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Needle stick injuries & the health care worker--the time to act is now.

Occupational exposures to pathogenic microbes as a result of needles and other sharps are an important public health concern. In the health care setting, transmission of disease from patients to health care workers can occur through percutaneous injuries such as accidental needle stick and sharps injuries. Health care workers who come in contact with medical devices as sharps including syringes or scalpels are at risk of injuries that can lead to serious blood borne infections. Although there are reports of bacteria, viruses (herpes, cytomegalovirus, Epstein Barr virus, fungi, protozoa (malaria) and even tumour cells being transmitted by percutaneous exposures, most studies focus on the main bloodborne pathogens as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) (1). In India, it is not known exactly how many occupation related injuries occur each year, and as data are scarce, it is not possible to estimate an annual incidence (2,3). Estimates from the USA indicate that 600,000-800,000 such injuries occur annually and approximately half of these go unreported. Data from the EPInet system suggest that in an average hospital, workers incur approximately 27 needle stick injuries / 100 beds / year (4). Gross under-reporting of needle stick injuries (NSI) should not lead health care administrators to underestimate the problem. Although the risk may be low, the psychological trauma as well as legal implications that follow such injuries can be considerable. Additionally, financial implications include initial first aid treatment, post-exposure prophylactic drugs, hepatitis B immunoglobulin, cost of baseline investigations and the inevitable cost of treating a disease once transmitted. At a tertiary care hospital in Mumbai, approximately Rs 9000/- HCW / episode of needle stick injury are incurred as short term costs (5). Long term costs as anxiety, personal impact, adverse effect on work performance and potential litigation have not been factored in.

The average transmission rates are highest for percutaneous injuries from hepatitis B (22-31%) that is positive for both hepatitis B surface antigen and hepatitis B antigen (1). The probability of transmission varies depending on whether the exposure is with a hollow bore needle or a solid needle due to higher fluid content and pathogen load.

Needle stick injuries can occur during a variety of procedures including needle recapping, injuries sustained in the operating room, during blood collection or intravenous line administration, suturing, checking blood sugar, careless disposal in garbage bags due to inadequate segregation at source, etc. In this issue Muralidhar and colleagues (6) cite alarming statistics on poor awareness and compliance of junior medical staff including junior doctors, undergraduate medical students, nurses and laboratory technologists on needle handling and disposal. The authors report a lack of knowledge about the seriousness of NSI, a careless attitude as well as indifference and apathy towards the subject. Surprisingly, even basic first aid treatment after a needle stick injury was found to be wanting and inadequate. The authors maintain that there is a huge scope for improvement.

So where can we begin?

Immunization: To begin with as hepatitis B is 100 times more transmissible than HIV and 10 times more transmissible than HCV and immunization of health care workers against HBV assumes great importance and is universally recommended, this is best done at time of employment and should be mandatory. Measurement of serum antibody levels of antiHBs 1 month after immunization is imperative (7). Those who achieve protective levels of > 10 mIU /ml are protected for life and do not need repeat antibody level estimation or even booster immunization.

Post-exposure prophylaxis: Indian hospitals should make it obligatory for a defined policy to record and report all NSI, with an active ongoing post-exposure prophylaxis (PEP) programme in place. For effective implementation of this programme, a policy needs to be formulated at the institutional level to establish a system for reporting injuries, performing relevant baseline tests for both the health care worker and the source (if not known) and administering prophylaxis if required. The risk of transmission is assessed by taking into account the degree of exposure and the evaluation of the source patient.

PEP for HBV positive sources for exposed health care workers who are antiHBs negative warrants hepatitis B vaccination and a full course of passive immunization with hepatitis B immunoglobulin preferably within 24 h. PEP for needle stick injuries from HIV positive sources includes 2 or 3 anti-retrovirals and warrants logistic support in terms of ready availability of a "starter pack" of these drugs being kept in the Emergency Room (ER) with sufficient drugs for 48 h so that injuries on week ends can immediately be initiated on treatment. All this costs both money and commitment as also counselling and reassurance and follow up of all injuries should form a vital part of the PEP programme.

Sharps injury surveillance: Surveillance can be improved by standardizing the collection / analysis of data with improvised ways of reporting exposures and using with different denominators for rate-based reporting, e.g., person hours. Applying root-cause analysis for better understanding of long-standing problems as well as linking data collection to dissemination of study results.

NSIs can be regarded as preventable if a needle was used unnecessarily; a safer work practice could have prevented the NSI; a device was disposed of improperly. NSIs that are caused by patient-related factors (e.g., a patient moved while the needle was being used or removed) are usually considered non preventable.

Preventive interventions to prevent needle stick injuries occurring in the workplace include the following:

(i) Continued education and effective training This can be addressed in various ways starting with fostering collaborations with medical, dental, and nursing schools in educating students about sharps injury prevention and improving post-exposure management. Induction programmes in hospitals should be held once a month for all new recruits and an infection prevention awareness week should be held frequently where needle stick injuries and interventions to prevent these should be adequately discussed. The concept of universal precautions (UP) should be explained to all healthcare workers and steps taken to enforce them. Appropriate disposal of sharps and avoidance of recapping or bending should form an essential component of this training.

(ii) Organisational factors--Specific organizational issues may have an impact on sharps injury rates. Nurses who work in units with low nurse-to-patient ratios are more likely to report the presence of sharps injury risk factors and sustain sharps injuries. As a corollary to this, personnel in hospitals with good infection control practices in place, high professional-to-patient staffing ratios are more likely to follow safer sharps handling practices. Further, healthcare personnel are more likely to adhere to Universal Precautions when they perceive a strong institutional commitment to safety, and detect fewer job hindrances in complying with UP.

(iii) Safer needle devices (SNDs)--It is sometimes easier to change technology than human behaviour. Safety devices are being used in several hospitals in developed countries, and this has shown to reduce needle stick injuries (7). The incorporation of safer needle devices (SNDs) and better utilization of safety devices such as needleless sets, safety cannula, self-capping intravenous catheters, self retracting lancets for blood glucose monitoring, auto disposable syringes certainly help in reducing injuries but these come at a cost. SNDs today encompass a large variety that include safety syringes / needles for hypodermic devices, prefilled medication syringes, safety intravenous catheters and needle less intravenous systems, safety and closed-system blood-collection devices, safety blades, scalpels, suture needles, and surgical sharps protection devices, hemodialysis safety needle sets, etc. Cost effective, practical and local solutions which can be rooted in the system need to be accomplished.

Lastly, exposure to blood borne pathogens is a harsh reality that one has to comprehend and be committed to prevent. Clearly transmission of these potentially infectious pathogens can be minimized by adopting effective precautionary measures. As needle stick injuries are the commonest source of occupational exposures to blood and body fluids, we need imaginative thinking, diligent commitment, renewed advocacy, innovative funding and more efficient implementation.

References

(1.) Arnold B. Needle stick and other safety issues. Anesthesiology Clin N Am 2004; 22 : 493-508.

(2.) Jayanth ST, Kirupakaran H, Brahmadatan KN, Gnanaraj L, Kang G. Needle stick injuries in a tertiary care hospital. Indian J Med Microbiol 2009; 27 : 44-7.

(3.) Rele M, Mathur M, Turbadkar D. Risk of needle stick injuries in health care workers--a report. Indian J Med Microbiol 2002; 20 : 206-7.

(4.) Pery J, Parker G, Jagger J. EPINET report: 2003 percutaneous injury rates. Adv Exposure Prev 2005; 7 : 2-45.

(5.) Mehta A , Rodrigues C, Ghag S, Bavi P, Shenai S, Dastur F . Needle stick injuries in a tertiary care centre in Mumbai, India. J Hosp Infect 2005; 60 : 368-73.

(6.) Muralidhar S, Singh PK, Jain RK, Malhotra M, Bala M. Needle stick injuries among health care workers in a tertiary care hospital of India. Indian J Med Res 2010; 131 : 405-10.

(7.) US Public Health Service. Updated US public health service guidelines for the management of occupational exposures to HBV, HCV and HIV and recommendations for post exposure prophylaxis. MMWR Morb Mortal Wkly Rep 2001; 50 : 1-57.

Camilla Rodrigues

Department of Microbiology

PD Hinduja National Hospital & Medical Research Centre

Mahim, Mumbai 400 016, India

dr_crodrigues@hindujahospital.com
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Title Annotation:Commentary
Author:Rodrigues, Camilla
Publication:Indian Journal of Medical Research
Article Type:Report
Geographic Code:9INDI
Date:Mar 1, 2010
Words:1520
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