Global Occupational Exposure to Blood and Body Fluids among Healthcare Workers: Systematic Review and Meta-Analysis

Background Occupational exposure to blood and body fluids has become a serious public health problem for healthcare workers and is a major risk for the transmission of various infections such as human immune-deficiency virus, hepatitis B virus, and hepatitis C virus. This systematic review and meta-analysis aims to determine the career time and previous one-year global pooled prevalence of occupational exposure to blood and body fluids among healthcare workers. Methods For the review, the articles published in English were searched using the electronic databases (SCOPUS/Science Direct, PubMed, Web of Science, Google Scholar, CINAHL, MEDLINE, Cochrane Library, DOAJ, and MedNar) with a combination of Boolean logic operators (AND, OR, and NOT), Medical Subject Headings (MeSH), and keywords. A quality assessment was conducted to determine the relevance of the articles using JBI critical appraisal tools. Furthermore, several steps of assessment and evaluation were taken to select and analyze the relevant articles. Results Of the 3912 articles identified through the electronic database search, 33 that met the inclusion criteria were included in the final analysis. The current study found that the global pooled prevalence of blood and body fluids among healthcare workers during career time and in the previous one year accounted for 56.6% (95% CI: 47.3, 65.4) and 39.0% (95% CI: 32.7, 45.7), respectively. Based on subgroup analysis by publication year, survey year, and World Health Organization regions, the highest prevalence of blood and body fluid exposure in the last 12 months was observed among articles published between 2004 and 2008 (66.3%), conducted between 2003 and 2008 (66.6%), and conducted in the Southeast Asia Region (46.9%). The highest career time prevalence was 60.6%, 71.0%, and 68.4% for articles published between 2015 and 2020, conducted between 2015 and 2019, and reported in the African region, respectively. Conclusion The current study revealed a high prevalence of occupational exposure to blood and body fluids among healthcare workers and suggests the need to improve occupational health and safety services in healthcare systems globally.


Introduction
Occupational exposure to blood-borne pathogens as a result of contact with human blood and body fluids has become a serious health concern for healthcare workers (HCWs) globally [1]. Occupational exposure to blood and body fluids (BBFs) constitutes a risk of transmission of blood-borne pathogens, such as human immune-deficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) [2][3][4][5], and other blood-borne pathogens, including cytomegalovirus, herpes simplex virus, and parvovirus B19 [4]. Healthcare workers are at high risk of being infected with various occupational-related diseases as a result of exposure to blood-borne pathogens [1,5,6]. e risk of transmission of infection after exposure to infected blood is 0.3% times greater for human immunodeficiency virus-infected blood than for uninfected blood, while it is estimated to be up to 100 times greater for the hepatitis B virus and from 3 to 10% for the hepatitis C virus [7,8]. Among the above infections (HBV, HCV, and HIV), only HBV had a vaccine until the time of this study [7].
According to the World Health Organization (WHO) report, about three million HCWs are exposed to bloodborne pathogens each year, of which 170,000 are exposed to HIV infections, 2 million to HBV infections, and 0.9 million to HCV infections [9]. Most of the time, healthcare providers get exposure through the splash of blood or other body fluids into the eyes, nose, or mouth or nonintact skin exposure, and percutaneous injury occurs as a result of a break in the skin caused by a needlestick or sharps contaminated with blood or body fluids [9].
Several studies, including systematic reviews and metaanalysis, have been conducted and published on the prevalence of BBFs among HCWs in different settings, such as at country or region levels. And also, a few studies reported the global prevalence of occupational exposure to needlestick injuries [10], the prevalence and device-related causes of needlestick injuries [11], percutaneous injury [1], and the prevalence of exposure to blood and body fluids in Africa [6].
However, there is no evidence regarding the global prevalence of blood and body fluids among healthcare workers. erefore, this is the only study that provides a global prevalence of blood and body fluid exposure among healthcare workers, which can be used as evidence and input to reduce the burden of BBF exposure and may prompt the development of appropriate policies, systems, and processes. Furthermore, this systematic review and meta-analysis estimated the regional levels, last year, and career time prevalence of BBFs among HCWs.

Protocol Registration and Search Strategy.
e research protocol was registered in the PROSPERO international prospective register of systematic reviews (CRD42017077201).
e Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline was used to perform this systematic review [12].

Inclusion Criteria.
e studies that met the following inclusion criteria were included in the systematic review and meta-analysis: (i) Study population: healthcare workers regardless of their occupation (ii) Outcomes: study reporting quantitative outcomes (    articles, and studies not available in full texts were excluded from the current study.

Information Sources and Search
Strategy. e articles were searched using ten electronic databases (SCOPUS/ Science Direct, PubMed, Web of Science, Google Scholar, CINAHL, MEDLINE, Cochrane Library, DOAJ, and MedNar) using a combination of Boolean logic operators (AND, OR, and NOT), Medical Subject Headings (MeSH), and keywords, such as health professionals, healthcare workers, healthcare system, developing country, developed country, blood, blood and body fluids, and occupational exposure.  ). en, all identified keywords and index terms were checked across the nine electronic databases included. Finally, searching the reference list of all identified articles for further articles was conducted.

Study Selection.
e study selection process was performed using the PRISMA flowchart, indicating the number of articles included in the review and articles excluded from the study with reasons. Following the search for articles through selected electronic databases, duplicate studies were removed using the ENDNOTE software version X5 ( omson Reuters, USA). e authors independently selected the articles based on the titles and abstracts by applying the inclusion criteria. Furthermore, the full text of the relevant articles was further read in detail and independently evaluated by the authors. Any disagreements made with respect to the inclusion of studies were resolved by consensus after discussion. Finally, studies that met the inclusion criteria were included in the systematic review and meta-analysis.

Data Extraction.
e authors (DAM, GDG, EM, DMA, KB, WD, FKA, and YAA) independently extracted the data from the included articles. A predefined Microsoft Excel 2016 format was used to extract information from selected studies under the following headings: author; publication year; country of study; study design; primary outcomes such as prevalence or magnitude of exposure to BBFs and possible confounding factors considered. In general, all data are extracted from the eligible articles.

Quality Assessment.
e selected articles were subjected to a rigorous independent assessment using a standardized critical assessment tool, the Joanna Briggs Institute (JBI) Critical Assessment Tools for prevalence studies [13]. ese articles were then evaluated by the authors (DAM, GDG, YMD, YAA, and AG) to confirm their relevance to the study and the quality of the work.  e evaluation tools have the following nine evaluation criteria or parameters: (1) appropriate sampling frame; (2) proper sampling technique; (3) adequate sample size; (4) description of the study subject and setting description; (5) sufficient data analysis; (6) use of valid methods for identified conditions; (7) valid measurement for all participants; (8) use of appropriate statistical analysis; and (9) adequate response rate. Failure to satisfy each parameter was scored as 0, if not 1. e score was then given across all studies and graded as high (85% and above), moderate (60-85% score), or low quality (60% score). Disagreement made on what was to be extracted was solved by discussion after repeating the same procedures. e PRISMA guidelines protocol [12] was used to conduct the review.

Statistical Procedures and Data Analysis.
e pooled prevalence of the BBFs was performed using Comprehensive Meta-Analysis (CMA) version 3.0 statistical software. A forest plot and a random-effects model were used to determine and visualize the pooled prevalence of the BBFs.
e Cochran Q test (Q) and I squared test (I 2 statistics) were used to evaluate the heterogeneity between the included articles. I 2 statistics is the proportion of variation in prevalence estimates due to genuine variation in prevalence [14,15]. e level of heterogeneity was classified into four categories: no heterogeneity (0%), low (25-50%), moderate (50-75%), and high heterogeneity (greater than 75%) [16].
e random-effects model was used to analyze the data. Furthermore, subgroup analysis was conducted based on the year of publication, survey period (when the study was conducted), and study areas. Publication bias among the included studies was evaluated using funnel plots. A sensitivity analysis was done to determine differences in pooled effects by dropping studies that were found to influence the summary estimates.

Study Selection.
A total of 2912 studies were retrieved from searches in selected electronic databases. en, 1430 duplicate articles were excluded. Out of 1610 nonduplicated studies, 327 studies were excluded based on titles and abstracts. Furthermore, 1759 full-text studies were further assessed to determine their eligibility, of which 1724 studies were excluded. ese articles were excluded as a result of not reporting the prevalence of blood and body fluids in their career time or last year;    unclear objectives, unclear methods, not available in full text; nonhealthcare worker study participants; review articles; letters to the editor; brief reports; and written in a non-English language. Finally, 33 studies that met the inclusion criteria were included in the review (Figure 1).

Prevalence of Blood and Body Fluids.
is systematic review and meta-analysis was conducted using the Comprehensive Meta-Analysis (CMA) Version 3 statistical package (software) to determine the pooled prevalence of blood and body fluids among healthcare workers.

Previous Last Year Prevalence of Exposure to Blood and Body Fluids.
e last year's prevalence of occupational exposure to blood and body fluids among healthcare workers was found to be 39.0% (95% CI: 32.7, 45.7) with a P-value of <0.001 (Figure 2).   (Figure 4).

Career Time Prevalence of Exposure to BBFs.
e career time prevalence of occupational exposure to blood and body fluids among healthcare workers was found to be 56.6% (95% CI: 47.3, 65.4) ( Figure 6).

Sensitivity Analysis Results.
e sensitivity analysis was conducted by dropping small sample size and large sample size. However, there was no significant change found in the prevalence of both career time and last year occupational exposure to blood and body fluids ( Table 2).

Discussion
A total of 3912 studies were retrieved from selected electronic databases, of which 1430 duplicate articles were excluded. A total of 33 studies conducted on 54328 HCWs from 2003 to 2021 were included in the systematic review and meta-analysis. Direct comparison of the current findings with other findings was difficult because of a lack of similar systematic reviews and meta-analyses. e authors found only one systematic review and meta-analysis conducted to determine occupational exposure to BBFs among HCWs in Africa. However, we considered other occupational-related injuries or exposures, such as percutaneous injuries and needlestick injuries.
In the workplace, blood and body fluids are a major risk factor for the transmission of various blood-borne infections to healthcare workers [49] such as hepatitis B virus, hepatitis C virus, and human immunodeficiency virus, the three leading causes of occupationally related blood-borne infections among HCWs [50]. However, this study found that the last year's prevalence of occupational exposure to blood and body fluids among healthcare workers accounted for 39.0% (95% CI: 32.7, 45.7). e current study found a lower prevalence of BBFs than another study conducted in 21 African countries, which discovered 48.0% prevalence [6].
Other studies conducted in Africa reported a one-year prevalence rate of blood exposure accounted for 84.0% [51], which was higher than the current finding. e variation may be related to the scope of the study because the current study included studies conducted in both developing and developed countries. Occupational exposure to hazards continues to be a public health concern globally. Another study found that about 36.4% (95% CI: 32.9-40.0) of HCWs were exposed to percutaneous injuries in the previous year, which is lower than the current finding. e variation could be due to differences in the outcomes of these studies because HCWs can be exposed  to blood and other body fluids in different ways, such as needlestick injuries or contact with contaminated objects or mucous membranes.
Similarly, this study found that the prevalence of BBF exposure in the last year in the Africa Region was 37.3% (95% CI: 26.4, 49.7), which was in line with the finding of another study, which reported about 48.0% prevalence of exposure [6]. Furthermore, this study found a variation in the prevalence of BBFs among different regions of the world. For example, the highest last 12-month prevalence of BBF exposure was reported from the Southeast Asia Region (46.9% (95% CI: 33.2, 61.0%)), while the lowest prevalence was observed in the study conducted in the European Region (22.6% (95% CI: 19.0, 26.7%). e variation may be related to the difference in implementation of health and safety guidelines or standard precautions or differences in the healthcare system.
On the other hand, this study found a career time prevalence of occupational exposure to blood and body fluids among healthcare workers accounted for 56.6% (95% CI: 47.3, 65.4).
is finding was lower than the finding of another study conducted in African countries that found 65.7% (95% CI: 59.7-71.6) prevalence of BBFs [6]. e variation may be related to the included region in the study because this study found the career time prevalence of BBF exposure among HCWs in the African region accounted for 68.4% (95% CI: 56.1, 78.6), which was in line with the finding of another study, which found 65.7% [6].
Furthermore, more than half of the HCWs in the African Region, Western Pacific and Pacific, and European Region were exposed to BBFs. e high prevalence could be due to inadequate healthcare systems and poor occupational health and safety practices. Additionally, even though the highest prevalence was observed in the African region, the study found an increase in the career time prevalence of BBF exposure from 2005 to 2020. is indicates that there is a high risk of being to be exposed to blood-borne diseases among HCWs.
Overall, the study found a high prevalence of occupational exposure to BBFs in the last year (more than one in three HCWs) and throughout the career time (more than two in three HCWs) among healthcare workers. However, exposure to blood and body fluids has serious health implications because exposure to blood and other body fluids is the potential source of blood-borne pathogens such as HBV and HIV that need critical attention to protect the workers' health.  erefore, applying standard precautions, occupational health and safety measures or services, regular training on infection prevention, and proper implementation of guidelines play a major role in reducing BBFs and preventing infectious diseases in the healthcare system.

Possible Prevention or Control Strategies.
Integrated approaches to occupational health and safety, including engineering measures, administrative policy, and the use of personal protective equipment, should be implemented to control, eliminate, or reduce occupational exposure to hazards [52], including BBFs. Furthermore, there is a need to implement priority strategies, which include strengthening of international and national policies for health at work, promotion of a healthy work environment, healthy work practices, strengthening occupational health services, development of occupational health standards, and strengthening of research [53].

Limitations of the Current Study.
ere was an unequal distribution of occupations among the included articles that make the comparison of BBFs exposure among different occupations more difficult. On the other hand, the prevalence of occupational exposure to BBFs in some regions was not covered due to the lack of studies in these regions. ere were a few studies from developed countries conducted on the outcome of interests.

Conclusions
is systematic review and meta-analysis found a higher percentage of career time and previous one-year global occupational exposures to blood and body fluids among healthcare workers. e study suggests that more than one in three and two in three healthcare workers were exposed to BBFs annually and in their career time, respectively. erefore, efforts should be made to reduce the high burden of occupational blood and body fluid exposures through effective implementation of standard precaution measures along with occupational health and safety measures.

BBF:
Blood and body fluids CMA: Comprehensive meta-analysis HBV: Hepatitis