Occupational exposures to HIV: Prevention and PEP

1. Occupational exposures to HIV: Prevention and PEP HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. Learning objectives At the end of this presentation, each trainee can understand: • the risk of transmission of HIV, HBV and HCV after a single percutaneous exposure. • the one handed or “scoop” technique of recapping needles • the way to wash a wound in the event of a needle stick to possibly HIV infected blood or fluids. • the indications for using PEP. • PEP regimens in Vietnam • 5 steps to prevent TB transmission in HIV care settings

3. Content of Presentation • Risks of HIV transmission through occupational exposures • Principles and practices of Universal Precautions • Post exposure prophylaxis: rationale and recommendations • Post exposure prophylaxis in Vietnam: procedures • Occupational exposures to HBV and TB and preventions in the healthcare setting

4. Estimated HIV risk for a single exposure to HIV+ source 90% 25-35% 0.67% 0.3% 0.5% 0.1% 0.065% 0.05% 0.01% 0.005% (CDC, MMWR, 2005)

5. HIV transmission in through occupational exposures • In general the risk for HIV transmission depends on the route and the severity of exposure to the HIV infected fluid • The most common source of HIV exposure is blood.

6. Data on occupational exposures to HIV in Vietnam • At one hospital in HCMC in 2000, 330/886 (38%) staff suffered a percutaneous exposure to blood. Sohn. 15th IAC: Abstract ThPeC7512.

7. HIV transmissions from patient to healthcare workers (HCW) in USA • 57 confirmed HIV seroconversions in HCWs following occupational exposures • 138 cases of HIV/AIDS among HCWs with no risk factors for HIV infection other than occupational exposure in which seroconversion after an exposure was not documented Centers for Disease Control and Prevention, December 2001

8. HIV transmissions from patient to HCWs in USA

9. Exposure types in 57 occupationally HIV infected healthcare workers in the United States

10. Fluid exposures that lead to HIV seroconversion in 57 healthcare workers in the United States

11. Risk of HIV transmission

12. Factors affecting risk of HIV transmission after percutaneous exposure

13. Follow Universal Precautions Safely manage sharps Universal Precautions #1 Treat ALL blood as potentially infectious #2 Prevent needlesticks

14. Universal Precautions Universal precautions minimizes exposure to blood in 5 ways: • Use of protective barriers • Hand hygiene • Safe injection practices • Environmental control of blood and bodily fluids • Sharps management

15. 1. Use of protective barriers Procedure Gloves Gown Goggles/Face Protection Giving an injection No No No Drawing blood Yes No No Irrigating a wound Yes Yes Yes Performing an operation Yes Yes Yes

16. 2. Hand hygiene • Prevents transmission of resistant organisms and infections • Before patient care • After blood/fluid contact, glove removal • Methods • Handwashing • (Water + soap) x >10s  single-use towel • Use of hand sanitizer • 50-95% ethyl or isopropyl alcohol http://www.cdc.gov/handhygiene

17. 3. Use of safe injection practices Best injection safety practices • Injection should be administered with a sterile syringe and needle, using the right medication, etc. • Needle should be placed in a puncture-proof container immediately after use. • Sharps waste should be discarded appropriately.

18. 4. Environmental control of blood and body fluids • Spills in patient-care areas • Clean visible blood/fluid with towel and discard • Disinfect area • 1:100 dilution (500 ppm) of hypochlorite • Spills in laboratory areas • Soak towel and blood/fluid spill in disinfectant before discarding • Use more potent disinfectant • 1:10 dilution (5000 ppm) of hypochlorite

19. 5. Sharps Management • Injuries can occur whenever a sharp is exposed in the work environment • Organize work areas • Have sharps containers nearby • Avoid hand-passage of sharps • Do not recap needles or, recap using a one-handed “scoop technique”

20. “One-hand” technique of recapping needles

21. Post-Exposure Prophylaxis (PEP) Rationale: • HIV pathogenesis: systemic infection does not occur immediately - “window of opportunity” when giving ARV may prevent HIV infection

22. Rationale for post-exposure prophylaxis

23. Efficacy of antiretroviral therapyHuman data-CDC Needlestick Surveillance Group • Case Control study: 31 cases and 679 controls • Cases: acquired HIV following an occupational exposure; 94% after a needlestick (all hollow needles) • 29% of cases received PEP (AZT) vs 36% of controls • Risk for HIV infection was reduced by ~81% in HCWs receiving AZT Cardo D. NEJM 1997; 337:1485-90

24. Steps for post-exposure management • Treat the exposure site • Report the exposure to the manager and complete the report form • Assess the risk of exposure • Determine the HIV status of the source of exposure • Determine the HIV status of the exposed person. • Counsel the exposed person. • Provide ARV prophylaxis (if indicated)

25. What to do immediately upon an exposure to a possibly HIV infected bodily fluid and/or blood • If there was a percutaneous exposure: • Flush the wound with tap water • Let the wound bleed for a short time without squeeze • Clean the wound with soap and water • Evaluate the need for PEP

26. What to do immediately upon an exposure to a possibly HIV infected bodily fluid and/or blood • If there was an eye exposure: • Wash the eye(s) with water or NaCl 0.9% solution continuously for 5 minutes • Evaluate the need for PEP • If there was a mouth and/or nose exposure: • Rinse with water or NaCl 0.9% solution. • Gargle with NaCl 0.9% solution for several times. • Evaluate the need for PEP

27. Evaluating the need for PEP: Assessing the risk of HIV transmission by occupational exposure • Risk presents with: • Deep wounds with large bleeding, caused by large-bore needles. • Deep and large percutaneous wounds with bleeding, caused by scalpels or broken blood containing tubes. • Existing lesions, ulcers or scratch on the skin or mucus membranes (e.g. eye, nose) exposed to patient's blood or body fluids. • No Risk if: • Contact of normal skin with patient’s blood or body fluid.

28. Additional PEP issues • Timing – as soon as possible!!! • Do not delay to obtain additional information on the source patient • Best if given within 2 - 6 hours, not recommended after 72 hours • Duration of PEP: 4 weeks

29. National Guidelines on PEP Regimens

30. National Guidelines on PEP Regimens • Dosages: • AZT: 300mg BID PO • 3TC: 150mg BID PO • d4T: 30mg BID PO • LPV/r: 400mg/100mg BID PO • Nevirapine is not recommended due to fulminant liver failure in 4 American HCW taking it for PEP.

31. Suggested postexposure follow-up & testing • HIV testing of healthcare worker after 1, 3 and 6 months. • Laboratory tests to monitor ARV side effects: • Consider CBC, ALT on the start of treatment and after 4 weeks • Education and counseling of the healthcare worker: • their risk of infection with HIV, HBV, HCV • symptoms suggestive of ARV toxicity and/or primary HIV infection • prevention of secondary transmission: condom use with their partners

32. Testing the source patient • Inform the source patient of the incident, counsel, & test (with consent) for HIV and hepatitis B and C • Use a rapid HIV antibody testing if possible • If source patient found to be HIV negative on rapid test or, rapid test not done: • inquire about source patient’s risk factors for HIV and risk of being in the “window period” of an acute HIV infection.

33. Testing the source patient • If source patient is known to be HIV positive: • define the patients clinical and immunological stage of HIV infection through a CD4 count and/or TLC. • Obtain HIV viral load data, if available • Obtain information on current and previous antiretroviral therapy • Obtain HIV resistance testing results, if done

34. Risk of seroconversion after percutaneous occupational exposure HBV is 100x more transmissible than HIV!

35. Hepatitis B prevention • The best way to avoid HBV infection is to vaccinate all health care workers against Hepatitis B. • HBV vaccination requires 3 injections at 0, 1 and 6 months. • This should be encouraged by all employers in health care settings!

36. TB prevention • TB is the most common OI in Vietnam. • In the HIV OPC, a significant percentage of patients will have TB or on TB treatment at any one time. • The waiting area and exam rooms at the OPC are an environment at high risk for TB transmission.

37. Five Steps to Prevent Transmission of TB in HIV Care Settings Step 1: Screen and test • Early recognition of patients with suspected or confirmed TB disease. • Symptoms that may indicate TB include: • Cough > 2 weeks, fever, weight loss, night sweats, lymphadenopathy • Screen all patients who have any symptoms: • CXR, sputum BK • lymph node aspirate (if indicated)

38. Five Steps to Prevent Transmission of TB in HIV Care Settings Step 2 : Education • Instruct patients to wear face masks if they have active TB or if they are coughing/sneezing.

39. Five Steps to Prevent Transmission of TB in HIV Care Settings Step 3: Separate • If possible, patients who have active TB or are TB suspects should wear a mask, be separated from other patients, and requested to wait in a separate well-ventilated waiting area

40. Five Steps to Prevent Transmission of TB in HIV Care Settings Step 4: Provide services quickly • If possible, triage active TB patients to the front of the line and quickly provide care to reduce the amount of time that others are exposed to them.

41. Five Steps to Prevent Transmission of TB in HIV Care Settings Step 5: Environmental Control • Ventilation • Natural ventilation relies on open doors and windows to bring in air from the outside • Fans may also assist to blow the air out of the room. • Prevent active TB in HIV patients : IPT should be supply for HIV patients meet MOH criteria

42. Face Masks • Standard Face Masks • Prevent TB transmission if worn by the TB patient • Do not prevent the wearer from acquiring TB • Special Face Masks: N95 or FFP2 • Protect the wearer • Only needed in high risk areas: • spirometry or bronchoscopy rooms, or • MDRTB treatment centers WHO Guidelines for the Prevention of Tuberculosis in Health Care Facilities in Resource-Limited Settings

43. Respirator – has only tiny pores which block droplet nuclei and relies on an air tight seal around the entire edge • Face mask – has large pores and lacks air tight seal around edges

44. Key Points • Universal precautions means treating all blood and body fluids as if they are infectious. • The risk of HIV transmission from a single occupational exposure is 0.3% • The risk of HBV transmission from a single occupational exposure is 30% • PEP in Vietnam is used: • two drugs (D4T or AZT) + 3TC • or three drugs (D4T or AZT) + 3TC + LPV/r • NVP should NOT be used for PEP due to high risk for hepatotoxicity. • Take steps to prevent TB transmission in the health care setting. are given 4 wks

45. Thank you! Questions?