Needle Pricks

1. “Needle Pricks”
or any occupation exposure to HIV and Hep B (and Syphilis)
don’t forget the patients and families also enter the
health facility

2. “Seroconversions” - Serological Conversion
Seroconversions are described in cases who cannot remember an incident!
Not only the clinical healthcare workers are at risk!
* Sharps injuries are the most frequent occupational hazard faced by nurses,
phlebotomists, doctors and other healthcare workers .
* Research has shown 40–75% underreporting of these injuries .
* Accidental exposure to blood by healthcare workers is frighteningly common.
◦ In 2001 over 69% of interns working at Chris Hani Baragwanath Hospital sustained percutaneous
injuries,
◦ Tygerberg Hospital 91% of junior doctors reported needlestick injuries in the 3 previous year

4. EXPOSURE

5. PROBABILITY OF EFFECT of Needle Prick

6. SEVERITY OF OUTCOME
✤ children less likely than adults to clear the infection. 95% clear as adults, 30% if younger children,
and only 5% of newborns who acquire from the mom at birth.
✤ ‘acute’ infection, long term complications (cirrhosis, hepatocellular carcinoma, membranous
glomerulonephritis)
✤ (Childhood Immunization) The Taiwan national program has been shown to be associated with a decrease
in the rate of HBsAg-positivity among children and infants, from nearly 10% in 1984 to only 1.3% in
1994. In conjunction with this decrease in hepatitis B, there has been a significant reduction in the
incidence of childhood HCC, much of which was HBV-related. Thus, the rate of childhood HCC (between
the ages of 6 and 14 years) was 0.7 per 100,000 population in the early 1980s, prior to the introduction of
the vaccine, whereas between 1996 and 1999, it had fallen to 0.19 per 100,000 population

8. IMMUNISATION
• Hep B - YES
• HIV - NOT YET

9. Immunize our babies

10. HepBsAg (Ag = Antigen)
HepBcAg
HepBeAg
HepBsAB (Antibody)
HepBeAB

11. ✤ The HepBsAg (Surface Antigen) is the used to screen for the presence of Hepatitis B. Traditionally,
HepBeAg (E- Antigen) is associated with high rates of replication/infectivity. “Clear the infection” if
HepBsAg becomes negative, If HepBsAg remains positive > 6 month : “carrier’ (UNDERSTAND THAT
THE SIMPLICITY OF UNDERSTANDING OF THE TESTS FOR HEPATITIS B, NEED TO TAKE INTO
COGNIZANCE THAT THE LIVER IS A DYNAMIC ORGAN - DR KUNENE COMMENT)
✤ Why don’t we test for HepBsAg (Surface Antigen) before we vaccinate? (We don’t normally) (There is
not danger vaccinating someone who is HepBsAg positive
✤ 3 shots over 3 months (OR local protocol) and in 4th month check HepBSAB (Surface ANTIBODY to
confirm immunity).
✤ A routine booster dose should be administered to healthy immunocompetent adults after 20 years. An
anti-HepBsAB (Surface Antibody) > 10 mIU/mL indicates immunity. If below <10mIU/ml, should be
revaccinated according to local protocol. (I WOULD CHECK EVERY 5 YEARS AT LEAST - DR
KUNENE COMMENT)

12. Hep B Vaccine
• Hep A - yes
• Hep B - yes
• Hep C - no
• Hep D - no, but prevention of hepatitis B with hepatitis B vaccine also protects
against future hepatitis D infection.
• Hep E - no (only in China, but only for genotype 4)
• No FDA-approved vaccine for hepatitis E is currently available in the United
States; however, in 2012 a recombinant vaccine was approved for use in China.

13. Needle Prick Management
• Hep B
• HIV - PEP
• AZT within 4 hours - 79% reduction in transmission rates (NEJM 1997; 337:
148533148)
• Basic actions: Clean exposure site with soap and water (no evidence that
antiseptic solution is useful). Flush mucous membranes. Irrigate eyes.
• (Rape Victims)

14. 1) Hepatitis B
• Three HIV arv’s
have anti-hepB
properties e.g.
Tenofovir (TDF)
and Emtricibine
(FTC)/Lamivudine
(3TC)

15. 2) Hep C
• Determine status of source (Anti-HCV)
• No active Prophylaxis-Immunoglobulins as not effective
• Interferon not recommended for prophylaxis
• Blood Test immediately and at 6 months LFT and Anti HCV

16. 3) HIV PEP

17. Types of Exposure
• No longer trying decide between 2 or 3 ARVs (it just gets confusing)
• Studies on the use of ART for PEP have not demonstrated conclusively that 3-drug regimens have superior
efficacy to 2-drug regimens, however 3-drug ART regimens have been shown to be more effective as
treatment, and therefore a 3-drug regimen is now recommended for all types of potential HIV exposure.
• Starter packs not recommenced due to the risk of defaulting treatment, rather a full 28 day supply of
medication be given e.g old ‘AZT+3TC+ALLUVIA’ which had side effects of nausea (AZT)/vomiting(AZT)/
diarrhoea(ALLUVIA, 2 pills BD), new ‘TDF+FTC+DOLUTEGRAVIR’ (TDF+FTC = one pill, DOLUTEGRAVIR =
one pill)
• Management of Side Effects e.g. Metoclopromide (Maxalon)
• Condoms of Needle Prick Patient and their partner. Family Planning?

19. ✤ Documentation
✤ When the source individual is known, getting voluntary consent (Ethics) for bloods
e.g. HIV, Hep B (?), Hep C (?), Syphilis (?)
✤ Source Individual - DO THEY HAVE AN ARV HISTORY - before they go home!
✤ Counseling
✤ Management of a needle prick. When you do your baseline bloods for a Injury on
Duty, need to include following blood tests e.g. HIV Elisa (not PCR), Hepatitis BsAg
and C, Syphilis (RPR,TPHA), Hb, Cr, ALT
✤ Visits: Blood Results, (2 weeks), Repeat Bloods (1,3,6 Months) - (Get person to type it
into cellphone calendar - negotiate the plan)
✤ ? Give Alluvia or Dolutegravir provisionally. Give PEP as early as possible to 72 hours

22. Three Row Schema….…….for PEP pick one from a row…..
• TDF ‘Two things - Creatinine + Hep B’
• alternative: AZT ‘A for Anemia’
• (D4T ‘D or Dirty” but actually a good PEP arv)
• (NOT ABC - HYPERSENSITIVITY + “RENAL Friendly”)
• —————————————————————
• “C for Crippler” 3TC or FTC
• (30% REDUCTION OF VIRAL EFFICIENCY when WITH MUTATION - M184V)
• ——————————————————————
• DOLUTEGRAVIR ( or RALTEGRAVIR) ‘dolu-take-over’
• alternative: ATAZANAVIR “yellow eyes”
• alternative: ALLUVIA “diarrhoea”
• EFAVIRENZ “eR5” (preferably not due to bad dreams side effect)
• (NOT ‘NASTY’ NEVIRAPINE)

23. nick names for the arvs……….
• TDF ‘Two things - Creatinine + Hep B’ ‘mercedes’
• AZT ‘A for Anemia’ ‘toyota’
• D4T ‘D or Dirty” ‘uno’
• (NOT ABC - HYPERSENSITIVITY + “RENAL Friendly”)
• —————————————————————
• “C for Crippler” 3TC or FTC
• (30% REDUCTION OF VIRAL EFFICIENCY WITH MUTATION - M184V)
• ——————————————————————
• DOLUTEGRAVIR ( or RALTEGRAVIR) ‘dolu-take-over’ (‘game changer’) e.g. also robust with few
side effects
• ATAZANAVIR “yellow eyes” (unconj Bilirubin e.g. like gilberts syndrome)
• ALLUVIA “diarrhoea” ‘four by four’ - it drives over anything e.g. robust and double dose from 2+2 pills to
4+4 pills if on Rifampicin
• EFAVIRENZ “eR5” - e five rands
• (NOT ‘NASTY’ NEVIRAPINE)

24. What do you do if you hit problems with side effects? or previous use of ARVS
by Source Patients
DR KUNENE QUICK SUMMARY OF ARVS (15MIN) - YOUTUBE

25. Quick Side-effects Profile Summary
• The end
• TDF ‘Two things - Creatinine + Hep B’ AZT ‘A for Anemia’ D4T ‘D or Dirty”
(NOT ABC - HYPERSENSITIVITY)
• —————————————————————
• “C for Crippler” 3TC or FTC
• ——————————————————————
• DOLUTEGRAVIR ‘dolu-take-over’ - insomnia and weight gain, present ?relative
contra-indication in pregnancy, double dose with rifampicin (which induces Cyto P450)
• ATAZANAVIR “yellow eyes” + Skin Rash
• ALLUVIA “diarrhoea” and need to double dose in Adults (only double ritonavir in
children)
• EFAVIRENZ “eR5” (neuropsychiatric, previous was considered teratogenic, and can
have ‘Nasty’ skin + liver side effects like cousin NEVIRAPINE but chances much lower)
• ‘NASTY’ NEVIRAPINE - Skin and Liver particularly if INITIATED at a CD4 > 250

26. Quick Mutations Profile Summary
• TDF 1 mutation blows it - K65R
• AZT + D4T 4 out of 6 TAMS blows it - Thymidine Analogue Mutations
• ABC = is blown by K65R + M184V
—————————————————————
• “C for Crippler” 3TC or FTC = 1 mutation = M184V
• ——————————————————————
• DOLUTEGRAVIR ‘dolu-take-over’ - Intergrase Inhibitor
• ATAZANAVIR “yellow eyes” - Protease Inhibitor
• ALLUVIA “diarrhoea”- Protease Inhibitor
• EFAVIRENZ “eR5” + ‘NASTY’ NEVIRAPINE - Non-nukes get mutation very easily, so
one mutation blows it. Particularly because of long half life in blood, exposing it as
mono-therapy to the HIV

27. • Traditionally HAART: 1ST LINE “Two Nukes (NRTI) and One Non-Nuke
(NNRTI). A 2ND LINE would include a PROTEASE INHIBITOR. A 3RD LINE
would normally have been a INTEGRASE INHIBITOR
• “sometimes the terms first and second line can be descriptive, but normally a
2nd line s
HOWEVER……..
Now a 1ST LINE is “Two Nukes + One Intergrase Inhibitor”