Transcript Clinical Approach to the Patient with a Work

Caring for the Worker
Potentially Exposed to
Bloodborne Pathogens
Lawrence D. Budnick, MD, MPH
Associate Professor of Medicine
Director, Occupational Medicine Service
New Jersey Medical School
University of Medicine & Dentistry of New
Jersey
December 10, 2001
Objectives
• Risks of exposure to blood and body
fluids (BBFs)
• Current regulatory environment
regarding bloodborne pathogens (BBPs)
• Prevention methods
• Clinical management
- Assessment
- Counseling
- Treatment
- Follow-up
Health Care Workers
>10 million persons in the US
• Paid and unpaid
persons whose
activities involve:
– Working in a health care
setting
– Contact with patients
– Contact with potentially
infectious materials
from patients in a health
care setting
• May include, but not
limited to:
– Patient care: nurses,
physicians, EMS
personnel, part-time staff,
temporary contractors,
students
– Non-patient care:
volunteers, dietary,
clerical, janitorial,
maintenance,
housekeeping
Potential Bloodborne Pathogens
B virus (Herpesvirus simiae)
Blastomycosis
Brucellosis
Creutzfeld-Jakob disease
Cyptococcosis
Cytomegalovirus
Diphtheria
Ebola fever
Gonorrhea (cutaneous)
Hepatitis B
Hepatitis C
Herpes
Human immunodeficiency
virus
Leptospirosis
Malaria
Mycobacteriosis
Rocky Mtn Spotted Fever
Mycoplasmosis
Prion
Sporotrichosis
Scrub Typhus
Sporotrichosis
Staphylococcus aureus
Streptococcus
Syphilis
Toxoplasmosis
Tuberculosis
Hepatitis B Virus
Hepadnavirus
• 42 nm doublestranded DNA
• 27 nm
nucleocapsid
core (HBcAg)
• Outer lipoprotein
coat contains
surface antigen
(HBsAg)
• 4 major subtypes
Hepatitis B - Clinical Features
Incubation period:
Clinical illness:
Average 9-13 weeks
Range 6-26 weeks
70%
Chronic infection:
2-8%
Death from chronic
liver disease:
15-25% of chronic inf.
Immunity:
Protective antibody
response identified
Hepatitis B Epidemiology
• Incidence 80,000 cases/year
– Was 450,000 in the 1980’s
• Prevalence 1.25 million are
chronically infected
• In 1994, 1000 health care workers
developed HBV infection
– Approx. 200 HCWs died each year
Source: CDC, 1991; 1997
Risk Factors for Acute Hepatitis B,
US, 1992-93
Heterosexual*
(41%)
Injecting
Drug Use
(15%)
Homosexual
Activity (9%)
Household
Contact (2%)
Health Care
Employment (1%)
Unknown (31%)
Other (1%)
* Includes
sexual contact with acute cases, carriers, and multiple partners.
Source: CDC Sentinel Counties Study of Viral Hepatitis
Hepatitis C Virus
Hepapavirus
• Enveloped RNA
virus
• 90 subtypes
Hepatitis C - Clinical Features
Incubation period:
Clinical illness:
Average 6-9 weeks
Range 2-28 weeks
20-40%
Chronic hepatitis:
70-85%
Death from chronic
liver disease:
<3% of chronic inf.
Immunity:
No protective antibody
response identified
Hepatitis C Epidemiology
• Incidence 40,000 cases/year
– Was 240,000 in the 1980’s
• Prevalence 3.9 million or 1.8%
persons have been infected with
HCV
– 2.7 million are chronically infected
Source: CDC, 1991; 1997
Click for larger picture
Occupational Transmission of HCV via NSI
Country
Setting
Period
No.
HCW
Japan
Hospital
1981-90
197
3
2.7
Hospital
1977-90
68
7
10
US
Hospital
1980-89
50
3
6
Europe
Hospital
1990-91
30
0
0
61
0
0
24
0
0
High risk
81
0
0
Hospital
53
1
1.9
331
4
1.2
805
18
2.2
Dialysis
Hospital
Hospital
Total
1992-93
1992-93
No.
%
Seroconv Seroconv
Human Immunodeficiency Virus
Retrovirus
• Core of diploid RNA
• Spherical lipid
envelope
• 2 major types
Acute HIV - Clinical Features
Incubation period: Avg 2-4 weeks, range 1-12
wks
Acute antiretroviral syndrome
• 50%, 1-2 weeks duration
• Most common symptoms
- Fever
- Lethargy
- Pharyngitis
- Lymphadenopathy - Maculopapular rash
- Myalgia
- Arthralgia
Immunity: No protective Ab response identified
AIDS incidence: 50% in 10 years without Rx
HIV Epidemiology in the U.S.
HIV + AIDS
• Incidence 42,156 cases/year
• Prevalence 450,151 persons
are living with HIV/AIDS
Source: CDC,2001
U.S. HCWs with Occupationally
Acquired AIDS/HIV, to October 2001
Documented N = 57
6
Possible N = 138
8
68
35
19
24
Nurse
Physician
Lab workers
Other
18
17
Other = Dental worker,
dentist, EMT/paramedic,
housekeeper, health aide,
other technician
Potential for Transmission of HIV
After Percutaneous Exposure
Risk Factor
Deep injury
OR (Adj) 95% CI
15.0
6.0-41
Source patient terminally ill
5.6
2.0-16
Visible blood on device
6.2
2.2-21
Needle was in blood vessel
4.3
1.7-12
Zidovudine post-exposure
0.2
0.1-0.5
Cardo, NEJM 337:1485;1997
Potential for Transmission of
Bloodborne Pathogens
HBV
HCV
HIV
Prevalence in hospitalized patients, %
2.1-4.7
0.7-12.7 0.1-14.5
Prevalence in health care workers, %
3-35
1.4-2.0
0.4
Viral particles/ml of serum or plasma
102-108
100-106
100-103
Rate of transmission post needlestick
injury, %
23-62
1.8
(0-7)
0.3
(0.2-0.5)
Lanphear, Epi Rev 16:437;1994
CDC. MMWR 2001.
Concentrations of Hepatitis B Virus
in Various Body Fluids
High
Moderate
blood
semen
serum
vaginal fluid
wound exudates saliva
Low/Not
Detectable
urine
feces
sweat
tears
breast milk
Needlestick Injuries
• 6-800,000 annually in US
• 16,000 (2%) of these are likely to
be contaminated by HIV
• Up to 80% of all unintentional
exposures to blood are caused
by needlestick injuries
Needlestick/Sharps Reports
Among Health Care Workers
25
12
5
7
1
50
MD Att
RN
MD PG
Tech
• Exposure Prevention
Information Network
• 1993-95
• 77 hospitals
• 10 639 cases
• 91 medical students
Med Stu
Other
Type of Sharps as Cause of Percutaneous
Injuries, NaSH Hospitals, 6/95-7/99
N=4951
Items Most Frequently Causing
Sharp-Object Injuries, 1995
Adapted from Ippolito
et al, 1997
Click for larger picture
Reported Cause of Percutaneous Injuries,
NaSH Hospitals, 6/95-7/99
N=3057
When Do Needlesticks Happen?
Centers for Disease
Control and Prevention
• 11/99 NIOSH Alert Preventing
Needlestick Injuries in Health Care
Settings
– DHHS (NIOSH) Publ 2000-108
• 6/29/01 Updated USPHS Guidelines for
the Management of Occupational
Exposures to HBV, HCV, and HIV and
Recommendations for Postexposure
Prophylaxis
– MMWR v 50, RR-11
NIOSH Alert - Employers
Improved engineering controls in a
comprehensive program involving workers
 Eliminate the use of needles where possible
 Implement the use of devices with safety features and
evaluate their use for effectiveness and acceptability
 Analyze injuries to identify hazards and injury trends
 Set priorities and strategies for prevention
 Training
 Modify work practices that pose a hazard
 Promote safety awareness
 Reporting and timely follow-up
 Evaluate program effectiveness and provide feedback
NIOSH Alert Health Care Workers
 Avoid needles where safe & effective alternatives
available
 Help employer select and evaluate safety devices
 Use safety devices
 Avoid recapping needles
 Plan for safe handling and disposal before procedure
 Dispose of used needles promptly in sharps disposal
containers
 Report all sharps-related injuries promptly
 Tell your employer about hazards
 Participate in training and follow recommended
infection prevention practices
OSHA General Duty
Clause
Section 5 (a) (1) of the OSH Act
“Each employer shall furnish to each
of his employees employment and a
place of employment which are free
from recognized hazards that are
causing or are likely to cause death
or serious physical harm to his
employees.”
OSHA Guidelines
• Management
commitment
• Employee
involvement
• Worksite analysis
• Hazard prevention
and control
– Engineering design
– Administrative
controls
– Personal protective
equipment
• Medical management
–
–
–
–
Prevention
Early identification
Systematic evaluation
Conservative
treatment
• Training and
education
• Recordkeeping
OSHA Bloodborne
Pathogens Actions
• 12/6/91 - Occupational Exposure to BBP; Final
Rule. 29 CFR 1910.1030
• 1988, 1990, 1992, 1999, 2001 - OSHA
Instruction: Enforcement Procedures for the
Occupational Exposure to BBP, CPL-2-2.69
• 11/6/00 - Needlestick Safety and Prevention
Act
• 1/18/01 - Revised BBP Standard
• 1/18/01 - Recording and Reporting
Occupational Injuries and Illnesses. 29 CFR
1904