1. M. A. El-Farrash

3. Practicing Medicine safely means that before you do any activity you should: Know the hazards, Know the worst things that could happen, Know what to do and how to do it if they should happen, Know and use the safe practices, protective facilities, and protective equipment needed to minimize the risks. M. A. El-Farrash

4. Radiation Flammable- oxidizing Toxic Explosive Low temperature US protectorsLaser Hazard M. A. El-Farrash

5. Workers in health care settings are constantly exposed to occupational hazards. But there is one hazard that people in the healthcare field fear most, the needle stick. M. A. El-Farrash

6. Nearly one million healthcare workers suffer needle stick injuries each year. At least 20 different pathogens (mainly viruses) may be transmitted by needle stick and sharps injuries. As a result, hundreds of workers are infected with diseases such as Hepatitis B, Hepatitis C and HIV. M. A. El-Farrash

7. Immediately following any exposure, the site of exposure (wound or non-intact skin) should be washed with soap and water without scrubbing. Exposed mucous membranes including conjunctivae should be irrigated with water, (after first removing contact lenses if present). If there has been a puncture wound, free bleeding should be encouraged gently but the wound should not be sucked. M. A. El-Farrash

8. Used disposable needles must not be bent, sheared, broken, recapped, removed from disposable syringes. They must be carefully placed in puncture- resistant containers used for sharps disposal. Non-disposable sharps must be placed in a hard-walled container for transport to a processing area for decontamination, preferably by autoclaving. M. A. El-Farrash

9. Puncture-resistant containers used for sharps disposal. M. A. El-Farrash

10. Broken glassware must not be handled directly by hand, but must be removed by mechanical means such as a brush and dustpan, tongs, or forceps. Containers of contaminated needles, sharp equipment, and broken glass are decontaminated before disposal, according to any local regulations. M. A. El-Farrash

11. There are more than 350 million HBV carriers worldwide (about 5% of world population). In studies done before introduction of HBV vaccine, doctors exposed to the risk of inoculation injury were shown to be four to five times more likely than others to be infected with HBV. M. A. El-Farrash

12. HBV Epidemiology Infection often results from inoculation with blood or serum, blood transfusions, transplants (HBV is common among IVDAs). Donors of blood or tissues for transplant are checked for HBsAg and positive persons are excluded. HBV is also transmitted sexually, and from mother to child (transplacental and by breast milk). M. A. El-Farrash

16. HBV Surface antigen (HBsAg): HBsAg may be present before symptoms are present. Its presence in serum indicates that virus replication is occurring in the liver. If this antigen level remains for more than 6 months, the case will probably become a carrier for HBV. HBsAg is one of the most frequently performed tests for HBV. M. A. El-Farrash

17. HBV e antigen (HBeAg): Its presence in serum indicates a high level of viral replication occurring in the liver. This test determines how contagious the patient is and may differentiate chronic replicative from chronic non-replicative states. Exposure to a needle stick from a patient who is positive for HBeAg may lead to infection of HCW. M. A. El-Farrash

18. Surface antibody (anti-HBs): Once HBsAb appears, HBsAg disappears. It indicates that infection is at the end of active stage. This antibody also protects positive persons from getting HBV again in the future (immunity). It is the antibody present after successful HBV vaccine. M. A. El-Farrash

19. Anti-HBe: It becomes detectable as viral replication falls. It indicates that infectivity of a carrier is greatly reduced. HBeAb is usually present during chronic non- replicative HBV infections. Its presence cannot be used to predict the outcome of a chronic infection. M. A. El-Farrash

20. Anti HBc IgM: It rises early in infection and indicates recent infection. Anti HBc IgG: It rises soon after IgM, and remains present for life in both chronic carriers as well as those who clear infection. Its presence indicates previous exposure to HBV. It is not present in vaccinated persons who were not exposed to HBV. M. A. El-Farrash

21. In the unvaccinated health care worker, the rate of transmission after percutaneous exposure to HBe antigen-positive blood may be higher than 30%. Staff who are carriers of HBV have been shown to present a risk of transmission to their patients during surgical or dental procedures. Vaccination can help. M. A. El-Farrash

22. Active Immunization: Recombinant HBsAg: It is produced in yeast transfected with the HBs genome has been available since 1986 and is now most widely used. The administration of three doses induces protective levels of antibodies in 95% of vaccine recipients. HBV Vaccination M. A. El-Farrash

24. Vaccine should be administered to people at high risk of infection with HBV: 1) Health care workers 2) Sexual partners of chronic carriers 3) Infants of HBV carrier mothers. 4) All newborn infants are now vaccinated. Effective vaccination campaigns could: 1) Save about one million lives p.a. 2) Eradicate the virus (no animal reservoir). HBV Vaccination M. A. El-Farrash

25. After 3-4 weeks from the last dose of the vaccine, vaccinated person should be tested for HBs Ab. In health care workers the protective titer should be above 100 mIU/ml of HBs Ab while in usual persons it is 10 mIU/ml. Booster doses (after the 3 doses course) are not necessary, and periodic serologic testing to monitor antibody titer after completion of the vaccine series is not recommended. M. A. El-Farrash

26. Single-room isolation is not routinely required for patients with acute HBV infection or carriers unless the patient is bleeding. Vaccination and careful attention to infection control procedures, including gloves and gown wearing, careful disposal of sharp instruments and needles, and satisfactory decontamination procedures, are the hallmarks of preventing transmission in the clinical setting. M. A. El-Farrash

27. HBV Treatment IFN-  is used for therapy of chronic HBV infection. Up to 50% chronic carriers respond to IFN treatment. Lamivudine (3TC an RT enzyme inhibtor). Combination therapy of both  -IFN and Lamividine gives better results. M. A. El-Farrash

29. HCV Genotypes Epidemiology M. A. El-Farrash

30. HCV Transmission X M. A. El-Farrash

31. Serology : Serological tests (ELISA and others) are available including simple rapid tests. Positive sera in low-prevalence regions needs confirmation by a more specific test like RIBA. In Egypt the predictability of positive tests is high so confirmation is not indicated (Instead of doing RIBA we advise to do PCR). Laboratory diagnosis of HCV Infection M. A. El-Farrash

32. Ag-detection kits are available; some of them are good others are doubtful. PCR detects viral genome in patient's serum, in liver biopsy or in macrophages. It can be done both quantitative or qualitative. Quantitative PCR is now in common use to decide the virus load before, during and after IFN therapy. Laboratory diagnosis of HCV Infection M. A. El-Farrash

33. In Egypt all our patients should be considered HCV-positive. The average incidence of HCV seroconversion after needle sticks or sharps exposures from an HCV-positive source is 1.8% (range: 0%-7%). HCV is a main killer of Egyptian doctors (from chronic hepatitis or Hepatocellular carcinoma). M. A. El-Farrash

34. HCV-positive persons should be advised to: (1)Not to donate blood, body organs or other tissues. (2)Cover cuts and sores on the skin to keep from spreading infectious blood or secretions. (3)Notify their doctors before doing any invasive activity including blood sample collection, minor operations, endoscopy ….etc. M. A. El-Farrash

35. The development of HCV vaccines, although proceeding, has been slowed by the extreme antigenic variability of the virus (6 genotypes, more than 60 subtypes). Inability to propagate HCV efficiently in any tissue-culture and lack of animal models other than the chimpanzee has also confounded the development of vaccines. M. A. El-Farrash

36. At present, there is no effective post-exposure prophylaxis against HCV infection. Until a vaccine is developed, prevention of spread and health education are essential to minimize exposure of non infected persons to the virus. HCWs and other people who may have contact with body fluids should learn and keep the principals of infection control. M. A. El-Farrash

37. Currently the best treatment for CHC patients is a combination of peg-IFN-a-2a and ribavirin. Genotypes 2 and 3 are responding well after 24 weeks of treatment. Genotypes 1 and 4 need 48 weeks of treatment and the outcome is not very good. New drugs like polymerase inhibitors (Sovaldi) or protease inhibitors are recently used. HCV Treatment M. A. El-Farrash

39. HIV Morphology M. A. El-Farrash

40. The initial target of HIV infection is the CD4 T- lymphocytes because CD4 receptor is the main receptor for almost all primate retroviruses. T4 are called helper lymphocytes as they are the main regulator of functions of all other T-cells. Killing T4 cells leads to severe defect in the cell- mediated immunity. M. A. El-Farrash HIV and Immunodeficiency

41. 1- Blood or blood products: Prior to 1985 HIV was transmitted by blood transfusions or blood products because there was no testing of blood for the AIDS virus. Since 1985 the blood supply has been screened for HIV with an effective test. Now HIV is transmitted by blood through the sharing of contaminated needles by persons abusing drugs. HIV Transmission M. A. El-Farrash

42. 2- Sexual contact: HIV can be passed in body fluids including semen or vaginal secretions. The infection can be passed from men to women, women to men, men to men, and women to women. Presence of other STDs or damage of intact epithelium increases the risk of transmission. HIV Transmission M. A. El-Farrash

43. 3- Mother to infant: HIV can be transmitted from mother to infant during pregnancy, at the time of birth, or by breast-feeding. Treatment of pregnant infected mothers with AZT during pregnancy is very effective in limiting transmission to infants. HIV Transmission M. A. El-Farrash

44. The average risk of transmission of HIV following percutaneous inoculation of blood from infected individuals is 0.32% (21 proved infections resulting from 6,498 inoculations). The current estimate of the infection risk following muco-cutaneous exposure to blood is 0.03% (1 infection following 2,885 exposures to mucous membranes and/or non intact skin). M. A. El-Farrash

45. Serology: Screening of blood is first done by ELISA which is very sensitive test (detecting all positive cases + few false positive). Positive results should be confirmed (before telling anyone) using more specific tests like Western Blot (WB) which will detect the true positive only. HIV Testing M. A. El-Farrash

46. Detection of p24 antigen: ELISA test detecting the viral antigen p24 is important to diagnose infection before sero-conversion and for confirmation of vireamic stage. PCR: Used mainly for detection of viral genome in suspected seronegative samples and also for determination of the viral load before and during therapy. HIV Testing M. A. El-Farrash

47. PEP means prophylactic drugs given after an HIV or suspected HIV exposure. The PEP used depend on the degree of exposure and the HIV status of the source of the exposure. Before any medications are prescribed, it has to be determined if PEP is indicated and appropriate. The sooner PEP is begun the better. M. A. El-Farrash

48. Two drugs PEP are recommended after: 1)Exposure to asymptomatic HIV positive person by solid needle stick or superficial injury that break the skin. 2)Mucous membrane exposure to a large volume of HIV infected blood from asymptomatic source. 3)Mucous membrane exposure to a small volume of HIV infected blood from is symptomatic source. M. A. El-Farrash

49. PEP should be started within hours of the potential exposure not days. Preferred regimen is AZT + lamivudine twice daily for a four week period. Three drugs combinations may be indicated in hollow needle stick or large volume of symptomatic patient’s blood exposure. M. A. El-Farrash

50. Attempts to make an effective AIDS vaccine have not been successful thus far. Numerous different methods are being tried, and progress is being made. More importantly we have to raise the awareness of people to stop the spread of infection. AIDS Vaccine M. A. El-Farrash

51. Any blood sample should be considered infectious even if proved otherwise. M. A. El-Farrash

52. Many infectious diseases can be prevented through simple and inexpensive methods. 1.Wash Your Hands Often 2.Routinely Clean and Disinfect Surfaces 3.Get Immunized. M. A. El-Farrash