Georgia epidemiology report, Vol. 16, no. 5 (May 2000)

May 2000

volume 16 number 5

Division of Public Health

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

http://health.state.ga.us

HIV POST-EXPOSURE PROPHYLAXIS FOR

NEEDLESTICKS AND OTHER OCCUPATIONAL

EXPOSURES (PART 2)

HIV POST-EXPOSURE
PROPHYLAXIS (PEP)
Determining appropriate HIV PEP is a three-step process. Using the flow charts, one must determine both the exposure code (step 1) and the status code (step 2) for the incident. The exposure code and the status code are then used to determine the appropriate PEP regimen from the table
(step 3).

Step 1: Determine the exposure code. What was the source material?

Semen or vaginal secretions; cerebrospinal, synovial, pleural, peritoneal, pericardial, or amniotic fluids; or tissue

Blood or bloody fluid

These are usually considered a low risk for transmission for the types of exposures which occur in health-care settings. Cases need to be evaluated on an individual basis.

Director Kathleen E. Toomey, M.D., M.P.H.
Epidemiology and Health Information Branch
Acting Director Kathleen E. Toomey, M.D., M.P.H.
Acting State Epidemiologist Paul A. Blake, M.D., M.P.H.

What type of exposure occurred?

Surface contact with mucous membranes or compromised skin Ways in which skin integrity can be compromised include open wounds, chapped skin, abrasions, and dermatitis.

Surface contact with intact skin

Percutaneous exposures These include needlesticks and cuts.

Epidemiology Section Chief
Paul A. Blake, M.D., M.P.H.
Public Health Advisor Mel Ralston
Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. - Editor Kathryn E. Arnold, M.D. Paul A. Blake, M.D., M.P.H.
Susan Lance-Parker, D.V.M., PH. D. Kathleen E. Toomey, M.D., M.P.H.
Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphics

Small volume
Few drops
and
Short
duration

Large volume
Many drops
and/or
Long
duration, such as
several minutes

PEP is usually not necessary unless exposure involved an extensive area of skin or involved prolonged contact with infected material.

Less severe
Solid needle
or
A superficial
scratch

More severe
Any one of the
following:
Large-bore hollow
needle
Deep puncture Visible blood on
device
Needle used in
source patients
artery or vein

Exposure code = 1

Exposure code = 2

Exposure code = 2

Exposure code = 3

Georgia Department of Human Resources Division of Public Health, Epidemiology Section Epidemiology & Health Information Branch Two Peachtree St., N.W., Atlanta, GA 30303 - 3186 Phone: (404) 657-2588 Fax: (404) 657-2586

Step 2: Determine the HIV status code HIV status of the source*

HIV negative

HIV positive

Unknown

Low titer exposure Source patient with the following:
Low viral load Asymptomatic High CD4 count

High titer exposure Source patient with one of the following:
High viral load Advanced AIDS Low CD4 count Primary HIV infection

No PEP needed

Status code = 1

Status code = 2

Status code = unk

*For more information on HIV testing see ADDITIONAL IMPORTANT INFORMATION FOR HIV-EXPOSED HCWs

Step 3: Determine the appropriate post-exposure prophylaxis.

Exposure code Status code PEP recommendation

1

1

PEP may not be necessary. Health Care Worker (HCW) and treating clinician should discuss the exposure to

decide if the risk of drug toxicity outweighs benefit of PEP.

1

2

Consider the basic regimen. Although exposure poses a minimal risk for HIV, PEP may be considered ifthe

source had a high HIV titer. HCW and treating clinician should discuss the exposure to decide if the risk of drug

oxicity outweighs benefit of PEP.

2

1

Recommend basic regimen.

2

2

Recommend expanded regimen.

3

1 or 2

Recommend expanded regimen.

Unk

PEP may be considered in situations where the HIV status of the source is unknown (e.g., delayed results from

IV testing, source patient refuses test, exposure to blood from unknown source). Consider the basic regimen

when the exposure code is 2 or 3 and the situation suggests a possible risk for HIV exposure (e.g., source patient

known to use injection-drugs, or exposure occurred on an AIDS treatment unit).

Basic regimen: Four weeks of zidovudine (AZT), 600mg per day in two or three divided doses, and lamivundine (3TC), 150mg twice daily. Of note, zidovudine and lamivudine are available in a single preparation, Combivir, containing 300mg AZT and 150mg 3TC, should be taken twice a day.

Expanded regimen: Includes the basic regiment plus either indinavir, 800mg every 8 hours, or nelfinavir, 705mg three times a day. Again, treatment is given for 28 days.

ADDITIONAL IMPORTANT INFORMATION FOR HIV-EXPOSED HCWs

1. The HIV status of the source should be determined as soon as possible following an exposure. An FDA-approved, rapid HIV-antibody test kit can be used to test the source if results by enzyme immunoassay (EIA) will not be available within 24-48 hours. Repeatedly positive tests by the rapid HIV-antibody method or EIA are highly suggestive of infection in the source; therefore, these tests can be used to make immediate decisions about PEP. Western blot or immunofluorescent antibody testing should still be done to subsequently confirm the HIV status of the source. The HIV testing of needles or other sharp instruments involved in the exposure is not recommended. If results for HIV testing will be delayed (i.e., >3 hours from the time of exposure), PEP should be initiated if the exposure and the setting in

which the exposure occurred suggest an increased risk for transmission.
2. Most persons who seroconvert do so within 6-12 weeks of exposure. During this time period, HIV-exposed HCWs should do the following to prevent possible secondary transmission: Abstain from sexual intercourse or use condoms to prevent sexual transmission and to avoid pregnancy Avoid donating blood, plasma, organs, tissue, or semen Exposed HCWs, who are breast-feeding infants, should consider discontinuing breast-feeding as this may transmit HIV, as well as expose the infant to PEP medications.

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3. A HCW does not need to modify patient-care activities following an HIV exposure. Only if seroconversion is detected might a HCW need to modify his/her patient-care responsibilities.
4. Exposed HCWs should be advised to seek medical advice for any acute illness occurring in the follow-up period, especially if it is accompanied by fever, rash, myalgia, fatigue, malaise, or lymphadenopathy.
5. If the source is known or suspected to be infected with HIV resistant to one or more of the drugs in the PEP regimen, alternative antiretroviral medications may be needed. If resistance is known or suspected a third or fourth anti-retroviral drug may be added to the PEP regimen while awaiting expert opinion from a person experienced in the treatment of HIV. Again, the possibility of resistance should not delay prompt initiation of PEP.
6. PEP should not be denied to a HCW solely on the basis of pregnancy. Full information about the risks and benefits of treatment, as well as the risk of HIV infection and transmission, must be provided.
7. All HCWs receiving PEP should be monitored for toxic effects from the medication. Testing should be performed at baseline and after two weeks of PEP. At a minimum these tests should include a complete blood count, renal chemistries, and liver function tests. Please see the INFORMATION ON DRUGS COMMONLY USED FOR HIV PEP for the toxicity of specific drugs.
8. Other professions, such as police officers and firefighters, may have similar HIV exposures as HCWs. Persons in these professions should follow the same PEP protocol.
9. National guidelines do not exist for PEP following an unprotected sexual encounter or injection drug use. Depending on the type of exposure, a regimen of two or more prophylactic drugs may be warranted. However, PEP in these cases needs to be decided on an individual basis by the patient and the treating clinician.
ADDITIONAL RESOURCES
National Clinicians Post-exposure Prophylaxis Hotline (PEP-line) (888) 448-4911
Georgia Division of Public Health (404) 657-2588

REFERENCES
Alter HJ, Seeff LB, Kaplan PM, et al. Type B hepatitis: the infectivity of blood positive for e antigen and DNA polymerase after accidental needlestick exposure. N Engl J Med 1976 Oct 21;295(17):909-13
Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med 1997 Nov 20;337(21):1485-90
Grady GF, Lee VA, Prince AM, et al. Hepatitis B immune globulin for accidental exposures among medical personnel: final report of a multicenter controlled trial. J Infect Dis 1978 Nov;138(5):625-38
Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Morb Mortal Wkly Rep. 1991 Nov 22;40(RR-13):1-25.
Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Morb Mortal Wkly Rep. 1997 Dec 26;46(RR-18):1-42.
Protection against viral hepatitis. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Morb Mortal Wkly Rep. 1990 Feb 9;39(RR-2):1-26.
Public Health Service guidelines for the management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 1998 May 15;47(RR-7):1-33.
Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR Morb Mortal Wkly Rep. 1991 Jul 12;40(RR-8):1-9.
Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 1998 Oct 16;47(RR-19):1-39.
Seeff LB, Wright EC, Zimmerman HJ, et al. Type B hepatitis after needlestick exposure: prevention with hepatitis B immune globulin. Final report of the Veterans Administration cooperative study. Ann Intern Med. 1978 Mar; 88(3): 285-293.

Information on Drugs Commonly Used for HIV PEP*

Nucleoside Reverse Transcriptase Inhibitors

Protease Inhibitors (PIs)

1. Zidovudine (RETROVIR, ZDV, AZT)

1. Indinavir (CRIXIVAN; IDV)

Dosage: 600 mg every day in divided doses (e.g., 300 mg twice a day, 200 mg three times a day, or 100 mg every four hours)

Dosage: 800 mg every 8 hours on an empty stomach (i.e., without food or with a light meal) Primary toxicities and/or side effects: Nephrolithiasis, crystalluria, hematuria, nausea, headache, indirect

Primary toxicities and/or side effects: Neutropenia, anemia, nausea, fatigue, malaise, headache, insomnia, and asthenia.

hyperbilirubinemia, elevated liver function tests (LFTs), and hyperglycemia/diabetes. Primary drug interactions: No PI should be co-administered with terfenadine (Seldane), astemizole

Comments: Should be used cautiously with other bone marrow suppressive drugs or cytotoxic therapy.

(Hismanal), cisapride (Propulsid), triazolam, and midazolam. Rifampin should not be administered with

2. Lamivudine (EPIVIR; 3TC)

PIs. Cytochrome P450 metabolism inhibitors like ketoconazole may increase PI plasma concentrations; dose reduction of the PI is only indicated for indinavir. Ergot alkaloid preparations should not be used in

Dosage: 150 mg twice a day Primary toxicities and/or side effects: Headache, abdominal pain, diarrhea, and in rare cases, pancreatitis.

combination with PIs. If rifabutin is used concomitantly, rifabutin dose should be reduced because of inhibition of rifabutin metabolism; with concomitant indinavir or nelfinavir use, reduce rifabutin dose by

Toxicity of ZDV and 3TC in combination is approximately equal to that of ZDV alone.

50%. Serum levels of PIs may be increased when multiple PIs are used in combination.

3. ZDV plus 3TC (COMBIVIR)

Comments: Incidence of nephrolithiasis may be reduced by consuming large quantities of water (i.e., drinking six 8 oz glasses of water (total 48 oz) throughout the day).

Dosage: 1 tablet twice a day; each tablet contains 300 mg ZDV and 150 mg 3TC.

Primary toxicities and/or side effects: See above for ZDV and 3TC.

2. Nelfinavir (VIRACEPT)

Comments: Should be used cautiously with other bone marrow suppressive drugs or cytotoxic therapy.

Dosage: 750 mg three times a day (with meals or a light snack)

Primary toxicities and/or side effects: Diarrhea and hyperglycemia/diabetes.

*MMWR Morb Mortal Wkly Rep. 1998 May 15; 47(RR-7):1-33

Primary drug interactions& See above for indinavir.

It is recommendend that consultation with experts in the treatment of HIV infection and disease be

Comments: Diarrhea usually can be controlled with over-the-counter antidiarheal drugs (e.g., loperamide).

sought when considering the inclusion of PIs or the use of alternative agents in PEP regimens.

If oral contraceptives are being used, alternative or additional contraceptive measures should be used while

&See package insert for other contraindications and possible drug interactions.

taking nelfinavir.

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

Bulk Rate U.S. Postage
Paid Atlanta, Ga Permit No. 4528

May 2000

Volume 16 Number 5

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for February 2000

Selected Selected Notifiable Notifiable Diseases Diseases
Campylobacteriosis Chlamydia genital infection Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for Feb 2000
2000 31
2190 12 0 98
1398 4
21 13
0 0 8 0 2 0 61 27 6 23 31 24 0 42

Previous 3 Months Total

Ending in Feb

1998

1999

2000

153

179

87

5518

6174

5633

22

44

38

4

6

8

214

281

292

4953

4788

3999

22

24

23

171

142

58

69

45

44

2

0

1

2

0

0

42

19

27

1

0

0

4

7

14

0

0

0

254

347

270

288

104

59

29

37

31

59

79

67

229

211

161

183

176

183

1

8

0

141

144

170

Previous 12 Months Total

Ending in Feb

1998

1999

2000

778

805

651

11406 24731 31162

85

170

162

35

83

44

902

1280

1339

12581 20141 21292

46

66

82

807

850

432

254

188

218

6

8

5

10

3

0

122

81

75

8

2

4

13

40

57

0

0

0

1357

1890

1923

1178

1039

275

143

127

136

307

250

276

1026

803

674

996

813

762

19

21

16

667

606

652

* 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 syphillis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.

AIDS Profile Update

Report Period Report Period
Latest 12 Months: 3/99 - 2/00 Five Years Ago: 3/94 - 2/95 Cumulative: 7/81 - 2/00

Total Cases Reported *
1638 2343 21603

Percent Female
26.6 18.5 16.2

Risk Group Distribution (%) MSM IDU MSM & IDU HS Blood Unknown

31

13.4

3.4

16.6

1.5

34.1

44.7

22.2

6.2

13.9

2

11

49.6

18.8

5.8

13

1.9

10.9

Race Distribution (%) White Black Other

19.1 78.5

2.4

33.3 65.3

1.4

36.7 61.2

2.1

MSM - Men having sex with men

IDU - Injection drug users

* Case totals are accumulated by date of report to the Epidemiology Section

HS - Heterosexual

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