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Occupational exposure to bloodborne pathogens among health care workers in Botswana: Reporting and utilization of postexposure prophylaxis
ARTICLE IN PRESS American Journal of Infection Control ■■ (2016) ■■-■■
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American Journal of Infection Control
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Original Research Article
Occupational exposure to bloodborne pathogens among health care workers in Botswana: Reporting and utilization of postexposure prophylaxis Getachew Kassa MSc, MPH a,*, Dejana Selenic MD, MPH b, Maria Lahuerta PhD, MPH a,c, Tendani Gaolathe MD d, Yang Liu PhD, MS b, Garegole Letang MSc d, Cari Courtenay-Quirk PhD b, Nelson Kiama Mwaniki MBCHB, MS e, Sarah Gaolekwe MSc f, Naomi Bock MD, MS b a
Mailman School of Public Health, ICAP-Columbia University, New York, NY Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, GA c Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY d Botswana Harvard AIDS Institute Partnerships, Gaborone, Botswana e Ministry of Health Botswana, Gaborone, Botswana f Centers for Disease Control and Prevention Botswana, Gaborone, Botswana b
Key Words: Bloodborne pathogens occupational exposure postexposure prophylaxis health care worker
Background: This study assessed reporting behavior and satisfaction with postexposure prophylaxis (PEP) systems among health care workers (HCWs) at risk for occupational bloodborne pathogen exposure (BPE) in 3 public hospitals in Botswana. Methods: A cross-sectional survey among HCWs provided information on perceptions, attitudes, and experiences with occupational exposures, reporting, and postexposure care. HCWs potentially in contact with blood or body fluids were surveyed using audio computer-assisted self-interview. Results: Between August 2012 and April 2013, 1,624 HCWs completed the survey; most were women (72%), and almost half (48%) were nurses. Sixty-seven percent of them had ever received training related to BPE management; 62% perceived themselves to be at high risk for BPE. Among the 426 HCWs who were exposed to sharps injuries or splashes in the last 6 months, 160 (37%) reported the exposure. Of these, 111 of the 160 (69%) received PEP, and 79 of the 111 (71%) completed their medication. Whereas >92% of the total HCWs had ever been tested for HIV, only 557 (37%) were tested in their own health facility. Most HCWs (87%, n = 1,406) reported they would be interested in testing themselves. Of HCWs who reported an exposure, less than half (49%, n = 78) were satisfied with existing reporting systems. Conclusions: Underreporting of occupational exposures and dissatisfaction with PEP management is common among HCWs. Improved PEP management strategies and regular monitoring are needed. © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Bloodborne pathogen exposure (BPE) can result from percutaneous injuries (PIs) (ie, needlestick, other sharps injuries) or through contact of blood or body fluids with mucous membranes or nonintact skin. BPE poses a risk of transmission of HIV, hepatitis B (HBV), hepatitis C (HCV), and other pathogens to health care workers (HCWs).1,2
* Address correspondence to Getachew Kassa, MSc, MPH, Mailman School of Public Health, ICAP-Columbia University, 722W 168th St, New York, NY 10032. E-mail address: [email protected] (G. Kassa). Conflicts of Interests: None to report. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Globally, it has been estimated that 3.35 million HCWs experience PI with a contaminated sharp object every year. 2 As a consequence of occupational exposures, 66,000 HBV, 16,000 HCV, and 1,000 HIV infections occur among HCWs each year.2 The World Health Organization estimates that HCWs in Africa, the Eastern Mediterranean, and Asia average 4 needlestick injuries per year.3 The Centers for Disease Control and Prevention estimate that 385,000 PIs occur among HCWs in U.S. hospitals per year.4 Only a few studies have been published on PIs in developing countries5-7; however, PIs in these settings account for 90% of occupationally exposed cases.2,3 Most developing countries do not have well-established surveillance systems for monitoring occupational BPE to blood and body fluids, limiting the accuracy of estimates.
0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2016.01.027
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The efficacy of available postexposure prophylaxis (PEP) regimens is approximately 81% for HIV8 and 85%-95% for HBV, using a combination of HBV immune globulin and vaccine series.9 Although PIs are one of the most common types of injury reported by HCWs, it is believed that they are vastly underreported. Various studies indicate that underreporting of BPE is prevalent in health care facilities worldwide, with rates of underreporting ranging from 19%-86%.9,10 Prompt reporting of needlestick injuries is important, not only for management of the exposure (the efficacy of PEP regimens is approximately 81% for HIV8 and 85%-95% for HBV9), but also for identification of workplace hazards and evaluation of prevention measures.2 Occupational exposure reporting and management systems are important elements of workplace safety programs in health facilities and are integral to preventing infections after BPE.11 In Botswana and the rest of Sub-Saharan Africa, limited data are available on reporting practices of BPE among HCWs. An assessment conducted in health care facilities in Botswana between 2003 and 2004 found that 26% of nurses sustained needlestick injuries annually; however, no information was presented on how many of these injuries were reported.12 The aim of the current study is to assess current reporting behavior and satisfaction with PEP systems among HCWs at risk for occupational BPE in 3 public hospitals in Botswana, a country with an HIV prevalence of 23% among adults.13
backed up daily onto a secure external hard drive. Data were checked periodically for completeness and duplicate entries prior to final analysis.
Statistical analysis Descriptive statistics were computed for variables of interest. Associations between selected covariates and the outcome of interest were examined using the SAS GLIMMIX procedure, with facility as a random effect to control for correlation within facility. Variables with P < .25 in bivariate analysis were included in an initial multivariable model. Backward stepwise elimination was used until all variables in the model had P < .05. Adjusted odds ratios (aORs) and 2-sided 95% confidence intervals (CIs) are presented. Analyses were performed with SAS version 9.2 (SAS Institute, Cary, NC).
Ethical considerations This study was approved by the Columbia University Medical Center Institutional Review Board, the Centers for Disease Control and Prevention Institutional Review Board, and the Botswana Health Research Development Committee.
METHODS Study design and setting A cross-sectional study was conducted in 3 public hospitals in Botswana: a referral hospital and 2 district hospitals. The 3 health facilities were selected using convenience sampling, prioritizing sites that were easily accessible (within a 3-hour drive by car) for study staff based in the country’s capital, Gaborone. Study population From August 2012-April 2013, a survey was conducted among all eligible, consenting HCWs at the 3 facilities using a structured questionnaire administered by the audio computer-assisted selfinterview (ACASI; Nova Research Company, Bethesda, MD) system. Eligible participants included HCWs employed in the facilities whose activities involve potential contact directly with patients or with blood or other body fluids from patients. This included nurses, doctors, clinical officers, dentists, laboratory workers, HIV testing and counseling counselors, phlebotomists, janitors, clinical interns, medical and nursing students, mortuary workers, cleaners, waste handlers, drivers transporting laboratory samples, and laundry workers. Additional eligibility criteria included being at least 18 years old, able to read and understand English or Setswana, and able to provide written consent. Data collection The structured questionnaire included questions about demographics, HCW cadre, and perceptions, attitudes, and experiences with occupational BPE and PEP. The questionnaire was administered in English and Setswana. ACASI data were collected using encrypted password-protected tablets that had been programmed using the Questionnaire Development System software (Nova Research, Bethesda, MD). The ACASI software was programmed to include skip patterns and internal data checks to avoid implausible answers. Data collected were automatically saved into an encrypted and password-protected database and
RESULTS Demographic characteristics of the participants Out of the 1,697 eligible HCWs invited to participate in the study, 1,624 (96%) completed the interview, 24 (1%) did not complete the interview (usually because of emergency calls after they initiated the survey), 48 (3%) did not show up for their scheduled appointment for the survey, and 1 (0%) refused to participate. The demographic characteristics of participants are shown in Table 1. Most respondents were women (72%). Most (70%) were between 21 and 39 years old. Nearly half (48%) were nurses. More than half (61%) had their current job for <5 years.
Table 1 Demographic characteristics of occupational exposure survey participants in Botswana, June 2012-April 2013 (N = 1,624) Variables Sex Male Female Age (y) <20 21-39 40-59 >60 HCW cadre Nurse Medical doctor/officer/HCT counselor Laboratory workers Support staff* Others Work experience in this facility (y) >1 1-5 6-10 >10
n
%
459 1,165
28 72
21 1,136 453 14
1 70 28 1
771 98 66 204 485
47 6 4 13 30
308 678 286 352
19 42 18 22
HCT, HIV counseling and testing; HCW, health care worker. *Includes laundry workers, waste handlers and cleaners.
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Occurrences of occupational exposures Eighty percent (1,297/1,624) of the HCWs had ever started vaccination (3-shot series) against HBV virus (Table 2). However, only 609 (47%) were fully vaccinated. A total of 504 (31%) HCWs reported ever being exposed to sharps injuries, 457 (28%) ever had a blood or body fluid splash, and 130 (8%) ever experienced a human bite injury (Table 2). Among all participants, 426 (26%) experienced a sharps injury or splash in the last 6 months. Among the
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426, 99 (23%) reported a sharps injury, 257 (60%) reported a splash, and 70 (16%) reported both injury and splash. More than onethird (n = 623, 38%) replied that their coworkers had experienced a needlestick or other sharps injury, and 377 (23%) had a coworker who experienced a blood or body fluid splash to eyes, mouth, or nose in the last 6 months. Among those (n = 132) HCWs who recalled their last sharps injury, the most common activities at the time of the injury were performing a procedure (36%) and preparing for a procedure (23%). For
Table 2 Experience with occupational exposure and management among health care workers in Botswana (N = 1,624) Variables Occupational exposure experiences of HCWs (N = 1,624) Ever stuck a needle or sharps injury Ever had blood or body fluid splash Ever had human bite injury Perceived risk to BPE High Medium Low/none Aware of coworkers needle or other sharps injury in the last 6 mo Aware of coworkers who had blood or body fluid splash(s) in the last 6 mo Exposed to sharps injury or body fluid or blood splash in the last 6 mo HCWs who had sharps injury(s) in the last 6 mo HCWs who had splash(s) in the last 6 mo HCWs who had both splash(s) and injury(s) in the last 6 mo Among the HCWs who remember their last injury (n = 87), the type of activity being performed during the incident Performing procedure Preparing for a procedure Cleaning Recapping needle Other or do not remember or do not know Among the HCWs who remember their last splash (n = 132), the type of activity being performed when splash occurred IV or arterial line placement, removal, or manipulation Surgical procedure Cleaning or transporting equipment Phlebotomy and specimen handling Tube placement Vaginal delivery Other HIV testing and hepatitis vaccination HCWs ever tested for HIV and their reasons for ever testing (n = 1,499, 92%) Reasons not related to work I am working at high risk for HIV To get treatment ANC Sharps injury Other Location where the HCWs get HIV testing (n = 1,498) In their own facility where they work Other facility Self-testing HCWs interested on HIV self-testing Received hepatitis B vaccine Completed ≥3 doses of the vaccine HCWs who reported their exposure (n = 160, 38%) How soon reported Immediately within 2 h 2-24 h Received pre- and post-HIV test counseling PEP offered Completed PEP medications (n = 111) Reason to not complete PEP medications (n = 32) Got sick after taking medicine Found out patient is negative or found out laboratory results Do not know or other Received initial (baseline) test for HIV Hepatitis B virus Hepatitis C virus Had follow-up HIV test Satisfied on the overall postexposure care services ANC, antenatal care; BPE, bloodborne pathogen exposure; HCW, health care worker; IV, intravenous PEP, postexposure prophylaxis.
n
%
504 457 130
31 28 8
1,007 419 198 623 377 426 99 257 70
62 26 12 38 23 26 23 60 16
31 20 7 6 23
36 23 8 7 26
34 19 13 12 10 12 32
26 14 10 9 8 9 24
403 264 181 170 80 402
27 18 12 11 5 27
557 888 53 1,406 1,297 609
37 59 4 87 80 47
152 8 86 111 79
95 5 54 69 71
20 6 6
62 19 19
129 27 20 91 78
81 17 13 57 49
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Table 3 Factors associated with occupational exposures in the last 6 months among health care workers in Botswana
Variables Gender Male Female Age ≤20 21 to 39 ≥40 HCW cadre Nurse Medical doctor/Officer/HTC counselor Laboratory workers Support staff Others Work experiences in this facility <1 year 1 to 5 years 6 to 10 years >10 years Ever received training on prevention of exposures Yes No/Don’t know Perceived risk related to BPE High Medium Low/no Availability of HIV PEP services Yes No/Don’t know Last time HIV tested (month) <1 1-6 6-12 >12 Don’t remember
Frequency (%) [n = 1,624]
Occupational exposure in the last 6mths (%) [n = 426]
OR (95% CI)
aOR (95% CI)
459 (28) 1,165 (72)
126 (30) 300 (70)
1.0 0.9 (0.7-1.2)
21 (1) 1,136 (70) 467 (29)
3 (1) 326 (77) 97 (22)
0.6 (0.2-2.2) 1.5 (1.2-2.0) 1.0
0.96 (0.3-3.5) 1.51 (1.1-2.0) 1.0
771 (47) 98 (6) 66 (4) 204 (13) 485 (30)
261 (61) 38 (9) 7 (2) 24 (6) 96 (23)
2.1 (1.6-2.7) 2.6 (1.6-4.1) 0.5 (0.2-1.1) 0.5 (0.3-0.9) 1.0
1.9 (1.4-2.5) 2.9 (1.8-4.8) 0.4 (0.2-1.0) 0.5 (0.3-0.8) 1.0
308 (19) 678 (42) 286 (18) 352 (22)
59 (14) 209 (49) 81 (19) 77 (18)
1.0 2.0 (1.4-2.7) 1.8 (1.2-2.6) 1.2 (0.8-1.8)
1.0 1.5 (1.0-2.2) 1.2 (0.8-1.9) 1.0 (0.6-1.5)
1,092 (67) 532 (33)
298 (70) 128 (30)
1.2 (0.9-1.5) 1.0
1,007 (62) 419 (26) 198 (12)
311 (73) 94 (22) 21 (5)
1.5 (1.2-2.0) 1.0 0.4 (0.3-0.7)
1,268 (78) 355 (22)
346 (81) 79 (19)
1.3 (1.0-1.7) 1.0
175 (12) 458 (31) 325 (22) 456 (30) 85 (6)
62 (16) 125 (32) 90 (23) 104 (26) 12 (3)
1.9 (1.3-2.7) 1.3 (0.9-1.7) 1.3 (0.9-1.8) 1.0 0.6 (0.3-1.1)
1.7 (1.3-2.2) 1.00 0.5 (0.3-0.9)
1.9 (1.2-2.9) 1.2 (0.9-1.6) 1.2 (0.8-1.7) 1.0 0.8 (0.4-1.5)
aOR, adjusted odds ratio; BPE, bloodborne pathogen exposure; HCW, health care worker; PEP, postexposure prophylaxis.
those who recalled their last splash exposure, the most common activities were intravenous or arterial line placement, removal, or manipulation (26%) and conducting a surgical procedure (14%) (Table 2). In multivariable analyses, factors associated with recent (ie, last 6 months) experience of occupational exposure (ie, sharps or blood or body fluid exposure) included the HCW being aged 21-39 years (aOR = 1.5; 95% CI, 1.1-2.0); being a medical doctor, officer, HIV testing and counseling counselor (vs other HCW) (aOR = 2.9; 95% CI, 1.84.8), or nurse (vs other HCW) (aOR = 1.9; 95% CI, 1.4-2.5); having work experience of 1-5 years (vs <1 year) (aOR = 1.5; 95% CI, 1.0-2.2); having a high level of perceived risk of BPE versus a medium risk (aOR = 1.7; 95% CI, 1.3-2.2); and having been tested for HIV in the last month (vs >12 months) (aOR = 1.9; 95% CI, 1.2-2.9) (Table 3). Reporting behavior and PEP management Among all participants, 67% had ever received training on infection prevention related to exposures to blood or body fluids (Table 3). Two-thirds (n = 1,092, 67%) perceived themselves as being at high risk of getting an infection from injection equipment, other bloody sharps, or from infected waste in the health facility. Of the 426 HCWs who had an occupational exposure in the last 6 months, 266 (62%) did not report their last exposure (Table 4). Figure 1 shows the distribution of reasons provided for not reporting occupational exposure. Among the 213 HCWs who provided a reason, 32% did not think that it was a serious injury, 25% perceived the needle or sharp instrument as being unused, 8% did not know that they were supposed to report the exposure, 8% thought nothing useful could be done after the incident, and
5% believed that there was no system in place for reporting occupational exposures at their facility. Among the 160 who reported their last exposure, 29% knew that the patient they were attending was HIV positive, 23% suspected that the patient might be HIV positive, 20% wanted to test themselves for other infections, and 8% felt that they were expected to report. Ninety-five percent of HCWs (n = 152) who reported their exposure did so within 2 hours (Table 2). Of the 111 HCWs who started PEP, 32 (29%) did not complete their medication for various reasons: 20 (62%) did not complete because they got sick after taking Antiretrovirals (ARVs), and 6 (19%) stopped because they found out the source patient was HIV negative. Baseline and follow-up HIV tests were done for 129 and 78 HCWs, respectively, whereas only 54% (86/160) received pre- and post-test counseling services. Only 27 HCWs were tested for HBV, and 20 were tested for HCV during their baseline examination. Less than half (49%) of the exposed HCWs were satisfied with the overall PEP management system in their health facility. HIV testing and vaccination against HBV Over 92% (n = 1,499) of HCWs had ever been tested for HIV. Reasons for HIV testing included reasons not related to work (27%, n = 403), their job put them at high risk for HIV infection (18%, n = 264), and specifically, experiencing a sharps injury (5%, n = 80) (Table 2). Among HCWs who had ever been tested for HIV, only 37% (n = 557) had been tested in their health facility, 59% (n = 888) were tested in another facility, and 4% (n = 53) tested themselves. A large majority (n = 1,406, 87%) of HCWs indicated that they were interested in HIV self-testing. There was a significant association between
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Table 4 Univariate and multivariate logistic regression model on factors associated with reporting an occupational exposure that occurred in the last 6 months among HCWs in Botswana (n = 426)
Variables
Reported exposure (n = 160), n (%)
Did not report or do not remember (n = 266), n (%)
OR (95% CI)
aOR (95% CI)
89 (56) 22 (14) 2 (1) 7 (4) 40 (25)
172 (65) 16 (6) 5 (2) 17 (6) 56 (21)
0.7 (0.4-1.2) 1.9 (0.9-4.2) 0.6 (0.1-3.0) 0.6 (0.2-1.6) 1.0
0.8 (0.4-1.3) 2.21 (1.0-5.1) 0.3 (0.1-1.9) 0.5 (0.2-1.7) 1.0
111 (69) 49 (31)
187 (70) 79 (30)
1.0 (0.6-1.5) 1.00
116 (73) 36 (23) 8 (5)
195 (73) 58 (22) 13 (5)
1.0 (0.6-1.5) 1.00 1.0 (0.4-2.8)
137 (86) 22 (14)
209 (79) 57 (21)
1.7 (1.0-2.9) 1.0
78 (49) 81 (51)
115 (43) 151 (56)
1.3 (0.9-1.9) 1.0
37 (25) 59 (40) 25 (17) 26 (18) 1 (1)
25 (10) 66 (27) 65 (27) 78 (32) 11 (4)
4.4 (2.3-8.7) 2.7 (1.5-4.7) 1.2 (0.6-2.2) 1.00 0.3 (0.0-2.2)
4.6 (2.3-9.2) 2.6 (1.4-4.6) 1.1 (0.6-2.1) 1.0 0.3 (0.0-2.3)
131 (82) 28 (18)
245 (92) 21 (8)
0.4 (0.2-0.7) 1.0
0.3 (0.2-0.6) 1.0
HCW cadre Nurse Medical doctor/Officer/HTC counselor Laboratory workers Support staff Others Ever received training on prevention of exposures Yes No or do not know Perceived risk related to BBP High Medium Low Availability of HIV PEP services Yes No or do not know HCW visit to another sites for PEP services Yes No or do not know Last time HIV tested (month) <1 1-6 6-12 >1 Do not remember HCW who would like to have HIV self-testing Yes No or do not know
1.5 (0.8-2.7) 1.0
aOR, adjusted odds ratio; BBP, bloodborne pathogen; CI, confidence interval; HCW, health care worker; HTC, HIV testing and counseling; OR, odds ratio; PEP, postexposure prophylaxis.
100% •
Others
•
Lack of confidentiality
•
Afraid of test results
•
No reporting system in place
•
Nothing useful could be done
•
Don’t know I was supposed to report
90%
80%
•
Others
•
To protect my family
•
I am expected to report
•
Reporting would help in some way
•
To test for other infections
•
Patient I was caring for might be HIV-positive
•
The patient I was attending to was HIV-positive
70%
60%
50% •
Sharp instrument was unused
40%
30%
20%
•
Not serious injury
10%
0%
Reasons for not reporting, n=213
Reasons for reporting, n=160
Fig 1. Self-reported reasons for occupational exposure reporting behavior among health care workers in Botswana (n = 373).
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having had occupational exposure to bloodborne pathogens and HIV testing (aOR = 1.9; 95% CI, 1.2-2.9). Eighty percent (1,297/1,624) of HCWs had ever started a vaccination series against HBV virus (Table 2). However, only 609 (47%) were fully vaccinated, having received ≥3 doses of the vaccine. Records of BPE reporting at the facilities There was no standardized register and summary report to monitor occupational exposures at the national level, but facilities developed their own registers. Only 2 facilities had reported occupational exposures in their register, and 89 exposures were registered during the 12 months prior to the survey. DISCUSSION Our study showed that although more than a quarter of HCWs in 3 public hospitals in Botswana had experienced an occupational BPE within the previous 6 months, nearly two-thirds did not report this exposure or undergo evaluation for PEP. These low rates of reporting and PEP were in spite of the fact that two-thirds of HCWs had received training on BPE. Although BPE training would be expected to change reporting and PEP practices, it was not associated with occupational exposure to sharps or blood or body fluid. In this sense, our finding differs from other reports, such as a study from Uganda in which the most important risk factor for needlestick injuries was lack of training on such injuries.6 The lack of association in our study suggests that the training administered was ineffective; however, there may be other reasons for the lack of association. Low reporting rates may also be because of inadequate reporting systems. This inference is supported by the low satisfaction with the reporting system among HCWs who reported an exposure. Our study also found that most HCWs had undergone HIV testing and that almost two-thirds had done so outside the facility where they worked. This suggests that there are concerns about the confidentiality of HIV testing within these facilities. Such concerns may also be a factor in low rates of reporting for BPE, for which onsite HIV testing is a routine part of the procedures. This might also help to explain the finding that most HCWs with recent occupational BPE were interested in self-testing for HIV. Occurrence of occupational exposure The occurrence of occupational BPE observed in our study was comparable with other studies conducted in Sub-Saharan Africa, which have reported rates of BPE in HCWs ranging from 25%-60%.5,6,14,15 Occupational BPE is of particular concern in Botswana, a country with the second highest HIV prevalence in the world.13 Interventions to prevent occupational exposures among HCWs in this setting are therefore especially important. Nurses had an increased likelihood of occupational BPE compared with other HCWs, followed by medical doctor, officer, and HIV testing and counseling counselors. Other studies have shown that nurses experience most occupational exposure.14-17 This is likely because of the nature of their work.14,16 A similar study conducted in Kenya showed that 25% of HCWs had been exposed to blood and body fluids.5 Higher occupational exposure has also been reported in other studies, which reported that of HCWs, 48% in Tanzania,14 57% in Uganda,6 and 60% in Zambia15 had experienced at least 1 needlestick injury in a year period. The occurrence of occupational exposure in our study was comparable with these studies and is of particular concern in a country with the second highest HIV prevalence in the world.13
Tailored interventions to prevent occupational exposures among HCWs in Botswana are therefore especially important. A combination of factors contribute for transmission of bloodborne pathogens and the high HIV prevalence itself indicate a great effort to reduce risk of exposure.
Reporting behavior of HCWs In this study, just more than a third of HCWs who had an occupational exposure in the last 6 months reported their exposure to the facility. Various studies identified underreporting as a major obstacle to developing accurate estimates of the incidence of BPE. This affects our ability to develop intervention strategies aimed at minimizing transmission during these incidents.1,6,10 In the current study, one of the major reasons HCWs gave for not reporting was the perception that the exposure was minor or not serious. The other predominant reason was that the sharps material was unused. These reasons are similar to what has been reported in other studies in Sub-Saharan Africa.5,15 Underreporting is a serious issue, and these findings highlight the need for clear protocols and procedures for managing BPE.2,11
PEP management system In this study, almost all HCWs who reported an exposure to the facility did so within 2 hours, but only half received pre- and postHIV test counseling. This could be because of PEP not being necessary for the exposure, ineffective PEP management systems, fear of positive test results, or lack of confidentiality. Low levels of HIV counseling and testing uptake have been documented in other SubSaharan African countries, which likely affects appropriate PEP administration.15 This is an issue that needs to be addressed because prompt reporting of occupational BPE is essential for counseling and PEP to be appropriately administered.14,17 PEP has been shown to effectively reduce the incidence of infection for HBV and HIV.2,9
Occupational exposure and HIV testing and counseling A large proportion of participants reported getting tested for HIV in another facility or testing themselves. This may be because of stigma, fear of being identified positive by their colleagues working in the same facility, or lack of confidentiality of HIV testing in the facility. Potentially, self-testing for HIV offers individuals the opportunity to test for HIV at a time and place they prefer and offers complete privacy to those concerned about confidentiality. However, in such cases, the HCW may not report sharps or blood or body fluid exposure to their health facility.18 Although self-testing for HIV is now feasible, appropriate use remains to be determined. Many questions arise about, for example, quality of results, lack of counseling and links to follow-up services, and potential for misuse.19
Hepatitis vaccination Vaccination is one of the best ways to protect HCWs from HBV infections, and the Centers for Disease Control and Prevention recommends that all HCWs be vaccinated against HBV infection.9 In this study, HBV vaccination was given to 80% of the staff, which was higher than reports from other resource-constrained settings and developed countries.5,15 This was likely impacted by the fact that the Botswana Ministry of Health had a vaccination campaign targeting HCWs at risk that took place during the course of the survey.
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CONCLUSIONS AND LIMITATIONS There were some limitations to the current study. First, it relied on self-report data, which are subject to social desirability and recall bias. This could have resulted in an underestimation of actual BPE. We did not confirm any BPE management by reviewing medical records; however, the ACASI was used to minimize social desirability bias.20 In addition, our results represent the HCWs at 3 health care facilities in Botswana (because we interviewed almost all HCWs in these 3 facilities), and caution should be exercised when generalizing outside of this setting. Understanding the reasons for underreporting BPE in health care facilities is important for informing interventions aimed at improved reporting and case management. This study identified predictors of underreporting. This study also found that most HCWs who reported their exposure were dissatisfied with the current occupational exposure management of BPE system in their health facility. Furthermore, despite many HCWs having received training on BPE, rates of underreporting were still very high. These findings, along with the observed hesitance to undergo HIV testing within their own facility suggest that multicomponent interventions are needed to improve occupational exposure reporting and case management in this and other similar settings. Implementation of well-designed intervention strategies integrated with effective training, assured confidentiality, and regular monitoring can help to improve reporting systems and ultimately decrease transmission of BPE to HCWs. Facilities should have in place a system that includes written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational exposures. References 1. Kessler C, McGuinn M, Spec A, Christensen J, Baragi R, Hershow RC. Underreporting of blood and body fluid exposures among health care students and trainees in the acute care setting: a 2007 survey. Am J Infect Control 2011;39:129-34. 2. Pruss-Ustun A, Rapiti E, Hutin Y. Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers. Am J Ind Med 2005;48:482-90. 3. Wilburn SQ, Eijkemans G. Preventing needlestick injuries among healthcare workers: a WHO-ICN collaboration. Int J Occup Environ Health 2004;10:451-6. 4. Panlilio AL, Orelien JG, Srivastava PU, Jagger J, Cohn RD, Carco DM. The NaSH Surveil lance Group; the EPINet Data Sharing Network. Estimate of the annual
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20.
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number of per cutaneous injuries among hospital-based healthcare workers in the United States, 1997-1998. Infect Control Hosp Epidemiol 2004;25:55662. Mbaisi EM, Naa Z, Wanzala P, Omolo J. Prevalence and factors associated with percutaneous injuries and splash exposures among health-care workers in a provincial hospital, Kenya. Pan Afr Med J 2013;14:10. Nsubuga FM, Jaakkola MS. Needle-stick injuries among nurses in Sub-Saharan Africa. Trop Med Int Health 2005;10:773-81. Reda AA, Fisseha S, Mengistie B, Vandeweerd J-M. Standard precautions: occupational exposure and behavior of health care workers in Ethiopia. PLoS ONE 2010;5:e14420. Cardo D, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboul D, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med 1997;337:1485-90. Centers for Disease Control and Prevention (CDC). Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Morb Mortal Wkly Rep 2001;50:1-33. Kim OS, Jeong JS, Kim KM, Choi JS, Jeong IS, Park ES, et al. Underreporting rate and related factors after needlestick injuries among healthcare workers in smallor medium-sized hospitals. Korean J Nosocomial Infect Control 2011;16:2936. Kuhar DT, Henderson D, Struble KA, Heneine W, Thomas V, Cheever LW, et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol 2013;34:875-92. Busato CR, Carneiro Leao MT, Gabardo J. Staphylococcus aureus nasopharyngeal carriage rates and antimicrobial susceptibility patterns among health care workers and their household contacts. Braz J Infect Dis 1998;2:78-84. UNAIDS. Global Report 2012: AIDSinfo. 2010. Available from: http://www .unaids.org/en/regionscountries/countries/botswana. Accessed November 2, 2013. Mashoto KO, Mubyazi GM, Mohamed H, Malebo HM. Self-reported occupational exposure to HIV and factors influencing its management practice: a study of healthcare workers in Tumbi and Dodoma Hospitals, Tanzania. BMC Health Serv Res 2013;13:276. Phillips E, Simwale OJ, Chung MJ, Parker G, Perry J, Jagger JC. Risk of bloodborne pathogen exposure among Zambian healthcare workers. J Infect Public Health 2012;5:244-9. Hadadi A, Afhami S, Karbakhsh M, Esmailpour N. Occupational exposure to body fluids among healthcare workers: a report from Iran. Singapore Med J 2008;49:492-6. Amoran OE. Occupational exposure, risk perception and access to prophylaxis for HIV/AIDS infection among health care workers in Northern Nigeria. Br J Med Med Res 2013;3:275-87. Spielberg F, Levine RO, Weaver M. Self-testing for HIV: a new option for HIV prevention? Lancet 2004;4:640-6. Nerby JM, Gorwitz R, Lesher L, Juni B, Jawahir S, Lynfield R, et al. Risk factors for household transmission of community-associated methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J 2011;30:927-32. Edwards S, Slattery ML, Murtaugh MA, Edwards RL, Bryner J, Pearson M, et al. Development and use of touch-screen audio computer-assisted self-interviewing in a study of American Indians. Am J Epidemiol 2007;165:1336-42.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Original Research Article
Occupational exposure to bloodborne pathogens among health care workers in Botswana: Reporting and utilization of postexposure prophylaxis Getachew Kassa MSc, MPH a,*, Dejana Selenic MD, MPH b, Maria Lahuerta PhD, MPH a,c, Tendani Gaolathe MD d, Yang Liu PhD, MS b, Garegole Letang MSc d, Cari Courtenay-Quirk PhD b, Nelson Kiama Mwaniki MBCHB, MS e, Sarah Gaolekwe MSc f, Naomi Bock MD, MS b a
Mailman School of Public Health, ICAP-Columbia University, New York, NY Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, GA c Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY d Botswana Harvard AIDS Institute Partnerships, Gaborone, Botswana e Ministry of Health Botswana, Gaborone, Botswana f Centers for Disease Control and Prevention Botswana, Gaborone, Botswana b
Key Words: Bloodborne pathogens occupational exposure postexposure prophylaxis health care worker
Background: This study assessed reporting behavior and satisfaction with postexposure prophylaxis (PEP) systems among health care workers (HCWs) at risk for occupational bloodborne pathogen exposure (BPE) in 3 public hospitals in Botswana. Methods: A cross-sectional survey among HCWs provided information on perceptions, attitudes, and experiences with occupational exposures, reporting, and postexposure care. HCWs potentially in contact with blood or body fluids were surveyed using audio computer-assisted self-interview. Results: Between August 2012 and April 2013, 1,624 HCWs completed the survey; most were women (72%), and almost half (48%) were nurses. Sixty-seven percent of them had ever received training related to BPE management; 62% perceived themselves to be at high risk for BPE. Among the 426 HCWs who were exposed to sharps injuries or splashes in the last 6 months, 160 (37%) reported the exposure. Of these, 111 of the 160 (69%) received PEP, and 79 of the 111 (71%) completed their medication. Whereas >92% of the total HCWs had ever been tested for HIV, only 557 (37%) were tested in their own health facility. Most HCWs (87%, n = 1,406) reported they would be interested in testing themselves. Of HCWs who reported an exposure, less than half (49%, n = 78) were satisfied with existing reporting systems. Conclusions: Underreporting of occupational exposures and dissatisfaction with PEP management is common among HCWs. Improved PEP management strategies and regular monitoring are needed. © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Bloodborne pathogen exposure (BPE) can result from percutaneous injuries (PIs) (ie, needlestick, other sharps injuries) or through contact of blood or body fluids with mucous membranes or nonintact skin. BPE poses a risk of transmission of HIV, hepatitis B (HBV), hepatitis C (HCV), and other pathogens to health care workers (HCWs).1,2
* Address correspondence to Getachew Kassa, MSc, MPH, Mailman School of Public Health, ICAP-Columbia University, 722W 168th St, New York, NY 10032. E-mail address: [email protected] (G. Kassa). Conflicts of Interests: None to report. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Globally, it has been estimated that 3.35 million HCWs experience PI with a contaminated sharp object every year. 2 As a consequence of occupational exposures, 66,000 HBV, 16,000 HCV, and 1,000 HIV infections occur among HCWs each year.2 The World Health Organization estimates that HCWs in Africa, the Eastern Mediterranean, and Asia average 4 needlestick injuries per year.3 The Centers for Disease Control and Prevention estimate that 385,000 PIs occur among HCWs in U.S. hospitals per year.4 Only a few studies have been published on PIs in developing countries5-7; however, PIs in these settings account for 90% of occupationally exposed cases.2,3 Most developing countries do not have well-established surveillance systems for monitoring occupational BPE to blood and body fluids, limiting the accuracy of estimates.
0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2016.01.027
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The efficacy of available postexposure prophylaxis (PEP) regimens is approximately 81% for HIV8 and 85%-95% for HBV, using a combination of HBV immune globulin and vaccine series.9 Although PIs are one of the most common types of injury reported by HCWs, it is believed that they are vastly underreported. Various studies indicate that underreporting of BPE is prevalent in health care facilities worldwide, with rates of underreporting ranging from 19%-86%.9,10 Prompt reporting of needlestick injuries is important, not only for management of the exposure (the efficacy of PEP regimens is approximately 81% for HIV8 and 85%-95% for HBV9), but also for identification of workplace hazards and evaluation of prevention measures.2 Occupational exposure reporting and management systems are important elements of workplace safety programs in health facilities and are integral to preventing infections after BPE.11 In Botswana and the rest of Sub-Saharan Africa, limited data are available on reporting practices of BPE among HCWs. An assessment conducted in health care facilities in Botswana between 2003 and 2004 found that 26% of nurses sustained needlestick injuries annually; however, no information was presented on how many of these injuries were reported.12 The aim of the current study is to assess current reporting behavior and satisfaction with PEP systems among HCWs at risk for occupational BPE in 3 public hospitals in Botswana, a country with an HIV prevalence of 23% among adults.13
backed up daily onto a secure external hard drive. Data were checked periodically for completeness and duplicate entries prior to final analysis.
Statistical analysis Descriptive statistics were computed for variables of interest. Associations between selected covariates and the outcome of interest were examined using the SAS GLIMMIX procedure, with facility as a random effect to control for correlation within facility. Variables with P < .25 in bivariate analysis were included in an initial multivariable model. Backward stepwise elimination was used until all variables in the model had P < .05. Adjusted odds ratios (aORs) and 2-sided 95% confidence intervals (CIs) are presented. Analyses were performed with SAS version 9.2 (SAS Institute, Cary, NC).
Ethical considerations This study was approved by the Columbia University Medical Center Institutional Review Board, the Centers for Disease Control and Prevention Institutional Review Board, and the Botswana Health Research Development Committee.
METHODS Study design and setting A cross-sectional study was conducted in 3 public hospitals in Botswana: a referral hospital and 2 district hospitals. The 3 health facilities were selected using convenience sampling, prioritizing sites that were easily accessible (within a 3-hour drive by car) for study staff based in the country’s capital, Gaborone. Study population From August 2012-April 2013, a survey was conducted among all eligible, consenting HCWs at the 3 facilities using a structured questionnaire administered by the audio computer-assisted selfinterview (ACASI; Nova Research Company, Bethesda, MD) system. Eligible participants included HCWs employed in the facilities whose activities involve potential contact directly with patients or with blood or other body fluids from patients. This included nurses, doctors, clinical officers, dentists, laboratory workers, HIV testing and counseling counselors, phlebotomists, janitors, clinical interns, medical and nursing students, mortuary workers, cleaners, waste handlers, drivers transporting laboratory samples, and laundry workers. Additional eligibility criteria included being at least 18 years old, able to read and understand English or Setswana, and able to provide written consent. Data collection The structured questionnaire included questions about demographics, HCW cadre, and perceptions, attitudes, and experiences with occupational BPE and PEP. The questionnaire was administered in English and Setswana. ACASI data were collected using encrypted password-protected tablets that had been programmed using the Questionnaire Development System software (Nova Research, Bethesda, MD). The ACASI software was programmed to include skip patterns and internal data checks to avoid implausible answers. Data collected were automatically saved into an encrypted and password-protected database and
RESULTS Demographic characteristics of the participants Out of the 1,697 eligible HCWs invited to participate in the study, 1,624 (96%) completed the interview, 24 (1%) did not complete the interview (usually because of emergency calls after they initiated the survey), 48 (3%) did not show up for their scheduled appointment for the survey, and 1 (0%) refused to participate. The demographic characteristics of participants are shown in Table 1. Most respondents were women (72%). Most (70%) were between 21 and 39 years old. Nearly half (48%) were nurses. More than half (61%) had their current job for <5 years.
Table 1 Demographic characteristics of occupational exposure survey participants in Botswana, June 2012-April 2013 (N = 1,624) Variables Sex Male Female Age (y) <20 21-39 40-59 >60 HCW cadre Nurse Medical doctor/officer/HCT counselor Laboratory workers Support staff* Others Work experience in this facility (y) >1 1-5 6-10 >10
n
%
459 1,165
28 72
21 1,136 453 14
1 70 28 1
771 98 66 204 485
47 6 4 13 30
308 678 286 352
19 42 18 22
HCT, HIV counseling and testing; HCW, health care worker. *Includes laundry workers, waste handlers and cleaners.
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Occurrences of occupational exposures Eighty percent (1,297/1,624) of the HCWs had ever started vaccination (3-shot series) against HBV virus (Table 2). However, only 609 (47%) were fully vaccinated. A total of 504 (31%) HCWs reported ever being exposed to sharps injuries, 457 (28%) ever had a blood or body fluid splash, and 130 (8%) ever experienced a human bite injury (Table 2). Among all participants, 426 (26%) experienced a sharps injury or splash in the last 6 months. Among the
3
426, 99 (23%) reported a sharps injury, 257 (60%) reported a splash, and 70 (16%) reported both injury and splash. More than onethird (n = 623, 38%) replied that their coworkers had experienced a needlestick or other sharps injury, and 377 (23%) had a coworker who experienced a blood or body fluid splash to eyes, mouth, or nose in the last 6 months. Among those (n = 132) HCWs who recalled their last sharps injury, the most common activities at the time of the injury were performing a procedure (36%) and preparing for a procedure (23%). For
Table 2 Experience with occupational exposure and management among health care workers in Botswana (N = 1,624) Variables Occupational exposure experiences of HCWs (N = 1,624) Ever stuck a needle or sharps injury Ever had blood or body fluid splash Ever had human bite injury Perceived risk to BPE High Medium Low/none Aware of coworkers needle or other sharps injury in the last 6 mo Aware of coworkers who had blood or body fluid splash(s) in the last 6 mo Exposed to sharps injury or body fluid or blood splash in the last 6 mo HCWs who had sharps injury(s) in the last 6 mo HCWs who had splash(s) in the last 6 mo HCWs who had both splash(s) and injury(s) in the last 6 mo Among the HCWs who remember their last injury (n = 87), the type of activity being performed during the incident Performing procedure Preparing for a procedure Cleaning Recapping needle Other or do not remember or do not know Among the HCWs who remember their last splash (n = 132), the type of activity being performed when splash occurred IV or arterial line placement, removal, or manipulation Surgical procedure Cleaning or transporting equipment Phlebotomy and specimen handling Tube placement Vaginal delivery Other HIV testing and hepatitis vaccination HCWs ever tested for HIV and their reasons for ever testing (n = 1,499, 92%) Reasons not related to work I am working at high risk for HIV To get treatment ANC Sharps injury Other Location where the HCWs get HIV testing (n = 1,498) In their own facility where they work Other facility Self-testing HCWs interested on HIV self-testing Received hepatitis B vaccine Completed ≥3 doses of the vaccine HCWs who reported their exposure (n = 160, 38%) How soon reported Immediately within 2 h 2-24 h Received pre- and post-HIV test counseling PEP offered Completed PEP medications (n = 111) Reason to not complete PEP medications (n = 32) Got sick after taking medicine Found out patient is negative or found out laboratory results Do not know or other Received initial (baseline) test for HIV Hepatitis B virus Hepatitis C virus Had follow-up HIV test Satisfied on the overall postexposure care services ANC, antenatal care; BPE, bloodborne pathogen exposure; HCW, health care worker; IV, intravenous PEP, postexposure prophylaxis.
n
%
504 457 130
31 28 8
1,007 419 198 623 377 426 99 257 70
62 26 12 38 23 26 23 60 16
31 20 7 6 23
36 23 8 7 26
34 19 13 12 10 12 32
26 14 10 9 8 9 24
403 264 181 170 80 402
27 18 12 11 5 27
557 888 53 1,406 1,297 609
37 59 4 87 80 47
152 8 86 111 79
95 5 54 69 71
20 6 6
62 19 19
129 27 20 91 78
81 17 13 57 49
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Table 3 Factors associated with occupational exposures in the last 6 months among health care workers in Botswana
Variables Gender Male Female Age ≤20 21 to 39 ≥40 HCW cadre Nurse Medical doctor/Officer/HTC counselor Laboratory workers Support staff Others Work experiences in this facility <1 year 1 to 5 years 6 to 10 years >10 years Ever received training on prevention of exposures Yes No/Don’t know Perceived risk related to BPE High Medium Low/no Availability of HIV PEP services Yes No/Don’t know Last time HIV tested (month) <1 1-6 6-12 >12 Don’t remember
Frequency (%) [n = 1,624]
Occupational exposure in the last 6mths (%) [n = 426]
OR (95% CI)
aOR (95% CI)
459 (28) 1,165 (72)
126 (30) 300 (70)
1.0 0.9 (0.7-1.2)
21 (1) 1,136 (70) 467 (29)
3 (1) 326 (77) 97 (22)
0.6 (0.2-2.2) 1.5 (1.2-2.0) 1.0
0.96 (0.3-3.5) 1.51 (1.1-2.0) 1.0
771 (47) 98 (6) 66 (4) 204 (13) 485 (30)
261 (61) 38 (9) 7 (2) 24 (6) 96 (23)
2.1 (1.6-2.7) 2.6 (1.6-4.1) 0.5 (0.2-1.1) 0.5 (0.3-0.9) 1.0
1.9 (1.4-2.5) 2.9 (1.8-4.8) 0.4 (0.2-1.0) 0.5 (0.3-0.8) 1.0
308 (19) 678 (42) 286 (18) 352 (22)
59 (14) 209 (49) 81 (19) 77 (18)
1.0 2.0 (1.4-2.7) 1.8 (1.2-2.6) 1.2 (0.8-1.8)
1.0 1.5 (1.0-2.2) 1.2 (0.8-1.9) 1.0 (0.6-1.5)
1,092 (67) 532 (33)
298 (70) 128 (30)
1.2 (0.9-1.5) 1.0
1,007 (62) 419 (26) 198 (12)
311 (73) 94 (22) 21 (5)
1.5 (1.2-2.0) 1.0 0.4 (0.3-0.7)
1,268 (78) 355 (22)
346 (81) 79 (19)
1.3 (1.0-1.7) 1.0
175 (12) 458 (31) 325 (22) 456 (30) 85 (6)
62 (16) 125 (32) 90 (23) 104 (26) 12 (3)
1.9 (1.3-2.7) 1.3 (0.9-1.7) 1.3 (0.9-1.8) 1.0 0.6 (0.3-1.1)
1.7 (1.3-2.2) 1.00 0.5 (0.3-0.9)
1.9 (1.2-2.9) 1.2 (0.9-1.6) 1.2 (0.8-1.7) 1.0 0.8 (0.4-1.5)
aOR, adjusted odds ratio; BPE, bloodborne pathogen exposure; HCW, health care worker; PEP, postexposure prophylaxis.
those who recalled their last splash exposure, the most common activities were intravenous or arterial line placement, removal, or manipulation (26%) and conducting a surgical procedure (14%) (Table 2). In multivariable analyses, factors associated with recent (ie, last 6 months) experience of occupational exposure (ie, sharps or blood or body fluid exposure) included the HCW being aged 21-39 years (aOR = 1.5; 95% CI, 1.1-2.0); being a medical doctor, officer, HIV testing and counseling counselor (vs other HCW) (aOR = 2.9; 95% CI, 1.84.8), or nurse (vs other HCW) (aOR = 1.9; 95% CI, 1.4-2.5); having work experience of 1-5 years (vs <1 year) (aOR = 1.5; 95% CI, 1.0-2.2); having a high level of perceived risk of BPE versus a medium risk (aOR = 1.7; 95% CI, 1.3-2.2); and having been tested for HIV in the last month (vs >12 months) (aOR = 1.9; 95% CI, 1.2-2.9) (Table 3). Reporting behavior and PEP management Among all participants, 67% had ever received training on infection prevention related to exposures to blood or body fluids (Table 3). Two-thirds (n = 1,092, 67%) perceived themselves as being at high risk of getting an infection from injection equipment, other bloody sharps, or from infected waste in the health facility. Of the 426 HCWs who had an occupational exposure in the last 6 months, 266 (62%) did not report their last exposure (Table 4). Figure 1 shows the distribution of reasons provided for not reporting occupational exposure. Among the 213 HCWs who provided a reason, 32% did not think that it was a serious injury, 25% perceived the needle or sharp instrument as being unused, 8% did not know that they were supposed to report the exposure, 8% thought nothing useful could be done after the incident, and
5% believed that there was no system in place for reporting occupational exposures at their facility. Among the 160 who reported their last exposure, 29% knew that the patient they were attending was HIV positive, 23% suspected that the patient might be HIV positive, 20% wanted to test themselves for other infections, and 8% felt that they were expected to report. Ninety-five percent of HCWs (n = 152) who reported their exposure did so within 2 hours (Table 2). Of the 111 HCWs who started PEP, 32 (29%) did not complete their medication for various reasons: 20 (62%) did not complete because they got sick after taking Antiretrovirals (ARVs), and 6 (19%) stopped because they found out the source patient was HIV negative. Baseline and follow-up HIV tests were done for 129 and 78 HCWs, respectively, whereas only 54% (86/160) received pre- and post-test counseling services. Only 27 HCWs were tested for HBV, and 20 were tested for HCV during their baseline examination. Less than half (49%) of the exposed HCWs were satisfied with the overall PEP management system in their health facility. HIV testing and vaccination against HBV Over 92% (n = 1,499) of HCWs had ever been tested for HIV. Reasons for HIV testing included reasons not related to work (27%, n = 403), their job put them at high risk for HIV infection (18%, n = 264), and specifically, experiencing a sharps injury (5%, n = 80) (Table 2). Among HCWs who had ever been tested for HIV, only 37% (n = 557) had been tested in their health facility, 59% (n = 888) were tested in another facility, and 4% (n = 53) tested themselves. A large majority (n = 1,406, 87%) of HCWs indicated that they were interested in HIV self-testing. There was a significant association between
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Table 4 Univariate and multivariate logistic regression model on factors associated with reporting an occupational exposure that occurred in the last 6 months among HCWs in Botswana (n = 426)
Variables
Reported exposure (n = 160), n (%)
Did not report or do not remember (n = 266), n (%)
OR (95% CI)
aOR (95% CI)
89 (56) 22 (14) 2 (1) 7 (4) 40 (25)
172 (65) 16 (6) 5 (2) 17 (6) 56 (21)
0.7 (0.4-1.2) 1.9 (0.9-4.2) 0.6 (0.1-3.0) 0.6 (0.2-1.6) 1.0
0.8 (0.4-1.3) 2.21 (1.0-5.1) 0.3 (0.1-1.9) 0.5 (0.2-1.7) 1.0
111 (69) 49 (31)
187 (70) 79 (30)
1.0 (0.6-1.5) 1.00
116 (73) 36 (23) 8 (5)
195 (73) 58 (22) 13 (5)
1.0 (0.6-1.5) 1.00 1.0 (0.4-2.8)
137 (86) 22 (14)
209 (79) 57 (21)
1.7 (1.0-2.9) 1.0
78 (49) 81 (51)
115 (43) 151 (56)
1.3 (0.9-1.9) 1.0
37 (25) 59 (40) 25 (17) 26 (18) 1 (1)
25 (10) 66 (27) 65 (27) 78 (32) 11 (4)
4.4 (2.3-8.7) 2.7 (1.5-4.7) 1.2 (0.6-2.2) 1.00 0.3 (0.0-2.2)
4.6 (2.3-9.2) 2.6 (1.4-4.6) 1.1 (0.6-2.1) 1.0 0.3 (0.0-2.3)
131 (82) 28 (18)
245 (92) 21 (8)
0.4 (0.2-0.7) 1.0
0.3 (0.2-0.6) 1.0
HCW cadre Nurse Medical doctor/Officer/HTC counselor Laboratory workers Support staff Others Ever received training on prevention of exposures Yes No or do not know Perceived risk related to BBP High Medium Low Availability of HIV PEP services Yes No or do not know HCW visit to another sites for PEP services Yes No or do not know Last time HIV tested (month) <1 1-6 6-12 >1 Do not remember HCW who would like to have HIV self-testing Yes No or do not know
1.5 (0.8-2.7) 1.0
aOR, adjusted odds ratio; BBP, bloodborne pathogen; CI, confidence interval; HCW, health care worker; HTC, HIV testing and counseling; OR, odds ratio; PEP, postexposure prophylaxis.
100% •
Others
•
Lack of confidentiality
•
Afraid of test results
•
No reporting system in place
•
Nothing useful could be done
•
Don’t know I was supposed to report
90%
80%
•
Others
•
To protect my family
•
I am expected to report
•
Reporting would help in some way
•
To test for other infections
•
Patient I was caring for might be HIV-positive
•
The patient I was attending to was HIV-positive
70%
60%
50% •
Sharp instrument was unused
40%
30%
20%
•
Not serious injury
10%
0%
Reasons for not reporting, n=213
Reasons for reporting, n=160
Fig 1. Self-reported reasons for occupational exposure reporting behavior among health care workers in Botswana (n = 373).
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having had occupational exposure to bloodborne pathogens and HIV testing (aOR = 1.9; 95% CI, 1.2-2.9). Eighty percent (1,297/1,624) of HCWs had ever started a vaccination series against HBV virus (Table 2). However, only 609 (47%) were fully vaccinated, having received ≥3 doses of the vaccine. Records of BPE reporting at the facilities There was no standardized register and summary report to monitor occupational exposures at the national level, but facilities developed their own registers. Only 2 facilities had reported occupational exposures in their register, and 89 exposures were registered during the 12 months prior to the survey. DISCUSSION Our study showed that although more than a quarter of HCWs in 3 public hospitals in Botswana had experienced an occupational BPE within the previous 6 months, nearly two-thirds did not report this exposure or undergo evaluation for PEP. These low rates of reporting and PEP were in spite of the fact that two-thirds of HCWs had received training on BPE. Although BPE training would be expected to change reporting and PEP practices, it was not associated with occupational exposure to sharps or blood or body fluid. In this sense, our finding differs from other reports, such as a study from Uganda in which the most important risk factor for needlestick injuries was lack of training on such injuries.6 The lack of association in our study suggests that the training administered was ineffective; however, there may be other reasons for the lack of association. Low reporting rates may also be because of inadequate reporting systems. This inference is supported by the low satisfaction with the reporting system among HCWs who reported an exposure. Our study also found that most HCWs had undergone HIV testing and that almost two-thirds had done so outside the facility where they worked. This suggests that there are concerns about the confidentiality of HIV testing within these facilities. Such concerns may also be a factor in low rates of reporting for BPE, for which onsite HIV testing is a routine part of the procedures. This might also help to explain the finding that most HCWs with recent occupational BPE were interested in self-testing for HIV. Occurrence of occupational exposure The occurrence of occupational BPE observed in our study was comparable with other studies conducted in Sub-Saharan Africa, which have reported rates of BPE in HCWs ranging from 25%-60%.5,6,14,15 Occupational BPE is of particular concern in Botswana, a country with the second highest HIV prevalence in the world.13 Interventions to prevent occupational exposures among HCWs in this setting are therefore especially important. Nurses had an increased likelihood of occupational BPE compared with other HCWs, followed by medical doctor, officer, and HIV testing and counseling counselors. Other studies have shown that nurses experience most occupational exposure.14-17 This is likely because of the nature of their work.14,16 A similar study conducted in Kenya showed that 25% of HCWs had been exposed to blood and body fluids.5 Higher occupational exposure has also been reported in other studies, which reported that of HCWs, 48% in Tanzania,14 57% in Uganda,6 and 60% in Zambia15 had experienced at least 1 needlestick injury in a year period. The occurrence of occupational exposure in our study was comparable with these studies and is of particular concern in a country with the second highest HIV prevalence in the world.13
Tailored interventions to prevent occupational exposures among HCWs in Botswana are therefore especially important. A combination of factors contribute for transmission of bloodborne pathogens and the high HIV prevalence itself indicate a great effort to reduce risk of exposure.
Reporting behavior of HCWs In this study, just more than a third of HCWs who had an occupational exposure in the last 6 months reported their exposure to the facility. Various studies identified underreporting as a major obstacle to developing accurate estimates of the incidence of BPE. This affects our ability to develop intervention strategies aimed at minimizing transmission during these incidents.1,6,10 In the current study, one of the major reasons HCWs gave for not reporting was the perception that the exposure was minor or not serious. The other predominant reason was that the sharps material was unused. These reasons are similar to what has been reported in other studies in Sub-Saharan Africa.5,15 Underreporting is a serious issue, and these findings highlight the need for clear protocols and procedures for managing BPE.2,11
PEP management system In this study, almost all HCWs who reported an exposure to the facility did so within 2 hours, but only half received pre- and postHIV test counseling. This could be because of PEP not being necessary for the exposure, ineffective PEP management systems, fear of positive test results, or lack of confidentiality. Low levels of HIV counseling and testing uptake have been documented in other SubSaharan African countries, which likely affects appropriate PEP administration.15 This is an issue that needs to be addressed because prompt reporting of occupational BPE is essential for counseling and PEP to be appropriately administered.14,17 PEP has been shown to effectively reduce the incidence of infection for HBV and HIV.2,9
Occupational exposure and HIV testing and counseling A large proportion of participants reported getting tested for HIV in another facility or testing themselves. This may be because of stigma, fear of being identified positive by their colleagues working in the same facility, or lack of confidentiality of HIV testing in the facility. Potentially, self-testing for HIV offers individuals the opportunity to test for HIV at a time and place they prefer and offers complete privacy to those concerned about confidentiality. However, in such cases, the HCW may not report sharps or blood or body fluid exposure to their health facility.18 Although self-testing for HIV is now feasible, appropriate use remains to be determined. Many questions arise about, for example, quality of results, lack of counseling and links to follow-up services, and potential for misuse.19
Hepatitis vaccination Vaccination is one of the best ways to protect HCWs from HBV infections, and the Centers for Disease Control and Prevention recommends that all HCWs be vaccinated against HBV infection.9 In this study, HBV vaccination was given to 80% of the staff, which was higher than reports from other resource-constrained settings and developed countries.5,15 This was likely impacted by the fact that the Botswana Ministry of Health had a vaccination campaign targeting HCWs at risk that took place during the course of the survey.
ARTICLE IN PRESS G. Kassa et al. / American Journal of Infection Control ■■ (2016) ■■-■■
CONCLUSIONS AND LIMITATIONS There were some limitations to the current study. First, it relied on self-report data, which are subject to social desirability and recall bias. This could have resulted in an underestimation of actual BPE. We did not confirm any BPE management by reviewing medical records; however, the ACASI was used to minimize social desirability bias.20 In addition, our results represent the HCWs at 3 health care facilities in Botswana (because we interviewed almost all HCWs in these 3 facilities), and caution should be exercised when generalizing outside of this setting. Understanding the reasons for underreporting BPE in health care facilities is important for informing interventions aimed at improved reporting and case management. This study identified predictors of underreporting. This study also found that most HCWs who reported their exposure were dissatisfied with the current occupational exposure management of BPE system in their health facility. Furthermore, despite many HCWs having received training on BPE, rates of underreporting were still very high. These findings, along with the observed hesitance to undergo HIV testing within their own facility suggest that multicomponent interventions are needed to improve occupational exposure reporting and case management in this and other similar settings. Implementation of well-designed intervention strategies integrated with effective training, assured confidentiality, and regular monitoring can help to improve reporting systems and ultimately decrease transmission of BPE to HCWs. Facilities should have in place a system that includes written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational exposures. References 1. Kessler C, McGuinn M, Spec A, Christensen J, Baragi R, Hershow RC. Underreporting of blood and body fluid exposures among health care students and trainees in the acute care setting: a 2007 survey. Am J Infect Control 2011;39:129-34. 2. Pruss-Ustun A, Rapiti E, Hutin Y. Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers. Am J Ind Med 2005;48:482-90. 3. Wilburn SQ, Eijkemans G. Preventing needlestick injuries among healthcare workers: a WHO-ICN collaboration. Int J Occup Environ Health 2004;10:451-6. 4. Panlilio AL, Orelien JG, Srivastava PU, Jagger J, Cohn RD, Carco DM. The NaSH Surveil lance Group; the EPINet Data Sharing Network. Estimate of the annual
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