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Needle stick Injury
- 1. Needle StickNeedle Stick && Post Exposure ProphylaxisPost Exposure Prophylaxis
- 2. HCW/HCP Exposure – NSIHCW/HCP Exposure – NSI An exposure that might place HCP at risk for HBV, HCV, or HIV infection • A per-cutaneous injury (e.G., A needle-stick or cut with a sharp object) or • Contact of mucous membrane or non-intact skin (e.g., exposed skin that is chapped, abraded, or afflicted with dermatitis)
- 3. Worldwide, the 1st documented case of HIV transmission from patient to HCW was a UK nurse who sustained a needle-stick injury whilst obtaining blood from the arterial line of an African patient with AIDS.
- 4. Infections Transmitted By Sharps InjuryInfections Transmitted By Sharps Injury Blastomycosis Malaria Brucellosis Mycobacteriosis Cryptococcosis Mycoplasmosis Diphtheria Rocky Mountain fever Ebola fever Scrub typhus Gonorrhoea Staphylococcus aureus Hepatitis BHepatitis B Streptococcus pyogenes Hepatitis CHepatitis C Syphilis Herpes Toxoplasmosis HIVHIV Tuberculosis Leptospirosis
- 5. Cost Of ExposureCost Of Exposure • Infectious diseases→ disability or death • Psychological trauma →months of waiting, fear of outcome • Altered lifestyle • Side effects of prophylactic medications • Job discrimination →Loss of employment, lack of compensation
- 6. Most Likely CausesMost Likely Causes • Unsafe work practices (recapping, removal of phlebotomy tube holder) • Failure to dispose properly • Disposal system failures (overfull containers, needles sticking out of containers or piercing sides)
- 7. Needle-stick InjuriesNeedle-stick Injuries • Most frequently during & after an injectionMost frequently during & after an injection • Recapping, carrying needles and syringes • Patient movement (children) • Inappropriate disposal
- 8. 0%0% 5%5% 10%10% 15%15% 20%20% 25%25% 30%30% 35%35% 0.30% 3% 30% Hepatitis B Virus Hepatitis C Virus HIV Estimated Risk of Infection Following NSIEstimated Risk of Infection Following NSI
- 9. Determinants of Risk Of TransmissionDeterminants of Risk Of Transmission • Prevalence of virus in patient population • Type of exposure – percutaneous/ muco-cutaneous • Extent of injury – superficial/deep • Type of device – hollow bore/solid needle • Plasma viraemia of source • Immune status of HCW • Immediate aftercare and use of PEP
- 10. At Risk Exposures Percutaneous Injury Splash Risk is more with Hollow Needle > Solid Sharp Visible Blood Deep Injury Device In Pts Artery or Vein Non Intact Skin Mucous Membrane Larger Volume Severe Injury
- 11. Body fluids to whichBody fluids to which universal precautions applyuniversal precautions apply •Blood •Vaginal secretions •Semen •Cerebrospinal fluid •Synovial fluid •Pleural fluid •Peritoneal fluid •Amniotic fluid •Pericardial fluid •Other body fluids containing blood Universal precautionsUniversal precautions DODO NOTNOT apply toapply to •Feces •Tears •Sputum •Sweat •Urine •Vomitus •Nasal secretions
- 12. Prevent Needle-sticksPrevent Needle-sticks • Organizing physical layout of injection work area • Minimize handling of injection equipment • Do not carry, do not recap or bend • Cleaning the injection environment – before and after injections • Safe disposal to prevent injuries to public X
- 13. Standard PrecautionsStandard Precautions • Barriers Protection • Hand washing • Safe techniques • Safe handling of – Sharp items – Specimens – Spill of blood / body fluids • Use of Disposable / Sterile items
- 14. One-handed Scoop TechniqueOne-handed Scoop Technique
- 15. Immediate Management of -NSIImmediate Management of -NSI • STOP THE PROCEDURE IMMEDIATELY!!!STOP THE PROCEDURE IMMEDIATELY!!! • IMMEDIATELY clean Exposure site –The most importantIMMEDIATELY clean Exposure site –The most important part of PEPpart of PEP • Skin wounds should be washed with soap and running water • No evidence that antiseptics are useful • Caustic agents (bleach) may do more harm than good • Flush mucous membranes thoroughly with water (no soap) • Eyes irrigated with a liter of saline
- 16. Immediate Management of -NSIImmediate Management of -NSI • Report to the Casualty Medical Officer • Promptly notify your supervisor. • Fill out the Needle Stick Injury form
- 18. Post Exposure Prophylaxis For HIV
- 19. Rationale for HIV PEPRationale for HIV PEP • HIV infects dendritic cells then regional lymph nodes beforeHIV infects dendritic cells then regional lymph nodes before becoming systemicbecoming systemic • AZT blocks infectivity of HIV infected dendritic cells • Goal of PEP : halt viral replication before systemic infection is established • Retrospective study : Risk of Seroconversion: 81% lower in HCP’s who took AZT PEP. • Several animal studies showing efficacy • Peri-natal prophylaxis has been effective
- 20. For HIV-VIRUS Time Is EssenceFor HIV-VIRUS Time Is Essence • Animal studies show that PEP should be given within 2-8 hours of exposure for maximal effect • PEP may have some benefit up to 36 hrs but seems to be ineffective if given later
- 21. Exposure code (EC) Exposure EC 1 Mucous Membrane / skin integrity compromised , Small Vol, Few drops Short Duration EC 2 1. Mucous Membrane / skin integrity, large volume,long duration (several minutes or more ) 2. Percutaneous Exposure ,Less severe (solid needle/Superficial scratch) EC 3 Percutaneous, more severe Hollow needle, major wound , bloody device PEP-HIV Classification ofPEP-HIV Classification of ExposureExposure - NACO- NACO
- 22. Source CodeSource Code (SC)(SC) HIV status of SourceHIV status of Source SC 1SC 1 HIV +ve , Low Titer Exposure,HIV +ve , Low Titer Exposure, asymptomatic with High CD4 Countsasymptomatic with High CD4 Counts SC 2SC 2 HIV +ve, High Titer ExposureHIV +ve, High Titer Exposure ( Advanced AIDS, Primary HIV( Advanced AIDS, Primary HIV infection/High Viral load or Low CD4infection/High Viral load or Low CD4 Counts)Counts) UnKnownUnKnown Status or Source is UnknownStatus or Source is Unknown PEP-HIV Classification ofPEP-HIV Classification of SourceSource -NACO-NACO
- 23. Exposure code (EC) Source Code (SC) Treatment EC 1 SC 1 PEP may be warranted EC 1 SC 2 Consider Basic Regime EC 2 SC 1 Recommend Basic Regime ( most exposures in this category) EC 2 SC 2 Recommend Expanded Regime EC 3 SC 1or2 Recommend Expanded Regime 2/3 Unknown Consider basic regime PEP-HIV Treatment – NACO
- 24. Antiretrovirals For PEPAntiretrovirals For PEP • Reverse transcriptase inhibitors RTI • Nucleoside Reverse Transcriptase Inhibitors (NRTI) - Ziduvidine, Lamuvidine • Non nucleoside (NNRTI) - Nevirapine (not recommended) • Protease inhibitors (PI)-Nelfinavir,Indinavir • Single drug v/s multiple drugs for PEP - no direct supportive evidence • Theoretical advantage of adding an agent at a different level
- 25. PEP HIV - Drug RegimensPEP HIV - Drug Regimens • Basic Regimen ZIDOVIDINE 200 mg tid plus LAMIVUDINE 150 mg bid for 4 weeks • Expanded Reg Basic Regimen + INDINAVIR 800 mg tid or NELFINAVIR 750 mg tid or Selquinavir (softgel) 1200 mg tid
- 26. Post Exposure ProphylaxisPost Exposure Prophylaxis For Hepatitis BFor Hepatitis B
- 27. NSI :Hepatitis B - Risk of DiseaseNSI :Hepatitis B - Risk of Disease depends on the HBeAg statusdepends on the HBeAg status HBV Remains active in dried blood at Room TemperatureHBV Remains active in dried blood at Room Temperature for at least 1 Week Can be a major cause of transmissionfor at least 1 Week Can be a major cause of transmission Clinical Hepatitis Both +ve 22-31% Only HbsAg +ve 1-6% Seroconversion Both +ve 37-62% Only Hbs Ag +ve 23-37%
- 28. Hepatitis B Vaccination in HCPHepatitis B Vaccination in HCP GOOD NEWSGOOD NEWS • Those HCP’s who have been vaccinated; the vaccine offers virtually complete protection to responders. • Hence all HCP should be HB vaccinated BAD NEWSBAD NEWS • Most HCP’s are NOT vaccinated • 6-10% of vaccines do NOT develop antibody • Repeat vaccine series – 30-50% respond • Really bad news: CDC estimates that 50-75 HCW die from Hepatitis B each year
- 29. Exposure To Hep B – HCP ManagementExposure To Hep B – HCP Management HCP Vaccinated Antibody >10 iu/ml Antibody <10 iu/ml No Addl T/T Pt HBs Ag -ve Unknown Source Pt HBsAg +ve HCP:Booster dose or Complete series HCP:Booster dose or Complete series + HBIg HCP Not Vaccinated Immediate Vaccine – (within 7 days) Along with HBIg (0.06 ml/Kg)
- 30. Blood Test immediately and at 6 mths LFT and Anti HCV at 4 – 6 Mths Interferon not recommended for prophylaxis No Active Prophylaxis-Immunoglobulins not effective Determine status of Source (Anti-HCV) HEPATITIS C –HEPATITIS C – POST EXPOSURE MANAGEMENTPOST EXPOSURE MANAGEMENT
- 32. Be Needle SmartBe Needle Smart –Do NOT recap –Do NOT bend –Do NOT remove –Do NOT transport –Do NOT re-use
Notes de l'éditeur
- Photograph of poorly introduced cannula and reference to HIV in healthcare workers
- List of infections that can be transmitted by sharps injury. One needs to stress that not only HIV but a host of other infections can be potentially transmitted by needle stick injury including HCV and HBV which are 10 & 100 time more potent in their eficacy of transmission percutaneously. We are only now aware and afraid of needle stick injury though HBV and HCV is known to the mankind for many decades before we knew of HIV.
- NSI occur most commonly when we are trying to recap needles either before injection or after injection. When we carry needles in a tray from one point to another without the cap on due to sudden movement of patients in an attempt to withdraw away we prick ourselves or any other person standing nearby. Inappropriate disposal like throwing away casually in the dustbin or in isolated corners can prick us or any other person who steps on them. It is dangerous to try to bend or recap the needle and the best is to dispose it by standard method i.e. cutting the needle and the needle hub in a syringe cutter or putting the used syringe with needle in a puncture proof container.
- Graph showing the estimated risk of infection by the commonest three blood borne pathogens from an infected source to healthcare professional. If the source was infected with HBV then there is a 30% chance that the healthcare professional will develop Hepatitis B infection. The same is for Hepatitis C and HIV. But the fear in our minds is converse more for HIV and less for Hepatitis B & C.
- Description of the causes increasing risk of transmission of blood borne pathogens due to NSI. It is important to note that the risk of transmission depends on so many variables and hence it is important to elicit details of the type of exposure which will help us decide the type of post exposure prophylaxis to be started after such an exposure.
- At risk type of exposures. In a Percutaneous injury the risk is more from hollow needles with visible blood if the injury is deep or the device is introduced directly into the vein or Artery. In a splash on a non intact skin or mucous membrane has the highest risk. The risk is high if the exposure is to large volume of blood and body fluids or the injury is severe.
- The basic interventions which can prevent needle stick are having a proper layout of the injection OPD or our office area. Minimizing the handling of injection equipment by not carrying them from one point to another in bare hands by not recapping and trying to bend the needle after giving the injection. Proper cleaning of the OPD pre and post can also minimize the chances of infection being spread. Safe disposal as per GOI recommendations is also imperative.
- Standard precautions for safety of self and primary prevention of needle stick injury are thorough hand washing before each procedure taking care that the web spaces and creases are properly cleaned. Barrier protection using gloves gives added protection. Studies have shown that the incidences of NSI is the same with a single pair of gloves or no gloves, it is with the double gloves that the incidence dramatically falls. Proper techniques of giving injections minimize NSI to a great degree. Safe handling of all Sharps (broken glass, blades, needles, etc) and Biological specimens including blood and body fluids (peritoneal fluids, urine, etc), and usage of disposable or pre-sterile equipment minimizes the chances of spread of blood borne pathogens.
- Immediate management of NSI is one of the most important steps in the long process of efforts to minimize chances of spread of BBV due to sharps injury. Immediate cleaning of the injury site followed by washing of skin wounds with soap and running water for 15 minutes (by the clock literally) is of paramount importance. Mucous membranes are flushed thoroughly with water and eyes irrigated with a liter of saline at least. There is no evidence that antiseptics and disinfectants have any role.
- The rationale for PEP is to block the dendritic cells before they can get infected with HIV and halt viral replication before it becomes systemic. Studies have shown that the risk of seroconversion is significantly lower in HCP who have taken immediate PEP. In case of a pregnant female HCP, mother to child transmission is also negligible if immediate treatment is started. PEP should be started within 2 to 8 hours of exposure for maximal benefit. Delays in starting PEP may prove costly in the long run. The risk of HIV infection depends on the type of exposure. The highest incidences is because of NSI and 0 incidence if contact with intact skin. NACO has for purposes of scientific management of NSI coded the type and severity of exposure to infected blood and body fluids into three. They have also classified the source of infection based on the HIV status, CD4 counts and viral load into three. A combination of the severity and type of exposure coupled with the HIV status of the source patient determines what treatment regime has to be followed. The Available antiretrovirals are grouped in to two regimes the basic regimes and the expended regime. Generally the basic regime is two drug regime given for a period of 4 to 6 weeks. The expanded regime adds one more drug to the basic regime. Improper and intermittent treatment has started to throw up resistance to the PEP .In pregnant HCP PEP started immediately to stop any chances of mother to child transmission. Of those who do not take post exposure prophylaxis or fail to respond and become infected with HIV, seroconversion occurs within 6 to 12 weeks; co infection with HCV delays seroconversion to HIV. The average time from exposure to symptoms is 2 to 6 weeks but in 50 to 90% cases acute symptomatic seroconversion may develop.
- The rationale for PEP is to block the dendritic cells before they can get infected with HIV and halt viral replication before it becomes systemic. Studies have shown that the risk of seroconversion is significantly lower in HCP who have taken immediate PEP. In case of a pregnant female HCP, mother to child transmission is also negligible if immediate treatment is started. PEP should be started within 2 to 8 hours of exposure for maximal benefit. Delays in starting PEP may prove costly in the long run. The risk of HIV infection depends on the type of exposure. The highest incidences is because of NSI and 0 incidence if contact with intact skin. NACO has for purposes of scientific management of NSI coded the type and severity of exposure to infected blood and body fluids into three. They have also classified the source of infection based on the HIV status, CD4 counts and viral load into three. A combination of the severity and type of exposure coupled with the HIV status of the source patient determines what treatment regime has to be followed. The Available antiretrovirals are grouped in to two regimes the basic regimes and the expended regime. Generally the basic regime is two drug regime given for a period of 4 to 6 weeks. The expanded regime adds one more drug to the basic regime. Improper and intermittent treatment has started to throw up resistance to the PEP .In pregnant HCP PEP started immediately to stop any chances of mother to child transmission. Of those who do not take post exposure prophylaxis or fail to respond and become infected with HIV, seroconversion occurs within 6 to 12 weeks; co infection with HCV delays seroconversion to HIV. The average time from exposure to symptoms is 2 to 6 weeks but in 50 to 90% cases acute symptomatic seroconversion may develop.
- This slide shows the risk of Hepatitis B after an NSI and is dependant on the HBeAg status of the source. Incidence of clinical Hepatitis will be high if both ‘s’ and ‘e’ antigens are positive. Percentage of seroconversion is higher when both are positive and a bit low when only surface antigen is positive. It is also known that the hepatitis B virus can survive and remain active in a dried blood clot for up to a week at room temperatures. It is also highly sensitive to commonly available disinfectants and sterilization procedures.
- The good news about Hep B immunization in health care professionals is that those who have taken all the doses of vaccine at the right interval and have responded to the immunization have virtually complete protection. The bad news is that a lot of health care professionals are still not immunized. The level of response to the antigen comes down with increasing age. 6 to 10 percent of vaccines do not develop antibodies, in these it is imperative to repeat the vaccine series still only 30 to 50 percent of non responders develop immunity. CDC in the US estimate that 50 to 75 health care professional die every year due to complication of Hep B infections acquired due to sharps injury.
- Management of health care professionals exposed to Hep B infection is as follows: 1) All vaccinated health care professionals have to get a serum antibody titer done. If it is more than 10 mIU/ ml no additional treatment is required; if the titers are below this and the source patient is HBsAg negative a new series of vaccines is given. If the source person is HBsAg positive then a complete series of vaccine is started with initial dose of HB immunoglobulin and booster given later. 2) If not vaccinated than immediate vaccine series to be started within seven days of injury along with the HB immunoglobulin in the dose of 0.06 ml/Kg body weight to a maximum of 5.0 ml. HBIg should be given as early as possible, preferably within 12-24 hours along with the vaccine at a separate site. However if the HBIg is delayed due to any reason, it can be still be given up to 7 days beyond its efficacy is doubtful.
- PEP of Hep C is relatively simple as immunoglobulins are not very effective and interferons have not been recommended for prophylaxis. The anti HCV status of source should be determined if possible and HCP tested immediately and at 6 months for both LFT and anti HCV. Really speaking there is no effective anti-HVC prophylaxis treatment available and hence it is all the more important to prevent this infection avoiding needle stick injury.
- Finally to reiterate LET ALL BE NEEDLE SMART.