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صدق اهللا العظيم صدق اهللا العظيم

Exposure to Exposure to Blood Blood

What Health What Health Workers Workers

Should Know Should Know Professor Dr. Professor Dr. Maysaa Maysaa El El Sayed Sayed

Zaki Zaki Professor of Clinical Pathology Professor of Clinical Pathology

n n The presentation will discuss the following The presentation will discuss the following points points

n n Exposure of health care workers to infection Exposure of health care workers to infection by blood borne pathogens and how to manage. by blood borne pathogens and how to manage.

n n Health care workers infected with blood borne Health care workers infected with blood borne infections and what to do. infections and what to do.

n n Health care workers with immunodeficiency Health care workers with immunodeficiency conditions and how to avoid infections. conditions and how to avoid infections.

n n Healthcare personnel (HCW) are at risk for Healthcare personnel (HCW) are at risk for occupational exposure to blood borne pathogens, occupational exposure to blood borne pathogens, including hepatitis B virus (HBV), hepatitis C virus including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). (HCV), and human immunodeficiency virus (HIV).

n n Exposures occur through needle sticks or cuts from Exposures occur through needle sticks or cuts from other sharp instruments contaminated with an other sharp instruments contaminated with an infected patient's blood or through contact of the eye, infected patient's blood or through contact of the eye, nose, mouth, or skin with a patient's blood. nose, mouth, or skin with a patient's blood.

n n Important factors that influence the overall risk for Important factors that influence the overall risk for occupational exposures to blood borne pathogens occupational exposures to blood borne pathogens include the number of infected individuals in the include the number of infected individuals in the patient population and the type and number of blood patient population and the type and number of blood contacts. Most exposures do not result in infection contacts. Most exposures do not result in infection

n n The following The following resentation resentation will discuss what all health will discuss what all health workers should know workers should know

n n Following a specific exposure, the risk of infection may vary Following a specific exposure, the risk of infection may vary with with

factors such as these: factors such as these: ­ ­ The pathogen involved The pathogen involved ­ ­The type of exposure The type of exposure ­ ­The amount of blood involved in the exposure The amount of blood involved in the exposure ­ ­ The amount of virus in the patient's blood at the time of The amount of virus in the patient's blood at the time of

exposure exposure n n Your employer should have in place a system for reporting Your employer should have in place a system for reporting

exposures in order to quickly evaluate the risk of infection, exposures in order to quickly evaluate the risk of infection, inform you about treatments available to prevent infection, inform you about treatments available to prevent infection, monitor you for side effects of treatments, and determine if monitor you for side effects of treatments, and determine if infection occurs. infection occurs.

n n This may involve testing your blood and that of the source This may involve testing your blood and that of the source patient and offering appropriate patient and offering appropriate postexposure postexposure treatment treatment. .

RISK OF INFECTION AFTER RISK OF INFECTION AFTER EXPOSURE EXPOSURE

HBV HBV n n Healthcare personnel who have received hepatitis B vaccine Healthcare personnel who have received hepatitis B vaccine

and developed immunity to the virus are at virtually no risk for and developed immunity to the virus are at virtually no risk for infection. infection.

n n For a susceptible person, the risk from a single needle stick or For a susceptible person, the risk from a single needle stick or cut exposure to HBV cut exposure to HBV­ ­infected blood ranges from 6 infected blood ranges from 6­ ­30% and 30% and depends on the hepatitis B e antigen ( depends on the hepatitis B e antigen (HBeAg HBeAg) status of the ) status of the source individual. Hepatitis B surface antigen ( source individual. Hepatitis B surface antigen (HBsAg HBsAg) )­ ­ positive individuals who are positive individuals who are HBeAg HBeAg positive have more virus positive have more virus in their blood and are more likely to transmit HBV than those in their blood and are more likely to transmit HBV than those who are who are HBeAg HBeAg negative. negative.

n n While there is a risk for HBV infection from exposures of While there is a risk for HBV infection from exposures of mucous membranes or non intact skin, there is no known risk mucous membranes or non intact skin, there is no known risk for HBV infection from exposure to intact skin. for HBV infection from exposure to intact skin.

HCV HCV n n The average risk for infection after a needle The average risk for infection after a needle stick or cut exposure to HCV infected blood is stick or cut exposure to HCV infected blood is approximately 1.8%. approximately 1.8%.

n n The risk following a blood exposure to the eye, The risk following a blood exposure to the eye, nose or mouth is unknown, but is believed to nose or mouth is unknown, but is believed to be very small; however, HCV infection from be very small; however, HCV infection from blood splash to the eye has been reported. blood splash to the eye has been reported.

n n There also has been a report of HCV There also has been a report of HCV transmission that may have resulted from transmission that may have resulted from exposure to non intact skin, but no known risk exposure to non intact skin, but no known risk from exposure to intact skin. from exposure to intact skin.

HIV HIV n n The average risk of HIV infection after a needle stick The average risk of HIV infection after a needle stick or cut exposure to or cut exposure to HlV HlV­ ­infected blood is 0.3% (i.e., infected blood is 0.3% (i.e., three three­ ­tenths of one percent, or about 1 in 300). Stated tenths of one percent, or about 1 in 300). Stated another way, 99.7% of another way, 99.7% of needlestick needlestick/cut exposures do /cut exposures do not lead to infection. not lead to infection.

n n The risk after exposure of the eye, nose, or mouth to The risk after exposure of the eye, nose, or mouth to HIV HIV­ ­infected blood is estimated to be, on average, infected blood is estimated to be, on average, 0.1% (1 in 1,000). 0.1% (1 in 1,000).

n n The risk after exposure of non The risk after exposure of non­ ­intact skin to intact skin to HlV HlV­ ­ infected blood is estimated to be less than 0.1%. A infected blood is estimated to be less than 0.1%. A small amount of blood on intact skin probably poses small amount of blood on intact skin probably poses no risk at all. There have been no documented cases no risk at all. There have been no documented cases of HIV transmission due to an exposure involving a of HIV transmission due to an exposure involving a small amount of blood on intact skin (a few drops of small amount of blood on intact skin (a few drops of blood on skin for a short period of time). blood on skin for a short period of time).

IF AN EXPOSURE OCCURS IF AN EXPOSURE OCCURS What should I do if I am exposed to the blood of What should I do if I am exposed to the blood of

a patient? a patient? n n 1. Immediately following an exposure to blood: 1. Immediately following an exposure to blood: Wash needle sticks and cuts with soap and water Wash needle sticks and cuts with soap and water Flush splashes to the nose, mouth, or skin with water Flush splashes to the nose, mouth, or skin with water Irrigate eyes with clean water, saline, or sterile Irrigate eyes with clean water, saline, or sterile irrigants irrigants

n n No scientific evidence shows that using antiseptics or No scientific evidence shows that using antiseptics or squeezing the wound will reduce the risk of squeezing the wound will reduce the risk of transmission of a blood borne pathogen. Using a transmission of a blood borne pathogen. Using a caustic agent such as bleach is not recommended. caustic agent such as bleach is not recommended.

n n Prompt reporting is essential because, in some Prompt reporting is essential because, in some cases, post exposure treatment may be cases, post exposure treatment may be recommended and it should be started as soon recommended and it should be started as soon as possible. as possible.

n n Discuss the possible risks of acquiring HBV, Discuss the possible risks of acquiring HBV, HCV, and HIV and the need for post exposure HCV, and HIV and the need for post exposure treatment with the provider managing your treatment with the provider managing your exposure. exposure.

n n You should have already received hepatitis B You should have already received hepatitis B vaccine, which is extremely safe and effective vaccine, which is extremely safe and effective in preventing HBV infection in preventing HBV infection

TREATMENT FOR THE TREATMENT FOR THE EXPOSURE EXPOSURE

n n Hepatitis B immune globulin (HBIG) alone or in combination with Hepatitis B immune globulin (HBIG) alone or in combination with vaccine vaccine (if not previously vaccinated) is effective in preventing HBV i (if not previously vaccinated) is effective in preventing HBV infection nfection after an exposure. after an exposure.

n n The decision to begin treatment is based on several factors, suc The decision to begin treatment is based on several factors, such as: h as: 켈 켈 Whether the source individual is positive for hepatitis B surfa Whether the source individual is positive for hepatitis B surface antigen ce antigen Whether you have been vaccinated Whether you have been vaccinated Whether the vaccine provided you immunity Whether the vaccine provided you immunity HCV HCV n n There is no vaccine against hepatitis C and no treatment after a There is no vaccine against hepatitis C and no treatment after an exposure n exposure

that will prevent infection. Neither immune globulin nor antivir that will prevent infection. Neither immune globulin nor antiviral therapy is al therapy is recommended after exposure. recommended after exposure.

n n For these reasons, following recommended infection control pract For these reasons, following recommended infection control practices to ices to prevent prevent percutaneous percutaneous injuries is imperative. injuries is imperative.

HIV HIV n n There is no vaccine against HIV. However, results There is no vaccine against HIV. However, results from a small number of studies suggest that the use of from a small number of studies suggest that the use of some antiretroviral drugs after certain occupational some antiretroviral drugs after certain occupational exposures may reduce the chance of HIV exposures may reduce the chance of HIV transmission. transmission.

n n Post exposure prophylaxis (PEP) is recommended Post exposure prophylaxis (PEP) is recommended for certain occupational exposures that pose a risk of for certain occupational exposures that pose a risk of transmission. transmission.

n n However, for those exposures without risk of HIV However, for those exposures without risk of HIV infection, PEP is not recommended because the infection, PEP is not recommended because the drugs used to prevent infection may have serious side drugs used to prevent infection may have serious side effects. effects.

n n You should discuss the risks and side effects with You should discuss the risks and side effects with your healthcare provider before starting PEP for HIV. your healthcare provider before starting PEP for HIV.

How are exposures to blood from an individual whose How are exposures to blood from an individual whose infection infection

status is unknown handled? status is unknown handled?

n n HBV HBV– –HCV HCV– –HIV HIV n n If the source individual cannot be identified or tested, If the source individual cannot be identified or tested, decisions regarding follow decisions regarding follow­ ­up should be based on the up should be based on the exposure risk and whether the source is likely to be exposure risk and whether the source is likely to be infected with a infected with a bloodborne bloodborne pathogen. pathogen.

n n Follow Follow­ ­up testing should be available to all personnel up testing should be available to all personnel who are concerned about possible infection through who are concerned about possible infection through occupational exposure occupational exposure

How soon after exposure to a blood borne How soon after exposure to a blood borne pathogen should treatment start? pathogen should treatment start?

HBV HBV n n Post exposure treatment should begin as soon as possible after Post exposure treatment should begin as soon as possible after

exposure, preferably within 24 hours, and no later than 7 days. exposure, preferably within 24 hours, and no later than 7 days. HIV HIV n n Treatment should be started as soon as possible, preferably Treatment should be started as soon as possible, preferably

within hours as opposed to days, after the exposure. Although within hours as opposed to days, after the exposure. Although animal studies suggest that treatment is less effective when animal studies suggest that treatment is less effective when started more than 24 started more than 24- -36 hours after exposure, 36 hours after exposure,

n n The time frame after which no The time frame after which no benefi benefi t is gained in humans is t is gained in humans is not known. not known.

n n Starting treatment after a longer period (e.g., 1 week) may be Starting treatment after a longer period (e.g., 1 week) may be considered for exposures that represent an increased risk of considered for exposures that represent an increased risk of transmission. transmission.

Can pregnant healthcare personnel take the drugs Can pregnant healthcare personnel take the drugs recommended recommended

for post exposure treatment? for post exposure treatment? HBV HBV n n Yes. Women who are pregnant or breast Yes. Women who are pregnant or breast­ ­feeding can receive the hepatitis B feeding can receive the hepatitis B n n vaccine and/or HBIG. Pregnant women who are exposed to blood sho vaccine and/or HBIG. Pregnant women who are exposed to blood should be uld be

vaccinated against HBV infection, because infection during pregn vaccinated against HBV infection, because infection during pregnancy can ancy can caus caus severe illness in the mother and a chronic infection in the newb severe illness in the mother and a chronic infection in the newborn. orn.

n n The vaccine does not harm the fetus. The vaccine does not harm the fetus. HIV HIV n n Pregnancy should not rule out the use of post exposure treatment Pregnancy should not rule out the use of post exposure treatment when it is when it is

warranted. warranted. n n If you are pregnant you should understand what is known and not If you are pregnant you should understand what is known and not known known

regarding the potential benefits and risks associated with the u regarding the potential benefits and risks associated with the use of antiviral se of antiviral drugs in order to make an informed decision about treatment drugs in order to make an informed decision about treatment

What follow What follow­ ­up should be done after up should be done after an exposure an exposure

HBV HBV n n Because post exposure treatment is highly effective in preventin Because post exposure treatment is highly effective in preventing HBV g HBV

infection, CDC does not recommend routine follow infection, CDC does not recommend routine follow­ ­up after treatment. up after treatment. However, any symptoms suggesting hepatitis (e.g., yellow eyes or However, any symptoms suggesting hepatitis (e.g., yellow eyes or skin, skin, loss of appetite, nausea, vomiting, fever, stomach or joint pain loss of appetite, nausea, vomiting, fever, stomach or joint pain, extreme , extreme tiredness) should be reported to your healthcare provider. tiredness) should be reported to your healthcare provider.

n n If you receive hepatitis B vaccine, you should be tested 1 If you receive hepatitis B vaccine, you should be tested 1­ ­2 months after 2 months after completing the vaccine series to determine if you have responded completing the vaccine series to determine if you have responded to the to the vaccine and are protected against HBV infection. vaccine and are protected against HBV infection.

HCV HCV n n You should be tested for HCV antibody and liver enzyme levels ( You should be tested for HCV antibody and liver enzyme levels (alanine alanine

aminotransferase aminotransferase or ALT) as soon as possible after the exposure (baseline) or ALT) as soon as possible after the exposure (baseline) and at 4 and at 4­ ­6 months after the exposure. To check for infection earlier, you 6 months after the exposure. To check for infection earlier, you can be tested for the virus (HCV RNA) 4 can be tested for the virus (HCV RNA) 4­ ­6 weeks after the exposure. 6 weeks after the exposure. Report any symptoms suggesting hepatitis to your healthcare prov Report any symptoms suggesting hepatitis to your healthcare provider. ider.

HIV HIV n n You should be tested for HIV antibody as soon as possible after You should be tested for HIV antibody as soon as possible after exposure exposure

(baseline) and periodically for at least 6 months after the expo (baseline) and periodically for at least 6 months after the exposure (e.g., at sure (e.g., at 6 weeks, 12 weeks, and 6 months). 6 weeks, 12 weeks, and 6 months).

n n If you take antiviral drugs for post exposure treatment, you sho If you take antiviral drugs for post exposure treatment, you should be uld be checked for drug toxicity by having a complete blood count and checked for drug toxicity by having a complete blood count and

n n kidney and liver function tests just before starting treatment a kidney and liver function tests just before starting treatment and 2 weeks nd 2 weeks after starting treatment. after starting treatment.

n n You should report any sudden or severe flu You should report any sudden or severe flu­ ­like illness that like illness that n n occurs during the follow occurs during the follow­ ­up period, especially if it involves fever, rash, up period, especially if it involves fever, rash,

muscle aches, tiredness, malaise, or swollen glands. muscle aches, tiredness, malaise, or swollen glands. n n Any of these may suggest HIV infection, drug reaction, or other Any of these may suggest HIV infection, drug reaction, or other medical medical

conditions. conditions. n n You should contact the healthcare provider managing your exposur You should contact the healthcare provider managing your exposure if you e if you

have any questions or problems during the follow have any questions or problems during the follow­ ­up period. up period.

What precautions should be taken What precautions should be taken during the follow during the follow­ ­up period? up period?

HBV HBV n n If you are exposed to HBV and receive post exposure treatment, i If you are exposed to HBV and receive post exposure treatment, it is t is

unlikely that you will become infected and pass the infection on unlikely that you will become infected and pass the infection on to others. to others. No precautions are recommended. No precautions are recommended.

HCV HCV n n Because the risk of becoming infected and passing the infection Because the risk of becoming infected and passing the infection on to on to

others after an exposure to HCV is low, no precautions are recom others after an exposure to HCV is low, no precautions are recommended. mended. HIV HIV n n During the follow During the follow­ ­up period, especially the first 6 up period, especially the first 6­ ­12 weeks when most 12 weeks when most

infected infected persons are expected to show signs of infection, you should foll persons are expected to show signs of infection, you should follow ow

recommendations for preventing transmission of HIV. recommendations for preventing transmission of HIV. These include not donating blood, or organs. In addition, These include not donating blood, or organs. In addition, women should women should consider not breast consider not breast­ ­feeding infants during the follow feeding infants during the follow­ ­up period to prevent up period to prevent the possibility of exposing their infants to HIV that may be in the possibility of exposing their infants to HIV that may be in breast milk. breast milk.

Incidents involving blood or body Incidents involving blood or body fluids contaminated with the infectious fluids contaminated with the infectious

agent for CJD agent for CJD n n Usually suspected in areas of transplantation of Usually suspected in areas of transplantation of cornea, Liver, heart cornea, Liver, heart

n n Immediately wash the wound/area with large Immediately wash the wound/area with large amounts of soap and water and report the amounts of soap and water and report the incident according to normal procedures for incident according to normal procedures for the health care establishment. the health care establishment.

Responsibilities of infected health care workers Responsibilities of infected health care workers n n HCWs HCWs have an obligation to care for the safety of others in have an obligation to care for the safety of others in

the workplace (this includes fellow workers and patients) the workplace (this includes fellow workers and patients) under both common law and the under both common law and the Occupational Health and Occupational Health and Safety and Welfare Act 1986 Safety and Welfare Act 1986. .

n n Nominated risk categories Nominated risk categories HCWs HCWs must not perform exposure must not perform exposure­ ­prone procedures if they prone procedures if they are: are:

n n HIV antibody positive HIV antibody positive n n HCV antibody positive and HCV RNA positive (by PCR or HCV antibody positive and HCV RNA positive (by PCR or

similar test); or similar test); or n n Hepatitis B e antigen ( Hepatitis B e antigen (HBeAg HBeAg) positive and/or HBV DNA ) positive and/or HBV DNA

positive at high titers. positive at high titers. n n Blood borne viruses such as HIV, HBV and HCV are all Blood borne viruses such as HIV, HBV and HCV are all

legally legally notifiable notifiable diseases and should be notified to the diseases and should be notified to the chief health officer. chief health officer.

n n An HCW infected with a blood borne virus should An HCW infected with a blood borne virus should be assessed in consultation with their treating be assessed in consultation with their treating medical practitioner, who should make a medical practitioner, who should make a recommendation about the continued involvement recommendation about the continued involvement of the HCW in direct patient care. of the HCW in direct patient care.

n n The practitioner should also determine (and make The practitioner should also determine (and make recommendations to the employer) about the recommendations to the employer) about the infected infected HCW HCW’ ’s s ability to: ability to:

• • Perform to the accepted professional standard Perform to the accepted professional standard without compromising the safety of others or without compromising the safety of others or themselves in the workplace; and themselves in the workplace; and

• • Continue to comply with health regulations. Continue to comply with health regulations.

n n An HCW who undertakes exposure An HCW who undertakes exposure­ ­prone procedures and prone procedures and who is infected with a blood borne virus should modify who is infected with a blood borne virus should modify their work practices so that they no longer participate in their work practices so that they no longer participate in exposure prone procedures where there is established exposure prone procedures where there is established evidence of a risk of transmission of infection from HCW evidence of a risk of transmission of infection from HCW to patient. to patient.

n n They should also undergo frequent medical follow They should also undergo frequent medical follow­ ­up by a up by a medical practitioner with appropriate experience. medical practitioner with appropriate experience.

n n The HCW and/or the medical practitioner may seek The HCW and/or the medical practitioner may seek confidential advice from a relevant registration board confidential advice from a relevant registration board (medical, nursing, dental etc) (medical, nursing, dental etc)

n n HCWs HCWs with a blood borne virus are not excluded from with a blood borne virus are not excluded from employment or functions they can safely perform under employment or functions they can safely perform under policies in place in the facility. policies in place in the facility.

How can occupational exposures be How can occupational exposures be prevented? prevented?

n n Many needle sticks and other cuts can be prevented Many needle sticks and other cuts can be prevented by using safer techniques (for example, not recapping by using safer techniques (for example, not recapping needles by hand), disposing of used needles in needles by hand), disposing of used needles in appropriate sharps disposal containers, and using appropriate sharps disposal containers, and using medical devices with safety features designed to medical devices with safety features designed to prevent injuries. prevent injuries.

n n Using appropriate barriers such as gloves, eye and Using appropriate barriers such as gloves, eye and face protection, or gowns when contact with blood is face protection, or gowns when contact with blood is expected can prevent many exposures to the eyes, expected can prevent many exposures to the eyes, nose, mouth, or skin. nose, mouth, or skin.

n n Hepatitis B virus is largely preventable Hepatitis B virus is largely preventable through vaccination. through vaccination.

n n For HCV and HIV preventing occupational For HCV and HIV preventing occupational exposures to blood can be prevented exposures to blood can be prevented

n n This includes using appropriate barriers such This includes using appropriate barriers such as gown, gloves and eye protection as as gown, gloves and eye protection as appropriate, appropriate,

n n Safely handling needles and other sharp Safely handling needles and other sharp instruments, and using devices with safety instruments, and using devices with safety features. features.

Precautions For Health Workers with Immunodeficiency Precautions For Health Workers with Immunodeficiency Conditions Conditions

n n For their own protection, For their own protection, HCWs HCWs with significant with significant immunodeficiency from any cause should not be involved in immunodeficiency from any cause should not be involved in the care of patients with certain communicable diseases the care of patients with certain communicable diseases — — for for example, tuberculosis, example, tuberculosis, varicella varicella– –zoster virus and zoster virus and cytomegalovirus (CMV). cytomegalovirus (CMV).

n n Immunodeficient Immunodeficient HCWs HCWs should be advised of the possible risks should be advised of the possible risks of live vaccines, including of live vaccines, including Bacille Bacille Calmette Calmette– –Guerin (BCG) Guerin (BCG) vaccine, that are available for vaccine, that are available for HCWs HCWs in health care in health care establishments. establishments.

n n Thank You Thank You