Prevention of NSI and Related Injuries - Post-Exposure Prophylaxis - Rapid HIV Testing PDF

PREVENTION OF NEEDLE STICK AND RELATED INJURIES, POST- EXPOSURE PROPHYLAXIS, RAPID HIV TESTING Clinical Skills MBChB III 2024  OBJECTIVES OF THIS SESSION Understand the risk of needlestick injuries and learn principles and safe habits to prevent them Go through the PEP protocol T...

PREVENTION OF NEEDLE STICK AND RELATED INJURIES, POST- EXPOSURE PROPHYLAXIS, RAPID HIV TESTING Clinical Skills MBChB III 2024  OBJECTIVES OF THIS SESSION Understand the risk of needlestick injuries and learn principles and safe habits to prevent them Go through the PEP protocol Technique and principles of rapid HIV testing  NEEDLE STICK INJURY (NSI) Broadly refers to an exposure to contaminated blood that might place health care workers (HCWs) at risk for blood borne infections Percutaneous injury, eg. a needle stick or cut with a sharp object Contact of mucous membrane or non-intact skin  WHAT INFECTIONS CAN BE CAUSED BY NEEDLESTICK INJURIES? NSIs can expose HCWs to a number of blood borne pathogens that can cause serious or fatal infections The pathogens that pose the most serious health risks are: Human Immunodeficiency Virus (HIV) Hepatitis B Virus (HBV) Hepatitis C Virus (HCV)  H O W C O M M O N A R E N E E D L E S T I C K I N J U R I E S A M O N G S T H E A LT H CARE WORKERS? It is estimated that around 3 million NSIs take place globally each year Unfortunately, only about half of such injuries are reported Always report needlestick injuries to ensure that you receive appropriate follow up care  COST OF EXPOSURE Infectious disease  disability or death Psychological trauma  months of waiting, fear of outcome Altered lifestyle S/E of prophylactic medication Job discrimination  loss of employment, lack of compensation  W H AT K I N D S O F N E E D L E S U S U A L LY C A U S E N E E D L E S T I C K INJURIES? Hypodermic needles Suture needles Blood collection needles Needles used in IV delivery systems  D O C E RTA I N W O R K P R A C T I C E S I N C R E A S E T H E R I S K O F N E E D L E S T I C K I N J U RY ? Studies have shown that NSIs are often associated with these activities: recapping needles transferring a body fluid between containers using a sharp failing to dispose of used needles properly in puncture- resistant sharps containers HOW CAN I PROTECT MYSELF FROM NEEDLESTICK INJURIES? Presence of mind Avoid the use of needles where safe and effective alternatives are available Avoid recapping needles Plan for safe handling and disposal of needles before using them Use devices with safety features provided by your employer Help your employer select and evaluate devices with safety features that reduce the risk of needlestick injury  HOW CAN I PROTECT MYSELF FROM NEEDLESTICK INJURIES? Promptly dispose of used needles in appropriate sharps disposal containers Tell your employer/supervisor about any needlestick hazards you observe in the work environment become familiar with the infection control protocols in your workplace Ensure that you are immunized against Hepatitis B Report all needlestick and sharps-related injuries promptly to ensure appropriate follow-up care SHARPS: HANDLING AND DISPOSAL Sharps are potentially the most hazardous elements of clinical waste Needles - injections, suture and dental needles, etc. IV cannulae, “butterfly needles” or scalp vein sets Blades - scalpels, razors, lancets Broken glasses - ampoules, vials, bottles Any other sharp object - sharp-edged or pointed  SHARPS: HANDLING AND DISPOSAL N ON - D IS P OS AB L E S H A R P S Non disposable sharp instruments must be handled with care at all times Using Cleaning Disinfecting Storing  SHARPS: HANDLING AND DISPOSAL OBJECTIVE: to reduce the risk of NSI Receptacles Protocols Training The onus is on every staff member and student to prevent injury and risk of infection PREPARING FOR A PROCEDURE Understand the procedure before you attempt it Equipment Preparation Be familiar with the instrument / device before use Safe habits  PREPARING FOR A PROCEDURE All items required must be within reach Once you begin the procedure, be aware of the sharps at all times The sharps disposal container must be within reach and correctly placed https://howtodoinjections.com  PREPARING FOR A PROCEDURE Explain to the patient exactly what you are going to do, and what you require of him/her Keep the limb supported against an immovable surface Special care and caution may be needed: assistance to support limbs restrain violent or uncooperative patients, and children  PRECAUTIONS DURING A PROCEDURE Do not use excessive force Position yourself correctly Keep your fingers BEHIND the sharp Don’t recap needles  PRECAUTIONS DURING A PROCEDURE Remember – grey rubber of vacutainer needle covers part of the needle and has a sharp tip Don’t bend or break needles Dispose of Butterfly as a complete set  PRECAUTIONS DURING A PROCEDURE Vacutainer system disposal Venoject Keyhole aperture NEVER leave sharps lying around On drapes, poked into mattress or on bed Use appropriate sharps disposal container  PRECAUTIONS DURING A PROCEDURE Dispose of syringe and needle as unit Syringes with exposed needles: mainly during emergencies must be carried in a receiver Never resheath needles Sharps container: drop sharp into container (don’t push) Close container when ¾ full  PRECAUTIONS AFTER A PROCEDURE Do not make sudden movements if you have a sharp object in your hand Keep sharps within visibility of everyone around Don’t carry sharps around - this is avoided by having a sharps container close at hand Be aware of the sharp at all times, until it is safely disposed of NEVER attempt to retrieve anything from a sharps container If the sharps container is full, get another one Never leave sharps lying around (eg. on a surface) You are responsible for your own sharps  SURGERY AND MINOR PROCEDURES : Additional caution required Concentration of HCWs in a limited working space with high number of potential hazards Hold needle with needle holder SURGERY AND MINOR PROCEDURES : A S S I S T I N G AT A N OP E RAT I O N Keep your eyes on the needle at all times Do not cross the surgeon’s path Do not make any sudden, unexpected movements Do not keep your fingers hidden under tissues, swabs or in a bloody field Do not allow sharps to be hidden within tissues, swabs or in a bloody field Do not swab or place your fingers in a field unless you are sure it is free of sharps Use appropriate instruments e.g. needle holders, blade handles  HANDLING OF SHARPS IN THEATRE https://youtu.be/CdajmI5v0vI Surgical Tech Tips  MEDICAL S AFETY DEVICES Pronto vacutainers (displaces / ejects needle without need to touch) “Blunt / round tip” needles Safety intravenous cannulae (tip of needle not exposed) Non-penetrable gloves Inconvenient costly used by mortuary staff POST-EXPOSURE PROPHYLAXIS (PEP)  PAPERWORK Detailed Extremely crucial facility policy on PEP ikw national policy Identify person in charge Familiar with protocols Available after hours Access to appropriate management  SPECIAL PROBLEMS Pregnancy – PEP is not contra-indicated Breastfeeding Drug interactions Severe side effects  STEPS TO FOLLOW FOR PEP FOLLOWING OCCUPATIONAL EXPOSURE Provide immediate treatment (by washing or flushing) Evaluate the exposure and determine the exposure risks Report occupational exposure Pre-test counselling and consent Start ARV-PEP within 1-2 hours  ASSESSMENT OF EXPOSURE RISK LOW RISK HIGH RISK Small volume Large volume Asymptomatic source patient Symptomatic / AIDS source Superficial injury patient Deep injury Mucocutaneous exposure Hollow bore needle No visible injury Injury noted Source patient with low viral load Source patient with high viral load  STEPS TO FOLLOW FOR PEP FOLLOWING OCCUPATIONAL EXPOSURE If HCW is HIV negative, then counsel and continue ARV’S for 28 days If HCW is HIV positive, refer to ARV clinic for CD4 count Do baseline tests Follow-up Testing of the source patient TABLE 1: DOES THE HIV-EXPOSED NEED PEP? Careful risk-benefit assessment needs to be done before initiating HIV PEP, as the antiretroviral drugs can cause serious side-effects HIV Status of source patient Exposure Negative Unknown or Positive Intact skin to infectious or non- no PEP no PEP infectious materials Mucous membrane or non-intact skin exposure, including splash or contact with open wound, to no PEP 3-drug regimen blood or other infectious materials Percutaneous exposure (needle stick) to blood or other infectious no PEP 3-drug regimen materials INFECTIOUS MATERIAL Blood or any bloodstained fluids, tissue or other material Vaginal secretions or penile pre-ejaculate and semen Fluid from any body cavity such as pleural, pericardial, amniotic, peritoneal, synovial and cerebrospinal fluids Breast milk Saliva, tears, vomitus, sweat and urine pose no risk of HIV, unless contaminated with infectious materials e.g. blood Medicines Information Centre, UCT 2019 TABLE 2: WHICH HIV PEP REGIMEN? Choose one option from each column: NRTI dual regimen PI-combination or INSTIs Atazanavir 300 mg PLUS ritonavir 100 mg daily Tenofovir 300 mg + emtricitabine 200 mg 1 tab daily OR OR Aluvia® (lopinavir/ritonavir 200/50 mg) 2 tabs Tenofovir 300 mg 1 tab daily PLUS lamivudine 300 mg 1 tab daily + 12 hourly OR OR Dolutegravir 50 mg daily Lamivudine 150 mg + zidovudine 300 mg 1 tab 12 OR hourly Raltegravir 400 mg 12 hourly SPECIAL PRESCRIBER’S POINTS Tenofovir is better tolerated than zidovudine Fixed-dose combinations preferred. (Dolutegravir + lamivudine + tenofovir now available) Atazanavir + ritonavir is given once daily and usually better tolerated than Aluvia® Always check for drug-drug interactions. Atazanavir is contra-indicated with rifampicin and proton-pump inhibitors e.g. omeprazole, lansoprazole. Antacids should not be used with raltegravir Dolutegravir should be avoided in woman of child-bearing age not on reliable contraception or during the first 8 weeks of pregnancy If source patients are on a third line regimen or salvage therapy or are failing second line, other ARVs may need to be considered and consultation with an Infectious Disease Specialist or the Hotline is recommended Note: Nevirapine and abacavir should be avoided in PEP HEPATITIS B TABLE 4: HEPATITIS B POST EXPOSURE PROPHYLAXIS Source patient Vaccination status and antibody response of healthcare worker HBsAg positive or HBsAg negative unknown HBIG, IM, 500 units* Unvaccinated or vaccination HepB vaccine (3 Initiate HepB vaccination incomplete doses at monthly (month 0, 1 and 6) intervals Vaccinated AND known to have No treatment No treatment HBsAb titre ≥ 10 units/mL# HBIG, IM, 500 units* Vaccinated AND HBsAb ≤ 10 HepB vaccine (3 No treatment units/mL OR unknown doses at monthly intervals) *Refer to secondary level of care for HBIG, IM. HBIG should be given as soon as possible, preferably within 24-72 hours after exposure (or within 7 days) # If obtaining HBsAb titre is more than 24 hours, initiate treatment as for vaccinated with HBsAb ≤ 10 units/mL; Note: Repeat HBsAb 1-2 months after last vaccine dose to ensure adequate immune response(i.e. HBsAb > 10units/mL) HBsAg: Hepatitis B surface antigen; HBsAb: Hepatitis B surface antibody; HBIG: Hepatitis B immunoglobulin  PEP FOLLOW UP Continue counselling Bloods: monitor toxicity FBC/LFT/Amylase/Lipid profile: 2 weeks, 4 weeks HIV: 6 weeks, 3 months, 6 months HBV Ag: 6, 9, 12 months  PEP COUNSELLING Adherence - 4 weeks Prevent transmission POSSIBLE SIDE-EFFECTS OF ANTIRETROVIRAL TREATMENT Condom use Generally well tolerated. Jaundice with Atazanavir/ Stop breastfeeding ritonavir unconjugated hyperbilirubinaemia occurs commonly, but is benign; hepatitis Side effects of medication Usually well tolerated. Avoid during the Dolutegravir first 8 weeks of pregnancy and in women of childbearing age not on a contraceptive Emtricitabine Generally well tolerated / Lamivudine Lopinavir/ Diarrhoea, nausea, vomiting, hepatitis ritonavir Generally well tolerated. Nausea, fatigue, Raltegravir Stevens-Johnson syndrome Generally well tolerated. Nausea, Tenofovir diarrhoea, vomiting, nephrotoxicity Nausea, vomiting, headache, fatigue, Zidovudine anaemia, neutropenia RAPID HIV TEST TABLE 3: TESTING SOURCE HIV-EXPOSED PATIENT BASELINE BASELINE 2 WEEKS 6 WEEKS 3# MONTHS Rapid test(s), if Rapid test, negative HIV HIV ELISA HIV ELISA AND HIV ELISA confirm with HIV ELISA Surface Surface Surface Hepatitis B antigen antibody antigen Hepatitis C Antibody Antibody* PCR** Serum If TDF part of If TDF part of creatinine PEP PEP If AZT part of If AZT part of FBC & diff PEP PEP * Only if source patient is positive; ** Only if source antibody positive, and health care worker antibody negative #Primary Care 2018, National Department of Health recommends final HIV test at 4 months. HIV Clinicians Society 2015 PEP Guidelines recommends 3 months  RAPID HIV TESTS Used for screening qualitative detection of Abs to HIV Examples include: SD Bioline SENSA Tri-line SmartCheck HIV Sensitivity = 99.9% Specificity = 99.9%  ELISA The ELISA test, also called the EIA for enzyme immunoassay, is used to detect the HIV antibody. The blood sample will be added to a cassette that contains the viral Ag. If the blood contains antibodies to HIV, it will bind with the antigen and cause the cassette’s contents to change colour. This very sensitive test was the first one widely used to check for HIV  RAPID HIV TEST VS. ELISA Advantage: cheap and quick Disadvantages Not as accurate Quality assurance difficult and costly Lots of documentation Variable field conditions  RAPID HIV TEST: EQUIPMENT PREPARATION Alcohol swab Capillary pipette Lancet Test device Assay diluent Abbott Point of Care Testing 202  RAPID HIV: PROCEDURE https://youtu.be/4B4wguDQsqM Exacto HIV Self test (Procedure) Abbott Point of Care Testing 2020  https://youtu.be/SZbe0ts8CVQ Back To Basics of HIV Rapid Testing Quality Testing Improvement Initiative (Doctors Without Borders) (watch from 2min 30sec to end) INTERPRETING THE RESULT Reactive Non- reactive invali d  RAPID HIV – POINTS TO REMEMBER Label the test strip with the Record results and other correct patient identification pertinent information thoroughly number and accurately  REFERENCES Clinical Skills Lecture 2022 Medicines Information Centre, UCT 2019 National Department of Health Clinical Guidelines of PEP in Occupational & non-occupational exposures Abbott Point of Care Testing 2020 https://youtu.be/4B4wguDQsqM (Laboratoire Biosynex, Exacto HIV Test) https://youtu.be/CdajmI5v0vI Surgical Tech Tips (Handling Sharps in Theatre) https://youtu.be/SZbe0ts8CVQ Back To Basics of HIV Rapid Testing Quality Testing Improvement Initiative (Doctors Without Borders) END