The Prevalence and Underreporting of Needlestick Injuries among Dental Healthcare Workers in Pakistan: A Systematic Review

Needlestick injuries (NSIs) are a major occupational health problem among dental healthcare workers (HCWs) in Pakistan, which places them at a significant risk of acquiring blood-borne infections. However, not all NSIs are reported, leading to an underestimation of the actual prevalence. The harmful impacts of NSIs on the healthcare delivery necessitate an urgent need to measure its actual prevalence. Objectives. The aim of this study was to review literature to estimate the prevalence and reporting rates of NSIs among dental-HCWs in Pakistan. Methods. 713 potentially relevant citations were identified by electronic databases and hand searching of articles. Nine primary studies were subsequently identified to be included in the review. Results. The results of the included studies indicate that the prevalence of NSIs among Pakistani dental-HCWs was between 30% and 73%. The rate of reporting of NSIs was between 15% and 76%, and the most common reason was found to be the lack of awareness regarding the reporting system, or of the need to report NSIs. Conclusion. It is evident from the review of the included studies that there is a significantly high prevalence and a low rate of reporting of NSIs among dental-HCWs in Pakistan, suggesting the need to setup an occupational health department in dental settings, for preventing, managing, recording, and monitoring NSIs.


Introduction
Globally, an estimated two million healthcare workers (HCWs) experience a needlestick injury (NSI) each year [1] putting them at risk of infectious diseases such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunode ciency virus (HIV) [2,3]. Globally, more than a third of hepatitis B and hepatitis C cases and approximately 5% of HIV cases result from an NSI [1] despite evidence to show e ective infection control policies that can successfully prevent HBV seroconversion and minimise rates of HCV and HIV seroconversion following an NSI [4]. NSIs have also been shown to transmit other bacterial, fungal, or viral infections, including blastomycosis, cryptococcosis, diphtheria, herpes, malaria, mycobacteriosis, and syphilis [5]. It is also reported that in up to 12% of cases, NSIs may also lead to psychiatric morbidity including posttraumatic stress disorder (PTSD) [6]. Furthermore, the presence of blood-contaminated saliva increases the risk of infection with blood-borne viruses or other infectious agents during an NSI [7][8][9], which can adversely a ect both personal and professional life and can restrict career opportunities due to the risk of transmission of blood-borne pathogens to patients [9][10][11].
In the prevaccination era, the rate of HBV infection amongst dental-HCWs was estimated to be 3-6 times higher than in the general population [12]. Although rates amongst dental-HCWs have fallen in developed countries, in many low-and middle-income countries, vaccine coverage rates remain low and awareness of postexposure prophylaxis (PEP) is poor [13,14]. e existing evidence base highlights that dental-HCWs appear to be at particularly high risk of NSIs [15][16][17]. is is mainly due to the use of sharp dental instruments often for multiple injections in the mouth where access and visibility can be poor [9,[18][19][20].
It is di cult to accurately estimate the global prevalence of NSIs among dental-HCWs due to the underreporting of incidents which is a signi cant issue in developing countries [21,22]. Iranian studies have shown that, in some settings, over 80% of dental-HCWs fail to report NSIs [23,24]. A national community survey which was carried out in 2007-2008 calculated that the prevalence of hepatitis B surface antigen (HBsAg) and hepatitis C virus in Pakistan were 2.5% and 4.8%, respectively, and estimated that there were approximately 13 million chronic hepatitis B and C carriers in the country [25], but this is now outdated. Taking into consideration the evidence on underreporting of NSIs, this gure could potentially be much higher, indicating dental-HCWs in Pakistan are at a particularly high risk of infection following an NSI. A number of factors for the underreporting of NSIs are presented in the literature and include lack of awareness that NSIs need to be reported [23,24], lack of awareness of where to report [26,27], the belief that there is no point in reporting incidents, and unwillingness to report the incident [26]. e fear of getting blamed was also found to be a common reason among dental students [28].
ere is, however, a dearth of information on the prevalence, risk factors, and reasons for underreporting NSIs among dental-HCWs in Pakistan despite the high NSI prevalence [17]. Synthesizing existing evidence on the prevalence and risk factors of NSIs and the rate and reasons of underreporting of NSIs among dental-HCWs in Pakistan can potentially underline the existing gaps in the available literature and dental practices that may require further consideration.

Aim and Objectives
e aim of this paper is to review the existing literature to determine the prevalence and rate of reporting of NSIs among dental-HCWs in Pakistan.

Selection Criteria.
Inclusion criteria for relevant studies were as follows: (1) Primary research studies published in peer-reviewed journals (2) Studies from Pakistan that sampled dental-HCWs (3) Studies that reported the prevalence and/or reporting rates of NSIs (4) Studies published in English between January 2000 and June 2016

Search Strategy
e search strategy included electronic database search and hand searching up to 30 June 2016. e electronic databases MEDLINE, Google Scholar, Discover, Cochrane Library, CINAHL, BMC, ScienceDirect, Web of Science, and the Directory of Open Access Journals (DOAJ) were searched using the following key words and Boolean operators: (prevalen * OR occur * OR rate * OR frequency * OR report * OR record * ) AND (needle * OR occupation * OR sharp * OR percutaneous) AND (injury * OR trauma * OR wound * ) AND (dental worker * OR dental student * OR dental assistant * OR dentist * OR dental sta ) AND (Pakistan * OR South Asia * OR developing country * ). e titles and abstracts of the papers identi ed were screened against the inclusion and exclusion criteria. Additional papers were identi ed from searching Pakistan-based dental journals not indexed in the databases listed above, a citation search of key authors, and screening the reference lists of the papers which passed the screening test for related articles.

Data Extraction
Relevant data were extracted from the studies based on the "STROBE" framework criteria for cross-sectional studies [29]. Data were extracted and entered on a Microsoft Excel spreadsheet. e data extraction headings were as follows: author(s), year of publication, journal title, article title, study aim and objectives, study design, participants, study location, sampling technique, study size, data collection method, response rate, descriptive data, data analysis, key results, and conclusions.

Quality Appraisal
Following data extraction, the methodological quality and rigour of the included studies were assessed using Boyle's [30] quality assessment framework criteria to evaluate the potential strength of the outcomes. e quality assessment followed a scoring system comprising eight questions, and studies were graded high (7-8 score), moderate (4-6 score), or low (1-3 score) quality based on three main criteria: sampling, measurement, and analysis [30][31][32]. e sampling framework was applied to all selected studies in a consistent fashion, and the minimum response rate in the reviewed studies was set at 80% [30].

Data Analysis
e results were analysed using narrative analysis. A textual approach was used to combine and summarise the ndings from di erent studies and subsequently explain the synthesised ndings [33]. It was selected as it systematically evaluates and incorporates the results from across the studies and explores the similarities and dissimilarities between the study ndings [34]. Since the included studies demonstrated heterogeneity with regard to their evaluation criteria and study results, performing a meta-analysis was not considered appropriate, as it would have yielded potentially insigni cant and misleading results [35]. Furthermore, the data required for performing a meta-analysis were absent in all the reviewed studies [36,37].

Methods of the Review
A review of the abstracts and titles was carried out by all the authors to determine the suitability of the papers and resolve any di erences as to whether to include or exclude papers. Mehak Parveiz extracted the data and assessed quality of the data, and Ruth Gilbert and Nasreen Ali cross-checked the extracted data and quality assessment to ensure data accuracy.

Overall Description of the Included and Excluded
Studies. A total of 713 potentially relevant citations were identi ed by electronic and hand searching. Following initial screening of titles and abstracts, 15 duplicate papers were excluded and 686 studies were excluded based on the prespeci ed inclusion and exclusion criteria. e full-text of the remaining 12 studies was scrutinized to determine their eligibility for inclusion in the review. Of these, three further articles were excluded as they failed to mention the prevalence or reporting rates of NSIs. As a result, nine primary studies met the inclusion criteria and were included in the review ( Figure 1).

Analysis of Included Studies
e nine included studies were conducted in seven di erent Pakistani cities: Karachi [38,39], Hyderabad [17,26], Lahore [40], Jamshoro [41], Quetta [42], Peshawar, and Abbottabad [43,44]. All the studies had an observational, cross-sectional study design, which quantitatively measured the prevalence of NSIs, whereas only four studies [17,26,39,41] measured the reporting rate of NSIs. All included studies were within the review's inclusion criteria as they were Pakistan-based primary studies reporting the prevalence and/or reporting rate of NSIs among dental-HCWs published between 2009 and 2015 in a peer-reviewed journal in English.

Study Sampling.
e study sample sizes ranged from 100 to 800. However, the included studies failed to specify the employed sampling technique, except for Khan et al. [43], which adopted a convenience sampling technique, though no rationale was provided. All studies used questionnaires as their measuring tool.

Study Population.
e gender ratio of the participants was not mentioned in three of the studies [38,43,44]. Nonetheless, in other studies [17, 39-42,], on average 53% of the sample were male and 47% were female, making the ratio roughly equal in all studies except for Jan et al. [26], in which 83% of the study participants were male. Almost all studies included dental-HCWs from di erent job categories including dentists, dental faculty, postgraduates, house ocers, undergraduates, assistants, technicians, and paradental sta . However, one study [44] sampled only dentists.

Age Range of Participants.
Age of the participants was recorded by only three of the included studies. In two of the studies [39,42], the majority of the study participants were between 20 and 30 years, whereas in one study [26], 50 participants were 25-35 years old, 73 were 36-45 years old, and 131 were older than 45 years. Six of the reviewed studies failed to report any information on the age of the participants [17,38,40,41,43,44].

Survey Duration.
e survey duration was stated by ve studies and varied considerably. Survey durations were one month [26], four months [43], nine months [38], and over one year [17,41]. Four of the selected studies failed to take account of their study period [39,40,42,44]. A full summary of the background information, methodological details, and key ndings of the included studies is presented in Table 1.

Data Analysis
ere were signi cant variations in the reporting of data on NSI prevalence, rate of reporting, and risk factors, as well as in the data on knowledge and awareness regarding NSIs and dental practices to prevent NSIs. As a result of which it was challenging to compare data across the studies.

Prevalence of NSIs.
e prevalence of NSIs among Pakistani dental-HCWs ranged from 30% [39,44] to 73% [38] (Table 1). In studies which compared the prevalence rate amongst di erent groups of dental-HCWs, dental undergraduate students generally experienced the highest rates of NSIs (15-60%) [17,39,41], while a lower prevalence of NSIs was observed among the quali ed dentists, including dental surgeons, postgraduates, and house o cers [17,39,41,42] However, there were variations in the ndings; Khan et al. [43] reported almost equal prevalence of NSIs amongst dentists and dental students, while Ikram et al. [38] observed that the majority (42%) of those reporting NSIs were dental house o cers. All studies which included dental assistants and technicians showed that they were the group with the lowest rates of NSIs [17,39,41], except for one study [26] which reported that 51% of dental technicians had experienced an NSI.
Five studies recorded the number of NSIs experienced by each participant (Table 2). Baig et al. [41] and Gichki et al. [42] recorded that most dental-HCWs who had experienced an NSI experienced just one incident (64%). However, Shahzad et al. [17] and Jan et al. [26] recorded that most dental-HCWs had experienced more than one NSI (67% and 88%, resp.). Furthermore, many participants reported having experienced more than two NSIs [17,26,41] with 9% of participants in one study [44] reporting that they experienced more than 10 incidents during their dental career.

Reporting of NSIs.
Only four studies asked participants whether they would report an NSI [17,26,38,41]. Baig et al. [41] recorded the highest underreporting rate (76%); most participants stated that they were unaware of the reporting system. Jan et al. [26] found that 60% of dentists and 92% of dental technicians failed to report injuries. e most common reason for underreporting amongst dentists was the belief that there was no point in reporting incidents (33%), whereas International Journal of Dentistry amongst dental technicians, it was not knowing where the incident should be reported to, or an unwillingness to report as they were practicing illegally (59%). Shahzad et al. [17] found that 15% of NSIs were not reported, usually because those a ected did not know who to report the incident to. Conversely, Malik et al. [39] noted that 28 of the 30 (93%) dental-HCWs who experienced an NSI reported it, thus making it the highest reporting rate observed amongst the included studies.
Only Shahzad et al. [17] investigated which departments had the highest rates of NSIs. e highest prevalence occurred in the oral surgery department (58%), followed by the operative department (18%), while the departments of prosthodontics, orthodontics, and periodontology had the lowest prevalence of NSIs (3% each). ree studies investigated human factors which may have led to NSIs. Each study reported di erent factors. Shahzad et al. [17] reported that working hastily was the most common reason for an NSI (42%), followed by fatigue (20%), lack of skill (14%), not wearing gloves (12%), lack of supervision (5%), and the practice of needle resheathing (5%). Baig et al. [41] reported stress as the most common cause of an NSI (43%), followed by work overload (38%), carelessness (8%), and unskilled handling of the instruments (5%), whereas Gichki et al. [42] recorded that negligence among dental-HCWs was the most likely cause of an NSI (20%).

Knowledge and Awareness regarding NSIs.
Five studies collected information on the awareness of measures to prevent NSIs among dental-HCWs [17,[38][39][40]42]. Ikram et al. [38] found that 82% of dental-HCWs had received training regarding the risk of blood-borne infections; 54% felt that training and education were important measures in preventing NSI, and 41% felt that outpatient departments (OPDs) needed to develop speci c protocols to protect workers. 3 studies did not include NSI prevalence or reporting rate   Also, the knowledge and attitude towards universal precautions. 53% (135) of the 254 participants (quali ed dentists and dental technicians) had experienced at least one NSI in the preceding 12 months. Among dentists, 54% experienced at least one NSI; 35% experienced two; and 11% experienced more than two NSIs. Among dental technicians, 51% experienced at least one NSI; 28% experience two; and 21% more than two. In ltration anaesthesia was the most common procedure causing NSIs (44.4% among dentists and 42% among dental technicians). 59.6% of dentists did not report their NSI; the most common reason given was lack of belief in the reporting system (33.1%), whereas 92% of dental technicians did not report their NSI; the most common reason given was not knowing where to report or did not want to report (59.1%). Dentists (62.6%) had more knowledge about the safety guidelines than dental technicians (8%) and also had a better vaccination coverage (81.3%) than dental technicians (10.2%). e majority of them washed and covered it after allowing it to bleed (85%). Most of the participants also took the patient's medical history (79%) and screened the patient (65%). 65% of dental workers practiced safe disposal, whereas 84% practiced needle resheathing after administering injection, in which onehanded technique was the most common (49%).

Low
International Journal of Dentistry Malik et al. [39] reported good knowledge among dental-HCWs regarding wearing gloves (97%) and universal precautions (74%); however, 88% of participants reported that needles should be recapped or bent needles after use, and only 53% were aware of needle-less safety devices. Ashfaq et al. [40] also found that many dental workers reported they were aware of precautionary measures which could prevent NSIs and transmission of infection (85%). However, Ikram et al. [38] found that only 39% of participants agreed that using surgical gloves would reduce the risk of NSIs, and less than 5% of participants agreed that needles should not be recapped after use. When questioned about strategies to prevent NSIs, only 38% of participants suggested that needles should not be resheathed, 34% suggested that needle approximation should be done carefully, and 27% suggested using sharps containers.
Knowledge and awareness also varied between di erent groups of dental-HCWs. Jan et al. [26] found 63% of dentists, but only 8% of dental technicians were aware of measures which could be taken to reduce the risk of NSIs, while Gichki et al. [42] found that 76% of house o cers and 63% of students were aware needles should not be recapped. Malik et al. [39] found that 98% of dental-HCWs were aware hepatitis B could be transmitted during an NSI, while only 84% were aware HCV and HIV could be transmitted in this way. Similarly, although Gichki et al. [42] reported that 98% of dental-HCWs were aware blood-borne viruses could be transmitted during an NSI, only 13% were aware that HIV could be transmitted during an NSI.

Dental Practices to Prevent NSIs.
Dental practices used to prevent NSIs were also reviewed. One of the main precautions used to prevent an NSI was wearing of gloves; however, there was a wide variation in the proportion of dental-HCWs who reported wearing gloves. Malik et al. [39] found that over 90% of dental-HCWs reported wearing gloves during phlebotomy, while withdrawing a needle from a patient, disposing of the contaminated needle, and when manipulating the sharps bin. Gichki et al. [42] found that 73% of dental-HCWs wore gloves; however, practice varied between students and quali ed dental-HCWs (69% of students and 83% of house o cers). Similarly, Khan et al. [43] recorded variation in practice between di erent groups of dental-HCWs (68% of all dental-HCWs wore gloves, 86% of students, and 44% of quali ed dentists). Khan et al. [43] also reported that 79% of respondents would change their gloves if they became dirty during a procedure. Some studies noted that other personal protective equipment was used. Mehboob et al. [44] found that 86% of dental-HCWs used masks and gloves as precautionary measures, but only 9% of dentists used all the recommended universal precautions during dental treatment. Meanwhile, Khan et al. [43] found that 10% of dental-HCWs wore goggles and 90% wore facemasks.
Several studies identi ed safe disposal of needles as playing an essential role in preventing NSIs. Khan et al. [43] noted that 65% of dental-HCWs reported they disposed of needles safely (60% of quali ed dental-HCWs and 68% of students); however, only 16% (23% of quali ed dental-HCWs and 11% of students) avoided resheathing needles after injecting local anaesthetic. Similarly, Malik et al. [39] found that only 12% of dental-HCWs avoided recapping needles after use, and approximately a third (36%) avoided separating the needle and syringe before disposal. By contrast, the more recent study by Gichki et al. [40] found that 67% of dental-HCWs did not recap needles after use (63% students and 76% house o cers).

Discussion
Nine studies were identi ed which reported data on the prevalence and reporting rates of NSIs amongst dental-HCWs in Pakistan. In each study, the prevalence of NSIs among dental-HCWs in Pakistan was found to be high, ranging from 30% [39] to 73% [38]. e ndings were consistent with previous studies from other low-and middle-income countries, including ailand, Colombia, Saudi Arabia, Iran, Romania, Nigeria, Jordan, and China [13,22,[45][46][47][48][49][50]. ey also con rmed that dental-HCWs in Pakistan were more likely to experience an NSI than dental-HCWs in developed countries. Only 14% of dentists in Scotland reported that they had experienced an NSI [51], while in UAE, Taiwan, and Australia, approximately 25% of dental-HCWs reported that they had experienced an NSI [10,52,53].
From the review, it was evident that many dental-HCWs in Pakistan experience multiple NSIs. Although Baig et al. [41] and Gichki et al. [42] found that most dental-HCWs who had experienced an NSI experienced just one incident (64%), indicating that the incident led to a change in practice; in other studies, many dental-HCWs reported that they had experienced multiple injuries. Consequently, NSIs represent a serious health and safety concern for dental-HCWs. Similarly, other studies conducted in low-and middle-income countries have concluded that over half of dental-HCWs have  [17] 89 (33%) 179 (67%) 121 (45%) NA NA been exposed to more than one NSI [22,23,54]. Furthermore, Jan et al. [26] reported that participants had experienced multiple NSIs in the preceding 12 months, indicating that NSIs remain an ongoing, contemporary risk to dental-HCWs. ese ndings highlight the need to investigate di erences in policies and working practices to identify how rates of NSIs can be e ectively reduced in Pakistan and other countries with high rates of injury. Experience appears to be one of a number of factors which play an important role in reducing rates of NSIs. Dental undergraduate students appeared to be more likely to experience an NSI than experienced, quali ed dentists. Similarly, the youngest dental-HCWs with the least experience were found to encounter more NSIs than older practitioners with more years of experience [41]. Presumably, this is in part due to a lack of experience when starting clinical practice; however, the heavy clinical load allocated during dental training was also reported to be a reason behind the high rates of NSI among dental students [17]. Dental assistants and technicians reported the lowest rate of NSIs, possibly due to having been in practice longer and having more experience than the other groups of dental-HCWs [17,39,41]. However, data from this group were limited, and consequently, it is di cult to draw rm conclusions. ese ndings were consistent with studies from many other countries, which also reported that dental students were the group most likely to experience an NSI due to their limited experience, skills, and frequent use of sharp instruments [4,19,54,55]. Interestingly, in some settings, experienced or older dental-HCWs were found to be more likely to experience NSIs; in these cases, workload was cited as a key risk factor [52,56,57]. Consequently, limited clinical skills, knowledge and experience, and workload all appear to increase the risk of NSIs for dental-HCWs. e evidence highlights the need to review the clinical workload of all dental-HCWs, to prevent work overload, stress, and fatigue, as well as the provision of adequate training and mentoring to reduce the risk of NSIs.
However, data on NSI prevalence are limited in Pakistan, and more robust surveillance data would help to support e ective policy development. ese studies con rmed that although most NSIs are o cially reported in some settings [39,42], underreporting of NSIs is an ongoing problem in Pakistan with over 75% of NSIs not being reported in some settings [41]. e problem appears to stem from many dental-HCWs being unaware of the reporting system and failing to understand the importance of reporting incidents [17,41]. Furthermore, some groups of dental-HCWs, such as dental technicians, appear to be particularly reluctant to report NSIs [26]. Poor surveillance of NSIs appears to be a widespread issue. Reporting rates in Pakistan were broadly in-line with rates in other low-and middle-income nations. Studies have shown that more than half of dental-HCWs failed to report their NSIs in Saudi Arabia, Kenya, and India [22,23,57] and more than three-quarters of dental-HCWs failed to report NSIs in China, North Jordan, and Iran [22,23,57]. Furthermore, in Nigeria, a study from one dental setting found that none of the dental students reported NSIs [27]. Similarly, reasons for underreporting of NSIs included fear of the consequences of infection, stigmatisation and blame, lack of awareness of the need to report NSIs, and not knowing how or where to report an NSI [23,24,27]. ese ndings highlight a widespread lack of awareness regarding reporting NSIs and indicate the need for further training and guidance to improve reporting rates and strengthen reporting systems. e included studies also provided insight into which working practices were most likely to result in an NSI. e results revealed that needle recapping or resheathing was the procedure responsible for the greatest number of NSIs [40,41]. Furthermore, bending a needle prior to disposing it also appeared to be a risk-prone procedure [39]. Similar ndings have been reported from other low-and middle-income countries including Iran, India, and China [28,49,57]. Despite WHO [50] recommendations that all HCWs should avoid recapping needles or bending, breaking, or manually removing needles before disposal, the majority of dentists in some settings still report resheathing needles [38,43]. Consequently, to e ectively reduce the risk of NSIs, it is essential that working policies and practices are updated to encompass the latest best practice. However, even if policies and protocols are based on best practice guidance, many factors will a ect rates of compliance. An individual's practice can be determined by the behavioural theory of health-belief model [58]. Analysis showed that in some settings, a high proportion of dental-HCWs was aware of good practice, such as wearing gloves, safe needle practice, and improved engineering-controlled devices [39,40,[42][43][44], whereas it was found to be low in other settings [38]. Likewise, perception of the risk of transmission of infection was found to vary considerably between settings [39,42], as were hepatitis B vaccine coverage rates [17,26,38,[40][41][42]44] and understanding of PEP [38,41,42]. Consequently, practice and perceived susceptibility which potentially in uences decisions to observe precautions was found to be variable between settings. e high prevalence of NSIs, particularly among dental students, indicates a crucial need for dental-HCWs to understand the risk of NSI-associated infections, in order for them to appreciate the importance of complying with the universal precautions and other safe working procedures. us, it is essential that education on NSI risks and prevention strategies is included early in the dental course curriculum and repeated regularly as part of ongoing continual professional development (CPD). e review also highlighted that hepatitis B vaccine coverage was extremely variable both between settings and di erent groups of dental-HCWs. erefore, measures should be put in place to ensure that all dental-HCWs have access to a ordable hepatitis B immunisation and good coverage rates are achieved amongst all groups of dental professionals. However, since there are no e ective vaccines available to protect against HCV and HIV infection, and their treatment is neither a ordable nor available in many countries, it is essential that dental-HCWs continue to be aware of the importance of developing good practice to avoid NSIs.
To the best of the authors' knowledge, this is the rst systematic review of its kind to highlight the issue of NSIs in dental-HCWs in Pakistan. In absence of the routine collection of accurate data on NSIs, small studies have been useful in highlighting which groups of dental-HCWs are most at risk from NSIs. A major limitation of this systematic review was the low quality of the reviewed studies, thus raising serious quality concerns for the review, which impacts the reliability, credibility, and applicability of the overall results, and consequently the drawn conclusion and recommendations of the review [36]. However, the quality assessment outcome recommends the need for further goodquality studies with robust methodology to increase the transparency, validity, and generalisation of the research outcomes and also highlights gaps in the present literature. Despite these limitations, it can be concluded that a high prevalence of NSIs and low rates of reporting, as well as a lack of awareness of the risks of NSIs, persist in many settings within Pakistan.

Conclusion
Reviews of the selected studies suggest that the prevalence of NSIs among dental-HCWs in Pakistan is high while reporting rates are low, suggesting the urgent need to develop educational programmes for all dental-HCWs on the importance of preventing and reporting NSIs. It also indicates the necessity for all dental-HCWs to be able to access a proper occupational health department in all dental settings, to prevent, manage, record, and monitor occupational injuries. ere is an urgent need for the development of national guidance protocols to prevent NSIs in Pakistan. Improving health literacy around the risks of NSIs should be accompanied by improving measures to report NSIs. ese should incorporate examples of good practice from countries where rates of NSIs have successfully been reduced. However, it is important to note that recommendations for new interventions should take an ecological approach and should be cost-e ective for the dental settings since this is crucial for their successful and sustainable application.