Policy on Exposure to Blood Borne Pathogens

Students may be exposed to blood borne pathogens (BBPs) in the course of their clinical and research duties. These BBPs include the human immunodeficiency virus (HIV), Hepatitis B virus (HBV) and Hepatitis C virus (HVC). An exposure is generally defined as a percutaneous injury (e.g., a needle stick or cut with a sharp object), contact of mucous membrane or non-intact skin with blood, tissue or body fluids that are contaminated with visible blood. Current estimates of average risk of transmission after percutaneous exposure are: HIV 3/1,000 (0.3%), Hepatitis C 1-3%, Hepatitis B 30% (in non-immune). This policy outlines the guidelines for action following such exposure. Students should keep this card with them and consult it in the event of BBP exposure.

Observing standard precautions is the single best strategy to reduce the risk of BBP exposure. This includes using adequate barrier protection (gloves, safety glasses, mask) when performing any activities where the potential exists for BBP exposure. Familiarity with and use of safety devices on needles, syringes, and intravenous equipment can also reduce your risk of accidental BBP exposure but will vary between medical institutions. Completion of the Hepatitis B immunization series with documented presence of antibody to Hepatitis B should provide full protection from transmission of this virus.

If an exposure should occur, the exposure site should first be thoroughly washed and/or irrigated. You should then promptly report the incident to your supervising attending or resident, and then seek evaluation by the staff or facility designated at that clinical site to provide evaluation and treatment of health care workers who have sustained a BBP exposure. At DHMC and most hospitals this will be the occupational medicine or employee health clinic during normal working hours with the emergency department providing these services at other times.

Your post exposure evaluation should include a risk assessment of the potential for HIV transmission based on the type of body substance involved, as well as the route and severity of the exposure. In addition, arrangements should be made to evaluate the person whose blood or body fluid was the source of your exposure. This is generally done through established institutional protocols that will be initiated by the health care provider evaluating your exposure, and may include serological assessment of Hepatitis B, Hepatitis C, and HIV infection. In the absence of known source HIV status, clinical information about the source, if known, will be used to suggest or rule out possible HIV infection. Using an algorithm established by the public health service, the risk assessment of both the severity of your exposure and the HIV status of the source will be used to determine whether post exposure prophylaxis (PEP) for HIV is recommended. If indicated, PEP should be initiated as soon as possible after an exposure (i.e., within a few hours), thus emphasizing the importance of prompt post exposure evaluation. If HIV PEP is initiated then medical follow up, further lab studies, and additional counseling should occur.

You will generally undergo baseline testing for susceptibility to BBPs at the time of your exposure including antibody to HIV. The need for and appropriate interval for follow up testing will depend to some degree on the source patient's test results as well as your baseline status. It is important to note that there is no recommended post exposure prophylaxis for Hepatitis C which is a more prevalent blood borne pathogen than HIV. Thus follow up testing after an exposure to a source infected with Hepatitis C is extremely important. Follow up testing for exposures incurred elsewhere can be done at occupational medicine at DHMC.

Students should cooperate with the evaluation, treatment and follow up recommendations made at the time of their exposure assessment. The exposure should also be reported by the student to the DMS, Assistant Dean for Student Affairs.

Occupational medicine at DHMC is open Monday through Friday from 7:00 am until 4:30 pm and is always staffed by a health care provider with training in evaluating potential BBP exposures. The phone number is 650-7018. When occupational medicine is closed, these same services are provided by the DHMC emergency department, with follow up by the occupational medicine staff.

All expenses incurred for testing, counseling, and post-exposure prophylaxis, that are not otherwise covered by the institution in which the BBP exposure occurred, should be billed to the student's health insurance carrier. If the student's health insurance carrier does not pay the charges in full, the student should pay the uncovered portion, and then submit copies of the bills, along with proof of payment, to the Assistant Dean for Student Affairs at DMS. Arrangements will be made for reimbursement directly to the student, in an amount to cover the student's out-of-pocket expenses.

Whether such payment is requested or not, students should report ALL such accidental occupational exposures to BBPs to the Assistant Dean for Student Affairs, whose office will track all such incidents experienced by all of our students at any of our affiliate teaching institutions or at other nonaffiliated teaching sites (such as during off-site electives).

Resources for occupational exposure to blood:

• DMS Occupational Medicine, 603-650-7018.
• Clinicians Post-Exposure Hotline, 888-448-4911
  http:///www.ucsf.edu/hivcntr

Questions about this process or the payment for it should be forwarded to the Assistant Dean for Student Affairs, DMS Office of Student Affairs, 603-650-1509.

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