International Healthcare Worker Safety Center

Bibliography

April 2008

1. Aisaka K, Itabashi K, Nagasaka K., Kuroda K, Arita S, Takane V. Influence of Novel Blunt Needles (Ethiguard) on Safety for Gynecologic Operations. Obstetrics & Gynecology 2008; 109(4 (supplement)):25S.
ABSTRACT: OBJECTIVE: The present study was performed to evaluate the safety of the Ethiguard (a new type of blunt needle) by measurement of the resistance to puncture using a surgical rubber glove and chicken breast meat.
METHODS: The resistance of a surgical glove and chicken breast meat (5 mm and 10 mm thick) to being punctured by three needles, a conventional round needle (J-765D), Ethiguard CTXB (circle taper extra large blunt), and a usual type of blunt needle (BP-1) was measured by the computer control system autograph (AGS-100B; Shimadzu Company, Tokyo, Japan). This procedure was repeated 10 times on each material.
RESULTS: The values measured for the resistance of the surgical glove to being pierced by the three needles were 27.110.1, 17515.4, and 352.421.7 g, respectively (P.001). In contrast, the resistance of the 5-mm and 10-mm chicken breast meat test pieces to being pierced by the blunt needle was found to be significantly greater than their resistance to being pierced by the other two needles (5 mm: 13.82.7, 18.64.2, 45.95.5 g, P.001; 10 mm: 32.44.2, 37.85.8, 77.96.8 g, P.001). These results demonstrated that the Ethiguard was less likely than the conventional round needle to puncture a surgical glove, but it had the same capacity as the conventional round needle to penetrate tissue.
CONCLUSION: The use of the Ethiguard is effective in preventing needle-stick accidents but still penetrates tissues satisfactorily, and also it is effective in protecting against such infections as human immunodeficiency virus (HIV) and hepatitis C virus (HCV).

2. Alamgir H, Cvitkovich Y, Astrakianakis G, Yu S, Yassi A. Needlestick and other potential blood and body fluid exposures among health care workers in British Columbia, Canada. Am J Infect Control 2008; 36(1):12-21.
ABSTRACT: BACKGROUND: Health care workers have high risk of exposure to human blood and body fluids (BBF) from patients in acute care and residents in nursing homes or personal homes. METHODS: This analysis examined the epidemiology for BBF exposure across health care settings (acute care, nursing homes, and community care). Detailed analysis of BBF exposure among the health care workforce in 3 British Columbian health regions was conducted by Poisson regression modeling, with generalized estimating equations to determine the relative risk associated with various occupations. RESULTS: Acute care had the majority of needlestick, sharps, and splash events with the BBF exposure rate in acute care 2 to 3 times higher compared with nursing home and community care settings. Registered nurses had the highest frequency of needlestick, sharps, and splash events. Laboratory assistants had the highest exposure rates from needlestick injuries and splashes, whereas licensed practical nurses had the highest exposure rate from sharps. Most needlestick injuries (51.3%) occurred at the patient's bedside. Sharps incidents occurred primarily in operating rooms (26.9%) and at the patient's bedside (20.9%). Splashes occurred most frequently at the patient's bedside (46.1%) and predominantly affected the eyes or face/mouth. The majority of needlestick/sharps injuries occurred during use for registered nurses, during disposal for licensed practical nurses, and after disposal for care aides. CONCLUSION: The high risk of BBF exposure for some occupations indicates there is room for improvement to reduce BBF exposure by targeting high-risk groups for prevention strategies

3. Apisarnthanarak A, Babcock HM, Fraser VJ. The effect of nondevice interventions to reduce needlestick injuries among health care workers in a Thai tertiary care center. Am J Infect Control 2008; 36(1):74-75.
ABSTRACT: To the Editor: It is estimated that more than 380,000 needlestick injuries (NSIs) are reported by hospital staff members each year in the United States.¹ In developing countries, health care workers (HCWs) face even greater risks because of the higher prevalence of bloodborne pathogens and the use of certain medical equipments, such as nonretracting finger-stick lancets and glass capillary tubes to test for common tropical diseases.^{[2] and [3]} Although safety-engineered devices have been incorporated to help reduce NSIs in the United States, the role of such devices in developing countries remains controversial.

4. Boal WL, Leiss JK, Sousa S, Lyden JT, Li J, Jagger J. The National study to prevent blood exposure in paramedics: Exposure reporting. Am J Ind Med 2008; 51(3):213-222.
ABSTRACT: BACKGROUND: This survey was conducted to provide national incidence rates and risk factors for exposure to blood among paramedics. The present analysis assesses reporting of exposures to employers. METHODS: A questionnaire was mailed in 2002-2003 to a national sample of paramedics selected using a two-stage design. Information on exposure reporting was obtained on the two most recent exposures for each of five routes of exposure. RESULTS: Forty-nine percent of all exposures to blood and 72% of needlesticks were reported to employers. The main reason for under-reporting was not considering the exposure a "significant risk." Females reported significantly more total exposures than males. Reporting of needlesticks was significantly less common among respondents who believed most needlesticks were due to circumstances under the worker's control. Reporting was non-significantly more common among workers who believed reporting exposures helps management prevent future exposures. Reporting may have been positively associated with workplace safety culture. CONCLUSIONS: This survey indicates there is need to improve the reporting of blood exposures by paramedics to their employers, and more work is needed to understand the reasons for under-reporting. Gender, safety culture, perception of risk, and other personal attitudes may all affect reporting behavior. Am. J. Ind. Med. 51:213-222, 2008. (c) 2008 Wiley-Liss, Inc

5. Byass P, D'Ambruoso L. Cellular telephone networks in developing countries. The Lancet 2008; 371(9613):650-642.
ABSTRACT: While undertaking community-based follow-ups of maternal deaths in Burkina Faso and Indonesia, we were struck by the irony of sitting in some of the world's poorest households, wherein many mothers had died after failing to access health services, and yet where good cellular telephone signals were available (figure). From such households it is possible to call anywhere in the world-but there is generally no designated emergency number nor means of getting medical advice or assistance via a portable telephone

6. Chopra M, Munro S, Lavis JN, Vist G, Bennett S. Effects of policy options for human resources for health: an analysis of systematic reviews. The Lancet 2008; 371(9613):668-674.
ABSTRACT: Background: Policy makers face challenges to ensure an appropriate supply and distribution of trained health workers and to manage their performance in delivery of services, especially in countries with low and middle incomes. We aimed to identify all available policy options to address human resources for health in such countries, and to assess the effectiveness of these policy options.

Methods: We searched Medline and Embase from 1979 to September, 2006, the Cochrane Library, and the Human Resources for Health Global Resource Center database. We also searched up to 10 years of archives from five relevant journals, and consulted experts. We included systematic reviews in English which assessed the effects of policy options that could affect the training, distribution, regulation, financing, management, organisation, or performance of health workers. Two reviewers independently assessed each review for eligibility and quality, and systematically extracted data about main effects. We also assessed whether the policy options were equitable in their effects; suitable for scaling up; and applicable to countries with low and middle incomes.

Findings: 28 of the 759 systematic reviews of effects that we identified were eligible according to our criteria. Of these, only a few included studies from countries with low and middle incomes, and some reviews were of low quality. Most evidence focused on organisational mechanisms for human resources, such as substitution or shifting tasks between different types of health workers, or extension of their roles; performance-enhancing strategies such as quality improvement or continuing education strategies; promotion of teamwork; and changes to workflow. Of all policy options, the use of lay health workers had the greatest proportion of reviews in countries with a range of incomes, from high to low.

Interpretation: We have identified a need for more systematic reviews on the effects of policy options to improve human resources for health in countries with low and middle incomes, for assessments of any interventions that policy makers introduce to plan and manage human resources for health, and for other research to aid policy makers in these countries

7. Crisp N, Gawanas B, Sharp I. Training the health workforce: scaling up, saving lives. The Lancet 2008; 371(9613):689-691.
ABSTRACT: Over a billion people worldwide have little or no access to health services and the help and advice of health workers. There is good evidence that health workers affect health outcomes. The density of health workers is significant in accounting for rates of maternal mortality, infant mortality, under-5 mortality, and immunisation rates across countries. Similarly, assessments of disease-oriented country programmes have found that the lack of health workers is one of the major bottlenecks in implementing evidence-based interventions to improve maternal and child health, and to address HIV/AIDS, malaria, and tuberculosis. There is also evidence for the effectiveness of specific cadres of health workers, including community and mid-level workers. But, as the 2006 World Health Report, Working Together for Health,highlighted, there is a global shortage of some 4·3 million health workers, with the greatest shortages in the poorest countries.

The causes of the crisis are many, from a global rise in chronic disease and an ageing population, to poor local working conditions and international migration.⁶ But the massive shortfall in production of trained health workers underpins all other problems. To take one example, Ethiopia trains about 200 doctors a year for a population of about 75 million; the UK trains more than 6000 for a population of about 60 million.

8. Doull L, Campbell F. Human resources for health in fragile states. The Lancet 2008; 371(9613):626-627.
ABSTRACT: Human resources are crucial for a functioning health system. The global shortage of health workers is evident in many developing countries, especially in. fragile states-countries whose governments, for various reasons, cannot or will not deliver core functions to most of the population. Building and retaining a skilled and motivated health workforce is particularly challenging in settings where staff might be under extreme pressure (eg, during conflicts, long-term underinvestment in the health sector, and the HIV/AIDS epidemic). Furthermore, for health professionals, there are growing opportunities that encourage movement from fragile states to search for better professional and economic environments. The results are shortages of health staff and an inability to provide even basic health care.

9. Gershon RR, Pogorzelska M, Qureshi KA, Sherman M. Home health care registered nurses and the risk of percutaneous injuries: a pilot study. Am J Infect Control 2008; 36(3):165-172.
ABSTRACT: BACKGROUND: Home health care is the fastest-growing sector in the health care industry, expected to grow 66% over the next 10 years. Yet data on occupational health hazards, including the potential risk of exposure to blood and body fluids, associated with the home care setting remain very limited. As part of a larger study of bloodborne pathogen risk in non-hospital-based registered nurses (RNs), data from 72 home health care nurses were separately analyzed to identify risk of blood/body fluid exposure. METHODS: A 152-item self-administered mailed risk assessment questionnaire was completed by RNs employed in home health care agencies in New York State. RESULTS: Nine (13%) of the home health care nurses experienced 10 needlesticks in the 12-month period before the study. Only 4 of the needlesticks were formally reported to the nurse's employer. The devices most frequently associated with needlesticks were hollow-bore and phlebotomy needles, and included 3 needles with safety features. Exposure was most commonly attributed to patient actions, followed by disposal-related activities. CONCLUSIONS: These data suggest that home health care nurses may be at potential occupational risk for bloodborne pathogen exposure. Risk management strategies tailored to the home health care setting may be most effective in reducing this risk

10. Glassman A, Becker L, Makinen M, de Ferranti D. Planning and costing human resources for health. The Lancet 2008; 371(9613):693-695.
ABSTRACT: Human resources are crucial for the provision of health care and represent the largest single use of public spending on health in developing countries. Yet countries face an ongoing challenge when it comes to financing human resources for health (HRH) sufficiently to sustain an adequate supply of health workers and stimulate greater productivity and more effective health care.

Several papers prepared for the 2006 World Health Report and the Global Health Workforce Alliance describe the HRH financing gap and the variables such as economic growth, government revenues, aid, fiscal sustainability targets, and priority-setting practices that affect the ability of governments and donors to increase spending on this input.

Inspired by the global HRH movement, some countries, mostly in Africa, have undertaken strategic planning exercises to estimate their HRH needs. But these plans rarely include a reliable analysis of the financing needs or structures required to achieve the desired levels of care. When they do address costs, they typically use provider-population ratios to estimate the number of additional staff needed in each cadre, then multiply those numbers by current public-sector salaries and allowances (or some assumed salary increment). Shortfalls are determined by comparing this figure with current and projected health-sector budgets. Resource mobilisation options via aid and public-sector priority-setting are then discussed.

11. Hagopian A, Micek MA, Vio F, Gimbel-Sherr K, Montoyo P. What if we decided to take care of everyone who needed treatment? Workforce planning in Mozambique using simulation of demand for HIV/AIDS care. Hum Resour Health 2008; 6(1):3.
ABSTRACT: ABSTRACT: BACKGROUND: The growing AIDS epidemic in southern Africa is placing an increased strain on health systems, which are experiencing rising steadily patient loads. Health care systems are tackling the barriers to serving large populations in scaled-up operations. One of the most significant challenges in this effort is securing the health care workforce to deliver care in settings where the manpower is already in short supply. METHODS: We have produced a demand-driven staffing model using simple spreadsheet technology, based on treatment protocols for HIV-positive patients that adhere to Mozambican guidelines. The model can be adjusted for the volumes of patients at differing stages of their disease, varying provider productivity, proportion who are pregnant, attrition rates, and other variables. RESULTS: Our model projects the need for health workers using three different kinds of goals: 1) the number of patients to be placed on anti-retroviral therapy (ART), 2) the number of HIV-positive patients to be enrolled for treatment, and 3) the number of patients to be enrolled in a treatment facility per month. CONCLUSIONS: We propose three scenarios, depending on numbers of patients enrolled. In the first scenario, we start with 8000 patients on ART and increase that number to 58 000 at the end of three years (those were the goals for the country of Mozambique). This would require thirteen clinicians and just over ten nurses by the end of the first year, and 67 clinicians and 47 nurses at the end of the third year. In a second scenario, we start with 34 000 patients enrolled for care (not all of them on ART), and increase to 94 000 by the end of the third year, requiring a growth in clinician staff from 18 to 28. In a third scenario, we start a new clinic and enrol 200 new patients per month for three years, requiring 1.2 clinicians in year 1 and 2.2 by the end of year 3. Other clinician types in the model include nurses, social workers, pharmacists, phlebotomists, and peer counsellors. This planning tool could lead to more realistic and appropriate estimates of workforce levels required to provide high-quality HIV care in a low-resource settings

12. Lefebvre DR, Strande LF, Hewitt CW. An enzyme-mediated assay to quantify inoculation volume delivered by suture needlestick injury: two gloves are better than one. J Am Coll Surg 2008; 206(1):113-122.
ABSTRACT: BACKGROUND: Acquiring a blood-borne disease is a risk of performing operations. Most data about seroconversion are based on hollow-bore needlesticks. Some studies have examined the inoculation volumes of pure blood delivered by suture needles. There is a lack of data about the effect of double-gloving on contaminant transmission in less viscous fluids that are not prone to coagulation. STUDY DESIGN: We used enzymatic colorimetry to quantify the volume of inoculation delivered by a suture needle that was coated with an aqueous contaminant. Substrate color change was measured using a microplate reader. Both cutting and tapered suture needles were tested against five different glove types and differing numbers of glove layers (from zero to three). RESULTS: One glove layer removed 97% of contaminant from tapered needles and 65% from cutting needles, compared with the no-glove control data. Additional glove layers did not significantly improve contaminant removal from tapered needles (p > 0.05). For the cutting needle, 2 glove layers removed 91% of contaminant, which was significantly better than a single glove (p = 0.002). Three glove layers did not afford statistically significant additional protection (p = 0.122). There were no statistically significant differences between glove types (p = 0.41). CONCLUSIONS: With an aqueous needle contaminant, a single glove layer removes contaminant from tapered needles as effectively as multiple glove layers. For cutting needles, double-glove layering offers superior protection. There is no advantage to triple-glove layering. A surgeon should double-glove for maximum safety. Additionally, a surgeon should take advantage of other risk-reduction strategies, such as sharps safety, risk management, and use of sharpless instrumentation when possible

13. Mbongwe B, Mmereki BT, Magashula A. Healthcare waste management: current practices in selected healthcare facilities, Botswana. Waste Manag 2008; 28(1):226-233.
ABSTRACT: Healthcare waste management continues to present an array of challenges for developing countries, and Botswana is no exception. The possible impact of healthcare waste on public health and the environment has received a lot of attention such that Waste Management dedicated a special issue to the management of healthcare waste (Healthcare Wastes Management, 2005. Waste Management 25(6) 567-665). As the demand for more healthcare facilities increases, there is also an increase on waste generation from these facilities. This situation requires an organised system of healthcare waste management to curb public health risks as well as occupational hazards among healthcare workers as a result of poor waste management. This paper reviews current waste management practices at the healthcare facility level and proposes possible options for improvement in Botswana

14. McCoy D, Bennett S, Witter S et al. Salaries and incomes of health workers in sub-Saharan Africa. The Lancet 2008; 371(9613):675-681.
ABSTRACT: Summary: Public-sector health workers are vital to the functioning of health systems. We aimed to investigate pay structures for health workers in the public sector in sub-Saharan Africa; the adequacy of incomes for health workers; the management of public-sector pay; and the fiscal and macroeconomic factors that impinge on pay policy for the public sector. Because salary differentials affect staff migration and retention, we also discuss pay in the private sector. We surveyed historical trends in the pay of civil servants in Africa over the past 40 years. We used some empirical data, but found that accurate and complete data were scarce. The available data suggested that pay structures vary across countries, and are often structured in complex ways. Health workers also commonly use other sources of income to supplement their formal pay. The pay and income of health workers varies widely, whether between countries, by comparison with cost of living, or between the public and private sectors. To optimise the distribution and mix of health workers, policy interventions to address their pay and incomes are needed. Fiscal constraints to increased salaries might need to be overcome in many countries, and non-financial incentives improved

15. Merli R. CDC Probes Needlesticks, Possible HIV Infection Among Laundry Workers. American Laundry News 2008; 3/21/08.
ABSTRACT: The Centers for Disease Control and Prevention (CDC) is investigating as many as four more potential cases of laundry and housekeeping workers infected with HIV, the virus that causes AIDS, as a result of needlestick injuries they suffered at work.

16. Mills EJ, Schabas WA, Volmink J et al. Should active recruitment of health workers from sub-Saharan Africa be viewed as a crime? The Lancet 2008; 371(9613):685-688.
ABSTRACT: Shortages of health-care staff are endemic in sub-Saharan Africa. Overall, there is one physician for every 8000 people in the region. In the worst affected countries, such as Malawi, the physician-to-population ratio is just 0·02 for every 1000 (one per 50 000). There are also huge disparities between rural and urban areas: rural parts of South Africa have 14 times fewer doctors than the national average. These numbers are very different to those in developed countries: the UK, for example, has over 100 times more physicians per population than Malawi. Furthermore, almost one in ten doctors working in the UK are from Africa. The insufficiency of health staff to provide even basic services is one of the most pressing impediments to health-care delivery in resource-poor settings. The consequences are clearly shown by the inverse relation that exists between health-care worker density and mortality

17. Mornar SJ, Perlow JH. Blunt suture needle use in laceration and episiotomy repair at vaginal delivery. Am J Obstet Gynecol 2008.
ABSTRACT: OBJECTIVE: By surveying obstetricians regarding the use of blunt suture needles for laceration and episiotomy repair, the purpose of this study was to determine whether blunt suture needles represent a safe and effective alternative to sharp needles. STUDY DESIGN: Blunt suture needles were made available at our institution for repairs at vaginal delivery. Participating physicians indicated their personal history of needlestick injuries and rated the blunt suture needle after completing the repair. Categorical variables were analyzed using Fisher's exact test and a 2-tailed P < .05 was considered significant. RESULTS: Attending and resident physicians completed 80 surveys, and 83% reported previous needlestick injuries. Blunt suture needles were rated as excellent or good by 92.5% (95% confidence interval 84.6 to 96.5%). No needlestick injuries occurred. CONCLUSION: In an effort to reduce needlestick injuries, the use of blunt suture needles is safe and effective for repairs at vaginal delivery

18. Musharrafieh UM, Bizri AR, Nassar NT et al. Health care workers' exposure to blood-borne pathogens in Lebanon. Occup Med (Lond) 2008; 58(2):94-98.
ABSTRACT: BACKGROUND: Accidental exposure to blood-borne pathogens (BBPs) is a risk for health care workers (HCWs). AIM: To study the pattern of occupational exposure to blood and body fluids (BBFs) at a tertiary care hospital. METHODS: This study reports a 17-year experience (1985-2001) of ongoing surveillance of HCW exposure to BBFs at a 420-bed academic tertiary care hospital. RESULTS: A total of 1590 BBF exposure-related accidents were reported to the Infection Control Office. The trend showed a decrease in these exposures over the years with an average +/- standard error of 96 +/- 8.6 incidents per year. In the last 6 years, the average rate of BBF exposures was 0.57 per 100 admissions per year (average of needlestick injuries alone was 0.46 per 100 admissions). For 2001, the rates of exposure were found to be 13% for house officers, 9% for medical student, 8% for attending physicians, 5% for nurses, 4% for housekeeping, 4% for technicians and 2% for auxiliary services employees. The reason for the incident, when stated, was attributed to a procedural intervention (29%), improper disposal of sharps (18%), to recapping (11%) and to other causes (5%). CONCLUSIONS: The current study in Lebanon showed that exposure of HCWs to BBPs remains a problem. This can be projected to other hospitals in the country and raises the need to implement infection control standards more efficiently. Similar studies should be done prospectively on a yearly basis to study rates and identify high-risk groups

19. Nsubuga P, White M, Fontaine R, Simone P. Training programmes for field epidemiology. The Lancet 2008; 371(9613):630-631.
ABSTRACT: Public-health systems are an important subset of the health systems that are needed to meet the Millennium Development Goals (MDGs). How many public-health workers will be needed to achieve the MDGs is unknown, but there is an urgent unmet need. Moreover, even as the MDGs are being implemented, the newly revised International Health Regulations call for the establishment of a group of experts in public-health surveillance and response in all countries.

One strategy that has worked in the building of public-health surveillance and response systems and the workforce to operate the systems is the implementation of training programmes in field epidemiology.³ Over the past 27 years, 29 countries have created these programmes in partnership with the US Centers for Disease Control and Prevention (CDC) and WHO to directly build and strengthen public-health systems, while simultaneously training future public-health leaders. The programmes are based on CDC's Epidemic Intelligence Service which is a 2-year public-health leadership-training programme. More than 1000 public-health leaders have graduated from the training programmes in field epidemiology, and many more have completed short courses. Many graduates of training programmes in field epidemiology have moved into leadership positions within the ministries of health of their own countries

20. Omaswa F. Human resources for global health: time for action is now. The Lancet 2008; 371(9613):625-626.
ABSTRACT: Over several decades, a global health-workforce crisis has developed before our eyes. The crisis is characterised by widespread global shortages, maldistribution of personnel within and between countries, migration of local health workers, and poor working conditions.

The factors that led to this crisis include increased demand for care in developed countries with ageing populations, an upsurge of new and old pandemics in low-income countries with poorly performing economies, and neglect. Counterproductive and poorly administered solutions, such as bans and across-the-board ceilings on recruitment, have aggravated these factors.

21. Ozgediz D, Galukande M, Mabweijano J et al. The Neglect of the Global Surgical Workforce: Experience and Evidence from Uganda. World J Surg 2008.
ABSTRACT: BACKGROUND: Africa's health workforce crisis has recently been emphasized by major international organizations. As a part of this discussion, it has become apparent that the workforce required to deliver surgical services has been significantly neglected. METHODS: This paper reviews some of the reasons for this relative neglect and emphasizes its importance to health systems and public health. We report the first comprehensive analysis of the surgical workforce in Uganda, identify challenges to workforce development, and evaluate current programs addressing these challenges. This was performed through a literature review, analysis of existing policies to improve surgical access, and pilot retrospective studies of surgical output and workforce in nine rural hospitals. RESULTS: Uganda has a shortage of surgical personnel in comparison to higher income countries, but the precise gap is unknown. The most significant challenges to workforce development include recruitment, training, retention, and infrastructure for service delivery. Curricular innovations, international collaborations, and development of research capacity are some of the initiatives underway to overcome these challenges. Several programs and policies are addressing the maldistribution of the surgical workforce in urban areas. These programs include surgical camps, specialist outreach, and decentralization of surgical services. Each has the advantage of improving access to care, but sustainability has been an issue for all of these programs. Initial results from nine hospitals show that surgical output is similar to previous studies and lags far behind estimates in higher-income countries. Task-shifting to non-physician surgical personnel is one possible future alternative. CONCLUSIONS: The experience of Uganda is representative of other low-income countries and may provide valuable lessons. Greater attention must be paid to this critical aspect of the global crisis in human resources for health

22. Ozgediz D, Kijjambu S, Galukande M et al. Africa's neglected surgical workforce crisis. The Lancet 2008; 371(9613):627-628.
ABSTRACT: Funding priorities in Africa typically favour infectious diseases, and surgery and perioperative care have been neglected, even though essential surgical care at district hospitals is more cost effective than some other highly prioritised interventions, such as antiretroviral therapy for HIV. Recent focus on the workforce needed for male circumcision to prevent HIV transmission is an exception. Injuries create the greatest surgical burden, followed by cancers, congenital anomalies, and complications of childbirth.

Few surgical procedures are done in Africa compared with the numbers in high-income countries, but precise information on the exact unmet need is lacking. Although workforce limitations contribute to this shortfall, detailed estimates of surgical and anaesthesia staff for the continent and individual countries are unavailable or outdated.

23. Peng B, Tully PJ, Boss K, Hiller JE. Sharps Injury and Body Fluid Exposure Among Health Care Workers in an Australian Tertiary Hospital. Asia Pac J Public Health 2008; 20(2):139-147.
ABSTRACT: To examine sharps injury and body fluid exposure among health care workers, a descriptive epidemiological study was conducted in a 1000-bed tertiary hospital between 2000 and 2003 using surveillance data of all reported sharps injuries and body fluid exposures. A total of 640 sharps injuries and body fluid exposures were reported from hospital and nonhospital staff, although no seroconversions to HIV, hepatitis B virus, or hepatitis C virus were observed during the study period. Nurses reported 47% of sharps injuries and 68% of body fluid exposures, medical staff reported 38% and 16%, and other nonmedical staff notified 5% and 4%, respectively, while nonhospital staff reported the rest. Hollow-bore needles accounted for 56% of sharps injuries, while 11% of the incidents were sustained during recapping and inappropriate disposal. Further research into Australian work practices, disposal systems, education strategies, and the use of safety sharps should be emphasized to implement strategies to reduce work-related injuries among health care workers

24. Pick W. Lack of evidence hampers human-resources policy making. The Lancet 2008; 371(9613):629-630.
ABSTRACT: In today's Lancet, Mickey Chopra and colleagues describe the dearth of evidence for policy making on human resources for health. Despite their study being a systematic review of systematic reviews over a set period, albeit of reports in English, they make a compelling case for more research to inform policy makers. At a time when there is a resurgence of interest in this field, Chopra and colleagues' overview serves as a timely reminder to researchers that much more information is needed if we are to persuade those responsible for health services, and especially human resources for health, to take decisions that will contribute to the solution of the global crisis in the staffing of health systems

25. Pillay Y, Mahlati P. Health-worker salaries and incomes in sub-Saharan Africa. The Lancet 2008; 371(9613):632-634.
ABSTRACT: There is global focus on the need to strengthen health systems to achieve the Millennium Development Goals by 2015, especially in sub-Saharan Africa. Health workers are a key ingredient of health systems. In today's Lancet, David McCoy and colleagues¹ contribute to the understanding of public-sector health workers' salaries. In sub-Saharan Africa in particular the recruitment and retention of public-sector workers are vitally important for health.

According to the Global Health Workforce Alliance in 2006, sub-Saharan Africa faces the most chronic shortage of health workers.² The Alliance noted that this region has 11% of the world's population and a quarter of the global burden of disease, but has only 3% of the world's health workforce and spends less than 1% of the global health expenditure. According to Physicians for Human Rights, more than 80% of sub-Saharan countries do not meet WHO's minimum recommendations for the numbers of doctors and nurses.³ And about 65 000 physicians and 70 000 nurses born in Africa were working in developed countries in 2000

26. Poz MRD. Understanding women's contribution to the health workforce. The Lancet 2008; 371(9613):641-642.
ABSTRACT: One of my first activities after my appointment as Director of Human Resources for Health for the State of Rio de Janeiro, Brazil, in 1987, was to assess and appraise the health workforce at that time. To me, if the government had a better understanding of its human resources in the health system, it could better plan and adopt adequate options to improve the health of the population, while ameliorating the working conditions of its more than 20 000 employees.

Globally, it is estimated that health workers account for some 2·5-10·0% of the total labour force in a country (Hum Resour Health 2003; 1 : 5). In Rio de Janeiro, about a third of the health workforce is found in the public sector. The results from our assessment of the state's health workforce showed that women were predominantly running the delivery of health-care services in Rio de Janeiro. And by that I do not just mean nursing aides or cleaning crews; nor did our figures include the immense burden of informal domestic care provided by women in the home. No, our analysis revealed that most health-care providers and administrative workers within the health-care system were women

27. Robinson M, Clark P. Forging solutions to health worker migration. The Lancet 2008; 371(9613):691-693.
ABSTRACT: All over the world, increased demand from wealthier countries resulting from ageing populations and medical advances has pulled large numbers of health workers from some of the world's poorest countries-many of whom are left with acute shortages of health workers of their own. Africa carries 25% of the world's disease burden yet has only 3% of the world's health workers and 1% of the world's economic resources to meet that challenge. Migration, together with other factors in many source countries such as insufficient health systems, low wages, and poor working conditions, are key factors determining low health-worker density in countries with the lowest health indicators, In Zambia, for example, there are fewer than 0·12 physicians for every 1000 people, whereas Italy enjoys 4·2 physicians for every 1000 people.¹ Between 1993 and 2002, Ghana lost 604 trained doctors; roughly half of all doctors and a third of nurses leave the country after training.² Globally, WHO estimates that 4·3 million more health workers are required to achieve the health-related Millennium Development Goals and has identified 57 countries with critical shortages of health workers-36 of these countries are in Africa

28. Schatz JJ. Zambia's health-worker crisis. The Lancet 2008; 371(9613):638-639.
ABSTRACT: Zambia has a dire shortage of health workers, with less than a third the doctor-patient ratio recommended by WHO. But the crisis is gaining new attention and the southern African nation has become a testing ground for several initiatives. Joseph J Schatz reports from Lusaka.

Just past the entrance to the sprawling University Teaching Hospital (UTH) in Lusaka, a yellow sign serves as a stark reminder of the massive health-worker shortage facing this southern African nation. "Kindly take note that members of the staff at UTH work under very strenuous and demanding conditions due to the increase in the disease burden and critical shortages of manpower", reads the sign, put up after a series of confrontations between angry patients and over-stretched nurses and doctors. "It may take a bit of time…Assaulting any member of staff is a criminal offence

29. Schatz JJ. Francis Omaswa: tackling the shortage of health workers. The Lancet 2008; 371(9613):643-642.
ABSTRACT: Francis Omaswa was working as head of cardiothoracic surgery at Kenyatta National Hospital in Nairobi, in 1982, leading an open-heart surgery team, when he decided to take a slight detour. At the invitation of the Association of Surgeons of East Africa, Omaswa travelled back to Uganda, his homeland, and set out for a remote mission hospital in the town of Ngora. He spent the next 5 years on an experimental project testing out the most cost-effective ways to deliver quality health services in a rural African setting. In so doing, he figured out how to make health systems work. And, according to Omaswa, one crucial thing about making health systems work is that they need health workers: "Money cannot take drugs from the airport into the mouths of humans. You need people. It sounds obvious but the world doesn't work like that."

More than two decades later, Omaswa looks back on his time in Ngora as a pivotal training ground for his current role as Executive Director of WHO's Global Health Workforce Alliance (GHWA). The group, which holds a major conference in Kampala next month, is charged with coordinating the global response to the massive shortage of doctors, nurses, and health workers that is paralysing the health systems of many countries throughout the developing world. "It's the basis on which I understand health systems and health care in low-income countries", Omaswa says

30. Taegtmeyer M, Suckling RM, Nguku PM et al. Working with risk: Occupational safety issues among healthcare workers in Kenya. AIDS Care 2008; 20(3):304-310.
ABSTRACT: The objective of this study was to explore knowledge of, attitudes towards and practice of post-exposure prophylaxis (PEP) among healthcare workers (HCWs) in the Thika district, Kenya. We used site and population-based surveys, qualitative interviews and operational research with 650 staff at risk of needlestick injuries (NSIs). Research was conducted over a 5-year period in five phases: (1) a bio-safety assessment; (2) a staff survey: serum drawn for anonymous HIV testing; (3) interventions: biosafety measures, antiretrovirals for PEP and hepatitis B vaccine; (4) a repeat survey to assess uptake and acceptability of interventions; in-depth group and individual interviews were conducted; and (5) health system monitoring outside a research setting. The main outcome measures were bio-safety standards in clinical areas, knowledge, attitudes and practice as regards to PEP, HIV-sero-prevalence in healthcare workers, uptake of interventions, reasons for poor uptake elucidated and sustainability indicators. Results showed that HCWs had the same HIV sero-prevalence as the general population but were at risk from poor bio-safety. The incidence of NSIs was 0.97 per healthcare worker per year. Twenty-one percent had had an HIV test in the last year. After one year there was a significant drop in the number of NSIs (OR: 0.4; CI: 0.3-0.6; p<0.001) and a significant increase in the number of HCWs accessing HIV testing (OR: 1.55; CI: 1.2-2.1; p=0.003). In comparison to uptake of hepatitis B vaccination (88% of those requiring vaccine) the uptake of PEP was low (4% of those who had NSIs). In-depth interviews revealed this was due to HCWs fear of HIV testing and their perception of NSIs as low risk. We concluded that Bio-safety remains the most significant intervention through reducing the number of NSIs. Post-exposure prophylaxis can be made readily available in a Kenyan district. However, where HIV testing remains stigmatised uptake will be limited - particularly in the initial phases of a programme

31. The L. Finding solutions to the human resources for health crisis. The Lancet 2008; 371(9613):623.
ABSTRACT: Earlier this month, medical workers at Lira Hospital in northern Uganda went on strike to demand unpaid allowances promised by the government for working in this war-torn area. Seven patients died. There were reports of bodies decomposing in wards and women in the maternity ward assisting with each other's deliveries. This shocking situation serves as a stark reminder of the reality of the human resources for health crisis in sub-Saharan Africa. It also highlights the complexities of the crisis, where competing human rights, health-care needs, and international agendas clash, and in which the poor and most vulnerable suffer the most.

32. Wada K, Sakata Y, Fujino Y et al. The Association of Needlestick Injury with Depressive Symptoms among First-year Medical Residents in Japan. Ind Health 2008; 45(6):750-755.
ABSTRACT: Depressive symptoms among medical residents are common. The objective of this study was to determine the association of depressive symptoms with needlestick injury among first-year medical residents (so-called "intern"). We conducted a prospective cohort study among 107 medical residents in 14 training hospitals. The baseline survey was conducted in August 2005 and the follow-up survey was conducted in March 2006. Depressive symptoms were based on the Center for Epidemiological Study of Depression. Factors associated with depressive symptoms were examined using logistic regression analysis. For medical residents without depressive symptoms at the baseline survey, needlestick injury events were associated with depressive symptoms at the follow-up survey (corrected odds ratio [cOR]=2.98; 95% confidence interval [CI], 1.16-3.70). Because it was not possible to determine when the medical residents developed depressive symptoms, it is not possible to definitely determine causality between needlestick injury and depressive symptoms, although these findings are suggestive. Therefore, it would seem prudent to suggest the provision of mental health services to medical residents sustaining a needlestick injury since this may be helpful in identifying and treating depression

33. Whitby M, McLaws ML, Slater K. Needlestick injuries in a major teaching hospital: the worthwhile effect of hospital-wide replacement of conventional hollow-bore needles. Am J Infect Control 2008; 36(3):180-186.
ABSTRACT: BACKGROUND: Needlestick injury (NSI) with hollow-bore needles remains a significant risk of bloodborne virus acquisition in health care workers. The impact on NSI rates after substantial replacement of conventional hollow-bore needles with the simultaneous introduction of safety-engineered devices (SEDs) including retractable syringes, needle-free intravenous (IV) systems, and safety winged butterfly needles was examined in an 800-bed Australian university hospital. METHODS: NSIs were prospectively monitored for 2 years (2005-2006) after the introduction of SEDs and compared with prospectively collected preintervention NSI data (2000-2004). RESULTS: Preintervention hollow-bore NSI rates over 10 years persisted at a constant rate between 3.01 and 3.77 per 100 full-time equivalent employees (FTE) (P = .31). Rates for 2005 (1.93; 95% CI: 1.48-2.47 per 100 FTE) and 2006 (1.50; 95% CI: 1.11-1.97 per 100 FTE) were significantly lower than the average rate for the preintervention years (3.39; 95% CI: 2.7-4.24 per 100 FTE, P = .00004). This represents a fall of 49% (43.1%-55.7%) in hollow-bore NSI, contributed to by the virtual elimination of NSI related to accessing IV lines. More importantly, high-risk injuries were also reduced 57% by retractable syringe use with an overall budgetary increase of approximately US $90,000 per annum. CONCLUSION: Introduction of SEDs results in an impressive fall in NSI with minimal cost outlay

34. White SM. Needlestick injuries - a testing time. Nurs Crit Care 2008; 13(1):1-2.

35. White SM. Needlestick injuries - a testing time. Nurs Crit Care 2008; 13(1):1-2.
ABSTRACT: Critical care staff need to be aware of recent changes in the law. Using the example of human immunodeficiency virus (HIV) and hepatitis screening after needlestick injuries involving unconscious patients, this editorial will examine the implications of the Human Tissue Act 2004 (HTA) and the Mental Capacity Act 2005 (MCA) for critical care practice and explore potential solutions to the problem.

In response to high-profile public concerns over unethical organ retention at Alder Hey Hospital and the Bristol Royal Infirmary, the government introduced the Human Tissue Bill that was enacted as the HTA in 2004 and enforced from 1 September 2006.

36. Wicker S, Jung J, Allwinn R, Gottschalk R, Rabenau HF. Prevalence and prevention of needlestick injuries among health care workers in a German university hospital. Int Arch Occup Environ Health 2008; 81(3):347-354.
ABSTRACT: OBJECTIVE: Health care workers (HCWs) are exposed to bloodborne pathogens, especially hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV) through job-related risk factors like needlestick, stab, scratch, cut, or other bloody injuries. Needlestick injuries can be prevented by safer devices. METHODS: The purpose of this study was to investigate the frequency and causes of needlestick injuries in a German university hospital. Data were obtained by an anonymous, self-reporting questionnaire. We calculated the share of reported needlestick injuries, which could have been prevented by using safety devices. RESULTS: 31.4% (n = 226) of participant HCWs had sustained at least one needlestick injury in the last 12 months. A wide variation in the number of reported needlestick injuries was evident across disciplines, ranging from 46.9% (n = 91/194) among medical staff in surgery and 18.7% (n = 53/283) among HCWs in pediatrics. Of all occupational groups, physicians have the highest risk to experience needlestick injuries (55.1%-n = 129/234). Evaluating the kind of activity under which the needlestick injury occurred, on average 34% (n = 191/561) of all needlestick injuries could have been avoided by the use of safety devices. Taking all medical disciplines and procedures into consideration, safety devices are available for 35.1% (n = 197/561) of needlestick injuries sustained. However, there was a significant difference across various medical disciplines in the share of needlestick injuries which might have been avoidable: Pediatrics (83.7%), gynecology (83.7%), anesthesia (59.3%), dermatology (33.3%), and surgery (11.9%). In our study, only 13.2% (n = 74/561) of needlestick injuries could have been prevented by organizational measures. CONCLUSION: There is a high rate of needlestick injuries in the daily routine of a hospital. The rate of such injuries depends on the medical discipline. Implementation of safety devices will lead to an improvement in medical staff's health and safety

37. Hospital's liability affirmed over nurse's needlestick injury. AIDS Policy & Law 2007; 22(12).
ABSTRACT: An appeals court affirmed a ruling that a nurse contracted HIV from a needlestick injury that occurred four years before she tested positive for the virus.

On June 30, 1994, Anglea Price was working as a certified nursing assistant for Christus Health/St. Joseph Hospital. While drawing blood from a patient with HIV who had developed AIDS, Price accidently stuck her finger with a needle that she used on the patient. Price immediately reported the needlestick to her supervisors and went to the hospital's emergency room. She tested negative for HIV on the date of the incident.

38. Study: Gaps persist in HBV immunizations. Hospital Employee Health 2007; 26(2):21-22.
ABSTRACT: About one in four health care workers who are offered the hepatitis B vaccine decline to take it, according to a study by the Centers for Disease Control and Prevention. Although the occupational risk of acquiring hepatitis B has declined dramatically since the 1980s, health care workers still need to be vigilant about vaccinations, says Ian Williams, PhD, MS, chief of the Epidemiologic Research and Field Investigations Team in the Division of Viral Hepatitis at the CDC.

39. Rapid response lowers HIV needlestick risk: Rural hospitals may not have PEP on stock. Hospital Employee Health 2007; 26(1):6-8.
ABSTRACT: AIDS has forever altered the way health care workers fiew the threat of infectious disease. Although HCWs had long been at risk of contracting tuberculosis, hepatitis B, and other serious diseases, the AIDS epidemic in the 1980s brought a new level of fear -- and a focous on the need for workplace protections.

40. Statement on sharps safety. Bull Am Coll Surg 2007; 92(10):34-37.
ABSTRACT: Sharps injuries and surgical glove tears continue to expose surgeons and operating room (OR) personnel to the risk of human immunodeficiency virus, viral hepatitis B, viral hepatitis C, and bacterial infections from patients. Patients' blood makes contact with the skin or mucous membranes of OR personnel in as many as 50 percent of operations, with cuts or needlesticks occurring in as many as 15 percent of operations. Surgeons and first assistants are at highest risk for injury, sustaining up to 59 percent of the injuries in the operating room. Scrub personnel have the second highest frequency of injuries in the OR (19%), followed by anesthesiologists (6%) and circulating nurses (6%). For surgeons, suture needles are the most frequent source of sharps injuries.

41. Nonhospital health-care workers at substantial risk of exposure to bloodbornepathogens. 12-20-2007. Columbia University's Mailman School of Public Health.
ABSTRACT: In one of the largest studies of its kind, researchers from the Columbia University Mailman School of Public Health assessed the risk of exposure to bloodborne pathogens among non-hospital based registered nurses (RNs), and found that nearly one out of 10 of the more than 1100 nurse participants reported at least one needlestick injury in the previous 12 months.

42. Computer-based training not up to OSHA bloodborne pathogen standard: Program must allow for real-time Q&A. Hospital Employee Health 2007; 26(3):25-27.
ABSTRACT: Technology has opened new avenues for health and safety training, but it comes with a caveat: Computer-based modules may not meet the requirements of the bloodborne pathogen standard.
The U.S. Occupational Safety and Health Administration (OSHA) requires employers provide "direct access to a qualified trainer during training," which can include e-mail only if the trainer is available to respond to the e-mail immediately.

43. Al-Dwairi ZN. Infection Control Procedures in Commercial Dental Laboratories in Jordan. J Dent Educ 2007; 71(9):1223-1227.
ABSTRACT: The risk of cross-infection in dental clinics and laboratories has attracted the attention of practitioners for the past few years, yet several medical centers have discarded compliance with infection control guidelines, resulting in a non-safe environment for research and medical care. In Jordan, there is lack of known standard infection control programs that are conducted by the Jordanian Dental Technology Association and routinely practiced in commercial dental laboratories. The aim of this study was to examine the knowledge and practices in infection control among dental technicians working in commercial dental laboratories in Jordan. Data were collected from the dental technicians by a mailed questionnaire developed by the author. The questionnaire asked respondents to provide demographic data about age and gender and to answer questions about their knowledge and practice of infection control measures: use of gloves, use of protective eyeglasses and face shields, hepatitis B virus (HBV) vaccination, laboratory work disinfection when sent to or received from dental offices. and regularly changing pot water or pumice slurry. Of the total respondents, 135 were males (67.5 percent) and sixty-five were females (32.5 percent) with a mean age of twenty-seven years. The results showed that 24 percent of laboratory technicians wore gloves when receiving dental impressions, while 16 percent continued to wear them while working. Eyeglasses and protective face shields were regularly worn by 35 percent (70/200) and 40 percent (80/200) of technicians, respectively. Fourteen (14 percent) had received an HBV vaccination, and 17 percent inquired if any disinfection measures were taken in the clinic. Eighty-six percent of the technicians reported that pumice slurry and curing bath water were rarely changed. Only five dental technicians (two males and three females) were considered to be fully compliant with the inventory of infection control measures, a compliance rate of 2.5 percent with no significant difference between males and females (p>0.05). In conclusion, there is lack of compliance with infection control procedures of dental technicians working in commercial laboratories in Jordan

44. Allegranzi B, Pittet D. Healthcare-associated infection in developing countries: simple solutions to meet complex challenges. Infection Control & Hospital Epidemiology 2007; 28(12):1323-1327.

45. Allos BM, Schaffner W. Transmission of hepatitis B in the health care setting: the elephant in the room ... or the mouse? J Infect Dis 2007; 195(9):1245-1247.
ABSTRACT: Most infections with hepatitis B virus in the United States occur as a result of specific high-risk behaviors. Most, but not all. Approximately 1.2 million people living in the United States have chronic hepatitis B virus infection [1]. Each year, another 8000 acute infections-mostly in adults-are reported to the Centers for Disease Control and Prevention (CDC) [1]. Many of these infections are the result of sexual activity (both heterosexual and homosexual) or intravenous drug use; however, up to one-third report no risk factors for infection [2]. Although it is likely that a large number of these risk-deniers simply are unwilling to acknowledge behaviors they may view as socially stigmatizing, it also is possible that some have acquired their hepatitis B infection in nonclassical ways. The blunt epidemiologic tools used in recent decades to assess risks of transmission have been important and useful. Nevertheless, finer implements may be needed to tease out smaller but perhaps substantial risk factors.

46. American Nurses Association. Medication errors and syringe safety are top concerns for nurses according to new national study. New Jersey Nurse 2007; 37(4):4-5.
ABSTRACT: SILVER SPRING, MD - June 19, 2007 --The American Nurses Association (ANA) today announced the findings of the 2007 Study of Injectable Medication Errors, an independent nationwide survey of 1,039 nurses. According to the research, the overwhelming majority of nurses (97 percent) say they "worry" about medication errors, and more than two-thirds (68 percent) believe medication errors can be reduced with more consistent syringe labeling.

47. Argentero PA, Zotti CM, Abbona F et al. [Regional surveillance of occupational percutaneous and mucocutaneous exposure to blood-borne pathogens in health care workers: strategies for prevention]. [Italian]. Medicina del Lavoro 2007; 98(2):145-155.
ABSTRACT: BACKGROUND: Several studies have investigated both the frequency and modality of occurrence of occupational exposure of health-care workers to blood-borne pathogens. At the moment no complete epidemiological data are available covering the hospitals of an entire Region. OBJECTIVES ANd METHODS: To describe the characteristics of mucocutaneous and percutaneous exposure to body fluids of the healthcare workers in 47 out of the 56 public hospitals (90% of a total 15,000 beds, 28,000 health-care workers full time equivalent) in Piedmont, Northern Italy (4.5 million inhabitants) over a three-year period (1999-2002), using