Management of occupational exposure to blood and body fluids in primary care

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Today's Australian Prescriber Podcast isn't for the squeamish. We're talking about something that's a bit icky, something that can be quite stressful and something we all try to make sure doesn't happen. But what are we going to do about it if it does? What is it? What do we do if we get exposed to a patient's blood or bodily fluids? I'm Dr Laura Beaton, a GP in Melbourne and your host for this episode. I'm joined by Dr Anna Pierce, an infectious disease physician at the Alfred and Monash, who has written a great article on this topic. Anna, welcome to the show.

Thanks, Laura.

In many ways, I actually hope that our listeners never have to use the advice that we're talking about, but I guess in healthcare, exposure to blood and bodily fluids is actually really common, so it's great to be able to chat through what are we going to do and have this article to come back to as a reference for if or when the situation actually arises. Before we get started, I will say that today's discussion and your article is focusing on the primary care setting. That's where I work, but not all of our listeners will work in that setting. And so a lot of the principles of what we talk about today might be transferable to other settings, but the specifics of that are out of the scope. So to start with, we're talking about a really common risk that we can't eliminate entirely. And before we talk about what to do when an exposure takes place, what are some of the elements of preventing exposures?

Prevention is the most important thing and all workplaces and healthcare workers who could potentially be exposed to blood or body fluids need to have standard precautions and work practices for safe use and disposal of sharps. One of the other key things is for all healthcare workers to be vaccinated against hep [hepatitis] B. And not only to know that they've been vaccinated, but really ideally should have documentation of their response to vaccination so that we know if they're immune if they have an exposure. And also, practices should really have policies in place so that they know what to do if an incident like this occurs. You don't want to be running around trying to figure out what to do when something happens like this because part of the key is to do things quickly if postexposure prophylaxis needs to be given.

Let's move on to when an occupational exposure happens. What is the very first step?

First aid is the first step. So if there's been an injury with a sharp, like a needle or a scalpel blade, then need to wash the site with soap and water and then apply a dressing to that; it’s important not to squeeze the wound to express blood. If there's been a splash to the eye, then need to flush the eyes with water or saline. If somebody's wearing contact lenses, obviously you need to remove those. And if you've had a splash inside the mouth or the nose, then just rinse that repeatedly with water.

These exposures can be a shock and also quite anxiety-provoking. So we really need to make a good assessment of actually how risky each individual exposure was. To start off with, what are the pathogens that we're mainly concerned about when we're thinking about occupational exposures to a patient's blood or bodily fluids?

When we talk about exposure to bloodborne viruses, we're essentially talking about the risk of exposure to hepatitis B, hepatitis C and HIV, and those 3 carry different risks. If somebody is exposed to somebody who has one of those bloodborne viruses, the risk of transmission is different for each of the viruses.

Your article goes through each of these bloodborne viruses, the risk depending on the source’s risk – whether they're known to have an infection or whether they're unknown status. And you talk about the risk really also depends on what type of exposure has happened. You really clearly lay out which of the exposures need blood testing for the source and which of those are actually low risk and don't require any testing. Can you talk us through those? Because often that can be the first immediate response, ‘Oh my gosh, do I need testing?’

When somebody has any kind of injury, it's always anxiety-provoking and sometimes people can panic and think that there's a risk when there isn't. But on the other hand, some people don't worry about the risk and really forget to report something that is a higher risk and needs to be followed up.

So things that require testing and when we say testing, testing the source to see if they do actually have one of the bloodborne viruses – if there's any penetrating injury that involves blood or blood-stained body fluids, so if there's blood-stained urine or saliva or amniotic fluid, for example, or if somebody's had a penetrating injury with a needle that has blood on it, then that requires source blood testing.

Same for mucous membrane exposures, so the eye or non-intact skin, if there's been a splash with blood or blood-stained body fluid, that needs follow-up. And we've put in there human bites or scratches that penetrate the skin and involve blood –  these are pretty rare, but if for example a source had bleeding gums and bit somebody, then that would classify as something that needed follow-up.

But if somebody has an exposure to intact skin, there's no break in the skin, then that doesn't require testing. If there's been an exposure to the eye or to the mouth with just urine that's not blood-stained, then that doesn't need follow-up testing. And if somebody has had an injury with a clean sharp, so an unused needle that has not been in contact with a patient, then that doesn't need follow-up either.

That's really helpful to know. In your experience, how acceptable do people find the idea of not testing in these lower-risk scenarios?

I think if it's explained to them clearly that there has been no blood or body fluid that actually has potential to carry the virus, then people are reasonably accepting of that, and I think sometimes it's very reassuring for them to have been told that actually you don't need to worry, we don't need to follow that up.

This is an important patient-centred approach. You actually are treating the exposed person here as a patient. It's really important that they are able to get individualised advice and some counselling. And in your article, you do talk through where you can get advice in these situations. If I was a GP and this has happened and I'm actually not sure what to do and I don't have your article up in front of me, where can I get some advice from?

Generally, infectious diseases physicians are used to dealing with this, particularly those that work in a hospital setting, certainly hospitals as a significant number of needlestick injuries occur every week. So speak to the infectious diseases physician or registrar on call in the local public hospital.

In your article, you mentioned that counselling of the source is also important and that sounds like it's around getting their consent for testing. Can you tell me how those conversations tend to go in your experience?

So yes, there's counselling and testing of both the source patient, so the person whose blood it is that might have the bloodborne virus, and then also of the healthcare worker who's had the injury.

So what happens, somebody has a needlestick injury, they report the incident, then there needs to be blood testing of the exposed healthcare worker. And the first thing that we really want to check and the easiest thing to check is whether or not they're immune to hepatitis B. And then we'll often do HIV and hepatitis C baseline testing. And part of that counselling is just letting them understand why you're doing the testing and what the risks of the exposure potentially are.

Then counselling and testing of the source. So it's important that the source is aware of the situation that's occurred, that the reason that they're being asked to have their blood tested for bloodborne viruses is because a staff member has had a needlestick injury or other exposure to their blood or potentially infectious body fluid. If that's explained to them, why they want to do the test, talk to them about potential risk factors, then generally people are quite happy to have that testing done. And it's important that it's not done without their consent.

And if somebody is not able to consent, so if they have an anaesthetic and they're unconscious, or they're not competent to consent, then it's not possible to just take blood and do the testing anyway. Legislation differs in different states. I know in Victoria the next-of-kin are not able to give consent to test that patient's blood. It has to be from the Chief Health Officer and they have to give an order for it to be tested, and that can be delegated to staff members of the hospital, but it can't be done by next-of-kin. I'm not sure what the other state guidelines are, but I imagine there would be some sort of similar process.

Always important to look up your local legislative requirements around these situations. So thanks for providing that great summary of how we're assessing risk. It's a mix of the source's infectivity status, the type of exposure, so what fluid into what part of the body, and then that exposed person's vaccination status particularly for hep B.

So let's move on to the meat of the article, which is management. What happens when this has actually happened? In your article you go through in depth what we do specifically for hep B, hep C and HIV exposure in detail, which is a great practical and easy-to-follow reference. And I actually recommend all of our listeners bookmark and download this to look it up when this becomes relevant, probably not an if but a when. But I guess, Anna, today let's have a chat through some of the principles of management for each of the bloodborne viruses, because they are a little bit different, and maybe a little bit of a chat around timeframe. So starting about hep B, you already mentioned that a lot of this depends on the exposed person's vaccination status.

Yes. So if the healthcare worker has had 3 doses of hepatitis B vaccine, has had post-vaccination serology and they have a positive hepatitis B surface antibody of 10 milli-international units per mL or higher, they are considered immune, and so if that is already known prior to the incident and it's been recorded in documentation, then nothing further needs to be done. If there's a record of them having 3 doses of vaccine but no serology has been taken, or there's no results known, then the first thing they need to know is do they have protective levels of hepatitis B surface antibody or not. And obviously if they've not been vaccinated, which I imagine would be an unusual situation in a healthcare setting because everybody's recommended to be vaccinated, then they should obviously undertake vaccination and have their serology checked prior to that. And then there's also the other less common incident of the healthcare worker who's had 3 doses of vaccine in 2 separate courses and has not seroconverted, and we call those the hepatitis B vaccine non-responders.

There's a really helpful table in your article that goes through this for the immunisation status of the source and the exposed person, check out table one if/when you need it. If we need hep B IG or immunoglobulin for postexposure prophylaxis for a high-risk exposure, how do we get it?

It's a blood product, so like other blood products, can be ordered through Lifeblood. General practices can be registered with Lifeblood. And so if they are a registered general practice, it can be ordered through Lifeblood via their online order form. Otherwise, hospitals also either have some in stock in their blood bank or can order it themselves through Lifeblood. So if the general practice is not able to source it themselves, then you can refer that person to the nearest hospital emergency department.

So moving on to hep C, let's talk a little bit more about the principles for hep C and the risks and what steps we do when thinking about how we manage an exposure.

So obviously there's no postexposure prophylaxis for hepatitis C. And part of the difficulty when testing the source is that they can have had hepatitis C in the past and cleared the virus but will remain hepatitis C antibody–positive. What we really want to know is if somebody who has chronic hepatitis C is currently viraemic, and that requires a PCR [test] to know that. Unfortunately, the same sample can't be tested for reflex testing and for PCR testing. So if a source is hepatitis C antibody–positive, then they really need to have another blood sample taken for a PCR. It would be easier if people took 2 tubes at the time of exposure, but I'm not sure that that's routine practice.

And you do make a special note in your article that while there is no postexposure prophylaxis for hep C, hep C is actually a treatable condition now.

Yes, that's right. With the availability of direct-acting antivirals, there's a very high cure rate of hepatitis C. So we just follow up somebody who is known to have been exposed to hepatitis C, and if they do seroconvert and become positive, then they can easily be treated with antiviral therapy.

And finally, for the 3 major bloodborne viruses that we're talking about today, HIV. You do make a special point in the article around the public health messaging of U equals U, which is the principle that if someone who has HIV is on medication with an undetectable viral load, they are essentially uninfectious. And so we don't obviously have occupational data around exposures to blood and bodily fluids in this context, but it does make sense that risks would be extremely low for anybody who is exposed, if someone has HIV is on treatment and has an undetectable viral load. You talk about the steps for postexposure prophylaxis (PEP) and the 2- and 3-drug regimens. So how do we get PEP, and how do we make the call if it's a 2-drug or 3-drug PEP?

Yeah, this is one of the trickier areas and part of it is tricky because there's not a lot of evidence. HIV is one of those things that everybody's been most highly anxious about with regards to a needlestick injury. Certainly, when talking about U equals U in sexual exposures, there's no risk of transmission, and as you say, we assume it's likely to be the case for occupational exposures. We don't have the data, but it does make sense if the viral load is undetectable, then there should not be transmission. It depends a little bit on the person's concept of risk and how much risk they're prepared to take. Some people might say, ‘Well look, if it's not sexually transmitted, it's not likely to be transmitted even if the person has undetectable viral load, I'm happy not to take any postexposure prophylaxis’, but somebody on the other hand might be highly anxious, and I think it's reasonable to offer that person postexposure prophylaxis.

The choice of 2 drugs versus 3 drugs is a little more tricky and a lot of this is historical, based on antiretroviral therapy being expensive, no generic formulations available. In the past, 2-drug PEP would've been about $700 for a one-month course. When you add in the third drug, that doubles it to $1,300, $1,400. So actually, to give somebody 3-drug PEP for a month is very expensive. And then add to that, there's actually no evidence that 3 drugs is better than 2. In the past, 3 drugs would be given for when we knew that somebody had a detectable viral load, we would give somebody exposed to them 3 drugs. And then somebody [exposed to a source] who had an undetectable viral load, we might give them 2 drugs. So unfortunately, there's not a huge amount of science to back up what we do. And I think things have changed quite a bit now that we have generic formulations, particularly of tenofovir and emtricitabine as a single-pill combination that is available in a generic formulation, and therefore makes it affordable to be given on a private prescription.

The other interesting thing with postexposure prophylaxis, these drugs, antiretrovirals that are used for HIV treatment, they're not actually TGA-approved for this indication, so they're not available on the PBS, and you don't need to be an S100 prescriber to prescribe them. If you want to prescribe somebody 2-drug PEP for a lower-risk exposure, so somebody might've had a needlestick injury, the source is known to have HIV but has undetectable viral load, and the exposed person really would like to take PEP, then any GP can write a private prescription for generic tenofovir+emtricitabine and it costs about $40 for a month's supply. If it was a very high-risk exposure and the healthcare worker was exposed to a source who was newly diagnosed with HIV and had a very high viral load – a high risk exposure – and you would really want them to have 3 drugs, then you wouldn't want to write a private prescription for the third drug because that would cost them $600 or $700 for the month, and at that point, you would want to refer them to a public hospital to source it through the hospital pharmacy.

Thanks for going through that. Certainly, this is an evolving space around the medical treatment of HIV and always a good reminder that a call to your local infectious diseases registrar will be able to help you sort out some of these nuances. And just thinking about follow-up of when we need to check in again for exposed people, when do you make your follow-up appointment and serology?

Follow-up depends a little bit and particularly if we're talking about HIV follow-up depends on whether or not somebody receives postexposure prophylaxis. If somebody does receive postexposure prophylaxis, there is evidence that taking antiretroviral therapy during primary infection can potentially alter the serological response. So you should delay follow-up testing in somebody who has PEP and we would test at 6 weeks and 12 weeks postexposure. But if somebody doesn't receive PEP, then the final HIV test can be 45 days after the incident, so about 6 weeks. And then we do similar follow-up for hepatitis B and hepatitis C testing as well.

Now as we are really wrapping up our summary of our management, this is a really important time to note as well that at the start we spoke about each workplace having really specific protocols and reporting systems around occupational exposures, but actually it's really important to know that there are some legislative reporting requirements in some jurisdictions, especially if an exposure has needed treatment or there has been an occupational acquisition of a bloodborne virus. Where do we look this up, Anna?

Safe Work Australia.

All of that information will be on their website. Reporting can be a requirement, but it's also really an important part of quality assurance and improvement at our practice sites. And so often these might trigger an incident review and think about any processes that could have been improved to reduce future risk, in whatever setting the exposure has happened. Anna, you do mention that HIV has historically and probably still is the virus that people are most anxious about contracting, and prevention of HIV has moved on so much over the last years. When we're thinking about an individual's risk assessment when they've been exposed, if someone is on PrEP [pre-exposure prophylaxis], does that change what we have to do if they have an occupational exposure?

If the healthcare worker is on PrEP, and they are taking it regularly, either daily or at least having 4 doses a week, then if they have an exposure to a source who is known to have HIV and has a detectable viral load, then they should be protected, and they would just continue taking their PrEP as per usual. They may want to have follow-up, but somebody on PrEP is already having 3-monthly follow-up for HIV and STI testing anyway, so you would just watch them a little bit more closely. But also bearing in mind that in somebody who is taking PrEP, it can be difficult sometimes to diagnose an HIV seroconversion because of the effect of antiretrovirals on the seroconversion process.

Thanks for going through that. It's always wonderful to have really up-to-date advice on clinical scenarios. Anna, thank you so much for our discussion today. We spoke through a lot of the what-ifs and it's great to have this article as a reference to come back to when we need it.

Thanks, Laura.

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The views of the hosts and the guests on this podcast are their own and may not represent Australian Prescriber or Therapeutic Guidelines. Anna Pierce is a member of the Expert Reference Group for ASHM Health's Australian HIV PEP Guidelines (3rd edition).