[Question #2024] PPD

93 months ago

Dear Drs.,

Yesterday (4/21/17) afternoon during a routine PPD, the nurse recapped the needle before administering the injection to me. Upon being concerned the following day (today) about the fact that the nurse recapped the needle before injecting me, I asked and the nurse said that they did not stick themselves by mistake. Is it possible in your experience that people could stick themselves and not be aware? Should I be concerned that the nurse recapped the needle before administering the injection to me? Could I have been exposed to any blood-borne infections in light of nurse recapping the needle before injecting me? And if so, would you recommend any post-exposure prophylaxis or any further steps I should take? Thank you so much for your help.

93 months ago

Just to clarify, the nurse drew up the PPD fluid for the test in the needle, then recapped the needle and set it down to prepare my arm, and then uncapped the needle to do the injection. I am worried about the part of the process when the nurse recapped the needle as it was prior to injecting the fluid into my arm.

H. Hunter Handsfield, MD

93 months ago

Welcome to the forum. thanks for your question.

Standard procedure is that needles are not recapped after drawing blood or giving a patient an injection. However, there is no recommendation that recapping not be done after drawing up PPD antigen (or any other medication), and in any case the recommendation against recapping has nothing to do with protecting the patient. The sole purpose of not recapping is to protect the provider after the needle has been used on a patient. The only ways you could have been at risk is if the needle had been used on a previous patient before it was used for your PPD; or in theory if the nurse (or other nurses) had previously used a needle on a patient, then used the same needle to draw up PPD antigen or other medication, then drew up that medication (with either the same needle or a fresh one). There is no reason to suspect either of these scenarios. I definitely do not recommend PEP -- indeed, I doubt you could find a physician willing to prescribe it. Also there are no other "steps you should take" -- for example, you don't need to have a blood test for HIV or any other blood borne infection.

And no, it is pretty much impossible that the nurse stuck herself with the needle and didn't know it. Or that she covered it up and lied to you if she did.

I hope this has helped. Please let me know if anything isn't clear.

HHH, MD

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92 months ago

Dr. HHH,

Thank you so much for your help! You greatly alleviated my concerns and your answers were most helpful. Everything checked out a-ok at the health office regarding my PPD. I am hoping to ask just a few more questions while I have the chance.

I sometimes worry about infectious disease risk while grocery shopping. Specifically, if I see a red spot on a food container or on a piece of fruit for example, or on meat, what is the risk of infectious disease transmission (HIV or hepatitis)? Along those lines, is there any risk of transmission to me of an infectious disease from the person ringing up the grocery items I am buying to me? For example, if I see or touch a bandaid on their finger or a red spot on the counter? I was worried about any risks if the red spot touches the food I am going to eat. Also, if I see someone with a bandaid or gauze or open wound and I walk near them with my food is there any risk of blood getting on my food or transmission of disease? I am a young healthy adult, and the reason I am worried so much about this is because I live in a US city with particularly high rates of HIV and this has escalated my concerns about possible random exposure either by touching an iffy area on the clerk’s hand, or a random red spots as I mentioned above. Could you comment on any HIV and hepatitis risks or risks of any other infectious diseases. Lastly, along those lines, I also worry if I have a scratch or open wound that touches a questionable red spot or near a bandaged area on another person is there a risk to me?
I am going to be working in a hospital and I am wondering about infectious disease transmission when performing a physical exam on a patient? Or is there a risk when examining a patient and for example touching their arm near where the IV is in their arm? Although I will receive training, I greatly value your thoughts and wisdom as an expert, about ways to stay safe in a hospital setting. Thank you so much for any pointers!
One time several years ago I borrowed a spring-type gadget to check my blood sugar (my sugar is normal). I used a new needle (lancet) but the spring-gadget was someone else’s and was not wiped off prior to my using it. I did not notice any obvious blood spots on the spring gadget that holds the lancet. It is used by someone else with very high ferritin levels. Specifically, I am wondering if there is any risk of hepatitis C transmission, as I read an article finding hepatitis C transmission among nursing home residents when spring-type blood sugar monitors are shared even when lancets are new (but I don’t remember all of the details of the study). I am immunized against hepatitis B but I am just concerned about hepatitis C.

Thank you so much again for your time and help!

H. Hunter Handsfield, MD

92 months ago

Thanks for the thanks. I'm happy to have helped. In response to these follow-up questions:

1,2) In the earliest days of the HIV/AIDS epidemic, health authorities were able to reassure the public that infection is transmitted only by intimate contact or direct blood contact, e.g. by needle sharing. There were no patients who didn't have these risk factors. That remains the case today: after 30+ years and millions of cases, nobody shows up in the busiest HIV/AIDS clinics who didn't have obvious risk factors. Those who claim otherwise are few, and they are virtually always proved to be wrong -- either because they denied obvious risk factors, or they were unaware of risks (think of the spouse who doesn't know his/her partner is bisexual or an injection drug user). If less intimate contact (shaking hands, being served by infected waiters, exchaning money at cash registers) could transmit infection, or if it were possible to catch it from exposure to the virus in the environment, there would be many more people without established risk factors than there are. And there is no increased frequency of infection people who work in health care settings, regardless of how many HIV infected patients there are in such clinics, hospitals, etc. (Health care workers themselves can be infected by injurty with contaminated instruments etc, but even these cases are very rare -- and do not come from simply being around HIV infected people or in their environment.) The same issues apply to other blood borne infections, like hepatitis B and C. The sorts of exposures you describe simply do not result in infection.

3) I'm skeptical about the study you cite showing that sharing sptring loaded lancets clearly explain hepatitis C transmission. If it happened, I have to assume there was some sort of special circumstance. In any case, it is universally recommended that such devices not be shared, even though they are designed to be pretty safe if someone screws up and has a previously used one. In any case, I see no reason to be concerned about the event you describe from several years ago.

You're obviously something of a germophobe. I get the sense that although you have concerns, this doesn't seem to be seriously dominating your life or happiness. If I am wrong, or if your fears continue to grow and they are indeed interfering with life, please seek professional counseling. Sometimes this is an early sign of serious mental health disability. (For an excellent example of how bad it can get, see The Avaitor, the film biography of Howard Hughes -- which by the way is a great movie, with Leonardo DiCaprio and Cate Blanchett.) In the meantime, use your obviously substantial intellect to overrule your gut fears.

I hope that helps. Best wishes.

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92 months ago

Hi Dr HHH,

I am most grateful for your very educational and insightful comments. I have no more specific questions so I thought I could devote my last question if you could share pearls of wisdom about staying safe as a medical provider. I will have ample resources and supervision but I thought, why not ask the expert while I have the chance! I'm most humbled to have this chance to ask if you have dos and dont's you could share, even briefly. You are a great role model and thank you again!

H. Hunter Handsfield, MD

92 months ago

1Thanks for the thanks; that's why we're here. However, what you ask now is a tall order: it would take a long essay to answer in detail. You can find plenty of online advice about safer sex to prevent HIV and other STDs. But here's a short version, copied from a response to a similar question a few days ago:

So what are the guidelines for "common sense" prevention? One size doesn't fit all. But you can select partners introduced by friends or in other social situations, as opposed to bar pick-ups and one night stands. Use condoms consistently unless and until mutual commitment is assured, and at that time perhaps get tested (along with your partner) for common STDs. Avoid sex when either partner has symptoms typical for many STDs, such as genital discharges, sores, or, for women, abnormal genital odors. Discuss risks and expectations with partners: if both acknowledge past partners, and therefore at least a slight possibility of infection (if not tested recently), then in the event an STD shows up, the discussion about it shouldn't be all that stressful.

I hope that helps get you started. Best wishes and stay safe.

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