12 At the sharp end


Injuries sustained from needles can be devastating for those affected. Dr Susan Purchase offers advice and guidance


common. Incidence data from Southern Africa is scarce, but in 2001 over 69% of interns working at Chris Hani Baragwanath Hospital sustained percutaneous injuries, and at Tygerberg Hospital 91% of junior doctors reported needlestick injuries in the previous year.1 The vast majority of these


A


occurred outside “normal” working hours.2


Every doctor


working in South Africa should know how to prevent injury, what to do if injured, and how to treat an injured colleague. This article aims to empower and inform junior doctors to ensure we do not become the victims of our own ignorance. Counselling and anxiety management must be actively addressed, while the high HIV and hepatitis B seroprevalence in South Africa make adequate prophylaxis crucial.


Know the risks Occupational exposures are usually either percutaneous (due to puncture or laceration) or mucocutaneous (such as an eye splash). Contact of infectious fluids with intact skin is not considered an exposure. Potentially infectious fluids


include the following: ■■ Blood ■■ Sexual fluids ■■ Any fluid drained from a body cavity


■■ Breast milk. Sweat, tears, saliva, sputum, nasal secretions, urine and stool are regarded as non-infectious, unless contaminated with the fluids listed above. Risk of HIV transmission


after percutaneous exposure is roughly 0.3% (or 3/1000). Factors that


ccidental exposure to blood by healthcare workers is frighteningly


increase risk would include: ■■ Deep injury ■■ Visible blood on the needle/instrument


■■ Needle used to enter blood vessel


■■ Source patient with a high viral load/terminal AIDS.


It is important to remember that risk of transmission of hepatitis C is about 3%, and hepatitis B 30%! These highly infectious viruses must not be forgotten when testing the source patient and when planning prophylaxis.3,4


Prevention of occupational exposure This is the responsibility of both the employer and the employee. South Africa has numerous laws and guidelines dealing with this issue, and the employer is obliged to provide, as far as is reasonably practicable, a safe working environment.4


The doctor


is required to work safely within that environment, and standard precautions should apply wherever infectious fluid contact is possible. The following


are key considerations: ■■ Gloves (in appropriate sizes) and protective eyewear must be readily available


■■ Needles should not be resheathed, and handling of needles after withdrawal from a patient should be kept to an absolute minimum. Needles should never be inserted into mattresses, where they are often either dislodged or forgotten


Baseline HIV ✓


HBV ✓ (If exposed not immune) HCV ✓ FBC


■■ All needles and sharp objects should be disposed of in dedicated sharps bins. Syringes and other blunt instruments should not be placed in these bins


■■ Areas requiring a large number of invasive procedures (such as casualty) should have a bin to bed ratio of 1:1. Wards should ideally have a ratio of 1:2, but at least 1 bin per cubicle


■■ Sharps bins must be sealed and disposed of once ¾ full. Overfull bins are a risk factor during use and disposal.


Immediate action


following exposure ■■ Puncture wounds should be washed with soap and large volumes of water


■■ Mucosal exposures should be irrigated with clean water


■■ The person in charge should be informed immediately


■■ Post-exposure prophylaxis should begin as soon as possible.


Routine blood testing Both the source patient and the doctor need to be tested as indicated in the table below. Both need to be carefully pre- and post- test counselled. The patient should be given the option of being tested anonymously. Should the patient refuse testing, he/she should be assumed to be positive for HIV and hepatitis. For source patients on anti-retrovirals, HIV RNA PCR should be


BLOOD SAMPLING PRE- AND POST-EXPOSURE4 Source


Exposed


Baseline 2 weeks 6 weeks 3 months 6 months ✓ ✓ ✓


✓ ✓ if on AZT ✓ if on AZT ✓


✓ ✓ ✓


performed. If the patient has a detectable viral load, genotypic testing should be considered, but should not delay the start of prophylaxis.


HIV prophylaxis There is understandably very little evidence available to guide post-exposure HIV prophylaxis, and advice is largely based on basic science and PMTCT principles. The following are key points to consider when


formulating an ARV regimen: ■■ Completion of 28 days of appropriate prophylaxis is fundamental to a good outcome


■■ Side-effect management is critical, and is often not well-handled by treating clinicians


■■ Side-effects appear to be more common and severe in HIV-negative exposed people than in HIV positive people starting ART


■■ There have been very few documented failures of appropriate ART


■■ A three-drug regimen should be considered, particularly in high-risk exposures. Triple ARV regimens in treatment and PMTCT settings have been shown to be superior to mono- or dual therapy, but the additional toxicities and side-effect burden must be considered.


ARV regimens These would usually consist


of 2 NRTIs +/- a third agent. ■■ Choice of NRTIs depends on side-effect profiles, local guidelines and availability. D4T given for one month has fewer side-effects than AZT, which commonly causes headaches, nausea and vomiting. Twice daily – Stavudine (D4T) and lamivudine (3TC) – AZT and 3TC


ARTICLE


JUNIOR DOCTOR | VOLUME 2 | ISSUE 1 | 2011 | SOUTH AFRICA www.medicalprotection.org


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