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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
02468
10121416
RN's
Steril
izat
ion A
ttendan
t
MD (S
pecia
list)
Resid
ents
Phleboto
mis
t
Nuclar
Med
Tec
h
Rates per100 FTE's
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