EHPs assess new CDC recommendations
Timing, testing, toxicity are trouble spots
Often the first to respond to occupational HIV exposures, hospital employee health practitioners are assessing the new chemoprophylaxis guidelines issued by the federal Centers for Disease Control and Prevention in Atlanta.1 Although most welcome the new protocols, some say exposures still should be considered on a case-by-case basis, while others have concerns about the complexity of the information, the feasibility of source-patient testing, and the speed recommended for initiating a prophylactic drug regimen.
Limited data on the antiretroviral drugs' toxicity in healthy people cause some EHPs to worry about the risks for health care workers. Although zidovudine (AZT, Retrovir) postexposure prophylaxis generally is well-tolerated, "the toxicity of other antiretroviral drugs in people not infected with HIV has not been well-characterized," the new CDC recommendations state.
At St. Joseph's Medical Center in Reading, PA, AZT combined with lamivudine (3TC, Epivir) has been offered to HCWs for about two months. Four employees have taken the drugs with no ill effects, but Sharon Magrowski, CMA, employee health coordinator at the 920-employee hospital, says she still worries.
"I'm putting these people on this strong medication, and I'm scared about this," says Magrowski, who is particularly concerned about possible toxicity of the newer antiretrovirals --3TC and indinavir (IDV, Crixivan) -- because fewer data are available. She is working with the hospital's infection control physician in postexposure follow-up.
The recommendation that chemoprophylaxis be initiated within one to two hours postexposure also could be problematic, she says. Employees exposed after the EHS is closed go to the emergency room, and physicians there call Magrowski at home.
"I like to be [at the ER] to help counsel if the exposure occurs after hours because some of the ER docs don't feel that it's necessary," she explains.
Magrowski says she will try to reach employees within an hour after exposure on weekends and at night, but she also is concerned about operating room personnel who might be exposed while working during the day.
"If there's a stick in the OR, the person can't just walk out. They might not be able to get out in time," she says.
Nevertheless, Magrowski says the CDC guidelines, particularly the risk classifications, are helpful for determining which employee exposures warrant chemoprophylaxis.
"We didn't have this information before," she says. "How do you explain to your employees that they really don't have a significant exposure? At least now we have something to go by."
Educate employees beforehand
Charlene M. Gliniecki, RN, MS, COHN-S, director of employee health and safety at 2,500-employee Camino Healthcare in Mountainview, CA, also acknowledges the new information published in the guidelines, but says its technical complexity makes employee education even more necessary.
"This document gives us more information about the characteristics of a high-risk exposure. [Employees] now have more information than they really want, which makes decisions more complex. Because a lot of this is technically very complicated, it may be information overload, so people need to hear it more than once so they can feel they made the right decision," she says.
Although AZT has been offered at Camino for more than five years, there have been no known HIV exposures and no takers for AZT. Gliniecki notes that EHPs at other facilities where high-risk exposures are a rarity still should become familiar with the information contained in the recommendations in case such an exposure does occur.
The complexity of the information, combined with the need to make fast, informed decisions about postexposure chemoprophylaxis, makes educating employees before an exposure occurs all the more important.
"Since we have to make decisions fairly quickly, we must invite people to think in advance what their philosophy is on this," she says. "In the intensity of the moment, I can't imagine that people could really understand what I'm telling them."
EHPs are the "first line" of postexposure counseling, she says, but they should not hesitate to bring in other experts. A hospital's employee assistance program can provide counseling and support if personal issues arise for employees and their significant others. And, as the recommendations state, involving a provider who is knowledgeable about the three drugs -- such as an infectious disease physician -- is advisable.
Despite all the specific information in the new recommendations, however, Gliniecki says there still is a "gray zone" that requires individual decisions regarding chemoprophylaxis with drugs that may carry unknown toxicity risks. Those decisions must be made both by providers regarding whether they recommend the drugs, and by HCWs regarding whether they want to take them.
"My goal is to work with [employees] to help them make the best decision," she says. "This is uncharted territory. Each person has to balance the risks vs. the benefits. If [an exposure] is in the gray zone and not clearly a high-risk exposure, we sit down and work with people to help them decide what is best for them. In practice, we err on the side of offering [chemoprophylaxis] to people if it comes to that."
Obtaining source-patient testing results as soon as needed for decision making could further complicate matters, Gliniecki adds.
"The time frame of one to two hours puts pressure on all parties," she says. "It can increase the complexity of managing follow-ups because some smaller hospitals do HIV testing only one or two days a week due to financial cutbacks."
The ideal situation is to know the HIV status of the source patient, or for the patient still to be in the hospital and willing to give consent for testing. Many state laws require patient permission for blood sample testing.
The need for fast postexposure response after EHS hours could be facilitated by hotlines or beepers, but for hospitals that do not provide those measures, Gliniecki offers the solution used at her facility. At Camino, trained nursing personnel function as administrative coordinators in "officer of the day" troubleshooting roles.
"They are already here nights and on weekends to handle unusual situations. We have a well-written protocol that they can implement, and employee health professionals can pick up the next piece when they come in. That, in combination with employee education up front, can help," she explains.
San Francisco General Hospital (SFGH) has long been a leader in managing occupational exposures to HIV. (See Hospital Employee Health, May 1995, pp. 69-71.) Rita Fahrner, RN, NP, MS, chair of the needlestick prevention committee, says combination therapy has been given to 10 HIV-exposed employees, two with the three-drug regimen and eight with the two-drug regimen.
Although SFGH officials are concerned about giving the drugs to healthy workers and have shared those concerns with workers, "on the other hand, the people who have taken the two- and three-drug combinations to this point have done quite well," Fahrner says. All were able to complete the course of drugs while continuing to work.
She notes that "liberally offering" anti-emetics to workers on chemoprophylaxis helped them complete treatment, but the greater motivator was the data derived from a case-control study showing efficacy of postexposure prophylaxis.2
Treatment can begin with status unknown
Because a source patient's HIV status sometimes is unknown at the time of an exposure, SFGH recommends beginning prophylaxis for high-risk exposures while waiting for test results.
"There is no contraindication to starting people on treatment before you know the source patient's status," she says. "If it's a high-risk exposure, it's reasonable to start people on treatment and then stop it when you get the source patient's status back. You can't wait for HIV results because you want to start them within an hour or so of the exposure."
SFGH began the new treatment protocol in April with a campaign to inform HCWs of the revised recommendations with flyers and articles in hospital publications.
Officials also created their own treatment algorithm, similar to the CDC's, but "a little clearer," says Fahrner. "The way the CDC one was written makes it a little difficult to follow unless you're really up on these things. It's hard to read all the footnotes."
The SFGH algorithm incorporates the footnote information in the form of exposure-level categories for each of the three injury types -- percutaneous, mucosal, and cutaneous. (See the SFGH algorithm, inserted in this issue.)
At Tampa (FL) General Healthcare, JoAnn Shea, ARNP, MSN, employee health manager, has two main concerns about the new guidelines. First, she worries about the lack of toxicity and efficacy data on the recommended drugs as prophylaxis.
"I'm concerned about side effects because we don't know enough about [those] drugs," she says. "We're a little apprehensive, but on the other hand, we want to do the right thing and at least give the option."
In addition, only one study has shown any efficacy of AZT given postexposure,2 and no efficacy data exist for 3TC and IDV in preventing HIV transmission after occupational exposure, she points out.
Second, Shea says determining a source patient's HIV status can take one to two days, while the CDC recommends beginning chemoprophylaxis in one to two hours.
Employee education will emphasize weighing risks vs. benefits, but "we won't offer [chemoprophylaxis] to everybody. If we think [the exposure involves] a low-risk patient, or if we don't know patients' status and they don't have risk factors, we won't offer it," she says.
Also, before a source patient's HIV status is known, she would be reluctant to offer chemo-prophylaxis to HCWs who are pregnant or could have toxicity problems with the drugs.
Shea says although policies have not been finalized, she probably will begin following the chemoprophylaxis recommendations only when the source patient is known to be HIV-positive, "and then go from there after we see how things work out. We want to inform workers of what we know about these drugs and what the recommendations are, and then let it be their choice."
Jeanne Culver, RN, COHN, director of employee health services at Emory University Hospital in Atlanta, attended a preliminary Public Health Service meeting of virologists and clinicians in March this year, where they discussed issues related to postexposure prophylaxis, and "there was not consensus at that meeting," she says.
AZT was recommended because the CDC case-control study found it to be effective prophylaxis if given as soon as possible after exposure and under specific circumstances, Culver points out. The criteria for high-risk exposures evolved from analysis of the HCW seroconversion list, which revealed that seroconversions generally resulted from deep punctures, large-bore needles, large volumes of blood, and AIDS patients in late-stage illness.
References
1. Centers for Disease Control and Prevention. Update: Provisional Public Health Service recommendations for chemoprophylaxis after occupational exposure to HIV. MMWR 1996; 45:468-472.
2. Centers for Disease Control and Prevention. Case- control study of HIV seroconversion in health-care workers after percutaneous exposure to HIV-infected blood -- France, United Kingdom, and United States, January 1988-August 1994. MMWR 1995; 44:929-933. *
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