Hepatitis B virus (HBV) infection was first recognized as a risk to health care workers (HCWs) in 1950s, when clusters of hepatitis B cases occurred among workers with percutaneous exposure to the blood of the same patient (Robinson et al, 1968). In the 1970s, specific serological tests were used to define the prevalence of HBV infection in HCWs and compared risk to that in the general population. These studies indicated three to five fold elevated risk in nursing staff, surgeons, pathologists, laboratory technicians, blood bank personnel, physicians, dentists and some groups of hospital workers (Lewis et al, 1973). Prevalence rates increased with duration in the profession, reaching 30% among those who had worked for 20 or more years, compared with 5% among persons of comparable age in the general population. Studies in the hospital personnel showed that risk of HBV infection varied with occupational group, being highest in such groups as emergency room nurses, blood bank and laboratory technicians, and pathology staff, but low in groups with little exposure to blood (Lewis et al, 1973).
This paper focuses on the rising incidence of hepatitis B infection among health care workers (HCWs) in Ghana particularly at the emergency department, it proposes adherence to universal precautions as a means of preventing the spread of HBV and designs and evaluate an educational intervention program to aid in combating this problem. The highest rates of HBV infection are found among HCWs due to highest risk of exposure in health care settings (Fizli et al, 1998). The United State Department of labor Occupational Safety and Health Administration (1994) postulated that every year about 8700 HCWs contract hepatitis B from occupational exposure and approximately 200 will die from this blood borne infection and some becoming carriers passing the infection to others. A study done on 199 HCWs at Combined Military Hospital in Pakistan reported a prevalence of 4.1% HBV infection. (Naz et al, 2002).
What Is Hepatitis?
Hepatitis B is a viral infection that causes a wide spectrum of liver diseases, including acute or fumigant hepatitis, inactive carrier state, chronic hepatitis,cirrhosis, and hepatocellular carcinoma ( Kao, 2007).
The likelihood that HBV infection will become chronic depends upon the age at which a person becomes infected, with young children being the most likely to develop chronic infections. About 90% of infants infected during the first year of life develop chronic infections, 30% to 50% of children infected between one to four years of age develop chronic infections, about 25% of adults who become chronically infected during childhood die from HBV related liver cancer or cirrhosis (WHO, 2008).
Mode Of Transmission
The virus is transmitted through contact with blood or other body fluids of an infected person but not through casual contact. HBV is 50 to 100 times more infectious than human immune-deficiency virus (HIV). HBV can survive outside the body for at least 7 days and can still cause infection (Day et al, 2007). The virus incubation period is 90 days on average, but can vary from about 30 to 180 days. HBV may be detected 30 to 60 days after infection and persist for widely variable periods of time (Day et al, 2007). Studies have also established that HBV transmission from infected HCWs to patients can occur under unusual circumstances, but is of minimal public health importance compared with the risk of HCWs acquiring disease from their patients (Rimlan et al, 1977).
Public Health Importance
Hepatitis B is a major public health problem in the world today. It is estimated that over 2 billion people have been infected with HBV resulting in 300 to 400 million carriers. During their life time 25% of these persistently infected persons develop chronic hepatitis or Hepatocellular Carcinoma resulting in 1.2 million deaths per year making HBV the 10th leading cause of death worldwide (Hollinger & Lau, 2006).Hepatocellular carcinoma is the third highest cause of death from cancer in the world, the fifth most common malignancy in males and the eighth in females. Untreated, it yields a dismal 5 years survival between two and six percent (Hollinger & Lau,2006).The impact of the disease is highly dependent on geographic location and countries are defined based on their prevalence of HBV infections, specifically high (>8%), intermediate (2% to 7%) and low (<2%) (Scarsi & Darin, 2009). Unfortunately the countries with the highest prevalence of HBV, including parts of sub- Saharan African and Asia account for 45% of the world's population and are hardest hit by this disease. The United States and Northern Europe represent the region with lowest prevalence, accounting for 1 to 1.4 million of those living with chronic hepatitis B (Scarsi & Darin, 2009). Africa being known as the highest endemic region of HBV infection has a carrier rate of 10.4% ( Kew,1996), 15% in young volunteer blood donors (Sarkodie et al, 2001), 15.8% in children 6-18years (Martinson et al,1996) .Ghana health service (GHS) as reported by Ghana business news (2009) estimated the disease prevalence as one in every six individual, representing 40% of the Ghanaian population.
Reasons For High Risk Among Hcw
A number of reasons have been proposed for the increased risk of HBV among HCWs in developing countries and Ghana included are; increased population prevalence, disease severity of the patient, high numbers of needle stick injuries, number of informal workers, lack of vaccination coverage against HBV, lack of availability of post-exposure prophylaxis(PEP) (Lee,2009), lack of adherence to standard precautions, unsafe practices and procedures, culture of using injections versus other methods and lack of occupational health services and organizations(Lee,2009).
Health care workers in developing settings like Ghana are more susceptible as there is higher disease prevalence in the general population (Lenoble et al, 1995). A study on school children in Ghana found that 61.2% had markers for HBV infection (Lenoble et al, 1995). By contrast, the HBV prevalence in United State of America (USA) is 4.9% (McQuilla et al, 1999). HCWs in developing countries are not only caring for a general population with high rates of blood borne disease, but are exposed to patients within that population who have even higher risk (Mcquilla et al, 1999)
Secondly in Ghana, patients are admitted with disease states that are high risk, should occupational exposure occur. In the case of HBV, the clinical severity of the patient also influences risk, with those who are chronic carriers having much higher risk of transmission compared with acute cases (Grady et al, 1978). Lavanchy (2004) was of the view that many developing countries have chronic carriers in the population making HCWs at risk.
The incidence of needle stick injuries among HCWs in Africa is far higher than in their western counterparts. A West African survey of 1241 HCWs found that 45% had sustained an accidental blood exposure in the previous year with 80.1% due to percutaneous injury with an estimated 0.33% accidental blood exposures per HCW per year (Taranttola et al, 2005). Also unsafe procedures and practices used in developing countries are frequently associated with increased risk. Example two-handed recapping, which is associated with twice the risk of inflicting a percutaneous injury according to a study in Egypt (Talaat et al, 2003).
Due to lack of resources, workers are often forced to re-use equipment. An Indian study found that during the process of washing and sterilizing needles there was an average of two or three needle stick injuries incurred per HCW per day. However many needles never go through that process (Rajasekaran et al, 2003).World Health Organization (2002) estimated that 75% of injections in south East Asia did not undergo sterilization, hence increases the risk to both patients and HCWs who may be exposed to blood from numerous patients due to improper sterilization of equipment. Kermode (2004) was of the view that unsafe injection practices including the re-use of unsterile needles and syringes in the health setting account for 32% of HBV infection. Moreover HCWs particularly in Ghana lack gloves, gowns, masks and goggles to protect them from contact with blood. It was reported in Tanzania that birth attendants cover their hands with plastic bags to protect themselves from exposure to HIV during deliveries because there were no gloves available.( Mfugale as cited in Sagoe-Moses et al, 2001).
Furthermore, in Ghana there are numerous informal health care providers and such providers working outside formal health systems might have neither access to training on occupational safety and universal precautions nor any monitoring of their practice to ensure their safety. A study in Cambodia found that only 13% of injection was administered in public hospitals or clinics (Vong et al, 2005).
Though vaccination against HBV has been shown to be highly effective, WHO (2003), estimated that only 18% of HCWs in Africa were vaccinated against HBV. This lack of coverage is mainly due to cost and lack of clear policies regarding implementation (Talaat et al, 2003). Lack of availability of Post Exposure Prophylaxis (PEP) in developing countries also put the HCWs at risk. Though PEP exists and administration of HBV immunoglobin decreases the chance of sero conversion by 90% (Center for Disease Control and Prevention, 1998) However, it is often not available in a developing country (Talaat et al, 2003) like Ghana.
Standard precautions for care of patients irrespective of their diagnosis or presumed infectious status have been shown to reduce occupational exposure, (Garner, 1996) are less adhered by HCWs in Africa for a number of reasons. HCWs had some misconceptions about maintaining precautions at all times and so adopted precautions only for those patients known to be HIV positive (Doebbeling et al, 2003). In addition, culture and attitudes often leads to excessive use of injections. In Ghana, treatments given as injections are believed to be more potent than when they are given through other routes. A study in Cambodia found that 75% of 288 subjects attributed a faster healing effect to injection (Vong et al,2005) This is also true in South East Asia where up to four injections per person per year are given . The chances of exposure are increased simply due to increased numbers of procedures being carried out. (Lee, 2009).
Lastly comprehensive occupational health services that are lacking in Ghana also put HCWs at risk and make their well-being not paramount, unlike western countries like United Kingdom that has occupational health departments and the health and safety executive that issue standards to protect workers and reduce occupational risk.
Consequences Of Hbv Infection
Loss of healthcare workers due to HBV infection can have disproportionate effect on the fragile health care infrastructure particularly in Ghana, where trained health professionals are scarce in relation to the over-all populations they serve (Sagoe-Moses et al, 2001). World Health Organization (1998) statistically indicated that there are fewer than ten physicians per 100,000 populations in fifteen Sub- Saharan countries, as compared with nearly 250 physicians per 100,000 populations in the United States. Similar discrepancies exist between the number of nurses in these countries and the number of nurses in the United States.
Secondly, there is also a loss of the national investment in training of workers whose career are cut short by occupationally acquired infection (Sagoe- Moses et al ).
Furthermore, HCWs who are infected may transmit disease to sexual partners or spouses and if pregnant when infected may transmit to neonates (Hadler, 1985).
Fourthly the health sector also faces huge demand as HBV spreads. It affect the health budget and also becomes a big financial burden to the society as a whole since drugs use in the treatment of hepatitis B are expensive (Ong et al, 2008).
Lastly, the loss of a wage-earning HCW can be devastating to the financial security of the worker's family since he/she might be the bread winner.
Promoting Adherence To Universal Precautions
It is estimated that over two billion people have been infected with hepatitis B virus (HBV) resulting in 300 to 400 million carriers (Hollinger & Lau, 2006). A Tanzania study by Gumudoka as quoted by Lee (2009) posited that healthcare workers (HCWs) in developing countries are less likely to adhere to standard precautions. He found that only 16% of HCWs used gloves during venepuncture. He also postulated that major barriers to adherence of universal precautions (UPs) in third world countries are lack of education, misconceptions, and lack of equipment. An assessment of knowledge about blood borne pathogens (BBPs) and the use of UPs among HCWs at first level care facilities in Pakistan showed low level of knowledge in UPs. A few Physicians, (7.1%) and fewer Dispensers (5.4%) mentioned appropriate disposal of syringes as a measure to prevent needle stick injuries (Janjua et al, 2007).Based on the above evidence, this paper will focus on an educational intervention aimed at improving adherence to UPs .
Purpose: The purpose of this educational intervention is to increase adherence to UPs among health care workers at the Emergency Department(ED) of the Korle-Bu Teaching Hospital, Ghana. The ED is a good window to implement UP practices because there is a significant potential for blood borne pathogen exposure. (Kellen et al, 1992).Specific strategies that will be applied include an assessment of HCWs adherence with UPs using baseline, post observations and questionnaire. Also, workshops where participants will be engaged in discussions, role modeling in the form of drama will be utilized. The goal is to reduce incidence of HBV infection among ED HCWs. The objectives are that by the end of the promotion the participants will be able to demonstrate the use of personal protective equipment (PPE) and to answer questions related to UPs and transmission of HBV.
Significance: The program will help reduce HBV and other blood borne pathogen infections, keep client safe from getting infected and in the long term prevent HBV related complications like hepatocellular carcinoma (.Gammon & Gould, 2005). Consequently there will be increase in man hours leading to high turnover.
Program Design: The program will be guided by the health belief model (HBM). This model explains the relationship between individual's belief and health behaviours (Nutbeam & Harris, 2004). This approach has mainly been used as a planning tool for promoting adherence with preventive health behaviours and health care recommendations (Nutbeam & Harris 2004). This model was used successfully to identify the variables influencing HCWs compliance with UPs in the emergency department (Williams et ai,1994) . The HBM has six constructs: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self efficacy. (Glanz et al, 2008). When the individuals recognize that they are susceptible to the risk of HBV infection and that they will suffer from serious consequences, they will be interested in taking UPs to prevent the disease (HBV).They will also take action if they perceive the potential health threat of HBV. Further, if they receive supportive cues to action such as posters, enough training to build their self efficacy and the belief that UPs will reduce risk of getting infected , and that those actions can outweigh the costs and barriers, they will be ready to comply.
Two tools will be considered in this interventional program: a questionnaire based on the HBM as a theoretical framework and baseline/post observation (checklist) to observe EDHCWs adherence with different guidelines of universal precautions. The questionnaire will include information on knowledge, beliefs, perceived susceptibility, perceived severity, cues to action and perceived barrier. Knowledge will be measured on mode of transmission of HBV infection and other blood borne pathogens using the questionnaire. One item will address measurement of knowledge regarding spread of HBV infection and other blood borne pathogens through syringe use. Respondents will be asked to mention transmission routes. Another item will inquire about the use of precautions that can reduce occupational risks. To assess respondent beliefs, questions like “do you believe immunity to HBV alone protect you from contracting the disease, do you believe PPE (use of gloves, hand washing, wearing goggle, mask and gown) is an effective way of preventing HBV infection and other blood borne pathogens?” will be used. Perceived susceptibility to acquire HBV infection will be assessed using one item: “how much risk of acquiring HBV or other blood borne infection is involved in your work?” Perceived severity will be assessed by another item: “what can happen if you get a needle stick injury? Cues to action will be assessed by: “what will act as a reminder to UP practices?” Perceived barriers will be measured using the item: “what prevents you from practicing UP?” Benefits will be assessed by asking: “what do you gain from hand washing?” Behaviour will be assessed using baseline observation: wearing gloves whiles performing medical-surgical procedures, non-recapping of needles and washing of hands before and after procedures (Janjua et al, 2007).
Implementation: Prior to the implementation of the educational intervention program a baseline observation notices regarding the program will be posted to the ED and it will include the general information that the program is related to health and safety practices for ED personnel. This is done with a permission granted by the hospital administration and the Infection Control Committee. The participants will be requested to answer questions to help assess their beliefs, perceived susceptibility, perceived barrier, perceived severity, cues to action and benefit. A baseline observation will be conducted by the researcher and a trained assistant on EDHCWs to assess behaviour on universal precaution practices for a period of one month. Participants will be involved (during the baseline assessment) in finding solutions to the lack of adherence to UPs among HCWs. They will be allowed to offer suggestions as to how to improve on the adherence. Participants will also be invited to respond to the questionnaire in order to assess their knowledge (Refer above). The educational intervention will utilize discussions and role modeling (e.g., having a drama where a reputable person in health demonstrates the use of PPE).The workshops will discuss epidemiology, occupational transmission of HBV, other blood borne infections, and methods to prevent exposures (simple hand washing, use of protective eye wear, gloves, gowns, and mask).The rest of the discussion will focus on procedure for reporting exposures, unvaccinated EDHCWs risk of infection after a needle stick injury from hepatitis B positive patient, misconceptions about precautions, and options for post exposure prophylaxis (Lynn et al,1999). These discussions will be compulsory for all EDHCWs. Participants will be given materials with information on how to reduce risks of exposure, reporting blood borne pathogens (BBP) exposure and post exposure prophylaxis. Participant will have the opportunity to demonstrate (self efficacy) the use of the personal protective equipment. Posters (cues to action) will be placed in the ED rooms, on wall and sinks with information on blood borne pathogen exposure prevention. (Lynn et al, 2001)
Evaluation: The program will be evaluated through process (attendance, return demonstration,), impact (participants observed using PPE[self efficacy] correctly among others.) and outcome (satisfaction, low statistical report on HBV and other BBP infections) evaluation using a post- intervention observation (conducted at six months and at one year) and questionnaire by same researcher and assistant to assess adherence. The primary objective of the evaluation is to assess the effectiveness of program on increase adherence of UPs among EDHCWs. The Questionnaire will be used to assess HCWs knowledge of disease susceptibility, severity, cues to action and appropriate use of protective device and knowledge of the possible negative consequences (seriousness) of infections with blood borne pathogens .Participants will be asked to list all experiences during the discussions in the work environment. They will be asked to express their perceived benefit and obstacles concerning the program. The researcher will observe change in behaviour in relation to adherence of UPs.
Projection: it is hoped once this intervention program is successfully implemented in the emergency department, it will be instituted in all the departments in the Korlebu teaching hospital and if the incidence of BBP remains low after another year of evaluation it will be a policy for all hospitals in the whole country.
Instituting the system of UP in an Emergency Department is a complex task. In the implementation of this program it is envisaged that difficulties will arise and different participants may decide to respond differently. However, careful administration of such a system can result in a better informed and more highly motivated work force, a safer Emergency Department, and even better patient care. The program will be sustained in the future by continuous education every six months.
Day,R. A.,Paul,P.,Williams,B.,Sneltzer,.S.C., Bare B., (2007).Brunner&Suddarth's textbook of medical-surgical nursing (1st Ed). Philadelphia: Lipincott William & Wilkins.
Doebbeling, B. N., McCoy, K. D., Vaughn, T. E., Beekmann, E. S., Woolson, R. F., Ferguson, K. J. & Torner, J. C.(2003). Percutaneous injury, blood exposure, and adherence to standard precautions: are Hospital-Based health care providers still at risk? Clinical Infectious Disease, 37, 1006-13.
Fazli, Z., Asghar, H. & Baig. (1998). Prevalence of Hepatitis B virus in Dental Clinics in Rawalpindi/Islamabad. Journal of Pakistan Medical Association, 48, 259
Gammon, J., & Gould, D. (2005). Universal Precautions: A review of knowledge, compliance and strategies to improve practice. Journal of Research in Nursing, 10 (5), 529-547.
Garner, J. & Hospital Infection Control Practices Advisory Committee. Guidelines for Isolation Precautions in Hospitals. Infect Control Hosp Epidemiol 1996; 17(1): 54-80.
Glanz, K., Rimer, B. K., & Viswanth, K. (2008). Health behaviour and health education: Theory, Research, and Practice (4th ed). San Francisco: Jossey-Bass.
Grady, C. (1989). Acquired immunodeficiency syndrome. The impact on professional nursing practice. Cancer Nursing, 12 (1), 1-9
Grady, G. F., Lee, V.A, & Prince, A. M. (1978). Hepatitis B immune globulin for accident exposures among medical personnel: final report of a multicentre controlled trial. Infectious Disease, 138, 625-638.
Hadler, S. C., Doto, I. L. & Maynard, J. E (1985). Occupational risk of hepatitis B infection in hospital workers. Infection Control, 6, 24
Hollinger, F. B. & Lau, D. T-Y.(2006). Hepatitis B: The pathway to recovery through treatment. Gastroenterology clinics of North America, 35, 425-461.
Janjua, N. Z., Razaq, M., Chandir, S., Rozi, S., & Mahmood, B. (2007).Poor knowledge predictor of nonadherance to universal precautions for bloodborne pathogens at first level care facilities in Pakistan. Journal of BioMed Central Infectious Disease, 7 (81) 1-11.
Kao, J-H. (2007).Role of viral factors in the natural course and therapy of chronic hepatitis. Hepatology International, 1, 415-430.
Kew, M. C. (1996). Progress towards the comprehensive control of hepatitis B in Africa: A view from South Africa. Gut, 38, S31-S36
5.Kellen,G.D., Green,G.B., & Purcell,H.R.( 1992).Hepatitis B and C in Emergency Department patients. New England Journal of Medicine, 326, 1399-404.
Lavanchy , D. (2004) Hepatitis B virus epidemiology, disease burden, treatment and current and emerging prevention and control measures. Journal of Viral Hepatology, 11, 97-107.
Lee, R. (2009). Occupational transmission of bloodborne diseases to healthcare workers in developing countries: meeting the challenges. Journal of hospital infection,72, 285-291.
Lenoble, R. D., Traore, O., Kombila, M., Roingeard, P., Dubois, F., Goudeau, A. (1995) Hepatitis B, C, D, and E markers in rural equatorial African villages Gabon. American Journal of Tropical Medicine & Hygiene, 53, 338-41.
Lewis, T. L., Alter, H. J., & Chalmers, T. C. (1973). A comparison of the frequency of hepatitis B antigen and antibody in hospital and non-hospital personnel. New England Journal of Medicine, 289,647.
Lynn,E. K., Bradley, A. E.,Parks,R. L., Donna,B.J., Mutha,S., Haase C., & Fraser,V.J. (1999). Compliance with universal precautions among emergency department personnel: Implications for prevention programs. American Journal of Infection Control, 27, 453-455.
Martinson, F. E., Weigle, K. A., Mushahwar, I. K., Weber, D. J., Royce, R. Lemon, S. M. (1996). Seroepidermiological survey of hepatitis B and C virus infection in Ghanaian children. Journal of Medical Virology, 48, 278-283.
McQuillan,G. M., Coleman, P. J., Kruszon-Moran, D., Moyer, L. A., Lambert, S. B, & Margolis, H.S.(1999) .Prevalence of hepatitis B virus in the United States. Journal Public Health, 89, 14-18
Motamed, N., BabaMahmoodi, F., Khalilian, A., Peykanheirati, M., & Nozari, M. (2006). Knowledge and practices of healthcare workers and medical students towards universal precautions in hospitals in Mazandaran Province. Eastern Mediterranean Health Journal, 12(5), 653-661.
Mujeeb, S. A., Khatri, Y. &Khanani, R (1998).Frequency of parenteral exposure and seroprevalence of HBV, HCV and HIV among operation room personnel. Journal of Hospital Infection, 38, 133-137
Naz, S., Ahmed, M. & Asghar, H. (2002). Prevalence of Hepatitis B among hospital personnel in Combined Military Hospital (CMH) Muzaffarabad. International Journal of Agriculture and Biology, 4(2), 227-230.
Nutbeam, D., & Harris, E. (2004). Theory in a nutshell: A practical guide to health promotion theories (2nd ed). Toronto: McGraw-Hill.
Ong, S. C., Lim, S. G. &Li, S. C. (2009). How big is the financial burden of hepatitis B to society? A cost-of-illness study of hepatitis B infection in Singapore. Journal of Viral Hepatitis, 16, 53-63.
Rajasekaran,M., Sivagnanam, G., Namasivayam, K., Ravindranath, C. & Thirumalaikolundu, S. (2003). Injection practices in southern part of India. Public Health Journal, 117,208-213.
Rimland, D., Parkin, W. E. & Miller, G. B.(1977).Hepatitis B outbreak traced to an oral surgeon. New England Journal of Medicine 296, 953.
Robinson, C.G., Gladstone, J. L., Goodman, S. & Schulman, B. D. (1968). Outbreak of viral hepatitis in a municipal hospital, Journal of International Medicine, 122,318
Sagoe-Moses, C. , Pearson, R. D., Perry, J. & Jagger, J. (2001). Risk to health care workers in developing countries. The New England Journal of Medicine, 345(7), 538-541.
Sarkodie, F., Adarkwa, M., Adu-Sarkodie, Y. , Candotti, D., Acheampong, J. W. Allian, J. P. (2001). Screening for viral markers in volunteer and replacement blood donors in West Africa. Vox Sang 80, 142-147.
Scarsi, K. K. & Darin, K. M. (2009). Chronic hepatitis B Infection: Principles of Therapy. Journal of Pharmacy Practice, 22(4), 359-387.
Talaat, M., Kandeel, A. & El-Shoubary, W. ( 2003). Occupational exposure to needlestick injuries and hepatitis B vaccine coverage among health care workers in Egypt. American Journal of Infection Control, 31,469-472.
Tarantola, A., Koumare, A., & Rachline, A.( 2005 ).A descriptive retrospective study of 567 accidental blood exposure in healthcare workers in three West African countries. Journal of Hospital Infection, 60, 276-282.
Vong, S.,Perz, J. & Sok, S. (2005).Rapid assessment of injection practices in Cambodia. BMC Public Health Journal, 5, 1471-1476.
World Health Organization.(WHO) Report, (2002). Reducing Risks, Promoting Healthy Life. Retrieved October 8, 2009, from
World Health Organization, (1998). Estimates of health personnel. Retrieved from
WHO-UNICEF-UNFPA (1999). Joint statement on the use of auto-disable syringes in immunization services. Retrieved from:
World Health Organization (2003) Environmental burden of disease series, No, 3. Geneva
World Health Organization (August, 2008). Fact sheet N204.
Williams, C.O., Scott, C., Keith, H., & Collier, P. (1994). Variables influencing worker compliance with universal precautions in the emergency department. American Journal of Infection Control, 22, 138-148.