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Rapid HIV testing in Health Care Worker Exposures

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					     Getting Unstuck
Guide to Occupational Blood-
   Borne Pathogens exposure
               Management

          Ellen M. Tedaldi, MD
   Director Temple HIV Program
Blood Borne Pathogens Exposure
What type of
 exposure?: needle
 stick, eye splash,
 puncture wound, cuts

What blood
 pathogens are of
 concern? : HIV,
 hepatitis C and B
   Occupational Risk Exposures in Health
                        Care Personnel

 Percutaneous injury       WITH:
  (needlestick, cut)
                           • Blood
  OR                       • Tissue
                           • Other body fluids that
 Contact of mucous          are potentially infectious
  membrane or non-intact     (cerebrospinal, synovial,
  skin                       pleural, pericardial,
                             peritoneal, or amniotic
                             fluids; semen or vaginal
                             secretions)




                                  December 2007
  NOT Considered Infectious for HIV,
              unless Visibly Bloody

Feces              Sweat
Nasal Secretions   Tears
Saliva             Urine
Sputum             Vomitus
                                       AE
                                       TC
                                       Na
                                       tio
                                       na
                                         l
                                       Re
                                        so
                                        ur
                                       ce
                      December 2007
                                       Ce
         Factors Associated with Increased Risk

Visible contamination of device (such as
 needle) with patient’s blood

Needle having been placed directly into vein
 or artery

Hollow-bore (vs solid) needle

Deep injury

Source patient with terminal illness

High viral load
 (not established in occupational exposure)
          AETC National Resource Center, www.aidsetc.org   December 2007
Risk of HIV Infection following Occupational
Exposure to HIV-Infected Blood

        Approximately 0.3% following
         percutaneous exposure

        Approximately 0.09% following
         mucous membrane exposure




                                 December 2007
             What to do if you have an
                            exposure ?
Immediately after
 exposure
  • Wash affected area
    thoroughly
  • Report to supervisor
  • Start incident report
    (MIDAS)
                  Report for assessment
Health Care
 Worker (HCW)
 goes to
 Occupational
 Health* from 9AM-
 4PM Monday-
 Friday.
Evenings/and
 weekends to ER.
Occupational Health services = OHS
Labs to be drawn on Health Care
                        Worker
Baseline rapid HIV Review Health
 antibody test        Care Worker’s
 (standard )          vaccination history
Hepatitis C          for hepatitis and
 antibody             tetanus
Hepatitis B surface For women, verify
 antibody and         pregnancy status
 antigen
RPR (syphilis)
             If PEP (Post-Exposure
         Prophylaxis) to be started
CBC
Basic Metabolic
Hepatic Panel
                     LPVr (Kaletra)




                   TDF/FTC
                   (Truvada)
               Evaluation by ER or
              Occupational Health
ER or OHS doctor
 decides if
 exposure is
 significant.
If significant,
 Medical Consult
 resident (day) or
 House Chief
 (night) is called to
 evaluate source
 patient
   Evaluation of source Patient
Med
 Consult/House
 chief reviews chart
 for HIV, HBV, HCV
 status
Discusses need for
 testing with source
 patient including
 info on HIV test
         HIV Consent of the Source
                            Patient
As of 9/6/2011—Act 59 Amendment in PA, No
 need for separate written consent required.

Do need to talk to patient- statement below is
  part of new HIV order:
I OBTAINED INFORMED CONSENT THAT
  INCLUDED AN EXPLANATION OF THE TEST,
ITS PURPOSE, POTENTIAL USES, LIMITATIONS
  AND THE MEANING OF ITS RESULTS.
  Labs to be drawn on Source Patient
Rapid HIV test
 (blood)
Acute Hepatitis
 panel (Hep C
 antibody, Hep B
 surface antigen
 and core antibody
 IgM
HIV 1/2 antibody
 + p24 antigen
   If patient known to be HIV+
Need CD4
HIV RNA PCR
 (viral load)
Current
 antiretroviral
 therapy
Any Genotype
Consult HIV
 doctor if possible
   If source patient’s HIV and HCV status is
                                    known
If source patient is   If source patient is
 HIV+:                   HCV antibody+:

Need HIV PCR           HCV PCR quant
 quant (Viral Load)      (Viral load)
HIV -1 genotype
   Obtaining sample from source
                         patient
Medical consult or house chief calls
 Phlebotomy to do “stat” draw blood if
 patient a floor patient.
ICU or ED source patient-blood drawn
 by nursing
Medical consult places order in TDS
 system
Blood sent to chemistry lab
on second floor
INSERT SLIDE HERE WITH
         ORDER SCREEN
                    Lab Ordering Guide
            Select >Needle stick Labs or
select >N under Index To All Blood Tests
                                               Needlestick Labs
This screen displays if selected Needlestick Labs (slides 1 or 2).
             Select appropriate answer to statement (Yes or No)
                                  Needlestick Labs
Select appropriate answer to statement (Yes or No)
                             Needlestick Labs
This screen displays when either YES or NO is
         selected on previous screen (slide 4).
   The Ambulatory source patient
If source patient is coming from a clinic
 and goes to ER: rapid test on blood is
 brought to SECOND FLOOR lab.

If source patient goes to
Occupational Health, the
HIV Rapid test is
performed there.
  What if source patient refuses? Can’t
                              consent?
Statute 148 in PA
 (amended 9/6/11)
 allows HIV to be
 drawn on available
 blood*



*i.e. CBC less than 24
 hours old
    HIV Test ordering & results
HIV Rapid testing results placed into MIS
 system
                                  Test results
Source is NEGATIVE          Source is POSITIVE

No PEP* for HCW             HCW starts PEP if
Disclose result to           exposure is significant
 source patient              Source patient has
Follow up in OHS             confirmatory HIV
                              ELISA and Western
                              Blot drawn for
                              confirmation
                             Disclosure to source
                              patient by primary
*Post-exposure prophylaxis    team
  Follow up for source patient who tests Reactive
                         on rapid HIV screening

If rapid screen is positive, contact
 Needle stick attending (AMION)

If source patient has positive
 confirmatory test, consult HIV program at
 215-707-2401
                PEP for Percutaneous Injuries

Exposure Type                   Infection Status of Source

                    HIV+, class 1    HIV+, class 2
Less severe         Recommend        Recommend
                    basic 2-drug PEP expanded ≥3-drug
                                     PEP
More severe         Recommend        Recommend
                    expanded 3-drug expanded ≥3-drug
                    PEP              PEP


                December 2007           AETC National Resource Center, www.aidsetc.org
                                        PEP for Percutaneous Injuries (2)


Exposure Type                       Infection Status of Source

                 Unknown HIV status*                       Unknown source
Less             Generally, no PEP                         Generally, no PEP
severe           warranted; consider basic 2               warranted; consider
                 -drug PEP if source has HIV               basic 2-drug PEP if
                 risk factors                              exposure to HIV-
                                                           infected persons is likely
More             As above                                  As above
severe

 *If PEP is given and source is later determined to be HIV negative,
 PEP should be discontinued.


                    December 2007           AETC National Resource Center, www.aidsetc.org
  How Many Drugs to Use? (2)
Assess risk for HIV infection:
Type of exposure
  • Less severe: solid needle or superficial injury
  • More severe: large-bore hollow needle, deep
    puncture, visible blood on device, needle used
    in patient’s artery or vein
Infection status of source
  • Class 1: asymptomatic HIV infection or known
    low viral load (<1,500 copies/mL)
  • Class 2: symptomatic HIV, AIDS, acute
    seroconversion, or known high viral load
                                  December 2007
    Which Drugs to Use?
                                  (3)


Basic 2-drug regimens:
Preferred:
  • ZDV + 3TC or FTC
    (Combivir)
  • TDF + 3TC or FTC
    (Truvada)***

Alternative:
  • d4T + 3TC or FTC
  • ddI + 3TC or FTC


                         December 2007
                             Which Drugs to Use?
Expanded ≥3-drug PEP + basic 2-drug
 regimens:            regimen
Preferred:
    • LPV/RTV (Kaletra) +
      basic 2-drug regimen
Alternative:
RAL = Isentress
    •   ATV* ± RTV
    •   FPV ± RTV
    •   IDV** ± RTV
    •   SQV + RTV
    •   NFV***
    •   EFV***
* If ATV is co-admnistered with TDF, RTV
   must be included in the PEP regimen.
   ** Avoid in late pregnancy.
    *** Avoid in pregnancy.
                          Stay tuned
Current PEP guidelines from 2005

Alternative: TDF/FTC (Truvada( +
 Raltegravir (Isentress)

This regimen especially for those HCW’s
 unable to tolerate meds
         Source patient is HCV+
No protocol for acute prophylaxis or anti
 -HCV treatment
perform follow-up testing (e.g., at 4–6
 months) for anti-HCV and ALT activity (if
 earlier diagnosis of HCV infection is
 desired, testing for HCV RNA may be
 performed at 4–6 weeks).
                   Useful Websites

http://aidsinfo.nih.gov/

National HIV/AIDS Clinical Consultation
 Center
http://www.nccc.ucsf.edu/

http://www.osha.gov/SLTC/etools/hospi
 tal/hazards/bbp/bbp.html#Ninjuries

				
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