1. Introduction

The health and wellbeing of workers in any occupation can be linked to the specificity of their jobs and attending hazards in the workplace ^[1]. However simple any job may seem there are usually specific hazards associated with it ^[1]. An occupational hazard is any harmful condition associated with work place, which can result in illness, injury, endangerment, jeopardy, or danger with the possibility of injury, and loss or misfortune ^[1]. Cleaners in hospital settings are particularly vulnerable to occupational hazard considering the fact that they are directly involved in the collection and disposal of medical waste- some of which are particularly infectious, toxic and could constitute an potential or actual threat to the wellbeing of the worker ^[2].

There are a numerous consequences of occupational diseases among hospital workers- these include economic, physical and mental harm to worker and their families ^{[3, 4]}. According the World Health Organization (WHO); injuries from contaminated needles and poor handling of medical waste is responsible for about 8 to 16 million new cases of Hepatitis B virus, 2.3 to 4.7 million cases of Hepatitis C virus and 80,000 to 160,000 cases of HIV annually ^{[5, 6]}.

The level of awareness of occupational hazards and indeed of post exposure prophylaxis (PEP) for human immune-deficiency virus (HIV) amongst hospital cleaners varies depending on the locality of work ^[4]. Awareness is low in low income countries where majority of individuals employed as cleaners are of poor socio-economic status, with little or no education and lacking in basic training or orientation on how to handle hazardous waste ^[4].

Reports from high income countries indicates that the main worries concerning infectious hospital waste were the transmission of HIV/AIDS and more often of Hepatitis B or C virus through injuries caused by sharps and infected body fluids, with hospital cleaners at greatest risk ^[3]. The vulnerability of hospital cleaners to occupational hazards stems from their low level of education, lack of training and/or orientation, lack of clear cut policies and protocols for handling of medical waste, poor remuneration, ignorance and little or no insurance cover.

However, evidence has shown that the risk of transmission is higher with larger quantity of blood or other infectious body fluid, prolonged exposure to infectious materials, exposure to the blood of patients with advanced or severe disease, deep percutaneous injury, and injuries from contaminated hollow bore instruments ^[7]. In such situations, hospital staffs are constantly faced with high level risks of occupational exposure during the course of their duties. Occupational hazards in health facilities may be classified into infections, accident, radiation, noxious chemicals, drug addiction, assault and psychological problems ^[4]. In order to safeguard health care workers, these hazards should be identified, quantified and standard mode of disposal instituted in hospitals to minimize the risk they pose to health workers ^[4].

All health care facilities should have protocols and standard operation procedure guild, as well as ensures that all staffs observe universal/standard precautions at work ^[8]. These precautions should include provision and use of gowns, water proof aprons, surgical masks, water proof boots, protective eye-goggles and gloves to minimize the level of exposure to infectious and toxic materials ^[7]. Workers should also be educated on the availability of post exposure prophylaxis for HIV in the event of an exposure and Hepatitis B vaccination should be administered to sero-negative individuals handling infectious materials ^{[8, 9, 10]}.

Occupational hazards exist wherever health care is practiced, but there is a dearth of information on the level of awareness of such occupational hazards, especially among hospital cleaners working in low resource settings like ours. Unfortunately, in low income countries like Nigeria, were many health concerns are competing for limited resources, it is not surprising that the training of healthcare workers, especially cleaners has received little or no attention in both government and private owned health facilities.

Research on the awareness and experience of hospital cleaners on exposure to hazardous waste and post exposure prophylaxis are lacking in Abakaliki, southeast Nigeria- this work was therefore designed to fill the gap.

2. Materials and Methods

Ebonyi State is one of the five states in the South-east Geopolitical zone of Nigeria. It was created in 1996 from the largely rural areas of the pre-existing Enugu and Abia states. It has an estimated population of about 2.1 million people (2006 census) and occupies a land mass of 5932km2, sharing boundaries in the West with Enugu state, Cross-river in the South and Benue state in the North. It has one Federal Teaching Hospital and several General, missionary and private hospitals attending to the health care needs of the populace.

This was a cross-sectional study of respondents distributed across 10 hospitals in Abakaliki and its metropolis. These hospitals include; 3 missionary hospitals and 7 private health facilities. The hospitals have several categories of skilled and unskilled workers, including cleaners- the focus of this study. The studied facilities had a total of 108 cleaners. Pre-tested Semi-structured questionnaires were used for collection of both qualitative and quantitative data. Convenient sampling method was used to select respondents and the information was both in English and Igbo language (which was translated to English) for those who were not proficient with English language. The data was analyzed using SPSS (statistical package for social sciences) version 19.

Ethical approval was obtained from the research ethics committees of the various hospitals that participated in this study and consent obtained from the participants.

3. Results

A total of 90 questionnaires were administered, only sixty-eight were properly filled and suitable for statistical analysis- representing a 75.6% response rate.

Table 1 describes the socio-demographic characteristics of the respondents. The mean age of the respondents is 38.6±5.4years. Their age ranged between 20 to ≥50 years. Majority of respondents were within the age bracket of 20 to 29 years (26/68; 38.2%). Most respondents were females (56/68; 82.4%), while males were only 12(17.6%). A good proportion (95.6%) of the respondents had some formal education, while only 3(4.4%) had no formal education- Table 1.

Table 1. Demographic characteristics of respondents

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Table 2 describes the work characteristics of the respondents. Most of them 60(88.2%) were fully engaged by their employers, while 8(11.8%) were contract staffs. Over four-fifth of the respondents 61(90%) had no insurance cover, while a paltry 10% of had insurance. The duration of time spent on the job varied from less than 1 year to more than 11years. Those who had spent between two to ten years made up 67.7%, while 14.7% had spent 11 years or more on the job. On provision of training for the job; 44(64.7%) had received training on occupational hazard, however all the respondents desire training. Vaccination status against Hepatitis B virus was evenly distributed between the respondents as half (50%) had been vaccinated, while the other half (50%) were not.

Table 2. Work characteristics of respondents

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More than two-third; 49 (72.1%) of the respondents were awareness of their HIV status, while 47.2% and 48.5% knew their Hepatitis B virus and Hepatitis C viral status respectively.

Table 3 shows the respondent’s level of knowledge of occupational hazards, safety measures and the existence of post exposure prophylaxis to HIV. Fifty-Six (82.4%) of cleaners were aware of the hazards associated with their job and their sources of information were- Employers (61.8%), colleagues (44.1%) and the mass media (82.4%). Their knowledge of the mode of infection or transmission- indicates that 82.4% and 73.5% knew that sharps and blood were infectious respectively. Table 3 shows the percentage of cleaners who used some form of protective equipments. Almost two-third; 43(63.2%) of respondents observed standard precautions for hospital waste disposal. Awareness of PEP for HIV was reported by only 34(50%) respondents.

Table 3. Awareness of Occupational Hazards/Safety and post-exposure prophylaxis for HIV

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4. Discussion

Healthcare workers are occupationally exposed to a variety of infectious diseases during the performance of their duty. The delivery of healthcare services requires a broad range of workers such as physicians, nurses, technicians, house-keepers (cleaners), mortuary attendants, administrative staff, social workers and this diversity of jobs keeps them at different degrees of occupational hazards as those who come in direct contact with medical wastes, with cleaners particularly vulnerable to the hazards associated with medical wastes ^[11].

Health care waste as defined by WHO means untreated materials from healthcare activities on humans or animals which have the potential of transmitting infectious agents to humans. These include discarded materials or equipment used for diagnosis, treatment and prevention of disease, assessment of health status- contaminated with blood and its derivatives, tissues, tissue fluids or excreta, or wastes from infectious wards ^{[12, 13, 14]}.

The mean age of the respondents was similar to the findings by Faremi et al in Ile-Ife, where the mean age of the responders was 39.6±6.2years ^[1]. The reason for the preponderance of young people is likely because they constitute the active working age group. However, knowledge of occupational hazards had no bearing on the participants’ age. Surprisingly, females made up majority of the study population. Traditionally, in the African setting females are more involved in house-keeping, while men engage in farm work and other similar activities.

This study found that only 4.4% of respondents had no formal education. This is encouraging as someone with some level of formal education is more likely to understand the implication of occupational hazards in a hospital setting, and may likely take measures to prevent or mitigate such, by adhering strictly to written instructions on simple safety rules, practice guidelines and proper use of protective aids.

The length of time the respondents had spent on the job was also observed to vary and appears to correlate with their level of awareness of hazards associated with their cleaning Job. Those who had spent up to two years on the job and above were more likely to have higher level of knowledge on occupational hazards and protective measures. This is because the experience and information garnered over the years may offer some advantage over those who were younger on the job and who are not trained- consistent with the findings of Shabab and colleagues ^[2].

Half of the participants had vaccination against Hepatitis B virus- consistent with the 52.2% reported by Al-Hazmi ^[15]. This could go a long way in protecting health care workers and their families from Hepatitis B virus. Maintenance of immunity is an essential part of prevention and infection control program for healthcare workers ^[8]. Optimal use of vaccines safeguards the healthcare worker from being infected following exposures ^{[8, 16]}. The CDC recommends routine vaccination for individuals involved in the management of hospital waste, especially against Hepatitis B virus ^[8].

The importance of training on the hazards associated with handling of medical waste and its disposal cannot be over emphasized. Our findings showed that 64.7% of the cleaners surveyed had received some forms of training on occupational hazards and safety, and they were equally more informed than those not trained. All of them indicated their desire to be trained/re-trained on risks associated with their job and how to mitigate them. Adequate orientation and training should form an essential part of the health care waste management policies for the generality of healthcare staffs and cleaners in particular ^{[10, 12, 14, 17, 18]}.

In the present study, respondents’ awareness of their HIV, hepatitis B and hepatitis C viruses’ status was highest for HIV followed by Hepatitis C virus. The reason for this disparity could be because HIV is an pandemic disease with lots of public health enlightenment provided, particularly in our Sub-region- which bears the greatest burden of HIV/AIDS. Indeed healthcare workers should be counseled and those who consent should be tested appropriately.

The fact that only 82.4% were aware of occupational hazards associated with their job- consistent with the findings by Bdour et al, Akuma et al and Manuel et al ^{[3, 14, 19]}, but less than the finding by Sheller in Germany ^[20], brings to the fore the need for training and orientation on hazards associated with hospital waste, and ways of preventing them. Knowledge of hazardous waste among the respondents also showed that there was greater awareness (82.4%)-less than the 96.3% reported in Tanzania ^[21].

Safety measures such as Universal precautions and use of other personal protective equipment meant to protect the workers from direct exposure to healthcare wastes should be implemented in line with the recommendations of other scientist and researchers ^{[5, 6, 10]}. The findings from this study indicates that personal protective devices were either unavailable or in very short supply. This is a fall out of poor funding and healthcare managers appropriating scarce resources to other more profit yielding ventures such as purchase of drugs- leaving the cleaners to their fate. Fadeyi et al reported that 41.5% of health workers were unaware of standard precautions (SP) and 25.4% do not observe SP- indicating the deficit in the awareness of SP among laboratory personnel which demonstrates that attitude and practice of safety rules are unsatisfactory ^[22].

Segregation (sorting and appropriate storage) of medical waste ought to be the standard practice in health care facilities ^{[23, 24]}, but that doesn’t seem to be the case from our findings- as only 43(63.2%) of the respondents observed standard precautions and practiced safety measures. This was less than the 94.8% of clinicians who used personal protective devices, reported by Enwere in Southeast, Nigeria ^[25]. Common mode of disposal was open dumping and in some cases waste bins, without following the recommended standards of waste segregation. This probably constituted the greatest risk to workers and should be discouraged.

Surprisingly, there was poor knowledge to post-exposure prophylaxis for HIV displayed by a significant proportion (50%) of the respondents in this study. In Tanzania, Moshoto et al reported that one third of healthcare workers did not have comprehensive knowledge on causes of occupational HIV transmission and did not know when post exposure prophylaxis is indicated ^[21], while Aminde et al in Cameroon reported that only 12.5% of HCW had received training on PEP ^[26].

In conclusion, it is apparent that there is still a wide gap to be closed regarding the level of knowledge of hospital cleaners on occupational hazards and necessary steps to take following exposure to hazardous substance. Government and policy makers should ensure adequate training and re-training of such vulnerable group of workers, provide adequate personal protective devices. Healthcare workers should equally be mandated to observe universal precautions in discharging their duties.

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