Coming from a place where this is the normal standard of sharps care in hospitals…
…. it came as quite a shock to me when I first visited a health care facility in a third world country and encountered this.
Puncture-proof, well designed plastic containers with clear labeling are the basic standard in western hospitals, with many guidelines strictly adhered to around the disposal of sharps waste. In comparison, waxed cardboard boxes are available in resource-poor settings, but stocks often run out, when they are replaced by ordinary boxes as seen here. The scarcity of appropriate resources encourages lower standards, such as over-filling containers to the dangerous levels as seen in this photograph. I have also caught children playing with potentially contaminated sharps left lying on hospital grounds. Medical waste disposal is a very difficult challenge in an environment where there is no waste disposal or landfill centre for the town’s waste.
In my other life I have a very vague theoretical clue of what happens to waste after it leaves the clean, well lined bins in our well stocked health facilities. Here I see the waste, smell the waste, breathe fumes from the burning waste, have discussions about the animals living amongst us because they are attracted to the waste, and have learned many things about the pros and cons of burying as opposed to incinerating waste depending on the type of waste and the risks each disposal method poses. I have become quite intimate with hospital waste, in fact!
Standard Precautions is the current term used to describe Infection Control practices in health care settings. Handwashing is the most basic Standard Precaution but also the single most important preventive measure against the spread of diseases. Standard Precautions also relate to other hospital hygiene practices, from clinical waste and sharps disposal to staff health policies and procedures, use of Personal Protective Equipment (PPE) and many other measures. Good implementation of Standard Precautions requires ongoing staff training as recommendations can change and Infection Control is an enormous topic in which academic degrees can be obtained. So a few short paragraphs here cannot begin to touch on the topic. Standard Precaution practices aim to reduce the transmission of pathogens between people and they successfully do so when properly implemented.
Knowing that one person has a particular disease does not preclude others from having the same disease. Many people carry viruses or bacteria without knowing, and negative test results only represent the single point in time when the test was carried out. This theory underpins the application of a minimum standard of Infection Control applied to everyone, which also serves to protect everyone from discriminatory practices. The worst case of discrimination I heard about was in Bryce Courtenay’s book April Fools Day in which he writes about his son’s experiences with haemophilia and HIV in the 1980s. He contracted HIV through a blood transfusion before the virus was identified or routinely screened for in blood donations. Lying alone in a Sydney hospital isolation room in very poor condition with AIDS, one night two male nurses entered the room and beat him to a pulp! Most discrimination is far more subtle than this and some of the most stigmatising diseases are Tuberculosis and HIV. But the main aim of Standard Precautions is to ensure a good standard of practice based on current knowledge about pathogen transmission, with minimised discrimination a secondary outcome.
Upon seeing sharps containers overfilled regularly, one of the first tasks I set myself in Cambodia was to teach staff about minimum standards of sharps safety. I have been consistently impressed at the dramatic improvement in practices in my time here and it has been months since I saw an overfilled sharps container. So it came as quite a shock earlier this week when I lifted a cardboard sharps container and felt a needle penetrate into my finger. The used needle had perforated through the wall of the waxed cardboard and was waiting for someone to stick. That someone happened to be me. Thankfully the only reason this occurred, was because of a fault with the box, which had been assembled properly and was not overfilled.
If a needlestick injury occurs with an infected needle (that is, a needle contaminated with virus-infected blood or body fluids, penetrates through the skin of another person), the estimated risk of transmission for the three main bloodborne viruses of concern is as follows:
- Hepatitis B – up to 40% risk if the source is carrying the infectious “e-antigen”, but as low as between 1-6% if the source is not carrying this antigen
- Hepatitis C – between 3 – 10%
- HIV – between 0.2 – 0.5%
The only vaccine-preventable virus in this trilogy is Hepatitis B, for which I have good antibody levels following vaccination over 20 years ago. The needle was situated approximately halfway down the box, which was approximately two thirds filled. The needle had probably been disposed of some time ago, meaning any possible virus particles were unlikely to have survived. No known HIV / Hepatitis B / Hepatitis C patients had been admitted for a week or more and so the chances of the needle having been used on an infected patient were very low. Even if the needle was contaminated, the transmission risk is extremely low.
The HIV prevalence rate in Cambodia is 0.7% and Hepatitis B and C prevalence are generally both below 10%. Post-Exposure Prophylaxis (PEP) guidelines, very briefly and applicable specifically to my situation, are:
- When the source HIV status is unknown in a low prevalence setting, PEP is unnecessary.
- There is no PEP available against Hepatitis C, so follow up serology to determine transmission is recommended.
- Hepatitis B vaccine or immunoglobulin are not necessary as I have adequate protective antibodies.
So after following the advised first aid procedures at the time of the incident, followed by the advised reporting procedures and baseline blood tests, there is now little for me to do but follow the usual six month follow up of blood tests to confirm that an exposure did not occur. I’ll update you in six months’ time!
Part of our project is based in the market town of Skun, on the highway between Phnom Penh and Kampong Cham. Even more markedly than in Kampong Cham, the agricultural lifestyle infiltrates Skun’s urban streets. Farm animals cart produce to market and everything from water buffalo to hay stacks travel from their rural origins, along dusty tracks through rice and corn crops, onto busy highways and into the busy market crowds.
The walk from our office in Skun to the local hospital took us along red dusty tracks, potholed by recent heavy rainfall. We turned the corner at a home construction site where women covered with kramars on their heads, tracksuit jackets and pyjama pants protecting their skin from the sun worked alongside bare-chested men with brick-like torsos working in jeans and bare feet as they pick-axed and bricklayed with only the most basic tools. Carrying loads on their heads and shoulders and digging into the ground with their manual tools, they slowed down or stopped to watch as four westerners walked by. Mutually interested smiles were exchanged. At the next corner two Buddhist monks were standing outside a house, alms bowls slung across their orange-swathed bodies like handbags, waiting for a donation from the home owner who was yet to materialise at the gate. One of them turned to us with a shy smile before watching us walk around the corner. Along this road we passed the local police station, a small brick building with a large verandah set behind an elaborate entranceway, where a man in plain clothes stood smoking a cigarette. At the corner past a few tin-roofed wooden shacks with produce hanging from hooks under tin verandahs, we strolled around the edge of a busy market place with piles of fruit lined up on bamboo mats placed on the dusty edges of the partly-muddied red dirt road. Vehicles were parked around the corner from here, which our local colleague explained were used to transport the produce to market – trailers with long wooden benches behind motos, beaten up mini buses and motos, all looking as though they had a reason to be waiting there as the drivers stood around chatting.
A short while later I did the return walk alone, and rather than shy stares and smiles, was greeted with friendly waves and shouts of “hello” from all directions. One man saw me from a distance and drove his moto over, motioning that there was room on the back for a passenger, smiling happily as I waved him off with “Ot te” (no). Halfway home a woman carrying a bunch of celery in her hand pulled up alongside me and spoke animatedly in Khmer. When I said “Ot yul te” (I don’t understand), she motioned to the back seat of her moto and again, smiled happily as I turned her down before driving ahead slowly and turning back regularly to wave goodbye repeatedly. Back past the construction site where more smiles and mutual gawking took place, a flooded water lily pond, noisy game of petanque happening on a square of dirt under a tin roof and fluorescent green rice fields in the distance, I made it back to the office feeling as though I’d just had a very “Skun experience”.
Back in Kampong Cham two days later I sat in a crowded room alongside my colleagues on wooden benches as our manager presented an update on MSF’s project plans. Five of my nursing team were informed during this presentation that due to an evolution in the project’s operation, after two years of gainful employment caring for some of the sickest people in Cambodia, their contracts are about to be terminated as the work is transferred back to the Ministry of Health. This was a very emotional announcement as the rest of the team are left to speculate on their own futures, which is a perpetual consideration for people living in a country with limited employment opportunities who are employed by NGOs with temporary, capacity-building objectives. The excitement of securing a job with an international aid agency is always going to eventually lead to the disappointment of losing your job when the agency moves towards achieving their goals and acting on their exit strategy. These young nurses have been a diligent, caring team to their patients as well as to each other and I am not sure if they believed our reassurances that this implementation does not reflect on them or their work. I also worry, having come to know and care about them, where they will go and what they will do now their financial security via MSF has ceased. It is very common for qualified professionals in Cambodia to spend months or years without work. I know this because I have listened to staff talk about unemployed husbands, siblings and friends with decent qualifications and experience. I have also fielded questions (which I don’t know the answers to) from staff, about how they might find and be sponsored to work in a “rich country”, where they believe they could spend a short amount of time saving huge (comparatively speaking) amounts of money which would allow them to return home financially secure.
This week the Mekong River reached flood levels with the esplanade in Kampong Cham submerged in shallow flowing muddy water, which of course I slipped on one evening, arriving home with one trouser leg soaked in mud. Sandbags line the streets and crowds flock every evening to check the river’s level which rose almost 10 metres in less than a month. At work doctors are speaking of the risk of a cholera outbreak when the river levels subside and I have been asked to ensure we have the latest Cholera Guidelines at hand. With the Wet Season arriving late this year, rice planting began late and now the very young crops are flooded, meaning they may not cultivate well. This places a large portion of the population at risk of famine as people rely on their own rice crops for sustenance as well as income.
The young woman whose home we cycled to recently as a team, attended hospital this week for an outpatient appointment and told us that her house is now above the Mekong, which has reached flood levels. She traveled to us this week by boat and then tuk-tuk and has invited us to visit her again, saying that we can go by road to a certain point and her father will then meet us in his wooden boat and bring us the rest of the way! So that is the next plot on our agenda – a boat ride with locals on the Mekong! This patient has gained 1kg in the past month, so she is now 24kg. Her condition is not significantly better but she is maintaining some level of stability and has started to walk again. After believing she would die, it seems as though there is some real hope for her to return to a semi-normal existence, as long as she doesn’t succumb to any other infections, which is a very real risk. She is an amazing example of the fact that in abject poverty, courage can triumph.
In a nutshell that has been the mixed bag that Cambodia threw at me this week, although I have not even mentioned the English lessons, the 6yo amputee boy living in a shack near our home who has befriended me, the visits from our Tokyo-based manager and Phnom Penh-based Head of Mission, dinner out with a lovely Canadian expat who found my blog and contacted me for a meet-up, or the Children’s Fair we are taking 18 children to this afternoon for some fun and frivolity. All very enjoyable parts to the week but perhaps less peculiar than the details I’ve noted.