2. Infection Control Overview: HIV and other Blood-Borne Pathogens Session 2: Infection Control Basics

3. 2: Infection Control Overview - HIV Slide 2 Learning Objectives This session deals with the control of HIV and other blood-borne pathogens By the end of session 2, participants will be able to: Protect themselves and others from HIV and other blood-borne pathogens Describe what to do after a needle prick or if blood and/or body fluids get into the eyes or mouth Provide input to the Hospital Infection Control Committee (HICC) on infection control procedures

4. 2: Infection Control Overview - HIV Slide 3 Discussion: Hepatitis B Immunisation Are you familiar with the current policy for Hep B vaccination before and after exposure? What is the procedure involved for a new hospital employee under this policy? What are the contraindications for the Hep B vaccination?

5. 2: Infection Control Overview - HIV Slide 4 Protecting Yourself from Blood-Borne Pathogens

6. 2: Infection Control Overview - HIV Slide 5 Protecting Yourself from Blood-Borne Pathogens (cont’d) Wear gloves Don’t recap needles Complete 3 doses of Hep B vaccine Eliminate unnecessary injections Dispose of sharps immediately after use to minimise handling that increases risk of needlesticks Substitute safer devices or tools whenever possible Report needlesticks

7. 2: Infection Control Overview - HIV Slide 6 Protecting Yourself from Blood-Borne Pathogens (cont’d) Which pathogen is most likely to be transmitted from a needle used on an infectious patient?  HIV  HEP B  HEP C

8. 2: Infection Control Overview - HIV Slide 7 HIV: 3 Infections per 1,000 Sticks with a HIV+ Needle 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000

9. 2: Infection Control Overview - HIV Slide 8 Hepatitis C: 18 Persons per 1,000 Needle-sticks 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000

10. 2: Infection Control Overview - HIV Slide 9 Hepatitis B is Most Infectious 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000000000000000000000 000000000000000000

11. 2: Infection Control Overview - HIV Slide 10 Why is Hep B Virus More Infectious than HIV? Viral concentration per mL Virulence factor Incubation period

12. 2: Infection Control Overview - HIV Slide 11 Protect Yourself! Get a Hepatitis B Vaccination and keep your Vaccine Record 3 doses of Hepatitis B vaccine protect most people for a lifetime The next dose at this facility will be given on _______________ Will you be there with your staff?

13. 2: Infection Control Overview - HIV Slide 12 Prevention of Injury Due to Sharps is Critical In some hospitals in India, staff report 1-2 sharps injuries per person per year Do you know how, when, with what device and to whom most sharps injuries occur?

14. 2: Infection Control Overview - HIV Slide 13 Exercise 2.1: Sharps Injury Role Play Instructions: Divide into groups of 5 Decide who will play the roles of supervisor, health worker, and observer The health care worker will pretend that they have just received a sharps injury The supervisor should interview the worker about the injury using worksheet 2.1 as a guide The observer will report back to the larger group on what took place

15. 2: Infection Control Overview - HIV Slide 14 Discussion: Sharps Reporting Form Is this Proforma sufficient for reporting sharps injuries? Why or why not? What changes could be made to current reporting procedures to make it easier to report injuries? Why do you think injuries are not always reported?

16. 2: Infection Control Overview - HIV Slide 15 What do We Mean by “Sharps” Needles and syringes Glass capillary tubes Glass ampoules Vacutainer needles Suture needles, IV introducers and IV flushes Test tubes and glass apparati used in lab

17. 2: Infection Control Overview - HIV Slide 16 Eliminate Needle use When Possible Do not use an injection or IV medicine when an oral medicine will do! Do not place a venting needle into an IV; this increases the risk of contamination and needlesticks

18. 2: Infection Control Overview - HIV Slide 17 Substitute Metal or Plastic for Glass when Possible Staff are discussing using metal tubes for pulmonary drainage rather than glass to help prevent accidents

19. 2: Infection Control Overview - HIV Slide 18 Sharps Injuries are Likely to Occur… During recapping needles During blood draws During IV insertion & removal When handling needles (taking them apart, picking up a dirty syringe, dumping containers, etc.) When disposing of sharps During waste collection and processing During breakages

20. 2: Infection Control Overview - HIV Slide 19 Safe Handling of Sharps Wear gloves when drawing blood or handling sharps—double glove for surgery Don’t recap! Don’t bend or break needles Never place used sharps on tables, beds, furniture Put used sharps immediately into a sharps container

21. 2: Infection Control Overview - HIV Slide 20 Disposal of Sharps: The Ideal Immediately after use, put sharps in a leak- proof and puncture- proof container The container should be within arm’s length

22. 2: Infection Control Overview - HIV Slide 21 Sharps Disposal at GHTM Needle destroyer Disposal of sharps in blue bins What are some potential problems with the current sharps disposal system?

23. 2: Infection Control Overview - HIV Slide 22 Sharps Disposal (cont’d) Disposal containers should be placed at all points of use Disposal bin should be rigid and should be leak and puncture proof Separate sharps from other waste so laundry workers or waste disposal staff do not get needlesticks Empty sharps containers when they are ¾ full

24. 2: Infection Control Overview - HIV Slide 23 Danger! Open containers of used needles like this put staff at risk each time they put a hand in to pick up one Keep your ward free of used sharps

25. 2: Infection Control Overview - HIV Slide 24 Remember this Procedure… If a needle pricks you or blood and/or body fluids enter your eye(s) or mouth  Wash wounds with soap and water  Flush eyes and mouth with water  Check the patient record to see if the patient is HIV+, HIV-, or untested  Check patient record for Hepatitis B or C infection  Call the medical duty officer immediately

26. NACO PEP Guidelines

27. 2: Infection Control Overview - HIV Slide 26 Determination of Exposure Code

28. 2: Infection Control Overview - HIV Slide 27 Determination of HIV Status Code

29. 2: Infection Control Overview - HIV Slide 28 Determination of PEP Recommendation EC HIV SCPEP Recommendation 11 Pep may not be warranted 12 Consider basic regimen Exposure type poses a negligible risk for HIV transmission 21 Recommend basic regimen Most HIV exposures are in this category; no increased risk for HIV transmission has been observed but use of PEP is appropriate 22 Recommend expanded regimen Exposure type represents an increased HIV transmission risk 31 or 2 Recommend expanded regimen Exposure type represents an increased HIV transmission risk UNKNOWN If the source, (in the case of an unknown source), the setting where the exposure and the EC is 2 or 3, consider PEP basic regimen

30. 2: Infection Control Overview - HIV Slide 29 HIV Testing and Counselling Post exposure HIV testing done at intervals of immediately, at 6 weeks and 6 months accompanied by Pre-test counselling Post test counselling

31. 2: Infection Control Overview - HIV Slide 30 Drugs Recommended for Post Exposure Prophylaxis Zidovudine – 300mg 12 hrly Lamivudine – 150 mg 12 hrly Indinavir – 800 mg thrice daily ( expanded regimen only) For 28 days

32. 2: Infection Control Overview - HIV Slide 31 Treatment for HIV after Needlesticks (Post Exposure Prophylaxis) It is most effective if started 1- 2 hours after exposure Can be given up to 72 hours after exposure Should NEVER be given without medical follow-up and filing an incident report because of the serious side effects, and the need to try to prevent similar injuries Must be taken for 28 days Pregnant staff can take PEP drugs. Tell the duty officer if you might be pregnant so he can give appropriate medications Staff member on PEP should avoid sex or practice safe sex (use condoms)

33. 2: Infection Control Overview - HIV Slide 32 Group Discussion: Help the Infection Control Committee What is the current PEP policy and practice at your facility?  How soon after an injury should it be reported?  What do you describe a significant exposure? How should the confidentiality of the test report be maintained? Where should an emergency stock of PEP drugs be stored? Should the source patient be tested?

34. 2: Infection Control Overview - HIV Slide 33 NACO PEP Policy - Role of the Medical Officer Decides if PEP is needed Tests the source patient and staff for HIV, if test results are not available Tests staff members who take PEP at six and 12 weeks for HIV, and monitors for side effects Gives reporting form to the Superintendent Keeps all information confidential

35. 2: Infection Control Overview - HIV Slide 34 When do you need to wear gloves? Discussion: Personal Protective Equipment

36. 2: Infection Control Overview - HIV Slide 35 Gloves Wear clean gloves when handing blood or body fluids Wear clean gloves when serving food Wear sterile gloves when handling sterile supplies, doing invasive procedures, suctioning, catheters, etc. Wear surgical gloves for surgery

37. 2: Infection Control Overview - HIV Slide 36 Utility Gloves Utility gloves are used repeatedly and have many germs Do not use them to touch patients, patient care items, or anything near patents Use the same utility gloves for the same tasks - use separate gloves for dirty and clean tasks Utility gloves must be washed with detergent and bleach and left to dry at the end of the shift

38. 2: Infection Control Overview - HIV Slide 37 Summary: Steps to Protect Yourself from Blood-Borne Pathogens Wear gloves Don’t recap needles Complete 3 doses of Hep B vaccine Eliminate unnecessary injections Dispose of sharps immediately after use to minimise handling that increase risk of needlesticks Substitute a safer substance or tool whenever possible Report needlesticks immediately

39. 2: Infection Control Overview - HIV Slide 38 Key Points HIV PEP should be in started within 1-2 hours and should be used for four weeks if needed You can help others by being a good role model Supervisors should tactfully correct staff if they are doing unsafe practices

40. 2: Infection Control Overview - HIV Slide 39 Hospital Infection Control Committee (HICC)

41. BREAK