Indian J Med Res 131, March 2010, pp 405-410

Needle stick injuries among health care workers in a tertiary care

hospital of India

Sumathi Muralidhar, Prashant Kumar Singh*, R.K. Jain, Meenakshi Malhotra & Manju Bala

Regional STD Teaching Training & Research Centre, Safdarjang Hospital, *Vardhman Mahavir Medical College
& Safdarjang Hospital, New Delhi, India

Received March 25, 2009

Background & objectives: Percutaneous injuries caused by needlesticks, pose a significant risk of
occupational transmission of bloodborne pathogens. Their incidence is considerably higher than current
estimates, and hence a low injury rate should not be interpreted as a non existent problem. The present
study was carried out to determine the occurrence of NSI among various categories of health care
workers (HCWs), and the causal factors, the circumstances under which these occur and to, explore the
possibilities of measures to prevent these through improvements in knowledge, attitude and practice.
Methods: The study group consisted of 428 HCWs of various categories of a tertiary care hospital in
New Delhi, and was carried out with the help of an anonymous, self-reporting questionnaire structured
specifically to identify predictive factors associated with NSIs.
Results: The commonest clinical activity to cause the NSI was blood withdrawal (55%), followed by
suturing (20.3%) and vaccination (11.7%). The practice of recapping needles after use was still prevalent
among HCWs (66.3%). Some HCWs also revealed that they bent the needles before discarding (11.4%).
It was alarming to note that only 40 per cent of the HCWs knew about the availability of PEP services in
the hospital and 75 per cent of exposed nursing students did not seek PEP.
Interpretation & conclusions: The present study showed a high occurrence of NSI in HCWs with a high
rate of ignorance and apathy. These issues need to be addressed, through appropriate education and
other interventional strategies by the hospital infection control committee.

Key words Disposal practices - health care workers - needlestick injury - recapping practices

Percutaneous injuries, caused by needle sticks
and other sharps, are a serious concern for all health
care workers (HCWs) and pose a significant risk of
occupational transmission of blood borne pathogens.
Needle stick injuries (NSI) are wounds caused by
sharps such as hypodermic needles, blood collection
needles, iv cannulas or needles used to connect parts of
iv delivery systems. The causes include various factors
405
like type and design of needle, recapping activity,
handling/transferring specimens, collision between
HCWs or sharps, during clean-up, manipulating
needles in patient line related work, passing/handling
devices or failure to dispose of the needle in puncture
proof containers1. Because of the environment in which
they work, many HCWs from physicians, surgeons,
and nurses to house keeping personnel, laboratory
406 INDIAN J MED RES, March 2010
technicians and waste handlers are at an increased
risk of accidental needle stick and sharps injuries.
As a result, these workers are prone to occupational
acquisition of various blood borne pathogens, including
the microorganisms causing HIV/AIDS, hepatitis B
and C, malaria, infectious mononucleosis, diphtheria,
herpes, tuberculosis, brucellosis, spotted fever and
syphilis1.
The incidence of NSI is considerably higher than
current estimates, due to gross under-reporting (often
less than 50%)2,3. In USA 6,00,000 to 10,00,000
receive NSI from conventional needles and sharps
every year, while in UK it is 1,00,000 HCWs/year4.
In India, authentic data on NSI are scarce. It is known
that around 3-6 billion injections are given per year, of
which 2/3rd injections are unsafe (62.9%) and the use
of glass syringe is constantly associated with higher
degree of unsafety5.
The financial impact of NSI includes both direct and
indirect costs6-8. The average percutaneous transmission
rates for hepatitis B (HBV) and C (HCV) are 33.3
(6-33%) and 3.3 per cent (1-10%), respectively, while
the seroconversion risk for HIV is 0.31 per cent9.
Although HBV exposures pose the highest risk for
infection, it has an effective vaccine and post exposure
prophylaxis (PEP) for HCWs which can dramatically
reduce the risk. This is not so for HCV and HIV.
Therefore, prevention is the only recourse for these.
Preventing NSI is an essential part of any blood
borne pathogen prevention programme in the work
place. Every healthcare facility should have an
infection control programme in place through a
working hospital infection control committee. The
present study addresses the important issue of NSI
and aims at determining the occurrence of NSI among
different categories of HCWs, the various factors
responsible, the circumstances under which these
occur and explores the availability and possibilities
of measures to prevent these through improvement
in knowledge, attitude and practice. The study also
aims at assessing the awareness levels among various
categories of HCWs, on issues like NSI policy,
segregation of sharps at source and the use and
availability of safety devices to prevent NSI.
Material & Methods
This study was carried out among the HCWs (both
males and females) of a large, 1600 bedded, Vardhman
Mahavir Medical College and Safdarjang Hospital, a
tertiary care, teaching hospital in New Delhi, India.
The study group consisted of various HCWs including
senior residents, junior residents, interns, undergraduate
medical students, staff and student nurses and staff and
student laboratory technicians. The study was carried
out over two months from July to September of 2007
with participation from 428 HCWs.
Subjects were fully informed about the design
and purpose of the study and a written informed
consent was obtained. The study was carried out
with the help of an anonymous, self-reporting
questionnaire structured specifically to obtain both
qualitative and quantitative data to identify predictive
factors associated with NSIs. Questions relating to
awareness regarding preventive measures like HBV
immunization, use of safety devices and course of
action in the event of a NSI from an unknown source,
were also included.
Case definition of NSI in the present study included
injuries caused by sharps such as hypodermic needles,
blood collection needles, iv cannulas, suture needles,
winged needle iv sets and needles used to connect parts
of the iv delivery systems.
The HCWs who gave a history of NSI were directed
to seek advice on PEP and infection control measures
from the Regional STD Centre, Safdarjang Hospital
which has a NSI protocol in place.
Clearance of study protocol was obtained from the
institutional ethics committee before the start of the
study. Findings were analyzed under different headings
to uncover various aspects of NSI. The statistical tools
employed were-ratio, proportion pie charts, histograms
and other basic methods of data interpretation.
Results
A total of 428 HCWs participated in the study,
including senior residents 60 (14%), junior residents-
24 (6%), interns-75 (17%), undergraduate medical
students-75 (18%), staff and student nurses -49 (11%)
and 75 (18%) respectively, staff and student laboratory
technicians -70 (16%).
Of these, 343 (80.1%) gave a history of NSI in the
preceding one year. Nineteen received the NSI outside
the healthcare facility. Among the HCWs with NSIs,
nurses had the highest percentage 49(100%), followed
by junior residents 21(87.5%), nursing students
64(85.3%), laboratory technicians 59(84.3%), interns
62(82.7%), senior residents 48(80%) and undergraduate
students 40(53.3%).
 Muralidhar et al: Needle stick injuries among healthcare workers 407

Fig. 1. Relation of NSI with phase of needle use.

Seventy four per cent of HCWs were wearing
gloves at the time of NSI, which included senior
residents (83.3%), interns (85%), junior residents
(62%), undergraduates (59%), staff nurses (71%),
student nurses (60%) and laboratory technicians
(85%).
The length of the needle in most cases of NSI was
medium sized (66.3%), while large (13.7%) and small
sized needles (20%) were also implicated. Seventy one
per cent of the needles involved were hollow bored,
with only 29 per cent being non-bored or curved.
Types of needles included injecting needle (50%),
suturing needle (33%), cannula (13%), other types of
needles (4%). Procedures performed at the time of NSI
included intravenous injections (60%), intramuscular
(37%), subcutaneous (2%) and CSF withdrawal (1%).
The degree of penetration of the needle in the HCW was
subcutaneous (68%), intramuscular (16%), intradermal
(13%) or intravenous (3%). The majority of HCWs
received the NSI after use but before disposal of the
needles (60%) (Fig.1).
The commonest clinical activity to cause the NSI
was blood withdrawal (55%), followed by suturing
(20.3%) and vaccination (11.7%). About 13 per
cent of the HCWs received the NSI due to patient
aggressiveness. Recapping needles was a common
cause of NSI (39%) (Fig. 2).
After a NSI, majority of HCWs took action
instantly (60%), while 14 per cent took action later on
the same day and 26 per cent did not take any action.

Fig. 2. Causes of NSI in HCWs.

408 INDIAN J MED RES, March 2010
The action taken included washing the site with soap
and water and/or cleaning the site with appropriate
agents like alcohol, dettol or other antiseptic agents,
reporting the incident to senior staff and seeking advice
on NSI protocol (testing for HIV/HBV/HCV and PEP)
from Regional STD Centre. It was noticed that 54 per
cent of NSI occurred in second 1/3rd of the duty period,
while 25 per cent occurred in the first 1/3rd and 21 per
cent in the third 1/3rd of duty period. A large number of
HCWs suffered stress after NSI (67%).
A total of 9 HCWs acknowledged receiving NSI
from known HIV seropositive patients (3 were senior
residents, 2 interns and 4 student nurses). None of them
became HIV seropositive over the next three months.
Except 3 student nurses, all these HCWs had full course
of ART drugs.
The effect of NSI on work efficiency reveals that
48 per cent became more cautious, 48 per cent took
better precautions, 1 per cent avoided such procedures,
while in 2 per cent the NSI had no effect and 1 per
cent of HCWs became more casual. Most of the HCWs
were aware of the possibility that NSI could lead to
the acquisition of diseases like HIV, hepatitis B and C,
but not any other diseases. About 34 per cent said that
they had read articles about NSI and thus knew how to
avoid them (mainly senior and junior residents).
Sixty two per cent of HCWs confirmed that they
would wash the area if needle contaminated with HIV
seropositive blood came in contact with skin, whereas
22 per cent said that they would take PEP. When
questioned about the steps to be taken after NSI, 14 per
cent opted for PEP, while 34 per cent felt that a shot of
tetanus toxoid was sufficient, 5 per cent felt that taking
analgesics was enough and 45.5 per cent preferred to
wash the area with soap and water. A small percentage
of HCWs (1.5%) said that they would tie the part with
some material. When questioned about the response to
bleeding at the site of NSI, 66 per cent said that they had
washed the area with soap and water, while 47 per cent
applied spirit/alcohol, 19 per cent used band aid, 0.5 per
cent said that they expressed the blood from the spot,
21.4 per cent scratched the NSI spot, 4 per cent applied
pressure to stop bleeding and 2 per cent left it as it was.
The practice of recapping needles after use was
still prevalent among HCWs (66.3%), with 59 per cent
using both hands. Some HCWs also revealed that they
bent the needles before discarding (11.4%).
When the HCWs were asked about the factors
responsible for NSI, 57 per cent felt that they themselves
were responsible, 12 per cent held the patient
responsible, while 5 per cent complained of employer
being responsible and 26 per cent blamed the facility.
The requisites stated by HCWs for reporting of
NSIs included-type of exposure-64 per cent, type of
device-55 per cent, activity at the time of exposure-
32 per cent, type/amount of fluid on the needle-30 per
cent, duration of the exposure-23 per cent and HIV
status of the source-60 per cent. Only 39 per cent of
HCWs knew about PEP to be taken after NSI.
Discussion
The present study addressed certain aspects of
NSI in a busy tertiary care government hospital and
derived some equivocal and some contrasting results.
It was found that 80 per cent of HCWs had experienced
NSI at some point in their careers. Among the HCWs,
nurses were most prone to NSI, with 100 per cent of
them having experienced it in the preceding one year.
These figures are nearly twice the figures of Exposure
Prevention Information Network (Epinet) data10. This
may be attributed to patient overload and different work
culture in the Indian scenario. Several other studies had
also shown high occurrence of NSI among nurses11-14.
Apart from nurses the NSIs were more among nursing
students, interns and resident doctors. Cervini and
Bell15, have shown that post-exposure practices for
NSI are inadequate among medical students and our
findings corroborate this fact. Another study showed
that increasing surgical experience lowered NSI rates16,
and that specific training and passive prevention
solutions seem more important than enhanced training
and reporting guidelines in preventing NSIs.
Among the HCWs studied, 74 per cent were using
gloves at the time of NSI, a figure which fell short of
the figures shown by Askarian et al (96.2%)17 in Iran.
Majority of the needles associated with NSI were of
medium size, as this was the size most commonly used
in patient care. Our study showed 71 per cent of NSI
to be associated with hollow bore needles, which is
almost the same as shown by Askarian et al (72.2%,)17
and Nee et al18 (62.2%). According to one study by
Epinet in 199910, out of 5000 percutaneous injuries due
to sharps, 62 per cent involved hollow bore needles.
This association can have an impact on transmission of
pathogens, as hollow bore needles are associated with
higher fluid content and pathogen load, with a higher
risk of disease transmission19.
Certain clinical practices such as recapping needles
were related more to the likelihood of being injured.
 Muralidhar et al: Needle stick injuries among healthcare workers 409
This points to inadequate training of HCWs , or their
refusal to follow correct procedures. Other studies have
also condemned the practice of recapping needles and
offered remedial measures20-22.
In >50 per cent NSI cases, the HCW was involved in
withdrawal of blood, as it is the most common activity
involving manipulation of needle in patient. In the
EPInet study10, 38 per cent NSI occurred during needle
use, while 42 per cent occurred after use of needle
and before its disposal. The comparative figures in the
present study were 34 and 60 per cent, respectively.
About 67 per cent of HCWs suffered stress as a
result of the NSI, by their own admission. Other studies
showed similar statistics of stress (55% in EPInet
study)10.
Less than 50 per cent HCWs knew about the
availability of PEP services in the hospital. This was
higher than the figures in a study by Chacko and Isaac
(31.6%)23.
Almost all HCWs were aware that AIDS and
hepatitis B and C can spread by NSI, but very few were
aware of the large number of other diseases linked to
NSI. Thus, increasing staff awareness and educating
them on NSI issues is a felt need, as only 34 per cent
read textbooks or articles about NSI and only 29 per
cent were aware of the average risk of HIV/AIDS from
NSI as against 87.8 per cent in a study from Iran24.
Most HCWs in the present study were of the opinion
that education, training, better safety devices, decreased
patient load per HCW, positive work environment and
following standard precautions can help prevent NSI.
According to a CDC report, use of safety engineered
devices would reduce NSIs by 76 per cent25. There is
much room for improvement in protecting the HCWs
from NSI, which can be accomplished through a
combination of comprehensive programmes, including
stress on institutional behaviour and device related
factors that contribute to the occurrence of these
injuries, seeking alternatives to use of needles wherever
possible, using newer devices with safety features,
ensuring adequate training in safe use and disposal of
needles, putting in place a culture of accident reporting,
especially sharps-related, and following preventive
practices like vaccinations for hepatitis B, as also
stressed by several others 25-27.
Some institutions in India28, have a staff student
health service facility in place, which maintains records,
and registers the incidence of NSI and has protocols for
management and follow-up of NSI cases. This is a dire
necessity in all large health care facilities with a large
turnover of patients and a high rate of NSI.
In conclusion, NSIs were observed in all categories
of HCWs. There is a scope for improvement in safety
protocols. Preventive strategies have to be devised
and reporting of NSI need to be made mandatory.
Issues requiring attention include use of safety
engineered devices (SED), recording and reporting
of incidents, training of all HCWs in handling and
disposal of sharps, establishing a staff student health
service and inculcating a responsible attitude among
HCWs.
Acknowledgment
The authors acknowledge the Indian Council of Medical
Research (ICMR-STS), New Delhi, for support rendered in carrying
out this study.
Conflict of interest: All authors report no conflicts of
interest relevant to this article.
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