Report on the national audit of community needle and syringe disposal facilities: legislation and literature review

Issues and barriers associated with needle and syringe disposal

Page last updated: June 2005

The following summarises the key issues.

Needlestick injuries
Needle and syringe return & disposal
Police activity
Legislation

Needlestick injuries

Macalino (1998), cites a study conducted in England and Wales that showed the following breakdown (by location), of needlestick injuries (based on 958 injuries over a 4 year period):
  • Streets – 16%
  • Contact with rubbish – 12%
  • Parks – 6%
  • Beach – 4%
Russell (2002), reports that in Melbourne, Australia the following breakdown by location:
  • 30% – public park
  • 18% – street
  • 6% – beach
  • 5% – carpark
This article also indicated that waste workers (outside healthcare workers), were most prone to needlestick injuries. However, there was no distinction made as to the source of the N&S as to whether from IDU or other sources.

Kelsall (2002) provided an estimate of approximately 50 needlestick injuries occurring in the community every month in Australia, with no reported seroconversion or infection.

An interesting comparison is provided by Philipp (1993), who analysed those people having Hepatitis B Immune Globulin as a prophylaxis against Hepatitis B infection. In the analysis, of those receiving a needlestick injury and having this treatment (and completing survey forms), 51% of accidental exposures occurred in the community and 45% in hospitals. Of the locations, the following was reported for community exposures:
  • 53% – accidents (not defined)
  • 16% – street
  • 12% – contact with rubbish
  • 4% – beach
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Needle and syringe return & disposal

By marking needles, a study measured the return rate of needles distributed by a NSP in the USA (Guydish 1991). Approximately 50% were returned within a two week period and 61% returned during the study period. This study also found that return rates were higher for stationary NSP than for mobile/roving sites (Guydish 1991). Another study reported in 1992 (Kelsall 2002), demonstrated a reduction in discarded needles from 5.14 needles/month to 1.9 after 20 months following the opening of an NSP in Portland USA.

Wood (2004a), found similar results in Canada, with a mean daily average of discarded needles declining from 11.5 to 5.4. This study also factored a range of variables such as weather and Police presence in the area of the NSP. Of interest was that disposal into public sharps containers rose after opening of the NSP.

A study undertaken of the literature on NSP return rate data was conducted (Ksobiech 2004b). The conclusions reached from the analysis of the literature were:
  • NSP are relatively effective as a disposal site for used needles.

  • Average worldwide return rate was 90%, with the range from 15-112%.

  • A study reported in this article showed a 41% return rate for Australia (no date was provided as to when this specific study was conducted). Gontasezewski (2003), indicates a return rate in Western Australia of >95%. PSA (2002), reports a return rate of 99% in Tasmania (additional data reported 2,800 syringes distributed for every report of discarded N&S equipment in 1997/98). In Brisbane, approximately 0.1% of injecting equipment distributed was discarded (equating to 871 pieces).

  • Data on return rates clearly indicate that studies conducted on larger numbers of needles distributed have a higher percentage rate of needles returned. The above Australian percentage was based on a distribution of 6,306 needles (which was relatively small compared to other studies.

  • Given that there were some reported return rates in excess of 100%, needles are obviously being obtained elsewhere, but returned to NSP. Therefore, it could be concluded that data on return rates could effectively be lower due to "imported" needles being included in return data.

  • Data indicating that a percentage of needles are not returned to NSP does not indicate that they are discarded. Use of public area sharps containers and disposal into domestic waste/recycling streams are other methods of disposing of used needles.
In 2001, Miller reported on a study conducted in Geelong, Victoria on N&S provision and disposal. This author concluded that while discarded N&S are a significant community concern, "the vast majority of needles and syringes are not discarded". The study showed that while there were a variety of methods used to dispose of used N&S, only approximately 0.38% of the N&S dispensed were collected by council staff (from community reports of them being discarded). While this number is still of a community concern, it does show that the majority of IDU do not discard used N&S into public areas.

A study by the Australian Injecting and Illicit Drug Users League (AIVL)(undated), showed that in a self reporting survey, IDU indicated that they felt that they safely dispose of used N&S 97.3% of the time (it was not clearly defined as what is determined as "safe" – however, discarding into public places was not considered as safe). In this report, many respondents indicated that they had to dispose of used N&S into full bins, thus requiring them to manually push waste into the container, and 57.7% reported that disposal container availability was not sufficient.

School of Public Health, University of California (undated) concluded that NSP in the United States have not been shown to increase the total number of discarded N&S and can be expected to result in fewer discarded N&S. In addition this report cited:
  • In Toronto Canada, the numbers of discarded N&S collected since the opening of the NSP has decreased.

  • This latter study is important as it actually answers criticism that opening of a NSP may reduce discarded N&S in the vicinity, by demonstrating that they are actually discarded elsewhere. This conclusion is supported by other authors (Ksobiech 2004b, Doherty 2000, Riley 1998, MacGowan 1998).

  • In Amsterdam, increased reports of discarded N&S following the opening of a NSP, is thought to be attributed to increased awareness of needle-borne infections.
Top of pageHowever, an article reviewing the impact of the closure of a NSP in Connecticut, America (Broadhead 1999), showed that the volume of discarded used N&S in the community did not rise.

NSP provide a forum whereby issues including safe disposal of N&S can be discussed (as well as providing the actual venue for such safe disposal (Stancliff 2003). In this article it is concluded also that IDU are more inclined to adopt safe N&S disposal if the actual obtaining of new N&S is conducted legally (eg. at a NSP or even able to be purchased from pharmacies). Latkin (2005), looked at the role of needle sellers in Maryland USA, and concluded that this sector is more likely to disseminate used N&S, so all IDU need to be educated as to safe disposal so as to prevent the used N&S being available to others.

Kermode (2003), cites several studies whereby it has been assumed that following self-reporting surveys, IDU indicate that they do dispose of N&S safely (this is for those N&S not returned to a NSP). However, as the disposal methods include; burying, burning, flushing down toilets and placement in drains and garbage bins – many of these would not be considered "safe" by others.

The City of Melbourne (MCC 2004), reports that the numbers of discarded N&S was reduced following the implementation of the council's "Syringe Management Plan 2001-2003". This plan provided a coordinated framework inter alia for providing public disposal boxes for N&S.

The Northern Territory report (2002), indicated that of approximately 500,000 N&S distributed in 2000, there were 132 reports of discarded N&S across the whole Northern Territory. This represents 0.003% of those distributed. As other authors have indicated, the origin of these N&S cannot be accurately determined.

The study conducted for AIVL by Kelsall (2002), provided a broad range of reasons as to why IDU do not dispose of N&S appropriately – these conclusions were based on a literature review by the authors. They include:
  • Fear of Police action based on having N&S found on them. Data quoted ranged from 16%-30% of IDU stating Police "fear" as a barrier to safe disposal.
  • Not wanting to go to a pharmacy for new N&S (and thus returning used N&S).
  • NSP not open at needed times.
  • Fear of disclosure of being an IDU to friends/family.
  • Other reasons included; access to services, stigma attached to accessing NSP, being "stoned", apathy, inexperience and lack of knowledge as to safe disposal.
The NSW Health Department (2004), has estimated of the 28 million N&S distributed annually in NSW (through National Diabetes Services Scheme and from NSP), approximately 20 million may end up in the domestic waste stream, with a very small number (not provided), ending up as what would be termed discarded.

Australian and international authors have provided comment on the harm minimisation aspects of the NSP programs implemented. There is a consistent finding that through these programs the number of N&S being discarded has declined and that the probability of disease transmission has also declined. What may have occurred though is a greater community awareness of the issues facing management of IDU and as a consequence, all discarded N&S (and other equipment), is linked in the community's mind to IDU activity.

Police activity

Wood (2004b), investigated the impact of Police "crackdown" on IDU in a specific area of Vancouver. This study concluded that this Police enforcement activity significantly increased unsafe N&S disposal (particularly in areas not necessarily sites for discarding of N&S), from 784 to 1,253 in a three month period. In addition there was a reduction of N&S being disposed of at NSP within the crackdown area – with reductions in the use of public sharp containers within the area as well (from a monthly average of 865 to 502 used syringes deposited into these containers). Wood (2004), also found that the proportion of N&S distributed and not returned to the NSP increased from 4.0% in the three months prior to the Police activity to 8.1% in the three months following.

Kermode (2003), also cites several studies (mainly international ones), that indicate that fear of Police harassment is a major barrier to safe disposal of N&S. Macalino (1998), indicates that while many IDU choose a disposal method for used N&S that will perceivably reduce harm to others in the community, fear of either arrest for possession of N&S or that this possession will identify them as an IDU leads to N&S being discarded.

Based on the conclusions reached by these authors and commented on by others reviewing their work, Police activity clearly has a negative influence on safe disposal of N&S – leading to increased instances of discarding into public areas.Top of page

Legislation

Legislative impacts on both safe disposal of N&S as well as prevention of disease are based on two types of laws. Laws that prohibit the possession of drug equipment as well as prescription laws that prohibit the obtaining of N&S without specific approval encourage N&S reuse and discarding in public areas (MCC 2004, School of Public Health, University of California (undated), Springer 1999).

Having different waste legislative requirements as well as lack of clarity in regards to obligations by the different participants in a NSP program compounds the problem of creating safe uniform avenues of needles disposal (Macalino 1998). Turnberg (2002), based on a study in America, supports this previous conclusion and indicates that "A national effort is needed to achieve consistent community syringe collection and disposal laws and guidelines for all states". This is a view supported within Australia by the many consultations conducted.