Needle stick sharps injury and its post exposure prophylaxis management

I have prepared this PPT with Dr bhavika patel (MD microbiologist Surat)

1. Needle stick / Sharps injury and its Post Exposure Prophylaxis / Management

2. What are sharp? A sharp is an object having an edge or point that is able to cut or pierce the skin. Sharp include needles as well as items such as scalpels , lancet, razor, blade,scissors , metal wire, retractor, clamps,pins ,. Staples,cutter and glass items.

3. CLASSIFICATION OF SHARP INJURIES SHARP INJURY Needle Sharp object stick injury injury

4. SHARP INJURY Sharp Injuries are accidental cuts, punctures, nicks and scratches to the healthcare personnel caused by used sharp objects.

5. NEEDLE STICK INJURY Needle stick Injury is defined as a cutaneus cut, scratch or puncture from a needle that was contaminated with patients blood or body fluid, whether or not the injury drew blood . It is an accidental injury caused by used needles.

6. Who are at risk ? Any worker handling sharp devices or equipment such as scalpels , sutures, hypodermic needles, blood collection devices, or phlebotomy devices is at risk Nursing staff are most frequently injured What can be cause? Unsafe work practice( recapping, removal of phlebotomy tube holder Failure to dispose properly Disposal system failures (overfull containers, needles sticking out of container or piercing sides)

7. Risk of seroconversion due to sharps injury from a known positive source Virus Risk (Range ) HBV 6-30% HCV ~2% HIV 0.3%

8. PREVENTION OF NEEDLE STICK INJURY : The " One-Hand " technique of recapping needles. THE RIGHT WAY TO RECAP Recapping with both hands. NOTE: THIS IS DANGEROUS Needles should not be recaped . Use “ONE HAND” technique

9. Step 1 Place the cap on a flat surface, then remove your hand from the cap. Step 2 With one hand, hold the syringe and use the needle to "scoop up" the cap. Step 3 When the cap covers the needle completely; use the other hand to secure the cap on the needle hub. Be careful to handle the cap at the bottom only (near the hub).

10. Newer Technologies for Safer Injections Auto Disable (AD) and Re Use Prevention (RUP) Syringes Prefilled Injection Devices: Safety Syringes : Vacuum Based Technology Safety Needles and Cannulas

11. Needle-based safety injection device 27G Hypo Needle BD Eclipse™ Safety- needle in these syringes is locked through a luer lock mechanism

12. 2. Never pass a sharp instrument from one hand to another person’s hand directly: use hand free technique Example : Pass instrument in the kidney tray

13. Dealing with Used Needle

14. Disposal of sharp Collect sharp items in puncture proof containers. Transport securely to disposal place. Burn in high temperature incinerator or decontaminate and bury in safe place.

15. Post-exposure prophylaxis(PEP) Post-exposure prophylaxis(PEP) is any prophylactic treatment started immediately after exposure to a pathogen in blood or body fluids Post Exposure Prophylaxis Guidelines Immediate first aid Report incident Risk assessment Counselling Decision regarding use of PEP Follow-up

16. Do Don’t Remove gloves, if appropriate Do not panic Wash the exposed site thoroughly with running water Do not put pricked finger in mouth Irrigate with water or saline if eyes or mouth have been exposed Do not squeeze wound to bleed it Wash the skin with soap and water Do not use bleach, chlorine, alcohol, betadine , iodine or any antiseptic or detergent Note: Do consult the designated physician immediately as per hospital guidelines for management of the occupational exposure. Report all needle stick injuries to unit head / casualty medical officer. Fill the requisite proforma (NSI Form) and send blood sample to microbiology laboratory for testing of HIV / HBsAg / HCV after pre-test counseling and consent of both patient and health care worker.

17. Post-HIV exposure management/ prophylaxis (PEP) It is necessary to determine the status of the exposure and the HIV/ HBsAg /HCV status of the exposure source before starting post-exposure prophylaxis(PEP) Immediate measures: • wash with soap and water • No added advantage with antiseptic/bleach Next step: • Prompt reporting in accident/incident reporting forms • Post-exposure treatment is begin as soon as possible • Preferably within two hours • Not recommended after seventy -two hours • Late PEP? May be yes Is PEP needed for all types of exposures? No

18. For HIV: Categories of exposure Category (Exposure code) Definition & examples Mild exposure (EC1) Mucous membrane/non-intact skin with small volumes Eg : a superficial wound with a plain or low caliber needle, Or contact with the eyes or mucous membranes, subcutaneous injections following small-bore needles Moderate exposure (EC2) Mucous membrane/non intact skin with large volumes or percutaneous Superficial exposure with solid needle Eg : a cut or needle stick injury penetrating gloves Severe exposure (EC3) Percutaneous with large volume. Eg : An accident with a high caliber needle (>18G)visibly contaminated with blood; A deep wound(haemorrhagic wound and/or very painful); Transmission of a significant volume of blood; An accident with material that has previously been used intravenously or intraarterially .

19. Categories of situations depending on results of the source Source HIV Status/Code Definition of risk in source HIV negative Source is not HIV infected but consider HBV & HCV Low risk (SC1) HIV positive & clinically asymptomatic High risk (SC2) HIV positive & clinically symptomatic Unknown Status of the patient is unknown & neither the patient nor his/her blood is available for testing. The risk assessment will be based only upon the exposure

20. Determine Post-Exposure Prophylaxis(PEP) Recommendation EC HIV SC PEP 1 1 Consider basic 1 2 Recommend basic regimen 2 1 Recommended expanded regimen 3 1 OR 2 Recommended expanded regimen 1,2,3 UNKNOWN If exposure setting suggests risks of HIV Exposure, consider basic regimen Basic regimen (Two Drug Regimen): Zidubudine 300 mg + Lamovudine 300 mg twice daily for 28 days. Expanded regimen: (Three drug regimen) • Basic regimen (+ Indinavir – 800 mg/thrice a day, or any other protease Inhibitor.

21. Testing and Counseling   The health care provider are tested for HIV as per the following schedule) t o monitor seroconversion. Base-line HIV test - at time of exposure Repeat HIV test - at six weeks following exposure 2nd repeat HIV test - at twelve weeks following exposure 3rd repeat HIV test - at 6 months following exposure

22. Pregnancy and PEP: Based on limited information, anti-retroviral therapy taken during 2nd and 3rd trimester of pregnancy has not caused serious side effects in mothers or infants. There is very little information on the safety in the 1st trimester. If the HCW is pregnant at the time of exposure to HIV, the designated authority/physician must be consulted about the use of the drugs for PEP. Side-effects of these drugs: Most of the drugs used for PEP have usually been tolerated well except for nausea, vomiting, tiredness, or headache.

23. Recommended PEP for exposure to Hep B virus

24. Role of vaccine 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

25. Recommended PEP for exposure to Hep C virus Known Hepatitis C NO ACTIVE PROPHYLAXIS AVAILABLE Check hepatitis C virus RNA testing at 6 and 12 weeks Check HCV antibody ( anti HCV ) at 12 and 24 weeks Source known not to be infected with hepatitis C following testing at time of incident Check serum if symptoms or signs of liver disease develop Hepatitis C status of source unknown A risk assessment should be done High risk – Manage as known infected source Low risk – Obtain serum for anti HCV testing at 24 weeks HCW found to be acquired hepatitis C infection following occupational exposure should be referred immediately to a specialist in infectious disease / physician for treatment.

26. FOLLOW UP SEROLOGY TESTING OF THE EMPLOYEE TO BE DONE AS PER FOLLOWING SCHEDULE : HIV - 0,6 WEEKS, 12 WEEKS, 6 MONTHS HbsAg - 0,6 WEEKS, 6 MONTHS ANTI HCV - 0,(4-6) MONTHS  

27. Laboratory test on follow up Recommended follow up laboratory tests Timing In persons taking PEP In persons not taking PEP Weeks 2 & 4 Transaminases Complete blood count Clinical monitoring for hepatitis Week 6 HIV Ab HIV Ab Month 3 HIV Ab, anti HCV, HBsAg Transaminases HIV Ab, anti HCV, HbsAg Month 6 HIV Ab , anti HCV, HBsAg Transaminases HIV Ab , anti HCV, HbsAg

28. Be Needle Smart Do NOT recap Do NOT bend Do NOT remove Do NOT transport Do NOT re –use Recap only when necessary. Report needle stick injury. Use puncture proof and leak proof containers to discard needles. Do not fill the container more than 3/4th. Do not leave needle protruding from containers.