PEP PRESENTATION FOR HEALTH CARE WORKERS

unpacking post exposure prophylaxis

1. ESHUN LORD FRANCIS. Occupational Exposure & Post-Exposure Prophylaxis LORD SERIES 1

2. INTRODUCTION This presentation is designed to assist with the training of staff on sharps management including safety devices The drug regime should be followed according to the best available options in resource poor circumstances. LORD SERIES 2

3. What is occupational exposure Occupational exposure   refers to exposure to potential blood-borne infections (HIV, HBV and HCV) that may occur in healthcare settings during performance of job duties.  Post exposure prophylaxis (PEP) refers to comprehensive medical management to minimize the risk of infection among Health Care Personnel (HCP) following potential exposure to blood-borne pathogens (HIV, HBV, HCV) LORD SERIES 3

4. What are “PEP”? PEP means taking antiretroviral medicines (ART) after being potentially exposed to HIV to prevent becoming infected. PEP should be used only in emergency situations and must be started within 72 hours after a recent possible exposure to HIV.  PEP is given in occupational exposure and rape BUT NOT CONSENSUAL SEX EXPOSURE LORD SERIES 4

5. Source Of Body Fluid Exposure Blood and visibly bloody fluid Potentially infectious CSF, Synovial Fluid, Pleural Fluid, Peritoneal Fluid, Pericardial Fluid And Amniotic Fluid Not Considered Infectious Unless Bloody Feces, Nasal Secretions, Saliva, Sputum, Sweat, Tears Urine, And Vomitus Semen and vaginal secretions are infectious but not implicated in occupational exposure. LORD SERIES 5

6. Classification Of Risk Of Exposure The risk of exposure should be assessed in terms of probability of transmission of HIV infection. Exposure to HIV may be classified in three categories: Very low risk exposure Splash onto intact skin Low risk exposure Splash unto broken/abraded (i.e. non-intact) skin An injury with a solid needle or small bore needle Any superficial injury or mucosal exposure LORD SERIES 6

7. Classification Of Risk Of Exposure High risk exposure Exposure to a large volume of blood or potentially infectious fluids Exposure to blood or blood contaminated fluids from a Client with a high viral load i.e. in the AIDS phase Injury with a hollow bore needle Deep and extensive injury HIV Drug resistance in source Client Puncture or cut with visible blood on instrument LORD SERIES 7

8. Increasing the risk of sharps injuries Past studies show sharps injuries are often associated with these activities: Recapping needles or other devices Transferring a body fluid between containers Failing to dispose of used needles or other devices properly in puncture-resistant sharps containers LORD SERIES 8

9. Sharps Management Who is at risk of an occupational exposure? All healthcare workers who have the potential for exposure to infectious materials (e.g. blood, tissue, and specific body fluids, as well as medical supplies, equipment or environmental surfaces contaminated with these substances) e.g: Nurses Doctors Laboratory staff Technicians Therapists Support personnel e.g. housekeeping, maintenance Dental staff Contractual staff Students LORD SERIES 9

10. What To Do When Exposed Step 1:Treatment of Exposure site Exposure sites should be washed with soap and water. Mucous membranes should be flushed with water. Application of caustic agents (e.g. bleach) on the wound site is NOT recommended NO evidence that expressing fluid by squeezing the wound reduces risk of transmission LORD SERIES 10

11. What To Do When Exposed Step 2: Reporting on Incidence of Exposure Inform your immediate superior of the exposure as soon as possible. Then inform the Medical Officer or any member of the ART team to assess the exposure risk (as defined above) LORD SERIES 11

12. What To Do When Exposed Step 3: Identify The Source Person If Possible And Determine HIV Status If the HIV status of the source person is not known, inform source person of the incident and obtain consent to perform HIV test. Testing of the source person should be performed as soon as possible. Confidentiality of the source person must be maintained at all times. If the source person refuses to be tested for HIV, assume high risk and offer PEP. LORD SERIES 12

13. What To Do When Exposed Step 3: Identify The Source Person If Possible And Determine HIV Status If the source person is negative for HIV, PEP may not be necessary. However further follow-up of the exposed HCW is still necessary. If the source person is not known at the time of exposure, assume high risk and offer PEP. LORD SERIES 13

14. What To Do When Exposed Step 4: Offer Counselling and Testing to HCW Assure maintenance of confidentiality Instruct on benefits and possible adverse effects of ARV prophylaxis Counsel on HIV risk of transmission to sexual partners Advise HCW to seek medical evaluation for any acute illness that occurs during the follow-up period LORD SERIES 14

15. What To Do When Exposed Step 4: Offer Counselling and Testing to HCW If HCW is negative to HIV test and risk of exposure is assessed to be very low, PEP may not be necessary. However further follow-up of the exposed HCW is still necessary If HCW is positive to HIV test, do not offer or continue PEP. Instead, refer for comprehensive care and support. LORD SERIES 15

16. What To Do When Exposed Step 5: Pregnancy test where relevant Offer pregnancy testing to all women of childbearing age not known to be pregnant before initiation of ARV prophylaxis LORD SERIES 16

17. Follow-up HIV Testing LORD SERIES 17

18. Deciding on PEP regimen There are two types of regimens:    Basic regimen: 2-drug combination   Expanded regimen: 3-drug combination The decision to initiate the type of regimen depends on the type of exposure and HIV serostatus of the source person. Prescribe PEP LORD SERIES 18

19. PEP Regimens: Basic regimens LORD SERIES 19 Age Group RECOMMENDED PROPHYLAXIS Children (<10 years old) AZT + 3TC (or FTC) + DTG or LPV/r OR ABC + 3TC(or FTC) + LPV/r or TDF + 3TC (or FTC) + LPV/r can be considered as alternative regimen if the child weighs above 30kg Adults and Adolescents (including pregnant and lactating mothers) TDF + 3TC+ DTG or LPV/r

20. Tolerability of HIV PEP in Health Care Workers Percent of HCWs Incidence of Common Side Effects LORD SERIES 20

21. For the unimmunized: prophylactic HBIG initiate the vaccine series Recommendations Hepatitis B LORD SERIES 21

22. General Principles in Hepatitis B Vaccination Hepatitis B Vaccination A primary course of hepatitis B vaccinations over six months Mandatory for all staff in contact with patients and patient-contaminated material Titre level (HBsAb) four to six weeks after last dose Booster doses not required if titre level >10 mIU/mL LORD SERIES 22

23. Protecting yourself from needle stick injuries a self responsibility ??? Avoid the use of needles where safe alternatives are available. Help your staff select and evaluate devices with safety features that reduce the risk of injury. Use devices with safety features provided by your employer. Do not recap needles or scalpels with both hands. Plan for safe handling and disposal of sharps before using them. LORD SERIES 23

24. Recommendations Hepatitis C No effective prophylaxis Immunoglobulin and antiviral agents are NOT recommended Determine status of source Establish baseline serology and serum ALT of employee and repeat testing at 4-6 months post-exposure Early treatment if infection occurs Refer to Hepatologist LORD SERIES 24

25. CDC guidelines: follow-up HCV Ab and ALT at 4-6 months 1 Consider periodic HCV RNA screening (monthly?) if earlier detection desired Note that unlike acute HIV infection, most patients are not symptomatic with acute HCV infectio n 2 Hepatitis C : follow-up testing LORD SERIES 25

26. Major references MMWR reviews CDC guidelines Post-Exposure Prophylaxis an evidence-based review Christopher Behrens, MD Hillary Liss, MD Northwest AIDS Education & Training Center University of Washington NACO guidelines on Post exposure prophylaxis Dr.T.V.Rao MD 26

27. THANK YOU LORD SERIES 27