Transcript Needlestick Injury: Epidemiology from a Hospital Perspective

Needle Stick Injury:
Epidemiology from a
Hospital Perspective
Dr Blánaid Hayes,
Beaumont Hospital,
Dublin
Epidemiology of NSI
Background
Risk and probability
Epidemiology of BBV; global
and local
International and local NSI
statistics
Challenges and
opportunities
Background
Definition

An exposure that might place HCW at risk for HBV,
HCV or HIV infection is defined as
Percutaneous:puncture, abrasion or laceration
caused by needle or other sharp device
Mucocutaneous: contact of mucous membrane or
non-intact skin with blood or potentially infectious
body fluid
Legislation

Health and Safety Act 2005

US: Needlestick Safety and Prevention Act of 2000
Consequences

Health (not negligible)
Infection
Anxiety
Drug S/E

Lifestyle restrictions (self and family)

Career

Organisational cost

Source patient testing
Impact:*



*Janine Jagger ICHE Jan 2007 Vol 28; No 1
Globally, HCW population is ’large and their impact is
felt everywhere’…35.7 million worldwide.
Worthy public health target: provide care worldwide in
sophisticated and humble settings. Depended upon for
life sustaining services.
Greatest risk is in countries of high prevalence where
PEP, patient treatments and safety technology are
unavailable
Infections Transmitted by NSI
hepatitis B*
hepatitis C*
HIV*
herpes*
TB
Malaria
Dengue fever
Rocky Mountain spotted fever
necrotising fasciitis (strep. A)
Risk and Probability
RISK =
HAZARD X FREQUENCY
SEROPREVALENCE IN POPULATION
& INFECTIVITY OF SOURCE
E XPOSURE NUMBER
EXPOSURE SEVERITY
Perception of Risk
Risk
Management
MYTH
RISK PERCEPTION
RISK = HAZARD + OUTRAGE
Sandman)
(Peter
BBV transmission to HCW
HBeAg + source
= 30%
HBeAg - source
<
6%
HCV + source
= 0.5%
HCV PCR+ source
=
10%

Australian study reviewed 29
articles on transmission of HCV
(vertical, via transplant /
transfusion or NSI). No
transmissions occurred from
PCR negative sources (BMJ
1997)
HIV+ (percutaneous)
= 0.3%
HIV+ (mucocutaneous) = 0.09%
HIV transmission: risk factors
RISK FACTOR ADJUSTED O/R
deep injury
16.1
visible blood
5.2
needle in vessel 5.1
terminal illness
6.4
PEP /ZDV
0.2
Case control study of HIV seroconversion in HCWs
NEJM 1997
Epidemiology of BBV Global vs Local
Hepatitis B
> 350 million worldwide
Irish notifications increased
annually 1996-2005 but reduced
by 20% 2006
More prevalent in IDUs,
prisoners and immigrants (high
endemicity)
Details since 2004

820 notifications

761 (93%) defined
668 (88%) chronic
93 (12%) acute
ASNR = +/- 20/100,000
Typical acute HBV: young man,
born in Ireland, sexually
acquired
‘Typical’ chronic HBV: from
countries of high endemicity
Source: www.hpsc.ie
Prevalence
%
High
>8
2–7
<1
Intermediate
Low
Epidemiology of BBV Global vs Local
Hepatitis C
170 million worldwide
Notifiable disease since Jan
2004 (SI 707 of 2003)
Irish ASIR = 36/100,000 (M>F
and HSE- E > than HSE
generally (rate rising)
Risk factors:

Sharing needles etc ++++

Unscreened blood / products
++

Mother to baby, occupational,
sexual +
90% cases in developed
countries current or former
IDUs or received unscreened
blood / products
Largely asymptomatic (90%)
Source: www.hpsc.ie
Epidemiology of BBV Global vs Local
HIV
Global HIV burden= 42 million
Globally during 2005:


4.1 million new infections
2.8 million RIP AIDS
End 2006 > 4,400 cases
reported
New diagnosis not
representative of incidence
Risk factors (2006) n=337



Heterosexual ++++ (50%)
MSM ++
IDUs +
9% new cases are Irish born
heterosexuals (31 per year)
Source: Epi – Insight, Vol 8, Issue 10, October 2007
How big is the problem?
8 million HCWs in US
Estimated US annual
figure is 384,325
Add factor 0.31 (for
needles bought
outside of hospitals =
503,466
Add another factor of
0.29 for all
mucocutaneous
injuries = 649,471
100,000 in Ireland
Crude estimate:
= 4804 p/a
= 6293 p/a
= 8118 p/a
But neither set of figures takes any account of underreporting
How to interpret figures?
Difficulty comparing data
between countries and studies
because of different formats
used for documenting rates:

Rate per 100 occupied beds

Rate per 1000 health care
staff (WTE or other)

Rate for specific
occupations

Rate per person per annum
etc.
One rate quoted by Jagger is 22
per 100 bed p/a (previously 30
per 100)
Local hospital rate tends to be
<20 per 100.
International Data on Incidence and Reporting Rates
Country
Year
Job
Rate
Reported
Canada
1990
House staff
0.7pp p/a
<5%
US
1995
Stds/ house staff
32% (6/12)
11%
UK
1999
Anaesthetists
50%
15%
UK
1999
Med students
33%
43%
*US
1998
All
?
55%
US (CDC)
1998
All (14,000)
?
42%
Surgeons 27%
Others 48%
Saudi Arabia
2002
All
33/1000
N/R
Taiwan
2002
All
87% (12/12)
N/R
UK
2004
All
38% (12/12)
51%
*US
2007
Surgical trainees
83% (in 5 yrs) 49%
Needlestick Injuries, According to Postgraduate Year
Needlestick Injuries among Surgeons in Training NEJM 2007;356:2693-9
Makary MA et al. N Engl J Med 2007;356:2693-2699
Behavior Associated
Nonreporting
Most Recent
Needlestick
Injury
Needlestick
Injuries with
among
Surgeonsofinthe
Training
NEJM
2007;356:2693-9
Makary MA et al. N Engl J Med 2007;356:2693-2699
Study Overview
Data from surgeons at 17
US centres:
 majority reported at
least one needlestick
injury during training
 half of the most recent
injuries (including
many sustained in the
care of high-risk
patients) were not
reported
An Irish Hospital’s Experience: who is at risk?
Occupation
Number
% Total
Nursing
150
49.5%
Medical
86
28.5%
Non Clinical
41
13.5%
Others
26
8.5%
Total
303
100
Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):
Where to they occur?
Location
Number
% total
Wards
176
53.4%
Theatre
45
13.8%
A&E
26
8.1%
Other
85
25.7%
332
+/-100
Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):
% Immunity to Hepatitis B
Hepatitis B Ab
testing of injured
HCWs
Immune
Number
%
285
85.8%
Unknown
18
5.4%
Non- immune
29
8.8%
Total
332
100
Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):
Test Results of Source Patients
Number
Tested
Number
Positive
% Positive
Hepatitis C
Antibody
HIV
Antibody
Hep B
Surface
Ag
254(76.5%)
119(35.8%)
103(31%)
8*
2
1
3.1%
1.6%
0.9%
* 5 of the 8 patients positive for hepatitis C Ab were also PCR +
Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):
Procedure Involved
Procedure
Number (%)
During procedure
72 (21.7)
Immediately after procedure
104 (31.3)
During disposal
42 (12.7)
After improper disposal
92 (27.7)
During instrument cleaning
9 (2.7)
Other / not recorder/ unknown
13 (3.9)
TOTAL
332 (100)
What factors impact on injury and infection rates?
Higher rates of NSI:






Teaching hospitals (vs
others)
Surgeons (vs physicians)
Theatre (vs other areas)
Emergency (vs elective
procedures)
Less experienced staff
Low staff numbers and
morale
Infection rates
reduced by:




Hepatitis B vaccine
PEP
HIV therapies have
reduced viral load in
source patients
Double gloving
Hepatitis B vaccine
Currently recommended for
high risk groups:

Babies of infected mothers

CRF, haemophilia

Occupational risk

Close contacts

IDUs

Prisoners

Homeless

Heterosexuals / multiple

MSM
NIAC in 2007 recommended
addition of HB vaccine to
primary childhood schedule. To
be introduced in Sept 2008
Source: www.immunisation.ie/en/Publications/PDFFile_14064
Solutions: what has been shown to
work to reduce frequency of NSI?
Standard Precautions
/ UPs
Cin bins
Avoiding re-sheathing
Safety technology
LEGISLATION

Do we need specific
legislation or a
directive in this country
to enforce a change in
practice
Challenges
Health care resources



Training
Technology
Safety management systems
Immunisation uptake


Senior clinicians
Childhood immunisation
Organisational culture



Compliance
Reporting
Macho-ism
Irish ‘psyche’



Ambivalent to authority
Anarchic
Fatalistic
Opportunities
Great strides have been made in hospital
hygiene
Accreditation and quality are ‘buzz words’
Clinicians and managers are more aware of
hidden costs of high risk practice
Hepatitis B vaccine is no longer just for limited
high risk groups
Safety technology is no longer cost prohibitive
and is user friendly
Time to invest in a nationwide surveillance
system incorporating all exposures and not
just those occurring in hospitals
Take Home Message…….
Engineering solutions
Managers who are role models, senior clinicians who are
‘physician champions’, leading by example, monitoring
etc
Putting training and education at the top of the agenda
and not as a dispensable item when times are tough