Blood-borne pathogen exposures (BBPE) among health care personnel (HCP) can occur in virtually all clinical settings with an estimated annual incidence of 650,000 in the United States.¹ Exposure to human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) occurs when an infected patient’s blood or other infectious material comes into contact with the blood of an exposed individual. Routes of exposure are percutaneous (sharp instrument), mucous membrane (eyes, nose, or mouth), or by contact with nonintact skin of the HCP.² Table 35-1 shows the risk of transmission after occupational BBPE by pathogen and route of exposure. Health care facilities should have policies in place to provide prompt response by someone familiar with current management guidelines in order to prevent transmission of pathogens and to reduce psychological trauma.^3,4 This chapter provides an outline for the management of occupational BBPE among HCP.

The first priority is immediate and thorough cleansing of the site of exposure. For percutaneous exposure or contact with nonintact skin, this should involve washing with soap and water with subsequent flushing for 5 minutes. In the case of mucous membrane exposure, the affected area should be flushed with water or saline solution for 5 to 10 minutes. Once the area has been cleaned or while this process is ongoing, the next step is to determine if there was penetration of the skin with a contaminated instrument, contact of blood/body fluids with mucous membranes, or contact of blood/body fluids with nonintact skin. Table 35-2 lists body fluids that are considered to be infectious versus those that are not considered infectious. Next, evaluate if the source patient is known to be infected with HIV, HBV, or HCV. Source patients whose HIV status is not known should have a rapid HIV test performed as soon as possible in accordance with state consent regulations. If the source patient’s hepatitis status is not known, testing for HBV and HCV can be initiated at the same time.^2,5

In the case of HIV exposure, baseline serologic testing of the HCP (HIV, complete blood count [CBC], and comprehensive metabolic panel [CMP]) should be performed, and postexposure prophylaxis (PEP) should be administered as described below.⁵ If the source patient is known to be infected with HBV or HCV, baseline
testing on the exposed HCP should be performed as soon as feasible. When a hepatitis B exposure has occurred, determine both the vaccination and responder status of the exposed employee. Personnel who have not completed the three-shot HBV vaccination series are classified as unvaccinated; they should receive a single dose of hepatitis B immune globulin (HBIG; 0.06 mL/kg), and the vaccine series should be started. Those who have received the full vaccination series but have not been tested for antibody levels should undergo testing for anti-HBs antibody. For those with adequate antibody levels, no further treatment is indicated. For those with inadequate antibody levels, a single dose of HBIG should be administered with a vaccine booster. Immune globulin administered within 7 days of exposure has been shown to be effective in preventing transmission. HCP who have inadequate antibody response to two vaccine
series should receive two doses of HBIG. Health care workers who have completed the three-shot HBV series and are known responders will require no further treatment or evaluation. Since there is no recommendation for PEP in the case of HCV exposure, the next step is to obtain baseline serologic testing for HCV as soon as feasible. When the HBV/HCV status of the source patient is not known initially, follow-up should be arranged to discuss the results of hepatitis testing when that information is available. PEP for HBV may be considered if the source patient is at high risk for having HBV. HCP should be advised to refrain from unprotected sexual activity and breast-feeding until hepatitis test results have been determined.²