Incidence of visits for health care worker blood or body fluid exposures and HIV postexposure prophylaxis provision at Rhode Island emergency departments

Patterns of Occupational Exposure to Human Immunodeficiency Virus and Post-Exposure Prophylaxis Among Health Care Personnel in a Tertiary Care Institute in South India - A Retrospective Case Series

Background

Post-exposure prophylaxis (PEP) for occupational human immunodeficiency virus (HIV) exposure involves the comprehensive measures used to prevent transmission of blood-borne pathogens such as HIV, hepatitis B virus, and hepatitis C virus through various strategies such as first aid, counseling, risk assessment, relevant laboratory investigations with informed consent, the provision of short-term anti-retroviral drugs, and follow-up testing.

Aim and Objectives

We sought to investigate the patterns and causes of occupational exposure in health care workers (HCWs) in our institute and the usage of PEP in our center, a tertiary care hospital in south India.

Materials and Methods

The study involved a retrospective analysis of data extracted from the records of PEP usage from the anti-retroviral treatment (ART) center attached to the dermatology, venereology and leprosy out-patient department of a tertiary care center in south India. The data were extracted into a pre-designed proforma and analyzed using descriptive statistics.

Results

A total of 352 health care professionals reported to the ART center for PEP from 2010 to 2020. One hundred and thirty-four patients took only the first dose as the source patient later tested to be HIV-negative. Among the 218 remaining patients, 84 were male and 134 were female patients. Only 56 health care workers started the regimen within 2 hours. One hundred and thirty-four patients completed the full course of PEP. Most HCWs (n = 68, 31%) sustained the exposure while doing a procedure on the patient followed by re-capping a needle (n = 64, 29%). Gastritis and drowsiness were the most common adverse effects.

Limitations and Conclusions

The study was limited by the retrospective nature of data collection and the lack of detailed interviews with HCWs. Knowledge about PEP, needle safety training, and training of early first aid measures should be increased among health care workers.

HIV post-exposure prophylaxis in the Emergency Department: a perspective from Singapore

Background:

Exposures to human immunodeficiency virus (HIV) commonly arrive at the Emergency Department (ED) for evaluation of transmission risk and the necessity for post-exposure prophylaxis (PEP). PEP aims to prevent HIV after exposure. International recommendations exist to guide eligibility assessment and standardise prescribing practices.

Objective:

The primary objective was to describe the patient cohort receiving HIV PEP at the ED. The secondary objective was to assess the ED physicians’ adherence to the 2005 guidelines provided by US Centers for Disease Control and Prevention for HIV PEP.

Methods:

This retrospective study identified patients prescribed with PEP after presenting with potential HIV exposure to a tertiary hospital ED in Singapore over 2 years. The exposure type and characteristics, source patient characteristics, indications for PEP, HIV status on presentation and on follow-up were assessed. Institutional guidelines recommended tenofovir/emtricitabine (Truvada) and raltegravir as HIV PEP.

Results:

Twenty-seven patients received HIV PEP during the study period. The majority (81.5%) presented after occupational exposure, with fresh needlestick injury (44.4%) being the most common cause. Amongst all recipients, PEP was indicated in 22.2% and not in 18.5%.

Conclusions:

With international guidelines simplifying eligibility assessment and prescribing practices, accurate and evidence-based PEP provision should be implemented at the frontline in the ED. These may be encouraged by enforcement of specific workflows and physician education.

Missed Opportunities for HIV Prophylaxis Among Emergency Department Patients With Occupational and Nonoccupational Body Fluid Exposures

STUDY OBJECTIVE

Exposures to HIV are frequently managed in the emergency department (ED) for assessment and potential initiation of HIV postexposure prophylaxis. Despite established guidelines, it is unclear whether patients with a nonoccupational exposure are managed similarly to patients with an occupational exposure.

METHODS

This retrospective study used an administrative database to identify consecutive patients at a single ED with a discharge diagnosis of "blood or body fluid exposure" without sexual assault from April 1, 2007 to June 30, 2013. Patient exposure details and physician management were ascertained according to predefined guidelines. The primary outcome was the proportion of patients with high-risk exposures who were correctly given HIV prophylaxis; the secondary outcome was the proportion of patients with low-risk exposures who were correctly not given HIV prophylaxis. Other outcomes included the proportion of patients who had a baseline HIV test in the ED, the proportion who followed up with an HIV test within 6 months, and the number of seroconversions in this group. All outcomes were compared between nonoccupational and occupational exposure.

RESULTS

Of 1,972 encounters, 1,358 patients (68.9%) had an occupational exposure and 614 (31.1%) had a nonoccupational exposure. In the occupational exposure group, 190 patients (14.0%) were deemed high risk, with 160 (84.2%; 95% confidence interval [CI] 78.1% to 88.9%) appropriately given prophylaxis. In the nonoccupational exposure group, 287 patients (46.7%) had a high-risk exposure, with 208 (72.5%; 95% CI 66.8% to 77.5%) given prophylaxis, for a difference of 11.7% (95% CI 3.8% to 19.1%). For low-risk exposures, appropriate management of both occupational and nonoccupational exposure was similar (92.4% versus 93.0%). At the index ED visit, 90.5% of occupational exposure patients and 76.7% of nonoccupational exposure patients received HIV testing, for a difference of 13.8% (95% CI 10.1% to 17.7%). At 6 months, 25.4% of patients with an occupational exposure and 35.0% of patients with a nonoccupational exposure had a follow-up test, for a difference of -9.6% (95% CI -14.2% to -5.1%). Of patients who had follow-up testing within 6 months, 4 of 215 (1.9%) in the nonoccupational exposure group tested newly positive for HIV, whereas 0 of 345 (0%) in the occupational exposure group tested positive.

CONCLUSION

For ED patients with blood or body fluid exposures, those with high-risk nonoccupational exposures were not given HIV prophylaxis nearly twice as often as those with high-risk occupational exposure. Although 6-month follow-up testing rates were low, 1.9% of high-risk nonoccupational exposure patients seroconverted.

Quantification of HIV-1 viral RNA in the blood in needles used for venous puncture in HIV-infected individuals

INTRODUCTION

Occupational HIV infection among healthcare workers is an important issue in exposures involving blood and body fluids. There are few data in the literature regarding the potential and the duration of infectivity of HIV type 1 (HIV-1) in contaminated material under adverse conditions.

METHODS

We quantified HIV-1 viral RNA in 25×8mm calibre hollow-bore needles, after punctures, in 25 HIV-1-infected patients selected during the sample collection. All of the patients selected were between the ages of 18 and 55. Five samples were collected from 16 patients: one sample for the immediate quantification of HIV-1 RNA in the plasma and blood samples from the interior of 4 needles to be analyzed at 0 h, 6 h, 24 h, and 72 h after collection. In nine patients, another test was carried out in the blood from one additional needle, in which HIV-1 RNA was assessed 168 h after blood collection. The method used to assess HIV-1 RNA was nucleic acid sequence-based amplification.

RESULTS

Up to 7 days after collection, HIV-1 RNA was detected in all of the needles. The viral RNA remained stable up to 168 h, and there were no statistically significant differences among the needle samples.

CONCLUSIONS

Although the infectivity of the viral material in the needles is unknown, the data indicate the need to re-evaluate the practices in cases of occupational accidents in which the source is not identified.

Efficiency of International Classification of Diseases, Ninth Revision, billing code searches to identify emergency department visits for blood or body fluid exposures through a statewide multicenter database

BACKGROUND

Blood and body fluid exposures are frequently evaluated in emergency departments (EDs). However, efficient and effective methods for estimating their incidence are not yet established.

OBJECTIVE

Evaluate the efficiency and accuracy of estimating statewide ED visits for blood or body fluid exposures using International Classification of Diseases, Ninth Revision (ICD-9), code searches.

DESIGN

Secondary analysis of a database of ED visits for blood or body fluid exposure.

SETTING

EDs of 11 civilian hospitals throughout Rhode Island from January 1, 1995, through June 30, 2001.

PATIENTS

Patients presenting to the ED for possible blood or body fluid exposure were included, as determined by prespecified ICD-9 codes.

METHODS

Positive predictive values (PPVs) were estimated to determine the ability of 10 ICD-9 codes to distinguish ED visits for blood or body fluid exposure from ED visits that were not for blood or body fluid exposure. Recursive partitioning was used to identify an optimal subset of ICD-9 codes for this purpose. Random-effects logistic regression modeling was used to examine variations in ICD-9 coding practices and styles across hospitals. Cluster analysis was used to assess whether the choice of ICD-9 codes was similar across hospitals.

RESULTS

The PPV for the original 10 ICD-9 codes was 74.4% (95% confidence interval [CI], 73.2%-75.7%), whereas the recursive partitioning analysis identified a subset of 5 ICD-9 codes with a PPV of 89.9% (95% CI, 88.9%-90.8%) and a misclassification rate of 10.1%. The ability, efficiency, and use of the ICD-9 codes to distinguish types of ED visits varied across hospitals.

CONCLUSIONS

Although an accurate subset of ICD-9 codes could be identified, variations across hospitals related to hospital coding style, efficiency, and accuracy greatly affected estimates of the number of ED visits for blood or body fluid exposure.

Blood or body fluid exposures and HIV postexposure prophylaxis utilization among first responders

OBJECTIVES

To estimate the incidence of first-responder visits to emergency departments (EDs) for blood or body fluid exposures, elucidate any temporal patterns of these visits, and quantify human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) utilization for these exposures.

METHODS

This was a retrospective study of first responders presenting to Rhode Island EDs for blood or body fluid exposures from 1995 to 2001. Incidence rates for exposures with 95% confidence intervals (CIs) were estimated. Temporal trends for visits were modeled. Factors associated with HIV PEP utilization were identified using logistic regression. Odds ratios (ORs) with 95% CIs were estimated.

RESULTS

The average incidence rate of ED visits for blood or body fluid exposures was 23.29 (20.07-26.52) ED visits per 100,000 ambulance runs. The incidence rose between 1995 and 1999 and then decreased. First-responder ED visits were lowest in October and highest in April and were lowest at 7 am and highest at 7 pm. First responders presenting with a percutaneous or blood-to-mucous membrane exposure had a 4.13 (1.82-8.89) greater odds and those exposed to a known HIV-infected source had a 9.03 (1.59-51.26) greater odds of being offered HIV PEP. First responders presenting to a teaching hospital had a 2.21 (1.02-4.77) greater odds of being offered prophylaxis and a 4.20 (1.08-16.32) greater odds of accepting prophylaxis when it was offered.

CONCLUSIONS

First responders face a risk of blood or body fluid exposure that varies over the course of the day and the year. HIV PEP is more likely to be used if the exposures are percutaneous, or blood-to-mucous membrane, or if the source is known to be HIV-infected. Standardization of protocols across EDs for administering HIV prophylaxis appears to be needed.