Role of saliva, urine and feces in the transmission of type B hepatitis

Health workers vaccination: Experience and lessons learned from Costa Rica

Objective

To describe the decision-making processes, enablers, challenges and lessons learned in Costa Rica for implementing a sustained and multi-pronged approach in health workers vaccination (HW).

Methods

A retrospective descriptive analysis was conducted by searching published and grey literature, including scientific publications, legislation, decrees, policies, manuals, technical reports, and platforms used for data register and coverage monitoring. Key informants from the Ministry of Health (MoH), the Costa Rican Social Security Fund (CCSS) were interviewed representing national, subnational and local levels; as well as members of the National Technical Advisory Group (NITAG) and the private sector. Collected data were transcribed and categorized by the following specific topics using a thematic content analysis approach: decision making process, pre-service screening, vaccination for current HWs and engagement with the private sector. Major findings were discussed and organized into enablers, challenges and lessons learned.

Results

Decision making processes to establish the vaccination strategies and schedules in Costa Rica were based on the epidemiological trends of vaccine-preventable diseases (VPDs) and cost analysis. Risk assessment and feasibility considerations determined that some vaccines such as hepatitis B, varicella and influenza, were first introduced in HWs and then were expanded to other target populations. These decisions were approved by the NITAG as the advisory technical advisory group of the MoH. Main enablers identified were: high level and sustained political will, decisions based on data analysis and feasibility considerations, HWs knowledge and high vaccine acceptance and demand. Challenges were related to effective coverage monitoring, and private sector engagement.

Conclusions

The Costa Rican experience provides lessons learned that can be leveraged by other countries to strengthen HWs vaccination strategies at regional and global levels.

Transmission of Infections during Cardiopulmonary Resuscitation

Cardiopulmonary resuscitation (CPR) is an emergency lifesaving endeavor, performed in either the hospital or outpatient settings, that significantly improves outcomes and survival rates when performed in a timely fashion. As with any other medical procedure, CPR can bear potential risks not only for the patient but also for the rescuer. Among those risks, transmission of an infectious agent has been one of the most compelling triggers of reluctance to perform CPR among providers. The concern for transmission of an infection from the resuscitated subject may impede prompt initiation and implementation of CPR, compromising survival rates and neurological outcomes of the patients. Infections during CPR can be potentially acquired through airborne, droplet, contact, or hematogenous transmission. However, only a few cases of infection transmission have been actually reported globally. In this review, we present the available epidemiological findings on transmission of different pathogens during CPR and data on reluctance of health care workers to perform CPR. We also outline the levels of personal protective equipment and other protective measures according to potential infectious hazards that providers are potentially exposed to during CPR and summarize current guidelines on protection of CPR providers from international societies and stakeholders.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Pregnancy and maternal chronic hepatitis B infection-Evidence of reproductive advantage?

PROBLEM

As multiparas have high prevalence of chronic hepatitis B virus (HBV) infection, we examined here the relationship between the number of pregnancies with HBV infection.

METHOD OF STUDY

Retrospective cohort study examining the prevalence of HBV infection by actual gravidity and parity in 104 242 gravidae managed during 1997-2013.

RESULTS

Infection rate increased from 8.5% to 10.6% for G1 to G≥6 and from 8.8% to 10.0% for P0 to P≥3 (P<.001). When stratified by parity, correlation with gravidity was maintained in the nulliparous gravidae. For the same gravidity, increasing parity was associated with higher rate of HBV infection for G2 and G3. Multiparas had higher HBV infection prevalence (all >10%) than nulliparas (<10%) for G2 to G≥4.

CONCLUSION

Prior pregnancies, especially successful ones, are associated with increased HBV infection in an endemic population, which could have enhanced reproduction and in the process facilitated its transmission to the following generations.

The Role of Body Fluids in the Horizontal Transmission of Hepatitis B Virus via Household/Close Contact

Hepatitis B virus (HBV) infection commonly occurs through horizontal transmission via household/close contact. Although the body fluids of patients infected with HBV are likely to play a significant role in horizontal transmission, the precise mechanism remains unclear. In the 1970s, the infectivity of body fluids including saliva, urine, and faeces was assessed for the presence of hepatitis B surface antigen (HBsAg). Over the last decade, the HBV DNA in the body fluids of chronically infected patients was quantified using real-time polymerase chain reaction. Chimpanzee, gibbon, and chimeric mice with human livers have also been used to investigate the infectivity of body fluids. HBsAg levels, HBV DNA levels, and animal experiments have indicated that saliva and tears are able to transmit HBV. Urine and faeces do not lead to horizontal transmission. The infectivity of the remaining body fluids remains controversial. Horizontal transmission is related to both virus and host factors; thus, evaluations of HBsAg and HBV DNA levels provide insufficient data to determine the infectivity of body fluids. Universal hepatitis B vaccination has been implemented worldwide (with the exception of Northern Europe); an understanding of the role that body fluids play in horizontal transmission will contribute to the eradication of HBV.

Lack of infectivity of HBV in feces from patients with chronic hepatitis B virus infection, and infection using chimeric mice

BACKGROUND

Body fluids such as saliva and tears from patients with hepatitis B virus (HBV) infection are known as infectious agents. The infectivity of feces from patients with HBV infection has not been established. The aim of this study was to determine whether feces from HBV carriers can be a source of HBV infection.

METHODS

Thirty-three children and 17 adults (ages 0-49 years, median age 13 years) who were chronically infected with HBV were enrolled. The levels of HBV DNA in the feces from these patients were quantified by real-time PCR, and the levels of fecal HBsAg were measured. Isolated human hepatocytes from chimeric mice with humanized livers were co-cultured with serum, tears and feces from the HBV carriers. Four chimeric mice were inoculated intravenously with sterilized feces from HBV carriers.

RESULTS

HBV DNA was detected in the feces of 37 (74%) of the 50 patients. The fecal HBV DNA levels ranged from 2.8 to 8.4 log copies/mL (mean ± SD  =  5.6 ± 1.2 log copies/mL). A significant correlation was observed in the levels of HBV DNA between serum and feces (r  =  0.54, p < 0.05). Of the 13 HBV carries, 7 (54%) were positive for fecal HBsAg. The fecal HBsAg levels ranged from 0.06 to 1.0 IU/mL (median 0.28 IU/mL). Immunogold electron microscopy showed Dane particles in feces. HBV DNA was detected in the human hepatocytes co-cultured with serum and tears, but not in those co-cultured with feces. HBV DNA was not detected in the serum of the chimeric mice after oral or intravenous inoculation with sterilized fecal samples, which contained 5 log copies/mL of HBV DNA levels.

CONCLUSIONS

Although the positive rate of fecal HBV DNA was high, the fecal HBsAg levels were extremely low. The chimeric mice were not infected with HBV after oral or intravenous inoculation with sterilized fecal samples. Therefore, feces from HBV carriers seem not to serve as an infectious vehicle for the transmission of HBV.

Prevalence of Hepatitis B surface antigen in dental personnel

Context:

Hepatitis B, a viral disease affecting the liver has high morbidity and mortality. Hepatitis B surface antigen (HBsAg) in serum is used to detect presence of active disease and chronic carrier status. The disease is transmitted predominantly through blood and saliva, hence dental professionals are considered a high risk group.

Aim:

To detect presence of HBsAg in serum of dental professionals.

Subjects and Methods:

The study was conducted in two parts viz., one in the year 1991 on 100 dental professionals in Nagpur using reverse passive hemagglutination and the other in 2012 on 50 dental professionals in Chennai using immunochromatography.

Results:

Ten percent of dental professionals screened in 1991 and 2% of dental professionals screened in 2012 showed HBsAg positive status and were predominantly periodontists with a history of needle-stick injury.

Conclusion:

This study highlights the importance of Hepatitis B vaccination and periodic evaluation of antibody titer to prevent spread of the disease.

Age-specific prevalence of hepatitis B virus infection in young pregnant women, Hong Kong Special Administrative Region of China

Objective

To investigate the age-specific prevalence of hepatitis B virus (HBV) infection in young pregnant women in Hong Kong Special Administrative Region (SAR), China, and to determine whether an increase in prevalence occurs during adolescence.

Methods

HBV prevalence was quantified using data from routine antenatal screening for hepatitis B surface antigen (HBsAg) in 10 808 women aged 25 years or younger born in Hong Kong SAR and managed at a single hospital between 1998 and 2011. The effect on prevalence of maternal age, parity and birth before or after HBV vaccine availability in 1984 was assessed, using Spearman’s correlation and multiple logistic regression analysis.

Findings

Overall, 7.5% of women were HBsAg-positive. The prevalence ranged from 2.3% to 8.4% in those aged ≤ 16 and 23 years, respectively. Women born in or after 1984 and those younger than 18 years of age were less likely to be HBsAg-positive (odds ratio, OR: 0.679; 95% confidence interval, CI: 0.578–0.797) and (OR: 0.311; 95% CI: 0.160–0.604), respectively. For women born before 1984, there was no association between HBsAg carriage and being younger than 18 years of age (OR: 0.60; 95% CI: 0.262–1.370) Logistic regression analysis showed that the prevalence of HBsAg carriage was influenced more by the woman being 18 years old or older (adjusted OR, aOR: 2.80; 95% CI: 1.46–5.47) than being born before 1984 (aOR: 1.42; 95% CI: 1.21–1.67).

Conclusion

Immunity to HBV in young pregnant women who had been vaccinated as neonates decreased in late adolescence.

Relationship between age and prevalence of hepatitis B infection in first-year university students in Hong Kong

PURPOSE

To determine the effect of age on the prevalence of hepatitis B virus (HBV) infection during a routine screening programme of first-year students enrolled in Health Sciences Studies at the Chinese University of Hong Kong from 2001 to 2009.

METHODS

In a retrospective cohort study, data on the hepatitis B surface antigen (HBsAg) status was retrieved from the University Health Service and analysed according to the age of the student at testing and year of birth.

RESULTS

Of the 2,688 students enrolled in the study group, 79 (2.9 %) tested positive for HBsAg. The prevalence increased significantly from 0.9, 2.3, 4.3 to 5.5 % for those tested at age ≤ 18, 19, 20 and ≥ 21 years, respectively (p < 0.001). On logistic regression analysis, taking age ≤ 18 years and year of birth before 1983 (before the availability of HBV vaccination) as the reference group, HBV infection increased progressively with age, with an adjusted odds ratio of 3.36 [95 % confidence interval (CI) 1.01-11.23], 6.04 (95 % CI 1.74-20.98) and 11.61 (95 % CI 3.20-42.13) for age 19, 20 and ≥ 21 years, respectively. There was no significant change in the odds ratio after adjustment for the year of birth before and after introduction of the vaccination programme.

CONCLUSION

Among the university students enrolled in our study, the overall prevalence of HBV infection before and after the introduction of HBV vaccination was lower than the 10 % found in the general population. There was, however, a significant progressive increase with age at testing from ≤ 18 to ≥ 21 years, suggesting a previously overlooked contribution of horizontal transmission to the high prevalence of HBV infection found in our adult population.

Impact of neonatal hepatitis B vaccination programme on age-specific prevalence of hepatitis B infection in teenage mothers in Hong Kong

We examined the impact of the neonatal hepatitis B immunization programme, first provided to all neonates born to mothers screened positive for hepatitis B surface antigen (HBsAg) in late 1983, on the age-specific prevalence of HBsAg carriage in teenage mothers managed in 1998–2008. HBsAg carriage was found in 2.5%, 2.7%, 8.8% and 8.0% of mothers aged ≤ 16, 17, 18, and 19 years, respectively (P=0.004), which was also correlated with advancing age (P=0.011). While neither difference nor correlation with age was found in mothers born before 1984, the prevalence of 1.2%, 1.5%, 7.1% and 8.3%, respectively, was significantly different among (P=0.008) and correlated with (P=0.002) age in mothers born 1984 onwards. Regression analysis indicated there was a significantly higher incidence of HBsAg carriage from age 17 onwards (adjusted odds ratio 2.55, 95% confidence interval 1.07–6.10, P=0.035), suggesting that the protective effect of the vaccine declined in late adolescence.

Correlation between maternal hepatitis B surface antigen carrier status with social, medical and family factors in an endemic area: have we overlooked something?

PURPOSE

Hepatitis B virus (HBV) infection is endemic in many countries, but the risk factors for HBV carriage in the obstetric population are unclear.

METHODS

A survey on 1,580 women attending the antenatal clinic in an endemic region was conducted in order to examine the prevalence of and factors associated with maternal HBV carriage, including socio-demographic, medical, and previous obstetrical and family history, by means of a questionnaire.

RESULTS

The prevalence of maternal HBV carriage was 9.1%, and 4.8% of women with a history of hepatitis B vaccination were found to be HBV carriers. Factors associated with maternal HBV carriage were residency status (adjusted odds ratio [aOR] 3.65 for immigrants; aOR 7.62 for non-residents), positive family history (aOR 3.72 for infected mother; aOR 5.36 for other family members), no previous vaccination (aOR 4.39) and having previous HBsAg testing (aOR 2.26).

CONCLUSIONS

The findings suggest that there was probably an overlooked role of horizontal transmission within the family setting in addition to perinatal transmission in determining the likelihood of HBV infection in our obstetric population. Reconfirmation of hepatitis B status might be necessary among individuals with a history of vaccination to ensure the effectiveness of their immunoprotection.

Plasma gelsolin protein: a candidate biomarker for hepatitis B-associated liver cirrhosis identified by proteomic approach

BACKGROUND

Despite the significant improvement in internal medicine and supportive therapy in recent years, liver fibrosis/cirrhosis remains a serious health issue in hepatitis B virus (HBV) infected patients. Invasive liver biopsy is presently the best means of diagnosing cirrhosis, but it carries a significant risk and has well recognised limitations such as sampling error, hence the importance in developing early diagnosis biomarkers. With this aim, we performed a pilot proteomic study to assess this as a strategy for plasma marker detection in patients suffering from HBV-associated liver cirrhosis.

METHODS

Plasma from eight chronic HBV-infection patients and from eight HBV-related cirrhotic patients were selected and proteome profiles were created by two-dimensional electrophoresis. The strategy included the use of ProteoMiner enrichment kit for the reduction of highly abundance proteins (e.g. albumin and IgG) prior to proteomic analyses with the goal to improve detection of novel candidate markers.

RESULTS

One reproducible spot was found to be completely repressed in plasma samples from cirrhotic patients and mass spectrometry analysis identified this a specific variant of the gelsolin actin-depolymerizing factor. Though further investigations are needed, especially in term of clinical validation, to our knowledge this is the first time that gelsolin is proposed as potential biomarker in HBV-related liver pathologies.

CONCLUSIONS

Our findings confirm the potential utility of gelsolin either as a prognostic marker or a replacement therapeutic agent to alleviate liver injury.

Viral hepatitis transmission in ambulatory health care settings

In the United States, transmission of viral hepatitis from health care-related exposures is uncommon and primarily recognized in the context of outbreaks. Transmission is typically associated with unsafe injection practices, as exemplified by several recent outbreaks that occurred in ambulatory health care settings. To prevent transmission of bloodborne pathogens, health care workers must adhere to standard precautions and follow fundamental infection-control principles, including safe injection practices and appropriate aseptic techniques. These principles and practices need to be made explicit in institutional policies and reinforced through in-service education for all personnel involved in direct patient care, including those in ambulatory care settings. The effectiveness of these measures should be monitored as part of the oversight process. In addition, prompt reporting of suspected health care-related cases coupled with appropriate investigation and improved monitoring of surveillance data are needed to accurately characterize and prevent health care-related transmission of viral hepatitis.

Transmission and prevention of occupational infections in orthopaedic surgeons

Microorganisms are transmitted in hospitals mainly by contact, droplet, and airborne routes. Orthopaedic surgeons have a substantial occupational risk of contracting a blood-borne infection because of frequent handling of sharp instruments and objects during operative procedures. Aerosolization means the formation of aerosols and droplets when blood or other body fluids are mechanically disturbed. Smaller particles (<5 microm) will remain suspended in air. Pathogens that can survive in these small airborne particles may cause infection if they are inhaled. Aerosol-generating procedures in patients with tuberculosis or severe acute respiratory syndrome (SARS) may facilitate airborne transmission. The Hospital Infection Control Practices Advisory Committee and the Centers for Disease Control and Prevention have established guidelines for isolation precautions in hospitals.

Pharmacologic management of HIV/STD exposure

Emergency physicians must be familiar with management of occupational exposures to HIV-infected bodily fluids. Victims of sexual assault also may be exposed to HIV and other sexually transmitted diseases. The Centers for Disease Control and Prevention guidelines for the management of occupational exposures include recommendations for administration of combination antiretroviral therapy to reduce the risk for HIV transmission. Antiretroviral therapy also may be indicated for certain types of sexual exposure to HIV. Drugs that are used to treat sexually transmitted diseases also may be given to prevent infection after possible exposures. This article reviews current recommendations for prophylaxis against HIV and other sexually transmitted diseases and the scientific basis for these recommendations.

Risk and management of blood-borne infections in health care workers

Exposure to blood-borne pathogens poses a serious risk to health care workers (HCWs). We review the risk and management of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections in HCWs and also discuss current methods for preventing exposures and recommendations for postexposure prophylaxis. In the health care setting, blood-borne pathogen transmission occurs predominantly by percutaneous or mucosal exposure of workers to the blood or body fluids of infected patients. Prospective studies of HCWs have estimated that the average risk for HIV transmission after a percutaneous exposure is approximately 0.3%, the risk of HBV transmission is 6 to 30%, and the risk of HCV transmission is approximately 1.8%. To minimize the risk of blood-borne pathogen transmission from HCWs to patients, all HCWs should adhere to standard precautions, including the appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments. Employers should have in place a system that includes written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational exposures that may place a worker at risk of blood-borne pathogen infection. A sustained commitment to the occupational health of all HCWs will ensure maximum protection for HCWs and patients and the availability of optimal medical care for all who need it.

Risk and management of blood-borne infections in health care workers

Exposure to blood-borne pathogens poses a serious risk to health care workers (HCWs). We review the risk and management of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections in HCWs and also discuss current methods for preventing exposures and recommendations for postexposure prophylaxis. In the health care setting, blood-borne pathogen transmission occurs predominantly by percutaneous or mucosal exposure of workers to the blood or body fluids of infected patients. Prospective studies of HCWs have estimated that the average risk for HIV transmission after a percutaneous exposure is approximately 0.3%, the risk of HBV transmission is 6 to 30%, and the risk of HCV transmission is approximately 1.8%. To minimize the risk of blood-borne pathogen transmission from HCWs to patients, all HCWs should adhere to standard precautions, including the appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments. Employers should have in place a system that includes written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational exposures that may place a worker at risk of blood-borne pathogen infection. A sustained commitment to the occupational health of all HCWs will ensure maximum protection for HCWs and patients and the availability of optimal medical care for all who need it.

Intrafamilial transmission of hepatitis C virus: a systematic review

To examine the risk of hepatitis C virus (HCV) transmission between patients infected with HCV and their household members (siblings, offspring and parents), as well as their stable heterosexual partners, a systematic search of the MEDLINE database was undertaken for all relevant articles published up to June 1997. English language publications or those supplemented with an English abstract that reported studies concerning hepatitis C, and household, intrafamilial, sexual and intraspousal transmission of HCV, were reviewed. Data from uncontrolled and controlled studies were collected and analysed separately. Studies reporting the exclusive use of first-generation anti-HCV antibodies without supplemental tests were excluded. Pre- or postnatal mother-to-child transmission of HCV and homosexual and heterosexual transmission of HCV among non-permanent couples were not included. Unweighted data from individual studies were pooled for each category of family member. Data were also analysed separately for Japanese and non-Japanese studies because there is evidence that intrafamilial transmission may differ, based on endemicity of the viral infection. Comparisons were drawn only from controlled studies that reported the prevalence of HCV in family members of both HCV-positive and HCV-negative controls. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated for each family category. In uncontrolled studies, the pooled prevalence of anti-HCV among 4250 stable sexual contacts of patients with HCV-related chronic liver disease (CLD) was 13.48%, while the pooled prevalence of anti-HCV among 580 stable sexual contacts of patients who contracted HCV as a result of multiple transfusions was 2.41%. In controlled studies, the pooled prevalence of anti-HCV among 175 siblings and household contacts of patients with CLD was 4.0% compared with 0% among 109 contacts of anti-HCV-negative controls (OR 9.75, 95% CI 0.91 ad infinitum). The pooled prevalence of anti-HCV among offspring of Japanese HCV-infected CLD patients was 17% compared with 10.4% among offspring of HCV-negative Japanese controls (OR 1.77, 95% CI 1.21-2. 58, P=0.002). The pooled prevalence of anti-HCV among spouses of non-Japanese HCV-infected CLD patients was 15.2% compared with 0.9% in the spouses of non-Japanese HCV-negative controls (OR 20.57, 95% CI 6.05-84.08, P=0.0001). The prevalence of anti-HCV among non-Japanese offspring and Japanese spouses of HCV-infected patients was not increased compared with controls. HCV genotype homology and mutant analysis studies in pairs of HCV-infected patients and their HCV-infected contacts showed that concordant genotype homology was found in 66% of non-sexual contacts and in 74% of sexual contacts. Sequence homology of greater than 92% was found in 19 out of 35 pairs. Hence, evidence exists that familial, non-sexual and sexual transmission of HCV does occur. In Japanese patients, transmission probably occurs in younger family members while, in non-Japanese patients, transmission probably occurs at an older age, after contact with an HCV-infected spouse.

Decreased splatter in dermabrasion

OBJECTIVE

To compare a new dermabrasion instrument equipped with a metal shield and hydration-suction apparatus with the standard instrument, with specific attention to the exposure of operating room personnel to potentially hazardous particles.

DESIGN

A surgical trial with each of the instruments was performed with a skin model. The splatter caused by the 2 instruments was evaluated and compared statistically and graphically.

SUBJECTS

Female hairless guinea pigs (450 g) were used as a skin model.

INTERVENTIONS

Ten guinea pigs were treated with the standard dermabrading instrument, and 10 were treated with a shielded suction-irrigating dermabrader. The splatter was analyzed by counting the number of particles landing on strategically placed glass slides. Evaluations of histologic cross-sections of the dermabraded skin were compared in a blinded fashion.

RESULTS

Statistical and graphic analysis showed the number of potentially hazardous particles generated by the suction dermabrader to be significantly less than that generated by the standard dermabrader. Histologic sections showed no difference between the 2 subsets.

CONCLUSION

The new shielded suction-irrigating dermabrader provides comparable surgical results while significantly decreasing exposure to potentially hazardous splatter particles. Arch Facial Plast Surg. 2000;2:23-26

Emergency department management of blood and body fluid exposures

Exposure to blood and body fluids that may be contaminated with infectious agents is a common occupational hazard for health care workers. Health care workers in the emergency department or out-of-hospital setting are at especially high risk for exposure to blood or body fluids. Nonemergency health care workers are frequently referred to hospital EDs for immediate treatment of occupation exposures. A series of recommendations by the Centers for Disease Control and Prevention evolved over the past decade, and changes are expected to continue. This state-of the-art article reviews current recommendations for management of persons exposed to blood or body fluids and discusses the scientific basis for recommendations regarding hepatitis B virus, hepatitis C virus, and HIV.

Hepatitis G virus infection in a high-risk subgroup of hospitalized dental patients

OBJECTIVE

The prevalence of hepatitis G virus infection was evaluated in dental patients whose clinical laboratory test results were positive for hepatitis C virus antibody, hepatitis B virus surface antigen, or elevated serum alanine transaminase concentrations.

STUDY DESIGN

Frozen serum samples from patients with hepatitis C virus antibody (n = 63), hepatitis B virus surface antigen (n = 20), or alanine transaminase concentrations greater than 100 IU (n = 14) were assessed for GB virus C (GBV-C)/hepatitis G virus RNA by a reverse transcriptase-polymerase chain reaction.

RESULTS

Six of 63 patients with hepatitis C virus antibodies had serum hepatitis G virus RNA (9.5%), and 2 of 20 subjects with hepatitis B virus surface antigen had hepatitis G virus RNA (10.0%). None of 14 patients whose alanine transaminase concentration was greater than 100 IU/L had hepatitis G virus RNA. Of 4 subjects with both hepatitis C virus antibody and hepatitis B virus surface antigen, 2 had hepatitis G virus RNA (50%). In the total study population (N = 92), 6 subjects (6.5%) had hepatitis G virus RNA. All hepatitis G virus-infected patients also had hepatitis C virus antibody. Neither serum alanine transaminase nor aspartate transaminase concentrations were different between subjects with and subjects without hepatitis G virus RNA. The lack of a relationship between hepatitis G virus infection and elevation of alanine transaminase and aspartate transaminase might suggest that this virus is not truly a hepatitis virus.

CONCLUSIONS

Hospitalized dental patients are infected with hepatitis G virus at a prevalence similar to or slightly higher than that seen in the general population. Dentists should pay close attention to infection control with respect to the potential new hepatitis virus known as hepatitis G virus.

Hepatitis B markers in heterosexual patients attending two genitourinary medicine clinics in the West Midlands

OBJECTIVE

To determine the prevalence of hepatitis B virus (HBV) infection in heterosexual patients attending two genitourinary medicine (GUM) clinics in the West Midlands and to examine whether heterosexual activity is a risk factor for acquiring HBV infection with the view to extend HBV vaccination policies to cover this group.

DESIGN

HBV markers were determined in the GUM study group and compared with that of the control groups. Responses to a questionnaire were used to examine sexual behaviour patterns that may be related to heterosexual acquisition of HBV infection.

SETTING

The West Midlands, UK April 1992-January 1993.

SUBJECTS

788 male patients and 688 female patients attending GUM clinics were compared with 498 male blood donors and 563 females attending antenatal clinics for the seroprevalence of HBV markers. Potential risk factors related to heterosexual activity were assessed in 1436 patients in the study group.

MAIN OUTCOME MEASURES

Prevalence of HBV markers in the GUM study group and the controls. The possible use of the risk factors examined as predictors for acquiring HBV infection.

RESULTS

The seroprevalence of hepatitis B core antibody (anti-HBc) in GUM patients was 1.9% and 0.5% in the control group. In the study groups the prevalence of anti-HBc from Birmingham was 3.2% while that from Coventry was 0.8%. The low seroprevalence of HBV prevented a multiple logistic analysis. A limited regression analysis showed that being non-white (p < 0.001) and duration of sexual activity (p = 0.013) were risk factors for HBV infection. However, these two factors were poor predictors of the risk to exposure to HBV infection.

CONCLUSION

The prevalence of HBV infection in heterosexual patients in the West Midlands is very low and does not provide any indications to broaden HBV vaccination into heterosexual patients attending GUM clinics. Risk factors were poor predictors of the exposure to HBV infection. This is partially due to the low prevalence of HBV infection in this study. Further studies are required before definitive conclusions are made regarding the potential predictive value of risk factors.

Reducing bacterial aerosol contamination with a chlorhexidine gluconate pre-rinse

The authors compared the effects of chlorhexidine gluconate, an antiseptic mouthwash with essential oils and water on the bacterial aerosol contamination generated by an air polishing device. Patients rinsed with one of the three solutions before treatment. Bacterial counts collected during the treatment indicate that the chlorhexidine pretreatment rinse was significantly more effective than the other solutions in reducing bacterial aerosols.

Hepatitis B immunization in adolescents

This article reviews the epidemiology of hepatitis B in the United States, previous vaccination strategy, and reasons for its failure and issues leading to the recommendation to vaccinate all adolescents. A review of specific hepatitis B virus risk behaviors of adolescents and barriers to vaccinating adolescents is covered. Strategies that favor successful completion of the immunization series are also examined. Hepatitis B infection is an important public health concern for adolescents. The previous vaccine strategy to immunize only individuals though to be at high risk was unsuccessful, especially because providers of care could not identify these individuals. Furthermore, many individuals thought not to be at high risk for infection were exposed through contacts which could not be identified. Challenges to immunization of adolescents include logistical issues, patient education, cost of the vaccine, and patient compliance. Several of these issues can be addressed by a school-based hepatitis B immunization program. The body of evidence and national policy is rapidly changing to support the recommendation that all adolescents receive the hepatitis B immunization series. The series would be most effective if administered during the middle-school years. A universal adolescent hepatitis B vaccination program would result in the most immediate health benefits and acceleration toward the eradication of hepatitis B in the United States.

Prevalence of Australia antigen (HBsAg) in institutionalised patients with psychosis

In a study of 100 institutionalised patients with psychosis and an equal number of age- and sex-matched healthy controls from the same regional background, the prevalence of Australia antigen (HBsAg) was 11 and 2, respectively. Institutionalised psychotic patients are a high-risk group for hepatitis B virus infection.

Hepatitis B virus replication in diverse cell types during chronic hepatitis B virus infection

Hepatitis B virus-specific nucleic acid sequences and proteins have been detected in extrahepatic tissues of acutely and chronically infected patients. However, apart from peripheral blood mononuclear cells and bone marrow cells, little is known about the specific cell types that permit viral replication. In this study, we assessed the extrahepatic tissues of four patients who died with chronic hepatitis B virus infection and two uninfected controls by means of in situ hybridization and immunohistochemical study. Three of these patients had diffuse extrahepatic distribution of the virus. Hepatitis B virus nucleic acid sequences and proteins were detected in the lymph nodes, spleen, bone marrow, kidney, skin, colon, stomach, testes and periadrenal ganglia. The following cell types were found to be positive for hepatitis B virus: endothelial cells, macrophages/monocytes, hematopoietic precursors, basal keratinocytes, mucosal epithelial cells, stromal fibroblasts and sustentacular and neuronal cells. It is probable that these cells could support viral replication because hepatitis B virus DNA replicative intermediates, viral transcripts and HBsAg and HBcAg proteins were detected in most. These findings may be relevant to the initiation of extrahepatic syndromes associated with chronic hepatitis B virus infection such as vasculitis, glomerulonephropathy, neuropathy and dermatitis.

What is the dentist's occupational risk of becoming infected with hepatitis B or the human immunodeficiency virus?

Surveys have shown that dentists are reluctant to treat persons infected with the human immunodeficiency virus (HIV). However, dentists are much more willing to treat patients with infectious hepatitis B virus (HBV). This study shows that the annual cumulative risk of infection from routine treatment of patients whose seropositivity is undisclosed is 57 times greater from HBV than from HIV, and that the risk of dying from HBV infection is 1.7 times greater than the risk of HIV infection, for which mortality is almost certain.

HBsAg in urine: a new approach for the detection of urinary antigens

In order to define the optimal conditions for detection of microbial antigens in urine, urinary HBsAg excreted during hepatitis B was chosen as a model. Using commercial kits, which mainly involve anti-discontinuous epitopes, we found urinary HBsAg in only 50% of patients with HBsAg in their sera. In contrast, with an inhibition method involving a monoclonal antibody recognizing a continuous epitope, urinary HBsAg was found in 100% of these patients. Structural analysis of HBsAg showed that urinary HBsAg is denatured; it can escape detection by commercial kits well fitted for detection of native serum HBsAg. General implications for the revelation of urinary microbial antigens are discussed.

Seroprevalence of hepatitis B surface antibody in South African dental personnel

Because there are no data available on the seroprevalence of hepatitis B in dental personnel in South Africa, a study was performed to assess the antibody status to hepatitis B surface antigen among 129 dental (preclinical) students and 62 dental hygienists at the Western Cape Dental School of South Africa. A total of 11 dental students and nine hygienists were positive to hepatitis B surface antibody, indicating a seroprevalence of 8.5% and 14.5%, respectively. These results, reported for the first time in dental personnel in South Africa, imply that dental students and hygienists in this part of the world are exposed to a significant risk of contracting hepatitis B.

Failure to detect hepatitis C virus genome in human secretions with the polymerase chain reaction

Although hepatitis C infection has been clearly demonstrated to be transmitted through blood products or blood contamination, most cases of sporadic hepatitis C infection are unassociated with parenteral risk factors, and it is unclear how infection might be acquired by nonparenteral means. One potential mode of nonparenteral transmission is through body secretions. We used a highly sensitive and specific polymerase chain reaction assay to determine whether hepatitis C viral genomic RNA could be detected in secretions obtained from nineteen individuals with chronic hepatitis C virus infection. Although hepatitis C genomic RNA was found in all 19 sera, hepatitis C virus RNA was not detected in any samples of saliva, semen, urine, stool or vaginal secretions from these patients. Viral titers in serum ranged from 10(2) to 10(7) polymerase chain reaction units/ml. The sensitivity of our polymerase chain reaction assay indicates that, if hepatitis C virus were in secretions, it would be present in amounts less than 1 to 4 polymerase chain reaction units/ml. This contrasts with hepatitis B virus infection, in which serum titers frequently are in excess of 10(9) copies of hepatitis B genomes/ml. Body secretions have been found to contain up to 10(6) copies of hepatitis B genomes/ml. Our findings support seroepidemiological studies indicating that nonparenteral transmission of hepatitis C through secretions is uncommon and probably much less efficient than hepatitis B virus infection.

Intrafamilial clustering of hepatitis B virus (HBV) infection: study of 10 Saudi families

In order to evaluate the extent of intrafamilial clustering of hepatitis B virus (HBV) infection, serological tests for evidence of HBV infection were performed on family members of 10 Saudi children who were found to be HBs Ag-positive. The overall prevalences of carriers (HBs Ag-positive) and exposure (presence of any HBV marker) in the 89 siblings were 17.9 and 34.8%, respectively. In siblings of families where the mother was a carrier, exposure to HBV (51.6%) was higher (chi 2 = 1.99, P = 0.15) than in siblings of families where only the father was a carrier (31.4%) and significantly higher (chi 2 = 5.24, P = 0.02) than in siblings of families where neither of the parents was a carrier but both had previous exposure to HBV infection (17.4%). Our data indicate that mainly horizontal and perhaps perinatal transmission could account for this relatively high level of intrafamilial clustering of HBV infection in Saudi families. These results are important for the development of a strategy for controlling HBV infection in Saudi Arabia and perhaps in similar HBV endemic areas.

The emergence of hepatitis B as a sexually transmitted disease

In the United States, approximately 300,000 cases of hepatitis B virus infection occur annually, and heterosexual activity is one of the most commonly reported risk factors for acquiring disease. Until the number of infections transmitted through heterosexual contact can be reduced through hepatitis B vaccination, there is little chance of controlling this infection.

Occupational hazards to health care workers: diverse, ill-defined, and not fully appreciated

Health care workers are challenged by an imposing group of occupational hazards. These hazards include exposure to ionizing radiation, stress, injury, infectious agents, and chemicals. The magnitude and diversity of these hazards are not fully appreciated. The acquired immunodeficiency syndrome epidemic has created additional occupational hazards and has focused attention on the problem of occupational hazards to health care workers. Concern over the nosocomial transmission of the human immunodeficiency virus has contributed to efforts to implement universal infection control precautions and to decrease needlestick injuries. Health care organizations and providers, who have prompted health and safety campaigns for the general public, should not overlook the dangers associated with the health care setting.

[Prevalence of virus B infection in a hospital community]

The authors studied the prevalence of HBV markers among health care personnel of the University Hospital of the Federal University of Rio de Janeiro. The aim of study was to identify the high risk groups, in order to counsel vaccination of those groups, in order to counsel vaccination of those groups at risk as a routine. As a control group, a group of office workers of the hospital were chosen. A significant difference of incidence of HBV markers, mainly in surgeons (40%) and hemodialysis unit personnel (36.4%) when compared to the control group, was observed (p less than 0.05). The incidence increased with age and the time spent in the profession. The authors concluded that vaccination is indicated in surgeons hemodialysis personnel, dentists and laboratory personnel.

Hepatitis B infection in Vanuatu: age of acquisition of infection and possible routes of transmission

Seroepidemiological studies of hepatitis B were carried out on diverse groups of children (477) and adults (629) from the Pacific Island country of Vanuatu. In children under 14 years, prevalences of HBsAg and of all markers were 6% and 53.3% respectively; in adults greater than or equal to 20 years the prevalences were 15% and 70%. Age specific prevalence of hepatitis B infection (all markers) was low in infancy (less than 1 year) but rose sharply afterwards, suggesting that the main mechanism of transmission was horizontal spread. This finding is consistent with other developing country studies from the Pacific Islands and elsewhere. In view of the main ages and mechanisms of transmission of hepatitis B in children in developing countries and the need for simple and inexpensive immunisation strategies in this context, it is recommended that mass vaccination of all infants with hepatitis B vaccine be undertaken in hyperendemic areas.

Risk of transmission of the human immunodeficiency virus to health care workers exposed to HIV-infected patients: a review

The possibility of transmission of the human immunodeficiency virus (HIV) to health care workers with occupational exposure to infected patients has caused concern since the beginning of the AIDS crisis. This report summarizes both national surveillance data for AIDS among health care workers and the results of prospective studies on the risk of HIV transmission in the health care professions. All the available evidence indicates that HIV infection in health care workers in the United States results primarily from exposure outside the health care setting, and is acquired by one of the conventional routes of transmission. A small number of health care workers have been infected with HIV through occupational exposure. Prospective surveillance studies indicate that the risk of seroconversion after needlestick exposure to HIV-infected blood is about 0.5%. The level of risk associated with exposure of mucous membranes or nonintact skin is far less.

Hepatitis B and Delta virus infection among heterosexuals, homosexuals and bisexual men

The hepatitis B virus (HBV) and hepatitis Delta virus (HDV) infection rates were estimated in patients attending a venereal disease outpatient clinic: 759 heterosexuals and 154 homosexual-bisexual men. The anti-HBc prevalence was higher in homo-bisexual men (68.8 per 100) than in heterosexuals (41.8 per 100), whereas HBsAg was roughly the same in the two groups (about 6 per 100). The anti-HBc prevalence rate among heterosexuals was higher than that estimated in hospital personnel from the same geographical area. A positive association between anti-HBc prevalence and present or past sexually transmitted diseases (STD) was found among homo-bisexual men. Anti-HBc was also positively associated with herpes simplex type 2 antibodies in both heterosexuals and homo-bisexual men. These data are consistent with the hypothesis that sexual behavior also plays a role in the spread of infection among heterosexuals. Ten of the 46 HBsAg-positive subjects were anti-HDV positive: 6 of the 36 heterosexuals and 4 of the 10 homosexuals. All HDV-positive subjects had present or past STDs. These findings suggest sexual transmission of HDV infection.

Low occupational risk of human immunodeficiency virus infection among dental professionals

We studied 1309 dental professionals (1132 dentists, 131 hygienists, and 46 assistants) without behavioral risk factors for the acquired immunodeficiency syndrome (AIDS) to determine their occupational risk for infection with human immunodeficiency virus (HIV). Subjects completed questionnaires on behavior; type, duration, and location of their dental practice; infection-control practices; and estimated numbers of potential occupational exposures to HIV. Serum samples were tested for antibodies to HIV and to hepatitis B surface antigen (unvaccinated subjects). Fifty-one percent of the subjects practiced in locations where many cases of AIDS have been reported. Seventy-two percent treated patients who had AIDS or were at increased risk for it. Ninety-four percent reported accidental puncturing of the skin with instruments used in treating patients. Adherence to recommended infection-control practices was infrequent. Twenty-one percent of unvaccinated subjects had antibodies to hepatitis B surface antigen. Only one dentist without a history of behavioral risk factors for AIDS had serum antibodies to HIV. We conclude that despite infrequent compliance with recommended infection-control precautions, frequent occupational exposure to persons at increased risk for HIV infection, and frequent accidental puncturing of the skin with sharp instruments, dental professionals are at low occupational risk for HIV infection.

The hazard of infection from the shared communion cup

Interest and concern that the shared communion cup may act as a vehicle for indirectly transmitting infectious disease was reawakened when the human immunodeficiency virus (HIV) was detected in the saliva of infected persons. Bacteriological experiments have shown that the occasional transmission of micro-organisms is unaffected by the alcoholic content of the wine, the constituent material of the cup or the practice of partially rotating it, but is appreciably reduced when a cloth is used to wipe the lip of the cup between communicants. Nevertheless, transmission does not necessarily imply inoculation or infection. Consideration of the epidemiology of micro-organisms that may be transmitted via saliva, particularly the herpes group of viruses, suggests that indirect transmission of infection is rare and in most instances a much greater opportunity exists for direct transmission by other means. There is substantial evidence that neither infection with hepatitis B virus nor HIV can be transmitted directly via saliva so that indirect transmission via inanimate objects is even less likely. No episode of disease attributable to the shared communion cup has ever been reported. Currently available data do not provide any support for suggesting that the practice of sharing a common communion cup should be abandoned because it might spread infection.