The Infection Center of Beijing Ditan Hospital undertakes medical treatment of hand, foot and mouth disease, various seasonal infectious diseases, and AIDS, with the Infection I Department mainly treating AIDS patients. Health care workers in this department are at the center of the risk of HIV occupational exposure, but the infection rate of health care workers here is zero. We are now asking relevant experts to introduce the practices of handling and preventing HIV occupational exposure to our doctors and friends.
How HIV occupational exposure can achieve zero infection.
China’s health authorities have promulgated the “Guidelines on HIV Occupational Exposure Protection for Medical Staff (for Trial Implementation)” to regulate the treatment and prevention of HIV after occupational exposure. According to this guideline, the first step after an HIV occupational exposure should be to take the correct local treatment measures. The second step is a risk assessment by a professional to determine the level of occupational exposure and the severity of the viral load of the source of exposure. The third step is to decide whether to take drug prophylaxis according to the assessed level. The fourth step involves reporting and monitoring in accordance with regulations.
Local treatment.
Epidemiological investigations have only demonstrated the role of HIV transmission in blood, semen, vaginal secretions and breast milk. Cerebrospinal fluid, synovial fluid, pleural fluid, pelvic fluid, ascites, pericardial fluid, and amniotic fluid are generally considered potentially infectious, but the risk of HIV infection from these body fluids is not known. The risk of HIV infection from feces, urine, sputum, nasal secretions, saliva, tears, sweat, and vomit is generally considered to be minimal.
The correct method of local treatment is to wash the contaminated skin with soap and running water immediately after occupational exposure, rinse the mucous membrane with saline, and if there is a wound, it should be squeezed gently from the proximal end to the distal end next to the wound to squeeze out as much blood from the injury as possible, then rinse with soap and running water. After rinsing the wound of the injured part, it should be disinfected with 75% alcohol or 0.5% iodophor and bandaged; the exposed mucous membrane should be repeatedly rinsed clean with saline.
It should be noted that local compression of the wound is prohibited when treating the wound; saline should be used for mucosal flushing, such as the eyes.
Risk assessment.
Professionals determine how to take the next step in infection prevention measures based primarily on the nature and extent of the exposure source and the severity of the viral load of the exposure source.
The degree of occupational exposure to HIV in China is divided into three levels: mucosal exposure and exposure of incomplete skin under the premise that the source of exposure is body fluids, blood or medical devices or articles containing body fluids or blood, and is graded according to the amount and duration of exposure. A few drops of blood shed or a short exposure time belongs to exposure level 1, while a large amount of bleeding or a long exposure time belongs to exposure level 2. Exposure to percutaneous injuries was graded according to the degree of injury, with solid needle punctures or superficial abrasions falling into Exposure Level 2, and hollow needle punctures or deep injuries and needle punctures of arteries and veins being graded as Exposure Level 3.
The viral load level of the source of exposure is classified as mild, severe, or unknown. If the source of exposure is HIV-positive, but the titer is low, the HIV-infected person has no clinical symptoms, and the CD4 count is normal, it is the mild type; if the source of exposure is HIV-positive, but the titer is high, the HIV-infected person has clinical symptoms, and the CD4 count is low, it is the severe type; if it is uncertain whether the source of exposure is HIV-positive, it is the unknown source type.
Post-exposure drug prophylaxis.
It has been demonstrated that the timely combination of two to three anti-HIV drugs after HIV occupational exposure can significantly reduce the risk of HIV infection after occupational exposure in laboratory and health care workers. Some sources report that taking the drugs can reduce the risk of infection by 81%.
The prophylactic drug regimen identified in China is divided into two types of basic and intensive drug regimens. The basic dosing regimen is two reverse transcriptase preparations at regular therapeutic doses for 28 days. The intensive dosing program is based on the basic dosing program, while adding a protease inhibitor, using conventional therapeutic doses, for 28 days.
Except for exposure level 1, where the viral load level of the source of exposure is mild and no drug prophylaxis is required, drug prophylaxis is required for all exposure levels and should be administered preferably within 4 hours and no later than 24 hours.
In terms of specific dosing regimens, basic dosing regimens should be used for Exposure Level 1 with a heavy viral load; Exposure Level 2 with a light viral load; Exposure Level 2 with a heavy viral load requiring intensive dosing regimens; and Exposure Level 3 with a light or heavy viral load requiring intensive dosing regimens. The level 3 exposure requires an intensive drug regimen for both mild and severe viral loads. If the HIV infection status or exposure level of the exposed source at the time of occupational exposure is unknown, post-exposure prophylaxis should be combined with clinical history, epidemiological data, and the type of exposure to analyze the likelihood of the exposed source being HIV antibody positive.
In terms of post-exposure monitoring, blood samples should be taken from the exposed person for HIV antibody background testing immediately after the occurrence of HIV occupational exposure to exclude whether there is previous HIV infection; if the test result is negative, regardless of whether post-exposure prophylaxis is selected after risk assessment, blood samples should be taken for HIV antibody testing at 6 weeks, 3 months, and 6 months after the accident to clarify whether HIV infection.
Universal prophylaxis.
We should pay special attention to universal prevention, medical personnel should develop good operating habits, and relevant institutions should strictly enforce internal safety and protection management systems and carefully implement relevant work regulations and relevant provisions for safe operation.
First, dispose of sharp instruments safely, i.e., do not pass used instruments to others, regardless of the circumstances.
When performing invasive operations, be sure to ensure sufficient light to minimize bleeding from wounds; never cover the needle sleeve to used disposable syringe needles and do not destroy used syringes by hand; pay special attention to reducing accidental stabbing injuries when suturing wounds; put used syringes directly into a special bucket (box) and dispose of them in a uniform manner; do not mix sharp waste with other waste.
Second, sterilize all instruments strictly. To ensure the effectiveness of disinfection, utensils must be washed with hot water and detergent before disinfection. All disinfection procedures that meet disinfection specifications are sufficient to kill HIV, hepatitis B virus and hepatitis C virus.
Third, wash your hands carefully. Body fluids on the hands of medical personnel can be easily removed with soap and water.
Fourth, use protective facilities to avoid direct contact with body fluids.
Fifth, dispose of waste safely. Those transporting waste must wear thick latex gloves; protective eyewear must be worn when handling liquid waste; waste that is not contaminated with blood or body fluids can be disposed of as general waste.