In this issue of the Journal, Whitby and McLaws (page 418) provide a thorough epidemiological account of occupational exposure to bloodborne pathogens by hollow-bore needles in one hospital.1 More studies such as theirs are needed in Australia, where there has been relatively little attention focused on this issue, as indicated by the few references to studies by Australian investigators cited in their article. As an American I find this surprising, because many successful prevention programs introduced in Australia have earned the admiration of public health professionals in other countries. Three examples come to mind: laws requiring seatbelt use and advanced passenger protection in motor vehicles; progressive HIV prevention programs; and programs to prevent ultraviolet light exposure and skin cancer. I am among the admirers of Australia's strong prevention record. In light of these progressive programs, how might one explain the relative neglect in Australia of such a serious occupational risk as bloodborne pathogen exposure?

Some answers may be extrapolated from the United States, where I have observed a culture of self-sacrifice among healthcare professionals that compels them to place self-interest at the bottom of their priority scale. I have also seen administrators make healthcare worker safety a low priority when protective measures for their employees require a financial commitment. Finally, resistance to new prevention policies for healthcare workers is likely to be strongest where there is a lack of surveillance data. This is the "no data, no problem" syndrome.

In Australia, an awareness of the significance of the problem of exposure to bloodborne pathogens is necessary before a national commitment can be made to its solution. Percutaneous injuries are the most frequent type of injury sustained by healthcare workers, and the most life-threatening.2 This remains true despite important advances, including the availability of the hepatitis B vaccine and post-exposure chemoprophylaxis for HIV-exposed healthcare workers.3,4 Therefore, I am convinced that the only choice is to accept the responsibility of caring for our caregivers — in Australia and elsewhere.

The first step towards overcoming neglect is documenting the problem. The report by Whitby and McLaws provides a fine example, on a small scale. With reported annual percutaneous injury rates of 4–15 injuries per 100 full-time-equivalent staff,1 and device-specific injury rates occurring usually in the range of 1–20 injuries per 100 000 devices used,5 the participation of numerous institutions and a long term commitment are required to maintain a database that can guide and sustain large-scale prevention programs.6,7 Active surveillance programs support strong policy initiatives, as has been seen in the US, where surveillance data have supported new regulations, guidelines and advisories issued by our government agencies, as well as state and national legislation.8,9 Widespread surveillance should become a national goal for Australia. There is a global network of countries in Europe, Asia and South America with advanced surveillance programs eager for collaborative exchange.

Surveillance data reveal the causes of bloodborne pathogen exposures and they lead to conclusions that are difficult to ignore. Surveillance data from the International Health Care Worker Safety Center, University of Virginia, from 1996 to 2000 (84 hospitals, 23 243 injuries) show that 98.5% of percutaneous injuries sustained by healthcare workers were caused by sharp medical devices (exceptions include injuries from windshield glass, teeth, fingernails and bone fragments). Therefore, the most direct route to preventing percutaneous injuries is to make injurious devices safer to handle. I find it incredible that the debate still persists whether educational programs or safer devices should be the preferred method of protecting healthcare workers. If you asked a soldier dispatched to the frontlines of battle whether he would prefer a protective shield or an educational poster, there would be no need for discussion. Let us move quickly to get protective devices into the hands of healthcare workers, while providing the best educational methods to support the use of safer technology.

The lack of data on the effectiveness of safety devices is often raised as a barrier to their adoption. Although there are several studies demonstrating the efficacy of safety-engineered needle devices, there nevertheless remains a need for further well-designed clinical trials as new and safer technology comes into the market place.10-11 But where data are lacking on potentially life-saving technology there should also be a responsibility to collect those data, rather than merely rejecting the technology by reason of their absence. But we should also not dismiss the use of common sense in weighing the potential safety impact of many safer devices: intravenous infusion systems with needleless access ports and needleless line connections cannot cause needlestick injuries (as long as one does not override the system and use needles with them); plastic capillary tubes and vacuum tubes all but eliminate the possibility of lacerations; blunt-tipped suture needles do not cause needlestick injuries. Not every device category requires a clinical trial to prove a reduction of injuries, especially if that device eliminates a needle or sharp item.

Another area of time-consuming debate is whether safety devices are cost-effective. We now have a law in the US, the first in the world, requiring healthcare employers to provide safety-engineered devices for the prevention of percutaneous injuries, without consideration of their financial impact on individual healthcare facilities.9 Whitby and McLaws say that "such a situation should not be allowed to occur in Australia". Perhaps they need not worry about the potential cost burden in Australia. As the first customers of this new technology, US healthcare institutions, which comprise the largest medical device market in the world, are bearing the brunt of the cost burden. The new law has caused medical device companies to shift into high-volume production of safety-engineered devices. Economies of scale are already bringing prices down, as is the intense competition to gain market share in this new product area. These benefits will no doubt spill over to other countries. But I would hope for the sake of its healthcare workers, and in keeping with its strong tradition in the field of prevention, that Australia's response would be more active than simply waiting to see what washes up on shore.