Manual for Healthcare workers on Viral Blood Borne Occupational Diseases

http://www.ohscmumbai.org/

Preface
 

Doctors and other medical employees care for patients. While caring for patients, health-care workers themselves are exposed to many risks.

In our trainings , we realised that the risks faced by health care workers (including doctors ) are not paid enough attention. Doctors , Laboratory workers, nurses and others have expressed a need for information regarding occupational health problems of others and their own too.

The risks involve diseases due to bacteria, viruses, chemical liquids, gases and also electrical accidents and falls.

Here we have concentrated only on viral blood borne pathogens. Due to increasing scare of AIDS many a research projects, educational projects are ongoing but in these the risk of doctors and medical workers seem to be neglected.

Actually part of the funds for AIDS control need to be spent on good protective equipments such as gloves, aprons etc…When it comes to treatment, "progress " is being made every year regarding AIDS. We have tried to put together latest information, but one will have to keep abreast of latest information, or we can be contacted for the same.

PRIA is involved in the field of occupational health for the last 15 years. For the past 3 years, PRIA is working with doctors too. In our orientation training programmes for doctors’ , we felt the need for a manual on viral blood borne pathogens.

Please do send us your comments to us regarding the manual.

Vijay Kanhere

Consultant ,PRIA

New Delhi.

July 1999.

Introduction:

Bloodborne pathogens are microorganisms such as viruses or bacteria that are carried in blood and can cause disease in people.

There are many different bloodborne pathogens including malaria, syphilis, and brucellosis, but Hepatitis B (HBV),Hepatitis C(HCV) and the Human Immunodeficiency Virus (HIV) are the three diseases specifically important since there is no cure, hence the infected patient will have life-long disabilities or lead to death.

While this module will focus primarily on HBV, HCV and HIV, it is important to know which bloodborne pathogens (from humans or animals) you may be exposed to at work, especially in laboratories. For example, personnel in the College of Veterinary Medicine might have the potential for exposure to rabies, and it would therefore be important to know specific information about rabies.

This module is meant for all Health-care workers (HCW).It gives recent relevant information on Hepatitis B and C and HIV, without going into details of symtomatology, differential diagnosis and treatment. The references used for preparing the document are given at the end of the document and can be procured from any medical college’s library in India. A notable feature of some of the references^1-13 is that they are in the public domain, the names of hospitals, where occupationally acquired viral infections have occurred-being clearly mentioned--a far cry from the situation in India where such incidents are held secretive. There have been anecdotal evidence of occupationally acquired HIV infection to health-care workers in Mumbai, Ahemedabad and Vellore.
 

Risk of Transmission: ¹⁴

Bloodborne pathogens such as HBV, HBC and HIV can be transmitted through contact with infected human blood and other potentially infectious body fluids such as:

o                    Semen

o                    Vaginal secretions

o                    Cerebrospinal fluid

o                    Synovial fluid

o                    Pleural fluid

o                    Peritoneal fluid

o                    Amniotic fluid

o                    Saliva (in dental procedures), and

o                    Any body fluid that is visibly contaminated with blood.

It is important to know the ways exposure and transmission are most likely to occur in your particular situation, be it providing first aid to a student in the classroom, handling blood samples in the laboratory, or cleaning up blood from a hallway.

HBV and HIV are most commonly transmitted through:

o                    Sexual Contact

o                    Sharing of hypodermic needles

o                    From mothers to their babies at/before birth

o                    Accidental puncture from contaminated needles, broken glass, or other sharps

o                    Contact between broken or damaged skin and infected body fluids

o                    Contact between mucous membranes and infected body fluids

o                    Contact with contaminated waste- especially in case of hepatitis B, which can last in dried body fluids for as long as 7 days.^11,15

Accidental puncture from contaminated needles and other sharps can result in transmission of bloodborne pathogens.

In most work or laboratory situations, transmission is most likely to occur because of accidental puncture from contaminated needles, broken glass, or other sharps; contact between broken or damaged skin and infected body fluids; or contact between mucous membranes and infected body fluids. For example, if someone infected with HBV cut their finger on a piece of glass, and then you cut yourself on the now infected piece of glass, it is possible that you could contract the disease. Anytime there is blood-to-blood contact with infected blood or body fluids, there is a slight potential for transmission.

Unbroken skin forms an impervious barrier against bloodborne pathogens. However, infected blood can enter your system through:

o                    Open sores

o                    Cuts

o                    Abrasions

o                    Acne

o                    Any sort of damaged or broken skin such as sunburn or blisters

Bloodborne pathogens may also be transmitted through the mucous membranes of the

o        Eyes

o        Nose

o        Mouth

For example, a splash of contaminated blood to your eye, nose, or mouth could result in transmission.

Sero-conversion following exposure:

Seroconversion means after being exposed to body-fluids from an proved infective source-the percentage of HCW’s developing the infection.

Blood is the single most important source of HIV infection in the health-care setting. Several studies have evaluated HCWs prospectively following an occupational exposures to blood from a patient with documented HIV infection as a result of a percutaneous injury or mucous membrane or cutaneous contact. In these studies, HCWs were tested for HIV antibodies at the time of exposure of HIV-infected blood (base line testing) and at periodic intervals thereafter for up to 12 months. Collectively, more than 3600 workers with percutaneous exposures to HIV-infected blood have been enrolled in such studies to date. The average risk of seroconversion after a needlestick injury has been found to be approximately 0.3%. Nearly all of the documented seroconversions in these studies occurred after a percutaneous injury with a hollow-bore needle; one each followed a cut with a lancet and broken glass.

Although individual cases of transmission of HIV after a mucous membrane exposure have been reported, only one seroconversion has occurred in the setting of a prospective study. Data from 21 studies worldwide include one seroconversion among 1107 mucous membrane exposures, for an estimated rate of 0.09%.

The likelihood of seroconversion following a percutaneous injury involving blood from an HIV-infected patient appears to be affected by overlapping factors related to:

1.                   the circumstances of the injury,

2.                   the infectiousness of the source patient, and

3.                   the susceptibility of the HCW.

First, possible considerations relevant to the injury include the time interval between needle use and exposure, the depth of severity of the exposure, the quantity of blood injected, and the bore of the needle. To date, none of the documented sero-conversions from percutaneous exposures have occurred following an injury with a solid suture needle. Studies have suggested that more blood is transferred by deeper injuries and by hollow-bore phlebotomy needles, especially those of larger gauges that with solid sutures needles. Two studies have shown that one layer of surgical gloves appears to decrease the volume of blood injected by solid suture needles by 70% or more in almost every simulation; adding a second layer of gloves resulted in further reductions of 50% or more.

Second, factors related to the source patient that may be associated with subsequent transmission and sero-converison in the HCW include the patient’s clinical status or stage of HIV-related disease and whether the patient is receiving antiviral therapy, both of which in turn may affect the titer of circulating virus. Some data suggest that antiretroviral therapy can decrease the risk of sexual or perinatal HIV transmission; such therapy may influence the risk of transmission through other routes, such as percutaneous injection.

Third, the HCW’s susceptibility to infection may be affected by the use of barriers, such as gloves, which may reduce the amount of inoculum, and postexposure treatment, including the use of zidovudine. However, several reported failures of zidovudine to prevent HIV infection in HCWs following an occupational exposure to HIV-infected blood suggest that if zidovudine is protective, such protection is not absolute. (see table below)

o                    POTENTIAL RISK FACTORS FOR SEROCONVERSION FOLLOWING PERCUTANEOUS INJURY

1.                   Interval between needle use and exposure

2.                   Depth or Severity of exposure

3.                   Quantity of blood injected

4.                   Bore of needle

5.                   Source Patient

6.                   Clinical status

7.                   Titer of circulating virus

8.                   Use of antiviral agents

9.                   Health care worker

10.               Use of barriers

11.               Postexposure management

More recently, Cardo et al ¹⁶ conducted a retrospective case control analysis of 33 HCWs who occupationally acquired HIV infection following percutaneous exposure to HIV-infected blood and 679 HCWs who did not seroconvert after a similar exposure. Preliminary analysis identified several potential risk factors that were statistically significant, including a "deep" injury, visible blood on the device causing the injury, injury by a device used to draw blood or used for vascular access, a source patient in the terminal stage of AIDS, and the lack of postexposure use of zidovudine. For needlestick injuries, injury with a large-gauge hollow needle was also a significant risk factor .Ippolito et al¹⁷ also followed up nearly 1500 HCW's who suffered exposure to HIV infected blood.
 
 

Controls:

At source:

Warning labels need to be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious material; and other containers used to store, transport, or ship blood or other potentially infectious materials.

These labels are fluorescent orange, red, or orange-red, and they can be easily produced by institutions. Bags used to dispose of regulated waste must be red or orange red, and they, too, must have the biohazard symbol readily visible upon them. Regulated waste should be double-bagged to guard against the possibility of leakage if the first bag is punctured.

Regulated waste refers to

o                    Any liquid or semi-liquid blood or other potentially infectious materials

o                    Contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed

o                    Items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling

o                    Contaminated sharps

o                    Pathological and microbiological wastes containing blood or other potentially infectious materials

All regulated waste must be disposed in properly labeled containers or red biohazard bags. These must be disposed at an approved facility. In India the waste is taken by workers belonging to civic bodies and take it to an approved incineration/disposal-facility.

Non-regulated waste (i.e. does not fit the definition of regulated waste provided above) that is not generated by a medical facility or human health-related research laboratory may be disposed in regular plastic trash bags if it has been decontaminated or autoclaved prior to disposal.

However, all bags containing such materials must be labeled, signed, and dated, verifying that the materials inside have been decontaminated according to acceptable procedures and pose no health threat. Pre-printed labels designed for this purpose can be easily made, and they must be placed on the bag so that they are readily visible.

Workers and housekeepers will not remove bags containing any form of blood (human or animal), vials containing blood, bloody towels, rags, biohazardous waste, etc. from laboratories unless the bag has one of these labels on it. They have to be given very strict instructions not to handle any non-regulated waste unless it has been properly marked and labeled (including signature).

Workers will not handle regulated waste (unless treated and segregated)

For more information on this as it pertains to laboratories, check out Bio -Safety Manuals.

Personal Protective Equipment (PPE):

It is extremely important to use personal protective equipment and work practice controls to protect yourself from bloodborne pathogens. It is must for nurses and wardboys and ayah's to wear gloves, while collecting blood samples, starting I.V infusion, giving bedpans and changing bedsheets.

"Universal Precautions" (see also pg.:*) is the name used to describe a prevention strategy in which all blood and potentially infectious materials are treated as if they are, in fact, infectious, regardless of the perceived status of the source individual. In other words, whether or not you think the blood/body fluid is infected with bloodborne pathogens, you treat it as if it is. This approach is used in all situations where exposure to blood or potentially infectious materials is possible. This also means that work practice controls shall always be utilized in situations where exposure may occur.

Personal Protective Equipment:

Probably the first thing to do in any situation where you may be exposed to bloodborne pathogens is to ensure you are wearing the appropriate personal protective equipment (PPE). For example, you may have noticed that emergency medical personnel, doctors, nurses, dentists, dental assistants, and other health care professionals always wear latex or protective gloves. This is a simple precaution they take in order to prevent blood or potentially infectious body fluids from coming in contact with their skin. To protect yourself, it is essential to have a barrier between you and the potentially infectious material.

Rules to follow:

o                                Always wear personal protective equipment in exposure situations.

o                                Remove PPE that is torn or punctured, or has lost its ability to function as a barrier to bloodborne pathogens.

o                                Replace PPE that is torn or punctured.

o                                Remove PPE before leaving the work area.

If you work in an area where exposure to blood or potentially infectious materials is routinely possible, the necessary PPE should be readily accessible.

Contaminated gloves, clothing, PPE, or other materials should be placed in appropriately labeled bags or containers until it is disposed of, decontaminated, or laundered. It is important to find out where these bags or containers are located in your area before beginning your work.

Gloves: ^7,18

Gloves should be made of latex, nitril, rubber, or other water impervious materials. If glove material is thin or flimsy, double gloving can provide an additional layer of protection. Also, if you know you have cuts or sores on your hands, you should cover these with a bandage or similar protection as an additional precaution before donning your gloves. You should always inspect your gloves for tears or punctures before putting them on. If a glove is damaged, don’t use it! When taking contaminated gloves off, do so carefully. Make sure you don’t touch the outside of the gloves with any bare skin, and be sure to dispose of them in a proper container so that no one else will come in contact with them, either.

Always check your gloves for damage before using them. (see table below)

Table 2

o        VOLUME OF BLOOD TRANSFERRED BY PHLEBOTOMY AND SUTURE NEEDLES IN LABORATORY SIMULATIONS

Goggles:

Anytime there is a risk of splashing or vaporization of contaminated fluids, goggles and/or other eye protection should be used to protect your eyes. Again, bloodborne pathogens can be transmitted through the thin membranes of the eyes so it is important

to protect them. Splashing could occur while cleaning up a spill, during laboratory procedures, or while providing first aid or medical assistance.

Face Shields:

Face shields may be worn in addition to goggles to provide additional face protection. A face shield will protect against splashes to the nose and mouth. They may be used during labour (delivery) -related procedures.

Aprons:

Aprons may be worn to protect your clothing and to keep blood or other contaminated fluids from soaking through to your skin. Normal clothing that becomes contaminated with blood should be removed as soon as possible because fluids can seep through the cloth to come into contact with skin. Contaminated laundry should be handled as little as possible, and it should be placed in an appropriately labeled bag or container until it is decontaminated, disposed of, or laundered.

Footwear:

Footwear, that cover your feet completely, can be worn in places like trauma ward, Operation theatre, mortuary etc.

remember to use universal precautions and treat all blood or potentially infectious body fluids as if they are contaminated. Avoid contact whenever possible, and whenever it’s not possible to avoid contact, wear personal protective equipment. If you find yourself in a situation where you have to come in contact with blood or other body fluids and you don’t have any standard personal protective equipment handy, you can improvise. Use a towel, plastic bag, or some other barrier to help avoid direct contact.

Hygiene Practices:

Handwashing is one of the most important (and easiest) practices used to prevent transmission of bloodborne pathogens. Hands or other exposed skin should be thoroughly washed as soon as possible following an exposure incident. Use soft, antibacterial soap, if possible. Avoid harsh, abrasive soaps, as these may open fragile scabs or other sores.

Hands should also be washed immediately (or as soon as feasible) after removal of gloves or other personal protective equipment. Because handwashing is so important, you should familiarize yourself with the location of the handwashing facilities nearest to you.

Laboratory sinks, public restrooms, janitor closets, and so forth may be used for handwashing if they are normally supplied with soap. If you are working in an area without access to such facilities, you may use an antiseptic cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. If these alternative methods are used, hands should be washed with soap and running water as soon as feasible. If you are working in an area where there is reasonable likelihood of exposure, you should never:

o        Eat

o        Drink

o        Smoke

o        Apply cosmetics or lip balm

o        Handle contact lenses

1.       No food or drink should be kept in refrigerators, freezers, shelves, cabinets, or on counter tops where blood or potentially infectious materials are present.

1.       You should also try to minimize the amount of splashing, spraying, splattering, and generation of droplets when performing any procedures involving blood or potentially infectious materials, and you should NEVER pipette or suction these materials by mouth.

Decontamination and Sterilization:

All surfaces, tools, equipment and other objects that come in contact with blood or potentially infectious materials must be decontaminated and sterilized as soon as possible. Equipment and tools must be cleaned and decontaminated before servicing or being put back to use.

Decontamination should be accomplished by using

o        A solution of 5.25% sodium hypochlorite (household bleach /Clorox) diluted with water to make a 1% solution.

o        Lysol or some other tuberculocidal disinfectant.

Check the label of all disinfectants to make sure they meet this requirement. -i.e. destruction of HIV virus and mycobacteria (T.B)

If you are cleaning up a spill of blood, you can carefully cover the spill with paper towels or rags, then gently pour your 1% solution of sodium hypochlorite, over the towels or rags, and leave it for at least 10 minutes.

This will help ensure that the bloodborne pathogens are killed before you actually begin cleaning or wiping the material up. By covering the spill with paper towels or rags, you decrease the chances of causing a splash when you pour the bleach on it.

If you are decontaminating equipment or other objects (be it scalpels, microscope slides, broken glass, saw blades, tweezers, mechanical equipment upon which someone has been cut, first aid boxes, or whatever) you should leave your disinfectant in place for at least 10 minutes before continuing the cleaning process.

Of course, any materials you use to clean up a spill of blood or potentially infectious materials must be decontaminated immediately, as well. This would include mops, sponges, re-usable gloves, buckets, pails, etc. Sharps .Far too frequently, housekeepers, custodians and others are punctured or cut by improperly disposed needles and broken glass. This, of course, exposes them to whatever infectious material may have been on the glass or needle. For this reason, it is especially important to handle and dispose of all sharps carefully in order to protect yourself as well as others.

Needles:

o        Needles or other sharps should not be bent, recapped, or moved except as noted below:

o        Needles may be recapped only by using a mechanical device.

o        Needles should be moved only by using a mechanical device or tool such as forceps, pliers, or broom and dustpan.

o        Never break or shear needles.

o        Needles shall be disposed of in labeled sharps containers only.

o        Sharps containers shall be closable, puncture-resistant, leak-proof on sides and bottom, and must be labeled or color-coded.

o        When sharps containers are being moved from the area of use, the containers should be closed immediately before removal or replacement to prevent spillage or protrusion of contents during handling or transport.

Broken Glassware:

o        Broken glassware that has been visibly contaminated with blood must be sterilized with an approved disinfectant solution before it is disturbed or cleaned up.

o        Glassware that has been decontaminated may be disposed of in an appropriate sharps container: i.e. closable, puncture-resistant, leak-proof on sides and bottom, with appropriate labels.

o        Broken glassware will not be picked up directly with the hands.

1.       Sweep or brush the material into a dustpan.

o        Uncontaminated broken glassware may be disposed of in a closable, puncture resistant container such as a cardboard box or coffee can.

By using Universal Precautions and following these simple work practice controls, you can protect yourself and prevent transmission of bloodborne pathogens.

The negative aspects of using specific kinds of PPE (like plastic aprons/face shields etc.) to reduce blood exposure must also be considered. The most important negative aspect for most surgeons is the loss of comfort that comes with wearing impervious or almost impervious garments. As already stated, the risk of acquiring and HIV infection in the operating room is extremely low, and we may be overreacting by going to some of these extremes to prevent cutaneous blood exposure. There is little doubt that continued use of these garments has helped to fuel the hysteria that is prevalent in many operating rooms and leaves our colleagues believing that we are all in grave danger of acquiring HIV infection during surgery. Again, although the risk of acquiring and HIV infection is extremely small, any manoeuvres used to avoid exposure to the hepatitis B or C viruses are highly recommended. Many of these garments are costly, and many have questioned whether the additional expense is justifiable.

The groups of individuals at greatest risk for blood exposure in uncontrolled or emergent circumstances are as follows for whom PPE is a must:

• Trauma surgeons
• Operating room personnel
• Intensive care unit personnel
• Emergency medicine physicians and nurses
• Labour room and neonatal unit
• Dialysis nurses and technicians
• EMTs and paramedics
• Police and firefighters
• Some laboratory personnel
• Mortuary attendants
• First-aid workers in road accidents and railways.

Of course, any barrier that reduces a surgeon’s exposure to blood contamination also reduces the chance that his skin bacteria will contaminate a patient’s wound, and that should lead to a decrease wound infection rate during clean procedures.

EPIDEMIOLOGY OF INJURIES BY NEEDLES AND OTHER SHARP INSTRUMENTS

Who is Being Injured? ¹⁹

Injury epidemiology can help delineate the personnel in surgical and obstetric settings who are at greatest risk for injury. In a study to identify risk factors for percutaneous injury during surgery, Tokars and colleagues observed 1382 orthopedic, general surgery, gynecology, trauma, and cardiac procedures, in areas of high AIDS incidence in the United States. At least one percutaneous injury occurred during 6.9% of these procedures (99 total injuries). Resident and attending surgeons had the highest rates (2.7 and 2.3 per 100 person-procedures, respectively) of injury; other personnel in the operating room were less likely to be injured.

When and Where Do Injuries Occur?^9,19

To target prevention resources, it is important to assess the risk of percutaneous injury according to procedure. In the Tokars et al study, the rate of injury ranged from 4% in orthopedic procedures to 10% in gynecologic procedures. Within a specialty, rates of injury also varied: the rate in abdominal hysterectomies was 10%, whereas the rate for vaginal hysterectomies was 21%.

Other studies have also found procedure-specified differences in rates of injury. For example, in a study of 664 vaginal and 181 cesarean deliveries, the rate of percutaneous injury to HCWs during cesarean sections, 3.3%, was higher than the rate during vaginal deliveries, 0.8%. Gynecology data showed that personnel sustained one or more percutaneous injuries during 7% (61/832) of procedures (64 total injuries). Procedure-specific rates of percutaneous injury ranged from 5% (8/174) in vaginal hysterectomies to 9% (25/295) in abdominal hysterectomies, to 12% (17/143) in myomectomies. In another study across several specialties, the highest rates of injury were found in trauma surgery, 9.5% (10/105); plastic surgery, 9% (6/55); and obstetric and gynecology, 7.4% (14/189).

Table 3:showing Injuries sustained in procedures (various) and depts.
 

How Are Injuries Occurring?

Irrespective of specialty or procedures performed, most percutaneous injuries in operative and delivery room settings are caused by suture needles. Blunt-tip needles are now available that may reduce the likelihood of suture-related injuries. Other objects that cause percutaneous injuries include scalpels, electrocautery instruments, hollow-bore needles, and occasionally retractors, wires, bone fragments, suture thread, and other specialty-specific equipment.

SAFETY WITH SHARP INSTRUMENTS:

When sharp instruments must be used, operating room personnel should take certain precautions. Scalpels and sharp needles should not be left exposed on the operative field but should be removed promptly by the scrub nurse. A surgeon or nurse who places a sharp instrument on the field should announce that fact aloud. Scalpels should, ideally, be passed in a pan rather than directly. Nurses may make direct passes of sharp instruments (they are educated to do so!), but physicians should not (unless they are trained!). There currently is no indication for the use of wire sutures in abdominal procedures. Tying, such sutures frequently causes lacerations and punctures. Furthermore, the sharp cut ends of the sutures lurk in the body to lacerate the next surgeon to operate. The use of wire in abdominal operations should be abandoned. Thick monofilament sutures made of polymers such as polyglyconate (Maxon), polydioxanone (PDS), nylon (Ethilon), and polypropylene (Prolene) incite minimal tissue reaction and retain their tensile strength for sufficient time to permit wound healing. These provide a satisfactory alternative to wire even in patients at highest risk for abdominal wound dehiscence.

When using sharp needles, surgeons should observe three precautions. First, they should grasp the needle with instruments, rather than fingers, when resetting the needle in the needle holder. Second, they should avoid passing the suture needle toward their nondominant hand or toward an assistant’s hand. Surgeons often retract tissue manually or have an assistant do so. They then may suture toward this retracting hand and frequently stab it. The necessary retraction can invariably be obtained with retractors, sponge sticks, or laparotomy pads. Finally, when sewing in a bloody field, surgeon should not grope for a sharp needle to identify its location. It is common for an obstetrician to repair profusely bleeding vaginal or cervical tears. When a needle is sewn through tissue, the tip sometimes is obscured in a pool of blood. This is an ideal circumstance to use blunt needles. if sharp needles are chosen, the needle tip should be identified by visualization, achieved if necessary by suction of the blood. Attempts to palpate the needle tip are likely to result in percutaneous injury. This is especially true during vaginal hysterectomy, which is associated with a percutaneous injury rate for the surgeon of upto 21%. Such bleeding that obscures a needle tip may also occur deep in the pelvis during difficult procedures such as those for endometriosis or ovarian cancer.

There must be a continuous training programme on safety in the operation theatre

Exposure to body fluids:

Lab technicians should use auto-pipette for drawing samples.

In an emergency situation involving blood or potentially infectious materials, you should always use Universal Precautions and try to minimize your exposure by wearing gloves, splash goggles, pocket mouth-to-mouth resuscitation masks, and other barrier devices.

If you are exposed, however, you should:

1. Wash the exposed area thoroughly with soap and running water. Use non-abrasive, antibacterial soap if possible.

o                    If blood is splashed in the eye or mucous membrane, flush the affected area with running water for at least 15 minutes.

2. Report the exposure to your supervisor as soon as possible.

3. Fill out an exposure report form, if you desire. This form can be kept in your personnel file for 40 years so that you can document workplace exposure to hazardous substances. This report can be made available from your supervisor .

4. You may also request blood testing or the Hepatits B vaccination if you have not already received it.

There should be a specific set of procedures they will have to be followed for all post-exposure cases. These are:

o                    Document the route(s) of exposure and the circumstances under which the exposure incident occurred.

o                    Identify and document the source individual unless such documentation is impossible or prohibited by law.

o                    Test the source individual’s blood for HBV and HIV as soon as possible after consent is obtained. If the source individual is known to be seropositive for HBV or HIV, testing for that virus need not be done.

o                    Collect your blood as soon feasible, and test it after your consent is obtained.

+ (If you consent to baseline blood collection, but do not give consent at that time for HIV serological testing, your blood sample will be kept for at least 90 days. If, within 90 days of the incident, you decide to consent to have the baseline sample tested, such testing shall be done as soon as possible, and at no cost to you.)

o                    Administer post exposure prophylaxes, when medically indicated, as per standard recommendations. (see below)

o                    Provide counseling.

o                    Evaluate reported illnesses.

Apart from the circumstances surrounding the exposure itself, all other findings or diagnosis should be kept confidential.

MANAGEMENT OF NEEDLE STICK INJURY:

Recommendations for hepatitis B prophylaxis following percutaneous exposure.¹
 

¹ Based on recommendations of the immunization Practices Advisory Committee, MMWR (February) 1990;39 See: Henderson DK Surg Clin North Am 1995 Dec 75:6 1175-87

² HBIG dose 0.06 ml/kg IM.

³ HB vaccine dose 20 u.g. IM for adults, 10 ug IM for infants or children under 10 years of age. First dose within 1 week, second and third doses, 1 and 6 months later.
 
 

Vaccination:
 
 

PREVENTION OF HEPATITIS B VIRUS INFECTION AMONG HEALTH-CARE WORKERS

The most important approach for the prevention of occupational HBV infection is use of hepatitis B vaccine among HCWs at risk. Hepatitis B vaccine has been available since 1981. These vaccines are very safe and highly effective in preventing HBV infection. More than 90% of recipient of the vaccine respond are with protective levels of antibody, and adults who respond are complete protected from clinical disease and chronic infection. Ongoing studies of cohorts vaccinated in the early 1980’s indicated that the duration of protection of is at least 13 years; booster doses of hepatitis B vaccine and testing to determine antibody persistence are not routinely recommended.

Since its introduction, the hepatitis B vaccine has been recommended for HCWs with frequent blood or needle exposure, preferably with vaccination occurring during training or early in their careers. However, implementation of this recommendation has been incomplete owing to the relatively high cost of the vaccine and to inaccurate perceptions among some HCWs that they are not at risk for HBV infection and therefore would not benefit from the vaccine. In 1991, the Occupational Safety and Health Administration (OSHA) issued the bloodborne standard that requires employers to offer hepatitis B vaccine to all employees with reasonably anticipated contact with blood or other potentially infectious materials, at no cost to the employee.

Additional measures to prevent HBV infection among HCWs, include (1) use of barrier precautions such as gloves, gowns, masks, and protective eyewear, when indicated; (2) proper handling and disposal of needles and other sharp instruments; (3)