see: [Dunn - body fluid exposure](x-devonthink-item://014E903A-FF61-4D75-9468-8428F7503ED8), [Bear HIV PEP](bear://x-callback-url/open-note?id=CB3972AB-DB72-4D71-AEA9-0523B742461B-34582-0000893039BFE3ED), [Cameron Needlestick injuries](x-devonthink-item://05082D11-9127-41D1-95F0-49EF3B1CF19A?page=57), [ASHM PEP guideliens](https://pep.guidelines.org.au/when-to-prescribe-pep/) see also: [[Sexually transmitted Infections|STI]] #infectious_diseases # Healthcare Needlestick overview Needlestick injuries are common among healthcare professionals, especially in nurses and physicians who perform invasive procedures. Mechanical damage from needlestick injuries is essentially negligible. The major concerns are the risk of infection with hepatitis viruses and human immunodeficiency virus (HIV). > The risk of infection in a nonimmune recipient after an inadvertent needle-stick contaminated from an infectious source has been estimated to be: > - negligible for hepatitis A > - 37% to 62% for hepatitis B if the source was hepatitis B e antigen positive; 5% if source is e antigen negative > - about 2-3% for hepatitis C > - 0.3% for HIV ==Postexposure prophylaxis is available for hepatitis B and HIV, but not for hepatitis C.== **first aid** - wash with soap and water and cleanse with antiseptic eg chlorhexidine - do NOT squeeze/encourage bleeding; may paradoxically increase risk of BBV transmission **factors that increase risk of BBV transmission?** - depth of needle - placement in artery or vein - bolus of blood injected - hollow bore needkle - larger needle eg central line needle - visible blood in needle - bare skin vs gloved finger ## Risk of acquiring HIV nb: unknown HIV status assuming MSM HIV seroprevalence of 10% - (brisbane 11.2%, Melbourne 9.5, Sydney 8.5) - HIV seroprevalence within IVDU population australia 0.5% - 30% within MSM IVDU population - 0.1% overall Australian seroprevalence ## Occupational needle stick risks | Virus | Risk of transmission | | ----- | -------------------- | | HIV | 0.3% | | HBV | 30% | | HCV | 3% | # Management ## Counselling exposed worker - advise of risk of specific exposure experienced - most exposures do not result in infection - HIV ~ 0.3% if exposed to HIV blood - Hep B ~25-30% if HBeAg +ve - Hep C 1.8-10% - PEP side effects and suspected efficacy as above - safe sex practices avoid 2ndary transmission first 6-12 weeks especially and generally until 6mo follow up serological test is negative - no need to modify their patient-care responsibilities - follow up imprtant - if pregnant, data shows safety of antiretroviral drugs - temporary discontinuation of breastfeeding following exposure until 6 month serological test is negative should be considered ## post-exposure prophylaxis (PEP) - HIV infection does not become established immediately; brief window of opportunity during which post-exposure antiretroviral intervention might modify or prevent viral replication - early case-control study demonstrated that zidovudine ↓ occupational HIV seroconversion by 81% - animal data also supports use - should start PEP promptly, within 2 hours but may still be effective for up to 72 hours - three drug therapy recommended for all high risk injuries, tenofovir + emtricitabine (or lamivudine) + dolutegravir. for 28 days - 50% of people get symptoms from PEP: - nausea, malaise, headache, diarrhea, anorexia) - 1/3 cease because of side effects ### Hep B ![[Pasted image 20240930100632.png]] ### HIV ![[Pasted image 20240930100924.png]] # Non-occupational risks table | type of exposure | known HIV +ve | unknown HIV status | | ---------------------------------------------------------- | ----------------- | ------------------- | | receptive anal intercourse<br>- ejaculation<br>- withdrawl | <br>1/70<br>1/155 | <br>1/700<br>1/1550 | | contaminated injecting equipment | 1/125 | 1/12,500 | | insertive anal intercourse (circumcised) | 1/900 | 1/9000 | | insertive anal intercourse (uncircumcised) | 1/160 | 1/1600 | | receptive vaginal intercourse | 1/1250 | 1/1.2 mil | | insertive vaginal intercourse | 1/2500 | 1/2.5 mil | | receptive / insertive oral sex | extremely low | | | needle-stick injury or sharps | 1/440 | low risk | | mucous membrane and non-intact skin exposure | <1/1000 | low risk | | needle-stick injury from discarded needle in community | - | low risk | ## Community needlestick - evaluate need for tetanus PPx - consider HBV immunoglobulin and vaccination > Baseline testing for HIV/HCV is NOT indicated or recommended initially. Patients should arrage 3 month testing via their GP ***Actions*** - clean wound with soap and water - Reassure patient that there is negligible risk of contracting a blood borne virus from used needle/syringe in the community (see [[#NPEP recommendations]] table below) - update ADT if due - [[Hepatitis#Hepatitis B|Hep B]] PPx - unimmunised: Immunoglobulin 400 units IM + vaccine 1mL. completion of immunisation course with GP - Immunised and conversion unknown: await serology, infectious diseases or GP can follow up - immune: no further immunisation required ## NPEP recommendations | type of exposure | HIV +ve<br>HIV viral load unknown / detectable | HIV +ve<br>undetectable viral load | Unknown HIV<br>↑↑ ↑ prevalence population (MSM who inject drugs) | Unknown HIV<br>↑ prevalence population (MSM or high prevalence country) | | ----------------------------------------------------- | ---------------------------------------------- | ---------------------------------- | ----------------------------------------------------------------- | ----------------------------------------------------------------------- | | receptive anal sex | 3 drug | Nil | 3 drug | 2 drug | | insertive anal sex (uncircumcised) | 3 drug | nil | 3 drug | 2 drug | | insertive anal sex (circumcised) | 3 drug | nil | 3 drug | nil | | receptive vaginal sex | 3 drug | nil | 3 drug | nil | | insertive vaginal sex | 3 drug | nil | 3 drug | nil | | receptive oral sex | consider if open lesion in mouth/throat | nil | consider mouth lesion | consider if mouth lesion | | semen splash in eye | nil | nil | nil | nil | | shared injecting equipment | 3 drug | 2 drug | 3 drug | 2 drug | | mucosal exposure / splash injury to infectious fluids | 3 drug | nil | 3 drug | nil | | Human bite | consider if visible blood | nil | consider if visible blood | consider if visible blood | | community needle-stick injury | nil | nil | nil | nil |