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ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 45-50

Knowledge, awareness, and practices regarding needlestick injury among health-care workers in a tertiary care hospital of India: Annual incidence versus reporting rate


1 Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Department of Medicine, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission17-Oct-2019
Date of Decision26-Oct-2019
Date of Acceptance31-Oct-2019
Date of Web Publication13-Jan-2020

Correspondence Address:
Dr. Manazir Athar
Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_88_19

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  Abstract 


INTRODUCTION: The objective of this study was to assess the knowledge and awareness regarding needlestick injury (NSI) among health-care workers (HCWs) in a tertiary care hospital.
MATERIALS AND METHODS: This cross-sectional observational study was conducted among HCWs of a tertiary care hospital, India. A predesigned closed-end questionnaire, which assessed knowledge and awareness about NSI, immunization status, and management of NSI, was the tool of data collection.
RESULTS: A total of 104 HCWs participated in the study. The annual incidence of NSI was 29.80% (n = 104), whereas only 35.48% (n = 31) of these NSI cases or 10.58% (n = 104) of total HCWs reported to the concerned authority. The causes of underreporting were ignorance about contacting authority (70%), busy schedule (15%), and nonsignificant (10%). Recapping was considered as the most common cause of NSI in 31.7% followed by “haste” in 28.8%. All the HCWs received vaccination against hepatitis B; however, only 71.2% got 3 doses and booster, but only 60% knew about their protective antibody level. Unprotected sexual contact and sharp injury were known to all as the route of human immunodeficiency virus (HIV) transmission, whereas blood transfusion as a source of HIV was known to 98%.
CONCLUSION: The knowledge of health-care professionals on NSIs and their preventive measures is adequate; however, training on the universal precautions guidelines and the use of safe devices has to be delivered to prevent such injuries. The importance of timely reporting and following protocols regarding postexposure prophylaxis needs emphasis. There is an urgent need for re-strengthening and expanding our knowledge of HIV transmission routes in the hospital. Awareness and importance of hepatitis B immunization status need more attention.

Keywords: Awareness, knowledge, needlestick injury, postexposure prophylaxis, practice


How to cite this article:
Ali S, Athar M, Zafar L, Siddiqi OA. Knowledge, awareness, and practices regarding needlestick injury among health-care workers in a tertiary care hospital of India: Annual incidence versus reporting rate. Int J Health Allied Sci 2020;9:45-50

How to cite this URL:
Ali S, Athar M, Zafar L, Siddiqi OA. Knowledge, awareness, and practices regarding needlestick injury among health-care workers in a tertiary care hospital of India: Annual incidence versus reporting rate. Int J Health Allied Sci [serial online] 2020 [cited 2020 Feb 25];9:45-50. Available from: http://www.ijhas.in/text.asp?2020/9/1/45/275662




  Introduction Top


Health-care workers (HCWs) comprise a workforce of 35 million people, representing 12% of the working population of the world.[1] Needlestick injuries (NSIs) are a serious concern for all HCWs and pose a significant risk of occupational transmission of blood-borne pathogens. As per definition, NSI is a penetrating wound caused by a needle, scalpel, or another sharp object that may lead to exposure to blood or other fluids of the body. The World Health Organization estimates that HCWs approximately incur 2 million needlesticks every year that causes viral infections such as human immunodeficiency virus (HIV), hepatitis B, and hepatitis C. The occupational exposure accounts for 2.5% of HIV infection and as high as 40% of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections globally.[1] Majority of occupational exposures (90%) occur in developing countries, but the United States and Europe have high reporting rates (90%).[2] The projected incidence of NSI is a gross underestimation of the problem due to underreporting of injuries (often <50%).[3],[4] In the USA, 6,00,000–10,00,000 people receive NSI from needles and sharps every year, whereas in the UK, it is 1,00,000 HCWs/year.[5] In India, actual data on NSI are limited, but it is estimated to be much higher because almost around 3–6 billion injections are given annually, out of which two-thirds of injections are unsafe (62.9%) as the use of glass syringe is associated with a higher degree of unsafety.[6] Hence, this study was planned with the intent to evaluate the incidence of NSI and knowledge, attitude, and practice (KAP) in postexposure prophylaxis (PEP).

Aims and objectives

Primary outcomes

  1. To determine the incidence rate of NSIs among HCWs in a tertiary care center of India and the incidence rate of reporting of NSI
  2. To evaluate the basic knowledge, awareness, and practices regarding NSI and PEP.


Secondary outcomes

  1. To evaluate awareness about HIV transmission and treatment
  2. To evaluate awareness about infection control programs.



  Materials and Methods Top


Design and setting

A study was conducted at Jawaharlal Nehru Medical College and Hospital, a tertiary care center and teaching hospital, in North India, from January 1, 2018, to December 31, 2018.

Population

The study population included HCWs, mostly nurses who were randomly selected. All participants were informed about the design and purpose of the study and have given their approval with written informed consent before enrollment into the study. The anonymity of the participants was maintained throughout the study. In total, from the 120 questionnaires distributed, 104 were returned fully completed, giving a response rate of 86.66% (response returned/survey sent × 100).

Data collection and analysis

A closed-ended questionnaire was prepared which included knowledge about blood-borne infections, immunization status, use of personal protective equipment (PPE), risk factors for NSI, emergency measures after NSI, reporting of incident, and availability/use of PEP. An observer was present during the survey to clarify any doubt regarding the questions, and the questionnaire was collected after a prespecified time. The data extracted were tabulated, statistical analysis was performed, and frequencies, percentages, and incidence were calculated.


  Results Top


Demographic characteristics remained similar during the study period [Table 1]. Out of the 104 HCWs, 31 disclosed that they have had NSI, but only 11 of them have reported the incident to the concerned authority.
Table 1: Demographic characteristics

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Annual incidence of NSI = 31/104 × 100 = 29.80%

Rate of reporting = 11/31 × 100 = 35.48%

Overall reporting rate of NSI = 11/104 × 100 = 10.58%

Reason for needlestick injury

Recapping of the needles was the most common reason for NSI estimated to be 31.7% followed by haste 28.8%. Lack of availability of sharp/needle cutter and dispensers was reported by 15.4%. Another reason cited was a heavy patient load (10.5%) and handling uncooperative patients (9.6%). Around 3.8% believed that not feeling well or tiredness is also a reason for NSI.

Reason for not reporting

The most common reason was that the studied population was not aware of either the place or the person to report the incident (70%). Heavy workload or busy work schedule was present in 15% of the cases. Injury was perceived as trivial in 10%, whereas 5% did not know the HIV and viral hepatitis status of the source.

Knowledge, awareness, and practice regarding needlestick injury and postexposure prophylaxis

The first section of the questionnaire focused on the knowledge and awareness of individuals regarding NSI and PEP. Almost all the participants were aware of the risk of transmission of HIV infection after NSI, but the transmission of HBV and HCV infection after NSI was known to 98.1% and 94.2%, respectively. The individuals were aware of the procedures/activities leading to NSI, such as suturing, recapping the needle, and passing sharp instruments, and 93 out of 104 (89%) participants agreed that recapping of the contaminated needle was the most common contributing factor. Some HCWs reported that their damaged skin and mucous membrane have been exposed to infected blood directly, but they were not considered in our study as per the protocol. The use of needle cutters was common among our study population, and 91% were using it always or almost always, but still, there were ten participants who were not practicing it routinely. Only four participants were aware of safety-engineered devices for preventing NSI. Although recapping of needles is discouraged, but if used, single-handed technique is a better option. In our study, 96% (100) of the responders agreed with the safety of single-handed technique while remaining 4% choose double-handed technique as safer option. Although all the HCWs were using PPE during contact with high-risk patients or procedures, only 88 participants (85%) were using PPE routinely in all patients to protect against NSI. Out of all, 62 respondents (60%) knew about the immediate and proper cleaning of the wound after NSI. Of all the participants, 90 had knowledge about PEP and 64 knew about the ideal timing of PEP. Although PEP for HIV is available at the hospital, only 77% were aware of its availability [Table 2].
Table 2: Knowledge, awareness, and practice regarding needlestick injury and postexposure prophylaxis

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Hepatitis B immunization status of health-care worker

The second part of the questionnaire dealt with the immunization status of the HCWs. Although all the HCWs have been vaccinated against HBV, only 63 (60%) knew about their protective antibody level. Some of the respondents (thirty) have either not received the scheduled three doses of vaccine or were not able to recall the number of doses received by them [Table 3].
Table 3: Hepatitis B immunization status of health-care workers

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Awareness about human immunodeficiency virus transmission and treatment

The third part of the questionnaire was aimed at assessing the knowledge of HCWs regarding routes of transmission of HIV and basic concepts about the treatment of HIV/AIDS. Most of the participants were aware of the major routes of transmission of HIV, i.e., unprotected sexual contact (100%), contaminated blood transfusion (98%), and needle or sharp injury (100%), but had limited knowledge of transmission during pregnancy, labor, and breastfeeding [Table 4].
Table 4: Awareness about human immunodeficiency virus transmission and treatment

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Awareness about infection control programs

The last part enquired if the participants had attended any infection control program or conference for HCWs, to which 67% gave a positive response. However, all the participants stressed the need for a regular training program to be conducted at the hospital [Table 5].
Table 5: Awareness of infection control program

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  Discussion Top


HCWs are routinely exposed to blood-contaminated needles, sharps, and other products making them vulnerable to blood-borne infections, which, in turn, depend on the number of infected patients attending the health-care facility and the precautions observed by the personnel while dealing with these patients.[7] This occupational hazard has always been stressed upon, but there is a gap in the KAP of HCWs.

All the 104 participants in our study were aware of risk of transmission of HIV infection after NSI, but transmission of HBV and HCV infection after NSI was known to 94% and 86%, respectively. Following NSI, the risks of transmission of infection to the HCWs from an infected person are highest for hepatitis B (3%–10%), followed by hepatitis C (3%) and least for HIV (0.3%) among various viral infections.[8] The risk of HIV transmission may increase to 5% from contaminated sharps in the presence of a deep wound, visible blood on the device, use of a hollow-bore needle filled with blood, and high viral load in the patient.[9],[10]

The National Institute for Occupational Safety and Health (NIOSH), USA, defines NSIs as injuries caused by needles such as hypodermic needles, blood collection needles, intravenous (IV) stylets, and needles used to connect parts of IV delivery systems.[11] Among the clinical practices that lead to NSI, recapping the needle after use is the most common cause of NSI. In our study, 89% of the participants agreed to it, whereas the rest suggested other activities such as suturing or passing sharp instruments. This may be due to their personal experience or the nature of their duties. It is documented that 10%–25% of injuries occur while recapping a used needle.[12] Hence, under the Occupational Safety and Health Administration (OSHA), the recapping of needles has been prohibited.[13] Although recapping of the needle is widely condemned even in India, if required 96% preferred single-handed procedure rather than double-handed. Now, needles are being manufactured in a way that they retract, sheath, or blunt immediately after use. However, due to their limited availability, only four participants were aware of such engineered devices. The “no-touch” protocols, which include avoiding contact with needles during their use and disposal, are very effective in reducing the rate of NSIs.[14] Makary et al. in a study regarding NSI among surgeons observed that the use of blunt-tip needles was associated with reduced risk of injury. The use of “Sharpless” methods, especially at the time for handoff and passing of instruments and needles, and innovative surgical techniques such as “Sharpless surgery” (using nonsharp alternatives whenever possible) also decreases the incidence of NSI.[3]

Out of the 104 participants, 31 had NSI, but only 11 of them have reported the incident to the concerned authority to get PEP. The annual incidence of NSI was 29.80%. Even data from the EPINet survey in the USA for the year 2011 reported a percutaneous injury rate for all hospitals as 19.46/100 occupied beds.[15] The estimation of incidence or injury rate can help hospitals focus on injury prevention efforts and can be compared to the institution's prior years data if any for assessing injury prevention performance.

In our study, the participants who had NSI were enquired about the factor they attribute to NSI. Majority of them (31.7%) agreed that it was recapping of the needle which led to the injury. About 28.8% said that their inattention/hurriedness while using or disposing of needles that contribute to the injury. This observation was similar to that of Makary et al. who suggested that most of the NSIs were accidentally self-inflicted and being in a hurry was the leading cause of this. The rest were of the view that heavy patient load or lack of awareness was the reason for not taking the requisite precaution causing NSI, despite adequate availability of gloves, needle disposers, etc.

However, what is of concern is the fact that a large number of NSIs have not been reported. The reason for nonreporting by 70% was lack of awareness about place or person to report. Another factor was that the injury might have been perceived as trivial or HIV, HBV, or HCV status of the patient was not known to the caregiver at the time of exposure, so they neglected the incident. Previous studies have also suggested that NSI-involving patients not considered to be at high risk were less likely to be reported.[3]

The attitude of health-care professionals toward the nonreporting of NSIs is found to be poor. Hence, awareness activities, training activities, and regular quality control measures are needed to implement safe practices by the HCWs. It is highly recommended that health-care service employers should adopt safety-engineered devices, and there should be safe systems at work to minimize hazard to HCWs

As per the National AIDS Control Organization (NACO), PEP means a comprehensive management plan to minimize the risk of infection following exposure to blood-borne pathogens (HIV, HBV, and HCV). Although antiretroviral drugs are an important component of the comprehensive management of a patient, it also includes prompt first aid, round of counseling, assessment of risk, laboratory investigations of the source and exposed person, and long follow-up. When the exposure is through NSI, the wound and the surrounding skin should be immediately washed with soap and water and rinsed. The area should not be scrubbed and antiseptics or skin washes (bleach, chlorine, alcohol, and Betadine) should not be applied. In our study, 62% of the participants were aware of the immediate wound care, and there is still a need to stress its importance as this first step of PEP has to be initiated by the exposed persons themselves as soon as possible.

In the study, almost 90 (86%) participants were aware of PEP for HIV, but only 64 had knowledge regarding the timing of PEP. Although PEP for HIV is available routinely in the ED, only 77% were aware of it. Thus, there is still a need for education and sensitization of HCWs. The NACO, India, recommends that PEP should be initiated ideally within 2 h but certainly within 72 h after NSI. The antiretroviral regimen depends on two factors: the nature/category of exposure of HCWs and the HIV status of the source patient.[16] There are three categories of exposure mild, moderate, and severe depending on the port of entry and amount of blood/fluid involved. Mild exposure is defined as exposure through mucous membrane/nonintact skin with small volumes of blood, for example, superficial wound with low caliber needle. Moderate exposure is defined as contamination of mucous membrane/nonintact skin with large volumes of blood or percutaneous superficial exposure with a solid needle, for example, a cut or NSI penetrating gloves. Severe exposure is percutaneous exposure with large volume of contaminated blood like NSI with a high caliber needle (>18 G) or an IV or intra-arterial line. The PEP should be initiated immediately after exposure (even if the HIV status of the source of exposure is not known and should not be delayed waiting for the results of testing). Furthermore, the results should be interpreted with caution as a single negative test result does not exclude HIV infection because during the “window period,” which lasts for approximately 6 weeks, the antibody level is still too low for detection, but infected persons can still have a high viral load.[16]

In our study, only 60% of the participants were aware of their protective antibody level against HBV, but it was alarming that some respondents were not able to recall the number of doses of vaccination they received. The Centers for Disease Control and Prevention recommends that all Health care providers (HCP) should be vaccinated with a complete three-dose hepatitis B vaccine series if they are involved in activities with anticipated risk of exposure to blood/body fluids. If HCP is incompletely vaccinated, they should receive additional dose(s) to complete the series.[17] Postvaccination serologic testing for antibody is recommended 1–2 months after the last vaccine dose for HCPs at risk for occupational percutaneous or mucosal exposures.[18] Completely vaccinated HCPs with anti-HBsAg <10 mIU/mL should receive an additional dose of hepatitis B vaccine, followed by anti-HBs testing 1–2 months later. Completely vaccinated HCPs with anti-HBsAg >10 mIU/mL are considered hepatitis B immune. Immunocompetent persons do not need further periodic testing to assess anti-HBs levels.[19]

Some supportive measures may be recommended for occupational safety of HCWs against NSI:

  1. Regular training programs to promote good injection practices and repeated emphasis on using PPE
  2. Awareness about the importance of reporting of NSI and immediate availability of PEP. In fact, reporting needs to be made mandatory for all HCWs
  3. Development of a hospital-based registry regarding NSI, in order to effectively plan remedial measures and help in policymaking
  4. The modification of duty schedule if required, by limiting working hours, providing sufficient human resources, and reducing the number of shifts
  5. Regular feedback from HCWs regarding workplace safety.


The NIOSH developed the STOP STICKS campaign with the goal to raise awareness about the risk of exposure to blood-borne pathogens such as HIV, hepatitis B, and hepatitis C from needlesticks and other sharp-related injuries in the workplace. While the campaign materials were developed mainly with the operating room and emergency department, the target audience includes clinical and nonclinical HCWs and administrators in hospitals, doctor's offices, nursing homes, and home health-care agencies.

Limitations

Our study has limitations with regard to the cross-sectional design of the study, the small sample size, and the self-reporting of collected data.


  Conclusion Top


NSI continues to be a serious occupational hazard to all health-care professionals. The knowledge and awareness of NSI and their preventive measure are adequate, but still, more training programs need to be conducted for HCWs to decrease the annual incidence. The poor attitude toward the nonreporting of NSIs is a major concern and needs attention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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World Health Organization. The World Health Report. Geneva, Switzerland: World Health Organization; 2002. Available from: http://www.who.int/whr/2002/chapter4/en/index8.html. [Last accessed on 2019 Nov 12].  Back to cited text no. 1
    
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Makary MA, Al-Attar A, Holzmueller CG, Sexton JB, Syin D, Gilson MM, et al. Needlestick injuries among surgeons in training. N Engl J Med 2007;356:2693-9.  Back to cited text no. 3
    
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National Institute for Occupational Safety and Health. Alert: Preventing Needlestick Injuries in Healthcare Settings. Washington DC: NIOSH; 1999.  Back to cited text no. 5
    
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Kermode M, Muani V. Injection practices in the formal & informal healthcare sectors in rural North India. Indian J Med Res 2006;124:513-20.  Back to cited text no. 6
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Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboul D, et al. Acase-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.  Back to cited text no. 9
    
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Ippolito G, Puro V, Heptonstall J, Jagger J, De Carli G, Petrosillo N, et al. Occupational human immunodeficiency virus infection in health care workers: Worldwide cases through September 1997. Clin Infect Dis 1999;28:365-83.  Back to cited text no. 10
    
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Shen C, Jagger J, Pearson RD. Risk of needle stick and sharp object injuries among medical students. Am J Infect Control 1999;27:435-7.  Back to cited text no. 11
    
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U.S. EPINet Sharps Injury and Blood and Body Fluid Exposure Surveillance Research Group. Sharps Injury Data Report for; 2011.  Back to cited text no. 15
    
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Mast EE, Weinbaum CM, Fiore AE, Alter MJ, Bell BP, Finelli L, et al. Acomprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the united states: Recommendations of the advisory committee on immunization practices (ACIP) part II: Immunization of adults. MMWR Recomm Rep 2006;55:1-33.  Back to cited text no. 17
    
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Schillie S, Murphy TV, Sawyer M, Ly K, Hughes E, Jiles R, et al. CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR Recomm Rep 2013;62:1-9.  Back to cited text no. 19
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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