Dr. Ashish Jawarkar

NEEDLE STICKS AND SHARPS INJURIES

FACTS , LEGAL CONCERNS, AND CARE

Dr. Ashish V. Jawarkar 1

THE PROBLEM• ~385,000 sharps injuries annually among hospital-

based healthcare personnel (>1,000 injuries/day)• Many more in other healthcare settings (e.g., emergency

services, home care, nursing homes)

• Increased risk for blood borne virus transmission

• Costly to personnel and healthcare system

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Exposures which place health personnel at risk of blood borne

infection –

• A percutaneous injury e.g. Needle stick injury (NSI) or cut with a sharp instrument

• Contact with the mucous membrane of eye or mouth• Contact with non-intact skin (abraded skin or with

dermatitis)• Contact with intact skin when the duration of contact is

prolonged with blood or other potential infected body fluids

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WHO IS AT RISK ? - • Nursing Staff

• Emergency Care Providers

• Labor & delivery room personnel

• Surgeons and operation theater staff

• Lab Technicians

• Dentists

• Health cleaning/ mortuary staff / Waste Handlers

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WHO GETS INJURED?

Nurse43%

Technician15%

Student4%

Dental1%

Housekeeping/Maintenance

3%

Clerical / Admin

1%

Other5%

Physician28%

Occupational Groups of Healthcare

Personnel Exposed to Blood/Body

Fluids,

NaSH June 1995—December 2003

(n=23,197)

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HOW DO INJURIES OCCUR WITH HOLLOW-BORE NEEDLES?

During Sharps Disposal

13%

During Clean Up9%

In Transit to Disposal

4%

Handle/Pass Equipment

6%

Improper Disposal

9%

Access IV Line5%

Transfer/Process Specimens

5%

Recap Needle6%

Collision W/Worker or

Sharp10%

Manipulate Needle in Patient

28%

Other5%

Circumstances Associated with Hollow-Bore Needle Injuries NaSH June 1995—December 2003 (n=10,239)

Disposal Related:

35%

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WORK PRACTICES WHICH INCREASE THE RISK OF NEEDLE STICK INJURY

• Recapping needles (Most important)• Performing activities involving needles and sharps in a

hurry • Handling and passing needles or sharp after use• Failing to dispose of used needles properly in puncture-

resistant sharps containers• Poor healthcare waste management practices• Ignoring Universal Work Precautions

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• Hypodermic needles

• Blood collection needles

• Suture needles

• Needles used in IV delivery systems

• Scalpels

WHAT KINDS OF DEVICES USUALLY CAUSE SHARPS

INJURIES?

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WHAT INFECTIONS CAN BE CAUSED BY SHARP INJURIES?

Sharps injuries can expose workers to a number of blood borne pathogens that can cause serious or fatal infections. The pathogens that pose the most serious health risks are• Hepatitis B virus (HBV)

• Hepatitis C virus (HCV)

• Human immunodeficiency virus (HIV)

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RISKS OF SEROCONVERSION DUE TO SHARPS INJURY

FROM A KNOWN POSITIVE SOURCE

Virus

HBVHCVHIV

Risk (Range)

6-30%*~ 2%

0.3%

(*Risk for HBV applies if not HB vaccinated)

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WHAT IS THE RISK FOR HIV ALONE?

• Percutaneous 0.3%

• Mucous membrane 0.1%

• Non-intact skin <0.1%

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• Who gets injured?

• Where do they happen?

• When do injuries occur?

• What devices are involved?

• How can they be prevented?

HOW DO SHARPS INJURIES HAPPEN?

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WORK PRACTICES WHICH INCREASE THE RISK OF NEEDLE STICK INJURY

• Recapping needles (Most important)• Performing activities involving needles and sharps in a

hurry • Handling and passing needles or sharp after use• Failing to dispose of used needles properly in puncture-

resistant sharps containers• Poor healthcare waste management practices• Ignoring Universal Work Precautions

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RISK FACTORS FOR HIV SEROCONVERSION IN HCWS

Risk Factor Adjusted Odds Ratio*

Deep Injury 15.0

Visible Blood on Device 6.2

Terminal Illness in Source Patient 5.6

Needle in Source Vein/Artery 4.3

From: NEJM 1997;337:1485-90.

*All Risk Factors were significant (P < 0.01)

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• Report all needle stick and sharps-related injuries promptly to ensure that you receive appropriate follow-up care.

• Tell your employer about any sharps hazards you observe.

• Participate in training related to infection prevention.

• Get a Hepatitis B vaccination.

PROTECTING YOURSELF …

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A. CATEGORIES OF EXPOSURE

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Category Definition and Example

Mild exposure

Mucous membrane/non-intact skin with small volumes e.g. a superficial wound with a low caliber needle, contact with eyes or mucous membrane, subcutaneous injections with a low caliber needle.

Moderate exposure

Mucous membrane/non-intact skin with large volumes or percutaneous superficial exposure with solid needle e.g. a cut or needle stick injury penetrating gloves.

Severe exposure

percutaneous exposure with large volumes e.g. an accident with a high caliber needle visibly contaminated with blood, a deep wound, an accident with material that has been previously been used intravenously or intra-arterially

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POST EXPOSURE PROPHYLAXIS (PEP)

It refers to the comprehensive management to minimize the risk of infection following potential exposure to blood borne pathogens (HIV, HBV, HCV ).It includes –

First AidRisk Assessment CounselingPEP drugs (4Weeks) depending upon risk assessment Relevant Lab Investigation on informed consent of the source and exposed personFollow up and support

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MANAGEMENT OF EXPOSED PERSON1st step: Management of exposed site - First Aid

Skin: Do not squeeze the wound to bleed it, do not put the pricked finger in mouth. Wash with soap &water, don’t scrub, no antiseptics or skin washes (bleach, chlorine, alcohol, betadine).

Eye: wash with water/ normal saline/ don’t remove contact lens immediately if wearing, no soap or disinfectant.

Mouth: spit fluid immediately, repeatedly rinse the mouth with water and spit / no soap/ disinfectant.

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2ND STEP: ESTABLISH ELIGIBILITY FOR PEP

Evaluation must be made rapidly so as to start treatment as soon as possible-ideally within 2hours but certainly within 72 hours of exposure. However all exposed cases don’t require prophylactic treatment.

Factors determining the requirement of PEP-

Nature/Severity of exposure and risk of transmission HIV status of the source of exposure HIV status of the exposed individual

3 rd step : administer PEPStatus of index case PEP Follow up

HIV Positive HAART (zido+lami) within 1-2 days, continue for 28 days

Check HIV antibody levls at 6 weeks, 3 months and 6 months

Negative Counselling only Do

HBV [psotove Counselling

HBIG prophylaxis

Not required

Negative Counselling Not required

HCV Positive No prophylaxis available

Treatment if disease occurs

Check anti HCV at 3 and 6 month

QUICK FACT:

HBV VACCINATION IS RECOMMENDED FOR ALL HEALTHCARE WORKERS (UNLESS THEY

ARE IMMUNE BECAUSE OF PREVIOUS EXPOSURE). HBV VACCINE HAS PROVEN TO

BE HIGHLY EFFECTIVE IN PREVENTING INFECTION IN WORKERS EXPOSED TO HBV.

HOWEVER, NO VACCINE EXISTS TO PREVENT HCV OR HIV INFECTION.

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SUPREME COURT DIRECTIVE TO ENSURE PEP DRUGS IN ALL GOVERNMENT HOSPITALS IN INDIA

1. Universal Work Precautions (UWP) and PEP guidelines should be followed by HCPs to prevent occupational transmission of HIV, Hepatitis B and hepatitis C.

2. This will develop confidence in HCPs while working with patients some of whom might be infected with HIV/HBV/HCV.

3. PEP drugs should be available in all Govt Hospitals to enable protection of HCPs dealing with potentially infected patients to make sure that no patients suffering from HIV be denied treatment/surgery/ procedures etc

4. Availability of UWP and PEP can minimize the stigma and discrimination against PLHIVs in Health Care facilities.

5. Above regulations to be practiced in Private hospitals and Establishments

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RESPONSIBILITY OF HEAD OF THE INSTITUTION

• To ensure that the hospital has a written protocol to handle exposure and the same is displayed at prominent locations within the hospital for information of staff.

• Sensitization of Doctors, Nurses, Paramedics & waste handlers

• To ensure that Universal precautions are followed.• Availability of Personal protective equipment.• Dissemination of procedure to be followed in case of

accidental exposure to Blood and Body fluids• Availability of Rapid HIV test kits.• Availability of other preventive measures including

vaccinations.

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AVAILABILITY OF PEP AT HEALTHCARE FACILITY

It is recommended that PEP drugs be kept available round-the-clock in any of the three locations - Emergency room, Labor room and ICU.

Drug Stock at the Healthcare facility

PEP kit comprises of 2 drug regimen:

Zidovudine(AZT) 300mg + Lamivudine (3TC) 150 mg as a fixed dose combination

WHAT ARE STRATEGIES TO ELIMINATE SHARPS INJURIES?

• Eliminate or reduce the use of needles and other sharps

• Use devices with safety features to isolate sharps

• Use safer practices to minimize risk for remaining hazards

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DO NOT FORGET HEPATITIS B VACCINATION AND UNIVERSAL PRECAUTIONS ……..

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THANK YOU