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What is an occupational exposure?

- A blood or body fluid exposure that occurs as a consequence of a work-related activity - There are two types of blood and body fluid exposure:
Percutaneous exposure (penetrates the skin) e.g. needlestick injury (NSI) or cut with a sharp object such as a scalpel blade Non-percutaneous or mucocutaneous exposure (contact of mucous membrane or intact skin with blood or body fluids) e.g. blood splash to the eye

Needle Stick Injury (NSI)


By definition,

Puncturing of the skin by a needle or similar sharp object


- Serious concern for health care professionals

Needle stick Injuries come under a category of sharp injuries.


Sharps are devices that are intentionally sharp to puncture or cut skin (needles, scalpels, etc.), or become sharp due to accident, such as broken glass tubes.
Hypodermic needles Scalpels Intravenous (IV) catheter stylets Arterial blood collection syringe needles Aspiration needles Injector pen needles

Magnitude of needle stick injury


The exact number of needle stick injury occuring annually is difficult to calculate - Lack of data from non hospital settings is a major obstacle

In hospital settings the rate is


-

India it is largely underestimated The WHO estimates about 3 million of the 35 million health care workers worldwide are exposed to blood-borne pathogens each year

Who are at risk?????


Any worker who may come in contact with contaminated needles is at risk -Doctors -Nursing Staff, -Lab Workers, -Housekeepers. Predominantly HEALTH CARE WORKERS

Where, when and how do NSI occur?


Where? Inpatient units Operating rooms Emergency Department Procedure Room When and How? During use After use and before disposal recapping) During or after disposal After appropriate disposal After inappropriate disposal

(including

Why do I need to be concerned if I have a needle stick injury


- A needle stick injury potentially exposes healthcare workers to blood that may contain blood borne viruses
Human Immunodeficiency Virus (HIV) Hepatitis B Virus (HBV) Hepatitis C Virus (HCV)

- Contaminated sharps pose the greatest risk to healthcare workers of occupational exposure to blood borne viruses

How does transmission of a blood borne virus occur from a contaminated sharp?
- Transmission requires transfer of bloodcontaining material by injection or via sharp instruments through the skin - The risk of transmission is influenced by: Organism Volume of blood Status of source Status of staff member

What is the risk of transmission following a NSI to a positive source?


- HIV 0.3% - HBV If healthcare worker susceptible (i.e. non-immune) 1% - 6% if the source is hepatitis B surface antigen (HBsAg)-positive 22% - 31% if the source is HBsAg- and HBeAgpositive - HCV 1.8% (range: 0% - 7%)

Sharps Management
Institutions should follow Universal Precautions strictly to reduce incidence of NSI Universal precautions are intended to prevent the exposure of health-care workers and patients to bloodborne pathogens.
These must be practised in regard to the blood and body fluids of all patients, regardless of their infection status

Universal precautions include:


1.

Hand-washing before and after all medical procedures 2.Safe handling and immediate safe disposal of sharps: Not recapping needles; Using special containers for sharp disposals; Using needle cutter/destroyers; Using forceps instead of fingers for guiding sutures; Using vacutainers where possible 3. Use of protective barriers whenever indicated to prevent direct contact with blood and body fluid such as gloves, masks, goggles, aprons, and boots. 4.A HCP who has a cut or abrasion should cover the wound before providing care

Sharps Management - General Principles

The person who has used the sharp is responsible for its immediate safe disposal following use, preferably at the point of use.

Sharps Management - General Principles

Sharps Management - General Principles


In the case of inappropriately disposed sharps, a sharps container should be taken to the location, the sharp handled and disposed of in a manner to avoid injury, and hands washed following disposal.
- Report inappropriate disposal

Protecting yourself from NSI


Avoid the use of needles where safe alternatives are available. Help your employer select and evaluate devices with safety features that reduce the risk of injury. Use devices with safety features provided by your employer. Plan for safe handling and disposal of sharps before using them.

Protecting yourself continued


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.

Examples of Safer Needle Devices


Self-Sheathing Safety Feature: Sliding
needle shields attached to disposable syringes and vacuum tube holders

Before use

After use

Examples of Safer Needle Devices


Retractable Technology:
Automatic retraction of the needle into the barrel of the syringe, after the plunger is fully depressed

Examples of Safer Needle Devices


Self Blunting Technology:
Self-blunting phlebotomy and winged-steel butterfly needles

Blunt-Tipped Blood Drawing Needle

Winged Steel Needles

Examples of Safer Needle Devices


Add-on Safety Features:
Hinged shields attached to phlebotomy needles, winged steel needles and blood gas needles

Add-on sliding shield

Retracting Finger Prick Lancets

Needle free IV access

Safe needle clipper

NEEDLE-PRICK INJURY ACCIDENTS MANAGEMENT 1. First Aid Measures 2. Immediate Follow-Up Actions 3. Filling in incident /accident report
the supervisor should complete Accident Report Form &sent it to Health and Safety Office through the Department within 72 hours Report of an accident arising out of and in the course of employment to an employee obtained from the HRD

4. Remedial action plan

Post exposure prophylaxis

By definition,

Post exposure prophylaxis (PEP) refers to the comprehensive management given to minimize the risk of infection following potential exposure to blood-borne pathogens (HIV, HBV, HCV).

Principles of providing PEP

1. Non discriminatory 2. Confidentiality 3. Detailed informed consent

HIV INFECTION
Percutaneous needle stick injury has an infectivity rate of 0.3 % The risk may appear trivial, however, it is a major concern for health care workers The chances of transmission of HIV were found to be higher

If blood is visible in device If needle is used in piercing artery or vein A deeper injury

PEP for HIV


1. A rapid baseline testing of HIV both for source as well as patient has to be done as soon as possible 2. PEP to be initiated as early as possible preferably within 2 hours and within 72 hours 3. Initiation of PEP should not be delayed while waiting for the results of HIV testing of the source of exposure. 4. Informed consent should be obtained before testing of the source as per national HIV testing guidelines.

Steps Followed In PEP


Step 1 : Manage exposed site Step 2 : Establish eligibility for PEP Step 3 : Counsel for PEP Step 4 : Prescribe PEP Step 5 : Laboratory Evaluation Step 6 : Follow up, Monitoring and Adherence

Categories of exposure and Exposure code (EC)


Categories of Area exposure Mild exposure Mucous membrane/non-intact skin with small volumes Moderate Mucous membrane/ intact skin exposure with large volumes Or Percutaneous superficial exposure with solid needle Severe Percutaneous with large exposure volume EC EC1 EC2

EC3

Categories based on test result of source


HIV negative Source is not HIV infected but consider HBV and HCV- NO PEP REQUIRED HIV positive and clinically asymptomatic - HIV SC1 HIV positive and clinically symptomatic -HIV SC2 Status of the patient is unknown, and neither the patient nor his/her blood is available for testing (e.g. injury during medical waste management the source patient might be unknown). HIV SC UNKNOWN In a region with high HIV prevalence a negative result is of less value due to the high possibility of window period

Low risk High risk Unknown

Determination of PEP Recommendation


EC 1 HIV SC 1 PEP Recommendation PEP may not be warranted

1
2 2 3 2/3

2
1 2 1or2 Unkno wn

Consider Basic Regimen


Recommend Basic Regimen (most exposures are in this category) Recommend Expanded regimen Recommend expanded regimen If setting suggests a possible risk (epidemiological risk factors) and EC is 2 or 3, consider basic regimen

Drugs Used
Basic regimen: Zidovudine (AZT) 600 mg in divided doses (300mg/twice a day or 200 mg/thrice a day for 4 weeks

+
Lamivudine (3TC) 150 mg twice a day for 4 weeks Expanded regimen:4 weeks therapy Basic regimen

+
Indinavir 800 mg/thrice a day, or any other protease Inhibitor.

Testing and Counseling


The health care provider should be tested for HIV as per the following schedule i)Base-line HIV test - at time of exposure ii) Repeat HIV test - at 6 weeks following exposure iii) 2nd repeat HIV test - at 12 weeks following exposure

Remember.
Provide a pre-test and post-test counselling. HIV testing should be carried out on three ERS (ELISA/ Rapid/ Simple) test Refrain from donating blood, semen or organs/tissues and abstain from sexual intercourse. Women should not breast -feed their infants

Steps to be undertaken by the Infection control officer on receiving information about exposure:
1. All NSI should be reported to the State AIDS Control societies giving the Exposure Code and the HIV Status code. 2. The State AIDS Societies should in-turn inform NACO about the cases periodically.

3.

A register should be maintained in all hospitals and at the level of the State AIDS Control societies

4. NACO has decided to supply PEP drugs to all cases in government hospitals through the State AIDS Control societies 5. Infection control officers in all hospitals have been directed to ensure that PEP drugs are available at all times.

Hepatitis B Virus
HBV vaccination status of exposed person
Never vaccinated

Action after exposure

Give complete hepatitis B vaccine series Hep B IV Ig , 0, 1 and 6 months of Hep B recombinant sub unit vaccine Give Hep B Vaccine Booster

Vaccinated, anti-HB-S not known

Vaccinated more than 5 years ago

Give Hep B Vaccine Booster

Quick FACT:

HBV vaccination is recommended for all healthcare workers (unless they are immune because of previous exposure).

HCV infection

The incidence in health care workers is equal to general population However, it is a major occupational hazard No prophylaxis available against hepatitis C.

Post-exposure management for HCV is based on early identification of chronic HCV disease.

References
1. Queensland Health. Infection Control Guidelines. Appendix P3: Management of Blood and Body Fluid Exposure (updated 2006). Brisbane: Queensland Government. 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 needlestick injuries in a tertiary teaching hospital: epidemiology, education and engineering. Med J Aust 2002; 177(8): 418-422.

2.

3.

4.

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 Postexposure Prophylaxis. MMWR 2001; 50(No. RR-11): 1-7.

Sources:
1. http://www.cdc.gov/niosh/2000-135.html
2. http://www.osha.gov/SLTC/etools/hospital/hazards/sharp s/sharps.html#NeedlestickInjuries

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