200 - Protocol for
Employee Exposure to Blood/Blood Products: Needlestick
and Mucous Membrane
Contact
A. Definition of an exposure
Any Santa Cruz County employee who is
exposed to blood or blood products in any of
the following ways should report immediately to his/her supervisor for possible post-exposure evaluation:
1. A wound caused by a sharp object contaminated by blood or blood
products;
2.
A splash of blood or blood products onto an open wound or an area of
dermatitis (skin rash); or
3. Contact of blood
or other body fluids with mucous membranes such as the eyes, nose, or mouth.
B.
Employee/Supervisor Response
1.
The employee who has had a blood or blood product exposure in one of the
above ways should immediately contact his/her supervisor.
2. The Supervisor's First Report/Incident
Report or Employee Accident Report must be completed.
3. The
supervisor will contact one of the following persons, listed in descending order
of preference: the Medical Director-
Occupational Health at HSA, the Communicable Disease (CD) Nurse, or the CD
Program Manager if the incident occurred during a weekday. If the exposure
occurred at night, on a weekend or holiday, one of the above persons must be
contacted within 48 hours. The purpose of this step is to substantiate significant
exposure and proceed with post-exposure evaluation.
4. If the exposure occurs during a weekday, evaluation
will be performed at the direction of one of the above named HSA Occupational
Health or CD personnel. If the incident occurs after normal HSA hours, the supervisor
will advise the employee regarding at which medical facility care should be initiated,
with scheduled follow-up performed by the Medical Director - Occupational
Health.
5. If the blood/blood product source person is
known, voluntary testing of his/her blood should be requested and arranged by the
employee's department. If blood tests
are performed on the source person for hepatitis, informed consent is encouraged.
The Medical Director-Occupational Health or CD personnel can arrange for counseling.
If blood tests are performed on the source person for HIV (the virus presumed
to cause AIDS),pretest counseling and informed consent from the source person
must be obtained prior to drawing a blood sample for testing. The employee’s
department should perform HIV counseling for the source patient when
appropriate, or referred to the HSA AIDS Program for counseling and testing. The
Medical Director-occupational Health or CD personnel may request blood testing
on the source person.
6. If the
source person is in a detention setting, voluntary testing of his/her blood
should be requested and arranged through the Detention Nurse Program Manager and/or
the Detention Public Health Nurse. If the exposure is deemed significant on discussion
between the employee and the Medical Director
- Occupational Health, mechanisms exist to obtain court-ordered mandatory
HIV testing of refusing juveniles and adult inmates. The need for such testing
must be discussed with the Detention Nurse Program Manager, Detention Medical Director,
and/or the County Health Officer before the court-ordered process is pursued.
7. The exposed employee will be requested to
provide a blood sample for baseline testing. The Medical Director-Occupational
Health or CD personnel will request blood tests on the employee.
8. The employee's department will be billed for all tests.
C.
Evaluation/Treatment Guidelines
The major communicable
diseases of concern after a blood/ blood product exposure are: tetanus, HIV
Disease, and hepatitis B and Non-A, Non-B. If the exposure is felt to be significant
by the medical care provider, the following disease- specific guidelines should
be closely adhered to.
TETANUS
Employees who receive any scratch, cut, or puncture wound
shall get an adult tetanus/diphtheria booster, if indicated, as per the
guidelines of the American College of Surgeons.
HIV DISEASE
1. Employee/Supervisor Information
The employee should be reassured as to the very low
risk (less than 1%) of acquiring HIV Disease from exposure to the blood of an
infected person or through a used needle. The importance of follow up and adherence
to these guidelines should be stressed, however.
The Medical
Director - Occupational Health or CD personnel to a designated HSA HIV
counselor, shall refer each exposed employee.
The exposed
employee should be encouraged to be tested for HIV at time of the exposure. The
confidentiality of employee HIV testing will be ensured at all times.
2. Health Care Provider Information
The source person should be informed of the
incident and have voluntary confidential HIV testing after pretest counseling
is provided and informed consent is obtained. Written consent to release the
test result to the exposed employee and to the Medical Director -Occupational
Health, should also be obtained. This should be arranged by the employee's
department and billed to that department. HSA clients and jail inmates shall, for
the purposes of this protocol, be considered at high risk for HIV infection
unless an accurate history is obtained from the source person and it is subsequently
determined that the client falls into a low-risk category. In addition, a cut
or puncture wound from any used needle, with no identifiable sources, shall be
considered a high-risk exposure.
The following guidelines are adapted from CDC recommendations for
health care workers, and apply to other employee exposures (MMWR - August 21,
1987 and June 24, 1988).
a. No
further follow up of the exposed employee is needed if the source blood tests negative
and the source is determined to be in a low-risk category. However, at the
employee's request, the employee may be retested at 3 months.
b. If
the source person has AIDS, is positive for the HIV antibody, refuses the test,
or is sero negative but in a high-risk group, the employee should be counseled
regarding the risk of infection and evaluated clinically and serologically for
evidence of HIV infection as soon as possible after exposure. The employee should
be advised to report and seek medical evaluation for any acute febrile illness
that occurs within 12 weeks of the exposure. Such an illness, particularly one
characterized by a fever, rash, and/or lymphadenopathy, may be indicative of
recent HIV infection. If the employee
elected to be tested for HIV and was initially negative, he/she should be
retested at 6 weeks, 12 weeks, and 6 months post-exposure to determine if HIV
transmission has occurred. During the
follow-up period, especially in the first 12 weeks after exposure, the exposed
employee should follow recommendations for preventing transmission of HIV.
c. appropriate counseling and education
regarding HIV Disease should be provided to the employee. The employee may be
referred to HSA CD personnel who can provide the counseling.
d. Medical interventions, such as the
prophylactic use of AZT following an exposure, are currently controversial and
left to the discretion of the physician providing ongoing care to the exposed
employee. Consultation on the prophylactic use of AZT may be obtained from the Medical
Director Occupational Health.
HEPATITIS B AND NON-A, NON-B
1. Employee/Supervisor Information
There are
several types of viral hepatitis, but the two most important types transmitted
by exposure to infected blood are hepatitis B and Non-A, Non-B. The risk of
hepatitis B infection from a needle stick or splash onto mucous membranes is
between 6 and 30% if the source person is infected and is similar for Non-A Non-B
hepatitis. Post-exposure treatment may be effective in reducing this risk if
done in a timely manner. A hepatitis B vaccine is available which may help prevent
this infection in the exposed employee. If the source person can be identified,
then it should be determined whether or not the source is at high risk for
hepatitis B.
There is a blood test that can detect active
hepatitis B, but there is currently no test for Non-A, Non-B.
2. Health Care Provider Information
a. If the source person is known, informed
consent should be obtained to perform testing for the hepatitis B surface antigen
after it has been determined that the source is at high risk for hepatitis B
surface antigen positivity.
b.
Employee exposure risk may be determined by risk category of the site of
exposure or by history obtained from the source:
1. Low Risk Category
a) Children being seen at immunization clinics are generally low risks.
b)
Otherwise, to qualify
as a low risk source, the
client should clearly
and reliably not fall into a high risk category as judged by the
provider who is evaluating the exposure.
2. High Risk Category
a)
Most HSA, Sheriff's Office,
and detention facility clients should be considered high risks unless it can be
established with reasonable certainty that the client does not fall into the
high risk category.
b)
Hemodialysis patients, patients
from institutions for the mentally
ill or retarded, Southeast Asians, IV drug users, gay males,
hemophiliacs, or persons with a past history of "hepatitis" or
with signs or symptoms of hepatitis
should be considered high risk individuals.
c)
If the source person cannot be
identified, the exposure should be
considered a high risk one.
C. Depending on the exposure risk and the
immunization status of the employee, one of the following treatment protocols
should be closely followed:
1. Hepatitis Non-A, Non-B: If the health care provider
has reason to suspect exposure to Non- A, Non-B hepatitis, immune serum
globulin (ISG) should be administered
as soon after significant exposure as possible.
2. Hepatitis B
NOTE: Employees currently receiving the
hepatitis B vaccination series and employees who have completed the vaccination
series and have not yet had the adequacy of their anti-HBs titer documented, should not be considered immune.
a) Low risk source/exposed employee
vaccinated - test exposed employee for anti-HBs unless an adequate* titer has been
demonstrated within the last two years. If the level is adequate, no further
action is required. If the level is inadequate, complete the series or give a
booster dose as appropriate.
b) Low risk
source/exposed employee not vaccinated - initiate hepatitis
vaccination series.
c) High risk source/exposed employee vaccinated
- test source blood for HBSAG and test exposed employee for anti-HBS titer. If the
HBsAg status of the source blood cannot be determined within 72 hours of the
exposure, treat the exposed employee as
if the source blood is HBsAg positive and initiate therapy immediately.
_______________________________________________________________________
EXPOSED EMPLOYEE
ANTI-HBs ADEQUATE* EXPOSED EMPLOYEE ANTI-HBs INADEQUATE
SOURCE POSITIVE SOURCE NEGATIVE
No further action No further action
Give HBIG 0.6cc/kg Give booster dose of
vaccine at different body site
Give booster dose of
vaccine
* Adequate anti-HBs is
greater than or equal to 10 SRU by RIA or positive by EIA.
_______________________________________________________________________
d) High risk source/exposed employee not vaccinated- test source blood for
HBsAg. If the HBsAg status of the source blood cannot be determined
within 72 hours of the exposure, treat the exposed employee as if the source blood
is HBsAg positive and initiate therapy immediately.
If the source blood is HBsAg positive, give the
exposed employee HBIG 0.06cc/kg and initiate the hepatitis
vaccine series at a different body
site.
If the source blood is HBsAg
negative, initiate the hepatitis
vaccine series