a sandpit for foley park, glebe - kidsafe nsw · report on the risks of community acquired...

A Sandpit for Foley Park, GlebeReport on the risks of community acquired needlestick injuries Prepared by Fiona Robbé Landscape Architects

Prepared ForCity of Sydney CouncilOctober 2006

108ArcadiaRoadArcadiaNSW2159

Phone:02 9653 1045Fax:029653 1229

FionaRobbéLandscapearchitecture,horticultureandplayspacedesign

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Copyright Fiona Robbé 2006

Contents

Executive Summary ...............................................................................3

The Proposal: A Sandpit for Foley Park ..................................................4

Precedents ............................................................................................8

Discarded Sharps in Inner City Parks and Playgrounds .......................13

Information about The Needle Syringe Programme ..............................18

Conclusions and Recommendations ...................................................20

Attachments

A – Landscape Plan of Foley Park, Glebe ............................................23

B - Location of Sharps Bins in Glebe ...................................................24

C – Excerpt from “Emergency Medicine” (2003) ...................................25

D– Unicef Child Friendly Cities ............................................................26

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1 Executive Summary

A sandpit is proposed in the current upgrade of Foley Park, Glebe. Sydney City Council officers are concerned about the possibility of a community acquired needlestick injury occurring in the sandpit, due to the park’s history of being frequented by intravenous drug users. Limited internet research findings indicate that:

Effective needle and sharps bins programmes are reducing the number of discarded needles in parksThe risk of a member of the community acquiring a needlestick injury in a park (hence sandpit) is very low (eg acquiring HIV is as low as 1 in 4,000 to 1 in 1,000,000). There are no known cases of this occurring in AustraliaSeroconversion does not automatically result from a needlestick injury

If a risk-benefit analysis of a sandpit is undertaken, the benefits to the community greatly outweigh the risks.

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2 The Proposal: A Sandpit for Foley Park

The proposed landscape plan for Foley Park, Glebe, as prepared in September 2006, indicates a sandpit for inclusion in the playground area. The sandpit is part of a larger playground, which will cater for children between the ages of six months to twelve years old. The park is used once a week for a play bus programme, which supports the play and socialising needs of families with children under the age of five. At other times, children of all ages and their carers visit the park.

Refer to Attachment A for a plan of the park.

A sandpit is proposed for this playground, with the following benefits in mind:

2.1 Developmental Play OutcomesCognitive skills being developed are prediction; cause and effect; seriation (concept of series); comparison (eg wet and dry); problem solving; and concepts of ‘more’, ‘less’ and ‘equal’Language skills being developed are descriptive vocabulary (wet, grainy, texture etc); expressive and receptive conversation skills (with playmates and adults)Physical development skills include fine and perceptual motor skills (moulding, sifting, measuring, rubbing etc). Gross motor skills include carrying sand and moving limbs through sand; jumping onto sand etcSocial and emotional skills include onlooker play; solitary play; parallel play; associative play and co-operative play. Sand play can be copied by others, and encourages fantasy playSand is a developmentally appropriate activity as it accommodates the needs of varying ages, abilities and interests of children

2.2 Free Play, the Development of Imagination and Appreciation of NatureResearch clearly indicates that children prefer natural landscapes and materials (as opposed to man-made materials). The suggestion is that humans are genetically programmed (by evolution) to have an affinity for vegetation, natural materials and nature, and children are particularly sensitive in this regard.

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The advantage of sand (as a natural material) is that it is a “loose parts” product, and hence offers a variety of flexible, open-ended, non-prescriptive, non adult-initiated, imaginative play outcomes (“free” play). Sand is a wondrous medium, capable of taking many forms.

There are many advocates for the addition of the quality of wonder in children’s outdoor environments, and sand varied qualities allow for this:

Sand is a fine particulate material – a solid that can behave in many waysSand has what is termed a “slump” characteristic (forming a mound when poured)Sand can be hot on top and cool below (varying temperatures)Sand is a different colour when wet as opposed to dry – it is almost two materials in oneWhen wet, sand can be moulded and shapedSand is portable, hence can be carried, pushed, poured, shoveled etcSand is free-draining, yet can form temporary dams if enough water is addedSand and water flowing together make beautiful patternsSand and water dribble forms are fascinatingSand has structural limits (it won’t support itself in, say, a bridge construction, hence encourages addition of other materials such as sticks)Shadows on sand creates colour interest

Because of the non-prescriptive nature of sand play, imaginative and sensory-rich play outcomes are likely in the sandpit. Sand play offers a natural play experience, which is valued for the following reasons:

Natural play provides an unrivalled immersion in a sea of sensory stimuli, unable to be emulated in a designed environment of play equipment and surfacingNatural play opportunities are concerned with intuitive knowledge (rather than facts or physical prowess) – nature play goes beyond the taughtNatural play encourages group play and co-operation, especially imaginative and dramatic playStudies have shown benefits of sand play in reducing stress, anxiety and depression (for all ages)

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2.3 Adult Participation and Community BuildingBeing with children at the sandpit can be relaxing and provides conversational time for both the child and adultAdults can take the cue from the child about when it is appropriate to extend the play, comment on play concepts, open up socialisation possibilities, resolve conflicts or remain un-involvedDr John Irvine, notable Sydney child and family psychologist, recently stressed the importance of public sandpits as supportive, social places for parents, and that this, in turn, supports children’s well-being issues. Well-being concerns are of great importance in Australia at present

2.4 Foley Park ConcernsFoley Park has had a history of being frequented by intravenous drug users. Reports from Mark Driver, Recreational Planner, Sydney City Council, indicate that prior to 2005 up to thirty-one (31) needles could be found in the park in one month.

Currently there are four syringe bins in the park (three in the amenities block and one outside). In August 2006, two hundred and twenty-four (224) syringes were removed from these four bins (presumably these numbers relate to August only, although this wasn’t stated). From July 2005 to June 2006 thirty-six (36) syringes were located in the park. Since July this year the average count has been one or two needles in the park per month.

These figures led to safety concerns over the provision of a sandpit in the park, primarily because sand is a medium in which syringe needles can be hidden. The perceived risk is that a child will dig in the sand and, without warning, acquire a needlestick injury, despite adequate parental/carer supervision.

The concern is that inner-city children and other park users and workers are at risk of contact with discarded sharps that could be contaminated with:

HIVHepatitis B (HBV)Hepatitis C (HCV)TetanusOther blood-borne viruses

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In response to these concerns, Sydney City Council has requested that a brief report be prepared to investigate:

Precedents of sandpit provision in SydneyAmsterdam sandpits, as a case studyThe risks associated with sandpits and community acquired needlestick injuries

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3 Precedents

There are a number of Councils and State Government organisations in Sydney who have installed sandpits or sand undersurfacing in playgrounds. The following list is representative only as there may be more Councils than those listed (a survey has not been conducted).

3.1 Local Government: Sydney City Council (Jubilee Park, Tote Park)Willoughby Municipal Council (several parks)Sutherland Shire Council (now in all playgrounds)Pittwater Council (various parks)Ku-ring-gai Municipal Council (Bicentennial Park, Pymble)Randwick City Council (Coogee Beach)Waverley Council (Bondi Beach)Ryde Municipal Council (Putney Park)

3.2 State Government:Centennial & Moore Park Trust (2 x sandpits in Centennial Park)Sydney Olympic Park Authority (2 x sandpits, 1 x playground area with sand undersurfacing)Powerhouse Museum (1 x sandpit to be installed 2006)Darling Harbour Authority (1 x sandpit)

Again, this list is representative only (a survey has not been conducted).

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Sand and water play: Centennial Park (source F. Robbé)

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Sutherland Shire Council provides an interesting case study as they have adopted sand as the undersurfacing of choice for their playgrounds. Discussions with Maritza Abra, Project Manager (Landscape) reveal that sand has been selected because:

It is the only organic material that can be effectively cleaned without a replacement programme. A sand-cleaning machine has been purchased for this purpose. It is the size of a lawnmower, costs approximately $25K, can be used by one operator, and can clean sand to a depth of 300mm (which includes removal of needles and fine glass)It is self leveling, which is useful in high wear areas (e.g. under swings)It offers a safer falling surface than rubber: sand absorbs the energy released in a fall (technical results can be provided)It has a good lifespanIt does not heat up to the point of burning skinIt is free drainingIt is a natural product (children need greater exposure to natural products in play environments in areas of intensive urban development)

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Sandpit: Centennial Park (source: F. Robbé)

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These precedents indicate the confident use of sand in playgrounds by several government organisations in Sydney. Sand requires a maintenance regime, as do other undersurfacing products. Daily inspections and raking are recommended. The Australian playground standards stipulate inspections and maintenance operations as follows:

AS/NZS 4486.1: 1997 – Playgrounds and Playground Equipment, Part 1: Development, installation, inspections, maintenance and operation

3.3 Amsterdam, the Netherlands:Amsterdam, as a city with a liberal drug control regime (and a lot of rain) also provides an interesting case study.

This city has included dedicated sandpits for children in inner city areas since the 1940’s, as illustrated below (all images from: L. Lefaivre, & I. de Roode (eds) 2002: “Aldo van Eyck; the playgrounds and the city”, NAi Publishers Rotterdam)

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Zaanhof, Amsterdam-Oudwest (1950)

Mendes da Costahof, Geuzenveld, Amsterdam-Nieuwwest (1960)

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Buskenblaserstraat, Amsterdam-Nieuwwest (1956)

Zeedijk, Amsterdam-Centrum (1956)

Rapenburg, Amsterdam-Centrum (1969) Climbing arch, Bertelmanplein (1948)

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It is common to see sandpit provision in most local city parks in Amsterdam today. It is interesting to note that Dutch sandpits have wide, raised edges and vinyl sandpit covers (with hold-down points), as illustrated below.

Typical Sandpit in Amsterdam 2005 (source: C. Robbé)

The public remove and replace the sandpit covers in their daily visits to the park (no signage is required for this). Sandpits and sandpit covers are generally in good condition: it is probably understood that respectful use of sandpits means their continued provision in city parks. It is also probable that there is an effective sandpit maintenance programme in place.

Sandpit covers have eyelets on the top surface to let both air into the space below and rainwater percolate into the sand (sand can get too dry for playing). This also provides an answer to the weight of the water lying on top.

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Eyelets on a sandpit cover in Amsterdam A hold-down point on a raised sandpit edge

The cord that attaches the cover to the hold-down point

Parents socialising at a sandpit in Amsterdam

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4 Discarded Sharps in Inner City Parks and Playgrounds

4.1 Definitions4.1.1 Sharps“A sharp is any device having corners, edges, or projections capable of cutting or piercing the skin” “Sharps are items that can cause cuts or puncture injuries and include needles, scalpels ….”“By definition, sharps are those objects which represent a puncture or laceration hazard. Such objects include (but are not limited to) the following: syringe needles (capped or uncapped), razor blades, scalpel blades …….. and broken glass objects” (University of Michigan, Occupational Safety and Environmental Health)

4.1.2 Seroconversion“Development of antibodies in blood serum as a result of infection or immunization” (Answers.com)“The development of detectable antibodies in the blood directed against an infectious agent. It normally takes some time for antibodies to develop after the initial exposure to the agent” (MedicineNet.com)

4.1.3 CANSIAn abbreviation for a “Community acquired needle stick injury”. Community-acquired needlestick injuries are those that occur outside the healthcare industry (where the exposure is much greater).

4.1.4 NSIAn abbreviation for a “Needle Stick Injury”. A sharps or needlestick injury can be defined as an injury from a needle or any other device that has been contaminated with blood or other body fluid and penetrates the skin percutaneously (access to inner organs or other tissue done via a needle-puncture of the skin).

4.1.5 InjectingDrugUser(IDU)An abbreviation for an “Injecting Drug User” or “Injecting Drug Use” (adin.com.au) An IDU is a person who uses a drug that is administered with a needle and syringe – as a term it is a means to separate the method in which drugs are administered (eg injecting or smoking)“IDUs are a group that engage in frequent and extensive polydrug use” (NDARC, UNSW, “Drug use and driving among injecting drug users” by Shane Darke, Erin Kelly & Joanne Ross)“The definition of ‘IDUs’ was also at times questionable. Some sources simply refered to ‘IDUs’ while others referred to drug users who have ever injected, people who injected in

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prison, or people who injected ‘regularly’ (which itself requires clarification). For the purpose of this report, all these groups have been included as IDU” (NDARC, UNSW “Review of injection drug users and HIV infection in prisons in developing and transitional countries”)

4.1.6 HIVPEP“PEP is any prophylactic treatment started immediately after exposure to a disease (such as a disease-causing virus), in order to prevent the disease from breaking out”“In the case of HIV (Human Immunodeficiency Virus) infection, PEP is a course of antiretroviral drugs which is thought to reduce the risk of seroconversion after events with high risk of exposure to HIV (e.g. needlestick injuries). To be effective, it must be started as soon as possible after exposure and not later than one hour. The treatment for HIV lasts four weeks” (Wikipedia)

4.2 Risk of Blood-borne Virus ExposureMuch anxiety exists in Australia regarding seroconversion to blood-borne viruses following community acquired needlestick injuries (NSI). For example, only half of over two million syringes distributed to injecting drug users (IDUs) in Melbourne are returned.

Limited data is available on the incidence of community acquired NSI and the risk of seroconversion to HIV, Hepatitis B and Hepatitis C.

Limited Internet-based research undertaken by this office has revealed that various studies have been undertaken in Australia and overseas as follows:

4.2.1 F.M.O’LearyandT.C.Green(seeAttachmentC)Department of Emergency Medicine, RPA Hospital, Sydney, NSWTitle: “Community acquired needlestick injuries in non-health care works presenting to an urban emergency department”Reported in: Emergency Medicine (2003) 15, pages 434-440

4.2.2 P.Nyiri,T.LeungandM.A.ZuckermanKings College Hospital, NHS Trust & Health Protection Agency, London, UKTitle: “Sharps discarded in inner city parks and playgrounds – risk of blood-borne virus exposure”Reported in: Communicable Disease and Public Health (2004) Vol 7 No. 4

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4.2.3 N.MakwanaandF.A.I.RiordanDepartment of Child Health, Birmington Heartlands Hospital. Birmingham, UKTitle: “Prospective study of community needlestick injuries”Reported in: Archives of Disease in Childhood (2005) 90, pages 523-524

4.2.4 W.A.RutalaandC.G.MayhallThe Society for Hospital Epidemiology of AmericaTitle: “Medical Waste”Reported in: SHEA Position Paper (1992) Vol 13 No. 1, pages 38-48

4.2.5 F.RusselandM.C.NashCentre for International Child Health, Royal Children’s Hospital, Parkville, VictoriaTitle: “A prospective study of children with community acquired needlestick injuries in Melbourne” Reported in: Letter to the editor; Journal of Paediatrics & Child Health; Vol 38 (June 2002) page 322

4.3 Findings of these studies include4.3.1 O’Leary&GreenReport(2003):

Community acquired needlestick injuries (CANSI) in non-health care workers have not been well described and researched, and the evidence base on which to recommend management strategies is poorTo date (2003) there have been no reports of HIV or HCV seroconversion from CANSI, and only one report of a four year old child contracting HBV. Therefore discarded syringes are thought to pose an extremely small risk.The risk of seroconversion following a CANSI from an unknown source is:

− 12% to 31% for HBV− 1.62% for HCV− 0.003% to 0.05% for HIV

Adverse physical and psychological effects may be considerable following a CANSI, regardless of whether Seroconversion takes place

4.3.2 Nyiri,Leung&ZuckermanReport(2004):Viral viability (HBV, HCV & HIV) can survive in the park environment for several weeks, but is dependent on several variables - viral genome, antigen load, ambient temperature, sunlight, humidity and volume of body fluid present. Survival of the virus may be tenuous

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Of the CANSI studied, 6% of cases studied occurred in public parks

4.3.3 N.Makwana&F.RiordanReport(2006)–UK:CANSI in children were first reported in 1987 in the UK (Walsh 1987; in Makwana & Riordan)Of fifty-three (53) children studied, none had contracted a blood-borne infection up to six months following a CANSIThe problem of CANSI is that the infectious source is often unknownStudies regarding the HIV PEP programme show that no children seroconverted despite not receiving HIV PEP

4.3.4 F.Russel,2002,RoyalChildren’sHospital,Victoria(sampleoffiftychildren):A study (at Melbourne’s Royal Children’s Hospital) of fifty (50) children over a thirty two month period who had CANSI, found that none had contracted HIV, HVB or HVCThe potential risk of acquiring HIV from CANSI is probably 1 per 4,000 to 1 per 1,000,000Children tested three months of more after the incident did not seroconvert, even though:

− HIV-1 can remain viable in a syringe for four weeks under the right conditions− The transmission of HBV and HCV is probably higher as the prevalence of

these infections are higher− HCV and HBV can survive for up to five weeks and twelve months

respectively under the right conditions

4.3.5 TheSHEAPositionPapertitledMedicalWaste(January1992)inInfectionControlandHospitalEpidemiology

This report states that the theoretical estimate that the events necessary for infection to occur in sequence, and for a person to develop HIV infection from CANSI on a beach, is 1 in 15 billion to 1 in 390 trillion (Vol 13, no. 1).Other articles available on the Internet also emphasise that there are other contributing factors to the low probability of an infection following a CANSI:

The virus must pierce clothes and shoesThe HIV virus (in particular) is fragile once it is living outside the body and when exposed to unfavourable environmental conditionsThe syringe needs to contain a sufficient quantity of bloodThe syringe needs to pierce the skin and tissue quite deeply – just scratching skin is not sufficient contact to acquire an infection

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4.4 Recommendations as a result of these studies4.4.1 O’Leary&GreenReport(2003):

Children stabbing each other with discarded needles accounted for 17% of ‘deliberate injuries’ in their study. Hence children and carers need to be educated about the dangers of needles and syringes, and discouraged from playing with themThe community needs to be educated that in the event of a CANSI, they should seek medical advice and assessment immediatelyImmunisation may play a role in increasing immunity to CANSI – Tetanus and HBV in particularCommunity education is required about possible high-risk areas (such as public toilets, beaches and parks) in order to reduce the frequency of these injuries

4.4.2 Nyiri,Leung&ZuckermanReport(2004):Local authorities should ensure that their workforce is staffed appropriately; educated about the risks of sharps injuries, and use of protective equipment; and has a virus exposure policy The public should be warned about the risk and what they should do on finding sharps in public placesTreatment programmes for injecting drug users should include education about the dangers of blood-borne infection and safe disposal of needles

4.4.3 N.Makwana&F.RiordanReport(2006)–UK:School educational programmes are important to reduce incidence of stabbing injuries (from child to child)Needle exchange programmes are important to put into place in order to reduce the risk of CANSIChildren with HIV from a CANSI should be given a course of Hepatitis B vaccinations. HIV PEP should only be administered to those children at very high risk of contracting HIV (i.e. injury from a known HIV source, with presence of fresh blood on the needle and a deep penetrating injury)

4.4.4 F.Russel,2002,RoyalChildren’sHospital,Victoria(sampleoffiftychildren):HBV prophylaxis and serological testing is important in the management of CANSIParents should be encouraged to disclose and report CANSI

4.4.5 TheSheaReport:An intensive public education programme regarding the actual risks posed by medical waste and methods for proper management may reduce public “fear and outrage”

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5 Information about The Needle Syringe Programme

The Needle Syringe Programme was generally introduced in 1986 in Sydney under the National Drug Strategy’s harm minimization framework, and includes provision of clean injecting equipment, distributed free of charge, usually from a community health centre (which, for Foley Park, falls under the Central Sydney Area Health Service).

The pack includes sterile syringes, water, spoons and swabs, all provided at no cost.

The box includes a section where a needle can be safely disposed of. The concept is that the box is returned or exchanged at the community outlet.

The aim is to minimise careless throwing-away of needles, and hence community acquired NSI.

All clients accessing this programme are comprehensively counseled about the need to exchange used needles and syringes or dispose of them safely and responsibly. Fear of losing the needle syringe programme minimizes the careless throwing away of needles.

There will always be ‘transients’ who do not use the needle syringe programme. In this regard, the City of Sydney has a Syringe Management Plan. The programme ensures that:

Sharps bins are located where required (four are located in Foley Park)Needle clean-up is part of the Council cleansing programmeThere is a needle and clean-up hotline (24 hour service) for discarded syringes

Numerous studies have shown that installing safe needle disposal bins in strategic locations reduces the number of needles and syringes that are inappropriately discarded.

An important outcome is that people who inject drugs can and do behave responsibly when given the resources to do so.

There is still a small percentage of people who, for whatever reason, do not throw needles in sharps containers. They tend to drop (or throw) needles if concerned that they will be caught injecting in a public place. This tends to occur at night, in secluded parts of a park environment.

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Good lighting and placement of seats may have an impact on this behaviour. A sandpit will be of interest (over bushes, for example) if it is sited near a dark secluded area of the park, with seats. Sandpits would be unlikely to be sought out specifically to hide needles in.

Refer to Attachment B for the locations of Sharp Bins in Glebe

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6 Conclusions and Recommendations

The following conclusions are evident from the research undertaken for this report:

Discarded needles in parks and playgrounds are reducing in numbers following government initiatives such as the Needle Exchange Programme, provision of sharps bins, and follow up cleansing servicesTo date, the probability of acquiring a CANSI is extremely lowIt can be difficult to get the type of wound that transfers the blood-borne disease to the injured person’s blood streamSeroconversion of a NSI to:

− HIV− Hepatitis B− Hepatitis C− Other blood-borne viruses

is a very low probabilitySandpits per se are not sought out as places to discard or hide needles. IDUs are not malicious by nature, but instead are rather careless, or acting in fear of being spotted

Regarding the provision of a sandpit in Foley Park, the following recommendations could be adopted:

6.1 Design GuidelinesSite the sandpit in a well-lit, well trafficked and unsecluded part of the playground. Do not enclose the sandpit with planting or structures which obscure sightlinesFencing of the playground (and sandpit) may assist with establishing the special purpose of the sandpit, as well as making it more difficult to access directly by IDUsComfortable seating in very close proximity to the sandpit may encourage ‘after-hours’ use by IDUs. This poses a conflict for aged carers or carers with a disability visiting the sandpit during the daytime. The Dutch model of a raised sandpit edge doubling up as a seat seems sensible in this case. If required, one seat in close proximity will be better than a grouping of seatsProvision of a vinyl sandpit cover is an inexpensive solution to many sandpit management issues. The covers are inexpensive, easy to replace if damaged, and easy for carers to remove and replace each day.One Council landscape architect has suggested that a rake (or sieve) could be provided in close proximity to the sandpit, so parents can always rake the sand if feeling

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concerned about hidden sharps. This again, is an inexpensive solution, empowering the public to participate in their own safety. The rake/sieve could be placed on a hook with signage about its usageBlue lighting is not recommended as a strategy as many IDUs know exactly where their veins are

6.2 Public Awareness and Education GuidelinesThe articles referenced in this report all stress the importance of public education in the ongoing debate of the risk of community acquired NSI. The points made are clear, and require ongoing partnerships between NSW Health, Sydney City Council, NSW Police and local community groups.

It may be difficult to establish whose responsibility this is, however, it is clear that this is the single most important factor in the prevention or treatment of CANSI.

6.3 Sydney City Council Sharps bins should continue to be provided in Foley Park. Bins should be located in the toilets, and near seatingThe Council support programmes and policies for safe needle and syringe disposal in this park should be continuedCouncil needs to adopt a daily inspection and maintenance regime for the proposed sandpit, which forms part of the inspection and maintenance regime for the Foley Park playground, as defined by AS4486.1Council has the opportunity to empower the community to recognise Foley Park as a safe, public space where priority has been given to ‘community building’Through provision of quality play facilities, Council has the opportunity for ongoing endorsement of Unicef’s Child Friendly Cities Initiative (see Attachment D)

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In conducting a simple “Risk-Benefit” analysis regarding provision of a sandpit in Foley Park, the following points are important:

RISKS BENEFITSCANSI: very, very low probability Rich developmental play outcomes for all

ages and disabilitiesOther Risks:

Broken glass Varied sensory stimulation

Bacterial growth Opportunities for free play

Cat/dog poo Opportunities for dramatic and imaginative playOther substances (e.g. vomit, blood, food)

Organic matter Sand is a natural material - provides valuable opportunities for appreciation of natureThese Risks Can Be Ameliorated By:

Good design Sandpits are intimate environments that improve community supportive links, and hence, children’s well-being

Community information and education

Regular maintenance regimes

Effective partnership between NSW Health and Sydney City Council regarding issues of intravenous drug usage in public spaces

Sand has known therapeutic value in regard to stress, anxiety and depression

Sand is an inexpensive medium

Sand is easy to top-up or replace

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Attachment A – Landscape Plan Of Foley Park, Glebe

Refer to “Attachment A.pdf” attached with this document

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Attachment B - Location of Sharps Bins in Glebe

Refer to “Attachment B.pdf” attached with this document

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Attachment C – Excerpt from “Emergency Medicine” (2003)(Pages 434-440)

Refer to “Attachment C.pdf” attached with this document

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Attachment D– Unicef Child Friendly Cities (Excerpts From)

Note: “Child Friendly” means kids are valued, respected and included so they feel confident they will be listened to.

A Child Friendly City is actively engaged in fulfilling the right of every young citizen to:

influence decisions about their cityExpress their opinion on the city they wantParticipate in family, community and social lifereceive basic services such as health care and educationDrink safe water and have access to proper sanitationBe protected from exploitation, violence and abuseWalk safely in the streets of their own city Meet friends and playHave green spaces for plants and animalsLive in an unpolluted environmentParticipate in cultural and social eventsBe an equal citizen of their city with access to every service, regardless of ethnic origin, religion, income, gender or disability

>>>>>>>>>>>>

Landscape Plan

Glebe Locations

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COMMUNITY SHARPS BIN LOCATION - Glebe

24 hour

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Neighbourhood Service Centre toilets - Female

Neighbourhood Service Centre toilets - Male

Dr HJ Foley park toilets

Dr HJ Foley park by southern wall, to right of 'Retirement Village' sign

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Copyright © 200 City of Sydney and Land & Property Information.5No part of this map may be reproduced without written permission. June 2005

N O R T H

Closed overnight(temporarily closed for repairs)

Emergency Medicine (2003) 15, 434–440

Blackwell Publishing Ltd.Original ResearchCommunity acquired needlestick injuries

Community acquired needlestick injuries in non-health care workers presenting to an urban emergency departmentFenton M O’Leary and Timothy C GreenDepartment of Emergency Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia

Abstract

Objectives: To review the epidemiology and demographics of community acquired needlestickinjuries in non-health care workers attending an urban ED.

Methods: A retrospective analysis of patients with needlestick injuries attending the Royal PrinceAlfred Hospital from 1996 to 2001.

Results: One hundred and twenty cases were reviewed. The most common mechanism ofinjury was exposure to discarded syringes (68%). Forty three (36%) injuries were workrelated. Twenty four (20%) were non-accidental. Ten (8%) patients received humanimmunodeficiency virus post exposure prophylaxis. There were no viral seroconversionsin the patients with data available.

Conclusions: We have identified three groups, males, cleaners and police officers, who are at particularrisk of injury. Community education is required so that medical assessment is soughtearly and to increase awareness of these injuries. The provision of post exposureprophylaxis requires individualized risk assessment, as only in a minority of cases is thesource available for testing.

Key words: accidents, needlestick injuries, occupational, police, syringes, violence.

Introduction

Needlestick injuries (NSI) to health care workersare now a well-recognized occupational hazard. Inter-national guidelines for the assessment and manage-ment of NSI in health care workers have been publishedwith evidence-based recommendations to reduce therisk of hepatitis B virus (HBV), hepatitis C virus(HCV) and human immunodeficiency virus (HIV)

transmission.1 However, community acquired needles-tick injuries (CANSI) in non-health care workershave not been well described, and the evidence baseon which to recommend management strategies ispoor. A small number of papers have described non-health care worker occupational risk groups such aspolice officers2,3 and clothing industry workers,4 whileothers have described the epidemiology and EDmanagement of non-occupational injuries especially

Correspondence: Dr Fenton O’Leary, PO Box 109, Concord, NSW 2137, Australia. Email: [email protected]

Fenton M O’Leary, MBBS, MRCS (Eng.), Registrar; Timothy C Green, MBBS, FACEM, Director of Emergency Medicine.

Community acquired needlestick injuries

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in children.5–8 CANSI cover a wide spectrum fromcriminal assault with blood filled syringes tochildren playing with discarded syringes in publicparks. Assessment and management is often difficultbecause of the unknown nature of the source of theblood. Recent guidelines from the AustralianNational Council on AIDS, Hepatitis C and RelatedDisorders make little mention of CANSI other thanfrom needle sharing.9 Guidelines from NSW Healthare more helpful, particularly stating that the riskfrom discarded needles is negligible, but offer littleadvice to those patients who are assaulted with bloodfilled syringes where the source of the blood isunknown.10

The aim of this study was to review theepidemiology of non-health care worker CANSIpresenting to the ED, the mechanism of injuriesand the associated risk of disease transmission, theprovision of postexposure prophylaxis (PEP) andthe rates of seroconversion.

Methods

This study was a retrospective case note reviewof community acquired non-heath care workerneedlestick injuries attending the Royal Prince AlfredHospital (RPA) Emergency Department between1st January 1996 and 31st December 2001. RPA is atertiary referral centre located in an urban area witha high incidence of illicit drug use. It has 45 000attendances a year (6000 paediatric) and a 28%admission rate. Ethics committee approval wasgained prior to commencement of this study.

All patients with needlestick injuries who attendedthe RPA ED were retrospectively identified using thediagnosis of ‘needlestick injury’ in the department’scomputer database: Emergency Department Informa-tion System (EDIS, Version 6.0. HAS Solutions PtyLtd, Sydney, Australia). Health care workers who wereinjured during their normal work were then excluded.

A single researcher reviewed each set of casenotes, which included EDIS files, written medicaland nursing notes and pathology reports. Data werecollected on a pre-designed proforma (Table 1), andentered into a computerized database (Microsoft Access1999, Microsoft Corporation, Seattle, USA). If datawere missing or the reviewer was unsure, the NSI wascategorized as ‘unsure or missing data.’

Data on ‘description of injury’ were entered freehandinitially, and subsequently categorized according to

the major groups identified when the results wereanalysed.

An attempt was made to categorize the risk ofdisease transmission from the type of injury sustainedaccording to exposure codes established by the Centrefor Disease Control (CDC) (Table 2).11 Unfortunately,due to the retrospective nature of the study, therewas insufficient information in the medical recordto complete this assessment.

Results were analysed for the entire cohort aswell as for four identified subgroups: Adults (16 yearsand over), children (less than 16 years), occupationalinjuries and non-accidental injuries.

In addition to descriptive statistics, the chi-squaredtest was used to examine the association betweencategorical variables. Although the significance levelwas set at 0.05, the Bonferroni method was used to

Table 1. Research fields

RecipientUnique identifierYear of injuryAgeSexWork related injuryOccupation (if work related)Non-accidental injuryDescription of incidentPrevious immunization history for tetanus and HBVPrevious exposure to HIV, HBV and HC

Source factorsNSI from known sourceKnown infectivity status sourceAbility to test sourceResults of any testingAssessment and treatmentTime to presentationTime to treatment from triageTriage categoryGrade of doctorDescription of injuryBlood tests performedResults of blood tests performedTetanus, HBV and HIV PEP prescribedTime to HIV PEP

Follow upResults of subsequent serology if knownWho was a patient referred to for follow up?

General comments

FM O’Leary and TC Green

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adjust for individual alpha levels when multipletestings were performed. SPSS 10.0 and SISA(Binomial Simple Interactive Statistical Analysis,http://home.clara.net /sisa/binomial.htm) were usedfor data analysis. As the chi-squared test was themain statistical procedure used in the study, samplesize calculation was performed using the chi-squaredmodule of the software ‘PASS’ (Power and SampleSize, NCSS, Kaysville, USA). Assuming a mediumeffect size (ES, Cohen 1988) of ES = 0.3,12 and degreesof freedom ranged from 1 to 3, a sample of size 90–120would be required to achieve 80% power at the 0.05alpha level.

Results

Approximately 260 000 patients attended the RPAEmergency Department over the six-year period ofthe study. One hundred and twenty-four cases of CANSI

were identified. Four case notes were not available;therefore, 120 patients were entered into the study.

The subjects had a median age of 26 years (17–35interquartile range [IR] ) with a range of 2–79 years.Twenty-five (21% [95% CI 11–24%]) patients wereless than 16 years old. When analysed separately themedian age of children was 6 years (4.5–12 IR) witha range of 2–15 years. There was a marked malepredominance in the entire cohort as well as thesubgroups (Table 3).

Injuries were work related in 43/120 cases (36%[95% CI 27–44%]), predominantly police officersand cleaners (Table 4). Eleven of 15 police officers wereinjured whilst searching suspects or their property.Seven of 16 cleaners were injured whilst cleaningtoilets. Of the three shop workers included in thestudy, two were deliberately assaulted and one wasinjured searching customers’ bags.

The mechanisms of injury are shown in Fig. 1.Eighty two (68% [95% CI 60–77%]) cases were as aresult of exposure to discarded syringes. These occurred

Table 2. Centre for Disease Control (CDC) exposure codes used tocategorize the risk of disease transmission from the type of injurysustained

Exposure code

1 Mucous membrane or skin integrity compromised.Small volume exposure. For example, a few drops,

short exposure.No percutaneous exposure.

2 Mucous membrane or skin integrity compromised.Large volume exposure. For example, major blood

splash, longer duration, or Percutaneous exposure.Less severe. For example, solid needle, superficial

scratch.3 Percutaneous exposure.

More severe. For example, large bore hollow needle, deep puncture, visible blood on needle, needle used in source patients artery or vein.

Table 3. Sex of the 120 cases of needlestick injuries in non-health care workers that attended the emergency department

Male Female Total

n % (95% CI) n % (95% CI) nAll cases 93 78 (70–85) 27 22 (15–30) 120Adults (≥ 16 years) 77 81 (73–89) 18 19 (11–27) 95Children (< 16 years) 16 64 (45–83) 9 36 (17–55) 25All occupational injuries 38 88 (79–98) 5 12 (2–21) 43Non-accidental injuries 18 75 (57–93) 6 25 (7–43) 24

Figure 1. Mechanisms of injury for all cases (n = 120).

http://home.clara.net/sisa/


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particularly in toilets, with the syringe being locatedaround the toilet roll, beaches and parks.

Non-accidental injuries were identified in 24/120cases (20% [95% CI 13–27%]). Eleven (9% of all cases[95% CI 4–14%]) of these injuries were sustainedby members of the general public following alleged

criminal assaults with blood filled syringes andneedles. Nine were occupational with the police (4/9)and shop assistants (2/9) being the most commongroups. Four of the non-accidental injuries were casesof children stabbing their playmates while playingwith used needles.

The time from injury to presentation was availablefor only 37 cases. The median time to presentation for thesepatients was 3 h (1–24 IR), with a range of 0.75–168 h.

Figures 2 and 3 show the prior immunizationhistory of all cases, as well as for the different subgroups.There was no statistical difference between adults andchildren when analysing prior hepatitis B immunization(P = 0.292). However, children were more likely to beimmunized against tetanus (P = 0.001). Police officerswere more likely to be immunized against both

Table 4. Non-health care worker occupational needlestick injuries

Male Female Total

Cleaners 13 3 16Police officers 13 2 15Shop workers 3 0 3Others 9 0 9

Figure 2. Previous hepatitis B virus (HBV) immunization history. �, immunized; �, not immune; , unsure or missing data.

Figure 3. Previous tetanus immunization history. �, immunized; �, not immune; , unsure or missing data.


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hepatitis B (P < 0.001) and tetanus (P = 0.004) thanother occupational groups.

The source of the blood in the syringe wasidentifiable in only 14/120 cases (12% [95% CI 6–17%]), and was able to be tested for blood-borneviruses in four cases (only 3% of all cases [95% CI 0.1–6%]). The source was identified in six of the 15 policeofficers who sustained injuries and were available fortesting in two cases. The results of source viral studieswere not available for this study and the authors wereunable to ascertain whether source testing had alteredcase management or not.

Over the six-year period 28/120 (23% [95% CI 16–31%]) patients received tetanus prophylaxis, 65/120(54% [95% CI 45–63%]) received HBV PEP and 10/120(8% [95% CI 3–13%]) received HIV PEP. Of the 10 patientswho received HIV PEP, seven also received HBV PEP.

The majority of patients were referred to their GPfor follow up and, unfortunately, subsequent serologywas only available for 10 patients. At six months postinjury there were no hepatitis B, hepatitis C or HIVseroconversions in these 10 patients. Three of thesepatients received HIV PEP and six of them receivedHBV PEP.

Discussion

The risks of seroconversion to HBV, HCV and HIV froma positive source have been well described in regard tohealth care workers exposed to needle stick injury atwork.1 In general terms the risk of seroconversion isrelated both to the type of needlestick injury, and theinfectivity or viral load of the source.

The risks of seroconversion from CANSI however,are not well described. This is because the eventsthemselves are rare, large-scale data collection hasonly just begun,10 and the source of the blood is oftenunknown. In addition no data is available on the

number of patients who do not seek medical attention.To date there have been no reports of HIV or HCVseroconversion from CANSI and only one report of a 4-year-old child contracting HBV.8 Therefore, discardedsyringes are thought to pose an extremely small risk.10

However, it is often not possible to determine how oldthe syringe is and recent data suggests that HIV maysurvive in syringes for more than six weeks.13 Injuriesthat occur from fresh blood filled syringes, such asdeliberate assaults or from searches, may not be suchlow risk.

When considering the risk after a CANSI froman unknown source, the seroprevalence within thecommunity must be considered. An estimation ofthe risk of viral transmission can be made by using thefollowing formula: risk carried per single exposuremultiplied by risk of source being virus positive.9Table 5 shows the risk of seroconversion from a positivesource, the prevalence of seropositive persons in thecommunity and the estimated risk of seroconversionafter a CANSI from an assumed IVDU for HIV, HBVand HCV.

Even though the risks from CANSI seem very low,particularly with discarded syringes, the effect on thepatient may be considerable. There may be adversephysical and psychological effects. Also, there havebeen two documented cases of fulminant hepaticfailure in health care workers given PEP followingneedlestick injuries. Both of these health care workerswere given PEP regimens including Nevirapine(Boehringer Ingelheim, Ridgefield, USA), which isno longer recommended.14

Patients at high risk of viral transmission arethose with deep injuries, from needles with visiblefresh blood, from a source that is known to be positiveor an unknown source likely to be from a high-riskpopulation.10 The use of Zidovudine (Glaxosmithkline,Baronia, Australia) as a single agent in PEP has beenshown to reduce the risk of HIV infection by 81%.1

Table 5. The estimated risk of seroconversion following a CANSI from an unknown source

HBV HCV HIV

Risk of seroconversion from a positive source 23–62%17 1.8%18 IVDU 0.6%9 HCW 0.3%1

Seropositive prevalence in the Sydney community 50%17 50–90%18 Homosexual IVDU 17%(assuming source is IVDU) Other IVDU 1%19,20

Risk of seroconversion following a CANSI from an 12–31% 1.62% 0.003–0.05%†unknown source (assuming source is IVDU)

†Assuming risk of 0.3%; CANSI, community acquired needlestick injury; HBV, hepatitis B virus; HCV, hepatitis C virus; HCW, health careworker; HIV, human immunodeficiency virus; IVDU, intravenous drug user.


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The provision of PEP should be guided by expertopinion based on local population factors, type ofinjury, previous immunization status of the recipientand the wishes of the recipient after careful discussion.In this study 8% of all cases received HIV PEP. Thesewere all after discussion with the immunologist oncall and follow up was arranged for the next day in theimmunology clinic.

The majority of cases in our study were male. Thisis supported by previous studies.5,7 The reasons forthis are not apparent but may include: males adoptinghigher risk behaviours and being more inclined toconfrontation; females being more careful, methodicalor observant.

We have identified cleaners as a high-risk group forCANSI, which to our knowledge has not previouslybeen described. Cleaners should receive immunizationagainst HBV on commencement of employment andeducated regarding the risks, avoidance and manage-ment of needlestick injuries. Particular care should betaken when cleaning public toilets.

Police officers are another important occupationalrisk group, as has been previously well described.2,3

They were predominantly injured whilst searchingsuspects or their property. Particular care should betaken in these circumstances and thought should begiven to the development of lower risk search methods.Police officers appear to attend the ED rather thantheir own occupational health department and weassume this is because of the acute nature of theinjuries and the need for a rapid assessment of theneed for PEP.

Although the overall numbers are small, shopworkers involved in security duties should be awareof the risk of needlestick injuries, either from deliberateassaults with blood filled syringes or from searchingcustomers’ bags.

The most common mechanism of injury was froma discarded syringe, and fortunately these pose thelowest risk. Areas to highlight include public toilets,beaches, parks, sandpits and train and cinemaseats. Over 20% of all cases were children less than 16years of age. The majority of these were injured bydiscarded syringes, however, children stabbing theirplaymate accounted for 17% of the deliberate injuries.This behaviour has been previously described inEdinburgh5 and Dublin.6 Children need to be educatedabout the dangers of needles and syringes anddiscouraged from playing with them.

Eleven out of the 120 cases (9% [95% CI 4–14%])were due to a deliberate assault with a blood filled

syringe. These patients represent a higher risk thanthe average and should be dealt with by senior staffand specialist advice sought early.

As the benefit of HIV PEP is thought to be criticallydependent on the time it is initiated post exposure,1the median time from injury to presentation of 3 h isreassuring. The community should be educated thatin the event of a CANSI they should seek adviceimmediately.

In this study the immunization history was foundto be incomplete or missing in a number of cases. Weidentified that police officers are significantly bettervaccinated than other occupational groups and thisis a credit to their occupational health policies. Inaddition, significantly more children are immunizedagainst tetanus than adults are. Parents generallycomply with the current immunization schedule, andthe recent introduction of HBV immunization mayincrease the rate of HBV immunity in the community.15

In only in a small minority of cases (3%), was thesource of the blood from needlestick able to be testedfor blood-borne viruses. This illustrates the fact thatthe majority of CANSIs are from an unknown source.We were unable to find out the results of the sourceserology for this study. If the source can be identifiedthen all attempts should be made to test them forblood-borne viruses.10

Our study was limited by its retrospective nature,by the lack of uniformity of data recording and by thelack of follow up data able to be obtained. The maineffect was to reduce the information on seroconversionrates: data were only available for 10 patients andnone of these seroconverted to HBV, HCV or HIV.Unfortunately, subsequent serology results werenot available for seven of the 10 patients treated withHIV PEP. This study may have underestimatedthe incidence of CANSI, as an unknown number ofpatients may not seek medical attention or may seekhelp from their local GP.

A prospective multicentre study is required, withuniform data collection and permission for follow up,which will enable these issues to be addressed. PEPregistries for CANSI are currently established by theNational Centre in HIV Epidemiology and ClinicalResearch10 in Australia and by the CDC.16

Conclusions

We have described the epidemiology and demo-graphics of CANSI in the Central Sydney area. In


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particular, we have identified at risk groups, parti-cularly males, cleaners and police officers. Communityeducation is required so that medical assessmentis sought as soon as possible after the injury andto inform of possible high-risk areas, such as publictoilets, beaches and parks, in order to reduce the fre-quency of these injuries.

Although it is likely that the risk of seroconver-sion is probably very small, this study was not able toanswer that question. Individualized risk assessmentis essential for every case of CANSI as the source israrely identified.

Further studies are required to determine the bestapproach to these injuries and the risk that they posein the community.

Acknowledgement

The authors thank Dr Sing Kai Lo, PhD, statisticianfrom the Institute of International Health, Universityof Sydney for his help in analysing the data andpreparing the statistics.

Accepted 22 July 2003

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