Community Acquired Needlestick Injuries (Reviewed May 2016) Injuries Communityacquiredneedlestick 4

due to deliberate assault withablood filled syringe represents ahigherriskthanaverage. booster was delayed. Hedidnot receive HBIG. I was reportedCANS from Australia. care providers whotreat them,transmission ofBBVs setting inanon-clinical isexceedingly rare. Although needlestickare injuries community acommonsource for ofanxiety thepublicandfor thehealth temperatures, are andinjuries usually superficial. needle rarely contains freshandenvironmental blood, anyto viruspresent drying exposed hasbeen not does occurimmediatelyin discarded after needlesisusually needle unknown,injury use,the In contrast to thesituation withneedlestickinhealth injuries care workers, thesource ofblood PEP (inthecase ofHBV andHIV). needle/syringe anduseof andtheavailability thelevel used, (inthecase hasbeen ofHBV) ofimmunity thebody, sustained, oftheparticularvirusoutside theviability howrecentlysetting, ofinjury the thetype depend onseveral factors. fromThe riskofBBV transmission through adiscarded aneedlestick injury needle/syringe islikely to needlestick injuries in the community have reported. been needlestick inthecommunity injuries follow-up for HIV, 452 for HBV and265for HCV. fromseries areas ofhighprevalence ofbloodborne viruses. A review oftheliterature upuntil September 2007 by the Canadian Paediatric yielded 12case Society However, compliancewith follow-up was generally poor. in Edinburgh, ofseroconversion Dublin,MelbourneandBirmingham. Nocases for BBVs were detected. otherSeveral studies reportedIs inchildren theoutcome ofCANS presenting to emergency departments 6 year period,ofwhich120 were described. In astudy inanemergency department medicine inSydney, 124I were identified ofCANS over cases a Case series post-exposure HBV vaccine orHBIG. case ofpresumed acute HBV infection was reported ina4year old boyinSpainwhodidnot receive There are currently few reportedI. ofBBV incidents toA aCANS infections thought to besecondary ofBBV cases transmissionReported following aCANSI on whichto recommend management strategies ispoor. Community acquired base andtheevidence needlestick(CANSIs)have not injuries welldescribed, been injuries a Community 19 -Appendix EMI Guidelines -66- assault withblood filled to children syringes playing withdiscarded inpublicparks. syringes found noseroconversions. A large study inMontreal of274 1988and2006 I between paediatric patients presenting withCANS was rarely visible onthe needle orsyringe. after 1997. and 92.6% received HBV vaccine. HIVchemoprophylaxis was given to 39%ofpatients whopresented I. CANS received HBV prophylaxis, ifitwas indicated. 130children received antiretroviral prophylaxis. follow-up serology. theremonths were post-injury noHBV, orHIVseroconversions HCV inthe10patients for whom there was was identifiable inonly 54%ofpatients 12% cases. HBVreceived PEPand8% HIVPEP.received At 6 were68% ofcases asaresult ofexposure to discarded syringes. predominance. were Injuries work-related predominantly in36%ofcases, policeofficersandcleaners. 8 he most common site of injury was were thehand.Most oftheinjuries andblood superficial The most commonsite ofinjury 1

8 hese factorsThese includetheprevalence ofBBVs amongPWIDintheparticular O f patients whowere not knownto beimmuneto HBV, received 82.2% HBIG Community acquired needlestick injuries (reviewed May 2016) injuries Communityacquiredneedlestick 4

c he patient had a history ofincompleteThe patientvaccination hadahistory andHBV vaccine 5 In2011, acase ofacute HBV infection occurring2months after a d needlest ick quired 8 he median agewasThe median 26years. 2

hree cases of HCV seroconversionThree ofHCV cases inadults following There were no infections. 3

9, 10,11,12 1 Is cover from awidespectrum CANS criminal 6, 7 hese involvedThese atotal children of483 with No HIVinfections have reported been after a The source oftheblood inthesyringe he majority ofchildrenThe majority There was amarked male 1

2 I CANS

toolkit detected indiscarded needles. viable virus. dialysis andwards units withimmunocompromised patients. studies that demonstrate highlevels transmission inhealth ofHCV care settings –particularly renal HCV: HBV: prophylaxis Post-exposure and to test themfor BBVs 3.3Investigation section (see ofsource). However, ifthesource can beidentified, thenall attempts should theirrisk bemade to assess factors I asthesource israrely case ofCANS for isessential riskassessment Individualised identified. every results in muchanxiety. Evaluation andcounselling are needed. low,Although theactual riskofinfection isvery theperception from ofriskby patients suchaninjury Risk assessment appendix3,algorithm (see forManagement ofCANSI needlestick exposure) withdrawn from thesource patient. transmission ofHIV, occurred after orminutes withinseconds theneedle was theneedlestick injury whether blood was injectedare alsoimportant considerations. Inmost reported instances involving and theconcentration ofvirusinthat blood. The riskisincreased withhigherviral inoculum,whichisrelated to theamount ofblood introduced source 0.2% and0.5%, isbetween onprospective based studies ofoccupational needlestick injuries. The riskofacquisitionHIVfrom ahollow-bore needle withblood from aknownHIVseropositive surface antigen (HBsAg)positive from ranges 2%to 40%,dependingonthesource’s level ofviremia. The riskofacquiringHBV whenthesource from ishepatitis B anoccupational needlestick injury estimatedIs: andmay beofvalue inestimating theriskinCANS The riskofBBV transmission following needlestick intheoccupational setting injuries hasbeen risk. The riskoftransmission ofBBVs followingIs isdifficultestimate. to CANS HBV represents thehighest Risk ofBBV transmission fromsyringes shooting galleries. intravenous drug users,while another study found HIVDNAinvisibly contaminated needlesand on ambient temperature. Onestudy foundIV proviral ofH notraces discarded DNAinsyringes by dependent inoculated demonstrated, withthevirushasbeen in syringes withduration ofsurvival HIV isarelatively fragile However, virusandissusceptible ofHIVfor to drying. days upto 42 survival to maintain ability its infectivity onenvironmental surfaces. Environmental HBV transmission iswelldocumented andrelates tohighconcentration its inblood and fortemperatures anindeterminate anddrying periodoftime. occupational setting asneedlesfound to environmental have exposed been inthecommunity Is are likelyCANS aconsiderably smaller riskofBBV to carry inthe transmission thaninjuries ofBBVsViability intheenvironment are little data at thistime. isthought to beafragileHCV viruswhichwould beunlikely intheenvironment, butthere to survive in dried bloodin dried at room temperature onenvironmental surfaces for at least 1week. positive source is1.8%. The average seroconversion incidenceofanti-HCV after accidental percutaneous exposure from aHCV V is very remote.The likelihood orHIVisvery oftransmission ofHCV recipients. HBIGmay occasionally beindicated HBV (see PEPappendix 8). HBV vaccine withanaccelerated schedule should beoffered to non-and partially-immune has been shown tohas been beeffective. Baselineand follow-up testing atand3months 6weeks for HCV There isnoeffective post-exposure prophylaxis for HCV. However, treatment ofearly infection

toolkit Appendix 19 Community acquired needlestick injuries (reviewed May 2016) injuries 19Communityacquiredneedlestick -Appendix EMI Guidelines 1 3 Supportfor thepotential for environmental from transmission comes HCV 3

3 However, thepresence ofviral DNAisnot adirect demonstration of 3 The size oftheneedle, thedepth ofpenetration and 4 HBV has been demonstrated to survive HBV demonstrated hasbeen to survive 4 8 1 HBV hasbeen 3

-67- 5. 4. 3. 2. 1. References by-case by opinion. basis,andguided expert ofantiretroviraltransmission, andrisksbenefits prophylaxis should ona case- beassessed 19 -Appendix EMI Guidelines -68- 7. 6. negative result not does rule ofinfection. out thepossibility T Testing andsyringes of needles outatand3monthsappendix9 be carried baseline,6 weeks (see for further testing. are negative,performed thenthere ofinfection isnopossibility at thetimeofinjury andnoneed appropriate arrangements are made.Patients assumethat sometimes ifblood teststhat are initial incident should ensure that thepatient understands theimportance offollow-up, andthat Follow-upessential. is after any significant needlestick injury BBV and follow-up testing The factors associated withincreased riskare: of PEPindecreasing theriskofHIVtransmission innon-occupationalsettings . HIV: HIVPEPremains anunresolved issue.Nostudies have directly measured theeffectiveness only ofhigh-risk. incases 12. 11. 10. 9. 8. esting needles and syringes foresting needlesandsyringes is not viruses indicated. Results are likely to benegative, buta

• • • • • Garcia-Algar O needlestick exposuresjustified?about community Aust NZJ Public Health 2003;27:602-7. intheenvironment: Dore ispublicconcern BoughtonThompson SC, GJ.Blood CR, andtheirsurvival borneviruses Child Health 2008;13:205-10. Canadian Paediatric Society. Needlestickinthecommunity. injuries Position statement (ID2008-01). Paediatr 2011;62:487-9. Res FJ. S,Bowden Acute hepatitis Binfection following acommunity-acquiredneedlestick injury. JInfect emergency department. Emerg 2003;15:434-40. Med O Haber PS, Haber PS, Young MM,Dorrington L 2005;41:129-30. Catro FumeroLibois E, P,A, et al. Makwana N,RiordanMakwana FA. Prospective needlestick study injuries. of community Arch DisChild 2005;90:523-4. J Paediatr Child Health 2002;38:322-3. Russell FM,NashMC. A prospective study ofchildren withcommunity-acquiredneedlestickinMelbourne. injuries area. J1997;90:66-9. IrMed McK Nourse CB,Charles CA, Wyatt JP, WG. Outofhospital Scobie needlestick Robertson injuries. Arch CE, Dis Child 1994;70:245-6. in thecommunity:epidemiology andriskofseroconversion. Pediatrics 2008;122:e487-92. Papenburg J, BlaisD, Moore D, Al-Hosni M,L settings. incommunity JGastroenterolneedlestick injury Hepatol 2007;22(11):1882-5. would therefore enable following early therapeutic intervention transmission HCV appendix 14 ’L blood may have injected. been the incident involved aneedle withvisible blood (particularly fresh blood) the needle was large-bore, hollow lumen was penetrating deep, the injury the source is considered likely to have HIV eary FM,Green eary , Vall O T 3 reatment ofacute hepatitis C). Ifasignificantexposure hasoccurred, testing the recipient for BBVs should T C. Community acquiredC. needlestickinnon-health injuries care workers presenting to anurban . Hepatitis Bvirusinfection from aneedlestick. Pediatr InfDisJ1997;16:1099. 3, 8,12 ay M,K (See appendix7, (See HIVPEP) T ransmission ofhepatitis Cvirusby discarded-needle injury. ClinInfect Dis , Jones A, K , Jones A, eenan P,eenan Butler KM.Childhood needlestick intheDublinmetropolitan injuries Community acquired needlestick injuries (reviewed May 2016) injuries Communityacquiredneedlestick aferriere C, aldor J, K De 1 Antiretroviral prophylaxis should berecommended T apiero B,et al.Pediatric from injuries needlesdiscarded anzow S,et al. 3 The cliniciandealing withthe T ransmission ofhepatitis Cvirusby T esting of recipient). esting ofrecipient). 12

The riskofHIV 4 (see (see

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