All right, so we are going to now get to a bread-and-butter topic, as in this is what you need to know day one in Med Center Occupational Health. In fact, the very first patient I ever saw in my career doing Medical Center Occupational Health was a needle stick. So this is your life. You live and breathe this. Our speaker for this topic next is Dr. Rachel Liebu. She's the Medical Director of Occupational Medicine Services with Atlantic Health System. She's a clinical assistant professor at the Sidney Kimmel Medical College, Thomas Jefferson University, and through the COVID pandemic has led the Medical Center Occupational Health section as our current section chair. And so we're very privileged to have her today to talk to us about blood-borne pathogen exposures. Dr. Liebu. Good afternoon, everybody. Welcome to the postprandial edition of Blood-Borne Pathogen Exposures. I used this joke before for our panel discussion, so I apologize for repurposing my jokes. What I want to talk to you today about is a very, very important topic. It's one of our true emergencies in occupational medicine, and I hope that you get some good information out of this. And if you have any other questions, please feel free to reach out to me. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. 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Tha dental worker who had a needle stick from a hep C and HIV co-infected source patient and they ended up developing hepatitis C, but thankfully they didn't get HIV. What are the risk factors that can lead to hepatitis C infection? This is important when you're doing histories on or looking at the histories of the source patient. If they've had a blood transfusion before 1990, before they were testing the blood that was donated, you have to be careful and have a high index of suspicion that they may have hepatitis C exposure, because hepatitis C can also be gotten through getting large volumes of hepatitis C infected blood. A needle stick is not really that high of an exposure, but obviously a blood transfusion would be. If somebody has a history of IV drug abuse, if they're employed in patient care or clinical lab work, that's a risk. If they've had exposure to multiple sexual partners, if they're on a low socioeconomic status, all those things are felt to be risk factors leading to hepatitis C infection. One thing that I just saw last week that was very interesting was that it was initially felt that hepatitis C transmitted through vertical transmission was not something that was very common, and they're seeing some new data that shows that it happens more frequently than we think. Sharp's injuries are the most common route for hepatitis C transmission in healthcare workers, and the CDC estimates that the average incidence of seroconversion to hep C, as I said before, is 1.8 percent after a needle stick from a source that has hepatitis C. But the risk of seroconversion depends on the type of injury. There was a study that was done in the UK where they looked at the type of procedure and depth of injury, and they were both independently associated with an increased risk of seroconversion. As I mentioned previously, there's no effective post-exposure prophylaxis, so management involves early diagnosis and treatment, and one of the fortunate things that we have now that we hadn't had for many years was treatment that's effective for hepatitis C. So any employee who is exposed to hepatitis C, we want to make sure that we're testing them, and I'll talk about that in a little bit, but the earlier that we can detect whether they developed hepatitis C or not, the sooner we can start treatment and the better chance we have of actually eradicating the disease. Since we don't have any post-exposure prophylaxis we can give them, that's as close as we get. You want to assess the source, and by doing that you want to see if they have a hepatitis C virus RNA. If that's negative, you don't need to do anything for the healthcare worker. They weren't exposed. If the hepatitis C virus RNA is negative, they were not. However, if you don't have hepatitis C RNA testing available at your facility, then you need to use hepatitis C virus antibodies, and if you test the hepatitis C virus for the antibodies and it's negative, you don't need to do anything further generally unless there's a concern that the person may be at high risk, the source patient may be at high risk, and then you will do additional testing. This chart is from the newest CDC guidelines updating the treatment of hepatitis C exposure in healthcare personnel. If you look, they have two options, and option A, which is the preferred option, is to test the hepatitis C virus RNA in the source patient, and then if that's positive, then you refer the patient, the source patient, for treatment of an infection if it's not known that they were infected, and you want to do follow-up testing and potential treatment of the healthcare worker who was exposed. If the RNA is negative, as I mentioned before, you don't need to do anything further. With option B, if you're using the hepatitis C virus antibody first and it's negative, you don't need to do anything. However, if the hepatitis C virus antibody is positive, then you need to go to the next step and check a hepatitis C virus RNA. If that's negative as well, you don't need to do anything further. If it is positive, then you do the same as you would as if the initial hepatitis C virus RNA test on the option A was. What testing do we do for people that are exposed? If the patient is negative, as I mentioned, we don't do any further follow-up. If the source patient is positive or we don't know if the source has hepatitis C or not, if it's an unknown exposure, you want to do a baseline hepatitis C antibody with reflex to hepatitis C RNA if it's positive, and then if there's no preexisting infection, you follow-up testing at three to six weeks. Usually six weeks coincides with HIV testing, but you can check for the hepatitis C RNA at three weeks. I personally would check at three weeks because if the employee is positive, you want to get treatment started as soon as possible. And then you check at four to six months, you check another hepatitis C virus antibody and you reflex to hepatitis C virus RNA if that's positive. Most facilities that do the fourth generation HIV testing choose to do testing at four months so that it can coincide with HIV follow-up and you don't have to stick the team member as much. As I mentioned, I think several times already, we don't currently have any post-exposure prophylaxis and we do want to promptly treat any hepatitis C virus that develops in a team member who has been exposed to hepatitis C and develops it as a result of the exposure. And these people should be promptly referred to a specialist and evaluated for antiviral treatment. People who are exposed to a source patient that's positive or an unknown status should have baseline testing done within 48 hours of the exposure. You want to test the employee as soon as possible after the exposure because you want to make sure that you have a baseline that's not influenced by their current exposure. And if the hepatitis C antibody returns positive in the healthcare worker, you test them for the hepatitis C virus RNA and if that's positive, you consider that this healthcare worker has had a previous hepatitis C virus infection and you refer them for treatment and evaluation and treatment. Okay, so now we're going to talk about the uglier, the scariest, one of, well, they're all scary, but I think HIV is probably the scariest for people that have had a needle stick injury. So we talked before about what's the risk of exposure from a needle stick injury to getting HIV is. There have been 58 confirmed and 150 possible causes of occupational acquired HIV reported between 1995 and 2013 and between 2000 and 2012, only one confirmed case. This is partially at least due to the ever-changing and improving post-exposure prophylaxis and HIV treatment drugs that we have for people. And in terms of how HIV is transmitted and how likely you are to get HIV from a needle stick, again, it's going to depend on the inoculum size, what is the viral load of the source, also, as well as how much volume of blood you're exposed to, how deep the needle stick is, and whether you're exposed to a hollow bore versus a suture needle with the hollow bore needles having more risk of infection. If somebody's exposed to HIV-positive blood and they have intact skin, we do not consider that a risk factor. And just so you know, we do worry about people getting exposed to HIV-positive blood who have non-intact skin from rashes or they have a cut on their hand. There have been no confirmed cases of HIV transmission this way. So it is something to be concerned about, but somewhat reassuring that there haven't been any reported cases. Bites have not ever been implicated in transmission unless, of course, if the bitee has very bloody gums or blood in their mouth for whatever reason and they bite somebody, then you would consider that definitely a high-risk kind of an exposure. The bitee. The biter. Oh, the biter. Oh, I'm sorry. The bite-er. But sometimes the bitee is really more at risk to the biter than the biter is to the bitee. Well, that's a whole other topic. That will bite you, but you've got to be careful about that. And also, people that have had needle stick injuries with potential exposure to HIV should be advised that they should practice safe sex or abstain until serologic testing in the source is reported to be negative. And when we're evaluating people that have had exposure to HIV or potential exposure to HIV, we have to have a discussion with them about the efficacy of post-exposure prophylaxis as well as the disadvantages. And those who may have had a needle stick, but it's a very low-risk exposure, unlikely to be HIV positive sometimes. Or the source patient is negative and the employee still wants to go on post-exposure prophylaxis. I would never say you can't go on it, but I certainly would have a discussion with them about the risks and the benefits, especially in terms of the side effects that they may experience. What are the risk factors for seroconversion? So there is another CDC study that shows you the odds ratio of getting HIV, depending on the type of exposure you have. So deep injuries had an odds ratio of 15. Devices that were visibly contaminated with blood had an odds ratio of 6.2. Needle placement in an artery or vein was 4.3. And when the source patient has terminal illness, the odds ratio was 5.6. The majority of cases were occurring, as I mentioned before, with a hollow bore as opposed to a solid needle. So now there are body fluids of concern. So they're stratified based upon what type of body fluid it is. Body fluids of concern include blood, semen, vaginal secretions, and other body fluids that are contaminated with visible blood. Then we have the potentially infectious body fluids that are listed here, cerebrospinal fluids, and ovial fluid, et cetera. And then fluids that are not considered infectious unless they contain blood include feces, nasal secretions, saliva, I apologize, this is a discussion after lunch, but gastric secretions, sweat, tears, sometimes people worry that they were exposed to the sweat of an HIV-positive patient. That's not something that you need to worry about. Urine is also not something you need to worry about unless it's contaminated with blood. And anybody that has direct contact without protection, this is going back to Mark's part of the lecture, to HIV in a research laboratory or in a production facility is considered an exposure that will require clinical evaluation and consideration of PEP. Intact skin is an effective barrier against HIV, and contamination of intact skin with blood or other potentially infectious fluids is not considered an exposure and does not require PEP. But again, if somebody is so upset about it that they want to go on post-exposure prophylaxis despite being dissuaded against doing that, they can. I would never deny somebody that to give them peace of mind. Other body fluids of concern are any fixed tissue or organ other than non-intact skin from a human, either alive or dead, HIV-containing cell or tissue cultures, organ cultures, and any HIV, Hep-B, or Hep-C-containing mediums or solids, and blood organs or other tissues from experimental animals infected with any one of those three viruses. So what do we do in terms of testing for people who have been exposed to HIV? We want to do baseline HIV testing immediately after the exposure, just like we want to do for hepatitis C and B. We want to follow up testing at six weeks and four months if your facility is using a fourth-generation antibody antigen HIV test. But if you're not using that test and you're using an HIV antibody test, you want to repeat HIV testing at six weeks, three months, and six months following the exposure. An antibody antigen test is preferred since this will detect seroconversion earlier. There are some situations where you want to do extended testing, and I alluded to that before. Anybody who is infected with hepatitis C after an exposure to a co-infected source should be tested longer than the normal type of blood-borne pathogen exposure, if there is such a thing. And that's based upon a case report of a delayed HIV seroconversion in a healthcare worker who was exposed to both. And you also might want to consider extended follow-up for those who have a medical history that's suggestive of impaired immunity, impaired humoral immunity specifically. But there are no data available yet to determine a specific approach for that. So in terms of discussing post-exposure prophylaxis, you really want to start post-exposure prophylaxis as soon as possible, ideally one to two hours after the exposure. And you can use a starter pack with the appropriate drugs, which we'll be discussing in a couple minutes. I had a situation where we had somebody who got a needle stick from after they were trying to draw blood on an HIV-positive patient. They came to see me, and then their colleague who was pregnant went to try and draw the blood, and they got a needle stick. So these two people, I started on post-exposure prophylaxis within one, this was a case where I started as soon as possible, I think it was one hour after the exposure. Fortunately, neither one of them did develop HIV. The one who was pregnant, we had to refer to an HIV pregnancy specialist to make sure that she was getting medications that weren't going to be harming the fetus. For most healthcare personnel, if you initiate post-exposure prophylaxis, you have to do it within 72 hours. If it's after 72 hours, it's really considered early treatment. It's not considered prophylaxis, although you may want to consider offering post-exposure prophylaxis after 72 hours and up to one week for people who have had a very, very high risk exposure. If a question exists concerning which antiviral drugs, antiretroviral drugs to use, or whether you should use a basic regimen or a different regimen because the source patient has resistance, you start with the basic regimen, and then you can get information and you can, with the consultation with the specialist, change the medications if needed. The optimal duration of post-exposure prophylaxis is unknown, but we use the four weeks of treatment. So as I said just a few minutes ago, if you want to modify the treatment because of possible history of resistance, you need to get expert consultation. And whenever possible, you want to consult with an ID or another physician who's experienced with antiretroviral drugs. The post-exposure prophylaxis line from San Francisco General Hospital, their number is listed at the bottom. They used to be open 24-7. You used to be able to get a hold of somebody 24-7 if you had a needle stick injury. They would advise you on what you needed to do, tell you if post-exposure prophylaxis needed to be changed. Now they're open more limited hours, but they do provide an excellent resource if you really don't know what to do or you just want to be reassured that you're doing the right thing or you want to make sure that it really wasn't exposures. Sometimes those situations are not as clear as we may think. Other decisions about antiviral drug resistance, I don't want to, I'm running out of time, so in the interest of time, I just want to say resistance of the testing of the source patient at the time of exposure isn't really practical. You want to give the employee the basic regimen and then you can always change it. And of course, you want to consult with an HIV specialist. The HIV specialist will consider resistance strains that were documented in the past as well as what their resistance pattern is to their current post-exposure prophylaxis. Women of childbearing age, so you need to be aware of several things about that. If somebody's breastfeeding, you have to look at the risk of infant exposure to the medication versus the risk of HIV transmission through breast milk. And there are certain drugs listed here that should not be used in pregnancy, including efavirenz, and indenivir is associated with some issues of hyperbilirubinemia and nephrolithiasis in newborns. And there are some other drugs that are of concern. People who are pregnant shouldn't or who are not using effective contraception need to avoid these drugs that are listed here that I'll let you read because you'll pronounce it better than I will. These are the references I used for the presentation and then this is the up-to-date slides that were on slide 2 and 16. Does anybody have any questions? Just a quick comment since it's been since 2013 that the recommendations were updated and I happen to be on the review group for that down at CDC. We would have said dolutegravir. It's actually a better antiretroviral. It can be dosed once a day. The data from Botswana on neural tube defects, there was some initial concern around that. But the consensus at this point is that you do not need to avoid all use of dolutegravir in women who are potentially about to conceive or who are pregnant. So it actually can be used. With respect to tenofovir, tenofovir alafenamide is probably better to use. So using discovy and tivicay, which is essentially tenofovir alafenamide plus emtricitabine plus dolutegravir is probably the ultimate regimen these days. At some point, CDC will update the recommendations. We'll see how soon that happens. Thank you. We've recently dealt with this in our hospital too because the clinical practice moved to dolutegravir routinely in pregnancy and we wanted to do that in the occupational health service as well. However, because there's just a risk assessment, institutional risk assessment needs to happen because the CDC still has this addendum regarding dolutegravir, but it is used, first line, for infected pregnant women. The issue we had is that our initial starter kits are administered really pretty with a conversation with the nurse and then straight to the pharmacy and you talk to the doctor a bit later. You know, we screen for things, but to get the medication quickly, we can't always do that counseling. And that's what you can do when you're starting a new infected person that you may not always have the time to do well and document that you've done before you give them that first prescription for PEP. So depending on your institution, you just need to know that that's there. Thank you. Thank you. Thank you.

Dr. Rachel Liebu

blood-borne pathogen exposures

hepatitis C

HIV

risk factors

testing protocols

post-exposure prophylaxis

antiretroviral drugs