Bloodborne Pathogen Exposures

1
Bloodborne Pathogen Exposures

• Usually refers to contact with body fluids or
  tissues known or suspected to be from an
  individual with HIV, hepatitis B or C.
• Includes needlesticks, exposure of fluid/blood to
  broken (or intact) skin and splashes to eye or
  mouth.

2
Basic ID Stuff

• WEAR GLOVES when dealing with wounds, drawing
  blood, assisting with surgical procedures, etc.
  Additional protection e.g. gowns, goggles or
  faceshields may be needed as determined by the
  circumstances
• WASH affected body part thoroughly and promptly
  when body fluid exposure may have occurred.
• Be vaccinated against hepatitis B.

3
What Not to Worry About

• Important to know which fluids are NOT
  contagious. Tears, feces, sweat, nasal
  secretions, urine, sputum, saliva and vomitus are
  not considered infectious unless visibly bloody.
  A gray area exists for amniotic, pleural,
  synovial and pericardial fluids and for CSF.
  Consider them to be infectious.

4
What to Worry About

• Truly infectious body fluids include blood,
  semen, vaginal fluid or other fluids contaminated
  with visible blood.
• Human bites raise the dilemma of both individuals
  being exposed to each others fluids.

5
EVALUATION

• Careful inspection of the injured body part
  should allow determination of whether skin is
  intact or not (chapped, abraded or affected by
  dermatitis).
• Medical history is obtained from the source
  patient (if known) regarding prior infectious
  diagnoses or high risk behavior.

6
Testing

• The source patient should be tested for
  antibodies to HIV, HCV and Hepatitis B surface
  antigen (HBsAg).
• The exposed individual should be tested for
  antibodies to HIV, HCV and HBV. If previously
  vaccinated against HBV, antibody to surface
  antigen (HBsAb) would indicate immunity.

7
Hepatitis B Exposure

• Management varies depending on the vaccination
  history and immune status of the exposed HCW and
  the status of the source.
• Summary Table will be distributed

8
Hepatitis C Exposure

• Hepatitis C-if source patient tests positive for
  HCV, exposed HCW should have LFTs and HCV RNA
  measured by PCR at 6 weeks. A repeat HCV antibody
  should then be done at 4-6 months. Individuals
  who have a positive early HCV PCR may require
  additional testing and may be offered interferon
  therapy after appropriate consultation.

9
Hepatitis C Exposure

• As HCV positive individuals are excluded from the
  blood donor pool, currently available
  preparations of IVIG contain no anti-HCV
  antibodies. Therefore, there is no benefit to
  post-exposure administration of gamma globulin.

10
HIV

• Actual risk of transmission following a
  percutaneous exposure is around 0.3 (3 in 1000)
  and, after mucous membrane exposure, around
  0.09.
• Many factors influence these numbersdeep
  puncture vs. superficial injury, hollow
  (venipuncture) vs. non-hollow (suture) needle,
  level of source HIV viremia, etc.

11
Post-Exposure Prophylaxis (PEP)

• Because of the proven efficacy of Zidovudine
  (AZT) in reducing vertical transmission of HIV,
  PEP is recommended in situations when potential
  exposure may have occurred.
• It should be implemented within hours of
  exposure. As a practical matter, this is usually
  before source testing is complete.

12
HIV PEP

• There are a number of variables to consider when
  deciding on whether a two- or three-drug
  combination is to be used. In addition, a number
  of different drug regimens are available.
• You may wish to consult with an infectious
  disease or HIV specialist for advice.

13
HIV PEP

• As PEP is usually started before HIV results from
  the source patient are known, you should initiate
  therapy and then re-evaluate the patient when
  testing is complete. If source patient is
  negative, PEP can be stopped. If source turns out
  to be HIV infected, 4 weeks of combination
  therapy is given.
• These drugs have some significant toxicities and
  close monitoring is necessary.

14
HIV PEP

• Although we must offer PEP to exposed HCWs, we
  cannot force them to start the medication
  regimen, nor can we force them to complete it.
  Women must also agree to avoid pregnancy during
  this period as some drugs (e.g. Efavirenz) are
  teratogenic. We have female HCWs sign a voluntary
  agreement to avoid pregnancy and get a signed
  declination if the HCW refuses PEP.