BLOOD AND BODY FLUID EXPOSURE MANAGEMENT TOOL

Transcription

1 655 West 12th Avenue Vancouver, BC V5Z 4R4 Tel Fax Clinical Prevention Services Tel Fax BLOOD AND BODY FLUID EXPOSURE MANAGEMENT TOOL The purpose of this tool is to assist health professionals in managing patients who have had a blood and body fluid exposure. A risk assessment should be performed on the exposed person within two hours of exposure. This is commonly performed at hospital emergency departments, institutional occupational health departments and public health units for community exposures. If the exposure occurred within 36 hours and there was significant risk for exposure to HIV transmission, clients may be offered post-exposure prophylaxis (PEP) for HIV at the nearest hospital emergency department. When indicated, it is important to start PEP as soon as possible after a high risk blood and body fluid exposure. (See the BCCDC Communicable Disease Control (CDC) Manual: CDC Manual: Blood and Body Fluid Exposure Management for HIV PEP recommendations). PEP will vary for pregnant women and for those exposed to a source known to have been on anti-retroviral therapy or a source whose HIV infection is known to be drug resistant. Refer to BC Centre for Excellence in HIV/AIDS or call The risk of developing HBV infection following exposure is extremely low. The majority of the BC population under the age of 30 has been vaccinated against HBV since the introduction of grade 6 hepatitis B immunization programs in 1992 and the implementation of a universal infant program in If the exposure occurred within the previous 14 days and the client is at significant risk for exposure to hepatitis B (HBV), HBV prophylaxis, (including hepatitis B vaccine and potentially hepatitis B immune globulin - HBIG), may be indicated depending on the clients HBV immune status and hepatitis B vaccination history. When indicated, it is important to administer HBIG as soon as possible after the exposure. (See the BCCDC CDC manual Blood and Body Fluid Exposure Management (BBF Exposure Management) for HBV post exposure prophylaxis recommendations). Prophylaxis for potential exposure to hepatitis C (HCV) is not available. DEFINITION Blood and body fluid exposure is an event where a person is exposed to potentially infectious blood or bodily fluids through the following: Percutaneous exposure through puncture of skin by needlestick or another sharp object; Permucosal exposure through contact with mucous membranes; or Non-intact skin exposure through eczema, scratches, and damaged skin.

2 CAUSES Post-exposure management must be undertaken when the following conditions are present: Exposure is through needlestick/scratches, mucosal contact or contact with compromised (damaged) skin; Exposure is to blood or high-risk body fluids from a source that is either known to be infectious or might be potentially infectious (high-risk source or in settings where individuals engage in high-risk activities); and The exposed person is known or considered to be at risk for HBV, HCV or HIV. PREDISPOSING RISK FACTORS Common Risk Factors for HBV, HCV and HIV include: Unprotected sexual activity where there is blood present (e.g. multiple sex partners, vaginal or anal sex without a condom); History of injection drug use; History of dialysis; Immigration from a high endemic country; and Tattoo and body piercing, electrolysis. TYPICAL FINDINGS Health History Assessment of the exposed person includes: HBV vaccine history or HBV immune status Personal risks for HBV, HCV and/or HIV. Obtain verbal informed consent for testing for HBsAg, Anti-HBs, Anti-HBc, Anti-HCV and HIV Ag/Ab. Also obtain consent for disclosure of their results to their: o Worksite occupational health department and WorkSafeBC; and o Follow-up physician. Refer to Fluids capable of transmitting bloodborne pathogens (Table 1) Inform that HIV testing can be performed both nominally (includes name, DOB, and PHN) or non-nominally, which implies that the results are not reported nominally to the MHO but will be reported to the patient s physician for follow-up purposes. Test results for HBV and HCV, if positive, will be reported to the person s physician and public health for follow up. 2

3 Table 1: Fluids capable of transmitting bloodborne pathogens FLUID HIV HBV HCV Blood and fluids visibly Yes Yes Yes contaminated with blood Yes if blood Semen Yes Yes present Yes if blood Vaginal secretions Yes Yes present Pleural, amniotic, pericardial, peritoneal, synovial and cerebrospinal fluids and inflammatory exudates Saliva Transplanted tissue or organs Breast milk Yes Yes Yes No, unless contaminated with blood. Yes Yes Yes Yes Yes Plausible, particularly if nipples are cracked or bleeding. Neonates given hepatitis B Immune globulin (HBIG) and HBV vaccine are not at risk. No, unless contaminated with blood. Plausible, particularly if nipples are cracked or bleeding but the risk of transmission is very low. Breastfeeding is recommended by HCV infected mothers. Faeces Nasal secretions Sputum Sweat Tears Urine Vomitus No, unless they contain visible blood. 3

4 Assessment of the source person includes: If the source person is known, test to confirm clinical status Physical Assessment 1. Needlestick/wound: o Allow the wound to bleed freely. o Do not promote bleeding by squeezing the wound. This may damage the tissues and increase uptake of any pathogen(s). 2. Mucous membrane or eye: o Rinse well with water or normal saline. 3. Skin: o o Wash well with soap and water. Note: Do not apply bleach to wound or mucosa. Diagnostic Tests Blood should be collected from both the exposed and source persons as soon as possible. At the time of the exposure, the exposed person should be tested for o HBsAg, o Anti-HBs, o Anti-HBc, o Anti-HCV, o HIV Ag/Ab (detects anti-hiv and P24 antigen). All laboratory based HIV screening tests in BC detect both antibody and antigen. If test results are negative, post-exposure follow-up testing should be at: o 3 weeks; o 6 weeks (HIV only); and o 3 months. Do not wait for test results before starting post-exposure management or PEP treatment, if appropriate. If HIV PEP was dispensed, complete post-exposure follow-up testing in: o 3 weeks post PEP course completion; o 6 weeks post PEP course completion; and o 3 months post PEP course completion. If the source is confirmed to be HIV-negative and not within a window period, only HIV testing of the exposed person at baseline is required. If a woman of childbearing age is exposed, consider pregnancy testing when appropriate. Refer to Table 2: Follow up Blood Testing after Exposure to Blood and Body Fluids 4

5 Table 2: Follow Up Blood Testing After Exposure to Blood and Body Fluids TIME SINCE EXPOSURE HIV Hepatitis C Virus (HCV) Hepatitis B Virus (HBV) RATIONALE FOR TESTING ASAP, usually in Emergency Rooms Yes Yes Yes To check your baseline status. Negative or nonreactive test results suggest no prior infection. 3 weeks after exposure Yes Yes Refer to Appendix 3 in BBF Management Exposure Guideline If HCV RNA +, early treatment may prevent chronic infection. 6 weeks after exposure Yes No Refer to Appendix 3 in BBF Management Exposure Guideline 3 months after exposure Yes Yes Yes A negative (or non-reactive) test result at 3 months following exposure indicates that you did not get infected. 5

6 MANAGEMENT AND INTERVENTIONS Goals of Treatment Reduce the potential of infection Prevent complications from undiagnosed and untreated infection Reduce anxiety TREATMENT OF CHOICE *Consultation/referral may be required depending upon the clinician s professional scope of practice* Treatment Notes Hepatitis B Immunoprophylaxis Hepatitis B immune globulin and hepatitis B vaccine series if indicated. HIV Post Exposure Prophylaxis (PEP) Refer to BC Centre for Excellence in HIV/AIDS for HIV PEP if indicated. Tetanus Vaccine Consider with a percutaneous injury 1. Refer to the BCCDC CDC manual Blood and Body Fluid Exposure Management for specific criteria regarding HBV immunoprohylaxis and HIV PEP 2. Refer to Tetanus Prophylaxis in Wound Management 528C4C20-F2F E8DC455A5E76/0/SectionVII_Biol ogicalproducts_april20142nd.pdf 6

7 PREGNANT OR BREASTFEEDING WOMEN Refer all pregnant or breastfeeding clients to a physician or nurse practitioner (NP). Breastfeeding concerns HBV: If exposure is to a high-risk HBV source, breastfeeding can continue in the following circumstances: o the mother is immune to HBV o the mother and infant are vaccinated and treated with HBIG immediately post-exposure. Mothers that suspend breastfeeding can store pumped milk in a freezer until cleared of an infection risk. HCV: If exposed to an anti-hcv positive source, continued breastfeeding is recommended. If the nipples become cracked or bleed, mothers are to abstain from breastfeeding until they are healed. To prevent cessation of milk supply, consider expressing and discarding breast milk until nipples are healed. HIV: If the source is HIV-positive, breastfeeding is not recommended. If the HIV status of the source is unknown, breastfeeding should be temporarily discontinued. During this time, the mother may pump and freeze breast milk while awaiting source test results. If the source has a baseline HIV-negative test result and has no recent high-risk behaviour, then breastfeeding can be resumed and the frozen milk used. Breastfeeding is contraindicated if the mother is receiving PEP due to a high-risk exposure. Breastfeeding can be resumed when PEP has been stopped. 7

8 PARTNER COUNSELLING AND REFERRAL Initiate counselling at the site of post-exposure management. Include discussion regarding window periods and ways of reducing potential infection transmission to sexual partners and contacts. If PEP is implemented, refer to the BC Centre for Excellence in HIV/AIDS Therapeutic Guidelines Accidental Exposure Guidelines available at: Guidelines_Nov82010.pdf MONITORING AND FOLLOW-UP If prophylaxis for HBV and/or HIV are started, it is essential that the exposed person is followed by a family or an assigned physician as soon as possible as the anti-retroviral starter kits contain only a five day supply of medication. POTENTIAL COMPLICATIONS The toxicity of some antiretroviral drugs is high. The exposed person should be aware of this and the potential for adverse effects before starting antiretroviral therapy. This information is provided on the attachments to the antiretroviral package provided in the emergency room. A small proportion of patients taking prophylaxis will be unable to work during the month of treatment. There are many drug interactions with antiretroviral medication, particularly with Protease inhibitors such as Kaletra. A careful medication history and use of all alternative therapy should be reviewed. Non-essential medications and all alternative therapy should be discontinued during antiretroviral therapy. Questions regarding drug interactions should be directed to the Centre for Excellence in HIV Pharmacy ( ). Specific cases should be discussed with a Centre for Excellence in HIV Physician or Pharmacist. Refer to the BC Centre for Excellence in HIV/AIDS Therapeutic Guidelines Accidental Exposure Guidelines: delines_nov82010.pdf 8

9 CLIENT EDUCATION Exposed persons may be anxious when initially assessed. They may not remember the information provided during the initial counselling session. It is important to repeat and followup with detailed counselling. While awaiting test results from the source and until the risk assessment is complete, the exposed person should be advised: to obtain baseline blood testing and follow-up testing to determine whether transmission took place regarding the appropriate use of medications (dosage, side effects). regarding the potential asymptomatic nature of HBV, HCV and HIV infections. to use latex condoms during intercourse; not to donate blood; not to share toothbrushes, razors, needles and other items potentially contaminated with bodily fluids; to keep cuts and abrasions covered until fully healed; to package any blood containing items separately before disposal; to clean any blood contamination with a 1:10 solution (9 part water to 1 parts bleach) of household bleach; to avoid sharing recreational drug paraphernalia; and to defer pregnancy. If pregnant, consult the Oak Tree Clinic at BC Women s Hospital, Tel # (604) or FOLLOW UP AND DOCUMENTATION Arrange a follow-up with the exposed person s physician or the physician designated by the healthcare facility by completing the following form: Management of Percutaneous or Permucosal Exposure to Blood or Body Fluid Letter for Follow-Up Physician Form (HLTH 3BF5FDC10D24/0/HLTH2340PRINT.pdf o Give the white copy to the client (exposed person) o Give the yellow copy to Worksite Occupational Health o Retain the pink copy in the client s chart 9

10 Complete the following laboratory requisition form for blood testing: Management of Percutaneous or Permucosal Exposure to Blood and Body Fluid/Laboratory Requisition Form (HLTH The white and yellow copies (page 1, 2) contain information on the source and/or exposed person(s). o Forward the white copy to the laboratory performing the testing o Forward the yellow copy (page 2) to the occupational health department of the exposed person s workplace. o Forward the pink copy (page 3) to WorkSafeBC. Fax numbers: (604) [lower mainland] or [toll-free]. For occupational exposures, the WorkSafeBC guidelines for injury reporting must be followed. o Attach the golden copy (page 4) to the exposed person s record. Risk assessment and management documentation should be recorded in the exposed person s health record. 10

11 REFERENCES BC Centre for Disease Control (2012). British Columbia Annual Summary of Reportable Diseases. Retrieved from: D33E-4755-B3F4-6844E01BD678/0/FinalAR2012.pdf BC Centre for Disease Control (2009). Communicable Disease Control: Blood and Body Fluid Exposure Management. BC Centre for Disease Control (2012). Communicable Disease Control: Chapter 1 Management of Specific Diseases Hepatitis C. BC Centre for Disease Control (2014). Communicable Disease Control Immunization Program Section VII Biological Products. Retrieved from: E8DC455A5E76/0/SectionVII_BiologicalProducts_April20142nd.pdf BC Centre for Excellence in HIV/AIDS: HIV Monitoring Quarterly report for BC (2014). Retrieved from: ug19.pdf BC Centre for Excellence in HIV/AIDS (2009). Therapeutic Guidelines Accidental Exposure Guidelines. Retrieved from: tic_guidelines_nov82010.pdf BC Ministry of Health. Management of Percutaneous or Permucosal Exposure to Blood and Body Fluid/Laboratory Requisition. Retrieved from: 83B934E090A6/0/2339_fill.pdf Beekmann, S. E., & Henderson, D. K. (2005). Protection of healthcare workers from bloodborne pathogens. Current Opinion in Infectious Diseases, 18(4), Canadian AIDS Society. HIV Transmission: Guidelines for Assessing Risk.(2004). Retrieved from: Centers for Disease Control and Prevention (CDC). CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management. MMWR 2013; 62(RR-10):1-19. Centers for Disease Control and Prevention (CDC). Immunization of Health-Care Personnel. MMWR 2011;60(RR-07):1-45. Centers for Disease Control and Prevention (CDC). Updated U.S. public health service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for post-exposure prophylaxis. MMWR 2001;50(RR-11):43-4. FitzSimons, D., Francois, G., De Carli, G., Shouval, D., Pruss-Ustun, A., Puro, V., Williams, I., Lavanchy, D., De Schryver, A., Kopka, A., Ncube, F., Ippolito, G., & Van Damme, P. (2008) Hepatitis B virus, hepatitis C virus and other blood borne infections in healthcare workers: Guidelines for prevention and management in industrialized countries. Occup Environ Med, 65, Heathcote, J., & Main, J. (2005). Treatment of hepatitis C. Journal of Viral Hepatology, 12(3), Kuhar, D, Henderson, D, Struble, K, Heneine, W, Thomas, V, Cheever, L, Gomaa, A, & 11

12 Panlilio, A. (2013). Updated U.S. Public health service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. Atlanta: U.S. National Center for Emerging and Zoonotic Infectious Diseases. Maheshwari, A., Ray, S., & Thuluvath, P. (2008). Acute hepatitis C. Lancet, 372, Taylor D, Durigon M, Davis H, Archibald C, Konrad B, Coombs D, Gilbert M, Cook D, Krajden M, Wong T, Ogilvie G (2014 IN PRESS). Probability of a false negative HIV antibody test result during the window period: A tool for pre- and post-test counselling. International Journal of STD&AIDS. Wong, T., & Lee, S. S. (2006). Hepatitis C: A review for primary care physicians. CMAJ, 174(5),