The major concern following needlestick injuries is the acquisition of bloodborne infectious diseases particularly human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV).1,2 Although the viability of infectious particles in sharps decreases with time, bloodborne viruses can survive up to several weeks in the environment.3 Consequently, there is a growing concern about bloodborne virus transmission after community needlestick injuries (CA-NSI).4–6 CA-NSI create a very complex management challenge. Information about the moment of previous use of the sharp and the CA-NSI is frequently not available.

Additionally, as opposed to sharps injuries occurring in health care settings, reported experience with management of community incidents is scanty, the source of needles is usually unknown and postexposure prophylaxis (PEP) is rarely offered.

Recently, the number of subjects with acute or chronic diseases receiving home care has increased steadily.7,8 In addition to regular teams of HCW providing home care, family members are frequently responsible for injections and other invasive procedures at home.

Consequently, an increased risk of exposure to blood among these non-health care workers, not aware of universal safety precautions, is expected. In addition, exposure to potentially contaminated needles happens in the streets, beaches or yards and often involve children.9 Several of these exposures have been reported in areas with high prevalence of illicit drug use.9,10 Occasionally, community-acquired needlestick injuries may occur during deliberate use of needles and syringes with fresh blood as a weapon.11

The risk of acquiring an infection following a CA-NSI is unknown and only a small number of case reports of infections have been described.12 Strategies to reduce CA-NSI associated infections include the use of devices with minimal residual fluid in discarded needles (e.g. low dead-space syringes), syringe exchange programs, and access to safe needle disposal systems.13

A surveillance system of occupational exposure to bloodborne pathogens among healthcare workers (HCW) has been implemented in Rio de Janeiro, Brazil, since 1997.14 Nevertheless, no specific monitoring system for CA-NSI is in use. Frequently, CA-NSI is reported to the municipality health system through the cited surveillance system. This study was planned to describe circumstances related to exposures to bloodborne pathogens after community-acquired needlestick injuries in Rio de Janeiro (Brazil) reported to this surveillance system from 1997 to 2010.

This was a cross-sectional analysis of reports of potential exposures to bloodborne pathogens among children, family members, and non-healthcare workers. Data were collected in a validated form from all reports of exposures to bloodborne pathogens in these subjects sent to the STD/AIDS Program of Rio de Janeiro City Health Department (RJCHD) in a period of 14 years (1997–2010).15 Variables collected included: sex, age, place of occurrence, type of exposure, serologic status of source, circumstances of the exposure, blood or other body fluids involved, hepatitis B vaccination status of the exposed subject, and use of postexposures prophylaxis (immunoglobulin, hepatitis B vaccine and antiretroviral drugs). Univariate analyses were performed using chi-square or Fisher exact test for categorical variables, and Student t test or Wilcoxon test for continuous variables. Odds ratios (OR) and 95% CIs were determined. All reported p-values are 2-sided.

The institutional review boards of the Hospital Universitário Clementino Fraga Filho/School of Medicine of the Universidade Federal do Rio de Janeiro and of the Rio de Janeiro City Health Department (RJCHD) approved the study protocol.

The results of this study demonstrate the public health importance of sharp injuries occurring in the community. Using a non-mandatory, voluntary surveillance system designed for health care workers it was possible to capture 582 of these accidents in the city of Rio de Janeiro, Brazil.14 The growing number of medical procedures performed outside the health-care setting, through practices of “home-care” and other outpatient treatment of various health conditions, including individuals self-injecting insulin, put these accidents as an emerging public health problem worldwide.16 In addition, illicit drugs use in the community further compound the challenges of health systems to deal with this problem. A national surveillance system to detect exposures to sharp injuries among non-HCWs in Brazil is not in use. The exposures analyzed in this study probably under-represent the real magnitude of the problem as they were captured through a system designed for HCWs. Most of the published studies reporting sharp injuries outside health-care units are related to home care provided by qualified nurses and few reports focusing on exposure to contaminated medical instruments of non health care workers are available in the literature.17–19

A great proportion of the accidents (38%) reported in this study occurred among workers that have contact with domestic or urban waste. This probably reflects a lack of appropriate handling of sharps after use in the community. These data is concordant with the description by Dorevitch et al. (2010) analyzing data from sharp injuries at the Chicago O’Hare International Airport.20 Thirteen of 14 sharp injuries reported involved subjects working in the cleaning process (garbage collectors, cleaners, and doorkeepers) in the airport. In addition, a study by Celenza et al. (2011) also reported that the most affected professions were cleaning workers and policemen.10

These accidents occur more frequently among men than women. Three-hundred and sixty-seven (63%) of the reports involved males. This is concordant with published data on community needlestick injuries.10,12,21–24 Although the explanation for this gender difference is not clear it is possible to suggest that men are present in greater numbers in the military and in professional activities that require handling of waste.

A small proportion (19%) of the exposed subjects described in this study reported complete immunization schedule against hepatitis B. These data reflect Brazilian immunization policy as hepatitis B vaccine became part of the mandatory schedule for children under one year of age only in 1996.25 Around half (53%) of the accidents described in this study were reported to have occurred at streets or residences. No specific geographic location in the city (data not shown) was predominant. These data is discordant with other studies in developed countries in which most accidents were associated with the presence of intravenous drug users.21,26 Although Brazil has a population of more than 100,000 IDUs, drug use is not associated with specific places, as described in North America and Europe.21,24,27

Most of the accidents occurred in situations where the ascertainment of the source was not possible. Three-hundred and ninety four (68%) accidents happened with sharps on the environment or in the trash. It is reasonable to speculate that blood was present. The source was described to be unknown for 470 (81%) reports.

Interestingly, 321 (68%) of these subjects were prescribed antiretroviral therapy. The decision to start antiretroviral therapy in this setting is controversial and was not indicated by Brazilian Guidelines at the time of the accidents.28 According to these guidelines antiretrovirals should generally not be recommended following needlestick injuries of unknown source patient. The over-prescription of antiretrovirals was also described in other studies that analyzed CA-NSI and may reflect the stigma and fear of HIV-infection. This finding of our study is repeated to a greater or lesser extent in the literature. The few studies that describe accidents with biological material occurring in the community point out the prescription of antiretroviral prophylaxis in excess to the recommendations of local health Departments.11,23,29,30

A high frequency of antiretroviral prophylaxis with two antiretrovirals (mainly zidovudine and lamivudine) was observed. This regimen was prescribed for 299 (51%) of the accidents involving unknown sources and 25 (50%) of the accidents involving HIV-infected sources. This is not in line with published international reports and guidelines that recommend a triple-drug antiretroviral regimen. The period of the study was extended for more than a decade and guidelines changed during that period. At the beginning of the study period two antiretroviral drugs were acceptable locally.23,29–31

HCV and HBV infection risk was not a major concern among health professionals who attended the subjects. One-hundred and twelve accidents had a known source. Serological status for HBV and HCV were not reported for 84 (75%) and 112 (100%) subjects, respectively. This lack of concern about the risk of infections other than HIV have also been reported by Osowicki and Curtis.32

Current guidelines recommended that the majority of the subjects should have received prophylaxis against hepatitis B. In 366 (63%) accidents the exposed individuals were unvaccinated or had incomplete vaccination schedule. Hepatitis B vaccine (associated or not to HBIG) was prescribed in 334 (57%) accidents. The frequency of post-exposure prophylaxis for hepatitis B was lower than that of antiretroviral prophylaxis, albeit the risk of acquiring HBV after this type of exposure has been estimated to be around 10 times greater than for acquiring HIV.33

The risk of HIV infection often leads to greater concern by exposed subjects and professionals who treat them than the risk of contamination by HBV.34,35

In this study, 83 (14%) subjects were younger than 10 years of age. These accidents may cause great parental anxiety. A systematic review published recently found one case of possible HBV transmission after a CA-NSI and suggested that the risks for children reside in HBV transmission, which can be prevented through immunization.32 Nevertheless, children do not have critical judgment to analyze a sharp in the streets as a potential hazard.

One limitation of this study is the retrospective design. In addition, data were collected in a form designed for exposures among health care workers. Data on the outcome and potential bloodborne infections as an outcome was also not available.

In summary, this study demonstrates the importance of CA-NSI. Public health actions can be valuable if directed to safe sharp disposal by persons legally using injections outside the health sectors. These actions include access to safe disposal containers and increase in the use of needless syringes and other safe devices. In addition, actions to prevent accidents caused by dispose of used needles, re-used and discarded by persons injecting intravenous illicit drugs are also urgently needed. Based on these results public health action should include training garbage collectors in work related safety and increasing education on sharp risks among students.

The authors declare no conflicts of interest.