OCCUPATIONAL HAZARD: NEEDLE STICK INJURY AMONG HEALTH CARE WORKERS

Received: 03 July 2018 Final Accepted: 05 August 2018 Published: September 2018 Many infectious diseases can be transmitted through injuries. Of most important are virus infections like human immunodeficiency (HIV), hepatitis C (HCV) and hepatitis B (HBV). Health workers are nurses the most affected . Needle stick injury is considered highly under reported. The world health organization and the International Council of Nurses introduced a pilot Project to decrease needle stick injury among health workers. Policies and methods of prevention of needle stick injury were distributed worldwide. Although WHO needle stick injury policies are recognized in Saudi Arabia, they are not implemented properly. This assignment will review the health issue of injuries and infectious diseases produced by needle stick injuries internationally and in Saudi Arabia (NGH).

Many infectious diseases can be transmitted through injuries. Of most important are virus infections like human immunodeficiency (HIV), hepatitis C (HCV) and hepatitis B (HBV). Health workers are nurses the most affected . Needle stick injury is considered highly under reported. The world health organization and the International Council of Nurses introduced a pilot Project to decrease needle stick injury among health workers. Policies and methods of prevention of needle stick injury were distributed worldwide. Although WHO needle stick injury policies are recognized in Saudi Arabia, they are not implemented properly. This assignment will review the health issue of injuries and infectious diseases produced by needle stick injuries internationally and in Saudi Arabia (NGH).

…………………………………………………………………………………………………….... Introduction:-
Needle stick injury is a very important issue to discuss as it is a major hazard to patients and health workers. Many infectious diseases can be transmitted through injuries. Of most important are virus infections like human immunodeficiency (HIV), hepatitis C (HCV) and hepatitis B (HBV) iii . Health workers are nurses the most affected 2iiiiv . Needle stick injury is considered highly under reported 2 . The world health organization and the International Council of Nurses introduced a pilot Project to decrease needle stick injury among health workers. Policies and methods of prevention of needle stick injury were distributed worldwide. 1 Although WHO needle stick injury policies are recognized in Saudi Arabia, they are not implemented properly.
Needle stick injury can cause serious infectious diseases by transmission of blood born pathogen from patients to the health workers and vice versa 15 . It represents eighty percent of contact causes between the blood borne pathogen and the health workers. 2 The most serious of the twenty blood borne pathogens that can affect the health workers during their daily contact with infected patients are hepatitis C (HCV) and human Immunodeficiency virus (HIV), and hepatitis B virus (HBV) 2 which is the only one that has immunization. 1 Generalized vaccination started in the beginning of the 1980s v . The percentage of contamination with hepatitis C is from 0 to 3% and increase to 10% when dealing with hepatitis C positive patient 5 .Recently the evaluation of the risk of hepatitis C easier by using serum marker detection technique 5 . There are other infectious diseases that can be transmitted during needle stick injury as syphilis, malaria, herpes, Rocky Mountain spotted fever and varicella zoster 12 .

Aim:-
This assignment will review the health issue of injuries and infectious diseases produced by needle stick injuries internationally and in Saudi Arabia (NGH).

Results:-
The numbers of health workers are thirty five million all over the world, which represent twelve percent of the working community. 1 Numerous studies have shown that health workers that are exposed to dangerous infectious diseases by needle stick injury are of considerable percentages, hence the WHO created policies about its prevention and management. Worldwide percentage of hepatitis B and C is 40% and 2.5% for HIV in health care workers due to needle stick injury which is about two million injuries per year 1 . This number is considered low as many cases of needle stick injures not reported and surveyed (40%-75% are underreporting) 1 . The center of disease control and prevention (CDC) reports that the number of American health workers that get needle stick injury range between 600,000 and one million annually 2 . In a study done in United Kingdom a 38% of 279 samples had needle stick injuries in the last year and about 74% during their careers 4 . Another Eight studies in United Kingdom showed 4% of needle injuries in ten thousands health care workers. In United Kingdom the number of injuries is still inaccurate due to underreporting vi . Another study done in Baylor College of medicine between December 2002 and December 2005 showed 98 injuries mostly in the operating room by hollow bore needles vii . One study done in a teaching hospital in 1990, ninety nine injuries occurred in 1382 surgical procedures viii . In Goa (India) a study showed 34.8% needle stick injuries in one year ix . In a Malaysian university a study was done to measure the incidence of needle stick injury between a sample of 417 medical students and the result was 14.1% x . Of 114 sample in operation room 58.8% reported more than four needle stick injury per year , 36.8% reported one to three needle stick injury per year , and only 4.4% reported no needle stick injury in last five year , among this studied group about 31% got infected with hepatitis B and C xi . The centers for Disease Control and Prevention (CDC) in United States of America reported 5100 cases of hepatitis B infection due to needle stick injury during health workers daily works and 54 cases of HIV resulting from exposure to infected blood 2 .
Studies have showed the common reasons and prevention methods of needle stick injury: In 1984 was the first report HIV infection from occupational exposure to health care worker 1 . 83% of needle stick injuries can be prevented by the use of safety features like needles or needleless system 2 . 64% 3 of nurses recap the needles after injection which increase the probability of getting injured, hence the policy of preventing recapping practice by education and using disposal puncture resistant containers to place sharp needles 34xii . The use of needles protective device rather than the usual needles is safe by covering the needle tip after activation. xiii In United Kingdom: doctors and nurses are the most affected by needle stick injuries mainly from hollow bore needles, so education and training programs will be beneficial in addition to substitution of conventional needle with needle protective device 6 . United States of America recommends training, evaluation and changes in equipment to prevent needle stick injuries 78 . 16% of outer gloves and 6% of inner gloves perforation occur due to needle injuries while no perforation with protective end needles xiv . The use of self-sheathing intravenous cannula with Safelon device (new protective device) will reduce the needle stick injury hazard xv . Another study recommends the use of safeguard cannula to reduce the risk of needle stick injury xvi . Centers for Disease Control recommend avoiding recapping the needles to prevent needle stick injury xvii . A university hospital showed 326 injuries over ten months period, one third of these injuries due to recapping the needle. They recommended a new device for capping contaminated needle xviii . New York recommends the use of sharp disposal system to prevent needle stick injury xix .The Immunization Practice Advisory Committee (USA) recommends injection of polyvalent gamma globulins to the health workers with needle injury from hepatitis C infected patient, and early treatment by interferon 5 . Pakistan recommends hepatitis B vaccination before working in the operation rooms 11 . In Malaysia: there is an adverse relation between the degree of practice and the risk of needle stick injuries among medical students 10 . Another study recommends that using of needle stick prevention devices are not enough in preventing 100% injuries. Education on how to use these devices is more important xx . In the united states of America education of medical students will be beneficial in reducing the risk of needle stick injury xxi .

Statistic of Needle Stick Injury in Kingdom of Saudi Arabia:
During my search only one published article that has been reported in Saudi Arabia regarding needle stick injury. The study showed that the Saudi heath workers that getting hepatitis B and C from needle stick injury are of considerable percentages which are 8-10% for HBV and 2-6% for HCV. Education programs were recommended xxii . All the hospitals have their own statistics which is considered undisclosed information and only authorized persons are allowed to access.

Discussion:-
Based on the literatures I can summarize that common reasons of needle stick injury are: the wrong way of recapping the needles 3 , the way of disposing sharp needles 34xxiii , perforated gloves xxiv and the degree of practice 10 . Also as literatures recommended the prevention control measures summarize as using needleless system 2 , preventing recapping xxvxxvi practice by education 6xxviixxviii and using disposal puncture resistant containers to place sharp needles 34xxixxxx , The use of needles protective device 6xxxi , use of safeguard cannula xxxiixxxiii , injection of polyvalent gamma globulins to the health workers with needle injury from hepatitis C infected patient, and early treatment by interferon 5 , hepatitis B vaccination before working in the operation rooms 11 .
From my view here in Saudi Arabia specifically in the hospital where I work (NGH) the most common reasons of needle stick injury are: The health's workers mainly nurse do not wear gloves when giving patients injection. Gloves that are available are of poor quality that tears easily, I noticed that from my daily clinical work (personnel experience). The policy here concentrate on recapping the needle technique (even if it is important in preventing injury) , forgetting the importance of implementation of new devices as retractor or blunt end needles which are already implemented in north America and Europe. Lack of knowledge of the health workers regarding the effect of needle injury on health and its hazard. And this result in not reporting of the injury or follow up the cases in employee or ER clinics, because job security. Lack of training programs.Over loading the health workers with heavy duty (especially nurses). Resulting in loss of concentration and increase the incidence of injuries.
Even though after the presence of all of these risk factors that can result in needle stick injury only one published article was found during my search. Because this is very important issue that effect the workers' health I suggested some guidelines and recommendations that listed below.

Conclusions and recommendations:-
The implementation of WHO needle stick injury guidelines is a big challenge in my country (KSA). Lack of resources, training programs and organization are major obstacles. I recommended that guidelines need to be reevaluated and tailored to the country with strict implementation policies. From all of studies and facts presented above, policies and guidelines to prevent needle stick injury became a necessity. Implementation of the universal precautions started from the first reported case of HIV infection in health workers. The guidelines consist of two parts: Standard precautions (control measures) xxxiv :"American nurses association" 1. Elimination of hazards: using another route of administration as tablet, inhaler and patches instead of injection. 2. Engineering controls: using of technologist devices as retractor needle or the one that be comes dull after use (available in North America and Europe). 3. Administrative controls: policies and training programs. 4. Work practice controls: avoid recapping the needles and emptying the containers of sharp needle regularly and practicing how to hold and dispose sharp objects. 5. Personal protective equipment (PPE): these are the barriers that protect the worker. 6. Post exposure measures 1 Any health worker that gets needle stick injury should follow the following steps: 1. Wash the area of injury with water and soap. 2. Visit the clinic within one hour of injury to take post exposure prophylaxis (PEP) recommended for HBV and HIV but not for HCV. 3. Follow up for evaluation and possible treatment. In my view the internal NGH policy should be reevaluated to fill the gap of the current one. Committees of infection control, finance, education, administrative, and nurses should meet to set the agenda, define the problems, set the objectives, priorities the problems then provide policies especially in developing training programs which are 100 more important than purchasing new technology devices. My job as a health worker is to convince each committee with the problems of our policy and how to solve them, as follows: Financial committee: make the cost analysis to provide the hospital with gloves with high quality, employing well qualified adequate number of nurses to avoid over loading and buying new technology needles.
Education committee: organize training programs to educate the health workers and improve their knowledge about the hazards of getting injury first by better practicing and second by reporting after injury.
Nursing committee: monitoring and evaluation of nurses at work when dealing with injections in regards to wearing gloves and other precautions.
Administrative committee: yearly evaluation of the health workers. If not following the needle stick policy regarding reporting and follow up to the employee clinic after injury implement, a strict policy as delayed promotion will be in effect.
Infection control committee: organize, monitor and evaluate the work of other committees in addition to statistics and surveillance.
I believe that having a strict policy regarding the employee that does not follow up after injury, will be effective in preventing the infection from developing into a chronic stage, and protecting the patients. The last step is evaluation which be regular like every three years to assure that the guidelines are followed, is effective and to continuously update it.
Is a strict policy as delaying the promotions of health workers who do not follow the needle stick guidelines would be beneficial in reducing the hazards of injury here in NGHA This need further studies.