Needlestick transmission of blood-borne viruses

Question 1

How to prevent Hep B infection from needlestick in HCW

Answer 1

Vaccination of non-responders or non-vaccinated

PEP - vaccination or HBIg

Question 2

How to prevent Hep B infection from needlestick in HCW

Answer 2

Vaccination of non-responders or non-vaccinated

PEP - vaccination or HBIg

Question 3

What type of Hep B positive patient is the most infectious?

Answer 3

HepB E Ag positive.

Reduced risk if Anti-E positive and low levels of HBV DNA

Question 4

What does a HBV vaccination consist of?

Answer 4

Purified surface Ag

Requires x 3 doses

Question 5

What is the definition of a non-response to HBV vaccination? What are its implications?

Question 6

How many adults are HBV vaccination non-responders?

Answer 6

5-10%

Question 7

What type of Hep B positive patient is the most infectious?

Answer 7

HepB E Ag positive.

Reduced risk if Anti-E positive and low levels of HBV DNA

Question 8

What does a HBV vaccination consist of?

Answer 8

Purified surface Ag

Requires x 3 doses

Question 9

What should the response be to Hep B vaccination?

Answer 9

Generation of anti- HBs

Question 10

What is the definition of a non-response to HBV vaccination? What are its implications?

Answer 10

0-10 iu

No hep b protection

Question 11

How many adults are HBV vaccination non-responders?

Answer 11

5-10%

Question 12

What is the definition of a hypo-response/sub-optimal responders to HBV vaccination? What are its implications?

Answer 12

10-100 iu/l 6-10 weeks after completion of vaccination schedule.
? protected against HBV infection or not
USA and Europe consider protective.
‘Seroconversion’

Question 13

How many adults are HBV vaccination sub-optimal responders?

Answer 13

5-10% adults

Question 14

What is the definition of an optimal response to HBV vaccination? What are its implications?

Answer 14

> 100 iu/l 6-10 weeks after completion of 3-dose vaccination schedule
Protected against HBV infection
‘Seroprotection’

Question 15

What can be done to increase protection of HBV vaccination non-responders?

Answer 15

Repeat course of vaccine and re-test anti-HBs (Complete course of 6)

Question 16

What can be done to increase protection of HBV vaccination in poor responders

Answer 16

Booster dose (x 4 in total)

Question 17

How are HCWs protected against HCV?

Answer 17

Treatment of acute infection within 3-6 months - very high clearance rates
Encourage reporting of needle stick exposures/mucosal splash
Monitor for evidence of HCV infection
Treat

Question 18

Why is the policy for HBV vaccination in childhood?

Answer 18

Vaccine response linked to age - better response vaccination people at younger age.
Reduce the no. of sub-optimal/non-responders seen.

Question 19

What is looked at to assess significance of exposure to HBV?

Answer 19

Route - percutaneous, mucocutaneous, sexual

Source material - blood > other bodily fluids

Question 20

How is an exposure incident managed?

Answer 20

Seek advice
Routine testing of needle stick source - need consent from person giving blood
Risk assess source and recipient: - what type of needle? where was the stick?
- HBV consider post exposure management
- HCV monitoring
- HIV consider PEP

Question 21

What intervention is taken for a HCW with exposure to HCV?

Answer 21

Monitoring and early diagnosis.

No HCV vaccine

Question 22

What prevention methods can be taken for HCV

Answer 22

None, no vaccine = no passive immunisation

Question 23

How are HCWs protected against HCV?

Answer 23

Treatment of acute infection within 3-6 months - very high clearance rates
Encourage reporting of needlestick exposures/mucosal splash
Monitor for evidence of HCV infection
Treat

Question 24

What are the stages of HCV monitoring?

Answer 24

6 weeks = HCV PCR
12 weeks = HCV PCR + anti HCV serology
6 months = HCV PCR + anti-HCV serology again

Question 25

What treatment is offered to prevent HIV infection post exposure?

Answer 25

PEP antiviral triple therapy offered if needle stick known HIV positive or not known but high risk. NRTI, NNRTI and PI 4 weeks.

Question 26

How is an exposure incident managed?

Answer 26

Seek advice Routine testing of needle stick source - need consent from person giving blood Risk assess source and recipient: - what type of needle? where was the stick? - HBV consider post exposure management HCV monitoring HIV consider PEP

Question 27

Exposure prone procedures are?

Answer 27

those where there is a risk that injury to the worker may result in the exposure of the patients open tissues to the blood of the worker.

Question 28

Latest/current guidelines of HBV and HCWs

Answer 28

anti-HBe +ve HCWs measure viral load: - >10^3 copies/ml = banned from EPPs -

Question 29

Examples of EPP

Answer 29

All surgery All dentistry Repair of episiotomy instrumental delivery

Question 30

Examples of non-EPP

Answer 30

``` Taking blood setting up IV lines Minor surface suturing Incision of abscesses Uncomplicated endoscopy Normal vaginal delivery ```

Question 31

Can HBV carriers/HBsAg pos be anti-HBs?

Answer 31

Yes. | Usually of low tire eg. 10-100 iu/l and non-neutralising

Question 32

What order of testing/vaccination for HCV is carried out on HCWs in order to catch HCV carriers before vaccination?

Answer 32

sAg testing If neg: Vaccine, test anti-HBs response (confidence in protection)

Question 33

Why can testing e markers (eAg +ve) be misleading in HCWs?

Answer 33

Assumed if HBeAg +ve = highly infectious But can have virus with pre-core mutants = unable to synthesise e antigen (HBeAg -ve) but highly replicative virus? - misleading as may be highly infectious and at at high risk of chronic liver disease

Question 34

Latest/current guidelines of HBV and HCWs

Answer 34

anti-HBe +ve HCWs measure viral load: - >10^3 copies/ml = banned from EPPs -

Question 35

Which antivirals are used to reduce infectivity but licensed to reduce liver damage?

Answer 35

Tenefovir and Entecavir (dec risk of resistance vs lamivudine)

Question 36

What actions are in place to protect patients from HCV from health care workers?

Answer 36

Known HCV RNA +ve workers = out Current HCWs doing EPPs encouraged to be tested if risk factors i.e. needlestick For HCWs entering EPP specialities test for HCV infection - doverts HCV pos trainees away from EPP specialities.

Question 37

Standard health checks offered to new employees/HCWs returning to NHS/HCWs performing EPPs for the first time/students

Answer 37

HBV vaccine testing for HCV Testing for HIV without affecting employment or training....

Question 38

Additional health checks offered to new NHS HCWs doing EPPs

Answer 38

Test for HBsAg, then vaccinate and test for anti-hsb Test for anti-HCV Test for anti-HIV

Question 39

Are you allowed to operate if you are HIV pos?

Answer 39

No