Needlestick

What is Needlestick?

Needlestick injuries happen when health care workers accidentally stab themselves with a needle. These injuries are risks that many health care workers face, especially in North America where millions of needles are used every day. Although we have made progress in reducing these injuries with safer needles and universal precautions, they still happen occasionally, though less frequently than in previous years.

Becoming aware of needlestick injuries became a priority in the early 1980s following the discovery of HIV. These days, while HIV is still a concern, it’s more common for a needlestick injury to result in hepatitis B or hepatitis C. To address these situations, guidelines have been put in place to help healthcare institutions quickly respond to and manage needlestick injuries. This includes deciding when to start HIV treatment after exposure. The Centers for Disease Control and Prevention (CDC) has even developed a model to help health care professionals decide when to start this type of therapy.

Keep in mind that needlestick injuries are mainly occupational hazards for those working in healthcare. Despite safety precautions, the injuries still happen, especially among surgeons, emergency room staff, lab technicians, and nurses. Generally, these injuries happen due to unsafe practices or carelessness from health care workers. Yet, most of these injuries are preventable if the established procedures are followed.

While needlestick injuries have decreased since universal precautions were adopted, they are still a major concern. Instead of HIV, however, diseases like hepatitis B and hepatitis C are the common threats after a needlestick injury today.

Previously, most needlestick injuries took place because of the way needles were handled after blood was drawn from a patient. Today, although we don’t recommend covering the needle after use anymore, not doing so increases the risk of injuries to cleaners and porters who handle the waste. This risk heightens when hospital staff throw needles directly into plastic bags instead of secure containers for sharp objects. With new procedures, these injuries can be avoided. For instance, there are policies in operating rooms about how nurses should pass sharp objects and needles to surgeons and vice versa. Wearing double gloves is another method to avoid needlestick injuries.

Certain factors can increase the risk of exposure to body fluids:

* Not following universal precautions
* Ignoring established safety protocols
* Performing high-risk procedures that increase the risk of exposure to blood such as taking blood, working in the dialysis unit, or giving someone a blood transfusion
* Using needles and other sharp devices that lack safety features

In reality, almost any microorganism can be transmitted following a needlestick injury, but a few are a notable concern. These include HIV, hepatitis B, and hepatitis C. All three viruses can infect a person in two ways – through a needlestick injury or through splashing of blood on the body’s mucus membranes. While HIV primarily affects the immune system, both hepatitis B and C affect the liver. A patient’s vaccination history must be checked in case of a needlestick injury as it’s always possible that they could catch tetanus.

What Causes Needlestick?

Needlestick injuries are quite common in healthcare settings. However, even after getting pricked or experiencing a spill onto their skin or membranes lining the body’s interior, most healthcare professionals do not develop any infection. Although there is general concern that these workers are in high risk of diseases from needlestick injuries, statistics don’t necessarily back this up.

The likelihood of an infection after needlestick injuries depends on several factors such as the type of needle used, how severe the injury is, the type of bacteria or virus in the patient’s blood, and whether the healthcare professional has been vaccinated. Post-exposure treatment (medical treatment provided after potential exposure to a disease) is another important factor in preventing infections.

HIV infection is a condition that weakens the immune system over time, eventually affecting almost every organ in the body and causing a variety of symptoms. HIV has a liking for the CD4 cells, a type of white blood cell, which leaves the body in a weak immune state. This can lead to getting diseases easily, cancer and severe weight loss. However, it’s rare for someone to develop HIV from a needlestick injury. From 1981 to 2010, there were only 143 possible cases of HIV among healthcare professionals, and of these, only 57 tested positive for HIV later on.

Hepatitis B is the most commonly gotten disease via needlestick injuries. Symptoms like yellowing of skin and eyes, fever, nausea and vague abdominal pain may develop if you get hepatitis B, however these symptoms typically subside in a month or two. The risk of developing chronic hepatitis B, liver cancer or scarring of the liver (cirrhosis) over a lifetime is around 15% if the virus remains.

Data gathered over 20 years ago in 1997, from the CDC National Hepatitis Surveillance showed nearly 500 healthcare workers got hepatitis B from a needlestick injury, a sharp decline from the high 17,000 new cases in 1983. This decrease in cases is largely because of the availability of the hepatitis B vaccine and universally following safety precautions. Before the vaccine, the infection rate from a needlestick was from 6% to 30%.

After needlestick injuries, healthcare professionals also risk getting another type of liver infection, hepatitis C. Sadly, it is not exactly known how many healthcare workers have gotten hepatitis C after a needlestick injury due to lack of follow-up. The exact number of hepatitis C cases has significantly dropped from over 110,000 in 1991 to 38,000 in 1997. Today it’s estimated that 2% to 4% of all the hepatitis C cases are healthcare workers who got the infection from a needlestick injury.

After a needlestick injury, most people don’t show symptoms of hepatitis C, and if they do, they are nonspecific and may resemble a flu. Unlike Hepatitis B, where less than 6% of adults develop a chronic disease, with Hepatitis C more than 75% of adults will develop a chronic illness. Among these, 20% could develop advanced liver disease or cirrhosis within the next 2 or 3 decades and 1% to 5% could get liver cancer. Although no preventive treatment is available after exposure to the hepatitis C virus, some new drugs can slow the progression of liver damage and reduce the rates of liver cancer.

Risk Factors and Frequency for Needlestick

Despite efforts to enhance safety, accidents involving needle pricks still happen quite often in healthcare settings. The exact number of these incidents is unclear because many are not reported. Small pricks, particularly in the operating room, are far from rare. It’s estimated there are around 600,000 needlestick injuries in the U.S. every year, but only half of these are reported. These injuries are not limited to hospitals – they can also happen in other healthcare facilities like clinics, outpatient services, and care homes.

• Needlestick injuries still happen frequently, despite safety guidelines.
• The actual number of these incidents is unknown since many are not reported.
• Estimates suggest that there are around 600,000 needlestick injuries in the U.S. per year.
• Not just hospitals, these injuries also occur in various other health-related facilities.

Not all healthcare workers face the same risk of needlestick injuries. These injuries most commonly occur among nurses, surgeons, emergency medical technicians, surgical technologists, and laboratory staff. Further, those who handle the cleaning of sharp boxes, like housekeeping personnel, are also at a high risk of getting pricked by needles.

Devices called Safety Engineered Devices (SEDs) were created to reduce these injuries. However, against expectations, the use of these devices might have actually increased the number of needlestick injuries. According to a study in the Netherlands in 2018, before using SEDs, the rate of needlestick injuries was 1.9 per 100 healthcare workers. Once the devices were introduced, the rate went up to 2.2 per 100. The most common reasons for needlestick injuries were reported to be issues in operating the safety device and continued improper disposal of needles.

Signs and Symptoms of Needlestick

When a person experiences a needlestick injury, it’s important to collect information about their medical history. This includes:

• All past vaccinations and booster shots
• Any piercings and when they were done
• Any history of hemodialysis
• Prior exposure to bodily fluids and treatment
• Complete medical history
• History of hepatitis B vaccination
• History of intravenous drug use
• When their last tetanus shot was received
• Prior blood transfusions
• Risk factors for HIV and viral hepatitis
• Sexual history
• Travel history outside the United States within the past 12 months

In most cases, the only noticeable physical symptom of a needlestick injury is a puncture wound. However, it’s important to also perform a thorough physical exam including checks of the skin, heart, lung, liver, and lymph nodes. This helps diagnose any potential infections that could develop in the future.

If the individual whose blood caused the needlestick injury is still in the hospital, it’s important to conduct additional tests. This includes checking their blood for HIV, HBV, and HCV. The healthcare worker who was injured should also undergo similar tests, including a complete blood count, electrolyte check, and liver function studies. If the injured individual is a woman of childbearing age, a pregnancy test should also be performed.

Lastly, we also need to check the person’s vaccination status for tetanus and hepatitis B. If they haven’t received a tetanus shot in the past 10 years, they should receive a booster shot. Since there’s no vaccine for hepatitis C, consulting an infectious disease expert as soon as possible is crucial to determine any recommended post-exposure treatment.

Testing for Needlestick

Often, a patient’s medical history and physical examination are enough for a proper diagnosis. However, in rare cases, doctors might worry about the presence of a foreign object in the body. In such situations, they might use imaging tests like X-rays, ultrasounds, or CT scans. Testing for HIV and hepatitis can also be performed.

If your doctor is considering the possibility of recent exposure to HIV, they will use a 3-step evaluation process developed by the Centers for Disease Control and Prevention (CDC). This process helps to understand the risk and decide whether to start post-exposure prophylaxis (PEP) – a treatment to prevent HIV infection after potential exposure.

This process includes the following steps:

Step 1: Determine the exposure source. This could be blood, bodily fluids, or an instrument contaminated with blood. Once exposure is confirmed, different factors like the type of exposure (skin or mucous membranes), extent (small or large amount of fluid), duration of contact, and the type and use of potentially contaminated needles are taken into account.

Step 2: Confirm the HIV status of the potential exposure source. If they’re HIV negative, PEP is not required. If they’re HIV positive or their status is unknown, further evaluation is needed based on information, such as the viral titer (amount of virus in the blood), CD4 count (indicator of immune system health), and other aspects of the patient’s medical history.

Step 3: Decision on treatment. Based on the above data, the doctor will decide whether PEP is needed. In low-risk cases, no treatment may be required, and observation is enough. In high-risk cases, PEP is generally recommended. For cases where the risk is unclear, the doctor will weigh the potential benefits and adverse effects of PEP.

The CDC provides a hotline and website that can assist with the management of potential HIV exposure as well.

You can learn more about PEP if you follow the links to the Non-Occupational Post-Exposure Prophylaxis (nPEP) Toolkit or the National Clinicians Consultation Center. You can also use the PEP Consultation Service for Clinicians by calling 1-888-448-4911 from 9 a.m. – 2 a.m. ET.

Treatment Options for Needlestick

If a healthcare worker who has been vaccinated for hepatitis B is found to have the HBsAg (hepatitis B surface antigen) in their blood, it means they have been infected with the virus. Their levels of anti-HBs (hepatitis B antibodies) should be checked. If they have high levels of these antibodies (above 10 mIU/mL), this means they are protected against the virus, and no further treatment or booster shots are needed. But, if their anti-HBs levels are low, or if there’s no vaccine available, they should get a treatment called hepatitis B immunoglobulin.

If a vaccinated healthcare worker tests negative for HBsAg, meaning they aren’t infected, their anti-HBs levels should be monitored.

Sometimes, patients can’t be tested because they have been discharged from the hospital or are unavailable. In such situations, healthcare professionals need to make judgments based on the available information. Generally, if there’s no evidence that the patient is at high risk for hepatitis B, such as history of intravenous drug use, they are assumed to be HBsAg negative, and the healthcare worker is observed closely.

On the other hand, if a healthcare worker hasn’t been vaccinated against hepatitis B, different guidelines apply. If the patient tests positive for HBsAg, the healthcare worker should be given hepatitis B immunoglobulin immediately. This should be followed by a fast track immunization that starts 14 days later. If the patient tests negative for HBsAg, the healthcare worker isn’t given hepatitis B immunoglobulin, but they should consider getting vaccinated for hepatitis B.

Regarding HIV, the current guidelines recommend using a treatment called post-exposure prophylaxis after being exposed to the virus. This involves taking three antiviral medications as soon as possible, ideally within hours of exposure. The treatment lasts for 4 weeks. The CDC recommends a combination of two types of drugs called nucleoside reverse transcriptase inhibitors (NRTIs), and a third one that is usually a protease inhibitor. For instance, one could take a combination of drugs called Tenofovir, emtricitabine and either dolutegravir or raltegravir.

If a healthcare worker suffers a needlestick injury, they must seek emergency care. The injury should be rinsed with saline or water and cleaned properly. Using antiseptic solutions to clean the area is not usually necessary. A common reaction to a needlestick injury is immediate pain followed by fear and anxiety due to the risk of infection.

It is essential to report all needlestick injuries following the guidelines set by your state, institution, and federal laws. Employees who suffer such injuries are entitled to comprehensive medical coverage, including post-exposure prophylaxis and vaccines, under federal law.

What else can Needlestick be?

There are certain situations that may require particular attention or specific tests. These situations include:

• Rapid HIV testing
• Sexual assault cases
• Viral hepatitis diagnosis
• Workers compensation claims

What to expect with Needlestick

If a healthcare worker gets pricked by a needle, they should visit a local Occupational Health and Safety Clinic within 12 to 72 hours. During this time, they are requested to avoid sexual intercourse until they test negative for HIV. Most experts specializing in infectious diseases recommend practicing safe sex or abstaining from sex until a second confirmatory negative HIV test, which usually happens between 4 to 6 months later.

If the initial tests are negative, the healthcare worker needs to return for follow-up checks at 2 and 6 months. For those who unfortunately catch an infection due to the needlestick injury, their outlook is similar to individuals who got the infection through other means.

Possible Complications When Diagnosed with Needlestick

Getting a needlestick injury can be a very unsettling experience. Even though such injuries typically don’t lead to infection, there’s always a risk, however small, of contracting a serious infection like HIV or hepatitis C. This can be a stressful time for healthcare workers, as they often need to consult with multiple specialists and undergo frequent blood tests.

Making decisions about treatment for needlestick injuries can be challenging. In addition to this, healthcare workers often grapple with the fear of uncertainty, since it can take many months before signs of HIV show up in a test. On top of this, HIV isn’t the easiest condition to treat. The antiretroviral therapy used, called HAART, can lead to a range of unpleasant side effects.

While dealing with the injury, people also have to manage their personal lives. This might mean practicing safe sex or abstaining altogether for a long time. Women infected might have to delay getting pregnant. Yet, the most challenging aspect might be the uncertainty about their infection status, even if they’re not showing any symptoms.

It’s worth noting that people with a low risk of infection who are awaiting their initial test results, and have taken post-exposure prophylaxis (PEP) for a few days, have little to no risk of experiencing side effects.

To summarise, difficulties faced in the event of a needlestick injury are:

• Potential risk of serious infections such as HIV or Hepatitis C
• Necessity of frequent consultations and blood tests
• The challenge of making treatment decisions
• Concern about delayed manifestation of HIV
• Unpleasant side effects of HIV treatment
• Restrictions in sexual activity
• Women may have to delay planning for a baby
• Uncertainty about infection status
• Minimal risk of side effects if PEP is used early for low-risk individuals