Occupational Exposure to HIV: Universal Precautions and PEP

1. Occupational Exposure to HIV: Universal Precautions and PEP HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. Learning Objectives By the end of this session, participants should be able to: • Explain the risk of HIV transmission after a single percutaneous exposure • Demonstrate “scoop” technique of recapping needles • List the steps involved in post-exposure prophylaxis (PEP) • Describe PEP regimens in Vietnam

3. HIV Transmission Through Occupational Exposure • HIV transmission as a result of an occupational exposure is a rare event • The majority of transmissions occur by exposure to HIV-infected blood • The overall risk of HIV transmission depends on the route and severity of exposure

4. Risk of HIV Transmission

5. Factors that Increase Risk of Transmission • Factors that increase the risk of HIV transmission from a needle stick injury include exposure: • through a visibly bloody device • through a device used in an artery or vein • via a deep injury • from a source individual with more advanced HIV disease and a high HIV viral load

6. Body Fluids and Risk for HIV Exposure Potential Risk Negligible Risk* Urine Saliva Sputum Sweat Feces Vomitus • Blood • Cerebrospinal fluid (CSF) • Pleural fluid • Peritoneal fluid • Any body fluid visibly contaminated with blood * If not visibly contaminated with blood

7. Questions: What does the term “Universal Precautions” mean?What are some examples of Universal Precautions?

8. Follow Universal Precautions Safely manage sharps Universal Precautions (1) #1 Treat ALL blood and body fluids as if they are potentially infectious #2 Prevent needle sticks

9. Universal Precautions (2) Following universal precautions means minimizing exposure to blood and body fluids through: • Use of protective barriers • Hand hygiene • Safe injection practices • Environmental control of blood and bodily fluids • Sharps management

10. 1. Use of Protective Barriers Guidelines on when to use 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

11. 2. Hand Hygiene • Prevents transmission of resistant organisms and infections • Before patient care • After blood/fluid contact, glove removal • Methods: • Hand washing • Use hand sanitizer • 60-95% ethyl or isopropyl alcohol http://www.cdc.gov/handhygiene

12. 3. Safe Injection Practices • Use a sterile syringe and needle for every infection; use the correct intended medication • Place needle in a puncture-proof container right after use • Discard sharps waste appropriately

13. 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

14. 5. Sharps Management Injuries can occur whenever a sharp is exposed in the work environment, therefore it is important to: • Organize work areas • Have sharps containers nearby • Avoid hand-passage of sharps • Not recap needles, or: recap using a one-handed “scoop technique”

15. “One-hand” Technique of Recapping Needles

16. Post-Exposure Prophylaxis (PEP)

17. Post-Exposure Prophylaxis (PEP) • The use of therapeutic agents to prevent infection following exposure to a pathogen • Types of occupational exposure include: • Percutaneous injury (needle-stick or cut through the skin) • Contact of mucous membrane or non-intact skin with bodily fluids that are potentially infectious

18. PEP Rationale (1) • Information about primary HIV infection indicates that systemic infection does not occur immediately • There is a brief delay between exposure to virus and appearance of HIV in the blood • During this “window of opportunity” antiretroviral treatment may prevent systemic infection

19. PEP Rationale (2) • Animal models show that following exposure to HIV: • immune cells at site of HIV entry become infected within first 24 hours • infected cells move to regional lymph nodes over next 24-48 hours • within 5 days HIV is detectable in the blood • ARVs given soon after exposure may prevent infection by blocking HIV replication in the few cells that are initially infected

20. Efficacy of Antiretroviral Therapy Human data-CDC Needle Stick Surveillance Group • Case Control study: 31 cases, 679 controls • Cases acquired HIV following an occupational exposure • 94% after needle stick (all hollow needles) • 29% of cases received PEP (AZT) vs. 36% of controls • Risk for HIV infection reduced by ~81% in HCWs receiving AZT Cardo D. NEJM 1997; 337:1485-90

21. 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)

22. National Guidelines on PEP Regimens (1)

23. National Guidelines on PEP Regimens (2) • 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

24. Suggested Post-Exposure Follow-up and Testing • Test health care worker for HIV after 4-6 weeks, 3 months, and 6 months • Conduct laboratory tests to monitor ARV side effects: • CBC, ALT at baseline and after 4 weeks

25. Risk of Seroconversion afterPercutaneous Occupational Exposure HBV is 100x more transmissible than HIV!

26. Case Study, Part 1 • A nurse sustains a percutaneous (needle stick) injury to her index finger • The source patient is a woman who is at the OPC for her second visit and is known to be HIV-infected • Her clinical status and CD4 count have not yet been established

27. Case Study: Questions • What steps should be taken immediately? • You are responsible for counseling the nurse about PEP. What is the risk of acquiring HIV from a known HIV-infected source patient? What questions about the incident could you ask her to assess her risk?

28. Case Study, Part 2 (1) • On questioning, the nurse reports that she was wearing gloves when her finger was stuck by a 21-gauge phlebotomy needle that had just been used to draw blood from the vein of the source patient • The needle was visibly bloody at the time she was stuck, and she is not sure if it was a ‘deep’ stick or not, but she says “it made my finger bleed” a lot.

29. Case Study, Part 2 (2) • She does not think she is pregnant • She has never been tested for HIV but has no reason to believe that she might have HIV infection

30. Case Study: Questions • What are your PEP recommendations for the nurse? • What additional testing and follow-up care should be performed for the exposed nurse? What additional advice and counseling would you offer?

31. Key Points • The term “Universal Precautions” means treating all blood and body fluids as if they are infectious • Risk of transmission from a single occupational exposure for: • HIV = 0.3% • HBV = 30% • PEP in Vietnam should follow MOH guidelines

32. Thank you! Questions?