How to cite this article: Alvarado-Cabrero I, Valencia-Cedillo R. Perception of health and safety risks among workers pathology laboratories. Rev Med Inst Mex Seguro Soc. 2015 Mar-Apr;53(2):206-13.
CLINICAL AND SURGICAL PRACTICE
Received: July 8th 2014
Accepted: August 21st 2014
Isabel Alvarado-Cabrero,a Raquel Valencia-Cedilloa
aDepartamento de Patología, Hospital de Oncología, Centro Médico Nacional Siglo XXI. Instituto Mexicano del Seguro Social. Distrito Federal. México.
Communication with: Isabel Alvarado-Cabrero
Telephone: (55) 5574 2322
Background: Health care workers are experiencing increasing numbers of occupational illnesses. Safety practices in anatomical pathology laboratories (APL) are crucial to prevent unnecessary exposures to both chemical and biological agents.
Methods: The main goal of this study was to determine if pathologists perceptions and actual practice mirror regulatory guidelines. Current available recommendations for APL were reviewed and used to construct an online survey distribuited to pathologists. The survey was completed by 121 participants.
Results: Eighty-seven (72 %) of respondents reported receiving inadequate safety training. Most Pathologists (82 %) were not well-informed about biosafety practices. Sixty-three (52 %) participants felt that the risks of chemical and infectious disease exposures in the APL were low.
Most respondents reported having a needle stick or cut (71 %). Eighty-six (71 %) of participants reported musculo skeletal problems.
Conclusions: This study indicated that there is a need for improving training in anatomical pathology safety practices in Mexican Laboratories as daily practices do not reflected current guidelines.
Keywords: Occupational exposure; Health risk; Safety management
Most people, including some doctors, believe that pathologists’ work consists exclusively of performing autopsies. However, this misconception ignores their most important tasks such as making diagnoses and characterizing tumors and infectious diseases in living patients.1
Occupational accidents and diseases have increased across the board in health professionals, and looking only at pathologists there are many health risks associated with their daily work; however, publications on this topic are scarce or very outdated.2,3
Exposure to formaldehyde can cause conjunctivitis in some people, as well as irritation of the nose, throat, or skin, and nausea. In 1987,4 the Environmental Protection Agency (EPA) of the United States classified formaldehyde as a probable human carcinogen in high and/or prolonged exposures. In 2011, the International Agency for Research on Cancer (IARC) classified formaldehyde as a human carcinogen.5 A study by the National Cancer Institute in the United States, which included 25,619 people who worked in sites with exposure to formaldehyde, showed an increased risk of death from myeloid leukemia.6 In another study involving a cohort of 11,039 workers in the textile industry, a relationship was found between prolonged exposure to formaldehyde and secondary leukemia deaths. In addition, several case-control studies have found an association between formaldehyde exposure and nasopharyngeal cancer.7
On the other hand, the pathologist is exposed to infectious agents that can harm their health (such as Mycobacterium tuberculosis, the human immunodeficiency virus (HIV), hepatitis B or C, among others), because their work requires constant contact with potentially infected fresh human tissue during dissection of organs, tissue handling, intraoperative consultation, or when performing autopsy.8 A constant source of infection is the potential risk of injuries with needles, scalpel blades, and/or contaminated knives.9
A seldom-considered health problem in pathology laboratories includes the long hours spent by the pathologist in front of the microscope. Microscopes that are used generally are not ergonomic, preventing a neutral posture, causing the observer to lean forward, which results in musculoskeletal problems, mainly in the neck and shoulders.10
In Mexico, there are several official standards (NOM) which relate to the proper handling of: hazardous chemical substances,11 hazardous bio-infectious waste (HBIW),12 personal protective equipment (PPE),13 contaminating chemicals in the workplace and their recognition, evaluation and control,14 etc. However there is no NOM to refer specifically to the pathology laboratory (PL), so both the hospital authorities and staff working in this area may not be aware of the risks to which they are exposed.
Moreover, in the academic training of the pathologist not a single item refers to training in workplace health and safety. Also, orientation provided by most health institutions to new staff does not include any training in this area.
The main objective of this study is to evaluate the level of knowledge of the pathologists who work in the various pathology laboratories of the Instituto Mexicano del Seguro Social, with respect to measures of health and safety carried out there.
The different factors that can jeopardize worker health and/or cause accidents in a PL and were identified and classified into 3 groups:
Regulatory measures to be implemented to prevent health risks and preserve the physical integrity of workers were sought for each item. For proper handling of organs, blood, and fluids, researchers looked to Norma Oficial Mexicana NOM-087-Ecol-SSA-1-2002.12 For identification and proper handling of hazardous chemicals they referred to NOM-018-STPS-2000.11
For evaluation of the proper use of personal protective equipment NOM-017-STPS-2008 was consulted.13 Information on the conditions required for proper handling and storage of hazardous chemicals (HC) was found in the criteria established by NOM-010-STPS-2013.14
Regulatory measures and guidelines established by agencies and/or international institutions of prestige were also consulted, such as: The Joint Commission15 and the CDC16 (Centers for Disease Control and Prevention), located in the city of Atlanta, Georgia, USA.
With the information obtained from previous sources a questionnaire was developed with 43 questions including 7 sections (Table I):
|Table I Assessment applied to study participants|
|1. Is your knowledge in the field of occupational health and safety in the pathology laboratory sufficient?
|Section I. Handling of tissues, organs, blood, and body fluids|
| 2. When is a waste considered hazardous bio-infectious (HBIW)?
3. What is meant by non-anatomical waste?
4. How are HBIW-generating facilities classified?
5. How many and what are the stages of HBIW management? 6. How must blood be packaged?
7. How must pathological waste be packed?
8. How must non-anatomical waste be packaged?
9. Up to what percentage may containers be filled with HBIW?
10. What should liquid HBIW containers be like?
11. How many days should the temporary storage of HBIW last?
|Section II.Biosafety: What is meant by biosafety practices?|
|12. Are biosafety practices necessary in a pathological anatomy laboratory?
13. What are the specimens in pathology that should be considered potentially infectious?
14. Can slides be contaminants?
15. What is the most effective way to clean the cryostat?
|Section III. Proper handling of hazardous chemicals (HC)|
|16. What are the hazardous chemicals to which you are exposed at work?
17. What is the HC safety data sheet?
18. How are the HC with which you work identified?
19. What characteristics of HC are considered to assess their level of risk?
20. What is the safety diamond used for?
21. What colors the does safety diamond include and what is its significance?
22. Where must the safety diamond be placed?
23. How must one control an HC spill?
24. What are the requirements that the HC storage area must meet?
|Section IV.Proper handling of cutting objects and sharps|
|25. What wastes are sharps?
26. What are the main diseases that can be caught from a sharp object?
27. How must needles be disposed of?
28. What are the characteristics of the container in which sharps must be packaged?
29. Up to what capacity may containers be filled with sharps?
|Section V. Personal protective equipment (PPE)|
|30. What is the Mexican official standard that refers to personal protective equipment in the workplace?
31. What is PPE named for?
32. What are the obligations of workers to use PPE?
33. What type of PPE is required for work in your area?
|Section VI.Ergonomics and work equipment|
|34. Is your microscope conventional or ergonomic?
35. Do you know what the correct posture is for using the microscope?
36. Have you had or do you have a skeletal muscle problem?
37. If the answer is Yes, in which anatomical region?
|Section VII.Reporting of incidents and accidents at work|
|38. Have you punctured or cut yourself at any time during your work activities?
39. Did you report the incident or accident at work to the appropriate authorities?
40. In your workspace is there a form for the reporting of incidents or accidents at work?
All pathologists (medical residents and staff doctors) at the Laboratorio de Patología of the Hospital de Oncología and 250 doctors in the same field working in other hospitals of the Instituto Mexicano del Seguro Social in the Distrito Federal of Mexico were invited to participate in the evaluation. Physicians who accepted the invitation were sent the survey via Internet. The time spent to answer the questionnaire was 25 minutes.
After the first assessment, specific information was provided to subjects regarding the questions asked. It was felt that a participant was not trained in health and safety at work when one or more items in each section was wrong.
The Hospital de Oncología had 11 staff doctors (SD) and 8 resident doctors in pathology (RP) who participated. Of the 250 people who were sent the invitation to participate in the study, only 102 accepted, of which 54 were pathology residents and 48 staff doctors (Table II).
|Table II Demographic information of study participants|
|Level of training|
|Type of Hospital|
|Number of surgeries per year|
In terms of health training, a total of 87 (72%) of those tested found that they had zero or minimal training in this regard. All pathology residents who participated in the study agreed that their academic programs did not have a single module referring specifically to the risks of disease and/or work accidents to which they are exposed by the nature of his work, or how to prevent them.
Moreover, when SD were asked if in the orientation to their job they had been given such training, only 6 (9.6%) answered yes. With respect to the two previous points (academic training and job orientation), no significant differences were found with the size of the hospital to which participants belonged (second vs third level), p = 0.58.
The percentage of correct responses was 34% and 32% for RP and SD, respectively, which was not significant (p = 0.56). Regarding the number of correct answers, for the sections of biosecurity and handling of hazardous bio-infectious waste (HBIW), a significant difference was observed between hospitals that had > 10,000 surgeries annually, versus those with ≤ 5000 annual surgical specimens (p = 0.002), with the first group having a higher number of correct answers than the second (p = 0.001).
Of all the sections included in the assessment, that with the lowest number of correct answers was Section II (Biosafety), followed by Sections III (Proper handling of hazardous chemicals) and I, proper handling of tissues, organs, blood, and body fluids; the number of correct answers was 34, 36 and 49% respectively. Note that in the question: Do you think that your work area is of low or high risk for infections?, 63 participants (52%) responded that it was low risk.
Only 25 participants (21%) correctly knew the concept of biosecurity and 62 (51%) knew the type of infectious agents to which they were exposed in their work area.
43% of RP and 49% of SD thought that the only dangerous chemicals used in the PL were formaldehyde, alcohol, and xylene. Only 41 participants (34%) knew the safety diamond and its meaning, and 23 (19%) knew the Material Safety Data Sheet. A total of 32 respondents (26%) knew the correct way to package HIBW.
Most participants (71%) reported having had at least one accident with needlesticks or sharps (needles, scalpel blades, knives); similarly, 64% of respondents also reported accidents with formaldehyde such as splashing their eyes, mouth, skin, etc. 62% of them did not report the incident and 36% did not know to whom they should report it.
Regarding the use of personal protective equipment, all participants reported using gloves in handling the tissues in the pathology and intraoperative surgical areas, but < 49% used goggles; < 39% facemasks; 7% safety masks, and 0% used the plastic apron, on top of the surgical gown.
A very interesting study finding was the fact that the start of the study, 104 participants (86%) felt they had adequate training in health and safety at work, however, at the end of the evaluation, only 22 of the 121 respondents (18%) felt that the information they had was clear and adequate (p = .0001). Only 13 people (11%) thought that they had a good level of training in health and safety (according to the criterion mentioned in material and methods), however not one participant had all the right answers.
In general, health workers are exposed to multiple occupational risks, mainly biological, by being in contact with patients with infectious diseases. Among these risks, accidental injury with sharps or cutting objects has been identified as the most common reason why such personnel is contaminated with blood or infectious body fluids.17
Moreover, in most pathology labs, even when handling dangerous chemicals and receiving potentially infectious specimens, there is little or no knowledge of the measures and/or practices to be carried out to avoid accidents or illness. This highlights the need to implement training programs to prepare staff in these areas.
The assessment of health and safety at work that we did in the pathology laboratories of participating hospitals allowed us to discover all the areas of opportunity we have to achieve a safe workplace.
According to the NOM-087-Ecol_SSA1-2002,12 for waste to be considered hazardous bio-infectious waste (HBIW) it must contain an organism that is capable of producing disease. This requires that the microorganism be capable of producing damage, that it be in a sufficient concentration, in the correct environment, and have an inlet and be in contact with a susceptible person. This standard describes which agents are considered part of the group of HBIW, and how to separate them, package them, and store them temporarily before final disposal.
In this study, only 25 participants (21%) knew the correct way to package HBIW.
Although the medical pathologist has the same risk of exposure as the clinician (direct patient contact), because they receive specimens (tissues, organs, fluids, etc.), potentially contaminated, less attention is paid to measures of health and safety at the PL.17-19 In this study, we found that only 11% of the participants had adequate training in this regard.
The emergence and development of the HIV-AIDS pandemic starting in the 80s, and a better understanding of the pathways and consequences of this disease, as well as hepatitis B and C and other infectious diseases, have shown that exposure to these infectious agents is a potential hazard for personnel.20,21 In addition to these diseases, there have been others acquired in the PL, including tuberculosis and other mycobacterioses.22
Of all the sections included in the assessment, the one with the fewest correct answers was biosafety; 83 participants (69%) felt that, not having direct contact with patients, their risk of infection was low, but this concept is wrong, given that any specimen that reaches the PL should be considered potentially infectious.
In addition, all pathology residents (54) responded that they did not have a single topic in their academic program that referred to measures to be taken in the PL to prevent workplace accidents and/or diseases. Also, only 6 (9.6%) of staff doctors responded that yes they were given adequate training in health and safety at work during their job orientation.
In Mexico we do not have an official law for PL,1 which makes it so that this specific hospital area is not duly considered by the general public or by the authorities.
People who work there, therefore, do not rigorously practice the necessary measures to prevent workplace disease and/or accidents.
There are, however, official Mexican laws that can be made available and implemented in the PL; NOM-018-STPS-2000,11 refers to the system for the identification and communication of hazards and risks from hazardous chemicals in the workplace, describing the characteristics of a hazardous chemical and establishing the systems by which one can identify them (rectangle or rhombus pattern).
On the other hand, every place where contaminant chemicals are handled must follow the concepts presented in NOM-010-STPS-2013,14 seeing as this law covers the limitation of time and frequency of exposure of exposed personnel, supplying the required personal protective equipment, and restricting outsiders’ access to chemical handling areas, among other items.
With regard to the category of hazardous chemicals, 43% of RP and 49% of SD responded that the only HC used in the PL were formaldehyde, alcohol, and xylene. This was underlined by the fact that, after the biosafety section, the section on HC handling had the most errors. In the pathology laboratory they use about a hundred HC, which are necessary for the development of the various reagents used in this area.23,24
Each PL must have a folder that includes all Material Safety Data Sheets (MSDS) for hazardous chemicals,25 which aims to inform the user about the physical properties of each substance, the adverse health effects that make it dangerous to handle, the type of personal protective equipment to be used for that substance, and first aid treatment to be applied if a worker has an accident. This folder should be accessible to everyone.
In this study, only 23 participants (19%) were aware of the material safety data sheets.
A total of 86 respondents (71%) reported having experienced at least one accident with sharps. A study by Collins et al.20 demonstrated that between 45.8% and 66.3% of nurses reported punctures or cuts, as well as 17.9% of all staff working in a pathology laboratory.
According to Diaz et al.26 28.2% of workers exposed to sharps had suffered at least one accidental puncture or injury during the twelve months preceding the survey.
According to international standards, if the technology, infrastructure, and control measures used in the workplace are not sufficient to eliminate the exposure, the use of personal protective equipment (PPE) is mandatory.9 In the PL it is impossible to eliminate contact with bio-infectious material; dissection of organs and tissues cannot be done in an automated fashion as with the material being processed in the clinical laboratory (e.g. blood count, urinalysis, etc.).
The use of a lab coat is not enough; an additional cover (apron) is needed, and the use of goggles, masks, gloves, facemasks, etc. For practical purposes, none of the study participants reported using the full EPP in the area of surgical pathology, intraoperative consultation, and/or autopsies. Only 60 to 80% wore gloves; < 52% used goggles, < 42% facemasks, 5% safety masks, and 0% plastic apron.
In the study of Ehdaivand et al.,27 only 60% of respondents used appropriate PPE for handling tissues in surgical pathology laboratories, but < 30% used safety masks and < 5% goggles. In this study and during the initial evaluation, 86% of respondents assumed that they had sufficient knowledge of the risks of disease involved in exposure without adequate protection to dangerous chemicals or different biological specimens, however, after the study, 18% considered themselves trained in that field. These findings indicate that participants are unaware of the magnitude of the risks to which they are exposed in their work environment, so they have a false sense of security, as has been reported in similar studies in some pathology laboratories in the United States of America.28
It was already mentioned that pathologists’ daily work results in various types of musculoskeletal disorders. It turned out that 112 (93%) participants reported using the traditional microscope, and only 11 (9%) had ergonomic microscopes. A total of 86 physicians (71%) reported some form of musculoskeletal harm, such as pain or limitation of movement. The sites most reported were neck (62%), followed by the upper back (34%) and lower back (24%) (Table III).
|Table III Skeletal muscle pain in study participants|
|Anatomic site||With symptoms (%)|
Knowledge of safety and health in the pathology doctors and pathology residents who participated in this study is little or none.
Specific modules in relation to safety and health at work must be implemented in the academic programs of pathology residents.
Job orientation for all health personnel should include the topic of safety and health in their respective work areas.
Each pathological anatomy laboratory should implement a culture of safety and develop manuals that can be accessed by workers.
In a search of the national literature we found no articles addressing this issue, so there is a great need for more research studies on the health and safety practices in pathology laboratories in Mexico, with the main objective of taking steps to create a true culture of safety there.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.