In the Middle East, the majority of HBV infections occur through childhood and perinatal transmission, yet there is limited information on sexual transmission in societies of the Middle East.[9
] To decrease the prevalence of HBV infection, many countries introduced Hepatitis B vaccination through their expanded program on immunization (EPI). In Syria Hepatitis B vaccination was added to the EPI program in 1991. Data from the Syrian Ministry of Health in 2004, shows that the overall prevalence of HBV is 5.62%, with Aleppo having the highest infection rate among all the Syrian provinces, with a rate of 10.6%.[10
It is well known that vaccine-induced antibodies decline gradually over time, and as many as 60% of those who initially responded to vaccination will lose detectable antibodies in eight years. However, booster doses of vaccines are not recommended for immunocompetent HCWs, because persons who respond to the initial vaccine series remain protected against clinical hepatitis and chronic infection even when their anti-HBs levels become low or undetectable.[13
] In our study of 180 workers, who previously received three doses of vaccination, 30 workers (16.7%) had anti HBs antibody titers of less than 100 IU/L, while nine had titers less than 10 IU/L.
In the Aleppo University Hospitals there are no designated trolleys, gloves, or disposal facilities at the bedside. HCWs frequently work alone, and patients are often unrestrained during these procedures. Sharps and needles used are either disposed in garbage collectors in the patient's rooms or carried back to the needle disposal box. With the huge workload and the absence of protective measures, HCWs at the Aleppo University Hospitals are exposed to a high risk of getting NSIs. Another dilemma that needs to be resolved is the underestimation of the importance of immediate NSI reporting among HCWs.
Underreporting of NSI is a common problem in our healthcare facilities. Although hospital employees are requested to report such accidents, a lot of injuries go unreported. One of the limitations that we had was the recall bias, which is why we reviewed each employee's medical charts and hospital injury reports. Nevertheless, some of these injuries were not previously reported.
To our knowledge, our study is the first to estimate the NSIs, HBV chronic infection, and vaccination status among HWCs in tertiary hospitals in Aleppo city and Syria. A previous biphasic study, the Focus Project, conducted in Syria from 2001 to 2004, was designed to follow-up on the effects of the implanted safety measures.[11
] The study showed that 61% of HCWs got at least one NSI during a period of 12 months, in 2001, which decreased to 14% after the implementation of safety instructions and measurements, compared to 76.6% in our study. That study was performed mainly in the primary and secondary healthcare facilities, along with some private hospitals. Seventy percent of the facilities were utilized for immunization purposes, with a much lower workload than the tertiary hospitals in the Aleppo University. This could explain the difference in results between our study and the Focus Project. Another explanation may be that it was due to the safety measures themselves: In 2001, safety boxes were used in 63% of the vaccination areas and 22% of the curative injection areas in the Focus Project, while in 2004, safety boxes were available in almost all healthcare facility departments where injections were given. In 2004, however, safety boxes were regularly supplied to only 13% of the hospitals. Consequently, sharps exposing staff to the risk of NSIs were found in open containers in 90% of the hospitals, two-handed recapping was performed in 76% of the hospitals, and NSIs were reported by 45% of HCWs in hospitals versus 14% of HCWs in other health facilities. These data are compatible with our results and highlight the fact that an increased workload leads to an increased chance of NSIs, due to the reluctance and delay in applying safety measures.
] conducted in 2001, shows that 76% of the Syrian general population previously received three doses of vaccination against HBV infection, while the percentage of complete vaccination among HCWs in our study is only 56.1%. In a study conducted in Turkey in 2005,[16
] 68% of the HCWs were completely vaccinated, and doctors and nurses were at the same risk of NSIs (27% of the nurses and doctors had sustained NSIs during a period of six months). In our study, anesthesiology technicians had the highest risk of NSIs followed by doctors and then nurses. Twenty workers (6%) were HBsAg positive compared to nine HCWs (2.8%), in our study.
In several investigations of nosocomial hepatitis B outbreaks, most infected HCWs could not recall an overt percutaneous injury.[17
] HBV infections in HCWs with no history of nonoccupational exposure or occupational percutaneous injury might have resulted from direct or indirect blood or body fluid exposures that inoculated HBV into cutaneous scratches, abrasions, burns, other lesions, or on mucosal surfaces.[19
A study by Fisman et al
] showed that nurses report the most frequent exposures to NSIs (37.9%), followed by resident or fellow physicians (11.4%), attending physicians (10.7 %), surgeons (9.0%), phlebotomists (5.4%), and non-laboratory technologists (4.7%). In our study anesthesiology technicians had the highest rate and risk in acquiring both NSIs and HBV infection, while doctors ranked second in NSI exposure. This could be explained by the fact that the risk of HBV infection is primarily related to the degree of contact with blood in the work place and the increased risk of exposure during long work shifts, factors which are associated with a three-fold increase in the risk of NSI.[22
In studies of HCWs who sustained injuries from needles contaminated with blood containing HBV,[23
] the risk of developing clinical hepatitis if the blood was both HbsAg- and HBeAg-positive was 22-31%, and the risk of developing serologic evidence of HBV infection was 37-62%. In comparison, the risk of developing clinical hepatitis from a needle contaminated with HBsAg-positive and HBeAg-negative blood was 1-6%, and the risk of developing serologic evidence of HBV infection was 23-37%. Other studies found that as little as 10 ml[8
] of HBV positive blood could transmit infection to a susceptible host.[24
In some studies, the prevalence of HBV carriers in Syria varies from 3 to 5%,[24
] while it ranges from 5 to 10% in others,[10
] which highlights that HCWs are at an increased risk of exposure to patients with asymptomatic HBV infection. This fact should promote the necessity of having all HCWs vaccinated against HBV. Although the prevalence of HBV chronic infection in our study (2.8%) is less than in other studies conducted in Pakistan (7.5%) and other countries, it should still be noted that there are simple ways to prevent transmission, which should not be overlooked.[25
] In 1991, OSHA required that all HCWs with reasonably anticipated exposure to blood be offered HBV vaccine. Studies suggest that this strategy has been highly successful in reducing HBV infection among HCWs with a 95% decline in the incidence of hepatitis B infection among American HCWs between 1983 and 1995.[26
Another method to reduce exposure is warning signs. Where needles are used, existing policies on their use and disposal should be implemented and regularly reinforced to minimize risk to staff and patients. To be safe, HCWs must adhere to standard precautions and follow fundamental infection-control principles. In our study, housekeeping workers reported that they injured themselves with needles not disposed of properly; concealed in linen or regular garbage.
Preventing NSIs is the most effective way to protect workers from the infectious diseases that needlestick accidents transmit. Therefore, pre-employment education in health and safety must be a part of all courses for prospective healthcare workers. Thorough occupational health and safety practices must be promoted to all staff throughout their career, while awareness of occupational health and safety and its importance to their own health and well being should be stressed. This could be achieved by continuing training programs over time to ensure that HCWs are kept up-to-date and aware of new needlestick policies, practices, and procedures. A comprehensive NSI prevention program would include: Employee training, recommended guidelines, safe recapping procedures, effective disposal systems, surveillance programs, and improved equipment design.