HTB

Updated US Public Health Service guidelines for the management of occupational exposures to HBV, HCV and HIV and recommendations for postexposure prophylaxis (PEP)

1 September 2001. Related: Guidelines.

This report [published in the June 29, 2001 MMWR] updates and consolidates all previous US Public Health Service recommendations for the management of health-care personnel (HCP) who have occupational exposure to blood and other body fluids that might contain hepatitis B virus (HBV), hepatitis C virus (HCV) or human immunodeficiency virus (HIV).

Summary of recommendations

Recommendations for HBV: postexposure management include initiation of the hepatitis B vaccine series to any susceptible, unvaccinated person who sustains an occupational blood or body fluid exposure. Postexposure prophylaxis (PEP) with hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine series should be considered for occupational exposures after evaluation of the hepatitis B surface antigen status of the source and the vaccination and vaccine-response status of the exposed person. Guidance is provided to clinicians and exposed HCP for selecting the appropriate HBV PEP.

Recommendations for HCV: Immune globulin and antiviral agents (e.g., interferon with or without ribavirin) are not recommended for PEP of hepatitis C. For HCV postexposure management, the HCV status of the source and the exposed person should be determined, and for HCP exposed to an HCV positive source, follow-up HCV testing should be performed to determine if infection develops.

Recommendations for HIV : PEP include a basic 4-week regimen of two drugs (zidovudine [ZDV] and lamivudine [3TC]; 3TC and stavudine [d4T]; or didanosine [ddI] and d4T) for most HIV exposures and an expanded regimen that includes the addition of a third drug for HIV exposures that pose an increased risk for transmission. When the source person’s virus is known or suspected to be resistant to one or more of the drugs considered for the PEP regimen, the selection of drugs to which the source person’s virus is unlikely to be resistant is recommended.

In addition, this report outlines several special circumstances (e.g., delayed exposure report, unknown source person, pregnancy in the exposed person, resistance of the source virus to antiretroviral agents, or toxicity of the PEP regimen) when consultation with local experts and/or the National Clinicians’ Post-Exposure Prophylaxis Hotline ([PEPline] 1-888-448-4911) is advised.

Occupational exposures should be considered urgent: medical concerns to ensure timely postexposure management and administration of HBIG, hepatitis B vaccine, and/or HIV PEP.

Avoiding occupational blood exposures is the primary way to prevent transmission of hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) in health-care settings (1). However, hepatitis B immunization and postexposure management are integral components of a complete program to prevent infection following bloodborne pathogen exposure and are important elements of workplace safety (2).

Recommendations for nonoccupational (e.g., sexual, paediatric, and perinatal) HBV, HCV, and HIV exposures are not addressed in these guidelines and can be found elsewhere (12—15).

Definition of health-care personnel and exposure: in this report, health-care personnel (HCP) are defined as persons (e.g., employees, students, contractors, attending clinicians, public-safety workers, or volunteers) whose activities involve contact with patients or with blood or other body fluids from patients in a health-care, laboratory, or public-safety setting. The potential exists for blood and body fluid exposure to other workers, and the same principles of exposure management could be applied to other settings.

An exposure that might place HCP at risk for HBV, HCV, or HIV infection is defined as: a percutaneous injury (e.g., a needlestick or cut with a sharp object) or contact of mucous membrane or nonintact skin (e.g., exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious (16,17).

In addition to blood and body fluids containing visible blood, semen and vaginal secretions also are considered potentially infectious. Although semen and vaginal secretions have been implicated in the sexual transmission of HBV, HCV, and HIV, they have not been implicated in occupational transmission from patients to HCP. The following fluids also are considered potentially infectious: cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid. The risk for transmission of HBV, HCV, and HIV infection from these fluids is unknown; the potential risk to HCP from occupational exposures has not been assessed by epidemiologic studies in health-care settings. Faeces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus are not considered potentially infectious unless they contain blood. The risk for transmission of HBV, HCV, and HIV infection from these fluids and materials is extremely low.

Any direct contact (i.e., contact without barrier protection) to concentrated virus in a research laboratory or production facility is considered an exposure that requires clinical evaluation. For human bites, the clinical evaluation must include the possibility that both the person bitten and the person who inflicted the bite were exposed to blood borne pathogens. Transmission of HBV or HIV infection only rarely has been reported by this route (18—20) (CDC, unpublished data, 1998)

Source: MMWR. June 29, 2001 / 50 (RR11); 1-42.

References:

  1. CDC. NIOSH alert: preventing needlestick injuries in health care settings. Cincinnati, OH: Department of Health and Human Services, CDC, 1999; DHHS publication no. (NIOSH)2000-108.
  2. Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910.1030. Occupational exposure to blood borne pathogens; final rule. Federal Register 1991; 56:64004—182.
  3. CDC. Public Health Service statement on management of occupational exposure to human immunodeficiency virus, including considerations regarding zidovudine postexposure use. MMWR 1990; 39(No. RR-1).
  4. CDC. Update: provisional Public Health Service recommendations for chemoprophylaxis after occupational exposure to HIV. MMWR 1996; 45:468—72.
  5. CDC. Public Health Service guidelines for the management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis. MMWR 1998; 47(No. RR-7).
  6. Panlilio AL, Cardo DM, Campbell S, Srivastava P, NaSH Surveillance Group. Experience of health care workers taking antiretroviral agents as postexposure prophylaxis for occupational exposure to HIV [Abstract 489]. In: Proceedings of the 1999 National HIV Prevention Conference. Atlanta, GA, 1999.
  7. Wang SA, Panlilio AL, Doi PA, et al. Experience of healthcare workers taking postexposure prophylaxis after occupational HIV exposures: findings of the HIV postexposure prophylaxis registry. Infect Control Hosp Epidemiol 2000;21:780—5.
  8. Puro V, Ippolito G, Italian Registry PEP. Antiretroviral post-exposure prophylaxis [Abstract 515]. In: Proceedings of the 1999 National HIV Prevention Conference. Atlanta, GA, 1999.
  9. Parkin JM, Murphy M, Anderson J, El-Gadi S, Forster G, Pinching AJ. Tolerability and side-effects of post-exposure prophylaxis for HIV infection [Letter]. Lancet 2000; 355:722—3.
  10. Jochimsen EM, Srivastava PU, Campbell SR, Cardo DM, NaSH Surveillance Group. Postexposure prophylaxis (PEP) use among health care workers (HCWs) after occupational exposures to blood [Abstract W6-F]. In: Keynote addresses and abstracts of the 4th ICOH International Conference on Occupational Health for Health Care Workers. Montreal, Canada, 1999.
  11. Critchley SE, Srivastava PU, Campbell SR, Cardo DM, NaSH Surveillance Group. Postexposure prophylaxis use among healthcare workers who were exposed to HIV-negative source persons [Abstract P-S2-64]. In: Program and Abstracts of the 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Atlanta, GA: CDC in conjunction with the 10th Annual Meeting of SHEA, 2000:126.
  12. CDC. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991; 40(No. RR-13).
  13. CDC. Recommendations for the prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998; 47(No. RR-19).
  14. CDC. Management of possible sexual, injecting-drug—use, or other nonoccupational exposure to HIV, including considerations related to antiretroviral therapy: Public Health Service statement. MMWR 1998; 47(no. RR-17).
  15. CDC. Recommendations of the U.S. Public Health Service Task Force on the use of zidovudine to reduce perinatal transmission of human immunodeficiency virus. MMWR 1994; 43(No. RR-11).
  16. CDC. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987; 36 (suppl no. 2S).
  17. CDC. Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other blood borne pathogens in health-care settings. MMWR 1988;37:377—82,387—8.
  18. Shapiro CN, McCaig LF, Gensheimer KF, et al. Hepatitis B virus transmission between children in day care. Pediatr Infect Dis J 1989; 8:870—5.
  19. Richman KM, Rickman LS. The potential for transmission of human immunodeficiency virus through human bites. J Acquir Immune Defic Syndr 1993; 6:402—6.
  20. Vidmar L, Poljak M, Tomazic J, Seme K, Klavs I. Transmission of HIV-1 by human bite [Letter]. Lancet 1996; 347: 1762—3.

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