Epidemiology and clinical consequences of occupational exposure to blood and other body fluids in a university hospital in Saudi Arabia

Discussion

Occupational exposure to BBFs is a problem in any healthcare setting. The possibility of acquiring a blood-borne infection following percutaneous or mucocutaneous exposure to BBFs is an alarming issue.11 It may also inflict substantial psychological stress on the exposed individuals particularly when the exposure is from an HIV infected source.3

The prevalence of BBFs exposure has been the focus of many studies worldwide with marked variation depending on region. In this study, the prevalence of occupational exposures to BBFs over the 7-years study period was on average 47 exposures per year or 43 per 1000 person-year. In a Canadian study, the reported rates of NSI were 17.4, sharp injuries were 3.0, and splashes were 5.2 per 1000 person-year.12 Locally, a rate of 33 NSSI per 1000 HCWs was reported in one study.10 In another local study, the annual rate of sharp injuries was one per 100 HCWs.13 However, most of these figures may be underrated due to concern of under-reporting as suggested by studies showing that less than half of the exposed individuals reported the incidents to the hospital’s concerned authorities.6-9,14 In our study, more female subjects reported occupational exposures than male subjects likely because 89.5% (930 of 1039) of the hospital nursing staff were females during the study period. The slightly higher prevalence in non-Saudis may, likewise, be attributed to the fact that almost 60% of the staff was non-Saudi.

There are certain groups of HCWs that are at a particularly high risk for accidental hazardous exposures because of the nature of their occupation. This study showed that nurses carry the highest rate for BBFs exposure events which is similar to what was reported in other local and international studies.15 This is likely to be due to their close contact with patients and the fact that they insert peripheral intravenous catheters much more frequently than any other specialties. Doctors were the second highest risk group with certain specialties and ranks carrying higher risks than others. Surgeons accounted for 26.3% (15 exposures), obstetricians and gynecologists, 24.6% (14 exposures), and emergency physicians, 14% (8 exposures) of total events experienced by doctors. Medical interns accounted for nearly one third of all exposures experienced by doctors. Their yet underdeveloped skills render them a particularly vulnerable group as previously reported.16 Surgeons had a higher risk for sharp injuries compared with other physicians, and this difference was statistically significant (p<0.005). This may be explained by the more frequent use of sharps relative to other specialties. A survey among surgical residents in 17 medical centers across USA in 2007 showed that around 83% of the respondents suffered from a needle stick injury at some point in their training period.17 In our study, dental students were the third highest risk group after physicians most likely due to their proximity to patients during work, use of many sharp items along with lack of experience.

The most commonly implicated devices in percutaneous injuries were hollow-bore needles followed by suture needles. Of the hollow-bore needles, hypodermic needles were the most common type, a finding that is similar to what was previously reported.11 Among the highest and most preventable percutaneous injury circumstances was recapping.11 A similar finding was reported in a study showing that recapping needles was independently associated with exposure to BBF.18 Lack of awareness is likely the cause of such unsafe practice. Educational campaigns should address this point to increase the awareness of staff to the fact that needles and sharps should not be recapped and to encourage the use of safety-engineered needles and other sharps. Disposal of sharps in trash was an unexpected issue that was brought to light. In the present study, waste handlers were involved in only 7.1% of all exposures. In contrast, a cross-sectional study performed in Iran found that housekeepers had the highest BBF exposure rate.19 The most frequent procedures that used sharps were obtaining a blood sample, followed by injections, and establishing or accessing a line, all of which are procedures frequently performed by nurses, the highest risk group.

The activities that were associated with higher incidence of splashes and mucocutaneous exposures were line and tube insertion or manipulation and surgical procedures, perhaps explained by the higher amount of bodily fluids in their work field. Mucocutaneous exposures are easily preventable by wearing personal protective equipment, such as eye goggles and face shields.

In this study, the source patients’ infectious status was evaluated to assess the risk for viral transmission. Fortunately, there were no cases of seroconversion in this study. To decrease the risk of infection, all persons exposed to BBFs contaminated with HIV were given post-exposure prophylaxis in the form of highly active anti-retroviral therapy (HAART) when advised by an infectious disease consultant.20 Although the risk of HBV transmission via occupational exposure is the highest among these viruses, it is, fortunately, the most preventable with concurrent administration of passive immunization in the form of immunoglobulins (HBIG), as well as active immunization starting promptly after exposure if the HCW’s level of HBsAb was not protective, namely, less than 10 IU/L.21 Compliance with post-exposure prophylaxis was excellent when HAART regimen was indicated, and less than ideal in case of HBIG. A study in another Middle East hospital showed that exposed individuals were more diligent in following post-exposure practices when the patient was known as opposed to be only suspected to have infection with one of the blood-borne viruses.22 In our study, serology follow-up among some exposed persons was deficient which could be due to lack of awareness, lack of concern, false self-reassurance with the early negative test results, or forgetting to complete the follow-up. Of note, the exposed persons’ follow-up was superior in exposures involving HIV-positive sources when compared with ones with HBV or HCV positive sources. Some of the exposed individuals received HBIG or vaccination when they were not required which could partly be due to delay in the release of HBsAb assay results for those staff who were not previously checked.

Since occupational exposure to BBFs is a major concern among training students and healthcare workers, effective preventive measures to reduce the risk of such events and to improve their clinical outcomes should be implemented by health care facilities. Interventions proposed to lower the rate of percutaneous and mucocutaneous exposures to BBFs include, but are not limited to, the following: the use of safety-engineered needles and sharps, encouraging prescribing oral medications instead of injections when applicable, education of all hospital staff and training students to increase awareness regarding occupational safety, avoiding recapping, and the importance of HBV vaccinations, optimizing post-exposure management through proper follow-up, and administering post-exposure prophylaxis only when indicated in order not to waste resources. High-risk groups should be targeted for focused specialty-specific guidance for the prevention of such accidents. For instance, stressing the importance of safe injection practice among nurses, as well as creating a safe zone whilst exchanging sharps amongst surgeons. Incorporating occupational safety education into the undergraduate curriculum, especially for dental students would also be recommended.

Limitations of our study include the fact that it was retrospective; hence, the results may only reflect the study period. Additionally, reliance on self-reporting of these exposures by the exposed staff might have led to underreporting. Loss of follow-up of several exposed individuals may have also affected the results.

In conclusion, proper occupational safety measures and educational programs need to be implemented to reduce the incidence of exposure to BBFs in health care facilities. Further research is needed to characterize the optimal means to establish efficient NSSI surveillance and management systems in healthcare facilities to improve reporting, provide timely post-exposure prophylaxis, and follow up.