Module 12

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Module 12

• Bloodborne Pathogens and the Dental Health Care
  Worker

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Bloodborne Pathogens and the Dental Health Care
Worker

• Christine Wisnom, RN, BS
• Nurse Educator
• Dental School
• University of Maryland Baltimore
• Helene Bednarsh, RDH, MPH
• Director, HIV Dental Ombudsperson Program
• Boston Public Health Commission
• Kathy Eklund, RDH, MPH
• The Forsyth Institute
• Boston, Massachusetts

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Updated Postexposure Protocols for HBV, HCV, HIV
Special Circumstances MMWR, CDC, 6-01,Vol.
50,RR-11

• HIV
• Hepatitis C
• Hepatitis B
• Pregnancy
• Delayed exposure report
• Unknown donor exposure
• Source patient drug resistant
• Human bite protocols

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Objectives Categories

• Prevention
• Planning
• Identification
• Implementation
• Evaluation

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Objectives-Prevention

• Prevention is best strategy to avoid infection
• Prevent HBV infection by HBV vaccine
• Prevent HBV transmission by HBV PEP
• Prevent HIV infection by timely HIV PEP
• Prevent injury through utilization of safe
  sharps, auto-recapping devices

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Safe Sharps Management
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Objectives- Planning

• Planning prior to occupational exposure is the
  key to efficient implementation of
  post-exposure protocols
• Establish a protocol for occupational exposures
• Educate health care workers regarding
  the implementation of the plan during
  job orientation and ongoing job training.
• CDC, MMWR 6-29-01,
  Vol.50/No. RR-11, 16.

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Objectives- Identification

• Identify
• Potential risk factors for transmission of HIV,
  HBV and HCV
• Health Care Professional (HCP) for medical
  follow-up
• Various recommendations for PEP based upon type
  of exposure for each

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Objectives- Implementation

• Implement Methods of risk reduction based on
  Work Practice Controls (WPC) Exposure Controls
  (EC)
• Emergency first aid for injury
• Post-exposure counseling
• Prophylaxis
• Medical evaluation and follow-up of exposed
  individuals

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Objectives- Evaluation

• Evaluate
• The effectiveness of the Occupational Exposure
  Monitoring System
• Adapt any necessary modifications for improvement
  
• Continue to maintain an evolving system based
  upon current scientific findings

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Exposure Definition

• An exposure is a percutaneous injury (e.g., a
  needle stick or cut with a sharp object) or
  contact of mucous membrane or nonintact skin
  (e.g., exposed skin that is chapped, abraded, or
  afflicted with dermatitis) with blood, tissue, or
  other body fluids that are potentially
  infectious.
• CDC, MMWR 6-29-01, Vol.
  50/No. RR-11, 3.

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Infectious Body Fluids

• In addition to blood and body fluids containing
  visible blood, semen and vaginal secretions are
  also considered potentially infectious. Although
  semen and vaginal secretions have been implicated
  in sexual transmission of HBV, HCV and HIV, they
  have not caused occupational transmission from
  patient to health care worker.
• CDC, MMWR 6-29-01, Vol.
  50/No. RR-11, 3.

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Potentially Infectious Fluids

• The risk for transmission of HIV, HBV and HCV
  with the following body fluids is unknown,
  caution is recommended when handling
  cerebrospinal fluid, synovial fluid, pleural
  fluid, peritoneal fluid, pericardial fluid, and
  amniotic fluid. They are considered to pose a
  potential risk for transmission.
• CDC, MMWR 6-29-01, Vol. 50/No.
  RR-11, 3.

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Low/No Risk Body Fluids

• Feces, nasal secretions, saliva, sputum, sweat,
  tears, urine and vomitus are not considered
  potentially infectious unless they contain blood.
  The risk for transmission of HBV. HCV and HIV
  infection from these fluids and materials is
  extremely low. Caution is recommended when
  handling these fluids.
• CDC, MMWR 6-29-01, Vol.
  50/No. RR-11, 3.

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Saliva Infectious for HIV?

• In the absence of visible blood in the saliva,
  exposure to saliva from a person infected with
  HIV is not considered a potential risk for HIV
  transmission. However, caution is recommended
  when handling.
• CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 3.

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Occupational Transmission of HCV

• Transmission from mucous membrane exposure to
  blood rarely occurs .
• HCV is not transmitted efficiently through
  occupational exposure to blood.
• Following percutaneous injury from HCV source
  infection rate is 1.8 (range 0-7).
• No transmission has been documented from
  nonintact or intact skin contact with HCV
  blood.
• CDC,
  MMWR, 6-29-01, Vol. 50/ No. RR-11, 5

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Survival of HBV in the Environment

• Only 1/2 of all HBV positive HCWs recall having
  an occupational injury. (DIRECT)
• Many infected individuals can recall caring for
  HBV patients. (INDIRECT)
• HBV can survive in dried blood at room
  temperature on environmental surfaces for at
  least 1 week. Exposures have occurred via
  scratches, abrasions, burns or on mucosal
  surfaces with poor infection control. Evidence of
  outbreaks have occurred in Hemodialysis Units.
• CDC, MMWR
  6-29-01, Vol. 50/No. RR-11, 4

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Occupational Transmission of HBV

• The risk of HBV transmission following needle
  stick is directly related to the amount of blood
  and the HBeAg status of the
  patient.
• Infection from HBeAg HBsAg is 37-62
• Infection from HBeAg- HBsAg is
  23-37
• CDC, MMWR 6-29-01,
  Vol. 50/No. RR-11, 3.

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Post-Hepatitis B Vaccine Testing

• Health Care Professionals 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.
• Hepatitis B vaccine may be given during
  pregnancy, contains no infectious particles.
• CDC, MMWR 6-29-2001/Vol.
  50/No. RR-11, 16.

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Nonresponders to HBV Vaccine

• People who do not respond to the first three
  vaccine series lt10 mIU/ml should complete a 2nd,
  3 vaccine series.
• People who do not respond to the first HBV series
  only have a 30-50 chance of responding to the
  2nd series.
• Testing at completion should be done to determine
  efficacy/or HbsAg status.
• CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 16.

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PEP for HBV Exposures in Non-vaccinated HCWs

• Health care workers who experience occupational
  exposure to the blood or body fluids of an HBsAg
  individual should receive
• 1 dose, 0.06mL/kg., of Hepatitis B immune
  globulin (HBIG), and
• The 1st dose of the HBV vaccine series.

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PEP for HBV Non-responders

• When a person has not responded to the 1st HBV
  vaccine series is exposed to the blood or body
  fluids of an HBsAg positive patient, a single
  dose of HBIG, preferably within 24 hrs. after
  exposure, and the first dose of the 2nd HBV
  vaccine series is preferred.
• CDC, MMWR. Vol. 50/ No. RR-11, 4.

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PEP for HBV for Non-responders

• HCWs that experience occupational exposures to
  the blood or body fluids of HBsAg positive
  patients who are non-responders to both the 1st
  and 2nd HBV vaccine series should receive 2 doses
  of HBIG.
• One at the time of injury and the 2nd dose 1
  month later.
• HBIG should be given with 24 hrs. if possible.
• When given in less than 7 days the effectiveness
  is approximately 75. When given in gt 7days after
  exposure effectiveness is uncertain.
• 
  CDC, MMWR 6-29-01, Vol50/No. RR-11, 4

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Expert Consultation Advised

• When drug resistance is evident
• HCW is pregnant
• Source is unknown
• Source is high risk for HIV infection

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Use of PEP When Source
is Unknown

• Decision made case-by-case
• PPE worn, removes 50 of inoculum
• Type puncture, splash, laceration
• Severity deep wound vs. superficial
• Body fluid and quantity blood, saliva, large
  amount vs. minimal amount of body fluid

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Use of PEP When Source
is Unknown (Cont)

• Environment IDU clinic, shelter, community
  prevalence, etc.
• To treat a 2 drug PEP for 4 weeks, reevaluate if
  new information is available, if negative
  discontinue medications. Do not test discarded
  needles for bloodborne pathogens.

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Factors that Increase the Probability of HIV
Infection

• Exposure to a larger quantity of blood
• Injury with a device with visible blood
• Deep injury
• Injury with device placed in vein/artery
• Injury to blood from patient with advanced AIDS
• Host defense, immune response may prevent
  infection

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Management of Occupational Blood Exposure

• When an exposure occurs, you should stop
  immediately
• Wash wound with soap water flush mucous
  membranes with water.
• Antiseptic use and/or bleeding the wound have not
  been proven to reduce infections.
• However, antiseptic use is not
  contraindicated.
• Bleach other caustic agents should not be
  poured directly into the wound.

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Evaluation of Occupational Exposure

• Obtain informed consent.
• Test source for HBsAg, anti-HCV, and HIV
  antibody. Consider using a rapid HIV antibody
  test if available.
• For patients who refuse testing/or unknown
  patients, consider medical diagnosis, risk
  behaviors and S/S.
• Do not test discarded needles for bloodborne
  pathogens.

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HCV Exposures

• Following occupational injury on an HCV patient
• Perform baseline F/U testing for anti-HCV and
  alanine aminotransferase (ALT) 4-6 months after
  exposure.
• Perform HCV RNA 4-6 weeks after exposure, to
  determine active viral replication.
• Confirm repeatedly positive anti-HCV (EIAs) with
  additional tests.
• No vaccine or PEP are available for protection
  against HCV. IG is not recommended for PEP.

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Treating early HCV disease

• While there is currently no vaccine to prevent
  HCV infection, or PEP to prevent infection
  immediately following exposure, recent studies
  suggest that early treatment of acute HCV may
  prevent chronic infection.
• Therefore HCWs should be vigilant with
  recommendations for follow-up and testing.

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Health Care Professional (HCP) Recommendations
for PEP in HIV Source

• When an exposure occurs on an HIV
  patient a HCP will
• Establish patientsstage of infection
  HIV or AIDS
• Obtain recent blood tests
  CD4 cells, T-cell
  count, viral load
  current medications
• Determine if donor patient has a resistant strain
• If information is not available, initiate PEP
• PEP should be initiated even if the exposure
  exceeds 36 hours

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Evaluation of HIV Exposure

• Following exposure on an HIV patient, assess
  and treat HCW, ideally within 2 hours.
• Perform HIV antibody testing for
  at least 6 months postexposure.
• Baseline
• 6 weeks
• 3 months and
• 6 months.

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Evaluation of HIV Exposure

• If symptoms of acute retroviral syndrome appear
  test HIV antibody immediately.
• Advise to use precautions to prevent secondary
  transmission.
• Evaluate for side effects at 72 hours and every
  2 week thereafter.
• Treat for 4 weeks.
• Consider the use of rapid testing.

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Basic PEP for HIV Exposures

• Basic Regimen (2 drugs)
  Zidovudine (AZT) Lamivudine (3TC)
  available as COMBIVIR.
• ZDV 600 mg/day, in 2 or 3 divided doses 3TC
  150mg twice daily, or give as one COMBIVIR tab
  twice daily for 4 weeks. Serious toxicity is
  rare, side effects are manageable, documented to
  reduce infection by approximately 81.
  CDC, MMWR, 6-29-01, Vol. 50/No. RR-11, 9.
• Other basic 2 drug regimens include
  3TC Stavudine (d4T) or d4T
  Didanosine (ddl), and should be considered in
  areas of the country where COMBIVIR resistance is
  common. CDC,MMWR, 6-29-01, Vol. 50/No.
  RR-11, 10.

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Expanded PEP for HIV Exposures

• An expanded 3 drug regimen should be considered
  for exposures that pose an increased risk for
  infection.
• A 3 drug regimen includes a basic 2 drug regime
  plus the addition of a Protease Inhibitor.
• Bartlett J. 2001-2 J. Hopkins Univ. School of
  Medicine, Medical Management of the HIV
  Infection, 66.

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HIV PEP for Percutaneous Injuries
Patient Status

Exposure Low Risk-Asymptomatic VL High Risk-AIDS Symptomatic, AIDS or VL Unknown
Not severe, superficial or injury with solid needle or instrument 2 drug PEP 3 drug PEP Usually none, consider 2 drug PEP
Severe, blood on device, deep wound 3 drug PEP 3 drug PEP Usually none, consider 2 drug PEP
VL- Viral load, low lt1,500 c/ml, high gt1,500c/ml

Consider if source is high
HIV risk
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HIV PEP for Non-intact Skin Mucous Membrane
Exposures
Patient Status
Exposure Low Risk- VL, Asymptomatic High Risk- VL AIDS, blood on instrument Unknown
Small volume (drops) Consider 2 drug PEP 2 drug PEP Usually none, consider 2 drug PEP
Large volume, major spill 2 drug PEP 3 drug PEP Usually none, consider 2 drug PEP
VL-Viral load, low lt1,500 c/ml., high gt1,500
c/ml.
Consider if
source has HIV risk
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Risk of HIV Infection Following Percutaneous
Exposure to HIV Blood

• For a mucous membrane exposure
• 0.09
• For a percutaneous exposure risk
• 0.3.
• For nonintact skin
• lt 0.09

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Management of HIV Negative Exposure

• If source person is HIV seronegative and has no
  clinical evidence of AIDS or symptoms of HIV
  infection, no further testing of the person for
  HIV infection is indicated.
• The likelihood of the source person being in the
  window period of HIV, in the absence of acute
  retroviral syndrome, is extremely small.

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Management of Human Bites

• Evaluation of human bites must include both the
  person who is bitten and the person who inflicted
  the bite, since both parties were potentially
  exposed to the other persons blood.
• All counseling, testing, PEP and follow-up must
  be conducted on both parties for HIV, HBV HCV.

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Surveillance of Health Care Workers with
HIV/AIDS, June 30, 2001Ref CDC Natl. Center for
HIV, STD and TB Prevention

• Through 6/30/01, 23,473 adults with AIDS
  reported working in health care. This represents
  5.1 of the 561,495 reported cases.
• Physicians 1,746 Therapists 1,042
• Surgeons 117 Health Aids 5,222
• Nurses 5,105 Maintenance workers
• Dental workers 482 Administrative staff
• Paramedics 453
• Technicians 3,046
• http//www.cdc.gov/hiv/pubs/facts/hcws
  urv.htm

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Surveillance of Health Care Workers with
HIV/AIDS, June 30, 2001Ref CDC Natl. Center for
HIV, STD and TB Prevention

• Fifty-seven health care workers in the U. S.
  have seroconverted to HIV following occupational
  exposures. Twenty-six have AIDS.
• Laboratory workers 19 (16 clinical
  labs)
• Nurses 24
• Physicians 6
• Surgical technicians 2
• Dialysis technicians 1
• Respiratory therapist 1
• Health aide 1
• Embalmer 1
• Housekeepers 2
• 
  http//www.cdc.gov/hiv/pubs/facts/hcwsurv.htm

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Surveillance of Health Care Workers with
HIV/AIDS, June 30, 2001Ref CDC Natl. Center for
HIV, STD and TB Prevention

• Types of Injuries
• Percutaneous 48 (puncture or cut)
• Mucotaneous 5 (mucous membrane and/or
  skin)
• Percutaneous Mucotaneous 2
• Unknown 2

• Body Fluids
• Blood 49
• Concentrated virus in a laboratory
  3
• Visibly bloody fluid 1
• Unspecified fluids 4

http//www.cdc.gov/hiv/pubs/facts/hcwsurv.htm
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Occupational Exposure Assessment Criteria

• Type of exposure
• Percutaneous
• Mucous membrane
• Nonintact skin
• Bites with blood contamination to either
  person

• Type Amount of fluid
• Blood
• Fluids containing blood
• Potentially infectious fluid/tissue, i.e. semen,
  vaginal secretions, etc.
• Direct contact with concentrated virus

CDC, MMWR 6-29-01, Vol. 50/ No. RR-11, 17.
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Occupational Exposure Assessment
Criteria

• Infectious Status of Source
• HIV antibody status
• HCV antibody status
• HBsAg status

• Immune Status of Exposed
  HCW
• HBV, HCV HIV immune status
• Hepatitis B vaccine vaccine response status

CDC, MMWR 6-29-01, Vol. 50/No. RR-11, 18.
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Occupational Exposure Report

• Date time of injury
• Procedure being performed,
• If sharp device caused injury, include type,
  manufacturer how injury occurred
• Type amount of fluid, severity (deep vs.
  superficial), condition of skin (chapped, intact)
• Source patients HIV, HBV, HCV status stage (HIV
  viral load, resistance antiretroviral meds)
• Exposed HCWs HBV vaccine status response
• Counseling, post-exposure treatment follow-up
• CDC, MMWR 6-29-01, Vol.
  50/No. RR-11, 17

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Occupational Exposure Resources

• National Clinicians Post-exposure Hotline
  PEPline or 1-888-448-4911
• CDC, STD, AIDS Hotline 800-342-AIDS
• Hepatitis Hotline [phone]
• CDC reporting for occupationally HIV infected
  HCWs PEP failures 800-893-0485
• HIV antiretroviral pregnancy registry
  800-258-4263

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Summary

• Occupational transmission for HIV and HCV is low
  
• HIV- .09- .3, HCV- 0- 7
• Occupational transmission for HBsAg and HBeAg
  source
• 37-62.
• Occupational transmission for HBsAg and HBeAg-
  source
• 23-37.
• Rapid PEP is effective for HIV and HBV
• HIV PEP-81, HBV PEP 70-75.
• No PEP available for HCV
• Standard Precautions, PEP and vaccination are
  critical
  components in reducing cross-transmission
  of bloodborne pathogens.

CDC, MMWR 6-29-01, Vol.50 No. RR-11, pp. 3, 6, 7,
9.