Of Staff Victims in Contact With Disease

Management in custody of staff/victims in contact with disease includes following the immediate management flow chart (Fig. 1) and contacting the designated hospital/specialist with details of the exposure. Where possible, obtain a blood sample from the contact. Regarding HBV and HCV blood samples in the United Kingdom, they can only be taken with informed consent. There is no need for the forensic physician to go into details about the meaning of the test, but the contact should be encouraged to attend the genitourinary department (or similar) of the designated hospital to discuss the test results. Should the contact refuse to provide a blood sample, then any information about his or her lifestyle, ethnic origin, state of health, etc., may be useful for the specialist to decide whether postexposure prophylaxis (PEP) should be given to the victim. Where only saliva is involved in a penetrating bite injury, there is every justification to reassure the victim that he or she is not at risk. If in doubt, then always refer.

In the United Kingdom, the current recommended regime for PEP is Combivir (300 mg of Zidovudine twice daily plus 150 mg of Lamivudine twice daily) and a protease inhibitor (1250 mg of Nelfanivir twice daily) given for 4 weeks (27). It is only given after a significant exposure to a high-risk fluid or any that is visibly bloodstained and the contact is known or is highly likely to be HIV positive. Ideally, treatment should be started within an hour after exposure, although it will be considered for up to 2 weeks. It is usually given for 4 weeks, unless the contact is subsequently identified as HIV negative or the "victim" develops tolerance or toxicity occurs. Weekly examinations of the "victim" should occur during treatment to improve adherence, monitor drug toxicity, and deal with other concerns.

Other useful information that may influence the decision whether to treat with the standard regimen or use alternative drugs includes interaction with other medications that the "victim" may be taking (e.g., phenytoin or antibiotics) or if the contact has been on antiretroviral therapy or if the "victim" is pregnant. During the second or third trimester, only Combivir would be used, because there is limited experience with protease inhibitors. No data exist regarding the efficacy of PEP beyond occupational exposure (27).

PEP is not considered for exposure to low- or no-risk fluids through any route or where the source is unknown (e.g., a discarded needle). Despite the appropriate use and timing of PEP, there have been reports of failure (28,29).

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