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DISCUSSION

Bloodborne viruses and workplace injury risk

  • Comment

Bloodborne viruses still pose a risk to health professionals, mainly through sharps-related injuries in the workplace. Increased awareness is needed to reduce this risk

Abstract

Staff working in healthcare settings face risk from bloodborne viruses through occupational injuries. Nurses and healthcare assistants (HCAs) represent the biggest group of healthcare workers reporting exposure to bloodborne viruses, with more than half of injuries among this group between 2004 and 2013 involving a needlestick injury. Action is needed to reduce these risks, such as the procurement and use of safety-engineered devices and the provision of safe working conditions. Raising awareness of needlestick injuries among all healthcare staff may also help.

Citation: Woode Owusu M et al (2015) Bloodborne viruses and workplace injury risk. Nursing Times; 111, 7: 12-14.

Authors: Melvina Woode Owusu is a senior HIV/STI scientist at Public Health England’s Centre for Disease and Infection Control; Edgar Wellington is an HIV/STI scientist; Malcolm Canvin is a data analyst; Brian Rice is a principal scientist; Vicky Gilbart is a nurse consultant; Fortune Ncube is a consultant epidemiologist and head; all at the bloodborne virus section at Public Health England’s Centre for Disease and Infection Control.

Introduction

The reported number of significant occupational exposures to bloodborne viruses among healthcare workers in England, Wales and Northern Ireland increased from 373 in 2004 to 496 in 2013, with a total of 4,830 significant exposures reported over the 10-year period. The Eye of the Needle report, published in 2014, highlighted these exposures (Woode Owusu et al, 2014).

An injury in the workplace is regarded as a significant occupational exposure if both of the following conditions are met:

  • The healthcare worker sustains broken skin or contamination of the mucous membranes (mouth, eyes, or nose);
  • The patient involved is known or thought to be infected with hepatitis B (HBV), hepatitis C (HCV) and/or HIV.

Risk of significant occupational exposures affect all healthcare workers but measures can be taken to prevent injuries and reduce the risk of bloodborne virus transmission.

Patterns of reported exposures

Half of the reported exposures involved HCV, one-third HIV and one in 10 HBV (Woode Owusu et al, 2014). The high proportion of HCV exposures is believed to reflect its higher prevalence in the general population (Public Health England, 2014).

Although doctors, nurses, and HCAs sustained over 80% of all occupational bloodborne virus exposure injuries between 2004 and 2013, reports were received from a wide range of occupational groups, including ancillary and domestic staff. The largest group reporting injuries were nurses and HCAs, with 42% of exposures among this group.

A review of national data shows that, while 65% of reported injuries sustained between 2004 and 2013 occurred during clinical procedures, 35% were sustained after the procedure and before, during, or after disposal. This highlights the importance of providing safety-engineered devices and safe working conditions and promoting safe practices, which extend beyond clinical procedures.

We found that 65% of exposures reported between 2004 and 2013 occurred in wards, theatres and A&E. While the annual number of exposures in theatres and A&E increased over time, exposures in wards declined. Over 70% of exposures involved a percutaneous needlestick injury; most of these involving hollowbore needles. While the number of percutaneous injuries was higher than mucocutaneous exposures, reports of mucocutaneous exposures rose by 61% during the study period compared with a 22% increase in percutaneous injuries.

Exposures among nurses and healthcare assistants

Compared with reports from all occupational groups, nurses and HCAs (as a single group) reported a slightly higher percentage of exposures to HCV (61% compared with 58% among all occupational groups), a higher percentage of injuries occurring outside of clinical procedures (41% compared with 35%) and a higher percentage of mucocutaneous injuries (35% compared with 29%). Midwives had a higher percentage (43%) of exposures involving mucocutaneous injuries than nurses and HCAs. Fig 1 (attached) illustrates occupational exposure between 2004 and 2013 based on reports from nurses and HCAs, showing at what stage of the procedure exposure took place, what viruses were implicated and what type of injury caused the exposure.

Preventing transmissions

While no HBV or HIV transmissions were reported between 2004 and 2013, nine HCV seroconversions were reported. Of the nine healthcare workers who seroconverted, eight received antiviral therapy, seven of whom achieved viral clearance; the viral clearance status of the remaining worker is currently unknown.

Comparison of published and observed risks following percutaneous injuries shows that national data on transmissions is lower than theoretical estimates (Yazdanpanah et al, 2005; Department of Health, 2008; 2006). This disparity is likely to result from a combination of the success of the HBV immunisation programme among healthcare workers, effective clinical management of exposures and the fact that many patients with HIV may be of low infectivity due to antiretroviral therapy.

Among healthcare workers exposed to HBV, 96% were known responders to the vaccine. Of those exposed to HIV who reported the time they started post-exposure prophylaxis (PEP), 97% did so within 72 hours of exposure. Starting PEP within 72 hours is known to maximise the effectiveness of the treatment (Department of Health, 2008). Another factor that may influence the observed seroconversion rates for HBV, HCV and HIV following percutaneous injury is the underreporting of exposures by individual healthcare workers to their organisation and by organisations to PHE. Hospitals are currently taking steps to implement safer practices in accordance with the 2010 EU directive (European Agency for Safety and Health at Work, 2010) and the sharps regulations (Health and Safety Executive, 2013).

While the use of safety-engineered devices represents a clear effort to reduce the risks of occupational injuries, raising awareness, education and training about needlestick injuries are also important in preventing and managing sharps injuries (Royal College of Nursing, 2013).

Awareness of needlestick injuries

POINTERS conference

Recognising the occurrence of needlestick injuries as a major concern, a discussion group session was added to the programme of the 2014 POINTERS conference. This biennial conference is a unique collaboration between the Infection Prevention Society and the Faculty of Occupational Medicine; it was supported by PHE, and hosted by Public Health Wales and the Welsh Government. The conference brought together expertise from a broad range of specialisms with an interest in preventing bloodborne viruses, including occupational health advisors, nurses, consultants, virologists, and health and safety professionals.

Delegates joined one of 12 discussion groups of approximately six participants, to explore the topic of raising awareness of needlestick injuries. Each group was assigned one of four primary questions to stimulate their discussion (Box 1) and given background information through presentations, oral instructions and a written information sheet. Group facilitators guided them through their discussion questions and they were prompted to consider two key points:

  • The resources needed to raise awareness of needlestick injuries in healthcare settings;
  • The impact, needs and responsibilities of different organisations or groups.

Box 1. Discussion group questions

  • What are the benefits of a needlestick injury awareness day in a healthcare setting?
  • What resources are needed to help raise awareness of needlestick injuries in healthcare settings?
  • How would you describe the ideal needlestick injury awareness day?
  • What key information or data would be useful to raise awareness of needlestick injuries in healthcare settings?

Raising awareness preventing injuries

Discussion points raised within the groups were recorded on flipcharts, written and shared with the wider group during a feedback session. Photos were taken of each group’s flipchart sheets and the groups’ discussion notes were later transcribed for analysis using an inductive technique. Through qualitative analysis, six key themes emerged:

  • National context, strategy and data;
  • Local leadership and ownership;
  • Practicalities of raising awareness of needlestick injuries;
  • Personalisation, and individualisation of impact and responsibility;
  • Shared responsibility, opportunity and impact;
  • Reporting practices, procedures and clinical management.

National considerations

Analysis of discussion group transcripts reveals that national priorities affect practitioners’ ability to organise local awareness raising sessions. Several discussion groups identified that, where NHS trust boards prioritise specific issues, there may be a stronger commitment and greater support for local initiatives. The groups also noted that NHS trust boards would be more likely to prioritise action to reduce the risks of exposure to bloodborne viruses if it was considered to be a national priority area with evidence generated through data, strategic reviews and audits. There was a desire for national data to be made available so infection control practitioners could present this at board level for the issue to be prioritised. The ability to provide national data is dependent on the continued and timely reporting of exposures and outcomes from local settings. The interdependence between national data, national strategy and local data and agendas was a shared observation.

Local considerations

Despite the importance of national support and data, the consensus was that local leadership, ownership and implementation would be the driving force for an initiative aimed at raising awareness of needlestick injuries. All discussion groups agreed that genuine support from trust leadership teams, strong ownership by an appointed team or individual, and understanding among staff of the risks posed in their clinical setting by needlestick injuries were needed. The importance of strong leadership and ownership, supported by local data and service-specific information were identified as key factors for implementing an awareness-raising initiative.

Several groups discussed the importance of understanding the local situation with regard to needlestick injuries. Some said risk assessments, audits of injuries, and reviews of clinical management processes may be useful to gain baseline figures to evaluate interventions.

The practicalities of raising awareness of needlestick injuries were discussed at length. Some delegates shared examples of best practice or lessons learned from their own settings, while discussion groups generated new ideas and approaches to raising awareness. Delegates wanted information about risks of transmission and available safety devices. A key feature suggested for inclusion in awareness-raising interventions was the assessment of staff’s knowledge and competence in using and disposing of devices appropriately, and the provision of resources for them to review later. While linking needlestick awareness-raising interventions to other campaigns, such as World Hepatitis or HIV Day was regarded as beneficial, it was suggested the impact might be short-lived. Delegates preferred a more continuous approach to raising awareness to achieve an attitudinal shift in the longer term that would have greater benefits for the organisation.

Individual considerations

Low risk perception
References were made to low-risk perception among healthcare workers and the notion that “it could never happen to me”. A common suggestion was that personal testimonies and/or case studies from healthcare workers, who had been exposed to a bloodborne virus, should be included in educational materials and in awareness raising events. This would help personalise the risks and increase risk perceptions among healthcare workers.

Under-reporting
Two issues relating to reporting were raised as important for inclusion in awareness-raising initiatives:

  • The time needed to report injuries, attend follow-up appointments and investigate an injury or incident may be a deterrent for some healthcare workers who feel they are too busy
  • Healthcare workers may be reluctant to report injuries due to fear of blame for causing the injury or of stigma associated with bloodborne viruses.

It was also suggested that healthcare workers may benefit from understanding the importance of reporting injuries and clarity around the likely tests, procedures and outcomes that might result from an exposure to a bloodborne virus.

Conclusion

An overarching theme from both the Eye of the Needle report (Woode Owusu et al, 2014) and the discussion group analysis is that the risk of bloodborne viruses affects all healthcare workers, regardless of whether they have clinical roles. Any effort to reduce risk, injuries and transmissions should, therefore, involve all groups of healthcare workers, including those who work on a locum and bank basis.

While some discussion groups at the 2014 POINTERS conference felt mandatory or induction training would ensure all employees in healthcare settings gained some form of training, they also considered the merits of an ongoing approach to preventing injuries. Suggestions included ongoing training opportunities, reviews, interdepartmental competitions for reducing injuries and local targets in order to maximise the level of personal responsibility of individual healthcare workers.

Preventing needlestick injuries was regarded as an important, multidisciplinary and shared endeavour, which should form part of a suite of undertakings to prevent percutaneous and mucocutaneous occupational exposures. This would ideally include increased procurement and use of safety-engineered devices, education and training, and improvements to local and national reporting practices surrounding occupational injuries

Key points

  • All healthcare workers face the risk of bloodborne viruses through occupational exposure injuries sustained at work
  • Between 2004 and 2013, of all occupational bloodborne virus exposures, 66% involved sharps, of which 87% were needlestick injuries
  • Healthcare workers are most likely to report having sustained injuries during clinical procedures, although a considerable number also occur after clinical procedures
  • NHS trusts should provide safety-engineered devices and appropriate training to reduce preventable injuries
  • Raising awareness of needlestick injuries and improving reporting are central to reducing risks of exposure to bloodborne viruses
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