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Prevention of and Protection Against Blood Borne Virus Infections (BBVI) in Dermatological Surgery

A doctor has a duty of care to all patients for whom he has responsibility irrespective of race religion age sex sexual or political orientation or disease state. However patients also have a responsibility to disclose to medical attendants any disease they may have that may affect the health of the treating physician or surgeon.

The risk of contracting a blood borne virus infection varies with the individual virus. Hepatitis B carries a relatively high risk while Hepatitis C and HIV infection carry a low low risk except from those individuals considered at high risk of carrying the disease themselves. These are practising homosexuals, intravenous drug abusers who share needles and individuals coming from an endemic high risk area. The overall risk in the UK is low.

Definition of Blood borne virus infection (BBVI)

The presence in the blood and body fluids of an infectious virus the usual route of transmission of which is by direct transfer of blood or body fluids from one individual to another.

Body fluids that may be responsible for BBVI are:

The blood borne viruses

Note: Hepatitis D virus is an incomplete virus and requires the presence of Hepatitis B virus.

Risk of Infection

The risk of infection following needle stick injury with HIV infected blood is small and estimated at approximately 3 per 1000 injuries while the risk for infection from Hepatitis B is estimated at approximately 1 in 5 injuries.

Some needle stick injuries carry a higher risk than others e.g. those resulting in deepinjury, those caused by hollow bore needles, those where the source patient is terminally ill with HIV infection and those where needles are visibly blood stained or have been in an artery or vein. The risk of acquiring HIV through mucous membrane exposure is less than 1 in 1000. Many studies have revealed no evidence of risk where blood is in contact with intact skin.

Prevention

(a) Some procedures carry a greater risk of exposure to blood and body products than others within the range of dermatological surgery. High risk involve those in which the potential for uncontrolled bleeding or spattering of blood is greater e.g. open surgery.

A lower risk would be associated with capillary oozing e.g. shave biopsy, curettage and cautery, cold point cautery, deroofing blisters, treating leg ulcers.

Very low probability of personal contact during cryotherapy.

Specific protective measures required

General preventative measures:

• Good basic hygiene practice with regular hand washing,
• Cover existing wounds or skin lesions with waterproof dressings or wear gloves
• Protect mucous membranes of eyes, mouth, nose from blood splashes·
• Do not pass sharps directly from one person to another but place them on an instrument tray between transfers.
• Institute a safe procedure for handling and disposal of Sharps e.g. the operator should dispose of sharps and not leave a third person to "tidy up".
• Needles should not be resheathed unless safe resheathing apparatus is available.
• Scalpel blades should be placed on and removed from handles using appropriate instruments.
• Suturing needles should be handled carefully and stored in a safe place when not in use.
• Potentially infected surfaces and spillages of blood should be disinfected appropriately e.g. a laboratory bench used for the preparation of micrographic surgical specimen may become contaminated during the preparation process.
• All used sharps must be placed in an appropriate puncture resistant container (sharps box) suitable for incineration.

Note:- Not all of the above preventative measures may be necessary all of the time. Departments should draw up there own code of practice for medical and nursing staff relevant to the tasks undertaken by that department in discussion with the Occupational Health Department and Microbiologists.

Immunisation

Immunisation is currently only available in an effective form against Hepatitis B virus (HBV).

All workers who regularly come into contact with blood or blood related products e.g. medical and nursing staff must be effectively immunised against this virus.

Post exposure prophylaxis - Immediate action

• In the event of a sharps injury or other significant contamination the following action should be taken without delay.
• Wash off splashes on skin with soap and running water.
• Encourage bleeding if the skin has been broken.
• Wash out splashes in the eye preferably using an eye wash from a fresh eye wash bottle or alternatively tap water on nose and mouth with copious amounts of tap water.
• Record source of injury e.g. name, type of fluid, type of injury, report incident to the expert medical adviser for risk assessment* and decisions about prophylaxis with anti viral drugs.

* This individual will probably vary from trust to trust and may be in infection control, occupational health, public health, or the accident department.

There is evidence that in HIV infected persons, the use of combinations of antiretroviral drugs suppresses viral replication. This together with knowledge of zidovudine resistance in this population, has led to the introduction of antiretroviral drug combinations following occupational exposure to HIV. Some of these drugs, especially the protease inhibitors carry significant and serious side effects.

The decision to use these drugs will depend upon

• Source of contamination
• The extent of injury and type of sharp causing the injury
• The likelihood of blood borne virus infection in the source case
• The vaccination history of the injured party and use of anti viral drugs
• An accident report form should be completed.
• Blood should be taken from the infection source and the injured party to establish the risk of infection (after consent obtained)
• Counselling may be needed for both injured party and potential infection source

References

Guidance for Clinical Health Care Workers:

Protection against Infection with HIV and Hepatitis viruses January 1990 HMSO Protection again blood borne infections in the workplace : HIV and Hepatitis Advisory Committee on Dangerous Pathogens HMSO 1995

Guidelines on Post Exposures Prophylaxis for Health Care Workers occupationally exposed to HIV UK Health Department June 1997