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TEXAS CONTAMINATED SHARPS INJURIES: 2004

This report contains the aggregate contaminated sharps injury data submitted to Texas Department of State Health Services as required by Texas Health and Safety Code, Chapter 81, Subchapter H (HB2085), 76 th Legislature.

Texas Bloodborne Pathogen law and federal bloodborne pathogen regulations seek to protect the health care worker from worksite acquired bloodborne diseases. Bloodborne pathogens of concern at the healthcare worksite are human immunodeficiency virus (HIV), Hepatitis B (HBV) and Hepatitis C (HCV) infections. United States (U.S.) and global surveillance of HIV, HBV and HCV acquired in the community and at the healthcare worksite are described below.

HIV/AIDS Statistics

At end of the year 2000, there was an estimated 36.1 million adults and children living with HIV/AIDS throughout the world 1 and an estimated 340,000 persons were living with AIDS in the U.S. at the conclusion of 2000. ² More than 1 million persons were estimated to be living with HIV infection in the U.S. in 2003. ³ Due to the highly active antiretroviral therapy (HAART) since 1996, persons with HIV are living longer and the progression to AIDS has lessened. ³ CDC thus recommends that states and territories adopt confidential, name-based surveillance systems that report HIV infections because AIDS surveillance no longer provides an accurate population-based monitoring of the epidemic. ³

Global and US Bloodborne Pathogen Infections among Health Care Workers

Reports of bloodborne infections among the estimated 35 to 100 million global health care workers world wide are fortunately small in comparison to the size of the at risk population: 65,000 Hepatitis B (HBV) infections, 16,400 Hepatitis C (HCV) and 1000 Human immunodeficiency virus (HIV) infections in the year 2000. ⁴ There continues to be fifty-seven health personnel in the U.S. that have been documented to seroconvert to HIV following occupational exposures. ⁵ Additionally, 139 other cases of HIV infection or AIDS have occurred among healthcare workers who have not reported other risk factors for HIV infection. ⁵ No new cases of occupational acquired HIV/AIDS have been documented since the end of 2001 in the U.S. ⁵

Texas Contaminated Sharps Injuries Reported in 2004

Texas Bloodborne Pathogen regulations require governmental entity reporting of contaminated sharps injuries as shown in table 1. A contaminated sharps injury is defined as any sharps injury that occurs with a sharp used or encountered in a health care setting that is contaminated with human blood or body fluids. ⁶

Aggregate reporting of contaminated sharps injuries among governmental entities in Texas during 2004 includes the following: where the injuries occurred; when did the injury occur by time and date; information about the workers who sustained injuries; what was the original intended use of sharps device involved in the injury; how the injury occurred; type of sharps device in use at time of injury; worksite safety controls; and safety engineered sharps protection status of device involved in the injury. ⁶

Where Sharps Injuries Occurred in Texas

Higher percentages of sharps injuries continue to reflect the higher urban populations and greater number of health care facilities in Health Service Regions 1, 3, and 6 (table 2).

Governmental entity hospital/medical/health centers continue to report the greatest number of injuries as shown in table 3. These numbers could be expected in relationship to higher number patient and staff populations and the higher number of procedures with potential sharps risk in a hospital, health care centers, and medical centers.

As noted in table 5, the highest percentage of sharps injuries were reported to have occurred in the operating room. It is of interest also, to compare reported operating room injuries with patient’s room injuries over time as seen in table 6.

The changes in percentages in table 6 could be possibly attributed to an increase in the use of safer devices or perhaps changes in reporting by healthcare workers or other unknown factors.

When Injuries Occurred

Sharps injuries per month do not reflect a seasonal variation. The majority of injuries continue to be reported during the day shift (7 am to 3 pm) as to be expected considering the greater number of both staff and procedures during the day shift. The greatest number of injuries continue to be reported to have occurred after use of a sharps device.

Texas Health Care Worker Information

The medical and nursing professions reported the highest number of injuries. Females ages 25 through 34 continued to report the most injuries and the greatest number of injuries were sustained to the hand.

How Sharps Injuries Occurred

A review of the stated reason for the injury, the device involved, and the original intended use of the sharps device provides a broad review of how sharps injures occurred.

Four years comparison of the reason for sharps injuries reveals a 1% decrease in injuries due to device being found in an inappropriate place and due to suturing. In comparison, use of the sharps container injuries has decreased by 5%.

A sum all needles and syringes (excluding iv needles/catheters) was 42% of the injuries. Suture needles and surgical instruments comprised 39% of the injuries.

Worksite Safety Control

Tables 18 and 19 show the compliance or lack of compliance in the use of safety engineered sharps and whether the safety mechanism was activated. In comparison, table 20 shows a high rate of compliance with glove use, Hepatitis B vaccination, bloodborne pathogen education, and availability of the sharps container.

Safer Devices and Practices in the Healthcare Field

U.S. Laws and Directives

In 1955, Roehr Products introduced a plastic disposal syringe. ⁷ Plastic disposal syringes replaced the reusable glass syringes thus reducing the potential of contaminates in a reused syringe and needle as well as eliminating the risk of breakage. Disposable plastic syringes were designed initially without safety features. The Federal Bloodborne Pathogen standard issued in 1991, required work place Bloodborne Pathogen Exposure Control Plans that described how the site would implement sharps containers, safety engineered devices, and bloodborne pathogen education. In 2001, the Federal Needlestick Safety and Prevention Act and Texas Bloodborne Pathogen Law as well as other state’s bloodborne pathogen laws required health care facilities to establish a team of direct care staff to screen, test, and recommend implementation of appropriate syringes and other devices that are safety designed.

Federal directives over time have addressed specific bloodborne pathogen risk issues. Occupational Safety Health Agency (OSHA) requires employers to substitute non-glass products (e.g., plastic) when available such as blood tubes and slides. ⁸ A joint FDA/NIOSH/OSHA advisory in February 1999 provided an alert as to the potential risk of use of glass capillary tubes and recommended that the users consider capillary tubes that are not made of glass, products that use a method of sealing that does not require manually pushing one end of the capillary tube, and products that allow the blood Hematocrit to be measured without centrifugation. ⁹ OSHA clarified its policy on the prohibition of removing contaminated needles from blood tube holders: “Removing contaminated needles and reusing blood tube holders can expose workers to multiple hazards”. ¹⁰ Blood tube holder reuse is a potential hazard also for the patient, clinical studies have shown a 50-80% contamination of the blood tube holder after one usage. ¹¹ CDC reported the transmission of Hepatitis B Virus in three long term care facilities was attributed to shared devices (blood glucose monitors, multi dose vials of insulin, and lancets), and other breaks in infection control practices related to blood glucose monitoring. ¹² Thus, single patient/resident dedicated glucose monitors, insulin vials, and lancets are the preferred infection control approach.

World Health Organization Study Considers the Global Burden of Disease Attributable to Contaminated Injections in Health Care Settings

As a part of the 2000 Global Burden of Disease study by the World Health Organization, the death and disability from injection-associated infections with hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) were quantified. The model based the study on the fraction of the annual number of infections attributable to injections, the proportion of infections resulting with reused equipment, the probability of infections resulting from percutaneous exposure, the prevalence of active infection, the prevalence of immunity and total incidence. ¹³ These infections were converted into disability-adjusted life years (DALYS) in 2000-2030. ¹³ During 2000, in Ten Global Burden of Disease regions, where persons received an average of 3.4 injections per year, 39.3% of the injections were given with reused equipment. ¹³ Thus contaminated injections were anticipated to cause an estimated 21 million HBV infections, two million HCV infections, and 260,000 HIV infections resulting in a new infection burden of 9,177,679 DALYS between the years 2000 and 2030. ¹³ The study demonstrated the need for policies and plans for safe and appropriate use of injections to reduce the burden of disability and death in countries with poor injection practices. ¹³

Recommendations:

1. Healthcare administration support and monitoring of worksite safety in relation to safety sharps selection and usage.
2. Annual update of worksite Bloodborne Pathogen Exposure Control Plans including policies and procedures to prevent sharps injuries and manage Post Exposure Prophylaxis
3. Continued encouragement of employees to report sharps injuries.
4. Conduct worksite tracking of sharps injuries in relationship to specific devices and work processes.
5. Revise worksite procedures for processes that have higher incidence of injuries.

References:

¹ Adler, M W. ABC of AIDS development of the epidemic. BMJ. May 19, 2001 322 (7296)
   1226-1229. Retrieved 1/23/06 from
     http://www.ncbi.nlm.nih.gov/entrez/query.fcgi

² Klevens, RM and Neal, JJ. Update: AIDS United States, 2000. CDC MMWR Weekly. July 12,
   2002/51(27); 592-595 Retrieved 1/23/2006 from
     http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5127a2.htm

³ Espinoza, L. et al. Trends in HIV/AIDS diagnosis---33 states, 2001-2004. CDC MMWR
  Weekly. November 18, 2005/54 (45); 1149-1153. Retrieved 1/31/2006 from:
     http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5445a1.htm

⁴ Puro, V. and Shouval, D. Conclusions of the meeting of the Viral Hepatitis Prevention Board    Meeting on Hepatitis B, hepatitis C, and other bloodborne infections in health care
   workers. Rome, Italy, March 17-18, 2005. Viral Hepatitis. November 2005 14 (1) 1-16.

⁵ Department of Health and Human Services Centers for Disease Control and Prevention.
   Surveillance of healthcare personnel with HIV/AIDS, as of December 2002. Retrieved
   2/10/2006 from:
     http://www.cdc.gov/ncidod/dhqp/bp_hiv_hp_with.html

⁶ Title 25. Health Services Part 1. Texas Department of State Health Services Chapter
   96. Bloodborne Pathogen Control.
     http://www.dshs.state.tx.us/idcu/health/bloodborne_pathogens/reporting

⁷ Who Invented the Hypodermic Needle or Syringe. Retrieved 2/17/06:
     http://inventors.about.com/libaray/inventors/blsyringe.htm

⁸ U.S. Department of Labor Occupational Safety And Health Administration Memorandum from    Cindy A. Coe. June 4, 2002 Bloodborne Pathogens Interpretation Request.

⁹ Joint FDA/NIOSH/OSHA Advisory on: Glass Capillary Tubes: Joint Safety Advisory About    Potential Risks. February 1999. Retrieved 3/8/2004 from:
     http://www.cdc.gov/niosh/capssa9.html

¹⁰ OSHA Trade News Release, U.S. Department of Labor, Office of Public Affairs, Trade News    Release, Wednesday, June 12, 2002. OSHA clarifies position on the removal of contaminated    needles.

¹¹ Perry, J. and Jagger, J. Reuse of blood tube holders, redux. Preventing Occupational Exposures to Bloodborne Pathogens. Articles from Advances in Exposure Prevention, 1994-2003 Vol.6, no.4, 2003; 230-231. The Safety Institute, Premier Inc. 2004.

¹² Webb, R. et al. Transmission of Hepatitis B Virus among persons undergoing glucose    monitoring in long-term care facilities Mississippi, North Carolina, and Los Angeles, California,    2003-2004. CDC MMWR Weekly March 11, 2005/54(09); 220-223. Retrieved 2/17/2006 from:
     http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5409a2.htm

¹³ Hauri AM, Armstrong, GL, Hutin YF. The global burden of disease attributable to    contaminated injections given in health care settings. Int J STD AIDS. January 2004 15 (1)    7-16.

Questions or comments may be directed to:

Kathryn Gardner DrPH, RNC, CIC, CPHQ
Texas Department of State Health Services
Communicable Disease Control Unit
(512) 458-7676
kathryn.gardner@dshs.state.tx.us

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