Needlestick injury

From Wikipedia, the free encyclopedia
Jump to: navigation, search
Needlestick injury
Classification and external resources
ICD-10 W46
ICD-9-CM E920.5
DiseasesDB 31976
MeSH D016602

A needlestick injury is a percutaneous piercing wound caused by a sharp instrument. Commonly encountered by people handling needles in the medical setting, such injuries are an occupational hazard for health care professionals. Law enforcement personnel are also at high risk for needle stick injuries at work. Needlestick injuries are particularly dangerous because they may transmit blood-borne diseases, including hepatitis B, hepatitis C, and HIV/AIDS.[1]

Despite their seriousness, it is estimated that half of all needlestick injuries go unreported.[2] On the other hand, as needlesticks have been recognized as occupational hazards, their prevention has become the subject of regulations.[3]


Needlestick injuries are a common event in the healthcare environment. When drawing blood, administering an intramuscular or intravenous drug, or performing other procedures involving sharps, the needle can slip and injure the healthcare worker. This allows for transmission of pathogens. These injuries also commonly occur during needle recapping and as a result of failure to place used needles in approved sharps containers. Lack of access to or failure to use appropriate personal protective equipment can cause needlestick injuries.[4] Night shifts also put practitioners at risk for needlestick injuries.[5]

During surgery, a surgical needle or other sharp instrument may inadvertently penetrate the glove and skin of the surgeon or other operating room personnel. Injuries may occur when needles are passed between personnel, when personnel load needles into a needle driver, when personnel place needles in an overfilled or poorly located sharps container, or tie off sutures while still connected to the needle. Generally needlestick injuries cause only minor bleeding or visible trauma, however, even in the absence of bleeding the risk of viral infection remains. Scalpel injuries tend to be larger than a needlestick. In turn, a needlestick injury may also pose a risk for a patient if the injured health professional has a bloodborne illness.[6]

Needlestick injuries are not limited to the medical community. Any environment where sharps are encountered poses a risk. Needlestick injuries are less frequent, yet still a serious concern among law enforcement. Eight million self-injectors generate up to three billion sharps outside formal healthcare settings in the United States every year. One-third of these sharps are produced by injection drug users of heroin, cocaine, and other illicit drugs.[7]

Injury to law enforcement officers can occur for many reasons, which include the dropping or throwing of needles in fear of arrest, use of sharps as weapons against police officers, and arrestees not declaring possession, typically during searches or pat downs.

Treatment and prognosis[edit]

While needlestick injuries have the potential of transferring bacteria, protozoa, viruses and prions,[8] transmission of hepatitis B, hepatitis C, and HIV is of greatest concern and happens most frequently. The World Health Organization estimated that in 2000, 66,000 hepatitis B, 16,000 hepatitis C, and 1,000 HIV infections were caused by needlestick injuries.[3][4] In addition, a needlestick injury or the risk of a needlestick injury may lead to significant stress and anxiety.[4][9]

Hepatitis B carries the greatest risk of transmission, with 37 to 62% of exposed workers eventually showing seroconversion and 22 to 31% showing clinical Hepatitis B infection.[10][11] Higher rates of hepatitis B vaccination among the general public and healthcare workers alike has reduced the risk of transmission.[4] The hepatitis C transmission rate has been reported at 1.8%,[10][12] but newer, larger surveys have shown only a 0.5% transmission rate.[13] The overall risk of HIV infection after percutaneous exposure to HIV-infected material in the health care setting is 0.3%.[14][15]

The specific risk of a single injury depends on a number of factors when the patients harbor the virus of concern. Injuries with a hollow-bore needle, deep penetration, visible blood on the needle, a needle that was located in a deep artery or vein, or with blood from terminally ill patients are known to increase the risk for HIV infection.[16][17]

Estimates of the risk of a single injury indicate a risk of 300 HBV infections (30% risk), 30 HCV infection (3% risk) and 3 HIV infections (0.3% risk) per 1,000 respective exposures.[18]

Treatment of a needlestick injury is costly, estimated to be between $376-$2,456 in the United States.[9] The costs of treating an injury include treatment of an acquired infection, blood testing, and lost time at work.[4] After a needlestick injury, certain procedures must be followed to minimize the risk of infection for the recipient. The affected area should be rinsed and washed thoroughly with soap and water, and any blood splashes flushed with ample water. If the eyes are exposed, they should be irrigated with water or saline.[1] Lab tests of the recipient are obtained for baseline studies: HIV, acute hepatitis panel (HAV IgM, HBsAg, HB core IgM, HCV) and for immunized individuals HB surface antibody.[19] Unless already known, the infectious status of the source needs to be determined by checking for HBsAG, anti-HCV, and HIV antibody.[19] Unless the source is known to be negative for HBV, HCV, and HIV, post-exposure prophylaxis (PEP) should be initiated, ideally within one hour of the injury;[20] typically this is done in the emergency department or the occupational health office. Guidelines for PEP have been updated over recent years in view of the introduction of new drugs, and protocols may differ somewhat between countries.

Hepatitis B prophylaxis[edit]

Current CDC guidelines call for the administration of hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine. While the efficacy of the combination has not been evaluated in the needlestick injury setting, it has been shown to be the most efficacious approach in the perinatal setting. The approach has no contraindications during pregnancy and lactation.[21]

Hepatitis C prophylaxis[edit]

CDC guidelines acknowledge that there is no active PEP for HCV, only recommendations intended to achieve early identification of chronic disease and, when detected, referral for evaluation of treatment options. According to the CDC identification of acute infection with HCV may not necessitate active intervention.[21] However, there is some evidence that treatment with interferon alfa-2b may be beneficial preventing chronic hepatitis.[22]

HIV prophylaxis[edit]

CDC guidelines generally recommend a PEP protocol with 3 or more antiviral drugs, when it is known that the donor was HIV positive; however, when the viral load was low and none of the above noted risk factors are met, the CDC protocol utilizes 2 antiviral drugs. Such a 2 drug protocol should also be considered when the donor status cannot be determined (e.g. injury by a random needle in a used sharps container), but there is an increased risk that the source was from a risk group for HIV.[16] PEP drugs for prevention of HIV infection are given for 4 weeks and may include nucleoside reverse transcriptase inhibitors (NRTIs), nucleotide reverse transcriptase inhibitors (NtRTIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), and a single fusion inhibitor. PEP anti-HIV regimens are accompanied by significant side effects and their utilization is not indicated when there is evidence that HIV transmission is not involved; also, initiated protocols can be stopped when data appear indicating that the source-person is HIV-negative. Regardless whether PEP is instituted, follow-up of exposed individuals includes counseling and HIV testing by enzyme immunoassay to monitor for a possible seroconversion for at least 6 months after exposure. Such tests are done at baseline, 6 weeks, 12 weeks, and 6 months, and longer in specific circumstances, such as co-infection with HCV.


Blood being drawn with a Vacutainer. A protective cap (pink) protects the needle after it is removed.

Prevention of needle sticks can include reduction or elimination of use of sharps as much as possible, engineering controls, including needles with safety devices, administrative controls including training and provision of adequate resources, and work practice controls; the latter may include using instruments (not fingers) to grasp needles, load scalpels, and avoiding hand-to-hand passing of sharp instruments. Engineering advances include the development of safety needles and needle removers.[23] Safety devices for needles include retractable needles, needle shields, and needle-less IV administration kits. Some studies have found these safer needles to reduce injuries, but others have shown mixed results or no benefit.[4] The adherence to "no-touch" protocols that eliminate direct contact with needles in their use and disposal greatly reduce the risk of injury. In the surgical setting, especially in abdominal operations, blunt-tip suture needles were found to reduce needle stick injuries by 69%. Blunt-tip suture needles can be used to sew muscle and fascia. Though they are more expensive than sharp-tipped needles, this cost is balanced by the reduction in injuries, which are expensive to treat.[9] Sharp-tipped needles cause 51-77% of surgical needlestick injuries.[6] The American College of Surgeons (ACS) has endorsed the adoption of blunt-tip suture needles for suturing fascia and muscle.[9][24] Hollow-bore needles pose a greater risk of injury than solid needles, but hollow-bore needle injuries are highly preventable: 25% of hollow-bore needle injuries to healthcare professionals can be prevented by using safer needles.[4]

In addition, the use of two pairs of gloves, double gloving, can halve the risk of needle stick injury in surgical staff. Triple gloving may be more effective than double gloving, but using thicker gloves does not make a difference.[25] A 2014 Cochrane review found low quality evidence showing that safety devices on IV start kits and venipuncture equipment reduce the frequency of needlestick injuries. However, these safety systems can increase the risk of exposure to splashed blood.[4]

Some countries have enacted legislation to protect healthcare workers. In the US, the Needlestick Safety and Prevention Act was signed in 2000 and Bloodborne Pathogens Standard in 2001. These regulations mandate the use of safety devices and needle-removers with any sharps or needles.[9][26] In the US, nonsurgical needlestick injuries decreased by 31.6% in the five years following the passage of the Needlestick Safety and Prevention Act. However, this legislation did not affect surgical settings, where injuries increased 6.5% in the same period.[2] Discarded sharps enter the medical waste stream.

Syringe exchange programs[edit]

Syringe exchange programs (SEPs), also known as needle exchanges or Syringe Access Programs (SAPs), are an effective way of decreasing the risk associated with needlestick injuries. Although SEPs may not reduce the prevalence of needlesticks, the risk of exposure to blood borne pathogens is reduced. SEPs provide benefits for many parties involved. Injection Drug Users (IDUs) are a very difficult population to reach, and SEPs act as a gateway for users to other resources and provide clean needles while collecting dirty sharps. These programs keep dirty syringes off the street, and in return stop the spread of disease. SEPs also benefit law enforcement through reducing risk of exposure to disease. A study in Hartford, CT looked at syringe access and law enforcement needlestick injuries before and after laws regarding needlestick access were implemented. A study found that needlestick injury rates among Hartford police officers were lower after the new laws (six injuries in 1,007 drug-related arrests for 6-month period before new laws vs. two in 1,032 arrests for 6-month period after new laws).[27]


About 384,825 needle-stick injuries were estimated to occur in US healthcare professionals in 1997-1998.[4] 23% of these injuries occur during surgery.[9] The annual number of needlestick injuries in Europe was estimated to be 1 million by the European Biosafety Network.[25] Another investigation estimates the rates of injuries on a global level to affect about 3.5 million individuals.[3] In 2007, the World Health Organization estimated global injuries at 2 million per year.[25] Among healthcare workers nurses and physicians appear especially at risk;[28] an investigation among American surgeons indicates that almost every surgeon experienced at least one such injury during their training.[29] More than half of needlestick injuries that occur during surgery happen while surgeons are sewing the muscle or fascia.[9] Within the medical field specialties differ in regard to the risk of needlestick injury, thus surgery, anesthesia, ENT, internal medicine, and dermatology tend to show relatively high, and radiology and pediatrics relatively low rates of injury.[20][30] Half or more events may go unreported as injured healthcare workers may not take the time to report, downplay the risk, or fear stigmatization and professional consequences.[8]

Needlestick injuries may occur not only with freshly contaminated sharps, but also, after some time, with needles that carry dry blood. While the infectiousness of HIV and HCV decrease within a couple of hours, HBV remains stable during desiccation and infectious for more than a week.[18]

Needlestick injuries are of significant concern to police workers. In San Diego 30% of police workers reported such injuries typically when searching suspects.[31]

A study of 1,333 police officers in the Denver Police Department found that only 43.4% of those exposed, reported their injuries. 42% of respondents indicated they were on second duty shift (evenings) when they were injured. Additionally, nearly two-thirds who experienced needlesticks indicated it was during their first five years of experience [31]

A law enforcement study in New York City Police Department identified 38.7 exposures per 10,000 police officers (includes bites & sticks), while Patrol & Narcotics officers had a 43.6/10,000 exposure rate.[32]


Surveillance systems have been to track sharps injuries and the progress that is achieved in their elimination. In the US there are two voluntary national surveillance systems for tracking sharps injuries: The National Surveillance System for Health care Workers (NaSH) of the CDC[33] and EpiNet of the International Health Care Worker safety center at the University of Virginia.[34] Also, some states have set up annual surveillance reporting such as Massachusetts.[35]


  1. ^ a b "Bloodborne Infectious Diseases: HIV/AIDS, Hepatitis B, Hepatitis C". National Institute for Occupational Safety and Health (NIOSH). 31 January 2012. 
  2. ^ a b "Stop Sticks". National Institute for Occupational Safety and Health (NIOSH). 24 June 2011. 
  3. ^ a b c Prüss-Ustün A, Rapiti E, Hutin Y (December 2005). "Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers". American Journal of Industrial Medicine 48 (6): 482–90. doi:10.1002/ajim.20230. PMID 16299710. 
  4. ^ a b c d e f g h i Lavoie, Marie-Claude; Verbeek, Jos H.; Pahwa, Manisha (2014). "Devices for preventing percutaneous exposure injuries caused by needles in healthcare personnel". The Cochrane Database of Systematic Reviews 3: CD009740. doi:10.1002/14651858.CD009740.pub2. ISSN 1469-493X. PMID 24610008. 
  5. ^ Ker, Katharine; Edwards, Philip James; Felix, Lambert M.; Blackhall, Karen; Roberts, Ian (2010). "Caffeine for the prevention of injuries and errors in shift workers". The Cochrane Database of Systematic Reviews (5): CD008508. doi:10.1002/14651858.CD008508. ISSN 1469-493X. PMC 4160007. PMID 20464765. 
  6. ^ a b "Use of Blunt-Tip Suture Needles to Decrease Percutaneous Injuries to Surgical Personnel" (PDF). DHHS (NIOSH) Publication No. 2008–101. National Institute for Occupational Safety and Health (NIOSH). 
  7. ^ Gebhart, Fred. "EPA issues new guidelines for sharps disposal". Retrieved 4 July 2012. 
  8. ^ a b Mülder K (2005). "Nadelstichverletzungen: Der bagatellisierte "Massenunfall"". Dtsch Arztebl (in German) 102 (9): 558–61. Retrieved 2009-05-30. 
  9. ^ a b c d e f g "Blunt-Tip Surgical Suture Needles Reduce Needlestick Injuries and the Risk of Subsequent Bloodborne Pathogen Transmission to Surgical Personnel". FDA/NIOSH/OSHA. 30 May 2012. 
  10. ^ a b Centers for Disease Control and Prevention, Updated US Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis.
  11. ^ Werner B.G., Grady G.F. (1982). "Accidental hepatitis-B-surface-antigen-positive inoculations: use of e antigen to estimate infectivity". Ann Intern Med 97: 367–369. doi:10.7326/0003-4819-97-3-367. 
  12. ^ Lanphear B.P., Linnemann C.C., Cannon C.G., DeRonde M.M., Pendy L., Kerley L.M. (1994). "Hepatitis C virus infection in healthcare workers: risk of exposure and infection". Infect Control Hosp Epidemiol 15: 745–750. doi:10.1086/646851. 
  13. ^ Jagger J., Puro V., DeCarli G. (2002). "Occupational transmission of hepatitis C virus [letter]". JAMA 288: 1469–1471. doi:10.1001/jama.288.12.1469. PMID 12243628. 
  14. ^ CDC Cooperative Needlestick Surveillance Group, Marcus R (1988). "Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus". N Engl J Med 319: 1118–1123. doi:10.1056/nejm198810273191703. 
  15. ^ Bell D.M. (1997). "Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview". Am J Med 102 (Suppl 5B): 9–15. doi:10.1016/s0002-9343(97)89441-7. 
  16. ^ a b CDC Guidelines (re HIV) 2005 Retrieved 2009-06-01
  17. ^ Cardo D.M., Culver K.H., Ciesielski C., Srivastava P.U., Marcus R., Abiteboul D.; et al. (1997). ", A case-control study of HIV seroconversion in health-care workers after percutaneous exposure". N Engl J Med 337: 1485–1490. doi:10.1056/nejm199711203372101. 
  18. ^ a b Sarrazin U, Brodt HR, Sarrazin C, Zeuzem S (2005). "Prophylaxe gegenüber HBV, HCV und HIV nach beruflicher Exposition". Dtsch Arztebl (in German) 102: 2234–2239. Retrieved 2009-05-30. 
  19. ^ a b Klein SM, Foltin J, Gomella LG (2003). Emergency Medicine on Call. New York: McGraw-Hill. p. 288. ISBN 0-07-138879-6. 
  20. ^ a b Diprose P, Deakin CD, Smedley J (1 June 2000). "Ignorance of post-exposure prophylaxis guidelines following HIV needlestick injury may increase the risk of seroconversion". British Journal of Anaesthesia 84 (6): 767–70. doi:10.1093/oxfordjournals.bja.a013591. PMID 10895754. Retrieved 2009-01-02. 
  21. ^ a b CDC Guidelines (re HBV and HCV) 2001 Retrieved 2009-06-01.
  22. ^ Jaeckel E, Cornberg M, Wedemeyer H, Santantonio T, Mayer J, Zankel M, Pastore G, Dietrich M, Trautwein C, Manns MP (November 2001). "Treatment of acute hepatitis C with interferon alfa-2b". New England Journal of Medicine 345 (20): 1452–1457. doi:10.1056/NEJMoa011232. PMID 11794193. 
  23. ^ Use of Blunt-Tip Suture Needles to Decrease Percutaneous Injuries to Surgical Personnel: Safety and Health Information Bulletin. Retrieved 2008-9-12.
  24. ^ "Statement on Sharps Safety". Bulletin of the American College of Surgeons (American College of Surgeons) 92 (10). October 1, 2007. 
  25. ^ a b c Mischke C, Verbeek JH, Saarto A, Lavoie MC, Pahwa M, Ijaz S (2014). "Gloves, extra gloves or special types of gloves for preventing percutaneous exposure injuries in healthcare personnel". Cochrane Database of Systematic Reviews (3): CD009573. doi:10.1002/14651858.CD009573.pub2. 
  26. ^ Jagger, J., De Carli, G., Perry, J., Puro, V., Ippolito, G. (2003). Chapter 31: Occupational Exposure to Bloodborne Pathogens: Epidemiology and Prevention. Prevention and Control of Nosocomial Infections (4th Ed). Lippincott, Williams, and Wilkins. pp. 27–28. 
  27. ^ Groseclose; Weinstein, Jones, Valleroy, Fehrs, Kassler (Sep 1995). "Impact of increased legal access to needles and syringes practices of injecting-drug users and police officers". CDC: J Acquir Immune Defic Syndr Hum Retrovirol 10 (1): 82–9. doi:10.1097/00042560-199509000-00012. PMID 7648290. 
  28. ^ Chalupa S, Markkanen PK, Galligan CJ, Quinn MM (March–April 2008). "Needlestick and Sharps Injury Prevention:Are We Reaching Our Goals?". AAACN Viewpoint. Retrieved 2009-06-01. 
  29. ^ Makary MA, Al-Attar A, Holzmueller CG, et al. (June 2007). "Needlestick injuries among surgeons in training". N. Engl. J. Med. 356 (26): 2693–9. doi:10.1056/NEJMoa070378. PMID 17596603. 
  30. ^ Wicker S, Jung J, Allwinn R, Gottschalk R, Rabenau HF (January 2008). "Prevalence and prevention of needlestick injuries among health care workers in a German university hospital". Int Arch Occup Environ Health 81 (3): 347–54. doi:10.1007/s00420-007-0219-7. PMID 17619897. 
  31. ^ a b J Lorentz, Hill L, Samimi B (2000). "Occupational needlestick injuries in a metropolitan police force". American Journal of Preventive Medicine 18 (2): 146–50. doi:10.1016/s0749-3797(99)00137-3. PMID 10698245. 
  32. ^ Pagane, J; Chanmugam, Kirsch, Kelen (1996). "New York City Police officers incidence of transcutaneous exposures" (PDF). Occupational Medicine 46 (4): 285–288. doi:10.1093/occmed/46.4.285. Retrieved 7 July 2012. 
  33. ^ NaSH Retrieved 2009-06-01
  34. ^ EpiNet Retrieved 2009-06-01
  35. ^ Massachusetts Surveillance Report Retrieved 2009-06-01

External links[edit]