The Prevalence of Needlestick Injuries and Exposure to Blood and Body Fluids Among Iranian Healthcare Workers : A Systematic Review

Injuries caused by needles and sharp and cutting objects include wounds, cuts, or abrasions caused by medical devices that may have already been contaminated with blood or other body fluids.1 In most studies on injuries caused by needles and sharp objects, the injuries are introduced as an important occupational hazard for healthcare workers.2,3 There are about thirty-five million healthcare workers in the world who make up 12% of the world labor force.4 The Center for Disease Control and Prevention estimates that 385 000 healthcare workers in America annually experience injuries caused by needles and sharp objects.5 In some countries, including Iran, despite safety precautions, injuries caused by needles and sharp objects still occur, inflicting significant economic and human costs.6 More than 90% of infections caused by sharp tools among healthcare workers occur in low-income countries where these injuries are preventable.7,8 Given the necessity for a coherent review study regarding injuries caused by needles, sharp objects, blood and body fluids, the current study aimed to make an analytical review of previous research conducted in this regard to determine the prevalence of the phenomenon among Iranian healthcare workers.


Search Strategy and Eligibility Criteria
In this study, a literature search strategy, selection of published studies, data extraction, and the reporting of the results of reviewed studies based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Figure 1) were employed.In the search, the following keywords were used: Needlestick injury AND Iran (Needlestick OR Needle-stick OR Sharp Injury).Inclusion criteria were as follows: study conducted in Iran, availability of full-text article, published in Farsi or English.Selection criterion was the relevance of the study subject.

Data Collection
Articles were collected from Iranian databases such as Scientific Information Database (SID), Iran Magazine Information Bank (Mag Iran), Iranian Journals of Nursing (N Index), and Directory of Medical Sciences Articles (Iran Medex) as well as international databases including Google Scholar, ISI Web of Knowledge, Scopus, PubMed, Science Direct, and CINAHL.In searching for a comprehensive strategy, all published full-text articles authored by Iranian researchers in Farsi or English in the field of needlestick injuries among healthcare workers during the period 2001-2016 were examined.The findings were then tabulated, and the necessary information was extracted.

Study Design
All studies with all designs that investigated and reported the prevalence of needlestick and sharp injuries among Iranian healthcare workers were included.

Data Extraction
After the screening and selection of eligible studies, the following data was extracted: name of first author, year of publication, study design, sample size, concerned healthcare workers, and prevalence of injury.

Results
In a preliminary search based on selected keywords, 4012 articles were found.After evaluation for duplication, relevancy, accordance with research question, and abstract screening, 60 papers were checked for eligibility.Ultimately, 49 articles with relevant research topics were selected (Figure 1).As shown in Table 1, 36 articles in Farsi published in Iranian journals (73.5%) 2,3,[9][10][11][12] and 13 articles in English published in Iranian and non-Iranian English language journals (26.5%) 11,54,65 were included in the study. The pevalence of injuries caused by needles ranged from 10.0% to 84.29% in different studies 13,14 and a total of 52 data in 49 studies showed that on average, damage caused by needles to healthcare workers is 47.9%.2,3, The prevalence of exposure to blood and body fluids ranged from 13.46% to 79%, 25,55 and a combination of 7 studies showed that the mean prevalence of exposure to blood and body fluids is 46.47%.15,25,30,37,38,54,55

Discussion
Injuries caused by needlestick and exposure to blood and body fluids are considered to be highly significant occupational hazards requiring special attention due to the risk of transmission of infection.This systematic review focused on the incidence of injuries caused by needlestick and exposure to blood and body fluids among healthcare workers in Iran.The results of several studies reviewed in this research showed that the prevalence of injuries caused by needles ranged from 10.0% to 84.29% and that on average, damage caused by needles among healthcare workers is 47.9%.As the results indicate, the prevalence of needlestick injuries among healthcare workers in Iran is significant; almost half of all healthcare workers are affected.Given that the majority of studies conducted around the world have indicated that many health professionals do not report injuries from needlestick, 57,56 the actual rate of injury caused by needlestick is probably higher than reported.The incidence of injury caused by needlestick and exposure to blood and body fluids is not expressed the same in all regions.This variability depends on economic prosperity and the health budgets of each country, the number of health staff in different therapeutic areas, different cultural and business environments, available   14 The lowest prevalence in Iran was approximate to the annual mean value reported for 100 beds in Japan (5.7-6.7) and healthcare workers in Switzerland (9.7%).  The ghest prevalence of injuries caused by needlestick, cutting, and sharp objects (84.29%) was reported by Taghavi et al in Sina hospital in Mashhad.In this study, healthcare workers from the emergency ward, inpatient wards, operating room, radiology, labor and laboratory were examined.The researcher named possible causes such as heavy workload of healthcare workers and non-compliance of the standard number of personnel in hospital with the number of beds. 13The highest prevalence was approximate to Ilhan's reported value in Turkey (79.9%) of staff experiencing needlestick during the course of their work. 60The wide range of the prevalence of injury among healthcare workers (10.0%-84.2%) can be attributed to differences in the samples of each study (for example, in one study, only nurses were evaluated, and in another, nurses, doctors, and other healthcare providers were evaluated), types of hospital (private vs. public), ward types (emergency department vs. other departments), and study methods.The mean prevalence of injury caused by needlestick and sharp objects for healthcare workers was 47.9%.2][63] The prevalence of exposure to blood and body fluids in different studies ranged from 79% to 13.46%, and the mean prevalence of exposure to blood and body fluids was 47.46%. 15,25,30,37,38,54,55As the results showed, exposure to blood and body fluids also affects almost half of the healthcare workers in Iran.This result was consistent with the result of a study conducted in a hospital in India, which reported the rate of exposure to blood and body fluids to be 47.14%. 64

Conclusions
Important factors affecting the reduction of the incidence rate of injury include the following: emphasis on efficient research and strategies based on evidence of reduced risk of injuries caused by sharp object penetration, the provision of continuing education on the risk of diseases transmitted through blood, emphasis on observing the principles of comprehensive precautions and standards, use of newly developed technologies in the manufacture of safe medical equipment, use of the systems and experiences of other countries in the field of reporting and methods of reducing risk, observation of standards and compliance of the ratio of number of beds and patients to personnel, immunization of the environment and observation of safety principles at work, understanding and evaluation of patients during interventions, performing invasive interventions based solely on basic needs while complying with standard principles, and maintenance of mental calmness during work.One possible limitation of this systematic study was the possibility of the occurrence of errors while searching based on the research strategies.

Figure 1 .
Figure 1.Flow Chart of the Study.

Table 1 .
Specifications of Studies on Needlestick in Iranian Healthcare Workers

Table 1 .
Continuedfacilities, as well as the awareness and importance of the issue for policymakers.The lowest incidence of injuries resulting from needlestick in Iran was 10.0% reported by Zeighami et al in training hospitals in Qazvin in a historical cohort study was done on nursing staff who were responsible for direct patient care.The nurses in the case group were selected from the emergency department, and the control group consisted of nurses from other wards.Zeighami et al mentioned that the risk of needlestick injuries among nurses in emergency wards is dramatically higher than in other wards.