A 30-year-old nurse comes to the occupational health clinic for evaluation. He accidentally pricked his finger with a needle after drawing blood from a woman with a known history of intravenous drug abuse. The nurse has no significant medical history and takes no medications. According to his employment record, he received a series of 3 vaccinations for hepatitis B when first employed 5 years ago, tetanus immunization 2 years ago, and a yearly influenza vaccination. However, a postimmunization titer for hepatitis B was never checked. Today, the titer is found to be 5 mIU/mL (10 mIU/mL is considered protective). The source patient is currently in the hospital for treatment of endocarditis. Laboratory testing of the source patient sent on the day of exposure shows the following results: What is the most appropriate strategy to prevent infection in this health care worker?

Question

A 30-year-old nurse comes to the occupational health clinic for evaluation.  He accidentally pricked his finger with a needle after drawing blood from a woman with a known history of intravenous drug abuse.  The nurse has no significant medical history and takes no medications.  According to his employment record, he received a series of 3 vaccinations for hepatitis B when first employed 5 years ago, tetanus immunization 2 years ago, and a yearly influenza vaccination.  However, a postimmunization titer for hepatitis B was never checked.  Today, the titer is found to be 5 mIU/mL (>10 mIU/mL is considered protective).  The source patient is currently in the hospital for treatment of endocarditis.  Laboratory testing of the source patient sent on the day of exposure shows the following results:  What is the most appropriate strategy to prevent infection in this health care worker?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf9a_1852_8f63_2d8617dfd477_MD0005_00 The source patient tested positive for hepatitis B surface antigen (HBsAg), indicating active infection with the hepatitis B virus (HBV). HBV has a high transmission rate with percutaneous exposure, which varies depending on the source patient's HBsAg and hepatitis B e antigen (HBeAg) status. Source patients positive for both HBsAg and HBeAg have transmission rates of 40%-60%; those with only HBsAg positivity have reduced transmission rates of 20%-40%. As a result, all health care workers (HCWs) are required to be offered hepatitis B vaccination by their employer. Immune response (ie, hepatitis surface antibody >10 mIU/mL) should be documented 1-2 months after the last vaccine dose. HCWs who do not respond to the first series of injections should be revaccinated. HCWs with an adequate response to the vaccine (initial hepatitis surface antibody [HBsAb] titer of >10 mIU/mL) are not at risk of contracting the virus and do not require post-exposure prophylaxis even if subsequent antibody titers fall below the threshold for immunity. Post-exposure prophylaxis for exposed nonimmune HCWs (unvaccinated or incomplete response to initial vaccination series) involves immediate simultaneous administration of both hepatitis B immunoglobulin (HBIG) and HBV vaccine (at different sites). The HCW should then receive the remaining 2 series of HBV vaccine according to the routine schedule. (Choices B and E) Antiviral therapy is standard post-exposure prophylaxis for HIV, but similar therapy (eg, tenofovir disoproxil fumarate, entecavir) does not have a role in the management of HBV exposure. (Choice C) In this patient, revaccination alone is insufficient due to the delayed development of neutralizing antibodies. HBIG is needed to obtain immediate antibody activity. (Choice D) HBsAg is the principle serologic marker for chronic HBV and is sufficient to make the diagnosis in the source patient. Treatment with HBIG and revaccination are necessary because the HCW does not have a history of a satisfactory antibody response after one vaccine series and is potentially susceptible to infection. Educational objective: Post-exposure prophylaxis consisting of hepatitis B immunoglobulin and hepatitis B vaccination should be given to people who have been exposed to hepatitis B virus and either have not been previously vaccinated or did not mount a satisfactory antibody response to the vaccine. References: CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. (http://www.ncbi.nlm.nih.gov/pubmed/24352112) Postexposure prophylaxis for common infectious diseases. (http://www.ncbi.nlm.nih.gov/pubmed/23939603)

A 30-Year-Old Nurse Comes to the Occupational Health Clinic for Evaluation