Estimation of the Prevalence of Occupational Exposure to Biological Fluids among Anesthesiologists: A Survey Study

Abstract

Background and Aims:

Percutaneous injuries caused by sharps and exposure to biological fluids are a serious concern for anesthesiologists and pose a significant risk of transmission of blood-borne pathogens.

Materials and Methods:

The aim of this study was to estimate the prevalence of exposure to biological fluids among anesthesiologists. A questionnaire designed initially was validated after it was sent to 10 anesthesiologists with more than 5 years’ experience. The validated questionnaire was then administered using Google Forms and the link was circulated electronically (e-mail, WhatsApp, and Telegram). This self-administered questionnaire was completed by 100 anesthesiologists. The various types and methods of body fluid years of exposure were also identified.

Results:

The prevalence of occupational exposure to body fluids was 100%. Exposure to either blood or cerebrospinal fluids by sharps was seen in 82%. Majority of the pricks were encountered during recapping of used needles followed by pricks during intravenous cannulation. Body fluid exposure onto the bare skin most frequently encountered was blood, mostly obtained during intravenous cannulation. There were 8% patients who had exposure to human immunodeficiency virus (HIV) and hepatitis B or C patients for which they had taken postexposure prophylaxis.

Conclusion:

Prevalence of exposure to biological fluids among anesthesiologists is alarmingly high. This poses a high risk for transmission of diseases. The use of protective gears and changing our casual attitude can prevent majority of the exposures. The practice of recapping of used needles should be stopped.

INTRODUCTION

Percutaneous injuries caused by sharps and exposure to biological fluids are a serious concern for anesthesiologists.[1] A needle stick injury (NSI) poses a serious risk of transmission of various blood-borne pathogens.[2]

Contact with biological fluids poses risk if there is any contact on skin and mucous membrane. Health-care workers (HCW) are much more likely to be infected with HIV and hepatitis viruses compared to the general population.

In a report published by the WHO, 40% of hepatitis B, 40% of hepatitis C, and 4.4% of HIV among HCW were due to needle stick injuries. Approximately 1000 HCW die annually from occupational HIV, which should have been prevented. Despite this, almost 80% of HCW remain unimmunized (against hepatitis B) in many parts of the world.[3]

These hazards not only potentiate health consequences but also cause emotional distress in HCW which result in missed workdays and directly affect the health-care services and resources.[4]

This survey attempts to estimate the prevalence of occupational exposure to biological fluids among anesthesiologists with the help of a validated questionnaire.

MATERIALS AND METHODS

This survey study was done among anesthesiologists across India. The study was approved by the Institutional Review Board and Institutional Ethical Committee (No-1617/IRB-IEC/13/MCC/16-09-2020/4).

The sample size was estimated using formula 4pq/(d²). p is the prevalence of exposure to biological fluids among anesthesiologists and q = 1 − p. The prevalence of needle stick injuries in anesthesiologists in Maharashtra, p, is 73.7% and d is the absolute precision and is taken as 10%. A minimum sample of 78 anesthesiologists is hence required.

A questionnaire was used to estimate the prevalence of occupational exposure to body fluids among anesthesiologists. The various types and methods of exposure were also identified.

The initial questionnaire designed had the first 19 questions [Appendix 1]. It was sent to 10 anesthesiologists with more than 5 years of experience, for validation. Based on their suggestions, three more questions were added (questions 20–22) and the final questionnaire had 22 questions [Appendix 1].

The questionnaire included basic data with respect to gender, practice type, work experience, and hours of shift. There were questions related to exposure to body fluids by sharps, exposure onto the bare skin, and general questions.

The questionnaire was then administered using Google Forms and the link was circulated electronically (e-mail, WhatsApp, and Telegram) to 106 anesthesiologist contacts in the Indian Society of Anaesthesiologists group over a period of 2 weeks. Reminder communications were sent after 1 week of initial communication. Responses were based on the incidents which they remembered only.

The data from Google Forms were collected, tabulated, and coded using Microsoft Excel 2021 and the analysis was done using SPSS software version 21. Descriptive statistics like frequency and percentages were used. The data was not normally distributed as the variables were categorical.

RESULTS

The validated questionnaire was completed by 100 anesthesiologists. The response rate was 94.3% (100/106).

Majority of the anesthesiologists were females. Most of the anesthesiologists worked in institutions. Table 1, shows the profile of the responders.

Table 1:

The profile of responders

	n=100	%
Gender	Male	41
	Female	59
Practice type	Institution	82
	Private practice	12
	Both	6
Work experience	1–5 years	66
	6–10 years	16
	11–20 years	9
	>20 years	9
Hours of shift	>8 h	77
	≤8 h	23

Figure 1 shows the pie diagram of injuries by sharps.

Figure 1:

Injuries by sharps (n = 100)

Injuries by sharps used for the patients were encountered in 82%.

The various methods by which injuries by sharps were encountered have been mentioned in Table 2.

Table 2:

Method of injuries by sharps

(n=100)	%
With the stylet used for intravenous cannulation	53
During recapping of used needles	59
During suturing of central line catheters	42
Due to fall of sharps onto the leg or foot	13
By sharps of the central line catheter set	15
Used spinal/epidural needles	19
During arterial line cannulation	10

Table 3 shows the type of body fluid exposure.

Table 3:

Type of body fluid exposure

(n=100)	%
Blood	97
Saliva/Oropharyngeal secretions	80
Amniotic fluid	32
Gastric	49
CSF	14
Urine	36
Fecal matter	1

Altogether 100% of the anesthesiologists were exposed to at least one of the above body fluids onto the bare skin. Figure 2, shows the body part with maximum exposure.

Figure 2:

Body part with maximum exposure in percentage

Disposable gloves were not worn by 4% while handling patients.

There was exposure to HIV and hepatitis B or C patients in 8% patients for which they had taken PEP.

Hepatitis B immunization was not taken in 5%.

Fifteen percent worked in hospitals were patients who were not fully screened for infectious diseases (HIV, and hepatitis B and C).

Table 4 shows the summary of various methods of exposure.

Table 4:

Summary of methods and types of exposure as mentioned by the respondents

Injuries by sharps

Exposure to blood: while shifting patients/spill from surgical site

Saliva/Oropharyngeal secretions: during intubation or extubation

Urine: while handling the urine bag

Gastric content: while handling Ryle's tube or by vomitus

CSF: spill during spinal anesthesia/lumbar puncture

Amniotic fluid: spill from surgical site

Fecal matter from surgical site

Ascitic fluid from the tapped site

Exposure to fluid from the intercoastal drainage bag

Pulmonary edema fluid exposure during resuscitation efforts

DISCUSSION

In day-to-day practice, anesthesiologists are exposed to numerous pathogens that include bacteria, viruses, and so on. The incidence of such hazards varies from hospital to hospital and from country to country and results in clinically asymptomatic carrier state to overt fatal infection.[5]

Anesthesiologists are usually at high risk of exposure to body fluids during various procedures in the operating room. Vessel cannulations, procedures involving the airway, regional anesthesia, and their close proximity with the surgical field usually pose a risk of injury with sharps and also to body fluid exposure.

The NSI, injury during suturing of central venous catheter, injury during local infiltration and regional anesthesia, accidental falls of sharp objects on the legs and foot, exposure to infected CSF, oro-pharyngeal secretions, infected wounds, and administration of anesthesia in infected burns and wounds are all possible mechanisms by which an anesthesiologist can contract infections.[6]

The risk is high in developing nations like India where many airborne and blood-borne diseases are prevalent not only in endemic form but do acquire epidemic proportions quite frequently.

In a prevalence study by Bashir et al.,[7] the NSI prevalence reported in Tamil Nadu is 28.0%.

Another study conducted by Rampal et al.[8] from Malaysia reported an NSI prevalence of 23.5% in HCW.

In a study done in Maharashtra, they observed a very high prevalence of 73.7% for NSI amongst anesthesiologists which is alarmingly high.[9]

In our study, the prevalence of injuries by sharps was 82%. It can be seen that majority of the pricks were obtained during recapping of used needles, a practice which is not encouraged.

The second most common cause of injuries by sharps was by the stylet encountered during intravenous cannulation.

In our study, blood was the most common body fluid exposure to the bare skin followed by oropharyngeal/gastric secretions. Exposure to body fluids onto the skin with minor abrasions/cuts or raw areas which are usually ignored by people poses a risk of transmission of pathogens through contact.

In case of hepatitis C infection, no vaccine is available till date and nor the postexposure prophylaxis is of much significance.[10]

There are chances of patients being in the window period even if they are screened for diseases.

This emphasizes the need of taking proper precautions while handling patients.

Anesthesiologists should make sure not to compromise on their safety as they are in contact with many patients. They should make sure to use disposable gloves at least while handling patients. Hospitals should make it mandatory to screen patients for HIV, and hepatitis B and C prior to any surgical procedure. Periodic audits should be conducted to make sure that they are complying with the said protocols.

Anesthesiologists should ensure a complete immunization with hepatitis B vaccine with a booster at regular intervals of 5 years.

The Centers for Disease Control and Prevention have laid down certain guidelines and should be followed in all form of anesthesiology practice to prevent any incidence of HIV infection. The recommended postexposure prophylaxis is immediate washing of the exposed site with plain water and soap.

In our study, other reasons given by the participants were (a) by the cuts obtained on the hand while breaking glass ampoules to load the drugs which increased their risk of exposure, (b) pressure from their senior coworkers to speed up the procedures done resulting in exposure or pricks, and (c) while handling patients coming for emergency procedures.

Simple measures such as wearing of protective clothing, gloves, masks, avoiding recapping of used needles, dressing of all abrasions and cuts, disposing of the contaminated material in a meticulous manner, sterilization of anesthesia equipment, and apparatus are sufficient enough to prevent infection to a large extent.[11] In addition, a calm and organized method of doing procedures by anesthesiologists will also help in preventing the exposures.

The greatest morbidity is likely to be from anxiety arising from the perceived risk.

Limitations of our study include a small sample size and memory bias as some may not be able to recall the incidents which had occurred previously during their practice.

CONCLUSION

The prevalence of exposure to biological fluids among anesthesiologists is alarmingly high. The use of protective gears and changing our casual attitude can prevent majority of the exposures. The practice of recapping of used needles should be stopped. Training and education are required in the formative years of the health-care curriculum.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Appendix 1 Questionnaire

• 1. Gender:

  • Male
  • Female

• 2. Practice type:

  • Institution
  • Private practice
  • Both

• 3. Work experience:

  • 1–5 years
  • 6–10 years
  • 11–20 years
  • >20 years

• 4. Hours of shift

  • ≤8 h
  • >8 h

Exposure to blood/CSF by sharps

• 5. Have you encountered any pricks with the stylet of the cannula after intravenous cannulation?

  • Yes
  • No

• 6. Have you encountered any pricks during recapping of needles used for the patients?

  • Yes
  • No

• 7. Have you encountered any pricks during suturing of central line catheters?

  • Yes
  • No

• 8. Have you encountered any pricks due to fall of sharps used for patients, onto your leg or foot?

  • Yes
  • No

• 9. Have you encountered any pricks with the sharps of central line catheter set used for the patient?

  • Yes
  • No

• 10. Have you encountered any pricks with the needle used for spinal/epidural anesthesia?

  • Yes
  • No

• 11. Have you encountered any pricks with the sharps used for arterial cannulation/regional blocks?

  • Yes
  • No

Exposure onto the bare skin

• 12. By which of the following body fluids have you been exposed onto the bare skin?

  • Blood
  • CSF
  • Gastric content-Ryle's tube aspirate, vomitus
  • Amniotic fluid
  • Urine
  • Saliva/Oropharyngeal secretions
  • Faecal matter

• 13. How did you get the exposure?

  • Blood: during cannulation/procedures
  • Blood: spill from the surgical area
  • Blood while shifting patients
  • Saliva/Oropharyngeal secretions: during intubation or patient bucking/coughing
  • Urine: while handling the urine bag
  • Gastric content: while handling Ryle's tube or by vomitus
  • CSF: spill during spinal anesthesia/lumbar puncture
  • Amniotic fluid: spill from surgical site
  • Faecal matter: from surgical site
  • Others

• 14. If others, please describe the incident in short.

General questions

• 15. Do you wear gloves while handling patients?

  • Always
  • Often
  • Sometimes
  • Never

• 16. How many times have you had any of these exposures?

  • None
  • 1–5 times
  • >5 times

• 17. Have you encountered any exposure to body fluids due to lack of protective gear in HIV/hepatitis B/hepatitis C patients?

  • Yes/No

• 18. Which body part was exposed the maximum?

  • Face
  • Hands
  • Eyes
  • Foot

• 19. In your opinion what would have prevented the exposure?

• 20. Have you taken post exposure prophylaxis anytime?

  • Yes
  • No

• 21. Have you taken hepatitis B vaccination?

  • Yes
  • No

• 22. Are all patients screened for infectious diseases?

  • Yes
  • No