International Journal of Hygiene and Environmental Health 214 (2011) 407–410
Contents lists available at ScienceDirect
International Journal of Hygiene and
Environmental Health
journal homepage: www.elsevier.de/ijheh
Lack of risk-awareness and reporting behavior towards HIV infection through
needlestick injury among European medical students
Helmut J.F. Salzer a,∗ , Martin Hoenigl a , Harald H. Kessler b , Florian L. Stigler c , Reinhard B. Raggam d ,
Karoline E. Rippel a , Hubert Langmann e , Martin Sprenger f , Robert Krause a
a
Section of Infectious Diseases, Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Austria
Research Unit Molecular Diagnostics, Institute of Hygiene, Microbiology and Environmental Medicine, Medical University of Graz, Austria
c
School of Community Based Medicine, University of Manchester, United Kingdom
d
Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University Hospital of Graz, Austria
e
Institute of Health Promotion and Prevention GmbH, Graz, Austria
f
Postgraduate Public Health Program, Medical University of Graz, Austria
b
a r t i c l e
i n f o
Article history:
Received 10 March 2011
Received in revised form 6 May 2011
Accepted 17 May 2011
Keywords:
Medical student
Needlestick injury
HIV
Post-exposure prophylaxis
Prevention
a b s t r a c t
Medical students are at risk for occupational needlestick injuries (NSIs) which can result in substantial
health consequences and psychological stress. Therefore, an open online survey among final year medical
students from Austria, Germany, and the United Kingdom (UK) was conducted. The aim of the study was
to evaluate risk-awareness and reporting behavior regarding needlestick injury (NSI), post-exposure
prophylaxis, and level of education regarding the transmission of HIV through NSIs. Of 674 medical
students, 226 (34%) reported at least one NSI during medical school. Respondents from Austria and
Germany experienced a significantly higher number of NSIs in comparison to respondents from the UK.
Seventy-six respondents (34%) did not report their most recent injury to an employee health office. Almost
one third were not familiar with reporting procedures in case of a NSI and 45% of the study population
feared that reporting an injury might have an adverse effect on their study success. 176 respondents
(78%) who had suffered a NSI were not aware of the patient’s HIV status. Education regarding NSIs and
HIV transmission reduced the actual risk of experiencing a NSI significantly. These data indicate that
medical students are at high risk of suffering NSIs during medical school. The rate of nonreporting of
such injuries to an employee health service is alarmingly high. Improved medical curricula including
precise recommendations may contribute to a more efficient prevention of occupational HIV infection in
medical students.
© 2011 Elsevier GmbH. All rights reserved.
Introduction
According to a WHO model, the worldwide annual incidence
of HIV infections among health care workers (HCW) is estimated
to be close to 1000 infections due to occupational exposure to
percutaneous injuries (Prüss-Üstün et al., 2005). Reporting occupational needlestick injuries (NSIs) immediately to the employee
health service is of major importance preventing transmission
of HIV (Hamlyn and Easterbrook, 2007). Furthermore, reporting
facilitates appropriate counseling and timely antiretroviral postexposure prophylaxis (PEP) (Panlilio et al., 2005). Additionally,
it may strengthen the awareness of the potential risk and contribute to the prevention of NSIs in general. However, recent
studies showed that the frequency of nonreported NSIs is alarm-
∗ Corresponding author. Tel.: +43 650 7828679; fax: +43 316 385 4622.
E-mail address: salzer.helmut@gmail.com (H.J.F. Salzer).
1438-4639/$ – see front matter © 2011 Elsevier GmbH. All rights reserved.
doi:10.1016/j.ijheh.2011.05.002
ingly high, especially among medical students, and surrounding
circumstances are not fully understood (Sharma et al., 2009; Wicker
et al., 2008).
The aim of this study was to evaluate risk-awareness and reporting behavior of medical students regarding transmission of HIV
through occupational needlestick injury (NSI).
Materials and methods
Medical students in the final year of medical education from
11 medical universities including 3 from Austria, 4 from Germany,
and 4 from the United Kingdom (UK) were invited to participate in
an open online survey regarding NSI, post-exposure prophylaxis,
and level of education. Personal invitations to participate in the
online survey were emailed to 1200 randomly selected medical students (400 in Austria, Germany, and the UK each). All completed
questionnaires without any contradictory answer were included
for evaluation. Exclusion criteria included participation in the
408
H.J.F. Salzer et al. / International Journal of Hygiene and Environmental Health 214 (2011) 407–410
Table 1
Responses (%) provided by 674 students (171 from Austria, 276 from Germany, and 227 from UK) regarding educational background.
Austria
Education regarding needlestick injuries
Short briefing
24
22
Lecture (≥30 min)
Theoretical and practical training
18
None
36
Which blood-borne pathogen do you fear most?
46
HIV
49
HCV
HBV
5
Are you familiar with the reporting procedures in case of a needlestick injury?
Yes
77
23
No
Do you think that reporting an incident will adversely affect your study success?
23
Yes
No
36
41
I don’t know
a
b
Germany
UK
Overall rate
25
21
16
38
26
11a
40b
23b
25
18
24
32
46
46
8
84b
12b
4
59
36
6
74
26
52b
48b
67
33
22
45
33
17
51a
32
20
45
35
Statistically significant difference between UK vs. Austria and Germany with p < 0.05.
Statistically significant difference between UK vs. Austria and Germany with p < 0.01.
survey without prior personal invitation and failure to complete
the questionnaire.
Data were obtained using a computer assisted self-administered
questionnaire designed by the software package LimeSurveyTM
(www.limesurvey.org). Completion of the survey included consent for study participation. The study was approved by the ethical
committee of the Medical University of Graz, Austria (permission
number: 21-297 ex 09/10).
The questionnaire consisted of a brief introduction covering
the potential risks associated with NSIs followed by 21 questions covering risk-awareness and reporting behavior. NSI was
defined as a laceration or puncture produced though a needle or
other sharp instrument contaminated with blood or another body
fluid. In addition, seven questions asked for personal data. All data
were collected anonymously in accordance with legal requirements
regarding data protection and medical confidentiality.
Completed questionnaires were coded, entered into Excel, version 5 (Microsoft, Mountain View, Calif.), and analyzed by SPSS,
version 10 (IBM Corp., Somers, NY) with p < 0.05 considered statistically significant.
Results and discussion
Of 1200 medical students, 674 (56%) returned questionnaires
according to inclusion criteria. Sixty-three percent (422/674) of
the participants were female and 37% (252/674) were male. The
mean age of the students was 24.9 years. Comparison of educational
background regarding NSIs is listed in Table 1.
In this study, 34% (226/674) of medical students experienced
the event of at least one NSI during medical school. The vast majority (75%) of students experienced one NSI, whereas 15% suffered
from two and 10% from three or more NSIs. Frequency of NSIs did
not differ significantly between male and female students. When
compared to respondents from the UK, Austrian and German students experienced significantly more NSIs (44% in Austria, 41% in
Germany, and 16% in the UK; p < 0.001 vs. Austria and Germany).
The overall nonreporting rate of the most recent NSI was 34%
(76/226). Characteristics of needlestick injuries and behavior associated with nonreporting of the most recent NSI are shown in
Table 2.
Regarding safety regulations, 28% (189/674) of respondents
(40% in Austria, 25% in Germany, and 22% in the UK) reported that
they did not follow established safety regulations such as accurate
disposal of contaminated needles and/or hand-disinfection to manage the clinical workload. The number of staff in the clinical setting
was reported insufficient to handle the number of patients by 37%
(252/674) of the study population with the percentage being significantly higher in Germany (52%) than in the UK (21%; p < 0.001).
Asked about the local working environment, 40% (269/674)
agreed to the statement that experienced HCW frequently disregard rules or guidelines established for infection control. Forty-five
percent (301/674) of respondents disagreed that most HCW report
all NSIs (57% in Germany and 25% in the UK; p < 0.001) and 21%
(142/674) agreed that trainees report more frequently than permanent employees do.
Respondents from Austria and Germany were significantly more
likely to have experienced a NSI compared to respondents from
the UK (Austria 76/171, p < 0.001; Germany 114/276, p < 0.001; UK
36/227). In the UK, any form of education regarding NSIs reduced
the actual risk of experiencing a NSI significantly (p = 0.014). In contrast, respondents from Austria and Germany had to attend at least
a lecture above 30 min of time or a theoretical and practical training
to reduce the risk of a NSI significantly, when compared to students
who received either a short briefing or no education at all (Germany
p = 0.046; Austria p = 0.017).
Frequency of NSIs among final year medical students has been
reported to be 11–59% (Deisenhammer et al., 2006; Osborn et al.,
1999; Rosenthal et al., 1999; Salzer et al., 2010a,b). In this study,
34% of medical students in their final year had suffered at least one
NSI during medical school education. A possible explanation for the
significantly higher rate among students in Austria and Germany
when compared to the UK may be the fact that training blood collection is an essential part of the medical curricula in Austria and
Germany because medical doctors are responsible for blood collection in these countries, while nurses or other HCWs bear this
responsibility in the UK. Therefore, Austrian and German students
face a higher workload regarding blood collection when compared
to students in the UK.
Percentages obtained in this study show that one out of three
medical students may be at risk of acquiring HIV, hepatitis B virus
(HBV), or hepatitis C virus (HCV) infection during medical education. Risk of HBV transmission is most relevant regarding NSI
associated diseases globally. However, in most European countries,
immunization against HBV is routinely performed among medical
students decreasing the risk of HBV transmission significantly. In
contrast to HCV, HIV highlights a blood borne disease that can be
reduced significantly through timely administration of post exposure prophylaxis. The risk of HIV transmission from patients to
HCWs due to occupational NSIs has been reported to be about 0.3%
(Marcus, 1988; Tokars et al., 1993). Immediate induction of bleeding (squeezing wound carefully and rinsing with a large volume of
skin disinfection agent) followed by timely administration of PEP
H.J.F. Salzer et al. / International Journal of Hygiene and Environmental Health 214 (2011) 407–410
409
Table 2
Responses (%) provided by 226 students (76 from Austria, 114 from Germany, and 36 from UK) who experienced at least one needlestick injury during medical school
education and who did not report the most recent injury.
Nonreporting of the most recent needlestick injury
Location injury occurred
Bedside
Operating room
Other
Task performed during injury
Cleaning up
Suturing
Recapping needle
Loading needle
Passing needle
Other
Perceived cause of injurya
Time pressure
Lack of experience
Equipment failure
Fatigue
Lack of skills
Patient movements
Lack of assistance
Other
Awareness of the patients HIV status
Yes
No
Did you modify your behavior after your most recent needlestick injury?
Yes
No
Reason for not reporting needlesticka
Little or no risk awareness
Presumption that the injury did not involve a high-riskb patient
Shame
Clean needle
“No utility in reporting”
“I did not know the reporting procedure”
Might negatively influence grades or even my future medical career
“Lack of time”
“Stigma of having had a needlestick”
Other
Education regarding needlestick injuries
Short briefing
Lecture (≥30 min)
Theoretical and practical training
None
a
b
Austria
Germany
UK
Overall rate
29
35
39
34
54
21
25
57
20
23
61
8
31
57
18
25
46
12
10
3
3
26
32
17
15
4
2
30
28
8
11
11
6
36
36
14
13
5
3
30
43
25
12
9
3
7
5
9
35
33
17
15
10
8
9
13
22
47
31
11
28
8
6
31
36
33
17
12
10
8
7
15
22
78
2
76
17
83
22
78
72
28
68
32
92
8
73
27
25
14
14
4
7
5
3
5
1
8
20
12
12
9
11
11
6
7
5
10
8
8
3
31
14
6
6
0
3
8
20
12
12
11
10
8
8
4
2
9
29
12
18
41
27
15
16
42
11
17
33
39
25
14
20
41
Respondents could select more than one response.
High-risk patient was defined as being infected with HIV, HBV, and/or HCV.
decreases this percentage additionally (Young et al., 2007). Reporting of any NSI is thus of paramount importance. However, this study
shows that the percentage of nonreporting of NSIs is alarmingly
high among medical students, with about one third of NSIs never
being reported.
While the nonreporting rate was found to be 34% in this study,
an even higher nonreporting rate (47%) among medical students in
the USA was published recently (Sharma et al., 2009). The authors
concluded that medical centers should strengthen efforts to implement novel prevention strategies and improved reporting systems
for medical students to address the urgency of this preventable
problem. Further European studies showed tremendous rates of
nonreporting up to 62% (Rosenthal et al., 1999; Wicker et al., 2008).
Reasons for nonreporting include students’ lack of knowledge
of being at risk, shame, fear of consequences resulting from reporting, and/or poor awareness of the institutional reporting facilities
(Raggam et al., 2009). One third of Austrian and German respondents and almost 50% in the UK were not familiar with reporting
procedures in case of a NSI. Interestingly, 45% (301/674) of the study
population feared that reporting an injury might have an adverse
effect on their study success.
To improve reporting compliance, a multifactor approach is
required (Salzer et al., 2010a,b). For example, a NSI hotline service
may be introduced (Osborn et al., 1999). Furthermore, Phillips et al.
demonstrated that the introduction of a multidisciplinary learning
program for teaching infection control, being a mandatory requirement for the final examination, was an effective tool (Phillips and
Ker, 2006).
Concerning the mostly frightening blood-borne pathogen, the
overall rate fearing HIV infection was 59% (396/674). In the UK,
the fear of acquiring HIV infection was close to 85%. In contrast,
only 36% (240/674) of respondents identified HCV as the mostly
frightening pathogen indicating lack of knowledge about the probability of HCV transmission which was reported to be up to 10
times higher compared to that of HIV (Chung et al., 2003). In addition, there is currently no post-exposure HCV treatment regimen
existing (Corey et al., 2009; U.S. Public Health Service, 2001). The
majority of respondents who had suffered a NSI were not aware of
the patient’s HIV status. Together with the overall 34% nonreporting
rate, this is an alarming fact.
Furthermore, data obtained by this study clearly indicate that
education regarding NSIs may reduce the risk significantly. A lecture of at least 30 min or, even better, theoretical and practical
training appear to be preferable alternatives to a short briefing that
showed some positive benefit in the UK but proved insufficient
in Austria and Germany. This finding highlights the demand for
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H.J.F. Salzer et al. / International Journal of Hygiene and Environmental Health 214 (2011) 407–410
qualitative and quantitative improvement of education regarding
NSIs and HIV.
Teachers and well-educated HCW play an important role model
for students, as medical students appear to copy behaviors of
health care professionals. Positive role models may help students
to bridge the gap between theoretical education and reality in
the clinical setting. However, this study indicates that experienced
HCW frequently disregard rules or guidelines established for infection control and NSIs often remain nonreported among permanent
employees. This was also reported by Makary et al. who found an
occupational nonreporting rate of 51% regarding NSIs among surgeons in training (Makary et al., 2007). When establishing a culture
of safety, not only the education of students but also the awareness
of health care professionals to act as positive role models in the clinical setting must be considered. For example, a personal testimonial
among respected peer surgeons was reported to be a powerful education tool to encourage safety and appropriate reporting (Salzer et
al., 2010a,b).
In conclusion, there is an urgent need to improve the awareness and knowledge of medical students about the risk of HIV
transmission through occupational NSIs. Introduction of improved
medical curricula including precise recommendations may have a
significant impact on the frequency of NSIs and reporting behavior contributing to a more efficient prevention of occupational HIV
infections in medical students.
Acknowledgments
The authors acknowledge Herwig Stieber for the design of the
online questionnaire. Furthermore, we want to thank Ane Straume
and Celia Serna-Bolea for proofreading the final manuscript and for
their helpful suggestions.
Preliminary results of this study have been presented at the 3.
GHUP meeting 2009 in Stuttgart, Germany and have been granted
with a travel award from the Society of Hygiene, Environmental
and Public Health Sciences (http://www.ghup.de/).
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