Warning!
Infected Health Care Worker
Gary E Garber MD FRCPC FACP
Professor of Medicine U Ottawa
Div of Infectious Diseases
The Ottawa Hospital
HCW has Blood Borne Pathogen
• Ban the worker from exposure prone
procedures?
• Report to the requisite licensing body?
• Run the worker out of town?
• Should we council students before
entering their chosen profession?
• Where does treatment fit into the mix?
Blood Borne Pathogens (BBP)
• HIV
• Hepatitis B
• Hepatitis C
Objectives
• Identify exposure prone procedures
• Risks of transmission of B.B.P from HCW
to patients
• Treatment guidelines for management
First Principles
• Don’t share body fluids!
• Don’t sleep with your patient…..
Condoms are effective but with not protect
you from the wrath of the CPSO
• Don’t share needles with you patient.
• Please do not stick yourself with a needle
before stabbing the patient.
Risk Exposure
• Blood but not if on intact skin
• Heavy blood contamination on damaged
skin or via needle exposure
• Mucosa…eye or mouth ?? Risk is a
fraction of a needle exposure
• Scalpel blade, very low risk of HIV
compared to a hollow bore needle
Transmission is tied to Viral Load
Organism Viral load Transm rate
HIV
50,000-500,000 0.3%
HEP C
100,0005,000,000
3%
HEP B
1,000,00010,000,000
30%
…………………
3%
eAb+
Management of Exposure
HIV
• Post-exposure prophylaxis
• Usually 3 drug therapy with
2-NRTI’s and 1-PI
• Lower risk, can use 2 drug regimen
• Only efficacy data is with Zidovudine alone
which decreased transmission by 80%
Clinical Experience
• Tx course is 28 days
• Majority of HCW’s will d/c PEP within 2
weeks due to adverse side effects
• Patients on the same regimen…98%
continue the same therapy after 1 month
• Motivation seems to play an important role
in compliance
Hepatitis B
• Prevention with vaccination
• Alternative is post exposure prophylaxis
with HBIG followed by vaccination
• Incidence of HCW associated HBV
outbreaks is way down likely due to
universal vaccination programs
Hepatitis C
• No vaccine available
• No prophylaxis available
• If infected ….
Interferon (Peg) given weekly for 6 months,
if started within 1st 6 months of
exposure…….95% cure
Infected HCW-Case 1
•
•
•
•
•
20 year old nursing student
In Canada since age 5
HBV vaccine given in grade 7
School entry screening…HBsAg +
Referred for
Investigation
Counselling
Suitability for clinical rotations
Case1-HBV
• Healthy young woman, no signs or
symptoms, one sexual partner ..used
condoms. No tattoos or transfusions
• HBsAg+, cAb+. eAb+
• HepB viral load…..102
• Advice????
Advice HBV
• Vaccine “failure” was actually neonatal
transmission of HBV.
• eAg- and eAb+ usually denotes a low viral
load and low infectivity
• In this case no treatment is advised and
no restriction on clinical contact
• Follow-up Q6 monthly
• If V/L >104 consider treatment
(3TC, tenofovir)
HCV –
Case2
• 58yr old male physician in Haiti , working
as a Personal support worker in LTC
• Sustains a cut on a misplaced razor left in
the sheets of a resident’s bed
• Resident and HCV are screened, resident
is neg for HIV,HBV, HCV
• HCW is positive for HCV
• HCW states on admission to Canada he
was negative
HCV-Case 2
• We don’t screen for HCV on admission to
Canada
• Most HCV don’t know their A. B and C’s
• Clinic workup; genotype 1 HCV v/l 106
• Liver biopsy…..stage 3 fibrosis, normal
LFT’s
• Opted to treat with Peg Interferon plus
ribavirin
• Needed sick days post some injection
days
HIV-Case 3
• 42 year old obstetrician cuts himself
performing a c-section on a 32 year old
HIV + woman
• He elects to take PEP
• Has to cancel OR time on day 5 due to
N&V on day 14 d/c’d therapy
• He never seroconverted but 5 years later
is still not happy with me
HIV Case 2
• 38 year old ER nurse HIV positive
• Has been on ART since 2001
• Viral load has been consistently
undetectable for 10 years. Had been on 2
NRTI’s and PI and 5 years ago changed to
Atripla single pill regimen.
• If the blood is consistently v/l negative how
will blood be able to spread disease??
Mitigating Risk
• HIV is completely suppressible but
requires meticulous adherence to
medication ( >95%)
• HBV is completely suppressible with
therapy breakthrough resistance with
Heptavir (lamivudine) occurs in 20% after
2 years
• Tenofovir more reliable-at twice the cost
• Not covered by ODB unless 3TC resistant
HCV
• Hardest to prevent
• Easiest to cure
• New triple therapy will achieve 70% cure
in genotype 1 (currently 45%).
• Medication has huge side effects
You Decide
• Surgeon has routine blood testing for BBP
to comply with provincial college
regulations
• He is completely asymptomatic
• HIV serology testing found to be positive
• Can he operate?
Surgeon
• The test was serology which has false
positive rates in low risk populations
• In this case the confirmatory test was
positive and the viral load was 15,280
• Can he operate?
Surgeon Part 3
• Results have to be reported to the
licensing College
• Case should be reviewed by an panel
including a peer and HIV expert
• However in the meantime, therapy is
stated and he become v/l undetectable
after 6 weeks of therapy
• Can operate as long as v/l remains
undetectable, and must be followed with
testing q 3months.
OSHA Guidelines
• Exposure plan, and embrace technology
to reduce risk exposure
• Universal precautions; provide PPE
• Identify and ensure the use of work
practice controls
• HBV vaccination and PPE
Why guidelines and procedures
fail?
• The are adopted by people
• As many needle stick injuries today as 10
years ago….
• Causes are inattention, distraction, or
equipment failure (needle shield jams)
• Disposal area is inconvenient, sharps
container is full
Summary
• Blood borne pathogens are not a
contraindication for working as a HCW
• Most can be well managed or treated
• Full compliance with medication and
follow-up is essential.