Accidental exposures to infected medical tools used by medical staff continue to be an issue. Despite good safety precautions put in place at the teaching hospital where I am a resident, doctors particularly the junior ones continue to prick themselves, once in awhile, with needles contaminated with body fluids.
The big problem arises when fluids are from patients suspected of or confirmed to be infected with hepatitis B virus (HBV), hepatitis C virus (HCV) or the human immunodeficiency (HIV) virus. Whatever the condition that is suspected, working to prevent these exposures should be key.
Hepatitis B infectivity rate is alarming!
What worse needle prick can one have than that from a confirmed chronic Hepatitis B carrier? Between the three medical conditions mentioned above, Hepatitis B carries the most risk. Its infectivity is about 100 times more deadly (i.e efficient) than that by HIV1. Now consider this from the renowned textbook of medicine Harrison's Principles of Internal Medicine (18th ed):Large, multi-institutional studies have indicated that the risk of HIV transmission following skin puncture from a needle or a sharp object that was contaminated with blood from a person with documented HIV infection is 0.3% and after a mucous membrane exposure it is 0.09% if the injured and/or exposed person is not treated within 24 h with antiretroviral drugs.You now understand my horror when my own house intern recently pricked himself with a needle contaminated with the body fluid of a confirmed chronic HBV patient during a liver biopsy for patient evaluation. The needle pierced his gloves, and sank deep enough that the puncture point bled rather profusely by my own reckoning.
The risk of hepatitis B virus (HBV) infection following a similar type of exposure is 6–30% in nonimmune individuals; if a susceptible worker is exposed to HBV, postexposure prophylaxis with hepatitis B immune globulin and initiation of HBV vaccine is >90% effective in preventing HBV infection. The risk of hepatitis C virus (HCV) infection following percutaneous injury is 1.8% [emphasis mine throughout]
I was more concerned and further horror-struck when I discovered that despite repeated reminders to all house interns, this particular intern was yet to commence the "mandatory" HBV vaccination recommended by the hospital for all staff and students who (constantly) come into contact with patients.
What to do after Hepatitis B exposure
The blame game was not going to solve anything. Do I blame the young man who failed to take his vaccine, myself for not asking for his vaccination status before allowing him to assist me or the hospital for not enforcing their own recommendations? The fact was a non-immune had inadvertently pricked himself with a confirmed HBV-contaminated needle.The important question at this stage was: what was to be done? Without a doubt, a post-exposure prophylaxis (PEP) therapy was essential.
According to the "Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis"2:
Efficacy of PEP for HBV.The guidelines go further to make these recommendations regarding management of healthcare personnel (HCP) following accidental exposures:
The effectiveness of hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine in various postexposure settings has been evaluated by prospective studies...In the occupational setting, multiple doses of HBIG initiated within 1 week following percutaneous exposure to HBsAg-positive blood provides an estimated 75% protection from HBV infection. Although the postexposure efficacy of the combination of HBIG and the hepatitis B vaccine series has not been evaluated in the occupational setting, the increased efficacy of this regimen observed in the perinatal setting, compared with HBIG alone, is presumed to apply to the occupational setting as well. In addition, because persons requiring PEP in the occupational setting are generally at continued risk for HBV exposure, they should receive the hepatitis B vaccine series. [emphasis mine throughout]
RECOMMENDATIONS FOR THE MANAGEMENT OF HCP POTENTIALLY EXPOSED TO HBV, HCV, or HIV
Exposure prevention remains the primary strategy for reducing occupational bloodborne pathogen infections; however, occupational exposures will continue to occur. Health-care organizations should make available to their personnel a system that includes written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational exposures that might place HCP at risk for acquiring a bloodborne infection. HCP should be educated concerning the risk for and prevention of bloodborne infections, including the need to be vaccinated against hepatitis B. Employers are required to establish exposure-control plans that include postexposure follow-up for their employees and to comply with incident reporting requirements mandated by the 1992 OSHA bloodborne pathogen standard. Access to clinicians who can provide postexposure care should be available during all working hours, including nights and weekends. HBIG, hepatitis B vaccine, and antiretroviral agents for HIV PEP should be available for timely administration (i.e., either by providing access on-site or by creating linkages with other facilities or providers to make them available off-site). Persons responsible for providing postexposure management should be familiar with evaluation and treatment protocols and the facility's plans for accessing HBIG, hepatitis B vaccine, and antiretroviral drugs for HIV PEP. [emphasis mine throughout]
Hepatitis B Vaccination.
Any person who performs tasks involving contact with blood, blood-contaminated body fluids, other body fluids, or sharps should be vaccinated against hepatitis B.
In conclusion
The young intern did finally receive the Hepatitis B Immune Globulin (HBIG) and the recombinant Hepatitis B vaccination series, as prescribed in the recommendations above.I hope to write more extensively on the Pre- and Post-exposure prophylaxis of Hepatitis B, Hepatitis C and HIV exposures; both in the non-occupational and the occupational (defined as "...an exposure that might place HCP at risk for HBV, HCV, or HIV infection...") settings.
References:
- Fauci AS, Lane HC. Human Immunodeficiency Virus Disease: AIDS and Related Disorders. In Longo DL, Kasper DL, Jameson JL, Fauci AS, Hauser SL, Loscalzo J (eds): Harrisons Principles of Internal medicine 18th ed.; chap 189; 2012. The McGraw-Hill Companies, Inc.
- CDC. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR June 29, 2001 / 50(RR11);1-42. Document accessed on 17 September 2012. Content available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm
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