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HIV, AIDS and Needlestick injuries

HIV, AIDS and Needlestick injuries. James Huffman, R-2 March 19, 2007 Thanks to Shawn Dowling, Cass Djurfors. Objectives. Not solely focused on occupational health Aspects of HIV and AIDS that are applicable to the emergency physician HIV testing in the ED AIDS defining illnesses

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HIV, AIDS and Needlestick injuries

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  1. HIV, AIDS and Needlestick injuries James Huffman, R-2 March 19, 2007 Thanks to Shawn Dowling, Cass Djurfors

  2. Objectives Not solely focused on occupational health • Aspects of HIV and AIDS that are applicable to the emergency physician • HIV testing in the ED • AIDS defining illnesses • Post-exposure prophylaxis • Acute complications of HIV infection • Needlestick injuries • Your potential roles and responsibilities as an EP • What to do if this happens to you

  3. Background • Advanced treatments and highly active antiretroviral therapy (HAART) have delayed development of AIDS in many HIV+ pts • More people live longer with HIV infection  ED presentations • New drugs and regimens  interactions with ED Rx

  4. Basics • HIV: • An RNA virus that attacks and weakens the body’s immune system • Transmitted though: • Unprotected sex with an infected partner • Sharing needles • Contact with infected blood • Mom to baby through pregnancy, birth or breast milk • Some individuals will experience a flu-like illness in first 1-2 months after HIV exposure (seroconversion illness) – many will have no symptoms

  5. Basics • AIDS: Diagnosis occurs when a person: • Has antibodies against HIV in their blood AND • Is diagnosed with one or more AIDS-defining illnesses • In the US (but not Canada or Europe) the AIDS definition also includes all HIV-infected individuals with a CD4 count lower than 200 cells/μL or a CD4 percentage less than 14%

  6. Pathophysiology of HIV infection • Virus infects host cells (lymphadenopathy) and incorporates its genetic code into the cell’s DNA • Very mutagenic process • High viral load early - until immune system kicks in • This accounts for the acute HIV syndrome (discussed later) • Once this resolves, pt is in the latent phase of infection • Virus replicates slowly until CD4 counts drop below ~200/microL (median time without treatment = 8-10yrs)

  7. Pathophysiology – transmission • Virus is passed in infected body fluids • High concentration in blood, semen, vaginal fluid and breast milk • Low levels in almost every other fluid (incl. sweat, urine, csf, tears, bone marrow, alveolar fluid, synovial fluid, amniotic fluid and saliva • small likelihood of transmission • Factors affecting risk of transmission: • Viral load (> 50 000) • CD4 count (less than 200 cells/microL) • Other sexually transmitted infections

  8. Pop-quiz • Not all blood products carry risk of transmission. Of those commonly used in the ED, which is/are capable of transmitting the virus? • PRBC • Platelets • FFP • Rh immune globulin

  9. Occupational TransmissionEmergency Medicine Reports. Vol. 27 No. 8. 2006 • Health care worker-to-Patient • Several hundred epidemiologic studies have traced thousands of patients treated by HIV+ surgeons, obstetricians, dentists and nurses • Only 3 HCW’s have been identified as the source of their pt’s HIV infection

  10. Occupational TransmissionEmergency Medicine Reports. Vol. 27 No. 8. 2006 • Patient-to-Health care worker • U.S.: 600 000 to 800 000 needle sticks and sharps injuries each year are reported • More to come on this later in the talk • Risk of HIV infection is well-studied and quoted to be ~0.3% for a needle stick injury • As of 2002, only 57 health care workers had become HIV+ from a documented occupational exposure • Of the 57, 1/3 were laboratory workers, 42% were nurses and 10% were physicians

  11. Post-Exposure Prophylaxis (PEP) • PEP drug regimes are based on: • Severity of Exposure • Degree of viremia in the source patient

  12. Post-Exposure Prophylaxis (PEP) • Regimes constantly changing • Most recent CDC guidelines from 2005 • www.cdc.gov/mmwr/PDF/rr/rr5011.pdf • Also contains most up to date CDC info for Hep B and C

  13. Post-Exposure Prophylaxis (PEP) • What about non-occupational PEP (nPEP)? • EDs an ideal place? • Drugs on hand since this is where occupational exposures handled • 24/7 access • Challenges: • Follow-up and counseling • Access to source patient • Repeat testing at 4-6 weeks, 3 months, 6 months • Compliance • 28d course • A/E: diarrhea, vomiting, rashes, interaction with other meds

  14. Post-Exposure Prophylaxis Quiz • True or False: • Pregnancy is a contra-indication for PEP • True • False • Children and adults receive different PEP regimes • True • False

  15. Antiretroviral TherapyCMAJ 2004; 170:229-38 • HAART is mainstay of treatment • Most drugs come from 3 classes: • Nucleoside reverse transcriptase inhibitors • Non-nucleoside reverse transcriptase inhibitors • Protease inhibitors • Limitations: • Do not prevent onset of AIDS or deaths from HIV  delay • Essentially prolongs the latent phase of the disease • Compliance is an issue  26% of pts d/c meds

  16. Antiretroviral Therapy • Drug-Drug interactions • MANY with HAART • NNRTI’s and PI’s affect the cytochrome p450 system • Of note: • TB meds drastically inhibit effectiveness of HAART • Effect of CCB’s, BDZ’s, Antihistamines become pronounced • Many side effects related to mechanism of action • Significant risk of ACS • Cost can be substantial

  17. HIV Testing in the EDAnn Emerg Med 2004; 44:31-42 • ED populations have a high incidence of undiagnosed HIV infection • New very rapid (20 min) tests are available (not in CHR yet) • However, issues of follow-up, counseling, referral are road-blocks to widespread ED testing

  18. Symptomatic HIV Disease • Widely variable and can appear in nearly any organ system • Usually arise when CD4 count drops below 200 cells/µL • CD4 <50 cells/µL = sign of end-stage disease and corresponds to onset of life-threatening opportunistic infections • Many pts will not know their count, but info is available through SAC • Counts are checked q4-6 months and tend not to shift drastically • Pt with counts >350 cells/µL canusually be treated as though they have a normal immune system • BUT, AIDS-defining illness can arise at any point during HIV infection

  19. Candidiasis of esophagus, trachea or lungs Cervical Cancer (invaisive) Coccidiomycosis Cryptococcosis Cryptosporidiosis Isosporiosis Cytomegalovirus disease HSV (>1month duration) Disseminated histoplasmosis HIV encephalopathy Kaposi’s sarcoma Lymphoma (CNS or Burkitt’s) Mycobacterium avium complex Mycobacterium tuberculosis (pulmonary) Pneumocystis pneumonia Recurrent bacterial pneumonia Progressive multifocal leukoencephalopthy Recurrent Salmonella septicemia Toxoplasmosis of the brain HIV wasting syndrome AIDS-Defining IllnessesEmergency Med Reports, Vol 27:9, Apr. 2006

  20. Approach to HIV Pt with Fever Obtain CD4 count / viral load CD4 > 350 cells/µL and/or Viral load < 50 000 Unavailable Counts out of range Immunocompromised Immunocompetent Total lymphocyte count as rough surrogate marker • Assess compliance with HAART: • Non-compliant pts at greater risk of serious illness • CD4 counts return to pre-Tx levels rapidly if treatment stopped • All pts with Hx of AIDS should be on HAART

  21. HIV Patient with FeverAcad Emerg Med 2002;9:880-8 • Fever with vague constitutional symptoms is one of the most common reasons for HIV+ pts to present to the ED • Can screen for AIDS-related conditions by asking about the most common complications of HIV: • Pulmonary(PCP, TB) • Neurologic (AIDS dementia, cryptococcal meningitis, toxoplasmosis, CNS tumors) • Gastrointestinal (candidiasis, intestinal infections, ADE) • Dermatologic(KS, herpes zoster, candidiasis, scabies) • Ophthalmologic (CMV retinitis, ocular herpes)

  22. HIV Patient with FeverAcad Emerg Med 2002;9:880-8 • Additional diagnostics to consider: • Blood cultures (aerobic, anaerobic, fungal) • LP • Serology for cryptococcus, toxoplasmosis, CMV, coccidiomycosis • Screen for AFB (MAC, TB) • Echocardiogram

  23. HIV and Respiratory DiseaseThe Clinical Practice of Emergency Medicine, 3rd Ed; 2001:926-34 • At least 80% of AIDS patients develop some kind of pulmonary disease • Pneumonia most common • Diverse causes • Immunocopetent patients can be treated as usual • If not using HAART, ~70% will acquire PCP at some point

  24. HIV and Respiratory DiseaseThe Clinical Practice of Emergency Medicine, 3rd Ed; 2001:926-34 • PCP: • Prolonged course (2 weeks) • Typical symptoms of pneumonia (+burning RSCP) • CXR  interstitial infiltrates in 80%, otherwise N • Treatment is TMP-SMX oral or IV • If oral, start 2 DS tabs q8h • Steroids show mortality benefit if paO2 is “low” look up # • TB • Skin test not reliable • Start 4 drug regime • Others (Bacterial, fungal)

  25. HIV and Neurologic ComplicationsEM: Concepts and Clinical Practice 6th ED; 2005:1843-60 • Neurologic disease is the initial AIDS-defining illness in up to 20% of cases • Up to 90% of AIDS patients will suffer neurologic problems during their illness • Manifestations depend of stage of HIV infection • Most commonly • HIV encephalopathy (AIDS dementia complex) • Cryptococcal meningitis • Toxoplamosis • Primary CNS lymphoma

  26. HIV EncephalopathySemin Neurology 1999;19:105-11 • Up to 1/3 of AIDS patients will be affected • Pathophysiology not fully understood but appears to be a direct effect of the virus on the CNS • Gradual onset of memory loss, cognitive impairment and gait problems • Focal signs, headaches or seizures occur only rarely • Treatment with HAART has significantly lowered the frequency of severe dementia and can slow progression • Diagnosis of exclusion • Spinal fluid is clear, CT unhelpful, MRI may show diffuse symmetrical hypodensities

  27. HIV and Neurologic ComplicationsEM: Concepts and Clinical Practice 6th ED; 2005:1843-60 • Jeopardy Question: • This protozoan parasite causes the second most common CNS infection in AIDS patients. Hint: • What is Toxoplasma Gondii

  28. HIV and Neurologic ComplicationsEM: Concepts and Clinical Practice 6th ED; 2005:1843-60 • Others to know about: • Cryptococcal meningitis • Primary CNS Lymphoma (primary B-cell non-Hodgkin’s lymphoma)

  29. HIV and Gastrointestinal ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139 • Nearly 50% of AIDS patients will suffer from GI opportunistic infections during the course of their illness – many of those will be acute • Most common complaints: • Abdominal pain, diarrhea, GI bleeding • Obviously still at risk for non-HIV related disease • HAART medications notorious for GI symptoms

  30. HIV and Gastrointestinal ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139 • Oral Lesions: • Fungal • Oral candidiasis – dysphagia and plaques can be scraped off • Viral • Oral hairy leukoplakia (EBV – can’t scrape off) and HSV • Bacterial • Neoplastic – KS and Hodgekin’s lymphoma

  31. HIV and Gastrointestinal ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139 • Esophagitis: • Can be extension of oral process or stand-alone • Most common cause is candidiasis • CMV, HSV also possible • Usually needs endoscopy for diagnosis • Liver Disease • Co-infection with Hepatitis B and/or C common • NNRTI’s often have hepatic complications

  32. HIV and Gastrointestinal ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139 • Diarrhea: • Reported almost universally • About half of cases are attributed to the virus itself but many cases don’t have an identifiable cause • If normal CD4 counts, Salmonella is the only pathogen of increased presence • If CD4 <200, C.difficile also becomes much more prevalent • Many of the antiretrovirals can cause diarrhea  Loperimide

  33. HIV and Cutaneous ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139 • Up to 90% of patients have skin disorders during the course of their illness • Rarely dangerous, often painful  ED • 5 General categories • Infectious • Inflammatory • Neoplastic • Drug-related • Acute exanthem of HIV seroconversion

  34. HIV and Cutaneous ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139 • Acute Exanthem of HIV Seroconversion

  35. HIV and Cutaneous ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139 • Seborrheic Dermatitis

  36. HIV and Cutaneous ComplicationsHarrison’s Principles of Internal Medicine, 16th ed. 2005; 1071-1139 • Drug reactions • NRTI’s in particular are bad (not used as commonly) • Erythema multiforme and Stevens Johnson syndrome have both been reported • Parasites • Scabies • Viral • HSV/Zoster • Molluscum contagiosum • Bacterial • Simple folliculitis

  37. HIV and Ophthmologic ComplicationsRosen’s Emergency Medicine 6th ed; 2005; 1843-60 • 75-90% of AIDS pts at some point will have ocular complications • Cotton wool spots are the most common finding • Stable, asymptomatic • Need follow-up

  38. HIV and Ophthmologic ComplicationsRosen’s Emergency Medicine 6th ed; 2005; 1843-60 • Need to differentiate CWS from CMV retinitis • Progressive, can lead to blindness • CD4 usually less than 50 cells/ μL

  39. Needlestick Injuries • What are blood and bodily fluid exposures? • Which diseases are we concerned with? • Who gets them? • What can be done? • What are our responsibilities?

  40. Definitions • Health Care Workers: • health-care workers (HCW) are defined as persons whose activities involve contact with patients or with blood or other body fluids from patients in a health-care, laboratory, or public-safety setting • Blood and Bodily Fluid: • Essentially anything that comes out of the patient (other than abusive language), but certain ones (feces, urine, vomitus, saliva) are unlikely to be infectious unless they contain blood • Occupational BBF Exposure • Any time A) comes in contact with B). • Usually classified as percutaneous or mucocutaneous or non-intact skin

  41. Epidemiology • 52% of all HCW report a needlestick injury, 24% had one in the last year • But, estimates are that only 10% of all needlestick injuries are reported • CHR: So far in 2008 (as of March 17th) • 125 percutaneous BBF exposures • 17 classified as “High Risk” • No known infections

  42. Who is Exposed?Emergency Medicine Reports; 2006:27(8)

  43. ….Other possible infections: Blastomycosis Brucellosis Cryptococcosis Diphtheria Cutaneous gonorrhea Herpes Malaria Mycobacteriosis Mycoplasma caviae Rocky Mountain spotted fever Sporotrichosis Staphylococcus aureus Streptococcus pyogenes Syphilis Toxoplasmosis Tuberculosis Tumor Cells Transmittable Infections Emergency Medicine Reports; 2006:27(8) The Big 3: • HIV • Hep B • Hep C

  44. Transmission • Same as described for HIV in previous section with the following exceptions: • Vaginal secretions or semen are unlikely to transmit HCV • HBV can be transmitted by saliva

  45. HIV in the CHRSAC Epidemiology Report September 2006 • New HIV pts in CHR by risk responsible for Dx (1996 vs 2006)

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