Managing Occupational Exposures to Bloodborne Pathogens in the Dental Setting

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Managing Occupational Exposures to Bloodborne
Pathogens in the Dental Setting

• IHS National Dental Update July 16, 2003
• Ronald H. Goldschmidt, MD

2
Objectives

• Identify risks for transmission of bloodborne
  pathogen (BBP) transmission in the dental setting
  
• Discuss methods of reducing risk
• Review principles of managing occupational
  exposures in the dental setting and ways to
  obtain expert help

3
National HIV/AIDS Clinicians Consultation Center

• University of California San Francisco
• San Francisco General Hospital
• Supported by
• Health Resources and Services Administration
  (HRSA)
• AIDS Education and Training Centers (AETCs)
• and
• Centers for Disease Control and Prevention (CDC)
• http//www.ucsf.edu/hivcntr

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National Clinicians Post-Exposure Prophylaxis
Hotline (PEPline)

• (888) HIV - 4911
• (888) 448 - 4911
• 24 hours/day
• 7 days/week

• For questions about occupational exposures to HIV
  and other blood-borne pathogens

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Occupational HIV exposures are crisis situations
demanding immediate, decisive action. Henderson
, Emerg Infect Dis 2001 7254-8.
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Extent of the problem

• 500,000 - 800,000 exposures annually
• Underreporting
• Nurses most common One exposure/year
• HIV, hepatitis B and C infections
• BBP transmission to HCP is rare
• Can have enormous emotional impact

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Goals in Post-Exposure Care

• Prevent transmission
• Avoid unnecessary PEP and PEP toxicity
• Provide counseling and follow-up

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Managing BBP Exposures

• Assess injury/exposure risk
• Assess source patient risk
• Determine whether to offer PEP
• Select PEP regimen
• Obtain baseline laboratory tests
• Counsel the HCW and/or treating clinician
• Follow-up care

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Phases in Managing BBP Exposures
Phase One First Aid Triage and Referral Crisis
Management
Phase Two Exposure Risk Assessment Source Patient
Evaluation PEP Decision Initiating Treatment
Phase Three Post-Exposure Follow-up Source
Patient Follow-up ARV Toxicity Monitoring
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Case 1

• Dental hygienist had superficial injury through
  glove

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What else do we need to know?

• ?
• ?
• ?
• ?
• ?

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What else do we need to know?

• ? Has an exposure occurred?

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First Aid

• Soap and water for percutaneous exposures
• gtnot caustic antiseptic solutions
• gtno back-bleeding

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Triage

• Goal is evaluation immediately after exposure
• Refer to qualified provider
• Employee health department
• Emergency department
• Urgent care
• Occupational medicine clinic

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Phases in Managing BBP Exposures
Phase One First Aid Triage and Referral Crisis
Management
Phase Two Exposure Risk Assessment Source Patient
Evaluation PEP Decision Initiating Treatment
Phase Three Post-Exposure Follow-up Source
Patient Follow-up ARV Toxicity Monitoring
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Exposure Risks

• What is the overall risk of transmission?
• What are the special risk factors?

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Risk of Transmission
Overall risk, percutaneous 0.3 (3 per
1000) Risk Factors Visibly blood device Device
used in artery or vein Deep injury End-stage
AIDS Decreased risk of transmission 80 w AZT PEP
Henderson, Tokars, Ippolito, Gerberding, Bell
Cardo, et al. N Engl J Med 19973371485-90.
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Exposure Risks

• HIV 0.3 percutaneous
• 0.09 mucous membrane
• Hepatitis B without immunity
• Serologic evidence of infection 22-62
  depending on e-antigen
• Hepatitis C
• 1.8

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Other Presumed Transmission Risks

• Percutaneous exposure
• Small vs. large bore needle
• Volume
• Device used recently vs. remotely
• Mucous membrane and non-intact skin exposure
• Volume of infectious fluid
• Duration of contact

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Timing of PEP

• 1-2 hours is ideal 4 hours is goal
• 24 - 72 hours
• 1 week (or more?)
• Start as soon as possible
• Efficacy decreases as time passes
• Do not delay pending test results

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Case 1

• Hygienist had superficial injury through glove
• Noted tiny puncture wound on finger after she
  took gloves off there was no blood under her
  glove or at puncture site
• Needle used to inject lidocaine
• Needle was not visibly bloody
• SP not known to be HIV positive status unknown

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Source Patient Factors Influence Transmission
Risk

• If source is HIV
• Viral load
• Stage of disease
• If HIV status is unknown
• Risk behavior history
• Signs/symptoms suggestive of primary HIV
  infection
• Prior testing history
• If source is unknown
• Background prevalence

23
Updated US Public Health Service Guidelines for
the Management of Occupational Exposures to HBV,
HCV, and HIV and Recommendations for Postexposure
Prophylaxis
MMWR, June 29, 2001 www.cdc.gov www.aidsinfo.nih.
gov
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Percutaneous Exposures
Exposure type Infection status of source Infection status of source Infection status of source Infection status of source Infection status of source
Exposure type HIV-Positive Class 1 HIV-Positive Class 2 Source of unknown HIV status Unknown source HIV-Negative
Less severe Recommend basic 2-drug PEP Recommend expanded 3-drug PEP Generally, no PEP warranted however, consider basic 2-drug PEP for source with HIV risk factors Generally, no PEP warranted however, consider basic 2-drug PEP in settings where exposure to HIV-infected persons is likely No PEP warranted
More severe Recommend expanded 3-drug PEP Recommend expanded 3-drug PEP Generally, no PEP warranted however, consider basic 2-drug PEP for source with HIV risk factors Generally, no PEP warranted however, consider basic 2-drug PEP in settings where exposure to HIV-infected persons is likely No PEP warranted
25
National Clinicians Post-Exposure Prophylaxis
Hotline (PEPline)

• (888) HIV - 4911
• (888) 448 - 4911
• 24 hours/day
• 7 days/week

• For questions about occupational exposures to HIV
  and other blood-borne pathogens

26
Guideline Definitions HIV Disease Status

• HIV Class 1
• Asymptomatic or
• Viral load lt1500
• HIV Class 2
• Symptomatic
• AIDS
• Known high VL
• Acute seroconversion illness

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The PEP Decision

• Usually must be made with incomplete source
  patient information
• Should not be delayed until SP lab results are
  available
• Consider and discuss risks and benefits of PEP in
  the context of a specific exposure
• Decision is the dental hygienists

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Case 1

• Counsel hygienist that generally, no PEP would
  be warranted however, PEP may be considered.
• Consider (offer) basic PEP regimen her decision

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Source Assessment Laboratory Testing

• Testing options
• Rapid vs standard HIV antibody test
• Antibody testing vs direct virus assay
  
• Testing discarded needles is not an option

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Case 1

• Decided to take AZT/3TC pending test results

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PEP selection

• 28-day treatment course
• Basic 2-drug regimen
• AZT 3TC
• Alternatives ddI/d4T d4T/3TC /- AZT/ddI
• Default can treat and stop
• Can be reassuring
• Allows time for test results
• Allows time for HCP reconsideration

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PEP BENEFITS MAY OUTWEIGH RISKS High risk
exposure Known positive source High risk
source No delay to rx Choice of drugs minimizes
toxicity
PEP TOXICITIES MAY OUTWEIGH BENEFITS Low risk
exposure Low risk source Found needle Delay (gt72
hrs) Drug interactions/co-existing medical
conditions. Pregnancy???
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PEP Prescribing Principles

• Make PEP decision and start antiretrovirals as
  soon as possible after exposure
• PEP rarely indicated gt72 hours after exposure
• Default can treat and stop
• Can be reassuring
• Allows time for test results
• Allows time for HCP reconsideration
• Continue PEP for 28 days
• Monitor closely for PEP toxicity

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Acute HIV Syndrome 1-8 weeks

• Fever 96
• Rash 70
• Sore Throat 70
• Adenopathy 74
• Myalgias 54
• Headache 32
• Diarrhea, N-V, malaise, thrush,
  hepatosplenomegaly, neuro sx (meningitis/neuropath
  y, facial palsy)
• Oral/Genital Ulcers -- Specific

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Phases in Managing BBP Exposures
Phase One First Aid Triage and Referral Crisis
Management
Phase Two Exposure Risk Assessment Source Patient
Evaluation PEP Decision Initiating Treatment
Phase Three Post-Exposure Follow-up Source
Patient Follow-up ARV Toxicity Monitoring
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Post-Exposure Follow-Up

• HIV Antibody Testing
• Baseline, 6 wks, 3 mos, 6 mos
• Consider 12 month for co-exposures to HIV/HCV
• HCV Antibody Testing ALT
• Baseline, 6 wks, 3 mos, 6 mos
• Confirm positives
• HCV RNA testing
• Consider at 4-6 weeks if earlier diagnosis needed
• HBV testing as clinically indicated

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Antiretroviral Toxicity Monitoring

• Symptoms/Signs GI intolerance, rash, etc
• Laboratory
• Baseline LFTs, CBC w/diff platelets
• Consider renal panel, amylase
• Repeat at 2 weeks
• Repeat at 4 weeks if any abnormalities

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Case 1

• Decided to take AZT/3TC pending test results
• Developed some headache and nausea in first day
  resolved with acetaminophen and taking meds with
  food
• Results of ELISA _at_ day 3 Negative

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Dental Exposures Setting Dental Exposures Setting
Calls Setting
196 DENTAL CLINIC
11 OTHER
4 UNKNOWN
211 Total
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Total Exposed Profession Total Exposed Profession
Calls Exposed
115 DENTAL TECH
60 DDS
25 STUDENT
10 OTHER
1 UNKNOWN
211 Total
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Exposure Type Exposure Type
Calls Exposure
192 PERCUTANEOUS
16 MUCOUS MEMBRANE
1 CUTANEOUS
2 UNKNOWN
211 Total
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Material exposed to Material exposed to
Calls Material Bloody?
135 BLOOD  
15 SALIVA NO
8 SALIVA YES
5 SALIVA PROBABLY
7 SALIVA UNKNOWN
34 UNKNOWN  
7 OTHER  
211 Total
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For Percutaneous Exposures For Percutaneous Exposures

Calls Device
94 HOLLOW BORE NEEDLE
87 SOLID DEVICE
4 SCALPEL
7 UNKNOWN
192 Total
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Deep Stick Deep Stick
Call Deep?
121 NO
14 YES
9 PROBABLY
41 UNKNOWN
7 BLANK
192 Total
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Visibly Bloody Device Visibly Bloody Device
Calls Visibly Bloody?
111 NO
19 YES
1 PROBABLY
55 UNKNOWN
6 BLANK
192 Total
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Used in Vein/Artery Used in Vein/Artery
Calls Used in Vein?
162 NO
4 YES
20 UNKNOWN
6 BLANK
192 Total
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SP Known
Calls SP Known?
184 YES
24 NO
3 UNKNOWN
211 Total
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HBsAg when SP is known HBsAg when SP is known
Calls HBsAg
151 UNKNOWN
19 NEGATIVE
5 POSITIVE
9 BLANK
184 Total
50
HIV Ab when SP is known HIV Ab when SP is known
Calls HIV
103 UNKNOWN
59 POSITIVE
18 NEGATIVE
4 BLANK
184 Total
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Case 2

• HIV patient spat in the eye of a dental hygienist

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What else do we need to know?

• ?
• ?
• ?
• ?
• ?

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Infectious Fluids

• Considered Infectious
• Blood, tissue
• Cerebrospinal, amniotic, pericardial,
  peritoneal, pleural, synovial fluids
• Semen, vaginal secretions, pus
• Considered Non-infectious (Unless visibly
  bloody)
• Urine, feces, nasal secretions, saliva, gastric
  fluid, sputum, tears, sweat, vomitus

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Phase 1 Actions

• First aid Water or saline for mucous membrane
  exposures
• Triage to designated clinician, ER, employee
  health, etc
• Crisis management make concerns realistic
  through data, understanding concerns, acting
  promptly

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Case 2

• HIV patient spat in the eye of a dental hygienist
• Hygienist had previous evidence of response to
  hepatitis B immunization series
• Saliva was visibly bloody

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Mucous Membrane Non-Intact Skin Exposures
Exposure type Infection status of source Infection status of source Infection status of source Infection status of source Infection status of source
Exposure type HIV-Positive Class 1 HIV-Positive Class 2 Source of unknown HIV status Unknown source HIV-Negative
Small volume Consider basic 2-drug PEP Recommend basic 2-drug PEP Generally, no PEP warranted however, consider basic 2-drug PEP for source with HIV risk factors7 Generally, no PEP warranted however, consider basic 2-drug PEP in settings where exposure to HIV-infected persons is likely No PEP warranted
Large volume Recommend basic 2-drug PEP Recommend expanded 3-drug PEP Generally, no PEP warranted however, consider basic 2-drug PEP for source with HIV risk factors7 Generally, no PEP warranted however, consider basic 2-drug PEP in settings where exposure to HIV-infected persons is likely No PEP warranted
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Guideline Definitions

• HIV Class 1 Asymptomatic or Viral load lt1500
• HIV Class 2 symptomatic, AIDS, known
• high VL, acute seroconversion illness
• Small volume a few drops
• Large volume a major splash
• Eye exposures same as other mucous membrane
  exposures?

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Case 2

• HIV patient spat in the eye of a dental hygienist
• Hygienist had previous evidence of response to
  hepatitis B immunization series
• Saliva was visibly bloody
• Patient is heavily ARV-experienced, currently on
  d4t/ddI/Kaletra with poor viral control. He is
  hepatitis B and hepatitis C co-infected.

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Post-Exposure Prophylaxis for Hepatitis B
Vaccination And antibody Response status of exposed workers Treatment Treatment Treatment
Vaccination And antibody Response status of exposed workers 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 If adequate, no treatment is necessary If inadequate, administer HBIG x 1 and vaccine booster No treatment Test exposed person for anti-HBs If adequate, no treatment is necessary If inadequate, administer vaccine booster and recheck titer in 1-2 months
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Hepatitis B Vaccine

• Protective immunity after
• 1 dose ? 50
• 2 doses ? 70
• 3 doses ? 90
• Positive titre 10mIU/ml or greater

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Hepatitis B Blood ExposureTransmission Rates

• Percutaneous
• Source has SAg and eAg 1.5 20
• Source has eAg 20 50
• Mucocutaneous
• ?

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Hepatitis B Immune Globulin (HBIG)

• Decreases transmission to 24 when given within
  1 week
• Decreases transmission to 2.4 when given with
  hepatitis B vaccine
• Not needed if HCP ever responded to hepatitis B
  vaccine

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Hepatitis C

• Risk of seroconversion 1.8 (0-10)
• Rare for mucocutaneous
• No prophylaxis
• Early treatment vs. careful follow-up (may clear
  the infection or have no clinically important
  sequellae 20 years latency continually
  improving antiviral drugs)
• Need to give HCP the options to make informed
  decision

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Institutions key roles in organizing local
systems for post-exposure care

• Establish organizational structure for exposure
  management
• OSHA Blood-Borne Pathogens Standards
• NIOSH Guidelines
• State Laws regarding reporting , etc.
• Hospital regulations
• Written policies and protocols for reporting,
  evaluating, counseling, treating, and follow-up.
• MMWR Guidelines
• Establish procedures to ensure confidentiality

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Who should provide post-exposure care?
Clinician should be - knowledgeable (can be
expert) - familiar with PHS Guidelines -
connected to others with expertise  
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Who should not provide post-exposure care?
Friend/colleagues Exposed HCP themselves Bosses Ov
er-involved Inexperienced  
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Who should provide post-exposure care? (cont.)
Local/State/Regional Experts PEPline Consultati
ve services are not a substitute for
face-to-face evaluation, counseling, and
follow-up
68
PEPline Caller Survey - 2002
Timely response to callers question 4.84
Information presented clearly 4.85
Recommendations useful in managing this exposure 4.87
Follow-up information received in a timely manner 4.85
Specific circumstances of the exposure incorporated into reply 4.74
Recommendations useful in managing subsequent exposures 4.87
Would call this service again 4.93
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Dental office exposure management

• Formal training for all
• Protocols for dealing with equipment
• Basic safety measures hepatitis B vaccination
  sharps containers, gloves, no re-capping, etc.
• Posting of exposures/non-exposures
• Readily available protocol for managing exposures
• Linkage with treating clinicians
• Protocols for obtaining source patient
  information and follow-up
• Non-judgmental attitude
• Insurance coverage

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Rationale For Expert Consultation

• Guidelines cant address all scenarios
• Clinicians may not have extensive exposure
  management experience
• Clinicians may not be familiar with HIV treatment
• Source patients on ARVs may have resistant virus
• Prompt consultation helps decision-making and
  provides reassurance to HCP

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PEPline Methodology

• Toll-free
• Clinicians available 24 hours
• 9 am 8 pm EST clinicians answer directly
• Off hours answering service pages clinicians
• respond within 15 minutes
• Clinicians UCSF faculty, HIV experienced
• Intensive PEP training (didactic and mentoring)
• Confidential documentation of caller information,
  exposure characteristics, and recommendations
• CQI

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PEPline Volume

• Call volume 550/month
• Approaching 25,000 total calls since October
  1997

77
Callers to PEPline

• Treating Clinicians 78
• MD 62
• NP, RN, PA, LVN 36
• Other 2
• Exposed HCPs 22

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Where Exposure Occurred
79
Profession of Exposed HCP
80

• Exposed HCWs
• Female 67.6
• 4.8 pregnant

81
Pregnancy

• Recommendations same, except
• Avoid efavirenz teratogenic
• Avoid ddI/d4T combination lactic acidosis
• (Note recommend discontinuing breast feeding
  while taking ARVs)

82
Exposure Type

• Percutaneous 78
• Mucous Membrane 15
• Cutaneous 5
• Other/Unknown 2

83
Exposure Fluids

• Blood 71.2
• Other 28.8
• Infectious 9.6
• Non-infectious 19.2

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Source Patient Characteristics

• Identity of Source Patient
• Known 78
• Unknown 22

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Challenges in Implementing the Guidelines The
Role of Expert Consultation
Assessing actual risk of exposure Questionable
exposures (skin, oral, scratch,etc) Unknown
source (includes found needle, sharps box)
Complicated exposures Source Patient with prior
or current ARV Rx Pregnancy Drug Toxicity
86
PEP Recommendations, Feb- July 2002

• Recommend 10
• Consider (benefits gt toxicity) 4
• Consider (benefitstoxicity unclear) 11
• Consider (benefits lt toxicity) 25
• Not recommended 23
• Stop 2
• Unspecified, not discussed 29

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Objectives

• Review management of occupational exposures
• Review PEPline services and experiences
• Discuss components of response to occupational
  exposures

88
Acknowledgments
Taejoon Ahn, MD Richard Aranow, MD Kirsten
Balano, Pharm D Nina Birnbaum, MD Larry Boly,
MD Steve Bromer, MD Betty Dong, Pharm D Monica
Ghandi, MD Cristina Gruta, Pharm D
Lisa Gooze, MD Donald Graves, MD Ann Harvey,
MD Mary Lawrence Hicks, NP Amy Kindrick, MD Jill
Legg, MD Gifford Leoung, MD Jason Tokumoto,
MD Jackie Tulsky, MD
89
National HIV Telephone Consultation Service
(Warmline)

• .

• For questions about HIV/AIDS clinical care

(800) 933 - 3413 Monday through Friday 9 am to 8
pm EST
90
Exposures in the Occupational Setting

• Needlestick .03 percent
• Risk Stratification
• a. Deep injury
• b. Visible blood
• c. Device used in artery or vein
• d. Advanced disease

91
Exposures in the Occupational Setting

• Treatment (PEP) reduced transmission 80
• Zidovudine plus lamivudine /- protease inhibitor
  
• Other regimens for exposures from source patients
  with documented or possible ARV drug resistance

92
Exposed Callers Exposed Callers
Calls Exposed
33 DDS
20 DENTAL TECH
4 STUDENT
4 OTHER
1 UNKNOWN
62 Total
93
Exposed Patient Exposed Patient
Calls Exposed
95 DENTAL TECH
27 DDS
21 STUDENT
6 OTHER
149 Total
exposed callers not included exposed callers not included
94
Caller Profession Caller Profession
Calls Caller
96 MD/DO
58 DDS
30 DENTAL TECH
28 RN/PA/NP
17 OTHER
229 Total
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Phase 2 Risk Assessment

• Injury severity
• Source patient evaluation
• PEP decision
• Initiating treatment

96
Case 2

• HIV patient spat in the eye of a medical
  assistant in your urgent care clinic
• Patient had been in a fist-fight and was bleeding
  from the mouth saliva was visibly bloody
• Patient is heavily ARV-experienced, currently on
  d4t/ddI/Kaletra with poor viral control. He is
  hepatitis B and hepatitis C co-infected
• Medical assistant had previous evidence of
  response to hepatitis B immunization series

97
Case 2 PEP Selection

• Resistant virus very likely
• Expanded regimen indicated
• Source patient history is key
• Obtain details ASAP
• Make best empiric decision and start immediately
• Modify regimen as more source patient info
  emerges
• Seek consultation as needed

98
Direct Virus Assays

• HIV RNA by PCR or bDNA
• Highly sensitive (too sensitive?)
• False positive rate 2-5
• Not standardized or FDA approved for diagnosis
• May identify source patients in window period

99
Rapid HIV Testing

• SUDS and OraQuick
• Results available within hours
• Negative result is highly reassuring
• False positive rate may be higher than the
  standard EIA, especially in low risk populations
• Positive tests must be confirmed
• Western Blot
• Immunofluoresence assay

100
Crisis Management and Exposed HCP Counseling

• Non-judgmental understanding acknowledge the
  value of their call
• Joining
• Statement about competence/expertise
• Calm control
• Facts gain perspective
• ltNote Treating Clinicians may need the samegt

101
Source Assessment Laboratory Testing

• Testing options
• Rapid vs standard HIV antibody test
• SUDS- almost no false negatives few false
  positives
• (Negatives reassuring)
• (True positives treat)
• (False positives treat discontinue in a
  few days)
• Antibody testing vs direct virus assay
  (false positives may help in
  window period)
• Testing discarded needles is not an option

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Ensuring timely and accurate response

• Establish designated person(s) or team trained in
  prevention measures and response to exposure
• Availability of ARV medications
• emergency supply 24-hours
• beware long weekends

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