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Survey on infection control in MOH dental clinics, Riyadh

No standard instruction or procedures for infection control are currently available for Ministry of Health (MOH) dental clinics. To discover the current level of infection control, set standards and procedures for infection control and advise dentists in correct universal precautions and sterilization techniques, a cross-sectional probability sample from 32 MOH dental clinics within 24 primary health care centers in Riyadh City was conducted between May 22 and June 20, 1997. All dentists except one (Syrian) were Saudi; 67% were females and 33% were males. The majority (91%) had graduated from King Saud University.
Dentists and assistants were questioned about universal precautions, procedures used for infection control in dental clinics, attitudes of dentists and assistants about universal precautions, knowledge of infection control, and available facilities for infection control in dental clinics.
Only 78% (95% C1=67-89) of dentists said they had been vaccinated against hepatitis B, and 58% (95% CI=45-70) had been vaccinated against meningococcal meningitis. Vaccination against other diseases ranged from 0% (BCG, DT, poliomyelitis, and chickenpox) to 3% (influenza Td) to 6% (MIVIR and hepatitis A).
All (95% C1=87-100) dentists reported that they practiced universal precautions (handwashing, gloving, wearing masks, wearing lab coats) with all patients. However, only 76% (95% CI= 64-87) reported that they wore protective eyewear. We observed directly in the clinic that 97% (95% CI=82-100) of dentists and 84% (95% CI=71-97) of assistants wore gloves, 94% (95% CI=70-92) of dentists and 81% (95% CI=87-92) of assistants wore masks, and 87% (95% CI=79-96) of dentists and 90% (95% CI=83-98) of assistants wore lab coats. Only 50% (95% CI=37-63) of dentists wore eye protectors during treatment. Because protective eye-wear is an essential component of universal precautions, only 76% of dentists reported practicing complete universal precautions and only 50% were actually observed doing so. Seventy-two percent of clinics (95% CI=60-84) had containers for disposable needles and sharp instruments. Of those, only 72% used hard plastic sharp containers The remaining 28% used plastic bags, thus risking injury and transmission of infectious agents to those handling the bags.
To protect patient against aerosols and spatter, 76% (95% CI=64-87) of dentists used saliva ejectors, 21% (95% C1=10-32) used rubber dams and 3% (95% CI=0.2-18) used both.
Only 60% (95% CI=45-70) of dentists sterilized all instruments after each patient. We found that only 16% (95% CI=33-60) of clinics had complete sets of instruments. Only 30% (95% CI=18-43) of dentists autoclaved hand pieces; 90% (95% CI=54-99) of those dentists autoclaved at the end of the day. Of dentists, 94% (95% CI=78-99) practiced the correct sequence of sterilization for instruments (presoaking, cleaning, packing, sterilization).
Of assistants, 58% (95% CI=44-72) practiced the correct sequence of sterilization steps, 71% (95% C1=54-84) sterilized instruments after each patient and 35% (95% CI=23-49) sterilized at the end of the session. Of assistants, 77% (95% CI=57-89) soaked instruments before cleaning. Only 32% (95% CI=19-45) knew the correct time and temperature required by the autoclave for sterilization (20-30 minutes at 121°C and 2-10 minutes at 134°C), and 45% (95% CI=32-59) knew the correct time and temperature required by dry heat for sterilization (1-2 hours at 60°C). We observed that 47 % (95% CI=33-60) of dental clinics had autoclaves, 47% (95% C1=33-60) had dry heat ovens and the remaining 6% had no device for sterilization so had to sterilize instruments in the autoclave in the dressing room. Only 50% (95% CI=35-65) had sterilization packages and so could monitor sterilization. To clean contaminated surfaces 81% (95% CI=70-92) of assistants used disinfectants. When we asked about radiographic asepsis, only 23% (95% CI=11-34) of assistants disinfected the machine daily and 26% (95% C1=13-39) felt that radiographic asepsis was not necessary. All clinics (95% C1=87-100) had saliva ejectors; however, only 16% (95% C1=26-51) had rubber dams.

Editorial note:

This study identified a number of deficiencies in infection control involving personal protection for dentists and assistants, knowledge of dentists and assistants, equipment, and protection of patients. Dentists have frequent exposure to saliva and blood of patients. Accordingly, vaccination against hepatitis B should be 100% among dentists. Other vaccines are of lower importance in the dental setting but are available, and dentists should be encouraged to receive them.
Under universal precautions, dental staff must assume that every patient could be infected with a transmissible agent. All dentists and assistants should have complete knowledge of universal precautions, and they should practice them. Universal precautions require dentists to wear gloves, masks and eye protectors with patients during dental procedures. The lack of eye protection resulted in a low rate of full compliance with universal precautions.
Sterilization and disinfection prevent transmission of organisms through contaminated instruments or contaminated surfaces. A deficiency in the number of instruments and equipment available interfered with full compliance with sterilization and disinfection practices. This was compounded by a lack of supplies such as sterilization packages and disinfectants. Finally, assistants were found to be deficient in knowledge of correct sterilization practices, indicating that retraining is needed. Patients must be protected from aerosols and spatter. Rubber dams are not available in most clinics and dentists do not like to apply them as doing so takes time and patient load is heavy. A decrease in the number of the patients during each session would give dentists and assistants more time to practice correct infection control techniques.
To ensure correct infection control techniques, dentists and dental assistants must have recommended vaccinations. In addition, both dental assistants and dentists should attend lectures both on infection control and on dental treatment of highly infectious patients. An adequate supply of instruments per patient is required for each session as well as a qualified dental assistant for each clinic. Facilities for sterilization, disinfection and universal precautions must be maintained in all dental clinics.

Doctors' knowledge of and attitudes toward NIDs for oral poliovirus vaccine in Riyadh, 1997

-Reported by Dr. Haya S. Al-Eid, Dr. Hassan E. El Bushra,Dr. Nasser A. Al-Hamdan (Field Epidemiology Training Program) and Dr. Abdulrahman M. Al-Mazrou (King Saud University).

National Immunization Days (NIDs) are mass vaccination campaigns in which supplemental doses of oral poliovirus vaccine (OPV) are given to all children under 5 years of age, regardless of immunization status, two rounds of door-to-door OPV delivery, 4-6 weeks apart over a short time period as possible, during low poliovirus transmission season, to interrupt the circulation of wild polioviruses. Effective implementation of NIDs has led to the eradication of wild polioviruses in the Americas and progress toward its eradication from several countries of other regions [1]. NIDs, a critical strategy for global poliomyelitis eradication, has been implemented in Saudi Arabia, simultaneously with other Gulf states. [2]
The objectives of this study are to find out the level of awareness of doctors working in Riyadh city, Kingdom of Saudi Arabia (KSA), about the objective of conducting NIDs, and to find out their knowledge, attitudes and practices toward NIDs.
The doctors' community was divided into three strata according to their place of work: hospitals, primary health centers and private polyclinics. From each stratum a probability sample was selected. Using a self-administered questionnaire, 175 doctors working in 23 health facilities were interviewed. In analysis, doctors were further stratified according to their nationalities and specialization. Tests between two proportions were used to examine the difference between different groups of doctors as indicated, using a level of significance (a) of 0.05 for one-tailed test.
A total of 175 physicians participated in this survey: 35 (20% of sample size) pediatricians (Peds), 82 (47%) general practitioners (GPs), and 58 (33%) physicians of other specialties (OS). Forty-eight doctors (27.4 %) were working in hospitals, 38 (21.7%) in primary health care centers (PHCCs) and 89 (50.8%) in private polyclinics (PCs). Of all doctors interviewed, 149 (85%) were from Arab countries and 106 (61%) were males. About 51% of Peds, 27% of GPs and 36% of OS thought NIDs were for developing countries only. between 9% to 23% of Peds, 15%28% of GPs and 22%-29% of OS were unaware of the main objective of NIDs, considered NIDs a simple booster dose for an already vaccinated child, and would not advise vaccinated children to receive additional oral polio vaccine (OPV) doses during NIDs scheduled for 1997. Five percent of doctors did not vaccinate their children during the NIDs of 1996. Five doctors (3%) stated that eradication of wild poliovirus in KSA was impossible due to the dynamic and continuous flow of religious visitors and expatriate workers. Peds, GPs and OS thought breast-feeding (9%), current routine childhood immunization, having three doses of OPV in the first year of life, and/or protein-energy malnutrition (9%-11% of Peds, 15%-22% of GPs, 19%-26% of OS) were contraindications for OPV. Two Peds (6%) did not know that prompt reporting of cases of acute flaccid paralysis was required.
Reading MOH circulars was associated with awareness about NIDs (p<0.05, chi-square test). Non-Arab doctors read MOH circulars more regularly than Arab doctors, and 45% of doctors preferred reading circulars from MOH written in English. Doctors working in PHCCs and private polyclinics, regardless of their specialty, were more aware about and familiar with activities related to NIDs. Conversely, doctors working in governmental hospitals were less informed about NIDs. Table 1 summarizes some of most important findings of the survey.

Editorial note:

The results of this survey showed that there were some deficiencies in knowledge regarding NIDs among physicians working in Riyadh. Although all doctors knew that poliomyelitis is currently targeted for eradication, some doctors, including Peds, were largely misinformed or had misconceptions about NIDs that potentially could have reduced the impact of such nationwide community-based health intervention programs The response of doctors could be due to inability of some doctors to understand the ultimate objective of NIDs, which is to interrupt the circulation of wild polioviruses through systematic and extensive mass immunization campaigns with OPV.
Failure to differentiate between the objectives of routine OPV vaccination and NIDs could be due to inadequate communications between MOH and doctors. Doctors, especially pediatricians, need to be more involved in planning, executing and evaluating any community outreach programs that relate to a child's health. During national intervention programs, circulars released by MOH must be written in both Arabic and English to all doctors, regardless of their specialty or their affiliation.
  1. Birmingham ME, Aylward RB, Cochi SL, Hull HF. National immunization days: state of the art. J Infect Dis 1977; 175 (Supp 1):S183-8.
  2. National immunization campaign for the eradication of poliomyelitis, Saudi Arabia, Nov. and Dec. 1996. Saudi Epidemiol Bull 1996;3:3:18.