Original Research
Occupational Health

Needlestick Injury Cases and Adherence to the Follow-Up Protocol Among Healthcare Workers in Selangor

Background

Needlestick injuries (NSIs) represent one of the most serious occupational hazards facing healthcare workers worldwide. These percutaneous injuries, caused by accidental puncture from hollow-bore needles, suture needles, or other sharp medical instruments, carry the risk of transmitting blood-borne pathogens including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). The World Health Organization has estimated that globally, approximately three million healthcare workers experience percutaneous exposure to blood-borne pathogens each year, resulting in significant morbidity, psychological distress, and in some cases, seroconversion to serious infectious diseases.

In Malaysia, the Ministry of Health (MOH) established the Sharps Injury Surveillance (SIS) system to systematically monitor and record needlestick and sharps injuries among healthcare workers in government hospitals. This surveillance programme, introduced in line with the guidelines on occupational exposure to HIV, HBV, and HCV, requires the notification and documentation of all sharps injuries, as well as the implementation of a structured post-exposure management protocol that includes baseline blood testing, post-exposure prophylaxis where indicated, and scheduled follow-up blood tests at intervals of six weeks, three months, and six months post-injury.

Adherence to this post-exposure follow-up protocol is critical for several reasons. First, it ensures early detection of seroconversion, enabling timely treatment initiation. Second, it provides important epidemiological data on transmission rates and risk factors. Third, it offers a mechanism for ongoing monitoring of the psychological well-being of affected workers, who frequently experience significant anxiety regarding potential infection. Despite the importance of follow-up adherence, previous studies have indicated that compliance rates are often suboptimal, with a substantial proportion of injured healthcare workers failing to complete the full course of scheduled follow-up testing.

Study Design and Population

This cross-sectional quantitative study reviewed retrospectively all notified NSI cases among healthcare workers in Ministry of Health hospitals in the state of Selangor, Malaysia, during the period of January to September 2016. Data were extracted from the Sharps Injury Surveillance (SIS) system, which is the national electronic database used for recording and tracking sharps injuries in MOH healthcare facilities.

Selangor, the most populous state in Malaysia with a population exceeding six million, is served by several major MOH hospitals and healthcare facilities. The state’s healthcare workforce includes thousands of medical doctors, nurses, dental staff, medical assistants, pharmacists, and allied health professionals, all of whom face varying degrees of exposure to needlestick injury risk depending on their specific roles and work environments.

The study analysed the distribution of NSI cases by demographic characteristics (gender, age, ethnicity), occupational factors (professional category, department, years of employment), and injury circumstances. Additionally, adherence to the post-NSI follow-up protocol was assessed by tracking the completion rates at each scheduled follow-up visit.

Principal Findings

During the nine-month study period, a total of 143 notified NSI cases were recorded across MOH hospitals in Selangor. The demographic profile of cases revealed a strong predominance of female healthcare workers (76.2%), which reflects the gender composition of the Malaysian healthcare workforce, particularly in the nursing profession which constitutes the single largest professional group in hospitals.

By ethnicity, Malay healthcare workers accounted for the majority of cases (60.1%), broadly consistent with the ethnic composition of the MOH healthcare workforce. Among professional categories, medical doctors represented the single largest group affected (56.6%), followed by nurses. This finding is notable because while nurses comprise a much larger proportion of the total healthcare workforce, the incidence rate per capita was highest among medical doctors.

The age and experience profile of affected workers is particularly informative for prevention strategies. The median age was 27 years, with an interquartile range of 5 years, and the median duration of employment was only 1.5 years (IQR: 4.5 years). This concentration of injuries among young, relatively inexperienced healthcare workers suggests that the early career period represents a window of heightened vulnerability, likely reflecting a combination of less developed procedural skills, greater unfamiliarity with sharps handling protocols, and potentially a higher-risk clinical workload in training rotations.

Medical-based departments accounted for the largest proportion of NSI cases (44.8%), consistent with the higher frequency of invasive procedures such as venepuncture, cannulation, and blood sampling performed in these settings.

Follow-Up Protocol Adherence

Analysis of adherence to the post-NSI follow-up protocol revealed that compliance declined progressively across the three scheduled follow-up visits. While initial baseline testing was generally completed, the proportion of workers completing the full sequence of follow-up blood tests at six weeks, three months, and six months showed a declining trend. This pattern of diminishing compliance is consistent with findings from studies in other countries and represents a significant concern for both individual worker safety and the integrity of the surveillance programme.

Multiple factors may contribute to suboptimal follow-up adherence. Logistical barriers include the difficulty of attending scheduled appointments around demanding clinical work schedules, particularly for junior doctors on rotating shifts. Psychological factors include both anxiety avoidance, where workers prefer not to confront the possibility of seroconversion, and premature reassurance, where negative early results lead workers to assume they are uninfected and discontinue follow-up. Systemic factors include inadequate tracking and reminder systems, unclear institutional responsibility for follow-up coordination, and insufficient emphasis on the importance of completing the full follow-up schedule in post-exposure counselling.

National Context

Malaysia’s national sharps injury surveillance data for 2016 recorded 1,234 NSI cases across the entire MOH healthcare system, yielding an overall national incidence of approximately 6 injuries per 1,000 healthcare workers. Medical doctors recorded the highest professional group-specific incidence rate at 21.1 per 1,000 workers, followed by dental staff (7.5), pharmacy staff (4.2), nurses (3.7), and medical assistants (3.4). These national figures provide important context for the Selangor data and confirm that the patterns observed in this study are broadly representative of the national picture.

Implications and Recommendations

The findings of this study have several important implications for occupational health policy and practice in Malaysian healthcare settings. The concentration of NSI cases among young, junior healthcare workers highlights the critical importance of comprehensive sharps safety training during undergraduate medical and nursing education, as well as during the induction and orientation of new hospital staff. This training should encompass not only the technical skills for safe sharps handling and disposal but also an understanding of the post-exposure management protocol and the rationale for complete follow-up adherence.

The suboptimal follow-up adherence rates underscore the need for improved institutional systems to track and support injured workers through the complete follow-up schedule. Specific recommendations include automated electronic reminder systems linked to the SIS database, designated follow-up coordinators in occupational health units, flexible appointment scheduling to accommodate clinical work demands, and clear institutional policies that grant protected time for follow-up appointments.

Limitations

This study was limited by its reliance on notified cases recorded in the SIS system. Underreporting of needlestick injuries is a well-documented phenomenon in healthcare settings worldwide, and the true incidence of NSIs in Selangor is likely higher than the notified figures suggest. Studies in other settings have estimated underreporting rates ranging from 22% to 66% of all sharps injuries. Additionally, the retrospective design precluded detailed investigation of the specific circumstances, contributing factors, and psychological impact of individual injury events.

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