INFECTION CONTROL

In
DENTAL SETTINGS

 Immunization Program

Immunizations substantially reduce both the

number of DHCP susceptible to these diseases,
and the potential for disease transmission to other
DHCP and patients. Thus, immunizations are an
essential part of prevention and infection-control
programs for DHCP.
Immunizations strongly recommended for health-care
personnel (HCP):

 Hepatitis B vaccine

 Influenza vaccine

 Measles, mumps, and rubella vaccines

 Varicella vaccine

 Acellular Pertussis vaccine

 Hepatitis B vaccine
 Three doses schedule administered 1ml intramuscularly (IM) in
the deltoid; 0,1,6; the second and third doses administered 1
and 6 months, respectively, after the first dose.

 Pregnancy is not a contraindication.

 DHCP shoul d b e te ste d f or anti - HBs 1 - 2 m onths af te r

completion of the 3 doses vaccination series. DHCP who do
not develop an adequate antibody response (i.e., anti HBs < 10
ml IU/ml) to the primary vaccine series should complete a
second 3-dose vaccines series or be evaluated to determine if
they are HBsAg-positive.
 Revaccinated persons should be retested for anti-HBs at the
completion of the second series. Approximately, half of non-
responders to the primary series will respond to a second 3-
dose series. If no antibody response occurs after the second
series, testing for HBsAg should be performed. Person who
proves to be HBsAg –positive should be counseled regarding
the need for medical evaluation.

 Non-responders to vaccination who are HBsAg-negative should

be considered susceptible to HBV infection and should be
counseled regarding precautions to prevent HBV infection, and
the need to obtain HBIG prophylaxis for any known or probable
parenteral exposure to HBsAg-positive blood.
 Vaccine-induced antibodies decline gradually over time, and
60% of persons who initially respond to vaccination will
lose detectable antibodies over 12 years. Booster doses of
vaccine and periodic serologic testing to monitor antibody
concentrations after completion of the vaccine series are
not necessary for vaccine responders. It is believed that
reliance on immunological memory rather than booster
doses will protect against infection. (HBIG=HB
immunoglobulin)
 Influenza vaccine:
Annual single-dose (0.5 ml) vaccination given (IM)
c on tai n i n g 3 or 4 s trai n s p re fe rab l y i n O c tob e r an d
November.

 Measles, mumps, and rubella vaccines:

Recommended for HCP believed to be susceptible, who
didn’t receive the vaccine during their childhood, and has
no proof of immunity. Two doses (0.5 ml) are given
subcutaneously with one month interval.
 Varicella vaccine
Two doses (0.5 ml, subcutaneous) 4-8 months apart

 Acellular Pertussis vaccine

Te tan u s an d d i p h th e r i a ( toxoi d s ) an d ac e l l u l ar
pertussis (Tdap). Recommended for HCP believed to
be susceptible, who didn’t receive the vaccine during
their childhood. Single dose IM then a booster dose is
given for DT every 10 years.
 Post exposure management and prophylaxis
Post exposure management is an integral component of a complex program to
prevent infection after an occupational exposure to body fluids. During dental
procedures, saliva is predictably contaminated with blood. Even when blood is not
visible, it can still be present in limited quantities and, therefore, is considered a
potentially infectious material.

Types of occupational exposures:

 Needle stick or sharp object injury from a contaminated device, used for the
patient.
 Splashes of the blood or body fluids to the mucous membrane.

 Exposure to the blood or body fluids when the skin is not intact.

 Post exposure management involves provision of first aid, reporting, risk

assessment, counseling and additional procedures specific to individual
pathogens implicated.
First Aid:
For needle stick injury: The wound should be washed immediately and thoroughly with
soap and water. The wound should then be disinfected and dressed.

For mucosal contact: e.g. spillage into the eyes, the exposed part should be washed
immediately and liberally with running clean water.

Reporting:
Fill the incident report form and contact the preventive medicine office as soon as
possible.

Risk assessment:
Blood sample should be taken from the source if possible, to be tested for the
suspected disease (HBV or HCV or HIV) to assess the risk, and the exposed person
should do blood testing as a baseline soon after exposure.
•Management of accidental exposure to HBV:

Vaccination Treatment when Treatment when Treatment when

status of source is Hbs Ag source is Hbs Ag source status
exposed person positive negative unknown or not
tested
Unvaccinated (no HBIG and Initiate/complete HBIG and
vaccination or initiate/complete HB vaccination. initiate/complete
incomplete course). HB vaccination. HB vaccination.
After review of
HBV status.

Previously No treatment No treatment. No treatment.

vaccinated known
responder
Vaccination Treatment when Treatment when Treatment when
status of source is Hbs Ag source is Hbs Ag source status
exposed person positive negative unknown or not
tested
Previously vaccinated They should receive reinitiate the hepatitis should receive a
known non-responder a single dose of HBIG B vaccine series. single dose of HBIG
who did not complete and should reinitiate anti-HB antibodies and should reinitiate
a second three-dose the hepatitis B should be tested 1-2 the hepatitis B
vaccine series. vaccine series with months after vaccine series with
the first dose of the completion of the 3 the first dose of the
hepatitis B vaccine as doses vaccination hepatitis B vaccine as
soon as possible after series to check the soon as possible after
exposure. response for exposure
vaccination
Previously vaccinated should receive two No treatment. should receive two
non-responders who doses of HBIG, one doses of HBIG, one
completed a second dose as soon as dose as soon as
three-dose vaccine possible after possible after
series. exposure, and the exposure, and the
second dose 1 month second dose 1 month
N.B.
 When hepatitis B immune globulin (HBIG) is indicated, it should
be administered as soon as possible after exposure (preferably
within 24 hours). The effectiveness of HBIG when administered
later than 7 days after exposure is unknown.
 When hepatitis B vaccine is indicated, it should also be
administered as soon as possible (preferably within 24 hours)
and can be administered simultaneously with HBIG at a
separate site (vaccine should always be administered in the
deltoid muscle).
⼀ Attenti on i s d rawn to the need of b l ood testi ng b ef ore
administering HBIG.
 Management of accidental exposure to HCV

Health care personnel exposed to HCV should have blood testing
as a baseline for HCV antibody testing.

Evaluate the source by testing HCV antibody.

Counsel the exposed health care personnel for no blood donation
until after 6 months of negative follow up when the source is anti
HCV positive or of unknown status.

To ascertain whether HCV infection has occurred from the
exposure, retest the exposed health care personnel 3 and 6 months
after exposure, when the source is anti HCV positive or of unknown
status.

Currently, there is no effective vaccine or chemoprophylactic agent
for preventing HCV infection after accidental occupational
exposure.

Appropriate medical referrals and counseling regarding optimal
treatment regimens and duration of treatment as well as optimal
 Management of accidental exposure to HIV

 The exposed person should have blood testing for HIV antibody testing as a
baseline.
 Assessment of source patient for risk of HIV infection, if possible, should be
made. Counseling and HIV testing with consent should be offered where
appropriate.
 Assessment of potential risk of HIV infection from the exposure is of
paramount importance in deciding on the need for chemoprophylaxis.
 The risk depends on the setting, type and severity of exposure, type and
amount of f lu id/tissue exposed/transferred, HIV status of source, and
susceptibility of the injured.
 It has been shown that some factors of the accident itself were associated
with a higher potential of seroconversion after percutaneous exposure to
HIV-infected blood: (a) injury with a device visibly contaminated with the
patient’s blood, (b) a procedure that involved a needle directly placed in a
vein or artery, (c) deep injury, and (d) exposure to source patients with AIDS
 If HIV status of the source unknown, in such case, the likelihood of HIV infection
in the source could be assessed by clues such as (a) HIV-related illnesses, e.g.,
pneumonia, oral thrush, (b) HIV-related risk behaviors, e.g., multiple sex partners,
needle-sharing for drug injection, and (c) HIV prevalence of the community group
which the source belongs to. Counsel the exposed health care personnel for no
blood donation.

 Antiretroviral prophylaxis should be offered to the injured if the exposure is

assessed to constitute signif ic ant risk of HIV infection. Prophylaxis should be
initiated as soon as possible, preferably within 1-2 hours post exposure, after the
decision is made; Data from animal models of prophylaxis with these agents
suggest that antiviral activity is diminished when treatment is delayed for more
than 24 hours.

 A basic two-drug regimen can be considered if high risk factors are not present.
Otherwise, expanded regimen is indicated as shown in the following table:
Post exposure prophylaxis against
HIV Regimen Dosage **Indications
Expanded regimen ⼀ Zidovudine (200 mg ⼀ Substantiated risk of
tid/300 mg bid)+ HIV infection from an
lamivudine (150 mg exposure with high risk
bid) + indinavir (800 factors
mg q8h)/nelfinavir
(750 mg tid/1250 mg
bid)
Basic regimen ⼀ Zidovudine (200 mg ⼀ Substantiated risk of
tid/300 mg bid)+ HIV infection from an
lamivudine (150 mg exposure without high
bid) risk factors
No PEP ⼀ no antiretroviral drugs ⼀ Risk not substantiated
or patient declined
PEP
⼀ The exposed person should be followed up for at least 6
months and be asked to report signs/symptoms of acute HIV
seroconversion. Blood testing (when the source anti-HIV
positive or of unknown status) should be performed 6 weeks,
3 months and 6 months days after exposure, and when there
is suggestion of seroconversion.

⼀ Individuals started on chemoprophylaxis should also be

monitored for drug toxicity and tolerance.

⼀ Strict confidentiality of the HIV status of source patient and

injured person must be observed.
HIV, HBV, and HCV data related to infection control

HIV:

⼀ HIV has been found in very low level in blood of infected persons, and even
less in their saliva.
⼆ In dried infected blood 99% of HIV has been found by CDC investigators to be
inactive in approximately 90 minutes. However, when kept wet, the virus may
survive for two or more days (caution is required with containers of used
needles in which the virus may remain wet)
三 HI V is kille d by all me tho d s o f ste rilizatio n. Whe n use d pro pe rly, all
disinfectants except some quaternary ammonium compounds are said to
inactivate HIV in less than 2 minutes.
四 HIV can be transmitted to DHCW by injuries with contaminated sharp
instrument and by spatter of blood contamination to eyes, mouth, or broken
skin. However, aerosols such as those produced during dental treatments,
have not been found to transmit HBV or HIV infection.
HBV:

⼀ HBV is a relatively stable virus that can withstand drying on surfaces, and
presumably upon equipment and clothing, for over 7 days.

⼀ It is found in high levels in blood of infected persons and found in their saliva at
lower concentrations.

⼀ Disinfectants selected for their ability to inactivate TB and hydrophilic viruses

appear to inactivate HBV.

⼀ All forms of sterilization destroy the virus.

⼀ HBV can be transmitted to DHCW by parental exposure, mucosal exposure to

infected blood or contaminated saliva, and by spatter of blood contaminations
to eyes, mouth, or broken skin. In public, however, neither HIV nor HBV are
transmitted by casual contact.
HCV:

⼀ HCV exposure risks for personnel appear to be low.

⼀ Follow-up studies of HCP exposed to HCV-infected blood through

percutaneous or other sharps injuries have determined a low
incidence.

 Although studies have not documented seroconversion

associated with mucous membrane or non-intact skin exposure,
at least two cases of HCV-transmission from a blood splash to
the conjunctiva and one case of simultaneous transmission of
HCV and HIV after non-intact skin exposure have been reported
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