| Treatment when source is found to be: | |||
|---|---|---|---|
| Vaccination and antibody response status of exposed persona | HBsAgb positive | HBsAg negative | Source not tested or status unknown |
| Unvaccinated | HBIGc × 1; and initiate HB vaccine seriesd | Initiate HB vaccine series | Initiate HB vaccine series |
| Previously vaccinated | |||
| Known respondere | No treatment | No treatment | No treatment |
| Known nonrespondere | |||
| After 3 doses | HBIG × 1 and initiate revaccination | No treatment | If known high-risk source, treat as if source were HBsAg positive |
| After 6 doses | HBIG × 2 (separated by 1 month) | No treatment | If known high-risk source, treat as if source were HBsAg positive |
| Antibody response unknown | Test exposed person for anti-HBsf 1. If adequate,e no treatment 2. If inadequate,e HBIG × 1 and vaccine booster | No treatment | Test exposed for anti-HBs: 1. If adequate, no treatment 2. If inadequate, initiate revaccination |
a Persons who have previously been infected with HBV are immune to reinfection and do not require postexposure prophylaxis.
b Hepatitis B surface antigen.
c Hepatitis B immunoglobulin; dose 0.06 mL/kg intramuscularly.
d Hepatitis B vaccine series. Healthcare personnel should be tested 1 to 2 months after completion of the vaccination series for anti-HBs.
e A seroprotective (adequate) level of anti-HBs after completion of a vaccination series is defined as anti-HBs ≥10 mIU/mL; a response <10 mIU/mL is inadequate and is not a reliable indicator of protection.
f Antibody to HBsAg.
For percutaneous exposures to HBV-infected blood, the decision to provide prophylaxis must take into account several factors, including the HBsAg status of the source and the hepatitis B vaccination and vaccine-response status of the exposed person. The hepatitis B vaccination status and the vaccine-response status (if known) of the exposed person should be reviewed. Table 104.1 summarizes prophylaxis recommendations for percutaneous exposure to blood according to the HBsAg status of the exposure source and the vaccination and vaccine-response status of the exposed person. When HBIG is indicated, it should be administered as soon as possible after exposure (preferably within 24 hours). The effectiveness of HBIG when administered >7 days after exposure is unknown. Hepatitis B vaccine, when indicated, should also be given as soon as possible (preferably within 24 hours) and can be given simultaneously with HBIG (though it should be administered intramuscularly at a separate site, with vaccine always given in the deltoid muscle). For exposed persons who are in the process of being vaccinated, but have not completed the vaccination series, vaccination should be completed as scheduled and HBIG added. HBV testing should be performed on any exposed person who has an illness compatible with hepatitis.
Hepatitis C virus infection
HCV is not transmitted efficiently through occupational exposures to blood. The average incidence of anti-HCV seroconversion after accidental percutaneous exposure from an HCV-positive source is 1.8% (range, 0% to 7%). The risk for transmission after exposure to fluids or tissues other than HCV-infected blood has not been quantified but is thought to be low.
Healthcare professionals who provide care to persons exposed to HCV in the occupational setting should be knowledgeable regarding the risk for HCV infection and appropriate counseling, testing, and medical follow-up. Immunoglobulin and antiviral agents are not recommended for postexposure prophylaxis (PEP) after exposure to HCV. For the person exposed to a source with HCV viremia, testing for anti-HCV and alanine aminotransferase (ALT) activity should be performed at baseline. Follow-up testing for anti-HCV and ALT at 4 to 6 months is recommended and will identify those who were infected. However, follow-up testing only at 4 to 6 months postexposure will not allow for early detection of HCV infection. As the treatment response rate is higher in persons with acute, rather than chronic, HCV infection, more frequent monitoring with early treatment of acute HCV infection is favored by some experts.
One follow-up strategy advocated by some authorities involves periodic monitoring (e.g., every 4 to 6 weeks postexposure) of exposed HCP by polymerase chain reaction (PCR) for HCV RNA, following those who develop viremia over time to see if chronic infection develops, and then treating only individuals who remain positive for HCV RNA by PCR and have elevated ALT levels 12 weeks into the course of their infections. By this strategy, infected individuals have an opportunity to spontaneously clear their infections and be spared the toxicities and expense of interferon therapy. Other authorities suggest monitoring exposed HCP more frequently and implementing treatment sooner among those who develop HCV infection. These strategies represent reasonable approaches to the management of occupational HCV exposures based on the currently available information. HCV testing should be performed on any exposed person who has an illness compatible with hepatitis.
Human immunodeficiency virus infection
Prospective studies of HCP have estimated that the average risk of HIV transmission after a percutaneous exposure to HIV-infected blood is approximately 0.3% (95% confidence interval [CI] = 0.2%–0.5%).
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