BERLIN — Each day, whether in a makeshift hospital outside Mosul, Iraq, or a private clinic in the United States, health care workers put their own health at risk by coming into close contact with various illnesses and infections. In fact, it’s estimated that each year, sharps injuries cause 66,000 hepatitis B virus, 16,000 hepatitis C virus, and 200-5,000 human immunodeficiency virus infections among health care workers.
Every day poses a threat, and as the primary link between patients and care, the good health status of health care workers is critical to overall community health.
“I don't think we prioritize the safety and occupational health of health care workers enough. It should be an intrinsic part of our health care systems approach.”— Dr. Peter Salama, former deputy director-general for emergency preparedness and response, WHO
“We want them to be the solution, but they can also be part of the problem because we know that health care facilities can be real transmission points for outbreaks and infectious diseases,” said Dr. Peter Salama, speaking in his role as former deputy director-general for emergency preparedness and response at WHO, at the World Health Summit last year.
“Sometimes we refer to health care workers as the ‘canary in the mine’ for emerging infections because often we pick [them] up because they're infecting health care workers. In North Kivu, in the eastern part of Democratic Republic of Congo, many of the first cases [of last year’s outbreak of Ebola] were health care workers,” he explained.
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Salama, who is now executive director of universal health coverage at WHO, also noted that during the 2002 SARS outbreak, 20% of infections belonged to health care workers, as was the case during the Middle East Respiratory Syndrome outbreak, and that 6% to 8% of the entire health care workforce both in Liberia and Sierra Leone died due to the recent Ebola outbreak.
In low- and middle-income countries, where health care resources are sparse and staff are stretched, how can health care workers adequately protect themselves from illness, infection, or disease in a bid to further safeguard the health of a wider community?
1. Get specific training
More specialized training for health care workers around management of sharps waste, safe injection practices, and bloodborne pathogens could reduce the likelihood of contracting a virus through a needlestick injury. Of the 3 million health care workers experiencing percutaneous exposure to infectious diseases each year, a significant amount of these — 385,000 according to the Centers for Disease Control and Prevention — are due to needlestick injuries. This does not include the 40% to 70% of needlestick injuries that go unreported.
In some cases — when adequate training around proper hypodermic syringe use in particular hasn’t been available — Seth Berkley, CEO at Gavi, the Vaccine Alliance, said Gavi has supplied auto-disable syringes to help tackle this issue. These are single-use needles with safety plunger that lock after use, preventing reuse of the syringe.
“We also provide disposal containers so you have a safe place to dispose of them and then you can go on to incinerate them or get rid of them in an appropriate fashion. Without that, then you put the health [care] workers at risk of infectious diseases, but also patients because of misuse,” Berkley said.
2. Get vaccinated
If there are vaccines available for certain diseases, then it makes sense that health care workers have access to them. It’s more complicated than that though, Berkley noted, explaining that a lot of vaccines administered during childhood may not have been available at the time current health care workers were children — for example, hepatitis A and B, and pneumococcal.
When new vaccines do become available, doses are often limited and children take priority, but Berkley argued that, as a rule, health care workers should always be vaccinated if there is one available.
“They set a standard for the community, so if a health [care] worker’s not willing to get a vaccine, then it's very hard to convince others that they need to do it.”
If and when new vaccines do become available, health care workers should be front of the line to receive them, said Frederik Kristensen, deputy CEO at the Coalition for Epidemic Preparedness Innovations.
3. Don’t forget the basics
In the meantime, protective equipment, basic hygiene, and access to clean water are key to safeguarding against infectious diseases, both airborne and bloodborne. However, in certain parts of the world, these may not be available either. For example, it is reported that 42% of health care facilities across Africa, in countries such as Benin, Uganda, and Zambia, don’t have access to clean water.
“Without that, how can we expect our sophisticated infection prevention and control measures to ever be practical in such settings?” Salama asked. “We face challenges in all of those dimensions in the DRC. We have facilities that, by and large, don't have running water in North Kivu ... then of course until WHO stepped in with its partners, there wasn't the personal protective equipment that was appropriate for dealing with Ebola in place.”
Gavi’s Berkley also stressed the importance of having a good hygiene technique and access to clean water which, according to WHO, means using alcohol-based hand rub if soap is not available. Diarrhea, cholera, pneumonia, parasites, and trachoma can all result from a lack of clean water and hands.
How the international community can safeguard health care workers’ safety
While many of these actions to prevent health care workers from contracting an illness — whether via a needlestick injury or airborne illness — seem simple, in many countries, access to sanitized needles, running water, and vaccinations are not available. Without these, will the onus be on health care workers to protect themselves?
“It's, of course, an individual obligation on behalf of the health care workers to be knowledgeable, to be aware of the latest information, the latest outbreaks, in their country or in their region, but it's also, of course, an obligation of the provider, of the employer — whether that's a government ministry of health or a private health care provider — as part of their duty of care, to make sure that health care workers are protected and that health care facilities enable that protection,” Salama said.
Many of the above recommendations require high-level support and implementation, something which can be absent in some LMICs. “I don't think we prioritize the safety and occupational health of health care workers enough,” Salama stated. “It should be an intrinsic part of our health care systems approach.”
Implementing WHO’s injection safety policy by 2020 is one way to move this issue forward. It calls on governments to transition to the exclusive use of safety-engineered injection devices. Following the joint WHO, International Labour Organization, and UNAIDS policy guidelines for improving health care workers' access to HIV and tuberculosis prevention, treatment, care, and support services is another.
CEPI’s Kristensen suggested that, in addition to in-country governments, the global health community should also step up and help ensure the provision of personal protective equipment and vaccines by making both financial and political commitments.
“They [health care workers] are the critical frontline and I think those who are working in this field should gather behind ensuring their safety for the future.”