Needlestick injury

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Read the full PCH Emergency Department disclaimer.

Aim

To guide staff with the assessment and management of community acquired needle stick injury.

Background

The risk of transmission of Blood Borne Viruses (BBV) to a needlestick recipient in a community setting is very low.
There are only a few reported cases of members of the public becoming infected by hepatitis B or hepatitis C and none with HIV following accidental injury from discarded injecting needles in the community setting.
Studies demonstrate long-term seroprotective hepatitis B immune responses following a three-dose infant hepatitis B vaccine schedule. There are limitations of hepatitis B serology testing as a correlate of seroprotection in the setting of community needle stick injury with waning Hepatitis B surface antibody levels demonstrated with increased time between testing and last hepatitis B vaccine receipt. This does not usually indicate lack of immunity, with an anamnestic response (Hepatitis B sAb level >100IU/ml) demonstrated in most children.
Follow up is essential.
Please note that the laboratory is unable to test used syringes for evidence of infective virus under any circumstances.

Risk associated with exposure

Blood borne virus	Estimated incidence in WA IV drug users*	Risk of transmission with a needlestick#	Calculated maximal risk of transmission✩
HIV	1.1 - 1.6%	0.3%	0 - 0.0048%
Hepatitis B	1.8%	30%	0 - 0.54%
Hepatitis C	55 - 58%	3%	0 - 1.74%

* The most likely source of discarded needles in the community
# Figures based on occupational exposure
✩ Calculated from column 1 and 2. Maximal risk is likely to be overestimated.

Assessment

History

Assess risk: presence of blood in the syringe, depth of injury, site of needlestick injury.
Assess patient's immunisation status (tetanus, hepatitis B) according to the Australian Immunisation Register (AIR)
Further AIR access advice can be provided by the PCH Immunisation Service: Monday to Friday, 8.30am-4.00pm Phone: 6456 3721 or general advice by the Infectious Diseases Department.

Investigations

Take baseline serology (hepatitis B, hepatitis C and HIV). This requires informed verbal consent from parent.
If the identity of the needle user is known, then the source should also have their blood taken for serology (hepatitis B, hepatitis C and HIV), after obtaining informed consent.

Management

If the source patient is known to have a blood borne virus (BBV), the Infectious Disease clinician should always be contacted.
In this setting contact the infectious diseases team (including after hours) to discuss the need for post-exposure prophylaxis (nPEP) and to organise follow-up

First aid

If not already done, clean the exposure site with soapy water.

Tetanus prophylaxis

If the child fulfils any of the below criteria:
- No Australian Immunisation Registry (AIR) or other written vaccination record available
- Has not received a full tetanus vaccine course (≥3 previous doses recorded on AIR)
- Is immune compromised
Give tetanus vaccine (DTPa or ADT depending on child’s age) and tetanus immunoglobulin. Access via Transfusion Management Unit (Blood Bank) Ext 34015 (from PCH) or 6383 4015 (for urgent requests)
If the child does not fulfil any of the above criteria and has not received a booster tetanus vaccine within the last 5 years, give tetanus vaccine only.

Hepatitis B prophylaxis

If the child fulfils any of the below criteria:
- No Australian Immunisation Registry (AIR) vaccination record or other written record available
- Has not received a full hepatitis B vaccine course (≥3 previous doses recorded on AIR)
- Is immune compromised
- Has a history of moderate prematurity (<32 weeks)
- Low birth weight infants (<2000gm)
Give hepatitis B vaccine (Engerix B Paed/Adult or H-B Vax II Paed/Adult depending on child’s age) and hepatitis B immunoglobulin (HBIG) at initial ED presentation. Access HBIG via Transfusion Management Unit (Blood Bank) Ext 34015 (from PCH) or 6383 4015 (for urgent requests).
If previously unimmunised against hepatitis B give further hepatitis B immunisations at 1 and 3 months following ED presentation. Arrange via the GP or the PCH Immunisation drop-in centre.
If the child does not fulfil any of the above criteria and has completed vaccinations against hepatitis B (≥3 previous doses recorded on AIR) then no HBIG or further hepatitis b vaccinations are required.

Hepatitis C

There is no available vaccine or post exposure prophylaxis currently recommended.

HIV Prophylaxis

No anti-retroviral prophylaxis should be routinely prescribed unless the source of the needlestick is known to be HIV positive
The risk of HIV transmission from community needlesticks is extremely small (presently no published cases), and anti-retrovirals do have significant side effects.

Referrals and follow-up

Needlestick Discharge Information Sheet: standard letter for children with community acquired needlestick injury
Arrange Hepatitis B vaccination course via the GP
- GP follow up 1 week after the initial serology to communicate the results of HIV, Hepatitis C serology
Review at PCH Infectious Diseases outpatient clinic at 6 weeks and 3 months. Complete the outpatient clinic eReferral.
Follow up HIV, hepatitis B surface antibody (sAb) and hepatitis B surface antigen (sAg) and hepatitis C serology to be done at PCH laboratory approximately 2 weeks prior to the outpatient clinic appointments.
- Ensure the patient has completed pathology request forms and some take home EMLA for both tests.

Health information (for carers)

Advice to reduce the risk of transmission to close contacts until final serology at 3 months:

If relevant (e.g. adolescent) advise against unprotected sex / needle sharing / sharing razors
Do not share toothbrushes.

Bibliography

Bagheri-Jamebozorgi M, Keshavarz J, Nemati M, Mohammadi-Hossainabad S, Rezayati M, Nejad-Ghaderi M, et al. The persistence of anti-HBs antibody and anamnestic response 20 years after primary vaccination with recombinant hepatitis B vaccine at infancy. Human Vaccines & Immunotherapeutics. 2014;10(12):3731-6.
Gilca V, De Serres G, Boulianne N, Murphy D, De Wals P, Ouakki M, et al. Antibody persistence and the effect of a booster dose given 5, 10 or 15 years after vaccinating preadolescents with a recombinant hepatitis B vaccine. Vaccine. 2013;31:448-51.
Papenburg J, Blais D, Moore D, Al-Hosni M, Laferrie`re C, Tapiero B, et al. Pediatric Injuries From Needles Discarded in the Community: Epidemiology and Risk of Seroconversion. PEDIATRICS. 2008;122(2):e487–e92.
Poovorawan Y, Chongsrisawat V, Theamboonlers A, Bock H, Leyssen M, Jacquet J. Persistence of antibodies and immune memory to hepatitis B vaccine 20 years after infant vaccination in Thailand. Vaccine. 2010;28(3):730-6.
Res S, Bowden FJ. Acute hepatitis B infection following a community-acquired needlestick injury. Journal of Infection. 2011;62:487-9

Endorsed by:	Co-Director, Surgical Services	Date:	Aug 2021
		Review date:	Jul 2024

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