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OSHA: Occupational Exposure to Bloodborne Pathogens (FL Autonomous Practice INITIAL Pharmacology)

2 Contact Hours including 2 Advanced Pharmacology Hours
Only FL APRNs will receive credit for this course
This course is only applicable for Florida nurse practitioners who need to meet the autonomous practice initial licensure requirement.
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP)
This course will be updated or discontinued on or before Sunday, October 22, 2023
FPTA Approval: CE21-536907. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.
BOC
Outcomes

≥92% of participants will learn the importance of using standard precautions and to update the healthcare professional on current treatment for occupational exposure to a bloodborne pathogen.

Objectives

After completing this course, the learner will be able to:

  1. Categorize the benefits of strategies that prevent exposure to bloodborne pathogens.
  2. Outline safe injection practices.
  3. Identify immediate post-exposure treatment.
  4. Describe disease-specific, post-exposure treatment recommendations.
  5. Describe post-exposure follow-up recommendations.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Dana Bartlett (RN, BSN, MA, MA, CSPI)

Introduction

Exposure to bloodborne pathogens, particularly hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV), is a constant risk for healthcare workers (Aljohan et al., 2021; CDC, 2019a; CDC, 2016a; Shenoy & Weber, 2021; Weber, 2020). Transmission of and infection with HBV, HCV, and HIV after an occupational exposure is very uncommon (CDC, 2016a). Still, needlestick and sharps injuries and splashes with blood and body fluids, situations that put healthcare workers at risk, are not (Mengitsu et al., 2021). This module will discuss the epidemiology and transmission of HBV, HCV, and HIV in healthcare settings and the prevention and treatment of exposure to these pathogens.

The term occupational exposure is frequently used in this module, and it refers to exposure in a healthcare setting.

Case Study

A nurse working in an emergency room (ER) is caring for a patient who has almost certainly taken an overdose of fentanyl. The patient has been treated many times before for fentanyl overdoses, and today he was found at home and had the characteristic signs and symptoms of opioid poisoning. The emergency medical services personnel at the scene determined that at the time, the patient could be safely managed and transported with the use of supplemental oxygen alone.

The nurse begins to insert an IV catheter into the patient's arm. However, before he can complete the procedure, the patient wakes up, he forcefully pulls back his arm, and the IV catheter — which is visibly covered with blood — slips out of the patient's arm, and the tip punctures the nurse's finger. The nurse places a pressure dressing on the catheter insertion site. He removes his gloves, washes the puncture wound with soap and water, and registers as a patient in the ER. The nurse is 29 years old, and he does not have any acute or chronic medical problems.

Because the nurse suffered a penetrating needlestick injury, the needle was contaminated with blood, and the source has a high risk of being infected with a bloodborne pathogen. This incident is an exposure that puts the employee at risk for infection with a bloodborne pathogen. The OSHA Bloodborne Pathogens Standard's definition of exposure is "a specific eye, mouth, other mucous membranes, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties."

The triage nurse draws a blood sample from the nurse, and the sample is sent to the laboratory to be tested for HCV antibodies and HIV antigen, and HIV antibodies. The nurse has completed the HBV vaccination series, and his post-vaccination HBV surface antibody level was ≥ 10 IU/mL, so he is protected against HBV infection. A sample of the patient's blood is sent to the laboratory. It will be tested for HBV antigen and HBV antibodies, HCV antigen and HCV antibodies, and HIV antigen and HIV antibodies. A rapid-result HIV test will be done for the employee and the source, and the results of these tests should be available within ~ 20 minutes. Post-exposure prophylaxis (PEP) for HIV should be started within several hours after exposure, so the nurse and the provider decide to wait for the test results and not begin PEP. The provider explains to the nurse that there is no effective prophylaxis for HCV.

The nurse and the patient are HIV-negative, but the patient has a measurable level of HCV RNA; the nurse's HCV tests are negative. The patient will be referred to a clinician for evaluation. The nurse makes an appointment to have an HCV RNA test done in three to six weeks. This test is negative, and a follow-up HCV antibody test four to six months after the exposure is done. This test is negative, and no further testing is needed.

Epidemiology

Hepatitis B, HCV, and HIV are transmitted by contact with blood or infected body fluids; the contact can occur by a percutaneous injury, e.g., a needlestick or a sharps injury, by contact with a mucous membrane, or by exposure to non-intact skin. (CDC, 2020a; Fauci et al., 2018; Shenoy & Weber, 2021; Weber, 2020).

The Occupational Safety and Health Organization (OSHA) definition of blood is blood, human blood components, and other products made from human blood (OSHA, 2016). The Occupational Safety and Health Administration considers these body fluids potentially infectious:

  • amniotic fluid
  • blood, organs, or tissues from experimental animals that are infected with HBV or HIV
  • cerebrospinal fluid
  • HBV- or HIV-containing culture medium and other solutions
  • HIV-containing cell cultures, organ culture, or tissue cultures
  • pericardial fluid
  • peritoneal fluid
  • pleural fluid
  • saliva during a dental procedure
  • semen
  • synovial fluid
  • unfixed tissue or organs, except for intact skin, from a dead or living human
  • vaginal secretions(OSHA, 2016)

Also, OSHA states that any bodily fluids visibly stained with blood should be considered potentially infectious (OSHA, 2016). Body fluids should be considered potentially infectious "in situations where it is difficult or impossible to differentiate between body fluids (OSHA, 2016)."

Occupational exposures to bloodborne pathogens are common. Each year, it has been estimated that in the United States, 600,000 to 800,000 healthcare workers get a needlestick or a sharps injury (Fauci et al., 2018). Mengitsu et al. (2021) did a systematic review and meta-analysis of the published literature. The authors found that worldwide, the career and the previous year prevalence of needlestick injuries in healthcare workers was 56.2% and 32.4%.

Transmission of and subsequent infection with HBV after occupational exposure to the virus is common; transmission of and subsequent infection with HCV and HIV after an occupational exposure is not.

  • The risk of developing serologic evidence of HBV infection after occupational, percutaneous exposure has been reported to be 37% to 62% (Shenoy & Weber, 2021; Weber, 2020), and the risk of developing clinical hepatitis has been reported to be 22% to 31% (Shenoy & Weber, 2021; Weber, 2020). A splash contact can transmit hepatitis B to a mucous membrane (Schillie et al.,2018). There are no reported incidents of transmission of HBV through intact skin (Chilaka et al., 2020).
  • The risk of HCV transmission from occupational, percutaneous exposure is estimated to be 0.2% (Moorman et al., 2020). Ergo et al. (2017) did not find any evidence of HCV transmission in 449 mucocutaneous exposures. There are no reported incidents of transmission of HCV through intact skin (Chilaka et al., 2020).
  • In the United States, there have been 58 documented cases of HIV infection contracted by healthcare workers, 150 possible cases, and no reported cases since 1999 (Fauci et al., 2018). The risk of HIV transmission from a needlestick/sharps injury has been estimated to be 0.23%, and from a mucous membrane exposure, 0.09% (Fauci et al., 2018). The risk of HV transmission after mucous membrane exposure has been estimated to be 0.09% (Fauci et al., 2018; Shenoy & Weber,2021). Transmission of HIV through non-intact skin has occurred, but the level of risk for this type of exposure is unknown (Fauci et al., 2018). There are no reported incidents of transmission of HIV through intact skin (Chilaka et al., 2020).

The risk of transmission of and infection with HBV, HCV, or HIV to healthcare workers depends on the HBV vaccination status of the employee, how common these viruses are in the patient population, the viral load of the source, and how the exposure occurred (Weber, 2020; Zachary, 2019). Transmission and infection are more likely to occur if the patient has a high viral load; if the needlestick was from a hollow bore needle; if the needle had been in an artery or a vein; the injury is deep; there was visible blood on the needle/instrument, or if a large volume of blood was involved (Weber, 2020; Zachary, 2019).

Situations that increase the risk of a needlestick injury include, but are not limited to:

  • CDC (2021a):
    • recapping a needle
    • transferring a body fluid from one container to another
    • failing to use or incorrectly using a safety-engineered sharp
    • incorrectly disposing of a used needle
  • Weber (2020):
    • obtaining a venous blood sample
    • suturing
  • Canadian Centre for Occupational Safety and Health (2018):
    • accessing an IV line
  • Cooke & Stevens (2017):
    • mental and physical stress
    • long working hours
    • understaffing

Prevention

Avoiding occupational blood exposures is the primary way to prevent the transmission of bloodborne pathogens in healthcare settings. The Occupational Safety and Health Administration Standard 1910.1030, Bloodborne Pathogens, mandates that in a workplace in which employees may be or are exposed to bloodborne pathogens, the employer must develop a written exposure control plan "designed to eliminate or minimize employee exposure” (OSHA, 2016). An exposure control plan has many parts; the ones that directly concern healthcare professionals include:

  1. Hepatitis B vaccination
  2. Engineering controls
  3. Standard Precautions
  4. Safe injection practice
  5. Post-exposure evaluation, treatment, and follow-up

The recommendations in Standard 1910.1030 differ slightly from infection control advice from the CDC and other authoritative sources. These differences are not important; the essential content and the basic recommendations are the same.

Hepatitis B Vaccination

Standard 1910.1030 states that employers must offer hepatitis B vaccination to at-risk employees at no cost (OSHA, 2016). Employees are exempt if they are vaccinated, antibody testing shows that they are immune, or the use of the vaccine is contraindicated (OSHA, 2016; OSHA, 2011).

Engineering and Work Practice Controls

Engineering controls are devices, equipment, and procedures that help reduce the risk of exposure to bloodborne pathogens (OSHA, 2016). Examples of engineering controls mentioned in Standard 1910.1030 are disposal containers for needles and sharps, needleless systems for self-sheathing needles, and sharps with built-in injury protection (OSHA, 2016). Example:

  • "Sharps with engineered sharps injury protections means a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident" (OSHA, 2016).

Standard Precautions

The OSHA Bloodborne Pathogens standard recommends using Universal Precautions. Universal Precautions were the original CDC infection guidelines for preventing exposure to and transmission of bloodborne pathogens. Standard Precautions, which were developed later, added to and expanded Universal Precautions. Standard Precautions are universally used by healthcare facilities today, and Standard Precautions will be covered.

Standard Precautions include:

  1. Hand hygiene
  2. Respiratory hygiene/cough etiquette
  3. Use of personal protective equipment (PPE)
  4. Safe injection practices

The safe use of needles and syringes as per the OSHA Bloodborne Pathogens Standard will also be covered.

Hand Hygiene

Hand hygiene has been identified as the most important method of preventing and reducing the transmission of pathogens from one patient to another and from an infected site on a patient to a clean site on the same patient (Anderson, 2020; Gammon & Hunt, 2020). Unfortunately, compliance with hand hygiene by healthcare workers is often sub-optimal (Hoffman et al., 2020). The OSHA Bloodborne Pathogens standard states that employers are required to provide handwashing equipment and facilities (OSHA, 2016), and employees are required to know when and how to wash their hands (OSHA, 2016).

Hand hygiene can be done with an alcohol-based hand sanitizer or soap and water (CDC, 2021b). Alcohol-based hand sanitizers are preferred because:

  1. They are more effective at killing microorganisms on the hands than soap
  2. They are simpler to use, and
  3. They are less likely than soap and water to dry or irritate the skin (CDC, 2019b)

An alcohol-based hand sanitizer should be used in these situations:

  • immediately before and immediately after touching a patient
  • immediately before performing an aseptic procedure or before handling an invasive device or a piece of invasive equipment
  • immediately after taking off gloves
  • after touching anything in the patient's immediate environment
  • after you have contacted blood, body fluids, or a contaminated surface
  • before touching a clean part of the patient after you have been working/touching a contaminated/soiled part (CDC, 2021b)

To use an alcohol-based hand sanitizer, put the recommended amount on your hands. Rub your hands together, covering every part of your hands and fingers until they are dry; this usually requires about 20 seconds (CDC, 2021b)

Soap and water should be used in these situations:

  • When your hands are visibly soiled
  • When you are providing direct care for someone who has or could have infectious diarrhea
  • If you have had contact or could have had contact with spores, e.g., B. Anthracis, C. difficile (CDC, 2021b)

To wash your hands with soap and water, wet your hands. Apply the recommended amount of soap and then rub your hands together, covering every part of your hands and fingers; do this for 15 to 20 seconds. Rinse your hands and fingers, use a paper towel to dry them, use the towel to turn the faucet handle to the off position, and discard the towel. The recommended time of 15 to 20 seconds is a guideline (CDC, 2019b). The CDC recommends that you should wash your hands for at least 15 seconds and that the length of time "is less important than making sure you clean all areas of your hands." (CDC, 2019b).

Note: The World Health Organization (WHO) Save Lives: Clean Your Hands program has a simple way to remember when to use hand hygiene: My Five Moments for Hand Hygiene:

  • before an aseptic/clean procedure
  • before touching a patient
  • after touching a patient
  • after exposure to a body fluid
  • after touching the patient surroundings (WHO, 2009)

Respiratory Hygiene and Cough Etiquette

Respiratory hygiene and cough etiquette were added to Standard Precautions in response to the severe acute respiratory syndrome (SARS) outbreak in 2003 (Siegel et al., 2019). The virus that caused the 2003 SARS outbreak and the COVID-19 virus cause respiratory infections. These viruses are transmitted by infected droplets that are spread when someone coughs, sneezes, talks, and airborne transmission to a lesser degree (McIntosh, 2020). Respiratory hygiene and cough etiquette can help prevent the transmission of viruses that cause respiratory infections, and this infection control technique includes the following measures:

  • Post signs that inform people that they should cover their mouth and nose with a tissue when they cough or sneeze.
  • The facility should provide tissues.
  • The tissue should be discarded after it has been used. The facility should provide a no-touch receptacle for discarding used tissues.
  • Wash your hands with an alcohol-based hand sanitizer or with soap and water after you touch your mouth or nose.
  • Alcohol-based hand sanitizer or soap and water should be provided.
  • Clean your hands with an alcohol-based sanitizer or with soap and water after contact with respiratory secretions or contaminated materials/objects.
  • Offer a mask to anyone who is coughing or sneezing.
  • Practice social distancing (CDC, 2016b).

Personal Protective Equipment

Personal protective equipment is equipment that is designed to prevent the transmission of pathogens by direct contact. Personal protective equipment includes eye shields, face shields, foot/shoe covers, gloves, goggles, gowns, head covers, and respirators.

Employers are required to provide employees with the PPE they need to protect themselves and provide training on how to use PPE (OSHA, 2016), and employees are expected to know how and when to use PPE (CDC, 2020b).

Choose the PPE to use by assessing a situation and determining what you may be exposed to and how you may be exposed. Healthcare facilities must train employees on the proper use of PPE, but healthcare professionals must use their judgment to decide what PPE they need to use.

Example: The OSHA Bloodborne Pathogens Standard states:

Masks, Eye Protection, and Face Shields. Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated." (OSHA, 2016).

Personal protective equipment must be donned and removed correctly to protect patients and healthcare workers.

Use these steps for donning PPE:

  1. Identify the PPE that you will need.
  2. Wash your hands with an alcohol-based hand sanitizer.
  3. Put on the isolation gown.
  4. Put on the respirator or face mask.
  5. Put on goggles or a face shield.
  6. Put on the gloves (CDC, 2020b).

Use these steps for removing PPE:

  1. Take off the gloves. The outside of the gloves is contaminated; therefore, you should not touch the outside of the gloves with your bare hands. Put the gloves in the proper receptacle, i.e., a trash receptacle for contaminated materials.
  2. Remove the gown. The outside of the gown is contaminated, and when you are taking it off, you should not touch the outside of the gown with your bare hands. Put the gown in the proper receptacle.
  3. Wash your hands.
  4. Take off the goggles or the face shield; do not touch the outside surfaces of the face shield or the goggles.
  5. Remove the face mask or respirator without touching the outside surfaces.
  6. If you were wearing a face mask or a respirator, wash your hands (CDC, 2020b).

Note: Handwashing and the proper use of gloves are effective infection control techniques. However, healthcare workers often do not follow handwashing recommendations (Moore et al., 2021), and gloves can tear and be penetrated (Zhang et al., 2021). The CDC's stance on the use of gloves and handwashing is: "The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves." (CDC, 2002). Gloves should be changed when they are damaged, when you move from a contaminated body site to a clean body site, and when the gloves are bloody, dirty, or contaminated by body fluids (CDC, 2019b)

Safe Injection Practices and Safe Use of Needles and Sharps

Safe injection practices, also called injection safety, are practices and techniques that:

  1. Prevent the transmission of bloodborne pathogens to patients and healthcare workers when IV catheters, IV equipment, needles, and sharps are used, and
  2. Prevent unsafe disposal of potentially harmful medical waste (CDC, 2019c)

The CDC states, "A safe injection does not harm the recipient, does not expose the provider to any avoidable risks, and does not result in waste that is dangerous for the community (e.g., through inappropriate disposal of injection equipment)" (CDC, 2019c).

Safe injection practices were added to Standard Precautions after four large outbreaks of HBV and HCV occurred in patients who had been treated in ambulatory care centers, i.e., an endoscopy clinic, a hematology/oncology clinic, a pain clinic, and a private physician's office (Siegel et al., 2019). The outbreaks were caused by failing to use proper infection control techniques, e.g.:

  1. Reinsertion of used needles into a multiple-dose vial or a container of a solution
  2. Using a single needle/syringe to give IV medication to multiple patients, and
  3. Preparing medications in the same place in which used needles/syringes were dismantled (Siegel et al., 2019)

The essential elements of Safe Injection Practices are listed below:

  • Whenever you are using IV catheters, IV delivery systems, or needles, use the aseptic technique.
  • Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed.
  • IV catheters, IV infusion sets, IV bags, IV medications, IV solutions, needles, syringes, and cannulas are sterile, single-use items, and they should never be re-used for another patient.
  • It should be considered contaminated after a cannula, a needle, or a syringe has been used to enter or connect to an IV tubing, IV administration set, or an IV bag.
  • Singe-dose medication vials should be used whenever possible.
  • Do not use a single-dose ampule or vial to give medications to multiple patients, and do not combine the leftover contents of single-dose ampules or vials.
  • Use a sterile cannula, needle, or syringe to enter a multiple-dose vial.
  • Do not leave a multi-dose vial in the immediate area where patient care is delivered—store multi-dose vials as per the manufacturer's instructions.
  • Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients.
  • Infection control practices for special lumbar puncture procedures: Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space, i.e., during myelograms, lumbar puncture, and spinal or epidural anesthesia (Siegel et al., 2019).

The OSHA Bloodborne Pathogens Standard recommendations for the safe use of needles and sharps are listed below:

  • Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed unless the employer can demonstrate that no alternative is feasible or that such action is required by a specific medical or dental procedure.
  • Bending, recapping, or needle removal must be accomplished using a mechanical device or a one-handed technique.
  • Shearing or breaking of contaminated needles is prohibited.
  • Immediately or as soon as possible after use, contaminated reusable sharps shall be placed in appropriate containers until properly reprocessed.
  • These containers shall be color-coded or labeled, leakproof on the bottom and the sides, and puncture-resistant(OSHA, 2016).

Post-Exposure Evaluation and Management

One serious bloodborne infection can cost more than a million dollars for medications, follow-up laboratory testing, clinical evaluation, lost wages, and disability payments. The human costs after exposure are immeasurable. Employees may experience adjustment disorders, anxiety, crying spells, depression, panic attacks, post-traumatic stress disorder, and family, occupational, and sexual trouble dysfunction (Cooke & Stephens, 2017; Green & Griffiths, 2013).

Reporting an Exposure

The OSHA Bloodborne Pathogens Standard's definition of exposure is "a specific eye, mouth, other mucous membranes, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties."

Employees should report exposure to blood, exposure to body fluids, a needlestick injury, or a sharps injury immediately or as soon as possible (CDC, 2016c). The importance of immediately reporting an exposure cannot be overstated; if the healthcare worker was exposed to HIV, post-exposure prophylaxis should be started within hours after the exposure.

First Aid

After a needlestick or a sharps injury, immediately wash the wound with soap and water (Weber, 2020); if there has been an ocular or mucous membrane exposure, flush the area with water (Weber, 2020). An antiseptic can be applied to the area of a needlestick or a sharps injury, but do not inject anything into the area, do not apply bleach, and do not waste time squeezing the area of the wound to try and express blood/fluid from the wound (Weber, 2020).

HBV Exposure

The treatment for exposure to HBV or possible exposure to HBV focuses on the HBV status of the source and the employee's immune status (Schillie et al., 2018; Weber, 2020). There are multiple possible scenarios:

  • The employee has been infected with HBV; no treatment is needed, even if the source has a positive hepatitis B surface antigen (HBsAg) test (Schillie et al., 2018; Weber, 2020).
  • If the employee has received HBV vaccination and they are a responder (Schillie et al., 2018; Weber, 2020), i.e., the HBV surface antibody level is ≥ 10 IU/mL, no treatment is needed, even if the source has a positive HBsAg test (Schillie et al., 2028; Weber, 2020).
  • If the employee has received HBV vaccination but they are considered to be a non-responder, i.e., the HBV surface antibody is < 10 IU/mL, and the source has a positive HBsAg test, or if the HBV status of the source cannot be determined, the employee should be given one dose of hepatitis B immunoglobulin (HBIG) and one dose of HBV B vaccine (Schillie et al., 2018; Weber, 2020). These should be given simultaneously at different sites (Schillie et al., 2018; Weber, 2020). The HBV vaccine series should be completed, and one to two months after the last dose, the employee's hepatitis B surface antibody level should be measured (Schillie et al., 2018; Weber, 2020). These employees should also have a hepatitis B surface antibody level measured and tested for HBsAg presence six months after the exposure (Schillie et al., 2018).
  • If the employee is a non-responder and the source's HBsAg test is negative, the employee should be given one dose of HBV vaccine. A hepatitis B surface antibody level should be measured one month later (Schillie et al., 2018; Weber, 2020). If the hepatitis B surface antibody level is < 10 IU/mL, two more doses of HBV vaccine should be given, and a hepatitis B surface antibody level should be measured one to two months later (Schillie et al., 2018; Weber, 2020).
  • For employees who have not received HBV vaccination or employees who have not completed their vaccination series, the HBsAg status of the source should be determined, but the employee's hepatitis B surface antibody level should not be measured if she/has not completed the vaccination series (Schillie et al., 2018; Weber, 2020). In these cases, a hepatitis B surface antibody level > 10 IU/mL does not indicate immunity (Schillie et al., 2018; Weber, 2020).
  • If the source is HBsAg positive, the employee should simultaneously get one dose of HBIG and one dose of HBV vaccine at different sites (Schillie et al., 2018; Weber 2020). The hepatitis B vaccination series should be completed, and one to two months after the last dose, a hepatitis B surface antibody level should be measured (Schillie et al., 2018; Weber, 2020). Schillie et al. wrote "Because anti-HBs testing of HCP who received HBIG should be performed after anti-HBs from HBIG is no longer detectable (6 months after administration), it might be necessary to defer anti-HBs testing for a period longer than 1–2 months after the last vaccine dose in these situations." After the vaccination series has been completed, an employee with a hepatitis B surface antibody level ≥ of 10 IU/mL is immune, and no further testing is needed (Schillie et al., 2018). If the employee's level is < 10 IU/mL, they should be revaccinated, and a hepatitis B surface antibody level should be measured one to two months after the last dose (Schillie et al., 2018).
  • If the source is HBsAg negative, the HBV vaccination series should be completed, and one to two months after the last dose, a hepatitis B surface antibody level should be measured (Schillie et al., 2018; Weber, 2020). After the vaccination series has been completed, an employee with a hepatitis B surface antibody level ≥of 10 IU/mL is immune, and no further testing is needed (Schillie et al., 2018). If the employee's level is < 10 IU/mL, they should be revaccinated, and a hepatitis B surface antibody level should be measured one to two months after the last dose (Schillie et al., 2018).

An employee exposed to an HBsAg positive source or a source whose HBsAg status is unknown should not donate blood, organs, plasma, semen, or tissues during the six-month follow-up period (Schille et al., 2018; Weber,2020). Sexual practices do not need to be changed, becoming pregnant is not contraindicated, and breastfeeding can be continued (Schillie et al., 2018). Also, the employee can continue their normal work responsibilities (Schillie et al., 2018).

HCV Exposure

There is no effective prophylactic treatment for acute exposure to HCV (Moorman et al., 2020; Weber, 2020). Direct-acting antivirals effectively treat chronic HCV infection, but there is no evidence that they are effective prophylactic (Weber, 2020).

The source should be tested, preferably within 48 hours after the exposure, preferably using a nucleic acid test that detects HCV RNA (Moorman et al., 2020). The alternative is to test the source for the presence of HCV antibodies and then test for HCV RNA if the antibody test is positive (Moorman et al., 2020).

Suppose the source has or is suspected of having had recent behavioral risk factors for HCV exposure like IV drug use. In that case, HCV RNA measurement should be done (Moorman) as someone who was recently infected may not have HCV antibodies yet, but they will have HCV RNA (Weber, 2020).

  1. In either case, if the source does not have HCV RNA, the exposed employee does not need to be tested (Moorman et al., 2020).
  2. If the source has HCV RNA or HCV antibodies, they should be referred to a clinician for evaluation (Moorman et al., 2020).
  3. The employee should be tested for HCV antibodies, and if the HCV antibody test is positive, a test for HCV RNA should be done as soon as possible and preferably within 48 hours (Moorman et al., 2020). If the source has HCV RNA or HCV antibodies or if the HCV status of the source is unknown or cannot be determined, the exposed employee should be tested for HCV antibodies and tested for HCV RNA within 48 hours of the exposure (Moorman et al., 2020; Weber, 2020).
  4. If the employee's HCV antibody test is positive, but the HCV RNA is negative, the employee was previously infected but cleared the infection (Moorman et al., 2020).
  5. If the employee's HCV RNA test is positive, the employee was previously exposed and had a preexisting HCV infection, and they should be referred for evaluation (Weber, 2020).
  6. A negative HCV RNA test would require that the exposed employee be re-tested for HCV RNA at three weeks to six weeks after the exposure, and if this test is positive, the employee has an HCV infection and should be referred for evaluation (Moorman et al., 2020; Weber, 2020). This test should also be done if the source had HCV antibodies and the source could not be tested for HCV RNA (Moorman et al., 2020).
  7. If the second HCV RNA test done at three to six weeks post-exposure is negative, the employee should be re-tested four to six months after that point. If that HCV antibody test is negative, no further testing is needed (Moorman et al., 2020). If the HCV antibody test is positive, HCV RNA should be measured (Moorman et al., 2020). Further follow-up may be done if the employee is immunocompromised or has liver disease (Moorman, 2020).

HIV Exposure

  1. The following tests should be done on the source: HIV antigen-HIV antibody test (Zachary, 2019), HCV antibody test or HCV RNA measurement (National Clinical Consultation Center, 2021), and HBsAg or a hepatitis panel consisting of HBsAg, hepatitis B antibody measurement, and hepatitis B core antibody test (National Clinical Consultation Center, 2021).
  2. The following tests should be done on the employee: HIV antigen-HIV antibody test (Zachary, 2019), HCV antibody measurement with an HCV RNA test if the antibody test is positive (National Clinical Consultation Center, 2021), and HBV testing if needed depending on the employee's immunization status (National Clinical Consultation Center, 2021).
  3. If the source's rapid HIV test is positive, this should be assumed to reflect the source's HIV status, and this information should be used to determine whether to begin post-exposure prophylaxis, aka PEP (National Clinical Consultation Center, 2021). A blood sample should be sent to confirm the rapid test results (National Clinical Consultation Center, 2021).
  4. According to the National Clinical Consultation Center (2021), "A negative rapid test should be considered a true negative. Investigation of whether a source might be in the "window period" is unnecessary for determining whether HIV PEP is indicated unless acute HIV (acute retroviral syndrome) is clinically suspected."

Post-Exposure Prophylaxis – HIV

Post-exposure prophylaxis should be given:

  1. If the source is known to be HIV positive
  2. While waiting for the results of the source's HIV tests, especially if the source has a high risk of having an HIV infection, and
  3. If the source's HIV status cannot be determined and if a high-risk needlestick or sharps injury occurred (Zachary, 2019)

Post-exposure prophylaxis should be started within one to two hours post-exposure, or sooner if possible (National Clinical Consultation Center, 2021; Zachary, 2019); do not wait for test results. Authoritative sources recommend that PEP should not be given ≥ 72 hours post-exposure (National Clinical Consultation Center; Zachary, 2019). However, this recommendation is based on drug testing in animals (National Clinical Consultation Center, 2021; Zachary, 2019), and Zachary (2019) wrote:

"For most HCP, we do not initiate PEP if more than 72 hours have elapsed after the initial exposure . . .However, we do offer PEP after a longer interval to patients with a very high-risk exposure (e.g., sharps injuries from a needle that was in an artery or vein of an HIV-infected source patient)."

It is recommended that clinicians get a consultation if they intend to prescribe PEP > 72 hours post-exposure (National Clinical Consultation Center, 2021). For advice about using PEP for an employee exposed > 72 hours ago, call National Clinical Consultation Center at 1-888-448-4911.

If the source's rapid HIV test is negative, the employee can discontinue using the PEP (National Clinical Consultation Center, 2021).

The recommended PEP drug regimen is:

  1. Tenofovir disoproxil fumarate-emtricitabine (Truvada®, 300 mg/200 mg) PO once a day and dolutegravir (Tivicay®) 50 mg once a day, or
  2. Tenofovir disoproxil fumarate-emtricitabine (Truvada®, 300 mg/200 mg) PO once a day and raltegravir (Isentress®) 400 mg PO twice a day
  3. The duration of treatment is 28 days (National Clinical Consultation Center, 2021; Zachary, 2019)

Pregnancy, Breastfeeding and HIV PEP

The risk of vertical transmission of HIV is high (National Clinical Consultation Center, 2021; Whiteley, 2019), breastfeeding can transmit HIV (National clinical Consultation Center, 2021), and the available information has shown that antiretroviral therapy during pregnancy is effective and safe (Hughes & Cu-Uvin, 2021; National Clinical Consultation Center, 2021; Rogers & Roberts, 2022). A pregnant employee who has been or may have been exposed to HIV should be evaluated and treated using the standard protocol that was previously described (National Clinical Consultation Center, 2021). Pregnant women prescribed antiretroviral therapy should be enrolled in the Antiretroviral Pregnancy Registry, www.apregistry.com (National Clinical Consultation Center, 2021). The Registry is intended to detect the teratogenic effects of antiretroviral drugs and pregnancy outcomes when used.

The recommended PEP for a pregnant employee after an HIV exposure is:

  1. Tenofovir disoproxil fumarate-emtricitabine (Truvada®,300 mg/200 mg) PO once a day and raltegravir (Isentress®) 400 mg PO twice a day or dolutegravir (Tivicay®) 50 mg PO once a day.
  2. Zidovudine/lamivudine (Combivir®) combination, 300 mg/150 mg PO one tablet twice a day and
    1. Darunavir (Prezista®) 600 mg PO plus ritonavir (Norvir®) 100 mg PO twice a day or
    2. Atazanavir (Reyataz®) 300 mg PO plus ritonavir (Norvir®) 100 mg PO, once a day. During the second and third trimesters, the atazanavir dose should be increased to 400 mg PO once a day (National Clinical Consultation Center, 2021).

Breastfeeding is not contraindicated during antiretroviral therapy (National Clinical Consultation Center, 2021).

Post-Exposure Testing and Monitoring"

  1. The employee should be evaluated 72 hours after beginning PEP to determine if PEP should be continued and to assess for the presence of adverse effects of the drugs (Fauci, 2018; Zachary, 2019).
  2. If PEP will be continued, the National Clinical Consultation Center recommends that the employee be tested for HIV at six weeks and three months after the exposure (National Clinical Consultation Center, 2021). The CDC and other authoritative sources recommend that the employee be tested four months after the exposure if a 4th generation antigen-antibody test is used or at other intervals if a test that only measures antibodies is used (National Clinical Consultation Center, 2021; Zachary, 2019).
  3. If the employee develops an HCV infection and the source was infected with HCV and HIV, testing of the employee for HIV should be extended to 12 months post-exposure (National Clinical Consultation Center, 2021; Zachary, 2019).
  4. Employees taking PEP should have baseline measurements of complete blood count (CBC) with a differential and tests of hepatic and renal function (Zachary, 2019). These should be repeated at two and fours weeks after PEP has begun (Zachary, 2019), and patients should also be monitored for hyperglycemia (Zachary, 2019).

National Clinical Consultation Center

The National Clinical Consultation Center provides telephone consultation by physicians and other healthcare professionals for occupational and non-occupational exposures to bloodborne pathogens. The service is available from 9 a.m. to 8 p.m., eastern time, Monday through Friday, and 11 a.m. to 8 p.m., Saturday, Sunday, and holidays. The Center's website has detailed instructions for treating exposure to a bloodborne pathogen if the exposure happens outside of its operating hours. 1-888-448-4911.

Conclusion

Healthcare workers are continually at risk for exposure to HBV, HCV, and HIV. Needlestick injuries and other exposures are common. Although the transmission of a bloodborne pathogen is uncommon to rare, the consequences can be costly and emotionally and psychologically devastating.

Fortunately, HBV vaccination, engineering and workplace controls, Standard Precautions — hand hygiene, respiratory hygiene/cough etiquette, the use of PPE, and safe injection practices — can significantly reduce the risk of exposure to and transmission of bloodborne pathogens. Also, post-exposure treatment can effectively reduce the risk of developing HBV or HIV infection from occupational exposure to these pathogens.

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