regarding good lab practices and biosafety measures among lab technicians in Karachi, Pakistan, as well as a need for organizing basic training programs to in-.
Articles
Practices and Awareness Regarding Biosafety Measures Among Laboratory Technicians Working in Clinical Laboratories in Karachi, Pakistan Sadia Nasim1, Anjum Shahid1, Muhammad Ayaz Mustufa1, Shahana Urooj Kazmi2, Taranum Ruba Siddiqui1, Sobiya Mohiuddin1, Munir Ahmed Sheikh1, and Sufia Usman1 1Pakistan
Medical Research Council, Karachi, Pakistan and 2University of Karachi, Karachi, Pakistan
Abstract The aim of this study was to find out the level of awareness and biosafety measures taken by hospitalbased laboratory technicians during their routine work in clinical laboratories in Karachi, Pakistan. Public- and private-sector hospital-based laboratory technicians (253) were recruited from all 18 towns in Karachi. After securing informed consent documents, the laboratory technicians were interviewed and a questionnaire was completed by the interviewer. A total of 200 males and 53 females participated in this study, with about 61.7% having more than 5 years of work experience. Results showed that 46.2% of the laboratory technicians did not use any kind of personal protective equipment, and almost 39.5% of the respondents recapped used syringes regularly while 10.7% recapped occasionally. To avoid the reuse of syringes, Pakistani authorities recommend that they be cut before discarding; however, only about 36% of the respondents do this prior to discarding used syringes directly into municipal dustbins. In addition, about 65.2% of the respondents declare that there is no separate discarder for sharps so they throw these too into municipal dustbins. Although mouth pipetting is considered obsolete, 38% of the technicians continue to do so for various purposes. Additionally, standard operating procedures were not available in 73.9% of the labs, and accident records were not maintained in 83.4%. No formal biosafety training had been provided to 85% of the respondents. Results of this survey confirm a lack of awareness regarding good lab practices and biosafety measures among lab technicians in Karachi, Pakistan, as well as a need for organizing basic training programs to increase awareness of good laboratory techniques and self-hygienic principles.
Introduction Biosafety is an important issue in laboratory settings worldwide and especially in developing countries where standard operating procedures (SOPs) are lacking. Biosafety during lab work and the transferring of lab material from one place to another is a critical tool in the global fight against infectious diseases and exposures to labor172
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atory personnel, particularly those working in microbiological laboratories as they are exposed to biohazards which may result in laboratory-acquired infections (Aksoy et al., 2008). Any laboratory worker who handles blood or any biological sample may be at risk for accidental injury or exposure. As all public- and private-sector hospital-based laboratory personnel continuously deal with known and/ or unknown pathogens, they are continuously at risk for occupational infection (Karamat et al., 2005; Tietjen et al., 2003). The lack of awareness regarding biosafety issues results in improper handling and/or dangerous laboratory practices during sample collection, processing, and discarding of specimens, potentially making laboratory technicians more exposed to pathogens. In Pakistan ignorance among laboratory technicians is mainly due to lack of awareness and the scarcity of biosafety training programs regarding the proper handling of clinical samples and instruments (Mujeeb et al., 2003). In addition to the potential spreading of infections to others, these workers are constantly exposed to opportunistic pathogens or potentially pathogenic organisms since thousands of healthcare workers in developing nations, including Pakistan, suffer accidental needlesticks every day (Habibullah & Afsar, 2007; Maqbool, 2002). Because identifying the epidemiological distribution of hazardous exposures during collection, processing, storage, and disposal of specimens is so important (Misra et al., 2001), the present study was conducted to assess biosafety knowledge among laboratory technicians in Karachi.
Method A survey was conducted to assess laboratory technicians’ awareness of biosafety measures during laboratory practices. After securing informed consent documents from each participant, a research team member anonymously interviewed each clinical laboratory worker and filled out a standard questionnaire. The questionnaire was developed on the basis of available standard texts (Barker et al., 1983; Misra et al., 2001; WHO, 1993). The questionnaire contained basic questions regarding routine laboratory practices, such as unsafe work practices (e.g., eating or drinking in laboratories), mouth pi-
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petting of biological samples, use of personal protective equipment, and proper disinfection, specimen handling, collection, and processing. Questions regarding disposal of used syringes and sharps were also included.
Sampling Plan
Simple random sampling was employed.
Study Design
A quantitative, cross-section survey was designed.
Sample Size
The sample size for this study was 230 with 10% added to cover non-respondents; therefore, a total of 253 respondents calculated based on a previous study (WHO, 1993) at a 95% confidence level with 0.035% precision (d) through sample size for n = (z2pq)/d2. The sample size (n) is unknown, at a 95% confidence level Z=1.96, and both p and q (proportions of the population that are aware/are not aware of biosafety) must equal 1.0 when added together. The values for p and q are not known and so the survey developer provides a best estimate for these values to identify the required number of
respondents that must complete the survey. Clinical laboratory workers from both public- and private-sector hospital-based laboratories were recruited from 18 towns in Karachi. However, it should be noted that the town of Gadap has no public-sector laboratory-based hospital, so all 14 technicians from that area were from private-sector-hospital-based laboratories. After securing informed consent documentation, research team members interviewed technicians, supervisors, assistant technicians, and trainees and filled out the questionnaire. Questionnaires were comprised of close-end questions.
Results and Discussion This study was conducted in 18 towns in Karachi in hospital-based laboratories from both the private and public sector (Table 1). The duration of the survey was 9 months from December 2008 to September 2009. The total number of participants was 253, of which 200 were males and 53 were females. About 61.7% of the technicians had working experience of more than 5 years.
Table 1
Public and private sector hospitals of Karachi.
Towns of Karachi
Overall
Type of Hospitals Private Hospital
Public Hospital
Baldia
14
7
7
Binqasim
14
7
7
Gadap
14
14
0
Gulberg
14
7
7
Gulshan-e-iqbal
15
7
8
Jamshed town
14
7
7
Korangi
14
7
7
Kemari
14
7
7
Layari
14
7
7
Landhi
14
7
7
Liqqat a bad
14
7
7
Malir
14
7
7
New Karachi
14
7
7
North Nazimabad
14
7
7
Orangi
14
7
7
Saddar
14
7
7
Shah Faisal
14
7
7
SITE
14
7
7
Total
253
133
120
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The biosafety practices among these laboratory personnel were noted and evaluated. The resulting data indicate very similar results from private and public hospitals in Karachi. Since improving laboratory workers’ knowledge of and capabilities for safe-handling of dangerous infectious agents and highly virulent pathogens is so important, biosafety issues within the BSL-2 laboratories are an important concern.
Personal Protective Equipment
All the labs surveyed were BSL-2 and wearing personal protective equipment (PPE) is an important requirement for all individuals (Karamat et al., 2005; WHO, 2004). For example, gloves play an important role in protecting personnel from contact with infectious materials. However, contaminated gloves can act as a means to spread infectious materials to environmental surfaces (CDC, 2004), knowledge of proper PPE usage is necessary. In the present study, 46% of the laboratory workers did not use any kind of PPE; this was more common in the public sector (49.2%) than in the private sector (43.6%). Both gloves and lab coats were used by 21.3% of the personnel, while a lab coat or gloves alone were used by 19.4% and 12.3%, respectively. These percentages are relatively low when compared with a Turkish study where 91.3% and 87.4% of the participants used gloves and lab coats, respectively (Aksoy et al., 2008). An earlier study from Karachi reported that out of 44 clinical laboratories evaluated, gloves were used by personnel in only two (4.5%) laboratories (Mujeeb et al., 2003). Safety glasses or other protective devices must be worn when it is necessary to protect the eyes and face from splashes. The choice of equipment depends on the activity performed, but in this study’s finding only 0.8% of the technicians used safety glasses or similar protec-
tive equipment. The percentages of lab technicians who use personal protective equipment during routine laboratory work are shown in Figure 1.
Disinfecting Work Benches
All the work tables, biosafety cabinets, and other surfaces of the lab should be wiped with a disinfectant after work is complete and also before starting any new work daily. But this study revealed that about 23.3% from the private sector and 24.2% from the public sector never disinfect their work tables, and about 63.9% from the private sector and 61.7% from the public sector disinfect their working surfaces daily. The remaining technicians disinfect laboratory surfaces weekly or monthly or call sweepers to clean on that time schedule. Frequency of disinfecting work benches by laboratory workers is illustrated in Figure 2.
Used Syringes and Sharps
Reuse of disposable syringes and their improper disposal is a major route of transmission for hepatitis B virus (Hutin et al., 1999), hepatitis C virus (Luby et al., 1997),, HIV (Hersh et al., 1993), abscesses (Soeters & Aus, 1989), septicemia (Archibald et al., 1998), malaria (Abulrahi et al., 1997), and viral hemorrhagic fevers (Fisher-Hoch et al., 1995; Hutin, Hauri, & Armstrong, 2003); Kamal & Khan, 2003; WHO, 1976). In the present study, on average, 39.5% (37.5% from the public sector and 41.4% from the private sector) of the respondents regularly recapped needles after use, while 10.7% recapped them occasionally. However, recapping used needles is strictly prohibited according to Biosafety in Microbiological and Biological Laboratories (BMBL) (U.S. Department of Health and Human Services, 2007) in BSL-2 labs. In Pakistan cutting syringe needles before disposal
Figure 1
Bar represents percentages of laboratory technicians in private or public sector using personal protective equipment during laboratory work.
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is recommended to avoid reuse of those needles, which is quite common in this country. A study conducted in Rawalpindi, Pakistan reported that the percentage of disposable syringe reuse was 24%, and most of the healthcare providers were unaware of the health consequences of reusing disposable syringes (Kamal & Khan, 2003). To avoid reuse of syringes, they must be discarded properly, however. This study showed that 43.3% of the respondents from the public sector still throw them in the dustbin without using proper disposal measures compared to 29% of respondents in the private sector. The present finding is also supported by a previous study from Karachi that reported that only 35% of healthcare
facilities cut needles before disposal (Habibullah & Afsar, 2007). Sharps constitute a special category of medical waste that can expose waste handlers to infection via puncture injuries during collection, transportation, and disposal. To comply with SOPs, sharps must be carefully placed in conveniently located puncture-resistant containers (U.S. Department of Health and Human Services, 2007). Contrary to this, over 67.7% of private-sector and 62.5% of public-sector laboratory workers do not discard sharps properly or place used syringes in separate sharp containers as illustrated in Figure 3. This may be one of the major causes of percutaneous injury in Karachi. A
Figure 2
Bar represents the frequency of laboratory bench disinfection reported by laboratory technicians in the private and public sector.
Figure 3
Percentages of technicians in the private and public sector reporting the specified handling and discarding procedures for used syringes and sharps.
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cross-sectional survey reported that approximately 63% of healthcare workers experience at least one percutaneous injury each year (Kermode et al., 2005).
Mouth Pipetting
Mouth pipetting is considered obsolete and is strictly prohibited in clinical laboratories (U.S. Department of Health and Human Services, 2007). However, in the present study lab workers used mouth pipetting for different purposes—approximately 19.4% for blood samples, 13.4% for chemicals, and 5.9% for preparing dilutions of various chemicals. Mouth pipetting practices for different specimens among laboratory workers in public and private hospitals of Karachi are presented in Figure 4.
Centrifuge Machines
Centrifuge machines are one of the main vectors to disperse aerosol in the laboratory environment as they spin at a great velocity and exert the force needed to produce respirable aerosols. If these aerosols are inhaled, laboratory-acquired infections could result. Therefore, while centrifuging, the tubes should be closed with a suitable cap to avoid biohazards due to inhalation (U.S. Department of Health and Human Services, 2007). Similarly, the centrifuge machine should also be closed before operating. However, in this study 34.6% of privatesector lab technicians and 34.2% of public-sector lab technicians never or only occasionally close centrifuge machines during centrifugation. These values are quite low compared to an Indian study (WHO, 1993)…where 63% of lab workers did not close the centrifuge machine while operating (Misra et al., 2001). Breakage of tubes in a centrifuge can also disperse large amounts of aerosols so sealed buckets should be used for all samples. If breakage of the tube occurs, the centrifuge buckets and rotor must be removed, auto-
claved, and disinfected. In this survey, 54.9% of privatesector and 69.2% of public-sector technicians experienced breakage accidents during centrifugation. However, only 48.9% from the private sector and 30.8% from the public sector knew the right procedure to clean up a spill after breakage. The remaining wipe up a spill with tissue or wash it with water, as shown in Figure 5.
Biosafety Cabinets, Fire Extinguishers, and a Separate Place for Eating and Drinking
Although biosafety cabinets, fire extinguishers, and a separate place for eating and drinking are the desirable requirement for BSL-2 labs, in the present study fire extinguishers were not available in 82.7% of privatesector and 76.7% of public-sector labs. Overall, on average, 82.2% of labs (85% private and 79.2% public) were without biosafety cabinets, and eating and drinking in the lab were common due to lack of availability of a separate place to eat (68.4% of the technicians from the private-sector labs and 64.2% from the public-sector labs had no separate place for eating and drinking), as shown in Figure 6.
SOPS, Accident Records, and Biosafety Training
On average, 73.9% of labs (75.9% private and 71.7% public) were operating without written standard operating procedures and, on average 83.4% of labs (85.7% private and 80.8% public) did not maintain any accident records. Strikingly, 85% of respondents did not have any training in biosafety. This percentage is relatively high in the private sector, which is about 88.7%, compared to 80.8% in the public sector. The percentages of laboratory technicians responding to the question regarding use of standard operating procedures, availability of accident records, and training on biosafety are shown in Figure 7.
Figure 4
Bar represents percentage of laboratory workers performing mouth pipeting for various purposes.
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Figure 5
Bar represents percentage of reported improper centrifugation procedures.
Figure 6
Laboratory Design
Figure 7
Shows percentages of laboratory technicians in the private and public sector reporting the absence of standard operating procedures (SOPs), accident records, and formal training on biosafety.
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Conclusion Results of this survey confirm a lack of awareness regarding good lab practices among the lab technicians in Karachi, Pakistan. To address this lack, there must be institutional biosafety support to control, maintain, and record, nosocomial infection and accidents. In addition, organizing basic training programs to increase awareness of basic biosafety principles and self-hygienic procedures for laboratory workers is greatly needed. In addition, a biological safety officer whose job is to become familiar with and provide oversight to the proposed work activities, procedures, equipment, personnel, storage, material transfer and transport, proper destruction of biological material is also needed. This biosafety officer should also complete risk analyses to assist with the development of written standard operating procedures for each lab in Karachi, Pakistan. There is also a need to conceptualize a national strategic framework for public- and private-sector hospital laboratories in Pakistan for efficient implementation of biosafety standards. Since Pakistan is a developing country, it enjoys fewer of the benefits of advanced biological and biomedical research and faces greater risks
because of more limited institutionalized biosafety measures. In recent years, remarkable advances have been made in advanced biological research in the country, which warrant the enforcement of standard biosafety principles. However, biosafety in Pakistan today is at the developing stage and biosafety policy and regulations are still evolving.
Acknowledgments The authors are grateful to the Pakistan Medical Research Council for financial assistance in this project via Grant No. 4-17-2/07/RDC/NICH Karachi and for the ability to continue this study as a multi-center study throughout Pakistan. All the private- and public-sector hospitals are acknowledged for their consent and cooperation. Thanks also to the Biosafety Association of Pakistan (BSAP) for its help in designing and implementing this project.
Authors’ Note
To understand the current situation regarding biosafety in Karachi, included are some photographs that were taken during the survey (Figure 8).
Figure 8
A—Blood collection without PPE. B—Pipettes without any mechanical device and also some recapped used syringes. C—Improper discarding of used syringes may be reused. D—Children picking laboratory waste.
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UNC Center for Public Health Preparedness Training Web Site This site (http://cphp.sph.unc.edu/training/training_list/?mode=view_kw_detail&keyword_id=2167) offers free, f short Internet-based trainings developed by the UNC Center for Public Health Preparedness (CPHP) on public health preparedness topics such as disease surveillance, basic epidemiology, bioterrorism and new/emerging disease agents. Trainings address emergency readiness competencies plus core public health and epidemiology competencies. There are 14 short audio courses on influenza that include topicssuch as “Overview of the 2009 H1N1 Influenza Pandemic.”
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