Needlestick injury: Difference between revisions

A needlestick injury or percutaneous injury is the penetration of skin resulting from a needle or other sharp object, which prior to the exposure was in contact with blood, tissue, or other body fluid.^[1] Occupational needle-stick injuries primarily affect healthcare workers, who make up 80% of needlestick injuries in the United States.^[1][2] Various other occupations are also at increased risk of needlestick injury, including but not limited to law enforcement, laborers, tattoo artists, food preparers, and agricultural workers.^[2][3] Though the acute physiological effects of a needlestick injury are generally negligible, the efficiency with which these devices transmit blood-borne diseases place those exposed at increased risk of contracting infectious diseases, such as hepatitis B (HBV), hepatitis C (HCV), and the human immunodeficiency virus (HIV). Among healthcare workers and laboratory personnel worldwide, more than 25 blood-borne viruses have been reported to be caused by needlestick injuries.^[4]

It is estimated that half of all occupational needlestick injuries are not reported.^[5][6] Additionally, an unknown number of occupational needlestick injuries are reported by the affected employee, yet due to organizational failure, institutional record of the injury does not exist.^[6] Increasing recognition of the unique occupational hazard posed by needlestick injuries, as well as the development of efficacious interventions to minimize the largely preventable occupational risk, encouraged legislative regulation in the US, causing a decline in needlestick injuries among healthcare workers.^[7][8]

Needlestick injuries are a common event in the healthcare environment. When drawing blood, administering an intramuscular or intravenous drug, or performing innumerable other procedures involving sharps, accidents transpire, facilitating the transmission of blood-borne pathogens. Injuries also commonly occur during needle recapping or via improper disposal of devices into an overfilled or poorly located sharps container. Lack of access to appropriate personal protective equipment, or alternatively, employee failure to utilize provided equipment, increases the risk of occupational needlestick injuries.^[4] NSI are also at increased risk of ensuing as needles are exchanged between personnel, loaded into a needle driver, or when sutures are tied off while still connected to the needle. Night shifts have demonstrated increased risk of occupational needlestick injuries in the healthcare environment.^[5] A lack of professional experience also demonstrates increased risk. During surgery, a surgical needle or other sharp instrument may inadvertently penetrate the glove and skin of operating room personnel; scalpel injuries tend to be larger than a needlestick. Generally though needlestick injuries cause only minor visible trauma or bleeding; however, even in the absence of bleeding the risk of viral infection remains.

In 2007, the World Health Organization estimated annual global injuries at 2 million per year. The European Biosafety Network estimated 1 million annual needlestick injuries in Europe.^[9] Another investigation estimated the rates of injuries on a global level to affect about 3.5 million individuals.^[3] The US Occupational Safety and Health Administration (OSHA) estimates 5.6 million workers in the healthcare industry are at risk of occupational exposure to blood-borne diseases via percutaneous injury.^[10] CDC estimates more than 600,000 NSI occur among HCW in the US annually.^[11] More than half of US healthcare workers are employed in healthcare settings other than hospitals, where surveillance efforts are not as robust.^[12]

Among healthcare workers, nurses and physicians appear especially at risk.^[13] An investigation among American surgeons indicates that almost every surgeon experienced at least one such injury during their training.^[14] More than half of needlestick injuries that occur during surgery happen while surgeons are sewing the muscle or fascia.^[10] Within the medical field specialties differ in regard to the risk of needlestick injury, thus surgery, anesthesia, ENT, internal medicine, and dermatology tend to show relatively high, and radiology and pediatrics relatively low rates of injury.^[15][16] Half or more events may go unreported as injured healthcare workers may not take the time to report, downplay the risk, or fear stigmatization and professional consequences.^[8]

Needlestick injuries may occur not only with freshly contaminated sharps, but risk is also manifest in needles contaminated by dry blood. Infectious agents that transmit HIV and HCV diminish within a couple of hours following contamination of bio-medical devices, but HBV remains stable during desiccation, engendering a protracted duration of risk for contaminated bio-medical devices relative to HBV.^[17] Accordingly, needlestick injuries are of significant concern to occupations working externally to the healthcare environment, such as law enforcement, municipal/commercial waste collectors, laborers, and agricultural workers. Similar to workers in the healthcare sector, law enforcement affected by occupational NSI demonstrate decreased rates of incident reporting. In San Diego 30% of police workers reported such injuries typically when searching suspects. A study of 1,333 police officers in the Denver Police Department found that only 43.4% of those exposed to occupational NSI reported the injury. 42% of respondents indicated they were on second duty shift (evenings) when they were injured. Additionally, nearly two-thirds of law enforcement personnel who experienced needlestick injuries indicated the incident occurred during their first five years of experience.^[18] A law enforcement study in New York City Police Department identified 38.7 exposures per 10,000 police officers (includes bites & sticks), while Patrol & Narcotics officers had a 43.6/10,000 exposure rate.^[19]

CDC estimates approximately half of sharps injuries go unreported.^[11] The literature detailed multiple rationales utilized to justify failure to report occupational NSI among HCW. The fundamental reason provided, the extended duration of the reporting process, incongruous with the schedules sustained by healthcare workers.^[20] Studies have shown more effective reporting systems, like internal hotlines or response teams, would likely effect increased reporting of needlestick injuries among HCW.^[20] Alternately, a witness to the incident was the strongest predictor of reporting.^[20]

Physicians have demonstrated decreased rates of reporting NSI needlestick injuries relative to other healthcare workers such as nurses and laboratory technicians. This phenomenon has been attributed to an unwritten “culture of silence”. Within the medical community, specifically among physicians, needlestick injuries are generally considered “part of the job”. Moreover, reporting a needlestick injury was associated with a detrimental professional impact.^[20] Reporting NSI is considered verboten, lest superiors and colleagues lose professional respect and esteem.^[20] Also noted in the literature, failure to report occupational NSI resulted from deficient education and a perception of minimal risk of disease transmission associated with NSI. Many healthcare workers erroneously believe receiving prompt medical attention will not affect risk of infection.^[20] Additionally, healthcare workers often decided whether or not to report an injury based on their subjective perception of the health and lifestyle of the patient.^[21] As medical experts, many HCW naively trust that they can properly assess the risk of contracting HIV, hepatitis B, and hepatitis C from respective patients via initial observation, which in itself is constructed upon pre-ordained subjective beliefs.^[21] Studies have observed that most surgeons substantially underestimate seroconversion rates of HIV, hepatitis B, and hepatitis C exposures, suggesting that more education on the subject in surgical training might improve rates of reporting and expedite PEP treatment.^[22] Finally, evidence in the literature demonstrated that a greater number of injuries over time was associated with a lower likelihood of reporting. Arguably, this results from increased desensitization with each new incident, or as noted above, chagrin.

Exposure to NSI occurs in diverging conditions relative to occupation type. Researching the epidemiology of occupational needle-stick injuries is problematic. Epidemiologic data characterizing occupational NSI is derived from highly variable comparisons of populations & settings. Epidemiologic data of occupational NSI thus is not representative of all hospitals, nor is representative of healthcare environments beyond hospitals. Available surveillance data, though incomplete and imperfect, demonstrates robust consistency such that expected injury patterns can be reasonably estimated.^[23]

Surveillance systems have been to track sharps injuries and the progress that is achieved in the elimination of NSI. Foremost in surveying occupational NSI are NaSH^[1] and EPINet, or the Exposure Prevention Information Network, managed by the International Healthcare Worker Safety Center at the University of Virginia.^[24] NaSH is a voluntary system used by hospitals to report occupational percutaneous injuries, exposure to blood & other bodily fluids, & other information corresponding to the prevention of occupational exposures & infections among US HCW.^[1] Participating hospitals are predominantly large institutions, most of which are located in the Northeastern United States.^[1] EPINet is a standardized method for recording and tracking needlestick injuries.^[24] More than 1500 hospital in the US voluntarily utilize EPINet, which can be acquired free of charge.^[24] Beginning in 1994, EPINet has collected annual reports with NSI data categorized by profession, location, and/or device.^[24] As of 2007 there were 33.49 reported needlestick injuries per 100 occupied beds in teaching hospitals, and 16.16 reported needlestick injuries per 100 occupied beds in nonteaching hospitals.^[24]

While needlestick injuries have the potential to transfer bacteria, protozoa, viruses and prions,^[8] transmission of hepatitis B, hepatitis C, and HIV is particularly concerning. The World Health Organization estimated that in 2000, 66,000 hepatitis B, 16,000 hepatitis C, and 1,000 HIV infections were caused by needlestick injuries.^[3][4] Hepatitis B carries the greatest risk of transmission, with 37-62% of exposed workers eventually showing seroconversion and 22-31% in which hepatitis B infection clinically manifests.^[11][12] Higher rates of hepatitis B vaccination among the general public and healthcare workers alike has reduced the risk of transmission.^[4]Though the prevalence of NSI is concentrated among HCW, other occupations at risk of exposure generally have lower vaccination rates than do HCW.^[25] Thereby risk of vaccine-preventable diseases among non-HCW, particularly hepatitis B, is increased relative to that of healthcare workers. The hepatitis C transmission rate has been reported at 1.8%,^[11][20] but newer, larger surveys have shown only a 0.5% transmission rate.^[21] The overall risk of HIV infection after percutaneous exposure to HIV-infected material in the health care setting is 0.3%.^[26][4] Individualized risk of blood-borne infection from a used biomedical sharp is further dependent upon additional factors. Injuries with a hollow-bore needle, deep penetration, visible blood on the needle, a needle located in a deep artery or vein, or a biomedical device contaminated with blood from a terminally ill patient increase the risk for contracting a blood-borne infection.^[24][25]

After a needlestick injury, certain procedures must be followed to minimize the risk of infection for the recipient. Lab tests of the recipient are obtained for baseline studies: HIV, acute hepatitis panel (HAV IgM, HBsAg, HB core IgM, HCV) and for immunized individuals, HB surface antibody.[19] Unless already known, the infectious status of the source needs to be determined by checking for HBsAG, anti-HCV, and HIV antibody.[19] Unless the source is known to be negative for HBV, HCV, and HIV, post-exposure prophylaxis (PEP) should be initiated, ideally within one hour of the injury;^[15] typically this is done in the emergency department or the occupational health office. Guidelines for PEP have been updated over recent years in view of the introduction of new drugs, and protocols may differ somewhat between countries.

After exposure to the hepatitis B virus (HBV), appropriate and timely prophylaxis can prevent HBV infection and subsequent development of chronic infection or liver disease. The mainstay of PEP is the hepatitis B vaccine, though in certain circumstances, hepatitis B immune globulin is recommended for added protection, in addition to the vaccine.^[17]

Immune globulin and antiviral agents are not recom¬mended for PEP after exposure to HCV-positive blood.^[27] No vaccine against HCV exists. In the absence of PEP for HCV, recommendations for postexposure management are intended to achieve early identification of infection; if present, referral are provided for treatment. No guidelines exist for administration of therapy during the acute phase of HCV infection. However, limited data indi¬cate that antiviral therapy might be beneficial when started early in the course of HCV infection. When HCV seroconversion is identified early, the person should be referred for medical management to a knowledgeable specialist.

If the status of the source patient is unknown, HIV tests should be initiated for the patient as soon as possible following exposure to determine the risk of the NSI to the exposed HCW.^[15] CDC recommends taking antiretroviral medicines as soon as possible, but no more than 72 hours (3 days) after you may have been exposed to HIV, to try to reduce the chance of becoming HIV-positive.^[15] All persons for whom HIV PEP has been initiated should be referred to a clinician experienced in HIV care for follow up. CDC guidelines generally recommend a PEP protocol with 3 or more antiviral drugs, when it is known that the donor was HIV positive; however, when the viral load was low and none of the above noted risk factors are met, the CDC protocol utilizes 2 antiviral drugs. Such a 2-drug protocol should also be considered when the donor status cannot be determined (e.g. injury by a random needle in a used sharps container), but there is an increased risk that the source was from a risk group for HIV.[16] PEP drugs for prevention of HIV infection are given for 4 weeks and may include nucleoside reverse transcriptase inhibitors (NRTIs), nucleotide reverse transcriptase inhibitors (NtRTIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors(PIs), and a single fusion inhibitor. PEP anti-HIV regimens are accompanied by significant side effects and their utilization is not indicated when there is evidence that HIV transmission is not involved; also, initiated protocols can be stopped when data appear indicating that the source-person is HIV-negative. Regardless whether PEP is instituted, follow-up of exposed individuals includes counseling and HIV testing by enzyme immunoassay to monitor for a possible seroconversion for at least 6 months after exposure. Such tests are done at baseline, 6 weeks, 12 weeks, and 6 months and longer in specific circumstances, such as co-infection with HCV.^[15]

Research concerning the psychological and behavioral effects of occupational NSI is limited. Psychological effects of occupational NSI include health anxiety (fear of contracting disease); general anxiety, corresponding to agonizing about negative reactions upon disclosure and/or unintended transmission to a sexual partner; NSI trauma-related anger/frustration; & depression.^[28] Consistently demonstrated across pyscho-behavioral research, concomitant self-destructive behaviors accompany traumatic mental distress. Exposure to occupational NSI potentially manifests as functional impairment across work, social, sexual, & familial relationships.^[28]

Research indicated objective knowledge concerning disease transmission and/or efficacy of PEP, which is presumably general knowledge among HCW, does not mitigate the effects of psychological trauma.^[28] Adverse psychological effects among the majority of those exposed to occupational NSI abate at the conclusion of testing, however.^[28] For some individuals exposed to occupational NSI though, the requisite repeated testing over six months compounds the initial anxiety experienced subsequent to the NSI.^[28] Among a further substantive minority of workers, adverse psychological effects persist, in spite of negative test results.^[28] Researchers have thus hypothesized occupational NSI provoke Post-Traumatic Stress Disorder (PTSD) in some individuals.^[28]

Prevention of needle-stick injuries should be founded upon a multi-faceted intervention strategy.^[23][29][30] Interventions to reduce NSI in the healthcare environment include proper utilization of the devices, elimination of unnecessary sharps use, engineering controls, training programs, and institutional provision of adequate resources. Work practice controls can also be introduced, such as using instruments (not fingers) to grasp needles, load scalpels, and avoiding hand-to-hand exchange of sharp instruments. Engineering controls, which include the development of safety needles and needle removers, can be adopted.[23] Engineered safety devices also include retractable needles, needle shields and sheaths, needle-less IV administration kits, passive devices that require no activation, and connectors of intravenous delivery systems that use blunt or valved ends.^[31]

Some studies have found these safer needles reduce injuries, but others have shown mixed results or no benefit.^[4] The adherence to "no-touch" protocols that eliminate direct contact with needles during use and disposal greatly reduce the risk of NSI. In the surgical setting, especially in abdominal operations, blunt-tip suture needles were found to reduce needle stick injuries by 69%. Blunt-tip suture needles can be used to sew muscle and fascia. Though they are more expensive than sharp-tipped needles, this cost is balanced by the reduction in injuries, which are expensive to treat.[9] Sharp-tipped needles cause 51-77% of surgical needlestick injuries.[6] The American College of Surgeons (ACS) has endorsed the adoption of blunt-tip suture needles for suturing fascia and muscle.[9][24] Hollow-bore needles pose a greater risk of injury than solid needles, but hollow-bore needle injuries are highly preventable: 25% of hollow-bore needle injuries to healthcare professionals can be prevented by using safer needles.^[4] In addition, the use of two pairs of gloves, double gloving, can halve the risk of needle stick injury in surgical staff. Triple gloving may be more effective than double gloving, but using thicker gloves does not make a difference.^[9] A 2014 Cochrane review found low quality evidence showing that safety devices on IV start kits and venipuncture equipment reduce the frequency of needlestick injuries. However, these safety systems can increase the risk of exposure to splashed blood.^[4]

A 2011 systematic review by Yang and Mullen^[29] established that training and the introduction of safety-engineered controls into the healthcare workplace reduced the risk of NSI. From the literature, they ascertained two safeguard interventions, double-gloving & blunt-tip needles, as well as educational training programs, reduce NSI among healthcare workers. A trial^[30] from an academic hospital in the Netherlands randomized almost 800 Dutch health care workers at risk of needle-stick injuries into three groups, a combined intervention consisting of an interactive workshop and introduction of safety-engineered devices, a group only participating in the interactive workshop, and a control group exposed to neither intervention. The combined intervention of the workshop and the introduction of SED demonstrated effectiveness to reduce the risk of NSI among healthcare workers.^[30] The 2014 Cochrane Review^[9] determined evidence related to safety-engineered devices and effecting reductions in occupational NSI among HCW was deficient in quality. Studies generally had a high risk of bias and found ‘only very low quality, inconsistent evidence that most safety devices prevent needlestick injuries’.^[9] The authors opined confounding & bias potentially produced the observed results.^[9] Accordingly, the authors noted that ‘[t]his does not mean that these devices are not effective’.^[9] A 2015 meta-analysis^[23] concluded needle-stick injuries are likely preventable. Interventions intended to reduce NSI in healthcare settings were compared, including proper use and safety training, safety-engineered device controls (SED), and a combined training and safety-engineered device intervention. Notwithstanding variability across study designs and populations of interest, the interventions were found to significantly reduce NSI in healthcare environments. Combined training and SED interventions demonstrated the greatest reduction in risk.

Costs of receiving a needlestick injury vary, encompassing both direct and indirect costs. Tasked with preparing a cost-benefit analysis, the US General Accounting Office (GAO) determined the reduction in costs associated with treating occupational NSI would exceed the costs related to updating hospital inventories with safety-engineered devices.^[12] In other words, the benefits of federal regulation exceeded the costs of implementation. Solely based on these savings, the nonpartisan governmental agency concluded the legislative intervention reasonable and warranted.^[12] The GAO noted additional savings that are more difficult to quantify, including cost of prophylaxes, wages and time lost by affected workers, reduced quality of life in affected workers, emotional distress of the affected individual, emotional distress of his/her family and colleagues, lifetime treatment costs associated with blood-borne diseases post-prophylaxis, potential decreased organizational liability expense, and an extremely remote possibility of mortality.^[12] Testing and follow-up treatment for healthcare workers who experienced a needlestick injury was estimated at $5,000, depending upon the medical treatment provided. Costs that are more difficult to predict due to accumulation over time include emotional consequences, such as fear and anxiety about potential exposure, costs associated with drug toxicity, work productivity loss, and societal costs relating to HIV, HBV, or HCV seroconversion. HIV, HBV, and HCV specifically include the loss of worker’s services in health care, economic hardship, and litigation costs. The American Hospital Association has said that a case of infection by blood-borne pathogens potentially total $1 million for testing, follow-up, and disability payments. An estimated $1 billion annually is saved by preventing NSI among HCW in the US, including fees associated with testing, laboratory work, counseling, & follow-up costs.^[11]

Led by its bio-medical engineering sector, the United States has been a global leader in minimizing the risk of needlestick injuries among healthcare workers.^[8] The primary pieces of federal legislation regulating this occupational hazard, the Needlestick Safety and Prevention Act of 2000 and the subsequent Bloodborne Pathogens Standard of 2001.^[8] These national regulations require that employers identify and implement safer needle devices, request employee input with respect to appropriate engineering controls, and require healthcare facilities to maintain a sharps injury log.^[8][32][33][9][26]9][26] In the US, nonsurgical needlestick injuries decreased by 31.6% in the five years following the passage of the Needlestick Safety and Prevention Act of 2000. However, this legislation did not affect surgical settings, where injuries increased 6.5% in the same period.[2]

Needle syringe programs were first established in 1981 in Amsterdam, the Netherlands, as a (persons who inject drugs) PWID-community initiated response to an influx of hepatitis B.^[13] Spurred to urgency by the introduction of HIV/AIDS, needle syringe programs (NSP) quickly became an integral component of public health across the developed world.^[14][16][18] NSP function as facilities in which PWID can receive sterile syringes and injection equipment.^{[13][18][19][34]} Preventing the transmission of blood-borne disease among PWID essentially requires sterile syringes and injection equipment for each unique injection,^[19][34] which is necessarily predicated upon access and availability of these materials at no cost for PWID.^[18][19]

NSP are an effective way of decreasing the risk associated with needlestick injuries. These programs remove syringes contaminated by use from the street, reducing the risk of inadvertent transmission of blood-borne infections to the surrounding community. SEPs benefit law enforcement by reducing risk of exposure to infectious disease through an occupational needlestick injury. A study in Hartford, CT looked at syringe access and law enforcement needlestick injuries before and after laws regarding needlestick access were implemented. A study found that needlestick injury rates among Hartford police officers were lower after the new laws (six injuries in 1,007 drug-related arrests for 6-month period before new laws vs. two in 1,032 arrests for 6-month period after new laws).[27]

Data almost universally confirm the value of NSP.^[14][16][35] The first systematic review of international evidence concluded NSP decrease the risk of HIV among PWID.^[13] Applying the Bradford-Hill criteria to NSP in locations worldwide, Wodak et al. determined there is “compelling evidence of effectiveness, safety, and cost-effectiveness” of NSP and found no “convincing evidence of any major unintended negative consequences".^[13] A 2013 meta-analysis^[35] similarly affirmed NSP, when instituted as part of a “comprehensive programme of interventions to reduce both injecting risk and other types of HIV risk behaviour"^8, decrease HIV infections. Seven reviews conducted by US agencies reached identical conclusions, as have WHO, the UN, and CDC.^[13][19] US states that publicly fund NSP are associated with reduced rates of HIV transmission, increased availability of sterile syringes among PWID, and increased provision of health and social services to PWID.^[36] States that do not fund NSP in contrast, are associated with increased rates of HIV/AIDS.^[36]

Nevertheless, the US government has explicitly prohibited federal funding for NSP since 1988.^[13] A manifestation of the zero tolerance approach of US drug policy,^[14] the prohibition of funding for NSP has ramifications for national and global population health.^[36] Structural barriers^[16][36] have acutely curtailed the implementation of NSP in the US, specifically the absence of public funding and the criminalization of IDU harm reduction.^[36] Explicit prohibition of federal funding for NSPs continues to obstruct national and global HBV, HCV, and HIV prevention.^[36]

• Scalpel#Scalpel injuries
• Sharps waste

• Animated Tutorials - Preventing Needlestick Injuries
• http://www.gao.gov/products/GAO-01-60R GAO
• Preventing Needlestick Injuries in Health Care Settings, an alert from the National Institute for Occupational Safety and Health (NIOSH)
• What Every Worker Should Know: How to Protect Yourself From Needlestick Injuries, from the National Institute for Occupational Safety and Health
• NIOSH Bloodborne Infectious Diseases Topic Page
• International Healthcare Worker Safety Center, University of Virginia
• Needlestick Injury Charts and Statistics by Revolutions Medical Corp
• Needlestick Health Risks by Revolutions Medical Corp
• Worker Information http://www.cdc.gov/niosh/topics/bbp/emergnedl.html