click here to download MS Word format

UNIVERSITY POLICY

The purpose of this policy is to outline the procedure under which postexposure prophylaxis will be made available to the University’s health-care personnel, including students, housestaff, faculty, staff and postdoctoral appointees who in the course of their studies and/or occupational activities are exposed to blood, tissue or other body or laboratory fluids that may contain human immunodeficiency virus (HIV), hepatitis B virus (HBV) and/or hepatitis C virus (HCV). This policy is based upon the available scientific data and Public Health Service recommendations for postexposure management of health-care personnel who have occupational exposure that may place them at risk of acquiring HIV, HBV and/or HCV.

II.       ACCOUNTABILITY

Under the direction of the President, the Executive Vice President for Academic and Clinical Affairs , and the Presidents/CEOs of the Healthcare Units shall ensure compliance with this policy. The Deans, Vice Presidents, Director of Risk and Claims Management , Director of Environmental and Occupational Health and Safety Services (EOHSS), Directors of Student Health Services, and Directors of Occupational Medicine Services shall implement this policy.

III.      REFERENCES

1.        Centers for Disease Control and Prevention, Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis. MMWR 2005;54(RR-9).

2.        Centers for Disease Control and Prevention, Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV and HIV and Recommendations for Postexposure Prophylaxis. MMWR 2001;50(RR11).

3.        Student Immunizations & Health Requirements            00-01-25-40:00

4.        Housestaff Immunizations and Health Requirements     00-01-40-45:00

5.        Bloodborne Pathogens                                                00-01-45-50:00

6.        HIV, HBV and HCV                                                  00-01-45-52:00

IV.      POLICY

1.       Avoiding occupational/educational exposures is the primary way to prevent transmission of HIV, HBV and HCV in health-care settings . However, hepatitis B immunization and postexposure management are integral components of a complete program to prevent infection following bloodborne pathogen exposure and are important elements of workplace safety.

2.       In an attempt to prevent HIV, HBV and/or HCV infection due to occupational/educational exposures, UMDNJ shall make postexposure prophylaxis available at no expense to the students, housestaff, faculty, staff and postdoctoral fellows of the University who have exposures in the course of their educational and/or professional activities at the University’s facilities or affiliated institutions which may place them at risk of acquiring HIV, HBV and/or HCV infection.

3.      The Deans, Presidents/CEOs of the Healthcare Units and Vice Presidents shall oversee the development of written detailed protocols which must be strictly adhered to following an exposure, and the dissemination of this information to all appropriate individuals on each Campus of the University. Those individuals, services or offices responsible for carrying out these protocols shall be identified and their names published on each Campus. The procedures developed to implement this policy shall ensure timely (within hours of exposure) availability of medical attention and counseling, and of postexposure prophylaxis if requested, 24 hours a day. The goal of these procedures is preparedness to begin postexposure prophylaxis as soon as possible, ideally within hours, following exposure. These protocols and lists of responsible individuals or offices shall be reviewed and updated on a regular basis as often as required. This policy and the references from the Centers for Disease Control and Prevention containing information on postexposure prophylaxis should be used as guidelines for the Campus protocols.

4.      Exposed individuals shall be counseled concerning: the risks of their exposure to HIV, HBV and HCV (including considerations of infectivity of exposure source and type of exposure); the known scientific facts, known and unknown risks and potential benefits of postexposure prophylaxis; the need for follow-up medical evaluations whether or not postexposure prophylaxis is elected; the necessity of precautions to prevent transmission of potential HIV, HBV and HCV infection during the follow-up period; and other relevant issues. Such counseling shall continue to be available throughout the medication period if postexposure prophylaxis is requested and during the follow-up period whether or not postexposure prophylaxis is requested.

5.      Individuals may accept or decline postexposure prophylaxis on a purely voluntary basis and will not be subject to any discrimination in their studies or job duties as a result of their decision. Exposed individuals shall receive follow-up counseling, postexposure testing and medical evaluation regardless of whether they receive postexposure prophylaxis. Those who become HIV seropositive, whether or not postexposure prophylaxis was taken, HBV seropositive or HCV seropositive should be evaluated, in discussions with appropriate HIV counselors and/or infectious disease experts according to published recommendations for HIV-infected, HBV-infected and HCV-infected health-care personnel.

6.      All individuals who sustain occupational/educational exposures to blood or other body fluids potentially infected with bloodborne pathogens must complete an incident report for the Office of Risk and Claims Management. If infection results from the exposure, another incident report must be filed with the Office of Risk and Claims Management. In addition, the UMDNJ Bloodborne Pathogens Potential Exposure Report must be submitted to the Department of Environmental and Occupational Health and Safety Services.

7.      A consent or declination of treatment form shall be completed and signed in all instances before initiation of HIV postexposure prophylaxis.

8.      Individuals electing to receive HIV postexposure prophylaxis who meet all criteria and have signed the required form shall receive medication and follow-up evaluations by health-care providers, health services or offices identified in advance on each campus and available 24 hours a day. At least the first one to three days’ supply of medications shall be available in all identified sites where individuals are instructed to report after an exposure so that prophylaxis can be started as soon as possible.

9.      Upon report of an exposure, date and time, source, and details of the exposure shall be recorded. These details must include type of procedure being performed, type and brand of device involved, department or work area where the exposure occurred, how the exposure occurred, amount and type of fluid or material, depth of injury and whether fluid was injected, duration and extent of skin or mucous membrane contact, condition of skin, and details about the exposure source (such as HIV/HBV/HCV status and/or risk for these infections). The course of counseling, medical care and medication received shall be documented in writing. A summary of the experience on each campus with occupational/educational exposures, postexposure prophylaxis, and the outcome with or without postexposure prophylaxis shall be sent to the Vice President for Academic Affairs annually by the Schools, Directors of Student Health Services and Directors of Occupational Medicine Services on all Campuses. The summary shall not identify exposed individuals or source persons by name.

10.    Confidentiality will be maintained to the extent possible and permitted by law.

11.    If the HIV, HBV and HCV status of the source person is not known, the source person should be informed of the incident and every effort made to obtain this information through appropriate testing. In most cases, this will be the responsibility of the source person’s health-care provider. Initiation of postexposure prophylaxis, if elected by the exposed individual, shall begin as soon as possible following exposure regardless of the availability of information about the source person’s HIV, HBV and HCV status. However, the results of source-person testing and/or information about the source person’s symptoms and risk factors may contribute to the decision to continue postexposure prophylaxis.

12.    As part of job orientation and annual training, all UMDNJ faculty and staff with potential exposure to bloodborne pathogens shall be educated concerning the risk for and prevention of bloodborne infections, including the need to be vaccinated against hepatitis B, and to report exposures immediately after they occur, and shall be familiarized with the principles of postexposure management and with their Campus’s, School’s or Unit’s specific procedures for obtaining postexposure care. This shall be the responsibility of the Vice President for Human Resources, the President/CEOs of the Healthcare Units and the Deans. All students and housestaff shall receive similar education and information prior to clinical or laboratory studies or duties. The Deans shall ensure that their students and housestaff are so educated and shall assign the direct responsibility for this to appropriate individuals at each School.

13.    For UMDNJ housestaff at non-UMDNJ clinical facilities, the pertinent School shall make arrangements concerning immediate care and shall determine cost responsibility in consultation with the affiliated institution. For UMDNJ students at non-UMDNJ clinical sites, the pertinent School shall make arrangements concerning immediate care and shall bear costs of any care charged by non-UMDNJ institutions. UMDNJ housestaff and students working/studying at non-UMDNJ clinical sites and who are exposed may receive medical care, including postexposure prophylaxis and follow up, at UMDNJ facilities designated to carry out this policy.

14.    Unreimbursed costs of the drugs, initial and follow-up laboratory tests for the exposed individual and for the source person (if not already performed), initial and follow-up visits, counseling and record-keeping shall be borne by the Schools and Student Health Services in the case of students; and by the University’s Workers’ Compensation Program in the case of University-employed faculty, non-faculty staff and housestaff.

By Direction of the President:

________________________________
Vice President for Academic Affairs

Policy Manual Table of Contents

OPPM Home Page

UMDNJ Home Page