Epidemiology of needlestick and sharp injuries at a university hospital in a developing country: A 3-year prospective study at the Jordan University Hospital, 1993 through 1995

Epidemiology of needlestick and sharp injuries at a university hospital in a developing country: A 3-year prospective study at the Jordan University Hospital, 1993 through 1995

Epidemiology of needlestick and sharp injuries at a university hospital in a developing country: A 3-year prospective study at the Jordan University H...

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Epidemiology of needlestick and sharp injuries at a university hospital in a developing country: A 3-year prospective study at the Jordan University Hospital, 1993 through 1995 Najwa A. Khuri-Bulos, MD Ala Toukan, MD Azmi Mahafzah, MD Manal AI Adham, RN Ibrahim Faori, RN Ilham Abu Khader, MPH, CIC Zuhdi I. Abu Rumeileh, RN, MSN Amman, Jordan

Objective: To study the epidemiology of needlestick and sharp injuries in a university hospital in a developing country, Jordan. Methods: A prospective study was undertaken of all needlestick and sharp injuries among workers at the Jordan University Hospital between 1993 and 1995. Health care workers were asked to report in person to the infection-control team to verify the incident and to respond to a questionnaire. Blood was obtained from patients and health care workers immediately and from the health care workers 6 months later for hepatitis B virus, hepatitis C virus, and HIV testing. Results: During the 3-year period, 248 health care workers had needlestick and sharp injuries. Of these, 34.6% were staff nurses, 19%, environmental workers, 15.7%, interns, 11.7%, residents, 8.5%, practical nurses, and 6% were technicians. The incidence density was highest for the interns followed by staff nurses and environmental workers. Of incidents, 22.6% occurred during blood drawing, 11.3% during placing intravenous lines, 8.5% during administration of medication, 11% during recapping the needle, 10.5% during needle disposal, 12.5% during garbage collection, and 5% were caused by a neglected needle. Only 117 patients were identified; 36 of 62 of these had positive results for hepatitis B surface antigen, and 8 of 13 for hepatitis C virus. Conclusion: Needlestick and sharp injuries occur frequently in developing countries. Safer disposal facilities and routine hepatitis B vaccine should be adopted. (AJIC Am J Infect Control 1997;25:322-9)

Even though employee health issues were not addressed until lately, 1 infection control (IC) From the Department of Pediatrics and Internal Medicine and Blood Bank,.Jordan University Hospital, Amman, Jordan. Supported in part by a grant from the Higher Council for Science and Technology, Amman, Jordan. Reprinf requests: Najwa Khuri-Bulos, MD, Professor, Department of Pediatrics, Jordan University Hospital, Amman, Jordan. Copyright © 1997 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/97 $5.00 + 0

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among health care workers (HCWs) has become a s u b j e c t o f m a j o r c o n c e r n i n r e c e n t y e a r s . 2-4 T h i s subject remains largely ignored in developing countries, however, because the magnitude of the p r o b l e m is ill d e f i n e d , a n d r e g u l a t i o n s t o e n f o r c e I C m e a s u r e s ( e v e n if t h e y a r e p r o p o s e d ) a r e nonexistent. Among the most serious infections acquired by HCWs are hepatitis B (HBV), hepatitis C (HCV), and HIV infections, all of which can be transmitted by blood and by contaminated n e e d l e s t i c k a n d s h a r p i n j u r i e s ( N S S I s ) 2 To p r e vent such infections, universal precautions were

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introduced in developed countries and are recomm e n d e d by such international groups as the World Health Organization. The necessary provisions for such recommendations, which include gloves and proper needle-disposal facilities, are costly and are usually not present in most health care facilities in developing countries, making adherence to universal precautions almost impossible. The risk from such incidents is further confused by the lack of reliable data about the incidence or prevalence of occupational exposure through NSSIs in these countries. In fact, a Medline search of the literature for the past 5 years showed that only three studies addressing this issue were published from such countries. 6-8 In 1992, after the occurrence of acute HBV infection in two HCWs, the IC committee at the Jordan University Hospital (JUH) r e c o m m e n d e d introducing HBV vaccine at no charge to all HCWs at risk for blood exposure. The committee also decided that this is justifiable because the HBV surface antigen (HBsAg) carrier rate in the Jordanian population is relatively high, 5% to 10%. 9 The hospital administration, however, could not justify the high cost of the vaccine, approximately $50 per HCW, and cited reports of such incidents, only two to four per year, as too rare to warrant this costly strategy. Because no system of reporting was in operation at that time, it was decided to study this subject further. A prospective study of NSSIs at the JUH was begun in January 1993 and is ongoing. The aim of this study was to identify the magnitude of such events, the types of HCWs involved, and the activities leading to NSSIs in HCWs. The ultimate aim was to introduce preventive strategies at the JUH and if possible in Jordan as a whole. MATERIALS AND METHODS

The JUH is a 500-bed teaching tertiary care hospital that started functioning in 1974. It is one of three major hospitals serving a population of approximately 1,500,000 inhabitants in the city of Amman, the capital of Jordan. It also serves as a referral center for m a n y of the peripheral hospitals in Jordan. The IC committee was started at the JUH in 1980. The work of this committee initially consisted of making IC policies. Surveillance was started in 1985, when an IC nurse joined the team. Employee health issues were limited to kitchen workers and food handlers, w h o had routine stool examinations for enteropathogens every 3 months. This practice was ultimately aband o n e d in 1989, after a massive o u t b r e a k of

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S a l m o n e l l a gastroenteritis among hospital work-

ers that occurred despite this policy. 1° Starting in January 1993, a written memorand u m was circulated to all hospital departments alerting their workers to report all NSSIs within 48 hours to a team of two IC nurses. After an initial report to their supervisors, the HCWs were to report in person to the IC office within 48 hours of the incident. Verification of the incident by the IC team was done at that time, and a questionnaire was completed and kept on file. This included the name, sex, work location, and activities leading to the incident, the type of injury incurred, the place, and wherever possible, the diagnosis of the involved patients. To document this for possible employee compensation, an incident report also was filed at the employee office and the social security office. HBV, HCV, and HIV status were to be determined on all patients and HCWs involved immediately after the incident. These were to be repeated on all HCWs 6 months later. The tests performed included HBsAg, which was done by a direct noncompetitive sandwich enzyme imm u n o a s s a y (Sorin Biomedica, Saluggia, Italy). The assay was performed as r e c o m m e n d e d by the manufacturer by using its equipment in a semiautomated system. Antibodies to HCV were measured by an enzyme i m m u n o a s s a y with Murex Diagnostics reagents (Murex anti-HCV Version III). HIV testing was done by an enzyme immunoassay with Wellcozyme HIV 1 and 2 reagents (Murex Diagnostics Ltd., Central Road, Temple Hill, England). HBV vaccine was offered to all involved HCWs at no charge, regardless of the HBV status of the patient, but the laboratory tests were to be paid for in part by the workers. The laboratory tests requested would have cost $150 for the HCWs and $75 for the patient. The vaccine used was Engerix B (SmithKline Beecham, Philadelphia, Pa.). All vaccines were given intramuscularly in the deltoid region. Because HBV i m m u n e globulin was unavailable in the hospital and most HCWs could not afford the increased expense ($100), only four HCWs received this for postexposure prophylaxis. The questionnaires were entered into Epi Info software (Epi Info; Centers for Disease Control and Prevention, Atlanta, Ga.), and the annual incidentdensity rates were calculated per 1000 HCW-years. This was performed by determining the n u m b e r of incidents encountered per year divided by the n u m b e r of employees in that category during that same year and multiplied by 1000. A Z2 analysis was used for comparison of rates by means of the

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Staff Nurses 34.7%

Practical Nurses 8.5%

Others 4.4%

Environmental Workers 19.0%

Interns 15.7%

A

Technicians 6.0% Resident 11.7%

Intern L

~se

Staff NurseJan

B

Enwlul.nunL

i Resident

Laboratory tecn

Fig, 1. A, Relative frequency of NSSIs among HCWs at the JUH, 1993 through 1995. B, Incidence of NSSIs among HCWs at the JUH, 1993 through 1995. CSSD, Central Supplies and Sterilization Department.

AICE statistical package (Infection Control and Prevention Analysts, Inc., Austin, Texas). RESULTS

From 1700 to 1750 workers were employed per year during the 3-year observation period. Of these, only 1015 of 1713 in 1993, 1023 of 1745 in 1994, and 1001 of 1750 in 1995 were engaged in patient-related activities. These are the only employees included in the data analysis. In the 3-year period between January 1993 and December 1995, 248 NSSIs were reported to the IC team. Seventy-nine (31.9%) were reported in 1993, 94 (37.9%) occurred in 1994, and 75 (30.2%) were reported in 1995. Fig. 1 (,4) depicts the number and relative frequency of involved HCWs. As can be seen, the nurses accounted for the largest n u m b e r of HCWs involved, 107. Eighty-six of these were staff nurses (SNs), and 21 were practical nurses (PNs). The housestaff, interns, and residents were the next largest group, followed by the environmental workers.

Consultants were the smallest group. Only three reported NSSIs in the period of observation. Fig. 1 (B) demonstrates the annual incidence density per 1000 HCWs. It is noteworthy that the interns had the highest incidence density, almost three times that noted in the nurses as a group. The difference between the interns and the SNs, who were the second largest group, was statistically significant (p < 0.05; odds ratio, 6.98; CI, 4.49 to 10.82). The environmental workers were the third largest risk group involved, with values almost as high as those of the SNs. Table 1 depicts the n u m b e r of reported incidents per HCW per year and the rates per 1000 HCW. The interns had the highest incidence density in all the years of observation, although there was a decrease in the incidence density between 1993 and the following years. This was statistically not significant, however. The lowest risk ratio was found for the consultants, w h o had a ratio of 11:1000. The total average annual rate was 82:1000 HCWs.

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Table t , Incidence and rate of NSSIs among different HCWs at JUH, 1993 through 1995 1993

HCW

Intern SN Environment Resident Laboratory technician Anesthesia technician CSSD technician SN Consultants Companion Medical student Nursing student Technician student Total

No. of incidents

1994

No. of workers

Rate*

No. of incidents

1995

No. of workers

Rate*

No. of incidents

Total incidents

No. of workers

Rate*

No.

%

Average rate*

12 29 11 10 5

19 258 171 138 69

632 112 64 72 72

15 33 22 8 4

36 281 171 139 69

417 117 129 58 58

12 24 14 11 2

31 270 155 151 69

387 89 90 73 29

39 86 47 29 11

15.7 34.6 19 11.7 4.4

453 106 95 68 53

0

13

0

1

13

77

1

13

77

2

0.8

51

0

20

0

0

20

0

2

18

111

2

0.8

37

8 1 0 1 0 2

231 96

35 10

8 1 1 0 1 0

200 94

40 11

5 1 1 0 1 1

200 94

25 11

21 3 2 1 2 3

8.5 1.2 0.8 0.4 0.8 1.2

33 11

79

1015

78

94

1023

92

75

1001

75

24

100

82

CSSD,Central Supplies and Sterilization Department. *Rate expressed as number per 1000 HCWs per year.

Table 2. Type and rate of incidents leading to NSSIs among HCWs at the JUH, 1993 through 1995 Total Type of incident

1993

1994

1995

No.

%

Annual rate*

During blood drawing, placing intravenous lines, or medication Garbage disposal Needle disposal Surgery-related injuries Others Total

35 11 18 10 5 79

47 24 16 4 3 94

23 13 19 17 3 75

105 48 53 31 11 248

45.3 19.3 21.4 12.5 4.4 100

34.5 15.9 17.6 10.4 3.6 82

*Rate expressed as number per 1000 HCWs per year.

Table 2 demonstrates the types of incidents leading to NSSIs. Of these incidents, 105 (42.4%) were related to gaining intravenous access; in 56 (22.6%) instances, the incidents occurred while trying to draw blood, 28 (11.3%) occurred during placing the needle in the patients, and 21 (8.5%) incidents occurred during administration of medication. Disposal of the needle accounted for 53 (21.4%) of the incidents; 27 (11%) occurred during recapping the needle, and 26 (10.5%) occurred during placing the needle in the disposal box. The 39 (15.6%) remaining incidents were also related to administering care to patients. Wounds sustained during cleaning surgical instruments occurred in 7 (2.8%) instances, blade injury not related to surgical intervention in 6 (2.4%) instances, cut wound contaminated by blood in 5

(2.0%), blade injury during surgery in 5 (2.0%), surgical suture stick in 5 (2.0%), drawing samples other than blood in 3 (1.2%), eye splash in 3 (1.2%), dental instruments in 1 (0.4%), drain injury in 1 (0.4%), laboratory stick during plasmapheresis in 1 (0.4%), mouth splash in 1 (0.4%), and human bite in 1 (0.4%). Thus 197 (79.4%) injuries occurred during patient-related activities by the HCWs. The remaining 51 (20.6%) incidents were deemed to be unrelated to direct patient care. These were 31 (12.5%) NSs during garbage collection, 12 (5%) NSs by a neglected needle in the patient's surroundings, 5 (2.0%) wound injuries caused by cut glass, 2 (0.8%) NSs in the soiled linen, and 1 (0.4%) was unknown. The annual incidence per HCW was highest for blood drawing (18.4/1000), placing intravenous and

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Table 3. Types of NSSIs in different HCWs at the JUH, 1993 through 1995 Type of incident

SN

PN

Resident

Environmental services

Intern

Others

Total

%

During blood drawing Garbage collection Placing intravenous lines Recapping Needle-disposal box Administering medication Neglected needle Cleaning surgical instrument Others Total

10 0 18 9 16 16 0 3 14 86

3 0 4 3 3 2 2 1 3 21

11 0 4 2 1 1 1 0 9 29

0 31 0 0 5 0 6 1 4 47

26 0 2 6 1 0 0 0 4 39

6 0 0 7 0 2 3 2 6 26

56 31 28 27 26 21 12 7 40 248

22.6 12.5 11.3 11.0 10.5 8.5 4.8 2.8 16 100

Table 4. Hospital service in which NSSIs occurred at the JUH, 1993 through 1995 Service

SN

PN

Intern

Resident

Environmental services

Others

Total

%

Medical/pediatric wards General/special surgery Operating room Medical/surgical/neonatal ICUs Obstetric and gynecologic wards Laboratories Others Total

34 20 4 14 7 0 7 86

7 6 1 2 1 0 4 21

24 6 1 4 3 1 0 39

9 8 5 5 2 0 0 29

10 14 2 4 3 1 13 47

3 7 3 1 0 10 2 26

87 61 16 30 16 12 26 248

34 24.6 6.5 12.1 6.5 4.8 10 100

ICUs, Intensive care units.

administering medications combined (16.1/1000), garbage collection (10.2/1000), recapping of needles (9/1000), cleaning box 8.5/1000, neglected needle (4/1(500), and other miscellaneous activities (15.5/1000). Table 3 shows the different incidents in the major groups of HCWs. Placing the intravenous and administering medication were the most c o m m o n causes of NSSIs among nurses. The interns were most frequently affected during blood drawing, whereas garbage collection was the most c o m m o n type of incident in the EWs. Recapping accounted for 11% of NSSIs. Nurses and interns were the most frequently affected HCWs during recapping. In all 3 years, the n u m b e r of incidents reported in July, August, and December exceeded those in other months. The collective n u m b e r for these months was 97 versus 151 for the remaining 9 months, with a monthly rate of 10.7 versus 5.6 (p < 0.05). The excess rate in these months was mainly caused by the increased numbers of incidents among the new interns and residents during the months of July and August and among nurses in December. The location of incidents also differed between the different groups of HCWs with

the medical and pediatric wards the most frequent sites (Table 4). Even though the employees were asked to submit serum for testing, only a minority did so. All HCWs were offered HBV vaccine at no charge, and even that was not fully adhered to. The identity of the index patient was known in 117 (47%) of 248 injuries, but blood for serologic testing was obtained in 62 instances only. Thirty-six (58%) of these patients tested were HBsAg seropositive. HIV was tested for in eight instances. The test results were weakly positive by enzyme-linked i m m u n o s o r b e n t assay but negative by Western blot in one instance. Only 13 samples obtained from patients were tested for HCV, and 8 (62%) yielded positive results. In reviewing the action taken on the HCWs who incurred NSSIs by HBsAg seropositive patients, only 5 were tested for HBV and were negative. None of them had repeated testing 6 months later. Nine of them received one dose of vaccine; 4 others had two doses, 8 had three doses of vaccine. Three received a booster dose, and 3 others received hepatitis B i m m u n e globulin because they had been previously vaccinated. In 9 others, the vac-

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cine was prescribed, but it is not known whether they received the vaccine. One year after the beginning of the study and after the first yearly report was submitted to the administration, HBV vaccine was provided free of charge to all HCWs at risk of exposure. The administration further agreed to provide HBV vaccine to all medical and dental students at half price. DISCUSSION

Although use of needles and sharps is part of routine hospital care, only lately have employeesafety aspects of these procedures been addressed seriously.3, u In developing countries, lack of interest in this subject occurs when many diseases transmitted by such devices, such as HBV and HCV, are endemic. 9, 12 HIV also is spreading in some of these countries at an alarming rate, further adding to the urgency of this matter. 13 Whereas the transmission of HIV poses great concern to HCWs, TM HBV and HCV seem to trigger lesser action, even though the risk of transmission of some of these diseases is greater than that for HIV. In a recent article by Zuckerman, 15 comparing the risk between HIV and HBV in the health care setting, the author concluded that the " r i s k . . . associated with a needle stick injury from a patient with symptomatic HIV infection is comparable to that from a patient w h o is seropositive for HBsAg and is less than that from a patient w h o is seropositive for HBeAg." Thus although HCWs are concerned mainly about HIV infection, in countries where HBV is prevalent, HCWs run a high risk of this infection being transmitted to them. HCV is also of some concern16. 17 because the rate of transmission may be as high as 8% to 10%. is, 19 In our population, 58% of patients tested were HBsAg seropositive, and 62% were HCV seropositive. Although this m a y be the result of sampling bias (HCWs more likely to check patients if they thought they were at high risk of infection), this rate is still very high and is worthy of further study. In comparing the leading incidents among the different HCWs, it became apparent that varying activities constituted major risks to the different HCWs. This has great implications for the types of preventive measures r e c o m m e n d e d to minimize such incidents. Placing the intravenous was the most important risk activity in the SNs followed by needle stick during placing the needle in the needle-disposal box. In the interns, who had the highest incidence density, drawing blood was

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the activity with the greatest risk. The rate in the interns was m u c h higher than that encountered in other series and is similar to the rate seen in phlebotomists. 2° Because the activities that led to the greatest n u m b e r of incidents were related to placing intravenous lines, administering medications, drawing blood, and disposal of needles, the existing procedures used at the time of the study were reviewed. The HCWs had no specific protocol for either obtaining blood or administering intravenous or intramuscular injections. There were no designated trolley, gloves, or disposal facilities at the bedside. HCWs frequently worked alone, and patients were often unrestrained during these procedures. Sharps and needles used were either disposed in garbage collectors in the patients' rooms or carried back to the needle-disposal box. Most nurses and housestaff knew that they should not recap the needles, but many of them felt compelled to do this because they might injure others. Needledisposal boxes were m a d e of cardboard boxes provided from the supplies department. These were empty boxes from the hospital receivables and were made up each morning by the nurses, who sealed the opening with tape and made a window about 15 x 10 cm in width. These were used until filled and then sealed with tape and placed in black u n m a r k e d non-puncture-resistant ordinary garbage-disposal bags and sent by the EW to the hospital incinerator. Assigning an assistant to help in restraining patients, as well as using needle cutters or burners, and placing disposal boxes either in patients' rooms or on special trolleys for that purpose, might decrease these incidents. Training newly recruited housestaff in early July in blood drawing and other procedures would be helpful. In the long run, use of punctureresistant disposable boxes is necessary, b u t their expense at this stage is prohibitive. The increase in NSSI rate among the nurses in December m a y be because many of them take their annual leave during that month, thus increasing the workload on the remaining personnel. Proper allocation of the workload should decrease this problem. The n u m b e r of NSSIs reported by the consultants was very low. Only three incidents were reported in the 3-year period. The ratio was 11/1000. This m a y be because most consultants are usually not involved in p r o c e d u r e s that increase the risk of NSSIs. In some high-risk occupations such as surgery, however, this may not be the case. A more plausible explanation may be that the consultants are less likely to

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report such incidents. Of eight surgeons interviewed, all confessed to having an NSSI in the past 3 years, and five of them had been exposed in the last year of observation. Many claimed they h a d no knowledge of the work of the IC team, and others had received the HBV vaccine and thus felt protected. An added concern is that only 20 of the 50 consultants completed the HBV vaccination series. The subject of underreporting of NSSIs among HCWs was further evaluated in a preliminary study on the nurses, both SNs and PNs, !67 of w h o m were queried a b o u t the occurrence of NSSIs in the past 12 months and whether they reported the incidents. Thirty-four, 26 SNs and eight PNs, had NSSIs but failed to report this because they had received the HBV vaccine and felt they did not need t o inform the IC team. Twenty-two others, 17 SNs and five PNs, reported the incident. Six of those needed further hepatitis B vaccines. The most c o m m o n cause cited for nonreporting was that the patient appeared well, had a negative HBsAg, and the nurse felt secure because of having received the hepatitis B vaccine. This finding is very worrisome and indicates the need for further education of the HCWs who feel secure after having received the HBV vaccine, without the proper knowledge of risk from other infections. The fact that HIV is distinctly rare in our population exaggerates this relaxed attitude toward NSSIs, The magnitude of and reasons for underreporting will be investigated further, b u t this indicates that the actual magnitude of the problem of NSSIs m a y even be greater than we had documented. In comparing our HCWs with others, most studies show that SNs and PNs as a group are the largest affected, followed by the EW and the medical staff. 2>23 In the AIDs era, the medical staff became the second largest group possibly b e c a u s e of increased reporting of N S S I s . 24

It is disappointing that HCWs failed to provide blood for testing. This is especially worrisome because the rate of HBsAg seropositive carriers in the patients tested was far in excess of that noted for the population as a whole (58% vs 5% to 10%). A similar finding among our patients was reported previously by Madanat and coworkers 25 and in other institutions by others. 26 It is also of concern that 8 of 13 patients tested for HCV antibodies were seropositive. This too is in excess of the national average (62% vs 1% to 3%) but must be verified. Because the HCWs were unwilling to pay

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for testing, this aspect of the study remains incomplete and will have to be studied further. This study underscores the inadequacy of policies pertaining to occupational health issues at our institution and the country as a whole. For example, although the social security office was informed about these incidents, that office did not recognize the incidents as related to any future illness such as HBV or HCV but rather was willing to give compensation for any immediate illness directly related to the NSSI. The administration also would not shoulder the cost of testing the HCWs for blood-borne pathogens at the time of exposure or afterward, which makes it very difficult for any HCW to claim benefits or compensations at a later date if infection with any of these agents led to infirmity, loss of work, or death. It is also noteworthy that postexposure prophylaxis was limited to the use of HBV vaccine only, because the hepatitis B i m m u n e globulin was deemed too expensive. The same administration was willing to assume the expense for a routine screening for enteropathogens at a cost of about $5000 per year, a procedure that is of dubious utility in preventing disease transmission in hospitals.10 All of this emphasizes the need for a wellorganized program addressing employee health issues. Such a program should include the administrative and logistic aspects of the recommendations made, m a n y of which were unhappily not followed at our institution with the existing resources. In conclusion, this study shows that NSSIs occur frequently in our institution. The rates encountered are in fact in excess of those encountered in similar U.S. institutions, especially for certain groups of HCWs, SNs and interns. Although it is difficult to ascertain, it is likely that similar patterns exist in the remaining hospitals in Jordan and perhaps in the surrounding Arab countries. Efforts should be directed at further definition of the epidemiology and actual risks entailed in different institutions in the country. Preventive measures such as routine use of HBV vaccine and provision of better needle-disposal facilities should be instituted immediately. Regulations that enforce the introduction of these measures will be necessary if compliance with such costly measures is to be assured. We hope that studies such as ours will help to raise the whole issue of employee health in HCWs in developing countries to prevent this major as yet unappreciated problem.

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References

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with acquired immunodeficiency syndrome (AIDS) and related disorders (ARC). Med Care 1987;25:675-85. 15. Zuckerman AJ. Occupational exposure to hepatitis B virus, human immunodeficiency virus: a comparative risk analysis. AJIC Am J Infect Control 1995;23:286-9. 16. Hernandez ME, Bruguera M, Puyuelo T, Barrera JM, Sanchez Tapias JM, Rodes J. Risk of needle-stick injuries in the transmission of HCV in hospital personnel. J Hepatol 1992;16:56-8. 17. Lanphear BP, Linnemann CC Jr, Cannon CG, DeRonde MM, Pendy L, Kerley LM. Hepatitis C virus infection in healthcare workers: risk of exposure and infection. Infect Control Hosp Epidemiol 1994; 15:745-50. 18. 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. AJIC Am J Infect Control 1995;23:273-7. 19. Mitsui T, Iwano K, Masuko K, Yamakazi C, Okamoto H, Tsuda F, et al. Hepatitis C virus infection in medical personnel after needlestick accidents. Hepatology 1992; 16:1109-14. 20. McCormick RD, Maid DG. Epidemiology of needle-stick injuries in hospital personnel. AJIC Am J Infect Control 1981;70:928-32. 21. Ruben FL, Norden CW, Rockewell K, Hruska E. Epidemiology of accidental needle-puncture wounds in hospital workers. Am J Med Sci 1983;286:26-30. 22. Jacobson JT, Burke JP, Conti MT. Injuries of hospital employees from needles and sharp objects. Infect Control 1983;4(2):100-2. 23. Jagger J, Hunt EH, Brand-Elnaggar J, Pearson RD. Rates of needlestick injury caused by various devices in a university hospital. N Engl J Med 1988;319:284-8. 24. McCormick RD, Meisch MG, Ircink FG, Maid D. Epidemiology of hospital sharps injuries: a 14-year prospective study in the pre-AIDS and AIDS eras. Am J Med 1991; 91 (suppl 3B):3015-75. 25. Madanat E Amaout M, Haddadin I, Khreisat M, KhuriBulos N. Prevalence of hepatitis B virus infection in a childhood cancer population in Jordan. Int J Pediatr Hematol OncoI 1995;2:419-21. 26. Louie M, Low DE, Feinman SV, McLaughlin B, Simor AE. Prevalence of bloodborne infective agents among people admitted to a Canadian hospital. Can Med Assoc J 1992;146:1331-4.