An occupational exposure that may place a worker at risk of HIV infection is a percutaneous injury, contact of mucous membrane or contact of skin ( Especially when the skin is chapped, abraded or afflicted with dermatitis or the contact is prolonged or involving an extensive area) with blood, tissue or other body fluids to which universal precaution apply.

Occupational Exposure to HIV – Very Low Risk

• needle stick injuries
• cuts from other sharps
• contact of eye, nose, mouth or skin with blood

Most exposures do not result in infection

Factors affecting transmission

• amount of blood in the exposure
• amount of virus in the patient’s blood
• whether P.E.P. took or not

The average risk of HIV infection after an occupational exposure

• Small Amount of Blood on Intact Skin No Risk
• Needle Stick Injury 1 In 300(0.3%)
• Exposure of Eye, Nose or Mouth 1 In 1000
• The risk with Damaged Skin 1 In 1000

Risk increases if the patient has a high viral load as in patients with acute HIV infection or patient near death

Compare

• The risk for hepatitis B 9-40%
• The risk for hepatitis C 1-10%

Prevention of Occupational Exposure

• Standard precautions (universal work precautions) and safe practices
• Wash hand after patient contact, removing gloves.
• Wash hands immediately if hands contaminated with body fluids.
• Wear gloves when contamination of hands with body substances anticipated
• Protective eyewear and masks should be worn when splashing with body substance is anticipated
• All health care workers should take precautions to prevent injuries during procedures and when cleaning or during the disposal of needles and other sharp instruments.
• The needle should not be recapped
• Needles should not be purposely bent or broken by hand
• Not removed from disposable syringe nor manipulated by hand
• After use disposable syringes and needles, scalpel blades and other sharp items should be placed in a puncture-resistant container.
• Health care workers who have exudative lesions or dermatitis should refrain from direct patient care and from handling equipment
• All needle stick injuries should be reported to the infection control officer.
• Handle and dispose of sharps safely
• Clean & disinfect blood/body substances spill with appropriate agents
• Adhere to disinfection and sterilization standards
• Regard all waste soiled with blood/body substance as contaminated and dispose of according to relevant standards
• Vaccinate all clinical and laboratory workers against hepatitis B
• Other measures double gloving changing surgical techniques to avoid “exposure-prone” procedures use of needle-less systems and other safety devices.

Body fluids to which universal precautions apply

• Blood
• Other body fluids containing visible blood
• Wound Pus
• Semen
• Vaginal secretions
• Cerebrospinal fluid (CSF)
• Synovial fluid
• Pleural fluid
• Peritoneal fluid
• Pericardial fluid
• Amniotic fluid

Body fluids to which universal precautions do not apply

The risk of HIV transmission is extremely low or negligible unless these contain visible blood

• Nasal secretions
• Sputum
• Sweat
• Tears
• Urine
• Vomitus
• Saliva
• Wound Pus

Use of Protective Barriers

• Protective barriers reduce the risk of exposure of the HCWs skin or mucus membrane to potentially infective materials
• Protective barriers include gloves gowns, masks, and protective eye wears.
  • Selection of protective barriers
  • The use of double gloves is not recommended. Heavy-duty rubber gloves should be worn for cleanings instruments, handling soiled linen or when dealing with spills

Type of exposure	Examples	Protective barriers
Low Risk contact with skin with no visible blood	·     Injections ·     minor wound dressing	Gloves helpful but not essential
Medium Risk probable contact with blood; splash unlikely	·     vaginal examination, ·     insertion or removal of intravenous cannula ·     handling of laboratory specimens ·     large open wounds dressing ·     venipuncture, spills of blood	Gloves Gowns and Aprons may be necessary
High Risk probable contact with blood, splashing, uncontrolled bleeding	·     major surgical procedures, particularly in orthopaedic surgery and oral surgery; ·     vaginal delivery	Gloves Waterproof Gown or Apron Eyewear Mask

Post-exposure management

Reporting

• All needle stick injury should be reported to the immediate supervisor soon after the incident, the supervisor will inform the Infection Control nurses and the Infection control Officer.
• Ensure that action is taken within 2 hours.
• not recommended after seventy -two hours
• In all incidents first proceed to the area where Prophylactic treatment may be administered.
• Obtain the source person’s blood for screening.

Needle sticks injury

• Do not panic
• Do NOT put cut / pricked finger into your mouth
• Encourage bleeding from the wound, do not squeeze.
• Wash for 10 minutes with soap and water or a disinfectant.
• Report immediately to ICN
• ART to be administered (Tab. Zidovudine  600mg) within 2 hours

Further management

1. 1. The source person should be checked for the following, after pretest counseling:
      • HIV Abs
      • HBsAg
      • HCV Abs
      • CBC
      • LFT
      • Pregnancy test (if applicable)
   2. The health care worker also is checked for the following, after counseling
      • HIV
      • HBsAg
      • HCV
   3. Consent to do the above tests should be taken.

Managing exposure to potentially infectious body fluid

Sr. No.	Category of exposure	Immediate action to be taken
1	Needlestick injuries	·      Briefly induce bleeding from the wound. ·      Wash for 10 minutes with soap and water. ·      Report to supervisor.
2	Non-intact skin exposure	·      Wash for 10 minutes with soap and water. ·       Report to supervisor.
3	Mucosal exposure e.g. splash into eyes	·     Wash for 10 minutes by using clean water or normal saline to irrigate the eye. ·     The eyelid should be held open by another person wearing sterile gloves. ·     Do not use soap and water or disinfectant.

Post-exposure prophylaxis to Human Immunodeficiency Virus (HIV)

For complete Post-exposure prophylaxis refer ‘Annexure 2’

• The probability of HIV infection following needle stick injury from an HIV positive patient is 0.2% to 0.4% per injury.
• Risk reduction must be undertaken for all bloodborne pathogens including adherence to standard (routine) precautions with additional barrier protection as appropriate.
• Use of safety devices and needle disposal system to limit sharp exposure and continuing training for health care workers in safe sharps practice should be done.
• Hospital policy must include measures to promptly obtain serological testing of source patients where necessary.
• If the source person is HIV negative or unknown, first screen the source person if possible for HIV.
• Blood samples must be obtained for HIV testing from the health care worker as soon as possible after exposure and at regular intervals to document a possible sero-conversion.

Counselling, testing:

• Counselling, testing and treatment must, therefore, be available round the clock.
• On all occasions, HCW must be provided with pre-test and post-test counselling.
• The HCW should be advised to refrain from donating blood, semen or organs/tissues and abstain from sexual intercourse. In case sexual intercourse is undertaken a latex condom is used consistently. In addition, women HCW should not breastfeed their infants during the follow-up period.
• Health care worker must be informed of the clinical presentation of the acute retroviral syndrome, resembling acute mononucleosis which occurs in 70-90% of patients.

Duration of PEP

• PEP should be started, as early as possible, after an exposure. It has been seen that PEP started after 72 hours of exposure is of no use and hence is not recommended.
• The optimal course of PEP is not unknown, but 4 weeks of drug therapy appears to provide protection against HIV.
• If the HIV test is found to be positive at any time within 12 weeks, the HCW should be referred to a physician for treatment.

Pregnancy and PEP:

• Based on limited information, anti-retroviral therapy taken during 2nd and 3rd trimester of pregnancy has not caused serious side effects in mothers or infants.
• There is very little information on the safety in the 1st trimester.
• If the HCW is pregnant at the time of exposure to HIV, the designated authority/physician must be consulted about the use of the drugs for PEP.

Side-effects of these drugs:

Most of the drugs used for PEP have usually been tolerated well except for nausea, vomiting, tiredness, or headache.

If the source person is HBsAg positive and the HCW is HBsAg negative, then the following action is taken for the health care worker.

For complete Post-exposure prophylaxis refer ‘Annexure 2’

Exposure to Hepatitis ‘C’ virus:

The routes of infection are similar to Hepatitis B infection. No post-exposure therapy is available for Hepatitis C but seroconversion (if any) must be documented. As for Hepatitis B viral infection, the source person must be detected for HCV infection.

For complete Post-exposure prophylaxis refer ‘Annexure 2’