Occupational Exposure and Observance of Standard Precautions Among Bucco-Dental Health Workers in Referral Hospitals (Yaoundé, Cameroon)

Introduction

The healthcare sector is the fastest-growing sector of the financial system, employing over 18 million workers worldwide. The hospital environment is one of the most hazardous work settings [1,2]. More than facilities employ some 60 million workers worldwide of whom two-thirds of Healthcare Workers (HCW) provide services directly to patients [3]. They are exposed to biological, chemical, physical and psychosocial hazards, resulting in the loss of some 24 million healthy life years [4]. HCWs sustain some 3 million percutaneous exposures annually, more than 90% of which occur in resource- limited countries [5,6]. Exposure to healthcare-related hazards is influenced by the occupational category, work experience and environment [7,8]. They cause work-related stress and sleep disturbances. Such exposures may lead to body fluids or airborne infections. [9,10]. The infectious agents involved include the human acquired immuno-deficiency virus (HIV/AIDS), hepatitis viruses A, B and C, Mycobacterium tuberculosis and a number of blood-borne pathogens, some which cause life-threatening illnesses. Most accidental exposures to blood and body fluids (AEBF) result from medical errors, causing more than 20,000 cases of viral hepatitis B, C (HCV) and HIV/AIDS among HCW [11,12]. They hold a high risk to the health, safety and quality of care delivered [11]. The working environment, availability of health and safety information, compliance with standard precautions (SP) are associated with AEBF [12-14]. Key components of SP include hand hygiene, use of personal protective equipment, development and implementation of preventive health policies [15]. Adherence to SP aims to minimize occupational exposure to body fluids. Compliance with SP is essential to reduce the spread of infectious agents to patients, HCW and visitors of healthcare settings [16]. Oral health practitioners are disproportionally exposed to healthcare associated infections. The accrued risk is related to the use of rotating instrumentation, aerosols produced during bucco-dental care and the closer contact required with the patient cared for [17]. Dental health practitioners have traditionally been among the HCW reporting the most needle stick injuries [12]. Observance of SP and adherence to vaccination are effective interventions to prevent the transmission of healthcare associated infections [18]. Within the Cameroonian healthcare system, referral hospitals are endowed with providing technical support through continued education including issues related to the promotion of infection control in their satellite establishments [10-13]. The present study aimed to determine the level of compliance with infection prevention guidelines among dental health workers in referral hospitals.

Methods

Study Design and Period

The present descriptive cross-sectional study was conducted in five purposefully selected Yaounde-based referral hospitals, from the March to April 2021. Referral hospitals were the University Teaching Hospital (YUTH), the Central (YCH), Jamot (JHY), Gyneco-Obstetric and Pediatric (YGOPH) and General (YGH) hospitals. Each of the hospital has a dental unit with cabinets where bucco-dental health workers operate from Monday to Friday. Dental care units typically bear sterilization rooms, prosthesis laboratory, dental services cabinets with an examination bed and water supply.

Study Participants

The study participants were dental healthcare workers including doctors, nurses, technicians and assistants, all working in the dental cabinets and accessory services.

Data Collection

Data on infection prevention practices were collected using including a self-administered questionnaire and an observation guide. Observations were made on working days (Monday to Friday) and during daily operating cycle. The questionnaire included topics related to hand hygiene, use of personal protective equipment, respiratory hygiene, injection safety, sharps disposal, antisepsis and sterilization.

Data Processing and Analysis

Data collected were entered and analyzed using the SPSS (Statistical Package for the Social Sciences) Version 26. HCWs’ knowledge and practices were assessed with relevance to socio-demographic characteristics. HCW knowledge score were classified as poor (less than 50%), insufficient (50-65%), average (65-85%) and good (more than 85%). Infection prevention practices were classified as very bad (less than 50%), bad (50-65%), inadequate (65-85%) and adequate (>85%).

Results

Out of 53 Bucco-Dental Healthcare Workers (BDHW) contacted, 40 completed the questionnaire, for a response rate of 75.5%.

Socio-Professional Characteristics of Bucco-Dental Health Workers

Study BDHW were mostly dentists (70%) or dental technicians (22.5%). They were women (65%). Participants aged 20-30 years were the most represented (Table 1).

Table 1: Socio-professional Characteristics of Bucco-dental Healthcare Workers in Yaoundé Referral Hospitals, April 2021 (n=40).

Knowledge of Infection Prevention and Control

Almost all participants (97.5%) reported being aware of the risk of infection associated with dental care. Half of the participants (50%) had heard of standard precautions. Less than half (35%) had received training in infection prevention in the healthcare setting. The overall level of knowledge of standard precautions was good for more than half of the HCW (58.5%) (Table 2).

Table 2: Buco-dental Healthcare Workers’ Knowledge of Standard Precautions in Referral Hospitals in Yaoundé, April 2021 (n=40).

Observance of Standard Precautions

Half of the participants (50%) reported washing their hands before procedures. Most dental staff reported a systematic use of Personal Protective Equipment (PPE). However, more than half were confronted with PPE shortcut during dental treatment (55%). All participants reported wearing facial, surgical (92.5%) and FFP2 (7.5%) masks while delivering dental care. More than two-thirds (70%) reported disposing single-use devices correctly. BHCW had inadequate (60%) and detrimental (15%) sharp waste disposal scores (Table 3).

Table 3: Compliance with Standard Precautions among Dental Care staff in Yaoundé Referral Hospitals, April 2021(n=40).

Accidental Exposure to Body Fluids

More than half of the respondents (60%) had experience AEBF in the last three months. The exposures were related to needle stick injuries (NSI). Less than half of the BDHCW (47,5%) were fully vaccinated against Hepatitis B, while 30% were knowledgeable about the immediate action of washing the wound with soap and water after a NSI (Table 4).

Table 4: Practices related to Occupational Exposure among Dental Care Staff in Yaoundé Referral Hospitals, April 2021 (n=40).

Constraints to the Observance of Standard Precautions

Reasons for not adhering to SP were the inadequacy or lack of medical supplies (40%), shortages in PPE (90%), lack of training and lack of time attributable to workload (33%). Discomfort was cited as a reason for not using the FFP2 masks, face shield and goggles (Figure 1).

Figure 1: Reported Barriers to the Observance of Standard Precautions among Bucco-dental Health Workers in Yaoundé Referral Hospitals (n=40).

Discussion

In the present study, we report a low level of knowledge of standard precautions among BDHW. This may be related to the inadequacy of the health and medical education systems to cover such in the initial curricula or as part of the continued education activities. The practice of bucco-dental medicine requires a closer contact with patients than standard clinical work, exposing to a higher risk of transmission of pathogens. Dental therapeutic procedures are often invasive and produce aerosols that contain biological fluids. All caregivers, patients and the working environment may be subject to soiling. Knowledge and adherence to standard precautions by BDHW is essential to manage their specific health risk.

The research team did not receive confirmation on the existence of infection control committees in the study settings. There is a need to include capacity building at the strategic level, training HCW and ensuring that equipment and supplies are provide to sustain infection prevention activities. Such measures should be nurtured and prioritized in health policies. Despite the low number of training sessions, participants had a good understanding of the practice of hand washing and the systematic use of gloves during bucco-dental care. The low proportion of participants having received SP training in the last five years corroborates observations made elsewhere [19-21]. There is a need to sustain adherence to good practice through continued education activities, as BDHW face evolving health technologies and emerging health challenges.

Deficiencies in the supply of PPE, the universal availability of disinfectants, the location of hand washing points were reported as barriers explaining poor compliance with SP among bucco-dental healthcare workers [10]. Though outside the IPC network of activities, heavy workload was reported as a barrier to compliance with standard precautions [22]. Working greater than eight hours per day, on night shifts are associated with exposure to occupational hazards and medical errors among HCW [23].

Almost all participants reported good knowledge, adequate practices related to hand washing. Lower adherence rates (19.4%) were reported in dental care settings in Tunisia [24,25] and Saudi Arabia [26]. The higher adherence reported in the present investigation could be explained by the interest arouse by the COVID-19 pandemic, as there was a widespread availability of disinfectants in healthcare settings. The present study took place during the third phase of the COVID-19 pandemic, as the country witnessed the promotion and distribution of alcohol-based hand sanitizers in health facilities and public places. Most participants reported using personal protective equipment, including masks, gloves and gowns when on duty in accordance with the usual instructions [27]. While gloves were routinely worn for all oral and dental care, they were not changed when care was interrupted, a practice similar to those reported in other dental care settings [25-28].

The low rate of use of FFP2 mask was explained by its unavailability in different departments, and its high cost when acquired at the user’s own expense, similar to reports in Pakistan [27] and Morocco [21]. Less than half of the participants were fully vaccinated against viral hepatitis B. The financial accessibility of the vaccine and the vaccine hesitancy under the COVID-19 interventions, could account for the low coverage. Establishing mandatory pre-engagement vaccination against hepatitis B for health workers could be an option [29,30].

The high prevalence of occupational exposure reported in this study is worrying, although it is similar to that reported in Morocco (58.9%) and Côte d’Ivoire (60%) [21,31]. A comprehensive approach including training, awareness raising, implementation of surveillance activities and ensuring adequate supply of necessary equipment and facilities are warranted [29,32]. Such measures should be scaled to bucco-dental health facilities at the regional and national levels.

Conclusion

Only half of the bucco-dental healthcare workers had good knowledge of standard precautions. The prevalence of accidental exposure to body fluids was unacceptably high and less than half of the BDHW were fully immunized against hepatitis B. Limited resources, insufficient knowledge and workload were the main barriers to compliance with standard precautions. There is an urgent need to set up infection control committees in the study settings to monitor and sustain measure for the occupational safety, the regular supply of PPE, training, promotion of vaccination and other infection prevention and control activities.

Declaration

Author’s Contribution

Drafting of the protocol, data collection, analysis and interpretation: ZFM; Drafting of original manuscript: ZFM and AN; Critical revision of the manuscript: FZLC and ML; Conception, design, supervision of implementation, editing and final validation of the manuscript: IT.

Funding Source

This study received no funding from any agency or organization.

Ethical Approval Statement

The protocol was approved by Institutional Review Board (IRB) of the Faculty of Medicine and Biomedical Sciences of Yaoundé and the ethical clearance: N°188/UY1/FMS/VDRC/DAASR/CSD issued. Informed consent was obtained from participants prior to inclusion in the study.

Declaration of Interests

All authors declare no conflict of interest and approve the final article.

Acknowledgements

We thank all the health personnel who participated in this study as well as well as the management of the hospitals who gave their authorization for this study to be carried out in their hospitals.

References

• Salvage J, Rogers R, Cowell R (1998) Nurses at risk. Nurs Times 94(33): 34-35.
• Moore RM, Kaczmarek RG (1990) Occupational hazards to health care workers: diverse, ill-defined, and not fully appreciated. Am J Infect Control 18(5): 316-327.
• Dal Poz M, Kinfu Y, Dräger S, Kunjumen T (2006) Counting Health Workers: Definitions, Data, Methods and Global Results. Dep Hum Resour Health Evid Inf Policy 1(1): 1-20.
• Fingerhut M, Nelson DI, Driscoll T, Concha Barrientos M, Steenland K, et al. (2006) The contribution of occupational risks to the global burden of disease: summary and next steps. Med Lav 97(2): 313-321.
• Sagoe Moses C, Pearson RD, Perry J, Jagger J (2001) Risks to Health Care Workers in Developing Countries. N Engl J Med 345(7): 538-541.
• Prüss Üstün A, Rapiti E, Hutin Y (2005) Estimation of the global burden of disease attributable to contaminated sharps injuries among health‐care workers. Am J Ind Med 48(6): 482-490.
• McDiarmid MA (2014) Hazards of the health care sector: looking beyond infectious disease. Ann Glob Health 80(4): 315-319.
• Orme NM, Rihal CS, Gulati R, Holmes DR, Lennon RJ, et al. (2015) Occupational Health Hazards of Working in the Interventional Laboratory. J Am Coll Cardiol 65(8): 820-826.
• Orji EO, Fasubaa OB, Onwudiegwu U, Dare FO, Ogunniyi SO (2002) Occupational health hazards among health care workers in an obstetrics and gynaecology unit of a Nigerian teaching hospital. J Obstet Gynaecol 22(1): 75-78.
• Adamu U, Abdullahi A (2017) Common occupational health hazards amongst Health care workers in a Tertiary Health Institution in Bida, North-central Nigeria. Int J Biomed Res 8(01): 1-6.
• Cheuyem FZL, Ndungo JH, Lyonga EE, Mbopi Keou FX, Takougang I (2023) Circumstances of Occurrence and Factors Associated with Occupational Exposure to Body Fluids in District Hospitals (Yaounde, Cameroon). Int J Prev Med Care 1(2):64-72.
• Alrebish SA, Yusufoglu HS, Alotibi RF, Abdulkhalik NS, Ahmed NJ, et al. (2022) Epidemiology of Healthcare-Associated Infections and Adherence to the HAI Prevention Strategies. Healthcare 11(1): 63.
• Degbey CC, Yansambou MS, Sopoh G, Amadou MH, Ouendo EMD (2019) Assessment of the quality of hospital hygiene at Gaweye District hospital in Niamey in 2018. Int J Biol Chem Sci 13(4): 2233-2244.
• Motaarefi H, Mahmoudi H, Mohammadi E, Hasanpour Dehkordi A (2016) Factors Associated with Needlestick Injuries in Health Care Occupations: A Systematic Review. J Clin Diagn Res JCDR 10(8): IE01-IE04.
• Nouetchognou JS, Ateudjieu J, Jemea B, Mesumbe EN, Mbanya D (2016) Surveillance of nosocomial infections in the Yaounde University Teaching Hospital, Cameroon. BMC Res Notes 9(1): 505.
• (2009) WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. World Health Organization.
• Barsotti O, Morrier JJ, Lecollier MD, Brisset L (2001) The risk of infection in the dental office: epidemiological assessment and control of cross-infection. Hygiene IX (3): 210-218.
• Adenlewo OJ, Adeosun PO, Fatusi OA (2017) Medical and dental students’ attitude and practice of prevention strategies against hepatitis B virus infection in a Nigerian university. Pan Afr Med J 28: 33.
• Sharir R, Teitler N, Lavi I, Raz R (2001) High-level handwashing compliance in a community teaching hospital: a challenge that can be met! J Hosp Infect 49(1): 55-58.
• Gorgen H, Kirsch Woik T, Schmidt Ehry B (2004) The District Health System Experiences and Prospects in Africa: manual for public health practitioners.
• Benboubker M, El Marnissi B, Nhili A, El Rhazi K (2017) Knowledge, attitudes and practices towards standard precautions (SP) among caregivers at Hassan II University Teaching Hospital in Fes, Morocco. East Mediterr Health J 23(1): 5-12.
• Ayenew E, Akafu W, Wolde Daka D (2022) Prevalence of Work-Related Health Hazard and Associated Factors among Health Workers in Public Health Institutions of Gambella Town, Western Ethiopia: Cross-Sectional Survey. J Environ Public Health 2022: e6224280.
• Sarsangi V, Salehiniya H, Hannani M, Marzaleh MA, Abadi YS, et al. (2017) Assessment of workload effect on nursing occupational accidents in hospitals of Kashan, Iran. Biomed Res Ther 4(8): 1527-1540.
• Arfaoui S, Maatouk F, Kammoun H, Saidani B, Mezni R, et al. (2013) Audit of dental care resources and hygiene practices in the Bizerte region - Tunisia (in French). HYGIÈNES XII (2): 29-34.
• Laraqui O, Laraqui S, Tripodi D, Zahraoui M, Caubet A, et al. (2008) Assessment of knowledge, attitudes and practices on blood exposure accidents in healthcare settings in Morocco. Med Mal Infect 38(12): 658-666.
• Haridi HK, Al Ammar AS, Al Mansour MI (2016) Compliance with infection control standard precautions guidelines: a survey among dental healthcare workers in Hail Region, Saudi Arabia. J Infect Prev 17(6): 268-276.
• Sarfraz S, Raza R, Aziz K, Umar M, Noreen K, et al. (2020) Compliance on the Use of Different Types of Face Mask by Healthcare Workers and General Public in Tertiary Care Hospital of RMU during COVID-19 Pandemic. J Rawalpindi Med Coll 24(Supp-1): 71-76.
• Onana J, Ngongang A (2002) Hygiene and methods of decontamination, disinfection and sterilization in dental offices in Yaounde. Odontostomatol Trop 25(97): 45-51.
• Cheuyem FZL, Lyonga EE, Kamga HG, Mbopi Keou FX, Takougang I (2023) Needlestick and Sharp Injuries and Hepatitis B Vaccination among Healthcare Workers: A Cross Sectional Study in Six District Hospitals in Yaounde (Cameroon). J Community Med Public Health 7(3): 1-9.
• Amani A, Mossus T, Cheuyem FZL, Bilounga C, Mikamb P, et al. (2022) Gender and COVID-19 Vaccine Disparities in Cameroon. COVID 2(12): 1715-1730.
• Eholie SP, Ehui E, Yebouet Kouame BY, Simo TA, Tanon A, et al. (2022) Analysis of the practices and knowledge of health care personnel on blood exposure accidents in Abidjan (Côte d'Ivoire). Medicine Ill Infected 32(7): 359-368.
• Takougang I, Cheuyem FZL, Lyonga EE, Ndungo JH, Mbopi Keou FX (2023) Observance of Standard Precautions for Infection Prevention in The Covid-19 Era: A Cross Sectional Study in Six District Hospitals in Yaounde, Cameroon. Am J Biomed Sci Res 19(5): 590-598.