∗ (7,9,11,13,113,120-123,125,126,136-138).
† Pathogenic organisms have been found on or around bar soap during and after use (139). Use of liquid soap with hands-free dispensing controls is preferable.
§ Time reported as effective in removing most transient flora from the skin. For most procedures, a vigorous rubbing together of all surface of premoistened lathered hands and fingers for ≥15 seconds, followed by rinsing under a stream of cool or tepid water is recommended (9,120,123,140,141). Hands should always be dried thoroughly before donning gloves.
¶ Alcohol-based hand rubs should contain 60%-95%, ethanol or isopropanol and should not be used in the presence of visible soil or organic material. If using an alcohol-based hand rub, apply adequate amount to palm of one hand and rub hands together, covering all surfaces of the hands and fingers, until hands are dry. Follow manufacturer’s recommendations regarding the volume of product to use. If hands feel dry after rubbing them together for 10-15 seconds, an insufficient volume of product likely was applied. The drying effect of alcohol can be reduced or eliminated by adding 1%-3% glycerol or other skin-condition agents (123).
∗∗ After application of alcohol-based surgical hand-scrub product with persistent activity as recommended, allow hands and forearms to dry thoroughly and immediately don sterile surgeon’s gloves (144,145). Follow manufacturer instructions (122,123,137,146).
†† Before beginning surgical hand scrub, remove all arm jewelry and any hand jewelry that may make donning gloves more difficult, cause gloves to tear more readily (142,143), or interfere with glove usage (e.g., ability to wear the correct sized glove or altered glove integrity).
From Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings—2003. MMWR 2003;52(No. RR-17):(15).
Personal Protective Equipment
30. What type of gloves should be worn for different procedures and tasks?
The type of glove must first provide appropriate hand protection for the anticipated exposures, such as biologic, chemical, and/or physical (sharp). Next, within each procedure or exposure category, there are choices of materials based on several factors, including personal health compatibility (allergies and fit).
31. How do you determine what types of personal protective equipment (PPE) you should use?
The selection of PPE should be based on the type of exposure anticipated and the quantity of blood, blood-derived fluids, or other potentially infective materials that might reasonably be expected in the performance of one’s duties. With normal use, the material should prevent passage of fluids to skin, undergarments, or mucous membranes of the eyes, nose, or mouth.
32. Do gloves provide protection from a sharps exposure?
They provide protection to a limited degree, at best. Some studies indicate that the mechanical action of a sharp passing through the glove may reduce the microbial load. However, even heavy-duty utility gloves do not block penetration. In addition, blunt instruments pose injury risks for the dental health care worker and patient.
33. Does clinic attire (lab coats) protect one from potentially infective fluids?
The intent of clinic attire is to prevent potentially infective fluids from reaching skin, especially nonintact skin, which can serve as a portal of entry for pathogenic organisms. Putting an effective barrier, such as a lab coat, between the body and these fluids reduces the risk of infection. Such garments are contaminated and should not be worn outside the clinic area.
34. Should clinic attire be long- or short-sleeved?
Because the OSHA standards are performance-based, the dental health care worker must determine whether the procedure is likely to result in contact with patient fluids or materials. If the answer is yes, the potential contact area should be covered.
35. How do you determine whether eyewear is protective?
The best way is to read the standards of the American National Standards Institute (ANSI). These describe protective eyewear as impact-resistant, with coverage from above the eyebrows down to the cheek and solid side shields to provide peripheral protection. The eyewear should protect not only from fluids but also from flying debris that might be generated during a dental procedure.
36. Is a surgical mask needed under a face shield?
Yes, it is needed, unless the face shield has full peripheral protection at the sides and under the chin. The mask protects the dental health care worker from splashes and spatters to the nose and mouth.
37. What type of protection do most masks used in dental offices offer?
The masks used in dental offices do not provide definable respiratory protection; their primary design is to protect the patient. However, the physical barrier certainly protects covered areas from droplet scatter generated during treatment. If respiratory protection is indicated, masks must be certified for respiratory protection. Read the product label.
38. How long can a mask be worn?
One can wear a mask until it becomes wet, torn, or somehow compromised. At a minimum, a new mask must be worn for each patient. Limited research indicates that the duration for use is about 1 hour for a dry field and 20 minutes for a wet field.
39. What is the purpose of heavy duty utility gloves?
Heavy duty utility gloves, such as those made of nitrile rubber, should be worn whenever contaminated sharps are handled. They are worn for safe pickup, transport, cleaning, and packing of contaminated instruments. They also should be used for housekeeping procedures such as surface cleaning and disinfection. Routine cleaning and disinfection are necessary because the gloves also become contaminated. They should not be worn when handling or contacting clean surfaces or items.
NOTE: Examination gloves are not appropriate for instrument cleaning or reprocessing or any housekeeping procedure (Table 12-2).
40. What is irritant dermatitis?
It is a nonallergic process that damages superficial layers of skin. It is mainly caused by contact that challenges the skin tissue.
41. What are its symptoms?
In general, the top layer of the skin becomes reddened, dry, irritated, or cracked.
42. What causes of dermatitis are associated with health care workers’ hands?
Nonallergic irritant dermatitis is the most common form of adverse reaction. It is often caused by the following: (1) contact with a substance that physically or chemically damages the skin, such as frequent antimicrobial hand washing agents on sensitive skin; (2) failure to rinse off chemical antiseptic completely; (3) excessive exposure to water; and (4) failure to dry hands properly and thoroughly.
43. What common types of hypersensitivity symptoms are caused by latex gloves and other latex items?
1. Cutaneous anaphylactic reaction (type I hypersensitivity) typically develops within minutes after an allergic individual comes into direct contact with allergens via tissues or mucous membranes (donning latex examination or surgical gloves) or is exposed via aerosolization of allergens. Natural rubber latex proteins adhering to glove powder particles can remain suspended in the air for prolonged periods after gloves are placed on the hands and when new boxes of gloves are opened. Wheal and flare reaction (e.g., urticaria, hives) may develop, along with itching and localized edema. Coughing, wheezing, shortness of breath, and/or respiratory distress may occur, depending on the person’s degree of sensitization. Type I hypersensitivity can be life-threatening; appropriate medical supplies (e.g., epinephrine) should always be immediately available.
2. Contact dermatitis (delayed type IV hypersensitivity) is characterized by a several-hour delay in the onset of symptoms and a reaction that peaks in 24 to 48 hours. This slow-forming, chronic inflammatory reaction is well demarcated on the skin and is surrounded by localized erythema. Healing may take up to 4 days, with scabbing and sloughing of affected epithelial sites.
44. What should be done for health care workers who develop symptoms or reactions that may be caused by latex hypersensitivity?
The first step is to determine that you are dealing with a true reaction to latex. The most common type of hand dermatitis is actually nonspecific irritation and not an immunologic response. Nonspecific irritation can have a similar appearance to a type I or IV reaction but often results from improper hand care, such as not drying hands completely before putting on gloves. In addition, allowing dry hands to go untreated, especially during colder seasons, may lead to development of chapped broken areas in the epithelium.
Table 12-2
How to Select Task-appropriate Gloves
| FOR THIS TASK: | USE THIS GLOVE: |
| Contact with body, as during surgery | Sterile surgical gloves |
| Routine intraoral procedures, routine contact with mucous membranes | Nonsterile examination gloves |
| Nonclinical care or treatment procedures, such as processing radiographs and writing in a patient record | Copolymer gloves or overgloves |
| Contact with chemical agents, contaminated sharps, and other potential exposure incidents not related to patient treatment | Heavy-duty utility gloves |
Definitive diagnosis through clinical and laboratory tests by a qualified health care professional is necessary. Specific treatment and latex avoidance recommendations must be followed by the latex-sensitive or allergic health care worker. Accommodations in products selection and work environment may be required in order for the health care worker to return to work safely. In an alert to health professionals in 1991, the U.S. Food and Drug Administration (FDA) also suggested that persons with severe latex sensitivity should wear a medical identification bracelet in case they require emergency medical care and are unable to alert hospital personnel.
45. What risk factors are associated with latex allergy?
• Frequent exposure to latex
• Frequent catheterization
• History of surgery
• Spina bifida
• Allergies to certain food, such as bananas, avocados, kiwi fruit, and chestnuts
46. What are the official recommendations for protection of health care workers with ongoing exposure to latex?
NIOSH recommends the following steps for worker protection:
1. Use nonlatex gloves for activities that are not likely to involve contact with infectious materials (e.g., food preparation, routine housekeeping and maintenance).
2. When appropriate barrier protection is necessary, choose powder-free latex gloves with reduced protein content.
3. When wearing latex gloves, do not use oil-based hand creams or lotions unless they have been shown to reduce latex-related problems.
4. Frequently clean work areas contaminated with latex dust.
5. Frequently change the ventilation filters and vacuum bags in latex-contaminated areas.
6. Learn to recognize the symptoms of latex allergy—skin rashes and hives; flushing and itching; nasal, eye, or sinus symptoms; asthma; and shock.
7. If you develop symptoms of latex allergy, avoid direct contact with latex gloves and products until you see a physician experienced in treating latex allergy.
8. Consult your physician about the following precautions:
• Avoid contact with latex gloves and products.
• Avoid areas in which you may inhale the powder from latex gloves worn by others.
• Wear a medical alert bracelet.
9. Take advantage of all latex allergy education and training provided by your employer.
See the NIOSH website (www.NIOSH.gov) for updated information.
47. A patient reports a latex allergy and says that if a glove touches her, she will break out. What type of glove should be used in place of latex?
There are nonlatex (synthetic) gloves which provide appropriate barrier protection and reduce concern for an allergic response. However, depending on the severity of the allergy, more serious responses may occur merely in the presence of latex. You may wish to consult with the patient’s allergist for additional recommendations.
48. Why are lanolin hand creams contraindicated with glove use?
The fatty acids in lanolin break down the latex, causing wicking. This same process can cause a buildup of film on the hands.
Bloodborne Infections and Vaccination
49. What are universal precautions?
Universal precautions, a concept of infection control, assume that any patient is potentially infectious for a number of bloodborne pathogens. Blood, blood-derived products, and certain other fluids that are contaminated with blood are considered infectious for human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and other bloodborne pathogens. Standard Precautions are procedure-specific, not patient-specific.
In dentistry, saliva is normally considered to be blood-contaminated. The basic principle and implementation of this concept is that gloves (and other PPE, as appropriate) should be worn “universally with all patients, i.e., without regard to whether a particular patient’s bloodborne infection state is known.”
50. What are Standard Precautions?
In 1996, the CDC developed new guidelines that combined the major components of universal precautions and body substance isolation into one set of precautions known as Standard Precautions. According to the Oral Health Division of the CDC, they are similar to universal precautions in that they are designed to reduce the risk of transmission of pathogens from recognized and unrecognized sources of infection to other patients and to health care workers. Standard Precautions apply to blood, body fluids, secretions, and excretions (except sweat), regardless of whether they contain blood, to nonintact skin and mucous membranes. Standard Precautions should be used in the care of all patients, regardless of their infectious status. This expanded set of precautions teaches simply that “if it’s a wet body substance and it doesn’t belong to you, wear your gloves and other PPE as appropriate to avoid direct contact with it while delivering health care to the patient.”
51. What is the chain of infection?
The chain of infection refers to the prerequisites for infection (by direct or indirect contact). The chain of infection must include the following:
• A susceptible host
• A pathogen with sufficient infectivity and numbers to cause infection
• An appropriate portal of entry to the host (e.g., a bloodborne agent must gain access to the bloodstream, whereas an enteric agent must enter the mouth [digestive tract])
• A reasonably efficient physical mode of pathogen transfer from source to host
52. Which factor is easiest to control—agent, host, or transmission?
Agent and host are more difficult to control than transmission. Standard Precautions are directed toward interrupting the transfer of microorganisms from patient to health care worker, and vice versa.
53. What is one of the single most important measures to reduce the risk of transmission of microorganisms?
Hand hygiene, such as hand washing, is one of the most important measures in reducing the risk of transmission of microorganisms. Hands should always be thoroughly washed between patients, after contact with blood or other potentially infective fluids, after contact with contaminated instruments or items, and after removal of gloves. Gloves also play an important role as a protective barrier against cross-contamination and reduce the likelihood of transferring microorganisms from health care workers to patients and from environmental surfaces to patients. A cardinal rule for safety is never to touch a surface with contaminated gloves that will subsequently be touched with ungloved hands.
54. Is exposure synonymous with infection?
No. An exposure is a contact that has a reasonable potential to complete the chain of infection and result in disease of the host. Infection occurs when the exposure leads to transmission of the pathogen.
55. What are hepatitis B and delta hepatitis?
Hepatitis B is one of most common reportable diseases in the United States. HBV is transmitted through blood or blood-contaminated body fluids. It is highly transmissible because of the large numbers of virus in the blood of infected persons (about 100 million/mL). Delta hepatitis is caused by a defective virus (hepatitis D virus [HDV]) that relies on HBV for its pathogenicity and can infect only in the presence of HBV. HBV and HDV co-infection, however, results in a fulminant course of liver disease. Hepatitis D is very rarely seen in the United States but may be encountered when traveling to certain countries. If successfully vaccinated against HBV, one cannot contract HDV.
56. Why is hepatitis B vaccination so important?
HBV is the major infectious occupational hazard to health care workers. Transmission has been documented from providers to patients, and vice versa. In 1982, a vaccine became available to provide protection from HBV infection. The first-generation vaccine was plasma-derived, but the vaccine in current use is genetically engineered. The safety and efficacy of the vaccine are well established, and there is no current recommendation for booster doses. Furthermore, protection from HBV also confers protection from HDV.
57. If you are employed in a dental practice, who pays for the HBV vaccine—you or your employer?
If an employee may be exposed to blood or other potentially infectious fluids during the course of work, it is the obligation of the employer to offer and pay for the series of vaccinations. According to OSHA regulations, the vaccine series must be offered to all at-risk employees within 10 working days of hire or reassignment to the position with occupational exposure to blood. A hepatitis B surface antibody titer test (referred to as anti-Hbs or HBsAb) is recommended 1 to 2 months after completion of the vaccine series to verify that the health care worker is protected. Because this is a U.S. Public Health Service (USPHS) recommendation, the employer is expected to pay the cost of the titer test.
58. What if I refuse the vaccination?
In most states, you have a right to refuse the vaccination. You should realize, however, that without the HBV vaccination series or evidence of previous infection, you remain at risk for acquiring HBV infection. Because OSHA considers the HBV vaccination one of the most important protections that a health care worker can have, the agency requires the employee to sign a waiver if the vaccination is refused. Only after the employee has been informed of the safety and efficacy of the vaccine and the potential consequences of not receiving the vaccine can they sign the declination form. The language used in the declination must be that which is specified in the OSHA Bloodborne Pathogens Standard. If an employee with occupational exposure to blood declines the vaccine and later decides to accept it, the employer must still pay the cost of the vaccination series.
59. What is the risk of acquiring HBV infection from a percutaneous exposure to blood known to be infected with HBV?
The risk of becoming infected with HBV varies with the presence or absence of HBeAg. If the source is e antigen-positive, the risk of 22% to 30%; if the source is e antigen–negative, the risk is 1% to 6%. This risk is for an unprotected, nonvaccinated health care worker.
60. What is the risk of HIV transmission associated with percutaneous and/or mucous membrane exposures to blood known to be HIV-positive?
The risk is about 0.3% (1/300) for percutaneous and about 0.09% (1/900) for mucous membrane exposures. Many factors, however, influence the likelihood of transmission (see question 66). Accumulated data from studies involving health care worker exposures suggest a 0.2% to 0.4% risk of HIV infection, with the worst case scenario of a severe percutaneous injury involving exposure to blood from a terminal HIV patient.
61. How can percutaneous injuries be prevented?
Use devices with engineered safety features designed to prevent injuries such as self-sheathing needles, blunt suture blades, other safe disposable needle systems, and the use of appropriate sharps containers.
Use safer work practices that avoid hand contact with sharps, such as not debriding an instrument by hand with gauze but rather by using a single-hand technique, such as cotton rolls taped to a bracket tray or use of a commercial safe wipe device. Also, when handling sharps, use caution not to come into contact with the sharp instrument, such as not recapping a syringe or disengaging needles from a reusable syringe by hand.
62. What are the elements of a postexposure management program?
1. Wound management
2. Exposure reporting and documentation
3. Medical follow-up
63. How do you assess the risk of infection?
The risk of infection is assessed by type of exposure, body substance involved, and source evaluation. Assessing the type of exposure determines whether it is percutaneous, mucous membrane, nonintact skin, or a bite resulting in blood exposure. Risk also depends on the type of body fluid, with blood or bloody fluid being a higher risk. Caution should also be used for potentially infectious fluid or tissue. In terms of the source evaluation, consideration must be given to the presence of HBsAg, presence of HCV antibody, and/or the presence of HIV antibody. If the source status is unknown, a community or practice assessment is indicated.
64. What is appropriate wound management?
1. Cleaning the wound with soap and water
2. Flushing mucous membranes with water
NOTE: Bleeding the wound or the use of bleach or caustic agents is not recommended.
65. Are any of these injuries preventable?
Yes. Data indicate that many reported injuries were preventable. In the event of a device failure, an injury may not have been preventable. Device failures should be reported to the FDA MedWatch program.
66. What is the major factor in the prevention of bloodborne pathogen transmission in health care settings?
Although engineering controls are a major factor in reducing the risk of an exposure, work practice controls have the greatest impact on preventing bloodborne disease transmission. Over 90% of the injuries leading to disease transmission have been associated with syringes and sharp instruments. Injuries also may be prevented by engineering controls, particularly the use of safer medical devices. A safe device will not prevent an injury unless it is properly used. The overall message is to maintain consistent levels of attention and take personal care (Box 12-1).
67. If I injure myself while working on a patient or using contaminated instruments from an identifiable patient, can someone call the patient’s personal physician for additional medical history information?
In almost all states, a written informed consent is necessary before a physician can release information on a patient. Obtaining information without this consent may be a violation of the Health Insurance Portability and Accountability Act (HIPAA) or other state laws. The situation may be discussed with the source patient to ask for consent to obtain additional information about his or her health. Regardless of the answer, an appropriate health care professional should evaluate you as soon as feasible if the injury warrants this.
68. What treatment options are available to a health care worker who has been exposed to HBV?
The health care worker may consider having a hepatitis B antibody titer to determine HBV serostatus. However, treatment should be initiated within 24 hours. If the health care worker was not vaccinated against HBV or does not have demonstrable antibody titer against hepatitis B surface antigen (anti-HBsAg), hepatitis B immunoglobulin (HBIG) should be administered as soon as possible. The HBV vaccination series should be initiated at the same time. An exposed health care worker may also need to consider the possibility that HIV and/or HCV exposure may have occurred simultaneously.
The efficacy of HBV postexposure prophylaxis (PEP) is based on perinatal data. These data indicate that if multiple doses of HBIG alone or the vaccine series alone is given within 1 week, the prevention of HBV infection is 70% to 75%. If a combination of HBIG and the vaccine series is administered, the efficacy increases to 85% to 95%.
69. How effective is the HBV vaccine?
Anti-HBs titers decline in 30% to 50% of adults within 8 to 10 years after vaccination. However, it is believed that the immune memory remains intact indefinitely after immunization. Chronic infection has rarely been documented in vaccine responders.
70. Describe postexposure follow-up for HBV.
The major elements are baseline evaluation and testing of the exposed health care worker, consideration of treatment options, and follow-up testing and counseling, as indicated. If the exposed person has been vaccinated but the vaccine response is unknown, test for anti-HBs. If, however, the exposed health care worker has not been vaccinated, or if the response is known, baseline testing is not necessary.
For health care workers who receive the HBV vaccine, follow-up testing for anti-HBs is indicated at 1 to 2 months after the last dose. If however, HBIG was also administered, the vaccine response cannot be ascertained until 3 to 4 months. If the source is not infected, follow-up is not necessary.
71. When must a percutaneous exposure (e.g., needlestick) be reported to OSHA?
Any occupational exposure or injury must be recorded on OSHA or the practice’s forms if it is work-related, required medical evaluation and/or follow-up, or resulted in seroconversion. There are some specific exceptions for small employers. Seroconversion as the result of occupational exposure also should be reported to the appropriate state agencies and the CDC.
72. If I am a hepatitis B carrier, can I continue work that involves patient contact?
You may continue clinical care as long as you adhere strictly to Standard Precautions. Only clinicians performing the most invasive of surgical procedures should consult with an expert panel to determine whether work restrictions are indicated.
73. What is hepatitis C?
HCV is a single-stranded RNA virus isolated in 1989. Much like hepatitis B, HCV may be transmitted via contact with HCV-infected blood. There are major differences between HCV and HBV. A large majority of individuals who contract HCV will develop chronic HCV infection. HCV is rarely implicated in health care–related transmissions, but there have been some cases documented in which HCV was transmitted to patients or clinicians. Cases of patient to patient transmission have been associated with a lack of good infection control practices, including improper instrument sterilization and mishandling of multidose medications.
74. How is HCV transmitted? What are the implications for health care workers?
HCV is a bloodborne disease and is spread primarily via a parenteral route; sexual and maternal-fetal (vertical) transmission are minor modes of viral passage. Health care workers should follow Standard Precautions, as indicated. HCV has not been found to be efficiently transmitted by occupational exposure, although it has been documented. The prevalence among health care workers is about 1% to 2% (less than in the adult general population) and 10 times lower than for HBV infection. The average risk is 1.8% after a percutaneous injury from an HCV-positive source.
75. What other information about HCV is important for health care workers?
1. No postexposure prophylaxis is available. However, medical follow-up for an exposure is important and should be considered an immediate medical concern. The exposed worker can be tested for possible prior exposure to HCV and monitored for early signs of seroconversion.
2. No vaccine is available.
3. Health care workers should be educated about risk and prevention.
4. Policies about testing and follow-up should be established.
5. There are no current recommendations for restriction of practice for HCV-infected health care workers.
6. Risk of transmission from health care worker to patient appears low.
7. Appropriate control recommendations for the prevention of bloodborne disease transmission should be followed.
76. Does the CDC have specific policy recommendations for follow-up after percutaneous or permucosal exposure to HCV-positive blood?
As of July 4, 1997, the CDC recommended that minimal policies should include the following:
1. For the source, baseline testing for antibody to HCV (anti-HCV)
2. For the person exposed to an anti-HCV-positive source, baseline and follow-up testing (e.g., 6 months) for anti-HCV and alanine aminotransferase (ALT) activity
3. Confirmation by supplemental anti-HCV testing of all anti-HCV results reported as repeatedly reactive by enzyme immunoassay (EIA)
4. Recommendation against postexposure prophylaxis with immunoglobulin or antiviral agents (e.g., interferon)
5. Education of health care workers about the risk for and prevention of bloodborne infections, with routine updates to ensure accuracy
77. In the absence of postexposure prophylaxis, what other issues should be considered?
The CDC recommends consideration of at least six issues in defining a protocol for the follow-up of health care workers occupationally exposed to HCV:
1. Limited data suggest that the risk of transmission after a needlestick is between that for HBV and HIV. Data for other routes of exposure are limited or nonexistent.
2. Newer generation tests, including rapid tests, are available and have a higher sensitivity and specificity than earlier tests.
3. The risk of transmission by sexual and other exposures is not well defined; all anti-HCV-positive persons should be considered potentially infectious.
4. There are new therapies for treating acute and chronic HCV that have proven to be effective. Therefore, monitoring for disease is important so that if transmission has occurred, treatment can be instituted at an early stage. There is evidence that newer treatment protocols have cleared HCV, but the long-term outcomes have not been established.
5. Costs associated with follow-up are a consideration.
6. A postexposure protocol should address medical and legal implications, such as counseling about an infected health care worker’s risk of transmitting HCV to others, therapy decisions, and individual worker concerns.
78. What are the elements of postexposure management for HCV?
As with other bloodborne exposures, baseline testing and follow-up testing and counseling are necessary. If the source patient is HCV-positive, the exposed health care worker should be tested for anti-HCV and ALT. If the source is not infected, baseline testing is not necessary. However, if the source is unknown, the risk of infection must be assessed to determine the indicated follow-up.
79. What if the source is HCV-positive?
If the source is HCV-positive, test for anti-HCV and ALT at baseline and 4 to 6 months after the exposure. For earlier diagnosis of HCV infection, an HCV-RNA test may be done at 4 to 6 weeks. Positive results should be confirmed with a supplemental Western blot confirmatory test. Note that there is a rapid test (screening) for HCV.
80. What is the relationship between viral load and potential rate of transmission to health care workers for HBV, HIV, and HCV?
See Table 12-3.
81. Have there been reports of transmission of HCV from health care workers to patients?
There have recently been reports of transmission in dental facilities. Past reports in the United States involved transmission from a cardiac surgeon to at least three patients. According to the CDC, the genetic match was “almost perfect” between the surgeon and the patients. The CDC further indicated that such transmissions are “exceedingly rare.”
82. What are the guidelines for postexposure management for occupational exposure to bloodborne pathogens?
In June 2001, the CDC updated and revised recommendations for HIV (2013) and the guidelines for HIV postexposure management (PEM) to occupational bloodborne exposures to reflect new information and considerations. This document also consolidated recommendations for post-exposure prophylaxis (PEP) for HBV and follow-up monitoring guidance for HCV.
Since 1998, the FDA has approved new antiretroviral (ARV) agents, and more is known of the safety and efficacy of PEP. In light of the newer classes of drugs and new drugs within classes, the CDC updated their guidelines in 2005 to discuss other PEM options. There was also concern over increased resistance, as well as when not to use PEP, such as for low-risk exposures. In 2013, the Society for Healthcare Epidemiology of America (SHEA) issued updated USPHS guidelines for the treatment of occupational exposures to HIV including recommendations for post-exposure prophylaxis (PEP). This updates all previous guidelines, but the principles of management remain the same. In December of 2013, CDC published updated guidance for Hepatitis B post exposure management, CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management.
83. What is included in their summary of recommendations?
• PEP is recommended when occupational exposures to HIV occur.
• The source patient status should be determined, when possible.
• PEP regimens should include three or more ARV drugs.
• There are situations for which expert consultation is indicated.
• Follow-up should include counseling, baseline testing, and monitoring for drug toxicity and begin at 72 hours postexposure. This is especially important if additional information becomes known about the source patient.
• The use of the newer fourth-generation combination HIV–p24 antibody test allows for testing to be concluded at 4 months, rather than 6 months.
84. What factors are associated with an increased risk of HIV transmission after a percutaneous injury?
The risk for HIV infection after an exposure to blood known to be infected with HIV is increased if the exposure is to a larger quantity from the source, as indicated by either or both of the following:
1. Visible blood on the device
2. A procedure that involved a needle being directly placed into a vein or artery
Risk is also increased if the source has terminal illness, possibly meaning a higher titer of virus in the blood. Studies have demonstrated that more blood is transferred if the injury is deep and if hollow bore needles are used.
85. What is the rationale for HIV PEP?
The rationale behind the use of PEP is based on the concept that infection can be prevented or ameliorated by the use of ARVs. There are indications that if ARVs are given early, the pathogenesis may be affected because systemic infection does not occur immediately. There is a window of opportunity during which ARVs may modify or prevent replication. There is also evidence from human and animal studies that specific agents may work if used appropriately. In addition, retrospective studies of exposed health care workers demonstrated that the use of zidovudine (ZDV; Retrovir) after an occupational exposure was associated with an 81% reduction in risk of seroconversion. Early treatment is most effective; therefore, an occupational exposure to HIV is an urgent medical concern.
86. What is the primary recommendation from SHEA for PEP after an HIV exposure?
Of primary importance is that the regimen can be tolerated, which eliminates the need to determine the number of drugs; it also expands the possible range of the regimen of ARVs to consider. Furthermore, monitoring the exposed worker for toxicity allows for earlier treatment of side effects or modification in the regimen.
87. What ARVs are FDA-approved and appropriate for HIV PEP under the new guidelines?
Currently, there are six classes of ARVs approved to treat HIV infection. The choice of an ARV from these classes is based on the knowledge of HIV infection and on which are most appropriate for PEP, with considerations for tolerability, toxicity, and source experience. It is important to note again that regardless of the regimen, the duration of PEP is 4 weeks.
88. What is the most frequently recommended PEP regimen in the new guidelines?
The USPHS now recommends emtricitabine (FTC) plus tenofovir, which can be taken as a combination (Truvada). Raltegravir (RAL) should be the other agent in the regimen, thereby constituting a three-drug regimen. Again, a qualified health care provider (QHP) would make the decision of what to offer as PEP. There are alternatives available that a QHP might recommend.
89. Have adverse effects been reported about the use of ARVs?
Studies indicate that about 50% of health care workers report some adverse symptoms, such as nausea, malaise, and headache, and about 33% discontinue use because of adverse symptoms. This consideration is important in designing a regimen that can be tolerable. More serious side effects have been reported, but are rare. The new guidelines emphasize the importance of a regimen that can be adhered to, and tolerability is one aspect. It is critical that the full 4-week course be completed.
90. What is the concern about resistance?
Resistance remains a concern in the use of ARVs because of source information about resistance or the potential resistance or cross-resistance associated with one or more of the agents used for PEP. There are tests for resistance, as well as more choices for ARVs. Drug resistance is among those issues for which expert consultation is advised. PEP should not be delayed if this consultation is not immediately available because the regimen may be modified if new information becomes available.
91. For what other situations with PEP is expert consultation indicated?
Pregnancy and breast-feeding are situations for which expert consultation is indicated. However, the decision to offer PEP should be the same as for anyone experiencing an occupational exposure, because HIV transmission is a risk to the mother and fetus. A qualified health care provider should seek expert consultation for ARV selection and monitoring
92. In what other situations is expert consultation advised?
Expert consultation is advised if there is a delay in medical follow-up (later than 24 to 36 hours after exposure), if the source is unknown and the injury is significant, if resistance is known or suspected to the recommended drug regimen, and if toxicity or adverse symptoms occur.
93. How long must PEP be taken?
The current recommendation is a 4-week regimen.
94. Do ARVs prevent occupational infection?
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