NIOSH issues guidelines for use of sharps boxes

One-third of sticks disposal-related

Citing the risk of infection with HIV, hepatitis, and other bloodborne pathogens, the Nation-al Institute of Occupational Safety and Health (NIOSH) has issued guidelines for selection and use of sharps boxes to prevent disposal-related needlestick injuries to health care staff. NIOSH, a branch of the Centers for Disease Control and Prevention in Atlanta, issued the document to assist infection control staff in selection, installation, and periodic review of sharps boxes.1

"When you evaluate your overall needlestick injury [rate] and prevention program in a hospital, if sharps disposal containers have been a problem, these would be some of the things that you could evaluate," says Linda Martin, PhD, director of NIOSH HIV activity. "Or, if you're replacing your sharps disposal containers for some reason, these would be recommendations to consider about height and placement. There is also a good bit of information in the document about doing a risk assessment to decide the kind of sharps that each area [in the facility] might be disposing."

NIOSH noted that studies show as many as a third of the nation's estimated 800,000 annual needlesticks are related to disposal.2-5 Among the contributing factors are sharps disposal practices, inadequate container design, inappropriate container placement, and overfilling.

Correct, consistent use of rigid sharps disposal containers in the health care environment has been shown to reduce the number of needlesticks, NIOSH stressed. Studies show placement of disposal boxes in all patient and treatment rooms decreases the frequency of injury; well-placed containers reduce recapping injuries sharps by as much as 80%, NIOSH noted.6 In addition to engineering controls such as the use of rigid sharps disposal containers, organizational controls are vital to prevention. Those include the elimination of unnecessary sharps, changes in device-handling procedures, worker education and training, and placement of sharps disposal containers where sharps are used, the document concludes.

While supporting the document's purpose, the American Nurses Association (ANA) in Washing-ton, DC, urged NIOSH to stress the use of needle safety devices as part of a needlestick reduction program. "Once you get the needle to the box, you're already past the point of when you could have implemented an engineering control to prevent needlesticks altogether," says Susan Wilburn, RN, MPH, senior specialist for occupational safety and health at the ANA. "But we are very supportive of the training and the package itself."

While the emphasis is on safe criteria for disposal boxes, the better solution still is to eliminate unnecessary needles, Martin agrees. "We emphasize that if there is technology that can eliminate the sharp, we would by far rather see the sharp eliminated than to have to dispose it," she says.

An individual or group in the health care set-ting should be assigned responsibility for regular maintenance of containers, including frequently assessing their fill levels and changing them before they are overfilled, NIOSH says. Also, each time a reusable container is returned to service after reprocessing, the facility should confirm that it meets its original performance criteria. Reusable containers should be rendered free of infectious organisms and material each time they are reprocessed and before they are returned to service.

Common pitfalls include placing containers too high (they should be at eye level) or making them otherwise inaccessible. "There have been a lot of people who have been stuck when putting a sharp in a box over their head," says Wilburn.

Part of the problem may be that security concerns have overridden safety in installing the boxes, with some facilities even placing them in locked bathrooms, Martin says. "Originally, when sharps containers were first installed, I think everybody worried that drug addicts might somehow get access to the needles. There was a lot of concern about that, but I don't think it has proven to be the case. Now the concern is to locate the sharps disposal container somewhere where it doesn't add to the injury [risk] for the worker."

Patients must be factored into the risk assessment. Pediatric or psychiatric units may need more secure or portable boxes than adult wards. "You have to weigh the safety of the worker vs. the safety of the patient," Martin says. "We emph-asize asking the workers to help evaluate the problem. Maybe, as a group, decide what are the greatest security needs and how they may conflict with worker safety."

[For copies of the document, contact NIOSH, Publi-cations Dissemination, EID, 4676 Columbia Parkway, Cincinnati, OH 45226-1998. Telephone: (800) 356-4674. E-mail:]


1. Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health. Selecting, Evaluating, and Using Sharps Disposal Containers. Atlanta; January 1998.

2. Slagle DC, McNicol LB. The epidemiology of injuries and splash exposures at a military medical center. Military Med 1994; 4:302-306.

3. McCormick RD, Maki DG. Epidemiology of needle stick injuries in hospital personnel. Am J Med 1991; 70:928-932.

4. Jagger J, Hunt EH, Pearson RD. Sharp object injuries in the hospital: causes and strategies for prevention. Am J Infect Control 1990; 18:227-231.

5. Haiduven DJ, DeMaio TM, Stevens DA. A five-year study of needlestick injuries: a significant reduction associated with communication, education, and convenient placement of sharps containers. Infect Control Hosp Epidemiol 1992; 13:265-271.

6. Linnemann CC, Cannon C, DeRonde M, Lanphear BP. Effect of educational programs, rigid sharps containers, and universal precautions on reported needlestick injuries in health care workers. Infect Control Hosp Epidemiol 1991; 12:214-219.