A competency-based framework for preventing blood-borne pathogen occupational exposures in medical students: literature review and Delphi study

Abstract

Section Background

Blood-borne pathogen occupational exposures pose significant hazard to medical students during clinical internships, with needlestick injuries being the primary transmission vector for blood-borne pathogens (hepatitis B virus, hepatitis C virus, human immunodeficiency virus). Current prevention guidelines lack tailored frameworks for this vulnerable population.

AbstractSection Methods

A two-phase method was conducted: literature review and Delphi method. Phase one conducted a literature review across PubMed, Web of Science, Embase, and Cochrane Library (2000–2024). Data were extracted to form an initial framework. During phase two, a modified Delphi method was employed with a multidisciplinary expert panel across two rounds to refine the initial framework developed from the literature review. Consensus thresholds required ≥ 70% agreement on 5-point Likert scale.

AbstractSection Results

The literature review initially identified 1,477 records, with 200 articles retained after search and selection process. During the modified Delphi process, a multidisciplinary panel of 25 experts (71.4% initial response rate; 65.7% retention) iteratively refined prevention strategies. The finalized framework comprises 13 actionable elements, stratified across prevention tiers: primary prevention (7 items), secondary prevention (4 items), and tertiary prevention (2 items).

AbstractSection Conclusion

This study provides the first competency-based framework for medical students to prevent blood-borne pathogen occupational exposures during clinical internships. The framework, informed by evidence-based strategies in conjunction with expert consensus, is a significant step forward in ensuring the occupational safety of medical students.

Background

Blood-borne pathogen occupational exposures experienced by medical students during clinical internships are major occupational hazards, emerging as an urgent issue requiring immediate action in medical education [1,2,3]. Blood-borne pathogen occupational exposure is defined as a percutaneous injury or contact between a mucous membrane or non-intact skin and blood, tissue, or other body fluids [4], with needlestick injuries representing the predominant sources [5]. The exposures may lead to serious and potentially fatal infections with blood-borne pathogens such as hepatitis B virus (HBV), hepatitis C virus (HCV), or human immunodeficiency virus (HIV) [6]– [7]. The risk of blood-borne pathogen transmission following occupational exposure depends on a variety of factors that include source patient factors (e.g., titer of virus in the source patient’s blood/body fluid), the type of injury and quantity of blood/body fluid transferred to the student during the exposure, and the student’s immune status [8]. Seroconversion rates after a percutaneous injury have been reported for HBV (2-30%), HCV (1.8%), and HIV (0.3%) [2].

While medical students gain opportunities for hands-on training in various invasive procedures during clinical internships, their lack of practical experience and/or technical expertise exposes them to a high risk of blood-borne pathogen occupational exposures, especially needlestick injuries [9,10,11,12]. An incidence of needlestick injuries in medical students of 0.3 per student per year has been reported [1]. The infectious result of such occupational exposure is severe. It not only threatens the physical and mental health of students, but also causes significant psychosocial consequences and economic costs. For example, students infected with HBV, HCV or HIV following exposures may be at risk of post-traumatic stress disorders (expressed as anxiety and depression), social discrimination, confrontation of potential limitation in their career or even practicing medicine withdrawal [13]– [14]. Moreover, medical evaluation, prophylactic medication, and follow-up after occupational exposure consume substantial medical resources, placing a heavy burden on healthcare institutions and public health systems [15]. Additionally, non-infectious consequences also include local damage and pain.

Although the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) have published guidelines for reducing occupational exposure in healthcare workers (HCWs) [16,17,18], which have apparent restrictions in terms of real-world applicability. The core provisions of these guidelines are intended for practicing professionals and do not take into account the special nature of medical students. Medical students have unique risk profiles compared to practicing HCWs because of their limited clinical exposure, developing technical skills, psychological stress, and frequent rotations across departments [5, 19,20,21,22]. Currently, no guidelines exist that are tailored specifically to preventing blood-borne pathogen occupational exposures among medical students. Although studies have identified risk factors for such exposures in this population and proposed certain preventive recommendations, these suggestions lack comprehensiveness and systematic implementation frameworks [21, 23,24,25].

There are major gaps in the current training system for occupational exposure prevention. Firstly, several institutions still emphasize theory in their protective training courses, neglecting simulation training, which leads to students lacking practical ability for real-world exposure risks [25]. Second, some medical schools have not introduced the prevention of occupational exposures into their required curriculum systems, resulting in little protective awareness among students and a lack of preparation for exposure-related difficulties [10, 26]. In addition, quality assurance and delivery of content vary significantly among training programs offered in different institutions giving rise to variable quality in the learning outcomes [27]– [28].

In health care, exposure prevention typically relies on a five-tiered hierarchy of controls: elimination, substitution, engineering controls, administrative controls, and personal protective equipment (PPE) [29]. Given that the majority of blood-borne pathogen occupational exposures are preventable [30]– [31], establishing a competency-based prevention framework that incorporates evidence-based practices within clinical contexts is not just an urgent requirement to ensure the occupational safety of medical students, but also a vital measure to enhance medical education frameworks and minimize healthcare expenditures. This study develops a three-tier prevention framework (primary, secondary, and tertiary prevention) for blood-borne pathogen occupational exposures among medical students, grounded in the hierarchy of controls principles from the National Institute for Occupational Safety and Health (NIOSH). This competency-based framework addresses critical gaps in current guidelines and provides key insights for global standardization of medical education in this field.

Methods

We established the framework using a two-phase approach. In the first phase, we carried out an extensive literature review to systematically extract the core elements of blood-borne pathogen occupational exposures prevention measures. In the second phase, we constructed an initial framework for preventing blood-borne pathogen occupational exposures among medical students. Then, through the Delphi method, experts’ professional insights and practical experiences were integrated to refine and optimize the framework.

Phase one: literature review

We conducted a literature review to identify the fundamental risk-factors and preventive measures associated with blood-borne pathogen occupational exposures. The search strategy, developed collaboratively by the authors and a research librarian, included an extensive search of four electronic databases: PubMed, Web of Science, Embase and the Cochrane Library, with the last search conducted on December 23, 2024.

The search included peer-reviewed English journal articles published from 2000 onwards and grey literature like institutional guidelines published by the WHO, CDC, and country-based health authorities. Search terms, combined with Boolean operators (AND/OR) were “blood-borne pathogens,” “medical students,” “clinical internship,” “occupational exposure,” “needlestick injury,” “nosocomial infection” and “infection prevention.”

An independent literature selection protocol by dual-reviewers was applied. First, researchers LV and XQ eliminated duplicate articles using EndNote software and non-research articles such as conference abstracts, opinion pieces, and correspondence based on title/abstract review. Next, the full-text assessment of the remaining articles was performed by researchers WPP and CMH.

To ensure comprehensive coverage of potential effective measures, this study focuses on identifying prevention and control strategies rather than evaluating their methodological quality. To this end, a tailored structured data extraction form was developed including four domains: study characteristics (authors/publication year/country/design type), sample features (target population/sample size), core findings (risk factors/preventive measures), and outcome indicators (exposure incidence/intervention efficacy).

Phase two: Delphi method

A modified Delphi method was employed to establish consensus on the blood-borne pathogen occupational exposures prevention framework for medical students, incorporating analytical findings from the literature review. This approach is widely adopted in medical education and healthcare research [32]. The multidisciplinary expert panel conducted two iterative rounds of review based on the preliminary framework proposed by the research team. Final framework content was rigorously refined and finalized by the research team following expert feedback. The Delphi consensus process spanned January to March 2025.

Expert Panel: The selection of an expert panel is very important because the results of the Delphi survey depend critically on expert knowledge, opinions, and intuition [33]. To guarantee diversity and representation, experts were carefully selected from multiple relevant fields, involving hospital infection prevention and control, clinical medicine, nursing, scientific research, microbiology, public health, and education. Potential members were identified based on their research areas and authoritative medical society recommendations. The inclusion criteria for experts were: (1) bachelor’s degree or above, (2) professional title of associate senior level or higher, and (3) ≥ 10 years of work experience. As Delphi studies typically require 10–50 participants for reliable results [34]– [35], the research team ultimately identified and invited 35 qualified potential experts to participate via email. All participants were recruited from tertiary hospitals in China, with complete anonymity maintained among experts-only study objectives were disclosed. Additionally, no form of remuneration was provided to participants.

Delphi procedure: Researchers compiled a master list of key items based on the literature review. A structured questionnaire containing these items was electronically distributed to experts via encrypted email platforms. Experts independently rated the relevance of each item for inclusion in the blood-borne pathogen occupational exposures prevention framework using a 5-point Likert scale (5 = very important, 4 = important, 3 = neutral, 2 = less important, 1 = unimportant). During the first-round survey, experts could propose additional topics through open-ended comments, which were subsequently entered into the second-round questionnaire. In the second round, experts received feedback on the previous round’s item-level ratings. Each survey round remained open for three weeks, with reminder emails sent after two weeks if responses were outstanding. Additionally, three experts in the fields of hospital infection prevention and control, medical education, and public health evaluated the face and content validity of the survey instrument.

Data analysis: Descriptive statistical methods were applied to analyze Delphi study outcomes, with a predefined consensus threshold of 70% established for item inclusion [36]. During the first-round filtration, items receiving ratings of 4 (“important”) or 5 (“very important”) from ≥ 70% of respondents were immediately included, while those with < 50% endorsement (ratings 4/5) were excluded; items attaining 50–69% endorsement, alongside newly proposed topics from open-ended responses, advanced to the second-round adjudication. In the subsequent round, previously included items were exempt from re-rating, and final inclusion required ≥ 70% endorsement of remaining items, with all non-consensus items permanently excluded. This tiered approach ensured methodological rigor while maintaining responsiveness to expert input through iterative refinement of the blood-borne pathogen occupational exposures prevention framework.

Ethical considerations

This study was approved by the ethics committee of Sichuan Provincial People’s Hospital (approval no.309 of 2025). Written informed consent was obtained from all participants, whose confidentiality was preserved.

Results

Literature review

The multi-phase screening protocol yielded 1,477 initial records, with 1,012 duplicates systematically removed using EndNote’s automated deduplication function. Subsequent title/abstract screening of 465 unique records excluded 37 publications irrelevant to the research scope. During full-text evaluation, 176 non-research publications (including conference abstracts, commentaries, letters, and unavailable full texts) and 52 non-English publications were excluded, culminating in 200 eligible articles for in-depth analysis. Figure 1 illustrates the detailed literature search process and results. Through iterative content synthesis, the research team extracted critical evidence regarding blood-borne pathogen occupational exposures prevention. This informed structured discussion sessions among principal investigators, ultimately generating a provisional prevention framework for medical students, which served as the foundational structure for the subsequent Delphi consensus process.

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Delphi method

A total of 35 professionals were initially invited via email, with six non-respondents and four declined participation, resulting in 25 experts completing the first Delphi round (71.43% response rate) and 23 participants retained in the second round (65.71% retention rate) after two attrition cases, as detailed demographically in Table 1.

The first Delphi questionnaire comprised fifteen items, with post-first-round analysis revealing eight items advancing directly to the second round, two revised based on expert feedback, five eliminated due to < 50% consensus, and four novel items added through open-ended suggestions. Consequently, the second-round questionnaire contained six items, with final analysis demonstrating one revised item achieving inclusion threshold and all four newly proposed items attaining ≥ 70% consensus. Through systematic synthesis of these outcomes (Table 2), the research team finalized a competency-based framework for medical students’ blood-borne pathogen occupational exposures prevention, integrating evidence from both Delphi iterations.

Main text of framework

The final framework comprises 13 actionable elements, stratified across prevention tiers: primary prevention (7 items), secondary prevention (4 items), and tertiary prevention (2 items) (Fig. 2).

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The operational implementation details of each tier are systematically outlined in Table 3. Selected framework elements align with four NIOSH hierarchy of controls dimensions: substitution, engineering controls, administrative controls, and PPE (Fig. 3). As complete elimination of blood-borne pathogen occupational exposures exceeds medical students’ capacity, the framework is not included in this most effective level of control.

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Primary prevention 1: receive occupational exposure training

Knowledge of occupational exposure significantly affects attitudes and practices [37,38,39], while concurrently increasing the risk of exposure [11, 40]. Thus, students should receive comprehensive training for occupational exposure before their internships. The training will provide them with crucial skills and knowledge, not only to avoid the dangers of exposure but to form appropriate safety habits that they can carry throughout their careers [41]. The core components of the training are given as follows:

*

Enhancing occupational safety awareness: Decreased observer acuity in hazard recognition is one of the main modifiable risk factors for occupational exposure events. By enhancing safety awareness, students become more vigilant during any medical activity in their internships. This increased awareness leads to compliance with safe practices, emphasis on protection, and heightened vigilance, all of which significantly reduce the risk of occupational exposures [10, 42].

*

Acquiring knowledge related to blood-borne pathogen occupational exposures: Educational programs should equip medical students with the foundational knowledge of common blood-borne pathogens and the associated risk, common occupational exposure situations in different forms of the health workforce, and essential knowledge of pre-exposure prevention and post-exposure management [1, 43].

*

Conducting simulated occupational exposure training: For high-risk procedures (e.g., surgical suturing), Artificial Intelligence (AI) enhanced simulation training with embedded exposure scenarios may be implemented [44,45,46]. Such simulation-based training enables the collection of possible mistakes and related improvement experiences, improving their abilities to handle occupational exposure events when needed [2, 25, 47].

Primary prevention 2: implement immunization

Vaccination is a key measure to protect HCWs from infection [48]– [49]. Currently, only HBV among blood-borne viruses has a preventive vaccine [50]– [51], while vaccines for HCV and HIV are still under development [21, 52]. The introduction of safe and effective hepatitis B vaccines on a massive scale since the 1980s has resulted in a substantial decrease in the rates of HBV infection and a parallel decline in HCWs’ susceptibility to HBV infection in many countries [53]– [54]. Consequently, the Occupational Safety and Health Administration (OSHA) suggests offering free hepatitis B vaccines to all HCWs with a risk of occupational exposure during patient care [55]. In 2006, the CDC also strongly recommended that HCWs, including medical students, be vaccinated for hepatitis B due to their potential exposure to blood-borne pathogens [56]. Given the high exposure risk during clinical internship, it is advisable for all students to complete hepatitis B vaccination before internship to ensure strong immunity at the beginning of their professional career [57]– [58].

However, it is important to note that not all individuals respond to vaccination. Approximately 5–10% of adults fail to mount an immune response to the standard hepatitis B vaccination series [59]. Therefore, it is essential to monitor the hepatitis B surface antibody (anti-HBs) response following vaccination [60]– [61]. Guidelines recommend testing HCWs for their anti-HBs levels 1–2 months after receiving the final dose of the vaccine to identify those who, despite vaccination, have not achieved protection against HBV infection [62]– [63]. An anti-HBs titer greater than 10 mIU/ml is generally considered protective [62]. If the vaccinee shows no antibody response (i.e., negative or anti-HBs level < 10 mIU/ml), additional hepatitis B vaccine doses (three more) should be administered, followed by retesting. Those who remain non-responders are at increased risk for HBV infection and should undergo regular screening or be tested after significant exposure [64].

Primary prevention 3: fatigue management

During the demanding schedule of clinical internships, medical students often face the expectation of extended working hours. While such high-intensity and high-density training is crucial for consolidating medical knowledge, prolonged work can lead to reduced memory and attention, as well as increased fatigue [65,66,67]. Fatigue elevates occupational exposure risks by impairing judgment, technical skills, and protective awareness, consequently increasing susceptibility to bloodborne pathogen infections [68].– [69]. Therefore, it is essential for interns to manage fatigue proactively and adopt strategies to mitigate its effects. Evidence-based fatigue mitigation can be achieved through Fatigue Risk Management System (FRMS), which constitutes a data-driven framework for identifying and mitigating fatigue-related safety risks [70]. The system deploys interventions across organizational policies, cultural norms, and individual behaviors [71]. For medical students, the following fatigue management strategies may be adopted:

*

Fatigue recognition: Characteristic symptoms include prolonged reaction time, diminished attention to detail, impaired problem-solving capacity, reduced energy/motivation, and increased inadvertent errors [72]– [73]. Fatigue assessment and fatigue mitigation strategies should be implemented upon recognition of these symptoms.

*

Fatigue assessment: The Occupational Fatigue Exhaustion Recovery scale (OFER) [74]– [75] and the Fatigue Assessment Scale (FAS) [76] may be utilized to quantify fatigue severity. These instruments enable medical students to objectively evaluate their fatigue patterns, facilitating the development of personalized fatigue management protocols.

*

Fatigue mitigation strategies: Evidence-based strategies encompass both preventive and reactive approaches [77]. These strategies are implemented through work and lifestyle interventions. Under conditions where workload modification is unfeasible, implementing structured work plans with optimized time management strategies can significantly enhance operational efficiency [78]. Concurrently, integrating scheduled napping into daily routines and utilizing brief rest periods during shifts are evidence-based approaches [71, 79]. Balanced dietary intake remains essential for sustaining metabolic demands during extended rotations [80], while regular physical exercise demonstrably improves systemic fatigue resistance [81].

Primary prevention 4: pre-exposure risk assessment

Occupational hygiene practice requires the anticipation, recognition, evaluation, and control of exposure to health hazards in the workplace [82]. Inexperienced interns must prioritize accurate assessment of occupational exposure risks and implementation of control measures. Prior to conducting any medical procedure, attention should be directed to the following four critical dimensions:

*

Self-competence assessment [83]: Required for interns to be able to evaluate their own proficiency and knowledge of the procedures they will perform. If in doubt, they ought to follow their instructors for complex operations such as venous catheterization or wound suturing. Unprepared rushes increase the risk of errors and occupational exposures.

*

Patient assessment [84]: Before contacting patients, the interns should familiarize themselves with patients’ medical histories, infectious status, and risk of transmission. For patients with confirmed HBV, HCV, or HIV infections, appropriate PPE must be donned and safety-engineered needles selected when performing procedures. Finally, special consideration must be made to the patient’s emotional state, using appropriate communication skills, or sedation if anxiety, fear, agitation, or non-compliance are present.

*

Environmental assessment [43, 85]: The safety of the procedural environment should not be overlooked. In high-risk areas, such as operating rooms and emergency departments, interns are mandated to thoroughly familiarize themselves with the environmental layout and the protocols for managing medical waste to prevent occupational exposure due to environmental factors. When confronted with challenging working conditions, characterized by overcrowding and noise, interns must consistently maintain an unwavering level of focus and vigilance.

*

Procedure risk assessment [43, 86]: Certain procedures, such as venous catheterization and surgical assistance, inherently pose higher risks for percutaneous injuries. Prior to performing these procedures, interns must select safety-engineered needles to prevent avoidable occupational exposure. The efficacy of safety-engineered needles in reducing percutaneous injuries has been documented in the literature [87].

According to NIOSH hierarchy of controls, safety-engineered needles represent an implementation of the substitution, wherein hazardous conventional equipment is replaced with technologically advanced alternatives. Consulting supervisors, enhancing communication protocols, and maintaining heightened attentiveness constitute administrative controls that modify work practices through procedural interventions and behavioral modifications. PPE forms the last barrier in the control hierarchy. Once high-risk factors are identified, interns must implement corresponding controls to prevent exposure based on their efficacy tier or deploy them in combination.

Primary prevention 5: standard precautions

To effectively protect HCWs from the risks associated with occupational exposure, the CDC has developed Standard Precautions (SP) [88]. The core principle of SP is the understanding that a patient’s blood, body fluids (except sweat), secretions, non-intact skin, and mucous membranes can all potentially carry infectious agents. In response to this, a comprehensive set of protective measures has been established to prevent occupational exposure to these infectious hazards [89]. For interns, it is crucial to understand and master the following SP:

*

PPE utilization [90]: The appropriate use of PPE, such as masks, gloves, goggles, face shields, and gowns, should be guided by the potential risk of exposure.

1. (1)

Gloves: It is imperative to wear gloves when coming into contact with patients’ blood, body fluids, secretions, excretions, as well as damaged skin or mucous membranes. Gloves must be changed between different patients or when switching between different body parts of the same patient to avoid cross-contamination. Handwashing or disinfection should be performed after glove removal.

2. (2)

Masks: In scenarios where there is a likelihood of exposure to patients’ respiratory droplets, blood, and body fluids, medical or surgical masks should be worn as a protective measure.

3. (3)

Goggles and face shields: To safeguard against the risk of blood or body fluids splashing onto the face, goggles or face shields should be worn as necessary.

4. (4)

Gowns: When handling infectious blood, secretions, exudates, splashed water, and substantial quantities of infectious materials, gowns should be worn to provide an additional layer of protection.

*

Safe injectionMedical and sharps injury prevention [91]: During invasive procedures, the use of safety-engineered needles is mandatory to prevent sharps injuries. Through special designs, such as automatic retractable features or protective devices, they can significantly reduce the risk of percutaneous injuries during the procedure [87].

*

Medical waste management [92]: Proper classification and handling of medical waste are crucial to reduce occupational exposure risks. All items must be collected according to set standards. Upon completion of their use, needles and other sharps should be immediately disposed of in puncture-resistant, leak-proof sharps containers. Re-sheathing of needles and direct manual handling of used needles, blades, and other sharps are strictly prohibited.

Primary prevention 6: standard operating procedures

Irregular or unreasonable operations increase occupational exposure risks [93]– [94]. So, interns must strictly follow Standard Operating Procedures (SOPs) [95]. These procedures are developed based on professional knowledge and practical experience [31, 96], mainly to reduce hazards and ensure safety. Due to the significant variations in SOPs that exist across different clinical specialties, interns must familiarize themselves with and diligently follow the specific procedures of each department during rotations [19, 97].

Primary prevention 7: enhance professional skills

Interns with weak skills are more prone to occupational exposure [27, 98], especially during early internships [6]. At this stage, they lack experience and are unfamiliar with procedures, leading to accidental contact from mistakes. Yet, as their clinical skills improve over time, the risk of accidental exposure decreases significantly [99]– [100].

During clinical internships, interns should actively learn by focusing on skill development [37, 101]. First, they must be observant, attentive, and curious, closely linking theory with practice. For example, when doing complex tasks, observing instructors’ correct methods, learning key steps, and practicing to improve can help. Second, interns should use all available resources such as training centers, online courses, and medical books to build their professional competence. Through repeated practice and simulations [22], they can enhance their skills and reduce errors that cause exposure.

Secondary prevention 1: emergency response

Following occupational exposure, emergency treatment must be swiftly administered to the exposed area to diminish the potential risk of blood-borne pathogen infection [102]. Vigorous washing with soap and water remains the cornerstone of post-exposure management. Specific protocols should be implemented as outlined in the CDC guidelines for managing occupational exposures to HBV, HCV, and HIV [4].

Secondary prevention 2: proactively report

Underreporting rates of occupational exposures among interns range from 22 to 75%, with primary contributing factors including: incidents being forgotten, underestimation of risk, reluctance to acknowledge gaps in procedural competence, avoidance of logistical burdens from reporting and follow-up, and fear of positive seroconversion test results [1]. Such underreporting may delay medical care, prophylactic treatment, and workers’ compensation claims [103]. Therefore, timely reporting of occupational exposures is important for effective post-exposure prophylaxis (PEP) and optimal clinical management [104].

Interns must be aware that proactive reporting will not result in punishment or have a negative impact on their academic mark. Conversely, not reporting could be considered unprofessional behavior [105]. Interns should receive comprehensive training on the reporting procedures during their pre-internship orientation to ensure they are fully capable of following the process correctly. Reports should include the following details: the exact time and location of the exposure, a detailed description of the incident, depth of injury, estimated exposure volume, and information about the source (HBV, HCV, or HIV infection). If the source is HIV-positive, information on the HIV disease stage, antiretroviral therapy history, viral load, and antiretroviral drug resistance profile must be collected [106]. Also, the report should include relevant details about the exposed intern, such as their hepatitis B vaccination status and vaccine responsiveness.

Secondary prevention 3: accept evaluation

Exposed interns should not assess risks by themselves. Instead, they should be evaluated by healthcare professionals after reporting [63, 107]. These professionals will assess the likelihood of HBV, HCV, and HIV transmission based on the type and severity of exposure, the infectious status of the exposure source, and the baseline immune status of the exposed individual. Then, they will provide expert recommendations, including the necessity for prophylactic medications and subsequent follow-up measures [106].

Secondary prevention 4: prophylactic medication

Based on a full evaluation by healthcare professionals, those at high risk of HBV or HIV infection after exposure should promptly initiate PEP. PEP has been proven to significantly reduce the risk of HBV and HIV infections, with reported efficacy rates of 85–95% for HBV and approximately 81% for HIV [104]. However, there are no effective prophylactic measures to prevent HCV infection [108]. For specific chemoprophylaxis regimens, refer to the most current CDC guidelines [4].

Tertiary prevention 1: regular follow-up

Research indicates that many interns lack a proper understanding of the importance of follow-up measures, which leads to poor adherence to post-exposure follow-up protocols. Inadequate follow-up can result in undetected infections, posing risks to the intern’s health [1]. Studies have shown that the effectiveness of post-exposure treatment is directly linked to completing follow-up protocols [109]. Therefore, all interns who have been exposed to blood-borne pathogens should undergo follow-up testing, counseling, and medical evaluations at the intervals recommended by established guidelines [4, 110].

Tertiary prevention 2: psychological adjustment

Accidentally exposing oneself to blood-borne pathogens can cause significant psychological sequelae, especially in interns, with the most common being depression, anxiety, fear and increased stress [51]. These psychological problems can immediately affect their mental health and in more severe cases, negatively impact in the long term on their career track, quality of daily life, physical and mental health [15].

Interns with such psychological issues should not belittle their gravity. Rather, they must take the step of entering into professional counseling and psychological support [111]. Support is available through university counseling services, licensed mental health professionals and employee assistance programs (EAPs) sponsored by their organizations. Interns can discuss their emotional concerns and receive personalized guidance and support through one-on-one sessions with professional counselors. Studies indicate that early psychological intervention plays an essential role in helping interns enhance emotional regulation and facilitating their reintegration into social and professional settings.

Strengths and limitations

Strengths: The literature review built a theoretical basis due to synthesis of empirical evidence from multi-center studies undertaken across healthcare settings, thus deriving an adaptable frame of context. The Delphi process enhances the operational feasibility of the framework by incorporating expert insights, particularly with regards to real-life clinical training environments. An innovative dual-evidence approach, drawing from academic literature and practitioner know-how, produced an actionable framework to prevent blood-borne exposures among medical students.

Limitations: First, the focus on English-language articles and field-specific databases may introduce bias in publication. Second, the lack of standardized quality assessment for included literature adds uncertainty in terms of evidence robustness. Third, the recruitment of participants confined to Chinese tertiary hospitals may have resulted in geographical and institutional bias, with caution needed when generalizing findings to other countries with different healthcare systems. Finally, the framework should be empirically validated through longitudinal implementation studies to quantify its impact on exposure reduction and compliance improvement.

Conclusion

Blood-borne pathogen occupational exposures pose significant hazards to medical students during clinical internships, with potentially significant implications for their health and career. This study provides the first competency-based framework for medical students to prevent blood-borne pathogen occupational exposures during their internships. The framework, informed by evidence-based strategies in conjunction with expert consensus, is a significant step forward in ensuring occupational safety of medical students.

This framework’s preventive measures (primary, secondary, and tertiary prevention) encompass the full continuum of exposure management, including pre-internship preparation, pre-exposure prevention, and post-exposure management. Pre-internship preparation, including occupational exposure training and immunization, provides medical students with a strong foundation of knowledge and skills needed to shield themselves from blood-borne pathogens. Pre-exposure prevention strategies, such as avoiding fatigue, conducting risk assessments, adhering to standard precautions, following standard operating procedures, and enhancing professional skills, further reduce the likelihood of occupational exposures. In the event of unfortunate exposure, appropriate post-exposure management including emergency response, reporting, evaluation, prophylactic medication, and regular follow-up as well as psychological adjustment should not be ignored so as to minimize the risk of infection and emotional impact.

Through synergistic integration of theoretical knowledge with practical implementation, this framework serves to medical students with the skills to deal with an increasingly complex, high-acuity clinical environment with confidence and safety. Incorporating it into medical curricula could create a culture of proactive safety awareness and ultimately reduce the number of exposure incidents and improve overall readiness in the healthcare workforce of the future.

Future steps should prioritize multi-center validation across diverse healthcare settings to assess the framework’s adaptability, with special emphasis on resource-constrained environments. Longitudinal studies following compliance and exposure rates after implementation will further refine its accuracy. Educators and institutions are urged to embrace this guidance, ensuring that the next generation of clinicians is equipped to protect themselves from blood-borne pathogen occupational exposures.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

HBV:

Hepatitis B virus

HCV:

Hepatitis C virus

HIV:

Human immunodeficiency virus

WHO:

World Health Organization

CDC:

Centers for Disease Control and Prevention

HCWs:

Healthcare workers

PPE:

Personal protective equipment

NIOSH:

National Institute for Occupational Safety and Health

AI:

Artificial Intelligence

OSHA:

Occupational Safety and Health Administration

anti-HBs:

Hepatitis B surface antibody

FRMS:

Fatigue Risk Management System

OFER:

Occupational Fatigue Exhaustion Recovery scale

FAS:

Fatigue Assessment Scale

SP:

Standard Precautions

SOPs:

Standard Operating Procedures

PEP:

Post-exposure prophylaxis

EAPs:

Employee assistance programs

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