Transcript Occupational HIV exposure

Occupational HIV
Exposure Prophylaxis
Dr Truong Anh Tan
June 30th , 2010
Infected post-exposure rate/1000
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Blood infusion
IDU (shared needle)
Anal sex receiver
Needlestick
Vaginal sex female
Anal sex giver
Vaginal sex male
Oral sex receiver
Oral sex giver
900
6,7
5,0
3,0
1,0
0,65
0,5
0,1
0,05
Estimated Pathogen-Specific
Seroconversion Rate Per Exposure
for Occupational Needlestick Injury
3
.
AETC http://depts.washington.edu/hivaids
Type of Exposure Way Involved in
Transmission of HIV to Health Care
Workers
AETC http://depts.washington.edu/hivaids
4
Source of HIV Involved in HIV
Transmission to Health Care
Worker
5
AETC http://depts.washington.edu/hivaids
Risk Factors for HIV Transmission
with Occupational Exposure to HIVInfected Blood
Odds Ratio
Confidence
Interval
Deep Injury
Visibly Bloody Device
15
6.2
6.0-41
2.2-21
Device Used in Artery or Vein
4.3
1.7-12
Terminally Ill Source Patient
Use of Zidovudine for PEP
5.6
0.19
2.0-16
0.06-0.52
Risk Factor
P<0.01 for all associations
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Other Possible Risk Factors
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Hollow bore vs solid bore
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Glove use
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No documented cases to date of seroconversion from suture
needles
50% decrease in volume of blood transmitted
Mucous membrane exposure
Mosquitoes bite?
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Standard Precautions
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Definition
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Standards developed to prevent exposure and
transmission of disease in occupational setting
Provide guidance for the safe handling of
infectious material
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Components of Standard
Precautions
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Hand washing
Use protective barriers when indicated
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Gloves: mucus membranes, body fluids, broken
skin
Goggles: procedures
Masks: procedures
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Components of Standard
Precautions (2)
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Sharps and waste - handle with gloves and
dispose in designated containers
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Needles
Scalpels
Suture material
Bandages
Dressings
Anything contaminated with any body fluid
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Handling with Disposing Sharps
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Do not recap needles!
Put containers within arms reach
Use adequate light source when treating
patients
Wear heavy-duty gloves when transporting
sharps
Incinerate used needles to a sufficient
temperature to melt
Keep sharps out of reach of children
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Components of Standard
Precautions (3)
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Re-usable instruments  must be thoroughly
disinfected
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Speculums
Surgical tools
Thermometers
Immunizations for Healthcare Workers
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Hepatitis A and B
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Recommended Antiseptic Solutions
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Alcohol 70%
Chlorhexidine, 2-4% (e.g. Hibtane, Hibiscrub)
Iodine 3%
Iodophores 7.5-10% (e.g. Betadine)
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Recommended Disinfectants
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Chlorine, 0.5% (Barkina)
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Sedex and Ghion brands contain 5% Chlorine,
dilute for use
Glutaraldehyde, 2-4% (e.g. Cidex)
Formaldehyde, 8%
Hydrogen peroxide, 6%
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Soak the instrument for 20 minutes after
decontamination and cleaning
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Management of Occupational
Exposure
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HIV AB: for both (giver and receiver)
Hepatitis : B & C
CBC
SGOT/SGPT
Blood Glucose
 136th month
1 mil
100,000
+
_
10,000
Ab
1,000
100
HIV
RNA
Exposure
HIV-1 Antibodies
HIV RNA
Diagnostic Testing
Symptoms
10
0
7
14
21
Days
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Image courtesy of The Center for AIDS Information & Advocacy, www.centerforaids.org
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The Early Stages of HIV
Infection
Cell free
HIV
T-cell
Immature Dendritic
cell
Skin or
mucosa
PEP
24 hours
1.
Burst of HIV
replication
Via lymphatics or
circulation
HIV co-receptors,
CD4 + chemokine
receptor CC5
48 hours
2.
Selective of
macrophagetropic HIV
3.
Mature Dendritic
cell in regional LN
undergoes a single
replication, which
transfers HIV to Tcell
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Wound Care
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Gently wash wounds with soap and water/ 5
minutes  alchol 70% 5 minutes (don’t scrub
vigorously)
Allow wounds to bleed freely
Irrigate exposed mucosal surfaces with sterile
saline
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Post Exposure Prophylaxis (PEP)
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Definition:
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Use of therapeutic agent to prevent establishment
of infection following exposure either
occupationally or non-occupationally to pathogen
Roles in Occupational Exposure:
HIV prevention
 HBV prevention
 Tests before ARVs therapy
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Step 1: Does This Patient
Need HIV PEP?
Source patient
HIV -
HIV +
Unknown /
Unwilling to
get tested*
High background risk
No PEP
PEP
Low background risk
No PEP
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*CDC recom: usually PEP unnecessary; consider use if source patient is high risk
Step 2: Determine HIV Status Code
of Source (HIV SC)
HIV Negative
HIV Positive
Asymptomatic/high CD4
= HIV SC 1
No PEP
HIV Status Unknown
or Source Unknown
= HIV SC Unknown
Advanced disease,
primary infection or low
CD4 =HIV SC 2
PEP
No PEP or + PEP
with 2 drugs
CDC Sep 2005
Occupational HIV PEP
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2 drug regimen
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Zidovudine plus lamivudine (combivir)
Stavudine plus Lamivudine
Tenofovir plus lamivudine
3 drug regimen
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LPV/r or Indinivr or Nelfinavir plus NRTI backbone
Efavirez plus NRTI backbone
Consider resistance potential of source patient
Don’t use NVP (hepatotoxic)
When to start  ASAP
 PEP no efficacy after 72 hours
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PEP Guideline from MOH
- PEP 1: AZT + 3TC
AZT: 300mg bid & 3TC: 150 mg bid.
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- PEP 2: 3TC + d4T
3TC: 150mg bid & d4T: 30-40mg bid.
< 60 kg, d4T: 30 mg bid.
> 60 kg, d4T: 40 mg bid.
AZT(Zidovudine);3TC(Lamivudine);D4T(Stavudine)
Advanced PEP(for high risk)
PEP 1 or 2 plus 1of following agents:
- NFV: 1,25 g bid.
- EFV: 300 mg bid
- LPV/r: 500 mg bid (recommended)
 28 days duration
(MOH guideline for PEP updated on 9/2009)
Follow-up HIV Testing
-CDC: HIV Ab at 6th week, 3rd month, 6th month
-Extended HIV Ab testing at 12 months
recommended if a source patient co-infected HCV
-VL testing not recommended unless Primary HIV
Infection (PHI) suspected
-Early diagnosis: HIV RNA PCR at 3th week
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MMWR June 29, 2001 / 50(RR11);1-42.
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Thank you for
your attention!