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Postexposure Evaluation and Follow-up

Course Number: 472

Healthcare-associated Exposure to Bloodborne Pathogens

An exposure that might place HCP at risk for HAIs with bloodborne pathogens (i.e., infection with hepatitis B, hepatitis C, or human immunodeficiency viruses) is defined as a (1) percutaneous injury (e.g., needlesticks or cuts with sharp objects), (2) direct contact of ocular, nasal, or oral mucous membranes, or (3) direct contact of nonintact skin (e.g., dermatitis, or chapped or abraded skin) with blood and OPIM.4

Percutaneous wounds and nonintact skin that have been in contact with blood or OPIM should be washed with soap and water; mucous membranes should be flushed with water5 Using antiseptics (e.g., chlorhexidine) for wound care or expressing fluid by squeezing the wound have not been shown to reduce the risk for infection. Injecting antiseptics or disinfectants into the wound and the application of caustic agents (e.g., bleach) is not recommended.

PEP intended to prevent HAIs is most effective when administered as soon after an exposure as possible (ideally within hours). Consequently, immediately after wound care, the exposure must be reported to the Office Infection Control Officer and the circumstances of the incident documented in accordance with all federal and state mandates.1,2,4 The report must include the date and time of exposure and details of the event (Box A).

Box A. Recommendations for the Content of an Occupational Exposure Report.4

  • Date and time of exposure
  • Details of the procedure being performed
    • Where and how the exposure occurred
    • If related to a sharp device, the type and brand of device
    • How and when in the course of handling the device the exposure occurred
  • Details of the exposure
    • Type and amount of source material
      • Blood
      • OPIM
      • Direct contact with concentrated virus (research laboratory)
  • Type of exposure
    • Percutaneous injury
      • Depth of injury
      • Whether blood or OPIM was injected
  • Mucous membrane exposure
    • Estimated volume of blood or OPIM
  • Nonintact skin exposure
    • Condition of the skin (e.g., chapped, abraded, open wound)
  • Bites resulting in blood exposure to either person involved

Following an exposure to blood and OPIM, the potential to transmit HBV, HCV, and HIV will depend on the type of body fluid involved and the route and severity of the exposure.4 Exposures to blood and OPIM through percutaneous injuries (i.e., needlesticks or other penetrating sharps-related events) or through direct contact with mucous membrane are situations that pose the greatest risk of bloodborne pathogen transmission in oral healthcare settings.

Exposure to a blood-filled hollow needle or visibly bloody instruments and other medical/dental devices suggests a higher risk than exposure to a needle that was used for administering an injection, e.g., a local anesthetic. Skin exposure to blood and OPIM, when the integrity of the skin is compromised (e.g., dermatitis, abrasion, or open wound), may potentially result in a healthcare-associated infection.

If the exposure incident was related to a human bite, possible exposure of both the person bitten and the person who inflicted the bite must be considered, especially if the bite resulted in bleeding. In addition, any direct contact (i.e., personal protective equipment was not used or was ineffective in protecting skin or mucous membranes) with concentrated HBV, HCV, or HIV in a research laboratory is considered a significant exposure incident.

The next step in data collection relates to the exposure source. The person whose blood or OPIM is the source of an occupational exposure should be evaluated for HBV, HCV, and HIV infection (Box B). Information already available in the chart of the source person at the time of exposure (e.g., medical history and/or laboratory test results) or other information obtained from the source person might provide clues to potential infection with a bloodborne pathogen.

Box B. Information to be Obtained From or About the Exposure Source.4

  • Infectious status of the source person
    • History of HBV, HCV, or HIV infection
    • Laboratory test results
      • Hepatitis B surface antigen (HBsAg)
      • Anti-hepatitis C antibody
      • Anti-HIV antibody
        • If the source person is HIV-infected
          • Stage of disease
          • History of antiretroviral therapy
          • Viral load
          • Antiretroviral resistance information

If the infectious status of the source person is unknown, he/she should be informed of the incident and after obtaining informed consent (in accordance with applicable state and local laws) should be tested for serologic evidence of HBV, HCV, and HIV infection. A source person determined to be infected with HBV, HCV, or HIV should be referred for medical treatment and counseling. Confidentiality of the source person must be maintained at all times.

If the source of blood or OPIM is unknown, information about where and under what circumstances the exposure occurred should be assessed. An important consideration is the prevalence of HBV, HCV, or HIV in the population from which the contaminated source material is derived. An exposure related to a community where injection-drug use is prevalent would present a higher risk for transmission than one related to a nursing home for the elderly.

The need for PEP should be determined within 2 hours after HCP experience any percutaneous, ocular, mucous-membrane or nonintact skin exposure to blood and OPIM. Exposed HCP should undergo postexposure evaluation by an expert consultant (a physician knowledgeable about occupational transmission and one who can deal with the many concerns of an exposed person). Exposed HCP should present for the evaluation with (1) the incident report, (2) all available information about the source person, and (3) his/her OSHA-mandated medical record maintained by the employer (Box C).1-3

Box C. Content of an OSHA-mandated Medical Record.1-3

  • Vaccination status
    • Dates of vaccinations (where appropriate or available)
    • Evidence of immunity (where applicable or available)
    • Documentation related to the individual’s inability to receive the vaccinations mandated or highly recommended
    • A signed copy of the mandatory hepatitis B vaccination declaration (if applicable)
  • A copy of all previous exposure reports (if applicable)