A.

DOCTORS & COLLEAGUES: HEP C & HIV INFECTION

1. NEEDLE STICK INJURY 2. COLLEAGUE WITH HEP B,

3. PROFESSIONAL MISCONDUCT IN A COLLEAGUE 4. INCOMPETENT COLLEAGUE

This is a gift of a scenario. In this scenario for once you have to have your facts right because otherwise you wont be able to suggest anything. There is a standard way to go about this and after discussing that a short description will be given regarding the different aspects of safety and post exposure prophylaxis. 1. Greet the patient and say that you have come to know about the incidence. 2. Come the doctor by sayong something like, I know that you are anxious but I can assure you that there are lot that we can do to minimize any risks that is involved. 3. Ask him/her when did it happen and what did he/she do immediately after that. 4. If the immediate 1st aid is correct, acknowledge that and say that it has already reduced the risk of transmission of any infection by 95 % 5. Enquire about the exact circumstances in which the needle prick has happened Was he or she wearing gloves? Single or double? Has she been pricked by a hollow needle? Was the needle inside a vein or artery of the patient Was there any visible blood on the needle tip? How deep was the injury? 6. Ask about the patient he/she was clarking Why was the patient admitted? Does he have a known HIV positive status? Was there any AIDS defining illness? If HIV positive then what was the viral load and the CD 4 T lymphocyte count? What about Hepatitis B & C status? Is the patient conscious & lucent?

Mention that you are going to talk to the patient for further assessment and try to get consent from him for blood samples in order to run a screening. 7. Now ask about the doctors immunization status, if female then when was her last period? Is she pregnant or planning pregnancy? 8. Now discuss with her what you think that whether the exposure was significant or not. 9. Assure her that even if the exposure is significant, the chances of transmission of these infections are usually low. 10. Mention that all activities will be co ordinate by the occupational health physician. Also mention that all the informations will be kept confidential. 11. Tell her that blood sample has to be stored for current and future screening. The purpose is in the case of unfortunate sero conversion in the future, this may help in compensation for work related injury benefit. 12. Mention that the screening process has to be repeated at 12 weeks & at 24 weeks. And if negative at 24 weeks then it is confirmed that no transmission has taken place through that prick. In case of PEP, which goes on for 28 days, the screening will be done 24 weeks after the completion of the PEP, 13. Tell her about the post exposure prophylaxis for HIV & also Hep B if it is justified. 14. Tell the side effects of the drugs and the benefits of taking them. If she is pregnant , say that the current HIV PEP is not considered to be teratogenic although there is lack of a randomized trial. Tell her the risk & benefits and let her decide. 15. Talk about the symptoms of HIV sero conversion and ask her to contact the occupational health physician if that happens. 16. Mention safe sex & avoid blood donation. Encourage to talk about this with the partner. 17. Mention that there will be no work restrictions put on him/her at the moment but if they turns positive then there can be some implications like restriction in exposure prone procedure and also insurance issues. 18. Check for understanding at regular interval. At the end say that, We have covered rather a lot. Is there anything you want me to go over again? 19. Tell her / him that you are going to contact the occupational health physician and get things into motion. Tell him/her that they can take the rest of the day off and you are going to manage a replacement for him/her. 20. Once again give assurance and conclude. INFORMATIONS ABOUT NEEDLE STICK INJURY & PEP:

Chance of transmission of infection Hep B> Hep C> HIV=30% >3%>.3% 1st aid following needle stick injury, Allow to flow blood from the wound freely under running water Dont squeeze, suck or rub Wash with soap water but do not use disinfectant Keep it under water till the blood flow stops. Screening process involves screening both the injured person and the patient. Blood is screened for HIV, Hep B and Hep C. An immediate sample is stored for future reference. It is repeated at 12 weeks & at 24 weeks ( 24 weeks after the completion of PEP) in case of the injured person. If the last screening is negative then we can rule out any transmission of infection. This delay is to cover the maximum length of window period. If the patient denies to give sample, then we can not force them. We can not take sample from an unconscious person but it may be justified to run the test in a sample previously taken for some other purpose. That needs to be discussed with proper authority. For HBV PEP If previously vaccinated then check titre, if < 100IU/L then give booster and recheck titre after 6 weeks If not vaccinated then give passive immunization with Hep B immunoglobulin with in 7 days. HIV PEP 1 Truvada Od Plus 2 Kelatra BID HIV Post-exposure prophylaxis: drug information

Truvada & Kaletra

Introduction

You have been prescribed post-exposure prophylaxis (PEP/PEPSE) because you may have been exposed to the HIV virus. Prophylaxis means a preventative treatment. The treatment consists of a combination of two tablets, containing three active drugs. All three are antiviral drugs which are effective against the HIV virus. Used together, there is evidence that they can reduce the risk of developing HIV infection following exposure to the virus. The names of your medicines are: Truvada, each tablet containing emtricitabine 200mg and tenofovir 245mg, blue capsule-shaped tablets, marked GILEAD and 701 Kaletra, each tablet containing lopinavir 200mg and ritonavir 50mg, yellow tablets, marked with the Abbott logo and KA. The active substance is lopinavir; the ritonavir acts to increase the blood levels of lopinavir by inhibiting enzymes which metabolise it. You have been supplied with enough medication to last for 5 days. Arrangements will be made for you to collect the rest of your treatment to complete 28 days and attend for appropriate follow up.

Taking your medicines

For this treatment to be effective, it is important that you take your medicines properly. Treatment should start as soon as possible after potential exposure to HIV. Read the label on your medicines. They should be taken as follows:

Medicine Truvada Kaletra

Morning Take one tablet with your breakfast Take two tablets with your breakfast

Evening Nil Take two tablets after your evening meal, ideally 12 hours after breakfast dose

Swallow the Kaletra tablets whole with plenty of water while sitting or standing in an upright position. It is important that they are not chewed or crushed. The Truvada tablets can be swallowed whole or can be disintegrated in approximately 100ml of water, orange juice or grape juice and taken immediately. Take the medicines at the approximate times indicated even if you have not actually had a meal. If you forget to take a dose, take it as soon as possible and then continue as before. If you have difficulty remembering to take them, use an alarm, e.g. on your mobile phone. You may drink moderate amounts of alcohol while taking these medicines (within normal recommended safe limits).

Other medicines and medical problems

With this treatment there is a risk of problems developing if you are taking other medication or if you have other medical problems (e.g. kidney or liver problems). You must tell your doctor about any and all medical problems you have, and about any medication you are taking, whether these are prescribed for you or bought over the counter including herbal products e.g. St Johns Wort. Do not start any new medication without discussing it with your doctor first. Just some of the drugs that are known to interact with these medicines include: warfarin (an anticoagulant)phenytoin, carbamazepine (used for treating epilepsy), rifampicin, erythromycin and clarithromycin (used for treating bacterial infections), quinidine (used to treat an irregular heart beat), methadone (used in the treatment of opiate dependence), simvastatin or lovastatin (used to lower cholesterol levels), dexamethasone, fluticasone proprionate(steroids), felodipine, nifedipine (heart medicines), ketoconazole, itraconazole (antifungals) and hormonal methods of contraception, including the combined pill and mini pill. You should not breast feed while taking these medicines.

General advice

Do not take more than the recommended dose. Do not give your medicines to others. Keep your medicines in a cool, dark, dry place, out of the reach of children.

If at any point during the follow up period you develop an acute illness or symptoms comprising any of the following such as sore throat, fever, rash, myalgia, fatigue, malaise or enlarged lymph nodes, representing seroconversion illness you have to inform PEP clinic. Some of these symptoms may, however, be side effects of the antiretroviral medications.

Side effects
The commonest side effects of the medicines are dizziness, nausea (feeling sick), diarrhoea, headache, vomiting (being sick), tiredness, weakness, and muscle aches. These usually settle if you keep taking the medicines as directed, but simple painkillers or tablets to prevent sickness or diarrhoea may help. Tell your doctor if the symptoms persist. Serious side effects are rare; they include allergic reactions, liver toxicity, pancreatic problems and reduced production of red blood cells, causing anaemia, or white blood cells, which can make you prone to infections. Blood tests will be taken at 2 and 4 weeks to check for blood counts and liver problems. Tell your doctor if you are concerned about any new symptoms.

Common side effects Feeling sick, stomach pains, wind, diarrhoea, digestive problems Headache, muscle aches

Can be caused by Truvada, Kaletra

What you should do Keep on taking the tablets with food it often settles. Tell your doctor if it persists or becomes distressing. Take a simple painkiller such as paracetamol or ibuprofen (Nurofen). Tell your doctor if it persists. Take care driving or operating machinery. It may go away. Tell your doctor if it persists. Tell your doctor if it persists.

Truvada, Kaletra

Difficulty sleeping, abnormal dreams, Truvada, Kaletra tiredness dizziness, Skin rash, itching Truvada, Kaletra

Rare side effects Tiredness associated with shortness of breath Fever associated with feeling unwell and other symptoms Jaundice (yellowing of the skin and eyes

Can be caused by Truvada, Kaletra

What you should do Tell your doctor this could be due to anaemia. Tell your doctor this could be due to a low white cell count. Tell your doctor this could be due to liver toxicity.

Truvada, Kaletra

Truvada, Kaletra

Pregnancy
The available evidence is that the recommended drugs are safe after 12 weeks of pregnancy, but we have less information about the safety of the drugs in early pregnancy. You must tell your doctor if you could be pregnant. You should take precautions to avoid becoming pregnant or fathering a child while taking the medicines. The medication will reduce the effectiveness of hormonal contraception; these methods should not be relied on while you are taking the medication, and you should use a barrier method (condoms) in addition.

INFORMATION REGARDING WORK RESTRICTIONS CAUSED BY HBV, HCV OR HIV INFECTION: HEPATITIS B: HBs Ag positive but HB e Ag negative & HBV DNA <103 copies per ml Can practice exposure prone procedure. If HB e Ag positive or HBV DNA >103 copies per ml should have restrictions imposed. If treated, the person should have a viral load less than 103 copies per ml 1 year after cessation of treatment to be allowed to carry out exposure prone procedure. Testing should be done only by the 2 designated laboratories. 2 ten ml samples has to be sent 1 week apart. Reports delivered within 4 weeks. The test has to be repeated every 12 months. The occupational health department should maintain confidentiality. Can inform employers to change area of work, but cannot disclose the status without the consent of the doctor. The post graduate dean has a duty for retraining or redeployment.

HEPATITIS C: If Anti HCV positive then viral RNA should be checked. If positive restrictions should be put in. If becomes RNA negative after treatment, the person should be allowed to perform exposure prone procedure if remains negative 6 months aftrr cessations of Rx. Thisvtestvshould bevrepeated 6 months after & then every 12 months. HIV/AIDS: If positive cannot perform exposure prone procedure ever.

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