Compiled by Archana Kher, Sandeep B. Bavdekar
for Pediatric HIV/AIDS, First National Conference (Held on 3^rd & 4^th November, 2001 at Delhi) Introduction

Medical professionals (MP) are at a greater risk of acquiring certain illnesses by virtue of their profession. These could include infections from patients and/ or specimens. The infections that can be acquired include those caused by bacterial, viral, parasitic or fungal species. Some of these infections are serious e.g. plague, hepatitis and HIV to name a few. These are potentially life- threatening infections. There are others that are not so serious but can cause significant morbidity. We will discuss the susceptibility of MPs to develop HIV infection. They can acquire HIV infection from a patient, fomite, contaminated environment or patient specimens either by direct contact [(only if there is contact with blood/ body fluids of patient), accidental inoculation of infected blood/ body fluids; accidental cuts with contaminated sharps] or through indirect contact with contaminated equipment or any other inanimate infected object.

It is important that all specimens, patients and clients are presumed to be infected and handled accordingly. This is because the correct HIV status of an individual can be determined only on the basis of laboratory tests. It is not feasible and not even legal, ethical or cost- effective to determine HIV- status of every individual entering a health care facility prior to attending to him. In addition, there are circumstances in which the tests give a false negative result. That is, the test can come negative in an infected individual. Considering these facts, it is prudent that MPs take all the possible precautions to ensure that they do not acquire infection through their professional work. It is, therefore, advisable that they practice "universal work precautions (U.W.P.)" at all times while providing medical care services in all kinds of health practices for all patients and all specimens. All persons who provide direct or indirect health care to people (e.g. nurses, midwives, community health workers, hospitals Housekeepers and doctors); handle samples of body fluids/tissues (Lab. Technicians, pathologists etc.); handle infected waste; transport potentially infected specimens and handle dead body/embalm dead bodies/perform autopsy are Health Care Workers (HCW) and should be aware of and practice these precautions. Infections Associated With Exposure To Contaminated Blood/Body Fluids

HCWs are at a higher risk of acquiring infections due to HBV, HIV and viral haemorrhagic fever agents (Lassa, Ebola etc.) due either to higher infectivity of the agent or higher prevalence of the infection. The transmission of these agents to HCWs has been much reduced since after the institutions of HBV vaccine and universal work precautions. The other infections are much less common. The micro- organisms that can be transmitted through blood and body fluids include viral hepatitis ( HBV, HCV, HDV and HGV; HIV, HTLV I and HTLV II), viral haemorrhagic fever viruses, Epstein-Barr virus, brucellosis, malaria, salmonellosis and rarely others. Risk Factors For Occupational Infection In Health Cate Workers

The amount of risk an individual HCW faces while providing services will depend on various parameters given below:

Frequency of occupational exposure: I) Contact with blood or bloody body fluids; ii) Accidental needle stick/ sharp instrument injuries

Occupational area in the hospital: i)Hemodialysis unit; ii) Pathology, Microbiology; iii) Surgery; iv) surgical intensive care; v) Emergency Room; vi) Blood bank; vii) Clinical laboratory; viii) Intravenous teams; ix) Dentistry, oral surgery; x) Gynecology and Obstetrics; xi) Geographic location of health care institution; xii) Urban versus rural

Patient Population: i) Hemodialysis patients; ii) Intravenous drug abusers; iii) Homosexual men; iv) Prison inmates; v) Developmentally disabled; vi) Immigrants from highly endemic areas.

Risk Procedures

Some of the medical procedures carry a greater risk of transmission of infections from patients to HCWs. These are: i)Specific examination procedures such as per- rectal (PR) or per- vaginal (PV) examination; ii) Invasive diagnostic & therapeutic procedures; iii) Wound dressing; iv) Operation theatre procedures; v) Various ward activities; vii) Handling of blood/ serum/ body fluids & tissues; viii) Cleaning of hospital/clinic & disposal of waste; ix) Faulty sterilization; x) Laundry; C.S.S.D. & kitchen incorrect procedures; xi) Post mortem/ embalming.

Magnitude of Risk to Health- Care Workers

Prospective studies demonstrate that risk of developing HIV infection per episode of percutaneous exposure to infected blood is approximately 0.3% (i.e. 1 per 300 exposures) and that after a mucocutaneous exposure is 0.05%. In contrast, the risk of acquiring HBV infection is much higher and is estimated to be 9-30% and that for HCV it is 3-10%. The risk depends on prevalence of infected individuals in the population. Other factors that determine the magnitude of risk include:I) Frequency of exposure to contaminated sharps etc.; ii) Relative infectivity of the virus; iii) Concentration of the virus in the blood; iv) Deep needle stick injury with inoculation of blood; v) Source patient who has AIDS or died within 60 days after the exposure occurred.

The following materials have been found to be infectious and thus require precautions in handling:
Blood
Blood is the single most important source of transmission of HIV, HBV and other blood- borne infections to HCWs. This risk is also dependent upon other factors, such as: i)Type of exposure (exposure of intact skin, non- intact skin, mucous membrane or needle stick injury); ii) The amount of blood involved in the exposure; iii) Hollow bore needles and canula may carry more blood than needles used for intramuscular injections; iv) The amount of virus in patient's blood at the time of ; exposure (Viral load); v) Prevalence of infection in the population; vi) Number of exposures in case of needle- stick injuries ; vii) Timely availability and use of post- exposure prophylaxis (PEP).
Semen and vaginal secretions
Although semen and vaginal secretions have been implicated in sexual transmission of HIV and HBV they have not been implicated in occupational transmission to HCWs, since chances of exposure to such infectious materials in health care setting are limited.
Cerebrospinal Fluid (CSF), Synovial fluid, Pleural fluid, Peritoneal fluid, Pericardial fluid and Aminotic fluid
HIV has been isolated from CSF, synovial and amniotic fluid and HBsAg has been detected in the synovial fluid, amniotic fluid and peritoneal fluid. Documentation in implicating these fluids in transmission of HIV and HBV in health care setting is uncertain. Feces, nasal secretions, sputum, sweat, tear, urine and vomitus do not require precaution, unless they are contaminated with blood:
Breastmilk
Human breastmilk has been implicated in the perinatal transmission of HIV infection, HbsAg has been found in the breastmilk of mothers infected with HBV. However, acquisition of infection following occupational exposure to human breastmilk has not been documented. Moreover, the HCW will not have the same type of intensive exposure to breastmilk as the nursing neonate. Nevertheless, gloves should be worn by HCWs working in the Breastmilk Bank.

Biosafety practices In a Health Care Setting include: i) Practice of universal work precautions at all time while providing services; ii) Effective disinfection and sterilization; iii) Safe disposal of hospital waste; iv) Immunization against HBV

Universal Work Precautions (UWP)

UWP are certain protective measures to be practiced by all the HCWs at all times while providing professional services. They are mainly directed at blood & body fluids & tissues to minimize the risk of HIV/HBV transmission.

Protective measures properly applied will prevent occurrence of accidental exposure & transmission of infection, control surface contamination, ensure safe disposal of contaminated waste.

Components of UWP(General blood & body fluid precautions)
These include I) Hand washing; ii) Careful handling of sharps; iii) Safe techniques; iv) Sterilization; v) Disinfection; vi) Disposal of disposables/ reusable materials: as appropriate; vii) Adherence to correct hospital sterilization & disinfection protocols; viii) Use of personal barrier precautions (gloves, masks, gowns/ aprons, protective eyewear, foot cover); ix) Immunization against HBV.

Occupational Exposure This include i) Contact with known HIV/HVB infected material resulting from; ii) Percutaneous inoculation (Needle stick, cut with a sharp etc.); iii) Contamination of an open wound; iv) Contamination of breached skin (chaped, abraded, dermatitis); v) Contamination of a mucous membrane including conjunctiva.

Post Exposure Management

First aid

Allow to bleed and wash with water
Minor bleed with percutaneous inoculation, open skin wound, breached skin, wound.

Apply antiseptic
Breached skin, exposed mucous membranes

Report
Employee identification, date, time & place of accident, circumstances around accident, action taken

Initial consultation
Easy access to medical advice & counseling

Laboratory testing
After consent & counseling within 2 weeks, 6 weeks, 12 weeks, 24 weeks and 1 year

Clinical follow up
For fever, pharyngitis, rash, Malaise, lymphadenopathy, myalgia, arthralgia within 7 months.
If the HCW tests negative 1 year after the accident means that the HCW is not infected.

Post Exposure Prophylaxis

This should begin as per the recommendations of NACO.

Spills and accidents
Recommendations are: i) Wear gloves throughout; ii) Cover spill with an absorbent material. Pour disinfectant around the spill and over the absorbent material. Leave it in place for 30 minutes. Clean the area with spillage with absorbent material and place them in a contaminated waste container; iii) Wipe the surface again with disinfectant; iv) Sweep broken glass etc. with a brush into the waste container; v) Needle stick injuries, puncture wounds, cuts, open skin contaminated by spills or splashes should be washed with soap and water; vi) Encourage bleeding from the wound; vii) Report all spills/accidents to the supervisor; vii) Keep a written record of all such accidents; viii) Appropriate medical evaluation, surveillance, treatment and counseling should be provided.

Serological laboratories
Recommendations are: i) Clearly identified adequate area should be provided either separately or within the laboratory; ii) Bio-safety cabinets are not required for serology of HIV; iii) Protective clothing, shield and glasses to be used to protect eyes and face; iv) Bench tops should be impervious and resistant to disinfectants; v) Walls, ceiling & floor should be smooth, easy to clean & impermeable & resistant to disinfectants; vi) Each Laboratory should be provided with washbasins near the exit; vii) Doors should be self- closing; viii) Autoclave, waste boxes and incinerator should be available on premises; ix) There should be separate space earmarked for activities like eating, drinking, dressing & smoking.

Transport of specimen by public conveyance
Recommendations are: i) Transport in leak proof, properly sealed labeled containers in upright position; ii) Wrap primary container in enough absorbent material; iii) Primary container is placed in the secondary container, which should be strong enough to withstand physical damage in transit; iv) Make arrangements for dispatch and collection in advance; v) Specimen data forms, letters and other relevant information are taped on the outside of secondary container; vi) National/ international shipping regulations are to be observed.

Sterilization and disinfection
Sterilization can be done by autoclaving at 121 0C for 20 minutes at 15 lbs pressure or Dry heat - 170 0C for 1 hour (holding time) or boiling for 20- 30 minutes.

Chemical disinfectants are sodium hypochlorite 1 gm/L, calcium hypochlorite 1.4 gm/L, Chloramine 20 gm/ L (available chlorine 0.1% chloramine most stable of above 3), ethanol 70%, polyvidone iodine (PVI), formaline: 3-4%, glutaraldehyde 2% for 30 minutes

Sterilization is a process that destroys all micro- organisms (bacterial, viral, parasitic and fungal) including the resistant spore forms. Dry and moist heat, certain gases and chemicals are used for sterilization.

Disinfection is the process that destroys the infectious micro- organisms. High- level disinfection destroys all pathogenic organizes and most of other micro- organisms but spores may survive. Intermediate & low- level disinfection destroy the pathogenic organisms. Decontamination is same as low- level of disinfection. This process gets rid of visible contamination of surfaces and equipments.

Safe Disposal Of Hospital Wastes

Hospital wastes are potential hazards. Infectious waste can transmit numerous diseases in the community and put those who handle waste or live in its proximity, at risk. Besides, the increasing use of disposables in health care is also posing an additional burden on the waste management facilities. It is extremely important that the recycling of these items is prevented. Only a small percentage (<10%) of the wastes generated in health care settings are infectious while another 55% is non-infectious but hazardous. The most practical approach to the management of biomedical waste is to identify and segregate infectious waste (with a potential for causing infection during handling and disposal), for which some special precautions appear prudent. This will drastically reduce the cost of the disposal methods in health care settings.

Setting up of biomedical waste facility

Every hospital, nursing home, veterinary institution, animal-house, blood banks, research institutes generating biomedical waste should install an appropriate biomedical waste disposal facility in the premises or should set up a common facility in accordance with the directions given by the appropriate authority. Biomedical waste should not be generated without authorization. Every hospital should have a waste management program. Waste survey is an important part of the waste management program and helps in determining both the type and quantity of waste being generated in the hospital including the laboratory and determines the feasible methods of disposal.

Containing waste at generation point

The waste is managed at the generation site by Collection, Segregation and weighing, Storage. Waste segregation is the key to any waste management scheme. It consists of placing different types of waste in different containers or color-coded-bags at the site of generation. This helps in reducing the bulk of infectious waste and contains the spread of infection to general waste. This practice reduces the total treatment cost, the impact of waste in the community and the risk of infecting workers. Proper segregation should identify waste according to source and type of disposal/disinfection.

Segregate the waste at source into: i) Solid noninfectious household type waste e.g. paper, fruit peels etc.: These are disposed off in the routine dustbin/ black bags. The final disposal is into the MCD bin. ii) Infected sharp waste disposable (e.g. disposable syringes-needles and others sharps): These are placed in a puncture resistant container containing 0.1-0.5% bleach solution. The container should be placed near the activity place. iii) Infected non- sharp disposable waste (e.g. catheters, gloves etc.): They are placed in a container containing 0.1- 0.5% bleach. iv) Infected reusable instruments such as endoscopes and speculum: These are placed in a container containing 2% glutaradehyde for 30 minutes. Wash and autoclave or place them in 2% glutaraldehyde solution for 6- 8 hours as per the specifications of the instrument for sterilization. v) Swabs: They should be chemically disinfected and then sent for incineration. vi) Disposable items include single use products (syringes, gloves, sharps etc.) - As these items are often recycled and have the risk of being reused illegally, these should be disinfected by dipping in freshly prepared 1% sodium hypochlorite for 30 minutes to 1 hour. Bins, which can be used for this purpose, are a set of twin bins, one inside the other with the inner one being perforated and easily extractable. This minimizes contact when the contents are being removed. Vii) Disposable items like gloves, syringes etc. should be shredded, cut or mutilated before disposal followed by deep burial and properly accounted for before disposal. Extreme care should be taken while handling the needles.

Liquid wastes generated are either pathological or chemical in nature and are disposed of as follows: I) Non-infectious chemical waste should first be neutralized with reagents and then flushed into conventional sewer system; ii) The liquid infectious waste should be treated with a chemical disinfectant for decontamination then neutralized and flushed into the sewer; iii) Solid wastes are collected either in leak-resistant single heavy- duty bags or double bags. It is recommended that bags having different color codes with red labels mentioning the date and details of waste are used. The bags are tied tightly after they are three-fourths full.

Packing, storage and transport of waste

All segregated and disinfected waste should be packed in proper containers and color coded bags with red labels mentioning details of biomedical waste and biohazard sign. All containers used for storage of such waste should be provided with a proper lid.

It is important that i) Such containers should be inaccessible to scavengers and protected from insects, birds, animals & rain; ii) There should not be any spillage during handling and transport of such waste; iii) The sharp waste after pre-treatment should be broken before placing in the container; iv) The waste should be transported in vehicles authorized for this purpose only; v) Waste should not be stored in the place where it is generated for a period of more than two days.

Disposal may be done by i) Muncipal Corporation; ii) Sanitary landfill; iii) If incinerator is not available, deep burial in controlled landfill sites is recommended. Decontamination should be carried out before burial; iv) Incineration (Temp. 7500C) Incinerator-burns/reduces the infectious waste to ashes and therefore is favoured by hospitals. It may be of two types - common or individual. There are some disadvantages like pollution/incomplete melting of needles. Hospitals with more than 30 beds or >1000 patients per month should have an incinerator. Plastics cannot be incinerated.

Implementation of biosafety practices

The Guidelines regarding universal precautions and other biosafety practices are available since long. However, they have not been strictly implemented in the health care setting in India even in the capital city. With increase in the prevalence of HIV infection, there is a definite need that the HCWs take biosafety practices seriously. For effective compliance, the hospital managers should ensure an adequate supply of personal protective equipments, availability of materials for hand washing and disinfection and set up an effective waste disposal program for the disposal of biomedical waste in a safe manner that will satisfy the statutory requirements. All HCWs should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when in contact with blood, body fluids containing visible blood, and other body fluids to which universal precautions apply. The type of protective barrier (s) should be appropriate to the procedure being performed and the type of exposure anticipated.

The gloves should be worn for touching blood and body fluids, mucous membranes, or non-intact skin of all patients, for handling items or surfaces soiled with blood or body fluids, and for performing venipuncture and other vascular access procedures. They should be changed after contact with each patient. Masks and protective eyewear or face shields should be worn during procedures that are likely to generate droplets or splashes of blood or other body fluids in order to prevent exposure of mucous membranes of the mouth, nose and eyes to these splashes. Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or other body fluids. Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood, body fluids containing visible blood, and other body fluids to which universal precautions apply. Hands should also be washed immediately after the gloves are removed.

Steps of effective hand washing

These are i) Wash palms and fingers and then the back of the hands; ii) Wash fingers and knuckles Wash thumbs; iii) Wash fingertips; iv) Wash wrists.

All HCWs should take precautions to prevent injuries caused by needles, scalpels and other sharp instruments or devices. Care should be taken during the procedures, while cleaning used instruments, during disposal of used needles and while handling sharp instruments after procedures. To prevent needle- stick injuries, needles should never be recapped, bent or broken by hand, removed from disposable syringes or otherwise manipulated by hand. After use, disposable syringes and needles, scalpel blades, and other sharp items should be placed in puncture-resistant containers to be used for disposal. The puncture- resistant containers should be located as close as is practical to the use area, preferably in each patient room.

There has been one possible case in which saliva has been implicated in HIV transmission. Therefore, the need for emergency mouth- to- mouth resuscitation should be minimized. Mouthpieces, resuscitation bags, or other ventilation devices should be available for use in areas in which the need for resuscitation is predictable. Disposable airway equipment and devices should be used. Use once and dispose.

HCWs with exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient care equipment until the condition resolves. Pregnant HCWs are not known to be at greater risk of contracting HIV infection than non- pregnant HCW. However, if an HCW develops HIV infection during or just prior to pregnancy, the infant is at risk of contracting infection due to perinatal transmission. Because of this risk, pregnant HCW should be familiarize herself with and strictly adhere to precautions to minimize the risk of HIV transmission.

Use of protective barriers

Whenever exposure to blood/ other potentially infected fluid is anticipated, protective barrier must be used.

1. Latex or vinyl gloves must be worn while carrying out any procedure and be decontaminated after each use. Gloves with holes should not be used. Double gloves are not preferred as the practice of wearing them is not more protective than that of single glove the former practice may be clumsier, as well. Heavy-duty rubber gloves are used while cleaning instruments, handling soiled linen and spills of blood/ body fluids. These can be washed & reused.
2. Gloves & aprons protect one from splashes of blood or body fluids e.g. during surgery and delivery. One may wear a waterproof gown or a sterile cloth with a plastic apron underneath. Protective eyewear may be used to prevent splashrs of fluids from coming in direct contact with the mucous membrane.
3. Safe handing of sharps: i) Careful handling of hollow bore needles is very essential, as they can cause deep injuries; ii) The needles should not be recapped. In situations where recapping is essential, use single hand method; iii) Needle should not be left on trolleys & beds. They must be safely disposed off immediately; iv) Never pass used sharps from one person to another directly; v) Use forceps instead of fingers for guiding sutures.; vi) The sharps should be disposed off in a puncture resistant container.

What should I do if I am exposed to the blood of a patient?

Immediately following an exposure to blood: Needle-stick injuries and cuts should be washed with soap and water; Splashes to the nose, mouth or skin, should be flushed with water; Eyes should be irrigated with clean water, saline or sterile irrigants; Do not put the pricked finger in mouth reflexly.

No scientific evidence shows that the use of antiseptic agents for wound care or squeezing the wound will reduce the risk of transmission of HIV. The use of a caustic agent such as bleach is not recommended.

Report the exposure to the appropriate authority and condition must be treated as an emergency. Prompt reporting is essential because in some cases, HIV post- exposure prophylaxis [PEP] may be recommended. If indicated it should be started as soon as possible, preferably within 2 hours. Based on animal models, the PEP therapy is of maximal benefit when started within a matter of hours after the exposure. Although perhaps not as effective as prophylaxis, late PEP (after 72 hours) may still be useful as early treatment.

Is PEP recommended for all types of occupational exposures to HIV?

No. Most occupational exposures do not lead to HIV infection. As the chances of possible serious side- effects (toxicity) from the drugs used to prevent infection may be much greater than the probability of contracting HIV infection from such exposures, such prophylaxis is indicated only under certain conditions. Both the risk of acquiring HIV infection and that of possible side- effects of drugs should be carefully considered while advising PEP. Exposures with a lower infection risk may not be worth the risk of the side effects associated with these drugs.

What about exposures to blood for which the HIV status of the source person is unknown?

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 HIV positive. Follow-up HIV testing should be available to all workers who are concerned about possible HIV infection through occupational exposure.

Pre- Test And Post- Test Counseling And Testing

The person should be provided with pre- test counseling and AZT be started as discussed. Before starting AZT, 3-5 ml of person's reference blood sample is taken and sent to hospital laboratory for separation of serum and kept at minus 200C. This first sample for ELISA/ HIV is collected immediately after exposure, 2nd at 6 weeks, 3rd at 12 weeks and last at 6 months after the exposure. The facilities for RT-PCR are available presently at MGM Medical College, Mumbai and NARI, Pune and these can give us results even at 2nd or 4th week after exposure. In case person is put on AZT, he is given post- test counseling. During the follow-up period, especially the first 6-12 weeks when most infected persons are expected to show signs of infection, recommendations for preventing transmission of HIV infection should be followed. These include refraining from blood, semen, or organ donation and abstaining from sexual intercourse. If you sexual intercourse can not be avoided, a latex condom should be used consistently and correctly during the intercourse so as to reduce the risk of HIV transmission. In addition, women should not breast-feed infants during the follow- up period to prevent exposing their infants to HIV in breast milk, in case they are infected due to the accidental exposure.

What specific drugs are recommended for post-exposure treatment?

ZDV should be considered for treatment of all exposures involving HIV-infected blood, fluid containing visible blood, or other potentially infectious fluid or tissue. (ZDV-200 mg every 8 hrs.) Lamivudine (3TC, 150 mg every 12 hours) should be added in selected cases to ZDV for increased effectiveness and for use against ZDV-resistant types of virus. Used in combination, ZDV and 3TC are very effective in treating HIV infection; and considerable information shows that they are safe when used for a short time.

How long do the drugs need to be taken?

Four weeks of ZDV therapy appears to provide protection against HIV infection. Therefore, if tolerated, the treatment should probably be taken for 4 weeks.

Should pregnant health care workers take these drugs?

Based on limited information, ZDV exposure in 2nd and 3rd trimesters of pregnancy has not caused serious side- effects in mothers or infants. There is very little information on the safety of ZDV administered during the first trimester or on the safety of other antiviral drugs taken during pregnancy. If a woman is pregnant at the time of an occupational exposure to HIV, she should consult a physician about the use antiviral drugs for post exposure treatment.

What is known about the safety and side effects of these drugs?

Most of the information known about the safety and side effects of these drugs is based on studies of their use in HIV-infected individuals. For these individuals, ZDV and 3TC have usually been tolerated except nausea, vomiting, diarrhea, tiredness, or headache for people taking ZDV.

What should the infection control officer do on receiving information about occupational exposure?

1. All the needle stick injuries should be reported to State AIDS Society in the Proforma.
2. The state AIDS Societies should, in turn, inform the NACO about the cases periodically.
3. The NACO plans to open a Registry for follow- up of such cases.
4. The NACO has decided, in principle, to supply drugs [ZDV or ZDV+3TC (wherever applicable)] to all cases of occupational exposure to HIV.

From Center for Disease Control and Prevention: Public Health Service [PHS] Guidelines for the management of health care worker exposures to HIV and recommendations for post exposure prophylaxis, MMWR 47(RR-7, 14- 15,1998)

The basic regimen is four weeks of zidovudine, 600 mg per day in two or three divided doses, and Lamivudine, 150 mg twice daily. Expanded regimen includes basic regimen as stated above plus either indinavir 800 mg every 8 hurs, or nelfinavir, 750 mg three times a day.