Needle stick injuries in the community

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Injury from used needles and syringes found in community settings arouses much concern, especially when children find discarded needles and injure themselves while playing with them. The user is generally unknown, and parents and health care providers fear that the needle may have been discarded by a person who injects drugs with a blood-borne infection. Although the actual risk of infection from such an injury is extremely low, the perception of risk by parents results in much anxiety. Evaluation, counselling, and follow-up with parents and the child are needed. This statement updates a Canadian Paediatric Society document published in 2008^[1].

The important pathogens to be considered in this situation are hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV)^[2][3]. It is essential that health care providers know about the risks of acquiring these viruses following needle stick injuries as well as current recommendations for management and follow-up. The prevalence of HBV, HCV, and HIV among persons who inject drugs varies among regions in Canada and may change rapidly. In the absence of up-to-date local data, it is prudent to assume that the needle may have been contaminated with one or more of these viruses.

To date there have been very few case reports of HBV^[4][5] or HCV ^[6][7] transmission and none of HIV transmission following injuries by needles discarded in the community. Most children received HBV prophylaxis, if it was indicated, while fewer than 20% received antiretroviral therapy (ART) prophylaxis^[8]-[25].

Needle stick injuries can be prevented by educating children, parents, educators, and health care providers about the dangers of handling used needles, syringes, and other objects contaminated with blood, including sharps containers designed for used needle disposal in public places. Children need to be made aware of these rules at an early age. In the studies of injuries from discarded needles referred to above, the mean ages of children injured ranged between 5 and 8 years. In one study^[10], 15% of injuries occurred in children pretending to use drugs. Communities are responsible for providing adequate cleanup of parks and schoolyards. Also, communities must commit to and support addiction treatment and infection prevention programs for injection drug users.

The risk of infection from exposure to blood by a needle stick injury depends on the size of the needle, the depth of penetration, and whether blood was injected. Risk is increased with the amount of blood introduced and the concentration of the virus in that blood. Follow-up after any significant needle stick injury is essential. The clinician dealing with the initial incident should ensure that the parents and child understand the importance of follow-up testing and that appropriate arrangements are made. Parents sometimes erroneously assume that if blood tests that are performed at the time of injury are negative, there is no possibility of infection and no need for further testing.

HBV

HBV is the most stable of the blood-borne viruses and can be transmitted by a minute amount of blood. The risk of acquiring HBV from an occupational needle stick injury when the source is hepatitis B surface antigen (HBsAg)-positive ranges from 2% to 40%, depending on the source’s viremia level^[2]. HBV can survive for up to 1 week under optimal conditions, and has been detected in discarded needles ^[8][26].  In both the paediatric^[4] and the adult reported cases^[5] of acquired HBV following needle stick injuries in the community, there was no documentation of prior HBV immunization or post-exposure prophylaxis.   

Although the HBV vaccine is now recommended for all children in Canada, most programs have targeted children who are older than the usual age at which they sustain accidental needle stick injuries^[27]. Thus, most children injured by needle sticks are likely to be susceptible to HBV infection. Recently introduced programs in some provinces provide HBV vaccine to infants, which will protect the age group at the highest risk of needle stick injuries. However, children not vaccinated in infancy because of jurisdictional policies or age, when infant HBV vaccination was introduced locally remain at risk, as do children whose antibody response to their first vaccine series (HBV surface antibody <10mIU/mL)is not adequately protective. For children who have not yet received the HBV vaccine, post-exposure prophylaxis with anti-HBV immunoglobulin and HBV vaccine is advised and is effective when provided promptly (Table 1)^[28].

HCV

The risk of acquiring HCV from an occupational needle stick injury when the source was infected varies from 3% to 10%^[2]. HCV is thought to be a fragile virus and therefore less likely to survive in the environment, but there have been case reports^[6][7] of HCV acquisition after an injury from discarded needles.

Although many drugs are now available for therapy of chronic HCV infection, their potential role for prophylaxis is not known. Because chemoprophylaxis is not yet available, follow-up HCV testing is important to determine whether a potential exposure results in transmission of HCV because 75% of infected children will develop chronic infection, which is usually asymptomatic. Children with chronic infection require referral to a specialist and antiviral treatment may be required^[29].

HIV

The risk of acquiring HIV from a hollow-bore needle with blood from a known HIV-seropositive source as a result of occupational needle stick injury was between 0.2% and 0.5% in prospective studies conducted before effective ART became available^[2][30]. The risk for transmission of HIV from a known HIV-seropositive source who is receiving ART and has an undetectable viral load is believed to be extremely low, but is likely not zero. In most reported instances involving transmission of HIV, the needle stick injury occurred within seconds or minutes after the needle was withdrawn from the source patient.

In contrast to the situation with health care workers, the source of blood in discarded needles is usually unknown, injury does not occur immediately after needle use, the needle rarely contains fresh blood, any virus present has been exposed to drying and environmental temperatures, and injuries are usually superficial. HIV is a relatively fragile virus and susceptible to drying. However, survival of HIV for up to 42 days in syringes inoculated with the virus has been demonstrated, with duration of survival dependent on ambient temperature^[31]. One study^[32] found no traces of HIV proviral DNA in syringes discarded by people who inject drugs, while another study^[33] found HIV DNA in visibly contaminated needles and syringes from sites with high drug injection activity.

It is extremely unlikely that HIV infection would occur following an injury from a needle discarded in a public place. However, if the incident involved a needle and syringe with fresh blood, and if some of the blood was injected into the child, infection is theoretically possible and prophylaxis is indicated. In early studies of occupational needle stick exposures, zidovudine prophylaxis alone was shown to reduce the risk of HIV transmission from a positive source by 80%^[30]. Prophylaxis with combination ART therapy is presumed to be more effective but has not been studied. Two-drug regimens have been used for low-risk exposures in the past, but currently three drugs are recommended for all prophylaxis, based on observations in treatment of HIV infection and the assumption that maximum suppression will be most effective in preventing infection^[2][34].

Other potential exposures

Although this document addresses potential exposures of children or youth to blood-borne viruses from injuries with discarded needles, the principles presented here could be extended to other potential exposures (e.g., injuries from other sharp objects contaminated with blood, sharing equipment for injection drug use, mucous membrane or nonintact skin exposure to used condoms or tampons, sexual exposure, etc.). On very rare occasions, young children have sustained a needle injury from reaching into an inappropriately accessible sharps container (e.g., one stored on the floor or table top) in various ambulatory settings. These should be considered higher-risk scenarios where post-exposure prophylaxis is administered. 

RECOMMENDATIONS

In the absence of specific studies, all recommendations are based on expert opinion and extrapolations from other scientific data, with a level of evidence rating of B-III.

Prevention

• Parents, educators, and health care providers should be made aware of the problem of discarded needles.
• Children and youth should receive age-appropriate education about the potential dangers of injection drug use.
• Children should be taught not to touch or handle needles and syringes, and to report finding them to a responsible adult (a parent, teacher, or police officer), who should then arrange for the safe disposal of the needle in a puncture-proof, closed container.
• Community programs should be in place to keep parks and public places, and other public areas where children generally play, free of discarded needles^[35]. Clinical settings should ensure sharps disposal containers are kept well out of reach of children.
• Programs should be in place for the treatment and control of injection drug addiction, and to adequately support HIV prevention, HBV vaccination, HCV eradication therapy, and harm reduction programs that distribute safer drug use equipment for injection drug users.

Management

• Clean the wound thoroughly with soap and water as soon as possible after the needle stick injury. Do not squeeze the area to induce bleeding.
• Assess the extent of the wound and the probability of exposure to blood through open skin lesions or mucous membranes.
• Determine the child’s immunization status for tetanus and HBV.
• Administer tetanus vaccine, with or without tetanus immunoglobulin, when indicated ^[36].
• Document the circumstances of the injury (date and time of injury or exposure, where the needle was found, how the injury happened, the description of the needle, whether a syringe was attached, whether blood was visible in or on the needle or syringe, whether the injury caused bleeding, and whether the previous user of the needle is known).
• Obtain a blood sample from the child for:
  • Baseline HBV, HIV, and HCV status.
  • In the rare instance where ART are being started, complete blood count, differential, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, blood urea nitrogen, and creatinine.
• Testing needles and syringes for viruses is not indicated. Results are likely to be negative, but a negative result does not rule out possibility of infection.
• When the user of the needle is known, attempts should be made to assess for risk factors for blood-borne viruses and, if possible, to test for these viruses. Pending results, proceed as for an unknown source.

HBV prophylaxis

Refer to Table 1.

HIV prophylaxis

• Assess risk of HIV transmission (Table 2) and the risks and benefits of ART prophylaxis on a case-by-case basis, taking into consideration the ability of the child to tolerate and adhere to an ART regimen for 4 weeks. Discuss the potential benefits, adverse effects, and costs of ART prophylaxis with parents—and with the child if age-appropriate—with a view to shared decision-making.
  • Recommend ART prophylaxis only in high risk situations, when the source is considered likely to have HIV, the incident involved a needle and syringe with visible blood, and blood may have been injected.
  • Discuss but do not recommend prophylaxis in low risk situations (source unlikely to have HIV or no visible blood in the device or superficial injury). Reassure parents that the chance of their child acquiring HIV as a result of this type of injury is extremely low and has, so far, never been reported.
• If the decision is made to begin ART prophylaxis:
  • Start ART as soon as possible, ideally within 1 hour to 4 hours of the injury. Prophylaxis is not indicated if it cannot be initiated within 72 hours of injury occurrence^[2][34][37].
  • When parents considering prophylaxis are undecided, advise them that starting prophylaxis immediately is preferable. Prophylaxis is of no benefit after 72 hours, but treatment can be discontinued later, if they wish.
  • Paediatricians unfamiliar with ART drugs may wish to consult a specialist in the care of children with HIV but consultation should not delay start of prophylaxis, when indicated.
  • The ART agents recommended are those currently used for occupational and nonoccupational exposures and for HIV therapy^[2][34][38]
    • For young children: zidovudine plus lamivudine plus raltegravir or dolutegravir (Table 3).
    • For children at least 12 years old and weighing at least 35 kg: emtricitabine plus tenofovir plus raltegravir or dolutegravir (Table 3). For some drugs, a pharmacist may be able to prepare a suspension if the smaller tablets are not locally available.
    • If alternative ARTs are needed (e.g., because of contraindication, intolerance, or suspected drug resistance), consult a specialist in the care of children with HIV. Alternate regimens should include two nucleoside reverse-transcriptase inhibitors and one integrase strand transfer inhibitor or protease inhibitor (Table 3).
    • Other regimens may be preferred by local authorities in some jurisdictions.
    • Tenofovir is contraindicated if renal function is abnormal.
  • The duration of prophylaxis is 28 days. For dosing and other details, refer to Table 3.
  • Recommendations may change as new ARTs become available. For up-to-date information and information on alternative ARTs, visit: https://clinicalinfo.hiv.gov/en/guidelines/pediatric-arv/whats-new. ^{[Note that American drug approvals may differ slightly from those in Canada]}
  • ARTs, especially protease inhibitors, may interfere with other medications. Check whether the child is taking other medications and assess for possible interactions.
  • Adverse effects: There are no data to suggest that a 4-week course of ARTs has serious or long-term detrimental effects (see Table 3, footnotes). Children with HIV infection have taken these drugs for years and serious side effects are rare.
  • Emergency departments and clinics in which children with needle stick injuries are seen should arrange to have ‘starter kits’ available, such that prophylaxis can begin with the least delay, when indicated.
  • At the initial visit, provide drugs for 2 to 3 days and schedule a reassessment immediately afterward to review adherence, check for adverse effects and arrange further follow-up.
  • If the decision is made to continue prophylaxis, prescribe drugs to complete the 28-day course.

Follow-up

• Arrange follow-up and advise parents of the need to monitor side-effects (if on ART prophylaxis), test for acquisition of infection and complete the HBV vaccination schedule.
• If the child is receiving ART prophylaxis:
  • Reassess at 2 to 3 days, by phone or visit.
  • Follow-up at 2 and 4 weeks for assessment of adherence, drug tolerance, complete blood count, differential, aspartate aminotransferase, alanine aminotransferase, and creatinine.
• At 4 weeks, give a second HBV vaccine dose if only one previous dose was received (consult Table 1) or if no antibody or antigen was detected on initial testing.
• At 4 to 6 weeks test for anti-HIV antibody, anti-HCV antibody, anti-HBs and HBsAg.
• At 4 to 6 months, test for anti-HIV antibody, anti-HCV antibody, anti-HBs, HBsAg and (unless previously positive)
• At 6 months, give a third HBV vaccine dose if only two previous doses have been received.
• If anti-HBsAg antibody tests negative at 6 months, test again 1 to 2 months after the third dose of vaccine. If still negative, test for HBsAg. If negative for both, give a fourth dose of HBV vaccine and test again 1 to 2 months later. If still negative, refer to an appropriate specialist.
• If HIV, HCV, or HBV infection occurs, arrange for appropriate follow-up.

Acknowledgements

This statement has been reviewed by the Community Paediatrics Committee of the Canadian Paediatric Society. We would also like to acknowledge Elaine Lau, BScPhm, PharmD, MSc, for her help with the antiretroviral medication table.

CPS INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE (2018)

Members: Michelle Barton-Forbes MD; Ari Bitnun MD; Natalie A. Bridger MD (past member); Shalini Desai MD; Michael Forrester MD (Resident Member); Ruth Grimes MD (Board Representative); Nicole Le Saux MD (Chair)

Liaisons: Ari Bitnun MD, Canadian Paediatric and Perinatal HIV/AIDS Research Group; Tobey Audcent MD, Committee to Advise on Tropical Medicine and Travel (CATMAT), Public Health Agency of Canada; Fahamia Koudra MD, College of Family Physicians of Canada; Marc Lebel MD, IMPACT (Immunization Monitoring Program, ACTIVE); Yvonne Maldonado MD, Committee on Infectious Diseases, American Academy of Pediatrics; Jane McDonald MD, Association of Medical Microbiology and Infectious Disease Canada; Dorothy L. Moore MD, National Advisory Committee on Immunization (NACI); Howard Njoo MD, Public Health Agency of Canada

Consultant: Noni E. MacDonald MD

Principal author: Dorothy L. Moore MD

Updated by: Ari Bitnun MD , Sergio Fanella MD, Justin Penner MD, Michelle Barton MD

References

Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.