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Needlestick injuries and related blood and body fluid exposures


Essentials

  • 1

    Avoiding blood and other body fluid exposure remains the primary means of preventing occupationally acquired blood-borne virus infections.

  • 2

    The risks of acquiring infection after occupational exposure to blood-borne viruses are human immunodeficiency virus (HIV) 0.3%, hepatitis B virus (HBV) 12% to 30%, hepatitis C virus (HCV) 1.8%.

  • 3

    HBV immunization is an integral part of workplace safety.

  • 4

    Effective post-exposure prophylaxis (PEP) is available for both HBV and HIV, but not HCV.

  • 5

    Significant emotional distress often complicates needlestick and related occupational injuries.

Introduction

Management of the health care worker who sustains an occupational exposure to blood or other potentially infectious body fluids (e.g. semen, vaginal secretions, cerebrospinal fluid [CSF] and fluids containing visible blood) is an important issue for the emergency department (ED) doctor. Overall, 16,000 hepatitis C virus (HCV), 66,000 hepatitis B virus (HBV), and 1000 human immunodeficiency virus (HIV) infections may have occurred in the year 2000 worldwide among Health Care Workers (HCWs) due to their occupational exposure to percutaneous injuries. The fraction of infections with HCV, HBV and HIV in HCWs attributable to occupational exposure to percutaneous injuries fraction reaches 39%, 37%, and 4.4%, respectively. This figure is a conservative estimate as many needlestick injuries go unreported. HBV, HCV and HIV are the most important occupationally acquired blood-borne pathogens; however, many other organisms, including malaria, syphilis, cytomegalovirus and possibly the prion diseases (e.g. Creutzfeldt–Jakob disease) also may be transmissible via this route.

When evaluating health care providers (HCPs) at risk for occupational infection with HIV, ‘exposure’ is defined as contact with potentially infectious blood, tissue or body fluids in a manner that allows for possible transmission of HIV, and therefore requires consideration of post-exposure prophylaxis (PEP).

Such potentially infectious contacts are:

  • a percutaneous injury (e.g. a needlestick or cut with a sharp object)

  • contact of mucous membrane or non-intact skin (e.g. exposed skin that is chapped, abraded or afflicted with dermatitis).

Body fluids of concern include:

  • body fluids implicated in the transmission of HIV: blood, semen, vaginal secretions, other body fluids contaminated with visible blood

  • potentially infectious body fluids (undetermined risk for transmitting HIV): cerebrospinal, synovial, pleural, peritoneal, pericardial and amniotic fluids.

Fluids that are not considered infectious unless they contain blood include faeces, nasal secretions, saliva, gastric secretions, sputum, sweat, tears, urine and vomitus.

In addition, any direct contact (i.e. without barrier protection) to concentrated HIV in a research laboratory or production facility is considered an ‘exposure’ that requires clinical evaluation and consideration of PEP.

Intact skin is an effective barrier against HIV infection. Contamination of intact skin with blood or other potentially contaminated fluids is not considered an exposure and does not require PEP.

Most exposures do not result in infection and the risk of infection following significant exposure varies with factors such as:

  • the pathogen involved (hepatitis B, hepatitis C or HIV)

  • the fluid involved—blood is generally the most infectious body fluid

  • the type of exposure—percutaneous or mucous membrane/non-intact skin

  • the amount of blood or other infectious body fluid involved in the exposure

  • the amount of virus in the patient’s blood at the time of exposure.

General issues

Prevention of needlestick injuries

The old adage ‘prevention is better than cure’ certainly rings true when considering needlestick injuries, as the cost of managing one needlestick injury exposure can range from 376 USD to 2456 USD.

The potentially infectious nature of all blood and bodily fluids necessitates the implementation of infection control practices. The universal application of standard precautions should be the minimum level of infection control when treating patients to prevent blood-borne virus transmission. The important elements of standard precautions are:

  • the use of gloves when contact with blood, body fluids or secretions is anticipated

  • the use of masks and protective eyewear during procedures that have the potential to generate splashes or sprays of blood or bodily fluids

  • the use of gowns to protect skin and clothing from soiling by blood and other bodily fluids

  • correct handling and disposal of needles and other sharp instruments:

    • disposal of sharps directly from patient immediately into sharps bins

    • locating sharps bins conveniently to reduce the unnecessary transportation of uncapped devices

    • avoiding overfilling sharps containers

    • never re-sheathing or re-capping needles

    • 100% attention when handling sharps.

More than 50 products with features designed to prevent needlestick injuries are currently available and fall broadly into two categories: those providing ‘passive’ or automatic protection, and those with a safety mechanism that the user must activate.

It has been demonstrated that most needlestick injuries are preventable and that the use of safety-engineered devices reduces needlestick injuries. The passive devices are most effective in preventing needlestick injuries.

Hospital systems

Hospitals need to have appropriate policies and procedures to deal with occupational exposures to blood and body fluids; these are best implemented through a comprehensive and coordinated occupational exposure programme. Depending on the individual institution, such a programme is usually managed by infection control personnel and involves staff health, occupational health, laboratory services, the ED and the infectious diseases service.

Staff needs to be aware of the appropriate steps to take in the event that they sustain an exposure, such as who to notify, incident reporting requirements, and where and how to seek medical evaluation. The programme should develop processes for consent and testing of the source individual (including situations where the individual refuses or is unable to give consent), prompt blood-borne virus testing and communication of results to the exposed person. Clear written guidelines and clinical pathways should be accessible to medical staff involved in managing these exposures (including specific recommendations for exposures involving a blood-borne virus positive source and antiretroviral PEP).

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