chapter 10 pt4 darby

DHCP Exposure Risks and Management

Policies and Compliance

  • Policies concerning types of exposure that place DHCP (Dental Healthcare Personnel) at risk, procedures for prompt reporting and evaluation, including counseling, testing, and follow-up, must align with the most current US Public Health Service (USPHS) guidelines.

  • These policies should comply with the OSHA bloodborne pathogen standard and all state/local laws/regulations.

Exposure and Exposure Risk

  • Definition: Occupational exposure is defined by the CDC as a percutaneous injury, contact of mucous membrane, or non-intact skin with blood, saliva, tissue, or other potentially infectious body fluids.

  • Exposure incidents may pose risks of HBV, HCV, or HIV infection, demanding medical urgency.

  • Exposure risk varies with:

    • Amount of blood involved.

    • Titer of virus in the source patient.

    • Depth of injury (if involving a contaminated device).

    • Type of exposure (percutaneous, mucous membrane, non-intact skin).

    • Immune status of the HCP.

Postexposure Management

  • Goal: To contain the injury ASAP to minimize transmission risk.

  • Offer immediate postexposure management to exposed DHCP, following current USPHS guidelines.

  • QHCP (Qualified Healthcare Provider): Selecting a QHCP trained in infectious diseases (including HIV) is critical.

  • The QHCP needs specific exposure incident information:

    • Circumstances.

    • Devices involved.

    • Degree/severity of exposure.

  • With source patient consent, QHCP determines their infectious disease status through testing.

Steps of Postexposure Management

  1. First Aid:

    • Wash percutaneous exposures and flush mucous membranes/skin with clean water, saline, or sterile irrigants.

    • Avoid: Antiseptics for wound care or attempts to bleed/milk the wound; caustic agents like bleach.

  2. Report the Incident:

    • Report to a designated individual.

    • Complete an incident report form with the source patient's name and nature of exposure.

    • Reporting should not delay treatment.

  3. Discuss with Source Patient:

    • If identified, a designated individual should discuss the incident with the source patient.

  4. Referral:

    • Immediate referral to a QHCP capable of treating the exposed individual.

  5. Medical Evaluation and Follow-up:

    • Follow current USPHS guidelines, including counseling and testing based on exposure's infection potential.

    • Testing may include HIV, HBV, or HCV; QHCP may repeat tests at intervals.

    • Rapid HIV/HCV tests should be accessible (results in <30 minutes).

    • Postexposure management with antiretroviral drugs within 1-2 hours may reduce infection risk by approximately 80% but is not always successful.

    • Reasons for failure: resistant virus, increased virus titer, increased blood dose, host factors.

    • PEP (Postexposure Prophylaxis) may be ineffective if not initiated promptly.

Exposure Followup Guidelines

  • Counseling on infection signs/symptoms, preventing transmission to others, and seeking advice if illness occurs is crucial.

HBV

  • Follow-up depends on the source patient's HBsAg status and the DHCP's vaccination/anti-HBs response.

  • Unvaccinated DHCP: Vaccination series likely initiated; pre-vaccination titer test is unnecessary.

  • Source w/ HBV history: Hepatitis B immune globulin administration is likely, ideally within 24 hours but less than 1 week.

  • Vaccinated & Responder: No action needed due to strong immunologic memory.

  • Immune Status Unknown/Non-Responder: Further actions are necessary.

HCV

  • No preexposure vaccination or PEP available.

  • Follow-up: Test the source patient for HCV RNA.

  • If source is HCV-negative, no further testing is needed.

  • If the source is HCV-positive or unknown, follow the CDC's algorithm (https://www.cdc.gov/hepatitis/pdfs/testing-followup-exposed-hc-personnel-3d.pdf).

  • Baseline and ≥3-week testing of source patient + testing of DHCP if source is positive/unknown. Monitor liver function; test DHCP for HCV RNA at 3+ weeks.

  • Early identification/referral to a specialist is important should transmission occur. Early antiviral treatment may be beneficial.

HIV

  • PEP recommendations are based on occupational exposure to a source patient known/likely to have HIV.

  • Standard protocol: Baseline testing, repeat testing at 6, 12 weeks, and 6 months may be indicated.

  • Start postexposure treatment ASAP (within 2 hours if indicated).

  • If source is HIV-positive, treatment typically involves a 4-week regimen of 2+ antiretroviral drugs (depending on exposure nature and source patient's medications).

  • DHCP may require drug toxicity tests.

  • Postexposure management recommendations are rapidly evolving. Consult appropriate provider familiar with the most current USPHS recommendations for testing/PEP is essential.

  • Counseling on potential side effects and illness reporting is crucial for appropriate medical management.

  • CDC recommends counseling on risks/benefits for pregnant DHCP and extensive followup, as pregnancy may affect antiretroviral drug selection (some are contraindicated).

Risk of Infection Considerations

  • Most exposures do NOT lead to infection. Seroconversion risk varies based on agent, exposure type, blood amount, and source patient's viral load.

  • QHCP reviews the following when assessing occupational exposure:

    • Exposure type (percutaneous, mucous membrane, non-intact skin, bite).

    • Type/amount of fluid (blood versus fluids containing blood).

    • Source's infectious status (HBsAg, HCV antibody, HIV antibody).

    • Exposed person's susceptibility (HBV vaccine response, HBV/HCV/HIV status).

Specific Risk Estimates

  • HBV: 6-30% risk in unvaccinated/unprotected individuals. Hepatitis e-antigen-positive sources are more infectious. Vaccination offers the best protection.

  • HCV: Average risk of 1.8% for percutaneous exposures. Risk to DHCP is no higher than average community risk.

  • HIV: Average risk after percutaneous exposure is ~$0.3\%$. Eye/nose/mouth exposure risk is ~$0.1\%$. Skin exposure risk is lower unless skin is damaged/compromised.

Ethical and Legal Considerations

  • Preventing exposure through proactive measures is the appropriate approach.

  • Refusing treatment to a patient of record or based on infectious disease presence is unethical and illegal.

Infection Prevention and Control (IPC) Program Evaluation

  • A compliant IPC program requires ongoing monitoring/evaluation.

  • Tools include:

    • CDC Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care.

    • Companion two-part compliance Infection Prevention Checklist for Dental Settings (http://www.cdc.gov/oralhealth/infectioncontrol/guidelines/index.htm).

Roles and Responsibilities

  • Each setting needs a designated infection prevention and safety coordinator to facilitate program implementation.

  • In smaller facilities, it may be one person; in larger, a committee.

  • Coordinator ensures equipment/supplies availability (hand hygiene products, safer devices, PPE) and maintains communication with staff regarding infection prevention.

Culture of Safety

  • Developing a true culture of safety requires commitment to IPC from all personnel, demonstrated through daily practices.

  • Demonstrations include:

    • Ensuring patients are part of the care team.

    • Explaining infection prevention practices to patients.

    • Eliciting questions from patients.

  • Dental hygienists must ensure practices are evidence-based, and new information is evaluated and implemented when appropriate.

Key Concepts

  • Heat sterilization is the most effective method for reprocessing semicritical and critical patient care items.

  • Clinical contact surfaces should be cleaned/disinfected or covered with barriers.

  • Hand washing is a key strategy in preventing infection transmission.

  • CDC recommendations for standard precautions indicate PPE use when exposure to body fluids is likely.

  • The basic tenet of standard precautions is that all body fluids (except sweat/tears) should be considered potentially infectious.

  • Healthcare practitioners should adhere to standard precautions to reduce infection risk for themselves, families, and patients.