Needle stick injuries in the community

Question 1

What is the risk of acquiring HBV from a needle stick injury when the source is HBsAg positive?

Answer 1

2-40%

Question 2

What is the risk of acquiring HCV from a needle stick injury when the source is HCV positive?

Answer 2

3-10%

Question 3

What is the risk of acquiring HIV from a needle stick injury when the source is HBsAg positive?

Answer 3

0.2-0.5%

Question 4

What are the recommendations re: prevention?

Answer 4

1. Parents, educators and health care providers should be made aware of the problem of discarded needles.
2. Children should be educated about the potential dangers of injection drug use.
3. Children should be taught not to handle needles and syringes, and to report finding them to an appropriate, responsible adult (parent, school teacher, police officer, etc), who should then arrange for the safe disposal of the needle in a puncture-proof, closed container.
4. Community programs should be in place to keep parks and public places, where children generally play, free of discarded needles.
5. Programs should be in place for the treatment and control of injection drug addiction, and to adequately support HIV prevention, HBV vaccination and needle-exchange programs for injection drug users.

Question 5

What is the management for a needle stick injury?

Answer 5

1. After the injury, the wound should be cleaned thoroughly with soap and water as soon as possible. It should not be squeezed to induce bleeding.
2. The extent of the wound, if any, or the probability of exposure of open skin lesions or mucous membranes to blood should be assessed.
3. The child’s immunization status for tetanus and HBV should be determined.
4. Tetanus vaccine, with or without tetanus immunoglobulin, should be given if indicated.
5. The circumstances of the injury should be documented (the date and time of injury or exposure, where the needle was found, circumstances of the injury, type of needle, whether there was a syringe attached, whether visible blood was present in or on the needle or syringe, whether the injury caused bleeding and whether the previous user of the needle is known).
6. Blood should be obtained from the child for:
   a) Baseline HBV, HIV and HCV status (may be stored for later testing).
   b) If antiretrovirals are being considered: complete blood count, differential, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, blood urea nitrogen and creatinine.
7. Testing needles and syringes for viruses is not indicated. Results are likely to be negative, but a negative result does not rule out possibility of infection.
8. If the user of the needle is known, attempts should be made to assess for risk factors for blood-borne viruses and, if possible, to test for these viruses. Pending results, proceed as for an unknown source.

Question 6

What are the recommendations re: HBV prophylaxis?

Answer 6

1. If the child is known to be HBV antibody or HBsAg positive no action is required.
2. If the child has not been fully vaccinated against HBV:
   a) Test for anti-HBsAb and HBsAg. If results are not available in 48h then:
   i/ Give HBIG immediately (ideally within 48h of injury, efficacy unknown if >7d after injury) dose = 0.06mL/kg OM
   ii/ Give HBV vaccine (ASAP, at latest within 7d of injury)
   b) If anti-HBsAb and HBsAg negative complete vaccine series
   c) If anti-HBsAb or HBsAg positive, discontinue vaccine series. Arrange appropriate f/u if HBsAg positive
3. If child has been fully vaccinated against HBV:
   a) Test for anti-HBsAb. If results not available in 48h give dose of HBV vaccine.
   b) If anti-HBsAb positive, no further action required
   c) If anti-HBsAb negative, test for HBsAg:
   i/ if HBsAg negative, give HBIG and dose of HBV vaccine
   ii/ if HBsAg positive, arrange appropriate f/u

Question 7

What are the recommendations re: HIV prophylaxis for needle stick injuries?

Answer 7

1. Risk of HIV transmission (Table 2), and risks and benefits of antiretroviral prophylaxis should be assessed on a case-by-case basis, taking into consideration the ability of the child to tolerate and adhere to an antiretroviral regimen for four weeks. The potential benefits, adverse effects and costs of antiretroviral prophylaxis should be discussed and decisions should be made in conjunction with the parents, and with the child if age appropriate.
2. Antiretroviral prophylaxis should be recommended only in cases of high risk, in which the source is considered likely to have HIV, the incident involved a needle and syringe with visible blood and blood may have been injected.
3. In situations of low risk (source unlikely to have HIV, no visible blood in the device or superficial injury), prophylaxis should not be recommended but should be considered. Parents should be reassured of the low probability of their child acquiring HIV as a result of the incident.
4. If the decision is made to begin antiretroviral prophylaxis:
   a) Antiretrovirals should be started as soon as possible, ideally within 1 h to 4 h of the injury. Prophylaxis is not recommended if it cannot be initiated within 72 h of the injury.
   b) If parents considering prophylaxis are undecided, they should be advised that it is preferable to start prophylaxis immediately and then discontinue if they wish because starting later may be of no benefit.
   c) The antiretroviral agents used should be those currently recommended for occupational and nonoccupational exposures:
   i/ For low-risk situations, zidovudine plus lamivudine.
   ii/ For high-risk situations, add lopinavir/ritonavir.
   d) The duration of prophylaxis is 28 days. For dosing and other details, refer to Table 3.
   e) If alternative antiretrovirals are needed, consult a specialist involved in the care of children with HIV.
   f) Recommendations may change as new antiretrovirals become available. For up-to-date information and information on alternative antiretrovirals, visit http://aidsinfo.nih.gov/Guidelines/Default.aspx?MenuItem=Guidelines (click on Pediatric Guidelines).
   g) Antiretrovirals, especially protease inhibitors, may interfere with other medications. Check whether the child is taking other medications, and assess for possible interactions.
   h) Adverse effects: There are no data to suggest that a four-week course of antiretrovirals will have serious or long-term detrimental effects (listed in Table 3 footnote). Children with HIV infection have taken these drugs for years and serious side effects are rare.
   i) Emergency departments and clinics in which children with needle stick injuries are seen should arrange to have ‘starter kits’ available so that, if indicated, prophylaxis can begin with the least delay.
   j) On the initial visit, drugs should be provided for two to three days and arrangements made for reassessment after that time to review adherence, assess adverse effects and arrange further follow-up. If the decision is made to continue prophylaxis, prescribe drugs to complete the 28-day course.

Question 8

What is the risk assessment for HIV transmission?

Answer 8

Source: Source unknown but known or presumed high prevalence of HIV in injection drug users in the region, or if source known to have HIV, consider high risk.

Device: Consider the size of needle, whether it is hollow-bore, presence of visible blood in the needle or syringe, probability of exposure to drying, heat and freezing since use. Large lumen devices with visible blood are highest risk.

Injury: Consider depth and extent of trauma (scratch or deep cut, injection of blood and bleeding at the site).

Injuries with actual blood injection are high risk. Superficial scratches are low risk. If exposure limited to mucous membranes or nonintact skin, consider extent of exposure. For example child put syringe with visible blood into mouth and possibly injected blood – high risk; suspected but unobserved splash onto eyes or lips – low risk. Splashes involving a large volume of blood (not just a few drops) coming into contact with extensive areas of nonintact skin – high risk.

Question 9

What antiretroviral agents are recommended for PEP?

Answer 9

Nucleoside reverse transcriptase inhibitors

1. Zidovudine (ZDV)
   a) 6w-12yo: 160mg/m2/dose PO TID or 240mg/m2/dose PO BID
   b) >12yo 300mg/dose PO BID
2. Lamivudine (3TC)
   a) 1m-16yo: 4mg/kg/dose (max 150mg/dose) PO BID
   b) >16yo and >50kg: 300mg PO daily
3. ZDV + 3TC (Combivir)
   13y and >37kg: 1 tab PO BID (ZDV 300mg + 3TC 150mg per tablet)

Protease inhibitor:

1. Lopinavir/ritonavir (LPV/RTV):
   a) 6m-12yo: 230mg LPV/57.5mg RTV/m2/dose PO BID (max 400mg LPV/100mg RTV/dose)
   b) >12yo 400mg LPV and 100mg RTV/dose PO BID

Question 10

What are the CPS recommendations regarding follow-up for needle stick injuries?

Answer 10

1. Arrange follow-up and advise parents of the need for it (eg, monitoring of side-effects if on antiretroviral prophylaxis, testing for acquisition of infection and completion of HBV vaccination).
2. If receiving antiretroviral prophylaxis:
   a) Reassess at two to three days, by phone or visit.
   b) Follow-up at two, four and six weeks for complete blood count, differential, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen and creatinine.
3. At four weeks, give second HBV vaccine dose if only one previous dose received (consult Table 1) or if no antibody or antigen detected on initial testing.
4. At six weeks, test for anti-HIV antibody.
5. At three months, test for anti-HIV antibody (unless previously positive) and anti-HCV antibody.
6. At six months, test for anti-HIV, anti-HCV and anti-HBsAg antibody (unless previously positive). Give third HBV vaccine dose if only two previous doses received.
7. If anti-HBs antibody negative at six months, test again one to two months after the third dose of vaccine. If still negative, test for HBsAg. If negative for both, give a fourth dose of HBV vaccine and test again one to two months later. If still negative, refer to an appropriate specialist.
8. If HIV, HCV or HBV infection occurs, test the stored baseline sera (unless already done) to determine whether infection was subsequent to the injury, and arrange for appropriate follow-up.