Accidental exposure to blood or body fluids (AEB) is defined as any accidental or involuntary contact with blood or an organic fluid that potentially contains the human immunodeficiency virus (HIV), hepatitis B (HBV) or C (HCV) virus, or other infectious agent following a wound from a needle or other sharp instrument or exposure to damaged mucous membranes or skin.
HIV infection can be prevented after an AEB by rapid post-exposure prophylaxis (PEP) with antiretroviral drugs; hepatitis B can be prevented by vaccination and/or immune globulin. While there is no hepatitis C vaccine, there is an effective treatment.
46.1 First aid
In case of a needle stick or a cut with blood-contaminated materials (percutaneous exposure):
Let the wound bleed (do not apply pressure or scrub the wound)
Clean the wound and the surrounding skin immediately with soap and water, and then rinse
Disinfect the wound and surrounding skin for 5 minutes with:
10% povidone-iodine (Betadine®) or
0.05-1% chlorine solution or
70% alcohol
Chlorhexidine-cetrimide is active against HIV but not against HBV, and so is not recommended for people not vaccinated against HBV and should not be used after an AEB.
46.2 Evaluating the risk of transmission
The likelihood of transmission depends on the type of exposure, the type of fluid, the amount of fluid transmitted and the source patient’s health status and viral load.
A doctor should assess the risk of HIV and hepatitis transmission after an AEB. This assessment should be prompt and thorough so that prophylaxis can begin as soon as possible after the accident
aCitation a.As soon as possible after the accident and within 72 hours at the latest. Beyond that point, the treatment will have no effect.
. Not all AEBs require prophylactic therapy.
The average seroconversion rate with percutaneous exposure is 0.3% for HIV and 10-30% for hepatitis B.
The actual transmission risk will depend on the depth of the wound, amount of infected blood transmitted and the source patient’s viral load. During vaccination campaigns, the most common accidents are needle stick injuries with a needle used for IM or SC injection. The risk is considered “intermediate”.
For an AEB with materials used more than 72 hours previously, the risk of infection is extremely low for HIV, but remains significant for hepatitis B.
46.3 Decision to treat
A medical focal person is responsible for analysing the risk, providing psychological support to the person exposed and choosing a course of action.
The risk analysis should be done quickly so that prophylaxis, if necessary, can be started as soon as possible The analysis should be painstaking in order to clearly determine whether or not antiretroviral prophylaxis is indicated.
The type of exposure, the source patient’s serological status and the status of the person exposed (for HBV) should be taken into account when deciding what to do.
Post-AEB prophylaxis in an intermediate exposure context:
Table 46.1 - Assessing the risk of HIV after an AEB and indications for PEP
| Status of source patient | ||||
|---|---|---|---|---|
| Type of exposure | Positive | Unknown (a)Citation a.Either the source patient is not known, or the source patient is known but his serological status is unknown. | Negative High risk (b)Citation b.The source patient belongs to a high-risk group (for example, sex workers, men who have sex with men, injection drug users, high-risk sexual behaviours) or come from a country where the HIV prevalence is >1%. | Negative Low risk |
| Percutaneous exposure to infectious fluids | PEP | PEP | PEP | No PEP |
| Intact skin exposed to any fluid | No PEP | No PEP | No PEP | No PEP |
Antiretroviral prophylaxis should ideally begin within 4 hours of the AEB, and within 72 hours at the latest. The total duration of treatment is 4 weeks.
Table 46.2- Evaluating the hepatitis B risk after an AEB and indications for PEP
| Vaccination status of the person exposed | ||||||
|---|---|---|---|---|---|---|
Fully vaccinated | Partially vaccinated (with documentation) | Not vaccinated or no documentation of vaccination status | ||||
HBsAb ≥ 10 IU/mL | HBsAb < 10 IU/mL (c)Citation c.HBV vaccine non-responder | HBsAb unknown | ||||
| HBsAg status of the source patient | HBsAg negative | No intervention | Full vaccination schedule (d)Citation d.Plan a 3-dose schedule: Day 0, at 1 month and at 6 months | One booster | Full vaccination schedule (e)Citation e.Resume the immunisation schedule to complete the three doses (Day 0, at 1 month and at 6 months) | Full vaccination schedule (f)Citation f.Plan a 3-dose schedule: Day 0, at 1 month and at 6 months |
| HBsAg positive or unknown | No intervention | Rapid hepatitis B immunisation schedule
(g)Citation g.Rapid immunisation schedule: Day 0, at 7 days and at 21 days, started within 24 hours
* | Rapid hepatitis B immunisation schedule
(g)Citation g.Rapid immunisation schedule: Day 0, at 7 days and at 21 days, started within 24 hours
* | Rapid hepatitis B immunisation schedule
(g)Citation g.Rapid immunisation schedule: Day 0, at 7 days and at 21 days, started within 24 hours
* | Rapid hepatitis B immunisation schedulee (i)Citation i.Rapid immunisation schedule: Day 0, at 7 days and at 21 days, started within 24 hours Immune globulind | |
* If the blood sample results – if available – show a protective level of antibodies (HBsAb ³ 10 IU/mL), there is no need for additional vaccine doses at follow-up visits.
| Treatment with the HBV vaccine and/or hepatitis B immune globulin (HBIG) can reduce HBV transmission by 70 to 90% when administered within 12 to 24 hours post-exposure; it is no longer useful after that point. |
46.4 Reporting the AEB and monitoring the person exposed
| Confidentiality is a must, even in emergency or difficult situations. |
After local first aid, the accident must be reported to the medical officer, whether post-AEB prophylaxis is prescribed or not.
An individual AEB reporting form (with the name of the person exposed) is used to describe the AEB and its management. This confidential form must be completed by the doctor.
Medical follow-up is compulsory, whether post-AEB prophylaxis is prescribed or not.
Clinical monitoring
Look for possible signs of seroconversion
Monitor for tolerance to the prophylactic treatment, if prescribed; look for and manage adverse effects
Provide support for the person exposed: psychological support: active listening and regular check-ins (exposure can be a source of worry); encourage adherence if PEP is prescribed
Laboratory monitoring
Perform antibody testing for HIV and HCV within 8 days of the AEB (this is a medico-legal requirement). If positive, the accident was not the cause of the seroconversion; if at least one of the tests is positive, refer for specialised follow-up.
If HIV-negative, HBV-negative and HCV-negative, follow this schedule:
| PEP prescribed | PEP not prescribed | |
|---|---|---|
| Between Day 0 and Day 7 (j)Citation j.Testing between Day 0 and Day 7 is required for the accident to be considered an occupational accident for insurance purposes. Only the tests in bold are absolutely necessary. If the other tests are not available, PEP can be managed without them. | Baseline serological status HIV (k)Citation k.Follow the MSF/WHO guidelines. Confirmation of seropositivity requires three different positive rapid tests. and HCV: rapid test or serology HBV: if HBsAb < 10 IU/mL or unknown, test quickly. Laboratory monitoring. | |
| Day 14 (or sooner if clinically indicated) | Laboratory monitoring according to PEP regimen prescribed | |
| Week 6 (or sooner if clinically indicated) | HIV
(l)Citation l.The HIV test done at 6 weeks, if negative, should reassure the person exposed.However, it is no guarantee against future seroconversion, especially among people on antiretroviral prophylaxis, where the immune response can be delayed and hence, when to do it?
, and HCV RNA if HCV RNA+ Monitoring according to PEP regimen prescribed | HIV
|
| Month 3 | HIV and HCV | HIV, ALT and AST |
46.5 AEB kit
The MSF AEB kits (KMEDMPE03- MODULE, PEP, post exposure prophylaxis for AIDS 2021) contain the PEP guidelines and a complete (28-day) PEP treatment for one person.
DORATELD1TPEP: 30 Tenofovir 300 mg/Lamivudine 300 mg/Dolutegravir 50 mg tablets
DORATELA1T-: 30 Tenofovir 300 mg/Lamivudine 300 mg tablets
DORADRVR45T: 60 Darunavir 400 mg tablets + 30 Ritonavir 100 mg tablets
The kit contains the standard MSF triple therapy (but kit contents can vary depending on the national protocol).
A stock of a few hepatitis B vaccines may be considered in a high HBV prevalence context, but not immune globulin.
- (a)
As soon as possible after the accident and within 72 hours at the latest. Beyond that point, the treatment will have no effect.
- a
Either the source patient is not known, or the source patient is known but his serological status is unknown.
- b
The source patient belongs to a high-risk group (for example, sex workers, men who have sex with men, injection drug users, high-risk sexual behaviours) or come from a country where the HIV prevalence is >1%.
- c
HBV vaccine non-responder
- d
Plan a 3-dose schedule: Day 0, at 1 month and at 6 months
- e
Resume the immunisation schedule to complete the three doses (Day 0, at 1 month and at 6 months)
- f
Plan a 3-dose schedule: Day 0, at 1 month and at 6 months
- g
Rapid immunisation schedule: Day 0, at 7 days and at 21 days, started within 24 hours
- h
If available, give one dose of hepatitis B immune globulin (100 IU) with the first vaccine dose at a different injection site
- i
Rapid immunisation schedule: Day 0, at 7 days and at 21 days, started within 24 hours
- j
Testing between Day 0 and Day 7 is required for the accident to be considered an occupational accident for insurance purposes. Only the tests in bold are absolutely necessary. If the other tests are not available, PEP can be managed without them.
- k
Follow the MSF/WHO guidelines. Confirmation of seropositivity requires three different positive rapid tests.
- l
The HIV test done at 6 weeks, if negative, should reassure the person exposed.However, it is no guarantee against future seroconversion, especially among people on antiretroviral prophylaxis, where the immune response can be delayed and hence, when to do it?