The presentation will discuss the following points
Exposure of health care workers to infection by blood borne pathogens and how to manage.
Health care workers infected with blood borne infections and what to do.
Health care workers with immunodeficiency conditions and how to avoid infections
Healthcare personnel (HCW) are at risk for occupational exposure to blood borne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).
Exposures occur through needle sticks or cuts from other sharp instruments contaminated with an infected patient's blood or through contact of the eye, nose, mouth, or skin with a patient's blood.
Important factors that influence the overall risk for occupational exposures to blood borne pathogens include the number of infected individuals in the patient population and the type and number of blood contacts. Most exposures do not result in infection
The following resentation will discuss what all health workers should know
Following a specific exposure, the risk of infection may vary with
factors such as these:
- The pathogen involved
-The type of exposure
-The amount of blood involved in the exposure
- The amount of virus in the patient's blood at the time of exposure
Your employer should have in place a system for reporting exposures in order to quickly evaluate the risk of infection, inform you about treatments available to prevent infection, monitor you for side effects of treatments, and determine if infection occurs.
This may involve testing your blood and that of the source patient and offering appropriate postexposure treatment.
Healthcare personnel (HCW) are at risk for occupational exposure to blood borne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).
Exposures occur through needle sticks or cuts from other sharp instruments contaminated with an infected patient's blood or through contact of the eye, nose, mouth, or skin with a patient's blood.
Important factors that influence the overall risk for occupational exposures to blood borne pathogens include the number of infected individuals in the patient population and the type and number of blood contacts. Most exposures do not result in infection
The following resentation will discuss what all health workers should know
Following a specific exposure, the risk of infection may vary with
factors such as these:
- The pathogen involved
-The type of exposure
-The amount of blood involved in the exposure
- The amount of virus in the patient's blood at the time of exposure
Your employer should have in place a system for reporting exposures in order to quickly evaluate the risk of infection, inform you about treatments available to prevent infection, monitor you for side effects of treatments, and determine if infection occurs.
This may involve testing your blood and that of the source patient and offering appropriate postexposure treatment.
RISK OF INFECTION AFTER EXPOSURE
HBV
Healthcare personnel who have received hepatitis B vaccine and developed immunity to the virus are at virtually no risk for infection.
For a susceptible person, the risk from a single needle stick or cut exposure to HBV-infected blood ranges from 6-30% and depends on the hepatitis B e antigen (HBeAg) status of the source individual. Hepatitis B surface antigen (HBsAg)-positive individuals who are HBeAg positive have more virus in their blood and are more likely to transmit HBV than those who are HBeAg negative.
While there is a risk for HBV infection from exposures of mucous membranes or non intact skin, there is no known risk for HBV infection from exposure to intact skin.
HCV
The average risk for infection after a needle stick or cut exposure to HCV infected blood is approximately 1.8%.
The risk following a blood exposure to the eye, nose or mouth is unknown, but is believed to be very small; however, HCV infection from blood splash to the eye has been reported.
There also has been a report of HCV transmission that may have resulted from exposure to non intact skin, but no known risk from exposure to intact skin.
HIV
The average risk of HIV infection after a needle stick or cut exposure to HlV-infected blood is 0.3% (i.e., three-tenths of one percent, or about 1 in 300). Stated another way, 99.7% of needlestick/cut exposures do not lead to infection.
The risk after exposure of the eye, nose, or mouth to HIV-infected blood is estimated to be, on average, 0.1% (1 in 1,000).
The risk after exposure of non-intact skin to HlV-infected blood is estimated to be less than 0.1%. A small amount of blood on intact skin probably poses no risk at all. There have been no documented cases of HIV transmission due to an exposure involving a small amount of blood on intact skin (a few drops of blood on skin for a short period of time).
IF AN EXPOSURE OCCURS
What should I do if I am exposed to the blood of a patient?
1. Immediately following an exposure to blood:
Wash needle sticks and cuts with soap and water
Flush splashes to the nose, mouth, or skin with water
Irrigate eyes with clean water, saline, or sterile irrigants
No scientific evidence shows that using antiseptics or squeezing the wound will reduce the risk of transmission of a blood borne pathogen. Using a caustic agent such as bleach is not recommended.
Prompt reporting is essential because, in some cases, post exposure treatment may be recommended and it should be started as soon as possible.
Discuss the possible risks of acquiring HBV, HCV, and HIV and the need for post exposure treatment with the provider managing your exposure.
You should have already received hepatitis B vaccine, which is extremely safe and effective in preventing HBV infection
TREATMENT FOR THE EXPOSURE
Hepatitis B immune globulin (HBIG) alone or in combination with vaccine (if not previously vaccinated) is effective in preventing HBV infection after an exposure.
The decision to begin treatment is based on several factors, such as:
Whether the source individual is positive for hepatitis B surface antigen
Whether you have been vaccinated
Whether the vaccine provided you immunity
HCV
There is no vaccine against hepatitis C and no treatment after an exposure that will prevent infection. Neither immune globulin nor antiviral therapy is recommended after exposure.
For these reasons, following recommended infection control practices to prevent percutaneous injuries is imperative.
HIV
There is no vaccine against HIV. However, results from a small number of studies suggest that the use of some antiretroviral drugs after certain occupational exposures may reduce the chance of HIV transmission.
Post exposure prophylaxis (PEP) is recommended for certain occupational exposures that pose a risk of transmission.
However, for those exposures without risk of HIV infection, PEP is not recommended because the drugs used to prevent infection may have serious side effects.
You should discuss the risks and side effects with your healthcare provider before starting PEP for HIV.
How are exposures to blood from an individual whose infection
status is unknown handled?
HBV–HCV–HIV
If the source individual cannot be identified or tested, decisions regarding follow-up should be based on the exposure risk and whether the source is likely to be infected with a bloodborne pathogen.
Follow-up testing should be available to all personnel who are concerned about possible infection through occupational exposure
How soon after exposure to a blood borne pathogen should treatment start?
HBV
Post exposure treatment should begin as soon as possible after exposure, preferably within 24 hours, and no later than 7 days.
HIV
Treatment should be started as soon as possible, preferably within hours as opposed to days, after the exposure. Although animal studies suggest that treatment is less effective when started more than 24-36 hours after exposure,
The time frame after which no benefi t is gained in humans is not known.
Starting treatment after a longer period (e.g., 1 week) may be considered for exposures that represent an increased risk of transmission.
Can pregnant healthcare personnel take the drugs recommended
for post exposure treatment?
HBV
Yes. Women who are pregnant or breast-feeding can receive the hepatitis B
vaccine and/or HBIG. Pregnant women who are exposed to blood should be vaccinated against HBV infection, because infection during pregnancy can caus severe illness in the mother and a chronic infection in the newborn.
The vaccine does not harm the fetus.
HIV
Pregnancy should not rule out the use of post exposure treatment when it is warranted.
If you are pregnant you should understand what is known and not known regarding the potential benefits and risks associated with the use of antiviral drugs in order to make an informed decision about treatment
What follow-up should be done after an exposure
HBV
Because post exposure treatment is highly effective in preventing HBV infection, CDC does not recommend routine follow-up after treatment. However, any symptoms suggesting hepatitis (e.g., yellow eyes or skin, loss of appetite, nausea, vomiting, fever, stomach or joint pain, extreme tiredness) should be reported to your healthcare provider.
If you receive hepatitis B vaccine, you should be tested 1-2 months after completing the vaccine series to determine if you have responded to the vaccine and are protected against HBV infection.
HCV
You should be tested for HCV antibody and liver enzyme levels (alanine aminotransferase or ALT) as soon as possible after the exposure (baseline) and at 4-6 months after the exposure. To check for infection earlier, you can be tested for the virus (HCV RNA) 4-6 weeks after the exposure. Report any symptoms suggesting hepatitis to your healthcare provider.
HIV
You should be tested for HIV antibody as soon as possible after exposure (baseline) and periodically for at least 6 months after the exposure (e.g., at 6 weeks, 12 weeks, and 6 months).
If you take antiviral drugs for post exposure treatment, you should be checked for drug toxicity by having a complete blood count and
kidney and liver function tests just before starting treatment and 2 weeks after starting treatment.
You should report any sudden or severe flu-like illness that
occurs during the follow-up period, especially if it involves fever, rash, muscle aches, tiredness, malaise, or swollen glands.
Any of these may suggest HIV infection, drug reaction, or other medical conditions.
You should contact the healthcare provider managing your exposure if you have any questions or problems during the follow-up period.
What precautions should be taken during the follow-up period?
HBV
If you are exposed to HBV and receive post exposure treatment, it is unlikely that you will become infected and pass the infection on to others. No precautions are recommended.
HCV
Because the risk of becoming infected and passing the infection on to others after an exposure to HCV is low, no precautions are recommended.
HIV
During the follow-up period, especially the first 6-12 weeks when most infected
persons are expected to show signs of infection, you should follow recommendations for preventing transmission of HIV.
These include not donating blood, or organs. In addition, women should consider not breast-feeding infants during the follow-up period to prevent the possibility of exposing their infants to HIV that may be in breast milk.
Incidents involving blood or body fluids contaminated with the infectious agent for CJD
Usually suspected in areas of transplantation of cornea, Liver, heart
Immediately wash the wound/area with large amounts of soap and water and report the incident according to normal procedures for the health care establishment.
Responsibilities of infected health care workers
HCWs have an obligation to care for the safety of others in the workplace (this includes fellow workers and patients) under both common law and the Occupational Health and Safety and Welfare Act 1986.
Nominated risk categories
HCWs must not perform exposure-prone procedures if they are:
HIV antibody positive
HCV antibody positive and HCV RNA positive (by PCR or similar test); or
Hepatitis B e antigen (HBeAg) positive and/or HBV DNA positive at high titers.
Blood borne viruses such as HIV, HBV and HCV are all legally notifiable diseases and should be notified to the chief health officer.
An HCW infected with a blood borne virus should be assessed in consultation with their treating medical practitioner, who should make a recommendation about the continued involvement of the HCW in direct patient care.
The practitioner should also determine (and make recommendations to the employer) about the infected HCW’s ability to:
• Perform to the accepted professional standard without compromising the safety of others or themselves in the workplace; and
• Continue to comply with health regulations.
An HCW who undertakes exposure-prone procedures and who is infected with a blood borne virus should modify their work practices so that they no longer participate in exposure prone procedures where there is established evidence of a risk of transmission of infection from HCW to patient.
They should also undergo frequent medical follow-up by a medical practitioner with appropriate experience.
The HCW and/or the medical practitioner may seek confidential advice from a relevant registration board (medical, nursing, dental etc)
HCWs with a blood borne virus are not excluded from employment or functions they can safely perform under policies in place in the facility.
How can occupational exposures be prevented?
Many needle sticks and other cuts can be prevented by using safer techniques (for example, not recapping needles by hand), disposing of used needles in appropriate sharps disposal containers, and using medical devices with safety features designed to prevent injuries.
Using appropriate barriers such as gloves, eye and face protection, or gowns when contact with blood is expected can prevent many exposures to the eyes, nose, mouth, or skin.
Hepatitis B virus is largely preventable through vaccination.
For HCV and HIV preventing occupational exposures to blood can be prevented
This includes using appropriate barriers such as gown, gloves and eye protection as appropriate,
Safely handling needles and other sharp instruments, and using devices with safety features.
Precautions For Health Workers with Immunodeficiency Conditions
For their own protection, HCWs with significant immunodeficiency from any cause should not be involved in the care of patients with certain communicable diseases — for example, tuberculosis, varicella–zoster virus and cytomegalovirus (CMV).
Immunodeficient HCWs should be advised of the possible risks of live vaccines, including Bacille Calmette–Guerin (BCG) vaccine, that are available for HCWs in health care establishments.
Hepatitis B virus is largely preventable through vaccination.
For HCV and HIV preventing occupational exposures to blood can be prevented
This includes using appropriate barriers such as gown, gloves and eye protection as appropriate,
Safely handling needles and other sharp instruments, and using devices with safety features.
Precautions For Health Workers with Immunodeficiency Conditions
For their own protection, HCWs with significant immunodeficiency from any cause should not be involved in the care of patients with certain communicable diseases — for example, tuberculosis, varicella–zoster virus and cytomegalovirus (CMV).
Immunodeficient HCWs should be advised of the possible risks of live vaccines, including Bacille Calmette–Guerin (BCG) vaccine, that are available for HCWs in health care establishments.
Exposure of health care workers to infection by blood borne pathogens and how to manage.
Health care workers infected with blood borne infections and what to do.
Health care workers with immunodeficiency conditions and how to avoid infections
Healthcare personnel (HCW) are at risk for occupational exposure to blood borne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).
Exposures occur through needle sticks or cuts from other sharp instruments contaminated with an infected patient's blood or through contact of the eye, nose, mouth, or skin with a patient's blood.
Important factors that influence the overall risk for occupational exposures to blood borne pathogens include the number of infected individuals in the patient population and the type and number of blood contacts. Most exposures do not result in infection
The following resentation will discuss what all health workers should know
Following a specific exposure, the risk of infection may vary with
factors such as these:
- The pathogen involved
-The type of exposure
-The amount of blood involved in the exposure
- The amount of virus in the patient's blood at the time of exposure
Your employer should have in place a system for reporting exposures in order to quickly evaluate the risk of infection, inform you about treatments available to prevent infection, monitor you for side effects of treatments, and determine if infection occurs.
This may involve testing your blood and that of the source patient and offering appropriate postexposure treatment.
Healthcare personnel (HCW) are at risk for occupational exposure to blood borne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).
Exposures occur through needle sticks or cuts from other sharp instruments contaminated with an infected patient's blood or through contact of the eye, nose, mouth, or skin with a patient's blood.
Important factors that influence the overall risk for occupational exposures to blood borne pathogens include the number of infected individuals in the patient population and the type and number of blood contacts. Most exposures do not result in infection
The following resentation will discuss what all health workers should know
Following a specific exposure, the risk of infection may vary with
factors such as these:
- The pathogen involved
-The type of exposure
-The amount of blood involved in the exposure
- The amount of virus in the patient's blood at the time of exposure
Your employer should have in place a system for reporting exposures in order to quickly evaluate the risk of infection, inform you about treatments available to prevent infection, monitor you for side effects of treatments, and determine if infection occurs.
This may involve testing your blood and that of the source patient and offering appropriate postexposure treatment.
RISK OF INFECTION AFTER EXPOSURE
HBV
Healthcare personnel who have received hepatitis B vaccine and developed immunity to the virus are at virtually no risk for infection.
For a susceptible person, the risk from a single needle stick or cut exposure to HBV-infected blood ranges from 6-30% and depends on the hepatitis B e antigen (HBeAg) status of the source individual. Hepatitis B surface antigen (HBsAg)-positive individuals who are HBeAg positive have more virus in their blood and are more likely to transmit HBV than those who are HBeAg negative.
While there is a risk for HBV infection from exposures of mucous membranes or non intact skin, there is no known risk for HBV infection from exposure to intact skin.
HCV
The average risk for infection after a needle stick or cut exposure to HCV infected blood is approximately 1.8%.
The risk following a blood exposure to the eye, nose or mouth is unknown, but is believed to be very small; however, HCV infection from blood splash to the eye has been reported.
There also has been a report of HCV transmission that may have resulted from exposure to non intact skin, but no known risk from exposure to intact skin.
HIV
The average risk of HIV infection after a needle stick or cut exposure to HlV-infected blood is 0.3% (i.e., three-tenths of one percent, or about 1 in 300). Stated another way, 99.7% of needlestick/cut exposures do not lead to infection.
The risk after exposure of the eye, nose, or mouth to HIV-infected blood is estimated to be, on average, 0.1% (1 in 1,000).
The risk after exposure of non-intact skin to HlV-infected blood is estimated to be less than 0.1%. A small amount of blood on intact skin probably poses no risk at all. There have been no documented cases of HIV transmission due to an exposure involving a small amount of blood on intact skin (a few drops of blood on skin for a short period of time).
IF AN EXPOSURE OCCURS
What should I do if I am exposed to the blood of a patient?
1. Immediately following an exposure to blood:
Wash needle sticks and cuts with soap and water
Flush splashes to the nose, mouth, or skin with water
Irrigate eyes with clean water, saline, or sterile irrigants
No scientific evidence shows that using antiseptics or squeezing the wound will reduce the risk of transmission of a blood borne pathogen. Using a caustic agent such as bleach is not recommended.
Prompt reporting is essential because, in some cases, post exposure treatment may be recommended and it should be started as soon as possible.
Discuss the possible risks of acquiring HBV, HCV, and HIV and the need for post exposure treatment with the provider managing your exposure.
You should have already received hepatitis B vaccine, which is extremely safe and effective in preventing HBV infection
TREATMENT FOR THE EXPOSURE
Hepatitis B immune globulin (HBIG) alone or in combination with vaccine (if not previously vaccinated) is effective in preventing HBV infection after an exposure.
The decision to begin treatment is based on several factors, such as:
Whether the source individual is positive for hepatitis B surface antigen
Whether you have been vaccinated
Whether the vaccine provided you immunity
HCV
There is no vaccine against hepatitis C and no treatment after an exposure that will prevent infection. Neither immune globulin nor antiviral therapy is recommended after exposure.
For these reasons, following recommended infection control practices to prevent percutaneous injuries is imperative.
HIV
There is no vaccine against HIV. However, results from a small number of studies suggest that the use of some antiretroviral drugs after certain occupational exposures may reduce the chance of HIV transmission.
Post exposure prophylaxis (PEP) is recommended for certain occupational exposures that pose a risk of transmission.
However, for those exposures without risk of HIV infection, PEP is not recommended because the drugs used to prevent infection may have serious side effects.
You should discuss the risks and side effects with your healthcare provider before starting PEP for HIV.
How are exposures to blood from an individual whose infection
status is unknown handled?
HBV–HCV–HIV
If the source individual cannot be identified or tested, decisions regarding follow-up should be based on the exposure risk and whether the source is likely to be infected with a bloodborne pathogen.
Follow-up testing should be available to all personnel who are concerned about possible infection through occupational exposure
How soon after exposure to a blood borne pathogen should treatment start?
HBV
Post exposure treatment should begin as soon as possible after exposure, preferably within 24 hours, and no later than 7 days.
HIV
Treatment should be started as soon as possible, preferably within hours as opposed to days, after the exposure. Although animal studies suggest that treatment is less effective when started more than 24-36 hours after exposure,
The time frame after which no benefi t is gained in humans is not known.
Starting treatment after a longer period (e.g., 1 week) may be considered for exposures that represent an increased risk of transmission.
Can pregnant healthcare personnel take the drugs recommended
for post exposure treatment?
HBV
Yes. Women who are pregnant or breast-feeding can receive the hepatitis B
vaccine and/or HBIG. Pregnant women who are exposed to blood should be vaccinated against HBV infection, because infection during pregnancy can caus severe illness in the mother and a chronic infection in the newborn.
The vaccine does not harm the fetus.
HIV
Pregnancy should not rule out the use of post exposure treatment when it is warranted.
If you are pregnant you should understand what is known and not known regarding the potential benefits and risks associated with the use of antiviral drugs in order to make an informed decision about treatment
What follow-up should be done after an exposure
HBV
Because post exposure treatment is highly effective in preventing HBV infection, CDC does not recommend routine follow-up after treatment. However, any symptoms suggesting hepatitis (e.g., yellow eyes or skin, loss of appetite, nausea, vomiting, fever, stomach or joint pain, extreme tiredness) should be reported to your healthcare provider.
If you receive hepatitis B vaccine, you should be tested 1-2 months after completing the vaccine series to determine if you have responded to the vaccine and are protected against HBV infection.
HCV
You should be tested for HCV antibody and liver enzyme levels (alanine aminotransferase or ALT) as soon as possible after the exposure (baseline) and at 4-6 months after the exposure. To check for infection earlier, you can be tested for the virus (HCV RNA) 4-6 weeks after the exposure. Report any symptoms suggesting hepatitis to your healthcare provider.
HIV
You should be tested for HIV antibody as soon as possible after exposure (baseline) and periodically for at least 6 months after the exposure (e.g., at 6 weeks, 12 weeks, and 6 months).
If you take antiviral drugs for post exposure treatment, you should be checked for drug toxicity by having a complete blood count and
kidney and liver function tests just before starting treatment and 2 weeks after starting treatment.
You should report any sudden or severe flu-like illness that
occurs during the follow-up period, especially if it involves fever, rash, muscle aches, tiredness, malaise, or swollen glands.
Any of these may suggest HIV infection, drug reaction, or other medical conditions.
You should contact the healthcare provider managing your exposure if you have any questions or problems during the follow-up period.
What precautions should be taken during the follow-up period?
HBV
If you are exposed to HBV and receive post exposure treatment, it is unlikely that you will become infected and pass the infection on to others. No precautions are recommended.
HCV
Because the risk of becoming infected and passing the infection on to others after an exposure to HCV is low, no precautions are recommended.
HIV
During the follow-up period, especially the first 6-12 weeks when most infected
persons are expected to show signs of infection, you should follow recommendations for preventing transmission of HIV.
These include not donating blood, or organs. In addition, women should consider not breast-feeding infants during the follow-up period to prevent the possibility of exposing their infants to HIV that may be in breast milk.
Incidents involving blood or body fluids contaminated with the infectious agent for CJD
Usually suspected in areas of transplantation of cornea, Liver, heart
Immediately wash the wound/area with large amounts of soap and water and report the incident according to normal procedures for the health care establishment.
Responsibilities of infected health care workers
HCWs have an obligation to care for the safety of others in the workplace (this includes fellow workers and patients) under both common law and the Occupational Health and Safety and Welfare Act 1986.
Nominated risk categories
HCWs must not perform exposure-prone procedures if they are:
HIV antibody positive
HCV antibody positive and HCV RNA positive (by PCR or similar test); or
Hepatitis B e antigen (HBeAg) positive and/or HBV DNA positive at high titers.
Blood borne viruses such as HIV, HBV and HCV are all legally notifiable diseases and should be notified to the chief health officer.
An HCW infected with a blood borne virus should be assessed in consultation with their treating medical practitioner, who should make a recommendation about the continued involvement of the HCW in direct patient care.
The practitioner should also determine (and make recommendations to the employer) about the infected HCW’s ability to:
• Perform to the accepted professional standard without compromising the safety of others or themselves in the workplace; and
• Continue to comply with health regulations.
An HCW who undertakes exposure-prone procedures and who is infected with a blood borne virus should modify their work practices so that they no longer participate in exposure prone procedures where there is established evidence of a risk of transmission of infection from HCW to patient.
They should also undergo frequent medical follow-up by a medical practitioner with appropriate experience.
The HCW and/or the medical practitioner may seek confidential advice from a relevant registration board (medical, nursing, dental etc)
HCWs with a blood borne virus are not excluded from employment or functions they can safely perform under policies in place in the facility.
How can occupational exposures be prevented?
Many needle sticks and other cuts can be prevented by using safer techniques (for example, not recapping needles by hand), disposing of used needles in appropriate sharps disposal containers, and using medical devices with safety features designed to prevent injuries.
Using appropriate barriers such as gloves, eye and face protection, or gowns when contact with blood is expected can prevent many exposures to the eyes, nose, mouth, or skin.
Hepatitis B virus is largely preventable through vaccination.
For HCV and HIV preventing occupational exposures to blood can be prevented
This includes using appropriate barriers such as gown, gloves and eye protection as appropriate,
Safely handling needles and other sharp instruments, and using devices with safety features.
Precautions For Health Workers with Immunodeficiency Conditions
For their own protection, HCWs with significant immunodeficiency from any cause should not be involved in the care of patients with certain communicable diseases — for example, tuberculosis, varicella–zoster virus and cytomegalovirus (CMV).
Immunodeficient HCWs should be advised of the possible risks of live vaccines, including Bacille Calmette–Guerin (BCG) vaccine, that are available for HCWs in health care establishments.
Hepatitis B virus is largely preventable through vaccination.
For HCV and HIV preventing occupational exposures to blood can be prevented
This includes using appropriate barriers such as gown, gloves and eye protection as appropriate,
Safely handling needles and other sharp instruments, and using devices with safety features.
Precautions For Health Workers with Immunodeficiency Conditions
For their own protection, HCWs with significant immunodeficiency from any cause should not be involved in the care of patients with certain communicable diseases — for example, tuberculosis, varicella–zoster virus and cytomegalovirus (CMV).
Immunodeficient HCWs should be advised of the possible risks of live vaccines, including Bacille Calmette–Guerin (BCG) vaccine, that are available for HCWs in health care establishments.
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