|Year : 2016 | Volume
| Issue : 2 | Page : 237-240
Seroepidemiological survey of health care workers in Maharashtra
S Taishete1, A Chowdhary2
1 Department of Coordination, Ministry of Petroleum and Natural Gas, Government of India, New Delhi, India
2 Head of Department of Virology, Haffkine Institute for Training, Research and Testing, Mumbai, Maharashtra, India
|Date of Submission||28-Oct-2014|
|Date of Acceptance||25-Jan-2016|
|Date of Web Publication||14-Apr-2016|
Department of Coordination, Ministry of Petroleum and Natural Gas, Government of India, New Delhi
Source of Support: None, Conflict of Interest: None
Context: HCWs all over the world carry occupational risk of getting infected with major blood borne infections through needle stick injuries (NSIs). As health care industry has been expanding, risk of nosocomial infections is increasing proportionately. Measures to prevent it and put in place a mechanism to control these injuries are needed urgently, especially in India where there is not only increase in domestic demand but impetus in health tourism. Aim: To determine HBs Ag, HBc IgM level and to assess anti-HBs level prevalence in HCWs, in a tertiary care hospital and to study the influence of factors like age and sex in the vaccinated HCWs and formulate mechanism to increase awareness to create a safe working environment in the hospitals. Settings and Design: 437 HCWs, working in Laboratories, Surgical, Medical or Dental departments in 11 Civil Hospitals and Sub-district Hospitals covering 8 circles of the State. Methods and Material: Qualitative and Quantitative estimation of HBs Ag and Anti-HBs by sandwich ELISA technique and qualitative HBc IgM level by antibody-capture, non-competitive test. Liver profile (SGPT, SGOT and Alkaline Phosphatase) by IFCC method done. Statistical Analysis Used: Tabulation and Pie Circle Result: 193 of the total 229 vaccinated HCWs tested positive for core antibody, meaning that they were infected prior to HBs Ag vaccination, leaving a total of 36 'truly' vaccinated HCWs. 11 HBs Ag positive HCWs were tested for Liver Profile and all had ALAT, ASAT and ALP within normal range. Out of total number of 141 HCWs having 10 and below IU/L anti HBs, 5 HCWs were positive for HBS Ag, showing a positivity of 3.5%. Conclusion: Need of vaccination and for post-vaccination serological testing of all HCWs considering the high rates of non-responders and low responders (anti-HBs-34.2%). Importance of educating the HCWs of safety precautions while handling body fluids, and the management of ' sharps ' injuries.
Keywords: Blood-borne infections, health care workers, needle stick injuries, vaccination
|How to cite this article:|
Taishete S, Chowdhary A. Seroepidemiological survey of health care workers in Maharashtra. Indian J Med Microbiol 2016;34:237-40
|How to cite this URL:|
Taishete S, Chowdhary A. Seroepidemiological survey of health care workers in Maharashtra. Indian J Med Microbiol [serial online] 2016 [cited 2019 Jun 18];34:237-40. Available from: http://www.ijmm.org/text.asp?2016/34/2/237/180355
| ~ Introduction|| |
Occupational exposure to pathogenic microbes as a result of needles and other sharps is an important public health concern. In India, it is not known exactly how many occupation related injuries occur each year, and as the data is scarce, it is not possible to estimate an annual incidence. Data from the EPINet system suggest that in an average a health care worker (HCW) incur approximately 27 needle stick and sharps injuries (NSIs)/100 beds/year.  HCWs, who come in contact with medical devices as sharps including syringes or scalpels, are at risk of injuries that can lead to serious blood-borne infections. This risk of infection depends on the pathogen involved, the immune status of the worker, the severity of the NSI and the availability and use of appropriate post-exposure prophylaxis (PEP). According to a World Health Organization study, the annual estimated proportions of HCWs exposed to blood-borne pathogens globally are 2.6% for hepatitis C virus (HCV), 5.9% for hepatitis B virus (HBV) and 0.5% for HIV, corresponding to about 16,000 HCV infections and 66,000 HBV infections in HCW worldwide.  The concentration of HBV in blood and body fluids is also much greater than HIV.
Poor needle disposal practices, recapping of used ones put HCWs at a high risk of blood-borne infections. Ward boys, housekeeping staff and those working in the surgical departments are at the highest risk of getting NSIs and are, as a result, most vulnerable to acquiring blood-borne infections. Unfortunately, HCWs safety has rarely been considered as a high priority by hospitals mostly run commercially. Because the risk of being infected is highest in the lower strata of the HCW hierarchy, most hospitals do not consider prevention of NSIs as an important task. In the developing countries, where already the qualified work force is limited with respect to the disease burden in the population, HCWs have increased the chance of acquiring blood-borne pathogens due to a combination of increased risk and fewer safety precautions.  As loss of workers can seriously undermine developing health systems, it is important that risks are minimised.
This study determining hepatitis B surface antigen (HBsAg), IgM antibody against hepatitis B core antigen (IgM anti HBc) and anti-HBs level prevalence and liver profile (selected) in HCWs working in the public sector hospitals across the state of Maharashtra was undertaken to evaluate protective antibodies in HBV vaccinated HCW's, to identify the non-responders high risk HCWs, influence of factors such as age and sex in the vaccinated HCWs and also to understand the knowledge, attitude and practice of associated risks and infection control measures to protect HCWs.
Gross under-reporting of NSIs should not lead health care administrators to underestimate the problem. Although the risk may be low, the financial implications, psychological trauma as well as legal implications that follow such injuries can be considerable. At an average, hospital workers incur approximately 30 needle stick injuries per 100 beds per year At a tertiary care hospital in Mumbai, approximately Rs. 9000/- HCW/episode of NSI is incurred as a short-term cost.  Long-term costs such as anxiety, personal impact, adverse effect on work performance, and potential litigation have not been factored in. This impact is particularly severe when the injury involves exposure to HIV. In one study of 20 HCWs with an HIV exposure, 11 reported acute severe distress, 7 had persistent moderate distress and 6 quit their jobs as a result of the exposure. 
The international and national studies stress the fact of NSIs acquired by HCWs at their work place and, in turn, the infections which could be life threatening in a long-term. An integrated and comprehensive approach to handle them has still been lacking in most part of the world even though there are stringent acts passed by some countries. A comprehensive program that addresses institutional, behavioural and device-related factors that contribute to the occurrence of NSIs in HCWs needs to be laid out. Critical to this effort are the elimination of needle-bearing devices where safe and effective alternatives are available and the development, evaluation and use of needle devices with safety features without adversely affect patient care.
| ~ Materials and Methods|| |
This study was carried out in 11 civil hospitals and sub-district hospitals covering 8 circles of the State of Maharashtra in HCWs. The study population consisted of 437 volunteers (229 were HBV vaccinated and 208 unvaccinated) working as ward helpers, ward attendants, laboratory technicians (LTs), nursing staff (operation theatre/wards/labour room), interns, medical officers (MOs) and senior clinicians working as specialists. In each hospital, a presentation was given on the study proposal, individual-level counselling done and interviews held with the participants. Informed consent was taken followed by filling up of a questionnaire by all participants. Non-vaccinated HCWs were selected to see if they have been exposed to infection and developed protective antibodies subsequently.
Qualitative and quantitative estimation of HBsAg and anti-HBs was done by a direct, non-competitive, enzyme-linked immunosorbent assay technique, Diasorin, Italy. Qualitative HBc IgM level was done by using the principle of antibody-capture, non-competitive test. Liver profile of HBsAg positive population, i.e., serum glutamic pyruvic transaminase, serum glutamic oxaloacetic transaminase, and alkaline phosphatase was measured by using the International Federation of Clinical Chemistry recommended method (ERBA kit).
Permission to carry out the study was obtained from the Institutional Ethics Committee at Haffkine Institute, Mumbai.
Regular statistical methods (Tables and Pie circle) were used for drawing conclusions.
| ~ Results|| |
Out of a total number of 437 HCWs, number of males and females were 198 (45.6%) and 239 (54.3%), respectively. The nurses constituted the bulk with their number being 156 (33.2%) compared to 70 (16.0%) MOs, 42 (10.0%) LTs, 38 (8.1%) ward helpers and 16 (4.0%) clinical specialists. There was preponderance of females (148 out of 156) in nurses. In the category of MOs and LT, there were more males at 57 (79.2%) and 26 (62%) out of a total number of 70 and 42, respectively.
About 229 HCWs had been vaccinated against HBsAg, and the remaining 208 HCWs had been non-vaccinated. The number of vaccinated HCWs was 192 with 86 males and 106 females. There were 3 (18.8%) HCWs (out of 19 HCWs who had booster dose), all females who had booster dose were found with antibody level ranging from 1 to 10 IU/L. Of the total number of 93 HCWs, who had taken 3 dose only 11 (11.82%) had antibody level ranging from 1 to 10 IU/L out of the total number of 50 HCWs who had taken 2 dose, only 8 (16%) had antibody level ranging from 1 to 10 IU/L Out of the total number of 30 HCWs, who had taken 1 dose only 9 (28.1%) had antibody level ranging from 1 to 10 IU/L. About 63 HCWs had antibody titre in the range of 101-1000 IU/L with 23 males and 40 females. About 75 HCWs had antibody titre from 11 to 100 IU/L with the breakup of 35 males and 40 females. About 23 (10.96%) HCWs out of 192 vaccinated HCWs had anti-HBs titres in excess of 1000 IU/L. All 4 HCWs, who had nil level of protective antibody, were non-vaccinated. Out of 4 HCWs, 3 were female staff nurse and 1 male councillor with ICTC. A total number of non-vaccinated HCWs was 245 with 112 males and 133 females.
All 437 samples were tested for the surface antigen (HBsAg), only 11 (0.002%) had tested positive. The number of males was 4 (36%) and 7 females (63.6%). Only 8 (72.7%) of these HCWs who tested positive for HBsAg had been vaccinated, out of which 4 had taken 3 doses, 3 taken 2 doses and one taken one dose. Three HCWs were not vaccinated, and hence, require full vaccination. Out of 11 HCWs, 6 (54.5%) were staff nurse, 3 (27.2%) LT and blood bank technician, 1 (9.0%) MO and 1 (9.0%) was an attendant. Liver profile (alanine transaminase, aspartate aminotransferase and alkaline phosphatase) of this population was performed which was within limits. Out of these 11 HCWs, 5 (45.4%) had level of antibody 10 and below 10 IU/L. Out of these 5 HCWs, 3 (60%) were not vaccinated. Other 2 HCWs, both females had 3 and 1 dose, respectively. These 5 HCWs may have had hospital-acquired infection or sexually acquired one. Even though history was taken, it could be presumed that it is hospital acquired infection seeing their professional background which is vulnerable to be infected. Vaccine is supposed to have failed to push up the antibody titre in case of 2 vaccinated and in case of other 8 HCWs who had antibody level of more than 10 IU/L. All these HCWs have been recommended to be evaluated clinically with liver profile and repeat HBsAg.
Out of all 437 HCWs tested for anti-HBs, 141 were 10 IU/L and below, 3 out of which had the level of 0 IU/L, showing a positivity of 32% and 2.2%, respectively. Three HCWs with 0 IU/L need full vaccination. Out of total number of 141 HCWs, 34 were vaccinated and remaining 107 were not vaccinated. Out of total number of 141 HCWs having 10 and below IU/L anti-HBs, 5 HCWs were positive for HBsAg, showing a positivity of 3.5%, meaning they may have hospital-acquired infection or sexually acquired the infection. About 193 of the total 229 vaccinated HCWs tested positive for core antibody, meaning that they were infected prior to HBsAg vaccination leaving a total of 36 'truly' vaccinated HCWs.
All 437 HCWs were tested for HBc IgM and all tested negative, ruling out recent infection. Out of a total number of 437 HCWs, 231 (52.8%) had a history of injury. Out of these 231 HCWs, 218 (94.3%) had superficial injury and only 13 (5.62%) had deep injury. Maximum number of injuries have occurred during sample collection (30.7%) followed by surgery (29%), cleaning job (16.8%), waste disposal (8.2%) and slide preparation (2.59%). PEP had been taken only by 5 (2.16%) HCWs, out of which two were MOs, one is LT, one lab assistant and one blood bank attendant. It reflects poor awareness on the importance of PEP. Only 121 (52.3%) HCWs had got vaccination done before injury occurred. Total number of 86 males and 106 females were found to be vaccinated. About 19 males out of these 86 males had taken 1 dose, 21 had taken 2 doses, 41 had taken 3 dose and only 5 had taken booster dose. Out of total number of 106 females, 11, 29, 52 and 14 females were found to be vaccinated with 1, 2, 3 and booster dose, respectively. Even though total of females 239 (54.3%) were more than 198 males (45.6%), more number of females have opted for booster dose 14 (8.2%) than 5 (1.8%) in males.
| ~ Discussion|| |
In this study, 11 HCWs had tested positive for surface antigen (HBsAg) out of which 5 HCWs had level of antibody 10 and below 10 IU/L. Out of these 5 HCWs, 3 HCWs were not vaccinated and other 2 HCWs had taken 3 and 1 dose, respectively. These 5 HCWs may have had hospital-acquired infection or sexually acquired one. Even though history was taken, it could be presumed that it is hospital acquired infection seeing their professional background which is vulnerable to be infected.
It is very significant to note that wide spectrum of HCWs participated in this study. Regarding awareness of various risk factors leading to injuries and transmission of infections, it was observed that 94.5% HCWs were aware of the infection risk. However, positive change in attitude and adoption of preventive practices was wanting. In the present study, the high rates of non-responders and low responders (anti-HBs - 34.2%) highlight the need for post-vaccination serological testing of all HCWs, although the same is not recommended after routine adult vaccination. However, if the vaccine is given for occupational protection and the booster level is low (<100 IU/L), a booster dose should be recommended. Low or no-responders need to be identified and informed that they are not protected and advised to seek prophylaxis on accidental exposure. After exposure to HBV, PEP with hepatitis B immunoglobulin and initiation of hepatitis B vaccine is more than 90% effective in preventing HBV infection. HBV vaccine also gives protection against HBV infection in almost 90% of the vaccines. However, 5-10% of the vaccines may not attain adequate protection levels.
Under the study, all HCWs who did not have protective fibodies were advised to get vaccinated or revaccinated. The test results along with the recommendations were forwarded to concerned Hospitals for necessary action so as to secure the safety of the staff. A brochure on 'Personal Protection in Hospital work-Some Good Practices' was prepared for distribution among HCWs for increasing awareness on the safety precautions to be taken by them at their work place.
In India, it is needed to conduct surveys to estimate the occupationally acquired infections by a large group of HCWs ranging from ward assistants to the clinical specialists. Training workshops on the importance of following the safety precautions at workplace and also reporting them appropriately once they occur, so that required measures could be taken are needed to be held for HCWs. Awareness creation as well as functioning the Hospital Infection Control Committee for laying down and following interventional strategies strictly is the need of the hour.
The ideal way would be to rein in hospitals who do not want to invest in the safety of their workers is to bring in legislation that penalizes non-compliance. India is in need of a regulatory agency Occupational Safety and Health Administration or National Institute for Occupational Safety and Health to control workplace safety. The regulatory mechanism along with strengthening training of HCWs and finding technological solutions to minimize these injuries would help in reducing these incidents.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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