The largest noticeable needlestick increases from 2020 to 2021 were among injections with disposable syringes, especially with insulin needles and those used for vaccinations, says Amber Mitchell, DrPH, director of the International Safety Center, noted for its longstanding EPINet surveillance system for needlesticks, sharps injuries, and mucosal blood exposures.
In 2020, they were 25.9% of injuries during injection and 29.2% in 2021, she tells Hospital Infection Control & Prevention. “Also, despite OSHA (Occupational Health and Safety Administration) regulations being in place for decades, there was a 7% increase in injuries from devices that did not have a sharps injury prevention or safety mechanism feature,” she says. “Of those devices that do have safety features or engineering controls to prevent needlesticks, in both years, activation of the safety feature did not happen about 66% of the time.”
These data may reflect the public health effect on occupational health, she says.
“Meaning, with increased people receiving insulin injections due to diabetes status and millions of people being vaccinated for COVID, that more injuries are occurring during the use of disposable syringes,” Mitchell said.
Eye protection to prevent blood and body fluid exposures also decreased from 2020 to 2021.
“There were reductions with those that indicated they used eye protection,” she says. “Exposures to eyes occur in 73.1% of all EPINet reported splashes and splatter incidents, and of those, only 11.2% indicate wearing any kind of eye protection. “This is slightly less than the numbers of workers who reported wearing eye protection in 2020.”
In a breakdown of the 2021 data, the sharps exposures were roughly divided primarily between physicians and nurses, Mitchell said at a recent podcast by the Association of Occupational Health Professionals in Healthcare (AOHP).
“Physician injuries are mostly occurring in operating rooms and surgical environments,” she said. “Suture injuries are No. 1, mostly in physicians in the operating room and emergency department. The other exposures are mostly to nurses responsible for patients. Then the third [highest injury] goes back to physicians, which is mostly with scalpels that do not have sharps injury prevention features on them.”
The problem with this instrument and other devices is that sometimes safety devices are too different in feel and weight from the equipment clinicians trained with.
“Going from a heavy, stainless steel scalpel to a plastic disposable scalpel is a very different feel,” she said. “They are hesitant. That’s another reason it is important to do simulations and have medical device manufacturers work with us.”
Blunt suture needles are similarly underused, resulting in many of the suture injuries.
“There are safety technologies now for skin closures, like adhesives and staples, that substitute out that suture [needle], but if you are constantly training to do skin closure with a sharp suture [needle], the learning curve is very high for a different kind of technology,” Mitchell said.
The failure to replace dangerous sharps with safety devices poses a downstream injury risk to laundry workers, housekeeping, and central sterile supply. “About 25% of injuries are to non-users of the needle,” she said.
There is concern that incoming nurse graduates who had training compromised to some degree by the COVID-19 pandemic may be vulnerable to needlesticks in clinical settings.
“With COVID, we saw nursing students not allowed in hospitals and so the training became essentially virtual,” Nancy Yuill, PhD, RN, former president of Chamberlain University Nursing School in Pearland, TX, said during the podcast. “We have a whole group of new nurses coming out of the education systems who are not well trained in the use of sharps.”
A related finding was presented as a poster at the 2022 AOHP conference.
The retrospective evaluation of sharps injuries sustained by registered nurses from January 2020 through June 2020, included a root cause analysis. In that time frame, 47 nurses experienced needlesticks.
Of those injured, “68% were between the ages of 19-25 [years], with 54% reporting a job tenure of one to two years,” the authors reported.1 “Technique was the primary cause of the sharps injuries among the RNs (registered nurses). Recent RN graduates had the highest rate of sharps injuries in this study. Training and education on sharps injuries and mitigating strategies should be an integral part of orientation for new RN graduates.”
The implications of the findings are that hospital administration and occupational health should prioritize training and education of new RNs, they concluded. “Results suggest that tenure, patient behavior, and technique were potential root causes of sharps injuries among RNs during the time frame,” they concluded.
Unusual Mpox Needlesticks
The emergence of monkeypox (mpox), which had caused about 30,000 cases and 20 deaths in the United States as of Dec. 7, 2022, has led to some unusual needlesticks and exposures.2 There is no formal surveillance system, only separate incident reports, so the total number of exposed healthcare workers is not known.
At least two healthcare workers have been occupationally infected with mpox in the United States and, in an unusual case, two caregivers apparently were infected by environmental fomites in the home of a patient in Brazil.
However, these are not traditional needlestick blood exposures, but often occurred after workers tried to remove the top or “roof” of a mpox pustule or lesion with a needle or sharp to get a sample of infectious fluid for testing.
The Centers for Disease Control and Prevention (CDC) emphasizes that this is not necessary, since swabbing a skin lesion will collect enough virus for testing.
The CDC recently reported one such needlestick case in a Florida nurse.
“While obtaining swabs from a patient with suspected mpox, the nurse used a needle to create an opening in the vesicular lesion to facilitate direct contact of the swab with fluid in the lesion,” the CDC reported.3 “The needlestick occurred when recapping the used needle by hand before disposal. It caused a break in the skin on the index finger through the nurse’s gloved hand, accompanied by a small amount of bleeding.”
The wound was immediately washed with soap and water and a chlorohexidine solution. The nurse received the first dose of a two-dose Jynneos vaccination series as post-exposure prophylaxis 15 hours after the injury. In accordance with CDC guidance, the nurse continued to work while asymptomatic and was actively monitored by hospital infectious disease experts.
“The nurse wore a surgical mask, consistent with CDC COVID-19 guidance, and chose to wear medical gloves when interacting with [all] patients,” the CDC reported. “Ten days after the exposure, a single skin lesion formed at the site of the needlestick. The nurse immediately began isolating at home and kept the lesion covered until it had crusted over, the scab had fallen off, and a new layer of skin had formed beneath the lesion 19 days later.”
A bizarre case in Brazil included a homebound patient and two nurses, all three of whom were subsequently found to be a 100% genetic match in their infecting mpox. The two nurses apparently were infected by objects or surfaces in the patient’s home environment, since they only wore gloves when collecting specimens for culture.
According to a preprint report by Brazilian investigators, on July 29, 2022, the nurses went to get a specimen collection from a suspected mpox patient at his home. The healthcare workers wore safety glasses, disposable isolation gowns, and N95 respirators. Lesion specimen collection was conducted using dry sterile swab procedure plastic gloves. After collection, the material was stored in a sample transport box and the workers sanitized their hands with 70% ethanol.
“Gloves were used only during collection; in the remaining time at the patient’s house and during sample box transport, the healthcare workers did not wear gloves, but the remaining personal protective equipment was used until the moment they returned to the workplace to store the collected material,” the investigators reported. “Work materials, such as a clipboard, sample transport box, and table, were not sanitized. The healthcare workers did not have contact with other suspected/confirmed cases of mpox on the same day or in the following days.”
The patient was confirmed to have mpox and, subsequently, both nurses became infected and developed relatively serious symptoms, with one suffering a progressive spread of lesions to her face and the other one developing lymphangitis.
“The interaction of patients with healthcare workers provides a window of opportunity for transmission,” they concluded. “The present case report highlights the possibility of fomite transmission route of mpox, suggesting that [viral] particles are infectious and resistant to environmental conditions. Therefore, extreme caution needs to be taken with general protection equipment and house objects used by suspected cases.”
- Stallard C, Heaton K, Montgomery A, et al. A snapshot of sharps injuries to RNs working in a large urban health system. Poster 2022PP002. AOHP Conference, Austin, TX. Sept. 7-10, 2022.
- Centers for Disease Control and Prevention. Mpox. U.S. map & case count. Updated Dec. 7, 2022. https://www.cdc.gov/poxvirus/monkeypox/response/2022/us-map.html
- Mendoza R, Petras JK, Jenkins P, et al. Monkeypox virus infection resulting from an occupational needlestick — Florida, 2022. MMWR Morb Mortal Wkly Rep 2022;71:
1348-1349.
- Salvato RS, Rodrigues Ikeda ML, Barcellos RB, et al. Healthcare workers occupational infection by monkeypox virus in Brazil. Preprints 2022; Aug 31. doi: 10.20944/preprints202208.0544.v1.
