ACCI DENTS W I TH POTENTI ALLY HAZARDOUS BI OLOGI CAL MATERI AL
AMONG W ORKERS I N HOSPI TAL SUPPORTI NG SERVI CES
Silvia Rit a Mar in da Silva Canini1 Elucir Gir2 Alcy on e Ar t iolli Mach ado3
Can in i SRMS, Gir E, Mach ado AA. Acciden t s w it h pot en t ially h azar dou s biological m at er ial am on g w or k er s in hospit al suppor t ing ser v ices. Rev Lat ino- am Enfer m agem 2 0 0 5 j ulho- agost o; 1 3 ( 4 ) : 4 9 6 - 5 0 0 .
Descr ipt iv e st udy w as car r ied out t o char act er ize t he occupat ional accident s inv olv ing pot ent ially cont am inat ed m at er ial am on g w or k er s of h ospit al su ppor t in g ser v ices. Th e st u dy r ev iew ed r ecor ds of w or k er s in v olv ed in t hese accident s and at t ended at a specialized out pat ient clinic of a lar ge t er t iar y car e hospit al bet w een Januar y 1997 and Oct ober 2001. A t ot al of 2814 w or k er s fr om differ ent pr ofessional cat egor ies w er e at t ended dur ing t his per iod. Of t hese, 1 4 7 ( 5 . 2 % ) belonged t o t he hospit al suppor t ing ser v ices and w er e t he v ict im s of 1 5 6 accident s, aux iliar y cleaning per sonnel ( 80.2% ) , and over a t hir d of t he w or ker s had not r eceived any dose of hepat it is B vaccine ( 35.4% ) . Most accident s w er e due t o shar p inj ur ies ( 96.8% ) caused by inadequat ely discar ded hollow needles. Chem opr ophy lax is for HI V w as not indicat ed in only 23. 1% of cases. We conclude t hat t hese w or k er s ar e also ex posed t o t he possibilit y of acquir ing blood- bor ne pat hogens and t hat per iodical educat ion p r ogr am s ar e n eed ed .
DESCRI PTORS: acciden t s, occu pat ion al; blood- bor n e pat h ogen s; su ppor t ser v ices; h ospit al
ACCI DENTES CON MATERI AL BI OLÓGI CO ENTRE TRABAJADORES
DE SERVI CI OS DE APOYO HOSPI TALARI O
Est u d i o d e scr i p t i v o f u e ca r a ct e r i za r l o s a cci d e n t e s o cu p a ci o n a l e s co n m a t e r i a l p o t e n ci a l m e n t e con t am in ad o y los t r ab aj ad or es d e los Ser v icios d e Ap oy o Hosp it alar io. El est u d io r ev isó los d at os d e los t r ab aj ad or es in v olu cr ad os en est os accid en t es y at en d id os en u n am b u lat or io esp ecializad o d e u n g r an d e hospit al t er ciar io, en el per iodo de ener o de 1997 a oct ubr e de 2001. Fuer on at endidos en est e per iodo 2.814 t r abaj ador es de div er sas cat egor ías pr ofesion ales. De est os, 1 4 7 ( 5 , 2 % ) per t en ecían al Ser v icio de Apoy o y r egist r ar on 1 5 6 acciden t es. La cat egor ía m ás at in gida f u e au x iliar de lim pieza ( 8 0 , 2 % ) . La m ay or ía de los t r ab aj ad or es n o h ab ía r ecib id o n in g u n a d osis d e la v acu n a con t r a h ep at it is B ( 3 5 , 4 % ) . La m ay or ía d e los acci d en t es f u e co r t o - p u n zan t e ( 9 6 , 8 % ) o casi o n ad o s p o r ag u j as o cas d escar t ad as en l o cal i m p r o p i o . La quim iopr ofilaxis no fue indicada apenas en el 23,1% de los casos. Se concluye que est os pr ofesionales t am bién est án suj et os a la cont am inación por pat ógenos vehiculados por el sangr e. Son necesar ios pr ogr am as educat ivos específicos par a est os t r abaj ador es, con énfasis el los aspect os pr ev ent iv os.
DESCRI PTORES: accident es de t r abaj o; pat ógenos de r esiduos de sangr e; ser v icios hospit alar ios de apoy o
ACI DENTES COM MATERI AL BI OLÓGI CO ENTRE TRABALHADORES
DOS SERVI ÇOS DE APOI O HOSPI TALAR
Est udo descr it iv o obj et iv ou car act er izar os acident es ocupacionais env olv endo m at er ial pot encialm ent e con t am in ado e os t r abalh ador es dos ser v iços de Apoio Hospit alar . O est u do r ev isou dados de t r abalh ador es en v olv idos n est es aciden t es e at en didos n u m am bu lat ór io especializado de u m h ospit al t er ciár io de gr an de por t e, no per íodo de j aneir o de 1997 a out ubr o de 2001. Nest e per íodo for am at endidos 2814 t r abalhador es de diver sas cat egor ias pr ofissionais, sendo que dest es 147 ( 5,2% ) per t enciam aos Ser viços de Apoio e r egist r ar am 1 5 6 acident es. A cat egor ia m ais at ingida foi aux iliar de lim peza ( 8 0 , 2 % ) , e um t er ço dos t r abalhador es não havia r ecebido nenhum a dose da vacina cont r a hepat it e B ( 35,4% ) . A m aior ia dos acident es foi per fur ocor t ant e ( 96,8% ) , ocasionados por agulhas ocas descar t adas em local im pr ópr io. A quim iopr ofilaxia não foi indicada em apen as 2 3 , 1 % dos casos. Con clu i- se qu e est es pr ofission ais t am bém est ão su j eit os a adqu ir ir em pat ógen os v eicu lados pelo san gu e e pr ogr am as edu cacion ais per iódicos são n ecessár ios.
DESCRI TORES: acident es de t r abalho; pat ógenos de r esíduos de sangue; ser v iços hospit alar es de apoio
1
BACKGROUND
D
iffer ent invest igat ions have been conduct ed o n o ccu p at i o n al acci d en t s w i t h b i o l o g i cal m at er i alam ong healt h car e w or ker s, show ing t hat t he w or ker s
m ost exposed t o t his t ype of accident ar e t hose w ho
dir ect ly car e for pat ient s( 1- 4).
I n o u r p r o f e s s i o n a l p r a c t i c e , w e h a v e
obser v ed t h at ot h er w or k er cat egor ies n ot in v olv ed
in dir ect cont act w it h pat ient s or body fluids have been
t h e v ict im s of acciden t s, am on g t h em t h e clean in g,
laundr y, m aint enance, and t r ash collect ion t eam s.
I t w as aft er t he descr ipt ion of t he fir st case
o f a cq u i si t i o n o f h u m a n i m m u n o d e f i ci e n cy v i r u s
( HI V)( 5) t hat m or e em phasis st ar t ed t o be placed on
p r ev en t iv e m easu r es ag ain st in f ect ion w it h b lood
-b o r n e p a t h o g e n s , t o d a y d e n o t e d s t a n d a r d
p r ecau t ion s. St an d ar d Pr ecau t ion s( 6 ) sy n t h esize t h e
m a j o r f e a t u r e s o f b o d y s u b s t a n c e i s o l a t i o n a n d
univ er sal pr ecaut ions( 7) t o pr ev ent t r ansm ission of a
v ar iet y of or ganism s, apply t o blood, all body fluids,
secr et ion s, ex cr et ion s ex cep t sw eat , r eg ar d less of
w het her or not t hey cont ain v isible blood.
Ge n e r a l p r e v e n t i v e m e a su r e s r e co m m e n d
t h e u se of in d iv id u al p r ot ect iv e eq u ip m en t su ch as
g l o v e s, m a sk s, e y e p r o t e ct o r s, a n d g o w n s w h e n
cont act w it h blood or body fluids is for eseen, as w ell
as t h e car ef u l m an i p u l at i o n o f n eed l es an d sh ar p
o b j e c t s a n d h a n d w a s h i n g . Th e g l o v e s a r e
r e co m m e n d e d w h e n t o u ch i n g b l o o d , b o d y f l u i d s,
secr et ion s, ex cr et ion s an d con t am in at ed it em s. Th e
u se of m ask , ey e pr ot ect ion , f ace sh ield t o pr ot ect
m u cou s m em b r an es of t h e ey es, n ose, an d m ou t h
dur ing pr ocedur es and pat ient - car e act ivit ies t hat ar e
lik ely t o gener at e splashes or spr ay s of blood, body
fluids, secret ions and excret ions. Gow ns are indicat ed
t o pr ot ect skin and t o pr event soiling of clot hing dur ing
pr ocedur es and pat ient - car e act iv it ies t hat ar e lik ely
t o gener at e splashes or spr ay s of blood, body fluids,
secr et ions, or ex cr et ions( 6 - 7 ).
Am ong specific m easur es for t he pr ev ent ion
o f a cq u i si t i o n o f b l o o d - b o r n e p a t h o g e n s, o n l y a
v a c c i n e a g a i n s t h e p a t i t i s B i s a v a i l a b l e f o r t h e
pr ev en t ion of acqu isit ion of blood- bor n e pat h ogen s,
w it h 90 a 95% efficacy. Hepat it is B im m une globulin
( HBI G) is r ecom m en d ed w h en a h ealt h car e w or k er
( HCW) , w h o didn ’t r eceiv ed t h e v accin e or h as n ot
r esponded t o it , has been exposed t o a sour ce pat ient .
Hepat it is B v accine also should be init iat ed w hen t he
H CW h a s n o t r e c e i v e d t h e v a c c i n e o r h a s n o t
r esponded t o it( 8).
Regar ding exposur e t o HI V, chem opr ophilaxis
i s r e c o m m e n d e d w h e n t h e e x p o s u r e t o H I V i s
est im at ed t o be high r isk and involves a sour ce pat ient
w it h posit iv e or unk now n ser ology( 9).
As far as hepat it is C ( HCV) is concer ned, t he
o n l y p r e v e n t i v e m e a su r e s a r e l i m i t e d t o t h e u se
st an d ar d p r ecau t ion s, p r ev en t ion of cu t an eou s an d
m u c o s a l e x p o s u r e a n d / o r p r o t e c t i o n a g a i n s t
needlest ick inj ur ies. To dat e, t her e is no vaccine for
t he pr ev ent ion of t his infect ion( 10).
Th e n u m b e r o f a cci d e n t s w i t h p o t e n t i a l l y
co n t am i n at ed m at er i al i s l o w er am o n g w o r k er s o f
h osp it al su p p or t ser v ices t h an am on g p r of ession als
pr ov idin g dir ect car e t o t h e pat ien t s. Th e acciden t s
inv olv in g su p por t per son n el, h ow ev er, ar e a sou r ce
of concern because in m any sit uat ions it is not possible
t o ident ify t he sour ce pat ient .
Alt hough t he cur r ent r ecom m endat ion of t he
Cent er for Disease Cont r ol ( CDC)( 11) is not t o inst it ut e
p r op h y lax is ag ain st HI V in cases of accid en t s w it h
biological m at er ial fr om unk now n sour ce, w e cannot
neglect t he r isk of infect ion w it h hepat it is C v ir us.
St u dies sh ow in g t h e ben efit s of edu cat ion al
p r o g r a m s i n t er m s o f r ed u ct i o n o f a cci d en t s w i t h
biological m at er ial ar e dir ect ed alm ost ex clusiv ely at
healt h car e w or k er s w ho hav e dir ect pat ient car e( 1 2
-13)
. I n addit ion, t he scar cit y of dat a about t his t ype of
accident am ong w or k er s of hospit al suppor t ser v ices
m ot iv at ed us t o conduct t he pr esent st udy.
OBJECTI VE
The obj ect ive of t his st udy w as t o char act er ize
t h e o c c u p a t i o n a l a c c i d e n t s i n v o l v i n g p o t e n t i a l l y
co n t am i n at ed m at er i al am o n g w o r k er s o f h o sp i t al
su p p o r t ser v i ces a t t en d ed a t a l a r g e u n i v er si t y
-af f iliat ed t er t iar y car e h ospit al in Sao Pau lo, Br azil,
dur ing t he per iod bet w een Januar y 1997 and Oct ober
2 0 0 1 .
METHODS
Th i s d e scr i p t i v e , r e t r o sp e ct i v e st u d y w a s
conduct ed in a specialized out pat ient clinic for healt h
car e w or k er s w ho suffer occupat ional accident s w it h
pot ent ially cont am inat ed biological m at erial. The clinic
w hich st ar t ed it s act iv it ies in a sy st em at ic m anner in
c a r e s e v e n d a y s a w e e k . Th e c l i n i c o f f e r s
chem opr ophilax is against HI V and HBV, evaluat ion of
r isk f or h ep at it is C, as w ell as ser olog ic ex am s f or
t he v ict im s of accident s and t he sour ce pat ient s.
All w or k er s of hospit al suppor t ser v ices w ho
r ecei v ed ca r e a t t h e cl i n i c f r o m Ja n u a r y 1 9 9 7 t o
Oct ober 2001 w er e included in t he st udy.
Dat a w er e obt ain ed f r om m edical ch ar t s of
all w or k er s in hospit al suppor t ser v ices w ho r eceiv ed
car e at t h e clin ic f ollow in g ex p osu r e t o p ot en t ially
infect ions m at er ial bet w een Januar y 1997 and Oct ober
2 0 0 1 . Th e d a t a w e r e a n a l y z e d w i t h EPI - I n f o 6 . 0
soft w ar e. The pr oj ect w as appr oved by t he Com m it t ee
o f Et h i ca l i n Resea r ch o f Ri b ei r ã o Pr et o Med i ci n e
College Clin ical Hospit al.
RESULTS AND DI SCUSSI ON
A t o t a l o f 2 , 8 1 4 e x p o su r e s t o p o t e n t i a l l y
h azar d ou s m at er ial in v olv in g cat eg or ies of h osp it al
per son n el w er e r ecor ded w it h 1 5 6 ( 5 . 5 % ) occu r r in g
in hospit al support services. Som e of t hese exposures
occu r r ed in t h e sam e w or k er s, p r ov id in g a t ot al of
1 4 7 w o r k e r s w h o h a d e x p o s u r e t o p o t e n t i a l l y
hazar dous m at er ials dur ing t he st udy per iod.
Th e ch a r a ct e r i st i cs o f t h e se 1 4 7 w o r k e r s
( Table 1 ) w er e: 1 1 6 ( 7 8 . 9 % ) w er e f em ales an d 3 1
( 21.1% ) w er e m ales, 82 ( 55.8% ) w er e 20 t o 40 year s
old, and 61 ( 41.5% ) had been on t he j ob for 1 t o 10
y e a r s. Th e f u n ct i o n a l ca t e g o r y t h a t su f f e r e d t h e
highest num ber of accident s w as cleaning aide, w it h
1 1 8 w or k er s ( 8 0 . 2 % ) , f ollow ed by lau n dr y aide, 1 7
( 1 1 . 6 % ) , g a r b a g e c o l l e c t o r s , 5 ( 3 . 4 % ) a n d
m aint enance aides, 7 ( 4. 8% ) .
Ge n e r a l s t u d i e s o f a c c i d e n t s w i t h s h a r p
o b j e c t s a m o n g h e a l t h c a r e w o r k e r s h a v e
dem on st r at ed an in ciden ce of 3 . 3 an d 5 . 2 % am on g
c l e a n i n g s e c t o r w o r k e r s( 1 3 - 1 5 ), w h e r e a s o t h e r s
sp ecif ically con d u ct ed on h osp it al su p p or t w or k er s
h av e r ep or t ed t h at m ost accid en t s in v olv in g sh ar p
obj ect s occur r ed am ong cleaning w or ker s ( 65.7% )( 15).
A n o u t s t a n d i n g r e s u l t w a s t h a t o n l y 5 2
( 3 5 . 4 % ) w o r k e r s h a d a c o m p l e t e s c h e m e o f
v accin at ion ag ain st h ep at it is B, 3 2 ( 2 1 . 7 % ) h ad in
incom plet e schem e, 52 ( 35.4% ) had not r eceived any
dose of t he vaccine, and 11 ( 7.5% ) could not pr ovide
infor m at ion. The w or k er s w ho had not r eceiv ed any
v a cci n e d o se o r h a d i n i n co m p l e t e sch e m e w e r e
v accinat ed on t he occasion of t he occur r ence of t he
accid en t .
These dat a indicat e t he need t o ext end bot h
educat ional pr ogr am s and cam paigns st im ulat ing t he
adhesion t o vaccinat ion against hepat it is B t o w or ker s
of t he hospit al suppor t ser v ices.
Table 1 - Charact er izat ion of w or ker s of t he hospit al
suppor t ser v ices w ho w er e v ict im s of accident s w it h
biological m at er ial, Januar y 1997 - Oct ober 2001, Br azil
Characteristics Nº %
Gender
Male 31 21.1
Female 116 78.9
Age (years)
< 20 04 2.7 20 to 40 82 55.8 41 to 60 59 40.1 > 60 02 1.4
Time on the job (years)
< 1 36 24.5 1 to 10 61 41.5 11 to 30 26 17.7 Not reported 24 16.3
Functional category
Cleaning aide 118 80.2 Laundry aide 17 11.6 Garbage collector 05 3.4 Maintenance aide 07 4.8
Vaccination status against hepatitis B
Complete 52 35.4
Incomplete 32 21.7
No dose 52 35.4 Does not know 11 7.5
Charact er izat ion of t he 156 accident s ( Table
2 ) show ed t hat 1 5 1 ( 9 6 . 8 % ) inv olv ed shar p obj ect s
and 5 ( 3. 2% ) inv olv ed cut aneous- m ucosal ex posur e.
The body par t m ost fr equent ly involved w as t he hand
120 ( 76. 9% ) .
Table 2 - Type of exposur e t o pot ent ially cont am inat ed
m at er ial by hospit al suppor t ser vice w or ker s, Januar y
1997 - Oct ober 2001, Br azil
Characteristics Type of exposure
Sharp objects Cutaneous-mucosal Affected area Hand Leg Foot Not reported Object Hollow needle Surgical knife Glass Others
Location of the object
The obj ect s m ost fr equent ly inv olv ed in t he
accid en t s w er e h ollow n eed les ( 1 2 5 , 8 0 . 1 % ) . Wit h
r espect t o t he locat ion of t he obj ect t hat caused t he
accident , 80 ( 51.3% ) w her e in com m on gar bage, 25
( 16.0% ) on t he floor, 18 ( 11.5% ) in dir t y laundr y bags,
and 30 ( 19.2% ) at ot her sit es. I n m ost cases it w as
n o t p o ssi b l e t o i d e n t i f y t h e so u r ce p a t i e n t ( 1 4 8 ,
94.9% ) . Analysis of t he sit es w er e shar p obj ect s w er e
f ou n d sh ow ed t h at 7 8 . 8 % w er e discar t ed or lef t in
i n a p p r o p r i a t e p l a c e s , p r o b a b l y b y p r o f e s s i o n a l
inv olv ed in dir ect pat ient car e.
A sim ilar st udy r epor t ed t hat m ost accident s
w it h shar p obj ect s inv olv ing cleaning sect or w or k er s
w as due t o im pr oper disposal of t he obj ect s in 54.7%
of all accident s( 15).
Ta b l e 3 l i s t s t h e d a t a c o n c e r n i n g t h e
ch em o p r o p h y l ax i s co n d u ct ad o p t ed f o r HI V. I n 3 6
ca se s ( 2 3 . 1 % ) n o m e a su r e w a s a d o p t e d , i n 1 0 5
( 6 7 . 3 % ) c h e m o p r o p h y l a x i s w i t h t w o d r u g s w a s
r ecom m en ded, an d in 1 5 ( 9 . 6 % ) ch em opr oph y lax is
w it h t hr ee dr ugs w as r ecom m ended.
Table 3 - Dist r ibut ion of w or ker s of hospit al suppor t
se r v i ce s w h o su f f e r e d a cci d e n t s w i t h p o t e n t i a l l y
cont am inat ed m at er ial accor ding t o chem opr ophylaxis
conduct , Januar y 1997 - Oct ober 2001, Br azil
Chemoprophylaxis against HIV Nº %
None 36 23.1
2 drugs 105 67.3 3 drugs 15 9.6 Total 156 100.0
We o b s e r v e d t h a t m o s t a c c i d e n t s w e r e
c o n s i d e r e d t o i n v o l v e a h i g h r i s k , r e q u i r i n g
chem opr ophylaxis. I n addit ion, in 94.9% of cases t he
sour ce pat ient w as not ident ified, fur t her aggr avat ing
t he sit uat ions of t he w orkers involved in t he accident s.
These w or ker s w er e follow ed up for one year, a per iod
during w hich no seroconversion for HI V or hepat it is B
or C w as obser v ed.
Dur ing follow - up t he vict im s of accident s, 21
w o r k er s p r esen t ed si d e ef f ect s d u e t o t h e u se o f
an t ir et r ov ir al dr u gs. Th e m ost f r equ en t side ef f ect s
w er e nausea and v om it ing, r epor t ed by 13 w or k er s,
follow ed by headache, fat igue, som nolence, and loss
of ap p et it e. Becau se of t h e sid e ef f ect s, 9 w or k er s
i n t e r r u p t e d c h e m o p r o p h y l a x i s o n t h e i r o w n a n d
aban don ed f ollow - u p.
CONCLUSI ON
Al t h o u g h n o ca se o f se r o co n v e r si o n w a s
obser v ed in t he pr esent st udy, em ploy ees of hospit al
su p p or t ser v ices ar e at r isk t o acq u ir e b lood b or n e
p a t h o g e n s si n ce m o st a cci d e n t s i n v o l v e d h o l l o w
n eedles fr om u n k n ow n sou r ce pat ien t s. Th is im plies
t h e u se of ch em op r op hy lax is ag ain st HI V, w h ich in
t ur n incr eases t he cost of at t ending t he v ict im s and
possibly causes leaves fr om w or k due t o t he possible
side ef f ect s.
Most accident s w er e caused by hollow needles
discar ded in inappr opr iat e places, dem onst r at ing t he
car elessn ess of h ealt h car e p r of ession als r eg ar d in g
t heir ow n safet y and t he safet y of pr ofessionals fr om
ot her areas, w ho should t heor et ically be less exposed
t o t hese accident s.
Th u s , w e b e l i e v e t h a t , i n a d d i t i o n t o
r einfor cing t he quest ions of adequat e disposal am ong
h e a l t h c a r e w o r k e r s , w e m u s t d e v e l o p s p e c i f i c
ed u cat ion al p r og r am s in v olv in g p r ev en t m easu r es,
including t he necessit y of vaccinat ion against hepat it is
B, dir ect ed at w or k er s of hospit al suppor t ser v ices.
REFERENCES
1 . Sh an k s NJ, AL- Kalai D. Occu p at ion al r isk of n eed lest ick i n j u r i es a m o n g h ea l t h ca r e p er so n n el i n Sa u d i Ar a b i a . J Hosp it al I n f ect 1 9 9 5 ; 2 9 ( 3 ) : 2 2 1 - 6 .
2 . Row e PM, Gu if f r e M. Ev alu at in g n eed lest ick in j u r ies in n u r sin g p er son n el. AAOHN J 1 9 9 1 ; 3 9 ( 1 1 ) : 5 0 3 - 7 . 3 . Por t a C, Han delm an E, McGov er n P. Needlest ick in j u r ies am on g h ealt h car e w or k er s. AAOHN J 1 9 9 9 ; 4 7 ( 6 ) : 2 3 7 - 4 4 . 4 . Mar zi al e MHP, Ni sh i m u r a KYN, Fer r ei r a MM. Ri sco s d e con t am in ação ocasion ad os p or acid en t es d e t r ab alh o com m at er ial per fur ocor t ant e ent r e t r abalhador es de enfer m agem . Re v La t i n o - a m En f e r m a g e m 2 0 0 4 j a n e i r o - f e v e r e i r o ; 1 2 ( 1 ) : 3 6 - 4 2 .
5 . Ne e d l e st i ck Tr a n sm i ssi o n o f H TVL- I I I f r o m a p a t i e n t in f ect ed in Af r ica. [ Ed it or ial] . Lan cet 1 9 8 4 ; 2 ( 8 4 1 6 ) : 1 3 7 6 -7 .
6. Gar ner JS. Guideline for isolat ion pr ecaut ions in hospit als. I n f ect Con t r ol Hosp Ep id em iol 1 9 9 6 ; 1 7 ( 1 ) : 5 4 - 8 0 . 7 . Ce n t e r s f o r D i se a se Co n t r o l a n d Pr e v e n t i o n . Up d a t e : Univer sal pr ecaut ions for pr event ion of t r ansm ission of hum an im m u n od ef icien cy v ir u s, h ep at it is B v ir u s, an d b lood b or n e pat hogens in healt h car e set t ings. MMWR Mor b Mor t al Wk ly Rep 1 9 8 8 Ju n 2 4 ; 3 7 ( 2 4 ) : 3 7 7 - 8 2 , 3 8 7 - 8 .
9. Cent er s for Disease Cont r ol and Pr ev ent ion. Public Healt h Ser vice guidelines for t he m anagem ent of healt h- car e w or ker ex p osu r es t o HI V an d r ecom m en d at ion f or p ost ex p osu r e p r op h y lax is. MMWR 1 9 9 8 ; 4 7 ( 7 ) : 1 - 3 3 .
1 0 . Ham id SS, Far ooqu i B, Rizv i Q, Su lt an a T, Siddiqu i AA. Ri s k o f t r a n s m i s s i o n a n d f e a t u r e s o f h e p a t i t i s C a f t e r n eed lest ick in j u r ies. I n f ect Con t r ol 1 9 9 5 ; 2 0 ( 1 ) : 6 3 - 4 . 11. Cent er s for Disease Cont r ol and Pr event ion. Public Healt h Se r v i ce g u i d e l i n e s f o r t h e m a n a g e m e n t o f o ccu p a t i o n a l ex posu r es t o HBV, HCV an d HI V an d r ecom m en dat ion s f or p ost ex p osu r e p r op h y lax is. MMWR 2 0 0 1 ; 5 0 ( RR- 1 1 ) : 1 - 4 2 . 12. Car do DM, Bell DM. Bloodbor ne pat hogen t r ansm ission in healt hcar e w or k er s - r isk s and pr ev ent ion st r at egies. I nf Dis Clin Nor t h Am 1 9 9 7 ; 1 1 ( 2 ) : 3 3 0 - 4 6 .
1 3 . Mon g e V, Mat o G, Mar ian o A, Fer n an d ez C, Fer er es J. Epidem iology of biological- ex posur e incident s am ong Spanish h eal t h car e w o r k er s. I n f ect Co n t r o l Ho sp Ep i d em i o l 2 0 0 1 ; 2 2 ( 1 2 ) : 7 7 6 - 8 0 .
14. Ling ML, Wee M, Chan YH. Shar ps and needlest ick inj ur ies: t h e i m p a ct o f h ep a t i t i s B v a cci n a t i o n a s a n i n t er v en t i o n m easu r e. An n Acad Med Sin gapor e 2 0 0 0 ; 2 9 ( 1 ) : 8 6 - 9 . 15. Shiao JS, Mclaw s ML, Huang KY, Guo YL. Shar ps inj ur ies am on g h ospit al per son n el. J Hosp I n f ect 2 0 0 1 ; 4 9 ( 4 ) : 2 6 2 -7 .
