Needle stick Injuriesconcerns and prevention by Dr.T.V.Rao MD

1. Dr.T.V.Rao MD
NEEDLE STICK
INJURIES
CONCERNS AND PREVENTION
DR.T.V.RAO MD 1

2. THE BASIS OF THIS PRESENTATION
• This presentation is designed to assist with the training of
staff on sharps management including safety devices
• The information relates to prevention of hollow-bore needle
stick injuries (NSI) and should be used in combination with
other training material
• The information includes the NACO guidelines concerning
the Indian law/ Supreme court guidelines and other
concerns.
• The Drug regimes for Post exposure practices should
be followed as per current guidelines
DR.T.V.RAO MD 2

3. THE PROBLEM
• CDC estimates ~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
DR.T.V.RAO MD 3

4. 4
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
DR.T.V.RAO MD 4

5. 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
DR.T.V.RAO MD 5

6. WHO GETS INJURED?
Nurse
43%
Technician
15%
Student
4%
Dental
1%
Housekeeping/
Maintenance
3%
Clerical /
Admin
1%
Other
5%
Physician
28%
Occupational
Groups of
Healthcare
Personnel Exposed
to Blood/Body
Fluids,
NaSH June 1995—
December 2003
(n=23,197)
DR.T.V.RAO MD 6

7. HOW DO INJURIES OCCUR WITH HOLLOW-BORE
NEEDLES?
During Sharps
Disposal
13%
During Clean Up
9%
In Transit to
Disposal
4%
Handle/Pass
Equipment
6%
Improper
Disposal
9%
Access IV Line
5%
Transfer/Process
Specimens
5%
Recap Needle
6%
Collision
W/Worker or
Sharp
10%
Manipulate
Needle in Patient
28%
Other
5%
Circumstances Associated with Hollow-Bore Needle Injuries NaSH June
1995—December 2003 (n=10,239)
Disposal
Related:
35%
DR.T.V.RAO MD 7

8. 8
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
DR.T.V.RAO MD 8

9. 9
Potentially infectious body fluids -
Exposure to body fluids
considered at risk
Exposure to body fluids
considered not at risk unless they
contain visible blood
Blood, Semen, Vaginal
secretions, CSF, Synovial,
Pleural and Pericardial fluid,
Amniotic fluid & other body
fluids contaminated with
visible blood
Tears, Sweat, Urine and
faeces, Saliva, Sputum and
vomitus
DR.T.V.RAO MD 9

10. • Hypodermic
needles
• Blood collection
needles
• Suture needles
• Needles used in IV
delivery systems
• Scalpels
WHAT KINDS OF DEVICES USUALLY
CAUSE SHARPS INJURIES?
DR.T.V.RAO MD 10

11. 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)
DR.T.V.RAO MD 11

12. RISKS OF SEROCONVERSION DUE TO SHARPS
INJURY
FROM A KNOWN POSITIVE SOURCE
Virus
HBV
HCV
HIV
Risk (Range)
6-30%*
~ 2%
0.3%
(*Risk for HBV applies if not HB vaccinated)
DR.T.V.RAO MD 12

13. WHAT IS THE RISK FOR HIV ALONE?
• Percutaneous 0.3%
• Mucous membrane 0.1%
• Non-intact skin <0.1%
DR.T.V.RAO MD 13

14. • 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?
DR.T.V.RAO MD 14

15. 15
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
DR.T.V.RAO MD 15

16. 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)
DR.T.V.RAO MD 16

17. HIV: SEROCONVERSION IN HEALTH CARE
WORKERS IN USA (CONTD.)
 Primary HIV Infection
- in 81% of HCWs
- median 25 days after exposure
 Seroconversion
- Median 46 days
- by 6 months in 95% of HCWs
- 3 persons Seroconversion at 6-12 months
From: CDC. MMWR 1998;47:No. RR-7.DR.T.V.RAO MD 17

18. • 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 …
DR.T.V.RAO MD 18

19. A. CATEGORIES OF EXPOSURE
19
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
DR.T.V.RAO MD

20. 20
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 Aid
 Risk Assessment
 Counseling
 PEP drugs (4Weeks) depending upon risk assessment
 Relevant Lab Investigation on informed consent of the
source and exposed person
 Follow up and support
DR.T.V.RAO MD

21. 21
MANAGEMENT OF EXPOSED PERSON
1st 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.
DR.T.V.RAO MD

22. 22
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
DR.T.V.RAO MD

23. 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.
DR.T.V.RAO MD 23

24. 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
DR.T.V.RAO MD 24

25. ROLE OF PEP IN PREVENTING TRANSMISSION
OF HIV- INDIAN STUDIES (CONTD.)2. LTM Hospital, Sion, Mumbai -2002
• Over a period of one year, June 2000 - 2001, a total number of 38 cases of
accidental exposures were self reported
• Of the 38 reported cases; 34 were NSIs, 2 were scalpel cuts, and 1 was exposure
to body fluids (vitreous humor) by splashing and 1 was a human bite, from a
psychiatric patient.
• The 38 source cases were also tested for HIV 1,2 antibodies and HBsAg. Ten
were HIV seropositive and 28 HIV seronegative and four were HBsAg positive
and 34 HBsAg seronegative.
• Majority of the 34 needle stick injuries were by hollow bore needles. Of these, 20
were during blood collection procedure by hollow bore needle, 5 during
angioplasty procedure, 4 during central venous puncture line cut down
procedures, 2 during suturing of contused lacerated wound and 3 while recapping
the needle. PEP was received regularly by 10 cases.
• All the HCWs were HIV and HBsAg seronegativee after one and half years.
- DR.T.V.RAO MD 25

26. 26
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.
DR.T.V.RAO MD

27. 27
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
DR.T.V.RAO MD

28. 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
DR.T.V.RAO MD 28

29. DO NOT FORGET HEPATITIS B VACCINATION AND
UNIVERSAL PRECAUTIONS ……..
DR.T.V.RAO MD 29

30. REFERENCES
1. Centers for Disease Control and Prevention. Workbook for Designing,
Implementing and Evaluating a Sharp Injury Prevention Program. 2004.
Atlanta: US Department of Health and Human Services.
2. Whitby R, McLaws M. Hollow bore needle stick injuries in a tertiary
teaching hospital: epidemiology, education and engineering. Med J Aust
2002; 177(8): 418-422.
3. Centers for Disease Control and Prevention. Updated U.S. Public Health
Service Guidelines for the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for Post exposure Prophylaxis.
MMWR 2001; 50(No. RR-11): 1-7.
4. Delhi AIDS control Society India
DR.T.V.RAO MD 30

31. DR.T.V.RAO MD 31
• Programme Created by Dr.T.V.Rao MD for
Basic understanding on Needle sticks
Injuries and Human and Legal concerns
• Email
• doctortvrao@gmail.com