Needlestick injury after perineal repair with an unknown source
A midwife at a soum hospital has just repaired a second-degree perineal tear. While disposing of the suture needle, she sustains a deep needlestick injury through her left glove into the index finger; the wound is bleeding. The patient is a 19-year-old woman who received no antenatal screening for HIV, hepatitis B or hepatitis C; her hepatitis B status is unknown. The midwife completed a three-dose hepatitis B vaccination series 8 years ago but has never had an anti-HBs titre checked. The hospital has a needlestick protocol, but the nearest HIV testing and post-exposure prophylaxis are at the aimag hospital, 4 hours away. It is 16:00 and the last bus has left.
1. What immediate wound care and risk assessment would you do?
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Wash the wound with soap and running water, allow it to bleed freely, and do not squeeze or milk the wound. Apply an antiseptic such as povidone-iodine or chlorhexidine and cover it. Do not use bleach or caustic agents. Record the time, the device, the depth of injury, whether the needle was hollow or solid, the presence of visible blood, and the source patient's known or unknown status.
Risk is increased by a deep percutaneous injury, visible blood on the device, a hollow-bore needle, and a source with a high viral load. A suture needle is solid, which lowers risk compared with a hollow needle, but this is still a significant exposure. The source patient's hepatitis B status is unknown, and the midwife's immune status is unknown despite vaccination. Both gaps must be closed urgently, not assumed.
2. What hepatitis B and HIV post-exposure management would you arrange, given the unknown source and distance?
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For hepatitis B, take blood from the midwife for anti-HBs and from the source patient for HBsAg if she consents. If the source is HBsAg-positive or cannot be tested, give hepatitis B immunoglobulin and a booster dose of vaccine within 24 hours, preferably within 12 hours, because the midwife's protection is unknown. If anti-HBs is later shown to be protective, further doses may not be needed, but do not delay the first dose while waiting for results.
For HIV, assess whether the source has risk factors or is from a high-prevalence group. If the source is unknown or HIV-positive, start HIV post-exposure prophylaxis as soon as possible, ideally within 2 hours and no later than 72 hours, with a 28-day regimen such as tenofovir, lamivudine and dolutegravir. Arrange urgent transport to the aimag hospital or call the provincial HIV focal point; do not wait for the next bus. Baseline HIV testing of the midwife should be done with consent and confidentiality.
3. What reporting and follow-up should be completed?
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Report the injury immediately to the hospital director and infection-control focal point, and complete the needlestick register: date, time, ward, device, source, immune status, action taken and follow-up plan. The source patient should be counselled and tested confidentially, with consent, and must not be identified in the register beyond what is clinically necessary. The midwife should be offered psychological support and temporary modification of duties if she is anxious or unwell.
Follow up at 6 weeks, 3 months and 6 months for HIV and hepatitis serology according to protocol, and check anti-HBs after vaccination. Monitor for acute hepatitis symptoms. Review the incident to identify prevention failures, such as a poorly placed sharps container or unsafe recapping, and correct them. Document that PEP was started within the window and that follow-up appointments were given.