Occupational Exposure

An occupational exposure is defined as a percutaneous injury (e.g., a needle stick or cut with a sharp object) or contact of mucous membrane or non-intact skin (e.g., exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other potentially infectious materials.

Exposure Risks

The CDC states that the risk of infection varies case by case. Factors influencing the risk of infection include: whether the exposure was from a hollow-bore needle or other sharp instrument; to non-intact skin or mucus membranes (such as the eyes, nose, and/or mouth); the amount of blood that was involved and the amount of virus present in the source's blood.

HIV Risks

The risk of HIV infection to a health care worker through a needle stick is less than 1 percent. Approximately 1 in 300 exposures through a needle or sharp instrument result in infection. The risks of HIV infection though splashes of blood to the eyes, nose or mouth is even smaller - approximately 1 in 1,000. There have been no reports of HIV transmission from blood contact with intact skin. There is a theoretical risk of blood contact to an area of skin that is damaged, or from a large area of skin covered in blood for a long period of time. Through December 2002, the CDC reports 57 documented cases and 139 possible cases of occupational exposure to HIV since reporting started in 1985.

Hepatitis B & C Risks

The risk of getting HBV from a needle stick is 22-31% if the source person tests hepatitis B surface antigen (HBsAg) and Hepatitis B e antigen (HBeAg) positive. If the source person is HBsAg positive and HBeAg negative one has a 1-6% risk of getting HBV unless the person exposed has been vaccinated. The risk of getting HCV from a needle stick is 1.8%. The risk of getting HBV or HCV from a blood splash to the eyes, nose or mouth is possible but believed to be very small. As of 1999, about 800 health care workers a year are reported to be infected with HBV following occupational exposure. There are no exact estimates on how many health care workers contract HCV from an occupational exposure, but the risk is considered low.

Treatment Following a Potential Exposure

FOLLOW THE PROTOCOL OF YOUR EMPLOYER. As soon as safely possible, wash the affected area(s) with soap and water. Application of antiseptics should not be a substitute for washing. It is recommended that any potentially contaminated clothing be removed as soon as possible. It is also recommended that you familiarize yourself with existing protocols and the location of emergency eyewash or showers and other stations within your facility.

Mucous Membrane Exposure

If the exposure is to the eyes, nose or mouth, flush thoroughly with water, saline or sterile irrigants. The risk of contracting HIV through this type of exposure is estimated to be 0.09%.

Sharps Injuries

Wash the exposed area with soap and water. Do not "milk" or squeeze the wound. There is no evidence that shows using antiseptics (like hydrogen peroxide) will reduce the risk of transmission for any bloodborne pathogens; however, the use of antiseptics is not contraindicated. In the event that the wound needs suturing, emergency treatment should be obtained. The risk of contracting HIV from this type of exposure is estimated to be 0.3%.

Bite or Scratch Wounds

Exposure to saliva is not considered substantial unless there is visible contamination with blood or the saliva emanates from a dental procedure. Wash the area with soap and water, and cover with a sterile dressing as appropriate. All bites should be evaluated by a health care professional.

Note: For human bites, the clinical evaluation must include the possibility that both the person bitten and the person who inflicted the bite were exposed to bloodborne pathogens.

Exposure to Urine, Vomit or Feces

Exposure to urine, feces, vomit or sputum is not considered a potential bloodborne pathogens exposure unless the fluid is visibly contaminated with blood. Follow your employer's procedures for cleaning these fluids.

Reporting the Exposure

FOLLOW THE PROTOCOL OF YOUR EMPLOYER. . After cleaning the exposed area as recommended above, report the exposure to the department or individual at your workplace that is responsible for managing exposure. Obtain medical evaluation as soon as possible. Discuss with a healthcare professional the extent of the exposure, treatment, follow-up care, personal prevention measures, the need for a tetanus shot and other care. Your employer is required to provide an appropriate post exposure management referral at no cost to you. In addition, your employer must provide the following information to the evaluating health care professional:

• A copy of WAC 296-823-160

• A description of the job duties the exposed employee was performing when exposed

• Documentation of the routes of exposure and circumstances under which exposure occurred

• Results of the source person's blood testing, if available

• All medical records that you are responsible to maintain, including vaccination status, relevant to the appropriate treatment of the employee.

Note: HIV and hepatitis infection are notifiable conditions under WAC 246-101.

Post-exposure Prophylaxis

Post-exposure prophylaxis (PEP) provides anti-HIV medications to someone who has had a substantial exposure, usually to blood. PEP has been the standard of care for occupationally exposed healthcare workers with substantial exposures since 1996. Animal models suggest that cellular HIV infection happens within 2 days of exposure to HIV. Virus in blood is detectable within 5 days. Therefore, PEP should be started as soon as possible, within hours not days, after exposure and continued for 28 days. However, PEP for HIV does not provide prevention of other blood-borne diseases, like HBV or HCV.

HBV PEP for susceptible persons would include administration of hepatitis B immune globulin and HBV vaccine. This should occur as soon as possible and no later than 7 days post-exposure. The benefit of the use of antiviral agents to prevent HCV infection is unknown and antiviral are not currently FDA approved for prophylaxis. Because of the frequent advances in treatment, doses and medications are not listed here. Post-exposure prophylaxis can only be obtained from a licensed healthcare provider. Your facility may have recommendations and a chain of command in place for you to obtain PEP. After evaluation of the exposure route and other risk factors, certain anti-HIV medications may be prescribed. The national bloodborne pathogen hotline provides 24-hour consultation for clinicians who have been exposed on the job. Call 1-888-448-4911 for the latest information on prophylaxis for HIV, hepatitis, and other pathogens. PEP is not as simple as swallowing one pill. The medications must be started as soon as possible, and continued for 28 days. Many people experience significant medication side effects.

It is very important to report occupational exposure to the department at your workplace that is responsible for managing exposure. If post-exposure treatment is recommended, it should be started as soon as possible. In rural areas, police, firefighters and other at-risk emergency providers should identify a 24-hour source for PEP. In addition, Washington state workers have a right to file a worker's compensation claim for exposure to bloodborne pathogens. Industrial insurance covers the cost of post-exposure prophylaxis and follow-up for the injured worker.

HIV/HBV/HCV Testing Post-exposure

All occupational exposures should be evaluated by a health care professional. Evaluation should include follow-up counseling, post-exposure testing, and medical evaluation regardless of whether or not PEP is indicated. Antibody testing for HIV, HBV and HCV should be conducted for >6 months after occupational exposure. After baseline testing at the time of exposure, follow-up testing is recommended to be performed at 6 weeks, 12 weeks, and 6 months after exposure. Extended HIV follow-up (e.g., for 12 months) is recommended for those who become infected with HCV after exposure to a source co-infected with HIV. Extended follow-up in other circumstances (e.g., for those persons with an impaired ability to mount an antibody response to infection) may also be considered.

Source Testing

WAC 296-823-16010 requires the employer to arrange to test the "source individual" – someone whose blood or OPIM an employee was exposited to - for HIV, HBV and HCV as soon as feasible after getting their consent. If the employer does not get consent the employer must document such and inform the employee.

Mandatory Source Testing

Because of an increased risk for HIV exposure, the Revised Code of Washington 70.24.340 provides for HIV antibody testing of a "source" when a law enforcement officer, fire fighter, health care provider or health care facility staff, and certain other professions experience an occupational exposure.

If you experience an occupational substantial exposure to another person's blood or OPIM, you can request HIV testing of the source individual through your employer or local health officer.

Before the health officer will issue a health order for HIV testing of the source individual, s/he will first make the determination of whether a substantial exposure occurred, and if the exposure occurred on the job. Depending on the type of exposure and risks involved, the health officer may make the determination that source testing is unnecessary.

In the case of occupationally exposed health care workers, if the employer is unable to obtain permission of the source individual, the employer may request assistance from the local health officer provided the request is made within 7 days of the occurrence.

Source testing does not eliminate the need for baseline testing of the exposed individual for HIV, HBV, HCV and liver enzymes. Provision of PEP should also not be contingent upon the results of a source's test. Current wisdom indicates immediate provision of PEP in certain circumstances, with discontinuation of treatment based upon the source's test results.

Non-Occupational Exposure

PEP should never be used for primary prevention of HIV. PEP can also be used to treat people who have been exposed to HIV during a single event unrelated to work such as sexual assault.