DR. VIBHA BHARGAVA

The Story of Ranjita Raje

A 26 year-old nurse with occupationally acquired AIDS

Detected accidentally, in a routine check up In 2002, approached the Municipal Nursing and

Paramedical Staff Union for help Initially, hospital management promised to

consider the demand, but in 2003 refused to take her back

Could this have been prevented ?

Is she entitled to compensation?

And, is Ranjita entitled to costs of treatment?

Healthcare Worker Safety

While safety is mandated in all walks of life, is healthcare worker safety amongst our highest concerns?

How the Healthcare Worker gets Exposed to Blood and Body Fluids Percutaneous Exposure to blood or other body

fluids by Needle stick Through a cut with a contaminated object

Mucocutaneous Exposure through blood/body fluid splash on

non-intact skin wounds and/or mucosa (eye, ear, nose)

The majority of needlesticks occur when health care workers: Dispose of needles Administer injections Draw blood Recap needles Handle trash and dirty linens

Source: Chiarello, 1992

When Do Needlesticks Happen?

Common Pathogens Transmitted by Exposure to Blood and Body Fluids Corynebacterium

diphtheriae Dengue Hepatitis B Hepatitis C Hepatitis G Herpes simplex Herpes zoster HIV

Malaria Mycobacterium

tuberculosis Plasmodium falciparum Staphylococcus aureus Streptococcus pyogenes Syphilis

0%0%

5%5%

10%10%

15%15%

20%20%

25%25%

30%30%

35%35%

0.30%

1%-10%

9%-30%

Hepatitis B Virus Hepatitis C Virus HIV

Antiretroviral Therapy Guidelines for HIV-Infected Adults and AdolescentsIncluding Post-exposure Prophylaxis – NACO, May 2007

Risk of Transmission of Infection Following Exposure to Blood and Body Fluids

Occupational Risk of Hepatitis C:

HCV - major cause of chronic liver disease

No vaccine No effective post-exposure

prophylaxis 85% of HCV infected people

develop chronic infectionSource: CDC, 1997; NIH, 1997

Global Incidence Rates of Exposure to Blood and Body Fluids

Data collection done through EPINet software (Exposure Prevention Information Network)

Developed by Professor Janine Jagger at International Healthcare Worker Safety Centre, University of Virginia, in association with BD

Allows collation of data - How and where exposures are occurring helps to develop targeted prevention strategies

Before & after data to measure effectiveness of prevention strategies

Health Care Workers Exposed to Blood and Body Fluids – by Category

Staff physicians (6%)

Residents (9%)Respiratory therapists (2%)

OR Nurses (5%)

Other assistants (4%)

Phlebotomists (5%)

Laboratory (4%)Technicians (5%)

Others (8%)

Students (2%)House keeping and laundry (4%)

International Health Care Worker Safety Center, Univ. of Virginia

EPINet USA - 87 institutions - 1993-2001 - incidents:25,577

Nurses ( 55%)

Patient’s room (34%)

Right outside patient’s room (2%)

Emergency Room (8%)

ICU (7%)

OR (23%)

Outpatient clinics (6%)

Procedure rooms (5%)

Laboratory (3%)

Disposal area (2%) Clinic (1%)

Other (9%)

EPINet US - 87 institutions, 1993-2001, incidents: 25,577

International Health Care Worker Safety Center, Univ. of Virginia

Health Care Workers Exposed to Blood and Body Fluids – by Area of Deployment

Health Care Workers with HIV acquired at workHealth Care Workers with HIV acquired at work

80

100

120

140

160

180

200

1992 '93 '94 '95 '96 '97 '98 '99 2000 '01

Nu

mb

er

of

ca

ses

Cumulative cases * 1992Cumulative cases * 1992--20012001

( BD introduced Safe IV catheters in US in mid nineties )( BD introduced Safe IV catheters in US in mid nineties )

Source: U.S. Centers for Disease Control and Prevention. For years 1992 through 1999: HIV/AIDS Surveillance Report, year-end reports.For 2000-2001: Fact Sheet: Health Care Workers with HIV/AIDS, pub’d on-line at: www.cdc.gov/hiv/pubs/facts/hcwsurv.htm.

Indian Scenario on Incidence of Blood and Body Fluid Exposure

1. Highlights of 1st Published Indian EPINet Data – Indian Journal of Medical Sciences, Dec 2010 – Authors Murali Chakravarty, Sanjeev Singh, Anita Arora, Sharmila Sengupta, Nita Munshi

Data from 4 Indian Hospitals located in 4 major cities over 2 years

Major sources of sharps injury: Needle on a disposable syringe - 42% Stylette of IV cannula - 9% Needle without syringes / on IV drip

sets - 9% 77% of the sharps injuries occurred, due to

lack of safety mechanisms in devices

Indian Scenario on Incidence of Blood and Body Fluid Exposure2. Needlestick Injuries in a Tertiary Care Centre in Mumbai, India – Journal of Hospital Infection, 2005 – Authors A. Mehta, C. Rodrigues, S. Ghag, F. Dastur and S. Iyer

Nursing staff is most highly affected upto 45%

Use of safer devices should be considered as one of the main approaches along with educational and immunisation programs for reducing occupational infection risk

3. Needle stick injuries & the health care worker – the time to act is now – Indian Journal of Medical Research, Mar 2010 – Author Camilla Rodrigues

The incorporation of safer needle devices (SNDs) and better utilization of safety devices such as needleless sets, safety cannula, self-capping intravenous catheters, self retracting lancets for blood glucose monitoring, auto disposable syringes certainly help in reducing injuries

Direct Costs

Cost of baseline and follow-up laboratory testing of an exposed healthcare worker and testing the source patient

Cost of post-exposure prophylaxis (PEP) and other treatment that might be provided

These costs may range from Rs 15,000 to Rs 1 lakh/incidence of exposure to blood and body fluids

Financial Implications of Clinical Risk

Financial Implications of Clinical RiskIndirect Costs

Emotional distress

Lost productivity

Healthcare provider time to evaluate and treat an employee and the source patient

Reduced quality of life

Loss of precious human lives

While there are financial implications, but at the end of the day, we cannot put a price to a precious human life

Can we ?

All the staff must take utmost care to avoid NSI

Recapping of the needles is prohibited as this is the most common cause of NSI. The needles after use should immediately be discarded in the Sharp Box.

Follow standard precaution -To reduce the risk of exposure to potentially infective material for patients and health care workers.

Hands must be washed thoroughly after contact with blood or body fluids/substances, secretions, excretions and contaminated items, whether or not gloves are worn.

Use Personal Protective barriers Staff members with cuts or abrasions

on exposed parts of the body must cover with a water proof dressing at all times whilst on duty.

Safer Needle Devices

Management of Needle stick injury

Encourage the blood to flow freely by itself without squeezing forcefully.

The wound should be washed with plenty of running water and soap. Do not scrub vigorously. (Alcohol based hand rinses or foams 60% - 90% alcohol by weight, should be used when water is not available.)

Exposed mucous membranes should be flushed with plenty of water; spit out, rinse with water and spit out again if blood or body fluids gets into mouth; flush the eyes preferably with sterile normal saline, or under the eye-shower.

 

Report to MO in Emergency immediately after the incident: Assessing the Significance of the Injury. This depends on:

The nature and extent of the injury – did it draw blood? The nature of the item that caused the injury hollow or

solid needle. Hollow needles pose the greatest risk. The nature of the body substance involved – blood or

blood strained fluid have the greatest risk. The volume of the material the HCW contacted – was

any blood or body fluid injected. The HIV, HCV status of the Source if known.

 

If status is unknown the following blood test should be undertaken from the Source individual: HIV HbsAg Anti-HCV

In the Emergency, blood specimen will be collected for the serological investigations, viz HBsAg, HIV, HCV for the victim and for the source, if not done recently.

The EMO would initiate PEP, post-exposure prophylaxis, unless the exposure to blood/body fluids is ruled out.

ART and/or HBIG and/or TT are given at the discretion of the EMO. No PEP is required if the exposure is limited to intact skin only.

No PEP is required if the source blood is confirmed Negative.