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Management of Occupational Exposures to Blood and Body Fluids

Module 6: VICNISS online self guided surveillance education

To download this module and/or the associated multiple choice exercises as PDF files, click on Education Resources.)

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Overview

This module gives an overview of the management of occupational exposures to blood and body fluids.

Objectives

After you have completed this module you should be able to:

  1. Understand the significance of an occupational exposure;
  2. Know how to interpret the results of antigen/antibody tests;
  3. Understand how hepatitis B, C and HIV are transmitted;
  4. Understand the recommended vaccination schedule for hepatitis B; and
  5. Understand the use of post-exposure prophylaxis to prevent infection.

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Introduction

Infection with bloodborne viruses is a global public health problem, and poses a potential risk for those who work in healthcare. The magnitude of risk of acquiring hepatitis B, C or HIV relates to the nature of the exposure, and the efficiency of transmission for that exposure.

Many occupational exposures can be prevented by the adoption of various safety practices and the use of new products. These include: wearing of personal protective equipment, not re-capping needles, the provision of sharps disposal containers, the use of needleless devices, and hepatitis B vaccination.

What Constitutes an Exposure

Surgery in Progress Exposures to blood, tissue, or other body fluids that may place a healthcare worker (HCW) at risk for acquisition of bloodborne viruses include:

  • A percutaneous injury (eg. a needlestick or cut with a sharp object); and
  • Contact of mucous membrane or nonintact skin (eg. exposed skin that is chapped, abraded, or afflicted with dermatitis).

Body fluids of concern include: semen, vaginal secretions, or other body fluids contaminated with visible blood. In addition, any direct contact (ie. without barrier protection) to concentrated virus in a research laboratory is considered an "exposure" that requires clinical evaluation and consideration of post exposure prophylaxis (PEP).

Transmission of Hepatitis B, C and HIV Infection

Hepatitis B

Body substances capable of transmitting HBV include: blood, and blood products; saliva; cerebrospinal fluid; peritoneal; pleural and pericardial fluid; synovial fluid; amniotic fluid; semen and vaginal secretions; and any other body fluid containing blood.

HBV is the most commonly transmitted blood-borne virus in the healthcare setting. Transmission generally occurs from patient-to-patient or from patient-to-health care personnel.

HBV can survive outside the body for about 7 days, and remain capable of causing infections. Transmission can occur via contaminated household articles such as toothbrushes, razors, and even toys. Certain practices like acupuncture, tattooing, and body piercing have also been associated with transmission of hepatitis B.

HBV has been transmitted by percutaneous and mucosal exposures and human bites. HBV has also been transmitted by fomites such as lancet devices used to obtain blood for glucose measurements, multi-dose medication vials, jet gun injectors, and endoscopes.

Hepatitis C

Hepatitis C is predominantly transmitted parenterally via exposure with blood. Injecting drug users sharing needles are a high-risk group. Sexual transmission has been documented but is a far less efficient mode of spread.

Saliva, urine and faeces from an infected person are unlikely to transmit hepatitis C. Transmission of HCV from blood splashes to the conjunctiva has been described.

HIV

HIV can be transmitted by exposure to blood, this includes needlestick injuries, the sharing of contaminated needles, and transfusion of infected blood or blood products. HIV may also be transmitted during unprotected sexual intercourse.

Cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids have an undetermined risk for transmitting HIV. In addition, although the virus has occasionally been found in saliva, tears, urine, and sputum, transmission after contact with these secretions has not occurred.

Of HCWs who have acquired HIV, the majority have sustained a percutaneous exposure to blood from an HIV-infected person. The risk factors for HIV transmission after a percutaneous injury are: a deep injury, a device visibly contaminated with the patient's blood, a procedure that involved a needle placed directly in a vein or artery, and terminal illness in the source patient.

In many developed countries, guidelines have been established to defined the parameters in which healthcare providers with hepatitis B can operate.

Transmission of bloodborne viruses from HCWs to patients have been documented, but are rare.

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Table 1. Risk of Acquisition of Bloodborne Pathogens

  HBV HCV HIV
Seroprevalence, general population 0.42% (95% CI, 0.32-0.55) 1.8% (95% CI, 1.5-2.3) 0.31-0.42%
Seroprevalence in HCW compared to general population Increased Similar Similar
Viral particles/mL of serum or plasma 102-108 106 100-107
Risk of infection by mode of exposure
Percutaneous 6-30% 1.8% (range, 0-7%) 0.3% (95% CI, 0.2-0.5)
Mucosal Risk not quantified, transmission documented Risk not quantified, transmission documented 0.09% (95% CI, 0.006-0.5)
Nonintact skin Risk not quantified, transmission not documented Risk not quantified, transmission not documented <0.1%, risk not completely quantified
Human bite Risk not quantified, transmission not documented Risk not quantified, transmission not documented Risk not quantified, transmission not documented
Infective material leading to HCW infection
Documented Blood, blood products Blood, immunoglobulin preparations Blood, blood products, body fluids
Possible Semen, vaginal fluid, bloody fluids, saliva Bloody products, bloody fluids, semen, vaginal fluid Semen, vaginal fluid, cerebrospinal fluid, breast milk, exudates, serosal fluids, amniotic fluid, saliva (during dental exams)
Unlikely Urine, faeces Saliva, urine, faeces Saliva, urine, faeces
* Courtesy of David Weber, MD, MPH.

Hepatitis B Vaccination

Routine infant immunisation is the main strategy to prevent HBV infection in the community. In addition, high-risk groups (such as injecting drug users, haemodialysis patients, patients with chronic liver disease, residents and staff of both correctional facilities and facilities for persons with intellectual disabilities, household contacts and sexual partners of HbsAg positive people, homosexual or heterosexual people with multiple sexual partners, and HCWs, tattooists and body-piercers) should also be targeted for vaccination.

Over 90% of people achieve protection against hepatitis B by vaccination, and immunity is believed to persist for at least 15 years after successful immunisation.

The vaccine is commonly administered in 3 IM doses: an initial dose followed by additional doses at 1-2 months, and 6-18 months later. The third dose may be given as early as 2 months after the second dose, but in this case a fourth dose at 12 months is recommended. Some 2-dose regimens are available for children, with vaccine given at 0 and 4-6 months. Vaccination may also be completed in a 3 week accelerated schedule (0, 7 and 21 days) if necessary, with a booster (4th dose) at 12 months.

Hepatitis B Vaccination for Healthcare Workers

All HCWs with potential exposure to blood or blood products should be immune to hepatitis B. Vaccination has been highly successful in reducing HBV infection among HCWs with a 95 percent decline in the incidence of hepatitis B infection among HCWs between 1983 and 1995.

Following a primary vaccination series, HCWs should be tested for anti-HbsAg, 1-2 months after the final vaccine dose.

HCWs whose anti-HBsAg titre is <10 mIU/mL should be tested for HBsAg and if positive, be evaluated for chronic HBV hepatitis. If HBsAg negative, they should receive up to 3 additional doses of vaccine and have their anti-HBsAg titre repeated. HCWs with a titer <10 mIU/mL after the second series of 3 doses of vaccines should be considered vaccine non-responders and provided hepatitis B immune globulin (HBIG) for documented exposure to HBsAg positive blood.

Vaccine-induced antibodies decline gradually with time; as many as 60 percent of those who initially responded to vaccination will lose detectable antibody by eight years. However, booster doses of vaccine are not recommended for immunocompetent HCWs, because persons who respond to the initial vaccine series remain protected against clinical hepatitis and chronic infection even when their anti-HBs levels become low or undetectable.

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Available Antigen/Antibody Tests for Hepatitis B, C and HIV

Hepatitis B

  1. Hepatitis B surface antigen (HbsAg): Present in acute infection, and persists with chronic infection. It indicates that a person is potentially infectious.
  2. Hepatitis B surface antibody (anti-Hbs): indicates immunity either via vaccination or past infection.
  3. Hepatitis B core antibody (anti-HBc): Indicates either past or current infection, persists indefinitely. IgM anti-HBc appears during acute infection and usually disappears within 6 months.
  4. Hepatitis B e antigen (HbeAg): The presence of this antigen is associated with high infectivity.
  5. Hepatitis B e antibody (anti-Hbe): The presence of this antibody is associated with low infectivity.

Hepatitis C

  1. Hepatitis C antibody (anti-HCV): Present in acute and chronic infection. This antibody appears after approximately 3-4 months.
  2. Hepatitis C RNA (via PCR): Indicates active viraemia and quantifies the viral load.

HIV

  1. HIV antibody: This includes the EIA screening assay which, if positive is followed by a Western Blot confirmatory test to exclude false-positive results.

Postexposure Prophylaxis to Prevent Infection

Postexposure prophylaxis is recommended for all non-vaccinated individuals who are exposed to blood or infectious secretions from a hepatitis B infected person. The first dose vaccine should be given as early as possible (ideally within 12 hours of exposure, but up to 7 days later), while administering one dose of HBIG (400 IU IM for adults within 72 hours) at the same time in another site. The other two doses of vaccine should be administered according to the usual schedule (see below).

Following sexual exposures HBIG and HBV vaccine may be given within 14 days of the exposure.

In individuals who have been vaccinated and have a documented response, no post-exposure prophylaxis is required. Individuals who have no post-vaccination testing will require a second course of vaccination unless anti-HBs is detectable at the time of exposure. Individuals who are documented to be non-responders will require two doses of HBIG given one month apart.

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Test your Knowledge - Exercise 1
Clicking the above link will take you to the Education Resources page where you can download a PDF version of the Exercises Questions and Answers

Further Information

References

  • 1. Maynard, JE. Hepatitis B: Global importance and need for control. Vaccine 1990; 8(Suppl):S18.
  • 2. Alter, MJ, Hadler, SC, Margolis, HS, et al. The changing epidemiology of hepatitis B in the United States. Need for alternative vaccination strategies. JAMA 1990; 263:1218.
  • 3. Dodd, RY. The risk of transfusion-transmited infection (editorial). N Engl J Med 1992; 327:419.
  • 4. Stevens, CE, Toy, PT, Tong, MJ, et al. Perinatal hepatitis B virus transmission in the United States. Prevention by passive-active immunization. JAMA 1985; 253:1740.
  • 5. Burk, RD, Hwang, LY, Ho, GY, et al. Outcome of perinatal hepatitis B virus exposure is dependent on maternal virus load. J Infect Dis 1994; 170:1418.
  • 6. American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, 4th edition. Washington, DC 1997 p286.
  • 7. Gerberding, JL. The infected health care provider. N Engl J Med 1996; 334:594.
  • 8. Harpaz, R, Seidlein, LV, Averhoff, FM, et al. Transmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control. N Engl J Med 1996; 334:549.
  • 9. Hallower, J, Kane, M, McCloy, E (Eds). Eliminating Hepatitis B as an occupational hazard. London medical imprint 1993. p.114.
  • 10. Wachs, ME, Amend, WJ, Ascher, NL, et al. The risk of transmission of hepatitis B from HBsAg(-), HBcAb(+), HBIgM(-) organ donors. Transplantation 1995; 59:230.
  • 11. Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1996; 45:1.
  • 12. Centers for Disease Control and Prevention. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR 2001;50(No. RR-11):1.
  • 13. Mahoney, FJ, Stewart, K, Hu, H, Coleman, P, Alter, MJ. Progress toward the elimination of hepatitis B virus transmission among health care workers in the United States. Arch Intern Med 1997; 157:2601.
  • 14. Weber, DJ, Rutala, WA. Hepatitis B immunization update. Infect Control Hosp Epidemiol 1989; 10:541.
  • 15. Bond, WW, Favero, MS, Petersen NJ, Gravelle, CR, Ebert, JW, Maynard, JE. Survival of hepatitis-B after drying and storage for one week. Lancet 1981; 1:550.
  • 16. Immunization of health-care workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR 1997; 46:1.
  • 17. Bolyard, EA, Tablan, OC, Williams, WW, et al. Guideline for infection control in healthcare personnel, 1998. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1998; 19:407.
  • 18. Beltrami, EM. The risk and prevention of occupational human immunodeficiency virus infection. Sem Infect Control 2001; 1:2.
  • 19. Centers for Disease Control and Prevention. HIV/AIDS surveillance report. June 2000; 12:24.
  • 20. Centers for Disease Control and Prevention. Case-control study of HIV seroconversion in health-care workers after percutaneous exposure to HIV-infected blood--France, United Kingdom, and United States, January 1988-August 1994. MMWR 1995; 44:929.

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VICNISS 10 Wreckyn Street North Melbourne 3051 Victoria Australia Phone +61 3 9342 2605 Fax +61 3 9342 2633 Last Updated:
22 February 2008