Management of Occupational Exposure
(Needlestick/Sharps and Muco-cutaneous Blood and Body Fluid Exposures)

Process

• Standard Precautions are used in the handling and disposal of blood and/or body fluids regardless of the patient’s perceived infectious status.
• Clinical staff, paid volunteers and students should report any exposure involving exposure to blood or body fluids, including needlesticks or cuts with contaminated sharp objects, splashes to the eye, mouth, nose or broken skin.  Broken skin includes cuts, abrasion, human bites, clenched fist injuries and skin conditions such as eczema and dermatitis.
• Staff/volunteers should receive appropriate risk assessment, blood testing and management following an exposure.
• Confidentiality of staff/volunteer/patient records must be maintained.

Definitions

• Exposed Person: the person exposed to blood and/or body fluid (e.g. clinical staff)
• Source: the person (e.g. patient) whose blood and/or body fluid was inoculated or splashed onto the exposed person.  The source may sometimes not be identifiable (e.g. when an exposed person has been injured by a needle/instrument and it is not known on whom it was used).
• Exposure: contact with blood or body fluids contaminated with blood.
• The following categories are used to assess the risk of exposure:
• Non Parenteral Exposure: Intact skin visibly contaminated with blood and/or body fluid.
• Doubtful Parenteral Exposure:
• Intradermal ("superficial") injury with a needle considered not to be contaminated with blood or body fluid.
• A superficial wound not associated with visible bleeding produced by an instrument considered not to be contaminated with blood and/or body fluid.
• Prior wound or skin lesion contaminated with a body fluid other than blood and with no trace of blood (e.g. urine).
• Mucous membrane or conjunctival contact with a body fluid other than blood.

The following exposures should be considerate high risk and appropriate care and follow-up provided

• Possible Parenteral Exposure
  • An injury with a needle contaminated with blood or body fluid.
  • A wound not associated with visible bleeding caused by an instrument contaminated with blood or body fluid.
  • Prior (not fresh) wound or skin lesion contaminated with blood or body fluid.
  • Mucous membrane or conjunctival contact with blood.
• Definite Parenteral Exposure
  • Skin penetrating injury with a needle contaminated with blood or body fluid.
  • Laceration or similar wound which causes bleeding and is produced by an instrument that is visibly contaminated with blood or body fluid.
  • In laboratory settings, any direct inoculation with human immunodeficiency virus (HIV) tissue or material likely to contain HIV, HBV or HCV not included above.
• Massive Exposure
  • Transfusion of blood.
  • Injection of large volume of blood/body fluids (>1ml).
  • Parenteral exposure to laboratory specimens containing high titre of virus.

Risk Assessment

Human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) may be transmitted by significant exposure to blood or other body substances, or by exposure to blood through contaminated needles or other sharp instruments which cause injury to the skin allowing potential exposure to blood-borne viruses.

Prospective studies of heath care workers occupationally exposed to HIV have estimated the average risk of HIV transmission after an exposure to HIV-infected blood is 0.3% (3 in 1000) and after mucous membrane exposures is 0.09% (9 in 10,000).  

The risk of HBV transmission from a person who is HBV surface antigen positive is approximately 6 – 30%, while the risk of transmission of HCV from a person who is HCV antibody positive is 1.8 – 10%.  The highest risk of transmission for any BBV is associated with:

• deep injury with a device visibly contaminated with blood;
• injuries associated with contaminated hollow bore needles;
• source patient with late stage HIV infection;
• source patient with HBV who is HBeAg positive;
• source patient with HCV who is HCV RNA PCR positive.

First Aid (Immediate)

• If the skin is penetrated, wash the exposed area well with soap and water (alcohol-based hand rub should be used if water is not available), and apply a waterproof sealed dressing.  Further management of wound will be dependent on nature of injury (e.g. suturing).
• If blood gets on the skin, irrespective of whether there are cuts or abrasions wash the area well with soap and water.
• If the eyes are contaminated, rinse gently but thoroughly with water or normal saline, while the eyes are open.  If contact lenses are worn, remove after flushing eye and clean as usual. If disposable contacts are worn, consider disposing based on risk assessment,
• If blood gets into the mouth, spit it out and then rinse the mouth with water several times.
• Remove any contaminated clothing.

Reporting and Recording

• Report all exposure incidents (no matter how trivial) to the Metropolitan Shift Area Manager or Country Regional Manager  immediately after the exposure incident
• Area Manager  will arrange immediate medical assessment with a local hospital/ED or GP for evaluation and risk assessment of all exposures as soon as possible.
• Country staff should proceed for assessment without delay and report to Regional Manager. 
• Complete an Incident Report Form available on Connect.
• Send all documentation related to the exposure (including blood test results and Workers Compensation Form) to your Manager in a sealed envelope marked ‘confidential’.

Regional Manager Responsibilities

• Provide clinical staff with an information pack (Incident Form, 2B Claim Form, Workers Compensation information).
• Maintain the confidentiality of the exposed person and provide all assistance where possible.
• Ensure the exposed person has initiated first aid treatment.
• Ensure  the exposed person has been referred for evaluation and risk assessment as soon as possible (within 24 hours).  
• Ensure the provision of peer support or counselling is provided.
• Document refusal by the exposed person to undergo risk assessment and evaluation.
• Make every effort to identify the source (e.g. patient) of the exposure. If the exposure is defined as massive, definite or possible exposure, contact the receiving hospital to conduct an assessment to determine the risk factors for hepatitis B, hepatitis C and HIV, (unless status of the source known at the time of the incident)
• In addition for Country staff exposed personnel to Make every effort to identify the source (e.g. patient) of the exposure. If the exposure is determined by the SOC CSP*  as massive, definite or possible exposure, CSP is to contact the receiving hospital to conduct an assessment to determine the risk factors for hepatitis B, hepatitis C and HIV, (unless status of the source known at the time of the incident). (* Where the Regional Manager cannot be contacted)
• It is the hospital’s responsibility to obtain consent for hepatitis and HIV testing if indicated, and provide pre-test counselling prior to collection of blood. 
• Further information, support and counselling are available from the Well Being and Support Services.

Management of Source by Nominated Service Provider

Obtain informed consent from the source to perform serology testing for HBV, HCV and HIV status.  If written or verbal consent is unable to be obtained then attempts should be made to obtain consent from next-of-kin.  In the event, consent cannot be obtained at the time of the incident, delayed testing of the source should be considered.

Ensure prompt reporting of BBV test results to the exposed person and to the source.

Source Negative for BBV

If the source is found to be HBV, HCV and HIV negative, further testing of the source is not required unless there is reason to suspect that the source is high risk for BBV infection.

Source Likely to be Positive for BBV

Where it is suspected that the source is in the window period for a BBV, the source should receive appropriate counselling and be asked to consent to follow-up at appropriate intervals (usually 6 weeks and 12 weeks) to ascertain whether or not they develop a BBV. Testing should include HIV antibody, HBsAg and HCV antibody.  Ensure HCV-RNA testing is ordered if the source is positive for antibody to HCV and HBeAg and HBV quantative PCR (or HBV DNA) if the source is positive for HBsAg.

Management of Exposed Person by Nominated Service Provider

Conduct a risk assessment and evaluation of the exposure that includes defining:

• the nature and extent of the injury;
• the nature of the object causing the exposure;
• the volume of blood or body fluid that the person was exposed to;
• the vaccination and immune status of the exposed person;
• the BBV status of the source; and
• the likelihood of an unidentified source being HBV, HCV or HIV positive.

Obtain informed consent with pre-test counselling from the exposed person to perform baseline serology to determine current HBV, HCV and HIV status.

If the incident involved non-parenteral or doubtful parenteral exposure, no further testing or examination is required other than the possibility of further counseling.  This should be determined according to the individual circumstances.  The opportunity can be taken to reinforce safe work practices. 

If the source is unknown, appropriate follow-up should be determined on an individual basis depending on:

• Type of exposure;
• Likelihood of source being positive for a blood-borne virus; and
• Prevalence of HIV, HBV and HCV in the setting in which the exposure occurs.

If the exposure involved massive, definite or possible parenteral exposure then arrangements for follow-up assessment of the exposed person should be made when the status of the source is confirmed:

Source Negative for HIV, HBV and HCV

When the source is confirmed negative for BBV, the exposed person should be offered follow-up serology testing at 3 months for reassurance. No behavioural or work practice modifications are required by the exposed person.

Source Unknown or Unable to be Tested

If after every effort has been made to ascertain the BBV status of the source or if the source remains unknown, the probable risk of the source being positive for a BBV must be inferred when considering management of the exposed person.  The probable risk of the source being positive and the risk to the exposed person must be assessed from epidemiological and historical information (i.e. type of exposure, probability that the vehicle was contaminated with blood/body fluids and the prevalence of HBV, HCV and HIV in the community from which the source came) and the exposed person treated as appropriate.

If it is considered there is a high risk of the source being infected with a BBV, then the exposed person is managed in accordance with the sections below relating of a source being positive for a BBV.

Source HBV Positive (Or Likely To Be Positive)

If the exposed person is immune to HBV, no further treatment or special precautions needs to be taken.

If the exposed person is not immune to HBV or is of unknown immune status, the schedule below should be followed:

Source Positive for HCV (or likely to be positive)

Currently there is no known treatment that can alter the likelihood of transmission of HCV.

If the source is found to be HCV RNA PCR positive, the exposed person should be referred to an Infectious Diseases Physician, Clinical Microbiologist or Hepatologist with expertise in managing HCV infection. 

If source HCV RNA positive, exposed person baseline and follow-up testing should include:

• HCV RNA PCR and ALT at 4, 8 and 12 weeks post exposure; and
  
• HCV antibody at 12 and 26 weeks.

Ongoing counselling and support of the exposed person must be continued for the duration of the post exposure follow-up.  Support and counselling must be extended to significant contacts of the exposed person.

Source Positive for HIV (or likely to be positive)

If the source is found to be HIV positive, then the exposed person must be referred immediately to a medical specialist with expertise in managing HIV infection for consideration of initiation of prophylactic treatment (HIV specialists are available on call 24 hours a day via Fremantle, Royal Perth, Fiona Stanley and Sir Charles Gairdner Hospital switchboards). 

Prevention of Other Potential Pathogens

Human bites and clenched fist injuries often become infected.  While there is the potential that other infectious diseases such as HBV, tetanus and to a lesser extent HIV, may be spread following a human bite, instances of this occurring have rarely been documented.

Thorough cleaning, debridement, elevation, immobilisation and prophylactic antibiotics is the recommended management for such injuries.

• Appropriate follow-up shall also determine the risk of tetanus.  Depending on the circumstances of the exposure, the following may need to be considered:
  
• Tetanus immunoglobulin;
  
• A course of adsorbed diphtheria tetanus vaccine – adult formulation (Td); or
• Td booster.