Needle Stick Injury – Management and Treatment with known Injury

What is a Needlestick Injury: In simple terms it is the injury caused due to needles or sharps (blades, lancets etc which are sharp) that accidentally puncture the tissue of the operator or handler. It is one of the most common work place injury seen in people who work with hypodermic syringes and needle based equipment mostly in hospitals and clinics (dental clinics). The Injury can occur during working with the needle or during dismantling or while disposing off of the needle or sharps. Hygiene workers are also exposed to Needle Stick injury when the needles are not disposed off properly. 

It is important to know the proper way to dispose Hospital waste, for this purpose WHO has classified hospital waste based on colors to help hospital staff dispose materials based on the type of product – Color Coding for Dental Hospital Waste management 

Diseases transmitted due to Needle Stick Injury:

Needle Stick injury is a common cause for transmitting infectious blood-borne viruses and diseases. The most common Virus infections which are seen transmitted through needle stick injuries are Hepatitis B, Hepatitis C and HIV which is the cause for (AIDS). If you are operating on a HIV AIDS patient, the chances of getting HIV from needle poke are high as direct transmission from patient to operator is high. Accidental needle pricks during a procedure or during disposal of the needle re one of the most common causes of Needle stick injury.

Rare Diseases transmitted through Needle stick injuries

Blastomycosis, Brucellosis, Cryptococcosis, Diphtheria, Cutaneous, Gonorrhea, Herpes, Malaria, Mycobacteriosis, Mycoplasma caviae, Rocky Mountain spotted fever, Sporotrichosis, Staphylococcus aureus, Streptococcus pyogenes, Syphilis, Toxoplasmosis, Tuberculosis.

How are blood borne diseases transmitted through Needle Stick Injury?

When health workers or operators of needles and sharps puncture their tissue accidentally with a needle or sharp item after using it on a patient or other person who is infected with any Viral infection. Needle Stick Injury is also seen in users of Drugs who share needles etc between multiple users. 

When a needle which was used on a person suffering from any Viral infection punctures the operators tissue, the infected body fluids can be injected or transferred to the blood stream and lead to infection. Little amounts of infectious fluid is enough to spread diseases.  

Needle Stick Injury Management

Management of Needle Stick Injuries – Post exposure prophylaxis:

The most important and initial step which should be taken is to immediately apply pressure and drain some amount of blood from the injury site in a hope that the infectious fluid does not enter the blood stream. The second step should be to identify the portal of entry which needs to be either of these to transmit the disease – through cutaneous membrane, percutaneous, mucous membrane, through any exposed injury. 

Body Fluids which transmit HIV – Blood, Semen, Breast milk, cerebrospinal fluid, vaginal fluid, semen, pleural fluid. Other body fluids like Saliva, urine, feces, tears vomit etc do not transmit HIV. It is important to know – Needle Stick Injury Protocol by CDC

1. SOURCE HBsAg NEGATIVE
no further action necessary

2. SOURCE HBsAg positive/ unknown

a. if the exposed person already receive full of hepatitis vaccine

1. if the hepatitis b antibody (anti HBS) Level is known to be > 100 IU/ml and a booster has been given 5 years after the primary course, no further action is needed. if it is more than 2 years since the primary course was given, but the 5 years dose has not be given, it should be given now.

2. if the post primary vaccination course antiHBS level is unknown or <100 IU/ml , take a 10 ml clotted blood sample for the level to be measured.
level > 100 IU/ml – no treatment
level >0, but <100 IU/ml give vaccine booster
level <10 IU/ml – give vaccine booster.

B. IF THE EXPOSED PERSON NOT VACCINATED.
* start course of hdepatitis b vaccine
* hepatitis b immunoglobin( HBIG) can also be required. IT is given transmucularly at a different site to a vaccine if the exposure is considerable. HBIG should be given as soon as possible after the exposure and certently with in 48 hours. it is of no value if it given later than 1 week after afte exposure.

C. EXPOSED PERSON VACCINATED BUT NOT COMPLETED THE COURSE
* Take 10ml clotted blood and measure antibody level.
* level > 100 IU/ml no furthur action necessary but vaccine course should be completed at recommened intervels.
* levels<100 IU/ml give furthur doe and complete vaccine course. seek advice medical micro microbiologists regarding intervels. HBIG will also be required if exposure is considerable.

HEPATITIS C

There is no specific prophylaxis or vaccination avaliable against hepatitis c. therefore, no immediate action needs to be taken following exposure to the possible hepatitis c source.
exposed health care should be managed as follows

1. KNOWN HEPATITIS C INFECTED SOURCE

* obtain baseline serum for storage from healthcare worker.

* obtain clotted blood sample (serum) for hepatitis c virus RNA testing at 6 and 12 weeks.

* obtain serum for HCV antibody ( anti- HCV) at 12 to 24 weeks.

2. SOURCE KNOWN TO BE UNINFECTED WITH HEPATIS C FOLLOWING TESING AT THE TIME OF INCIDENT.

* Obtain base line serum from the health care worker for storage.

* obtain follow up serum if the symptoms or signs of liver disease develop.

3. HEPATITIS C STATUS OF SOURCE UNKNOWN

* obtain baseline serum for storage from health care worker.

* A risk assessement should be performed of the likelihood that the source is hepatitis c postive (assessed by clinician in charge of patient or occupational health or consultant microbiologist)
High risk – manage as known infected source.
low risk – obtain serum for anti-HCV testing at 24 weeks.
health care workers found to have acquired hepatitis c infection following occupational exposure should be referred immediately for specialist assessment. early treatment of acute hepatitis c infection may prevent chronic hepatitis c infection.

HIV ( HUMAN IMMUNODEFICIENCY VIRUS)
*This procedure applies to all possible exposures, whether they involve staff, patients or members of public.
* if there is risk of hiv exposure, the individual must dealt urgently to obtain prophylaxis as ssoon as possible and preferably with in one one hour.

* if the source is in the high risk group or exoposures considerable, the source patient should be tested for HIV antibody. this requires informed consent to be given. these tests are not performed out of hours for this indication. The decision whether or not to start peophylactic treatment must not be based solely on results of an HIV antibody test and any prophylaxis should be given within an hour of exposure.

*for any exposure incident when the source patient is known it is recommended that hepatitis B,C and HIV tests are carried out as a routine from that patient. for the high risk sources or exposures, these tests should be arranged as quickly as possible.

* a blood damople must be sent be taken from the injuired or exposed person and sent to microbiology laboratory to be stord. this will be used for futher testing if necessary.

* the risk of seroconversion following a single percutaneous exposure to HIV is only 0.3 % and following mucous membrane and skin exposure is 0.1% and <0.1 % respetively.

THREE TYPES OF EXPOSURES POSE RISK
* Percutaneous exposure i.e needle stick
* exposure of broken skin
* mucous membrane exposure

THE RISK O F TRANSMISSION IS INCREASED WITH
*Hollow bore needles.
* needles that are visibly blood stained.
* A high viral load in the source, ge.g patient with AIDS/TERMINALLY ILL

POST EXPOSURE PROPHYLAXIS (PEP)
Post exposure prophylaxis should be considered whwn ever there ishas been exposure to material known to be, or storngly suspected to be ,infected with HIV.
* High risk body fluids are blood are : blood , amniotic fluid, vaginal secretions, semen, breast milk, CSF, peritonial fluid, pericardial fluid, synovial fluid, unfixed tissues, and organs and saliva in association with dental surgery.
* post exposure prophylaxis should not be offered following contact through any route of urine, vomitus, saliva and eaces unless tney are visibly blood stained.

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