A prospective study of children with community‐acquired needlestick injuries in Melbourne

5 February 2002 Dear Editor Much anxiety exists within Australia regarding seroconversion to blood borne viruses following community-acquired needlestick injuries (NSI). Only half of over 2 million syringes dis­tributed to injecting drug users (IDUs) in Melbourne are returned.1 Limited data are available on the incidence of community-acquired NSI and the risk of seroconversion to HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) following community- acquired NSI (Table 1). There is one case report of a child contracting HBV following a community-acquired NSI. This child was also exposed to HIV but did not seroconvert.6 We performed a study to document the transmission of HIV, HBV, or HCV in children with community-acquired NSI seen at the Royal Children’s Hospital (RCH), Melbourne. We prospectively followed all children with community-acquired NSI seen at RCH over 32 months and documented the provision of HBV prophylaxis and serological follow up at 3 and 8 months post injury. If general practitioner (GP) follow up was arranged, telephone calls were made to document completion of HBV vaccination, if required, and serology. Fifty cases of community-acquired NSI were identified. Thirty-six were tested at least 3 months post-injury and there were no seroconversions to HIV, HBV, or HCV. No HIV post-exposure prophylaxis was given. Children who were not immune to HBV and were reviewed within 72 h of injury received hepatitis B immunoglobulin. The first HBV vaccination was administered in 41/42 non-immune cases. Forty-two cases had follow up arranged at RCH 3 months post-injury, 34 of whom attended and had blood taken. Six cases had follow up arranged with their GP, 2 of whom attended and had blood taken. No review was arranged for two cases, including a child who refused venepuncture. Seventeen of 50 cases had blood taken at least 8 months post-injury. Of these, 15/50 cases attended RCH and had blood taken, six were booked to clinic but failed to attend. Two of 50 cases attended their GP and had blood taken and 13 cases were asked to go to their GP but failed to attend. Completion of three doses of HBV vaccine was achieved in 22/42 non-immune cases. The median age of injury was 6.9 years (1.8−14.3 years). 32/50 cases were boys. Thirty per cent of the children sustained their injury in a public park, 18% in a street, 6% at the beach, and 5% in a carpark. This report confirms that the risk of seroconversion to HIV, HBV, or HCV from a community acquired NSI is low, which is consistent with other studies2-6 with the exception of one case report of a child contracting HBV.6 The incidence of HIV, HBV, and HCV in Victorian IDUs is 0.2, 1.8, and 10.7 per 100 person years, respectively.7 The estimated risks of transmitting HIV, HBV, and HCV from occupational NSIs from known positive donors are 0.4%, 6−30%, and 0−7%, respectively.8 The potential risk of acquiring HIV from community acquired NSIs is probably lower (1 per 106−1 per 4000).8 However, HIV-1 can remain viable in a syringe for four weeks.9 The transmission of HBV and HCV is probably higher as the prevalences of these infections are higher; there are higher viral titres in blood, and longer survival of these viruses in the environment. HCV and HBV can survive for up to 5 weeks and 12 months, respectively.9 Almost half of the NSI in this cohort occurred in public places for recreation, consistent with previous studies.4, 5,10 This has important public health implications. This is a small number of NSI reported compared with the large number of visitors each year to these public places. However, it is likely that many cases are unreported. The sample of 50 children in this study, seen in the emergency department over 32 months, may underestimate the true incidence of these injuries. Parents may seek medical advice elsewhere. In addition, undisclosure by children, and/or their parents, of a NSI would compound this. Some children were lost to follow up despite their parents being given written documentation of the dates of follow-up serology and subsequent HBV vaccinations. In addition, detailed letters are sent to their general practitioners. Parents may have been over-reassured that the risk of seroconversion was so low that they were unwilling to subject their child to another painful procedure. We would recommend that continued surveillance of ­community-acquired NSIs is required. Follow up is important with reassurance to the families of the low risk of seroconversion. However, HBV prophylaxis and serologically testing is important in the management of these injuries. We would like to thank all the staff in the immunisation clinic at RCH, Nigel Kelly, and Peter Barnett for data extraction.