Epidemiology

Needlestick and sharps account for 400,000 injuries to NHS staff each year.¹ The average risk following percutaneous exposure to HIV-infected blood in healthcare settings is about 3 per 1,000 injuries, less than 1:1000 following mucocutaneous exposure and has never been recorded following contact of HIV blood with intact skin.

The Health Protection Agency (HPA) published its report The Eye of the Needle (United Kingdom Surveillance of Significant Occupational Exposures to Bloodborne Viruses in Healthcare Workers) in 2006. This stated that there had been 5 documented cases of HIV infection and 14 possible or probable cases in healthcare workers after exposure at work. Of these, 5 died. Many of these workers had worked in countries of high HIV prevalence and were presumed to have been infected outside the UK.² Hepatitis B and Hepatitis C infection were more likely than HIV and it was felt that healthcare workers did not fully appreciate the risk.³

An update HPA report was released in 2008.³ This stated that:

• A further 914 needlestick incidents had been reported through the HPA Centre for Infections scheme. Hollow-bore needles were the greatest risk (68% of all percutaneous exposures between 2000-2007).
• The greatest source of infection was percutaneous exposure to patients with hepatitis C virus (48% of exposures between 2000-2007).
• Most exposures between 2000-2007 involved nurses, although in the year 2007 alone they were outnumbered by doctors and dentists. A third of doctors involved were senior house officers.
• A third of exposures between 2000-2007 occurred in hospital wards or accident and emergency departments.
• Over 20% occurred in intensive care units and were deemed preventable if universal precautions and safe waste disposal policies had been adhered to.
• Most healthcare workers exposed to an HIV-positive source in 2007 began post-exposure prophylaxis (PEP) within 24 hours of exposure.
• No new HIV conversions have been reported since 1999 so the number remains at 5.
• The relative risks of exposure following percutaneous injury, especially from deep penetrating injury involving a hollow-bore needle or one visibly contaminated with blood was 1 in 3 for hepatitis B virus (HBV), 1 in 30 for hepatitis C virus (HCV) and 1 in 300 for HIV.

Certain features of a percutaneous injury carry a particularly high risk:⁴

• A deep injury
• Terminal HIV-related illness in the source patient
• Visible blood on the device which caused the injury
• Injury with a needle which had been placed in a source patient's artery or vein

In one study of 98 UK surgeons in a large district general hospital, 44% anonymously admitted to having a needlestick injury. The study concluded that the incidence of such injuries was likely to be under-reported, particularly in the surgical sector.⁵

Management

Follow local or national or international protocol.^6,7 The study of surgeons in a district general hospital found that only 3% followed agreed local policy and promotion of the importance of safety procedures needed to be emphasised.⁵

First aid

• Contaminated needlestick, sharps injury, bite or scratch - encourage bleeding, wash with soap and running water
• Blood or body fluid in eyes or mouth - irrigate with copious quantities of cold water
• Blood or body fluid on broken skin - encourage bleeding if possible and wash with soap under running water (but without scrubbing)

Report incident and discuss with local public health consultant immediately

Discuss type of injury, donor HIV status if known, etc. If this urgent preliminary risk assessment considers there is a significant risk of HIV, post-exposure prophylaxis (PEP) needs to be started as soon as possible - ideally within 1 hour. This reduces risk of transmission by 80%. It may be appropriate to give the first dose of PEP pending a fuller assessment after the HIV status of the 'donor' is known. Where the donor is unknown, epidemiological likelihood of HIV in the source needs to be considered, although in most cases PEP will not be justified.

PEP currently consists of a 28-day course of treatment with a triple combination of antiretroviral drugs, has significant side-effects and needs careful follow-up.⁶

Hepatitis B immunoglobulin should be given within 72 hours if the source is known to be HBeAg positive or their status is unknown and the exposed person has negative serology. HBV vaccination should be offered to all health workers who have never been immunised or are non-immune.

The exposed person should also be advised to have safe sex for three months, not to donate blood until all necessary screening tests are clear, and to see their GP if they develop a fever.

Investigations⁶

• Take blood for virology, (HIV, hepatitis B, hepatitis C) from the injured worker. Start PEP where appropriate and consider the need for antibiotic therapy or hepatitis B immunisation. Recheck HIV status 3 months later and hepatitis serology 3 and 6 months later.
• Liver function tests should be performed and repeated at 3 and 6 months.
• Female workers should have a B-hCG check to exclude pregnancy.
• The 1997 GMC guidance concerning donor patients who refuse consent has been
  superseded by various other pieces of legislation, including the Human Tissue Act and the Mental Capacity Act.⁸ Different laws apply to different countries within the UK and, in this situation, advice should be sought from your medical defence organisation.

Documentation

Fill out accident book and complete critical event audit. How can subsequent events be prevented?

Follow-up

Ensure there is adequate follow-up of both care worker and donor. The care worker in particular will require early involvement by the Occupational Health service. They may need specific advice about having to take sick leave if medication is required and the possible requirement for psychological support.

Prevention of avoidable exposure in an occupational setting

This is of prime importance. The HPA advises the following:⁷

General measures

• Wash hands before and after contact with each patient and before putting on and after removing gloves.
• Change gloves between patients.
• Cover with waterproof dressings any existing wounds, skin lesions and all breaks in exposed skin, and wear gloves if hands are extensively affected.
• Wear gloves where contact with blood can be anticipated.
• Avoid sharps usage where possible and, where sharps usage is essential, exercise particular care in handling and disposal.
• Avoid wearing open footwear in situations where blood may be spilt, or where sharp instruments or needles are handled.
• Clear up spillage of blood promptly and disinfect surfaces.
• Pre-employment occupational health assessment should identify those with damaged skin, e.g. fissured hand eczema, who may be at higher risk of occupationally acquired infection and ensure that advice is given about minimising any occupational health risk to which they may be exposed.
• Wear gloves when cleaning equipment prior to sterilisation or disinfection, when handling chemical disinfectant and when cleaning up spillages.
• Follow safe procedures for disposal of contaminated waste.⁹

Specific measures

This will obviously depend on the procedure being undertaken but may include:

• Use of new, single-use disposable injection equipment for all injections is highly recommended. Sterilisable injection should only be considered if single use equipment is not available and if the sterility can be documented with Time, Steam and Temperature indicators.
• Discard contaminated sharps immediately and without recapping in puncture- and liquid-proof containers that are closed, sealed and destroyed before completely full.
• Document the quality of the sterilisation for all medical equipment used for percutaneous procedures.
• Wash hands with soap and water before and after procedures; use protective barriers such as gloves, gowns, aprons, masks, and goggles for direct contact with blood and other body fluids.
• Disinfect instruments and other contaminated equipment.
• Handle soiled linen properly. (Soiled linen should be handled as little as possible. Gloves and leakproof bags should be used if necessary. Cleaning should occur outside patient areas, using detergent and hot water).

More detailed advice, including use of blunt-tipped needles, and 'neutral zones' for passing of sharps during surgery, are available in Guidance for clinical health care workers.¹⁰

Guidance for NHS employers (who are now under a statutory obligation to prevent and control spread of healthcare-associated infection) can be found on the NHS Employers' website.¹

Document references

1. Needlestick Injuries; NHS Employers, 2009.
2. HIV and AIDS: information and guidance in the occupational setting, Health Protection Agency (2008)
3. Eye of the Needle, Health Protection Agency, November 2008
4. AVERT - Healthcare workers and HIV Prevention - Website
5. Thomas WJ, Murray JR; The incidence and reporting rates of needle-stick injury amongst UK surgeons. Ann R Coll Surg Engl. 2009 Jan;91(1):12-7. Epub 2008 Nov 4. [abstract]
6. HIV Post exposure Guidelines, Dept of Health (2004)
7. Universal Precautions, World Health Organization; A strategy to protect health workers from infection from bloodborne viruses.
8. Good Surgical Practice; The Royal College of Surgeons of England, 2008.
9. Safe disposal of clinical waste. HSE, HMSO, 1992. ISBN 0 11 886355X.
10. Guidance for Health Care Workers; Prevention of Blood Borne infections (Hep B and HIV).

Internet and further reading

• Needle-Stick Injuries; Health and Safety Executive 2009.

Acknowledgements