1. Protocols Involving MRSA Infection Lice & Scabies Tuberculosis Influenza HIV, Hepatitis B & C Presented By: Stephen W. Munday, MD, MPH, MS Sharp Rees-Stealy Medical Group, Inc. Occupational Medicine

2. MRSA Spread by direct contact/fomites 30% of general public is colonized with SA Now most common type of SA isolated in all settings (greater than 50% of isolates) Most cases similar to MSSA clinically Certain strains are more virulent and are more likely to cause severe disease Presumptive for Firefighters/Police 01/01/2009 (methicillin-resistant Staphylococcus aureus) For MRSA photos, click here: http://www.staph- infection- resources.com/mrsa- pictures.htmlhttp://www.staph- infection- resources.com/mrsa- pictures.html

3. Head Lice Adult head lice are 2.1-3.3 mm in length. Head lice infest the head and neck and attach their eggs to the base of the hair shaft. Lice move by crawling; they cannot hop or fly. Head lice infestations (pediculosis, pronounced peh-DICK-you-LO-sis) are spread most commonly by close person-to- person contact. Dogs, cats, and other pets do not play a role in the transmission of human lice. Both over-the-counter and prescription medications are available for treatment of head lice infestations. Treatments include use of pyrethrins (OTC), malathion (Rx), 2 nd treatment is often necessary after 7-10 days

4. Body Lice Adult body lice are 2.3-3.6 mm in length. Body lice live and lay eggs on clothing and only move to the skin to feed. Body lice are known to spread disease. (i.e. louse-borne typhus) Body lice infestations (pediculosis, pronounced peh- DICk-you-LO-sis) are spread most commonly by close person- to-person contact but is generally limited to persons who live under conditions of crowding and poor hygiene (for example., homeless, refugees, etc.). Dogs, cats, and other pets do not play a role in the transmission of human lice. Improved hygiene and access to regular changes of clean clothes is the only treatment needed for body lice infestations.

5. Pubic Lice Adult pubic lice are 1.1-1.8 mm in length. Pubic lice typically are found attached to hair in the pubic area but sometimes are found on coarse hair elsewhere on the body (for example, eyebrows, eyelashes, beard, mustache, chest, armpits, etc.). Pubic lice infestations (pthiriasis, pronounced THIR-i-a-sus) are usually spread through sexual contact. Dogs, cats, and other pets do not play a role in the transmission of human lice. Both over-the-counter and prescription medications are available for treatment of pubic lice infestations. Treatments include use of pyrethrins (OTC), malathion (Rx), 2nd treatment may be necessary after 7- 10 days

6. Scabies Treatment is by Rx only Topical treatment is usually done with permethrin crème 5% or crotamiton can be used; a 2 nd treatment is sometimes necessary if symptoms persist more than 2-4 weeks Oral ivermectin can be used but a 2 nd dose Must be given 2 weeks later

7. Tuberculosis Spread by aerosol droplets / air-borne transmission 1 / 3 – ½ of household droplets infected Drug resistance increasingly common Treatment is complicated and lengthy requiring multiple drugs for a minimum of 6 months

8. Tuberculosis Work-related exposure still common in San Diego – not just healthcare workers New blood tests (eg, Quantiferon) available and will likely eventually replace PPD Persons infected but not ill have LTBI –They have a ~10% chance of developing acute TB in future Treatment with INH for 9 months or Rifampin for 4 months greatly decreases risk of later developing acute TB

9. H1N1 First cases identified were two Southern California children in April 2009 Currently over 1 million Americans have been infected and many more worldwide Predominant flu circulating in North America Spread by direct contact and respiratory droplets Not sure how much is by airborne transmission ILI defined as fever (100  ) and cough but nasal and GI symptoms can also occur

10. H1N1 Limit spread by social distancing and good hygiene –Hand washing! (soap & water or alcohol-based hand sanitizers) –Stay home if sick! –Use a fit tested N-95 respirator (IOM) to limit exposure in appropriate settings –General work setting: may return 24 hours after cough and fever have resolved –Healthcare setting: 7 days after onset and 24 hours after fever and cough resolved –Use an antiviral (Tamiflu) for exposures or illness in high-risk persons

11. H1N1 Flu (Swine) AND SEASONAL FLU VACCINE 2009-2010 is a confusing year. There will be two kinds of flu vaccines available - seasonal and H1N1. It is recommended that everyone be vaccinated against both. The supply of H1N1 flu vaccine may be limited at first, but eventually there will be enough vaccine for anyone who wants protection from H1N1 flu.

12. H1N1 Flu Vaccine Seasonal Influenza Vaccine What types of flu vaccine are available? Both vaccines will be available either as shots (inactivated, injectable vaccine) or as a nasal spray (live, attenuated virus vaccine). ). The nasal spray vaccine can only be used in healthy individuals between the ages of 2 and 49 years. Everyone else should receive the injectable vaccines (shots). Both vaccines are manufactured the exact same way and are equally safe.

13. H1N1 Flu Vaccine Seasonal Influenza Vaccine How many doses will I need? Everyone will need 2 doses separated by at least 3 weeks Everyone needs one dose Children under age 9 may need 2 doses – ask your doctor

14. H1N1 Flu Vaccine Seasonal Influenza Vaccine Who should be vaccinated and when? H1N1 flu vaccine should go first to those in groups who are at highest risk for more severe disease. Seasonal flu vaccine can go to anyone who wants protection starting as early as September.

15. Seasonal Influenza Vaccine Target Groups (September –March) (order of target groups does not indicate priority) all children age 6 months through 18 years pregnant women persons age 50 years and older persons who have chronic underlying medical conditions (such as asthma) or weakened immune systems residents of long-term care facilities health care personnel household contacts and caregivers of children aged 50 years, with particular emphasis on vaccinating contacts of children aged 50 years, with particular emphasis on vaccinating contacts of children aged <6 months; and household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza

16. H1N1 Flu Vaccine Priority 1 (October - March): (order of target groups does not indicate priority) (order of target groups does not indicate priority) Pregnant women Persons who live with or provide care for infants aged <6 months (e.g. parents, siblings, & childcare providers) Health-care & emergency medical services personnel who have direct contact with patients or infectious material Children aged 6 months – 4 years Children & adolescents aged 5 – 18 years who have medical conditions that put them at higher risk for influenza-related complications

17. H1N1 Flu Vaccine Priority 2 (November - March): (order of target groups does not indicate priority) (order of target groups does not indicate priority) All other health-care and emergency medical services personnel All persons aged 6 months-24 years Persons aged 25-64 years who have medical conditions that put them at higher risk for influenza-related complications

18. H1N1 Flu Vaccine Priority 3 (December - March): (order of target groups does not indicate priority) (order of target groups does not indicate priority) All persons aged 25 and older Anyone else wanting protection from H1N1

19. H1N1 Flu Vaccine Seasonal Influenza Vaccine Can I get H1N1 and Seasonal Flu vaccine at the same time? Yes. It is fine to receive seasonal flu vaccine and H1N1 vaccine at the same time. However, if you choose to receive the nasal spray vaccine for both H1N1 and seasonal flu protection, they must be given three- four weeks apart from each other.

20. Estimates indicate that 600,000 – 800,000 needlestick injuries occur yearly in the USA Only about 50% are reported An average hospital has approximately 30 needlestick injuries per 100 bed-years Nursing staff have the highest risk Blood-borne Pathogens

21. Hepatitis B Clinical Features Incubation period: 6 weeks - 6 months May have prodrome of fever, malaise, headache, myalgia Jaundice may persist for days or weeks Symptoms not specific for hepatitis B At least 50% of infections asymptomatic

22. Chronic Carriage Chronic viremia Responsible for most mortality Overall risk: 10% Higher risk with early infection

23. Annual Disease Burden from Hepatitis B Virus Infection Total infections = 150,000 Symptomatic infections = 50,000 Hospitalized = 8,000 Death –Fulminant Hepatitis = 200 –Liver Cancer = 1,500 –Cirrhosis = 4,000

24. Hepatitis B Epidemiology Reservoir:Human; Endemic Transmission:Bloodborne; Subclinical cases transmit Communicability:1-2 months before and after onset of symptoms; Chronic carriers

25. Risk Factors for Hepatitis B Heterosexual Homosexual Drug Abuse Unknown HouseholdContact Health Care Other

26. Hepatitis B Vaccine Composition: Recombinant HBsAg Efficacy: 95% (Range, 80%-100%) Duration of immunity: >15 years Schedule: 3 doses at least 1 month apart and repeat Titer at least 1 month after last dose Booster doses not routinely recommended, however non- responders should receive 3 additional doses at least 1 month apart and repeat titer

27. Hepatitis B High-Risk Populations Clients in institutions for developmentally disabled Immigrants/refugees from areas of high HBsAg endemicity Patients of hemodialysis units Intravenous drug users cont’d...

28. Hepatitis B High-Risk Populations Homosexual males Household contacts of HBV carriers Recipients of certain blood products Alaskan Natives, Pacific Islanders

29. Hepatitis B Intermediate-Risk Populations Male prisoners Health care workers with frequent blood contact Staff of institutions for developmentally disabled

30. Hepatitis B

31. Recommendations for hepatitis B prophylaxis following percutaneous or permucosal exposure

32. 1 = HBIG dose is 0.06 ml/kg IM 2 = Adequate anti-HBs is>10 SRU by RIA or positive by EIA

33. Hepatitis C Transmission is similar to Hep B but the risk is much lower due to low levels of virus outside the liver Seroconversion can be delayed up to 6 months after exposure therefore evaluate patient for seroconversion with Hep C RNA and Hep C antibody testing Causes chronic infection in 70-85% of those infected who are not treated acutely cont’d… cont’d…

34. Hepatitis C (cont’d) Interferon and Ribavirin have been demonstrated to give clinical remission in a minority of those treated Treatment of acute infection in order to prevent chronic infection is effective There is no vaccine that will likely become available in the foreseeable future.

35.   Hepatitis C

36. HIV As of June 2000, 56 documented and 138 possible cases of occupational HIV transmissions to US health care workers were reported to the CDC Most involved nurses and laboratory technicians Percutaneous injuries (“needlesticks”) were associated with 89% (49) of the documented cases cont’d… cont’d…

37. HIV (cont’d) 44 of the 49 involved hollow-bore needles, the majority of which were used for blood collection or insertion of an IV catheter Based on data collected prospectively from 20 studies worldwide, 21 of 6498 (0.3%) health care workers with percutaneous exposure to HIV developed infection cont’d… cont’d…

38. HIV (cont’d) Based on a case-control study of health care workers, transmission risk is increased by: –A visibly bloody device –A procedure which placed a needle in the source’s vein or artery –A deep injury This same study estimated that use of AZT decreased the risk of HIV infection from a percutaneous exposure by 79% cont’d… cont’d…

39. HIV (cont’d) Studies of perinatal transmission have shown that AZT can decrease the risk by two-thirds. There are no human data regarding optimal timing of post-exposure prophylaxis. There are 21 cases in which transmission occurred despite almost immediate institution of antiviral prophylaxis cont’d… cont’d…

40. HIV Animal data suggest that optimal protection occurs if the prophylaxis is given within 1-2 hours of exposure. There is no evidence of benefit after 24-36 hours Combination therapy, while theoretically sound, remains unproven Toxicity may be increased with combination therapy –2 cases of progressive fatal neurologic disease associated with ZDV and 3TC used for perinatal protection –Fatal lactic acidosis has been reported in pregnant women treated with d4T and DDI

41. HIV

43. Putting it all together…

44. * Unnecessary if Hep BsAg or sAb is positive  Archive blood for 90 days if HIV testing is declined

45. Prevention of Exposure to Blood-born Pathogens Universal precautions – –Assume everyone is potentially infectious –Use appropriate barrier protection, especially gloves

46. Case Study After performing phlebotomy on a patient with AIDS, a health care worker sustained a deep needlestick with the used phlebotomy needle. Blood from the collection tube also spilled into the space between the wrist and cuff of the health care worker’s gloves, contaminating her chapped hands. The health care worker removed the gloves and washed her hands immediately. Cont’d…

47. Case Study (cont’d) She had a negative baseline HIV test and refused zidovudine prophylaxis. Because the source patient was not known to have HCV infection and did not have clinical evidence of liver disease, the health care worker did not receive baseline testing for exposure to HCV. Eight months after the incident, the health care worker was hospitalized with acute hepatitis. cont’d… cont’d…

48. Case Study (cont’d) She was found to be seropositive for HIV 9 months after the incident. 16 months after the incident, she tested positive for anti-HCV antibodies and was diagnosed with chronic HCV infection. Her clinical condition continued to deteriorate, and she died 28 months after the needlestick injury [Ridzon et al. 1997].

49. Occupational Exposure to Bloodborne Pathogens Post-Test

50. The average rate of HIV transmission from an infected source during a needle stick is? 3/100,0003/10,0003/10003/100

51. AZT has been shown to decrease the risk of HIV transmission from a needlestick in a single case/control study. The magnitude of this decrease was closest to: 20%40%60%80%

52. The risk of HIV transmission is greater for a solid-bore than for a hollow-bore needle TrueFalse

53. Combination antiretroviral treatment has been demonstrated in controlled trials to be better than AZT alone in preventing HIV transmission from a needlestick. TrueFalse

54. The risk of Hepatitis B transmissions from an infected source is closest to 0.1% 1% 1%6-30%60-80%

55. In general, Hep B virus is more likely to be transmitted by a needlestick than HIV TrueFalse

56. Based on currently available data, a healthcare worker who has completed all 3 doses of Hep B vaccine and has a positive Hep B surface antibody titer, should have a repeat titer (or “booster shot”) after 5 years TrueFalse

57. Hep B virus more commonly causes chronic infection than Hep C virus ? TrueFalse

58. Hep C transmission after a needlestick exposure from an infected source occurs ____% of the time on average 1.8%15%18.5%27.2%

59. Serum immune globulin has been shown to decrease the risk of Hep C infection after needlestick exposure TrueFalse

60. Hep C and HIV transmission have occurred from a single needlestick injury TrueFalse