2. NEEDLE STICK INJURY
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.
The "Exposed Person" is the person who is potentially at risk of acquiring HIV
infection due to exposure to blood or potentially infectious body fluids in his on her
occupation.
The "Source Person" is the person who is (either identified or not identified as) the
possible source of contamination through blood or potentially infectious body fluids. A
needle stick injury is the result of an accident with a needle.
Consider all the sharps items as potentially infectious and handle them with care to
prevent accidental exposure.
Should never be recapped and reused.
No attempt should be made to remove the needles from the body of the syringe (eg.
bending, breaking or shearing).
An appropriate sharp container must be used (they should be closable, leak proof, and
puncture resistant).
3.
4. MANAGEMENT OF NSI
• Step 1:Management of Exposure Site-First Aid For skin—
• If the skin is pierced by a needle-stick or sharp instrument:
• Immediately wash the wound and surrounding skin with water and soap and rinse
• Do not scrub
• Do not use antiseptics or skin washes o Don’t use bleach, chlorine, alcohol, betadine
• After a splash of blood or body fluids:
• To unbroken skin: o Wash the area immediately o Do not use antiseptics
5. POST EXPOSURE PROPHYLAXIS
For the eye:
o Irrigate exposed eye immediately with water or normal saline
o Sit in a chair, tilt the head back and ask a colleague to gently pour water or normal saline over the eye
o If wearing contact lens, leave them in place while irrigating, as they form a barrier over the eye and will help protect it.
Once the eye is cleaned, remove the contact lens and clean them in the normal manner. This will make them safe to wear
again o
Do not use soap or disinfectant on the eye
• For Mouth:
o Spit fluid out immediately
o Rinse the mouth thoroughly, using water or saline and spit again. Repeat this process several times
o Do not use soap or disinfectant in the mouth
6. • Step 2:
Establish eligibility for PEP The average rate of HIV sero-conversion afterafter an Accidental Exposure to Blood (AEB) (for per-cutaneous exposure) is 0.3 %.
The real risk of transmission depends on the amount of HIV transmitted (= amount of contaminated fluid and the viral load)
Report to ICTC [in the Dept. of Microbiology] immediately.
PEP must be initiated as soon as possible, preferably within 2 hrs but not later than 72 hrs.
Baseline tests should be done for hepatitis B & C and HIV
• Step 3: Counselling for PEP
• Step 4: Assessing Need for PEP and Prescribing PEP
• Step 5: Laboratory Evaluation
• Step 6: Follow-up of an Exposed Person:
7.
8.
9. Needle Stick injury
• A needle stick injury is the result
of an accident with a needle.
• These injuries can occur at any
time when people use,
disassemble, or dispose of
needles
10. How to prevent needle stick
injury??
consider all the sharps items as potentially
infectious and handle them with care to prevent
accidental exposure.
should never be recapped and reused.
No attempt should be made to remove the
needles from the body of the syringe (eg.
bending, breaking or shearing).
11. How to prevent needle stick
injury??
An appropriate sharp container must be used (they should
be closable, leak proof, and puncture resistant).
The container should be placed in easily accessible
locations where the sharps are being used.
Sharp containers should never be over filled. Make sure
they are sealed, collected, and disposed of in accordance
with recommended guidelines for biomedical waste.
12. Post Exposure Prophylaxis
• Do not panic
• Do not put the pricked finger in the mouth
• Do not squeeze the wound to bleed it
• Immediately wash the wound and surrounding
skin with water and soap, and rinse.
• Do not scrub.
• Do not use antiseptics or skin washes (bleach,
chlorine, alcohol, betadine).
13. After a splash of blood or body fluids:
-Irrigate exposed eye immediately with water or normal
saline.
-If wearing contact lens, leave them in place while
irrigating, as they form a barrier over the eye and will
help protect it.
-Do not use soap or disinfectant on the eye.
For mouth: - Spit fluid out immediately.
-Rinse the mouth thoroughly, using water or saline and
spit again. Repeat this process several times.
-Do not use soap or disinfectant in the mouth.
14. Post Exposure Prophylaxis
Inform your senior
Report to ICTC [in the Dept. of Microbiology]
immediately.
PEP must be initiated as soon as possible,
preferably within 2 hrs but not later than 72 hrs.
Baseline tests should be done for hepatitis B & C
and HIV
15.
16.
17. Dosages of the Drugs for PEP for adults
and adolescents-
Tenofovir ( TDF) 300 mg plus
Lamivudine (3TC) 300 mg plus
Efavirenz (EFV) 600 mg once daily for 4
weeks.
Post exposure prophylaxis according to NACO
guidelines
18. Prevention of Hepatits B
• HBV vaccination is recommended for all
healthcare workers
• HBV vaccine has proven to be highly
effective in preventing infection in workers
exposed to HBV.
• no vaccine exists to prevent HCV or HIV
infection.
19. Hepatitis B Vaccination
– A primary course of hepatitis B vaccinations over
six months
• Mandatory for all staff in contact with patients and
patient-contaminated material
– Titre level (anti HBsAb) four to six weeks after last
dose
– Booster doses not required if titre level >10
mIU/mL
20.
21. • Baseline HIV test of the HCW should be done
at the time of exposure and repeated at 6
weeks following exposure. If second test is
also negative, HIV test to be repeated at 12
weeks and 6 months
anti-HCV and HBsAg-baseline, 3 months and
6 months after exposure
23. Incubation Period
• Incubation period is uncertain, from a few months to
10 years or even more.
• However it is estimated that 75% of people infected
with HIV will develop AIDS at the end of 10 years.
23
24. Clinical manifestations-
Clinical features of HIV infection classified in 4 broad
categories-
1. Initial Infection
2. Asymptomatic Carrier State
3. AIDS-related Complex(ARC)
4. AIDS
24
25. Initial infection
• Mild illness of fever, sore throat and rash
• Most HIV – infected people have no symptoms for
the first five years.
• However they can infect others, once infected the
people are infected for life.
25
26. Antibody response usually takes 2-12 weeks to appear in the
blood stream.
The period before antibodies are produced is called ‘the
window period’. (Tests- Negative)
26
28. Asymptomatic Carrier State
• Infected people have antibodies but no overt signs of
the disease, except persistent generalized
lymphadenopathy.
• It is however not firmly clear about how long does
the asymptomatic stage lasts.
28
29. AIDS related complex
• Develops in 25-30% of HIV infected people.
• Has illnesses caused by damage to immune
system, but without the opportunistic infections
and cancers associated with AIDS.
29
31. • Has one or more following clinical signs-
Unexplained diarrhoea (lasting more than a month),
Fatigue, malaise,
Loss of body weight(>10%),
Fever, night sweats.
Signs of Mild infections like oral thrush, generalized
lymphadenopathy, enlarged spleen.
31
32. AIDS
• Final stage of HIV infection - AIDS
• Occurs when the destruction of peripheral
lymphoid tissue is complete and the blood CD4+
cell count drops below 200 cells/mm3. (Healthy
adults usually have CD4+ T-cell counts of 1000 or
more.)
32
33. • Death is due to uncontrolled or untreatable
infections.
• AIDS – acquired immunodeficiency syndrome – is
marked by development of various opportunistic
infections and malignancies.
• The level of virus in the blood and CD4+ T cell
count can predict the risk of developing AIDS
33
35. TEST SIGNIFICANCE
HIV ELISA Screening test for HIV infection.
(sensitivity > 99.9%)
Western blot Confirmatory test for HIV ( specificity in combination
with ELISA>99.99% )
Detect specific antibodies to viral core protien p24 and
envelop glycoprotein gp41
CBC (non specific) Anaemia, neutropenia and thrombocytopenia
Absolute CD4 lymphocyte count Predictor of HIV progression
CD4 lymphocyte Percentage •More reliable than CD4 count
•Risk of progression to AIDS opportunistic
infection/malignancy high with percentage< 14%
HIV viral load tests •Measures the amount of actively replicating HIV virus.
•Correlates with disease progression and response to ART
B2-microglobulin Cell surface protein indicative of macrophage-monocyte
stimulation( levels >3.5mg/dl- rapid progression)
p24 antigen Indicates active HIV replication
35
36. • VIRAL ISOLATION: HIV can be recovered from cultured
lymphocytes.
• Current trend in HIV-antibody test is towards- cheap,
reliable test kits whose results can be read on spot
without much waiting and much need of laboratory
backup.
• WHO 5C’s – consent, confidentiality, counselling,
correct test results and connection to care and
treatment - are principles that apply to all models of
HIV test services and in all circumstances
36
48. PEP to prevent HIV infection
48
Post-exposure prophylaxis (PEP) involves taking a
28-day course of ARVs in case of accidental
exposures.
PEP should be offered, and initiated as early as
possible, for all individuals with an exposure that has
the potential for HIV transmission, and ideally within
72 hours.
49. • Exposures that may warrant PEP-
1. Parentral and mucous membrane exposure (sexual
exposure, splashes to eye,nose,oral cavity)
2. Exposure to following body fluids -Blood , blood
stained saliva, breast milk, genital secretions, CSF,
amniotic, peritoneal, pericardial, synovial and
pleural fluids.
49
50. • Exposure where no PEP needed-
1. Exposed individual HIV positive
2. Source established HIV negative
3. Exposure to body fluids as- tears, non-blood stained
saliva ,urine and sweat
50
51. • If started soon after exposure, PEP can reduce the
risk of HIV infection by over 80%.
The recommended PEP regimens are:
For adults:
• Tenofovir + Lamivudine (3TC) or Emtricitabine
(FTC) as preferred backbone drugs.
• The recommended third drug is Ritonavir-boosted
lopinavir (LPV/r).
51
52. 52
For children aged below 10yrs:
Zidovidune (AZT) + Lamivudine (3TC) backbone
drugs
Ritonavir-boosted lopinavir (LPV/r) recommended
as the third drug choice.
53. Specific prophylaxis
HIV and TB: Isoniazide preventive therapy
with ART , given together reduce risk of TB
among PLHIV by upto 97%.
300 mg Isoniazid daily for 9 months to 1 yr. (given to all
HIV patients with positive PPD reactions >5mm induration)
P.carinii pneumonia: Primary prophylaxis
in patients with CD4< 200cells/microlit, with
co-trimoxazole/ aerosolised pentamidine
/dapsone.
53
54. M.avium complex: Rifabutine in patients with CD4<
200cells/microlit
Kaposi sarcoma – Interferon, chemotherapy or
radiation.
Cytomegalovirus retinitis –Ganciclovir
Cryptococcal meningitis –Fluconazole
Esophageal or vaginal candidiasis- Fluconazole
Herpes simplex or Herpes zoster infections—Acyclovir
or Foscarnet.
54
55.
56. LEARNING OBJECTIVES
• HIV VIRUS MORPHOLOGY
• MODES OF TRANSMISSION
• DISEASES
• LABORATORY DIAGNOSIS
• ART
• PREVENTION & PROPHYLAXIS
57. LEARNING OBJECTIVES
HEPATITIS B VIRUS (HBV)
• MORPHOLOGY
• MODE OF TRANSMISSION
• CLINICAL FEATURES
• LABORATORY DIAGNOSIS
• PROPHYLAXIS
70. HEPATITIS B VIRUS (HBV)
CLINICAL FEATURES
CLINICAL
PHASE
FEATURES
PREICTERIC
PHASE
Anorexia (loss
of appetite),
weakness,
nausea,
vomiting
ICTERIC PHASE JAUNDICE, Pale
stools & dark
urine
CONVALESCEN
T PHASE
Fatigue and
weakness
71. HEPATITIS B VIRUS (HBV)
LABORATORY DIAGNOSIS
1. DETECTION OF VIRAL MARKERS
2. VIRAL DNA POLYMERASE
3. POLYMERASE CHAIN REACTION
4. BIOCHEMICAL TESTS
72. HEPATITIS B VIRUS (HBV)
1. DETECTION OF VIRAL
MARKERS :
• HBsAg (Surface Antigen of HBV)
1. Specific marker for HBV.
2. FIRST Marker in blood.
3. Present in blood throughout
symptoms
• Anti-HBsAg :
1. This is the antibody to HBsAg
2. Appears in blood after HBsAg is
negative
3. Protective antibody.
73. HEPATITIS B VIRUS (HBV)
1. DETECTION OF VIRAL
MARKERS :
• HBeAg ( Hidden Antigenic part of
the Core of HBV)
1. Appears in serum at same time as
HBsAg.
2. HBeAg + =>HIGHLY INFECTIOUS.
3. Indicator of ACTIVE
INTRAHEPATIC (within liver)
VIRAL REPLICATION
• Anti-Hbe
1. Antibody to HBeAg.
2. Appears after HBeAg disappears in
serum
74. HEPATITIS B VIRUS (HBV)
1. DETECTION OF VIRAL
MARKERS :
• HBcAg (CORE ANTIGEN)
1. NOT Detectable in serum.
2. Immunofloresence to detect in liver
cells.
• Anti-HBc:
1. Antibodies to HbCAg
2. Appear in serum in a week after
HBsAg appears.
3. IgM type Anti-HBc appears first.
4. Anti-HBc + => Previous infection
with HBV.
75.
76. HEPATITIS B VIRUS (HBV)
2. Viral DNA Polymerase
Detection:
• Appears in serum during
pre-icteric phase.
3. Polymerase Chain
Reaction:
• HBV DNA detection.
• HBV DNA + => another
indicator of Viral
replication.
• Helps monitor Antiviral
treatment.
77. HEPATITIS B VIRUS (HBV)
PROPHYLAXIS
1. General Preventive Measures – Health
education, personal hygiene, screening of
blood donors, use sterile needles etc..
78. HEPATITIS B VIRUS (HBV)
2. Immunization :
• ACTIVE
IMMUNIZATION –
Types of Vaccines –
Plasma derived (plasma
of healthy carriers
used), Recombinant
Hepatits B Vaccine,
Synthetic peptide
vaccines.
• PASSIVE
IMMUNIZATION –
i. Following accidental HBV
infection,
ii. HBIG – Human
Immunoglobulin
iii. Given IM (300-500IU),
iv. Within 48hours of
exposure
v. Prevents development of
carrier state.
81. Occupational PEP
QUESTIONS 1
History- A 32-year-old physician accidentally sticks herself in the thumb after drawing blood
during a cardiopulmonary resuscitation involving a man with HIV and severe pneumonia. The site of
the needlestick in the thumb bled for approximately 2 minutes. The source patient has not been
engaged in medical care and laboratory studies obtained at the time of hospital admission 3 days
prior showed a CD4 count of 112 cells/mm3 and HIV RNA of 48,120 copies/mL.
If the physician does not take antiretroviral postexposure
prophylaxis (PEP), what would be the approximate risk of
acquiring HIV from this needlestick injury?
A) 0.02%
B) 0.3%
C) 2%
D) 7%
E) 13%
82. QUESTIONS 2
• A 25-year-old nurse is splashed in the eye with urine of a patient with HIV and advanced immunodeficiency. The source
patient was newly diagnosed with HIV and was hospitalized for a sudden change in mental status. The source patient’s initial
laboratory studies obtained 36 hours prior show a CD4 count of 62 cells/mm3 and the plasma HIV RNA test is pending. The
splash happened when the nurse was inserting a urinary catheter, and he did not see any visible blood in the urine. He
rinsed his eye immediately with water and presented to employee health within 1 hour of the incident.
What would be the best course of action in the management of this incident?
a) Wait for the result of source patient’s plasma HIV RNA level to further assess the risk of exposure
b) Since the source patient has a CD4 cell count less than 200 cells/mm3, antiretroviral postexposure
prophylaxis is indicated
c) Since the nurse’s conjunctivae were exposed to urine, the risk of HIV transmission is high and antiretroviral
postexposure prophylaxis is indicated
d) Since the nurse was exposed to urine without blood contamination, no antiretroviral postexposure prophylaxis
is indicated
e) No immediate postexposure prophylaxis is recommended, but the source patient's urine sample should
undergo molecular testing for HIV RNA and antiretroviral postexposure prophylaxis started if HIV RNA is
detectable in urine
83.
84. QUESTIONS 3
• A 42-year-old obstetrician has a needlestick injury in the palm of her hand with a hollow-bore
needle while delivering a baby; the mother had a positive point-of-care HIV antibody test at
the time she presented in labor. The mother’s confirmatory HIV antibody test and HIV RNA
level are pending.
Ques-Based on the 2013 USPHS Occupational PEP Guidelines, which one of the following would
be recommended as postexposure prophylaxis (PEP) for the obstetrician in this situation?
A) Initiate PEP with a single antiretroviral medication
B) Initiate PEP with two antiretroviral medications
c) Initiate PEP with three antiretroviral medications
D) Initiate PEP with two antiretroviral medications and add a third medication if the source
patient's testing shows an HIV RNA level greater than 50,000 copies/mL
E) Initiate PEP with two antiretroviral medications and add a third medication if the source
patient's testing shows an HIV RNA level greater than 100,000 copies/mL
85. Table 1. USPS Guidelines for the Use of Antiretroviral Agents for Occupational Exposures to HIVHIV
Postexposure Prophylaxis Regimens
•Preferred HIV Postexposure Prophylaxis Regimen-Raltegravir (400 mg twice daily) plus Tenofovir DF-
Emtricitabine (300 mg-200 mg [1 tablet] daily)
Alternative HIV Postexposure Prophylaxis Regimens
May combine 1 anchor drug or drug pair from the left column with 1 pair of nucleoside/nucleotide reverse
transcriptase inhibitors from the right column; prescribers unfamiliar with these agents/regimens should
consult clinicians who are familiar with the agents and their toxicitiesa
Anchor Drug
•Raltegravir
•Darunavir + ritonavir
•Etravirine
•Rilpivirine
•Atazanavir + ritonavir
•Lopinavir-ritonavir
Nucleoside Reverse Transcriptase Inhibitors
Tenofovir DF-emtricitabine
Tenofovir DF + lamivudine
Zidovudine-lamivudine
Zidovudine + emtricitabine
86. Non occupational PEP QUESTION 4
• A 30-year-old man who regularly injects drugs and recently tested negative for HIV presents for evaluation
of a skin abscess. He injects heroin daily and typically uses his own clean needles. During the evaluation he
reveals that approximately 24 hours ago he shared a needle with another person who is not well known to
him. Prior to this recent event, the last time that he had shared needles or injecting equipment was about 4
months ago.
Should HIV nonoccupational postexposure prophylaxis (PEP) be started in this 30-year-old man?
A)No, because he frequently injects drugs
B) No, because the source individual is not known to have HIV
C) No, because only one instance occurred and risk of HIV transmission from needle-sharing is not high enough
to warrant nonoccupational PEP
D) Yes, because the needle-sharing instance represents a unique event (out of the ordinary for this person’s usual
drug use) with significant HIV transmission risk
E) Yes, because it will also reduce his risk of acquiring hepatitis C virus
Editor's Notes
Post-exposure prophylaxis, also known as post-exposure prevention (PEP), is any preventive medical treatment started immediately after exposure to a pathogen, in order to prevent infection and the development of disease. For both viral and bacterial diseases.
NACO recommends the use of ELISA kits with a sensitivity of ≥99.5 percent and the specificity of ≥98 percent and rapid kits with a sensitivity of ≥99.5 percent and the specificity of ≥98 percent. Assays A1, A2, A3 represent 3 different assays based on different principles or different antigenic compositions. Assay A1 should be of high sensitivity and A2 and A3 should be of high specificity
