Review
Blood-borne viruses in health care workers: Prevention and management

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Abstract

Three pathogens account for most cases of occupationally acquired blood-borne infection: hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). The highest proportion of occupational transmission is due to percutaneous injury (PI) via hollow-bore needles with vascular access. We briefly review prevention and management of blood-borne pathogens in health care workers (HCWs) in developed countries. HCW compliance with standard precautions is necessary for prevention of PI. Safety-engineered devices are now being increasingly promoted as an approach to decreasing the rate of PI. Prevention of HBV transmission requires HCW immunization through vaccination against HBV. In non-vaccinated HCWs (or HCWs with an unknown antibody response to vaccination) exposed to an HbsAg-positive or an untested source patient, post-exposure prophylaxis with HBV vaccine, hepatitis B immunoglobulin or both must be started as soon as possible. Although no available prophylaxis exists for HCV, it is crucial to identify HCV exposure and infection in health care settings and to consequently propose early treatment when transmission occurs. Following occupational exposure with potential for HIV transmission, use of antiretroviral post-exposure prophylaxis must be evaluated. Patients need to be protected from blood-borne pathogen-infected HCWs, and especially surgeons performing exposure-prone procedures (EPPs) with risk of transmission to the patient. However, HCWs not performing EPPs should be protected from arbitrary administrative decisions that would restrict their practice rights. Finally, it must be emphasized that occupational blood exposure is of great concern in developing countries, with higher risk of exposure to blood-borne viruses because of a higher prevalence of the latter than in developed countries, re-use of needles and syringes and greater risk of sustaining PI, since injection routes are more frequently used for drug administration than in developed countries.

Introduction

Twenty-six different viruses have been shown to be responsible for occupational transmission in the literature.1 Three pathogens account for most cases due to their prevalence in patients and the severity of infections they cause: hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Pruss-Ustun et al.2 estimated that, in the year 2000, 16,000 HCV, 66,000 HBV and 1000 HIV infections may have occurred worldwide among health care workers (HCWs) due to their occupational exposure to percutaneous injuries (PIs).

In the present paper, we review data on management and prevention of blood-borne viruses in HCWs, focusing on HBV, HCV and HIV. For this purpose, systematic search was performed of Medline literature databases for papers published from January 1995 to March 2010 using the following search terms: health care workers, hepatitis C, hepatitis B/vaccination, HIV-1, injections/practices/utilization, equipment/re-use, personal protective equipment, infection control/standards, needle stick injuries/epidemiology, standard precautions, safety-engineered devices and post-exposure prophylaxis. We also searched for national guidelines on management and prevention of blood-borne viruses in HCWs via websites of public health institutes in specific countries (Centers for Disease Control, Health Protection Agency, CCLIN), and international guidelines via the WHO website (specifically, the Safe Injection Global Network).

Section snippets

Occupational risk of exposure to and transmission of blood-borne pathogens

Although case reports have documented transmission of these viruses as a result of splashes of blood from infected patients onto HCW mucous membranes, the highest proportion of transmission occurs through PI with hollow-bore needles for vascular access, i.e. blood-drawing and intravenous/arterial catheters.3, 4, 5, 6 Risk of transmission is closely related to work practices. Surgeons and laboratory assistants have been identified as having the highest risk of PI.7, 8, 9 When PI occurs, the risk

Preventing PI

Preventive methods and standard precautions for protecting both HCWs and patients from infection with blood-borne pathogens include hand washing after patient contact, use of barrier precautions (e.g. gloves), minimal manual manipulation of sharp instruments/devices (e.g. avoidance of needle recapping) and disposal in specific resistant containers.14 Regular training sessions targeting both long-term HCWs, students and residents at high risk of injury15 can help to ensure compliance with

HBV vaccination of HCWs

All HCWs in contact with patients, blood or other body secretions should be vaccinated for HBV. HBV vaccination protects HCWs not only against HBV infections but also against delta virus infections occurring only in individuals positive for HBV surface antigen.28, 29 However, vaccine coverage remains disparate in western countries, and poor vaccine coverage has been reported in some countries despite recommendations.30 To ensure wider hepatitis B vaccine coverage, vaccination should be carried

Management of HCWs exposed to blood-borne pathogens

The exposed site should be washed with soap and water. The potential for transmitting HBV, HCV and HIV should be evaluated based on the type of exposure and body material involved. The risk of transmission of these viruses increases with deep injuries and procedures involving hollow-bore needles.3, 13 The source patient's serostatus for antibodies against HIV, HCV and HBsAg should be obtained. If the source patient is at risk of recent HIV or HCV infection on the basis of recent exposure (e.g.,

Preventing transmission from HCWs to patients

The Society for Healthcare Epidemiology of America (SHEA) has recently reviewed data on HCW-to-patient transmission.53 Reports of HBV, HCV and HIV transmission from HCWs to patients exist.54 Occupational transmission of blood-borne viruses to patients almost exclusively occurs via infected HCWs such as surgeons performing EPPs. EPPs are “those where there is a risk that injury to the worker may result in exposure of the patient's open tissues to the blood of the worker. These procedures include

Conclusion

Here we have briefly reviewed prevention and management of blood-borne pathogens in HCWs in developed countries. It is important to emphasize the fact that occupational blood exposure is of great concern in developing countries; indeed, a high proportion of worldwide occupationally acquired HCV, HBV and HIV infections occur in these countries. HCWs are exposed to patients with a higher prevalence of blood-borne viruses than in developed countries. Moreover, re-use of needles and syringes in the

Conflict of interest

S. Deuffic-Burban received grants from Roche and Janssen-Cilag. Y. Yazdanpanah received travel grants, honoraria for presentations at workshops and consultancy honoraria from Bristol-Myers Squibb, Gilead, Glaxo-SmithKline, Merck, Pfizer, Roche and Tibotec. None of the authors report any association that might pose a conflict of interest.

Acknowledgments

The authors thank Céline Ciotti and Gérard Pellissier from the Groupe d’Etude sur le Risque d’Exposition au Sang (GERES) for their valuable assistance on research data of occupational exposure in the world.

Funding: None.

Ethical approval: Not required.

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