Transmitting times

A
study to identify staff knowledge about infection transmission and to quantify
the incidence of infection to develop a strategy to reduce it.  By Thea Van Mortel

Abstract

In response to concerns about infection rates at Southern Cross University in
New South Wales, a study was undertaken to identify staff knowledge about
infection, and to quantify the incidence of infections to develop a strategy to
reduce it.

Of the 294 staff sent questionnaires, 41 per cent responded. The survey,
Infection transmission in the university workplace: incidents and staff
knowledge of the modes of transmission, found that 60 per cent of staff
suffered an infectious illness over the study period and one-third took an
average of three days’ sick leave. The average score on questions regarding
infection transmission was 48.5 per cent.

There was no significant relationship between knowledge and incidence of
illness, however a non-significant trend was noted between the frequency of
handwashing and illness rates. Given that knowledge of disease transmission was
poor and that the incidence of illness was lower in people who washed their
hands more frequently, a workplace education strategy on hygiene may reduce the
incidence of infectious illness.

Introduction

The acquisition of an infection requires a source of infectious agents, a
mode of transmission, and a susceptible host1. In the community, contact with
contaminated objects is a common means of infection transmission. Cold viruses
are most frequently transmitted in this manner2,3. Thus, handwashing is an
important strategy for decreasing the incidence of infection in the community.

A number of studies have shown a relationship between the frequency of
hand-washing and illness absenteeism. Kimel found that handwashing education
significantly decreased illness absenteeism among school children following an
education programme4. Similarly, a study in a childcare setting found that
there was a significant decrease in colds among a group of children who
improved their handwashing behaviour when compared to a control group who did
not5.

Most people will contract an infectious disease at some time and the source
of contagion may be the workplace. To illustrate the impact of such illnesses,
66 million individuals required medical attention or had to reduce activity
levels, and 20 million school days were lost due to colds in the US in 19946.

Influenza can have an even greater impact, as it can be fatal. Statistics
collected in Belgium, during an influenza outbreak in 1993-94 showed an
increase in mortality of 14 per cent and in work absenteeism of 56 per cent.

The current study arose when staff concerns regarding the rates of
infectious illness during the winter months were brought to the attention of
the Occupational Health and Safety Committee. A research strategy was designed
to address these concerns.

Research objectives and design

The objectives of the study were to identify the level of knowledge about
infection transmission and prevention among staff, to gather data on the
incidence of infectious disease in the workplace and to examine any
relationships between knowledge, practice and infection rates. A questionnaire
consisting of two parts was used to gather this information.

Part A of the study elicited the age range, gender and highest level of
education of the participants. The respondents were asked to state if they had
suffered any infectious illness over the winter of 1998 and were asked to
describe the type of illness and absenteeism due to sickness (if any). Part B
included multiple-choice questions that tested the respondents’ knowledge of
the means of transmission and treatment of various infectious diseases such as
a cold and glandular fever.

The respondents were also asked to identify some of the vaccines available
against adult infectious diseases and to state whether or not they had received
any of these vaccines. The respondents were asked to indicate whether they
washed their hands after toileting and before eating, and were asked a question
on handwashing technique. Research literature related to infection transmission
and control provided guidance when framing the questions.

Research method

The sample consisted of staff who worked in four of the university’s 16
buildings. These areas – named blocks A, F, P and R – were selected as they
housed a number of departments and were representative of the employee mix of
the site. Following approval from the Ethics Committee, a questionnaire was
distributed to all 294 staff in those areas.

A total of 121 staff returned the completed forms. Data was analysed via the
statistical package SPSS. The categorical data were analysed via contingency
Chi2 tables. Relationships between demographic variables and scores on
infection transmission questions were examined by regression analyses. Staff
were subsequently provided with the correct answers and a short paper on
infection control via e-mail.

Results and findings

Demographics
Of the respondents, 61 per were female, 38 per cent were male and one
person was unsure; 16 per cent were aged 21-30, 29 per cent were aged 31-40,
32.5 per cent were aged 41-50 and 22.5 per cent were aged over 50; 17 per cent
had a certificate, 15 per cent had a diploma, 38 per cent had a degree, and 30
per cent had a higher degree as their highest qualification.

Frequency and type of illness
In total, 60 per cent of the respondents contracted an infectious illness
during the study period. The most frequent illness was the common cold (60.6
per cent), followed by influenza (23.9 per cent); 11 per cent suffered both a
cold and influenza, while 4.2 per cent suffered from other illnesses. Sick
leave was taken by 53 per cent of staff. The mean period of absenteeism was
3.19 days (+/-2.55 std. dev) and the range was 0.5 to 10 days.

The study found that 50 per cent, 69 per cent, 36 per cent, and 66 per cent
of staff suffered an illness in A, F, P and R blocks, respectively. There was
no significant difference in the frequency of illness between areas (p = 0.14).
The mean number of days off work in those areas was 2 (+/-1.3), 4.3 (+/-3.1),
0.5, and 3.5 (+/-2.5) days, respectively.

In total, 73.4 per cent of those who became ill felt that something in their
work environment contributed to their illness. The most common comment made by
respondents was that everyone around them was sick.

Demographic factors and the frequency of illness
There was a significant relationship (p = 0.041) between age and the
frequency of illness: 74 per cent of respondents in the 21- to 30-year age
group became ill, in comparison to 63 per cent in the 31-40 age group, 67 per
cent in the 41-50 age group and 38 per cent in the over-50 group.

There was no relationship between gender and the incidence of illness (60
per cent of females vs 61 per cent of males became ill). The incidence of
infectious illness was highest in the group whose highest qualification was a
degree (75 per cent), lowest in the group with a certificate (45 per cent), and
intermediate in those with a diploma (71 per cent) or a higher degree (51 per
cent). These results fell just short of statistical significance (p = 0.05017).

Knowledge of infection transmission
The mean score on the infection transmission questions was 5.33 +/-1.51
(out of a possible score of 1I), and scores ranged from 1 to 9. There was no
significant relationship between the score on the infection transmission
questions and the frequency of illness (p = 0.92.

Demographics and score
There were no significant relationships between demographic factors and
score. However, the power of the analyses to detect a significant difference
was low (-13 per cent) due to the small sample size in each category.

Handwashing
When asked, "Do you wash your hands after going to the toilet?"
one person (0.8 per cent) replied "never", 3 per cent responded
"sometimes", 19 per cent replied most of the time, 75 per cent
replied "always" and 2 per cent left the question unanswered. Reasons
given for failure to handwash included "I don’t consider urination to be
dirty", "lazy", and "too busy".

When asked, "Do you wash your hands before handling food?" 19 per
cent said "sometimes", 42 per cent replied "most of the
time", 37 per cent replied "always" and 2 per cent left the
question unanswered. Reasons given for failure to handwash included
"lazy", and "too busy". Forty-three per cent of respondents
answered correctly that washing hands for 10 seconds with soap and water would
clean them effectively.

Relationship between illness and frequency of handwashing
There was a trend towards an increased incidence of infectious illness in
people with a lower frequency of handwashing before eating, however this
relationship was not statistically significant (p = 0.168). Seventy-eight per
cent of those who sometimes washed their hands before eating became ill,
whereas 57 per cent of those who said they mostly or always washed hands before
eating became ill.

Knowledge of vaccine availability
Four per cent of respondents correctly identified which vaccines are
available for infectious illnesses from the range of choices offered. The
scores on this question ranged from 3 to 7 out of 7, while the average score
was 4.8 (+/- 0.93): 25 per cent of the respondents were vaccinated against at
least one of the following: influenza, pneumococcal pneumonia. Hepatitis A and
B, while 5 per cent were vaccinated against more than one disease.

Discussion

While there were no significant differences in the incidence of infectious
illness between areas, the sample size may have been a limiting factor
decreasing the ability to detect a significant difference. It was hard to
compare illness and absentee rates with other workplaces, as the published data
tend to be reported for different durations, or include conditions other than
infectious ones.

However, Saxen and Verten reported an average of 1.4 days of work lost due
to respiratory infections among healthcare workers, in comparison with the
average of three days at this university8.

As only four of 16 buildings were surveyed, one cannot confidently
extrapolate the results to the university as a whole or to other workplaces.

Staff knowledge of infection transmission was poor. There was no
relationship between the incidence of infection and knowledge on infection
transmission and treatment. But illness rates were more than 20 per cent higher
in those people who washed their hands infrequently before eating, than in
those who reported always handwashing.

Perhaps if the questions had been more specific to infection transmission
only, a relationship between knowledge and incidence may have been seen. But
much of the data from research studies on handwashing in the hospital workplace
suggests that having knowledge is not the same as applying it9.

There was a surprising relationship between age and illness, with infection
rates in the over 50 age group 36 per cent lower than those aged 21-30, and
25-29 per cent lower than the other groups. It is possible that the younger age
group had younger families, and so were exposed to more infectious illnesses,
or that people in the older age group were more likely to be in senior
positions in which they had less contact with large numbers of people.

There may be other contributing variables. A National Health Survey in
Australia in 1989-90 found smokers had a 23-66 per cent greater probability of
work absenteeism than non-smokers10. As smoking impairs respiratory defences,
it would increase one’s susceptibility to respiratory tract disease11.

Conclusions and implications

Given that knowledge of infection transmission among staff was often poor,
and that those staff who reported higher handwashing rates had a 20 per cent
reduction in illness rates, an educational strategy related to infection
prevention may reduce the incidence of infections. This workplace has
implemented harm minimisation policies on blood-borne diseases.

However the findings of this study indicate that consideration should be
given to formulating a broader infection control policy as part of the
university’s occupational health platform. Research is needed to determine the
effectiveness of this approach and to determine why people continue to place
themselves at risk of contracting infections that may be prevented by simple
hygiene measures.

References

1. National Health and Medical Research Council and Australian National
Council on Aids (1996). Infection control in the health care setting,
Guidelines for the prevention of transmission of infectious diseases. Canberra:
AGPS.

2. Hendley J, Wenzel R, & Owaitney J. (1973) Transmission of rhinovirus
colds by self-inoculation. New England Journal of Medicine; 288:1361.

3. Gwaltney J, Moskalski P, & Hendley J. (1978) Hand to hand
transmission of rhinovirus colds. Annals of Internal Medicine; 88: 464.

4. Kimel LS. (1996) Handwashing education can decrease illness absenteeism.
Journal of School Nursing; 12(2): 14-6,18.

5. Niffenegger JP. (1997) Proper handwashing promotes wellness in childcare.
Journal of Paediatric Health Care: 11 (1):26-31.

6. National Institute of Allergy and Infectious Diseases, National
Institutes of Health. (1998) Fact Sheet: The Common Cold Department of Health
and Human Services: Bethesda.

7 Snacken, R. (1996) Weekly monitoring of influenza impact in Belgium
(1993-1 995). Pharmacoeconomics; 9(Suppl 3): 34-7.

8. Saxten H & Verten M. (1999) Randomised, placebo-controlled double
blind study on the efficacy of influenza immunisation on absenteeism of health
care workers. Pediatric Infectious Disease Journal; 1B(9):779-83.

9. Van de Mortel TF & Heyman, L. (1995) Performance feedback increases
the incidence of handwashing by staff following patient contact in intensive
care. Australian Critical Care; 8(2): 8-13.

10. Bush R & Wooden M. (1995) Smoking and absence from work: Australian
evidence. Social Science & Medicine; 41(3):437-46.

11. Porth CM. (1998) Pathophysiology: concepts of altered health states.
Lippincott: Philadelphia.

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