Once daily – Tenofovir (TDF) and emitricitabine (FTC)
■■ Third agents Twice daily – Lopinavir/ritonavir – Saquinavir/ritonavir (400/100) Once daily – Efavirenz (not in patients with history of mental illness, or in pregnancy) – Atazanavir/ritonavir
■■ NOT recommended – Nevirapine (high risk of hepatotoxicity) – Indinavir (significant side-effects) – Abacavir (risk of hypersensitivity reaction)
Hepatitis post-exposure prophylaxis The primary defence against hepatitis B exposure is the routine immunisation of all HCWs. If you do not know your hepatitis B immune status, do something about it now! It is best to approach the exposure incident in two steps: Step 1: The HCW’s immune status is tested. No hepatitis B tests are performed on the source patient. Step 2: If the HCW is not immune (definition: anti-HBs <10 IU/ml), then the vaccine is provided and the source patient’s blood is tested for Hepatitis B. If the source patient is hepatitis B infective, the HCW should receive immunoglobulin. The first dose should be given immediately and the second at one month. If the HCW is immune, but the antibody levels are between 10-100 IU/ml, a vaccine booster dose should be given. If levels are above 100, give routine booster (every five years). There is no known prophylaxis for hepatitis C.
Counselling and follow-up Exposure to potentially life-threatening diseases is traumatic and frightening.3 There needs to be advice and support around potential side effects, informing partners, safe sexual practices, and the follow-up schedule. There should be an open door policy for the affected person to discuss new and ongoing concerns.
Reporting All occupation exposures are potentially preventable. While it is less than helpful to tell an exhausted doctor to “be more careful”, extensive reporting needs to occur to guide future policies and prevention efforts. All healthcare facilities should have documentation in place to facilitate this process.
1. Karstaedt, AS, Pantanowitz, L, Occupational exposure of interns to blood in an area of high HIV seroprevalence, S Afr Med J 92:57-61 (2001).
2. Marias, BJ, Cotton, M, Occupational exposure to HIV in paediatricians – a previously undescribed high risk group, XIV International Aids Conference, Barcelona, Spain, Abstract MoPeC3515 (2002).
3. Wilson, D, Cotton, M, Bekker, LG et al. (2008) Handbook of HIV Medicine Second Edition, Oxford University Press, Cape Town
4. Post-exposure Prophylaxis Guidelines, Expert Committee, S Afr Med J Winter:36-45 (2008)
Case scenario D
r M, a medical officer, was working in the children’s HIV clinic in a large township hospital. She was 34 weeks pregnant, and about to go on maternity leave. A child
came to her to start antiretroviral treatment. The child had a low CD4 count, and a very high viral load. The child also had symptoms of TB, so she decided to do a Mantoux skin test. The procedure room was being used, so she gathered what
she needed and did the test in her office. She used an insulin syringe to inject the tuberculin intradermally. After finishing she recapped the needle using the scoop technique. A few minutes later Dr M picked up the used needle to dispose of it in the sharps bin. Unbeknown to her the needle had bent during recapping and was now protruding through the orange needle cap. She sustained a needlestick injury while picking up the needle. Dr M immediately washed the wound and ran it under tap
water for some time. Having informed her superviser, she then reported to the staff clinic. She took her first dose of AZT and 3TC within 15 minutes of the injury. She also met with a senior staff member, highly experienced in HIV management, who took time to counsel her regarding the possible emotional trauma she and her partner may suffer as a result of the injury. He also suggested 3-drug therapy for HIV prophylaxis. She began treatment with D4T, 3TC and Lopinavir/Ritonavir, as she had suffered severe nausea and vomiting when using AZT after a previous exposure. Dr M was counselled regarding safe sexual practices, but
breastfeeding and testing of the infant were never discussed. The source patient was never tested for hepatitis B. After some consultation and confusion, hepatitis B immunoglobulin was provided. Dr M’s antibody titres came back as >100 IU/ml and thus no vaccination schedule was commenced. Dr M experienced some mild nausea, but no other side effects.
She delivered a healthy term baby on the day she completed her course of ARVs. Subsequent HIV tests at three months and six months were negative. The baby was never tested for HIV.
■■ Always perform procedures (however minor) in an area set up to facilitate sharps disposal.
■■ Never recap a needle. ■■ Dispose of sharps immediately after use. ■■ In special circumstances (such as pregnancy), get expert advice regarding post-exposure prophylaxis.
■■ Not only the doctor but also partners and family members may suffer emotional trauma as a result of a needlestick injury, and may need counselling.
■■ Hepatitis B prophylaxis must be instituted as soon as possible in non-immune doctors.
Dr Susan Purchase is a sub-investigator at KIDCRU (Children’s Infectious Diseases Clinical Research Unit), at Tygerberg Hospital, Western Cape.
JUNIOR DOCTOR | VOLUME 2 | ISSUE 1 | 2011 | SOUTH AFRICA www.medicalprotection.org
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