Dr. SHABIN UL HASSAN
PEP is the guideline given by the World Health Organization for prevention of infection if there was risk of contact with potentially hazardous materials. To avoid the risk of possible infection, the World Health Organization introduced guidelines for prevention of possible infection caused by hepatotropic viruses and HIV.
Mandatory protocol PEP is implemented in six steps discussed below.
Step one: Treatment of the site of exposure
The site of exposure to potentially infectious fluids should be washed as soon as possible using soap and water only, while the exposed mucus membranes should be washed with water only. Eyes should be flushed with water and saline solution (if there was contact with potentially infectious fluids). Do not use caustics and do not rinse the wound with antiseptics and disinfectants.
Step two: Report and documentation
Occupational exposure should be reported immediately. Details regarding the circumstances under which the exposure happened and the employee was administered prophylaxis should be recorded in the employee's medical record. The documentation should include: Date and time of exposure, details of the accident (where and how the exposure happened, what was the site or sites of exposure on the body, if the exposure was associated with a sharps – type and brand of sharp), details of exposure accident (type and amount of fluid or material a person was exposed to), severity of injury (or different kind of exposure), and details about the source of infectious material. The following should be checked:
- Does the source of potentially infectious material have HBV, HCV, or HIV infection?
- If a patient, the source of material, is HIV positive, the stage of disease or the level of infectious particles in the blood should be determined.
- It is important to note the history of taking antiretroviral therapy, or antiretroviral resistance (if known).
- It is necessary to record the details of the exposed person (HBV vaccination, the response to vaccination, other medical conditions and medications used, existence of pregnancy or lactation).
Step three: Evaluation of exposure
The potential for spreading the infection of HBV, HCV, or HIV should be evaluated based on the type of infective material, the site of entry of material into the body of the exposed person, and the severity of exposure. Significant exposure may be a risk for further transmission of pathogens by blood and requires further evaluation of body fluids: Blood, sperm, vaginal secretions, cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluid. Body fluids that do not present the risk of transmitting infectious agents of this type, unless they clearly contain blood, are urine, sputum, saliva, stool, vomit, nasal excrete, tears, and sweat.
Step four: Evaluation of sources
When the patient source of infectious material is known, it is necessary to follow these:
- Test the patient for anti-HBsAg, HCV and HIV antibodies
- Evaluation of “viral load” (the level of infectious particles in the blood) for routine control of a patient source is NOT recommended
- Test the patient by rapid HIV test.
If the patient is NOT infected with either of these viruses, after primary test of the exposed person, further control monitoring is not required. When the patient source is not known, it is necessary to evaluate the possibility and the level of risk of exposure. To consider the possibility of infection by these viruses in patients, who were connected to the circumstances of exposure (e.g., What is the rate of infected people in the community? Does the clinic, where the exposure happened, treat a great number of infected or high-risk patients?). Do not test the wasted needles for these pathogens because the reliability of obtained results is not known.
Step five: Specific prophylaxis
Primary testing of all exposed persons to HBV, HCV, and HIV should be done after each exposure to potentially infectious fluids. If the exposed person had previous infection caused by any of those viruses and did not know about it, he/she should receive the antiviral treatment rather than prophylaxis.
Step six: Control monitoring
If any of medical staff was exposed to hepatitis, it would be necessary to do control testing for HBV, including mandatory counseling. This considers the following:
- Testing for anti-HBs antibodies 1–2 months after the last dose of vaccine[anti-HBs antibodies cannot be tested 6–8 weeks after the administration of anti-HBs immunoglobulin (HBIG) because of the possibility for false-positive results].
- Advising the exposed person not to donate blood, plasma, organs, tissue, sperm, and to abstain from risky behavior.
- Offering the psychological counseling if needed.
Control testing and advising after exposure to HCV include the following:
- Repeat the test for anti-HCV antibodies and ALT at the earliest 4–6 months after exposure.
- Do the test for HCV RNA for 4–6 weeks for early diagnosis (caution due to the possibility of obtaining false-positive results).
- During the testing period, the exposed person must not donate blood, plasma, organs, tissue, or sperm.
- Exposed person should abstain from changes in sexual activity, pregnancy, breastfeeding, or professional activities.
- Counseling services should be offered.
The role that a dentist can play in prevention of hepatitis is by considering each and every patient as a potential carrier of hepatitis. Proper infection control and sterilization protocols should be followed in order to reduce the risk of infection. Dental surgeons are at a greater risk of exposure than the other specialists in the medical fields because of their exposure to aerosols during ultrasonic scaling. So, they should lay special emphasis on prevention and protection against hepatitis.
(Author is Dental Surgeon, BioDentis Dental Clinic Magarmal Bagh, Srinagar. Email: firstname.lastname@example.org)