Occupational Blood Borne Infections: Prevention is Better than Cure

Occupational Blood Borne Infections: Prevention is Better than Cure

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  Occupational Blood BorneInfections: Prevention is Better than Cure
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  Quality in Health OCCUPATIONALBLOOD BORNE INFECTIONS: PREVENTION IS BETTER THAN CURE Nlrupam Prakash', Anupam Prakash", Shweta Saxena'" and Aruna Nigam' 'Senior Medical Officer. Departmentof Posts. tucknow.Indla, "Assistant Professor. Departmentof Medicine. Lady Hardinge Medical College & SSK Hospital. New Delhi 110001. India."'Medical Officer HAL. Lucknow.India. 'Assistant Professor. Department of Obstetrics & Gynaecology. Lady Hardinge Medical College & SSK Hospital. New Delhi 110001. India. Correspondence10: Dr Nirupam Prakash. 41/42 Rani Laxmi Bai Marg. Kaiserbagh. Lucknow 226 001. India. Viral infections like HIV. hepatitis Band C virus pose a big risk to the contacts of individuals with high risk behaviour as well as to the affending health care workers. Blood. semen. vaginal and other potentially infectious materials can transmit the infection to the susceptible contacts. Universal precautions should be strictly implemented during clinical examination. laboratory work and surgical procedures to prevent transmission to the health care providers. Health care workers should receive vaccination for hepatitis B infection. An inadvertent exposure should be managed with proper first aid and infectivity of the source and severity of exposure should be assessed. Severity of exposure is based on the nature and area of exposed surface. mode of injury and volume of infective material. Post-exposure prophylaxis (PEP) should be started as soon as possible after a proper counseling about the effectiveness of post-exposure prophylaxis. side effectsand risk of carrying the infection to his familial contacts and its prevention. Key words: Post-exposureprophylaxis (PEPI. HIV. Hepatitis B virus. Hepatitis C virus. Universal precautions. Other potentially infectious material (OPIM). The increasing spread of blood borne infections like hepatitis B. hepatitis C and HIV posesa major challenge 10 the medical fraternity. These diseases not only share a common mode of transmission viz. sexual contact. parenteral route or perin atal mode. but also have a chronic insidious course and lack a definiti ve treatment. Hence. infected individuals not only pose a ri sk to their family contacts bUI also a much greater ri sk to their health care providers. Although handling sharp instruments and needle-stick injuries are the common modes of exposure. contamination may also occur during bites. scratches or exposure to mucous membranes and conjunctiva. Prevention or transmission is the best means of cure because medical treatment after exposure is less effective. Universal precautions were formulated 10 serve this purpose. These precautio ns have been fun her revised 10 give way to a new set guiderlincs termed as Standard Precautions Il l. These set of guidelines aim 10 prevent exposure 10 infected material and reduce the risk of transmission of infectious agents. from the patient to the health care provider and vice versa. STANDARDPRECAUTIONS These lay pri mary emphasis on hand antisepsis as the simplest and most effective means of breaking the chain of transmission. Contaminated hands have been implicated as the 1110s1 important means of propagating transmission of 85 disease. The norm al non-pathogenic nora residing on the ski n surface can cause disease if they gain percutaneous access through insertion of intravenous canulae or needles. like coagulase negative Staphylococcus. enterococci. methicillin sensrnve and resistant Staphylococcus aureus, Pseudomonas sp.• Candida etc. These organisms can easily be removed by following standard precautions for hand antisepsis. Few terms have been described to stratify degree of hand amisepsis.These have been outli ned below: Hand washing: Washing hands with non-medicated soa ps/detergents and water or water alone. This removes din and loose transient nora on the skin surface. Hygienic hand washing refers to hand washing wi th an antiseptic agent mi xed with a detergent [2.31. Hand disinfection refers to hand washi ng with an untisepuc solution along with a soap or alcohol. Hygienic hand rub refers 10 rubbing hands with a small quantity of fast acting highly effective antiseptic agent (4]. Standard precautions for hand antisepsis di ffer depending on the types of procedure and exposure. Precautions to be observed while deali ng with patients duri ng routi ne visi ts to the ward IIIarc asunder: Apollo Medicine. Vol. 7. No. 1. March 2010
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  Quality in Health •Avoid undue physical contact with the patient and his belongings. which may he: contaminated. • Wear gtoves when in contact wi th infected material like blood and other potenti ally infectious materi al <OPIM I. OPIM co nstitutes synovial Iluid. cerebrospinal fluid. pleural fluid, per itoneal fluid, pericardi al fluid and am niotic Iluid. which are many times less infectious thanblood. Wash hand... thoroughly after contact with infectious material. takingoffgloves ami in betweenexamining two patients. For general patient care and hands not visibly soiled washing hand s with soap and water is sufficient . Anti-microbial containing soaps and antiseptic solutions should be used before perform ing invasive procedures, to reduce resident cutaneous nora and for persistent antimicrobial activity. If hand washing facilities arc inadequate or inaccessible. alcohol based hand rubs (if hands are not soiled) and detergent containing toilettes (if hand, arc soiled ) should he used . • All sharp instruments should be handled with extreme care. Need le, should never be recapped. bent/broken or removed by hand from the syringe, Sharp instruments should be placed in puncture resistantcontainers for properdisposal. • Any spillage of infective material (instruments or linen ) should be disin fected or sterilized properly. The spi llage should first be cleared of any organic matter and then covered with adsorbent material. Bleaching powder should then he poured on and around it for 30 minutes. TI,e adsorbent material should then be properly removed and disposed in waste containers. The area should be cleaned with disinfectant solution and once cleaned should he WOller wiped and dried (5 ). • Proper waste handling should be emphasized to all healt h care personnel. For easy disposal of waste material three colour coded hags should he placed ut all places [I ]. Black bags arc mcunt 10 co llect household waste. like fruit peels. vegetable material. packing paperetc. Yellow hags arc meant for human anatomical waste s like tissue parts. blood , sputum. body fluid s, placenta and solid wastes like cotton, gau ze. dressing materials and POP cast. Blue hags arc meant for disposal of syringes. need les, glass material. plastic bags. intravenous canula. drip sets ere. All health care professionals should undergo proper training to ensure compliance of these guidelines. TI,e following persona l protective and periopcrative measures need tn he observed while performing operative/ invasive procedures. I. Barrier protection should he strictly observed, 10 prevent skin ami mucous mem brane contamination. Barrier protection should suit the type of procedures bein g performed and the likely ex posure anticipated viz . > • Gloves need 10 be worn when there is potential for hand or skin contact. A greater emphasis should he laid on simple practices like wearing two pairs of latex glove» ora pairof clothgloves worn with latex gloves. which C'1I1 significantly reduce risk of expos ure (from 17'« 10 5<;f ) [6]. • Face protection (face shield. masks or goggles) during procedures likely to generate droplets of blood or body fluid, to shield mucous membranes of mouth. nose and eyes should he observed. Caps should be worn to cover hair during asept ic procedures 171. • Protective impervious body cloth ing (disposable laboratory coats) during procedures with potential for splashing of blood or body fluids. Go wns and shoes arc essenti al while conducting caesarian deliveries. cardiopulmonary resuscitation and autopsies , Additiona l protection may be had. hy wearinga plastic apron under the gown. 2. A classical surgical hand scrub should be performed before any operative procedure. This involve. washing hands and foreurm s for 5 min utes and cleaning underthe nails. Nails should he short enough to allow easy cleaning and not cause glove tears. An antiseptic solution should be rubbed on for OIl least two minutes. Hand, should he dried with paper towels or hand blowers. which should be easily accessible hUI at an adequate distance fromthesink 10 avoid splashes. 3. Changes in Surgical Tech nique. Surgeons and the assisting staff should avoid hand-to-hand passage of sharp instrument s and increasingly use stapling devices instead of suturing to reduce inadvertent injuries. Sharp instruments may be placed on a sterile stand positioned between the scrub nurse and the surgeo n. Potentially dangerous practices like usc of fingers to protect underlying viscera. while closing the abdomen should be avoided. Blunted needles should replace existing method, for fascial closure, Laproscopic pnx.-edures should be avo ided a, they pose a risk of contaminating the operating room environment with patient 's blood during pneumoperitoneum evacuation {HI. 4. Mandatory preoperative HIV and HBsAg testing. Preoperative HIV testing is considered essential by most Apollo Medicine, Vol. 7, No.1 , March 2010 86
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  surgeons as itnot only pick s up asymptomatic or minimally sym ptomatic subjects who benefi t the most from an earlier institution of antiviral therapy and prophylaxis against oppununistic infec tions but also presen'cs the right of the surgical (cam to know the potential risk of acquiring a fatal infection following inad vcrant ex pos ure. However. an informed conse nt anti pretest counse ling is mandatory before subjecting a patient tu HIV resting. Subjects who do not consent for preoperative test ing should be managed as if they arc serologically positi ve. Some surgeons do question the benefit of HIY and HB,Ag testing as it docs not reveal the concurrent risk from other infec tious age nts including hum an T-Iympholrop k virus type s I and 11. hepatitis C virus and other agent s with similar mode of transmi ssion . Therefore it is reasonable to consider all patients to be potent ially infectious and III offer them preoperative HIY testing if they have risk factors for infection or if they request the lest. 5. Nonoperative Treatment of Hl v-lnfcctcd Patient s. Su rgeo ns plann ing treatment mu st weigh the risks to the patient and of exposure to the surgical tCiJ01 against the potential ben efits of surgery. lt is the responsibi lity of surgeo ns 10 prote ct them selves. their coworkers and their families against transmission of occupationally acquired illnesses. Monitori ng of co mpliance of these meth ods is the responsibility of both the health ca re workers and the hospital managem ent . In a study aimed to find nut the practice of universal precautions amongst nurses and gastroenterologists. it was observed that less than 50th· of health professionals followed simple precautions like hand washing. wearin g gloves. face shields and protective gowns during procedures [9). Hence periodic educa tional. and remed ial programs need to be organized and strictly en forced . Written decon tamination. disinfection. and steri lization pro tocols and adequate decomam inating containers should be provided for processing reusa ble supplies. laboratory equipment. laboratory waste, machi ne effl uent. ami environmental surfaces , POST·EXPOSURE MANAGEMENT An "exposure" is defined as a percutaneou s rnjury (e.g.. a ncedlestick or cu t with a sharp objecu or contac t with mucous mcmbranc/non intact skin te.g.. when the exposed skin is chapped. abraded. or afflicted with dermatitis) or pro longed contac t with intact skin (i.e.. several minutes or more) or invo lving an extensive area, with blood.tissue or OPIM. Inspire of adhering 10 the requ isite precauti ons health cure providers do encounter acc idental expos ure to 87 Quality In Health potentially infecti ve materials. In a prospective trial conducted at Sa n Francisco General Hospital, acci dental exposure of surgical personnel to patient's blood was observed during 8-1 procedures ((.-I'7r I. out of which parenteral ex posure occurred in 1.7'7r procedures. Risk of exposure was found to he high in procedures lasting marc than 3 hours. with more than 300 mL blood loss. and in major vascular or intra-abdo minal gy necolog ic surgeries [IOJ. Th e transmission of blood borne diseases depends on: Volume of inoculum and the vira l load. Exposure through deep imramuscular injections or hollow bore needles involving injection of blood. • Prolonged contac t or contact with large volume of blood 10 mucocutaneou s surfaces. • Stage of infection in the source patient. • Immunological status of the ex posed individual. A rough es timate of the risk follow ing a single percutaneous exposure to infec tious material reveals 1120 chances of infection for HBY ( 1/3 if source is HBcAg + ). 1/33 for HCY. and 1/333 for HIY [1 1- 131. Th e risk of Hl Y transmission following a mucous membrane exposure is estimated In be 1/ 11 00 [1-11. This risk increases I(·fold if inju ry is thro ugh a hollow needl e with a deep soft tissue penetration. 5·fold if the re is either visible blood on the needl e or the procedure involves placement of the needle in an artery or vei n. and 6-fold if the source has adva nced or terminal AIDS (hig h viral load ). Hence a definite knowledge of the steps for primary preve ntion and post- exposure prophylaxis for lilY. HBY. lICY infection is essential for every health care provider. Exposed individua ls sho uld be managed in a sys tematic stepwise approac h as recommended by the updated US Public health guide lines for pos texposure manugem ent l tS]. Step I: Management 01the exposed site Th e exposed site should he was hed thoroughly with soap and water and mucous rncmbranes sho uld he flushed copiously with water or saline . No scru bbi ng should be performed at the sire of exposure. Antiseptics can be app lied although no evi dence ex ists to suggest reduction in risk of transm ission . Free bleeding at the puncture site should he enco uraged but the wo und should not be sucked. Step II: Coilect blood Sample Blood sample of the exposed and the source should be collected after proper counsel ing and conse nt. A record should be maintained of the occurre nce of an acc idental Apollo Medicine. Vol. 7. No.1 . March 2010
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  Quality In Health exposureand concerned virolog ist and empl oyer should be informed. Step III: Assessment of the type of exposure The clinician should observe if the: C:JX1Un: involves body fluids incapable of transmitting disease and whether it is limited to intact skin. hair or clothing, These ind ividuals do not need post-exposure prophylaxis (PEP). However if the ex pos ure occurred through blood/OPIM 10 non -ima ct skin. mucous membrane or percutaneous injury. there is a significant risk of transmission. Step IV: Evaluation of the source factors If the source is unknown or his serological stalu, for HIV. HB V. HC V arc unknown. PEP measure« should be started considering him 10 be infected. A recent negative serology and a lack of further high risk behaviour ruleout the infectivity of the source. If serological status is positive. the stage of disease and viral load in the source shou ld be assessed. Step V: Evaluate the exposed individual Assess the pre-exposure HIV. HB,Ag and f1 CV status. Enquire about the inu nunization status of the ex posed and hi:-. response to vaccinat ion by perform ing antibody levels 10 HB,Ag. An immunized ind ividual with ade quate antibody response (anti.HBs aruibody levels more than IOIU/mL)docs not require any PEP for HRV exposure. Step VI: PEP for HBV infection PEP should be initi ated in all ind ivid uals with needlestick inj ury or percutaneous. ocular. mucosal exposure. Non -immunized contacts should be given a single intramuscular dose of hcpariris B immunoglohulin IHRIG) . 0.06 ml.Jkg as soon as possible after exposure. followed by a complete courseof hepatitis R vaccine (0 he started preferably within the first week ofex posure. HRI G provides protection lasting for nearly 5 years after administration. Anti-lIB, antibod y levels should be ~ISSCSSCc.J 1 to 2 month, following completion of three closes of vaccination to isolate primary non-responders. ll1C'SC' ind ividuals should have a second three dose course of HBV vaccination after neguting existence of HBsAg positive status, A third course should be administered if these individuals fail 10 respo nd 10 second dose of vaccination . Anti -HR, antibody testing should be performed in all exposed individuals at baseline and 1-2 month, following completion of vaccination. Anti-HBs antibody levels should be periodically tested in all vaccinated individuals at risk of contruct ing infection. A booster dose may he administered if serum anti-HBS titre falls below IOmIUlmLlTcil,/.. I) . Step VII: PEP for HCV No effec tive PEP is available against HCV infection bUI an early institution of interferon therapy after seroconve r- sio n may provide higher cure rates, Hence exposed individuals should he serologically tested for anti-HeY untibodies and ALT level s at baseline. I> weeks, 3 months and I> months. To facilitate an ea rly diagnosis. HCV RNA may be tested "t 4-1> weeks, Exposed individuals should be co unseled to follow univerval precautions 10 avoid tr•msmission 10 other healthcare workers. Tablel 1. PEP for HBV In exposed health professionals (16) Status of exposed Source HB, Ag positive Source HB. Ag negative Source unknown Not immunized HBIG ... vaccination Vaccinate Treat source as HB,A g pos. 1 dose HB vaccine pre-exposure HBIG + Accelerated Vaccinate Acceterated HBV HBV vaccination vaccination 12 doses HB vaccine pre-exposure One dose of HB vaccine followed FinishcourseofHB One dose of HB by 2nd dose one month later vaccine vaccine Immunised.but response unknown Testanti.HB,Ab." pos.no Tit. No treatment Tesl HB,Ab. If pos.no if neg.booster dose til. ifneg.revaccinale Immunisednon-responder HBIG + booster vaccination No treatment Treat source as HB, Ag pas. source Immunised responder No Vt consider booster dose No Vt consider booster No VIconsider booster dose dose pos.· positive; neg.- negative: lit· treatment: accelerated course 01 vaccmation consis ts 01 doses spaced at O. t and 2 months. Aboosterdose may be given at 12 months to Ihose at continuing risk a/ exposure 10 HBY.Non-responder-anti·HBs < 10miU/mL 2·4 months post-vaccination. Apollo Medicine. Vol. 7. No.1 , March 2010 88
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  Step VIII: PEPfor HIV The risk of HIV Iransmission has been variably observed depe nding on the mode and nature of exposure <0.09% 10 0.3%) and so is the lime for seroconversion from 25 days of exposure (8 1% of exposed individuals) to until 6 months (14%) (17). Efficacy and timing of PEP The administration of zidovudine (AZT) therapy for 4 wee ks period has been demonstrated to reduce HIV transmission by 8 I% when started early after exposure [18). Single drug use at present is not recom mended. The use of co mbination therapy not only prevents deve lopment of resistance. it exerts cumulative effect by acting at different stages in the life cycle of the virus. Also mutations induced followi ng 3TC therapy make virus more respon sive 10 AZT [191. However. combination therapy is associated with a higher incide nce of adverse effect (50·90%) and drop out rates <36%) [20.211 in comparison to zidov udi ne therapy alone (50% & 30% respectively) (22). Trials performed in animals reveal increased efficacy of PEP with early initiation of therapy and a small viral inoculum. PEP initiated in between I to 24 hours of infection has bee n show n to prevent infectio n in I out of 3 animals. However, PEP initiated after 36 hours did not show any significant preventive effect [23.24). This should not dissuade treating physicians from starting PEP in subjects reporting later than 36 hours where it works as an early therapeuti c regimen. which carries a higher response rate. Health care professionals should be educated to immediately report and follow the primary steps in manage ment of occupational exposure. The circumstances and the post-exposure management should be specifically recorded in the worker s health record. Factors to be co nsidered when deci ding whether to offer PEP after exposure include the probability of Table 2. PEP for percutaneous exposure to HIV Infected source Source Exposure Post-exposure prophylaxis Class IHIV + less severe 2 drug basic regimen x4wks More severe 3 drug expanded regimenx4 wks Class II HIV + Less/more severe Expand ed regimen of >3drugs x4wks 89 Quality In Health transmission. the degree of protection anticipated from the use of PEP. and the cosIS and side effects of ava ilable anriretroviral agents 125). Recentl y. CDC has upd ated its recommendations for HIV post-exposure proph ylaxis which are discussed below (26). No treatment is advocated - If the source is HIV negative. o the exposure is on to an intact skin. o for exposures of small volumes to the mucous membrane from a low titre HIV positive source. HIV status of the source is unknown. However. a basic two drug PEP should be considered if the source has HIV risk factors or in a selling where exposure to HIV infected person is likely. As per the CDC guidelines a less severe exposure is defined as a solid needle inju ry or a superficial inj ury while a more severe injury involves injury from a large bore hollow needle. deep puncture. visibly co ntaminated device or needle used in patient's artery or vein. A source with asy mptomatic HIV infec tion or a documented low viral load «1500 ribonucliec acid copies/ml.) have been described as class I source while individuals with acute seroconversion illness. AIDS. symptomatic infection and high viral load have been classified as class 2 sources. Different strategies have bee n outlined to manage parenteral and mucosal or non-intact skin exposures. These guidelines have been outlined in Tables 2 & 3. Basic regimen advocates administrationof zidov udine (AZT) 600 mg in three divided doses and lamivudine (3TC ) 150 mg SD for 4 weeks. Alternately a co mbination of lam ivud ine or didanosine with stavudine can be ad ministered. Expanded regimen advocates addi tion of protease inhibitor (indinavir 800mg tds or nelfinavir 750 mg Ids) to be admi nistered along with 4 wee ks dosing of basic regimen (zidovudine and lamivudiue j. Table 3. PEP for mucosal or non-Intact ex posure to HIV Infected source Source Exposure Post-exposure prophylaxis Class IHIV + Smallvolume Two drug basic Large volume regimenx4wks Class II HIV + Smallvolume Expanded regimen with Large volume >3drugs x4wks ApollO Medicine. Vol. 7, No. 1, March 2010
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  Quality In Health Counseling Thecontact should he provided extensive counseling anti trained to follow univerval precautions strictly, He should be exp lai ned Ihal PEP although effective is "ill experimental ami ih res uhs arc variable. TIlt: importance of regular follow up and investigation ... ...hould be stressed to the ...ubjcct andhi... family. Follow up Pat ients started 0 11 PEPshould undergo busclinc blood counts.renal and hepatic function (cs(!to be repeated after :! weeks to assess drug tox icity, Besides a wat ch ...houl d he kept on the blood sugar leve ls in individuals receiving protease inhibitors, Pos icxpo...ure antibody tC'sling and medical evaluation should be carr ied out in all exposed persons. wh ether being started on PEP or not HIV antibody testing is conducted for at leasl () month... ru...t-exposurc i.H 4-0 weeks. 12 weeks and 6 month s, Patients with high ri,k of infection should continue PEP unt il repeat HI V lesl 'II four to six weeks, Subjects who show positive' ant ibody testing during follow up should he advised to continue with PEP and referre d In centers specialized in HIV care. Exposed individuals ..houl d he advised to seck medical attention for any new symptoms. hich may arise as a result of side effects of therapy or acute seroconve rsion illness. lndividuals with severe side effects like naUSCH. vomiting. diarrhoea should he man aged symptomutically, Modifying the dose of the drug hy adminis ter ing smaller doses at frequent intervals may reduce side effects and promote adherence 10 therapy. An extended follow up has been ad vocated in circumstances where a late seroconvcrsion is ex pected as in co-expos ure with He V and in subjects receiving ex panded PEPregimen, Inspite of the developments in the field of medicine and discovery of meth ods for carly diagnosis ami treat ment. the medi cal fraternity suffers from lack of knowledge regarding protection of self. As can very well he inferred from u study conducted on practitioners of Del hi [here is a high level of ignorance regarding post- ex pos ure prophylactic measures and universal precaution s 1271. Many healt h care professionals were found 10 he ignorant of their response 10 HBV vaccination and most of needle-stick inj urie s went unreported, Only 36'« of doctors knew thin PEP was to he started as soon as possible. Hence all aspirants of a medi cal degree shou ld undergo a proper teaching with demonstrm ion of safe techniques before they arc exposed to worki ng in the out- pati ent clin ics and thewards. Apollo Medicine. Vol, 7. No.1 . March 2010 90 REFERENCES 1, Sridhar MR. Boopalhi S. tocna R. Kabra SK, Standard precautions and post-exposure prophylaxis for preventing infecllons. Indian J Ped,atr 2004;71: 617·625. 2. Larson EL APIC guidelines for hand washing and hand antrsepsis m heallh care sellings. Am J Infect Control 1995: 23(4): 251-269. 3. Roner ML Hand washing and hand disinfeclion, In Mayhall CG, eds. Hospital Epidemiologiy and lntection Control, 2nd edn, Philadhelphia: Lippincott. Williams and Wilkins. 1999: 1339·1385, 4. Pittet D. 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