Post-Exposure Programs in the Event of Occupational Exposure to HIV/HBV

It is essential that all health care employers develop protocols for managing occupational exposures to bloodborne pathogens. Regardless of the size of the health care agency, prompt access to confidential post-exposure evaluations, counseling, and follow-up by knowledgeable clinicians should be regarded as the standard of care. An occupational exposure is defined as a percutaneous injury (needlestick), contact of mucous membranes, or contact of non-intact skin with blood or other body fluids or tissues containing blood that may potentially contain bloodborne pathogens.

The risk for developing bloodborne strains of hepatitis infection after a percutaneous exposure from someone who is known to be a hepatitis antigen carrier can be from 7 to 30%. Every year, more than 200 health care workers die from bloodborne hepatitis infection, and approximately 18,000 become occupationally infected (OSHA). ANA supports the need for health care workers to be immunized with the hepatitis B vaccine to reduce risks for contacting this particular strain of preventable hepatitis.

The current known risk for becoming occupationally infected with HIV after a percutaneous exposure to blood containing HIV is approximately 0.3% or 1 out of 300 exposures will result in sero-conversion, In November 1990, a National Institutes of Health study on occupational transmission of HIV found that 1 worker out of 159 would contract HIV-1 through a skinbreak injury. There are 40 nationally documented health care worker sero-conversions from occupational exposure (January 1991).

Goals of ProgramTo Manage Occupational Exposure to Bloodborne Pathogens and Standards of Care

1. improve reporting of occupational exposures by decreasing impediments to reporting.
2. provide employees with adequate post-exposure counseling, testing, education, treatment and prophylaxis for those who experience parenteral, mucous membrane, or cutaneous exposure to blood or other body fluids,
3. identify factors which put employees at risk for exposure,
4. identify injury control methods to prevent or reduce the risk of exposures and to evaluate the success of such intervention,

The institution should develop policies with the following standards of care in mind:

1. Services including pre- and post-test counseling should be provided by qualified personnel who have received training in counseling HIV-exposed individuals and who are sensitive to the issues.
2. Pre- and post-test counseling to employees and family members should be provided by qualified personnel.
3. Services should be available 24 hours per day via a pager or through other identified means.
4. Services should be available to all individuals who may be inadvertently exposed to HIV through legitimate health care delivery activities on the employers' premises, including, but not limited to, students, volunteers, and family members.
5. Documentation of all counseling and testing procedures should remain confidential and records should be kept in separate files with limited access. Disclosure of any information should be done only with the employee's consent.
6. The source patient should be tested for HIV antibodies and hepatitis B antigen, as well as other strains of hepatitis, as soon as possible.
7. Determination of post-exposure therapeutic and experimental interventions and protocols.
8. Hepatitis B vaccination, immune globulin, tetanus and prophylactic AZT related laboratory monitoring should be provided at no cost to the employee.
9. Education regarding prevention of needlesticks or other traumatic injury should be provided. Work committees should be established to develop injury prevention programs that meet the needs of staff.

Definitions of Exposures

Massive Exposure is defined as a transfusion of blood, an injection of a large volume of blood or other bodily fluid (1 ml), or a probable parenteral exposure to laboratory specimens containing a high titer of virus.

Definite Parenteral Exposure is defined as an injection of less than 1 ma of blood or other fluid, a deep intramuscular injury with a contaminated needle or instrument, a laceration produced by a visibly contaminated instrument, or a visible laceration or wound inoculated with blood or body fluids.

Probably Parenteral Exposure is a subcutaneous or superficial injury produced by contaminated needle or instrument, a laceration or wound produced by a contaminated instrument that does not cause spontaneous bleeding, a wound or skin lesion that becomes visibly contaminated with blood or body fluids, or a mucous membrane inoculation with blood or body fluids.

Doubtful Parenteral Exposure is a subcutaneous injury with a non-contaminated needle or instrument, a laceration or wound produced by a non-contaminated instrument, a wound or lesion that is contaminated with a non-hazardous body fluid, or a mucous membrane inoculation with a non-hazardous body fluid.

Non-Parenteral Exposure occurs when intact skin is visibly contaminated with body fluid.

ATTACHMENT: Guidelines for Post-Exposure Programs

Immediate Treatment

1. Wound Care/ First Aid
   • A. Clean wound with soap and water.
   • B. Flush mucous membranes with water or normal saline solution.
   • C. Other wound care as indicated.
2. Notification of Responsible Parties
   • A. Notify supervisor or on-call staff member at the 24-hour hotline after wound care has been provided.

Early Treatment

1. Provide tetanus prophylaxis if indicated.
2. Provide HBV prophylaxis, including vaccine, if indicated.
3. Provide Immune Serum Globulin Prophylaxis as soon as possible and less than 24 hours after a parenteral exposure, if indicated.
4. Azidothymidine (AZT) or Zidovudine (ZVD) prophylaxis.
   
   If indicated, AZT prophylaxis should begin as soon as possible, preferably within one hour, or at the most, within two hours of the HIV exposure. Opinions vary as to the exact time from 30 minutes to four hours. If AZT is elected, counseling regarding possible side-effects should be provided.
   • A. AZT treatment is recommended if there has been an exposure to concentrated virus in research laboratories, or through a transfusion of HIV.
   • B. AZT treatment is routinely encouraged for massive exposures, deep intramuscular injections, high titer exposures, or parenteral exposures with blood or body fluids from severely ill patients with AIDS who are known or presumed to be highly viremic.
   • C. AZT should be available in other situations such as superficial needlesticks and mucosal splashes. It is not routinely encouraged for other exposures, but the risks and benefits should be discussed, and may be prescribed for any exposure at the discretion of the treating clinician.
   • D. AZT is not prescribed in non-parenteral exposures, and is not recommended for pregnant women, breast-feeding women, and/ or men or women at risk for conception.
   • E. Informed consent must be obtained, since the use of AZT is experimental at this time.
   • F. Dosage of AZT should be prescribed according to current community standard. Some communities prescribe the following dosage: 200 mg, po, 6 x day for 3 days, then 200 mg, po, 5 x day for 25 days.
   • G. Monitor health care provider at least bi-weekly for evidence of systemic, hematologic, neurologic, hepatic, or other subjective and/ or objective toxicity. Drug dosage may be reduced or drug discontinued depending on toxicities.

Testing and Counseling the Source Patient

All source patient HIV/bloodline hepatitis testing should be coordinated by staff skilled in interviewing and counseling. When source testing is sought, the source patient should be approached and counseled by a clinician other than the exposed individual. At all times, the confidentiality of the source patient should be maintained. Breaches of confidentiality can have extremely serious emotional and financial implications.

Source patients should be tested according to state laws. ANA believes source patient testing is necessary unless the source patient is known to be HIV-infected or bloodborne hepatitis antigen positive. All source patient testing should be done with the informed consent of the individual, in conjunction with the patient's primary physician, and with proper pre- and post-test counseling. ANA also recommends that testing be done at no cost to the patient. Such billings result in loss of confidentiality and adverse insurance actions.

Testing and Counseling the Exposed Health Care Worker

All testing and counseling of exposed health care workers should be provided by staff skilled in interviewing and counseling. All documents, files, and specimens are to be kept confidential, and preferably labeled with a confidential identifier. It is recommended that a separate medical record, containing only the documentation of post-exposure management, be established for the health care worker.

1. Exposed Health Care Worker Testing
   • A. Immediate baseline testing is recommended to establish pre-exposure HIV/bloodborne hepatitis status. If the HIV antibody test is negative, it is likely that either the employee has not been to HIV or has not sero-converted. The need for HBV prophylaxis and vaccination would be indicated if the HBV antigen test is negative.
   • B. If the HIV test is positive by the ELISA method, a confirmatory Western Blot test should be performed.
   • C. The health care worker should be tested at the following intervals: baseline, 3 months, 6 months, and 1 year post-exposure. Based on current knowledge, if the employee remains negative at one year, it is almost certain they will not sero-convert from this incident.
   • D. If an employee refused testing at the time of exposure, serum of the health care worker should be obtained with informed consent. Serum may be tested at a later date.
2. Exposed Health Care Worker Counseling
   • A. Counseling should be provided by skilled personnel through previously established agency protocol.
   • B. Counseling should include the following: meaning of test results; discussion of personal life factors such as, safer sex practices, conception/ contraception, and informing sexual partners; discussion regarding avoidance of blood, semen, and tissue donation.
   • C. Counseling should include a validation of the health care worker's concerns and fears, and the implications of disclosure to other persons in their support system.
   • D. The health care worker should be encouraged to monitor for signs/ symptoms of acute sero-conversion illness (fevers, myalgias, rash, etc.) and to report these symptoms to designated personnel immediately.
   • E. Information regarding workers' compensation, disability, and other benefits should be provided.

Documentation and Evaluation of Exposures

Documentation of exposure should include the following information:

1. The date and time of exposure;
2. Job function being performed at the time of the exposure, the circumstances surrounding the injury, and the equipment being used at the time of the exposure;
3. Details of the exposure including the amount and type of fluid, the area of exposure, the severity of the exposure, indication of any barriers the health care worker may have been wearing at the time of the injury;
4. Details regarding the decontamination measure taken at the time of the injury;
5. Description of the source of exposure, including, if known, whether the source material contained HIV or strains of bloodborne hepatitis;
6. Details about counseling, post-exposure management, and follow-up and documentation if the health care worker refused counseling or follow-up treatment.

ANA believes that the time period following an exposure to a bloodborne pathogen is likely to be extremely stressful and employees need accurate information, guidance, reassurance and supportive care. Post-exposure programs should provide both health care and appropriate counseling and be designed to provide exposed employees with prompt, supportive, and comprehensive services.

References

THIS INFORMATION COPYRIGHT 1997 AMERICAN NURSES ASSOCIATION

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