|Year : 2017 | Volume
| Issue : 2 | Page : 94-101
Needlestick, sharp, and splash injuries in a tertiary care government hospital of South India
Apurba Sankar Sastry, Deepashree Rajshekhar, Prasanna Bhat
Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Submission||04-Aug-2017|
|Date of Acceptance||23-Sep-2017|
|Date of Web Publication||8-Jan-2018|
Dr. Apurba Sankar Sastry
Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
Source of Support: None, Conflict of Interest: None
Background: Needlestick, sharp, and splash injuries (NSSSIs) are the major occupational hazards among the healthcare workers (HCWs) for blood-borne viruses (BBVs) such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). This study was designed to determine the impact of an established nodal center for NSSSI management and to analyze the epidemiological characteristics.
Materials and Methods: Dedicated nodal center was established for NSSSI documentation. A standard operating protocol was set for NSSSI management and postexposure prophylaxis (PEP) for BBVs. The epidemiological characteristics of NSSSIs were collected using a structured pro forma.
Results: Between December 2014 and November 2016, 452 NSSSIs were reported, which included 411 (90.9%) needlestick and other sharp injuries and 41 (9.1%) splash injuries. Doctors reported the maximum episodes (32.5%), followed by attenders (28.8%) and nurses (21.9%). Most injuries were contracted during device use (44.8%), followed by after withdrawal before disposing (28.5%) and recapping (14.8%). Increased reporting was observed among newly-joined junior doctors. 6.9% of source was positive for BBVs (1.8% HIV; 4.0% HBV; 1.1% HCV). PEP first dose was taken by 30.5% of HCWs. PEP continuation was indicated in 161 cases but could not be traced. 40.9% HCWs were completely vaccinated for HBV (of which 49.2% are protected), 7.1% were partially, and 52.0% were not vaccinated.
Conclusion: Our findings endorse the essential role of an established nodal center for NSSSI documentation. Continuous education, engineering control, vaccination campaign, and other interventional strategies such as biomedical waste auditing are crucial measures which should be taken to tackle this issue.
Keywords: Needlestick injury, sharp injury, splash injury
|How to cite this article:|
Sastry AS, Rajshekhar D, Bhat P. Needlestick, sharp, and splash injuries in a tertiary care government hospital of South India. J Curr Res Sci Med 2017;3:94-101
|How to cite this URL:|
Sastry AS, Rajshekhar D, Bhat P. Needlestick, sharp, and splash injuries in a tertiary care government hospital of South India. J Curr Res Sci Med [serial online] 2017 [cited 2018 Jan 20];3:94-101. Available from: http://www.jcrsmed.org/text.asp?2017/3/2/94/222417
| Introduction|| |
Needlestick, sharp, and splash injuries (NSSSIs) are the major occupational hazards among healthcare workers (HCWs). Hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) are the most common blood-borne viruses (BBVs) that are transmitted by NSSSIs. The risk of transmission of HBV, HCV, and HIV following NSSSIs is about 3%–10%, 3%, and 0.3%, respectively.
Every year, globally, more than 35 million HCWs are at risk of acquiring NSSSIs. On an average, every HCW contracts four NSSSIs per annum, especially in developing countries. It is estimated that nearly 2 million NSSSIs per year are reported globally, the majority being reported from developed countries. This estimate is very low as majority of exposures (40%–75%) particularly those from developing countries are underreported. This may be due to unavailability of active surveillance system, lack of awareness, or lack of time resulting from increased work pressure.
The World Health Organization recommends that every hospital should possess an established nodal center for documenting NSSSIs., Timely reporting of NSSSIs has several benefits as it (i) warrants necessary counseling, (ii) facilitates initiating early prophylaxis, testing the source status, (iii) helps investigate the cause of exposures and finding out methods including engineering control that would prevent further injuries, and (iv) establishes any legal prerequisites for HCWs reimbursement or compensation.
Unfortunately, there are very few landmark studies from large-scale government hospitals in India documenting the existence of a dedicated nodal center for NSSSIs. Failure to report NSSSIs precludes the HCW from receiving postexposure prophylaxis (PEP). In our hospital, NSSSI was highly underreported as there was no well-established active reporting system. Therefore, this study was designed to determine the impact of an established nodal center for NSSSI management and to study the epidemiological characteristics of NSSSIs and PEP follow-up.
| Materials and Methods|| |
The study was conducted for 2 years from January 2015 to December 2016 at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), a 2150-bedded tertiary care government teaching hospital, South India. The Hospital Infection Control Committee (HICC) was made the central nodal center for reporting of NSSSIs. A designated infection control nurse (ICN) was appointed for NSSSIs management. Four peripheral nodal centers were created, one for each building, where the first dose of PEP for HIV was made available. The antiretroviral therapy (ART) clinic was the nodal center for continuation of PEP for HIV, and the Department of Medical Gastroenterology was the nodal center for PEP for hepatitis B. Posters were distributed and an educational session was taken to create awareness at the beginning.
Protocol for the management of needle stick, sharp, and splash injuries
HICC has established the protocol for management and follow-up of NSSSIs.
- First step ( first aid): Soon after the injury, the HCW has to clean the site with soap and water
- Second step (PEP first dose): The HCW has to go to the designated peripheral nodal centers and receive the first dose PEP for HIV within 2 h
- Third step (reporting to HICC): The HCW has to report to HICC immediately. Round-the-clock helpline numbers were provided to HCWs
- Fourth step (Filling NSSSI Reporting Proforma): Detailed information about the incident, source status, etc. was collected by the ICN using a reporting pro forma which was adapted and modified from EPINet Blood and Body Fluid Exposure report.
Protocol for postexposure follow-up for human immunodeficiency virus, hepatitis B, and hepatitis C
The source as well as the HCWs were tested for HIV (anti-HIV antibody), hepatitis B (surface antigen, i.e., HBsAg, and anti-HBs antibody if the HCW is previously vaccinated), and hepatitis C (anti-HCV antibody).
- PEP for HIV: If the source was unidentified or found positive for HIV antibodies, the HCW was directed to attend ART clinic for PEP continuation for 28 days. The HCW was also advised for follow-up testing at 6 weeks, 3 months, and 6 months
- PEP for hepatitis B: If the source was unidentified or found positive for HBsAg and the HCW was not protected, the HCW was advised to take hepatitis B immunoglobulin (HBIG). The HCWs who were partially or not vaccinated or vaccinated but not protected were advised to take hepatitis B vaccine. The HCW was also advised to test for HBsAg at 6 months
- PEP for hepatitis C: If the source was unidentified or was found positive for HCV, counseling was given to HCW about the mode of transmission of the virus and hence to avoid working in high-risk area and to avoid sexual activity. The HCW was also advised to test for HCV antibody at 6 months.
| Results|| |
We conducted a detailed analysis of NSSSIs among HCWs reported in our hospital between December 2014 and November 2016.
Epidemiology of needlestick, sharp, and splash injuries
[Table 1] describes the epidemiological characteristics of NSSSIs. Out of 507 cases of NSSSIs (13.1 episodes per 100 occupied beds per year or OBY), 55 cases were incompletely reported, i.e., they took advice over telephone but never turned up to report to the nodal center), therefore were excluded from data analysis. The remaining 452 cases (11.6/100 OBY) reported to HICC, which includes 411 (90.9%, 10.6/100 OBY) needlestick and other sharp injury (NSSIs) and 41 (9.1%, 1.0/100 OBY) splash injuries. NSSIs were further categorized into 354 (78.3%) needlestick injuries (NSIs) and 57 (12.6%) other sharp injuries.
Male to female ratio was found to be 1:1.6. HCWs between 20 and 30 years of age reported maximum injuries (51.1%). Doctors reported the maximum episodes (32.5%), followed by attendants (28.8%) and nurses (21.9%). Most injuries occurred in the wards (28.3%), operation room (17.7%), and ICUs (16.2%). Fingers (62.5%) accounted for maximum injuries, most commonly affected being being left index (51%); while splash injury occurred most commonly on nonintact skin (53.7%) followed by conjunctiva (36.6%). Analysis of the items involved in injuries revealed that hollow needles accounted for 86.7% of episodes of NSIs whereas most of the other sharp injuries were due to surgical blades. 67.2% of NSSIs were moderate severity while most of the splash injuries (78%) were mild severity. Gloves were used only by 37.2% of HCWs. Analysis of PPEs used by HCWs with splash injuries showed that mask, gown, and laboratory coats were worn by 29.3%, 26.8% and 4.9% of HCWs, respectively, whereas goggles or eyeglasses were used by none of them. [Figure 1] depicts the month-wise break-up of NSSSIs during the study period.
|Figure 1: Activity during which needlestick and sharp injuries occurred (n = 411)|
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As shown in [Figure 1], most injuries occurred during device use (44.8%), followed by after withdrawal before disposing (28.5%). Recapping was the reason for 14.8% of episodes.
[Figure 2] depicts the month-wise trend of NSSSIs. There was baseline reporting of 11 to 16 NSSSIs every month with occasional peaks (24–31 cases) at February–March 2015, October–November 2015, February 2016, and November 2016. The number of NSSSIs cases was 234 and 218 for the years 2015 and 2016, respectively.
Source status was not known in 33.8% (153/452) of episodes and maximum of those exposures occurred to attenders (41.8%, 64/153). In about 6.9% (31/452) of episodes, the source tested positive for BBVs, of which 8 (1.8%), 18 (4.0%), and 5 (1.1%) were positive for HIV, HBV, and HCV, respectively. The first dose of PEP for HIV was taken only by 30.5% (138/452). PEP continuation for HIV was indicated for 161 HCWs which includes eight source positive and 153 source unidentified cases and these HCWs were directed to attend the ART clinic.
About 185 out of 452 HCWs (40.9%) were completely vaccinated for hepatitis B (of which 91, i.e., 49.2% are protected) and 32 (7.1%) were partially vaccinated and 235 (52.0%) were not vaccinated. Follow-up advice was given to the HCWs depending on the source status and vaccination status of the HCW as per the Centers for Disease Control and Prevention (CDC) Guideline [Figure 3], [Figure 4], [Figure 5].
|Figure 3: Source status for human immunodeficiency virus, hepatitis B, and hepatitis C, n = number of episodes (% out of total episodes of 452)|
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|Figure 4: Postexposure prophylaxis follow-up for human immunodeficiency virus|
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|Figure 5: Postexposure follow-up for hepatitis B. Only the advice was given but was not followed up thereafter, **hepatitis B immunoglobulin|
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| Discussion|| |
Percutaneous exposure to needle, other sharps, and splash by blood or body fluid are major occupational hazards to HCWs, endangering them to increased risk of contracting many blood-borne infections. The present study was conducted in Puducherry, India at a premier medical institute of national importance, to study the epidemiological profile and the PEP follow-up for the NSSSIs cases reported over 2 years.
We recorded 507 injury episodes over 2 years (out of which 55 did not report to us); in contrast to Epinet data which shows the average number of injuries for a 2150-bedded teaching hospital like ours would be 594 reports per year. There were 411 episodes of NSSIs and 41 splash injuries which corresponded to 10.6 and 1.0 episodes per 100 OBY. Though this incidence is in concordance with a recently published Indian study at AIIMS, Delhi (8.9 NSSIs per 100 OBY), it is much lower when compared to EPINet Report 2014 (24.7 NSSIs and 8.9 splash injuries per 100 OBY)., We believe that though our reporting has grossly improved after establishment of nodal center, there still might be substantial underreporting which should be addressed by intense active surveillance and awareness campaigns.
In concordance with few other studies, women reported more injuries than men,, though the gender distribution among HCWs was not equal. However, Goel et al. had reported a male predominance among NSSSIs cases. Most common age group to sustain NSSSIs was 20–30 years which suggests that inexperience has direct relationship with the occurrence of NSSSIs, as published elsewhere.,,
Though nurses are the most vulnerable and the largest group of HCW to get NSSSIs as published by several literature including EPINet Report 2014,,,, we observed that exposures were more commonly reported from doctors (32.5%) followed by attenders (28.8%) and nurses (21.1%). Several concordant studies from India reported doctors as the most common group to sustain NSSSIs ranging from 25% to 40%;,, or even higher (65%–75%).,, In all these studies including ours, most doctors who reported NSSSIs were junior doctors such as residents and interns. The reckless practice of junior doctors toward sharp handling and a higher awareness for reporting NSSSIs than nurses could be the probable reasons which accounted for their increased rate of exposures. There are studies that documented increased reports of NSSSIs among attenders.,
Analogous to several studies, we also observed that wards, operation room, ICUs, and emergencies are the common locations for NSSSIs.,,,, A higher number of cases being reported from the wards probably reflects the bed strength and occupancy, whereas higher reporting in ICUs, operation theater, and emergency was due to various factors such as increased work pressure due to understaffing, carrying out high-risk procedures procedures likely to result in injuries on an urgent basis.
Left index finger was the most common site reported as concurred by several other studies.,, Most splashes occurred on nonintact skin (53.7%) followed by conjunctiva (36.6%), in contrast to the latter being documented as the most common site by few researchers., Hollow needles were the most frequent device (87%) associated, which is comparable to several other studies (60%–90%).,,, PPE usage was found to be very low such as 37.2% gloves usage and 0% use of eyeglasses among splash victims as concurred by other studies., The most commonly stated reason was unavailability or short supply. Splash injuries can be largely prevented by use of appropriate PPEs. Though gloves cannot prevent the occurrence of NSSIs but surely protect from splashes. Use of heavy duty gloves during high-risk work such as handling biomedical waste (BMW) is crucial to prevent injuries.
We have carried out a meticulous analysis of the clinical activities involved during the injuries and factors associated with the incidence, and measured which would prevent similar incidents in future. Most injuries occurred during device use (44.8%) for instance blood withdrawal, injections, and suturing. This is in agreement with several studies published elsewhere.,,, Most common reasons behind these injuries were unavailability of safety devices and under-staffing. Some studies have shown that suturing accounted for 29%–46%,, of episodes of NSSIs in contrast to 7.1% in our study and 6.1% in a study by Goel et al. This difference might be due to better amenities and direct supervision of procedures carried out by junior doctors at our center.
Recapping has been recognized as one of the key factors causing 5%–15% of NSSIs , or even higher (34.0%–65%) in some studies.,, We observed 14.8% association of recapping with NSSIs; the primary reason being lack of awareness or negligence. Complete ban of recapping or practice of one hand technique in unavoidable situations is the recommended measures to prevent NSIs. After use-before disposal accounted for higher proportion of NSSIs (28.5%); the underlying reasons being inaccessibility of sharp container and needle destroyer (due to inadequate supply), carelessness (needles lying on floor or beds), improper segregation of BMW (injuries while handling/transportation of bags). Several published studies documented a considerable occurrence of NSSIs after device use-before disposal.
We also observed that 7.5% of injuries occurred at final disposal site in contrast to 8%–31% in few other studies., As the segregation of BMWs was improper at source, a practice of re-segregation of waste was observed at the final disposal site. Strict auditing of BMWs segregation at source, complete stoppage of re-segregation practice at final disposal site, and use of heavy duty gloves are few measures which can prevent such injuries in the future.
Another alarming finding was that attenders accounted for most of the NSSSIs that occurred after device use and during disposal. Hepatitis B vaccination coverage was very poor in this group. More so, the awareness of postexposure follow prophylaxis for HIV (ART) and hepatitis B (immunoglobulin and vaccine) was also lacking. As the source patients of such devices were mostly untraceable, these HCWs were advised to take PEP for HIV (ART) and hepatitis B (HBIG and vaccine). However, the compliance to PEP was found to be very poor due to various reasons such as lack of awareness, side effects of ART, lack of paid leaves (most of them were daily wagers) during ART, unavailability of HBIG.
The month-wise distribution of NSSSIs showed there were occasional peaks which coincided with the joining of interns or 1st-year resident doctors. Studies have shown an inverse relationship of experience with occurrence of NSSSIs. An induction training at joining and monitoring their practice of sharp handling during first few months of service are essential measures to prevent such higher incidence of NSSIs.
In spite of increasing the accessibility (by creating four peripheral centers), the first dose of PEP was taken only in 29.2% of cases. This may be due to a lack of knowledge of the need to take the first dose of PEP within 2 h of exposure and lack of awareness among HCWs about the peripheral centers where PEP first dose was made available. Continuous education and awareness programmes and display posters will augment the usage of PEP first dose.
Overall source positivity for BBVs was 6.9% (31/452), of which 1.8%, 4.0%, and 1.1% of index patients were positive for HIV, HBV, and HCV, respectively. A recently published Indian study documented similar rates of source positivity (2.3, 5.0, and 1.9% respectively) among occupational exposures. A study by Jayanth et al. reported 17% source positivity for BBVs.
PEP continuation was a colossal challenge in most of the literature published elsewhere, documenting variable rates (3%–50%) of PEP completion.,,, In the present study, 161 HCWs in whom PEP continuation was indicated were directed to the ART clinic but could not be followed up on whether they had started and/or completed the course or not. Proper counseling regarding importance of PEP continuation and managing the adverse effects of ART, providing paid leaves during PEP continuation (especially to the daily wagers), maintaining confidentiality of the ART intake, continuous telephonic contact with the HCWs are some of the key measures required to address this problem.
There is a diverse rate of hepatitis B vaccination coverage across the globe ranging from 18% in Africa to 77% in Australia , in contrast 40.9% among HCWs with NSSSIs in our study. To address this issue, our institute has recently initiated mandatory hepatitis B vaccination campaign to achieve 100% coverage by the next World Hepatitis Day. A recent study at AIIMS, Delhi, had shown that an institute policy for making vaccination available to all HCWs had a remarkable difference in the vaccination coverage (52%–97%).
Although only 49.2% of the fully vaccinated HCWs were protected (anti-HBs antibody titer <10 IU/ml), we cannot comment on whether the titers of the remaining HCWs (51.8%) were truly low (and a second series of vaccines warranted before declaring them as 'nonresponders'), or if they were protected earlier with titers dropping subsequently. According to the CDC guidelines, the ideal time for checking the titer is 1–2 months following the last dose of vaccine. Thereafter, the titer may fall, but it does not mean that the person is unprotected. Immunological memory will help resurge the titer following subsequent infection or vaccination. A study by AIIMS, Delhi, had reported a protection rate of 25% among the vaccinated HCWs who suffered NSSSIs.
The major limitation of our study was we could not track the HCWs meticulously during postexposure follow-up period. Details of first aid measures taken was not recorded. Mean time in taking the first dose PEP for HIV was also not recorded. We would like to focus on these areas in future research.
| Conclusion|| |
The present study showed a significant incidence of NSSSIs among HCWs despite the possibility of sizable underreporting. Though doctors are most commonly involved, occurrence of NSSSIs among attender group is a big challenge as most of them are lack awareness, are not vaccinated, and are source unidentified. Continuous education, engineering control, vaccination campaign, and other interventional strategies such as BMW auditing are the crucial measures which should be taken to tackle this issue.
We would like to acknowledge to Dr. J. Balachander, Medical superintendent, JIPMER and Dr. S. Sujatha, Professor and Head, Microbiology, JIPMER, for their continuous encouragement and support in setting up of the NSI nodal centers; Dr. Rahul Dhodapkar, Additional Professor, Microbiology, JIPMER, and Dr. Rakesh Singh, Additional Professor, Microbiology, JIPMER, for providing testing facility for HBV, HCV, and HIV; Dr. Abdoul Hamide, Professor and Head of Medicine, JIPMER, and Dr. Vadivelan, Associate Professor of Medicine, JIPMER, for their immense help for providing PEP; infection control nurses (Mrs. Rani Thamizharasan, Mrs. Ruth Lilly, Mrs. Djiva Azhwar, Mr. Thirumavarasu G., Mrs Rajalakshmi Garnett, Mrs. J Radjalatchoumy, Mrs. Lathika Gladson, Mrs. Vijitha V, Mr. Mohammad Aslam, Mrs. Mehertaz Begum) of JIPMER during data collection; Mr. Sulfihar Ali for laboratory testing and Mrs. Ilaveni and Mr. Venkatachalapathy for their contribution during data entry.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]