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 Table of Contents  
PERSPECTIVE
Year : 2018  |  Volume : 6  |  Issue : 3  |  Page : 90-92

Needle-stick injury: A perspective


1 Department of Microbiology, Sri Ramachandra University, Chennai, Tamil Nadu, India
2 Department of Waste Management and Environmental Health, National Institute of Urban Affairs, Delhi, India

Date of Web Publication4-Mar-2019

Correspondence Address:
Dr. Padma Srikanth
Department of Microbiology, Sri Ramachandra University, No. 1, Ramachandra Nagar, Porur, Chennai - 600 106, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_16_18

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How to cite this article:
Srikanth P, Ravi Y, Mani S. Needle-stick injury: A perspective. J Patient Saf Infect Control 2018;6:90-2

How to cite this URL:
Srikanth P, Ravi Y, Mani S. Needle-stick injury: A perspective. J Patient Saf Infect Control [serial online] 2018 [cited 2019 Dec 13];6:90-2. Available from: http://www.jpsiconline.com/text.asp?2018/6/3/90/253383




  Introduction Top


Needle-stick injury (NSI) poses a threat to health-care workers (HCW) for the acquisition of Hepatitis B (HBV), HIV or Hepatitis C (HCV). It is estimated that globally 35 million health-care workers are at risk.[1] The HCWs who are affected include doctors, nurses, paramedical staff and housekeeping staff. The risks include a splash or a NSI. Although the risk of acquisition varies from 37% for HBV, 4% for HIV and 39% for HCV, HBV occurs in 6–30 out of 100 people, HCV in 3–10 out of 100 people and HIV in 1 out of 300 people.[2]

Many reasons are attributed for the occurrence of NSIs. These reasons may stem from a lack of awareness and lack of implementation of protocols. Training in infection control practices is inadequate and only recently with the need for accreditation, has this training gathered momentum. However, often it is only during the 'inspection' that the protocols are adhered to. This is where 'mindset' comes into the picture. There is a false sense of belief that 'nothing will happen to me' when procedures are undertaken on the patient (PS unpublished observation). This attitude results in not using appropriate personal protective equipment (PPE). Often many procedures are performed by HCWs with their bare hands or deliveries undertaken without use of appropriate PPE to prevent direct exposure.[3]

What constitutes a needle-stick injury?

The World Health Organization (WHO) defines NSIs as a penetrating stab wound from a needle (or other sharp object) that may result in exposure to blood or other body fluids.[4] The main concern is exposure to the blood or other body fluids of another person who may be carrying infectious disease.[5]

NSIs are a hazard for people who work with hypodermic syringes and other needle equipment. These injuries can occur at any time when people use, disassemble or dispose of needles. When not disposed of properly, needles can become concealed in linen or garbage and injure other workers who encounter them unexpectedly.[3]

The WHO reports in the World Health Report 2002, that of the 35 million health-care workers, 2 million experience percutaneous exposure to infectious diseases each year.[4]

When do needle stick injuries occur?

NSIs occur in busy areas such as emergency room, operation theatre and intensive care units.[6] While it is of importance to deliver health-care rapidly in such situations the lack of attention to using PPE is puzzling. The reasons given by HCWs for lack of use of PPE include 'Lack of availability or PPE kept under lock and key' (PS unpublished observation).

In India, two-thirds of HCWs were exposed to NSIs, as per a study conducted by Ashat et al. in two government tertiary care hospitals of Chandigarh.[7] The main factor for NSIs was heavy patient load and maximum accidents occurred during emergency care. A systematic review of literature by Motaarefi et al. in 2016 established that there are no randomised control trials attempting to decrease NSIs, hence limiting the reliability of scientific evidence available.[6]

Factors that increase risks of transmission of HIV include a deep wound, visible blood on the device, a hollow-bore blood-filled needle, use of the device to access an artery or vein and high-viral-load status of the patient. Taken together, these factors can increase the risk of transmission of HIV from a contaminated sharp to 5%.[4] (WHO) Of the 55 centres for disease control and prevention (CDC) documented cases of occupational transmission of HIV, 90% were from contaminated hollow-bore needles that pierced the skin.[8] A study by Wicker et al. shows that among health-care workers stress and tiredness were common factors contributing to NSI.[9] The occupational distribution of NSI is 45% in nurses, 20% in technicians and doctors and 5% among maintenance workers and the most commonly associated procedures are injection, venipuncture, suture and insertion and manipulation of IV catheters.[1]

'Recap of Needles' and Disposal of sharp

Recap of needles poses the highest risk for NSI.[4] Many HCWs have been trained to recap needles and often a NSI occurs during the recap. HCWs have to unlearn the practice to recap the needle. There must be a zero tolerance for recap of the needle, as advocated by the CDC at an institutional level.[10] Recapping of hypodermic needles before disposal into sharps containers, by unnecessary opening of these containers and using poorly designed improper non-puncture proof containers.[5] The data in [Table 1] highlights the incidence and related cause of needlestick injuries in certain countries across the world.
Table 1: Incidence and related cause of needlestick injuries in certain countries across the world

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Another practice of leaving needles lying around without disposing them often occurs during health-care delivery. This may be because the HCW could not access a sharp disposal container or inadvertently forgot to dispose the needles. The absence of use of PPE such as gloves significantly increases the risk of NSI as compared to when gloves are used.

Strategies for needle-stick injury prevention

Centers for disease control and prevention

The CDC standards must be adhered to prevent NSIs. The awareness must be created at an institutional level.

Occupational safety and health administration

The Occupational Safety and Health Administration (OSHA) standards for the prevention of exposure to infectious material (taken from OSHA guidelines for universal precautions, 1992) can also serve as a reference. OSHA guidelines are very comprehensive and include aspects related especially to engineering and administrative controls.

Institutional level

The signage of a NSA prevention protocol must be displayed at different areas of the healthcare facility, especially in busy areas such as the ER. This signage will also assist HCWs to report NSIs. A policy on NSI prevention must be formulated with clear evidence based processes for successful implementation. A NSI reporting form should be readily available for download, to assist the HCW to seek the measures to prevent transmission of infection especially post-exposure prophylaxis (PEP).

Formulation and implementation of other policies are the 'basis of infection control', such as adherence to standard precautions. Vaccinations against Hep B (under vaccinations for HCWs) and estimation of antibody levels to HBV to prevent occupational exposure are necessary to support the NSI prevention strategies.

Further engineering controls such as provision of sharp disposal device at appropriate areas such as the patient bedside and nurse's station also contributes in a major way to prevent NSI.

World Health Organization

To provide a political framework for policy development, a Global plan of Action on Workers' Health (2008–2017) was developed by the WHO in 2007. This framework, addresses worker health, hazard prevention, employment conditions, health promotion and health systems. As a result, this would achieve basic health protection across workplaces, at a global level. Moreover, in this manner, it links occupational health to public health.[1]

Policy strategies to reduce/avoid NSI-associated disease burden must include vaccination against HBV, PEP for HBV, HCV and HIV, reduction in invasive procedures, injections, substitution of equipment to using safer devices and proper disposal techniques (needles/sharps). The impact of NSIs is not recognised and this is especially true within developing countries, where poor knowledge and practices add to the probability of increased sharps injuries.[5]

The Society for Healthcare Epidemiology of America (SHEA) suggests that a HIV/HBV/HCV infected HCW need not be displaced from core clinical practice. He/she may continue to practice after informing patients about the status. Although scientifically this is acceptable, such policies will be difficult to implement in India, as the stigma will preclude the possibility of its implementation.


  Conclusion Top


Increasingly, health-care facilities are applying for the National Accreditation Board for Hospitals and Health care Providers (NABH) and Joint Commission International (JCI) accreditation. All accrediting bodies give emphasis on the implementation of NSI protocols and occupational safety of the HCW. Thus, policies and processes are clearly established in such NABH and JCI accredited facilities. However, there may be occasional lapses as there has to be a systemic change in the behaviour of every HCW to prevent NSI, report NSI and follow-up after an NSI. The non-compliance with reporting of NSI is often out of fear of consequences which may include termination of responsibilities.

At the institutional level, a “No blame no shame” approach to reporting of NSI may go a long way in ensuring high degree of compliance with NSI reporting. The implementation of NSI injury protocol for prevention is not resource intensive and can therefore be easily followed in resource limited settings. Another reason for not reporting a NSI is lack of awareness. Furthermore, frequent trun over of employees especially among housekeeping staff and nursing can create a pool of HCW who are un-trained frequently. The introduction of NSI prevention protocol in the orientation programme for all HCW will also lead to better compliance and create sustained awareness.

Thus, an investment in training and re-training must happen by the stakeholders as the benefits of this training and re-training will go a long way in controlling occupational health hazards leading to better outcome among HCWs and better outcome in public health

Global awareness and prevention of NSIs and safe disposal of sharps has gained momentum. The CDC, SHEA, OSHA and WHO are organisations actively promoting the importance of awareness and training of health-care workers. In India, new biomedical waste management rules 2016 and its amendment in 2018 mandate the reporting of NSI. The successful implementation of such regulations will definitely reduce the health hazards of NSI considerably.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gopar-Nieto R, Juárez-Pérez CA, Cabello-López A, Haro-García LC, Aguilar-Madrid G. Overview of sharps injuries among health-care workers. Rev Med Inst Mex Seguro Soc 2015;53:356-61.  Back to cited text no. 1
    
2.
Prüss-Ustün A, Corvalán C. How much disease burden can be prevented by environmental interventions? Epidemiology 2007;18:167-78.  Back to cited text no. 2
    
3.
Senthil A, Anandh B, Jayachandran P, Thangavel G, Josephin D, Yamini R, et al. Perception and prevalence of work-related health hazards among health care workers in public health facilities in Southern India. Int J Occup Environ Health 2015;21:74-81.  Back to cited text no. 3
    
4.
Yves Chartier JE, Pieper U, Prüss A, Rushbrook P, Stringer R, Townend W, editors. WHO Guidelines-Safe Management of Wastes from Health-Care Activities. 2nd ed. Geneva, Switzerland: World Health Organization Library Cataloguing-in-Publication Data; 2014.  Back to cited text no. 4
    
5.
Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. Centers for disease control and prevention. MMWR Recomm Rep 1998;47:1-39.  Back to cited text no. 5
    
6.
Motaarefi H, Mahmoudi H, Mohammadi E, Hasanpour-Dehkordi A. Factors associated with needlestick injuries in health care occupations: A Systematic review. J Clin Diagn Res 2016;10:IE01-4.  Back to cited text no. 6
    
7.
Ashat M, Bhatia V, Puri S, Thakare M, Koushal V. Needle stick injury and HIV risk among health care workers in North India. Indian J Med Sci 2011;65:371-8.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
New guidelines issued for occupational exposures. AIDS Policy Law 1998;13:10.  Back to cited text no. 8
    
9.
Wicker S, Ludwig AM, Gottschalk R, Rabenau HF. Needlestick injuries among health care workers: Occupational hazard or avoidable hazard? Wien Klin Wochenschr 2008;120:486-92.  Back to cited text no. 9
    
10.
Rishi E, Shantha B, Dhami A, Rishi P, Rajapriya HC. Needle stick injuries in a tertiary eye-care hospital: Incidence, management, outcomes, and recommendations. Indian J Ophthalmol 2017;65:999-1003.  Back to cited text no. 10
[PUBMED]  [Full text]  



 
 
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