Surgeons' Perception to Needle Stick Injuries and Transmission of Blood Borne Viral Infections

Needle stick injuries (NSI) are commonly seen in health care workers and those into surgical practice are at a higher risk of sustaining such injuries. As per WHO Report of 2002, of the 35 million health-care workers, 2 million experience percutaneous exposure to infectious diseases every year. It further adds that 37.6% of Hepatitis B, 39% of Hepatitis C and 4.4% of HIV/AIDS in Health-Care Workers (HCWs) around the world are due to NSI. There are more than 20 blood-borne pathogens which can be transmitted by contaminated needles or sharps, but those which are of utmost significance to HCWs include HBV, HCV and HIV [1].

The risk of needle stick injuries to health care workers is higher in developing countries as compared to developed and in most cases, it remains unreported or under-reported. There is a scarcity of data from India and hence difficulty in estimating the annual incidence [2]. However, studies have shown that the average transmission rates for HBV, HCV and HIV are 33.3%, 3.3% and 0.3 & respectively [3].

A questionnaire based survey was conducted by the department of Microbiology at a tertiary care hospital in Mumbai. The proforma was completed by 31 surgeons of different specialties belonging to different age groups with varying years of experience. Any sex wise differentiation among surgeons was not considered. The survey aimed at three aspects:

a) To assess the surgeons' perception to the transmission of blood borne infections primarily HBV, HCV and HIV

b) Their experience in dealing with such an occupational risk

c) To identify why NSI remains unreported

Thirty-one surgeons from different surgical specialties participated in the survey, of which twelve (38.7%) chose not to disclose their departments. Remaining participating surgeons were from the departments of orthopedics (n=5), ENT (n=3), general surgery (n=6) and gynecology (n=5). A total of 19 surgeons (61.2%) had a history of occupational exposure to NSI. Sixteen of 31(51.6%) surgeons were under 35 years of age with 11surgeons (35.4%) having just one to five years of clinical experience. Though these surgeons were aware of the occupational risk of transmission of blood borne viral pathogens following NSI, only six (19.35%) felt that they were at a high risk of infection whereas twenty (64.5%) surgeons believed were at moderate risk.

There were 19surgeons with a history of needle-stick injuries in the past but none of them ever reported the incidence of NSI. They mentioned that excessive paperwork is the main reason for not reporting the incidence and a few were also of the opinion that it's pointless to report. Of all the surgeons, twenty-one (67.7%) were aware of the existence of post-exposure protocols but only ten (32.3%) were familiar with the standard post-exposure reporting procedure and appropriate use of post-exposure prophylaxis (PEP). Twenty-three (74.1%) of these surgeons were aware of their immunization status and reported having been vaccinated against HBV.

Needle-stick injuries are common amongst surgical practice. The surgeons do not report these injuries routinely and therefore; the injury rates remain extremely under-estimated. In this study, we have attempted to find out the barriers to under-reporting. Majority of the surgeons attributed this to excessive paperwork, too time consuming a process of reporting, and that the risk of transmission of viruses is low since they have received vaccination against HBV in the past However, the risk of viral transmission for HCV and HIV is quite significant with an average seroconversion rate of 3% for HCV and 0.3% for HIV [4- 6]. Wallis et al have documented in their study that the orthopedic consultants found this reporting system far too complex to report incidences of percutaneous exposure [7]. This was a small, retrospective study confined to only one tertiary care centre and we could not rule out some degree of recall bias to the study. However, our results are quite comparable to studies conducted by Kennedy et al [8] in UK in which 81% of surgeons had suffered at least one NSI. Another study by Makary et al [9] showed that 51% of NSIs remain unreported among residents and trainees.

Around 74.1% had received vaccination against hepatitis B as compared to 57.1% reported by Randive et al [10] and 60% by Gurubacharya et al [11]. We postulate that the surgeons have a sense of security arising from HBV vaccination. They would make an initial risk assessment and if they deem patient to be low risk, it's quite unlikely to report incidences of NSI.

In conclusion, we perceive that the surgical cohort is at a higher risk than the need be. So there should be strategies to overcome the differences between incident and reporting rate. The reporting system can be made more user-friendly along with less paper work. They should be encouraged to report each incidence of NSI for the correct management of potential transmission, no matter how rare an event of exposure is. Our focus should be to remain vigilant and be pro-active in case of such an event. This should be combined with a regular review of preventive guidelines and promotion of awareness to universal safety precautions.

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