Hepatitis B virus was one of the first bloodborne pathogens to be recognized as an occupational risk

among health care workers [44-46]. An early review [46] found a preponderance of cases of hepatitis B
among pathologists, laboratory workers, and blood bank workers, alerting investigators to the risks of
exposure to blood. Subsequent studies confirmed these early observations [47-63]. In general, the
seroprevalence of HBV in health care workers is twofold to fourfold higher than that of blood donor
controls [47, 61]; the highest rates are seen among dentists [8, 47]; physicians [8, 47, 61, 63]; laboratory
workers [8, 47, 63, 64]; dialysis workers [63]; cleaning service employees [51, 62]; and nurses [8],
including emergency department nurses [56]. Widespread transmission may occur from a single surgical
procedure [65]. Many infections in health care workers are asymptomatic [48].

In prevaccine surveys, the annual incidence of hepatitis B was 5 to 10 times higher among physicians and
dentists than among blood donors and more than 10 times higher among surgeons, dialysis workers,
persons caring for the mentally handicapped, and laboratory workers exposed to blood [47, 61, 66].

The risk for transmission from a single needlestick varies according to E antigen status: 1% to 6% for E
antigen-negative blood comared with 22% to 40% with E antigen-positive blood [8-10, 67]. However,
transmission of E antigen-negative blood has caused fulminant hepatitis requiring liver transplantation
[68]. Hepatitis delta virus has been transmitted to a surgeon [69]. The quality-adjusted loss in life
expectancy is similar for persons who receive needlesticks involving a source patient who has HBV
infection and for persons who receive needlesticks involving a source patient with HIV infection [70, 71].
Not all cases of HBV transmission are explained by needlesticks, suggesting that other modes of spread
may be possible [8, 9, 72].

Infection control interventions, such as the segregation of dialysis recipients according to surface
antigen status [73, 74] and vaccination [74, 75], have effectively reduced occupational acquisition of
HBV. However, the Centers for Disease Control and Prevention (CDC) calculate that 6500 to 9000 new
HBV infections occurred among health care workers in 1990 [8]. Given the natural history of HBV
infection, 300 to 950 of these health care workers (5% to 10%) will eventually develop chronic HBV
infection that will lead to death from cirrhosis in 100 to 150 persons and to fatal hepatocellular
carcinoma in 25 to 40 persons [8]. Despite this, HBV vaccination of health care workers remains
incomplete. In one study, 23% of health care workers were unvaccinated [52], a rate similar to that of
anesthesiologists in the United Kingdom [76]. A three-vaccine series is 88% effective [77, 78]; decreased
response is seen among recipients who are older, who smoke, or who are obese [77, 78].

Hepatitis C

The 1990 introduction of a test for HCV infection has dramatically improved our understanding of
disease epidemiology. Because HBV and HCV have similar modes of transmission, it was assumed that
groups of health care workers at increased risk for hepatitis B also would be at risk for hepatitis

also would be at risk for hepatitis C [19, 52, 60]. This, however, has not proven to be true for many
groups, including dialysis workers [79-82], laboratory workers [83], persons who work with the mentally
impaired [84], and surgical staff [83]. Indeed, although “occupational exposure” accounts for about 2%
of all cases of hepatitis C [19], the seroprevalence of HCV among health care workers is roughly similar
to that of the general population (about 1%) [83, 85-89]. Dentists do have increased risk [16, 17]: In one
serosurvey [16], significantly more dentists (1.7%) than blood donors (0.13%) were seropositive for HCV;
the highest rate of seroprevalence was seen among oral surgeons (9%).

Seroconversion occurs in 1.2% to 10% of nonimmune health care workers who receive needlesticks from
a source patient with hepatitis C [11-15]. Variation among control populations [90-92], variation in
employee populations [18, 93, 94], and variation in the sensitivity of tests for HCV [19] have contributed
to the lack of consensus about risk [14, 18, 94]. Optimal management of a needlestick is unknown, but
the administration of immune globulin is not recommended [18, 40].

Cytomegalovirus Infection

The prevalence of CMV infection in the United States varies according to geography, patient age, and
group studied and ranges from 40% to 95%. The annual community incidence among adults is about 2%
[21]. Transmission of CMV may occur through sexual contact or through contact with infectious blood.
Respiratory secretions, saliva, and urine may also transmit CMV, as shown by increased rates of CMV
infection among day care workers (8% to 10% per year) [95, 96]. Early incidence [97-99] and prevalence
studies [100], as well as meta-analyses [101, 102] and reviews [103, 104], suggested that pediatric
health care workers had elevated risk, similar to that of day care workers. Subsequent reports [20, 21,
35, 105, 106], however, have not shown this risk, perhaps because many recent studies were done in
the era of universal precautions. Similarly, no increase in CMV infection among dialysis workers [107] or
renal transplantation workers [108] has been found.

Studies using molecular epidemiologic techniques have also shown that health care workers are at low
risk for occupational transmission of CMV [109, 110]. No transmission was documented among 188
health care workers at a pediatric chronic care or neonatal unit in which many of the patients were
heavy CMV shedders [110]. Molecular analysis of CMV recovered from one of two nurses who
seroconverted showed discordance with CMV taken from a known occupational contact and
concordance with CMV from a family member with new disease.

Ebola Virus Infection and Other Viral Hemorrhagic Fevers

The recent outbreak of Ebola virus infection in Zaire involved 296 cases and was associated with a 79%
mortality rate [22-24]. At least 90 persons (32%) were health care workers [24, 25], a fact that led the
CDC to issue recommendations for the management of persons with suspected viral hemorrhagic fevers
[26]. Among the recommended practices were use of universal precautions, use of strict barrier
protection, restriction of workers and visitors, and use of negative-pressure ventilation in the presence
of respiratory symptoms.

In a 1979 outbreak of Ebola virus infection in Sudan, persons who provided nursing care were five times
more likely to develop disease than were those who provided no care [111]. In all, 34 cases of infection
occurred and 22 persons died. Similar outbreaks involving health care workers have been reported with
Crimean hemorrhagic fever-Congo virus infection in Pakistan, where 10 of 17 exposed workers
developed disease and 2 died [112]; Lassa fever virus infection on an obstetrics ward, where 7 of 26
exposed workers developed disease and at least 1 died [113]; and Marburg virus infection [114, 115].
Ribavirin was effective as therapy for 3 health care workers with Crimean hemorrhagic fever-Congo virus
[116].

B Virus Infection

Fatal, occupationally acquired infection with B virus (Herpesvirus simiae) was described in 1932, when a
physician died of encephalomyelitis 3 days after being bitten by a clinically well rhesus monkey [117,
118]. Since that time, more than 24 infections with B virus have occurred in humans, and 18 persons
have died [119]. The peak incidence of B virus infection occurred in 1957-1958, in conjunction with the
production and testing of poliomyelitis vaccines [119]. In the 1980s, a cluster of four cases (two of which
were fatal) occurred in a research facility in Pensacola, Florida [27], leading to the development of new
recommendations for monkey handlers [28]. Treatment with acyclovir may be effective [27, 29], but the
optimal duration of therapy is unknown and may extend years.

Other Infections

Creutzfeldt-Jakob disease is a uniformly fatal neurodegenerative disorder that has been the subject of
extensive epidemiologic investigation [31, 32]. Health care workers are not considered to be a group at
risk [31], but cases have been reported in two neurosurgeons [31, 32], two histopathology technicians
[120, 121], and one pathologist [122]. In none of these cases could a specific incident that may have led
to transmission be recalled. Recent recommendations stress sterilization of equipment to minimize the
risk [30].

Outbreaks of Epstein-Barr virus infection have seldom been reported. Transmission of Epstein-Barr virus
to 9 of 29 medical staff (31%) in an obstetrics and gynecology clinic was never explained [123].
Investigators at a hospital that treated hundreds of cases of nasopharyngeal carcinoma suggested that
nosocomial spread was a major source of Epstein-Barr virus infection among health care workers at their
institution [124]. Occupationally acquired cases of syphilis [125], malaria [126], and yellow fever [127]
have been reported.

Previous SectionNext SectionOral-Fecal Transmission

Enteric pathogens spread in various ways, including through the ingestion of contaminated food;
through direct person-to-person contact; and through contact with infectious waste, usually feces (Table
3). Insufficient handwashing by health care workers probably contributes more to the transmission of
these pathogens than to the transmission of bloodborne or airborne pathogens.

View this table:

· In this window· In a new windowTable 3. Occupationally Acquired Infections Resulting from

Oral-Fecal Transmission*

Salmonellosis
The number of cases of salmonellosis has increased steadily since the 1950s, and food-related outbreaks
continue to occur. The effect of contaminated food was vividly shown by a recent outbreak that was
traced to ice cream and that caused more than 200 000 cases of salmonellosis across 41 states [153]. In
general, institutional disease accounts for 10% to 30% of all cases [138, 154, 155]. Hospitals, nursing
homes, psychiatric facilities, pediatric wards, and nurseries are common sites [138, 154-157].

Massive contamination of mashed potatoes was responsible for a large outbreak at a hospital in Jordan
[128], where 183 of 619 persons (19.6%) (including 150 hospital employees) developed disease.
Investigation showed that 11 of 61 kitchen workers (18%) were infected with salmonella; all had been
negative on cultures taken 3 months earlier, suggesting that routine surveillance cultures may not be
useful.

Person-to-person transmission of salmonella occurred in a hospital in Maine [158], where several

workers who drank tainted eggnog developed salmonellosis. As the outbreak progressed, at least eight
additional workers who had not drunk eggnog also developed disease. Person-to-person spread has
been suggested by other studies [159, 160], including the report of an outbreak that involved fasting
patients who had recently had gastrectomy and infants who were not receiving hospital food. In a
nursing home in Tennessee, 8 of 160 employees (5%) developed salmonellosis; the highest attack rate
was seen in laundry workers [129]. Several laundry workers had no direct contact with infected patients,
suggesting that transmission occurred through contaminated linen.

Interrupting an identified outbreak may be difficult. In Cincinnati, Ohio, 24 of 52 kitchen workers were
found to have Salmonella drypool, which accounted for at least 11 cases of salmonellosis among staff
who ate food that had been prepared at the hospital [161]. The epidemic was stopped only after 50 of
52 kitchen workers were treated with trimethoprim-sulfamethoxazole. Because 32% of treated
employees developed reactions to drug treatment, this approach may not be advisable for routine
outbreaks. In one study [162], the cost of identifying and treating one salmonella-infected health care
worker, including cultures, antibiotic therapy, and lost work time, was $3500.

Hepatitis A

The number of cases of hepatitis A gradually increased in the United States in the 1980s; incidence
peaked in 1989 [163]. Common risk factors for the acquisition of HAV include contact with an infected
person (26%), employment in or attendance at a day care center (14%), and use of injection drugs (11%)
[163]. The overall prevalence rate of HAV infection in the United States is about 38%, similar to rates
described in health care workers (35% to 54%) [164-166]. In one report [165], the rates of antibodies to
HAV were significantly higher in nurses older than 30 years of age than in office workers; in another
study, charwomen had the highest rate [166].

Many outbreaks have been reported in pediatric or neonatal intensive care units [130, 133-136] and
orphanages [167]. A neonate who acquired HAV through a transfusion spread the organism to 10 of 61
susceptible nurses (16%) [136]. An infected child who had an immune defect that resulted in an inability
to seroconvert to HAV remained undiagnosed for a protracted period, leading to transmission of HAV to
15 of 102 staff [131]. Adults with diarrhea have also transmitted the virus to health care workers [168,
169].

An outbreak of HAV infection in a burn unit occurred despite the use of appropriate infection control
measures, and HAV was spread to 11 of 59 susceptible nurses (18.6%) [132]. Eating on the hospital ward
was the most important risk factor for infection. Other nosocomial outbreaks have resulted from the
consumption of contaminated food, including orange juice [170] and sandwiches [171]. One outbreak
resulted in 66 cases of clinical or subclinical disease [171].

The intramuscular administration of immune globulin to persons who have contact with HAV-infected
patients has been used effectively for many years to prevent secondary cases. Defining which, if any,
health care workers should routinely be vaccinated for HAV is currently being discussed [137, 172].

Shigellosis

Given the small inoculum size required for transmission of shigella [173], the reason for the relative
infrequency of nosocomial shigella infection has been the subject of speculation but remains obscure
[138]. Outbreaks in day care centers have been reported [153, 174]. At a teaching hospital in Kenya
[175], salmonella accounted for 10% and shigella accounted for 2.5% of 360 cases of nosocomial
diarrhea. In another report [139], 3 of 32 workers in a newborn nursery developed shigellosis. All were
chronic nail-biters. The cost of controlling the outbreak was $5000.

Cryptosporidiosis

Cryptosporidia have been spread to a medical intern and possibly other staff [176], a nurse [177], and a
laboratory researcher [178]. Proper infection control techniques failed to control an outbreak in Wales,
where 5 of 16 nurses developed disease [140]. This outbreak was perpetuated by severe environmental
contamination; replacement of sinks and hand basin taps with leg-operated machinery proved to be an
effective intervention. Veterinarians and animal handlers also have an increased risk for
cryptosporidiosis. In one outbreak [141], cryptosporidiosis developed in 10 of 20 veterinary students
who worked with calves that had died of the disease. This outbreak was similar to another calf-related
outbreak, in which 12 of 18 animal handlers became infected [142].

Helicobacter pylori Infection

Several recent reports have examined the seroprevalence of antibodies to Helicobacter pylori among
health care workers [143-147]. One found that seroprevalence was higher among endoscopists (69%)
than among internists (40%) [145]. Two other studies [143, 147] found that about 52% of endoscopists
and only about 14% to 21% of blood donors were seropositive for H. pylori[143, 147]. Dentists have no
increased seroprevalence despite contact with saliva [144]. These findings suggest that contact with
contaminated equipment, rather than routine patient care or contact with saliva [144], is an important
mode of transmission.

Other Infections
Clostridium difficile has emerged as an important cause of hospital-acquired diarrhea and has been
cultured from the hands of 14% to 59% of asymptomatic health care workers during outbreaks [179,
180]. However, controversy exists about the potential role of C. difficile as an occupationally acquired
organism [181-183]. Possible nosocomial transmission of fatal C. difficile infection to an otherwise
healthy worker has recently been reported [184]. Several nursing home outbreaks of infection with the
Norwalk virus (a small, round-structure virus) have resulted in rates of transmission to staff that range
from 30% to 50% [148-152]. In one outbreak, “care attendants” had an incidence rate of 92% [149]. In
an outbreak of Escherichia coli O157: H7-associated hemorrhagic colitis in a nursing home [185], 18 of
137 staff members (13%) developed symptoms; 5 of the 18 had bloody diarrhea. No health care worker
developed the hemolytic-uremic syndrome. Cholera has spread to staff [186], but studies done before
vaccination found no risk to personnel on a polio ward [187].

Eating hospital food and drinking hospital beverages expose health care workers to the same risks faced
by patients and visitors, as shown by hospital food-related outbreaks of salmonellosis [128, 158, 161],
hepatitis A [170, 171], yersiniosis [188], campylobacteriosis [189], cyclospora infection [190], and
typhoid fever [191].

Previous SectionNext SectionDirect Contact

Infection may spread to health care workers as a result of direct contact. Outbreaks of scabies,
particularly among nurses and laundry workers, have been reported from several hospitals [192-195]. In
one hospital [193], almost 300 health care workers were affected, including 45 of 200 laundry workers
(22.5%), 126 of 1448 nurses (8.7%), and 32 of 87 health care workers (36.8%) who had direct contact
with patients. The outbreak cost about $50 000 for days of work missed and for treatment. In another
outbreak [194], secondary spread to the spouses of health care workers was seen. A large, sustained
outbreak at an extended-care facility [195] resulted in the infection of 26% of the staff, including half of
all nurses.

Cutaneous herpes (herpetic whitlow) is an occupational hazard for dentists; anesthesiologists; dialysis
technicians; physiotherapists; physicians; and nurses [196, 197], particularly nurses in intensive care
units [196, 198, 199]. That dermatologists face risk associated with laser treatment of warts with lasers
has been suggested [200, 201], including a recent study [202] in which molecular epidemiologic
techniques were used. Tinea corporis may spread to staff [203, 204], further thwarting control efforts.

Previous SectionNext SectionSpecific Groups of Health Care Workers at Risk

Laboratory personnel, veterinarians and animal handlers, pathologists, surgeons, dentists,

anesthesiologists, and laundry workers are at risk for an array of specific infections (Table 4). In addition,
the concerns of pregnant health care workers are considerable and unique because certain otherwise
mild infections may affect fetal development.

View this table:

· In this window· In a new windowTable 4. Occupationally Acquired Infections Encountered in
Specific Groups of Health Care Workers*

Laboratory-acquired infections have been extensively studied [205-207]. Collins [205] identified 2168
infections and 48 deaths from diseases ranging from brucellosis and Q fever (the most common) to
rabies and the plague. The potential danger of working in laboratories is dramatically illustrated by the
fate of Ricketts (for whom Rickettsia was named), who died of laboratory-acquired rickettsiosis [205].
Neisseria meningitidis has fatally infected laboratory workers [208]. Although many clinical health care
workers receive prophylaxis after exposure to N. meningitidis, studies have not documented the spread
of this organism to health care workers in the clinical setting [209].

Previous SectionNext SectionInterventions

Despite the seemingly limitless number of infections that health care workers can acquire on the job,
the interventions to prevent transmission are simple, well known, and effective. Compliance with three
practices—handwashing, vaccination, and appropriate isolation of infected patients—can control
transmission dramatically and cost-effectively.

Handwashing

Handwashing is the oldest, simplest, and cheapest way to control the nosocomial spread of infectious
organisms. In the 1840s, Semmelweis introduced the practice of “hygienic hand disinfection” on
obstetric wards in Vienna, decreasing the maternal mortality rate from 13.7% to 1.3% [241-243]. Since
that time, handwashing has become routine for all persons doing any surgical procedures; however,
workers involved in medical care have notoriously low rates of handwashing—usually less than 50%
[244-248].

Numerous studies have examined the specific aspects of handwashing, including type of soap [249,
250], type of sink [251], drying method [252], and method of scrubbing [243, 253-255]. One study
showed that chlorhexidine was both significantly more effective and more often used than alcohol and
soap [249]. Additional strategies to improve compliance [244, 247, 251] are necessary because
compliance, not brand of soap or type of sink, remains the major obstacle to preventing transmission. In
addition to preventing patient-to-patient spread, handwashing may prevent the acquisition by health
care workers of such infections as those caused by rhinovirus, respiratory syncytial virus, HAV,
adenovirus, and salmonella. Emphasis of this might promote compliance and lead to an overall
reduction of transmission.

Vaccination

Recommendations about vaccines are updated frequently [256], but vaccination of health care workers
remains incomplete [257-259]. Indeed, compliance with HBV vaccination remains appalling: In a recent
survey in an inner-city hospital, 23% of workers were unvaccinated [52]. Health care workers are often
the source of outbreaks of measles and rubella [257] and, less commonly, HBV infection [260], further
emphasizing the need for improved compliance with vaccination. A demonstration of evidence of
antibodies to vaccine-preventable diseases, including measles, mumps, rubella, and hepatitis B, is
required of employees at many hospitals. The varicella-zoster virus has recently been recommended
[261], whereas the role of the HAV vaccine is being determined.

Isolation

Appropriate isolation of infected patients is another time-honored practice [262]. It is the most
complicated and potentially expensive of the three standard interventions. Difficulties arise when trying
to balance the need to protect health care workers against the realities of cost, as shown by the recent
debate surrounding tuberculosis control [263]. A common sense approach may find an acceptable
middle ground [264, 265]. In general, universal precautions for infections with bloodborne organisms,
respiratory and droplet isolation precautions for infections with airborne organisms, and contact
isolation precautions (or enteric precautions) for infections caused by organisms spread by the oral-fecal
route are effective and widely used [33]. Updated guidelines for isolation precautions have recently
been published [33].

Previous SectionNext SectionConclusions

Public attention has recently focused on the risk to patients posed by infectious health care workers.
Transmission of HIV from an infected dentist to four patients [266] stirred a national debate in the
United States about mandatory HIV testing of health care workers. Workers have been the source of
many infections other than HIV infections, including tuberculosis [267], hepatitis B [260], measles, and
rubella [257]. Little public concern or awareness, however, has been directed toward the risk to health
care workers of caring for contagious persons, despite the continuing illness and occasional death that
result from occupationally acquired diseases.

Several recent developments have changed many aspects of occupational risk. Old diseases that may be
spread to health care workers, such as tuberculosis and diphtheria, have reemerged, forcing the
reexamination of existing infection control policies [268]. New technology has identified old infections,
such as hepatitis C. This, in turn, has been followed by numerous studies delineating the natural history
and transmission rates of disease, including risk to health care workers [11-19, 79-94]. Seemingly new
diseases with undefined risks, such as HIV and Ebola virus infection, have become evident, leading to
appreciation of risks to health care workers and recommendations for worker safety [7, 26].

Recognition and confirmation of outbreaks, as well as improved understanding of transmission [269,

270], rely increasingly on molecular epidemiologic techniques. These techniques have been applied to
investigations of many diseases, including CMV infection [109], adenovirus infection [271, 272], hepatitis
B [260], hepatitis C [273], HIV infection [274], and tuberculosis [275, 276]. Molecular analysis may
identify previously undiscerned outbreaks [275] or rule out others [276].

The recent trend toward an increase in the use of outpatient care has also changed the risk for
occupationally acquired infection, as well as the groups of health care workers at risk [64, 277, 278]. In
1867, Simpson expressed his hope that, given the high concentrations of sick patients, “hospitals should
not become pesthouses, and do more harm than good” [279]. Since that time, the risk posed to patients
and staff by nosocomial infection has been repeatedly shown. In this regard, the result of shorter
hospitalizations may well be salutary, although the risk for undetected infection may increase as
patients receive more care away from diagnostic centers.

In summary, daily patient care presents the health care worker with a real, although small, risk for
infection. Indeed, the cost to prevent, control, and treat occupationally acquired infections is
considerable, in terms of both dollars spent and lives affected. This does not imply that working with
contagious persons is a heroic endeavor. Rather, incurring the risk for occupationally acquired infection
is necessary for daily health care delivery. Indeed, the willingness of health care workers to accept this
risk is, in many ways, as important to health care as their professional skills. This should be considered in
the coming years as health care delivery in the United States continues to be reformed. General beliefs
about medicines among doctors and nurses in out-patient care: a cross-sectional study

This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

Doctors and nurses are two natural partners in the healthcare team, but they usually differ in their
perspectives on how to work for increased health. These professions may also have different beliefs
about medicines, a factor important for adherence to medicines. The aim was to explore general beliefs
about medicines among doctors and nurses.

Methods

Questionnaires were sent to 306 private practitioners (PPs), 298 general practitioners (GPs) and 303
nurses in the county of Västra Götaland, Sweden. The questionnaire included sociodemographic
questions and the general part of the Beliefs about Medicines Questionnaire (BMQ), which measures
the beliefs people have about medicines in general. General beliefs about medicines in relation to
background variables were explored with independent t-tests and ANOVA analyses. Differences
between occupations and influences of interaction variables were analysed with multiple linear
regression models for general beliefs about medicines.

Results

The data collection resulted in 616 questionnaires (62.1% PPs; 61.6% GPs; 80.5% nurses). The majority
of the PPs and 40% of the GPs were male but most of the nurses were female. The GPs' mean age was
47 years, PPs' 60 years and nurses' 52 years. Few nurses originated from non-Nordic countries while
15% of the PPs and 25% of the GPs did. Nurses saw medicines as more harmful and less beneficial than
did PPs and GPs. These differences could not be explained by the included interaction variables. GPs
with a Nordic background saw medicines as more beneficial and less harmful than did GPs with a non-
Nordic background.
Furthermore, GPs of non-Nordic origin were most likely to believe that medicines were overprescribed
by doctors.

Conclusion

Doctors were more positive about medicines than nurses. The differences in beliefs about medicines
found between doctors and nurses could not be explained by any of the included interaction variables.
These differences in beliefs may be useful in discussions among future and practising doctors and nurses
to enhance understanding of each other's profession and teamwork.

Exposure to blood borne pathogens poses a serious risk to healthcare workers (HCWs). This study was
undertaken to investigate knowledge, attitudes and practices among HCWs towards blood borne
pathogens. We carried out a cross sectional KAP (Knowledge, Attitudes and Practice) study, using self-
administered questionnaire. The study population consisted of 127(23.6%) physicians, and 410 (76.4%)
nurses and laboratory technicians. Factor analysis and conditional multiple logistic regression were used
in statistical analysis. We found that the knowledge of the epidemiological characteristics of blood-
borne infection, the risk of acquisition and available preventative measures among HCWs is insufficient.
Doctors were more knowledgeable about the transmissibility of blood borne pathogens regarding sexual
transmission after percutaneous exposure (odds ratio) OR=2.71; 95% (confidence interval) CI=1.51–4.84,
OR=2.45; 95% CI=1.21–4.96), respectively. Nurses reported professional exposure to patient’s blood
more often than doctors (OR=0.90; 95% CI=0.84–0.96). Negative attitudes towards HIV positive patients
were also noted. Less than half of HCWs used appropriate barriers (gloves, mask, and glasses) to protect
them regularly. The compulsory preventive measures implied by the results of this study are continuous
education, immunization against Hepatitis B, implementing Standard Precautions, as well as the
development of written guidelines on the prevention of blood-borne infections

Nurses and the occupational risk of blood-borne infections

Scant attention is paid to occupational health safety for nurses in Indian hospitals in the context of
blood-borne infections. Yet studies of health care workers exposed to HIV-infected blood through
percutanous injury estimate a transmission rate of 0.3% per injury, says Shreedevi Balachandran

There is one subject related to health care workers, particularly nurses, that I have never heard
discussed, whether in government or in private hospitals, where nurses form the largest workforce. I
refer to occupational health safety for nurses in the context of blood-borne infections including HIV. This
includes training to reduce the risk of HIV exposure, availability of appropriate protection, post-exposure
care, and employment security on becoming HIV-positive. This has serious implications in the context of
people's right to treatment regardless of HIV status.

In the absence of statistics from India, statistics from the United States provide some insight into this
occupational risk. Needle stick and other percutaneous injuries are among the most common and
avoidable occupational hazards in the hospital. Percutaneous injury was associated with 89% of
documented transmissions of HIV.(1)

Based on data from a number of prospective studies of health care workers exposed to HIV-infected
blood through percutaneous injury, the CDC estimates a transmission rate of 0.3 % per injury. (2, 3) The
total number of needle stick injuries that the average nurse in India experiences is likely to be higher,
given the absence of training and protective devices, thus increasing the total exposure to possibly
infected blood or body fluids.

The public tends to believe that patients are cured solely due to the efforts of doctors. The doctor may
be the team leader, but it is the nurses who physically care for patients. Common procedures that
involve blood and body fluids - starting an intravenous line, suctioning a patient's throat, mouth,
handling a bleeding accident victim in the emergency department - expose nurses to a variety of
diseases. It is the nurse who generally attempts to stop bleeding, cleans the patient of blood on his
body, and starts blood transfusions.

A visit to any government or municipal hospital provides a clear picture of the risks faced by nurses.
There is a lack of basic protective barriers like gloves and masks, and absolutely no training on universal
precautions.

A colleague with over 26 years of experience recollects, "During our training days in the 1960s, we did
not get gloves in the government hospitals. If there were gloves available it would be given to the
doctor. We had to conduct deliveries with our bare hands." The situation is not very different in most
hospitals today. The only exception is in private hospitals, where patients pay for every pair of gloves
used by the hospital staff.

Student nurses are far worse off. In teaching hospitals, senior ward sisters would scream if they found
student nurses using gloves. It was a lucky student who was given a pair of gloves - which they could use
for the whole shift. Imagine the level of hygiene this implies, and the scope for cross infection.

If these are the circumstances in teaching hospitals, is it possible to even talk of adequate protective
facilities in primary and secondary care facilities, let alone in remote parts of the country?

The emotional impact of a needle stick injury can be severe and long lasting, even when a serious
infection is not transmitted. The impact is particularly severe when the injury involves exposure to HIV.
In one study of 20 health care workers with an HIV exposure, 11 reported acute severe distress, six quit
their jobs, and seven had persistent moderate distress as a result of the exposure. (4) Other stress
reactions requiring counselling have also been reported. (5)

Case reports

In one of the private hospitals that I worked in, we kept detailed assessments and follow-up reports of
all needle stick injuries as part of our infection control programme. Forty-six cases of needle stick
injuries were reported over two years by various categories of health care workers. The following case
reports illustrate a number of preventable practices that can lead to needle stick injuries.
--In a paediatric intensive care unit the resident doctor collected blood from a patient. He left the
sample - in the syringe with an uncapped needle - on the bed, where it got lost in the bedclothes. Some
time later, the nurse tidied the bed clothes to make the patient comfortable when she was pricked by
the sharp needle. Later she was told that the child was HIV-positive. She was treated with two drugs as
prophylaxis. She developed toxic effects of the liver and also went through a phase of depression.

--A patient suffering from AIDS was admitted to the private ward of the hospital. As part of the
admission routine, the nurse did a finger prick to collect a drop of the patient's blood and assess his
glucose levels. After the prick and before collecting the drop of blood on to the test strip, she tried to
recap the needle in a hurry and sustained a deep injury with the needle. We did the necessary blood
tests and started the nurse on a two-drug regimen. This nurse, too, went into a deep depression and
had to be granted leave for over a month. The total cost of treatment of Rs 18,000 was borne by the
hospital.

--A nurse was walking out of the patient's room with a used syringe and needle in an injection tray, after
having given an intra-muscular injection when she bumped into another nurse in a hurry. When the two
banged into each other, the syringe with the needle fell from the tray on the nurse's hand and she got a
prick.

--The nurse was starting an intravenous line on a patient. She had identified the vein and placed the
cannula. As she was removing the steel stilette from the cannula, the patient pulled his hand back
violently. The stilette went through the nurse's forearm and she suffered a deep injury. A year later she
tested HIV-positive. She had to move from active --. clinical work into teaching. Since she was working in
a government set-up she is being treated free of cost.

Indiscipline on the part of medical staff also results in percutaneous injuries. Sharp objects such as
trocars, surgical blades and needles are left on the trolley for nurses to clear up after procedures. At the
hospital where I worked in the United Kingdom, it was mandatory for the user of sharps to clear them
into the sharps container. Nurses had the authority to make sure that this etiquette was followed
strictly. This rule applied to all health care workers who used any kind of sharps.

Nurses who are known to be HIV-positive face discrimination at the work place. There is a constant
threat of loss of employment. They are rejected by their peers and co-workers. They become subjects of
humiliating remarks. Their career comes to a full stop and they suffer from severe depression.

I have found that the majority of new graduate nurses cannot answer basic questions on universal
precautions. But there are also instances where nurses are fully aware of the universal precautions, but
have no supplies to practice them.

Inadequate protective facilities, and cumbersome procedures to get even basic materials such as gloves,
directly affect the attitudes of nursing personnel. Indifference to the sick, and ineffective and inefficient
management of health services can sometimes be related to health workers' concern for personal
safety. This has serious implications in the context of people's right to treatment regardless of HIV
status. How can one enforce that right unless health care workers are assured that they are adequately
protected? How can one talk of the ethical duty of a nurse to provide care unless the nurse is enabled to
do so without the constant risk of injury? Can they even prevent harm to their patients? Can we have
patient autonomy if there is no autonomy of action for nurses? How does one expect them to care for
patients in the true meaning and philosophy of nursing?

In the context of the occupational risk faced by health care workers, the best way to prevent
occupationally acquired infection is to prevent needle stick injury. Employers must ensure the
availability of adequate protective devices. The least that can be done is to provide disposable gloves (50
paise per pair) and equipment such as needle destroyers. They must also eliminate the use of needles
where safe and effective alternatives are available. All nurses must be properly trained in the safe use
and disposal of needles. Procedures must also be established to encourage reporting and timely follow-
up of all needle stick and other sharp related injuries. Hospitals must give support to injured staff

Nurses should also be empowered to speak out on occupational safety, and their suggestions given
immediate attention