Jun 30, 2009 ... worker (HCW) should act promptly to carry out the steps listed below. 2. ...
Exposures for Mucous Membrane and Non-Intact Skin Exposures. • Consider ....
and the HCW is a female of child-bearing age, a stat pregnancy test.
Postexposure Prophylaxis for
Occupational Bloodborne Exposures
A Manual for Health Care Providers
Kathy Hall, PA-C Christopher Behrens, MD David H. Spach, MD and
The Northwest AIDS Education and Training Center
Last Updated: June 30, 2009
Dear Health Care Workers: Any health care worker who experiences a bloodborne pathogen exposure should receive a timely and accurate evaluation, as well as appropriate management and follow-up. Although many institutions have a Postexposure Prophylaxis (PEP) protocol, most lack a user-friendly, single-source document that addresses the multiple complex issues associated with an exposure. The Northwest AIDS Education and Training Center (NW AETC) has developed a postexposure evaluation, treatment, and follow-up manual titled Postexposure Prophylaxis for Occupational Bloodborne Exposures: A Manual for Health Care Providers. The recommendations in this manual are based on the 2005 U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis. We hope this manual will serve as a useful resource for you as you develop or update your Postexposure Prophylaxis program. Sincerely,
Kathy Hall, PA-C RiverStone Health and Northwest AIDS Education and Training Center HIV Specialist, American Academy of HIV Medicine
Christopher Behrens, MD Medical Director, International Training and Education Center on HIV (I-TECH) Clinical Assistant Professor of Medicine, Division of Infectious Diseases University of Washington School of Medicine
David H. Spach, MD Clinical Director, Northwest AIDS Education and Training Center Professor of Medicine, Division of Infectious Diseases University of Washington School of Medicine
TABLE OF CONTENTS
INTRODUCTION INSTRUCTIONS FOR HEALTH CARE WORKERS …………………….….. 1 EVALUATION AND RECOMMENDATIONS BY EXPOSURE TEAM …….. 2 72 HOUR FOLLOW-UP VISIT ..………………………….…..…………..…… 7 TWO WEEK FOLLOW-UP VISIT ………………………………….….….…… 8 SIX WEEK FOLLOW-UP VISIT ……….……..………………………..…….… 9 12 WEEK FOLLOW-UP VISIT ………..………………………………..…..…. 10 24 WEEK FOLLOW-UP VISIT ………..………………………………………. 11 48 WEEK FOLLOW-UP VISIT (IF INDICATED) ….…….………………………. 11 REFERENCES ……..…………………………….…….….…………………… 12
TABLES TABLE 1: TABLE 2: TABLE 3: TABLE 4: TABLE 5:
CLASSIFICATION OF EXPOSURES VERSUS NON- EXPOSURES TO HIV ………………………………….……………………..…..
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CLASSIFICATION OF EXPOSURES VERSUS NON- EXPOSURES TO HBV AND HCV .….……...………………………..…..….……..
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HIV PEP FOR PERCUTANEOUS INJURIES: SOURCE WITH KNOWN HIV INFECTION …………………….…….....……..……...
15
HIV PEP FOR PERCUTANEOUS INJURIES: SOURCE WITH UNKNOWN HIV STATUS, UNKNOWN SOURCE, OR HIV-NEGATIVE
… 16
HIV PEP FOR MUCOUS MEMBRANE AND NON-INTACT SKIN EXPOSURES ……………………………………..…..……….…..
TABLE 6:
PREFERRED BASIC REGIMENS
TABLE 7:
ALTERNATIVE BASIC REGIMENS
TABLE 8:
PREFERRED AND ALTERNATIVE EXPANDED REGIMENS
TABLE 9:
AUTHORS’ RECOMMENDED BASIC AND EXPANDED REGIMENS
TABLE 10:
PRIMARY SIDE EFFECTS AND TOXICITIES ASSOCIATED WITH ANTIRETROVIRAL AGENTS ………………………………..….….
TABLE 11:
17
….…………………………….…. 18 ...……………………………….. 19
RECOMMENDED PEP FOR EXPOSURE TO HBV
..…….….. 20 ..... 21 22
.…………....….… 26
FORMS FORM 1:
SUPERVISOR’S FOLLOW-UP REPORT OF INCIDENT
FORM 2:
EXPOSURE CONTROL TEAM ASSESSMENT AND REPORT OF POSSIBLE BLOODBORNE PATHOGEN EXPOSURE .……..…..…….
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INFORMED REFUSAL OF MEDICAL EVALUATION FOLLOWING EXPOSURE TO BLOODBORNE PATHOGEN(S) ....……….…..……..
32
FORM 4:
EMPLOYEE REFUSAL TO RECEIVE HEPATITIS B VACCINATION .......
33
FORM 5:
LACK OF DOCUMENTATION OF HEPATITIS B VACCINATION AND REFUSAL OF EVALUATION FOR IMMUNITY ..…….…..……....
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FORM 6:
CONSENT FOR HIV TEST ….……….……….……………………..
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FORM 7:
INCIDENT REPORT
FORM 8:
SHARPS INJURY LOG
FORM 9:
SEVENTY-TWO HOUR FOLLOW- UP VISIT
FORM 10:
HEALTH CARE WORKER WRITTEN OPINION
FORM 11:
TWO WEEK FOLLOW-UP VISIT: RECOMMENDATIONS FOR HCW
FORM 12:
SIX WEEK FOLLOW-UP VISIT: RECOMMENDATIONS FOR HCW
FORM 13:
TWELVE WEEK FOLLOW- UP VISIT: RECOMMENDATIONS FOR HCW
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FORM 14:
TWENTY-FOUR WEEK FOLLOW-UP VISIT: RECOMMENDATIONS FOR HCW ………………………………………………………...
44
FORM 3:
…...………… 27
...……….……….…………….……….…….. 36 ………….…………….……………….….. 37 ..………….…...………. 38 …….…..…....…….... 39 …. 41
…… 42
INSTRUCTIONS FOR HEALTH CARE WORKERS 1. In the Event of An Exposure In the event of a possible exposure to a bloodborne pathogen, the health care worker (HCW) should act promptly to carry out the steps listed below. 2. Decontaminate the Area of the Exposure • Needle stick o Remove gloves immediately, if present o Wash area with soap and water o Avoid squeezing or milking the wound o Do not use caustic agents, such as bleach • Blood splash on skin o Wash area with soap and water • Blood/body fluid splash to mucous membranes o Wash/irrigate area copiously with water or sterile saline 3. Contact Designated Person or Exposure Control Team All health care facilities should have an established system that assigns a designated person or team to respond to a HCW who experiences an occupational exposure to a bloodborne pathogen. The HCW should contact this designated person (or exposure team) immediately after decontaminating the area of exposure. Henceforth in this document, we will refer to the person or team that responds to the exposure as the “Exposure Control Team”. 4. Source Patient If possible, the HCW should attempt to keep the source patient in the clinic until the Exposure Control Team can evaluate the situation. 5. Contact your Supervisor The HCW should contact his or her supervisor. The supervisor should complete Form 1: Supervisor’s Follow-up Report of Incident (or a form similar to this). 6. Evaluation of Exposure and Follow-up The evaluation of the exposure and the follow-up for the HCW will be performed and arranged for by the Exposure Control Team.
The National Clinicians’ Post Exposure Prophylaxis Hotline (PEPline) at 1-888-448-4911 offers free advice on the management of occupational exposures to HIV, hepatitis B and hepatitis C. Clinical consultation is available 24 hours/day, 7 days/week.
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EVALUATION AND RECOMMENDATIONS BY EXPOSURE CONTROL TEAM 1. Decontaminate • Check to make sure the HCW has decontaminated the area where the exposure occurred. If the HCW has not already done this, decontaminate as instructed below: o Decontamination of needlestick injury Remove gloves immediately, if present Wash area with soap and water Avoid squeezing or milking the wound Do not use caustic agents, such as bleach o Decontamination of blood splash to skin Wash area with soap and water o Decontamination of blood/body fluid splash to mucous membranes Wash/irrigate area copiously with water or sterile saline. 2. Determine the Risk of the Exposure • To determine whether or not the incident represents an actual exposure for HIV use Table 1: Classification of Exposures Versus NonExposures to HIV. For hepatitis B virus (HBV) and hepatitis C virus (HCV) use Table 2: Classification of Exposures Versus NonExposures to HBV and HCV. You may find it helpful to begin to complete Form 2: Exposure Control Team Assessment of Possible Bloodborne Pathogen Exposure, as this form will help you obtain the information necessary for the exposure evaluation and subsequent steps. • If the source for the exposure is unknown, such as a needlestick injury involving a needle in a sharps container, expert consultation is recommended. • If the incident does not represent an exposure, skip to step 11, as no further action is required apart from completion of certain forms. • If the incident does represent an exposure, proceed with medical evaluation as outlined in the following steps. If the HCW refuses medical evaluation they should complete and sign Form 3: Informed Refusal of Medical Evaluation Following Exposure to Bloodborne Pathogen(s). 3. Counsel for HIV Exposure Risk and Postexposure Prophylaxis • If the HCW may have been exposed to HIV, counsel the HCW about the risk of acquiring HIV from the exposure and the pros and cons of taking HIV Postexposure Prophylaxis (PEP) antiretroviral medications. Use Table 3: HIV PEP for Percutaneous Injuries: Source with Known HIV Infection to assist in exposure risk stratification for a Percutaneous Injury Involving Source with Known HIV Infection, and use Table 4: HIV PEP for Percutaneous Injuries: Source with Unknown HIV Status, Unknown Source, or HIV-Negative for Percutaneous Injury Involving Source with
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Unknown HIV Status, Unknown Source, or HIV-Negative Source. Use Table 5: HIV PEP for Mucous Membrane and Non-Intact Skin Exposures for Mucous Membrane and Non-Intact Skin Exposures. • Consider contacting a local/regional PEP expert or the PEPline for assistance with counseling and risk stratification. The National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline) offers free advice to Health Care Workers on the management of exposures to HIV, HBV, and HCV, 24 hours/day, 7 days/week. The PEPline phone number is 888-448-4911. 4. Start HIV Antiretroviral PEP • If indicated and the HCW consents, start HIV PEP as soon as possible (ideally within 1-2 hours). The sooner PEP is started, the more effective it is thought to be. The time interval beyond which there is no benefit remains unknown. Antiretroviral PEP can be considered after 24-36 hours after the exposure, but expert consultation is recommended in this situation. • If the source patient has known HIV infection, try to obtain pertinent information about their stage of HIV disease: most recent viral load, antiretroviral therapy history, and results from resistance testing (if previously performed). Obtaining source patient information may help in estimating the exposure risk and in designing an HIV PEP regimen, but gathering this information should not delay timely administration of PEP. • Based on the information you have obtained and the risk stratification, prescribe either a Basic (2-drug) or Expanded (3-drug) regimen. The 2005 U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis provides recommendations for Preferred Basic Regimens (Table 6: Preferred Basic Regimens), Alternative Basic Regimens (Table 7: Alternative Basic Regimens), and Preferred and Alternative Expanded Regimens (Table 8: Preferred and Alternative Expanded Regimens). Nevirapine is contraindicated for use in PEP due to its potential life-threatening toxicity in this setting. • Given that new advances and data regarding antiretroviral therapy have occurred since the release of the 2005 U.S. Public Health Service Guidelines, we have included our 2009 authors’ recommendations for Preferred Basic Regimen and Preferred Expanded Regimens (Table 9: Authors’ Recommended Basic and Expanded Regimens). • We do not recommend using efavirenz as a preferred postexposure agent for two reasons: (1) central nervous system adverse effects frequently occur during the initial weeks after starting this medication, a problem that could be particularly problematic HCWs, and (2) efavirenz may be ineffective if the source patient’s strain of HIV is resistant to nonnucleoside reverse transcriptase inhibitors (NNRTIs). • We do not recommend initial use of abacavir because of the risk of hypersensitivity reaction in the HCW (obtaining HLA-B5701 testing for the HCW would delay use of abacavir). • We do not recommend the use of maraviroc since the source patient may 3
•
• • •
have X4-tropic HIV, or a mixture of HIV strains that include X4 HIV; a rapid HIV tropism assay is not commercially available. In the rare circumstance when the source patient very recently had an HIV tropism assay performed, use of maraviroc could be considered if the source patient had pure R5 HIV; expert consultation is advised in this circumstance. When a source patient has known antiretroviral-resistant HIV, expert consultation should be obtained to review any known resistance information on the source patient and to determine the optimal PEP regimen. If the HCW is breastfeeding or pregnant, expert consultation is recommended. In addition, review any medications or supplements the HCW may be taking, and investigate potential drug-drug interactions. Provide a minimum of 3-day supply of PEP medications. The total duration of antiretroviral PEP is 28 days. Discuss the dosing and common side effects of the medications prescribed (Table 10: Primary Side Effects and Toxicities) and provide the HCW with contact numbers in the event they have significant side effects. If side effects develop, provide appropriate prescription(s), such as anti-emetics and/or anti-diarrheals. If the side effects are severe, assess whether the medications need to be changed.
5. Determine HBV Immune Status and Administer HBV PEP if Needed • If the HCW may have been exposed to hepatitis B, determine whether the HCW has been immunized against HBV, and if so, whether the HCW is known to have responded to this vaccination (e.g. has documented protective hepatitis antibody titer). Details for HBV PEP are provided in Table 11: Recommended PEP for Exposure to HBV. • If hepatitis B vaccination is indicated but the HCW declines immunization, they should complete and sign Form 4: Employee Refusal to Accept Hepatitis B Vaccination. • If the HCW claims to have had hepatitis B vaccination series and does not wish to accept HBV antibody testing or hepatitis B vaccine at the time of exposure, they should complete and sign Form 5: Lack of Documentation of Hepatitis B Vaccine. The HCW may request this vaccine at any time in the future. 6. Counsel after Exposure to Hepatitis C Virus • In the event the HCW was exposed to hepatitis C, there is no proven effective PEP for HCV and thus PEP for hepatitis C is not recommended. Perform baseline testing for anti-HCV and ALT activity. • The recommended baseline and follow-up testing consists of: o Testing for anti-HCV and ALT activity o Testing (at 4-6 months) for anti-HCV and ALT activity o Some experts recommend HCV RNA testing at 4-6 weeks to make an earlier diagnosis of HCV infection, mainly because treatment of persons with very recently acquired HCV has been shown to have very high cure rates 4
o Confirm all anti-HCV results reported positive by enzyme immunoassay with supplemental anti-HCV testing (recombinant immunoblot and/or HCV viral load) 7. Obtain Baseline Laboratory Studies for the HCW • Draw relevant baseline labs on the HCW. These generally include baseline serologic testing for HIV, HCV, and hepatitis B (HIV Ab, HCV Ab, HBsAb), plus a baseline ALT level. In addition, if PEP is being considered and the HCW is a female of child-bearing age, a stat pregnancy test should be performed. • If HIV PEP is initiated, a baseline complete blood count (CBC), BUN, Creatinine, and ALT should also be drawn. • If written consent for HIV testing is required in the state where the exposure occurred, complete Form 6: Consent for HIV Test prior to drawing blood for the HIV antibody test on the HCW. • Drawing blood for laboratory studies on the HCW should not delay timely administration of PEP. If PEP is indicated, administer the first dose of PEP and then obtain blood for laboratory studies. 8. Test Source Patient • Attempt to obtain permission to perform testing on the source patient for HIV Ab, HCV Ab, and HBsAg. If these tests have previously been performed on the source patient, clinical judgment should be used to determine whether the studies need repeating. The source patient should not be charged for these tests. • In certain circumstances where immediate information is needed on the source patient, such as the situation where the exposed HCW is pregnant, use of the rapid HIV test (if available) may be appropriate for testing a source patient with unknown HIV status. Expert consultation is advised in this situation. • If the source patient refuses to give permission to have blood drawn, you should contact your local health department for assistance in the matter. Laws and regulations regarding this scenario vary from state to state. 9. Counseling HCW About Preventing HIV Transmission • During the follow-up period, especially the first 6-12 weeks, the following precautions are recommended for the HCW to prevent transmission of HIV: o Do not donate blood, tissue, semen, or organs. o Do not become pregnant. o Do not engage in sexual intercourse during this time period. If the HCW chooses to have sexual intercourse, they should use a condom consistently and correctly to reduce the risk of HIV transmission. o Women should not breast-feed infants during the follow-up period.
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10. Arranging Follow-up for the HCW • Schedule a follow-up appointment that takes place within 72 hours. • Provide the HCW with a copy of “Exposure to Blood—What Healthcare Workers Need to Know”. • Provide a contact number for the HCW in the event he or she has further questions, or if problems develop with the PEP regimen. • Offer psychological counseling referral for the HCW if indicated. • Provide return precautions: instruct the HCW to return immediately for evaluation (e.g., Emergency Department or Urgent Care) if he or she develops significant adverse effects from the PEP regimen. 11. Complete Remaining Paperwork (forms not already completed) • Form 1: Supervisor’s Follow-Up Report of Incident (the HCW’s supervisor should have completed) • Form 2: Exposure Control Team Assessment & Report of Possible Bloodborne Pathogen Exposure (jointly completed by HCW and Exposure Control Team) • Form 7: Incident Report Form 8: Sharps Injury Log
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72 HOUR FOLLOW-UP VISIT Instructions for the Managing Clinician 1. Address HCW Questions or Concerns At this visit address any questions or concerns the exposed HCW may have about the exposure or PEP recommendations to date. Form 9: 72 Hour Follow-up Visit provides a template that can be used to record details of this and subsequent follow-up visits. Offer psychological counseling referral if indicated. 2. Incorporate New Information Evaluate and incorporate any new information that may have become available about the source patient since the initial evaluation. Decide whether or not any of the PEP recommendations made at the initial evaluation should be changed in light of this new information. Consider consulting the PEPline for advice (888-448-4911). 3. Review Baseline Labs Review the labs drawn on the HCW at the Initial Visit. Investigate any abnormalities with further studies as indicated. If any baseline laboratory studies are abnormal and PEP was prescribed, re-evaluate the appropriateness of the HCW’s specific PEP regimen. If baseline labs were not drawn at the initial evaluation, draw them at this 72 hour visit. 4. Complete Form 10: Health Care Worker Written Opinion Complete this form at this visit if follow-up not planned. Otherwise have the form completed at the two week follow-up visit. Provide a copy to the HCW. 5. Educate the HCW about Primary (Acute) HIV Manifestations Advise the HCW regarding signs and symptoms of primary (acute) HIV infection, which typically develop within 1 to 6 weeks of exposure and may include fever, rash, sore throat, lymphadenopathy, headache, or flu-like symptoms. If these symptoms should occur, advise HCW to seek prompt evaluation for possible primary HIV infection. 6. Complete Outstanding Forms Complete any forms that were not completed at the Initial Evaluation.
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TWO WEEK FOLLOW-UP VISIT (FOR HCWS WHO INITIATED ANTIRETROVIRAL PEP) 1. Address HCW Questions or Concerns Address any questions or concerns the exposed HCW may have about the exposure or PEP recommendations to date. Use Form 11: Two Week Follow-up Visit: Recommendations for HCW to record details of this and subsequent steps. Offer psychological counseling referral if indicated. 2. Incorporate New Information Evaluate any new information that may have become available about the source patient since the initial evaluation. Decide whether or not any of the PEP recommendations made at the initial evaluation should be changed in light of this new information. Consider consulting the PEPline for advice (888-448-4911). 3. Review All HCW Lab Studies Review all of the lab studies drawn on the HCW to date. Investigate any abnormalities with further studies as indicated. If any laboratory studies are abnormal, re-evaluate the appropriateness of the specific PEP regimen. 4. Draw Chemistry Panel and CBC Draw chemistry panel and CBC to screen for toxicities from the antiretroviral medications. 5. Complete Form 11: Two Week Follow-up Visit: Recommendations for HCW Complete this form and provide a copy to the HCW. 6. Complete Form 10: Health Care Worker Written Opinion If not already done, complete this form and provide a copy to the HCW. 7. Discuss Primary (Acute) HIV Manifestations Remind the HCW about signs and symptoms of primary HIV infection, which typically develop within 1 to 6 weeks of exposure: fever, rash, sore throat, lymphadenopathy, headache, or flu-like symptoms. If these symptoms should occur advise HCW to seek evaluation immediately for possible primary HIV infection.
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SIX WEEK FOLLOW-UP VISIT 1. Address HCW Questions or Concerns Address any questions or concerns the exposed HCW may have about the exposure. Offer psychological counseling referral if indicated. 2. Review All HCW Lab Studies Review any of the lab studies that have not already been reviewed with the HCW and inform the HCW about subsequent lab draws. 3. Evaluate for Acute (Primary) HIV If the exposure involved HIV, review whether the HCW has experienced (or is currently experiencing) any symptoms that would suggest acute (primary) HIV infection. The constellation of symptoms that would suggest acute HIV infection includes fever, rash, sore throat, lymphadenopathy, headache, or flulike symptoms. Patients who have symptomatic acute HIV typically present within 28 days of the initial infection. If you suspect acute HIV infection, then order an HIV RNA test along with HIV antibody testing. 4. Evaluate for Acute Viral Hepatitis If the exposure involved HCV (or HBV in a HCW not immune to HBV), review whether the HCW has experienced (or is currently experiencing) any symptoms that would suggest acute hepatitis (nausea, abdominal pain, fatigue, flu-like symptoms, jaundice, or dark urine). Patients with acute HCV infection are usually asymptomatic, but those with symptomatic acute disease typically present 6-8 weeks after infection (range 5-12 weeks). If you suspect acute HCV infection, order an HCV RNA test along with HCV antibody testing. 5. Complete Form 12: Six Week Follow-up Visit: Recommendations for HCW Complete this form and provide a copy to the HCW. 6. Draw Laboratory Studies for HIV and HCV as Indicated Order an HIV test if the HCW exposure involved HIV. Similarly, if the exposure involved HCV, then HCV antibody testing should be performed. Routine use of HIV RNA testing, without suspected acute HIV, is NOT recommended. Considering most adults with acute HCV do not have obvious clinical symptoms (and treatment of adults with acute HCV results in very high cure rates), some experts recommend obtaining an HCV RNA test at this visit.
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12 WEEK FOLLOW-UP VISIT 1. Address HCW Questions or Concerns Address any questions or concerns the exposed HCW may have about the exposure. Offer psychological counseling referral if indicated. 2. Review All HCW Lab Studies Review any of the lab studies that have not already been reviewed with the HCW and inform the HCW about subsequent lab draws. 3. Evaluate for Acute (Primary) HIV If the exposure involved HIV, review whether the HCW has experienced (or is currently experiencing) any symptoms that would suggest acute (primary) HIV infection. The constellation of symptoms that would suggest acute HIV infection includes fever, rash, sore throat, lymphadenopathy, headache, or flulike symptoms. Patients who have symptomatic acute HIV typically present within 28 days of the initial infection. If you suspect acute HIV infection, then order an HIV RNA test along with HIV antibody testing. 4. Evaluate for Acute Viral Hepatitis If the exposure involved HCV (or HBV in a HCW not immune to HBV), review whether the HCW has experienced (or is currently experiencing) any symptoms that would suggest acute hepatitis (nausea, abdominal pain, fatigue, flu-like symptoms, jaundice, or dark urine). Patients with acute HCV infection are usually asymptomatic, but those with symptomatic acute disease typically present 6-8 weeks after infection (range 5-12 weeks). If you suspect acute HCV infection, then order an HCV RNA assay along with HCV antibody testing. 5. Complete Form 13: Twelve Week Follow-up Visit: Recommendations for HCW Complete this form and provide a copy to the HCW. 6. Draw Laboratory Studies for HIV and HCV as Indicated If the HCW exposure involved HIV, then order an HIV antibody test. Similarly, if the exposure involved HCV, then order an HCV antibody test. Any HCW who has a positive HCV antibody test should undergo supplemental testing with an HCV RNA test. Routine use of HIV RNA testing, without suspected acute HIV, is NOT recommended. Considering most adults with acute HCV do not have obvious clinical symptoms (and treatment of adults with acute HCV results in very high cure rates), some experts recommend obtaining an HCV RNA test at this visit.
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24 WEEK FOLLOW-UP VISIT 1. Address HCW Questions or Concerns Address any questions or concerns the exposed HCW may have about the exposure. Offer psychological counseling referral if indicated. 2. Review All HCW Lab Studies Review any of the lab studies that have not already been reviewed with the HCW and inform the HCW about subsequent lab draws. 3. Complete Form 14: Twenty-four Week Follow-up Visit: Recommendations for HCW Complete this form and provide a copy to the HCW. 4. Draw Laboratory Studies for HIV and HCV as Indicated If the HCW exposure involved HIV, then order an HIV antibody test. Similarly, if the exposure involved HCV, then HCV antibody testing should be performed. Any HCW who has a positive HCV antibody test should undergo supplemental testing with an HCV RNA test.
48 WEEK FOLLOW-UP (IF INDICATED) 1. Address HCW Questions or Concerns Address any questions or concerns the exposed HCW may have about the exposure. Offer psychological counseling referral if indicated. 2. Review All HCW Lab Studies Review any of the lab studies that have not already been reviewed with the HCW and inform the HCW about subsequent lab draws. 3. Draw Laboratory Studies for HIV and HCV Antibody Tests as Indicated If the original exposure involved both HIV and HCV (or the HCW has a medical condition that would impair their ability to mount an antibody response to viral pathogens), then order antibody testing for HIV and HCV. If the exposure involved only HIV, then antibody testing after 24 weeks is not required. Similarly, if the exposure involved HCV only, then HCV antibody testing is not required after 24 weeks.
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SELECTED REFERENCES Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med. 1997;337:1485-90. http://content.nejm.org/cgi/content/abstract/337/21/1485 Henderson DK. Managing occupational risks for hepatitis C transmission in the health care setting. Clin Microbiol Rev. 2003;16:546-68. http://cmr.asm.org/cgi/content/full/16/3/546?view=long&pmid=12857782 Henderson DK, Fahey BJ, Willy M, et al. Risk for occupational transmission of human immunodeficiency virus type 1 (HIV-1) associated with clinical exposures. A prospective evaluation. Ann Intern Med. 1990;113:740-6. http://www.annals.org/cgi/content/abstract/113/10/740 Gerberding JL. Clinical practice. Occupational exposure to HIV in health care settings. N Engl J Med. 2003;348:826-33. http://content.nejm.org/cgi/content/extract/348/9/826 Ippolito G, Puro V, Petrosillo N, et al. Simultaneous infection with HIV and hepatitis C virus following occupational conjunctival blood exposure. JAMA. 1998;280:28. http://jama.ama-assn.org/cgi/content/full/280/1/28 Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. November 3, 2008;1-139. http://aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?MenuItem=Guidelines&Search= Off&GuidelineID=7&ClassID=1 Panlilio AL, Cardo DM, Grohskopf LA, Heneine W, Ross CS; U.S. Public Health Service. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2005;54(RR-9):1-17. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm Sulkowski MS, Ray SC, Thomas DL. Needlestick transmission of hepatitis C. JAMA. 2002;287:2406-13. http://jama.ama-assn.org/cgi/content/full/287/18/2406 Wang SA, Panlilio AL, Doi PA, et al. Experience of healthcare workers taking postexposure prophylaxis after occupational HIV exposure: findings of the HIV Postexposure Prophylaxis Registry. Infect Control Hosp Epidemiol. 2000;21:780-5. http://www.journals.uchicago.edu/doi/abs/10.1086/501736
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TABLE 1: CLASSIFICATION OF EXPOSURES VERSUS NONEXPOSURES TO HIV
EXPOSURES • Transfusion of blood or blood components • Intravenous, intramuscular or subcutaneous injury with a needle contaminated with a potentially infectious body fluid* whether or not the injury results in visible bleeding • Any mucous membrane or break in the skin (e.g., non-healed wound or dermatologic condition that compromises the integrity of the skin) exposed to a potentially infectious body fluid • Human bites: o Exposure to the individual doing the biting if the skin was broken resulting in visible bleeding; o
Exposure to the bitten individual if the skin was broken and visibly bleeding AND the individual who was doing the biting was bleeding in the mouth at the time of the bite
NON-EXPOSURES • Intact skin or healed wound/skin lesion contaminated with potentially infectious body fluid • Intravenous, intramuscular or subcutaneous injury with a needle contaminated with a fluid that is not potentially infectious • Mucous membrane or break in the skin exposed to a fluid that is not
potentially infectious *For exposures to HIV, a potentially infectious body fluid includes blood, amniotic fluid, spinal fluid, pleural fluid, pus, semen, vaginal fluid, breast milk, or any fluid that is visibly bloody. Saliva, urine, and feces are not considered to be potentially infectious for HIV unless visibly bloody.
Modified from: Panlilio AL, Cardo DM, Grohskopf LA, Heneine W, Ross CS; U.S. Public Health Service. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2005;54(RR-9):1-17.
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TABLE 2: CLASSIFICATION OF EXPOSURES VERSUS NONEXPOSURES TO HBV AND HCV
EXPOSURES • Transfusion of blood or blood components • Intravenous, intramuscular or subcutaneous injury with a needle contaminated with a potentially infectious body fluid* whether or not the injury results in visible bleeding • Any mucous membrane or break in the skin (e.g., non-healed wound or dermatologic condition that compromises the integrity of the skin) exposed to a potentially infectious body fluid • Human bites: o Exposure to the individual doing the biting if the skin was broken resulting in visible bleeding; o Exposure to the bitten individual if the skin was broken and visibly bleeding NON-EXPOSURES • Intact skin or healed wound/skin lesion contaminated with potentially infectious body fluid* • Intravenous, intramuscular or subcutaneous injury with a needle contaminated with a fluid that is not potentially infectious • Mucous membrane or break in the skin exposed to a fluid that is not
potentially infectious *For exposures to HBV, potentially infectious body fluids include blood, amniotic fluid, spinal fluid, pleural fluid, pus, saliva, semen, vaginal fluid, breast milk, or any fluid that is visibly bloody. Transmission of HBV via saliva exposure has been documented in rare cases involving highly infectious (HBeAg+) source individuals. Urine and feces are not considered to be potentially infectious for HBV unless visibly bloody. For exposures to HCV, the same rules are thought to apply with the exception of saliva, because transmission of HCV via exposure to saliva has not been clearly documented.
Modified from: Panlilio AL, Cardo DM, Grohskopf LA, Heneine W, Ross CS; U.S. Public Health Service. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2005;54(RR-9):1-17.
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TABLE 3: HIV PEP FOR PERCUTANEOUS INJURIES: SOURCE WITH KNOWN HIV INFECTION
Exposure Type
Source with Known HIV Infection HIV-Infected Class 1*
Less Severe – Solid needle
HIV-Infected Class 2^
Recommend basic 2-drug PEP
Recommend expanded 3-drug PEP
Recommend expanded 3drug PEP
Recommend expanded 3-drug PEP
– Superficial injury More Severe – Large-bore, hollow needle – Deep puncture – Visible blood on device – Needle used in patient's artery or vein * HIV-positive, class 1 = asymptomatic HIV infection or known HIV RNA
