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Indian Journal of Medical Microbiology, Vol. 27, No. 1, January-March, 2009, pp. 44-47 Brief Communication Needle stick injuries in a tertiary care hospital Jayanth ST, Kirupakaran H, Brahmadathan KN, Gnanaraj L, Kang G Hospital Infection Control Committee, Christian Medical College, Vellore, Tamil Nadu-632 004 Date of Submission: 09-Oct-2007 Code Number: mb09010 Abstract Background: Accidental needle stick injuries (NSIs) are an occupational hazard for healthcare workers (HCWs). A recent increase in NSIs in a tertiary care hospital lead to a 1-year review of the pattern of injuries, with a view to determine risk factors for injury and potential interventions for prevention.Methods: We reviewed 1-year (July 2006-June 2007) of ongoing surveillance of NSIs. Results: The 296 HCWs reporting NSIs were 84 (28.4%) nurses, 27 (9.1%) nursing interns, 45 (21.6%) cleaning staff, 64 (21.6%) doctors, 47 (15.9%) medical interns and 24 (8.1%) technicians. Among the staff who had NSIs, 147 (49.7%) had a work experience of less than 1 year ( P < 0.001). The devices responsible for NSIs were mainly hollow bore needles ( n = 230, 77.7%). In 73 (24.6%) of the NSIs, the patient source was unknown. Recapping of needles caused 25 (8.5%) and other improper disposal of the sharps resulted in 55 (18.6%) of the NSIs. Immediate post-exposure prophylaxis for HCWs who reported injuries was provided. Subsequent 6-month follow-up for human immunodeficiency virus showed zero seroconversion. Conclusion: Improved education, prevention and reporting strategies and emphasis on appropriate disposal are needed to increase occupational safety for HCWs. Keywords: Hospital-acquired infection, needle stick, standard precautions, waste disposal Percutaneous injuries caused by needlesticks pose a significant risk of occupational transmission of bloodborne pathogens such as human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) to healthcare workers (HCWs) . According to the Centers for Disease Control and Prevention, approximately 384,000 percutaneous injuries occur annually in US hospitals, with about 236,000 of these resulting from needlesticks involving hollow-bore needles. EPInet data for 2003 reports a rate of approximately 27 needle stick injuries (NSIs) per 100 beds in teaching hospitals. [1] There are few reports on NSIs from India, [2],[3],[4],[5] and with limited data, it is not possible to estimate an annual incidence. This study was undertaken in response to a perceived increase to review the epidemiology of NSIs and to determine the risk factors and the population at risk in a tertiary care teaching hospital, which has staff and trainees of varying levels of experience. Materials and Methods Study site and procedures The study hospital is a 2234 bed tertiary care hospital that serves as the teaching hospital for colleges of medicine and nursing. The Staff Student Health Service has maintained a NSI register since 1993, and protocols for management and follow-up of NSIs have been established. As soon as a health worker sustains a NSI, he/she is to induce bleeding from the wound and wash with soap and water and to report to the Staff Student Health Services duty doctor immediately. The duty doctor collects information regarding the index patient/source and completes a proforma, which has details of (i) the source, including diagnosis, hepatitis B surface antigen (HBsAg), HIV and HCV antibody status before and after the NSI. If these have not been tested earlier, the investigations are sent and followed-up within 6 h, (ii) health worker, position and work experience, previous history of NSIs or blood transfusions, (iii) vaccination status, including anti-HBs titre, HIV, HBsAg, anti-HCV antibody and (iv) details of the incident, time of incident, time of reporting, place of incident, description of the incident, type of first aid given and whether universal precautions were followed by the HCW. The hepatitis B and HIV follow-up protocol are as follows: in case of a NSI from a HBsAg-positive patient, the anti-HBs titre is checked, and if < 10mIU/mL, a full course of vaccination is given and if between 10 and 100 mIU/mL, a booster dose is given and if more than 100mIU/mL, the HCW is reassured. NSIs from HIV-positive patient are started on antiretroviral therapy (ART, AZT 600 mg/day, lamivudine 300mg/day and indinavir 800 mg every 8 h) for 4 weeks. The health workers are followed-up at 6 weeks, 3 months and 6 months for HIV by enzyme-linked immunosorbent assay (ELISA). We conducted a review and analysis of sharps and NSIs among HCWs in our hospital between July 2006 and June 2007. Statistical analysis Statistical analysis was performed using EpiInfo 6. Associations between categorical variables were assessed using Chi-square tests. A P -value less than 0.05 was considered statistically significant. Results Review of data from the past 5 years showed a distinct increase in 2006 [Figure - 1]. During the period from July 2006 to June 2007, 296 HCWs sustained NSIs. Of them, 84 (28.4%) were nurses, 27 (9.1%) were student/intern nurses, 45 (15%) were class IV or cleaning staff, 64 (21.6%) were doctors, 47 (15.9%) were interns, 24 (8.1%) were technicians and five (1.7%) were other categories of staff [Table - 1]. Nursing and medical interns were a significantly larger proportion of staff sustaining NSIs ( P < 0.001) [Figure - 2]. Among the staff with NSIs, 147 (49.7%) were those who had a work experience of less than 1 year [Table - 1]. It is important to note that the Christian Medical College has approximately 6000 staff, of whom approximately 8% are in their first year of service at any given time. Based on this, the proportion of NSIs among those with a work experience of less than 1 year is significantly higher ( P < 0.001). The majority of the devices responsible for the NSIs were hollow-bore needles ( n = 230, 77.7%), with solid needles accounting for 62 (20.9%) and others for 1.4%. Evaluation of the kind of activity during which the NSI occurred showed that most occurred during procedures ( n = 172, 58.1%). The most common procedure was blood collection (n=102, 59.3%), followed by surgical procedures (22%). Approximately 8% were during checking blood sugar and 3.5% each were contributed by injection administration, intravenous cannulation and others. A large proportion occurred because of incorrect handling such as recapping ( n = 25, 8.5%) and improper disposal of the sharps ( n = 55, 18.6%) and overflowing containers, passing of the device, etc., which accounted for 44 (14.7%) of the NSIs. Despite regular and intensive educational efforts, most NSIs occurred when universal precautions or standard procedures were not followed ( n = 223, 75.3%), while a much smaller proportion ( n = 73, 24.7%) had a NSI despite following adequate precautions. Most NSIs occurred in the wards ( n = 128, 43.2%), followed by operating rooms ( n = 14.9%), secondary-level hospital ( n = 43, 14.5%), accident and emergency/casualty ( n = 34, 11.5%), intensive care units ( n = 19, 6.4%) and other sites ( n = 28, 9.5%). Of the health workers who sustained NSIs, 98 (33.1%) were not adequately immunized for hepatitis B, while 198 (66.8%) had received three doses of the vaccine and a booster within 5 years or had an anti-HBs titre > 100mIU/mL. There was no association between incidence of NSIs and the shift/time of work. At least two-thirds ( n = 202, 68.2%) of the NSIs were reported within 1 h. Known sources accounted for 223 (75.3%) NSIs and unknown sources accounted for 73 (24.6%) of the injuries. Of the known sources, 20 (9.0%) were positive for HBsAg, 14 (6.3%) for HIV and three (1.3%) for HCV. Health workers were followed-up at 1, 3 and 6 months for HIV. The follow-up was complete in 293 (98.9%) individuals and showed zero seroconversion at 6 months. Discussion According to EPInet data, [1] an equivalent number of injuries for a 2200-bed teaching hospital such as the Christian Medical College would be 594 reports in a year. The number reported in 2006 represents a large increase over previous years, but is less than that expected based on EPINet data. In the absence of active surveillance, it is not possible to define whether the perceived increase in 2006 is a true finding or is due to increased reporting. In our study, the majority of the HCWs who had NSIs were nurses and doctors (43.2%), followed by interns and class IV staff (8 and 15% respectively). Interns form a small proportion of the medical or nursing staff in a teaching hospital, but accounted for a large proportion of the injuries. This can be a reflection of the larger number of exposure-prone procedures conducted by these categories, or of their inexperience, a finding also supported by the fact that almost half the NSIs involved staff with less than 1 year of work experience. Our findings also point to the need for greater and continuing education on the use of universal precautions or standard procedures in all categories of the staff because most NSIs occurred in staff who did not follow protocol. It is estimated that approximately 3 million HCWs experience percutaneous exposure to bloodborne viruses (BBVs) each year. This results in an estimated 16,000 hepatitis C, 66,000 hepatitis B and 200-5000 HIV infections annually. [6] However, at least 11% of the NSIs that were contributed by blood sugar monitoring and intravenous cannulation could potentially be prevented by the use of safety devices such as special cannulae and lancet pens for sugar estimation. Our findings showed that 17% of index patients were known to be infected with a BBV. It would be interesting to analyse data on BBV infections on a hospital-wide basis because it is unlikely that the general patient population would have such a high proportion of positivity for these viruses. In this situation, it is important to consider that there may be significant under-reporting of NSIs, with reports being made more often if the index patient is a known positive, but less often if the index patient is not known to be positive. Six-month follow-up showed zero seroconversion for HIV ELISA, which is similar to the other studies in India India [Table - 2]. [2],[5] Worldwide, there are 296 cases of HIV seroconversion after occupational exposure, of which 56 are documented while 138 are possibly occupationally acquired. [1] In India, two possible cases of occupationally acquired HIV infection have been reported from Chandigarh. [7] There is a paucity of data on NSIs in India [Table - 2]. While we appear to have lower levels of NSIs than expected, this may be due to underreporting. Improper handling and disposal and a lack of adherence to standard procedures are responsible for the majority of NSIs, indicating that there is the opportunity for significant reduction of NSIs through education and other interventional strategies. References
Copyright 2009 - Indian Journal of Medical Microbiology The following images related to this document are available:Photo images[mb09010t2.jpg] [mb09010t1.jpg] [mb09010f1.jpg] [mb09010f2.jpg] |
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