Managing exposures to blood and body fluids or substances

Exposures include sharps injuries (including needlestick) and splashes into or onto mucous membranes or non-intact skin.

Occupational hazards for healthcare workers from sharps injuries (including needlestick injury), and other blood or body fluid incidents include human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV).

Exposure is an injury or incident that involves direct skin contact with a body fluid or substance (listed below), where there is compromised skin integrity (such as an open wound, abrasion or dermatitis) or direct mucous membrane contact.

For exposure to skin, the larger the area of skin exposed and the longer the time of contact, the more important it is to verify that all the relevant skin area is intact.

Exposure to blood and body fluids or substances

The following body fluids pose a risk for bloodborne virus transmission:

• blood, serum, plasma and all biological fluids visibly contaminated with blood
• laboratory specimens that contain concentrated virus
• pleural, amniotic, pericardial, peritoneal, synovial and cerebrospinal fluids
• uterine/vaginal secretions or semen.

Exposures and infection control protocols

All health services must develop their own infection control protocols for communicable diseases. This includes clear written instructions on the appropriate action to take in the event of an exposure to blood or body fluids/substances, such as needlestick injuries and other blood or body fluid incidents involving either patients or healthcare workers. The protocol should include:

• the physician, medical officer or other suitably qualified professional to be contacted
• the laboratory that will process emergency specimens
• the pharmacy that stocks prophylactic medication
• procedures for investigating the circumstances of the incident and measures to prevent recurrence (this may include changes to work practices, changes to equipment and/or training)
• details for prompt reporting, evaluation, counselling, treatment and follow-up of occupational exposures to bloodborne viruses.

Exposures – immediate action

Treatment protocols should include removal of contaminated clothing and thorough washing of the injured area with soap and water. Affected mucous membranes should be flushed with large amounts of water. Eyes should be flushed gently.

The exposed person must report any occupational exposures immediately.

The exposed person should have a medical evaluation, including information about medications they are taking and underlying medical conditions or circumstances. Postexposure prophylaxis (PEP), non-occupational post-exposure prophylaxis (N-PEP) and counselling should be available and offered as appropriate. Treatment should be available during all working hours and on call after hours (for example, through an on-call infectious diseases physician).

Patients or others exposed to blood or other body fluids/substances must be informed of the exposure by a designated professional, while maintaining confidentiality about the source of the blood. Baseline serum should be collected from the patient and expert counselling provided on the implications of what has happened. PEP, N-PEP and appropriate long-term follow-up should be offered, where applicable. Patient or source refusal for testing and serum storage should be documented.

Document the incident and include:

• date, time and type of exposure
• how the incident occurred
• name of the source individual (if known).

Exposure incidents that do not occur in a health service should be reported to a general medical practitioner or the emergency department at the nearest hospital.

Post-exposure management of the source individual

The person whose blood or body fluids are the source of an occupational/non-occupational exposure or other injury should be evaluated for infection with HIV, HBV and HCV. Information available in the medical record or from the source person may suggest or rule out infection with each virus. If the source is known to have HIV infection, then information on stage of infection, and current and previous antiretroviral therapy should be gathered and used in deciding the most appropriate regimen of PEP.

If the HIV, HBV or HCV status of the source person is unknown, then the source person should be informed of the incident, and their consent sought to test for these viruses, with appropriate pre- and post-test counselling. Their consent to having the information in their patient record used should be also sought. If consent cannot be obtained – for example, if the patient is unconscious or unwilling to consent – then procedures should be followed that comply with legislation in Victoria.

The source individual should be tested for, as follows, at the time of injury:

• HIV antibody
• HBV surface antigen (HBsAg)
• HCV antibody.

If the HCV antibody test is positive, then HCV polymerase chain reaction (PCR) should be performed to test for HCV RNA. Transmission is much less likely to occur from a source who is PCR negative. The status of the source individual may be known at the time of the incident. In this case the affected person should be managed as described below under ‘Immediate management’. If the source is unknown, the case should be managed as described in ‘Management of the exposed person’.

Source individual unknown

Reasonable efforts should be made to identify the source. If the source remains unknown, appropriate follow-up should be determined on an individual basis depending on:

• the type of exposure
• the likelihood of the source being positive for a blood pathogen
• the prevalence of HIV, HBV and HCV in the community of the likely source on whom the instrument or needle was used.

Management of the exposed person

Immediate care of the exposure site

Contaminated clothing should be removed, and the injured area should be washed well with soap and water (an antiseptic could also be applied). Any affected mucous membranes should be flushed with large amounts of water. If the eyes are contaminated, they should be rinsed gently but thoroughly with water or normal saline, while kept open.

Evaluation of the exposure

The exposed person should be examined to confirm the nature of exposure and counselled about the possibility of transmission of bloodborne disease.

Evaluation and testing of the exposed person

The exposed person should have a medical evaluation, including information about medications they are taking, and underlying medical conditions or circumstances. All exposed people should be assessed to 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) vaccine
• Td booster.

The current edition of The Australian immunisation handbook should be consulted for further details.

The exposed person would normally be tested for HIV antibody, HCV antibody and antibody to HBsAg at the time of the injury, to establish their serostatus at the time of the exposure. Expert counselling on the implications of the event, PEP and appropriate long-term follow-up should be offered.

An option that may be offered to healthcare workers who do not wish to undergo testing at the time of the exposure is to have blood collected and stored but not tested. Blood that is collected and stored for this purpose must be retained for a minimum of 12 months.

If the source person is found to be HIV, HBV and HCV negative, no further follow-up of the exposed person is generally necessary, unless there is reason to suspect the source person is seroconverting to one of these viruses, or was a high risk of bloodborne viral infection at the time of the exposure. If the source is positive for one of these viruses, pregnancy testing should be offered to women of child-bearing age who have been exposed and whose pregnancy status is unknown.

Postexposure counselling

A specialist with knowledge of bloodborne infections should do the follow-up. If it is demonstrated that a person has been exposed to a bloodborne pathogen, they should not donate blood, semen, organs or tissue for 6 months, and should not share implements that may be contaminated with even a small amount of blood (for example, razors or toothbrushes).

For HIV and HBV, the exposed person should be informed of the risk of transmission to sexual and injecting partners for a 6-month period, and be counselled about issues of safe sex and safe injecting.

If PEP is indicated, or if there is a risk of acute infection with HIV, HCV or HBV, advice should be offered on pregnancy and breastfeeding based on an individual risk assessment. In the case of HIV, patients should be advised of the remote risk of seroconversion up to 12 months post-exposure, particularly if specific PEP was undertaken.

Follow-up for the exposed person

If the source person is seronegative for HIV, HBsAg and HCV, baseline testing or further follow-up of the healthcare worker is normally not necessary. If the source person has recently engaged in behaviours that are associated with a risk for transmission of these viruses, baseline and follow-up HIV-antibody testing of the healthcare worker should be considered.

Summary: management of exposure to blood and body fluids or substances

Table 1 summarises the management of exposures to blood, body fluids or body substances.

Table 1: Management of exposures to blood, body fluids or body substances.