Managing Occupational Risks for Hepatitis B & C Transmission in the Health Care Settings BY DR:

Hepatitis B & C infections are significant health problem worldwide. HBV Prevalence

Health-care personnel (HCP) Housekeepers Nurses Physicians Medical Students Public-safety workers Whose activities involve contact with patients or with blood or other body fluids from patients in a health-care, laboratory, or public-safety setting.

Exposure Percutaneous injury Needlestick or cut with a sharp object Contact of mucous membrane or non intact skin With blood, tissue, or other body fluids that are potentially infectious (CSF, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid).

Feces VomitusUrine Tears Sweat Sputum Saliva Nasal secretions Not considered potentially infectious unless they contain blood with risk of transmission very low.

Rate of infection House keepers Nurses Physicians > >

Occupational Transmission of HBV

Risk for Occupational Transmission of HBV Related to: Degree of contact with blood in the work place HBeAg status of the source person

HBsAg and HBeAg +ve blood HBsAg +ve, HBeAg -ve blood 37%–62% 22%–31% 23%–37% 1%–6% Clinical hepatitis Serologic evidence of HBV Clinical hepatitis Serologic evidence of HBV

HBV has been demonstrated to survive in dried blood at room temperature for at least 1 week. Blood contains the highest HBV titers of all body fluids and is the most important vehicle of transmission in the health-care setting. The concentration of HBsAg in body fluids can be fold higher than the concentration of infectious HBV particles. Therefore, most body fluids are not efficient vehicles of transmission because they contain low quantities of infectious HBV, despite the presence of HBsAg.

Although percutaneous injuries are among the most efficient modes of HBV transmission, these exposures probably account for only a minority of HBV infections among HCP. Thus, HBV infections that occur in HCP with no history of nonoccupational exposure or occupational percutaneous injury might have resulted from: –Direct or indirect blood or body fluid exposures that inoculated HBV into cutaneous scratches, abrasions, burns, other lesions, or on mucosal surfaces.

Management of HCP potentially exposed to HBV Administered IM in the deltoid muscle in three doses at 0, 1-2 and 4-6 months. Hepatitis B vaccine If 2 nd dose delayed Given as soon as possible If 3rd dose delayed Given when convenient

Testing 1–2 months after completion of the3-dose for anti-HBs Responders anti-HBs > 10 mIU/mL Nonresponders anti-HBs < 10 mIU/mL Second 3-dose vaccine series Evaluated for HBsAg-positive. RetestedMedical evaluation

Postexposure management Date and time of exposure Type of exposure — Percutaneous injury — Mucous membrane exposure — Non intact skin exposure — Bites resulting in blood exposure Type and amount of fluid/tissue — Blood — Fluids containing blood — Potentially infectious fluid or tissue Factors to consider Infectious status of source — Presence of HBsAg — Presence of HCV antibody Susceptibility of exposed person — Hepatitis B vaccine — Vaccine response status HBV and HCV immune status

Treatment of an Exposure Site Wounds and skin sites that have been in contact with blood or body fluids should be washed with soap and water. Mucous membranes should be flushed with water. No evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of bloodborne pathogen transmission. Application of caustic agents, antiseptics or disinfectants into the wound is not recommended.

Postexposure prophylaxis for exposure to hepatitis B virus HBIG & Hepatitis B vaccine (at a separate site) should be administered as soon as possible after exposure (preferably within 24 hrs, not effective > 7 days).

Postexposure prophylaxis for HBV Sources Vaccination status Unvaccinated Vaccinated Known responder Known nonresponder HBsAg +veUnknown HBsAg - ve HBIG x 1 + HB vac. HB vac. NO Treatment NO ttt. HBIG x 1 + HB revac. or HBIG x 2 If high risk treat as HBsAg +ve

Postexposure prophylaxis for HBV Sources Antibody response unknown HBsAg +veUnknown HBsAg - ve NO ttt. Do HBsAb AdequateInadequate Do HBsAb NO ttt. HBIG x 1 + vaccine booster Adequate NO ttt. Inadequate Vaccine booster + recheck titer in 1–2 months

Occupational Transmission of HCV Risk for Occupational Transmission of HCV Not transmitted efficiently through occupational exposures to blood. Average incidence of anti-HCV seroconversion after accidental percutaneous exposure from an HCV +ve source is 1.8%. Environmental contamination with blood containing HCV is not a significant risk for transmission in the health-care setting, with the exception of hemodialysis. Transmission rarely occurs from mucous membrane exposures to blood.

Postexposure Management for HCV IG and antiviral agents are not recommended for PEP after exposure to HCV-positive blood. No guidelines exist for administration of therapy during the acute phase of HCV infection. Recommendations for postexposure management are intended to achieve early identification of chronic disease and, if present, referral for evaluation of treatment options.

Follow-up of occupational HCV exposures For the source Testing for anti-HCV For the person exposed to an HCV-positive source Baseline testing for anti-HCV and ALT activity Follow-up testing HCV RNA at 4–6 weeks Anti-HCV & ALT activity at 4–6 months

Counseling for HCP Exposed to Viral Hepatitis Should refrain from donating blood, plasma, organs or tissue. No need to modify sexual practices or not becoming pregnant. Does not need to discontinue breast feeding. If an exposed person becomes acutely infected with HBV, the person should be evaluated. No recommendations exist regarding restricting the professional activities of HCP with HCV infection. HCP chronically infected with HBV or HCV should follow all recommended infection-control practices.