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ASSESSMENT OF PREVALENCE OF HEALTH CARE WORKERS OCCUPATIONAL EXPOSURE TO HIV/AIDS AND POST EXPOSURE PROPHYLAXIS IN DILLA UNIVERSITY REFERAL HOSPITAL, SOUTHERN ETHIOPIA


Author: Kaleab Tesfaye Tegegne  (BSCPH, MPH) 


Department of Public Health, Hawassa College Of Health Science, Hawassa, Ethiopia 




 
Email   kaleabtesfaye35@gmail.com








Abstract
Background:- Occupational injuries are injuries like needle stick or cut with a sharp object or contact of mucous membrane or non-intact skin (e.g.., Exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue or other potentially infectious body fluid. Each day thousands of Health Care Workers (HCWs), Around the World, Suffers accidental occupational injuries. These injuries can result in a variety of serious and distressing consequence. This study will help the healthcare workers to know the severity and prevalence, to minimize its impact, to be safe in their working environment, and remain healthy.
Objective: To assess the prevalence of the health care workers occupational exposure to HIV and Post Exposure Prophylaxis in Dilla University Referral Hospital, Gedeo Zone, SNNPR, Ethiopia.
Methods and Materials: A descriptive cross-sectional institution based study was conducted from May 1-30 in Dilla University Referral Teaching Hospital. Data was collected using semi structured interviewer administered questionnaire from 272 participants by simple random sampling method. The collected data was entered, cleaned and analyzed using SPSS version 20. Descriptive statistics and chi-square test was employee to assess association among variables. Additionally the data was arranged and presented using different tables and graphs. P-value less than 0.05 were considered statistically significant.
Result: - From a total of 272 healthcare workers involved in this study, and revealed that occupational exposure to blood and body fluid were 76.1%, among the exposed healthcare professionals 11.4% use post-exposure prophylaxis. Majority of the exposed health profession were found to be nurses which accounts (36.1%). Out of 76.1% exposed to HIV risk, 39.7% sustained needle stick injury. nearly all (80.1) perceived that personal protective equipments can prevent from occupational risk to HIV infection.    
Conclusion and Recommendation: - this study showed that occupational exposure to HIV were common among healthcare workers and continue to occur presenting a very real of HIV infection, and the utilization of post-exposure prophylaxis among healthcare profession was low. Dilla university referral hospital should make available within their system a standardize written protocol for infection prevention and reporting unit for management of occupational exposure, and to increase the utilization of post-exposure prophylaxis. 
Key words      Occupational exposure, post exposure prophylaxis, Health care workers, HIV/AIDS 







Introduction 
Health care workers are exposed to different kinds of occupational hazards due to their day to day activities. The most common occupational exposure like body fluids is a potential risk of transmission of blood-borne infection like human immunodeficiency virus.
Occupational injuries like injuries needle stick or cut with sharp object or contact of mucous membrane or non-intact skin (e.g. exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue or other potentially infectious body fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid and amniotic fluid (12).
Each day Thousands of Health Care Workers (HCWs), Around the world, Suffer accidental occupational injuries during the course of their role of caring for patient who have the potential for exposure to infectious material like blood tissue, and specific body fluid and medical supplies, equipment or environmental surface contaminated with these substance. These injuries can result in a variety of serious and distressing consequences ranging from extreme anxiety to chronic illness and premature death for the individual involved (19, 22, and 16).
These all variety of serious and distressing consequence are linked with occupational exposure to blood and body fluid that are recognized as a mode of transmission of blood born pathogen such as hepatitis B virus, hepatitis C virus, and HIV. Exposure to HIV infection is probably the most serious and causes the highest level of anxiety among HCWs. (12, 16)
Although preventing exposure to blood and body fluid is the primary means of preventing occupationally acquired HIV infection, appropriate post exposure management is the important element of workplace safety. Moreover, there is often suboptimal adherence to standard precaution (21, 7, and 5).
HIV/AIDS is a serious public health problem costing the lives of many people including health care workers (1). It is probably the most serious and causes the highest level of anxiety amongst HCWs in many countries including Ethiopia. Ethiopia is one of the hardest hit countries by HIV/AIDS epidemic with the National HIV prevalence of 1.4% in Adult (19, 27, and 9). Each day Thousands of HCWs around the world suffers accidental occupational exposures to blood borne pathogens (12, 17). Health care worker can minimize their risk of occupation HIV infection by following the universal precaution. (19) Even though adherence to universal standard precautions supposed to optimal, exposure may occur in difficult situations. The prescription of antiretroviral therapy as a PEP following a significant potential exposure to HIV has a great value. (22)
Most case of Health Care Worker Sero-conversion occurs as a result of needle stick injuries. When one considers the circumstances that result in needle stick injuries, it is immediately obvious that adhering to the Standard Guideline for dealing with sharp object would result in a significant decrease in this type of accident.
Dilla University Referral Hospital is one of the hospital has large number of HIV positive case registered each year. According to the recent report of DURH with in 10 year of service 4849 HIV positive cases are registered. This may indicate there is significant occupational exposure to HIV unless otherwise the exact status and magnitude is identified. Thus, this study assessed  the health care workers occupational exposure to HIV and PEP in Dilla University Referral Hospital.

Subjects and Methods
Study area and period 
This study was conducted at Dilla University Referral Hospital, which is found in Dilla town, Gedeo zone, SNNPR, Ethiopia. DURH is established in 1977 E.C/1985 G.C as zonal Hospital in Gedeo Zone with former name of Dilla Hospital until June 11/2001 E.C that changed in to DURH.  It is located 360 Km from A.A (capital city of Ethiopia) and 90 Km from Hawassa (the capital city of SNNPRE). It provides curative and rehabilitative services for about 2 million catchment populations. At the same time of its establishment, about 154 staffs were present, of them 104 were health professionals and the remaining were supportive staffs. Now they have 5 wards, Medical, Surgical, OBY/GYN, pediatrics, Psychiatry. The Hospital services around million peoples from which 95% belong to Gedeo ethic group (Dilla municipality, 2007)
The study was conducted   from May 1-30, 2016
Study design
 Cross-sectional study design was conducted from May 1-30, 2016
 2.3 Study population
All health care workers working in Dilla University Referral Hospital
  Inclusion and Exclusion criteria
Inclusion Criteria 
All healthcare workers working in Dilla University referral hospital who have a potential to be exposed to human immunodeficiency virus in their day to day professional activities such as medical doctors, nurses, laboratory technologist/technicians, health officers, anesthesiologist psychiatry, and midwifes.
Exclusion criteria
Health care workers who were not voluntary, critically ill (to the extent of unable to read and write) during the data collection and HCWs who have communication problem will be exclude from this study
Sample size and Sampling technique 
The sample size was determined using single population proportion formula by assuming confidence level of 95 % (z=1.96) estimate of proportion towards Occupational exposure to HIV and PEP as P=0.5( b/c there is no similar study ) and marginal error as 5% (w=0.05).
              Ni=z2 x p x (1-p)             	
                           W2
Where ni = initial sample size 
           z = critical value of 95% confidence interval
           p = estimate proportion of population
           w = marginal error
ni = (1.92)2 x 0.5 x 1-05/(0.05) =384
Since the population Size (number of Health workers in DURH) less than 10000 which is 676 the formula will be
nf = ni / (1+ni/N)
Where ni = initial sample size
nf = final sample size
 N = total population
Nf = 384 / (1 + 384/676) =246
Contingency of non-respondents as 10% = 10 x 246/100 = 24.6
Sample size = Nf + contingency which is 246 + 24.6 = 272
A simple random sampling technique was used to select health care workers. This was done after collecting the sample frame from Dilla University Referral hospital. 
Data collection procedures
Data was collected by using semi structured interviewer administered questionnaire. The questionnaire has three parts; part one: socio-economic and demographic characteristics of healthcare workers, part two: organizational and behavioral factors, and part three: occupational exposure to human immunodeficiency virus infection. The questionnaire was prepared in  English later. To collect the data each respondent was invited to a private room for face-to-face interview with data collectors.
Data quality assurance	
All Group members of research were undertake data collection .Before the actual data collection, the questionnaire was pre tested in 5 %  of health care workers  in yirgalem referal hospital Based on the pretest, necessary modification were made on the questions and the data of the pretest was  excluded in the actual data analysis 
To keep the data as accurate as possible, the structured check list for data collection was used thoroughly throughout the process. Completeness of the data and possible errors was also be monitored carefully.
Data processing and analysis 
After the data was collected The frequency distribution of dependent and independent variables was organized using frequency table, graph, and chart. Chi-square was used to determine the associations between the selected variables. 5�C�-value also was calculated in order to identify possible statistically significant risk factors
Ethical considerations 
Ethical clearance was obtained from research and ethical committee (REC) of rift valley University, department of public health. Permission for conducting the study were obtained from Dilla university referral hospital. In addition written informed consent was obtained from the study participant before data collection and all data obtained from individual was kept confidentially by using codes instead of any personal identifier.
The positive finding obtained was given to the physician for possible treatment of patient with depression with HIV.
 Results
A total of 272 HCWs in DURH were selected for the study. The age of the respondent in this study ranges between 20 and 54, about 82.4% of them is between 26-35 years. When we look the respondents in terms of profession most of them are clinical nurse 38.2%, physician 28.3%, 9.6% are lab technicians, psychiatry (6.3%) and anesthesia�s (5.9%). In terms of sex (59.6%) are male and (40.4%) are females. About respondent marital status (58.5%) of them are married, and (26.5%) are unmarried.













Table 1:- Socio-demographic characteristics of healthcare workers occupational exposure to HIV and PEP usage DURH from May 1-30, 2008 E.C


VariableFrequencyPercent (%)Sex (n=272)  Male
                     Female162
11059.6
40.4Age (n=272)   18-25   
                         26-35
                        36-45
                        >4513
224
26
94.8
82.4
9.6
3.3Educational status(n=272)  Diploma      
                                              Bachelor Degree  
                                             Other higher level47
220
517.3
80.9
1.8Total work experience (n=272)  1-3yr
                                                       4-6yr
                                                       7-9yr185
69
1868.0
25.4
6.5






















Table 2:- Socio-demographic characteristics of healthcare workers occupational exposure to HIV and PEP usage DURH from May 1-30, 2008 E.C
VariableFrequencyPercent (%)Marital status(n=272)   Married
                                        Unmarried
                                        Widowed
                                        Separated 159
72
5    
36                                                    58.5
26.5
1.8
13.2Occupational status(n=272)  Nurse
                                                General practioner
                                                Lab technicians
                                                Midwife
                                                Anesthesia 
                                                Psychiatry 
                                                Health officer 
                                                Senior104
77
26
19
16
17
9
438.2
28.3
9.6
7.0
5.9
6.3
3.3
1.5Religion(n=128)    Protestant
                               Orthodox
                               Muslim
                               Others 62
43
21
248.4
33.6
16.4
1.6Monthly income(272) 1000-2400
                                     >2500                                                      37
23513.6
86.4





                   Organizational and Behavioral information
Out of the total study participant (37.1%) were reported that training and other seminar on universal infection prevention were given. 76.5% of the study participant reported that universal precaution and guideline about infection prevention had been posted in their institution, and followed the posted guideline. Majority (68.4) of the respondent was agree to availability of personal protective equipment. Out of the total respondent, nearly all (80.1) perceived that personal protective equipments can prevent from occupational risk to human immunodeficiency virus acquiring. 19.9% of the respondent perceived that personal protective equipment cannot prevent occupational risk as well as they failed to use this equipment. 82.7% of Healthcare workers who had extended working hours (>40hr/week). 74.3% of the respondent was a behavior that uses personal protective equipments. 44.1% of the respondent was negligence on the written guideline.
Table 3:- About Organizational and Behavioral information on healthcare workers occupational exposure to HIV and PEP usage DURH from May 1-30, 2008 E.C
Organizational and Behavioral informationFrequencyPercent (%)Hours worked per week     1. >40hr
                                            2. <40hr225
4782.7
17.3Read Universal guidelines/protocol                                                                        1. Ye 
 2. no
208
64
76.5
23.5Attained or experienced with any Training/seminars on infection prevention           1. yes
                       2. no	
101
171
37.1
62.9A behavior that Use of personal protective equipment           1. No
                                       2. Yes
70
202
25.7
74.3Negligence on written guidelines 1. yes
                                                2. no120
15244.1
55.9


Exposure information 
Among the total respondents (76.1%) of healthcare workers have exposed to HIV infection in there working place. Most of them (45.2%) were exposed during night duty and the remaining in day duty.
In this study 58.5% of healthcare workers respondents there hand is mostly exposed in needle stick and sharp object and 17.6% of the respondent exposed to their face, and at the time of injection 35.7%, and dressing 16.2% of healthcare workers was exposed.
Looking the respondent in terms of profession 36.1% are clinical nurse, 7.0% of midwifes, 19.1% of physicians, 6.3% lab technicians, anesthesiology 3.3%, psychiatry 0.7%, health officer 2.6% and senior 1.5% are mostly exposed to HIV  
HCWs that faced HIV exposure has taken immediately a treatment is about 16.2% and 11.4% of them get post exposure prophylaxis in the hospital. 57.7% of them use glove as protective equipments where as 16.9% use gown.
Table 4 :- Exposure information healthcare workers occupational exposure to HIV and PEP usage DURH from May 1-30, 2008 E.C
Exposure information Frequency Percent Exposed to HIV     1.Yes
                2.No207
6576.1
23.9Exposed to occur to     1. blood 
                            2. body fluid 141
6251.8
22.8Parental exposure       1. needle stick 
cut 108
5539.7
20.2At the time of          1. Phlebotomy
                        2. injection
                        3. dressing 
                        4. other1
97
44
700.3
35.7
16.2
25.7Personal protective equipments    1. Glove
gown 157
4657.7
16.9Treatment used    1,first aid 
                              2.post-exposure prophylaxis56
3120.6
11.4


Figure 1:- Relation between occupational status and exposure to HIV, DURH from May 1-30, 2008 E.C








Result of chi square  	
Table 5 :- Association between professional status and exposure         
VariablesCategories
�Do you exposed 
d.fChi-
SquareP-
ValueexposedNon exposedWhat is your professionNurse98621456.0000.000General practioner 5225Lab technician 179Midwife 190Anesthesia 97Psychiatry215Health officer 72Senior13













Table 6 :- Association between personal protective equipment users and exposure         
VariablesCategories
�Personal Protective equipment 
DfChi-
SquareP-
Value

Do you have a behavior that Use of personal protective equipmentUsers Non user Nurse 8810140.2050.000General practioner 448Lab technician 710Midwife 109Anesthesia 90Psychiatry 20Health officer 70Senior 31






                                                        



Discussion and Conclusion 
In this study female workers were less likely to be exposed than males. This finding was consistent to the study finding done in northern Uganda.
The result of this study shows that (76.1%) of the healthcare workers who participate in the study had experienced risky occupational exposure during their professional activity. This found to be higher than the finding of other study conducted in London teaching hospital 76% (31), united state of America emergency medical hospital (56.1%) (32), Kenya rift valley provincial hospital (51%) (33), and Jimma zone, oromia region southwest Ethiopia. This difference might be due to small sample size of the study, variation in the study area, and economic development variation of nation, but this finding was less than the study done in Serbia (98.4).
Regarding the mode of exposure to human immunodeficiency virus this study reveals that (39.7%) of the healthcare workers experienced needle stick injury, and (22.8%) of them experienced contact with potentially infectious body fluids. This result was higher than the study conducted in northern Uganda (38) which was 27% of health care workers experienced needle stick injury. But the finding was less than the study done in Serbia (35) which was 89% had needle stick injury, 59% skin contact with potential infections blood and fluids and finding of the study done Jimma zone, oromia region, southwest Ethiopia (34), which was 105(60.3%) sustained needle break/cut by sharps, 77(44.3%) to blood, and 68(39.1%) exposed to patients body fluids. Moreover, it was higher than the result in Kenya (33) which was 19% had needle stick injury, 25% had contact with blood and other body fluid in the past one year and results of the study conducted in Ethiopia, Tigray region (1) which was 17.2% had needle stick injury, 56.3% contact with blood and body fluids in the past 12 months this discrepancies� due to difference in baground of healthcare workers, difference in sample size and the concern of employing organization. 
Likewise, in this study most of the respondents were exposed to risky condition, this finding was similar with finding of the study done in northern Uganda (38).
The result of this study showed that 80.1% of the respondent perceived that they were at risk of exposure to human immunodeficiency virus infection due to their profession. This finding was almost similar to the result of health care worker in Ghana 79% (36). This discrepancy might be due to the effect of globalization, global burden of HIV/AIDS, and internet technology that was helpful to update themselves. 
This study shows that majority 67.8% 0f health care workers identified the commonest occupational risk to human immunodeficiency virus infection. This finding was completely contradictory to the report from south Africa (37) which was 83% of the health care workers did not identified. This discrepancy might be due to lack of training, variation in organizational safety policies and procedures, and less exposure to the occupational hazards.
76.5% the study participant were informed about the universal precaution and guidelines about infection prevention. In contrary to this finding, the study conducted in Serbia (35) discovered that 80% of the healthcare workers had not been informed. This might be due to variation in training to healthcare workers on universal precaution to decrease the rate of occupational exposure. 
In this study 74.3% of the respondent was used personal protective equipment, only 23.9% of them were protected from injury. This was almost similar to Serbian healthcare workers that only 17% had been protected this does not mean that using personal protective equipment can expose healthcare workers to injury but it is the fail to use them at appropriate time and condition and problem in the quality of the personal protective equipment .  
Among the exposed health care workers about (16.2%) taken treatment immediately and 11.4 of them take PEP. Most of HCWs use gloves to personal protective from infection. 
This study was likely to be the actual reflection of the occupational exposure to human immunodeficiency virus infection of healthcare workers in Dilla referral hospital.
Even though most of healthcare workers were informed as well as being familiar to universal standard and guidelines, this study reveals that majority (76.1%) of healthcare worker had experience the risky occupational exposure during their profession. A number of determinant factor which were potential acquisition of occupational hazard were identified. The statistically significant determinant factor were professional status and personal protective equipment usage.
Healthcare workers can minimize the risk of occupational HIV infection by universal precaution using the prescription of antiretroviral therapy as Post exposure prophylaxis following significant potential exposure to HIV. In This study 16.4% of exposed healthcare get the treatment.

Acknowledgment
I would like to express my gratitude to all data collectors for their unreserved help and facilitation. 
My heartfelt thanks also goes to Rift valley University for giving me this chance to do this research work.  Finally, I am greatly indebted to my wife Netsanet Desalegne she gave me courage deserves my utmost gratitude for helping me to do this Research work
 
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