Needle Stick Injury Protocol

Most infectious diseases can be transmitted by needlestick injury.

Steps to be followed after a needle stick injury:

• Encourage bleeding at the injury site and wash it with either 70% alcohol, antiseptic hand- wash or soap and water. Do not scrub the injury.
• You should explain to the patient what has happened and obtain informed consent to take their blood to screen for HIV, Hepatitis B, C and for storage of serum. If infection is transmitted, it will be necessary to compare the patient's sample and your sample for industrial injury benefit or insurance purposes. Most patients will be happy to give a sample under these circumstances but, if not, you may need to point out your duties in respect to infection control and the need to protect your other patients.
• If a patient refuses to give blood, ask whether they will let their medical practitioner take it. It is not unusual for patients to be upset, worried or angry about being tested for Hepatitis. The general population have little knowledge of Hepatitis and HIV but may be aware that it is transmitted sexually.
• Blood should be obtained to store the serum in case testing is required at a later date. As a last resort, permission to speak to the patient's medical practitioner should be obtained in case the patient has recently been tested for another reason.
• The possibility that the patient might be HIV-positive or suffering from Hepatitis will have to be addressed in order to assess the risk of transmission. This must be done in a sensitive manner.

HIV

Post Exposure Prophylaxis (PEP) for HIV: (0.3% risk of transmission)

The most urgent priority is to assess whether there is a significant risk of transmission of HIV infection. Post exposure prophylaxis with anti-retroviral drugs can significantly reduce the chance of transmission of HIV, but for maximum effectiveness it is recommended that it is administered within one hour. The decision to start PEP is made on the basis of degree of exposure to HIV and the HIV status of the source from whom the exposure/infection has occurred.

Basic regimen

Zidovudine (AZT) – 600 mg in divided doses (300 mg/twice a day or 200 mg/thrice a day for 4 weeks + Lamivudine (3TC) – 150 mg twice a day for 4 weeks.

Expanded regimen

Basic regimen + Indinavir – 800 mg/thrice a day, or any other protease inhibitor, 4 weeks therapy.

Testing and Counseling

The health care provider should be tested for HIV as per the following schedule :

1. Base-line HIV test - at time of exposure.
2. Repeat HIV test - at six weeks following exposure.
3. 2nd repeat HIV test - at twelve weeks following exposure.

On all three occasions, HCW (health care workers) must be provided with a pre-test and post- test counseling. HIV testing should be carried out on three ERS (Elisa/ Rapid/ Simple) test kits or antigen preparations.The HCW should be advised to refrain from donating blood, semen or organs/tissues and abstain from sexual intercourse.

Duration of PEP

PEP should be started, as early as possible, after an exposure. It has been seen that PEP started after 72 hours of exposure is of no use and hence is not recommended. The optimal course of PEP is not unknown, but 4 weeks of drug therapy appears to provide protection against HIV.

If the HIV test is found to be positive at anytime within 12 weeks, the HCW should be referred to a physician for treatment.

Pregnancy and PEP

Based on limited information, anti-retroviral therapy taken during 2nd and 3rd trimester of pregnancy has not caused serious side effects in mothers or infants. There is very little information on the safety in the 1st trimester. If the HCW is pregnant at the time of exposure to HIV, the designated authority/physician must be consulted about the use of the drugs for PEP.

Side-effects of these drugs

Most of the drugs used for PEP have usually been tolerated well except for nausea, vomiting, tiredness or headaches. Due to these debilating side effects, routine post exposure prophylaxis cannot be advocated.

Hepatitis B

Risk of trasmission is 30%. 0.1 ml of blood is sufficient to transmit infection.

Hepatitis C

Risk of transmission is 3%.

How to minimize chances of needle stick injury?

Needlestick-type injuries do not always result from needles. Burs, broken plastic or hand instruments and other contaminated sharps all constitute a risk. You should ensure that the entire dental team are trained in the disposal of sharps.

• Identify and dispose of needles and other sharps immediately after use.
• Pass instruments with the sharp end pointing away from any person.
• Remove burs and ultrasonic tips from hand pieces immediately after use.
• Pick up instruments individually.
• Never resheath a needle holding the sheath in a hand: use a one-handed technique or dispose of the needle immediately.
• Dispose of sharps into a solid container.
• Ensure that sharps are disposed off by incineration and by an authorized person registered to collect such waste.
• Use heavy-duty gloves when cleaning instruments prior to autoclaving.
• Keep your working area well organized and uncluttered, with sharps in a separate area. Do not place waste material such as swabs or tissues over instruments.