CHAPTER ONE

INTRODUCTION

1. BACKGROUND OF THE STUDY

A heightened understanding of transmission of blood-borne diseases in the mid-1980s 1,6 to healthcare workers (HCWs), including surgeons, physicians, and residents in training, and the importance of adherence to standard precautions (SP) is well accepted. Adherence to SP is even more important with the emergence of infectious diseases, such as avian influenza, severe acute respiratory syndrome, and the threat of bioterrorism.7 The problems of containing drug resistant organisms such as methicillin-resistant staphylococcus 8,10 and vancomycin-resistant enterococci from colonizing patients give a continuous reminder to HCWs that adherence to SP is also pivotal to patient safety in terms of healthcare-associated infections. In 1996, the Centers for Disease Control proposed Guidelines for Isolation Precautions in Hospitals, as new, two-tiered best practice of infection control precautions that are standard for all patients who are to be regarded as potential carriers of pathogenic microorganisms.1,10 Strict adherence to SP guidelines is necessary to prevent exposure to potentially life-threatening infections,3,15 yet a high level of compliance with SP has been reported to be problematic worldwide.3,4.

            Generally, health care workers are at risk of infection with bloodborne pathogens such as hepatitis B virus, human immunodeficiency virus, and hepatitis C virus etc 5. Dentistry is a high-risk profession with respect to occupationally acquired infectious diseases as it mostly involves a surgical field with frequent exposure to blood and body fluids of patients 6. Dental professionals are particularly predisposed to occupational hazards such as exposure to infections, percutaneous exposure incidents, dental materials, respiratory disorders, eye insults etc 7. As a result, oral health care workers, through occupational exposure, may have a 10 times greater risk of becoming a chronic hepatitis B carrier than the average citizen 5. It is therefore pertinent that strict infection prevention and control measures are instituted and adhered to in any dental facility to protect both patients and oral healthcare workers 8. Standard Precautions are the basic level of infection control precautions which are to be used, as a minimum, in the care of all patients 9. Standard Precautions are used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin (including rashes), and mucous membranes 10. They are meant to reduce the risk of transmission of pathogens from dental healthcare personnel to patients; from patients to dental healthcare personnel; and from one dental healthcare personnel to another 11. Standard Precautions were introduced in 1996 by the Centre for Disease Control (CDC) as a set of infection control measures applicable when contacting all patients 12. Components of Standard Precautions include the use of protective attire and barrier techniques (Personal Protective Equipment) such as gloves, surgical masks, face shields, aprons and reusable or disposable gowns; handwashing and care of hands; use and care of sharp instruments and needles (including Sharps Injury Management) and; appropriate healthcare waste management 13. The attitude to, and practice of standard precautions amongst allied dental personnel will stem from their knowledge and understanding of the importance of standard precautions. This study will focus on assessing the knowledge of infection control amongst allied dental personnel, and how the knowledge has influenced their attitude and practice of standard precautions. An assessment of the knowledge, attitude and practice of standard precautions by healthcare workers is a prerequisite for initiating and implementing a successful infection prevention and control strategy in any health facility 14.

1.2 STATEMENT OF THE PROBLEM

Healthcare workers (HCWs) are at risk of occupational hazards as they perform their clinical activities in the hospital.72  The occupational health of the health care workforce of about 35 million people representing about 12% of the working population has been neglected.72  They are exposed to blood borne infections by pathogens such as HIV, hepatitis B and hepatitis C viruses, from sharps injuries and contacts with deep body fluids.4, 5, 58 In an era of HIV epidemic in sub-Saharan Africa,73 this occupational risk is real and significant.  It has been found that the risk of transmission of HIV/AIDS via needle stick incidents is 0.3 %;4,15,27,29  i.e, 1 case per 300 needle stick incidents.  

The Occupational Safety and Health Administration estimates that 5.6 million HCWs worldwide who handle sharp devices, are at risk of occupational exposure to blood borne pathogens.74  These injuries are usually under-reported for so many reasons such as stigmatization, should HIV result from such incidents.15 The sero-prevalence of HIV varies widely from country to country and from one region to another within the same country.75  Sub-Saharan Africa (SSA) has the highest HIV sero-prevalence in the world.75 The 2005 sero-sentinel survey conducted in Nigeria reported an overall HIV sero-prevalence of 4.4%.75 This high prevalence in the country poses an occupational risk to HCWs.  HIV/AIDS constitutes a major health problem in Nigeria.76 Nigeria is one of the countries worst hit by the HIV/AIDS epidemic, with about 2.99 million people currently infected.76   Over a million people (» 1.70 million) have already died from AIDS76 since it was first reported and confirmed in Nigeria in 1986.77

            The health consequences of these infections are enormous; symptoms of HCV infection may not manifest until 20-30 years after viral transmission.78 Also, about 60-85% of HCV infections result in liver cirrhosis and liver cancer.61 There is no immunization for HCV and HIV, it becomes important to prevent infection by preventing exposure.7 

            The rising prevalence of morbidity and mortality following exposure to blood borne infections is due to the lack of knowledge, wrong attitude towards and non-compliance to standard precautions as well as bad practices such as bending of needles, recapping of needles, detachment of needles, reuse of needles and lack of adequate sharps containers and disposal facilities, shortage of supply of injection equipment and unwarranted and unsafe use of injections, that put both patients and HCWs at risk of occupational exposure.  The improper disposal of used sharps and needles is known to cause needle stick injuries.81

            WHO estimates that annually, 16 billion injections are given each year in developing and transitional countries with an annual mean 1.5 injections per person per year.17  70 to 99% of these injections are unnecessary, while 50% are unsafe in 14 of 19 countries in five developing world regions with data.18,19,20  In Nigeria, the annual mean was found to be 4.9 injections per person per year.21  The socio-economic and psychological burden of unsafe injections occur at individual, family, community and national levels.  It is estimated that each year, the annual global burden of indirect medical cost due to hepatitis B and C and HIV/AIDS is estimated to be US $535 million.83

Globally, in 2000, unsafe injection was responsible for an estimated 21 million cases of Hepatitis B virus (HBV) infection, 2 million cases of Hepatitis C virus (HCV) infection and 260,000 cases of HIV infection, making up 32%, 40% and 5% of infections due to unsafe injection practices respectively.84

It is estimated that 9.18 million DALYs would be lost between 2010 and 2030 although interventions implemented in the year 2000 for the safe and appropriate use of injections could reduce it. 22, 84

            WHO estimates that 501,000 deaths have occurred because of unsafe injection practices.84These deaths could have been prevented by injection safety practices, which is an element of standard precautions, an integral component of infection prevention and control as well as a key element of health care worker safety.

            Such deaths involving members of the family especially the bread winners could lead to sorrow and poverty for many families.  Also, the rising prevalence of morbidity and mortality from these blood-borne infections can cause absenteeism from work, use of huge sums of money for treatment, reduced worker effect and decreased productivity, which will affect the economy adversely.

            In spite of the risk HCWs are exposed to, studies have extensively reported sub-optimal and non-uniform adherence to standard precautions by HCWs in both developed and developing countries. 12, 55, 65, 66  For instance, in a study done in Benin City, only 34.2% of nurses had heard of universal precautions,85 and in another study done in South East Nigeria, only 15.2% of Doctors had good practice of standard precautions.7

            Compliance with these universal precautions has been shown to reduce the risk of exposure to blood and body fluids.64  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.25,33,61,86,87,88  Standard precautions is practiced in high income countries to protect HCWs from occupational exposure to blood and the consequent risk of infection with blood-borne pathogens, but the situation is different in low income countries, where standard precautions are partially practiced.65 

            Occupational safety of HCWs is often neglected in low income countries in spite of the greater risk of infection due to higher disease prevalence, low level awareness of the risks associated with occupational exposure to blood, inadequate supply of personal protective equipment (PPE), and limited organizational support for safe practices.33 Efforts to reduce population levels of infections such as hepatitis and HIV are important goals. 

Identified and similar problems exist in Central Hospital, Sapele, other health establishments in Delta State as well as other states.  However, the knowledge, attitude and practice of standard precautions among HCWs in Central Hospital, Sapele, have not been assessed before.

1. OBJECTIVES OF THE STUDY

1. To assess the level of knowledge of standard precautions among health care workers in Central Hospital, Sapele.
2. To ascertain the attitude of health care workers in Central Hospital, Sapele towards standard precautions.
3. To determine the level of practice of standard precautions among health care workers in Central Hospital, Sapele.
4. To determine the level of immunization of the health care workers against infectious diseases such as HBV.
5. To describe the action taken by the health care workers when they are exposed to occupational hazards and injuries.
6. To ascertain the attitude of the health care workers towards patients with

HIV-AIDS.

1. To determine the practice of environmental cleanliness and waste disposal of the health care workers in Central Hospital Sapele.
2. To determine some of the factors that affect knowledge, attitude and practice of standard precautions among the health care workers.

1.4 RESEARCH QUESTIONS/HYPOTHESIS

1. What is the level of knowledge of standard precautions among health care workers in Central Hospital, Sapele?
2. What is the attitude of health care workers in Central Hospital, Sapele towards standard precautions?
3. What is the level of practice of standard precautions among health care workers in Central Hospital, Sapele?
4. What is the level of immunization of the health care workers against infectious diseases such as HBV?
5. What is the action taken by the health care workers when they are exposed to occupational hazards and injuries?
6. What is the attitude of the health care workers towards patients with HIV-AIDS?
7. How is the practice of environmental cleanliness and waste disposal of the health care workers in Central Hospital Sapele?
8. What are some of the factors that affect knowledge, attitude and practice of standard precautions among the health care workers?

1.5 SIGNIFICANCE OF THE STUDY

On the whole, available data show that needle stick injuries and blood borne pathogens are serious threats to patients, HCWs and to the host community.  The rising prevalence of morbidity and mortality as a result of nosocomial and blood borne infections such as HIV/AIDS, HBV and HCV among others is as a result of lack of awareness, wrong attitude towards and non-compliance with the definitions and recommendations of standard precautions.  Compliance with standard precautions has been shown to reduce risk of exposure to blood and body fluids.64 Due to this, surveillance of HCWs’ compliance to standard precautions is an important element of occupational and nosocomial infection control as it enables assessment of risks from occupation exposure to infection.89

            This study will expose the level of awareness, attitude and practice of standard precautions among the HCWs and hence could be used as a baseline for intervention.  It will also identify gaps which would be recommended for correction through interventions.  This study could be used to monitor trends of events concerning knowledge, attitude and practice of standard precautions among health care workers in Central Hospital, Sapele, by reviewing from time to time, the incidence of needle stick injuries and the morbidity and mortality pattern.  It will also identify gaps in the standard precaution practices among these HCWs and the results from the study will be used for the planning of health education intervention programme.  It will also provide reference material for the academic society as well as further research.

1.6 SCOPE OF THE STUDY

The study covers on knowledge, attitude and practice of standard precautions of infection control among health care workers in central hospital sapele

1.7 OPERATIONAL DEFINITION OF TERMS

Attitude:         Way of feeling, thinking or behaviour.  In this study, the same definition/assumption applies.

Blood-borne infections: Occupation Safety and Health Administration (OSHA) defines blood-borne infections as infections from pathogenic micro-organisms that are present in human blood and can cause diseases in humans.  These pathogens include, but not limited to HBV, and HIV.  In this study, the same definition applies.

Compliance:   Practice of obeying rules or request made by people in authority.  In this study, it is the extent, to which the HCWs obey or implement the definitions and recommendations of standard precaution laid down by the Centres for Disease Control (CDC).

Knowledge:    The Oxford Advanced Learner’s Dictionary (2001:658) defines knowledge as the information, understanding and skills that one gains through education or experience.  It also defines knowledge as the state of knowing about a particular fact or situation.  In this study, knowledge refers to the awareness of basic principles of standard precautions.

Practice:         Is the usual or expected way of doing something in a particular organization or situation.  In this study, practice refers to the extent that the HCWs implement or comply with recommended strategies of standard precautions.

Safety (sharps) container or box:  A puncture/liquid proof container designed to hold used sharps safety during collection, disposal and destruction.

Sharps injury:   An injury, which occurs when a sharp object penetrates the skin or mucous membranes.

Standard precautions: Care taken in advance to avoid a risk.  In this study, it is an approach to infection control to treat all human blood and certain human body fluids as if they were known to be infectious for HIV, HBV and other blood borne pathogens, by use of barrier equipment like hand gloves, face masks, gowns, boots.