What Anesthetists Should Know about HIV and Hepatitis

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What Anesthetists Should Know about HIV and
Hepatitis?

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Topics

• Updates in management of patients with HIV and
  hepatitis
• Prevention of transmission during anesthesia
• Postexposure prophylaxis

3
Guidelines for Management of Occupational
Exposures to HBV, HCV, and HIV and
Recommendations for Postexposure Prophylaxis
MMWR 2001 / Vol. 50 / No. RR-11. MMWR 2005 / Vol.
54 / No. RR-9.
4
Hepatitis B, Hepatitis C, and HIV

• Bloodborne viruses
• Can produce chronic infection
• Transmissible in healthcare settings

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
5
Factors Influencing OccupationalRisk of
Bloodborne Virus Infection

• Prevalence of infection among patients
• Type of exposure and type of virus
• Nature and frequency of blood exposures

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
6
Prevalence of Bloodborne VirusInfection in
Patients

• Generally higher in hospitalized patients than
  general population
• Varies with geographic area
• Varies with patient risk factors (injecting drug
  use, multiple sex partners)

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
7
Elements of Postexposure Management

• Wound management
• Exposure reporting
• Assessment of infection risk
• type and severity of exposure
• bloodborne infection status of source
  person
• Appropriate treatment, follow-up, and counseling

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
8
Postexposure ManagementWound Care

• Clean wounds with soap and water
• Flush mucous membranes with water
• No evidence of benefit for
• application of antiseptics or disinfectants
• squeezing (milking) puncture sites
• Avoid use of bleach and other agents

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
9
Postexposure ManagementAssessment of Infection
Risk

• Type of exposure
• percutaneous
• mucous membrane
• non-intact skin
• bites resulting in blood exposure

• Body substance
• blood
• bloody fluid
• semen, vaginal secretions, CSF, pleural,
  peritoneal, pericardial, amniotic

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
10
Postexposure ManagementAssessment of Infection
Risk

• Source person
• presence of HBsAg
• presence of HCV antibody
• presence of HIV antibody

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
11
Postexposure ManagementUnknown or Untestable
Source

• Consider information about exposure
• where and under what circumstances
• prevalence of HBV, HCV, or HIV in
  population
• Testing of needles and other sharp instruments
• NOT RECOMMENDED
• unknown reliability and interpretation of
  findings
• hazard of handling sharp instrument

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
12
Postexposure ManagementEvaluating the Source

• Informed consent
• Confidentiality of source person

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Risk of HBV, HCV and HIV Transmission after
Occupational Percutaneous Exposure

• HBV
• If both HBsAg and HBeAg are positive
• ? Risk of clinical hepatitis
  2231
• ? Risk of serologic evidence of HBV
  infection
  
  3762
• If HBsAg-positive, HBeAg-negative
• ? Risk of clinical hepatitis
  16
• ? Risk of serologic evidence of HBV
  infection
  
  2337
• HCV
• Anti-HCV seroconversion after accidental
  percutaneous exposure from HCV source is 1.8
  (07)
• HIV
• HIV risk is 0.3 (range of 0.2-0.5)

MMWR 2001 / Vol. 50 / No. RR-11
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Occupational HBV Exposures
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Concentration of HBV in Body Fluids
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Postexposure ManagementBaseline HBV Testing of
Exposed Person

• Anti-HBs test for vaccinated person unknown
  vaccine response
• Baseline testing not necessary for known vaccine
  response
• PEP is not necessary for known vaccine responder.

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
17
Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
18
Postexposure ManagementFollow-up HBV Testing of
Exposed Person

• Follow-up anti-HBs response in HCP who receive HB
  vaccine
• anti-HBs 1-2 months after last dose
• anti-HBs response to vaccine cannot be
  ascertained if HBIG received in the previous 3-4
  months

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
19
Occupational HCV Exposures
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Occupational Transmission of HCV

• Inefficiently transmitted by occupational
  exposures
• Case reports of transmission from blood splash to
  mucous membrane
• Prevalence 1-2 among HCP
• lower than among adults in general
  population
• 10 times lower than for HBV infection

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
21
Elements of Postexposure Management HCV

• Baseline evaluation/testing
• Follow-up testing/counseling
• PEP not recommended after exposure
• immunoglobulin not effective
• no data on use of antivirals (e.g.,
  interferon), and may be effective only with
  established infection
• antivirals not FDA approved for this
  setting

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
22
Postexposure ManagementBaseline HCV Testing of
Exposed Person

• If HCV source, test exposed person for
• anti-HCV and ALT
• If source not infected, baseline testing not
  necessary

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
23
Hepatitis C follow-up testing

• CDC guidelines follow-up HCV Ab and ALT at 4-6
  months1
• Note that unlike acute HIV infection, most
  patients are not symptomatic with acute HCV
  infection2

1. MMWR June 29, 2001 / 50(RR11)1-42. 2.
Mandell Principles and Practice of Infectious
Diseases, 5th ed., p. 1279.
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Occupational HIV Exposures
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HIV PEP

• Exposures common
• 57 documented cases of health care workers
  contracting HIV from exposures 137 other
  possible cases
• Area of considerable concern but little data

MMWR June 29, 2001 / 50(RR11)1-42
26
Occupations of US Healthcare Personnel
withDocumented/Possible Occupational AIDS/HIV
Infection
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Details of the 57 Exposures Resultingin
Occupational HIV Transmission
Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
28
Risk of HIV Transmission Following Percutaneous
(Needlestick) Exposure

• Pooled analysis of prospective studies on health
  care workers with occupational exposures suggests
  risk is approximately 0.3 (95 CI, 0.2 - 0.5)1
• Presence or absence of key risk factors may
  influence this risk in individual exposures

1. Bell DM. Am J Med 1997102(suppl 5B)9-15.
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Average Risk of HIV Infection toHealthcare
Personnel by Exposure Route

• Percutaneous 0.3
• Mucous membrane 0.09
• Non-intact skin lt0.1

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
30
Risk Factors for HIV Transmission
AfterPercutaneous Exposure to HIV-Infected Blood

• Risk factor adjusted Odds
  ratio (95 CI)
• - Deep injury
  15 (6.0-41)
• - Visible blood on device
  6.2 (2.2-21)
• - Procedure involving needle
  4.3 (1.7-12)
• placed in artery or vein
• - Terminal illness in source patient
  5.6 (2.0-16)
• - Postexposure use of zidovudine 0.19
  (0.06-0.52)

Cardo DM et al. NEJM 19973371485-90
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Other Likely Risk Factors

• HIV viral load
• Glove use
• 50 decrease in volume of blood transmitted1
• Hollow bore vs solid bore
• Large diameter needles weakly associated with
  increased risk (p 0.08)2
• Drying conditions
• tenfold drop in infectivity every 9 hours3

1. Mast ST et al. JID 1993168(6)1589-92. 2.
Cardo DM et al. NEJM 19973371485-90 3. Resnick
L et al, JAMA 1986255(14)1887-91.
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Evaluation of occupational exposure sources
Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
33
How effective is PEP?
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Evidence of Efficacy of PEP

• Animal models high level of protection when
  started within 24 hours1
• OR 0.19 for zidovudine use in case-control
  study2
• Two drugs, three drugs
• No direct evidence that more effective than 1
  drug
• Cases of seroconversion despite 3-drug PEP imply
  efficacy less than 1003,4

1. Tsai C-C et al. J Virol 1998724265-73. 2.
Cardo DM et al. NEJM 19973371485-90. 3.
Jochinsen EM et al. Arch Int Med
19991592361-3. 4. MMWR June 29, 2001 /
50(RR11)1-42
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What are the drawbacks of PEP?
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PEP
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Tolerability of HIV PEP in Health Care Workers
Incidence of Common Side Effects
Percent of HCWs
Myalgias
Vomiting
Fatigue Malaise
Wang SA. Infect Control Hosp Epidemiol
2000231780-5.
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HIV Postexposure ProphylaxisSerious Adverse
Events Associated with Nevirapine
22 Serious Adverse events - 12 hepatotoxicity
- 2 cases of liver failure - 14 dermatologic
Number
Year
MMWR 200149(51)1153-6.
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When should PEP be started?
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When should PEP be started?

• Efficacy of PEP thought to wane with time
• At what point is PEP no longer worth it?

benefits of PEP
risks of PEP
time
exposure
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Timing of PEP CDC Guidelines

• PEP should be initiated as soon as possible,
  preferably within hours of exposure.
• Interval after which there is no benefit for
  humans is not known
• Obtain expert advice when interval has exceeded
  24-36 hours

MMWR 200554(No. RR-9).
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Duration of PEP

• In animal model, 28 days more effective than 10
  days or 3 days of PEP1
• 4 weeks (28 days) used in case-control study2 and
  recommended by CDC guidelines3

1. Tsai C-C et al. J Virol 1998724265-73. 2.
Cardo DM et al. NEJM 19973371485-90. 3. MMWR
June 29, 200150(RR11)1-42.
43
Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to HIV
and Recommendations for Postexposure Prophylaxis.
MMWR 2005 / Vol. 54 / No. RR-9
44
Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to HIV
and Recommendations for Postexposure Prophylaxis.
MMWR 2005 / Vol. 54 / No. RR-9
45
Situations Where PEP is Rarely, ifEver, Warranted

• Intact skin contact with blood and potentially
  infectious body fluids
• Exposure to unknown source in populations where
  HIV prevalence is low
• Low-risk exposure to unknown source

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to HIV
and Recommendations for Postexposure Prophylaxis.
MMWR 2005 / Vol. 54 / No. RR-9
46
PEP Regimens Basic regimens

• Two NRTIs
• Simple dosing, fewer side effects
• Preferred basic regimens
• zidovudine (AZT) OR tenofovir (TDF)
• plus
• lamivudine (3TC) OR emtricitabine (FTC)
• Alternative basic regimens
• stavudine (d4T) OR didanosine (ddI)
• plus
• lamivudine (3TC) OR emtricitabine (FTC)

MMWR 200554(No. RR-9).
47
Expanded PEP Regimens

• Basic regimen plus a third agent
• Rationale 3 drugs may be more effective than 2
  drugs, though direct evidence is lacking
• Consider for more serious exposures or if
  resistance in source patient is suspected
• Adherence more difficult
• More potential for toxicity

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to HIV
and Recommendations for Postexposure Prophylaxis.
MMWR 2005 / Vol. 54 / No. RR-9
48
Expanded PEP Regimens

• Preferred Expanded Regimen
• Basic regimen plus lopinavir/ritonavir
  (KaletraTM)
• Alternate Expanded Regimens
• Basic regimen plus one of the following
• Atazanavir /- ritonavir
• Fosamprenavir /- ritonavir
• Indinavir /- ritonavir
• Saquinavir (hgc Invirase) ritonavir
• Nelfinavir
• Efavirenz

Atazanavir requires ritonavir boosting if used
with tenofovir
MMWR 200554(RR-9)
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Adverse Effects Basic vs Expanded Regimens
of individuals
Lower GI
Elevated TG
2xALT
Puro V et al. 9th CROI, February 2002, Abstract
478-M
50
Follow-up of health-care personnel (HCP) exposed
to known or suspected HIV-positive sources
0

• Exposed HCP should be advised to use precautions
  (e.g., avoid blood or tissue donations,
  breastfeeding, or pregnancy) to prevent secondary
  transmission, especially during first 612 weeks
  post-exposure.
• For exposures for which PEP is prescribed, HCP
  should be informed regarding
• need for monitoring
• possible drug interactions
• the need for adherence to PEP regimens.
• Consider re-evaluation of exposed HCP 72 hours
  post-exposure, especially after additional
  information about the exposure or SP becomes
  available.

MMWR 200554(No. RR-9).
51
Post-Exposure Prophylaxis Core Principles

• Evidence is limited
• Balancing of risks vs benefits
• Timing the sooner the better, but interval
  beyond which there is no benefit is unclear

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Postexposure Management Follow-up HIV Testing
of Exposed Person

• If source HIV , test at 6 wks, 3 months, 6
  months
• EIA standard test
• direct virus assays not recommended
• Extending follow-up to 12 months
• recommended for HCP who become infected
  with HCV following exposure to co-infected
  source
• optional in other situations

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to HIV
and Recommendations for Postexposure Prophylaxis.
MMWR 2005 / Vol. 54 / No. RR-9
53
Primary HIV Diagnostic Testing
1 mil
HIV RNA
100,000

HIV-1 Antibodies
HIV RNA
_
10,000
Ab
1,000
Exposure
100
Symptoms
10
0
20
30
40
50
Days
54
Primary Prevention of Occupational Transmission
of HIV

• Standard precautions

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to HIV
and Recommendations for Postexposure Prophylaxis.
MMWR 2005 / Vol. 54 / No. RR-9
55
Fundamentals of Standard Precautions

• Hand washing hand hygiene remains the most
  crucial element of prevention of nosocomial
  infections.
• Gloves
• Mask, Eye Protection, Face Shield
• Gown
• Patient Care Equipment
• Environmental Control
• Linen
• Occupational Health and Bloodborne Pathogens
• Patient Placement

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Role of HIV Testing in Preventing
Occupational/Nosocomial HIV Infection

• HIV testing is not recommended as an
  infection-control procedure
• Current standards of practice are designed to
  prevent transmission of blood-borne pathogens
  from all patients, whether HIV infection is known
  or not.
• May be important for clinicians to address HIV
  risk in the context of clinical care of patients
  at risk for HIV infection

Gerberding JL, et al. N Engl J Med.
19903221788
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Preventing Transmission of Bloodborne Viruses in
Healthcare Settings

• Promote hepatitis B vaccination
• Treat all patients as potentially infectious
• Use barriers to prevent blood/body fluid contact
• Prevent percutaneous injuries

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001 / Vol. 50 /
No. RR-11.
58
Preventing Percutaneous Injuries

• Eliminating unnecessary needle use
• Using devices with safety features
• Developing safe work practices for handling
  needles and other sharp devices
• Safely disposing of sharps and blood-contaminated
  materials

Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to HIV
and Recommendations for Postexposure Prophylaxis.
MMWR 2005 / Vol. 54 / No. RR-9
59
Anesthetic considerations

• When planning an anesthetic for HIV-infected
  patient
• ? careful review of disease process and
  current status of disease and management
• - multiorgan disease
• - complex drug interactions
• - pulmonary complications
  greater risk for postoperative
  complications
• General anesthesia not linked to adverse outcomes
  despite theoretical concerns

Hughes SC. Anesthesiology Clin N Am 200422379
404
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Conclusion

• Occupational exposure management is complex
• Prevention is best
• hepatitis B immunization
• avoiding occupational blood exposures

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Sources of Additional Information

• Division of Healthcare Quality Promotion
  http//www.cdc.gov/ncidod/hip/
• National Institute for Occupational Safety and
  Health bloodborne pathogens
• http//www.cdc.gov/niosh/bbppg.html
• Occupational Safety and Health Administration
  bloodborne pathogens
• http//www.oshaslc.gov/SLTC/bloodbornepathogen
  s/index.html
• Hepatitis Homepage
• http//www.cdc.gov/hepatitis

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Thank you for your attention