Universal Precautions for Prevention of Transmission of HIV and Other Bloodborne Infections

Fact Sheet Updated: 1996 Released: 1987 "Universal precautions," as defined by CDC, are a set of precautions designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other bloodborne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV and other bloodborne pathogens. Universal precautions took the place of and eliminated the need for the isolation category "Blood and Body Fluid Precautions" in the 1983 CDC Guidelines for Isolation Precautions in Hospitals. However, implementing universal precautions does not eliminate the need for other isolation precautions, such as droplet precautions for influenza, airborne isolation for pulmonary tuberculosis, or contact isolation for methicillin-resistant Staphylococcus aureus. Universal precautions differ from the system of Body Substance Isolation (BSI) used in some institutions. For information about BSI, refer to the following articles: Lynch P, et al. Rethinking the role of isolation precautions in the prevention of nosocomial infections. Annals of Internal Medicine 1987;107:243-246. 1. Lynch P, et al. Implementing and evaluating a system of generic infection precautions: Body substance isolation. American Journal of Infection Control 1990;18:1-12. 2. In 1996, CDC published new guidelines (standard precautions) for isolation precautions in hospitals. Standard precautions synthesize the major features of BSI and universal precautions to prevent transmission of a variety of organisms. Standard precautions were developed for use in hospitals and may not necessarily be indicated in other settings where universal precautions are used, such as child care settings and schools. Universal precautions apply to blood, other body fluids containing visible blood, semen, and vaginal secretions. Universal precautions also apply to tissues and to the following fluids: cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids. Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine, and vomitus unless they contain visible blood. Universal precautions do not apply to saliva except when visibly contaminated with blood or in the dental setting where blood contamination of saliva is predictable. Universal precautions involve the use of protective barriers such as gloves, gowns, aprons, masks, or protective eyewear, which can reduce the risk of exposure of the health care worker's skin or mucous membranes to potentially infective materials. In addition, under universal precautions, it is recommended that all health care workers take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices. Pregnant health care workers are not known to be at greater risk of contracting HIV infection than are health care workers who are not pregnant; however, if a health care worker develops HIV infection during pregnancy, the infant is at risk of infection resulting from perinatal transmission. Because of this risk, pregnant health care workers should be especially familiar with, and strictly adhere to, precautions to minimize the risk of HIV transmission. Universal Precautions for Prevention of Transmission of HIV | CDC http://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html 1 of 3 7/30/09 8:47 AM WRITTEN GUIDELINES: UNIVERSAL PRECAUTIONS Universal precautions are discussed in the following documents: CDC. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36(suppl no. 2S). 1. CDC. Update: Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR 1988;37:377-388. 2.

CDC. Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus to health-care and public-safety workers. MMWR 1989;38(S-6):1-36. 3. These three documents may be obtained by calling the AIDS Hotline at 1-800-342-2437 or the National AIDS Information Clearinghouse at 1-800-458-5231. In addition, the Occupational Safety and Health Administration (OSHA) has published a standard on "bloodborne pathogens." For information about this document, call 202-219-7157. For information on infection control in dental practice, call 1-800-458-5231 to obtain "The Infection Control File." For further questions on dental practice, call the Division of Oral Health, CDC, telephone 770-488-3034. GLOVING, GOWNING, MASKING, AND OTHER PROTECTIVE BARRIERS AS PART OF UNIVERSAL PRECAUTIONS All health care workers should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure during contact with any patient's blood or body fluids that require universal precautions. Recommendations for the use of gloves are presented in detail in the Morbidity and Mortality Weekly Report dated June 24, 1988, which is available by calling the National AIDS Information Hotline at 1-800-342-2437 or the National AIDS Information Clearinghouse at 1-800-458-5231. Gloves should be worn: for touching blood and body fluids requiring universal precautions, mucous membranes, or nonintact skin of all patients, and for handling items or surfaces soiled with blood or body fluids to which universal precautions apply. Gloves should be changed after contact with each patient. Hands and other skin surfaces should be washed immediately or as soon as patient safety permits if contaminated with blood or body fluids requiring universal precautions. Hands should be washed immediately after gloves are removed. Gloves should reduce the incidence of blood contamination of hands during phlebotomy, but they cannot prevent penetrating injuries caused by needles or other sharp instruments. Institutions that judge routine gloving for all phlebotomies is not necessary should periodically reevaluate their policy. Gloves should always be available to health care workers who wish to use them for phlebotomy. In addition, the following general guidelines apply: Use gloves for performing phlebotomy when the health care worker has cuts, scratches, or other breaks in his/her skin. 1. Use gloves in situations where the health care worker judges that hand contamination with blood may occur, e.g., when performing phlebotomy on an uncooperative patient. 2. 3. Use gloves for performing finger and/or heel sticks on infants and children. 4. Use gloves when persons are receiving training in phlebotomy. Universal Precautions for Prevention of Transmission of HIV | CDC http://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html 2 of 3 7/30/09 8:47 AM
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The Center for Devices and Radiological Health, Food and Drug Administration (FDA), has responsibility for regulating the medical glove industry. For more information about selection of gloves, call FDA at 301-443-8913. Masks and protective eyewear or face shields should be worn by health care workers to prevent exposure of mucous membranes of the mouth, nose, and eyes during procedures that are likely to generate droplets of blood or body fluids requiring universal precautions. Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or body fluids requiring universal precautions. All health care workers should take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices during procedures; when cleaning used instruments; during

disposal of used needles; and when handling sharp instruments after procedures. To prevent needlestick injuries, needles should not be recapped by hand, purposely bent or broken by hand, removed from disposable syringes, or otherwise manipulated by hand. After they are used, disposable syringes and needles, scalpel blades, and other sharp items should be placed in puncture-resistant containers for disposal. The puncture-resistant containers should be located as close as practical to the use area. All reusable needles should be placed in a puncture-resistant container for transport to the reprocessing area. General infection control practices should further minimize the already minute risk for salivary transmission of HIV. These infection control practices include the use of gloves for digital examination of mucous membranes and endotracheal suctioning, handwashing after exposure to saliva, and minimizing the need for emergency mouth-to-mouth resuscitation by making mouthpieces and other ventilation devices available for use in areas where the need for resuscitation is predictable. Although universal precautions do not apply to human breast milk, gloves may be worn by health care workers in situations where exposures to breast milk might be frequent, e.g., in breast milk banking. Date last modified: February 5, 1999 Content source: Division of Healthcare Quality Promotion (DHQP) National Center for Preparedness, Detection, and Control of Infectious Diseases
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niversal Pencegahan untuk Pencegahan Penularan HIV dan infeksi melalui darah lainnya Lembar Fakta Diperbarui: 1996 Dirilis: 1987 "Kewaspadaan universal," seperti yang didefinisikan oleh CDC, adalah seperangkat tindakan yang dirancang untuk mencegah penularan human immunodeficiency virus (HIV), virus hepatitis B (HBV), dan lainnya melalui darah patogen ketika memberikan pertolongan pertama atau perawatan kesehatan. Di bawah kewaspadaan universal, darah dan tertentu cairan tubuh dari semua pasien dianggap berpotensi menular HIV, HBV dan lainnya melalui darah patogen. Kewaspadaan universal mengambil tempat dan menghilangkan kebutuhan untuk Darah isolasi kategori "dan Cairan Tubuh Kewaspadaan "di tahun 1983 Pedoman CDC untuk Kewaspadaan Isolasi di Rumah Sakit. Namun, menerapkan kewaspadaan universal tidak menghilangkan kebutuhan untuk tindakan pencegahan isolasi lainnya, seperti sebagai tindakan pencegahan tetesan untuk influenza, isolasi udara untuk TB paru, atau isolasi kontak

untuk methicillin-resistant Staphylococcus aureus. Kewaspadaan universal berbeda dari sistem Isolasi Zat Tubuh (BSI) yang digunakan dalam beberapa lembaga. Untuk informasi tentang BSI, lihat artikel berikut: Lynch P, dkk. Rethinking peran kewaspadaan isolasi dalam pencegahan nosokomial infeksi. Annals of Internal Medicine 1987; 107:243-246. 1. Lynch P, dkk. Melaksanakan dan mengevaluasi sistem pencegahan infeksi umum: Tubuh zat isolasi. American Journal of Pengendalian Infeksi 1990; 18:1-12. 2. Pada tahun 1996, CDC menerbitkan panduan baru (tindakan pencegahan standar) untuk kewaspadaan isolasi di rumah sakit. Kewaspadaan standar mensintesis fitur utama dari BSI dan kewaspadaan universal untuk mencegah transmisi dari berbagai organisme. Kewaspadaan standar dikembangkan untuk digunakan di rumah sakit dan tidak selalu harus ditunjukkan dalam rangkaian lain dengan kewaspadaan universal yang digunakan, seperti perawatan anak pengaturan dan sekolah. Kewaspadaan universal berlaku untuk darah, cairan tubuh lainnya yang mengandung darah terlihat, air mani, dan vagina sekresi. Kewaspadaan universal juga berlaku untuk jaringan dan cairan berikut: serebrospinal, sinovial, pleural, peritoneal, perikardial, dan ketuban cairan. Kewaspadaan universal tidak berlaku untuk kotoran, cairan hidung, dahak, keringat, air mata, urin, dan muntahan kecuali mereka mengandung darah terlihat. Kewaspadaan universal tidak berlaku bagi air liur kecuali bila jelas terlihat terkontaminasi dengan darah atau dalam pengaturan gigi mana darah kontaminasi air liur mudah ditebak. Kewaspadaan universal melibatkan penggunaan hambatan pelindung seperti sarung tangan, baju, celemek, masker, atau pelindung kacamata, yang dapat mengurangi risiko pajanan kulit perawatan kesehatan pekerja atau lendir membran untuk berpotensi bahan infektif. Selain itu, dalam kewaspadaan universal, adalah direkomendasikan bahwa petugas kesehatan semua mengambil tindakan pencegahan untuk mencegah cedera yang disebabkan oleh jarum, pisau bedah, dan instrumen atau peralatan yang tajam. Petugas kesehatan perawatan hamil tidak diketahui beresiko lebih besar tertular infeksi HIV daripada yang kesehatan pekerja yang tidak hamil, namun jika seorang petugas kesehatan mengembangkan infeksi HIV selama kehamilan, bayi berada pada risiko infeksi akibat transmisi perinatal. Karena risiko ini, petugas kesehatan perawatan hamil seharusnya terutama kenal, dan ketat mematuhi, tindakan pencegahan untuk meminimalkan risiko penularan HIV. Universal Pencegahan untuk Pencegahan Penularan HIV | CDC http://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html

1 dari 3 7/30/09 8:47 PEDOMAN TERTULIS: TINDAKAN UNIVERSAL Kewaspadaan universal dibahas dalam dokumen-dokumen berikut: CDC. Rekomendasi untuk pencegahan penularan HIV dalam pelayanan kesehatan. MMWR 1987; 36 (suppl tidak 2S.). 1. CDC. Update: Kewaspadaan universal untuk pencegahan penularan dari manusia immunodeficiency virus, virus hepatitis B, dan patogen melalui darah lainnya di pelayanan kesehatan. MMWR 1988; 37:377-388. 2. CDC. Pedoman untuk pencegahan penularan human immunodeficiency virus dan virus hepatitis B untuk layanan kesehatan publik dan-keselamatan pekerja. MMWR 1989; 38 (S6) :1-36. 3. Ketiga dokumen dapat diperoleh dengan menghubungi Hotline AIDS di 1-800-342-2437 atau AIDS Nasional Informasi Clearinghouse di 1-800-458-5231. Selain itu, Keselamatan dan Kesehatan Administrasi (OSHA) telah menerbitkan standar pada "Patogen melalui darah." Untuk informasi tentang dokumen ini, hubungi 202-219-7157. Untuk informasi tentang pengendalian infeksi di praktek dokter gigi, hubungi 1-800-458-5231 untuk mendapatkan "Infeksi Kontrol File "Untuk pertanyaan lebih lanjut mengenai praktek gigi., Hubungi Divisi Oral Health, CDC, telepon 770-488-3034. GLOVING, GOWNING, MASKING, DAN HAMBATAN PROTECTIVE LAIN SEBAGAI BAGIAN DARI UNIVERSAL PENCEGAHAN Semua petugas kesehatan harus menggunakan tindakan pencegahan rutin penghalang yang tepat untuk mencegah kulit dan selaput lendir eksposur selama kontak dengan darah setiap pasien atau cairan tubuh yang memerlukan universal, tindakan pencegahan. Rekomendasi penggunaan sarung tangan disajikan secara rinci dalam Morbiditas dan Mortalitas Weekly Laporan tanggal 24 Juni 1988, yang tersedia dengan menghubungi AIDS Nasional Informasi Hotline di 1-800-342-2437 atau AIDS Nasional Clearinghouse Informasi di 1-800-458-5231. Sarung tangan harus dipakai: untuk darah dan cairan tubuh menyentuh memerlukan kewaspadaan universal, membran mukosa, atau nonintact kulit semua pasien, dan untuk menangani item atau permukaan yang kotor dengan darah atau cairan tubuh yang kewaspadaan universal berlaku. Sarung tangan harus diubah setelah kontak dengan setiap pasien. Tangan dan permukaan kulit lainnya harus dicuci segera atau segera setelah izin keselamatan pasien jika terkontaminasi dengan darah atau

cairan tubuh memerlukan kewaspadaan universal. Tangan harus dicuci segera setelah sarung tangan dilepas. Sarung tangan harus mengurangi timbulnya kontaminasi darah dari tangan selama proses mengeluarkan darah, tetapi mereka tidak dapat mencegah cedera tembus yang disebabkan oleh jarum atau alat tajam lainnya. Lembaga yang hakim rutin gloving untuk semua phlebotomies tidak perlu harus secara berkala mengevaluasi kembali kebijakan mereka. Sarung tangan harus selalu tersedia untuk petugas kesehatan yang ingin menggunakannya untuk proses mengeluarkan darah. Di Selain itu, pedoman umum berikut berlaku: Gunakan sarung tangan untuk melakukan proses mengeluarkan darah ketika petugas kesehatan memiliki luka, goresan, atau lain istirahat dalam / kulitnya. 1. Gunakan sarung tangan dalam situasi di mana para hakim petugas kesehatan bahwa tangan kontaminasi dengan darah dapat terjadi, misalnya, saat melakukan proses mengeluarkan darah pada pasien tidak kooperatif. 2. 3. Gunakan sarung tangan untuk melakukan jari dan / atau tongkat tumit pada bayi dan anak. 4. Gunakan sarung tangan ketika orang menerima pelatihan dalam proses mengeluarkan darah. Universal Pencegahan untuk Pencegahan Penularan HIV | CDC http://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html 2 dari 3 7/30/09 8:47 Pusat Pengendalian dan Pencegahan Penyakit, 1600 Clifton Rd, Atlanta, GA 30333, USA 800-CDC-INFO (800-232-4636) TTY: (888) 232-6348, 24 Jam / Hari Setiap - cdcinfo@cdc.gov (TTY) Pusat Perangkat dan Radiologi, Food and Drug Administration (FDA), memiliki tanggung jawab untuk mengatur industri sarung tangan medis. Untuk informasi lebih lanjut tentang pemilihan sarung tangan, memanggil FDA di 301-443-8913. Masker dan pelindung mata atau pelindung wajah harus dipakai oleh pekerja perawatan kesehatan untuk mencegah paparan dari selaput lendir mulut, hidung, dan mata selama prosedur yang mungkin menghasilkan tetesan darah atau cairan tubuh yang memerlukan kewaspadaan universal. Gowns atau celemek harus dikenakan selama prosedur yang cenderung menghasilkan percikan darah atau cairan tubuh yang membutuhkan yang universal tindakan pencegahan. Semua petugas kesehatan harus mengambil tindakan pencegahan untuk mencegah cedera yang disebabkan oleh jarum, pisau bedah, dan lainnya tajam instrumen atau perangkat selama prosedur; saat membersihkan instrumen yang digunakan; selama pembuangan jarum yang digunakan, dan saat menangani peralatan tajam setelah prosedur. Untuk

mencegah luka jarum suntik, jarum tidak boleh menutupnya kembali dengan tangan, sengaja bengkok atau patah dengan tangan, dihapus dari jarum suntik sekali pakai, atau dimanipulasi dengan tangan. Setelah mereka digunakan, jarum suntik sekali pakai dan jarum, pisau bedah, dan benda tajam lainnya harus ditempatkan dalam tahan tusukan wadah untuk dibuang. Para tahan tusukan kontainer harus ditempatkan sebagai sedekat praktis ke daerah digunakan. Semua jarum dapat digunakan kembali harus ditempatkan dalam tahan tusukankontainer untuk transportasi ke daerah pengolahan ulang. Praktek pengendalian infeksi Umum lebih lanjut harus meminimalkan risiko sudah menit untuk saliva penularan HIV. Praktek pengendalian infeksi Ini termasuk penggunaan sarung tangan untuk pemeriksaan digital pada membran mukosa dan pengisapan endotrakeal, cuci tangan setelah terkena air liur, dan meminimalkan kebutuhan darurat mulut ke mulut resusitasi dengan membuat corong dan lainnya ventilasi tersedia untuk digunakan di daerah di mana kebutuhan untuk resusitasi diprediksi perangkat. Meskipun kewaspadaan universal tidak berlaku untuk susu payudara manusia, sarung tangan dapat dipakai oleh kesehatan pekerja perawatan dalam situasi di mana eksposur terhadap air susu ibu mungkin sering, misalnya, dalam ASI perbankan. Tanggal last modified: 5 Februari 1999 Konten sumber: Divisi Promosi Kualitas Kesehatan (DHQP) Pusat Nasional untuk Kesiapsiagaan, Deteksi, dan Pengendalian Penyakit Infeksi Depan Kebijakan dan Peraturan Sangkalan e-Government FOIA Hubungi Kami Departemen Kesehatan dan Manusia Layanan Universal Pencegahan untuk Pencegahan Penularan HIV | CDC http://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html 3 dari 3 7/30/09 8:47 Urungkan pengeditan Google Terjemahan untuk Bisnis:Perangkat PenerjemahPenerjemah Situs WebPeluang Pasar Global

Standard Precautions: Occupational Exposure and Behavior of Health Care Workers in Ethiopia
PLoS ONE /article/crossref/i /article/metrics/inf info:doi/10.1371/j Standard%20Pre 1293091200000

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Ayalu A. Reda1*, Shiferaw Fisseha2, Bezatu Mengistie3, Jean-Michel Vandeweerd4 1 Department of Public Health, College of Health Sciences, Haramaya University, Harar, Ethiopia, 2 Environmental Health Section, East Hararghe Zone Health Bureau, Harar, Ethiopia, 3 Department of Environmental Health Science, College of Health Sciences, Haramaya University, Harar, Ethiopia, 4 University of Namur, FUNDP, Namur, Belgium

Abstract Top
Background
Occupational exposure to blood and body fluids is a serious concern for health care workers, and presents a major risk for the transmission of infections such as HIV and hepatitis viruses. The objective of this study was to investigate occupational exposures and behavior of health care workers (HCWs) in eastern Ethiopia.

Methods
We surveyed 475 HCWs working in 10 hospitals and 20 health centers in eastern Ethiopia using a structured questionnaire with a response rate of 84.4%. Descriptive statistics and multivariate analysis using logistic regression were performed.

Results
Life time risks of needle stick (30.5%; 95% CI 26.434.6%) and sharps injuries (25.7%; 95% CI 21.829.6%) were high. The one year prevalence of needle stick and sharps injury were 17.5% (95% CI 14.120.9%) and 13.5% (95% CI 10.416.6%) respectively. There was a high prevalence of life time (28.8%; 95% CI = 24.732.9%) and one year (20.2%; 95% CI = 16.6

23.8%) exposures to blood and body fluids. Two hundred thirteen (44.8%) HCWs reported that they were dissatisfied by the supply of infection prevention materials. HCWs had sub-optimal practices and unfavorable attitudes related to standard precautions such as needle recapping (46.9%) and discriminatory attitudes (30.5%) toward HIV/AIDS patients.

Conclusion
There was a high level of exposure to blood and body fluids among HCWs. We detected suboptimal practices and behavior that put both patients and HCWs at significant risk of acquiring occupational infections. Health authorities in the study area need to improve the training of HCWs and provision of infection prevention equipment. In addition, regular reporting and assessment of occupational exposures need to be implemented. Citation: Reda AA, Fisseha S, Mengistie B, Vandeweerd J-M (2010) Standard Precautions: Occupational Exposure and Behavior of Health Care Workers in Ethiopia. PLoS ONE 5(12): e14420. doi:10.1371/journal.pone.0014420 Editor: Srikanth Tripathy, National AIDS Research Institute, India Received: July 6, 2010; Accepted: November 30, 2010; Published: December 23, 2010 Copyright: 2010 Reda et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The Ethiopian Public Health Association (EPHA) and Haramaya University funded the study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. * E-mail: ayaluaklilu@yahoo.com

Introduction Top
Occupational exposure to blood and body fluids is a serious concern for health care workers and presents a major risk for the transmission of infections such as human immuno-deficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) [1], [2], [3]. Recognizing this threat, the U.S. Centers for Disease Control and Prevention (CDC) proposed a series of procedures for preventing occupational exposures and for handling potentially infectious materials such as blood and body fluids. These procedures, known as standard precautions (SPs), advise health care workers (HCWs) to practice regular personal hygiene; use protective barriers such as gloves and gown whenever there is contact with mucous membranes, blood and body fluids of patients; and dispose of sharps, body fluids, and other clinical wastes properly [4], [5], [6].

The World Health Organization (WHO) estimates that about 3 million HCWs face occupational exposure to blood borne viruses each year (2 million to HBV, 900,000 to HCV, and 300,000 to HIV), 90% of the infections that result from these exposures are in low income countries [2], [7]. Developing countries, especially those in sub-Saharan Africa, that account for the highest prevalence of HIV-infected patients in the world also report the highest incidences of occupational exposures [2], [3], [8]. Reports indicate that SPs are effective in preventing both occupational exposure incidents and associated infections [3], [9]. Due to this, surveillance of HCWs' compliance to SPs is an important element of occupational and nosocomial infection control as it enables assessment of risks from occupational exposure to infection. Studies have extensively reported suboptimal and non-uniform adherence to SPs by HCWs in both developed and developing countries [2], [10] [12]. For instance only 58% of nurses from a study in Australia reported using gloves when handling blood or blood equipment [13]. Up to half of HCWs from southern Ethiopia recapped needles [14], a third of HCWs from a study in Nigeria reported to always recap [15], while 40% from a study in India recapped at least sometimes and only 32% wore eye protection when indicated [16]. HCV and HBV infections are generally considered endemic in sub-Saharan Africa [8]. National data are unavailable for these blood borne infections in Ethiopia. However, surveys in different parts of the country indicate the prevalence of HCV to be 0.95.8% [17], [18] and estimates for HBV range from 4.7% to 14.4% [18][22]. According to projections for 2010, the prevalence of HIV/AIDS for Ethiopia is estimated at 2.8% [23]. Blood is routinely screened before transfusion. An official supply of disposable syringes and related devices are available even though little is known about their adequacy and replenishment. In Ethiopia, there are only a few studies that describe occupational exposures and compliance to SPs among HCWs. In 2006, the Ethiopian Public Health Association indentified standard precautions as an area of research gap and public health importance in the country citing lack of investigations in this area and the apprehension of HCWs in handling HIV/AIDS cases [24]. Since then, the governmental and non-governmental organizations (NGOs) have given attention to standard precautions by initiating post-exposure prophylaxis (PEP) and increased supply of materials such as safety boxes. However, the evidence base surrounding SPs in this resource poor setting remains limited. This study aims to investigate occupational exposure and the behaviour of health care workers in eastern Ethiopia.

Methods Top
Settings, study design and participants We conducted a cross-sectional survey in 10 hospitals and 20 health centers in two administrative regions of Ethiopia (Harari and Dire Dawa). All health care personnel including physicians, nurses, laboratory technicians and health assistants, working in the institutions and directly involved in day-to-day patient care were included in the study. The researchers reached participants through their respective institution and department heads. Data collection took place from February 1 to May 30, 2010.

Ethiopian health care institutions are structured according to the World Health Organization's recommendation for primary health care [25] and consist of community health centers and hospitals with governmental and private ownership. The surveyed institutions serve more than 620,000 people residing in urban and rural areas [26]. Projected estimates of HIV/AIDS prevalence for 2010 are 4.4% for Harari and 5.7% for Dire Dawa [23]. There is limited information on the prevalence of blood borne infections in the study area apart from HIV/AIDS. In addition, limited information is available on routes of transmission such as traditional practices and injection drug use. Questionnaire and data collection Data were collected using a self administered structured questionnaire. It was developed after reviewing qualitative and quantitative literatures for relevant items. Final items were generated after running a partial Delphi process. This is an interactive and multistage group facilitation technique designed to transform opinion into group consensus [27]. After consensus, the items were checked for clarity and translated into the local language of Amharic. The resulting questionnaire was pretested on a convenience sample of 30 HCWs in a nearby health center in another neighboring region (Oromia) and corrections were made afterwards. The final questionnaire with 58 close ended questions included basic demographic information such as age and sex; behavior and attitudes toward standard precautions; and occupational exposure incidents. The questionnaire specifically asks respondents to list life time and previous one year exposures specifically from needle-stick injuries, other sharps injuries, and blood and body fluids splashing (refer to supporting File S1 for questionnaire). Statistical analysis SPSS version 15.0 was used for data analysis. Associations were examined using Chi-square tests and multivariate logistic regression. Multicollinearity was examined using linear regression. Unadjusted and adjusted (AOR) odds ratios were used as indicators of the strength of association. Alpha was set at less than or equal to 0.05. Ethical clearance The Institutional Research Ethics Review Committee of Haramaya University gave ethical approval. The HCWs were informed about the study, its importance and confidentiality of the information requested. Written consent was obtained from participants in a form provided with the questionnaire.

Results Top
Population From among a total of 563 HCWs working in 30 health care institutions in the area, 484 responded giving a response rate of 84.4%. We discarded 9 incomplete questionnaires, and based our analysis on the remaining 475 respondents. The mean age and work experience of the respondents were 30.8 (SD8.9) and 8.2 years (SD8.7) respectively (Table 1).

Table 1. Characteristics of the study population (N = 475). doi:10.1371/journal.pone.0014420.t001 Occupational exposure The self-reported life time risk of at least one needle stick or sharps injury among HCWs was 30.5% (95% CI 26.434.6%), and 25.7% (95% CI 21.829.6%) respectively. The self-reported one year prevalence of needle stick- and sharps injury was 17.5% (95% CI 14.120.9%) and 13.5% (95% CI 10.416.6%) respectively. The self-reported life time- and one year risk of splashing of blood and body fluids was 28.8% (95% CI 24.732.9%) and 20.2% (95% CI 16.6 23.8%) (Table 2).

Table 2. Responses of HCWs to items related to standard precautions (N = 475). doi:10.1371/journal.pone.0014420.t002 Working in hospitals was associated with risk of needle stick injury (OR 3.2; 95% CI 2.24.8; AOR 1.75; 95% CI 0.961.10), sharps injury (OR 2.2; 95% CI 1.24.0) but not with body fluids splashing to mouth or eyes (OR 1.7; 95% CI 1.052.8; AOR 1.53; 95% CI 0.892.62) in the past one year. Needle stick injury was significantly associated with females (AOR 1.75; 95% CI 1.042.92) and HCWs that practice needle recapping, but it failed to reach statistical significance (AOR 1.27; 95% CI 0.762.13). Findings of the multivariate logistic regression analysis are displayed in Table 3. Taking training was not protective against needle stick injury in the past one year (OR 0.9; 95% CI 0.61.5). Needles stick injury (p 0.53) or body fluid splashing to the eyes and mouth (p.06) were not significantly different across professions. The main reasons for the last injury in the past one year were sudden movement of the patient (45%) and recapping (36.3%). Last one year incidence of needle stick injury and blood and body fluids splashing were significantly associated with each other independently (OR 3.20; 95% CI 1.915.37; AOR 3.21; 95% CI 1.865.48). The measures HCWs took in the event of occupational exposures and injuries included PEP (88, 18.5%) and getting tested for HIV (126, 26.5%) (Table 2).

Table 3. Multivariate logistic regression model (1 and 2) results. doi:10.1371/journal.pone.0014420.t003 Behavior and attitudes Two hundred thirteen (44.8%) HCWs reported that they were dissatisfied by the supply of infection prevention materials, while three hundred thirty seven (70.9%) respondents perceived

their work place to have put them at high risk of HIV. One hundred forty five (30.5) HCWs reported that HIV patients should be cared for separate from other patients. One hundred forty four (30.3%) participants reported that patients may have acquired nosocomial HIV infection. This response was significantly associated with HCWs working in hospitals (OR 2.2; 95% CI 1.43.4). Three hundred eighty four (80.8%) HCWs reported that they regularly follow standard precautions. Two hundred thirty three (46.9%) HCWs practice needle recapping, while 28 (5.9%) reuse syringes, the main reason cited for reuse being shortage (78.5%, n 22). Those working at hospitals had a higher frequency of needle re-use (OR = 2.8; 95% CI 1.047.5) and recapping (OR 3.2; 95% CI 2.24.8) compared to their peers in health centers. Recapping was also highest among physicians (73.3%), health assistants (65.0%) and laboratory technicians (57.4%) (p 0.04). Three hundred seventy nine (79.8%) HCWs responded that gloves are required for any contact with patients (Table 2).

Discussion Top
We detected a high level of self-reported exposure to blood and body fluids. Life time risks of needle stick (30.5%) and sharps injuries (25.7%) were high. There was a high prevalence of both life time (28.8%) and one year (20.2%) exposures to body fluids. HCWs had poor practices like needle recapping (46.9%) and unfavorable attitudes such as discriminatory opinions (30.5%) toward HIV/AIDS patients. The logistic regression model indicated that needle stick injuries and body fluid exposures are strongly associated with each other, indicating the clustering nature of exposure incidents on groups of HCWs probably based on risky habits and suboptimal SPs compliance. The 17.5% one year prevalence of needle stick injury is similar to a report from the United Arab Emirates (UAE) by Jacob et al. [28] in which 19% of HCWs faced injury, but lower than a finding in northern Ethiopia [29] in which a three month prevalence of 17.2% was reported; and much lower than that of a report from southern Ethiopia in which the one year prevalence was 30.9% [14] and a study in Uganda (57%) by Nsubuga et al. [30]. A higher percentage of respondents (47%) in this study as well as in southern Ethiopia [14] (57%) had risky practices such as needle recapping. The risks of infection following percutaneous exposure to infected blood is lower for HIV (0.3%) [31], [32] compared to hepatitis C (3%) and hepatitis B (30%) [32]. However, this is not reassuring as the higher frequency of injury and exposures reported and the high prevalence of these infections mean that HCWs in developing countries are at a magnified risk of acquiring the infections. The level of training about SPs by the current participants (39.6%) is similar to a finding in India by Kermode et al. [16] in which 36% HCWs have taken training. Unfortunately, taking training was not found to be protective from occupational exposures such as needle stick injury in the past one year (OR 0.9; 95% CI = 0.61.5). This will be a serious challenge to infection prevention efforts. This is similar to previous reports [14], [33], [34] in which training to HCWs seems to not necessarily bring about protection from exposures. The reason for this may be that the knowledge acquired may not necessarily translate into practice of preventive measures or that the trainings provided may be more theoretical than practical and the limited sources of

continuous information on standard precautions. Lack of an enabling environment to comply with standard precautions may also contribute to poor compliance. In this study 80.8% of HCWs reported that they regularly follow SPs and the regression model indicated that HCWs who regularly apply standard precautions reduced their risks to exposure incidents by 20%. The level of compliance in this study similar is to a finding from Australia [13] and higher than the report from the UAE (19%) [28]. However, when we consider contradictory findings such as belief by 79.8% HCWs that gloves are required for any contact with patients, and 46.6% recapped needles, we know that the rate of proper compliance is probably much lower, as documented in a study in Australia [13]. In addition, HCWs commonly over estimate their knowledge and practices on infection prevention [13], [16], [35], the magnitude of which is methodologically difficult to estimate. Partial compliance and suboptimal practices were also reported in other countries such as Nigeria [15], India [16] and the UK [36] where HCWs make unjustified assessments of risks from- and infection status of clients rather than properly and consistently applying standard precautions. About 45% of the participants reported dissatisfaction by the provision of infection prevention materials (44.8%); and reuse of syringes was practiced by 5.9% HCWs, 78.5% of whom cited lack of supply as the main reason. Lack of infection prevention supplies seriously hampers prevention efforts and puts patients and HCWs at greater risk of infection and adds to the dissatisfaction of HCWs with their work environment. In fact, on top of the dangerous practice of needle reuse in a minority of HCWs, the report by 30.3% that patients may have acquired nosocomial HIV infection is a worrisome finding that adds credence to the foregoing argument. It is known that HCWs in sub-Saharan Africa are dissatisfied with their job, underpaid and overworked, and ill-protected [8], [37][39]. Even though the authors of this report have witnessed an increased attention to provision of infection prevention materials recently, such findings indicate the need to further increase supplies. Furthermore, 70.9% of the HCWs perceived their work place to have put them at higher risk of acquiring HIV infection and 30.5% preferred treating HIV patients separate from other patients. This may indicate the general level of apprehension in the work environment and the associated stigma toward HIV/AIDS patients on the part of HCWs in this and previous surveys in the country [24], [34] and elsewhere [40] [42]. There have been very few randomized controlled trials conducted that provide evaluative evidence for effectiveness of interventions for reducing occupational exposure [31]. The commonly recommended preventive strategies for reducing occupational injuries and to increase conformity with standard precautions include education, awareness campaigns, risk reducing devises such as single use needles, reduction of unnecessary injections, legislative action, provision of personal protective equipment (PPE), introduction of safety guidelines and reporting mechanisms, and creating a compliance-enabling environment [3], [32], [43], [44]. Involvement of HCWs in infection control decisions is considered important [31]. Efforts toward reducing population levels of infections such as hepatitis and HIV are also important goals. However, it is known that these preventive strategies are mostly not implemented fully and/or compromised in the health care systems of most developing countries [3], [8], [28], [30], [44]. In Ethiopia, despite recognition of the importance of HIV/AIDS and other diseases transmitted through blood and body fluids by policy makers and public health professionals alike [24], there are no

formalized post-exposure counseling, reporting procedures and infection control strategies in general. For instance, hepatitis and tetanus vaccinations remain inaccessible for Ethiopian HCWs. In addition, the recently launched post exposure prophylaxis (PEP) against HIV infection is available only at selected hospitals in urban areas and as a result it is not easily accessible to most HCWs. Therefore, governmental and non-governmental organizations need to expand and revise the currently available prevention facilities and put in place infection control and prevention strategies that are locally sustainable, cost-effective and scientifically sound. The response rate of 84.4% is higher [13], [28], [36] or similar [16] to previous studies. No particular characteristic could be identified in non-respondents except that some HCW were unavailable as they had either joined short courses or enrolled in higher institutes for further study. Social desirability bias is also a potential limitation in self-reported studies like this one, in that HCWs might report socially acceptable responses than their actual day to day practice. The lack of standardized questionnaires with acceptable reliability and validity for assessing compliance to standard precautions limits comparison of our findings with previous research. To overcome this problem we included items used by other authors in order to aid comparison. As this is a cross-sectional study, the limitations that come with this type of design need to be taken into consideration when interpreting the findings. We conclude that there is a high level of exposure to blood and body fluids among health care workers in the study area. We detected suboptimal practices and behavior that put both patients and HCWs at significant risk of acquiring occupational infections. Health authorities in the study area need to improve the training of HCWs and provision of infection prevention equipment. In addition, regular reporting, follow up and assessment of occupational exposures need to be introduced.

Supporting Information Top

File S1. Questionnaire (0.16 MB DOC)

Acknowledgments Top
We thank the Ethiopian Public Health Association for funding the study. We gratefully acknowledge the staffs of Haramaya University who were involved in reviewing the questionnaire; and participants and heads of the institutions for their kind cooperation. We thank Thomas Syre (PhD) for his editorial help.

Author Contributions Top

Conceived and designed the experiments: AAR SF BM JMV. Performed the experiments: AAR SF BM JMV. Analyzed the data: AAR SF BM JMV. Contributed reagents/materials/analysis tools: AAR SF BM JMV. Wrote the paper: AAR SF BM JMV.

References Top
1. Anonymous (2005) Joint ILO/WHO guidelines on health services organization and HIV/AIDS. Geneva, Switzerland: International Labor Organization and World Health Organization. 2. WHO (2002) The world health report: reducing risks, promoting healthy life. Geneva, Switzerland: World Health Organization. 3. Hutin Y, Hauri A, Chiarello L, Catlin M, Stilwell B, et al. (2003) Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections. Bulletin of the World Health Organization 491500. Find this article online 4. CDC (1987) Recommendations for prevention of HIV transmission in health care settings. MMWR 36: Find this article online 5. CDC (1989) Guidelines for prevention of transmission of immunodeficiency virus and hepatitis B virus to health-care and public-safety workers. MMWR 38: Find this article online 6. Molinari JA (2003) Infection control: Its evolution to the current standard precautions. Journal of the American Dental Association 569574. Find this article online 7. Pruss-Ustun A, Rapiti E, Hutin Y (2005) Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers. American Journal of Industrial Medicine 482490. Find this article online 8. Sagoe-Moses C, Pearson RD, Perry J, Jagger J (2001) Risks to health care workers in developing countries. New England Journal of Medicine 345: Find this article online 9. Redecki S, Abbott A, Eloi L (2000) Occupational human immunodeficiency virus exposure among residents and medical students. Archives of Internal Medicine 3107 3111. Find this article online 10. Bennet G, Mansell I (2003) Universal precautions: a survey of community nurses' experience and practice. Journal of Clinical Nursing 413421. Find this article online 11. Kermode M, Jolley D, Langkham B, Thomas MS, Crofts N (2005) Occupational exposure to blood and risk of bloodborne virus infection among health care workers in rural north Indian health care settings. American Journal of Infection Control 3441. Find this article online 12. Zhang M, Wang H, Miao J, Du X, Li T, et al. (2009) Occupational exposure to blood and body fluids among health care workers in a general hospital, China. American Journal of Industrial Medicine 8998. Find this article online 13. Knight VM, Bodsworth NJ (1997) Perceptions and practices of universal blood and body fluid precautions by registered nurses at a major Sydney teaching hospital. Journal of Advanced Nursing 746751. Find this article online 14. Tadesse M, Tadesse T (2009) Epidemiology of needlestick injuries among health-care workers in Awassa City, Southern Ethiopia. Tropical Doctor 111113. Find this article online 15. Sadoh WE, Fawole AO, Sado AE, Oladimeji AO, Sotiloye OS (2006) Practice of universal precautions among health care workers. Journal of the National Medical Association 98: 2006. Find this article online 16. Kermode M, Jolley D, Langkham B, Thomas MS, Holmes W, et al. (2005) Compliance with universal/standard precautions among health care workers in rural north India. American Journal of Infection Control 2733. Find this article online

17. Ayele W, Nokes DJ, Ababe A, Messele T, Dejene A, et al. (2002) Higher prevalence of anti-HCV antibodies among HIV-positive compared to HIV-negative inhabitants of Addis Ababa, Ethiopia. Journal of Medical Virology 1217. Find this article online 18. Diro E, Alemu S, G-Yohannes A (2008) Blood safety & prevalence of transfussion transmissible viral infections among donors at the Red Cross Blood Bank in Gondar University Hospital. Ethiopian Medical Journal 46: 713. Find this article online 19. Ababe A, Nokes DJ, Dejene A, Enquselassie F, Messele T, et al. (2003) Seroepidemiology of hepatitis B virus in Addis Ababa, Ethiopia: transmission patterns and vaccine control. Epidemiol Infection 757770. Find this article online 20. Chen Z, Ron D, Doron Z, Shmuel R, Drora F, et al. (1999) Evaluation of screening for hepatitis B surface antigen during pregnancy in a population with a high prevalence of hepatitis B surface antigen-positive/hepatitis B antigen-negative carriers. The Pediatric Infectious Disease Journal 18: 262266. Find this article online 21. Rahelenbeck SI, Yohannes G, Molla K, Reifen R, Assefa A (1997) Infection with HIV, syphilis and hepatitis B in Ethiopia: a survey in blood donors. International Journal of STD & AIDS 261264. Find this article online 22. Shimelis T, Torben W, Medhin G, Tebeje M, Andualem A, et al. (2008) Hepatitis B virus infection among people attending the voluntary counselling and testing centre and antiretroviral therapy clinic of St Paul's General Specialized Hospital, Addis Ababa, Ethiopia. Sexually Transmitted infections 3741. Find this article online 23. Anonymous (2005) The sixth report: AIDS in Ethiopia. Addis Ababa, Ethiopia: Federal Ministry of Health, National HIV/AIDS prevention and control office. 24. Anonymous (2005) Identifying HIV/AIDS, sexually transmitted infections and tuberculosis research gaps and priority setting agenda in Ethiopia. Addis Ababa, Ethiopia: Ethiopian Public Health Association. 25. Kloos H (1998) Primary health care in Ethiopia under three political systems: community participation in a war torn society. Soc Sci Med 505522. Find this article online 26. Anonymous (2006) Health and related indicators. Addis Ababa: Federal Democratic Republic of Ethiopia, Ministry of Health. 27. Jones J, Hunter D (1995) Consensus methods for medical and health services research. British Medical Journal 376380. Find this article online 28. Jacob A, Newson-Smith M, Murphy E, Steiner M, Dick F (2010) Sharps injuries among health care workers in the United Arab Emirates. Occupational Medicine. Find this article online 29. Gessessew A, Kahsu (2009) Occupational exposure of health workers to blood and body fluids in six hospitals of Tigray region (August 1-30, 2006): magnitude and management. Ethiopian Medical Journal 47: 213219. Find this article online 30. Nsubuga FM, Jaakola MS (2005) Needle stick injuries among nurses in sub-Saharan Africa. Tropical Medicine and International Health 10: 773781. Find this article online 31. Rose G, Roth VR (2009) Infections in healthcare workers. In: Loeb M, Smaill F, Smieja M, editors. Evidence-based infectious diseases: BMJ. pp. 291301. 32. Trim JC, Elliott TSJ (2003) A review of sharps injuries and preventive strategies. Journal of Hospital Infection 237242. Find this article online 33. Parmeggiani C, Abbate R, Marinelli P, Angelilo IF (2010) Health care workers and health care-associated infections: knowledge, attitudes, and behavior in emergency departments in Italy. BMC Infectious Diseases 35. Find this article online

34. Reda AA, Vandeweerd J-M, Syre TR, Egata G (2008) HIV/AIDS and exposure of health care workers to body fluids in Ethiopia: attitudes toward universal precautions. Journal of Hospital Infection 163169. Find this article online 35. Henry K, Campbell S, Maki M (1992) A comparison of observed and self-reported compliance with universal precautions among emergency department personnel at a Minnesota public teaching hospital: implications for assessing infection control programs. Annals of Emergency Medicine 234239. Find this article online 36. Cutter J, Jordan S (2003) Uptake of guidelines to avoid and report exposure to blood and body fluids. Journal of Advanced Nursing 46: 441452. Find this article online 37. McCoy D, Bennet S, Witter S, Pond B, Baker B, et al. (2008) Salaries and incomes of health workers in sub-Saharan Africa. Lancet 371: 675681. Find this article online 38. Gostin LO (2008) The international migration and recruitment of nurses: Human rights and global justice. JAMA 299: 18271829. Find this article online 39. Connel J, Zurn P, Stilwell B, Awases, Braichet J-M (2007) Sub-Saharan Africa: Beyond the health workers migration crisis? Social Science and Medicine 18761891. Find this article online 40. Mbanya DN, Zebaze R, Kenghe AP, Minkoulou EM, Awah P, et al. (2001) Knowledge, attitudes and practices of nursing staff in a rural hospital of Cameroon: how much does the health care provider know about the human immunodeficiency virus/acquired immune deficiency syndrome? International Nursing Review 241249. Find this article online 41. Bishop GD, Oh HM, Swee HY (2000) Attitudes and beliefs of Singapore health care professionals concerning HIV/AIDS. Singapore Med J 5563. Find this article online 42. Reis C, Heisler M, Amowitz LL, Moreland RS, Mafeni JC, et al. (2005) Discriminatory attitudes and practices by health workers toward patients with HIV/AIDS in Nigeria. PLoS Medicine 2: e246. Find this article online 43. Simonsen L, Kane A, Lloyd J, Zaffran M, Kame M (1999) Unsafe injections in the developing world and transmission of bloodborne pathogens: a review. Bulletin of the World Health Organization 77: 789800. Find this article online 44. Fingerhut M, Driscoll T, Nelson DI, Concha-Barrietos M, Punnett L, et al. (2005) Contributioon of occupational risk factors to the global burden of disease - a summary of findings. SJWEH suppl5861. Find this article online Declare any competing interests.

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