INTRODUCTION

Healthcare workers (HCWs) are at a risk of exposure to blood and other body fluids that can transmit various bloodborne pathogens (BBPs) like human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV).[1] Cutaneous and mucocutaneus exposure to blood can occur through various incidents such as injury by contaminated sharp instruments or as a result of splash of blood or other body fluids into eyes, nose, or mouth.[1] Non-sterile injections, accidental needle sticks, and improper recycling of needles and syringes can transmit BBPs.[2] Needle stick injuries (NSIs) can cost a lot for diagnostic tests, prophylaxis that is about $118 to $591 million in the United States, annually, excluding the costs from possible infection by BBPs.[3]

According to the Center for Disease Control and Prevention data, approximately 385,000 needle and sharps-related injuries occur annually in the United States hospitals[1] and, 236,000 of these, result from hollow-bore needles.[4] In 2003, Exposure Prevention Information network estimated the rate of NSIs in teaching hospitals about 27 per 100 beds.[4] The World Health Report 2002 estimated that 2.5% (1000 cases) of HIV and 40% of HBV and HCV (6000 and 16000, respectively) among HCWs occurred as a result of occupational exposures annually. Although a lot of studies have evaluated prevalence or incidence of NSIs and sharp injuries or mucous membrane exposure to blood or body fluids among health care workers, a little data has come out of developing countries. In a study by Chakravarthy et al. in 2010 in India, 243 sharp injuries and 22 non-sharp blood or body fluid contamination happened during 50 months of their study.[5] In a study by Ilhan et al., in 2006, 79.7% of Turkish nurses experienced a NSI or sharp injury (SI) during their work.[6] Musharrafieh et al., in 2008 revealed that 1,590 Lebanese HCWs reported accidental exposure to bloodborne fluid to the Infection Control Office through 17 years.[7] Some causes of high incidence rate are lack of sufficient supervision and inadequate preventive measures and education.[8] Despite the high incidence rate of the injuries, it might be still higher because underreporting leads to serious underestimation of the actual incidence of occupational BBPs transmission.[9]

Reduction in BBPs exposure is possible with the use of double gloves, eye protection, hepatitis B vaccination, and use of different needle protection devices.[10] As in other developing countries, preventive measures such as safe needles are not available in Iran,[11] but some common factors, e.g., recapping, collection, and proper disposal of sharp wastes can be modified with training.[1]

There are some mandatory college courses on the hazards of exposure to BBPs for health care professionals in Iran. As a routine and repetitive everyday work, they will lose some of their information and safety attitudes after employment; therefore, the knowledge of HCWs about NSI hazards is insufficient and they have a careless attitude in clinical practice.[12, 13, 14] Although some studies in developed and developing countries have shown that education can effectively reduce the incidence of NSIs/SIs among HCWs,[11, 15, 16] unfortunately we have very limited data in Iran.

In this interventional study, we intended to evaluate the effects of training course on the rate of NSIs and its reporting and design a better system to supervise HCWs and a more powerful communication between training system and health employees, after assessing the relevant modifications.

METHODS

Study population

Hospital A and B had 431 and 1025 HCWs, respectively, including doctors, nurses, nurse-aids, surgery technicians, clinical laboratory workers, and housekeeping staffs [Table 1]. In hospital A, we invited all employees potentially exposed to BBPs to participate in our educational courses. Almost all invited health care workers, except physicians and clinical laboratory workers, accepted to participate.

Table 1. Comparison of demographic and work related factors between two hospitals

RESULTS

Through self-reporting surveillance system, in hospital A, 121 of 431 (28.1%) NSIs were reported by the HCWs from January 2009 to December 2011 and reported cases in hospital B during the same period were 181 of 1025 (17.6%). Table 1 shows some demographic and work related variables for HCWs in two hospitals. HCWs in two hospitals were different in mean of working years, gender, job and education; the difference of mean in age was not statistically significant. Mean age and experience were 33.5, 6.14 and 38, 8/43 years in hospital A and B, respectively.

Some demographic and work related variables for injured employees in two hospitals are indicated in Table 2. Differences between mean of age and working years between two groups were statistically significant. Gender, job title, education, and history of HBV vaccination were different between the two groups. Mean age and experience were 30.9, 4 and 34, 6.9 years in hospital A and B, respectively. In both hospitals, the highest number of injuries was reported among nurses [Table 2]; disposable syringes were responsible for 78.5% of NSIs; the highest number of NSIs occurred in “patient room” and “emergency department,” respectively [Table 3].

Table 2. Needle sticks injuries among health care workers from 2009-2011 in hospitals A and B

Table 3. Frequency of NSI according to device types and hospital sections

During the study, 291 out of 431 HCWs (67.5%) in hospital A participated in the training course, including 159 nurses (72.6%), 47 nursing aids (92.2%), 13 midwives (76.5%), 59 housekeeping staffs (86.6%), and 13 surgery technicians (76.5%). Unfortunately, doctors and clinical laboratory workers did not accept our invitation. Data analysis of NSIs before intervention showed that the highest number of incidents was reported during recapping 49.3%, and, after our intervention, it reduced to 17.3%. The use of personal protective devices was 30.4% before intervention and it increased to 80.8% afterward (P < 0.001; OR = 9.61) [Figure 1].

[Figure ID: F1] Figure 1. Use of protective device among health care workers before and after intervention in hospital A

When we compared the rates of NSI during pre-intervention and post-intervention periods in hospital A, we found an increase in NSIs/100FTE/year. On the other hand, in hospital B (no intervention), these rates remained unchanged [Table 4].

Table 4. Number of NSI per 100 full-time HCWs per year

DISCUSSION

Preliminary investigations showed that HCWs are at a high risk for bloodborne infections. Among full-time employees in hospital A, the incidence of NSIS was 9.35/100 _FTE/year through 3 years of our study. A similar study in 2002 by R. Michael Whitby in Australia revealed the incidence rate of 8.79 NSI/100 _FTE/year among HCWs.[17] Another study in Australia reported the overall incidence rate of 6.1 NSI/100 _FTE/year for all HCWs, with 9.4 NSI/100 _FTE/year for the nursing staff.[18] Rate of 7.16 NSI/100 _FTE/year was reported in hospital A before the interventions, which increased to 12.06 NSI/100 _FTE/year after the intervention. Our results were in contrary with some other similar studies. In a study by Zafar et al., a statistically significant reduction in the rate of NSIs occurred after intervention, with the greatest reduction in affected nurses from 13 to 5 NSI/100 _FTE/year.[1] Another multi-focused interventional study (administrative, work practice, and engineering controls), by Gershon et al., revealed diminished incidence rate during 9 years (1990-1998).[19] During the same period, the incidence rate of NSIs in hospital B showed trivial change (from 5.36 to 5.79 NSI/100 _FTE/year), which was predictable regarding lack of intervention in this hospital. This unchanged rate in hospital B makes the increased rate in the hospital A more remarkable.

As a matter of fact, the unexpected increase in NSIs in our study is a result of a noticeable increase in reported cases and not a net increase in NSIs itself. Case reporting increased because of the following reasons:

• Before the education course, there was no center to record NSIs cases
• Most HCWs did not have enough information about post exposure prophylaxis policy
• Some HCWs did not consider NSIs as a serious potential danger
• Some HCWs assumed hepatitis B as the only necessary prophylaxis so they considered themselves as a protected person.

During the educational course, HCW's awareness about NSIs increased and their attitude changed.

Response rate in our study was 67.5%. The response rate of 89.7% in a study by Singra et al., was achieved.[20] In spite of all our efforts to encourage HCWs to participate in the course, the response rate was not satisfactory mostly due to two factors:

• High workload of some groups of HCWs (72.6% of nurses and 76.5% of midwives attended the course)
• Clinical laboratories and physicians refusal to participate. The reason for this refusal may be the concept of having sufficient information about NSIs, prevention methods, required post exposure accommodations by physicians, in addition to their lack of awareness about the meticulous control and follow-up of the NSIs cases by the occupational health center.

Physicians reported only one NSI during 3 year in hospital A, showing low report of physicians. The highest number of incidents (66.1% in hospital A and 35.4% in hospital B) was reported among nurses. This high occurrence was the case in another study by Singra et al., in 2008.[20] Despite high NSIs risk and report among nurses, we believe that this can be much higher in reality. In 2011, Azadi et al., stated that underreporting in nurses is a major concern. In their study, two main causes of underreporting in nurses were dissatisfaction with follow-up investigations and safe/low risk considering of the source patient.[21]

These factors played the same role in our study.

In this study, injured HCWs in both hospitals were younger and less experienced staff. A study by Cho et al., in South Korea had similar result;[22] another study in Taiwan by Wu et al., mentioned that less experienced HCWs had more injuries.[23] But two studies in Iran, by Galougah in 2010 and Askarian et al., in 2008 did not show any relation between ages, experience, and NSIs.[24, 25] As personal protection can play an important role in prevention of BBPs,[14, 26, 27] it was included in our educational program. The use of safety equipment showed an increased from 30.4% to 80.8% after the course, which displays positive impact of training and enhanced staff awareness. Although this was a great success, there is still a lot of work to do in this field.

In our study, 35.5% damages occurred after “Recapping” and 33.1% were during use and disposal of devices. In a study in Pakistan, “Waste Disposal” and “Recapping” accounted for 24-33% of NSIs[1] that is lower than in our study. An important way to reduce “NSI” is using “Safety Devices” and designing “Safer Products.” Unfortunately, due to high cost of these materials, their use is limited in some developing countries such as Iran.

This study had the following limitations:

Only one hospital was included in our study because of legal and administrative problems.

• Under-reporting, especially among physicians, which is an important issue and requires further investigation
• Limited interval between completion of the education course and gathering the last information about the results; extending the time of the study might result in diminishing the rate of NSI cases because of better prevention after the first period of higher reported cases as mentioned above
• Existence of a retrospective fraction resulting in drawbacks to provide accurate information.

Despite the limitations, this was the first interventional study with sufficient population to examine the effects of surveillance and an organized training program on the rates of incidence of “NSIs” in Iran.