Kathryn Nichol: Thanks, Karen. Good morning, everyone. My name is Katherine Nichol and it is my privilege to introduce our guest speaker this morning, Dr. Tony Mazzulli. Dr. Mazzulli is a specialist in the areas of internal medicine, infectious diseases and medical microbiology. He is an Associate Professor with the Departments of Medicine and Laboratory Medicine and Pathobiology at the University of Toronto. Dr. Mazzulli spent two years as an MRC Fellow with Dr. Martin Hersh at Massachusetts General Hospital affiliated with Harvard University studying anti-viral resistance of HIV. Presently, Dr. Mazzulli directly supervises the diagnostic virology and serology laboratory within the Microbiology Department at Mount Sinai Hospital. He is also a consultant in infectious diseases. As well as being a member of several hospital and non-hospital committees and organizations, Dr. Mazzulli works closely with infection control and employee and occupation health in the development of policies and procedures as they relate to the prevention of viral and non-viral infections. His research interests include anti-viral drug susceptibility testing, mechanisms of anti-viral resistance and rapid diagnostic testing. Good morning, Dr. Mazzulli. It's a pleasure to have you here. 

Dr. Tony Mazzulli: Good morning. Thank you. I'd just like to thank Ontario Safety Association for Community and Healthcare for inviting me to speak this morning and thank you to those who have joined us. What I'd like to do is take your through some of the issues related to what is your risk as a health care worker in terms of being exposed to infectious material and what can be done. Certainly some of the traditional strategies remain the same. First aid is clearly the most important thing, but you'll see that in the past couple of years, particularly with HIV or the AIDS virus, that new recommendations for what you should do should you be injured with a needle stick or exposed to blood from a patient. 

So what are the main viruses that we're concerned about when a person gets stuck with a needle or gets splashed in the face or the eye with blood or body fluids, and there's really three main viruses at least that we know about and those continue to be Hepatitis B, Hepatitis C and the HIV or AIDS virus. Clearly, those are the only ones we recognize. There may be other risks for viruses or other infectious agents which we just don't know, but for now we'll just focus on these three viruses. What I'd like to do is just take you through a case which I saw a couple of years ago but I see these almost approximately once a week now of some type of health care worker who gets injured or gets exposed to a patient's blood or body fluids and I'm asked to manage them and follow them over the next six months following their injury. 

This was an interesting case. It was a 37-year-old dentist working in the community, but this could have easily been a nurse or a dentist working in our clinic within the hospital, who on a Friday afternoon, as it always is, stuck himself while he was giving some anesthetic to a patient while he was preparing him to do some dental work. The problem became that he knew the patient was an HIV-positive patient to start with but he was an otherwise healthy patient. The second problem became that while he was trying to be extra careful -- and those were his words, "I wanted to be extra careful" -- he tried to recap the needle after he had injected the patient with local anesthetic, and clearly I think that is a no-no I think as most people know that recapping is not the way to go, but this case does illustrate what can happen when you deviate from what your normal practice is. Well, he finished his procedure on the patient, managed to then clean himself up, come down to the Emergency Department at Mount Sinai Hospital. He in fact brought a sample of the patient's blood with me -- the patient consented to have it tested. Unfortunately, the Emergency Department wouldn't accept it because they didn't collect it so we couldn't test the blood. 

But we knew that the patient was HIV-positive, he told us that. We didn't know however whether the patient was a carrier of Hepatitis B and Hepatitis C but you have to keep in mind that people who are at risk for one of these viruses may also be at risk for one of the others or for all of them. For example, HIV is known to be transmitted in IV drug users, but the single most common risk factor for having Hepatitis C is also IV drug users. The point here is don't forget the other viruses for which the patient may not have been tested for and just focus on the one you think that scares you the most or the one that the patient knows that he or she is positive for. I'll tell you towards the end what happened to this particular individual. 

Well, there are cases in the literature of people who have acquired, health care workers, one of these viruses or as you'll see there was a report a couple of years ago in The New England Journal of Medicine where a nurse got both HIV and Hepatitis C from the same needle stick injury and she died very quickly thereafter within a few months. So it does happen, it has been reported, and it is something that you should be aware of. Clearly, in Canada there was a recent case which is now before the courts of a physician working in the Montreal area at McGill University who stuck his finger on a sharp object, on a needle, while he was trying to put it into a Sharps box and now is suing the McGill University for $1 million in compensation because he then became HIV-positive and now has AIDS. I mean it's a small compensation of $1 million given that the implications if you get HIV and AIDS is essentially it's a life sentence, there is no cure. 

Well, each virus has different risks and just because you get stuck or exposed to a patient's blood, your risk of getting one of these viruses isn't the same. Clearly, the most infectious is Hepatitis B virus. That is if the patient that you happen to be exposed to is a carrier of Hepatitis B and you stick yourself with the needle, assuming you've not had the vaccine and you do nothing, then the risk to you can be as high as 30%. That's almost a one-in-three change that you will become infected with Hepatitis B. For Hepatitis C virus, the risk is about 10 times less but it's still about 3% or three in 100. So again it's not zero, it's not as high as Hepatitis B, but clearly the implications of getting Hepatitis C are quite serious. The one that most people worry about and the first thing that jumps into people's mind when they get an injury is obviously HIV or AIDS virus. On the one hand fortunately the risk for this virus, given all things being equal, and you get the same injury, it's about three in 1,000 chance that you will become HIV-positive if you are stuck with a needle or exposed to a patient's blood. Again, that's the smallest risk but as you know once you get HIV there is no cure. All patients now are estimated to progress to AIDS and will eventually die from their disease. 

So why are we worried about these particular three viruses? Well, if you look at Hepatitis B the risk after you get the injury is about 5% for you to carry this virus the rest of your life. So there's a one-in-three change you become infected. Fortunately, most people will be able to deal with it and clear it out of their system, but about 5 or 10% will not be able to clear Hepatitis B, they will carry it the rest of their life and after many years they run the risk of developing cirrhosis of the liver, in which case the liver shrivels up and becomes ineffective, and of developing liver cancer in about 15% after about 10 years of infection. Keep in mind although in North America we often worry about lung cancer in men, breast cancer in women, on a world scale liver cancer is by far the most common because of Hepatitis B infection leading to and predisposing to getting liver cancer. 

If you get Hepatitis C the story is very similar to Hepatitis B except the biggest difference is that if you get Hepatitis C infection you are almost certainly going to carry that virus the rest of your life. As I said, for Hepatitis B, most people will fortunately be able to clear the virus and only 5 or 10% become carriers. With Hepatitis C it's the exact opposite. At least 85 to 90%, if not everybody, becomes a carrier of Hepatitis C once they're infected. The implications are the same: You have a high risk of developing cirrhosis of the liver and of cancer about 1 to 5% after about 15 years. 

The last one of course, HIV, as I said, virtually everybody who gets HIV will over many years develop AIDS and once you develop AIDS you will almost certainly die from AIDS. There's a lot of public press and interest in new HIV drugs and clearly they're beneficial, they're helping patients live longer, but they are not cures. The virus remains there. When the patients stop taking the drugs, the virus then begins to grow and continue to destroy the patient's immune system. The other thing to understand about these viruses is that again when you become infected in many of these, when you become a carrier you become infectious to other people and this is important because you become a potential source to your patients or other patients in the hospital, you become a potential source for your friends, your family members depending on the contact and their exposure to your blood now, and it has implications obviously for medical care down the road. 

Now, how do you acquire these infections? Well, there's three routes by which a person could acquire one of these three viruses. Clearly the one we're interested in today is an exposure to blood or blood products or blood and body fluids. But clearly, as I said, if you become a carrier you run the risk of transmitting any one of these viruses to your sexual partner. We also know that if you're a woman and you become pregnant there's a risk of transmitting these viruses from the mother to the baby, and again that has obviously quite serious implications. But today of course we're just interested in exposure to blood. 

The other problem with these viruses is that again you're not immediately sick, you're not sick for many years, and if you're not tested you may not know that you actually carry the virus which means that most of these infections for an average of 10 or so years or more, they are what are called silent infections. They're in your system. If they're the Hepatitis viruses they're multiplying in your liver, slowly destroying it. If it's the HIV virus, it's in your immune system slowing destroying it. You feel well but you are infectious to other people. Remember, you don't have to have symptoms to be infectious to someone else nor does the patient whose blood you've been exposed to have to have symptoms for you to be at risk. 

Which body fluids might you come in contact with which have been implicated or have been suggested to transmit one of these viruses? Well clearly, blood or any fluid that's been visibly contaminated with blood has been shown to transmit all three of these viruses. Organs and tissues, all of them. Again, it doesn't have to be just liver tissue. Lung tissue, heart tissue, any other biopsy material or patient material can carry these viruses and have been shown to transmit it to others. Any body fluids internally such as pleural fluid, amniotic fluid, pericardial fluid and so on, and saliva but saliva has only been shown to transmit the Hepatitis B virus. The ones which have not been implicated -- and this is important to distinguish because all these viruses have been isolated from virtually every body fluid and tissue in the body. You can get HIV out of feces, you can get Hepatitis B out of feces, but it's never been shown to contaminate or infect another person. Urine, similarly you can identify these viruses in urine but they have not been shown to infect other people. So that again the ones which are not implicated but do carry these viruses, feces, urine, sputum, tears and even vomitus, unless they contain visible blood will not transmit one of these viruses to you. 

Well, what kind of injuries? Remember, getting a splash or a drop of blood on your finger or your hand as you're doing a procedure or something or assisting to care for a patient is not sufficient to cause one of these viruses to penetrate your skin. None of them will penetrate your skin and none of them will cause infection. However, if they get in contact such as through a needle stick injury, a cut, a bite or some other sharp object with blood or tissues underneath the skin, then you're at risk for acquiring one of these viruses. If you have dermatitis, some inflammation or eczema or your hands where the skin is red and raw and sore, and you get blood or contaminated body fluid on your hand, then the virus can penetrate but that's because the skin barrier which protects you is no longer working. And then finally if you get a splash of blood or body fluid into your eyes, into your mouth, into your nose where it comes in contact with mucous membranes, again any one of these viruses could lead to an infection within yourself. 

The other thing that people often ask in terms of health care workers but also people in the community is that they found a syringe or they found some other object which looks like something perhaps an IV drug user might have used, and can these viruses survive in the environment. You don't know when you go pick up a bag of garbage that there's a needle in it. You stick yourself and you don't know - is the virus still alive or not? Now, it's difficult to know for sure but there are sort of controlled experiments which suggest for example that the Hepatitis B virus can survive for at least seven days in dried blood at room temperature, about 25 degrees. For Hepatitis C, some studies say within less than a day the virus will die, others have shown it'll survive at room temperature for weeks. And finally HIV, again some studies suggest only about a day to a week in certain blood and tissues but others have shown that at 4 degrees -- that's sort of roughly refrigerator temperature -- it'll survive for months at a time. So it's hard to know if these experiments translate into the real world, and when somebody brings me a needle I have no way of knowing is the HIV virus or the Hepatitis C still alive. But I have to assume that it could be and therefore treat the person appropriately. 

Who's at risk? Of course anybody who's in contact with any of the patient's blood or body fluids. And again it doesn't have to be the physician, the nurse, it can be the janitor, it can be the food service person, anybody who's a potential risk of getting a Sharps Injury because they're in contact with the patient can be at risk of getting one of these viruses. In fact, if you look at the slide which... a table from a study done in the U.S. just published a couple of years ago, which looked at 63 different hospitals and who were the people who got Sharps Injuries. Well clearly, the biggest category is nurses. That may be two reasons. One is nurses are more likely to report their injuries, but the other main reason is that nurses obviously are doing a lot of procedures, taking blood, starting IVs, giving medications, giving intramuscular injections which puts them at risks for Sharps-type injuries. Physicians again forms the second-largest category but probably would be much higher because physicians are notoriously poor at reporting their injuries. But when you look at the fourth one, housekeeping, laundry workers, central supply, they make up the fourth-largest category of people who sustain Sharps Injuries. Again, that's somewhat surprising. You figure why would housekeeping be exposed to a patient's blood and get a Sharps Injury? Well again, if the nurses the physicians or anybody else throws the needle in the garbage it's the housekeeper who then has to go clean that up who may not recognize there's a needle, they pick up the garbage can, they stick their hand. So keep in mind that it doesn't have to be true health care workers, it's the allied people, the other people working in the hospital settings that may be at risk. 

So what do you do if you get an injury? And obviously that falls under this category of post-exposure management. Well again, as I said before, first aid is clearly the first step. Flush the area, wash it. You can wipe off the area with an alcohol or betadene or some other disinfectant. People have asked, you know, "What happens if I tie off my finger because I could stop the blood flow?" Well, if you tied it off enough to stop the blood flow you'd lose your finger. Besides, the contact with your blood is instant, therefore trying to squeeze it, squish it or do whatever else, tie it off, isn't going to prevent any of these viruses from coming into contact with your blood. But clearly first aid is important. Go to Occupational Health or to the Emergency Department if it's in off hours and report your injury. Most Emergencies and most Occupation Health Departments now have a plan for managing people who have been exposed to blood and body fluids. 

What will happen is again... it would be ideal if we could get baseline blood work both on yourself as well as the source patient. Again, if we know what the source patient's status is -- that is, if we know they're HIV-positive -- then it's better able to counsel you and tell you about the risks and manage you. If we deal with a source unknown, because it was in a garbage bag and somebody stuck their finger in and nobody knows where that needle came from, it becomes much more difficult to counsel somebody and tell them about the risks because we don't know what that needle might or might not contain. And then finally we try and counsel the health care worker as well as the source. Remember, the poor source patient. Now, when you're asking them "Can I do an HIV test?" or "Can I do a Hepatitis B test?", they need to be told what the implications of that are because that's going to affect their life as well. 

So if we look at each virus in turn then, starting with Hepatitis B, because that one is the biggest risk as I said before, clearly the best strategy is prevention. If you're a health care worker you're at higher risk than the general population of being exposed to Hepatitis B and clearly you should get the Hepatitis B vaccine. If you get all three shots over the six-month period you're well on to 97/98% that the vaccine will be effective and you basically just don't have to worry about it anymore. It doesn't matter if the source patient is positive. If you've had the vaccine and you know you're a responder, which is 97%, then you don't have to worry about Hepatitis B anymore. The concern of course of the side effects of long-term consequences is unfounded. Again, benefits of the vaccine far outweigh any potential theoretical risks. But the one thing that I must emphasize is if you get the vaccine please make sure that you get tested afterwards to make sure that you are a responder. You don't want to be falsely led down the garden path because you're one of those 3 or 5% of people who did not respond, because if you get an injury and you were a non-responder then all bets are off, you're at risk just like everybody else. So get the vaccine but you need to be tested afterwards to make sure that you are in fact now have the antibodies to protect you in case you're exposed. 

Well, what happens if you didn't get the vaccine, or you did get it and you were a non-responder? Well, there are still two things that can be done. You can be given a substance known as Hepatitis B immune globulin, and basically this is just antibodies taken from blood donors who are known to be immune to Hepatitis B. So you take their blood, you take out the antibodies against Hepatitis B and you concentrate them together and then in the event of an injury or an exposure you give them back to somebody through an intramuscular injection and the idea is here I give you instantly antibodies to protect you. They work very well, they're not quite 100% effective, but clearly if you get them within 48 hours of your exposure they are almost 99 to 100% effective in protecting you. The issue of course is they don't last forever. They usually are cleared out of your system by three to four months and therefore they don't give you long-term protection which means you still should get the vaccine. And that's the second part of managing somebody after an exposure. If you've been exposed, you get the Hepatitis B immune globulin and you should get vaccinated to start your vaccine series if you've never had the vaccine in the past or you were a non-responder. And again you can see there's combinations we use between the immune globulin plus or minus the vaccine depending upon what your risk was before you got exposed. 

For Hepatitis C, unfortunately the news is not so good. There is no vaccine, there are no antibodies we can take from blood donors to give you, there's no medication we can give you and basically with Hepatitis C it's sort of a wait--and-watch type approach -- that is, you need to be tested for the next six months and only after six months if you're still negative do we say you don't have to worry, you will not get Hepatitis C from that particular injury. So unfortunately with Hepatitis C there is no intervention either before or after that we can do that can protect you from getting Hepatitis C if the source patient had Hepatitis C. 

Well, what about HIV/AIDS? This is the one which in the past few years has had the greatest interest because new recommendations and new guidelines have been published on how to manage people exposed to blood and body fluids contaminated with this virus. Well, as I said, what's the risk of getting HIV? Well, if it's a percutaneous, a needle stick, a Sharps Injury and you're exposed to blood, it's about .3% or 3 in 1,000. If you get splashed in the face or the eye with body fluid or blood it's about 1 in 1,000. As I said before, if it's just a drop of blood or splash of blood on hands or other parts of your body where the skin is intact, it's really no risk, essentially zero risk of getting HIV. But the two most common scenarios are the first two: Sharps Injury or a splash in the face when you're doing a procedure. 

Just to give you some background before I talk about the management. Again, there are... been almost 15,000 cases of HIV or AIDS reported up until April 1997. Now, it's estimated there's probably about 20,000 but again the reporting is slow and not everybody gets reported. About 15 to 20% drop in the death rate from AIDS ever since new anti-AIDS drugs have been available in the past few years. That's the good news, that people are not dying from AIDS. On the other hand, the bad news is new HIV infections are almost double what they were four or five years ago. So when you look at the number of people getting new HIV infections, somewhere between 3,000 to 5,000 new HIV infections in 1996, which was almost double the preceding five years from 1989 to 1994. So what's happening then is that the number of people getting infected is going up, the number of people at the other end who are dying is dropping so the pool of people in the middle who are carriers, whether they know it or not, is increasing, therefore the chance that you will exposed to somebody who is an HIV-positive person increases. 

Well, have there been cases of people getting HIV? Again, I showed you the one example in the beginning where the person got both HIV and Hepatitis C. In Canada there have only been three reported cases. One was a biochemist working in a lab, one was a lab technician and one was a nurse out in British Columbia a few years back. All of them got HIV through occupational exposure. Now, you have to understand that a reported case just means somebody took the time to fill out the forms, to write up what happened and publish it somewhere. There are other cases which have not been reported but the health care workers have acquired HIV through their work and work exposure. 

On a worldwide basis, the CDC, or the Centers for Disease Control, in the U.S. keeps track of these and again the best numbers are unfortunately back to 1996, but as of June '96 there have been what are referred to as 51 documented and 108 possible cases. Just so you understand what the difference is: A documented case is one in which the health care worker got stuck with a needle for example, went to the Emergency Department or the Occupational Health, was tested at time zero to make sure they didn't have any of these viruses because if you have them immediately right at the time zero then it wasn't from this injury. Nobody gets infected that fast, you must have been infected from some other exposure, some other life risk factor. The 108 that are possible cases are people who got the same kind of injury except they didn't go at time zero to be tested to make sure they were negative a time zero. They showed up a few weeks later when they got a flu-like illness or some other fever and they were being investigated and then were found to be positive a few weeks after the injury. Again, they're only called possible because they're no way to prove that at the time of the injury they didn't have it. 

Again, 90% of them were exposed to HIV-infected blood and again almost 85 or 86% were due to Sharps Injuries and only about 10% were due to cutaneous exposures - splashes in the face, in the mouth, in the eyes. When you look at the breakdown of who these people are, again the largest group tends to be the nurses again probably because they're most likely exposed to blood and body fluids. The second category tends to be lab technicians again who are dealing with patients' blood samples, body fluids, specimens in the laboratory, and then there is a smaller number of health care workers in other categories. 

So what is your risk of getting HIV? We have to look at three factors. One is what's my risk of getting an injury, and we'll talk about that. Again, if you do certain types of work like a nurse where you're constantly exposed your risk of getting injured is much higher than if you're sitting at a desk and not directly dealing with Sharps or sharp objects. The second factor is whether you're going to get HIV or any of these viruses for that matter is how common it is in the patient population you deal with. If it's not very common in your patient population you may get lots of injuries but the chance of being exposed to the virus is very small. On the other hand, if you're working in the HIV clinic or you're working in an inner city hospital that serves a large HIV or AIDS population or you're working in a liver clinic, then you may have a greater risk of being exposed to someone who's a carrier or infected with one of these viruses. 

And then finally the third factor is the efficiency of transmission after exposure. As I said, just because you got stuck with a needle it's not a 100% guarantee that you're going to get one of these viruses. With HIV it's about three in 1,000, with Hepatitis B about 30% or a one-in-three chance. So if you look at these in turn, so looking first at what's your risk of getting an injury? Well, there's some good data from the United States and again you can divide these by 10 to determine Canadian figures, but there's about 4.4 million health care workers in the U.S. It's estimated that there are about 800,000 -- so that's almost a million, not quite -- but 800,000 needle sticks or Sharp Injuries per year in the United States of which it's estimated that 16,000 are contaminated with HIV. Now, if you take that and multiply it by the risk of 3%... or .3% or three in 1,000, you can see that about 48 or 50 people will acquire HIV in the U.S. every year. If you take those as Canadian numbers and divide by a factor of about 10, that means that somewhere around five or so people per year in this country will acquire HIV through their work or work exposure. 

The second factor was how frequent were you likely to come in contact with blood, who was the ones most likely to be exposed? Well, as you'd expect, surgeons because of the type of work they do obviously, are at highest category but nurses, other surgical assistants, dentists and so on, also fall into that category. What about the patient population? And again it's hard to know where anybody works in terms of... unless all patients are tested routinely, what the prevalence or how common HIV is in your population, and the ranges have varied, for example in some New York hospitals as high as 14 or 15% of the patients coming through those hospitals are HIV-positive, to centers like Utah where less than two in 1,000 are HIV--positive. At Mount Sinai Hospital about 10 years ago, and we're looking to repeat this now, we did an anonymous survey of 3,000 new admissions, anonymously tested them all for HIV and found that about six in 1,000 were HIV-positive who did not know they were HIV-positive patients. So again it's not as high as the 15% in New York but it's certainly not zero. 

The other problem, as I said, because most of the patients are asymptomatic the ratio is about 10 to 1. For every one known HIV patient there's probably another nine of them who are HIV-positive who just don't know because they've never been tested. In outpatient clinics there was a large study in British Columbia that looked at over 65,000 people and they show that in men coming to that clinic about .8% or almost one in 1,000 of men were HIV-positive whereas about 7 in 10,000 were HIV-positive women. 

Again, what factors are associated with increasing the risk of getting HIV from your injury? Well clearly, if it's a deep injury you take that.3% and multiply it 15 times. So if you get stuck with a sharp object into a deep muscle it's not three in 1,000 anymore, it's 15 times three in 1,000 as your risk. If there was visible blood on the needle, on the scalpel, on the sharp object, if you could see the blood there's got to be a lot more virus in that than if it was invisible in which case you didn't see the blood and therefore the risk goes up six times higher. If it was a needle which was already used to take blood from a patient, so it was inside their vein or their artery for blood collection or for starting an IV and so on, as opposed to something, a needle that was used to give an intramuscular injection, the risk is about four times greater. And if obviously the patient is in the final stages of AIDS, presumably at that point the virus in their blood system is very high, therefore when you get exposed you're exposed to a lot more virus and the risk goes up about five and a half times. 

What about the converse? The question is what can I do or what can you do to reduce the risk of getting HIV from one of these types of injuries, and the two things then are is it helpful to wear gloves and secondly can I take something or do something after the fact that can hopefully prevent or reduce my risk. Well gloves, at least in the laboratory, have been shown that if you took some of these latex or vinyl gloves that we have common in the hospital and you take a syringe, dip it in HIV, you puncture the glove with the HIV needle and you measure how much virus comes out on the other side after it's punctured the glove, it does reduce the amount of virus by about six times, but it's not zero... if it's a solid needle like a scalpel needle as opposed to only reducing it by about a half if it's a hollow needle like a needle you might use to take blood. That's the laboratory. The problem becomes the reality of life. If you look further down, when they looked at all the cases of health care workers who became HIV-positive following a needle stick injury and they looked at whether in fact wearing gloves or not wearing gloves made any difference, it made absolutely no difference. Those who were wearing gloves and became positive were just as likely as those who were not wearing gloves and got the same kind of injury. So unfortunately, although in the laboratory we can show that gloves seem to reduce the risk, in the real world studies haven't shown that gloves actually make a difference. 

The other issue with gloves is... again a headline from a couple of years ago for The Medical Post reading "Leaky gloves have become an infection control nightmare". Again after about five minutes of use by a dentist, after about two minutes of light work by a nurse or other health care worker, they leak almost 80 to 100%. Now again, that isn't bad because, as I said, even if the virus will penetrate the gloves and get on your hands as long as your hands... the skin isn't broken, it's not chapped, you don't have cuts, the virus won't penetrate. But the issue there is that even if you can't see visible tears or breaks in the gloves, when you take them off wash your hands. There's no guarantee that something hasn't gone through the glove even though to you the gloves look perfectly fine. 

The second factor then which is what's created the most interest in the past few years is the use of what we call PEP or post-exposure prophylaxis. That is, you get stuck with a needle, you know the source patient is HIV or is at high risk for being HIV-positive - can I take something to prevent me from getting HIV? Well clearly, there's no vaccine yet -- and people are still working on that - - there's no immunoglobulin or antibody I can give you and so basically now the recommendation is to take the same AIDS drugs that people take for treatment. And there was a study which showed that if you took the drug Zidovudine or AZT or Retrovirus it's sold, that if you took that drug within a few hours after the injury it reduced your risk by 80%. It wasn't perfect but it did decrease your risk from three in 1,000 down to less than 1 in 1,000. Again, when one decides whether to take the drugs or not, one has to understand what you're trying to do here. On the one hand, the risk is relatively low to start with. You could say okay, if it's three in 1,000 that I'll get HIV, the opposite is that it's 99.7% chance I won't get HIV so why bother, the odds are in my favor. That's true. The converse is that if you are one of the unfortunate people to get HIV... as I said before, there's no cure, it's a lifelong illness, all the implications are there for the rest of your life for you, your family and so on. 

There are other things which showed in fact that the AZT drug works to reduce the risk. When we look at pregnant women who are known to be carriers of HIV, when they take the AZT during pregnancy it reduces the risk by almost two-thirds of transmitting it from the mother to the baby. So based on that, based on the animal experiments, based on the few studies we have where people have taken it after a needle stick, it is recommended that you should within the first few hours after getting stuck with the needle start therapy with one of these anti-HIV drugs. The key here is that you take it within the first few hours. Waiting a day or a weekend to think about it is too late. The guidelines for this... there are two now published, one in the U.S. and on in Canada, and I apologize - on your handout the date for the U.S. one was actually 1998. that was the updated version, and the one in Canada was from March '97. 

But they are very similar in their recommendations. Again, first aid: Clean the area, flush it and so on. Report urgently. You must take the drugs, the PEP within a couple of hours of your injury. Evaluate the significance of the exposure, the type of body fluid you were exposed to, the type of exposure, whether it was a splash, a cut, a sharp object, and then counsel the health care worker and test the source and the health care worker as I mentioned earlier. Again, sometimes the source patient is gone therefore you don't know. Even though you know who the patient is you won't be able to test him or her immediately. But some of the risk factors which are known to be risks for HIV of course is if they're IV drug users, if they're men who have sex with men, if they have a history of sexually-transmitted diseases, tattooing, body piercing and so on, then one should consider them as high-risk sources and even if they were never tested consider them to be HIV-positive at least for the purposes of taking prophylaxis. 

If the source is still around, keep in mind you must get informed consent to test the source patient. It isn't good enough to just phone the lab and say "Oh, I sent a blood sample down this morning for a CBC, a blood count. Can you please add an HIV test?" That isn't good enough. You must get consent. It's the one test in this country and perhaps in many others that you need consent from the patient. It's unethical to test a source patient without getting consent to do the test. Again, obviously maintain confidentiality about the source as well as the health care worker. It would be nice if we had instant rapid tests but unfortunately in most centers they don't have access to this. The test is done at the public health lab. It may take a few days to get results back if you're lucky, which means, as I said before, if you're going to take the drugs to prevent HIV then oftentimes you take them without knowing the patient's result and then a few days later you can decide depending upon whether the patient is positive or negative whether to continue or not continue.

 What tests do we do? Again, we check the source patient for the HIV, the Hepatitis C and the Hepatitis B. We want to know if they're carrying any of those. We also test the health care worker for the same three viruses. The biggest difference is that in the health care worker we check them for antibodies to Hepatitis B. Hopefully if you've had the vaccine or you know you've been infected in the past and have recovered, you should have those antibodies. But otherwise we check HIV and Hepatitis C to make sure that if you're positive now it was not this injury, it was from a previous exposure. It also has implications to you for compensation down the road should you become infected and going on Workers Compensation disability and other potential benefits that you may be entitled to. 

As I said before, the studies show that if you took that drug, Zidovudine or AZT, it reduced the risk to you by 80%. Because many patients are now taking these drugs because many patients have resistance virus, we don't recommend a single drug anymore, it's now a combination of three different HIV drugs. You take those for a total of 28 days or four weeks. Now, in most centers that have a policy or program, what we do we give the patient or the health care worker what's called a three-day pack. That's free. That's what we have in our Emergency Department and our Occupational Health is stocked with these. The idea is give it to them immediately. We know that the HIV test may take a few days to come back. At least they're taking the drug and if the result comes back, then they can either decide to continue or not continue.

And again the problem with these drugs is they have a lot of side effects and a lot of drug interactions. For example, about 5 to 10% of people will complain of getting severe nausea, diarrhea, stomach upset. They feel extremely tired, it's difficult to work, difficult to concentrate, it's difficult to sleep when you're taking these drugs, and then there are other more potentially serious ones such as a drop in your blood count, development of kidney stones, pancreatitis, neuritis and so on. So these drugs are not inconsequential and often although people recognize the risk of getting HIV, they also have to balance that with all the side effects from taking these drugs. 

Another problem with these drugs is they're not cheap. If you look at what it costs to take them for four weeks, the combination of the three drugs, it's about $1,300 for four weeks. Again, for some people who have insurance plans, eventually they get reimbursed. For others, that's out-of-pocket expense. Again, hopefully cost isn't what decides whether you take it or not but it is an important factor to consider and something I warn patients about when I make a recommendation to take the drugs. 

What happens after that? Well, there is counselling for the next six months and that is to say the patient has to be followed to check that they're not getting any side effects from the drugs. They have to be told about the risk that they could get HIV or one of the other viruses and transmit it to their partners, so they have to avoid blood, semen, organ donation. They should practice safe sex because they could transmit the virus to their partners. Avoid pregnancy if at all possible, and if they're a woman who is breastfeeding they should try to defer breastfeeding because we know HIV can come out through breast milk. 

So in summary, again I think some key things: One is if you haven't already been vaccinated, get your Hepatitis B vaccine. Not only get it, but after you've finished, wait about a month or so and go get tested to make sure you responded to the vaccine and you're immune. Follow what are called now standard precautions. In the past these were called universal precautions, body substance precautions, a whole host of names. Now they're called standard precautions and that means simply if you're going to do a procedure or be in contact with a patient that you know there's a risk of being exposed to their blood or body fluids, wear the appropriate gear to protect yourself. Also protect your patients, be careful in what you do for them, as well as protecting your colleagues - don't leave sharp objects around, needles around and so on. 

Probably the most important thing is don't change your practice. Once you're in the habit of following good infection-control type practices, don't start wearing double, triple, quadruple gloves because you know this patient is HIV but that one isn't. So for this patient I'll wear three pairs of gloves and that one I won't wear any. The problem happens when you change your usual practice. That's when you're more likely to get injuries. That's what happened to the dentist. He knew the patient was HIV-positive so he figured well, it's probably safer if I cap the needle because that way nobody else will get exposed. That's not what he normally did. Normally he would take the needle, put it in the Sharps box and that would be the end of it. When you change your practice that's when you're more likely to develop an injury. When you start wearing double, triple gloves your fingers become less coordinated, more clumsy, you're more likely to stick yourself and so on. So just develop good practice and follow that regardless of whether you know the patient's got HIV or Hepatitis B or whatever. And again, given that there is things you can do for HIV, seek medical attention quickly, don't wait two, three, four days to think about it. Again, I know it's hard. It's easy now that you're sitting relaxed quietly to think about it but I know at the time of the injury a lot of things run through people's minds. Get the attention first and then at least if you're on the drugs if it's appropriate then you have time to sit back and think about it. Taking a few doses of the drug, you can always stop later. But waiting a few days and then starting the drug may be too late. Well, I'll stop here and be happy to answer any questions.

Operator: Thank you. We'll poll for questions today using our quick queue polling feature. If you have a question, please press 1 on your touch-tone telephone. You will hear an entry tone once you are in the queue. If you are using a speakerphone, please lift the handset and then press 1. Should you wish to cancel your question, please press the number sign. Please press 1 at this time if you do have a question. Our first question comes from Linda Farrell from South Bruce Grey Health. Please go ahead. Please go ahead. Your line is now open, Ms. Farrell. 

Linda Farrell: My question is: Sir, if you know the source and have been able to secure their blood and you know that they are negative for Hep B and HIV, do you for your health care worker have to do any more testing for Hep C rather than the initial testing? Like are there any false negatives for the source? 

Dr. Tony Mazzulli: Right. Yeah, I guess there are two issues here. One is that you have to understand that if the patient... the source patient is at high risk for any of these viruses, IV drug user, body piercing, all the rest of it, then a negative test does not necessarily rule out any of these viruses. Because we know that the incubation time for Hepatitis B for example can be as long as six months, we know that it might take a person six weeks, three months or even up to six months to become HIV-positive after they've been infected, but during that incubation time they're infectious to others, their blood test is negative. So if the person, the source patient is still in one of these high- risk categories and you have a negative test, you have to be cautious here and perhaps err on the side of safety and assume that they could still be incubating it. As far as lab tests and their false positives, false negative rates, clearly this could happen and therefore if you tested them only for Hepatitis B, HIV but didn't test them for Hepatitis C, you can't assume that Hepatitis C is not there. And again, if the source patient was still in a high-risk group I would still follow the health care worker over the next six months with regular follow-up and repeat testing at six weeks, three months and six months to make sure they do not become Hep C positive or HIV positive or Hep B positive. 

Linda Farrell: Okay, thank you. Some of the guidelines had said that if the source was negative for HIV you wouldn't have to do more testing on the employee. We're in a low-risk, 0.4, but from your information I think we should be testing as the guidelines say in case we miss something. 

Dr. Tony Mazzulli: That's right. Again, you have to do an assessment of the source patient, and sometimes that's difficult, sometimes you can get the information and patients are quite forthright with that and if they fit in any of the high-risk categories despite a negative test I would still follow the health care worker. 

Linda Farrell: Our region is 0.3 or 0.4% for the province. What about these PEP drugs? We have PEP drugs 30 miles, we have four sites 30 miles from the sites. Some of the reading didn't say one to two hours, some had said up to a day. What's your line of thinking for that? 

Dr. Tony Mazzulli: Again, I still believe that the sooner the better, that the animal studies and that the... when they looked at the clinical cases, the real patients who decided to take and not take the drug, those who seemed to... there was a trend towards a greater benefit if you took the drug earlier within the first few hours after the exposure. Again, we wouldn't deny anybody 24 hours, but we also know that perhaps at 24 hours it may be too late, the virus has already got into your lymph nodes, your white cells, etc., and it may be too late to stop it. 

Linda Farrell: Thank you very much. 

Operator: Thank you. Our next question comes from Sally Lloyd from Lake Ridge Health. Please go ahead. 

Sally Lloyd: Yes, you mentioned that the effectiveness of the Hepatitis B immunoglobulin is obviously best within 48 hours but I was wondering what would be the maximum number of hours that you'd consider still giving it for any sort of benefit at all? 

Dr. Tony Mazzulli: Oh, the current standard is that after seven days there has never been shown to be a benefit from the H-BIG so that again we would still consider it up to seven days but not beyond because there's no benefit after seven days. 

Sally Lloyd: Thank you. 

Operator: Thank you. Our next question comes from Helen Ayers from West Parry Sound Hospital. Please go ahead. 

Helen Ayers: What is the present policy on Hepatitis B? You've been vaccinated with the three doses. Do you have booster shots or do you just check the blood level . every so often? What's the present policy? 

Dr. Tony Mazzulli: Recurrent Health Canada immunization guide, which was published in '98, the fifth edition, now recommends two things. One is after you're had your series of three shots because your health care worker is therefore at higher risk than the general population, you should be tested to make sure you've responded to the vaccine which is again 95 to 97% of people. Once you've been tested and you know you're positive, that's it. You don't need to have testing again. If you know that you were positive at any time after the vaccine, even if 10 years from now the antibody level drops to below being positive, because you were positive right after the vaccine and you responded, you don't need repeat testing. This is a change from the previous Health Canada Guidelines which said that you should be tested every two years to make sure you have enough antibodies. The current recommendation is that if you're tested at least once, you know you're a responder, you don't need to be retested again. 

The second thing is that as far as getting boosters, at the moment we do not recommend getting boosters at five, 10 or 15 years anymore. Again, in the early days of the vaccine when we weren't sure how long the immunity would last, when we were using plasma-derived vaccine, vaccine which came from blood donors rather than the current recombinant vaccines, we did recommend boosters initially at five and then 10 years, but at the moment there's no recommendation to get a booster if you've responded to the vaccine. 

The third scenario is you get your three shots, you get tested about a month or so later and found that you don't have any antibodies. The current recommendation is you don't just get a booster, you get all three shots again, and if you get all three shots those few percentage of people who didn't respond the first time by getting all the three shots again you capture another 70% of people become positive. 

Helen Ayers: Thank you. 

Operator: Thank you. Our next question comes from Catherine Richard from Smooth Rock Falls Hospital. Please go ahead. 

Catherine Richard: Thanks. You already answered our question with the previous one. 

Operator: Our next question comes from Keitha Harris from Perth and Smith Falls. Please go ahead. 

Keitha Harris: Hello. I was just inquiring about... there was some literature about the possibility of getting Hepatitis... or people who have had the Hep B vaccine developing Juvenile Diabetes. Is that any correlation there or... 

Dr. Tony Mazzulli: No. Again, to the best of my knowledge there isn't a correlation there. There are again case reports of temporal association - get the vaccine and shortly thereafter, weeks, months later, the trial then develops Diabetes. Is it simply coincidental or is it real? As far as I know, there's no study which has shown a true association with getting the vaccine and subsequently being at higher risk for Juvenile Diabetes or any other... there's been reports of people getting Bells Palsy after the vaccine, other neurologic problems, but again my feeling is based on what's out there that these are isolated case reports and are basically simply just coincidental association. As you know, in the province we do have a vaccine, or the government has implemented a routine vaccination program for all students roughly in grade 6 and 7, so 11- and 12-year-olds, that get it throughout the school year. And again there's been no change as far as I'm aware in that policy. 

Keitha Harris: Thank you. 

Operator: Our next question comes from Diane Airhart from Lennox & Addington. Please go ahead. 

Diane Airhart: Yes. Thank you for a very interesting program, Dr. Mazzulli. My question is if the person remains a non-responder following the second series of the vaccination, what would your treatment course be? 

Dr. Tony Mazzulli: Okay. In that situation, basically the option there is to then give then H-BIG after an exposure. The H-BIG or the Hepatitis B immune globulin, as I said, is extremely effective. It gives them instant antibodies by giving someone else's, and is almost certainly guaranteed to work at preventing infection. The issue here becomes really is the person truly negative and didn't respond or were they too late in their testing? For example, if you get all three shots and never get tested and then six years from now or 10 years from now you get your injury and then you go get tested for your Hepatitis B surface antibodies, to see if you have the antibodies, at that point if they're negative we never know did you really respond and now the level has fallen to just below the detectable level, which means if you were a responder you don't need to do anything, you're immune, or were you truly a non-responder right from day one in which case the Hepatitis B immune globulin is indicated. Ultimately when the injury happens, if we have no record of the person before and they test negative, we assume they were a non-responder right from day one and we give them H-BIG. 

Operator: Do you have a follow-up question? Miss Airhart? 

Diane Airhart: No, that was great. Thank you very much. 

Operator: Thank you, and at this time our final question comes from Cathy Hinchberger from MDS Health Group. Please go ahead. 

Cathy Hinchberger: Good morning. How effective is hand barrier cream to wearing gloves? Some of the workers prefer hand cream over wearing gloves. 

Dr. Tony Mazzulli: Again, I'm not sure what they're trying to prevent. I would still recommend the use of gloves simply because... as I said before, as long as the skin is intact, these viruses won't penetrate your skin. As far as I know, skin barrier creams are not going to block or prevent if you have cuts and wounds and seal them up completely. The reason for wearing gloves is not so much to prevent the HIV or other viruses from getting through and then infecting you, but rather as long as people have gloves or something else on their hands they tend to be a little more cautious in terms of rubbing their eyes, rubbing their nose, doing something else, picking up a phone with a glove on, and if there's blood on the gloves, again if you rub your eye you then self--inoculate yourself. It's been shown that people who do not wear the gloves are more likely, either consciously or subconsciously, to stick their hand in their eye, rub their nose, even stick their hand in their mouth. So if gloves do nothing else, they're a warning sign that you have to be a little more careful and therefore be cautious where you put your hands. 

Operator: At this time there are no questions. I'd like to turn the meeting back over to you, Ms. Nichol. 

Kathryn Nichol: Okay, thank you. Dr. Mazzulli, on behalf of the Ontario Safety Association for Community and Healthcare, I'd like to thank you for your very informative message on the risk and management of needle stick injuries. I would also like to thank all of our participants for joining us and for asking their very valid questions. 

Just a quick piece of information: The next Ontario Safety Association for Community and Healthcare teleconference will be Tuesday, June the 12th, 2001, in the afternoon from 1:30 to 2:30, and the topic will be "Developing and Implementing a Workplace Violence Program". Once again, Dr. Mazzulli, thank you very much for your presentation. 

Dr. Tony Mazzulli: Thank you.