DR.T.V.RAO MD 1

Dr.T.V.Rao MD

NEEDLE STICKS AND SHARPS INJURIES

FACTS , LEGAL CONCERNS, AND CARE

DR.T.V.RAO MD 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 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 44

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 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

WHO GETS INJURED?

Nurse43%

Technician15%

Student4%

Dental1%

Housekeeping/Maintenance

3%

Clerical / Admin

1%

Other5%

Physician28%

Occupational Groups of Healthcare

Personnel Exposed to Blood/Body

Fluids,

NaSH June 1995—December 2003

(n=23,197)

DR.T.V.RAO MD 6

HOW DO INJURIES OCCUR WITH HOLLOW-BORE NEEDLES?

During Sharps Disposal

13%

During Clean Up9%

In Transit to Disposal

4%

Handle/Pass Equipment

6%

Improper Disposal

9%

Access IV Line5%

Transfer/Process Specimens

5%

Recap Needle6%

Collision W/Worker or

Sharp10%

Manipulate Needle in Patient

28%

Other5%

Circumstances Associated with Hollow-Bore Needle Injuries NaSH June 1995—December 2003 (n=10,239)

Disposal Related:

35%

DR.T.V.RAO MD 7

DR.T.V.RAO MD 88

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

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Potentially infectious body fluids -Exposure to body fluids

considered at riskExposure 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 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 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 12

RISKS OF SEROCONVERSION DUE TO SHARPS INJURY

FROM A KNOWN POSITIVE SOURCE

Virus

HBVHCVHIV

Risk (Range)

6-30%*~ 2%

0.3%

(*Risk for HBV applies if not HB vaccinated)

DR.T.V.RAO MD 13

WHAT IS THE RISK FOR HIV ALONE?

• Percutaneous 0.3%

• Mucous membrane 0.1%

• Non-intact skin <0.1%

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• 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 1515

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 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 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.

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• 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

A. CATEGORIES OF EXPOSURE

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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

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 AidRisk Assessment CounselingPEP drugs (4Weeks) depending upon risk assessment Relevant Lab Investigation on informed consent of the source and exposed personFollow up and support

DR.T.V.RAO MD 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

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 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 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.

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DR.T.V.RAO MD 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.

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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 facilityPEP kit comprises of 2 drug regimen:

Zidovudine(AZT) 300mg + Lamivudine (3TC) 150 mg as a fixed dose combination

DR.T.V.RAO MD

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 29

DO NOT FORGET HEPATITIS B VACCINATION AND UNIVERSAL PRECAUTIONS ……..

REFERENCES1. 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

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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 concern for Medical care workers in INDIA

• Email

• doctortvrao@gmail.com