ADDIS ABABA UNIVERSITY FACULITY OF MEDICINE SCHOOL OF PUBLIC HEALTH

ASSESSMENT ON PREVLENCE OF WORK RELATED INJURIES AND PREVENTION PRACTICES OF HEALTH PROFESSIONALS TOWARDS

OCCUPATIONAL TRANSMISSION OF HIV IN SELECTED HOSPITALS OF ADDIS ABABA

By ZUFANHADIS(BSc) ADVISER:SOLOMONSHIFERAW (MD, MPH)

, A THESIS SUBMITTED TO THE SCHOOL OF GR ADUATE STUDIES OF ADDISABABA UNIVERSITY IN PARTIAL FULFILLMENT
)

OF THE

REQUIREMENT FOR THE DEGREE OF MASTER OF PUBLIC HEALTH

JULY 2008 ADDIS ABABA ETHIOPIA

Acknowledgement
First of all, I would like to acknowledge my adviser Dr. Solomon Shiferew for his invaluable inputs, suggestions and constructive comments at the various stages of this thesis from proposal development through out the study. My sincere acknowledgement is also extended to the study participants, facility heads of all hospitals and owners of private hospitals of Addis Ababa. I would also like to acknowledge School of Public Health in AAU for sponsoring this thesis. I would like to extend my thank Dr.Amunieal Gesessaw and Dr.Kesetebirhan Adrnasu, for

supplying me with some materials to accomplish this work. Lastly, I would like to extend my thanks to my husband and my family. I also thank all my teachers and staff in the school of public health.

2. TABLES OF CONTENTS
1. ACKNOWLEGEMENT ""\ TABLES OF CONTENTS
.J..

PAGE

I II , .. III V VI 1 5 16 17 27 48 OF THE STUDy 55 56 '" 58 59 62

LIST OF TABLES AND FIGURES

-t. LIST OF ABBEREVATION

5. ABSTRACT...... 6. INTRODUCTION......................................................................... 7. LITRATURE REVIEW 8. OBJECTIVE OF THE STUDy............................. 9. METHODOLOGy 10. RESULT 11. DUSCUSSION 12. STRENGTH AND LIMITATION

13. CONCLUSION.................................... 14. RECIMMENDATION 15. REFERENCES.................................... 16. ANNEX...........................

List of Acronyms AIDS AAHB AAU

Cl
DCH EC Acquired immunodeficiency Addis Ababa health bureau Addis Ababa university Confidence interval Department of community health Ethiopian calendar Federal ministry of health Faculty of research and publication Hepatitis B virus Hepatitis C virus Health care workers Health institution Human Immunodeficiency
High Level Disinfection

syndrome

Fl\10H FRPC
HBV

Hev
HCWs HI HIV
HLD

virus

HP

Health professionals Infection prevention

Ministry of Health

IP
MOH

NGOs NSI ., OPD OR

PEP
PPE

N on-Governmental Needle sticks injury

Organization

Out Patient Department Odds Ratio Post exposure prophylaxis

Personal Protective Equipment

RHB SNNPR
TST

Regional health bureau Southern, Nation ,Nationalities, and People Region

Time, Steam and Temperature

UN UP 'VHO

United Nations Universal precaution World Health 'Organization

Abstract
Introduction: The increasing prevalence of HIV increases the risk that health care workers will be exposed to blood from patients infected with HIV, especially when blood and body fluid precautions are not routinely followed. Universal precautions mean taking precautions with everybody. Health providers should have the right to be able to protect themselves against infection; whether it is HIV, Hepatitis or other disease, clients have also the right to get safe service. Objective: prevention To assess prevalence of occupational of work related injuries, knowledge and practice of in selected

transmission of HIV among health professionals

hospitals of Addis Ababa Methods: Health institution based cross-sectional survey was conducted from January

through April/OS. Selected hospitals of Addis Ababa were included in the study. Three hundred sixty two health professionals were interviewed; interview of appropriate persons was conducted. Prevention practice of study department's was assessed by observation using standard checklist. Result: One hundred and five, 29 %of health professional reported that they had sustained accidental needle stick injury and 61 (16.9%) sustained sharp injuries in the past one year. Two hundred thirty (5S%) of health professional sustains exposure of blood and body fluids to skin, eyes and mucous membrane.

Majority (69%) of health professional have knowledge about the presence of post exposure prophylaxis (PEP) in their hospitals for a person sustaining needle stick injury or sharp injury. Majority of respondents knew the most common diseases that can be transmitted by

accidental needle stick injunes or contaminated majority of respondents. Forty-seven (27.5%)ofpublic

blood. HlV, HBV were mentioned by

hospital healthcare workers and 23 (16.7%) of the interviewed in the last two

private healthcare workers had reported to have received training on IPIUP years.

Conclusion and recommendation Considerable proportions of needle sticks, sharp injuries and exposure of blood and body fluids occurred mainly due to recapping of needles, improper collection and handling of sharps. In-service trainings of health professionals through mass

campaign concerning infection prevention is necessary by involving health professionals in . the private sector, and national IP guideline should be made available to all health institutions and health professionals should used it.

1. Introduction
1.1 Statement of the problem HIV has significantly altered the face of health care and the lives of almost everyone in our community. Health providers are at risk of developing infections in their work place. The increasing prevalence of HIV increase the risk that health care workers will be exposed to blood from patients infected with HIV, especially when blood and body fluid precautions are not followed for all patients. The risk of transmission, particularly

through accidental needle stick injuries, contacts of blood and body fluids with broken skin, and splash of the eye and other mucous membranes infections. HIV, HBV, and HCV are the commonest is known to transmit these transmitted viruses and are

continuous to be a major concern for all of working in healthcare services. (l)

Occupational exposure to blood and body fluids puts healthcare

providers at risk of

.,
infection with blood-borne pathogens, such as hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV. Of the 35 million health workers worldwide, exposed to such pathogens each year through percutaneous about three million are

injuries (from syringes and occur in developing

other sharp instruments) and more than 90% of these infections

countries, where health workers often lack the knowledge, skills and resources necessary to protect themselves and their clients from becoming infected.(2)

Studies have shown the risk of diseases after exposure to HBV from a single needle stick injury ranges from 27-37%, while the risk following a single needle stick exposure to HIV is much lower 0.2-0.4%, and 3-10% for HCV( 3) People who provide or receive health care service whether in hospitals, clinic, or any other health care setting are the risk of acquiring and transmitting potentially life threatening infections through accidental exposure to blood and body fluids or

contaminated objects. Over the past two decades, considerable progress has been made globally in understanding the basic principles of preventing such infections, but they

continue to be a significant cause of morbidity and mortality through out the world. (4) The health care workers most often involved have been nurses, laboratory technicians, surgical physicians, midwifery, gynecologists, health assistance, hospital laundries and cleaners, emergency health workers, medical students and other workers have been infected. From these surgical physicians and midwifes are at great risk. (4)

The World Health Organization

(WHO) estimates that each year some

16 billion

ihjections are administered in developing and transitional countries. In some situations, as many as nine out of ten patients presenting to a primary health care provider receive an injection, of which over 70% are unnecessary or could be given in an oral formulation (5). At the same time, there is lack of evidence about the number of needle stick injuries and their consequences to health care providers, although unsafe injection practices have been linked to the transmission of blood-borne pathogens between patients and health

care providers. To prevent the transmission of blood-borne pathogens that result from unsafe injections, injection use must be reduced and injection safety achieved. A safe

injection does not harm the recipient, does not expose the health care worker to any risk .and does not result in waste that is dangerous for the community.(S)

Specimens including blood, blood products, and body fluids, obtained from all patients should be considered hazardous and potentially infected with transmissible agents (6). Between 200 and 400 health care workers die each year as a result of hepatitis B infection acquired on the job. The use of universal precautions helps minimize the transmission of many transmissible diseases in addition to HIV. In the absence of any effective treatment, prevention is the only way to combat the spread of HIV (6). Despite relative ease of implementation, many health care providers have not used

universal precautions routinely. Recent studies have shown that >50% of health providers engage in inadequate infection control practices, even in high-impact AIDS centers, and up to 40% of the needle stick exposures were judged to be preventable (6). Medical transmission of HIV-through unsafe injection, sharps injury and other unsafe

practices account for a significant proportion of new infections each year illness due to HBV, HCV and HIV infection accounts for 1.3 million deaths and to a loss of 26 million

life years.(7) Antiretroviral treatments after exposure to HIV can reduce the risk of infection. After a needle stick injury with HIV -infected blood, zidovudine alone can reduces the risk of HIV transmission form an average of 3 in 1,000 injuries less than 1 in 1,000. and lamivudine is recommended for deeper

Combination therapy with zidovudine injuries and laceration (8).

Health professionals are considered necessary to study because they are essential in the prevention and management of diseases. This study applies the concept to health workers as a group likely to be at risk due to the nature of their occupation, since they may expose to infection while on routine duty through either accident, negligence, inadequate

protection or other unforeseen circumstances. Infection prevention is critically important to the effective provision and management of health care services. So far, very few studies were .conducted in Ethiopia to assess frequency of exposure of . HP to occupational injuries and status of knowledge and practice of health professionals on preventive measures. Therefore, this study will help to identify practice of HP on safety precautions and would have a significant preventive measures in the clinical areas. in put for improving practice of

9. Reference

1. The prevalence of needle stick injuries in Medical, Dental, Nursing and Midwifery Students at the university Teaching Hospitals of Shiraz, Iran Mehardad Askarian, Leila melekmakan Medical Bulletin volume 60 June 2006 number 6.

2. Infection prevention and control (home page on the internet). C2007 (updated 2007 June 7; , cited 2007 June 21) Available from: http://www.jhpiego.org

3. CDC. ALERT: Preventing needle stick injuries in Health care settings. (NIOSH): 2000 (108): 1-23. 4. Joseph R~ Thum, HIV and Occupational risk Evolving ways to protect health care workers vol 102/no 4 October 19971 postgraduate medicine. 5. Hauri AM, Armstrong GL and Hutin Yl The global burdens of disease attributable to contaminated injections give in health care settings. IntJ STD-AIDS.2004; 15(1}: 1-:-16.

6. Transmission of HIV 'to Health Care workers HIV and the Acquired Immunodeficiency syndrorneIl prevention of HIV the Armenian medical net work Jan 25 2006 available on line httpwww.health.am. 7. Simonsen L;Kane A.,. Lioyd J. Zaffran M., and Kane M. Unsafe injections in the developing world and transmission of blood born pathogens:
')

a review. B WHO 1999; 77

(10): 789-799. (June 29, 2001). 8-Health Resources and Services Administration Ryan White CARE Act and the AIDS Education and Training Centers and CDC available on the Internet at

(http://pepline. ucsf.edu/pepline) 9. Hutin, Y~ et al. Best injection practices for intradermal, subcutaneous and intramuscular

needle injection. Bulletin of World Health Organization (WHO), 2003;81: 491-500 10. Updated U.S. public health service Guidelines for the Management of occupational

Exposures to HBV, HCV, and HIV and Recommendation for post exposure prophylaxis (June 26, 2001).
G

11. ILo cod of practice hfpp://www.ilo.org/public

on HIV/ AIDS /.

and the

world

of work

available

on

Lemessa Oljira (BSc) impact of HIV/AIDS on the public sector Health care services in Dire Dawa administrative counsel, L, EASTERN ETHIOPIA JULY 2000 . . HIV and safe mother hood: what else can Health workers do? AIDS action (home page on the internet) http://www.aidsaction.infolhsm/index.htm '.

~ . Case- control study of HIV Sero conversion in Health - care workers after percutaneous exposure to HIV-infected blood --- France, United Kingdom, and United States, January 1988 - August 1994. ~5. Emilie H.S. Osborn,; Academia and clinic, Occupational Exposures to body fluids

among, medical students a seven-year longitudinal study mexine a papadakis, and Julie Louise Gerberding, Simonsen L, Kane A., Lio. 6. Amuniel Gessessew Occupational Exposure of Health Workers to Blood and Body fluid: Magnitude and Management in Tigray Hospitals 2007. 17. Who is at risk of infection? (Home page on the internet) h~m:/{\'y'~Y~y'"t,~!1.g~n9~X health.org/ip/about/copyright.htm/ 2004.

18. HIV and safe mother hood: what else can Health workers do? AIDS action (home page on the internet) lutn.r/www.a idsaction. info/hsm/index.htm.' t.-:: _. .._.~ . _ __ _
'~"'M

19. Christine L. Case, Ed.D. Microbiology Professor at Skyline College. Biography, In: Access Excellence collection, Hand washing. Available pnline at: http://www.accessexcellence.org/LC/SS/ferm_biography.html 20. Yosef W. Assessment of the safety of injections and related medical practices in health institutions at Sidama Zone, SNPPRS IMPH thesis/. Addis Ababa University; 2004. 21. World Health organization. Geneva: WHO; 1999. 22. Perspectives in disease prevention and health promotion update", Universal precaution for prevention of transmissionofHIV, settings 2005. 23. Christine L. Case, Ed.D. Microbiology Biography, In: Access Excellence collection, Hand washing. Available online at: HBV, and other blood born pathogens in Health-care Safe management of wastes from healthcare activities

http://www .accessexcellence .0rg/LC/S S/ferm_ biograph y. html

_-. National Health Facilities Survey in Ethiopia, Addis Ababa; 2005 (22-23) -. Batters by A, Feildon R steckel p, da salva A, Nelson C, and Bass A. strategies for safe injection. B WHO. 1999; 77 (12):99 6-9 . . Gumodoka b, Favot 1, Berega Z. A and Dulmans U.M.V. Occupational exposure to the risk of HIV infection among health care workers in Muaza Region, United Republic of Tanzania. B WHO; 75 (2): 134-140. _ . Family health department of FMOH Assessment of infection prevention Management of _IPS sites in 4 regions: summary of findings. Addis Ababa: FHD; 2006 . Kiragu, Karusa, Thabale Ngulube, Mutinta Nyumbu, Panganani Njobvu, Peter Eerens,

d Chilufya Mwaba. 2007. "Sexual risk-taking and HIV testing among health workers in Zambia," AIDS and Behavior 11(1): 131-136) 29: HIV rife among health workers available at htpp://www.aegis.comldefault.asp O. Addis Ababa Health Bureau: Distribution of government and private health facility by type 1998 -99 E.c. Draft Report. Addis Ababa: .-\AHB; 2007 1.. Planning and programming department of federal ministry of health: health and health related indicators, 2005/06. Addis Ababa: FMOH; 2007 . .)2. Assessment ofK.I\P of health care provider on universal precaution, at north wollow zone Anihara Region Northeastern Ethiopia by Mesele Damte, 2007 .)3. Assessment of health care waste generation rate and evaluation of health care waste

"

management in Debrbirhan zonal hospital, Amhara region 2007

By Esubalew Tesfahun July

34- Federal Ministry of Health. Infection Prevention guideline for healthcare facilities in Ethiopia. Addis Ababa: FMOH; 2005.