Healthcare worker safety in the operating room is of prime concern in regions where disease prevalence is high and healthcare providers are low. In.
Healthcare worker safety a vital component of surgical capacity in lowresource settings Petroze RT, Phillips EK, Nzayisenga A, Ntakiyiruta G, Calland, JF
Int J Occup Environ Health. 2012 Oct-Dec;18(4):307-11. doi: 10.1179/2049396712Y.0000000005.
Department of Surgery, University of Virginia, Charlottesville, VA, USA.
Abstract INTRODUCTION: A disparate number of occupational exposures to bloodborne pathogens occur in low-income countries where disease prevalence is high and healthcare provider-per-population ratios are low. METHODS: In an effort to highlight the important role of healthcare worker safety in surgical capacity building in Rwanda, we measured self-reported presence of safety materials and compliance with personal protective equipment in the operating theatre as part of a nationwide survey to characterize emergency and essential surgical capacity in all government hospitals. RESULTS: We surveyed 44 hospitals. While staff report general availability of safe disposal of sharps and hazardous waste, presence of and compliance with eye protection was lacking. Staff were cognizant of prevention measures such as double-gloving and 'safe receptacles', as well as hospital policies for post-exposure prophylaxis for HIV following needlesticks, but there was little awareness of hepatitis exposure. CONCLUSIONS: Healthcare worker safety should be a key component of hospital-level surgical capacity.
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Introduction Coming more to the forefront since the start of the HIV/AIDS epidemic in the 1980s, occupational exposure to bloodborne pathogens is a serious concern for healthcare workers worldwide.1 The World Health Organization (WHO) estimates that 9% of healthcare workers globally experience percutaneous exposure to bloodborne pathogens each year. Of these 3 million individuals, 90% live in low-income countries.2 In the year 2000, contaminated sharps exposure resulted in approximately 16,000 HCV, 66,000 HBV, and 1000 HIV infections worldwide. Half of the associated deaths are estimated to have occurred in sub-Saharan Africa.3 Healthcare worker safety in the operating room is of prime concern in regions where disease prevalence is high and healthcare providers are low. In most regions of Africa, for example, the populace has over 100-fold fewer surgeons per capita than are found in the United States and Europe.4 Over 230 million surgical procedures are estimated to be performed worldwide each year, but 70% of countries have no data on the frequency and type of surgical conditions.5 Even fewer have data on surgical safety measures, including occupational exposure of healthcare workers in the operating room. Most documented infections from occupational exposure occur in industrialized countries where monitoring and reporting procedures are more standard. 1 In high-income countries, the use of personal protective equipment (PPE) such as eye shields, fluid resistant gowns, and double-gloving practices have
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been shown to be effective in reducing operating room occupational exposure. 6 Similarly, hepatitis B vaccination of healthcare workers in the US has decreased occupational transmission of the virus compared to high rates of transmission in unvaccinated personnel in other countries.7, 8 Reducing exposure risks in lowresource settings around the world, where the prevalence of bloodborne pathogens is higher, is increasingly gaining notice. A survey of surgeons in subSaharan Africa revealed a low rate of hepatitis B vaccination.9 Surgery has been regarded as the “neglected stepchild of global health”. 10 Much of this is likely due to the high initial costs of training surgeons in addition to infrastructure and materials necessary for safe surgery. Given the time and financial investments required to train a surgeon in resource-limited settings, reducing occupational exposure to bloodborne pathogens should be paramount. Therefore, as part of a larger study to characterize emergency and essential surgical capacity at the hospital-level in Rwanda, we evaluated self-reported presence of safety materials and compliance with personal protective equipment in the operating theatre in order to identify targets to reduce occupational risks.
Methods We utilized a locally-adapted WHO situational analysis tool to survey emergency surgical capacity at every government-supported hospital in Rwanda.11 This tool was used to evaluate surgical capacity in five areas: infrastructure, human resources, interventions, emergency equipment and supplies, and personal protection. This study focuses on the emergency
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equipment and supplies and personal protection responses as relate to occupational exposure to bloodborne pathogens. Site visits were made in November, 2010 to 44 hospitals, including 41 district hospitals and 3 referral hospitals. Hospital staff involved in the survey and interview process included a data manager and at least 2 of the following: hospital director or administrator, theatre nurse, anesthetist, and doctor performing surgery. We further evaluated local literature and public (or hospital?) sources for local prevalence of Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV), policies regarding occupational exposures including post-exposure prophylaxis (PEP), vaccination policies, and reported needlestick incidents.
Results Country Background Rwanda is a landlocked country in sub-Saharan Africa with a population of over 10 million and the highest population density on the African continent. The economic and political capital is Kigali with a population of nearly one million. At the end of 2009, there were 541 health facilities under the jurisdiction of the MOH, including 428 health centers and the 44 surveyed hospitals.12 The Faculty of Medicine at the National University of Rwanda (NUR), located two hours south of Kigali in Butare, is the only medical school in country, with medical students performing clinical rotations in surgery at the three referral hospitals in country.
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There are five nursing schools distributed throughout the country with a masterslevel program available at the Kigali Health Institute. Following the genocide of 1994, HIV prevalence was high but a drastic fall was remarked in voluntary testing positivity, ranging from 10% in 2003 to 2.3% in June 2010.12(Source: TRAC Plus , annual report 2009-2010) Over the past 15 years, aggressive programs targeted at HIV/AIDS prevention and treatment has shown excellent results; Demographic and Health Survey (DHS) HIV prevalence at the community level was 3 % in 2005; another DHS is ongoing and will provide information on current HIV prevalence.13 More than 10% of the government’s budget is allocated to healthcare.12 National prevalence data for HBV and HCV are not available, but HBV infection is estimated to be around 5-10%. The National Centre for Blood Transfusion reported a 1.63 % prevalence of HBsAg, 1.06% HCV prevalence, and 0.48% HIV prevalence in blood donations for 2009-2010.12 Highly Active Anti-Retroviral Therapy (HAART) for post-exposure prophylaxis of occupational exposure is readily available in Rwanda. NUR has a policy to ensure HAART therapy to all staff and students in the instance of occupational exposure. HBV vaccination is not routinely provided as a scheduled childhood immunization in Rwanda. Only one hospital--a referral hospital in Kigali— requires HBV vaccination for its staff; this does not include postgraduate students and medical students on clinical rotations. Routine HBV vaccination is NOT provided at the university hospitals or district hospitals.
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Survey results Eight hospital materials items representing either PPE or safe waste disposal were extracted for further evaluation. Figure 1 shows the general availability at all hospitals of materials related to healthcare worker safety. Safe sharps and hazardous materials disposal are reported to be available greater than 95% of the time. PPE materials are generally available, but eye protection was the least available, with 36% of hospitals reporting frequent shortages or general unavailability. Figure 1 120.0 100.0
90.9
90.9
100.0
95.5
95.5 84.1
75.0
80.0
63.6
Always Available
60.0 36.4
40.0 20.0 0.0
25.0 9.1
9.1
4.5
15.9 0.0
Frequent shortages or Unavailable
4.5
A qualitative survey of the prevalence of the use of PPE was added to the original WHO survey tool. Detailed in Figure 2, this showed nearly universal use of double gloving but poor use of eye protection. 88.6% of hospitals reported that extra precautions were taken with sharps (“safe receptacle” for needles and scalpels). 81.8% of hospitals reported having needlestick guidelines in place for
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staff that experienced sharps injuries. In general, this was taken to refer to postexposure prophylaxis and testing for HIV. During staff interviews, awareness and testing for hepatitis following sharps exposure was less available and raised as a need for protecting staff.
100.0 88.6 86.4 86.4 81.8 90.0 72.7 80.0 70.5 Figure 70.02 60.0 50.0 40.0 29.5 27.3 30.0 18.2 13.6 13.6 11.4 20.0 10.0 0.0
Always or Most of the time with rare exception Sometimes but use is inconsistent or Never
Discussion Healthcare workers are a precious commodity in Africa. Sub-Saharan Africa carries 68% of the world’s HIV/AIDS burden but has only 3% of healthcare workers worldwide and 1% of financial resources for health.14, 15 Surgical disparities are even more profound, and Rwanda is no exception. Given the scarcity of surgical personnel in Rwanda, healthcare worker safety should be a priority. By utilizing the WHO tool for assessment of hospital-based surgical capacity, we aimed in this study to highlight the important role of healthcare worker safety in surgical capacity.
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A previous study utilizing a hospital-based capacity survey in Sierra Leone showed poor compliance with universal precautions, including the use of PPE, issuing an advocacy call for prevention of occupational exposure to HIV in the operating room.16 In Rwanda, we found that availability and utilization of PPE was generally available, with the exception of eye protection. (risk of eye splashes) Utilization of eye protection is an easy and important safety measure to implement.17 A recall survey in Tanzania health workers revealed at least five needlestick accidents and nine splashes per health worker per year, signifying the incredible occupational risk of African healthcare workers. Furthermore, due to limited funding for surgical supplies, quality is not always a priority, with surgeons in the survey recalling one perforated glove every ten operations.(Gumodoka) While interviewed Rwandan staff were generally cognizant of prevention measures such as double-gloving and “safe receptacle” as well as hospital policies for post-exposure prophylaxis for HIV following needlesticks, there was little awareness of hepatitis exposure. Based on interviews, we found that only one referral hospital provided universal hepatitis vaccination for healthcare workers, which did not include rotating medical and postgraduate students. In fact, national hepatitis prevalence data is severely lacking. Globally, viral hepatitis affects greater than 10 times the number of people affected by HIV/AIDS each year, and hepatitis exposure awareness is vitally important in the surgical population. To fully protect this precious human resource, HIV
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awareness is not enough. Further awareness and prevention of hepatitis, including access to HBV vaccination for healthcare workers, is now paramount.
Conclusions Healthcare worker safety should be a key component of hospital-level surgical capacity. As efforts are made to increase capacity, adherence to healthcare worker safety is a prime factor.
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Sagoe-Moses C, Pearson RD, Perry J, Jagger J. Risks to health care workers in developing countries. N Engl J Med 2001; 345(7):538-41. (WHO) WHO. Aide-memoire for a strategy to protect health workers from infection with bloodborne viruses. Geneva: Department of Blood Safety and Clinical Technology, WHO, 2003. Pruss-Ustun A, Rapiti E, Hutin Y. Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers. Am J Ind Med 2005; 48(6):482-90. Lopez AD, Mathers CD, Ezzati M, et al. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006; 367(9524):1747-57. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372(9633):139-44. Telford GL, Quebbeman EJ. Assessing the risk of blood exposure in the operating room. Am J Infect Control 1993; 21(6):351-6. Talaat M, Kandeel A, El-Shoubary W, et al. Occupational exposure to needlestick injuries and hepatitis B vaccination coverage among health care workers in Egypt. Am J Infect Control 2003; 31(8):469-74. Mahoney FJ, Stewart K, Hu H, et al. Progress toward the elimination of hepatitis B virus transmission among health care workers in the United States. Arch Intern Med 1997; 157(22):2601-5. Phillips EK, Owusu-Ofori A, Jagger J. Bloodborne pathogen exposure risk among surgeons in sub-Saharan Africa. Infect Control Hosp Epidemiol 2007; 28(12):1334-6. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg 2008; 32(4):533-6. WHO. situational analysis. MOH. Annual Report. 2009-2010. Macro INdlSdRIaO. Rwanda Demographic and Health Survey 2005. 2006. Maddison AR, Schlech WF. Will universal access to antiretroviral therapy ever be possible? The health care worker challenge. Can J Infect Dis Med Microbiol 2010; 21(1):e64-9. Anyangwe SC, Mtonga C. Inequities in the global health workforce: the greatest impediment to health in sub-Saharan Africa. Int J Environ Res Public Health 2007; 4(2):93-100. Kingham TP, Kamara TB, Daoh KS, et al. Universal precautions and surgery in Sierra Leone: the unprotected workforce. World J Surg 2009; 33(6):1194-6. Jagger J, Perry J. Exposure safety. When the eyes have it. Nursing 1999; 29(2):20.
(Other reference info)
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Institut National de la Statistique du Rwanda (INSR) and ORC Macro. 2006. Rwanda Demographic and Health Survey 2005. Calverton, Maryland, U.S.A.: INSR and ORC Macro. “The university students and staff are ensured the HAART for post-exposure prophylaxis of HIV/AIDS in case of accidental professional exposure, rape or high risk sex through the national treatment programmes; in case these are insufficient, the National University of Rwanda ensures the HAART for post-exposure prophylaxis.” http://www2.aau.org/aur-hivaids/docs/institutional_HIVAIDS_polices/NUR/NUR%20HIV%20Policy.pdf The National University of Rwanda: HIV/AIDS Control Policy There are now four geographically-based provinces (North, South, East, and West) and the City of Kigali, these being further subdivided into 30 districts, 415 sectors, cells and, finally, villages (Imidugudu).
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