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Community-acquired needlestick injury

Disclaimer

These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. 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.

 

This guideline supports clinicians in the initial assessment, management and referral of children with community-acquired needlestick injuries (CA-NSI). It aims to ensure timely care, including counselling and investigations, to streamline referrals and reduce outpatient clinic wait times.

Most children with community acquired needlestick injuries can be investigated and followed up at the primary care level. 

If the source is known to be high-risk for blood-borne viruses (e.g., HIV, Hepatitis B or C positive), or if urgent clinical concerns exist, contact the Infectious Diseases consultant on-call at Perth Children’s Hospital immediately via Switchboard: (08) 6456 2222.

Introduction

The risk of transmission of blood-borne viruses (BBVs) such as HIV, Hepatitis B (HBV), and Hepatitis C (HCV) to a child from a discarded needle in a community setting is very low.

The data in the following table on risk of BBV transmission is based on occupational exposures (e.g., healthcare workers) which may represent a higher risk than community exposure1

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

Pre-referral investigations

1.  History:

  • Patient's immunisation status: specifically, Tetanus and Hepatitis B. Verify with the Australian Immunisation Register (AIR) if possible (Access the Australian Immunisation Register - Health professionals - Services Australia)
  • Circumstances of the injury: date, time, location, activity at the time of injury.
  • Details of the sharp: type of needle/sharp, presence of visible blood, depth of injury, site of injury.
  • Any first aid measures taken.
  • Medical history of the child, including any conditions causing immunocompromise.
  • Information about the source of the needle, if known (though often it is not). 

2.  Baseline serology:

  • 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.

**Note: Testing for BBV cannot be performed on used syringes**

Pre-referral management

1.  First aid:

  • If not already done, clean the exposure site thoroughly with soap and water. Do not encourage bleeding by squeezing the wound.
  • Assess the wound for any foreign material.

2.  Tetanus prophylaxis:

  • Community needlestick injuries are considered tetanus prone wounds. Please refer to PCH Tetanus Prone Wounds guideline and manage according to tetanus vaccination status.

3.  Hepatitis B prophylaxis:

Unvaccinated / incompletely immunised against Hepatitis B Fully Immunised against Hepatitis B

If the child fulfills any of the following criteria:

  • Not immunised, or no immunisation record available (see above instructions for accessing the Australian Immunisation Register).
  • Has not received a full hepatitis B vaccine course (≥ 3 previous doses recorded on AIR), or ≥ 4 doses if born < 32 weeks or < 2000 g.
  • Is immunocompromised.

Give:

  • Age-appropriate monovalent hepatitis B vaccination (Engerix B® Paediatric/Adult IM OR H-B-Vax II® Paediatric/Adult IM).

AND

  • Hepatitis B immunoglobulin <30 kg: 100 units IM ≥30 kg: 400 units IM (Access is via BloodStar – patient may need to attend local emergency department to facilitate access.

If previously unimmunised against hepatitis B, give further hepatitis B vaccinations at 1 and 3 months following presentation. 

 
 If aged 5 years or younger

No HBIG or additional hepatitis B vaccinations are required.
 If aged 6 years or older

Give age-appropriate monovalent hepatitis B vaccine (Engerix B® Paediatric/Adult IM or H-B Vax II® Paediatric /Adult IM).
This is recommended due to high rates of HBsAb <10 mIU/mL in this age group despite immunisation.2,3,4,5
 

For all patients

Arrange follow-up of serology results. Fully immunised patients with a hepatitis B surface antibody (HBsAb) <10 mIU/mL should be offered a booster dose of hepatitis B vaccine and follow-up serology as per Australian Immunisation Handbook advice for hepatitis B non-responders.

4. Hepatitis C and HIV:

  • No post-exposure prophylaxis is available for hepatitis C.
  • Only children with high-risk CA-NSI are offered HIV post-exposure prophylaxis - discuss with Infectious Diseases.

5.  Counselling and follow-up serology testing:

  • Reassure parents/guardians and the child (age-appropriately) about the very low BBV transmission risk, referencing introductory statistics.
  • Explain the need for baseline and follow-up (at 3 months) blood tests and emphasise the importance of completing the follow-up schedule. This can be performed by the patient’s GP if family / GP are comfortable. Follow-up testing is HIV, Hepatitis B surface antibody (sAb), Hepatitis B surface antigen (sAg) and Hepatitis C serology.
  • Advise on reducing theoretical (very low) secondary transmission risk until final serology at 3 months:
    • Avoid sharing toothbrushes/razors; cover open wounds.
    • For adolescents: avoid unprotected sex and sharing injecting equipment.

When to refer

Referral is recommended for:

All children who have sustained a community-acquired needlestick injury for follow-up testing and counselling, where this is not able to be arranged through the patient’s general practitioner.

Immediate telephone consultation with the PCH Infectious Diseases consultant on call is required if:

  • The source of the needle is known to be positive for HIV, HBV, or HCV.
  • The injury is considered high-risk (e.g., deep penetration, visible blood in syringe from a known high-risk source).
  • The child is significantly immunocompromised.

How to refer

  • Routine non-urgent referrals from a GP, Private Specialist, Doctors from WACHS or Nurse Practitioners should go to the Central Referral Service (CRS).
  • Routine non-urgent referrals from non-medical referrers or private hospitals go to the PCH Referral Office.
  • Urgent referrals (less than seven days) are made via the PCH Referral Office. Please call PCH Switch on 6456 2222 to discuss referral with the Paediatric Infectious Diseases Registrar. 

Essential information to include in your referral

  • Reason for specialist referral and specific questions to be addressed.
  • Patient demographics: Name, DOB, address, contact numbers, Medicare number, hospital UMRN (if known).
  • Parent/guardian contact details.
  • Parent/guardian consent.
  • Detailed history of the needlestick injury (as per "Pre-referral Investigations").
  • Child's Tetanus and Hepatitis B immunisation status (include AIR record if available).
  • Details of any prophylaxis (Tetanus, Hepatitis B vaccine, HBIG) given, including dates.
  • Results of baseline serology (HBsAb, HBsAg, HCV Ab, HIV Ab) for the child.
  • Results of source serology (if performed and available).
  • Any relevant past medical history, especially immunocompromising conditions.
  • Referring practitioner details.

Useful resources

  1. Australian Immunisation Register (AIR) - Australian Immunisation Register - Services Australia
  2. PCH Needlestick Injury Guideline (available on PCH intranet/website for hospital staff – GPs may refer to key principles outlined here) 
  3. WA Department of Health – Sharps and Needlestick Injuries Treating needlestick injuries
  4. Post-exposure prophylaxis following non-occupational exposure to body fluids (nPEP) - CHAMP Guideline
  5. Needlestick Discharge Information Sheet (if available from local health service or PCH ED)

References

  1. Osowicki, J & Curtis, N; Question 2: A pointed question: is a child at risk following a community-acquired needlestick injury? | Archives of Disease in Childhood; https://doi.org/10.1136/archdischild-2014-306929 
  2. 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.
  3. Res S, Bowden FJ. Acute hepatitis B infection following a community-acquired needlestick injury. Journal of Infection. 2011;62:487-9
  4. 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.
  5. 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.
  6. The Australian Immunisation Handbook - The Australian Immunisation Handbook
  7. 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.
  8. 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.
Reviewer/Team: Surgical Services  Last reviewed: Oct 2026


Next review date: Oct 2029


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