principles of oral health management for the hiv/aids patient
TRANSCRIPT
Principles of Oral HealthManagement for the
HIV/AIDS Patient
A Course of Training for the Oral Health Professional
Made possible from a grant to the New York State Department of Health AIDS Institute from the HIV/AIDS Bureau, Division of Community Based Programs, Health Resources and Services Administration, DHHS
June 2000
Jennifer L. Cleveland, DDS, MPHBarbara F. Gooch, DMD, MPH
Denise Cardo, MDHelene Bednarsh, RDH, MPHKathy J. Eklund, RDH, MHP
Jennifer L. Cleveland, DDS, MPHBarbara F. Gooch, DMD, MPH
Denise Cardo, MDHelene Bednarsh, RDH, MPHKathy J. Eklund, RDH, MHP
Module 1Occupational Exposures to
Bloodborne Pathogens: Risk, Prevention, and
Management
Module 1Occupational Exposures to
Bloodborne Pathogens: Risk, Prevention, and
Management
June 2000
Risk for transmission is low
Preventing exposures is primary goal
Prompt reporting and management is
essential
PEP may be effective in preventing HIV
Risk for transmission is low
Preventing exposures is primary goal
Prompt reporting and management is
essential
PEP may be effective in preventing HIV
SummarySummary
June 2000
Documented vs. possible case of HIV infection
Risk factors for HIV transmission
Characteristics of PIs in dentistry
Three categories of prevention strategies
Considerations for PEP
Qualifications of a health care provider
Documented vs. possible case of HIV infection
Risk factors for HIV transmission
Characteristics of PIs in dentistry
Three categories of prevention strategies
Considerations for PEP
Qualifications of a health care provider
ObjectivesObjectives
June 2000
Need for prompt medical evaluation
Dentist/employer role
Elements of an exposure report
Importance of counseling
Issues of confidentiality
Ethical and legal considerations
Need for prompt medical evaluation
Dentist/employer role
Elements of an exposure report
Importance of counseling
Issues of confidentiality
Ethical and legal considerations
ObjectivesObjectives
June 2000
Determinants of Risk
Determinants of Risk
Prevalence of infection in patients
Risk of infection after single blood contact
Nature and frequency of blood contacts
Prevalence of infection in patients
Risk of infection after single blood contact
Nature and frequency of blood contacts
June 2000
Health Care Workers with Documented and Possible Occupationally Acquired HIV/AIDS
Infection
Health Care Workers with Documented and Possible Occupationally Acquired HIV/AIDS
Infection
Documented Documented
Possible Possible
NurseNurse 2323 3434
Lab Tech, clinicalLab Tech, clinical 1616 1616
Physician, nonsurgicalPhysician, nonsurgical 6 6 1212Lab Tech, nonclinicalLab Tech, nonclinical 3 3 – –
Dental WorkerDental Worker 0 0 6 (*) 6 (*)
OtherOther 7 7 68 68TotalTotal 5555 136136
CDC Database as of June 1999CDC Database as of June 1999
(*) 3 dentists, 1 oral surgeon, 2 assistants(*) 3 dentists, 1 oral surgeon, 2 assistants
June 2000
HIV Seroprevalence, U.S. DentistsHIV Seroprevalence, U.S. Dentists
Author
Flynn
Klein
ADA News
Siew
Author
Flynn
Klein
ADA News
Siew
Location
Sacramento,1987
ADA meeting and New York City,1986
ADA meetings, 1987–1998
AAOMS** meeting, 1992
Location
Sacramento,1987
ADA meeting and New York City,1986
ADA meetings, 1987–1998
AAOMS** meeting, 1992
No. Tested
89
1132*
>18,000
321
No. Tested
89
1132*
>18,000
321
No. Pos.(%)
0 (0)
1 (0.09)
2 (<0.01)
0 (0)
No. Pos.(%)
0 (0)
1 (0.09)
2 (<0.01)
0 (0)
* Community risk excluded** American Association of Oral and Maxillofacial Surgeons* Community risk excluded** American Association of Oral and Maxillofacial Surgeons
June 2000
Average Risk of HIV Infection to HCWs by Exposure Route (%)
Average Risk of HIV Infection to HCWs by Exposure Route (%)
Percutaneous 0.3
Mucous membrane 0.1
Non-intact skin <0.1
Percutaneous 0.3
Mucous membrane 0.1
Non-intact skin <0.1
June 2000
Average Risk of Transmissionafter Percutaneous Exposure to
Blood
Average Risk of Transmissionafter Percutaneous Exposure to
Blood
HIVHepatitis CHepatitis B (only HBeAg)
HIVHepatitis CHepatitis B (only HBeAg)
0.31.8
30.0
0.31.8
30.0
SourceSource Risk (%)Risk (%)
June 2000
Risk Factors for HIV Transmission after Percutaneous Exposure to HIV-Infected
Blood CDC Case-Control Study
Risk Factors for HIV Transmission after Percutaneous Exposure to HIV-Infected
Blood CDC Case-Control Study
Risk Factor Adjusted OR ratio (95% CI)
Deep injury 15.0 (6.0-41)
Visible blood on device 6.2 (2.2-21)
Procedure involving needle 4.3 (1.7-12) placed in artery or vein
Terminal illness in source patient 5.6 (2.0-16)
Postexposure use of zidovudine 0.19 (0.06-0.52)
Cardo et al., NEJM;1997;337:1485-90
Risk Factor Adjusted OR ratio (95% CI)
Deep injury 15.0 (6.0-41)
Visible blood on device 6.2 (2.2-21)
Procedure involving needle 4.3 (1.7-12) placed in artery or vein
Terminal illness in source patient 5.6 (2.0-16)
Postexposure use of zidovudine 0.19 (0.06-0.52)
Cardo et al., NEJM;1997;337:1485-90
June 2000
Annual Number ofPercutaneous Injuries*
1987–1993
Annual Number ofPercutaneous Injuries*
1987–1993
00
22
44
66
88
1010
1212
19871987 19881988 19891989 19901990 19911991 19921992 19931993
11.411.4
8.88.8
6.26.25.45.4
3.53.5 2.92.92.22.2
Number
*ADA Health Screening, per dentist
June 2000
Dentists Oral Surgeons – burs – wires
– extraoral – fracture reductions
– hands/fingers
Dentists Oral Surgeons – burs – wires
– extraoral – fracture reductions
– hands/fingers
Characteristics ofPercutaneous Injuries
Characteristics ofPercutaneous Injuries
June 2000
Percutaneous Injuries AmongDental Workers (n=19) in
CDC Needlestick Study, 1995
Percutaneous Injuries AmongDental Workers (n=19) in
CDC Needlestick Study, 1995
One third of instruments visibly bloody at time of injury
Hollow-bore needles of smaller gauge (>18 gauge)
No deep puncture wounds
One third of instruments visibly bloody at time of injury
Hollow-bore needles of smaller gauge (>18 gauge)
No deep puncture wounds
June 2000
Prevention StrategiesPrevention Strategies
Categories
Engineering controls
Work practice controls
Personal protective equipment
Categories
Engineering controls
Work practice controls
Personal protective equipment
June 2000
Engineering Controls
Remove the hazard from the worker
Technology based, safer design of instruments
Engineering Controls
Remove the hazard from the worker
Technology based, safer design of instruments
Prevention StrategiesPrevention Strategies
June 2000
Work Practice Controls
Behavior based
Change the manner in which the task is performed
Work Practice Controls
Behavior based
Change the manner in which the task is performed
Prevention StrategiesPrevention Strategies
June 2000
Personal Protective Equipment
Gloves, masks, protective eyewear
Puncture-resistant gloves and thimbles
Double gloves
Personal Protective Equipment
Gloves, masks, protective eyewear
Puncture-resistant gloves and thimbles
Double gloves
Prevention StrategiesPrevention Strategies
June 2000
Worker Education and Training
Strategies to prevent occupational exposure to blood
Importance of reporting exposure incidents
Worker Education and Training
Strategies to prevent occupational exposure to blood
Importance of reporting exposure incidents
Prevention StrategiesPrevention Strategies
June 2000
Public Health Service Guidelines for the Management of Health-Care Worker Exposures to HIV and Recommendations for Postexposure Prophylaxis (PEP)
Public Health Service Guidelines for the Management of Health-Care Worker Exposures to HIV and Recommendations for Postexposure Prophylaxis (PEP)
MMWR , May 15, 1998;47(No. RR-7)MMWR , May 15, 1998;47(No. RR-7)
Provide scientific rationale
Emphasize consultation with HIV Expert
Provide scientific rationale
Emphasize consultation with HIV Expert
June 2000
Biologically plausible
Animal studies
Human studies– case-control
– perinatal transmission
Biologically plausible
Animal studies
Human studies– case-control
– perinatal transmission
Efficacy of PEPEfficacy of PEP
June 2000
“in the absence of visible blood in the saliva, exposure to saliva from a person infected with HIV is not considered a risk for HIV transmission”
MMWR 1998/Vol. 47/No. RR-7
“in the absence of visible blood in the saliva, exposure to saliva from a person infected with HIV is not considered a risk for HIV transmission”
MMWR 1998/Vol. 47/No. RR-7
June 2000
PEPPEP
Risk of Adverse EffectsRisk of Adverse Effects
Risk of TransmissionRisk of Transmission
June 2000
Assess epidemiologically
Review medical records
Modify PEP if new information becomes available
Assess epidemiologically
Review medical records
Modify PEP if new information becomes available
Unknown HIV Status of Source Unknown HIV Status of Source
June 2000
PEP RegimensPEP Regimens Basic regimen
– For exposures with recognized risk of HIV transmission
– Drugs•ZDV •3TC
Basic regimen– For exposures with
recognized risk of HIV transmission
– Drugs•ZDV •3TC
Expanded regimen– For exposures with
increased risk of HIV transmission
– Drugs•Basic regimen PLUS
•Indinavir OR•Nelfinavir
Expanded regimen– For exposures with
increased risk of HIV transmission
– Drugs•Basic regimen PLUS
•Indinavir OR•Nelfinavir
June 2000
Initiation of PEPInitiation of PEP
Start PEP as soon as possible after exposure
– Hours rather than days
– Regard as an urgent medical concern
– Duration 4 weeks
Start PEP as soon as possible after exposure
– Hours rather than days
– Regard as an urgent medical concern
– Duration 4 weeks
June 2000
Monitor blood, renal, liver function
Subjective symptoms (nausea,
fatigue, malaise) are frequent
30%–50% cases stopped treatment
Monitor blood, renal, liver function
Subjective symptoms (nausea,
fatigue, malaise) are frequent
30%–50% cases stopped treatment
PEP Safety and ToxicityPEP Safety and Toxicity
June 2000
Possible Reasons for PEP FailuresPossible Reasons for PEP Failures
Exposure to ZDV-resistant strain of HIV
High titer or large inoculum
Delayed initiation or short duration of PEP
Host factors, e.g., diminished immune response
Exposure to ZDV-resistant strain of HIV
High titer or large inoculum
Delayed initiation or short duration of PEP
Host factors, e.g., diminished immune response
June 2000
Policy statementStaff education and training Identification of a health care professional
Policy statementStaff education and training Identification of a health care professional
Postexposure Managementand Follow-up
Postexposure Managementand Follow-up
June 2000
Promote prompt reporting
Facilitate access to care
Ensure confidentiality
Consistent with OSHA and PHS
Promote prompt reporting
Facilitate access to care
Ensure confidentiality
Consistent with OSHA and PHS
Policy StatementPolicy Statement
June 2000
Prevention strategies
Principles of postexposure management
PEP efficacy and toxicity
Importance of prompt reporting
Prevention strategies
Principles of postexposure management
PEP efficacy and toxicity
Importance of prompt reporting
Staff Education and TrainingStaff Education and Training
June 2000
Qualified to manage, counsel, provide medical follow-up
Selected before exposure incident
Familiar with dental aspects of risk assessment and management
Qualified to manage, counsel, provide medical follow-up
Selected before exposure incident
Familiar with dental aspects of risk assessment and management
The Health Care ProfessionalThe Health Care Professional
June 2000
Clean wounds with soap and water Flush mucous membranes with water
Avoid use of bleach and other caustic agents
Clean wounds with soap and water Flush mucous membranes with water
Avoid use of bleach and other caustic agents
Wound CareWound Care
June 2000
Facilitate prompt and confidential reporting
Provide timely access to PEP
Designate knowledgeable personnel to– evaluate exposure
– initiate referral to HCP
– complete forms
Facilitate prompt and confidential reporting
Provide timely access to PEP
Designate knowledgeable personnel to– evaluate exposure
– initiate referral to HCP
– complete forms
Reporting SystemReporting System
June 2000
Copy of the Standard
Description of the employee’s job duties
Report of the specific exposure incident– Route(s)/Circumstances
– Results of source blood testing, if available
– Relevant employee medical records
Copy of the Standard
Description of the employee’s job duties
Report of the specific exposure incident– Route(s)/Circumstances
– Results of source blood testing, if available
– Relevant employee medical records
Information Provided to HCPInformation Provided to HCP
June 2000
Elements of an Exposure ReportElements of an Exposure Report
Date and time of exposure
Procedure details… where, when, how, with what device
Exposure details...route ,body substance involved, volume/duration of contact
Information about source patient
Exposure management details
Date and time of exposure
Procedure details… where, when, how, with what device
Exposure details...route ,body substance involved, volume/duration of contact
Information about source patient
Exposure management details
June 2000
Document source in writing, unless– not feasible or prohibited by law
Contact source for consent for HIV testing and disclosure of results to exposed person
Maintain confidentiality
Document source in writing, unless– not feasible or prohibited by law
Contact source for consent for HIV testing and disclosure of results to exposed person
Maintain confidentiality
Source Patient Identification and TestingSource Patient Identification and Testing
June 2000
Baseline, 6 and 12 weeks, 6 months
Extending to 12 months optional
HCP will notify employee of results
Baseline, 6 and 12 weeks, 6 months
Extending to 12 months optional
HCP will notify employee of results
Testing of Exposed WorkerTesting of Exposed Worker
June 2000
Employee’s infectious status
Potential risk of infection
Considerations for PEP
Results of and interpretation of tests
Employee’s infectious status
Potential risk of infection
Considerations for PEP
Results of and interpretation of tests
CounselingCounseling
June 2000
Seek medical evaluation for acute illness (e.g., fever, rash, flu-like illness)
Prevent secondary transmission– no blood/tissue donation– no breast feeding– use sexual abstinence or condoms
Seek medical evaluation for acute illness (e.g., fever, rash, flu-like illness)
Prevent secondary transmission– no blood/tissue donation– no breast feeding– use sexual abstinence or condoms
EducationEducation
June 2000
Management of Exposures to HBVManagement of Exposures to HBV
HBsAg status of source
Immunization status of exposed person
HBsAg status of source
Immunization status of exposed person
Need for postexposure prophylaxis and/or vaccination depends on:Need for postexposure prophylaxis and/or vaccination depends on:
June 2000
Baseline testing for anti-HCV
Follow-up testing for anti-HCV and liver enzyme activity
No prophylaxis with IG or antiviral agents
Education on risk and prevention
Baseline testing for anti-HCV
Follow-up testing for anti-HCV and liver enzyme activity
No prophylaxis with IG or antiviral agents
Education on risk and prevention
Management of Exposures to HCVManagement of Exposures to HCV
June 2000
Ethical ConsiderationsEthical Considerations
ConfidentialityConfidentiality
Legal IssuesLegal Issues
June 2000
Risk for transmission is low
Preventing exposures is primary goal
Promptly report and manage exposures
PEP may be effective in preventing HIV
Risk for transmission is low
Preventing exposures is primary goal
Promptly report and manage exposures
PEP may be effective in preventing HIV
SummarySummary
June 2000
Sources of Additional InformationSources of Additional Information
CDC Hospital Infections Program Home Page: http://www.cdc.gov/ncidod/hip/
PEPline: toll-free 888-448-4911
National Prevention Information Network: 800-458-5231
CDC Hospital Infections Program Home Page: http://www.cdc.gov/ncidod/hip/
PEPline: toll-free 888-448-4911
National Prevention Information Network: 800-458-5231
June 2000
Intact skin only
Intact skin only
STEP 1: Determine the Exposure Code (EC) STEP 1: Determine the Exposure Code (EC)
Percutaneous exposure
Percutaneous exposure
Mucous membrane or skin, integrity compromised
Mucous membrane or skin, integrity compromised
NoNoYesYes
OPIMOPIM Blood or bloody fluidBlood or bloody fluid
EC 1EC 1
What type of exposure has occurred?What type of exposure has occurred?
No PEP neededNo PEP needed
Is the source material blood, bloody fluid, other potentially infectious material (OPIM), or an instrument contaminated with one of these substances?
Is the source material blood, bloody fluid, other potentially infectious material (OPIM), or an instrument contaminated with one of these substances?
No PEP neededNo PEP neededVolume?Volume? Severity?Severity?
Small (e.g., few drops,
short duration)
Small (e.g., few drops,
short duration)
Large (e.g., several drops,
major blood splash and/or longer
duration)
Large (e.g., several drops,
major blood splash and/or longer
duration)
Less Severe (e.g., solid
needle, superficial scratch)
Less Severe (e.g., solid
needle, superficial scratch)
More Severe (e.g., large-bore hollow
needle, deep puncture, visible blood on device,
needle used in source patient’s artery or
vein)
More Severe (e.g., large-bore hollow
needle, deep puncture, visible blood on device,
needle used in source patient’s artery or
vein)EC 2EC 2 EC 2EC 2 EC 3EC 3
June 2000
What is the HIV Status of the Exposure Source?
What is the HIV Status of the Exposure Source?
HIVnegative
HIVnegative
HIVpositive
HIVpositive
Statusunknow
n
Statusunknow
n
SourceunknownSource
unknown
No PEP neededNo PEP needed
HIV SC UnknownHIV SC
Unknown
HIV SC 2
HIV SC 2
HIV SC 1HIV SC 1
Lower titer exposure,e.g., asymptomatic and high CD4 count
Lower titer exposure,e.g., asymptomatic and high CD4 count
Higher titer HIV exposure,e.g., advanced AIDS, primary HIV infection, high or increasing viral load or low CD4 count
Higher titer HIV exposure,e.g., advanced AIDS, primary HIV infection, high or increasing viral load or low CD4 count
STEP 2: Determine the HIV Status Code (HIV SC)
STEP 2: Determine the HIV Status Code (HIV SC)
June 2000
STEP 3: Determine the PEP Recommendation
STEP 3: Determine the PEP Recommendation
EC
1
1
2
2
3
2 or 3
EC
1
1
2
2
3
2 or 3
HIV SC
1
2
1
2
1 or 2
Unknown
HIV SC
1
2
1
2
1 or 2
Unknown
PEP recommendation
PEP may not be warranted
Consider basic regimen
Recommend basic regimen
Recommend expanded regimen
Recommend expanded regimen
Consider basic regimen if setting suggests risk for HIV exposure
PEP recommendation
PEP may not be warranted
Consider basic regimen
Recommend basic regimen
Recommend expanded regimen
Recommend expanded regimen
Consider basic regimen if setting suggests risk for HIV exposure