The Deadly "Sins" of Vaccinations: Avoiding Bloodborne Diseases
As pharmacists administer more vaccines, the risks of needle-stick injury and transmission of a bloodborne disease increase among pharmacists.
Pharmacists can now administer all vaccines in 45 states, 27 of which impose no patient age restrictions.1 In addition, during the 2014-2015 flu season, American retail pharmacists administered 25% of adult and 5% of pediatric flu vaccines of the 147 million doses administered nationwide.2,3
As pharmacists administer more vaccines, the risks of needle-stick injury (NSI) and transmission of a bloodborne disease increase among pharmacists. Researchers at the Centers for Disease Control and Prevention found the incidence of NSIs increased from 0 to 5.65 per 1000 immunizing pharmacists after 1 chain pharmacy started administering vaccinations.4 Although the incidence of NSIs among pharmacists may seem low, only half are likely reported.5-7 In addition, just 1 exposure is needed to transmit dangerous pathogens such as HIV, hepatitis B virus (HBV), or hepatitis C virus (HCV).8 Most NSIs can be prevented, however, by following the Department of Labor’s Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogens Standard.9 Other ways to prevent bloodborne diseases include avoiding the following potentially deadly “sins.”
Two of the 3 most common bloodborne pathogens, HIV and HBV, are transmitted primarily through sexual contact (Table 110-18).10,11 HBV is 50 to 100 times more infectious than HIV and can survive on surfaces for up to 7 days.12,13 HIV’s prevalence is increasing most rapidly, however, at 50,000 new cases annually, although it is the least pathogenic.14 HCV, meanwhile, is the most prevalent bloodborne pathogen in the United States and is spread primarily through intravenous drug use.15,16 Although chronic HCV infection is now curable, treatment can be prohibitively expensive.17,18
Prevention is the best way to block transmission of bloodborne diseases. Preventive measures are so important that Congress’s Needlestick Safety and Prevention Act of 2000 mandates them.19 The act mandates OSHA to enforce Title 29 of the Code of Federal Regulations §1910.1030: the Bloodborne Pathogens Standard. The law applies to all employees with occupational exposure to blood or other potentially infectious materials, including pharmacists who handle sharps, needles, and syringes during the vaccination process. The law establishes 5 general requirements (Table 219). When implemented consistently, these requirements prevent occupational exposure to bloodborne disease.
Pharmacies and pharmacists should avoid time- and money-saving shortcuts. Although reusing gloves, overfilling sharps containers, and storing food in the vaccine refrigerator may be convenient, these actions endanger employees and patients. Immunizing pharmacists’ other dangerous and illegal habits may include removing needle caps with the teeth and storing sharps containers near nonhazardous trash. Filling the syringe behind the counter, recapping the needle, then immunizing the patient over the counter is also improper, even when using retractable needles. Pharmacists should note there is little evidence to show retractable needles reduce incidences of NSIs compared with standard needles.20
Do not tough out an NSI! If percutaneous injury, mucous membrane exposure, or nonintact skin exposure occurs, wash the wound with soap and water and flush the mucus membrane with water.21 The risk of contracting disease from an NSI ranges from 0.09% to 31% (Online Table 321-22).22 Post-exposure prophylaxis (PEP) treatment for HIV with tenofovir, emtricitabine, and raltegravir has an 81% success rate when administered within 72 hours and is well tolerated.22 Although there is no PEP for HCV, follow-up HCV antibody testing is recommended at 4 to 6 months after the NSI. PEP is only required for employees unvaccinated against HBV; for these employees, concomitant administration of the HBV vaccine and hepatitis B immunoglobulin prevents HBV infection in 85% to 95% of cases.22 Any NSI should always be documented in the sharps injury log.9
Table 3: Risk of Transmission from a Needle-Stick Injury
Risk of Transmission
Post-Exposure Prophylaxis Efficacy
HIV: mucous membrane exposure
81%; no case of occupationally acquired HIV has been reported since 2008
HIV: percutaneous exposure
81%; no case of occupationally acquired HIV has been reported since 2008
HCV: percutaneous exposure
HBV: surface-antigen positive
HBV: surface-antigen negative
HBV = hepatitis B virus; HCV = hepatitis C virus; HIV = human immunodeficiency virus.Adapted from References 21-22.
As pharmacists administer vaccines, safety rules are vital and continuous training and vigilance are necessary. If you see unsafe or illegal conditions in your pharmacy, notify your supervisor or file a complaint with OSHA. Consult OSHA’s quick reference guide at www.osha.gov/SLTC/bloodbornepathogens/ bloodborne_quickref.html. For urgent postexposure questions, call the University of California, San Francisco Clinician Consultation Center’s PEPline at (888) 448-4911.23 Knowledge—and a little virtue—go a long way toward preventing a bloodborne illness.
Dr. Gaudette is a doctor of pharmacy and master of business administration candidate at the University of Connecticut and is a certified immunizer.
- Number of states/territories. American Pharmacists Association website. www.pharmacist.com/sites/default/files/files/Pharmacist_IZ_Authority_1_31_15.pdf. Accessed June 23, 2015.
- Seasonal influenza vaccine & total doses administered. Centers for Disease Control and Prevention website. www.cdc.gov/flu/professionals/vaccination/vaccinesupply.htm. Updated February 17, 2015. Accessed June 23, 2015.
- National early season flu vaccination coverage, United States, November 2014. Centers for Disease Control and Prevention website. www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2014.htm. Updated December 11, 2014. Accessed June 23, 2015.
- de Perio MA. Needlestick injuries among employees at a nationwide retail pharmacy chain, 2000-2011. Infect Control Hosp Epidemiol. 2012;33(11):1156-1158. doi: 10.1086/668033.
- Lauer AC, Reddermann A, Meier-Wronski CP, et al. Needlestick and sharps injuries among medical undergraduate students. Am J Infect Control. 2014;42(3):235-239. doi: 10.1016/j.ajic.2013.08.013.
- Quinn MM, Markkanen PK, Galligan CJ, et al. Sharps injuries and other blood and body fluid exposures among home health care nurses and aides. Am J Public Health. 2009;99(suppl 3):S710-S717. doi: 10.2105/AJPH.2008.150169.
- Stop Sticks: campaign user’s guide and resources. Centers for Disease Control and Prevention - The National Institute for Occupational Health and Safety website. www.cdc.gov/niosh/stopsticks/. Updated June 24, 2011. Accessed June 23, 2015.
- Bloodborne pathogens and needlestick prevention. Occupational Health and Safety Administration website. www.osha.gov/SLTC/bloodbornepathogens/. Accessed June 23, 2015.
- Title 29 CFR 1910.1030: bloodborne pathogens. Occupational Health and Safety Administration website. www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051. Accessed June 23, 2015.
- Gitlin N. Hepatitis B: diagnosis, prevention, and treatment. Clin Chem. 1997;43(8 pt 2):1500-1506.
- Rom W, Markowitz S. Environmental and Occupational Medicine. 4th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins. 745.
- Hepatitis B general fact sheet. Centers for Disease Control and Prevention website. www.cdc.gov/hepatitis/HBV/PDFs/HepBGeneralFactSheet.pdf. Published June 2010. Accessed June 23, 2015.
- Emergency preparedness, response: hepatitis B. World Health Organization website. www.who.int/csr/disease/hepatitis/whocdscsrlyo20022/en/index1.html. Accessed June 23, 2015.
- HIV in the United States: at a glance. Centers for Disease Control and Prevention website. www.cdc.gov/hiv/statistics/basics/ataglance.html. Updated May 11, 2015. Accessed June 23, 2015.
- Hepatitis C FAQs for the public. Centers for Disease Control and Prevention website. www.cdc.gov/hepatitis/hcv/cfaq.htm#cFAQ31. Updated May 31, 2015. Accessed June 23, 2015.
- Hepatitis C: the facts. US Department of Health and Human - Office of Population Affairs website. www.hhs.gov/opa/pdfs/hepatitis-c-fact-sheet.pdf. Updated October 19, 2012. Accessed June 23, 2015.
- Faster, easier cures for hepatitis C. US Food and Drug Administration website. www.fda.gov/ForConsumers/ConsumerUpdates/ucm405642.htm. Published July 28, 2014. Updated February 26, 2015. Accessed June 23, 2015.
- Hiltzik M. High cost of hepatitis drug reflects a broken pricing system. LA Times website. www.latimes.com/business/hiltzik/la-fi-hiltzik-20150621-column.html#page=1. Published June 19, 2015. Accessed June 23, 2015.
- Needlestick Safety and Prevention Act: 106th Congress Public Law 430. US Government Printing Office website. www.gpo.gov/fdsys/pkg/PLAW-106publ430/html/PLAW-106publ430.htm. Published November 6, 2000. Accessed June 23, 2015.
- Lavoie MC, Verbeek JH, Pahwa M. Devices for preventing percutaneous exposure injuries caused by needles in healthcare personnel. Cochrane Database Syst Rev. 2014;3:CD009740. doi: 10.1002/14651858.CD009740.pub2.
- Stop Sticks campaign: sharps injuries: what to do following a sharps injury. Centers for Disease Control and Prevention - The National Institute for Occupational Health and Safety website. www.cdc.gov/niosh/stopsticks/whattodo.html. Updated September 28, 2010. Accessed June 23, 2015.
- Kuhar DT, Henderson DK, Struble KA, et al; US Public Health Service Working Group. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013;34(9):875-892. doi: 10.1086/672271.
- PEP quick guide for occupational exposures. University of California, San Francisco, Clinician Consultation Center website. http://nccc.ucsf.edu/clinical-resources/pep-resources/pep-quick-guide/. Updated December 2, 2014. Accessed June 23, 2015.