NEEDLE STICK INJURY

Dr.G.Ashok M.D.,
Needle Stick Injury (NSI)

By definition,
Puncturing of the skin by a needle or similar sharp object

- Serious concern for health care professionals

Needle stick Injuries come under a category of sharp injuries.

Sharps are devices that are intentionally sharp to puncture or

cut skin (needles, scalpels, etc.), or become sharp due to
accident, such as broken glass tubes.

◦ Hypodermic needles
◦ Scalpels
◦ IV devices
◦ Capillary tubes
◦ Glass containers
◦ Pipettes
◦ Others
Magnitude of needle stick injury

The exact number of needle stick injury occuring annually is difficult to

calculate

- Lack of data from non hospital settings is a major obstacle

- In hospital settings the rate is

- India – it is largely underestimated

The WHO estimates about 3 million of the 35 million health care workers
worldwide are exposed to blood-borne pathogens each year
Who are at risk??

Any worker who may come in contact with contaminated needles is at risk

-doctors
-nursing staff,
-lab workers,
-housekeepers.

Predominantly HEALTH CARE WORKERS

Risk Involved

Significant
Injuries expose health care workers to diseases caused by bloodborne
pathogens.

The risk after exposure to infected blood has been estimated as:
Hepatitis B (risk ~30%)
Hepatitis C (risk ~10%)
HIV (risk ~0.3%)

Emotional distress
RISK OF INFECTON FOLLOWING A Needle Stick Injury DEPENDS ON,

the pathogen involved,

the immune status of the worker,
the severity of the needlestick injury
appropriate postexposure prophylaxis.
Hepatitis B Virus

The risk of transmisson of virus is highest in HBV following a NSI

The incidence of HBV following NSI has shown a rapid decline from 1980 s to
2000

The decline is due to widespread vaccination done for health care workers

Following an acute Hep B infection,

30 – 50 % of people develop jaundice, nausea and vomiting
Most resolve, 10 – 15 % develop chronic infection
In chronicity, 20 % develop cirrhosis in their lifetime
6 % has a lifetime risk of hepatocellular carcinoma.
HIV INFECTION

Percutaneous needle stick injury has an infectivity rate of 0.3 %

The risk may appear trivial, however,

it is a major concern for health care workers

The chances of transmission of HIV were found to be higher

If blood is visible in device

If needle is used in piercing artery or vein
A deeper injury
HCV infection

The incidence in health care workers is equal to general population

However, it is a major occupational hazard

Following HCV infection,

Acute infection is rare

70 % develop chronic HCV infection

10 – 20 % of active liver disease develop cirrhosis

1- 2% develop liver cell carcinoma
Methods of prevention of NSI

1. Report ALL needle stick injury

2. Switch to safer alternatives if available
3. DO NOT RECAP NEEDLES.
4. Safe handling and disposal of needles
5. Training and awareness programmes for needle stick injury
6. Hepatitis B vaccination to be made mandatory not only for doctors but
also lab technicians and housekeepers
7. If injury occurs follow a good Post Exposure Prophylaxis routine
Safe needle devices

Ideal safe device should have following characteristics

 The device is needleless.

 The safety feature is an integral part of the device.
 The safety feature cannot be deactivated and remains protective through
disposal.
 The device performs reliably.
 The device is easy to use and practical.
 The device is safe and effective for patient care.
BLUNT TIPPED
NEEDLE
 "Add on" Safety Feature

Retracting Finger Prick Lancets

SAFETY ENGINEERED
NEEDLE TIPS
NEEDLE FREE IV ACCESS
SAFE NEEDLE CLIPPER
POST EXPOSURE PROPHYLAXIS

By definition,

Post exposure prophylaxis (PEP) refers to the comprehensive management

given to minimize the risk of infection following potential exposure to
blood-borne pathogens (HIV, HBV, HCV).
This includes
- counselling,
- risk assessment,
- relevant laboratory investigations based on informed consent
of the source and exposed person,
- first aid and
- depending on the risk assessment, the provision of short term
(4 weeks) of antiretroviral drugs, with follow up and support.
Exposure” which may place an health care professional at risk of blood-
borne infection is defined as:

- a percutaneous injury (e.g. needle-stick or cut with a sharp instrument),

- contact with the mucous membranes of the eye or mouth,

- contact with non-intact skin (particularly when the exposed skin is

chapped, abraided, or afflicted with dermatitis),

- contact with intact skin when the duration of contact is prolonged (e.g.
several minutes or more) with blood or other potentially infectious body
fluids.
Priniciples of providing PEP

1. Non discriminatory
2. Confidentiality
3. Detailed informed consent

Institutions should follow Universal Precautions strictly to reduce incidence

of NSI
Universal precautions are intended to prevent the exposure of health-care
workers and patients to bloodborne pathogens.

These must be practised in regard to the blood and body fluids of all
patients, regardless of their infection status.
Universal precautions include:
1. Hand-washing before and after all medical procedures
2.Safe handling and immediate safe disposal of sharps:
not recapping needles;
using special containers for sharp disposals;
using needle cutter/destroyers;
using forceps instead of fingers for guiding sutures;
using vacutainers where possible
3. Safe decontamination of instruments;
4. Use of protective barriers whenever indicated to prevent direct contact
with blood and body fluid such as
gloves, masks, goggles, aprons, and boots.

5.A HCP who has a cut or abrasion should cover the wound before providing
care
PEP for HIV

1. A rapid baseline testing of HIV both for source as well as patient has to be
done as soon as possible

2. PEP to be initiated as early as possible preferably within 2 hours and

within 72 hours

3. Initiation of PEP should not be delayed while waiting for the results of
HIV testing of the source of exposure.

4. Informed consent should be obtained before testing of the source as

per
national HIV testing guidelines.
STEPS FOLLOWED IN PEP

STEP 1 Manage exposed site

STEP 2 Establish eligibility for PEP

STEP 3 Counsel for PEP

STEP 4 Prescribe PEP

STEP 5 Laboratory Evaluation

STEP 6 Follow up, Monitoring and Adherence

Categories of exposure

Mild exposure Mucous membrane/non-intact skin with small

volumes

Moderate exposure Mucous membrane/non intact skin with large

volumes
or

Percutaneous superficial exposure with solid

needle

Severe exposure Percutaneous with large volume

Categories based on test result of source

HIV negative Source is not HIV infected but consider HBV and
HCV

Low risk HIV positive and clinically asymptomatic

High risk HIV positive and clinically symptomatic

Unknown Status of the patient is unknown, and neither the

patient nor his/her blood is available for testing

(e.g. injury during medical waste management the

source patient might be unknown).

In a region with high HIV prevalence a negative result is of less value due to
the high possibility of window period
Drugs Used

Zidovudine (AZT) 300 mg twice a day

Stavudine (d4T) 30 mg twice a day
Lamivudine (3TC) 150 mg twice a day

Protease Inhibitors 1st choice : Lopinavir/ritonavir (LPV/r)

2nd choice : Nelfinavir (NLF)
3rd choice : Indinavir (IND)
drink 8–10 glasses of water everyday to
prevent stones
Regimen 2-drug regimen
1st choice: Zidovudine (AZT) + Lamivudine (3TC)
2nd choice: Stavudine (d4T) + Lamivudine
3 drug regimen expert opinion needed on third drug

NOT RECOMMENDED ddI + d4T combination

NNRTI such as Nevirapine should not be used in PEP
Hepatitis B Virus

HBV vaccination status of exposed Action after exposure

person
Never vaccinated Give complete hepatitis B vaccine series
HEP B IV Ig , 0, 1 and 6 months of Hep B
recombinant sub unit vaccine

Vaccinated, anti-HB-S not known Give Hep B Vaccine Booster

Vaccinated more than 5 years ago Give Hep B Vaccine Booster

Hepatitis C Virus

No prophylaxis available against hepatitis C.

No evidence that interferon, with or without ribavirin is effective.

Post-exposure management for HCV is based on early identification

of chronic HCV disease.