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Sharon McMullen, RN BSN Vanessa Stoloff, MD

“Help! I stuck myself! Now what?!” Evaluation and Treatment of Body Fluid Exposures in the Health Professional Student. Sharon McMullen, RN BSN Vanessa Stoloff, MD. Bloodborne Pathogens. Transmissible in healthcare settings Can produce chronic infections Hepatitis B Virus (HBV)

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Sharon McMullen, RN BSN Vanessa Stoloff, MD

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  1. “Help! I stuck myself! Now what?!”Evaluation and Treatment of Body Fluid Exposures in the Health Professional Student Sharon McMullen, RN BSN Vanessa Stoloff, MD

  2. Bloodborne Pathogens Transmissible in healthcare settings Can produce chronic infections Hepatitis B Virus (HBV) Hepatitis C Virus (HCV) Human Immunodeficiency Virus (HIV) McMullen/Stoloff, ACHA, 6.2011

  3. Factors Influencing Risk of Infection • Prevalence of infection among patients • Experience of clinician • Nature of exposures • Risk of infection transmission after exposure McMullen/Stoloff, ACHA, 6.2011

  4. ?

  5. http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/hepatitis-b.htmhttp://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/hepatitis-b.htm HBV Prevalence

  6. HCV Prevalence Modified from Perz JF, Farrington LA, Pecoraro C, et al. Estimated global prevalence of hepatitis C virus infection. 42nd Annual Meeting of the Infectious Diseases Society of America; Boston, MA, USA; Sept 30–Oct 3, 2004. Data source: World Health Organization

  7. HIV Incidence and PrevalenceUnited States, 1977-2006 CDC. HIV prevalence estimates—US, 2006. MMWR 2008;57(39):1073-76 McMullen/Stoloff, ACHA, 6.2011

  8. http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-5/hiv-aids.htmhttp://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-5/hiv-aids.htm HIV Prevalence

  9. Elements of an effective post-exposure management program • Clear policies/procedures • Rapid access to • Expert evaluation • Post-exposure prophylaxis (PEP) • Testing McMullen/Stoloff, ACHA, 6.2011

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  11. McMullen/Stoloff, ACHA, 6.2011

  12. “Help! I stuck myself! Now what?!” McMullen/Stoloff, ACHA, 6.2011

  13. Body Fluid Type McMullen/Stoloff, ACHA, 6.2011

  14. Concentration of Virus in Body Fluids HighModerate Low/NotDetectable BloodSemenUrine SerumVaginal FluidFeces Wound exudatesSalivaSweat Tears Breast Milk McMullen/Stoloff, ACHA, 6.2011

  15. Exposure Type (Human Bite) McMullen/Stoloff, ACHA, 6.2011

  16. Relatively Lower Risk Instruments Suture Needle Solid metal needle with exposure to non-intact skin and often blood. Dental Metal Burrs Solid metal instruments that may contact gum tissue and are exposed to saliva (often with blood). McMullen/Stoloff, ACHA, 6.2011

  17. Hollow bore needles are usually placed directly into a vein or artery and may contain blood within (not always visible to the eye). Relatively Higher Risk Instruments McMullen/Stoloff, ACHA, 6.2011

  18. Mucous Membrane Exposure • Mucous membranes are tissues that line body cavities or canals such as the throat, nose, mouth, urethra, rectum, and vagina. • Conjunctiva is also considered a mucous membrane. • Non-intact Skin Exposure • Less Severe (Solid Needle, Superficial Injury) • Evidence of compromised skin integrity (Dermatitis, Abrasion, Open wound) McMullen/Stoloff, ACHA, 6.2011

  19. Source person • presence of HBsAg • presence of HCV antibody • presence of HIV antibody • if source unknown, assess epidemiologic and clinical evidence Assessment of Infection Risk • Type of exposure • percutaneous • mucous membrane • non-intact skin • bites resulting in blood exposure • Body substance • blood • bloody fluid • potentially infectious fluid or tissue • Source patient • presence of HBsAg • presence of HCV antibody • presence of HIV antibody • if source unknown, assess epidemiologic and clinical evidence • Exposed patient McMullen/Stoloff, ACHA, 6.2011

  20. Source Patient’s History • HBV (HBsAg) • HCV (HCV Ag) • If positive: • HCV RNA • HIV* (HIV EIA) • If positive: • Viral load • CD4 count * Consent & confidentiality McMullen/Stoloff, ACHA, 6.2011

  21. Infection Status of Source Patient • Hepatitis B Status +/- (HBsAg) • Hepatitis C Status +/- (HCV Ag, HCV RNA) • HIV-Negative • HIV-Positive – Class 1 • Asymptomatic HIV infection • Known low viral load (eg. <1500 RNA copies/ml), HIV + • HIV-Positive – Class 2 • Symptomatic HIV infection • AIDS • Acute sero-conversion • Known high viral load • Source of unknown HIV status • Bloodwork from source patient is still pending • Patient is refusing to test • Deceased source patient with no samples available • Unknown Source • Needle from sharps container McMullen/Stoloff, ACHA, 6.2011

  22. Exposed Patient’s History • HBV immunity • Series of 3 HBV vaccines (0,1,6 mos) • Known titer >0.9 (HBsAb) • If unknown or negative titer, check HBsAb • HCV baseline (HCV Ab) • HIV baseline* (HIV ½ EIA Ab Screen w/reflexes) McMullen/Stoloff, ACHA, 6.2011

  23. UpToDate - Management of healthcare workers exposed to hepatitis B virus or hepatitis C virus – October 26, 2010, David J Weber, MD, MPH et al Risk of acquisition of bloodborne pathogens

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  25. Initial Treatment McMullen/Stoloff, ACHA, 6.2011

  26. Post-exposure Management: HBV • Baseline evaluation and testing of source patient • If Source is HBV+ (Presence of hepatitis B surface antigen (HBsAg) indicates source is infected with HBV) • Baseline evaluation and testing of HCW • Consideration of treatment for HCW • Check Hep B immune status • Did exposed patient have 3-dose Hep B series? • Hep B Surface Ab Positive? (titers >0.9 mIU/mL)  no testing or treatment needed • When to give HBIG (Hepatitis B Immune Globulin) • Exposures to unvaccinated healthcare workers- should receive 3 addn’l doses of vaccine and consider HBIG • Exposures with no titers, consider HBIG • Ideally administer HBIG within 24 hours ; the effectiveness of HBIG is unknown if administered more than 7 days after exposure. • Interesting Fact • HBV can survive on counter tops for 7 days and remain capable of causing infection. McMullen/Stoloff, ACHA, 6.2011

  27. Post-exposure Management: HCV • Baseline evaluation and testing of source patient • Baseline evaluation and testing of HCW • If HCV + Source, labs for HCW: • Baseline HCV Ab, baseline LFTs (ALT), and HCV RNA (if +HCV Ab)* • Follow-up testing for HCV RNA between 4-6 weeks after exposure (Penn has f/u in 2 weeks*) • Follow-up testing for HCV Ab, HCV RNA, and ALT between 4-6 months after exposure • There is NO proven effective post-exposure prophylaxis for persons exposed to HCV BFEs. Immunoglobulin and antiviral agents are NOT recommended. • When HCV transmission is identified early, the individual should be referred to a specialist knowledgeable in the management of acute HCV infection, since early treatment is associated with excellent cure rates. • HCV can remain infectious for between 16 hours and 4 days. McMullen/Stoloff, ACHA, 6.2011

  28. Average Risk of HIV Infection to Healthcare Personnel by Exposure Route • Percutaneous 0.3% • Mucous membrane 0.09% • Non-intact skin <0.1% McMullen/Stoloff, ACHA, 6.2011

  29. Post-exposure Management: HIV • Baseline evaluation and testing of source patient • CD4 count, viral load, HIV meds patient is on • Baseline evaluation and testing of HCW • Consideration of treatment • when to give Post-Exposure Prophylaxis (PEP) • what to give (cost, schedule of meds, toxicity) • When to start medications • Pregnant? Breastfeeding? • Follow-up testing and counseling • HIV virus is very fragile outside the body, but it can live from several minutes to several hours on the surface of objects in the environment, depending on the situation and environmental factors. McMullen/Stoloff, ACHA, 6.2011

  30. Toxicity of PEP Inconvenience of meds Cost of PEP Risk of infection for HIV* Considerations for When to Use PEP Risk of Transmission Risk of Adverse Effects *Risk varies widely according to exposure McMullen/Stoloff, ACHA, 6.2011

  31. Initiation of HIV Postexposure Prophylaxis (PEP) • If indicated, start PEP as soon as possible after exposure • regard as an urgent medical concern • Should be initiated as soon as possible • Starter pack available • Interval after which PEP is no longer likely to be effective in humans is unknown • Offer for up to 24-36 hours after exposure • initiating PEP days or weeks after an exposure might be considered if warranted for increased risk exposure McMullen/Stoloff, ACHA, 6.2011

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  34. Situations Where PEP is Rarely, if Ever, Warranted • Intact skin contact with blood and potentially infectious body fluids • Exposure to unknown source in populations where HIV prevalence is low • Low-risk exposure to unknown source McMullen/Stoloff, ACHA, 6.2011

  35. Postexposure Prophylaxis (PEP) • Basic 4-week regimen of two drugs for most HIV exposures • Expanded regimen (addition of a third drug for HIV exposures that pose an increased risk for transmission). • When the source person's virus is known or suspected to be resistant to one or more of the drugs considered for the PEP regimen, the selection of drugs to which the source person's virus is unlikely to be resistant is recommended. McMullen/Stoloff, ACHA, 6.2011

  36. Most commonly prescribed drugs for PEP or Aluvia McMullen/Stoloff, ACHA, 6.2011

  37. Penn SHS provides Truvada and Isentress Penn Global Health programs supply Truvada and Aluvia or Aluvia McMullen/Stoloff, ACHA, 6.2011

  38. PEP Medications Penn SHS: Truvada - dosing is 1 tablet daily (Tenofovir 300 mg/Emtricitabine 200 mg) Issentress - dosing is 1 tablet twice daily (Raltegravir 400mg) McMullen/Stoloff, ACHA, 6.2011

  39. Main Side Effects of PEP Drugs McMullen/Stoloff, ACHA, 6.2011

  40. Postexposure Management:Follow-up Testing of Exposed Person Follow UP McMullen/Stoloff, ACHA, 6.2011

  41. Side effects of PEP drugs • Signs and symptoms of acute HIV infection • Fever, rash, flu-like illness • Prevention of secondary transmission • sexual abstinence or condom use • no blood/tissue donation • Transmission and PEP drug risks if breastfeeding • No work restriction is indicated Postexposure Management:HIV Postexposure Counseling McMullen/Stoloff, ACHA, 6.2011

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  43. Anxiety “Can I still be a doctor/nurse/dentist if I am infected with HBV, HCV, and/or HIV?” McMullen/Stoloff, ACHA, 6.2011

  44. Society for Healthcare Epidemiology of America http://www.premierinc.com/safety/safety-share/02-10-downloads/12_HBV_HCV_HIV.pdf McMullen/Stoloff, ACHA, 6.2011

  45. SHEA’s position: “Infection with a bloodborne pathogen does not itself justify restriction on the practice of an otherwise competent healthcare provider.” McMullen/Stoloff, ACHA, 6.2011

  46. 3-tier Risk Schema • Category I • Minor suturing, Elective phlebotomy • Category II • Vaginal delivery, Line insertion • Category III • General surgery, Non-elective procedures performed in the ED, risk of being bitten McMullen/Stoloff, ACHA, 6.2011

  47. Restrictions Category I and II No restriction solely on the basis of infection Category III Restrictions tied to circulating viral burden McMullen/Stoloff, ACHA, 6.2011

  48. Privacy • Our duty is to the patient • Who tells the school? • The student McMullen/Stoloff, ACHA, 6.2011

  49. Global Health Rotations • Risks • Policies/protocols to safeguard students travelling to low-resource areas for clinical experiences McMullen/Stoloff, ACHA, 6.2011

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