hbv, hcv, and hiv in the dental office prevention and recommendations for post exposure prophylaxis...

8/6/2019 HBV, HCV, And HIV in the Dental Office Prevention and Recommendations for Post Exposure Prophylaxis (PEP)

1/71

11

Roseann Mulligan DDS, MSRoseann Mulligan DDS, MSUniversity of Southern CaliforniaUniversity of Southern California

Pacific AIDS Education and Training CenterPacific AIDS Education and Training Center

HBV, HCV, and HIV in theHBV, HCV, and HIV in the

Dental Office:Dental Office:Prevention and RecommendationsPrevention and Recommendations

forfor

Postexposure Prophylaxis (PEP)Postexposure Prophylaxis (PEP)


2/71


3/71

33

Preventing Transmission ofPreventing Transmission of

Bloodborne Viruses inBloodborne Viruses inHealthcare SettingsHealthcare Settings

Promote HB VaccinationsPromote HB Vaccinations Treat all patients as potentiallyTreat all patients as potentially

infectiousinfectious

Use barriers to prevent blood or bodyUse barriers to prevent blood or bodyfluid contactfluid contact

Prevent percutaneous injuriesPrevent percutaneous injuries


4/71

44

Annual Number ofAnnual Number ofPercutaneous Injuries*Percutaneous Injuries*

1987199319871993

1987 1988 1989 1990 1991 1992 19930

2

4

6

8

10

12 11.4

8.8

6.25.4

3.52.9

2.2

Num

ber

*ADA Health Screening, per dentist


5/71

55


6/71

66

Factors Influencing Risk ofFactors Influencing Risk of

Occupational ExposureOccupational Exposure

Consistent usage of engineeringConsistent usage of engineering

controlscontrols

Proper handling and disposal of sharpsProper handling and disposal of sharps Prevalence of infection among patientsPrevalence of infection among patients

Nature and frequency of exposureNature and frequency of exposure

Type of virusType of virus

Body fluid and level of infectivityBody fluid and level of infectivity


7/71

77

Prevalence of Bloodborne VirusPrevalence of Bloodborne Virus

Infection Varies in PatientInfection Varies in PatientPopulationsPopulations

GeographyGeography Patient risk behaviorsPatient risk behaviors

Type of care or living arrangementType of care or living arrangement

IncarcerationIncarceration Sex workerSex worker

IV Drug userIV Drug user


8/71

88

Question: The greatest risk ofQuestion: The greatest risk of

transmission of disease occurs:transmission of disease occurs:

A.A. From the dental healthcare worker toFrom the dental healthcare worker to

the patient.the patient.B.B. From the patient to the dentalFrom the patient to the dental

healthcare worker.healthcare worker.

C.C. From one patient to another patient.From one patient to another patient.D.D. All transmission routes have the sameAll transmission routes have the same

risk.risk.


9/71

99

Potential Routes ofPotential Routes of

Transmission of BloodborneTransmission of Bloodborne

PathogensPathogens

Patient DHCP

DHCP Patient

Patient Patient


10/71

1010

Transmission of HBV fromTransmission of HBV from

Infected Dentists to PatientsInfected Dentists to Patients Nine clusters of HBV transmissionNine clusters of HBV transmission

from infected dentists and oralfrom infected dentists and oralsurgeons to patients weresurgeons to patients weredocumented between 1970 1987documented between 1970 1987

Lack of documented transmissionsLack of documented transmissionssince 1987since 1987 may reflect increased use of glovesmay reflect increased use of gloves

and hepatitis B vaccinationand hepatitis B vaccination


11/71

1111

Estimated Incidence of HBV InfectionsEstimated Incidence of HBV Infections

Among HCW and General Population,Among HCW and General Population,

United States, 1985-1999United States, 1985-1999

0

50

100

150

200

250

300

350

1985 1987 1989 1991 1993 1995 1997 1999

Year

Incid

ence

per100,000

Health Care Workers

General U.S. Population


12/71

1212

Average Risk of Bloodborne VirusAverage Risk of Bloodborne Virus

Transmission after NeedlestickTransmission after Needlestick

Source Risk

HBVHBsAg+ and HBeAg+ 22 %-31 % clinical hepatitis;

37%-62% serological evidence ofHBV infection

HBsAg+ and HBeAg- 1%-6 % clinical hepatitis;

23% - 37% serological evidence ofHBV infection

HCV 1.8% (0%-7% range)

HIV 0.3% (0.2%-0.5% range)

DC http://www.cdc.gov/OralHealth/infectioncontrol/guidelines/ppt.htm


13/71

1313CDC http://www.cdc.gov/OralHealth/infectioncontrol/guidelines/ppt.htm


14/71

1414


15/71

1515

Characteristics ofCharacteristics of

Percutaneous Injuries AmongPercutaneous Injuries Among

DHCPDHCP Reported frequency among generalReported frequency among general

dentists has declineddentists has declined Caused by burs, syringe needles, otherCaused by burs, syringe needles, other

sharpssharps Occur outside the patients mouthOccur outside the patients mouth

Involve small amounts of bloodInvolve small amounts of blood Among oral surgeons, occur moreAmong oral surgeons, occur more

frequently during fracture reductions andfrequently during fracture reductions andprocedures involving wireprocedures involving wire


16/71

1616


17/71

1717


18/71

1818

Wound CareWound Care

Clean wounds withClean wounds withsoap and watersoap and water

Do not squeezeDo not squeeze Flush mucousFlush mucous

membranes with watermembranes with water Avoid use of bleachAvoid use of bleach

and other agentsand other agentscaustic to skincaustic to skin


19/71

1919


20/71

2020


21/71

2121


22/71

2222


23/71

2323


24/71

2424

Occupational Exposure to HBVOccupational Exposure to HBV


25/71

2525


26/71

2626


27/71

2727

Hepatitis B VaccineHepatitis B Vaccine

The vaccine consist of a series of 3 doses via IMThe vaccine consist of a series of 3 doses via IM

injection into the deltoid muscle of the arm.injection into the deltoid muscle of the arm.

Dose # 1 is time zeroDose # 1 is time zero

Dose # 2 given one month after dose #1Dose # 2 given one month after dose #1 Dose # 3 is given 6 months after dose #1Dose # 3 is given 6 months after dose #1

A QUANTITATIVE TITER IS DUE 30-60 DAYSA QUANTITATIVE TITER IS DUE 30-60 DAYS

AFTER THE LAST DOSEAFTER THE LAST DOSE


28/71

2828

Antibody (titer) level determines effectiveness.Antibody (titer) level determines effectiveness.

Titer level 10 or less - entire series needsTiter level 10 or less - entire series needs

repeating (all 3 doses)repeating (all 3 doses) After the second series, titer less than 10, theAfter the second series, titer less than 10, the

person is considered to be a primaryperson is considered to be a primary

nonrespondernonresponder

Nonresponder will need the HBIG if aNonresponder will need the HBIG if a

contaminated puncture/body fluid exposure.contaminated puncture/body fluid exposure.

Hepatitis BHepatitis B


29/71

2929


30/71

3030

Hepatitis D depends on Hepatitis B forHepatitis D depends on Hepatitis B for

propagation/transmission.propagation/transmission.

Hepatitis D infections usually injectionHepatitis D infections usually injection

drug users and hemophiliacsdrug users and hemophiliacs

Immunization with HBV vaccine confersImmunization with HBV vaccine confers

immunity to HDVimmunity to HDV

Hepatitis DHepatitis D


31/71

3131


32/71

3232


33/71

3333


34/71

3434


35/71

3535


36/71

3636

RecommendationsRecommendations

Hepatitis B VaccineHepatitis B Vaccine

Offer vaccination to all personnel who are atOffer vaccination to all personnel who are at

risk of exposure to bloodrisk of exposure to bloodProvide access to qualified health-careProvide access to qualified health-care

professional for administration and follow-upprofessional for administration and follow-up

testingtesting

No need for pre-vaccination testingNo need for pre-vaccination testingfor HBVfor HBV

antibodiesantibodies


37/71

3737

Immunizations for DentalImmunizations for Dental

Healthcare WorkersHealthcare Workers

Hepatitis B vaccineHepatitis B vaccine

must be offered at nomust be offered at no

charge to employeescharge to employeeswho may be exposedwho may be exposed

to body fluids withinto body fluids within

10 days of the10 days of the

potential initialpotential initialexposure. They doexposure. They do

have the right tohave the right to

refuse.refuse.

If the employeeIf the employee

refuses the vaccine,refuses the vaccine,

they must sign thethey must sign theOSHA BloodborneOSHA Bloodborne

Pathogens StandardPathogens Standard

(29 CFR 1910.1030)(29 CFR 1910.1030)

Hepatitis B VaccineHepatitis B VaccineDeclination form.Declination form.


38/71

3838

Hepatitis B Vaccine DeclinationHepatitis B Vaccine Declination

(Mandatory) - 1910.1030 App A(Mandatory) - 1910.1030 App AI understand that due to my occupational exposure to blood orI understand that due to my occupational exposure to blood orother potentially infectious materials I may be at risk ofother potentially infectious materials I may be at risk ofacquiring hepatitis B virus (HBV) infection. I have been givenacquiring hepatitis B virus (HBV) infection. I have been giventhe opportunity to be vaccinated with hepatitis B vaccine, at nothe opportunity to be vaccinated with hepatitis B vaccine, at nocharge to myself. However, I decline hepatitis B vaccination atcharge to myself. However, I decline hepatitis B vaccination at

this time. I understand that by declining this vaccine, I continuethis time. I understand that by declining this vaccine, I continueto be at risk of acquiring hepatitis B, a serious disease. If in theto be at risk of acquiring hepatitis B, a serious disease. If in thefuture I continue to have occupational exposure to blood orfuture I continue to have occupational exposure to blood orother potentially infectious materials and I want to beother potentially infectious materials and I want to bevaccinated with hepatitis B vaccine, I can receive thevaccinated with hepatitis B vaccine, I can receive the

vaccination series at no charge to me.vaccination series at no charge to me.

[56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717,[56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717,April 13, 1992; 57 FR 29206, July 1, 1992; 61 FR 5507, Feb.April 13, 1992; 57 FR 29206, July 1, 1992; 61 FR 5507, Feb.13, 1996]13, 1996]

http://www.osha.gov/pls/oshaweb/owadisp.show_documehttp://www.osha.gov/pls/oshaweb/owadisp.show_docume

nt?p_table=STANDARDS&p_id=10052nt?p_table=STANDARDS&p_id=10052


39/71

3939

Occupational Exposure to HCVOccupational Exposure to HCV


40/71

4040


41/71

4141

Hepatitis C - transmitted like HBV.Hepatitis C - transmitted like HBV. Chances of infection following an exposure 10Chances of infection following an exposure 10

times higher for HBVtimes higher for HBV

HCV - RNA virus with at least 6 differentHCV - RNA virus with at least 6 differentgenotypes and 90+ subtypes.genotypes and 90+ subtypes.

U.S. - Most common genotype is type 1 -U.S. - Most common genotype is type 1 -accounts for ~70% of Hepatitis C infectionsaccounts for ~70% of Hepatitis C infections

No vaccine available for Hepatitis CNo vaccine available for Hepatitis C Genotype 1 responds least favorably to alphaGenotype 1 responds least favorably to alpha

interferon and ribavirin treatments.interferon and ribavirin treatments.

Hepatitis CHepatitis C


42/71

4242

Reported Cases of Acute Hepatitis C byReported Cases of Acute Hepatitis C bySelected Risk Factors, United States,Selected Risk Factors, United States,

1982-2001*1982-2001*

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

1 9 82 1 9 84 1 9 86 1 9 88 1 9 90 1 9 92 1 9 94 1 9 96 1 9 98 2 0 00 2 0 01

Y e a r

PercentageofCa

ses

Injecting drug use

Sexual

Health related workTransfusion

* 1982-1990 based on non-A, non-B hepatitis


43/71

4343

HCV Infection in DentistryHCV Infection in Dentistry

Frequency of HCV infection among dentistsFrequency of HCV infection among dentistssimilar to that of general population (~ 1-2%)similar to that of general population (~ 1-2%)

No reports of an HCV transmission fromNo reports of an HCV transmission from

infected dental personnel to patientsinfected dental personnel to patients No reports of patient-to-patient transmissionNo reports of patient-to-patient transmission

of HCVof HCV

Risk of HCV transmission is very lowRisk of HCV transmission is very low


44/71

4444


45/71

4545


46/71

4646

Occupational Exposure to HIVOccupational Exposure to HIV


47/71

4747

(*) 3 dentists, 1 oral surgeon, 2 assistants

*


48/71

4848


49/71

4949


50/71

5050

Source: Cardo, et al., N England J Medicine 1997;337:1485-90.


51/71

5151


52/71

5252


53/71

5353


54/71

5454


55/71

5555

Assessment of Infection RiskAssessment of Infection Risk Source evaluationSource evaluation

Presence of HBsAgPresence of HBsAg

Presence of HBeAgPresence of HBeAg

Presence of HCV antibodyPresence of HCV antibody

Presence of HIV antibodyPresence of HIV antibody

If source unknown, assess epidemiologic evidenceIf source unknown, assess epidemiologic evidence

Susceptibility of the exposed personSusceptibility of the exposed person

Immunity to HBV infection?Immunity to HBV infection?


56/71

5656


57/71

5757


58/71

5858


59/71

5959


60/71

6060


61/71

6161


62/71

6262


63/71

6363


64/71

6464

Exposure Prevention MethodsExposure Prevention Methods

Standard/Universal PrecautioStandard/Universal Precaution

Engineering controlsEngineering controls

Work place practicesWork place practices


65/71

6565

Post-Exposure ManagementPost-Exposure Management

OSHA requires post exposure protocols to be inOSHA requires post exposure protocols to be in

placeplace

Physician providing counseling , medication, andPhysician providing counseling , medication, and

follow up care.follow up care.

At USC we test for : HBV, HCV, HIV, andAt USC we test for : HBV, HCV, HIV, and

VDRL (syphilis)VDRL (syphilis)

USC protocol states to report the injury within 2-USC protocol states to report the injury within 2-

4 hours of sustaining the injury.4 hours of sustaining the injury. Can only ask source patient to be tested onceCan only ask source patient to be tested once

Post Exposure ManagementPost Exposure Management


66/71

6666

p gp g

ProtocolProtocol

An exampleAn example All exposed faculty, staff and students are testedAll exposed faculty, staff and students are tested

atat 1 month, 3 months and 6 months1 month, 3 months and 6 months from the date offrom the date of

exposureexposure

Employer pays forEmployer pays for all medical exams and blood tests for all employeesall medical exams and blood tests for all employees

and students.and students.

exam and test for source patient if he/she agrees toexam and test for source patient if he/she agrees to

be testedbe tested HBIG and any antiviral medication(s) recommendedHBIG and any antiviral medication(s) recommended

and agreed to.and agreed to.


67/71

6767

HIV Post Exposure TreatmentHIV Post Exposure Treatment

Considers:Considers:

the type of injurythe type of injury

the severity of thethe severity of the

injuryinjury

the infection status ofthe infection status of

the sourcethe source


68/71

6868

Standard PrecautionsStandard Precautions

Apply toApply to allall patientspatients

Expand Universal Precautions to includeExpand Universal Precautions to include

organisms spread by other body fluidsorganisms spread by other body fluids

Apply toApply to

Blood and body fluids, except sweatBlood and body fluids, except sweat

Non-intact skinNon-intact skin

Mucous membranesMucous membranes

Postexposure ManagementPostexposure Management


69/71

6969

Postexposure ManagementPostexposure Management

ProgramProgram

Clear policies/proceduresClear policies/procedures

Education of healthcare personnel (HCP)Education of healthcare personnel (HCP)

Rapid access toRapid access to

Clinical careClinical care

Postexposure prophylaxis (PEP)Postexposure prophylaxis (PEP)

Testing of source patients/HCPTesting of source patients/HCP


70/71

7070

WarmlineNational HIV Telephone ConsultationService

1-800-933-3413

PEPlineNational Clinicians' Post-ExposureProphylaxis Hotline

1-888-HIV-4911

Perinatal HIV HotlineNational Perinatal HIV Consultation andReferral Service

1-888-448-8765

National HIV/AIDSClinician Consultation Center


71/71

www.cdc.gov/oralwww.cdc.gov/oral

healthhealth

hbv, hcv, and hiv in the dental office prevention and recommendations for post exposure prophylaxis...

Documents