WHO reports in the World Health Report 2002, that of the 35 million health-care workers, 2 million experience percutaneous exposure to infectious diseases each year. It further notes that 37.6% of Hepatitis B, 39% of Hepatitis C and 4.4% of HIV/AIDS in Health-Care Workers around the world are due to needlestick injuries.

Needlestick injuries (NSIs) as defined by the United States National Institute of Occupational Safety and Health are injuries caused by needles such as hypodermic needles, blood collection needles, intravenous (IV) stylets, and needles used to connect parts of IV delivery systems.

NSIs are common and to an extent inevitable in health-care workers (HCWs) during execution of their patient care services. Percutaneous exposure occurs as a result of a break in the skin caused by a needlestick or sharps contaminated with blood or body fluids. Mucocutaneous exposure occurs when body fluids come into contact with open wounds, nonintact skin such as found in eczema, or mucous membranes such as the mouth and eyes. HCWs are also exposed to droplets or splashes of blood, saliva, and urine. Percutaneous injury and splashes of fluids have been recognized as a source of exposure to blood-borne pathogens such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) for HCWs and responsible for a significant proportion of HBV, HCV, and HIV infections in this group

An assessment done by the WHO Eastern Mediterranean Regional Office shows an average of 4 needlestick injuries per year per health-care worker.

According to the Center for Disease Control and Prevention, only 10% of these injuries are reported

Risk of Infection after Exposure:

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.

The average risks 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.

The average risk of HIV infection after a needle stick or cut exposure to HIV-infected blood is 0.3%. The risk after exposure of the eye, nose, or mouth to HIV-infected blood is estimated to be on average, 0.1%. The risk after exposure of non-intact skin to HIV-infected blood is estimated to be less than 0.1%.

Management of NSI:

  • First aid to the site of exposure.
    • Do not squeeze blood
    • wash with soap & water
    • Flush / irrigate with water / sterile water for mucous membrane / eyes.
  • Promptly notify the designated personnel (ICN, HICC, Casualty Doctor)
  • Initiate baseline testing for the source & HCW for HBsAg, HCV & HIV.
  • Initiate Post Exposure Prophylaxis with 2 hours injury

Testing and Counselling

Healthcare workers – baselines serologist include tests for:

  • HBsAg (ELISA )
  • Anti-HBs titre
  • HCV antibody (ELISA)
  • HIV (ELISA )
  • Counsel the HCW. In high risk exposures counselling includes advice on safe sexual practice to protect the HCW’s Partner until the follow-up tests are negative.
  • Initiate PEP as early as possible.
  • Perform follow-up testing –
  1. If source is HIV positive
  2. Collect the details regarding the CD4/CD8 count, viral load and antiretroviral drug use of the source.
  3. Consult casualty medical officer on duty for counselling or need for prophylaxis.
  4. Post exposure prophylaxis for HIV positive patient and for unknown source.

Recommended regime :

  1. Lamivudine 150mg BD x 1 month.
  2. Stavudine 30mg BD x 1 month.
  3. Tab. Efaviranz 600mg OD X1month
  4. Test HIV status of the exposed by ELISA/CLIA at 6 weeks, 3 and 6 months
  5. For exposure to HCV, test for anti HCV and baseline LFT. Follow up testing for antibody at 3 months & 6 months

àAt 3 moths if Positive check HCV RNA quantitative

àRepeat after 4-6 weeks. If rising levels then treat.

  1. Hepatitis B serology is repeated at 1month & 6month intervals

Post exposure Prophylaxis for HBV

Recipient

vaccination

status

Recipient unvaccinated

against HBV

Recipient not fully

vaccinated against HBV (<3 doses)

Recipient fully vaccinated

against HBV but anti-HBs unknown

Recipient known

responder

to HBV vaccine,

ie anti-HBs≥10 mIU/ml

Source known to be HBsAg positive Give HBIG 0.06ml/kg

Start accelerated HBV

vaccine course (with HBV Vaccine at 0,1,2 months)

 

Give HBV vaccine dose. Test recipientanti-HBs levels.

Consider HBIG  if <10 mIU/ml. Recommend vaccination be

completed

Test recipientanti-HBs levels

Consider Booster dose of vaccine if <10 mIU/ml.

 

No need for further

vaccine dose

Source HBV status unknown but potential

high risk

Make every effort to test source for HBSAG.

Start accelerated HBV

vaccine (with HBV Vaccine at 0, 1,2 months). Recommend vaccination be

completed

Make every effort to test source for HBSAG.

Give HBIG 0.06ml/kg

Start accelerated HBV vaccine course (with HBV Vaccine at 0,1,2 months)

 

Make every effort to test source for HBSAG. Check for recipient Anti-HBs-levels. Give HBV vaccine booster dose No need for further

vaccine dose

Source HBV status unknown – no high risk features, Start accelerated HBV vaccine (with HBV Vaccine at 0, 1, 2 months). Recommend vaccination be

Completed

Give HBV vaccine dose. Recommend vaccination be

completed

Give HBV vaccine dose No need for further

vaccine dose

Source HBsAg negative Routine (opportunistic) HBV

vaccination course

Routine (opportunistic) HBV vaccination course No need for further vaccine dose No need for further

vaccine dose

  • Hepatitis B Immunoglobulin must be administered within 72 hrs of exposure to the virus. Active immunization with Hepatitis B vaccine should always be commenced in conjunction with administration of Hepatitis immunoglobulin in patients exposed to Hepatitis B virus

Prevention of NSI

  • Review the procedure to be performed ahead of time & plan the ways to prevent potential injuries, to protect yourself and your fellow workers.
  • Wear gloves during invasive procedures. Gloves have been shown to reduce the injection volume by 86% for solid needles & 50% for hollow needles.
  • Use disposable plastic items instead of glass whenever possible.
  • Do not recap, bend, break needles or manipulate needles & sharps.
  • Dispose of all sharps (needles, scalpel blade, ampoules etc) in puncture resistant containers. Do not remove needles from disposable syringes – discard the whole unit.
  • Employ one – handed scoop method for recapping needles when absolutely indicated.
  • Avoid ‘by – feel’ manipulations & hand retractions during surgeries.
  • Avoid stitching, suturing or the use of sharps without direct visualization.
  • Eliminate hand to hand passing of sharp instruments.

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