TABLE 3

Management of Potential Occupational Exposure to Bloodborne Pathogens

A written policy should be developed, available, and followed.
The definition of exposure that might place HCP at risk for hepatitis B, hepatitis C, or HIV infection is as follows: a percutaneous injury (eg, needlestick or cut with a sharp object) or contact of mucous membrane or nonintact skin (eg, exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious. Body fluids that are potentially infectious include those contaminated with visible blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid. Feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus are not considered potentially infectious for these pathogens unless they contain blood; the risk of transmission of these pathogens from these fluids and materials is extremely low.
The exposed employee should immediately follow these steps:
 • Wash needlestick site or cut with soap and water.
 • If splashes to the nose, mouth, or skin occur, flush involved area with water.
 • If splashes to the eye occur, irrigate eyes with clean water, saline, or sterile irrigants.
 • Report the incident to your supervisor and immediately seek medical treatment.
 • Document the type of injury including the involvement of blood, the source of the blood, and the extent of the injury (eg, deep injection, blood spill onto intact skin).
In all cases, the physician should do the following:
 1. Document the type of injury, including the involvement of blood.
 2. Identify the source patient, if possible, and make a judgment of the likelihood that the source patient may have HIV, hepatitis B, or hepatitis C infection.
 3. Determine if the source patient’s HIV, hepatitis B, and hepatitis C infection status is documented in the patient’s medical records.
 4. Have an established policy for the management of an exposure such as described below or an arrangement for immediate referral to a person or location with expertise in the management of such exposures, such as the emergency department of a specific hospital or the occupational health department of a large health care organization.
 5. Ensure follow-up for the potentially exposed employee.
 6. Ensure that all employees know how to access this policy.
Management includes the following steps:
 Step 1: Determine the infection status of the source patient. If this is not possible, base actions on the likelihood of exposure considering source of needle and type of exposure. If the source is known, obtain permission consistent with local statutes and determine the serologic status of the source for hepatitis B virus, hepatitis C virus, and HIV.
 Step 2: Determine the immunity of the employee. Was a hepatitis B vaccine received? Was the employee tested for antibody to HBsAg (anti-HBs)? If response to immunization is unknown, obtain blood to test for anti-HBs. Test for antibody to hepatitis C. Obtain consent and test for antibody to HIV.
 Step 3: Hepatitis B. Follow the steps outlined below for hepatitis B prophylaxis after percutaneous or permucosal exposure.
  A. If exposed person is unimmunized against hepatitis B:
   • Source HBsAg-positive: administer HBIG (0.06 mL/kg; maximum dose: 5 mL) intramuscularly and begin hepatitis B vaccine series
   • Source HBsAg-negative: begin hepatitis B vaccine series
   • Source not tested or unknown: begin hepatitis B vaccine series
  B. If exposed person was immunized and responded:
   • No treatment necessary
  C. If exposed person immunized but did not adequately respond (anti-HBs <10 mIU/mL)
   • Source HBsAg-positive: HBIG immediately and in 1 mo or HBIG and initiate reimmunization
   • Source HBsAg-negative: no treatment
   • Source not tested or unknown: if high-risk source, consider HBIG or HBIG and HBV reimmunization as for HBsAg-positive source
  D. If exposed person was immunized and not tested for a response or response is unknown
   • Source HBsAg-positive: test exposed for anti-HBs; if positive, no treatment; if negative, 1 dose of HBIG and 1 dose of vaccine, retest exposed for anti-HBs 4–6 mo later
 Step 4: Consider prophylaxis against HIV.64,65 Antiretroviral prophylaxis should be initiated as soon as possible within hours and not days after exposure. Thus, clinicians in ambulatory settings should be prepared to arrange for urgent consultation with a specialist in the management of HIV infection who will prescribe antiretrovirals and provide follow-up care of the employee. There are 2 postexposure HIV prophylaxis regimens: the “basic regimen,” a 4-wk course of 1 of several regimens containing 2 anti-HIV drugs and an “expanded regimen” containing 3 anti-HIV drugs for exposures with an increased risk of transmission.56 Updated information can be found at AIDSinfo (http://aidsinfo.nih.gov/) or the National HIV/AIDS Clinician’s Postexposure Prophylaxis Hotline at 1-888-448-4911. The PEPline provides consultation 24 h a day, 7 d a week for questions about managing occupational exposures to HIV, hepatitis B and C, and other bloodborne pathogens.
 Step 5: Use this opportunity to educate the exposed person regarding risks of exposure, safe handling of sharps, immunization, standard precautions, and safe work habits.
 Step 6: If the initial serologic test results for hepatitis C and HIV are negative, repeat these at 6 mo after potential exposure. Repeat serologic testing for hepatitis B (HBsAg and anti-HBs) at 6 mo if the exposed person was not previously documented to be anti-HBs–positive.
  • Adapted from Occupational Safety and Health Administration. Bloodborne pathogens and needlestick prevention: overview. Available at: www.osha.gov/SLTC/bloodbornepathogens/index.html. Accessed March 6, 2017. anti-HB, hepatitis B surface antibody; HBIG, hepatitis B immune globulin.