Georgia epidemiology report, Vol. 14, no. 2 (Feb. 1998)

Georgia Epidemiology

Report
The Georgia Epidemiology Report is a publication of the Epidemiology Section of the Epidemiology and Prevention Branch, Division of Public Health, Department of Human Resources

February 1998

Volume 14 Number 2
Antiretroviral Prophylaxis After Occupational Exposure To HIV

http://www.ph.dhr.state.ga.us
Division Of Public Health
Kathleen E.Toomey, MD, MPH- Director
Epidemiology and Prevention Branch State Epidemiologist Kathleen E. Toomey, MD, MPH- Acting Director
Epidemiology Section Paul A Blake, MD, MPH- Chief
Notifiable Diseases
Jeffrey D. Berschling, MPH; Cherie L. Drenzek, DVM, MS; Katherine Gibbs McCombs, MPH; Karen R. Horvat, MPH; Amri B Johnson, MPH; Jane E. Koehler, DVM, MPH; Preeti Pathela, MPH, Laura Gilbert
Chronic Disease
Ken Powell, MD,MPH- Program Manager , Nancy E. Stroup, PhD, Patricia M. Fox, MPH; A. Rana Bayakly, MPH; Mary P. Mathis, PhD, MPH
Tuberculosis
Rose Marie Sales, MD, MPH- Program Manager Naomi Bock, MD, MS; Beverly DeVoe
HIV/AIDS/Sexually Transmitted Diseases
John F Beltrami, MD, MPH- Program Manager Andrew Margolis, MPH, Lyle McCornick,MPH
Perinatal Epidemiology
James W. Buehler, MD- Program Manager Leslie E. Lipscomb, MPH, Cheryl Siberman,PHD,MPH
Preventive Medicine Residents
Scott E. Kellerman, MD,MPH; Alexander K. Rowe, MD,MPH; Danielle Sara, MD
EIS Officer
Michael S. Friedman, MD
Georgia Epidemiology Report
Editorial Board
Editorial Executive Committee Cherie Drenzek, DVM, MS - Editor Jeffrey D. Berschling, MPH Paul A. Blake, MD, MPH Kathleen E. Toomey, MD, MPH Mailing List Marsha Wilson
Graphics Jimmy Clanton & Christopher DeVoe

The estimated risks for HIV infection without prophylaxis following exposure to HIV-infected blood are 0.3% for percutaneous exposures, 0.1% for mucous membrane exposures, and < 0.1% for skin exposures (1). The risk is likely to exceed 0.3% for percutaneous exposures involving a large blood volume or a higher HIV titer in blood (1,2). Post-exposure prophylaxis (PEP) therapy with zidovudine (ZDV) has been associated with a decrease of approximately 79% in the risk for HIV seroconversion after occupational exposure to HIV-infected blood (3). In June 1996, the United States Public Health Service (USPHS) issued updated provisional recommendations for chemoprophylaxis after occupational exposure to HIV (2). The recommendations are considered provisional because they were based on limited data regarding the efficacy and toxicity of PEP and risk for HIV infection after different types of exposure. The Georgia Division of Public Health recommends that the USPHS recommendations be considered for all occupational exposures to blood.
1. When possible, PEP should be implemented after consultation with persons having expertise in antiretroviral therapy and HIV transmission. In addition to compliance with the procedures for incident reporting detailed in the Georgia Division of Public Health's HIV/Hepatitis B Policy Manual, the employee should immediately consult with both his/her physician and the local District Health Director regarding PEP therapy upon occupational exposure to blood. Also, there is a new national toll-free hotline for clinicians who counsel and treat healthcare workers with job-related exposures to blood-borne infections, including HIV By calling 1-888-448-4911 from anywhere in the U.S. 24 hours a day, clinicians can access the post-expoure prophylaxis hotline (PEPline), which has trained clinical staff prepared to give counseling and treatment recommendations for these occupational exposures.
2. The USPHS has defined three risk groups by which to determine the use of PEP following percutaneous exposure to blood:
a. Highest Risk -- BOTH large volume of blood (e.g. deep injury with large diameter hollow needle previously in source patient's vein or artery, especially involving an injection of source-patient's blood) AND blood containing a high titer of HIV (e.g. source with acute retroviral illness or end-stage AIDS.) Viral load measurement may be considered, but its use in relation to PEP has not been evaluated.

Epidemiology Section, Epidemiology & Prevention Branch, Two Peachtree St., N.W., Atlanta, GA 30303-3186

Phone: (404) 657-2588

FAX: (404) 657-2586

b. Increased Risk -- EITHER exposure to large volume of blood OR blood with a high titer of HIV.
c. No Increased Risk -- NEITHER exposure to large volume of blood NOR blood with a high titer of HIV (e.g. solid suture needle injury from source patient with asymptomatic HIV infection).
3. For percutaneous exposure to fluid containing visible blood OR other potentially infectious fluid (semen, vaginal secretions, internal body fluids) or tissue, no separate risk levels have been defined.
4. For skin exposure, risk is increased for exposure involving a high titer of HIV, prolonged contact, an extensive area, or an area in which skin integrity is visibly compromised. For skin exposures without increased risk, the risk for drug toxicity outweighs the benefit of PEP.
5. Because most occupational exposures to HIV do not result in HIV transmission, potential drug toxicity must be carefully considered when prescribing PEP. Changes in drug regimens may be appropriate, based on factors such as local availability of drugs, underlying medical conditions, concurrent drug therapy, drug toxicity in the exposed worker, and, if known, the probable antiretroviral drug resistance profile of HIV from the source patient.
6. PEP should be initiated promptly, preferably within 1-2 hours postexposure. Although animal studies suggest that PEP probably is not effective when started later than 24-26 hours postexposure, the interval after which there is no benefit for humans is undefined. Initiating therapy after a longer interval (e.g. 1-2 weeks) may be considered for the highest risk exposures; even if infection is not prevented, early treatment of acute HIV infection may be beneficial. The optimal duration of treatment is unknown; because 4 weeks of ZDV therapy appeared protective experimentally, PEP should probably be administered for 4 weeks, if tolerated.

(3TC) should usually be added to ZDV for increased antiretroviral activity and activity against many ZDV-resistant strains. A protease inhibitor, such as indinavir (IDV), should be added for exposures with the highest risk for HIV transmission (Table 1). Adding a protease inhibitor also may be considered for lower risk exposures if ZDV-resistant strains are likely, although it is uncertain whether the potential additional toxicity of a third drug is justified for lower risk exposures. For HIV strains resistant to both ZDV and 3TC or resistant to a protease inhibitor, or if these drugs are contraindicated or poorly tolerated, the optimal PEP regimen is uncertain; expert consultation is advised. NOTE: An HIV strain is more likely to be resistant to a specific antiretroviral agent if it is derived from a patient who has been exposed to the agent for a prolonged period of time (e.g. 6-12 months or longer). In general, resistance develops more readily in persons with more advanced HIV infection.
9. Recommended treatment regimens are include ZDV, 600 mg per day (in divided doses); lamivudine (3TC), 150 mg two times per day; and a protease inhibitor such as indinavir (IDV), 800 mg three times per day with increased fluid consumption. Prophylaxis is given for 4 weeks. See package inserts for full prescribing information and potential side effects of medications. (continued on page 3)
CDC RECOMMENDS ENHANCED SURVEILLANCE FOR INFLUENZA A (H5N1)
As recommended by the Centers for Disease Control and Prevention (CDC), the Georgia Department of Human Resources will immediately institute enhanced surveillance for importation of influenza A subtype H5N1 into the United States. We request that the medical community remain vigilant for patients who are hospitalized with severe influenza-like illness after traveling to either Hong Kong or southern China. Since the influenza season in Hong Kong peaks in both March and July, we request that the following surveillance protocol be continued until September 1998:

7. PEP should be recommended to exposed workers after occupational exposures associated with the highest risk for HIV transmission. For exposures with a lower, but nonnegligible risk, PEP should be offered, balancing the lower risk against the use of drugs having uncertain efficacy and toxicity. For exposures with negligible risk, PEP is not justified (Table 1). Exposed workers should be informed that: a) knowledge about the efficacy and toxicity of PEP is limited; b) for agents other than ZDV, data are limited regarding toxicity in persons without HIV infection or who are pregnant; and, c) any or all drugs for PEP may be declined by the exposed worker.

A. Specimens for viral cultures should be obtained (nasopharyngeal or throat swabs) from patients who meet ALL of the following criteria:
1. Patient hospitalized with unexplained pneumonia or adult respiratory distress syndrome (ARDS);
2. Fever (temperature>1000 F);
3. Age > 1 year and < 60 years;
4. History of travel to Asia within 10 days before symptom onset.

8. At present, ZDV should be considered for all PEP regimens, because it is the only agent for which data support the efficacy of PEP in the clinical setting. Lamivudine

B. Please contact the Notifiable Disease Unit, Epidemiology and Prevention Branch, at 404-657-2588 to report any suspect case that meets the criteria listed above. Instructions for viral culture specimen submission will be given at that time.

- 2 -

10. If the source patient or the patient's HIV status is unknown, initiating PEP should be decided on a case-by-case basis, based on the exposure risk and likelihood of HIV infection in known or possible source patients. If additional information becomes available, decisions about PEP can be modified.

11. If PEP is used, drug-toxicity monitoring should include a complete blood count and renal and hepatic chemical function tests at baseline and 2 weeks after starting PEP. If subjective or objective toxicity is noted, dose reduction or drug substitution should be considered with expert consultation, and further diagnostic studies may be indicated.

12. Workers with occupational exposures to HIV should receive counseling and medical evaluation, including HIV-antibody tests, at baseline and, if negative, periodically for at least 6 months postexposure (e.g. 6 weeks, 12 weeks, and 6 months). Potentially exposed workers should observe precautions to prevent possible secondary transmission during this time.

13. Workers who receive PEP should be enrolled (by phone, at 888-737-4448) in an anonymous registry developed by the Centers for Disease Control and Prevention (CDC), Glaxo Wellcome, Inc., and Merck & Co., Inc., to assess toxicity. Unusual or severe toxicity from antiretroviral drugs should also be reported to the manufacturer and/or the Food and Drug Administration (800-332-1088).

TABLE 1. Provisional Public Health Service recommendations for chemoprophylaxis after occupational exposure to HIV, by type of exposure and source material -- 1996

Type of Exposure

Source Material*

Antiretroviral Prophylaxis^

Regimen

Percutaneous

Blood Highest risk Increased risk No increased risk

Recommend Recommend Offer

ZDV and 3TC and protease inhibitor ZDV and 3TC+ protease inhibitor** ZDV and 3TC

Fluid containing visible blood, other potentially infectious fluid/tissue

Offer

ZDV and 3TC

Other body fluid (e.g. urine)

Not offer

N/A

Mucous membrane

Blood

Offer

ZDV and 3TC+ protease inhibitor**

Fluid containing visible blood, other potentially infectious fluid/tissue

Offer

ZDV + 3TC

Other body fluid

Not offer

N/A

Skin, increased risk (See text)

Blood
Fluid containing visible blood, other potentially infectious fluid/tissue

Offer Offer

ZDV and 3TC + protease inhibitor** ZDV + 3TC

Other body fluid * Any exposure to concentrated HIV (e.g. in a research laboratory or production facility) is treated as percutaneous exposure to blood with highest risk.
^ Recommend--Postexposure prophylaxis (PEP) should be recommended to the exposed worker along with counseling (see text).

Not offer

N/A

REFERENCES:

1. Bell DM. Occupational Risk of Human Immunodeficiency Virus Infection in Healthcare Workers: An Overview. Am J Med 1997;102(5B):9-15.

Offer--PEP should be offered to the exposed worker along with counseling (see text).
Not offer--PEP should not be offered because these are not occupational exposures to HIV.
** Possible toxicity of additional drug may not be warranted (see text).
This article was contributed by John F. Beltrami, MD, MPH & TM, Program Manager, HIV/STD, Epidemiology Unit Epidemiology and Prevention Branch Georgia Department of Human Resources

2. CDC. Update: Provisional Public Health Service Recommendations for Chemoprophylaxis After Occupational Exposure to HIV. MMWR 1996;45:468-472.
3. CDC. Case-control study of HIV seroconversion in health-care workers after percutaneous exposure to HIV-infected blood-France, United Kingdom, and United States, January 1988-August 1994. MMWR 1995;44:929-933.

- 3 -

The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186

February 1998

Volume 14 Number 2

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for November 1997

Selected Notifiable Diseases

Total Reported for Nov. 1997 1997

Previous 3 Months Total

Ending in Nov.

1995

1996

1997

Previous 12 Months Total

Ending in Nov.

1995

1996

1997

Campylobacteriosis

70

278

196

216

1093

799

610

Chlamydia genital infection

1463

2605

3903

3116

10342

13898

15087

Cryptosporidiosis

6

40

41

27

109

92

73

E. coli O157:H7

1

9

8

8

29

39

43

Giardiasis

86

195

299

329

567

792

865

Gonorrhea

1603

5840

4707

3814

19215

20843

17995

Haemophilis influenzae (invasive)

3

3

13

12

38

48

46

Hepatitis A (acute)

49

17

126

196

85

388

681

Hepatitis B (acute)

12

14

27

30

109

60

147

Lead Poisoning (capillary BLL >= 10 ug/dL)

0

914

753

191

2776

3045

1826

Lead Poisoning (venous BLL >= 10 ug/dL)

0

176

158

44

581

615

694

Legionellosis

1

1

0

2

24

4

2

Lyme Disease

0

0

0

3

20

1

8

Meningococcal Disease (invasive)

7

29

24

17

102

156

102

Mumps

0

3

4

0

10

9

11

Pertussis

0

7

10

1

28

36

16

Rubella

0

0

0

0

0

0

0

Salmonellosis

91

663

442

392

1680

1443

1263

Shigellosis

173

288

497

428

1554

1007

1100

Syphilis - Primary

4

88

50

30

290

204

152

Syphilis - Secondary

10

197

128

57

646

504

357

Syphilis - Early Latent

39

381

336

185

1724

1340

1033

Syphilis - Other

57

290

227

231

1168

953

1225

Syphilis - Congenital

0

17

7

3

60

39

24

Tuberculosis

56

170

178

164

807

784

720

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office; and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.

** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.
AIDS Profile Update

Report Period

Total Cases Reported *

Percent Female

Risk Group Distribution (%)

Race Distribution (%)

MSM IDU MSM&IDU HS Blood Unknown White Black Other

Latest 12 Months: 02/97 to 01/98 Five Years Ago: 02/92 to 01/93 Cumulative: 7/81 to 01/98

1720 1898 18903

20.9 13.5 15.0

37.1

17.9

4.0

17.5

1.3 22.1

51.9

21.5

7.5

10.7

2.1

6.3

51.1

19.1

5.8

11.8

2.0 10.1

24.8 72 3.1 37.1 60.9 1.9 39.3 58.6 2.1

MSM - Men having sex with men IDU - Injection drug users HS - Heterosexual * Case totals are accumulated by date of report to the Epidemiology Section

- 4-