Needle Stick Injury: Epidemiology from a Hospital Perspective

1. Needle Stick Injury: Epidemiology from a Hospital Perspective Dr Blánaid Hayes, Beaumont Hospital, Dublin

2. Epidemiology of NSI • Background • Risk and probability • Epidemiology of BBV; global and local • International and local NSI statistics • Challenges and opportunities

3. Background • Definition • An exposure that might place HCW at risk for HBV, HCV or HIV infection is defined as • Percutaneous:puncture, abrasion or laceration caused by needle or other sharp device • Mucocutaneous: contact of mucous membrane or non-intact skin with blood or potentially infectious body fluid • Legislation • Health and Safety Act 2005 • US: Needlestick Safety and Prevention Act of 2000 • Consequences • Health (not negligible) • Infection • Anxiety • Drug S/E • Lifestyle restrictions (self and family) • Career • Organisational cost • Source patient testing • Impact:* • Globally, HCW population is ’large and their impact is felt everywhere’…35.7 million worldwide. • Worthy public health target: provide care worldwide in sophisticated and humble settings. Depended upon for life sustaining services. • Greatest risk is in countries of high prevalence where PEP, patient treatments and safety technology are unavailable *Janine Jagger ICHE Jan 2007 Vol 28; No 1

4. Infections Transmitted by NSI • hepatitis B* • hepatitis C* • HIV* • herpes* • TB • Malaria • Dengue fever • Rocky Mountain spotted fever • necrotising fasciitis (strep. A)

5. Risk and Probability RISK = HAZARD X FREQUENCY SEROPREVALENCE IN POPULATION & INFECTIVITY OF SOURCE E XPOSURE NUMBER EXPOSURE SEVERITY

6. Perception of Risk Risk Management MYTH RISK PERCEPTION RISK = HAZARD + OUTRAGE (Peter Sandman)

7. BBV transmission to HCW • HBeAg + source = 30% • HBeAg - source < 6% • HCV + source = 0.5% • HCV PCR+ source = 10% • Australian study reviewed 29 articles on transmission of HCV (vertical, via transplant / transfusion or NSI). No transmissions occurred from PCR negative sources (BMJ 1997) • HIV+ (percutaneous) = 0.3% • HIV+ (mucocutaneous) = 0.09%

8. HIV transmission: risk factors • RISK FACTOR ADJUSTED O/R • deep injury 16.1 • visible blood 5.2 • needle in vessel 5.1 • terminal illness 6.4 • PEP /ZDV 0.2 Case control study of HIV seroconversion in HCWs NEJM 1997

9. Epidemiology of BBV Global vs LocalHepatitis B • > 350 million worldwide • Irish notifications increased annually 1996-2005 but reduced by 20% 2006 • More prevalent in IDUs, prisoners and immigrants (high endemicity) • Details since 2004 • 820 notifications • 761 (93%) defined • 668 (88%) chronic • 93 (12%) acute • ASNR = +/- 20/100,000 • Typical acute HBV: young man, born in Ireland, sexually acquired • ‘Typical’ chronic HBV: from countries of high endemicity Source: www.hpsc.ie

10. Epidemiology of BBV Global vs Local Hepatitis C • 170 million worldwide • Notifiable disease since Jan 2004 (SI 707 of 2003) • Irish ASIR = 36/100,000 (M>F and HSE- E > than HSE generally (rate rising) • Risk factors: • Sharing needles etc ++++ • Unscreened blood / products ++ • Mother to baby, occupational, sexual + • 90% cases in developed countries current or former IDUs or received unscreened blood / products • Largely asymptomatic (90%) Source: www.hpsc.ie

11. Epidemiology of BBV Global vs LocalHIV • Global HIV burden= 42 million • Globally during 2005: • 4.1 million new infections • 2.8 million RIP AIDS • End 2006 > 4,400 cases reported • New diagnosis not representative of incidence • Risk factors (2006) n=337 • Heterosexual ++++ (50%) • MSM ++ • IDUs + • 9% new cases are Irish born heterosexuals (31 per year) Source: Epi – Insight, Vol 8, Issue 10, October 2007

12. 8 million HCWs in US Estimated US annual figure is 384,325 Add factor 0.31 (for needles bought outside of hospitals = 503,466 Add another factor of 0.29 for all mucocutaneous injuries = 649,471 100,000 in Ireland Crude estimate: = 4804 p/a = 6293 p/a = 8118 p/a How big is the problem? But neither set of figures takes any account of underreporting

13. How to interpret figures? • Difficulty comparing data between countries and studies because of different formats used for documenting rates: • Rate per 100 occupied beds • Rate per 1000 health care staff (WTE or other) • Rate for specific occupations • Rate per person per annum etc. • One rate quoted by Jagger is 22 per 100 bed p/a (previously 30 per 100) • Local hospital rate tends to be <20 per 100.

14. International Data on Incidence and Reporting Rates

15. Needlestick Injuries, According to Postgraduate Year Needlestick Injuries among Surgeons in Training NEJM 2007;356:2693-9 Makary MA et al. N Engl J Med 2007;356:2693-2699

16. Needlestick Injuries among Surgeons in Training NEJM 2007;356:2693-9 Behavior Associated with Nonreporting of the Most Recent Needlestick Injury Makary MA et al. N Engl J Med 2007;356:2693-2699

17. Study Overview • Data from surgeons at 17 US centres: • majority reported at least one needlestick injury during training • half of the most recent injuries (including many sustained in the care of high-risk patients) were not reported

18. Occupation Number % Total Nursing 150 49.5% Medical 86 28.5% Non Clinical 41 13.5% Others 26 8.5% Total 303 100 An Irish Hospital’s Experience: who is at risk? Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):

19. Location Number % total Wards 176 53.4% Theatre 45 13.8% A&E 26 8.1% Other 85 25.7% 332 +/-100 Where to they occur? Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):

20. Hepatitis B Ab testing of injured HCWs Number % Immune 285 85.8% Unknown 18 5.4% Non- immune 29 8.8% Total 332 100 % Immunity to Hepatitis B Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):

21. Hepatitis C Antibody HIV Antibody Hep B Surface Ag Number Tested 254(76.5%) 119(35.8%) 103(31%) Number Positive 8* 2 1 % Positive 3.1% 1.6% 0.9% Test Results of Source Patients * 5 of the 8 patients positive for hepatitis C Ab were also PCR + Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):

22. Procedure Involved

23. Higher rates of NSI: Teaching hospitals (vs others) Surgeons (vs physicians) Theatre (vs other areas) Emergency (vs elective procedures) Less experienced staff Low staff numbers and morale Infection rates reduced by: Hepatitis B vaccine PEP HIV therapies have reduced viral load in source patients Double gloving What factors impact on injury and infection rates?

24. Hepatitis B vaccine • Currently recommended for high risk groups: • Babies of infected mothers • CRF, haemophilia • Occupational risk • Close contacts • IDUs • Prisoners • Homeless • Heterosexuals / multiple • MSM • NIAC in 2007 recommended addition of HB vaccine to primary childhood schedule. To be introduced in Sept 2008 Source: www.immunisation.ie/en/Publications/PDFFile_14064

25. Solutions: what has been shown to work to reduce frequency of NSI? • Standard Precautions / UPs • Cin bins • Avoiding re-sheathing • Safety technology • LEGISLATION • Do we need specific legislation or a directive in this country to enforce a change in practice

26. Challenges • Health care resources • Training • Technology • Safety management systems • Immunisation uptake • Senior clinicians • Childhood immunisation • Organisational culture • Compliance • Reporting • Macho-ism • Irish ‘psyche’ • Ambivalent to authority • Anarchic • Fatalistic

27. Great strides have been made in hospital hygiene Accreditation and quality are ‘buzz words’ Clinicians and managers are more aware of hidden costs of high risk practice Hepatitis B vaccine is no longer just for limited high risk groups Safety technology is no longer cost prohibitive and is user friendly Time to invest in a nationwide surveillance system incorporating all exposures and not just those occurring in hospitals Opportunities

28. Take Home Message……. • Engineering solutions • Managers who are role models, senior clinicians who are ‘physician champions’, leading by example, monitoring etc • Putting training and education at the top of the agenda and not as a dispensable item when times are tough