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Council Directive 2010/32/EU and needlestick injuries

DIRECTIVE
Sabine Wicker MD PhD
Occupational Health Service
Holger F Rabenau MD PhD
Institute of Medical Virology,
Hospital of the Johann Wolfgang
Goethe-University, Frankfurt am Main,  Germany
Email: Sabine.Wicker@kgu.de

Under-reporting of needlestick injuries will, if left untreated, seriously compromise implementation of Council Directive 2010/32/EU

Human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV) are blood-borne pathogens that pose occupational hazards to healthcare workers (HCWs) exposed to the blood or body fluids of infected patients.(1)
Each year, around 66,000 HBV, 16,000 HCV and 1000 HIV infections were estimated to occur worldwide among HCWs – mostly in developing countries – due to their occupational exposure to percutaneous injuries. Work-related infections are responsible for approximately 37% of the HBV infections of HCWs, 39% of the HCV infections and 4.4% of the HIV infections of HCWs worldwide.(2) 
Although the risks of needlestick injuries (NSI) have been well recognised for many years, significant numbers of exposure continue to occur.(3–5)
Change is afoot: European Directive6 has to be implemented by 11th May 2013. Appropriate strategies reduce the probability of transmitting blood-borne pathogens. For this reason, the purpose of the Council Directive 2010/32/EU is to achieve "the safest possible working environment" in healthcare by preventing HCWs' injuries caused by all medical sharps.
In achieving the safest possible workplace, a combination of planning, awareness-raising, information, training, prevention and monitoring is essential. Continuous reporting mechanisms are required, which should include local, national and Europe-wide systems.(6)
The measures specified in the Directive (training, safer working procedures and the use of safety engineered devices) might prevent the majority of injuries, if implemented together and implemented effectively. However, if one element is missed, the impact will be disappointing and the HCWs will not be well protected against occupational-acquired infections.
The issue of needlestick injuries
The majority of NSI occur when HCWs dispose of needles, administer injections, draw blood, recap needles or handle trash or dirty laundry. Before the introduction of safety devices, the Frankfurt Needlestick Study was conducted to describe the epidemiology of NSI at our hospital. Data were obtained between April and June 2006 (anaesthesia, dermatology, gynaecology, paediatrics, surgery) and between February and April 2007 (ear, nose and throat medicine, internal medicine, neurology/psychiatry, ophthalmology, pathology/forensic medicine, radiology) by an anonymous survey administered to 2085 HCWs. The data of our study clearly point out that there is a high rate of NSI in the daily life of a hospital. The rate of such injuries depends on the medical discipline and the occupational group. In our study, 31.4% of the HCWs had sustained at least one NSI within one year (Fig. 1). The number of NSI per person and year varied significantly from 1 to 55. The highest numbers were reported by surgeons.(7)
Current economic constraints in the healthcare system mean that HCWs are becoming more and more under stress with increasingly heavy workloads. Lapses in concentration and fatigue are nowadays the most common reasons for NSI.(7)
The emotional impact of a NSI should not be underestimated.(8,9) Several cases of post-traumatic stress disorder had been described after NSI involving high-risk patients.(10,11)
HCWs are concerned when they suffer a NSI. They want to take action, and the employers need to make sure that all HCWs know what to do when a NSI happens. Regular training and information are the crucial points in creating a safe working environment.
Under-reporting
The rate of NSI is often widely underestimated, as most HCWs do not report the incidents. In our studies among HCWs and medical students, fewer than 30% of injured persons reported all of their NSI and had seen a physician after the incident.(7,12) Consistent reporting of NSI is, however, an essential prerequisite for providing appropriate treatment and taking post-exposure prophylactic measures in a timely fashion.
Council Directive 2010/32/EU makes demands on local, national and European-wide systems and assumes that a complete recording of all NSI is crucial to minimise the occupational hazards. The management of NSI ought to be given high priority and all healthcare institutions should have processes for reporting and managing NSI 24 hours a day and 365 days a year.(8)
Why is the Directive important?
Due to the severe occupational hazards of NSI, preventing NSI should be in everybody's interest. Despite the wide introduction of safety devices at the University Hospital Frankfurt, Germany almost every day at least one NSI is reported by our HCWs (for example 519 needlestick injuries occurred between October 2010 and April 2012).
During the study period, testing for blood-borne pathogens among the index patients of the University Hospital Frankfurt was performed in 86.5% (449/519) of patients; overall, 20.5% of the index patients were infected with a blood-borne pathogen (Fig. 2). One case of HCV transmission occurred in a physician,(13) two initial diagnoses (active hepatitis B and hepatitis C infection) among index patients were made during the observation period.(14) These results clearly point out a serious risk for occupational infections.
It is our hope that the new EU Directive will minimise the severe health risks caused by NSI. The legislator, the employers and the occupational health physicians should make every effort to implement and support the new legislation.
References
  1. Ridzon R CC, DeMaria A. Simultaneous transmission of human immunodeficiency virus and hepatitis C virus from a needlestick injury. N Engl J Med 1997; 336:919–22.
  2. Prüss-Üstün A, Rapiti E, Hutin Y. Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers. Am J Ind Med 2005;48:482–90.
  3. Phillips EK, Conaway MR, Jagger JC. Percutaneous injuries before and after the Needlestick Safety and Prevention Act. N Engl J Med 2012;366:670–1.
  4. Tomkins SE. Occupational transmission of hepatitis C in healthcare workers and factors associated with seroconversion: UK surveillance data. J Viral Hepat 2012;19:199–204.
  5. Voide C. Underreporting of needlestick and sharps injuries among healthcare workers in a Swiss University Hospital. Swiss Med Wkly 2012;142: w13523.
  6. Council Directive 2010/32/EU of 10 May 2010 implementing the Framework agreement on prevention from sharp injuries in the hospital and healthcare sector concluded by HOSPEEM and EPSU. Official Journal of the European Union 2010;134:66–72.
  7. Wicker S et al. Needlestick injuries among Healthcare workers: Occupational hazard or avoidable hazard? Wien Klin Wochenschr 2008; 120:486–92.
  8. Henderson DK. Management of needlestick injuries – A house officer who has a needlestick. JAMA 2012;307:75–84.
  9. Louie T. Occupational hazards. N Engl J Med 2005;353:757–9.
  10. Worthington MG, Ross JJ, Bergeron EK. Posttraumatic stress disorder after occupational HIV exposure: two cases and a literature review. Infect Control Hosp Epidemiol 2006;27:215–7.
  11. Howsepian AA. Post-traumatic stress disorder following needle-stick contaminated with suspected HIV-positive blood. Gen Hosp Psychiatry 1998;20:123–4.
  12. Wicker S, Rabenau HF. A review of the control and prevention of needlestick injuries. Eur Infec Dis 2011;5:60–3.
  13. Himmelreich H et al. Early diagnosis of hepatitis C transmission after needlestick injury [Frühzeitige Diagnose einer Hepatitis C-Übertragung nach Nadelstichverletzung – article in German]. Der Unfallchirurg 2012; Epub ahead of print 8 September 2012.
  14. Wicker S et al. Blood examinations after needlestick injuries. Benefits for healthcare workers and indexpatients. [Blutuntersuchungen nach Nadelstichverletzungen: Vorteile für Mitarbeiter und Indexpatienten – article in German]. Zahnärztliche Mitteilungen 2011; 101, Nr. 24 A, 46–8.

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