Occupational exposure to bloodborne pathogens in a specialized care service in Brazil

In a retrospective study about the epidemiology of exposure to bloodborne pathogens among health care providers, 71.10% of the analyzed events occurred among health professionals, mainly auxiliary nurses. Percutaneous exposure (83.04%) was the most frequent. Greater advances are necessary in the development of public policies for this issue in terms of inspection of regulatory norms and raising the professionals' awareness through policy and education. In a retrospective study about the epidemiology of exposure to bloodborne pathogens among health care providers, 71.10% of the analyzed events occurred among health professionals, mainly auxiliary nurses. Percutaneous exposure (83.04%) was the most frequent. Greater advances are necessary in the development of public policies for this issue in terms of inspection of regulatory norms and raising the professionals' awareness through policy and education. Daily and routine work shifts can cause either temporary or permanent functional disorders and physical and mental exhaustion in health care providers (HCPs).1Marziale M.H. Silva E.J. Haas V.J. Robazzi M.L. Acidentes com material biológico em hospital da Rede de Prevenção de Acidentes de Trabalho - REPAT.Rev Bras Saúde Ocup. 2007; 32: 109-119Crossref Google Scholar A total of 5,735 cases involving HCPs were notified to the Brazilian National Notifiable Diseases Information System in 2010.2Jagger J. Berguer R. Phillips E.K. Parker G. Gomaa A.E. Increase in sharps injuries in surgical settings versus nonsurgical settings after passage of national needlestick legislation.J Am Coll Surg. 2010; 210: 496-502Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar As a result, the Brazilian Ministry of Health published Ministerial Ordinance N.1271/2014,3Ministério da Saúde (Brasil). Portaria 1271 de 06 de junho de 2014. Define a Lista Nacional de Notificação Compulsória de doenças, agravos e eventos de saúde pública nos serviços de saúde públicos e privados em todo o território nacional, nos termos do anexo, e dá outras providĉncias. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2014/prt1271_06_06_2014.html. Accessed July 19, 2015.Google Scholar which provides a compulsory notification list for diseases, health issues, and health events in the public and private health services and which recommends that state health departments are notified of occupational accidents involving exposure to biologic material. In this study we describe the epidemiologic profile of occupational exposure to biologic materials and examine the postexposure management strategies of the professionals of a specialized care service (SAE) located in southeastern Brazil. We conducted a retrospective review of occupational accidents with biologic materials reported in the SAE of São José do Rio Preto, SP, Brazil, over an 18-month period (January 2011–July 2012). The study population was recruited in sequence, retrospectively, in medical records, within an established data collection period of 18 months. All the medical records that were open and notified in the period stipulated for data collection were included; as exclusion criteria, it was established that data from medical records that were inconclusive or not specified by the SAE information system and occurrence of work accidents outside the study would be excluded from the analyses. The data used in the medical records catalogued in the SAE totaled 403 professionals who had suffered accidents, which made up the final population of the study. This study was approved by the Institutional Board Review of the São José do Rio Preto Medical School, under process N.150.060. All statistical analyses were completed using Minitab 17.0 (Minitab, Sydney, Australia). Initially, the distribution normality of the data was verified and confirmed by the Shapiro-Wilk test. We used descriptive and nonparametric statistics through the χ2 test for the categorical or dichotomous variables to detect statistical bivariate associations among the study variables. All analyses were done with 95% confidence intervals, and the level of significance was set at P < .05. Of the 403 accidents evaluated in the study period, 303 (75.19%) occurred among women, and 100 (24.81%) were among men. In relation to age, it was ascertained that the HCPs' mean age was 31.88 ± 10.28 years old. Among the professionals evaluated, 100 (26.81%) were auxiliary nurses, 61 (16.35%) were nursing technicians, 33 (8.85%) were physicians, 29 (7.77%) were cleaning assistants, 18 (4.83%) were nurses, 14 (3.75%) were from general services, 10 (2.68%) were dentists, 8 (2.14%) were dental assistants, 3 (0.80%) were laundry staff, and 97 (26.01%) were from other professions. Most of the accidents occurred during the morning shift, with 168 (42.75%) cases, followed by the evening period, with 153 (38.93%) cases. The predominant form of occupational exposure among HCPs was inappropriate disposal, with 110 (28.57%) cases. Table 1 presents a strong association between the type of exposure and the study participants' profession. When percutaneous exposure is compared with other types of exposure, a significant statistical association was ascertained among the professional categories (P < .001; λ2 = 41.42).Table 1Association between profession and type of exposure to occupational accidentsType of exposureProfessionTotalOthersHealthGeneral services and cleaningEyes2 (2.94)40 (14.44)0 (0.00)42 (10.77)Others14 (20.59)12 (4.33)0 (0.00)26 (6.67)Percutaneous52 (76.47)225 (81.23)45 (100)332 (82.56)Total68 (17.44)277 (71.03)45 (11.54)400 (100)P value<.001∗P value obtained using the λ2 test.NOTE. Values are n (%) or as otherwise indicated.∗ P value obtained using the λ2 test. Open table in a new tab NOTE. Values are n (%) or as otherwise indicated. Among the conduct undertaken in the 359 cases of occupational accidents, 172 (47.91%) used soap and water; 59 (16.43%) used water, soap, and alcohol; 58 (16.16%) used no intervention; 38 (10.58%) used only water; and 32 (8.91%) used other measures. In relation to the postexposure prophylactic measures, 283 (82.75%) of the HCPs (ie, most) used personal protective equipment (PPE). However, when the 206 (82.07%) health professionals were compared with the 42 (95.45%) professionals from general and cleaning services in relation to the use of PPE, there was no statistically significant difference according to the λ2 test (P = .012; λ2 = 8.77). When the various HCP types were compared in relation with the measures adopted after exposure to biologic materials, it was ascertained that there was greater prevalence of the use of soap and water by the 127 (50.40%) health professionals than by the 15 (36.59%) professionals from general and cleaning services; this difference was statistically significant (P = .009; λ2 = 20.26) (Table 2).Table 2Measures adopted after occupational exposure related to the professions of the specialized care serviceMeasuresProfessionTotalOthersHealthGeneral and cleaning servicesWater6 (10.71)31 (12.30)0 (0.00)37 (10.60)Soap and water24 (42.86)127 (50.40)15 (36.59)166 (47.56)Soap, water, and alcohol8 (14.29)41 (16.27)9 (21.95)58 (16.62)None10 (17.86)33 (13.10)13 (31.71)56 (16.05)Others8 (14.29)20 (7.94)4 (9.76)32 (9.17)Total56 (16.05)252 (72.21)41 (11.75)349 (100)P value.009∗P value obtained through the λ2 test.NOTE. Values are n (%) or as otherwise indicated.∗ P value obtained through the λ2 test. Open table in a new tab NOTE. Values are n (%) or as otherwise indicated. Regarding the evaluation of bloodborne diseases, after the exposure, in relation to the transmitter, principally HIV and hepatitis C virus (HCV), 248 (63.43%) were HCV negative, 9 (2.30%) were HCV positive, and 134 (34.27%) were not specified. In relation to HIV, 249 (63.68%) were HIV negative, and 10 (2.56%) were HIV positive, whereas 132 (33.76%) were not specified. We ascertained that among all the HCPs, 9 (100%) from the health area were HCV positive (P < .001; λ2 = 111.85). However, for unspecified HCV, there was a prevalence of 54 (42.19%) professionals who worked in the area of health and 43 (33.59%) professionals from general and cleaning services. A similar result was found for the prevalence of HIV in the transmitter, that is, most (80%) were also constituted by health professionals (P < .001; λ2 = 112.40). Negative results for HIV in the transmitters were also verified for the professionals who worked in the health area (86.07%); however, the unspecified nature of HIV for the transmitter was ascertained both among professionals from the health area (41.27%) and those who work in general and cleaning services (34.13%). The data demonstrated a greater occurrence of occupational accidents among health professionals who were women (75.19%), with prevalence in the area of nursing. These results are similar to those found in other works which researched this issue, which indicated that approximately 90% of nursing professionals are women.1Marziale M.H. Silva E.J. Haas V.J. Robazzi M.L. Acidentes com material biológico em hospital da Rede de Prevenção de Acidentes de Trabalho - REPAT.Rev Bras Saúde Ocup. 2007; 32: 109-119Crossref Google Scholar, 4Galon T. Marziale M.H. Souza W.L. Brazilian legislation and the international recommendations related to the occupational exposure to agents.Rev Bras Enferm. 2011; 64: 160-167Crossref PubMed Scopus (4) Google Scholar It is well known that the nursing staff represents a group that is particularly vulnerable to biologic risks because of the specific characteristics of their work activities, which involve direct and continuous care to patients.5Bonini A.M. Zeviani C.P. Facchin L.T. GIR E. Canini S.R. Exposição ocupacional dos profissionais de enfermagem de uma unidade de terapia intensiva a material biológico.Rev Eletr Enf. 2009; 11: 658-664Google Scholar Among the main recommendations for preventing accidents, emphasis is placed on maximum attention while undertaking procedures, not using the finger as a buffer, not resheathing needles, not bending or removing needles with the hands, and finally, placing sharp materials in a lidded receptacle that is puncture-resistant.6Ministério da Saúde (Brasil). Secretaria de Vigilância em Saúde. Programa Nacional DST/ Aids. Recomendações para atendimento e acompanhamento de exposição ocupacional a material biológico: HIV e hepatites B e C. Brasília (DF): Ministério da Saúde; 2010. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/04manual_acidentes.pdf. Accessed July 19, 2015.Google Scholar The resheathing of needles and instruments was the cause of accidents in approximately 6.49% of the professionals analyzed. In cases of exposure involving a source patient who is positive for HIV, chemoprophylaxis with antiretrovirals is recommended.7Ministério da Saúde (Brasil). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Exposição a materiais biológicos. Brasília (DF): Ministério da Saúde; 2006. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/protocolo_expos_mat_biologicos.pdf. Accessed Jul 19, 2015.Google Scholar, 8U.S. Public Health ServiceUpdate U.S. Public Health Service Guideline for the management of occupational exposure to HBV, HCV, and HIV and recommendations for postexposure prophylaxis.MMWR Recomm Rep. 2001; 50: 1-52Google Scholar In the case of HCV, the measures are restricted to the use of standard precautions because there is currently no other effective measure for reducing the risk of its transmission.9Siegel J.D. Rhinehart E. Jackson M. Chiarello L. Healthcare Infection Control Practices Advisory CommitteeGuidelines for isolation precautions: preventing transmission of infectious agents in healthcare settings.Am J Infect Control. 2007; 35: S65-S164Abstract Full Text Full Text PDF PubMed Scopus (1432) Google Scholar Accidents involving blood infected by hepatitis B virus with a high rate of viral replication, the risk of clinical hepatitis varies between 22% and 31%, and for those there is serological evidence of infection varies between 37% and 62%.1Marziale M.H. Silva E.J. Haas V.J. Robazzi M.L. Acidentes com material biológico em hospital da Rede de Prevenção de Acidentes de Trabalho - REPAT.Rev Bras Saúde Ocup. 2007; 32: 109-119Crossref Google Scholar In those cases in which the source patient presents a low rate of viral replication, the risk of clinical hepatitis varies from 1%-6%, and the risk of seroconversion varies from 23%-37%. The main risk of infection for HCV is contact with blood. The mean incidence of seroconversion, following percutaneous exposure with HCV-infected blood, is from 0.5%-1.8%.1Marziale M.H. Silva E.J. Haas V.J. Robazzi M.L. Acidentes com material biológico em hospital da Rede de Prevenção de Acidentes de Trabalho - REPAT.Rev Bras Saúde Ocup. 2007; 32: 109-119Crossref Google Scholar The use of PPE is of extreme importance in preventing exposure to biologic material because it confers greater safety for professionals and patients alike. However, for safety to be effective, it is necessary that not only is there adherence to the use of PPE, but the PPE be used correctly and kept hygienically and in working condition.10Tipple A.F. Souza A.C. Souza C.P. Paiva E.M. Pereira M.S. Equipamentos de Proteção Individual: uso e manuseio por alunos em uma instituição de ensino odontológico.Revista ABO Nacional. 2003; 11: 153-161Google Scholar The following of international standards regarding the use of syringes and needles with safety devices is scarce. Although Brazilian legislation covers the internationally required aspects of safety, gaps are identified in monitoring auditing regarding the adoption of safe practices in the workplace, mainly related to preventing and controlling occupational accidents. In addition, there is a lack of dialog between major research centers and health services. Washing the affected area with soap and water was the conduct used most following accidents, which is in consonance with current Brazilian regulations. In this study's results, illness of HCPs reflects the transformation of the laws into bureaucratic documents. However, advances in public policies, effective inspection of regulatory norms, and professionals' political-educational understanding in health care will result in safer practices, with a consequent reduction in the rates of occupational accidents.