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

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 INTERVENTIONS IN SELECTED HOSPITALS IN HANOI Specialization: PUBLIC HEALTH Code: 62.72.03.01 SUMMARY OF PUBLIC HEALTH DOCTORAL THESIS Người hướng dẫn: PGS.TS. Nguyễn Thị Hồng Tú PGS.TS. Trịnh Thị Ngọc Hanoi, 8/2012 The thesis has been completed at: National Institute of Epidemiology SUPERVISORS : Prof. Nguyen Thi Hong Tu, MD, MPH, PhD Prof. Trinh Thi Ngoc, MD, PhD Reviewer 1: Reviewer 2: Reviewer 3: ABBREVIATIONS AIDS Acquidred Immunodeficiency Syndrome 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. OBJECTIVES: 1. To describe the actual situation and characteristics of occupational needlestick injuries amongst HCWs in selected hospitals in Hanoi. 2. To estimate burden of diseases caused by occupational needlestick injuries of HCWs in a hospital. 3. To assess effectiveness of interventions on prevention of needlstick injuries in HCWs. RESEARCH CONTENTS - 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 2 – Using gloves 3 – Using PPEs (masks, googles, shoes…) 4 – Safe injection 5 – Treatment of medical equipment: cleaning, disinfection, sterilization 6 – Management of cloth 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. 2.3.1.3. Intervention study: - Study design: Interventional epidemiology study with Before – After study design in order to assess effectiveness of some intervention measures in 2 selected HCFs. - Sample size and sampling: 602 HCWs of Thanh Nhan Hospital and Dong Anh HCC these 2 HCFs were intentionally selected for intervention. For injection practice assessment, due to limitations in time and budget, observations were just carried out in departments at high risk in these 2 HCFs. 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: [...]... working condition and knowledge on prevention of NSI in selected hospitals in Hanoi Journal of Preventive Medicine, Module XIX, No 7 (106) 2009, p.5-13 Hanoii, 2009 2 Investigation of safe injection practice in some health care facilities in Hanoi Journal of Preventive Medicine, Module XX, No 8 (116) 2010, p.113119, Hanoi, 2010 3 Study on needlestick injuries in selected health care facilities in Hanoi. .. equipment and personal protective equipment; Building an effective occupational health program including vaccinations, personal protective equipment, health monitoring The construction of an effective occupational health program including health surveillance, exposure monitoring, to improve working conditions for health workers is essential, it should be added to the interference pattern CONCLUSIONS 1 Actual... providing new first disposable syringes and needles when conducting injection Use injection equipment and safety is a factor contributing to reduce the risk of infection through NSI Orenstein et al compared the NSI 6 months before and after the application of safety-cylinder device and injection needle The results show overall percentage of NSI is 61%, the proportion of NSI related to needle injection... Withdrawing piston to check before pumping 0.29 38.0 Two-hand re-capping (before injection) 52.4 50.0 Two-hand re-capping (after injection) 60.6 36.2 Isolating contaminated syringes and needles in hard containers 31.2 52.8 3.4.3 Model of reporting and notifying of NSI: A model of report, record, follow-up and management os NSI (postexposure management) was applied in order to minimize the consequences... intervention efficiency index (29.2% and 76, 9%) Table 5 Effective intervention to improve the practice of HCWs Practice indicators Before-After Effectiveness indicator (%) Thanh Nhan Thanh Nhan Preparation on a clean designated table or tray 11.1 6.1 Proper hand-washing/ disinfecting before preparing for injection and conducting injections 36.5 21.4 Keeping needle used for extracting the medicine on the... After the intervention, the hospital was in the process of building up a system of reporting and tracking system records, recognizing the injuries with the participation of the Board of Directors, leaders of hospitals and the Department of Infection Control CHAPTER 4 DISCUSSION 4.1 Situation of NSI in HCWs and related factors: Research results indicate that the number of health workers FLC by VSN in the... number of infections related to NSI Initial prevalence estimates: With HBV is based on the prevalence in the community But HCWs exposed to populations of patients can have significantly higher prevalence The rate of infection in patients: In the study of occupational health in our country often described the rate of infection in healthcare workers that is not interested in the rate of infection in patients... (preparation given in a table / tray clean, antiseptic hand before preparing the injection and before the injection or withdrawal of the piston pump test before drug) are good effective interventions (6.1% and 38.0%) The high-risk practice (store needles to take drugs on the bottle, use two hands to close the needle before and after injection) were significantly reduced after intervention with the intervention... against hospital infections - Instrument cleaning, sterilization: After the intervention, the number of health workers to provide a full range of cleaning equipment sterilization also increased significantly compared with before the intervention According to Wilburn S Et al the occupational health and safety measures urgently needed include: appropriate training for employees; Provide equipment and. .. perfect to expand in the country will bring many benefits useful strategy to prevent injuries in healthcare workers 4.3.2 Effectiveness of interventions by health education measures: Post-intervention survey results showed that health workers have been raising awareness, improve the practice, namely: Knowledge: Percentage of health workers know about the transmission of pathogens through blood increased . 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 INTERVENTIONS. Preparation on a clean designated table or tray 11.1 6.1 Proper hand-washing/ disinfecting before preparing for injection and conducting injections 36.5 21.4 Keeping needle used for extracting. effective and feasible interventions aiming at protecting HCWs’ health is neccessary. OBJECTIVES: 1. To describe the actual situation and characteristics of occupational needlestick injuries amongst