A Needle, a Cough and a Sister Who Is Busy
During a busy morning outpatient session at a district hospital in Barpeta, a 21-year-old nursing student recaps a 22-gauge needle after drawing blood from a man admitted with fever, weight loss and a chronic cough. The needle passes through the cap and pierces the pad of her left index finger, and a drop of blood appears at the puncture site. The patient's HIV status is unknown; he has never been tested, has had two episodes of herpes zoster in the past year, and has been losing weight for three months. The student had her first dose of hepatitis B vaccine as a child but cannot find any record of the remaining doses. The ward sister is busy with a cardiac arrest and tells her to wash it and get back to work.
1. What should the student do in the first five minutes, and what should she not do?
Read the worked answer
Do:
- Wash the puncture site with soap and running water for about a minute and let it bleed freely under the water. Do not scrub.
- Dry it and apply chlorhexidine or povidone-iodine, then cover with a waterproof dressing.
- Note the time, the needle gauge, the source patient and how deep the injury was, then report immediately to the designated officer, the ICTC or the employee health nurse. Speed matters, because post-exposure prophylaxis works best within two hours.
Do not:
- Squeeze, milk or suck the wound. This does not remove virus and damages tissue.
- Use bleach, spirit, kerosene or cautery.
- Wait until the end of the shift or until the sister is free.
- Take the source patient's blood for HIV without his consent, or discuss his status with other patients or staff.
The sister's instruction to wash it and get back to work is not a risk assessment. Comply with the washing, then escalate. A needlestick is a reportable occupational exposure and there should be an accident register to record it.
2. Carry out a risk assessment and set out the prophylaxis and baseline investigations needed for the student and the source.
Read the worked answer
Why this is a significant exposure: it is a percutaneous injury with a hollow-bore needle, visible blood, and a source whose weight loss, chronic cough and two episodes of herpes zoster in a year raise both HIV and tuberculosis. The average transmission risk per percutaneous exposure to HIV-infected blood is about 0.3%, higher with a hollow needle, visible blood and a deep injury. Hepatitis B is far more transmissible and survives longer on surfaces.
Source patient: explain the situation and request consent for HIV, HBsAg and anti-HCV testing. If he refuses, do not test covertly; start prophylaxis based on the risk assessment.
Student:
- Baseline HIV test with counselling, HBsAg and anti-HBs, anti-HCV, pregnancy test, full blood count, and renal and liver function before starting medicines.
- Post-exposure prophylaxis: a three-drug regimen such as tenofovir plus lamivudine plus dolutegravir, started as soon as possible and certainly within 72 hours, continued for 28 days, with adherence and side-effect counselling.
- Follow-up HIV testing at 6 weeks, 3 months and 6 months.
- Hepatitis B: if she is not immune, give hepatitis B immunoglobulin and start an accelerated vaccine course.
- Document in the accident register and incident report, and keep the source patient's identity confidential.
3. Three days later the source patient's HIV test comes back negative. What do you advise the student, and what does this episode say about the ward?
Read the worked answer
Interpret the result with care. A negative antibody test on day three reflects the source's status months earlier but does not exclude a very recent infection within the window period, and the interpretation depends on which assay was used. Ask the treating physician to review the whole picture. If the source has no risk factors, is clinically well and a fourth-generation assay is negative, prophylaxis may be stopped after discussion with the student; the decision belongs to the physician, not to the student alone. Continue hepatitis B follow-up regardless, and complete HIV testing at 6 weeks, 3 months and 6 months if the window period cannot be excluded. Give the advice in writing, check for side-effects and confirm the incident was reported.
What the episode says about the ward: recapping is the system failure, not the student's personal failing. She should not be blamed, transferred or discouraged from reporting. The ward should move to sharps containers at the point of use, ban recapping, provide a visible post-exposure protocol, and ensure the sister knows her role in releasing a colleague immediately for assessment. Confidentiality for the source patient must be maintained throughout.