Informatieblad PEP profylaxe voor studenten van het UMC St Radboud in het buitenland

Transcriptie

1 Introduction Bloodborne diseases we are most frequently confronted with during daily routine are HIV/AIDS, hepatitis B and C. Hepatitis B transmission can be prevented by vaccination. It is important to know when vaccination has been applied and to be informed about the antibody response afterwards. Hepatitis C cannot be prevented by vaccination, and there is no prophylaxis. Early treatment however is a possibility. Transmission of hepatitis C is possible by a needle stick injury so attention will be paid to this after an accident. In this document you will find information about (the prevention of) HIV transmission risk. HIV can be transmitted in different ways, especially by sexual contact and by needle stick injuries or blood transfusions. The highest risk of acquiring an HIV-infection is by unsafe sex. Advice: avoid unsafe sex 1 ; always carry condoms, even if you have a strong intention to avoid sex. (This also applies to women; safe condoms are not always available.) Mostly, needle stick injuries can be prevented by applying the skill correctly (do not put back the needle in the cap), right discipline at work, and protection by gloves and spectacles. (If you do not wear spectacles, use protective glasses to avoid splash incidents during deliveries and surgery.) The third risk, transmission by blood transfusion and contaminated needles, can be avoided by trying to prevent road accidents and infections (e.g. do not travel at night if it is not absolutely necessary and take malaria prophylaxis). If you go to tropical Africa, it is recommended to take a set of approximately 5 needles and syringes which can be used if you need an injection yourself. The AMD (UMCN Occupational Health Service) will give medical students a box of non-sterilized gloves. Background Since January 1998 the Radboud UMC handles a procedure how to act at needle stick injuries in case the patient is HIV-positive or might be infected with HIV (patient source). A decision has to be made whether antiretroviral therapy (PEP) has to be started. Obviously, this rule is applied to medical and dental students and for students during their internship. This procedure has been applied to medical students who go to low-resource countries for an internship since August It has also been applied to student nurses who go to developing countries for a practical training since March This policy has been formulated starting from a zero-risk policy. Because of impurities in Viracept tablets, nelfinavir was replaced by lopinavir/ritonavir tablets (Kaletra ) in Whether treatment is started depends on the way of transmission and the possible seriousness of the accident. Two main factors determine the decision whether treatment will be started or not: 1. Seriousness of the accident (table 1) The highest risk, besides transmission by unsafe sex, is transmission by blood, especially when infected blood enters the bloodstream directly. Cuts and deep needle stick injuries by a needle are examples of relatively high risks. 1 All partners, other than a monogamous, proven HIV-seronegative steady partner, are unsafe concerning HIV/SOA transmission. Safe sexual procedures don t exist; transmission depends on the applied sexual technique; in order of increasing risk: manual / oral / vaginal / rectal. Condoms decrease the risk of sexual transmission, but don t exclude it. Spermicides don t protect from HIV transmission, but may even increase the risk when used regularly. Pagina: 1/6

2 Examples of relatively low risk are e.g. the contact of drops of blood, fluid or saliva with mucous membranes like eye or mouth. From risk two and upwards it is called a significant accident. 2. HIV- Prevalence in the patient population (table 2). When the HIV-prevalence of the patient group is low, as in the Netherlands, e.g. in Indonesia and Nicaragua, we assume that the patient is not infected in case the HIV-test is negative, and in case the HIV-status is unknown often the PEPprophylaxis will not be started. When the HIV-prevalence of the patient population is middle to high, as is the case in Ghana, Tanzania and Suriname, there is a small chance (about 25% of the yearly incidence) that the source is infected although the HIV test is negative so in case of an unknown or negative HIV-status the PEPprophylaxis will be started. Procedure for students abroad 1. PEP prophylaxis has been available for medical students of the Radboud UMC who go abroad for an internship since August 2004 and it has been available for student nurses of the HAN who go abroad for a practical training from March 2005 as they can get in contact with contaminated blood. It is also available for (bio-)medical and dental students who follow recognized courses (e.g. research elective, internship). 2. Students will be informed about PEP-prophylaxis by the AMD. The information includes the medication itself, possible side effects and indications. For this purpose a flow diagram has been constructed. 3. The information meetings organized by the AMD will take place four times a year (for medical students: on the day of the continuous assessment ( voortgangstoets ); student nurses will be informed by the HAN). At the same time the students will be informed when to collect the PEPkit at the AMD. 4. Basic assumption is, that in case PEP is required, because of a needle stick injury, the student returns to the Netherlands as soon as possible. The PEP-kit contains medication for 10 days as the student has to start PEP-prophylaxis immediately and it will take some days before he is back in the Netherlands. At the delivery of the kit the students have to sign a receipt including that they are informed on the rules concerning the PEP-kit. 5. The costs for the PEP-kit are at the expense of Radboud UMC (medical students) or HAN (student nurses) 6. During the practical training / internship the AMD is the medical confidant. The AMD can be reached during working hours at afspraakbga@amd.ru.nl. Beyond working hours the specialist who is on call for infectious diseases of Radboud UMC can be reached at phone number: In case the PEP-kit is unused after the practical period / internship, the student hands the PEP-kit to a pharmacist. Pagina: 2/6

3 8. PEP medication consists of Combivir (zidovudine/lamivudine 300/150mg) BD 1 tablet + Kaletra (lopinavir/ritonavir 200/50mg) 2 tablets BD. Most important side effects are abdominal pain and diarrhoea; in case of diarrhoea loperamide (Imodium, Diacure, 2mg) 1 caps 1-3 times daily, can be used. 9. After the practical period / internship the student from the Radboud University contacts the AMD for a medical check-up. Please note that the medicines are put at the disposal of the students who go abroad for their practical training / internship and not at the disposal of the hospitals or hospital staff. Pagina: 3/6

4 Table 1 Assessment risk and indication for PEP Type and extend accident body fluid risk Splash accident intact skin all body fluids 1 Splash accident not intact skin (e.g. eczema, abrasion) blood, spinal fluid, fluid from ascites, pleural,fluid, amniotic fluid 2 saliva, urine, stools 1 Splash accident mucous membranes blood, spinal fluid, fluid from ascites, pleural fluid, amniotic fluid 2 saliva, urine and stools 1 Percutaneous accidents Scratch, no blood visible all body fluids 1 Percutaneous puncture, cut with blood visible after accident blood, spinal fluid, fluid from ascites, pleural fluid, amniotic fluid 3 saliva, urine, stools 1 Sexual accident after consultation only Pagina: 4/6

5 Table 2. Estimation of risk of HIV positive patient by country. Country Place Nr of UMCN students. Risk Ghana Berekum Techiman Tanzania Sengerema Rubya Sumve Biharamulo Machame Cameroon Shisong High Njinikom High Malawi Mzuzu High Suriname Paramaribo 2 Middle Nicaragua Managua 1 Low Léon 1 Low Indonesia Semarang 4 Low Pagina: 5/6

6 FLOW diagram Needle stick injury First aid : squeeze the lesion and wash with water and soap Assess the seriousness of the injury (table 1) Risk 2 or upwards Risk 1 determine risk country (table 2) no PEP Risk middle or high Risk low Start PEP Determine status source Source HIV positive HIV status unknown urgent HIV test Test not possible or negative Pagina: 6/6