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Health-care Exposure to Hepatitis & HIV DR. ABDULRAHMAN LOTFY PREVENTIVE MEDICINE -- JAHRA HOSPITAL 13 September 2005

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Health-Care Personnel <ul><li>persons whose activities involve contact with patients or with blood or other body fluids from patients in a health-care, laboratory, or public-safety setting. </li></ul>

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EXPOSURE <ul><li>a percutaneous injury (e.g., a needle stick or cut with a sharp object) or contact of mucous membrane or non intact skin (e.g., exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious </li></ul>

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POTENTIALLY INFECTIOUS SECRETIONS <ul><li>, semen and vaginal secretions also are considered potentially infectious. Although semen and vaginal secretions have been implicated in the sexual transmission of HBV, HCV, and HIV, they have not been implicated in occupational transmission from patients to HCP. </li></ul><ul><li>The following fluids also are considered potentially infectious: </li></ul><ul><ul><li>cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid . But the risk for transmission of HBV,HCV, and HIV infection from these fluids is unknown; </li></ul></ul>

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HEPATITIS B OCCUPATIONAL HAZARD

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HEPATITIS B <ul><li>MOST COMMON INFECTIOUS HAZARD FOR HCW’S. </li></ul><ul><li>KILLS DAILY MORE THAN AIDS KILLS YEARLY. </li></ul><ul><li>2 MILLION DEATHES / YEAR. </li></ul><ul><li>350 MILLION CARRIERS WORLDWIDE. </li></ul><ul><li>SECOND IN IMPORTANCE TO TOBACCO SMOKING AMONG HUMAN CARCINOGENS. </li></ul><ul><li>HEPATITIS B </li></ul><ul><li>HEPATITIS C </li></ul><ul><li>RUBELLA </li></ul><ul><li>T.B. </li></ul><ul><li>MENINGITIS </li></ul><ul><li>INFLUENZA </li></ul><ul><li>HIV INFECTIONS </li></ul><ul><li>SCABIES </li></ul><ul><li>MUMPS </li></ul><ul><li>STAPH. INFECTIONS </li></ul>

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CARRIER RATE <ul><li>. </li></ul>

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MODES OF TRANSMISSION <ul><li>. </li></ul>BLOOD SALIVA PLACENTA& B.MILK SEMEN& VAG.DISCHARGE PARENTRAL SEXUAL VERTICAL HORIZONTAL

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RISKY MODES <ul><li>. </li></ul>

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HB HB

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Sequelae of infection <ul><li>. </li></ul>Infection Clinical Sub-Clinical 65% 35% Fulminant Recovery & immunity 1% 9% 90% Chronic carrier Death <ul><li>Chronic persistent </li></ul><ul><li>Chronic active </li></ul><ul><li>Cirrhosis </li></ul><ul><li>Carcinoma </li></ul>

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ACUTE SEROLOGICAL RESPONCE HBsAg Anti-HBc HBeAg Anti-HBs Anti- HBe INCUBATION 3 months ACUTE INFECTION 6 MONTHS CONVALESCENCE RECOVERY +12 MONTHS HBsAg HBcAb HBeAg HBeAb HBsAb

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CHRONIC SEROLOGICAL RESPONCE HBsAg HBeAg Anti-HBc INCUBATION 4-12 WEEKS ACUTE INFECTION 6 MONTHS CHRONIC INFECTION YEARS

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1 1. recovering from acute HBV infection. 2. distantly immune and test not sensitive enough to detect very low level of anti-HBs in serum. 3. susceptible with a false positive anti-HBc. 4. undetectable level of HBsAg present in the serum and the person is actually a carrier negative positive negative HBsAg anti-HBc anti-HBs chronically infected positive positive negative negative HBsAg anti-HBc IgM anti-HBc anti-HBs acutely infected positive positive positive negative HBsAg anti-HBc IgM anti-HBc anti-HBs immune due to hepatitis B vaccination negative negative positive HBsAg anti-HBc anti-HBs immune due to natural infection negative positive positive HBsAg anti-HBc anti-HBs susceptible negative negative negative HBsAg anti-HBc anti-HBs Interpretation Results Tests Interpretation of the Hepatitis B Panel

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PREVALENCE OF HBV MARKERS

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FREQUENCY OF POTENTIAL HEPATITIS B EXPOSURE INCIDENTS

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Risk for Occupational Transmission of HBV <ul><li>The risk of HBV infection is primarily related to the degree of contact with blood in the work place and also to the hepatitis B e antigen (HBeAg) status of the source person. </li></ul>23-37% 1-6% HBsAg-positive, HBeAg-negative 37-62% 22-31% (HBsAg)- and HBeAg-positive Serological evidence Clinical hepatitis Source person

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DIRECT AND INDIRECT TRANSMISSION <ul><li>HBV has been demonstrated to survive in dried blood at room temperature for at least 1 week. </li></ul><ul><li>Thus, HBV infections have resulted from direct or indirect blood or body fluid exposures that inoculated HBV into cutaneous scratches, abrasions, burns, other lesions, or on mucosal surfaces </li></ul>

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LOCATION OF INCIDENTS

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WHO WILL BE AT RISK ? <ul><li>NURSES </li></ul><ul><li>HOUSEKEEPERS </li></ul><ul><li>CENTRAL SUPPLY WORKERS </li></ul><ul><li>LABORATORY TECHNICIANS </li></ul><ul><li>SURGICAL TECHNICIANS </li></ul><ul><li>X- RAY TECHNICIANS </li></ul><ul><li>PHYSICIANS </li></ul>

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HEPATITIS B VACCINE <ul><li>THE FIRST ANTI-CANCER VACCINE. </li></ul><ul><li>SAFE & EFFECTIVE. </li></ul><ul><li>NO ADVERSE REACTIONS . </li></ul>

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THE ACTION -- THE VACCINE <ul><li>YEAST DERIVED -- RECOMBINANT DNA TECHNOLOGY. </li></ul><ul><li>ADULT DOSE IS 20 UNITS ( 10 U FOR CHILDREN ) . </li></ul><ul><li>Given I.M. in deltoid muscle with a needle 1-1.5 inches long . </li></ul>

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VACCINE SCHEDULE <ul><li>Vaccine can be given as 0,1,6 months schedule. </li></ul><ul><li>If the vaccination series is interrupted after the first dose, the second dose should be administered as soon as possible. The second and third doses should be separated by an interval of at least 2 months. </li></ul><ul><li>If only the third dose is delayed, it should be administered when convenient </li></ul>

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BOOSTER DOSE <ul><li>Vaccine-induced (anti-HBs) levels may decline overtime; BUT , immune memory response remains intact indefinitely following immunization . Persons with declining antibody levels are still protected against clinical illness and chronic disease. </li></ul><ul><li>SO , booster doses of vaccine are not recommended </li></ul>

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POST VACCINATION SCREEN <ul><li>After routine vaccination of infants, children, adolescents, or adults post-vaccination testing for adequate antibody response is not necessary . </li></ul><ul><li>Post-vaccination testing IS recommended for persons whose medical management will depend on knowledge of their immune status. This includes : </li></ul><ul><ul><li>Immunocompromised (e.g., hemodialysis patients) </li></ul></ul><ul><ul><li>Persons received the vaccine in the buttock </li></ul></ul><ul><ul><li>Infants born to HBsAg (hepatitis B surface antigen)-positive mothers </li></ul></ul><ul><ul><li>Healthcare workers who have contact with blood </li></ul></ul><ul><ul><li>Sex partners of persons with chronic hepatitis B virus infection </li></ul></ul><ul><li>Post-vaccination testing should be completed 1-2 months after the third dose. A protective antibody response is (>=10mIU/mL). </li></ul>

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No Response <ul><li>Persons who do not respond to the primary vaccine series should complete a second 3-dose vaccine series or be evaluated to determine if they are HBsAg-positive. </li></ul><ul><li>Revaccinated persons should be retested at the completion of the second vaccine series. </li></ul><ul><li>Persons who do not respond to an initial 3-dose vaccine series have a 30%–50% chance of responding to a second 3-dose series .. </li></ul><ul><li>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. </li></ul>

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POST- EXPOSURE PROPHYLAXIS

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HBIG administration <ul><li>When HBIG is indicated, it should be administered as soon as possible after exposure (preferably within 24 hours). The effectiveness of HBIG when administered >7 days after exposure is unknown. </li></ul><ul><li>When hepatitis B vaccine is indicated, it should also be administered as soon as possible (preferably within 24 hours) and can be administered simultaneously with HBIG at a separate site (vaccine should always be administered in the deltoid muscle). </li></ul>

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<ul><li>For exposed persons who are in the process of being vaccinated but have not completed the vaccination series, vaccination should be completed as scheduled, and HBIG should be added as indicated. </li></ul><ul><li>Persons exposed to HBsAg-positive blood or </li></ul><ul><li>body fluids who are known not to have responded to a primary vaccine series should receive a single dose of HBIG and reinitiate the hepatitis B vaccine series with the first dose of the hepatitis B vaccine as soon as possible after exposure. </li></ul><ul><li>Alternatively, they should receive two doses of HBIG, one dose as soon as possible after exposure, and the second dose 1 month later </li></ul>

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Surveillance sheet used in hospital

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PROTECTIVE EFFICIENCY

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<ul><li>Hepatitis C Exposure </li></ul>

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Occupational Transmission of HCV <ul><li>HCV is not transmitted efficiently through occupational exposures to blood. The average incidence of anti-HCV seroconversion after accidental percutaneous exposure from an HCV-positive source is 1.8% (range: 0%–7%) </li></ul><ul><li>Transmission rarely occurs from mucous membrane exposures to blood, and no transmission in HCP has been documented from intact skin exposures to blood. </li></ul><ul><li>Data are limited on survival of HCV in the environment. </li></ul>

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Post-exposure Management for HCV <ul><li>The use of IG as PEP for hepatitis C was not supported </li></ul><ul><li>No clinical trials have been conducted to assess post exposure use of antiviral agents to prevent HCV infection. </li></ul><ul><li>In the absence of PEP for HCV, recommendations for post exposure management are intended to achieve early identification of chronic disease and, if present, referral for evaluation of treatment options. </li></ul>

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Management of Exposures to HCV <ul><li>For the source, perform testing for anti-HCV. </li></ul><ul><li>For the person exposed to an HCV-positive source: </li></ul><ul><li>1. perform baseline testing for anti-HCV and ALT activity; </li></ul><ul><li>2. perform follow-up testing (e.g., at 4–6 months) for anti-HCV and ALT activity . </li></ul><ul><li>• Confirm all anti-HCV results reported positive by enzyme immunoassay using supplemental anti-HCV testing (e.g., recombinant immuno blot assay [RIBA™]) </li></ul>

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<ul><li>HIV Exposure </li></ul>

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Risk for Occupational Transmission of HIV <ul><li>The average risk of HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3%. </li></ul>

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factors affecting risk of HIV transmission after an occupational exposure <ul><li>Exposure to a larger quantity of blood from the source person as indicated by: </li></ul><ul><ul><li>a device visibly contaminated with the patient’s blood. </li></ul></ul><ul><ul><li>a procedure that involved a needle being placed directly in a vein or artery. </li></ul></ul><ul><ul><li>a deep injury </li></ul></ul><ul><li>exposure to blood from source persons with terminal illness. </li></ul>

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Recommendations for HIV PEP <ul><li>a basic 4-week regimen of two drugs (zidovudine [ZDV] and lamivudine [3TC]; 3TC and stavudine [d4T]; or didanosine [ddI] and d4T) for most HIV exposures and an expanded regimen that includes the addition of a third drug for HIV exposures that pose an increased risk for transmission. When the source person’s virus is known or suspected to be resistant to one or more of the drugs considered for the PEP regimen. </li></ul>

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RECOMMENDATIONS FOR THE MANAGEMENT OF HCP POTENTIALLY EXPOSED TO HBV, HCV, or HIV <ul><li>HCP should report occupational exposures immediately after they occur to infection control personnel at hospital, particularly because HBIG, hepatitis B vaccine, and HIV PEP are most likely to be effective if administered as soon after the exposure as possible. </li></ul>

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Treatment of an Exposure Site <ul><li>Wounds and skin sites that have been in contact with blood or body fluids should be washed with soap and water; mucous membranes should be flushed with water. </li></ul><ul><li>No evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of blood borne pathogen transmission; </li></ul><ul><li>however, the use of antiseptics is not contraindicated. The application of caustic agents (e.g., bleach) or the injection of antiseptics or disinfectants into the wound is not recommended. </li></ul>

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Evaluation of the Exposure Source <ul><li>The person whose blood or body fluid is the source of an occupational exposure should be evaluated as soon as possible for infection . </li></ul><ul><li>If the HBV, HCV, and/or HIV infection status of the source is unknown, the source person should be informed of the incident and tested for serologic evidence of blood -borne virus infection. </li></ul>

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www.cdc.gov Referrences

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