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 National Institute of Occupational Safety and Health (NIOSH) has issued comprehensive guidelines for the selection and use of sharps boxes to prevent disposal-related needlestick injuries to health care workers.

NIOSH, a branch of the Centers for Disease Control and Prevention in Atlanta, issued the document to assist infection control professionals in the selection, installation, and periodic review of sharps boxes.1 (See illustration and recommendations, pp. 41-42.)

"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."

In issuing the document, NIOSH noted that studies have shown as many as one-third of the estimated 800,000 annual needlesticks in the United States are related to disposal.2-5 The injuries are related to a number of factors, including sharps disposal practices by the user, inadequate sharps disposal container design, inappropriate sharps disposal container placement, and overfilling of sharps disposal containers.

The correct and consistent use of rigid sharps disposal containers in the health care environment has been demonstrated to reduce the number of needlesticks, NIOSH emphasized. Studies indicate that placement of disposal boxes in all patient and treatment rooms decreases the frequency of sharps injury. Investigators have concluded that appropriately placed sharps disposal containers reduce injuries related to recapping of 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 a vital part of an overall prevention strategy. 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 overall purpose, the American Nurses Association in Washington, DC, urged NIOSH to emphasize the use of needle safety devices as part of an overall 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 is still 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," Martin says.

Taking responsibility

An individual or a group within the health care setting should be assigned the responsibility for regular monitoring and maintenance of sharps disposal containers, including frequently assessing fill levels of containers and changing containers before they are overfilled, NIOSH recommends. In addition, each time a reusable sharps disposal container is returned to service after reprocessing, the facility should confirm that it meets its original performance criteria. Reusable sharps disposal containers should be rendered free of infectious organisms and infectious material each time they are reprocessed and before they are returned to service.

Common pitfalls that have been identified in the sharps disposal process include placing the container too high or making it otherwise inaccessible, placing workers at risk of injury as they attempt to dispose of needles.

"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 been given greater weight than worker safety in installing the boxes, with some facilities going to the extreme of placing them in locked bathrooms, Martin notes.

"Originally, when sharps containers were first installed, I think everybody worried that drug addicts might somehow get access to the needles," Martin says. "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."

The patient population must be factored into the risk assessment, as pediatric or psychiatric patients may warrant more secure or portable boxes than designs used on a typical adult patient ward.

"You have to weigh the safety of the worker vs. the safety of the patient," Martin notes. "We emphasize 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."

[Editor’s note: Copies of the document are available by contacting NIOSH, Publications Dissemination, EID, 4676 Columbia Parkway, Cincinnati, OH 45226-1998. Telephone: (800) 356-4674; fax: (513) 533-8573; 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.