3.3 Injection Safety, Sharps Injury Prevention & Occupational Post-Exposure Prophylaxis

3.3 Injection Safety, Sharps Injury Prevention & Occupational Post-Exposure Prophylaxis

Healthcare workers in Ghana face significant occupational risks from bloodborne viral pathogens, most notably Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV). Percutaneous sharps injuries represent the primary vector of occupational transmission in hospital wards, maternity units, and emergency theaters. In response, the Ministry of Health and Ghana Health Service have established rigid injection safety standards and Post-Exposure Prophylaxis (PEP) protocols to eliminate preventable transmission.

---

Principles and Standards of Injection Safety

The World Health Organization (WHO) and Ghana Health Service define a safe injection as an intervention that:

1. Does not harm the recipient;
2. Does not expose the healthcare provider to any avoidable occupational risk; and
3. Does not result in hazardous infectious waste that puts the community at risk.

Auto-Disable (AD) Syringe Technology

To prevent intentional or accidental syringe reuse, the Ghana Health Service mandates the exclusive use of single-use Auto-Disable (AD) syringes across the Expanded Programme on Immunization (EPI) and standard curative services:

• Internal Locking Mechanism: AD syringes feature an internal mechanism (such as a breaking plunger ring, a locking clip, or an auto-retracting needle) that permanently locks the plunger after a single complete forward stroke, preventing aspiration of a second dose.
• Re-use of syringes and needles is prohibited under national injection-safety policy.

Aseptic Technique in Medication Preparation and Administration

• Work Environment: Medications must be prepared on a dedicated, clean, dry medication trolley or preparation surface that is physically separated from biological specimen handling areas.
• Skin Antisepsis: Cleanse the patient’s injection site with a 70% isopropyl alcohol swab using a circular motion moving from the center outward. Allow the alcohol to air-dry completely for 30 seconds. Injecting through wet alcohol causes severe stinging pain and impairs microbial killing.
• Multi-Dose Vial Safety Rules:
  • Whenever feasible, single-dose ampoules or vials must be selected.
  • When multi-dose vials are utilized (e.g., insulin, depot medroxyprogesterone, local anesthetics), a sterile syringe and needle must be used for every single vial entry.
  • Never leave a needle inserted in the rubber stopper of a multi-dose vial for drawing multiple doses; this breaches the sterile barrier and allows atmospheric contaminants into the vial.
  • The vial's rubber septum must be wiped with 70% alcohol and allowed to dry prior to every needle penetration.
  • Multi-dose vials must be clearly labeled with the date, time, and nurse's initials upon opening, and must be discarded within 28 days (unless a shorter manufacturer stability duration is specified). Discard immediately if cloudiness, precipitation, or contamination is suspected.

---

Safe Sharps Handling and Puncture-Proof Safety Box Protocols

Sharps injuries occur predominantly during needle recapping, blood sampling, intravenous cannulation, and unsafe disposal practices.

The Absolute Ban on Two-Handed Recapping

• Healthcare providers are strictly forbidden from recapping needles using a two-handed technique.
• Bending, breaking, shearing, or manually manipulating contaminated needles by hand is strictly prohibited.
• If recapping is unavoidable in an emergency (e.g., carrying an arterial blood gas sample to a laboratory):
  • The healthcare worker must execute the One-Handed "Scoop" Technique:
    1. Place the needle cap on a flat, stable horizontal surface.
    2. With the dominant hand holding the syringe, gently guide the needle tip directly into the cap without touching the cap with the other hand.
    3. Once the needle is fully covered, tilt the syringe upright to seat the cap, and firmly snap the cap into place using the edge of a hard surface or pressing the cap base with one hand while the other hand remains behind the needle.

ONE-HANDED SCOOP TECHNIQUE
1. Cap rests on flat surface:      [=============] ===> (Cap opening)
2. Syringe guides needle inside:   [Syringe]-----> ===> [Cap]
3. Snap tight with single hand against flat ledge.
(NEVER bring opposing hand near the needle point!)

Safety Box Management Protocols

• Puncture-proof, leak-resistant cardboard safety boxes (or rigid polypropylene containers) must be stationed within direct arm's reach of every clinical injection, phlebotomy, and suture station.
• Sharps must be dropped directly into the safety box aperture immediately after use without passing them to a colleague or placing them on bedside tables.
• The 3/4 (75%) Fill Rule: A safety box must be filled to a maximum of 3/4 capacity (or up to the visible black fill line). Overfilling risks needles protruding through the opening, causing needle-stick injuries during handling.
• Safety Box Prohibitions: Staff must never shake, press down, squeeze, or retrieve items from a sharps box. Once the box reaches 3/4 capacity, the aperture flap must be permanently sealed, locked, and transported directly to the facility's incinerator or storage holding bay.

---

Immediate First-Aid Management Following Occupational Exposure

When a healthcare professional experiences an accidental sharps injury or biological fluid splash, rapid first-aid intervention must occur before seeking medical evaluation.

Action Protocols by Exposure Type

1. Percutaneous Injury (Needle-stick or Scalpel Cut):
   • Immediately wash the wound gently with mild soap and copious running water.
   • DO NOT squeeze, press, or suck the wound. Squeezing induces localized mechanical micro-trauma and hyperemia, which accelerates cellular uptake and systemic vascular dissemination of viral particles.
   • Do not use harsh corrosive chemical agents (e.g., concentrated bleach, alcohol, or formalin) on the open wound, as this causes severe tissue necrosis.
   • Apply a standard non-irritating antiseptic (e.g., 70% alcohol or povidone-iodine) and cover with a sterile, waterproof adhesive dressing.
2. Mucous Membrane Exposure (Eye, Mouth, or Nose Splash):
   • Immediately flush the affected mucosal area with copious volumes of sterile normal saline or clean running tap water.
   • For ocular splashes, irrigate the eye continuously for at least 10 to 15 minutes using an eye-wash station or IV saline infusion line, irrigating from the inner canthus outward with the eyelids held widely open. If contact lenses are worn, remove and discard them.
   • For oral splashes, spit out the biological matter immediately and rinse the mouth repeatedly with water; do not swallow the rinse water.
3. Non-Intact Skin Exposure:
   • Wash thoroughly with soap and water; do not scrub with abrasive brushes.

---

Ghana Health Service HIV Post-Exposure Prophylaxis (PEP) Protocols

Post-Exposure Prophylaxis (PEP) represents a comprehensive medical strategy to prevent HIV acquisition following an occupational exposure to blood or infectious bodily fluids.

The Golden Timeframe for Initiation

• Initiation Window: PEP must be initiated as an emergency intervention as soon as possible, ideally within 2 hours of exposure.
• Hard Clinical Cutoff: PEP should be started no later than 72 hours (3 days) post-exposure. Research demonstrates that HIV integrates into dendritic cells and migrates to regional lymph nodes within 72 hours; initiation beyond 72 hours is scientifically ineffective and not recommended by national guidelines.

Baseline Clinical Evaluation and Diagnostic Testing

1. Testing of the Exposed Healthcare Worker:
   • Perform an immediate rapid HIV antibody/antigen test to determine the worker's baseline HIV status.
   • If the baseline test is HIV-negative, PEP is indicated.
   • If the baseline test is HIV-positive, the worker is already living with HIV; PEP is withheld, and the worker is immediately referred to the facility's Antiretroviral Therapy (ART) clinic for ongoing clinical care.
   • Other baseline laboratory tests: Hepatitis B surface antigen (HBsAg), Hepatitis C antibody (anti-HCV), serum creatinine, alanine aminotransferase (ALT), and a urine pregnancy test for female clinicians.
2. Evaluation of the Source Patient:
   • If the source patient is identifiable, obtain informed consent and perform rapid HIV testing.
   • If the source is confirmed HIV-negative, PEP can be discontinued immediately.
   • If the source is HIV-positive, determine their current ART regimen, recent viral load, and clinical staging.
   • If the source patient is unknown or refuses testing (e.g., anonymous needle from a sharps container), perform an institutional risk assessment; if the risk is substantial, complete the PEP regimen.

The 28-Day Antiretroviral Regimen in Ghana

Under WHO guidance and Ghana's national antiretroviral therapy guidelines, the preferred adult PEP regimen is a three-drug single-tablet daily fixed-dose combination (TLD) taken for 28 consecutive days:

Tenofovir Disoproxil Fumarate (TDF 300 mg) + Lamivudine (3TC 300 mg) + Dolutegravir (DTG 50 mg) orally once daily for 28 days

• Components:
  • Tenofovir Disoproxil Fumarate (TDF): 300 mg (Nucleotide Reverse Transcriptase Inhibitor - NRTI)
  • Lamivudine (3TC): 300 mg (Nucleoside Reverse Transcriptase Inhibitor - NRTI)
  • Dolutegravir (DTG): 50 mg (Integrase Strand Transfer Inhibitor - INSTI)
• Alternative Regimens: If Dolutegravir is unavailable, poorly tolerated, or contraindicated, an alternative protease-inhibitor-based regimen is prescribed:
  • TDF (300 mg) + 3TC (300 mg) + Atazanavir/ritonavir (ATV/r 300 mg/100 mg) once daily; OR
  • TDF + 3TC + Lopinavir/ritonavir (LPV/r 400 mg/100 mg) twice daily.
• Counseling & Adherence: Nurses must receive structured adherence counseling regarding medication side effects (nausea, fatigue, mild headache, insomnia). The entire 28-day course must be completed to prevent breakthrough infection. During the PEP period, the worker must practice safer sex (condom use) and refrain from donating blood or breastfeeding.

Clinical Follow-Up Schedule

Exposed personnel must undergo repeated HIV serological testing to confirm non-seroconversion:

• Repeat rapid antibody/ELISA test at 6 weeks post-exposure.
• Repeat testing at 3 months (12 weeks) post-exposure.
• Final testing at 6 months (24 weeks) post-exposure.

---

Occupational Hepatitis B and Hepatitis C Prophylaxis

Hepatitis B virus is the most infectious bloodborne pathogen in the healthcare setting, carrying an transmission risk of up to 30% following a needle-stick from an HBsAg-positive source (compared to approximately 3% for HCV and 0.3% for HIV).

Pre-Exposure Hepatitis B Vaccination

All nurses and healthcare workers in Ghana must receive the complete 3-dose Hepatitis B immunization series administered intramuscularly into the deltoid at 0, 1, and 6 months.

• An anti-HBs antibody titer check should be performed 1 to 2 months following the third dose.
• A titer of ≥10 mIU/mL confirms protective, durable immunity.

Post-Exposure Management Matrix for Hepatitis B

[!NOTE] Hepatitis C Protocol: There is currently no effective vaccine and no approved Post-Exposure Prophylaxis (PEP) for Hepatitis C. If an exposure occurs, baseline testing for anti-HCV and ALT is performed, followed by HCV RNA testing at 4 to 6 weeks and anti-HCV at 4 to 6 months. Healthcare workers who seroconvert are promptly referred for curative treatment with Direct-Acting Antivirals (DAAs, e.g., Sofosbuvir/Velpatasvir).

---

Documentation, Surveillance, and Root Cause Analysis under GHS Guidelines

Under facility occupational health and safety procedures:

1. Immediate Notification: The exposed nurse must report the incident immediately to the Ward In-Charge, the Facility IPC Coordinator, or the OHS Unit.
2. Occupational Exposure Incident Form: An occupational exposure incident form is completed promptly (many facilities require it within 24 hours), documenting:
   • Date, time, ward, and exact clinical procedure being performed.
   • The type and gauge of sharp device involved, and whether it was an engineered safety device.
   • The depth of the injury, visible bleeding, and biological fluid volume involved.
   • Personal protective equipment worn at the time of exposure.
   • Source patient identification, medical record number, and known viral serostatus.
3. Confidentiality and Support: The records must be maintained confidentially, distinct from the employee’s regular personnel file. Psychological support and adherence counseling must be provided throughout the 28-day PEP regimen.
4. Institutional Root Cause Analysis: IPC committees must audit injury patterns to rectify system vulnerabilities—such as procuring additional safety boxes, redesigning crowded injection areas, or eliminating multi-dose vial hazards—fostering a proactive, non-punitive culture of healthcare safety.