Protocol for the Prevention of Infection of Council Employees Through Exposure to Blood

1

Annexure ‘B’

PROTOCOL FOR THE PREVENTION OF INFECTION OF COUNCIL EMPLOYEES THROUGH EXPOSURE TO BLOOD BORNE PATHOGENS

OBJECTIVES

• To know and practice Universal Precautions at all times.
• To know the risks of exposure to blood and body fluids.
• To know the procedure if an episode of exposure occurs.
• To understand and think about the tests that need to be done during an exposure situation.
• To decide on a plan of action if the situation arises.

1. PRECAUTIONARY MEASURES

1.1 Personal procedures

• Regard all patients as possibly HIV infected and take precautions at all times – i.e. Universal Precautions.
• All blood and body fluids should be treated as potentially infective.
• Use good basic hygiene practices including hand washing and avoidance of hand-to-mouth contact.
• Cover all skin lesions such as cuts, abrasions that you may have with waterproof dressings until they are fully healed.
• Wear gloves to protect yourself. If the lesions cannot be covered then staff must avoid handling blood and body fluids.
• Prevent puncture wounds, cuts and abrasions. Needles must not be recapped or stripped.

1.2 Equipment and clothing

• Always place syringes and needles in a safe disposal box immediately after use.
• Sharps must be disposed of in puncture resistant sharps containers.
• Supervise the storage, transport and incineration of the syringes and needles in disposal box and maintain records of disposal and destruction.
• Clean and disinfect all surfaces with chlorinated detergent.
• Dispose all contaminated waste in leak-proof containers.
• Soiled linen should be handled as little as possible.
• Wear gloves and a plastic apron when handling contaminated linen, dressings etc.
• Soak in hypochlorite. (1% hypochlorite should be diluted five fold (1:4).) Transport in leak-poof bags.

Appropriate personal safety equipment should be used at all times - such as gloves masks, goggles and aprons.

Use only sterile equipment for all procedures and remember to clean all equipment before sterilization.

Transmission of BBP can also occur from patient to patient and from employee to patient. Provided the precautionary measures are followed, the risk is minimal.

MANAGEMENT OF EMPLOYEE’s FOLLOWING OCCUPATIONAL EXPOSURE TO BLOOD-BORNE PATHOGENS

STEP 1Ask source patient to remain in the clinic, (He/She has the right to refuse).

STEP 2 FIRST AID

• Allow the wound or needle prick to bleed
• Wash the area thoroughly with any available antiseptic soap and water
• Mucous membranes should be flushed with water for 3 minutes
• Report incident to the operational facility Manager/Health and Safety Representative immediately
• Establish risk of exposure – whether no risk, mild risk or sever risk.

STEP3ASSESSMENT OF INFECTION RISK AFTER EXPOSURE

After an occupational exposure the patient/client (source person) and the exposed employee should be assessed to determine the risk of exposure to HIV, Hepatitis B and C virus and other blood-borne pathogens.

The exposure should be evaluated for potential to transmit HIV or other viruses, the type of body substance involved, the route and severity of exposure e.g. is it a deep penetrating injury, is blood visible on the needle, is the needle in a vein or artery and s the needle a hollow-bore needle.

The average risk of HIV infection after a needle-stick exposure to HIV-infected blood/body fluid is 0.3% (about 1 in 300) i.e. 99.7% of needle-stick exposures do not lead to infection.

The risk after exposure of the eye, nose or mouth to HIV-infected blood is estimated to be 0,1% (1 in 1000)

The risk after exposure of the skin to HIV-infected blood is estimated to be less than 0.1%. If the skin is damaged or if the contact involves a large area of the skin, the risk may be higher.

Risk from all exposures is increased if the exposure involves a larger volume of blood or a higher amount of HIV in the patient’s blood (i.e. Source patient) has full blown AIDS

NO RISK

/ LOW RISK / HIGH RISK
No evidence of any significant exposure or superficial injury splashes onto intact skin / - Any superficial injury
- Exposure to small volume of blood
- Exposure to blood contaminated fluids from a symptomatic HIV positive patients with low viral titre
- Solid needle injury / - Exposure to a large volume of blood or potentially infectious fluids
- A deep penetrating injury
- Visible blood on the needle or hollow bore filled with blood
- The needle was in a vein or artery of the source patient
- Exposure to blood or blood contaminated fluids from a patient with high viral titre i.e. in AIDS phase or early sero conversion stage of HIV
Table 1: Risks of transmission of blood-borne pathogens following occupational exposure

VIRUS

/ RISK
HIV
Hepatitis B – eAg negative
- eAg positive
Hepatitis C
Ebola
Congo – Crimean hemorrhagic fever / 0.1 – 0.4%
2%
20 – 40%
1.2 – 10%
High
Moderate to high

STEP 4EVALUATE SOURCE PATIENT (SP) INFORMATION

Testing of the SP can help to avert unnecessary testing and anxiety.

Check the patient’s history and clinical records to establish which BBP the patient is most likely to be exposed to. If possible, the situation should be explained to the patient, permission obtained to do blood test and counselling. Based on clinical findings a decision should be made about what tests need to be done.

1. HIV: Counselling (pre and post test) must be provided and informed consent obtained. If patient refuses to consent to testing for treatment purposes it should be assumed that SP is HIV positive. If consent is obtained test for HIV antibodies and results should be available within 24 hours.

1. Syphilis serology: RPR test is recommended. Treat patient according to result.

1. HBeAg and HBsAg: Testing for Hepatitis B is recommended if the health worker has not been immunised or the status is unknown.

1. Hepatitis C: Testing for Hepatitis C is recommended.

Blood samples source patient
1 x 5 ml red tube for HIV Antibodies + RPR
1 x 10ml red tube HBsAg, HBsAb, HBcAb, HCV
Labelled Urgent. Get results back within 24 hours

If the SP is unknown or unavailable or refuses to be tested then follow-up care of the employee should be based on the best estimate of the risk of infection.

STEP5MANAGEMENT OF EXPOSED EMPLOYEE

1. Counselling of the employee

This is a sensitive matter and the employee should decide whether colleagues or a Counsellor elsewhere should do counselling.

Staff member should have the operational manager/colleague accompanying him/her if so desired.

Counselling should be done immediately. The facility manager/or similar needs to ensure that this is done and that the staff member is fully supported throughout the process.

1. Decide the risk of exposure

According to information available from Step 3. The risk of exposure guides the use of post exposure prophylaxis (PEP).

Establish whether the employee is pregnant – if not, make sure that she remains so (provide contraceptives if necessary) – if pregnant, the risk of taking PEP should be carefully considered. Most occupational exposures do not lead to HIV infection and the possible side effects should always be considered against the benefits of taking PEP.

Evaluation should also include information about the medication the employee may be taking and any current or underlying medical conditions (i.e. pregnancy, breast-feeding or renal or hepatic disease) that may influence drug selection. Establish pregnancy, avoid it-provide contraception. The risk should be carefully considered before deciding whether to take PEP.

If no risk, or decision is taken not to administer PEP, reassure employee and give health education on transmission of HIV. Re-affirm Universal Precaution.

1. Obtain blood samples

For low-risk and high-risk exposure obtain blood samples as follows:

Have baseline blood samples done for: HIV, Hepatitis B&C, Syphilis Serology,

BLOOD SAMPLES
NB: All tubes must be full

For all injuries

1x5 ml red stopper tube: HIV antibodies & RPR
1x10 ml red stopper tube: HBsAg, HBsAb, HBcAb,
HCV Only if Prophylaxis is used:
1x5 ml purple stopper tube: FBC
1x5 ml red stopper tube: U&E, LFT, k CPK,
LDH Amylase

Bloods to be submitted to SAIMR for testing. Label blood specimen as “exposed staff member” - accounts to be forwarded to the Department. Results should be strictly confidential.

1. Post Exposure Prophylaxis (PEP) for exposure to HIV (28 day treatment can still be started within 72 hours – but it is less effective).

PEP should be started urgently, preferably within 2 hours after exposure. Initiating therapy after a longer interval e.g. 1-2 weeks may be considered for exposures that represent an increased risk for transmission.

The selection of a drug regiment for HIV PEP must strive to balance the risk for infection against the potential toxicity of agents used. Because PEP is potentially toxic, its use is not justified for exposures that pose a negligible risk for transmission.

STARTER PACK WILL BE SUPPLIED TO EMPLOYEES, (Supplied by Regions).

The rest of the 28-days treatment will be administered at the Occupational Health and Safety Department.

REGIMEN CATEGORY / APPLICATION / STATUS
SOURCE PATIENT
No risk / No evidence of any significant exposure or superficial injury. / Re-assure employee & health education transmission. / -
Lower risk exposure. / Any significant non-penetrating exposure (e.g. Heavy mucosal or skin splashes) or superficial penetrating injury with solid e.g. suturing needle. / Issue AZT 200 mg and 3 TC 150mg within 1 hour from 3-day starter pack. Refer to Occupational Health and Safety Department for further management / * If the source patient is HIV positive continue with prophylaxis.
* If the employee is HIV+ thus previously infected, refer for medical management and support/counselling.
Higher risk exposure / Deep penetrating exposure e.g. large volume of blood. / Same as above Indinavir 800mg, 8 hourly should be added. Refer to Occupational Health and Safety Department for further management.

STEP 6FOLLOW-UP MANAGEMENT

• Employees with occupational exposure to HIV should receive follow-up counselling, at any of one of our facilities as mentioned earlier. HIV serology to be repeated at 6 weeks, 3 months and 6 months.

• Drug-toxicity monitoring should be performed at baseline and again at 2 weeks after starting PEP. Clinical judgement, based on medical conditions that may exist in employee and toxicity associated with other drugs should determine scope of testing. (FBC + platelets, LFT at 2 and 4 weeks, U&E, Muscle enzymes). The clinician of referral centre will manage the latter.

• However all exposed employees must be carefully monitored for any signs of HBV, HCV, Syphilis and/or VHF, (see page 7/8 for symptoms)

The employee must be informed about:

• The side effects of PEP drugs: The side effects may induce or interfere with the normal health of a person and sick leave may be increased as a result. General side effects are nausea, fatigue, headache, muscle pains, insomnia. Indinavir should be taken one hour before meals, fatty foods to be avoided. Increase fluid consumption.

• Knowledge about the efficacy and toxicity of drugs used for PEP is limited, only ZDV has been shown to prevent HIV transmission in humans. There are no data to address whether adding other anti-retroviral drugs provide any additional benefit, however, experts recommend combination regimens because of increased potency and concerns about resistant virus.

• Employee may decline any or all drugs for PEP.

• The employee should avoid becoming pregnant and having unprotected sex during the monitoring period.

• If the employee is pregnant, the evaluation of risk and need for PEP should be approached as with any other employee who has had an HIV exposure. However, the decision to use any anti-retroviral drugs during pregnancy should involve discussion between the woman and her health-care (gynaecologist) provider regarding the potential benefits and potential risks to her and her foetus.

RECOMMENDATIONS FOR POST-EXPOSURE PROPHYLAXIS (PEP) FOR EXPOSURE TO HBV, HCV OR HIV

Of course, the first step recommended is immediate treatment of the exposure site with washing of wounds and skin with soap and water and flushing mucous membranes. Thereafter, the type of fluid and exposure should be assessed and any potential exposure should have the appropriate laboratory determinations made.

The use of PEP in a person potentially exposed to HBV depends upon the vaccination and antibody status of the exposed person, as well as the hepatitis B surface antigen (HbsAg) status of the source person. Therefore, assessing the need for PEP involves an assessment of the exposure, examining the history of HBV vaccination and vaccine response in the exposed person, and testing the source for the presence of HbsAg.

If the source person is HbsAg negative, no prophylaxis is required, but consideration should be given to vaccination of the exposed person if vaccination has not previously been given or if protective levels of hepatitis B surface antibody (HbsAb) are not present.

If the source person is HbsAg positive, no prophylaxis is required in any patient with adequate HbsAb levels due to prior vaccination; however, patients who do not have protective HbsAb, whether previously vaccinated or not, should receive hepatitis B immunoglobulin (HBIG) [0.6 mL/kg IM] and the HBV vaccine or a second dose of HBIG.

If the HbsAg status of the source person is unknown, all unvaccinated persons should be vaccinated and patients with a high-risk exposure should be treated as if the source were known to be HbsAg positive.

No post-exposure prophylaxis is recommended for HCV; however, the patient should be monitored for evidence of HCV infection. [Note: Recent data suggest that early treatment of HCV infection may be more likely to result in sustained virologic response. Therefore, consideration should be given to treatment of any exposed person who experiences HCV seroconversion.]

Needless to say, patients with any potential exposure to HBV or HCV should be monitored carefully and often. Follow-up testing should be performed regularly following the exposure, for at least 6 months. Further, patients should be advised of signs and symptoms of acute HBV and HCV seroconversion and advised to seek immediate medical attention if this is suspected.

VIRAL HAEMORRHAGIC FEVER

V.H.F is the collective name given to the diseases caused by a group of viruses such as Ebola virus and Marburg virus. Viral H.F. begins with fever and muscle aches and can result in a relatively mild illness or can lead to death.

The disease is contracted through direct contact with blood, semen or other body fluids.

There is no known treatment for V.H.F. Treatment for these infections is mainly supportive. There is no vaccine to prevent either of these viral infections.

STEP 7REPORTING OF EXPOSURE

1. All injuries must be immediately reported to appropriate supervisor and health and safety representative.

1. Complete form as required.

• WCl2 (Employers report of an accident.

1. Record data in register: Data to be captured to include the following:

• Date and time of incident
• Name and SAP number of employee
• Where incident occurred
• Name and clinic number or contact details of source patient where possible.
• PEP administered and time frame
• COID completed WCl2 form to be submitted to COID
• Mechanism of exposure
• Activity in progress at time of exposure
• Precautionary measurers used.
• Patient co-operation

Register to be kept at clinic/departmental administration office

SYPHILIS

Syphilis is a chronic infection caused Treponema pallidum, is usually sexually transmitted but rarely, can be transmitted through contact with blood. It has an incubation period of (3) three weeks.

An RPR blood test will determine the syphilis status of an individual and the treatment protocol is attached as Annexure ‘B’.

CONCLUSION

The most effective way to prevent transmission of BBP in the health care setting is the implementation of Universal Precautions.

However, the importance of the moral and physical support of the employee in the event of exposure to BBP cannot be over emphasized. It should be remembered that every person has the right to privacy, dignity, autonomy and bodily integrity.

REFERENCE

1. CDC: Public Health Services Guidelines for the Management of Health Care Worker exposure to HIV and Recommendations for post exposure Prophylaxis.

MMWR1998 (Vol47 noRR7).

1. Aids Care policies for Gauteng Province February 1997.
2. AIDSTEC: Information Pack: Workshop for Mental Health Professional and Experienced counsellors 1998.
3. Aspects of the Law relating to AIDS 1997.
4. Aids and the Law: Maintaining the Balance: Ann Strode Information for Health Care Workers: Occupational exposure to HIV: Glaxo Welcome.
5. Policy documents:

• Needle Stick Policy SMLC: Community Health 1998 – Prophylaxis and steps to take after possible exposure of Health Care Workers in the Central Wits Region to Blood Borne Pathogens: Dr L Pein 01-09-98
• Occupational exposure to Blood Borne Pathogens Needle stick injury protocol Dr L Pein 23.11.98
• Occupational exposure to blood borne pathogens
• Needle stick injury protocol – WMLC 1998.
• Protocol following a needle stick or sharp injury or splash of body fluid into face of Health Care Worker: Coronation Hospital- Infection Control 1998.
• Hospital Health Care Workers following possible risky exposure to HIV – March 1997.
• First draft HIV/AIDS policy for GJTMC: 1995
• Draft Policy Durban North Central and South Central Local Councils

Compiled by A Barnard & Dr N Mayet January 2000.

Revised by Occupational Health and Safety Department – Metro Centre