Who

Healthcare Workers

According to a National Institute of Occupational Safety and Health (NIOSH) alert, more than 8 million health care workers in the United States work in hospitals and other health care settings. Health care workers include physicians, nurses, laboratory and dental personnel, pre-hospital care providers, and housekeeping, laundry, and maintenance workers.

Annual needle stick injuries in the US average between 600,000 to 1 million. About half of these injuries go unreported. Data suggests that at an average hospital, workers may incur as many as 30 needle sick injuries per 100 beds per year. Estimates indicate that as many as 80 per cent of needle stick injuries could be prevented with the use of safety devices, such as safety syringes.

Laboratory staff, physicians, housekeepers, and other health care workers are included in these statistics, but the majority of needle stick injuries involve nursing staff. Some of these injuries expose workers to blood borne pathogens that can cause infection. The most important of these pathogens are HBV, HCV, and HIV. Infections with each of these pathogens are potentially life threatening and preventable.

The emotional impact of a needle stick injury can be severe and long lasting, even when a serious infection is not transmitted. This impact is particularly severe when the injury involves exposure to HIV. In one study of 20 health care workers with an HIV exposure, 11 reported acute severe distress, 7 had persistent moderate distress, and 6 quit their jobs as a result of the exposure.

Other stress reactions requiring counseling have also been reported. Not knowing the infection status of the source patient can accentuate the health care workers stress. In addition to the exposed health care worker, colleagues and family members may suffer emotionally.

Case Reports

The following case reports briefly describe the experiences of five health care workers who developed serious infections after occupational exposures to blood borne pathogens. Their cases illustrate a number of the preventable hazardous conditions and practices that can lead to needle stick injuries.

• Case 1
  A hospitalized patient with AIDS became agitated and tried to remove the intravenous (IV) catheters in his arm. Several hospital staff members struggled to restrain the patient. During the struggle, an IV infusion line was pulled, exposing the connector needle that was inserted into the access port of the IV catheter. A nurse at the scene recovered the connector needle at the end of the IV line and was attempting to reinsert it when the patient kicked her arm, pushing the needle into the hand of a second nurse. The nurse who sustained the needle stick injury tested negative for HIV that day, but she tested HIV positive several months later [American Health Consultants 1992a].
  
  
• Case 2
  A physician was drawing blood from a patient in an examination room of an HIV clinic. Because the room had no sharps disposal container, she recapped the needle using the one-handed technique. While the physician was sorting waste materials from lab materials, the cap fell off the phlebotomy needle, which subsequently penetrated her right index finger. The physician's baseline HIV test was negative. She began post-exposure prophylaxis with zidovudine but discontinued it after 10 days because of adverse side effects. Approximately 2 weeks after the needle stick, the physician developed flu-like symptoms consistent with HIV infection. She was found to be seropositive for HIV when tested 3 months after the needle stick exposure [American Health Consultants 1992b].
  
  
• Case 3
  After performing phlebotomy on a patient with AIDS, a health care worker sustained a deep needle stick injury with the used phlebotomy needle. Blood from the collection tube also spilled into the space between the wrist and cuff of the health care worker's gloves, contaminating her chapped hands. The health care worker removed the gloves and washed her hands immediately. She had a negative baseline HIV test and refused zidovudine prophylaxis. Because her patient was not known to have HCV infection and did not have clinical evidence of liver disease, the health care worker did not receive baseline testing for exposure to HCV. Eight months after the incident, the health care worker was hospitalized with acute hepatitis. She was found to be seropositive for HIV 9 months after the incident. Sixteen months after the incident, she tested positive for anti-HCV antibodies and was diagnosed with chronic HCV infection. Her clinical condition continued to deteriorate, and she died 28 months after the needle stick injury [Ridzon et al. 1997].
  
  
• Case 4
  During bronchoscopy to determine the cause of shortness of breath in a patient infected with HBV, a health care worker sustained a percutaneous injury with a 25-gauge needle while extracting tissue from biopsy forceps. The worker did not receive post-exposure prophylaxis with hepatitis B immune globulin or hepatitis B vaccine. Approximately 15 weeks after the needle stick injury, the worker noted fatigue, malaise, and jaundice. Later, he was found to have abnormal liver enzymes and a positive test for hepatitis B surface antigen, consistent with acute hepatitis B infection. The patient who underwent bronchoscopy was diagnosed with Pneumocystis carinii pneumonia and died 8 months later after he was diagnosed with disseminated Kaposi's sarcoma and overwhelming opportunistic infection. The injured worker had an uncomplicated medical course, and his liver enzymes and his health eventually returned to normal. He later tested negative for hepatitis B surface antigen and positive for hepatitis B surface antibody, indicating recovery from his HBV infection. On follow-up 15 months after the needle stick injury, the worker also tested HIV negative; serum from the deceased patient was not available for antibody testing [Gerberding et al 1985].
  
  
• Case 5
  In 1972, a nurse sustained a needle stick injury to her finger while removing a hypodermic needle from a patient's arm. At the time of the injury, the source patient had apparent acute non-A, non-B hepatitis. The nurse developed hepatitis 6 weeks after the needle stick injury. Her liver enzymes remained elevated for nearly a year. Later examination of serum samples from the nurse and the source patient showed that both persons were infected with HCV. The initial serum sample from the nurse in 1972 was negative for anti-HCV antibody, but the sample obtained 6 weeks after the needle stick injury was seropositive. Although the nurse was clinically well at the time of the report, she remained seropositive for HCV [Seeff 1991].