Sharps injuries - WHO

1 Environmental Burden of Disease Series, No. 3 Sharps injuriesGlobal burden of disease from Sharps injuriesto health-care workersAnnette Pr ss- st nElisabetta RapitiYvan HutinSeries EditorsAnnette Pr ss- st n, Diarmid Campbell-Lendrum, Carlos Corval n, Alistair WoodwardWorld Health OrganizationProtection of the Human EnvironmentGeneva 2003 WHO Library Cataloguing-in-Publication DataPr ss- st n, injuries : global burden of disease from Sharps injuries to health-careworkers / Annette Pr ss- st n, Elisabetta Rapiti, Yvan Hutin.(Environmental burden of disease series) injuries - complications , Stab - complications pathogens B - etiology C - etiology infections- etiology , Occupational personnel of illness , Elisabetta. , Yvan J. F. ISBN 92 4 156246 3 (NLM classification: WO 700) ISSN 1728-1652 Suggested citationPr ss- st n A, Rapiti E, Hutin Y.

2 Sharps injuries : global burden of disease fromsharps injuries to health-care workers. Geneva, World Health Organization, 2003(WHO Environmental Burden of Disease Series, No. 3). World Health Organization 2003 All rights reserved. Publications of the World Health Organization can be obtained fromMarketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: for permission to reproduce or translate WHO publications whether for sale or fornoncommercial distribution should be addressed to Publications, at the above address (fax:+41 22 791 4806; email: designations employed and the presentation of the material in this publication do notimply the expression of any opinion whatsoever on the part of the World Health Organizationconcerning the legal status of any country, territory, city or area or of its authorities, orconcerning the delimitation of its frontiers or boundaries.))

3 Dotted lines on maps representapproximate border lines for which there may not yet be full mention of specific companies or of certain manufacturers products does not imply thatthey are endorsed or recommended by the World Health Organization in preference to othersof a similar nature that are not mentioned. Errors and omissions excepted, the names ofproprietary products are distinguished by initial capital World Health Organization does not warrant that the information contained in thispublication is complete and correct and shall not be liable for any damages incurred as aresult of its by the WHO Document Production Services, Geneva, of ContentsiiiTable of and Study Exposed Exposure Minimum Estimating risk Number of health-care workers exposed to contaminated Distribution of health-care workers at risk, by Age distribution of health-care Exposed Estimating the number of Sharps Estimating hepatitis B vaccine coverage among health-care Prevalence of infection with HBV.

4 HCV and HIV in thegeneral The relationship between risk factor and Estimating contamination rates from disease Postexposure Estimation of the number of Uncertainty Sharps injuries and Sharps injuries and Sharps injuries and Limitations to the 1 Country groupings for global of TablesivList of TablesTable 1 Proportion of professional nurses and midwifes among allhealth-care workers at 2 Number of health-care workers at 3 Proportion of males among "health-care workers" and"health and social workers", selected 4 Proportion of males among at-risk health-care 5 Annual incidence of Sharps 6 Country populations covered by injury 7 Health-care workers exposed to at least one percutaneous injurywith a sharp object contaminated with HBV, HCV and 8 Proportions of health-care workers exposed to contaminatedsharps injuries per 9 Hepatitis B vaccine coverage among health-care 10 Prevalence of HBV, HCV and HIV among hospital patientsand the general 11 Sharps -associated infections in health-care 12 Sharps -associated HBV and HIV infections in health-careworkers without 13 Fraction of HCV, HBV and HIV infections in health-careworkers attributable to contaminated workers are at increased risk of infection with bloodborne pathogensbecause of occupational exposure to blood and other body fluids (Gerberding, 1990;Mangione et al.)

5 , 1991). Most exposures among health-care workers are caused bypercutaneous injuries with sharp objects contaminated with blood or body fluids(Romea et al., 1995; EPINet, 1998; NaSH, 1999; CCOHS, 2000; Puro et al., 2001). These Sharps include needles, scalpels, lancets and broken glass. The pathogensmost commonly transmitted to health-care workers in occupational settings are thehepatitis B and C viruses (HBV, HCV) and the human immunodeficiency virus(HIV) (Sepkowitz, 1996a). Health-care workers may also acquire other infectionsfrom bloodborne pathogens ( Creutzfeld-Jakob disease), airborne pathogens ( , varicella, influenza) or faecal-oral pathogens ( hepatitis A,salmonellosis) (CDC, 1995; Sepkowitz, 1996a,b). However, the risk of infectionfrom these pathogens is either lower than that from HBV, HCV and HIV, or has onlybeen poorly risk of infection of health-care workers from contaminated Sharps should beconsidered part of a larger risk-factor group called unsafe injections (Hutin &Chen, 1999).

6 A safe injection is defined as one that does not harm the recipient, theprovider or the community. Thus, unsafe injections include those that lead toinfections in injection recipients (Hauri et al., 2003), or in providers before, duringor after injections, as well as injections by contaminated Sharps that have beenimproperly disposed of in the community and that lead to infection. Although theimpact of unsafe injections is far greater among recipients, the bloodborne pathogensintroduced by contaminated needle-sticks nevertheless cause a high burden of deathand disability among health-care workers. Because of their effect on health-careworkers, unsafe injections may also have indirect consequences on health-caredelivery, particularly in regions where the qualified work force is small compared tothe disease burdens in the percutaneous exposures to bloodborne pathogens can be prevented bystrategies that include: immunization against HBV; procedures to preventpercutaneous injuries ; and postexposure prophylaxis (PEP) to prevent thedevelopment of disease.

7 But in many countries, it has not been possible toimplement such strategies because no supporting estimates of the disease burdenassociated with occupational exposure to bloodborne pathogens have been separate guide is being prepared to help countries assess the national or localdisease burden from Sharps injuries in health-care workers (Rapiti et al., 2003). Theguide will provide a practical step-by-step approach, using numerical examples, andcan be adapted to local circumstances and data and acknowledgementsviAffiliations and acknowledgementsAnnette Pr ss- st n, Elisabetta Rapiti, Yvan Hutin, Carlos Corval n and DiarmidCampbell-Lendrum are from the World Health Organization and Alistair Woodwardis from the Wellington School of Medicine, New would like to thank the numerous reviewers, in particular Janine Jaegger, JulianGold, Jukka Takala, Winnie Boal, Daniel Lavanchy, Neff Walker and BernhardSchwartlander and the anonymous reviewers, who have contributed, by their valuablecomments and contributions, to the development of this study.

8 We also would like tothank the US Environmental Protection Agency for having supported the developmentof the Environmental Burden of Disease approaches. Finally, we are grateful to KevinFarrell and Eileen Brown who put this document into its final the occupational transmission of hepatitis B virus (HBV), hepatitis C virus(HCV) and human immunodeficiency virus (HIV) has been documented in health-care personnel, and a number of countries have national surveillance programmes foroccupational infections, the burden of disease from such infections has not yet beenestimated at the global modelled the incidence and fraction of HBV, HCV and HIV infections that wereattributable to a workplace percutaneous injury with a needle or sharp contaminatedwith bloodborne pathogens. The model was based on probabilities for the occurrenceof joint events or states, including the probability of injury, the prevalence of activeinfection in the population, the susceptibility of the worker, and the percutaneoustransmission potential.

9 The model assumed that the risk of infection increased almostproportionally to the number of infectious individuals in the population, and wasapplied to 14 geographical regions, grouped on the basis of the WHO Region andmortality strata (Annex). For developed regions, the effects of PEP for HBV andHIV were included in the proportion of health-care workers in the general population varied substantiallyby region ( ), as did the average number of injuries per health-care worker( Sharps injuries per year). The annual proportions of health-care workersexposed to bloodborne pathogens was for HCV, for HBV and forHIV, corresponding to about 16 000 HCV infections and 66 000 HBV infections inhealth-care workers worldwide. According to the model, 200 5000 HIV infectionswould also be caused (with an expected value of 1000 HIV infections).

10 Indeveloping regions, 40% 65% of HBV and HCV infections in health-care workerswere attributable to percutaneous occupational exposure. In developed regions, bycontrast, the attributable fraction for HCV was only 8% 27%, and that for HBV wasless than 10%, largely because of immunization and PEP. The attributable fractionfor HIV in the various regions ranged between 11%.ConclusionsHealth-care workers are frequently exposed to percutaneous injuries withcontaminated Sharps , which cause a large proportion of all HCV, HBV and HIVinfections in this group. These infections could largely be prevented, as shown bythe lower numbers of infections in regions where efforts have beenmade to reduce such World Health Organization estimated the global disease burden fromcontaminated Sharps injuries to health-care workers at the workplace by analysing25 risk factors that covered occupation, environment, lifestyle, diet, health practicesand substance abuse (WHO, 2002).