Needlestick injury – Community Acquired

Aim

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

Background

Community acquired needlestick injuries in children are uncommon but cause a great deal of worry for families. They mostly occur in public places such as the park or street and often after the child intentionally picks up the syringe or needle.

Key points

• The risk of transmission of Blood Borne Viruses (BBV) to a needlestick recipient in a community setting is very low.¹
• 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.^1,2
• Hepatitis B transmission risk can be reduced through vaccination and hepatitis B immunoglobulin (HBIG) administration in unimmunised or under-immunised individuals.
• There is no available vaccine or post exposure prophylaxis currently recommended for hepatitis C, though effective treatments are available should acquisition occur.
• Antiretroviral prophylaxis should not be routinely prescribed unless the source of the needlestick is known to be HIV positive. The risk of HIV transmission from community needlestick injury is extremely small (presently no published cases), and antiretrovirals have significant side effects.¹
  
  • See Post-exposure prophylaxis following non-occupational exposure to body fluids (nPEP)  - (ChAMP Guideline) for antiretroviral prophylaxis.
• Follow up is essential.
• Please note that the laboratory is unable to test used syringes for evidence of infective virus under any circumstances.

Estimated risk associated with exposure

* 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. High risk Community Acquired Needlestick Injury (CA-NSI) is any of the following:
  • Source known to be infected with a blood borne virus
  • CA-NSI from a deliberate assault
  • Deep, large volume injection with a hollow bore needle
  • Personal history of injecting drug use (adolescents)
• Assess patient's immunisation status (tetanus, hepatitis B) according to the Australian Immunisation Register (AIR) – this can be accessed through MyHR via i.CM, DMR or via PRODA.
  • Further AIR access advice can be provided by the PCH Immunisation Service: Monday to Friday, 8.30am-4.00pm Phone: 08 6456 3721

Investigations

• Take baseline serology (hepatitis B, hepatitis C and HIV). This requires informed verbal consent from parents / carers. Contact microbiology to request urgent processing of serology.
• 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

Refer to Appendix 1 - see below.

• Assess and manage associated injuries prior to specific management of CA-NSI
• First aid – wash site with soap and water
• Dispose of needle safely
• If High Risk CA-NSI, discuss with Infectious Diseases

Medical prophylaxis

Referrals and follow-up

• Needlestick Discharge Information Sheet: standard letter for children with community acquired needlestick injury
• Arrange follow up of baseline Hepatitis B serology with GP as above
• If further Hepatitis B vaccines are required, arrange this course via the GP or Stan Perron Immunisation Centre
• Review at 3 months with repeat testing to ensure no BBV acquisition. This can be with PCH infectious diseases outpatient clinic (complete outpatient eReferral) or with the patient’s GP, according to family preference.
  • Follow up serology: HIV, Hepatitis B surface antibody (sAb), Hepatitis B surface antigen (sAg) and Hepatitis C serology to be done at PCH laboratory or other PathWest collection centre approximately 2 weeks prior to the outpatient clinic appointment/GP review. Ensure the patient has 
    • a pathology request form and
    • lidocaine 2.5% with prilocaine 2.5% cream (EMLA^®) for the test, if required, which must be prescribed if provided by PCH or it can be obtained from a Community Pharmacy without a prescription. Refer to Supply of Medications by Approved Prescribers (internal WA Health only). 

Bibliography

1. 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.
2. Res S, Bowden FJ. Acute hepatitis B infection following a community-acquired needlestick injury. Journal of Infection. 2011;62:487-9
3. Ewe KYH, Blyth CC, McLeod C, Borland M, Bowen AC, Yeoh DK, Campbell AJ. Re-examining Hepatitis B Postexposure Prophylaxis Following Pediatric Community-acquired Needle-stick Injury in an Era of a National Immunization Registry. The Pediatric Infectious Disease Journal 41(1):p 80-84, January 2022.
4. 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.
5. 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.
6. 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.

Appendix 1: Needlestick injury management pathway

Click the image below to download a copy of the needlestick injury management pathway.

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