eMedicine Specialties > Emergency Medicine > Infectious Diseases

Body Fluid Exposures

Darrell Looney, MD, Attending Physician, Associate Professor of Emergency Medicine, Department of Emergency Medicine, Long Island College Hospital
Peter B Richman, MD, Consulting Staff, Department of Emergency Medicine, Morristown Memorial Hospital; Richard Shih, MD, Program Director, Department of Emergency Medicine, Morristown Memorial Hospital; Director of Toxicology Fellowship, New Jersey Poison Center, Newark Beth Israel Medical Center

Updated: Jul 2, 2007

Introduction

Background

Occupational transmission of blood-borne infections may occur through parenteral, mucous membrane, and nonintact skin exposure. The greatest risk for transdermal transmission is via a skin penetration injury sustained with a sharp hollow-bore needle that was recently removed from a blood-contaminated source. Although many infections may be transmitted by such contact, the most consequential are hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). In addition, skin and soft tissue infection at the site of inoculation through introduction of staphylococcal species is an issue of concern and must not be neglected. Tetanus prophylaxis is also an important issue of concern. Another important concept is the fact that many clinical pathways adopt plans for management primarily of health care personnel but are woefully lacking when faced with the outside individual at risk for significant exposure.

Pathophysiology

When intact, the integumentary system serves as an effective physical barrier to the entry of infectious elements into the body. However, a special situation exists in terms of mucous membranes. Across these membranes, lies a layer of mucus secreted by specialized columnar cells that are closely associated with each other through gap junctions, which are little more than specialized cell surface projections that allow intercellular communication. The presence of a moist mucous layer tends to prolong the viability of fragile viruses, such as HIV and HBV, which cannot survive long in drier environments. However, HBV has been demonstrated to survive in dried blood for extended periods.

Higher vascularity coupled with a relatively permeable cellular layer gives rise to a presumed heightened risk of transmission of HBV, HCV, and HIV across this organ system and into the bloodstream. Still, at least for occupational HIV exposures, transmission rarely occurs. Intact, keratinized skin does not possess these characteristics and is virtually impermeable unless disrupted. Viral transmission here is not readily possible, hence the association with transmission caused by needlestick injury or (less frequently) through open wounds.

In terms of blood and body fluids, semen and vaginal secretions with visible blood should be considered potentially infectious vehicles. Similarly, cerebrospinal fluid, amniotic fluid, pleural fluid, synovial fluid, and peritoneal and pericardial fluids carry a high suspicion of risk for transmission. In addition, unless blood is present, saliva, sputum, sweat, tears, feces, nasal secretions, urine, and vomitus carry a low risk of transmission of HBV, HCV, and HIV.

Frequency

United States

Sharps injuries occur at a rate of 1.8 per year per physician and 0.98 per year per nurse, while working on the same medical ward. Statistically, twice as many nurses as doctors have been reported with occupationally acquired HIV infection. Whether this is a functionality of the significance of the exposure (ie, severity of the stick) or the route of exposure remains to be studied. If the inoculum were blood and positive for both hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg), the risk for developing clinical hepatitis due to HBV infection may lie somewhere between 22% and 31%. The risk for developing HIV remains around 0.3%.

Mortality/Morbidity

• Health care workers who have a significant exposure (ie, inoculation with an open-bore needle from a source known to have active HBV disease) to HBV but have not previously received hepatitis B vaccine and do not receive postexposure prophylaxis have a 6-30% risk of becoming infected.
• The risk of HCV transmission from a known HCV-positive source by a sharps injury is 2-7%. The vast majority of individuals who develop HCV infection progress to become long-term carriers of the virus, and about two thirds have elevated liver enzyme levels.
• The rate of HIV transmission from a known infected individual via a sharps injury is 0.3%. The rate is higher if the injury was sustained by a hollow-bore needle, if the injury was deeply penetrating, or if blood was injected during injury. Risk to the injured health care worker is greater if the source patient has a high HIV viral load and/or lower CD4 count.

Clinical

History

Patients present with a history of exposure. Typically, this is a splash-type exposure to mucosal or nonintact skin or a needle-stick injury to intact skin. Patients may often report exposures to intact keratinized skin out of uninformed concern or they are aware of some preexisting injury and may be predisposed to infection. Reassurance through awareness of the risks for viral transmission in various scenarios is of significant importance to both the health care provider and the patient.

• Health care personnel includes employees, volunteers, attending clinicians, students, contractors, and any public safety workers whose activities involve contact with patients and their environment such that exposure to blood or other body fluids can occur.
• Non–health care personnel may also be exposed by way of social interaction, sexual encounters, trauma scenarios, or intentional inoculations consistent with contemporary terrorist activity. Note that any postexposure program that does not provide for management and follow-up of nonhospital personnel is woefully inadequate for the needs of a given community.

Physical

During the physical examination, be sure to assess body area of exposure and depth of any wounds. The neurovascular status in the setting of extremity wounds is an important and often omitted element. The clinician should remain suspicious of occult injury, such as paper cuts or abrasions, which may threaten the integrity of the skin. For mucosal exposures, especially on the face, keep in mind that the exposure may not be limited to only one area, and it may occur simultaneously in nasal, mucosal, and conjunctival mucosae.

Causes

Most exposures are the result of a departure from universal precautions on some level—whether it is the result of recapping, failure to use personal protective equipment, or the unintentional sharp left in an inappropriate container for disposal. When dealing with blood and body fluid exposures, document whether the exposure represents a departure from universal precautions, Occupational Safety and Health Administration (OSHA) standards, or a true accident (eg, projectile vomiting, precipitous labor with spontaneous rupture of membranes). This information is vital to the institutional safety committee whose function is to monitor the safety of the environment for the entire facility and make recommendations for upgrades and changes in policy.

Differential Diagnoses

Hepatitis
HIV Infection and AIDS
Sexual Assault
Workers' Compensation

Other Problems to Be Considered

OSHA regulations
Safety issues

Workup

Laboratory Studies

• Testing for HBV, HCV, and HIV is recommended at the time of injury. This is useful, primarily as baseline evaluation, because patients would not have undergone seroconversion in such a short time frame. Testing to determine the HBV, HCV, and HIV infectious status of the source patient is recommended only if the source individual consents. Under no circumstances should a source patient be tested in the absence of consent because of the obliged consultation and treatment constraints should the result return positive. In many institutions, using surrogate consent is acceptable in cases in which patients cannot consent to the evaluation themselves. This may involve family members, legal guardians, or 2 consenting attending physicians. Regardless, a cogent plan of action and response is necessary should the result be affirmative.
• Many clinicians obtain routine laboratory evaluations, such as a complete blood cell count and chemistries, which likely are not of much value acutely. However, sending rapid plasma reagent (RPR) and human chorionic gonadotropin (if pregnancy status is unknown) would be prudent because their prognostic value can be reasonably high in these cases.

Imaging Studies

• Acutely, imaging studies are of little use unless the presence of a foreign body or radiopaque material is suspected.

Procedures

• The single most pertinent procedure to undertake in the patient after exposure is lavage. Copious amounts of irrigation fluid are appropriate in cases of mucosal exposure (ocular and oral), as well as soap and water washing in cases of needlestick injury. Although no regimen has been shown to affect viral transmission rates, this is an empiric regimen aimed at decreasing the level of exposure to the viral agent and, thereby, decreasing the associated risk of transmission.

Treatment

Prehospital Care

The single most useful element here is the limitation of exposure and immediate cleaning of the area exposed. Copious amounts of soap and water are appropriate. Many health care workers use rapid sanitation solutions, but while theoretically applicable, no documentation supports any benefit in this scenario.

Emergency Department Care

The treating clinician should obtain and assess potential risk factor information concerning the source patient (he or she must also be mindful of any risks to the source patient on the behalf of the treating clinician). Detailed information regarding the volume of blood/body fluid transmission, duration, and extent of the exposure is also important. In addition, if the source patient is known to be HIV positive, a history of which antiretroviral medications are being used (as well as the patient's response to therapy, including CD4 counts and viral load data if known) should be obtained, as this directly impacts the therapy chosen for prophylaxis of the exposed individual. If a "significant" or highly suspicious exposure did occur and the source patient is potentially (or definitively) infected with HIV or HBV, then prophylaxis is to be offered and risk-versus-benefit counseling undertaken.

• Wound management
• • Copiously irrigate wounds with antiseptic soap.
  • Copiously irrigate exposed mucous membranes with saline (3-6 L is a good start).
     
• Tetanus prophylaxis: Administer when immunization status is not up-to-date.
• Counseling
• • Patients should receive immediate counseling about the risk of their exposure to infectious agents and the indications for antiviral prophylaxis. Pregnancy should not preclude the use of optimal regimens, and postexposure prophylaxis should not be denied to an individual solely on the basis of pregnancy. Issues that must be discussed include HIV transmission to the fetus, the effects of the medications on the development of the fetus (the first trimester posing the maximal risk of teratogenesis), and the potential risk of fetal loss. Consultation with an infectious disease specialist should be sought.
  • Patients should be referred to the appropriate and reliable site for outpatient counseling and long-term testing for seroconversion.
• HIV prophylaxis
• • Generally, most emergency departments only stock a limited supply of these (currently) very expensive medications. In light of this, an appropriate supply of medication is often provided to allow the patient to follow up with the Occupational Health Service on the next available business day, or in the case of the weekend or frequent weekend/holiday exposures, a supply to cover 3-5 days.
  • Consider one of the following regimens (if the source is known to have HIV, an alternate regimen may be required):
  • • Combivir 1 tab (300 mg) PO bid and nelfinavir 750 mg PO tid
    • Combivir 1 tab (300 mg) PO bid and indinavir 800 mg PO q8h
       
• Hepatitis B prophylaxis: Provide hepatitis B immunoglobulin (HBIG) and HBV vaccine if indicated as per vaccination and immunity status.
• Hepatitis C prophylaxis: No effective Food and Drug Administration (FDA) – approved treatment currently exists for hepatitis C. Management is expectant, with close follow-up as appropriate.

Consultations

• Referral to an infectious disease specialist may be warranted, especially in cases where pregnancy is suspected or confirmed. In addition, HIV-positive sources require further consideration for a specialized regimen for prophylaxis of exposed individuals because of demonstrated insensitivity of HIV to some agents over time.
• Several resources have recently been made available. Health care providers are encouraged to use consultation services such as the National Clinician's Postexposure Prophylaxis Help Line, which is available 24 hours per day and provides advice regarding management of blood and body fluid exposures, including risk assessment, choice of postexposure prophylaxis medications, and assistance with difficult-to-manage scenarios (eg, pregnancy). They can be contacted toll free at (888) 448-4911. In addition, clinicians with on-site Internet access may use an ever-growing number of online resources.
  
  
  • American Nurses Association
  • NIOSH Alert: Preventing Needlestick Injuries in Health Care Settings
  • National Alliance for the Primary Prevention of Sharps Injuries
  • Needlestick.org

Medication

A tetanus toxoid should be administered intramuscularly. Health care workers who sustain a significant exposure to HBV and have not been immunized should receive passive immunization with HBIG.

Information on HIV prophylaxis is as follows:

• Standard exposure (presence of identified risk factor* for occupational exposure) - Zidovudine 600 mg/d in divided doses plus lamivudine 150 mg bid for 4 wk
• High-risk exposure (presence of 2 or more risk factors* for occupational exposure) - Zidovudine plus lamivudine as above, plus indinavir 800 mg q8h or nelfinavir 750 mg q8h for 4 wk
• Pediatric dosing
  
  
  • Zidovudine 180 mg/m²/dose bid (max 600 mg/d)
  • Lamivudine (3TC) 4 mg/kg/dose bid (max 300 mg/d)
  • Nelfinavir (Viracept) 50-55 mg/kg/dose bid (max 2500 mg/d)
  *Risk factors include (1) deep injury, (2) presence of visible blood on the instrument causing the exposure, (3) injury with a device that was placed in the vein or the artery of the source patient, or (4) terminal illness in the source patient.

Nucleoside reverse transcriptase inhibitors

These agents inhibit reverse transcriptase and cause chain termination when incorporated into a growing viral strand.

Zidovudine (AZT, ZDV, Retrovir)

Thymidine analog that inhibits viral replication.

Dosing

Adult

200 mg PO tid
1-2 mg/kg/dose IV q4h

Pediatric

90-180 mg/m²/dose PO q6h
1-2 mg/kg/dose IV q4h

Usually, now the AZT 180 mg/m²/dose, given bid (max 600 mg/d)

Body surface area calculation

Usually confusing to most physicians; 5 equations are used currently, although the Mostellar equation is most often recommended.

The Mosteller formula

BSA (m²) = ([Height(cm) X Weight(kg)]/3600)^½

For example, BSA = SQRT[(cm*kg)/3600]

In inches and pounds: BSA (m²) = ([Height(in) X Weight(lb)]/3131)^½

The DuBois and DuBois formula

BSA (m²) = 0.20247 X Height(m)^0.725 X Weight(kg)^0.425

A variation of DuBois and DuBois that gives virtually identical results: BSA (m²) = 0.007184 X Height(cm)^0.725 X Weight(kg)^0.425

The Haycock formula

BSA (m²) = 0.024265 X Height(cm)^0.3964 X Weight(kg)^0.5378

The Gehan and George formula

BSA (m²) = 0.0235 X Height(cm)^0.42246 X Weight(kg)^0.51456

The Boyd formula

BSA (m²) = 0.0003207 X Height(cm)^0.3 X Weight(grams)^{[0.7285 - ( 0.0188 X LOG(grams))]}

For more information on BSA calculation, see Standardization of Body Surface Area Calculations.

Interactions

Acetaminophen may decrease bioavailability of zidovudine; zidovudine toxicity increases when administered concurrently with amphotericin B, flucytosine, doxorubicin (Adriamycin), vincristine, vinblastine, cimetidine, indomethacin, probenecid, lorazepam, aspirin, acyclovir, ganciclovir, dapsone, and pentamidine

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution in impaired hepatic or renal function; reduce or stop therapy in hematologic disorders such as thrombocytopenia, granulocytopenia, and severe anemia

Lamivudine (3TC, Epivir)

Thymidine analog that inhibits viral replication.

Dosing

Adult

150 mg PO bid

Pediatric

4 mg/kg PO bid

Interactions

Trimethoprim/sulfamethoxazole increases bioavailability of lamivudine; lamivudine increases concentration of zidovudine when administered concurrently

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Primary toxicities and/or adverse effects include headache, abdominal pain, diarrhea, and pancreatitis (rare); toxicity of zidovudine and 3TC when used in combination is approximately equal to that of zidovudine alone; adjust dose in renal impairment; caution in children with history of pancreatitis

Protease inhibitors (PI)

These agents block modification of precursor poly proteins responsible for the synthesis of reverse transcriptase and HIV-1 protease.

Indinavir (IDV, Crixivan)

Prevents formation of protein precursors necessary for HIV infection of uninfected cells and viral replication.

Dosing

Adult

800 mg PO q8h on empty stomach

Pediatric

Not established

Interactions

Indinavir increases blood concentrations of astemizole (recalled from US market), cisapride, midazolam, isoniazid, stavudine, trimethoprim, terfenadine (recalled from US market), triazolam, and PO contraceptives; fluconazole and rifampin decrease blood concentration of indinavir; quinidine and ketoconazole increase blood concentrations of indinavir; indinavir decreases blood concentration of lamivudine

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution in hepatic impairment; primary toxicities and/or adverse effects include nephrolithiasis, crystalluria, hematuria, nausea, headache, indirect hyperbilirubinemia, elevated LFT results, and hyperglycemia/diabetes mellitus; caution in hepatic impairment

Nelfinavir (Viracept)

Inhibits HIV-1 protease, resulting in production of an immature and noninfectious virus.

Dosing

Adult

750 mg PO tid ac

Pediatric

<2 years: Not established
2-12 years: 20-30 mg/kg PO tid ac
>12 years: Administer as in adults

Interactions

Nelfinavir increases blood concentrations of astemizole (recalled from US market), cisapride, midazolam, isoniazid, stavudine, trimethoprim, terfenadine (recalled from US market), triazolam, and PO contraceptives; fluconazole and rifampin decrease blood concentrations of nelfinavir; quinidine and ketoconazole increase nelfinavir blood concentrations; nelfinavir decreases lamivudine blood concentrations

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

If PO contraception desired, should use alternative or additional contraceptive measures while taking nelfinavir as opposed to standard oral contraceptive therapy
Primary toxicities and/or adverse effects include diarrhea and hyperglycemia/diabetes mellitus due to effects on pancreas; caution in hepatic impairment

Immunoglobulins

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin (Hyper-Tet).

Tetanus immune globulins (Hyper-Tet)

Used for passive immunization of any person with a wound that might be contaminated with tetanus spores.
See Tetanus Immunoglobulin Drug Data Sheet.

Dosing

Adult

Currently, only tetanus immunoglobulin for IM use is available from BPL (020 8258 2200 - 24 hours); no product suitable for IV use will be available in foreseeable future
Prophylaxis IM for tetanus prone wounds (licensed): 250 U for most uses (500 U if more than 24 h have elapsed or there is risk of heavy contamination or following burns)
Available in 1-mL ampules containing 250 U

Pediatric

Prophylaxis: 250 U IM in opposite extremity as tetanus toxoid
Clinical tetanus: 3,000-10,000 U IM

Interactions

None reported

Contraindications

Administration within 3 mo of live-virus immune globulin because antibodies in globulin preparation may interfere with immune response to vaccination (may be necessary to revaccinate persons who received immune globulin shortly after live-virus vaccination)

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Persons with isolated immunoglobulin A (IgA) deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing because ID injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing the medication to be withheld from a patient not allergic to this material; true allergic responses to human gamma globulin administered in prescribed IM manner are extremely rare; do not admix with other medications because usually incompatible

Toxoids

These agents are used for tetanus immunization. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Tetanus toxoid

Induce active immunity against tetanus in selected patients. Tetanus and diphtheria toxoids are immunizing agents of choice for most adults and children (>7 y). Necessary to administer booster doses to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen–containing product.
May be administered into deltoid or midlateral thigh muscles of children and adults. In infants, preferred site of administration is mid thigh laterally.

Dosing

Adult

Primary immunization: 0.5 mL IM; administer 2 injections 4-8 wk apart and a third dose 6-12 mo after second injection
Booster dose: 0.5 mL q10y

Pediatric

Administer as in adults

Interactions

Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization because of poor immune response; cimetidine may enhance or augment delayed-type hypersensitivity responses to skin test antigens; avoid concurrent use of medication with systemic chloramphenicol because it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude its concurrent use)

Contraindications

Documented hypersensitivity; history of any type of neurologic symptoms or signs following administration of this product; immunization during poliomyelitis outbreak (FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis)

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Do not use to treat actual tetanus infections or for immediate prophylaxis of unimmunized individuals (instead use tetanus antitoxin, preferably human tetanus immune globulin); diminished antibody response to active immunization may be observed in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended

Follow-up

Further Inpatient Care

• If the source patient is positive for HBV, HCV, and/or HIV, repeatedly test the exposed caregiver at timed intervals of 0, 3 months, and 6 months. This requires close and reliable follow-up mechanisms, such as Occupational Health Services or primary care physicians.

Deterrence/Prevention

• OSHA standards are to be encouraged and reinforced by all hospital employees consistently because prevention is the single best weapon against blood/body fluid exposures.
• The following universal precautions should be followed in all patient contact situations:
• • Wash hands between care of each patient.
  • Use gloves when handling body fluids or performing procedures where exposure is possible, including contact with mucous membranes.
  • Use protective gowns, eyewear, and masks during procedures when risk of splash or spray of body fluids exists.
  • Never recap needles. If recapping is necessary, the cap should not be held by hand, rather lay the cap on a firm surface and insert the needle. Then, the entire system is lifted, and the cap is secured in place.
• OSHA requirements are now moving toward needleless and needlestick prevention systems as basic requirements in health care facilities. Institutions must evaluate these systems and employ those that function best within their departments.
• Wearing gloves may reduce (>50%) the volume of blood introduced through the injury.

Complications

• Infection is still a significant concern at any given exposure, especially those involving disruption of the normal integumentary barrier. Antibiotic prophylaxis should be considered.

Prognosis

• Prognosis is associated with risk of infection and its sequelae. This is difficult to specify in any given patient. However, given the risk of HIV transmission of less than 1%, the prognosis of any given exposed patient may be listed as good but may only remain so with vigilant follow-up and consistent use of prophylaxis against infection.

Patient Education

• For excellent patient education resources, visit eMedicine's Public Health Center and Sexually Transmitted Diseases Center. Also, see eMedicine's patient education articles Hepatitis B, Hepatitis C, and HIV/AIDS.

Miscellaneous

Medicolegal Pitfalls

• Failure to provide appropriate counseling and HBV/HIV prophylaxis when indicated could leave the ED physician vulnerable to adverse liability if the injured patient seroconverts. This is of paramount importance, not just medicolegally, but also in terms of the overall management of the blood/body fluid exposed individual. These efforts serve to "close the loop" in the quest to eliminate preventable occurrences. Still, one of the greatest difficulties remains in "making the call" as to whether an exposure warrants prophylaxis or not. While leaving the decision up to the patient will result in a higher than necessary rate of medication dispensing, until methods of HIV detection and management can provide both more timely and greater levels of reassurance, this will likely remain the course most practitioners will take.

Multimedia

Media file 1: Flowsheet for management of blood/body fluid exposures.

References

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5. CDC. Public Health Service guidelines for the management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis. Centers for Disease Control and Prevention. MMWR Recomm Rep. May 15 1998;47(RR-7):1-33. [Medline].

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9. Marcus R. Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus. N Engl J Med. Oct 27 1988;319(17):1118-23. [Medline].

10. Mast ST, Woolwine JD, Gerberding JL. Efficacy of gloves in reducing blood volumes transferred during simulated needlestick injury. J Infect Dis. Dec 1993;168(6):1589-92. [Medline].

11. Mauskopf JA, Bradley CJ, French MT. Benefit-cost analysis of hepatitis B vaccine programs for occupationally exposed workers. J Occup Med. Jun 1991;33(6):691-8. [Medline].

12. Merchant RC, Becker BM, Mayer KH, et al. Emergency department blood or body fluid exposure evaluations and HIV postexposure prophylaxis usage. Acad Emerg Med. Dec 2003;10(12):1345-53. [Medline].

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14. Stewardson DA, Burke FJ, Elkhazindar MM, et al. The incidence of occupational exposures among students in four UK dental schools. Int Dent J. Feb 2004;54(1):26-32. [Medline].

15. Vu T. Standardization of Body Surface Area Calculations. halls.md. Available at http://www.halls.md/bsa/bsaVuReport.htm.

Keywords

needle sticks, needlestick, needlestick injury, body fluid exposures, splash exposures, mucous membrane exposures, sharps injury, hepatitis B virus, HBV, hepatitis C virus, HCV, human immunodeficiency virus, HIV

Contributor Information and Disclosures

Author

Darrell Looney, MD, Attending Physician, Associate Professor of Emergency Medicine, Department of Emergency Medicine, Long Island College Hospital
Darrell Looney, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and National Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Peter B Richman, MD, Consulting Staff, Department of Emergency Medicine, Morristown Memorial Hospital
Peter B Richman, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Richard Shih, MD, Program Director, Department of Emergency Medicine, Morristown Memorial Hospital; Director of Toxicology Fellowship, New Jersey Poison Center, Newark Beth Israel Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Samuel M Keim, MD, Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine
Samuel M Keim, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Barry J Sheridan, DO, Chief, Department of Emergency Medical Services, Brooke Army Medical Center
Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School
John Halamka, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

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