Alfie, 6, is playing at local playground under Mum’s watchful eye. He goes down the slide and jumps off, landing on his hands and feet. He starts to cry and shows his Mum a syringe lying in the bark and a needlestick injury of his left hand. Mum is distraught when she brings Alfie into your department. What next?
- Needlestick injuries in the community are a source of great concern for parents.
- There is one reported case of seroconversion of Hepatitis B in children.
- The actual chance of viral transmission is very low.
- Ensure your patient is immunised!
- High risk patients should be discussed with your local infectious disease team for consideration of post-exposure prophylaxis.
- Educate children not to handles needles – 2/3 CANSI’s are from intentional handling!
There is a risk of transmission of Hepatitis B, Hepatits C or HIV from a community-acquired needlestick injury (CANSI). Although the risk is very low, this is a source of significant concern to parents. Several studies lasting from several months to nearly two decades in length have looked at the epidemiology of CANSIs. These studies, undertaken in Melbourne, Montreal, Birmingham and Perth broadly agree that;
~65% CANSIs occur in boys
Mean age is around 6-8 years
In two-thirds of CANSIs, the syringe or needle was intentionally handled by the child
The most common site of injury was the hand
About a quarter of wounds bled
In the Melbourne study CANSIs often occurred in public places in parks (30%), in the street (18%), in carparks (5%) and at the beach (6%). In Montreal, CANSIs occurred predominantly in the street (30%) and in parks (24%). Whilst the obvious difference is the lack of beaches in downtown Montreal, it’s also worth noting that a number of CANSIs must also occur in private residences.
So, what’s the risk?
Each of the papers described the baseline prevalence of HBV, HCV & HIV in their population, as well as the same prevalence within the IVDU community. None of the papers reviewed (total patients 416) reported any cases of seroconversion to Hep B, Hep C or HIV. There is a single case report of seroconversion to Hepatitis B after a CANSI in a child, reported in Barcelona in 1997. In 1999, Bowden et al, proposed conversion rates in the Victorian population to be around 6-30% for HepB, 0-7% for HepC and 0.4% HIV.
Although the risk is largely theoretical, factors that are considered to be high risk for acquired infection are:
- known needle source user
- needle user known to be infected
- a deliberate assault
- a large-volume injection
- wide bore, hollow needle
- blood in or on syringe
- deep wound (vs superficial)
These children should be discussed with your local infectious diseases team for consideration of HIV post-exposure prophylaxis, after their initial management.
What is the initial management?
Wash the wound with soap and water.
Ensure the syringe/needle has been safely disposed
History of note:
- Time, date and location of CANSI
- Type of exposure?
- What did the needle look like?
- What kind of needle was it?
- Is the child immunised? (specific details of each)
- Were there other children around that may have an unreported CANSI?
- Is this a high-risk exposure, as outlined above?
Take blood for HepB Surface antibody (HepB AbS) in a serum gel tube to store.
Consider tetanus vaccine +/- tetanus immunoglobulin.
Not required if immunised against tetanus in last five years.
If unimmunised, for immunoglobulin and vaccine.
Otherwise, if previously immunised, for booster dose.
Hepatitis B vaccination +/- Hep B immunoglobulin
If unimmunised, give first dose of vaccine and HepB Ig within 72 hours of exposure (in different limbs!)
If immunised, check titre & give booster.
Luckily, Alfie is immunised for both Hepatitis B and Tetanus. After a thorough wash of his hand, and some relatively obliging blood tests, he’s ready for home. His Mum asks if he needs any other medicine to reduce the risk of “catching one of those viruses you mentioned.”
Post-exposure prophylaxis : Hepatits B immunoglobulin
There is a larger argument that there are risks associated with Hepatitis B immunoglobulin, including that of acquired infection, which must be weighted against the potential benefits of preventing a seroconversion when this may be highly unlikely in the first instance.
In the UK, Hep B immunoglobulin is only recommended in patients with exposure to known Hepatitis B source, although there is some leeway depending on the clinical circumstances. The Auckland District Health Board (ADHB), in NZ states “Administration of hepatitis immune globulin (HBIG) is not indicated if the child has completed a standard three-dose regimen of hepatitis B vaccination.” RCH Melbourne advises to offer HBIG to all unimmunised children with CANSI. There remains controversy in this component of management.
Hence, if the decision is made to treat, give HBIG within 72hrs.
(In Australia, Hep B Immunoglobulin is provided by the Red Cross Blood Service.)
Give the HBIG in a different limb to the Hep B booster you’ve just administered!
<30kg – give 100 iu IM injection
>30kg – give 400 iu IM injection
Post-exposure prophylaxis: HIV
The papers reviewed had no reports of viral transmission of HIV from a CANSI. All mentioned antiretroviral therapy as potential post-exposure prophylaxis for HIV exposure. There were no clear guidelines on which children should be offered HIV-PEP; the ‘high-risk’ patients identified in the list above were more likely to receive prophylaxis. In the Montreal study, of the 210 patients who presented thereafter, an offer of prophylaxis to 87 patients (41.4%) was documented, and 82 (94.3%) of these patients accepted. Prophylaxis was zidovudine and lamivudine for 28 days in 74 patients (90.2%), additionally eight patients were also prescribed a protease inhibitor (nelfinavir, indinavir or ritonavir). Papenburg and colleagues go on to describe the rates of adverse effects from these medications. Consideration of HIV:PEP should be discussed with the local infectious diseases team.
Follow up & counselling
Although the risk of seroconversion is low, it’s important not to underestimate the stress a needlestick will place on the child and family. Provide reassurance that the risk of viral transmission from a CANSI is very low. Don’t forget some written information about completing a catch-up course of immunisation. Contact your local paediatric infectious disease team; they may be happy to provide additional follow-up or counselling. That being said, always consider the prevalence of the blood-borne viruses where you work! The majority of DFTB readers are working in the Australasian, United Kingdom & North American settings; within and without these areas, the prevalence of Hep B, C & HIV can vary considerably.
It’s also worth noting that the studies mentioned probably underestimate the rate of CANSIs; not all children with a needlestick injury will tell their parents, and likewise, not all parents whose child reports a needlestick injury will present for care.
Finally, there’s clearly a huge public health component of this issue. Papenburg et al. identified that in nearly two-thirds of cases, the child actively handled the needle; it’s important to teach children to avoid any discarded syringes or needles and to tell an adult.
Russell FM. Nash MC. A prospective study of children with community-acquired needlestick injuries in Melbourne. Journal of Paediatrics & Child Health. 38(3):322-3, 2002 Jun. https://onlinelibrary.wiley.com/doi/10.1046/j.1440-1754.2002.t01-2-00859.x/abstract
Papenburg J. Blais D. Moore D. Al-Hosni M. Laferriere C. Tapiero B. Quach C. Pediatric injuries from needles discarded in the community: epidemiology and risk of seroconversion. Pediatrics. 122(2):e487-92, 2008 Aug. https://www.academia.edu/942640/Pediatric_injuries_from_needles_discarded_in_the_community_epidemiology_and_risk_of_seroconversion
Celenza, A. et al. Audit of emergency department assessment and management of patients presenting with community-acquired needle stick injuries. Australian Health Review, 2011, 35, 57–62. https://www.ncbi.nlm.nih.gov/pubmed/21367332
Garc ́ıa-Algar O, Vall O. Hepatitis B virus infection from a needle stick. Pediatr Infect Dis J. 1997;16(11):1099 https://journals.lww.com/pidj/Citation/1997/11000/Hepatitis_B_Virus_Infection_From_A_Needle_Stick.27.aspx
Makwana N. Riordan FA. Prospective study of community needlestick injuries. Archives of Disease in Childhood. 90(5):523-4, 2005 May. https://adc.bmj.com/content/90/5/523.short
Bowden S, Druce J, Kelly H. Stability of blood-borne viruses in the environment and risk of infection. Victorian Infect. Dis. Bull. 1999; 2: 71–2. https://docs.health.vic.gov.au/docs/doc/D785EE77B8899CD1CA2578C4000219EA/$FILE/vidbv2i4.pdf
Starship Children’s Hospital, Auckland, NZ – Clinical Guidelines (Needlestick Injuries) https://www.adhb.govt.nz/starshipclinicalguidelines/Needlestick%20Injuries.htm
Decle, P. Post-Exposure Prophylaxis (PEP) guidelines for children and adolescents exposed to blood-borne viruses 06/08/2011 https://www.chiva.org.uk/professionals/health/guidelines/pep/young-pep-ref.html
Royal Children’s Hospital, Melbourne, Clinical Practice Guidelines – Needlestick Injury https://www.rch.org.au/clinicalguide/guideline_index/Needle_Stick_Injury/
Updated 5/11/2017: Corrected initial investigations from HepB Surface
Antigen to Antibody. See comments below.