Needle stick injury management

Overview
Introduction to Needle Stick Injury(NSI)
Definition and History
Organisms transmitted due to NSI
Cause of Injury
Preventing Occupational injuries
Management of Exposed person
Data from AIIMS
Burden of NSI related diseases
Changing trend of NSI related disease
What can be done?
Summary

1. Needle Stick Injury: Management Presenter:- Dr. Chandan Mishra

2. Overview Introduction to Needle Stick Injury(NSI) Definition and History Organisms transmitted due to NSI Cause of Injury Preventing Occupational injuries Management of Exposed person Data from AIIMS Burden of NSI related diseases Changing trend of NSI related disease What can be done? Summary

3. Introduction Essentials of Medical Microbiology 5 th Edition

4. Definition The term "Needle Stick Injury" is a broad term that includes injuries caused by needles or other sharp objects (e.g. glass vials, surgical blades, forceps) that accidentally puncture the skin . [ NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India; https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf ] Needle-Stick Injury :-Penetrating stab wound caused by a needle. [ https://www.ncbi.nlm.nih.gov/books/NBK138670/def-item/glossary.gl1-d30/ ] Injuries from needles used in medical procedures are sometimes called needle-stick or sharps injuries . Sharps can include other medical supplies, such as syringes, scalpels and lancets, and glass from broken equipment . [ https://www.nhs.uk/common-health-questions/accidents-first-aid-and-treatments/what-should-i-do-if-i-injure-myself-with-a-used-needle/ ]

5. History 1 st documented case of Needle stick Injury was transmission of human T-lymphotropic virus type III (HTLV-III) infection to a health care worker(nurse) in the UK from a patient who was presumably infected while in Africa .[ Lancet.  1984 Dec 15;2(8416):1376-7. PMID: 6150372 ] 1 st documented case of Needle stick Injury in India was transmission of HIV infection to a health care worker (nurse) in Kolkata on September 1998 from a HIV positive patient. [First Documented Transmission of HIV Infection in a Health Care Worker in West Bengal; D K Neogi ; PMID: 17664805]

6. Most important organisms transmitted Hepatitis B virus (HBV) Hepatitis C Virus (HCV) Human Immunodeficiency Virus (HIV) Rarely CMV TB HSV Parvovirus B19 [ Needlestick Kevin C. King; Ronald Strony . PMID: 29630199 ] [ Infectious Risk for Healthcare Workers: Evaluation and Prevention ; M Triassi   ,  F Pennino , DOI:  10.7416/ai.2018.2234 ) [ Determination of Risk of Infection with Blood-borne Pathogens Following a Needlestick Injury in Hospital Workers .; Wicker et al; doi:10.1093/ annhyg /men044 ] [ Infectious Risk for Healthcare Workers: Evaluation and Prevention ; M Triassi   ,  F Pennino , DOI:  10.7416/ai.2018.2234 ) Malaria HTLV Ebola Organisms transmitted due to NSI

7. Transmission rate of HIV, HBV and HCV due to NSI NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf Organisms transmitted due to NSI

8. International Safety Center. U.S. EPINet Sharps Injury and Blood and Body Fluid Exposure Surveillance Research Group. Sharps Injury Data Report for Jan 01, 2018 to Dec 31, 2018; 34 hospitals contributing data, 1170 total injuries. Report available at [ https://internationalsafetycenter.org/wp-content/uploads/2019/07/Official-2018-US-NeedleSummary-FINAL.pdf ] Devices that caused the injury. Cause of Injury

9. International Safety Center. U.S. EPINet Sharps Injury and Blood and Body Fluid Exposure Surveillance Research Group. Sharps Injury Data Report for Jan 01, 2018 to Dec 31, 2018; 34 hospitals contributing data, 1175 total injuries. Report available at [ https://internationalsafetycenter.org/wp-content/uploads/2019/07/Official-2018-US-NeedleSummary-FINAL.pdf ] Job category of the injured person Cause of Injury

10. PRACTICES THAT INFLUENCE RISK Certain work practices increase the risk of needle stick injury such as: Recapping needles (most important) Transferring a body fluid between containers Handling and passing needles or sharps after use Failing to dispose of used needles properly in puncture-resistant sharps containers Poor healthcare waste management practices NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf Preventing Occupational injuries

11. How to protect oneself from needle stick/sharps injuries: Strict compliance to universal work precautions Avoid the use of injections where safe and effective alternatives are available e.g. oral, drugs Avoid recapping needles Plan for safe handling and disposal of needles after use Promptly dispose of used needles in appropriate sharps disposal containers NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf Preventing Occupational injuries

12. “DO NOT RECAP NEEDLE” Performing activities involving needles and sharps, in a rush increases the likelihood of an accidental exposure NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf Preventing Occupational injuries

13. Staff Information: Universal precautions to be followed in health services Use of personal protective equipment (PPE) All hospital staff members must know whom to report for PEP and where PEP drugs are available in case of occupational exposure. Safe handling and disposal of sharps/ injections: Use needle destroyers Protection against hepatitis B: All HCWs must have complete Hep B vaccine Record and monitor injuries with an injury register in each location of healthcare setting . NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf Preventing Occupational injuries

14. MANAGEMENT OF THE EXPOSED PERSON If the skin is pierced by a needle-stick or sharp instrument: Do not panic. Immediately wash the wound and surrounding skin with water and soap and rinse Do not scrub Do not squeeze blood form the wound Do not put pricked/cut finger in the mouth- a childhood reflex NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf STEP 1:-Management of Exposure Site-First Aid

15. MANAGEMENT OF THE EXPOSED PERSON Summary of Do’s and Don’t Do’s Don’t Remove gloves, if appropriate Do not panic Wash the exposed site thoroughly with running water Do not put the pricked finger in mouth Irrigate with water or saline if eyes or mouth have been exposed Do not squeeze the wound to bleed it Wash the skin with soap and water Do not use bleach, chlorine, alcohol, betadine, iodine or other antiseptics/detergents on the wound ** Do - Consult the designated physician immediately as per institutional guidelines for management of the occupational exposure ** Antiretroviral Therapy Guidelines for HIV-Infected Adults and Adolescents Including Post-exposure Prophylaxis; May 2007; NACO MoHFW GoI .

16. Step 2: Establish eligibility for Post Exposure Prophylaxis (PEP) Assess HIV status of Source of exposure Assess exposed individual – known HIV (+) no PEP – give comprehensive HIV service Evaluation must be made rapidly, to start treatment ASAP. All Accidental Exposure to Blood(AEB) do not need PEP. The first dose of PEP - within 2 hours (if not –certainly in first 72 hours) of exposure – evaluate risk ASAP . NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf MANAGEMENT OF THE EXPOSED PERSON

17. Categories of situations depending on Lab results of the source MANAGEMENT OF THE EXPOSED PERSON NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf

18. Step 3: Counselling for PEP Informed consent to be taken after explaining risk and benefit of PEP. PEP is not mandatory . Counselling for safe sexual practices till both baseline and 3 months HIV test are found to be negative. Relieve the anxiety of patient – psychological support Documentation on record is essential MANAGEMENT OF THE EXPOSED PERSON NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf

19. Step 4: Assessing Need for PEP and Prescribing PEP The decision on PEP for HIV (following an AEB in HCW) - depend on the exposed person and source person’s HIV status. Depends upon extent of disease – if source is positive It is decided - based on exposure code(EC) and source code(SC) . MANAGEMENT OF THE EXPOSED PERSON NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf

20. HIV Exposure Codes NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf MANAGEMENT OF THE EXPOSED PERSON

21. HIV Source Codes NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf MANAGEMENT OF THE EXPOSED PERSON

22. NACO Recommendations of PEP for HCP based on Exposure and HIV Source codes NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf MANAGEMENT OF THE EXPOSED PERSON

23. Recommended PEP regimens NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf MANAGEMENT OF THE EXPOSED PERSON

24. Hepatitis B Virus All health staff should be vaccinated against Hepatitis B . Vaccination - 3 doses- initial (zero) dose, 2 nd at 1 month and 3 rd dose at 6 months Sero -conversion after completing the full course is 99%. If unvaccinated or unclear vaccination status, give complete Hep-B vaccine . NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf MANAGEMENT OF THE EXPOSED PERSON

25. HBV vaccination after an AEB NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf MANAGEMENT OF THE EXPOSED PERSON

26. Hepatitis C Virus Presently no prophylaxis is available against Hepatitis C . There is no evidence that interferon, pegalated or not, with or without Ribavirin is more effective when given during this time than when given at the time of disease. Post-exposure management for HCV is based on the early identification of chronic HCV disease and referral to a specialist for management. NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf MANAGEMENT OF THE EXPOSED PERSON

27. [ Source: CDC. Testing for HCV infection: An update of guidance for clinicians and laboratorians. MMWR 2013;62(18). ] Interpretation of results of tests for hepatitis C virus (HCV) infection and further actions MANAGEMENT OF THE EXPOSED PERSON

28. Step:5 Laboratory Evaluation Prompt test to establish a "baseline" for comparing future test results. Informed consent for testing. Confidentiality of the test result must be ensured . Do not delay PEP if HIV testing is not available . NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf MANAGEMENT OF THE EXPOSED PERSON

29. Recommended baseline laboratory investigations Pregnancy testing should also be available, but its unavailability should not prevent the provision of PEP. NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf MANAGEMENT OF THE EXPOSED PERSON

30. Step:6 Follow-up of an Exposed Person: Clinical monitoring in PEP: Monitor for acute sero-conversion illness If suspected, refer to ART centre Psychological support Ask to avoid: Blood donation Breast feeding Pregnancy Person should use precautions: Sexual relationship (CONDOM protection) Adherence & Adverse Drug Reaction counselling NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf MANAGEMENT OF THE EXPOSED PERSON

31. Follow-up of an Exposed Person: *It is important to remember that the person exposed to the risk of transmission of HIV is also at risk of getting infected with HBV and HCV. Hence, that too needs to be addressed Minimum Laboratory Follow-up recommended for PEP for HIV* NATIONAL TECHNICAL GUIDELINES ON ANTI RETROVIRAL TREATMENT. October 2018; NACO MoHFW , Government of India https://lms.naco.gov.in/frontend/content/NACO%20-%20National%20Technical%20Guidelines%20on%20ART_October%202018%20(1).pdf MANAGEMENT OF THE EXPOSED PERSON

32. Care pathway for PEP Assessment Counselling and support Prescription Follow up Clinical assessment of Exposure Eligibility assessment for Post-Exposure Prophylaxis HIV testing of exposed people and source, if possible Provision of first-aid in case of broken skin or other wounds Risk of HIV Risk and benefits of Post-Exposure Prophylaxis Side-Effects Enhanced counselling if Post-Exposure Prophylaxis to be prescribed Specific Support in case of sexual assault PEP should be initiated as early as possible following exposure 28-day prescription of recommended ARV drugs Drug information Assessment of underlying co-morbidities & possible drug-drug interactions HIV test 3-months after exposure Link to HIV treatment, if possible Provision of prevention intervention as appropriate

33. A study by Sharman et al at AIIMS, New Delhi, from January 2011 to December 2013 A total of 476 occupational injuries were reported. 410 (86.1%)were needle prick. Doctors were found to have the highest exposure rate (73.7%) distantly followed by nurses (19.1%). A study by Mathur P, Rajkumari N, at JPNATC from Jan 2008 to Sep 2013 A total of 356 occupational injuries were reported. 157(44%) were sharp injuries. Doctors were found to have the highest exposure (129, 36.2%), followed by nurses (52, 14.6%) Data of AIIMS, New Delhi [Occurrence of Needlestick and Injuries among Health‑ careWorkers of a Tertiary Care Teaching Hospital in North India; DOI: 10.4103/0974-2727.187917 ] [A prospective look at the burden of sharps injuries and splashes among trauma health care workers in developing countries: True picture or tip of iceberg; http://dx.doi.org/10.1016/j.injury.2014.03.001 ]

34. Exposure according to staff category Data of AIIMS, New Delhi Data taken from ED of AIIMS New Delhi from 15 th Feb 2020 – 15 th Jun 2020

35. Device caused the injury Data taken from ED of AIIMS New Delhi from 15 th Feb 2020 – 15 th Jun 2020 Data of AIIMS, New Delhi

36. Format for record maintenance of NSI at Microbiology Section of Department of Lab Medicine . Data of AIIMS, New Delhi

37. Treatment given at AIIMS for NSIs Assessment of risk of HIV and HBV transfer. Inj Hep B Vaccine + Inj Hep B Ig + Tab TLE (stat) in case of unknown source status and known/unknown exposure status, followed by lab test for Hep B, HIV and HCV of the source and exposed. If the exposed has recent h/o Hep B complete vaccinated source status known/unknown then Inj Hep B booster + Tab TLE (stat), followed by lab test for Hep B, HIV and HCV of the source and exposed. After the status of the exposed and the source are available further treatment follows as per the NACO guideline. Data of AIIMS, New Delhi

38. Combination Drug used for the PEP of HIV in AIIMS, New Delhi The combination Drug Tenofovir 300mg Lamivudine 300mg Efavirenz 600mg Taken form the ED of AIIMS, New Delhi Data of AIIMS, New Delhi

39. Burden of NSI related diseases.  In 2000, WHO estimated - developing and transitional countries, the use of unsafe injections lead to- 5% of new HIV infections, 32% of new HBV infections and 40% of new HCV infections. SEAR (mostly India) had represented > ½ of the global cases of injections-related cases of HIV, As 75% of injections in SEAR were made with re-used needles and syringes. [Evolution of the Global Burden of Viral Infections from Unsafe Medical Injections, 2000–2010.; Pépin et al; https://doi.org/10.1371/journal.pone.0099677 ]

40. Burden of NSI related Disease According to a study by Harui et al   in 2000, contaminated injections caused an estimated 21 million HBV infections, 2 million HCV infections and 260,000 HIV infections After converting into disability-adjusted life years (DALYs) for 2000–2030 period HBV burden - 3,114539 DALYs HCV burden - 324,198 DALYs HIV burden - 5,738,942 DALYs Thus a total burden of 9,177,679 DALYs because of contaminated injection in 2000 - 2030. [The global burden of disease attributable to contaminated injections given in health care settings. Hauri et al; DOI:  10.1258/095646204322637182 ]

41. Changing trend of NSI between 2000 -2010. Despite a 13% population growth (2000-2010), reduction of 87% in HIV and 83% in HCV infections transmitted through unsafe injections. For HBV, marked reduction of 91% due to the additional impact of vaccination. While injections-related cases had accounted for 4.6%–9.1% of newly acquired HIV infections in 2000, this proportion decreased to 0.7%–1.3% in 2010 In 2010 unsafe injections caused between 16,939 and 33,877 HIV infections, between 1,57,592 and 3,15,120 HCV infections, and 16,79,745 HBV infections. Today the major threat after a needlestick injury is not HIV but acquiring hepatitis B or hepatitis C. Evolution of the Global Burden of Viral Infections from Unsafe Medical Injections, 2000–2010.; Pépin et al ; https://doi.org/10.1371/journal.pone.0099677

42. What can be done? WHO is committed to promoting safe injection practices by switching to the exclusive use of reuse-prevention syringes (RUPs) for all injections by 2020. WHO also recommends syringes with sharp injury protection (SIPs) features. National Accreditation Board for Hospitals and Health care Providers (NABH) and Joint Commission International (JCI) accreditation for all hospitals. All accrediting bodies give emphasis on the implementation of NSI protocols and occupational safety of the HCW. At the institutional level, a “No blame no shame” approach to ensuring high degree of compliance with NSI reporting. [ Needle-stick injury: A perspective; Srikanth et al; DOI:  10.4103/jpsic.jpsic_16_18 ]

43. Summary Needlestick injuries are known to occur frequently in healthcare settings and can be serious Needlestick injuries can be prevented by use of new safer instruments and strict adherence to standard guidelines. Record maintenance of NSIs should be promoted in all Medical Care Settings. PEP should never be delayed in any circumstances. Accreditation of hospitals to various accreditation bodies like NABH,JCI etc. Last but not least healthy HCW delivers better care for patient, so safety of HCWs is must.