Needlestick Injury  

 

Hepatitis B Virus (HBV), Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV) are the three recognised blood born pathogens that are most commonly involved in occupational transmission.

The risk of transmission of HBV to a non-immune health care worker ranges from 2% if the source patient is Hepatitis B e antigen negative to 40% if the patient is positive. HBV hyperimmune globulin and/or recombinant HBV vaccine is recommended for health care workers exposed to HBV who have anti-HBsAg titre less than 10 mIU per millilitre (1).

The risk associated with occupational exposure to HCV is not well established but is estimated to range between 3 and 10% (1). Available data do not support the use of immunoglobulin, interferon- or anti-viral agents for prophylaxis against HCV. However it is important to document infection because chronic hepatitis will develop in more than 50% of infected adults and these patients may respond to treatment with interferon-.

The average risk for HIV infection from percutaneous exposures to HIV infected blood is 0.3%. In a case-control study among health care workers exposed to HIV infected blood the risk was increased for exposures involving 1) a deep injury, 2) visible blood on the device, 3) a device previously placed in the source patient's vein or artery or 4) a source or patient who died as a result of AIDS within 60 days post exposure (2). In the same case-control studies zidovudine post-exposure prophylaxis (PEP) was associated with a decrease of approximately 79% in the risk for HIV seroconversion. In HIV infected patients combination therapy with zidovudine and lamivudine (3TC) has greater anti-retroviral activity than zidovudine alone and adding a protease inhibitor such as indinavir provides even greater anti-retroviral activity.

The provisional 1996 US public health service (CDC) recommendation for chemoprophylaxis (3) are as follows. Chemoprophylaxis should be recommended for occupational exposures associated with the highest risk for HIV transmission and offered for exposures with a lower but non-negligible risk. 3TC should usually be added to zidovudine and a protease inhibitor such as indinavir added for exposures with the highest risk for HIV transmission. The antiretroviral drug history of the source patient and the results of available HIV resistance studies of source patient's blood should be considered when selecting the antiretrovirals for chemoprophylaxis for exposed health care workers.

PEP should be initiated promptly, preferably within one to two hours post-exposure. However initiating therapy after a longer interval (eg 1-2 weeks) may be considered for the highest risk exposures. Workers with occupational exposure to HIV should receive follow up counselling, medical evaluation and HIV antibody testing (eg baseline, six weeks, twelve weeks and six months) and should observe precautions to prevent possible secondary transmission.

References

1 Gerberding J L. Management of Occupation exposures to blood-borne viruses. N Engl J Med 1995: 332;444-51.

2 CDC. Case-Control Study of HIV seroconversion in health-care workers after percutaneous exposure to HIV infected blood-France, United Kingdom, and United States, January 1988-August 1994, MMWR 1995;44:929-33.

3 CDC. Update: provisional Public Health Service recommendations for chemoprophylaxis after occupational exposure to HIV. MMWR 1996:45:468-472.


 Needlestick Injury

 Source from the AMERICAN NURSES ASSOCIATION

  • Health care workers (HCWs) suffer between 600,000 and one million injuries from conventional needles and sharps annually. These exposures can lead to hepatitis B, hepatitis C and Human Immunodeficiency Virus (HIV), the virus that causes AIDS.
  • At least 1,000 HCWs are estimated to contract serious infections annually from needlestick and sharps injuries.
  • Registered nurses working at the bedside sustain an overwhelming majority of these exposures.
  • Needlestick injuries are preventable. Over 80% of needlestick injuries could be prevented with the use of safer needle devices.
  • Less than 15% of U.S. hospitals use safer needle devices and systems.
  • In 1992, the Food and Drug Administration issued an alert to all health care facilities to utilize needleless IV systems wherever possible. This alert is merely a recommendation, not a mandate. Therefore, health care facilities are under no legal obligation to comply.
  • The first safe needle designs were patented in the 1970s, and the FDA has approved over 250 devices for marketing as safety devices.
  • More than 20 other infections can be transmitted through needlesticks, including: tuberculosis, syphilis, malaria and herpes.

Cost Savings from Needlestick Prevention

  • Hospitals and health care employers in California are expected to save over $100 million per year after implementing the California Occupational Safety and Health Administration's requirement for safe needle devices.
  • According to the American Hospital Association, one case of serious infection by bloodborne pathogens can soon add up to $1 million or more in expenditures for testing follow-up, lost time and disability payments.
  • The cost of follow-up for a high-risk exposure is almost $3,000 per needlestick injury even when no infection occurs.
  • Safe needle devices cost only 28 cents more than standard devices.

Hepatitis B

  • Hepatitis B is now preventable due to the vaccine that must be offered to HCWs and is given to children at birth.
  • Regulatory and legislative efforts were largely responsible for the reduction of deaths from hepatitis B as a result of vaccine programs.
  • Following these regulatory and legislative efforts, including the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard, cases of hepatitis B in health care workers dropped from 17,000 annually to 400 annually–and continue to drop.
  • Transmission rate: 2?0%

Hepatitis C

  • Testing for hepatitis C after needlestick injuries was only recommended in 1998. It is a silent epidemic. There could be thousands and thousands of nurses with occupationally acquired hepatitis C who do not know it.
  • Hepatitis C is the most frequent infection resulting from needlestick and sharps injuries. Of health care workers who become infected, 85% become chronic carriers.
  • Chronic carriers have the potential to spread the disease to others, including their partners.
  • Drugs that slow the progression of hepatitis C are available, but average $1,700 each month.
  • Hepatitis C leads to liver failure, liver transplants and liver cancer. A liver transplant costs $500,000.
  • At least 4 million Americans are infected with hepatitis C.
  • Transmission rate: 2.7?0%

HIV

  • Human Immunodeficiency Virus (HIV) is the virus that causes AIDS, a fatal disease.
  • Advances in treatment prolong the time before HIV becomes AIDS. The drug treatment can cost up to $6,000 per month.
  • 16,000 of the 600,000 to one million needlestick injuries each year result in HIV exposure.
  • There are over 54 documented cases of HCWs with occupationally acquired HIV and at least 133 cases of possible transmissions of HIV.
  • There are 35 new cases each year.
  • Transmission rate: .2?4%

REFERENCES

Centers for Disease Control and Prevention. "Evaluation of Safety Devices for Preventing Percutaneous Injuries Among Healthcare Workers During Phlebotomy Procedures--Minneapolis-St. Paul, New York City, and San Francisco," MMWR 46 (1997): 21-23.

Centers for Disease Control and Prevention. "Guideline for Infection Control in Health Care Personnel," Infection Control and Hospital Epidemiology 19 (6):445 (1998).

Centers for Disease Control and Prevention. "Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease," MMWR: 47:21 (1998).

Chiarello, L. "Selection of Safer Needle Devices: A Conceptual Framework for Approaching Product Evaluation," American Journal of Infection Control: 23 (6): 386-395 (1995).

Fowler, C. "Needlestick Injuries and Subsequent Disease: First-person Accounts from Three Nurses," Journal of Emergency Nursing: 25(2):93-101 (1999).

International Health Care Worker Safety Center, "Estimated Annual Number of U.S. Occupational Percutaneous Injuries and Mucocutaneous Exposures to Blood or Potentially At-Rick Biological Substances," Advances in Exposure Prevention 4(1):3 (1998).

Ippolito, G., Puto, V., Petrosillo, N., et al. Prevention, Management & Chemoprophylaxis of Occupational Exposure to HIV. Charlottesville, VA: International Health Care Worker Safety Center, 1997.

Jagger, J. "Reducing Occupational Exposure to Bloodborne Pathogens: Where do We Stand a Decade Later?" Infection Control Hospital Epidemiology 17 (1996): 573-575.

Mahoney, F.J., Stewart, K., Hu, H. et al. "Progress Toward Elimination of Hepatitis B Virus Transmission Among Health Care Workers in the United States," Archives of Internal Medicine 157 (1997):2601-2603.

McCormick, R. "Selecting Safety Products for Evaluation." In Sharps Injury Prevention Program A Step-By-Step Guide edited by G. Pugliese and M. Salahuddin, Chicago: American Hospital Association, 1999.

Moyer, L. and Hodgson, W. "Hepatitis B Vaccine and Healthcare Workers," Advances in Exposure Prevention 2(7):1-10 (1996).

Pugliese, G. The Hospital Perspective: Institutional Challenges to Overcome in Implementing Safer Needles. Presentation at Health Care Worker Safety Educational Forum, International Health Care Worker Safety Center, Charlottesville, VA (Nov. 17, 1998)

Pugliese G. and M. Salahuddin, Sharps Injury Prevention Program A Step-By-Step Guide, Chicago: American Hospital Association, 1999.

U.S. Department of Health and Human Services, Food and Drug Administration. FDA Safety Alert: Needlestick and Other Risks from Hypodermic Needles on Secondary I.V. Administration Sets - Piggyback and Intermittent I.V. Washington DC, 1992

U.S. Department of Labor, Occupational Safety and Health Administration. Safer Needle Devices: Protecting Health Care Workers. Washington, DC: GPO, 1997.

  

 


Safety in the Laboratory

Bloodborne pathogens