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AN ACCIDENTAL exposure to blood or other potentially infectious material (OPIM) such as cerebrospinal or pleural fluid can be a life-changing experience. Among the bloodborne and OPIM pathogens are HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV). Postexposure prophylaxis (PEP) exists for HBV and HIV, but not for HCV, which is the most common chronic bloodborne infection in the United States; approximately 3.2 million persons are chronically infected.1 Fortunately, however, exposure to blood or OPIM usually doesn't translate into disease transmission. (See After an exposure: What's your risk?)
In this article, we'll discuss how you can minimize the risk of disease transmission if you or a coworker is accidentally exposed to blood or another potentially infectious body fluid. But first, let's review some key definitions.
Throughout this article, we refer to individuals with the terms source and exposed. For our purposes, the source is the patient whose blood or OPIM has come in contact with a healthcare worker, who is the exposed person. In some cases (such as a sharps injury to a healthcare worker during surgery) the healthcare worker and the surgical patient may be both source and exposed because their blood has mingled, but this unusual circumstance is beyond the scope of this article.
Another term we use is exposure (as in occupational exposure or exposure incident). An exposure requires contact with a potentially infectious body fluid as defined by the Occupational Safety and Health Administration (OSHA).2 Besides blood and any fluid contaminated with blood, these include semen, vaginal secretions, pleural fluid, and pericardial fluid (although some are considered less likely than others to transmit infection). Feces, urine, and vomitus aren't considered OPIM unless visibly contaminated with blood. For a summary of OPIM, see Classifying potentially infectious body fluids.
Exposure also requires a portal of entry, either through nonintact skin or mucous membranes. The CDC doesn't recommend prophylaxis in cases of contact with intact skin.3 Determining whether exposure has occurred can be challenging in cases of body fluid splashes on apparently intact skin or needle sticks that don't draw blood.
Now let's consider how to minimize the risk of disease transmission if you or a coworker is exposed to potentially infectious body fluid.
Ada Collins, a nurse in your unit, was just stuck with a needle she'd used to administer a subcutaneous injection. In a panicky voice, she asks for your help. What should you do?
Rule one for responding to accidental exposure to blood or OPIM is to follow facility policy, which is based on guidelines from OSHA, the CDC, the Health Insurance Portability and Accountability Act (HIPAA), and state law. The general principles we discuss here apply at most facilities.
If you're at the scene of an exposure incident (or are exposed yourself), be aware of the emotional component of an occupational exposure. Knowing the risks, an exposed healthcare worker like Ada may panic. So the first step is to calm her by reminding her that disease transmission via blood or OPIM exposure is uncommon. She should take the following steps to minimize transmission risks after a potential exposure:
* If the potential exposure involves a needle stick, puncture injury, cut, or fluid contact with nonintact skin, wash the area with soap and water.
* In the case of a mucous membrane exposure, rinse the site with copious amounts of water or normal saline solution.
* Irrigate the eyes with commercially prepared isotonic solution in eye wash stations, if available, or with saline solution or clean water.
* Flush splashes to the nose, mouth, or skin with water.4
No evidence indicates that squeezing a wound or washing with an antiseptic or a caustic solution reduces the risk of disease transmission. The CDC says that using antiseptics "is not contraindicated," but doesn't recommend application of caustic solutions such as bleach or the injection of antiseptics into a wound.5
Because some decisions about PEP should be made within hours, urge Ada to immediately seek further care and counseling from the department in your facility responsible for managing occupational exposures, such as the occupational health, infection control, or employee health department. Support her by alerting her manager so her patient-care responsibilities can be delegated to others.
Ada's employer is required to follow all federal and state requirements for recording and reporting occupational exposures. For example, OSHA requires employers to maintain a sharps injury log.2 Completing an event report designated by the employer helps risk managers assess the reason for the exposure and take steps to prevent similar incidents.
At this time, the source patient must be identified using at least two valid patient identifiers, such as his name, date of birth, or healthcare system medical record number. (These are the same patient identifiers you use before giving a medication.) The patient's room number isn't a valid patient identifier because patients can change rooms.
Facility policy, HIPAA guidelines, and regional regulations determine how to handle the source specimen. The CDC doesn't recommend trying to preserve body fluid or the contaminated sharp device for testing, because this could be hazardous to people handling them and results are unreliable.5
Occupational health personnel should follow these general guidelines to assess Ada's need for PEP.
Determine if a true exposure to blood or OPIM has occurred. For example, being splashed with blood or any fluid containing blood is considered a potential exposure. Being splashed with urine, feces, or vomitus is not, because these substances aren't OPIMs.
Determine if the blood or OPIM had a portal of entry. The CDC doesn't recommend prophylaxis when source fluids make contact with intact skin. The route of exposure plays a role in the likelihood of transmission. For example, the average risk for HIV transmission after percutaneous exposure to infected blood is 0.3%, or about 1 in 300. After mucous membrane exposure, the risk is 0.09%, or about one in 1,000.3
Evaluate the source. If the source patient's HIV, HBV, and HCV status are unknown, occupational health personnel can question him about his status and initiate testing. If he's known to be HIV positive, information should be gathered from him and the medical record about any current HIV antiretroviral therapy and its effectiveness, as determined by viral load or CD4 count.
If testing is indicated, your facility's exposure control policy addresses informed consent issues based on state law and CDC guidelines. In 2006, the CDC recommended eliminating the requirement for specific written consent for HIV testing: "general consent for medical care should be considered sufficient to encompass consent for HIV testing."6 However, this recommendation hasn't been adopted in all jurisdictions. For example, California requires a separate consent for HIV testing.
The rapid HIV test can provide results in 20 to 40 minutes. This is ideal, because PEP for HIV infection should begin within 2 hours after exposure for best results. A negative rapid HIV test can ease the exposed person's anxiety and spare her from unnecessary PEP, which can cause significant adverse reactions.
If the test is positive, it should be confirmed with more definitive HIV testing. In the meantime, starting PEP is indicated for the exposed person. If the source's HIV status can't be quickly determined, the exposed person may start PEP and discontinue it later if the source is negative.
The rapid HIV test may produce a false-negative result if the source has been infected for less than 90 days, the time needed for his body to develop enough telltale antibodies. However, barring unusual circumstances, a negative rapid HIV test on the source is generally accepted as definitive.
Unlike HIV testing, HBV and HCV testing has never required a separate consent, and blood already drawn from the source patient may be used for testing. However, the patient could refuse to have additional blood drawn for testing, and drawing blood against his will could be considered assault.
The HBV panel for a source patient varies among facilities, but a hepatitis B surface antigen (HBsAg) is standard in all of them. A positive result indicates that the source is capable of transmitting HBV. HBsAg appears in about 4 weeks after HBV infection and remains in those who are chronically infected. Some facilities also include a hepatitis B surface antibody (HBsAb or anti-HB) in the test bundle; a positive result is generally interpreted as immunity to HBV due to natural infection or vaccination, and the source isn't infectious to others.7
Anyone who's been vaccinated for hepatitis B and developed an immune response is considered to have virtually no risk of contracting HBV from exposure. If the exposed person isn't immune, her risk of infection from a single needle-stick or cut exposure ranges from 6% to 30%, depending on the source's hepatitis B e antigen (HBeAg) status. (HBeAg is a viral protein associated with HBV infection.) A source patient who's both HBsAg-positive and HBeAg-positive is more likely to transmit disease because he has more virus in his blood.8
Hepatitis C antibody testing, also known as an anti-HCV test, has a high false-positive rate, so a positive result must be confirmed with further testing. The preferred approach is to confirm with the recombinant immunoblot assay or HCV RNA. The advantage of the quantitative HCV RNA is that it reveals how infectious the person is, which helps clinicians counsel the exposed person. No PEP is available for HCV.
Assess and test the exposed person. Baseline assessment and testing for an exposed healthcare worker such as Ada is important to determine if she already harbors a bloodborne infection. Her history should include this information:
* current pregnancy or breast-feeding. Pregnancy testing should be considered for women of childbearing potential based on the healthcare professional's assessment of her exposure risk.
* medication reconciliation
* history of HBV vaccination and whether she developed an immune response (more on this shortly)
* history of any liver or kidney problems, dyslipidemia, anemia, pancreatitis, depression, or insomnia
* any other medical or occupational information that affects her risk of infection from bloodborne pathogens.
Like the source, she has the right to consent to or refuse baseline testing. However, by refusing testing, she may jeopardize her workers' compensation benefits. As an alternative, she may be offered the option of having her blood drawn and preserved for later testing if the source person's results are positive. Or, she may want another facility to conduct the test.
Decisions about HBV testing can be complicated. If Ada never received the HBV vaccine series, she should have HBsAb and HBsAg testing. If she completed the HBV vaccine series and tested afterward as HBsAb positive, she needs no hepatitis B testing. The vaccine is considered to give lifetime protection against HBV in people who respond in this way, and further testing would be confusing and not meaningful. Although many people have undetectable blood antibody levels 12 years after vaccination, studies have shown that their immune system increases production of antibodies to protective levels when they're exposed to HBV.9
An exposed person who completed the vaccine series and was never tested for an immune response should have HBsAb and HbsAg testing, because either she may never have developed an immune response to the vaccine or she may be chronically infected with HBV.
If Ada completed HBV vaccination over 10 years ago and wasn't tested afterward, she should be advised that the HBsAb test may be falsely negative because of waning antibodies. If she completed the vaccine series and was tested but doesn't remember the results, refer her to the facility's Occupational Health department for a review of records to determine if additional doses of vaccine are indicated. This information should be shared with her healthcare practitioner.
Some healthcare workers are known nonresponders to the vaccine, many because they've been chronically infected with hepatitis B. These people should also be offered HBsAb and HBsAg testing.
Baseline hepatitis C testing should be done with serum liver enzyme levels (alanine aminotransferase or ALT) as soon as possible after the exposure.
Determine how the exposed person will get follow-up care. Regardless of whether she receives PEP, anyone exposed to HIV or HCV should have follow-up testing, counseling, and medical evaluation at intervals recommended by CDC guidelines.8 If the results are negative, no additional follow-up is needed. The CDC doesn't recommend routine follow-up after PEP for HBV because PEP is highly effective at preventing infection. However, advise the exposed person to seek treatment if she develops any signs and symptoms of hepatitis, such as yellow sclerae or skin, loss of appetite, and nausea.
If getting follow-up at the current facility isn't appropriate or feasible, another healthcare provider should be chosen to receive the test results on both the exposed person and the source patient.
If the rapid HIV test on the source patient is positive, Ada should be told that the test can produce false-positive results. She should be asked to maintain confidentiality until confirmatory testing is complete and reminded not to share the information with the source patient. If appropriate, his healthcare provider will discuss test results and their implications with him.
Discussing Ada's treatment options is very important at this point because the 2-hour window for starting HIV PEP began at the time of exposure and decisions about HIV PEP can be complex. Therapy lasts 30 days and can cause many adverse reactions. The clinician working with Ada should call the National Clinicians' Postexposure Prophylaxis Hotline (1-888-448-4911) for advice before proceeding. Given key information about the source and the exposed person, experts can help Ada's clinician make the best treatment recommendations for her.
A person exposed to bloodborne pathogens who decides to go on HIV PEP should be fully informed about possible adverse reactions, including nausea, diarrhea, abdominal pain, anemia, and neutropenia. Identify follow-up resources to answer her questions, help her manage adverse reactions, or provide additional testing.
Advise Ada that she'll need blood tests to monitor for toxic drug levels: At a minimum, testing should include a complete blood cell count and renal and hepatic function tests at baseline and after 2 weeks of therapy. If her drug regimen includes a protease inhibitor, teach her how to monitor for signs and symptoms of hyperglycemia, such as polydipsia, polyuria, polyphagia, fatigue or weakness, and blurred vision. If the protease inhibitor indinavir is prescribed, she'll also require periodic monitoring for crystalluria, hematuria, hemolytic anemia, and hepatitis. She shouldn't take indinavir if she's pregnant or breast-feeding.
Advise Ada to immediately see her healthcare practitioner if she develops a rash, fever, back or abdominal pain, dysuria, hematuria, or signs and symptoms of hyperglycemia.
Stress the importance of completing the prescribed regimen. Many people who start an HIV PEP regimen don't complete it because of adverse reactions such as nausea and diarrhea. Advise Ada that antimotility and antiemetic drugs or medications that target specific symptoms can help her manage adverse reactions and stay on the prescribed regimen. If adverse reactions become intolerable, urge her to discuss them with her healthcare provider, who may modify the regimen. Serious adverse events should also be reported to the FDA's MedWatch program.3
Don't overlook the powerful effect Ada's exposure will have on her family. Refer her and family members for counseling if indicated. Advise Ada not to have sex (preferably) or to practice safer sex for the first 3 months until her HIV status is proven negative and follow-up care is complete. She should also avoid breast-feeding, pregnancy, and blood donation.3
An exposed person who has antibodies to HBV (positive HBsAb test) isn't considered at risk for infection, regardless of test results on the source patient, so PEP isn't indicated. Appropriate PEP should be initiated if, based on the complete occupational assessment of the risks of an exposure incident, the exposed person is susceptible to HBV infection and the source patient tests positive for HbsAb, HbeAg, or IgM antibody to hepatitis B core antigen (HBcAb IgM). The exposed person should be offered hepatitis B immune globulin (HBIG) and the HBV vaccine; both can safely be given even if she's pregnant or breast-feeding.8
HBIG is most effective when given within 24 hours of exposure and offers immediate passive protection. If the source patient's results aren't available within 24 hours but he's at high risk for hepatitis B and the exposed person is susceptible, HBIG may be administered as a safeguard because it rarely causes serious adverse reactions. However, people with a history of anaphylaxis to human immune globulin preparations shouldn't receive HBIG.5
Because HBIG and the HBV vaccine are both highly effective at preventing infection, no special precautions are recommended as long as the exposed person remains symptom-free.5,8 However, the person shouldn't donate blood, organs, tissues, or semen until follow-up is completed at 6 months. No work restrictions are necessary for a healthcare worker like Ada unless she develops infection.
If HBsAb and HBsAg testing shows that Ada has no antibodies to HBV, advise her to complete the hepatitis B vaccine series to protect her against this and any future occupational exposures.
A confirmed positive HCV result would mean that Ada has been exposed to HCV. No PEP regimen is available for HCV, and immune globulin and antiviral drugs aren't recommended. The exposed person should be followed for 4 to 6 months as recommended by CDC guidelines and receive the same counseling that would be given for HBV.
No work restrictions are necessary for a healthcare worker infected with HCV, according to the CDC.5,8 All healthcare workers should know and observe principles of sharps safety, use personal protective equipment appropriately, and follow standard precautions according to current infection control guidelines.
In rare cases, healthcare workers who know they have HIV, HBV, or HCV are reexposed to these diseases while providing care. Ironically, these exposures also carry risk because the source patient's pathogens may have different resistance patterns, affecting the exposed person's response to exposure and treatment. The exposed person should follow the facility's policy and procedure for postexposure care and discuss with the healthcare provider whether additional action is required.
A quick and appropriate response to a potential exposure can greatly reduce the risk of disease transmission following an occupational exposure to potentially infectious material. But preventing exposures is best of all. Learn your facility's infection control standards and policies, and follow them as though your life depends on it.
Most people who are exposed to blood or OPIM don't develop an infection. The type of exposure, the amount of blood or body fluid involved, and the viral load in the source patient's blood all affect risk. If the source patient isn't infected with a bloodborne pathogen, only superficial wound care may be needed after a needle-stick or sharps injury. Here's how the risks of disease transmission compare for three bloodborne pathogens.
HIV transmission. Contracting HIV from accidental occupational exposure is quite rare, as indicated by these seroconversion rates.
* sharps injury, 0.3%, or about 1 in 300.
* mucous membrane exposure, 0.09%, or about 1 in 1,000
* exposure to nonintact skin, probably lower than the risk for mucous membrane exposure.3
From 1981 to 2006, the CDC documented 57 cases of HIV/AIDS among healthcare personnel following occupational HIV exposure, and identified an additional 140 "possible" cases. This included 24 documented and 35 possible cases of occupationally acquired HIV infection among nurses.10
HBV transmission. The risk of a susceptible person developing clinical HBV following exposure ranges from 1% to 31%, depending on the source person's HBV status. Unlike HIV, which breaks down quickly in the environment, HBV can remain infectious on environmental surfaces for over a week, even in dried blood.5
OSHA regulations require offering the HBV vaccine to all healthcare workers who may be exposed to blood or OPIM on the job. These vaccinations have dramatically decreased transmission of HBV via occupational exposure. However, some healthcare workers don't accept the vaccine or complete the vaccine series, and others who are properly vaccinated don't mount an immune response.
HCV transmission. The risk of HCV transmission after percutaneous exposure is about 1.8%. The virus can remain viable in the environment between 16 hours and 4 days, although HCV transmission via environmental contamination isn't considered a significant risk in healthcare settings with the possible exception of hemodialysis units.5 No vaccine has been developed and the predominant HCV strain in the United States is resistant to current antiviral agents.
Blood and any visibly bloody body fluids are considered potentially infectious under OSHA guidelines. Other potentially infectious material (OPIM) include:
* semen and vaginal secretions
* cerebrospinal fluid
* synovial fluid
* pleural fluid
* peritoneal fluid
* pericardial fluid
* amniotic fluid.
Materials not considered OPIM include feces, urine, vomitus, nasal secretions, saliva (except during dental procedures), sputum, sweat, and tears.2
1. CDC. http://www.cdc.gov/hepatitis/HCV.htm. [Context Link]
2. United States Department of Labor, OSHA Standard 29 CFR. Bloodborne Pathogens-1910.1030. http://www.osha.gov. [Context Link]
3. CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR. 2005;54(RR-9):1-17, September 30, 2005. [Context Link]
4. CDC. NIOSH Publication no. 2007-157. Bloodborne Pathogen Exposure. http://www.cdc.gov/niosh/docs/2007-157. [Context Link]
5. CDC. Updated U.S. Public Health Service Guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR. 2001;50(RR-11):1-42, June 29, 2001. [Context Link]
6. CDC. Revised Recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. 2006;55:(RR-14), September 22, 2006. [Context Link]
7. CDC. Interpretation of hepatitis B serologic test results. http://www.cdc.gov.hepatitis/HBV/PDFs/SerologicChartv8.pdf. [Context Link]
8. CDC. Exposure to blood: what healthcare personnel need to know. July 2003. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a3.htm. [Context Link]
9. CDC. Immunization of health care workers. MMWR. 1987;46(RR-18):28, December 26, 1987. [Context Link]
10. CDC. Surveillance of occupationally acquired HIV/AIDS in healthcare personnel, as of December 2006. http://www.cdc.gov/ncidod/dhqp/bp_hcp_w_hiv.html. [Context Link]
Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. http://www.cdc.gov/std/treatment/2006/hepatitis-b.htm.
National clinicians' post-exposure prophylaxis hotline, University of California, San Francisco: 1-888-448-4911
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