Recommendations for an Integrated Protocol

[Table of Contents]

Volume: 23S2 • March 1997

AN INTEGRATED PROTOCOL TO MANAGE HEALTH CARE WORKERS EXPOSED TO BLOODBORNE PATHOGENS

4. Testing the Source and the HCW

It is in the interest of the HCW to determine if the blood from the source is infected with HBV, HCV, or HIV. In addition to secondary prevention measures and counselling of the HCW, potential compensation for an occupational infection must be considered.

Every reasonable effort should be made to obtain permission to test the source for HBV, HCV, and HIV. Obtaining informed consent from the source is an integral part of all post-exposure testing procedures, as is maintaining confidentiality of all information. Testing the source without consent is unethical. When consent is given to draw blood for all three viruses, the appropriate pre- and post-test counselling for all three bloodborne pathogens should be done.

Information from the source's test result will be used to determine which tests will be done for the HCW.

Different testing procedures are required for the HCW if the source agrees to testing and is positive for HBV, HCV, or HIV; if the status of the source is unknown; or if the source is negative but has risk factors for bloodborne pathogens. If the source is negative for HBV, HCV, or HIV and has no risk factors, testing the HCW is not necessary.

4.1 Testing the source (Table 1)

Table 1 Testing the source, upon consent
Bloodborne Pathogens	TEST THE SOURCE
HBV	Do not test the source if the HCW is known to be immune ⁺ to HBV. (This is presently under review by NACI.) Test for hepatitis B surface antigen (HBsAg) at the time of injury if the HCW is known to be susceptible ⁺ to HBV, a non-responder ⁺ , or has an unknown ⁺ HBV status.
HCV	Test for HCV antibodies (anti-HCV) at the time of injury.
HIV	Test for HIV antibodies at the time of injury.
⁺ See section 7.

4.2 Testing the HCW (Tables 2 and 3)

If the results of testing indicate the source is positive for anti-HCV, HBsAg, or HIV antibodies, or if the status of the source is unknown, further investigation of the HCW is warranted (Table 2).

Table 2 Testing the HCW, if the source is positive or the status of the source is unknown
Bloodborne Pathogens	TEST THE HCW
HBV	Do not test the HCW if known to be immune ⁺ to HBV. (This is presently under review by NACI.) Test for HBsAg, anti-hepatitis B surface antigen (anti-HBs), and anti-hepatitis B core antigen (anti-HBc) at the time of injury, if the HWC is known to be susceptible ⁺ to HBV, a non-responder ⁺ , or has an unknown ⁺ HBV status. If tests are negative, retest at 6 months after exposure. Some experts suggest a medical assessment 3 months after exposure to assess the clinical evidence for hepatitis.
HCV	Test for HCV antibodies (anti-HCV) at the time of injury. If the test is negative, retest for anti-HCV at 3 months and 6 months after exposure. Test for liver function using serum alanine aminotransferase (ALT) at the time of injury and 6 months after exposure.
HIV	Test for HIV antibodies at the time of injury. If tests are negative, retest at 6 weeks, 3 months, and 6 months (if subsequent tests continue to be negative). Virtually all seroconversions occur within 6 months of exposure ^(11,12), although there have been rare reports of seroconversions after 6 months ⁽¹³⁾. Given the very low probability of seroconversion after 6 months and the unnecessary anxiety that would be caused by extending the testing period beyond 6 months, testing at 12 months is not recommended, but may be considered on a case-by-case basis. When the status of the source is unknown, the risk of infection should be assumed to be present unless local epidemiology or the clinical setting strongly suggests otherwise.
⁺ See section 7.

If the source is negative but has risk factors for bloodborne pathogens, testing and following up the HCW may still need to be done (Table 3).

Table 3 Testing the HCW, if the source is negative but has risk factors for bloodborne pathogens
Bloodborne Pathogens	TEST THE HCW
HBV	Test for HBsAg, anti-HBs, and anti-HBc if the HCW is known to be susceptible ⁺ to HBV, a non-responder ⁺ , or has an unknown ⁺ HBV status and the possibility exists that the source is in the window period (up to 3 months after exposure). Risk factors within the last 3 months include: - high-risk sexual behaviour [i.e. men who have sex with men, sexual partner who is an injection drug user (IDU), multiple sexual partners] - sexually transmitted disease(s) - sexual or blood contact with a known case of HBV infection - IDU or tattoo/body piercing.
HCV	Test for anti-HCV at the time of injury if the source has one or more lifetime risk factors. Retest at 3 months and 6 months after exposure. Lifetime risk factors include: - high-risk sexual behaviour (i.e. a sexual partner who is an IDU, multiple sexual partners) - sexual or blood contact with a known case of HCV infection - IDU or tattoo/body piercing - receipt of blood or blood products before 1990 - receipt of blood-derived coagulation products before 1985 - origin in a developing country - dialysis.
HIV	Test for HIV antibodies at the time of injury if the source has one or more risk factors and the possibility exists that the source is in the window period (up to 6 months after exposure). Retest at 6 weeks, 3 months, and 6 months if the previous test is negative. Risk factors within the last 6 months include: - high-risk sexual behaviour (i.e. men who have sex with men, sexual partner who is an IDU, multiple sexual partners) - sexually transmitted disease(s) - sexual or blood contact with a known case of HIV infection - IDU or tattoo/body piercing.
⁺ See section 7.

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	Last Updated: 1997-03-13		Important Notices