Needle Stick Injuries among Health Care Workers of Alexandria University Hospitals

Background: Needle stick injury has been recognized as one of the occupational hazards which results in transmission of blood borne pathogens. As there was limited data on the national level about these injuries determinants of such injuries are important to investigate and to design effective prevention programs. Objective: The purpose of this study was to investigate the prevalence and circumstances of needle stick injuries among heath care personnel working at Alexandria University hospitals. Effectiveness of the existing control measures and practice of standard precautions were also assessed. Methods: A cross-sectional survey was carried out among 913 health care workers (HCW) in different clinical departments of the three teaching hospitals from January to December 2007. Data were obtained by an anonymous, self-reporting questionnaire. Health Belief Model (HBM) was used to explain standard precautions practice. Multiple linear regression was performed to predict factors associated with the practice of standard precautions. Results: Of the recruited participants, 70.6% (645/913) had completed the questionnaires. Nurses had the highest response rate (92.5%). More than two thirds (68.0%, n=438) of participating HCWs had sustained at least one needle stick injury in the last 12 months. Risk of (Needle Stick Injuries (NSIs) was significantly associated with younger age of the participants and fewer years of work experience. More specifically, of all occupational groups, nurses have the highest risk to experience needle stick injuries (62.3%). Disposable syringes accounted for 38.4% of injuries. Most needle stick injuries (36.5%) occurred at the patient's ward. Evaluating the kind of activity under which the needle stick injury occurred, on average 36.0% of injuries occurred during recapping of a needle especially if this practice was handily done. High risk patients (one with a history of infection with HIV, hepatitis B, hepatitis C, or injection drug use) were involved in 8.2% of injuries. The majority of NSIs (73.1%) occurred at end of the shift. Most health care workers (77.4%) were mentally distressed during their injury. Factors increase possibility of infection transmission were the procedure involving a needle placed directly in patient’s vein or artery, exposure to a source patient who had evidence of blood borne infection, low immune status of the HCW (i.e., no vaccination with HBV), deep injury, and lack use of personal protective equipment. A total of 327 respondents (74.7%) did not report the injury to an employee health service. Lack knowledge of appropriate procedure after injury was the most common cited reason for not reporting the injury. The survey revealed that use of preventive measures was inadequate. Only 10.0% of all participant workers knew new needless safety devices. The significant protective factors that decreased the frequency of needle stick injuries were using devices with safety features (OR=0.41), satisfactory adherence of a health care worker to infection control guidelines (OR=0.42), having training in injection safety and appropriate work practices (OR=0.14), comfortable room temperature during injection (OR=0.32), and availability of written protocol for prompt reporting of such injuries (OR=0.37). The mean standard precautions practice percent score for the health care workers was 46.32%. In multiple linear regression model, knowledge score of infection transmission (adjβ: 0.18) and the work experience (adjβ: 0.06) were the only significant predictors of standard precautions 127 Bull High Inst Public Health Vol.38 No.1 [2008] score. Conclusion: There is a high rate of needlestick injuries in the daily routine of Alexandria teaching hospitals with subsequent risk of infection transmission. Greater collaborative efforts are needed to prevent needlestick injuries. Such efforts are best accomplished through a comprehensive program that addresses all circumstances that contribute to the occurrence of needlestick injuries in health care workers. Critical to this effort is the elimination of needle use where safe and effective alternatives are available and the continuing development, evaluation, and use of needle devices with safety features. All such approaches must include serious initial and ongoing training efforts. INTRODUCTION Workplace safety is a very important aspect of occupational health practice in many countries. In industrialized and developing countries alike, there is legislation on safety and health at work with recognized codes of practice. Among health care workers (HCWs), HIV, hepatitis B and C, and cytomegalovirus are recognized occupational health infections of special importance[1,2]. According to a World Health Organization estimate, in year 2002, needle stick injuries resulted in 16,000 hepatitis C virus (HCV), 66,000 hepatitis B virus (HBV) and 1000 human immunodeficiency virus (HIV) infections in health-care workers worldwide[3]. Previously in 1998, the Centers for Disease Control and Prevention (CDCP) estimated that approximately 800,000 US HCWs were injured by patient needles; and about 2000 of those workers were tested positive for infections of hepatitis C, 400 had got hepatitis B, and 35 contracted HIV[4]. Despite of the prevalence of these injuries varies from 0.11 up to 11.05 per 100 workers in Swiss hospitals[5]; there was no clear figure of occurrence of these injuries in Alexandria teaching hospitals. In Egypt, like most of the developing countries, very few efforts have been undertaken to raise awareness of the health-care workers and hospital managers. Concrete knowledge on the transmission of blood-borne diseases in health-care facilities is very limited. Unsafe practices are very common. Additionally, there is a lack of regulation and policy to protect health workers from exposure[6].


INTRODUCTION
Workplace safety is a very important aspect of occupational health practice in many countries.In industrialized and developing countries alike, there is legislation on safety and health at work with recognized codes of practice.Among health care workers (HCWs), HIV, hepatitis B and C, and cytomegalovirus are recognized occupational health infections of special importance [1,2] .
According to a World Health Organization estimate, in year 2002, needle stick injuries resulted in 16,000 hepatitis C virus (HCV), 66,000 hepatitis B virus (HBV) and 1000 human immunodeficiency virus (HIV) infections in health-care workers worldwide [3] .
Previously in 1998, the Centers for Disease Control and Prevention (CDCP) estimated that approximately 800,000 US HCWs were injured by patient needles; and about 2000 of those workers were tested positive for infections of hepatitis C, 400 had got hepatitis B, and 35 contracted HIV [4] .
Despite of the prevalence of these injuries varies from 0.11 up to 11.05 per 100 workers in Swiss hospitals [5] ; there was no clear figure of occurrence of these injuries in Alexandria teaching hospitals.
In Egypt, like most of the developing countries, very few efforts have been undertaken to raise awareness of the health-care workers and hospital managers.Concrete knowledge on the transmission of blood-borne diseases in health-care facilities is very limited.Unsafe practices are very common.Additionally, there is a lack of regulation and policy to protect health workers from exposure [6] .and have a high likelihood of being adopted [7] .
Recapping, disassembly, and inappropriate disposal increase risk of NSI [7] .In developing countries, the frequency of these factors gets accentuated with high injection use at health care facilities, most of which are provided with previously used syringes [8] .Injection use is very common in Alexandria teaching hospitals.More than 30% of these injections are provided with previously used syringes.Prevalence of HBV and HCV in Egypt is high and unsafe injections transmit most of these infections.
Hence, risk of NSI and associated infections is higher in Egypt as compared to those countries that have a low prevalence of HBV and HCV [9] .Timely reporting of occupational exposures to an employee health service is required to ensure appropriate counseling, facilitate prophylaxis or early treatment, and establish legal prerequisites for workers' compensation.Failure to report exposures precludes interventions that could benefit the injured party, placing health care workers at unnecessary risk [10] .

Occupational Safety and Health
Administration (OSHA) regulations aim at decreasing occupational exposures through use of personal protective equipment, work practice controls and education and training [11] .Moreover, The prove to be more effective at reducing the risk of NSI occurrence [12] .

AIM OF THE WORK:
Since

Study design
A cross-sectional survey was conducted during January through December 2007.

Study population & setting
The study population included health care personnel working at three Alexandria

Sample size
Health care in the three teaching hospitals is provided by 6087 workers (Statistical Administrative Records of University Hospitals, 2007).The total number of health care workers to be selected was estimated using the following equation: n= (Z 2 X p X q) / D 2 .Since the actual prevalence of the condition under the study is unknown, the probability of its occurrence was estimated to be equal to that of its non-occurrence (p = q = 0.50) and a value of 0.20 was chosen as the Health Belief Model (HBM) was used in the questionnaire [13] .In HBM, knowledge influences perception about disease susceptibility and disease severity.Both of these determine perceived disease threat which, in turn, influences behavior.
Behavior is also determined by perceived self efficacy (confidence in one's ability to perform certain activity), cues to action and barriers and benefits (Figure 1).

Prevalence of NSIs
More than two-thirds (68.0%, n=438) of participant HCWs had sustained at least one needlestick injury in the last 12 months.For the workers who reported that they had NSI, 33.0% had one, 18.0% had two, 12.0% had three, and 5.0% had more than three NSIs (Figure 2).3).

Self-reporting effectiveness of existing control measures
.Lower prevalence of needle stick injuries among Malaysian health care workers in two teaching hospitals were reported to be 31.6%and 52.9%, respectively [14] .
Data from injection safety surveys conducted by the WHO and others show on average: four NSIs per worker per year in the African, Eastern Mediterranean, and Asian populations [8] .In Vietnam, 38% of physicians and 66% of nurses reported sustaining a sharp stick injury in the previous nine months [15] .In South Africa, 91% of junior doctors reported sustaining a needlestick injury in the previous 12 months, and 55% of these injuries came from source patients who were HIVpositive [16] .
The Overall, the epidemiological patterns of reported NSI were consistent with other authors' reviews [17][18][19] .Physicians mostly do not provide injections as nurses do and hence their risk of injury exposure is lower.
The housekeepers clean and collect waste without protective equipment and hence are at the high risk of injury exposure.
Concerning device-specific needlestick injury, syringe needles, were associated with 38.4% of all NSI experienced by studied HCWs.This finding was consistent with data presented by Ippolito et al.
1997 [20] , where hollow-bore needles accounted for 38.5% of percutaneous injuries.Some prevention strategies need to be developed, including important and cost effective behavioral changes in HCWs.Implementing engineering control, for example, by providing safer needle devices to all HCWs has constantly been suggested (Sohn, 2004) [21] .It has also been suggested that implementing sharps containers at desirable spots will shorten the distance that a used needle being held has to travel (Shiao, 1997) [22] .
More NSIs occurred at geographic locations that were, surprisingly, less intensive such as patient rooms than more intensive in activity.This phenomenon may be associated with HCWs who, perhaps, were being more cautious while working in higher intensive units where highly invasive procedures are performed.Alternatively, this result may be associated with a workload related phenomenon where the HCW to patient ratio may be higher in more intensive units than in a low intensive unit.
So that clinical manipulations may be performed with more staff and hence a more controlled environment.While HCWs in the less intensive units may have responsibilities for more patients which may then cause staff to rush [23] .
In contrary to finding of the present work, 38% of percutaneous injuries among Taiwan HCWs occur during use, when a needle being manipulated in a patient becomes accidentally dislodged [24] .

Recapping of needles was prevalent in
Alexandria HCWs.This survey revealed that 36.0% of injuries occurred while recapping a used needle.Inspite that recapping was prohibited by the Occupation Safety and Health Administration (OSHA); it continues to be an identified cause of injury [25] .
Of the blood borne pathogens, HBV is 1983 [27] .Fortunately, not all needle stick injuries result in exposure to an infectious disease, and of those that do, the majority do not result in the transmission of infection.Nevertheless, needle stick injuries may expose workers to blood borne pathogens such as human immunodeficiency virus (HIV), hepatitis B virus, and/or hepatitis C virus [28] .percutaneous injury have found that the incidence of anti-HCV sero-conversion averages 1.8% (range 0%-7%) per injury [29] .A data combined from more than 20 prospective studies worldwide of health care workers exposed to HIV infected blood through percutaneous injury revealed an average transmission rate of 0.3% per injury [30] .
Understanding of all injuries go unreported [31] .
The present study identified common reasons for non-reporting of needle stick injuries that warrant attention.In the absence of access to post-exposure prophylaxis, there is little perceived benefit with HCV RNA can identify HCV infection at an early stage, during which treatment is highly effective in preventing chronicity.
Furthermore, reporting of needle stick injuries may be required to establish the causal relationship of the exposure and subsequent complications (e.g., chronic infection or inability to practice medicine).Although legal requirements vary, failure to report an occupational exposure may lead to the denial of subsequent claims [32] .
Health workers in the present study were to safety climate [32] .
Certain working conditions increase the risk of needle stick injury.Those were staff reductions where health care workers assume additional duties or are rushed; difficult patient care situations; and working at night with reduced lighting [34] .However, the present work found that these factors conditions had no effect on the occurrence of NSIs. Standard

Hanafi
et al., 128 Most of the time, health care workers never receive training in infection control and standard precautions although such trainings and practices are low cost solution to reducing risk of sharp injuries information is limited regarding the prevalence of needle stick injuries, the circumstances surrounding them, and the barriers to reporting them.This study was conducted to investigate the prevalence and context of needle stick injuries and behavior associated with the reporting of injuries among health care workers.An assessment of knowledge about risk perception and practice of standard precautions was also conducted.This assessment will provide essential baseline data for developing and testing low cost training interventions in standard precautions.
present study provided descriptive epidemiological evidence of how such injuries occur, including under what circumstances, with what devices and during what types of procedures.The picture that emerges reflects a continuum of risk opportunities throughout the lifecycle of the device use involving interactions among patients, workers, devices, and the environment.
have not made the provision of HBV vaccination a requirement of employment at a health care facility.Just less than a fifth, 18.9%, of staff surveyed reported to be either unprotected or be unaware of their serological status.This means that those health care facilities surveyed have allowed this proportion of staff to remain a risk to themselves or to their patient population.A vaccination program for staff, including clinical and non-clinical has been recommended by the Centers for Disease Control (CDC) since to reporting occupational exposures, especially when reporting can result in punishment, blame, or job loss.When onsite evaluation and treatment is not available, workers may not be able to receive antiretroviral medication, if needed, on a timely basis.In addition health workers commonly minimize the risk of the exposure.Barriers to reporting should be appropriately identified and eliminated in order to ensure appropriate care and treatment of health workers to prevent infection as a result of exposure.Reporting the injury to an employee health service enables counseling regarding the risk of exposure and prevention of secondary transmission, including possible transmission to patients, and may alleviate associated anxiety.It also allows medical evaluation, including testing and, if warranted, antiretroviral therapy or administration of the HBV vaccine containing hepatitis B immune globulin.Antiretroviral therapy administered within 24 to 36 hours after exposure has been associated with an 81% reduction in HIV infection.Although no post-exposure prophylaxis is available for HCV, testing Bull High Inst Public Health Vol.38 No.1 [2008] not educated in occupational blood borne hazards as indicated by low percent score of infection transmission following needle stick injuries.Accurate information about the risk of blood borne transmission from occupational exposure to needle sticks is necessary and should include information about the most effective measures to control exposure and infection.This study assessed the effectiveness of existing control measures.The survey revealed that use of preventive measures was inadequate.Although an increasing number and variety of needle devices with safety features are now available.Only 10.0% of workers knew about new needleless safety devices.In accordance to finding of the present research, needleless or protected needle IV systems have decreased the incidence of needle-stick injuries by 62%-88%.Health care worker can help the employer in the selection and evaluation of such devices [33] .A satisfactory adherence of HCWs to infection control guidelines was a protective factor to prevent NSIs.Noncompliance to a safe work practice is determined by a range of factors including lack of knowledge, interference with work skills, risk perception, conflict of interest, not wanting to offend patients, lack of equipment, and time, uncomfortable personal protective equipment, inconvenience, work stress, and perceiving a weak organizational commitment

1Figure 2 :
Figure 2: Prevalence of needle stick injuries (NSIs) among health care workers (n=645) in teaching hospitals of Alexandria No NSIs 32%

Table 2
shows that health care workers aged forty years and more (16.4% for age group 40-<50 years, and 11.6% for the age group 50-60 years) and those with 5 years of work experience or more (26.1%)were

Figure1: Health Belief Model constructs used in questionnaire for study of needle stick injuries among health care workers in Alexandria teaching hospitals TABLE 1: JOB CATEGORY BY RESPONSE RATE, GENDER, AND AGE OF HEALTH CARE WORKERS.
*Mass media campaign, advice from others, reminder pamphlet from the administration, illness of a friend or workmate, newspaper or magazine article.