Occupational Exposures to Hepatitis B, C, and HIV: What you need to know W Y OMING DEPA R TMENT OF HEALTH

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1 Occupational Exposures to Hepatitis B, C, and HIV: What you need to know C OURTNEY SMITH, M PH C OMMUNICABLE DISEASE SURV E ILLANCE M A NAGER W Y OMING DEPA R TMENT OF HEALTH

2 Objectives Discuss characteristics of hepatitis B, C, and HIV Risks Transmission Progression Describe the epidemiology of these diseases in Wyoming Explore methods to prevent occupational exposures Describe the management of occupational exposures Understand recommendations for postexposure prophylaxis (PEP)

3 Hepatitis B Risks Unvaccinated Blood transfusions/components prior to 1992 Persons born in areas where hepatitis B is endemic People who inject drugs Those exposed to a hepatitis B positive person (sexual, drug use, household, occupational) Transmission Blood to blood exposure (needle stick, injection drug use) Mother to baby transmission Sexual transmission Can survive on surfaces for up to 1 week Progression 30-50% of adults and <10% of children experience acute illness 2-10% of adults and 30-90% of children will become chronically infected 15-25% of chronically infected experience premature mortality

4 Epidemiology Hepatitis B Approximately 30 (rate= 5.3/100,000) newly reported cases each year in Wyoming (2015 = 32) Relatively low incidence CDC estimates 2013 national incidence = 19,800 cases (6.2/100,000) Wyoming does not track prevalence, Hepatitis B Foundation estimates 2 million Americans live with chronic infection (0.6% of population) Risk of developing clinical hepatitis from occupational exposure to HBsAG positive = 1%-6%

5 Hepatitis C Risks Blood transfusions/components prior to 1992 Baby Boomers Current/past resident of a detention/correction facility People who inject drugs Men who have sex with other men HIV+ Transmission Blood to blood exposure (needle stick, injection drug use) Mother to baby transmission Sexual transmission (rare) *Transmission due to blood splashing into an eye is very low Progression <20% infected experience acute illness 60-85% will become chronically infected 15-30% of chronically infected develop cirrhosis

6 Epidemiology Hepatitis C Approximately 500 newly reported cases/year in Wyoming, increasing over time Rates of Hepatitis C and B Rate per 100, Hep C (chronic) Hep B In 2015, 56% of cases reported in Baby Boomers, 32% reported in year olds Risk of developing infection after occupational exposure: 1.8%

7 Epidemiology Hepatitis C 2015 Incidence by county/100, Wyoming does not track prevalence. CDC estimates prevalence is about 1.0% of the US population

8 HIV Risks Blood transfusions/components prior to 1992 People who inject drugs Unprotected sex with multiple partners, people who inject drugs, anonymous partners Transmission Blood to blood exposure (needle stick, injection drug use) Mother to baby transmission (birth and breast milk) Sexual transmission Progression Can progress to AIDS (HIV stage 3) if untreated

9 Epidemiology HIV cases/year in Wyoming. Of the 15 cases from 2015: Male Transmission (n=13): MSM (23%) IDU (23%) MSM & IDU (15%) Heterosexual sex (15%) No Risk Identified (15%) Female Transmission (n=2): Heterosexual sex (100%) Approximately 290 prevalent cases in Wyoming Laramie County = 31.8% Natrona County =13.0% Sweetwater County = 9.6% Risk of transmission through occupational exposure: 0.3%

10 Epidemiology Why is epidemiology important? When exposure source is unknown or cannot be tested and PEP may have risks, provider may consider the following when making follow-up plan for HCP. Prevalence of disease in population When/where exposure occurred Needle stick in which source was a 76 year old that came in for a knee replacement in Crook County VS Needle stick in which source was an injection drug user from Laramie County

11 Prevention of Occupational Exposure Treat all patients as if they are potentially infectious PPE and Standard Precautions Eliminate unnecessary needle use Use needles/blood draw equipment that have safety features Develop and ensure safe practices for needle use and discard Sterilization of medical and patient-care equipment Washing infected materials (sheets, blankets, etc.) Promote vaccination for hepatitis B

12 Management of an Occupational Exposure Have a clear, up-to-date, policy/procedure in place and training for staff Wash wounds/skin sites that have been in contact with blood or bodily fluid with soap and water Flush mucous membranes with water Report exposure Test the source

13 Management of an Occupational Exposure Hepatitis B Vaccination Status of HCP Source HCP PEP (if source is positive) Vaccinated: anti-hbs 10 miu/ml Vaccinated: anti-hbs <10 miu/ml Vaccinated: anti-hbs level unknown Incomplete Vaccination No testing needed No testing needed No PEP needed Test ASAP for HBsAg Test ASAP for HBsAG Test ASAP for HBsAg No testing needed Test ASAP for anti- HBs No immediate testing needed. *Testing those that are unvaccinated or incompletely vaccinated can be misleading 2 doses HBIG -1 dose ASAP -1 dose in 1 month Refer to appropriate PEP above for respective anti- HBs level 1 dose HBIG 1 dose Hep B vaccine -complete vaccine series according to schedule -test for anti-hbs 1-2 months after last dose of vaccine If the source patient is unknown: Hepatitis B vaccine should be administered if HCP is not vaccinated. *All HBsAG positive results should be reported to the Wyoming Department of Health and referred to appropriate care

14 Management of an Occupational Exposure Hepatitis C Test the source Perform baseline anti-hcv testing If positive, source should be referred to appropriate medical care and reported to the Wyoming Department of Health in accordance with State Statute If the source is positive for: Hepatitis C: 1. Test person exposed for a baseline anti-hcv and ALT AND 2. Conduct follow-up anti-hcv and ALT testing 4-6 months after exposure (RNA testing may be performed 4-6 weeks after exposure if an earlier diagnosis is desired) 3. Confirm infection for all anti-hcv results reported as positive If the source patient is unknown: The exposed person should be managed as if the source patient were positive for hepatitis C pathogens *PEP is NOT recommended for hepatitis C exposures

15 Management of an Occupational Exposure - HIV Recommendations were updated in September 2013 (US Public Health Service Guidelines) Test the source Perform baseline HIV testing If positive, source should be referred to appropriate medical care and reported to the Wyoming Department of Health in accordance with State Statute If the source is positive for: HIV: Start employee on PEP immediately, no later than 72 hours of exposure Short course, 28 days, three-drug regimen Three drug regimen now recommended for all exposures regardless of severity Baseline testing at time of exposure then at 6 weeks, 12 weeks, and 6 months (rapid, 3 rd generation, etc.) If testing w/ 4 th generation technology test at time of exposure, 6 weeks, and 4 months If source patient s results will not result quickly, HCP should be started on PEP and can discontinue once negative results are known

16 What if the source patient is unknown? The exposed person should be managed as if the source patient were positive for bloodborne pathogens

17 Special Considerations for HIV PEP When to consult an expert: Delayed exposure report (after 72 hours) Unknown source Pregnancy in exposed person Breast-feeding in exposed person Known or suspected resistance to antiretrovirals Toxicity of PEP regimen Serious medical illness in the exposed person

18 Questions? -Hepatitis B and C: Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. (2001, CDC MMWR 50(RR11); 1-42) -HIV: Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. (2013, Kuhar et al)