Occupational exposure

Background

• The majority of persons (e.g. source patients) chronically infected with hepatitis B and C (65% to 75%) are not aware of their infection

Clinical Features

• Frequently from needlestick injuries or other occupational exposures to bodily fluids

Evaluation

• In many systems, a standardized baseline lab panel is sent in the ED and then followed up at employee health the next day
• Frequently, the only actionable lab on the day of exposure is a rapid HIV test from the source patient (for consideration of PEP)

Source labs

• Rapid HIV, hepatitis panel, RPR?
• Hepatitis B and C infectivity of source patient
  • HBs-Ag (active infection)
  • HBc-Ab IgM (window period)
  • HepC-Ab, plus or minus viral load

Exposed labs

• Rapid HIV (if considering PEP only), hepatitis panel, RPR?
• If considering PEP
  • CBC, C7, LFTs, pregnancy test

Management

HIV

• Consider HIV post-exposure prophylaxis

Hepatitis B Post-Exposure Prophylaxis

Treatment is generally initiated after coordination with occupational health and infectious disease service and based the the exposed patient's vaccination history

Unvaccinated

• If the source is HBsAg(+) then give HBIG x1 and initiate HBV vaccine in two separate sites
• If source is HGsAG(-) then start the HBV vaccine series
• If source blood is unavailable and high risk then give HBIG x1 initiate the HBV series
  • If source blood is low risk and unavailable then begin HBV series

Previously vaccinated non responder (one series)

Non responder status is defined as anti-has <10mIU/mL

• If the source is HBsAg(+) then give HBIG x 1 and begin revaccination series
  • Can also opt to perform second HBIG administration in one month
• If source is HBsAg(-) then no treatment is needed
• If source blood is unavailable and high risk then treat as if HBsAg(+)

Previously vaccinated non responder (two series)

Non responder status is defined as anti-has <10mIU/mL

• If the source is HBsAg(+) then give HBIG x2 and no HBV series
• If source is HGsAG(-) then no treatment is needed
• If source blood is unavailable then initiate the HBV series

Treatment Dosing

No contraindications for pregnancy or breast feeding

• HBIG 0.06 mL/kg IM
• Vaccination series: HBV vaccine options:
  • Engerix-B 20mcg IM
  • Recombivax HB 10mcg IM

Hep C

• No prophylaxis regimen has any benefit
• Draw anti-HCV on the source and the exposed patient
• Draw ALT level on exposed patient and repeat in 6 months or perform HCV RNA PCR in 4 weeks
  • If the patient is anti-HCV positive then confirm the diagnosis with HCV RNA PCR.

Disposition

• Outpatient management with employee health follow-up

See Also

• HIV post-exposure prophylaxis

References

Authors

Ross Donaldson, Yos Yachivev, Tom Heston, Kevin Lu, Jonathan Osgood, Daniel Ostermayer, Michael Holtz, Amr Badawy