European Journal of Social Sciences Volume 13, Number 3 (2010)

Needle Stick and Sharps Injuries and Factors Associated Among

Health Care Workers in a Malaysian Hospital
Lekhraj Rampal
Corresponding Author, Consultant Epidemiologist, Department of Community Health
Faculty of Medicine and Health Science, Universiti Putra Malaysia
E-mail: rampal@medic.upm.edu.my
Tel: 03- 89472411
Rosidah Zakaria
Hospital Putrajaya, Ministry of Health Malaysia
E-mail: rosidah_zakaria@yahoo.com
Tel: 0163721373
Leong Whye Sook
Department of Medicine, Nursing Unit, Faculty of Medicine and Health Science
Universiti Putra Malaysia
E-mail: wsleong@medic.upm.edu.my
Tel: 03- 89472437
Azhar Md Zain
Dean, Faculty of Medicine and Health Science, Universiti Putra Malaysia
E-mail: azharmz@medic.upm.edu.my
Tel: 03- 89472602
Abstract
Introduction: Needle stick and sharps injuries (NSSIs) have been recognized as one of the
occupational hazards among health care workers (HCWs). They increase risk of spread of
diseases like HIV, Hepatitis B and Hepatitis C. The objective of this study was to
determine the prevalence and factors associated with needle stick and sharps injuries.
Methods: This cross sectional study was conducted in Serdang Hospital Malaysia using a
self-administered validated questionnaire. The respondents consisted of 345 HCWs namely
medical assistant officer, staff nurses, medical laboratory technician and community nurse.
Data was analysed using SPSS version 17.
Results: Results showed that the overall mean age of the 345 respondents was 29.7years
and it ranged from 22 years to 45 years with a median of 29 years. The mean age for the
males (28.9 years) did not differ significantly from the females (29.9 years). The overall
prevalence of needle stick or sharps injuries was 23.5%. Staff nurses had the highest
prevalence (27.9%). The causes of NSSI in 58% of cases were hypodermic needle and
27.2% cases were recapping. Medical ward reported the highest NSSIs (51.9%).
Knowledge on body fluid transmitted by HIV/AIDS and blood products was high (99.1%).
Majority stated that they throw needles or sharps immediately after use in sharp bins
(92.7%), do not separate needles from syringes prior to disposal (98.0%) and do not
dissemble needles or sharps with hand (98.5%) and do not recap needles after use (94.3%).
Majority also stated that they were aware about universal precaution guideline (96.5%) and
needle stick and sharps injury needs to be reported (99.1%). However, out of those health
care workers (23.5%) who had NSSI, only 30.9% had reported the incident of needlestick
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and sharps injuries indicating that there were gaps between knowledge and practice among
the HCWs. There was a statistically significant association between NSSIs and age
(p=0.01) of respondent, working experience (p=0.001) and job categories (p=0.03).
Conclusions: The prevalence of NSSI was 23.5%. Although the knowledge on Universal
Precautions is good, the prevalence of NSSIs is still high and there are gaps between
knowledge and practice related to HIV prevention. NSSIs continue to pose a serious
occupational problem.

Keywords: Needle stick / sharp injuries, Factors Associated, Health Care Workers,
Malaysia

1. Introduction
Needle sticks and sharp injuries (NSSIs) have been recognized as one of the occupational hazards
among health care workers (HCWs). An estimated 600,000 to 800,000 needle stick and other
percutaneous injuries are reported annually among U.S. HCWs [1]. It is estimated that 100,000 needle
stick injuries occur annually in UK alone [2] and 500,000 annually in Germany[3].Occupational
exposures to percutaneous injuries are substantial source of infections with blood borne pathogens
among health-care workers and can cause substantial health consequences and psychological stress for
HCWs and their loved ones [4]. Occupational blood borne transmission of more than 50 different
pathogens has been reported [5]. NSSIs increase risk of spread of diseases like HIV, Hepatitis B and
Hepatitis C [6,7]. Sharps injuries are a major source of HCV infection among HCWs, accounting for
almost 40% of HCV infections [8]. Jagger (2007) reported that the risk of occupational infection with
HIV, although alarming, has never reached the scale of hepatitis B [9]. Out of the total of 94
documented and 170 possible cases of occupational HIV infection had been identified worldwide up to
1997, nearly two-thirds of cases were reported from the United States [10]. This could be due to the
fact that most countries, especially those with a high population prevalence of HIV infection, have
never instituted surveillance systems that would capture data on such case [9]. Certain groups of
individuals are at greater risk than others because of the nature of their work. Numerous studies have
found nurses to be the commonest group of HCWs experiencing needle stick injuries [11]. The
objectives of the study were to determine the prevalence of needle sticks and sharps injuries and its
associated factors among HCWs at Serdang Hospital.

METHODS
Study location: This study was carried out at Serdang Hospital Malaysia
Study design: A cross-sectional study design was used.
Estimated sample size: The estimated sample size for this study was 287. An additional 20% for non
response was added to give a sample seize of 345 HCWs.
Sampling frame: A list of all HCWs (assistant medical officer, staff nurses and medical laboratory
technician and community nurses) in Serdang Hospital Malaysia. This study did not include doctors.
Sampling technique: Simple random sampling technique using table of random number was used to
select the respondents.
Instrument: a structured pre tested validated questionnaire was used in this study
Data analysis: Data was analyzed using Statistical Package for the Social Sciences (SPSS) version 17.
Descriptive statistics were performed on the knowledge on blood borne diseases and universal
precaution, socio-demographic data, work factors, and practice on universal precaution influence to
needle stick or sharp injury. Age was computed from the information on date of birth and date of
interview. Categorical variables were presented as percentages. The x2 test was used to evaluate the
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relationship between variables. Independent sample t-test was used to compare the means of two
independent continuous variables. A p-value of < 0.05 was considered as statistically significant.
Ethnic Approval: Ethical approval was obtained from Ministry of Health Medical Research Ethics
Committee (MREC) and Ethics Committee of Faculty of Medicine and Health Science, UPM; Consent
was also obtained from all respondents before being interviewed.

Results
Response rate and socio-demographic characteristics
All the 345 HCWs agreed to participate giving a response rate of 100%. Table 1 shows the sociodemographic characteristics of the respondents by age, sex, ethnicity, education level, job categories
and working experience. Majority of the 345 HCW were females (87.5%). Majority were Malay
96.8%. The overall mean age of the 345 respondents was 29.7years (95% CI = 29.2 to 30.2) and it
ranged from 22 years to 45 years with a median of 29 years. The mean age for the males (28.9 years)
did not differ significantly from the females (29.9 years; p > 0.05). Majority (83.2%) of respondents
had 10 years and below working experience. Among the 345 respondents majority (63.5%) were staff
nurses, followed by community nurses (20.3%), assistant medical officers (11.0%) and medical
laboratory technicians (5.2%).
Table 1:

Socio-demographic characteristics of respondents

Variable
Age group

Gender
Ethnicity
Job category

Education level
Years of services

Description
20 24 years
25 29 years
30 34 years
35 39 years
40 years or more
Female
Male
Malay
Non-Malay
Staff Nurse
Community Health Nurse
Assistant Medical Officer
Medical Laboratory Technician
Diploma/Degree
Certificate
< 10 years
10 years or more

Frequency
N
30
165
97
40
13
302
43
334
11
219
70
38
18
256
89
287
58

%
8.7
47.8
28.1
11.6
3.8
87.5
12.5
96.8
3.2
63.5
20.3
11.0
5.2
74.2
25.8
83.2
16.8

Knowledge, attitude and practice of health care workers of biological hazards and preventive
measures regarding needle stick and sharp injuries.
Table 2 shows the level of knowledge, attitude and practice of health care workers of biological
hazards and preventive measures regarding needle stick and sharp injuries. The results show that
majority stated that were aware about universal precaution guideline (96.5%) and that needle stick and
sharps injuries need to be reported (99.1%). Only minority did not know Hepatitis B (2.6%) and
Hepatitis C (7%) can be transmitted by needle stick and sharp injuries. However, 18.8% of the HCW
were unaware of the fact that HIV/AIDS can be transmitted by needlesticks and sharps injuries and
19.4% did not know that they need to wear gloves during handling phlebotomy administration.
Majority (66.1%) of the HCW were of the impression that needles should be recapped after use and
only 52.5% knew about needleless safety devices. Majority (98.3%) stated that they use gloves for
phlebotomy, during withdrawing needles from patient (97.4%), wear gloves during manipulating sharp
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bin (95.4%) and during disposal contaminated needles or sharps (96.5%). Majority also stated that they
throw needles or sharps immediately after use in sharp bin (92.7%), do not separate needles from
syringes prior to disposal (98.0%) and do not dissemble needles or sharps with hand (98.5%) and do
not recap needles after use (94.3%). The results also show that out of the 345 respondents, 81 had
experienced needle stick or sharps injury giving an overall prevalence of 23.5%. However, out of these
81 health care workers who had NSSI, only 25 (30.9%) had reported the incident of NSSI. Those HCW
who had stated that they had experienced NSSI, were then asked the work place where there had
experienced it. Table 3 shows work place at the time of needle stick or sharp injuries. Majority (51.9%)
experienced NSSI in the medical ward. They were then also asked the type of devices involved in
needle stick or sharps injuries. Out of the 81 HCW who had NSSI, majority (58%) reported
hypodermic needle, followed by suture needle (21%), butterfly needle (8.6%), venofix / branula (7.4%)
and lancet (5%).
Table 2:

Respondents knowledge, attitude and practice regarding biological hazards and preventive
measures in needle stick and sharp injuries
Item

Description

Do you know about the universal precaution guidelines?

Do you know about the needleless safety device?
Can Hepatitis B be transmitted by needle stick and sharp injuries?
Can Hepatitis C be transmitted by needle stick and sharp injuries?
Can HIV/AIDS be transmitted by needle stick and sharp injuries?
Do you need to wear gloves during phlebotomy?
Do you use gloves during phlebotomy?
Do you wear gloves when withdrawing a needle from a patient?
Should needles be recapped/bent after use?
Do you recap needles after use?
Do you disassemble used needle or sharp with your hands?
Do you wear gloves when disposing of contaminated needles or
sharps?
Do you separate the needle from the syringe prior to disposal?
Do you throw used needles or sharps into the sharp bin immediately?
Do you wear gloves when manipulating the sharp bin?
Do needle stick and sharp injuries need to be reported?
Have you ever had a needle stick or sharp injury?
Was the incident of needle stick or sharp injury reported?

357

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Frequency
N
333
12
181
164
336
9
321
24
280
65
278
67
339
6
336
9
228
117
20
325
5
340
333
12
7
338
320
25
329
16
342
3
81
264
25
56

%
96.5
3.5
52.5
47.5
97.4
2.6
93.0
7.0
81.2
18.8
80.6
19.4
98.3
1.7
97.4
2.6
66.1
33.9
5.8
94.2
1.5
98.5
96.5
3.5
2.0
98.0
92.7
7.3
95.4
4.6
99.1
0.9
23.5
76.5
30.9
69.1

European Journal of Social Sciences Volume 13, Number 3 (2010)

Table 3:

Work place at the time of needle stick or sharp injuries

Frequency

Location

N
42
13
8
7
7
2
2

Medical Wards
Labor Room
Operation Theatre
Emergency Department
Intensive Care Units
Surgical Wards
Laboratories

%
51.9
16.0
9.9
8.6
8.6
2.5
2.5

Procedure performed at the time of needle stick or sharps injuries

The respondents were also asked what was the procedure performed at the time of NSSIs occurred
among respondents who had experienced NSSI. Table 4 shows the activities at time of needle stick or
sharp injuries. Out of the 81 respondents who had experienced needle stick or sharps injury, 22
(27.2%) were recapping needle or sharp devices at the time of needle stick or sharp injuries, followed
by handling needle or sharps devices on tray (21.1%), suturing (18.5%), passing or transferring needle
(13.6%), transit disposal needle or sharp devices (12.3%) and dissembling needle or sharp devices
(7.4%).
Table 4:

Activities at time of needle stick or sharp injuries

Frequency

Activity

N
22
17
15
11
10
6

Recapping needle
Handling needle or sharp on a tray
Suturing
Passing or transferring needle or sharp
Transit of disposal needle or sharp device
Disassembling needle or sharp device

%
27.2
21.0
18.5
13.6
12.3
7.4

Relationship between prevalence of needle sticks/sharps injury and age, gender, ethnicity,
educational level, job category and working experience
Table 5 shows the relationship between prevalence of NSSI and age, gender, ethnicity,
educational level, job category and working experience. The results show that there was a significant
relationship between prevalence of NSSIs and age (p<0.01). The prevalence of NSSIs was significantly
higher (p=0.05) among those age aged 35 years and above (32.6%) as compared to those below 35
years of age (19.5%). Although the prevalence of NSSIs was higher among the female respondents
(24.2%) as compared to males (18.6%); the difference was not statistically significant. There was also
no significant relationship between prevalence of NSSIs and ethnicity, educational level and working
experience (p>0.05). Overall the results showed that there was a significant relationship between
prevalence of NSSIs and job category (p<0.05). The staff nurses had the highest prevalence (27.9%)
followed by medical laboratory technician (27.8%), assistant medical officer (18.4%) and community
nurse (11.4%). Further analysis using chi square test showed that there was a significant difference in
the prevalence of NSSIs between community nurses and staff nurses (p<0.01). However, there was no
significant difference in the prevalence of NSSIs between staff nurses and assistant medical officer
(p=0.22), between staff nurses and medical laboratory technician, between medical laboratory
technician and assistant medical officer (p =0.43), between assistant medical officer and community
nurses (p =0.32), between community nurses and medical laboratory technician (p=0.08). The results
also showed that there was no significant difference in the prevalence of NSSIs and number of years of
working experience (p=0.69).
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Table 5:

Relationship between prevalence of needle stick or sharp injuries and socio- demographic
characteristics

Variable
Age group

Gender
Ethnicity

Job
category

Education
level
Years of
services

Description
20 24 years
25 29 years
30 34 years
35 39 years
> 40 years
Male
Female
Malay
Chinese
Indian
Staff Nurse
Community Health Nurse
Assistant Medical Officer
Medical Laboratory Technician
Degree
Diploma
Certificate
< 10 years
> 10 years

Needle stick/sharp injuries

Yes
No
Frequency
N
%
N
%
4
13.3
26
86.7
36
21.8
129
78.2
17
17.5
80
82.5
18
45.0
22
55.0
6
46.2
7
53.8
8
18.6
35
81.4
73
24.2
229
75.8
78
23.4
256
76.6
1
50.0
1
50.0
2
22.2
7
77.8
61
27.9
158
72.1
8
11.4
62
88.6
7
18.4
31
81.6
5
27.8
13
72.2
1
100
0
0
64
25.1
191
74.9
16
18.0
73
82.0
66
23.1
220
76.9
15
25.4
44
74.6

Value
x2

17.9

0.001

0.65

0.42

0.79

0.67

8.72

0.03

1.87
Diploma vs.
Certificate
0.15

0.17

0.69

Discussion
The prevalence of needle stick or sharps injuries among HCWs in this study carried out in 2008 was
23.5% which is slightly lower compared to prevalence of 24.9% reported by Lee and Hassim in 2005
[12]. However this is much lower than 74% reported by Maqbool Alam in a study carried out in 2002
at the 100-bed Armed Forces Hospital, Saudi Arabia [13], 74% reported by Gurubacharya et al in their
study carried out in Nepal in 2003 [14] and 39.4% reported by Hofranipour et al, 2009 in Iran [15]. In
our study the prevalence was highest in staff nurses. Similar results have been reported in several other
studies [16,17]. This can be explained by the fact that nurses administer most of the injections and are
responsible for venipunctures, intravenous fluid administration and other procedures which require the
use of needles. Gerberding in 1991 stated that one reason that may account for the increased
vulnerability of injury among nurses is the greater amount of time nurses spent in direct patient contact
[18]. Our study showed that there was no significant association between gender with needle stick and
sharp injury. Similar results have also been reported by Hadadi et al. (2008) [16].
Prospective studies have reported that the estimated risk for HIV infection after a percutaneous
exposure to HIV infected blood is approximately 0.3% [19-20]. Pruss-Ustun et al reported that an
estimated of more than three million HCWs experience a percutaneous injury with a contaminated
sharp object each year and these exposures result in about 16,000 infections of HCV, 66,000 of HBV
and about 1,000 of HIV that lead to about 1,100 deaths and significant disability. They also estimated
that 4.4% (0.8%18.5%) of HIV infections among HCWs may be attributable to occupational sharps
injuries worldwide [8]. There is a widespread availability of safety-engineered needles and sharp
devices. The new generation of devices has shown a high degree of safety efficacy, especially those
used for vascular access and drawing blood, the procedures that are associated with the greatest risk of
blood-borne pathogen transmission. Jagger and Bentley in 1997 [21] and Mendelson et al [22] in 2000
have reported reductions of 83% and 89% in the number of needle sticks after the introduction of
safety engineered intravenous catheters. Lamontagne et al. in 2007 reported a 74% reduction in the
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number of injuries from needles for drawing blood after the introduction of safety-engineered
alternatives [23]. The recapping of needles has been prohibited under the Occupation Safety and Health
Administration (OSHA) blood-borne pathogen standard [24]. Our study also showed that majority
(66.1%) of the HCW had the misconception that needles should be recapped after use and only 52.5%
knew about needleless safety devices. The availability and compliance to adopting safety-engineered
devices will help in the reduction of NSSI and risk of blood-borne infections including HIV/AIDS.
Timely reporting of occupational exposures to an employee health service is required to ensure
appropriate counselling, facilitate prophylaxis or early treatment, and establish legal prerequisites for
workers' compensation [25]. This study result showed that although majority (96.5%) stated that they
know about the Universal precaution guidelines, however, there are gaps in the knowledge and
practice. Majority (99.1%) reported that needle stick and sharp injuries need to be reported, however,
only 30.9% who had needle stick and sharp injuries reported the incident. The failure to report NSSI
has been highlighted in this study. Knowledge is not sufficient, it must be accompanied by practice.
These health care workers expose themselves with unnecessary risk of not reporting thus depriving
themselves of the benefit of intervention.

Conclusions
The prevalence of needle stick or sharp injuries among HCWs in this hospital was 23.5%. There are
gaps in the knowledge and practice among the HCWs. Only 30.9% who had needle stick and sharps
injuries reported the incident. The is a need to report NSSIs to the relevant authorities so as to facilitate
and ensure appropriate counselling, prophylaxis or early treatment. There is also a need for strict
compliance to adopting safety-engineered devices which will help in the reduction of NSSI and risk of
blood-borne infections.

Acknowledgement
We are grateful to Tan Sri Datuk Sri Dr. Hj. Mohd. Ismail b. Merican, Director General, Ministry of
Health Malaysia and Dean, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia for
permission to publish this paper. Our thanks are also due to the Director and staff of Serdang Hospital
for their assistance and cooperation.

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