Elise M. Beltrami

Risk and Management of Blood-Borne Infections in Health Care Workers

Exposure to blood-borne pathogens poses a serious risk to health care workers (HCWs). We review the risk and management of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections in HCWs and also discuss current methods for preventing exposures and recommendations for postexposure prophylaxis. In the health care setting, blood-borne pathogen transmission occurs predominantly by percutaneous or mucosal exposure of workers to the blood or body fluids of infected patients. Prospective studies of HCWs have estimated that the average risk for HIV transmission after a percutaneous exposure is approximately 0.3%, the risk of HBV transmission is 6 to 30%, and the risk of HCV transmission is approximately 1.8%. To minimize the risk of blood-borne pathogen transmission from HCWs to patients, all HCWs should adhere to standard precautions, including the appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments. Employers should have in place a system that includes written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational exposures that may place a worker at risk of blood-borne pathogen infection. A sustained commitment to the occupational health of all HCWs will ensure maximum protection for HCWs and patients and the availability of optimal medical care for all who need it.

Comparative Analysis of Two Commercial Phenotypic Assays for Drug Susceptibility Testing of Human Immunodeficiency Virus Type 1

ABSTRACT Human immunodeficiency virus type 1 (HIV-1) isolates from 50 plasma specimens were analyzed for phenotypic susceptibility to licensed reverse transcriptase inhibitors and protease inhibitors by the Antivirogram and PhenoSense HIV assays. Twenty of these specimens were from recently seroconverted drug-naïve persons, and 30 were from patients who were the sources of occupational exposures to HIV-1; 16 of the specimens in the latter group were from drug-experienced patients. The phenotypic results of the Antivirogram and PhenoSense HIV assays were categorized as sensitive or reduced susceptibility on the basis of the cutoff values established by the manufacturers of each assay. Data for 12 to 15 drugs were available by both assays for 38 specimens and represented a total of 529 pairs of results. The two data sets had a 91.5% concordance by phenotypic category. The discordant results (n = 45) were distributed randomly among 26 specimens and included 28 results (62.2%) which were within a twofold difference of the assay cutoff values. None of the discordant results were associated with primary resistance mutations that predicted high-level (>20-fold) resistance. Discordant results were distributed equally among specimens from drug-experienced and drug-naïve individuals and were slightly higher for protease inhibitors than for nonnucleoside reverse transcriptase inhibitors or nucleoside reverse transcriptase inhibitors. The findings of the present study demonstrate that the results of the Antivirogram and PhenoSense HIV assays correlate well, despite the use of different testing strategies.

Transmission of drug-resistant HIV after an occupational exposure despite postexposure prophylaxis with a combination drug regimen.

We documented a case of occupational human immunodeficiency virus (HIV) despite postexposure prophylaxis (PEP) with a combination drug regimen after percutaneous injury with a needle from a sharps disposal container in the hospital room of an HIV-infected patient. This failure of PEP with a combination drug regimen may have been related to antiretroviral drug resistance, other factors, or both. This case highlights the importance of preventing injury to prevent occupational transmission of HIV.

The nature and frequency of blood contacts among home healthcare workers.

OBJECTIVE To estimate the frequency of, and assess risk factors for, percutaneous, mucous membrane, and cutaneous blood contacts sustained by healthcare workers (HCWs) during the delivery of infusion therapy and the performance of procedures involving sharp instruments in the home setting. DESIGN Prospective surveillance of percutaneous, mucous membrane, and cutaneous blood contacts. SETTING Eleven home healthcare agencies in the United States and Canada from August 1996 through June 1997. PARTICIPANTS HCWs who provided home infusion therapy or performed procedures using hollow-bore needles and other sharp instruments in the home setting. METHODS Each participating worker recorded information about the procedures performed and blood contacts experienced during each of his or her home visits for a 2- to 4-week period using standard questionnaires. HCWs also completed questionnaires regarding job duties, reporting of previous occupational blood contacts, and their use of protective barriers in the home setting. RESULTS Participating HCWs provided information about 33,606 home visits. A total of 19,164 procedures were performed during 14,744 procedure visits. Fifty-three blood contacts occurred during these visits, for a blood-contact rate of 2.8 blood contacts per 1,000 procedures and 0.6 percutaneous injuries per 1,000 procedures with needles or lancets. Gloves were worn for 52%, masks for 5%, gowns for 3%, and protective glasses or goggles for 2% of all procedure visits. HCWs used barriers for 53% of visits during which at least 1 procedure was performed and for 27% of other visits. CONCLUSIONS HCWs involved in home health care are at risk for blood contact. Infection control barrier use was low in our study. The majority of skin contacts could have been prevented by glove use.

Antiretroviral Drug Resistance in Human Immunodeficiency Virus–Infected Source Patients for Occupational Exposures to Healthcare Workers

OBJECTIVE To assess the prevalence of HIV antiretroviral resistance among source patients for occupational HIV exposures. DESIGN Blood and data (eg, stage of HIV, previous antiretroviral drug therapy, and HIV RNA viral load) were collected from HIV-infected patients who were source patients for occupational exposures. SETTING Seven tertiary-care medical centers in five U.S. cities (San Diego, California; Miami, Florida; Boston, Massachusetts; Albany, New York; and New York, New York [three sites]) during 1998 to 1999. PARTICIPANTS Sixty-four HIV-infected patients who were source patients for occupational exposures. RESULTS Virus from 50 patients was sequenced; virus from 14 patients with an undetectable (ie, < 400 RNA copies/mL) viral load could not be sequenced. Overall, 19 (38%) of the 50 patients had primary genotypic mutations associated with resistance to reverse transcriptase or protease inhibitors. Eighteen of the 19 viruses with primary mutations and 13 wild type viruses were phenotyped by recombinant assays; 19 had phenotypic resistance to at least one antiretroviral agent. Of the 50 source patients studied, 26 had taken antiretroviral agents in the 3 months before the occupational exposure incident. Sixteen (62%) of the 26 drug-treated patients had virus that was phenotypically resistant to at least one drug. Four (17%) of 23 untreated patients had phenotypically resistant virus. No episodes of HIV transmission were observed among the exposed HCWs. CONCLUSIONS There was a high prevalence of drug-resistant HIV among source patients for occupational HIV exposures. Healthcare providers should use the drug treatment information of source patients when making decisions about post-exposure prophylaxis.

Postexposure interventions to prevent infection with HBV, HCV, or HIV, and tetanus in people wounded during bombings and other mass casualty events-united states, 2008 recommendations of the centers for disease control and prevention and disaster medicine and public health preparedness

People wounded during bombings or other events resulting in mass casualties or in conjunction with the resulting emergency response may be exposed to blood, body fluids, or tissue from other injured people and thus be at risk for bloodborne infections such as hepatitis B virus, hepatitis C virus, human immunodeficiency virus, or tetanus. This report adapts existing general recommendations on the use of immunization and postexposure prophylaxis for tetanus and for occupational and nonoccupational exposures to bloodborne pathogens to the specific situation of a mass casualty event. Decisions regarding the implementation of prophylaxis are complex, and drawing parallels from existing guidelines is difficult. For any prophylactic intervention to be implemented effectively, guidance must be simple, straightforward, and logistically undemanding. Critical review during development of this guidance was provided by representatives of the National Association of County and City Health Officials, the Council of State and Territorial Epidemiologists, and representatives of the acute injury care, trauma, and emergency response medical communities participating in the Centers for Disease Control and Preventions Terrorism Injuries: Information, Dissemination and Exchange project. There recommendations contained in this report represent the consensus of US federal public health officials and reflect the experience and input of public health officials at all levels of government and the acute injury response community.