Occupational Exposure to Blood and Body Fluids Among Nurses in Public Hospitals of the Emergency Department and Intensive Care Unit, Addis Ababa, Ethiopia: Cross-sectional Study

Background: Exposure to blood and body uids causes major health hazards and serious concerns among health care professionals in their work settings. The prevalence of exposure to blood and body uids is increasing, particularly for nurses who work in the emergency unit. The study aimed to assess the prevalence of occupational exposure to blood and body uids, and its associated factors among nurses in public hospitals in the emergency department and intensive care unit, in Addis Ababa, Ethiopia. Methods: A cross-sectional study was conducted from March 18, 2021, to April 20, 2021. Simple random sampling was used to select the studies in public hospitals. Semi-structured self-administer questioners were used to collect the data and analysis using SPSS version 25. Logistic regression model was used to identify the factors associated with exposure to blood and body uids. Results: About 198 (0.76 with 95% CI: 0.71, 0.81) had been exposed to blood and body uids in their professional lifetime, and 167 (0.64 with 95% CI: 0.58, 0.70) were exposed to blood and body uids in the last 12 months. Being male (AOR = 2.88, 95% CI: 1.35, 6.12), a lack of access to handwashing facilities (AOR = 5.02, 95% CI: 3.73, 14.51), not wearing a face shield and apron (AOR = 6.21, 95% CI: 2.39, 9.55), and a lack of personal protective equipment (AOR = 5.53, 95% CI: 1.87, 10.38) were all found to be signicantly associated with exposure to blood and body uids. Conclusion: As a result of the lack of personal protective equipment, the majority of nurses did not consistently wear an apron and face shield while providing patient care, putting them at a higher risk of acquiring blood-borne pathogens.


Introduction
In every clinical setting, health care professionals often face numerous occupational hazards, such as exposures to human blood and body uids (BBFs), because of working at health facilities whose activities involve direct contact with their patients (1).
Nurses, as the staff group, particularly in the emergency department (ED) and intensive care unit (ICU), are always in contact with their patients to provide immediate care. It is also overcrowded and tied-down work, so they are at the highest risk of such exposure (1,2).
Recent research shows that exposure to BBFs is mostly caused by needle stick injuries (42.6%), and developing countries such as, Ethiopia, Nigeria, Tanzania, Kenia and Tunisia account for over 90% of these events (2). This preventable exposure affects approximately 1000 infections a year with exposure to 20 different blood-borne pathogens (3).
The consequences of exposure to BBFs comprise the transmission of various types of pathogens like hepatitis B virus (HBV), hepatitis C virus (HCV), human immune de ciency virus (HIV), and other bloodborne pathogens that result in systemic and localized site infection (4,5). Furthermore, nerve damage from a needle stick may occur, as well as the possibility of the needle breaking off into the skin.
Additionally, signi cant anxiety and depression may occur following an event related to fear of infection (6).
Exposure to blood and body uids is a serious concern among health care professionals in their work settings. The prevalence is increasing, particularly for nurses in the emergency unit (7)(8)(9). For example, a study conducted in the United States of America (USA) revealed that the prevalence of exposure to BBFs among nurses was (31.3%) (10). In a similar study done in Iran among health care workers (HCWs), the highest rates of exposure were among nurses with less than 3 years of experience (74.6%) who were young and recently employed. Of those nurses, 3% of them had got an infection from known HIV positive, 13% of nurses were known hepatitis B serum antigen (HBs Ag-positive) and 2% were HCV positive patients, but the study was not speci c to nurses, and nurses in ICU were excluded (11).
The frequency and an annual rate of exposure to BBFs among nurses are higher in the emergency department. For instance, according to the research conducted by Gourni P et al. reported that (39.5%) and 27% of nurses were exposed to BBFs respectively (7) but, the study didn't include nurses working in ICU. Based on the above study, 2.9% of nurses had obtained diseases related to their exposure (7,12).
A systematic review and meta-analysis conducted in 2017 from 21 African countries disclosed that from 65.5% of HCWs were exposed to BBFs, and nurses accounted for (67.2%) (13). Overcrowding, a lower ratio of HCWs to patients, limited awareness of the risks associated with exposure to BBFs, failure to implement standard precautions, inadequate supplies of basic safety equipment, lack of training, and inadequate supply of PPE are factors that increase the burden (13,14).
Currently, in Ethiopia, a lack of reports exists to quantify the pooled prevalence of exposures to BBFs among health care workers (HCWs). Moreover, the epidemiology of blood-borne infections in Ethiopia has been on the rise and dynamically changing over the past decades, along with poor compliance with standard precautions among HCWs (15).
There is a limitation of a study conducted on occupational exposure to BBFs among nurses rather than the study available on overall HCWs in Ethiopia. And also, there is no published study yet, particularly at the ED and ICU regarding occupational exposure to BBFs. Therefore, this study was aimed at determining occupational exposure to BBFs and its associated factors among nurses in Addis Ababa city in the public hospitals of the ED and ICU. This study also serves to provide new knowledge regarding occupational exposure to BBFs among nurses in emergency departments and intensive care units.

Study design and area
A cross-sectional study was conducted among nurses in public hospitals in Addis Ababa city in the emergency department and intensive care unit from March 18, 2021, to April 20, 2021. Addis Ababa is the capital city of Ethiopia, which is located in the central part of Ethiopia. Also, it is the seat of the African Union and the United Nation's World Economic Commission for Africa. In Addis Ababa city, there are more than 53 hospitals, thirteen (13) are public hospitals and more than 40 are private hospitals (16). The study population contains all nurses who were working in ve randomly selected public hospitals in Addis Ababa city in the ED and ICU. The lottery method of simple random sampling technique was used to select ve public hospitals from thirteen public hospitals. All nurses in randomly selected public hospitals who were involved in patient care in the ED and ICU were enrolled in this study.
Sample size, sampling procedure and technique The actual sample size for the study was determined using a single population proportion formula {n = [(zα/2) 2 p(1-p)]/d 2 }, n = sample size, zα/2 = 95% con dence level, P = the proportion of exposure to BBFs in the previous study (41.2%) (17), d = margin of error (0.05). By considering 10% of non-response rate, the nal sample size of the study was 266. The lottery method of simple random sampling technique was used to select ve public hospitals. The sample size for each hospital was proportionally allocated based on the number of nurses in each ED and ICU. Individuals who ful lled the inclusion criteria were selected using systematic random sampling at two intervals from their list.

Data collection tools
The English version of the self-administer questionnaire was used to collect the data. The tools were divided into four sections: participant sociodemographic (7 items), participant behavioral characteristics (5 items), institutional factors (4 items), and exposure to blood and body uids (12 items) obtained from a modi ed version of the study conducted at Tikur Anbessa specialized hospital (17).

Data quality control
Training was given to data collectors, and appropriate supervision was done. A pre-test was conducted two weeks before actual data collection using 5 % of the sample size. The internal consistency of instruments in the pretest data (questioners) was reliable (Cronbach's alpha = 0.766). After the pretest, some explanations were modi ed, re-edited, and arranged. The collected data was checked for completeness and some of unclear statements were corrected.

Data processing and analysis
Data was cleaned up, checked the completeness of questioners, and given code, and entered into EPI-Data version v4.6.0.4. Then it was exported to SPSS version 25 for further analysis. The result was presented in narration, graphs, and tabulations. Binary logistic regression analysis model was used to identify factors that determine exposure to BBFs. The model tness of the variable was tested using Hosmer's and Lemons show test. All independent variables with a p-value of < 0.25 from bivariate logistic regression analysis were tted into a multivariable logistic regression analysis to control the possible effect of confounders. Finally, the variables which were independently associated with exposure to BBFs were identi ed on OR, with 95% CI and p-value < 0.05.

Results
Sociodemographic characteristics of study participants (Table1) The majority of respondents (88.5%) had used a glove, gown, and face mask consistently during patient care.  Almost (76.2%) nurses were exposed to BBFs in their professional lives. Of those, nearly (64.2%) were exposed to BBFs in the last 12 months. Among (76.2%) of the exposed nurses, the majority (79.8%) of them were exposed more than once a year. About (73.2%) of the study participants identi ed the status of the source patients, and from those tested, nearly (19.3%), (8.2%), and (6.9%) of them were positive for HIV, HBV, and HCV respectively. Factors associated with occupational exposure to blood and body uids (Table5) The model tness of the variable using the Hosmer and Lemeshow test showed that the dependent variable was 99.6% explained by the independent variables. In multivariable logistic regression analysis, gender, wearing of face shield and apron, accessibility of handwashing facilities, and availability of PPE in their hospital were found to be signi cantly associated with occupational exposure to BBFs at p-value < 0.05. Males had 2.8 times the odds of being exposed to BBFs than females (AOR = 2.88, 95% CI: 1.35, 6.12). Nurses who complained about the lack of handwashing facilities in their hospital had 5 times more odds of exposure to BBFs compared to those who had not complained (AOR = 5.02, 95% CI: 3.73, 14.51). Nurses who did not consistently wear face shields and an apron during the procedure had a 6 times higher risk of BBF exposure than those who did (AOR = 6.21, 95% CI: 2.39, 9.55). Nurses who reported the lack of PPE in their hospital had 5.5 times higher odds of exposure to BBFs compared to those who reported that PPE was available in their hospital throughout the year (AOR = 5.53, 95% CI: 1.87, 10.38).

Discussion
Occupational exposure to blood and body uids among nurses during patient care leads to the transmission of different blood-borne pathogens, which is impacting their health and health care service for patients. In particular, developing countries such as Ethiopia can exacerbate the problem due to a lack of PPE, a low nurse-to-patient ratio, poor infrastructure, fragmentary hygienic service, overcrowding of patients, and inconsistent use of PPE (18).
In this study, the prevalence of exposure to BBFs among nurses in the emergency department and ICU was (0.76 with 95% CI: 0.71, 0.81) in their professional lifetime, and nearly (0.64 with 95% CI: 0.58, 0.70) exposed to BBFs in the last 12 months. This implies that a higher proportion of nurses are exposed to BBFs at the ED and ICU. The one-year exposure to BBFs is comparable with the study that was reported from India (68.64%), Tanzania (63%), Nigeria (68%), Gondar town (65.3%), and Mizan Tepi University (65.3%) (4,14,(19)(20)(21). However, the result is much higher than the study conducted in Turkey (13.7%), Iran This discrepancy may be due to variation in the study participants, lack of PPE, a higher load of patients, and infrequent use of PPE among participants in this study setting. For instance, in this study, participants were only nurses working in the ED and ICU, which is over-crowded, and infrequent lack of PPE was frequently observed, although in the above-mentioned study were conducted at all departments in the study hospitals on all HCWs (22)(23)(24)(25)(26)(27)(28)(29)(30).
The ndings of this study showed that 79.8% of nurses were exposed to BBFs more than once per year, which is a greater variation to a study done at Jimma University (38.5%) (31). The variation could be a result of the inadequacy of PPE, and infrequent use of it by nurses in this study setting (23). The study also revealed that blood/body uid splash (46%) was the most common way of exposure. This is consistent with the ndings of a study conducted in Turkey (40.6%) (28), but differs from ndings in Iran (92.8%), Australia (57%), Nigeria (38.4%), Tanzania (71%), Haramaya University (26.5%), and Jimma University (78.8%), in which NSI was the most common mode of exposure (14,21,22,24,30,31). The discrepancy might be due to variation in the study period, population, and setting, for instance, this study was conducted in ve public hospitals and particularly on nurses at the ED and ICU, whereas a study in Haramaya was conducted in only one institution on all health care workers, including all working units (22,31).
The nding showed that exposure to blood and body uids mostly happens on hands (44.9%). This is supported by a study published by Tanzania and Haramaya University, which found that exposure to BBFs on hands accounted for 85.5% and 86.6%, respectively, but the proportion is higher (14,22). In this study, 96% of nurses took action immediately after exposure through both washing the exposed site and reporting to the respective person. This is agreed with the study conducted in India (100%), Tunisia (92.8%), and Tanzania (91%) (14,19,25). About (73.8%) of nurses have identi ed the status of the source patients and from those tested patients nearly 19.3%, 8.2%, and 6.9% of them were positive for HIV, HBV, and HCV respectively, which indicated that nurses are threatened by the transmission of blood-borne pathogens commonly for HIV, HBV, and HCV. Moreover, the ndings of this study showed that the risk of transmission of blood borne pathogens among nurses exposed to BBFs is higher than the study done in Tunisia (25), which was (1.1%, 1.6%, and 5.25%) of source patients were positive for HIV, HCV, and HBV respectively. The difference is explained by the fact that this study was conducted at the ED and ICU, which is twinge work, thus nurses are attributed to such exposure (13).
In this nding, the sex of respondents, accessibility of handwashing facilities, wearing of a face shield, and apron consistently during the procedure, and availability of PPE constantly throughout the year in their hospital were found to be factors associated with occupational exposure to blood and body uids.
Males had 2.8 times the odds of being exposed to BBFs than females. This is congruent with the studies reported in Turkey, South Africa, Kenia, and Jimma (26-28, 31) but contrary with the study in Tanzania (14). The possible explanation is that male nurses underestimated the facts, paying no attention to the burden and the consequence of exposure to blood and body uids (32).
Nurses who complained about the lack of handwashing facilities in their hospital had 5 times more odds of exposure to BBFs compared to those who didn't complain. Nurses who didn't wear face shields and an apron consistently during the procedure had 6 times higher odds of exposure to BBFs. Nurses who reported, there was a lack of PPE in their hospital had 5.5 times higher odds of exposure to BBFs than those who reported that personal protective equipment was available in their hospital throughout the year. This is further supported by many studies, such as the studies in Tanzania, Wolaita Zone (southern Ethiopia), Awi Zone (Northwest Ethiopia), Gondar town, Bahir Dar town, and Arada health center (Addis Ababa, Ethiopia) (4,6,14,23,33,34). The reason could be described as the availability of PPE in health care facilities in uencing nurses' habits of using PPE during patient care and procedures, thereby reducing exposure to contaminated BBFs and its impact on the outcome of exposure. Furthermore, the infrequent availability of PPE reduced nurses' compliance to wear PPE such as a glove, face mask, face shield, and apron, potentially amplifying exposure to BBFs; and nally, increasing the transmission of blood borne pathogens. Giving patients care without PPE can also reduce nurses' concentration during activities, which can lead to anxiety and further exposure to blood and body uids. (15,18,20).

Implications of the study
This study will be used to provide information to health care providers, non-governmental organizations, and policymakers for appropriate planning and interventions regarding occupational BBFs, as well as its associated factors in nurses.
This study also serves as new knowledge regarding occupational exposure to blood and body uids.
Moreover, the result of this study helps as baseline data for further longitudinal and action-based studies.

Strength and limitations
As the strength, this study was conducted in ve randomly selected public hospitals, thus it could be generalized to all nurses working in public hospitals in the emergency department and intensive care unit.
This study shared the limitation of cross-sectional study design, hence it is di cult to determine the causal relationships between variables.

Conclusion
This study showed that a higher proportion of nurses at the emergency department and intensive care unit were exposed to blood and body uids in the study area. Exposure to blood and body uids was positively associated with a lack of personal protective equipment, inconsistent use of face shields and aprons, inaccessibility of handwashing facilities, and being male. Ousman Adal developed the proposal, analyzed the data, interpreted the results, and drafted the manuscript. Asmamaw Abebe revised the proposal, checked the data, and revised the manuscript.

Funding: No
Availability of data and materials The data that supports the ndings of this study is available upon reasonable request from the corresponding authors.
Ethical approval and consent to participants This study was approved by ethical review board of the College of health sciences, Addis Ababa University. Written consent was obtained from each study participant. Con dentiality and privacy were maintained through the study period.

Consent for publication: Not applicable
Computing interest The authors declare that they have no computing interest.