1. BLOOD BORNE PATHOGEN EXPOSURE Management – What you need to know about Needlesticks and Splashes Amy J. Behrman, MD Occupational Medicine Dept of Emergency Medicine University of Pennsylvania

2. EPIDEMIOLOGY OF EXPOSURES l Blood and Body Fluid Exposures (BFEs) are common l 33 events/year/100 beds in the US l Most are preventable –Assess the situation prior to procedure –Dispose of sharps safely at the bedside –Never Never Never Recap –Help your colleagues and trainees

3. EPIDEMIOLOGY OF EXPOSURES l EXPOSURE RATES ARE HIGHEST AMONG HCW who do the most procedures –NURSES –OR STAFF –EMERGENCY DEPARTMENT STAFF –HOUSE OFFICERS

4. HEPATITIS B l Percutaneous transmission rate 2- 40% for unimmunized HCW –e Antigen correlates with viral titer and replication –Exposure to e antigen-positive or high titer blood carries highest risk

5. HEPATITIS B l Shed in many body fluids l Multiple transmission modes –Percutaneous –Mucous Membrane/Broken Skin splash –Bite l Long Term Sequelae

6. HEPATITIS B l Vaccine Preventable l Vaccine is safe, effective, recombinant l Available free to all HCWs per OSHA l Universally recommended (AAP) l Minimal Side Effects l >95% immune after 3 doses l Long term protection

7. HEPATITIS B Vaccine l Follow-up testing to detect non- responders is crucial. l Booster series may be helpful. l HBIG: Post-exposure prophylaxis is effective for non-responders. l Non-responders should be evaluated for chronic HBV infection

8. HEPATITIS C l Prevalent in many patient populations l Long term sequelae l The most common bloodborne pathogen at HUP and PMC l Shed in blood, semen, vaginal fluid l “Splash” transmission documented l Nosocomial infectivity between HBV and HIV

9. HEPATITIS C l No Vaccine l No Post-exposure prophylaxis l Prompt Reporting and Follow-up are crucial to identify infections early l Early rx may improve outcomes in acute infection l PCR-based testing facilitates management in high-risk situations

10. HIV l More complex exposure management l Percutaneous transmission rate.3% l Post-exposure prophylaxis (PEP) with anti-retrovirals is effective l PEP effectiveness is greatest if started early l Immediate Reporting and Prompt Follow- up is crucial to preventing infection

11. HIV l Counseling and PEP are available 24 hours/day at HUP and PMC l Starter Packs of Anti-Retrovirals are available in EDs and OM sites l It is your responsibility to report any BFEs in person as soon as possible l It is your responsibility to facilitate reporting for trainees and colleagues l It is your responsibility to assist in source patient testing

12. HIV l Current first-line PEP consists of Combivir or Combivir and Kaletra www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm l Modified per source status and resistances l 4 week regimen for known HIV exposures l Follow-up for toxicity l 6-9 months follow-up testing

13. HIV l The source patient with unknown HIV status –Most common scenario –HCWs may choose to treat pending source patient test results Usually 2 drug regimen –Source patient testing requires cooperation between Occupational Medicine and the Source Patient’s Physicians

14. HIV –Source patient testing must be done in conformance with hospital policy and state law. http://uphsxnet.uphs.upenn.edu/hupinfpl/inf _pdfs/appendix_practice%20guidelines.pdfhttp://uphsxnet.uphs.upenn.edu/hupinfpl/inf _pdfs/appendix_practice%20guidelines.pdf http://uphsxnet.uphs.upenn.edu/hupadmpl/1 _12_33.pdf –Source patient testing is successful > 95% of the time at HUP and PMC.

15. BBPs and HCWs l KNOW WHERE TO GO l HUP –DAYS: OCC MED – 1 SILVERSTEIN –NIGHTS/EVENINGS/WEEKENDS – ED –215-662-2367 or 215-662-2358 l PMC DAYS: –OCC MED –NIGHTS/EVENINGS/WEEKENDS – ED –215-662-8278 l 24 Hour Consult Coverage is available –HUP: Occupational Med On Call 215-524-8864 –PMC: Infectious Disease On Call

16. BBPs and HCWs l FOLLOW-UP IS CRUCIAL l Follow-up is based on CDC Guidelines: www.cdc.gov/mmwr/PDF/rr/rr5011.pdf www.cdc.gov/mmwr/preview/mmwrht ml/rr5409a1.htm l Follow-up is customized for each exposure based on the BBPs involved, the likelihood of drug resistance, and the HCW medical history

17. BBPs and HCWs l WE NEED YOUR HELP TO TEST SOURCE PATIENTS l HBV Surface Antigen and HCV Antibody l HIV Antibody (which always requires written consent from patient or proxy) l “Rapid” HIV is available when appropriate with OM approval –Requires charted source patient consent –Specimens sent directly to Microbiology Lab

18. BBPs and HCWs - Goals l Start anti-HIV prophylaxis (PEP) within 1-2 hours if appropriate. l Occupational Medicine follow-up on next business day to ensure: –F/U Testing for HCW –F/U for Source Patient Testing –Drug safety monitoring (if appropriate) –Immunization review