There has been an increasing tendency in recent years to downplay the risks of acquiring bloodborne virus infection. Statistics are quoted, showing that in general the risks of acquiring a bloodborne virus infection are:
- for HIV transmission after a percutaneous exposure approximately 0.3%
- for HBV transmission 6 to 30%,
- and for HCV transmission is approximately 1.8%
Easy stats and generally low numbers. Reinforcing the message that the risks might be small is the fortunately exceptionally low incidence of reported cases of seroconversion, and an understanding that the risks may be higher with a deep wound, with a large bore hollow needle, with a needle heaving contaminated with fresh blood, with a needle used only moments before with a patient who had a high viral load. Added to this are reassuring messages of the value of immediate first air – making the wound bleed and washing it thoroughly with soap and water – or seeking immediate medical advice and, if appropriate, of taking post-exposure prophylactic (PEP) drugs to prevent HIV and a big jab in the buttock to protect against Hepatitis B. And then, all will be hunky dory!
But of course that isn’t quite so straightforward. Not everyone will receive that immediate first aid from an infectious diseases specialist who can properly manage subsequent PEP and follow-up. Others may be fobbed off and sent away from A&E for just a ‘trivial’ wound without thought for the impact and implications.
Others may simply fob off a small scratch or blood splash to already broken skin or to the eyes, dismissing that splash inoculation as simply a nuisance without recognition of the significant infection risks that it may carry. And how to manage the post-injury follow-up in the information is incomplete; if the needle had been discarded and the period between use and injury is not known; if the needle user cannot be identified?
Since a high proportion of IV drug users are Hepatitis C positive the risks must be heightened, but evidence from albeit a handful of reports are that assessment in A&E is inadequate and even if you can progress past the first triage assessment and see a junior doctor few such sharps injuries are recognised as potentially serious enough to warrant immediate referral to a specialist.
That immediate referral is now mandated by EU Council Directive 2010/32/EU for health service employees but as yet there is no evidence for similar standards for non-healthcare employees such as waste handlers and local authority staff who are being fobbed off with possibly inadequate treatment.
The implications may be profound.
We are increasingly aware of the often severe and profound psychological impact of sharps or needlestick injury† that has been in the news recently after a scientific investigation of this problem but which has been discussed many times over the years on the Clinical Waste Discussion Forum (check using the search system and browse the archive files). This too requires care in the immediate management and follow-up of sharps injuries and other blood and bloodstained body fluid exposures. Those who may be at risk by virtue of their employment must be trained properly and adequately briefed to ‘make a fuss’ for prompt specialist treatment in exposure does occur.
The various criteria and conditions of exposure or injury noted above can heighten or reduce the risk profile of any individual sharps injury event. So it is with considerable concern to read a recent case report from Brazil:
Brum MCB, Filho FFD, Yates ZB, Viana MCV, Chaves EBM. HIV seroconversion in a health care worker who underwent postexposure prophylaxis following needlestick injury. American Journal of Infection Control 2013; 41: 471-2
They describe a case of HIV seroconversion in a health care worker who underwent PEP after accidental HIV exposure in Brazil. In December 2007 a nursing assistant aged 42 years working in an infectious disease unit experienced a thumb injury while performing a hemoglucotest. The health care worker wore a latex glove during the procedure yet was injured while collecting the test device, the lancet of which had not been completely enclosed and was left on the table after the procedure. The percutaneous injury on the surface of the thumb caused slight bleeding that was immediately washed.
Leaving aside the possibility of drug resistance of this particular strain of HIV, which was a possibility but was not proven by laboratory testing, this worker had PEP initiated within 2 hours of injury, maintained for 28 days. However, 4 months after exposure the worker was diagnosed with HIV infection.
There are several levels of concern. Not least is the observation that injury was caused by a lancet, a thin cutting spike intended to draw just a drop of blood from a finger prick for blood sugar testing. No hollow bore needle, and no deep injury – lancets are designed to prevent deep injury no matter how hard you try. These circumstances would, almost certainly, screen out a sharps injury victim from almost every sharps injury management protocol.
† Green B, Griffiths EC. Psychiatric consequences of needlestick injury. Occupational Medicine 2013; 63: 183–8