OCCUPATIONAL RISK TO HEALTH CARE WORKERS AND THEIR PATENTS

Needlestick injury and the transfer of potentially fatal infectious diseases to health care
workers from unsafe injectable devices are a worldwide problem and of growing concern.

Until recently, the response of health departments and issuers has been to take more care using traditional needle devices. Health care workers are obliged to follow the rigid procedures of universal precautions that include the use of gloves and special sharps containers for needle disposal.

However, it is widely acknowledged that universal precautions alone are not enough to prevent
needlestick incidents, especially under the demanding pressures of a medical setting.


Five primary activities are associated with the majority of needlestick injuries.
They are:

Disposing of needles, including collection and disposal of materials used during patient care procedures Administering injections Drawing blood Recapping needles Handling trash and dirty linens (termed “downstream injuries”).Hollow-bore needles (the type of needle used for giving injections or drawing blood) are implicated as the devices most often associated with the transmission of bloodborne pathogen infections, in fact they are the cause of injury in 68.5% of cases.

Research has shown that almost 83% of injuries from hollow-bore needles can be prevented by using devices that have needles with safety features.Authorities around the world are slowly introducing laws to require the use of safety injectable devices in hospitals.One of the most critical control components of health care worker protection against bloodborne pathogens must be the reduction of sharps-related incidents. The statistics cited below provide a picture of the seriousness of the problem:

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Over 2,000,000 needlestick injuries are reported each year worldwide. About 2% or approximately 40,000 of these are likely to be contaminated by HIV. According to these statistics, over US$3 billion a year is currently being spent on the treatment of accidental needlesticks.

Researchers have documented that needlestick injuries are under reported by health care workers. A recent US research shows that as many as 60% of incidents remain unreported. More than 20 pathogens have been transmitted through sharps or needlestick injuries. Of these, HIV, Hepatitis B virus (HBV) and, Hepatitis C virus (HCV) pose the greatest risk to the health care worker, the risk of transmission of HBV and HCV through percutaneous injury is much higher than for HIV. 80% of health care workers, who contracted HIV/AIDS or hepatitis B, did so as the result of needlesticks.




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TURNING THE CORNER ON HIV/AIDS:

Safe Health Care in HIV/AIDS Prevention. New information to stop HIV epidemics in Africa. By: David Gisselquist, PhD Recent review of accumulated evidence shows that unsafe injections and other medical exposures may well be the driving force for Africa 's AIDS epidemics. For example, studies linking HIV to sexual exposures – having an infected spouse, having multiple sexual partners – seem to explain only about a third of HIV in African adults. On the other hand, studies of new HIV infections link them in many cases with recent injections, antenatal care, blood tests, and blood transfusions. Moreover, HIV has been found in African children with HIV-negative mothers, and in children 5-14 years old; such infections are far more likely due to health care than to sexual exposure.

These reviews reopen an old debate that was aborted without resolution. In the mid-1980s, many experts held that unsterile injections were important contributors to Africa 's HIV epidemics. Around 1988, despite abundant evidence to the contrary, WHO's Global Programme on AIDS circulated estimates that 90% of HIV in African adults was from sex and less than 2% from unsterile medical injections. Many experts and much of the public have accepted these figures as facts. Although these estimates are no longer tenable, it may take years to reach a new consensus on the proportions of HIV from health care and sex.

However, agreement on proportions is not necessary to take advantage of new information to help people protect themselves and their children from HIV infections.



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Break the silence, end the stigma, empower people For many years, international and donor organizations were largely silent about HIV risks in health care. Recent studies have broken that silence. As people become more aware of non-sexual HIV transmission as a risk and – far too often – a reality, this may reduce the stigma associated with HIV.

Wives may, for example, be able to confide that they are HIV-positive without fearing that husbands will accuse them of extramarital affairs that did not happen. Current HIV prevention messages that recognize non-sexual transmission encourage trust and mutual support among spouses in trying times. That alone is an enormous boon from more accurate public health messages.

HIV/AIDS experts often fight over the contents of public health messages for Africans. Some worry, for example, that Africans will forget about safe sex if messages discuss health care risks. These debates are off the mark. For people living and raising families in countries with generalized HIV/AIDS epidemics, prevention is a life-or-death challenge. From this perspective, a country has as many HIV prevention programs as it has people aware of risks.

Since people find themselves in all sorts of situations that experts cannot consider in detail, the best policy is to give out full information, including all sides of continuing debates. That gives people a chance to decide for themselves what works and what is relevant for their own circumstances.

Safe sex messages are relevant for some people, but not for others who are not sexually active or who are in long-term monogamous relationships. But sex is not the only risk. When a Zambian schoolteacher wakes up with a toothache, ensuring sterile dental care becomes a concern. When a mother takes a child for a vaccination, safety of syringes and multi-dose vials are life-and-death concerns. Many such risks and their solutions are specific to local communities and individuals. With more information, people are empowered to implement more effectively their own personal HIV prevention programs.


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SUPERBUGS

Date: 17 July 2005
Producer: Nicole Turner
Presenter: Ruda Landman – Carte Blanche
Researcher: Nikki Lindsay,Seamus Reynolds
Genre: Medical and Health


In 1997 the World Health Organisation warned that antibiotic resistance was a major threat to human health. It's a global phenomenon that has led to the emergence of bacteria that are resistant to antibiotics and extremely difficult to treat. Hospitals have become danger zones - incubators of previously harmless bacteria turned into killer bugs that prey on the sick, injured and the weak. In the UK infections from the drug resistant staph MRSA have risen 24 fold in the last decade.

The Center for Disease Control estimates that 2 million Americans are infected during hospital stay every year. It's a growing international crisis and as dire in South Africa as the rest of the world. Ruda Landman (Carte Blanche presenter): Hospitals do everything in their power to prevent infection, but they can never exclude it completely. It is estimated that about 15% or one in every six patients who enter a South African hospital will acquire a bacterial infection in that environment. In the last 18 months at least 50 babies have fallen victim to outbreaks in public hospitals. Last month resistant Klebsiella rampaged through a Durban hospital killing 21 newborns.

Ruda: The Mahatma Gandhi Hospital in Phoenix on the outskirts of Durban is the only hospital serving a population of almost a million. About 1 500 babies are born here every month. Amish Davnairan was one of only four babies who beat the infection. His mother Aziza says his prognosis is still uncertain.

Aziza Davnairan (Mother): Every single day there was one baby dying. And it was frightening. Whenever they opened the door I knew they were calling a mother.

Ruda: What's that like?

Aziza: Oh God! When the mothers used to come out they used to come out screaming, frantic and you could only sit there hoping – what's going on with your baby.

Ruda: Giving birth is one of the most joyful experiences of life. Lynette Chetty's baby boy, Moses, was born on the 31st of May. He was big and healthy, three-and-a-half kilograms. He died six days later.

Lynette Chetty (Mother): I never knew that baby was going to die because he was so like healthy and I thought I was going to bring him home. Lynette's was the 12th baby to die in the ward… it was only then that the problem was recognised.

Lynnette: They couldn't know there was something wrong in the unit. They had to wait for so many babies to die and then they had to come to know. After baby Moses died the neonatal unit was temporarily closed and the Health Ministry launched an enquiry.

Manto Tshabalala-Msimang (Minister of Health): Well the experience is chilling and I think it is traumatic for one hospital to lose 12 infant lives and I think we must all of ourselves commit ourselves that it must not happen again. The bereaved families were given R7 000 each to bury their babies.

Lynette: Money will not bring our babies back. Their money is not important to me at this time.

Alvin Brijlal, Director of the NGO ‘Voice', says complaints about Mahatma Gandhi Hospital are nothing new. According to him, 40 babies died from various hospital infections in 2002.

Alvin Brijlal, Director, ‘Voice': I know there is a huge shortage of nurses and doctors; I've seen patients lying there, really messed up and nobody's helping them.

Aziza: It stinks. The stench - the visitors coming there want to run away. If you need to use the loo or the bath you cannot because there is droppings of blood, faeces all over the place.

Not long after the outbreak we went to see for ourselves. Despite a recent clean-up, the maternity ward toilets were soiled with blood and urine, there was no soap, toilet paper, no towels. Professor Adrian Duse is South Africa 's foremost expert in infection control, called on to catch culprits in similar outbreaks.

Prof Adrian Duse Clinical Microbiologist, WITS: Breakdowns in control are universal; they happen in every single health care facility, whether you like it or not.

Experts agree that hospitals cannot do anything about two thirds of hospital infections. One third, however, can be prevented with good old-fashioned hygiene, as it's unwashed hands that spread bacteria. In fact, correct hand washing can slash infections by 70%.

Prof Duse: Handwashing is the single most important strategy to prevent the spread of what many people call superbugs.

The state report on the outbreak, released last week, found that poor infection control and contaminated intravenous equipment had led to the neonatal deaths.

Prof Duse: So every time you give an injection of what is meant to be doing good to the patient, you're actually giving them a lethal injection of a bug that eventually results in their death. Under-staffing, overcrowding and lack of resources had contributed, but the report found no single person responsible. Some of the parents are suing the ministry.

Lynette: I can't blame anyone, but doctors should be more sensitive to babies… babies that are premature and they die. They just left it like that. Klebsiella is a common bacterium found in most people's gut, but what made this outbreak so lethal was that the bug was resistant to antibiotics. It's been over sixty years since Alexander Fleming discovered penicillin. Antibiotics were hailed as a wonder drug, at first restricted to military use. But the super drug produced its own worst enemy: the superbug.

The majority of bacteria are useful and mostly harmless, but they can cause infections. Our only defence, once infected, is antibiotics, which work by attacking various mechanisms in the bacteria to destroy them or stop them replicating. But bacteria develop sophisticated defence mechanisms to overcome antibiotics. They can even transfer their resistance to other bacteria. This alarming trend is blamed on over-use of antibiotics in medicine and especially farming. With discovery and production of new antibiotics trailing the bugs' ability to mutate, are we facing a future where our most valuable drugs don't work at all?

Dr Adrian Brink, Clinical Microbiologist, Ampath: Many bacteria that you find in the community are resistant to five or more antibiotics, so it's not single drug resistance, it's multi drug resistance.

Dr Adrian Brink is a clinical microbiologist. His expertise is also called on when outbreaks occur.

Dr Brink: It costs about up to R5-billion to develop an antibiotic and bring it to market, so as soon as it's introduced into the market the bacteria become resistant to it, the antibiotics don't work. So it's not worthwhile for them to develop it. We have to use the antibiotics we have very, very judiciously and very, very specially.

Ruda [in pristine hospital ward]: Sometimes you can see that it's dirty. But even when it's gleaming and looks perfectly cleaned, that doesn't mean that there's no bacteria. It may be tempting to think that hospital infections only occur in public hospitals, but this is not the case. The private sector, monopolised by three groups, claims infection rates well below those deemed internationally acceptable. Professor Duse doubts that's accurate.

Prof Duse: There is what we call in infection control the irreducible minimum where, in most countries in the world and counting all the infection types, it would be surprising if a health care facility did not have a rate of these infections that is 5% or more. Only about one percent of hospital infections are fatal. When seven patients in the ICU ward at Pretoria East Netcare died within ten days in February and March - all of them infected with various bacteria that thrive in intensive care settings - family members suspected there might have been a breakdown in infection control.

Amin Chotia (Father): We don't want compensation but at least ... not even a word of sympathy from the hospital, nothing. A simple routine operation where a patient goes home in a day's time and here she stayed 31 days.

Ruda: And then never went home? The Chothias' youngest daughter, Razia, was infected with two resistant bugs. Ingrid Theres lost her fiancé, Heinrich Welscher. He had five different infections and his bill came to over a million Rand.

Ingrid Theres (Fiancé): The doctor said there is a bug in ICU. But the sisters, the staff, said there is no bug. I mean he had the same symptoms as all the other people had who died.

Aysha Chothia (Mother): Her ears were so big, her lips were big, you couldn't even recognise that was Razia. She was double or triple size.

Ruda: So everything was swollen up?

Aysha: Yes, her hands were like balloons – big.

Ingrid: I wanted to see the people from the hospital; they didn't want to see me. They said if I had a complaint then I must put it in writing and fax it to them. They didn't even want to talk to me. The hospital insisted there was no negligence and flatly refused to talk to us. They also barred us from all Netcare hospitals. It was only after we advised family members, believing their rights had been violated, to use the Access to Information Act, that the hospital gave us the information we wanted.

Ruda: They say, ‘be careful what you ask for'. We asked for the patient records, so they sent us the patient records. Dr Brink investigated the case for the hospital. He couldn't find a common source of infection and thus a lapse in infection control. But neither did his report rule it out completely. There were antibiotic resistant bugs among the several that infected the patients in the ward… even so, the report insisted there were “no superbugs”

Ruda: How would you define a superbug?

Brink: A superbug… I don't know a scientific definition. There isn't one.

Ruda: How does one explain that seven people died over a ten day period in the same ward? Brink: The mortality rate in ICUs is high as it is, and it might be a coincidence.

Duse: An intensive care environment lends itself to the selection of very resistant organisms - antibiotics are used on a very large scale. Bugs that are generally found in the environment and are fairly ubiquitous within the context of an intensive care unit can become very problematic and very resistant.

Ruda: So an ICU sounds like a very dangerous place to be? Brink: It's a place where your life is saved in most cases.

Duse: A report like this is not conclusive in my opinion. It does not completely exclude the possibility of there having been a breach in infection control. Both Razia and Heinrich were infected with multi-drug resistant acinetobacter, which can be lethal - especially in people already so compromised. After they died the ward was closed and then moved.

Ruda: Why are hospitals in general so defensive about this?

Brink: Because you get them into trouble.

Duse: I think a lot of hospitals really fear the concept of their reputation will be maligned. Bacterial infections mean higher hospital bills. More than half of one medical aid scheme's 30 highest bills involved hospital acquired infections. But with the burden of proof so difficult, who, if anyone, should take the blame?

Brink: It's a very, very tricky affair because the hospital cannot be held responsible if the majority of the infections that people get, they get from their own bacteria.

Duse: Then the hospitals can turn around and say, well really it was hospital acquired because the patient was in for longer than 48 hours, but we would like to argue whether it was preventable or not. And that's where the big debate comes in. The Medical Research Council is embarking on a major study to track hospital infections and make policy recommendations. We can only hope this will encourage all hospitals to be more accountable and open.



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IMPORTANT DISCLAIMER: While every attempt has been made to ensure this transcript or summary is accurate, Carte Blanche or its agents cannot be held liable for any claims arising out of inaccuracies caused by human error or electronic fault. This transcript was typed from a transcription recording unit and not from an original script, so due to the possibility of mishearing and the difficulty, in some cases, of identifying individual speakers, errors cannot be ruled out.