Needlestick Injury

Authors: Fraser Birse, Helen Mansfield / Reviewer: Lauren Fraser / Codes: C3AP7, IP4, SeP4, SLO1 / Published: 22/10/2020

 

Needlestick injury is a wound piercing the skin caused by a contaminated sharps instrument, most commonly a hypodermic needle. This session considers needlestick injuries in both healthcare workers (HCW) and members of the public. An occupational exposure occurs when a HCW is exposed to the blood or other bodily fluids of another person. Although particular attention must be paid to the exact nature of the exposure to determine the risk of transmission, needlestick injuries and exposure incidents in healthcare workers should be managed along similar lines.

The most significant risk from needlestick injuries and exposures is the transmission of blood borne viruses.

  • Human immunodeficiency virus (HIV)
  • Hepatitis B
  • Hepatitis C

Sexual exposure to blood borne viruses requires a similar process of risk assessment, appropriate testing, and decisions regarding post exposure prophylaxis (PEP). This is usually managed by sexual health services and is not included within the scope of this learning session.

Needlestick injuries and exposure incidents are an occupational hazard for healthcare workers. Reported incidence rates vary from country to country.

  • Public Health England received report of 8,765 significant exposures in healthcare workers between 1997 and 2018 (1).
  • In the UK they are most common among nursing staff, with up to 48% reporting having incurred one in their career (2).

The emergency department (ED) should provide initial assessment and treatment for HCWs incurring a needlestick injury who cannot access occupational health services directly. This usually means those presenting out of hours (3). Members of the public who incur a needlestick injury will often present to the ED. All patients should have immediate access to PEP 24 hours a day. It is common practice in hours for HCW to be sent directly to the local occupational health service.

Significant infective consequences of needlestick injuries are rare. The 2020 Public Health England ‘Eye of the Needle report’, considers 8,765 reported significant occupational exposures in healthcare workers in England, Wales, and Northern Ireland between 1997 and 2018 (1).

  • It identifies 23 cases of seroconversion to active infection of hepatitis C, all following hollow bore needle injury.
  • The only reported case of HIV seroconversion as a result of an occupational needlestick injury in a healthcare worker in the UK dates back to 1999.
  • There are no reported cases of hepatitis B seroconversion.

There is no such consistently recorded data on the consequences of needlestick injuries among the general public.

The risk of BBV transmission from needlestick injury is frequently quoted as (4):

BBV UK prevalence (%) Risk of transmission
Hep B <1 1:3
Hep C <0.5 1:30
HIV <0.3 1:300

Learning bite

HCWs and members of the public who incur a needlestick injury present directly to the ED. Emergency department clinicians should be familiar with how to risk assess, investigate, and manage them.

Risk assessment is a key part of the ED clinician’s role and determines subsequent management.

Is the fluid involved significant?

Significant fluids are:

  • Blood
  • Internal body fluids
  • Semen
  • Vaginal secretions
  • Saliva (dentists)

NOT urine or faeces.

Was the nature of the exposure significant?

Incidents considered to be significant include:

  • Percutaneous injury from anything that breaks the skin ie. needles, instruments, bone fragments, bites.
  • Splash exposure to broken skin, abrasions, wounds, eczema etc.
  • Splash exposure to mucous membranes, most commonly the eye.

Four factors are associated with an increased risk of occupationally acquired HIV infection after needlestick injury (5).

  • Deep injury.
  • Visible blood on the device involved.
  • Injury from a needle that has entered the source’s blood vessel.
  • Terminal HIV-related illness in the source.

There is insufficient evidence to suggest double – gloving for procedures reduces the risk of sharps injury (6).

Is the source high risk?

Does the source patient have any previous results for HIV, hepatitis C, or hepatitis B?

The following factors would place the source in a high risk category:

  • Intravenous drug user.
  • Sex industry worker.
  • Originally from sub-Saharan Africa.
  • Regularly has unprotected sex with any of the above.
  • If the source is a child, they are high risk if their mother has HIV.
  • The source has, or is under investigation for, an AIDS defining illness.

If the source patient is unknown, then the usual approach is to assume a low risk exposure.

Learning bite

Risk assessment must take into account both the nature of the exposure and the risk profile of the source patient.

The injured HCW should have blood sent for a sample to be stored for further testing if it becomes necessary.

Blood should be taken from the source patient, if known, for:

  • Hepatitis B surface antigen.
  • Hepatitis C antibody.
  • HIV antibody.

The  Department of Health recommends that all hospitals have the capacity to obtain an HIV test result ideally within 8 hours, and no more than 24 hours after blood is taken, to limit the exposure to anti-retroviral medication in the injured HCW (7).

Sending the above tests from the source patient of course relies on obtaining appropriate consent.

Consent

The source patient should not be approached by the exposed healthcare worker.

Sensitive discussion is sometimes needed to explain the process, how and with whom the test results will be shared, and the impact of positive results in terms of future health implications and health or life insurance policies.

The BMA has published specific guidance on testing adults who lack capacity (8). The guidance states that all decision making should follow a structured process. It should not be undertaken without considering several key points, which include:

  • If a patient is expected to regain capacity before a decision on testing is needed, it should not happen until consent is obtained.
  • If a relevant advanced decision to refuse treatment is not in place:
    • In England, Wales, and Northern Ireland the doctor must assess whether testing is in the best interests of the patient.
    • In Scotland the doctor must assess whether testing will benefit the patient and is reasonable in the circumstances to safeguard or promote their physical or mental health.
  • In England, Wales and Northern Ireland, where there is no potential clinical benefit to the patient, in the absence of evidence otherwise, it is safe to assume that patients would want to ‘do the right thing’. In the same circumstance in Scotland it is not clear that the legislation would support the same approach.
  • If the patient regains capacity, they should be informed that the test has been taken and provided with enough information to decide whether to receive the results.

Learning bite

Obtaining consent to test the source should be done by a doctor not involved in the needlestick injury. In patients without capacity the decision to test should be carefully considered and documented.

Immediate management

Following all needlestick injuries or exposures, regardless of whether the exposure is from a source known to be high risk, the following steps should be taken:

  • Wash the site liberally with soap and running water. Antiseptics or skin washes should not be used as their effect on local immunological defenses is not known and there is no evidence that they are more effective.
  • Puncture wounds should be encouraged to bleed freely but should not be sucked.
  • Any exposed mucous membranes should be irrigated liberally with water. In the case of conjunctivae this should be before and after the removal of contact lenses.

HIV post exposure prophylaxis

If the source is known to be HIV positive or assessed as high risk, PEP should be considered. The decision to start treatment must incorporate the injured healthcare worker’s perception of risk. Nationally, the risk of transmission is no more than 0.3%. Local departmental guidelines may include guidance on local risk based on the local incidence of HIV.

If the source patient is known to be HIV positive and their viral load is known this can further inform the decision. The Chief Medical Officer’s Expert Advisory Group on AIDS advise that if the source’s viral load is undetectable (<200 copies HIV RNA/ml), PEP is not recommended. Although there may still be a theoretical risk of transmission, it is extremely low. PEP should still, however, be offered to those who are anxious about the risk (9). If the assessing clinician or patient require further guidance on assessing or discussing risk, seeking advice from the infectious diseases or microbiology team maybe appropriate.

If HIV PEP is to be prescribed, it should be started as soon as possible after exposure, ideally within 1 hour. It is not recommended beyond 72 hours post exposure (7).

Emergency departments should have packs containing a 3-5 day supply of PEP (remember to account for weekends and bank holidays) available to dispense immediately. Packs should contain, in line with DoH guidance (10):

  • Truvada (245mg tenofovir and 200mg emtricitabine) once daily.
  • Raltegravir 400mg twice per day.

Remember that this presentation is likely to be out of hours, and a source of some concern for the healthcare worker. Provide some written information for reference at home about PEP, such as the information leaflet produced by the HIV Pharmacy Association (11).

Don’t forget to consider:

  • HIV PEP should not be taken with rifampicin.
  • It should be taken at least 4 hours after taking any vitamin supplements, or calcium, iron, and magnesium supplements.
  • Patients using oral contraception should be advised to use barrier contraception while taking PEP and awaiting results.
  • If pregnancy cannot be excluded then a pre-treatment pregnancy test should be performed, but pregnancy should not preclude the use of PEP. There is no evidence to suggest decreased efficacy or toxicity, and HIV PEP is commonly used during pregnancy.

Hepatitis B post exposure prophylaxis

Hepatitis B PEP is in the form of an accelerated course, or booster dose of the hepatitis B vaccine, with or without hepatitis B immunoglobulin (HBIG). The table below, adapted from chapter 18 of the Public Health England Green Bookprovides a summary of the recommended management (12).

HBV status of exposed person   Significant exposure Non-Significant exposure
HBsAg positive source Source unknown HBsAg negative source Continued risk No further risk
Unvaccinated

Accelerated hep B vaccine course

 

HBIG with first dose

Accelerated hep B vaccine course Consider course of hep B vaccine Start course of hep B vaccine No hep B prophylaxis
Partially vaccinated One dose of hep B vaccine and finish course One dose of hep B vaccine and finish course Complete course of hep B vaccine Complete course of hep B vaccine Complete course of hep B vaccine
Fully vaccinated with primary course Hep B vaccine booster if last dose ≥1year ago Consider hep B vaccine booster if last dose ≥1year ago No hep B prophylaxis No hep B prophylaxis No hep B prophylaxis
Known non-responder to hep B vaccine

HBIG

 

Hep B vaccine booster

 

Second dose of HBIG at one month

HBIG

 

Consider hep B vaccine booster

 

Second dose of HBIG at one month

No HBIG

 

Consider hep B vaccine booster

No HBIG

 

Consider hep B vaccine booster

No hep B prophylaxis

Hepatitis B Immunoglobulin 

Hep B Immunoglobulin is administered as an intramuscular injection. The doses are as follows:

  • Adults and children over 10 years of age – 500IU.
  • Children 5-9 years of age 300IU.
  • Newborn and children 0-4 years of age 200IU

HBIG provides passive immunity and can give immediate but temporary protection. It does not have any effect on long term active immunity. It is prepared from donated plasma of immunised and screened human donors and is usually available via the blood transfusion service.

Hepatitis B vaccination

The hep B vaccines available are Energix B and HBVaxPRO.  As with HIV PEP medications Hep B vaccine should be available in the ED. An accelerated course of hep B vaccine consists of doses at 0, 1, and 2 months.

Vaccine product Ages and group Dose Volume
Energix B 0-15 years 10ug 0.5ml
Energix B 16 years and over 20ug 1.0ml
Fendrix Renal insufficiency and 15 and over 20ug 0.5ml
HBvax PRO Paediatric 0-15 years 5ug 0.5ml
HBvax PRO 16 years and over 10ug 1.0ml
HBvax PRO40 Adult dialysis and pre-dialysis patients 40ug 1.0ml

Hepatitis C

There is currently no PEP for hepatitis C. If a source patient is found to be hep C positive, this will be managed by the occupational health service following up with the healthcare worker.

There is a significant rate of hepatitis C co-infection in those who are HIV positive, particularly in intravenous drug users, with 82% of HIV infected individuals also co-infected with hep C (13).

Reporting incidents is important not only to prompt appropriate individual management, but also to ensure local practices are reviewed to minimise the risk of subsequent occupational injury.

There is a significant rate of under-reporting of needlestick injuries and exposures. This as high as 50% in the US and 26.9% in Sweden (14,15).

Reasons for lack of reporting among healthcare workers include (16):

  • They presume risk of disease transmission is low.
  • There is a lack of knowledge of systems for reporting, or local protocols are complicated or unclear.
  • There is a lack of knowledge of the importance of reporting.
  • There is a belief that reporting an injury may reflect badly their standards of practice.

Learning bite

Needle stick injuries are underreported. After initial first aid is complete PEP should be prescribed according to risk assessment and local protocol.

Members of the public can also come into contact with contaminated needles and sharps. RCEM recommends that the ED should provide initial care to all patients presenting with needlestick injuries sustained in the community (3).

  • Hypodermic needles may be intentionally shared among intravenous drug users.
  • Discarded needles may be encountered in public spaces or the home.
  • Inappropriately disposed needles and sharps may be encountered in any activity that involves handling waste.

In most cases, when a potentially contaminated needle has been encountered by accident, it will not be possible to ascertain:

  • Whether the needle is contaminated and what it has been used for.
  • The BBV status of the source.
  • The time between the needle use and the needlestick injury.

Investigations

Blood should be sent from the recipient for:

  • Hepatitis B surface antigen.
  • Hepatitis C antibody.
  • HIV antibody.

In some circumstances the donor patient may also present to the ED and be willing to undergo investigation. If their BBV status is unknown, following appropriate consent, their blood should be sent for the same investigations. Results may be available within hours. If awaiting results will not exceed the 72 hour window for HIV PEP, and a reliable route for potentially same day follow up can be arranged, it may be appropriate to delay making treatment decisions until the source’s results are available.

HIV

Once blood has dried, HIV becomes non-viable within 2 hours. In general HIV PEP is not recommended following an accidental community needlestick injury.

When needle sharing has occurred, a risk assessment considering the likelihood of the individual being HIV positive must be carried out. In the UK this would include:

  • Men who have sex with men.
  • Originally from sub-Saharan Africa.
  • Intravenous drug user from a country where there is a high prevalence of HIV among IVDUs.

The UNAIDS GAP Report considers how HIV prevalence among intravenous drug users varies from country to country. The prevalence is particularly high in Eastern Europe and Central Asia (17).

The BASHH HIV PEP guideline summarises recommendations for PEP use in needlestick injury in the community and needle sharing. These are adapted below (18):

Vaccine product Ages and group Dose Volume
Energix B 0-15 years 10ug 0.5ml
Energix B 16 years and over 20ug 1.0ml
Fendrix Renal insufficiency and 15 and over 20ug 0.5ml
HBvax PRO Paediatric 0-15 years 5ug 0.5ml
HBvax PRO 16 years and over 10ug 1.0ml
HBvax PRO40 Adult dialysis and pre-dialysis patients 40ug 1.0ml

HIV PEP prescription follows the same principles as those applied to healthcare workers. The prescription should consist of:

  • Truvada (245mg tenofovir and 200mg emtricitabine) once daily.
  • Raltegravir 400mg twice per day.

Remember:

  • It must be prescribed within 72 hours of exposure.
  • A 3 day supply is common but enough must be given to cover the period until follow up will be accessed.
  • Provide sufficient written information, such as the HIV Pharmacy association leaflet.
  • It should not be taken with rifampicin.
  • It should be taken at least 4 hours after vitamin supplements, or calcium, iron, and magnesium supplements.
  • A pregnancy test should be performed when indicated but pregnancy should not preclude the use of HIV PEP.
  • Patients using oral contraception should be advised to use barrier contraception while taking PEP and awaiting results.

Hepatitis B

Hepatitis B PEP should be prescribed and administered following the table consulted for needlestick in healthcare workers.

The hep B vaccine has been part of the routine vaccination schedule from the 1st of August 2017. Anyone born before then will only have had the vaccine if they are in a high risk group and have requested it, or been offered it by their GP or a sexual health service.

The first dose of the vaccine should be given in ED if indicated, and subsequent doses arranged via the patient’s GP.

  • Pending investigation results and follow up any patient considered to have had a high risk exposure should be advised to:
    • Use barrier contraception for any sexual contact, but does not otherwise need to adjust their activity in any way.
    • Avoid sharing razors and toothbrushes.
    • Not donate blood until results are back.
  • Healthcare workers can continue to undertake procedures at work as normal provided they adhere to usual PPE requirements.

The ED clinician’s role will end after risk assessment, initial investigations, and provision of PEP where appropriate.

The exposed HCW should be encouraged to contact their local occupational health team as soon as possible to arrange further follow up.

Follow up for those presenting to ED from the community may differ trust by trust. It may be carried out by the local sexual health service, by the trust’s infectious disease team, or by the patient’s GP. It is vital that ED guidelines clearly state who will be responsible for follow up, and that there is a reliable and sufficiently fast referral pathway.

  1. Public Health England. Eye of the Needle Report. 2020. [accessed May 2020]
  2. Royal College of Nursing. Needlestick injury in 2008: results from a survey of RCN members. 2008.
  3. Royal College of Emergency Medicine Clinical Effectiveness Committee. Emergency department care of patients who have been potentially exposed to blood borne viruses by needlesticks – a position statement.  2013 [accessed May 2020]
  4. Health and Safety Executive. Risk to Healthcare workers. [accessed May 2020].
  5. Cardo DM, Culver DH, Ciesielski CA, et al. A Case–Control Study of HIV Seroconversion in Health Care Workers after Percutaneous Exposure. N Engl J Med 1997; 337(21):1485-1490.
  6. Tort S and Burch J. Do gloves, extra gloves, or special types of gloves help prevent percutaneous exposure injuries among healthcare personnel. Cochrane Clinical Answers 2020.
  7. Department of Health. HIV post-exposure prophylaxis: guidance from the UK Chief Medical Officers’ Expert Advisory Group on AIDS. 2008. [accessed May 2020].
  8. British Medical Association. Needlestick injuries and blood-borne viruses: testing adults who lack capacity. 2020. [accessed May 2020].
  9. Expert Advisory Group on AIDS. Updated recommendations for HIV post-exposure prophylaxis following occupational exposure to a source with undetectable HIV viral load. 2013. [accessed June 2020].
  10. Expert Advisory Group on AIDS. Change to recommended regimen for post -exposure prophylaxis. 2014. [accessed May 2020].
  11. HIV Pharmacy Association. Expert Advisory Group on AIDS PEP information pack. 2018. [accessed May 2020].
  12. Public Health England. Hepatitis B: the green book, chapter 18. 2013.  [accessed June 2020].
  13. Platt L, Easterbrook P, Gower E, et al. Prevalence and burden of HCV co-infection in people living with HIV: a global systematic review and meta-analysis. The Lancet Infectious Diseases. 2016;16(7):797-808.
  14. The National Institute for Occupational Safety and Health (NIOSH). Stop Sticks Campaign. [accessed May 2020].
  15. Voide C, Darling K, Kenfak-Foguena A, et al.  Underreporting of needlestick and sharps injuries among healthcare workers in a Swiss University Hospital. Swiss Med Wkly. 2012 10;142:w13523
  16. Cooke CE, Stephens JM. Clinical, economic, and humanistic burden of needlestick injuries in healthcare workers Medical Devices. 2017; 10:225-235.
  17. UNAIDS. The GAP Report. People who inject drugs. 2014. [accessed May 2020].
  18. Cresswell F, Waters L, Briggs E, et al. UK guideline for the use of HIV Post-Exposure Prophylaxis Following Sexual Exposure. International Journal of STD and AIDS 2016; 0(0):1-26

12 Comments

  1. Mrs. Cheryl Ann Barnes says:

    This learning was really helpful thank you

  2. Daniel Dutfield says:

    Useful read

  3. Dr. Mohammed Abdelghani Siddeeg Fgeer says:

    Very helpful, thanks.

  4. Dr. Mehdi Hassan Teeli says:

    Good summary

  5. Mahmoud Shagabi says:

    very good

  6. Dr. David Jonathan Jones says:

    The algorithm is really helpful. Thanks

  7. Dr. Kenneth Onyedikachi Igwe says:

    very good especially defining clearly what is expected of the ED doctor.

  8. Kerry Chaplin says:

    Very informative

  9. Dr. Ivan DSouza says:

    Excellent module

  10. Olubusola says:

    Excellent module. A refresher for me

  11. Sahithi Tirumala Sundarraj says:

    Very helpful. Thank you.

  12. Can Ozen says:

    A very precise and practival summary of needlestick injuries.

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