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Healthcare workers are at risk for occupational exposure to bloodborne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Exposures occur through needlesticks or cuts from other sharp instruments contaminated with an infected patient’s blood or through contact of the eye, nose, mouth, or skin with a patient’s blood. Important factors that may determine the overall risk for occupational transmission of a bloodborne pathogen include the number of infected individuals in the patient population, the chance of becoming infected after a single blood contact from an infected patient, and the type and number of blood contacts.
Are healthcare workers at risk of getting HIV on the job?The risk of healthcare workers getting HIV on the job is very low, especially if they carefully follow universal precautions (i.e., using protective practices and personal protective equipment to prevent HIV and other blood-borne infections). It is important to remember that casual, everyday contact with an HIV-infected person does not expose healthcare workers or anyone else to HIV. For healthcare workers on the job, the main risk of HIV transmission is through accidental injuries from needles and other sharp instruments that may be contaminated with the virus. Even this risk is small, however. Scientists estimate that the risk of infection from a needle jab is less than 1 percent, a figure based on the findings of several studies of healthcare workers who received punctures from HIV-contaminated needles or were otherwise exposed to HIV-contaminated blood. |
Most exposures do not result in infection. Following a specific exposure, the risk of infection may vary with factors such as these:
Your employer should have in place a system for reporting exposures in order to quickly evaluate the risk of infection, inform you about treatments available to help prevent infection, monitor you for side effects of treatments, and to determine if infection occurs. This may involve testing your blood and that of the source patient and offering appropriate postexposure treatment.
Many needlesticks and other cuts can be prevented by using safer techniques (e.g., not recapping needles by hand), disposing of used needles in appropriate sharps disposal containers, and using medical devices with safety features designed to prevent injuries. Many exposures to the eyes, nose, mouth, or skin can be prevented by using appropriate barriers (e.g., gloves, eye and face protection, gowns) when contact with blood is expected.
No scientific evidence shows that using antiseptics or squeezing the wound will reduce the risk of transmission of a bloodborne pathogen. Using a caustic agent such as bleach is not recommended.
Report the exposure to the department (e.g., occupational health, infection control) responsible for managing exposures. Prompt reporting is essential because, in some cases, postexposure treatment may be recommended and it should be started as soon as possible. Discuss the possible risks of acquiring HBV, HCV, and HIV and the need for postexposure treatment with the provider managing your exposure.
You should have already received hepatitis B vaccine, which is extremely safe and effective in preventing HBV infection.
HBV
Healthcare workers who have received hepatitis B vaccine and have developed immunity to the virus are at virtually no risk for infection. For an unvaccinated person, the risk from a single needlestick or a cut exposure to HBV-infected blood ranges from 6-30% and depends on the hepatitis B e antigen (HBeAg) status of the source individual. Individuals who are both hepatitis B surface antigen (HBsAg) positive and HBeAg positive have more virus in their blood and are more likely to transmit HBV.
HCV
Based on limited studies, the risk for infection after a needlestick or cut exposure to HCV-infected blood is approximately 1.8%. The risk following a blood splash is unknown, but is believed to be very small; however, HCV infection from such an exposure has been reported.
HIV
HBV
The annual number of occupational infections has decreased sharply since hepatitis B vaccine became available in 1982 (i.e., there has been a 90% decrease in the number of estimated cases from 1985 to1996). Nonetheless, approximately 800 healthcare workers become infected with HBV each year following an occupational exposure.
HCV
There are no exact estimates on the number of healthcare workers occupationally infected with HCV. However, studies have shown that 1% of hospital healthcare workers have evidence of HCV infection (about 1.8% of the U.S. population has evidence of infection). The number of these workers who may have been infected through an occupational exposure is unknown.
HIV
As of December 1998, CDC had received reports of 54 documented cases and 134 possible cases of occupationally acquired HIV infection among healthcare workers in the United States since reporting began in 1985.
HBV
As mentioned above, hepatitis B vaccine has been available since 1982 to prevent HBV infection. All healthcare workers who have a reasonable chance of exposure to blood or body fluids should receive hepatitis B vaccine. Vaccination ideally should occur during the healthcare worker’s training period. Workers should be tested 1-2 months after the vaccine series to make sure that vaccination has provided immunity to HBV infection.
Hepatitis B immune globulin (HBIG) is effective in preventing HBV infection after an exposure. The decision to begin treatment is based on several factors, such as:
HCV
There is no vaccine against hepatitis C, and no treatment after an exposure that will prevent infection. Immune globulin is not recommended. For these reasons, following recommended infection control practices is imperative.
HIV
There is no vaccine against HIV. However, results from a small number of studies suggest that the use of zidovudine after certain occupational exposures may reduce the chance of HIV transmission.
Postexposure treatment is not recommended for all occupational expo-sures to HIV because most exposures do not lead to HIV infection and because the drugs used to prevent infection may have serious side effects. Taking these drugs for exposures that pose a lower risk for infection may not be worth the risk of the side effects. You should discuss the risks and side effects with a healthcare provider before starting postexposure treatment for HIV.
HBV–HCV–HIV
If the source individual cannot be identified or tested, decisions regarding follow-up should be based on the exposure risk and whether the source is likely to be a person who is infected with a bloodborne pathogen. Follow-up testing should be available to all workers who are concerned about possible infection through occupational exposure.
HBV
If you have not been vaccinated, then hepatitis B vaccination is recommended for any exposure regardless of the source person’s hepatitis B status. HBIG and/or hepatitis B vaccine may be recommended depending on your immunity to hepatitis B and the source person’s infection status.
HCV
Currently there is no recommended postexposure treatment that will prevent HCV infection.
HIV
The Public Health Service recommends a 4-week course of two drugs (zidovudine and lamivudine) for most HIV exposures, or zidovudine and lamivudine plus a protease inhibitor (indinavir or nelfinavir) for exposures that may pose a greater risk for transmitting HIV (such as those involving a larger volume of blood with a larger amount of HIV or a concern about drug-resistant HIV). Differences in side effects associated with the use of these two drugs may influence which drug is selected in a specific situation.
These recommendations are intended to provide guidance to clinicians and may be modified on a case-by-case basis. Determining which drugs and how many drugs to use or when to change a treatment regimen is largely a matter of judgement. Whenever possible, consulting an expert with experience in the use of antiviral drugs is advised, especially if a recommended drug is not available, if the source patient’s virus is likely to be resistant to one or more recommended drugs, or if the drugs are poorly tolerated.
HBV
Postexposure treatment should begin as soon as possible after exposure, preferably within 24 hours, and no later than 7 days.
HIV
Treatment should be started promptly, preferably within hours as opposed to days, after the exposure. Although animal studies suggest that treatment is not effective when started more than 24-36 hours after exposure, it is not known if this time frame is the same for humans. Starting treatment after a longer period (e.g., 1-2 weeks) may be considered for the highest risk exposures; even if HIV infection is not prevented, early treatment of initial HIV infection may lessen the severity of symptoms and delay the onset of AIDS.
HBV
Yes. Both hepatitis B vaccine and HBIG are approved for this use.
HIV
No. The FDA has approved these drugs for the treatment of existing HIV infection, but not as a treatment to prevent infection. However, physicians may prescribe any approved drug when, in their professional judgment, the use of the drug is warranted.
HBV
Hepatitis B vaccine is very safe. There is no information that the vaccine causes any chronic illnesses. Most illnesses reported after an HBV vaccination are often related to other causes and not the vaccine. However, you should report any unusual reaction after a hepatitis B vaccination to your healthcare provider.
HIV
All of the antiviral drugs for HIV have been associated with side effects. The most common side effects include upset stomach (nausea, vomiting, diarrhea), tiredness, or headache. The few serious side effects that have been reported in healthcare workers using combination postexposure treatment have included kidney stones, hepatitis, and suppressed blood cell production. Protease inhibitors (indinaivir and nefinavir) may interact with other medicines and cause serious side effects and should not be used in combination with certain other drugs, such as prescription antihistamines. It is important to tell the healthcare provider managing your exposure about any medications you are currently taking, if you need to take antiviral drugs for an HIV exposure.
HBV
Yes. Women who are pregnant or breast feeding can be vaccinated against HBV infection and/or get HBIG. Pregnant women who are exposed to blood should be vaccinated against HBV infection, because infection during pregnancy can cause severe illness in the mother and a chronic infection in the newborn. The vaccine does not harm the fetus.
HIV
Pregnancy should not rule out the use of postexposure treatment when it is warranted. If you are pregnant you should understand what is known and not known regarding the potential benefits and risks associated with the use of antiviral drugs in order to make an informed decision about treatment.
HBV
Because postexposure treatment is highly effective in preventing HBV infection, CDC does not recommend routine follow-up after treatment. However, any symptoms suggesting hepatitis (e.g., yellow eyes or skin, loss of appetite, nausea, vomiting, fever, stomach or joint pain, extreme tiredness) should be reported to your healthcare provider.
HCV
You should have an antibody test for hepatitis C virus and a liver enzyme test (alanine aminotransferase activity) as soon as possible after the exposure (baseline) and at 4-6 months after the exposure. Some clinicians may also recommend another test (HCV RNA) to detect HCV infection 4-6 weeks after the exposure. Report any symptoms suggesting hepatitis (mentioned above) to your healthcare provider.
HIV
You should be tested for HIV antibody as soon as possible after exposure (baseline) and periodically for at least 6 months after the exposure (e.g., at 6 weeks, 12 weeks, and 6 months).
If you take antiviral drugs for postexposure treatment, you should be checked for drug toxicity by having a complete blood count and kidney and liver function tests just before starting treatment and 2 weeks after starting treatment.
You should report any sudden or severe flu-like illness that occurs during the follow-up period, especially if it involves fever, rash, muscle aches, tiredness, malaise, or swollen glands. Any of these may suggest HIV infection, drug reaction, or other medical conditions.
You should contact the healthcare provider managing your exposure if you have any questions or problems during the follow-up period.
HBV
If you are exposed to HBV and receive postexposure treatment, it is unlikely that you will become infected and pass the infection on to others. No precautions are recommended.
HCV
Because the risk of becoming infected and passing the infection on to others after an exposure to HCV is low, no precautions are recommended.
HIV
During the follow-up period, especially the first 6-12 weeks when most infected persons are expected to show signs of infection, you should follow recommendations for preventing transmission of HIV. These include not donating blood, semen, or organs and not having sexual intercourse. If you choose to have sexual intercourse, using a condom consistently and correctly may reduce the risk of HIV transmission. In addition, women should consider not breast-feeding infants during the follow-up period to prevent exposing their infants to HIV in breast milk.
Are patients in a dentist’s or doctor’s office at risk of getting HIV?Although HIV transmission is possible in health care settings, it is extremely rare. Medical experts emphasize that the careful practice of infection control procedures, including universal precautions, protects patients as well as health care providers from possible HIV infection in medical and dental offices. In 1990, the CDC reported on an HIV-infected dentist in Florida who apparently infected some of his patients while doing dental work. Studies of viral DNA sequences linked the dentist to six of his patients who were also HIV-infected. The CDC has as yet been unable to establish how the transmission took place. Further studies of more than 22,000 patients of 63 health care providers who were HIV-infected have found no further evidence of transmission from provider to patient in health care settings. |