This study revealed that occupational injuries are still common and a concern among health-care workers. The high prevalence of percutaneous injuries (19.3%) could be attributed to the fact that being a public hospital, it has a high workload, a factor identified to be associated with occurrence of occupational injuries [12
]. The prevalence of 19.3% of sharps injuries is similar to a report from United Arab Emirates [13
], in which 19% of HCWs reported sharps injuries in one calendar year. It is reported that in developing countries where the prevalence of HIV-infected patients is the highest in the world, the number of needle-stick injuries is also the highest [14
]. However, the prevalence of splash exposure to mucous membrane was low (7%) as compared to that reported (25%) in Ethiopia [10
] and 18% in a study conducted in India [8
]. Other possible reasons for high prevalence of percutaneous injuries include lack of specific programme measures to address occupational challenges such as inadequate PPEs, lack of safer sharp devices, lack of information and non-adherence to standard precautions.
The prevalence of percutaneous injuries was high among those with experience less than 10 years (20.4%). Clarke et al. in their study found that the probability of ever having a needle-stick injury was inversely related to years of experience [15
]. This may be attributed to inadequate skills and knowledge regarding injection safety.
Accidental exposures were more frequently reported by females (Prevalence of 21%). Despite the absence of a statistically significant association between gender and occupational exposure to blood, similar results have been previously reported [16
Among the procedures that placed HCWs at risk of NSIs, stitching was the highest (29%), followed by blood specimen collection (19%). Cervini & Bell reported that majority of injuries among doctors occurred while stitching (46%) [17
]. Situations precipitating injuries include manipulating needles (34%), patient movement (20%), recapping (3.4%), and the unsafe collection of sharps and sharps disposal (3%). This is comparable to findings in which manipulating the needle contributed to 26% and recapping 6% of injuries [11
]. In another study, recapping was identified to account for 8.3% of percutaneous injuries [8
Although all healthcare workers in contact with patients are at risk to exposure to blood and body fluids, nurses reported most percutaneous injuries (50%) and splash exposures (40%). According to other studies, nurses experience the majority of needle-stick injuries in the world including half of the exposures that occur in USA [5
]. Nurses are more likely to handle sharp devices and have more contact with patients.
Hypodermic needle caused 39% of percutaneous injuries. Other hollow-bore needles that caused injuries include branulars and phlebotomy needles. Overall, hollow-bore needles caused 67% of injuries. Russi et al. reported that 62% of exposures to blood and body fluids involved hollow-bore needles [18
]. Hollow-bore needles have been identified as a risk factor that enhances transmission of pathogens, due to its nature of containing residual blood and other fluids and hence the most hazardous instruments among medical sharp devices [12
Majority of exposures occurred during the morning shift (42%). This may be attributed to busy schedule at the time and the pressure among staff to complete tasks. In addition, more invasive procedures are performed in the morning. In other studies, analysis of 411 recorded exposures demonstrated that more people were exposed between 9.00 am and 11.00 a.m. [19
Health-care workers of the age-group 31 to 40 had the highest prevalence of percutaneous injuries (26.4%). Age below 40 years was significantly associated with sharps injuries (aOR= 3.7; P-value = 0.034). This is comparable to a study conducted in Turkey in 2008 in which young age was a risk factor for occupational injuries [20
]. This is possibly due to limited professional experience and the fact that young HCWs tend to be enthusiastic and aggressive in their work.
Previous training in infection prevention was protective (aOR= 0.52; P-value = 0.029).. According to a study conducted by Nsubuga et al. in Uganda, lack of training was identified as a risk factor for needle-stick injuries [21
]. Training enhances awareness and improves skills among health-care workers.
Working in casualty (aOR = 4.05, P-value = 0.03) and surgical department (aOR = 3.5, P-value = 0.014) were identified as risk factors for sustaining splash exposure to mucocutaneous membrane. This is comparable to findings by Hosoglu et al. in Turkey, in which working in a surgical site was a significant factor for occupational exposure [20
]. Possible explanation is that casualty is an emergency unit where procedures are carried out as urgent, while in surgical department, the kind of procedures carried out tend to predispose HCWs to splashes.
National Institute of Occupational Safety and Health, United States identifies the following as predisposing factors to needle-stick injuries; over-use of injections and unnecessary sharps, lack of supplies (disposable syringes, safer needle devices, sharps disposal containers), lack of access to, and failure to use sharps container immediately after use, poorly trained staff, needle-recapping, no engineering control, such as safer needle devices, passing instruments from hand to hand as on operating room, and lack of hazard awareness and training [22
]. This is in agreement with findings from this study in which 51% of staff are untrained, facilities lack safety devices and needle recapping is still practiced.
Hepatitis B vaccination coverage among HCWs was low at 40% (fully vaccinated). According to the WHO estimates, vaccination coverage varies from 18% in Africa to 77% in Australia and New Zealand [23
]. In a study conducted in 2005, Thika district Kenya, only 12.8% of HCWs were vaccinated [24
]. Doctors were more likely to be vaccinated among the HCWs (OR = 38, P-value25].
There are many potential reasons for low HBV vaccine coverage, the most common being unavailability of the vaccine at the health facility. While the vaccine is available at the market at a cost, HCW have relied on provision by their institutions. However, there is a moderately good awareness among HCWs. Other potential reasons identified in our study and supported by other studies include busy schedules, lack of knowledge about severity and vaccine efficacy, and low risk perception [26
]. Seven percent of health workers did not use barrier protection during execution of procedures. Skin and mucous membrane contacts can be prevented with the use of barrier precautions such as gloves, masks, gowns, and goggles. However since the greatest risk of blood-borne pathogen transmission come from percutaneous injuries, changes in techniques or use of safety devices is required. Tokars et al. noted that half of the percutaneous injuries during suturing occurred when fingers instead of instruments were used [27
]. Use of personal protective equipment is critical in prevention of exposures.
In this study, over 80% of HCWs washed the injured site under running water and 54% took no action. However, a number of staff used disinfectants (hypochlorite solution or methylated spirit) to clean the site, while others squeezed the site probably due to lack of knowledge about what immediate action to take. In a study conducted by Rahul et al. in India, 60.9% of HCWs washed the site with soap and water and 14.8% took no action [28
Forty five percent of HCWs did not report the occurrence of exposures. Unreported needle-stick and sharp injuries are a serious problem and prevent injured HCWs from receiving PEP against HIV, which is shown to be 80% effective against HIV infection. According to researchers, 40%-70% of all needle-stick injuries are unreported [14
]. According to Clarke et al. in their study, only 29% of exposed respondent reported the incident [15
]. Reasons for not reporting include; source thought to be non-infectious, too little time to report, lack of reporting protocol, low risk perception while other feared stigma. Moreover, underreporting may be related to unwillingness to reveal incidence or lack of motivation due to the belief that HCWs can handle the issue themselves.
Less than half of the exposed (25%) took a course of PEP against HIV/AIDS. However, this figure is high as compared to that reported in a study conducted in India where only 7.8% of HCWs took a course of PEP [28
]. As most HCWs did not report the exposures, they were not evaluated for indication of PEP, therefore it is important to note that the number required to take PEP may not be exact. Over 59% of HCWs ignored the exposure. Fear of side effects has been cited as one factor against HCWs taking ARVs. A significant proportion of HCWs demonstrated lack of knowledge concerning PEP. No laboratory testing is carried out for HBV and HCV infections. Reporting injuries and documenting all blood-borne exposures are essential for having the evidence to analyze for preventive measures.
We recognized certain limitations in our study. As information was self reported, misclassification of HCWs as exposed or not exposed is possible. Information on exposure was sought for the preceding 12 months; there is a possibility of recall bias among the HCWs. Due to the study design, temporal sequence cannot be ascertained.