BBP: What To Do After an Exposure

In the last few decades, thanks to concerted efforts by both the youth-serving community organizations we work with and a broader push by government entities such as OSHA, Blood Bourne Pathogen (BBP) protocols and practices have greatly improved. Yet even with best-practice adherence to preventive strategies, occupational exposures to bloodborne pathogens can still occur and its important to know how to respond—both to mitigate and treat any actual exposure, and also to ensure the peace of mind of the exposed.

Our provider network can assist in evaluating and treating the exposed employee, using the following BBP exposure management protocol developed by a team of medical experts. It is consistent with updated national guidelines such as the CDC published “Guidance for Evaluating Health-Care Personnel (HCP) for Hepatitis B Virus Protection and for the Administering Post exposure Management” in December 2013 and the “Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus” published in August 2013.

Our BBP protocol covers, but is not limited to:

• Determination of risk of exposure
• Decontamination
• Obtaining or testing source employee HIV, hepatitis B and hepatitis C results when applicable
• Determining hepatitis B immune status of exposed employee and obtaining baseline labs
• Counseling on the risks of infection and the benefits and risks of post-exposure prophylaxis
• Administering hepatitis B post-exposure prophylaxis when indicated
• Administering first dose and/or prescribed HIV post-exposure prophylaxis (PEP)
• Follow up visits at 3-4 days, 6 weeks, 4 months and 6 months after exposure for evaluation, lab testing and treatment as indicated. Closer follow-up indicated if employee is on HIV PEP.

Our partners understand that time is of the essence when the decision is made to start HIV PEP. Therefore, we need to make sure that staff are trained to prioritize employees presenting with potential BBP exposures from the time they report the exposure to the time they get to the clinic and are seen by a treating provider. This is not something to take risks on. From the initial encounter to the final 6 month encounter, your employees that have sustained a possible exposure to BBP need to receive best-in-class care based on national guidelines and experts in the field.

The following is an outline of steps that can be expected when evaluating and treating a BBP exposure by visit. While it is beyond the scope of this synopsis to go over every possible scenario and corresponding evaluation and treatment, the most common course of action is presented here.

The protocol is subject to change based on the CDC and other national guideline updates.

The Initial Visit
During the initial evaluation with the exposed employee, the clinician gathers information regarding the exposure and medical history, and performs a physical exam. If indicated, decontamination of the area of exposure occurs. The provider seeks to determine the hepatitis B vaccine history, post-vaccination immune response; as well as the HIV, hepatitis B and hepatitis C status of the exposed. If the source is known, but not tested, source testing is pursued when possible and permitted by state law. Our clinical partners counsel the employee on the risks of this particular exposure, as well as the risks and the benefits of taking HIV post-exposure prophylaxis (PEP). Currently, the recommended HIV PEP in most cases is Truvada and Isentress. If the exposed employee decides to start HIV PEP, typically the clinician dispenses the initial dose at the clinic and writes a prescription for at least enough medication until the recheck visit (3-4 days). In complex cases (for example, when the source person is known to have HIV or is pregnant), we may obtain immediate consultative services with an infectious disease specialist.

Additionally during the initial visit, blood is drawn from the exposed employee to perform baseline laboratory studies to include hepatitis B, hepatitis C and HIV. If the exposed employee decides to begin HIV PEP, additional baseline blood work is necessary. If the exposed employee has not completed the hepatitis B vaccine series, hepatitis B vaccine as well as hepatitis B immune globulin (HBIG) will be administered until it can be determined that the source is negative for hepatitis B. If the exposed employee has had the vaccine series and a previous positive titer blood test has been obtained, neither hepatitis B testing nor hepatitis B PEP will be indicated regardless of the status of the source. Regardless of whether any PEP is administered or prescribed, the employee will need to schedule a follow-up visit with the clinician in 3-4 days.

3-4 Day Follow-Up Visit
At the first recheck visit, the clinician will review all the lab work from both the exposed and (where available) the source person. If the source is negative for HIV, hepatitis B and hepatitis C, no further testing or follow-up is indicated in the majority of cases. However, if the exposed employee has started the hepatitis B vaccine series, it should be completed and a post-vaccination titer performed 1-2 months after the final dose. If the source is not known or cannot be tested, and the exposed employee has been started on and is tolerating HIV PEP, a follow-up appointment will be made for 2 weeks for further testing and evaluation. If the exposed is not on HIV PEP, the next clinician follow-up visit will be at 6 weeks from the time of the exposure. In some cases, hepatitis B vaccine and/or lab testing may be indicated at 4 weeks from the exposure. “The Healthcare Professional Written Opinion”, which is required by OSHA, will be completed by the treating clinician and sent to the employer.

2 Week and 4 Week Clinician Visits
These visits are only indicated if the exposed has been started on HIV PEP due to the possible side effects of the medications. Lab testing will be indicated as well as a symptom screen. Unless the source employee is negative for HIV or the exposed has discontinued the medication due to the side effects, the clinician will ensure that the employee receives a prescription for HIV PEP medications to complete a 4 week course. A clinician visit will be scheduled for 6 weeks post-exposure.

6 Week Clinician Visit
At this visit, in addition to a symptom screen and review of previous labs and vaccines, the 4^th generation HIV blood test and the hepatitis C RNA PCR test are ordered in most cases. If either test is positive, the employee will be referred to an appropriate specialist.

4 Month Clinician Visit
At this visit, the clinician screens the employees for symptoms and orders the 4^th generation antibody/antigen HIV test. If this test is negative, no further testing for HIV is needed . The 3^rd hepatitis B vaccine may be administered at this time.

6 Month Clinician Visit
At the final visit, hepatitis C antibody is drawn from the exposed employee and the employee is referred to a specialist if positive. If indicated, the hepatitis B vaccine is administered or post-vaccination titer may be performed. (Hepatitis B antibody bloodwork) If all tests are negative, the claim is closed.