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InternationalHealthcareWorkerSafetyCenter, University of Virginia
Occupational Exposures to Bloodborne Pathogens in Sub-Saharan Africa
Bibliography of Country-Specific & Regional Needlestick,
Surveillance, and Exposure Risk Studies
REGIONAL DATA/POLICY
Baggaley RF, Boily M-C, White RG, Alary M. Risk of HIV-1 transmission for parenteral exposure and blood transfusion: a systematic review and meta-analysis. AIDS 2006;20:805-12.
ABSTRACT- Background: The role of iatrogenic transmission within the HIV/AIDS pandemic remains contentious. Estimates of the risk of HIV transmission from injections and blood transfusions are required to inform appropriate prevention policy. Objectives: Systematic review and meta-analysis of the literature on HIV-1 infectivity for parenteral transmission and blood transfusion. Review methods: All identified studies with relevant transmission probability estimates up to May 2005 were included. Statistical methods: When appropriate, summary estimates for accidental percutaneous and blood product exposures were derived. Results: Infectivity estimates following a needlestick exposure ranged from 0.00 to 2.38% [weighted mean, 0.23%; 95% confidence interval (CI), 0.00-0.46%; n = 21]. Three estimates of infectivity per intravenous drug injection ranged from 0.63 to 2.4% (median, 0.8%); a summary estimate could not be calculated. The quality of the only estimate of infectivity per contaminated medical injection (1.9-6.9%) was assessed. Instead we propose a range of 0.24-0.65%. Infectivity estimates for confirmed contaminated blood transfusions range from 88.3 to 100.0% (weighted mean, 92.5%; 95% CI, 89.0-96.1%; n = 6). Conclusions: Infectivity estimates for infected blood transfusions are larger than for other modes of HIV transmission. Few studies on transmission risk per contaminated injection were found. However, transmission risk per needlestick injury, where needles are more likely to be rinsed or disinfected between recipients (especially for medical injections), may be representative of non-intravenous medical injections and lower than the risk from intravenous injections, which are likely to be deeper and to involve more fluids. Further work is needed to better estimate transmission probability related to contaminated injections and its likely contribution to overall HIV transmission.
Berkley S. Parenteral transmission of HIV in Africa. AIDS 1991;5:S87-S92.
ABSTRACT- HIV is known to be transmitted sexually, perinatally, and parenterally. Parenteral transmission is defined as that which occurs outside of the alimentary tract, such as in subcutaneous, intravenous, intramuscular, and intrasternal injections. The relative percentage of HIV infection caused by each of these routes depends upon the prevalence of infection among particular groups of the population and on their shared behaviors. Although heterosexual transmission is the primary mode of HIV infection in Africa, health care providers and traditional healers both in and out of the health care setting in Africa administer a large number of injections. As such, parenteral transmission could be contributing significantly to HIV infection in the region. This paper reviews what is known about the parenteral transmission of HIV in Africa. The biology of parenteral transmission in blood and in interstitial fluid is described, then sections follow on HIV transmission by injection, occupational transmission, transmission by scarification, and transmission by immunization. Available data suggest that while HIV may be occasionally transmitted in Africa through injections, it is most likely not a major route of infection in the region. Sterilizing needles and syringes, and using injections as last resort therapy will greatly reduce the risk of parenteral HIV transmission.
De Baets AJ, Sifovo S, Pazvakavambwa IE. Access to occupational postexposure prophylaxis for primary health care workers in rural Africa: a cross-sectional study. American Journal of Infection Control 2007;35:545-51.
ABSTRACT- Background: For many primary health care workers in developing countries, the limited availability and cost of public transport hinders timely access to occupational postexposure prophylaxis (PEP) at referral hospitals. Adapted PEP training and a starter's kit (for human immunodeficiency virus, hepatitis B virus, and syphilis prophylaxis) could improve access. Methods: The evaluation method, based on the 12 steps of the decentralized phase of PEP management, calculated different scores from the responses for 51 anonymous surveys and allowed comparison among different groups. Listed obstacles and clinic visits provided further information. Results: Respondents who received in-service PEP training had significantly higher mean knowledge and confidence scores but no different mean attitude scores than those who did not. The mean total score for those who received the adapted PEP training (10.7 of 12) was significantly higher (P = .008) than for those who did not (8.8 of 12). Conclusion: Decentralizing the first phase of PEP management for primary health care workers in rural Zimbabwe attends to an unmet need. The evaluation facilitates checking completeness of course contents, stresses the need to pay equal attention to attitudes toward the referral and reporting system, and identifies specific challenges for delivering PEP in rural settings. The finding may inspire to improve access to PEP for other health care workers and phlebotomists employed in remote areas.
de Graaf R, Houweling H, van Zessen G. Occupational risk of HIV infection among western health care professionals posted in AIDS endemic areas. AIDS Care 1998; 10:441-52.
ABSTRACT- In this study on occupational risks of HIV infection among 99 Dutch medics working in AIDS endemic areas, 61% reported percutaneous exposures during an average stay of 21 months. The mean number of injuries was lower among physicians (2.0 versus 3.9 per year) and higher among nurses (1.9 versus 1.2) than in previous research conducted in 1987-1990 among Dutch medics returning from Africa. But the reduction of exposures among physicians might be explained by the fact that the number of procedures they carried out was less in the later study. Also among nurses a shift of tasks was seen. On the basis of an estimated HIV prevalence in the patient population of 19%, a chance of transmission per accident of 0.3%, and 1.9 percutaneous exposures per year, the mean occupational risk of HIV infection per year can be estimated at 0.11% per person. Besides length of stay and number of activities, characteristics of the work setting were associated with the frequency of different kinds of injuries. From the analysis of 109 extensive descriptions of recent accidents, it appeared that the majority of the injuries occurred during routine activities and were self-inflicted. Injuries with hollow needles usually occurred after the actual medical act (e.g. during recapping). Carelessness (e.g. due to fatigue) or being in a hurry (e.g. because of an emergency) were also often the cause of percutaneous injuries, as were the poor quality of the equipment, lack of professional skills, or a combination of these factors. Prevention activities are still important to reduce the frequency of occupational exposures. But they will not eliminate them totally; from the descriptions of recent exposures it was clear that some of the injuries occurred in spite of precautions.
Ekwueme DU, Weniger BG, Chen RT. Model-based estimates of risks of disease transmission and economic costs of seven injection devices in sub-Saharan Africa. Bulletin of the World Health Organization 2002;80(11):859-70.
ABSTRACT- Objective: To investigate and compare seven types of injection devices for their risks of iatrogenic transmission of bloodborne pathogens and their economic costs in sub-Saharan Africa. Methods: Risk assumptions for each device and cost models were constructed to estimate the number of new hepatitis B virus (HBV) and human immunodeficiency virus (HIV) infections resulting from patient-to-patient, patient-to-health care worker, and patient-to-community transmission. Costs of device purchase and usage were derived from the literature, while costs of direct medical care and lost productivity from HBV and HIV disease were based on data collected in 1999 in Cote d’Ivoire, Ghana, and Uganda. Multivariate sensitivity analyses using Monte Carlo simulation characterized uncertainties in model parameters. Costs were summed from both the societal and health care system payer’s perspectives. Findings: Resterilizable and disposable needles and syringes had the highest overall costs for device purchase, usage, and iatrogenic disease: median US$ 26.77 and US$ 25.29, respectively, per injection from the societal perspective. Disposable-cartridge jet injectors and automatic needle-shielding syringes had the lowest costs, US$ 0.36 and US$ 0.80, respectively. Reusable-nozzle jet injectors and auto-disable needle and syringes were intermediate, at US$ 0.80 and US$ 0.91, respectively, per injection. Conclusion: Despite their nominal purchase and usage costs, conventional needles and syringes carry a hidden but huge burden of iatrogenic disease. Alternative injection devices for the millions of injections administered annually in sub-Saharan Africa would be of value and should be considered by policy-makers in procurement decisions.
Newman MJ. Infection control in Africa south of the Sahara [letter]. Infection Control and Hospital Epidemiology 2001;22:68-9.
No abstract; first paragraph:The translation of US-style infection control practices into healthcare provision in Africa, especially for the extremely poor African countries, is not an easy program to envisage. Procedures that are standard practices in the United States may be practically impossible to implement in most African countries. This letter discusses some of the universal problems associated with infection control in the African context. There are also problems due to ignorance, poverty, and the resulting lack of even the most basic resources for health care. Solutions to some of these problems are suggested.
Phillips EK, Owusu-Ofori A. Jagger J. Bloodborne pathogen exposure risk among surgeons in sub-Saharan Africa. Infection Control and Hospital Epidemiology 2007;28:1334-6.
ABSTRACT- To document the frequency and circumstances of bloodborne pathogen exposures among surgeons in sub-Saharan Africa, we surveyed surgeons attending the 2006 Pan-African Association of Surgeons conference. During the previous year, surgeons sustained a mean of 3.1 percutaneous injuries, which were typically caused by suture needles. They sustained a mean of 4.1 exposures to blood and body fluid, predominantly from blood splashes to the eyes. Fewer than half of the respondents reported completion of hepatitis B vaccination, and postexposure prophylaxis for human immunodeficiency virus was widely available. Surgeons reported using hands-free passing and blunt suture needles. Non-fluid-resistant cotton gowns and masks were the barrier garments worn most frequently.
Sagoe-Moses C, Pearson RD, Perry J, Jagger J. Risks to health-care workers in developing countries [Sounding Board]. New England Journal of Medicine 2001;345:538-41.
ABSTRACT- The authors describe the increased risks and substantial costs of occupational exposures to bloodborne pathogens in developing countries, particularly in sub-Saharan Africa, and recommend specific policy actions to help protect the lives of healthcare workers in these regions.
BURUNDI:
Le Pont F, Hatungimana V, Guiguet M, Ndayiragije A, Ndoricimpa J, Niyongabo T et al. Assessment of occupational exposure to human immunodeficiency virus and hepatitis C virus in a referral hospital in Burundi, Central Africa [letter]. Infection Control and Hospital Epidemiology 2003;24:717-18.
ABSTRACT- The occupational risk of viral infection among healthcare workers (HCWs) is well documented. Although universal precautions were established many years ago, their application is difficult in developing countries, owing to organizational problems and a lack of necessary materials such as gloves and proper needle-disposal facilities. Data on the frequency and circumstances of occupational exposures in developing countries are sparse. We report data from Burundi, a country with high rates of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) seroprevalence, based on a questionnaire that surveyed HCWs and auxiliary staff regarding perceptions of occupational exposure, frequency of exposures as defined by Centers for Disease Control and Prevention criteria, circumstances of exposures, and postexposure practices. We also estimated a cumulative risk for seroconversion to HIV and HCV due to parenteral exposure based on data from the survey.
COTE D’IVOIRE:
Tarantola A, Koumare A, Rachline A, Sow PS, Diallo MB, Doumbia S, Aka C, Ehui E, Brucker G,BouvetE. Groupe d'Etude des Risques d'Exposition des Soignants aux agents infectieux (GERES). A descriptive, retrospective study of 567 accidental blood exposures in healthcare workers in three West African countries [Cote d’Ivoire, Mali, Senegal].Journal of Hospital Infection. 2005;60:276-82.
ABSTRACT- We conducted a multi-centre study in West African hospital wards to document accidental blood exposure (ABE) risks in these settings, and assessed the incidence of ABE in participating healthcare workers (HCWs) retrospectively. In total, 1241 HCWs participated in the survey from 43 hospital wards. Among them, 567 (45.7%) had sustained at least one ABE with an estimated incidence of 0.33 percutaneous injuries (PCIs) and 0.04 mucocutaneous contacts (MCCs)/HCW/year in medical or intensive care personnel and 1.8 PCIs/HCW/year in surgeons. The ABE was a needlestick in 454 (80.1%) of 567 cases, a cut in 19 cases (3.4%), a splash or contact with non-intact skin in 87 cases (15.3%), and was undocumented in seven cases (1.2%). The source patient's human immunodeficiency virus (HIV) serostatus was positive in 74 cases (13.1%), negative in 65 cases (11.5%), and unknown in 416 cases (73.4%). The ABE was not notified in the ward in 392 cases (69.1%). Healthcare structures can improve HCWs' safety and reduce the stigma against HIV-infected patients by improving access to training, information, primary prevention (ABE prevention equipment) and secondary prevention (postexposure prophylaxis) of occupational infection risks.
DEMOCRATIC REPUBLIC OF THE CONGO
Borchert M, Mulangu S, Lefevre P, Tshomba A, Libande ML, Kulidri A, et al. Use of protective gear and the occurrence of occupational Marburg Hemorrhagic Fever in health workers from Watsa Health Zone, Democratic Republic of the Congo.Journal of Infectious Diseases 2007;15(196 Suppl 2):S168-75.
ABSTRACT- BACKGROUND: Occupational transmission to health workers (HWs) has been a typical feature of Marburg hemorrhagic fever (MHF) outbreaks. The goal of this study was to identify cases of occupational MHF in HWs from Durba and Watsa, Democratic Republic of the Congo; to assess levels of exposure and protection; and to explore reasons for inconsistent use of protective gear. METHODS: A serosurvey of 48 HWs who cared for patients with MHF was performed. In addition, HWs were given a questionnaire on types of exposure, use of protective gear, and symptoms after contact. Informal and in-depth interviews with HWs were also performed. RESULTS: We found 1 HW who was seropositive for MHF, in addition to 5 cases of occupational MHF known beforehand; 4 infections had occurred after the introduction of infection control. HWs protected themselves better during invasive procedures (injections, venipuncture, and surgery) than during noninvasive procedures, but the overall level of protection in the hospital remained insufficient, particularly outside of isolation wards. The reasons for inconsistent use of protective gear included insufficient availability of the gear, adherence to traditional explanatory models of the origin of disease, and peer bonding with sick colleagues. CONCLUSIONS: Infection control must not focus too exclusively on the establishment of isolation wards but should aim at improving overall hospital hygiene. Training of HWs should allow them to voice and discuss their doubts and prepare them for the peculiarities of caring for ill colleagues.
KENYA:
M’ikanatha NM, Imunya SG, Fisman DN, Julian KG. Sharp-device injuries and perceived risk of infection with bloodborne pathogens among healthcare workers in rural Kenya [letter]. Infection Control and Hospital Epidemiology 2007;28:761-3.
ABSTRACT- [W]e documented HCWs’ concerns about and exposure to bloodborne pathogens in a rural Kenyan setting where HIV and viral hepatitis may be prevalent. Although there is a need for improvement, some measures are being taken to prevent and respond to occupational exposure to bloodborne pathogens. To support much-needed occupational safety among HCWs in rural Kenya, it is hoped that coverage for HBV vaccination will be expanded, access to sharps safety devices will be increased, and postexposure prophylaxis will be offered for HIV exposure. So that hospitals are not operating in isolation in regard to this important public health activity, there is a need for national campaigns to address cultural perceptions leading to the overuse of injections and to support broader training for and implementation of occupational safety measures to protect HCWs against bloodborne pathogens.
Taegtmeyer M, Suckling RM, Nguku PM, Meredith C, Kibaru J, Chakaya JM,
Muchela H, Gilks CF. Working with risk: Occupational safety issues among healthcare workers in Kenya. AIDS Care. 2008;20(3):304-10.
ABSTRACT- The objective of this study was to explore knowledge of, attitudes towards and practice of post-exposure prophylaxis (PEP) among healthcare workers (HCWs) in the Thika district, Kenya. We used site and population-based surveys, qualitative interviews and operational research with 650 staff at risk of needlestick injuries (NSIs). Research was conducted over a 5-year period in five phases: (1) a bio-safety assessment; (2) a staff survey: serum drawn for anonymous HIV testing; (3) interventions: biosafety measures, antiretrovirals for PEP and hepatitis B vaccine; (4) a repeat survey to assess uptake and acceptability of interventions; in-depth group and individual interviews were conducted; and (5) health system monitoring outside a research setting. The main outcome measures were bio-safety standards in clinical areas, knowledge, attitudes and practice as regards to PEP, HIV-sero-prevalence in healthcare workers, uptake of interventions, reasons for poor uptake elucidated and sustainability indicators. Results showed that HCWs had the same HIV sero-prevalence as the general population but were at risk from poor bio-safety. The incidence of NSIs was 0.97 per healthcare worker per year. Twenty-one percent had had an HIV test in the last year. After one year there was a significant drop in the number of NSIs (OR: 0.4; CI: 0.3-0.6; p<0.001) and a significant increase in the number of HCWs accessing HIV testing (OR: 1.55; CI: 1.2-2.1; p= 0.003). In comparison to uptake of hepatitis B vaccination (88% of those requiring vaccine) the uptake of PEP was low (4% of those who had NSIs). In-depth interviews revealed this was due to HCWs fear of HIV testing and their perception of NSIs as low risk. We concluded that Bio-safety remains the most significant intervention through reducing the number of NSIs. Post-exposure prophylaxis can be made readily available in a Kenyan district. However, where HIV testing remains stigmatised uptake will be limited - particularly in the initial phases of a programme.