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NeedleStick Injuries

Overdose & Poisoning

In cases where the person who is the source of the exposure is known to be HIV, hepatitis B or hepatitis C positive, you need to urgently contact a physician with experience in managing these infections. Combination antiretroviral therapy is now recommended for some HIV exposures and the selection of appropriate agents should be decided in consultation with the physician. Contact NSW Health Needle Stick hotline 1 800 804 823 for assistance.

Following is a brief description of the course of action to take for an uncomplicated needlestick injury where the original user of the needle is unknown.

Your initial efforts need to be directed at reducing the risk of the exposed patient contracting an infectious illness. Immediate first aid is required if the event is recent and if the patient has not already done this. The accompanying checklist specifies first aid steps to follow and some prophylactic medications to offer.

The next step is to collect blood from the patient for baseline testing after counselling and obtaining informed consent.

A thorough assessment of the exposure is then required to determine the risk of disease transmission. Reassure the patient that only a small proportion of blood exposures result in infection.

It is impossible to precisely determine this risk, but factors that have been identified as being associated with HIV transmission include:

• terminal AIDS illness in the source person,
• deep injury, visible blood on device, procedure involving needle placed directly into a vein or artery.

HIV	0.2-0.5%
Hepatitis B - HBeAg absent - HBeAg present (prompt administration of HBIG and hepatitis B vaccination can prevent transmission in most cases)	2% 40%
Hepatitis C (2 separate studies with small samples) (Ref 1)	3-10%

Your next step is to advise the patient about the precautions to take until final testing confirms lack of disease transmission. Precautions and testing schedules are listed below. Counselling should be offered during this worrying period.

Finally, in the unfortunate event of disease transmission occurring, the patient may call on you for evidence in support of their claim that transmission was related to the exposure injury. Your documentation and the patient's negative baseline test results provide this evidence.

Consider the following scenario. A patient attends your practice after treading on a needle and syringe while walking through parkland. What action do you take?

Body substance exposure accidents to GPs or co-workers in the practice setting require similar management to that described above. Often in these circumstances the person who is the source of the injury is known, and can therefore be approached for testing if their status is not already known. Approaching the person who is the unwitting source of an exposure requires sensitivity. The circumstances of these exposures should be investigated and action taken to prevent recurrence. This may lead to changes in work practices, changes to equipment or education.

Needlestick injury - management of exposed person CHECKLIST 1. REVIEW THE CIRCUMSTANCES OF THE EXPOSURE Determine how long ago the incident occurred Determine the nature and degree of exposure - whether skin was punctured, bleeding occurred (examine for skin perforation) - depth of needle penetration - whether the needle or syringe was visibly blood contaminated Determine First Aid response - was the site washed immediately, how? - wash, disinfect and consider surgical treatment if the wound is tetanus prone   2. ASSESS RISK, COUNSEL AND EDUCATE PATIENT Assess the degree of exposure Reassure the patient that the risk of disease transmission is small Advise that consideration should be given to the following: - need to avoid donating blood, organs or semen - possibility of risks associated with breast feeding, pregnancy Explain precautions to avert disease transmission to close contacts eg safe sex, no sharing of toothbrushes or any item which may be blood contaminated.   3. PROVIDE POST EXPOSURE PROPHYLAXIS (normally) Hepatitis B immune globulin (HBIG), IM, if less than 72 hours from time of exposure injury. Hepatitis B vaccination, IM (separate site from HBIG) Tetanus vaccination - use of CDT (children < 8)or ADT (persons over 8 years), with or without tetanus immunoglobulin will be based on tetanus immunisation history and the type of wound. Refer to NHMRC, The Australian immunisation procedures handbook, Fifth edition (1994) , p.30 (tetanus) & p. 67 (hepatitis B) for post-exposure prophylaxis guidelines.   4. COLLECT BLOOD FOR BASELINE TESTING (after counselling and obtaining informed consent) Request HIV Ab, Anti-HCV, and HBcAb if the patient is not vaccinated, or HBsAb if already vaccinated Provide history on HIV testing form and on routine serology request forms eg ìNeedlestick injury - exposed person, not hepatitis B vaccinatedî. Forms are ideally coded.   5. FOLLOW UP Arrangements should be made to: Complete the full course of hepatitis B vaccination followed by antibody testing at 2-4 months after completion of the vaccine course Retest for HIV Ab (at 3 months), hepatitis B and hepatitis C (at 3 and 6 months)   6. DOCUMENTATION Date and time of exposure/injury Circumstances of the injury First aid applied Risk assessment and explanations given to the patient Tests ordered Prophylactic antimicrobial medications administered Follow up arrangements for receiving test results and continuing vaccinations Precautions advised during follow up period. NOTE: Confidentiality must be maintained at all times.

Becky Wright Infection control project officer, NRDGP

Reference:

1 Gerberding JL. Management of occupational exposures to blood-borne viruses. N Engl J Med 1995;332:444-51.