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%).

This is a particularly significant fact, since it becomes increasingly likely that discarded needles and other drug litter may be contaminated with Hepatitis C virus. Risks of sharps injury are high when retrieving these discarded needles. With a high incidence of virus carriage in these IV drug users the probability of infection after sharps injury is particularly high.

Key public health recommendations in a recent HPA report Hepatitis C in the UK include, inter alia,

• In England, local authorities, as the new commissioners of prevention services for people who inject drugs, need to sustain the current broad range of provision (including needle and syringe programmes) to minimise on-going transmission of hepatitis C

Reported levels of direct sharing of needles and syringes were 17% in England, 29% in Northern Ireland, and 11% in Wales. In Scotland in 2010/11 17% of IV drug users attending drug treatment services who had injected in the previous month reported needle/syringe sharing in the previous month.

Needle sharing promotes the spread of bloodborne virus disease, increasing the probability that discarded needles and syringes will be highly infective.

To help reduce levels of sharing, Needle and Syringe Programmes (NSP) are being developed throughout the UK. In Scotland, the number of injection equipment provider outlets has increased to 255 in 2009/10 and approximately 4.7 million needles/syringes were distributed to IV drug users during 2009/10. In Northern Ireland, the number of packs dispensed by NSP has increased year-on-year since 2007/08, reaching 25,530 in 2011/12. In England, indirect measures of NSP coverage in 2011 suggest that the vast majority of those are accessing NSP (in the 2011 UAM survey, 87% of people who had injected drugs in the previous year reported that they had used an NSP during that time). These and other data suggest that whilst NSP are being accessed by increasing numbers of IV drug users across the UK, there remains a need to increase the amount of equipment distributed with better targeting of this provision.

Since a key public health recommendation is the provision of needle and syringe programmes that will reduce considerably this particular problem a main difficulty will be funding for these services that are forever the Cinderalla of the public health services. Where funding is available, many studies attest to the reduction is infection rates that might be achieved.

The next step is the issue of safety syringes – fully automatic ones – to IV drug users. This will increase costs dramatically, and may necessitate supplementary training sessions to ensure correct use. This may help protect those retrieving discarded needles but will appal the moral majority who may baulk at this degree of practical support offered to IV drug users.

The expansion of existing needle exchange schemes and other initiatives to reduce the burden of infection in IV drug users is of course commendable. The next step – which may be difficult in political and well and more practical ways – will be to introduce automatic safety syringes/needles to exchange programmes. This may engage users currently outside the existing exchange programmes by reducing needle sharing opportunities, contributing still further to the reduction in the pool of infection. The protection provided to waste handlers, especially those engaged in the retrieval of discarded drug litter, will be invaluable.