Lecture for medical students, , doctors or ant health care workers. It gives details how a medico can protect one self while caring for patients. Without discrimination.
1. Are we at risk of HIV?
Dr Madhu Oswal
SAMVAD HIV HELPLINE
Muktaa Charitable Foundation
2.
3.
4.
5. Procedures we perform in the
clinic set-up
- General Examination of patients
PV exam, P/A exam, oral cavity
- Giving IM injection
- Giving IV injection
- Drawing blood for lab investigation
• Minor Procedures – Catheterization,
pap smear, IUD insertion, ascitis
fluid tapping, etc.
• Minor Surgeries – Suturing, I& D,
removing corn,lipoma, taking biopsy,
etc.
6. Procedures we perform in the Hospital
set-up
•
-
All as above, plus (all that we do in clinic)
Ryles tube insertion
Plural tapping
CSF tapping
Suction
Intubation
• In operation Theatres
- Invasive procedures
- Vaginal delivery
7. Duties your assistant/Nurses/Aaya/mama
perform
• Handling bio-medical waste
• Cleaning soiled surfaces
• Washing soiled linen – clothes, bed
sheets, etc.
• Handling vomitus, urine, stools, suction
material
• Handling lab specimen – sputum, blood,
urine, etc.
• Cleaning toilets, bathrooms, urinals, bed
pan, suction jar, etc.
9. Universal precautions
UP means-EVERYONE,
EVERYWHERE,ALWAYS,
UP applies to – blood, semen, vaginal
secretons, cerebro-spinal fluid, ascitic
fluid, pericardial fluid & amniotic fluid
UP does not apply to urine, stools, saliva,
tears, sputum, vomitus – if not blood
stained or contaminated with blood
10. How much is the risk?
• HBV
• HCV
• HIV
-
4%
1.8%
0.4%
HIV is an very fragile virus. Then why
‘phobia’ about HIV?
12. Type of Exposure Involved in Transmission
of HIV to Health Care Workers
AETC http://depts.washington.edu/hivaids
6
13. Risk Factors for HIV Transmission with
Occupational Exposure to HIV-Infected Blood
Odds Ratio
Confidence
Interval
Deep Injury
15
6.0-41
Visibly Bloody Device
6.2
2.2-21
Device Used in Artery or Vein
4.3
1.7-12
Terminally Ill Source Patient
5.6
2.0-16
0.19
0.06-0.52
Risk Factor
Use of Zidovudine for PEP
P<0.01 for all associations
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15. Hand Washing
Before-
Examining patient
Removal of glove
Before wearing glove
AfterExamining a patient
Contact potentially contaminated
body secretions/excretions, instruments
routine surgical scrub
After removing glove
Too simple to be important but Most Important
16. Gloves, apron, goggles, etc
• For protection of HCW from infection
from the patient.
• For protection of patient from infection
from HCW or other source.
• Be judicious in use of gloves.
• Utility gloves, sterile gloves, non-sterile
gloves.
17. Handling needles and sharps
- Disposable needles
-
Do not RECAP – 80%
Do not BEND
Do not BREAK
Cut the needle in a puncture resistant
container
- Use hands- free technique while passing
‘sharp’ instruments.
18. Things/Instruments we need to reuse
or dispose off safely
• Decontamination
• Disinfection – removing and reducing
some agents of infection
• Sterilization – Killing all organisms
including spores
19. Dis-infection
- Cleaning with soap and water
- Heat – boiling for a minute kills all organism.
For spores – 20
- Chemical - Sodium Hypochlorle 1%
- Glutaarlderyde 2%(Sterylium)
- Ethyl alcohol – 70%
(Hospital spirit)
- Chlorhexidine – 3%(Savlon)
-Iodine tinc-3%
-Iodophores 7.5-10%(Betadine)
20. Sterilization
Dry Heat – (Incirinators) – destroy soiled
dressings, biomedical, waste, equipments
Autoclave – For equipment which can tolerate
heat – clothes, dressing, instruments,
apparatus, etc.
Ethylene oxide- Respirator, HL machine
Gamma radiation – Suture material,
catheters, gloves, etc.
21. What to do if one gets a pinprick/exposure?
Do not Panic!!!
- Do not squeeze the wound or suck.
- Allow the wound to bleed freely.
- Wash the puncture site with soap & water
- Confirm the serostatus of the source case
If negative – do nothing
If positive – know your sero-status at
baseline
- Assess the risk(with the help of an HIV
expert)
- Seek for PEP, if necessary with 6 hrs, not
later than 72 hrs
22. Decision-making Tools for PEP
• Source code (SC)
– Risk assessment of the source patient
– SC 1, SC 2, SC Unknown
• Exposure code (EC)
– Risk assessment of exposure type
– EC 1, EC 2, EC 3
23. Step 1: Does This person
Need HIV PEP?
Source patient
HIV -
HIV +
Unknown /
Unwilling to
get tested*
High background risk
No PEP
PEP
Low background risk
No PEP
*CDC recom: usually PEP unnecessary; consider use if source patient is high risk
24. Step 2: Determine HIV Status Code of
Source (HIV SC)
HIV Negative
HIV Positive
Asymptomatic/high CD4
= HIV SC 1
No PEP
Advanced disease,
primary infection or low
CD4 =HIV SC 2
HIV Status Unknown
or Source Unknown
= HIV SC Unknown
25. Step 4: Determine PEP Regimen (2)
Exposure Type
Source Infection Status
HIV+ Class 1
HIV+ Class 2
Less Severe
Basic (2 Drugs)
Expanded (3 Drugs)
More Severe
Expanded (3 Drugs)
Expanded (3 Drugs)
• Less Severe: Solid needle, superficial injury
• More Severe: Large-bore hollow needle, deep punture,
visible blood on device, or needle used in patient's artery
or vein
• HIV Class 1: Asymptomatic or HIV RNA less than 1500
copies/ml
• HIV Class 2: Symptomatic HIV infection, AIDS, acute
seroconversion, or known high HIV RNA
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26. Step 4: Determine PEP Regimen
HIV SC
EC
PEP Recommendation
1
1
PEP may not be warranted
2
1
Consider basic regimen
1
2
Recommend basic regimen
2
2
Expanded regimen recommended
1 or 2
3
Expanded regimen recommended
Unknown
If EC is 2 or 3 and a risk exists, consider
PEP basic regimen
27. HIV Post Exposure Prophylaxis
• 2 drug regimen
Zidovudine plus lamivudine (combivir)
Stavudine plus Lamivudine
Tenofovir plus lamivudine
• 3 drug regimen
LPV/r or Indinivr or Nelfinavir plus NRTI backbone
Efavirez plus NRTI backbone
Consider resistance potential of source patient
Don’t use NVP (hepatotoxicity)
29
The SC and EC are used to estimate the risk of transmission from the occupational exposure and help determine the type of PEP regimen
The initial step - not shown here - is to determine the status of the exposed person. If this person is seronegative (and the exposure was not simply cutaneous) then:
Determine the status of the source patient
If the source patient’s status is unknown or the patient is unwilling to get tested, assess the background risk of the patient. In general, hospitalized patients in Ethiopia are high risk (>3% background prevalence)
If the source patient is positive or comes from a high risk background, PEP is indicated
If the patient needs PEP, then the next step (Step 2) is to determine the HIV status of the source patient or (SC). If the HIV positive patient is asymptomatic and their CD4 count is preserved, the source code (SC) = 1. In the case of advanced disease, primary infection, or a low CD4 count/high viral load, the SC = 2. In some cases you may not know the HIV status or the source and in this case the HIV SC is unknown.
This code will help determine the most appropriate PEP regimen, as shown later.
The combination of EC and SC guides the recommendation for 2 or 3 drug PEP regimens.
The important thing to consider is the fact that you have only one chance to give PEP. It is better to err on the side of treatment with 3 versus 2 drugs if there is doubt. However, it is equally important protect scarce resources when PEP is not warranted.