Chapter 2The Pre-Travel ConsultationSelf-Treatable Conditions

Eli W. Warnock III, V. Ramana Dhara, Alan G. Czarkowski

RISK FOR HEALTH CARE WORKERS TRAVELING OUTSIDE THE UNITED STATES

The risk of occupational exposure to HIV is most closely related to the activities and duties of the health care worker, but geographic location can also affect the risk of exposure and the quality of postexposure care. Many factors can increase the risk of occupational HIV exposure in developing countries:

• Less stringent safety procedures and standards
• Limited resources for postexposure evaluation and treatment
• High rates of undiagnosed HIV infection
• Limited access to personal protective equipment

MODES OF TRANSMISSION

HIV may be transmitted occupationally to health care workers engaged in routine medical activities and procedures that can result in needlesticks or blood splashes. The routine nature of these procedures may cause health care workers to relax their vigilance and adherence to safety details. Typically exposures occur as a result of percutaneous exposure to contaminated sharps, including needles, lancets, scalpels, and broken glass. Needlesticks from large-bore hollow needles that have contaminated material in the bore are thought to carry a high risk of transmission. Contact between infectious material and mucous membranes or nonintact skin may also transmit HIV.

EPIDEMIOLOGY

The global number of HIV infections among health care workers attributable to sharps injuries has been estimated to be 1,000 cases (range, 200–5,000) per year. In prospective studies, the average risk for HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3% (95% confidence interval [CI], 0.2%–0.5%) and after a mucous membrane exposure, approximately 0.09% (95% CI, 0.006%–0.5%). Although HIV has been transmitted through exposure to nonintact skin, the average risk for transmission by this route has not been quantified but is estimated to be less than the risk for mucous membrane exposures.

PREVENTIVE MEASURES FOR TRAVELERS

People working internationally who will be engaging in high-risk occupational health care activities, such as drawing blood or the other use of sharps during patient care, should consistently follow standard precautions to reduce the risk of occupational exposure to HIV and other bloodborne pathogens. Standard precautions involve the use of protective barriers such as gloves, gowns, aprons, masks, or protective eyewear. Additional information about occupational health and safety standards for bloodborne pathogens can be found at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051

In addition, clinicians working internationally should:

• Always be mindful of the hazards posed by sharps injuries.
• Maintain strict safety standards while working in environments that may have less stringent standards.
• Use devices with safety features and improved work practices (www.cdc.gov/niosh/docs/2000-108/).
• Consider bringing their own protective equipment if they are unsure of its availability at their destination.
• Consider bringing postexposure prophylaxis (PEP) for HIV in the event that they are injured with a potentially contaminated sharp.

POSTEXPOSURE MANAGEMENT

Health care workers who may have been occupationally exposed to HIV should immediately perform the following steps:

• Wash the exposed area with soap and water thoroughly. If mucous membrane exposure has occurred, flush the area with copious amounts of water or saline.
• If possible, assess the HIV status of the source. Rapid HIV testing is preferred. If the source’s rapid HIV antibody test result is positive, assume that it is a true positive.
• Seek qualified medical evaluation as soon as possible to guide decisions on postexposure treatment and testing.
• Contact the National Clinicians’ Postexposure Prophylaxis Hotline (PEPline) at 1-888-448-4911 (24 hours a day, 7 days per week) for assistance in assessing risk and advice on managing occupational exposures to HIV and other bloodborne pathogens (www.nccc.ucsf.edu/about_nccc/pepline). If the toll-free number is not accessible when calling from another country, the main administrative line for the National HIV/AIDS Clinicians’ Consultation Center is 415-206-8700.
• Consider beginning PEP for HIV (see below).

Postexposure Prophylaxis

A number of medication combinations are available for PEP. Since these regimens may change based on new research, refer to MMWR’s Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis (http://aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?MenuItem=Guidelines&Search=Off&GuidelineID=10&ClassID=3) and the PEPline for more information about PEP recommendations. Specific regimens should be determined by clinicians familiar with the medications and the health care worker’s medical history.

If the exposed person chooses to initiate PEP, he or she must do so within hours of the exposure. PEP can be stopped if new information changes the assessment; however, waiting to start PEP until all information is gathered can decrease its efficacy. If indicated, arrange for procurement or shipment of additional PEP from a credible source to complete the recommended 4-week course of treatment.

Consider other potential infectious disease exposures from the source material, including hepatitis B virus or hepatitis C virus (HCV), and manage as appropriate.

Postexposure Testing

People with occupational exposure to HIV should receive HIV antibody testing by enzyme immunoassay as soon as possible after exposure as a baseline, with follow-up testing at 6 weeks, 3 months, and 6 months. Extended HIV follow-up testing for up to 12 months is recommended for those who become infected with HCV after exposure to a source coinfected with HIV and HCV. Postexposure counseling and medical evaluation should be provided, whether or not the exposed person receives PEP (http://aidsinfo.nih.gov/contentfiles/Health CareOccupExpoGL_PDA.pdf).

Exposed health care workers should be advised to use precautions (avoid blood or tissue donations, breastfeeding, or pregnancy) to prevent secondary transmission, especially during the first 6–12 weeks after exposure. For exposures for which PEP is indicated, exposed people should be counseled regarding possible drug toxicities and interactions, the need for monitoring, and the importance of careful adherence to PEP regimens.

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