UWP & PEP 15-10-07

UNIVERSAL WORK PRECAUTIONS &POST EXPOSURE PROPHYLAXIS

FOR HIV

Dr. B.B. RewariNational Programme Officer (ART)National AIDS Control Organisation

New Delhi

Training for Infection Control Officers on Management of Ois and PEPDSACS, New Delhi, 15 October 2007

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Modes Of Transmission• Hetrosexual 85%• Infected Blood & Blood Products 2.5%• Injectable Drug users (IV) 4.5%• Children born to HIV infected mothers 2%• Another Mode of transmission that is largely

undocumented, is the transmission ofinfection by needle stick injury/sharp injuriesin an hospital or any other health care setting.

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PEP For Whom

• Health Care Personnel• Relations looking after

HIV+ Patients• Victims of sexual assault• Unprotected casual sex

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Health Care Personnel

• Health care personnel (HCP) is definedas any person (Employee, student,contractor, attending clinician, publicsafety worker or volunteer)whoseactivities involve contact with patients orwith blood or with other body fluids frompatients in a health care or laboratorysetting

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Exposure

• OCCUPATIONAL EXPOSURE that mayplace a worker at risk of HIV infection is apercutaneous injury ,contact of mucousmembrane or contact of skin (espacially whenthe skin is chapped, abraded or affected withdermatitis or the contact is prolonged orinvolves an extensive area ) with blood tissueor other body fluids to which universalprecautions apply.

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Core Issues• What constitutes a “Needle stick injury”?• Who is at risk of getting needle stick injury?• How much is the risk?• What factors influence this risk?• How can we reduce the risk of acquiring these

infections?• How can we reduce the risk after the exposure

to these infections has occurred?• What is the role of different Post exposure

Prophylaxis (PEP) regimens in reducing thisrisk?

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Needle Stick Injuries

• Needle stick injuries can lead to serious or fatalinfections with different blood borne pathogens.

• More than twenty pathogens have beenreportedly transmitted from needle stick.

• The most common ones are hepatitis B virus,hepatitis C virus and human immunodeficiencyvirus (HIV).

• The needle stick injury can not only lead to somelife threatening blood borne infections as well ashave severe emotional impact on health carepersonnel.

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Needle Stick Injuries

• Approximately 8 million heath workers inUS

• 6,00,000 to 8,00,000 needle stick injuriesoccur annually in US.

• Approximately 30 needle stick injuries per100 beds per year are seen.

• No such data is available from our country.

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How do needle stick injuries occur?

Source – CDC 1999

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Risk for occupationaltransmission to HCP

• In India no data on needle stick injury /muco-cutaneous exposure.

• Unofficial one case each from MumbaiDelhi, Lucknow

• One case reported from NICD to NACO• USA.

• Till June 2000 ,56 cases with sero-conversion and 138 possible cases

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RISK OF INFECTION AFTEROCCUPATIONAL EXPOSURE

NO RISK ON EXPOSURE TO INTACT SKIN

The risk of HIV transmission after a percutaneous exposure toHIV infected blood is approx. 0.3% (1 in 300) and after mucusmembrane exposure is 0.09%(I in 1000)

HBV - Rate of HBV transmission ranges from 6-30% after asingle needle stick exposure to a HBV infected patient.

HCV - The incidence of acute HCV seroconversion averages 1.8%(from 0 - 7% per injury)

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• THE RISK OF TRANSMISSION IS INCREASEDWHEN THE HCP IS EXPOSED TO:– large quantity of blood

– visible blood device

– procedure that involved placing a needle in a patient’svein or artery

– deep injury

– recent sero conversion

– exposure to an advanced case of AIDS

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Prevention of occupational exposure

Universal Work PrecautionsThe basic principle for preventing these occupational hazard is theadoption of universal precautions which have been developed tominimize the exposure of HCW to blood and body fluids of HIVpatients

Wash hands after patient contact,or with body substance

Plan safe handling and disposal before beginning any procedure

Dispose of used needles promptly in sharp disposal containers

Wear gloves when contamination of hands with body substancesis anticipated

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Protective eyewear and masks should be worn when splashing withbody substances/fluids is anticipated

Adhere to disinfection and sterilization standards

Regard all waste soiled with blood/body substances ascontaminated and dispose of according to relevant standards

Vaccinate all clinical and laboratory workers against hepatitis B

Other measures: such as double gloving, changing surgicaltechniques to avoid exposure prone procedures, use of needlelesssystems and other safer devices

UWP & PEP 15-10-07

Body fluids to which UniversalPrecautions apply

• Blood Vaginal secretions• Semen Cerebrospinal

fluid• Synovial fluid Pleural fluid• Peritoneal fluid Amniotic fluid• Pericardial fluid• Other body fluids containing blood.

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Body fluids to which UniversalPrecautions do not apply• Tears Sputum• Sweat• Urine Vomitus• Nasal secretions• The risk of transmission is

extremely low or negligible unlessthese contain visible blood.

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NEEDLE AND SHARPS CARE• No recapping of needles• No bending/breaking of needles by hands• Puncture resistant containers• Needle shredders• Do not leave needles on trolleys/beds• Do not pass sharps by hands• Ensure that health workers are properly

trained in safe use and disposal of needles

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Use Protective Gears

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Say NONO to Mouth Pipetting

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Consider all samples Infectious

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Safer Needle Device” Has Certain Built InSafety Controls To Reduce Needle Stick

Injuries Before, During, Or After Use

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WHAT TO DO ON EXPOSURE

• It is a medical emergency

• Do not panic

• Immediate measures

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IMMEDIATE MEASURES• DO NOT PUT YOUR CUT/PRICKED

FINGER INTO MOUTH REFLEXLY• WASH WITH SOAP AND WATER

IMMEDIATELY• No evidence that use of antiseptic for care or

expressing fluid by squeezing the woundfurther reduces the risk of HIV transmission,however they are not contra - indicated

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WHAT NEXT

• REPORT PROMPTLY

• PEP MUST START AT THE EARLIEST– PREFERABLY WITHIN TWO HOURS– MAY BE UPTO 72 HOURS

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Why PEP at all?

Rationale of PEPInformation about primary HIV infectionindicate that systemic infection does notoccur immediately leaving a brief periodwithin ‘window of opportunity’ during whichpost exposure anti-retroviral interventionmay modify viral replicaiton

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Efficacy of Antiretroviral Drugsfor PEP

• Definite prevention of infection• Early successful PEP• Delaying initiation initiation of PEP and small

inculum size are correlates of, shortening theduration or reducing the antiretroviral dose ofPEP individually or in combination decreasesefficacy

• Failure of ZDV PEP to prevent HIV infectionhas been reported in at least 14 instances

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Anti-retroviral agents in PEP.

• ZDV(NRTI) is the only agent shown toprevent HIV transmission in humans.

• No data to support that the addition ofother ARV drugs to ZDV enhance theeffectiveness of PEP regimens.

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IS PEP NEEDED FOR ALLTYPES OF EXPOSURE?

NOCHANCES OF INFECTION MUST BEWEIGHED WITH SIDE EFFECT OFDRUGS.

HOW TO DECIDE ABOUT PEP

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Exposure Code (EC)Is the source material blood, body fluid, other potentially infectious material(OPIM), ofan nstrument contaminated with one of these substances

No YesNo. REP Required

OPIM, Blood / body fluds

Type of exposure?

Intact SkinMucous membrane/skn orintegrity compromised

Percutaneous exposure

EC1 EC2 EC2EC3

Large Volume(eg- Several

drops,major splash /longer duration

(several mnutes or more)

SmallVolume (eg-

Fewdrops /short

duration

Less severe(eg solid

Needle,Superticial

Scratch)

More severe(eg large-bore

hollow Needle.Deep Puncture,Visible bloodOn device orNeedle usedIn patients

Arteray/vein

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HIV STATUS CODE

HIV status of exposure source

HIVnegative

HIV positive StatusUnknown

Sourceunknown

Low titerExposure (eg-

Asymptomatic/high CD4

count

High titereg- advancedAIDS, primary

HIVInfection/highViral load orLow CD4 count

HIV SC 1 HIV SC 2HIV SCUnknown

No PEPrequired

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Determination of PEP Recommendation

If setting Suggests a possible risk(epidemiological risk factors) and EC is 2 or 3 ,consider basic regimen

Unknown2/3

Recommend Expanded regimen1 of 23

Recommend Expanded regimen22

Recommend Basic Regimen ( Most Exposuresare in this category

12

Consider Basic Regimen ( Negligible risk)21

PEP may not be warranted11

PEP RecommendationHIV SCEC

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DRUGS FOR PEP• BASIC REGIMEN• Zidovudine 300mg BD• +Lamivudine 150mg BD• EXPANDED REGIMEN

– ZDV +LMV– +Indinavir 800mg TDS– or any other protease inhibitor

• Duration of PEP 28 days• Nevirapine and delavirdine have not been included in

the regimes of PEP

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COMMON ADVERSE EFFECTS OFARV DRUGS

• NAUSEA, VOMITTING• HEADACHE• DIARRHOEA• MYALGIA• MALAISE,FATIGUE• ABD. PAIN• RASH

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PRE & POST TESTCOUNSELLING

• BASE LINE TESTAt time of exposure

• REPEAT TESTAfter 6 wks

• 2nd REPEAT TESTAfter 12 wks

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Recommendations for themanagement of potentially exposed

HCP• Hospitals should make available to their workers,

written protocols for prompt reporting, evaluation,counseling, treatment and follow up of occupationalexposures that may place HCP at risk of acquiringany blood bone infection including HIV

• Exposure reporting should be made mandatory• Clinicians responsible for providing care should be

available all the 24 hrs• PEP drugs should be available for timely

administration

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Conclusion• HIV transmission to HCP a minimum

possibility• Universal precautions minimize risk• Few cases reported world over• Responsibility lies in the individual to

protect from the dangers of thisinfection and continue caring of patientswithout fear and apprehension