Occupational Medicine and Needle-Stick Injuries

Cass Djurfors

October 10, 2002

Objectives:

Define Occupational Exposure Review Infection Control Measures Needlestick Injuries: risks

HIV Hepatitis C Hepatitis B

Post-exposure prophylaxis Latex Allergy

Occupational Exposure:

Occupational Safety and Health Administration (USA): a “reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of the employee’s duties.”

Occupational Exposure

At risk groups: Health Care Workers: nurses, physicians, dentists,

dental workers, lab and blood bank technologists, medical examiners, phlebotomists, ED personnel, intensive care and operating room technicians, orderlies, housekeeping staff, laundry workers

Non Health Care Workers: law enforcement, fire, rescue, EMS, correctional facilities, research lab workers, funeral industry employees

At risk activities:

Intravenous access Phlebotomy Recapping of

needles Specimen handling Med injection Lumbar puncture Chest tube insertion

Suturing Ng and og

placement Intubation Urinary catheter

insertion Hemorrhage control Any airborne or

direct contact

Infectious Agents:

Parenteral: HIV, Hepatitis B and C Airborne/droplet: measles, varicella, TB, H.

flu, N. meningitidis, pertussis, adenovirus, influenza, mumps, rubella, the plague and others

Contact: C. difficile, pediculosis, scabies, diphtheria, HSV, enteric organisms (E. coli, Hepatitis A, etc.), RSV, viral hemorrhagic infections (Ebola, Lassa, Marburg) and others

Infection Control Measures:

Although risk estimation may be made by history, there is no reliable method of identifying all infectious patients, therefore…

Universal Precautions!!!

Infection Control:

Handwashing Cleaning, sterilizing and disinfecting of patient

care equipment and exposed surfaces Laundering of contaminated uniforms,

clothing and linens Proper sharps and infectious waste disposal Appropriate isolation and patient placement

Infection Control:

Personal Protective Equipment (PPE): Gloves Masks Eye protection Face shields Gowns/aprons

Needlestick Injuries:

Exposure is common: 52% of health care workers report at least one prior exposure, 24% within the preceding year

Under-reported: estimates suggest that only 10% of exposures are actually reported

US National Surveillance of Occupational Exposure to HIV: Exposure by Occupation (‘96)Nurse Therap

ist or tech

Student/resident

Lab tech Physician

Other Total

Needlestick

281 15 20 26 20 16 378 (60%)

Surgi-cal

18 0 3 6 3 5 351 (6%)

MM 44 6 1 9 4 4 68 (11%)

Intact Skin

5 1 0 2 2 4 14 (2%)

Non-intact

59 5 1 4 4 7 88 (14%)

Unknown

34 3 0 0 0 4 43 (7%)

Total 441 (70%)

30

(5%)

25

(4%)

57

(9%)

33

(5%)

40

(7%)

626 (100%)

High Risk Groups:Slide courtesy of Dr. Ian Walker

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US National Surveillance of Occupational Exposure to HIV: Preventable Exposures (to ‘96)Description of Exposure

Number of Workers

Percent

Recapping a used needle

5725%

Improper disposal of a used needle

44 20%

Skin contact 122 55%

Total 223 100%

HIV: The Risk

Generally reported in the literature as 0.3% on average for a percutaneous exposure

Mucous Membrane: 0.1% Skin exposure: <0.1%

Seroconversion has been reported with non-intact skin. No reported events have occurred with intact skin although a theorectical risk remains.

HIV: Southern Alberta StatsCourtesy of SAC

Canadian HIV Statistics:

HIV Risk Assessment: Needlesticks

Risk is increased by: High viral load in source patient Deep injury Volume of blood/visible blood on device Death of source patient of AIDS in 60 days Gauge of needle Procedure involving an artery or vein

Post Exposure Prophylaxis The evidence:

1994 study showing that zidovudine administered to an HIV-infected mother during pregnancy and labour, then to the infant post-partum reduced the risk of HIV transmission to the baby from 25% to 9% (67% relative risk reduction)

Case-control study of HCWs the showed zidovudine PEP reduced seroconversion by 79% (however, ARR=0.24, NNT=417)

PEP has had documented failures

When to give PEP?

Most effective within 1 to 2 hours post-exposure.

May be given up to 72 hours post. Consider it for anyone who has received

a percutanous or acute sexual exposure Start ASAP and continue for 4 weeks

Who gets PEP? The current SAC (and CDC) guidelines

state: “Prophylaxis is recommended for incidents with

highest or increased risk of transmission following percutaneous exposure to blood. Prophylaxis is not offered for percutaneous skin exposure to non-bloody body fluids. In other situations of intermediate risk, prophylaxis is offered and the decision rests with the individual to make a decision whether to initiate prophylaxis based on the best information available and their personal acceptance of risk.”

PEP: the drugs

Basic Regimen: Combivir (AZT 300mg + 3TC 150mg) bid

Expanded Regimen: Basic Regimen + Nelfinavir 1250mg bid

Other: consider other drugs for source patients

already on antiretrovirals or for patients with a known resistant virus

Who gets What? Basic regimen is given to most exposures Expanded regimen is prescribed in

consultation with ID for those patients with significant exposure to known HIV +ve source

Studies done with AZT alone, but 3TC is added out of concern for resistance and from known superiority in treatment of HIV+ patients

Current SAC Guidelines1 Is the source known HIV+?

Yes: proceed to step 2 of protocol No:

Test source (with consent) using rapid point-of-care HIV test available through CLS at any Emergency Room or 8th and 8th health centre

If negative, and no risk of “window period”, reassure If source unknown or refuses testing and has risks

for or symptoms of HIV, proceed to step 2 of protocol Consider source testing for HBV, HCV

Current SAC Guidelines

2 Timing and Type of Exposure: Assess fluid type, volume, viral titre, mode

of exposure. Assess exact timing of exposure

3 Decision: Make a decision for or against PEP based

on risk assessment

Current SAC Guidelines

4 Drug Selection Basic Regimen for most exposures Expanded regimen for significant exposure

to a known HIV+ source (concern is that a resistant organism may have been transmitted)

If the source patient is already on antiretrovirals or has a virus with know resistance, alternative drugs may be used

Current SAC Guidelines

5 Duration of Prophylaxis: Start ASAP and continue for 4 weeks

6 Adverse reactions: 88% with two-drug prophylaxis 97% with three-drug prophylaxis Majority are GI: N/V/D and can be managed

with antiemetics/antidiarrheals Long-term adverse effects such as

lipodystrophy and DM are rare with PEP

Current SAC Guidelines

7 Access and Cost: Starter kits contain 72 hours of drugs Free for occupational exposure and non-

voluntary or violent (assault) exposures Non-occupational voluntary exposures

(needles or sex): PEP is available, but cost not absorbed by CHR

Current SAC Guidelines

8 Follow-up: Baseline HIV, HBV, HCV, CBC, Cr, and

LFTs should be done in recipient Follow-up with ID at HPTP clinic within 72

hours HIV testing at 6 wks, 12 wks, 6 months

Current SAC Guidelines9 Other considerations:

For occupational exposures: WCB Physician’s First Report Employee Accident Report form #00169

Prevent transmission while in 6 month window period: Abstain from intercourse or use condoms Avoid pregnancy Discontinue breastfeeding Do not donate blood, plasma, organs, tissues... Do not share toothbrushes, razors, needles etc.

When to Speak to ID

Source patient already on antiretrovirals or has known resistant virus

Delayed exposure Significant renal or hepatic disease Unknown source Pregnant or breast feeding patients

Rapid Point-Of-Care Testing

CLS test: Sensitivity and Specificity both 99.9%

Current turn around time 1 hr 24 min Confirmed by Western Blot at Prov Lab Can be done as an “add-on” to serum

sample Legal and ethical issues involving

incompetent, unconscious or dead patients

Hepatitis C

Virus discovered in 1988 First immunoassay for anti-HCV available in 1990 Most common chronic blood-borne infection in USA (1-2%

of general population, prevalence no higher in health care workers)

Acute infection usually asymptommatic Persistent infection develops in >85% Chronic hepatitis in 60-70% Cirrhosis in 10-20% Severity and progression of disease influenced by EtOH,

increasing age at time of infection, male sex, immunodeficiency

Hepatitis C Prior to 1990: blood and blood product

transfusion responsible for 90% of infections Today:

risk with transfusion < 1 in 100 000 per unit IVDU most common risk factor (60% of

infections)

Average seroconversion rate with sharps exposure is 1.8%

No PEP available

Hepatitis B

Adult infections: 95% resolve spontaneously 5% develop chronic hepatitis

Neonatal infections: 90% progress to chronic infections

Hepatitis B

Vaccine available since 1982 Unclear need for booster - consider at 10 years

post immunization Passive immunity available as HBIG:

indicated for both unimmunized adults and neonates post exposure

Give within 12 hours

Risk of seroconversion with needlestick: 20% if source is HBSAg +ve 66% is source is HBSAg +ve and HBeAg +ve

Hepatitis D

Co-infection with HBV or superinfection with chronic HBV carriers

Worsens severity of HBV illness

Latex Allergy

Latex: milky cytosol from rubber tree (Hevea brasiliensis)

Gloves, IV tubing, intravascular balloon catheters, airways, endotracheal tubes, oxygen masks, tourniquets, blood pressure cuffs, ECG leads, tape, dressings

Latex Allergy

Immune reactions may be irritant contact dermatitis (type IV) IgE (type I)

Latex Allergy

Higher risk workers: multiple allergies eczema multiple food allergies (banana, avocado) frequent surgical or dental procedures multiple urogenital procedures spina bifida congenital urinary anomalies sensitivity to ethylene oxide

Thank you’s…

Dr. Ian Walker SAC FMC Pharmacy Tintinalli www