Evaluation of infectious risk among biomedical agents in Morocco

INTRODUCTION

Biological safety or biosafety covers working methods associated with the handling of biological materials, in particular infectious agents. It is about principles, containment technologies and practices, which are implemented to prevent unintentional exposure to pathogens and toxins or their accidental release.^1,2

The risk of infection among biomedical technicians and engineers (BMTE), as well as healthcare personnel, is a major public health problem, particularly in developing countries.³

The risk of acquiring an infection is influenced by many variables. Among these factors are the health and immune status of the worker and the education and training they had, the suitability of the establishment for work with highly pathogenic agents, the characteristics and the concentrations of the microbe being handled, and the specific manipulations involved in its handling.⁴

Indeed, technicians and biomedical engineers, as other health workers, are exposed to different reservoirs of infections. One of the main reservoirs of germs may be the patient but other activities can also present a risk of infection like repair and maintenance of contaminated equipment and objects.⁵

The objective of this study is the evaluation of the perception of the infectious risk and the assessment of the biosafety knowledge and behaviors among technicians and biomedical engineers in Morocco.

METHODS

After approval by the institutional ethics committee of the Abulcasis international university of health sciences, Rabat, Morocco, this study was carried out in higher institute of engineering and health technologies of Rabat-Morocco, during May and June 2020. We used technique snow ball and the Google form® developed by Google® (Google LLC, Silicon Valley, California, USA).^6,7

The sample size formula (n=Z²p (1-p)/d²) for field studies according to Thrusfield was used to obtain the target sample size.⁸ This gave a minimum sample size of 72 respondents. For the calculation of frequencies, the data was analyzed on excel® (Microsoft corporation®, Washington, USA).

The questionnaire was sent to engineers and technicians and distributed via the websites or Facebook® pages (Facebook®, Menlo Park, Californie) to national associations (Moroccan Association of Biomedical Engineers (AMIB), Moroccan association of biomedical maintenance (AMMB) etc.)

The study included all engineers and technicians professionally active during the study and excluded those who had an exclusively administrative activity. The questionnaire contained the participant's consent in its first paragraph. It was subdivided into three sections (Table 1): A - socio-demographic, professional, educational and medico-professional characteristics of the studied population, B - dangers encountered, routes of transmission, exposure to risks, training and prevention awareness, C - data concerning accidents and their procedures and treatment.

RESULTS

A total of 84 persons participated to the survey. Approximately 70%, 4/5 persons were male and half of participants have less than 50 years old.

The majority of those studied are engineers and held official positions. Environ 70% of participants work in laboratory of human medical biology or in technical service in a health care establishment.

Less than a third of the participants confirm having benefited from training courses in infection risk, medical surveillance or specific vaccinations.

Biomedical agents report that the risk is either direct because they handle microorganisms, but above all indirect, since these are situations where they handle contaminated instruments or waste produced during care activities. Further information about the socio-demographic, professional, educational and medico-professional characteristics of the studied population are described in Table 2.

In our series, the majority of participants describe indirect exposure to pathogens, most often bacteria and viruses, through the handling of medical instruments, pathological products or potentially infectious waste (41.7%; 48/84). The participants reported all the routes of contamination with a slight predominance for the cutaneous route (71.6%; 60/84). The degree of exposure is rated medium to low by most BMTIs even if the exposure time exceeds one hour a day and even if the participants use sharp and sharp tools (64.3%; 54/84). Table 3 provides a summary of this group of results.

More than half of the participants state that they know the regulatory measures to be taken when they are victims of potentially infectious accidents, but the application of hygiene rules remains the most common procedure (74.5%; 62/84) and only half know they have to report this kind of incident (56.8%; 48/84).

Less than one in five participants (17.9%; 15/84) report accidents with infectious potential but among these individuals, more than half say they have not taken regulatory measures such as notification, medical consultation and application of hygiene rules (57.1%; 48/84). Further results are shown in the Table 4.

DISCUSSION

Assessing the situation of biomedical engineers and technicians with regard to the infectious risks incurred during their duties and the means placed at their disposal to prevent this type of risk are the objectives of this work.

Our study revealed very interesting results that accurately describe the risks faced by engineers and biomedical technicians in Morocco.

Biomedical engineers and technicians all work in the health sector. Most jobs are located in hospitals or medical biology laboratories. In the literature, they are found to work primarily in the public sector or in public sector partnerships as biomedical or clinical engineers and the objective of their work is to provide a broad-based engineering program that addresses all aspects of medical instrumentation and systems support.⁹

In many publications, WHO recommend to countries to protect the health of their workers by optimizing their working conditions.¹⁰

Moroccan law has not ignored occupational risk, which defines occupational accidents in article 3 (of the Dahir of June 25, 1927). These accidents are the responsibility of the employer, and this implies that if a technician or engineer is contaminated or infected during his activity, his treatment and medical care are the responsibility of the employer.¹¹

The Moroccan guide to the correct performance of medical biology analyzes also emphasizes the need to protect personnel whether they are engineers, technicians, biologists or nurses. They must be informed about the risk and protected against incidents and transmission of microorganisms and in general against all other risks. This is defined in chapter IV of "safety and hygiene" and other similar articles.¹²

The director of the establishment must ensure the protection of the staff, technicians and engineers. For example, the medical laboratory must put in place measures to protect personnel and the environment and ensure that appropriate safety measures are implemented at all levels. To avoid aerosol contamination, all hazardous handling must be carried out under protective enclosures such as laminar flow fume hoods or biological safety cabinets.

Indeed, certain articles of chapter 1 of the general provisions of the health and safety of employees stipulate that the employer must ensure that the packaging of products containing dangerous substances include warnings of the danger on their packaging

The employer is under an obligation to inform employees about the legal provisions in terms of protection from the dangers that machines can generate. He must also post a readable notice on the work premises on the dangers as well as the precautions to be taken. Employees are strictly prohibited from handling a machine without the necessary protective devices in place and must not render the protective devices inoperative.

Most of the participants did not receive specialized education or training in infection risk management. In academic education, during the engineering curriculum, training related to biosafety and risk management is very insufficient or non-existent. Biology teachers include some notions of risk in biology courses and each time they approach a pathogenic microorganism (tuberculosis, hepatitis, salmonellosis) they initiate future engineers to the precepts of protection, clothing, use of particular protective means.¹³

The infections that can be contracted by a technician or engineer, as the other health workers, in the course of their work are many and varied.¹⁴ The most common bacterial infections contracted in the health care setting are tuberculosis and typhoid fevers, and the viral infections most likely to be transmitted through blood and body fluids are hepatitis B, C, and HIV.¹⁵ From this survey, we observe that the types of microbes most familiar to the participants are indeed bacteria and viruses.

Most biomedical technicians or engineers do not benefit from medical supervision. This creates a situation of unprotected status which, combined with the fact that they are not vaccinated, makes the agent very vulnerable.¹⁵

Technicians or engineers working in the health care facility are most directly exposed to infectious risks due to the nature of their work while those working outside are exposed indirectly. Many factors make biomedical devices vulnerable to infectious risks: duration of exposure to agents, use of sharps, etc.

The availability of equipment of protection in their workplaces and knowledge of the behaviors of prevention are elements in favor of risk reduction.¹⁶ However, it is legitimate to ask the question about the actual use of this equipment by biomedical technicians and engineers. This risk reduction is moderately felt by technicians and engineers, since few of them consider the risk to be low because they use the means of protection.

In the event of contamination, all the health and administrative provisions are described at different levels of adherence by the participants in this study. Overall, the participants are well aware of the actions to be taken in the event of an incident.

However, only 57% declared the accident of which they had been victims. In Morocco, accidents of exposure to blood are underreported by health workers and the declaration rate does not exceed 26%.¹⁷

The main reasons given by the authors are the slowness or ignorance of administrative procedures, ignorance or banalization of the risk, negligence by the victims.¹⁸

Our study shows a few biases that are related to the type of sampling or to the procedure for distributing the questionnaire; for example, the selection of the initial participants to whom the questionnaire was sent, who were all engineers have as consequence that the majority of the population studied is composed of engineers (79%; 66/84). Also, the fact that there are more male participants than female. This fact is explained in a report from the high commission for planning, the feminization rate of engineering schools in Morocco rose from 21.2% in 2000 to 36% in 2012.¹⁹

CONCLUSION

Infectious risk is related to the presence of pathogens in the workplace. Its evaluation is done by analyzing the protective facilities, knowledge, and behaviors of the exposed agents. Prevention involves measures for work organization, collective and individual protection, as well as staff information and training.

Risk assessment is useless if it is not followed by preventive actions. It is a prerequisite for the definition of preventive actions based on knowledge of the risks to which biomedical engineers and technicians are exposed.

In Morocco, engineers and technicians have tools and equipment of protection, are vaguely familiar with reporting procedures, but they lack training specifically dedicated to their safety. Hence, the need to adopt training courses in biosafety and infectious risk management during the training of engineers and technicians, as well as training and retraining of employees in this field.

This study can be complemented by an analysis of the seroprevalence of the most frequently implicated infectious diseases. This will allow further assess the impact of this risk in the population of biomedical engineers and technicians.

ACKNOWLEDGEMENTS

Authors would like to thank professor Nabil Ngote, director of the higher institute of engineering and health technologies of Rabat, Morocco for the support given to us in doing this investigation.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. World Health Organisation. Laboratory biosafety manual, third edition, Geneva 2004, ISBN 92 4 154650 6 (LC/NLM classification: QY 25) WHO/CDS/CSR/LYO/2004.11 Available from: https://www.who.int/csr/resources/publications/biosafety/Biosafety7.pdf?ua=1. Accessed 26 October 2020.
2. 2. Beeckman DSA, Rüdelsheim P. Biosafety and Biosecurity in Containment: A Regulatory Overview. Front Bioeng Biotechnol. 2020;8:650.
3. 3. The European Commission's Scientific Panel for Health (SPH). Better research for better health, A vision for health and biomedical research from the Scientific Panel for Health, May 2016, Available from: https://ec.europa.eu/programmes/horizon2020/sites/horizon2020/files/SPH_VisionPaper_02062016.pdf. Accessed 26 October 2020.
4. 4. National Research Council (US) Committee on Hazardous Biological Substances in the Laboratory. Biosafety in The Laboratory: Prudent Practices for the Handling and Disposal of Infectious Materials. Washington (DC): National Academies Press (US); 1989. 3, Safe Handling of Infectious Agents. Available from: https://www.ncbi.nlm.nih.gov/books/NBK218635/. Accessed 26 October 2020.
5. 5. European Commission. Occupational health and safety risks in the healthcare sector, Guide to prevention and good practice, December 2010. Available from: https://www.ilo.org/dyn/travail/docs/1965/osh.pdf. Accessed 26 October 2020.
6. 6. Johnson TP. Snowball Sampling. Encyclopedia of Biostatistics, John Wiley et Sons. 2005.
7. 7. Dragan IM, Isaic-Maniu A. Snowball Sampling Completion. J Studies Social Sci. 2013;5(2):160-77.
8. 8. Thrusfield M. Veterinary Epidemiology. 3^rd ed. Oxford, UK, Blackwell. 2009.
9. 9. Bronzino JD. Clinical engineering: evolution of a discipline (chapter 1) In: Management of Medical Technology, Eds. Butterworth-Heinemann. 1992;1-30.
10. 10. WHO, ILO, UNAIDS. Joint WHO/ILO policy guidelines on improving health worker access to prevention, treatment and care services for HIV and TB, Geneva, Switzerland November, 2010. Available from: https://www.who.int/occupational_health/publications/hiv_tb_guidelines/guidance_note_edited.pdf?ua=1. Accessed 26 October 2020.
11. 11. Ministry of Justice and Freedoms of the Kingdom of Morocco. Law No. 65.99 forming the Labor Code, Law No. 58.11 relating to the Court of Cassation and amending Dahir No. 1.57.223 of 2 Rabii I, 1377 (September 27, 1957), Chapter III: Obligations of the employee and the employer, article 24 Available from: http://adala.justice.gov.ma/production/legis-lation/fr/Nouveautes/code%20du%20travail.pdf. Accessed 26 October 2020.
12. 12. Moroccan Minister of Health. Law N°2598-10 of September 7, 2010 relating to the guide to the correct performance of medical biology analyzes (GBEA), September 7, 2010. Available from: http://www.sgg.gov.ma/Portals/0/profession_reglementee/Dec_2598.10_Fr.pdf. Accessed 26 October 2020
13. 13. Bajjou T, Ennibi K, Amine IL, Mahassine F, Sekhsokh Y, Gentry-Weeks C. Role of Training and Experience in Biosafety Practices Among Nurses Working in Level 2 or 3 Patient Containment. Applied Biosafety. 2020;25(2):96-103.
14. 14. National Research Council (US) Committee on Hazardous Biological Substances in the Laboratory. Biosafety in The Laboratory: Prudent Practices for the Handling and Disposal of Infectious Materials. Washington (DC): National Academies Press (US); 1989. 2, Descriptive Epidemiology of Occupational Infections of Laboratory Workers. Available from: https://www.ncbi.nlm.nih.gov/books/NBK218642/. Accessed 26 October 2020.
15. 15. Centers for Disease Control and Prevention. Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services, 2019. Available from: https://www.cdc.gov/infectioncont-rol/guidelines/healthcare-personnel/index.html). Accessed 26 October 2020.
16. 16. Kim Y, Park J, Park M. Creating a Culture of Prevention in Occupational Safety and Health Practice. Saf Health Work. 2016;7(2):89-96.
17. 17. Azzouzi Y, EL Bakkali M, Khadmaoui A, Thami Alami AO, Hamama S. Occupational exposure to blood among health-care workers: knowledge, attitude, practice and prevention of the Gharb region in Morocco. Int J Inno App Studies. 2014;7:557-70.
18. 18. Laraqui O, Laraqui S, Tripodi D, Zahraoui M, Caubet A, Verger C et al. Evaluation des connaissances, attitudes et pratiques sur les accidents d’exposition au sang en milieu de soins au Maroc. Médecine et maladies infectieuses. 2008;38:658-66.
19. 19. High Commission for Planning of the kingdom of Morocco. Women and men in numbers, 2016, Available from: https://www.hcp.ma/file/176550/. Accessed 26 October 2020.