|Year : 2016 | Volume
| Issue : 2 | Page : 79-85
Occupational exposure to blood and body fluids among primary health-care workers in Kaduna State, Nigeria
Awawu Grace Nmadu1, Kabir Sabitu2, Istifanus Anekoson Joshua1
1 Department of Community Medicine, Kaduna State University, Kaduna, Nigeria
2 Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
|Date of Web Publication||13-Oct-2016|
Awawu Grace Nmadu
Department of Community Medicine, Kaduna State University, Kaduna
Source of Support: None, Conflict of Interest: None
Background: Primary Health-Care Workers (PHCWs) are at a high risk of contracting blood-borne infections due to their occupational exposure to blood and body fluids (BBFs). The aim of this study is to determine the frequency of occupational exposures and associated factors contributing to the exposure to BBFs. We also evaluated the post-exposure practices among PHCWs in Kaduna State.
Materials and Methods: A cross-sectional study was carried out from September 26 to October 7, 2011. One hundred and seventy-two PHCWs were included in the study using a multistage sampling technique. A structured questionnaire was used to obtain the data on sociodemographic characteristics, occupational exposures to BBFs and post-exposure practices of PHCWs. Data were analyzed using SPSS version 20.0 statistical software, and descriptive, bivariate, and multiple logistic regression analyses were performed. The level of significance was set at P ≤ 0.05.
Results: One hundred and seventeen (68%) PHCWs had been exposed to BBF during their professional practice, of which 53.5% and 38.4% were needlestick and blood splash exposures, respectively. Needlestick and blood splash exposures 3 months prior to the survey occurred in 27.2% and 53.0% of them, respectively. The most common causes of needlestick injuries were during disposal of needles (44.0%) and administration of injections (28.0%). The majority of the respondents (79.8%) failed to report the exposure incidents. Only 8% of the respondents preformed the desirable post-exposure action of washing the exposure site immediately with soap and water. Primary health care workers < 40 years of age had significantly lesser odds of exposure compared to those aged 40 years and above (adjusted odds ratio = 0.18, P = 0.02).
Conclusion: The high rate of occupational exposure to BBFs among health-care workers reveals an urgent need to raise awareness and to provide periodic training in infection prevention.
Keywords: Blood splashes, needlestick injury, Nigeria, occupational exposures, primary health-care workers
|How to cite this article:|
Nmadu AG, Sabitu K, Joshua IA. Occupational exposure to blood and body fluids among primary health-care workers in Kaduna State, Nigeria. J Med Trop 2016;18:79-85
|How to cite this URL:|
Nmadu AG, Sabitu K, Joshua IA. Occupational exposure to blood and body fluids among primary health-care workers in Kaduna State, Nigeria. J Med Trop [serial online] 2016 [cited 2017 Jul 23];18:79-85. Available from: http://www.jmedtropics.org/text.asp?2016/18/2/79/192223
| Introduction|| |
Health-care workers (HCWs) are at a risk of various occupational hazards in health-care settings, including exposure to blood-borne infections such as HIV, Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV).  Blood-borne infections occur mostly by percutaneous and mucosal exposure of HCWs to the blood, tissue, or other infectious body fluids of infected patients. ,
The World Health Organization estimates that 3 million percutaneous exposures occur annually among 35 million health-care workers globally, with over 90% occurring in resource-constrained countries such as Nigeria where HIV, HBV, and HCV are also prevalent. , The number of needlestick injuries is higher in developing countries, and African health-care workers are said to suffer on an average of two to four injuries per year. Worldwide, it is estimated that about 2.5% of HIV cases and 40% of HBV and HCV cases among health-care workers occur as a result of these occupational exposures.  In absolute numbers, an estimated 66,000 HBV, 16,000 HCV, and up to 1000 HIV infections occur among health-care workers each year.  Health-care workers in developing countries are particularly at an increased risk of infections from blood-borne pathogens (BBPs) not only because of the high prevalence of such pathogens in their communities, but also due to the lack of basic personal protective equipment (PPE) such as gloves, gowns, and goggles. , The risk of occupational transmission of BBPs is also increased in developing countries by excessive handling of contaminated needles that result from unsafe practices such as administration of unnecessary injections on demand, the reuse of nonsterile needles, capping needles, and the unregulated disposal of hazardous waste. 
The Centers for Disease Control and Prevention has proposed Universal Precautions (UPs), which are a series of procedures for preventing occupational exposure and for handling potentially infectious materials such as blood and body fluids (BBFs). Health care workers are advised to practice UPs, such as observing regular hand hygiene; and using protective barriers, for example, gloves and gowns, whenever there is going to be in contact with the mucous membranes or BBFs of patients; and disposing of sharps and other clinical waste properly. ,
Primary Health-Care Workers (PHCWs) play a major role in health care delivery in Nigeria and are also at a risk of occupational exposure to BBFs. The cadres of PHCWs in Nigeria include nurses/midwives, Community Health Officers (CHOs), cCommunity Health Extension Workers (CHEWs), laboratory technicians, pharmacy technicians, environmental officers, medical records officers, and support staff such as health attendants/assistants, security personnel, and general maintenance staff.  There is a paucity of data in Nigeria describing occupational exposures to BBFs among PHCWs. Such data would be useful in identifying any gaps in the implementation of infection control practices and in providing feedback about improving safe practices. Therefore, the aim of this study was to determine occupational exposure to BBFs and the associated factors among PHCWs in Kaduna State, Nigeria.
| Materials and Methods|| |
The study was carried out in Primary Health-Care Centers (PHCCs) in Kaduna North Local Government Area (LGA) and Zaria LGA. Kaduna North LGA has a population of 357,694 and is situated in the capital city of Kaduna. Zaria LGA is located 80 km from Kaduna city and has a population of 408,198.  At the time of the study, Kaduna LGA had 12 public PHCCs, whereas Zaria LGA had 13 PHCCs. Records from the Primary Health-Care (PHC) departments in the LGAs indicated a total staff strength of 670 PHCWs, 350 in Kaduna LGA and 320 in Zaria LGA LGA at the time of the study. There had been no training on injection safety or UPs organized for PHCWs in both LGAs in the 2 years preceding the survey.
This research used a descriptive cross-sectional study which was carried out between September 26 and October 7, 2011.
The study population included all PHCWs who were employed in Zaria LGA and Kaduna LGA. Inclusion criteria were all PHCWs in selected PHCCs who were directly involved in patient care and were at the risk of contact with blood, blood products, and who were present at the time of data collection and consented to be interviewed. The criteria included nurses, midwives, CHOs, CHEWs, laboratory technicians, pharmacy technicians, and ward attendants. The workers whose jobs were not directly related to patient care were excluded from this study, such as the administrative and technical staff.
Sample Size Determination
The sample size was determined using Cochran's formula  (n = Z 2 pq/d 2), where Z = 1.96, P = prevalence of occupational exposure to BBF in a previous study of 85%,  and d = 5% of marginal error. This gave a sample size of 196. Since the source population of respondents was <10,000, a correction formula of nf = ni/(1 + ni/n) was used, where nf = corrected sample size; ni = uncorrected sample size; and n = total number of the source population. Therefore, with (196/[1 + 196/400] =670), we obtained a sample size of 152.
A multistage sampling technique was used in selecting the respondents. Two LGAs (Kaduna North and Zaria) were purposively selected out of 23 LGAs in Kaduna State being that both LGAs had numerically high strength in diverse cadres of PHCWs compared to other LGAs in the state. Seven PHCCs were selected from each LGA by simple random sampling technique. At each of the seven PHCCs, all eligible PHCWs were interviewed since the population of eligible PHCWs was not many. At the end, a total of 172 respondents participated in the study.
Data were collected using a pretested structured interviewer-administered questionnaire. The information collected included sociodemographic characteristics such as age, gender, years of work experience, job category, whether they were trained on UPs, and hepatitis B immunization status. Data were also collected on the history of exposure and measures taken after exposure. Needlestick injury was defined as a prick with a needle or other sharp object during use of the object for patient care, and splash exposures were defined as mucocutaneous exposure to blood and other body fluids. Six research assistants were recruited and trained for data collection. The researcher was responsible for overall supervision, monitoring, coordination of the data collection and ensured adherence to the research protocol.
The data was analyzed using Statistical Package for Social Sciences (SPSS) Version 20.0 software. Descriptive statistics was used to describe the demographic data of PHCWs. Bivariate analysis was done to assess the associations of selected independent variables with occupational exposure, and independent variables that had P ≤ 0.25 were entered into a multivariate logistic regression model using the forward stepwise method. The strength of the association of predictor variables was assessed using Odds Ratio (OR) and Adjusted Odds Ratio (AOR). P value ≤ 0.05 at 95% confidence interval was considered statistically significant.
Ethical approval was obtained from the Ethical and Scientific Committee of Ahmadu Bello University Teaching Hospital. Permission was obtained from the Director of PHC, the PHC coordinators of LGAs, and all the supervising heads of the selected PHCCs before the study was conducted. Informed written consent was sought from the respondents before carrying out the study.
| Results|| |
Characteristics of Respondents
A total of 172 questionnaires were administered with a response rate of 100%. The mean age of respondents was 36.7 ± 8.6 years. Most of the respondents were females (79.1%). A greater proportion of PHCWs was CHEWs (40.7%). The mean duration of practice were 9.2 ± 7.6 years. Most of the respondents had practiced for <10 years (60%). About a quarter had received training on UPs and three quarter reported being vaccinated against HBV [Table 1].
|Table 1: Characteristics of Primary Health Care Workers in Zaria and Kaduna North LGAs (N=172)|
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One hundred and seventeen PHCWs (68%) had occupational exposure to either needlestick injury or blood splash, 44.0% of these exposures occurred 3 months prior to the survey. A total of 92 (53.5%) and 66 (38.4%) respondents had been exposed to needlestick injury and blood splashes, respectively, out of which, 25 (27.2%) and 35 (53.0%) respondents, respectively, were exposed to needlestick injury and blood splashes 3 months prior to the survey [Table 2]. The occurrences of needlestick injury were associated with disposal of needles (44.0%), injection administration (28.0%), recapping of needles (12%), suturing wounds (8%), and during venipuncture (8%).
|Table 2: Occupational exposure to BBPs among PHCWs in Zaria and Kaduna North LGAs|
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Occupational exposures were higher in females, in those more than 40 years of age and in those with more than 10 years of working experience. The laboratory technicians (66%) had the highest frequency of needlestick exposures followed by nurses/CHOs (50%) and then ward attendants (45%). Blood splashes exposure occurred highest in CHEWs (79%) and ward attendants (76%) [Table 3].
|Table 3: Prevalence of occupational exposures by potential risk factors among PHCWs in Zaria and Kaduna North LGAs 3 months prior to the survey (N=52)|
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Management of Occupational Exposure
Of the respondents that had needlestick and blood splash exposure incidents 3 months prior to the survey, a majority (40.3%) cleaned the site with bleach, this was followed by cleaning with methylated spirit (20.9%). Only 4% of the respondents in the study performed the correct measure of immediately washing with soap and water [Table 4]. Majority (79%) of PHCWs who had needlestick and blood splash exposures did not report the incident. The common reasons for not reporting exposures were perception of little or no risk (36.6%) and that management would not do anything about it (26.8%), while others did not know whom to report to (22%) and felt it was unnecessary (14.6%). The practice of screening the source of occupational exposure (11.5%) and taking HIV post-exposure prophylaxis (PEP) was 11.5%.
|Table 4: Measures taken by respondents immediately after needle stick or blood splash exposure 3 months prior to survey (N=52)|
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Factors Associated with Occupational Exposure 3 Months Prior to the Study
Bivariate analysis revealed that male gender (OR = 0.40, P = 0.08) and being >40 years (OR = 0.53, P = 15) decreased the odds of exposure to BBPs though not statistically significantly. Multivariate analysis showed that being <40 years significantly decreased the odds of exposure to BBP (AOR = 0.18, P = 0.02) [Table 5].
|Table 5: Factors associated with occupational exposure 3 months prior to the survey among PHCWs in Zaria and Kaduna North LGA (N=52)|
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| Discussion|| |
Occupational risk of transmission of BBPs is a major concern for HCWs worldwide. In this study, the PHCWs' ages ranged between 20 and 59 years, majority of them falling between the productive age group of 30-49 years, similar to the reports of studies conducted in Ethiopia and Nepal. , Only about a quarter of the PHC workers had received training in UPs. This can have serious implications, as health-care workers with insufficient knowledge of infection control measures would experience higher risks of exposure to BBPs and at the same time show poor compliance with UPs.  Hepatitis B vaccination that has produced sufficient antibody levels virtually eliminates the risk of contracting HBV, and all HCWs are required to be vaccinated against HBV.  However, a quarter of PHCWs in this study reported not to have been vaccinated against HBV. There is a need for increasing awareness of the risk of HBV infections and importance of HBV vaccination among the PHCWs.
In this study, 68% of the PHCWs reported occupational exposure to BBFs in their professional practice, which is comparable with the findings from China (66%) and Serbia (66%). , However, this value is lower than the studies from Iran (74%) and India (73%). , Nearly, 54% of the PHCWs reported occupational exposure to needlestick injury in their work experience, which is lower than the findings in India (63%). Thirty-eight percent reported blood splash exposures, which was also lower than the findings in Ethiopia.  In this study, occupational exposure to needlestick injuries among HCWs 3 months before the study (27%) was similar to a study in the United States (28%),  but the blood splash exposures 3 months before the survey (53%) in this study were much higher than that of the study in the United States (33%).  These differences may be due to variations in the study area, the experience of HCWs, the health-care setting, the availability of PPE in health-care facilities, and on training about infection prevention.
The major sources of needlestick injury in this study were during disposal of needles and injection administration. This was similar to that found in a study in the United Kingdom,  but different from the reports of a study by the United States National Surveillance System for HCWs, where manipulating needles in patients was reported as the major source of needlestick injury.  The prevalence of occupational exposure of needlestick and blood splash exposure in this study is comparable to that found in some Western settings, but it is in contrast with the typical picture of reports in developing countries where the prevalence of HIV is the highest in the world and the number of occupational exposure to needlestick injuries is also highest.  This may not be unconnected to the increased awareness about HIV/AIDS and sensitization from other sources of health education. In this study, percutaneous exposures were more frequently reported that mucocutaneous exposures, which is in agreement with some other studies. ,
The measures taken by the health-care workers who had occupational exposure revealed poor post-exposure practice [Table 4], as only 8% of the respondents performed the desirable practice of washing the exposure site immediately with soap and water. This was much lower than findings reported in India (82%) and Pakistan (89.4%). , The rate of notification of exposures was also low, as less than a quarter of respondents notified their exposure to the concerned authority [Table 4]. This was similar to the findings reported in Port Harcourt (18.4%) and Brazil (11%), , but in contrast to a study in Birmingham, where 65% of the HCWs notified the appropriate authorities.  The common reasons for not notifying exposures were that they did not know who to report to and the management would not do anything about if even if they were notified, these were similar to the reasons given in reports from studies done in Port Harcourt and Ethiopia. , The practice of screening the source of occupational exposure and taking PEP in exposed PHCWs was very poor in this study. This is similar to the findings in studies conducted in India and Uganda. ,
Bivariate analysis did not reveal any statistically significant factors associated with occupational exposure, which was similar to a study conducted in Iran,  but in sharp contrast to other studies where variables such as age, gender, and job category were significantly associated with occupational exposure. ,, Having been trained on UP was not found to be protective from occupational exposures in this study (OR 0.9; P = 0.74). This will be a serious challenge to infection prevention efforts. This is similar to the previous reports, , in which training of HCWs on UP did not seem to necessarily bring about protection from exposures. The reason for this may be that the knowledge acquired may not necessarily translate into positive practice of preventive measures or that the trainings provided may be more theoretical than practical and also the limited sources of continuous information on UPs. It was noticed that there had not been trainings conducted for the PHCWs on UPs within the past 2 years. Lack of an enabling environment to comply with UPs may also contribute to poor compliance. In this study, the only significant predictor of occupational exposure by multivariate logistic regression was age, with PHCWS <40 years being significantly less likely than those >40 years to get exposed to needlestick injuries and blood splash exposures. This was sharply in contrast to the findings in studies conducted in Kenya, Ethiopia, and Tanzania, ,, which reported the reverse. In these studies, other factors that were reported as predictors of occupational exposure to BBPs included health-care workers' work experience, infection prevention training, and gender. ,,
| Conclusion|| |
This study has shown a high prevalence of needlestick injuries and blood splash exposures among PHCWs in Zaria and Kaduna North LGA, Nigeria, and the measures taken by the health-care workers after these exposures were grossly inadequate. There was also a high rate of non-reporting of these exposures by the PHCWs to relevant authorities. Hepatitis B vaccination coverage among health-care workers was not adequate and majority of the PHCWs did not have training in UPs. Being <40 years of age was found to be protective against occupation exposure to BBP.
A strength of this study is the high response rate, while limitations of the study include that the study relies on self-report of PHCWs which could not be verified through records or observation; there is a possibility of recall bias among respondents and also being a cross-section study, it does not allow establishment of causal relationships between variables and occupational exposure to BBP.
All HCWs should be trained, sensitized, and updated on issues related to infection prevention and occupational risk reduction. Hepatitis B vaccination is recommended for all HCWs, and institutions should provide mandatory immunization programs for their HCWs. A surveillance system for registering, reporting, and management of occupational injuries and exposures needs to be established to increase occupational safety for health-care workers in our setting.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]