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WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy. Geneva: World Health Organization; 2010.
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Health workers may occasionally be accidentally exposed to blood and other body fluids that are potentially infected with HIV, hepatitis virus or other bloodborne pathogens. Occupational exposure may occur through direct contact from splashes into the eyes or mouth, or through injury with a used needle or sharp instrument. Post-exposure prophylaxis (PEP) can help to prevent the transmission of pathogens after a potential exposure (6).
This annex describes the steps in managing exposure to blood or other fluids that are potentially infected with hepatitis B virus (HBV); hepatitis C virus (HCV) or HIV.
Provide immediate first-aid care as follows.
Wash wounds and skin with soap and water. Do not use alcohol or strong disinfectants. Let the wound bleed freely. Do not put on a dressing. Flush eyes, the nose, the mouth and mucous membranes with water for at least 10 minutes.Determine the risk associated with the exposure by considering:
the type of fluid; for example, blood, visibly bloody fluid, other potentially infectious fluid, or tissue and concentration of virus;
the type of exposure; for example, there is a higher risk associated with percutaneous injury with a large, hollow-bore needle, a deep puncture, visible blood on the device, a needle used in an artery or vein, and exposure to a large volume of blood or semen, and less risk associated with exposure of mucous membranes or nonintact skin, or exposure to a small volume of blood, semen or a less infectious fluid (e.g. cerebrospinal fluid).
To evaluate the source of the potential exposure:
assess the risk of infection, using available information; test the source person whenever possible, and only with his or her informed consent; but do not test discarded needles or syringes for virus contamination.There is no PEP regimen recommended for HCV; however, there are specific steps that can be taken to reduce the risk of infection for those exposed to HBV and HIV, as described below.
A person's response to exposure to HBV depends on his or her immune status, as determined by the history of hepatitis B vaccination and vaccine response if tested 1–2 months after vaccination (see Table D.1), and whether the exposure poses a risk of infection. HBV PEP is safe for women who are pregnant or breastfeeding.
Recommendations for HBV post-exposure prophylaxis, according to immune status.
Check the current national guidelines. This section is based on the WHO/ILO Guidelines on post exposure prophylaxis prophylaxis (PEP) to prevent human immunodeficiency virus (HIV) infection (6). In addition to first-aid care and evaluation of exposure and risk, PEP for HIV includes counselling, HIV testing based on informed consent, and - depending on the risk assessment - the provision of a short course (28 days) of antiretroviral (ARV) drugs, with follow-up and support.
The recommendation for HIV PEP is based on an evaluation of the risk of infection described in step 2.
If the source person is identified, it is important to obtain information on that person's serostatus and, if positive, an evaluation of the clinical status and treatment history.
If testing is available, the exposed person should be offered the chance to be tested for HIV and receive appropriate counselling. The person should always have the choice to refuse testing. Perform HIV-antibody testing at baseline, and at 6-12 weeks and 6 months after exposure. If the person develops HIV antibodies, he or she should be referred for treatment, care and support.
Whenever possible, the source patient should also be tested, with his or her informed consent.
ARV drugs should be started as soon as possible, and certainly within 72 hours of exposure. The drugs should be taken continuously for 28 days. Health workers should not wait for tests results before taking or administering PEP. If the test results show that the source person is negative, the prophylaxis can be stopped. Counselling should include provision of information on the importance of adhering to treatment, and information on HIV prevention in general and in the workplace. The person should be advised to use condoms, and not to donate blood or organs for up to 6 months after exposure. Women of childbearing age should be advised to use contraception, and alternatives to breastfeeding should be discussed with women currently feeding their infants, because there is a high risk of transmitting HIV to the infant if the mother becomes infected during breastfeeding.
Based on WHO recommendations, a two-drug PEP regimen should be used (see Table D.2), unless there is suspicion or evidence of drug resistance. The standard regimen consists of two nucleotide reverse transcriptase inhibitors (NRTIs). When there is suspicion that the virus could be resistant to one or more of the drugs included in the standard PEP regimen, a third drug – a protease inhibitor – should be added to the two chosen NRTIs (see Table D.2). In this situation, it is best to consult an HIV expert.
Recommended two and three-drug post-exposure prophylaxis regimens.
Women of childbearing age should not be prescribed medications such as the combination didanosine plus stavudine. They should be offered a pregnancy test before starting the PEP regimen. Lactating women should be aware that ARVs are excreted in breast milk, and that the virus itself can be transmitted through breastfeeding. When and where feasible, alternatives options to breastfeeding should be discussed with the mother.
Follow-up visits should aim to support the person's adherence to PEP, prevent or treat adverse effects of the medicines, and detect seroconversion, if it occurs.
Advise those who have been exposed to take precautions to prevent secondary transmission during the follow-up period. Such precautions include:
avoiding pregnancy and seeking safe alternatives to breastfeeding; avoiding donating blood, tissue or sperm;using condoms during sexual intercourse, until the test at 6 months confirms that the exposed person remains seronegative.
PEP for HIV and hepatitis B is not indicated:
if the exposed person is already HIV-positive from a previous exposure;in the context of chronic exposure (e.g. repeated exposure to HIV from unprotected sexual intercourse with a known HIV-positive partner); or
if the exposure poses no risk of transmission; for example, in the case ofAfter the incident, refer the exposed person to a trained service provider who can give counselling, evaluate the risk of transmission of bloodborne pathogens having occurred, and decide on the need to prescribe ARV drugs or hepatitis B vaccine to prevent infection with HIV or HBV, respectively.
Both the incident report and the evaluation of the risk of exposure should lead to quality control and evaluation of the safety of working conditions.
Take correctional measures to prevent exposure to HIV and other bloodborne pathogens.
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