Preventing Hepatitis C in Nurses


 
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Hepatitis C

     Hepatitis C refers to a blood borne viral disease caused by a hepatotropic virus called HCV or Hepatitis C virus. HCV infection causes inflammation of the liver and liver cirrhosis at later stages. HCV typically spreads by blood transmission. Nurses are occupationally exposed to HCV infection by accidental exposure to infected blood by needles and sharps. Professional precautions reduce the risk of exposure to HCV in nurses.

Occupational Prevalence

     Needlestick and sharps injuries are the most common method of transmitting blood-borne pathogens between patients and the nurses. A research study to examine nurse’s risk of exposure to blood resulting from injuries with needles and sharps in 40 medical units in 20 hospitals in cities with a high incidence of blood borne infections in US has shown that the rate of injuries to staff nurses was 0.8 per nurse in a year (Aiken et.al, 1997). Recapping needles and temporary work assignments have been identified as the major factors associated with increased injuries. The study has also suggested that reducing the frequency with which nurses recap needles and increasing the precautions lower the chances of nurses being injured. A questionnaire survey in a total of 8645 health care workers to determine the yearly incidence and causes of sharps injuries has shown that the most frequently reported circumstances of needlestick injuries were recapping of needles and those of sharps injuries were opening of ampoules or vials. About 52% of the needle injuries have been found to be caused by ordinary syringe needles, usually in the patient units (Guo et.al, 1999). The risk of HCV transmission after percutaneous exposure increases with a larger volume of blood, and, a higher titer of HCV in the source patient's blood (Yazdanpanah et.al, 2006). The risk of acquiring HCV after percutaneous exposure seems to be higher in deep injury and injury with a blood-filled needle (De Carli et.al, 2003). A study to define the risk factors of blood contamination and injury to operating room nurses has shown at least fifty percent of the operations resulted in an adverse event where at least one person was contaminated with patient blood (Quebbeman et.al, 1991).
     Seroprevalence rates of HCV antigens in healthcare personnel have been shown to match with that of those detected in local blood donors in a one year period in a sample study suggesting occupational exposure of HCV (Thomas et.al, 1993). A recent study to assess the occupational exposure to blood borne viruses during a one year period has shown a total of 236 incidents of which 83% have been related to sharps, 32% clearly avoidable, and 7% involving an infected source patient (Gyawali et.al, 1998). A recent study to estimate the annual number of cases of hepatitis C virus transmission from infected patients to uninfected nurses due to percutaneous injury during invasive procedures has shown that during a single invasive procedure, the estimated probability of hepatitis C virus transmission from an infected patient to an uninfected nurse ranged from 2.98x10(-6) % to 2.98x10(-5)% with an estimated annual cumulative risk of occupational infection range from 0.0054% to 0.054% taking us to a strong conclusion that between 16 and 167 nurses out of a total 300000 are estimated to acquire occupationally-related hepatitis C virus infection (Yazdanpanah et.al,1999).Published reports have confirmed that even a splash of blood from patients who are HCV positive into the face or eyes poses an occupational  risk for health care workers (Hosoglu et.al,2004).
Prevention
   The best approach to prevent occupational bloodborne HCV infection is the prevention of blood exposures and the development of improved engineering controls, work practices, and personal protective equipment (Cardo and Bell, 1997). The effectiveness of the hands-free technique, whereby a tray or other means are used to eliminate simultaneous handling of sharp instruments to avoid percutaneous injuries, contaminations, and glove tears arising from handling sharp instruments has been evaluated recently in reducing operating theatre injuries (Stringer et.al, 2002).Although educational programs, awareness campaigns and policy implementation do have an impact on the level of knowledge of these risks and compliance with universal precautions, a recent study based on a research questionnaire has demonstrated that despite a comprehensive education program for nurses and training for medical staff, knowledge of inoculation injuries and associated issues remained inadequate .This has given rise to a need to evaluate the efficacy of such programs and planning alternative strategies (Trim et.al,2003). It is also important to emphasize the principles of infection-control training and reporting of all needlestick and sharps throughout undergraduate nursing education (Smith et.al, 2005).A recent study has indicated that a structured training in prevention of occupational exposure to blood borne pathogens would improve the knowledge and behavior reducing the number of needle stick/sharp injuries among nurses. The study has also shown that training in the techniques of Universal Precautions could play a role in reducing the risk for occupational exposure to HCV and other pathogens (Wang et.al, 2003). A comparative user evaluation of three needle-protective devices has been done recently (Adams and Elliot, 2003) focusing on safety, utility and compatibility of such devises. Results have shown that nurses readily adapt to use the new safety devices and a training program shall ensure effective implementation. It has been also demonstrated that such evaluations identify the right methodologies for the attachment of the safety needles. New safety devises that automatically retract the needle once the injection is complete and that are simple to use requiring little training are available in the health care sector today (Jeanes,1999). The most recent preventive strategy has been the needle-protective devices that have been developed from conventional products with a safety mechanism that, when activated, covers the needle tip and thus preventing needlestick injuries and potential seroconversion to bloodborne pathogens (Trim, 2004).These safety devices decrease the rate of Needle stick injuries (NSI). A cross-sectional study of Maryland State correctional health care workers to evaluate compliance with work practices designed to minimize exposure to blood and body fluids and to identify correlates of compliance with universal precautions to determine the relationship between compliance and exposures has shown that compliance was positively associated with several work-related variables and inversely related to blood and body fluid exposures taking us to the conclusion that infection-control interventional strategies specifically tailored to these health care workers may therefore be most effective in reducing the risk of bloodborne exposure (Gershon.et.al,1999). Staffing and organizational climate seem to influence hospital nurses' likelihood of sustaining needlestick injuries (Clarke et.al, 2002).Employers should have in place a system that includes written protocols for prompt reporting, evaluation, counselling, treatment, and follow-up of occupational exposures that may place a worker at risk of blood-borne pathogen infection (Beltrami et.al,2000). The pilot project launched by World Health Organization and the International Council of Nurses in 2003 in three countries to protect healthcare workers from needlestick injuries recommends eliminating unnecessary injections, implementing Universal Precautions, eliminating needle recapping and disposing of the sharp into a sharps container immediately after use, use of safer devices such as needles that sheath or retract after use, provision and use of personal protective equipment, and training workers in the risks and prevention of transmission to prevent infections from occupational exposure(Wilburn and eijkemans,2004).
 
Conclusion

     Needlestick injury (NSI) is an important although rare cause of the transmission of blood-borne viruses like HCV to nurses. Many NSIs are avoidable by means of universal precautions and careful sharps disposal. The utilization of safety devices that are easy to use and compliance with work practices reduce the transmission of such blood borne pathogens to nurses.

Reference

• Annette Jeanes (1999). Zero-Stik® Safety Syringe: an automatic safety syringe. British Journal of Nursing, 8(8):530 – 535.
• B Stringer, C Infante-Rivard, J A Hanley (2002). Effectiveness of the hands-free technique in reducing operating theatre injuries. Occupational and Environmental Medicine.59:703-707.
• Cardo DM, Bell DM (1997). Bloodborne pathogen transmission in health care workers. Risks and prevention strategies. Infect Dis Clin North Am. 11(2):331-46.
• D. L. Thomas, S. H. Factor, G. D. Kelen, A. S. Washington, E. Taylor Jr and T. C. Quinn(1993). Viral hepatitis in health care personnel at The Johns Hopkins Hospital. The seroprevalence of and risk factors for hepatitis B virus and hepatitis C virus infection. Archives of Internal Medicine 153(14).
• De Carli G, Puro V, Ippolito G; Studio Italiano Rischio Occupazionale da HIV Group(2003). Risk of hepatitis C virus transmission following percutaneous exposure in healthcare workers. Infection. 2:22-7.
• Debra Adams, TSJ Elliot (2003). A comparative user evaluation of three needle-protective devices. British Journal of Nursing, 12(8); 470 – 474.
• Derek R. Smith and Peter A. Leggat (2005). Needlestick and sharps injuries among nursing students. Journal of Advanced Nursing.51 (5); 449-455.
• Gershon, Robyn , Karkashian, Christine , Vlahov, David , Kummer, Leslie ; Kasting, Christine ; Green-McKenzie, Judith,; Escamilla-Cejudo, Jose A. ; Kendig, Newton ; Swetz, Anthony ; Martin, Linda (1999). Compliance with Universal Precautions in Correctional Health Care Facilities. Journal of Occupational & Environmental Medicine. 41(3):181-189.
• Hosoglu S, Celen MK, Akalin S, Geyik MF, Soyoral Y, Kara IH(2003). Transmission of hepatitis C by blood splash into conjunctiva in a nurse. Am J Infect Control. 31(8):502-4.
• Joanna C Trim, Debra Adams, TSJ Elliott (2003). Healthcare workers' knowledge of inoculation injuries and glove use. British Journal of Nursing, 12(4); 215 – 221.
• Joanna Trim (2004). A review of needle-protective devices to prevent sharps injuries. British Journal of Nursing. 13(3); 144 – 153.
• L H Aiken, D M Sloane, and J L Klocinski (1997). Hospital nurses' occupational exposure to blood: prospective, retrospective, and institutional reports. Am J Public Health. 87(1): 103–107.
• M. F. Ozsoy, O, O. Oncul, S. Cavuslu, A. Erdemoglu, G. Emekdas and A. Pahsa (2003). Seroprevalence of hepatitis B and C among health care workers in Turkey. Journal of Viral Hepatitis. 10(2); 150-156.
• P Gyawali, PS Rice and AJ Tilzey (1998). Exposure to blood borne viruses and the hepatitis B vaccination status among healthcare workers in inner London, Occupational and Environmental Medicine, 55; 570-572.
• Quebbeman, G L Telford, S Hubbard, K Wadsworth, B Hardman, H Goodman, and M S Gottlieb (1991). Risk of blood contamination and injury to operating room personnel. Ann Surg. 214(5): 614–620.
• Sean P. Clarke, Douglas M. Sloane, and Linda H. Aiken (2002). Effects of Hospital Staffing and Organizational Climate on Needlestick Injuries to Nurses. American Journal of Public Health. 92(7); 1115-1119.
• V Puro, N Petrosillo, G Ippolito, M S Aloisi, E Boumis, and L Ravà (1995). Occupational hepatitis C virus infection in Italian health care workers. Italian Study Group on Occupational Risk of Bloodborne Infections. Am J Public Health; 85(9): 1272–1275.
• Wilburn SQ, Eijkemans G (2004). Preventing needlestick injuries among healthcare workers: a WHO-ICN collaboration. Int J Occup Environ Health. 10(4):451-6.
• Y. L. Guo, J. Shiao, Y.-C. Chuang and K.-Y. Huang (1999). Needlestick and sharps injuries among health-care workers in Taiwan. Epidemiology and Infection , 122: 259-265.
• Yazdanpanah Y, Boëlle PY, Carrat F, Guiguet M, Abiteboul D, Valleron AJ(1999). Risk of hepatitis C virus transmission to surgeons and nurses from infected patients: model-based estimates in France. J Hepatol. 30(5):765-9.
• Yazdanpanah Y, De Carli G, Migueres B, Lot F, Campins M, Colombo C, Thomas T, Deuffic-Burban S, Prevot MH, Domart M, Tarantola A, Abiteboul D, Deny P, Pol S, Desenclos JC, Puro V, Bouvet E(2006). Risk factors for hepatitis C virus transmission to Health Care Workers after occupational exposure: a European case-control study. Rev Epidemiol Sante Publique.54 (1):23-31.

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