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ORIGINAL ARTICLE
Year : 2011  |  Volume : 14  |  Issue : 1  |  Page : 34-37

Percutaneous injuries and accidental blood exposure in surgical residents: Awareness and use of prophylaxis in relation to HIV


Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Enugu, Nigeria

Date of Acceptance13-Apr-2010
Date of Web Publication11-Apr-2011

Correspondence Address:
T O Nwankwo
Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1119-3077.79237

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   Abstract 

Objective: To determine the occurrence of percutaneous injuries (PI) and accidental exposure to patients' blood (AEPB) in surgical residents in Enugu, Nigeria, their awareness of universal precautions (UP), and use of post-exposure prophylaxis (PEP).
Materials and Methods: Self-administered semi-structured pre-tested questionnaires were administered to 230 consenting trainee surgeons.
Results: The rate of exposure to PI/ABE was 67.5%. The number of exposures ranged from 1 to 5 with a mean of 1.9±0.99. Senior registrars had the highest rate of exposure (76.9%). In 89 exposures (63.6%) needle-prick injuries were reported. Adequate knowledge of the UP and PEP to HIV virus was only 41%. In most cases (72.1%) respondents subsequently disregarded the exposure.
Conclusion : The high rate of exposure to PI/ABE, inadequate knowledge and poor practice of UP/PEP seen in this study underscore the need for creating high level of awareness about UP/PEP, the development of clear institutional guideline and the provision of adequate materials and supervision to ensure adherence with the guideline. The practice of UP and PEP in PI and AEPB are life saving and should be emphasized in residency training.

Keywords: Percutaneous injury, HIV, trainee surgeons


How to cite this article:
Nwankwo T O, Aniebue U U. Percutaneous injuries and accidental blood exposure in surgical residents: Awareness and use of prophylaxis in relation to HIV. Niger J Clin Pract 2011;14:34-7

How to cite this URL:
Nwankwo T O, Aniebue U U. Percutaneous injuries and accidental blood exposure in surgical residents: Awareness and use of prophylaxis in relation to HIV. Niger J Clin Pract [serial online] 2011 [cited 2017 Jun 28];14:34-7. Available from: http://www.njcponline.com/text.asp?2011/14/1/34/79237


   Introduction Top


The global burden of HIV/AIDS has continued to be greatest in the sub-Saharan Africa. As at 2003, 70% of the estimated 37.8 million people with HIV and 70% of the 4.8 million new infections were from the region. The epidermic of the virus has been increasing in Nigeria since the first diagnosis of AIDS was made in the country in 1986 in a 13-year-old girl. The 2005 national HIV sero-prevalence sentinel survey, however, showed reversal of this trend, which is probably due to various interventions by governmental and non-governmental organizations. [1] The first occupational infection with HIV, was acquired from a patient who originated from sub-Saharan Africa. [2] In developed countries were basic precautionary measures are in place, transmission of HIV in the operating room is uncommon. Few centers in Nigeria have institutionalized strict reporting and follow-up for percutaneous injuries (PI) and there is paucity of information on HIV transmission in the work place in Nigeria. This has raised increasing concern among surgeons and those in training as to the safety of caring and operating on patients with HIV infection. This concern arises from the risk of transmission of virus through PI and other forms of accidental exposure to patient's blood (AEPB). An earlier study 13 years ago in a Nigerian hospital documented a risk of 2 PCI/ surgeon/year, 0.4 PCIs/ medical/year and 0.6PCI/nurse/year. [3] The occurrence of PI and other exposures to patients' blood may likely be higher in trainee surgeons whose skills are still limited.

Universal precautions (UP) have been advocated by Centre for Disease Control (CDC) USA as means to reduce occupational exposures to HIV virus. [4] The aim of this study is to determine the occurrence of PI and AEPB in surgical resident and medical officers working in surgical units in Enugu, Nigeria and their awareness and use of UP and post-exposure prophylaxis (PEP).


   Materials and Methods Top


Self-administered semi-structured pre-tested questionnaires were administered to all consenting trainee surgeons in the three hospitals that are involved in the training of surgeon in Enugu, South Eastern Nigeria. The hospitals were University of Nigeria Teaching Hospital (UNTH), Enugu State University Teaching Hospital and National Orthopaedic Hospital. UNTH and National Orthopaedic Hospital are Federal Government-funded institutions, while Enugu state University Teaching Hospital is funded by Enugu State Government. A written institutional guideline about UP and PEP was seen in only one of the hospitals.

The questionnaire had sections on the demographic information, the institution of training, level of specialization, occurrence of needle injury and percutaneous exposure to blood in last 6 months, and the frequency in last 1 year, the nature of the exposure to blood and the type of procedure being performed when the exposure or injury occurred. Exposure is regarded as contact between patient's blood and the care giver's mucous membranes or non-intact skin. AEPB is when exposure occurs following needle or instruments injury or splashing of blood during procedures. Respondents were also asked about needle manipulation, preventive measures (such as personal barrier method) used and how they managed the exposure or needle stick injury. The Likert's scale was used in structuring responses to questions in the questionnaire.

Knowledge of the doctors' personal HIV status was inquired as well as their awareness and knowledge of UP for prevention of HIV infection. A respondent was said to have adequate knowledge when he/she was able to tick correctly 50% of the measures (UP) recommended by CDC and 50% of the usual post-exposure prevention measures to HIV. The data was analyzed using a computer software program SPSS for windows version 11. Statistical analysis utilized the c2 test and statistical significant was considered present when the P-value was 0.05 or less.


   Results Top


A total of 230 questionnaires were distributed to consecutive consenting residents and 184 were properly filled and returned giving a response rate of 80%. [Table 1] shows the sex, age, field of specialization and ranks of respondents. Male respondents were 81.5% and females 18.5%. Their age range was 22-40 years with a mean age of 31.8 +/- 5 years. The rate of exposure of respondents to PI/ABE in the previous 6 months was 67.5%. The annual rate of exposure ranged from 1 to 5 with a mean of 1.9 +/-0.99. Male respondents had an exposure rate of 70% and females 55.9% (P=0.10). Senior registrars had the highest rate of exposure (76.9%) followed by house officers (57.9%) (P=0.11). Respondents in orthopedic surgery (75%) and obstetrics and gynecology (70%) had the highest rate of exposure. Those in ophthalmology/accidents and emergency and ENT had the least rate of exposure and the differences were almost statistically significant (P=0.06).
Table 1: The demographic characteristics of the respondents and their frequency of exposure in the previous 6 months to percutaneous injury/accidental exposure to patients' blood

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The source of exposure to PI/ABE and the procedures being carried out at the time of exposure are shown in [Table 2]. In 89 exposures (63.6%), the respondents reported needle-prick injuries, 23.6% blood splashes and non-sharp instrument injuries while only 2.8% were injuries from surgical blades. Surgical operations (28.3%) were the commonest procedures being carried out at the time of exposure. Venopuncture was reported in 26.4% of cases, intravenous infusions in 20.7% and biopsy and aspiration in only 1.4% of cases.
Table 2: The pattern of sources of Exposure in 140 exposures

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[Table 3] shows the respondents' knowledge of the UP and the PEP and the HIV status of self and patient at the time of exposure. Awareness of the UP and PEP to HIV viruses was claimed by 93.55 of the respondents. Of these, 41% had adequate knowledge, 51.6% had inadequate knowledge and 6.5% had no knowledge. One hundred and thirty (70.7%) respondents were aware of their HIV status at the time of exposure and 38.6% of them knew the patients HIV status. Of these, 26 (14.1%) patients were positive of HIV.
Table 3: Knowledge of universal precaution and post exposure prophylaxis, HIV status of self and that of the patient when PI/BE occurred in 184 respondents

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[Table 4] shows the comparison of the level of knowledge of UP/PEP in the area of specialization and rank. Twenty-four (49%) respondents specializing in general surgery had adequate knowledge, 13 (46.4%) respondents in orthopedic/plastic surgery and 29 (37.7%) respondents in obstetrics and gynecology were also found to have adequate knowledge of UP/PEP. Doctors in ENT, ophthalmology and accidents and emergency departments had the least number with adequate knowledge of UP/PEP and 51.1% of the senior registrars had adequate knowledge while only 35.0% of house officer had adequate knowledge. The differences in both the area of specialization and rank were not statistically significant (P-value = 0.12 and 0.20).
Table 4: Comparison of level of knowledge of UP/PEP with area of specialization/rank of respondents

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[Table 5] shows the post-exposure practices of the respondents surveyed. Their commonest method of first aid was to wash with water and clean with spirit (53.6%). Only 6.4% of them cleaned with hypochlorite solution at the time of exposure and 72.1% of the respondents subsequently disregarded the exposure. Two (1.4%) respondents commenced ART following exposure to PI in patients confirmed to be HIV positive.
Table 5: The practice of post-exposure first aids and prophylaxis by exposed respondents

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   Discussion Top


PI/AEPB remain risk factors for transmission of blood-borne pathogens such as HIV virus to the health workers especially those in training. The result of our study showed that 67.5 % of resident doctors in Enugu, Eastern Nigeria had at least one PI/AEPB in the previous 6 months. The mean annual exposure was 1.9±.99. The rate of exposure to PI/AEPB in this study is an improvement on 88% and 81% exposure rate reported in similar earlier studies in Nigeria.. [5],[6],[7] The rate is, however, much higher than results in some other studies from Africa and other developing countries. [8],[9],[10]

Needle prick has been reported by some studies as the commonest cause of PI/ABE. [5],[8],[11] This was corroborated by this study in which 63.6% of PI/ABE was due to needle prick. Surgical operation was the commonest procedure during which exposure occurred in this study. This agrees with the finding of Lowenfel et al. [12] who surveyed PI/ABE in surgeons and contrasts the finding in studies involving other health workers in which intravenous punctures, intramuscular injections and infusions were the most common procedures. [10],[11] The Epinetac project study showed that obstetrics and gynecological procedures have the highest risk of exposure. [13] Residents from the department of orthopedic surgery followed by those from obstetrics and gynecology reported the highest percentage of PI/ABE in this study. Senior registrars were the most commonly exposed but this is in contrast to a previous study in South Africa in which registrars were the commonest group at risk. [14]

There was a high level of general awareness (93.5%) of UP and PEP in the trainee surgeons in Enugu. This was comparable to the finding in a similar study among other health professionals and an improvement on 44% awareness of CDC guideline for UP in a previous study 5 years ago in Nigeria. [5],[15] The depth of knowledge, however, remained almost the same as in the last study. Trainee surgeons run risk of contacting HIV infection through PI/ABE and inadequate knowledge and practice of UP/PEP increases their vulnerability. Only about half of the respondents who had PI/ABE knew the HIV status of their patients and 14.1% of these patients were HIV positive. Although definitive studies are limited PEP has been demonstrated in animal and human studies on HIV to reduced the transmission after the occurrence of occupational exposure. [16],[17] This study recorded a very poor practice of PEP by the resident doctors as respondents disregarded the situation in 72.2% of cases.

Inadequate knowledge and poor practice of UP/PEP underscore the need for creating high level of awareness about UP/PEP, the development of clear institutional guideline and the provision of adequate materials and supervision to ensure adherence with the guideline. The use of proper barriers such as foot wears, gloves, masks, goggles and aprons should be made mandatory for doctors in all health delivery centers. Effective training on UP/PEP is life saving and should be emphasized in residency training especially in a resource poor setting.

 
   References Top

1.2005 National HIV Sero-prevalence Sentinel Survey by National AIDS/STDS Control Programme Federal Ministry of Health Abuja.  Back to cited text no. 1
    
2.Anonymous. Needlestick transmission of HTLV 111 from a patients infected in Africa. Lancet 2; 1984:1376-7.  Back to cited text no. 2
    
3.Adegboye AA, Moss GB, Soyinka F, Kreiss JK. The epidemiology of needlestick and sharp instrument accidents in a Nigerian hospital. Infect Control Hosp Epidemiol 1994;15:27-31.  Back to cited text no. 3
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4.Centre for Disease Control and Prevention, Recommendations for prevention of HIV and transmission in health care setting. MMWR Morb Mortal Wkly Rep 1987;36:15-85.  Back to cited text no. 4
    
5.Adebamowo CA, Ezeome ER, Ajuwon JA, Ogundiran TO. Survey of the knowledge, attitude and practice of Nigerian surgery trainees to HIV-infected persons and AIDS patients. BMC Surg 2002;2:7.  Back to cited text no. 5
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6.Olubuyide IO, Olawuyi F. Self-reported incidence of accidental exposures to patients' blood and body fluids by resident doctors in Nigeria. J R Soc Health 1995;115:235- 6, 241-3.  Back to cited text no. 6
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7.Obi SN, Waboso P, Ozumba BC. HIV/AIDS: occupational risk, attitude and behaviour of surgeons in southeast Nigeria. Int J STD AIDS 2005;16:370-3.  Back to cited text no. 7
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8.Tarantola A, Koumaré A, Rachline A, Sow PS, Diallo MB, Doumbia S, et al. A descriptive, retrospective study of 567 accidental blood exposures in healthcare workers in three West African countries. J Hosp Infect 2005;60:276-82.  Back to cited text no. 8
    
9.Talaat M, Kandeel A, El-Shoubary W, Bodenschatz C, Khairy I, Oun S, et al. Occupational exposure to needlestick injuries and hepatitis B vaccination coverage among health care workers in Egypt. Am J Infect Control 2003;31:469-74.   Back to cited text no. 9
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10.Mehta A, Rodrigues C, Ghag S, Bavi P, Shenai S, Dastur F. Needlestick injuries in a tertiary care centre in Mumbai, India. J Hosp Infect 2005;60:368-75.  Back to cited text no. 10
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11.Needle stick injuries: nurses at risk. Mich Nurse 2000;73:8-9.  Back to cited text no. 11
    
12.Lowenfels AB, Wormser GP, Jain R. Frequency of puncture injuries in surgeons and estimated risk of HIV infection. Arch Surg 1991;126:789-90.  Back to cited text no. 12
    
13.Arribas Llorente JL, Hernández Navarrete MJ, Campins Martí M, Martín Sánchez JI, Solano Bernad VM. Risk injuries at operating and delivery rooms. Epinetac Project 1996-2000. Med Clin (Barc) 2004;122:773-8.  Back to cited text no. 13
    
14.Gounden YP, Moodley J. Exposure to human immunodeficiency virus among healthcare workers in South Africa. Int J Gynaecol Obstet 2000;69:265-70.   Back to cited text no. 14
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15.Bodkin C, Bruce J. Health professionals' knowledge of prevention strategies and protocol following percutaneous injury. Curationis 2003;26:22-8.  Back to cited text no. 15
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16.Collins CH, Kennedy DA. Microbiological hazards of occupational needlestick and 'sharps' injuries. J Appl Bacteriol 1987;62:385-402.  Back to cited text no. 16
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17.Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G, O'Sullivan MJ, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med 1994;331:1173-80  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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