Medical Office Information

Directions for Field Exposures

We at the UFA want to ensure long, healthy and productive lives for our members. A union’s two main reasons for existence are wages and working conditions.

With that in mind, the following information is provided to give guidance, direction and a starting point to be better informed about possible exposures. This information is by no means complete and will change from time to time as better information becomes available. It is meant to get information to the members while protecting their right to privacy and to comply with HIPPA regulations.

CLICK HERE for the Infectious Disease Exposure Chart

PROCEDURE:

  • Notify your officer immediately

  • Notify the medical office immediately
    • Give a complete description of what happened
    • If it is recommended to you to start taking medication, take it immediately, do not delay

  • Complete a CD-73; that is the form for Chemical Exposures
    • Examples are: acid gases, hydrocarbons, asbestos

  • Complete an MD-X3, the field exposure form for Biological Exposures
    • Examples are: Blood or other bodily fluids, anthrax, rabies, Animal bites of any kind.

  • Contact Al Vaughn at the Infections Disease Control unit during business hours at 718-999-1851/1850.
    • During non-business hours contact the medical officer on duty
    • Make sure that follow-up is done with hospital and patient

  • Documentation is extremely important!
    • Follow up is extremely important

The Officer should immediately fax the completed MD-X3 to the Medical Officer on Emergency Duty at 718-999-0035. If the Officer is unable to complete the transmission via fax, or if telephone confirmation of receipt of the MD-X3 is not received, the Officer should notify the Bureau of Health Services at 718-999-1849/1850. A doctor from the Bureau of Health Services should call back or visit the exposed member to obtain information concerning the exposure during your tour. The doctor will make the determination as to whether the exposure requires tests or treatments and provide counseling pertaining to the exposure.

TESTING

HIV Infection:

How Do I Know If I Have HIV?

The only way to know for sure if you have HIV is to get an HIV test.

If you are at risk of HIV, you should have an HIV test every six months. You should also reduce your risk (by following safety procedures and wearing protective clothing in all medical situation where patient contact is possible). Soon after HIV infection, the body begins to make antibodies that fight the virus. The HIV test looks for these antibodies in your blood. After about three months, most people have enough anti-HIV antibodies to test positive on standard HIV tests. Some people don't test positive for six months or even a year, so repeat testing is needed.

The HIV test is simple. Home tests are available. You can also get tested at labs that keep your identity secret. You can also get tested by your doctor, the medical office, and at your public health department. If you are doing a home test, or if you order a test from a lab, a positive result means you should see a doctor to confirm that you're really infected.

If you know you are at high risk of HIV infection and come down with a bad case of the flu, see a doctor right away. It could be the early signs of HIV infection. Tell your doctor about your risk behavior. There are very sensitive tests that can tell if you've got HIV -- and treatment during this very early stage of infection works best.

Before getting tested, think about what your test result will mean to you, your family and the people around you. Most people need help with this, so see a counselor, psychologist, a doctor from the medical office, or your private doctor for advice. Check our WEB site for additional medical & counseling services -- or call your local AIDS hotline. Prepare for your result.

If you test negative, you may want to talk about how to reduce your future risk. There are many private AIDS organizations that can give you this kind of help. Usually these organizations have "been-there, done-that" counselors you can relate to.

If you test positive, you'll need help deciding what to do. HIV infection isn't a death sentence. It does mean that you will need to take special care of your health. It also means that you will have to take special care not to infect anybody else (your family & friends and members of the department) with the AIDS virus.

If you test positive for HIV, you must have medical care and notify the medical office. If you don't have a doctor, a local AIDS organization or AIDS hotline can help you find one. Get some help from a person you trust. If you don't have a person like this in your life, get help from a professional counselor (CSU or services provided on the UFA WEB SITE). Have this person go with you to the doctor.

If you test positive, you have to tell your sex and/or needle-sharing partners that they, too, need to be tested. But you don't have to tell everybody else. Tell only those people who can support you. If you have children, talk with a counselor about what to tell them, and when.

What Are the Treatments?

Treatment with combinations of AIDS drugs can keep people with HIV from getting AIDS.

In clinical studies, where everybody gets state-of-the art treatment and very regular medical exams, the drugs work for the vast majority of people. In the real world, some AIDS doctors say, the drugs fail in about half of their patients.

Why? Not all AIDS drugs work for all people. It's absolutely essential to take the drugs at the right time of day, every single day. Sometimes the drugs' side effects -- or simple human nature -- make this very hard to do. And because HIV is constantly mutating, no two people are infected with exactly the same virus.

Treatment must be planned and adjusted for every individual person with HIV. When to start treatment is a big question. Everybody agrees that starting aggressive treatment in the early days after infection -- the stage of acute HIV infection -- is most effective. But most people don't find out they have HIV until the stage of chronic HIV infection, when the virus has a firm hold on the body. There's no hard and fast rule about when to start treatment for such patients.

Most AIDS/HIV doctors now recommend holding off on treatment until a person's immune system starts to fail. This decision is based on the CD4 T-cell count, the best measure of HIV disease. Another factor is how much HIV is in the blood -- a measure called viral load.

When treatment begins, the decision on which anti-HIV drugs to use is crucial. New tests can tell which drugs will work best on the HIV infecting an individual patient.

There are several types of anti-HIV drugs. Because HIV mutates so quickly, it soon is able to resist any single treatment. That's why doctors use combinations ("cocktails") of anti-HIV drugs. Virus that's resistant to one drug gets killed by another. Over time, even this strategy isn't always enough, and virus resistant to multiple drugs may appear. At this point, a doctor will switch to another drug combination. While there are many AIDS drugs, the possibilities are not endless. Researchers are working hard to find new ways to treat patients who have run through several different combination treatments.

The different types of anti-HIV drugs each target a different aspect of HIV's life cycle:

  • Entry. HIV has to get into a T cell to start its dirty work. First it has to latch on to the cell. Next it has to fuse its own outer membrane to that of the cell. New drugs called attachment inhibitors and fusion inhibitors are being tested in humans.

  • Early replication. HIV's goal is to take over a T cell's genetic machinery. After fusing with a cell, the virus spills its genetic material into the cell. HIV has a problem here -- its genetic code is written in a form called RNA. But in humans, our genetic code is written in DNA. HIV solves this problem by making an enzyme -- called reverse transcriptase or RT -- that translates its RNA into DNA. The class of AIDS drugs called nucleoside RT inhibitors ("Nukes") fools HIV into making flawed reverse transcriptase out of bogus raw materials. Another class -- the non-nucleoside RT inhibitors or Non-Nukes -- gums up reverse transcriptase so it doesn't work. Several Nukes and Non-Nukes are now in use.

  • Late replication. HIV has to snip apart the cell's DNA, put its own DNA in, and sew the DNA strand back together. The sewing kit it needs to do this is called integrase. Human tests of an integrase inhibitor began in 2001.

  • Assembly. Once HIV has taken over a cell's genetic material, it gets the cell to make the pieces from which a new virus is made. These pieces have to be cut into the right size -- and that's what HIV's protease enzyme does. Several protease inhibitors (or PIs) are now on the market.

Another approach is to make the body's immune system fight HIV more effectively. One way to do this is with a chemical messenger called interleukin-2 or IL-2, now in advanced human tests. Other immune stimulators are in various stages of development.

Yet another strategy is to use antisense drugs. These are strands of genetic material that form a kind of mirror image of HIV's genetic code. This throws a monkey wrench into the virus's replication machinery. One antisense drug has entered human tests.

Side effects are common with all of these medications. These can include:

  • Nausea and vomiting. These side effects are most common in the first weeks or months of anti-HIV treatment. Often they go away as the body gets used to the drugs.

  • Diarrhea. Most common early in treatment. Call your doctor if diarrhea lasts for more than three days.

  • Rash. Rash is common among people who start taking anti-HIV drugs. Usually it goes away by itself. IMPORTANT: Rash could be a sign of an allergic reaction to a drug. This happens more often to patients taking Ziagen, but also happens to a few patients taking Viramune, Rescriptor, or Sustiva. If you get a rash after taking these drugs, call your doctor right away.

  • Problems falling asleep or staying asleep.

  • Fatigue.

  • Dry skin and/or ingrown toenails sometimes happen with Crixivan.

  • Pain, numbness, tingling, and or burning in the hands and/or feet.

  • Kidney stones sometimes occur in people who take Crixivan.

  • Changes in the way your body deals with fat. This is called lipodystrophy syndrome. It includes a range of symptoms including a roll of fat between the shoulders ("buffalo hump"); enlarged breasts; and loss of fat in the face, arms, and legs.

How often should you test?

A baseline test should be administered as soon as possible;
Six weeks after exposure – a second test should be taken;
Three months after exposure - a third test should be taken;
Six months after exposure – a fourth and final test will be taken

TUBERCULOSIS (TB):

A baseline test (PPD-intradermal) should be administered as soon as possible (absolutely within ten days of exposure); 48-72 hours after skin test you must return to the clinic to have the test read by a nurse or doctor; If the PPD skin test is positive, the member must then get a chest X-ray at the medical office or with their private medical doctor (PMD). The member must also be started on a several-months regimen of oral medication(s) to decrease the chance of TB infection becoming TB disease. Assuming the first chest X-ray was negative, a second chest X-ray will be required 12 months after the first chest X-ray.

How the TB/PPD Skin Test is administered: If you have had a recent measles (MR, MMR) vaccine, the TB skin test will be delayed for one month to prevent a false negative result. Site of the test: the dorsal area of the forearm approximately 4" below the elbow. A small needle is inserted intradermally (under the top layer of skin) of the forearm. The tuberculin solution is injected resulting in a small raised area approximately 3/8" in diameter. This absorbs quickly. No band aid is put over the site as the pressure of the band aid may push the tuberculin solution out of the site before it has an opportunity to absorb.

Test Results:

No red, raised area up to a 4mm red, raised area at injection site = negative.

5mm - 9mm red, raised area at injection site = doubtful result and the TB/PPD skin test must be repeated in the other arm

9mm+ = positive result and a chest X-ray must be obtained

Eight weeks after exposure – repeat testing procedure

HEPATITIS B (HEP B):



If you were vaccinated, a test may be administered to determine if the vaccination was effective. If you were not vaccinated, the vaccination will be offered

What is the procedure for obtaining the HBV vaccination series at the medical office?

An employee is identified as being at-risk for contracting HBV due to their employment classification according to the protocols established by the federal government. HBV vaccinations shall be made available to all employees who have an occupational exposure unless the employee has previously received the complete Hepatitis B Virus vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons. The vaccination series, post-exposure evaluation and follow up - when necessary - is offered at no cost to the employee.

The Medical office submits the member's name to the Environmental Health and Safety (EHS) Department at the District office to receive notification of the availability of the HBV vaccination series. The member will receive several forms regarding the HBV vaccination series. The member may choose to sign and return the "Declination" form whereby he/she declines to receive the HBV vaccinations. If the member changes his/her mind at a later date, and if the employee is still employed in an at-risk category, he/she may receive the HBV vaccination series at that time.

If the member chooses to receive the HBV vaccination series, he/she must bring the one-page notification letter with them to the District's Environmental Health & Safety department to begin the series. The HBV pre-exposure vaccination series is as follows:
Engerix-B 20 mcg. (1 ml) injection in the deltoid (arm) muscle. (3 injections given at 0, 1 and 6 month)

HEPATITIS C (HEP C):

If you think you had an exposure to hepatitis C, it is important that you get tested as soon as possible. Hepatitis C is diagnosed based on the results of specific blood tests so the first step is to ask the medical officer to perform a blood test for hepatitis C. The most commonly used tests are the ELISA which stands for enzyme-linked immunosorbent assay. These tests detect the presence of antibodies to the hepatitis C virus in the blood, and the HCV RNA test, which directly detects hepatitis C virus particles in the blood.

Six weeks after exposure – a second test should be taken;
Three months after exposure - a third test should be taken;
Six months after exposure – a fourth and final test will be taken

RABIES:

There is no treatment for rabies after symptoms of the disease appear. However, two decades ago scientists developed an extremely effective new rabies vaccine regimen that provides immunity to rabies when administered after an exposure (post-exposure prophylaxis) or for protection before an exposure occurs (pre-exposure prophylaxis). Although rabies among humans is rare in the United States, every year an estimated 18,000 people receive rabies pre-exposure prophylaxis and an additional 40,000 receive post-exposure prophylaxis.

Purpose of pre-exposure prophylaxis Pre-exposure prophylaxis is given for several reasons. First, although pre-exposure vaccination does not eliminate the need for additional medical attention after a rabies exposure, it simplifies therapy by eliminating the need for human rabies immune globulin (HRIG) and decreasing the number of vaccine doses needed – a point of particular importance for persons at high risk of being exposed to rabies in areas where immunizing products may not be available, and it minimizes adverse reactions to multiple doses of vaccine. Second, it may enhance immunity in persons whose post-exposure therapy might be delayed. Finally, it may provide protection to persons with unapparent exposures to rabies.

Pre-exposure prophylaxis regimen - Pre-exposure prophylaxis consists of three doses of rabies vaccine given on days 0, 7, and 21 or 28.
Post-exposure prophylaxis
Post-exposure prophylaxis (PEP) is indicated for persons possibly exposed to a rabid animal. Possible exposures include animal bites, or mucous membrane contamination with infectious tissue, such as saliva. {For more information on types of exposures, see Human Rabies Prevention - United States, 1999 Recommendations of the Immunization Practices Advisory Committee (ACIP).} PEP should begin as soon as possible after an exposure. There have been no vaccine failures in the United States (i.e. someone developed rabies) when PEP was given promptly and appropriately after an exposure.

Administration of rabies PEP is a medical urgency, not a medical emergency. Department medical officers should evaluate each possible exposure to rabies and as necessary consult with local or state public health officials regarding the need for rabies prophylaxis.

Post-exposure prophylaxis regimen - In the United States, PEP consists of a regimen of one dose of immune globulin and five doses of rabies vaccine over a 28-day period. Rabies immune globulin and the first dose of rabies vaccine should be given as soon as possible after exposure. Additional doses of rabies vaccine should be given on days 3, 7, 14, and 28 after the first vaccination. Current vaccines are relatively painless and are given in your arm, like a flu or tetanus vaccine. Members should realize that they are not on medical leave during this inoculation period; the days you are visiting the medical office for these shots do not count towards medical leave.

What to do after a possible exposure
If you are exposed to a potentially rabid animal, wash the wound thoroughly with soap and water, and seek medical attention immediately. A health care provider will care for the wound and will assess the risk for rabies exposure. The following information will help your health care provider assess your risk:

  • the geographic location of the incident
  • the type of animal that was involved
  • how the exposure occurred (provoked or unprovoked)
  • the vaccination status of animal
  • whether the animal can be safely captured and tested for rabies

Steps taken by the medical officer will depend on the circumstances of the bite. The Medical Officer should consult state or local health departments, veterinarians, or animal control officers to make an informed assessment of the incident and to request assistance. The important factor is that you seek care promptly after you are bitten by any animal.

Rabies diagnosis in animals
the direct fluorescent antibody test (dFA) is the test most frequently used to diagnose rabies. This test requires brain tissue from animals suspected of being rabid. The test can only be performed post-mortem (after the animal is dead).

Rabies diagnosis in humans
Several tests are necessary to diagnose rabies ante-mortem (before death) in humans; no single test is sufficient. Tests are performed on samples of saliva, serum, spinal fluid, and skin biopsies of hair follicles at the nape of the neck. Saliva can be tested by virus isolation or reverse transcription followed by polymerase chain reaction (RT-PCR). Serum and spinal fluid are tested for antibodies to rabies virus. Skin biopsy specimens are examined for rabies antigen in the cutaneous nerves at the base of hair follicles.

The importance of routine rabies tests
Rapid and accurate laboratory diagnosis of rabies in humans and other animals are essential for timely administration of post-exposure prophylaxis. Within a few hours, a diagnostic laboratory can determine whether or not an animal is rabid and inform the responsible medical personnel. The laboratory results may save a patient from unnecessary physical and psychological trauma, and financial burdens, if the animal is not rabid.

In addition, laboratory identification of positive rabies cases may aid in defining current epidemiologic patterns of disease and provide appropriate information for the development of rabies control programs.

Laboratory tests for rabies
The standard test for rabies testing is dFA. This test has been thoroughly evaluated for more than 40 years, and is recognized as the most rapid and reliable of all the tests available for routine use. All rabies laboratories in the United States perform this test (post-mortem) on animals suspected of having rabies.

Other tests for diagnosis and research, such as electron microscopy (EM), histologic examination, immunohistochemistry (IHC), RT-PCR, and isolation in cell culture are useful tools for studying the virus structure, histopathology, molecular typing, and virulence of rabies viruses.