Universal precautions are a set of evidence based clinical work practices and precautions recommended by Centers for Disease Control and Prevention (CDC) in 1987 to be followed while handling blood and body fluids of patients1. Here CDC recommended blood and body fluids of all patients to be considered as a potential source of infection regardless of the infection status of patients. This extension of blood and body-fluid precautions to all patients is referred to as universal precautions. Infections remain one of the important causes of hospital admissions worldwide and contribute significantly to morbidity and mortality. Health care workers are exposed to infective pathogens on a daily basis at their work place...HIV, Hepatitis B, Hepatitis C etc. are some of the common pathogens that are transmitted through blood and body fluids. Health care workers are exposed to these pathogens through mucocutaneous exposure that’s through splashes or spills of infected body fluids on to skin or mucous membrane or through percutaneous exposure by means of contaminated sharp instruments or needles by way of cuts or pricks while managing patients or disposing infected waste materials. As per WHO data annually around 3 million health care workers receive injury through sharps or needles while working in the hospital settings. Globally its estimated that 40% of HBV and HCV infections and 2.5% of HIV infections in health care workers are attributable to injury by sharp instruments while at work2,3. Internship is the period in which the medical graduates gain practical experience in patient care under supervision and guidance of senior faculties and residents. Interns get real world experience of patient care during this period and are exposed to maximum number of patients in Outpatient departments, wards, Emergency rooms, labour room, operation theatre etc.The relative inexperience in invasive procedures coupled with increased patient numbers and subsequent workload put interns at a high risk of occupational exposure to harmful pathogens like HIV,HCV,HBV etc.This is particularly true especially in government hospitals in developing countries like India. Even though Universal Precautions are taught in the curriculum, its practice in hospital settings is found to be lacking in health care workers including interns. Studies assessing practice of Universal precautions among interns are few in number and have shown poor knowledge and practice of universal precautions4,5,6. Once the internship is completed, they are usually posted as medical officers with independent charge in health centers and are supposed to lead a team of health care workers in delivering health care to the public. While working as medical officers they may encounter situations where health care workers under them may have exposure to these blood borne pathogens. So, a sound knowledge and practice of universal precautions is necessary for safe delivery of health care to the public. They also should have a good knowledge about the protocol to be followed for post exposure prophylaxis for Human Immunodeficiency Virus. Objective of our study is to assess the knowledge and practice of universal precautions among interns and awareness regarding post exposure prophylaxis (PEP) for Human Immunodeficiency Virus. By doing this study we tried to find the lacunae in the knowledge and practice of universal precautions among interns if any .

The study was conducted among interns at the teaching hospital of Government Medical College Palakkad during a period of March to May of 2021 (3 months). The study pattern was an observational cross-sectional study based on a printed questionnaire where the respondents could mark their answers. The data for the study was collected using a validated printed questionnaire. Validation was done by using the questionnaire with other healthcare workers who were not participating in the study. Each willing participant was handed over the questionnaire to be filled and returned to the investigators. The questionnaire contained questions that tested the participants’ knowledge as well as practice of universal precautions and PEP for HIV.Depending on their response the knowledge was categorized into “correct” or “incorrect”. Practice of universal precautions were categorized into “always practiced” and “not always practiced”. Inclusion and Exclusion criteria All the interns who gave signed consent were included in the study and those who did not give consent were excluded Sample size All 65 interns doing internship during the study period gave consent and were thus included in the study. Statistical analysis Descriptive statistics were used for all the variables in the study.Statstical analysis was done using Statistical package for social sciences for windows (SPSSversion 16) Ethical approval and funding. This cross-sectional observational study was approved by the Institutional ethics review board government medical college Palakkad.The study received no funding from any agency

65 interns who were doing internship during study period participated in the study. All the participants had received training in Universal Precautions just before the beginning of their internship.All the participants 65(100%) were aware of the term universal precautions and its concept. The awareness was further assessed under the following subheadings of hand hygiene, personal protection equipments and measures, prevention of needle stick injuries, disposal of biomedical wastes. Regarding hand hygiene and its importance in prevention of infections, 65(100%) answered that hand washing reduced the risk of infections .63(96.92%) had good knowledge about the importance of hand washing before and after patient examination. Regarding basic steps of hand-washing correct response was obtained from 56(86.15%) while 9 (13.8%) got it wrong. Regarding knowledge about personal protection equipments and measures 63(96.9%) had correct knowledge about the use of gloves. Regarding the use of goggles face-shield, aprons and face mask 51(78.46%) had correct knowledge while the response of 14(21.53%) was incorrect. Regarding needle stick injury and risk of HIV, HBV, HCV infections only 38(58.46%) responded correctly while 27(41.53%) had incorrect response. Regarding recapping of needles 46 (70.76%) gave correct response while 19 (29.23%) gave incorrect response. As far as biomedical waste management was considered 53(81.53%) responded correctly regarding the knowledge of waste segregation, while 12(18.46%) got it wrong. Regarding post exposure prophylaxis (PEP) awareness, 65 (100%) was aware about the availability of PEP in the hospital. But only 51(78.46%) had correct knowledge about immediate measures after a needle stick injury.43(66.15%) had corrected response regarding PEP duration of treatment and time interval regarding initiation of PEP after exposure. Only 28 (43%) interns answered correctly regarding drugs used for PEP for HIV while the response of 37(56.92%) was incorrect. Regarding practice of universal precautions, the results obtained were as follows. Hand washing in the proper way before and after patient contact was practiced by 28(43.07%) while 37(56.9%) did not practice this. But hand washing after patient contact was done by 56(86.15%) and not done by 9(13.84%). As far as use of gloves was concerned, gloves were used always by 44(67.69%) while handling a potentially infectious material while 21(32.30%) did not follow this always. Masks were always used by 41(63.07%) and not always used by 14(21.53%). Aprons or gowns were used by 23(35.38%) during invasive procedures while 42(64.6%) did not use these always. Goggles or face shields were not routinely used by participants during invasive procedures. Its use was limited to major invasive procedures like surgeries in patients known to be sero positive for HIV, HBV, HCV only. Recapping of the needle was practiced by 59(90.76%) and only 6(9.23%) did not re-cap used needles. And use of puncture proof containers to dispose sharps was practiced by 65(100%). 7(10.7%) had history of needle stick injury and 3(4.61%) gave history of needle stick injury more than once. 4(7.07%) had taken post exposure prophylaxis for HIV. Proper disposal of biomedical waste was practiced by 57(87.69%) while 8(12.3%) did not practice this. Results obtained regarding knowledge are summarized in Table 1 and results obtained regarding practices in Table 2. Table 1: Knowledge regarding Universal Precautions and Post Exposure Prophylaxis (n = 65) Parameter Correct n (%) Incorrect n (%) Hand hygiene role in infection control 65 (100%) 0 (0%) Hand washing before and after patient contact 63 (96.92%) 2 (3.07%) Basic steps of hand washing 56 (86.15%) 9 (13.8%) Personal Protective Equipment Use of gloves 63 (96.92%) 2 (3.07%) Use of masks, goggles, aprons etc. 51 (78.46%) 14 (21.53%) Risk % of HIV, HBV, HCV following needle stick 38 (58.46%) 27 (41.53%) Recapping of needle 46 (70.76%) 19 (29.23%) Post Exposure Prophylaxis (PEP) PEP availability in hospital 65 (100%) 0 (0%) PEP duration of treatment and time interval for initiation of PEP 43 (66.15%) 22 (33.84%) Drugs used for PEP 28 (43%) 37 (56.92%) Measures after needle stick injury 51 (78.46%) 14 (21.5%) Table 2: Practice of Universal Precautions (n = 65) Assessing the Practice Always Practiced n (%) Not Always Practiced n (%) Hand washing before and after patient contact 28 (43.07%) 37 (56.9%) Hand washing after patient contact 56 (86.15%) 9 (13.84%) Use of gloves 44 (67.69%) 21 (32.3%) Use of masks 41 (63.07%) 14 (21.53%) Use of aprons/gowns in invasive procedures 23 (35.38%) 42 (64.6%) Re-cap needles after use 59 (90.76%) 6 (9.23%) Disposal of sharps in puncture-proof containers 65 (100%) 0 (0%) Proper disposal of biomedical waste 57 (87.69%) 8 (12.3%)

Healthcare workers face the potential risk of acquiring blood borne infections during their day-to-day work. Interns handle the maximum number of patients in whichever work station they are posted. Being in their training period, the workload of interns is high especially in government hospital settings. The relative inexperience in invasive procedures coupled with high workload and extended duty hours put interns at a high risk of occupational exposure to blood borne pathogens if universal precautions are not strictly adhered to. In this study we assessed the knowledge as well as practices of universal precautions among interns in a tertiary care teaching hospital. Knowledge about universal precautions Regarding hand hygiene and hand-washing techniques, the knowledge of interns was very good. All interns (100%) had knowledge that hand washing reduced the risk of infections. Regarding hand washing technique 86.15% had good knowledge while 13.8% got it wrong. 96.92% responded that hand washing was necessary before and after each patient examination while about 3% responded it was needed only after patient examination. This shows overall knowledge regarding hand hygiene was very good. This is comparable to a study conducted among residents in an obstetrics department in USA where the knowledge about hand hygiene was nearly 100%. In a study conducted by Mukherjee et all 90% of participants had good knowledge about hand hygiene14. Another study done by Al-Zahrani15 had similar results with knowledge about hand hygiene among participants was 91.6%. Knowledge regarding Personal protective equipments and measures, 63(96.9%) had correct knowledge about the use of gloves in universal precautions. Regarding the use of goggles, faceshield,aprons and face mask 51(78.46%) had correct knowledge while 14(21.53%) had inadequate knowledge. This shows good knowledge regarding gloves and its use and a fair knowledge about the use of other protective equipments like face masks, goggles,faceshield,aprons etc.In a study by Shuvankar et al the knowledge regarding goggles was found to be poor (54.6%). Regarding needle stick injury and risk of HIV, HBV, HCV infections only 38(58.46%) responded correctly while 27(41.53%) had incorrect response. The interns’ knowledge about the risk percentage of contracting infections like HIV, HBV and HCV after needle stick injury was found to be poor. Regarding recapping of needles 46 (70.76%) gave correct response while 19 (29.23%) gave incorrect response. As far as biomedical waste management was considered 53(81.53%) responded correctly regarding the knowledge of waste segregation, while 12(18.46%) got it wrong. Regarding post exposure prophylaxis (PEP) awareness, 65 (100%) was aware about the availability of PEP in the hospital. But only 51(78.46%) had correct knowledge about immediate measures after a needle stick injury.43(66.15%) had corrected response regarding PEP duration of treatment and time interval regarding initiation of PEP after exposure. Only 28 (43%) interns answered correctly regarding drugs used for PEP for HIV.This shows that even though all are aware about the availability of PEP in the hospital the knowledge about correct steps to be followed following an occupational exposure like needle stick injury was present in 78.46% and only 43% had correct knowledge about drugs used,66.15% the time interval for initiation of PEP and duration of PEP, reflecting the need for further improvement in knowledge regarding PEP through periodic refresher classes as well as dissemination of knowledge through various platforms including social media. Practice of universal precautions. When it comes to practice it has been found that a definite gap exists between knowledge and practice. Hand washing in the proper way before and after patient contact was practiced by 28(43.07%) only. But hand washing after patient contact was done by 56(86.15%). This point to the fact that even though all the interns (100%) knew that proper hand washing decreased the risk of infections only 43% practiced it. This significant gap in knowledge and practice point to the fact that major steps like periodic supervision by senior faculties and residents and refresher courses regarding technique are needed to improve the compliance to hand washing practices before and after each patient care. As far as use of gloves was concerned, gloves were used always by 44(67.69%) while handling a potentially infectious material while 21(32.30%) did not follow this. This shows that even though the knowledge about this is good when it comes to practice there is a significant gap. The use of gloves is not practiced usually during drawing of blood samples, removal of dressings urinary catheters etc. Aprons or gowns were used by 23(35.38%) during invasive procedures while 42(64.6%) did not use these always. Goggles or face shields were not routinely used by participants during invasive procedures. Its use was limited to major invasive procedures like surgeries in sero positive patients only. In a study by Ouguamanam et al 58% of participants used aprons during invasive procedures. This shows that there is poor compliance with practice of universal precautions when it comes to use of protective equipments like aprons, faceshields, goggles etc.Limited supply of these coupled with the difficulty in performing or assisting invasive procedures using goggles, face shields etc may also contribute to poor compliance regarding use of these Recapping of the needle was practiced by 59(90.76%) and use of puncture proof containers to dispose sharps was practiced by 65(100%). Even though re capping of needles is not routinely recommended 90% of interns practiced it significantly increasing the risk of needle stick injury. Needle stick injury commonly occurs during recapping and a dedicated campaign is required to prevent interns from this practice. 7(10.7%) had history of needle stick injury and 3(4.61%) gave history of needle stick injury more than once. 4(7.07%) had taken post exposure prophylaxis for HIV.In a study by Khapare 11.7% of interns reported needle stick injuries. The finding was similar in our study also. the Proper disposal of biomedical waste was practiced by 57(87.69%) indicating a good compliance. From our study it has been found that even though the knowledge about universal precautions is good among interns, when it comes to practice there exists a wide gap between knowledge and practice. Catering to a large number of patients within a limited time frame especially in emergency room, inpatient wards, labor rooms etc make it difficult for them to follow universal precautions diligently in every patient. Difficulty in performing invasive procedures especially with the use of protective gears like goggles and face shield partially limiting vision due to fogging etc may also contribute to non-adherence to the use of these. Limited availability of consumables like gloves, masks, sanitizers etc, are some of the reasons cited by the participants for poor compliance to universal precautions. The findings in our study regarding adherence to universal precautions was similar to other studies done on the subject.Simple practices like avoiding recapping of needles can significantly reduce risk of needle stick injuries and subsequent infections associated with it. Strict adherence to protective measures is always followed in case of sero-positive patients. But this practice has the risk of missing patients in the window period. The principle of universal precautions addresses this issue by following same precautions in all patients irrespective of their infective status. In our study it was found that the knowledge regarding universal precautions was good among interns but when it comes to practice there were several areas were the adherence to the practice of universal precautions was lacking significantly especially regarding use of protective gears and recapping of needles. Simple measures like hand washing, use of gloves and other protective gears and safe disposal of biomedical waste can significantly decrease the transmission of infections in healthcare settings and hence has to be adhered to at all times. Repeated training and prompt monitoring regarding adherence to universal precautions at work stations among health care workers will help to achieve this goal.

Practice of universal precautions has to be mandatorily followed in all patient interactions in health care facilities. Interns being novices in medical profession were chosen in our study to assess their knowledge and practice of universal precautions. In our study it was found that the knowledge regarding universal precautions was good among interns but when it comes to practice there were several areas were the adherence to the practice of universal precautions was lacking, especially regarding use of protective gears and recapping of needles. Regarding knowledge of post exposure prophylaxis further training is required to improve the knowledge. Frequent refresher courses, dissemination of information through various platforms including social media, monitoring of interns at work place regarding practice of universal precautions by senior faculties and residents under whom they work and adequate supply of protective gears like gloves, aprons, faceshields goggles etc can definitely improve the current situation, ultimately leading to complete adherence to universal precautions in every patient interaction.

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