OCCUPATIONAL ACCIDENTS INVOLVING BIOLOGICAL MATERIAL AMONG PUBLIC HEALTH WORKERS

This descriptive research aimed to recognize the occurrence of work accidents (WA) involving exposure to biological material among health workers at Public Health Units in Ribeirão Preto-SP, Brazil. A quantitative approach was adopted. In 2004, 155 accidents were notified by means of the Work Accident Communication (WAC). Sixty-two accidents (40%) involved exposure to biological material that could cause infections like Hepatitis and Aids. The highest number of victims (42 accidents) came from the category of nursing aids and technicians. Needles were responsible for 80.6% of accidents and blood was the biological material involved in a majority of occupational exposure cases. This subject needs greater attention, so that prevention measures can be implemented, which consider the peculiarities of the activities carried out by the different professional categories.


INTRODUCTION
According to the Ministry of Social Security (1) , occupation accidents (OA) are defined as accidents that occur in performing work in a firm's service or yet by the exercise of work by especially insured workers, causing body injury or functional disorder that leads to death, to the permanent or temporary loss or reduction of work capacity.Occupational accidents are traditionally classified as type or typical accidents (those that occurred in the work environment and/or during the work journey), route accidents (those that occur in the trajectory from home to work and from work to home) and those related to work.This is an issue of national and international relevance due to the losses it causes to health workers, employment institutions and governmental institutions.
Regarding health institution workers, the OA can be related to a series of predisposing factors, due to the peculiarities of human care activities.Among these, occupational violence, physical, chemical, biological, psychosocial and ergonomic factors stand out (2)   .
A study performed at health units in Cuiaba-MT, Brazil, demonstrated that violence in the nursing work context in health units happens in two distinct ways: structural/institutional and behavioral/ relational, which turn into the following types of violence: structural violence (imposition to workers of physical and mental overload); repressive violence (denying the right to implement care activities safely and to act in a safe work environment); violence alienation (explicitly impeding workers to perform competently, effectively and professionally and to be socially valued); and classic violence (physical and verbal aggressions by health team members and users) (2) .or yet which, by the nature of the activity and exposure, can be in contact with or absorbed by the organism through the skin or ingestion (3) .
Psychosocial factors can be associated to fatigue and tension; loss of control on the job; impact of night and shift work schedules, overtime, double shifts; subordinated work; disqualification of the worker; work interrupted by fragmented and repetitive tasks; accelerated pace of work (4) .
Ergonomic factors are related to the adoption of an inadequate and/or prolonged posture during the transport and movement of users, equipment, materials and to non-adaptable furniture, work pace and shift work scheme among others (5) .
Biological factors are represented by biological agents like bacteria, fungi, bacilli, parasites, microorganisms and viruses (4) .These are the most evident due to the exposure to blood and body fluids that cause infection, due to bloodborne pathogens like the hepatitis B (HBV), hepatitis C (HCV) and Acquired Immunodeficiency Syndrome (AIDS) viruses, which can be lethal.This contamination occurs more frequently through the cutaneous route, due to OA with piercing and cutting material.
The main causes attributed to the occurrence of OA with piercing and cutting material are: discarding in inadequate sites or overloaded recipients, transport or manipulation of unprotected needles and disconnection of needle from the syringe, but the main associated factor is needle recapping which, although recommended for years through standard precaution measures, has been evidenced as a cause of between 15 and 35% of OA with piercing and cutting material (6) .
The corresponds to the first level of medium-complexity care (secondary level) (7) .At the FHC, the activities are directed at preventive actions, health promotion and recovery of people in an integral and continuous way (8) .
The UMCS is available 24 hours per day for rescue calls from the entire city (9) .The workers' activities are related to health care in urgency and emergency situations.The workers go to the site of the occurrence, offer first aid and forward the patient to the institutions determined by the Regulation Central.
Most studies about occupational risks carried out in the Primary Health Network appoint the psychosocial risk as the most reported by workers (10)   .
In a research performed at a Public Health Unit in Ribeirão Preto, SP, Brazil, it was demonstrated that 46.7% of the workers population considered the work environment as the most stressing factor and that a majority identified the risk of infection due to exposure to biological material and the existence of dangerous situations in the work site, due the aggressiveness of the assisted clientele, as one of the triggering factors of stress (11-12)   .
What motivated us to perform this study was the fact that, in 2001, 52% of the total number of OA notified by Nursing professionals from the health units of the Municipal Government of Ribeirão Preto-SP (13) involved exposure to biological material.

OBJECTIVE
Investigate the occurrence of occupational accidents involving exposure to biological material among health workers in Public Health Units.

MATERIAL AND METHOD
It is an exploratory research with a qualitative approach for data analysis.

Study site characteristics
The OMSD is responsible to register OA that occur in all health units from the Primary Health There is a District Primary Health Unit in each Health District which, in addition to primary care in its coverage area, is also a referral unit for some specialties for the entire district.The Districts are also composed by several Health Primary Units, aimed at delivering primary care in the medical, dental and nursing areas to the population in its coverage area (14)   .
In 2004, 2818 workers were active in the Ribeirão Preto Health Secretary (14) .A total of 155 occupation accidents were registered in this period and, in 40% of them, the worker was exposed to biological material.justified by workers because they considered the injury very small (53.1%) and also due to a lack of knowledge about the obligation to communicate the OA (6) .
During data collection, we observed that the majority of the COA was not properly filled out and that the records contained blanks.Such information is important to identify the actual accident situation at the service.This fact indicates that the service under study needs to adopt new strategies in order to improve the information records.

Characteristics of the injured worker
Data indicated that 82.3% of the OA occurred with female workers.This result is related to the fact that most (75.6%)workers in the PHU and DPHU in Ribeirão Preto are women (12)   .The nursing profession in Brazil is composed by 88.26% of women, according to data by the Federal Nursing Council (15) .
Regarding the characteristics of the injured workers, the average age was 41 years, with 23 years as the minimum and 61 as the maximum age; 51.6% of them were between 40 and 61 years and 48.4% between 20 and 39 years old.Regarding marital status, 61.3% of them were married. .
In Brazil, nursing aids represent more than half of the total number of nursing workers in the country.According to data informed by the Federal Nursing Council (COFEN), the nursing work force is composed by: nurses (13.35%), nursing technicians (24.47%), nursing aids (59.04%) and nursing attendants (3.12%) (15) .The nursing workers registered 45 OA (72.5 %) with exposure to biological material.Forty-two of these (67.7%) belonged to the nursing technician and aid* category and three victims (4.8%) were nurses.These data were expected due to the high contingency  ).These data differ from those presented in a study carried out earlier at the same institution (13) , where DPHU were responsible for the highest number of registered OA, with 43.2%.
Regarding the accident characteristics, the following variables were analyzed: injured body part; biological material involved; object that caused the accident; activity performed at the moment of the accident; reason the person got injured.These variables were selected for analysis since they permitted showing the circumstances in which the OA occurred, with a view to planning strategies for the prevention of these OA.
Regarding the injured body part, the superior limbs corresponded to 93.5% of the OA, while the fingers were injured in 80.6% of the events.The data corroborate with other studies and with the most recent national statistics, where more than 1/3 of occupational accidents in Brazil affect the workers' hands.In 2004, for example, in 161,000 accidents, hands, wrist and fingers were injured (17) .
Regarding the biological material involved in the exposure, 82.3% of the workers had contact with blood.The contact with blood can be responsible for the transmission of the HIV and hepatitis viruses.The literature shows that, due to OA involving exposure to blood, 99 health workers were infected with HIV as consequence of accidental inoculations (6)   .
In 80.6% of the OA, needles caused piercing injuries and, in 4.8%, scalpel blades caused cuts.
These figures are similar to those found in studies performed in the hospital area of the same city, where 89.35% of the OA were caused by needles and 6.4% by scalpel blades (18) .These objects, called piercing and cutting material, also caused 52.01% of the OA according to a study previously performed at the WMSD (13) .Table 2 shows the distribution of OA according to the object that caused the injuries.Preto -SP (19) , where 89.5% of the OA occurred when these same activities that involved the constant handling of needles were performed.
Dental surgeries were responsible for 17.74% of the OA.Sutures corresponded to 11.29% and discarding cutting material to 9.68% of the OA.
Regarding the discarding of piercing and cutting material, other studies report this occurrence, with an average of 10 to 20% of OA (6) .The cleansing of the work place affected 4.84% of workers, 3.22% occurred during wound dressing and 1.61% in the placement of nasogastric tubes.
As to the motive why the worker got injured, in 59.68% of the COA, there was no information about the reason attributed to the OA.Among the motives informed, 16.13% indicated the user as responsible for the OA, due to moving during care delivery and, in 3.22%, the motive was the accidental collision between workers.
Among the notified accidents, 6.45% of the workers got injured when they were disconnecting the uncapped needle from the syringe and 9.68% when actively recapping the needle, procedures not recommended by safety norms and internationally recommended standard precautions.There is evidence in literature that the non use of standard precautions favors the occurrence of OA involving exposure to potentially contaminated material among nursing workers (6) .The implementation of in-service education strategies is recommended in this situation.

CONCLUSIONS
The The activities performed at the moment of the OA were of professional competence and all of them contained the risk of exposure to biological material, especially blood.Twenty-one percent of the OA occurred during venipuncture; 15.1% in the Network of Ribeirão Preto-SP, divided in five regions called Health Districts.They are located in the following regions: North -Simioni District, South -Vila Virginia District, East -Castelo Branco District, West -Sumarezinho District and Central -Central District.

Figure 1 -
Figure 1 -Number of WA according to work site

Table 1 -
Distribution of the number of injured workers

Table 2 -
Distribution of the number of OA involving workers active in Public Health Units are exposed to the risk of OA involving exposure to concern because of the high incidence of patients with theses viruses in Brazil.However, a literature review revealed little research studying this population of workers.It was found that, in 2004, from the 155 OA registered among the 2818 workers from the Ribeirão