The Deadly "Sins" of Vaccinations: Avoiding Bloodborne Diseases

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 1^10-18).^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.

Greed

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

Pride

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 3^21-22).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

Pathogen

Risk of Transmission

Post-Exposure Prophylaxis Efficacy

HIV: mucous membrane exposure

0.09%

81%; no case of occupationally acquired HIV has been reported since 2008

HIV: percutaneous exposure

0.3%

81%; no case of occupationally acquired HIV has been reported since 2008

HCV: percutaneous exposure

1.8%

Not recommended

HBV: surface-antigen positive

22%-31%

85%-95%

HBV: surface-antigen negative

1%-6%

85%-95%

^{HBV = hepatitis B virus; HCV = hepatitis C virus; HIV = human immunodeficiency virus.Adapted from References 21-22.}

End Note

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.
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