HBV and HCV seroprevalence
In Ethiopia data about HBV and HCV among medical waste handlers are lacking. Hence the present study tried to provide the seroprevalence of HBV and HCV in medical waste handlers and some possible risk factors observed in this group of people. The present study has found that 7.0% of MWHs had either HBV (6.0%) or HCV (1.0%). This rate is significantly higher (OR = 7.5; X2 = 5.2; P: 0.02) than that in NCWHs (1.0%).
Comparison with similar studies
Lower and higher prevalence rates were also detected as compared to similar study populations in different parts of the world. Lower prevalence found in Tripoli, Libya with reported rate of 2.3% HBV; whereas 2.7% HCV positivity which was slightly higher [26]; and prevalence of 1.59% also reported in Palestinian medical waste handlers [30]. A higher prevalence rate was reported from Turkey due to injury with various blunt and penetrating objects among housekeepers of whom >70% had been working in a University Hospital [27]. It is worth mentioning that the injuries among housekeepers in Turkey occurred while collecting waste material in the hospital [27]. In Rio de Janeiro, Brazil, a higher rate of 12.9% and 14.2% for HBV in hospital and municipal waste collection workers were reported, respectively [31]. This difference might be due to large sample size, immunization status and methodology used.
The present study showed that high prevalence rate of HBsAg (6.0%) positivity as compared to male (1.0%). Totally opposite result reported in Libyan's study where none of female medical waste handlers were positive compared to 2.9% HBsAg positivity in male [26]. This discrepancy might be due to the fact that the majority of the study participants in Libyan's study were male (four times the number of female participants). However; in our case almost all of the study participants were female (24:1). Regarding impact of educational status on the risk of acquisition of hepatitis viruses, no significant difference was observed between those who had secondary or above (4.0%) and those with primary or less school education (3.0%). Comparable result was obtained in Libya [26].
Comparison with related domestic studies
In Ethiopia, previous population-based surveys had reported medium to high endemicity of viral hepatitis HBV and HCV infection [20, 32, 33]. Although direct comparison is difficult because of methodological and sample size differences, the prevalence obtained in the present study was 6.0% for HBsAg and for 1.0% anti-HCV appears to be in line with a 7% HBsAg and 1.3% ant-HCV prevalence reported previous among the general population in Addis Ababa [18, 24] and a 7.3% HBsAg and 1.3% anti-HCV among antenatal attendees of Gondar health center [34]. It is also consistent with the rate in women attending antenatal clinics in Addis Ababa (5%) HBsAg [35]; to a previous estimate of HBV infection rate in the voluntary counseling and testing (VCT) clients and known HIV-positive cases of St Paul's General Specialized Hospital, Addis Ababa 4.7% HBsAg [36] and also the study in Gondar University Teaching Hospital among blood donors HBsAg 4.7% and anti-HCV 1.3% [37]. However, the present finding was comparable with a studies conducted to pregnant women in Jimma (South west part of Ethiopia) 3.7% HBsAg [38]; with Armed Forces General Hospital, prevalence rate was 9.02% HBsAg [33], but street dwellers in Gondar city resulted 10.9% HBsAg prevalence [39]. This difference might be due to the methodology used, large sample size and the study participants were all health care workers and administrative staff and there are highly vulnerable groups for sexual transmitted disease and sharing of sharp materials potential to hepatitis infections, respectively.
Sharps injuries & splash exposures
Blood Born Virus (BBV) infection may follow needle or sharps injury, contamination of pre-existing skin lesions or splash inoculation to the eyes, nose or mucous membranes [40]. The present study reported that, 25.0% of the medical waste handlers were found to have needle stick or sharp injuries while handling medical waste. This finding was inconsistent with the studies revealed in Nigeria where needle stick injuries among healthcare workers were the commonest forms of exposure to HBV infections [41]. In Italy, needle sticks constituted the most common source of exposure (58.4%), followed by non-intact skin and mucous membrane contamination (22.7% and 11.2% respectively), and cuts (7.7%) [42].
Occurrence analysis revealed 60% of MWHs experienced multiple sharp injuries in similar sites i.e., on fingers and palms during collection, transporting, decanting and disposal of sharps and the rest took place on legs and different body parts (data not presented here). Even though it was difficult to tell here the exact figure for the share of different types of reason for the occurrence of ships injuries due to recall problem, incorrect and inadequate closure of sharp containers and sharp carelessly discarded into waste sack intended only for soft wastes were responsible for these injuries.
Similarly, 44.0% of the study participants were also exposed to blood or others body fluid splash in mouth, nose and eye. This finding was comparable to the study done in UK and China [40, 43]. Participants also indicated carrying of overfilled waste bags, compression of overfilled waste bags/sacks and sharp-edged tearing waste bags/sacks were the major reason for generation and occurrence of blood and body fluids splash.
Personal Protective Equipment (PPE) usage
All medical waste handlers knew that PPE can protect them from infection, though 55% did not use PPE regularly that had 9.1% hepatitis viruses positivity compared to those individual who regularly used PPE 4.4% and more than 85% did not wear boots while performing their duties. This may be the result of lack of training, as < 40% of MWHs were trained to handle medical waste, and shortage of supply since the majority of MWHs complained about shortage of PPE. This was comparable with the study in Libya [26] and Palestinian [30] which found that the level of occupational safety is below standard requirements, as protective equipment and clothing were not available for most workers and only < 20% and 37.2% of the workers were trained in handling medical waste, respectively.
The incidents of sharp injury and splash among MWHs were unacceptably high. It may be prevented though the use of puncture-resistant gloves, poly cotton trousers, penetration-proof masks and protective glasses. Use of PPE is not the only solution for preventing the occurrence of sharp injury and splash. Effective segregation of wastes at source and the correct use of waste containers provide the most effective safeguards [44].
Waste management system
This study discovered that segregation of all waste materials was not conducted according to definite rules and standards. Sometimes hazardous waste was stored in the same containers as the household waste, and no control measures existed for the management of these waste materials. None of the health institution provided strong plastic bags for medical waste segregation and most of the time they used thin plastic bags that can easily tear. None used color coded plastic bags. The same kind and color of household waste bags were used for medical waste. They used any color available in the market, which was normally black, for both general and medical waste materials. In these health institutions, most departments disposed sharp in reusable plastic cans, except in the laboratory where they sometimes used carton sharp boxes when available. Similar situation was observed study conducted in Palestine [30].
It is important to collect and properly contain syringes and needles at the point of use and should seal before it is completely full. After closing and sealing, sharp containers must not be opened, emptied, reused, or sold [45]. In the same manner free flowing liquid waste should contain in leak-proof, rigid durable containers [43]. Red or orange bags are usually used for infectious waste. The containers should also be marked with the universal symbol for biological hazards. Infectious wastes should be contained from the point of origin to the point at which they are not longer infectious [46].
When the waste is to be moved about for treatment or storage, special handling or packaging may be necessary to keep bags intact and to ensure containment of the waste. Single-bagged waste and containers of sharp and liquid should be placed within a rigid or semi rigid container such as a bucket, box, or carton lined with plastic bags. Containers should be covered with lids during transportation and storage. When handling or transporting plastic bags of infectious waste, care should be taken to prevent tearing the bags. Infectious waste should not be compacted before treatment. This process could damage the packaging and disperse the contents, or it could interfere with the effectiveness of treatment. Outside the hospital, infectious waste should be transported in closed, leak proof dumpsters or trucks [46].
Training and supply
Healthcare management should provide education and training to waste generators, handlers, collectors, transporters, and waste treatment facility operators. Handlers must be trained and equipped to undertake the handling, internal transport, spill management and storage requirements for the different types of wastes arising at the facility. The purpose of education and training is to minimize the risk of injury associated with waste handling and facilitate efficient waste management [47]. However, in the studied health institutions the training offered to waste handlers were inadequate and lack regularity. Some of MWHs received training which last for short duration and most did not obtain any training at the time of employment.
The management of each health institution is responsible for the purchasing of sharps and others waste containers. In all studied health institutions because of financial problems there was shortage of safety boxes or proper waste bin. So they used overfilled safety boxes to save these materials. Again shortage and ill fitted size personal protective devices were common in the hospitals. As indicated, few amounts of money were allocated every time for waste management sectors. This financial deficit created problems for continuous availability of waste management equipments and PPE for waste handlers. This could aggravate the existing problems and continuous occurrence of accidents in waste disposal sectors.
Documentation of waste handling errors, injury and exposure
Since there were no well established waste management policies and accident management sections in the studied health institutions, almost all waste handling errors and injuries were not documented. Documentation of waste handling errors, injury and exposure in work place contribute a lot for preventing the re-occurrence of similar cases and a source of information for policy maker to develop and improve rule and regulation.
In most of the cases MWHs took their own measures either alone or with consultation of Infectious Disease Clinic to reduce the chance of infection following injuries. According to article 92 of the Labor Law of Federal democratic Republic of Ethiopia (issued 2003, numbered 377), it is the responsibility of employers to take appropriate steps to ensure that workers are properly instructed and notified concerning the hazards of their respective occupations and the precautions necessary to avoid accident and injury to health; register employment accident and occupational diseases and notify the labor inspection of same and ensure that the work place and premises do not cause danger to the health and safety of the workers. However, this study indicates that the relevant articles of the law and the actual activities are not complied with.
Immunization
In Ethiopia universal infant HBV immunization started in 2007. However, there is no universal availability of the vaccine for adult population and it may be the reason that none of the medical waste handlers in the present study were immunized. Concerning immunization status present study showed inferior result 0.0% compared to studies takes place in Turkey 27.5% [27], Libya 21% [26] and UK 21% [40]. This might be due to the availability of free HBV immunization to risk groups, intensive periodic educational program and implementation of universal precautions which were absent in our study areas.