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needlestick exposure
Not a great situation. I am currently feeling very torn. I am an emergency physician doing international work with Doctors without Borders in Cite Soleil, Haiti - the biggest slum and HIV capital of the Americas. Estimated prevalence about 6%. Yesterday very careless nurse (of which we have many I regret to say) had a 21G 1.5 inch needle in her hand that was formerly residing in an IV port 4 cm from the skin surface. As per DWB and other nurses I asked, there is the real possibility of reflux of blood (I have seen it many times) and that the needle was exposed. Anyway, while I was examining the patient the nurse, not paying attention (and already having left an uncapped needle on another bed that very day) stuck the needle square into my hand, the wound oozed blood and it was deep. We tested the patient - she was convulsing with eclamptic seizures and she was negative. I felt reassured but MSF recommended PEP nonetheless for a number of reasons 1) the nature of the wound 2) the window 3-6 months 3) the neighbourhood we work in is very hight risk and 4) Men in Haiti are EXTREMELY unfaithful and it is highly possible this woman's partner has had other recent partners who are high risk. All of this is well known. Moroever, if I did not take the PEP I would worry about my fiancee's risk as well - she means the world to me and I will do all I can not to put her at any risk. I have started PEP and under MSF's recommendations and my own concerns about side effects and being followed in my own healthcare system have been advised to return to Canada. However, I feel terribly guilty about leaving this place and mission where this is so much need. I know it is irrational and that I do have OCD/excessive guilt traits but I can't help but feel that I somehow have failed. I guess I would just like your thoughts.
MEDICAL PROFESSIONAL
Welcome to the forum.
First and foremost, if the MSF colleagues advising you on the scene are legitimate HIV experts, you should follow their advice. Do not rely exclusively on this or any other online forum.
My personal judgment is that I would not generally recommend PEP in this situation, i.e. when the source of the contaminated sharp instrument has tested negative for HIV. Even in a country like Haiti, with very high sexually transmitted HIV infection rates, the statistical likelihood of infection in a person with a negative antibody test -- i.e. that your patient was in the window period before positive test results -- is very, very low.
A middle ground solution would be to begin PEP, while arranging for a virological test of the patient, i.e. a PCR test for HIV RNA/DNA. My understanding is that these tests are available in Haiti -- although depending on local lab resources, perhaps a specimen would have to be referred to a lab in Canada, the US, or elsewhere. In the meantime, you could initiate PEP for a few days until that test result is available, then discontinue it when you get the negative result.
As for leaving Haiti on this account, strictly from an HIV risk standpoint I see no need for that. If your anxieties about all this are affecting your work performance, perhaps that's the best approach. But I don't think you should make this decision without careful consideration, and without discussing it with trusted professional colleagues in person. Of course you should also respect your wife's opinion and advice -- but also please make sure she understands that the chance you have acquired HIV from the needlestick are very, very low.
Thanks for your humanitarian work in a part of the world that needs the kind of services you are providing.
Regards-- HHH, MD
I hope this has been helpful.
First and foremost, if the MSF colleagues advising you on the scene are legitimate HIV experts, you should follow their advice. Do not rely exclusively on this or any other online forum.
My personal judgment is that I would not generally recommend PEP in this situation, i.e. when the source of the contaminated sharp instrument has tested negative for HIV. Even in a country like Haiti, with very high sexually transmitted HIV infection rates, the statistical likelihood of infection in a person with a negative antibody test -- i.e. that your patient was in the window period before positive test results -- is very, very low.
A middle ground solution would be to begin PEP, while arranging for a virological test of the patient, i.e. a PCR test for HIV RNA/DNA. My understanding is that these tests are available in Haiti -- although depending on local lab resources, perhaps a specimen would have to be referred to a lab in Canada, the US, or elsewhere. In the meantime, you could initiate PEP for a few days until that test result is available, then discontinue it when you get the negative result.
As for leaving Haiti on this account, strictly from an HIV risk standpoint I see no need for that. If your anxieties about all this are affecting your work performance, perhaps that's the best approach. But I don't think you should make this decision without careful consideration, and without discussing it with trusted professional colleagues in person. Of course you should also respect your wife's opinion and advice -- but also please make sure she understands that the chance you have acquired HIV from the needlestick are very, very low.
Thanks for your humanitarian work in a part of the world that needs the kind of services you are providing.
Regards-- HHH, MD
I hope this has been helpful.
MEDICAL PROFESSIONAL
Good luck to you.
Also, thanks for your answers. I pretty much agree with your analysis of things re: HIV risk but I did look up some guidelines including a Canadian city's occupational exposure protocol and the AETC guidelines...in my case where the source is tested as negative, they generally recommend no prophylaxis EXCEPT if the source as any recent risky exposure and here it is, from my own experience, EXTREMELY hard to know. 25% of my patients at the hospital in our IM ward are HIV positive and I can tell you with certainty that people here just don't talk about HIV. They don't talk about risks, physicians ask about it only cryptically, patients refuse to answer questions - it is like "black magic." And so the possibility that she was exposed in the last 8 or so weeks - couple with the very high rates of infidelity - is I agree incredibly small but I am not convinced it is 0. And I guess that is a major part of the basis for MSF's reasoning. Thanks again, that will be my last comment as I know you have other things to attend to.
I had the advice of two doctors, who serve as the doctors for international workers. I don't know what their expertise specifically on HIV is but it must be something significant as they see these things all the time and have protocols approved by MSF. I was ready upon arriving at the appointment for them to tell me all was well and I had no worries. They didn't quite do that, saying they still recommended prophylaxis.
There is no doubt that I am very tired and drained and yes that played a role. I would have been fine had this not happened. But it did and I thought carefully about if I take the ARVs - and I have been formally advised by my employer to do so and forfeit all rights to insurance should anything ever just somehow come back positive - do I want to be in the dissarrayed health system of Haiti and do I want to be doing the already gruelling work with now the added side effects of ARVs. My colleague took it a few months ago and she said it was horrible and had she to do it again she would go home. I want to be followed in a medical system I trust while on these and I felt as well that I can handle alot but only so much...add nausea, fatigue, diarrhea (some of which I am already experiencing) onto all the other stuff and it was a potential recipe for burnout. Therefore we decided together that a return to Canada was best with MSF recommending me highly for a future mission. I don't know if this was the right or best choice - I have a lot of doubts (I almost always do). I guess I just hope it was reasonable and understandable.
There is no doubt that I am very tired and drained and yes that played a role. I would have been fine had this not happened. But it did and I thought carefully about if I take the ARVs - and I have been formally advised by my employer to do so and forfeit all rights to insurance should anything ever just somehow come back positive - do I want to be in the dissarrayed health system of Haiti and do I want to be doing the already gruelling work with now the added side effects of ARVs. My colleague took it a few months ago and she said it was horrible and had she to do it again she would go home. I want to be followed in a medical system I trust while on these and I felt as well that I can handle alot but only so much...add nausea, fatigue, diarrhea (some of which I am already experiencing) onto all the other stuff and it was a potential recipe for burnout. Therefore we decided together that a return to Canada was best with MSF recommending me highly for a future mission. I don't know if this was the right or best choice - I have a lot of doubts (I almost always do). I guess I just hope it was reasonable and understandable.
MEDICAL PROFESSIONAL
See above. Actually, I think "negligible" is a more accurate characterization of the HIV risk than "low". But as I said, I defer on that assessment to local experts on the scene.
If you have been medically advised by your employer that you should return to Canada, perhaps that's the best option. But I have to wonder whether s/he made that recommendation more because of your emotional state and work effectiveness than because of a real risk for HIV. Beyond that, I cannot advise you on that aspect of this problem. My advice has to be limited to the issues of HIV risk and prevention, nothing more. Maybe it would be helpful to show this discussion to both your employer and your wife, but that's as far as this forum can go.
If you have been medically advised by your employer that you should return to Canada, perhaps that's the best option. But I have to wonder whether s/he made that recommendation more because of your emotional state and work effectiveness than because of a real risk for HIV. Beyond that, I cannot advise you on that aspect of this problem. My advice has to be limited to the issues of HIV risk and prevention, nothing more. Maybe it would be helpful to show this discussion to both your employer and your wife, but that's as far as this forum can go.
I was thinking maybe I didn't explain what is going through my mind quite well. The possibility of HIV exposure for me, I do think, is very low- not negligible but low. I am very tired after having slogged away here for 11 weeks in brutal heat, smelly and unhygenic conditions and 6 long days a week with little rest. But my mission is only half-done and I am of course very excited about being able to see my fiancee again and being home. So I worry that maybe I "know" rationally I don't need the meds but am taking them because with them I need to be back in Canada. But the facts are a) I have been medically advised my my employer - an international expert in this issue b) I refuse to put my spouse at risk c) I don't want to be in Haiti when and if the nausea, vomiting, diarrhea etc. come and I feel horrible and d) as my spouse said - if this was me you would insist I come home so why do you think it is different for you? You have a lot of respect for the organisation - why aren't you listening to them?...Anyway, sorry to blab on, it has been a hard and stressful 2 days and I guess I just want to know if I am overreacting or 'copping out' by taking the meds and heading back to Canada for solid surveillance.
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