Prevalence of exposure to needle stick and sharp‐related injury and status of hepatitis B vaccination among healthcare workers: A cross‐sectional study

Abstract Background and Aims Hepatitis B is a leading cause of chronic liver disease and subsequent liver transplantation. This is a vaccine‐preventable illness. Health workers continue to be at risk for blood‐borne pathogens due to occupational exposures. The overall goals of our study were to determine the prevalence of exposure to needle sticks and sharp‐related injuries (NSSI) and hepatitis B vaccination status among healthcare workers (HCWs) of Nepalgunj Medical College Teaching Hospital (NGMCTH), Kohalpur, Banke, Nepal. Methods A descriptive cross‐sectional study was conducted among HCWs at the NGMCTH following ethics approval by the NGMCTH Ethics Review Committee. A pretested structured questionnaire was used to compile the data. Data was collected from September 15, 2021 to September 14, 2022. Collected data entered in Microsoft Excel and analyzed using statistical package for social sciences version 22. Analyzed data were presented using simple descriptive statistics with appropriate figures and tables. Results A total of 304 among 506 HCWs (60.1%) participated in the survey were exposed to Needle sticks. Nine of whom (3.7%) were injured substantially (more than 10 times). Among nursing students, 21.3% had experience with NSSI. 71.7% of HCWs had received at least one dose of the hepatitis B vaccine, of whom 61.9% (44.5% of total HCWs) had received three doses. Conclusions This study demonstrated that more than two‐quarters of HCWs were exposed to NSSI. Despite being at risk, vaccination status was still low, and less than half only received three complete doses. Precaution should be taken when working with instrumentation and procedures. Hepatitis B immunization programs for HCWs should be delivered at no cost with 100% coverage and protection. Raising awareness about hepatitis B infection and immunization remains crucial to primary prevention.


| INTRODUCTION
Hepatitis B virus (HBV) is the most common blood-borne transmissible disease seen in healthcare settings with higher endemicity in Asian countries (75%) especially South East Asia Region (10%-20%). [1][2][3] The Centers for Disease Control and Prevention estimates that over 380,000 percutaneous-related injuries occur annually among hospital employees and approximately half of such exposures go unreported.
Globally, about 32.4%-44.5% of healthcare workers (HCWs) report annual report states such injuries occur four per HCWs in Asia. 6 HBV infection is a preventable disease by vaccination. The risk of transmission in nonimmunized is about 6%-30%. HBV Vaccine and gamma globulin reduce this risk by 90%-95%. But unfortunately, the WHO report shows vaccine coverage among HCWs worldwide is very low. In underdeveloped and developing countries, it is about only 18%-39%. 7,8 Though WHO has recommended special consideration for HCWs and medical students for a screening of HBV and vaccination, Nepal Government lacks a policy-level program to vaccinate such at-risk populations. 9 Similarly, health institutions cannot make necessary arrangements to protect their staff and trainees. 10 HCWs, especially nurses and laboratory staff, are the first level of contact between patients and medical care. 11 About three million HCWs every year are exposed to pathogens, of which two million are exposed to HBV, 0.9 million to hepatitis C (HCV), and 0.1 million are exposed to HIV.

| Questionnaire administration
Pretested semistructured self-administered questionnaire in printed form was administered to obtain primary data from study participants. Sociodemography details, the prevalence of NSSI, and the status of hepatitis B vaccination were major parameters used in the questionnaire.

| Statistical analysis
Collected primary data were later tabulated and analyzed using crosstabulation and descriptive analysis. All the collected information was entered using Microsoft Excel and analyzed using the statistical package for social sciences version 22 and STATA version 15 for descriptive analysis. The normality of data was tested using the Shapiro-Wilk test. A χ 2 test was done to see the association between categorical variables and NSSI experience. Further association is delineated using logistic regression analysis using STATA for NSSI.
Analyzed data were thus presented in the form of tables and charts and interpreted accordingly. The association is considered significant if the p < 0.05.

| RESULTS
A total of 506 medical/nursing students and care providers were included in the study. The majority (64%) were females. Only about one-third (29.6%) was older than 30 years. A total of 30.6% were doctors, followed by nursing students (29.6%) and nurses (20%), then medical students and paramedics. A total of 88.7% of the participants know having HBV risk (Table 1). NSSI was reported in 304 (60.08%), of them 19 (3.75%) reported being exposed >10 times (Supporting Information: Figure 1).
Among 304 injured participants, the maximum was exposed to blood percutaneously and most of the injury was due to hollow bore needles (46.1%) followed by suture needles. There was a slight difference in whether they know the HBV status of patients they were exposed to. IV cannulation was the maximum procedure and the emergency department (ER) was found at the major site for injury followed by the ward (Table 2). Nursing students were found to have exposure to NSSI with surprisingly lowest exposure experience in the laboratory (Supporting Information: Figure 2).
Our participants believed most of the time NSSI happened accidentally and while not taking safety precautions. Few of them supported vision problems and lack of proper sleep to be the cause.
Phobia and overconfidence in the procedure were least likely (Supporting Information: Figure 3). About 71.7% of total participants were found to be vaccinated against HBV and among them, 61.9% (44.5% of total HCWs included) have a total of three complete doses.
Out of 363 vaccinated participants, only 34.2% of them had taken a booster dose (Supporting Information: Table 1). Among all the professionals, 133 doctors were found to have been vaccinated followed by nursing students (Figure 2).
While accessing the knowledge about the correct dose of the HBV vaccine that provides immunity in the body, the majority of the participants were unaware of it (Supporting Information: Figure 4).
The normality of data distribution was tested using the Shapiro-Wilk test. Our data were nonnormal in distribution. The χ 2 test was used to see the association between NSSI experience and determinant variables (profession, sex, age, vaccine status, and dose of vaccination). Among all tested variables, p < 0.05, suggesting a significant association (Table 3). clinical year medical students (aOR: 0.08) in reference to nurses.
However vaccinated individuals have higher odds of having NSSI experience (aOR: 4.5). Though age and sex categories were found to have associated in the χ 2 test, multiple logistic regression analysis adjusting with other tested variables did not show such association (Supporting Information: Table 2).

| DISCUSSION
Among 506 participants in our study, the majority were females (64%), with age groups ranging from 15 to 30 years of age. Most of the participants were in the age group of 20-25 years. Doctors (30.6%) were the major profession followed by nursing students (29.6%) among the participants. Among participants, 88.7% were aware of being at the high risk to the HBV exposure. In our current study, we found that 304 (60.08%) reported being exposed to NSSI.
This finding is consistent with similar studies conducted among nursing and midwifery students in Eastern Ethiopia, where 62.8% reported NSSI. 12 We also observed a comparable rate among nurses working in Northeast Ethiopia, with 34.5% self-reporting needle stick injuries.
Notably nursing students accounted for the higher proportion of injuries in our study (35.5%). 13 On the other hand, our finding was lower than a study conducted among midwives and nurses in Northeast Ethiopia, where 75.5% reported NSSI. 14 Additionally, the NSSI injury rate in our study was higher than a similar study conducted among HCWs in Nepal, which reported a prevalence of 37.6% of Needle stick injuries. 15 Another study carried out in Nepal among HCWs reported an NSSI rate of 74%. 16 In our study, NSSI was more prevalent among individuals aged >30, whereas a study conducted at B.P. Koirala Institute of Health Sciences (BPKIHS), Nepal, found that NSSI was more common in the ≤22 years age group. 8 A significant association was found between the prevalence of NSSI and the types of profession (p < 0.001) which has been supported by the studies done in other parts of Nepal (p < 0.05). 15 Our study also showed a significant difference between the prevalence of NSSI and other variables like age, sex, vaccination against HBV, and so on. This finding is consistent with studies done by Bhattrai et al. 10 Similarly, Knowledge was assessed for the prevalence of NSSI with Sex and was found to have no any significant differences. 9 However, in the study done among HCWs of Saudi Arabia, no any evidence of an association between NSSI with profession and sex had been found. 4 In the study done at students of eastern Ethiopia, males were 1.56 times more likely to be injured with NSSI while in our study after analyzing with multiple logistic regression, no significant association was seen between sex and age. 12 Our study showed NSSI experience was low in ACHWs and clinical-year medical students in comparison to the nurses. In contrast to our study, NSSI was not found to be significantly associated with the Nurses done in the study in Northeast Ethiopia. 14 The majority of incidents in our study occurred with hollow bore needles, consistent with other studies conducted in Nepal. 6 Mon et al., 2014 in their study report the same finding. 17 The most common place of injury was the ER (49.7%) followed by the ward.
This could be attributed to rush hours and the increased need for sample collection in the ER. About 52% of the participants had been accidentally exposed to the blood which aligns with a study conducted among medical students in Cameroon. 18  writing-review and editing.

ACKNOWLEDGMENTS
We thank all the participants who helped us by participating in this study. We would like to acknowledge Dr. Ajaya Raj Gautam and Dr.
Sibika Malla for their valuable insight into this paper. Our study lacks the assessment of knowledge about prevention from NSSI and hepatitis B vaccination. Recall bias was also significant.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.

ETHICS STATEMENT
Ethics approval for the research project was obtained from the NGMCTH Ethics Review Committee. All co-authors have read and approved the final version of the manuscript. The lead author K. C.
Rupak had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

TRANSPARENCY STATEMENT
The lead author K. C. Rupak affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.