Needle Stick Injury & PEP
DEPT OF MICROBIOLOGY
Dr Vasantrao Pawar Medical College Hospital & RC,
Nashik
WHAT IS OCCUPATIONAL EXPOSURE
• Occupational exposure refers to exposure to
potential blood-borne infections (HIV, HBV
and HCV) that may occur in healthcare settings
during performance of job duties. Post exposure
prophylaxis (PEP) refers to comprehensive
medical management to minimize the risk of
infection among Health Care Personnel (HCP)
following potential exposure to blood-borne
pathogens (HIV, HBV, HCV)
2
WHOARE AT RISK
• All Health Care Personnel,
including emergency care
providers, laboratory personnel,
autopsy personnel, hospital
employees, interns and medical
students, nursing staff and
students, physicians, surgeons,
dentists, labour and delivery
roompersonnel, laboratory
technicians, health facility
sanitary staff and clinical waste
handlers and health care
professionals at all levels
3
WHAT ARE “SHARPS”?
Sharps are devices that are intentionally sharp to puncture or
cut skin (needles, scalpels, etc.), or become sharp due to
accident, such as broken glass tubes.
• Hypodermic needles
• Scalpels
• IV devices
• Capillary tubes
• Glass containers
• Pipettes
• Others
4
WHAT KIND OF DEVICES USUALLY
CAUSE SHARPS INJURIES?
• Hypodermic
needles
• Blood collection
needles
• Suture needles
• Needles used in IV
delivery systems
• Scalpels
5
HOW COMMON ARE
SHARPS INJURIES?
• Estimates indicate that 600,000 to
800,000 needle stick injuries occur each
year.
• Unfortunately, about half of these
injuries are not reported.
• ALWAYS REPORT sharps injuries to
your employer to ensure that you
receive appropriate follow-up care.
6
SHARPS MANAGEMENT
• What is an occupational exposure?
• A blood or body fluid exposure that occurs as a
consequence of a work-related activity
• There are two types of blood and body fluid exposure:
• Percutaneous exposure (penetrates the skin) e.g.
needle stick injury (NSI) or cut with a sharp object such
as a scalpel blade
• Non-percutaneous or Mucocutaneous exposure
(contact of mucous membrane or non-intact skin with
blood or body fluids) e.g. blood splash to the eye
7
INCREASING THE RISK
OF
SHARPS
Past studies show sharps injuries are often associated with these activities:
INJURIES
• Recapping needles or other
devices
• Transferring a body fluid between
containers
• Failing to dispose of used needles or
other devices properly in punctureresistant sharps containers
8
WHOAREAT RISK
• Health Care Personnel are at risk of blood-borne
infection transmission through exposure of a
percutaneous injury (e.g. needle-stick or cut with a
sharp instrument), contact with the mucous
membranes of the eye or mouth of an infected
person, contact with non-intact skin (particularly
when the exposed skin is chapped, abraded, or
afflicted with dermatitis or contact with blood or
other potentially infectious body fluids. potentially
infectious body fluids
PROTECTING YOURSELF
• 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.
SHARPS MANAGEMENT
• Who is at risk of an occupational exposure?
• All healthcare workers who have the potential for exposure to infectious
materials (e.g. blood, tissue, and specific body fluids, as well as medical
supplies, equipment or environmental surfaces contaminated with these
substances) e.g:
• Nurses
• Doctors
• Laboratory staff
• Technicians
• Therapists
• Support personnel e.g. housekeeping, maintenance
• Dental staff
• Contractual staff
• Students
SHARPS MANAGEMENT GENERAL PRINCIPLES
• Needles should not
be recapped, bent or
broken by hand,
removed from
disposable syringes
or otherwise
manipulated by
hand.
WHAT INFECTIONS CAN BE
CAUSED BY SHARPS
Sharps injuries
can expose workers to a
INJURIES?
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)
RISK OF ACQUIRING INFECTION
• The average risk of
acquiring HIV infection from
different types of
occupational exposure is
low compared to risk of
infection with HBV or HCV.
In terms of occupational
exposure the important
routes are needle stick
exposure (0.3%risk for
HIV, 9–30% for HBV and 1–
10%for HCV) and mucous
membrane exposure
0A.O0M9
DR.T.V(.R
D %for HIV).
15
WHICH FLUIDS ARE
POTENTIALLY
INFECTIOUS FOR HIV?
• blood?
• spinal fluid?
• saliva?
• pleural fluid?
• sweat?
• pus?
• feces?
• urine?
WHICH FLUIDSARE POTENTIALLY
INFECTIOUS FOR HIV?
• blood
• spinal fluid
• saliva
• pleural fluid
• sweat
• pus
• feces
• urine
NEEDLE STICK AND SHARPS
INJURIES
Procedures
for
Effectively Handling
Sharps Injuries
HIV PEP
• Exposures common
• 56 documented
cases of health care
workers contracting
HIV fromexposures;
138 other possible
cases
• Area of considerable
concern but little data
19
RISK OF HIV TRANSMISSION
FOLLOWING PERCUTANEOUS (NEEDLE
• Pooled analysis of
STICK) EXPOSURE
prospective
studies on
health care workers
with occupational
exposures suggests
risk is approximately
0.3%(95%CI, 0.2% 0.5%)1
• Presence or absence of
key risk factors may
influence this risk in
individual exposures
20
•
ASSESS EXPOSED
INDIVIDUAL
Theexposed
individual should haveconfidential
counseling andassessmentby anexperienced
physician. Exposedindividuals whoare knownor
discovered to be HIV positive should not receive PEP.
They should be offered counseling and information on
prevention of transmission and referred to clinical and
laboratory assessmentto determine eligibility for
antiretroviral therapy (ART). Besides the medical
assessment,counselling exposed HCPis essential to
allay fear and start PEP.
IMMEDIATE MEASURES
• Percutaneous:
• wash needle sticks and cuts with soap and water
• remove foreign materials
• Non-intact skin exposure:
• wash with soap and water or antiseptic
• Mucous membrane
• flush splashes to the nose, mouth or skin with water
• irrigate eyes with clean water, sterile saline or sterile
irrigants
COUNSELLING FOR PEP
• Exposed persons
(clients) should receive
appropriate information
about what PEP is
about and the risk and
benefits of PEP in order
to provide informed
consent for taking PEP.
It should be clear that
PEP is not mandatory.
PSYCHOLOGICAL SUPPORT
• Many people feel anxious
after exposure. Every
exposed person needs to
be informed about the risks,
and the measures that can
be taken. This will help to
relieve part of the anxiety.
Some clients may require
further specialized
psychological support.
DOCUMENT EXPOSURE
• Documentation of
exposure is
essential. Special leave
fromwork should be
considered initially for a
period of two weeks.
Subsequently, it can be
extended based on the
assessment of the exposed
person’s mental state, side
effects and requirements.
PRACTICALAPPLICATION IN THE CLINICAL
SETTINGS
•
For prophylactic treatment the exposed person must sign
consent form.
• ·
Informed consent also means that if the exposed person
has been advised PEP, but refuses to start it, this needs to be
recorded. This document should bekept by the designated
officer for PEP.
• ·
An information sheet covering the PEP and the biological followup after anyAEB must be given to the person under treatment.
However, this sheet cannot replace verbal explanations.
•
SHARPS
MANAGEMENT GENERAL PRINCIPLES

Policies and procedures including NSI management

Standard Precautions including personal protective
equipment (PPE)

Hepatitis B vaccination

Education programs

Modifications to work practices including alternatives to
using needles

Safe handling of sharps

Sharps disposal systems i.e. puncture-resistant containers

Injury prevention features/safety devices

Active

Passive
27
PRESCRIBE PEP
Deciding on PEP regimen
There are two types of
regimens:
Basic regimen: 2-drug
combination
Expanded regimen: 3-drug
combination
• The decision to initiate the
type of regimen depends
on the type of exposure
and HIV serostatus of the
person.
28
OUTCOMES OF HIV EXPOSURES
• No infection 
no immune memory
• Aborted infection 
cellular immune
• Acute infection 
response seroconversion
29
HIV CHEMOPROPHYLAXIS
• Because post-exposure
prophylaxis (PEP) has its
greatest effect if begun within
two hours of exposure, it is
essential to act immediately. The
prophylaxis needs to be
continued for four weeks.
Exposure must be immediately
reported to designated authority
and therapy administered. Never
delay start of therapy due to
debate over regimen. Begin with
basic 2-drug regimen, and once
expert advice is obtained,
change as required.
•
30
PEPREGIMENS: BASIC REGIMENS
• Two NRTIs
• Simple dosing, fewer side effects
• Preferred basic regimens:
Zidovudine (AZT) OR tenofovir (TDF)
plus
lamivudine (3TC) OR emtricitabine (FTC)
• Alternative basic regimens:
stavudine (d4T) OR didanosine (ddI)
plus
lamivudine (3TC) OR emtricitabine (FTC)
31
EXPANDED PEP REGIMENS
• Basic regimen plus a third
agent
• Rationale: 3 drugs may be
more effective than 2
drugs, though direct
evidence is lacking
• Consider for more serious
exposures or if resistance
in the source patient is
suspected
• Adherence more difficult
D
potential for toxicity
32
EXPANDED PEP REGIMENS
• PreferredExpanded Regimen:
• Basic regimen plus lopinavir/ritonavir (Kaletra)
• Alternate Expanded Regimens:
• Basic regimen plus one of the following:
• Atazanavir* +/- ritonavir
• Fosamprenavir +/- ritonavir
• Indinavir +/- ritonavir
• Saquinavir (hgc; Invirase) + ritonavir
• Nelfinavir
• Efavirenz
33
SEEK EXPERT OPINION IN CASE OF
• Delay in reportingexposure (>
72 hours).
• ·
Unknown source
• ·
Known or suspected
pregnancy, but initiate PEP
• ·
Breastfeeding mothers,
but initiate PEP
• ·
Source patient is onART
• ·
Major toxicity of PEP
regimen.
34
Percent of HCWs
TOLERABILITY OF HIV PEP IN HEALTH CARE
WORKERS
100
90
80
70
60
50
40
30
20
10
0
Incidence of Common Side Effects
Nausea
Fatigue Headache Vomiting Diarrhea Myalgias
35
FOLLOW-UP HIV TESTING
• CDC recommendations: HIVAb
testing for 6 months postexposure (e.g., at 6 weeks, 3
months, 6 months)
• Extended HIVAb testing at 12
months is recommended if health
care worker contracts HCV from
a source patient co-infected with
HIV and HCV
• VL testing not recommended
unless primary HIV infection
(PHI) suspected
39
RECOMMENDATIONS
HEPATITIS B
• For the
unimmunized:
• prophylactic
HBIG
• initiate the
vaccine series
•
GENERAL PRINCIPLES IN
HEPATITIS B
VACCINATION
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 (HBsAb) four to six weeks after last dose
• Booster doses not required if titre level >10 mIU/mL
42
PROTECTING YOURSELF FROM NEEDLE
STICK INJURIES
A SELF RESPONSIBILITY ???
• Avoid the use of needles where safe alternatives are
available.
• Help your employer select and evaluate devices with
safety features that reduce the risk of injury.
• Use devices with safety features provided by your
employer.
• Do not recap needles or scalpels.
• Plan for safe handling and disposal of sharps before
using them.
RECOMMENDATIONS
HEPATITIS C
• No effective prophylaxis
• Immunoglobulin and antiviral agents are NOT
recommended
• Determine status of source
• Establish baseline serology and serumALT of
employee and repeat testing at 4-6 months postexposure
• Early treatment if infection occurs
• Refer to Hepatologist
HEPATITIS C: FOLLOW-UPTESTING
• CDC guidelines: follow-up
HCVAb andALT at 4-6
months1
• Consider periodic HCV
RNAscreening (monthly?)
if earlier detection desired
• Note that unlike acute HIV
infection, most patients are
not symptomatic with acute
HCV infection2
45
MAJOR REFERENCES
• MMWRreviews
• CDC guidelines
• Post-Exposure Prophylaxis
an evidence-based review Christopher Behrens, MD Hillary Liss, MD Northwest
AIDS Education & Training Center University of Washington
•
NACO guidelines on Post exposure prophylaxis