Transcript Session 19 - Teaching Slides

Occupational Exposure to HIV:
Universal Precautions and PEP
HAIVN
Harvard Medical School
AIDS Initiative in Vietnam
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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
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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
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Risk of HIV Transmission
Blood exposures
Risk of HIV
Transmission
Percutaneous needlesticks
0.3%
(95% CI=0.2-0.5%)
Mucous membranes
0.09%
(95% CI 0.006% -0.5%)
Intact Skin
0%
(95% CI =0.0%-0.77%)
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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
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Body Fluids and Risk for HIV
Exposure
Potential Risk
 Blood
 Cerebrospinal fluid
(CSF)
 Pleural fluid
 Peritoneal fluid
 Any body fluid visibly
contaminated with
blood
Negligible Risk*
 Urine
 Saliva
 Sputum
 Sweat
 Feces
 Vomitus
* If not visibly contaminated
with blood
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Questions:
What does the term
“Universal Precautions” mean?
What are some examples of
Universal Precautions?
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Universal Precautions (1)
#1 Treat ALL blood and body fluids as
if they are potentially infectious
Follow Universal Precautions
#2 Prevent needle sticks
Safely manage sharps
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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
•
•
•
•
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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
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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
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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
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4. Environmental Control of
Blood and Body Fluids
Spills in patientcare 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
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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”
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“One-hand” Technique of
Recapping Needles
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Post-Exposure
Prophylaxis (PEP)
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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
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PEP Rationale (1)

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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
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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
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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)

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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
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Steps for Post-Exposure
Management
1. Treat the exposure site
2. Report the exposure to the manager and
complete the report form
3. Assess the risk of exposure
4. Determine the HIV status of the source
of exposure
5. Determine the HIV status of the exposed
person.
6. Counsel the exposed person.
7. Provide ARV prophylaxis (if indicated)
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National Guidelines on PEP
Regimens (1)
Medications
Indications
2 drug regimen
(basic regimen)
AZT+ 3TC
OR
d4t + 3TC
All exposures
with risk
3 drug regimen
AZT+ 3TC
OR
d4t + 3TC
In case source of
exposure is
known to have or
suspected of ARV
resistance
Plus: LPV/r
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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
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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
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Risk of Seroconversion after
Percutaneous Occupational Exposure
Virus
Range
Mean
HBV
2 – 40 %
30%
HCV
0–7%
3%
HIV
0.2 – 0.5 %
0.3%
HBV is 100x more transmissible
than HIV!
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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
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Case Study: Questions
1. What steps should be taken
immediately?
2. 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?
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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.
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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
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Case Study: Questions
3. What are your PEP
recommendations for the nurse?
4. What additional testing and followup care should be performed for the
exposed nurse? What additional
advice and counseling would you
offer?
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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
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Thank you!
Questions?
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