All facilities responsible for trauma care should monitor adherence to antimicrobial prophylaxis regimens.14 Special situation: care of combat injured secondary to suicide bomber/blast injury

Blast injuries, especially those related to suicide bomber attacks, present a unique bloodborne pathogen risk if an impaled body part is introduced into the trauma patient. There have been reported cases of Hepatitis B virus (HBV)-positive impaled bone fragments recovered from suicide bomber victims in Israel.15,16  This prompted the Israeli Ministry to provide post-exposure HBV vaccination as a practice. Since the initiation of the vaccine, HBV impaled fragments have been reported but no disease transmission.17

Prior to deployment, U.S. forces are required to receive a three-dose vaccine series, but 5-14% of vaccinated patients fail to achieve immunity (anti HBs <10 mlU/ml) which places them at increased risk of transmission.18,19 Thus we recommend attempting to verify anti-HBV status in those who are combat injured secondary to a suicide bomber and provide HBV immunoglobulin (HBIG) and HBV vaccine for those incompletely vaccinated with unknown titers or anti-HBs<10 mlU/ml. Recombinant Hepatitis B vaccine may be considered in those who have failed to respond to conventional Hepatitis B vaccine.

The risk of transmission for human immunodeficiency virus (HIV) is considered very low after blast injury and generally warrants no action.17  However, in the case of penetrating blast injury in a highly endemic region, expert teleconsultation should be obtained to discuss case specifics. Specific recommendations can be obtained via email (usarmy.jbsa.medcom-rhc-c.list.amedd-ic-consult@health.mil) or the AD.VI.S.OR hotline found at https://prolongedfieldcare.org/telemed-resources-for-us-mil/ or with infection prevention or infectious disease consultants (usarmy.jbsa.medcom-rhc-c.list.amedd-ic-consult@health.mil) or with infectious disease consultants through the AD.VI.S.OR hotline. Hepatitis C (HCV) prophylaxis is not recommended, but testing can be considered in penetrating blast injury at the time of injury and at two, four, and six months.20