Multiple studies have suggested that the risk of bloodborne virus transmission through a community-acquired needlestick—mainly HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV)—is exceedingly low. However, a lack of clear safety protocols and public education beyond laboratory, hospital, and clinic settings may be needlessly contributing to improper disposal of needles, syringes, and other sharps and to an inflated perception of viral transmission risk. At most health care sites, a standardized cascade of analysis and preventive therapy kicks in after a needlestick injury (or, less commonly, after a cut with a contaminated scalpel). A blood sample is routinely collected as a baseline measure for communicable diseases. A months-long surveillance period begins, and immunoglobulins or antivirals may be initiated. These protocols became formalized in the 1980s and 1990s through greater awareness of the risk to laboratory and health care workers, for whom most needlesticks occur seconds to minutes after they withdraw a needle from a patient. The potential for needlesticks during fine-needle aspiration has been documented in cytopathology laboratories as well. A survey of 63 pathologists in New Delhi, India, found that 90% reported fine-needle aspiration stick injuries at some point during their career.1 The study noted that the hollow-bore needles used in fine-needle aspiration can confer more risk because they convey more blood and that referred patients are not generally screened for HIV, HBV, or HCV because of economic constraints. The risk is considerably lower beyond laboratory, clinic, and hospital workers, but other research points to wide gaps in public knowledge of how to properly dispose of sharps and what to do in case of an accidental injury. In a small 2018 study, researchers found that only 59% of patients with diabetes receiving care at an endocrinology clinic reported properly disposing of their pen needles, syringes, or other sharps in a designated sharps box or other puncture-resistant container at home.2 The study, led by Li Huang, MD, then a medical resident in endocrinology at Stony Brook University Hospital in New York, anonymously surveyed approximately 150 patients with diabetes. Nearly one-third said that they had never received any formal training on how to dispose of their sharps. Perhaps unsurprisingly, those who had received some form of guidance, whether from a nurse or another source, were significantly more likely to report correct disposal practices. Nine of the study participants reported a needlestick injury in their household. Even proper training in sharps disposal is not a failsafe: the needlestick incidents included 5 that were reported by participants who said that they had received prior training. However, Dr. Huang and her colleagues concluded that a greater emphasis on provider-patient education as a part of routine care could help to reduce the risk. “Our study suggests that there may be many missed opportunities to educate patients with diabetes on proper disposal methods over the course of their medical care,” they wrote. Education, awareness, and proper disposal of sharps in towns and cities have varied enormously as well. Some restaurants, coffee shops, and parks have begun installing sharps containers in bathrooms and other accessible areas, often after pressure from local residents. In 2019, a team of nursing and business students from the British Columbia Institute of Technology in Burnaby, Canada, developed the Vancouver Safe Sharps Disposal Education Plan for the city,3 with a particular focus on educating children, their guardians, and their teachers. Among the project’s motivations was the fact that “an overall lack of education about safe sharps disposal was one of the leading points of stigma for Vancouver residents toward sharps.” Over the past year, the COVID-19 pandemic has exacerbated the opioid epidemic and homelessness, both of which have been cited as contributing factors to accidental needlesticks. At the same time, financially strapped communities have had fewer resources to regularly check for and safely dispose of discarded needles in public spaces. Perhaps the biggest shortfall, however, has been a lack of education about the exceptionally low risk of acquiring a bloodborne disease from an accidental needlestick in those settings. A systematic 2014 literature review by Australian researchers, which included 17 studies published over a 24-year period, uncovered only 1 case of HBV transmission after a community needlestick injury (in the Republic of Georgia).4 A handful of separate case reports documented 2 additional HBV infections after community needlestick injuries (in Spain and Australia) and 3 HCV infections (also in Spain and Australia). Overall, only 1 of these 6 cases involved a child, a 4-yearold boy who developed a chronic HBV infection. The 2014 review did not find any cases of HIV transmission after a community needlestick injury, and a more recent review, in 2018, found no additional HIV, HBV, or HCV cases.5 “The bottom line is that out-of-hospital needlestick injuries have an incredibly low risk,” said Andrew Riordan, MD, now a consultant in pediatric infectious diseases and immunology at Alder Hey Children’s Hospital National Health Service Foundation Trust in Liverpool, United Kingdom, to CytoSource. In a study of 53 children with needlestick injuries referred to a pediatric infectious diseases clinic at Birmingham Heartlands Hospital over an 8-year period, Dr. Riordan and his colleagues did not uncover a single bloodborne infection.6 They also did not identify any cases in which HIV postexposure prophylaxis (PEP) would have been advised. From the more than 1500 needlesticks covered by the 2014 review, including Dr. Riordan’s study, the 4-week prophylaxis regimen was recommended in only 13% of cases. “I wouldn’t say PEP is dangerous in children, just that the risks in these cases are greater than the potential benefit,” Dr. Riordan said. HBV and HCV can remain active in a discarded needle for considerably longer than HIV. No effective PEP therapy yet exists for HCV exposure, but multiple drugs are available in the rare event that the virus is transmitted and a chronic infection develops. The 2014 Australian review concluded that the highest risk is for HBV transmission but that the risk in a nonimmunized person could be “virtually eliminated” by PEP (the HBV vaccine plus anti-HBV immunoglobulin) after a needlestick injury. A 2018 statement paper by the Canadian Paediatric Society and other reports have been careful to point out that community viral transmission is theoretically possible under the right circumstances.5 Even so, the society agreed that risk perception often far surpasses reality. “Although the actual risk of infection from such an injury is extremely low, the perception of risk by parents results in much anxiety. Evaluation, counselling, and follow-up with parents and the child are needed,” the statement read. Among the society’s specific recommendations is that “community programs should be in place to keep parks and public places, and other public areas where children generally play, free of discarded needles.” Advocates have argued that establishing needle exchange programs for injection drug users, part of another recommendation by the Canadian Paediatric Society, may further reduce the number of discarded needles and the risk of accidental injuries. Research suggests that such exchanges, often highly controversial because of the misperception that they encourage more illicit drug use, can reduce the risk of bloodborne viral transmission among injection drug users as well and thereby offer more protection to the wider community. Some harm reduction programs, including one in Charleston, West Virginia, have affixed barcodes to distributed clean needles to help to track them and aid in decision-making after any accidental needlestick. In the October 2020 incident cited previously, the young boy was stuck with an unlabeled needle that was not part of the distribution program; this led to more uncertainty and triggered both a medical evaluation and a police investigation. The test results have not been made public, but rising HIV transmission linked to injection drug use in Charleston’s Kanawha County has concerned both county and federal health officials. Research suggests that a combination of proactive education, awareness, and harm reduction initiatives may help to spare other parents and children from a similar ordeal.