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


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


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


Jeopardy Question:

This protozoan parasite causes the second most common CNS infection in AIDS patients. Hint:

What is Toxoplasma Gondii


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


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


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


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


Acute Exanthem of HIV Seroconversion


Seborrheic Dermatitis


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


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


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



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



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

hiv, aids and needlestick injuries

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