Occupational exposure of health care workers to blood and body uids in West Shewa Zone, Oromia, Ethiopia, 2018: A cross-sectional study


 Background: Health care workers are susceptible to acquiring blood and body fluids borne infections due to their occupations involving contact with patients and their body fluids, although studies conducted in Ethiopia are scarce. Therefore, the aim of this study was to investigate the magnitude of exposure to blood and body fluids among health care workers in governmental health facilities in West Shewa Zone, Ethiopia.Materials and methods: A facility-based cross-sectional study was conducted from May 19 to June 25, 2018. A total of 381 health care workers were selected by simple random sampling from 31 sampled governmental health facilities using proportional to size allocation. Data were collected through self-administered questionnaires, entered into Epi-info version 7, and analyzed by SPSS version 21. Adjusted odds ratio (AOR) with 95% confidence intervals (CI) calculated for variables retained in the multivariable logistic regression and significance declared at p<0.05.Results: Of 377 health care workers who participated, the study found that 233 (61.2%) were exposed to blood and body fluids in their lifetime. Previous needle stick injury (AOR=0.30; 95%CI: 0.12-0.75), type of health facility (AOR=0.42; 95%CI: 0.26-0.68), handwashing practice (AOR=0.15; 95%CI: 0.07, 0.31), and perceiving at risk (AOR=0.16; 95%CI: 0.03, 0.98) were protective factors whereas long work experience (AOR=1.47; 95%CI: 1.13-1.93) was a risk factor for the exposure.Conclusions: Exposures to blood and body fluids during patient care were common among health care workers in the study area. Therefore, health care workers especially those newly hired and working in hospitals should pay due attention to their occupation's safety and regularly practice hand washing during critical times.


Introduction
Health-care workers (HCW), whose occupations involve contact with patients and their body uids, face a risk of exposure to occupational infections with a subsequent risk of contracting diseases, disability, and even death. HCW are constantly susceptible to acquiring blood-borne infections such as human immunode ciency virus (HIV) and hepatitis [1,2].
Occupational infections can be transmitted through inhalation, ingestion of contaminated material, and accidental needlestick inoculation [1]. Needlestick injuries are one of the most common methods of occupational transmission. HCW handling sharps such as scalpels and blood collection devices are also are also at risk of self-inoculating or needle-sticking wounds and subsequent exposure to bloodborne pathogens [3]. Occupational blood exposure can occur through percutaneous injuries (needle sticks or other sharp injuries), mucocutaneous (splashing of blood or other body uids into the eyes, nose or mouth) or contact with non-intact skin [4].
Health workers are exposed to a variety of hazards at work; including needlestick injuries, back injuries, latex allergy, violence, and stress [5]. The occupational risk of blood and body uids (BBF) exposure and needlestick injuries not only affects the safety and well-being of HCWs but also affects the quality of medical care [6]. The risk of infection for healthcare workers from blood-borne pathogens depends on the prevalence of these pathogens in the patient population and the type and frequency of exposure [7]. Most of these infections, however, can be prevented by practicing standard precautions, immunization against Hepatitis B, provision of personal protective equipment, and the management of exposure [4]. The transmission of HIV, Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV) to patients by infected healthcare workers has also been documented [8].
Standard precautions are based on the principle that all blood, body uids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions include hand hygiene and, depending on the intended exposure, the use of gloves, gowns, masks, goggles, or faces shields. It also includes equipment or items in the patient's environment that may have been contaminated with infectious uid sand that must be handled to prevent transmission of infectious agents [9].
Of the 35 million healthcare workers worldwide, the World Health Organization estimates that approximately 3 million percutaneous injuries are sustained each year. Of these injured health workers, 70,000 are likely to become infected as a result of exposure to the hepatitis B virus, 15,000 with HCV and 1,000 with HIV [10] and 90% of the infections resulting from these exposures are carried by developing countries [11].
Exposure to needlestick injuries is higher in African countries than elsewhere and is a major public health concern due to overworked health workers. Similar studies in Ethiopia show that 32% of needlestick injuries were reported in the Sidama region, 31% in northwest Ethiopia, and 66% in 52 of the health facilities [12].
Few studies has been conducted in Ethiopia to assess the exposure status of blood and body uids among health care workers and factors in health care facilities showed that the risk of exposure to BBF, particularly needle stick injuries, was widespread [13,14]. The proportions of exposure to patients' body uids differ signi cantly between different occupational groups [14].
Therefore, this study aimed to assess levels of exposure to blood and body uids among health workers in government health facilities in the West Shewa Zone, Ethiopia. Hence it provides information for program managers, practitioners, and decision-makers to focus and act on appropriate interventions. Additionally, it helps health workers know the severity and prevalence, minimize its impact, and be safe in their work environment.

Study setting
The study was carried out in West Shewa Zone which is located in Oromia Regional State, Ethiopia. The zonal capital town, Ambo, is 112 km far to the west of the capital city, Addis Ababa. There are 22 districts in the zone. The zone has one referral, three general, and three primary hospitals; and 91 health centers. Health Center is the primary level of care in Ethiopia's health tier-system that has been serving around 25,000 in rural and 40,000 in urban catchment population with the aim of improving overall health outcomes, sanitation, maternal health, and infectious diseases. According to the West Shewa Zonal Health O ce report [15], there are 1,959 health professionals and 821 supportive staff among the health facilities in the zone.

Study design, participants and period
A cross-sectional study design was used to assess levels of occupational exposure to BBFs and to identify associated factors among the sampled HCWs in selected governmental health care facilities in the West Shewa Zone. The government-employed health professionals like pharmacists, environmental health professionals, and other supportive staff in the selected governmental health facilities were excluded because they were less likely to be exposed to blood and body uids. The data were collected The sample size was determined by using a single population proportion formula with the assumptions of a 95% con dence level, an error margin of 5%, and the prevalence of occupational exposure to BBFs (65.7%) [6]. Considering a 10% nonresponse rate, the nal sample size was 381.
Sampling procedure A total of 99 governmental health facilities were divided into hospitals and health centers. Twenty-eight (30%) out of 91 health centers; and three (33%) out of nine hospitals were selected randomly. The sampled health professionals were then assigned in proportion to the total number of health care providers in each selected health facility. The register of health care workers in selected governmental health facilities served as a sampling frame; and nally, a simple random sampling method was used to select health care workers.

Data collection tools and procedures
The data were collected through a self-administered questionnaire adapted from previous instruments used in various studies of exposure to blood and body uids [6, 16, 18]. The questionnaire has been grouped and arranged according to the speci c objectives they can address. The questionnaire was originally prepared in English and translated into the local language, Afan Oromo. To check consistency, experts translated Afan Oromo's questionnaires back into English. A supervisor (BSC) was employed in each hospital. Four BSc supervisors were employed for the health centers (one supervisor: seven health centers).

Data quality assurance
The data collectors received one-day training on the objective, data collection process, and eld ethics. Each questionnaire was checked daily by the supervisors and the principal investigator. The pre-test was carried out at a non-sampled health center with 38 (5%) of the study. Due to the gaps found in the pretest, the necessary adjustments were made to the questionnaire. At the end of each day, the supervisors and investigators checked the questionnaire for completeness, correctness, and consistency and were discussed with all data collectors and supervisors.

Data processing and analysis
The collected data was cleaned, manually coded, and entered into EPI Info version 7, and exported to SPSS version 21 for analysis. A univariate analysis was done for continuous variables. A frequency distribution was carried out for categorical data. Bivariable analysis was performed to select candidate variables with p<0.25. Then entered multivariate analysis to identify independent predictor variables and control confounders. In the multivariate logistic regression, the adjusted odds ratio (AOR) with its 95% con dence intervals (CI) was computed for the variables retained in the nal model, and the statistical signi cance was declared at p<0.05.

Operational de nitions
Health care worker: Those people who do have contact with syringes, needles, other sharp materials, blood, and body uids by virtue of their duties. Thus, nurses, laboratory technicians, physicians, dentists, health o cers, x-ray technicians, cleaners, and laundry workers were considered.
Exposure to blood & body uids: Exposure of health care workers to blood or other body uids like semen, vaginal secretions, cerebrospinal, pleural, peritoneal, pericardial, and amniotic uids via broken skin, eyes, mucous membranes, and sharp materials injury.

Results
Socio-demographic characteristics A total of 377 health care workers participated in the study, yielding a response rate of 98.95%. The majority of the respondents 300 (79.58%) belonged to the age group 25 to 34 years. More than half of the participants, 225 (59.68%) were nurses by occupation (Table 1) Behavioral factors and history of exposure to blood and body uids Of the total participants, 230 (61.01%) and 195 (51.72%) of healthcare workers, respectively, have been exposed to BBFs and suffered needlestick injuries during their lifetime. Of 230 healthcare workers exposed in the course of their lives, 174 (75.65%) had been exposed to blood at least once in the last year and 81 (21.49%) in the last six months. The second most common uid to which workers were exposed was amniotic uid 71 (18.83%), followed by breast milk 27 (7.16%). The majority of the exposed HCWs were 34 (14.78%) midwives. Performing multiple procedures simultaneously was the most common cause of exposure to blood and body uids, 199 (52.79%) ( Table 2).
Factors associated with exposure to blood and body uids A multivariate analysis was performed to determine independent predictors of exposure to blood and body uids. Those candidate variables with p<0.25 in the bivariate logistic regression were included in the multivariate logistic regression and considered signi cant in the model if the P-value was less than 0.05.
Health care workers with less than or equal to two years of work experience were 1.47 times more likely to be exposed to blood and body uids than those with ten years of work experience (AOR = 1.47; 95% CI: 1.13, 1.93).
Health care workers who worked in health centers were 58% less likely to be exposed to blood and body uids than those who worked in hospitals (AOR = 0.42, 95% CI 0.26, 0.68).
Healthcare workers who were ever exposed to a needlestick injury during the procedure were 70% less likely to be exposed to blood and body uids than those who were never exposed to a needlestick injury; 0.12, 0.75).
Pre-and post-procedure handwashing was an independent predictor of blood and body uids exposure.
Healthcare workers who wash their hands before and after a procedure are 85% less likely to be exposed to blood and body uids than those who don't do not wash hands (AOR = 0.15, 95% CI: 0.07, 0.31).
Healthcare workers' perception of whether they are at risk for infections carried by blood and body uid was found to be an associated factor in exposure to blood and body uids. HCWs who were perceived as at risk were 85% times less likely to have had occupational exposure to blood and body uids than those HCWs who did not consider themselves at risk (AOR=0.16; 95%CI: 0.09-0.98) ( Table 3).

Discussion
This study was conducted to assess the magnitude of exposure to blood and body uids in 377 participated health care workers in governmental health facilities in the West Shewa Zone of central Ethiopia.
This study found that the lifetime exposure of health care workers in government health care facilities to blood and body uids was very high at 230 (61.2%), which exceeds reports from Harari and Dire Dawa (28.8%) [13], Georgia 53% [10] and Lebanon (30%) [19], but, lower than a report from Wolaita (73.8%) and Gondar University Hospital (70.2%) [11,16]. This suggests that health care workers' exposure to blood and body uids may be due to different routes of exposure and a lack of PPE in their health care facilities, which in turn may expose them to various body uids and blood.
In this study, 81 (21.5%) of the study participants had been exposed to blood and body uids in the last six months, which is less than in the study in Wolaita 386 (62%) [11] and Bahir Dar Town 145 (45.7%) ) [20]. This difference may be due to the presence of safety signs in health facilities and the training of health workers in the workplace. One hundred ninety-ve (51.7%) of the study participants were injured by needle sticks in their lifetime, as this study shows, that is more than one study in Harari and Dire Dawa City, 145 (30.5%) and less than a nding in Nigeria 92 (53.5%) [21]. This suggests that health workers are at increased risk of work-related infections from blood and body uids if effective measures are not taken.
In this study, 134 (35.5%) healthcare workers were injured by needle sticks in the past year, which is much higher than the results from Awi Zone 36 (18.7%), Bahir Dar Town 92 (29.0%), but less than a nding from Bale zone 126 (37.1%) [20,22,23]. This difference could be due to socio-demographic and economic differences in the study areas and the experience of health workers in following standard precautions. This study found that health care workers who were exposed to needlestick injuries were 70% less exposed to blood and body uids compared to their counterparts, which could be due to the workers' care for themselves learning from the exposure to needlestick injuries.
This study found that the place in the level of health care system matter for occupational exposure to blood and body uids. Health care workers who work in the health center were 58% times less likely to be exposed to blood and body uids compared to those who work in the hospital. This could be because health care providers who work in hospitals are more likely to come into contact with blood and body uids from patients, are more involved in patient care activities, and have more contact with sharp instruments.
Health care workers' perception of whether they were or not at-risk to body uid and blood-borne infection was found to be an associated factor. HCWs who were perceived as being at risk of body uid and bloodborne infection were 85% times less likely to have had occupational exposure to blood and body uids than those who were perceived not at risk. Similar or different results have not yet been found in the literature reviewed. However, it appears to be due to the increased personal self-care through the use of personal protective equipment.
The year of service in the health system was also found to play a role in the occurrence of BBF exposure. In this study, healthcare workers who had two or fewer years of work experience were 1.47 times more likely to be exposed to blood and body uids as compared to healthcare workers who had 10 or more years of job experience. This could be because young health workers may receive less infection prevention training as they stay in the system less.
Healthcare workers who wash hands before and after each procedure were 85% less likely to be exposed to blood and body uids than their counterparts. Since hand washing is a part of personal protection, these workers may be the ones who routinely take care of themselves. Washing hands after a procedure helps to protect healthcare workers from infection with patients' harmful germs and to protect the healthcare environment from germ spread. Hence, healthcare workers who wash their hands before and after a procedure might practice strong precautions against exposure to BBFs.

Limitation of the study
The study relies on self-report rather than having a record review of healthcare workers. Therefore, recall bias likely occurred as the information was obtained retrospectively.

Conclusions
Exposure to blood and body uids during patient care was common among health care workers in the study area. During their lifetime, 195(51.7%) and 230(61%) of the workers encountered needle stick injury and exposure to blood and body uids, respectively. History of previous needle stick injury, place of work, and hand washing were protective factors, whereas long work experience was a risk factor associated with blood and body uid exposure.

Recommendations
The health care workers especially those newly hired and working in hospital should pay due attention to their occupation's safety and regularly practice hand washing during critical times. The health facilities should avail and implement appropriate infection prevention protocols to reduce the risk of acquiring infection in health institution. The study protocol was approved by the Institutional Review Board (IRB) of Arsi University (IRB No./AU/028/2018) and submitted to West Shewa Zonal Health O ce. A permission letter from the zone was provided to the selected governmental health facilities. Informed consent was con rmed by the IRB.

Consent for publication
The Ethics committee approved that the nding of this study could publish since identifying images or clinical details of participants that compromise anonymity was not applicable.

Data availability
All data supporting our ndings are already described and included in the manuscript.