INTRODUCTION:

In health care set up, risk of acquiring infection by both patents and health care workers from each other is fairly high. Many different microbes include various pathogenic bacteria, viruses, parasites and fungi cause hospital acquired infection. Among these HIV, Hepatitis B and hepatitis C are of major significant to health care workers.

Practices for proper use of Post Exposure Prophylaxis for

· Blood borne pathogens

· Microorganism transmitted by either airborne or droplet spread or through direct contact.

Infection acquired after traumatic injuries.

What is post exposure prophylaxis?

Post - After

Exposure - Contact with something

Prophylaxis - Preventive treatment

Also known as ‘Post Exposure Prevention.’

Post Exposure Prophylaxis is any preventive treatment started immediately after exposure to pathogen in order to prevent infection by the pathogen and the development of disease.

Indication for Post Exposure Prophylaxis:

· The source person is HIV or hepatitis B or hepatitis C or high risk of recent infection.

· The exposed person is HIV or hepatitis B or hepatitis C virus positive.

· The exposure poses a risk of transmission that is

· Percutaneous exposure to potentially infectious fluid.

· Exposure to non – intact skin or mucous membrane to potentially infectious body fluid.

· The exposure occurred less than 72 hrs previous.

Potentially infectious body fluids:

Exposure to body fluids considered at risk

· Blood

· Semen

· Vaginal secretion

· CSF

· Synovial, peritoneal

· Amniotic fluid

· Other body fluid contaminated with visible blood

Who are at risk?

Health care personal include

· Physician

· Surgeon

· Nurse

· Lab technician

· Dentist

· Labour and delivery room personal

· Emergency care provider

· Health facility sanitary staff and clinical waste handlers.

Post Exposure Prophylaxis for Blood Borne Infection:

· Hepatitis B virus

· Hepatitis C virus

· Human Immunodeficiency Virus

Causes of HIV, Hepatitis B and C among Health Care Workers:

· Handle with contamination of blood and other body fluid

· Needle stick injury

· Lack of proper needle disposal technique

· Blood transfusion

HIV:

· Human- infecting human being

· Immunodeficiency: Decrease or weakness in the body’s ability to fight of infections and illness.

· Virus: A pathogen having the ability to replicate only inside a living cell.

Mode of transmission of HIV:

· Sexual transmission

· Exposure to infected blood and blood products

· Use of contaminated clotting factors by haemophilia

· Sharing contaminated needles (I.V drug users)

· Transplantation of infected tissues or organs

· Mother to fetus (Perinatal transmission)

Average risk of HIV infection to health care personal by exposure route:

· Percutaneous - 0.3%

· Mucous membrane - 0.09%

· Non intact skin - < 0.1%

Management of exposed person of HIV:

Step 1: Management of exposed site – First aid

Skin:

· Do not squeeze the wound to bleed of.

· Do not put the pricked finger in mouth.

· Wash with soap and water

· Do not scrub

· No antiseptics or skin washer. (Bleach, Chlorine, Alcohol, Betadine)

Eyes:

· Wash with water or normal saline.

· Do not remove contact lens immediately if wearing.

· No soap or disinfectant.

Mouth:

· Spit fluid immediately

· Repeatedly rinse the mouth with water and spit

· No soap or disinfectant.

Step 2: Establish eligibility for PEP:

· Evaluation must be made rapidly as soon as to start treatment as soon as possible ideally within 2 hrs, but certainly within 72 hours of exposure. However all exposed cases don’t require prophylactic treatment.

· Factors determining the requirement of PEP

· Nature of severity of exposure and risk of transmission

· HIV status of the source of exposure

· HIV status of the exposed individual

Step 3: Prescribe PEP:

There are two types of regimen.

1. Basic Regimen – 2 drug combination

2. Expanded Regimen – 3 drug combination

Drug	2 drug regimen	3 drug regimen
Zidovudine (AZT)	300 mg twice a day	300 mg twice a day
Or	Or	Or
Stavudine (d4t)	30 mg twice a day	30 mg twice a day
+	+	+
Lamivudine (3TC)	150mg twice a day	150mg twice a day
		+
Protease inhibitors	Nil	1^st choice: Lopinavir/Ritonavir: 400mg /100mg twice a Day.
`		Or
If protease inhibitor is not available	Nil	2^nd choice: Nelfinavir 1250mg twice a day. Efavirenz 60mg once a day

Step 4: Laboratory evaluations:

· Reason for testing soon after exposure is to establish baseline against which to compare future test results.

Timing	In Persons on PEP	In Persons not on PEP
Baseline (Within 8 days of Exposure)	HIV, anti-HCV, complete blood counts transaminases	HIV, HCV, HBV

Step 5: Follow up:

Clinical:

· Monitoring for appearance of signs of HIV zero conversion

· Use precaution to prevent secondary transmission (Blood donation, breast feeding, pregnancy, unprotected sexual relations especially during 6-12 weeks following exposure, condom use is essential)

· Monitor drug adherence

· Psychological support

· Counselling

Adverse effects of PEP regimen:

· Myalgia

· Diarrhoea

· Nausea and vomiting

· Headache

· Fatigue

Hepatitis B:

· A serious liver infection caused by the hepatitis B virus that’s early preventable by a vaccine.

· The virus is found in the blood, body fluids of an infected person.

Mode of transmission of Hepatitis B:

· Sexual contact

· Sharing of needles

· Contaminated instruments

· Direct Contact

Management of exposed person in Hepatitis:

· Immediate care to exposure site

· Wash wounds and skin with soap and water

· Flush mucous membranes with water

Determine the risk of exposure:

Type of fluid - Body fluid, saliva, potentially infectious fluid or tissue

Type of exposure:

· Percutaneous injury

· Mucous membrane or non intact skin exposure

Hepatitis B Vaccine:

· Initiation of the hepatitis B vaccine within 12 to 24 hours of an exposure.

· The vaccine should not be given greater than 14 days post exposure

· The 3 doses of hepatitis B vaccine 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

HBV Post exposure counselling:

· Refrain from donating blood, plasma, organ, tissue or semen.

· No need for

· Modification to patient care responsibilities for exposed person.

· If acute HBV infection evaluate according to published recommendations.

Hepatitis C:

· Hepatitis C transmitted by breast feeding, hugging, kissing or holding hands, coughing and sneezing.

· Sexual transmission

· Sharing razors and tooth brushes

· Tattooing

Management of exposed person in Hepatitis C:

· Baseline evaluation and testing

· Follow up testing and counselling

· PEP not recommended after exposure

· No vaccine or treatment will prevent infection

· Immune globulin not recommended- not effective

· Early infection effectively treated with peg-interferon+/-ribavirin

Baseline HCV testing of exposed person:

· If HCV positive source, test exposed person for anti – HCV and ALT.

· If source not infected, baseline testing not necessary.

HCV Post Exposure Counselling:

· Refrain from donating blood, plasma, organ, tissue or semen.

· No need for

· Special precaution to prevent secondary transmission.

· Modification to patient care responsibilities for exposed person even if HCV infected.

SUMMARY:

Post exposure prophylaxis (PEP) in short term treatment to reduce the likelihood of infection after potential exposure. With in the health section PEP should be provided as part of a comprehensive universal precautions package that reduce staff exposure to infectious hazards at work.

REFERENCES:

1. D.R. Arora, B. Arora, (2008). Text book of microbiology (3^rd ed). CBS Publishers and Distributors, Bangalore.

2. Rajesh Bhatia, Rathan Lal Ichbpujani, (2004). Essential of medical microbiology (3^rd ed). Jaypee brothers, Medical Publishers, New Delhi.

3. Ananthanarayan and Paniker’s (2005). Text Book of Microbiology (7^th ed). Orient Logman Pvt Ltd, Chennai.

4. http://www.aafp.org.

5. http://www.pmj.bmj.com

6. http://www.slideshare.net.contentmgmch.

Received on 09.02.2021 Modified on 11.03.2021

Int. J. of Advances in Nur. Management. 2021; 9(3):332-335.

DOI: 10.52711/2454-2652.2021.00076

Vaccination / Ag response status of exposed patient	Treatment when source patient is
	HBS Ag Positive	HBS Ag Negative	Source Unknown Not available for treatment
Un Vaccinated / Non- immune	HBIGX1 Initiate HB Vaccine series	Initiate HB vaccine series	Initiate HB vaccine series
Previously Vaccinated, Known responder	No Treatment	No Treatment	No Treatment
Previously Vaccinated, Known non responder	HBIGX1 and initiate revaccination or HBIGX2	No Treatment	No Treatment, unless high risk source, if high risk source treat source were HBSAG positive
Previously Vaccinated, Known responder	Simple vaccine booster dose	No Treatment	No Treatment, unless high risk source, if high risk source, treat source were HBSAG negative
Still undergoing vaccinated	HBIGX Complete Series	Complete Series	Complete Series