Occupational accidents with biological material among professionals in clinical laboratories in Cajazeiras , Paraíba , Brazil

| Context: Occupational accidents in health institutes can result in the transmission of human infectious diseases. The collection and processing of biological samples are risk factors for accidents involving clinical laboratory workers. Objective: To identify occupational accidents with biological material among healthcare workers in the clinical laboratories of Cajazeiras city, Paraíba, Brazil. Methods: We conducted a cross-sectional and analytical study using a semi-structured questionnaire distributed to 38 workers at six clinical laboratories. Social-demographic data, types of occupational accidents, post-exposure procedures, biosafety practices, and emotional impact were analyzed. Results: Workplace accidents were reported by 22 (57.9%) interviewees. Female gender (81.6%) was more prevalent in this study population. Nurse technicians and biochemists related the most frequent exposures. Accidents occurred mainly in the upper extremities (91%). The biological fluids related to the occupational accidents included blood (81.8%) and urine (45.5%).  Thirty-three (86.8%) workers reported undergoing a post-exposure evaluation in the workplace. Fourteen (63.6%) participants underwent laboratory testing after biological material exposure. Conclusion: The data showed that occupational accidents in clinical laboratories are frequent among healthcare workers. We suggest new approaches for occupational accidents in the clinical laboratories to ameliorate the biosafety guidelines and working conditions of healthcare professionals.


INTRODUCTION
The collection, processing, and storage of biological samples are laboratory procedures that have resulted from the evolution of biotechnology methods.Consequently, scientific methods and clinical activities have expanded knowledge regarding the pathogens present in biological fluids.Therefore, health organizations have supported and implemented guidelines to prevent occupational accidents and to promote safe practices for working with biological samples [1][2][3] .In Brazil, the Ministry of Labor and Employment proposed Regulatory Standard 32 (NR 32), which focuses on biological, chemical, and ionizing radiation risks 4 .In addition, Brazilian health professionals have access to seroconversion and post-exposure prophylaxis and/or immunization to prevent infection with hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) 5 .However, negligence or lack of knowledge regarding biosafety guidelines can contribute to occupational accidents and temporary and permanent treatments, elevated costs to professionals and employer 6,7 .
A number of studies have evaluated occupational accidents in hospitals 8,9 and research laboratories 10,11 .Research on occupational accidents involving clinical laboratory workers is fundamental to ameliorate the manipulation of biological samples and to prevent incorrect procedures.Therefore, the present study identified occupational accidents with biological material and verified post-exposure behaviors among healthcare workers in clinical laboratories in Cajazeiras city, Paraíba, Brazil.

METHODS
We conducted a cross-sectional and analytical study by distributing a questionnaire to 38 workers at six clinical laboratories in Cajazeiras city, Paraíba, Brazil.The interviewees signed a free and informed consent form, as required by Brazilian Federal Resolution National Health Council (Conselho Nacional de Saúde -CNS) 466/12.The participants' privacy and confidentiality were maintained during data collection.The study design was approved by the Research Ethics Committee of Santa Maria College.The data were collected between September and November 2016.The semi-structured questionnaire collected information on social-demographic variables including age, gender, occupation, and length of employment.The types of occupational accidents and the presence of biological fluids were also investigated.The knowledge, attitude, and practice regarding the use of personal and collective protective equipment ( PPE/ CPE) were verified.
We also asked about the biosafety practices, post-exposure procedures, and emotional impacts following occupational accidents..The resultant database was structured and analyzed using IBM Statistical Package for the Social Sciences (SPSS) Statistics for Windows, version 23.0 (IBM Corp., Armonk, NY).The relationships between variables were analyzed using χ 2 tests and p<0.05 was considered significant.

RESULTS
We first identified four private and two public laboratories in the city.We distributed 49 questionnaires to the healthcare professionals.Of these, 38 (77.55%) workers answered the survey.Table 1 shows the basic characteristics of the study population.We received responses from 31 (81.6%)female and seven (18.4%) male workers.In this study, the mean age was 36.61±1.85years.The most frequent length of employment was 1-15 years (65.8%)(p<0.001).Tertiary education and complete secondary technician were most frequently reported (Table 1).
Next, we verified that 26 (68.4%) participants used PPE at all times in the workplace.The use of gloves, coats, and masks were reported by more than 85% of workers.Twenty-three (60.5%) workers had access to biosafety training.When asked which potentially hazardous material could be involved in laboratory accidents, the most frequent responses included blood (89.5%), microorganisms (60.5%), and other bodily fluids (55.3%), followed by fomites (18.4%).In addition, the interviewees reported rushing on the job (68.4%), lack of attention (63.3%), stress (57.9%), and lack of PPE use (57.9%) as possible motives for accidents (Table 1).
Table 2 shows the association between occupational accidents and gender, role, and working hours.In this study, 22 (57.9%)participants reported having experienced occupational accidents with biological material; of these, 19 women (61.3%) reported exposure.No statistically significant association was found between gender and occupational accidents (p=0.425).However, nursing technicians (57.1%) and biochemists (64.3%) frequently reported experiencing accidents.There was no statistically significant association between working hours and occupational accidents (p=0.779).We observed an association between the number of exposure episodes reported by 17 (77.3%)interviewees and their professional category (p=0.035)(Table 3).

DISCUSSION
This study observed a 59.7% prevalence of occupational accidents in clinical laboratories, which involved female workers in 86.4% of cases, mainly biochemists and nurse technicians.Other studies have also reported that female technicians [12][13][14][15] and undergraduate dental students 16 are most frequently exposed to biological materials.The higher frequency of accidents in women is associated with their increased participation in the health market.In addition, nurse technicians have increased exposure because they work directly with patients and perform procedures with biological material 14 .Interestingly, 41% of biochemical workers in the present study reported accidental exposure, higher than the rates reported by Caixeta and Barbosa-Branco 8 and Julio et al. 17    The frequency of occupational accidents was corroborated by Pimenta et al. 18 .The authors showed a prevalence of exposure of between one and five episodes.In this study, 60% of the injured interviewees reported working more than 40 hours per week.The literature has associated long working hours with a high risk of occupational accidents among health care workers 11,19 .However, we did not observe an association between those variables.Access to biosafety guidelines may contribute to the use of PPE and correct post-accident behaviors.The incidence of occupational accidents is lower when workers receive biosafety training 18 .We found that 60.5% of workers had access to biosafety training.We believe that continuous interventions are necessary to ensure adherence to prevention standards.
In this study, laboratory workers reported that blood and microorganisms are potentially hazardous.Notably, blood was most frequently reported in the occupational accidents.In a previous study, biological samples were the main cause of accidents in public laboratories 20 .According to Lima et al. 13 , blood can be a risk factor in 87.5% of accidents involving health care professionals.We observed that the skin was the most commonly exposed body region.However, the percutaneous region has been reported by other workers 8,17 .Therefore, in agreement with Marziale et al. 21and Oliveira and Paiva 22 , the upper extremities are more often affected in occupational accidents.In addition, a Brazilian study showed that percutaneous instruments caused frequent injuries among dental surgeons 23 .In this study, injuries were frequently caused by needle manipulation.
We verified that 36.4% of the workers did not conduct laboratory tests.This could explain why the occupational accidents were not reported.In Brazil, the Ministry of Health has recommended mandatory notification after exposure 18 .
Here, more than 90% of workers did not report the accidents to their employers.In addition, the accidents were classified as providing a low risk of contracting an infectious disease.One interviewer reported their accident.Facchin et al. 5 showed that Brazilian nursing professionals did not report exposure because the accident was considered low-risk.However, notification is the correct procedure in the clinical laboratory because bodily fluids can transmit human infectious diseases.Workplace accidents can emotionally affect the injured individuals.Depression and stress disorders are present after exposure 24 .Anxiety, anger, and reduced resilience also affect the mental health of victims 25 .In this study, we did not observe a significant difference between emotional changes and workplace accidents.This might be associated with negative test results for infectious diseases in the majority of interviewees.

CONCLUSION
The data showed that occupational accidents in clinical laboratories are frequent in healthcare workers.Nurse technicians and biochemists had the highest levels of exposure because they work directly with biological fluids.Knowledge regarding biosafety was reported by the majority of interviewees.However, negligence in reporting exposure was evident even with biosafety training.Also, the post-exposure procedures need to be improved.Therefore, both extrinsic and intrinsic factors contributed to biological material exposure and post-exposure conduct.Interestingly, emotional changes were not affected.We suggest new approaches to occupational accidents in clinical laboratories in order to ameliorate the biosafety guidelines and working conditions of healthcare professionals.
*More than one answer
*More than one answer; PPE: personal protective equipment.