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Needlestick injuries in a tertiary care centre in Mumbai, India
Journal of Hospital Infection (2005) 60, 368–373
www.elsevierhealth.com/journals/jhin
Needlestick injuries in a tertiary care centre in Mumbai, India A. Mehta*, C. Rodrigues, S. Ghag, P. Bavi, S. Shenai, F. Dastur P.D. Hinduja National Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim (West), Mumbai 400 016, India Received 1 April 2004; accepted 6 December 2004
KEYWORDS Needlestick injuries; Healthcare works; Prevention; Occupational exposure
Summary Accidental exposure from blood/body fluid of patients is a risk to healthcare workers (HCWs). Percutaneous injury is the most common method of exposure to blood-borne pathogens. A policy was formulated at our institute, a tertiary care centre in central Mumbai, and we report a six-year (1998–2003) ongoing surveillance of needlestick injuries. Of the 380 HCWs who reported needlestick injuries, 45% were nurses, 33% were attendants, 11% were doctors and 11% were technicians. On source analysis, 23, 15 and 12 were positive for Hepatitis B surface antigen (HBsAg), human immunodeficiency virus (HIV) and hepatitis C virus (HCV), respectively. Immediate action following potential exposure included washing the wound with soap and water, encouraging bleeding and reporting the incident to the emergency room. Analysis of the source of injuries revealed that known sources accounted for 254 injuries, and unknown sources from garbage bags and Operating Theatre instruments accounted for 126 injuries. Most needlestick injuries occurred during intravenous line insertion (NZ112), followed by blood collection (NZ69), surgical blade injury (NZ36) and recapping needles (NZ 36). Immediate postexposure prophylaxis (PEP) for HCWs who sustained injuries with hepatitis-B-virus-positive patients included booster hepatitis B immunization for those positive for antiHBs. A full course of immunization with hepatitis B immunoglobulin was given to those who were antiHBs negative. All staff who sustained injury with HIV were given immediate antiretroviral therapy (AZT 600 mg/day) for six weeks. Subsequent six-month follow-up showed zero seroconversion. Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: C91 22 24447189; fax: C91 22 24442318/24449151. E-mail address: [email protected] 0195-6701/$ - see front matter Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2004.12.015
Needlestick injuries in a tertiary care centre in Mumbai, India
Introduction Healthcare workers (HCWs) who come into contact with medical devices incorporating ‘sharps’, such as syringes or scalpels, are at risk of injuries that can lead to serious or fatal blood-borne infections, including hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), cytomegalovirus and Epstein–Barr virus. Although the risk of contracting these blood-borne pathogens is low (Table I), the psychological trauma that follows the injury can be considerable. It is not known exactly how many work-related needlestick injuries occur in India each year; however, estimates indicate that 600,000–800,000 such injuries occur annually in the USA and around half of those go unreported.1,2 Data from the EPINet system suggest that in an average hospital, workers incur approximately 30 needlestick injuries/100 beds/year.3 Healthcare institutions in most parts of India are still not well equipped to provide timely and effective postexposure prophylaxis (PEP) for HCWs. For effective implementation of PEP, a policy was formulated at our institute to establish a system for reporting injuries, performing necessary tests and administering prophylaxis. In this article, we report a six-year ongoing surveillance of needlestick injuries.
Materials and methods At the P. D. Hinduja National Hospital, 380 needlestick injuries were reported from January 1998 to December 2003. Immediate action following potential exposure included thorough washing with soap and water or an antiseptic, encouraging bleeding
369
and reporting the incident to the emergency room (ER). The protocol that HCWs follow immediately after a needlestick injury at our institute includes: reporting the incident to the ER to give a detailed history of the exposure and hepatitis B immunization status; testing of a blood sample along with the source patient’s blood sample for baseline testing of antiHBs/Hepatitis B surface antigen (HBsAg)/ HCV/HIV; reporting the incident to the head of department/supervisor/manager; and contacting the infection control committee chairman/infection control nurse with all the reports within 24 h. The risk of transmission is assessed by taking into account the degree of exposure and the evaluation of the source patient. The type of exposure (puncture, laceration, abrasion, mucosal inoculation, contamination of non-intact skin, bite) is recorded. The type of device causing exposure is identified and recorded for information regarding epidemiology of infection. Determination of the type of needle, depth of penetration, volume of blood injected, estimated fluid volume and duration of contact in mucocutaneous injury with a detailed history of the HCW is recorded in the Post Exposure Prophylaxis form by the Medical Officer in the ER. This form is then collected by the Infection Control Nurse (ICN) who reports each day to the Infection Control Chairman. The ICN is also responsible for the six-month follow up of all injured HCWs.
Postexposure prophylaxis (PEP) Table I Estimation of the probability of transmission following a needlestick injury Mucosal
Minimal blood volume (mL)
Rate of infection/ seroconversion agent
Hollow needle (%)
HIV HBV (Hbe AgCve) Hepatitis seroconversion HbeAg Kve Hepatitis seroconversion HCV
0.3–0.4 22–31
0.09% –
0.1 0.0004
37–62
–
0.0004
3–6 23–37 0–7
Not known
HIV, human immunodeficiency virus; HBV, hepatitis B virus; HbeAg, hepatitis B e antigen HCV, hepatitis C virus.
Postexposure management includes first aid, serological testing and counselling in all cases. Immunoprophylaxis and antiviral medications are used wherever indicated.
PEP for HBV-positive source PEP for HCWs who are antiHBs negative and who have sustained injuries from an HBV-positive patient includes hepatitis vaccination and a full course of immunization with hepatitis B immunoglobulin (HBIG), preferably within 24 h. The option of giving one dose of HBIG (0.06 mg/kg of body weight) and re-initiating the vaccination series is preferred for non-responders who have not completed a three-dose vaccination series. For people
370 who completed a second vaccination series but failed to respond, two doses of HBIG are preferred. People who have been infected with HBV previously are considered to be immune to re-infection and are not given PEP.4,5
PEP for HCV-positive source In such cases, the source patient undergoes antiHCV antibody testing. Baseline testing of the HCW’s antiHCV and alkaline phosphatase is performed with follow-up for six months if the source patient is positive for HCV. All antiHCV-positive results are confirmed by recombinant immunoblot assay.
PEP for HIV-positive source HCWs exposed to an HIV-positive source are tested for HIV at baseline, and prophylaxis is started as early as possible. The Centers for Disease Control and Prevention (CDC) prophylaxis guidelines are followed. In the case of an HIV-positive source, the HCW is given a ‘starter pack’ [zidovudine (AZT) 600 mg/day!2 doses 3TC (150 mg)] in the ER with sufficient drugs for 48 h. HIV antibody testing is performed three and six months post exposure.4-6
Unknown source When the source patient of the needlestick injury is unknown, the protocol for HBV prophylaxis is followed. Establishing the need for HIV PEP is controversial in such instances. However, according to the policy of our hospital, unless it is likely that the needle is associated with a patient known to be infected with HIV, PEP for HIV is not indicated.
A. Mehta et al. were followed to completion. In 12 cases, follow-up was not possible as the injured HCWs had relocated. Amongst the cases followed-up, not a single case of seroconversion to HIV, HCV or HBV was observed. Analysis of the source of injuries (Table II, Figure 2) revealed that unknown sources accounted for 126 injuries, the majority of which were due to garbage bags (NZ92) followed by OT instruments (NZ34). For injuries from known sources (Table II, Figure 2), most were due to intravenous line insertion/manipulation or checking for blood sugar (NZ112), followed by blood collection (NZ69), surgical blade injury (NZ36) and recapping of needles (NZ36). Seventy-two percent of the cases had superficial injuries. Deep injuries were observed in 27% of the cases, and the remaining 1% of cases had experienced splashing of blood on intact skin. Most needlestick injuries were caused by recapping of needles and improper disposal of sharps. Winged infusion needles (butterflies) and intravenous catheters were found to be associated with high rates of needlestick injuries. Safe handling and disposal of sharps in separate puncture proof containers immediately after use is vital to minimize these injuries. At our institute, we discourage dangerous practices such as recapping of needles. Garbage disposal is widely publicized in well-illustrated charts at the nursing stations and explained to all HCWs. Waste segregation is performed at the site of generation. This could be the reason for the decrease in the number of cases of needlestick injuries from garbage bags [22 (46%) in 1998 compared with 13 (27%) in 2003 (Table II, Figure 2)], indicating increased HCW awareness. Of the 50 source-positive cases, only one source
Results and discussion At our institute, a policy was devised to establish a surveillance system for needlestick injuries and 380 cases were reported from January 1998 to December 2003. As shown in Figure 1, most reported needlestick injuries involved nursing staff (45%), followed by attendants (33%), doctors (11%) and technicians (11%). In the present study, of 380 injured HCWs, the source identity could be established in 254 cases and the source was unknown in the remaining cases. Of the 254, where the source was known, 50 HCWs were found to be injured with HBsAg positive (23), HCV positive (12) and HIV positive (15) sources respectively. In remaining 204 cases the source was negative for all 3 i.e. HBsAg, HCV and HIV. Of the 380 reported cases, 368 cases
Figure 1
Percentage of staff affected.
Needlestick injuries in a tertiary care centre in Mumbai, India Table II
371
Source analysis of needlestick injuries to the healthcare workers
Garbage bags Needle recapping OT instruments Checking blood sugar Intravenous line administration Surgical blade Blood collection Suturing Total no. of cases/year
1998
1999
2000
2001
2002
2003
Total
22 8 3 2 4 2 7 – 48
20 7 12 10 16 7 8 – 80
18 5 9 8 10 14 19 – 83
8 5 5 5 15 5 13 – 56
10 4 3 7 18 6 15 – 63
13 7 2 5 10 2 7 1 47
92 36 34 38 74 36 69 1 380
patient was found to be positive for both HBsAg and HCV. Infections with more than one blood-borne virus are generally observed in intravenous drug users due to sharing of infected needles. In India, sharing contaminated needles officially accounts for less than 3% of HIV transmission,7 indicating that transmission of blood-borne viruses is largely through blood transfusion or sexual routes rather than intravenous drug use. The emotional impact of needlestick injury can be severe and long lasting, especially when the injury involves exposure to HIV.8 As shown in Table I, the knowledge that the risk of transmission of HIV from a significant needlestick injury is only 0.3% only partially comforts the injured person. Not knowing the infection status of the source patient can accentuate the HCW’s stress. At our institute, HCWs exposed to needlestick injuries are reassured and asked to follow certain behavioural measures until absence of infection is established. These include sexual abstinence or condom use, refraining from donating blood, plasma, organs and semen, and refraining from breastfeeding and pregnancy.
Figure 2 Source analysis of needlestick injuries to the healthcare workers.
Appropriate PEP was provided to the 50 sourcepositive cases and follow-up was performed at three and six months. The ‘starter pack’ was given immediately in the ER when the source was HIV positive. Immediate PEP plays an important role when the source is HIV positive by interrupting the viral replication after exposure prior to systemic infection (during the window period).4 Although definitive studies are limited, the benefits of PEP have been demonstrated in animal and human studies of maternal–infant transmission, and smaller, retrospective, case–control studies in which PEP reduced the transmission after occupational exposure by 81%.9,10 To reduce the risk to staff from HBV infection, we have made vaccination mandatory for employment. When personnel are appointed, a medical check is performed to collect baseline data on certain infections. At this time, the health service also confirms that vaccination requirements are complete. Hepatitis B vaccine is freely available in the ER at any time for the hospital staff. However, despite HBV vaccination, HCWs have a much higher rate of infection than the general population, and HBV remains a well-recognized occupational risk.11,12 In the present study, the antiHBs antibody (antiHBsAB) status of 50 HCWs infected by positive sources was as follows: 43 had been vaccinated at the time of employment and were antiHBsAB positive. In two cases, antiHBsAB status was not done prior to percutaneous injury but these two HCWs were found to be antiHBsAB negative and were vaccinated after needlestick injury. Three HCWs were vaccinated but were negative for antiHbsAB; in these cases, a booster dose and HBIG were given (Table II). The risk of transmission of HCV through occupational exposure is lower than that for HBV. The incidence of seroconversion after percutaneous exposure from an HCV-positive source is 1.8%.4 There has been no proven benefit of prophylaxis with either immunoglobulin or antiviral medications
372 Table III
A. Mehta et al. Compulsory use of protective equipment
Procedure Gloves Vascular access Intubation/endotracheal intubation Delivery Lumbar puncture/ascetic tap Blood collection Handling specimens Cleaning spills
Yes Yes Yes Yes Yes Yes Yes
to reduce the risk of transmission. As such, the CDC does not currently recommend the administration of PEP for HCV exposure. However, source testing for antiHCV, baseline testing of the exposed HCW for antiHCV along with liver profile, and referral for close follow-up, monitoring and counselling was instigated in cases where the source patient was HCV positive. Effective training and education regarding these related precautions are clearly important weapons in the war against sharps injuries. At our institute, all HCWs are well informed of the need to report exposure to blood or potentially infectious body fluids to the infection control team without any delay. The infection control nurse collects the needlestick injury forms from the ER and follows-up the cases. To create awareness (from 1998 onwards), we hold an induction programme once a month for all new HCW recruits and an ‘infection prevention awareness week’ every year where needlestick injury is adequately addressed. The concept of universal precautions is explained to all HCWs and steps are taken to enforce them. This programme is so effective that we often have to reassure HCWs injured with sterile blades or needles who insist on reporting the injury. We believe that every HCW is aware of the needlestick injury policy and knows that it is in his/her interest to report the event. Under-reporting is likely to be very rare. It is easier to change technology than human behaviour. At our institute, the use of proper protective barriers (Table III) such as gloves, goggles, masks, apron and footwear is compulsory for all HCWs who are at risk. The incorporation of safer medical devices such as needleless sets, selfcapping intravenous catheters, retractable lancets and needle guards is a step towards reducing needlestick injuries. From 2004 onwards, we have used passive safety intravenous cannulas at all nursing stations, especially in known HBV, HCV and HIV cases. Our hospital incurs approximately Rs. 9000/HCW/episode of needlestick injury. These are
Protective equipment Goggles/mask Apron No Yes Yes Yes No Yes No
No Yes Yes No Yes Yes No
Footwear No Yes Yes No No No No
mainly short-term costs, accounting for laboratory tests, immunoglobulin, vaccination and retroviral treatment. Long-term costs are still not determined. They include HCW anxiety, personal impact, adverse effect on work performance and litigation. The present study emphasizes the fact that the number of needlestick injuries can be minimized by adopting effective precautionary measures. This requires constant education at all levels to adopt universal precautions. All hospitals should have a functioning built-in infrastructure for reporting injuries, and PEP should be available at all times. Above all, the philosophy of the hospital must be to safeguard the health of its employees.
Conclusions Exposure to blood-borne pathogens is a harsh reality that one has to understand and take active measures to prevent. Out of the three pathogens, the risk of transmission is least with HIV (0.3%) and greatest with HBV (37–62%). HCV is the most dangerous hazard as there is no effective PEP or vaccine available. Transmission of these potentially infectious blood-borne pathogens can be minimized by adopting effective precautionary measures. This requires constant education of HCWs at all levels. Use of safer devices should be considered as one of the main approaches, together with educational and immunization programmes for needlestick injuries, in order to reduce the occupational risk of infection. The hospital should have a functioning built-in infrastructure to report and administer PEP to workers at any time.
References 1. NIOSH ALERT. Preventing needlestick injuries in health care settings. DHHS (NIOSH) Publication No 2000-108. Nov 1999.
Needlestick injuries in a tertiary care centre in Mumbai, India 2. Roy E, Robillard P. Underreporting of accidental exposures to blood and other body fluids in health care settings: an alarming situation. Adv. Exposure Prev 1995;1:11. [abstract]. 3. EPINet. Exposure prevention information network data reports. University of Virginia: International Healthcare Worker Safety Center; 1999. 4. Gerberding JL, Henderson DK. Management of occupational exposures to blood borne pathogens: hepatitis B virus, hepatitis C virus and human immunodeficiency virus. Clin Infect Dis 1992;14:1179—1885. 5. US Public Health Service. Updated US public health service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Morb Mortal Wkly Rep 2001;50:1—57. 6. Henry K, Campbell S. Needlestick/sharps injuries and HIV exposure among healthcare workers: national estimates based on a survey of U.S. hospitals. Minn Med 1995;78: 1765—1768. 7. Cohen J. The needle and the damage done. Science 2004; 304:509—512.
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8. Bowden FJ, Pallett B, Birrell F, Dar EM. Occupational exposure to the human immunodeficiency virus and other blood-borne pathogens. A six-year prospective study. Med J Aust 1993;158:810—812. 9. Cardo DM, Culver DH, Carol A, et al. A case–control study of HIV seroconversion in health care workers after injury. N Engl J Med 1997;337:1485—1490. 10. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal–infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med 1994; 331:1173—1180. 11. West DJ. The risk of hepatitis B infection among health professionals in the United States: a review. Am J Med Sci 1984;287:26—33. 12. Grady GF, Lee VA, Prince AM, et al. Hepatitis B immune globulin for accidental exposures among medical personnel: final report of a multicenter controlled trial. J Infect Dis 1978;138:625—638.
www.elsevierhealth.com/journals/jhin
Needlestick injuries in a tertiary care centre in Mumbai, India A. Mehta*, C. Rodrigues, S. Ghag, P. Bavi, S. Shenai, F. Dastur P.D. Hinduja National Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim (West), Mumbai 400 016, India Received 1 April 2004; accepted 6 December 2004
KEYWORDS Needlestick injuries; Healthcare works; Prevention; Occupational exposure
Summary Accidental exposure from blood/body fluid of patients is a risk to healthcare workers (HCWs). Percutaneous injury is the most common method of exposure to blood-borne pathogens. A policy was formulated at our institute, a tertiary care centre in central Mumbai, and we report a six-year (1998–2003) ongoing surveillance of needlestick injuries. Of the 380 HCWs who reported needlestick injuries, 45% were nurses, 33% were attendants, 11% were doctors and 11% were technicians. On source analysis, 23, 15 and 12 were positive for Hepatitis B surface antigen (HBsAg), human immunodeficiency virus (HIV) and hepatitis C virus (HCV), respectively. Immediate action following potential exposure included washing the wound with soap and water, encouraging bleeding and reporting the incident to the emergency room. Analysis of the source of injuries revealed that known sources accounted for 254 injuries, and unknown sources from garbage bags and Operating Theatre instruments accounted for 126 injuries. Most needlestick injuries occurred during intravenous line insertion (NZ112), followed by blood collection (NZ69), surgical blade injury (NZ36) and recapping needles (NZ 36). Immediate postexposure prophylaxis (PEP) for HCWs who sustained injuries with hepatitis-B-virus-positive patients included booster hepatitis B immunization for those positive for antiHBs. A full course of immunization with hepatitis B immunoglobulin was given to those who were antiHBs negative. All staff who sustained injury with HIV were given immediate antiretroviral therapy (AZT 600 mg/day) for six weeks. Subsequent six-month follow-up showed zero seroconversion. Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: C91 22 24447189; fax: C91 22 24442318/24449151. E-mail address: [email protected] 0195-6701/$ - see front matter Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2004.12.015
Needlestick injuries in a tertiary care centre in Mumbai, India
Introduction Healthcare workers (HCWs) who come into contact with medical devices incorporating ‘sharps’, such as syringes or scalpels, are at risk of injuries that can lead to serious or fatal blood-borne infections, including hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), cytomegalovirus and Epstein–Barr virus. Although the risk of contracting these blood-borne pathogens is low (Table I), the psychological trauma that follows the injury can be considerable. It is not known exactly how many work-related needlestick injuries occur in India each year; however, estimates indicate that 600,000–800,000 such injuries occur annually in the USA and around half of those go unreported.1,2 Data from the EPINet system suggest that in an average hospital, workers incur approximately 30 needlestick injuries/100 beds/year.3 Healthcare institutions in most parts of India are still not well equipped to provide timely and effective postexposure prophylaxis (PEP) for HCWs. For effective implementation of PEP, a policy was formulated at our institute to establish a system for reporting injuries, performing necessary tests and administering prophylaxis. In this article, we report a six-year ongoing surveillance of needlestick injuries.
Materials and methods At the P. D. Hinduja National Hospital, 380 needlestick injuries were reported from January 1998 to December 2003. Immediate action following potential exposure included thorough washing with soap and water or an antiseptic, encouraging bleeding
369
and reporting the incident to the emergency room (ER). The protocol that HCWs follow immediately after a needlestick injury at our institute includes: reporting the incident to the ER to give a detailed history of the exposure and hepatitis B immunization status; testing of a blood sample along with the source patient’s blood sample for baseline testing of antiHBs/Hepatitis B surface antigen (HBsAg)/ HCV/HIV; reporting the incident to the head of department/supervisor/manager; and contacting the infection control committee chairman/infection control nurse with all the reports within 24 h. The risk of transmission is assessed by taking into account the degree of exposure and the evaluation of the source patient. The type of exposure (puncture, laceration, abrasion, mucosal inoculation, contamination of non-intact skin, bite) is recorded. The type of device causing exposure is identified and recorded for information regarding epidemiology of infection. Determination of the type of needle, depth of penetration, volume of blood injected, estimated fluid volume and duration of contact in mucocutaneous injury with a detailed history of the HCW is recorded in the Post Exposure Prophylaxis form by the Medical Officer in the ER. This form is then collected by the Infection Control Nurse (ICN) who reports each day to the Infection Control Chairman. The ICN is also responsible for the six-month follow up of all injured HCWs.
Postexposure prophylaxis (PEP) Table I Estimation of the probability of transmission following a needlestick injury Mucosal
Minimal blood volume (mL)
Rate of infection/ seroconversion agent
Hollow needle (%)
HIV HBV (Hbe AgCve) Hepatitis seroconversion HbeAg Kve Hepatitis seroconversion HCV
0.3–0.4 22–31
0.09% –
0.1 0.0004
37–62
–
0.0004
3–6 23–37 0–7
Not known
HIV, human immunodeficiency virus; HBV, hepatitis B virus; HbeAg, hepatitis B e antigen HCV, hepatitis C virus.
Postexposure management includes first aid, serological testing and counselling in all cases. Immunoprophylaxis and antiviral medications are used wherever indicated.
PEP for HBV-positive source PEP for HCWs who are antiHBs negative and who have sustained injuries from an HBV-positive patient includes hepatitis vaccination and a full course of immunization with hepatitis B immunoglobulin (HBIG), preferably within 24 h. The option of giving one dose of HBIG (0.06 mg/kg of body weight) and re-initiating the vaccination series is preferred for non-responders who have not completed a three-dose vaccination series. For people
370 who completed a second vaccination series but failed to respond, two doses of HBIG are preferred. People who have been infected with HBV previously are considered to be immune to re-infection and are not given PEP.4,5
PEP for HCV-positive source In such cases, the source patient undergoes antiHCV antibody testing. Baseline testing of the HCW’s antiHCV and alkaline phosphatase is performed with follow-up for six months if the source patient is positive for HCV. All antiHCV-positive results are confirmed by recombinant immunoblot assay.
PEP for HIV-positive source HCWs exposed to an HIV-positive source are tested for HIV at baseline, and prophylaxis is started as early as possible. The Centers for Disease Control and Prevention (CDC) prophylaxis guidelines are followed. In the case of an HIV-positive source, the HCW is given a ‘starter pack’ [zidovudine (AZT) 600 mg/day!2 doses 3TC (150 mg)] in the ER with sufficient drugs for 48 h. HIV antibody testing is performed three and six months post exposure.4-6
Unknown source When the source patient of the needlestick injury is unknown, the protocol for HBV prophylaxis is followed. Establishing the need for HIV PEP is controversial in such instances. However, according to the policy of our hospital, unless it is likely that the needle is associated with a patient known to be infected with HIV, PEP for HIV is not indicated.
A. Mehta et al. were followed to completion. In 12 cases, follow-up was not possible as the injured HCWs had relocated. Amongst the cases followed-up, not a single case of seroconversion to HIV, HCV or HBV was observed. Analysis of the source of injuries (Table II, Figure 2) revealed that unknown sources accounted for 126 injuries, the majority of which were due to garbage bags (NZ92) followed by OT instruments (NZ34). For injuries from known sources (Table II, Figure 2), most were due to intravenous line insertion/manipulation or checking for blood sugar (NZ112), followed by blood collection (NZ69), surgical blade injury (NZ36) and recapping of needles (NZ36). Seventy-two percent of the cases had superficial injuries. Deep injuries were observed in 27% of the cases, and the remaining 1% of cases had experienced splashing of blood on intact skin. Most needlestick injuries were caused by recapping of needles and improper disposal of sharps. Winged infusion needles (butterflies) and intravenous catheters were found to be associated with high rates of needlestick injuries. Safe handling and disposal of sharps in separate puncture proof containers immediately after use is vital to minimize these injuries. At our institute, we discourage dangerous practices such as recapping of needles. Garbage disposal is widely publicized in well-illustrated charts at the nursing stations and explained to all HCWs. Waste segregation is performed at the site of generation. This could be the reason for the decrease in the number of cases of needlestick injuries from garbage bags [22 (46%) in 1998 compared with 13 (27%) in 2003 (Table II, Figure 2)], indicating increased HCW awareness. Of the 50 source-positive cases, only one source
Results and discussion At our institute, a policy was devised to establish a surveillance system for needlestick injuries and 380 cases were reported from January 1998 to December 2003. As shown in Figure 1, most reported needlestick injuries involved nursing staff (45%), followed by attendants (33%), doctors (11%) and technicians (11%). In the present study, of 380 injured HCWs, the source identity could be established in 254 cases and the source was unknown in the remaining cases. Of the 254, where the source was known, 50 HCWs were found to be injured with HBsAg positive (23), HCV positive (12) and HIV positive (15) sources respectively. In remaining 204 cases the source was negative for all 3 i.e. HBsAg, HCV and HIV. Of the 380 reported cases, 368 cases
Figure 1
Percentage of staff affected.
Needlestick injuries in a tertiary care centre in Mumbai, India Table II
371
Source analysis of needlestick injuries to the healthcare workers
Garbage bags Needle recapping OT instruments Checking blood sugar Intravenous line administration Surgical blade Blood collection Suturing Total no. of cases/year
1998
1999
2000
2001
2002
2003
Total
22 8 3 2 4 2 7 – 48
20 7 12 10 16 7 8 – 80
18 5 9 8 10 14 19 – 83
8 5 5 5 15 5 13 – 56
10 4 3 7 18 6 15 – 63
13 7 2 5 10 2 7 1 47
92 36 34 38 74 36 69 1 380
patient was found to be positive for both HBsAg and HCV. Infections with more than one blood-borne virus are generally observed in intravenous drug users due to sharing of infected needles. In India, sharing contaminated needles officially accounts for less than 3% of HIV transmission,7 indicating that transmission of blood-borne viruses is largely through blood transfusion or sexual routes rather than intravenous drug use. The emotional impact of needlestick injury can be severe and long lasting, especially when the injury involves exposure to HIV.8 As shown in Table I, the knowledge that the risk of transmission of HIV from a significant needlestick injury is only 0.3% only partially comforts the injured person. Not knowing the infection status of the source patient can accentuate the HCW’s stress. At our institute, HCWs exposed to needlestick injuries are reassured and asked to follow certain behavioural measures until absence of infection is established. These include sexual abstinence or condom use, refraining from donating blood, plasma, organs and semen, and refraining from breastfeeding and pregnancy.
Figure 2 Source analysis of needlestick injuries to the healthcare workers.
Appropriate PEP was provided to the 50 sourcepositive cases and follow-up was performed at three and six months. The ‘starter pack’ was given immediately in the ER when the source was HIV positive. Immediate PEP plays an important role when the source is HIV positive by interrupting the viral replication after exposure prior to systemic infection (during the window period).4 Although definitive studies are limited, the benefits of PEP have been demonstrated in animal and human studies of maternal–infant transmission, and smaller, retrospective, case–control studies in which PEP reduced the transmission after occupational exposure by 81%.9,10 To reduce the risk to staff from HBV infection, we have made vaccination mandatory for employment. When personnel are appointed, a medical check is performed to collect baseline data on certain infections. At this time, the health service also confirms that vaccination requirements are complete. Hepatitis B vaccine is freely available in the ER at any time for the hospital staff. However, despite HBV vaccination, HCWs have a much higher rate of infection than the general population, and HBV remains a well-recognized occupational risk.11,12 In the present study, the antiHBs antibody (antiHBsAB) status of 50 HCWs infected by positive sources was as follows: 43 had been vaccinated at the time of employment and were antiHBsAB positive. In two cases, antiHBsAB status was not done prior to percutaneous injury but these two HCWs were found to be antiHBsAB negative and were vaccinated after needlestick injury. Three HCWs were vaccinated but were negative for antiHbsAB; in these cases, a booster dose and HBIG were given (Table II). The risk of transmission of HCV through occupational exposure is lower than that for HBV. The incidence of seroconversion after percutaneous exposure from an HCV-positive source is 1.8%.4 There has been no proven benefit of prophylaxis with either immunoglobulin or antiviral medications
372 Table III
A. Mehta et al. Compulsory use of protective equipment
Procedure Gloves Vascular access Intubation/endotracheal intubation Delivery Lumbar puncture/ascetic tap Blood collection Handling specimens Cleaning spills
Yes Yes Yes Yes Yes Yes Yes
to reduce the risk of transmission. As such, the CDC does not currently recommend the administration of PEP for HCV exposure. However, source testing for antiHCV, baseline testing of the exposed HCW for antiHCV along with liver profile, and referral for close follow-up, monitoring and counselling was instigated in cases where the source patient was HCV positive. Effective training and education regarding these related precautions are clearly important weapons in the war against sharps injuries. At our institute, all HCWs are well informed of the need to report exposure to blood or potentially infectious body fluids to the infection control team without any delay. The infection control nurse collects the needlestick injury forms from the ER and follows-up the cases. To create awareness (from 1998 onwards), we hold an induction programme once a month for all new HCW recruits and an ‘infection prevention awareness week’ every year where needlestick injury is adequately addressed. The concept of universal precautions is explained to all HCWs and steps are taken to enforce them. This programme is so effective that we often have to reassure HCWs injured with sterile blades or needles who insist on reporting the injury. We believe that every HCW is aware of the needlestick injury policy and knows that it is in his/her interest to report the event. Under-reporting is likely to be very rare. It is easier to change technology than human behaviour. At our institute, the use of proper protective barriers (Table III) such as gloves, goggles, masks, apron and footwear is compulsory for all HCWs who are at risk. The incorporation of safer medical devices such as needleless sets, selfcapping intravenous catheters, retractable lancets and needle guards is a step towards reducing needlestick injuries. From 2004 onwards, we have used passive safety intravenous cannulas at all nursing stations, especially in known HBV, HCV and HIV cases. Our hospital incurs approximately Rs. 9000/HCW/episode of needlestick injury. These are
Protective equipment Goggles/mask Apron No Yes Yes Yes No Yes No
No Yes Yes No Yes Yes No
Footwear No Yes Yes No No No No
mainly short-term costs, accounting for laboratory tests, immunoglobulin, vaccination and retroviral treatment. Long-term costs are still not determined. They include HCW anxiety, personal impact, adverse effect on work performance and litigation. The present study emphasizes the fact that the number of needlestick injuries can be minimized by adopting effective precautionary measures. This requires constant education at all levels to adopt universal precautions. All hospitals should have a functioning built-in infrastructure for reporting injuries, and PEP should be available at all times. Above all, the philosophy of the hospital must be to safeguard the health of its employees.
Conclusions Exposure to blood-borne pathogens is a harsh reality that one has to understand and take active measures to prevent. Out of the three pathogens, the risk of transmission is least with HIV (0.3%) and greatest with HBV (37–62%). HCV is the most dangerous hazard as there is no effective PEP or vaccine available. Transmission of these potentially infectious blood-borne pathogens can be minimized by adopting effective precautionary measures. This requires constant education of HCWs at all levels. Use of safer devices should be considered as one of the main approaches, together with educational and immunization programmes for needlestick injuries, in order to reduce the occupational risk of infection. The hospital should have a functioning built-in infrastructure to report and administer PEP to workers at any time.
References 1. NIOSH ALERT. Preventing needlestick injuries in health care settings. DHHS (NIOSH) Publication No 2000-108. Nov 1999.
Needlestick injuries in a tertiary care centre in Mumbai, India 2. Roy E, Robillard P. Underreporting of accidental exposures to blood and other body fluids in health care settings: an alarming situation. Adv. Exposure Prev 1995;1:11. [abstract]. 3. EPINet. Exposure prevention information network data reports. University of Virginia: International Healthcare Worker Safety Center; 1999. 4. Gerberding JL, Henderson DK. Management of occupational exposures to blood borne pathogens: hepatitis B virus, hepatitis C virus and human immunodeficiency virus. Clin Infect Dis 1992;14:1179—1885. 5. US Public Health Service. Updated US public health service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Morb Mortal Wkly Rep 2001;50:1—57. 6. Henry K, Campbell S. Needlestick/sharps injuries and HIV exposure among healthcare workers: national estimates based on a survey of U.S. hospitals. Minn Med 1995;78: 1765—1768. 7. Cohen J. The needle and the damage done. Science 2004; 304:509—512.
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8. Bowden FJ, Pallett B, Birrell F, Dar EM. Occupational exposure to the human immunodeficiency virus and other blood-borne pathogens. A six-year prospective study. Med J Aust 1993;158:810—812. 9. Cardo DM, Culver DH, Carol A, et al. A case–control study of HIV seroconversion in health care workers after injury. N Engl J Med 1997;337:1485—1490. 10. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal–infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med 1994; 331:1173—1180. 11. West DJ. The risk of hepatitis B infection among health professionals in the United States: a review. Am J Med Sci 1984;287:26—33. 12. Grady GF, Lee VA, Prince AM, et al. Hepatitis B immune globulin for accidental exposures among medical personnel: final report of a multicenter controlled trial. J Infect Dis 1978;138:625—638.