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Needlestick injuries: control and prevention

Priv-Doz Dr Dr Sabine Wicker 
Occupational Health Service
Prof Dr Holger Holger F Rabenau
Institute of Medical Virology,
Hospital of the Johann Wolfgang
Frankfurt am Main, Germany
Every year, even in industrialised countries, a remarkable number of healthcare workers (HCWs) is still infected with blood-borne pathogens as a result of their work. In spite of hepatitis B vaccination programmes, the implementation of standard precautions and the introduction of safety devices, occupationally acquired infections still occur.(1)
The prevention of percutaneous injuries is vital because they present one of the most common forms of injury among HCWs and the most efficient mechanism of transmission of blood-borne pathogens, such as hepatitis B, hepatitis C and HIV, in the workplace.
Blood-borne pathogen transmission occurs predominantly by percutaneous or mucosal exposure – so-called ‘needlestick injury’ (NSI) – of HCWs to the blood or body fluids of infected patients. Studies of HCWs have estimated that the average risk for HIV transmission after a percutaneous exposure is approximately 0.3%, the risk of hepatitis B transmission is 6–30% and the risk of hepatitis C transmission is approximately 1.0%.(2–4)
Each year around the world approximately 66,000 hepatitis B, 16,000 hepatitis C and 1000 HIV infections were estimated to occur in HCWs – mostly in developing countries – due to percutaneous injuries through occupational exposure. Work-related infections are responsible for approximately 37% of the hepatitis B infections of HCWs, 39% of the hepatitis C infections and 4.4% of the HIV infections of HCWs worldwide.(5) 
The ‘Frankfurt needlestick study’
The Frankfurt University Hospital is a 1169-bed hospital with 4055 employees and 12 medical disciplines. The HCWs receive individual regular training in blood/body fluid exposure prevention by the occupational health service and/or the supervisors. HCWs holding a job that involved direct contact with patients as well as contact with blood or body fluids or sharp objects were asked to complete a survey. Data were obtained between April and June 2006 (anaesthesia, dermatology, gynaecology, paediatrics, surgery) and between February and April 2007 (ear, nose and throat medicine, internal medicine, neurology/psychiatry, ophthalmology, pathology/forensic medicine, radiology) by an anonymous survey administered to 2085 HCWs.(6) 
The data of our study clearly point out that there is a high rate of NSIs in the daily life of a hospital. The rate of such injuries depends on the medical discipline. In our study, 31.4% of the HCWs had sustained at least one NSI within one year. The number of NSIs per person and year varied significantly from 1 to 55. The highest numbers were reported by surgeons. Our data are in line with an article by Makary et al. who published the results of a large US multicentre study on the frequency of NSI among surgeons in training, showing that the frequency of NSI is much higher than commonly assumed. By their final year of training, 99% of residents had had at least one NSI.(7) 
In the studies of the University Hospital Frankfurt,(8) physicians had the highest risk of all occupational groups of being injured by NSI (55.1% reported an NSI in the last 12 months), followed by nurses (22.0% had received an NSI). Risk of NSI varied according to procedure: sewing (23%), venipuncture (13%) and capillary puncture (8.7%) present higher risks for injury than other types of procedures such as intramuscular/subcutaneous injections (3%). While most of the NSIs occurred during routine activities (80.8%), a few took place in emergency situations (13.4%).
Stress (39.6%), lapses in concentration and fatigue (39.4%) were the most common reasons for NSI. Extended working hours and night shifts were associated with 16.4% and 22.1%, respectively, of percutaneous injuries.(3,4) 
Under-reporting of NSIs
The rate of NSIs is widely underestimated, since most HCWs do not report incidents. In our studies among HCWs, dental HCWs, and dental and medical students fewer than 30% of injured persons reported their NSIs and had seen a physician after the incident.(3,4) Consistent reporting of NSIs is, however, an essential prerequisite for providing appropriate treatment and taking post-exposure prophylactic measures (PEP) in a timely fashion. A complete recording of all NSIs is crucial for hospital operators in their efforts to acquire and evaluate high-risk activities.
Risk factors
Various factors determine whether or not an NSI will lead to an infection, including the infection state of the index patient (virus load), the immune status of the injuring carrier, the puncture depth (grade of NSI), the duration of contact, the interval between injury and cleaning procedure, prophylactic measures taken, and the probability of transmission.
Strategies to prevent occupational infections
The pre-exposure hepatitis B immunisation, access to HIV post-exposure prophylaxis (HIV-PEP) for HCWs and the use of standard precautions to prevent exposure to blood are the most important measures for preventing HCWs from occupational infections with HBV and HIV.(3) 
For hepatitis C virus there is neither a vaccination nor post-exposure prophylaxis available; for this reason, early diagnosis and treatment of acute hepatitis C is crucial, and every NSI requires stringent follow-up.
An important tool to protect HCWs against NSI is the use of safety devices (Figure 1). Safety devices have been found to reduce the risk of NSI so their implementation should result in an improvement in the health and safety of medical staff.(4) The continued use of ‘unsafe devices’ for invasive procedures when safety devices are available needs to be addressed.(9) 
However, safety devices would not completely eradicate NSIs but their frequency will decline.(4,10) More technical interventions are necessary to reduce the incidence of NSI in the different healthcare departments. Preventive measures should be introduced in all specialties. The use of cut-resistant gloves may reduce NSIs for example from bone fragments during palpation and double gloving lowers the risk of inner-glove perforations.
A sustained commitment to the occupational health of all HCWs and stringent follow-up of NSIs will ensure the best possible protection for HCWs and patients.(2) 
International data showed that patient-to-HCW as well as HCW-to-patient transmissions of blood-borne pathogens continues to occur and many cases are likely to go undetected because HCWs and patients infected with hepatitis B, hepatitis C or HIV often remain asymptomatic for years.(11) 
Approximately 10% of workers in the European Union are employed in the healthcare setting, with a significant proportion employed in hospitals. This makes healthcare one of the biggest employment sectors in Europe, covering a vast range of different occupations and it is estimated that 1.2 million NSIs occur in Europe each year.(12) 
It is the responsibility of chief executives and department heads to create a safe work environment and educational concept for their HCWs, before workers are exposed to the risk of blood-borne infections, which might have a long-lasting impact on their personal lives, their private environment, their professional perspective and on the patients they treat. The HCWs in Europe merit better protection for their health and greater recognition for their contribution. We propose that national organisations assume responsibility for accurately tracking occupationally acquired infections.(13) A worldwide surveillance system of occupationally acquired infections and deaths should determine the magnitude of the problem and could lead to future interventions.(3) 
Conflict of interest
The views in this article are the personal views of the authors and do not necessarily represent the views of the professional organisations or institutions that they are members of.
The authors declare that they have no conflicts of interest. 
  1. FitzSimons D et al. Hepatitis B virus, hepatitis C virus and other bloodborne infections in healthcare workers: guidelines for prevention and management in industrialised countries. Occup Environ Med 2008; 65: 446–51.
  2. Beltrami EM et al. Risk and management of blood-borne infections in health care workers. Clin Microbiol Rev 2000;13:385–407.
  3. Wicker S et al. Needlestick injuries among healthcare workers: Occupational hazard or avoidable hazard? Wien Klin Wochenschr 2008; 120:486–92.
  4. Wicker S, Rabenau HF. A review of the control and prevention of needlestick injuries. Eur Infect Dis 2011;5:60–3.
  5. Prüss-Üstün A, Rapiti E, Hutin Y. Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers. Am J Ind Med 2005;48:482–90.
  6. Wicker S et al. Determination of risk of infection with bloodborne pathogens following a needlestick injury in hospital workers. Ann Occup Hyg 2008;52:615–22.
  7. Makary MA et al. Needlestick injuries among surgeons in training. N Engl J Med 2007; 356: 2693–9.
  8. Wicker S et al. Prevalence and prevention of needlestick injuries among HCWs in a German university hospital. Int Arch Occup Environ Health 2008;81: 47–54.
  9. Laramie AK et al. Sharps injuries among employees of acute care hospitals in Masschusetts, 2002–2007. Infect Control Hosp Epidemiol 2011;32:538–44.
  10. Vaughn TE et al. Factors promoting consistent adherence to safe needle precautions among hospital workers. Infect Control Hosp Epidemiol 2004;25:548–55.
  11. Perry JL, Pearson RD, Jagger J. Infected health care workers and patient safety: a double standard. Am J Infect Control 2006;34:313–19. 
  12. Proposal for a Council Directive implementing the Framework Agreement on prevention from sharp injuries in the hospital and healthcare sector concluded by HOSPEEM and EPSU. Commission of the European Communities. (accessed 9 January 2012).
  13. Sepkowitz KA, Eisenberg L. Occupational deaths among healthcare workers. Emerg Infect Dis 2005;11:1003–8.