Type McMullen/Stoloff, ACHA, 6.2011

15. Concentration of Virus in Body Fluids High Moderate Low/Not Detectable Blood Semen Urine Serum Vaginal Fluid Feces Wound exudates Saliva Sweat Tears Breast Milk McMullen/Stoloff, ACHA, 6.2011

16. Exposure Type (Human Bite) McMullen/Stoloff, ACHA, 6.2011

17. Relatively Lower Risk Instruments Suture Needle Solid metal needle with exposure to non- intact skin and often blood. Dental Metal Burrs Solid metal instruments that may contact gum tissue and are exposed to saliva (often with blood). McMullen/Stoloff, ACHA, 6.2011

18. Relatively Higher Risk Instruments Hollow bore needles are usually placed directly into a vein or artery and may contain blood within (not always visible to the eye). McMullen/Stoloff, ACHA, 6.2011

19. Mucous Membrane Exposure Mucous membranes are tissues that line body cavities or canals such as the throat, nose, mouth, urethra, rectum, and vagina. Conjunctiva is also considered a mucous membrane. Non-intact Skin Exposure Less Severe (Solid Needle, Superficial Injury) Evidence of compromised skin integrity (Dermatitis, Abrasion, Open wound) McMullen/Stoloff, ACHA, 6.2011

20. Assessment of Infection Risk Type of exposure ▫percutaneous ▫mucous membrane ▫non-intact skin ▫bites resulting in blood exposure Body substance ▫blood ▫bloody fluid ▫potentially infectious fluid or tissue Source patient ▫presence of HBsAg ▫presence of HCV antibody ▫presence of HIV antibody ▫if source unknown, assess epidemiologic and clinical evidence Exposed patient Source person ▫presence of HBsAg ▫presence of HCV antibody ▫presence of HIV antibody ▫if source unknown, assess epidemio logic and clinical evidence McMullen/Stoloff, ACHA, 6.2011

21. Source Patient’s History HBV (HBsAg) HCV (HCV Ag) If positive: HCV RNA HIV* (HIV EIA) If positive: Viral load CD4 count * Consent & confidentiality McMullen/Stoloff, ACHA, 6.2011

22. Infection Status of Source Patient Hepatitis B Status +/- (HBsAg) Hepatitis C Status +/- (HCV Ag, HCV RNA) HIV-Negative HIV-Positive – Class 1 o Asymptomatic HIV infection o Known low viral load (eg. <1500 RNA copies/ml), HIV + HIV-Positive – Class 2 o Symptomatic HIV infection o AIDS o Acute sero-conversion o Known high viral load Source of unknown HIV status o Bloodwork from source patient is still pending o Patient is refusing to test o Deceased source patient with no samples available Unknown Source o Needle from sharps container McMullen/Stoloff, ACHA, 6.2011

23. Exposed Patient’s History HBV immunity Series of 3 HBV vaccines (0,1,6 mos) Known titer >0.9 (HBsAb) If unknown or negative titer, check HBsAb HCV baseline (HCV Ab) HIV baseline * (HIV ½ EIA Ab Screen w/reflexes) McMullen/Stoloff, ACHA, 6.2011

24. Risk of acquisition of bloodborne pathogens HBVHCVHIV Percutaneous6-30 %1.8 %0.3 % Mucosal Risk not quantified, transmission documented 0.09 % Non-intact Skin Risk not quantified, transmission NOT documented < 0.1 %, risk not completely quantified Human bite Risk not quantified, transmission documented Risk not quantified, possible transmission reported UpToDate - Management of healthcare workers exposed to hepatitis B virus or hepatitis C virus – October 26, 2010, David J Weber, MD, MPH et al

25. McMullen/Stoloff, ACHA, 6.2011

26. Initial Treatment McMullen/Stoloff, ACHA, 6.2011

27. Post-exposure Management: HBV Baseline evaluation and testing of source patient If Source is HBV+ (Presence of hepatitis B surface antigen (HBsAg) indicates source is infected with HBV) Baseline evaluation and testing of HCW Consideration of treatment for HCW ▫Check Hep B immune status  Did exposed patient have 3-dose Hep B series?  Hep B Surface Ab Positive? (titers >0.9 mIU/mL)  no testing or treatment needed ▫When to give HBIG (Hepatitis B Immune Globulin)  Exposures to unvaccinated healthcare workers- should receive 3 addn’l doses of vaccine and consider HBIG  Exposures with no titers, consider HBIG  Ideally administer HBIG within 24 hours ; the effectiveness of HBIG is unknown if administered more than 7 days after exposure. Interesting Fact ▫HBV can survive on counter tops for 7 days and remain capable of causing infection. McMullen/Stoloff, ACHA, 6.2011

28. Post-exposure Management: HCV Baseline evaluation and testing of source patient Baseline evaluation and testing of HCW If HCV + Source, labs for HCW: ▫Baseline HCV Ab, baseline LFTs (ALT), and HCV RNA (if +HCV Ab)* ▫Follow-up testing for HCV RNA between 4-6 weeks after exposure (Penn has f/u in 2 weeks*) ▫Follow-up testing for HCV Ab, HCV RNA, and ALT between 4-6 months after exposure There is NO proven effective post-exposure prophylaxis for persons exposed to HCV BFEs. Immunoglobulin and antiviral agents are NOT recommended. When HCV transmission is identified early, the individual should be referred to a specialist knowledgeable in the management of acute HCV infection, since early treatment is associated with excellent cure rates. HCV can remain infectious for between 16 hours and 4 days. McMullen/Stoloff, ACHA, 6.2011

29. Average Risk of HIV Infection to Healthcare Personnel by Exposure Route Percutaneous 0.3% Mucous membrane 0.09% Non-intact skin<0.1% McMullen/Stoloff, ACHA, 6.2011

30. Post-exposure Management: HIV Baseline evaluation and testing of source patient ▫CD4 count, viral load, HIV meds patient is on Baseline evaluation and testing of HCW Consideration of treatment ▫when to give Post-Exposure Prophylaxis (PEP) ▫what to give (cost, schedule of meds, toxicity) ▫When to start medications ▫Pregnant? Breastfeeding? Follow-up testing and counseling HIV virus is very fragile outside the body, but it can live from several minutes to several hours on the surface of objects in the environment, depending on the situation and environmental factors. McMullen/Stoloff, ACHA, 6.2011

31. Risk of Adverse Effects Risk of Transmission Considerations for When to Use PEP *Risk varies widely according to exposure Risk of infection for HIV* Toxicity of PEP Inconvenience of meds Cost of PEP McMullen/Stoloff, ACHA, 6.2011

32. Initiation of HIV Postexposure Prophylaxis (PEP) If indicated, start PEP as soon as possible after exposure ▫regard as an urgent medical concern ▫Should be initiated as soon as possible ▫Starter pack available Interval after which PEP is no longer likely to be effective in humans is unknown ▫Offer for up to 24-36 hours after exposure ▫initiating PEP days or weeks after an exposure might be considered if warranted for increased risk exposure McMullen/Stoloff, ACHA, 6.2011

35. Situations Where PEP is Rarely, if Ever, Warranted Intact skin contact with blood and potentially infectious body fluids Exposure to unknown source in populations where HIV prevalence is low Low-risk exposure to unknown source McMullen/Stoloff, ACHA, 6.2011

36. Postexposure Prophylaxis (PEP) Basic 4-week regimen of two drugs for most HIV exposures Expanded regimen (addition of a third drug for HIV exposures that pose an increased risk for transmission). When the source person's virus is known or suspected to be resistant to one or more of the drugs considered for the PEP regimen, the selection of drugs to which the source person's virus is unlikely to be resistant is recommended. McMullen/Stoloff, ACHA, 6.2011

37. Most commonly prescribed drugs for PEP or Aluvia McMullen/Stoloff, ACHA, 6.2011

38. Penn SHS provides Truvada and Isentress Penn Global Health programs supply Truvada and Aluvia or Aluvia McMullen/Stoloff, ACHA, 6.2011

39. Penn SHS: Truvada - dosing is 1 tablet daily (Tenofovir 300 mg/Emtricitabine 200 mg) Issentress - dosing is 1 tablet twice daily (Raltegravir 400mg) PEP Medications McMullen/Stoloff, ACHA, 6.2011

40. Main Side Effects of PEP Drugs Tenofovir (Viread) Headache, nausea/vomiting Emtricitabine (Emtriva) GI side effects, usually well tolerated Tenofovir/Emtricitabine *(Truvada) Headache, nausea/vomiting, muscle pain/weakness Lamivudine (Epivir) GI side effects, usually well tolerated Lopinavir/Ritonavir (Aluvia or Kaletra) Diarrhea, nausea/vomiting Raltegravir *(Isentress) GI side effects, usually well tolerated McMullen/Stoloff, ACHA, 6.2011

41. Postexposure Management: Follow-up Testing of Exposed Person Follow UP McMullen/Stoloff, ACHA, 6.2011

42. Postexposure Management: HIV Postexposure Counseling Side effects of PEP drugs Signs and symptoms of acute HIV infection ▫Fever, rash, flu-like illness Prevention of secondary transmission ▫sexual abstinence or condom use ▫no blood/tissue donation Transmission and PEP drug risks if breastfeeding No work restriction is indicated McMullen/Stoloff, ACHA, 6.2011

44. Anxiety “Can I still be a doctor/nurse/dentist if I am infected with HBV, HCV, and/or HIV?” McMullen/Stoloff, ACHA, 6.2011

45. Society for Healthcare Epidemiology of America http://www.premierinc.com/safety/safety-share/02-10-downloads/12_HBV_HCV_HIV.pdf McMullen/Stoloff, ACHA, 6.2011

46. SHEA’s position: “Infection with a bloodborne pathogen does not itself justify restriction on the practice of an otherwise competent healthcare provider.” McMullen/Stoloff, ACHA, 6.2011

47. 3-tier Risk Schema Category I ▫Minor suturing, Elective phlebotomy Category II ▫Vaginal delivery, Line insertion Category III ▫General surgery, Non-elective procedures performed in the ED, risk of being bitten McMullen/Stoloff, ACHA, 6.2011

48. Restrictions Category I and II No restriction solely on the basis of infection Category III Restrictions tied to circulating viral burden McMullen/Stoloff, ACHA, 6.2011

49. Privacy Our duty is to the patient Who tells the school? ▫The student McMullen/Stoloff, ACHA, 6.2011

50. Global Health Rotations Risks Policies/protocols to safeguard students travelling to low-resource areas for clinical experiences McMullen/Stoloff, ACHA, 6.2011

51. Travel consultation All of the usual travel advice PLUS ▫N95 fit testing, pre- and post-travel TTBI ▫HIV PEP  Starter pack  Expert evaluation  Plan for treatment continuation  Disposal of unused meds  Post-travel BFE follow up McMullen/Stoloff, ACHA, 6.2011

53. Thank you!