Prevalence, Knowledge, Attitude and Practice Regarding Management of Needle Stick Injuries at a Private Teaching Tertiary Care Hospital in Chennai City - A Cross Sectional Study

Introduction

Health care workers (HCWs) represent 12% of the global workforce. Approximately three million HCWs worldwide experience Needle stick injuries (NSIs) annually, exposing them to causative microorganisms.¹ Needle stick injury (NSI) is a penetrating stab wound from a needle (or any other sharp object) that may result in blood-borne infections such as AIDS, Hepatitis B and Hepatitis C. Variety of procedures (needle recapping, injuries sustained in the operating room, blood collection, suturing) can lead to accidental NSI.² NIOSH (National Institute for Occupational Safety and Health) defines NSI as injuries that are caused by objects such as hypodermic needles, blood collection needles, cannulas and needles used to connect parts of IV delivery systems. Health professionals working in the clinics, minor or major OTs are at a high risk for acquiring NSI injury leading to serious or fatal infections with blood borne pathogens such as Hepatitis B virus (HBV), Hepatitis C virus (HCV) or Human immunodeficiency virus (HIV).³ Globally, more than a third of Hepatitis B & Hepatitis C cases and approximately 5% of HIV cases result from NSI.⁴ Every year, 16 billion injections are administered in developing countries and transitional nations. Due to needle sticks and sharp injuries, approximately three million individuals are exposed to blood-borne diseases and life-ending conditions.⁵

The routine use of sharp instruments in dental treatment contributes to the hazardous nature of the dental workplace for blood-borne infections. NSIs prevention is a challenge to face in virtually every medical workplace. The burden of NSIs and Stick injuries (SIs) can be reduced when a dental professional abides by the current and universally accepted standard precautionary measures against NSIs.⁶ It is difficult to precisely estimate the global prevalence of NSIs among dental health care workers due to the under-reporting of incidents which is a significant issue in developing countries.⁴ Dental specialty involves the use of various small and very sharp instruments that are quite different from those used in medical care. The real scenario in which NSIs occur at dental care facilities has not been analyzed and is published in very few articles. Majority of dental institution’s undergraduate students begin their clinical rotations from third year onwards. They are at risk of exposure to occupational hazards. With this as the background, a cross-sectional survey was conducted. In order to enhance dental students’ safety and establish standard guidelines, more information is necessary. We, therefore conducted the present study to assess the prevalence, knowledge, attitude, and practice of dental students towards needle stick injuries.

Methodology

A cross-sectional questionnaire study was conducted among third-year, final year students and interns in Chennai city during the months of September and October 2018.

Source of data

The data were collected through a primary, closedended, structured, self-administered questionnaire.

Study subjects

Study participants included third year, final year undergraduate dental students and interns of a tertiary care dental hospital in Chennai city.

Inclusion criteria

The undergraduate dental students of third year, final year and interns who were present on the day of the study and those who provided informed consent were included.

Exclusion criteria

The students who were not willing to participate in the study, students of pre-clinical years (1st and 2nd year), and questionnaires with incomplete responses were excluded.

Questionnaire

The questionnaire was developed to assess the prevalence, knowledge, attitude and practice about the management of NSIs. A self-administered, close ended questionnaire in English language, comprising a total of 24 questions with eight questions pertaining to knowledge, seven questions pertaining to attitude and eight practice based questions was used.

Sample size

The sample size depended on the distribution of students’ responses to the needle stick injury questionnaire. Based on the literature, an answers rate of 50 - 60% was expected. At 95% confidence interval (CI), non-response rate 5% marginal error, the sample size was estimated to be 251 (Calculated from: http:// www.raosoft.com/samplesize. html). The questionnaire was also pre-tested on 10% of the sample (n=30). This population was not included in the final sample. Based on the pre-test, whenever necessary, the questions were revised, edited, and those found to be unclear or confusing were modified. The principal investigator was trained prior to the study and data collection procedure. The participation in the study was completely voluntary and complete anonymity of the participants was maintained. The questionnaires were distributed during the break time (1 – 1.30 pm). The principal investigator was available throughout the data collection period to address any queries raised by the participants while answering the questionnaire.

Statistical analysis

The collected data were analysed using SPSS Version 16. Descriptive analysis of the continuous variables and percentages of categorical variables was done. Associations were assessed using Chi-square test. The p-values for different cross tabulations have been mentioned in the tables alongside each variable. A p-value of <0.05 was considered as statistically significant, unless otherwise specified. The study was approved by the Ethical review committee and all ethical considerations including informed consent and confidentiality of respondents was ensured throughout the project.

Results

A total of 251 dental students belonging to 3rd year, 4th year and Internship were included in the study (Figure 1). Among them, 211 students provided consent to participate in the survey giving a response rate of 84%. The overall prevalence of NSI in the study was 18%, which was statistically significant (p <0.005). The prevalence of NSI was high among interns [n=16, 32%].

Knowledge

Majority of interns [n= 34, 68%] and final year students [n= 59, 68.6%] had better knowledge about the disease transmission through needle stick injury when compared to third year students [n= 26, 34.7%]. Around 9/10^th of the students were aware that Hepatitis B vaccine can protect them from acquiring the disease, though it was not statistically significant. Less than half of the final years [ n=37, 43.5%] and interns [ n= 20, 40%], and only 1/4^th of the third year students [ n=19, 25.3%] knew about the actual schedule for Hepatitis vaccination which was statistically significant (p <0.001). Majority of the participants, third year [n=52, 69.3%], final year students [n= 40, 46.5%] and interns [n= 27, 54%] reported that the awareness about Positive Expiratory Pressure (PEP) technique was not sufficient, which was statistically significant. After a needle stick injury, [n=62], 81.6% of third year students did not recommend to squeeze or rub the area of injury in contrast to final years and interns, which was statistically significant (Figure 2).

Attitude

Majority of the participants [80%- 91.7%] reported that the training regarding PEP technique was not sufficient, which was not statistically significant. About 9/10^th [83.3% - 91.9%] of all the participants acknowledged to follow post exposure prophylaxis technique following exposure to body fluids. More than 3/4^th [78.9% - 93%] of the students from all the years felt the need for extra training sessions on PEP techniques which was statistically significant (p <0.001) (Figure 3).

Practice

Most of the students included i.e from third year, final year and interns (89.5%, 98.8% and 94%) acknowledged that it was mandatory for dental students to undergo full course of Hepatitis B vaccination during first year of their undergraduate programme. But more than half of the third-year students [n=42, 56.8%] had not taken Hepatitis B vaccine during the start of the course, while more than 3/4th of the final year students [n=72, 85.7%] and interns [n= 43, 86%] were vaccinated, which was significant (p <0.001). Sudden, unexpected movements by uncooperative patients was the reason for NSIs as acknowledged by third years [n= 52, 68.4%], final years [n=27, 31.4%], and interns [n= 12, 24.5%]. Apart from the same, a particular procedure for the first time followed by an unexpected reason totally accounted for about [n=16] 21% of third years, [n= 37, 43.1%] of final years and [n= 20, 45.1%] of interns. Almost all the students of third year, final year and interns (93.4%, 87.2% and 68%, respectively), reported that they had never encountered needle stick injury. 24% of interns had reported to have experienced NSI once (Figure 3).

When asked about the diseases that spread through body fluids, majority of the participants i.e., third year, final year and interns responded as HIV (17.6%, 14.0% and 24.5% respectively), followed by Hepatitis B (6.8%, 15.1% and 16.3%, respectively), and then Hepatitis C (third year 2.7%, and Interns 4.1%), and this was not significant. Dentists are more susceptible to Hepatitis B infection is what was acknowledged by all the students (62.7%, 93.0% and 88.0%, respectively), followed by HIV and Pneumonia. Regarding the question of which blood antigen indicates hepatitis infection, almost equal number of third years [n= 57, 76%], final years [n= 64, 76.2%] and interns [n= 31, 67.4%] reported correctly as Hepatitis B surface antigen. More than 3/4^th [77.9%] of the participants in the final year and almost 3/4^th [73.5%] of interns and third years were not taught about PEP. But more than 90% of the participants among all the groups acknowledged the need for PEP after exposure to body fluids which was not statistically significant. Almost more than 1/2 [60%] of the participants in third year, final year and interns responded about contacting a general physician immediately after an NSI. The common response cited by all the students for not reporting NSI to appropriate authority was fear, uncertainty about confidentiality, lack of awareness and lack of support. More than 8/10^th [85%] of the participants in all the years acknowledged that dentists must get themselves tested for Hepatitis after a NSI from a hepatitis patient despite previous vaccinations.

About NSIs, majority of the students responded that they would not deny dental treatment for Hepatitis B positive or HIV positive patients. Majority of the 3^rd years felt the use of a needle destroyer after using syringe, and an equal number of participants from final years and interns answered that NSI cannot be prevented as they occur accidentally. More than three-fourth (82%) of all the participants were not denying dental treatment for Hepatitis B and HIV positive patients, which was not significant. It represents that these students have good post-exposure prophylactic techniques. Almost 1/4^th [22%] of the students from all three years acknowledged that NSI cannot be prevented as they occur accidentally. Around 11% reported following scoop technique and 14% used needle burner after using a syringe to prevent NSI. When asked to rate themselves how confident the participants were regarding PEP techniques, 1/4^th of all the participants, third years [24.6%], final years [22.5%] and interns [25%] graded themselves as 5.

Around 22% of participants in final year graded themselves on a scale of 6 to 7, while third years and final years graded themselves on a scale of 8. About 11% of third years and final years were 100% confident about PEP (Figure 4).

Discussion

Occupational health in dental practice are concerning issue in India. NSI is one such issue that needs to be addressed for preventing various blood borne diseases. 

In the present study, NSI prevalence was found to be 18% which is in line with the findings of the study conducted by Al Qadire M et al.,⁷ while lower prevalence was mentioned in one of the previous studies by Veronesi L⁸ and high prevalence was mentioned in another study by Suliman M.⁹

Reda S et al.,¹⁰ revealed that Integrated Personnel and Payroll System (IPPS) training and needle recapping behaviour could significantly affect the prevalence of occupational blood exposure. Prevalence was shown to be 13.5 times higher in those who do not attend training courses.¹⁰

Around 66.3% of all the participants answered that Hepatitis B, Hepatitis C, and HIV diseases spread via body fluids which were reported by the Ontario Hospital Association/Ontario Medical Association (2016). They estimated that after an injury in the workplace, there is 6% to 30% chance that an exposed person will be infected. In a similar situation with HIV, there is about 0.3% chance of infection, and about 1.8% chance of infection in Hepatitis C.¹¹

Around 57.1% of final year students and interns answered that Hepatitis B, Hepatitis C, and HIV can be transmitted by NSIs. This is in accordance with the study conducted by Kasat et al., Ontario Hospital Association/Ontario Medical Association (2016), and Qazi AR, where 90% of the doctors were aware that NSIs can transmit blood borne infections. Alam reported that 21% of AIDS and 30% of Hepatitis C were not known to be caused by NSIs. 73.2% named Hbs-Ag as the screening tool for HBV, which was similar to Rafieian N where a result of 75.6% was observed^11-15.

According to the present study, 94.1% of the students from all the three years were aware of the mandatory course of Hepatitis B vaccination during the first year of undergraduate program and 71.2% of students had completed their vaccination during the start of BDS program, which was higher (86.5%) in a study carried out in Nepal.¹⁶ Asif M et al., ¹⁷ reported in their study that students were not vaccinated because of lack of motivation among peers (29.2%) and some even did not feel the need for it (24.8%), which was not commonly observed in our study.

According to WHO, the risk of infection by needle stick injuries can be calculated from the number of accidents, the prevalence of active infection in the patient population, the probability of infection after percutaneous exposure and the proportion of health care workers susceptible to infection.¹⁸

Around 91% opined that the Hepatitis B vaccine can protect them from acquiring the disease, which was similar to the findings of a recent study by Qazi AR¹⁴ where 80.6% knew about the availability of HBV vaccination and also a study by Habiba SA¹⁹ reported that 81.5% were aware of HBV vaccination.

Around 36.2% of the participants were aware of the schedule of Hepatitis B vaccination which is in accordance with the study conducted by Habiba SA.¹⁹ 65.9% were aware of the number of doses of vaccination required for complete protection, and 84.0% had completed the vaccination doses which was higher than observed in our study.

The main reasons for NSIs reported in our study were uncooperative patients (41%), particular procedure being done for the first time (24.5%) and other unexpected reasons (14.5%). It was higher (28%) in a study conducted by Al Qadire et al. ⁷ Patric Cervini et al., reported that majority of injuries among doctors occurred while suturing (46%), and while assisting a procedure (25%). These practices are prevailing all over the world even though according to USA OSHA’s blood-borne pathogen standards (1996), in order to reduce the transmission of blood-borne pathogens, recapping a needle is prohibited. Bali et al., observed 23% NSIs during intermaxillary fixation in oral and maxillofacial surgeons. This can be explained by the fact that students are inexperienced and there is a lack of awareness in following universal precaution protocols.^14,20,21

CDC guidelines quote devices with Sharps Injury Protection (SIP) features built and designed to control sharp injuries like needleless systems that do not use a needle or sharp at all.²² 6.0% of students experienced the event of NSIs which was very less compared to the findings reported by Bindra S et al.,² which was 61% and Sharma et al.,²³ who reported a rate of 79.5% experiencing NSIs. In a study by Garima M et al.,²⁴ only 21.7% filed an incident report at integrated counselling and testing centre (ICTC). 43% were aware about the PEP in the management of NSIs. This was in accordance with the study conducted by Pavithran VK et al.,⁶ where 47.50% of dentists knew to use safety devices and 62% were aware of the PEP to prevent NSIs. Other similar studies were conducted by Alam et al.¹³ in which 50% of HCWs including nurses and paramedical staff were aware of the PEP to prevent NSIs. In relation to this aspect, our study participants had better knowledge of the new needle devices, were aware of PEP and the safety features.  

In our study, 74.5% reported that PEP techniques were not taught as a part of the BDS curriculum and 83.9% of them felt that the training given to them regarding PEP techniques was insufficient which is in accordance with the study conducted by kasat VO et al.,¹² where 89.9% reported the coverage of PEP in BDS curriculum. Similar study conducted by Kasat VO et al.,²⁵ reported that only 3.2% of postgraduate students participated in lectures, workshops, or seminars on PEP.

A Standard Operating Procedure (SOP) should be formulated regarding needle stick injuries in every hospital and college. It should outline the precautions to be taken when dealing with blood and body fluids. It must also contain reporting procedures and management of all NSIs.¹³

PEP to body fluids reduces the risk of contact of the disease. Dentists are equally exposed to body fluids accidentally during various procedures. According to our study, 90% of students reported PEP technique is important. In another study by Diprose P et al.,²⁶ less than 2/3^rd of the study participates reported that post-exposure prophylaxis should be started within one hour and continued for at least four weeks. It is crucial for dentists to remember that even 72 hours after injury, prophylaxis is still effective.¹⁵ In delayed exposure report (> 24-36 hours post exposure), the time period after which PEP is not beneficial is not clearly defined. Therefore, start PEP if indicated. In cases of unknown source (e.g., injury while handling waste), the need for PEP is decided on a case-to-case basis. The severity of injury and likelihood of infected material must be considered (Kapila K et al.)²⁷

In the present study, after needle stick injury, 56% of students reported that the site of injury should not be squeezed or rubbed. In a study conducted by Sharma R et al.,²⁸ 60.9% washed the site of injury with soap and water. Another study by Salelkar S et al.,²⁹ reported that around 52% of the health care workers were concerned of the post injury action who immediately washed the injury site with soap and water and 71.5% applied an antiseptic.

In our study, almost 47.3% of the participants expressed the reasons for non-reporting of NSI to be uncertainty, lack of awareness, lack of support. A study conducted by Prasuna et al., (2015)³⁰ in India found that 54.5% did not report NSI. A study by Suliman M et al.,9 showed that many students were unaware of what to do in the event of NSI.

In 2017, the healthcare and social assistance industry reported more injury and illness cases than any other private industry sector - 582,800 cases (2017 Survey of Occupational Injuries and Illnesses, BLS). That is 153,900 more cases than the next industry sector, manufacturing.³¹ According to our study, 60% of them immediately contacted a general physician, which was comparable to the study by Agaba PA et al.,³² where the participants reported to have contacted family physician (57.0%), while Chacko J et al.,³³ reported that the participants contacted medical interns (50.0%). Kasat V et al.,²⁵ reported that 48.4% of dental students contacted interns and 43.7% contacted PGs.

According to our study, 85.5% of the participants reported that the dentist must undergo serological testing for Hepatitis B after NSI from a hepatitis patient despite previous vaccination, which is in accordance with the study conducted by Al Qadire M et al.,⁷ where 40% of students underwent blood investigations after the injury.

Another important aspect of this study was that 82% of students did not deny dental treatment for Hepatitis B and HIV-positive patients which is in contrast with the study conducted by Rafieian N et al. ¹⁵ 41.5% of dentists expressed a degree of unwillingness towards accepting infected patients. This sheds light on the awareness of the students about the precaution guidelines. In a survey conducted by Sarourah et al. ¹³ at Armed Forces Hospital, 61% of HCWs were aware of the universal precaution guidelines.

According to our study, 24% of the participants opined that NSIs cannot be prevented as they occur accidentally and as a precautionary measure, 17% reported to be following the scoop technique and 23% reported using a needle destroyer after using a syringe which is in contrast with the study conducted by Pavithran VK et al.,²⁵ where 41.81% of dental professionals had an injury during recapping of the device and 5.45% during device disposal and a study by Bhattarai S et al.,¹⁶ showed recapping of the needles led to 19% of injuries.

Limitation

This study had few limitations. First, we examined associated risks and preventive measures using a cross-sectional questionnaire design. As a result, we could not examine the causal relationship between variables. Secondly, self-reported questionnaires are vulnerable to social desirability and recall biases. So, the management of NSI, and the dental professional’s response may vary for each individual, to what they actually know and practice. The results obtained from the study cannot be extrapolated.

Conclusion

In summary, this Prevalence, Knowledge, Attitude and Practices (PKAP) study showed that the overall knowledge of the study participants about associated risks and preventive measures to avoid needle stick injuries improved with seniority in dental college. However, an increasing prevalence of NSI was observed among students with the increase in the year of dental education, strongly suggesting the need for improvement in the domains of attitude and practice. Further teaching and training sessions on sharps injuries need to be incorporated in the dental curriculum to minimize these incidents in the future.

Conflict of interest

None