Management of Exposures to Bloodborne Pathogens

Purpose:

To provide a standard of care for evaluation and treatment of occupational exposures to Bloodborne Pathogens. To be used in conjunction with Chemoprophylaxis for HIV Exposures Protocol.

Definitions:

AHIV
Antibody to Human Immunodeficiency Virus. A positive result indicates infection with HIV. Confirmatory tests are done to exclude false positive result. Antibody can be done via rapid method with results available in 1 - 2 hours.
Bloodborne Pathogen
A pathogen that is largely transmitted by the bloodborne route and a major occupational risk for health care workers. Hepatitis B virus, Hepatitis C virus and the Human Immunodeficiency Viruses are the most common bloodborne pathogens in occupational exposures.
Body Substance Exposure ("exposure")
A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious material.
EIA
Enzyme Immunoassay Assay Test; to detect presence of HIV-1/HIV-2 antibodies (positive results are repeated for verification; repeatable specimens are sent out for Western Blot)
Employee
Includes any full or part-time, temporary or regular employee. Includes volunteers, students, and Special Purpose Trainees who experience an exposure while performing a service for University of Michigan Health System
HBSAB
Antibody to Hepatitis B virus antigen. A positive result indicates immunity to Hepatitis B from either previous infection or immunization.
HBSAG
Hepatitis B antigen. Antigen found in blood indicates ongoing infection and possible infectivity. Infectivity is more likely if Hepatitis B e Antigen is also present. Can be found in acute infection and chronic carrier state.
HCAB
Antibody to Hepatitis C virus. A positive result indicates infection with Hepatitis C and probable infectivity. Confirmatory tests such as PCR and RIBA are done to exclude false positive result.
Hepatitis B
RNA virus that causes an inflammation of the liver. Transmitted by parenteral, mucous membrane, sexual or trans-placental routes. Risk of transmission from percutaneous exposure to infected source is in the 2 - 40% range. Infection can be prevented through vaccination.
Hepatitis B Immune Globulin (HBIG)

Preparation prepared from plasma containing high titers of antibody to Hepatitis B virus.

Used to confer passive immunity to Hepatitis B virus for susceptible persons exposed to Hepatitis B virus.Hepatitis B Vaccine: A product produced by recombinant technology (no human derived material) for active immunization against Hepatitis B virus. Administered as a series of three injections during a six month period. About 90% of people develop adequate immunity after the vaccination series. An additional few percent of people will develop immunity after an additional series. Protection is considered to be long-lived and routine boosters are not indicated per CDC.

Hepatitis C
A RNA virus that causes inflammation of the liver. Transmitted primarily by parenteral route although sexual contact poses a low risk. Risk of transmission from percutaneous exposure to infected source is in the 3-10% range. No proven effective pre or post exposure treatment.
Human Immunodeficiency Virus (HIV)
DNA virus that causes the disease AIDS. Transmitted by parenteral, mucous membrane, sexual, transplacental or breastfeeding exposure. Risk of transmission from a percutaneous exposure to HIV positive source is 0.2%-0.5% range with risk higher for larger volume of blood and high titer of HIV virus in source. Transmission risk can be modified by post exposure prophylaxis. Post exposure prophylaxis is discussed in a separate U-M OHS protocol.
Isolated Body Substance Exposure
Exposure to blood or other potentially infectious material (OPIM) from a percutaneous injury or splash event involving a limited number of individuals.
Other Potentially Infectious Materials
Defined by the OSHA Bloodborne Pathogens Standard as "(1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, and body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. (2) any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV containing cell or tissue cultures, organ cultures and HIV or HBV containing culture medium or other solutions; and blood, organs or other tissues from experimental animals infected with HIV or HBV." For the purpose of this protocol, exposure to saliva from a bite will be considered an exposure.
PCR Hepatitis C
Assay for Hepatitis C virus (RNA test for Hepatitis C virus) - diagnosis of Hepatitis C infection can be made by qualitatively detecting HCV RNA using gene amplification techniques (RT-PCR). HCV-RNA can be detected in serum or plasma within 1-2 weeks after exposure to the virus and weeks before the onset of ALT elevations or the appearance of anti-HCV.
Reverse Exposure
An exposure incident where the employees blood or OPIM, is the source of an exposure to a patient.
RIBA
Recombinant immunoblot assay - confirmatory test for samples positive for Hepatitis C by immunoassay.
Western Blot
HIV antibody confirmation test. Supplementation of a positive anti-HIV-1/HIV-2 infection enzyme immunosorbent assay test result.

Policy:

  • Employees shall notify U-M Occupational Health Services of all potential exposures as soon as possible. The employee can contact U-M OHS by using pager #5356 (call 734-936-6266, pager #5356, if you don't have access to the paging website), 24 hours/day.
  • When U-M OHS is closed, the ED charge nurse conducts initial assessment for HIV risk and orders blood for rapid HIV test (if rapid test is available). Employee will be notified of the Rapid HIV test results. If test is negative, employee is told to follow up for remainder of evaluation with U-M OHS. If rapid HIV is positive, employee is referred to ED for evaluation and prophylaxis.
  • U-M OHS conducts assessment for HIV risk and orders blood for rapid HIV test (if rapid test is available). U-M OHS documents route of exposure including any safety devices used and whether personal protective equipment was utilized. U-M OHS assesses whether "reverse exposure" has occurred. If so, consent will be obtained from the employee for HIV, Hepatitis B and Hepatitis C testing as appropriate. Risk Management is notified of the "reverse exposure" incident. Subsequent evaluation is completed, per U-M OHS protocol. Employees will be educated by U-M OHS regarding safe practices.
  • Pre and Post test counseling for HIV and Hepatitis B/C will be done according to the CDC recommendations.
  • Employees will be informed about which blood tests are being done and will have the opportunity to refuse testing.
  • Employee blood for any HIV testing, Hepatitis C testing and Hepatitis B antigen testing will be done using a coded specimen so that confidentiality of employee information is preserved. Instructions for coding samples is maintained in a secure site.
  • Source blood testing for HIV will be done according to Michigan law which requires consent for sources that have not been informed in writing that blood will be drawn in the event of an exposure. If the source has been informed in writing of this fact, HIV testing may be done without consent but the source must be informed of the result and counseled appropriately.
  • Notification that blood has been drawn for HIV and Hepatitis on source patients will be placed in the patient chart with instructions that the physician caring for the patient is responsible for notifying the patient of the results and delivering appropriate counseling. If a review of patient information reveals that a positive result is not already known or documented in CareWeb, the Attending Physician of record will be alpha paged with the results.
  • Results of employee blood testing (baseline and followup) will preferably be delivered in person but normal results may be given over the phone or by email if an appointment cannot be arranged. Abnormal results must be communicated in person.
  • If any employee tests positive for HIV by EIA, no results will be given until a confirmatory EIA and a Western Blot have been done. HIV tests will be called positive if the Western Blot is positive per accepted laboratory standards. Intermediately reactive Western Blot tests will be sent for HIV virus by PCR. An employee with an HIV test that is positive or indeterminate by Western Blot will be referred to his/her primary care physician for follow up.
  • Hepatitis C testing in employees and source patients will be called positive based on the current recommendations for testing. Confirmatin with a RIBA is performed only if the s/c ratio is between 1.00 and 10.99. Confirmation with a RIBA will not ber performed on specimens positive with an s/c ration > than 10.99. (UMHS pathology handbook.)
  • There are data to suggest that early treatment for Hepatitis C may improve chances for viral eradication. Employees that are exposed to Hepatitis C blood or body fluids will be assessed with a PCR for Hepatitis C virus at one month and three months, so that early treatment may be considered. Employees with presumed occupational infection from exposure to Hepatitis C will be referred to the GI Liver Outpatient Service for consideration of early treatment of acute Hepatitis C infection.
  • All BBP percutaneous exposures will be entered into the OSHA log.

Procedure:

  • Employee reports exposure to Occupational Health as soon as exposure is recognized. May present to U-M OHS or call in the necessary information. After Occupational Health business hours, the Emergency Department will perform an initial evaluation and render any treatment that must be done prior to next U-M OHS business day.
  • U-M OHS nurse performs initial intake with information as specified in the Body Substance Exposure Note (Appendix A). Tetanus immunization status is assessed and employee is given Td or Tdap booster if indicated.
  • U-M OHS nurse makes initial assessment of HIV risk in source. Information gathered includes AHIV status on computer and/or call to physician/nurse taking care of patient to determine whether an HIV risk is substantial. If potential exposure to HIV, remainder of evaluation proceeds per Chemoprophylaxis for HIV positive Exposures Protocol.
  • U-M OHS nurse assesses Hepatitis B and C risk by looking up Hepatitis B and C serologies on computer or identifying known history of Hepatitis B or C infectivity.
  • If HIV and Hepatitis B/C status is unknown and no blood is available for testing, Phlebotomy supervisor (pager 8079) is contacted to have blood drawn on patient unit. If blood is available in Pathology, that blood can be used rather than drawing a new specimen. Prior consent for HIV testing is not required for inpatients or other patients who have signed a waiver regarding body substance exposures. All other patients require consent prior to HIV testing. Rapid HIV testing will be used. For off-site areas, after blood from the source patient is obtained, it can be sent to UMHS by contacting the courier service. Metro Courier: 973-0973. This service should be used for exposure labs, in place of the standard courier pick up service.
  • Employee is offered baseline blood testing for HBSAG and AHIV in accordance with Bloodborne Pathogens Standard. If the employee consents to baseline blood collection but not to HIV testing at the time, the sample will be drawn and held for up to 90 days. HBSAB titer is drawn if there is no documentation of immunity to Hepatitis B. All employee bloods except HBSAB are sent as a coded specimen per U-M OHS HIV Testing Protocol. CDC recommendations from MMWR June 29, 2001 indicate if the source person is not infected with a bloodborne pathogen, baseline testing or further follow-up of the exposed person is not necessary. For sources whose infection status remains unknown, consider medical diagnoses, clinical symptoms, and history of risk behaviors.
  • Treatment for exposure to Hepatitis B surface antigen positive source patient is as follows:
    • Unvaccinated: 1 dose of HBIG; start vaccine
    • Previously vaccinated:
      • Known responder: No treatment
      • Known non-responder: HBIG x 2 or HBIG x 1 and initiate revaccination
      • Anti-body response unknown: Test exposed person for antibody to Hepatitis B
        • If adequate, no treatment
        • If inadequate, HBIG x 1 and vaccine booster
  • Treatment when source not tested or status unknown:
    • Unvaccinated: Initiate HB vaccine series
    • Previously vaccinated:
      • Known responder: No treatment
      • Known non-responder: If known high-risk source, treat as if source were HBsAg positive
      • Anti-body response unknown: Test exposed person for antibody to Hepatitis B
        • If adequate, no treatment
        • If inadequate, HBIG x 1 and vaccine booster
  • Hepatitis B immune globulin dose 0.06 mL/kg (HBIG)
  • Responder is defined as a person with adequate levels of serum anti-body to hepatitis B surface antigen (i.e., anti-HBs 10 mlU/mL; inadequate response to vaccination defined as serum anti-HBs < 10mlU/mL
  • For exposure to Hepatitis C positive source patients, a baseline anto-HCV, AST and ALT will be obtained. HCV RNA by PCR, Quantitative, will be obtained at one month and three months post exposure. At six months post exposure, anti-HCV, AST, and ALT will be obtained. If the PCR is positive for Hepatitis C RNA, the employee will be referred to the GI Liver Outpatient Service. Appointments can be made by calling 6-0496 and requesting urgent (within 1 wk) appt.
  • Follow up blood tests for Hepatitis B Survace Antigen (HBSAG) and AHIV will be completed at 3 months and 6 months. For exposures treated according to the HIV exposure protocol, testing will be completed according to protocol.
  • >After counseling and testing is done, the employee is given a copy of the U-M OHS Body Substance Exposures Fact Sheet. Employee is instructed to return to U-M OHS with any symptoms of prolonged fever, rash, lymphadenopathy, jaundice or fatigue that may occur in the next six months. Reinforcement of proper Body Substance Precautions according to the Infection Control Policy "Body Substance Precautions."
  • A health care professional's written opinion will be sent within 15 working days of the completion of the evaluation. The written opinion will be sent to the employee; the employer's copy is housed in U-M OHS.
  • For isolated body substance exposures, U-M OHS will evaluate all exposure incidents in a standardized manner consistent with the latest CDC recommendations per the Isolated Body Substance Exposure Guidelines.

Infection Prevention’s Bloodborne Pathogens Exposure Control Plan.