HIV and Sexually Transmitted Diseases

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BLOOD-BORNE

PATHOGENS AND OSHA

CDM 2280

MICHAEL A. SIEGEL, DDS, MS, FDS RCSEdPROFESSOR AND CHAIR

ORAL MEDICINE & DIAGNOSTIC SCIENCESCOLLEGE OF DENTAL MEDICINE

PROFESSORINTERNAL MEDICINE (DERMATOLOGY)COLLEGE OF OSTEOPATHIC MEDICINE

NOVA SOUTHEASTERN UNIVERSITY3200 SOUTH UNIVERSITY DRIVE

FORT LAUDERDALE, FLORIDA 33328-2018

PHONE: 954-262-4309

E-MAIL: [email protected]

PREVIEW

• Blood-borne Pathogens

– Hepatitis

– HIV And AIDS

• Tuberculosis

• OSHA And AWDA

BLOOD-BORNE

PATHOGENS (BBP)

• Needles, Blades, Other Sharps

• Splash To Mucosa Of Eye, Nose, Mouth,Skin

• Viruses, Prions?

– Hepatitis B,C,D,E,F,G,TT, SENV, YoBin?

– HIV

• Blood Or Body Fluids Contaminated

With Blood

OCCUPATIONAL

EXPOSURE

• Exposure Is A Needlestick Or Cut With AContaminated Sharp Object

• Splash Of Blood Or Body Fluids Into Eyes, Nose,Mouth

• Blood, Body Fluids (Cerebrospinal, Synovial,Pleural, Peritoneal, Pericardial, Amniotic,

Vaginal), Semen **Not Saliva**



VIRAL HEPATITIS

• Symptoms

– Flu-like To Hospitalization

• Signs

– Jaundice Appears In Less Than Half

– Impaired Liver Function

– Tests Are Improving

• Acute vs. Chronic

• Risk Of Transmission

HEPATITIS B

• About 320,000 New Cases/Year In US

– Blood Supply Safe After 1972

• Estimated 1.25 Million Chronic Cases In US(Virus In Blood > 6 Months) (Who?)

• Vaccine

– Booster?

• Hepatitis D Superinfection Or Coinfection

HEPATITIS C

•4 Million Cases In US (4x HIV)

•85% Carrier Or Chronic

•#1 Cause For Liver Transplant

•8,000-10,000 Deaths/Year

HEPATITIS C

• Estimated 36,000 New Cases/Year In US

• 2.7 Million Chronic Cases In US (Who?)

– Blood Supply Safe After 1992

• No Vaccine

• Treatment 30% Successful, Weekly Injections And

Daily Pills, $$$$$$

• LONG Time From Infection To Manifestation Of Disease

HEPATITIS. SO WHAT?

•Normal Liver Functions:– Clotting Factors, Etc.

– Detox

– Digestion

HIV

• 46,000 New Cases/Year In US

• Estimated 1 Million Infected In US; (Who?)

Laws Regarding Disclosure

• Trend Of Infection Becoming More HeteroAnd Younger

• Length Of Time To Manifestation Of AIDS Is

Getting Longer: 8-12 Years

– “Cocktail”



New HIV+ Cases* 5.0 Million

Deaths* 3.1 Million

(*In 2003)

Total Deaths 29.8 Million

People Living W/HIV,AIDS 40.0 Million

HIV EPIDEMIOLOGY

U.N. ESTIMATES AS OF 12/03AIDS CASES DATA FOR

2002

• Florida #3 In US AIDS Cases

– 90,233 56% Have Died

– Miami #4 Metro Area 24,800

• #2 In Pediatric And Female

• 12% Of New Cases In The US

– 5,058 Adults, 34 Pedo

• Approximately 900,000 HIV+ In US

41%

38%

19%

2%

MSM

Hetero

IDU

Other

In Florida, 1/4-1/3 Don’t Know Their Status; 1/3 Won’t Tell!

HIV EPIDEMIOLOGY AIDS CASES IN FLA THROUGH 12/02

• Risk Of Transmission From Infected Mother

Estimated At 20% To 30%

• 96% Of FL Pedo Cases Are Perinatal Transmission

• 7,000 Births Per Year In US To HIV Infected Mothers

– AZT Prophylaxis Reduces Risk Of Transmission To Fetus

PEDIATRIC HIV

INFECTION

9% Of First 100,000 Cases Of Aids In

U.S. Were Women12% Of Next 100,000 Cases Of AIDS In

U.S. Were Women

Risk Of Transmission Is Greater For

Man⎭woman Than For Woman⎭man

HIV INFECTION IN WOMEN

One Quarter Of U.S. Women With AIDS WereDiagnosed In Their 20’s

Likely Infected As TeenagersNYC - 50% Of HIV Infected Women Had <5

Sex Partners

Teenagers / Adolescents ⇒ Leading Edge Of Next Wave Of Epidemic

HIV INFECTION IN WOMEN



More Than 90% Of The Transmission OfHIV Is By Sexual Intercourse, With ASteadily Increasing Proportion Due ToHeterosexual Intercourse

Less Than 10% Of Cases Result FromBlood Transfusion Or Injection Drug Abuse

TRENDS IN HIV TRANSMISSION

Time Of Initial

Infection With HIV

8 -12 Years AIDS

DYNAMICS OF HIV INFECTIONSPECTRUM OF DISEASE

• ~110 Million Virions Are CreatedAnd Cleared Daily

– 30% Of Entire Viral Population

– Half-life Of Viral Population Is 2 Days

DYNAMICS OF HIV INFECTION

• ~2 Billion CD4+ Cells Are Created And Destroyed

Daily

– ~5% Of Total Lymphocyte Population

– Creation Of CD4+ Cells Continues Even In Late Stage Of

Disease

• The Vast Majority Of Plasma HIV Is From Newly

Infected Lymphocytes

DYNAMICS OF HIV INFECTION

Continuous Rounds OfDe Novo Infection

Replication

Rapid Cell Turnover

Rapid, Ongoing Virus Expression Is DirectlyInvolved In CD4+ Cell Destruction

HIV PATHOGENESIS

THE NEW PARADIGMHIV Is Active At All Stages Of Disease

HIV Becomes Sequestered In Lymph

TissuesLymph Nodes Are Destroyed By HIV

Subsequent Escape Into PeripheralTissues

Clinical Latency Does Not Equal ViralLatency (Viral Load “Non Detectable”)

HIV PATHOGENESISVIRAL REPLICATION IN LYMPH TISSUE



• Rapid HIV Test Takes 5-30 Minutes

• EIA (Enzyme Immunoassay Takes 1-2 Weeks

– Test Is Repeated If Positive

– Western Blot Test Used To Confirm

• ***About 25 Days From Infection To Antibody Production***

TESTING FOR HIV

CDC System (Modified In 1993)

Aids-Defining Illness

CD4+ Lymphocyte Count

Viral Load

CLASSIFICATION OF HIV DISEASE,ARC, AND AIDS

• Progressive Illness

• Manage Infection

• Psychosocial Support

• Education Is Critical

– Abstinence/Safe Sex

– Occupational Exposure

– Other Risky Behaviors

MANAGEMENT OF HIV INFECTION

• Nucleoside Analogs (For Example)

– Zidovudine - AZT Retrovir

– Didanosine - DDI Videx

– Zalcitabine - DDC Hivid

• Protease Inhibitors

– Saquinavir Invirase

– Ritonavir Norvir

– Indinavir Crixivan

MANAGEMENT OF HIV INFECTION

AVAILABLE ANTI-HIV DRUGS

Combination Drug Regimens UsingAgents Targeted At Several Points In

The HIV Life Cycle Need To BeDeveloped To Prevent And Treat DrugResistant HIV Isolates; Side Effects Of

Meds Becoming More Problematic

MANAGEMENT OF HIV INFECTIONCURRENT / FUTURE CONCERNS

Oral Candidiasis Is Frequently

Observed In The HIV PatientAppearance

Importance In Staging

Management

COMMON ORAL FINDINGS

FUNGAL INFECTIONS



Hairy Leukoplakia And Herpes

Lesions Are Commonly Found InThe HIV Patient

Appearance

Management

COMMON ORAL FINDINGSVIRAL INFECTIONS

HIV Patients May Suffer From

Painful, Aggressive Oral Ulcers

Appearance

Management

Common Oral FindingsOral Ulcers

Kaposi’s Sarcoma

Appearance

Management

COMMON ORAL FINDINGS

NEOPLASMS Common Bacterial Infections Include

Linear Gingival Erythema (LGE) AndNecrotizing Ulcerative Periodontitis(NUP)

Appearance

Management

COMMON ORAL FINDINGSBACTERIAL INFECTIONS

TUBERCULOSIS (TB)

• Mycobacterium Tuberculosis

• Can Be In Lungs (85%), Brain, Spine

• Spread Through Air Droplets

– Cough, Spit, Sneeze, Laugh, Sing, Dentistry?

• Symptoms: Feeling Weak Or Sick, Weight Loss,Fever And/Or Night Sweats, Productive Cough,

Chest Pain

TB INFECTION VS.

ACTIVE CASE

• 10-15 Million Infected In US (<5%)

• About 10% Will Become Active

– HIV+ Has 40x Greater Risk Of Infection, And

100x Greater Risk Of Active Case

• 5% Will Become Active In First Year

• 2-10 Weeks After Exposure To Show A

Positive Skin Test (PPD Or Tine Test)



TB TREATMENT

• “Prophylaxis” Is INH X 6 Months

• Treatment Is With Multiple Drugs

– INH, Rifampin, Ethambutol, Pyrazinamide, Streptomycin

– Poor Compliance Leads To Multiple Drug Resistance (MDR-TB)

• Be Suspicious Of High Risk Patients

TB HIGH RISK

• High-risk Patients (CDC Definition)

– The CDC Recommends That The Following Groups Be

Screened For TB And TB Infection:

• Close Contacts (E.G., Those Sharing The Same Household)

Of Persons Known Or Suspected To Have TB;

• Persons Infected With HIV;

TB HIGH RISK

• High-risk Patients (CDC Definition) Continued:– Persons Who Inject Illicit Drugs Or Other Locally Identified High Risk

Substance Users;

– Persons Who Have Medical Risk Factors Know To Increase The Risk

Of The Disease If Infection Occurs;

– Residents And Employees Of High Risk Congregate Settings (E.G.,

Prisons, Nursing Homes, Mental Institutions

TB HIGH RISK

• High-risk patients (CDC Definition)

continued:• Healthcare workers who serve high risk clients;

• Foreign born persons recently arrived (within 5

years) from countries that have a high TB

incidence or prevalence;

• Some medically under-served, low income

populations

TB HIGH RISK

• High-risk patients (CDC Definition) continued:

– High risk racial or ethnic minority populations, as definedlocally; and

– Infants, children, and adolescents exposed to adults in high

risk categories

• Consultation may include PPD, report of chest x-ray

• No treatment until more information

WORLDWIDE

EPIDEMIOLOGY - ‘02

• About 8 Million New Cases/Year

• About 2 Million Deaths

• 1.9 Billion People Are Infected!

– Percentage Of Infection Is More Than 30%



TB MORBIDITY

UNITED STATES, 1998-2002

Year Cases Rate*

1998 18,361 6.81999 17,531 6.42000 16,377 5.82001 15,989 5.62002 15,075 5.22003 est. 14,871 5.1

*Cases per 100,000

REPORTED TB CASESUNITED STATES, 1982-2002

10000

12000

14000

16000

18000

20000

22000

24000

26000

28000

83 85 87 89 91 93 95 97 99 2001

Year

1982 1986 1990 1994 1998 2002

N o . o f C a s e s

REPORTED TB CASES

IN FLORIDA

•1997 1400 new

•1998 1304

•1999 1271

•2000 1171

•2001 1145

•2002 1086

•Highest In Dade County,

Then Broward, Palm

Beach, Orange, Tampa BayArea, Jacksonville Area

•Up To 10% MDR-TB

TB CASE RATES, UNITED

STATES, 2002

< 3.5 (year 2000 target)

3.6 -5.2

> 5.2 (national average)

D.C.

Rate: cases per 100,000

NUMBER OF TB CASES INU.S.-BORN VS. FOREIGN-BORN

PERSONSUNITED STATES, 1992-2002

0

5000

10000

15000

20000

1992 1994 1996 1998 2000 2002

U.S.-born Foreign-born

N o . o f C a s

e s

ESTIMATED HIV COINFECTION IN PERSONS

REPORTED WITH TB

UNITED STATES, 1993-2001

0

10

20

30

1993 1994 1995 1996 1997 1998 1999 2000 2001

All Ages Aged 25 - 44

% C

o i n f e

c t i o n

Note: Minimum estimates based on reported HIV-positive statusamong all TB cases in the age group. All 2001 cases from Californiahave an unknown HIV status.



OCCUPATIONAL SAFETY ANDHEALTH ADMINISTRATION

• President Nixon In 1970• To Protect Employees

• Dental Office Implications

– Universal Precautions*, Vaccination

– Infectious/Hazmat Waste

– Msds

– Sharps And Needlestick Safety

– Ergonomics (Pending)

Use Of Mouth Pieces, Etc.Use Of Disinfectants

Labeling And Signs

Inspections

Training And Education Programs

Post-exposure Follow-up

OSHA REGULATIONS

Comprehensive Medical History

Hepatitis B Vaccine

Antiseptic Mouthrinse

Antiseptic Handwash

Disposable Latex Gloves...

STANDARD PRECAUTIONSPROVEN & PRACTICAL INFECTION CONTROL MEASURES

Disposable Facemasks

Protective Eyewear

Clinic Attire

Rubber Dam

Sharps Disposal System

...STANDARD PRECAUTIONS...

Sterilizable Handpieces

Ultrasonic Cleaning

Instrument Packaging

Heat Sterilization

Monitoring

...STANDARD PRECAUTIONS...

Glutaraldehydes

Surface AsepsisWaste Disposal System

OSHA Poster

Training And Education

...STANDARD PRECAUTIONS



NEW INFORMATIONJANUARY 2004

• CDC 2003

• More Scientific Evidence

– Articles Are Referenced

– Weighted Values

• Added Hand Washing, Water Lines,

Dental Devices, Immunizations, Etc.

• Patient To HCW

• HCW To Patient

• Occupational Exposure

OCCUPATIONAL RISK

OCCUPATIONAL

EXPOSURE

• Exposure Is A Needlestick Or Cut With A ContaminatedSharp Object

• Splash Of Blood Or Body Fluids Into Eyes, Nose, Mouth

• Blood, Body Fluids (Cerebrospinal, Synovial, Pleural,

Peritoneal, Pericardial, Amniotic, Vaginal), Semen **NotSaliva**

Comparison of HIV exposure to Hepatitis B/C exposure* - Risk from single needlestick:

HBV 6% to 30%

HIV 0.04%

HCV 1.8%

* Without HB vaccination.

OCCUPATIONAL RISK

As Of 12/31/2001, The CDC Reported:

23,951 HCWs With HIV/AIDS

57 Documented Occupational Exposures To HIV

138 Cases Under Investigation AsPossible Occupational Exposures

OCCUPATIONAL RISK

Occupation

Physician

Surgeon

Nurse

Dental worker

Paramedic

Technician

# with AIDS

1,760

119

5,211

486

463

3,086

HIV IN HEALTH CARE

CDC - THROUGH 12/31/01



19 Laboratory Workers

24 Nurses / 6 Physicians (No Surg.)

2 Surgical Techs / 1 Dialysis Tech /1 Respiratory Therapist / 1 HealthAide 2 Housekeepers / 0 Dental!

26 Have Developed Aids

OCCUPATIONAL RISK57 OCCUPATIONAL EXPOSURES TO HIV:

48 Had Percutaneous Exposure

5 Had Mucocutaneous Exposure

2 Had Both Percutaneous AndMucocutaneous Exposure

2 Had An Unknown Route OfExposure

OCCUPATIONAL RISK

57 OCCUPATIONAL EXPOSURES TO HIV:

Determine Extent Of Exposure

Determine Need PostexposureProphylaxis (PEP) / Follow-up

ZDV Plus 3TC ± IDV

Prophylaxis Is For 4 Weeks

* Mmwr 45(22):468-72, 1996

OCCUPATIONAL RISKHIV POST-EXPOSURE PROTOCOL*

HEPATITIS POST-

EXPOSURE

• Hepatitis B Immune Globulin In

Non-Vaccinated Individuals

– Start Heptavax Series At The Same

Time

• No Options For Hep C

NSU POST-EXPOSURE

PRINCIPLES

• Immediately!

– Wash Needlesticks And Cuts With SoapAnd Copius Amounts Of Water

– Flush Splashes To Nose, Mouth, Or SkinWith Water

– Irrigate The Eyes With Clean Water,Saline, Or Sterile Irrigant

NSU CDM

• Also:

– Report Exposure To Supervisor (May Only Be AnInjury, Not Exposure)

– Complete Appropriate Paperwork

– Go To COM Medical Clinic Or Westside Regional

Hospital ER As Needed

• Counseling For Rx, Other Follow-up



PRIVATE PRACTICE

• Owner Responsible For Staff – Ethics, Confidentiality

– Training

– Vaccinations

– PPE, MSDS, Waste

– Record Keeping

• OSHA Inspections

ADA Council On Ethics, Bylaws AndJudicial Affairs

Precedents

Americans With Disabilities Act (AWDA)

State Laws Differ

Defer Vs. Deny

MORAL, ETHICAL & LEGAL ISSUES

CONFIDENTIALITYISSUES

• Public Health Issues Vary By State

TB

HIV

• Conduct Of Office Staff

Referrals

Paperwork

Training!

EMPLOYEES…

• Clean Wound Immediately AND

– Report Exposure To Infection Control

Officer/Dentist

– Go To Medical Center Or Hospital ER

As Needed…

• Counseling For Rx, Other Follow-up

EMPLOYEES…

• Pre-HIV Test Counseling

• Post-Exposure Evaluation– HIV

– Hepatitis

– Choice Of Meds

(If Employee Declines Post-ExposureEvaluation, Must Sign Waiver)

QUESTIONS???

HIV and Sexually Transmitted Diseases

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