HEPATITIS B INFECTION

Background

Hepatitis B virus (HBV) infection was first recognized as a risk to health care workers (HCWs) in the 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). This paper focuses on the rising incidence of hepatitis B infection among health care workers (HCWs) in Ghana, it proposes a policy focusing on 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. Hepatitis B is a serious Public Health problem, it is caused by virus which can lead to a wide spectrum of liver diseases, including acute or fumigant hepatitis, inactive carrier state, chronic hepatitis, cirrhosis, and hepatocellular carcinoma (Kao, 2007). The virus is transmitted through contact with bodily fluids and blood of an infected person and is proven to be 50 to 100 times more infectious than human immune-deficiency virus because HBV can survive outside the body for at least 7 days and still cause infection (Day et al, 2007). 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 also postulated that major barriers to adherence to universal precautions (UPs) in countries like Ghana are lack of education, misconceptions and lack of equipment. An assessment of knowledge about blood borne pathogens (BBPs) and the use of universal precautions (UPs) among HCWs at first level care facilities also showed low level of knowledge in UPs. A few Physicians and Dispensers mentioned appropriate disposal of syringes as a measure to prevent needle stick injuries but only 16% of HCWs used gloves during venepuncture (Lee, 2009). Health care workers in Ghana are more susceptible due to higher disease prevalence in the general population (Richard-Lenoble et al, 1995). Amongst school children alone a study found 61.2% had markers for HBV infection (Richard-Lenoble et al, 1995) this is in contrast with the 4.9% HBV prevalence in United State of America (McQuilla et al, 1999). The Ghana health service as reported by Ghana business news (2009) also estimated the disease prevalence to be one in every six individuals; representing 40% of the Ghanaian population, HCWs in Ghana 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 of HBV should occupational exposure occur (McQuilla et al, 1999). 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). Unsafe procedures and practices used in the healthcare settings in Ghana are frequently associated with increased risk. For Example, two-handed recapping, which is associated with twice the risk of inflicting a percutaneous injury (Talaat et al, 2003) and re-use of equipments. 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. In addition, culture and attitudes often leads to excessive use of injections. In Ghana, treatments given as injections are believed to be more effective than when given through other routes this is consistent with a study in Cambodia which found 75% of 288 subjects attributed a faster healing effect to injection (Vong et al, 2005). The chances of exposure are increased simply due to increased numbers of injections being administered (Lee, 2009). Moreover HCWs in Ghana lack gloves, gowns, masks and goggles to protect themselves from contact with blood and other bodily fluids. Similar reports from Tanzania show that birth attendants cover their hands with plastic bags to protect themselves from exposure to HIV during deliveries because, gloves were not available (Mfugale as cited in Sagoe-Moses et al, 2001). Although the aforementioned problems exist, some HCW do not adhere to UPs due to misconceptions about maintaining precautions at all times and so adopt UPs only for patients known to be HIV positive (Doebbeling et al, 2003). 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. And in Ghana lack of coverage is mainly due to cost, lack of clear policies regarding implementation and lack of availability of Post Exposure Prophylaxis (Talaat et al, 2003). Comprehensive occupational health services that are lacking in Ghana also put HCWs at risk and make their well-being not paramount, unlike western countries, United Kingdom for example has occupational health departments, Department of Health and the health and safety executive which issues standards to protect workers and reduce occupational risk. Loss of healthcare workers due to HBV infection can have disproportionate effect on the fragile health care infrastructure in Ghana where trained health professionals are scarce in relation to the over-all populations they serve (Sagoe-Moses et al, 2001). According to WHO (1998) there are fewer than ten physicians per 100,000 populations in fifteen Sub- Saharan African countries, as compared to nearly 250 physicians per 100,000 populations in the USA. Similar discrepancies exist between the number of nurses in these countries and the number of nurses in the United States. There is also loss of national investment in training workers whose career are cut short by occupationally acquired infection (Sagoe- Moses et al,2001 ). Furthermore, HCWs who are infected may transmit the disease to partners and if pregnant to their unborn babies (Hadler, 1985). Also the health sector faces huge demand as HBV spreads, It affect the health budget and also becomes a big financial burden to the society as a whole (Ong et al, 2008). Policies: Although safer use of needle, universal precautions and other innovations may reduce the incidence of occupational exposure substantially, it is not possible to eliminate these risks completely (Gerberching and Henderson, 1992). It is the responsibility of the Ghana health service to develop and implement protocols for managing HCWs who are occupationally at risk and sometimes exposed. Written protocols such as prompt reporting, treatment, counseling and follow ups of HCWs after occupational exposures should be provided by employers (Department of Labour, 1994). The WHO department of communicable diseases and surveillance (2002) suggest three measures in controlling HBV. These measures will be adapted in the healthcare settings to aid the prevention of HBV among HCW in Ghana. These are immunization as a means of prevention, prevention of HBV infection through blood by implementing appropriate systems to properly screen blood and blood products and lastly by reducing the risk of HCWs and high risk individuals through education on UPs and acceptance of the vaccination schemes. Though studies was not found on the incidence of HBV infection among HCW in Ghana, a study by Braka et al (2006) to assess hepatitis B exposure in Uganda found out that among 311 HCW 60.1% had evidence of HBV infection, 8.7% were chronic carriers, and 0.3% were acutely infected. 36.3% remained susceptible and could benefit from vaccination. Only 5.1% reported having had at least a dose of hepatitis B vaccine, 3.5% had become immune through vaccination; however 98% were willing to be vaccinated. This result forecasts the need for protection and vaccination of healthcare workers in Uganda and is applicable to Ghana which is likely to suffer similar trends. Screening and Immunization of all HCWs prior to the start of their post is an effective way of preventing HBV spread and its consequences (WHO, 2002), and should be part of the written guidelines. Any markers identified through this process should be thoroughly treated before the start of the post. Procurement of vaccines and facilitation of this process should be the responsibility of the employers (WHO, 2002). In prevention of HBV infection, apart from provision of equipments and protocols by employers the main players in the prevention league are the HCWs who are in direct contact with the population. Hence considering every hazardous bodily fluids and blood as infectious irrespective of whether the patient diagnosis is known or unknown (SHEA, 1997) brings home the most effective means of preventing HBV through UPs which reduces the opportunity of direct exposure to blood and bodily fluids for both HCWs and patients (New York State Department of Health, 1992). Staff should receive ongoing training on Universal precautions and the use of protective equipments when handling body fluids and bloods. This paper will focus on designing an educational intervention program, this will then be pilot tested to detect the effectiveness of strict adherence to universal precaution in preventing the spread of HBV and the importance of educating staff to continuously update their knowledge. For the program to be effective, it is based on the health belief model which will guide the practice and aid in predicting outcomes (Hildon, 2010). The educational intervention program is chosen because its outcome is observable and can be used as evidence to aid in implementation of the intervention program and the evaluation strategy (CDC, 1999). After careful examination of the pilot intervention, it is hoped that the outcome will be one of the strategic frameworks for preventing HBV infections among HCWs in Ghana. Promoting Adherence to Universal Precautions using the health belief model Purpose: The purpose of this educational intervention is to increase awareness and adherence to UPs among health care workers of Ghana. Specific strategies that will be applied include an assessment of HCWs knowledge and adherence to 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 HCWs. Objectives are for participants to be able to use personal protective equipments (PPE) appropriately and to demonstrate increased knowledge in observing universal precautionary measures. 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 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 (Nut beam & Harris, 2004). This approach is widely used in public health as a foundation for developing educational interventions (Stretcher & Rosenstock, 1997), also 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 al, 1994). The HBM has six components: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self efficacy (Glanz et al, 2008). When the individuals recognizes 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 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. HCWs 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 hospitals and will include the general information that the program is related to health and safety practices for HCWs. This is done with a permission granted by the hospital administration and the Infection Control Committee. HCWs 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 on HCWs 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 HCWs 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 HCWs. 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 clinical areas, on wall and sinks with information on blood borne pathogen exposure prevention. (Lynn et al, 2001)

Evaluation

program evaluation is an integral part in public health practice (CDC, 1999). 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 to assess adherence (Daly,2004). The primary objective of the evaluation is to assess the effectiveness of program on increase adherence of UPs among HCWs. 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. Change in behaviour in relation to adherence of UPs will be observed. Because UPs is one of the main tools in combating the spread of HBV infection it is important the effect of the program is observable, to be able to secure more funding from employers and other stake holders to make available the equipments needed such as PPE for HCWs to use (CDC, 1999). Projection: it is hoped that once this educational intervention program has been successful after a pilot study, written protocols and appointed persons will be put in charge to monitor the program. This program will be a national strategy and all hospitals will be expected to comply with the protocols. Making UPs mandatory with some element of monitoring is effective in ensuring an equitable level of adherence (Kellen et al, 1991)

Conclusion

Instituting the system of UP in the healthcare setting in Ghana 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, safer hospitals, and even better patient care. The program will be sustained in the future by continuous education every six months.

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