4 0 5
ARTIGO/ARTICLE
Revista da Sociedade Brasileira de Medicina Tropical 3 7 ( 5 ) :4 0 5 -4 0 8 , set-out, 2 0 0 4
Training-related accidents during teacher-student-assistance
activities of medical students
Acidentes relacionados ao treinamento durante a atividade
docente-discente-assistencial de estudantes de medicina
José Mauro Barbosa Reis
1, Adilson Lamounier Filho
1, Cristiano Ângelo Rampinelli
1,
Eliane Cristina de Souza Soares
1, Renata da Silva Prado
1e Ênio Roberto Pietra Pedroso
2ABSTRACT
A surve y wa s do ne to de te rm ine the m o st co m m o n ho spita l a ccide nts with b io lo gica lly co nta m ina te d m a te ria l a m o ng stude nts a t the Me dica l Co lle ge o f the Fe de ra l Unive rsity o f Mina s Ge ra is. Six hundre d a nd nine ty- fo ur stude nts ( b e twe e n fifth a nd twe lfth se m e ste rs o f the co lle ge co urse ) a nswe re d the q ue stio nna ire individua lly. Thre e - hundre d a nd fo rty- nine a ccide nts we re re po rte d. The a ccide nt ra te wa s fo und to b e 33.9% in the third se m e ste r o f the co urse , a nd incre a se d o ve r tim e , re a ching 52.3% in the la st se m e ste r. Sixty- thre e pe rce nt o f the a ccide nts we re ne e dle stick o r sha rp o b je ct injurie s; 18.3% m uco us m e m b ra ne e xpo sure ; 16.6% we re o n the sk in, a nd 1.7% we re sim ulta ne o usly o n the sk in a nd m uco us m e m b ra ne e xpo sure . The co nta m ina ting sub sta nce s we re : b lo o d ( 88.3%) , va gina l se cre tio n ( 1.7%) , a nd o the rs ( 9.1%) . The pa rts o f the b o dy m o st fre q ue ntly a ffe cte d we re : ha nds ( 67%) , e ye s ( 18.9%) , m o uth ( 1.7%) , a nd o the rs ( 6.3%) . The pro ce dure s b e ing pe rfo rm e d whe n the a ccide nts o ccurre d we re : suture ( 34.1%) , a pplying a ne sthe sia ( 16.6%) , a ssisting surge ry ( 8.9%) , dispo sing o f ne e dle s ( 8.6%) , a ssisting de live ry ( 6.3%) , a nd o the rs ( 25.9%) . Fo rty- nine pe rc e nt o f tho se invo lve d re po rte d the a c c ide nt to the a ccide nt co ntro l de pa rtm e nt. Of the se 29.2% did no t re ce ive a de q ua te m e dica l a ssista nce . Eight pe rce nt o f tho se invo lve d use d a ntire tro vira l drugs a nd o f the se 86% disco ntinue d the tre a tm e nt o n re ce iving the ELISA m e tho d a pplie d to the pa tie nt ( HIV-ne ga tive ) ; 6.4% disco ntinue d the tre a tm e nt due to its side - e ffe cts; a nd 1 6% co m ple te d the tre a tm e nt.
Ke y-words: Hu m a n Im m u n o d e f i c i e n c y Vi ru s. Me d i c a l stu d e n ts. Ne e d le sti c k i n ju ri e s. Ai d s.
RESUMO
Este e stu do tra n sve rsa l fo i re a liza do pa ra a va lia r a c ide n te s c o m m a te ria l b io lo gic a m e n te c o n ta m in a do e n tre e stu da n te s de m e dic in a da Un ive rsida de Fe de ra l de Min a s Ge ra is. Fo i a plic a do u m q u e stio n á rio in dividu a l de re spo sta e spo n tâ n e a e sigilo sa , e m 694 ( 43,4%) e studa nte s do q uinto a o dé c im o se gundo se m e stre s do c urso m é dic o . Fo ra m re la ta do s 349 a c ide nte s, c o m a u m e n to pro gre ssivo de 33,9 a té 52,3% e n tre o s e stu da n te s do q u in to a o dé c im o prim e iro pe río do s, re spe c tiva m e n te . Ce rc a d e 6 3 % d o s a c i d e n te s f o ra m c o m a gu lh a o u o b je to c o rta n te ; 1 8 ,3 % a f e ta n d o m u c o sa s; 1 6 ,6 % a p e le ; 1 ,7 % sim u lta n e a m e n te a pe le e a m u c o sa . Os c o n ta m in a n te s prin c ipa is fo ra m sa n gu e ( 88,3%) e se c re ç ã o va gin a l ( 1,7%) . As re giõ e s do c o rpo m a is fre q ü e n te m e n te a fe ta da s fo ra m a s m ã o s ( 67%) , o lho s ( 18,9%) , b o c a ( 1,7%) e o u tra s ( 6,3%) . Os pro c e dim e n to s re a liza do s n o m o m e n to e m q u e o a c ide n te o c o rre u fo ra m su tu ra ( 34,1%) , a dm in istra ç ã o de a n e ste sia ( 16,6%) , pa rtic ipa ç ã o e m c iru rgia c o m o o b se rva do r ( 8,9%) , pu n ç ã o de ve ia c o m a gu lha ( 8,6%) , o b se rva ç ã o de pa rto ( 6,3%) e o u tro s ( 25,9%) . O se to r de b io sse gu ra n ç a da in stitu iç ã o fo i pro c u ra do po r 49% do s a c ide n ta do s pa ra a b u sc a de pro vidê n c ia s pe rtin e n te s à c a da c a so . De ste s e stu da n te s, 29,2% n ã o re c e b e ra m a ssistê n c ia m é dic a c o n side ra da a de q u a da e e sc la re c e do ra pa ra su a situ a ç ã o . Ce rc a de 8 % do s e stu da n te s re c e b e ra m a n tire tro vira is, de ste s 86% de sc o n tin u a ra m o tra ta m e n to c o m o re su lta do do e xa m e ELISA rá pi do f e i to n o pa c i e n te f o n te ( VIH- n e ga ti vo ) ; 6,4% de sc o n ti n u a ra m o tra ta m e n to de vido a o s e fe ito s c o la te ra is da s dro ga s u sa da s e 1 6 % c o m ple ta ra m c o rre ta m e n te o tra ta m e n to .
Pal avr as-chave s: Vi ru s d a Im u n o d e f i c i ê n c i a Hu m a n a . Estu d a n te s d e m e d i c i n a . Le sõ e s p ro vo c a d a s p o r a gu lh a s. Si d a .
1 . Fac uldade de Me dic ina da Unive r sidade Fe de r al de Minas Ge r ais. 2 . De par tame nto de Clínic a Mé dic a da Fac uldade de Me dic ina da Unive r sidade Fe de r al de Minas Ge r ais, B e lo Ho r izo nte , MG.
Addr e ss to: Dr. Enio R. P. Pe dr o so . DCM/FM/UFMG. Av. Alfr e do B ale na 1 9 0 /4 ° andar, Santa Efigê nia, 3 0 1 3 0 - 1 0 0 B e lo Ho r izo nte , MG, B r asil. Te l: 5 5 3 1 3 2 4 8 - 9 4 0 0
4 0 6 Reis JMB e t al
Cir c um s ta n c e s in B r a zil o b lige m e dic a l s tude n ts to
par tic ipate in ac tivitie s that o r dinar ily o nly pr o fe ssio nals wo uld do in many c o untr ies. In their eager ness to lear n mo r e,
stude nts may also ge t invo lve d in e xtr ac ur r ic ular ac tivitie s
to o e ar ly. Suc h c ase s ar e po o r ly supe r vise d. So me B r azilian
r e se ar c he r s have inve stigate d HIV infe c tio n amo ng ho spital wo r k e r s, b ut no ne spe c ific ally de al with stude nts5 8. The se
pec uliar ities highlight the need to evaluate the r isk o f medic al
stude nts c o ntr ac ting dise ase s fr o m patie nts in the ho spital
dur ing the ir te ac he r-stude nt-assistanc e wo r k .
The risk of transmitting human immunodeficiency virus ( HIV) as a result of a single perc utaneous exposure to c ontaminated
material is c onsidered low. The Centers for Disease Control
e stimate d this r isk to b e 0 .4 %9. The fac t that e ve r y he alth
professional is c ontinuously exposed inc reases the risk fac tor. Based on previously published seroc onversion rates, estimated
numbers of ac c idents, and estimated number of HIV-positive
patients, it is possible to calculate the annual contamination index
for students. This fluc tuates between 2 7 and 4 6 per 1 0 0 ,0 0 0 individuals1 0. Personal ac c idents, the leading c ause of death in
this age group, has an equivalent death toll.
Several reports evaluate ac c idental HIV exposure7 8 1 0 1 1 1 2 1 4.
The researc h diffic ulties inc lude rec all bias, the limited sc ope of
the survey, the c hanc e of obtaining inac c urate information, and the subjec tive nature of the responses. Some retrospec tive studies
have b e e n c o nduc te d, inte r vie wing stude nts that r e po r te d
exposure to potentially c ontaminated material8 1 1. Others used a
daily q ue stio nnair e to o ve r c o me r e c all b ias1 4. Still o the r s,
inc luding this study, distributed questio nnaires to a sample
number of students7 1 0 1 2. In spite of the diffic ulties involved in
eac h researc h method they c an all provide valuable information.
This study had the objec tive of evaluating the risk of medic al
students to ac c idental exposure to potentially infec ted material in a hospital setting during their undergraduate training ac tivities
and their ac c ess to biosafety measures whenever nec essary.
MATERIAL AND METHODS
Students were studied at the Medic al College/UFMG ( between
fifth and twelve semesters) . Multiple-c hoic e questionnaires were
used, distributed individually by the researc hers just before
theo retic al c lasses fo r eac h level. The fo rm was c o mpleted
spontaneously and handed bac k at the end of the c lass period.
All the researc h was done from Oc tober to Dec ember, 1 9 9 9 . To
prevent anyone from partic ipating twic e, one of the opening
questions asked whether the student had already answered the
questionnaire, in whic h c ase it was exc luded.
The q ue stio nnair e was made up o f two par ts: the fir st
c o nsisted o f a questio n ab o ut whether the student had alr eady
suffe r e d an ac c ide nt with b io lo gic ally c o ntaminate d mate r ial;
the se c o nd par t was o nly answe r e d b y stude nts who had in
fac t b e e n invo lve d in suc h an ac c ide nt.
I n the se c o nd par t, stude nts we r e ask e d to answe r a spe c ific q ue stio nnair e ab o ut e ac h ac c ide nt the y r e c alle d,
regarding the type of ac c ident, c ontaminating material, body
part affec ted, hospital setting where the ac c ident oc c urred, and subsequent proc edures that were undertaken. It was possible
to mark more than one option as an answer to the questions
about the use of personal protec tion equipment ( barrier use)
a nd a b o ut the fa c to r s tha t c o ntr ib ute d to the a c c ide nta l exposure. It was asked if the student reported the ac c ident to
the medic al c enter and what proc edures they followed.
The sample c alc ulate d was b ase d o n an e stimate o f the
ac c ide nt r ate . Eac h se me ste r o f the me dic al c o ur se r e quir e d
its o wn e stimate . The se e stimate s, se t b y a pr e vio us study1 3.
Calc ulatio ns we r e do ne using Epi Info pr o gr am2 to de te r mine
th e m i n i m u m s a m p l e n e c e s s a r y to e s ta b l i s h s ta ti s ti c a l
signific anc e fo r e ac h se me ste r. The 8 % mar gin o f e r r o r was
ado pte d. This info r matio n is sho wn in Tab le 1 .
The sample obtained was analyzed by the Epi Info program2.
Those interviewed as well as those who dec lined to partic ipate
were guaranteed their identities would not be disc losed.
RESULTS
The to tal numb e r inte r vie we d r e pr e se nte d a signific ant
sample o f the po pulatio n.
Th e r a te a t wh ic h s tude n ts b e twe e n fifth a n d twe lve
se m e ste r s o f the m e dic a l c o ur se suffe r e d a c c ide nts with
po te ntially b lo o d- c o ntam inate d m ate r ial was fo und to b e 3 4 . 2 % ( 2 3 6 /6 9 1 ) ( Tab le 1 ) . The r ate s ac c o r ding to e ac h
se me ste r ar e give n in Tab le 2 .
The to tal numb e r o f ac c ide nts r e po r te d b y 2 3 6 stude nts
wa s 3 4 9 : 6 3 . 3 % ( 2 2 1 /3 4 9 ) we r e n e e dle s tic k o r s h a r p
o b j e c t i n j u r i e s ; 1 8 . 3 % ( 6 4 /3 4 9 ) m u c o u s m e m b r a n e e xpo sur e ; 1 6 .6 % ( 5 8 /3 4 9 ) o n the sk in; and 1 .7 % ( 6 /3 4 9 )
simultane o usly o n the sk in and muc o us me mb r ane .
The hospital setting whic h presented the highest number of
ac c idents was the small wounds sec tor, with 4 2 .1 % of the c ases
( Table 3 ) . The contaminating materials were: blood, 8 8 .3 % ( 3 0 8 / 3 4 9 ) of the ac c idents; vaginal sec retion, 1 .7 % ( 6 /3 4 9 ) ; nasal
Ta ble 1 - The ca lcula ted sa m ple o f students fo r ea ch sem ester o f the m edica l co urse a t the Medica l Co llege o f the Federa l University o f Mina s Gera is sho wing the estim a ted o f the a ccident ra te with po tentia lly co nta m ina ted m a teria l in ho spita l setting during 1999.
Semester of the Total number Estimated Necessary Total of those
medical course of students accident rate ( %) sample interviewed
Fifth 1 7 2 3 16 58
Sixth 1 7 2 3 16 66
Seventh 1 5 6 15 51 87
Eighth 1 6 4 25 67 1 0 7
Ninth 1 6 6 45 78 1 1 3
Tenth 1 6 2 50 78 1 1 3
Eleventh 8 2 * 60 53 61
Twelfth 1 6 9 65 78 86
Total 1 ,2 4 3 - 4 3 7 6 9 1
4 0 7 Revista da Sociedade Brasileira de Medicina Tropical 3 7 ( 5 ) :4 0 5 -4 0 8 , set-out, 2 0 0 4
secretion, 1 .1 % ( 4 /3 4 9 ) ; bloodless pus, 1 .1 % ( 4 /3 4 9 ) ; others,
6 .9 % ( 2 4 /3 4 9 ) . The most affected body parts were: hands, 6 7 % ( 2 3 4 /3 4 9 ) ; eyes, 1 8 .9 % ( 6 6 /3 4 9 ) ; mouth, 1 .7 % ( 6 /3 4 9 ) ; eyes
and mouth, 2 % ( 7 /3 4 9 ) ; others 6 .3 % ( 2 2 /3 4 9 ) .
Fo ur pe r c e nt ( 1 4 /3 4 9 ) o f the ac c ide nts o c c ur r e d while
the stude nt was no t using pe r so nal pr o te c tio n e q uipme nt.
The fr e que nc y with whic h glo ve s, go wns, mask s, and go ggle s we r e use d is sho wn in Tab le 4 .
disc o ntinue d the tr e atm e nt afte r r e c e iving the b lo o d te st
r e sults o f the patie nt invo lve d; 6 .4 % ( 2 /3 1 ) disc o ntinue d the
tr e atme nt due to its side e ffe c ts; 1 6 % ( 5 /3 1 ) c o mplie d with the tr e atme nt c o mple te ly.
DISCUSSION
The ac c ide nt r ate fo r me dic al stude nts with po te ntially
c ontaminated material is high, although it is lower than that of medic al interns1 0. About one third of the population surveyed
were involved in ac c idents. During the final semesters of the c ourse, more than half of the students suffered some kind of
ac c ident involving blood. The data c ollec ted here are similar to those observed at the University of California, USA, where 6 5 % of the medic al students had been involved in some kind
of ac c ident by the end of the c ourse1 1. Blood transmitted viruses,
suc h as HIV, hepatitis B , and hepatitis C, are not unc ommon in suc h c ases. This demonstrates the great ethic al responsibility
of medic al teac hing institutions.
T h e i m p a c t o f tr a i n i n g, a wa r e n e s s p r o gr a m s , a n d
supervision to reduc e ac c ident risk has been analyzed by some studie s1 1 1 4. In spite o f de te r mine d e ffo r t b y the institutio n to
tr a in s tude n ts to a vo id a c c ide n ts dur in g te a c h e r- s tude n t
ac tivities, the Univer sity o f Califo r nia c o ntinued to have a high
a c c ide nt r a te a m o ng stude nts3 1 1, due to fa c to r s tha t a r e
inhe r e nt to me dic al le ar ning. Natur al stude nt anxie ty as the y
treat patients is o ne o f the fac to rs that go es beyo nd the c o ntro l
o f pr e c autio nar y tr aining. Exte nsive tr aining o n manne quins,
emotional support, and extra teac her attention during teac her-Ta ble 2 - Accident ra te by sem ester o f the m edica l co urse with po tentia lly
blo o d-co nta m ina ted m a teria l in ho spita l setting a t the Medica l Co llege o f the Federa l University o f Mina s Gera is during 1999.
Number of accidents/
Semester of the students ( NA) Number of students Accident
medical course absolute % interviewed ( NI) Rate ( NA/NI X 1 0 0 )
Fifth 2 0 .8 5 8 3 .4
Sixth 6 2 .5 6 6 9 .1
Seventh 12 5 .1 87 1 3 .8
Eighth 27 1 1 .4 1 0 7 2 5 .2
Ninth 49 2 0 .9 1 1 3 4 3 .4
Tenth 60 2 5 .4 1 1 3 5 3 .1
Eleventh 35 1 4 .8 6 1 5 7 .4
Twelfth 45 1 9 .1 86 5 2 .3
Ta ble 3 - The ho spita l se ttings which pre se nte d the highe st num be r o f a ccidents with po tentia lly blo o d-co nta m ina ted m a teria l a t the Medica l Co llege o f the Federa l University o f Mina s Gera is during 1999.
Hospital Setting Number of accidents Percentage
Small wounds sector 1 4 7 4 2 .1
Maternity 7 8 2 2 .3
Surgery unit 4 6 1 3 .2
Out-patient surgery unit 3 6 1 0 .4
Intensive care unit 1 3 3 .7
Patient ward 1 2 3 .4
First aid unit 6 1 .7
Others 1 1 3 .2
Total 3 4 9 1 0 0 .0
Ta ble 4: Use o f perso na l pro tectio n equipm ent during 349 a ccidents with po tentia lly blo o d-co nta m ina ted m a teria l in ho spita l setting a t the Medica l Co llege o f the Federa l University o f Mina s Gera is during 1999.
Equipment Frequency of the use of personal protection Percentage
Gloves 3 1 3 8 9 .7
Gowns 2 2 6 6 4 .8
Masks 1 7 2 4 9 .3
Goggles 1 1 5 3 3 .0
None 1 4 4 .0
Sutur ing ac c o unte d fo r 3 4 % ( 1 1 9 /3 4 9 ) o f the ac c ide nts and was the mo st fr e que nt fo r m o f e xpo sur e to ac c ide nts.
The r ate at whic h o the r pr o c e dur e s r e sulte d in ac c ide nts is
give n in Tab le 5 .
Tab le 6 sho ws that the gr e ate st fac to r c o ntr ib uting to
ac c ide nts was c ar e le ssne ss, with 4 4 .7 % ( 1 5 6 /3 4 9 ) .
Fo r ty- n in e pe r c e n t ( 1 7 3 /3 4 9 ) o f th e a c c ide n ts we r e r e po r te d to the he alth c e nte r. Of the se , 5 7 % c o nside r e d the y
did no t r e c e ive ade quate assistanc e .
Nine perc ent ( 3 1 /3 4 9 ) o f tho se invo lved in ac c idents used
a a n ti r e tr o vi r a l dr u gs . S e ve n ty s e ve n p e r c e n t ( 2 4 /3 1 )
Ta ble 5 - Pro cedures which invo lved the m o st frequent a ccidenta l expo sures with po tentia lly blo o d-co nta m ina ted m a teria l in ho spita l setting a t the Medica l Co llege o f the Federa l University o f Mina s Gera is during 1999.
Procedures Number of accidents Procedure rate ( %)
Suturing 1 1 9 3 3 .8
Applying local anesthesia 58 1 6 .6
Assisting surgery 31 8 .9
Recapping needle 30 8 .6
Assisting delivery 22 6 .3
Handling needle case 12 3 .4
Handling knife 6 1 .7
Others 69 1 9 .8
Did not respond 2 0 .6
Total 3 4 9 1 9 .7
Ta ble 6 - Fa cto rs co ntributing to 349 a ccidents with po tentia lly blo o d-co nta m ina ted m a teria l in ho spita l setting a t the Medica l Co llege o f the Federa l University o f Mina s Gera is during 1999 a s repo rted by the students.
Factors contributing to accidents Number of accidents Percentage
Carelessness 1 5 6 4 5 .3
Lack of experience 1 0 8 3 0 .9
Carelessness of others 1 0 1 2 8 .9
Lack of personal protection equipment 49 1 4 .4
Long work hours 43 1 2 .3
Poor instructions 31 8 .9
Inadequate facilities 19 5 .4
4 0 8
stude nt assistanc e ac tivitie s c o uld play a de c isive r o le in
r e duc ing the r isk o f ac c ide ntal HIV e xpo sur e .
De spite the se que stio ns, the me dic al c ur r ic ulum sho uld pr e par e stude nts witho ut e xpo sing the m to unac c e ptab le
r isk s. The m e dic al te ac hing institutio n sho uld guar ante e
ade quate instr uc tio n to the pupils as we ll as wo r k ing to war d
this o b j e c tive in o the r ways. Fo r b idding stude nts to have c o ntac t with HIV po sitive patients is c o nsider ed unethic al and
a po o r teac hing metho d3. Po st-ac c ident pr o phylaxis, ho wever
has b e e n pr o ve n to r e duc e the r isk o f HIV c o ntaminatio n1 4,
and sho uld, in suc h c ir c umstanc e s, b e c o nside r e d a pr io r ity and made e asily availab le , inc luding te c hnic al and e mo tio nal
suppo r t, as we ll as me dic al fo llo w up.
REFERENCES
1 . Car do DM, Culver DH, Ciesielsk i JL. Sr ivastava PU, Mar c us R. A c ase-c o ntr o l study o f HIV se r o c o nve r sio n in he alth c ar e wo r k e r s afte r pe r c utane o us e xpo sur e . Ne w England J o ur nal o f Me dic ine 3 3 7 : 1 4 8 5 - 1 4 9 0 , 1 9 9 7 .
2 . De a n AG, De a n J A, Co ulo m b ie r D. Ce n te r s fo r Dis e a s e Co n tr o l a n d Pr e ve ntio n ( CDC) . Epi Info ve r sio n 6 , 0 4 , 1 9 9 4 .
3 . Fe de r man DD. Pr o te c ting the futur e o f Me dic ine – fr o m the mse lve s. Annals o f Inte r nal Me dic ine 1 3 0 : 6 6 - 6 7 , 1 9 9 9 .
4 . Ge r b e r ding J L. Manage m e nt o f o c c upatio nal e xpo sur e to b lo o d- b o r ne vir use s. Ne w England J o ur nal o f Me dic ine 3 3 2 : 4 4 4 - 4 5 1 , 1 9 9 5 .
5 . Gi r E , Co s ta FP P, S i l va AM. A e n fe r m a ge m fr e n te a a c i d e n te s d e tr a b a l h o c o m m a te r ia l po te n c ia lm e n te c o n ta m in a do n a e r a do HI V.
Re vis ta da Es c o la de Enfe r mage m da Unive r sidade de São Paulo 3 2 : 2 6 2 -2 7 -2 , 1 9 9 8 .
6 . He r m a nn RC. Ris k s o f HI V e xpo s ur e to m e dic a l s tude nts a nd he a lth c a r e
pe r s o nne l. J o ur na l o f Am e r ic a n Me dic a l As s o c ia tio n 2 6 4 : 1 1 8 7 - 1 1 9 2 , 1 9 9 0
7 . Ke ita- Pe r se O, Pr adie r C, Ro se nthal E, Altar e J , Cassuto J P, De llamo nic a P. Ho spital me dic al stude nts: a po pulatio n at r isk fo r ac c ide ntal e xpo sur e to b lo o d. Pr e sse Me dic ale 2 7 : 1 7 2 3 - 1 7 2 6 , 1 9 9 8 .
8 . Mac hado AA, Co sta J C, Gir E, Mo r iya TM, Figue ir e do FC. Risc o de infe c ç äo pe lo vír us da imuno de fic iê nc ia humana ( HIV) e m pr o fissio nais de saúde . Re vista de Saúde Púb lic a 2 6 : 5 4 - 5 6 , 1 9 9 2 .
9 . Mar c us R. Sur ve illanc e o f he alth c ar e wo r k e r s e xpo se d to b lo o d fr o m patie nts infe c te d with the human immuno de fic ie nc y vir us. Ne w England J o ur nal o f Me dic ine 3 1 9 : 1 1 1 8 - 1 1 2 3 , 1 9 9 8 .
1 0 . O’Ne ill TM, Ab b o tt AV, Rade c k i SE. Risk o f ne e dle stic k s and o c c upatio nal e xpo sur e s am o ng r e side nts and m e dic al stude nts. Ar c hive s o f Inte r nal Me dic ine 1 5 2 : 1 4 5 1 - 1 4 5 6 , 1 9 9 2 .
1 1 . Osb o r n HE, Papadak is MA, Ge r b e r ding JL. Oc c upatio nal e xpo sur e s to b o dy fluids am o ng m e dic al stude nts. A 7 - ye ar lo ngitudinal study. Annals o f Inte r nal Me dic ine 1 3 0 : 4 5 - 5 1 , 1 9 9 9 .
1 2 . Resnic SF, No er dlinger MA. Oc c upatio nal Expo sur e Amo ng Medic al Students and Ho use Staff at a Ne w Yo r k City Me dic al Ce nte r. Ar c hive s o f Inte r nal Me dic ine 1 5 5 : 7 5 - 8 0 , 1 9 9 5 .
1 3 . S o a r e s E S , S a l l e s J A, P r a d o R S , P e d r o s o E R P. Ava l i a ç ã o d o s c o m po r ta m e n to s de r is c o de e s tuda n te s de m e dic in a e m r e la ç ã o à síndr o me de imuno de fic iê nc ia adq uir ida. In : Resumo s do XXXV Co ngr e sso da So c ie dade B r asile ir a de Me dic ina Tr o pic al, 1 9 9 9 . Re vista da So c ie dade B r a s ile ir a de Me dic ina Tr o pic a l 3 2 ( s upl I ) : 3 5 0 , 1 9 9 9 .
1 4 . Wo ng ES, Sto tk a J L. Ar e Unive r sal Pr e c autio ns Effe c tive in Re duc ing the Numb e r o f Oc c upatio nal Expo sur e s Amo ng He alth Car e Wo r k e r s?Jo ur nal o f Ame r ic an Me dic al Asso c iatio n 2 6 5 : 1 1 2 3 - 1 1 2 8 , 1 9 9 1 .
