Occupational Exposure & Post-Exposure Prophylaxis

1. Occupational Exposure&Post-Exposure Prophylaxis Dr.T.V.Rao MD Dr.T.V.Rao MD

2. This presentation is designed to assist with the training of staff on sharps management including safety devices • The drug regime should be followed according to the best available options in resource poor circumstances. Dr.T.V.Rao MD

3. What is occupational exposure • Occupational exposurerefers to exposure to potential blood-borne infections (HIV, HBV and HCV) that may occur in healthcare settings during performance of job duties. Post exposure prophylaxis (PEP) refers to comprehensive medical management to minimize the risk of infection among Health Care Personnel (HCP) following potential exposure to blood-borne pathogens (HIV, HBV, HCV) Dr.T.V.Rao MD

4. Who are at risk • All Health Care Personnel, including emergency care providers, laboratory personnel, autopsy personnel, hospital employees, interns and medical students, nursing staff and students, physicians, surgeons, dentists, labour and delivery room personnel, laboratory technicians, health facility sanitary staff and clinical waste handlers and health care professionals at all levels Dr.T.V.Rao MD

5. Sharps are devices that are intentionally sharp to puncture or cut skin (needles, scalpels, etc.), or become sharp due to accident, such as broken glass tubes. Hypodermic needles Scalpels IV devices Capillary tubes Glass containers Pipettes Others What are “sharps”? Dr.T.V.Rao MD

6. What kind of devices usually cause sharps injuries? • Hypodermic needles • Blood collection needles • Suture needles • Needles used in IV delivery systems • Scalpels Dr.T.V.Rao MD

7. Estimates indicate that 600,000 to 800,000 needle stick injuries occur each year. Unfortunately, about half of these injuries are not reported. ALWAYS REPORT sharps injuries to your employer to ensure that you receive appropriate follow-up care. How common are sharps injuries? Dr.T.V.Rao MD

8. What is an occupational exposure? A blood or body fluid exposure that occurs as a consequence of a work-related activity There are two types of blood and body fluid exposure: Percutaneous exposure (penetrates the skin) e.g. needle stick injury (NSI) or cut with a sharp object such as a scalpel blade Non-percutaneous or Mucocutaneous exposure (contact of mucous membrane or non-intact skin with blood or body fluids) e.g. blood splash to the eye Sharps Management Dr.T.V.Rao MD

9. Past studies show sharps injuries are often associated with these activities: Recapping needles or other devices Transferring a body fluid between containers Failing to dispose of used needles or other devices properly in puncture-resistant sharps containers Increasing the risk of sharps injuries Dr.T.V.Rao MD

10. Who are at risk • Health Care Personnel are at risk of blood-borne infection transmission through exposure of a percutaneous injury (e.g. needle-stick or cut with a sharp instrument), contact with the mucous membranes of the eye or mouth of an infected person, contact with non-intact skin (particularly when the exposed skin is chapped, abraded, or afflicted with dermatitis or contact with blood or other potentially infectious body fluids. potentially infectious body fluids Dr.T.V.Rao MD

11. Protecting yourself • Report all needle stick and sharps-related injuries promptly to ensure that you receive appropriate follow-up care. • Tell your employer about any sharps hazards you observe. • Participate in training related to infection prevention. • Get a Hepatitis B vaccination. Dr.T.V.Rao MD

12. Who is at risk of an occupational exposure? All healthcare workers who have the potential for exposure to infectious materials (e.g. blood, tissue, and specific body fluids, as well as medical supplies, equipment or environmental surfaces contaminated with these substances) e.g: Nurses Doctors Laboratory staff Technicians Therapists Support personnel e.g. housekeeping, maintenance Dental staff Contractual staff Students Sharps Management Dr.T.V.Rao MD

13. Sharps Management -General Principles • Needles should not be recapped, bent or broken by hand, removed from disposable syringes or otherwise manipulated by hand. Dr.T.V.Rao MD

14. Sharps injuries can expose workers to a number of blood borne pathogens that can cause serious or fatal infections. The pathogens that pose the most serious health risks are Hepatitis B virus (HBV) Hepatitis C virus (HCV) Human immunodeficiency virus (HIV) What infections can be caused by sharps injuries? Dr.T.V.Rao MD

15. Risk of acquiring infection • The average risk of acquiring HIV infection from different types of occupational exposure is low compared to risk of infection with HBV or HCV. In terms of occupational exposure the important routes are needle stick exposure (0.3% risk for HIV, 9–30% for HBV and 1–10% for HCV) and mucous membrane exposure (0.09% for HIV). Dr.T.V.Rao MD

16. blood? saliva? sweat? feces? spinal fluid? pleural fluid? pus? urine? Which fluids are potentially infectious for HIV? Dr.T.V.Rao MD

17. blood saliva sweat feces spinal fluid pleural fluid pus urine Which fluids are potentially infectious for HIV? Dr.T.V.Rao MD

18. Needle Stick and Sharps Injuries Procedures for Effectively Handling Sharps Injuries Dr.T.V.Rao MD

19. HIV PEP • Exposures common • 56 documented cases of health care workers contracting HIV from exposures; 138 other possible cases • Area of considerable concern but little data Dr.T.V.Rao MD MMWR June 29, 2001 / 50(RR11);1-42

20. Risk of HIV Transmission Following Percutaneous (Needle stick) Exposure • Pooled analysis of prospective studies on health care workers with occupational exposures suggests risk is approximately 0.3% (95% CI, 0.2% - 0.5%)1 • Presence or absence of key risk factors may influence this risk in individual exposures Dr.T.V.Rao MD 1. Bell DM. Am J Med 1997;102(suppl 5B):9-15.

21. Assess exposed individual • The exposed individual should have confidential counseling and assessment by an experienced physician. Exposed individuals who are known or discovered to be HIV positive should not receive PEP. They should be offered counseling and information on prevention of transmission and referred to clinical and laboratory assessment to determine eligibility for antiretroviral therapy (ART). Besides the medical assessment,counselling exposed HCP is essential to allay fear and start PEP. Dr.T.V.Rao MD

22. Percutaneous: wash needle sticks and cuts with soap and water remove foreign materials Non-intact skin exposure: wash with soap and water or antiseptic Mucous membrane flush splashes to the nose, mouth or skin with water irrigate eyes with clean water, sterile saline or sterile irrigants Immediate Measures Dr.T.V.Rao MD

23. Counselling for PEP • Exposed persons (clients) should receive appropriate information about what PEP is about and the risk and benefits of PEP in order to provide informed consent for taking PEP. It should be clear that PEP is not mandatory. Dr.T.V.Rao MD

24. Psychological support • Many people feel anxious after exposure. Every exposed person needs to be informed about the risks, and the measures that can be taken. This will help to relieve part of the anxiety. Some clients may require further specialized psychological support. Dr.T.V.Rao MD

25. Document exposure • Documentation of exposureis essential. Special leave from workshould be considered initially for a period of two weeks. Subsequently, it can be extended based on the assessment of the exposed person’s mental state, side effects and requirements. Dr.T.V.Rao MD

26. Practical application in the clinical settings • For prophylactic treatment the exposed person must sign consent form. • ·          Informed consent also means that if the exposed person has been advised PEP, but refuses to start it, this needs to be recorded. This document should be kept by the designated officer for PEP. • ·          An information sheet covering the PEP and the biological follow-up after any AEB must be given to the person under treatment. However, this sheet cannot replace    verbal explanations. Dr.T.V.Rao MD

27. Sharps Management -General Principles • Policies and procedures including NSI management • Standard Precautions including personal protective equipment (PPE) • Hepatitis B vaccination • Education programs • Modifications to work practices including alternatives to using needles • Safe handling of sharps • Sharps disposal systems i.e. puncture-resistant containers • Injury prevention features/safety devices • Active • Passive Dr.T.V.Rao MD

28. Prescribe PEP Deciding on PEP regimen There are two types of regimens:    Basic regimen: 2-drug combination   Expanded regimen: 3-drug combination • The decision to initiate the type of regimen depends on the type of exposure and HIV serostatus of the source person. Dr.T.V.Rao MD

29. No infection  Aborted infection  Acute infection  no immune memory cellular immune response seroconversion Outcomes of HIV Exposures Dr.T.V.Rao MD

30. HIV chemoprophylaxis • Because post-exposure prophylaxis (PEP) has its greatest effect if begun within two hours of exposure, it is essential to act immediately. The prophylaxis needs to be continued for four weeks. Exposure must be immediately reported to designated authority and therapy administered. Never delay start of therapy due to debate over regimen. Begin with basic 2-drug regimen, and once expert advice is obtained, change as required. Dr.T.V.Rao MD

31. Two NRTIs Simple dosing, fewer side effects Preferred basic regimens: Zidovudine (AZT) OR tenofovir (TDF) plus lamivudine (3TC) OR emtricitabine (FTC) Alternative basic regimens: stavudine (d4T) OR didanosine (ddI) plus lamivudine (3TC) OR emtricitabine (FTC) PEP Regimens: Basic regimens Dr.T.V.Rao MD MMWR 2005;54(No. RR-9).

32. Expanded PEP Regimens • Basic regimen plus a third agent • Rationale: 3 drugs may be more effective than 2 drugs, though direct evidence is lacking • Consider for more serious exposures or if resistance in the source patient is suspected • Adherence more difficult • More potential for toxicity Dr.T.V.Rao MD

33. Preferred Expanded Regimen: Basic regimen plus lopinavir/ritonavir (Kaletra) Alternate Expanded Regimens: Basic regimen plus one of the following: Atazanavir* +/- ritonavir Fosamprenavir +/- ritonavir Indinavir +/- ritonavir Saquinavir (hgc; Invirase) + ritonavir Nelfinavir Efavirenz Expanded PEP Regimens MMWR 2005;54(RR-9) Dr.T.V.Rao MD *Atazanavir requires ritonavir boosting if used with tenofovir

34. Seek expert opinion in case of • Delay in reporting exposure (> 72 hours). • ·          Unknown source • ·          Known or suspected pregnancy, but initiate PEP • ·          Breastfeeding mothers, but initiate PEP • ·          Source patient is on ART • ·          Major toxicity of PEP regimen. Dr.T.V.Rao MD

35. Tolerability of HIV PEP in Health Care Workers Incidence of Common Side Effects Percent of HCWs Dr.T.V.Rao MD Wang SA. Infect Control Hosp Epidemiol 2000;231:780-5.

36. CDC Post-Exposure Prophylaxis Guidelines MMWR 2005;54(No. RR-9). http://www.aidsinfo.nih.gov Dr.T.V.Rao MD

37. CDC Post-Exposure Prophylaxis Guidelines Dr.T.V.Rao MD MMWR 2005;54(No. RR-9).

38. CDC Post-Exposure Prophylaxis Guidelines Dr.T.V.Rao MD MMWR 2005;54(No. RR-9).

39. Follow-up HIV Testing • CDC recommendations: HIV Ab testing for 6 months post-exposure (e.g., at 6 weeks, 3 months, 6 months) • Extended HIV Ab testing at 12 months is recommended if health care worker contracts HCV from a source patient co-infected with HIV and HCV • VL testing not recommended unless primary HIV infection (PHI) suspected Dr.T.V.Rao MD MMWR 2005;54(No. RR-9).

40. HAVE A PLAN for immediate evaluation of employees HAVE A PLAN for financial provision of PEP HAVE A PLAN to protect employee confidentiality about exposure, treatment and test results Review and Update annually Institutional Procedures Dr.T.V.Rao MD

41. Recommendations Hepatitis B • For the unimmunized: • prophylactic HBIG • initiate the vaccine series Dr.T.V.Rao MD

42. General Principles in Hepatitis B Vaccination • Hepatitis B Vaccination • A primary course of hepatitis B vaccinations over six months • Mandatory for all staff in contact with patients and patient-contaminated material • Titre level (HBsAb) four to six weeks after last dose • Booster doses not required if titre level >10 mIU/mL Dr.T.V.Rao MD

43. Avoid the use of needles where safe alternatives are available. Help your employer select and evaluate devices with safety features that reduce the risk of injury. Use devices with safety features provided by your employer. Do not recap needles or scalpels. Plan for safe handling and disposal of sharps before using them. Protecting yourself from needle stick injuriesa self responsibility ??? Dr.T.V.Rao MD

44. No effective prophylaxis Immunoglobulin and antiviral agents are NOT recommended Determine status of source Establish baseline serology and serum ALT of employee and repeat testing at 4-6 months post-exposure Early treatment if infection occurs Refer to Hepatologist Recommendations Hepatitis C Dr.T.V.Rao MD

45. Hepatitis C: follow-up testing • CDC guidelines: follow-up HCV Ab and ALT at 4-6 months1 • Consider periodic HCV RNA screening (monthly?) if earlier detection desired • Note that unlike acute HIV infection, most patients are not symptomatic with acute HCV infection2 1. MMWR June 29, 2001 / 50(RR11);1-42. 2. Mandell: Principles and Practice of Infectious Diseases, 5th ed., p. 1279. Dr.T.V.Rao MD

46. Major references • MMWR reviews • CDC guidelines • Post-Exposure Prophylaxisan evidence-based review Christopher Behrens, MD Hillary Liss, MD Northwest AIDS Education & Training Center University of Washington • NACO guidelines on Post exposure prophylaxis Dr.T.V.Rao MD

47. Programme created by Dr.T.V.Rao MD for Medical and Paramedical Professionals in the Developing world. • Email • doctortvrao@gmail.com Dr.T.V.Rao MD