Occupational health in the developing world is largely a neglected concept, and this is ultimately very costly. The economic burden of occupational injuries is estimated to be as high as 10% of the GDP in some countries in Latin America and the Caribbean.1 In Peru, these costs are up to 5.5 billion dollars per year,2 according to the International Labor Organization, but many injuries go unreported.3–5
The situation of health care workers (HCW) in the developing world is emblematic of this neglect, and unfortunately, there is a paucity of data concerning the extent of occupational injuries among them. HCW should legitimately lead the efforts to improve occupational health in the developing world, but they are too often unaware of the dangers or the culture of prevention. They face significant risks that are often under-appreciated, including severe acute respiratory syndrome (SARS), human immunodeficiency virus (HIV), extensively drug resistant tuberculosis (XDR TB), and even avian (H5N1) influenza. The SARS outbreak clearly illustrates the danger posed to HCW in the performance of their duty6,7; 21% of the clinical cases were HCW,8 and even occurred in resource-available settings with adequate personal protective equipment (PPE).9 In current avian influenza (H5N1) outbreaks, human-to-human transmission appears to be inefficient, although several studies have concluded that precautions are still necessary, because the virus may evolve to become more transmissible among humans.10–12 Most importantly, it should be noted that these emerging infections arose in developing countries where resources are limited and occupational health is either nonexistent, or at best, not given high priority.
One of the most significant occupational threats that HCW around the world face daily is needlestick injury, and this provides a proxy tool for assessing occupational health in general—the lessons learned will likely apply to SARS, XDR TB, avian influenza, Marburg virus infection, or other important transmissible agents. Approximately 3 million percutaneous exposures to bloodborne pathogens occur annually among 35 million HCW worldwide,13 resulting in an estimated 6600 hepatitis B infections, 16,000 hepatitis C infections, and up to 5000 HIV infections.14 The WHO estimates that 40% of hepatitis B and C, and 2.5% of HIV infections among health workers are attributable to work exposures.15 Developing countries shoulder most of the burden, as 90% of infections due to these exposures occur in low-income countries.16 Subregional data from the WHO estimates the incidence of sharps injuries at 2.53 per health care worker each year in countries like Bolivia, Ecuador, Guatemala, Haiti, Nicaragua, and Peru. This is especially pertinent given the mean HBV immunization rate among HCW in developing regions is only 39%, underscoring that this is a population at risk for even preventable diseases.14
Underreporting of occupational exposures also seems to be a widespread problem among HCW, both in the United States and other countries, like Costa Rica.17–19 The Centers for Disease Control and Prevention and the International Health Care Worker Safety Center have estimated an annual underreporting rate of 57% and 39%, respectively, of percutaneous injuries among US phlebotomists.20 Similarly, only 9% of exposures in health care facilities are ultimately documented, with lowest reporting rates especially in developing countries.21 Occupationally acquired HIV seems to be particularly under-reported, as 70% of all HIV cases live in sub-Saharan Africa, but only 4% of all occupationally acquired HIV infections are reported from this region,22 and only 5% of HIV infection acquired among HCW worldwide were reported from developing countries.23
Perhaps one of the most accessible and appropriate settings in the developing world to observe the state of occupational health is international collaborative medical research. Medical research often involves potential exposure to blood or body fluids, and there are proven methods for attenuating this risk, such as engineering controls, training, PPE (ie, gloves, eye protection), and the availability of postexposure prophylaxis for HIV. Conducting medical research in the developing setting also involves having some level of local infrastructure and locally based employees, creating an interface between developing and developed worlds.
The Naval Medical Research Center Detachment is a US Navy research facility located in Lima and Iquitos, which conducts research on tropical diseases, employing over 250 local staff. At our field site in Iquitos, there are 21 phlebotomists who draw blood for an epidemiology of febrile disease study. These personnel received training on biosafety and personal protection when they were first hired. Several months later, in March 2005, the occupational health program at Naval Medical Research Center Detachment discovered an unreported needlestick during a routine annual review and encouraged this investigation to identify the causes for this situation.
The following case study addresses our experience with occupational health in a developing country, outlines some of the challenges that exist, and offers suggestions on how to incorporate occupational health into the medical culture in this setting.
Materials and Methods
Following the unreported needlestick, an anonymous questionnaire was distributed among the phlebotomists to assess their knowledge and practices to develop an educational intervention.
All statistical analysis was performed using Stata 8.0 software. The nonparametric Mann-Whitney test was used to correlate practices and knowledge with frequency of needlesticks at a 95% confidence level.
All 21 phlebotomists working in the epidemiology of febrile diseases study were included in the survey, most were women (17 of 21; 81%), most were nurses’ aides (19 of 21;90%), and they had a mean age 33.5 years. These personnel had been trained in biosafety and proper phlebotomy techniques by the investigators when they were first hired for this task in September 2003.
The results of this survey were unexpected and identified several issues that needed to be addressed by continuing education. Knowledge about some bloodborne infections was poor, with only 57% and 38% of the respondents indicating that hepatitis B and C viral infections could be transmitted by blood, respectively. However, all understood that HIV could be transmitted by blood. Risky practices were common: 24% used gloves inconsistently and recapping needles apparently was a frequent practice (86% reported always recapping needles), even though sharps containers were provided and personnel had been trained in their use. Ten phlebotomists reported having one or more needlesticks in their lifetime, and a self-estimation of the rate of needlesticks in their working life was conservatively calculated at 0.15 events per person-year, although only seven people ever reported these events to their supervisors or their physician when they occurred. The reasons for not reporting are unclear, since only five people responded as to why they had not reported them; two each reported being afraid of losing their jobs or appearing negligent and one person thought it was not important. The lack of responses to this question likely also indicates a discomfort in reporting needle sticks. Personnel who had needlesticks or mucous membrane splashes and never reported them had been working longer (Mann-Whitney test: P = 0.016). Wearing gloves consistently was associated with a lower frequency of needlesticks (Mann-Whitney test: P = 0.039). Finally, we did not find a correlation between time at work and the total frequency of needlesticks, although the small sample size may have limited this analysis.
To correct the deficiencies we found in our occupational health program, we immediately implemented a more comprehensive and continuous training program. To identify the specific retraining needs of this group, an experienced monitor accompanied the phlebotomists for a period of time and directly observed their job performance. Targeted training sessions were then designed on such topics as the proper use of PPE, proper phlebotomy techniques and bloodborne pathogens. In addition, each phlebotomist was told directly that their employment would not be terminated for needlestick injuries and that there is effective postexposure prophylaxis for occupational HIV exposures if it is given soon after the injury. These interventions have resulted in improved communications and the timely reporting of a subsequent needlestick.
The results of the questionnaire revealed interesting insights into the practice of occupational health in developing areas. The limited knowledge and high-risk practices observed in this group confirm observations of high occupational health risk among health care providers in other settings,16,24–30 and suggest that the provision of general training and PPE is insufficient to guarantee acceptable occupational health standards. Some of the predictors for percutaneous injuries that have been identified in other studies include low perception of risk, low compliance with standard precautions, and lack of training.16,31,32 Our findings, although a significant surprise to us, mirror these predictors of risk. We assumed the baseline training of the personnel, vaccinations for appropriate illnesses, and specific guidance on biosafety would be adequate. Several assumptions from the phlebotomists and the investigators may have contributed to this situation, including the general unfamiliarity with occupational health programs in developing settings, scarce health care resources, and the perception of offending patients by wearing PPE.16,30,32 See Table 1 for barriers to effective occupational health.
It is of greater concern, though, that the occupational health deficiencies we identified may simply be the tip of the iceberg in the developing world. The risks are likely as high or higher among similar groups not included in this survey, considering that the mere existence of occupational health programs is inconsistent at best. And even with these resources in place, it appears that beyond initial training and provision of preventive equipment, we as researchers must better address the clear need for targeted, periodic retraining about occupational hazards among field research staff.
Disclosure of unsafe events also needs to be facilitated and encouraged, particularly in the developing setting. The fear of job loss is significant in this scenario and needs to be directly confronted and eliminated. In addition, the benefits (and limitations) of postexposure prophylaxis for HIV must be carefully explained and appropriate antiretroviral medications should be readily available should an injury occur that is deemed high risk. At a minimum, the provision of PPE should be guaranteed, as well as training in its proper use and a vaccination program appropriate to the risks associated with the work. Annual risk factor screening of HCW is also strongly encouraged and can take advantage of the regular preventive programs in some areas. This process should not be punitive, since its main objective is to help address training gaps, identify unsafe practices, and reinforce a trusting and open environment to discuss occupational health concerns.
These measures are not exceedingly expensive, considering the alternative. Calculated expenses in Peru, for example, represent an investment of US $300 whereas the maintenance of the occupational health program would be US $265 per person per year (see Table 2). On the other hand, each new HIV infected patient would represent a cost of up to US $10,000 per year for the Peruvian government, since the government is required by law to provide this service.33 The amount for one infected patient could provide the expenses for appropriate PPE, vaccines, and training for about 17 new HCW during the same period.
As has been presented, occupational health for HCW in the developing setting is not always a high priority, but it is garnering some attention by international health organizations. The WHO addresses the challenge of occupational health via programs at its headquarters, regional and country offices. These programs have the support of a strong network of Collaborating Centers, which play a key role in capacity building. As part of their 2006 to 2010 work plan, Activity Areas 2, 3, and 4 have projects targeted specifically to HCW and their needs. Along the same line, the Global Occupational Health Network newsletter has been published since 2001, and dedicated a special issue on the health of HCW in 2005. However, these efforts clearly need to be expanded when compared with the burden of occupationally acquired illness among HCW in the developing setting.
The encouragement of occupational health initiatives can be effectively supported through international health research. North-South research collaborations in countries where occupational health and safety were virtually nonexistent has undoubtedly led to improvement of the situation of workers.34 These partnerships can serve as a positive influence to expand and reinforce local regulations by generating awareness in the workforce and among responsible government agencies.35 In addition, visiting medical researchers are often looked upon as sage experts in developing countries, and local physicians and students often emulate their practices, both good and bad (Fig. 1).
Finally, the absence of occupational health in the medical research setting is particularly striking, given that there are multiple discrete and regulatory steps that must be completed before conducting international research. All investigators are required to maintain training in human subject protection and studies require the approval of multiple institutional review boards to ensure the protection of participating human subjects36,37; further, most funding sources, including the National Institutes of Health, require documentation of this process. A similar process is in place to guarantee humane treatment in animal research.38,39 However, there are often limited or no efforts, and no documentation required, to attenuate the risks confronted by personnel conducting the actual field research. This situation is most obvious in developing countries where there are very limited resources to enforce and enhance existing workplace safety regulations. Some of the same conditions that favor research investments in developing countries (lower costs among them) also may create disincentives to enhance the intensity and quality of occupational health regulations.40 This apparent deficiency is a suitable opportunity for donors and research funding agencies to encourage occupational health guidelines and require at least the minimal safety standards. Currently, no concerted efforts from donors or researchers address this issue—a situation that clearly deserves more attention and support.
Occupational health within medical settings in developing countries is neglected, and as an emerging concept, requires better description and study. Addressing occupational health will be difficult, but the international research community has the opportunity and obligation to amplify the hard-learned lessons from developed countries and apply these standards to collaborative research in developing countries where significant medical research is currently performed, most directly funded by developed countries. This issue is especially critical since the prevalence of many diseases that can be transmitted in the health care setting are higher in developing countries, including HIV, XDR TB, hepatitis, and avian (H5N1) influenza. This effort will not be without significant cost and time investment, two commodities in short supply in the current research climate. However, if a goal of our research efforts is to improve public health and prevent disease, should we not lead by example by first ensuring the protection of our partners who conduct this research?
This work was funded by DoD-GEIS and supported by work unit number 847705 82000 25GB B0016.
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the US Government.
IRB statement: The Naval Medical Research Center Institutional Review Board determined the investigation (PJT-08) did not meet the definition of human subject research.
The authors are military service members and employees of the US Government. This work was prepared as part of their official duties. Title 17 U.S.C. §105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. §101 defines US Government work as a work prepared by a military service member or employee of the US Government as part of that person’s official duties.
Gabriela Salmon Mulanovich, BS
Andres G. Lescano, MHS, PhD
Víctor E. Gonzaga, BS
David L. Blazes, MD, MPH
US Naval Medical Research Center Detachment, Peru
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