Managing Blood Borne Virus Exposure Incidents in A/E

1. Managing Blood Borne Virus Exposure Incidents in A/E Paul Gueret Occupational Health

2. What Is the Injury? • Exposure to body fluids may occur by • Inoculation-penetration of the skin by a sharp object such as a needle, scalpel blade, glass or plastic, • Splash-into the eye or onto skin surface, • Ingestion-e.g. pipetting accident, • Bite-human bite that breaks the skin.

3. What Are the Main Risks? • Hepatitis B • Hepatitis C • HIV

4. Hepatitis B • In those not previously vaccinated risk of infection transmission from infected donor is very high - as much as 1 in 3 where source is ‘e’ antigen positive • Following inoculation by a positive donor- an un-immunised recipient will need treatment within 48 hours with Hep B vaccine and Hep B immune globulin to prevent infection • Moderate urgency- up to 48 hours to treat

5. Hepatitis C • Risk of infection following a sharps injury from a known positive donor varies according to reports from 0 to 10%. Study review suggest average risk probably around 1.8%. • There is no vaccine • This is not an emergency

6. HIV • Risk of infection following exposure to known positive donor is about 0.3%. • Mucocutaenous exposure risk <0.1% • Skin intact –no risk

7. HIV • Four factors associated with significant risk • Deep injury • Visible blood on the device which caused the injury • Injury with a needle which had been placed in a source patient’s artery or vein • Terminal HIV-related illness in the source patient

8. HIV • Early PEP makes a difference • Zidovudine alone within an hour 80% reduction in risk • In combination with other drugs may be 100% • Must be started early ideally best results within an hour of injury • May be some effect up to 2 weeks post event • This is VERY URGENT- minutes matter

9. Steps in Event of Injury • Step one Needlestick/sharps injury Encourage free bleeding gently of the wound under running water. The wound should not be sucked. • Wash the wound thoroughly under running water using Betadine or Hibiscrub. Do not use a nail brush. • Cover the wound with a waterproof dressing

10. Steps in the Event of an Injury • Injured party arrives in A/E • Step one Mucocutaneous exposure Wash the affected area with copious amounts of water Eye splash Irrigate the affected eye with copious amounts of saline or water-before and after removal of contact lenses.

11. Step 2 • Ensure blood-body fluid exposure report form has been completed • Part 1 by the recipient

12. Part One of Blood Body Fluid Exposure Report Form • Recipient • Personal details, name, dob, job etc • Where incident occurred, hours on duty, PPE • HBVaccine status • Details on incident • Source of needle - bm stix, sharps box etc • Nature incident - splash, bite, duration contact • Severity incident – superficial, deep, visible blood

13. Step 2 • Ensure blood-body fluid exposure report form has been completed • Part 1 by the recipient • Part 2 by the donors team

14. Part Two of Blood Body Fluid Exposure Report Form • Source patient • Personal details, name, dob, ward etc • Donor risk factors – jaundice, iv drug abuse, etc • Bloods sent for HBsAg, HCV + HIV antibodies • Reasons for not testing-should be rare • Signature of doctor

15. Step 2 • Ensure blood-body fluid exposure report form has been completed • Part 1 by the recipient • Part 2 by the donors team • Get written recipient bloods-consent- You do this

16. Recipient Bloods Consent • For HBV, HCV HIV • Identify tests required of recipient • Stress confidentiality • Personal implications of result of test pos+neg • Describe procedure and results • If high risk exposure – lifestyle precautions • Window period • Mark sharps injury on blood request- you may need to mark urgent

17. Step 2 • Ensure blood-body fluid exposure report form has been completed • Part 1 by the recipient • Part 2 by the donors team • Get written recipient bloods-consent- You do this • Ensure you have written donor bloods consent- from ward- phone and get it.

18. The Bloods • The donor bloods should come down to the A/E with the injured party- If not get someone to chase them up- its urgent • You will take bloods from the recipient

19. Sending out the Bloods • Phone the Lab and tell them the bloods are coming and indicate which results are urgent • Urgent Results required from recipient’s blood • HBV antibodies are urgent only if individual’s HBV antibody titre is not known- or known and is not immune.- Other bloods HCV and HIV are held and are not urgent • Urgent bloods required from donor’s blood • HIV is very urgent. HBsAg is only urgent if recipient’s HBV antibody status is unknown or is known but not immune. HCV is not urgent

20. Blood Results HIV • If donor positive for HIV and nature of injury was significant- see slide 7 • Then immediately contact consultant microbiologist on call and consider institution of post exposure prophylaxis for HIV. • NOW –URGENTLY-MINUTES MATTER

21. Blood Results Hep B • If recipient is not hepatitis B immune and donor is positive for Hepatitis B surface antigen- then give the recipient Hepatitis B vaccine and urgently consider use of Hepatitis B immune Globulin- effective up to 48 hours post injury

22. Finally • When bloods sent to Lab- get someone to chase results urgently • Refer all cases to next occupational health clinic for follow up.