research on needle stick injuries amongst health care workers and interventions in selected hospitals in hanoi

ABBREVIATIONS BV Hospital BKT Syringe CDC Centers for Disease Control and Prevention HCF Health Care Facilities HBV Hepatisis B virus HCV Hepatitis C virus HIV Human Immunodeficie

MINISTRY OF EDUCATION MINISTRY OF HEALTH AND TRAINING

NATIONAL INSTITUTE OF EPIDEMIOLOGY

DƯƠNG KHÁN

H VÂN

RESEARCH ON NEEDLESTICK INJURIES

AMONGST HEALTH CARE WORKERS AND

Hanoi, 8/2012

The thesis has been completed at:

National Institute of Epidemiology

ABBREVIATIONS

BV Hospital

BKT Syringe

CDC Centers for Disease Control and Prevention

HCF Health Care Facilities

HBV Hepatisis B virus

HCV Hepatitis C virus

HIV Human Immunodeficiency Virus

K.A.P Knowledge – Attitude – Practice

Tec Technicians

HCW Health Care Worker

No Number

PPE Personal Protective Equipment

NSI Needlestick injury

HCC Health Care Centre

WHO World Health Organisation

CONTENTS

Inroduction and Objectives: 2 pages

Chapter 1 Literature review: 49 pages

Chapter 2 Studied population and Methodologies: 24 pages Chapter 3 Results: 48 pages

Chapter 4 Discussion: 43 pages

Conclusions: 2 pages

Recommendations: 1 page

INTRODUCTION

In Vietnam, health care workers (HCW) occupied an important part in the labour forces with nearly 250,000 people in the whole country, providing health care services everday in about 970 governmental and private hospitals,, 500 maternity houses, 700 governmental and more than 16.000 private clinics in the whole country Statistics in 2009 showed that there were 116,825,901 examinations, 10,328,096 in-patients, 13,626,739 out-patients, and 2,064,010 operations done in governmental health care facilities

In their work, besides physical and psychological workload, HCWs have

to face with infectious risks, risks from exposure to blood-born pathogens through occupational needlstick injuries According to World Health Organization (WHO), amongst 35 millions HCWs in the world, 3 millions have to exposure to blood-born pathogens among which 2 millions exposed

to HBV, 0.9 milion exposed to HCV and 17,000 exposued to HIV Needlstick injuries can cause 15,000 HCV infections, 70,000 HBV infections and 1,000 HIV infection every year More than 90% infectious cases happend

in developing countries Estimated attributable fraction of occupational subcutaneous exposure of HBV, HCV, HIV every year are 37.0%, 39.0% and 4.4 % respectively Blood-born infection can lead to serious consequences such as prolonged illness, work capacity loss and death

Development of strategies and prevention pprogram on needlestick injuries has been becoming an emmerged issue but up to now there were not any comprehensive studies on occupational needlestick injuries and related factors to find out effective Therefore, to study on the actual situation of needlestick injuries in HCWs, risk factors and recommend effective and feasible interventions aiming at protecting HCWs’ health is neccessary

- To investigate the actual situation and characteristics of occupational NSI in HCWs

- To investigate K-A-P of HCWs on risk factors and prevention of NSI

- To estimate burden of diseases caused by occupational NSI

- To develop and implement a pilot intervention model and assessment of its effectiveness

CONTRIBUTION OF THE THESIS

- In-depth analysis of the actual situation and some characteristics of occupational NSI in HCWs, actual situation of management of NSI in HCFs, management of sharps and medical waste including sharps

- Developed and introduced pilot model of prevention of occupational NSI: Under this study, a comprehensive occupational approach intervention model has been developed, implemented and assessed This is a remarkable contribution to preventinng and controlling risks of NSI as well as recommendation for development and implementation of NSI surveillance and management in HCFs

- This is the first study in Vietnam applying WHO guidelines on estimation of burden of diseases caused by occupational NSI amongst HCWs

in hospitals and provided the estimated incidence of HBV and HIV, the estimated attributable fraction of occupational NSI for HBV and HIV in HCWs

CHAPTER 1 LITERATURE REVIEW

1.1 Characteristics of work conditions of HCWs:

In working environment, HCWs are exposed many health risk factors: biological factors, physical factors (X-rays, ultrasound, etc.), chemical elements, psycho-physiological factors that cause a burden to their health

1.2 NSI and related factors in HCWs:

Health workers face an increasing risk of infecting blood-born pathogens because they have occupational exposure to blood and body fluids Most cases the exposure due to subscuneous injuries caused by containimated sharps

According to WHO estimates based on 14 geographic regions (2003), the average number of injuries VSN in HCWs is 0.2 - 4.7 times / year Proportion of health workers exposed to pathogens transmitted through blood

is 2.6% for HCV, 5.9% for HBV and 0.5% for HIV This means that in the world every year an estimated 16,000 cases of HCV infection and 66,000 cases of HBV infection 200 - 5,000 cases of HIV infection in HCWs In developing countries, about 40 - 65% of cases of HBV and HCV infection in healthcare workers due to occupational exposure by skin lesions through In developed countries, on the other hand, the applicable rate of with HCV only around 8 - 27% and below 10% for HBV, largely thanks to the application of vaccination and use of safe personal protective equipment The percentage of HIV between regions in the range of 0.5 - 11%

In Vietnam, the survey results show that those who have contact with patients and clinical testing of patients at risk for hepatitis seven times higher than normal The process of infection is usually caused by exposure of mucous membranes or skin lesions with HBV-infected blood or blood products

Factors related to NSI include: Abuse injection, unsafe injection, injection frequency; unnecessary injections, Knowledge - Attitudes - Practices of HCWs, medical waste management, including sharps waste

1.3 Assessment of burden of diseases caused by NSI in HCWs:

According to the guidelines on Assessment of burden of diseases caused

by environmental factors, burden of diseases include the following indicators:

- Number of NSI per a HCW a year (n);

- Incidence of infection caused by NSI in HCWs (In(HCW))

- Attributable risk (AF) of disease caused by NSI

1.4 Policies and measures of prevention of NSI in HCWs:

1.4.1 Measures of prevention of NSI in HCWs:

As occupational health intervention approach, applicable measures for NSI prevention can be prioritised based on their effectiveness as follows: (1) Remove risk: Reduce the number of injection

(2) Control by technical measures: Use safe syringes (auto-disable syringes, auto-lock syringes, retractable syringes, etc), use safety boxes

(3) Control by adminsitrative measures: Training to improve KAP, monitoring, management

(4) Control by improved practice: Improve injection procedure and practice

(5) Using personal protective equipment (PPEs)

1.4.2 Universal Precaution:

Universal prevention based on the principle: all blood and body fluids of all patients are capable of transmission of HBV, HCV, HIV and other blood-

born pathogens The content of universal precautions are as follows:

1 – Routine hand washing and hand disinfection

7 – Hospital environmental hygiene

8 – Treatment of medical waste, especially sharps waste

9 – Treatment of NSI

Requirements of applying universal precautions are: All health facilities - All HCWs - Anytime - Anywhere exposure to blood and body fluids of an

infected patient

1.4.3 Policies and solutions for prevention of NSI in Vietnam:

- Regulations on infection control in hospitals:

+ Regulations on medical waste management issued together with Decision No 43/2007/QD-BYT of the Ministry of Health, Hanoi 03/12/2007

+ Circular No 18/2009/TT-BYT of the Ministry of Health, Guide the implementation of infection control in medical examination and treatment Hanoi, 14/10/2009

- Regulations on occupational diseases and occupational exposure:

+ Circular No 08/1998/TTLT-BYT-BLĐTBXH on 20/4/1998 of Ministry of Health and Ministry of Labour – Invalids and Social Affairs: there are 3 diseases in HCFs in the list of compensated occupational diseases

+ Circular No 10/2003/TT-BLĐTBXH on 18/4/2003 of the Ministry of Labour - Invalids and Social Affairs Guiding the implementation of compensation and benefits for employees with occupational accidents and occupational diseases

+ Circular No 09/2005/TT-BYT on 28/3/2005 of the ministry of Health Instructions for determining the conditions of exposure to HIV or HIV due to occupational accidents

+ Circular No 10/2005/TTLT-BYT-BTC on 30/3/2005 of the Ministry

of Health and Ministry of Finance Guiding on implementation of Decision

No 265/2003/QĐ-TTg on 16/12/2003 of the Prime Minister on

compensation to people who are occupationally exposed to HIV or infected HIV/AIDS

+ Decision No 3003/QĐ-BYT on 19/8/2009 of the Ministry of Health promulgating the Guidelines for diagnosis and treatment of HVI / AIDS

+ Circular No 42/2011/TT-BYT on 30/11/2011 of the Ministry of Health on Adding occupational Cadmium poisoning disease, occupational disease due to whole body vibration, HIV infection due to occupational accidents in the list of occupational diseases are covered and guide for diagnostic criteria and assessment

HCWs working in the hazardous working environment, but in some health facilities less attention given to the occupational safety and hygiene; occupational health care and protection, safe workplace for health care workers in the coming years should be pushed stronger and more attention to ensure that medical personnel are working in a safe environment with no risk factors to health

CHAPTER 2 STUDIED POPULATION AND METHODOLOGIES

2.1 Studied population:

- HCWs working in health care facilities, including: physicians, pharmacists, surgeons, KTV, nursing, nurse, assistant pharmacists, midwives, nurses, janitors who are in direct contact with the patient, the patient's blood and body fluids and medical waste

- Work condition with sharps and sharps wastes in HCFs

2.2 Studied site and time:

2.2.1 Studied sites:

– The cross-sectional study on actual situation of NSI among HCWs in 6 HCFs: Bach Mai, National Hospital for Obstetrics and Gynecology (NHOG), Vietnam – Germany, Saint Paul, Thanh Nhan, and Dong Anh HCC

– The follow-up study on incidence and incidence rate of exposure in one

year: Saint Paul Hospital

– The intervention study: Thanh Nhan Hospital and Dong Anh HCC

2.2.2 Study time: 2005 - 2009

2.3 Research methodologies:

2.3.1 Study design and sampling:

2.3.1.1 Study on actual situation and characteristics of NSI in HCWs:

- Study design: Croxx-sectional study

- Sample size: 3,462 HCWs

- Sampling: Simple random, select 50% HCWs in each HCFs

2.3.1.2 Study on the incidence of NSI:

- Study design: Follow-up study

- Sample size: 599 HCWs

- Sampling: Intentional follow-up NSI cases in 599 HCWs who directly work in health care and treatment in a hospital (Saint Paul Hospital) in one year

2.3.2 Study indicators and methodologies:

2.3.2.1 Prevalence and characteristics of NSI in HCWs:

- Questionnaires on NSI for HCWs

- Observation checklist on injection practice of HCWs

- Interviews of the managers of HCFs

2.3.2.2 Estimate burden of diseases attributed to NSI in HCWs:

To estimate burden of diseases attributed to NSI in HCWs (Incidence and Attributable fraction) followed the guidelines of WHO (2002)

2.3.2.3 Model of intervention:

- Intervention contents:

Based on traditional occupational health approach on control and prevention of work place hazards, a comprehensive intervention program has been developed and implemented include; (1) Health education; (2) Technical improvement; (3) Health care; (4) Administrative management

- Intervention model:

To establish a steering committee on prevention of NSI in each HCF with imvolvement of leaders/managers of the HCF and each department/unit Intervention measures were introduced and applied in intergration with routine activities

2.3.3 Data collection:

- Test the data collection tools (Pilot)

- Select and training for data collectors

- Sampling from sample frame

- Implementation and supervision

2.3.4 Data management and treatment:

- Collected data were saved confidentially by the data manager

- Data were cleaned, entered and analysed by EPI INFO 6.04 and STATA 8.0

2.3.5 Error controls in the study:

The questionnaire was developed carefully to ensure that it is clear and understanable, accompanied by a clear guidelines Definitions and criteria were given clearly and accurately; Data colletors were trained well; The data collection tools were tested before the main study; Close monitoring and supervision during the whole study process; Data had been cleaned before being analysed

CHAPTER 3 STUDY RESULTS 3.1 Some characteristics of the studied population:

74.4% of HCWs of this study were females, 43.3% were nurses, 21.3% were medical doctors, 12.3% were nurse’ aid 21.3% at university level and higher, 43.4% were at intermediate level, and 12.3% at lower level 46.7% had working time les than 10 years and 8% more than 30 years

3.2 Situation of NSI in HCWs:

3.2.1 Prevalence and risk of NSI in HCWs:

Table 1 Prevalence of NSI in HCWs in last 12 months

Bach Mai Hospital 619 68.0 917

Vietnam – Germany Hospital 644 77.0 834

Saint Paul Hospital 348 58.1 599

Thanh Nhan Hospital 251 54.6 460

Dong Anh HCC 106 74.6 142

Table 1 showed that in general, the rate of HCWs got injured in the last 12 month was 64.8% In the same hospital, the rate of female HCWs got injured (66.3%) was higher than that of the males (60.4%) with statistical significant (p<0.05)

Most of the HCWs (83.9%) got injured less than 5 times in a year, some (9.9%) got 6 - 10 times, and just few got more than 10 times

Table 2 showed that nurses had the highest incidence (19/100 persons/year), followed are medical doctors (11/100 persons/year) Other groups (nurses’ aid, technicians ) had a lower incidence rate 9/100

persons/year) This difference is statistically significant (p<0.05)

Table 2 Incidence of NSI by occupations

(Results from the follow-up study in Saint Paul Hospital in one year)

Doctor 22 11.0 p 1-4 <0.05

p 3-4 <0.05 Pharmacists 0 0

Doctor Assistant 1 11.1

Nurses 93 19.0 p 4-5 <0.05

Hộ lý/Y công 7 6.7 p 4-6 <0.05

3.2.2 Characterics of NSI in HCWs:

Is the most common NSI were at hands and fingers (94.5%) Most of the

damage is subcutaneous (77.8%) and scratch (19.6%) The damage is very

dangerous because it is risk for infection with blood transmitted disease

Most of the NSI occurred in the morning (46.6%), followed by the

afternoon (22.3%), less than in the evening (19.8%) and at night (11.3%)

46.0% of NSI cases happened after injection, then instrument cleaning

(14.9%), the procedures (14.0%), surgery (13.5%), discarded and garbage

collection (8.8%)

In the NSI causes, hypodermic needles rate was highest (31.7%), followed

by winged needle (19.2%), needles (16.0%), metal static blood vessels

(15%), needle biopsy has low percentage (2%)

Table 3 Information of the potential sources of blood-born pathogens

Patient with other transmitted diseases 211 9.4

Patient without other transmitted diseases 585 26.1

No information of the patient 1184 52.8

Table 3 showed that the NSI cases could be exposed to HIV patients

(3.9%), patients with HBV / HCV (7.8%) A very dangerous thing is a big

part of health workers (52.8%) in the hospitals did not have any information

about the patient that they were exposured when the injury occurs

3.2.3 Treatment for NSI:

96.3% of the injured people had applied at least one of the first aid

methods after being injured The most common measure is using

disinfectants (83.4%) and washing hands with soap (83.3%), squeezing the

blood (77.7%) Only 14.2% of FLC by VSN had treatment after injury and

only 96.6% compliance with treatment regimens

3.2.4 KAP and prevention measures of HCWs: