Needle stick injury is defined as penetration of skin by a needle or other sharp object that has been in contact with blood products, tissue or any other body fluids before exposure. Even though the effect is negligible, it predisposes the patient to occupational exposure of human immunodeficiency virus (HIV), hepatitis B virus (HVB), and hepatitis C Virus (HVC). ( ) The most common population to be affected is health care workers and lab personnel. The occupational exposure of such viruses is not only transmission via needle stick injury but also via contamination of mucous membranes e.g. eyes, blood or body fluids, even though needle stick injuries make up the majority of all percutaneous exposure cases. Other occupations with increased risk of needle stick injury are tattoo artists, agriculture workers, law enforcement workers, and laborers. ( ) Recognizing the occupational hazard posed by needle stick injury and the long term effect it could have on a health care worker is the most important need, with developing interventions to minimize it.

1. DTMU
20
Postexposure prophylaxis after needle
sticks injury
Review paper
Vedica Sethi

2. Table of contents:
1. Abstract
2. What is needle stick injury?
(i) Health effects
(ii) Psychosocial effects
(iii) Causes
3. Post exposure management
(i) HBV
(ii) HCV
(iii) HIV
4. Approach considerations
5. Conclusion
6. References

3. 1. Abstract
Needle stick injury is defined as penetration of skin by a needle or other sharp object
that has been in contact with blood products, tissue or any other body fluids before
exposure. Even though the effect is negligible, it predisposes the patient to occupational
exposure of HIV, HVB, and HVC. It is a big concern after realizing that HIV, HVB, and HVC
are transmitted through bodily fluids, a major occupational threat. The viruses require a
percutaneous or mucosal introduction for infectivity, and the major target organ is the
immune system for HIV and liver for HBV and HCV. A non- important concern is tetanus,
which attacks the central nervous system. Occupational transmission of HIV from blood
of an HIV- positive is 0.3% for percutaneous exposure and 0.1% for a mucous membrane
exposure. For an exposure to intact skin the transmission is negligible if removed in
timely fashion via washing. Similarly, transmission of HBV positive source to a non-
immunized person is 6% to 24% and 1% to 8% for HCV
Key words: Needle stick injury, body fluids, HIV, HVB, and HVC, percutaneous, mucosal
membrane, infectivity, transmission

4. 2. What is a needle stick injury?
Needle stick injury is defined as penetration of skin by a needle or other sharp object
that has been in contact with blood products, tissue or any other body fluids before
exposure. Even though the effect is negligible, it predisposes the patient to occupational
exposure of human immunodeficiency virus (HIV), hepatitis B virus (HVB), and hepatitis
C Virus (HVC). (1) The most common population to be affected is health care workers
and lab personnel. The occupational exposure of such viruses is not only transmission
via needle stick injury but also via contamination of mucous membranes e.g. eyes, blood
or body fluids, even though needle stick injuries make up the majority of all
percutaneous exposure cases. Other occupations with increased risk of needle stick
injury are tattoo artists, agriculture workers, law enforcement workers, and laborers. (2)
Recognizing the occupational hazard posed by needle stick injury and the long term
effect it could have on a health care worker is the most important need, with developing
interventions to minimize it. (3)
(i) Health effects:
While needle stick injuries transmit upto 25 identified blood born infections and
predisposes the person in acquiring various bacteria, protozoa, viruses and
prions, (4) the risk of acquiring Hepatitis B, Hepatitis C and HIV is the highest. (5)
Health care workers are more susceptible to contracting these diseases from
needle stick injury.
Factors influencing occupational risk of blood borne diseases-
 Prevalence of infection among patients
 Type of exposure and virus
 Frequency and type of virus amongst the population
Risk of acquiring HVB, HCV and HIV after percutaneous exposure-
 HBV risk varies depending on HBeAg status of source person (6)
- If HBeAg positive, risk is up to 30%
- If HBeAg negative, risk is 1-6% (7)
 HCV risk is 1.8% (range of 0 - 7%)
 HIV risk is 0.3% (range of 0.2 - 0.5%)
1 “Needlestick Injury.”
2 Tarigan et al., “Prevention of Needle-Stick Injuries in HealthcareFacilities.”
3 Alamgir and Yu, “Epidemiology of Occupational Injury amongCleaners in the Healthcare Sector.”
4 Wicker et al.,“Needlestick Injuries amongHealth Care Workers.”
5 Phillipset al.,“Issues in Understandingthe Impact of the Needlestick Safety and Prevention Act on Hospital
Sharps Injuries.”
6 Parantainen et al.,“Blunt versus Sharp Suture Needles for Preventing Percutaneous Exposure Incidents in Surgical
Staff.”
7 “Hepatitis B Virus Infection and WasteCollection:Prevalence, Risk Factors,and Infection Pathway - PubMed.”

5. The risk of blood-borne infection from a used medical device-
 Injuries with a hollow-bore needle: penetration of needle in skin, with
visible blood on it, maybe removed from artery or vein.
 A medical device contaminated with blood from a ill patient increase the
risk for contracting a blood-borne infection (8)
(ii) Psychosocial effect:
 Health anxiety associated to repeated testing
 Anxiety about disclosure or transmission to a sexual partner
 Trauma- related emotions
 Depression
 Post traumatic stress disorder
 Occupational safety recommends the incident of needle stick injury to be
reported to facility based on WHO guidelines (9)
(iii) Causes:
Common event in healthcare environment which predisposes the worker to a
needle stick injury:
 Drawing blood
 Administering an intramuscular or intravenous drug
 Performing procedures involving sharp devices
 Needle recapping
 Unable to dispose devices or sharp medical equipment due to an
overfilled or poorly located container
 appropriate personal protective equipment (PPE) inability of access
 Failure of employee to use provided equipment
 Exchanging of needles between personnel e.g. needle driver or while
sutures are tied, still connected to the needle
 Needle stick injuries are common during night shifts due to:
- Less experienced workers
- High workload and high pressure
- shift work
- high perception of risk
 During surgery where scalpel injuries are more common than needle stick
injuries. (10) (11)
8 Makary et al.,“Needlestick Injuries amongSurgeons in Training.”
9 Wald,“The Psychological Consequences of Occupational Blood and Body Fluid ExposureInjuries.”
10 Office, “Occupational Safety.”

6. 3. Post exposure management:
The healthcare facility should have clear policies regarding such occupational hazard and
thus, protect the confidentiality of the exposed and the source person and provide with
a proper management of exposures. Training medical personnel and rapid access to
clinical care, post exposure prophylaxis (PEP) and testing of source patient or exposed
person is mandatory necessity.
(i) Postexposure management should contain:
 Wound care:
- Clean wounds with soap and water
- Put water on mucous membranes
- Do not use bleach and other acidic agents which may irritate the
puncture site
 Reporting the exposure:
- Noting down the date and time of exposure
- Details of events: what, where, how, with the device used
- Details of exposure: route, body substance
- Involvement, and duration of contact
- Identifying the source person and exposed person is very important
 Assessming the risk of infection:
- type and severity of exposure: percutaneous or mucous membrane or
non-intact skin or bites
- body substance: bloody fluid, semen or vaginal secretions, CSF, pleural,
peritoneal, pericardial, amniotic fluid
- blood- borne infection status of source person: presence of HBsAg,
HCV or HIV Antibody
 Appropriate treatment, follow-up, and counseling
(ii) For an unknown or unidentifiable source:
 Considering the information about exposure:
- under what circumstances and what, when of the of the event
- prevalence of HBV, HCV, or HIV in the populous you treat_
epidemiology of the area
 NOT RECOMMENDED: testing of sharp medical devices or needles for-
- Unknown reliability and interpretation of findings
- Hazard of handling sharp instrument
 Evaluating the source:
11 Patrick et al.,“Sharps Injuries amongHospital Workers in Massachusetts,2010.”

7. - Informed consent should be obtained in accordance with state and local laws to
maintain confidentiality of the source person. (12
) (13
)
a) Hepatitis B:
 The evaluation and testing of exposed person with unknown HBV immune status:
- testing not needed if vaccine response is known
- If exposed person has been vaccinated, no PEP is necessary
- Test for HbsAg titers, if person has been vaccinated, but vaccine response is
unknown
 Identifying a appropriate treatment: when and what to give
 Follow-up of the patient with proper testing and counseling
 Recommended management:
- Unvaccinated: Hepatitis B Immunoglobulin and initiate hepatitis B vaccine series
- Previously vaccinated: Antibody response unknown, Test exposed person for
anti-HBsAg: If adequate, no treatment or If inadequate, HBIG x 1 and vaccine
booster
 Regimen efficacy: Multiple doses of HBIG alone when 1st dose initiated within 1 week <
Hepatitis B vaccine series alone < Combination of HBIG and vaccine series (70-75% < 75-
80% to 80-85%)
 Follow- up of HBV testing of exposed person:
- Perform follow-up anti-HBsAg test in healthcare worker who has received HBV
vaccine
- test for anti-HBsAg 1-2 months after last dosage
- anti-HBsAg response to vaccine cannot be studied if HBIG received in the
previous 4 months
 Counseling:
- Should not donate blood, plasma, organs, tissue, or semen.
- There is no need to refrain from sexual practices or avoiding pregnancy and
breastfeeding and also modification of patient care in exposed person
- If acute HBV infection, evaluate according to published recommendations (14)(15)
b) Hepatitis C
 Transmitted by occupational exposures, inefficiently transmitted by blood
introduction into mucous membranes
 Average incidence 1.8% (normal range 0-7%) following a percutaneous exposure
from HCV-positive source. Prevalence 1-2% among healthcare personnel
comparatively lower than in the general population
 The evaluation and testing of exposed person of HCV immune status:
12 “Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic
Disease.Centers for DiseaseControl and Prevention.”
13 Kuhar et al.,“Updated US Public Health ServiceGuidelines for the Management of Occupational Exposures to
Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis.”
14 Lavoie, Verbeek, and Pahwa, “Devices for Preventing Percutaneous Exposure Injuries Caused by Needles in
HealthcarePersonnel.”
15 Mast et al.,“A Comprehensive Immunization Strategy to EliminateTransmission of Hepatitis B Virus Infection in
the United States.”

8. - If HCV-positive source, test exposed person for anti-HCV and liver
enzymes i.e. ALT and AST
- If the patient is not infected, baseline testing not necessary
 Follow-up testing and counseling necessary
 PEP Not recommended after exposure
- immunoglobulin not effective
- Use of antivirals (e.g., interferon), is effective only with established
infection
 Counseling:
- Similar counseling like HBV (16)
c) HIV
 Efficacy of PEP in humans is questionable
 Occupational exposure to HIV-infected blood leads to serconversion infrequently
 Zidovudine (ZDV) has shown to decrease the transmission of HIV by 80% and for
pregnancy, labor, and delivery by 67%. (17) ZDV provides protection when given
to the newborn within the first 48-72 hours. (18) (19) (20) Decrease in maternal
viral load not well understood.
 The evaluation and testing of exposed person to HIV:
- ELISA standard test
- Direct virus assays: p24 antigen or PCR for HIV RNA (usually not
recommended)
 Consideration the treatment is based on when and what to give or if the exposed
person is pregnant
 Follow-up testing and counseling:
- If the source is HIV positive: Continuous testing from 6 weeks, 3 months,
6 months is necessary, via ELISA standard test (direct virus assays not
recommended)
- Follow-up to 12 months is recommended for health care personnel who
become infected with other blood borne pathogen e.g. HCV following
exposure to co-infected source.
 HIV PEP:
- It is an urgent medical concern: Start PEP as soon as possible after exposure
(hours rather than days)
16 Hughes and Henderson, “Post-Exposure Prophylaxisafter Hepatitis C Occupational Exposurein the Interferon-
Free Era.”
17 Connor et al.,“Reduction of Maternal-InfantTransmission of Human Immunodeficiency Virus Type 1 with
ZidovudineTreatment. Pediatric AIDS Clinical TrialsGroup Protocol 076 Study Group.”
18 Wade et al.,“Abbreviated Regimens of ZidovudineProphylaxis and Perinatal Transmission of the Human
Immunodeficiency Virus.”
19 Musoke et al.,“A PhaseI/II Study of the Safety and Pharmacokineticsof Nevirapinein HIV-1-Infected Pregnant
Ugandan Women and Their Neonates (HIVNET 006).”
20 “Intrapartum and Neonatal Single-DoseNevirapineCompared With Zidovudinefor Prevention of Mother-To-
Child Transmission of HIV-1 in Kampala,Uganda:HIVNET 012 Randomised Trial - PubMed.”

9. - PEP might not be helpful after an interval but there is o study that proves
otherwise: initiating use of PEP, days or weeks after an exposure should
be considered
 Reevaluate the exposed personnel: Consider re-evaluation of the exposed
person in the next 72 hours
- New information about the source person may become available
- if the source person has a negative HIV antibody test, there is no need
for PEP
 HIV PEP:
- Determining which and how many agents to use for PEP should be based
on professional judgement and on his/ her local knowledge and
experience in treating HIV
- Also to keep in mind that the selected regimen should be tolerable to the
exposed person
 Situations where HIV PEP is not necessary:
- Intact skin contact with blood and potentially infectious body fluids
- Exposure to unknown source in populations where HIV prevalence is low
- Low-risk exposure to unknown source
 HIV PEP may not be necessary if there is:
- Resistance to antiretroviral agents in the exposed source
- Pregnancy is suspected in the known exposed person
- Toxicity of the initial PEP regimen
 HIV PEP in pregnant Women:
- pregnancy is not a contraindication for PEP
- exposed person should take the decision about PEP, after proper
information is provided
- *Choosing the right regimen is complex as it may exacerbate physiologic
changes in pregnancy, produce short/long-term effects on fetus/newborn
unknown and the fact that some drugs are contraindicated in pregnancy
 Counseling:
- Side effects of AntiRetroviral drugs should be discussed
- *Signs and symptoms of acute HIV infection: fever, rash, flu-like illness
- Prevent secondary transmission via sexual abstinence or by use of
condom and no blood/tissue donation is recommended
- Transmission and PEP drug risks if breastfeeding (21)
4. Approach Considerations:
 To establish a blood- borne infection management policy
 Implementing management policies e.g., training, hepatitis B vaccination, exposure
reporting, PEP access, etc.
 To need a laboratory capacity for bloodborne virus testing
 Selective versus necessary use appropriate PEP regimens
 Provide counseling for exposed personnel
21 Saleem et al.,“Knowledge, Attitudes and Practices of Medical Students Regarding Needle Stick Injuries.”

10.  Monitor and follow up of the adverse events and seroconversion in the patient
 Exposure management e.g., time between exposure and evaluation, testing of health
care worker and the source persons, follow-up and regular testing with appropriate
testing counseling. (22)
5. Conclusion:
Occupational exposure management is complex hence, Prevention is best
*e.g., hepatitis B immunization and avoiding occupational blood exposures*
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