Needle stick injury management

Needle Stick Injury:
Management
PRESENTER:- DR. CHANDAN MISHRA

Overview
 Introduction to Needle Stick Injury(NSI)
 Definition and History
 Organisms transmitted due to NSI
 Cause of Injury
 Preventing Occupational injuries
 Management of Exposed person
 Data from AIIMS
 Burden of NSI related diseases
 Changing trend of NSI related disease
 What can be done?
 Summary

Introduction
Occupational injury
Percutaneous injury
Needle stick injury
Other sharp injury
Splash injury
Contact with the mucous membrane e.g. eye
mouth
Contact with non-intact skin e.g. abraded skin or
dermatitis skin
Contact with intact skin when the duration is prolonged e.g. several
minutes or more
Essentials of Medical Microbiology 5th Edition

Definition
 The term "Needle Stick Injury" is a broad term that includes injuries caused by
needles or other sharp objects (e.g. glass vials, surgical blades, forceps) that
accidentally puncture the skin. [NATIONAL TECHNICAL GUIDELINES ON
ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW, Government of India; https://lms.naco.gov.in/frontend/content/NACO%20-
%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf]
 Needle-Stick Injury:-Penetrating stab wound caused by a needle.
[https://www.ncbi.nlm.nih.gov/books/NBK138670/def-item/glossary.gl1-d30/]
 Injuries from needles used in medical procedures are sometimes called needle-
stick or sharps injuries. Sharps can include other medical supplies, such as
syringes, scalpels and lancets, and glass from broken equipment. [ https://www.nhs.uk/common-
health-questions/accidents-first-aid-and-treatments/what-should-i-do-if-i-injure-myself-with-a-used-needle/ ]

History
 1st documented case of Needle stick Injury was transmission of
human T-lymphotropic virus type III (HTLV-III) infection to a
health care worker(nurse) in the UK from a patient who was
presumably infected while in Africa.[ Lancet. 1984 Dec 15;2(8416):1376-7. PMID: 6150372 ]
 1st documented case of Needle stick Injury in India was
transmission of HIV infection to a health care worker (nurse) in
Kolkata on September 1998 from a HIV positive patient. [First Documented
Transmission of HIV Infection in a Health Care Worker in West Bengal; D K Neogi; PMID: 17664805]

 Most important organisms transmitted
 Hepatitis B virus (HBV)
 Hepatitis C Virus (HCV)
 Human Immunodeficiency Virus (HIV)
 Rarely
 CMV
 TB
 HSV
 Parvovirus B19
[ Needlestick Kevin C. King; Ronald Strony. PMID: 29630199 ]
[ Infectious Risk for Healthcare Workers: Evaluation and Prevention; M Triassi , F Pennino, DOI: 10.7416/ai.2018.2234 )
[Determination of Risk of Infection with Blood-borne Pathogens Following a Needlestick Injury in Hospital Workers.; Wicker et al; doi:10.1093/annhyg/men044 ]
[ Infectious Risk for Healthcare Workers: Evaluation and Prevention; M Triassi , F Pennino, DOI: 10.7416/ai.2018.2234 )
 Malaria
 HTLV
 Ebola
Organisms transmitted due to NSI

Transmission rate of HIV, HBV and HCV due to NSI
NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW, Government of India
https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf
Organisms transmitted due to NSI

International Safety Center. U.S. EPINet Sharps Injury and Blood and Body Fluid Exposure Surveillance Research Group. Sharps Injury Data Report for Jan 01, 2018 to Dec 31, 2018; 34 hospitals
contributing data, 1170 total injuries. Report available at [https://internationalsafetycenter.org/wp-content/uploads/2019/07/Official-2018-US-NeedleSummary-FINAL.pdf]
Disposabel syringe
24%
Suture needle
25%
Other sharp items
7%
Other needle
7%
Scalpel disposable
4%
Electrocautery
1%
retractors, hooks
forceps,hemost
others
29%Devices that caused the injury.
Cause of Injury

Doctor (attending.staff)
specialty
16%
Doctor
(intern/resident/fellow)
specialty
17%
EMT/Paramedic/ First
Responder/C.N.A./H.H.
Medical student
1%
Nurse
35%
Nursing student
1%
Respiratory therapist
1%
Surgery attendant
9%
EVS/Housekeeper/Othe
r attendant
4%
Phleboto
Clinical laboratory
worker
1%
Technologist (non lab)
4% Other
5%
International Safety Center. U.S. EPINet Sharps Injury and Blood and Body Fluid Exposure Surveillance Research Group. Sharps Injury Data Report for Jan 01, 2018 to Dec 31, 2018; 34 hospitals
contributing data, 1175 total injuries. Report available at [https://internationalsafetycenter.org/wp-content/uploads/2019/07/Official-2018-US-NeedleSummary-FINAL.pdf]
Job category of the injured person
Cause of Injury

PRACTICES THAT INFLUENCE RISK
 Certain work practices increase the risk of needle stick injury such
as:
 Recapping needles (most important)
 Transferring a body fluid between containers
 Handling and passing needles or sharps after use
 Failing to dispose of used needles properly in puncture-resistant
sharps containers
 Poor healthcare waste management practices
Preventing Occupational injuries

 How to protect oneself from needle stick/sharps injuries:
 Strict compliance to universal work precautions
 Avoid the use of injections where safe and effective alternatives
are available e.g. oral, drugs
 Avoid recapping needles
 Plan for safe handling and disposal of needles after use
 Promptly dispose of used needles in appropriate sharps disposal
containers

“DO NOT RECAP NEEDLE”
Performing activities involving needles and sharps, in a rush increases the likelihood of an
accidental exposure

 Staff Information:
 Universal precautions to be followed in health services
 Use of personal protective equipment (PPE)
 All hospital staff members must know whom to report for PEP and
where PEP drugs are available in case of occupational exposure.
 Safe handling and disposal of sharps/ injections:
 Use needle destroyers
 Protection against hepatitis B:
 All HCWs must have complete Hep B vaccine
 Record and monitor injuries with an injury register in each location of
healthcare setting.

MANAGEMENT OF THE EXPOSED PERSON
 If the skin is pierced by a needle-stick or sharp instrument:
 Do not panic.
 Immediately wash the wound and surrounding skin with water
and soap and rinse
 Do not scrub
 Do not squeeze blood form the wound
 Do not put pricked/cut finger in the mouth- a childhood reflex
 STEP 1:-Management of Exposure Site-First Aid

Summary of Do’s and Don’t
Do’s Don’t
Remove gloves, if appropriate Do not panic
Wash the exposed site thoroughly with
running
water
Do not put the pricked finger in mouth
Irrigate with water or saline if eyes or
mouth have been exposed
Do not squeeze the wound to bleed it
Wash the skin with soap and water Do not use bleach, chlorine, alcohol, betadine,
iodine or other antiseptics/detergents on the
wound
** Do - Consult the designated physician immediately as per institutional guidelines for
management of the occupational exposure **
Antiretroviral Therapy Guidelines for HIV-Infected Adults and Adolescents Including Post-exposure Prophylaxis; May 2007; NACO MoHFW GoI.

 Step 2: Establish eligibility for Post Exposure Prophylaxis (PEP)
 Assess HIV status of Source of exposure
 Assess exposed individual – known HIV (+) no PEP – give
comprehensive HIV service
 Evaluation must be made rapidly, to start treatment ASAP.
 All Accidental Exposure to Blood(AEB) do not need PEP.
 The first dose of PEP - within 2 hours (if not –certainly in first 72
hours) of exposure – evaluate risk ASAP.

Categories of situations depending on Lab results of the source

 Step 3: Counselling for PEP
 Informed consent to be taken after explaining risk and benefit of PEP.
 PEP is not mandatory.
 Counselling for safe sexual practices till both baseline and 3 months
HIV test are found to be negative.
 Relieve the anxiety of patient – psychological support
 Documentation on record is essential

 Step 4: Assessing Need for PEP and Prescribing PEP
 The decision on PEP for HIV (following an AEB in HCW) - depend
on the exposed person and source person’s HIV status.
 Depends upon extent of disease – if source is positive
 It is decided - based on exposure code(EC) and source code(SC).

HIV Exposure Codes

HIV Source Codes

NACO Recommendations of PEP for HCP based on Exposure
and HIV Source codes

Recommended PEP regimens

Hepatitis B Virus
 All health staff should be vaccinated against Hepatitis B.
 Vaccination - 3 doses- initial (zero) dose, 2nd at 1 month and 3rd
dose at 6 months
 Sero-conversion after completing the full course is 99%.
 If unvaccinated or unclear vaccination status, give complete Hep-B
vaccine.

HBV vaccination after an AEB

Hepatitis C Virus
 Presently no prophylaxis is available against Hepatitis C.
 There is no evidence that interferon, pegalated or not, with or
without Ribavirin is more effective when given during this time than
when given at the time of disease.
 Post-exposure management for HCV is based on the early
identification of chronic HCV disease and referral to a specialist for
management.

[ Source: CDC. Testing for HCV infection: An update of guidance for clinicians and laboratorians. MMWR 2013;62(18). ]
Interpretation of results of tests for hepatitis C virus (HCV)
infection and further actions

Step:5 Laboratory Evaluation
 Prompt test to establish a "baseline" for comparing future test
results.
 Informed consent for testing.
 Confidentiality of the test result must be ensured.
 Do not delay PEP if HIV testing is not available.

Recommended baseline laboratory investigations
 Pregnancy testing should also be available, but its unavailability should not prevent the
provision of PEP.

Step:6 Follow-up of an Exposed Person:
 Clinical monitoring in PEP:
 Monitor for acute sero-conversion illness
 If suspected, refer to ART centre
 Psychological support
 Ask to avoid:
 Blood donation
 Breast feeding
 Pregnancy
 Person should use precautions:
 Sexual relationship (CONDOM protection)
 Adherence & Adverse Drug Reaction counselling

Follow-up of an Exposed Person:
*It is important to remember that the person exposed to the risk of transmission of HIV is also at risk of
getting infected with HBV and HCV. Hence, that too needs to be addressed
Minimum Laboratory Follow-up recommended for PEP for HIV*

Care pathway for PEPAssessment
Counselling and support
Prescription
Follow up
• Clinical assessment of Exposure
• Eligibility assessment for Post-Exposure Prophylaxis
• HIV testing of exposed people and source, if possible
• Provision of first-aid in case of broken skin or other wounds
• Risk of HIV
• Risk and benefits of Post-Exposure Prophylaxis
• Side-Effects
• Enhanced counselling if Post-Exposure Prophylaxis to be prescribed
• Specific Support in case of sexual assault
• PEP should be initiated as early as possible following exposure
• 28-day prescription of recommended ARV drugs
• Drug information
• Assessment of underlying co-morbidities & possible drug-drug interactions
• HIV test 3-months after exposure
• Link to HIV treatment, if possible
• Provision of prevention intervention as appropriate

 A study by Sharman et al at AIIMS, New Delhi, from January 2011 to December
2013
 A total of 476 occupational injuries were reported. 410 (86.1%)were needle
prick.
 Doctors were found to have the highest exposure rate (73.7%) distantly
followed by nurses (19.1%).
 A study by Mathur P, Rajkumari N, at JPNATC from Jan 2008 to Sep 2013
 A total of 356 occupational injuries were reported. 157(44%) were sharp
injuries.
 Doctors were found to have the highest exposure (129, 36.2%), followed by
nurses (52, 14.6%)
Data of AIIMS, New Delhi
[Occurrence of Needlestick and Injuries among Health-careWorkers of a Tertiary Care Teaching Hospital in North India; DOI:10.4103/0974-2727.187917]
[A prospective look at the burden of sharps injuries and splashes among trauma health care workers in developing countries: True picture or tip of iceberg;
http://dx.doi.org/10.1016/j.injury.2014.03.001]

JR, 14, 34%
Nurse, 8, 20%
NO, 3, 7%
Nursing Student, 2, 5%
Lab technician, 2, 5%
Clerk, 1, 3%
Intern, 2, 5%
OT attendent, 1, 2%
sanitation worker, 7, 17%
SR, 1, 2%
Exposure according to staff category
Data taken from ED of AIIMS New Delhi from 15th Feb 2020 – 15th Jun 2020

Hollow needle, 13, 62%
Cleaning, 2, 9%
Solid needle, 4, 19%
Canula, 1, 5%
other OT instrument, 1, 5%
Device caused the injury
Data taken from ED of AIIMS New Delhi from 15th Feb 2020 – 15th Jun 2020

Format for record maintenance of NSI at Microbiology Section of
Department of Lab Medicine .

Treatment given at AIIMS for NSIs
 Assessment of risk of HIV and HBV transfer.
 Inj Hep B Vaccine + Inj Hep B Ig + Tab TLE(stat) in case of unknown
source status and known/unknown exposure status, followed by lab test
for Hep B, HIV and HCV of the source and exposed.
 If the exposed has recent h/o Hep B complete vaccinated source status
known/unknown then Inj Hep B booster + Tab TLE(stat), followed by lab
test for Hep B, HIV and HCV of the source and exposed.
 After the status of the exposed and the source are available further
treatment follows as per the NACO guideline.

Combination Drug used for the PEP of HIV in AIIMS, New Delhi
 The combination Drug
 Tenofovir 300mg
 Lamivudine 300mg
 Efavirenz 600mg
Taken form the ED of AIIMS, New Delhi

Burden of NSI related diseases.
 In 2000, WHO estimated - developing and transitional countries, the use
of unsafe injections lead to-
 5% of new HIV infections,
 32% of new HBV infections and
 40% of new HCV infections.
 SEAR (mostly India) had represented > ½ of the global cases of
injections-related cases of HIV,
 As 75% of injections in SEAR were made with re-used needles and
syringes.
[Evolution of the Global Burden of Viral Infections from Unsafe Medical Injections, 2000–2010.; Pépin et al; https://doi.org/10.1371/journal.pone.0099677]

Burden of NSI related Disease
 According to a study by Harui et al in 2000, contaminated injections caused an
estimated 21 million HBV infections, 2 million HCV infections and 260,000 HIV
infections
 After converting into disability-adjusted life years (DALYs) for 2000–2030 period
 HBV burden - 3,114539 DALYs
 HCV burden - 324,198 DALYs
 HIV burden - 5,738,942 DALYs
 Thus a total burden of 9,177,679 DALYs because of contaminated injection in 2000 -
2030.
[The global burden of disease attributable to contaminated injections given in health care settings. Hauri et al; DOI: 10.1258/095646204322637182]

Changing trend of NSI between 2000 -2010.
 Despite a 13% population growth (2000-2010), reduction of 87% in HIV
and 83% in HCV infections transmitted through unsafe injections.
 For HBV, marked reduction of 91% due to the additional impact of
vaccination.
 While injections-related cases had accounted for 4.6%–9.1% of newly
acquired HIV infections in 2000, this proportion decreased to 0.7%–1.3% in
2010
 In 2010 unsafe injections caused between 16,939 and 33,877 HIV
infections, between 1,57,592 and 3,15,120 HCV infections, and 16,79,745
HBV infections.
 Today the major threat after a needlestick injury is not HIV but acquiring
hepatitis B or hepatitis C.
Evolution of the Global Burden of Viral Infections from Unsafe Medical Injections, 2000–2010.; Pépin et al ; https://doi.org/10.1371/journal.pone.0099677

What can be done?
 WHO is committed to promoting safe injection practices by switching to
the exclusive use of reuse-prevention syringes (RUPs) for all injections by
2020.
 WHO also recommends syringes with sharp injury protection (SIPs)
features.
 National Accreditation Board for Hospitals and Health care Providers
(NABH) and Joint Commission International (JCI) accreditation for all
hospitals.
 All accrediting bodies give emphasis on the implementation of NSI
protocols and occupational safety of the HCW.
 At the institutional level, a “No blame no shame” approach to ensuring
high degree of compliance with NSI reporting.
[ Needle-stick injury: A perspective; Srikanth et al; DOI: 10.4103/jpsic.jpsic_16_18 ]

Summary
 Needlestick injuries are known to occur frequently in healthcare settings and can be
serious
 Needlestick injuries can be prevented by use of new safer instruments and strict
adherence to standard guidelines.
 Record maintenance of NSIs should be promoted in all Medical Care Settings.
 PEP should never be delayed in any circumstances.
 Accreditation of hospitals to various accreditation bodies like NABH,JCI etc.
 Last but not least healthy HCW delivers better care for patient, so safety of HCWs is
must.

Needle stick injury management

Needle stick injury management

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