FACTS , LEGAL CONCERNS, AND CARE Dr.T.V.

Rao MD

NEEDLE STICKS AND SHARPS INJURIES

DR.T.V.RAO MD

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

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

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

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

WHO GETS INJURED?

Housekeeping/ Maintenance 3% Student 4% Clerical / Admin 1% Dental 1%

Occupational Groups of Healthcare Personnel Exposed to Blood/Body Fluids, NaSH June 1995 December 2003 (n=23,197)

Other 5%

Technician 15%

Nurse 43%

Physician 28%

DR.T.V.RAO MD

HOW DO INJURIES OCCUR WITH HOLLOW-BORE NEEDLES?

Circumstances Associated with Hollow-Bore Needle Injuries NaSH June 1995December 2003 (n=10,239)
Transfer/Process Specimens 5% Other 5% During Sharps Disposal 13% Improper Disposal 9% During Clean Up 9% In Transit to Disposal 4% Manipulate Needle in Patient 28%

Access IV Line 5% Handle/Pass Equipment 6%

Recap Needle 6%

Disposal Related: 35%

Collision W/Worker or Sharp 10%

DR.T.V.RAO MD

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 punctureresistant sharps containers

Poor healthcare waste management practices

Ignoring Universal Work Precautions
DR.T.V.RAO MD

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 Tears, Sweat, Urine and secretions, CSF, Synovial, faeces, Saliva, Sputum and Pleural and Pericardial fluid, vomitus Amniotic fluid & other body fluids contaminated with visible blood
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DR.T.V.RAO MD

WHAT KINDS OF DEVICES USUALLY CAUSE SHARPS INJURIES?

Hypodermic needles Blood collection needles Suture needles Needles used in IV delivery systems Scalpels
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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)
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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)

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WHAT IS THE RISK FOR HIV ALONE?

Percutaneous Mucous membrane Non-intact skin 0.3% 0.1% <0.1%

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HOW DO SHARPS INJURIES HAPPEN?

Who gets injured? Where do they happen? When do injuries occur? What devices are involved?

How can they be prevented?

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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 punctureresistant sharps containers Poor healthcare waste management practices Ignoring Universal Work Precautions
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RISK FACTORS FOR HIV SEROCONVERSION IN HCWS

Risk Factor
Deep Injury Visible Blood on Device Terminal Illness in Source Patient Needle in Source Vein/Artery

Adjusted Odds Ratio*

15.0 6.2 5.6 4.3

*All Risk Factors were significant (P < 0.01)

From: NEJM 1997;337:1485-90.
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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

DR.T.V.RAO MD

From: CDC. MMWR 1998;47:No. RR-7.

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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.

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A. CATEGORIES OF EXPOSURE
Category
Mild exposure

Definition and Example

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
DR.T.V.RAO MD

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
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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
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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, dont scrub, no antiseptics or skin washes (bleach, chlorine, alcohol, betadine). contact lens immediately if wearing, no soap or disinfectant.

Eye: wash with water/ normal saline/ dont remove

Mouth: spit fluid immediately, repeatedly rinse the mouth with water and spit / no soap/ disinfectant .
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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 dont 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
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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.
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SUPREME COURT DIRECTIVE TO ENSURE PEP DRUGS IN ALL GOVERNMENT HOSPITALS IN INDIA
1. 2. Universal Work Precautions (UWP) and PEP guidelines should be followed by HCPs to prevent occupational transmission of HIV, Hepatitis B and hepatitis C. 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. 5. Availability of UWP and PEP can minimize the stigma and discrimination against PLHIVs in Health Care facilities. Above regulations to be practiced in Private hospitals and Establishments

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2.

LTM Hospital, Sion, Mumbai -2002

ROLE OF PEP IN PREVENTING TRANSMISSION OF HIV- INDIAN STUDIES (CONTD.)

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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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 roundthe-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

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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
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DO NOT FORGET HEPATITIS B VACCINATION AND UNIVERSAL PRECAUTIONS ..

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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. 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.

2.

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.
Delhi AIDS control Society India

4.

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 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

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