Post-Exposure Employee Followup for Bloodborne Pathogens

What to Do After an Occupational Exposure

Excerpted from Quality America 's OSHA Safety Program Manual:

OSHA requires that medical facilities follow the most recent Public Health post exposure guidelines current at the time of the employee exposure. The following information is taken from the most current CDC guidelines (Morbidity and Mortality Weekly Report.

Vol 50, No. RR-11, June 29, 2001 ). Whenever new guidelines are released, Quality America's OSHA Safety Program Manual will be updated via Quality America's OSHA Watch newsletter.

STEP 1. Provide immediate care to the exposure site.

• Wash with soap and water. If appropriate, bandage the site.
• Flush contaminated mucosal and conjunctival sites with large quantities of water using an eyewash for at least 15 minutes (See Tab 8: Decontamination for more information about eyewashes).

STEP 2. Report accidents as soon as possible to the OSHA Safety Officer. Give the OSHA Safety Officer information needed to complete the Accident Report/Sharps Injury Log. Failure to report an exposure incident is a serious offense. The fact that an exposure incident is reported will not, per se, reflect negatively on an employee. If subsequent investigation reveals violation of personal protective equipment use or other procedures required by this Exposure Control Plan, disciplinary action is limited to those violations.

STEP 3. Obtain consent* from the source patient to draw blood to test for HBV, HCV and HIV infection.

• For known sources whose infection status is unknown (e.g., patient refuses testing), consider medical diagnoses, clinical symptoms, and history of risky behaviors.
• Test known source for HBsAg, anti-HCV, and HIV antibody (consider using rapid testing for HIV). If the source person is NOT infected with a bloodborne pathogen, further follow-up of the exposed worker is NOT necessary.
• If the source person is HIV seronegative and has no clinical evidence of AIDS or symptoms of HIV infection, no further testing of the exposed employee for HIV infection is indicated. The likelihood of the source person being in the "window period" of HIV infection in the absence of symptoms of acute retroviral syndrome is extremely small.
• For unknown sources, assess risk of exposure to HBV, HCV, or HIV infection by considering the likelihood of bloodborne pathogen infection among patients in the exposure setting.
• Do not test discarded needles or syringes for virus contamination.

*In most states, the source patient or anyone authorized legally to give consent on his/her behalf must be asked to donate blood for testing. The source patient's response (signed consent form or verbal denial) must be documented and retained. For jurisdictions that do not require consent of the source patient, "available" blood may be used for testing, if a sample is available that had previously been drawn from the source patient.

STEP 4. Evaluate the exposed worker by assessing his/her HBV immune status (i.e., by history of hepatitis B vaccination and vaccine response). If worker was exposed to substance with known HBV, HCV or HIV, follow the guidance below.

For HBV Exposures:

• Provide HBV vaccine for any unvaccinated person, plus potential post exposure prophylaxis (PEP) of hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine series.
• Perform follow-up anti-HBs testing in persons who receive hepatitis B vaccine one to two months after last dose of vaccine. Anti-HBs response to vaccine cannot be ascertained if HBIG was received in the previous three to four months.

For HCV Exposures:

• Immune globulin (IG) and antiviral agents are not recommended for PEP after exposure to HCV-positive blood. When HCV infection is identified early, refer the infected worker for medical management to a specialist knowledgeable in this area.
• Perform baseline and follow-up testing for anti-HCV and alanine aminotransferase (ALT) at four to six months after exposure.
• Perform HCV RNA at four to six weeks if earlier diagnosis of HCV infection is desired.
• Confirm repeatedly reactive anti-HCV enzyme immunoassays (EIAs) with supplemental tests.
• No recommendations exist regarding restricting the professional activities of healthcare workers with HCV infection.

For HIV Exposures:

• Perform HIV-antibody testing for at least six months post exposure (e.g., at baseline, six weeks, three months and six months).
• Perform HIV antibody testing if illness compatible with an acute retroviral syndrome occurs.
• Advise exposed persons to use precautions to prevent secondary transmission during the follow-up period.
• Extended HIV follow-up (e.g., for 12 months) is recommended for employees who become infected with HCV following exposure to a source co-infected with HIV and HCV.
• Provide a four-week regimen of a two-drug combination, plus a third drug for exposures that pose an increased risk for transmission. Avoid the drug nevirapine during post exposure prophylaxis because of the risk for liver damage.
• Evaluate exposed persons taking PEP within 72 hours after exposure and monitor for drug toxicity for at least two weeks. Minimally, lab monitoring for toxicity should include a complete blood count and renal and hepatic function tests.

STEP 5. Give PEP for employee exposures posing risk of infection transmission of HBV and HIV.

• Initiate PEP as soon as possible, preferably within hours of exposure.
• Offer pregnancy testing to all women of childbearing age not known to be pregnant.
• Seek expert consultation if viral resistance is suspected.
• Administer PEP for four weeks if tolerated.

STEP 6. Obtain consent from the exposed employee to take a blood sample to be tested as soon as possible after the exposure incident for HBV, HCV and HIV. The exposed employee does not have to make an immediate decision about having blood tested; 90 days are given after the baseline blood sample is collected to decide whether or not to be tested. If the employee decides against immediate testing, the OSHA Safety Officer ensures that the blood sample is preserved for 90 days.

STEP 7. Refer the exposed employee to a healthcare professional* who provides counseling and, if required, appropriate post exposure prophylaxis.

Provide the exposed employee with the following documents to take to a healthcare provider:

1. A copy of the Bloodborne Pathogens Standard (located behind Tab 12 ).
2. A copy of the Accident Report/Sharps Injury Log (located behind Tab 11 ).
3. Results of the source individual's testing (if the source individual was tested).
4. All medical records relevant to the appropriate treatment of the employee.

*OSHA defines a "licensed healthcare professional" as a person whose legally permitted scope of practice allows him or her to independently perform the activities required for hepatitis B vaccination and post exposure evaluation and follow-up. In some states, the State Board of Nursing allows licensed healthcare professionals other than physicians to carry out the procedures and evaluations required by OSHA for post exposure follow-up.

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