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By Amber Hogan Mitchell, DrPH, MPH, CPH and Ginger B Parker, MBA
November is National Diabetes Awareness Month sponsored by the American Diabetes Association (ADA). Diabetes is a critical underlying chronic disease with important considerations not just with regard to infection prevention and control and patient safety, but also in the management of infectious disease and occupational safety and health.
Today, approximately 30.3 million Americans have diabetes – that is 1 in 11 people – and each year onset and incidence increases as Americans grow in size (weight) and in their addiction to carbs, refined sugars, and inactivity. In fact, the U.S. Department of Health and Human Services and the ADA estimate that about 86 million adults in the U.S. are at high risk of developing type 2 diabetes (CDC 2017, DHHS 2017). This is an almost 400 percent increase from 1988, i.e. in less than one generation!
The harsh reality of a nation with increasing incidence of type 2 (adult- or adolescent-onset) diabetes is that not only can un- or mis-managed diabetes cause disability and death from complications such as blindness, kidney disease, heart and nerve damage, but also from secondary illnesses and infections from infectious disease, including bloodborne pathogens like HCV and multi-drug resistant organisms like MRSA. These secondary illnesses or infections arise with improper use or reuse of devices used to test blood sugar and/or deliver insulin. These devices include lancets, blood glucose testing devices, needles and syringes, and pen needles. Therefore, we must increase our overall awareness about changing risks and what that means for the institution of safer controls and practices.
The largest health system in the U.S., the Veterans Health Administration, estimates that nearly 25 percent of veterans receiving care have diabetes requiring delivery of insulin (VHA 2017). In addition, approximately 11 million people age 65 and older have diabetes, many of whom may frequent healthcare institutions and require the delivery of insulin while under someone else’s care.
The increasing incidence and sustained prevalence of diabetes not only has an impact on personal health and well-being as well as public health, but also on occupational health and safety. As we rely on healthcare personnel to deliver insulin and other affiliated medications for those with diabetes, in and out of healthcare institutions, we must be cognizant of their safety needs – this includes safety considerations for both needles and syringes as well as pen needles used to deliver insulin.
Risks of Co-Infection with a Bloodborne Pathogen
Since diabetes is essentially more prevalent than any other chronic disease requiring regular injections, it is crucial to determine what that means for the risk of sharps injuries to those delivering care. It is estimated that 28 percent of Americans with diabetes utilize insulin injections to help control their disease (CDC 2011). For those that are treated and/or admitted into acute or long-term healthcare settings, testing and injections will be provided by a healthcare provider. If a contaminated needlestick injury occurs, the risks to that healthcare provider are high.
Hepatitis C is the leading cause of infectious disease deaths among the Baby Boomer generation, more so than 60 other infectious diseases combined. Only around half of the more than 4 million people living with HCV know that they are infected and only about 40 percent are seeking treatment to improve their own health outcomes (Health Union 2017).
Unfortunately, hepatitis C is often associated with onset of type 2 diabetes, as cells have difficulty absorbing blood sugar or glucose and can increase the body’s resistance to insulin – the primary risk factor for developing diabetes. Additional side effects from autoimmunity from HCV may also result in onset of type 1 diabetes. Curiously, a person with diabetes may eventually develop hepatitis C. According to experts, the reasons for this are unclear but may be due to the liver storing more fat or being inflamed, and, if there is an exposure, it may also decrease the liver’s ability to fight off HCV infections (Health Line 2016).
Regarding hepatitis B, the ADA warns that people with diabetes have a higher prevalence of hepatitis B. It is common that people with diabetes are either knowingly or unknowingly sharing blood testing and insulin delivery devices. Additionally, they strongly suggest that adults who haven’t already been vaccinated for HBV, do so to mitigate their risk.
There are several other examples of populations of people with diabetes suffering from co-infections from both bloodborne pathogens and other infectious and communicable diseases. There are too many to list for the purposes of this article, so ultimately it is important to understand that for healthcare personnel giving injections to patients or residents under their care, that they think about the fact that a contaminated needlestick or blood splash or splatter can result in potential exposure to multiple pathogens and as such, sharps safety related to syringe needle use, as well as pen needle delivery, is paramount.
Cost of Occupational Exposures
Over the years, ICT has published dozens of articles and resources related to establishing the cost of occupational exposure to bloodborne pathogens, both direct and indirect. We won’t reiterate them all here in detail, but as an overview, they do include direct costs to healthcare facilities including baseline testing for patient/source and employee; post-exposure evaluation, follow-up and treatment; workers compensation costs; insurance premiums; alternate staffing; and more. Indirect costs include those associated with emotional distress; side effects from treatment; negative impact of marketing/communications as it relates to both staff and patient recruitment; and many, many more.
These costs are just those associated with a needlestick or blood exposure, they do not include the exacerbated financial burdens associated with potential legal and malpractice suits from patients because of poor injection/device practices, as well as carriage of increased insurance and risk premiums for institutions.
As a long-time occupational health and safety professional with focus on preventing occupational exposure to infectious disease, I often hear people say, “Safety Doesn’t Pay” and the reason this makes sense to many is because it is nearly impossible to rely on cost or avoidance of cost as a motivator for safety. Who measures what was prevented, especially regarding occupational injuries and illnesses? Many, like me, agree. It’s why cost cannot be the leading reason to move to safety or safer devices for all insulin delivery; it must be based more so on potential patient and employee exposure to, and avoidance of, potential illness or infection from multiple pathogens.
Regulatory and Safe Injection Practice Compliance
OSHA requires the use of safety-engineered devices for skin injections. This isn’t new and doesn’t require additional justification here. What does require additional conversation is that the Agency not only requires it for syringe needles, but also for any device with a commercially available safety (safer) option, this includes pen needles and lancets.
For those still not using safety lancets -- let’s end the discussion here and just do it. Swap out those archaic non-retracting lancets now. According to 2015 EPINet data, lancets still account for nearly 2 percent of all sharps injuries (EPINet 2016). We can knock those out and bring that down to 0 percent next year.
The OSHA Bloodborne Pathogens Standard requires not only the use of engineering controls to reduce sharps injuries and mitigate risks to the lowest feasible extent, the agency also requires that employers make and maintain a Sharps Injury Log. The log captures injury incidents and is part of the larger requirements under the OSHA Recordkeeping Standard (OSHA 300, 301 Logs). In 2017, OSHA will, for the first time, require employers to submit their injury and illness logs electronically. This includes employers who are required to keep records in high risk industries like healthcare, regardless of size.
Sharps Injury Log Example of Required Elements
It is important to note that safety-engineered devices must be evaluated and used where and when they are commercially available. Having not sustained and recorded an injury from devices used to deliver insulin and otherwise test or treat someone with diabetes is not a valid reason to not institute safety devices now. The reason the Sharps Injury Log is so important as it relates to injuries from devices used to deliver insulin, is because a facility can identify and target devices causing injuries including insulin syringe needles and pen needles.
According to EPINet data, insulin needles account for the largest percentage of injuries from all needles on syringes – 20 percent. In 2018, the International Safety Center will be launching its long-awaited 2018 EPINet Version that includes among other things, injuries from pens and pen needles, including not just the front (patient) end but also the back (device) end. Pen needles are unique in this regard because a needle is required not just to pierce the skin and deliver the medication/insulin, but also to pierce the multi-dose or dosing “vial” of medication/insulin inside of the pen. Both “sides” of pen needles can have potential injury and infectious disease risks.
There are commercially available safer options for pen needles that incorporate engineering designs for both front and back ends. Employers using pen needles for delivery of insulin or other medications to patients or residents should evaluate these devices in accordance with the OSHA Bloodborne Pathogens Standard.
In partnership with Dr. June Fisher’s TDICT Organization, the Safety Center does plan to build out a safety device evaluation form for insulin delivery including design parameters and considerations for multi-use pens. Stay tuned.
Considerations in Selection of Insulin Delivery Safety Devices
Any Device Used for Insulin Delivery
• Appropriate needle length to reduce the need for “pinch up”
• Devices with intuitive designs that are easy to train and master
Safety Insulin Syringe Safety Pen Needle
• One-handed safety activation that minimizes body parts moving toward the needle
• Safety mechanism that covers the patient and non-patient ends of the needle
• Clear unit marking on syringe barrel
• Passive activation in that the safety mechanism activated in the process of insulin delivery with no additional steps
To summarize, with a growing domestic population of people with diabetes resulting in an influx of insulin skin injection and blood glucose testing, it is essential that we keep sharps safety top of mind to best protect healthcare personnel. This includes considering the safety of all devices used by healthcare personnel to diagnose, treat, and maintain health and well-being for those living with diabetes including safety needles on syringes, front and back end protected safety pen needles, as well as blood glucose capillary testing via safety lancets.
As a critical reminder, injection safety includes the concept, especially for those with diabetes, that devices used for blood testing and medication delivery must not be used on more than one patient, resident, or person. This includes not reusing needles for multiple injections on a single person but rather using the needle, activating the safety mechanism, and appropriately disposing of the used sharp immediately.
Amber Hogan Mitchell, DrPH, MPH, CPH and Ginger B Parker, MBA, are from the International Safety Center.
CDC. Number (in Millions) of Adults with Diabetes by Diabetes Medication Status, United States, 1997–2011. https://www.cdc.gov/diabetes/statistics/meduse/fig3.htm
CDC. National Diabetes Statistics Report, 2017 Estimates of Diabetes and Its Burden in the United States. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
Department of Health and Human Services. https://healthfinder.gov/NHO/NovemberToolkit.aspx
Veterans Health Administration. https://www.va.gov/health/NewsFeatures/20111115a.asp
Health Union. HepatitisC.Net https://hepatitisc.net/answers/why-does-hepatitis-c-often-go-undiagnosed/
Health Line. The Link Between Hepatitis C and Diabetes. http://www.healthline.com/health-slideshow/hepatitis-c-and-diabetes#4
International Safety Center, Exposure Prevention Information Network (EPINet) 2015. https://internationalsafetycenter.org/wp-content/uploads/2017/06/Official-2015-NeedleSummary.pdf