Needle stick injuries and postexposure prophylaxis for hepatitis B infection

Tarika Sharma; Ashok Chaudhary; Jitender Singh

doi:10.4103/jascp.jascp_10_20

REVIEW ARTICLE

Year : 2021 | Volume : 2 | Issue : 1 | Page : 4-8

Needle stick injuries and postexposure prophylaxis for hepatitis B infection

Tarika Sharma¹, Ashok Chaudhary², Jitender Singh³
¹ College of Nursing, Institute of Liver and Biliary Sciences, New Delhi, India
² Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
³ Department of Interventional Radiology, Shanti Mukand Hospital, New Delhi, India

Date of Submission	28-Nov-2020
Date of Decision	05-Dec-2020
Date of Acceptance	12-Dec-2020
Date of Web Publication	23-Mar-2021

Correspondence Address:
Ms. Tarika Sharma
College of Nursing, Institute of Liver and Biliary Sciences, New Delhi
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jascp.jascp_10_20

Abstract

Hepatitis B virus (HBV) infection is a global public health challenge as roughly a quarter of the world's population has serological evidence of past or present hepatitis B virus (HBV) infection. Healthcare personnel, who work in healthcare settings, represent a high-risk population for serious, potentially life-threatening Hepatitis B Virus infections. Needle stick injuries pose a serious risk for occupational transmission of hepatitis B virus and may occur during various procedures such as needle recapping, operative procedures, blood collection, intravenous line administration, blood sugar monitoring, and due to improper sharps/needle disposal. Infections acquired through occupational exposure are largely preventable through strict control measures such as the use of safe devices, proper waste disposal, immunization and prompt management of exposures including the use of Post Exposure Prophylaxis. The current review highlights the first aid management, reporting, baseline investigations as well as post exposure prophylaxis for Hepatitis B following needle stick injury.

Keywords: Blood borne infections, first aid management, hepatitis B, needle stick injuries, postexposure prophylaxis, prevention, vaccine nonresponder, vaccine responder

How to cite this article:
Sharma T, Chaudhary A, Singh J. Needle stick injuries and postexposure prophylaxis for hepatitis B infection. J Appl Sci Clin Pract 2021;2:4-8

How to cite this URL:
Sharma T, Chaudhary A, Singh J. Needle stick injuries and postexposure prophylaxis for hepatitis B infection. J Appl Sci Clin Pract [serial online] 2021 [cited 2023 Mar 29];2:4-8. Available from: http://www.jascp.org/text.asp?2021/2/1/4/311759

Introduction

Hepatitis B is a dreadful infectious disease and a major global health problem.^[1] Accidental exposure to blood and body fluid presents a serious public health concern, especially among healthcare workers (HCW) and constitutes a risk of transmission of blood borne viruses such as Hepatitis B virus, Hepatitis C virus and HIV.^[2] Roughly a quarter of the world's population has serological evidence of past or present hepatitis B virus (HBV) infection. A total of 250 million people are estimated to have chronic hepatitis B (CHB) infection.^[3] Viral hepatitis continues to be a major public health problem in India as well.^[4] About 15-30 per cent cases of acute hepatitis in India is due to Hepatitis B Virus. HBV is contagious and can easily be transmitted from one infected individual to another by blood contact, from mother to child or by unprotected sexual intercourse. The main transmission routes include prenatal infection, skin and mucous membrane infections caused by contaminated blood or body fluid, sexual contact, and injection drug abuse. In addition, tattooing, ear piercing, acupuncture, dialysis, and even use of a syringe can be the source of infection.^[5]

Healthcare personnel, including support staff, who work in healthcare settings, represent a high-risk population for serious, potentially life-threatening Hepatitis B Virus infections. Direct contact with blood and other body fluids is the most common or frequent risk healthcare workers encounter while caring for patients.^[6] Studies in the United States have shown that the risk of acquiring HBV after being stuck with a needle from an HBV+ client ranged from 27 to 37%.^[7]

Needle stick injuries (NSIs) are one of the most important occupational hazards among healthcare workers (HCWs) globally. According to WHO, more than two million occupational exposures to sharp injuries occur among around 35 million HCWs annually.^[8] Results of a systematic review and meta analysis inclusive of 87 studies performed on 50,916 HCWs in 31 countries worldwide to determine the global prevalence and causes of NSIs among HCWs shows that the one-year global pooled prevalence of NSIs among HCWs was 44.5% (95% CI: 35.7, 53.2).^[9] Needle stick injuries pose a serious risk for occupational transmission of blood pathogens such as human immunodeficiency virus (HIV), hepatitis B virus and hepatitis C virus (HCV).^[10] The risk of seroconversion following a NSI is highest for HBV (6%–30%) followed by HCV (0.5%–10%) and is lowest for HIV (0.3%).^[11] Needle stick injury (NSI) is defined as percutaneous exposure where the skin is breached by a needle or any sharp object contaminated by blood or other bodily fluid due to accidental pricks.^[12] NSI is the second most common cause of occupational injury within the National Health Services^[13] and can occur during various procedures such as needle recapping, operative procedures, blood collection, intravenous line administration, checking blood sugar, and due to improper sharps/needle disposal.

The incidence of needle injury reported is about 100,000/year in the United Kingdom and about 600,000–1,000,000/year in the United States of America.^[14] The reported authentic data of NSI in India are scarce due to infrequent reporting.^[15] The main problem because of underreporting of NSIs is that the people who are exposed could not be given post exposure prophylaxis (PEP) at appropriate time to prevent the development of infection in the person who has experienced NSI.^[16]

Infections acquired through occupational exposure are largely preventable through strict control measures such as the use of safe devices, proper waste disposal, immunization and prompt management of exposures including the use of Post Exposure Prophylaxis. This review presents the first aid management, reporting, baseline investigations as well as post exposure prophylaxis for Hepatitis B following needle stick injury.

First Aid Management after Occupational Exposure

First aid management depends on the type of exposure to blood and body fluids. Broadly the health care professionals may have two types of exposure; Percutaneous Exposure and Mucocutaneous exposure. Percutaneous Exposure is defined as an exposure event occurring when a needle or other sharp object penetrates the skin whereas mucocutaneous exposure refers to the contact of mucous membrane (e.g., eyes, nose, or mouth) with the body fluids or blood. Depending on these two, there may be four types of occupational exposures to blood and body fluids as described in [Table 1].

Table 1: Types of occupational exposures to blood and body fluids

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The first aid management for each type of exposure is different and is shown in the following [Figure 1].

Figure 1: First aid management depending on type of exposure to blood and body fluids

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Reporting

Report the exposure to the department responsible for managing exposures (e.g., occupational health, infection control) is very important. Prompt reporting is essential because, in some cases, postexposure treatment may be recommended and it should be started as soon as possible. It is mandatory for all the hospitals to have a preset reporting protocol and all health care professionals must be aware of this protocol.

Baseline Investigations

The source patient must be tested for HbsAg as soon as possible after taking his consent. If the report is found to be positive (reactive for HbsAg), the exposed person must also be tested for HbsAg.

Postexposure Prophylaxis

The mainstay of postexposure prophylaxis (PEP) is hepatitis B vaccine, but, in certain circumstances, hepatitis B immune globulin is recommended in addition to vaccine for added protection. The decision to begin treatment is based on several factors, such as:

Whether the source individual is positive for hepatitis B surface antigen
Whether exposed person has been vaccinated
Whether the vaccine provided immunity to the exposed person.

The exposed person can be classified into any of the following category

Unvaccinated

An individual who has not received Hepatitis B vaccine.

Responder

Individuals in whom anti HBs titre is ≥10mIU/ml after receipt of the Hepatitis vaccine series (anti HBs testing done 1-2 months after final dose of Hepatitis B vaccine) are considered as vaccine responders or immune to Hepatitis B vaccine.

Nonresponder

Hepatitis B vaccine “non-responder” refers to a person who does not develop protective surface antibodies after completing two full series of the hepatitis B vaccine
Persons who do not respond to the primary hepatitis B vaccine series (i.e., anti-HBs <10 mIU/mL) should complete a second 3-dose vaccine series
Revaccinated persons should be retested at the completion of the second vaccine series, 1-2 months following the last shot of the series^[17]
If anti HBs titre is <10 mIU/mL the person is considered as non responder.

Unknown response

An individual who has received the complete series of Hepatitis B vaccine but has not undergone anti HBs testing afterwards.

Postexposure prophylaxis for hepatitis B depends on the three scenarios given below

Scenario 1: Source patient is found to be HbsAg Positive
Scenario 2: Source patient is found to be HbsAg Negative
Scenario 3: Source patient could not be tested or unknown.

Scenario 1: Source patient is found to be hepatitis B surface antigen positive

Exposed person: Unvaccinated

If the exposed person is unvaccinated or incompletely vaccinated and source patient is HBsAg-positive, the PEP has be started as early as possible preferably within 48 hours (but not later than 7 days after exposure). The exposed person should receive 1 dose of HBIG (0.06 ml/kg or 5.0 ml for adults) and 1 dose (1 ml = 20 ug) of Hepatitis B vaccine administered after the exposure. Hepatitis B vaccine may be administered simultaneously with HBIG at a separate anatomical injection site (e.g., separate limb). The HCP should complete the Hepatitis B vaccine series according to the vaccination schedule (0, 1 and 6 months)

Exposed person: Previously vaccinated known responder

Exposed person should be tested for anti HBs titre. If anti-HBs titre is adequate (≥10 mIU/mL), treatment is not required. If anti-HBs titre is inadequate (<10 mIU/mL), booster dose of Hb vaccination (2ml = 40 ug) must be administered

Exposed person: Previously vaccinated known non responder

The exposed person should receive 2 doses of HBIG. The first dose should be administered as soon as possible after the exposure, and the second dose should be administered 1 month later

The exposed person should receive 1 dose of HBIG and 1 dose of Hepatitis B vaccination as soon as possible after the exposure.

Exposed person: Previously vaccinated, response unknown

In this case, the exposed person must be tested for anti HBs titre, if titre value is adequate (≥10 mIU/mL), there is no need of any treatment. If titre value is inadequate (<10 mIU/mL), the exposed person must be administered 1 dose of HBIG and booster dose of Hepatitis B vaccination as soon as possible after the exposure.

Scenario 2: Source patient is found to be hepatitis B surface antigen negative

If the source patient is HBsAg-negative, the unvaccinated exposed person should complete the Hepatitis B vaccine series according to the vaccination schedule.

Scenario 3: Source patient could not be tested or unknown hepatitis B surface antigen status

Exposed person: Unvaccinated

The exposed person should complete the Hepatitis B vaccine series according to the vaccination schedule.

Exposed person: Previously vaccinated known responder

In this case the treatment is not required as the exposed person is already vaccinated and a responder too.

Exposed person: Previously vaccinated known nonresponder

If known high risk source, may treat as if source is HbsAg positive and follow the following regimen
The exposed person should receive 2 doses of HBIG. The first dose should be administered as soon as possible after the exposure, and the second dose should be administered 1 month later

Or
The exposed person should receive 1 dose of HBIG and 1 dose of Hepatitis B vaccination as soon as possible after the exposure.

Exposed person: Previously vaccinated, response unknown

The exposed person must be tested for anti HBs titre, if titre value is adequate (≥10 mIU/mL), there is no need of any treatment. If titre value is inadequate (<10 mIU/mL), the exposed person must be administered booster dose of Hepatitis B vaccination as soon as possible after the exposure.^[18] A brief explanation of post exposure prophylaxis is also given in [Table 2].

Table 2: Postexposure prophylaxis for hepatitis B infection

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Prevention of Needle Stick Injuries

Following points can be taken into consideration to prevent the Needle stick injuries and associated exposure to blood and body fluids among health care professionals:

Avoid using needles whenever safe and effective alternatives are available
Use needle devices with safety features
Follow standard precautions for all patients
Strictly adhere to the bio medical waste management protocol of the facility
Avoid recapping or bending needles that might be contaminated. One hand scoop technique may be used as an alternative to recapping
Take extra caution while handling needles or any other sharps
Plan for the safe handling and disposal of needles before use
All the healthcare professionals must be vaccinated against hepatitis b virus
Report any needle stick and other sharps injury immediately as per the hospital protocol^[19]
Efforts should be taken to initiate effective surveillance as well as a reporting system that could contribute to reducing the occurrence of needle stick injuries at large.^[20]

Conclusion

Needle stick injuries are the potential mode of exposure to and transmission of Hepatitis B infection among healthcare workers. These may occur in the emergency departments, in the operating room, in the wards, in the radiology or other departments and may be related to faulty needle insertion techniques, needle recapping, or incautious disposal of contaminated needles and sharps. Standard precautions, Preventive measures, Safe injection practices, Prompt first aid management, Appropriate reporting and Post exposure prophylaxis (if required) are the main strategies for dealing with this dreadful condition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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