Post-exposure management of viral hepatitis in healthcare setting

1. Post-exposure management of viral hepatitis in healthcare setting Dr. Ann Wong Department of Microbiology, PWH

2. Blood-borne virus in healthcare setting HBV HCV HIV Risk of chronic infection There are many other viruses that can be transmitted by blood-borne route

3. Type of exposure Contact with blood or body fluids with - non-intact skin - mucous membranes Percutaneous injury with needles or sharp instruments contaminated with blood or body fluids that are potential infectious Human bite

4. Potentially Infectious blood and body fluids Potential infectious body fluids e.g. CSF, synovial, pleural, pericardial and peritoneal, amniotic fluids Faeces, nasal secretions, saliva, sputum, sweat, tears, urine and vomitus are considered potentially infectious unless contain blood Blood Semen and vaginal secretion

5. Blood-borne infections in healthcare settings • Primary prevention: • Vaccination for HBV • Post-vaccination check • No vaccine for HIV & HCV • Many other unknown blood-borne pathogens • Minimize accident: • Standard precautions • Engineering controls • (e.g. sharps disposal containers) • Work place controls • Management of accident: • Immediate wound care • Reporting • Post-exposure prophylaxis • Advice & medical follow-up

6. First-aid care management of exposure to blood-borne pathogens 1. Wash the wound and skin site immediately with soap and water 2. Wound should not be sucked 3. Mucosal / eye exposure: • Remove contact lens if present • Flush with running water 4. No evidence of efficacy • Use of antiseptics • Expressing fluid by squeezing the wound 5. Avoid use of bleach

7. Sharps injury management : reporting • Report to supervisor-in-charge • “Injury-On-Duty” form to Hospital Infection Control team • Attend Accident & Emergency Department with name and identification of the source patient

8. Risk assessment Disease prevalence Type and nature of exposure e.g. deep puncture, large bore needles containing blood Status of the source - multiple sexual partner - intravenous drug abuse (IVDA) - history of dialysis - Tattooing , body piercing, acupuncture - know HBV or HCV infection with high viral load Susceptibility of the exposed

9. HBV Prevalence of HBV in HK about 8% but varies with age group and specific population group Risk of infection if source is: HBsAg + and HbeAg + (21-30%) HBsAg + and Hbe Ag – (1-6%) If source can be identified, get consent for blood checking History of hepatitis B vaccine of the victim and any documented post-vaccination serological status e.g. immunization card, pre-employment record, laboratory report

10. Serology testing Source identified and consent for blood checking: Check HBsAg of source patient Victim: Check HBsAg and anti-HBs (antibody level ≥ 10 mIU/mL is considered as protective) Baseline LFT

11. Sharps injury management : post-exposure prophylaxis – HBV • Vaccine +/- HBIG can be considered, depends on: • HBsAg status of source patient • Post-vaccination anti-HBs result of staff • Anti-HBs decreases with time, but still protective • Best time to document a vaccine responder is 1-4 months after completing vaccination

12. Where indicated, one dose of HBIG (dosage as recommended by the manufacturer) should be given within 7 days, preferably within 24 hours of exposure. Attention is drawn to the need of blood taking before administering HBIG. • For a previously vaccinated person with unknown response, he/she should be tested for anti-HBs • no treatment is required if anti-HBs is positive • HBIG ± HBV vaccine is offered if anti-HBs is negative

13. Post-exposure prophylaxis Timing - HBIg: 1st dose within 7 days but preferably within 24 hrs 2nd dose 1 month later - Hep B vaccine: 0, 1 and 6 months (3 doses) Efficacy: Multiple dose of HBIg or vaccine alone: about 70% HBIg + vaccine: about 90%

14. Follow up testing for antibody Follow up testing of anti-HBs for those given post-exposure prophylaxis: Only HBV vaccine given: check anti-HBs at 1-4 months post vaccination - If anti-HBs < 10 after the 1st 3 dose series, consider 1 booster dose or repeat another 3 dose series ( efficacy after a 2nd 3 dose series about 30-50%) - Anti-HBs <10 after 2nd 3 dose series, no more vaccine required - Advise precaution and give HBIg if future exposure Effect HBIg on anti-HBs may last for at least 3-4 months

15. HCV: risk assessment Prevalence among general population about 0.3% • Risk of transmission if source positive: 1.8 % (range 0-7%)

16. Laboratory testing Source: check anti-HCV antibody Victim collect baseline blood and stored If source HCV negative or unknown source: check anti-HCV at 3 and 6 months HCV antibody negative at 6 month: not infected HCV antibody positive, retrieve baseline blood for testing if baseline positive: previously exposed if baseline negative: seroconverted (infected)

17. Laboratory testing If source positive: Check HCV RNA at 6-8 weeks post-exposure for victim check anti-HCV at 3 and 6 months any one positive, baseline blood retrieve for testing to determine previous infection status If source is HIV and HCV coinfected, consider repeat testing for anti-HCV at 12 months

18. Post-exposure prophylaxis Currently, no PEP available for HCV If HCV RNA is detected in the victim, repeat HCV RNA at 6 months to determine whether infection has spontaneously resolved (~20%) or established chronic infection. Refer for specialist care

19. Counselling Do not donate blood, semen, organs or tissue for six months Do not share toothbrushes, razors or items contaminated with body fluid Practice safe sex Keep wound covered until healed No need to modify professional activities to reduce risk of transmission to patients Practice standard precaution

20. Thank you