Needlestick injuries

From Ganfyd

(Redirected from Needlestick injury)
Jump to: navigation, search

Needles and other sharps may cause injuries to people working in healthcare environments, either during their use or afterwards by their improper disposal. Such injuries can be occupational, in the case of doctors and nurses, but porters and cleaning staff may also be affected. There are also community acquired injuries, occurring outside of hospitals and health care settings, usually relating to injecting drug use. Police officers and paramedics may sustain injuries during encounters with drug users, else needles are discarded improperly into the environment. In addition to accidental occupational or non-occupational contact, children are known to play with found sharps and even to imitate drug taking behaviour.[1] [2] [3]

Guidelines exist on the prevention of tetanus and blood borne viruses from such injuries, generally in agreement with each other. [4][5][6][7] [8][9] These are discussed in more detail below.

The risks of blood borne virus transmission appear to be small, given prior immunization and use of post-exposure prophylaxis. But the high prevalence of Hepatitis C in the drug using population and the absence of a vaccine or post-exposure prophylaxis regimen will continue to cause concern.

Contents

Prevention

Ingeniously designed device
  • "No-hands" transfer of sharps, e.g. passing scalpel in metal dish
  • Safe and prompt disposal of sharps.
  • Protective gear where possible (gloves, aprons, eye-protection, etc.)
  • Ingeniously designed devices which cover the needle after it has been used.
  • Avoidance, wherever possible, of exposure-prone procedures.

Complications

  • Tissue damage as for any other non-contaminated injury with identical mechanism.
  • Tetanus - see Green Book.
  • Blood Borne Viruses

Blood Borne Viruses

Hepatitis A has spread in epidemic form among injecting drug users by unhygienic injection practices.[10] HTLV-II (Human T-cell Lymphotropic Virus type II) has been documented among European injecting drug users, but is not routinely tested for and in the UK only 2 cases have been attributed to injection practices, with a further case possibly due to needlestick injury.[11][12]

The more usual suspects are Hepatitis B, C and HIV.

Hepatitis B

Of the three viruses, HBV has the highest transmission risk as it has the highest virus titres in untreated individuals and is viable for the most prolonged periods in needle syringes stored at room temperature.[13] The risk of contracting disease from a single percutaneous exposure to HBV-infected blood without any post exposure prophylaxis is very high, ranging from 6% to more than 30%. High rates are associated with exposure to HBeAg-positive blood.[14]

There have been very few if any cases of HBV transmission in occupational settings since post-exposure prophylaxis with hepatitis B vaccine has been available, and now that immunisation of healthcare workers is routine.[15] Post-exposure prophylaxis may still be necessary where immunisation has been missed or ineffective. An accelerated course of hepatitis B vaccine with doses at 0, 1, and 2 months is recommended, ideally starting within 48 hours of exposure, and not longer than 7 days post exposure. A booster dose at 12 months is recommended for those at continuing risk. Specific immunoglobulin (HBIG) is recommended where the source is known to be hepatitis B positive. [16]

Hepatitis C

Estimates of the risk of acute HCV infection following a percutaneous injury from an HCV positive source vary between 0 and 10% across studies.[17] The risk obviously depends on the prevalence of the disease in the population. Where the source has a high viraemia, the risk is considerably higher.

There is no established post-exposure prophylaxis protocol. Some cases develop a transient viraemia and antibody response. Antivirals are used for HCV disease, and early treatment of new infections where spontaneous clearance does not take place has been validated.[18]

HIV

There have been at least 5 cases of HIV infection occurring through needlestick injury, all occupational.[19] The risk of transmission of HIV from a known source is estimated at 0.29-0.56%.[20] Logistic-regression analysis based on 33 cases and 665 controls showed that significant risk factors for HIV seroconversion were:

  • deep injury (OR=15; 95% CI 6.0-41)
  • injury with a device that was visibly contaminated with the source patient's blood (OR=6.2; 95% CI 2.2-21)
  • a procedure involving a needle placed in the source patient's artery or vein (OR=4.3; 95% CI 1.7-12)
  • exposure to a source patient who died of AIDS within two months (OR=5.6; 95% CI 2.0-16).
  • large bore (>18) needle (OR=14, 95% CI 4.9-39)

Use of zidovudine post-exposure prophylaxis was about 80% protective (OR=0.19; 95% CI 0.06-0.52).[21] There have been at least 2 cases of fulminant hepatic failure with HIV post-exposure prophylaxis.[21] [22] More recent protocols do not include nevirapine, the agent most likely responsible for hepatic failure, but instead recommend zidovudine (or stavudine) and lamivudine, with or without Kaletra or nelfinavir, for low risk cases.[5][23][8][24] Post-exposure prophylaxis is probably of no benefit if started later than 72 hours after exposure and should ideally start as soon as possible.

Testing the sharp/source

Testing the sharp or source may clarify whether or not virus exposure has occurred. It is not currently advised for unknown sources, and it is unclear whether a positive result would significantly increase the risk of transmission. It would probably enhance compliance with post-exposure prophylaxis and follow up. Where the source is known, the issue of confidentiality would need to be considered before testing and disclosure could be made.[25]

Survival of viruses in the environment

Hepatitis viruses and HIV can be detected outside the human body for at least several weeks, and possibly for up to 12 months.[26] [13] [27] Detection of virus outside the body is influenced by virus titre, volume of blood, ambient temperature, exposure to sunlight and humidity. In a simulation study, blood borne viruses could be detected by enzyme linked immunosorbent assay (ELISA) in blood residues and from needle tips for up to 5 weeks.[28] In contrast, HIV proviral DNA could not be found in 28 syringes found outdoors or 10 syringes from needle exchange programme.[29] But it is not clear whether a positive result (for DNA, enzymes, RNA, etc) equates to the virus actually retaining the ability to infect.

Community Acquired Injuries

HBV post-exposure prophylaxis should be offered. Since the source is generally unknown, HBIG is not recommended. HIV post-exposure prophylaxis on the other hand should only be started in exceptional circumstances, eg if the source is known to be positive, if the injury was particularly deep or if there was fresh blood in the syringe. Where it is started, 16-96% of patients do not complete the full 4 week course, which may relate to side effects, the degree of parental motivation or cost considerations.[1] [3] [30] [31] Low motivation may relate to attempts to reassure families that there is minimal risk of infection.

Children

There have been 13 studies looking at community acquired needlestick injury in children.[1] [3] [30] [32] [33] [34] [35] [36] [37][31] [38] [39] [40] [31] Some of these studies describe mass exposure incidents, others describe a series of patients. In most, HBV vaccine was offered, and in some HBV immunoglobulin was offered. Most looked at all 3 viruses of interest. In only 1 study was seroconversion seen - a case of HBV in which post exposure prophylaxis was not given.9859551 Evidence of transient infection with HBV was seen in several other patients in this same study. However, follow up rates across the different studies were variable and sometimes poor.

There has been only 1 other report of CANSI associated with a blood borne virus infection in a child.[41] In this case, a patient presented with hepatitis and HBV infection, and retrospectively CANSI was the most likely mode of transmission; HBV immunisation had not been offered.

Adults

There are only a few adult studies, and some relate to police officers which may reflect a different risk group.[31] [38][42] 11957386 15710272 [43] To date there has not been a single report of HIV or HBV seroconversion from CANSI among adults. 3 cases of HCV seroconversion were reported recently.[44] [45]So discarded needles appear to pose a small but not negligible risk.

Blood Borne Virus Prevalence

The risk of an unknown source depends on background virus prevalence. Estimating the prevalence of blood borne viruses among injecting drug users (IDUs) is difficult, and different methods are used in different regions. The prevalence of HIV among current injecting drug users in 2007 was 1.1% in England and Wales, varying regionally. In London, the prevalence was 4.4%. In Scotland in 2005, 0.3% of injecting drug users undergoing HIV testing were positive.[46] The prevalence of HCV antibodies among current injecting drug users in 2007 was 40% in England and Wales. In Scotland it varies from 28% in Dumfries & Galloway to 71% in Greater Glasgow, and is around 44% overall.[47]Data for HBV is even less informative. In England, Wales and Northern Ireland in 2007 15% of current and former injecting drug users were positive for HBV core antibody, demonstrating past exposure but not necessarily infectivity. There is no reliable data for the prevalence of HBV in Scotland - it is around 19% but again varies regionally.[48] Prevalence of HBV surface antigen is closely related to vaccination coverage which continues to increase; but new cases continue to be reported in the injecting drug user population.[49]

External Reference

References

  1. ↑ a b c de Waal N, Rabie H, Bester R, Cotton MF. Mass needle stick injury in children from the Western cape. Journal of tropical pediatrics. 2006 Jun; 52(3):192-6.(Link to article – subscription may be required.)
  2. ↑ Wyatt JP, Robertson CE, Scobie WG. Out of hospital needlestick injuries. Archives of disease in childhood. 1994 Mar; 70(3):245-6.
  3. ↑ a b c Thomas HL, Liebeschuetz S, Shingadia D, Addiman S, Mellanby A. Multiple needle-stick injuries with risk of human immunodeficiency virus exposure in a primary school. The Pediatric infectious disease journal. 2006 Oct; 25(10):933-6.(Link to article – subscription may be required.)
  4. ↑ Immunisation against infectious disease. Salisbury DM and Begg NT, editors. The Stationery Office; 2006.
  5. ↑ a b Merchant RC, Mayer KH, Browning CA. Development of guidelines on nonoccupational HIV postexposure prophylaxis for the state of Rhode Island. Public health reports (Washington, D.C. : 1974). 2004 Mar-Apr; 119(2):136-40.
  6. ↑ HIV post-exposure prophylaxis: Guidance from the UK Chief Medical Officer's Expert Advisory Group on AIDS. Department of Health 2008
  7. ↑ Injuries from discarded needles in the community. In: Pickering LK, editor. Red Book: 2006 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics. p188-91.
  8. ↑ a b Havens PL. Postexposure prophylaxis in children and adolescents for nonoccupational exposure to human immunodeficiency virus. Pediatrics. 2003 Jun; 111(6 Pt 1):1475-89.
  9. ↑ Tudor-Williams G. Post-exposure prophylaxis (PEP) guidelines for children exposed to blood-borne viruses. CHIVA Children's HIV Association of UK and Ireland. September 2007.
  10. ↑ Roy K, Howie H, Sweeney C, Parry J, Molyneaux P, Goldberg D, Taylor A. Hepatitis A virus and injecting drug misuse in Aberdeen, Scotland: a case-control study. Journal of viral hepatitis. 2004 May; 11(3):277-82.(Link to article – subscription may be required.)
  11. ↑ Krook A, Blomberg J. HTLV-II among injecting drug users in Stockholm. Scandinavian journal of infectious diseases. 1994; 26(2):129-32.
  12. ↑ Dougan S, Smith A, Tosswill JC, Davison K, Zuckerman M, Taylor GP. New diagnoses of HTLV infection in England and Wales: 2002-2004. Euro Surveill. 2005;10(10):pii=569.
  13. ↑ a b Thompson SC, Boughton CR, Dore GJ. Blood-borne viruses and their survival in the environment: is public concern about community needlestick exposures justified? Australian and New Zealand journal of public health. 2003 Dec; 27(6):602-7.
  14. ↑ Goldmann DA. Blood-borne pathogens and nosocomial infections. The Journal of allergy and clinical immunology. 2002 Aug; 110(2 Suppl):S21-6.
  15. ↑ Failde I, López FJ, Córdoba JA, Zarzuela M, Benítez E, Senabre V. Evolution and factors associated with biological-risk accidents reported in a university hospital in Spain, 1989 to 1995. Clinical performance and quality health care. 1998 Jul-Sep; 6(3):103-8.
  16. ↑ Green book
  17. ↑ Kubitschke A, Bader C, Tillmann HL, Manns MP, Kuhn S, Wedemeyer H. Injuries from needles contaminated with hepatitis C virus: how high is the risk of seroconversion for medical personnel really?. Der Internist. 2007 Oct; 48(10):1165-72.(Link to article – subscription may be required.)
  18. ↑ Santantonio T, Fasano M, Sinisi E, Guastadisegni A, Casalino C, Mazzola M, Francavilla R, Pastore G. Efficacy of a 24-week course of PEG-interferon alpha-2b monotherapy in patients with acute hepatitis C after failure of spontaneous clearance. Journal of hepatology. 2005 Mar; 42(3):329-33.(Link to article – subscription may be required.)
  19. ↑ Marcus R. Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus. The New England journal of medicine. 1988 Oct 27; 319(17):1118-23.
  20. ↑ Lee JM, Botteman MF, Xanthakos N, Nicklasson L. Needlestick injuries in the United States. Epidemiologic, economic, and quality of life issues. AAOHN journal : official journal of the American Association of Occupational Health Nurses. 2005 Mar; 53(3):117-33.
  21. ↑ a b Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboul D, Heptonstall J, Ippolito G, Lot F, McKibben PS, Bell DM. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. The New England journal of medicine. 1997 Nov 20; 337(21):1485-90.
  22. ↑ Serious adverse events attributed to nevirapine regimens for postexposure prophylaxis after HIV exposures--worldwide, 1997-2000. MMWR. Morbidity and mortality weekly report. 2001 Jan 5; 49(51-52):1153-6.
  23. ↑ HIV post-exposure prophylaxis: Guidance from the UK Chief Medical Officer's Expert Advisory Group on AIDS. Department of Health 2008
  24. ↑ Tudor-Williams G. Post-exposure prophylaxis (PEP) guidelines for children exposed to blood-borne viruses. CHIVA Children's HIV Association of UK and Ireland. September 2007.
  25. ↑ Mayo TW. Managing and reporting community incidents: Ethical considerations. The Pediatric infectious disease journal. 2006 Oct; 25(10):937-8.(Link to article – subscription may be required.)
  26. ↑ Bowden S, Druce J, Kelly H. Stability of blood-borne viruses in the environment and risk of infection. Victorian Infect. Dis. Bull. 1999; 2: 71–2
  27. ↑ Heimer R, Khoshnood K, Jariwala-Freeman B, Duncan B, Harima Y. Hepatitis in used syringes: the limits of sensitivity of techniques to detect hepatitis B virus (HBV) DNA, hepatitis C virus (HCV) RNA, and antibodies to HBV core and HCV antigens. The Journal of infectious diseases. 1996 Apr; 173(4):997-1000.
  28. ↑ Cattaneo C, Nuttall PA, Sokol RJ. Detection of HIV, hepatitis B and hepatitis C markers in discarded syringes and bloodstains. Science & justice : journal of the Forensic Science Society. 1996 Oct-Dec; 36(4):271-4.
  29. ↑ Zamora AB, Rivera MO, García-Algar O, Caylà Buqueras J, Vall Combelles O, García-Sáiz A. Detection of infectious human immunodeficiency type 1 virus in discarded syringes of intravenous drug users. The Pediatric infectious disease journal. 1998 Jul; 17(7):655-7.
  30. ↑ a b Papenburg J, Blais D, Moore D, Al-Hosni M, Laferrière C, Tapiero B, Quach C. Pediatric injuries from needles discarded in the community: epidemiology and risk of seroconversion. Pediatrics. 2008 Aug; 122(2):e487-92.(Link to article – subscription may be required.)
  31. ↑ a b c d Kowalska JD, Firlag-Burkacka E, Niezabitowska M, Bakowska E, Ignatowska A, Pulik P, Horban A. Post-exposure prophylaxis of HIV infection in out-patient clinic of hospital for infectious diseases in Warsaw in 2001-2002. Przegla̧d epidemiologiczny. 2006; 60(4):789-94.
  32. ↑ Aragón Peña AJ, Arrazola Martínez MP, García de Codes A, Dávila Alvarez FM, de Juanes Pardo JR. Hepatitis B prevention and risk of HIV infection in children injured by discarded needles and/or syringes. Atencion primaria / Sociedad Española de Medicina de Familia y Comunitaria. 1996 Feb 15; 17(2):138-40.
  33. ↑ Gómez Campderá J, Rodríguez Fernández R, Navarro Gómez M, González Sánchez MI. Accidental contact with syringes used by intravenous drug users (IDU): a decade of study. Anales españoles de pediatría. 1998 Oct; 49(4):375-80.
  34. ↑ Szenborn L. Owoc-Lempach J. Mordak M. Czerniak T. Klinowska J. Kacprzak-Bergman I. Accidental needlestick injuries by children - Prophylaxis of HBV and HIV infections in children - Own experiences. Pediatria Polska. Vol. 81(9)(pp 650-655), 2006.
  35. ↑ Slinger R, Mackenzie SG, Tepper M. Community-acquired needle stick injuries in Canadian children: Review of Canadian Hospitals Injury Reporting and Prevention Program data from 1991 to 1996. Paediatr Child Health 2000; 5(6): 324-8
  36. ↑ Russell FM, Nash MC. A prospective study of children with community-acquired needlestick injuries in Melbourne. Journal of paediatrics and child health. 2002 Jun; 38(3):322-3.
  37. ↑ Makwana N, Riordan FA. Prospective study of community needlestick injuries. Archives of disease in childhood. 2005 May; 90(5):523-4.(Link to article – subscription may be required.)
  38. ↑ a b O'Leary FM, Green TC. Community acquired needlestick injuries in non-health care workers presenting to an urban emergency department. Emergency medicine (Fremantle, W.A.). 2003 Oct-Dec; 15(5-6):434-40.
  39. ↑ Nourse CB, Charles CA, McKay M, et al. Childhood needle stick injuries in the Dublin metropolitan area. Ir Med J 1997;90:66–9.
  40. ↑ Babl FE, Cooper ER, Damon B, Louie T, Kharasch S, Harris JA. HIV postexposure prophylaxis for children and adolescents. The American journal of emergency medicine. 2000 May; 18(3):282-7.
  41. ↑ García-Algar O, Vall O. Hepatitis B virus infection from a needle stick. The Pediatric infectious disease journal. 1997 Nov; 16(11):1099.
  42. ↑ Welch J. Risk to Metropolitan police officers from exposure to hepatitis B. BMJ 1988;297:835
  43. ↑ Hoffman RE. Henderson N. O'Keefe K. Wood RC. Occupational exposure to human immunodeficiency virus (HIV)-infected blood in Denver, Colorado, police officers. American Journal of Epidemiology 1994; 139(9):910-917
  44. ↑ Haber PS, Young MM, Dorrington L, Jones A, Kaldor J, De Kanzow S, Rawlinson WD. Transmission of hepatitis C virus by needle-stick injury in community settings. Journal of gastroenterology and hepatology. 2007 Nov; 22(11):1882-5.(Link to article – subscription may be required.)
  45. ↑ Libois A, Fumero E, Castro P, Nomdedeu M, Cruceta A, Gatell JM, Garcia F. Transmission of hepatitis C virus by discarded-needle injury. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2005 Jul 1; 41(1):129-30.(Link to article – subscription may be required.)
  46. ↑ Health Protection Agency, Health Protection Scotland, National Public Health Service for Wales, CDSC Northern Ireland, CRDHB. Shooting up; infections among injecting drug users in the United Kingdom 2007. An update: October 2008. London: Health Protection Agency; October 2008.
  47. ↑ Hutchinson SJ, Roy KM, Wadd S, Bird SM, Taylor A, Anderson E, Shaw L, Codere G, Goldberg DJ. Hepatitis C virus infection in Scotland: epidemiological review and public health challenges. Scottish medical journal. 2006 May; 51(2):8-15.
  48. ↑ Health Protection Scotland, University of the West of Scotland. The needle exchange surveillance initiative (NESI): Prevalence of HCV, HIV and injecting risk behaviours among injecting drug users attending needle exchanges in Scotland, 2007. Glasgow: Health Protection Scotland; May 2008.
  49. ↑ Hutchinson SJ, Wadd S, Taylor A, Bird SM, Mitchell A, Morrison DS, Ahmed S, Goldberg DJ. Sudden rise in uptake of hepatitis B vaccination among injecting drug users associated with a universal vaccine programme in prisons. Vaccine. 2004 Nov 25; 23(2):210-4.(Link to article – subscription may be required.)
Retrieved from "http://www.ganfyd.org/index.php?title=Needlestick_injuries"
Personal tools