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Post Exposure Prophylaxis (PEP/oPEP). Dr Don Ajith Karawita MBBS (PERA), PgD Ven (COL), MD Venereology (COL) (Senior Registrar in Venereology) National STD/AIDS Control Programme. CDC Guidelines 2001. CDC headquarters in Atlanta. Hand washing Gloves Personal protective equipment (PPE)

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post exposure prophylaxis pep opep

Post Exposure Prophylaxis (PEP/oPEP)

Dr Don Ajith Karawita

MBBS (PERA), PgD Ven (COL), MD Venereology (COL)

(Senior Registrar in Venereology)

National STD/AIDS Control Programme

cdc guidelines 2001
CDC Guidelines 2001.

CDC headquarters in Atlanta

standard precautions
Hand washing

Gloves

Personal protective equipment (PPE)

Patient care equipments

Cleaning of instruments

Environmental control

Management of spills

Linen management

7. Occupational health and blood borne pathogens

Handling of sharps

Prevention of mucous membrane exposures

Management of needle stick accident or mucous membrane exposure

Collection and transport of specimens

8. Patient isolation

Standard Precautions
additional precautions
Additional Precautions
  • Transmission based precautions
    • Airborne precautions (droplet nuclei < 5µm)
    • Droplet precautions (droplet nuclei > 5µm)
    • Contact precautions / isolation
  • Strict isolation
  • Aseptic precautions
    • Cleaning of entry site of the body
    • Hands of the staff must be disinfected and gloved.
disinfectant antiseptic
Alcohol

Surgical spirit

(60% isopropyl alcohol)

70% ethyl alcohol

Alcohol hand rub (Isopropyl alcohol with glycerol)

Aldehydes

Cidex

(2% glutaraldehyde solution)

Chlorhexidines

Hibisol

(0.5% chlorhexidine in 70% alcohol

Hibitane

(4% chlorhexidine gluconate

Hibiscrub

(4% chlorhexidine gluconate with a detergent)

Disinfectant / Antiseptic
disinfectant antiseptic1
Chlorine releasing agents

TCL, Bleaching powder (Calcium hypochiorite 35% w/w of available chlorine)

Sodium hypochlorite liquid form

5% stock solution

1% (10,000ppm)

0.1%(1000ppm)

0.01% (125ppm) Milton

Iodophors

Betadine, Wokadine (10% solution, available iodine 1%)

Betadine scrub, Wokadine scrub (7.5% Povidone iodine scrub, avilable iodine 0.75%

Peracetic acid

Perasafe(Peracetic acid)

Phenolic disinfectants

Lysol(2%, 5% solutions)

Disinfectant / Antiseptic
slide19

Hospital waste

Hazardous waste

General or Non-hazardous waste

  • Sharps
  • Infectious waste (incinaration/ Burial)
  • Pathologicl waste (incinaration/ Burial)
  • Chemical waste (Returned to supplier/ MSD)
  • Pharmaceutical waste (Returned to supplier/ MSD)
  • Radioactive waste (Keep for radioactive decay→Dispose as non hazardous waste)

Dispose to common garbage site/bin

Collected by local authorities

hepatitis b virus hbv hepatitis c virus hcv and human immunodeficiency virus hiv
Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV)
  • Bloodborne viruses
  • Can produce chronic infection
  • Transmissible in healthcare settings
  • Data from multiple sources (e.g., surveillance, observational studies, serosurveys) used to assess risk of occupational transmission
slide22

3. Determine Infectious Status of Source

Patient

Percutaneous

Severe, Less severe

Mucous membrane/Non intact skin

Small volume, Large volume.

2. Exposure Substance

1.Exposure

Blood, Bloody fluid, OPIM

4. Determine Susceptibility of Exposed Person

Health care worker (HCW)

Evaluation - Occupational exposure to infectious materials

elements of postexposure management
Elements of Postexposure Management
  • Wound management & Exposure reporting → Step 1
  • Risk Assessment → Step 2
    • (1) blood borne infection status of source person
    • (2) Infectious material
    • (3) type and severity of exposure
    • (4) Susceptibility of HCW
  • Appropriate treatment → Step 3
  • Follow-up, and counseling → Step 4
step 1 provide immediate care to the exposure site
Step 1 Provide immediate care to the exposure site
  • Post exposure Wound Management:
    • Wash wounds and skin with soap and water
    • Flush mucous membranes with water
    • No evidence of benefit for:
      • application of antiseptics or disinfectants
      • squeezing (“milking”) puncture sites
  • Avoid use of bleach and other agents caustic to skin
  • Inform authorities → Infection control unit.
elements of postexposure management1
Elements of Postexposure Management
  • Wound management & Exposure reporting → Step 1
  • Risk Assessment → Step 2
    • (1) blood borne infection status of source person
    • (2) Infectious material
    • (3) type and severity of exposure
    • (4) Susceptibility of HCW
  • Appropriate treatment → Step 3
  • Follow-up, and counseling → Step 4
postexposure management risk assessment seek expert advice
Infectious status of the source person (SC)

presence of HBsAg

presence of HCV antibody

presence of HIV antibody

if source unknown, assess epidemiologic and clinical evidence (Do not test discarded needles)

Body substance

blood

bloody fluid

Other potentially infectious materials (OPIM)

(semen, vaginal secretions and CSF, synovial, pleural, peritoneal, pericardial and amniotic fluids) or tissue

Type of exposure (EC)

percutaneous

mucous membrane

non-intact skin

bites resulting in blood exposure

Determine susceptibility of exposed person (HCW)

Hepatitis B vaccine status

HBV immune status if vaccine response status in unknown

Anti-HCV and ALT

HIV antibody

Postexposure Management: Risk Assessment (Seek expert advice)

1

3

4

2

elements of postexposure management2
Elements of Postexposure Management
  • Wound management & Exposure reporting → Step 1
  • Risk Assessment → Step 2
    • (1) blood borne infection status of source person
    • (2) Infectious material
    • (3) type and severity of exposure
    • (4) Susceptibility of HCW
  • Appropriate treatment → Step 3
  • Follow-up, and counseling → Step 4
step 3 give pep for exposures posing risk of infection transmission
Step 3 Give PEP for exposures posing risk of infection transmission
  • HBV
    • Give oPEP as soon as possible within 24 hours.
    • PEP can be given to pregnant women
  • HCV
    • PEP not recommended
  • HIV
    • Initiate PEP within hours of exposure (2-72 Hours)
    • Offer pregnancy testing to all women of child bearing age not known to be pregnant.
    • Seek expert consultation if viral resistance suspected.
    • Administer PEP for 4 weeks if tolerated.
concentration of hbv in body fluids
Concentration of HBV in Body Fluids

HighModerate Low/Not Detectable

BloodSemen Urine

SerumVaginal FluidFeces

Wound exudatesSaliva Sweat

Tears

Breast Milk

slide37
Persons who have previously been infected with HBV are immune to reinfection and do not require PEP.
  • Hepatitis B immunoglobulin: dose 0.06ml/kg im
  • A responder is a person with adequate levels of serum antibody to HBsAg (i.e. anti-HBs > 10mIU/ml): a non-responder is a person with inadequate response to vaccination (i.e. serum anti-HBs antibody< 10mIU/ml)
  • The option of giving one dose of HBIG and reinitiating the vaccine series is preferred for non-responders who have not completed a second 3-dose vaccine series. For those who previously completed a second vaccine series but failed to respond, 2doses of HBIG are preferred. Give one dose at time of exposure, and the second dose one month later.
hepatitis b vaccine long term efficacy
Hepatitis B Vaccine: Long-Term Efficacy
  • Anti-HBs titers decline to <10 mIU/mL in 30-50% of adults within 8-10 years after vaccination
  • Exposure to HBV results in anamnestic anti-HBs response that prevents clinically significant HBV infection
  • Immune memory remains intact for at least 20 years after immunization
  • Chronic HBV infection rarely documented among vaccine responders
  • Booster doses currently not recommended
overview of the hiv clinical disease
Overview of the HIV clinical disease

AIDS

Clinical stage 4

AIDS Defining illnesses

HIV Seroconversion illness

Clinical stage 3

Clinical stage 2

75%

33%

Clinical stage 1

3wks

1-4wks

8 to 12 years

slide49
If drug resistance is a concern, obtain expert consultation. Initiation of PEP should not be delayed pending expert consultation and, because expert consultation alone cannot substitute for face-to-face counseling, resource should be available to provide immediate evaluation and follow-up care for all exposures.
  • The designation “consider PEP” indicates that PEP is optional and should be based on as individualized decision between the exposed person and the treating clinician. However, consider basic 2-drug PEP for a source with HIV risk factors, or occurs in a setting where exposure to HIV-infected persons is likely.
  • If PEP is offered and taken, and the source is later determined to be HIV negative, PEP should be discontinued.
  • For skin exposures, follow-up is indicated only if there is evidence of compromised skin integrity (e.g. dermatitis, abrasion, or open wound)
slide50

Considerations When Using PEP

Risk of Transmission

Risk of Adverse Effects

PEP

elements of postexposure management3
Elements of Postexposure Management
  • Wound management & Exposure reporting → Step 1
  • Risk Assessment → Step 2
    • (1) blood borne infection status of source person
    • (2) Infectious material
    • (3) type and severity of exposure
    • (4) Susceptibility of HCW
  • Appropriate treatment → Step 3
  • Follow-up, and counseling → Step 4
frequency of percutaneous injury in healthcare personnel
Frequency of Percutaneous Injury in Healthcare Personnel
  • Based on CDC estimates, 384,325 (95% CI 311,091-463,922) percutaneous injuries are sustained by healthcare personnel in US hospitals annually*
  • The number of injuries sustained outside of hospital settings is unknown
  • Frequency of percutaneous injury varies by occupational group and healthcare setting

* Panlilio, AL, et. al. Estimate of the Annual Number of Percutaneous Injuries in U.S. Healthcare Workers. 4th Decennial Conference, March 5-9, 2000

preventing transmission of bloodborne viruses in healthcare settings
Preventing Transmission of Bloodborne Virusesin Healthcare Settings
  • Promote hepatitis B vaccination
  • Treat all patients as potentially infectious
  • Use barriers to prevent blood/body fluid contact
  • Prevent percutaneous injuries