Needlestick Injuries 

among Employees at a 

Retail Pharmacy Chain 

– Nationwide

Marie A. de Perio, MD

Health Hazard Evaluation Report

HETA 2011-0063-3154

March 2012 

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

Workplace

Safety and Health

 National Institute for Occupational 

Safety and Health
The employer shall post a copy of this report 

for a period of 30 calendar days at or near 

the workplace(s) of affected employees. The 

employer shall take steps to insure that the 

posted determinations are not altered, defaced, 

or covered by other material during such 

period. [37 FR 23640, November 7, 1972, as 

amended at 45 FR 2653, January 14, 1980].
Health Hazard Evaluation Report 2011-0063-3154 Page i

Report Abbreviations................................................................................................ii

Highlights of the NIOSH Health Hazard Evaluation........................iii

Summary .........................................................................................................v

Introduction ...................................................................................................1

Assessment.....................................................................................................3

Results..............................................................................................................5

Discussion.................................................................................................... 11

Conclusions................................................................................................. 13

Recommendations.................................................................................... 14

References.................................................................................................... 16

Contents

Acknowledgments Acknowledgments and Availability of Report................................ 21

Appendix Bloodborne Pathogens ........................................................................ 18
Page ii Health Hazard Evaluation Report 2011-0063-3154

Abbreviations

CFR Code of Federal Regulations

HHE Health hazard evaluation

HIV Human immunodeficiency virus

NAICS North American Industry Classification System

NIOSH National Institute for Occupational Safety and Health

OSHA Occupational Safety and Health Administration 
Health Hazard Evaluation Report 2011-0063-3154 Page iii

The National Institute for 

Occupational Safety and 

Health (NIOSH) received 

a management request 

for a health hazard 

evaluation at a nationwide 

retail pharmacy chain. 

The request concerned 

the potential exposure 

of pharmacists to 

needlestick injuries while 

administering vaccines 

in pharmacy locations 

nationwide.

Highlights of the

NIOSH Health

Hazard Evaluation

What NIOSH Did

● We reviewed the company’s written policies and procedures 

regarding vaccine administration, needlestick injuries, and 

bloodborne pathogens.

● We reviewed the company’s needlestick injury reports and 

then analyzed the information in them.

● We observed work practices and interviewed eight employees 

at two pharmacies in October 2011.

What NIOSH Found

● The company has comprehensive written policies and 

procedures.

● Thirty-three needlestick injuries were reported across an 11-

year period.

● The annual incidence of needlestick injuries ranged from 

0–3.62 per 100,000 vaccinations and ranged from 0–5.65 per 

1,000 immunizing pharmacists.

● Observed work practices involving sharps were safe at both 

pharmacies we visited.

What Managers Can Do

● Continue to encourage employees to follow all written work 

procedures.

● Promote prompt reporting of all needlestick injuries.

● Make sure that the needlestick injury reports have complete 

information.

● Ask for additional information about the circumstances of 

the injury for these reports.

What Employees Can Do

● Continue to follow safe work practices during all clinical 

procedures.

● Wash your hands before and after every clinical procedure.

● Dispose of used needles promptly in appropriate sharps 

disposal containers.

● Promptly report all needlestick injuries.

● Follow company health and safety policies and procedures.
Page iv Health Hazard Evaluation Report 2011-0063-3154

NIOSH investigators 

examined pharmacists’ 

exposure to needlestick 

injuries in a retail 

pharmacy chain. We 

found 33 reported 

needlestick injuries 

across an 11-year period. 

The company’s written 

policies and procedures 

were comprehensive. 

Work practices relating to 

sharps were safe at both 

pharmacies we visited.

Summary

In February 2011, NIOSH received an HHE request from management 

representatives at a nationwide retail pharmacy chain. The request 

concerned pharmacists’ potential exposure to needlestick injuries 

while administering vaccines in pharmacy locations nationwide. The 

pharmacy chain began offering adult vaccinations in 2000 in select 

locations and had since expanded this service to all locations.

Prior to our visit, we reviewed the company’s written policies and 

procedures regarding vaccine administration, needlestick injuries, 

and bloodborne pathogens. We also analyzed the information in the 

company’s needlestick injury reports. We visited two pharmacies in 

October 2011 where we observed work processes, work practices, and 

workplace conditions. We also interviewed pharmacy employees.

The company’s written policies and work procedures were 

comprehensive. In our review of needlestick injury reports, we 

found 33 reported needlestick injuries over an 11-year period. The 

annual incidence of needlestick injuries ranged from 0–3.62 per 

100,000 vaccinations and ranged from 0–5.65 per 1,000 immunizing 

pharmacists. Work practices relating to sharps were observed to be 

safe at both of the pharmacies we visited.

Pharmacists who have the added responsibility of administering 

vaccinations have become an emerging occupational group at risk of 

needlestick injuries. However, the incidence of needlestick injuries 

among employees at this retail pharmacy chain appears to be lower 

than that found in the hospital setting. This may be due to the nature 

of the procedures being performed, which require less manipulation 

(such as phlebotomy or suturing), activation of the safety devices, the 

company’s training programs, and safe work practices.

We recommended that the company continue to encourage 

employees to follow all written work procedures. We recommended 

improvements to the positioning of patients and equipment during 

vaccine administration and health screenings to improve safety. 

We also recommended obtaining additional information on the 

circumstances of the injury for the needlestick injury reports. This 

information may be useful in determining factors contributing to 

these injuries at the pharmacy and in evaluating the safety of devices. 

Employees should continue to use safe work practices during vaccine 

administration and health screenings and should promptly report all 

needlestick injuries.

Keywords: NAICS 446110 (Pharmacies and Drug Stores), 

needlestick injuries, sharps injuries, bloodborne pathogens, 

pharmacy, pharmacists, vaccination
Health Hazard Evaluation Report 2011-0063-3154 Page 1

Introduction

In February 2011, NIOSH received an HHE request from 

management representatives at a nationwide retail pharmacy 

chain. The request involved the potential exposure of pharmacists 

to needlestick injuries from the administration of vaccines across 

pharmacy locations nationwide. The pharmacy chain began 

offering adult vaccinations in 2000 in select locations and had 

expanded this service to all locations.

Prior to our visit, we reviewed the company’s written policies and 

procedures regarding vaccine administration, needlestick injuries, and 

bloodborne pathogens. We also reviewed manufacturer information 

on the injection devices used by pharmacy employees and analyzed 

the information collected by the company in its needlestick injury 

reports. During our on-site evaluation at two locations in October 

2011, we observed work processes, work practices, and workplace 

conditions and interviewed pharmacy employees.

Retail Pharmacy Chain

At the time of our evaluation, the retail pharmacy chain was 

located within a national retail grocery company. The company 

operated approximately 2,500 retail grocery locations and more 

than 800 in-store pharmacies in 25 states.

At the time of our evaluation, vaccinations offered at the 

retail pharmacy chain included the influenza, pneumococcal, 

tetanus/diphtheria/pertussis, hepatitis A, hepatitis B, human 

papillomavirus, herpes zoster, and meningococcal vaccines. 

Vaccinations were offered by appointment or on a walk-in basis at 

the pharmacies or in a clinic setting. As of February 2011, 2,150 

certified immunizing pharmacists were employed at 805 pharmacy 

locations within the company.

Needlestick Injuries and Exposure to 

Bloodborne Pathogens

Needlesticks and other percutaneous injuries pose the greatest 

risk of occupational transmission of bloodborne pathogens 

to healthcare workers [Beltrami et al. 2000; CDC 2001]. The 

bloodborne pathogens of most concern include hepatitis B virus, 

hepatitis C virus, and HIV. More information on these pathogens 

can be found in the Appendix.
Page 2 Health Hazard Evaluation Report 2011-0063-3154

Introduction

 (continued) In 1991, OSHA issued its bloodborne pathogens standard, requiring 

employers to maintain a written exposure control plan and adopt 

engineering and work practice controls that would eliminate 

or minimize employee exposure from hazards associated with 

bloodborne pathogens [29 CFR 1910.1030]. The standard was most 

recently revised in 2001. This revision added new requirements 

for employers, including additions to the exposure control plan 

and keeping a sharps injury log. It specifies in greater detail the 

engineering controls, such as safer medical devices, that must be used 

to reduce or eliminate worker exposure [29 CFR 1910.1030].

Most recent estimates have calculated the number of percutaneous 

injuries sustained annually by hospital-based healthcare workers 

to be 384,325 [Panlilio et al. 2004]. About half of these injuries go 

unreported [CDC 1997; EPINet 1999; Osborn et al. 1999]. Data 

has shown that most reported percutaneous injuries are associated 

with hollow-bore needles and that approximately 38% of injuries 

occur during use, and 42% occur after use and before disposal 

[NIOSH 1999]. Most studies have focused on these types of injuries 

in hospital settings while fewer have focused on long-term care 

facilities and outpatient medical and dental settings. Few studies 

have focused on injuries associated with vaccination campaigns 

[Haire and Sharma 1996; Abraham and Middleton 1997], and no 

studies have focused on injuries occurring in retail pharmacies.
Health Hazard Evaluation Report 2011-0063-3154 Page 3

Assessment

The purpose of our evaluation was to determine the incidence of 

needlestick injuries among pharmacy employees from 2000–2011 

and to assess and make recommendations to improve the controls 

in place to reduce the potential for needlestick injuries.

Our evaluation included the following activities: (1) a review of 

the company’s written policies and procedures regarding vaccine 

administration, needlestick injuries, and bloodborne pathogens; 

(2) an analysis of the company’s needlestick injury reports; and (3) 

an on-site evaluation at two pharmacy locations where we observed 

work processes, work practices, and workplace conditions and 

interviewed pharmacy employees.

Review of Company’s Written Policies 

and Procedures

We reviewed the company’s written policies and procedures 

regarding vaccine administration, needlestick injuries, and 

bloodborne pathogens. We determined if these policies met 

the requirements set forth by the OSHA bloodborne pathogens 

standard [29 CFR 1910.1030].

Analysis of the Company’s Needlestick 

Injury Reports

The company’s centralized needlestick injury reports from all 

pharmacy locations were obtained and reviewed. We characterized 

the circumstances surrounding these reported injuries. We calculated 

the annual incidence of percutaneous injuries using two methods: 

(1) by dividing the total number of needlestick injuries reported 

during a given year by the total number of vaccinations administered 

by the company during that same year and (2) by dividing the total 

number of needlestick injuries reported during a given year by the 

total number of immunizing pharmacists employed by the company 

during that same year. Because the focus of our evaluation was on 

the potential exposure of pharmacists to needlestick injuries from 

the administration of vaccines, we excluded injuries involving 

lancet needles in our annual incidence calculations. Although the 

company did not collect information on the purpose for which 

the sharps device was initially used, on the basis of our discussions 

with management representatives and employees, we made the 

assumption that all non-lancet needle related injuries were associated 

with vaccination in our annual incidence calculations.
Page 4 Health Hazard Evaluation Report 2011-0063-3154

On-site Evaluation

The two locations for the site visit were chosen in conjunction with 

management representatives at the company because of the high 

volume of vaccinations administered at both. During the visits in 

October 2011, we met with the staff at both pharmacies to discuss 

the HHE request. We observed work processes, work practices, 

and workplace conditions particularly associated with vaccine 

administration and other clinical procedures. We conducted semistructured interviews with all employees working at both pharmacies 

on the dates of the visit. We discussed their work history and 

exposures as well as other health and workplace concerns.

Assessment

 (continued)
Health Hazard Evaluation Report 2011-0063-3154 Page 5

Results

Review of Company’s Written Policies 

and Procedures

The company’s bloodborne pathogens exposure control plan 

was comprehensive and contained all of the required elements 

according to the OSHA bloodborne pathogens standard [29 

CFR 1910.1030]. These required elements include an exposure 

determination, methods of compliance, hepatitis B vaccination, 

post-exposure evaluation and follow-up, communication of hazards 

to employees, and recordkeeping [29 CFR 1910.1030]. At the time 

of our evaluation, the exposure control plan was accessible to all 

employees through the company’s intranet.

Pharmacy employees identified as being at risk for occupational 

exposure to blood or other potentially infectious materials included 

pharmacists giving vaccinations or performing a laboratory test 

or an education session and pharmacy technicians performing 

laboratory tests. All company employees at risk of exposure to 

bloodborne pathogens were encouraged to receive the hepatitis B 

vaccination, which was provided at no charge to them. Employees 

declining hepatitis B vaccination must sign a waiver.

Injured employees were instructed to contact the clinical programs 

department immediately after the injury. The facility/store director 

was required to complete the exposure incident report within 48 

hours and the needlestick injury report form within 72 hours. 

Copies were kept at the facility/store and in the clinical programs 

department. Injured employees were required to visit the designated 

medical provider within 48 hours of the incident for appropriate 

evaluation. The clinical programs department contacted the source 

individual and requested that he or she visit the designated facility 

to get blood tests for hepatitis B, hepatitis C, and HIV.

The company’s vaccine administration protocol stated that 

employees should never bend, break, or recap needles; remove 

needles from disposable syringes; or overfill, reach into, open, 

empty, or reuse a sharps container. Employees were instructed to 

dispose of all sharps items immediately in marked containers.

At the time of our evaluation, the company’s immunizing 

pharmacists were required to be specially trained by attending 

an immunization certificate program. The company offered 

the American Pharmacists Association’s Pharmacy-Based 

Immunization Delivery, a national certificate program for 

pharmacists. Training consisted of self-study followed by a live 
Page 6 Health Hazard Evaluation Report 2011-0063-3154

training seminar. Once these two modules are complete, the 

pharmacist attends an immunization orientation. We reviewed 

the presentation slides for this orientation and found that they 

included information on bloodborne pathogens, the needlestick 

protocol, and use of the retractable safety syringes. The orientation 

also included hands-on practice.

The company’s needlestick injury reporting form contained all of the 

information required by the OSHA bloodborne pathogens standard 

[29 CFR 1910.1030]. This information included the type and brand 

of device involved in the incident, the work area where the exposure 

occurred, and an explanation of how the incident occurred.

Analysis of the Company’s Needlestick 

Injury Reports

Of the 34 injuries reported to the company’s clinical program 

department from 2000–2011, only 33 were actual sharps or 

needlestick injuries. The other report was about a splash rather 

than a needlestick injury.

The 33 total needlestick injuries were reported by 31 different 

pharmacy locations. Two injuries did not have a pharmacy location 

reported. Seventeen (52%) injuries occurred in front of the 

pharmacy, 10 (30%) in the pharmacy, 3 (9%) in flu clinic, 1 (3%) 

in the pharmacy waiting area, 1 (3%) by the consultation window, 

and 1 (3%) in a non-pharmacy location.

Of the 33 needlestick injuries, 24 (73%) occurred from September 

through January, the period during which influenza vaccines are 

commonly administered; 12 (36%) occurred in the month of 

October. Eight injuries (24%) occurred between midnight and noon, 

while the other 25 (76%) occurred between noon and midnight.

Five (15%) injuries occurred with a lancet needle, while 28 (85%) 

injuries occurred with a syringe needle. Of these 28 injuries, the 

VanishPoint® syringe was used in 7 injuries, the BD SafetyGlideTM 

needle was used in 12 injuries, the BD PrecisionGlideTM needle 

was used in 1 injury, and the BD Safety-LokTM syringe was used 

in 1 injury. The type of needle was not reported in seven injuries. 

A finger was the injured body part in 30 cases, and the palm in 1 

case. The injured body part was not recorded in 2 cases.

Results

 (continued)
Health Hazard Evaluation Report 2011-0063-3154 Page 7

Results

 (continued)

Table 1. Explanation of how the needlestick injuries occurred as contained in the company’s needlestick 

injury reports

Explanation* No. (%) Injuries

After use and before disposal of sharp 19 (58)

During use of sharp 6 (18)

While putting sharp into disposal container 5 (15)

Disassembling 2 (6)

Sharp left, inappropriate place 2 (6)

Other† 4 (12)

*Employees could choose more than one explanation of how the incident occurred.

†Other explanations included “while activating safety device,” “taking bag from patient,” “glove got caught in 

safety glide and accidentally got stuck,” “lancet fell on floor, happened while picking it up.”

The company’s sharps injury report form contained check boxes 

for an explanation of how the injury occurred. These explanations 

are displayed in Table 1. Most commonly, the injury was reported 

after use and before disposal of the sharp (58% of injuries). 

Additional details of the circumstances surrounding these injuries, 

such as for what purpose the sharp item was originally used, were 

lacking from the reports.

Numbers of needlestick injuries ranged from 0–14 per year (Table 

2). The years 2000–2001 and 2004–2007 had no needlestick 

injuries reported, while 2010 was the year of the highest number 

of needlestick injuries at 14. We excluded the 5 needlestick injuries 

associated with lancet needles from annual incidence calculations. 

The annual incidence of needlestick injuries ranged from 0–3.62 

per 100,000 vaccinations and ranged from 0–5.65 per 1,000 

immunizing pharmacists (Table 2 and Figure 1). The year 2010 

had the highest incidence at 3.62 needlestick injuries per 100,000 

vaccinations and 5.65 per 1,000 immunizing pharmacists.

On-site Evaluation

At the time of our visit, the first pharmacy had 14 employees, 

including 3 pharmacists, and the second pharmacy had 18 

employees, including 3 pharmacists. All pharmacists administered 

vaccination as part of their responsibilities. Both pharmacies had 

extended hours of operation during the week and regular hours 

during the weekends. The first pharmacy had administered 341 
Page 8 Health Hazard Evaluation Report 2011-0063-3154

Results

 (continued)

Figure 1. The annual number of needlestick injuries per 100,000 vaccinations.

*2011 data as of November 3, 2011

Table 2. Annual numbers of needlestick injuries, administered vaccinations, and immunizing pharmacists

Year No. needlestick 

injuries

No. 

administered 

vaccinations

Annual 

incidence 

per 100,000 

vaccinations 

No. immunizing 

pharmacists

Annual 

incidence 

per 1,000 

immunizing 

pharmacists

2000 0 9,900 0 67 0

2001 0 38,000 0 120 0

2002 1 55,685 1.80 270 3.70

2003 1 156,000 0.64 400 2.50

2004 0 42,000 0 540 0

2005 0 225,000 0 731 0

2006 0 129,965 0 538 0

2007 0 146,525 0 821 0

2008 2 232,050 0.86 1,043 1.92

2009 6 391,850 1.28* 1,450 3.45*

2010 14 358,800 3.62† 2,300 5.65†

2011‡ 9 286,383 2.10§ 2,164 2.77§

*One injury was excluded from the 2009 incidence calculation because it was associated with a lancet needle.

†One injury was excluded from the 2010 incidence calculation because it was associated with a lancet needle.

‡2011 data as of November 3, 2011

§Three injuries were excluded from the 2011 incidence calculation because they were associated with a 

lancet needle.
Health Hazard Evaluation Report 2011-0063-3154 Page 9

vaccinations, including 286 influenza vaccinations, from February 

27, 2011, (the start of the company’s fiscal year) through October 

21, 2011. The second pharmacy had administered 897 vaccinations, 

including 790 influenza vaccinations, over the same period. As 

of October 2011 neither pharmacy had reported any needlestick 

injuries since 2002.

Confidential Medical Interviews

We interviewed all four pharmacy employees working at each 

pharmacy on the dates of the visits. These 8 employees included 

3 pharmacists and 5 pharmacy technicians. Only the three 

pharmacists reported administering vaccinations, and all were 

certified by the American Pharmaceutical Association to provide 

immunizations. All three reported completing the American 

Pharmaceutical Association Pharmacy Based Immunization 

Delivery training program and internal company training. All three 

estimated administering vaccines 2–4 years, and all three estimated 

that they had given more than 350 influenza vaccinations during 

the calendar year 2011. Four of the five pharmacy technicians 

reported that they did not come into contact with sharps items 

during their job; the other one performed fingersticks as part of 

her job.

The four pharmacy employees who came into contact with sharps 

items reported never recapping used needles, and all reported they 

always disposed of used needles promptly in appropriate sharps 

disposal containers. None of the eight interviewed employees 

reported ever experiencing a needlestick injury, and none had any 

health concerns related to their work.

Observation of Procedures

During the visit, we observed the following procedures at both 

pharmacies: 11 influenza vaccinations, 2 zoster vaccinations, and 2 

health screenings. For all 13 vaccination procedures, the pharmacy 

employees drew up the syringe and placed all necessary supplies 

in a plastic bin before administering the vaccine. Sharps disposal 

containers were portable. In the first pharmacy, the sharps disposal 

container was also placed in a larger plastic bin that contained 

the other supplies. The sharps disposal container was placed 

conveniently next to the employee for immediate disposal of the 

needle in all but one instance.

Results

 (continued)
Page 10 Health Hazard Evaluation Report 2011-0063-3154

During 9 vaccination procedures, the pharmacy employees sat 

in a chair perpendicular to the patient’s chair. However, during 

the other 4 vaccination procedures, the vaccinator either stood 

or squatted by the patient’s chair. During 2 of the vaccination 

procedures, the patient was seated in a chair that had wheels.

We observed hand hygiene before administering the vaccine during 

6 of 13 procedures and after administering the vaccine during 

the same 6 procedures. During all 13 procedures, the pharmacy 

employees wore gloves while administering the vaccine, and they 

also activated the safety syringe while the needle was still in the 

patient’s arm (Figure 2). The pharmacies used the VanishPoint® 

syringe, which has a safety device that automatically and instantly 

retracts the needle from the patient into the barrel of the syringe 

when the injection is complete. No recapping of used needles was 

observed. The used syringe was promptly placed in the sharps 

disposal container during 11 procedures. During the other 2 

procedures, the used syringe was placed first in the plastic bin and 

then transferred to the sharps disposal container shortly thereafter.

The health screenings consisted of a blood pressure check and 

a fingerstick for basic laboratory work. During both observed 

screenings, all of the necessary supplies were placed on the 

workspace. Sharps disposal containers were appropriately placed. 

In one screening, the employee stood next to the patient, who 

was seated in a chair with wheels. The employee practiced hand 

hygiene before the fingerstick one out of the two times, wore gloves 

during the fingerstick both times, and practiced hand hygiene after 

the fingerstick both times. During the fingerstick, the safety device 

was activated, and the used lancet needle was promptly placed in 

the sharps disposal container in both instances.

Results

 (continued)

Figure 2. A pharmacist administering 

the influenza vaccine to a patient. 

She can be seen activating the 

retraction mechanism of the 

introducer needle while the needle is 

still in the patient’s arm.
Health Hazard Evaluation Report 2011-0063-3154 Page 11

Discussion

An increasing proportion of influenza vaccinations are taking 

place in nonmedical or nonclinical settings. During the 1998–

1999 influenza season, 5% of adults reported being vaccinated 

in stores (supermarket or drug store) [Singleton et al. 2005]. 

At that time, only 22 states allowed pharmacists to administer 

influenza vaccinations to adults. By June 2009, all 50 states 

allowed pharmacists to administer influenza vaccinations (under 

prescribing protocols or prescription) to adults [APHA 2009]. For 

the 2010–2011 influenza season, 18.4% of adults received the 

influenza vaccination at stores (supermarket or drug store), which 

was the second most common place of vaccination after a doctor’s 

office [CDC 2011].

To date, no studies have examined needlestick injuries occurring 

in a retail pharmacy setting, and few studies have examined 

needlestick injuries associated with vaccination. Haire and Sharma 

surveyed 28 nurses and 26 physicians during a measles and rubella 

immunization campaign in Britain in 1994 [Haire and Sharma 

1996]. They found that two nurses and three physicians reported 

sustaining a contaminated needlestick injury, though only two 

reported the injury.

In another study, Abraham and Middleton reported that 6 

contaminated needlestick injuries were reported during a measles 

mass vaccination campaign in Canada in 1996 [Abraham and 

Middleton 1997]. This campaign had 63 nurses immunize 112,727 

children at 238 schools, and the needlestick injury rate was 

calculated to be 1 needlestick injury per 18,788 vaccinations, or 

5.32 needlestick injuries per 100,000 vaccinations. Circumstances 

leading to the injuries included technical factors, human factors, 

and disposal issues. These numbers are higher than those found 

in our evaluation, where we found a maximum of 3.62 needlestick 

injuries per 100,000 vaccinations in 2010, the year with the highest 

annual incidence.

Our range of 0–5.65 needlestick injuries per 1,000 immunizing 

pharmacists is also lower than the range of 23–103 needlestick 

injuries per 1,000 healthcare workers calculated by Lee et al. 

in five studies of reports in hospital settings [Linnemann et al. 

1991; Haiduven et al. 1992; Longbottom et al. 1993; Jackson et 

al. 1994; Hatcher 2002; Lee et. al 2005]. This discrepancy can be 

explained by a few potential factors. First, the risk of needlestick 

injuries from vaccinations compared to other procedures 

involving sharps items such as phlebotomy and suturing may be 
Page 12 Health Hazard Evaluation Report 2011-0063-3154

lower because of the nature of the procedure that requires less 

manipulation. Second, all of the syringes and lancet needles used 

by the company’s immunizing pharmacists had safety devices, and 

this likely also lowers the risk. Third, the pharmacists we observed 

during our visit all adhered to safe practices when administering 

vaccinations and obtaining fingersticks (i.e., activation of the safety 

device and optimal placement of sharps disposal containers), and 

the company’s training programs were comprehensive.

Our evaluation was subject to some limitations. First, we analyzed 

33 reports of needlestick injuries recorded in the company’s 

national sharps injury reports. The incidence of needlestick 

injuries reported here is likely an underestimation of the actual 

incidence of these injuries among employees for two reasons. 

Studies have shown that underreporting of percutaneous injuries 

in healthcare workers occurs widely; calculations have estimated a 

43.4% underreporting rate [Panlilio et al. 2004]. Also, it is possible 

that not all incidents at the individual pharmacy locations were 

reported to the national program office. Second, some needlestick 

injury reports had missing information, including type of device, 

pharmacy location, and injured body part. Third, we were unable to 

obtain the laboratory testing results of the source patients involved 

in the needlestick injury. Thus, we are unable to determine the 

actual exposure of the injured employees to hepatitis B, hepatitis 

C, or HIV. Fourth, we had limited information on the injured 

employee so were not able to determine work factors associated 

with an injury. Also, because the company did not collect the job 

titles of affected employees on the needlestick injury report form, 

we were unable to ascertain the number of injuries that occurred 

among pharmacists and pharmacy technicians. However, only 

pharmacists are certified to administer vaccinations, and this 

makes it less likely that needlestick injuries associated with vaccine 

administration occurred among pharmacy technicians. Finally, we 

observed vaccinations and health screenings at only two of the over 

800 pharmacy locations. Thus, our observations are unlikely to be 

representative of all pharmacy employees at all locations.

Discussion

 (continued)
Health Hazard Evaluation Report 2011-0063-3154 Page 13

Conclusions

Pharmacists who have the added responsibility of administering 

vaccinations have become an emerging occupational group 

at risk of needlestick injuries. In our retrospective review of 

reports of needlestick injuries of a large retail pharmacy chain, 

we found 33 reported needlestick injuries across an 11-year 

period. The annual incidence of needlestick injuries ranged 

from 0–3.62 per 100,000 vaccinations and ranged from 0–5.65 

per 1,000 immunizing pharmacists. These rates appear to be 

lower than those found in the hospital setting. Work practices 

relating to sharps items were observed to be safe at both 

locations of our visit. Though needlestick injuries occur in this 

setting, the pharmacy employees appear to be at relatively low 

risk for needlestick injuries during administration of vaccines 

mainly because of the nature of the procedures that require less 

manipulation, the activation of the safety devices, the company’s 

training programs, and safe work practices.
Page 14 Health Hazard Evaluation Report 2011-0063-3154

Recommendations

On the basis of the findings of the HHE, we offer some additional 

recommendations to further protect the health and safety of 

pharmacy employees with regard to bloodborne pathogens. We 

encourage the company to use a labor-management health and 

safety committee or working group to discuss the recommendations 

in this report and develop an action plan. Those involved in 

the work can best set priorities and assess the feasibility of our 

recommendations for the specific situation at the company.

More comprehensive recommendations, such as those 

regarding a culture of safety, procedures for reporting and 

examining needlestick injuries, selection of devices, and 

training of employees, can be found in CDC’s “Workbook 

for Designing, Implementing and Evaluating a Sharps Injury 

Prevention Program” at http://www.cdc.gov/sharpssafety/pdf/

sharpsworkbook_2008.pdf [CDC 2008].

1. Practice hand hygiene before and after giving an injection or 

performing a fingerstick. Hand hygiene can consist of hand 

washing or antiseptic hand rub.

2. Position the patient in a chair without wheels for vaccine 

administration and health screenings. Pharmacy employees 

should also be seated in a chair perpendicular to the 

patient. A table or other flat surface on which to lay 

supplies and the sharps disposal container should be 

within reach of the pharmacist.

3. Dispose of used needles promptly in appropriate sharps 

disposal containers. Ensure that these containers are placed 

in a location convenient to the pharmacist for immediate 

disposal. Consider placing the sharps disposal container 

along with the necessary supplies in a larger bin, as we 

observed at one location.

4. Encourage employees to report all needlestick injuries 

immediately. Emphasize the importance of timely medical 

evaluation and treatment, if indicated.

5. Ensure that each needlestick injury report contains all of the 

information required by the OSHA bloodborne pathogens 

standard [29 CFR 1910.1030]. This information includes the 

type and brand of device involved in the incident, the work 
Health Hazard Evaluation Report 2011-0063-3154 Page 15

Recommendations 

(continued) area where the exposure occurred, and an explanation 

of how the incident occurred. Each submitted report 

should be checked for completeness, and missing or 

incomplete responses should be addressed. Consider 

listing the possible devices that employees use during 

their work and asking injured employees to check 

the device used instead of having them write in this 

information. This change may facilitate more accurate 

reporting about the device.

6. Consider obtaining additional information in the 

sharps injury reports to include information about 

whether or not the device’s protective mechanism 

had been activated and whether or not the sharps 

item penetrated gloves. This information will give 

insights into employee compliance with activation 

of the device protective mechanisms and glove use. 

Consider obtaining information on the job title of 

the affected employee, the purpose for which the 

sharp item was originally used, if it was contaminated 

or uncontaminated, and if blood was present on the 

device if contaminated. This information will also help 

in characterizing the circumstances of these injuries. 

In addition, consider asking injured employees to give 

their opinions on whether any engineering controls or 

administrative or work practices could have prevented 

the injury. The forms in CDC’s “Workbook for 

Designing, Implementing and Evaluating a Sharps 

Injury Prevention Program” and from the International 

Healthcare Worker Safety Center can be used as guides 

for information to collect and can be adapted to the 

pharmacy setting [IHWSC 2001; CDC 2008].

7. Send at least annual reminders to individual pharmacy 

locations to send all local needlestick injury reports 

and exposure incident reports to the clinical programs 

department. It is important to have an accurate central 

location for these records.

8. Review the needlestick injury reports at the local and 

corporate levels at least annually to determine which 

factors contribute to these injuries at the pharmacy 

and gain information that may be helpful in evaluating 

devices.
Page 16 Health Hazard Evaluation Report 2011-0063-3154

Abraham E, Middleton D [1997]. Needlestick injuries during a 

mass vaccination campaign. Can J Public Health 88(1):38–39.

American Pharmacists Association [2009]. States where pharmacists 

can immunize. Washington, DC: American Pharmacists Association. 

[http://www.pharmacist.com/am/template.cfm?section=pharmacist_

immunization_center1&template=/cm/contentdisplay.

cfm&contentid=21623]. Date accessed: December 2011.

Beltrami EM, Williams IT, Shapiro CN, Chamberland ME [2000]. 

Risk and management of blood-borne infections in health care 

workers. Clin Microbiol Rev 13(3):385–407.

CDC [1997]. Evaluation of safety devices for preventing 

percutaneous injuries among health-care workers during 

phlebotomy procedures—Minneapolis-St.Paul, New York City, and 

San Francisco, 1993–1995. MMWR 46(2):21–25.

CDC [2001]. Updated U.S. Public Health Service guidelines for 

the management of occupational exposures to HBV, HCV, and 

HIV and recommendations for postexposure prophylaxis. MMWR 

50(RR-11):1–52.

CDC [2008]. Workbook for Designing, Implementing and 

Evaluating a Sharps Injury Prevention Program. [http://www.cdc.

gov/sharpssafety/pdf/sharpsworkbook_2008.pdf]. Date accessed: 

December 2011.

CDC [2011]. Places of influenza vaccination among adults — United 

States, 2010–2011 influenza season. MMWR 60(23):781–785.

CFR. Code of Federal Regulations. Washington, DC: U.S. 

Government Printing Office, Office of the Federal Register.

EPINet [1999]. Exposure prevention information network data 

reports. University of Virginia: International Health Care Worker 

Safety Center.

Haiduven DJ, DeMaio TM, Stevens DA [1992]. A five-year study 

of needlestick injuries: significant reduction associated with 

communication, education, and convenient placement of sharps 

containers. Infect Control Hosp Epidemiol 13(5):265–271.

Haire AR, Sharma A [1996]. Fewer needlestick injuries than 

expected occurred during immunization campaign. BMJ 

312(7041):1303.

References
Health Hazard Evaluation Report 2011-0063-3154 Page 17

Hatcher IB [2002]. Reducing sharps injuries among health care 

workers: a sharps container quality improvement project. Jt Comm 

J Qual Improv 28(7):410–414.

IHWSC (International Healthcare Worker Safety Center) 

[2001]. Needlestick & sharp object injury report. [http://www.

healthsystem.virginia.edu/internet/epinet/forms/soi2001.pdf]. 

Date accessed: December 2011.

Jackson MA, Williams K, Olson-Burgess C, Kinney J, Olson LC, 

Burry VF [1994]. Needlestick injuries in a pediatric hospital. 

Pediatr Infect Dis J 13(4):318–320.

Lee JM, Botteman MF, Xanthakos JD, Nicklasson L [2005]. 

Needlestick injuries in the United States. Epidemiologic, 

economic, and quality of life issues. AAOHN J 53(3):117–133.

Linnemann CC, Cannon C, DeRonde M, Lanphear, B [1991]. 

Effect of educational programs, rigid sharps containers, and 

universal precautions on reported needlestick injuries in healthcare

workers. Infect Control Hosp Epidemiol 12(4): 214–219.

Longbottom HM, Cox K, Sokas RK [1993]. Body fluid exposure in 

an urban tertiary care medical center. Am J Ind Med 23(5):703–

710.

NIOSH [1999]. NIOSH Alert: preventing needlestick injuries 

in health care settings. Cincinnati, OH: National Institute for 

Occupational Safety and Health. DHHS (NIOSH) publication no. 

2000-108.

Osborn EHS, Papadakis MA, Gerberding JL [1999]. Occupational 

exposures to body fluids among medical students: a seven-year 

longitudinal study. Ann Intern Med 130(1):45–51.

Panlilio AL, Orelien JG, Srivastava PU, Jagger J, Cohn RD, Cardo 

DM, the NaSH Surveillance Group, the EPINet Data Sharing 

Network [2004]. Estimate of the annual number of percutaneous 

injuries among hospital-based healthcare workers in the United 

States, 1997–1998. Infect Control Hosp Epidemiol 25(7):556–562.

Singleton JA, Poel AJ, Lu P, Nichols KL, Iwane MK [2005]. Where 

adults reported receiving influenza vaccination in the United 

States. Am J Infect Control 33(10):563–570.

References

 (continued)
Page 18 Health Hazard Evaluation Report 2011-0063-3154

Human Immunodeficiency Virus

HIV, also known as the human immunodeficiency virus, is the virus that can lead to acquired immune 

deficiency syndrome, or AIDS. HIV attacks part of the body’s immune system by destroying specific blood 

cells, called CD4+ T cells, which are crucial to helping the body fight diseases. Each year, approximately 

50,000 U.S. residents become infected with HIV [CDC 2011a]. In 2008, an estimated 1,178,350 persons 

were living with HIV, including 236,400 (20.1%) whose infection was undiagnosed [CDC 2011a]. Through 

December 2001, 57 cases of occupational HIV transmission to healthcare workers in the United States 

were documented, and no confirmed cases have been reported since 1999 [Do et al. 2003; CDC 2011b]. 

No cases have been documented in pharmacists [Do et al. 2003]. The average risk for HIV transmission 

after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3% 

[Gerberding 1994; Bell et. al 1997; Ippolito et al. 1999].

Hepatitis B

Hepatitis B is a contagious liver disease that results from infection with the hepatitis B virus. It can range 

in severity from a mild illness lasting a few weeks to a serious, lifelong illness. Effective hepatitis B vaccines 

have been available in the United States since 1981, and since then, the incidence of acute hepatitis B has 

declined. The estimated incidence of hepatitis B infection was 38,000 in 2009, but an estimated 700,000–

1.4 million persons are living with chronic hepatitis B infection [CDC 2008; CDC 2011c; Ioannou et al. 

2011]. The rate of hepatitis B transmission to susceptible (or non-immunized) healthcare workers ranges 

from 6%–30% after a single needlestick exposure from a hepatitis B infected patient [CDC 1997].

Hepatitis C

Hepatitis C is a contagious liver disease that results from infection with the hepatitis C virus. It can range in 

severity from a mild illness lasting a few weeks to a serious, lifelong illness. It more commonly causes chronic 

infection than hepatitis B. An estimated 2.7–3.9 million persons are chronically infected with hepatitis C 

[Armstrong et al. 2006; CDC 2011c]. The number of acute hepatitis C cases has declined to an estimated 

16,000 cases in the United States. The average rate of hepatitis C transmission averages 1.8% for healthcare 

workers exposed to hepatitis C through a needlestick or percutaneous injury [Alter 1997; CDC 1998].

References

Alter MJ [1997]. The epidemiology of acute and chronic hepatitis C. Clin Liver Dis 1(3):559–569.

Armstrong GL, Wasley AM, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ [2006]. The prevalence of 

hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med 144(10):705–714.

Appendix: Bloodborne Pathogens
Health Hazard Evaluation Report 2011-0063-3154 Page 19

Appendix: Bloodborne Pathogens

 (continued)

Bell DM [1997]. Occupational risk of human immunodeficiency virus infection in health-care workers: an 

overview. Am J Med 102(3B):294S–300S.

CDC [1997]. Immunization of health care workers: recommendations of the Advisory Committee on 

Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee 

(HICPAC). MMWR 46(RR–18):1–42.

CDC [1998]. Recommendations for prevention and control of hepatitis C virus (HCV) infection and 

HCV-related chronic disease. MMWR 47(RR–19):1–39.

CDC [2008]. Recommendations for identification and public health management of persons with chronic 

hepatitis B virus infection. MMWR 2008;57(No. RR-08).

CDC [2011a]. HIV Surveillance — United States, 1981–2008. MMWR 60(21):689–693.

CDC [2011b]. Occupational HIV transmission and prevention among health care workers. [http://www.

cdc.gov/hiv/resources/factsheets/hcwprev.htm]. Date accessed: November 2011.

CDC [2011c]. Viral hepatitis surveillance – United States, 2009. [http://www.cdc.gov/hepatitis/

Statistics/2009Surveillance/index.htm]. Date accessed: December 2011.

Do AN, Ciesielski CA, Metler RP, Hammett TA, Li J, Fleming PL [2003]. Occupationally acquired human 

immunodeficiency virus (HIV) infection: national case surveillance data during 20 years of the HIV 

epidemic in the United States. Infect Control Hosp Epidemiol 24(2):86–96.

Gerberding JL [1994]. Incidence and prevalence of human immunodeficiency virus, hepatitis B virus, 

hepatitis C virus, and cytomegalovirus among health care personnel at risk for blood exposure: final report 

from a longitudinal study. J Infect Dis 170(6):1410–1417.

Ioannou G [2011]. Hepatitis B virus in the United States: infection, exposure, and immunity rates in a 

nationally representative survey. Ann Intern Med 154(5):319–328.

Ippolito G, Puro V, Heptonstall J, Jagger J, De Carli G, Petrosillo N [1999]. Occupational human 

immunodeficiency virus infection in health care workers: worldwide cases through September 1997. Clin 

Infect Dis 28(2):365–383.
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Acknowledgments and

Availability of Report

The Hazard Evaluations and Technical Assistance Branch 

(HETAB) of the National Institute for Occupational Safety and 

Health (NIOSH) conducts field investigations of possible health 

hazards in the workplace. These investigations are conducted 

under the authority of Section 20(a)(6) of the Occupational Safety 

and Health Act of 1970, 29 U.S.C. 669(a)(6) which authorizes 

the Secretary of Health and Human Services, following a written 

request from any employer or authorized representative of 

employees, to determine whether any substance normally found 

in the place of employment has potentially toxic effects in such 

concentrations as used or found. HETAB also provides, upon 

request, technical and consultative assistance to federal, state, and 

local agencies; labor; industry; and other groups or individuals to 

control occupational health hazards and to prevent related trauma 

and disease.

Mention of any company or product does not constitute 

endorsement by NIOSH. In addition, citations to websites 

external to NIOSH do not constitute NIOSH endorsement of 

the sponsoring organizations or their programs or products. 

Furthermore, NIOSH is not responsible for the content of these 

websites. All Web addresses referenced in this document were 

accessible as of the publication date.

This report was prepared by Marie de Perio of HETAB, Division of 

Surveillance, Hazard Evaluations and Field Studies. Subject matter 

expertise consultation was provided by Ahmed Gomaa of the 

Surveillance Branch, Division of Surveillance, Hazard Evaluations 

and Field Studies. Health communication assistance was provided 

by Stefanie Evans. Editorial assistance was provided by Ellen 

Galloway. Desktop publishing was performed by Greg Hartle.

Copies of this report have been sent to employee and management 

representatives at the pharmacy chain, the state health department, 

and the Occupational Safety and Health Administration 

Regional Office. This report is not copyrighted and may be freely 

reproduced. The report may be viewed and printed at http://

www.cdc.gov/niosh/hhe/. Copies may be purchased from the 

National Technical Information Service at 5825 Port Royal Road, 

Springfield, Virginia 22161.
Below is a recommended citation for this report:

NIOSH [2012]. Health hazard evaluation report: needlestick injuries among 

employees at a retail pharmacy chain – Nationwide. By MA de Perio. Cincinnati, 

OH: U.S. Department of Health and Human Services, Centers for Disease Control 

and Prevention, National Institute for Occupational Safety and Health, NIOSH 

HETA No. 2011-0063-3154.

To receive NIOSH documents or information about 

occupational safety and health topics, contact NIOSH at:

1-800-CDC-INFO (1-800-232-4636)

TTY: 1-888-232-6348

E-mail: cdcinfo@cdc.gov

or visit the NIOSH web site at: www.cdc.gov/niosh.

For a monthly update on news at NIOSH, subscribe to 

NIOSH eNews by visiting www.cdc.gov/niosh/eNews.

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Safety and Health