May 21, 2020
Background: While all healthcare workers are exposed to occupational hazards, workers in sub-Saharan Africa have higher rates of occupational exposure to infectious diseases than workers in developed countries. Identifying prevalence and context of exposure to blood and blood borne pathogens may help guide policies for prevention.
Objective: This systematic review examined occupational exposure rates to blood and blood borne pathogens among healthcare workers in sub-Saharan Africa.
Findings: Fifteen studies reported a variety of exposures. The lifetime prevalence of needle stick injury ranged from 22 - 95%, and one-year prevalence ranged from 39 - 91%. Studies included a range of descriptive statistics of knowledge, attitudes, practice and access factors related to exposures.
Two studies reported 21 - 32% of respondents linked poor knowledge or training with prevention of needle stick injuries.Rates of recapping needles ranged from 12 - 57% in four studies. Attitudes were generally positive toward occupational safety procedures while access was poor.
Conclusions: The high burden of blood and blood borne pathogen exposures demonstrated here indicates a high risk for contracting blood borne illnesses. Although the data is sparse, implementation of preventative policies based on current knowledge remains critical to minimise risk and reduce exposure.
There remains a pressing need for high quality data on occupational hazards to identify the burden of exposures and inform preventive policies in Sub-Saharan Africa. Additional studies are needed to determine whether differential exposures exist between professions and the associations with knowledge, attitudes, practices, and access factors to create targeted strategies to diminish occupational hazards.
Healthcare workers provide patient care in environments that are considered to be one of the most unsafe occupational settings. Globally, it is estimated that 1 in 10 healthcare workers experience a sharp injury every year.
In the year 2000, sharps injuries to healthcare workers resulted in 16 000 Hepatitis C virus (HCV) infections, 66000 Hepatitis B virus (HBV) infections, and 1 000 Human Immunodeficiency Virus(HIV) infections.
The impact of these infections is significant. Between 2000and 2030, these infections are estimated to cause 145 premature deaths due to HCV, 261 premature deaths due to HBV, and 736 premature deaths due to HIV. In sub-Saharan Africa, the limited studies conducted have demonstrated that healthcare workers are frequently exposed to biological, chemical, and physical occupational hazards.
The higher prevalence is partly explained by the higher prevalence of blood borne pathogens in the general population but can also be attributed to poor healthcare infrastructure in sub-Saharan Africa. There are well-established guidelines to prevent exposure to occupational hazards, including blood and blood borne pathogens.
These include educating healthcare workers on safer use of devices, procedures and management of exposures. Furthermore, the World Health Organisation (WHO) has instructed governments to transition to the exclusive use of safety injection devices by 2020.
While developed countries have heeded this recommendation, the vast majority of sub-Saharan African countries have failed to enact legislation to protect healthcare workers.
Unsafe conditions in the healthcare environment, lack of personal protective equipment (PPE), and high provider to patient ratio increase the risk of exposure to blood borne pathogens and cause preventable infections. The influence of occupational hazards on healthcare worker shortages in sub-Saharan Africa has dire implications for patient outcomes, productivity and life expectancy in the continent.
This review sought to identify studies that examined occupational exposures to blood and body fluids in healthcare workers and potential factors predisposing workers to exposures in sub-Saharan Africa. Our review identified a high burden of occupational hazards as well as knowledge, attitude, practice and access factors among healthcare workers representing different professions.
Several of the prevalence estimates of occupational hazards had a wide range. Lifetime prevalence of needle stick injuries spanned from 22–95% in the five studies reporting this statistic.These differences may be partially explained by variations in sampling among the studies. Isolating the studies that included only physicians (surgeons and gynaecologists)shows that they both had high rates, although relatively small sample sizes (n< 100).
Surgeons have high exposure rates to sharps in the operating room, which may increase the likelihood of a needles tick or other sharp injury.Similarly, if gynaecologists are also practising as obstetricians and performing caesarean sections or performing gynaecological surgeries in the operating room, they may also have higher exposures to sharps.
Of the remaining studies that included a diverse sample of healthcare workers, the study with the highest lifetime prevalence rate (95%) was in a single hospital in Nigeria. It is possible that this hospital is an outlier with a high rate for a variety of contextual reasons that are not immediately apparent. The two studies with the lowest prevalence rates (<53%) each took place in multiple hospitals with amore diverse sample of healthcare workers including physicians, nurses, nursing assistants, midwives, and clinical officers.
The one-year incidence of needle stick injuries ranged from 39 - 91%. These differences may also be related to the population that was sampled in the respective studies, although this is unlikely to account for all the variation in rates. Similar to the high lifetime prevalence reported in surgeons above, the study that included only surgeons had the highest incidence. Again, this may be partially explained by the high exposure rates surgeons have to sharps in the operating room.
The study that reported the lowest one-year incidence included students, who may have a lower incidence rate because as a student they have lower exposures in general.
While the prevalence and incidence findings have limited applicability because of their significant variability, the qualitative findings concerning knowledge, attitudes, practices, and access factors provide critical information to help inform prevention strategies.
While the amount of data in the studies we examined concerning these factors varied widely, it begins to present a picture of potential provider and system issues that may be contributing to sub-Saharan African healthcare workers’ exposures to blood and body fluid.
Provider knowledge does appear to be a contributing factor to some extent. It is troubling that 21 - 32% of respondents linked the lack of training and poor knowledge to prevention of needle stick injuries in two studies. There was also a notably wide range of adequate knowledge in PEP practices (42 – 93%). So even if PEP (Post Exposure Prophylaxis), is available, it is likely that providers with inadequate knowledge may not complete PEP treatment.
While there were generally positive attitudes towards preventative safety practices reported, albeit in only three studies, there were some negative attitudes worth noting. A small percentage of respondents (6 – 8%) were non-compliant with safety equipment or practices because they did not consider them useful.
More in-depth exploration of these beliefs could provide data for potential interventions. One study reported a high rate of discomfort as a reason for not using goggles in the operating room. Because this finding was only observed in one study, and a single piece of equipment, it is unclear whether discomfort is a common reason for non-compliance with other safety equipment use.
This finding is worth exploring in future research. Considering the wide range in knowledge about PEP, it is not surprising that there was a range in practices in takingPEP (1 - 88%), although only two studies collected data about knowledge of PEP and practice in taking PEP. The results from these studies appear to be discordant.
One study reported 42% adequate knowledge, yet only 1% PEP, while the other study reports 63% adequate knowledge and 74% PEP. It is difficult to draw meaningful conclusions from such sparse data. Among the five studies that reported PEP uptake, there was no clear contextual factor that explained the wide range. Three out of five of the studies took place in an individual hospital, it is possible that contextual factors within each hospital account for the higher or lower rates of PEP uptake.
Preventing and mitigating occupational hazards among healthcare workers in sub-Saharan Africa requires a systematic approach to providing occupational safety and health at the national, district and facility levels with careful integration into outbreak preparedness plans. The protection of healthcare workers requires institutionalisation of occupational health risk assessment and risk-based medical surveillance.
In the recent inter-country workshop on occupational safety and health in Africa, it was identified that many countries lack national regulations for occupational safety and health which cover public healthcare facilities.
A call was made for all sub-Saharan African countries to develop regulations, standards, and management according to the WHO / International Labour Organisation global framework. This strategy will likely have the most significant and sustained impact on managing occupational safety and health in sub-Saharan Africa.
Low levels of knowledge demonstrated by healthcare workers in this review, call for policies that create a culture of awareness of occupational hazards and their influence on patient outcomes.These policies may include mandatory workshops and training on occupational hazards and dedicated occupational health units at healthcare institutions. These units may address the inadequacies in the safe provision of health services, occupational hazards, and statistics on the healthcare environment to ensure that healthcare workers are adequately rehabilitated and protected.
There is a dire need for national policies to address insufficient and, in some cases, absence of PPE in many sub-Saharan Africa countries. When worn correctly, PPE provides a barrier to protect healthcare workers from exposure to contaminated body fluids which may contain infectious agents. At the basic level, PPE protects the hands, eyes, nose, and mouth and includes equipment such as boots, gloves, and face shields.Extended PPE includes impermeable gowns, head covers and face masks.
Among healthcare workers inGhana, 74% reported that sometimes PPE was not available but also stated that donning PPE during emergencies would result in adverse outcomes or death or cause patients to panic.
This scenario paints a complex picture of why PPE may not be used consistently. Use of PPE may result in significant physiological or physical stresses to healthcare workers. The most common stress associated with PPE in the African context is heat stress which may limit compliance, performance and could be life-threatening. The standards for the production ofPPE should therefore be re-evaluated to take into consideration the warmer climate in Africa to promote adherence.
To our knowledge, this is the first examination of occupational exposure to blood borne pathogens in sub-Saharan Africa. The examination of knowledge, attitudes, practices and access factors may inform strategies to reduce exposures in diverse clinical settings.There are some limitations to our review worth noting. Further research exploring rates within different professions would be helpful to build a basis for targeted interventions in these heterogeneous groups.
This study identified a high burden of needle stick injuries and mucocutaneous exposures to blood and blood borne pathogens for healthcare workers in sub-Saharan Africa. This finding indicates that these healthcare workers are at high risk of contracting blood borne illnesses such as HCV, HBV, and HIV.
This review identified that sparse data exists exploring factors correlated with these exposures and inconsistent research among studies which explored these factors.The development of effective interventions to counteract causes of increased prevalence and incidence of needle stick injuries or mucocutaneous exposures is necessary even in light of the limited available knowledge of factors influencing these rates.
Mossburg S, Agore A, Nkimbeng M and Commodore-Mensah Y.Occupational Hazards among Healthcare Workers in Africa: A Systematic Review.Annals of Global Health. 2019; 85(1): 78, 1–13. DOI:https://doi.org/10.5334/aogh.2434
Published: 06 June 2019
In 2018, Daniels Health US hosted an event to bring the gravity of sharps injuries in healthcare back into conversation. With a variety of ever-increasing occupational health risks and infection concerns for clinicians, sharps injury reduction and prevention absolutely must remain a priority.
Dr. Terry Grimmond was one of Daniels Health’s guest speakers and gave insight into the microbiology of sharps injuries – and why we must be vigilant in our efforts to make healthcare safer.
“My answer would be: a cure for what? People tend to think there are the top three pathogens: HIV, Hep B, and Hep C, but actually there are 60 different pathogens that can be transmitted from a needle stick injury; so no we don’t have a cure for sharps injuries.”
“I don’t think there is just one strategy – when Safety Engineered Devices (SEDs)were made law, injuries fell 38% in one year. So, people thought that was the solution – but then it stopped falling. We’ve only fallen 11% in the US in the 16 years following the legislative change to use SEDs. We now know there isn’t just one strategy. SEDs alone don’t work without thorough education and training:education as to why and training as into how. Competency-based training that proves you retained the information is imperative.”
“There’s a number of reasons. In 2003, 87% of clinicians said that they were moderately concerned about safety in their job, and now it’s 65%. What we’re trying to do with Daniels is to tell people: don’t be complacent when it comes to your safety. Another issue is we’ve done surveys that show that not all people use SEDs.
The research indicates that not everyone is using them when they’re available and even when they do use them, my research says, that 22% were not being activated properly. Sharps injuries need to be taken as seriously as any other occupational health risk like slips, trips, and sprains.”
“There was an excellent paper compiled over a 12-year period and they actually asked those who didn’t report why they didn’t. The main reason was inconvenience, time, and that they were rushed. The other reason for not reporting is people just saying or having the attitude of “oh it was just a scratch.” “It wasn’t a big deal, just a nick, didn’t see any blood.” People do give these reasons.
People wrongly assume that we can handle all the repercussions of a sharps injury or infection now and have cures for it all – we don’t. We need to know about every single sharps injury so we know what behaviour caused it. We need to know the behaviours to get the overview of how needle sticks are caused and to prevent them.”
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