Needle Stick Injury and Standard Precautions

Standard Precautions

Applied to ALL patients/specimens/sharps regardless of apparent infectivity. Replaced “universal precautions” (which covered only blood via nonporous PPE) — now covers ALL body fluids.

Components: Hand hygiene, PPE, BMW segregation/disposal, spillage cleaning, disinfection of reusable items, environmental cleaning, safe sharps handling, respiratory hygiene/cough etiquette.

Hand Hygiene

Hand rub: 70-80% ethyl alcohol or 0.5-4% chlorhexidine. ≥20-30 sec. Self-evaporates. Routine care/rounds — EXCEPT visibly soiled hands (need wash instead).

Hand wash: antimicrobial soap (4% chlorhexidine) or plain soap. ≥40-60 sec. Visibly soiled, before/after eating, after toilet, before/after shift, diarrhea patient care.

Surgical hand scrub: 3-5 min, 4% chlorhexidine. Before surgery + between cases.

WHO 5 Moments: (1) before touching patient (2) before clean/aseptic procedure (3) after body fluid exposure risk (4) after touching patient (5) after touching surroundings.

PPE

Selection based on: contamination risk level (standard precaution factor) + transmission route (contact/droplet/airborne — transmission-based factor). Remove immediately after indication ends.

Gloves: standard (before sterile procedure, anticipated blood/fluid contact even if sterile), contact precaution, heavy-duty (BMW handlers/sharps risk). NOT substitute for hand hygiene — hygiene BEFORE (prevent glove contamination) AND AFTER (moist warm environment = microbe haven; microtears risk). Single-use, change between patients/procedures, never wipe/wash gloved hand.

Surgical (3-ply) mask: loose, single-use. 3 layers: outer fluid-repellent, middle melt-blown filter (unstandardized pore, unlike N95), inner hydrophilic. Standard + droplet precaution. Discard 4-6hr or if soiled/wet. “Hanging mask syndrome” = contaminates inner surface — avoid.

N95 respirator: airborne protection (TB classic example). N95 = filters ≥95% particles, no oil resistance. 4 layers (outer/inner spunbond PP + 2 middle cellulose/polyester meltblown filter). NEGATIVE PRESSURE device. Single-use, change q8hr or if clogged/wet/torn. FIT CHECK — every single use (seal check: exhale=positive pressure check, inhale=negative pressure check). No clinical work until fit check passes. FIT TESTING — different from fit check! Determines correct size/style + trains donning/doffing. At joining + ANNUALLY.

Body clothing (scaling risk): Lab coat (standard, all lab staff, NOT fluid-resistant) < Plastic apron (fluid-resistant, single-use, low risk) < Disposable gown (long-sleeve, fluid-resistant, moderate risk) < Coverall (full body+hood — large splash risk e.g. cardiac surgery, extensive skin contact e.g. uncontrolled diarrhea, high-mortality pathogens e.g. Nipah/Ebola).

Eyewear: facial splash protection. Head cover: blood spillage anticipated (cardiac surgery). Shoe cover: ICU/OT floor organisms. Gumboots: sharps injury risk (BMW handlers, laundry, housekeeping).

DONNING: Gown → Mask/respirator → Goggles/face shield → Gloves DOFFING: Gloves → Face shield/goggles → Gown → Mask/respirator (reverse order, most contaminated first)

Doffing errors = major HCW infection risk (COVID-19 example). All PPE removed before exiting room EXCEPT respirator (removed after exiting + closing door). Disposal: Yellow bag = gown/coverall/mask/respirator/shoe cover/cap. Red bag = plastic apron/goggles/face shield/gloves.

Blood Spill Management

Steps: attend immediately → mark area/wet floor sign → PPE (gloves+gown) → confine+absorb with towel (dispose as infectious waste) → hypochlorite disinfect (large spill >10cm: 1:10/0.5%/5000ppm; small <10cm: 1:100/0.05%/500ppm) → 10 min contact time → rinse with clean water.

Transmission-Based Precautions (TBPs)

Added ON TOP of standard precautions for known/suspected specific-route organisms. Start on CLINICAL SUSPICION, stop only if ruled out. 3 types: Contact, Droplet, Airborne.

Contact Precautions

Route: direct (hands = commonest; blood/body fluid contact) or indirect (fomites/surfaces/devices).

Agents: MRSA, CRE, VRE, MDR-GNB (Acinetobacter/Pseudomonas), conjunctivitis (adenovirus/gonococcus/Chlamydia), contagious skin lesions (GAS/Staph/HSV), scabies, diarrhea agents (rotavirus/cholera/C.diff), HAV/HEV.

Measures: strict hand hygiene, gloves+gown ESSENTIAL (donned on entry, removed before exit), single-use dedicated equipment, single room preferred (or cohorting/≥3ft separation+curtain), limited transport (cover infected areas), daily disinfection of frequently-touched surfaces.

Droplet Precautions

Route: large droplets (>5µm), close contact <3ft (don’t stay airborne), also settle on surfaces within 1m (contact spread possible too).

Agents: Diphtheria, H. influenzae type b, meningococcus, pertussis, pneumonic plague, Mycoplasma pneumoniae, GAS pharyngitis, influenza, SARS-CoV-2, VHF (Lassa/Ebola/Marburg/CCHF), mumps/parvovirus B19/rhinovirus/rubella/adenovirus.

Measures: hand hygiene (droplet overlaps contact), surgical mask (HCW on entry/close contact; patient ALWAYS). Mask primary function = SOURCE CONTROL (prevent spread FROM wearer). Secondary = protects wearer. N95 gives NO extra environmental protection here — reserved for AGPs in droplet patients specifically. Respiratory hygiene/cough etiquette (tissue/inner elbow not hands, yellow bin disposal, ≥1m social distance). Single room preferred, limited transport (patient masked), daily disinfection.

Airborne Precautions

Route: aerosols (<5µm), stay suspended, travel with air current.

Agents: M. tuberculosis, measles, varicella (chickenpox/zoster), smallpox/monkeypox, aerosolizable B. anthracis spores, pulmonary aspergillosis.

AGPs (aerosol-generating procedures): ET intubation, open airway suctioning, tracheostomy care, CPR, sputum induction, bronchoscopy — generate MORE aerosol than coughing, warrant airborne precautions.

Measures: N95+ respirator, fit-check EVERY time. Gloves/gown/eyewear as needed. AIIR (Airborne Infection Isolation Room) = ventilation + UVGI + filtration.

Natural ventilation: door+windows opposite, kept open. Consultation room: doctor sits AWAY from airflow direction. Ward: beds away from door-window airflow path.

Mechanical/negative pressure: room pressure < surrounding (air flows in, not out). ≥12 ACH (high-risk: TB ward, bronchoscopy room, MDR-TB clinic, airborne room) vs 6 ACH (low-risk). Negative pressure differential >2.5 Pascal. Door ALWAYS closed. Precede by anteroom.

UVGI: supplements ventilation, wall-mounted, >8ft height (avoid direct patient irradiation).

Filtration: exhaust fan (properly fitted) or HEPA.

Transport: only if necessary, patient masked+lesions covered, HCW full N95/PPE.

Visitors/staff: restricted/PPE required. Immune staff (e.g. chickenpox-immune) preferentially posted to airborne rooms.

Needle Stick Injury (Occupational Exposure)

Definition — broader than name suggests: percutaneous injury (needle/sharp) + splash (mucous membrane/eye/mouth) + non-intact skin contact + prolonged intact-skin contact.

3 BBVs, DECREASING risk: HBV (30%) > HCV (3%) > HIV (0.3%). [Note: HIV is NOT the highest risk despite common assumption]

Infectious specimens: blood, genital secretions, CSF/synovial/pleural/peritoneal/pericardial/amniotic fluid. NOT infectious (unless blood-visible): feces, nasal secretions, saliva, sputum, sweat, tears, urine, vomitus.

Risk factors: hollow-bore needle (>solid), visible blood on device, injury depth, blood volume, source viral load, promptness of first aid + PEP.

Prevention

Handling: standard precautions, 0.5% hypochlorite surface disinfection, mandatory HBV vaccination (documented protective titer), prompt spill cleanup, disposable needles only (never reuse), NEVER RECAP (if unavoidable — single-hand scoop technique only), immediate sharp box disposal (never leave on trolley/table), engineering controls (retractable lancets, safety-lock syringes, needleless IV systems).

Surgical: “confine and contain.” Sharp instruments passed by pre-agreed non-touch method (never direct hand-to-hand). Suturing: forceps/needle holder only, never fingers; blunt needles for abdominal closure where practical. Preop BBV testing NOT mandatory (only if clinical indication). Known BBV-positive patient: team awareness, double gloves, limited essential staff, optionally scheduled last.

Post-Exposure Management — 9 Steps

1. First aid: splash — irrigate 5+ min with water; mouth — spit+rinse repeatedly; contact lens — leave in during irrigation, clean after. AVOID: panic, sucking finger, squeezing wound, antiseptics/detergents on site.
2. Report to nodal center (usually HICC office/staff clinic/casualty).
3. First dose PEP for HIV ASAP — max effect <2hr, NIL effect >72hr. NACO regimen: Tenofovir 300mg + Lamivudine 300mg (1 tab OD) + Lopinavir 200mg + Ritonavir 50mg (2 tabs BD). Skip if source documented HIV-negative. Don’t wait for result if unavailable — start immediately.
4. Testing for BBVs: anti-HIV, HBsAg, anti-HCV (source + HCW) + anti-HBs (if HCW previously vaccinated, untested titer). Rapid test, 1-2hr result. HCW baseline needed for later attribution/compensation claims.
5. PEP decision (NACO for HIV, CDC for HBV — see below).
6. Informed consent + counseling. PEP NOT mandatory — refusal documented after risk explained.
7. Documentation: structured proforma (date/time/place/procedure/exposure type/duration/source status/specimen) + signed consent (or refusal documented).
8. Follow-up testing (if source positive/unknown): HIV at 6wk, 3mo, 6mo. HBV/HCV at 6mo.
9. Follow-up precautions (first 6-12wk, if source positive/unknown): no blood/semen/organ donation, abstinence/condom until baseline+3mo HIV negative, no breastfeeding, prompt eval of fever within 12wk.

HIV PEP — NACO 2018

Exposure Code (EC):

• EC-1 Mild: small volume/brief mucous membrane or non-intact skin
• EC-2 Moderate: large volume/prolonged mucocutaneous, OR superficial percutaneous with solid needle
• EC-3 Severe: percutaneous, large volume, hollow/wide-bore needle, deep puncture, visible blood, needle used in artery/vein

Source Code (SC): SC-1 (HIV+, asymptomatic, low viral load <400 copies/mL), SC-2 (HIV+, symptomatic/high viral load), Unknown.

PEP NOT warranted: source HIV-negative (any EC), OR EC-1+SC-1. PEP RECOMMENDED: every other positive combination. 28 days. Primary regimen: TL+LR (same as first dose combo above). Alternative: TLE (Tenofovir 300mg + Lamivudine 300mg + Efavirenz 600mg, 1 tab OD).

PEP also skipped: exposed person already HIV+ (→ART clinic, not PEP), intact skin exposure, low-risk specimen (tear/saliva/urine/stool/vomitus/nasal/sweat), unknown source in low-prevalence area, delay >72hr (initiation optional).

Side effects: Early — nausea/diarrhea/myalgia/headache/fatigue. Late — anemia/leukopenia/thrombocytopenia. NEVER discontinue for side effects EXCEPT jaundice/liver tenderness. Compliance >95% needed for efficacy.

HBV PEP — CDC 2013

Notes: check anti-HBs titer only ≥2mo after last vaccine dose + ≥6mo after HBIG (earlier = erratic). HBIG+vaccine same time, DIFFERENT sites. HBIG protection = temporary (3-6mo). Documented titer report only (verbal not acceptable). Unprotected HCW: baseline HBsAg + 6mo follow-up regardless of vaccination history.

Standard Precautions

Standard precautions are the baseline infection-control practices applied to every patient, every specimen, and every needle/sharp — regardless of whether any of them look infectious. This is the whole point of the concept: infection status is frequently unknown or asymptomatic, so precautions have to be universal rather than triggered by visible risk. The term replaced the older “universal precautions,” which covered only blood exposure via nonporous PPE (gloves, goggles, face shields); standard precautions deliberately broadens this to any body fluid, whether or not blood is visibly present.

The components of standard precautions are: hand hygiene; personal protective equipment; safe segregation and disposal of biomedical waste (including sharps); prompt cleaning of any spillage of infective material; disinfection of reusable patient-care items before reuse; environmental cleaning of surfaces and floors; safe sharps handling and disposal; and respiratory hygiene/cough etiquette.

Hand Hygiene

Hands are the principal vehicle for transmitting infection between patients in a healthcare setting, which makes hand hygiene the single most important infection-control measure available.

Hand rub (70–80% ethyl alcohol, or 0.5–4% chlorhexidine-based) needs at least 20–30 seconds of contact and evaporates on its own, so no separate drying is required. It’s indicated for routine care and ward rounds whenever a hand-hygiene opportunity arises — except when hands are visibly soiled, which requires washing instead.

Hand wash (antimicrobial soap, typically 4% chlorhexidine, or plain soap and water if unavailable) needs at least 40–60 seconds and is specifically indicated when hands are visibly soiled with blood/excreta/pus, before and after eating, after using the toilet, before and after a duty shift, and when caring for a diarrhoea patient.

Surgical hand scrub (3–5 minutes, 4% chlorhexidine) precedes any surgical procedure and is repeated between cases.

WHO’s “Five Moments for Hand Hygiene” define exactly when hand hygiene is indicated: before touching a patient, before a clean/aseptic procedure, after body-fluid exposure risk, after touching a patient, and after touching a patient’s surroundings.

Personal Protective Equipment (PPE)

PPE protects HCWs’ skin and mucous membranes from blood/body-fluid exposure, and protects patients from HCW-to-patient transmission during sterile procedures. Selection is driven by two factors: the level of contamination risk (a standard-precautions consideration) and the specific transmission route of a suspected organism — contact, droplet, or airborne (a transmission-based-precautions consideration). PPE must always be removed immediately once the indication for wearing it has passed.

Gloves protect both parties from hand-colonizing organisms. They’re indicated before sterile procedures, whenever blood/body-fluid contact is anticipated (even with sterile conditions in place, and including contact with non-intact skin/mucosa), as part of contact precautions, and — as heavy-duty gloves specifically — for biomedical waste handlers facing sharps risk. Gloves are not a substitute for hand hygiene: hand hygiene is still required before donning (prevents contaminating the gloves with the HCW’s own flora) and after removal (the warm, moist, occlusive environment under a glove is an ideal microbial breeding ground, and micro-tears can let organisms through during use). Gloves are single-use, changed between patients and between procedures on the same patient, and never wiped or washed while still worn.

Surgical (3-ply) masks are loose-fitting, single-use, and structured in three layers — an outer fluid-repellent layer, a middle melt-blown filter layer (unstandardized pore size, unlike N95), and an inner hydrophilic layer absorbing moisture. They’re used as standard precaution against splashes and as droplet-precaution protection, discarded after 4–6 hours or sooner if soiled/wet. A genuine practical pitfall: “hanging mask syndrome” — letting the mask dangle around the neck between uses — contaminates its inner surface and defeats the purpose.

N95 respirators protect against airborne organisms (M. tuberculosis being the classic example). “N95” means it filters ≥95% of airborne particles and has no oil resistance. Built from four layers (outer/inner spun-bond polypropylene, two middle cellulose/polyester melt-blown filter layers), it’s a negative-pressure device — pressure inside the facepiece drops below ambient during inhalation. It’s single-use, changed every 8 hours or sooner if clogged/wet/damaged, and requires a fit check every single time it’s donned (compressing the seal across face/cheeks/nasal bridge, then verifying both a positive-pressure seal on exhaling and a negative-pressure seal on inhaling) — no clinical activity proceeds until the fit check passes. Separately, fit testing (determining which size/style suits a given individual, and training them on donning/doffing) is done at joining and annually thereafter — a genuinely different, less frequent process from the fit check performed at every use.

Protective body clothing scales with contamination risk: laboratory coats (standard precaution for all lab staff, but not fluid-resistant), plastic aprons (fluid-resistant, single-use, low contamination risk), disposable gowns (long-sleeved, fluid-resistant, moderate risk), and coveralls (full-body including hood — reserved for anticipated large-volume splash risk like cardiac surgery, extensive skin contact risk like lifting an uncontrolled-diarrhoea patient, or handling high-mortality pathogens like Nipah or Ebola). Protective eyewear (goggles/face shields) guards against facial splash during procedures generating droplets or aerosols. Head covers are used when blood spillage is anticipated (major cardiac surgery); shoe covers/surgical slippers protect against floor organisms in ICUs/OTs, while gumboots specifically protect against anticipated sharps injury (biomedical waste handlers, laundry, housekeeping staff).

Donning and doffing sequence matters, and getting it backwards is a genuine transmission risk: donning goes gown → mask/respirator → goggles/face shield → gloves; doffing goes gloves → face shield/goggles → gown → mask/respirator — essentially the reverse order, removing the most contaminated items first. Doffing errors are considered a real contributor to HCW infections during outbreaks like COVID-19, precisely because a minor breach at this step directly exposes the HCW. All PPE is removed just before leaving the patient room, except the respirator, which stays on until after leaving and closing the door. Used PPE goes into the correct BMW bin: yellow for gown/coverall/mask/respirator/shoe cover/cap, red for plastic apron/goggles/face shield/gloves.

Blood Spill Management

Any blood or body-fluid spillage — from a few drops to several millilitres — must be treated as infectious and cleaned promptly, following a defined sequence: attend immediately → mark the spill area and post wet-floor signage → don PPE (gloves and gown) → confine and absorb the spill with a towel/cloth that solidifies it, then dispose as infectious waste → disinfect with freshly prepared hypochlorite (1:10 dilution/0.5%/5000 ppm for spills over 10 cm, 1:100 dilution/0.05%/500 ppm for smaller spills) → allow at least 10 minutes contact time → rinse with clean water to remove disinfectant residue.

Transmission-Based Precautions

Transmission-based precautions (TBPs) layer on top of standard precautions specifically when a patient is known or suspected to carry an organism with a defined transmission route — and precautions should start on clinical suspicion alone, before confirmation, discontinuing only if the suspected diagnosis is later ruled out. There are three types, matched to route: contact, droplet, and airborne.

Contact Precautions

Applied for organisms spreading by direct contact (contaminated hands are the most common transmission route in healthcare settings, or direct contact with an infected person’s blood/body fluids) or indirect contact (via a contaminated intermediate object — clothing, devices, surfaces). Agents include MRSA, CRE, VRE, MDR non-fermenting Gram-negative bacilli (Acinetobacter, Pseudomonas), conjunctivitis agents (adenovirus, gonococcus, Chlamydia), highly contagious skin lesions (Group A Streptococcus, staphylococcal, HSV), scabies, diarrhoea agents (rotavirus, cholera, C. difficile), and enterically transmitted hepatitis (A and E).

Measures beyond standard precautions: strict hand hygiene (since contaminated hands drive most contact transmission); gloves and gown as essential PPE on room entry, removed before leaving; single-use patient-dedicated equipment where possible; single isolation room preferred, or cohorting (grouping similar-infection patients together, or maintaining ≥3 feet spatial separation with privacy curtains) if unavailable; patient transport limited to medical necessity, with infected body areas covered; and daily room disinfection focused on frequently touched surfaces.

Droplet Precautions

Applied for organisms spreading via large respiratory droplets (>5 μm, generated by coughing/sneezing/talking), which require close contact (<3 feet) since they don’t remain airborne and travel only short distances — though they can also settle within 1 metre and cause secondary contact transmission via contaminated surfaces. Agents include diphtheria, H. influenzae type b, meningococcus, pertussis, pneumonic plague, Mycoplasma pneumoniae, group A streptococcal pharyngitis, seasonal influenza, SARS-CoV-2, viral haemorrhagic fevers (Lassa, Ebola, Marburg, Crimean-Congo), and mumps/parvovirus B19/rhinovirus/rubella/adenovirus.

Measures: hand hygiene (droplet transmission overlaps with contact transmission); surgical mask for the HCW on room entry or anticipated close contact, worn by the patient at all times, with the mask’s primary role being source control (blocking spread from the wearer outward) and its secondary role protecting the wearer — notably, N95 offers no additional environmental protection here and shouldn’t be used just for droplet precautions (it’s reserved for aerosol-generating procedures on droplet-precaution patients specifically); respiratory hygiene/cough etiquette (covering coughs/sneezes with a tissue or the inner elbow, never bare hands, disposing tissues into yellow bins, maintaining ≥1 metre social distance); single-room placement preferred (cohorting/spatial separation as fallback); limited transport with the patient masked; and daily surface disinfection.

Airborne Precautions

Applied for organisms transmitted via aerosols (<5 μm particles that remain suspended and travel on air currents) — M. tuberculosis, measles, varicella (chickenpox/zoster), smallpox/monkeypox, aerosolizable B. anthracis spores, and pulmonary aspergillosis. Aerosol-generating procedures (AGPs) — endotracheal intubation, open airway suctioning, tracheostomy care, CPR, sputum induction, bronchoscopy — generate far higher aerosol concentrations than ordinary coughing and warrant airborne precautions even outside a confirmed airborne-transmitted diagnosis.

Measures: N95 (or higher) respirator for the HCW, with fit-checking performed every single time; gloves/gown/eyewear as exposure risk warrants; placement in an airborne infection isolation room (AIIR), which combines adequate ventilation, UV germicidal irradiation, and filtration. Natural ventilation (fresh air via windows/doors) works best with door and windows positioned opposite each other and kept open — in a consultation room, the doctor should sit away from the natural airflow direction (downstream of the patient relative to airflow raises exposure risk); in wards, beds are positioned away from the door-window airflow path. Mechanical (negative-pressure) ventilation keeps room pressure below the surrounding area’s, so air flows in but not out, requiring ≥12 air changes per hour (ACH) in high-risk areas (TB wards, bronchoscopy rooms, MDR-TB clinics, airborne precaution rooms) versus 6 ACH in low-risk areas, a negative pressure differential >2.5 Pascal, a permanently closed door, and a preceding anteroom. Where ventilation alone is insufficient, wall-mounted UV germicidal irradiation (UVGI) supplements it, installed above 8 feet to avoid direct patient irradiation. Filtration exhausts room air outward via a properly fitted exhaust fan or HEPA filtration. Transport outside the negative-pressure room is limited to genuine necessity, with the patient masked, skin lesions covered, and the transporting HCW in full N95/PPE. Visitor/staff entry is restricted or requires PPE, and immune staff (e.g. those already immune to chickenpox) are preferentially assigned to airborne-precaution rooms when possible.

Needle Stick Injury (Occupational Exposure)

An occupational exposure covers more than the name “needle stick injury” implies: it includes percutaneous injury (needle or other sharp), mucous-membrane splash contact (eyes, mouth), non-intact-skin contact (abraded skin, dermatitis), and even prolonged (several minutes or more) intact-skin contact.

The three major blood-borne viruses transmitted this way, in decreasing order of transmission risk, are HBV (30%) > HCV (3%) > HIV (0.3%) — a hierarchy worth remembering precisely, since it inverts the popular assumption that HIV is the biggest needle-stick threat. Potentially infectious specimens include blood, genital secretions, and the major body fluids (CSF, synovial, pleural, peritoneal, pericardial, amniotic fluid); feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus are not considered infectious unless visibly blood-contaminated.

Risk of actually acquiring infection after exposure depends on: needle type (hollow-bore carries more risk than solid), visible blood contamination on the device, depth of injury, volume of blood involved, the source’s viral load at exposure, and — critically — how promptly first aid and post-exposure prophylaxis are started.

Prevention

Handling precautions: standard precautions (hand hygiene, PPE) for all blood/body-fluid contact; 0.5% sodium hypochlorite for work-surface disinfection; mandatory HBV vaccination for HCWs with documented protective titre; prompt spill cleanup; disposable needles only, never reused; never recap needles (if genuinely unavoidable, the single-hand scoop technique only); immediate disposal into the sharp box, never left on trolleys or bedside tables; and engineering controls (retractable lancets, safety-lock syringes, needleless IV systems) designed specifically to reduce injury risk.

Surgical precautions follow a “confine and contain” approach: sharp instruments passed by a pre-agreed, non-touch method between surgeon and assistant, never handed directly; needles picked up only with forceps/needle holder during suturing, never fingers, with blunt needles preferred for abdominal closure where practical. Preoperative blood-borne-virus testing is not mandatory and should only be done on clinical indication; for a patient known to carry a blood-borne virus, additional precautions (team-wide awareness, double gloves, a limited essential-staff team, and optionally scheduling the case last on the list) apply.

Post-Exposure Management

Management follows nine sequential steps:

1. First aid — started as early as possible: for splash injury, irrigate the site (eyes, mouth, exposed area) vigorously with water for at least 5 minutes; spit out and rinse the mouth repeatedly if fluid entered it; contact lenses stay in during irrigation, removed and cleaned normally afterward. Explicitly avoided: panicking, reflexively sucking the pricked finger, squeezing blood from the wound, or applying antiseptics/detergents to the site.
2. Report to the designated nodal centre — usually the HICC office, or a designated staff clinic/casualty department.
3. First dose of PEP for HIV, taken as early as possible — maximally effective within 2 hours, ineffective beyond 72 hours. NACO’s first-dose regimen: Tenofovir 300 mg + Lamivudine 300 mg (one tablet daily) plus Lopinavir 200 mg + Ritonavir 50 mg (two tablets twice daily). If the source’s HIV-negative status is already documented, the first dose isn’t required; if the result isn’t yet available, the first dose is given without waiting for it.
4. Testing for blood-borne viruses — anti-HIV, HBsAg, anti-HCV for both source and HCW (plus anti-HBs for a previously vaccinated HCW with untested titre), using a rapid test format with results in 1–2 hours. The HCW’s baseline status matters for later attribution — establishing whether a subsequent infection genuinely came from this exposure or a prior one, which also has real implications if the HCW later claims compensation.
5. PEP decision for HIV and HBV, based on standardized exposure/source-status coding (NACO for HIV, CDC for HBV — detailed below).
6. Informed consent and counselling — addressing the near-universal anxiety after exposure, explaining PEP risks/benefits; PEP is not mandatory, and a refusal should simply be documented after the risk has been explained.
7. Documentation — a structured proforma capturing exposure date/time/place, procedure type, exposure type and duration, source status, and specimen volume/type, plus a signed consent form for prophylactic treatment (or documented refusal).
8. Follow-up testing if source status is positive/unknown — HIV at 6 weeks, 3 months, and 6 months; HBV/HCV at 6 months.
9. Follow-up precautions, mainly during the first 6–12 weeks if source status is positive/unknown: no blood/semen/organ donation, sexual abstinence or condom use until both baseline and 3-month HIV tests are negative, no breastfeeding, and prompt medical evaluation for any febrile illness within 12 weeks.

HIV PEP — NACO Guidelines (2018)

PEP decisions combine an exposure code (EC) — EC-1 mild (small-volume/brief mucous-membrane or non-intact-skin contact), EC-2 moderate (large-volume/prolonged mucocutaneous contact, or superficial percutaneous injury with a solid needle), EC-3 severe (percutaneous injury with large volume transfer, hollow/wide-bore needle, deep puncture, visible blood on the device, or a needle used in a patient’s artery/vein) — with a source HIV status code (SC) — SC-1 (HIV-positive, asymptomatic, low viral load <400 copies/mL), SC-2 (HIV-positive, symptomatic/advanced/high viral load), or unknown.

PEP is not warranted if the source is HIV-negative (any exposure code), or for EC-1 + SC-1 specifically. It is recommended for every other positive-source combination, for 28 days, using the primary TL+LR regimen (same as the first-dose combination above) or the alternative TLE regimen (Tenofovir 300 mg + Lamivudine 300 mg + Efavirenz 600 mg, one tablet daily).

PEP is also skipped when: the exposed person is already HIV-positive (they’re referred to ART clinic instead, not given PEP); exposure was on intact skin only; the exposure involved a low-risk specimen (tear, saliva, urine, stool, vomitus, nasal secretion, sweat); source status is unknown in a low-HIV-prevalence area; or reporting was delayed beyond 72 hours (initiation becomes optional at that point, since efficacy is essentially gone).

Common side effects cluster by phase — nausea, diarrhoea, muscle pain, headache, fatigue early on; anaemia, leukopenia, thrombocytopenia later — and PEP should never be discontinued for side effects except jaundice or liver tenderness. Since efficacy depends on maintaining >95% compliance with the full 28-day schedule, counselling to manage side effects and sustain adherence matters as much as the regimen choice itself.

HBV PEP — CDC Guidelines (2013)

The decision tree depends on the HCW’s own vaccination and antibody status, crossed against the source’s HBsAg status:

• Fully vaccinated, protective titre (≥10 mIU/mL): no further treatment needed at all, regardless of source status or any later titre decline (memory B cells respond fast enough on re-exposure that booster doses aren’t needed even if titre has since fallen).
• Fully vaccinated, non-protective titre (<10 mIU/mL): if source is positive/unknown — HBIG dose 1 immediately (within 7 days) plus starting a second full vaccine series; if source is negative — just start the second vaccine series.
• Unvaccinated or partially vaccinated: if source is positive/unknown — HBIG dose 1 immediately (within 7 days) plus completing the vaccine series from the last dose given (never restart from scratch); if source is negative — just complete the existing series.
• Non-responders (two full 6-dose series completed, titre still non-protective): HBIG, two doses one month apart (0.06 mL/kg or 10–12 IU/kg), regardless of source status.

Practical notes: anti-HBs titre should only be checked ≥2 months after the last vaccine dose and ≥6 months after HBIG (checking earlier gives erratic results); HBIG and vaccine can be given simultaneously but at different injection sites; HBIG’s protection is temporary (3–6 months); a documented previous anti-HBs titre report is acceptable, but a verbal report is not; and any HCW who remains unprotected needs baseline HBsAg testing plus follow-up at 6 months regardless of vaccination history.

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