Needlestick Injuries and Blood and Body Fluid Splash Among Health Care Workers: A Trend Analysis

Introduction

Health care workers involved in patient care include doctors, nurses, lab technicians, and support staff, such as housekeeping personnel. These workers are exposed to occupational hazards, including physical, biological, chemical, and psychosocial risks.¹ Among these, the most important biological infections-hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), are primarily transmitted through needlestick injuries (NSIs) or blood and body fluid splashes. The estimated risk of infection following exposure is approximately 30%-60% for HBV, 10%-50% for HCV, and 0.3% for HIV.² In developing countries, the risk of these infections is high due to inadequate safety precautions and overuse of injections for treatment.³

Globally, an estimated three million health care workers experience sharp injuries each year. Among them, nurses are at the highest risk due to their frequent involvement in direct patient care.⁴ In developing countries, however, it is reported that up to 75% of needlestick injuries go unreported.⁵ The primary reasons include a lack of awareness, and the perception that such injuries are trivial.⁶ Contributing factors for NSI include the failure to use appropriate personal protective equipment (PPE), limited clinical experience, particularly among resident doctors, and long working hours. Needle recapping after injection administration can also pose a significant risk of injury. Patients may move unexpectedly while an IV line is being started or during intramuscular or IV injections. Syringes with needles and intravenous cannulas can cause injuries to the fingers. Often, health care workers (HCWs) disregard such pricks, perceiving them to be insignificant to report, as they do not affect their health immediately. Consequently, first aid measures are frequently overlooked, especially when the patient's status regarding HBV, HCV, or HIV is unknown.

With this background, the present study was undertaken with the following objectives: To study the trends in the incidence of needlestick injuries and blood/body fluid splashes and to determine the proportion of health care workers experiencing NSIs, identify contributing factors, and assess measures taken in response.

Material and Methods

Institutional ethical clearance was obtained prior to the commencement of the study. Retrospective data were collected over a seven year period (2017-2023). Monthly data were presented by the infection control nurse during hospital infection control meetings. Doctors and nurses received orientation on needlestick injuries and incident reporting during induction training. Each ward maintained an injury register, including nil reporting, and the ward supervisor was responsible for monitoring such events. A written report was sent to the nominated Nodal Officer, which included the details of first aid measures taken, as well as HIV, HBV, and HIV status of both source patient and the exposed health care worker. Further action was recommended by the Nodal Officer based on WHO and CDC guidelines. Prior to 2017, training on NSIs was need-based and unstructured. Information on the number of staff involved in patient care from 2017 onward was obtained from the Human Resources department of the hospital. The health care workers included postgraduates and interns, doctors, nursing staff and students, lab technicians, housekeeping staff, waste handlers, and other personnel involved in patient care. During the study period, total number of nursing staff ranged from 723 to 1,160, doctors from 390 to 490, and housekeeping staff from 175 to 400.

Results

A total of 207 needlestick injuries (1.47%) were reported over the seven-year period among an average of 2,003 staff. Of these, 90 cases (43.5%) occurred among doctors, 60 (29.0%) among nurses, 46 (22.2%) among housekeeping staff, and 11 (5.3%) among waste handlers employed in the hospital and the urban local body (ULB).

Table 1 shows an increasing trend in the incidence of needlestick injuries among health care staff. The highest incidence (2.12%) was observed in the year 2019, with the lowest incidence (1.10%) observed in 2020 during the COVID-19 pandemic. It was also noted that from 2022 to 2023, there was a reduction in staff numbers, most noticeably among nurses.

Table 2 shows that 90 doctors experienced at least one needlestick injury during the seven-year period. Contributing factors include lack of experience, long hours of duty, and exhaustion. Most affected were interns and junior doctors with limited practical experience. Injuries reported from camps and government health centers were also included in the analysis.

Table 3 shows that 60 staff nurses experienced needlestick injuries during the study period. When compared with doctors, the difference between the two groups of hospital staff was statistically significant (P <0.001). These findings suggest that staff nurses exercise greater caution while handling syringes, needles, and performing procedures.

As shown in Table 4, proportion of doctors sustaining needlestick injuries as compared to nurses was higher in the years 2018, 2019, 2021 and 2022, which was statistically significant (P <0.001).

Blood and body fluid splashes were observed exclusively among doctors (n=5, 2.4%). The majority of injuries occurred in the upper limbs (n=195, 94.2%) among doctors and nurses, followed by the lower limbs among waste handlers (n=7, 3.4%).

The most common device responsible for injuries was the needle, particularly during biomedical waste handling and suturing procedures performed by surgeons. Needlestick injuries were most frequently reported from the wards (n=84, 40.5%) (Table 5). Following an injury, immediate first aid and incident notification were carried out. Waste handlers from ULB were vaccinated as per schedule. Among those who had completed the full course of immunization (n=136, 65.7%), testing for antibody titre was advised, while the health care staff who were partially immunized (n=30, 14.5%) were instructed to complete the course.

Among the source patients, 17 (8.2%) were HBsAg positive, 9 (4.3%) were HCV positive, 11 (5.3%) were HIV positive, 1 (0.5%) was positive for both HIV and HBsAg. A total of 120 patients tested negative (29.5%), while 49 cases (23.6%) had an unknown status. These findings highlight that health care staff are at considerable risk of exposure, particularly during emergency situations.

Discussion

This retrospective record analysis covered a seven-year period beginning in 2017. The infection control nurse, in collaboration with the hospital microbiologist from the Infection Control Committee, analyzed the root causes of incidents and presented monthly reports on the incidence of needlestick injuries. These reports included details on the site and mechanism of injury. Self-reporting forms captured the viral marker status of both patients and health care workers. The hepatitis B vaccination status of health care workers-complete, incomplete, or partialwas documented, and follow-up was conducted for six months. 

Among the NSIs, totalling approximately 47 cases, the annual incidence rate was 0.13, with the highest observed in ICUs and most frequently attributed to needle recapping (36.2%).⁷ A systematic review reported a one-year prevalence of 26.0% and 20.9% between 2012 and 2020. These findings underscore the urgent need to strengthen occupational safety practices and implement protective devices in healthcare systems.⁸ In the present study, the highest incidence was recorded in the wards, primarily due to biomedical waste handling. It was also noted that 41 health care workers, including waste handlers, had not been immunized against hepatitis B.

In a study conducted among 656 health care workers, sharp injuries and blood and body fluid exposures were reported in 40.7% and 39.8% of participants, respectively. Students were noted to be at greater risk of needlestick injuries (P =0.04).⁹ In a tertiary care hospital in Delhi, among 322 resident doctors, 169 reported immediately washing the injury site, while 38 did not wash or clean the site. Additionally, only 20 doctors sought post-exposure prophylaxis (PEP).¹⁰ In the present study, all injured health care staff were observed for adherence to first aid measures, including cleaning the site, informing the nodal officer, and seeking post-exposure advise and prophylaxis.

A three-year analysis of NSIs reported 56 cases, with an incidence of 10.4 per 100 occupied beds per year. Similar to the present study, the highest occurrence was noted among doctors, in the wards, and during phlebotomy. In that study, 64.2% of health care workers had received hepatitis B vaccination, but only 5.4% completed post-exposure prophylaxis.¹¹ In the present study, 138 (66%) health care workers had completed the full course of hepatitis B vaccination. Infection control nurses are responsible for identifying the immunization status of health care workers and assuring appropriate implementation. 

In a systematic and pooled review of 18 years of data, the highest prevalence of NSIs was reported from the Southeast Asia region, with hypodermic needles identified as the most common cause.¹² The causes for NSIs in that review were comparable to the present study (77.7%). In a study conducted among nurses working in a tertiary hospital in North India, the majority of injuries occurred in the wards, a finding consistent with the present study.^13,14

In a cross-sectional study conducted in 2012 among 209 health care workers, 29% reported needlestick injuries, with nurses accounting for the majority (62.2%), followed by lab technicians (17.7%).¹⁵ In another study involving 268 nurses, 36.2% sustained needlestick injuries from contaminated needles, most often due to recapping after use and while working in paediatric wards.¹⁶ In contrast, in the present study, the highest incidence was observed among doctors (n=90, 43.5%).

In a study on NSI reporting among 60 randomly selected doctors, nurses, and support staff, only 40% reported their injuries to the appropriate authorities.^17,18 In another study involving 173 health care workers, the one-year prevalence of NSIs was 44.1%, with IV needles, surgical blades, and intramuscular needles. Hollow-bore needles accounted for 46.4% of cases.¹⁹ In a government hospital, the maximum injuries occurred in the wards and involved nursing staff and students. While some workers reported the injuries, only a few had received three doses of HBV vaccination.²⁰

In a similar ten-year analysis conducted at a tertiary hospital, 76 NSI incidents were reported. Among these, three cases involved hepatitis B positive sources, one involved HIV positive source. PEP was administered to eight health care workers who had high-risk exposures.²¹

Conclusion

This study demonstrates that despite regular training and monitoring, lapses persist among health care workers in adhering to standard guidelines. Incorporating NSI surveillance into academic evaluations or performance appraisals may further help reduce the incidence of needlestick injuries.

Conflict of Interest

Nil