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This presentation is designed to assist with the training of staff on sharps management including safety devices

  • The drug regime should be followed according to the best available options in resource poor circumstances.

Dr.T.V.Rao MD

what is occupational exposure
What is occupational exposure
  • Occupational exposurerefers to exposure to potential blood-borne infections (HIV, HBV and HCV) that may occur in healthcare settings during performance of job duties. Post exposure prophylaxis (PEP) refers to comprehensive medical management to minimize the risk of infection among Health Care Personnel (HCP) following potential exposure to blood-borne pathogens (HIV, HBV, HCV)

Dr.T.V.Rao MD

who are at risk
Who are at risk
  • All Health Care Personnel, including emergency care providers, laboratory personnel, autopsy personnel, hospital employees, interns and medical students, nursing staff and students, physicians, surgeons, dentists, labour and delivery room personnel, laboratory technicians, health facility sanitary staff and clinical waste handlers and health care professionals at all levels

Dr.T.V.Rao MD

what are sharps
Sharps are devices that are intentionally sharp to puncture or cut skin (needles, scalpels, etc.), or become sharp due to accident, such as broken glass tubes.

Hypodermic needles

Scalpels

IV devices

Capillary tubes

Glass containers

Pipettes

Others

What are “sharps”?

Dr.T.V.Rao MD

what kind of devices usually cause sharps injuries
What kind of devices usually cause sharps injuries?
  • Hypodermic needles
  • Blood collection needles
  • Suture needles
  • Needles used in IV delivery systems
  • Scalpels

Dr.T.V.Rao MD

how common are sharps injuries
Estimates indicate that 600,000 to 800,000 needle stick injuries occur each year.

Unfortunately, about half of these injuries are not reported.

ALWAYS REPORT sharps injuries to your employer to ensure that you receive appropriate follow-up care.

How common are sharps injuries?

Dr.T.V.Rao MD

sharps management
What is an occupational exposure?

A blood or body fluid exposure that occurs as a consequence of a work-related activity

There are two types of blood and body fluid exposure:

Percutaneous exposure (penetrates the skin) e.g. needle stick injury (NSI) or cut with a sharp object such as a scalpel blade

Non-percutaneous or Mucocutaneous exposure (contact of mucous membrane or non-intact skin with blood or body fluids) e.g. blood splash to the eye

Sharps Management

Dr.T.V.Rao MD

increasing the risk of sharps injuries
Past studies show sharps injuries are often associated with these activities:

Recapping needles or other devices

Transferring a body fluid between containers

Failing to dispose of used needles or other devices properly in puncture-resistant sharps containers

Increasing the risk of sharps injuries

Dr.T.V.Rao MD

who are at risk10
Who are at risk
  • Health Care Personnel are at risk of blood-borne infection transmission through exposure of a percutaneous injury (e.g. needle-stick or cut with a sharp instrument), contact with the mucous membranes of the eye or mouth of an infected person, contact with non-intact skin (particularly when the exposed skin is chapped, abraded, or afflicted with dermatitis or contact with blood or other potentially infectious body fluids. potentially infectious body fluids

Dr.T.V.Rao MD

protecting yourself
Protecting yourself
  • Report all needle stick and sharps-related injuries promptly to ensure that you receive appropriate follow-up care.
  • Tell your employer about any sharps hazards you observe.
  • Participate in training related to infection prevention.
  • Get a Hepatitis B vaccination.

Dr.T.V.Rao MD

sharps management12
Who is at risk of an occupational exposure?

All healthcare workers who have the potential for exposure to infectious materials (e.g. blood, tissue, and specific body fluids, as well as medical supplies, equipment or environmental surfaces contaminated with these substances) e.g:

Nurses

Doctors

Laboratory staff

Technicians

Therapists

Support personnel e.g. housekeeping, maintenance

Dental staff

Contractual staff

Students

Sharps Management

Dr.T.V.Rao MD

sharps management general principles
Sharps Management -General Principles
  • Needles should not be recapped, bent or broken by hand, removed from disposable syringes or otherwise manipulated by hand.

Dr.T.V.Rao MD

what infections can be caused by sharps injuries
Sharps injuries can expose workers to a number of blood borne pathogens that can cause serious or fatal infections. The pathogens that pose the most serious health risks are

Hepatitis B virus (HBV)

Hepatitis C virus (HCV)

Human immunodeficiency virus (HIV)

What infections can be caused by sharps injuries?

Dr.T.V.Rao MD

risk of acquiring infection
Risk of acquiring infection
  • The average risk of acquiring HIV infection from different types of occupational exposure is low compared to risk of infection with HBV or HCV. In terms of occupational exposure the important routes are needle stick exposure (0.3% risk for HIV, 9–30% for HBV and 1–10% for HCV) and mucous membrane exposure (0.09% for HIV).

Dr.T.V.Rao MD

which fluids are potentially infectious for hiv
blood?

saliva?

sweat?

feces?

spinal fluid?

pleural fluid?

pus?

urine?

Which fluids are potentially infectious for HIV?

Dr.T.V.Rao MD

which fluids are potentially infectious for hiv17
blood

saliva

sweat

feces

spinal fluid

pleural fluid

pus

urine

Which fluids are potentially infectious for HIV?

Dr.T.V.Rao MD

needle stick and sharps injuries

Needle Stick and Sharps Injuries

Procedures for Effectively Handling Sharps Injuries

Dr.T.V.Rao MD

hiv pep
HIV PEP
  • Exposures common
  • 56 documented cases of health care workers contracting HIV from exposures; 138 other possible cases
  • Area of considerable concern but little data

Dr.T.V.Rao MD

MMWR June 29, 2001 / 50(RR11);1-42

risk of hiv transmission following percutaneous needle stick exposure
Risk of HIV Transmission Following Percutaneous (Needle stick) Exposure
  • Pooled analysis of prospective studies on health care workers with occupational exposures suggests risk is approximately 0.3% (95% CI, 0.2% - 0.5%)1
  • Presence or absence of key risk factors may influence this risk in individual exposures

Dr.T.V.Rao MD

1. Bell DM. Am J Med 1997;102(suppl 5B):9-15.

assess exposed individual
Assess exposed individual
  • The exposed individual should have confidential counseling and assessment by an experienced physician. Exposed individuals who are known or discovered to be HIV positive should not receive PEP. They should be offered counseling and information on prevention of transmission and referred to clinical and laboratory assessment to determine eligibility for antiretroviral therapy (ART). Besides the medical assessment,counselling exposed HCP is essential to allay fear and start PEP.

Dr.T.V.Rao MD

immediate measures
Percutaneous:

wash needle sticks and cuts with soap and water

remove foreign materials

Non-intact skin exposure:

wash with soap and water or antiseptic

Mucous membrane

flush splashes to the nose, mouth or skin with water

irrigate eyes with clean water, sterile saline or sterile irrigants

Immediate Measures

Dr.T.V.Rao MD

counselling for pep
Counselling for PEP
  • Exposed persons (clients) should receive appropriate information about what PEP is about and the risk and benefits of PEP in order to provide informed consent for taking PEP. It should be clear that PEP is not mandatory.

Dr.T.V.Rao MD

psychological support
Psychological support
  • Many people feel anxious after exposure. Every exposed person needs to be informed about the risks, and the measures that can be taken. This will help to relieve part of the anxiety. Some clients may require further specialized psychological support.

Dr.T.V.Rao MD

document exposure
Document exposure
  • Documentation of exposureis essential. Special leave from workshould be considered initially for a period of two weeks. Subsequently, it can be extended based on the assessment of the exposed person’s mental state, side effects and requirements.

Dr.T.V.Rao MD

practical application in the clinical settings
Practical application in the clinical settings
  • For prophylactic treatment the exposed person must sign consent form.
  • ·          Informed consent also means that if the exposed person has been advised PEP, but refuses to start it, this needs to be recorded. This document should be kept by the designated officer for PEP.
  • ·          An information sheet covering the PEP and the biological follow-up after any AEB must be given to the person under treatment. However, this sheet cannot replace    verbal explanations.

Dr.T.V.Rao MD

sharps management general principles27
Sharps Management -General Principles
  • Policies and procedures including NSI management
  • Standard Precautions including personal protective equipment (PPE)
  • Hepatitis B vaccination
  • Education programs
  • Modifications to work practices including alternatives to using needles
  • Safe handling of sharps
  • Sharps disposal systems i.e. puncture-resistant containers
  • Injury prevention features/safety devices
    • Active
    • Passive

Dr.T.V.Rao MD

prescribe pep
Prescribe PEP

Deciding on PEP regimen

There are two types of regimens:

   Basic regimen: 2-drug combination

  Expanded regimen: 3-drug combination

  • The decision to initiate the type of regimen depends on the type of exposure and HIV serostatus of the source person.

Dr.T.V.Rao MD

outcomes of hiv exposures
No infection 

Aborted infection 

Acute infection 

no immune memory

cellular immune response

seroconversion

Outcomes of HIV Exposures

Dr.T.V.Rao MD

hiv chemoprophylaxis
HIV chemoprophylaxis
  • Because post-exposure prophylaxis (PEP) has its greatest effect if begun within two hours of exposure, it is essential to act immediately. The prophylaxis needs to be continued for four weeks. Exposure must be immediately reported to designated authority and therapy administered. Never delay start of therapy due to debate over regimen. Begin with basic 2-drug regimen, and once expert advice is obtained, change as required.

Dr.T.V.Rao MD

pep regimens basic regimens
Two NRTIs

Simple dosing, fewer side effects

Preferred basic regimens:

Zidovudine (AZT) OR tenofovir (TDF)

plus

lamivudine (3TC) OR emtricitabine (FTC)

Alternative basic regimens:

stavudine (d4T) OR didanosine (ddI)

plus

lamivudine (3TC) OR emtricitabine (FTC)

PEP Regimens: Basic regimens

Dr.T.V.Rao MD

MMWR 2005;54(No. RR-9).

expanded pep regimens
Expanded PEP Regimens
  • Basic regimen plus a third agent
  • Rationale: 3 drugs may be more effective than 2 drugs, though direct evidence is lacking
  • Consider for more serious exposures or if resistance in the source patient is suspected
  • Adherence more difficult
  • More potential for toxicity

Dr.T.V.Rao MD

expanded pep regimens33
Preferred Expanded Regimen:

Basic regimen plus lopinavir/ritonavir (Kaletra)

Alternate Expanded Regimens:

Basic regimen plus one of the following:

Atazanavir* +/- ritonavir

Fosamprenavir +/- ritonavir

Indinavir +/- ritonavir

Saquinavir (hgc; Invirase) + ritonavir

Nelfinavir

Efavirenz

Expanded PEP Regimens

MMWR 2005;54(RR-9)

Dr.T.V.Rao MD

*Atazanavir requires ritonavir boosting if used with tenofovir

seek expert opinion in case of
Seek expert opinion in case of
  • Delay in reporting exposure (> 72 hours).
  • ·          Unknown source
  • ·          Known or suspected pregnancy, but initiate PEP
  • ·          Breastfeeding mothers, but initiate PEP
  • ·          Source patient is on ART
  • ·          Major toxicity of PEP regimen.

Dr.T.V.Rao MD

tolerability of hiv pep in health care workers
Tolerability of HIV PEP in Health Care Workers

Incidence of Common Side Effects

Percent of HCWs

Dr.T.V.Rao MD

Wang SA. Infect Control Hosp Epidemiol 2000;231:780-5.

cdc post exposure prophylaxis guidelines

CDC Post-Exposure Prophylaxis Guidelines

MMWR 2005;54(No. RR-9).

http://www.aidsinfo.nih.gov

Dr.T.V.Rao MD

cdc post exposure prophylaxis guidelines37
CDC Post-Exposure Prophylaxis Guidelines

Dr.T.V.Rao MD

MMWR 2005;54(No. RR-9).

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CDC Post-Exposure Prophylaxis Guidelines

Dr.T.V.Rao MD

MMWR 2005;54(No. RR-9).

follow up hiv testing
Follow-up HIV Testing
  • CDC recommendations: HIV Ab testing for 6 months post-exposure (e.g., at 6 weeks, 3 months, 6 months)
  • Extended HIV Ab testing at 12 months is recommended if health care worker contracts HCV from a source patient co-infected with HIV and HCV
  • VL testing not recommended unless primary HIV infection (PHI) suspected

Dr.T.V.Rao MD

MMWR 2005;54(No. RR-9).

institutional procedures
HAVE A PLAN for immediate evaluation of employees

HAVE A PLAN for financial provision of PEP

HAVE A PLAN to protect employee confidentiality about exposure, treatment and test results

Review and Update annually

Institutional Procedures

Dr.T.V.Rao MD

recommendations hepatitis b
Recommendations Hepatitis B
  • For the unimmunized:
    • prophylactic HBIG
    • initiate the vaccine series

Dr.T.V.Rao MD

general principles in hepatitis b vaccination
General Principles in Hepatitis B Vaccination
  • Hepatitis B Vaccination
    • A primary course of hepatitis B vaccinations over six months
      • Mandatory for all staff in contact with patients and patient-contaminated material
    • Titre level (HBsAb) four to six weeks after last dose
    • Booster doses not required if titre level >10 mIU/mL

Dr.T.V.Rao MD

protecting yourself from needle stick injuries a self responsibility
Avoid the use of needles where safe alternatives are available.

Help your employer select and evaluate devices with safety features that reduce the risk of injury.

Use devices with safety features provided by your employer.

Do not recap needles or scalpels.

Plan for safe handling and disposal of sharps before using them.

Protecting yourself from needle stick injuriesa self responsibility ???

Dr.T.V.Rao MD

recommendations hepatitis c
No effective prophylaxis

Immunoglobulin and antiviral agents are NOT recommended

Determine status of source

Establish baseline serology and serum ALT of employee and repeat testing at 4-6 months post-exposure

Early treatment if infection occurs

Refer to Hepatologist

Recommendations Hepatitis C

Dr.T.V.Rao MD

hepatitis c follow up testing
Hepatitis C: follow-up testing
  • CDC guidelines: follow-up HCV Ab and ALT at 4-6 months1
  • Consider periodic HCV RNA screening (monthly?) if earlier detection desired
  • Note that unlike acute HIV infection, most patients are not symptomatic with acute HCV infection2

1. MMWR June 29, 2001 / 50(RR11);1-42.

2. Mandell: Principles and Practice of Infectious Diseases, 5th ed., p. 1279.

Dr.T.V.Rao MD

major references
Major references
  • MMWR reviews
  • CDC guidelines
  • Post-Exposure Prophylaxisan evidence-based review Christopher Behrens, MD Hillary Liss, MD Northwest AIDS Education & Training Center University of Washington
  • NACO guidelines on Post exposure prophylaxis

Dr.T.V.Rao MD

slide47

Programme created by Dr.T.V.Rao MD for Medical and Paramedical Professionals in the Developing world.

  • Email
  • doctortvrao@gmail.com

Dr.T.V.Rao MD