Post Exposure Prophylaxis for HIV by liaoqinmei


									 Occupational Health Aspects of Infection
         Prevention and Control
• Legislative backdrop
• Infectious occupational hazards
• NSI prevention and management
• Role of OH
Occupational Diseases in Healthcare:

•   Specific occupational hazards
    encountered by healthcare workers are
    well-documented and generally fall into 5

     a)   Biological / Infectious hazards
     b)   Chemical hazards
     c)   Environmental / Mechanical hazards
     d)   Physical hazards
     e)   Psychological hazards
• The main legislation covering the risk of
  exposure to injury and infection from sharps at
  work is the Safety, Health and Welfare at Work
  Act, 2005 and the Safety, Health and Welfare at
  Work (Biological Agents) Regulations, 1994
  and amendment Regulations, 1998.
               Directive 2010/32/EU
•   Directive 2010/32/EU provides a legislative framework for the agreement on the
    prevention of sharps injuries in hospitals and the healthcare sector (signed in July
    2009) by the Social Partners
•   Each member state has 3 years to transpose the Directive into national legislation (by
    May 2013).
•   The aim of the Directive is:
     – To achieve the safest possible working environment
     – To prevent workers' injuries caused by all medical sharps
     – To protect workers at risk
     – To set up an integrated approach establishing policies in risk assessment, risk
        prevention, training, information, awareness raising and monitoring
     – To put in place response and follow up procedures
    Health and Safety Management
The employer must ensure that there is a management framework in place to protect
    the safety health and welfare of all employees and to provide a safe working
                       environment. Evidence of this includes;

                                            • A comprehensive education and
•   An up to date and relevant safety statement training program
•                                             • A robust
    A process of hazard identification and risk assessmentsystem of reporting of
•   Clear procedures on safe work practices     incidents including a systems cause
•   Access to competent advice                  analysis and identification of
                                              remedial measures
•   Consultation and communication with staff
                                          • A system to monitor, review and
                                                audit health and safety performance
                      Risk Assessment
    Risk assessment must be undertaken where there is potential for sharps
           injury. Risk assessment should include the following steps;

•   Identify the Hazards
•   Decide who might be harmed and how
•   Assess the Risk
•   Record the Findings of the risk assessment and implement them
          Who is responsible for carrying out any further actions
    A timescale for doing so.
•   Review and Revise (if necessary) the risk assessment on a regular, scheduled basis or
    ahead of schedule if something suggests that the original assessment is no longer valid
    e.g. as a result of an incident or a change in work practices.
 Controls Relating to the Prevention of Sharps

• The Department of Health and Children has stated that the
  most effective way of preventing transmission of blood-
  borne pathogens in the healthcare setting is to make the
  working environment as safe as possible by having good
  infection control practices, by the implementation of
  standard precautions and by the provision of effective risk
  management policies.
      Principles of Control

– Substitute
– Technological Measures
– Organisational Measures
– Personal Measures
 Substitution and Technological Measures

• Eliminating the unnecessary use of sharps by implementing
  changes in practice where this is possible.

• The provision of medical devices incorporating safety
  engineered protection mechanisms which are safe to use,
  based on risk assessment.

• Where these devices are provided healthcare workers must
  be trained in their correct use.
          Safe Use and Disposal of Sharps

• Specify and implement procedures for the safe use and
  disposal of sharp instruments and for the safe storage and
  disposal of contaminated waste.

• Workers must be made aware of the correct procedures and
  the procedures should be regularly assessed to ensure they
  are effective
    Organisational Measures

• Improving the work organisation and the
 work environment can help reduce the risk of
 injury, such as improving supervision to
 ensure compliance with safe work practices,
 ensuring good task lighting, etc
                 Personal Measures

• Where the risk assessment indicates that there is
  a risk of exposure to BBVs, the appropriate
  vaccines must be made available (free of charge)
  to the employee where required. It is also
  necessary to test for an appropriate response to
  the vaccine.
• Gloves, splash protection
                Other Measures
• Access to competent advice with regard to the management of
  sharps injuries may include access to competent occupational
  health advice and infection control specialists.
• Measures to raise awareness, and make available information
  and training on the relevant policies, procedures and preventive
• Post exposure Management
• Reporting
       Reporting of Accidents, Incidents and
             Dangerous Occurrences
• To the person in charge any work related accident, incident or
  near miss event, without unreasonable delay. This includes sharps
  injuries and near miss events

• Part X of the Safety, Health and Welfare (General Application)
  Regulations 1993, where a work related injury results in an
  employee being absent from work for 3 consecutive days or more,
  the employer must report it to the Health and Safety Authority
  (HSA) on line or by using an Form IR1
        Reporting of Accidents, Incidents and
              Dangerous Occurrences
• Biological Agents Regulations 1994 and amendment Regulations
   1998, the employer must inform the HSA of any work related
   sharps injury where the circumstances of the event are such that
   the incident could cause severe human infection/human illness e.g.
   a percutaneous injury with a contaminated sharp where the source
   patient is known or found to be positive for hepatitis B, hepatitis C
   or HIV. (Form IR3)
• There is a voluntary system of user reporting of incidents involving
   medical devices to the Irish Medicines Board
   Post Exposure Management
Post-exposure-rule of 3’s
1. Initial First Aid
2. Rapid Assessment and Treatment
        hepatitis B (Hepatect)
        HIV (Prophylaxis)
3. Appropriate Follow up
        Usually 6 weeks, 3 and 6 months
        Sometimes 12 months
Risk of occupational acquisition of
              a BBV
In General Terms this is related to:
• The prevalence of the virus in the patient population
• The efficiency of the virus transmission after a single
  contact with blood
• The nature and frequency of occupational blood
• The susceptibility of the healthcare worker
  Sharps Injuries/Blood and body
          fluid exposures
Rule of 3’s

•Risk depends on 3 things:

              1. Status of source
              2. Nature of injury
              3. Status of victim
Risk of Infection Following a
   Needlestick Exposure
3 main viruses
       1. Hepatitis B: 1.9% - > 40% (3 to 30%)
       2. Hepatitis C: 2.7% - 10% (about 3%)
       3. HIV: 0.2% - 0.44% (about 0.3%)

                                    Gerberding, New Engl J Med 1995
              Hepatitis C

• Follow up at 6 weeks, 3 months, 6 months,
 sometimes 12 months.
Hepatitis B
       Estimated risk of acquisition of HIV
Exposure route                          Risk per 10,000 exposures to infected
Blood transfusion                       9000 (90%)

Needle-sharing injection drug use       67 (0.67%)

Percutaneous needle stick               30 (0.3%)

Sexual intercourse                      5-10 (0.05-0.1%)

Oral intercourse                        0.5-1 (0.005-0.01%)

Eye, nose /mouth exposure to infected 0.1%
Skin exposure to infected blood         < 0.1%: Intact – no risk, broken skin –
                                        depends on extent of skin damage
                                        and amount of blood exposed to.
     Collated From US Dept of Health and Human Services Recommendations
            When to give PEP

1.   Establish if source person is infected with HIV or
     has higher risk of having HIV.

2. Establish exposure risk (significance)
              Significant Exposure
• Exposure = percutaneous injury (e.g., a needlestick or cut with a
  sharp object) or contact of mucous membrane or non-intact skin
  (e.g., exposed skin that is chapped, abraded, or afflicted with

• Infectious material:
       High risk: blood,
       Also may be of risk: cerebrospinal fluid, synovial fluid,
       pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid
       Low risk: Faeces, nasal secretions, saliva, sputum, sweat,
       tears, urine, and vomitus are not considered potentially
       infectious unless they are visibly bloody
     To give or not to give PEP
• Weigh risks and benefits of PEP
• There is a chance of toxicity from PEP. Lower exposure risk
  may not warrant treatment.
• Examples of when treatment generally not recommended
  are exposure to urine, nasal secretions, saliva, sweat or tears,
  not contaminated with blood, regardless of HIV status of
  source, skin intact in occupational exposure
• If seen >72 hours after exposure (unless source extremely
  high risk)
• If HIV source unknown – case-by-case determination:
  consider if source is high risk. Source needs to be tested if
                When to start

• The sooner the better – best chance of prevention of
  transmission is if PEP given within 24 hours of
  exposure. Preferably within 2 hours.

• If unsure whether to start, may be advantageous to
  start PEP regardless. Can be discontinued if felt
The current CUH recommendations for the
    choice of drugs for Post-Exposure
             Prophylaxis are:
• Combivir Tablets - 1 tablet - twice a day
  (Zidovudine and Lamivudine)

• Kaletra Tablets - 2 tablets - twice a day
  (Lopinavir 200mg and Ritonavir 50mg)
                 Side Effects
•   Tingling in hands and feet
•   Nausea, abdominal pain
•   Skin Rashes
•   Muscle Pain
•   Low Red and White Blood Cell Counts
•   Fatigue, insomnia
•   Dyslipidemia
•   Headache
•   Diarrhoea
    If source is HIV positive…

• Need to ascertain if he/she is resistant to any
  antiretrovirals – as will transfer resistant virus.
  Certain drugs may not be effective.
               Drug counselling
• Supplied initially with 5 day starter pack of antiretrovirals,
  then given remainder of 4 week supply at follow up
• How drugs work
• Length of treatment
• How and when to take them
• Side effects that may occur and how to deal with them
• Check for interactions with other medicines / herbal meds /
  recreational drugs taken
            Other counselling
• Risk of transmission very low
• Need to practice safer sex – use condoms
• Avoid blood /semen/ organ donation during 6 month
  HIV testing period
• Avoid breastfeeding during this period
• Report any sudden flu like illness: fever, rash, muscle
  aches, swollen glands – may suggest drug reaction
  or HIV infection
• Clear instructions on follow up
         Follow up monitoring
• HIV antibody test at baseline, week 6, 3 months, 6 months
  and possibly 12 months
• If acute retroviral syndrome symptoms, ID clinic follow up –
  test for HIV antibody and viral load.

• Also follow up at week 2 and week 4 of treatment in addition
  to above
 FBC week 2 and 4, LFT week 2 of treatment
  Making sure employees who join the
         organisation are well

• Pre-employment health assessments

• Immunisation Programs

• Ruling out active infections

• Minimising risk to the public or other staff
  Making sure that staff stay well during
• Advising on elimination and reduction of risk from
  hazards at work
• Managing staff contact with hazards at work such as
  tuberculosis, needle-stick injury, chemotherapy
  drugs, chemicals etc
• Assessing staff who may be unwell or under pressure
• A confidential counselling service
• Health promotion & education
• Medical management of illness/injury
• Physiotherapy Service
Helping to ensure that staff come to work
          and attend regularly

• Health assessments

• Sickness Absence management

• Advising on rehabilitation and redeployment

• Assessing applications for ill health

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