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Occupational Medicine Advance Access originally published online on October 25, 2006
Occupational Medicine 2006 56(8):566-574; doi:10.1093/occmed/kql122
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© The Author 2006. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Sharps injuries in UK health care: a review of injury rates, viral transmission and potential efficacy of safety devices

Alexander Elder1 and Caron Paterson2

1 Salus Occupational Health and Safety, NHS Lanarkshire, Centrum Park, Coatbridge, Lanarkshire, UK
2 BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK

Correspondence to: Alexander Elder, Salus Occupational Health and Safety, NHS Lanarkshire, Centrum Park, Coatbridge, Lanarkshire, UK. Tel: +44 01236 438181; e-mail: sandy.elder{at}lanarkshire.scot.nhs.uk


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Aims To review the literature on sharps injuries and occupational bloodborne virus transmission in health care in the UK and the worldwide evidence for injury prevention of sharps safety devices.

Methods Literature review by online database and Internet resource search.

Results Twenty-four relevant publications were identified regarding UK reported sharps injury rates. UK studies showed as much as a 10-fold difference between injuries reported through standard reporting systems (0.78–5.15 per 100 person-years) and rates estimated from retrospective questionnaires of clinical populations (30–284 per 100 person-years). National surveillance data from England, Wales and Northern Ireland gives a rate of 1.43 known hepatitis C virus or human immunodeficiency virus (HIV) transmissions to health care workers per annum. When extrapolated, this suggests an approximate rate of 0.009 such viral transmissions per 1000 hospital beds per annum. Risk of infection from sources with no risk factors is extremely small (less than one in one million for HIV transmission based on Scottish data). Thirty-one studies on the efficacy of sharps safety devices showed evidence of a reduction in injuries, with the greatest reductions achieved by blunt suture needles and safety cannulae.

Conclusions Although injuries remain common, confirmed viral transmission in the UK has been relatively rare. The degree of under-reporting of sharps injuries may be as much as 10-fold. Safety-engineered devices are likely to be effective at injury reduction.

Keywords      Injury rates; occupational bloodborne virus transmission; prevention; sharps and needlestick injuries; sharps safety devices


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Although sharps injuries are one of the most common types of injury incurred by health care workers (HCW), the estimated rates of injury can vary due to uncertainties about underreporting. Instances of occupational bloodborne virus (BBV) transmission in the UK have been reported, but assessments of transmission incidence and absolute risk of infection have rarely been published. Devices which incorporate safety features such as a blunting, shielding or retracting mechanism are claimed to reduce the risk of an exposure incident. This review sought to (i) describe published injury and transmission rates in the UK setting, (ii) review transmission risk and (iii) review the worldwide published evidence for the efficacy of safety-engineered sharps devices.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conflicts of interest
 References
 
We conducted an online search of the electronic databases MEDLINE (1990–2003), CINAHL (1990–2003) and EMBASE (1990–2003) for relevant literature. The MeSH terms used were: engineering controls, safety devices, occupational exposures, exposure incidents, needlestick injury, percutaneous injury, human immunodeficiency virus (HIV), hepatitis B, hepatitis C and viral transmissions. We scanned citations from relevant identified papers to supplement the search. We also used Internet resources from the UK [e.g. Department of Health, Health & Safety Executive, Health Protection Scotland (HPS), Health Protection Agency (HPA)] and USA [e.g. Exposure Prevention Information Network (EPINet), Centres for Disease Control and Prevention, National Institute of Occupational Safety and Health, Occupational Safety and Health Administration].


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conflicts of interest
 References
 
In terms of the UK incidence of sharps injuries, we found 24 papers or Internet publications [1–24] which could show sharps injury rates or rates of underreporting in UK health care (Table 1). Some data derived from the voluntary surveillance programme operated by the Royal College of Nursing from 2000 onwards [16], with up to 19 participating hospitals utilizing Exposure Prevention Information Network (EPINet) software [17]. This showed overall reported injury rates (12.74/100 beds/year) [24] which are lower than US counterparts (18–26/100 beds/year) [25]. The chosen denominator of hospital beds is at variance with most other studies where the HCW population is used as a denominator. The true incidence of such injuries is difficult to ascertain, with some authors estimating under-reporting of between 29 and 61% [26]. The UK studies show a striking contrast between rates reported in standard organizational systems with those derived from prospective or research settings using questionnaires on HCW cohorts, suggesting very significant under-reporting, of up to 10-fold.


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  		Table 1 Rates of sharps injuries, UK studies

 
Using the EPINet data, with ~166 000 acute, maternity and elderly care beds (see below) in the National Health Service (NHS) in England, Wales and Northern Ireland, the overall extrapolated incidence of injuries would be 21 148 per annum. When Scotland is included (26 000 beds), this increases to 24 460. A recent estimate of percutaneous injuries, using EPINet data in the USA, was 384 325 [27]. This analysis employed weighting calculations based on the size of institution and adjusted for under-reporting, using an assumption of 43.4% as the reporting rate. If a similar under-reporting adjustment is made to the UK rate, this results in a revised estimate of 56 359. Given that the USA has about five times the UK population, and that UK reported EPINet injury rates are 50–70% of those in the USA, this figure is comparable to the overall US estimate [27].

In 1984 the first occupational transmission of HIV from patient to HCW worldwide was reported from the UK [28]. In response to this, a voluntary surveillance system was introduced to monitor occupational exposure rates to HIV and other BBVs in the UK, though historically, hepatitis B virus (HBV) transmissions were not included. Since 1984, the HPA reports that in total, there have been five documented occupational HIV seroconversions and 14 possible seroconversions in the UK, though many of the latter are thought to have occurred overseas [29]. HPA (formerly CDSC—Communicable Disease Surveillance Centre) launched an enhanced level of occupational BBV exposure surveillance in July 1997. Data relating to occupational exposures to BBV were collected from >200 occupational health and genitourinary medicine clinics in England, Wales and Northern Ireland. Over a 7-year period, 2140 reports on occupational exposures to one or more BBVs were received by the CDSC. Of all initial reports, hepatitis C virus (HCV) represented 47% with HIV accounting for 26%, and coinfected sources a further 9%. Follow-up was sought at 6 months for exposure to HIV and HCV with reports sent to CDSC. The reported data for the 7-year surveillance period identified seroconversions in 10 HCW. One HCW seroconverted to HIV, despite triple post exposure prophylaxis. There were nine documented seroconversions to HCV, six of which occurred in the year 2003–04 [30].

From these data, HPA quote seroconversion rates of 1.5% and 0.8% for HCV and HIV, respectively, though these may be overestimates as only those cases with 6 month reports were used as a denominator. It is difficult to relate this to the overall number of sharps devices used, but it is possible to calculate the incidence of seroconversion per annum per 1000 beds. The number of beds (acute, maternity and elderly care) in 2000/2001 was 146 394 in England [31] with 11 683 in Wales [32] and 8419 in Northern Ireland [33]. These figures give a rounded total of 166 000 hospital beds. The incidence of HCV or HIV seroconversion in HCW was 1.43 per annum for the whole geographical area equating to 0.0086 per 1000 beds per annum. Thus, for an acute hospital organization with 1500 beds, a HCV or HIV seroconversion of a HCW from an exposure incident could be expected every 78 years. This crude rate assumes that all seroconversions were identified and notified through surveillance, which may not be the case. HPS operated a similar surveillance arrangement to monitor occupational exposure of HCWs to HIV and other BBV. To date, there have been no occupational seroconversions recorded by the surveillance system (D. Goldberg, personal communication).

Estimates of risk of viral transmission to non-immune HCW vary [34–39] and are summarized in Table 2. HBV and HIV transmission rates are well-established and accepted. HCV transmission rates are quoted much more variably, ranging from the higher early estimates of 3 to 4% reported particularly in Japan, to the much lower rates seen in more recent very large studies in Europe. From a UK perspective, the Italian and Spanish studies with rates of 0.4–0.6% are likely to be more applicable. HCV transmission is only likely to occur from RNA positive sources [39]. Solid bore needles are very unlikely to transmit infection, which is associated with deep injuries from hollow bore needles [39]. The importance of blood volume and injury depth has also been confirmed in HIV transmission studies [40], while other likely risk factors include the viral load of some patients, glove use (50% decrease in volume of blood transmitted) [41], and drying conditions (10-fold drop in infectivity every 9 h) [42]. Mucocutaneous transmission of HIV and HCV appears rare but has been documented [38].


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  		Table 2 Risk of viral transmission from percutaneous exposure

 
Extrapolating from known data in Scotland, the risk of HCV or HIV transmission can be calculated where the lifestyle risk factor only is known, but the BBV status of the source is not (Table 3). HPS surveillance data to June 2002 indicated that one in 390 of Scotland's populace was antibody positive for HCV [43], and that the cumulative total of HIV positive cases was, up to June 2003, 3722 [44]. With current population at 5 062 011 (census data 2001) this equates to a prevalence of 1:1428 (0.07%). Figures for the UK as a whole at June 2003 were of 57 763 cases of HIV infection and 19 656 acquired immunodeficiency syndrome (AIDS) cases. Overall, the absolute risk of BBV transmission from a patient with no known factors is extremely low. In contrast, the risk of HIV and HCV transmission is more significant from sources dependant on risk factors. HBV transmission to HCW should now be exceptionally rare due to the vaccination programme.


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  		Table 3 Estimated risk of HIV/HCV transmission following percutaneous injury where risk factor only is known (Scottish data)

 
A report on sharps injury prevention in the USA [45] suggested that the use of safer devices could prevent 29% of needlestick injuries. A Scottish report concluded that 61% of venepuncture-related injuries were ‘probably’ preventable by safety device use and 21% were ‘definitely’ preventable [46]. Most of the marketed devices do not have published original data that demonstrate they are effective at injury prevention. Sample sizes required are prohibitive: for a device with an injury rate of 5 per 100 000 usages (for example, syringe devices) the sample size to achieve 80% power at the 5% level of significance has been calculated as one million devices to show a 50% reduction in injuries [47]. Reviews on this subject are scarce [48,49]. We were able to identify 31 studies (Table 4) [12,13,18,19,50–77], some of which were unpublished.


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  		Table 4 Published studies or abstracts on device efficacy

 
Virtually all studies were undertaken in the USA and these have mainly ceased since 2001 when US Congress published the Needlestick Safety and Prevention Act, requiring all health care facilities to select and implement sharps injury prevention devices. In addition, the studies are mainly uncontrolled and involve ‘before-and-after’ assessments of injury rates when new devices are introduced, bringing the potential for several biases. However, if these results are valid and can be extrapolated to non-research settings, a reduction in injury rate of ~50–60% might be possible with phlebotomy devices and safety butterflies [50–52] and ~80% for cannulae [53–55]. There is little published evidence for needle and syringe devices. One study of a shielded safety syringe suggested an 86% reduction in injuries [56], while another controlled study found a 50–61% reduction, but with similar findings in areas which did not use safety devices [57]. A study of safety syringes in a dental setting reportedly reduced the injury rate to zero [58]. An extrapolation from the similar shielding technologies used for phlebotomy devices would suggest up to 50% of injuries associated with intramuscular injections drawn up with needle-and-syringe might be preventable. The Scottish study concluded that up to 78% of injection-related injuries might be preventable [46]. At present, there appear to be few pre-filled syringe products with engineered safety features.

Although little is published [59,60] on automatically retracting lancet devices, intuitively these ought to have a very high rate of injury prevention due to the nature of their design. There are several studies [61–68] of needleless intravenous devices showing large reductions in injuries associated with accessing IV lines (70–80%). Some of the best quality of evidence is for blunt suture needles. Studies in operative surgery [13,18,19,69–74] including controlled trials, showed evidence of injury reduction of 70–80%. We could find no published evidence either on efficacy concerning sharps pads in theatre or for safety scalpels. Several before-and-after studies [75–77] of the effect of conversion to safety devices show an association with injury reduction. One such study, by Sohn et al. [75], demonstrated a 58.2% decrease in rate of injuries per 1000 employees. The largest effect was shown for intravenous cannulae (88.2%, P < 0.001).


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conflicts of interest
 References
 
This review found that organizational rates of reported sharps injury in the UK vary between 0.8 and 5 per 100 person-years. Using another denominator, organizational rates are of 11–14 injuries per 100 hospital beds per annum. These figures are comparable, although lower than those reported from some US health care settings (5.5 per 100 person-years [79] and 18–26 per 100 hospital beds [25]). Blood or body fluid exposure data are beset by the problem of under-reporting and estimates of true injury rates have varied significantly. When questionnaire-based UK studies of HCW cohorts are compared with the organizational studies, the results are striking. Estimated rates of injury of between 30 and 284 per 100 person-years are seen. This suggests that the true rate of injury in UK settings is a multiple of the reported rates, possibly as much as 10-fold. A recent US calculation of numbers of percutaneous injuries [27] applied a reporting rate of 43% and when this is applied to UK EPINet figures, results in an estimate of ~56 000 injuries per annum. However, if UK HCW are even worse at reporting than their American counterparts, this figure could be considerably higher.

Syringes are normally reported as the device responsible for the greatest number of injuries but when the rate is calculated per device usage [80,81] analysis of injury rates reveals that syringes account for the lowest rate of needlestick injury (3.8–6.9 per 100 000 devices used) and IV catheter stylets accounted for the highest rate (15.7–18.4/100 000 devices used). This situation may be changing, with phlebotomy devices catching up or overtaking syringes. Clinical practice is changing, with far fewer intramuscular injections as a means of drug delivery in hospital. Parenteral drug administration now tends to be intravenous or by subcutaneous infusion. This might account for some of the reduction in rates seen in the USA, as well as the mandated use of engineering controls. The absolute number of sharps injuries is often reported as highest in nursing staff. Proportionally, the number of injuries sustained by medical staff is higher, given their representation in the workforce [82]. Data summarized from prospective studies of sharps injuries indicated a rate of 1.8 sharps injuries per year for physicians and 0.98 for nurses working on the same medical wards [83].

The risk of viral transmission in most UK settings is, overall, relatively low. This needs to be borne in mind during follow-up and management of workers following such exposures. The greatest morbidity is likely to be from anxiety arising from perceived risk. This is why this review included Table 3, an extrapolation of Scottish population data in order to calculate likely risk when the precise serological status of the source patient is unknown, as is often the case. This suggests that the risk of acquiring HIV from a source with no risk factors is of the order of one in one million, and of HCV, one in 62 000 (using a transmission rate of 0.6%, likely to be a more realistic figure than the older assumed rate of 3% and the more recently accepted 1.8%). Further extrapolating from HPA data, a rate of transmission by acute hospital bed was calculated for the geographical area. This figure must be interpreted with caution, but it does illustrate the relative rarity of BBV transmission to date. Whether the six HCV transmissions within the 2003–04 year is a harbinger of increased rates remains to be seen. The statistic of only one definite HIV transmission to a HCW in the UK since 1993 offers further reassurance, though not complacency.

While iterative training of users will always be important in prevention, engineering controls are likely to be more effective. Although safety-engineered devices have been in use in the USA for several years, efficacy data are sparse, possibly due to the sample sizes required to demonstrate injury reductions. The data that exist are reasonably persuasive, though the magnitude remains uncertain, particularly for devices such as syringes. All devices will have instances of equipment failure or in the case of passive devices, operator misuse therefore are never likely to be 100% effective. Cannulation devices, especially those with passive safety controls, have good evidence of injury reduction. Similarly, blood collection devices have reasonable evidence for efficacy. Before-and-after studies by Sohn et al. [75] and Rogues et al. [76], showed substantial overall reductions in injury rates following conversion to safety devices. The Sohn study, although uncontrolled, showed that reporting rates appeared unaffected by the intervention, suggesting this was not an important bias [78]. The best quality evidence is for blunt suture needles and the fact that randomized controlled trials have been possible eloquently demonstrates the high rate of injury found in operative surgery. Surgical directorates should be strongly encouraged to use these routinely for appropriate indications such as fascial closure.

In summary, sharps injuries in the UK remain common and are likely to be grossly under-reported. However, given this rate of injury, proven BBV transmission is rare. Occupational health staffs need to tread a fine line between adequate aftercare and follow-up, which should include serological testing for high-risk exposures, and causing ill-health by provoking anxiety. Safety-engineered sharps devices, dependent on type, are likely to be successful in preventing injury and should be considered as part of any sharps injury prevention programme.


Key points
  • Sharps injuries recorded through standard occupational reporting systems may underestimate the true injury rate, as much as 10-fold.
  • Recorded occupational HCV or HIV transmission in the UK remains rare at 1.43 transmissions per annum in England, Wales and Northern Ireland.
  • Risk of BBV infection from sources with no risk factors is extremely small.
  • Safety-engineered sharps devices are likely to reduce rates of injury with the greatest reductions seen with safety cannulae and blunt suture needles.

 


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
References
 
None declared.


   Acknowledgements
 
We thank the Occupational Health and Safety Strategy Implementation Group of the Scottish Executive for funding this study.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 

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