CHAPTER ONE

INTRODUCTION

History has it that anything that the hand of Midas touched turned to gold.  There is power in the touch.  As healing can come from a touch, so also infection, disease and eventually death can come from a touch, be it for the person touching or the person being touched.

The normal skin is designed to reduce water loss, protect against abrasions and to act as a permeability barrier1.  It is colonized by bacteria usually of two categories: Resident flora and transient flora.  The Resident flora are less likely to cause health care related infections, while the transient flora are the ones mostly implicated in healthcare associated infections.  The transient flora is gotten from hand contact with patients, their belongings, beddings, body fluids, etc.  These hands are used to transfer infection from person to person.  Because the hands play an important role in transmitting infection, hand hygiene is therefore of importance in reducing the transmission of infection.  It is for this reason that the Centre for Disease Control (CDC) added Hand Hygiene to the Universal or standard precautions.

Health care workers who have occupational exposure to blood are at increased risk for acquiring blood-borne infections.  The level of risk depends on the number of patients with that infection in the health care facility and the precautions the health care workers observe while dealing with these patients.

There are more than 20 blood borne diseases, but those of primary significance to health care workers are, hepatitis due to either the hepatitis B virus (HBV) or hepatitis C virus HCV) and acquired immuno-deficiency syndrome (AIDS) due to human immuno-deficiency virus (HIV)2.

Contaminated sharps such as needles, lancets, scalpels, broken glass, specimen tubes and other instruments, can transmit blood borne pathogens such as HIV, Hepatitis B (HBC) and Hepatitis C viruses (HCV)3.

Unsafe injections and the consequent transmission of blood borne pathogens are suspected to occur routinely in the developing world.  Furthermore, 18 studies present convincing evidence on the association of unsafe injection practices and the transmission of blood borne viruses such as hepatitis B and C, Ebola, Lassa virus infections and malaria.  Such practices account for a significant number of hepatitis B and C infections.  Quantitative information on injection use and unsafe injections (defined as the reuse of syringe or needle between patients without sterilization) was obtained by reviewing the published literature and unpublished WHO reports.  It was estimated that each person in developing countries receives an average of 1.5 injections per annum, but those confined to hospitals receive 10 – 100 times as many injections.  Of these injection, 95% are therapeutic, majority of which are unnecessary.  At least 50% of these injections are unsafe in developing countries4.

Injection overuse and unsafe practices account for a substantial burden of death and disability worldwide5.  The circumstances leading to needle-stick injury depends partly on the type and design of the device and certain work practices.    Recapping of needles is a common cause of needle-stick injury.  It is documented that 10-25% injuries occurred while recapping a used needle6.  The recapping of needles has been prohibited under the occupation safety and Health Administration (OSHA) blood-borne pathogen standard7.

An increasing number and variety of needle devices with safety features are now available.  Needleless or protected needle I.V. systems have decreased the incidence of needle-stick injuries by 62% – 88%8.

The prevalence of HBS Ag in healthy blood donors in Kathmandu valley has been reported to be about 1.67%9.  Sero prevalence study suggests that the overall anti-HCV positivity in blood donors is about 0.3% in Nepal10.  The prevalence of HIV sero-positivity in healthy blood donors has been reported to be about 0.2% in Nepal10.

In Saudi Arabia, the prevalence of HBs Ag in healthy blood donors ranges from 2.7% to 9.8% 9-10.  Sero-prevalence studies suggest that the overall anti-HCV positivity is about 3.5% to 5% 10=11.

Thalassemia and Sickle Cell disease are common in Saudi Arabia and prevalence of hepatitis C virus antibodies among this high risk group is about 40%12.  The prevalence of HIV sero-positivity has been reported to be about 0.09% in the Kingdom13.

These figures suggest that a sizeable number of individuals are a potential risk for transmission of blood-borne diseases to doctors, laboratory technicians, blood bank workers, nurses, personnel working in renal dialysis and transplant units, and other health care workers.

It has been found that the risk of transmission of HIV/AIDS to health care workers via needle stick incidents is 0.3% (1 case per 300 needle stick incidents).  A data combined from more than 20 prospective studies worldwide of healthcare workers exposed to HIV infected blood through percutaneous injury revealed an average transmission rate of 0.3% per injury14.

The above studies including the study carried out by Ofili et al on nurses in Central Hospital in Benin City clearly revealed that knowledge of healthcare workers about the risk associated with needle stick injuries and blood-borne infections in their day to day activities in the work place and use of preventive measures is inadequate15.  It is believed that only one out of three needle stick injuries are reported in the U.S., while these injuries virtually go undocumented in many developing countries.16

The incidence of infection with Hepatitis B virus has declined in healthcare workers in recent years largely due to the widespread immunization with hepatitis B vaccine.17  In many health facilities, even though the personnel are vaccinated, the sero-conversion status after vaccination is not assessed.

The potentially infectious nature of all blood and body substances necessitates the implementation of infection control practices and policies.

In 1985, in order to increase awareness among healthcare workers of the dangers of sharp injuries and other types of disease transmission, the Centres for Disease Control (CDC) and the Occupational Safety and Health Administration (OSHA) in the United States introduced the “universal precaution Guidelines, which became the worldwide standard in both hospital and community care settings until 1996.18

In 1996, the definition and recommendations of universal precautions was revised by the centre for disease control and prevention (CDC) and given the new name of standard precaution.

Today, standard precaution is the primary strategy to be used to reduce the risk of transmission of blood borne pathogens from moist body substances and applies to all persons, patients, clients and staff regardless of their diagnosis or presumed infectious status.  Their implementation is meant to reduce the risk of transmitting micro-organisms from both known and unknown sources of infection within the health care system.

Applying standard precautions has become the primary strategy to preventing nosocomial infections in hospitalized patients.  The health, safety and welfare of employees have been a major concern of the Nigerian Government.  “The Workmen’s Compensation Act” of June 11, 1987 is a clear demonstration of the Federal Government’s concern for health, safety and welfare of the Nigerian worker.

The requirements for standard precautions in everyday practice include: hand washing, personal protective equipment (PPE), safe waste disposal system, correct sterilization and disinfection processes, appropriate use of instruments and equipment, vaccination, education and post exposure protocol (PEP).

STATEMENT OF THE PROBLEM

Health Care Workers (HCWs) are exposed to blood borne infections by pathogens such as HW, Hepatitis B and C viruses, as they perform their clinical activities in the hospital.  There is a rising prevalence of morbidity and mortality as a result of hospital acquired infections (noso comical infections and blood-borne infections like HIV, HBV and HBC).  There is a continued unwarranted and unsafe use of injections, lack of adequate sharps containers and disposal facilities, shortage of supply of injection equipment which has led to the increased incidence of needle stick injuries and blood-=borne infections among health care workers.  Lack of knowledge and noncompliance with standard precautions place health care workers at significant health risks.

Identified and similar problems exist in Central Hospital, Warri, other health establishments in Delta State as well as other states, but no study has been done to address the issue.

JUSTIFICATION FOR THE STUDY

The rising prevalence of morbidity and mortality as a result of nono comical and blood borne infections is as a result of lack of awareness, wrong attitude towards and non-compliance with the definitions and recommendations of standard precautions.  Compliance with standard precautions has been shown to reduce the risk of exposure to blood and body fluids.

This study will expose the level of awareness, attitude and practice of standard precautions among the HCWs and hence the study could be used as a baseline for intervention.  It could identify gaps which would be recommended for correction through interventions.  Also, in the design of an evaluation, it could be pre and/or post-test depending on the study design.  This study could also be used to monitor trends of events concerning knowledge, attitude and practice of standard precautions among health care workers in Central Hospital, Warri by reviewing from time to time, the incidence of needle stick injuries and the morbidity and mortality pattern.

AIMS AND OBJECTIVES

The general objective is to assess the knowledge, perception and practice of standard precautions among health care workers in Central Hospital, Warri, Delta State.

Specific objectives:

1.      To determine the level of knowledge of standard precautions among health care workers in Central Hospital, Warri.

2.      To determine the attitude of health care workers in Central Hospital, Warri towards standard precaution.

3.      To determine the level of practice of standard precaution among health care workers in Central Hospital, Warri.

REFERENCES

Al Faleh F.Z., Ramia S.  Hepatitis C. Virus (HCV) infection in Saudi Arabia:  A review.  A Saudi Medical 1997, 17:77-82.

Bahakim, H., Bakir, T.M.F., Arif, M., Ramia, S.  Hepatitis C. Virus antibodies in high-risk Saudi groups.  Vox Sang 1991; 60:162-164.

Bernvil S.S., Sheth K., Ellis M. et al.  HIV antibody screening in Saudi Arabian blood donor population:  Five years experience.  Vox Sang 1991; 61: 71-73.

Calver J.  Occupational Health Services, American Journal of Infection Control, 1997; 25: 363 – 365.

Fathalla S.E., Al Jama A.A., Badawy M.S., et al.  Prevalence of Hepatitis C Infection in the Eastern province of Saudi Arabia by R.E. – DNA second generation and supplemental EIA tests.  Saudi Medical Journal 1994; 15:11-3.

Fathalla, S.E., Namnyak S.S., Al Jama A, Rabaria Bautista M.M.  The prevalence of Hepatits B surface antigen in healthy subjects resident in the Eastern province of Saudi Arabia.  Saudi Medical Journal 1985; 6: 236 – 239.

Gerberding J.L.  Incidence and prevalence of human immuno-deficiency virus, hepatitis B virus, hepatitis C virus and Cytomegalo virus among health care personnel at a risk of blood exposure: a final report from a Longitudinal study.  Journal on Infectious Disease 1994; 170: 1410 – 1417.

Hauri, A.M., Armstrong, G.L., Hutin, Y.J.  The global burden of disease attributable to contaminated injections given in health care settings.  Department of Essential Health Technologies, World Health Organization, Avenue Appia 20, CH 1211 Geneva 27, Switzerland.  International Journal STD AIDS, 2004 January; 15 (1): 7 – 16.

John M. Boyce M.D., Didier Pittet MD, Recommendations of the healthcare infection control practices, Guidelines for hand hygiene in healthcare settings, www.cdc.gov, October 2002.  (3,4,6,10,21,25,26,27).

Moro, P.L.,  Moore, A., Balcacer, P., Montero, A., Diaz, D., et al.  Epidemiology of needle sticks and other sharps injuries and injection safety practices in the Dominican Republic.  American Journal of Infection Control 2007 October, 35 (8): 552 – 559.

Ofili A.N., Asuzu, M.C., Okojie O.H.  Knowledge and practice of universal precautions among nurses in Central Hospital, Benin City, Edo State, Nigeria.  Nigeria Postgraduate Medical Journal, 2003 March; 10 (1): 26-31.

Poole C.J.M., Miller S.,  Fillingham G.  Immunity to hepatitis B among health care workers performing exposure-prone procedures.  B Medical Journal 1994; 309: 94 – 95.

Rajasekaran, M., Sivagnanam, G., Thirumalai Ko Lundusu branmainan P, Namasivayam, K., Ravindranath C.  Injection practices in the State of Tamilnadu, India.  Department of Pharmacology, KAP Viscoanatham Government Mideical College, Trichy, Tamilnadu, India.  [email protected] (cited 2010, Februaty, 11).

Roy E., Robillard P.  Under-reporting of an accidental exposures to blood and other body fluids in health care setting:  an alarming situation.  Adv. Exposure Prev. 1995; 14: 11-13.

Simansen, L., Kane, A., Lloyd, J., Zaffran, M., Kane, M.  Unsafe injections in the developing world and transmission of blood borne pathogens: a review.  World Health Organization, Geneva, Switzerland, Bulletin World Health Organization. 1999; 77 (10):  789 – 800.

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