Needle sticks and Sharps Injuries facts , legal concerns , and care

1. Needle sticks and Sharps Injuriesfacts, legal concerns, and care Dr.T.V.Rao MD Dr.T.V.Rao MD

2. The basis of this presentation • This presentation is designed to assist with the training of staff on sharps management including safety devices • The information relates to prevention of hollow-bore needle stick injuries (NSI) and should be used in combination with other training material • The information includes the NACO guidelines concerning the Indian law/ Supreme court guidelines and other concerns. • The Drug regimes for Post exposure practices should be followed as per current guidelines Dr.T.V.Rao MD

3. CDC estimates ~385,000 sharps injuries annually among hospital-based healthcare personnel (>1,000 injuries/day) Many more in other healthcare settings (e.g., emergency services, home care, nursing homes) Increased risk for blood borne virus transmission Costly to personnel and healthcare system The Problem Dr.T.V.Rao MD

4. Exposures which place health personnel at risk of blood borne infection – • A percutaneous injury e.g. Needle stick injury (NSI) or cut with a sharp instrument • Contact with the mucous membrane of eye or mouth • Contact with non-intact skin (abraded skin or with dermatitis) • Contact with intact skin when the duration of contact is prolonged with blood or other potential infected body fluids 4 Dr.T.V.Rao MD

5. Who is at Risk ? - • Nursing Staff • Emergency Care Providers • Labor & delivery room personnel • Surgeons and operation theater staff • Lab Technicians • Dentists • Health cleaning/ mortuary staff / Waste Handlers Dr.T.V.Rao MD

6. Who Gets Injured? Occupational Groups of Healthcare Personnel Exposed to Blood/Body Fluids, NaSH June 1995—December 2003 (n=23,197) Dr.T.V.Rao MD

7. How Do Injuries Occur With Hollow-Bore Needles? Circumstances Associated with Hollow-Bore Needle Injuries NaSH June 1995—December 2003 (n=10,239) Disposal Related: 35% Dr.T.V.Rao MD

8. Work Practices which Increase the Risk of Needle Stick Injury Recapping needles (Most important) Performing activities involving needles and sharps in a hurry Handling and passing needles or sharp after use Failing to dispose of used needles properly in puncture-resistant sharps containers Poor healthcare waste management practices Ignoring Universal Work Precautions 8 Dr.T.V.Rao MD

9. Potentially infectious body fluids - 9 Dr.T.V.Rao MD

10. What kinds of devices usually cause sharps injuries? • Hypodermic needles • Blood collection needles • Suture needles • Needles used in IV delivery systems • Scalpels Dr.T.V.Rao MD

11. Sharps injuries can expose workers to a number of blood borne pathogens that can cause serious or fatal infections. The pathogens that pose the most serious health risks are Hepatitis B virus (HBV) Hepatitis C virus (HCV) Human immunodeficiency virus (HIV) What infections can be caused by sharp injuries? Dr.T.V.Rao MD

12. Risks of Seroconversion due to Sharps Injury from a known positive source Virus HBV HCV HIV Risk (Range) 6-30%* ~ 2% 0.3% (*Risk for HBV applies if not HB vaccinated) Dr.T.V.Rao MD

13. Percutaneous 0.3% Mucous membrane 0.1% Non-intact skin <0.1% What is the Risk for HIV Alone? Dr.T.V.Rao MD

14. How Do Sharps Injuries Happen? • Who gets injured? • Where do they happen? • When do injuries occur? • What devices are involved? • How can they be prevented? Dr.T.V.Rao MD

15. Work Practices which Increase the Risk of Needle Stick Injury Recapping needles (Most important) Performing activities involving needles and sharps in a hurry Handling and passing needles or sharp after use Failing to dispose of used needles properly in puncture-resistant sharps containers Poor healthcare waste management practices Ignoring Universal Work Precautions 15 Dr.T.V.Rao MD

16. Risk Factors for HIV Seroconversion in HCWs Risk Factor Adjusted Odds Ratio* Deep Injury 15.0 Visible Blood on Device 6.2 Terminal Illness in Source Patient 5.6 Needle in Source Vein/Artery 4.3 *All Risk Factors were significant (P < 0.01) From: NEJM 1997;337:1485-90. Dr.T.V.Rao MD

17. HIV: Seroconversion in Health Care Workers in USA (contd.) Primary HIV Infection - in 81% of HCWs - median 25 days after exposure Seroconversion - Median 46 days - by 6 months in 95% of HCWs - 3 persons Seroconversion at 6-12 months Dr.T.V.Rao MD From: CDC. MMWR 1998;47:No. RR-7.

18. Protecting yourself … • Report all needle stick and sharps-related injuries promptly to ensure that you receive appropriate follow-up care. • Tell your employer about any sharps hazards you observe. • Participate in training related to infection prevention. • Get a Hepatitis B vaccination. Dr.T.V.Rao MD

19. A. Categories of exposure Dr.T.V.Rao MD

20. It refers to the comprehensive management to minimize the risk of infection following potential exposure to blood borne pathogens (HIV, HBV, HCV ).It includes – First Aid Risk Assessment Counseling PEP drugs (4Weeks) depending upon risk assessment Relevant Lab Investigation on informed consent of the source and exposed person Follow up and support Post Exposure Prophylaxis (PEP) Dr.T.V.Rao MD

21. 1ststep: Management of exposed site - First Aid Skin: Do not squeeze the wound to bleed it, do not put the pricked finger in mouth. Wash with soap &water, don’t scrub, no antiseptics or skin washes (bleach, chlorine, alcohol, betadine). Eye: wash with water/ normal saline/ don’t remove contact lens immediately if wearing, no soap or disinfectant. Mouth: spit fluid immediately, repeatedly rinse the mouth with water and spit / no soap/ disinfectant. Management of exposed person Dr.T.V.Rao MD

22. 2nd step: Establish eligibility for PEP • Evaluation must be made rapidly so as to start treatment as soon as possible-ideally within 2hours but certainly within 72 hours of exposure. However all exposed cases don’t require prophylactic treatment. • Factors determining the requirement of PEP- • Nature/Severity of exposure and risk of transmission • HIV status of the source of exposure • HIV status of the exposed individual Dr.T.V.Rao MD

23. Quick FACT:HBV vaccination is recommended for all healthcare workers (unless they are immune because of previous exposure). HBV vaccine has proven to be highly effective in preventing infection in workers exposed to HBV. However, no vaccine exists to prevent HCV or HIV infection. Dr.T.V.Rao MD

24. Supreme Court Directive To Ensure PEP Drugs in All Government Hospitals in India • Universal Work Precautions (UWP) and PEP guidelines should be followed by HCPs to prevent occupational transmission of HIV, Hepatitis B and hepatitis C. • This will develop confidence in HCPs while working with patients some of whom might be infected with HIV/HBV/HCV. • PEP drugs should be available in all Govt Hospitals to enable protection of HCPs dealing with potentially infected patients to make sure that no patients suffering from HIV be denied treatment/surgery/ procedures etc • Availability of UWP and PEP can minimize the stigma and discrimination against PLHIVs in Health Care facilities. • Above regulations to be practiced in Private hospitals and Establishments Dr.T.V.Rao MD

25. Role of PEP in Preventing Transmission of HIV- Indian Studies (Contd.) 2. LTM Hospital, Sion, Mumbai -2002 Over a period of one year, June 2000 - 2001, a total number of 38 cases of accidental exposures were self reported Of the 38 reported cases; 34 were NSIs, 2 were scalpel cuts, and 1 was exposure to body fluids (vitreous humor) by splashing and 1 was a human bite, from a psychiatric patient. The 38 source cases were also tested for HIV 1,2 antibodies and HBsAg. Ten were HIV seropositive and 28 HIV seronegative and four were HBsAg positive and 34 HBsAg seronegative. Majority of the 34 needle stick injuries were by hollow bore needles. Of these, 20 were during blood collection procedure by hollow bore needle, 5 during angioplasty procedure, 4 during central venous puncture line cut down procedures, 2 during suturing of contused lacerated wound and 3 while recapping the needle. PEP was received regularly by 10 cases. All the HCWs were HIV and HBsAg seronegativee after one and half years. - Dr.T.V.Rao MD

26. To ensure that the hospital has a written protocol to handle exposure and the same is displayed at prominent locations within the hospital for information of staff. Sensitization of Doctors, Nurses, Paramedics & waste handlers To ensure that Universal precautions are followed. Availability of Personal protective equipment. Dissemination of procedure to be followed in case of accidental exposure to Blood and Body fluids Availability of Rapid HIV test kits. Availability of other preventive measures including vaccinations. Responsibility of Head of the institution Dr.T.V.Rao MD

27. Availability of PEP at Healthcare facility It is recommended that PEP drugs be kept available round-the-clock in any of the three locations - Emergency room, Labor room and ICU. Drug Stock at the Healthcare facility PEP kit comprises of 2 drug regimen: Zidovudine(AZT) 300mg + Lamivudine (3TC) 150 mg as a fixed dose combination Dr.T.V.Rao MD

28. Eliminate or reduce the use of needles and other sharps Use devices with safety features to isolate sharps Use safer practices to minimize risk for remaining hazards What are Strategies to Eliminate Sharps Injuries? Dr.T.V.Rao MD

29. Do not forget Hepatitis B vaccination and Universal precautions …….. Dr.T.V.Rao MD

30. References • Centers for Disease Control and Prevention. Workbook for Designing, Implementing and Evaluating a Sharp Injury Prevention Program. 2004. Atlanta: US Department of Health and Human Services. • Whitby R, McLaws M. Hollow bore needle stick injuries in a tertiary teaching hospital: epidemiology, education and engineering. Med J Aust 2002; 177(8): 418-422. • Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Post exposure Prophylaxis. MMWR 2001; 50(No. RR-11): 1-7. • Delhi AIDS control Society India Dr.T.V.Rao MD

31. Programme created by Dr.T.V.Rao MD for Basic understanding on Needle sticks Injuries and Human and Legal concern for Medical care workers in INDIA • Email • doctortvrao@gmail.com Dr.T.V.Rao MD