Management of occup exposures


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Management of occup exposures

  1. 1. Management of Occupational Exposure to BBV Dr. Faisal Al Hadad Consultant of Family Medicine & Occupational Health (ABFM, SBFM, MSc Occupational Health (UK Incharge of Occupational Health PSMMC
  2. 2. Outline Primary Prevention of Blood-borne infections Management of exposure to blood or body fluid Management of exposure to blood or body fluid infected with BBV Employment infections Implications of blood-borne
  3. 3. Primary Prevention of Bloodborne Infections  Vaccination  Standard Precautions: 1) Hand hygiene 2) Use of personal protective equipment (e.g., gloves) 3) Safe injection practices 4) Safe handling of potentially contaminated equipment or surfaces in the patient environment 5) Respiratory hygiene/cough etiquette.
  4. 4. Hepatitis B Vaccination  Any person who performs tasks involving contact with blood, blood-contaminated body fluids, other body fluids, or sharps should be vaccinated against hepatitis B.  HCP who have contact with patients or blood and are at ongoing risk for percutaneous injuries should be tested 1–2 months after completion of the 3-dose vaccination series for anti-HBs  Booster doses of hepatitis B vaccine are not necessary, and periodic serologic testing to monitor antibody concentrations after completion of the vaccine series is not recommended.
  5. 5. Hepatitis B Vaccination  Non-responders to vaccination who are HBsAg-negative: - Considered susceptible to HBV infection - Should be counseled regarding precautions to prevent HBV infection - Should obtain HBIG prophylaxis for any known or probable parenteral exposure to HBsAg-positive blood.
  6. 6. Case Study Nora is a 35 year-old Registered Nurse experienced a needle-stick injury during .night shift What is the risk of HBV, HCV and HIV ?transmission ?What should Nora do in respect to this event
  7. 7. Risk of HBV, HCV and HIV Transmission after Occupational Percutaneous Exposure • HBV risk varies depending on e-antigen status of source person – If e-antigen positive, risk is up to 30% – If e-antigen negative, risk is 1-6% • HCV risk is 1.8% (range of 0 - 7%) • HIV risk is 0.3% (range of 0.2 - 0.5%)
  8. 8. Management of Occupational Exposure to Blood or Body fluid  Treatment of exposure site : wash exposure site with water ± soap. No evidence exists that using antiseptics or squeezing the wound reduces the risk of BBV transmission.  Inform supervisor about the incident  Complete  Report the exposure incident report the incident to Preventive Medicine during working hours and the A/E out of working hours.
  9. 9. Exposure Incident Report  Date and time of exposure  Details of the procedure being performed including where and how the exposure occurred.  Details of the exposure including type and amount of fluid and the severity of exposure (e.g. depth of injury, whether fluid was injected, skin integrity)  Details about the exposure source - Infectious status - Stage of the disease, HX of antiretroviral therapy and viral load if the source is HIV-infected,  Details about the exposed person (Hepatitis B vaccination and vaccine response status)  Details about counseling, post-exposure management, and follow-up.
  10. 10. Management of Exposure in Preventive Medicine  Reviewing the exposure incident report  Evaluation of the exposure incident  Evaluation of the exposure source  Baseline screening of the exposed person for BBV  Follow up testing of the exposed person  Post-exposure prophylaxis  Counseling
  11. 11. Evaluation of the Exposure Incident Factors to consider in assessing the need for follow up of occupational exposures: Type of body substance: - Blood - Fluids containing blood - Potentially infectious fluid or tissue (semen; vaginal secretions; and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids) - Direct contact with concentrated virus    Route of exposure: - Percutaneous injury - Mucous membrane exposure - Nonintact skin exposure - Bites resulting in blood exposure Amount of exposure
  12. 12. Evaluation of the Exposure Source  The person whose blood or body fluid is the source of an occupational exposure should be evaluated for BBV infection.  Information available in the medical record at the time of exposure or from the source person, might confirm or exclude BBV infection.  If the infectious status of the source is unknown, the source person should be informed of the incident and tested for serologic evidence of BBV infection.  Informed consent must be obtained and confidentiality of the source person should be maintained at all times.
  13. 13. Evaluation of the Exposure Source Known exposure source  Test known sources for HBsAg, anti-HCV, and HIV antibody  Direct virus assays (e.g. tests for HIV RNA or HCV RNA) for routine screening of source patients are not recommended  For sources whose infection status remains unknown, consider medical diagnoses, clinical symptoms, and history of risk behaviors  Do not test discarded needles for bloodborne pathogens Unknown exposure source Evaluate the likelihood of exposure to a source at high risk for infection
  14. 14. Management of Exposure to HBV  Baseline screening of exposed person for HBV (HBsAg) and immune status (anti-HBs).  Follow up testing if exposed person is not immune at time of exposure: - LFT at 6 weeks and 12 weeks - HbsAg 12 weeks and 6 months  If exposed person is immune at time of exposure, followup for Hepatitis B is not indicated.  Post-exposure prophylaxis if indicated
  15. 15. Management of Exposure to HBV
  16. 16. Management of Exposure to HCV For the person exposed to an HCV-positive source: - Perform baseline testing for anti-HCV and ALT activity - Perform follow-up testing (e.g., at 4–6 months) for anti-HCV and ALT activity. If earlier diagnosis is desired, testing for HCV RNA may be performed at 4–6 weeks.   If the source person is not infected with HCV, baseline testing or further follow-up of the exposed person is not necessary.  Confirm all anti-HCV results reported positive by enzyme immunoassay using supplemental anti-HCV testing (e.g. RIBA)  IG and antiviral agents are not recommended for PEP after exposure to HCV-positive blood.
  17. 17. Management of Exposure to HIV  HCP exposed to HIV should be evaluated within hours after their exposure and should be tested for HIV at baseline.  HIV-antibody testing should be performed for at least 6 months postexposure.  If the source person is seronegative for HIV, baseline testing or further follow-up of the exposed person normally is not necessary.  HIV testing should be performed on any exposed person who has an illness compatible with an acute retroviral syndrome.
  18. 18. Management of Exposure to HIV
  19. 19. Management of Exposure to HIV
  20. 20. HIV Post-exposure Prophylaxis  If indicated, start PEP as soon as possible after an exposure.  Reevaluation of the exposed person should be considered within 72 hours postexposure, especially as additional information about the exposure or source person becomes available.  Administer  If PEP for 4 weeks, if tolerated. a source person is determined to be HIV-negative, PEP should be discontinued.
  21. 21. Preferred Basic & Expanded Regimen  Basic 2-drugs PEP - Zidovudine + lamivudine - Tenofovir DF + emtricitabine  Expanded 3-drugs PEP Basic regimen plus Lopinavir/ritonavir
  22. 22. Counseling for HCP Exposed to HBVor HCV-infected blood  Do not need to take any special precautions to prevent secondary transmission during the follow-up period.  The exposed person does not need to modify sexual practices or refrain from becoming pregnant.  If an exposed woman is breast feeding, she does not need to discontinue.  They should refrain from donating blood, plasma, organs, tissue, or semen.
  23. 23. Counseling for HCP Exposed to HIV infected blood  Exposed HCP should be advised to use precautions to prevent secondary transmission during the follow-up period: - Exercise sexual abstinence or use condoms to prevent sexual transmission and to avoid pregnancy - Refrain from donating blood, plasma, organs, tissue, or semen. - If an exposed woman is breast feeding, discontinuation of breast feeding should be considered.   For exposures for which PEP is prescribed, HCP should be informed about possible drug toxicities and the need for monitoring, and possible drug interactions.  Exposed HCP should be advised to seek medical evaluation for any acute illness suggestive of HIV infection during the follow-up period.
  24. 24. Employment Implications of Bloodborne Infection in RMH  Those who are anti HCV+ve and PCR+ve should be transferred to a non-high risk area.  Those who are anti HCV+ve but PCR-ve can continue their work since they are not dangerous .  Those who are PCR-ve for two (2) consecutive tests, one month apart, are considered free from Hepatitis C  Those who received treatment for Hepatitis C and declared cured with PCR-ve for six (6) months from stopping the treatment are considered free from Hepatitis C.
  25. 25. Employment Implications of Bloodborne Infection in RMH Employees with positive HBsAg  If PCR is positive and viral load is more than 100,000 copies/ml the employee should be prohibited from work in high-risk area and transferred to a non-high risk area.  If PCR is negative or viral load is less than 100,000 copies/ml twice one (1) month apart, the employee can continue working in high-risk area, but should be followed up by PCR yearly. Employees with positive HIV Staffs who are HIV positive should be dealt with according to the Government/RMH Policy .