Introduction

It's late in the afternoon on Christmas Eve, and you receive a call that a correctional officer has just suffered a deep needle stick from a syringe found during a cell search. Are you prepared?

Managing a successful blood borne pathogen (BBP) exposure control program within a correctional setting can be very challenging. Ensuring that exposed employees have 24-hour access to PEP knowledgeable clinicians, educating staff about appropriate policies and procedures, and ensuring compliance with union agreements and applicable departmental, state and federal laws requires a great deal of planning. The rewards, however, can be great: creating an environment in which employees trust that all possible measures are in place to protect them from communicable diseases, avoiding sanctions from relevant agencies, and most importantly, preventing the transmission of serious and potentially fatal BBPs to your colleagues. This article will address some of the key features of a correctional BBP PEP program.

The Law

Each program must ensure that they are in compliance with applicable federal and state OSHA regulations. These include the existence of an exposure control plan dealing with BBPs including:

1. training of all at-risk employees
2. provision of free hepatitis B vaccination to staff (all at-risk employees must either accept HB vaccination or sign a waiver form),
3. provision of personal protective equipment and devices,
4. provision of free post exposure care to exposed employees, and
5. maintenance of OSHA logs documenting exposures.

BBP exposure incidents must be regularly evaluated with an eye towards ensuring compliance with BBP policies and, where possible, modifying procedures to decrease risk to staff.

The Risks

In the correctional setting the primary risks for transmission of hepatitis B (HBV), hepatitis C (HCV) and HIV are percutaneous or mucosal exposure to blood or other potentially infectious body fluids.

Significant exposures to correctional staff can occur in the course of providing healthcare, contact with sharps while cleaning or searching cells, during physical altercations, and by intentional "gassing" in which staff members are deliberately exposed to a patient's body fluids. A rough estimation of the risk following one percutaneous exposure to infectious material is 1/20 for HBV (1/3 if HB e Ag +), 1/33 for HCV, and 1/333 for HIV. The risk of HIV transmission following a mucous membrane exposure is estimated to be 1/1100.

Given the nationwide high prevalence of BBP, in corrections, prevention must be the cornerstone of an exposure control plan and will go a long way toward decreasing those late afternoon calls. For HBV, an aggressive vaccination program for at-risk employees is essential. HBV is the #1 infectious cause of cancer worldwide (hepatoma), and more healthcare workers die each year from complications of occupationally acquired HBV than the total number who have acquired HIV on the job in the entire history of the epidemic. If possible, obtain HBV serology on all incoming employees, as this data will greatly simplify future PEP evaluations.

The Tough Stuff

No, it's not the science, nor the treatment algorithms described below. In the correctional setting, the main difficulty is creating a mechanism for delivering PEP to employees within the recommended time frames (1-2 hours in the case of HIV). Is the closest emergency room 3 hours away? Do you have physicians on site 24-hours per day? Each facility and system will need to address these questions individually, based upon the available resources and any applicable union agreements. For those facilities with 24-hour physician availability, the fastest approach is to provide HIV PEP, HBIG, and HBV vaccine on site. For HIV PEP, following an initial dose, employees will also need 2-3 days worth of medications and a prescription to be filled later for a full four weeks. Keep in mind that not all pharmacies stock these medications, and for maximal effectiveness no doses can be missed.

A mechanism for obtaining baseline and follow-up labwork as well as monitoring for side effects of PEP must be in place. If the decision is made to utilize a nearby emergency room, the initial wound care and information collection should rapidly take place at your facility. Protocols must be in place with the receiving ER to triage these cases as emergencies, to provide initial and follow-up doses of PEP, and to arrange follow-up appointments with Occupa-tional Health clinics.

Management of Exposures

STEP 1: Wash the site. The initial management of all BBP exposure is the same: immediately wash with soap and water all wounds and skin sites that have been in contact with blood or body fluids. For mucous membranes, flush copiously with water or saline.

STEP 2: Evaluate the type of exposure. Ask yourself: Did it involve tissue or fluids capable of BBP transmission? If not, no further treatment is necessary. If yes, evaluate the exposed body site. Was the site intact skin, hair, or clothing? If so, no further treatment is needed. If, however, the potentially infectious material made contact with an infectable body site (non-intact skin, mucous membrane like the mouth or eyes, or was parenteral, such as a needle stick or bite), transmission of a BBP is possible.

STEP 3: Evaluate for other source factors. Is the source known? If the source is not known, in a correctional setting it is prudent to proceed as if the source is infected with HIV, HBV, and HCV. If the source is known, review the source's chart for HIV, HBV, and HCV serology. Recent negative serology and a lack of evidence of high-risk behaviors since the negative test make the presence of BBPs much less likely.

In the absence of recent negative serology, proceed as if the source is infected and initiate whatever measures are allowable within your system to obtain stat HIV, HCV and HBV testing of the source. For those facilities that do not do labwork on site, it is imperative to have a contract that allows for 24-48 hour reporting in stat situations.

STEP 4: Evaluate the exposed individual. Is the exposed person already infected with HBV, HCV, or HIV? Has the individual been vaccinated for HBV? If so, was an antibody response documented?

STEP 5: HIV PEP (see algorithms)

HIV RISKS

The risk for transmission of HIV is increased in cases of deep injuries. Those with large gauge hollow bore needles, those involving devices visibly contaminated with the patient's blood or used directly in the source's artery or vein, and exposure to blood with a high titer of HIV (as in late stage AIDS) are examples. Among healthcare workers with documented seroconversions, over 80% experienced a syndrome consistent with primary HIV infection median of 25 days after exposure. Of those who seroconverted, 95% did so within 6 months.

WHY PEP?

The evidence for efficacy of PEP comes from both animal studies with SIV and ACTG 076, which demonstrated that AZT decreased the transmission of HIV to the offspring of HIV infected pregnant women. A retrospective analysis of exposed healthcare workers demonstrated a 81% reduction in HIV transmission among those given AZT. The recommendations for expanded regimens are extrapolated from what is known from trials for treatment of established HIV infection.

WHICH PEP?:

Once the evaluations of the exposure incident, the source, and the exposed individual have taken place as described above, proceed to the following algorithms 1-3 included in this article.

Employees with occupational exposure to BBPs require follow-up counseling, post exposure testing, and medical evaluation regardless of whether they receive PEP. Monitoring of medication toxicities and the management of side effects must be performed.

STEP 6: Hepatitis B PEP (see HEPPigram below)

STEP 7: Hepatitis C

Thus far, there is no effective PEP for the prevention of transmission of HCV. Exposed individuals should have blood drawn for HCV Ab at baseline, and, if negative, it should be repeated at 6 weeks, 3 months, and 6 months. If they are infected, they should be counseled about the possibility of transmitting HCV to others. Early treatment with Interferon may be appropriate in some cases if seroconversion occurs.

Not all aspects of BBP PEP are covered in this article. Issues such as PEP for those exposed to drug resistant viruses and management of PEP for pregnant workers can complicate the picture. For an excellent recent reference, the reader is referred the Public Health Service Guidelines for PEP published in the MMWR vol. 47/No.RR-7 from May 15, 1998.

HEPPigram: Algorithm for HBV treatment after exposure

* (see how much easier it is when all of your staff are vaccinated?)

1999-0210
HEPP1999-0201

©1997,1998,1999,2000. The recently formed HIV Education Prison Project (HEPP) is a medical education program that targets a growing population, inmates in correctional facilities, that has been underserved in HIV care. It is part of the Brown University AIDS Program. Permission to use and reproduce portions of this newsletter is hereby granted provided that author and publication are fully credited and both copyright and permission notice appear with reprinted material. Inquiries may be directed to heppnews@brown.edu. Website: HIV Education Prison Project.

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