GRANADA, Spain — The COVID-19 pandemic has highlighted the very real dangers that front-line health care workers face while doing their jobs each and every day.
Currently, the news cycle has focused on the pressing need for personal protective equipment to shield health care personnel from contracting the coronavirus. But these professionals are also routinely exposed to other hazards that receive less attention, such as bloodborne pathogens, which can be transmitted via needle stick injuries.
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 occupational illness, infection, or disease to further safeguard the health of the wider community?
Despite the real danger that needle stick injuries pose, there is a lack of data on the true scope of the problem. According to the most recent statistics, which date back to 2002, at least 3 million health care workers globally suffer needle stick injuries on the job each year, resulting in occupational exposure to bloodborne pathogens.
More recent statistics from 2017 indicate that needle stick injuries account for about 40% of hepatitis B virus and hepatitis C virus infections and 2.5% of HIV infections in health care workers globally. And more than 90% of these infections occur in developing countries — “particularly in Africa, where infection is more prevalent and adherence to standard precautions can be poor,” according to the World Health Organization.
In addition to the risk of contracting bloodborne pathogens, the health care workers who suffer needle stick injuries also often face stigma — which can impact their health-seeking behavior, according to Dr. Daniel Kimani, technical adviser to the lab services branch of the U.S. Centers for Disease Control and Prevention’s division for HIV and tuberculosis in Nairobi. In conversation with Devex, Kimani discussed why stigma is such a big problem and what can be done to combat it.
This conversation has been edited for length and clarity.
How have you seen health care workers in Kenya affected by stigma in the context of needle stick injuries in high-HIV-prevalence settings?
People don’t want to talk about HIV. People fear the possibility of getting HIV and other bloodborne pathogens. … For you to get the post-exposure prophylaxis [or PEP], you first have to [have been] tested for HIV. So there is first the fear that you may end up being HIV infected at that first test.
The second reason there is stigma is that people may think you are incompetent and that’s why you got an injury. I have this vivid [memory] of last year where I met a doctor working in the field. From my clinical acumen, I could see that he was most likely suffering from advanced HIV disease, but when I asked him if he was OK, he told me that he had a kidney problem.
Unfortunately, this doctor died a month later, and I learned that he died from HIV-related complications. Why didn’t this doctor talk about it? Stigma, fear about what would be said about him.
How does stigma affect self-reporting of needle stick injuries? What can be done to improve the situation?
Stigma is real, and what it does is inhibit health care workers who get needle stick injuries from reporting and getting the HIV post-exposure prophylaxis to prevent them from getting infected with HIV. One of the concerns that the health care workers have is that the report will be written in a register that can be accessed by other people.
We have a solution to this. Through the CDC-BD partnership, together with the Ministry of Health and an organization called mHealth Kenya, we have come up with an innovative solution using technology. Over 99% of health care workers have a mobile phone, so we said, “Why don’t we develop an app where, with the click of a button on your phone, you can report a needle stick injury? And what this does is you can do it at the private space.”
But secondly, the mobile app will give you reminders on adherence to PEP, because from a study we conducted in Kenya for 1,665 health care workers who had a needle stick injury, only 30% completed the PEP. So this mobile app will help you with completion of PEP because it also becomes a patient support system. As of January 2020, over 8,000 health care workers have enrolled.
What else can be done to address the issue of stigma and needle stick reporting?
Safety training is quite critical, because if you are a health care worker, there is a very real risk of occupational exposure to bloodborne pathogens. Safety training can help with reduction of stigma — it improves worker practices to make sure that they are safer, which means that health care workers are less likely to be injured. It also gives health care workers valuable prevention and intervention information, so they know how to get treatment in case they are exposed.
Another thing that we did in Kenya is roll out a self-test kit. This was initially piloted among health care workers — who preferred it, because if a doctor gets exposed, they often don’t want to go to another doctor or nurse to get tested because it means a colleague may know their HIV status. So if there’s a confidential way they can test themselves to know their status upfront and early enough, it’s a really excellent tool to combat stigma.
“Stigma is real, and what it does is inhibit health care workers who get needle stick injuries from reporting.”— Dr. Daniel Kimani, CDC technical adviser
Additionally, it’s important to make sure that health care workers have universal access to PEP so that in case they are exposed, they can get treatment with the drug. I remember a few years back, I met a patient who had to travel 50 kilometers [31 miles] from a health center to a district hospital to get PEP, but now it’s universally available. That’s very important. Knowing that it’s possible to prevent getting infected also helps to reduce stigma.
What role can surveillance systems play in improving health worker safety for needle stick injury and decreasing stigma?
It is vital to make sure that there is a surveillance system in place to document what injuries are taking place. We have introduced a surveillance system in Kenya to look at needle stick injuries, where we mapped out 35 health facilities in Kenya and analyzed 1,665 injuries. And just imagine — in so few facilities, so many people were injured.
This shows the magnitude of this issue, and it can also be used to track stigma. Because usually the recommendation after exposure is to try to find out the HIV status of the patient. But we found that only about half were documented, and about 40% of those were infected with HIV — so it means there’s very real risk after a single exposure. Of the health workers who were exposed, 11 of them were found to have been HIV infected already, and so were ineligible to take the PEP. In the end, only 30% completed the post-exposure prophylaxis.
There are a lot of reasons for this — there could have been a documentation issue, perhaps people completed and didn’t report, while others said the drugs had side effects so they didn’t complete the course. And stigma could be another reason. Having this surveillance information is really important.