Recent reports from New Zealand and Ireland report underreporting of sharps injuries in around one third of doctors and nurses respectively. This is in accord with the many other studies on this subject but surprisingly no comparable studies have adressed sharps injury and blood and body fluid exposures in ancillary and support staff or in waste handlers.

The initial deposit of clinical waste into an appropriate sharps bin or waste sack takes but a moment’s thought, though all of those who might come into contact with those wastes as they pass along the disposal chain are wholly dependent on that simple act. Overfilled sacks that tear and spill their content and inappropriate packaging of wet wastes are common problems. Many support staff and waste handlers will attest to occasional soakings with blood and bloodstained fluids spilling from clinical waste containers.

Though used sharps should be placed immediately into a sharps bin for safe disposal, it is still common for sharps to find their way into thin-walled clinical waste sacks intended only for soft wastes. As a result, and despite wearing needlestick-resistant ballistic gloves or gauntlets and trousers with similar reinforced ballistic panels protecting thighs and lower leg, waste handlers continue to suffer sharps injury. In one series of 40 sharps injuries, occurring at a rate of 1 per 29,000 man hours, injuries were caused by hypodermic needles from improperly closed or overfilled sharps bins (n=6) or from sharps incorrectly discarded into plastic waste sacks (n=34). Most injuries occurred to the hands and outer aspect of the legs. No seroconversions occurred, though two waste handlers suffered disabling anxiety/stress disorder necessitating prolonged leave of absence and extensive counselling and support (Blenkharn & Odd, 2008).

Introduction of engineered sharps safety devices under European Union Council Directive 2010/32/EU is likely to deliver substantial reduction in sharps injuries among sharps users (Elder & Paterson, 2006; Jagger et al, 2010), but disposal errors may be unchanged. Under this Directive, obligations are placed on employers to develop policies and procedures for sharps use, and disposal, and to investigate the cause of sharps incidents with implementation of all necessary corrective actions where appropriate. The employer must take immediate steps for the care of the injured worker, including post-exposure prophylaxis where indicated and appropriate follow-up health surveillance. Though healthcare professionals will welcome these developments, the protection they afford may be somewhat selective.

Outsourcing ancillary services creates unforeseen problems in sharps safety. Although sharps injury rates are highest among frontline healthcare professionals, comparison of injury rate against employment statistics shows an overall rate for support staff ten times greater than nurses, and 30-40 times greater than clinicians (Leigh et al, 2008). Contract staff suffering sharps injury report incidents through their own management structures, under-representing the incidence of site-wide disposal errors unless coordinated universal reporting is enshrined in contract terms. Many Trusts limit training and restrict access to occupational health services to their own employees only. Contract workers and agency staff, and clinical waste handlers, are thus at considerable disadvantage if they suffer sharps injury. Though the speed of administration of post-exposure prophylaxis is crucial to success, without access to on-site occupational health services many individuals record considerable delay, in excess of 5 hours, before being seen in a local Accident & Emergency department (Blenkharn & Odd, 2008). Indeed, waste handlers presenting with sharps injury have been dismissed at triage for ‘a trivial and time-wasting minor puncture wound’ without consideration of the potential impact of bloodborne virus transmission. This sits uneasily with Council Directive 2010/32/EU, which implements the Framework Agreement on sharps injury prevention in the hospital and healthcare sector.

Quite how far this Directive is intended to operate is a matter for interpretation. Though the business model of outsourced NHS support services and contract waste disposal has been highly successful, discordant safety and occupational health standards for core staff and contractors working side-by-side on the [extended] healthcare team is cause for concern. Clinical waste disposal carries a risk of serious and possibly life-threatening infection. That risk may be small and serious incidents fortunately rare, but the need for precautions does not diminish at any stage in the disposal chain. Common training and incident reporting are essential. Subcontracting should not create barriers to sharps injury prevention and the protection afforded by Council Directive 2010/32/EU but sadly, working side-by-side does not always create a partnership of equals and for some the exclusions that this creates will have serious and potentially life-threatening consequences.

Blenkharn JI, Odd C. (2008) Sharps injuries in healthcare waste handlers. Ann Occupat Hyg 52(4):281-6

Elder A, Paterson C. (2006) Sharps injuries in UK health care: a review of injury rates, viral transmission and potential efficacy of safety devices. Occupat Med (Lon) 56(8):566-74

Jagger J, Berguer R, Phillips EK, et al. (2010) Increase in sharps injuries in surgical settings versus nonsurgical settings after passage of national needlestick legislation. J Am Coll Surg 210(4):496-502

Leigh JPO, Wiatrowski WJ, Gillen M, Steenland NK. (2008) Characteristics of persons and jobs with needlestick injuries in a national data set. Amer J Infect Contr 36(6):414-20