pep- dr rms

8/3/2019 PEP- dr RMS

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Who is at risk

What is the risk?

What practices may influence this risk and

how to minimize the risk? What is the role of HAART in reducing this

risk?

Issues about safety of PEP drugs and theiruse in pregnancy

Operational recommendations with 24houraccess to the needed drugs



Definitions Occupational exposure: exposure to potential blood borne infections(HIV,

HBV and HCV) that occurs during performance of job duties Non-occupational exposure: exposure to potential blood borne infections

outside of the work setting

Post Exposure Prophylaxsis(PEP): comprehensive management given tominimize the risk of infection following potential exposure (includingcounseling, risk assessment, relevant lab. Investigations, first aid, short

term retroviral drugs , follow up and support) Health Care Personnel(HCP) is defined as any person paid, or unpaid,

working in health care settings who are potentially exposed to infectiousmaterials (eg. Blood, tissue and specific body fluids and medical supplies,equipment, or environmental surfaces contaminated with thesesubstances)

Exposure:- a percutaneous injury (eg. Needle-stick or cut with sharp instrument)

- contact with mucuous membranes of the eye or mouth

- contact with non-intact skin(abraded, chapped or afflicted withdermatitis)

- contact with intact skin when the duration of contact is prolonged(eg. Several minutes or more)



Principles of providing PEP

Non-discrimination: based on clinicalconsideration of risk only. Providers shouldgive information, services and education

without discrimination Confidentiality: HIV testing, PEP provision and

reasons for seeking PEP all should be

confidential Informed consent: needs to be obtained in

written as per national counseling and testingguidelines



Who is at risk?

o Interns and medical students

o Nursing staff and students

o Physicians

o Surgeonso Emergency care providers

o Dentists

o Labour and delivery room personnel

o Laboratory technicians

o Health facility cleaning staff and clinical wastehandlers



Potentially infectious body fluids

Exposure to body fluids considered‘at risk’

Exposure to body fluids considered‘not at risk (unless these

secretions contain visible blood)

Blood Tears

Semen Sweat

Vaginal secretions Urine

Cerebrospinal fluid Faeces

Synovial, pleural, peritoneal,pericardial fluid

Saliva

Amniotic fluid

Other body fluids contaminated withvisible blood



.

Occupational Blood-borne ExposuresRelative Risk of Seroconversion with PercutanousInjury

0.3% 2%

30%

50%

0

10

20

30

40

50

S e r o c o n v e r s i o

n %

HIV HCV HBsAg+

HBeAg-

HBsAg+

HBeAg+

From: CDC. MMWR 2001;50 (RR11):1-42.



HIV transmission risk of different

routes

Exposure route HIV

Blood transfusion 90-95%

Perinatal 20-40%

Sexual intercouse 0.1-10%

Vaginal 0.05-0.1%

Anal 0.065-0.5%

Oral 0.005-0.01%

Injecting drugs use 0.67%

Needle stick exposure 0.3%

Mucous membrane splash to eye, oro-nasal 0.09%



Risky work practices

Recapping the needles (most important)

Transferring a body fluid between containers

Failing to dispose of used needles properly inpuncture-resistant sharps containers

Poor healthcare waste management practices



Prevention of exposure and

transmission

Staff information

Hospital infection control committee

Regular trainings on infection control and universalprecaution and PEP

Use of personal protective equipment Vaccination against hepatitis B and C

SOP in case of accidental exposure

Minimize the use of injections/sharps

All Hospital staff must know whom to report for PEP incase of occupational exposure



Step 1- management of exposed

site- First Aid

Summary of do’s and don’ts

**Do consult the designated physician immediatelyas per institutional guidelines for PEP

Do Do Not

Remove gloves if appropriate Do not panic

Wash the exposed site thoroughly withrunning water Do not put pricked finger in mouth

Irrigate with water or saline if eyes ormouth have been exposed

Do not squeeze the wound to bleed it

Wash the skin with soap and water Do not use bleach, chlorine, alcohol,betadine, iodine or otherantiseptics/detergents on the wound



Step 2- Establish eligibility forPEP

PEP must be initiated as soon as possiblewithin 2 hours

Category Definition and examples

Mild exposure Mucous membrane/non-intact skin with small volumes.Eg. Superficial wound (erosion of epidermis) with plain orlow caliber needle, or contact with eyes or mucousmembranes

Moderate exposure Mucous membranes/non-intact skin with large volumesOR percutaneous superficial exposure with solid needlesEg. A cut or needle stick injury penetrating gloves

Severe exposure Percutaneous with large volumeEg. An accident with a high caliber needle (>18G) visibly

contaminated with bloodA deep wound(haemorrhagic wound and /or very painful)Transmission of a significant volume of bloodAn accident with material that has previously been usedintravenously or intra-arterially



Step 2 – contd.,• Assessing the HIV status of the source of

exposure(PEP should not be delayed waitingfor the results; needs to be started within 72hours)

• Assessment of exposed individualCategories of situations depending on results of the

source:-Source of HIV status Definition of risk in source

HIV negative Source is not HIV infected but consider HBV and HCV

Low risk HIV positive and clinically asymptomatic

High risk HIV positive and clinically symptomaticUnknown Status of the patient is unknown, and neither the patient

nor his/her blood is available for testing(eg. Injuryduring medical waste management the source patientmight be unknown) The risk assessment will be basedonly upon the exposure (HIV prevalence in the

locality can be considered)



Step-3 counseling for PEP

Risk of acquiring HIV infection

PEP efficacy and side effects

Adherence to PEP

PEP and sexual intercourse, Pregnancy

Breast feeding to be stopped if on PEP

Risk of HBV and HCV - vaccinations



Step 4 – Prescribe PEP

Two types of regimens:

Basic regimen: 2-drug combination;

Expanded regimen: 3-drug combination

HIV post-exposure prophylaxis evaluation:-

Exposure Status of Source

HIV+ andasymptomatic

HIV+ and clinicallysymptomatic

HIV status unknown

Mild Consider 2-drug PEP Start 2-drug PEP Usually no PEP orconsider 2-drug PEP

Moderate Start 2-drug PEP Start 3-drug PEP Usually no PEP orconsider 2-drug PEP

Severe Start 3-drug PEP Start 3-drug PEP Usually no PEP or

consider 2-drug PEP



Step 4 –Prescribe PEP

Greatest effect if begun within 2 hours

Little benefit if >72hours later of exposure

PEP regimens:-

Preferred Alternative

2-drugregimen(basic PEPregimen)

1st choice: Zidovudine(AZT)+Lamivudine(3TC)

2nd choice: Stavudine(d4T)+Lamivudine(3TC)

3-drugregimen(expandedPEP regimen)

Consult expert opinion starting 3rd drug eg.LPV/r,NLF or IND

Not recommended ddI+d4T combination; NNRTI such as Nevirapine should notbe used in PEP



COST OF PEP

BASIC REGIMEN:

A) ZDV(300mg) + 3TC (150mg) Cipla- Duovir- Rs. 274/ 10 tabs Zydus Bigeri-Lamuzid- Rs. 470/ 10 tabs Immunus Aurobindo-Zidovex L- Rs. 280 / 10 tabs

B) d4T(40 mg) + 3TC(150mg):Immunus Aurobindo

- Rs. 1020/ mth

FOR EXPANDED REGIMEN: Indinavir(400mg)-Immunus Aurobindo-Indivex- Rs.

1200 / 10 tabs Nelfinvair(250mg)-Immunus Aurobindo- Nelvex-

Rs. 3600 / 90 tabs

Efavirenz(200mg)-Immuno Aurobindo-Viranz- Rs.3600 / 90 tabs



Tolerability of HIV PEP in HCWs

57

38

18

16

14

6

0 20 40 60 80 100

Percent

Nausea

Fatigue

Headache

Vomiting

Diarrhea

Myalgias

Adverse Effects of PEP Regimens



Step 5 – Laboratory evaluation

Do not delay PEP if HIV testing is not available

Recommended baseline laboratory evaluation:-

HIV, HBV,HCV testing of exposed staff within 8 days of AEB(Accidental Exposure to Blood) is required (baseline serostatus).Offer an HIV test in case of AEB, as a positive HIV may indicate theneed to disontinue PEP

Timing In persons taking

PEP(standard regimen)

In persons not taking PEP

Baseline (within 8days after AEB)

HIV,HCV, anti-HBs,complete blood count,transaminases

HIV,HCV, anti-HBs



Step 6- Follow up of an exposed

person

Clinical follow up

Laboratory follow up

Recommended follow-up Laboratory tests:

Timing In persons taking PEP(standard regimen)

In persons not takingPEP

Weeks 2 and 4 Transaminases, completeblood count

Clinical monitoring forhepatitis

Week 6 HIV-Ab HIV-AbMonth 3 HIV-Ab, anti HCV. HBsAg,

TransaminasesHIV-Ab, anti HCV, HBsAg

Month 6 HIV-Ab, anti HCV, HBsAg,Transaminases

HIV-Ab, anti HCV, HBsAg

ccess an va a y o n



ccess an va a y o ntertiary care hospital and medicalcollege

Designated Team: Infection control officer,Physician, Casualty Medical Officer, ART NodalOfficer (reference person for PEP)

Minimum drug stock of PEP exposure-responsekits: 3 kits of 7 days supply ie FDC(AZT/3TC)

2tabs/day x 7 days x 3 kits = 42 tabs



What are UniversalPrecautions?

Universal precaution are controlguidelines designed to protect workers

from exposure to Diseases spread by

Blood and other Body fluids.

CDC



Cardinal rules of Universalprecautions

Consider all patients potentially infectious

Assume all blood ,body fluids and tissue are

contaminated with a blood borne pathogen Assume all unsterile needles and other sharps

are similarly contaminated



Components of Standard

Universal Precautions

Personal Protective

Equipment

Biohazard Labeling

Waste Management Post Exposure

Management



HAND WASHING

There is no Health precaution like Handwashing.

Washing with simple toilet soap - reduces the

rate of transmission of common infectionsincluding the HIV.



How to Wash our hands

T f PPE U d i H lth



Types of PPE Used in HealthcareSettings

Gloves – protect hands

Gowns/aprons – protect skin and/or clothing

Masks and respirators – protect mouth/nose – Respirators – protect respiratory tract from

airborne infectious agents

Goggles – protect eyes

Face shields – protect face, mouth, nose,and eyes



What type of PPE would you wear?

Transporting patientin a wheelchair?

Responding to an

emergency whereblood is spurting?

Drawing blood from avein?

Cleaning anincontinent patientwith diarrhea?

Taking vital signs?

Generally noneneeded

Gowns, gloves,

goggles/face shield,mask

Gloves

Gloves with orwithout gown

Generally noneneeded

30



Use of Gloves

Use of a pair of

disposable plasticgloves can protect ifchances of contactwith Blood or Body

fluid isanticipated/inevitable.



Personal Protective Equipment



Biohazard label



Major categories of waste

Non infectiouswaste

Domestic waste

kitchen waste

Papers/wrappers

Ampoules /vials

IV bottles

Infectious waste

Sharps

Plastic

Non-plastic



Color Coding For Segregation OfHospital Waste

Yellow –Infective waste

Red- infected and contaminated plastics

Blue or transparent white- Sharps

Green/black- Non infectious waste



Segregation of hospital waste

Anatomical and

soiled waste

Human tissue

Soiled dressing

Microbiological waste

Surgical waste

Discarded specimens

YELLOW

http://images.google.co.in/imgres?imgurl=http://www.bio-waste.com/images/BY.jpg&imgrefurl=http://www.bio-waste.com/segre_storage.html&h=85&w=91&sz=8&hl=en&start=21&tbnid=qTa8_3-4KnFBAM:&tbnh=74&tbnw=79&prev=/images?q=waste+segregation+yellow+bags&start=20&gbv=2&ndsp=20&hl=en&sa=N



Segregation of hospital waste-

BLUE

All infected sharpobjects

Needles

Blades/saws

Glass ampoules

slides

Suture needles

Scalpels

http://images.google.co.in/imgres?imgurl=http://www.bio-waste.com/images/BL.jpg&imgrefurl=http://www.bio-waste.com/segre_storage.html&h=85&w=91&sz=8&hl=en&start=12&tbnid=Vs_LDhiBBEGAAM:&tbnh=74&tbnw=79&prev=/images?q=waste+segregation+blue+bag&gbv=2&hl=en



Disposal methods of segregatedwaste

Segregatedwaste in colorcoded bags

Disposal methods ofsegregated waste

Yellow Incineration or deep burial

Red Autoclaving /chemicaltreatment

Blue/white Autoclaving /chemicaltreatment/shredding

Black Disposal in secure landfill

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