during surgery happen while surgeons are sewing the muscle or fascia. within the medical field, specialties differ in regard to the risk of needlestick injury: surgery, anesthesia, otorhinolaryngology (ent), internal medicine, and dermatology have high risk, whereas radiology and pediatrics have relatively low rates of injury. a systematic review of 45 studies of sharps injuries in surgical staff found that sharps injuries occur once in 10 operations per staff member. per 100 person-years, the injury rate in surgical staff was 88.2 (95% ci, 61.3-126.9; 21 studies) for self-reported injuries, 40.0 for perforations (95% ci, 19.2-83.5; 15 studies), and 5.8 for administrative injuries (95% ci, 2.7-12.2; 5 studies). self-report probably overestimates the real risk and administrative data underestimate the risk considerably. perforation data are probably the most valid indicators. considering that the perforation rates provided here are much lower than the self-reported injuries used to calculate the burden of disease due to sharps injuries by the who, these calculations should be revised. in the united states, approximately half of all needlestick injuries affecting health care workers are not reported, citing the long reporting process and its interference with work as their reason for not reporting an incident. the availability of hotlines, witnesses, and response teams can increase the percentage of reports. physicians are particularly likely to leave a needlestick unreported, citing worries about loss of respect or a low risk perception. low risk perception can be caused by poor knowledge about risk, or an incorrect estimate of a particular patient's risk. surveillance systems to track needlestick injuries include the national surveillance system for healthcare workers (nash), a voluntary system in the northeastern united states, and the exposure prevention information network (epinet), a recording and tracking system that also gathers data. society and culture cost there are indirect and direct costs associated with needlestick injuries. the us government accountability office (gao) determined that requiring hospitals to use safety-engineered needles would result in substantial savings due to the reduction in needlestick injuries requiring treatment. costs of needlestick injuries include prophylaxis, wages and time lost by workers, quality of life, emotional distress, costs associated with drug toxicity, organizational liability, mortality, quality of patient care, and workforce reduction. testing and follow-up treatment for healthcare workers who experienced a needlestick injury was estimated at $5,000 in the year 2000, depending upon the medical treatment provided. the american hospital association found that a case of infection by blood-borne pathogens could cost $1 million for testing, follow-up, and disability payments. an estimated $1 billion annually is saved by preventing needlestick injuries among healthcare workers in the us, including fees associated with testing, laboratory work, counseling, and follow-up costs. legislation in the united states, the needlestick safety and prevention act of 2000 and the subsequent bloodborne pathogens standard of 2001 require safer needle devices, employee input, and records of all sharps injuries in healthcare settings. in the us, nonsurgical needlestick injuries decreased by 31.6% in the five years following the passage of the needlestick safety and prevention act. however, this legislation did not affect surgical settings, where injuries increased 6.5% in the same period. outside healthcare four u.s. states have banned the disposal of any syringes into the trash, requiring the use of waste collection centers, mail-back programs, or other alternatives. the coalition for safe community needle disposal estimates there are over 7.5 billion syringes used for home medical care in the united states. this large amount of home medical syringes has added to the problem of non-healthcare related needlestick injuries due to mishandling and improper disposal of the syringes. blood on any sharp instrument may be infectious, whether or not the blood is fresh. hiv and the hepatitis c virus (hcv) are only viable for hours after blood has dried, but the hepatitis b virus (hbv) is stable even when dried. the risk of hepatitis b transmission in the community is also increased due to the higher prevalence of hepatitis b in the population than hiv and the high concentration of hbv in the blood. many professions are at risk of needlestick injury including law enforcement, waste collectors, laborers, and agricultural workers. there is no standard system for collecting and tracking needlestick injuries in the community, which makes it difficult to measure the full impact of this problem. law enforcement workers, like healthcare workers, under-report needlestick injuries. in san diego, 30% of police reported needle sticks. a study of 1,333 police officers in the denver police department found that only 43.4% reported a needlestick injury they received; 42% of which occurred during their evening shift. most of the needlestick injuries experienced by these workers occurred in their first 5 years of employment. in new york city, a study found a rate of 38.7 exposures (needlesticks and human bites) per 10,000 police officers. in tijuana, mexico, 15.3% of police officers reported ever having a needlestick injury, with 14.3% reporting a needlestick within the past year. needlestick injuries are among the top three injuries that occur among material-recovery facility workers who sort through trash to remove recyclable items from the community-collected garbage. housekeeping and janitorial workers in public sites, including hotels, airports, indoor and outdoor recreational venues, theaters, retails stores, and schools are at daily risk of exposure to contaminated syringes. a small study of sanitation workers in mexico city found that 34% reported needlestick injuries while working in the past year. needlestick injuries that occur in children from discarded needles in community settings, such as parks and playgrounds, are especially concerning. while the exact number of needlestick injuries in children in the us is unknown, even one injury in a child is enough to cause public alarm. studies in canada have reported 274 injuries from needlesticks in children with the majority being boys (64.2%) and occurring from needles discarded in streets and/or parks (53.3%). there are a number of ways in which needlestick injuries could be prevented. first and foremost, increased education in the community is vital. it is especially important to educate kids while they are young. studies of injuries from discarded needles have reported that the average age of children injured is between five and eight years. in one study, 15% of injuries occurred in children pretending to use drugs. therefore, children should be taught at a young age about the risks of handling needles and the correct actions to take if they find a syringe. more outreach programs for addiction treatment and infection prevention programs for injection drug users would be very beneficial. public needle disposal and syringe service programs (ssps) or needle exchange programs (neps) have also proven to reduce the number of needles discarded in public areas. according to the cdc, these programs are effective in the prevention of hiv, and they help reduce the risk of infection with hcv. additionally, in 2004, the environmental protection agency came up with a number of program options for safe disposal including: drop-off collection sites syringe exchange programs mail-back programs home needle destruction devices household hazardous waste collection sites residential waste special pick-up programs in the event that needlestick prevention programs are not put in place in a given community, a 1994 study suggests an alternative for "high risk" areas. the study proposed the implementation of a vaccination effort to give children a routine prophylaxis against hepatitis b to prevent the development of the illness in the event that a child encounters an improperly disposed needle. needle exchange programs needle exchange programs were first established in 1981 in amsterdam as a response from the injecting-drug community to an influx of hepatitis b. spurred to urgency by the introduction of hiv/aids, needle syringe programs quickly became an integral component of public health across the developed world. these programs function by providing facilities in which people who use injecting drugs can receive sterile syringes and injection equipment. preventing the transmission of blood-borne disease requires sterile syringes and injection equipment for each unique injection, which is necessarily predicated upon access and availability of these materials at no cost for those using them. needle exchange programs are an effective way of decreasing the risk associated with needlestick injuries. these programs remove contaminated syringes from the street, reducing the risk of inadvertent transmission of blood-borne infections to the surrounding community and to law enforcement. a study in hartford, connecticut found that needlestick injury rates among hartford police officers decreased after the introduction of a needle exchange program: six injuries in 1,007 drug-related arrests for the 6-month period before vs. two in 1,032 arrests for the 6-month period after. data almost universally confirm the value of needle exchange programs, which substantially decrease the risk of hiv among injectable drug users and do not carry unintended negative consequences. us states that publicly fund exchange programs are associated with reduced rates of hiv transmission, increased availability of sterile syringes among injecting drug users, and increased provision of health and social services to users. states that do not fund needle exchange programs are associated with increased rates of hiv/aids. nevertheless, the us government has explicitly prohibited federal funding for needle exchange programs since 1988, as part of the zero tolerance drug policy in that country. needle exchange programs have therefore been sparsely implemented in the united states.