Transcript Document 7175261

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
 Suturing
 Phlebotomy
 Ng and og
 Recapping of




needles
Specimen handling
Med injection
Lumbar puncture
Chest tube insertion




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 Studen Lab tech
ist or
t/resid
tech
ent
Physi
cian
Other
Total
Needles
tick
281
15
20
26
20
16
378 (60%)
Surgical
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%)
Nonintact
59
5
1
4
4
7
88 (14%)
Unknow
n
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
16
14
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10
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6
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Rates per
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US National Surveillance of Occupational
Exposure to HIV: Preventable Exposures
(to ‘96)
Description of Number of
Exposure
Workers
Recapping a
57
used needle
Percent
Improper
disposal of a
used needle
Skin contact
44
20%
122
55%
Total
223
100%
25%
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 Stats
Courtesy 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 nonbloody 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 Guidelines
1 Is the source known HIV+?
 Yes:
proceed to step 2 of protocol
 No:
Test source (with consent) using rapid point-ofcare 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 nonvoluntary 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 Guidelines
9 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