Blood Borne Blood Borne PathogenesPathogenes

“BBP “ “BBP “

Blood Borne Pathogens & Blood Borne Pathogens & DiseasesDiseases

Blood BorneBlood Borne = = Found in BloodFound in Blood

PathogenPathogen = = Disease-Producing Disease-Producing Microorganism.Microorganism.

Protecting yourself & Your Patients Protecting yourself & Your Patients from blood and other body fluids is from blood and other body fluids is

essentialessential

Blood Borne DiseasesBlood Borne Diseases

Hepatitis BHepatitis B

Hepatitis CHepatitis C

HIV ( AIDS )HIV ( AIDS )

Standard (Universal) Standard (Universal) PrecautionsPrecautions

CDC recommendation: Blood and/or CDC recommendation: Blood and/or body fluid precautions should be body fluid precautions should be observed for all patientsobserved for all patients

Individualized guidelines set up for Individualized guidelines set up for specific settingsspecific settings

HospitalHospital

DentistDentist

Day Care/SchoolDay Care/School

Hepatitis BHepatitis B Incubation: 42-160 daysIncubation: 42-160 days TransmissionTransmission

Hepatitis B virusHepatitis B virus Blood borneBlood borne

blood, saliva (tattooing, acupuncture, razors, toothbrushes)blood, saliva (tattooing, acupuncture, razors, toothbrushes) SexualSexual

semen, vaginal fluidssemen, vaginal fluids PerinatalPerinatal

High risk populationsHigh risk populations HemophiliacsHemophiliacs Dialysis patientsDialysis patients IV drug abusersIV drug abusers Health care personnelHealth care personnel Infants of infected mothersInfants of infected mothers

Can survive as dried, visible blood for > 7 daysCan survive as dried, visible blood for > 7 days Chronic carrier state existsChronic carrier state exists

5-10% of infected become asymptomatic carriers5-10% of infected become asymptomatic carriers

Hepatitis BHepatitis B About 30% of persons have no signs or

symptoms Symptoms & SignsSymptoms & Signs

Within 2-3 months, gradually develop non-specific Within 2-3 months, gradually develop non-specific SxSx

AnorexiaAnorexia N/V, FeverN/V, Fever Abdominal discomfortAbdominal discomfort Joint pain, FatigueJoint pain, Fatigue Generalized rashesGeneralized rashes Dark urine, clay-colored stoolDark urine, clay-colored stool May progress to jaundiceMay progress to jaundice

Treatment & Preventive careTreatment & Preventive care Supportive careSupportive care Prevention: BSI and HandwashingPrevention: BSI and Handwashing Vaccine availableVaccine available

Protective immunity develops if HBs antibody is present in Protective immunity develops if HBs antibody is present in serumserum

Provide long lasting immunity, 95-98% of timeProvide long lasting immunity, 95-98% of time

HEPATITIS B HEPATITIS B VACCINATIONVACCINATION

Effective in preventing hepatitis BEffective in preventing hepatitis B 95% develop immunity95% develop immunity

3-dose vaccination series (0-1-6 months )3-dose vaccination series (0-1-6 months ) May be given to Pregnant ptsMay be given to Pregnant pts Test for Antibodies to HBsAg 1 to 2 months Test for Antibodies to HBsAg 1 to 2 months

after 3-dose vaccination series completed.after 3-dose vaccination series completed. Re-vaccinate who do not develop adequate Re-vaccinate who do not develop adequate

antibody response.antibody response. HBIG + vaccine (exposed is HBsAg HBIG + vaccine (exposed is HBsAg

negative)negative) Blood exposure to pt w/acute Hep BBlood exposure to pt w/acute Hep B

Postexposure prophylaxis against HBV infection

   Previously VaccinatedPreviously Vaccinated UnvaccinatedUnvaccinated

   KnownKnownRespondersResponders

Known Hypo/Known Hypo/Non-Non-

respondersresponders

UnknownUnknownResponseResponse

HBsAg -ve AND HBsAg -ve AND anti-HBs -veanti-HBs -ve

HBsAg +ve OR HBsAg +ve OR anti-HBs +veanti-HBs +ve

I. SOURCE I. SOURCE KNOWNKNOWN               

(a) HBsAg + ve(a) HBsAg + ve N/AN/A

HBIG within 24 HBIG within 24 hourshours

repeat after 1 repeat after 1 monthmonth

Dependent on Dependent on anti-HBs* status anti-HBs* status of exposed of exposed personperson

HBIG + HB VacHBIG + HB Vac N/AN/A

(b) HBsAg - ve(b) HBsAg - ve N/AN/A N/AN/A N/AN/A HB VacHB Vac N/AN/A

(c) HBsAg (c) HBsAg unknownunknown N/AN/A

Dependent on Dependent on source HBsAg source HBsAg

status status

Dependent on Dependent on anti-HBs* status anti-HBs* status

of exposed of exposed person person

HBIG + HB Vac, HBIG + HB Vac, or or

HB Vac; HB Vac; depending ondepending onsource HBsAg source HBsAg

statusstatus

N/AN/A

II. SOURCE II. SOURCE UNKNOWNUNKNOWN N/AN/A as in I(a)as in I(a) as in I(a)as in I(a) as in I(a)as in I(a) N/AN/A

HBV - SUMMARYHBV - SUMMARYTransmissionTransmission

OralOral Not likely Not likelyPercutaneousPercutaneous Common CommonSexualSexual Common CommonPerinatalPerinatal Common Common

Incubation periodIncubation period 60-180 60-180(days)(days)

Clinical Illness atClinical Illness at 10 - 15% 10 - 15%presentationpresentation

JaundiceJaundice 5 –20% 5 –20%

FulminantFulminant <1% <1%Diagnostic testsDiagnostic tests

Acute infectionAcute infection HBsAg, IgM anti-HBc HBsAg, IgM anti-HBcChronic infectionChronic infection HBsAg, IgG anti-HBc HBsAg, IgG anti-HBc

ImmunityImmunity IgG anti-HBc, anti-HBs IgG anti-HBc, anti-HBsCase-fatality rate Case-fatality rate 1 – 3% 1 – 3%

Chronic infection >90% infantsChronic infection >90% infants <5% adults<5% adults

Hepatitis D (Delta Virus)Hepatitis D (Delta Virus) Defective, requires HBV presence to replicateDefective, requires HBV presence to replicate

Acquired as HBV coinfection or chronic HBV superinfectionAcquired as HBV coinfection or chronic HBV superinfection Increases disease severity, fulminant hepatitis risk Increases disease severity, fulminant hepatitis risk

(2 to 20%)(2 to 20%) Increases chronic liver disease risk (70 to 80%)Increases chronic liver disease risk (70 to 80%)

When virus becomes active with HBV, resulting disease When virus becomes active with HBV, resulting disease extremely pathogenicextremely pathogenic

Transmission similar to HBVTransmission similar to HBV Most cases transmitted percutaneouslyMost cases transmitted percutaneously Coinfection can be prevented by HBV vaccineCoinfection can be prevented by HBV vaccine No products exist to prevent superinfectionsNo products exist to prevent superinfections

Symptoms & SignsSymptoms & Signs abrupt onset with Sx/Sx like HBV infectionabrupt onset with Sx/Sx like HBV infection always associated with HBV infectionalways associated with HBV infection

Treatment and Prevention similar to HBVTreatment and Prevention similar to HBV HBV vaccine indirectly prevents HDVHBV vaccine indirectly prevents HDV

HDV - SUMMARYHDV - SUMMARYTransmissionTransmission

OralOral No NoPercutaneousPercutaneous Common CommonSexualSexual Yes, rare Yes, rarePerinatalPerinatal No No

Incubation period Incubation period 21 - 45 21 - 45(days)(days)

Clinical Illness atClinical Illness at 10%, higher with 10%, higher with presentationpresentation Superinfection Superinfection

JaundiceJaundice Unknown Unknown

FulminantFulminant 2 – 7.5% 2 – 7.5%Diagnostic testsDiagnostic tests

Acute infectionAcute infection IgM anti-HDV IgM anti-HDVChronic infectionChronic infection IgG anti-HDV, HBsAg + IgG anti-HDV, HBsAg +

ImmunityImmunity Not applicable Not applicableCase-fatality rateCase-fatality rate 1 – 2% 1 – 2%Chronic infectionChronic infection Superinfection – 80%Superinfection – 80%

Coinfection < 5%Coinfection < 5%

12

Hepatitis CHepatitis CHepatitis C is the major cause of liver cancer

No immunization availableNo immunization available

Can live in a drop of dried blood for as long as 30 days-Can live in a drop of dried blood for as long as 30 days-HIV lives outside the body for only a few secondsHIV lives outside the body for only a few seconds

Develops into a chronic infection in 85% of all infected Develops into a chronic infection in 85% of all infected personspersons

Chronic liver diseases in 70 %Chronic liver diseases in 70 %

HCV related deaths will most likely double or triple in the HCV related deaths will most likely double or triple in the next 10-20 years.next 10-20 years.

Many with chronic disease are now in the 40-65 age Many with chronic disease are now in the 40-65 age range.range.

Hepatitis CHepatitis C TransmissionTransmission

Hepatitis C virusHepatitis C virus Primarily bloodbornePrimarily bloodborne Also sexual, perinatalAlso sexual, perinatal

High risk populationsHigh risk populations IV drug abusersIV drug abusers Dialysis patientsDialysis patients Health care personnel Health care personnel Clotting factors before 1987Clotting factors before 1987 Transfusion before 1982Transfusion before 1982

Occupational Transmission Occupational Transmission of HCVof HCV

Inefficient by occupational exposuresInefficient by occupational exposures Incidence <0.5%-2% following needle Incidence <0.5%-2% following needle

stick from HCV-positive source stick from HCV-positive source Associated with hollow-bore needles, deep Associated with hollow-bore needles, deep

injuryinjury Case reports of transmission from blood Case reports of transmission from blood

splash to eye; one from exposure to non-splash to eye; one from exposure to non-intact skinintact skin

Prevalence 1-2% among health care Prevalence 1-2% among health care workers workers Lower than adults in the general populationLower than adults in the general population 10 times lower than for HBV infection10 times lower than for HBV infection

Global Differences in HCV Transmission Patterns

Exposures amongprevalent infections Low Moderate High

Contribution of exposures to disease burden by HCV prevalence

Injecting drug use ++++ ++ +Transfusions before testing - +/- +++Unscreened transfusions - - +++Unsafe therapeutic injections + ++++ ++++Occupational + + +Perinatal + + +High-risk sex ++ + +/-

Hepatitis CHepatitis C Symptoms & SignsSymptoms & Signs

Same as Hepatitis B, less progression to jaundiceSame as Hepatitis B, less progression to jaundice Possible association of Hepatitis C infection with Possible association of Hepatitis C infection with

liver cancerliver cancer Degree of post infection immunity unknownDegree of post infection immunity unknown High percentage of infected become carriersHigh percentage of infected become carriers Treatment & Preventive CareTreatment & Preventive Care

Interferone & RibavirinInterferone & Ribavirin No recognized benefit from prophylactic IgGNo recognized benefit from prophylactic IgG No Vaccine available yetNo Vaccine available yet Standard precautions Standard precautions

17

Recommendation for HCVRecommendation for HCV

If you have an exposure history: Get tested.If you have an exposure history: Get tested.

If you have any of these risk factors: Get If you have any of these risk factors: Get tested. tested. Injection drug useInjection drug use Blood transfusion before 1982Blood transfusion before 1982 Use of blood clotting components before 1987Use of blood clotting components before 1987 Tatoos/piercings with questionable sterile Tatoos/piercings with questionable sterile

techniquetechnique Occupational exposure to bloodOccupational exposure to blood Sexual contact with an infected partner (risk Sexual contact with an infected partner (risk

less)less)

Postexposure Management Postexposure Management for HCVfor HCV

IG, Antivirals not recommended for IG, Antivirals not recommended for prophylaxisprophylaxis

Follow-up after needlesticks, sharps, or Follow-up after needlesticks, sharps, or mucosal exposures to HCV-positive bloodmucosal exposures to HCV-positive blood Test source for anti-HCV Test source for anti-HCV Test worker if source anti-HCV positiveTest worker if source anti-HCV positive

Anti-HCV and ALT at baseline and 4-6 months Anti-HCV and ALT at baseline and 4-6 months laterlater

For earlier diagnosis, HCV RNA at 4-6 weeksFor earlier diagnosis, HCV RNA at 4-6 weeks Confirm all anti-HCV results with RIBAConfirm all anti-HCV results with RIBA

Refer infected worker to specialist for Refer infected worker to specialist for medical evaluation and managementmedical evaluation and management

19

Hepatitis C:Hepatitis C:The Course of the DiseaseThe Course of the Disease

Acute infection= rarely recognizedAcute infection= rarely recognized Acute stage=flu-like symptoms or no Acute stage=flu-like symptoms or no

symptomssymptoms Evolution from acute phase to cirrhosis Evolution from acute phase to cirrhosis

usually requires decades: average time usually requires decades: average time is 20-30 years is 20-30 years

When disease discovered, damage to When disease discovered, damage to the liver has most likely occurred.the liver has most likely occurred.

HCV - SUMMARYHCV - SUMMARYTransmissionTransmission

OralOral No NoPercutaneousPercutaneous Common CommonSexualSexual Yes, rare Yes, rarePerinatalPerinatal Yes, low frequency Yes, low frequency

Incubation periodIncubation period 14 - 160 14 - 160(days)(days)

Clinical Illness atClinical Illness at 5 - 10% 5 - 10%presentationpresentation

JaundiceJaundice 5 – 10% 5 – 10%

FulminantFulminant Rare Rare

Diagnostic testsDiagnostic testsAcute infectionAcute infection HCV RNA (anti-HCV) HCV RNA (anti-HCV)Chronic infectionChronic infection HCV RNA (anti-HCV), >6 months HCV RNA (anti-HCV), >6 months

ImmunityImmunity Unknown UnknownCase-fatality rateCase-fatality rate 1 – 2% 1 – 2%

Chronic infectionChronic infection 55 – 85%55 – 85%

Human Immunodeficiency Human Immunodeficiency VirusVirus

Kills TKills T44 lymphocytes lymphocytes Interferes with immune system functionInterferes with immune system function Produces acquired immunodeficiency syndrome Produces acquired immunodeficiency syndrome

(AIDS)(AIDS) Virus present in all body fluids, all body tissuesVirus present in all body fluids, all body tissues Virus spread by:Virus spread by:

BloodBlood SemenSemen Vaginal fluidVaginal fluid Breast milkBreast milk Other body fluids containing bloodOther body fluids containing blood

Health care workers may be at risk from CSF, Health care workers may be at risk from CSF, synovial fluid, and amniotic fluidsynovial fluid, and amniotic fluid

HIVHIV Epidemiology (worldwide)Epidemiology (worldwide)

2.8 million deaths worldwide in 19992.8 million deaths worldwide in 1999 18.8 million cumulative deaths18.8 million cumulative deaths

80% of cases have 80% of cases have resulted from resulted from heterosexual heterosexual intercourseintercourseAIDS is the 5th leading cause AIDS is the 5th leading cause

of deaths in the U.S. for people of deaths in the U.S. for people ages 24 to 44ages 24 to 44

HIGH HIGH CONCENTRATIONCONCENTRATION

Contains sufficient Contains sufficient amount of virus to infectamount of virus to infect

LOW LOW CONCENTRATIONCONCENTRATIONHIV is present in HIV is present in negligible quantities negligible quantities (no possibility of (no possibility of infection)infection)

CONTAINS CONTAINS NO VIRUS NO VIRUS

AT ALLAT ALL

1.1.Blood and blood Blood and blood productsproducts2.2.SemenSemen3.3.Vaginal and cervical Vaginal and cervical secretionssecretions4.4.Breast milkBreast milk5.5.Amniotic fluidAmniotic fluid6.6.Synovial fluid Synovial fluid

1.1.Saliva ( only found in Saliva ( only found in minute amounts in a minute amounts in a very small number of very small number of people)people)2.2.TearsTears3.3.Blister fluidsBlister fluids

1.1.Urine Urine 2.2.FaecesFaeces3.3.VomitusVomitus4.4.SweatSweat

Risk of Contracting Risk of Contracting InfectionInfection

Dependent onDependent on Viral loadViral load Integrity of the exposed siteIntegrity of the exposed site Type of body fluidType of body fluid Volume of body fluidVolume of body fluid

Risk after a single exposureRisk after a single exposure TRANSFUSION- 3-5%TRANSFUSION- 3-5% 5 10 % vertical5 10 % vertical 0.5-1% injection drug use0.5-1% injection drug use 0.2-0.5% genital mucous membrane0.2-0.5% genital mucous membrane <0.1% non-genital mucous membrane<0.1% non-genital mucous membrane HEALTH CARE WORKERS- <0.01%HEALTH CARE WORKERS- <0.01%

BREASTMILK

VAGINALSECRETION

SBLOOD

SEMEN

CERVICALSECRETION

S

2. Through these acts:

H

INFECTED MOTHER:DURING1. PREGNANCY2. BIRTH3. BREAST FEEDING

UNPROTECTED PENETRATIVE INTERCOURSE (HOMOSEXUAL OR HETEROSEXUAL) WITH SOMEONE WHO IS INFECTED

1. INJECTION OR TRANSFUSION OR INFECTED BLOOD / BLOOD PRODUCTS2. SHARING UNSTERALISED NEEDLES WITH SOMEONE WHO IS INFECTED

1. Through these bodily fluids

Modes of HIV/AIDS Transmission

AIDSAIDS Asymptomatic infection (1 to 10 years)Asymptomatic infection (1 to 10 years) About 50% of HIV-infected patients develop About 50% of HIV-infected patients develop

true AIDS within 10 yearstrue AIDS within 10 years Acute InfectionAcute Infection

Lasts 2 to 4 weeksLasts 2 to 4 weeks SymptomsSymptoms

FeverFever Sore throatSore throat LymphadenopathyLymphadenopathy

Seroconversion Seroconversion Occurs at 6 to 12 weeksOccurs at 6 to 12 weeks

AIDSAIDS AIDS - related complex (ARC)AIDS - related complex (ARC)

Weight loss > 10%Weight loss > 10% Diarrhea for >1 month Diarrhea for >1 month Fever Fever Night sweatsNight sweats

True AIDS = Life-threatening True AIDS = Life-threatening opportunistic infectionsopportunistic infections Pneumocystis cariniPneumocystis carini Candida albicansCandida albicans Cytomegalovirus (CMV)Cytomegalovirus (CMV) Kaposi’s sarcomaKaposi’s sarcoma

AIDSAIDS Pneumocystis cariniPneumocystis carini

Most common life-Most common life-threatening opportunistic threatening opportunistic infectioninfection

PneumoniaPneumonia Often leads to AIDS Often leads to AIDS

diagnosisdiagnosis Candida albicansCandida albicans

Yeast infectionYeast infection Called “thrush” in infantsCalled “thrush” in infants Can disseminate to GI tract, Can disseminate to GI tract,

bloodstreambloodstream Cytomegalovirus (CMV)Cytomegalovirus (CMV)

Retinitis, blindnessRetinitis, blindness ColitisColitis PneumonitisPneumonitis

AIDSAIDS

Kaposi’s sarcomaKaposi’s sarcoma Purple-brown, painless Purple-brown, painless

lesionslesions May enlarge, coalesce, May enlarge, coalesce,

bleedbleed Can affect internal Can affect internal

organsorgans

AIDSAIDS

FungiFungi AspergillosisAspergillosis

pulmonary infectionpulmonary infection CryptococcusCryptococcus

meningitis, pulmonary meningitis, pulmonary infection, infection, disseminated infectiondisseminated infection

HistoplasmaHistoplasma disseminated infectiondisseminated infection

CoccidiomycesCoccidiomyces disseminated infectiondisseminated infection

VirusesViruses Herpes simplex skin Herpes simplex skin

and visceraland visceral Herpes zoster skin, Herpes zoster skin,

ophthalmic nerve, ophthalmic nerve, disseminated, disseminated, visceralvisceral

JC virus progressive JC virus progressive multifocal multifocal leukoencephalopathleukoencephalopathyy

AIDSAIDS

ParasitesParasites ToxoplasmaToxoplasma

encephalitisencephalitis CryptosporidiaCryptosporidia IsosporaIsospora MicrosporaMicrospora GiardiaGiardia

BacteriaBacteria Streptococcus Streptococcus

pneumoniapneumonia Hemophilus influenzaHemophilus influenza Nocarida asteroidesNocarida asteroides Pseudomonas Pseudomonas

aeruginosaaeruginosa Rhodococcus equiRhodococcus equi Bartonella hanselaeBartonella hanselae SalmonellaSalmonella Staphylococcus aureusStaphylococcus aureus Treponema pallidumTreponema pallidum

AIDSAIDS MycobacteriaMycobacteria

Mycobacterium Mycobacterium tuberculosistuberculosis

M. aviumM. avium M. kansasiiM. kansasii M. haemophilumM. haemophilum M. gordonaeM. gordonae M. genavenseM. genavense M. xenopiM. xenopi M. fortuitumM. fortuitum M. malmoneseM. malmonese M.cheloneiM.chelonei

AIDSAIDS

AIDS Dementia ComplexAIDS Dementia Complex Infection of CNS cells Infection of CNS cells Cerebral atrophyCerebral atrophy Characterized by:Characterized by:

Cognitive dysfunctionCognitive dysfunction Declining motor performanceDeclining motor performance Behavioral changesBehavioral changes

AIDSAIDS SafetySafety

Wash hands between patientsWash hands between patients Clean blood spills with bleach solutionClean blood spills with bleach solution All sharp objects potentially infectiveAll sharp objects potentially infective Do Do NOTNOT recap needles recap needles Wear mask to avoid exposing patientWear mask to avoid exposing patient Pregnant paramedics should avoid contact with Pregnant paramedics should avoid contact with

AIDS patients (risk of CMV exposure)AIDS patients (risk of CMV exposure)

AIDSAIDS TreatmentTreatment

Support careSupport care No immunization availableNo immunization available Post Exposure Prophylactic treatmentPost Exposure Prophylactic treatment

Recommended within 3 hours of significant exposureRecommended within 3 hours of significant exposure CDC recommendationsCDC recommendations

zidovudinezidovudine lamivudinelamivudine indinavirindinavir nelfinavirnelfinavir

36

HIVHIV

Less than 1% seroconversion rate Less than 1% seroconversion rate for health care professionals if for health care professionals if exposed to a exposed to a know HIV positive know HIV positive source.source.

37

Why is Privacy Important?Why is Privacy Important?

Patients have a right to privacyPatients have a right to privacy

Violation of patient’s privacy Violation of patient’s privacy (confidentiality) can affect the (confidentiality) can affect the personal lives and careers of personal lives and careers of patientspatients

It is your job to protect patient It is your job to protect patient privacyprivacy

38

Potentially Harmful Body Fluids with Potentially Harmful Body Fluids with

Universal/Standard PrecautionsUniversal/Standard Precautions

BloodBlood SemenSemen

Vaginal Secretions Vaginal Secretions Pleural Pleural FluidFluid

Cerebrospinal Fluid Synovial Cerebrospinal Fluid Synovial FluidFluid

Synovial FluidSynovial Fluid Pleural Fluid Pleural Fluid

Peritoneal FluidPeritoneal Fluid Pericardial Fluid Pericardial Fluid

Amniotic fluidAmniotic fluid

39

Fluids to Which Universal/Standard Fluids to Which Universal/Standard PrecautionsPrecautions Do Not Apply Unless Do Not Apply Unless

Blood is VisibleBlood is Visible

FecesFeces Nasal secretionsNasal secretions SputumSputum SweatSweat TearsTears VomitusVomitus

UrineUrine Saliva-except inSaliva-except in dental situations*dental situations* Breast milk*Breast milk* *only in large *only in large

quantities (breast quantities (breast milk bank or dental milk bank or dental work)work)

High ModerateLow/NotDetectable

Blood Semen UrineSerum Vaginal fluid Feces

Wound exudates Saliva Sweat

TearsBreast milk

Concentration of Hepatitis B Virus in

Various Body Fluids

Relative Efficiency of HBV, Relative Efficiency of HBV, HCV, HIV Transmission by HCV, HIV Transmission by

Type of ExposureType of ExposureType of exposure Efficiency of transmissionto infected source HBV HCV HIV

Transfusion ++++ ++++ ++++Injecting drug use ++++ ++++ ++++Unsafe injections +++ +++ +Needlestick +++ + <+Sexual +++ + +++Perinatal ++++ ++ +++Non-intact skin ++ +/- +/-Intact skin - - -

Relative Infectivity of HBV, Relative Infectivity of HBV, HCV, HIVHCV, HIV

HBV HCV HIV

Copies/mL 108-9 105 103

Environmental stability ++++ ++ -Infectious after dryingat room temperature >7 days >16

h 0

HCV HCV NOTNOT EASILY TRANSMITTED EASILY TRANSMITTED IN HEALTH CARE SETTINGIN HEALTH CARE SETTING

POTENTIAL TRANSMISSION RISK TO HEALTH CARE WORKERS POTENTIAL TRANSMISSION RISK TO HEALTH CARE WORKERS CONC/ml TRANSMISSION RATE (%)CONC/ml TRANSMISSION RATE (%) PATHOGENPATHOGEN SERUM/PLASMASERUM/PLASMA POST NEEDLESTICK INJURYPOST NEEDLESTICK INJURY

HBV 1000 - 100,000,000 6.0 - 30.0 HBV 1000 - 100,000,000 6.0 - 30.0 HCV 10 - 1,000,000 2.7 - 6.0HCV 10 - 1,000,000 2.7 - 6.0

HIV 10 - 1000 0.31HIV 10 - 1000 0.31

Average Risk of Average Risk of Transmission after Transmission after

Percutaneous InjuryPercutaneous Injury

HIVHepatitis CHepatitis B (only HBeAg+)

Risk (%)

0.31.830.0

Source

PREVENTION STRATEGY -PREVENTION STRATEGY - HBV, HCV, HDV HBV, HCV, HDV

CLEAN BLOOD SPILLS WITH CLEAN BLOOD SPILLS WITH BLEACHBLEACH

DON’T SHARE RAZORS, DON’T SHARE RAZORS, TOOTHBRUSHES, NAIL CLIPPERS or TOOTHBRUSHES, NAIL CLIPPERS or NEEDLESNEEDLES

WHEN GETTING A MANICURE, TATTOO, WHEN GETTING A MANICURE, TATTOO, or HAVING A BODY PART PIERCED, MAKE or HAVING A BODY PART PIERCED, MAKE SURE THE INSTRUMENTS ARE STERILESURE THE INSTRUMENTS ARE STERILE

46

Standard PrecautionsStandard Precautions

A set of precautions designed to prevent A set of precautions designed to prevent transmission of HIV, HBV, and other transmission of HIV, HBV, and other blood borne pathogens blood borne pathogens

Blood and certain body fluids of all Blood and certain body fluids of all patients are considered potentially patients are considered potentially infectiousinfectious

Universal precautions are actually Universal precautions are actually a part a part ofof what is now referred to as Standard what is now referred to as Standard PrecautionsPrecautions..

47

Protect YourselfProtect Yourself GlovesGloves GownGown ApronApron MasksMasks Hand washingHand washing Safety precautions Safety precautions

with sharpswith sharps Eye shieldsEye shields

AA“ Infectious”

“ Serum”

Viral hepatitis

Entericallytransmitted

ParenterallytransmittedF, G,

TTV? other

EE

NANBNANB

BB DD CC

Viral Hepatitis - Historical Perspectives

Viral HepatitisViral Hepatitis

NoneNoneInterferon Interferon ++

InterferonInterferon

RibavirinRibavirinIFNIFN

LamivudineLamivudine NONENONETherapyTherapy

NONENONEHBV HBV vaccinevaccine

NONENONEImmune globulinImmune globulin

Recombinan vaccRecombinan vaccImmune Immune globulinglobulin

Inactivated vaccInactivated vacc

ProphylaxisProphylaxis

++++++HCCancerHCCancer

1 – 2%1 – 2%

NoneNone5 – 20 %5 – 20 %

CommonCommon

0.1 %0.1 %

Infect 80-90%Infect 80-90%

Hepatitis –Hepatitis –70%70%

0.1 – 1 %0.1 – 1 %

Neonates Neonates 90%90%

Adults 1-10%Adults 1-10%

0.1 %0.1 %

NoneNone

ClinicalClinical FulminantFulminant

Progression Progression toto

chronicitychronicity

Fecal - oralFecal - oral++++++

++

++++

++++++

variablevariable

++

Parenteral +Parenteral +++++

Perinatal +Perinatal +++++

Sexual ++Sexual ++

Fecal – oralFecal – oralTransmissioTransmissionn

AcuteAcuteAcute / Acute / insidiousinsidious

InsidiousInsidiousAcute / Acute / insidiousinsidious

AcuteAcuteOnsetOnset

    6 weeks6 weeks4 – 12 weeks4 – 12 weeks7 weeks7 weeks 4 – 12 weeks4 – 12 weeks    4 weeks4 weeksIncubationIncubation

HEVHEVHDVHDVHCVHCVHBVHBV    HAVHAV

Viral Hepatitis Viral Hepatitis B & C B & C B and C B and C transmit by blood and blood products transmit by blood and blood products

MMethodsethods MM other to child at birth other to child at birth SSexex IVDUIVDU SS ame razor, tooth brush, tattoo etc. ame razor, tooth brush, tattoo etc.

Differences between Differences between B B & & CC B B - - TT ransmitted mainly (90%) from mother at birth ransmitted mainly (90%) from mother at birth C C - - TT ransmitted < 8% from mother at birth ransmitted < 8% from mother at birth BB - - TT ransmitted more sexually ransmitted more sexually CC - - TT ransmitted less sexually ransmitted less sexually CC - and B - and B TT ransmitted by IVDU ransmitted by IVDU

Sequele of Sequele of AA cute cute VV iral iral HHeepatitispatitis

Acute V iral Hepatitis

UncomplicatedHepatitis

FulminantHepatitis

ProlongedHepatitis

ChronicHepatitis

Cholestatic

Acute vs. Chronic Viral Hepatitis

AcuteAcute ChronicChronic

DurationDuration < 6 months< 6 months > 6 months> 6 months

OutcomeOutcome Spontaneous Spontaneous resolutionresolution

Unlikely to Unlikely to clear on its clear on its

ownown

Permanent Permanent Liver Liver DamageDamage

NoneNone LikelyLikely

Progression of Chronic Hepatitis

Chronic HepatitisChronic Hepatitis

FibrosisFibrosis

CirrhosisCirrhosis

Liver Failure or Liver CancerLiver Failure or Liver Cancer

HepatitisHepatitis Acute Hepatitis Acute Hepatitis 6: < months 6: < months Chronic Hepatitis Chronic Hepatitis mmmmmm: > 6 mmmmmm: > 6 CirrhosisCirrhosis

mmmmmmmmmmmm mmmmmmmmm mmmmmmmmmm mm mmmmmmmm mmm mmmmmm: mmmmmmmmmmmm mmmmmmmmm mmmmmmmmmm mm mmmmmmmm mmm mmmmmm: rating nodule rating nodule

Cirrhosis from any cause can go on to Cirrhosis from any cause can go on to HH epatocellular epatocellular CCarcarcinomainoma

- Natural history of cirrhosis die from : - Natural history of cirrhosis die from :

13Bleeding varices ( / ) 13Bleeding varices ( / ) LLLLL LLLLLLLLLLLL LLLLLLL LLLLLLLLLLLLLLLL ( HCC ) ( HCC ) LLLLLLLLLLLLLLLLLL LLLLL LLLLLLLLLLLL LLLLLLL

SYMPTOMS&SIGNS OF VIRAL SYMPTOMS&SIGNS OF VIRAL HEPATITISHEPATITIS

Diagnosis of Diagnosis of AAcutecute VV iral iral HHeepatitispatitis

Etiology

Viral studyHAV AntiHAV IgM

HBV

HBsAg, AntiHBc IgM

HCV

AntiHCV, HCV RNA ? ?HDV Anti del ta IgMHEV AntiHEV IgM

ACUTE = IgM

LFT in Acute Viral HepatitisLFT in Acute Viral Hepatitis

- Transaminase - - 3100Level times - mmm mm mmmm> 1 0 0 - 1RatioAST/ ALT< - mmm: 10 % /- mmmmmmmm mmmmmmmmmmm - m mmm mm< 2

- Total bilirubin - - 253> . mg% : icteric - 20> mg% uncommon - 30> mg% rare - 50Decrease : % wk- Albumin : chr oni c and sever e- m m mmm m : mmm mm mmmmm , mm mmmmmmm

Alcoholic hepatitis AST < 500, AST/ ALT > 2

Acute viral hepatitis C transaminase not > 1,000

Treatment of Treatment of AA cute cute VV iral iral HHeepatitispatitis

- Evaluation- DDx: F irst acute hepatocellular by lab the

- n Viral study

- Specific therapy : no

- General measurements

- Prevention

General measurement General measurement s s 1( )1( ) Rest

- W ithin the limits of fatigability

- B ed rest : severely symptomatic

- Prolonged PT

- O lder than 40 years of age Diet - N o restriction - V itamin : Unnecessary - F luid and E lectrolyte if severe, continued vomiting

Treatment of Treatment of AA cute cute VV iral iral HHeepatitispatitis - Hospitalization

- LLLLLLLLLL LLLLLLLL LL LLL LLLLL- L LLLLLLLL LLLLLLLLLLLLL- L LLLLLL LLLL L LLLLLLLL

- rising bilirubin (with rapidly declining LLLLLLL LLL)

- prolonged PT - LLLLLLL LLLLL LL LLLLL

- LLL L LLL LLLL > 2 0 0 / 6 wks

- - feature of PHT eg. ascites Drugs - Avoid : alcohol, narcotics, analgesics, tranquilizers - Beware : paracetamol

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