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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 2  |  Page : 45-50

Prevalence of needle-stick injuries among health-care workers in a tertiary care centre in North India


Department of Microbiology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication10-Jan-2019

Correspondence Address:
Dr. Vineeta Mittal
Department of Microbiology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_13_18

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  Abstract 


Background: Healthcare-associated infections among health-care workers (HCWs) commonly follow occupational exposures to pathogens through sharp, cuts and splashes contaminated with infected blood or body fluids of patients. The objective of this study was to determine the occurrence of self-reported occupational exposures to these hazards and to know the prevalent practices following the exposure.
Materials and Methods: An observational prospective study was done in the HCWs of a tertiary care centre of North India from January 2015 to December 2016. At the time of self-reporting of injury, a questionnaire was administered. Blood sample of HCWs and of the source, if identified, was collected for baseline hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) serum markers. Follow-up status before and after needle-stick injuries (NSIs) was done.
Results: NSIs were reduced from 18 (70.37%) in 2015 to 8 (29.62%) in 2016 with P < 0.05. The maximum numbers of NSIs were found in staff nurses (68.64%), mostly with hollow bore needle (68.75%), during insertion of intravenous cannula (29.66%). Maximum type of injury was superficial percutaneous (62.82%). 35.89% of the HCWs who had NSI were not immunised with HBV vaccines. Post-exposure prophylaxis for HIV was started within 2 h of exposures in whom it was warranted.
Conclusions: The study indicates that supervised training, especially during initial stressful years, is needed not only to reduce the incidence of NSIs but also to improve work performance.

Keywords: Health-care workers, needle-stick injury, tertiary care centre


How to cite this article:
Islahi S, Mittal V, Sen M. Prevalence of needle-stick injuries among health-care workers in a tertiary care centre in North India. J Patient Saf Infect Control 2018;6:45-50

How to cite this URL:
Islahi S, Mittal V, Sen M. Prevalence of needle-stick injuries among health-care workers in a tertiary care centre in North India. J Patient Saf Infect Control [serial online] 2018 [cited 2019 Jun 18];6:45-50. Available from: http://www.jpsiconline.com/text.asp?2018/6/2/45/249842




  Introduction Top


Needle-stick injuries (NSIs) as defined by the United States National Institute of Occupational Safety and Health are injuries caused by needles such as hypodermic needles, blood collection needles, intravenous (IV) stylets and needles used to connect parts of IV delivery systems.[1] Mucocutaneous exposure occurs when body fluids come into contact with open wounds, non-intact like in eczema or mucous membranes such as the mouth and eyes.[2] Injuries and splashes of fluids have been recognised as a source of exposure to blood-borne pathogens.[3],[4] According to the Centers of Disease Control and Prevention, every year, more than 3 million health-care workers (HCWs) are exposed to blood and body fluids in the United States alone, with an annual estimated 6 million NSIs.[5] The WHO reports that of the 35 million HCWs, 2 million experience percutaneous exposure to infectious diseases each year.[6] Due to NSIs, the risk of infections ranges from as low as 0.2%–0.5% for human immunodeficiency virus (HIV) to as high as 3–10% for hepatitis C virus (HCV) and 40% for HBV.[7] Although contaminated needles and other contaminated sharps should not be bent, recapped or removed, many studies have revealed that recapping being still prevalent among HCWs.[5],[8] The prevalence of NSI and its associated risk factors varied among different HCW groups such as doctors and nurses depending on the place of studies such as teaching institutes, hospitals and corporate set-ups.[7],[8] There are limited comprehensive data from India on this aspect, so this study was conducted to know the prevalence of NSI and also to understand the post-exposure measures taken by the HCWs in a tertiary care teaching hospital in North India.


  Materials and Methods Top


Ethics

All applicable institutional guidelines for the participants were followed. It was a purely observational study. Confidentiality of identity was insured to all the persons, and a verbal consent was obtained before filling up of the questionnaire. This retrospective study was approved by the Institutional Ethical Committee.

Study design

This study was carried in the new super-speciality post-graduate institute, where there is functional infection control committee. Every NSI case has to be reported to the committee. We conducted a cross-sectional study of sharps and NSIs among HCWs in our hospital in 2015 and 2016.

There were 867 HCWs working in different departments of the institute at the time of this study. All the HCWs comprising resident doctors, nurses, laboratory technicians, ward attendants and ward sweepers were included in the study. The standard pro forma for tests as prescribed in the National AIDS Control Organization, Government of India guidelines for each occupational exposure was followed.[9] The pro forma contained information on the demographic characteristics of the HCWs such as name, age sex, employment number, department, hepatitis B vaccination (complete/incomplete/unvaccinated), anti-hepatitis B antibody level in the past (done/not done/value), the details of the injury such as the date and time, time since injury, source, type of injury, procedure, the NSIs they sustained 12 months before the study, the circumstances under which they sustained the injuries, the factors associated with the injuries and the actions taken by the HCWs following the NSIs (wound care) including diagnosis, source of blood sent, exposed blood sent, HBV vaccine indicated or not, antiretroviral starter pack – indicated or not, time of starter pack since injury, referral and counseling, follow-up - hepatitis B surface antigen, HIV and HCVAb status before and after NSI. If these had not been tested earlier, the investigations were sent and follow-up was done within 6 h. Hospital infection control nurses, clinical microbiology residents and trained technical staff was actively involved in follow-up and counselling of each exposed HCWs in our post-exposure prophylaxis (PEP) program. The pro forma retrieved from the HCWs was screened for completeness, coded and analysed.

Statistical analysis

The statistical analyses were performed using Statistical Package for the Social Science software (SPSS version 16.0, IBM corporation, US) and Microsoft Office Excel 2010. A P < 0.05 was considered statistically significant.


  Results Top


A total of 27 HCWs (3.11%) reported to the committee after NSI, out of which 75% were female and 25% were male. Their age ranged from 17 to 57 years, with a mean age of 31.3 ± 8.9 years. Higher proportions 55.1% (54/98) of the respondents were females while nurses and paramedics constituted the highest occupation accounting for 40.8% (40/98) and 30.6% (30/98), respectively.

According to the study, it was found that the number of NSIs were reduced from 18 (70.37%) in 2015 to 8 (29.62%) in 2016 [Table 1]. The resulting odds ratio is 0.42 with a 95% confidence interval ranging from 0.85 to 86.9. The z-statistic is 2.04 and the associated P= 0.04 and this decrease is statistically significant.
Table 1: Needle-stick injuries in the institute from January 2015 to December 2016

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Among the exposed HCW, staff nurses (68.64%) had maximum number of NSIs followed by ward attendants (15.25%) [Figure 1]. It was found that maximum numbers of NSIs were with hollow bore needle (68.75%), followed by those who were not aware of the type of needle they got injured (25%) [Figure 2]. Maximum numbers of NSIs were during insertion of IV cannula (2966%) followed by the process of handing garbage bag (20.51%). [Figure 3]. Maximum number of NSIs were superficial percutaneous (62.82%) followed by deep percutaneous (33.33%) [Figure 4]. According to the study, 35.89% of the HCWs who had NSI were not immunised with HBV vaccines while equal number (32.05%) were found to be incompletely and completely immunised. According to the study, PEP for HIV was started within 2 h in only 28% of exposures in whom it was warranted. After NSIs, 100% HCW removed their gloves and washed their wounds with running water and then spirit swab, and then, bandaging was done followed by reporting the incident to senior staff and seeking advice on NSI protocol.
Figure 1: Types of devices causing needle-stick injuries

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Figure 2: Numbers of needle-stick injuries reported by different categories of staff

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Figure 3: Most common clinical activity to cause needle-stick injuries

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Figure 4: Type of injury

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  Discussion Top


This study provides significant data regarding the self-reported risk for NSI among HCWs in a tertiary care centre in North India. Occupational injuries with a needle or other sharps are common among HCWs. These injuries increase the risk of many blood-borne infectious diseases. Various studies have reported the prevalence of NSIs in India [Table 2].[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25] The present study was conducted to know the prevalence of voluntarily reported the incidence of NSIs and other occupational injuries. A total of 3.11% (27/867) incidences of exposure to blood and body fluids were reported in the study period of 2 years which is quite similar to a study at Maharashtra by Gita and Rao in 2017.[13]
Table 2: Various studies in India showing the prevalence of needle stick injuries

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In our study, it was found that the number of NSIs was markedly reduced from 70.37% (18/27) in 2015 to 29.62% (8/27) in 2016 and this decrease was statistically significant (P = 0.04). Our findings indicate that nurses (44.44%) were found to be the most occupational health group to have NSIs, which was similar to most of the Indian studies.[10],[11],[13],[18],[19],[20],[21],[22],[23] This can be explained by the facts that nurses administer most of the injections and IV fluid administration, basically nurses are the most common HCWs, dealing with injections and sharp objects, and also the numbers of nurses are usually higher than any other occupational group inside hospitals, though shortage of nurses inside hospitals is also an issue.

In our study, most of the injuries were caused by hollow bore needle (66.66%) which was in accordance with the various studies conducted in India.[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25]

According to our study, the maximum number of NSIs were during insertion of IV cannula (29.66%) followed by the process of handling garbage bag (20.51%) and procedure of dusting through blood sugar needle (12.82%) while NSIs during recapping were found to be only 8.97%. However, it was in contrast to the various study, who reported that recapping was a major problem causing NSIs.[11],[12],[16],[17],[19],[20],[25] After interventions, it was noted that main cause of NSI in 2016 was during procedures of needle handling.

In our study, maximum numbers of NSIs were superficial percutaneous (62.82%) followed by deep percutaneous (33.33%) which was quite similar to the study done by Goel et al. (70.8%) in which most of the injuries were superficial percutaneous.[26]

Estimates of hepatitis B vaccine coverage among HCWs were needed to calculate the proportion of workers susceptible to HBV infection. Our study shows that 40.74% (11/27) participants were completely immunised, whereas 29.62% (8/27) were incompletely immunised and the same number of HCWs had not received any vaccine. In a study conducted at AIIMS, New Delhi, by Singhal et al. in 2011[27] and in G. B. Pant Hospital, New Delhi, by Sukriti et al. in 2008,[28] 50% and 55.4%, respectively, were completely vaccinated.[26],[27] In a study conducted in Rewa, Madhya Pradesh, by Kumar et al. in 2000,[29] 42.4% of the HCWs had received partial or full course of vaccination against hepatitis B. The finding in present study was quite similar with these studies regarding status of hepatitis B vaccination in HCWs.

In the present setting of our tertiary care centre, due to HCW education and a structured PEP program, utilisation and appropriate implementation of PEP increased over time. PEP for HIV was started within 2 h in only 28% of exposures in whom it was warranted. Although this proportion was similar to other studies from India and elsewhere,[29],[30],[31] various guidelines clearly recommend to start PEP preferably within 2 h to have its best efficacy.[32],[33] The use of PEP is a veritable tool in the prevention against HIV as it has been shown that if started soon after exposure, PEP can reduce the risk of HIV infection by over 80%.[34] Our hospital authorities have instituted a continuing medical education (CME) program to sensitise HCWs on infection control measures with particular emphasis on PEP. There is also a monitoring team that actively keep watch on all occupational exposures and injuries and ensure that they are reported and managed appropriately.

In our study, it was found that number of NSIs was markedly reduced from 70.37% (18/27) in 2015 to 29.62% (8/27) in 2016 and this decrease was statistically significant (P = 0.04), this may be due to major interventions done in our institute such as regular classes on education and training for preventing sharp injuries and splash exposures in HCWs as a part of study curriculum was conducted separately for each group of HCWs via interactive lectures, audiovisual aids and hands-on practices, especially among newly inducted staff, twice in 2015. Proper administrative control was provided which focussed on policies and practices guidelines, in-service education, regular training and vaccination with hepatitis B. CME and workshops were conducted and trainings were provided to nurses, ward attendants and sweepers by going to the different wards. The focus was on behaviour change strategies to reduce exposure to NSIs and sharp injuries. Practices such as no needle recapping, provision of safety-engineered manual needle cutter, sharp containers, hub cutter, needle shedders in every ward made them accessible for all HCWs. Proper disposal of sharps after use, timely management of sharp containers when three quarter are full were main focus of work practice control. Personal protective equipment were provided, which also helped to reduce NSI, helped to limit exposure to blood splashes, etc. and it was ensured that every NSI should be notified to the infection control nurse in the department of microbiology.


  Conclusions Top


Although highly preventable with proper handling and equipment, NSIs are still a significant issue among HCWs globally despite legislation in many countries. Results of this study clearly indicate that supervised training, especially during initial stressful years, is needed not only to reduce the incidence of NSIs but also to improve work performance. Although on-site practices were widely prevalent for NSI prevention, educational classes on NSIs must be broadened to reach more nurses as well as cleaners showing high NSI prevalence, in an effort to transfer hands-on techniques to strengthen NSI precautions and prevention for HCWs in our tertiary care hospital.

Acknowledgement

We would like to thank all the staff of the hospital infection control team especially infection control nurse for their help in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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