Practice Guidelines

PHS Guidelines for Management of Occupational Exposure to HBV, HCV and HIV: Management of Occupational Blood Exposures

Am Fam Physician. 2001 Dec 15;64(12):2012-2014.

The U.S. Public Health Service (PHS) has updated and consolidated all of its previous guidelines and recommendations for the management of health care personnel 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). The new PHS guidelines were published in the June 29, 2001 issue of the Recommendations and Reports series of Morbidity and Mortality Weekly Report.

The updated guidelines provide recommendations on postexposure management and prophylaxis, and offer practice recommendations for implementation of the guidelines in health care facilities. In the previous issue of American Family Physician, the PHS recommendations for implementation of the guidelines in health care facilities were outlined. In this issue, the PHS recommendations for the management of occupational blood exposures are discussed. The December 1 issue will conclude the PHS series with the recommendations for basic and expanded HIV postexposure prophylaxis regimens.

Recommendations for the Management of Occupational Blood Exposures

When health care personnel are exposed to bloodborne pathogens, the PHS recommends that immediate care be given to the exposure site by washing the wounds and skin with soap and water and flushing mucous membranes with water. Health care personnel should then determine the risk associated with the exposure by evaluating the type of fluid and type of exposure.

Evaluating the source of exposure should involve assessment of the risk of infection using available information and testing known sources for hepatitis B surface antigen, anti-HCV and HIV antibody (consider using rapid testing). For unknown sources, the risk of exposure to HBV, HCV and HIV infection should be assessed. The PHS recommends against testing discarded needles or syringes for virus contamination. When evaluating the exposed person, immune status should be assessed for HBV infection by examining the history of hepatitis B vaccination and vaccine response.

The PHS guidelines recommend postexposure prophylaxis for exposures that may pose a risk of infection transmission Table 1. describes postexposure prophylaxis for exposure to HBV. The PHS does not recommend postexposure prophylaxis for persons exposed to HCV. The recommended postexposure prophylaxis for percutaneous injuries and for mucous membrane and nonintact skin exposures to HIV are outlined in Tables 2 and 3.

Postexposure prophylaxis for personnel exposed to HIV should be initiated as soon as possible, preferably within hours of exposure, and should be continued for four weeks if tolerated. Pregnancy testing should be offered to all women of childbearing age who are not known to be pregnant. Expert consultation should be sought if viral resistance is suspected.

Exposed persons should be advised to seek medical evaluation for any acute illness that occurs during follow-up. For HBV exposures, follow-up anti-HBs testing should be performed in persons who receive hepatitis B vaccine. Testing for anti-HBs should be done one to two months after the last dose of vaccine. Anti-HBs response to vaccine cannot be ascertained if HBIG was received in the previous three to four months.

TABLE 1

Recommended Postexposure Prophylaxis for Exposure to Hepatitis B Virus

Vaccination and antibody status of exposed workers* Treatment
Source HbsAgpositive Source HbsAgnegative Source unknown or not available for testing

Unvaccinated

HBIG‡ x 1 and initiate HB vaccine series.§

Initiate HB vaccine series.

Initiate HB vaccine series.

Previously vaccinated

Known responder‖

No treatment

No treatment

No treatment

Known nonresponder¶

HBIG x 1 and initiate revaccination or HBIG x 2.#

No treatment

If known high-risk source, treat as if source were HbsAg positive.

Antibody response unknown

Test exposed person for anti-HBs.**

No treatment

Test exposed person for anti-HBs.

1. If adequate,‖ no treatment is necessary.

1. If adequate,§ no treatment necessary.

2. If inadequate, administer HBIG x 1and vaccine booster.

2. If inadequate,§ administer vaccine and booster and recheck titer in one to two months.


HbsAg = hepatitis B surface antigen; HB = hepatitis B; HBIG = hepatitis B immune globulin.

*—Persons who have previously been infected with hepatitis B virus are immune to reinfection and do not require postexposure prophylaxis.

†—Hepatitis B surface antigen.

‡—Hepatitis B immune globulin; dose is 0.06 mL per kg intramuscularly.

§—Hepatitis B vaccine.

‖—A responder is a person with adequate levels of serum antibody to HbsAg (i.e., anti-HBs 10 mIU per mL).

¶—A nonresponder is a person with inadequate response to vaccination (i.e., serum anti-HBs < 10 mIU per mL).

#—The option of giving one dose of HBIG and reinitiating the vaccine series is preferred for nonresponders who have not completed a second three-dose vaccine series. For persons who previously completed a second vaccine series but failed to respond, two doses of HBIG are preferred.

**—Antibody to HbsAg.

Adapted from 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 Morb Mortal Wkly Rep 2001;50(No. RR-11):22.

TABLE 1   Recommended Postexposure Prophylaxis for Exposure to Hepatitis B Virus

View Table

TABLE 1

Recommended Postexposure Prophylaxis for Exposure to Hepatitis B Virus

Vaccination and antibody status of exposed workers* Treatment
Source HbsAgpositive Source HbsAgnegative Source unknown or not available for testing

Unvaccinated

HBIG‡ x 1 and initiate HB vaccine series.§

Initiate HB vaccine series.

Initiate HB vaccine series.

Previously vaccinated

Known responder‖

No treatment

No treatment

No treatment

Known nonresponder¶

HBIG x 1 and initiate revaccination or HBIG x 2.#

No treatment

If known high-risk source, treat as if source were HbsAg positive.

Antibody response unknown

Test exposed person for anti-HBs.**

No treatment

Test exposed person for anti-HBs.

1. If adequate,‖ no treatment is necessary.

1. If adequate,§ no treatment necessary.

2. If inadequate, administer HBIG x 1and vaccine booster.

2. If inadequate,§ administer vaccine and booster and recheck titer in one to two months.


HbsAg = hepatitis B surface antigen; HB = hepatitis B; HBIG = hepatitis B immune globulin.

*—Persons who have previously been infected with hepatitis B virus are immune to reinfection and do not require postexposure prophylaxis.

†—Hepatitis B surface antigen.

‡—Hepatitis B immune globulin; dose is 0.06 mL per kg intramuscularly.

§—Hepatitis B vaccine.

‖—A responder is a person with adequate levels of serum antibody to HbsAg (i.e., anti-HBs 10 mIU per mL).

¶—A nonresponder is a person with inadequate response to vaccination (i.e., serum anti-HBs < 10 mIU per mL).

#—The option of giving one dose of HBIG and reinitiating the vaccine series is preferred for nonresponders who have not completed a second three-dose vaccine series. For persons who previously completed a second vaccine series but failed to respond, two doses of HBIG are preferred.

**—Antibody to HbsAg.

Adapted from 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 Morb Mortal Wkly Rep 2001;50(No. RR-11):22.

For HCV exposures, baseline and follow-up testing for anti-HCV and alanine aminotransferase should be performed four to six months after exposure. HCV RNA should be performed at four to six weeks if earlier diagnosis of HCV infection is desired. Repeatedly reactive anti-HCV enzyme immunoassays should be confirmed with supplemental testing.

TABLE 2

Recommended HIV PEP for Percutaneous Injuries

Exposure type Infection status of source
HIV-positive class 1* HIV-positive class 2* Source of unknown HIV status† Unknown source‡ HIV-negative

Less severe§

Recommend basic two-drug PEP.

Recommend expanded three-drug PEP.

Generally, no PEP warranted; however, consider basic two-drug PEP|| for source with HIV risk factors.¶

Generally, no PEP warranted; however, consider two-drug PEP|| in settings where exposure to HIV-infected persons is likely.

No PEP warranted

More severe#

Recommend expanded three-drug PEP.

Recommend expanded three-drug PEP.

Generally, no PEP warranted; however, consider basic two-drug PEP|| for source with HIV risk factors.

Generally, no PEP warranted; however, consider basic two-drug PEP|| in settings where exposure to HIV-infected persons is likely.

No PEP warranted


HIV = human immunodeficiency virus; PEP = postexposure prophylaxis.

*—HIV-positive, Class 1—asymptomatic HIV infection or known low viral load (e.g., < 1,500 RNA copies per mL). HIV-positive, Class 2—symptomatic HIV infection, acquired immunodeficiency virus, acute seroconversion or known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of PEP should not be delayed pending expert consultation, and, because expert consultation alone cannot substitute for face-to-face counseling, resources should be available to provide immediate evaluation and follow-up care for all exposures.

†—Source of unknown HIV status (e.g., deceased source person with no samples available for HIV testing).

‡—Unknown source (e.g., a needle from a sharps disposal container).

§—Less severe (e.g., solid needle and superficial injury).

‖—The designation “consider PEP” indicates that PEP is optional and should be based on an individualized decision between the exposed person and the treating clinician.

¶ —If PEP is offered and taken and the source is later determined to be HIV-negative, PEP should be discontinued.

#—More severe (e.g., large-bore hollow needle, deep puncture, visible blood on device or needle used in patient's artery or vein.

Adapted from 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 Morb Mortal Wkly Rep 2001;50(No. RR-11):24.

TABLE 2   Recommended HIV PEP for Percutaneous Injuries

View Table

TABLE 2

Recommended HIV PEP for Percutaneous Injuries

Exposure type Infection status of source
HIV-positive class 1* HIV-positive class 2* Source of unknown HIV status† Unknown source‡ HIV-negative

Less severe§

Recommend basic two-drug PEP.

Recommend expanded three-drug PEP.

Generally, no PEP warranted; however, consider basic two-drug PEP|| for source with HIV risk factors.¶

Generally, no PEP warranted; however, consider two-drug PEP|| in settings where exposure to HIV-infected persons is likely.

No PEP warranted

More severe#

Recommend expanded three-drug PEP.

Recommend expanded three-drug PEP.

Generally, no PEP warranted; however, consider basic two-drug PEP|| for source with HIV risk factors.

Generally, no PEP warranted; however, consider basic two-drug PEP|| in settings where exposure to HIV-infected persons is likely.

No PEP warranted


HIV = human immunodeficiency virus; PEP = postexposure prophylaxis.

*—HIV-positive, Class 1—asymptomatic HIV infection or known low viral load (e.g., < 1,500 RNA copies per mL). HIV-positive, Class 2—symptomatic HIV infection, acquired immunodeficiency virus, acute seroconversion or known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of PEP should not be delayed pending expert consultation, and, because expert consultation alone cannot substitute for face-to-face counseling, resources should be available to provide immediate evaluation and follow-up care for all exposures.

†—Source of unknown HIV status (e.g., deceased source person with no samples available for HIV testing).

‡—Unknown source (e.g., a needle from a sharps disposal container).

§—Less severe (e.g., solid needle and superficial injury).

‖—The designation “consider PEP” indicates that PEP is optional and should be based on an individualized decision between the exposed person and the treating clinician.

¶ —If PEP is offered and taken and the source is later determined to be HIV-negative, PEP should be discontinued.

#—More severe (e.g., large-bore hollow needle, deep puncture, visible blood on device or needle used in patient's artery or vein.

Adapted from 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 Morb Mortal Wkly Rep 2001;50(No. RR-11):24.

For HIV exposures, HIV-antibody testing should be performed for at least six months postexposure. HIV antibody testing should be performed if illness that is compatible with an acute retroviral syndrome occurs. Exposed persons should be advised to use precautions to prevent secondary transmission during the follow-up period. Exposed persons taking postexposure prophylaxis should also be evaluated within 72 hours after exposure and monitored for drug toxicity for at least two weeks.

TABLE 3

Recommended HIV PEP for Mucous Membrane Exposures and Nonintact Skin* Exposures

Exposure type Infection status of source
HIV-positive class 1† HIV-positive class 2† Source of unknown HIV status‡ Unknown source§ HIV-negative

Small volume‖

Consider basic two-drug PEP. ¶

Recommend basic two-drug PEP.

Generally, no PEP warranted; however, consider basic two- drug PEP ¶ for source with HIV risk factors.#

Generally, no PEP warranted; however, consider basic two-drug PEP ¶ in settings where exposure to HIV-infected persons is likely

No PEP warranted

Large volume**

Recommend basic two-drug PEP.

Recommend expanded three-drug PEP.

Generally, no PEP warranted; however, consider basic two-drug PEP ¶ for source with HIV risk factors.#

Generally, no PEP warranted; however, consider basic two-drug PEP ¶ in settings where exposure to HIV-infected persons is likely.

No PEP warranted


HIV = human immunodeficiency virus; PEP = postexposure prophylaxis.

*—For skin exposures, follow-up is indicated only if there is evidence of compromised skin integrity (e.g., dermatitis, abrasion or open wound).

†—HIV-positive, Class 1—asymptomatic HIV infection or known low viral load (e.g., < 1,500 RNA copies per mL). HIV-positive, Class 2—symptomatic HIV infection, acquired immunodeficiency syndrome, acute seroconversion or known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of PEP should not be delayed pending expert consultation, and, because expert consultation alone cannot substitute for face-to-face counseling, resources should be available to provide immediate evaluation and follow-up care for all exposures.

‡—Source of unknown HIV status (e.g., deceased source person with no samples available for HIV testing).

§—Unknown source (e.g., splash from inappropriately disposed blood).

‖—Small volume (i.e., a few drops).

¶—The designation, “consider PEP,” indicates that PEP is optional and should be based on an individualized decision between the exposed person and the treating clinician.

#—If PEP is offered and taken and the source is later determined to be HIV-negative, PEP should be discontinued.

**—Large volume (i.e., major blood splash).

Adapted from 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 Morb Mortal Wkly Rep 2001;50(No. RR-11):25.

TABLE 3   Recommended HIV PEP for Mucous Membrane Exposures and Nonintact Skin* Exposures

View Table

TABLE 3

Recommended HIV PEP for Mucous Membrane Exposures and Nonintact Skin* Exposures

Exposure type Infection status of source
HIV-positive class 1† HIV-positive class 2† Source of unknown HIV status‡ Unknown source§ HIV-negative

Small volume‖

Consider basic two-drug PEP. ¶

Recommend basic two-drug PEP.

Generally, no PEP warranted; however, consider basic two- drug PEP ¶ for source with HIV risk factors.#

Generally, no PEP warranted; however, consider basic two-drug PEP ¶ in settings where exposure to HIV-infected persons is likely

No PEP warranted

Large volume**

Recommend basic two-drug PEP.

Recommend expanded three-drug PEP.

Generally, no PEP warranted; however, consider basic two-drug PEP ¶ for source with HIV risk factors.#

Generally, no PEP warranted; however, consider basic two-drug PEP ¶ in settings where exposure to HIV-infected persons is likely.

No PEP warranted


HIV = human immunodeficiency virus; PEP = postexposure prophylaxis.

*—For skin exposures, follow-up is indicated only if there is evidence of compromised skin integrity (e.g., dermatitis, abrasion or open wound).

†—HIV-positive, Class 1—asymptomatic HIV infection or known low viral load (e.g., < 1,500 RNA copies per mL). HIV-positive, Class 2—symptomatic HIV infection, acquired immunodeficiency syndrome, acute seroconversion or known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of PEP should not be delayed pending expert consultation, and, because expert consultation alone cannot substitute for face-to-face counseling, resources should be available to provide immediate evaluation and follow-up care for all exposures.

‡—Source of unknown HIV status (e.g., deceased source person with no samples available for HIV testing).

§—Unknown source (e.g., splash from inappropriately disposed blood).

‖—Small volume (i.e., a few drops).

¶—The designation, “consider PEP,” indicates that PEP is optional and should be based on an individualized decision between the exposed person and the treating clinician.

#—If PEP is offered and taken and the source is later determined to be HIV-negative, PEP should be discontinued.

**—Large volume (i.e., major blood splash).

Adapted from 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 Morb Mortal Wkly Rep 2001;50(No. RR-11):25.


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