1. Needle Stick Injury: Epidemiology from a Hospital Perspective Dr Blánaid Hayes, Beaumont Hospital, Dublin

2. Epidemiology of NSI Background Risk and probability Epidemiology of BBV; global and local International and local NSI statistics Challenges and opportunities

3. Background Definition An exposure that might place HCW at risk for HBV, HCV or HIV infection is defined as Percutaneous:puncture, abrasion or laceration caused by needle or other sharp device Mucocutaneous: contact of mucous membrane or non-intact skin with blood or potentially infectious body fluidLegislation Health and Safety Act 2005 US: Needlestick Safety and Prevention Act of 2000Consequences Health (not negligible) Infection Anxiety Drug S/E Lifestyle restrictions (self and family) Career Organisational cost Source patient testingImpact:* Globally, HCW population is ’large and their impact is felt everywhere’…35.7 million worldwide. Worthy public health target: provide care worldwide in sophisticated and humble settings. Depended upon for life sustaining services. Greatest risk is in countries of high prevalence where PEP, patient treatments and safety technology are unavailable *Janine Jagger ICHE Jan 2007 Vol 28; No 1

4. Infections Transmitted by NSI hepatitis B* hepatitis C* HIV*herpes*TBMalaria Dengue fever Rocky Mountain spotted fever necrotising fasciitis (strep. A)

5. Risk and Probability RISK = HAZARD X FREQUENCY SEROPREVALENCE IN POPULATION & INFECTIVITY OF SOURCE E XPOSURE NUMBER EXPOSURE SEVERITY

6. Perception of Risk Risk RISK PERCEPTION MYTH Management RISK = HAZARD + OUTRAGE (Peter Sandman)

7. BBV transmission to HCW HBeAg + source = 30% HBeAg - source < 6% HCV + source = 0.5% HCV PCR+ source = 10% Australian study reviewed 29 articles on transmission of HCV (vertical, via transplant / transfusion or NSI). No transmissions occurred from PCR negative sources (BMJ 1997) Australian study reviewed 29 articles on transmission of HCV (vertical, via transplant / transfusion or NSI). No transmissions occurred from PCR negative sources (BMJ 1997) HIV+ (percutaneous) = 0.3% HIV+ (mucocutaneous) = 0.09%

8. HIV transmission: risk factors HIV transmission: risk factors RISK FACTORADJUSTED O/R deep injury16.1 visible blood 5.2 needle in vessel 5.1 terminal illness 6.4 PEP /ZDV 0.2 Case control study of HIV seroconversion in HCWs NEJM 1997

9. Epidemiology of BBV Global vs Local Hepatitis B > 350 million worldwide Irish notifications increased annually 1996-2005 but reduced by 20% 2006 More prevalent in IDUs, prisoners and immigrants (high endemicity) Details since 2004 820 notifications 820 notifications 761 (93%) defined 761 (93%) defined 668 (88%) chronic 93 (12%) acute ASNR = +/- 20/100,000 Typical acute HBV: young man, born in Ireland, sexually acquired ‘Typical’ chronic HBV: from countries of high endemicity Source: www.hpsc.ie Prevalence% High > 8 Intermediate 2 – 7 Low < 1

10. Epidemiology of BBV Global vs Local Hepatitis C 170 million worldwide Notifiable disease since Jan 2004 (SI 707 of 2003) Irish ASIR = 36/100,000 (M>F and HSE- E > than HSE generally (rate rising) Risk factors: Sharing needles etc ++++ Sharing needles etc ++++ Unscreened blood / products ++ Unscreened blood / products ++ Mother to baby, occupational, sexual + Mother to baby, occupational, sexual + 90% cases in developed countries current or former IDUs or received unscreened blood / products Largely asymptomatic (90%) Source: www.hpsc.ie

11. Epidemiology of BBV Global vs Local HIV Global HIV burden= 42 million Globally during 2005: 4.1 million new infections 4.1 million new infections 2.8 million RIP AIDS 2.8 million RIP AIDS End 2006 > 4,400 cases reported New diagnosis not representative of incidence Risk factors (2006) n=337 Heterosexual ++++ (50%) Heterosexual ++++ (50%) MSM ++ MSM ++ IDUs + IDUs + 9% new cases are Irish born heterosexuals (31 per year) Source: Epi – Insight, Vol 8, Issue 10, October 2007

12. How big is the problem? 8 million HCWs in US Estimated US annual figure is 384,325 Add factor 0.31 (for needles bought outside of hospitals = 503,466 Add another factor of 0.29 for all mucocutaneous injuries = 649,471 100,000 in Ireland Crude estimate: = 4804 p/a = 6293 p/a = 6293 p/a = 8118 p/a = 8118 p/a But neither set of figures takes any account of underreporting

13. How to interpret figures? Difficulty comparing data between countries and studies because of different formats used for documenting rates: Rate per 100 occupied beds Rate per 100 occupied beds Rate per 1000 health care staff (WTE or other) Rate per 1000 health care staff (WTE or other) Rate for specific occupations Rate for specific occupations Rate per person per annum etc. Rate per person per annum etc. One rate quoted by Jagger is 22 per 100 bed p/a (previously 30 per 100) Local hospital rate tends to be <20 per 100.

14. CountryYearJobRateReported Canada1990 House staff 0.7pp p/a <5% US1995 Stds/ house staff 32% (6/12) 11% UK1999Anaesthetists50%15% UK1999 Med students 33%43% *US1998All?55% US (CDC) 1998 All (14,000) ?42% Surgeons 27% Others 48% Saudi Arabia 2002All33/1000N/R Taiwan2002All 87% (12/12) N/R UK2004All 38% (12/12) 51% *US2007 Surgical trainees 83% (in 5 yrs) 49% International Data on Incidence and Reporting Rates

15. Needlestick Injuries, According to Postgraduate Year Makary MA et al. N Engl J Med 2007;356:2693-2699 Needlestick Injuries among Surgeons in Training NEJM 2007;356:2693-9

16. Behavior Associated with Nonreporting of the Most Recent Needlestick Injury Makary MA et al. N Engl J Med 2007;356:2693-2699 Needlestick Injuries among Surgeons in Training NEJM 2007;356:2693-9

17. Study Overview Data from surgeons at 17 US centres: majority reported at least one needlestick injury during training majority reported at least one needlestick injury during training half of the most recent injuries (including many sustained in the care of high-risk patients) were not reported half of the most recent injuries (including many sustained in the care of high-risk patients) were not reported

18. An Irish Hospital’s Experience: who is at risk? 100303Total 8.5%26Others 13.5%41Non Clinical 28.5%86Medical 49.5%150Nursing % TotalNumberOccupation Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):

19. Where to they occur? +/-100332 25.7%85Other 8.1%26A&E 13.8%45Theatre 53.4%176Wards % totalNumberLocation Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):

20. % Immunity to Hepatitis B 100332Total 8.8%29Non- immune 5.4%18Unknown 85.8%285Immune %NumberHepatitis B Ab testing of injured HCWs Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):

21. Test Results of Source Patients 0.9%1.6%3.1% Positive 128*Number Positive 103(31%)119(35.8%)254(76.5%)Number Tested Hep B Surface Ag HIV Antibody Hepatitis C Antibody * 5 of the 8 patients positive for hepatitis C Ab were also PCR + Occupational Sharps Injuries in a Dublin Teaching Hospital. IMJ 2003;96(5):

22. Procedure Involved Procedure Number (%) During procedure 72 (21.7) Immediately after procedure 104 (31.3) During disposal 42 (12.7) After improper disposal 92 (27.7) During instrument cleaning 9 (2.7) Other / not recorder/ unknown 13 (3.9) TOTAL 332 (100)

23. What factors impact on injury and infection rates? Higher rates of NSI: Teaching hospitals (vs others) Teaching hospitals (vs others) Surgeons (vs physicians) Surgeons (vs physicians) Theatre (vs other areas) Theatre (vs other areas) Emergency (vs elective procedures) Emergency (vs elective procedures) Less experienced staff Less experienced staff Low staff numbers and morale Low staff numbers and morale Infection rates reduced by: Hepatitis B vaccine PEP HIV therapies have reduced viral load in source patients Double gloving

24. Hepatitis B vaccine Currently recommended for high risk groups: Babies of infected mothers Babies of infected mothers CRF, haemophilia CRF, haemophilia Occupational risk Occupational risk Close contacts Close contacts IDUs IDUs Prisoners Prisoners Homeless Homeless Heterosexuals / multiple Heterosexuals / multiple MSM MSM NIAC in 2007 recommended addition of HB vaccine to primary childhood schedule. To be introduced in Sept 2008 Source: www.immunisation.ie/en/Publications/PDFFile_14064www.immunisation.ie/en/Publications/PDFFile_14064

25. Solutions: what has been shown to work to reduce frequency of NSI? Standard Precautions / UPs Cin bins Avoiding re-sheathing Safety technology LEGISLATION Do we need specific legislation or a directive in this country to enforce a change in practice

26. Challenges Health care resources Training Technology Safety management systems Immunisation uptake Senior clinicians Childhood immunisation Organisational culture Compliance Reporting Macho-ism Irish ‘psyche’ Ambivalent to authority Anarchic Fatalistic

27. Opportunities Great strides have been made in hospital hygiene Accreditation and quality are ‘buzz words’ Clinicians and managers are more aware of hidden costs of high risk practice Hepatitis B vaccine is no longer just for limited high risk groups Safety technology is no longer cost prohibitive and is user friendly Time to invest in a nationwide surveillance system incorporating all exposures and not just those occurring in hospitals

28. Take Home Message……. Engineering solutions Managers who are role models, senior clinicians who are ‘physician champions’, leading by example, monitoring etc Putting training and education at the top of the agenda and not as a dispensable item when times are tough