COMMENTARY

HIV Prophylaxis Following Occupational Exposure: Guideline and Commentary

Barry S. Zingman, MD

Disclosures

January 30, 2013

In This Article

Occupational Exposures to Hepatitis B and C

Recommendation: When an occupational exposure occurs, the source patient should be evaluated for both hepatitis B and hepatitis C. (AII)

The risk of transmission of HBV and HCV from an occupational exposure is significantly greater than the risk of HIV transmission. The risk of HCV infection following a needlestick is 1.8%, whereas the risk of HBV infection ranges from 1% to 30% depending on the presence of hepatitis e antigen (see Table 8). The risk of transmission of HCV from a single mucous membrane exposure is negligible.

Table 8. Average Risk for Transmission of Hepatitis B and C Viruses After Needlestick Compared With HIV

Source Risk
HBV
    HBeAg+
    HBeAg-

22.0% - 30.0%
1.0% - 6.0%
HCV+ 1.8%
HIV+ 0.3%

Hepatitis B Virus Post-Exposure Management

Recommendations:

The hepatitis B vaccine series should be initiated in non-HBV-immune exposed workers who sustain a blood or body fluid exposure. (AI)

Determination of antibody response of previously vaccinated exposed workers should be based on information available at presentation. Decision-making should not be delayed while testing for anti-HBs (see Table 9).

Administration of prophylactic hepatitis B immune globulin (HBIG) and the initiation of the hepatitis B vaccine series injected at different sites is recommended when the non-HBV-immune exposed worker sustains a blood or body fluid exposure to a source patient with known acute or active HBV (see Table 9). (AI) Both HBIG and the first dose of the hepatitis B vaccine series should be ideally administered within 24 hours of exposure (AII); HBIG should not be given later than 14 days post-exposure. The three-dose HBV vaccine series is given at 0, 1 to 2 months, and 6 months. Hepatitis B antibodies should be obtained 1 to 2 months after completion of the third dose of the vaccine.

Needlestick injuries and wounds should be washed with soap and water and should not be squeezed. Mucous membranes should be flushed with water. (AIII)

Initiation of the HBV vaccine series within 12 to 24 hours of an exposure has been demonstrated to be 70% to 90% effective in preventing HBV infection. The combination of vaccine and HBIG achieves a similar level of efficacy. Among known non-responders to vaccination, one dose of HBIG is 70% to 90% effective in preventing HBV when administered within 7 days of percutaneous HBV exposure,[34] and multiple doses have been shown to be 75% to 95% effective.[35] Pregnant women can safely receive both the HBV vaccination and HBIG.

When considering PEP for HBV exposures, both the source patient’s HBsAg status and the exposed worker's vaccination status should be considered (see Table 9). Determination of antibody response of previously vaccinated exposed workers should be based on information available at presentation. It is not recommended that decision-making be delayed while testing for anti-HBs. If antibody response is unknown, follow recommendations for "antibody response unknown" in Table 9.

Both HBIG and the first dose of the hepatitis B vaccine should be ideally administered within 24 hours of exposure; HBIG should not be given later than 14 days post-exposure. The three-dose HBV vaccine series is given at 0, 1 to 2 months, and 6 months. Hepatitis B antibodies should be obtained 1 to 2 months after completion of the third dose of the vaccine.

Even if the risk of exposure to HBV is not deemed significant, HBV vaccination should still be advised for all non-HBV-immune exposed workers (see Hepatitis B Virus guidelines for more information). Household, sex, and needle-sharing contacts of HBsAg-positive individuals should be identified and vaccinated according to the guidelines for patients exposed to known HBsAg-positive individuals.

Table 9. Recommended Post-Exposure Prophylaxis for Hepatitis B Virus

Vaccination and/or antibody response status of exposed persona Treatment when source patient is:
HBsAg positive HBsAg negative Source unknown or not available for testing
Unvaccinated/non-immune HBIGb ×1; initiate HBV vaccine series Initiate HBV vaccine series Initiate HBV vaccine series
Previously vaccinated,c known responderd No treatment No treatment No treatment
Previously vaccinated,c known non-responderd HBIGb ×1 and initiate revaccinatione or HBIGb ×2 No treatment No treatment unless known high-risk source; if high-risk source,f then treat as if source were HBsAg positive
Previously vaccinated,c antibody response unknown Single vaccine booster dose No treatment No treatment unless known high-risk source; if high-risk source,f then treat as if source were HBsAg positive
If still undergoing vaccination HBIGb ×1; complete series Complete series Complete series

a Persons who have previously been infected with HBV are immune to re-infection and do not require PEP. b Dose 0.06 mL/kg intramuscularly. c Vaccinated with full three-dose series. d Based on information available at presentation. Responder is defined as person with previously documented adequate levels of serum antibody to HBsAg (serum anti-HBs ≥10 mIU/mL); non-responder is a person with previously documented inadequate response to vaccination (serum anti HBs < 10 mIU/mL). It is not recommended that decision-making be delayed while testing for anti-HBs at presentation. e The option of giving one dose of HBIG and re-initiating the vaccine series is preferred for non-responders who have not completed a second three-dose vaccine series. For persons who previously completed a second vaccine series but failed to respond, two doses of HBIG are preferred. f High-risk is defined as sources who engage in needle-sharing or high-risk sexual behaviors, and those born in geographic areas with HBsAg prevalence of ≥ 2%.[36]

Hepatitis C Virus Post-Exposure Management

Recommendations:

  • Clinicians should consider concurrent exposure to HCV when exposed workers present with an HIV exposure. (AII)

  • Neither immunoglobulin nor antiviral agents are recommended for HCV post-exposure prophylaxis.

  • When HCV infection is identified, the exposed worker should be referred for medical management to a clinician with experience in treating HCV. (AII)

Currently, no effective prophylaxis for HCV has been identified. Immunoglobulin and antiviral agents are not recommended for HCV post-exposure prophylaxis (PEP). However, if an individual becomes acutely infected with hepatitis C and is diagnosed at that time, immediate referral to a specialist experienced in the treatment of hepatitis C is strongly recommended. Recent data suggest that early treatment of acute hepatitis C with interferon is highly effective, perhaps as high as 98%.[37] The best regimen or duration of therapy is unknown. However, observation for a period of 8 to 12 weeks post-infection is reasonable to assess for possible spontaneous resolution of acute hepatitis C.[38] Whether standard interferon or pegylated-interferon with or without ribavirin is used will depend on the individual scenario, as there have been no randomized, controlled trials to guide this decision.

Baseline Management

Recommendations:

  • Following an exposure to blood or body fluid, the clinician should assess the risk for exposure to HCV. (AII) Wounds should be washed with soap and water, and should not be squeezed. (AII) Mucous membranes should be flushed with water.

  • Once the clinician has determined that exposure to blood or body fluid has occurred, the following baseline tests should be obtained (see Table 10 for follow-up according to baseline results):

  • Source patient:

    • HCV antibody test (eg, EIA/ELISA), and if positive, HCV RNA test or recombinant immunoblot assay (RIBA)

  • Exposed worker:

    • Liver panel including liver enzymes

    • HCV antibody, and if positive, HCV RNA test

If the source patient is tested with an EIA/ELISA and found to be positive, then follow-up testing is necessary to confirm the source patient's status. According to the most recent Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis (2001), either HCV RNA or RIBA may be used as the confirmatory test. However, most clinicians currently obtain HCV RNA testing, instead of RIBA, to confirm a positive antibody screening result. When the source patient tests positive by either RIBA or HCV RNA test, the exposed worker should be managed as though the source has chronic HCV.

Table 10. Hepatitis C Post-Exposure Management According to Baseline Test Results

Clinical Scenario Follow-Upa
Source patient is HCV-antibody negative No further testing or follow-up is necessary for source patient or the exposed workerb
Source patient is unavailable or refuses testing Exposed worker: Follow-up HCV antibody at 3 and 6 monthsb
Source patient is HCV-antibody positive and HCV RNA negative Manage the exposed worker as if the source patient has chronic hepatitis C (see Post-Exposure Follow-Up for HCV below)c
Source patient is positive for both HCV antibody and HCV RNA
and
Exposed worker is HCV-antibody negative
  • Source patient: Counsel and manage as chronic hepatitis C regardless of status of exposed worker


  • Exposed worker: Follow up as outlined in Post-Exposure Follow-Up for HCV, below

Exposed worker tests positive for both HCV antibody and HCV RNA Counsel and manage as chronic hepatitis C

a Refer to Appendix E for information about HCV tests and how to interpret results. b If at any time the serum ALT level is elevated in the exposed worker, the clinician should test for HCV RNA to assess for acute HCV infection. c A single negative HCV RNA result does not exclude active infection.

Clinicians should educate exposed workers about the natural history of HCV infection and should counsel exposed workers about the following:

  • Avoidance of alcohol and, if possible, medications that may be toxic to the liver

  • Risk of transmission related to:

    • Blood-to-blood contact, including sharing personal care items that may have come in contact with another person's blood, such as razors or toothbrushes; occupational needlestick injuries; and sharing needles, syringes, or other equipment to inject drugs

    • Sexual activity

    • Donating blood, plasma, organs, tissue, or semen

    • Perinatal transmission

  • Hepatitis C virus is not spread via food or water and is not transmitted by:

    • Sharing eating utensils

    • Hugging, kissing, or holding hands

    • Coughing or sneezing

    • Breastfeeding: HCV is not transmitted by breastfeeding; however, clinicians should advise women who may have been exposed to HIV to avoid breastfeeding for 3 months after the exposure

Factors that may increase the risk of sexual transmission include sex with multiple partners, history of STIs, including HIV, or any other practice that might disrupt mucous membranes. The potential need for mental health counseling should be anticipated and offered as needed.

Post-Exposure Follow-Up for HCV

Recommendations:

  • If the source patient is known to be positive for HCV antibody and/or HCV RNA, the follow-up schedule for the exposed worker should be as follows (AII):

    • Week 4: HCV RNA and liver panel

    • Week 12: HCV RNA and liver panel

    • Week 24: Liver panel and HCV antibody

  • If at any time the serum ALT level is elevated, the clinician should repeat HCV RNA testing to confirm acute HCV infection. (AIII)

  • At any time that exposed workers test positive for HCV RNA, the clinician should refer for medical management and possible treatment by a clinician with experience in treating HCV. (AIII)

For individuals exposed to hepatitis C-infected source patients, regular follow-up with HCV RNA testing is recommended in addition to HCV antibody testing, because HCV RNA testing can identify acute infection within 2 weeks of exposure, whereas accuracy of the antibody test can be delayed up to several months after acute infection (ie, "window period").

Seroconversion with the ELISA antibody test occurs in 50% of patients within 9 weeks of exposure, in 80% of patients within 15 weeks of exposure, and in at least 97% of patients within 6 months of exposure.[39] The ELISA test is highly sensitive but relatively nonspecific, resulting in a low positive predictive value in low-prevalence populations. Positive HCV ELISA antibody test results require confirmation by a quantitative viral load assay, such as HCV PCR.

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