Needlestick Inoculation

Objectives

To guide clinicians operating in the deployed environment in the management of individuals who sustain needlestick/inoculation injuries, or are exposed to blood, tissue, or body fluids.

Scope

This guideline covers the investigation and management of inoculation injuries and exposure to blood, tissue or bodily fluids. The term “BBV exposure incident” will be used to refer to any incident where an individual: 

• sustains a puncture wound or laceration might be contaminated with blood or body fluids; or 

• receives a splash of blood, bodily fluids or human tissue to the eyes, mouth, mucous membranes or to broken skin.

BBV exposure incidents include:

• Injuries resulting from contaminated sharp instruments, needles, blades or broken glass
• Puncture wounds or lacerations caused by bone/tooth/human tissue fragments, human scratches or injuries by items which may be contaminated with blood or body fluids (e.g. shrapnel)
• Any splash of blood, body fluids or body tissues into the eyes, mouth, mucous membranes or onto broken skin
• Human bites which break the skin
• Needle spiking incidents  

For sexual exposures please refer to separate Sexual & Reproductive Health guidance.

Audience

This guideline is intended for the use of registered healthcare professionals fulfilling a general role in a forward medical location or in an Emergency Department or ward on deployed operations. 

Initial Assessment & Management

Immediate First Aid

Immediately following an BBV exposure incident (other than sexual exposures), the individual should: 

Encourage free bleeding of any puncture wound or laceration - but do NOT suck or squeeze the wound.  

Wash liberally with soap and water. Use skin wipes and water where no running water is available, but do not scrub the wound. Small wounds can be cleaned with alcohol based hand rub. scrub the wound. 

Rinse any exposed mucous membranes with copious amounts of water.  Contact lenses should be removed as soon as possible and eye irrigation performed in the event of exposure to eyes.    

Apply a clean dressing to any puncture wound, laceration or area of broken skin as appropriate. 

Do not use antiseptic or skin wash solution to clean wounds or on broken skin.

If exposure is associated with other injuries, these should be treated in accordance with normal protocols. 

Initial assessment

Following a BBV exposure incident, a clinician should undertake an initial risk assessment to determine whether the exposure is non-significant or potentially significant.

Contamination only of intact skin is considered a non-significant exposure irrespective of the body fluids involved. 

If there has been any percutaneous inoculation, mucous membrane exposure or splash exposure of non-intact skin then consider whether the body fluids involved are high-risk or low-risk.

High-risk body fluids include: 

• Blood, or other body fluids stained with blood 

• Exudate or tissue fluid from burns or lesions; or direct contact with broken skin 

• Peritoneal, pericardial, pleural, cerebrospinal and synovial fluid 

• Vaginal secretions, semen, amniotic fluid or breast milk 

• Saliva from a dental procedure or blood-contaminated 

• Unfixed tissues or organs 

Percutaneous inoculation, mucous membrane exposure, or splash exposure of non-intact skin involving a high-risk body fluid is considered a potentially significant exposure.

All other body fluids including faeces, urine, vomit and saliva (except during dentistry) are considered low-risk unless visibly bloodstained.

Percutaneous inoculation or mucous membrane exposure involving a low-risk body fluid is considered a non-significant exposure. 

Contamination of intact skin by high-risk body fluids is considered a non-significant exposure. 

Management of non-significant exposures

Reassure patient that the risk of transmission of blood borne viruses is low. 

Ensure the incident is documented in the individual’s health record 

No further action is required.

Management of potentially significant exposures

The patient requires baseline bloods and should be formally risk assessed for post-exposure prophylaxis for blood borne viruses. See Advanced Assessment & Management below.

Advanced Assessment & Management

For patients who have experienced a potentially significant exposure:

Baseline bloods for HBsAg, HIV Ab/Ag and HCV Ab, creatinine and ALT should be taken from the exposed individual. If this is not immediately possible, arrange for these to be done as soon as reasonably practical. 

Assess Hepatitis B vaccination status. HBV post-exposure prophylaxis should be considered for all individuals who have a significant exposure. If possible, consult JSP 950 Lft 7-2-1 Annex E; otherwise see summary below. 

Assess source individual for risk of blood borne viruses, if the source patient is known: where possible, obtain a history from the source individual to ascertain whether they are living with HIV/HBV/HCV or are at increased risk of blood borne viruses. Individuals are increased risk of BBV include:

• People who inject drugs (including people who inject non-prescription drugs e.g. anabolic steroids and injectable tanning agents) 
• Individuals from a HIV high-prevalence country (>1%) 
• Commercial sex workers 
• Gay, bisexual and men who have sex with men 
• Individuals who have received blood transfusions abroad at any time, or in the UK before 1985. 

Where possible, clinicians should complete the source risk assessment form contained within JSP 950 Lft 7-2-1 Annex D and file this in the source individual’s health record.

Where possible take bloods from source patient with informed consent for HBsAg, HIV Ab/Ag and HCV Ab2. You should obtain consent to disclose the results of these tests to the exposed patient.

If consent cannot be obtained for bloods from the source individual, or if the source individual cannot be identified, management of the exposed patient will be dictated by the source risk assessment based on best available evidence.

Post-Exposure Prophylaxis (PEP)

The decision to start HIV PEP should always be supported by discussion with the Centre for Defence Sexual and Reproductive Health via the 24/7 reach-back service if possible. If reach-back cannot be contacted, review guidance in accordion content below. Do not delay starting HIV PEP if indicated.If HIV PEP is being considered, a pregnancy test should be obtained for all women of childbearing age. 

Follow-up

Ensure arrangements are made for bloods to be obtained 12 weeks following exposure. 

Pending results of follow-up testing, the exposed individual should be advised: 

• they should use condoms for any sexual contact, and avoid sharing razors or toothbrushes until they have the results of the follow up testing; 
• that they must not donate blood until results are back. 

Healthcare workers can continue to undertake procedures at work as normal provided they adhere to usual personal protective equipment requirements. 

Prolonged Casualty Care

Individuals exposed to BBVs can generally be managed in country with appropriate support from local health services or the Centre for Defence Sexual and Reproductive Health (CD SRH) provided there is adequate facilities for testing and follow up. 

Ensure appropriate arrangements for HBsAg, HIV Ab/Ag and HCV Ab testing at 12 weeks post-exposure.

Paediatric Considerations

For an exposed individual: 

First aid and initial management for a child who is exposed to blood/bodily fluids is the same as with an adult patient. Seek advice via the Centre for Defence Sexual and Reproductive Health (CD SRH) via the 24/7 reach-back service.

Consider whether safeguarding concerns need to be addressed in the operational environment. 

For a source patient:

If the source individual is a child or young person, situation-specific advice should be sought from CD SRH for regarding the appropriateness of BBV testing. 

The clinician should assess whether the child or young person is competent to consent to testing and whether consent from the parent or legal guardian should be obtained.