Section 5: Health and safety of staff, clients and the community
This final section makes recommendations about health and safety issues. It is assumed that NHS Boards have carried out a detailed risk assessment for all IEP services in their area, and that procedures are in place, not only to protect staff, but also clients and members of the public.
The two recommendations made in this section aim specifically to reduce the risk of transmission of BBVs among staff, clients and the general public.
Recommendation 16: Ensuring the safe disposal of used injecting equipment
As part of wider risk assessment procedures, NHS Boards should ensure that all services in their area have robust policies and procedures in place in relation to the safe disposal of used injecting equipment.
To prevent the transmission of BBVs through improperly discarded injecting equipment, IEP services should:
An Australian review of the international evidence on needle and syringe programmes found no evidence from numerous studies that these programmes increase the number of needles discarded in public. 23 In addition, the risk of a member of the public acquiring a BBV through an accidental needlestick injury appears to be low. This same Australian review reported that to-date, there is only one published case in the world of Hepatitis C transmission after an injury from a discarded used needle in the community. 80 In Scotland, there are no published cases of a member of the public acquiring a blood-borne virus through a needlestick injury received from an inappropriately discarded needle. 81
Nevertheless, as the Department for Environment, Food and Rural Affairs ( DEFRA) points out in their guidance on reducing drug-related litter, whatever the actual health risks, it is clear that the public perceives those risks to be much higher. 54 This perception can lead to public opposition to IEP services. Therefore, services should remind clients at regular intervals to dispose of used injecting equipment safely. Clients can also be encouraged to educate their peers about safe disposal - particularly if they are involved in a secondary distribution network.
The DEFRA guidance recommends the following actions be undertaken to educate and motivate clients to dispose of used injecting equipment safely:
- Users accessing needle exchanges or any other type of drug treatment service, should be given information that encourages them to think responsibly about needles and other drug litter. Where necessary and appropriate, the dangers of unsafe disposal of needles should be explained, including explicitly outlining the facts that it can increase negative attitudes to all users in the community and in extreme cases may result in closure of facilities.
- Homeless, new and younger users should be especially targeted for this type of information, with clear information on safe disposal.
- Drug service (including needle exchange) premises should have posters or written material that carries safe disposal messages. Written material of this type should be distributed to other places where users may go - including police stations, drop-ins for homeless people and so on. Leaflets can be put in bags containing supplies that are given out. Safe disposal stickers could be placed on sharps bins. Regularly changing this material helps motivate users to look at it each time.
- Service users should always be encouraged to take away sharps bins from a range that suits their needs, from small and discreet bins to those suitable for larger quantities. They should also be encouraged both to use them and return them…. Services should invite comments from users about the type and availability of bins and adjust their range as necessary.
One possible barrier to appropriate disposal of used injecting equipment by injectors is the lack of facilities, particularly outside the hours during which IEP services operate. Public sharps bins provide one means of removing that barrier, and DEFRA recommends that local partnerships fully explore the potential for public sharps bins, liaising closely with drug users and services to ensure the siting and promotion of bins is as effective as possible. In relation to this, GIS software can be a useful tool, as it can be used to map "hot-spots" where drug-related litter is currently found. (This assumes, of course, that Environmental Health Departments are recording this information.)
Other options are to locate return bins outside the premises of IEP services to allow injectors to return needles when the services are shut, or to negotiate with staff from other agencies (hostels, for example) to locate bins on their premises. By providing multiple options and locations for the return of used equipment, it may be possible to increase return rates and reduce drug-related litter. If public sharps disposal bins are available locally, IEP service staff should know the locations of these bins, and provide this information to clients.
It is suggested that local NHS Board risk management staff should be consulted for advice on the appropriate choice of public and individual safe disposal bins.
In order to educate clients, staff need to be educated themselves about the safe handling of injecting equipment and the safe disposal of used injecting equipment. Robust procedures should also be in place to protect IEP service staff from accidental needlestick injury. For example, when estimating the number of returned needles in the bins (for monitoring purposes), disposal bins can be weighed or shaken to determine how full they are. Alternatively, clients can be asked how many needles they are returning.
Recommendation 17: Hepatitis B vaccination for staff
NHS Boards should work together with employers to facilitate vaccination for Hepatitis B, free of charge, for all staff who are responsible for delivering an IEP service.
Chapter 18 of the Department of Health guidelines, Immunisation against Infectious Diseases 2006 (The Green Book) recommends that immunisation against Hepatitis B is provided to individuals who are at increased risk of infection because of their lifestyle, occupation or other factors such as "close contact with a case or carrier". 79
Hepatitis B vaccination is recommended for healthcare workers who may have direct contact with patients' blood or blood-stained body fluids. This includes any staff who are at risk of injury from blood-contaminated sharp instruments, or of being deliberately injured or bitten by patients.
The Control of Substances Hazardous to Health ( COSHH) Regulations 2002 require employers to assess the risks from exposure to hazardous substances, including pathogens (called biological agents in COSHH), to bring into effect measures necessary to protect workers and others who may be exposed from those risks, as far as is reasonably practicable. 82 Therefore, the provision of Hepatitis B vaccination for IEP service staff is the responsibility of the individuals' employer, and NHS Boards should work with employers to facilitate this.