Needlestick Injury from a Source with HIV
At 09:20, a 26-year-old midwife at a health center sustains a needlestick while suturing a perineal tear. The glove was torn, and the hollow-bore needle went about 3 mm into her left index finger. The source is a 31-year-old woman who had no antenatal records and whose rapid HIV test is positive; her hepatitis B status is unknown. The midwife received two doses of hepatitis B vaccine three years ago but never had a post-vaccination antibody test. She has no PEP medicines at the health center, and the district hospital is one hour away by car. She is tearful, asks whether she should wash the wound with bleach, and says she is breastfeeding a 7-month-old infant.
1. What immediate wound care and reporting steps should be taken, and what should you tell her about bleach?
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Tell her not to use bleach; it damages tissue and does not reduce HIV transmission. Immediate care is to wash the wound thoroughly with soap and running water, allow it to bleed freely, and do not squeeze or scrub the wound. If there is mucous-membrane exposure, rinse with water or saline. Dry and cover with a simple dressing. Report immediately to the IPC focal point and document the time, type of needle, hollow-bore status, glove tear, depth, source patient's HIV and hepatitis B status, and the midwife's vaccination history. Send a rapid HIV test on the source if not already confirmed, but do not wait for the result to arrange PEP. Because PEP is not stocked at the health center, arrange urgent transport to the district hospital now. She should not express breastmilk from the injured hand until reviewed, but she can continue breastfeeding; HIV transmission through breastmilk is not increased by a needlestick, and her own HIV status must be checked. Offer emotional support and confidentiality.
2. Outline the HIV post-exposure prophylaxis and hepatitis B management, including timing.
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Start HIV PEP as soon as possible, ideally within 2 hours and no later than 72 hours after exposure. A standard adult regimen is tenofovir 300 mg + lamivudine 300 mg once daily + dolutegravir 50 mg once daily for 28 days, according to national guidelines. Take a baseline HIV test with consent, but do not delay PEP while waiting for the result. Explain adherence, possible nausea and headache, and the need to complete all 28 days. For hepatitis B: she has an incomplete vaccine series and unknown immunity. Give hepatitis B immunoglobulin and start or complete the vaccine series according to national schedule; if she has documented two doses, complete the remaining dose and later check anti-HBs. Because she is breastfeeding, reassure her that PEP and hepatitis B vaccine are not reasons to stop breastfeeding. Arrange follow-up HIV testing at 6 weeks, 3 months and 6 months, and monitor for seroconversion or drug toxicity.
3. What follow-up, prevention and documentation should the IPC focal point ensure?
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Ensure the midwife receives the first PEP dose before she leaves the district hospital and has a 28-day supply or a clear plan for refills. Give a written follow-up schedule for HIV testing, adherence review, side-effect check and hepatitis B vaccination completion. Advise her to return urgently for rash, jaundice, severe fatigue or other serious symptoms. The IPC focal point should complete the exposure report, keep it confidential, and notify the appropriate level without naming the source patient unnecessarily. Review why the injury happened: glove tear, suturing technique, needle recapping, and sharps disposal. Check that puncture-resistant sharps containers are available at the point of use, that staff are trained, and that PEP stock is accessible at the health center or via a clear emergency pathway. Offer psychological support and check that she is not pressured to continue unsafe work while distressed. Document the corrective actions and set a review date.