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Needle-Stick Exposure Protocol and CDC Recommendations for Dental Health-Care Providers Infected with the Hepatitis B Virus

NEEDLE-STICK EXPOSURE OVERVIEW

Needle-stick exposure in the dental setting can predispose to hepatitis B, hepatitis C, or HIV infection. Every effort should be made to minimize risk and prevent such accidents from happening.

Exposure Risks with Percutaneous and Mucocutaneous Exposures

The risk of exposure with percutaneous injury is 0.3%, and with mucocutaneous exposure the risk is 0.09%. The risk increases with deep exposures and/or large volume exposure.

Risk-Reduction Steps

The two steps that can decrease the risk of infection are (1) development of an accident prevention protocol and (2) development of a percutaneous and mucocutaneous exposure protocol to implement once exposure occurs.

ACCIDENT PREVENTION PROTOCOL

An ideal accident prevention protocol should have the following steps implemented at all times during patient care:

All these steps should be periodically reviewed and reinforced, particularly in a large multi-provider office or student setting.

PERCUTANEOUS AND MUCOCUTANEOUS EXPOSURE PROTOCOL

In the event of an injury, every health-care setting must have a written percutaneous/needle-stick and mucocutaneous exposure protocol that must be implemented immediately. It is necessary to test and treat the exposed person within one hour of the exposure.

The dental office must designate in advance a neighboring physician’s office or hospital emergency room as the site responsible for providing immediate and follow-up care for both the provider/health-care worker (HCW) and the source patient.

Every member of the dental setting should be familiar with the protocol, which should be visibly posted in the clinical care areas with all the appropriate telephone numbers listed.

The needle-stick exposure protocol should be periodically discussed among all members to ensure awareness. In the event of an accident, non-injured members can actively help, and this, in turn, decreases the anxiety experienced by the injured/exposed HCW.

EXPOSURE PROTOCOL

Postexposure Steps

Once exposure occurs, implement the following steps:

Postexposure Tests: Protocol for the Source and the Provider/Healthcare Worker (HCW)

Postexposure Tests for the Source

The source patient’s status for HIV, hepatitis B, and hepatitis C are determined by conducting the following tests: rapid HIV test, HBsAg and HBeAg, anti-HCV, and hepatitis C RNA.

The rapid HIV test results are obtained within twenty minutes. If the source is positive for hepatitis C, the provider has to be tested at baseline and have follow-up serology tests at six and twelve weeks. If conversion occurs the provider/HCW is referred to an infectious disease specialist for hepatitis C infection evaluation and treatment.

Known HIV/AIDS-Positive Source

If the source patient is a known HIV-infected patient, the HIV PCR or viral load of the source patient is determined immediately. The viral load is also determined if the source tests positive with the rapid HIV test. In this case, it is clear that the source was unaware of the HIV status prior to the rapid HIV test. The designated physician will, in this case, inform the CDC about detection of a new HIV case, because it is mandatory for the MD to report all HIV sero-conversions.

Tests for the Provider/HCW

The provider must be tested for baseline HCV and HIV infections using the anti-HCV and the rapid HIV tests, respectively. Additionally, the anti-HBs titer test is done to determine the provider’s immunity status with the hepatitis B vaccine. The hepatitis B vaccine and/or HBIG (hepatitis B immune globulin) are given dependent upon the provider’s vaccination and antibody status.

The provider must be reevaluated at six weeks, twelve weeks, and six months. If the provider sero-converts for HIV or HCV, the testing is continued for an additional six months, for a total of twelve months from the time of exposure.

Postexposure Medications

When the source patient is a known or newly discovered HIV/AIDS patient, or the HIV/AIDS status of the source is unknown, the HCW must be protected immediately with postexposure medications. Postexposure prophylaxis (PEP) with three antiretroviral drugs must be given within 72/>