Management of needlestick injury

The risk of transmission of BBV to an HCW following a needle stick injury is:

• 1 in 3 for Hepatitis B when the Source Patient has Hepatitis B and is e Ag positive

• 1 in 30 for Hepatitis C when the Source Patient has Hepatitis C

• 1 in 300 for HIV when the Source Patient has HIV

• If NO – assure the recipient, but check the hepatitis B status. See the chart below.

• If Yes – Obtain blood from the recipient and store the blood (it is usually stored for 2 years).

Take consent from the donor:

Consent donor/source for Hep B, Hep C & HIV testing. Consent MUST be obtained for the test and disclosing the result to the recipient. Consent should be taken by a healthcare professional other than the recipient.

• Where a source patient lacks the capacity to consent (e.g. because they are unconscious), his/her tissue etc can only lawfully be tested for serious communicable diseases if it is reasonably held to be in his/her best interests in accordance with the Mental Capacity Act 2005.

• The General Medical Council, therefore, withdrew its guidance that set out exceptional circumstances in which the testing of an unconscious patient may be undertaken without their consent.

1. If a patient specifically refused testing prior to death then the wish must be upheld post mortem.

2. If the patient prior to his/her death has nominated an individual to provide consent for medical interventions then this individual can provide consent for testing.

3. A person in a “qualifying relationship” can give consent. The Human Tissue Authority’s Code of Practice (2004) states: “Consent is needed from only one person in the hierarchy of qualifying relationships and should be obtained from the person ranked highest. If a person high up the list refuses to give consent, it is not possible to act on consent from someone further down the list.”

• Spouse, civil partner or partner,

• Parent or child,

• Brother or sister,

• Grandparent or grandchild,

• Child of a person falling within paragraph (c)

• Stepfather or stepmother,

• Half-brother or half-sister,

• Friend of longstanding.

4. If none of the above is applicable or available to provide consent then consent should be sort from the Coroner.

Manage as unknown source exposure – it is seldom appropriate to test discarded needles and syringes; they should generally be safely disposed off instead.

Please note Children born in the UK should have 3 doses of the Hepatitis B vaccine by 16 weeks. It was incorporated into the routine immunisation schedule in late 2017. When assessing for hep B, take this information into consideration.

Assess eligibility

• (a) - High prevalence countries or risk groups are those where there is a significant likelihood of the index case individual being HIV positive. Within the UK at present, this is likely to be MSM (men who have sex with men), people who inject drugs from high-risk countries (see d below) and individuals who have immigrated to the UK from areas of high HIV prevalence, particularly sub-Saharan Africa (high prevalence is >1%). HIV prevalence country-specific HIV prevalence can be found at https://aidsinfo.unaids.org

• (b) - The index case has been on ART for at least 6 months with an undetectable plasma HIV viral load at the time of the last measurement and within the last 6 months) with good reported adherence. Where there is any uncertainty about HIV VL results or adherence to ART then PEP should be given. The viral load threshold considered ‘undetectable’ in the PARTNER 1 and 2 and HPTN052 studies was <200 copies/ml

• (c) - Factors that influence decision-making in all exposures: More detailed knowledge of local HIV prevalence within index case subpopulations. The recommendations relate to high-risk groups living in the UK (based on the known prevalence of detectable HIV viraemia in the UK, guideline table 1). Where the index case is from a high-risk group and normally resides outside the UK, the risk may be greater and where there is doubt PEP should be given.

• (d) -HIV prevalence amongst IDUs varies considerably depending on whether there is a local outbreak and country of origin and is particularly high in IDUs from Eastern Europe and Central Asia. Region-specific estimates can be found in the UNAIDS Gap Report http://www.unaids.org/sites/default/files/media_asset/05_Peoplewhoinjectdrugs.pdf.

• (e) Factors that may influence decision-making include occupational exposures: Deep trauma or bolus of blood injected.

• (f) - PEP should only be considered after a bite if all three criteria are met: 1) the biter’s saliva was visibly contaminated with blood; 2) the biter is known or suspected to have a plasma HIV viral load >3.0 log copies/ml; 3) the bite has resulted in severe and/or deep tissue injuries.

If eligible for PEP

• If eligible, give PEP preferably within an hour of exposure, and certainly no later than 48-72 hours.

• Discuss with the recipient and take into account their view regarding PEP and take their consent.

• All individuals commencing PEP should have a test (rather than just a specimen for storage) for HIV as in the unlikely event that they have HIV, treatment with 28 days of PEP alone would result in potential harm as resistance to the treatments given could arise once this is stopped at the end of the course.

There is no post-exposure prophylaxis for hepatitis C.

• Any sharps injury to the staff should be reported to occupational health.

• Incident form/Datix.

• Occupational health (on behalf of the trust), under RIDDOR, should report to Health and Safety Executives within 10 days.

• Any occupationally acquired HepB, HepC, HIV must be reported to the local health protection unit in confidence by occupational health.

• Any HepB, HepC, HIV, that patient may have acquired from a BBV infected staff due to a sharps injury must be reported to the local health protection unit in confidence, by an infection control doctor/microbiologist.