HIV : awareness of management of occupational exposure in health care workers. Wig N - Indian J Med Sci
About us | Subscription | Contact Us | Feedback | Login
Users Online : 9
Home
Current Issue
Back Issues
Search
e-Alerts
Navigate here
Search
¤ Next Article
¤ Previous Article
¤ Table of Contents
Resource links
¤ Similar in PUBMED
¤ Search Pubmed for
- Wig N
¤ [PDF Not available] *
¤ Citation Manager
¤ Access Statistics
¤ Reader Comments
¤ Email Alert *
¤ Add to My List *
* Registration required (free)
In this article
¤ Abstract
¤ Methods
¤ Results
¤ Discussion
¤ Conclusions
¤ References
Click on image for details.
ORIGINAL ARTICLE
Year : 2003 | Volume : 57 | Issue : 5 | Page : 192-198
HIV : awareness of management of occupational exposure in health care workers.
Wig N
Department of Medicine, AIIMS, New Delhi-110 029,
Date of Acceptance
31-Jan-2003
Correspondence Address:
Department of Medicine, AIIMS, New Delhi-110 029,
naveetwig@vsnl.com
¤ Abstract
BACKGROUND: There is need for safe working environment in both government and private hospitals for the safety of health-care workers (HCWs). The present study was conducted to know the present knowledge regarding occupational exposure to HIV amongst doctors in non-governmental hospitals and clinics across Delhi. METHODS: Seventy doctors from different medical and surgical specialties in various non-government hospitals/nursing homes in Delhi were given a structured questionnaire. RESULTS: Majority of them have suffered needle stick injuries. Many had also experienced splash over face, eyes. Some participants were still recapping needles most of times. 85.7% of participants were fully vaccinated for hepatitis B. 44.2% didn't know if they were responders to hepatitis B vaccine or not. Most of them didn't report the needle stick injuries. In majorities of incidents source patient was not tested for blood born infections. Many of participants were not aware of post exposure prophylactic measures to be taken if there is an occupational exposure to the blood of HIV positive patient. Awareness that drugs for postexposure prophylaxis are to be started immediately was low (36%). CONCLUSIONS: The study highlights the low awareness of postexposure prophylaxis measures amongst HCWs. Many HCWs were also not aware if they were responders to hepatitis B vaccine or not. Most of the needle stick injuries were neither reported nor investigated.
Keywords: Awareness, HIV Infections, prevention & control,transmission,Health Personnel, Human, India, Occupational Exposure, prevention & control,
How to cite this article:
Wig N. HIV : awareness of management of occupational exposure in health care workers. Indian J Med Sci 2003;57:192-198
How to cite this URL:
Wig N. HIV : awareness of management of occupational exposure in health care workers. Indian J Med Sci [serial online] 2003 [cited 2005 Nov 18];57:192-198. Available from: http://www.indianjmedsci.org/article.asp?issn=0019-5359;year=2003;volume=57;issue=5;spage=192;epage=198;aulast=Wig
Health care workers, especially who deal with large number of HIV infected patients have a small but definite risk of becoming infected with HIV as a result of professional activities. The magnitude of the HIV/AIDS epidemic is increasing in developing countries. At the end of December 2001, there were 40 million people worldwide with HIV infection or AIDS according to estimates by the Joint United Nations Programme on HIV/AIDS (UNAIDS). More than 95 percent of these new infections occurred in developing countries. India at present is estimated to have maximum number of HIV infected individuals. In India, there is a clear indication of spread of HIV to general population from high risks groups. The different parts of the country and different groups of population are in different stages of the epidemic. There are estimated -3.97 million HIV positive people in India. However, proved HIV+ve are only -0.1-0.2 million and total AIDS cases in India are 35128 till date. Hence there are many asymptomatic and hidden HIV+ve people.
There is need for safe working environment in both government and private hospitals for the safety of healthcare workers (HCWs). It is important that universal precautions are adhered to in all hospitals of India. Easy and immediate availability of Postexposure Prophylaxis (PEP) against HIV has been one of the most important pillars to fight discrimination of HIV/AIDS patients across the globe. Immediate access of PEP goes a long way in ameliorating the concerns in the mind of HCWs who work day and night for the benefit of patients. The present study was conducted to know the present knowledge regarding occupational exposure to HIV amongst doctors in non-governmental hospitals and clinics across Delhi.
¤ Methods
A total of seventy doctors working in various non-governmental hospitals/ nursing homes in Delhi were given a structured questionnaire. The purpose of the study was made clear to them and they were assured of confidentiality. No personal data were recorded in the structured questionnaire (which was used as a tool to elicit information about various aspects of occupational exposure to blood borne pathogens). These data were coded and then analyzed.
¤ Results
Majority of them have suffered needle stick injuries, [Table - 1] . Common conditions leading to needle stick injuries include accidental injury (63.6%), haste (15.2%), intravenous cannulation (9.1 %), suturing etc. Many participants had also experienced splash over face and eyes 1-5 times a year. Some participants were still recapping needless most of times, though 53.3% never recapped needles. 80% of participants said that they adhere to universal precautions. Most of participants felt that they had adequate knowledge about universal precautions. About 48.3% of participants considered that adequate equipment and supplies are provided to implement universal precautions. 87.7% of participants were fully vaccinated for hepatitis B but 44.2% didn't know if they were responders to hepatitis B vaccine or not. Most of them did not report the needle stick injuries. In majority of incidents source patient was not tested for blood borne infections. At many places facilities for rapid test for HIV were not available.
62.8% of participants were not aware of post exposure prophylactic measures to be taken if there is an occupational exposure to the blood of HIV positive patient. Of those who knew of prophylactic measures, 71.4% of participants knew washing as the immediate measure for the management of exposure. Of participants who were aware 84.2% knew zidovudine as the recommended drug. Awarness about other antiretroviral drugs that are used for prophylaxis such as lamivudine, saquinavir and indinavir was low. Awareness that these drugs are to be started immediately was low (36%).
¤ Discussion
Avoiding occupational blood exposures is the primary way to prevent transmission of hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) in healthcare settings. [1] However, hepatitis B immunization, universal precautions and postexposure management are integral components of a complete program to prevent infection following bloodborne pathogen exposure and are important elements of workplace safety. [2] An exposure that might places HCW at risk for HBV, HCV, or HIV infection can be a percutaneous injury (e.g., a needlestick or cut with a sharp object) or contact of mucous membrane or nonintact skin (e.g., exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious. [3] , [4]
Majority of HCWs had needlestick injuries and splash in our study. The risk of developing HBV clinical hepatitis is 22-31% if the blood is positive for both (HBeAg) and HBeAg while it is only 16% with blood positive only for HBsAg.s The average incidence of anti-HCV seroconversion after accidental percutaneous exposure from an HCV positive source is 1.8% (range 0%-7%) [6] , [7] The average risk of HIV transmission after a percutaneous exposure to HIV infected blood has been estimated to be approximately 0.3% (95% CI = 0.2% - 0.5%) [8] and after a mucous membrane exposure, approximately 0.09% (95% CI = 0.006% - 0.5%) [9] . Studies of HCWs have demonstrated that the risk for HIV infection has been found to be increased with exposure to a larger quantity of blood from the source person as indicated by a) device visibly contaminated with the pateint's blood, b) a procedure that involved a needle being placed directly in a vein or artery, c) a deep injury d) hollow-bore needless and persons with terminal illness. [10] , [11]
In 1983, the Centers for Disease Control (CDC), Atlanta instituted a set of guidelines (termed 'universal precautions') for patients known to harbour blood-borne pathogens. With the increase in prevalence of these pathogens, these guidelines were extended in 1987 to all patients, irrespective of their serological status. These precautions are a few simple steps and call for an organized method of dealing with blood and body fluids. These have to be met at all costs. Most of participants in our study thought they had adequate knowledge about universal precautions. They also considered that adequate equipment and supplies are provided to implement universal precautions. The benefits of universal precautions are significant. The implications of non implementation are grave in the form of seroconversion in HCWs.
Majority of HCWs were vaccinated for HBV infection. A sharp decline has occurred in the incidence of HBV infection among HCWs because of routine vaccination of HCWs against hepatitis B2. However, majority of HCWs is our study were not aware of their anti-HbsAg status. The HCWs who are not vaccinated with hepatitis B vaccine series or who are non-responders to hepatitis B vaccine, in the occupational exposure setting, should be treated with multiple doses of HBIG initiated in 1 week following percutaneous exposure to HBsAg-positive blood. It provides an estimated 75% protection from HBV infection. [12] , [13] However, the combination of HBIG and the hepatitis B vaccine series is presumed to be more efficacious. In the absence of PEP for HCV, recommendations for postexposure management are intended to achieve early identification of chronic disease and if present, referral for evaluation of treatment options.
Occupational exposures will continue to occur. Most of HCWs didn't report the exposures. HCWs should be educated to report occupational exposures immediately after they occur, particularly because HBIG, hepatitis B vaccine, and HIV PEP are most likely to be effective if administered as soon after the exposure as possible.
Many HCWs were aware of adequate prophylactic measures and drugs to be taken in event of occupational exposure to HIV. However, many were not clear from where to get the drugs and when these drugs to be started. HCWs who are at risk for occupational exposure to blood borne pathogens should be familiarized with the principles of postexposure management as part of job orientation and ongoing job training.
Limited information exists about the efficacy of PEP in humans. In a retrospective case-control study of HCP, use of ZDV as PEP was associated with a reduction in the risk of HIV infection by approximately 81%. [10] Although the results of this study suggest PEP efficacy, its limitations include the small number of cases studied and the use of cases and controls from different cohorts. The use of two or three drugs certainly adds to efficacy.
The drugs for HIV PEP need to be started as soon as possible. Studies among animal models have demonstrated that larger viral inocula decrease prophylactic efficacy. [14] , [15] In addition, delaying initiation, shortening the duration, or decreasing the antiretroviral dose of PEP, individually or in combination, decreases prophylactic efficacy. [16] ,[17] In a primate model of simian immunodeficiency virus (SIV) infection, infection of dendritic-like cells occurred at the site of inoculation during the first 24 hours following mucosal exposure to cell-free virus. Hence the treatment needs to be started immediately but HIV PEP can be given up to 48 or 72 hours postexposure. Theoretically, initiation of antiretroviral PEP soon after exposure might prevent or inhibit systemic infection by limiting the proliferation of virus in the initial target cells or lymph nodes. When administering PEP, an important goal is completion of a 4-week PEP regimen.
Health-care organization should make available to their personnel a system that includes written protocols for prompt reporting, evaluation, counseling, treatment and follow-up of occupational exposures that might place HCW at risk for acquiring a bloodborne infection. NACO has ordered all government hospitals to provide PEP drugs to their HCWs free of cost. However, private hospitals and nursing hospitals should ensure the same for their HCWs in an event of exposure to bloodborne pathogens. This will go a long way in reducing the panic which sets in HCWs in event of exposure to HIV-infected blood.
¤ Conclusions
Although preventing blood exposures is the primary means of preventing occupationally acquired blood borne diseases, appropriate postexposure management is an important element of workplace safety. The study highlights the need of standardized protocols for management of exposure to blood borne pathogens. It also reflects the need for safe working environment in all hospitals. There is a need to report, investigate and follow up needle stick injuries. Drugs for PEP for HIV should be available 24 hours readily in hospitals for immediate use by HCWs.
¤ References
1.
CDC NIOSH alert: preventing needlestick injuries in health care settings. Cincinnati, OH: Department of Health and Human Services, CDC, 1999; DHHS publication no. (NIOSH) 2000-108.
2.
Department of Labor, Occupational Safety and Health Administration, 29 CFR Part 1910, 1030, Occupational exposure to bloodborne pathogens; final rule, Federal Register 1991; 56, 64004-182.
3.
CDC, Recommendations for prevention of HIV transmission in health-care settings, MMWR 1987,36 (suppL Na 2S).
4.
CDC, Update universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings, MMWR 1988; 37, 377-82, 387-8.
5.
Werner BG, Grady GF, Accidental hepatitisB-surface-antigen-positive inoculations: use of e antigen to estimate infectivity. Ann Iternm Med., 1982,97,367-9.
6.
Lanphear BP, Linnemann CC Jr., Cannon CG, DeRonde MW, Pendy L, Kerley LM. Hepatitis C virus infection in healthcare workers: risk of exposure and infection. Infect Control Hosp Epidemiol 1994; 15, 745-50.
7.
Puro V, Petrosillo N, Ippolito G. Italian Study Group on Occupational Risk of HIV and Other Bloodborne Infections. Risk of hepatitis C seroconversion after occupational exposure in health care workers. Am. J. Infect Control, 1995, 23,273-7.
8.
Bell DM. Occupational risk of human immunodeficiency virus infection in healthcare workers, an overview. Am. J. Med. 1997, 102, (suppl58), 9-15.
9.
Ippolito G, Puro V, De Carli G. Italian Study Group on Occupational Risk of HIV Infection. The risk of occupational human immunodeficiency virus in health care workers. Arch Int Med. 1993, 153: 1451-8. [ PUBMED ]
10.
Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. N Engl. J. Med. 1997, 337, 1485-90.
11.
Mast ST, Woolwine JD, Gerberding JL, Efficacy of gloves in reducing blood volumes transferred during simulated needlestick injury. J. Infect. Dis. 1993, 168, 1589-92.
12.
Grady GF, Lee VA, Prince AM, et al. Hepatitis B immune globulin for accidental exposures among medical personnel: final report of a multicenter controlled trial J. Infect Dis 1978, 138: 365-38.
13.
Seeff LB, Zimmerman HJ, Wright EC, et al. A randomized, double blind controlled trial of the efficacy of immune serum globulin for the prevention of post-transfusion hepatitis: a Veterans Administration cooperative study. Gastroenterology 1977, 72, 111-21.
14.
Ruprecht RM, Bronson R. Chemoprevention of retroviral infection: success is determined by virus inoculum strength and cellular immunity. DNA Cell Biol 1994; 13: 59-66. [ PUBMED ]
15.
Fazely F, HaseltineWA, Rodger RF, Ruprecht RM. Postexposure hemoprophylaxis with ZDV or ZDV combined with interferon-a: failure after inoculating rhesus monkeys with a high dose of SIV J. Acquir Immune Defic Syndr 1991, 4: 1093-7.
16.
Otten RA, Smith DK, Adams DR, et al. Efficacy of postexposure prophylaxis after intravaginal exposure of pig-tailed macaques to a human-derived retrovirus (human immunodeficiency virus type 2) J. Vro12000; 74:9771-5.
17.
Martin LN, Murphey-Corb M, Soike KF, Davison-Fairburn B, Baskin GB. Effects of initiation of 3'-azido, 3'-deoxythymidine (zidovudine) treatment at different times after infection of rhesus monkeys with simian immunodeficiency virus. J. Infect Dis 1993; 168: 825-35. [ PUBMED ]
Tables [Table - 1]
Previous Article
Next Article
Contact us | Sitemap | Advertise with us | What's New | Disclaimer
© 2004 Indian Journal of Medical Sciences
A journal site by Medknow
Dublin Core used here
W3C XHTML 1.0
W3C CSS
Bioline
213,400 visitors since 15 th December '04