NEEDLE STICK INJURY AND POST EXPOSURE PROPHYLAXIS NARRATION
Slide 2
Description of the types of injury and exposure which can put us at a risk of getting infected with blood borne pathogens like HBV, HCV and HIV.
Slide 3
Photograph of poorly introduced cannula and reference to HIV in healthcare workers.
Slide 4
List of infections that can be transmitted by sharps injury.
Slide 5
Graph showing the estimated risk of infection by the commonest three blood borne pathogens from an infected source to healthcare professional. If the source was infected with HBV then there is a 30% chance that the healthcare professional will develop Hepatitis B infection. The same is for Hepatitis C and HIV. But the fear in our minds is converse more for HIV and less for Hepatitis B & C.
Slide 6
Description of the causes increasing risk of transmission of blood borne pathogens due to NSI.
Slide 7
At risk type of exposures. In a Percutaneous injury the risk is more from hollow needles with visible blood if the injury is deep or the device is introduced directly into the vein or Artery. In a splash on a non intact skin or mucous membrane has the highest risk. The risk is high if the exposure is to large volume of blood and body fluids or the injury is severe.
Slide 8
Line diagram showing different types of infectious body fluids.
Slide 9
NSI occur most commonly when we are trying to recap needles either before injection or after injection. When we carry needles in a tray from one point to another without the cap on due to sudden movement of patients in an attempt to withdraw away we prick ourselves or any other person standing nearby. Inappropriate disposal like throwing away casually in the dustbin or in isolated corners can prick us or any other person who steps on them.
Slide 10
The basic interventions which can prevent needle stick are having a proper layout of the injection OPD or our office area. Minimizing the handling of injection equipment by not carrying them from one point to another in bare hands by not recapping and trying to bend the needle after giving the injection. Proper cleaning of the OPD pre and post can also minimize the chances of infection being spread. Safe disposal as per GOI recommendations is also imperative.
Slide 11
Standard precautions for safety of self and primary prevention of needle stick injury are thorough Hand washing before each procedure taking care that the web spaces and creases are properly cleaned. Barrier protection using gloves gives added protection. Studies have shown that the incidences of NSI in the same with a single pair of gloves or no gloves, it is with the double gloves that the incidence dramatically falls. Proper techniques of giving injections minimize NSI to a great degree. Safe handling of all Sharps (broken glass, blades, needles, etc) and Biological specimens including blood and body fluids (peritoneal fluids, urine, etc), and usage of disposable or presterile equipment minimizes the chances of spread of blood borne pathogens.
Slide 12
Immediate management of NSI is one of the most important steps in the long process of efforts to minimize chances of spread of BBV due to sharps injury. Immediate cleaning of the injury site followed by washing of skin wounds with soap and running water is of paramount importance. Mucous membranes are flushed thoroughly with water and eyes irrigated with a liter of saline at least. There is no evidence that antiseptics and disinfectants have any role.
Slide 13
A general guide line for PEP is given in this slide and will be dealt in detail in following slides.
Slide 14
This slide shows the risk of Hepatitis B after an NSI and is dependant on the HBeAg status of the person affected. Incidence of clinical Hepatitis will be high if both surface and envelope antigens are positive. Percentage of seroconversion is higher when both are positive and a bit low when only surface antigen is positive. It is also known that the hepatitis B virus can survive and remain active a dried blood clot for up to a week at room temperatures. It is also highly sensitive to commonly available disinfectants and sterilization procedures.
Slide 15
The good news about Hep B immunization in health care professionals is that those who have taken all the doses of vaccine at the right interval and have responded to the immunization have virtually complete protection. The bad news is that a lot of health care professionals are still not immunized. The level of response to the antigen comes down with increasing age. 6 to 10 percent of vaccines do not develop antibodies, in these it is imperative   to repeat the vaccine series still only 30 to 50 percent of non responders develop immunity. CDC in the US estimate that 50 to 75 health care professional die every year due to complication of Hep B infections acquired due to sharps injury.
Slide 16
Management of health care professionals exposed to Hep B infection is as follows
1. All vaccinated health care professionals have to get a serum antibody titer done. If it is more than 10 IU/ ml no additional treatment is required if below this and the source patient is HBsAg negative a new series of vaccines is given. If HBsAg positive then a complete series of vaccine started with initial dose of HB immunoglobulin and booster given later.
2. If not vaccinated than immediate vaccine series to be started within seven days of injury.
Slide 17
PEP of Hep C is relatively simple as immunoglobulins are not very effective and interferons have not been recommended for prophylaxis. The anti HCV status of source should be determined if possible and HCP tested immediately and at 6 months for both LFT and anti HCV.
Slide 18
CDC has proposed post exposure counseling of all HCP who have been exposed Hep B or C due to NSI. The given chart is self explanatory.
Slide 20 to 31
The rationale for PEP is to block the dendritic cells before they can get infected with HIV and halt viral replication before it becomes systemic. Studies have shown that the risk of seroconversion is significantly lower in HCP who have taken immediate PEP. Mother to child transmission is also negligible if immediate treatment is started. PEP should be started within 2 to 8 hours of exposure for maximal benefit. Delays in starting PEP may prove costly in the long run. The risk of HIV infection depends on the type of exposure the highest incidences is because of NSI and 0 incidences if contact with intact skin. NACO has for purposes of scientific management of NSI coded the type and severity of exposure to infected blood and body fluids into three. They have also classified the source of infection based on the HIV status, CD4 counts and viral load into three. A combination of the severity and type of exposure coupled with the HIV status of the source patient determines, what treatment regime has to be followed. The Available antiretrovirals are grouped in to two regimes the basic regimes and the expended regime. Generally the basic regime is two drug regime given for a period of 4 to 6 weeks. The expanded regime adds one more drug to the Basic regime. Improper and intermittent treatment has started to throw up resistance to the PEP .In pregnant HCP PEP started immediately to stop any chances of mother to child transmission. Most of the HCP seroconvert within 6 to 12 weeks, co infection with HCV delays seroconversion to HIV. The average time from exposure to symptoms is 2 to 6 weeks but in 50 to 90% cases acute symptomatic seroconversion develop.
Slide 32
The conclusion that can be drawn from this presentation is that all health facilities should have are reporting set up we have to keep updating ourselves on all aspects of PEP. Start up packs should be available with the nearest reporting centre and these are provided by NACO on demand.The psychological impact of the NSI is enormous so we should be prepared for type of reaction. Patience and understanding is one of the best PEP available.
Slide 33
Finally to reiterate LET ALL BE NEEDLE SMART.