Am Fam Physician. 2001;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.
| Vaccination and antibody status of exposed workers* | Treatment | |||||
|---|---|---|---|---|---|---|
| Source HbsAg† positive | Source HbsAg†negative | 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. | |||||
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.
| 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 |
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.
| 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 | |