Occupational Exposure to Body Fluids

When healthcare workers are exposed to bodily fluids at work, they face the risk of occupational exposure and infection1. Occupational exposure occurs when bodily fluids come into contact with a healthcare worker’s non-intact skin via abrasions, mucous membranes such as the mouth, nose and eyes, and percutaneous injuries from needlesticks or sharp objects.

HIV, HBV, HCV: Assessing the Risks

Although there are a number of pathogens that healthcare workers could be exposed to during an occupational exposure, human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) rank as the most critical when considering exposure prevention and management.

To assess your exposure risk, it is essential to determine the type of bodily fluid you have been exposed to. Some bodily fluids are considered potentially infectious for pathogens such as HIV, HBV and HCV, while others are not2.

 Body fluids that may pose a risk
 of infection from HIV, HBV, HCV
Body fluids that do NOT pose a risk
of infection from HIV, HBV, HVC
unless visibly contaminated with blood
Blood Urine
Vaginal secretions Saliva
Anal secretions Non-purulent sputum
Cerebrospinal fluid Stool
Pleural fluid Vomit
Peritoneal fluid Nasal discharge
Amniotic fluid Tears
Breastmilk Sweat

Transmission of a blood borne pathogen requires exposure to an infectious bodily fluid via a portal of entry (i.e., non-intact skin, percutaneous injury, mucous membrane). If a blood borne pathogen has no portal of entry into the body, there is no risk of transmission.

Occupational exposures most commonly occur as a result of sharps injuries1. Although HIV, HBV and HCV can be transmitted through blood or other bodily fluids, their estimated risk of transmission following percutaneous (sharps) exposure is2:

  • HIV: 0.3%
  • Hepatitis B: 6-30%
  • Hepatitis C: 3-10%

Occupational exposure to bodily fluids that can
transmit pathogens should be treated as a
medical emergency.

The College of Midwives of Ontario (CMO) Standard on Blood Borne Pathogens outlines midwives’ ethical obligation to determine their serologic status following any direct exposure to blood or human tissue in the workplace.

Exposure Management: Next Steps

Post-Exposure Prophylaxis

If you have been exposed to blood borne pathogens, consult with a physician as soon as possible. The physician can provide a risk assessment on the likelihood of pathogen transmission and the potential need for post-exposure prophylaxis (PeP). PeP is medication that you take after exposure to a pathogen to prevent becoming infected.

You can make decisions regarding the use of PeP in consultation with the occupational health team or the physician to whom you have been referred. You and your physician will determine if unknown viral status should be treated as positive or if PeP should be initiated based on risk factors

(e.g., sharps injury, pathogen contact with mucous membranes (including the eye) or contact with skin that is abraded, inflamed or otherwise not intact).
If PeP is necessary, rapid response increases its potential for effectiveness.

If a decision to use PeP has been made, it’s potential to effectively prevent infection is extremely time


Baseline Testing and Follow-Up

If the viral status of the client/source is unknown, it is important to obtain baseline testing for HIV, HBV and HCV immediately after exposure. Follow-up testing should be arranged at six weeks and four months for HIV, and at three months and six months for HBV and HCV1
 

Management of Occupational Exposure to HIV, HBV, HCV

Treat exposure
  • Use soap and water to wash areas potentially exposed to infectious fluids; do NOT scrub the exposure site.
  • For a needlestick injury, allow the wound to bleed freely. Do not squeeze site.
  • Flush exposed mucous membranes with water or saline.
  • Flush exposed eyes with water or saline.
  • NB: Caustic agents, antiseptics and disinfectants are not proven to be effective in decreasing the risk of seroconversion.
Gather information
  • In a birth centre or hospital, follow the institution's procedures. Outside of those facilities, take the following steps:
    • Immediately consult the practice group’s or hospital’s Infection Prevention and Control/ Occupational Health and Safety officer.
    • Get details of exposure and record pertinent information (e.g., date and exact time of exposure, how exposure occurred, follow-up done, type and amount of exposure, client’s serology status).
    • Assess risk factors (e.g., blood transfusion, shared needle drug use, viral load if HIV positive).
    • Request that the client provides updated blood work as soon as possible, as their serology status may have changed during the pregnancy.
    • Obtain written client consent to test for HIV, HBV and HCV. Bloodwork should be drawn as soon as possible.
    • Arrange for the client’s blood work and identifiers (i.e., contact and OHIP number) to go to the same hospital as the exposed midwife/student.
Seek treatment
  • Immediately go to an emergency department or health  centre for up-to-date information, baseline HIV, HBV and  HCV serology and medication access.
  • The efficacy of PeP is extremely time sensitive, especially  for HIV which requires treatment within hours1. Tests/assessments require time, and delaying medical  care is not advisable.
  • Following referral to an Infectious Disease specialist from  the hospital or upon the advice of Public Health, follow-up  serology and HIV and/or HBV prophylaxis may be  indicated.
  • Practitioners have access to the PeP line between the  hours of 9am and 2am (EST) at 1-888-448-4911. This line provides clinicians with the most up-to-date information  regarding risk of exposure and PeP.
Report
  • File an incident report as per clinic protocol.

IPAC Clinical Office Practice 2013 (page 63-64)3.

Preventing Exposure

Prevention is the best way to decrease the risks of occupational exposure. There are several ways healthcare providers can protect themselves from exposure to blood borne pathogens and infection: 
  • Know your immune status to HBV and if you are not immune. get immunized4.
  • Assess your risk of exposure and wear personal protective equipment (PPE) as indicated.
  • Use only safety-engineered medical sharps with hinged caps, retracting needles and sliding sleeves.
  • Use only automatic retracting heel stick lancets.
  • Do not recap needles.
  • Dispose of all sharps and needles at point of use in an appropriate sharps container.

What If I Test Positive?

If an exposure incident with a specific client leads to a positive test result for HIV, HBV or HCV, midwives are legally obligated to report the result to Public Health. After the exposure incident, midwives also have an ethical obligation to inform the client that their testing revealed a positive serologic status. The CMO requires that this information be reported to the client so they may seek appropriate care and prevent further transmission. The CMO also requires that members report positive serologic status to the College as soon as reasonably possible4. Finally, to reduce the risk of transmission to other clients, midwives have an ethical obligation to seek advice on appropriate measures to prevent transmission in their clinical practice.

HIROC, midwives’ Professional Liability Insurance provider, provides supplementary coverage for all HIV positive individuals who are working for midwifery practice group. To obtain payment, HIROC requires that the notice of positive test result be filed within 90 days of first learning of the incident. 

Ongoing Considerations

References

       1. Ontario Hospital Association and Ontario Medical Association. Blood Borne Diseases Surveillance Protocol For Ontario Hospitals. [Internet]. 2018. [cited 2019 June 19]. Retrieved from https://www.oha.com/Documents/Blood%20Borne%20Diseases%20Protocol%20(November%202018).pdf

       2. St. Michael’s Hospital. Pocket P.E.P. Clinical management of non-occupational and occupational exposure to blood borne pathogens: A pocket reference [Internet]. Toronto; 2013 [Updated 2019; cited 2019 Apr 10]. Retrieved from: http://www.stmichaelshospital.com/pdf/programs/pocket-pep.pdf

       3. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Provincial Infectious Diseases Advisory Committee (PIDAC). Infection Prevention and Control for Clinical Office Practice. 2 ed. [Internet] Toronto, ON: Queen’s Printer for Ontario. April 2015. [cited 2019 Apr 10]

       4. College of Midwives of Ontario. Standard on Blood Borne Pathogens. [Internet]. Toronto; 2014 [Cited 2019 Apr 10]. Retrieved from: http://www.cmo.on.ca/wp-content/uploads/2017/12/Blood-Borne-Pathogens.pdf