HIV PEP UP HARI PANKAJ VANAM

Slide 1: 

HARI PANKAJ VANAM ASSISTANT PROFESSOR DEPT OF MICROBIOLOGY BHASKAR MEDICAL COLLEGE,INDIA Know the facts!!!

Universal Precautions and Bio-Medical Waste Management: 

Universal Precautions and Bio-Medical Waste Management

Some components of the UP: 

Some components of the UP Hand hygiene and use of Personal Protection Equipments (PPE). Appropriate needle and sharps disposal methods. Waste disposal methods. Post exposure prophylaxis. Adherence to universal precautions amongst all levels of staff.

STANDARD PRECAUTIONS FOR HCP: 

STANDARD PRECAUTIONS FOR HCP

Hand Hygiene and Personal Protection Equipment (PPE): 

Hand Hygiene and Personal Protection Equipment (PPE) Always wash hands before/after removing gloves Gloves are not a substitute for hand washing Gloves need to be removed between patients Handle used items with care–reuse only after disinfection Disposal of single use items correctly after use Image Courtesy GHTM/ I-TECH

Remember: For All Types of Hand Hygiene: 

Remember: For All Types of Hand Hygiene Keep nails short (1-2mm) Do not wear nail polish Remove jewellery, bracelets, wrist watches Do not dry hands on clothes/uniforms after hand washing  × × ×

Slide 7: 

Areas frequently missed during hand washing

Ensure Good Ventilation: 

Ensure Good Ventilation Open windows Ensure proper airflow direction in wards with TB patients Supervise proper patient placement and spatial separation Health worker Patient Open window Ideal Airflow Direction

Standard Precaution Measures : Blood Borne Pathogens: 

Standard Precaution Measures : Blood Borne Pathogens Hand hygiene Use PPE Disinfect and Sterilize Proper waste management Instrument safety Reduce risk of sharps injuries

To Prevent Needlestick Injuries: 

To Prevent Needlestick Injuries Needles should never be recapped After use, disposable syringes and needles, scalpel blades, and other sharp items should be placed in puncture-resistant containers for disposal ; the puncture-resistant containers should be located as close as practical to the use area.

HOW Needle stick injury occur?: 

HOW Needle stick injury occur?

Activities associated with needle stick injuries: 

Activities associated with needle stick injuries

Slide 13: 

Recapping Strictly Prohibited use one hand scoop technique only

Selection of Protective Barriers: 

Selection of Protective Barriers

How to Manage Spills ?: 

How to Manage Spills ? Immediate Measures - Cover spills for 10 min in 1% NaHOCl/bleach and dispose. Disinfectants effective in inactivating HIV Chlorine releasing agents, chemical disinfectants.

Slide 16: 

Mopping with Disinfectant

Disinfect and Sterilize: Agents Used in Disinfection: 

Disinfect and Sterilize: Agents Used in Disinfection EFFECTIVE against HIV: Household bleach / sodium hypochlorite Chlorhexidine 2-4% Glutaraldehyde 2% Ethanol 70% Formalin 4% Povidone iodine 2% INEFFECTIVE against HIV: Savlon - poor effect Dettol solution - no effect Lysol – poor effect

Instrument Safety: 

Instrument Safety How will you ensure the safety of instruments you would use? First choice, use disposable needles Never reuse a disposable needle or instrument Disinfect reusable needles /syringes /instruments with hypochlorite first, then sterilize by autoclaving or boiling before re-use Safely dispose all sharps (needles, lancets, scalpels) after use

Bio-Medical Waste Management: 

Bio-Medical Waste Management

Steps for Bio-Medical Waste Management : 

Steps for Bio-Medical Waste Management Segregation and weighing Transport Temporary storage Treatment and final disposal

Segregation and Weighing: 

Segregation and Weighing Image Courtesy GHTM, Chennai we have these protocols...but do we follow 'em

Segregation at source: 

Segregation at source Red Contaminated plastics Yellow Anatomical and infectious but non-plastic waste Blue Sharps (puncture proof container) Black Toxic and radioactive waste (hazardous non-infectious waste) No breakable items

Waste disposal of sharps is done in: 

Waste disposal of sharps is done in Black Bin Blue Bin Yellow Bin Red Bin

Waste disposal of Infected Swabs and Placenta is done in: 

Waste disposal of Infected Swabs and Placenta is done in Black Bin Blue Bin Yellow Bin Red Bin

Waste disposal of contaminated Plastics is done in : 

Waste disposal of contaminated Plastics is done in Black Bin Blue Bin Yellow Bin Red Bin

Waste disposal of General Waste is done in: 

Waste disposal of General Waste is done in Black Bin Blue Bin Yellow Bin Red Bin

Which bin would you use: 

Which bin would you use Post delivery placenta ? Y Post LP – needle ? B Post ICD – bag ? Left over food ? B Post injection cotton swab ? Y Glove ? & Glove cover ? R Urine bag and catheter ? B/Y

Treatment and Final Disposal: 

Treatment and Final Disposal Non plastic infectious waste Incinerate Autoclave and bury in secure landfill Infectious plastics Autoclave, shred and bury Sharps Mutilate immediately after use, autoclave and then landfill Chemical/ Liquid waste Neutralize/disinfect before discharge into sewer

Protect Yourself: 

Protect Yourself Take three doses of hepatitis B vaccine. It gives you life long protection Follow universal precautions at all times Take measures to prevent accidents Take Post Exposure Prophylaxis (PEP) in the event of any occupational exposure

Definitions: 

Definitions Occupational exposure refers to exposure to potential blood-borne infections (HIV, HBV and HCV) during performance of duties. Non-occupational exposure refers to exposure to potential blood-borne infections (HIV, HBV, HCV) outside work setting- e.g. sexual assault /rape/sodomy etc Post exposure prophylaxis (PEP) refers to the comprehensive management given to minimize the risk of infection following potential exposure to blood-borne pathogens (HIV, HBV, HCV).

Exposed Person: 

Exposed Person Exposed person is the person who is at risk of acquiring HIV/HBV/HCV infection through exposure to blood or body fluids . Who is at Risk ? - occupational Nursing Staff Emergency Care Providers Labor & delivery room personnel Surgeons and operation theater staff Lab Technicians Dentists Health cleaning/ mortuary staff / Waste Handlers

Recent Occupational Epidemiology: 

Recent Occupational Epidemiology HIV Documented occupational infections in health care workers, (Dec 2002) Hepatitis B 16,000/yr in 1983 compared to 400/year in 1995 Hepatitis C 1-2% of health care workers infected (same as general population) Hepatitis C data from CDC Recommendations fro Prevention and Control of Hepatitis C Virus Infection and HCV-Related Chronic Disease

Exposure Risks (average, per episode, involving HIV-infected source patient): 

Exposure Risks (average, per episode, involving HIV-infected source patient) Percutaneous (blood) 1 0.3% Mucocutaneous (blood) 2 0.09% Receptive anal intercourse 3 1 - 2% Insertive anal intercourse 4 0.06% Receptive vaginal intercourse 5 0.1 – 0.2% Insertive vaginal intercourse 6 0.03 – 0.14% Receptive oral (male) 7 0.06% Female-female orogenital 8 4 case reports IDU needle sharing 9 0.67% Vertical (no prophylaxis) 10 24%

Slide 35: 

Which Body fluid has the highest potential of transmission?

Occupational Blood-Borne Exposures Relative Risk of Sero-conversion with Percutaneous Injury: 

. Occupational Blood-Borne Exposures Relative Risk of Sero-conversion with Percutaneous Injury Mucous membrane splash to eye, oro nasal 0.09%

Work Practices which Increase the Risk of Needle Stick Injury : 

Work Practices which Increase the Risk of Needle Stick Injury Recapping needles ( Most important) Performing activities involving needles and sharps in a hurry Handling and passing needles or sharp after use Failing to dispose of used needles properly in puncture-resistant sharps containers Poor healthcare waste management practices Ignoring Universal Work Precautions

What is the risk of contracting HIV after needle stick injury?: 

What is the risk of contracting HIV after needle stick injury? What factors affect this risk?

Risk Factors for Seroconversion: 

Risk Factors for Seroconversion Cardo DM et al. NEJM 1997;337:1485-90 *p<0.01 for all

Other Likely Risk Factors: 

Other Likely Risk Factors Viral load Glove use 50% decrease in volume of blood transmitted 1 Hollow bore vs solid bore Large diameter needles weakly associated with increased risk (p = 0.08) 2 Drying conditions tenfold drop in infectivity every 9 hours 3 1. Mast ST et al. JID 1993;168(6):1589-92. 2. Cardo DM et al. NEJM 1997;337:1485-90 3. Resnick L et al, JAMA 1986;255(14):1887-91. 3.

Non-occupational epidemiology: 

Non-occupational epidemiology

Management of Exposure: 

Management of Exposure Manage Exposure Site Establish eligibility for PEP Counsel for PEP Prescribe PEP Laboratory Evaluation Follow up and monitor and adherance 6 STEP STRATEGY

Steps for managing occupational exposure: 

Steps for managing occupational exposure Skin: Do not squeeze the wound to bleed it, do not put the pricked finger in mouth. Wash with soap &water, don’t scrub, no antiseptics or skin washes (bleach, chlorine, alcohol, betadine). Eye: wash with water/ normal saline/ don’t remove contact lens immediately if wearing, no soap or disinfectant. Mouth: spit fluid immediately, repeatedly rinse the mouth with water and spit / no soap/ disinfectant . STEP-1: Manage exposure site Refer to physician

Steps for managing occupational exposure: 

Do ‘s Do not’s Remove gloves, if appropriate Wash the exposed site thoroughly with running water Irrigate with water or saline if eyes or mouth have been exposed Wash the skin with soap and water Do not panic Do not put the pricked finger in mouth Do not squeeze the wound to bleed it Do not use bleach, chlorine, alcohol, betadine, iodine or other antiseptics/detergents on the wound Steps for managing occupational exposure

Step 2: Establish eligibility for PEP: 

Step 2: Establish eligibility for PEP Assessing the nature of exposure and risk of transmission Assessing the HIV status of the source of exposure Source material: Blood, bloody fluid, other potentially infectious fluid Type of exposure Mucous membrane or non-intact skin Intact Skin Percutaneous exposure Assessing the nature of exposure and risk of transmission Assessing the HIV status of the source of exposure Volume Severity (no PEP needed)

Slide 46: 

Step 2: Establish eligibility for PEP Exposure within 72 hours Assess exposed individual Assess exposure source Assess type of exposure Determine risk of transmission Determine eligibility for PEP

Slide 47: 

Category Definition and example Mild exposure Mucous membrane/non-intact skin with small volumes E.g. : a superficial wound (erosion of the epidermis) with a plain or low calibre needle, or contact with the eyes or mucous membranes, subcutaneous injections following small-bore needles Moderate exposure Mucous membrane/non intact skin with large volumes OR Percutaneous superficial exposure with solid needle E.g. : a cut or needle stick injury penetrating gloves Severe exposure Percutaneous with large volume e.g. : An accident with a high calibre needle (>18 G) visibly contaminated with blood; a deep wound (haemorrhagic wound and/or very painful); transmission of a significant volume of blood; an accident with material that has previously been used intravenously or intra-arterially. A. Categories of exposure

Risk based on source : 

Risk based on source Source HIV status Definition of risk in source HIV negative Source is not HIV infected but consider HBV & HCV Low risk HIV positive and clinically asymptomatic High risk HIV positive and clinically symptomatic Unknown Status of the patient is unknown and neither the patient and nor his/her blood is available for testing (e.g. injury during medical waste management the source patient might be unknown). The risk assessment will be based only upon the exposure ( HIV Prevalence in the locality can be considered) Exposure with discarded sharps / needles , contaminated for over 48hrs, the risk for HIV is negligible but risk for HBV remains significant as HBV survives longer outside the body.

B. Assessment of HIV status of the source of exposure: 

B. Assessment of HIV status of the source of exposure A baseline rapid HIV testing should be done before starting PEP. Further initiation of PEP where indicated should not be delayed for want of report. A + HIV test result can help taking a decision but a negative test result does not exclude HIV infection as the source may be in the window period. When the status of source is unknown or the sample is not available for testing the risk is based on the HIV prevalence in the geographical area. C. Assessment of the exposed individual Exposed individual should be tested for pre-existing HIV infection. HIV + cases should not receive PEP and should be referred to ART centre for eligibility of ART and further management.

Slide 50: 

Step 3: Counsel for PEP Provide information on HIV and PEP Obtain consent for PEP Offer special leave from work

Slide 51: 

Information to exposed person includes - Assess Risk of exposure PEP is provided to prevent potential transmission of HIV virus. It is not 100% effective and should be given preferably within 2 hours but certainly within 72 hours if eligible. Baseline HIV testing is important. PEP medicines will be discontinued if the initial baseline HIV test is positive. In that case further assessment for initiating ART would be done. Duration of course of medicine is 4 weeks. Importance of adhering to medication once started. Medicines can be stopped at any time but benefit of PEP will not be obtained. Common side effects of medicines. After exposure the person should not have unprotected sexual intercourse until it is confirmed, 3months after the exposure that he/she is not HIV infected. Condom use is essential The PEP drugs are usually safe during pregnancy. If the lady gets HIV due to exposure during pregnancy, the baby will have some risk of becoming HIV infected. The PEP drugs are usually safe during breast feeding but the lady may consider stopping breast feeding if PEP is indicated. Symptoms and signs of early HIV sero conversion Risk of Hepatitis B and Hepatitis C after needle stick exposure and available prophylaxis for this. 3 rd step – Counseling for PEP

Slide 52: 

Step 4: Prescribe PEP Assess source patient’s ARV status Check for pregnancy if exposed female HCP Explain side effects of ARVs Explain post exposure measures against HBV and HBC

Slide 53: 

There are 2 types of regimen Basic - 2 drug combination Expanded regimen - 3 drug combination 4 th step – Prescribe PEP Drug 2 drug regimen 3 drug regimen Zidovudine(AZT) Or Stavudine (d4T) + Lamivudine (3TC) Protease inhibitors If Protease inhibitors is not available 300 mg twice a day or 30 mg twice a day + 150 mg twice a day Nil Nil 300 mg twice a day or 30 mg twice a day + 150 mg twice a day + 1 st choice: Lopinavir/ ritonavir 400mg/100mg twice a day or 2 nd choice : Nelfinavir 1250 mg twice a day Efavirenz (EFV) 600 mg once a day

Slide 54: 

Exposure Status of source HIV+ and asymptomatic HIV+ and symptomatic HIV status not known Mild Consider 2 drug PEP Start 2 drug PEP Usually no PEP or Consider 2 drug PEP Moderate Start 2 drug PEP Start 3 drug PEP Usually no PEP or Consider 2 drug PEP Severe Start 3 drug PEP Start 3 drug PEP Usually no PEP or Consider 2 drug PEP HIV testing of source should not delay the decision of starting PEP. Start 2 drugs first if required then obtain consultation. Prophylaxis needs to be continued for 4 weeks. For a female under consideration of PEP a pregnancy test is recommended. Efavirenz is contraindicated in first 3months and Indinavir during Pre natal time. It is recommended to begin with basic regimen and if 3 rd drug is required then add Nelfinavir.

Tolerability of HIV PEP in HCWs: 

Tolerability of HIV PEP in HCWs From: Wang SA. Infect Control Hosp Epidemiology 2000;231:780-5.

Slide 56: 

STEP 5: Laboratory evaluation Provide HIV pretest counseling Provide HIV post-test counseling Reason for testing soon after exposure is to establish “baseline’ against which to compare future test results. Timing In persons on PEP In persons not on PEP Baseline (with in 8 days of exposure) HIV,HCV,HBV Complete blood counts Transaminases HIV,HCV,HBV

Slide 57: 

Step 6: Follow up and monitor adherence Record-keeping Follow up visits for clinical assessment at 2 weeks Clinical – Monitoring for appearance of signs of HIV sero conversion Use precautions to prevent secondary transmission (Blood donation, Breast feeding ,Pregnancy, Unprotected Sexual relations especially during 6-12 wks following exposure. Condom use is essential. Drug adherence, Psychological support HIV test at 3 and 6 months

Slide 58: 

Lab follow up for HIV and Hepatitis – Timing In persons taking PEP In persons not taking PEP Weeks 2 & 4 Transaminases Complete blood counts Clinical monitoring for Hepatitis Week 6 HIV-Ab HIV-Ab Month 3 HIV-Ab, anti - HCV, HBsAg, Transaminases HIV-Ab, anti- HCV, HBsAg Month 6 HIV-Ab, anti –HCV, HBsAg, Transaminases HIV-Ab, anti-HCV,HBsAg Exposed persons should have post PEP HIV test. Testing at end of PEP may give indication of sero conversion. To diagnose all persons who sero convert testing at 3 and 6 months is recommended.

How effective is PEP?: 

How effective is PEP?

Indian Experience on PEP : 

Indian Experience on PEP 1. Safdarjung Hospital- March 2010 428 HCWs were asked to fill an anonymous, self-reporting questionnaire structured specifically to identify predictive factors associated with NSIs. Of these, 343 (80.1%) gave a history of NSI in the preceding one year. The commonest cause of NSI was blood withdrawal (55%), followed by suturing (20.3%) and vaccination (11.7%). The practice of recapping needles after use was still prevalent among HCWs (66.3%). Some HCWs also revealed that they bent the needles before discarding (11.4%). Only 40 per cent of the HCWs knew about the availability of PEP services in the hospital and 75 per cent of exposed nursing students did not seek PEP A total of 9 HCWs acknowledged receiving NSI from known HIV seropositive patients (3 were senior residents, 2 interns and 4 student nurses). None of them became HIV seropositive over the next three months., all these HCWs had full course of PEP drugs

Role of PEP in Preventing Transmission of HIV- Indian Studies (Contd.): 

Role of PEP in Preventing Transmission of HIV- Indian Studies (Contd.) 2. LTM Hospital, Siom, Mumbai -2002 Over a period of one year, June 2000 - 2001, a total number of 38 cases of accidental exposures were self reported Of the 38 reported cases; 34 were NSIs, 2 were scalpel cuts, and 1 was exposure to body fluids (vitreous humor) by splashing and 1 was a human bite, from a psychiatric patient. The 38 source cases were also tested for HIV 1,2 antibodies and HBsAg. Ten were HIV seropositive and 28 HIV seronegative and four were HBsAg positive and 34 HBsAg seronegative. Majority of the 34 needle stick injuries were by hollow bore needles . Of these, 20 were during blood collection procedure by hollow bore needle, 5 during angioplasty procedure, 4 during central venous puncture line cut down procedures, 2 during suturing of contused lacerated wound and 3 while recapping the needle. PEP was received regualarly by 10 cases. All the HCWs were HIV and HBsAg seronegative after one and half years. -

Evidence of Efficacy of PEP: 

Evidence of Efficacy of PEP Animal models: high level of protection when started within 24 hours 1 OR = 0.19 for zidovudine use in case-control study 2 Two drugs, three drugs: No direct evidence that more effective than 1 drug Cases of seroconversion despite 3-drug PEP imply efficacy less than 100% 3,4 1. Tsai C-C et al. J Virol 1998;72:4265-73. 2. Cardo DM et al. NEJM 1997;337:1485-90. 3. Jochinsen EM et al. Arch Int Med 1999;159:2361-3. 4. MMWR June 29, 2001 / 50(RR11);1-42

What are the drawbacks of PEP?: 

What are the drawbacks of PEP? I cant take the morning pill anymore!!!!!

HIV Post Exposure Prophylaxis Serious Adverse Events Associated with Nevirapine: 

HIV Post Exposure Prophylaxis Serious Adverse Events Associated with Nevirapine 22 Serious Adverse events - 12 hepatotoxicity - 2 cases of liver failure - 14 dermatologic Year Number MMWR 2001;49(51):1153-6.

Adverse Effects: Basic vs Expanded Regimens: 

Adverse Effects: Basic vs Expanded Regimens % of individuals Puro V et al. 9th CROI, February 2002, Abstract 478-M

When should PEP be started?: 

When should PEP be started?

When should PEP be started?: 

When should PEP be started? Efficacy of PEP thought to wane with time At what point is PEP “no longer worth it”? benefits of PEP risks of PEP exposure time

Timing of PEP: what’s the evidence?: 

Timing of PEP: what’s the evidence? Animal models and animal PEP studies: suggest substantially less effective beyond 24 - 36 hours 1,2 Case-control study: most subjects in each group received PEP within 4 hours 3 Analysis of PEP failures does not suggest a clear cut-off 4 1. Tsai C-C et al. J Virol 1998;72:4265-73. 2. Shih CC et al. JID 1991. 3. Cardo DM et al. NEJM 1997;337:1485-90. 4. MMWR June 29, 2001:50(RR11);1-42.

How Long Should PEP be Administered?: 

How Long Should PEP be Administered? N = 24 macaques inoculated with SIV intravenously PEP initiated 24 hours post-inoculation PEP administered for 3, 10, or 28 days Tsai C-C et al. J Virol 1998;72:4265-73.

Duration of PEP: 

Duration of PEP In animal model, 28 days more effective than 10 days or 3 days of PEP 1 4 weeks (28 days) used in case-control study 2 and recommended by CDC guidelines 3 1. Tsai C-C et al. J Virol 1998;72:4265-73. 2. Cardo DM et al. NEJM 1997;337:1485-90. 3. MMWR June 29, 2001:50(RR11);1-42.

PreEP!!!!! A future companion!!: 

PreEP!!!!! A future companion!! Pre-exposure prophylaxis has been studied in animal and human trials. Results from a human trial published in late 2010 were the first to provide proof of concept for PrEP. PrEP consists of antiretroviral drugs to be taken before potential HIV exposure in order to reduce the risk of HIV infection. Currently tested PrEP antivirals  tenofovir and emtricitabine or tenofovir alone. Taken once a day, these drugs have limited side effects and slow development of associated drug resistance. "For MSM at high risk for HIV infection, PrEP may represent a much-needed additional prevention tool. However, PrEP should be used only in combination with other HIV prevention strategies, requires strict adherence, and is an intensive approach that won't be right for everyone.“ CDC 2010

Who would be likely to benefit from PrEP? : 

Who would be likely to benefit from PrEP? There are cases of couples wishing to conceive a child where one partner is HIV positive and the other HIV negative. PrEP could be used as an alternative to sperm washing , a procedure currently being used in many parts of the developed world by HIV different couples. Sperm washing is costly and is believed to have a low conception rate, which is why PrEP could be a more effective option It has been suggested the PrEP would be an effective way to “protect women (and men) who are victims of sexual violence or coercion, or who are afraid to insist that their partners use condoms”. Worldwide the most common form of HIV transmission is through unprotected vaginal sex with an infected partner. Therefore millions of people could conceivably benefit from taking a pill a day as a way of reducing their risk of contracting HIV. Rape survivors are not receiving vital anti-HIV treatment due to ignorance and a lack of basic treatment procedure at government health facilities and justice departments” (IRIN, 2007) 11 . Homophobia and lack of understanding regarding male-on-male rape also explain why some men in South Africa do not access PEP treatment. 12

Real Time Experiences: 

R eal Time Experiences PEP CASES: MUST KNOW SCENERIOS

Case 1: Male Paramedic: 

Case 1: Male Paramedic Male paramedic splashed with large volume of bloody amniotic fluid onto open ulcers on his arms. Washed arms approximately one hour later. He has diabetes, hypertension, hyperlipidemia, GERD, peripheral neuropathy and history of kidney stones. Source is HIV+ without any treatment during this pregnancy. Paramedic started on AZT, 3TC and indinavir. Two days later he complains of overwhelming nausea and vomiting. Assess injury: Large volume exposure to skin with compromised integrity. Assess source : Known HIV+, likely Class II (high viral load), but virus also likely wild-type. Recommend management : Manage symptoms using anti-emetics and consider pro-motility agent for diabetic gastroparesis. Consider other regimens: AZT/3TC (wild type virus in source), AZT/3TC/Nelfinavir, AZT/3TC/RTV/SQV, AZT/3TC/EFV. Consider drug interactions.

Case 2: Doc stuck Needle!!: 

Case 2: Doc stuck Needle!! Doctor stuck with needle used to inject lidocaine. Not visibly bloody, superficial stick. Concern about pus on the needle . Source patient denied any risks, married for 20yrs, rural area of Moinabad. Rapid HIV test (Tridot or IC strip) run immediately showed positive, Doctor started promptly on AZT, 3TC and indinavir, but complained of severe nausea and vomiting and had family history of kidney stones. Three days later, source patient Hepatitis B and C serologies both came back positive. Western Blot confirmation of HIV ELISA still pending. Assess injury : Less severe Assess source : Potentially HIV+, although asymptomatic and virus likely wild-type. Recommend management : Continue PEP, but consider stopping indinavir, or changing to nelfinavir, especially if toxicity limits ability to complete regimen. Follow-up:6 week follow up serologies all negative.

Case 3: Intern stuck needle: 

Case 3: Intern stuck needle Intern calls the ER middle of the night unable to sleep. She had had a needle stick 6 weeks earlier while inserting an IV into a pregnant woman who was HIV- early in pregnancy and HIV- after the exposure. Assess injury : More severe. Assess source : Not HIV infected. Recommend management : Manage emotional crisis: normalize her reaction, help identify fears, clarify difference between rational concern and fear-driven anxiety, strategize about getting support.

Case 4:Nurse stuck needle in labor: 

Case 4:Nurse stuck needle in labor Nurse stuck with catheter used to insert IV for woman in labor. Stick was deep. Source is known Hepatitis B S Ag+ and Hepatitis C infected. Nurse is in good health with adequate Hepatitis B titers. Assess injury : high risk Assess source : high risk based on history of IV drug use and known BBP infection. Recommend management : Offer PEP for HIV, but benefits probably outweigh toxicities. Two drugs likely adequate, since source virus would be wild type. Follow closely for HCV. RN is HBV protected.

Case 5: Pregnant Resident Exposed !!: 

Case 5: Pregnant Resident Exposed !! Resident stuck superficially with suture needle in the OR. Needle not bloody . She is 8 wks pregnant . Source known HIV+, not on meds. Died of GI bleed, cause not HIV related. VL and CD4 unknown. Assess injury : Low risk Assess source : Thought to be asymptomatic from HIV (Class I), but VL unknown. Virus likely wild type. Recommend management : Recommend 2 drug HIV PEP, consider a third drug. Include counseling about risks of ARVs and HIV seroconversion in pregnancy.

Case 6: Garbage collector: 

Case 6: Garbage collector Garbage collector stuck with needle from the trash in a residential neighborhood. Stick was deep, but needle never recovered. Area with relatively high prevalence of viral hepatitis, as well as HIV, among IV drug users. Assess injury : More severe based on deep injury. Assess source : Unknown, although high prevalence area. Recommend management : Consider basic (2 drug) PEP for HIV. Initiate Hepatitis B vaccination series, consider HBIG X 1.

Case 7: Nurse exposed to High risk: 

Case 7: Nurse exposed to High risk Nurse stuck after giving insulin injection 3 days ago . Stick not deep. Nurse in good health. Source ELISA now positive, she admits to a history of heterosexual promiscuity. Assess injury : Less severe Assess source : Preliminary positive HIV result with recent high risk behavior, however asymptomatic for HIV, so likely Class I. Recommend management : Recommend PEP - basic (2 drug) regimen, but with option of adding a protease inhibitor until test results can be confirmed and, if necessary, viral load assessed. Efficacy of PEP delayed beyond 3 days is not known, but some experts recommend more aggressive treatment for significant injuries, when there is a delay in initiation of treatment.

Case 8: Security guard outside ER: 

Case 8: Security guard outside ER Security guard stuck outside of ER by a needle just used by someone to inject drugs. Needle visible bloody and used in vein , but stick not deep. Guard has history of kidney stones. Source claims to be HIV and Hepatitis C infected . Consented to testing in the ER. Assess injury : More severe Assess source : High risk, could be HIV Class II. Recommend management : Recommend expanded (3 drug) regimen, based on source report of HIV status, and severity of the injury. Prefer nelfinavir as third drug over indinavir, since guard has history of kidney stones. HBIG and Hepatitis B vaccination warranted if guard is not previously vaccinated.

Case 9: Phlebotomist stuck to a resistant case: 

Case 9: Phlebotomist stuck to a resistant case Phlebotomist stuck with vacutainer needle while transferring blood. Wearing gloves. Deep stick. Source is HIV+, and Hepatitis C +. Started on AZT, ddI and nelfinavir one month ago when VL <750,000 and CD4 73. His doctor thinks adherence is good. Three months before starting new regimen, genotype while on d4T, 3TC, efavirenz had shown resistance to 3TC, all NNRTIs . Assess injury : More severe Assess source : Probably Class II, with resistant virus. Recommend management : Recommend expanded (3 drug) regimen for HIV PEP. 3TC likely ineffective. Protease inhibitor resistance unlikely to have developed during one month of therapy. Consider AZT, ddI, nelfinavir (same as source regimen), as option most likely to combine effectiveness with tolerability. Follow closely for Hepatitis C seroconversion.

“Spread the Message…Not the VIRUS.”: 

“Spread the Message…Not the VIRUS.” THANK U ALL