Download - HIV, AIDS and Needlestick injuries
HIV, AIDS and Needlestick injuries
James Huffman, R-2
March 19, 2007
Thanks to Shawn Dowling, Cass Djurfors
Objectives
Not solely focused on occupational health
Aspects of HIV and AIDS that are applicable to the emergency physician HIV testing in the ED
AIDS defining illnesses
Post-exposure prophylaxis
Acute complications of HIV infection
Needlestick injuries Your potential roles and responsibilities as an EP
What to do if this happens to you
Background
Advanced treatments and highly active antiretroviral therapy (HAART) have delayed development of AIDS in many HIV+ pts More people live longer with HIV infection ED presentations
New drugs and regimens interactions with ED Rx
Basics
HIV: An RNA virus that attacks and weakens the body’s immune
system
Transmitted though:
Unprotected sex with an infected partner
Sharing needles
Contact with infected blood
Mom to baby through pregnancy, birth or breast milk
Some individuals will experience a flu-like illness in first 1-2 months after HIV exposure (seroconversion illness) – many will have no symptoms
Basics
AIDS:
Diagnosis occurs when a person:
1. Has antibodies against HIV in their blood
AND
2. Is diagnosed with one or more AIDS-defining illnesses
In the US (but not Canada or Europe) the AIDS definition also includes all HIV-infected individuals with a CD4 count lower than 200 cells/μL or a CD4 percentage less than 14%
Pathophysiology of HIV infection
Virus infects host cells (lymphadenopathy) and incorporates its genetic code into the cell’s DNA Very mutagenic process
High viral load early - until immune system kicks in This accounts for the acute HIV syndrome (discussed later)
Once this resolves, pt is in the latent phase of infection
Virus replicates slowly until CD4 counts drop below ~200/microL (median time without treatment = 8-10yrs)
Pathophysiology – transmission
Virus is passed in infected body fluids High concentration in blood, semen, vaginal fluid and breast
milk
Low levels in almost every other fluid (incl. sweat, urine, csf, tears, bone marrow, alveolar fluid, synovial fluid, amniotic fluid and saliva
small likelihood of transmission
Factors affecting risk of transmission: Viral load (> 50 000)
CD4 count (less than 200 cells/microL)
Other sexually transmitted infections
Pop-quiz
Not all blood products carry risk of transmission. Of those commonly used in the ED, which is/are capable of transmitting the virus?
PRBC
Platelets
FFP
Rh immune globulin
Occupational TransmissionEmergency Medicine Reports. Vol. 27 No. 8. 2006
Health care worker-to-Patient Several hundred epidemiologic studies have traced
thousands of patients treated by HIV+ surgeons, obstetricians, dentists and nurses
Only 3 HCW’s have been identified as the source of their pt’s HIV infection
Occupational TransmissionEmergency Medicine Reports. Vol. 27 No. 8. 2006
Patient-to-Health care worker U.S.: 600 000 to 800 000 needle sticks and sharps injuries
each year are reported
More to come on this later in the talk
Risk of HIV infection is well-studied and quoted to be ~0.3% for a needle stick injury
As of 2002, only 57 health care workers had become HIV+ from a documented occupational exposure
Of the 57, 1/3 were laboratory workers, 42% were nurses and 10% were physicians
Post-Exposure Prophylaxis (PEP)
PEP drug regimes are based on:
1. Severity of Exposure
2. Degree of viremia in the source patient
Post-Exposure Prophylaxis (PEP)
Regimes constantly changing Most recent CDC guidelines from 2005
www.cdc.gov/mmwr/PDF/rr/rr5011.pdf
Also contains most up to date CDC info for Hep B and C
Post-Exposure Prophylaxis (PEP)
What about non-occupational PEP (nPEP)? EDs an ideal place?
Drugs on hand since this is where occupational exposures handled
24/7 access
Challenges:
Follow-up and counseling
Access to source patient
Repeat testing at 4-6 weeks, 3 months, 6 months
Compliance
28d course
A/E: diarrhea, vomiting, rashes, interaction with other meds
Post-Exposure Prophylaxis Quiz
True or False: Pregnancy is a contra-indication for PEP
True
False
Children and adults receive different PEP regimes
True
False
Antiretroviral TherapyCMAJ 2004; 170:229-38
HAART is mainstay of treatment
Most drugs come from 3 classes: Nucleoside reverse transcriptase inhibitors
Non-nucleoside reverse transcriptase inhibitors
Protease inhibitors
Limitations: Do not prevent onset of AIDS or deaths from HIV delay
Essentially prolongs the latent phase of the disease
Compliance is an issue 26% of pts d/c meds
Antiretroviral Therapy
Drug-Drug interactions MANY with HAART
NNRTI’s and PI’s affect the cytochrome p450 system
Of note:
TB meds drastically inhibit effectiveness of HAART
Effect of CCB’s, BDZ’s, Antihistamines become pronounced
Many side effects related to mechanism of action
Significant risk of ACS
Cost can be substantial
HIV Testing in the EDAnn Emerg Med 2004; 44:31-42
ED populations have a high incidence of undiagnosed HIV infection
New very rapid (20 min) tests are available (not in CHR yet)
However, issues of follow-up, counseling, referral are road-blocks to widespread ED testing
Symptomatic HIV Disease
Widely variable and can appear in nearly any organ system
Usually arise when CD4 count drops below 200 cells/µL
CD4 <50 cells/µL = sign of end-stage disease and corresponds to onset of life-threatening opportunistic infections
Many pts will not know their count, but info is available through SAC
Counts are checked q4-6 months and tend not to shift drastically
Pt with counts >350 cells/µL can usually be treated as though they have a normal immune system
BUT, AIDS-defining illness can arise at any point during HIV infection
AIDS-Defining IllnessesEmergency Med Reports, Vol 27:9, Apr. 2006
Candidiasis of esophagus, trachea or lungs
Cervical Cancer (invaisive)
Coccidiomycosis
Cryptococcosis
Cryptosporidiosis
Isosporiosis
Cytomegalovirus disease
HSV (>1month duration)
Disseminated histoplasmosis
HIV encephalopathy
Kaposi’s sarcoma
Lymphoma (CNS or Burkitt’s)
Mycobacterium avium complex
Mycobacterium tuberculosis (pulmonary)
Pneumocystis pneumonia
Recurrent bacterial pneumonia
Progressive multifocal leukoencephalopthy
Recurrent Salmonella septicemia
Toxoplasmosis of the brain
HIV wasting syndrome
Approach to HIV Pt with Fever
Obtain CD4 count / viral load
CD4 > 350 cells/µL and/or
Viral load < 50 000
Unavailable
Immunocompetent
Total lymphocyte count as rough surrogate marker
Assess compliance with HAART:
•Non-compliant pts at greater risk of serious illness
•CD4 counts return to pre-Tx levels rapidly if treatment stopped
•All pts with Hx of AIDS should be on HAART
Counts out of range
Immunocompromised
HIV Patient with FeverAcad Emerg Med 2002;9:880-8
Fever with vague constitutional symptoms is one of the most common reasons for HIV+ pts to present to the ED
Can screen for AIDS-related conditions by asking about the most common complications of HIV:
1. Pulmonary (PCP, TB)
2. Neurologic (AIDS dementia, cryptococcal meningitis, toxoplasmosis, CNS tumors)
3. Gastrointestinal (candidiasis, intestinal infections, ADE)
4. Dermatologic (KS, herpes zoster, candidiasis, scabies)
5. Ophthalmologic (CMV retinitis, ocular herpes)
HIV Patient with FeverAcad Emerg Med 2002;9:880-8
Additional diagnostics to consider: Blood cultures (aerobic, anaerobic, fungal)
LP
Serology for cryptococcus, toxoplasmosis, CMV, coccidiomycosis
Screen for AFB (MAC, TB)
Echocardiogram
HIV and Respiratory DiseaseThe Clinical Practice of Emergency Medicine, 3rd Ed; 2001:926-34
At least 80% of AIDS patients develop some kind of pulmonary disease
Pneumonia most common Diverse causes
Immunocopetent patients can be treated as usual
If not using HAART, ~70% will acquire PCP at some point
HIV and Respiratory DiseaseThe Clinical Practice of Emergency Medicine, 3rd Ed; 2001:926-34
PCP: Prolonged course (2 weeks)
Typical symptoms of pneumonia (+burning RSCP)
CXR interstitial infiltrates in 80%, otherwise N
Treatment is TMP-SMX oral or IV If oral, start 2 DS tabs q8h
Steroids show mortality benefit if paO2 is “low” look up #
TB Skin test not reliable
Start 4 drug regime
Others (Bacterial, fungal)
HIV and Neurologic ComplicationsEM: Concepts and Clinical Practice 6th ED; 2005:1843-60
Neurologic disease is the initial AIDS-defining illness in up to 20% of cases
Up to 90% of AIDS patients will suffer neurologic problems during their illness
Manifestations depend of stage of HIV infection
Most commonly HIV encephalopathy (AIDS dementia complex)
Cryptococcal meningitis
Toxoplamosis
Primary CNS lymphoma
HIV EncephalopathySemin Neurology 1999;19:105-11
Up to 1/3 of AIDS patients will be affected
Pathophysiology not fully understood but appears to be a direct effect of the virus on the CNS
Gradual onset of memory loss, cognitive impairment and gait problems
Focal signs, headaches or seizures occur only rarely
Treatment with HAART has significantly lowered the frequency of severe dementia and can slow progression
Diagnosis of exclusion
Spinal fluid is clear, CT unhelpful, MRI may show diffuse symmetrical hypodensities
HIV and Neurologic ComplicationsEM: Concepts and Clinical Practice 6th ED; 2005:1843-60
Jeopardy Question:
This protozoan parasite causes the second most common CNS infection in AIDS patients. Hint:
What is Toxoplasma Gondii
HIV and Neurologic ComplicationsEM: Concepts and Clinical Practice 6th ED; 2005:1843-60
Others to know about:
Cryptococcal meningitis
Primary CNS Lymphoma (primary B-cell non-Hodgkin’s lymphoma)
HIV and Gastrointestinal ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139
Nearly 50% of AIDS patients will suffer from GI opportunistic infections during the course of their illness – many of those will be acute
Most common complaints:
Abdominal pain, diarrhea, GI bleeding
Obviously still at risk for non-HIV related disease
HAART medications notorious for GI symptoms
HIV and Gastrointestinal ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139
Oral Lesions: Fungal
Oral candidiasis – dysphagia and plaques can be scraped off
Viral
Oral hairy leukoplakia (EBV – can’t scrape off) and HSV
Bacterial
Neoplastic – KS and Hodgekin’s lymphoma
HIV and Gastrointestinal ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139
Esophagitis: Can be extension of oral process or stand-alone
Most common cause is candidiasis
CMV, HSV also possible
Usually needs endoscopy for diagnosis
Liver Disease Co-infection with Hepatitis B and/or C common
NNRTI’s often have hepatic complications
HIV and Gastrointestinal ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139
Diarrhea:
Reported almost universally
About half of cases are attributed to the virus itself but many cases don’t have an identifiable cause
If normal CD4 counts, Salmonella is the only pathogen of increased presence
If CD4 <200, C.difficile also becomes much more prevalent
Many of the antiretrovirals can cause diarrhea Loperimide
HIV and Cutaneous ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139
Up to 90% of patients have skin disorders during the course of their illness
Rarely dangerous, often painful ED
5 General categories
1. Infectious
2. Inflammatory
3. Neoplastic
4. Drug-related
5. Acute exanthem of HIV seroconversion
HIV and Cutaneous ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139
Acute Exanthem of HIV Seroconversion
HIV and Cutaneous ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139
Seborrheic Dermatitis
HIV and Cutaneous ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139
Drug reactions
NRTI’s in particular are bad (not used as commonly)
Erythema multiforme and Stevens Johnson syndrome have both been reported
Parasites
Scabies
Viral
HSV/Zoster
Molluscum contagiosum
Bacterial
Simple folliculitis
HIV and Ophthmologic ComplicationsRosen’s Emergency Medicine 6th ed; 2005; 1843-60
75-90% of AIDS pts at some point will have ocular complications
Cotton wool spots are the most common finding
Stable, asymptomatic
Need follow-up
HIV and Ophthmologic ComplicationsRosen’s Emergency Medicine 6th ed; 2005; 1843-60
Need to differentiate CWS from CMV retinitis
Progressive, can lead to blindness
CD4 usually less than 50 cells/ μL
Needlestick Injuries
What are blood and bodily fluid exposures?
Which diseases are we concerned with?
Who gets them?
What can be done?
What are our responsibilities?
Definitions
A. Health Care Workers:
health-care workers (HCW) are defined as persons whose activities involve contact with patients or with blood or other body fluids from patients in a health-care, laboratory, or public-safety setting
B. Blood and Bodily Fluid:
Essentially anything that comes out of the patient (other than abusive language), but certain ones (feces, urine, vomitus, saliva) are unlikely to be infectious unless they contain blood
C. Occupational BBF Exposure Any time A) comes in contact with B).
Usually classified as percutaneous or mucocutaneous or non-intact skin
Epidemiology
52% of all HCW report a needlestick injury, 24% had one in the last year
But, estimates are that only 10% of all needlestick injuries are reported
CHR: So far in 2008 (as of March 17th) 125 percutaneous BBF exposures
17 classified as “High Risk”
No known infections
02468
10121416
Rates per100 FTE's
Who is Exposed?Emergency Medicine Reports; 2006:27(8)
Transmittable Infections Emergency Medicine Reports; 2006:27(8)
The Big 3:
HIV
Hep B
Hep C
….Other possible infections: Blastomycosis Brucellosis Cryptococcosis Diphtheria Cutaneous gonorrhea Herpes Malaria Mycobacteriosis Mycoplasma caviae Rocky Mountain spotted fever Sporotrichosis Staphylococcus aureus Streptococcus pyogenes Syphilis Toxoplasmosis Tuberculosis Tumor Cells
Transmission
Same as described for HIV in previous section with the following exceptions:
Vaginal secretions or semen are unlikely to transmit HCV
HBV can be transmitted by saliva
HIV in the CHRSAC Epidemiology Report September 2006
New HIV pts in CHR by risk responsible for Dx (1996 vs 2006)
Other2%
Blood & blood products
1%
Gay & Bisexual& IVDU
10%
Heterosexual21%
Heterosexual & IVDU21%
Gay & Bisexual48%
Blood & blood products
0%
Other(maternal, endemic)
20%
Heterosexual & IVDU14%
Heterosexual34%
Gay & Bisexual & IVDU2%
Gay & Bisexual36%
Occupational Transmission Emergency Medicine Reports. Vol. 27 No. 8. 2006
HIV: As of 2002, only 57 health care workers had become HIV+
from a documented occupational exposure
Of the 57, 1/3 were laboratory workers, 42% were nurses and 10% were physicians
~94% of exposures were percutaneous
2 cases of seroconversion in Alberta ever (no denominator)
Canadian Needle Stick Surveillance Network
Numbers are from 12 sites (8 teaching, 4 community) from April 2000 to March 2002 (ongoing…)
2,621 occupational exposures to BBF (3.8/100 FTE’s)
Needlesticks: 65.7%,
splashes from patients: 13.7%,
cuts with sharp objects: 8.6%,
sticks other than needles: 7.2%,
Others: scratches 1.9%, direct contacts with patients 1.8% (i.e. touching patients directly) and bites with broken skin 1.2%
Prevalence of HCV = 7.6%, HIV = 2.6% and HBV = 1.8% amongst source patients
As a result the rate of exposure to infected BBF was 0.3%
Hepatitis B
Percutaneous is the most efficient route of transmission
In several studies, HCW could not recall an overt percutaneous injury,
And since HBV can survive in at room temp for a week, transmission is thought to primarily arise from contact with cuts, abrasions or mucosal surfaces
95% 5%
Hepatitis C
Best transmitted via percutaneous exposure
Minimal risk w/mucous membranes or contact with blood
Crappy dz (since no PEP, but fortunately, but risk of transmission is lower)
15%85%
Hep B Hep C
Transmission Risk 40-60% 0.5-2%
Incubation Pd 4-26 wks 2-26 wks
Carrier State 0.1-1.0% of blood donors 0.2-1.0% of blood donors
Chronic Hepatitis 5-10% of acute infections
85% of acute infections
Increased risk of HCC
Yes Yes
Emergency Medicine Reports. Vol. 27 No. 8. 2006
Case
48 yr female, lab tech at the PLC, is waiting to be seen in the MT area. An hour ago she was poked with an 20g needle while drawing blood from an agitated patient.
When you go to see her, she’s obviously distressed and concerned about AIDS. What do you do?
If you do get poked/exposed
Remove the contaminated clothes – undergarments excepted
Allow immediate bleeding of the wound
Wash the injured area well with soap and water, and apply an antiseptic
If the eyes, nose, or mouth are involved, flush them well with large amounts of water
Report all cases
Call OH & S Nurse (234-7799) Available 24 hrs/day
Provides patient with appropriate f/u
Will do Risk Assessment
Allows for surveillance/monitoring
Inform ED charge nurse Access to PEP kit and exposure protocols
Southern Alberta Clinic Guidelines
1 Is the source known HIV+?
Yes: proceed to step 2 of protocol
No:
Test source (with consent) using rapid point-of-care HIV test available through CLS at any Emergency Room or Chumir Centre
If negative, and no risk of “window period”, reassure patient
If source unknown or refuses testing and has risks for or symptoms of HIV, proceed to step 2 of protocol
Consider source testing for HBV, HCV – most guidelines suggest testing for this
Rapid HIV Testing
Sensitivity and Specificity both >90%
Done in the on-site rapid response labs
Current turn around time 1 hr 24 min
Confirmed by Western Blot at Prov Lab
Consider giving dose of PEP before results arrive (based on your pre-test probability)
CDC now endorsing more liberal use of rapid point-of-care testing
2 Timing and Type of Exposure: Assess fluid type, volume, viral titre, mode of exposure
Assess exact timing of exposure
If exposure is not considered infectious for HIV/HBV/HCV (i.e. vomit, feces, etc. without blood – see slide #10) – reassure and arrange f/u if patient desires
If exposure considered potentially infections go to 3
Southern Alberta Clinic Guidelines
3 Decision: Make a decision for or against PEP based on risk
assessment (these are debatable)
HIV + = start PEP
HIV – and no risk of source pt being in “Window period” = don’t start PEP
Unknown (source not tested or refuses testing) = evaluate risk (OHS and protocols binder)
HEP B – see slides on HBIG and Hep B vaccine
Southern Alberta Clinic Guidelines
Risk Assessment-Done by EP / OHS – guidance in protocols and PEP kit
High risk IVDU High risk sexual behaviour (MSM,
sex w/IVDU, multiple sexual partners (3 or more sexual partners/yr w/I past 5 yrs), prostitution
Blood transfusion prior to 1985 Sex w/HIV + person Clinical suspicion of HIV infections
by physicians Prior HIV test HIV as part of a Ddx Unexplained opportunistic
infections (i.e. PCP, toxo, crypto, histo, TB, MAC)
Low Risk HIV - Serology unknown but answers no
to all high risk questions
Unknown Source is not assessed
4 Drug Selection
Best to start within 1-2 hrs, consider dose before Rapid HIV test returns depending on risk of source patient
CHR has PEP kits prepared for us
Basic Regimen: If Low risk exposure (unknown source or mucocutaneous exposure)
Combivir: (AZT 300mg + 3TC 150mg) bid
Expanded Regimen: For most percutaneous to known HIV + IN CONTACT WITH ID
Basic Regimen + Nelfinavir 1250mg bid
Other: consider other drugs if source patient is already on antiretrovirals or if
source patient is known to have resistant HIV
Southern Alberta Clinic Guidelines
Southern Alberta Clinic Guidelines
5 Duration of Prophylaxis: Start ASAP and continue for 4 weeks
6 Discuss adverse reactions w/patient:
7 Access and Cost: Starter kits contain 72 hours of drugs
Free for occupational exposure and non-voluntary or violent (assault) exposures
Non-occupational voluntary exposures (needles or sex): PEP is available, but cost not absorbed by CHR
In Calgary, starter kits are available in all hospital ED’s, and at the 8th & 8th 24-hour walk-in medical clinic. All antiretroviral drugs are stored in the Pharmacy at Foothills Medical Centre.
Cost: approx $1000 for 4 wks of combivir
Southern Alberta Clinic Guidelines
Southern Alberta Clinic Guidelines
8 Follow-up: Baseline HIV, HBV, HCV, CBC, Cr, LFTs and bHCG should
be done in recipient
Follow-up with ID at HPTP clinic within 72 hours (my understanding is this is only required if exposed to HIV, HBV, HCV + source)
HIV testing at 6 wks, 12 wks, 6 months
Hep B Tx/Management-Only consider Tx if HBsAg +
If immunized and adequate titers (>10IU) Do nothing (no need to test either HCW or source pt)
If immunized and ? Anti HBs-Titers Get titer levels (can delay as long as HBIG can be initiated within at
least 72 hrs, 24 hrs preferred) If immunized and titers <10IU after 1 series of vaccination
HBIG (0.6mL/kg/admin) and 1 dose of vaccine or 2 HBIG If immunized and known non-responder (low titers after two series
of vaccination) HBIG now and then repeated in 1 month
If not immunized HBIG and give 1st dose of vaccine (repeat vaccine at 1 and 5 mths)
Hep C PEP: studies
Animal study looking at the use of high dose anti-HCV IG administered 1 hr after transmission did not prevent infection
Use of antivirals: no studies, but not thought to be effective
Therefore, aim is early detection of HCV an early referral for possible Tx options
Take-Home Points
HIV+ patients will show up more and more
If CD4 level is >350 cells/ microL or viral load is less than 50 000 within the past 4-6 months, can be treated as immunocompetent
Most common complications of HIV are: Neurologic
Ophthalmologic
Pulmonary
Dermatologic
Gastrointestinal
Take-Home Points
Occupational exposures:
HIV exposure If HIV + = start PEP
If HIV - = don’t start PEP
If unknown HIV status = MD and Pt need to make a decision, generally start PEP if high risk exposure/patient/setting
Hep B If pt has adequate titers = do nothing
If titers are not adequate = HBIG +/- vaccine
Hep C No Tx, but goal is early identification in order to institute appropriate f/u,
Tx as needed