HIV, Hepatitis B, Hepatitis C Exposure Added to Risks that Police Face Daily

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When four St. Paul Minneapolis officers pursued a suspect in a chase in September 2009, the pursuit ended with apprehension of their suspect with their K-9 taking down the suspect with a dog bite that caused a lot of bleeding.

Later it was learned that the suspect was HIV positive. One of the police officers had a previous open wound already, so he was considered at potential risk for HIV infection. He was counseled and placed on a 28-day medication regimen, known as PEP or Post-Exposure Prophylaxis to prevent a potential HIV infection. A course of antiretroviral drugs which reduces the risk of seroconversion of an HIV negative person after events with high risk of exposure to HIV. To be most effective, treatment should begin within an hour of exposure, and after 72 hours post-exposure PEP is much less effective, and may not be effective at all.

The three other police officers were evaluated, and it was determined that they didn’t have to undergo PEP treatment.

Police officers — like medical personnel — are evaluated and/or treated the same after all exposure to potential blood-borne pathogens, including HIV and Hepatitis B and C. Police can be exposed to a wide variety blood-borne pathogens at crime scenes. They can also be exposed to contaminated needles at scenes where they are called to administer naloxone as an emergency antidote for heroin and other opioid overdoses.

However, compared to medical personnel, police (and paramedics, too) have little time to protect themselves from exposure, and they may be present at a scene with broken glass, blood-stained weapons, hypodermic needles or scenes with a variety and higher volume of blood, body fluids and feces. The scene may be in the dark, and police may only have a flashlight to use to determine whether fluids contain blood, and potential blood-borne pathogens. Furthermore, they may come across scenes where there is blood and other bodily fluids, matter, etc., but no victim or offender available for testing. There may be no offender in custody or victim on scene to test for the presence of HIV or Hepatitis B or Hepatitis C. Many non-blood fluids and other matter could be difficult to assess whether there is blood in the mix at a dark crime scene. There really could be a lot of different fluids and matter at a crime scene — cerebrospinal fluid, urine, feces, vomit, and tissue. Blood is the most high-risk for carrying the concentration of virus that could be infectious. And blood in the mix with any other fluids or matter makes that fluid or matter higher risk.

HIV doesn’t survive long when blood and body fluids are drying. The common understanding is that HIV becomes inactivated soon, and inactivated once it hits air. But if a police officer or healthcare worker is exposed to an HIV-laden blood sample or solution in the environment, how soon is soon? This becomes a concern and a source of anxiety. The only commonly cited study of HIV viability in the environment involves an experiment conducted in a laboratory. The study involved a non-clinical volume of HIV in a highly concentrated viral preparation — a level well above what would be detected in a human exposure. Experts say the results of this study can’t be directly applied to clinical HIV exposures. However, the study does offer a benchmark. In the study of the highly concentrated viral preparation, instead of all the viral preparation being inactivated immediately while outside a human body, an infectious dose could be recovered for more than a week from an aqueous environment held at room temperature (23 to 27 degrees C). When the highly-concentrated HIV viral preparation was dried and held at room temperature, HIV retained infectivity for more than three days. Fortunately, historically very few HIV infections are reported from occupational healthcare settings, but any infection is one too many. Furthermore, the study does create concern, and serves as motivation for personal protection (gloves, goggles, and sharps avoidance) when there may be a high volume of potentially infected or seropositive blood or blood-contaminated fluid or matter at a fresh crime scene. And remember there may be other more viable pathogens also present in blood, body fluids and matter.

In many cases, once exposed, police are encouraged to have a doctor evaluate them, offer counseling, follow up with testing; and possibly offer the 4-week antiviral treatment to err on the safe side. But remember the clock is ticking following an exposure … to be most effective, treatment should begin within an hour of exposure, and after 72 hours post-exposure, PEP is much less effective, and may not be effective at all. That means decision-making must happen fast.

Sexual assault or rape victims, with an offender at large with unknown HIV-status, may also undergo PEP treatment depending on the circumstances. Certain sexual activities (including comparison to occupational exposure) are considered the highest risk for HIV infection and seroconversion, but even a single per-act consensual sex act is only 0.1-0.2% risk for vaginal intercouse and 0.5-3% for receptive rectal intercourse, according to the Centers for Disease Control and Prevention (CDC).

Postexposure prophylaxis (PEP) with a 28-day course of zidovudine was associated with an 81% reduction in risk for acquiring HIV in a study of health-care workers who had percutaneous (needlestick) exposures to HIV-infected blood, according to a report in Infection Control & Hospital Epidemiology. On the basis of these results and results from animal studies, PEP has been recommended for health-care workers who have occupational exposures to HIV, according to the CDC. These findings have been extrapolated to nonoccupational injection (drug abuse exposures) and sexual HIV exposures, including sexual assault. The possibility of HIV exposure from the assault should be assessed at the initial examination. Survivors determined to be at risk for HIV should be informed about the possible benefit of nonoccupational postexposure prophylaxis (nPEP) in preventing HIV infection. Again, initiation of nPEP as soon as possible after the exposure increases the likelihood of prophylactic benefit.

SOURCES: HIV — one more on -the-job risk cops face daily

Resnick L, Veren K, Salahuddin SZ, Tondreau S, Markham PD. Stability and inactivation of HTLV-III/LAV under clinical and laboratory environments. JAMA. 1986 Apr 11;255(14):1887-91.

Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol 2013;34:875–92.

CDC Sexual Assault and Abuse and STDs

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