Accident | Blenkharn Environmental

HIV infection after sharps injury

There has been an increasing tendency in recent years to downplay the risks of acquiring bloodborne virus infection. Statistics are quoted, showing that in general the risks of acquiring a bloodborne virus infection are:

for HIV transmission after a percutaneous exposure approximately 0.3%
for HBV transmission 6 to 30%,
and for HCV transmission is approximately 1.8%

Easy stats and generally low numbers. Reinforcing the message that the risks might be small is the fortunately exceptionally low incidence of reported cases of seroconversion, and an understanding that the risks may be higher with a deep wound, with a large bore hollow needle, with a needle heaving contaminated with fresh blood, with a needle used only moments before with a patient who had a high viral load. Added to this are reassuring messages of the value of immediate first air – making the wound bleed and washing it thoroughly with soap and water – or seeking immediate medical advice and, if appropriate, of taking post-exposure prophylactic (PEP) drugs to prevent HIV and a big jab in the buttock to protect against Hepatitis B. And then, all will be hunky dory!

But of course that isn’t quite so straightforward. Not everyone will receive that immediate first aid from an infectious diseases specialist who can properly manage subsequent PEP and follow-up. Others may be fobbed off and sent away from A&E for just a ‘trivial’ wound without thought for the impact and implications.

Others may simply fob off a small scratch or blood splash to already broken skin or to the eyes, dismissing that splash inoculation as simply a nuisance without recognition of the significant infection risks that it may carry. And how to manage the post-injury follow-up in the information is incomplete; if the needle had been discarded and the period between use and injury is not known; if the needle user cannot be identified?

Since a high proportion of IV drug users are Hepatitis C positive the risks must be heightened, but evidence from albeit a handful of reports are that assessment in A&E is inadequate and even if you can progress past the first triage assessment and see a junior doctor few such sharps injuries are recognised as potentially serious enough to warrant immediate referral to a specialist.

That immediate referral is now mandated by EU Council Directive 2010/32/EU for health service employees but as yet there is no evidence for similar standards for non-healthcare employees such as waste handlers and local authority staff who are being fobbed off with possibly inadequate treatment.

The implications may be profound.

We are increasingly aware of the often severe and profound psychological impact of sharps or needlestick injury† that has been in the news recently after a scientific investigation of this problem but which has been discussed many times over the years on the Clinical Waste Discussion Forum (check using the search system and browse the archive files). This too requires care in the immediate management and follow-up of sharps injuries and other blood and bloodstained body fluid exposures. Those who may be at risk by virtue of their employment must be trained properly and adequately briefed to ‘make a fuss’ for prompt specialist treatment in exposure does occur.

The various criteria and conditions of exposure or injury noted above can heighten or reduce the risk profile of any individual sharps injury event. So it is with considerable concern to read a recent case report from Brazil:

Brum MCB, Filho FFD, Yates ZB, Viana MCV, Chaves EBM. HIV seroconversion in a health care worker who underwent postexposure prophylaxis following needlestick injury. American Journal of Infection Control 2013; 41: 471-2

They describe a case of HIV seroconversion in a health care worker who underwent PEP after accidental HIV exposure in Brazil. In December 2007 a nursing assistant aged 42 years working in an infectious disease unit experienced a thumb injury while performing a hemoglucotest. The health care worker wore a latex glove during the procedure yet was injured while collecting the test device, the lancet of which had not been completely enclosed and was left on the table after the procedure. The percutaneous injury on the surface of the thumb caused slight bleeding that was immediately washed.

Leaving aside the possibility of drug resistance of this particular strain of HIV, which was a possibility but was not proven by laboratory testing, this worker had PEP initiated within 2 hours of injury, maintained for 28 days. However, 4 months after exposure the worker was diagnosed with HIV infection.

There are several levels of concern. Not least is the observation that injury was caused by a lancet, a thin cutting spike intended to draw just a drop of blood from a finger prick for blood sugar testing. No hollow bore needle, and no deep injury – lancets are designed to prevent deep injury no matter how hard you try. These circumstances would, almost certainly, screen out a sharps injury victim from almost every sharps injury management protocol.

† Green B, Griffiths EC. Psychiatric consequences of needlestick injury. Occupational Medicine 2013; 63: 183–8

Community drug waste collections

Once again, we can report of the success of one of the very many drug waste take-back schemes operating in communities in the US.

The Clark County Sheriff’s Office, the federal Drug Enforcement Administration and other local agencies collected 819 pounds of medical waste at a drug take-back event Sept. 29 in Fisher’s Landing. The event collected 10 pounds of inhalers used for asthma. The most recent have occurred in Washington State, netting 420 pounds of medical waste during a four-hour take-back event organised by the Battle Ground Police Department [great name!] which included 267 pounds of controlled substances which will be shipped to the Drug Enforcement Administration for destruction.

The event was sponsored by the DEA in partnership with the Clark County Sheriff’s Office, Clark County Environmental Services, PREVENT! Coalition, and Prevent Together: Battle Ground Prevention Alliance.

The intention of the drug take-back event was to keep medications out of the hands of kids, while also safely disposing of them and preventing them from seeping into landfills and water supplies.

Medications can still disposed of at the Battle Ground Police Department office, thus promoting regular safe disposal without stockpiling, and offering a disposal option that improves on placing unwanted drug waste into the domestic waste stream or down the toilet thus improving environmental protection. Continue reading “Community drug waste collections” »

Non-BBV infections after needlestick injury

Needle with drop of blood Sharps or needlestick injury carries with it, in some circumstances, a predictable risk of bloodborne virus infection. The statistics, from which risk can be calculated, are well known and relate to the “average” used hollow bore needle used in clinical practise, and sharps injuries occurring during or soon after use.

There are many additional variables including the time between use of the needle and its involvement in a sharps injury, the amount of blood that it contains, the bore of the needle and depth of injury, the immune status of the victim, post-injury care, the virus concentrations in the blood if any, the time interval between injury and post-exposure prophylaxis if this is indicated, and probably other factors of which we know very little.

But we must not close our minds to the possibility that sharps-related infections are limited to HIV, Hepatitis B and Hepatitis C infections. Other infections can and do occur. In fact, the diversity of infections that have been reported is substantial though the list is bolstered by many individual laboratory acquired infections that arise as, one must hope, a one-off occurrence. Continue reading “Non-BBV infections after needlestick injury” »

Reversal of no liability finding for needlestick injury

In a landmark case involving reversal of a no liability finding for needlestick injury that occurred in a Queensland holiday apartment the circumstances of injury, and the legal wrangles, send shivers down the spine.

Wright v KB Nut Holdings Pty Ltd [2013] QCA 66

The Queensland Court of Appeal has held a hotel manager liable for a needlestick injury that a guest sustained while staying in a short-term rental apartment, reversing the original decision of no liability.

The trial judge had not been satisfied that a more competent cleaner or system of cleaning would have led to the discovery of the needle (which was in the crease of a stairwell and was dislodged by the guest when she was cleaning the apartment). He did not consider it reasonable to expect an apartment manager or cleaner to search and discover a concealed needle.

The Court of Appeal reversed this decision, finding that:

it is likely a cleaner using normal skill, diligence and equipment would have detected the needle;
it was probable that the needle was obscured from the guest’s vision as a direct result of the unclean state in which the apartment was handed over to her;
the hotel manager knew or should have known of the risk of injury; and
the build-up of ‘filth’ in the apartment increased the risk that dangerous objects would not be seen until after they were stood on or touched, which may have been with bare feet or hands.

The hotel manager was ordered to pay compensation of $494,759.38, plus interest.

This decision confirms the importance that rental property owners need to place on implementing thorough systems of regular cleaning and inspections.

Quite right too. But isn’t it a warning also, that if you arrive at a rental apartment or hotel room, the immediate response when finding it dirty is to walk back out again and go somewhere else – its not your job to get down and clean it!

And of course, we wish the injured guest well, with the medical and psychological implications of that sharps injury. AS$494,759.38 (about £330.000) should help.

Psychiatric consequences of needlestick injury

Some time has passed since this paper by Green and Griffiths was published. Unsurprisingly, the professional journals and magazines, and the trades union RCN are up in arms about the impact to nurses, and separately to surgeons and physicians. Quite right too.

But the paper, which investigated the psychological welfare of 17 individuals having sharps injury. Only 5 of these five (29%) were in “the health sector (nurses and paramedics)” while the remainder fell into a category of ‘other occupations’ which involved police officers, porters, cleaners, a builder, a manager and one unemployed person.

Of the 3 brief case individual reports included in the paper, only 1 was a healthcare worker. This lady was injured while working in an accident and emergency department. Perhaps a nurse, or possibly a support worker/cleaner, we are not told, the lady was emptying a clinic bin and was replacing a bag when a needle, which had been incorrectly disposed of, pierced her leg. The remaining 2 cases involved a coach driver and postal worker respectively.

Leaving aside the serious issue of a healthcare professional incorrectly placing a used needle into a soft-walled clinical waste sack, the occupations of those involved in this sharps injury series requires further consideration. With so much noised from the medical and nursing professions, about the risks and impact of sharps injury that they may face, it seems that it is the ancillary worker and others who are at real risk.

We at Blenkharn Environmental and at the Clinical Waste Discussion Forum and are doing all we can to highlight the risks of waste handlers and ancillary and support staff. Perhaps the waste and services sectors simply have no voice. At least, they could shout a little louder.

Sharps injury – how much compensation?

Needle with drop of blood I am often asked how much compensation might be expected after a sharps injury, and this is one of the common search terms used when visiting the Clinical Waste Discussion Forum.

For most ancillary workers and waste handlers, expect around £3k, though with legal fees the defendant might expect the cost to fall between £7-10k.

In one notable case here in London, a young doctor suffered a sharps injury and claimed post-traumatic anxiety and stress symptoms that made it impossible for her to handle a needle again. This blighted her career and in the High Court she picked up £500,000! But not so for the rank and file who fare much less well.

Now a recent South Australia case a mum of four has been awarded $494,750 compensation after a holiday unit needlestick incident. The Claimant lived for 18 months with the fear of getting HIV after being stuck by a needle in a “filthy” Brisbane holiday apartment and says she has never recovered from the anxiety of having repeated “indeterminate” HIV test results, until finally getting the all-clear. “It’s ruined my life”.

We should be pleased for the Claimant, that she has finally been shown not to be infected with HIV. The sum awarded, plus no doubt not inconsiderable costs will be picked up by the insurance company. That sum total is the true cost of a sharps injury, which pays more for the post-injury psychological damage than physical injury. Quite rightly, this shows some recognition of the sometimes profound stress and anxiety that can follow sharps injury. In the UK and UK, solicitors are becoming well aware of this and plan their case accordingly, so expect the defence to demand ever more stringent tests to conform the validity of psychological trauma.

Regrettably, there still seems a considerable divide in the sum awarded with compensation payments ranging from £3k to £500k. But then, life is not fair.

‘Sharps’ injury is as traumatic as car crash

The psychiatric distress caused by having a ‘sharps’ injury is consistent with being in a car crash, a study has revealed.

Published in the journal Occupational Medicine, the study explored the psychological effects of needlestick injuries, which can affect an estimated 100,000 people per year.

The study compared levels of depression and symptoms of post-traumatic stress disorder in people who had a ‘sharps’ injury with a control group who had suffered a different psychiatric trauma.

The researchers found that although none of the participants contracted an infection from their injury, psychiatric illness and distress lasted close to two months longer for every month the patient waited for test results.

“The chances of physical damage are what are focused on by society, but these risks are in reality very small,” said lead researcher Professor Ben Green.

He said: “The main health implication of needlestick incidents is probably psychiatric injury caused by fear and worry.” Continue reading “‘Sharps’ injury is as traumatic as car crash” »

Needlestick – does the law help protect?

In a House of Lords debate on 14 March 2013, Lord Turnburg asked the Government “what is their policy on testing for HIV in patients lacking capacity to give consent following a needlestick injury to a healthcare worker”.

It’s an important question, since source testing can shape the early decisions to administer potent but toxic and unpleasant anti-HIV drugs to the injured person.

The reply, from Earl Howe (Parliamentary Under Secretary of State (Quality), Health; Conservative) was that “Where a person lacks capacity to consent their rights are protected by the Mental Capacity Act 2005, which determines that decisions on behalf of such a person have to be made in their best interests.

The department’s view is that both the taking of samples and the testing of samples previously obtained from a patient who lacks capacity to consent are therefore acts that may only be undertaken if they are in the best interests of the patient. This would include testing a patient for a serious communicable disease such as HIV following a needlestick injury to a healthcare worker.

The department’s view is that determining whether it is in the best interests of a patient who lacks capacity to take and test samples for the purpose of determining what treatment, if any, to offer a healthcare worker with a needlestick injury is a stringent test to pass. It involves assessment of the individual circumstances of the patient on a case-by-case basis.”

That’s a tough call, and one that might be better answered by the Government rather than the patient’s carers. A policy would help, rather than a fudge answer that expects the healthcare team to interpret complex legal matters – in haste – in the knowledge that it may come back and bite them in later High Court action. For the needlestick ‘victim’ that offers no solace.

Neither too does it offer anything to the injured waste handler working as a hospital ancillary and support worker, in the waste management sector or for a Local Authority. For them, a needlestick injury will always be the same result – do we assume the worst and embark on a long and difficult course of ant-HIV medications since the source patient on whom the needle was used, or the user who discarded the needle, will always be unknown.

The Government might have helped with a straightforward yes or no, but regrettably the law is almost never that simple. But for those in eh waste management sectors, the opportunity will not arise anyway. The source is unknown.

On every post-exposure treatment algorithm, this places the injured person in the highest risk category. Other factors are involved such as the likely age of the needle, was it a deep wound from a large hollow bore needle – but did you stop to find out? – but this involves always something of a terrible gamble.

A gamble with a life. Make sure that its not yours or one of your workforce.

Needle spill on US street

Dozens of used medical needles scattered along a Long Beach street next to a youth handball court were removed Sunday by a Nassau hazardous-materials team.

The syringes were found by three children who rode their bikes and scooters to East State Street just off Monroe Avenue, and reported the finding to their parents around 12:25 p.m.

Well done, kids, for reporting this.

http://longisland.news12.com/news/children-find-thousands-of-used-needles-on-east-state-street-in-long-beach-1.4888496?firstfree=yes

Anxious wait for 12 year old girl who fell onto a discarded needle

A 12 year old Sunbury, Australia, girl faces an anxious wait after falling onto a discarded needle.

The girl slipped and fell playing in a park near Gibbons St Sunbury, cutting her arm on the hidden needle. She did not tell parents until later, when the arm became sore and swollen and they got medical help.

“I remember running towards the slide when I slipped and fell, landing on my left arm,” she said.

“I felt a sharp pain … and saw the needle, which I picked up and put in the bin.

“I wasn’t very happy about it at the time but I was too scared to tell my parents in case they blamed me.”

Her angry father has hit out at whoever discarded the needle, labelling it “irresponsible and dangerous”.

http://www.heraldsun.com.au/leader/north/agonising-wait-for-12-year-old-sunbury-girl-after-she-fell-on-a-discarded-needle/story-fnglenug-1226605528310

Understandably, this is the cause for great distress, for the child and her parents and family. Not just today, but for the many months of follow-up that will follow, and possibly beyond. The impact is profound, and we wish them well.

Regrettably, stories like this are not uncommon. They serve to highlight the considerable risks from discarded needles, that seem far more common in recreational areas than elsewhere.

Foetus in clinical waste bin

The press is getting exercised about a foetus – described boldly as an unborn baby in some of the more lurid headlines – found in a clinical waste bin.

The foetus was believed to have been between 15 and 20 weeks gestation. An investigation has now been started at Monklands Hospital in Airdrie. NHS Lanarkshire apologised for the distress caused by the incident and said it aimed to treat all families with dignity and respect. Scottish Health Minister Alex Neil, who is the MSP for Airdrie, said something had gone “seriously wrong”.

A spokeswoman for the Stillbirth and Neonatal Death Society said hospitals should be following guidance issued by the Royal College of Nursing and the Institute of Cemetery and Crematorium Management.

It’s a tough call, wondering how best to manage the foetus in circumstances where getting a clear and final answer from a distressed and distraught Mum may be almost impossible. A private burial or cremation, or a ‘hospital cremation’, are the key options though the latter, even if performed with dignity and respect, is little more than a euphemism for incineration with other clinical wastes.

Whatever happens, placing the foetus into a clinical waste bin (presumably a sack mounted into a sack holder) is wrong. Who saw it? Who then reported it, and how did it get as far as the newspapers? These are matters about which we have no information. It may have been a concerned staff member, a whistleblower, since that seems to be becoming an increasingly popular pastime among NHS staff. Perhaps supply chain problems had resulted in shortage of a more suitable container? But if that resulted in a hospital visitor or patient fining the foetus then clearly that is more than regrettable, it should never have happened.

The key failure was to choose the wrong waste container, in contravention of what should have been a clear and easily understood policy.

Cock-ups happen occasionally. But sometimes the consequences are profound, from even the a seemingly trivial slip. This one will cause distress for many women who have miscarried, at Monklands or elsewhere, now and in the future.

Safer sharps – are they protecting against sharps injury?

As the archive files of the Clinical Waste Discussion Forum will attest, several years before the start of the move toward introduction of engineered safety sharps I took a sceptical view of the protection that they might afford. Not for sharps users, the clinicians, nurses and scientists who might wield a syringe and needle to draw blood or administer an injection, but for those working as ancillary and support staff, and waste handlers, who might be exposed to used sharps as they pass along the disposal chain.

So sure was I that the potential reduction in injury would be manifest in fewer sharps injury events in ancillary and waste handlers that I placed a small wager with a colleague. It was will deep regret that I have been able to collect on that wager - a modest lunch – having seen the evidence of sustained carelessness in sharps disposal.

Has that claim really come true?

needleGl Sharps incidents and sharps injuries to waste handlers have reduced only where mechanisation and bulk handling of carts, as opposed to manual handling of individual clinical waste bags and sharps bins, reduces opportunity for direct contact. Even where this has been possible, waste containers are still managed by hand as they are removed from wards and clinics, generally by cleaners and other ancillary workers who might have access to latex gloves or a pair of Marigolds but who will never have the benefit of sharps-safe gloves.

Safety engineered sharps come in tow distinct types, passive devices that activate automatically, usually via a spring-loaded retraction mechanism, and active devices that need some positive action by the user to flip a shield over the exposed needle.

My hypothesis was that a) since the passive devices are more complex they will be more expensive, b) financial constraints will see many Trusts choose the cheaper active devices, and that c) careless failures to engage the safety features of those active safety sharps who result in many of these devices discarded without activation. This would result in no protection for those encountering the needle during its journey through the disposal chain. To make matters worse, would those who can’t manage activation of the sharps safety feature be so concerned to dispose of the used sharps with the required care, or would these unprotected sharps be found in an overfilled sharps bin, in a waste sack or in the soiled lined on its way to the hospital laundry?

A new research paper from France (Needlestick injury rates according to different types of safety-engineered devices: results of a French multicenter study. Infection Control and Hospital Epidemiology 2010; 31(4):402-7 DOI: 10.1086/651301 makes depressing reading. The authors objective was to evaluate the incidence of needlestick injuries (NSIs) among different models of safety-engineered devices (SEDs) automatic, semiautomatic, and manually activated safety) in healthcare settings. This was done by a multicenter survey involving no less that sixty-one hospitals in France, conducted from January 2005 to December 2006, examining all prospectively documented SED-related NSIs reported by healthcare workers to their occupational medicine departments. Participating hospitals were asked retrospectively to report the types, brands, and number of SEDs purchased, in order to estimate SED-specific rates of NSI.

More than 22 million SEDs were purchased during the study period, and a total of 453 SED-related NSIs were documented. The mean overall frequency of NSIs was 2.05 injuries per 100,000 SEDs purchased. Device-specific NSI rates were compared using Poisson approximation. The 95% confidence interval was used to define statistical significance. Passive (fully automatic) devices were associated with the lowest NSI incidence rate.

Among active devices, those with a semiautomatic safety feature were significantly more effective than those with a manually activated toppling shield, which in turn were significantly more effective than those with a manually activated sliding shield (p<0.001, Chi² test). The same gradient of SED efficacy was observed when the type of healthcare procedure was taken into account.

The authors conclude that passive SEDs, devices that do not require any action on the part of the user, are most effective for NSI prevention.

So perhaps we should expect that passive devices should be the gold standard safety-engineered device, for the protection of sharps users and inevitably therefore for the protection of ancillary and waste handlers.

And who else should we consider? Insulin-dependent diabetics not using insulin pens and IV drug users are particular problems since neither group is being offered safety-engineered sharps of any kind.

The devices look and feel differently and it takes some instruction and practice to use them effectively. For diabetics, that will involve a hugely complex and costly program of instruction – even if it takes just 2 minutes per patient that necessitates a hospital visit or GP appointment.

And for IV drug users, the probability for manual activation of a safety device after shooting up are probably small and possibly so small as to be negligible. For those clearing discarded sharps, the huge risk of injury and infection thus remains unchanged. There would (could?) be further advantages, since fully automatic and tamper-proof passive safety sharps are effectively single use only. This would eliminate needle sharing with a major impact on disease transmission rates among this vulnerable group.

Politics and public opinion will get in the way. Will it be accepted that IV drug users should be provided with expensive safety sharps? Would it be acceptable that they are trained in shooting-up? Should public money be spent in support of this group, even if there might be additional gains to society for reduced disease transmission rates though less needle sharing, and protection for those in the public sector who are tasked to clear discarded drug litter? The vociferous moral majority may well say no; there is considerable evidence for this with similar proposed public health interventions, for the creating of safe and accessible injection rooms that are provided in some other countries, or even the placement of secure sharps bins in high risk hot spots.

None of this bodes well for the safety of ancillary and waste handlers.

“Janitor dies from inhaling medical waste”

Boston Personal Injury News carries a brief report that may be of interest, as improbablye as it may seem:

“A wrongful death lawsuit from is reported to be a concern for anyone who has spent time at a hospital, whether for visiting a patient or as a patient, in the belief that germs are always a key concern.

If you’ve been in a hospital, you’ve probably seen boxes or bins for biomedical waste. It’s a relevant question to ask: What happens to all the blood from surgeries, the human waste, contaminated needles and other items of biomedical waste?

Manuel F. Crespo was cleaning the waste bins as part of his job at Wuesthoff Memorial Hospital, Florida. While he was picking up waste bags, a bag broke, spilling the contents onto the floor.

The lawsuit alleges that Manuel Crespo was exposed to airborne pathogens and the exposure resulted in acute bacterial lung infection and diffuse lung damage. He died on May 9, 2008, five days after exposure to the contaminants.

The lawsuit (regrettably, the link to the Court papers seems to link only to a defective file) alleges premises liability as the underlying cause of action in the wrongful death lawsuit. Essentially, what the lawsuit argues is that the medical center had a duty to label its biomedical waste and to dispose of it properly.

As it would appear in the complaint, the medical center was not disposing of sharp items in proper containers and as such, raising the threat of exposure to contaminants.”

It would be interesting to know the outcome of this case, and we will continue some inquiries. However, the circumstances, which are described in a technically inadequate news report, as most improbable. But who knows? It was for the Court to decide, but if there did exist some preventable exposure and risk of infection occurring in this way then worldwide there would be so many more similar cases that we could hardly have missed them all.

Needlesticks injuries in domestic refuse collection

Sharps injury is a not uncommon problem for domestic waste handlers, who face injury from metal wood, plastic and glass. Most serious is a sharps injury involving a used needle, but the high risks of bacterial contamination of items from waste and thereby of the wound itself makes serious sepsis a common consequence of these sometimes severe infections.

In the US, sharps management from domestic users is generally not as advanced as in the UK. Most cities provide limited collection facilities, with users needing to take their sharps to a local police or fire station for disposal: competitive private medicine and an underfunded public service ensures that takeback of sharps by family physicians or hospitals is almost unknown. Though there is much variation across and between individual states, sharps bins for domestic producers are a rarity and improvisation is a way of life.

US waste collections staff have produced a short film, on YouTube, to show the risks they face and to encourage waste producers to take care with their sharps

Let’s hope that their waste producers/customers will take heed, to reduce these sometimes devastating accidents and improve the health, safety and welfare of waste handlers.

Waste sector injury rate higher that reported

It has become apparent that the waste sector injury rate is actually higher than reported because of a data error by HSE; accident rates for 2011/12 were actually UP rather than down as it had previously stated.

Mistakes happen, though this one is perhaps an error too far.

Provisional statistics issued last month (October 2012) by the HSE showed a slight decrease in the number of injuries recorded in the waste and recycling sector for the 2011/12 financial year (see letsrecycle.com).

However, it has now emerged that a coding error by the HSE saw 314 waste-related injuries wrongly allocated to the heading ‘Public administration and defence; compulsory social security’ instead of waste management.

The HSE has now corrected the data which can be found in a report entitled Waste and recycling – work related injuries and ill health, which offers detailed analysis of the injury rate for the waste industry.

	Fatalities	Major injuries	Over three day injuries	Total non- fatal injuries
2010/11	9	482	1,967	2,449
2011/12	5	465	1,876	2,341

Injury statistics for waste and recycling sector

Clearly, injury rates are a far better measure of performance that are fatalities though it is headline fatality rate that is the focus of attention. This can be misleading – not as misleading as an error in reporting by HSE – since , even when a small increase in fatalities is noted there can be a downward trend that tells a tale of overall improvement. In essence, the numbers are too small to be a useful indicator or progress, though we should be grateful for that (Blenkharn JI, Gladding T, Moffatt T. Nine deaths is nine too many. CIWM Journal 2011 August; 34-5).

So now we can use injury, or incident, rates. Inevitably, the numbers are bigger and trends become more apparent. The next problem is the availability of these data. Most are captured through RIDDOR. Under-reporting is high, so this is just the tip of a probably very big iceberg. Under-reporting may be due to an individual decision not to report an injury to a line manager, perhaps failing to recognise the potential severity and impact, and negating any possibility of prevention of recurrence. Moreover, it seems to be the way of the waste sector in particular, and industry in general, to work hard to avoid the filing of a RIDDOR report. Perhaps too many reports paint an unfortunate, though not necessarily accurate, picture of overall H&S performance and can affect success in contract negotiation.

And now, regrettably, HSE themselves are down-rating RIDDOR, eliminating over 3 day injuries in preference to over 7 day injuries. In parallel with this change, we might have hoped to see, at least, mandatory reporting of all sharps injuries and blood/bloodstained body fluid exposures to the face but no, this didn’t happen. It would have complemented upcoming sharps safety legislation applicable only to the healthcare sector. As it is, its just less work for HSE.

The change to RIDDOR will result in a notional decrease in accident stats next year, and no doubt someone will trumpet this fall as a success for the waste sector safety performance. Not so.

Sharps safety regulation

The consultation on the HSE review of impending sharps safety regulation following EU Council Directive 2010/32/EU is now closed.

Currently, IOSH is trumpeting its own submission that proposes, as Blenkharn Environmental and others have also done, an extension of the formal protection afforded to include protection to those outside the healthcare sector who might be exposed to, or injured by, sharps.

That stance cannot be criticised. However sympathetic this stance may be, the thrust of their argument misses important detail. There is little value in providing safety sharps as far as sharps injury reduction from discarded drug litter is concerned. It will still be discarded, and safety devices, if provided, are unlikely to be activated. The issue of fully automatic devices to diabetics and IV drug uses is unthinkable. Sad as it is, it will simply be too expensive.

The real necessity is to comprehend the need for defined protocols for sharps injury management, for use in every A&E department. This will stop Local Authorities suggesting that residents stuck by a needle should write in for a free leaflet or make an appointment with their GP, and will stop those working in the commercial sector being referred to an off-site occupational health provider that might result in a week-long delay for attention. That is simply not good enough.

It is imperative that those presenting to A&E should not be fobbed off as time wasters with nothing more that a trivial injury. The potential impact far outweighs the mechanical aspect of the injury received.

2010/32/EU goes much further that requiring safety sharps. It requires also urgent access to specialist Infectious Diseases teams for assessment of the need for and management of post-exposure prophylaxis and careful follow-up. That should apply to all and the DoH, supported by HSE, must ensure that is available for all sharps injury “victims”.

To assess the scale of these problems, and ensure effective monitoring by HSE, it would be advantageous that sharps injury was incorporated specifically into RIDDOR. Mandatory reporting would give HSE some data upon which to act, since their current plan is to puss and blow, but with no plan to develop mechanisms for monitoring of compliance with the new sharps regulation. Cost is no barrier, as the new FFI seems to be an effective money spinner than neutralises the excuse of budget constraint on questions about the activities of HSE.

Lastly, science would fail if it did not flag the importance, yet again, of splash inoculation. This can be an important mechanism for the transmission of bloodborne virus infection. Splashes onto damaged skin, a previous cut or damage due to eczema, psoriasis or chronic dermatitis and splashes to teh eyes of mouth can and do transmit infection. It would be advantageous to include these events also into the upcoming legislation since such events are almost always due to some defect in safe working practice. This is the exact scenario in which HSE would be expected to intervene, but by excluding its incorporation to the proposed legislation and insisting on a mandatory notification scheme it is difficult to envisage a way in which HSE might properly manage this new legislation.

Bullying – not the way to manage sharps injury

Twice in the last 10 days I have had calls from individuals concerned about sharps injury.

One, a waste handler working at a domestic waste recycling operation, was concerned that he and his colleagues were not provided with sharps resistant gloves. He drove many miles to bring me a pair of the gloves provided and they were clearly inadequate for handling mixed recyclable wastes whizzing by on a fast moving conveyor. In another case, a care home (hospice) assistant asked if simple nitrile gloves were sufficient.

In each case, the gloves provided were not suitable, though it was difficult to say much about the latter case as the use of sharps was said to be infrequent – I would have thought it would have been significantly greater in a hospice. In the former, I was told of the repeated cuts and scrapes from all sorts of sharp items, and the frequency with which sharps were identified. That was sufficient to make a robust case for better gloves.

What was clear in both cases that money was at the root of local decisions not to provide a better glove suitable for the purpose. Neither individual was in a union, and neither felt confident to challenge their manager again as each had already been rebuffed for an earlier request.

Looking through the various nursing forums it seems not uncommon that bullying takes place, to persuade individuals NOT to report sharps injury for fear of regulatory intervention. I suppose its much the same as the UK situation, where many companies and their H&S advisers will work hard to avoid RIDDOR reporting, twisting words with the most catholic interpretation of RIDDOR wording to avoid a bad record and possible HSE visit.

Of course, this can lead to entrenchment on both sides, but the decision should be clear. For the waste handler, he opted to move on – there seemed to him to be no reason to stay in an unsecured minimum wage job when he could go to another and be safe. But he has called HSE and an appointment has been made for interview, so I presume this will be carried forward for the protection of others. Will we see a prosecution, for failing to supply the appropriate PPE items?

I have not head back from the care assistant. I doubt if we meet again that he will take this forward as he was obviously concerned about the impact on employment, with this hospice or any other through the agency that provides placements. He is well aware that nobody likes a “troublemaker”.

I have been glad to provide support. It’s not easy for individuals, nor for Blenkharn Environmental in circumstances future contracting will be as rare as hen’s teeth after interventions of this kind. But it is important to stand up and be counted and prevent this bullying attitude to the provision of sharps safety prevention.

Radioactive clinical waste spill

Sometimes, when it rains it pours and yes, it does get worse.

A tractor-trailer hauling radioactive clinical (medical) waste crashed last Saturday, closing a portion of Nebraska Highway 2. The radioactive medical waste shifted into the semi’s cab when the driver braked to avoid another crash.

http://www.ketv.com/news/local-news/Highway-2-closed-in-Lincoln-due-medical-waste-spill/-/9674510/16790330/-/3lg9pgz/-/index.html#ixzz282Vf7ONB

Though I’m not quite sure how a semi- can transfer its load into the drivers cab there are good reasons, now quite obvious to the people involved in this incident, or keeping the drivers compartment entirely separate from the load compartment in any vehicle carrying clinical or other hazardous wastes.

Mum’s horror over needle on beach

“A furious mum has sounded a warning after her little boy came within inches of picking up a used needle on a South Tyneside beach.

“Two-year-old Lucas Bain had no idea of the potential danger he was putting himself in when he reached out to pick up the discarded needle.

“The toddler had been running in front of his mum, Rochelle Spiller, during a trip to Little Haven Beach in South Shields last Thursday, when he came across the syringe lying on dry sand.

“Luckily, his 23-year-old mum was quick to react and managed to pick her son up before he had the chance to touch it.

http://www.shieldsgazette.com/news/local-news/video-mum-s-horror-over-needle-on-beach-1-4939207#

In so many seaside towns, it seems inevitable that there is a disproportionate influx of IV drug users. Congregating on the beachfront seems to be particularly common and inevitably sharps will be discarded onto the sand. This creates a high risk for beach users as needles tend to sink into soft sand, ready to trap unsuspecting beach users and children playing barefoot in the sand.

Sharps waste found in domestic refuse from UK hospital

Basildon Hospital is under investigation for failing to properly dispose of potentially hazardous medical waste, including used syringes.

The Environment Agency are ‘probing’ how syringes and other equipment used to drain bodily fluids from patients, as well as other used medical supplies, made it into the general waste and from there to a Veolia recycling centre!

Veolia Environmental Services, which removes the hospital’s general waste, discovered used equipment was being thrown out with the rubbish this month. An Environment Agency spokeswoman said: “Regulations are designed to ensure different wastes are dealt with in appropriate ways to protect the environment and human health. “We are investigating the destination of waste from the hospital.”

A Veolia whistleblower said: “The hospital failed to spot dangerous contaminants in clear rubbish bags and failed to check before decanting it into a large loader.

http://www.echo-news.co.uk/news/9937827.Used_syringes_thrown_in_hospital___s_rubbish/

Though rarely identified this type of problem occurs more often that is generally realised. Waste audits have become part of the routine of clinical waste management. As we have criticised bitterly on many occasions previously, almost all audits focus on the content of clinical waste containers, often finishing with indignation about the presence of a few sweetie wrappers or an empty drinks can in a yellow or orange sack. That simply does not matter!

Of concern is the finding of rogue wastes in black, or clear, general waste sacks. Clear sacks aid recognition of these fugitive clinical wastes, but in black sacks nobody will know unless there is a sharps injury or blood spillage. By then, it is too late.

Clear sacks are a great idea, but so too is the inclusion in regular waste audits of the composition of wastes in black (clear) sacks as this gives a better indication of segregation standards.

And though the trend is to ever more source segregation, there is another option. In clinical areas including wards and ITU, operating theatres, some laboratories and pharmacies, black bags can be removed entirely. With all but primary packaging waste removed for separate disposal, the system is largely fail safe for all but stray sharps placed into a waste sack. The amounts of domestic type waste generated in a busy surgical ward is modest at best, and its disposal with clinical wastes is fail safe, environmentally sound and of little economic impact.

As an aside, at Basildon the investigations may perhaps find a culprit. Will there be robust disciplinary action taken?

With increasing concern about pharmaceutical residues on drug packaging waste, the management of these wastes with all other pharmaceutical waste will soon be upon us. We have proposed before these developments, of waste audit to encompass examination of non-clinical waste containers, and of the removal of black bags from clinical areas. We will continue to do so.

With developments in materials or energy recovery from treated wastes, this approach becomes even more practicable. Watch this space.

Waste drug theft did not pay

The last of four co-defendants was sentenced Monday to a year in federal custody for his role in a conspiracy to intercept and resell prescription painkillers slated for destruction as medical waste via a disposal company in Vista, authorities said.

The defendant, John Francis Bonavita, 34, beginning in May 2009, planned with co-defendants Michael Andrew Girvin, Larry Ray Martin and Joseph Andrew Daly, to intercept medications from Enserv West LLC, a medical waste disposal company in Vista, where Martin and Girvin were employed at the time, according to the U.S. attorney’s office in San Diego. The conspiracy continued into July 2010.

Girvin, Daly and Martin pleaded guilty earlier this year to separate charges, receiving sentences ranging from 12 months in custody to 3 years probation.

http://www.nctimes.com/news/local/sdcounty/courts-defendant-in-drug-sale-conspiracy-sentenced-to-prison/article_a57c40d4-7902-5e2d-aa6e-1add4ec571d1.html?goback=%2Egde_2865387_member_165466690

The theft of pharmaceuticals from clinical wastes is well know, generally by addicts searching for residues in sharps containers. Others have stolen in hospital, generally hospital employees with a drug habit. And of course theft of drugs from clinical wastes by disposal staff and waste handlers is not unknown, but never on such an organised scale.

The statistics of fatal accident prevention

A recent announcement from HSE records nine deaths involving the UK waste and recycling industry since June 15, 2012. That is an appalling statistic, and HSE are sending “warnings” to the waste sector to improve safety performance.

The fatalities are:

June 15: employee crushed when operating forklift that overturned at a waste site in Towcester
June 19: employee crushed between two vehicles at a scrap metal site in Dudley
June 28: employee struck by a boom while working atop a skip at a skip-hire premises in Wolverhampton
July 25: self-employed person died after falling out of the bucket of an excavator at a skip-hire premises in Arundel
Aug. 7: employee crushed by a skip that fell on him at a skip-hire premises in Kempton Hardwick
Aug. 10: member of the public run over by a backing refuse collection vehicle in Glasgow
Aug. 17: employee run over by a wheeled loading shovel at a waste transfer site in Watford
Aug. 17: employee trapped in a waste compactor/baling machine at a recycling plant in Batley, Leeds
Sept. 5 member of the public found crushed in a refuse collection vehicle’s compacting mechanism in Wirral

Continue reading “The statistics of fatal accident prevention” »

HSE issues autoclave guidance

The Health and Safety Executive (HSE) has published guidance on the safe use of industrial autoclaves, which can be used to treat waste.

The guidance ‘Safety requirements for autoclaves’, addresses the risks associated with the safeguarding, training and maintenance of the equipment. It is aimed at all employers, supervisors and managers responsible for its safe operation and maintenance.

This is high risk equipment. Explaining the risks associated with the technology, the guidance states: “The most serious risks come from the uncontrolled release of stored energy, which happens when safety critical parts fail. This can cause violent ejection of: components/pieces of equipment; the pressurising medium; the vessel contents.” Burns are also commonly encountered injuries but as reporting is infrequent this additional hazard rarely appears on the regulatory radar.

The HSE’s guidance offers operators a practical step-by-step guide on how to best control and minimise the risks associated with autoclaves, across all industrial applications.
It offers guidance on various scenarios, including:

The difference in control between automated and manual systems;
Inadvertent pressurisation with a person inside the autoclave;
The door/ lid opening violently under pressure; and,
Inadvertent pressurisation of blowdown, drain and transfer lines.

It also offers advice on the instruction and training that should be given to those working with autoclaves. In addition, it looks at the need for maintenance and inspection of the equipment and what this should involve.

Hepatitis C – a growing hazard for waste handlers

The most recent national estimates suggest that around 216,000 individuals are chronically infected with hepatitis C (HCV) in the UK. A proportion of these, especially those on the farthest periphery of society are co-infected with HIV and/or Hepatitis B virus. For HIV, this is around 1.2%. This indicates a particularly high risk from discarded needles since the probability for transmission may be substantially higher that the often quoted (0.3% for HIV, 1.8% (range 0% to 7%) for Hepatitis C, and between 1% and 40% for Hepatitis B) since these data refer primarily to occupational exposures in the healthcare sector.

Injecting drug use continues to be the most important risk factor for HCV infection in the UK. Data from the Unlinked Anonymous Monitoring (UAM) survey of people who inject drugs (PWID) suggest that levels of infection in this group remain high in 2011 (45% in England, 29% in Northern Ireland and 39% in Wales); levels of infection among PWID surveyed in Scotland in 2010 are higher still (55%). Continue reading “Hepatitis C – a growing hazard for waste handlers” »

South coast bin men face needles in black sacks

Two binmen from West Sussex are facing a risk of infection and months of blood tests after being accidentally pricked by hypodermic needles.

The needles had been left incorrectly in black bags by a resident for collection in the Arun district.

Despite wearing protective clothing, both men were pierced in the hands. Continue reading “South coast bin men face needles in black sacks” »

HSE Consultation on proposals to implement the 2010 Sharps in Healthcare Directive

Far better late than never, HSE is proposing consultation on proposals to implement the 2010 Sharps in Healthcare Directive. Late because the implementation date will soon be upon us and the NHS Trusts must be well along the road of trialling safety sharps devices with a view to restocking, staff training, and sharpening up (no pun intended) their sharps incident policy and practice. Continue reading “HSE Consultation on proposals to implement the 2010 Sharps in Healthcare Directive” »

Road spillage of medical (clinical) wastes

A report from the US tells of an accidental spillage of sharps waste from a truck.

“The driver was on a routine route was unaware that a five gallon and a one quart container toppled out of his van.

“The driver said that a bystander stopped him and told him his door was open so he closed it and continued on his route. He said he was unaware of the spill.

“Another man, unrelated to the incident, stopped and picked up the containers which was earlier reported to police by a witness.

http://www.register-pajaronian.com/v2_news_articles.php?heading=0&page=72&story_id=12775

The images provided with the report certainly show some syringes and other plastic items but it is unclear if this is clinical waste as opposed to, for example, similar sharps waste from a manufacturing or craft activity. However, the headline makes clear that this is “Spilled biological medical waste”. If this is so, the the intervention of a passer-by to collect the spilled waste, though a generous intervention, was entirely wring an the driver should have alerted him or her to keep well clear.

Also of note are the police officers sweeping the roadway to gather together the spilled wastes. Using brooms might be practical though individual sharps may become trapped in the bristles and more generally the broom heads will become contaminated. Once the spillage is cleared, they those brooms should also be safely disposed.

Perhaps vehicles carrying clinical waste should carry a suitable spill kit that includes brooms and dustpans as well as spare bags and sharps bins, litter pickers, disinfectant products, suitable sharps-resistant gloves and suitable provision for final hand hygiene when the job is done. Regulation is weak in this area, and in all probability the majority of vehicles have insufficient aids to manage anything but the smallest of spillage. Though accidents of this kind are few, there are many spillages “off the back of a lorry” as wastes are uploaded from customer premises.

Bournemouth toddler suffers sharps injury in local park

The mother of a toddler who rolled onto a drug addict’s needle in a park is facing an agonising wait to see if her daughter has caught HIV.

Two-year-old Siann Parkinson was doing barrel rolls down a grassy slope when she landed on the discarded hypodermic syringe.

The needle pierced Siann’s right thigh, causing the youngster to scream out.

By the time mum Annabel, 25, turned round, Siann had pulled the syringe out and was holding it with blood splattered on her trousers.

Horrified Miss Parkinson, a hairdresser, rushed the youngster to hospital and Siann was given a Hepatitis B injection and blood tests.

They now face a distressing two-month wait until Siann can have more blood tests and injections to see if she has caught HIV from the needle.

Offering solutions, solving problems…Not!

Waste Management World reports that cleansing bosses in Exeter are appealing to people not to put hypodermic needles into their recycling boxes.

“In one week alone, 113 needles were found in recycling passing through the city’s materials reclamation facility (MRF) in Exton Road. Since the beginning of the year the number of needles found has topped 400. Continue reading “Offering solutions, solving problems…Not!” »

Sharps injury – a personal story

For anyone uncertain or unconvinced about the implications of a sharps injury or blood exposure, take a look at the video by the CDC’s STOP STICKS Campaign.

This 9-minute video features an interview with nurse Diane Mawyer. Diane’s life was forever changed by a sharps injury that infected her with hepatitis C. Though Mawyer’s injury resulted from the legitimate use of a needle during collection of blood for transfusion rather than being disposal-related, the interview leaves no doubt about the impact of sero-conversion and the need for great care when dealing with accident- and exposure-prone events during healthcare or waste management.

http://www.cdc.gov/niosh/stopsticks/video/needlestick2.wmv

Blenkharn Environmental Led by Science Driven by Research

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Blenkharn
Environmental

Led by Science
Driven by Research