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Occupational Medicine Advance Access originally published online on July 14, 2008
Occupational Medicine 2008 58(7):502-505; doi:10.1093/occmed/kqn083
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© The Author 2008. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Short Reports

HIV post-exposure prophylaxis among police and corrections officers

Roland C. Merchant1,2, Jacob E. Nettleton3, Kenneth H. Mayer2,4 and Bruce M. Becker1,2

1 Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
2 Department of Community Health, Warren Alpert Medical School, Brown University, Providence, RI, USA
3 Brown University, Providence, RI, USA
4 Department of Medicine, Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, RI, USA

Correspondence to: Roland C. Merchant, Department of Emergency Medicine, Rhode Island Hospital, 593 Eddy Street, Claverick Building, Providence, RI 02903, USA. Tel: +1 401 444 5109; fax: +1 401 444 4307; e-mail: rmerchant{at}lifespan.org


   Abstract
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 Abstract
Introduction
 Methods
 Results
 Discussion
 Funding
 Conflicts of interest
 References
 
Background Police and correctional officers face the occupational hazard of blood and body fluid exposures, which carry the risk of infection with HIV.

Aims To estimate the incidence rate (IR) of emergency department (ED) visits for blood or body fluid exposures sustained by police and corrections officers in an entire state and to quantify the utilization of HIV post-exposure prophylaxis (PEP) in response to these exposures.

Methods A retrospective study of police and corrections officers presenting to EDs in Rhode Island between 1995 and 2001. The investigators estimated IRs of ED visits for these exposures with 95% confidence intervals and determined factors associated with HIV PEP using bivariate Pearson's {chi}2 analyses.

Results The average annual incidence of ED visits for blood or body fluid exposures over the study period was IR 4.41 (2.31–6.51) exposures per 1000 police and corrections personnel. Only 15% of officers sustained percutaneous injuries or blood-to-mucous membrane exposures. Sixteen officers were offered HIV PEP and 10 accepted it. Offering of HIV PEP was 3.3-fold greater for officers sustaining percutaneous and blood-to-mucous membrane exposures instead of other body fluid exposures.

Conclusion The incidence of ED visits for blood or body fluid exposures by police and corrections officers was low and most exposures did not have the potential for HIV transmission. HIV PEP was infrequently used for these exposures.

Keywords      Blood-borne pathogens; HIV; needlestick injuries; occupational exposure; police; post-exposure prophylaxis


   Introduction
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 Abstract
 Introduction
Methods
 Results
 Discussion
 Funding
 Conflicts of interest
 References
 
Police and corrections officers, unlike health care workers, often operate in surroundings that lack measures for reducing blood and body fluid exposures. Evidence collection, suspect apprehension, inmate processing or searches carry the risk of physical violence which can entail exposures to blood and body fluids that can transmit HIV and other pathogens. In this study, the annual incidence of visits to Rhode Island emergency departments (EDs) for blood and body fluid exposures among police and corrections officers and the factors associated with HIV post-exposure prophylaxis (PEP) utilization as a response to exposures were described. ED visits from 1 year prior to the release of Centers for Disease Control and Prevention (CDC) guidelines on occupational HIV PEP (1995) until the second revision of these guidelines (June 2001) were included in this study [1–3].


   Methods
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 Introduction
 Methods
Results
 Discussion
 Funding
 Conflicts of interest
 References
 
ED visits for blood or body fluid exposures to the 10 acute care general medical hospitals in Rhode Island from 1 January 1995 to 30 June 2001 were identified. The 10 hospitals comply with the 1996, 1998 and 2001 CDC occupational HIV PEP guidelines [1–3]. All hospital institutional review boards approved the study.

ED visits for blood or body fluid exposures were identified from hospital and ED provider billing databases using International Classification of Disease codes [4]. These codes were E920.5 (needlestick), V01.7 (exposure to other viral diseases), V01.8 (exposure to other communicable disease), V07.8 (other specific prophylactic measure), V07.9 (unspecified prophylactic measure) and V15.85 (exposure to potentially hazardous body fluids). Trained research assistants reviewed the ED medical records and extracted the age, gender and occupation of the patient; the hospital where the patient presented, the type and the time of exposure; the HIV status of source and whether or not HIV PEP was utilized. ED visits that did not involve a blood or body fluid exposure were not reviewed. ED visits by police and corrections officers were identified and included in this analysis. There are 42 municipal and 1 state police force and 1 correctional officer force in the state [5]. Of the police officers, 93% are male and of the correctional officers, 89% are male.

Annualized incidence rates (IRs) using the total number of police and corrections officers employed in Rhode Island in each year of the study were calculated. The number of police and corrections officers employed in the state was obtained from the Rhode Island State Police [5]. Because the study period covered only half of 2001, all data from that year was doubled before being included in the analysis. IRs and corresponding 95% confidence intervals were generated using a Poisson regression model. Bivariate analyses using Pearson's {chi}2 were conducted to evaluate factors potentially associated with the offering and acceptance of HIV PEP when it was offered. Differences at the {alpha} = 0.05 level were considered significant.


   Results
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 Abstract
 Introduction
 Methods
 Results
Discussion
 Funding
 Conflicts of interest
 References
 
Of the 105 police and corrections officers who visited Rhode Island EDs for blood or body fluid exposures from 1995 to mid-2001, the majority (92%) were men and had a median age of 31 years (range: 20–49 years). Most (86%) were exposed to an unknown HIV status source. Table 1 shows the IRs of ED visits for exposures among police and corrections officers. The exposures included percutaneous injuries (10%), blood-to-mucous membrane splashes (6%), blood splashes to skin (59%), body fluid-to-mucous membrane splashes (14%) and body fluid splashes to skin (11%). Percutaneous and blood-to-mucous membrane contacts (significant exposures), which are of concern for hepatitis and HIV transmission, accounted for 15% of the exposures.


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  		Table 1. Incidence of police and correctional officer ED visits following exposure

 
Table 2 describes the percentages of officers who were offered PEP, as well the percentages that accepted it when it was offered. Offering of HIV PEP was 3.3-fold greater for officers who sustained a significant than non-significant exposure. Acceptance of HIV PEP when it was offered was 2.5-fold greater for officers who were evaluated at a teaching instead of non-teaching hospital.


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  		Table 2. Percentage of police and corrections officers offered and receiving PEP, by factor

 

   Discussion
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 Methods
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Funding
 Conflicts of interest
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These data show that there were approximately four ED visits for exposures to blood or body fluids per 1000 police and corrections officers between 1995 and 2001. In a 2000–03 study of the Amsterdam police force, Sonder et al. [6] found an IR of 6.8 blood or body fluid exposures per 1000 officers annually, only slightly higher than in this study. In this study, the IR for the more significant exposures was considerably lower than the 3.9 percutaneous exposures per 1000 officers per year found by Pagane et al. [7] among New York City police officers between 1992 and 1993. This difference might be because our data reflect ED visits for exposures across a whole state rather than for one large urban centre; the data of Pagane et al. comprise self-reported incidents of exposures for which these officers might not have sought medical attention, or because of improvements in safety measures and universal precautions and the release and propagation of the CDC guidelines that occurred during the time that passed between the two studies [1–3].

It is reassuring to observe that a low percentage (15%) of officers sustained higher-risk exposures—exposures that should be considered for HIV PEP under the CDC guidelines [1–3]. Most of the officers presented within 24 h, which is within the window of greatest efficacy for HIV PEP. Unfortunately, most of the exposures were from sources of unknown HIV status, thus complicating the decisions about HIV PEP. The increasing availability of rapid HIV testing will expedite confirmation of source status, thus avoiding unnecessary HIV PEP prescription.

The overall low use of HIV PEP suggests that officers are unfamiliar with treatment options or that hospitals are unsure whether to evaluate them in the same way as for health care workers, for whom the evaluations are clearly defined by the CDC guidelines [1–3]. It was reassuring to find that sustaining a significant exposure was associated with being offered HIV PEP, but it is concerning that acceptance of HIV PEP was greater at teaching than non-teaching hospitals. Standardization of protocols for dealing with blood and body fluid exposures among police and corrections officers as well as increased education regarding these protocols for these personnel appear indicated.


Key points
  • There are a relatively low number of significant blood and body fluid exposures sustained by police and corrections officers in this state.
  • HIV PEP is offered more often for officers who have significant exposures and is accepted more often by officers who present to EDs at teaching hospitals.
  • The CDC guidelines for occupational HIV PEP may not be having an adequate effect on the ED management of exposures sustained by police and corrections officers.

 


   Funding
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
Conflicts of interest
 References
 
R.C.M. and this research were supported by: National Institutes of Health training grant through the Division of Infectious Diseases, Brown Medical School, The Miriam Hospital from the National Institute on Drug Abuse (5 T32 DA13911), National Institutes of Health to the Brown/Lifespan/Tufts Centers for AIDS Research (P30 AI42853), Rhode Island Foundation, Elizabeth Glaser Pediatric AIDS Foundation. J.E.N. was supported by the Karen T. Romer Undergraduate Teaching and Research Award from Brown University.


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
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References
 
None declared.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
 Conflicts of interest
 References
 

  1. Centers for Disease Control and Prevention. Update: provisional Public Health Service recommendations for chemoprophylaxis after occupational exposure to HIV. MMWR Morb Mortal Wkly Rep (1996) 45:468–480.[Medline]

  2. Centers for Disease Control and Prevention. Public Health Service guidelines for the management of health-care worker exposures to HIV and recommendations for post exposure prophylaxis. Centers for Disease Control and Prevention. MMWR Recomm Rep (1998) 47:1–33.[Medline]

  3. 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 post exposure prophylaxis. MMWR Recomm Rep (2001) 50:1–52.[Medline]

  4. US Department of Health and Human Services. International Classification of Disease, Ninth Revision, Clinical Modification (2001) 6th edn. Washington, DC.

  5. Rhode Island State Police. Uniform Crime Reports. http://www.risp.state.ri.us (date last accessed 24 April 2008).

  6. Sonder GJ, Bovée LP, Coutinho RA, Baayen D, Spaargaren J, van den Hoek A. Occupational exposure to bloodborne viruses in the Amsterdam police force, 2000–2003. Am J Prev Med (2005) 28:169–174.[Web of Science][Medline]

  7. Pagane J, Chanmugam A, Kirsch T, Kelen GD. New York City police officers incidence of transcutaneous exposures. Occup Med (Lond) (1996) 46:285–288.[Medline]


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