Which actions should the nurse initiate to reduce the risk of needlestick injury?

Imani is a head nurse in the adult female internal medicine ward of her facility. She has been trained in injection safety and is often asked by other colleagues for guidance. One afternoon, as Imani was almost ready to go home, a colleague asked her for help drawing a blood sample from a patient. The young patient was nervous about his blood being taken, and prone to moving or shaking when approached with a needle. Imani had a particularly good reputation for soothing nervous patients.

Tired, but always willing to help, Imani approached the young patient. Soothing the young boy was fairly easy; sometimes, patients just need to be heard when they are uncomfortable. Imani performed hand hygiene, put on clean gloves, successfully drew the sample after skin disinfection, removed the needle, and applied pressure to the vein puncture site to stop the bleeding. With her other hand, she reached for the sharps container behind her; it was full, causing her to be stuck by another needle. With a deep sigh, she shoved the needle into the sharps container and inspected the injury. Since she was already late to pick up her child from school, she felt she only had time to wash her hands with soap and water and make a note of what happened. She rushed off without reporting her injury to her supervisor. Imani knew that Hepatitis B (HBV) and other bloodborne diseases can survive outside of the human body for an extended period of time, but she assumed that the risk of her getting infected was low because the needle had been dry for a while.

Imagine for a moment that you are in Imani’s position. What would you have done?

In the following learning activities you will see how needle-stick injuries like this one can be handled when they do occur.

Needle-stick injuries can occur in your facility in many ways. Certain situations increase the risk of injury for health care workers. These situations include:

• patients suddenly moving or jerking during an injection;
• a culture that accepts re-capping needles after an injection as normal practice;
• using a syringe to transport a sample after collecting blood; and
• needles improperly disposed of due to lack of or inadequate sharps containers, or a lack of timely waste management.

Click or tap the arrows on the image gallery to see which types of needles can cause injury:

In case of a needle-stick injury, follow these steps:

1. Wash the wound with soap and water.
2. Immediately inform your supervisor. Be sure to follow the needle-stick injury reporting protocol for your health facility.
3. If possible, identify the source patient and test for HIV, hepatitis B, and hepatitis C after providing counselling and obtaining informed consent.
4. With informed consent, it is recommended, but not mandatory, to test the health care worker for HIV, hepatitis B and hepatitis C.

For recommended best practices on what to do in case of needle-stick injury, refer to "WHO Best Practices for Injections and Related Procedure Toolkit" in the Resources section of this course.

Reporting an exposure

All needle-stick injury incidents must be reported to assess safety and working conditions in your facility. The information gathered should be applied to inform facility-level prevention strategies. If your facility does not have a needle-stick injury reporting system, efforts should be made to institute such a system.

The following should always be done whenever a needle-stick injury is reported:

• conduct a risk assessment;
• record exposure engagement;
• describe the situation, including where the incident occurred; and
• evaluate the need for prophylaxis/treatment interventions.

As you learned in the previous module, a needle-stick injury carries the risk of contracting viruses, such as HBV and HCV. Recall that the risk of infection from a sharps injury is as high as 31% for HBV, and as high as 3% for HCV. Both HBV and HCV can survive outside of a human body for an extended amount of time. Because needle-stick injuries can occur easily, it is important to know the risk factors and how to manage exposures.

Click or tap each tab to learn more about exposure management for HBV and HCV infections from needle-stick injuries.

• Hepatitis B: Risk of Exposure
• Hepatitis B: Post-exposure

Hepatitis B: Risk of Exposure

Three factors determine whether HBV has been contracted:1

1. The degree to which the person stuck has come into contact with blood.
2. The amount of hepatitis Be antigen (HBeAg) present. Hepatitis Be antigen is an indicator of how infectious the source may be; its presence in the blood increases the risk of infection.

HBeAg is a small polypeptide. It exists in a free form in the serum of individuals during the early phase of hepatitis B infection, soon after hepatitis B surface antigen (HBsAg) becomes detectable.

3. Whether only hepatitis B surface antigen (HBsAg) is present. If this is the case, the risk of infection is significantly lower.

HBsAg is a protein on the surface of hepatitis B virus. It can be detected in high levels in serum during acute or chronic hepatitis B virus infection. The presence of HBsAg indicates that the person is infectious. The body normally produces antibodies to HBsAg as part of the normal immune response to infection. HBsAg is the antigen used to make hepatitis B vaccine.

Hepatitis B: Post-exposure Prophylaxis (PEP)

Post-exposure prophylaxis (PEP) is not necessary for those vaccinated against HBV.

If an injured health worker has not been vaccinated:

• The worker must receive an initial vaccination dose immediately after exposure.
• All scheduled doses of the vaccination series should be completed even if the source of exposure is hepatitis B negative.
• The most effective PEP regimen (between 85% and 95%) for HBV is a combination of Hepatitis B immunoglobulins (HBIG) and the vaccine series.
• Two doses of either HBIG alone or the hepatitis vaccine alone are about 70% to 75% effective.

If the health worker received the vaccine after the injury, test for antibody formation against the vaccine one to two months after vaccination. If HBIG was given in combination with the vaccine, you cannot determine if antibodies formed in response to the vaccine within this period.2, 3, 4, 5

An antibody is a protein produced by the immune system to neutralize pathogens.

• Hepatitis C: Risk of Exposure
• Hepatitis C: Post-exposure

Hepatitis C: Risk of Exposure

The chance of becoming infected following exposure to HCV is relatively low. The average seroconversion rate after a sharps injury exposure from an HCV source is 1.8%. One study suggests that transmission can occur only from hollow-bore needles.6

The period of time during which HCV antibodies develop and become detectable.

Hepatitis C: Post-exposure

While the risk of exposure to HCV is low, the consequences of infection are high. There is no recommended PEP for HCV-positive blood, and there are no immunoglobulin, antiviral agents or vaccines against HCV.

Note on new HCV treatment: The treatment of HCV with new drugs can cure most persons with HCV in 12 weeks. WHO is currently updating its treatment guidelines to include direct-acting antiviral (DAA) drugs and simplified laboratory monitoring. The role of pegylated interferon (PEG-INF) and ribavirin is very limited at present, but prices of these DAAs have dropped dramatically in resource-limited countries due to the introduction of generic versions of these medicines.

After exposure:

• Perform baseline testing for antibodies, as well as alanine aminotransferase (ALT) blood testing.
• At 4 to 6 months after exposure, retest the exposed person for antibodies and ALT.
• For early diagnosis, test RNA 4 to 6 weeks after exposure.
• If HCV antibodies repeatedly return positive enzyme immunoassay (EIA) results, supplemental tests may be needed.
• If infection is identified, the exposed person must be referred to a specialist for treatment.

Now that you are more familiar with hepatitis exposure management, let us focus on HIV exposure management. HIV can survive in dried blood at room temperature for up to three days. While risk of infection is relatively low (0.3%), the implications of getting HIV are lifelong. Risk of exposure may be much higher in countries or facilities with a high prevalence of HIV, or where safety standards are low and medical equipment is re-used. For more information about HIV exposure management, click or tap the tabs below.

• Post-exposure
• PEP Counselling and Follow-up

Post Exposure

The type of exposure and HIV status of the source patient will determine whether PEP should be provided to the exposed person.

PEP is recommended if the exposure meets all the following criteria:

• exposure to the HIV virus occurred within 72 hours;
• the exposed individual is HIV negative;
• the source of the exposure is either HIV positive, or their status is unknown;
• the source of the exposure is blood, body tissue, visibly blood-stained fluid, cerebrospinal fluid (CSF), or synovial, peritoneal, pericardial, or amniotic fluid; and
• the puncture is deep, from a hollow-bore needle, or from other sharps visibly contaminated with any of the above-mentioned fluids.

If the HIV status of the source is positive, a two-drug regimen is recommended for any percutaneous injury or severe blood splash; the source patient treatment history and resistance pattern, if available should be considered to decide the PEP regimen. PEP for HIV should be taken for 28 days.

If the HIV status of the source is unknown, consider the HIV prevalence of the population. For a less-severe wound or splash, do not recommend PEP.

Made, done, or effected through the skin.

A severe needle-stick injury could occur via hollow-bore needle, a deep or forceful injury, or the sharpness of the object.

No PEP for HIV is recommended if any of the following criteria apply:

• more than 72 hours have passed;
• the exposed individual is HIV positive;
• the source of the body fluid is an HIV-negative individual who is not high risk for infection; or
• the skin of the exposed individual is intact (not broken or punctured).

PEP Counselling and Follow-up

Explain to the exposed individual about how HIV is transmitted (via blood and sexually) and provide counselling about proper use of contraception (such as condoms) during any sexual act. The exposed person should avoid organ and sperm donation until testing negative. For lactating mothers, suggest alternatives to breastfeeding.

Follow-up visits are crucial to ensure adherence to PEP, prevent or treat any side effects, and identify possible seroconversion. Drug reactions must be monitored within 72 hours of initiating PEP treatment. HIV testing is recommended at baseline, 6 weeks and 6 months after exposure. If the exposed person seroconverts, refer for treatment.

The following week after Imani was stuck by the needle, she finally reported the injury to her supervisor. He was disappointed that it had taken her a week to report the incident, but he was more concerned for her health and well-being. Since she let a week go by before reporting the incident, there was no way to track the source of the blood, nor was there any chance to identify or test the source patient for bloodborne viruses. Imani had been vaccinated for HBV and she knew her risk of getting HCV and HIV was low.

On the advice of her supervisor, Imani was tested for HBV and HIV, and after another few weeks, got an RNA test. Unfortunately, she tested positive for HIV.

Injection safety best practices protect you, your colleagues, and the community from needle-stick injuries. The WHO multimodal strategy for infection prevention and control (IPC) consists of elements implemented in an integrated way to guide action and prevent such injuries.

Click or tap on each multimodal strategy to see how it applies to preventing needle-stick injury.

• Build it
• Teach it
• Check it
• Sell it
• Live it

Build it

Create system change by adopting WHO guidelines and introducing re-use prevention (RUP) or sharp injury protection (SIP) syringes and make sure that safety boxes are continuously available at the point of care.

Teach it

Train and educate health care workers to improve their knowledge of how to avoid needle-stick injuries and what to do if one occurs. Be sure to include housekeeping and other support staff in your training. This group is often ignored while organizing trainings on health care waste and sharps management. The more staff who are trained in injection safety, needle-stick injury prevention and sharps disposal, the more the occurrence of harmful incidents can be reduced.

Check it

Develop a needle-stick injury/accident reporting mechanism if one does not exist. Implement routine monitoring to assess the problem and bring appropriate changes into practice. Analysing each needle-stick event can help identify potential reasons why such injuries are occurring—for example, if staff members continue to re-cap needles, or if safety boxes are over-filled—and translate to action.

Sell it

Remind staff members about the risks of needle-stick injuries, and ways to appropriately prevent and manage them, by using posters at points of care, displaying flowcharts of post-exposure procedures, and distributing leaflets on how RUPs or SIPs work. Use effective means of communication, such as newsletters or videos.

Live it

Senior managers can be champions of change and lead from the front. To promote a safety climate, they can advocate for the resources required to purchase safer syringes that protect against needle-stick injuries. Although you may not be able to immediately change what types of syringes your facility uses, your input as the IPC focal person is important. You can advocate for decision makers to Consider that prices can bework to negotiate pricesd with syringe manufacturers, and that for Ministries of Health often to work to reduce levies and taxes to decrease the price of these safe syringes.

The following single-use injection devices are recommended by WHO to ensure safer injections:

2Identify the following types of needles that cause needle-stick injury (matching):

3What is the correct order of steps to follow after a needle-stick injury? Use the drop-down lists to select the right answers.

Test the health-care worker for HIV, hepatitis B and hepatitis C. Wash the wound with soap and water. Identify the source patient. They should be tested for HIV, hepatitis B and hepatitis C after counselling and informed consent. Inform your supervisor. Follow the needle stick injury reporting mechanism in your health facility.

Safe injection practices and safe handling of sharps can prevent needle-stick injuries. The possibility of an accident does exist. This module has shown that needle-stick injuries can happen when:

• a patient is nervous and experiencing unexpected bodily movements;
• staff re-cap needles;
• body fluids are transferred between containers;
• sharps are improperly disposed of;
• there is no waste-management system;
• health care workers are not trained; and
• there are no job aides.

If a needle-stick injury does occur, there are steps you can follow immediately thereafter.

• First, wash the wound thoroughly.
• Next, report the incident.
• Then, identify and test the source patient.
• Next, test the exposed individual.
• Lastly, consider whether PEP should be administered.

Consult the “WHO Best Practices for Injections and Related Procedure Toolkit” found in the Resources section of this course for more information.

In this module we also addressed what to do if a person is exposed to HBV, HCV or HIV. The status of the source patient, the status of the exposed individual, and the type of exposure (blood splash or needle-stick) will determine whether PEP should be administered. Be sure to consider the prevalence of these diseases amongst the population that your facility serves. Using safe equipment and proper training, awareness and advocacy at both the facility and national levels can greatly reduce the occurrence of needle-stick injury, thereby helping to reduce the spread of infection and disease.

• 1Werner BG, Grady GF. Accidental hepatitis-B-surface-antigen-positive inoculations: Use of e antigen to estimate infectivity. Ann Intern Med. 1982 Sep;97(3):367–9.
• 2Hauri AM, Armstrong GL, Hutin YJ. The global burden of disease attributable to contaminated injections given in health care settings. Int J STD AIDS. 2004 Jan;15(1):7–16.
• 3Grady GF, Lee VA, Prince AM, Gitnick GL, Fawaz KA, Vyas GN, et al. Hepatitis B immune globulin for accidental exposures among medical personnel: final report of a multicenter controlled trial. J Infect Dis. 1978 Nov;138(5):625–38.
• 4Seeff LB, Zimmerman HJ, Wright EC, Finkelstein JD, Garcia-Pont P, Greenlee HB, et al. A randomized, double blind controlled trial of the efficacy of immune serum globulin for the prevention of post-transfusion hepatitis: a Veterans Administration cooperative study. Gastroenterology. 1977;72:111–21.
• 5Prince AM, Szmuness W, Mann MK, et al. Hepatitis B immune globulin: effectiveness in prevention of dialysis-associated hepatitis. N Engl J Med. 1975;293:1063–7.
• 6Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR. 1998;47(No. RR-19):1–39.