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importance of reporting incidents as soon as they occur is essential. Several institutions use a comprehensive template for the report, to guarantee adequate documentation and standardization in the reporting and subsequent follow-up. It may be
useful to include some guidance to the reporter to expedite the management and
ensure compliance.
T. Ballouz et al.
Assessment oftheExposure Risk
An important part of the evaluation of the exposure is assessing the risk of infection. As detailed above, the risk of transmission is dependent on several factors.
These factors may increase or decrease the risk of transmission of blood-borne
pathogens. These include the type and extent of exposure/injury, the type and volume of body uid involved, the status of the source of exposure, and the susceptibility of the exposed HCW. As an example, exposure to a blood-lled hollow
needle or visibly bloody device poses a greater risk for HIV or HCV than a needle
used for injection. A thorough examination of both the source and the exposed
person is needed for the assessment of the transmission risks. In the event that the
status of the source is unknown, serological testing for HIV, HBV, and HCV should
be performed only after obtaining the necessary consent for such testing.
Condentiality needs to be maintained throughout the process. Any results ought
to be communicated to the exposure source, who will be referred accordingly for
counseling and treatment.
General Approach toRisk Assessment andManagement
Exposure source (source patient): Initial steps include clinical assessment of any
evidence or signs of HIV, HBV, or HCV.Additionally, available laboratory results
or medical history can help in determining whether the patient already has a bloodborne infection or not.
All source patients should be tested for HIV serology, hepatitis B surface antigen
(HBsAg), and hepatitis C virus (anti-HCV), unless they are known to be infected.
Some sources do not recommend testing the source for HBV infection if the EE has
completed three doses of hepatitis B vaccine with documentation of adequate vaccination response. In that case, only HCV and HIV testing needs to be done. If a
patient is known to be infected with HIV, additional information regarding the most
recent HIV viral load and antiretroviral treatment history, including any drug resistance information, will be gathered. The same applies to the treatment of hepatitis C
infection and any hepatitis B treatment.
Exposed employee (healthcare worker): For any EE, information regarding
their immunization status (tetanus and hepatitis B); post-immunization titers;
previous HIV, HBV, and HCV testing; and any underlying medical conditions
and medications needs to be obtained from their medical/occupational health
records.
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Specific Approaches toRisk Assessment andManagement
Occupational HBV Exposure
Risk Assessment andManagement
Postexposure management of any healthcare worker with a possible exposure to
HBV depends on two elements: the immune status of the EE and the HBsAg status
of the SP.
The medical/occupational health records of all EEs should have evidence of their
HBV status (HBsAg, hepatitis B surface antibodies [anti-HBs]). However, if that is
not available, prompt baseline testing of the healthcare worker is needed before
determining the next steps in postexposure management. The EE and thus postexposure management might fall into several categories (Table21.2) [32].
Table 21.2 HBV postexposure management
EE
SP HBsAg
EE status
Previous infection No action
Vaccinated,
vaccine responder
Vaccinated,
vaccine
nonresponder
Vaccinated,
response unknown
Non-vaccinated Positive HBIG*1 and HB
EE Exposed employee, SP Source patient, HBsAg Hepatitis B surface antigen, anti-HBs Hepatitis
B surface antibodies, HBIG Hepatitis B immunoglobulin, IU International unit, mL Milliliter
status
needed
No action
needed
Positive or
unknown
Negative <10
Positive or
unknown
Negative <10
Any result
Unknown HB vaccination
Negative HB vaccination
anti-HBs
status
No action
needed
No action
needed
<10
milli-IU/
mL
milli-IU/
mL
<10
milli-IU/
mL
milli-IU/
mL
≥10
milli-IU/
mL
Postexposure
management
No action needed No action needed
No action needed No action needed
HBIG *2 separated
by 1month
No action needed No action needed
HBIG * 1 and
revaccinate
Revaccinate Anti-HBs
No action needed No action needed
vaccination series
series
series
Follow-up
No action needed
Anti-HBs
1–2months after last
vaccine dose
1–2months after last
vaccine dose
Anti-HBs
1–2months after last
vaccine dose
Anti-HBs
1–2months after last
vaccine dose
Anti-HBs
1–2months after last
vaccine dose
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T. Ballouz et al.
1. Evidence of a previous infection of the EE (anti-HBs and hepatitis B core anti-
bodies [anti-HBc] are positive): in this case, the HCW is deemed to be protected
and no postexposure prophylaxis is needed.
2. Immunized healthcare worker and is a known vaccine responder (anti-HBs
≥10 milli-international unit [IU/milliliter[mL]]): no baseline testing is required
and no postexposure prophylaxis is needed.
3. Immunized healthcare worker but is a vaccine nonresponder (anti-HBs
<10milli-IU/mL after receiving 2 full doses of hepatitis B vaccine, i.e., 6 injections): in such case, the status of the source patient needs to be determined. If the
source patient has a positive HBsAg or if it is unknown, the healthcare worker
should receive two doses of the hepatitis B immunoglobulin (HBIG), separated
by 1month.
4. Immunized healthcare worker with unknown vaccine status: immediate test-
ing of the source patient (SP) for HBsAg and of the EE for anti-HBs. If EE’s
anti-HBs is ≥10 milli-IU/mL, then no additional testing or management is
required.
If the anti-HBs are <10 milli-IU/mL, postexposure management depends on
the source patient’s status. If HBsAg of the SP is positive, the EE should receive
one dose of HBIG and one dose of the hepatitis B vaccine. Afterwards, the EE
should receive two more doses of the vaccine to complete the immunization
series. Anti-HB testing should be done 1–2months after the last dose of the
hepatitis B vaccine to determine the EE’s immunity status. Management is similar if the status of the source patient cannot be determined, where the EE should
be managed as if the source is HBsAg positive.
If the source patient SP has a negative HBsAg, the EE should be immunized
for hepatitis B and checked for anti-HBs 1–2 months after completing the
5. Healthcare workers who have not received or completed hepatitis B vacci-
nation: The source patient should be tested for HBsAg. If found positive or
cannot be determined, the EE should immediately receive one dose of HBIG and
one dose of the hepatitis B vaccine. Afterwards, the EE will receive the additional doses of hepatitis B vaccine to complete the immunization series with
anti-HB testing to assess vaccination response. If the source patient is negative
for HBsAg, the EE should receive the complete hepatitis B vaccination series
followed by anti-HB testing.
Postexposure Prophylaxis withHepatitis B Immunoglobulin
The role of antivirals in postexposure prophylaxis of hepatitis B has not been
established. Guidelines recommend administering HBIG as soon as possible
after the exposure (preferably within 24hours). However, if that is not possible,
it can be given up to 7days after exposure. Studies have shown that if the rst
dose was initiated within the rst week, multiple doses of HBIG are 70–75%
effective in preventing HBV infection. Benet beyond 7 days is unknown
[12, 32].
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Postexposure Prophylaxis (PEP) withHepatitis B Vaccine
Similarly, hepatitis B vaccine alone is 70–75% effective in preventing HBV infection [12, 32]. Ideally, HBV vaccine should be given within 24h of exposure. The
mostly highly effective postexposure management is a combination of HBIG and
hepatitis B vaccination, where effectiveness reaches 85–95% in HBV infection prevention [32–34].
Follow-Up Counseling andTesting
In cases where the EE has no evidence of HBV immunity at the time of immunity,
follow-up testing with anti-HBc and HBsAg needs to done 6months after exposure
to determine HBV transmission. In those that have received hepatitis B vaccinations
and HBIG, anti-HB testing should be performed 1–2months after the last vaccine
dose and at least 6months after the last HBIG dose.
The EE should be counseled to refrain from donating blood, plasma, semen, or
organs. However, there is no need to modify sexual practices or breastfeeding. In
addition, there is no need to modify any of the patient care responsibilities of the
EE.Counseling should include immediate reporting of any illness, symptoms of
fever, chills, nausea, vomiting, jaundice, and/or change in color of urine and stools.
If acute hepatitis B infection is documented, evaluation and referral should be
performed according to published guidelines and recommendations.
Occupational HCV Exposure
Risk Assessment andManagement
To this day, there has been no effective postexposure prophylaxis for individuals
exposed to HCV.Despite the availability of highly effective HCV direct-acting antiviral drugs, there is not enough evidence for the use of these drugs in postexposure
prophylaxis, and they are not FDA approved in such contexts [35]. Similarly, the
use of immunoglobulins as postexposure prophylaxis for hepatitis C has not been
recommended due to the lack of data on its effectiveness in preventing such infections [36]. Therefore, in the cases of possible HCV exposure, management lies in
the early detection and treatment of HCV.
Based on CDC guidelines for the follow-up of occupational HCV exposures
(Table21.3) [12]:
Table 21.3 Postexposure HCV testing
Baseline testing Follow-up
Anti-
HCV HCV RNA A LT HCV RNA Anti-HCV A LT
SP Yes If anti-HCV is
positive
EE Yes If anti-HCV is
positive
HCV Hepatitis C virus, ALT Alanine transaminase, SP Source person, EE Exposed employee
– – – –
Yes At 4–6weeks if earlier
diagnosis is desired
At
4–6months
At
4–6months
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(a) The SP should be tested for anti-HCV at baseline.
(b) The EE should be tested at baseline, preferably within 48h, for anti-HCV and
alanine transaminase (ALT). Follow-up testing with ALT and anti-HCV is usually performed at 4–6months; however, if earlier diagnosis is desired, HCV
RNA can be done at 4–6weeks.
(c) If anti-HCV for SP or EE returns positive, a conrmatory test with another anti-
HCV testing is needed.
T. Ballouz et al.
Follow-Up Counseling
At any point, if the EE has evidence of acquiring HCV infection, they should be
referred to a specialist for appropriate management. Signs and symptoms of acute
hepatitis C infection may be subtle most of the time; however, in certain instances,
there may be evidence of constitutional symptoms, jaundice, abdominal pain, etc.
Similar to HBV, EEs with possible exposure to HCV do not need to abstain from
sexual practices, breastfeeding, or pregnancy during the follow-up period. However,
they need to refrain from donating blood, plasma, semen, or organs. Patient care
responsibilities do not need to be modied solely on the basis of possible exposure
to HCV-infected blood or tissue [12].
Occupational HIV Exposure
Risk Assessment andManagement
Healthcare workers who are potentially exposed to HIV should receive immediate
evaluation and care. This prompt management critically reduces the likelihood of
HIV transmission. Generally, the approach to assessing the risk of HIV exposure
includes determining the status of the source patient and EE, assessing the type of
body uid and the nature of the exposure, and nally the timing of the exposure [30].
Testing
1. Determine the status of the source patient. If unknown, the HIV status of the
source needs to be immediately determined, preferably using a fourth- generation
antibody-antigen test [30]. If HIV serology in a source patient is negative, no
further testing is normally required. If the testing is going to be delayed, PEP
should be initiated right away while awaiting the test results. If the source is later
found to be HIV negative, PEP can be discontinued. If HIV serology is negative
but there is clinical suspicion of acute HIV infection, PEP should be initiated and
the HIV viral load performed.
2. HIV testing in exposed HCWs. All EEs need to have a baseline HIV serology
testing immediately after exposure. Since seroconversion occurs usually within
the rst 3 months, it is important to perform follow-up HIV tests. Timing of
follow-up testing depends on the test used. Ideally, a fourth-generation combination antibody-antigen test is preferred, since it detects seroconversion earlier,
where follow-up testing can be done at six weeks and 4months after exposure.
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However, if an antibody test is used, follow-up should be done at 6 weeks,
3months, and 6months postexposure. A longer follow-up is recommended in
those with impaired humoral immunity and in those exposed to a source with
HIV-HCV co-infection.
In determining statuses of SP or exposed EE, it is important to start with a serology test rather than with HIV RNA, since there is a high likelihood of a falsepositive test.
Postexposure Prophylaxis (PEP) forHIV
When a person is exposed to HIV, the virus rst replicates in the dendritic cells of
the skin and mucous membrane before disseminating. It takes HIV up to 72 h,
5days, and 8days to be detected in regional lymph nodes, blood, and cerebrospinal
uid, respectively. This “window of opportunity” allows PEP to prevent HIV acquisition after exposure, if started early enough [37]. A landmark case-control study
published in 1997 provides the best available evidence on the effectiveness of PEP
in preventing HIV acquisition in healthcare workers. This study included 33 cases
(HCW who became infected with HIV) and 665 controls (HCW who did not become
infected with HIV). Multivariate analyses revealed that after controlling for other
risk factors, the odds of HIV transmission after exposure in those who received
zidovudine were reduced by 81% (95% CI 48–94%) [29]. This study, along with
other smaller human (mainly on prevention of perinatal transmission) and animal
studies (on PEP efcacy), has supported the use of PEP [38].
Indication
PEP is given to EEs on a case-by-case basis, taking into consideration the risk of
HIV transmission, weighing it against individual preference, inconvenience, and
toxicity of PEP.However, generally PEP is recommended when there is percutaneous mucous membrane or non-intact skin exposure to blood or bloody body uids
from a patient known or suspected to be HIV positive. If the status of the source
patient is unknown, PEP is continued until the results of the HIV testing are available. If the source patient cannot be identied, PEP is recommended in settings with
a high likelihood of HIV infection, such as in the case of a prick from a needle in a
sharps disposal container [30].
Timing andDuration
PEP should be initiated as soon as possible after exposure, preferably within 1–2h.
Animal studies have highlighted the importance of starting PEP soon after an exposure, with a reduced effectiveness if started more than 36–72h after exposure [39–
41]. Unless there is a very-high-risk exposure (such as needle injury that was in an
artery or vein of an HIV-infected patient), recommendations state that PEP should
not be offered if it has been more than 72h after the exposure. In the cases of veryhigh- risk exposures, PEP might be initiated up to 1week following the exposure
(Table21.4) [30].
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Table 21.4 Postexposure HIV follow-up testing and monitoring
Baseline
(within
24h)
HIV test
– Fourth- generation x – – x – x –
– Antibody test x – – – x x x
Complete blood count,
renal and hepatic
function, and pregnancy
test
HIV Human immunodeciency virus
x x x – – – –
Two
weeks
Four
weeks
Six
weeks
Three
months
T. Ballouz et al.
Four
months
Six
months
The optimal duration of PEP is unknown; however, it is generally given for
4weeks, based on studies assessing zidovudine protectiveness against HIV transmission [29, 39, 40].
Antiretroviral Therapy Regimens
Three-drug regimens are the preferred regimens for occupational PEP.The recommendations for regimens to use in PEP are based on studies evaluating the safety,
tolerability, and effectiveness of such regimens in patients with HIV infections,
since studies assessing the effectiveness of these regimens as PEP are lacking.
The recommended regimens are:
1. Tenofovir disoproxil fumarate-emtricitabine (300/200 mg once daily) plus
dolutegravir (50mg once daily)
2. Tenofovir disoproxil fumarate-emtricitabine (300/200mg once daily) plus ralte-
gravir (400mg twice daily)
The dolutegravir-based regimen is preferred, due to its once-daily dosing and
higher genetic barrier to resistance. The use of dolutegravir in females who are
pregnant or of childbearing potential should be carefully discussed with the EE
due to some reports of potential serious threat of neural tube defects associated
with this drug. The data is still evolving in this eld, and up to the time of writing
of this chapter, the WHO continues to recommend dolutegravir as the rst-line
therapy for the treatment of HIV-infected women. The use of dolutegravir for
prophylaxis has not been studied in this group.
3. Other regimens include tenofovir disoproxil fumarate-emtricitabine plus a
boosted protease inhibitor (such as ritonavir-boosted darunavir or ritonavirboosted atazanavir) or tenofovir disoproxil fumarate-emtricitabine plus
cobicistat- boosted elvitegravir. The latter is not a preferred agent due to potential
drug–drug interactions and the restrictions for use that require dosage at the
same time daily and with a fatty meal.
Certain regimens should be avoided when selecting PEP, such as nevirapine, due
to the potential risk of fatal hepatotoxicity and Stevens-Johnson syndrome. Likewise,
abacavir should not be used without appropriate consultation and HLA-B*5701
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testing, due to the risk of developing a fatal hypersensitivity reaction. The use of
Atripla is not favored due to the potential for viral resistance to the constituent
agents and the associated side effects [42].
The National Clinician’s Post-Exposure Prophylaxis Hotline (PEPline) provides
guidance for choosing a regimen.
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PEP inCertain Populations
1. Known or suspected drug resistance: Rare cases of PEP failure have occurred
due to the transmission of resistant strains from an HIV-infected source.
Therefore, if the source is known to be HIV infected, it is important to gather
information on their history of antiretroviral treatment and any possible genetic
resistance. This allows the tailoring of the PEP regimen. In any suspected or
known case, expert consultation is recommended. However, unavailability of an
expert or needed information should not delay PEP, and if resistance is suspected, dolutegravir-based or boosted darunavir regimens are preferred until
resistance testing is available.
2. If pregnant or of childbearing potential: Choosing a PEP regimen in pregnant
people is complex. Antiretrovirals may exacerbate physiologic changes in pregnancy, and some drugs are contraindicated and some may have short- or longterm effects on the fetus or newborn. In May 2018, the FDA released a warning
on the use of dolutegravir in pregnant or of childbearing females due to a preliminary report suggesting an increased risk of neural tube defects in four infants
born to 426 women in Botswana who were on dolutegravir at the time of conception [43, 44]. Following the warning, the HHS Antiretroviral Guideline Panels
issued recommendations guiding the use of dolutegravir in such populations.
Alternative regimens include tenofovir disoproxil fumarate-emtricitabine plus
raltegravir or tenofovir disoproxil fumarate-emtricitabine plus a boosted protease inhibitor [45].
Patient Follow-up andMonitoring
HCWs who have been started on PEP need to be followed up within 72h of exposure and PEP initiation to assess baseline tolerance of PEP and to provide any
needed psychological counseling if needed. Baseline labs should also be performed,
and these include complete blood count and renal and hepatic function. In addition
the following should be performed:
1. Follow-up with laboratory testing. As mentioned previously, exposed EEs
need to have repeat HIV testing to detect seroconversion. If a fourth-generation
combination antibody-antigen test is used, then follow-up can be done at 6weeks
and 4months after exposure. However, if an antibody test is used, follow-up
should be done at 6weeks, 3months, and 6months postexposure. Repeat laboratory testing includes complete blood count and renal and hepatic function at 2
and 4weeks. Further laboratory testing might be required if drug toxicity is suspected or ordered according to the medications included in the regimen, such as
monitoring of hypoglycemia in those on protease inhibitors.
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2. Extended follow-up. Several case reports have described delayed cases of sero-
conversion in healthcare workers who had been exposed to sources that had
HIV-HCV co-infection. Therefore, in cases with exposure to such a source, or if
the EE has been found to have acquired HCV, a longer follow-up, up to
12months, is recommended.
T. Ballouz et al.
Counseling andEducation
Counseling and educating EEs on HIV risk acquisition and PEP are very important.
This guides them in making educated choices on PEP and helps in reducing stress
and anxiety associated with the exposure incident. Additionally, EEs should be
advised to use preventative measures 6–12weeks after exposure, such as barrier
contraception, and avoiding breastfeeding and pregnancy, to avoid secondary transmission of HIV.
Psychological Counseling andStress Management
Exposure incidents are distressing to the EEs, their co-workers, and their families.
These events may trigger various psychological reactions including stress, anxiety,
and depression and could even lead to post-traumatic stress disorder (PTSD) [11,
46, 47]. Evidence has shown that the lack of social and psychological support may
affect the development of PTSD.Therefore, it is essential to provide EEs with psychological counseling to avoid any potential psychological harms [30]. Even though
no guidelines outline psychological management of exposure incidents, approaches
could include the integration of psychosocial components and education into institutions’ postexposure management systems [46].
Prevention
In the United States, OSHA issued the OSHA Bloodborne Pathogens Standard
in 1992 because of the signicant health risk associated with exposure to viruses
and microorganisms that cause blood-borne diseases [2]. The standard applies
to all occupational exposures to blood or other potentially infectious materials.
The standard requires that the employer must implement an exposure control
plan for the worksite. The plan must include industrial hygiene measures
designed to decrease the potential for exposure. Such measures include the
following:
– Engineering controls: use of safer medical devices, such as needleless devices,
shielded needle devices, and plastic capillary tubes
– Work practice controls: ban bending, recapping, or removing contaminated
needles and other sharps (unless there is no alternative available)
– Offer these: use of personal protective clothing and equipment; free hepatitis B
immunization to workers with potential exposure to BBP; postexposure evalua-
tion and follow-up, including postexposure prophylaxis when appropriate; train-
ing in appropriate engineering controls and work practices
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In order to further reduce healthcare workers’ exposure to BBP, the BBP standard was amended in 2000, pursuant to the 2000 Needlestick Safety and Prevention
Act [48]. Additional requirements were imposed upon employers, whereby employers shall keep a sharp injury log. Employers’ exposure control plan shall be reviewed
annually to reect improvement of technology by considering and implementing
effective newer, safer, medical devices designed to reduce or eliminate exposure to
BBP.Employers shall also solicit input from nonmanagerial employees providing
direct patient care in the assessment and implementation of effective engineering
and work practice controls.
Among surgical personnel, sharp-tip suture needles are responsible for the
majority of percutaneous injuries, causing 51–77% of these exposures [6, 49, 50].
Suture needle injuries can occur at different stages of the surgery. Examples include,
but are not limited to, when team members pass needles hand to hand; when a needle is loaded or repositioned into the needle holder; when the surgeon/assistant is
sewing toward himself/herself while the other team member is holding back other
tissue; when a needle is left on the operative eld; when a needle is placed in overlled sharp containers; and when a needle is placed in poorly located sharps containers [51].
Suturing muscle and fascia frequently results in exposure injuries [49]. Blunt-tip
suture needles can be used to suture less dense tissue such as muscle and fascia and
have been shown to signicantly decrease the risk of percutaneous injuries to surgical personnel [5]. OSHA, National Institute for Occupational Safety and Health
(NIOSH), and the American College of Surgeons (ACS) currently recommend their
use when applicable [5, 52].
Other OR work practices that have been shown to decrease the risk of percutaneous injury include the use of double gloves. The ACS recommends the universal
adoption of the double glove technique, unless it may compromise the safe conduct
of the operation or the safety of the patient [52].
OSHA and the ACS also recommend the use of a neutral zone to transfer sharps
(except in situations where it may compromise the safe conduct of the operation). A
sharp neutral zone is dened as a towel or magnetic pad used for the pickup and
release of surgical sharps. This technique does not allow direct handling of instruments between team members [52].
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Conclusion
Exposure to blood-borne pathogens in healthcare settings is a potential serious risk
to all healthcare workers, especially surgeons. Prevention lies in applying standard
precautions including hand hygiene, use of protective barriers and safer equipment,
and appropriate use and disposal of needles and other sharp instruments. In the case
where an exposure incident occurs, prompt recognition is crucial to avoid unintended complications and costs. All healthcare institutions should have a system in
place with protocols that ensure early reporting, initiation of testing, and appropriate postexposure prophylaxis. In addition, it is important to assert the importance of
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