Needle Stick Injury: Needle Stick Injury: Epidemiology from a Epidemiology from a Hospital PerspectiveHospital Perspective

Dr Blánaid Hayes,Dr Blánaid Hayes,

Beaumont Hospital,Beaumont Hospital,

DublinDublin

Epidemiology of NSIEpidemiology of NSI

BackgroundBackground

Risk and probabilityRisk and probability

Epidemiology of BBV; global Epidemiology of BBV; global and localand local

International and local NSI International and local NSI statisticsstatistics

Challenges and Challenges and opportunitiesopportunities

BackgroundBackgroundDefinitionDefinition

An exposure that might place HCW at risk for HBV, An exposure that might place HCW at risk for HBV, HCV or HIV infection is defined as HCV or HIV infection is defined as

Percutaneous:puncture, abrasion or laceration Percutaneous:puncture, abrasion or laceration caused by needle or other sharp devicecaused by needle or other sharp deviceMucocutaneous: contact of mucous membrane or Mucocutaneous: contact of mucous membrane or non-intact skin with blood or potentially infectious non-intact skin with blood or potentially infectious body fluidbody fluid

LegislationLegislation Health and Safety Act 2005Health and Safety Act 2005 US: Needlestick Safety and Prevention Act of 2000US: Needlestick Safety and Prevention Act of 2000

ConsequencesConsequences Health (not negligible)Health (not negligible)

InfectionInfectionAnxietyAnxietyDrug S/EDrug S/E

Lifestyle restrictions (self and family)Lifestyle restrictions (self and family) CareerCareer Organisational costOrganisational cost Source patient testingSource patient testing

Impact:*Impact:* Globally, HCW population is ’large and their impact is Globally, HCW population is ’large and their impact is

felt everywhere’…35.7 million worldwide. felt everywhere’…35.7 million worldwide. Worthy public health target: provide care worldwide in Worthy public health target: provide care worldwide in

sophisticated and humble settings. Depended upon for sophisticated and humble settings. Depended upon for life sustaining services. life sustaining services.

Greatest risk is in countries of high prevalence where Greatest risk is in countries of high prevalence where PEP, patient treatments and safety technology are PEP, patient treatments and safety technology are unavailableunavailable

*Janine Jagger ICHE Jan 2007 Vol 28; No 1

Infections Transmitted by NSIInfections Transmitted by NSI

hepatitis B*hepatitis B*

hepatitis C*hepatitis C*

HIV*HIV*

herpes*herpes*

TBTB

MalariaMalaria

Dengue feverDengue fever

Rocky Mountain spotted feverRocky Mountain spotted fever

necrotising fasciitis (strep. A)necrotising fasciitis (strep. A)

Risk and ProbabilityRisk and Probability

RISK =

HAZARD X FREQUENCY

SEROPREVALENCE IN POPULATION & INFECTIVITY OF SOURCE

E XPOSURE NUMBER EXPOSURE SEVERITY

Perception of RiskPerception of Risk

Risk

RISK PERCEPTION

MYTH

Management

RISK = HAZARD + OUTRAGE (Peter Sandman)

BBV transmission to HCWBBV transmission to HCW

HBeAg + source = 30%HBeAg + source = 30%

HBeAg - source < 6%HBeAg - source < 6%

HCV + source HCV + source = = 0.5%0.5%

HCV PCR+ source = 10%HCV PCR+ source = 10% Australian study reviewed 29 Australian study reviewed 29

articles on transmission of HCV articles on transmission of HCV (vertical, via transplant / (vertical, via transplant / transfusion or NSI). No transfusion or NSI). No transmissions occurred from transmissions occurred from PCR negative sources (BMJ PCR negative sources (BMJ 1997)1997)

HIV+ (percutaneous) = 0.3%HIV+ (percutaneous) = 0.3%

HIV+ (mucocutaneous) = 0.09%HIV+ (mucocutaneous) = 0.09%

HIV transmission: risk factorsHIV transmission: risk factors

RISK FACTORRISK FACTORADJUSTED O/RADJUSTED O/R

deep injurydeep injury 16.116.1

visible bloodvisible blood 5.2 5.2

needle in vesselneedle in vessel 5.1 5.1

terminal illnessterminal illness 6.4 6.4

PEP /ZDVPEP /ZDV 0.2 0.2

Case control study of HIV seroconversion in HCWs NEJM 1997

Epidemiology of BBV Global vs LocalEpidemiology of BBV Global vs LocalHepatitis BHepatitis B

> 350 million worldwide> 350 million worldwideIrish notifications increased Irish notifications increased annually 1996-2005 but reduced annually 1996-2005 but reduced by 20% 2006by 20% 2006More prevalent in IDUs, More prevalent in IDUs, prisoners and immigrants (high prisoners and immigrants (high endemicity) endemicity) Details since 2004Details since 2004

820 notifications820 notifications 761 (93%) defined761 (93%) defined

668 (88%) chronic668 (88%) chronic93 (12%) acute93 (12%) acute

ASNR = +/- 20/100,000ASNR = +/- 20/100,000Typical acute HBV: young man, Typical acute HBV: young man, born in Ireland, sexually born in Ireland, sexually acquiredacquired‘‘Typical’ chronic HBV: from Typical’ chronic HBV: from countries of high endemicitycountries of high endemicity

Source: www.hpsc.ie

PrevalencePrevalence %%

HighHigh > 8> 8IntermediateIntermediate 2 – 72 – 7LowLow < 1< 1

Epidemiology of BBV Global vs Local Epidemiology of BBV Global vs Local Hepatitis CHepatitis C

170 million worldwide170 million worldwideNotifiable disease since Jan Notifiable disease since Jan 2004 (SI 707 of 2003)2004 (SI 707 of 2003)Irish ASIR = 36/100,000 (M>F Irish ASIR = 36/100,000 (M>F and HSE- E > than HSE and HSE- E > than HSE generally (rate rising)generally (rate rising)Risk factors:Risk factors:

Sharing needles etc ++++Sharing needles etc ++++ Unscreened blood / products +Unscreened blood / products +

++ Mother to baby, occupational, Mother to baby, occupational,

sexual +sexual +90% cases in developed 90% cases in developed countries current or former countries current or former IDUs or received unscreened IDUs or received unscreened blood / products blood / products Largely asymptomatic (90%)Largely asymptomatic (90%)

Source: www.hpsc.ie

Epidemiology of BBV Global vs LocalEpidemiology of BBV Global vs LocalHIVHIV

Global HIV burden= 42 millionGlobal HIV burden= 42 millionGlobally during 2005:Globally during 2005:

4.1 million new infections4.1 million new infections 2.8 million RIP AIDS2.8 million RIP AIDS

End 2006 > 4,400 cases End 2006 > 4,400 cases reportedreportedNew diagnosis not New diagnosis not representative of incidencerepresentative of incidenceRisk factors (2006) n=337Risk factors (2006) n=337

Heterosexual ++++ (50%)Heterosexual ++++ (50%) MSM ++MSM ++ IDUs +IDUs +

9% new cases are Irish born 9% new cases are Irish born heterosexuals (31 per year)heterosexuals (31 per year)

Source: Epi – Insight, Vol 8, Issue 10, October 2007

How big is the problem?How big is the problem?8 million HCWs in US 8 million HCWs in US Estimated US annual Estimated US annual figure is figure is 384,325384,325Add factor 0.31 (for Add factor 0.31 (for needles bought needles bought outside of hospitals = outside of hospitals = 503,466503,466Add another factor of Add another factor of 0.29 for all 0.29 for all mucocutaneous mucocutaneous injuries = injuries = 649,471649,471

100,000 in Ireland100,000 in Ireland

Crude estimate: Crude estimate: = = 48044804 p/a p/a

= = 6293 6293 p/ap/a

= = 8118 8118 p/ap/a

But neither set of figures takes any account of underreporting

How to interpret figures?How to interpret figures?

Difficulty comparing data Difficulty comparing data between countries and studies between countries and studies because of different formats because of different formats used for documenting rates:used for documenting rates:

Rate per 100 occupied bedsRate per 100 occupied beds Rate per 1000 health care Rate per 1000 health care

staff (WTE or other)staff (WTE or other) Rate for specific Rate for specific

occupationsoccupations Rate per person per annum Rate per person per annum

etc.etc.

One rate quoted by Jagger is 22 One rate quoted by Jagger is 22 per 100 bed p/a (previously 30 per 100 bed p/a (previously 30 per 100)per 100)

Local hospital rate tends to be Local hospital rate tends to be <20 per 100. <20 per 100.

CountryCountry YearYear JobJob RateRate ReportedReported

CanadaCanada 19901990 House staffHouse staff 0.7pp p/a0.7pp p/a <5%<5%

USUS 19951995 Stds/ house staffStds/ house staff 32% (6/12)32% (6/12) 11%11%

UKUK 19991999 AnaesthetistsAnaesthetists 50%50% 15%15%

UKUK 19991999 Med studentsMed students 33%33% 43%43%

*US*US 19981998 AllAll ?? 55% 55%

US (CDC)US (CDC) 19981998 All (14,000)All (14,000) ?? 42%42%Surgeons 27% Surgeons 27% Others 48%Others 48%

Saudi Arabia Saudi Arabia 20022002 AllAll 33/100033/1000 N/RN/R

TaiwanTaiwan 20022002 AllAll 87% (12/12)87% (12/12) N/RN/R

UKUK 20042004 AllAll 38% (12/12)38% (12/12) 51%51%

*US*US 20072007 Surgical traineesSurgical trainees 83% (in 5 yrs)83% (in 5 yrs) 49%49%

International Data on Incidence and Reporting Rates

Needlestick Injuries, According to Postgraduate Year

Makary MA et al. N Engl J Med 2007;356:2693-2699

Needlestick Injuries among Surgeons in Training NEJM 2007;356:2693-9

Behavior Associated with Nonreporting of the Most Recent Needlestick Injury

Makary MA et al. N Engl J Med 2007;356:2693-2699

Needlestick Injuries among Surgeons in Training NEJM 2007;356:2693-9

Study OverviewStudy Overview

Data from surgeons at 17 Data from surgeons at 17 US centres:US centres:

majority reported at majority reported at least one needlestick least one needlestick injury during traininginjury during training

half of the most recent half of the most recent injuries (including injuries (including many sustained in the many sustained in the care of high-risk care of high-risk patients) were not patients) were not reportedreported

An Irish Hospital’s Experience: who is at risk?An Irish Hospital’s Experience: who is at risk?

100303Total

8.5%26Others

13.5%41Non Clinical

28.5%86Medical

49.5%150Nursing

% TotalNumberOccupation

Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):

Where to they occur?Where to they occur?

+/-100332

25.7%85Other

8.1%26A&E

13.8%45Theatre

53.4%176Wards

% totalNumberLocation

Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):

% Immunity to Hepatitis B% Immunity to Hepatitis B

100332Total

8.8%29Non- immune

5.4%18Unknown

85.8%285Immune

%NumberHepatitis B Ab testing of injured HCWs

Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):

Test Results of Source PatientsTest Results of Source Patients

0.9%1.6%3.1%% Positive

128*Number

Positive

103(31%)119(35.8%)254(76.5%)Number

Tested

Hep B Surface Ag

HIV

Antibody

Hepatitis C

Antibody

* 5 of the 8 patients positive for hepatitis C Ab were also PCR +Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):

Procedure InvolvedProcedure Involved

ProcedureProcedure Number (%)Number (%)During procedureDuring procedure 72 (21.7)72 (21.7)

Immediately after procedureImmediately after procedure 104 (31.3)104 (31.3)

During disposalDuring disposal 42 (12.7)42 (12.7)

After improper disposalAfter improper disposal 92 (27.7)92 (27.7)

During instrument cleaningDuring instrument cleaning 9 (2.7)9 (2.7)

Other / not recorder/ unknownOther / not recorder/ unknown 13 (3.9)13 (3.9)

TOTALTOTAL 332 (100)332 (100)

What factors impact on injury and infection rates?What factors impact on injury and infection rates?

Higher rates of NSI:Higher rates of NSI: Teaching hospitals (vs Teaching hospitals (vs

others)others) Surgeons (vs physicians)Surgeons (vs physicians) Theatre (vs other areas)Theatre (vs other areas) Emergency (vs elective Emergency (vs elective

procedures)procedures) Less experienced staffLess experienced staff Low staff numbers and Low staff numbers and

moralemorale

Infection rates Infection rates reduced by:reduced by:

Hepatitis B vaccineHepatitis B vaccine PEPPEP HIV therapies have HIV therapies have

reduced viral load in reduced viral load in source patientssource patients

Double glovingDouble gloving

Hepatitis B vaccineHepatitis B vaccine

Currently recommended for Currently recommended for high risk groups:high risk groups:

Babies of infected mothersBabies of infected mothers CRF, haemophiliaCRF, haemophilia Occupational riskOccupational risk Close contacts Close contacts IDUsIDUs PrisonersPrisoners HomelessHomeless Heterosexuals / multipleHeterosexuals / multiple MSMMSM

NIAC in 2007 recommended NIAC in 2007 recommended addition of HB vaccine to addition of HB vaccine to primary childhood schedule. primary childhood schedule. To be introduced in Sept 2008To be introduced in Sept 2008

Source: www.immunisation.ie/en/Publications/PDFFile_14064

Solutions: what has been shown to Solutions: what has been shown to work to reduce frequency of NSI?work to reduce frequency of NSI?

Standard Precautions Standard Precautions / UPs/ UPsCin binsCin binsAvoiding re-sheathingAvoiding re-sheathingSafety technologySafety technologyLEGISLATIONLEGISLATION Do we need specific Do we need specific

legislation or a legislation or a directive in this country directive in this country to enforce a change in to enforce a change in practicepractice

ChallengesChallenges

Health care resourcesHealth care resources TrainingTraining Technology Technology Safety management systemsSafety management systems

Immunisation uptakeImmunisation uptake Senior cliniciansSenior clinicians Childhood immunisationChildhood immunisation

Organisational cultureOrganisational culture ComplianceCompliance ReportingReporting Macho-ismMacho-ism

Irish ‘psyche’Irish ‘psyche’ Ambivalent to authorityAmbivalent to authority AnarchicAnarchic FatalisticFatalistic

OpportunitiesOpportunities

Great strides have been made in hospital Great strides have been made in hospital hygienehygieneAccreditation and quality are ‘buzz words’Accreditation and quality are ‘buzz words’Clinicians and managers are more aware of Clinicians and managers are more aware of hidden costs of high risk practice hidden costs of high risk practice Hepatitis B vaccine is no longer just for limited Hepatitis B vaccine is no longer just for limited high risk groupshigh risk groupsSafety technology is no longer cost prohibitive Safety technology is no longer cost prohibitive and is user friendlyand is user friendlyTime to invest in a nationwide surveillance Time to invest in a nationwide surveillance system incorporating all exposures and not system incorporating all exposures and not just those occurring in hospitalsjust those occurring in hospitals

Take Home Message…….Take Home Message…….

Engineering solutionsEngineering solutionsManagers who are role models, senior clinicians who are Managers who are role models, senior clinicians who are ‘physician champions’, leading by example, monitoring ‘physician champions’, leading by example, monitoring etcetcPutting training and education at the top of the agenda Putting training and education at the top of the agenda and not as a dispensable item when times are toughand not as a dispensable item when times are tough