Clinical practice. Occupational exposure to HIV in health care settings

Systemic Factors Affecting Orthodontic Treatment Outcomes and Prognosis-Part 2

This article explores the various challenges systemic conditions can pose before and during orthodontic treatment. Cardiovascular conditions like infective endocarditis require antibiotic prophylaxis before certain orthodontic procedures are started. Patients with bleeding disorders require special considerations in regards to viral infection risk and maintenance of excellent atraumatic oral hygiene. Orthodontists play an important role in early identification of signs and symptoms of eating disorders and should deal with these patients sensitively. Congenital disorders, craniofacial anomalies, and nutritional deficiencies require special considerations and should be addressed appropriately before orthodontic treatment is started.

Safe performance of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with HIV infection

Background

Patients with HIV (PHIV) are living longer with the adoption of anti‐retroviral therapy. As such, more patients are presenting with advanced cancer diagnoses, including peritoneal surface malignancies. The objective of this study was to assess the safety of CRS/HIPEC in this cohort of patients.

Case

Five PHIV were identified, four of whom underwent CRS/HIPEC. Primary sites of disease were low‐grade appendiceal mucinous tumors in three patients and peritoneal mesothelioma in the other. Operative time ranged from 7 to 14 h. One patient developed a Clavien grade II complication postoperatively. There was no instance of neutropenia identified. One patient died of disease 19 months after surgery; the remaining three patients are alive 11, 21, and 33 months postoperatively.

Conclusion

This study demonstrates that CRS/HIPEC can be performed in PHIV without prohibitive complications and operative recovery approximates that of non‐HIV patients. Though more study is needed, HIV should not preclude a patient from being offered CRS/HIPEC.

The Prevalence of Blood-Borne Pathogens in Maxillofacial Trauma Patients

BACKGROUND

Blood-borne pathogen infections (BPIs), caused by the human immunodeficiency virus, hepatitis C and hepatitis B viruses pose an occupational hazard to healthcare workers. Facial trauma reconstruction surgeons may be at elevated risk because of routine use of sharps, and a higher than average incidence of BPIs in the trauma patient population.

METHODS

The authors retrospectively reviewed health records of patients admitted to a level 1 trauma center with a facial fracture between January 2010 and December 2015. Patient demographics, medical history, mechanism of injury, type of fracture, and procedures performed were documented. The authors detemined the frequency of human immunodeficiency virus, hepatitis B, and hepatitis C diagnosis and utilized univariable/multivariable analyses to identify risk factors associated with infection in this population.

RESULTS

In total, 4608 consecutive patients were included. Infections were found in 4.8% (n = 219) of patients (human immunodeficiency virus 1.6%, hepatitis C 3.3%, hepatitis B 0.8%). 76.3% of BPI patients in this cohort were identified by medical history, while 23.7% were diagnosed by serology following initiation of care. 39.0% of all patients received surgical treatment during initial hospitalization, of whom 4.3% had a diagnosed BPI. History of intravenous drug use (odds ratio [OR] 6.79, P < 0.001), assault-related injury (OR 1.61, P = 0.003), positive toxicology screen (OR 1.56, P = 0.004), and male gender (OR 1.53, P = 0.037) were significantly associated with a BPI diagnosis.

CONCLUSION

Patients presenting with facial fractures commonly harbor a BPI. The benefit of early diagnosis and risk to surgical staff may justify routine screening for BPI in high risk facial trauma patients (male, assault-related injury, and history of intravenous drug use).

Stigma and Dissatisfaction of Health Care Personnel in HIV Response in Iran: A Qualitative Study

Background and Aims:

With regard to the disease pandemics of HIV/AIDS, it is clear that there is need for prevention, treatment, care, and support of HIV positive patients in the health care system. In order to achieve these goals, job satisfaction should be a priority for health care staff. This study examined the problems of health care personnel and the behavior of patients undergoing HIV/AIDS counseling at Imam Khomeini Hospital in Tehran, Iran.

Methods:

Interviews were conducted individually with 5 health care personnel who participated in this study. Participants had 30 to 45 minutes each per session at the clinic, during which they were able to discuss the problems they faced in their careers. All conversations were officially recorded.

Results:

The most common problems mentioned by these health care workers included the lack of safety and standardization of work conditions, the lack of appropriate equipment, limited space, high numbers of patients, low staffing levels and financial and morale problems compounded by the lack of support by hospital authorities.

Conclusion:

The authorities need to allocate more funds to provide facilities and appropriate working conditions for health care staff in order to increase job satisfaction and enable staff to provide the best services and care to HIV positive patients.

False-Positive Results for Human Immunodeficiency Virus Type 1 Nucleic Acid Amplification Testing in Chimeric Antigen Receptor T Cell Therapy

Chimeric antigen receptor (CAR) T cell immunotherapy has been a major advancement in cancer therapeutics. Reprogramming of T cells is achieved by using gammaretroviral or lentiviral vectors, which may interfere with human immunodeficiency virus type 1 (HIV-1) nucleic acid amplification testing (NAAT). Here, we describe three clinical scenarios in which CAR T cell immunotherapy interfered with HIV-1 testing, including (i) routine infectious disease screening prior to stem cell transplantation in a 16-year-old female with B cell acute lymphoblastic leukemia, post CAR T cell treatment; (ii) routine infectious disease screening prior to second CAR T cell collection in a 65-year-old male with diffuse large B cell lymphoma who failed initial CAR T cell treatment; and (iii) routine infectious risk assessment following an occupational health exposure from a 58-year-old male with multiple myeloma, who received CAR T cell treatment. In each case, patients initially tested negative by the "fourth-generation" HIV-1 screening enzyme immunoassay (targeting the p24 antigen and anti-HIV-1 antibodies), but positive by the Roche Cobas AmpliPrep/Cobas TaqMan HIV-1 test v2.0 (targeting gag and the long terminal repeat [LTR]). These samples subsequently retested negative using the Abbott m2000 RealTime HIV-1 assay, which targets the integrase gene. These results indicated that cross-reactions between lentiviral vectors and LTR genomes targeted in the HIV-1 NAAT caused the HIV-1 NAAT false-positive results.

[Reduction of needlestick injuries by 48 % in 1 year : Effects of improvement of the safety concept according to the European Union Council directive 2010/32/EU at a large regional hospital]

BACKGROUND

Needlestick injuries (NSI) are potentially infectious injuries from sharp or pointed medical instruments and through contact with blood on mucous membranes or nonintact skin. Although the European Union (EU) Council directive 2010/32/EU on the prevention of NSI was implemented in EU countries in 2013, information on the effectiveness of the measures is limited.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a safety concept according to the EU Council Directive 2010/32/EU on prevention of NSI.

MATERIAL AND METHODS

In 2016 the NSI safety concept at a large regional hospital was improved according to 2010/32/EU, specifically by an update of blood screening profiles and standard operating procedures (SOP), better dissemination of information to employees and complete conversion to safety cannulas and scalpels. The medical records of all NSIs from 2015-2017 were retrospectively anonymized and evaluated and a cost analysis was performed.

RESULTS

The number of NSIs in 2017 was significantly reduced by 48.4% as compared to 2016 and NSIs with scalpels were completely prevented. The proportion of employees with NSIs who were adequately immunized against hepatitis B was significantly increased to 84.1% in 2017. Furthermore, identification of the index patient was significantly increased to 82.5% in 2017. The cost of avoiding NSIs increased by a total of 24.1% in 2017 as compared to 2015 before introduction of the safety concept.

CONCLUSION

Implementation of the EU Council directive 2010/32/EU, resulted in an almost 50% reduction in NSIs over 1 year, including the complete prevention of NSIs due to scalpels. In addition, the anamnestic presence of immunization against hepatitis B and index patient identification were significantly increased.

Current Knowledge, Attitudes, and Practice of Medical Students Regarding the Risk of Hepatitis B Virus Infection and Control Measures at Qassim University

BACKGROUND:

Medical students are exposed to occupational health hazards in hospitals during their studies and lack sufficient education about infection control measures. Injury to medical students is a substantial problem and students have an increased risk of hepatitis B virus (HBV). To understand how medical students think about infection control, it is important to identify the strengths and weaknesses of their education.

AIM:

To assess current knowledge, attitudes, and practice of medical students regarding HBV infection and control measures at Qassim University, Saudi Arabia.

MATERIAL AND METHODS:

A cross-sectional study was conducted at a medical college. Participants completed a 39-item self-administered questionnaire assessing demographics, knowledge, attitudes, and practice. Item response frequencies were calculated. Responses were recorded into yes (strongly agree and agree) and no (neutral, disagree, and strongly disagree) answers. Correct responses were totalled and categorised as good or poor performance. A scale cut-off of less than 75% correct responses was considered poor, and 75% or more correct responses was considered good. Odds ratios and 95% confidence intervals were calculated, and the chi-square test was used for analysis.

RESULTS:

A total of 21%, 41%, and 8% of students expressed good knowledge, attitudes, and practice, respectively. There was no statistically significant difference between males and females on knowledge (p = 0.089), attitudes (p = 0.829), and practice (p = 0.248). There was a statistically significant difference between academic years on knowledge (p = 0.0001), attitudes (p = 0.0001), and practice (p = 0.0001).

CONCLUSION:

Most medical students have poor knowledge, attitudes, and practice regarding the risk of HBV infection. It is recommended that a policy is implemented for training on infection prevention for all medical students before they start clinical practice. Prevention programs about HBV infection should be instituted, and existing programs must be strengthened.

Antiretroviral Drug Resistance Among Patients With Human Immunodeficiency Virus Who Act as Sources or Potential Sources in Occupational Accidents Involving Healthcare Workers

Objective:

To determine human immunodeficiency virus (HIV) type 1 genotypic antiretroviral drug resistance profiles of patients presenting a risk or potential risk for occupational exposure of healthcare workers.

Design:

Observational survey involving HIV-infected patients. Blood samples collected from source-patients and potential source-patients underwent HIV-1 genotypic antiretroviral resistance testing and determination of CD4 counts and viral load. Affected healthcare workers were monitored for 6 months after exposure.

Setting:

The survey was conducted in a tertiary-care hospital located in Sao Paulo, Brazil. Sao Paulo is considered the epicenter of the HIV-acquired immunodeficiency (AIDS) virus epidemic in Brazil.

Participants:

Source-patients, potential source-patients, and affected healthcare workers.

Results:

A total of 371 occupational exposures to biological materials were reported, 46 (12.3%) of which were from HIV-seropositive source-patients. Samples from 18 source-patients and 26 patients considered “potential sources for accidents” were analyzed. Of these 44 samples, 18 (41%) presented resistance-related mutations in reverse transcriptase, protease, or both. Of these 18 samples, 16 (89%) had resistance to drugs included in the prophylactic schedule recommended by the Brazilian Ministry of Health.

Conclusions:

Use of the Centers for Disease Control and Prevention-Brazilian post-exposure prophylaxis regimen will result in the administration of antiretroviral agents to which the source HIV-1 isolate will often be resistant. Therefore, it would be advisable to carefully investigate the history of use of antiretroviral agents by source-patients and adjust the prophylactic therapy based on those data and, subsequently, the results of resistance testing.

Adverse events and adherence to HIV post-exposure prophylaxis: a cohort study at the Korle-Bu Teaching Hospital in Accra, Ghana

Background

There is strong evidence that post-exposure prophylaxis (PEP) with antiretroviral drugs in the timely management of occupational exposures sustained by healthcare workers decreases the risk of HIV infection and PEP is now widely used. Antiretroviral drugs have well documented toxicities and produce adverse events in patients living with HIV/AIDS. In the era of “highly active antiretroviral therapy”, non-adherence to treatment has been closely linked to the occurrence of adverse events in HIV patients and this ultimately influences treatment success but the influence of adverse events on adherence during PEP is less well studied.

Methods

Following the introduction of a HIV post-exposure prophylaxis program in the Korle-Bu Teaching Hospital in January 2005, the incidence of adverse events and adherence were documented in occupationally-exposed healthcare workers (HCWs) and healthcare students (HCSs). Cohort event monitoring was used in following-up on exposed HCWs/HCSs for the two study outcomes; adverse events and adherence. All adverse events reported were grouped by MedDRA system organ classification and then by preferred term according to prophylaxis regimen. Adherence was determined by the completion of prophylaxis schedule. Cox proportional regression analysis was applied to determine the factors associated with the cohort study outcomes. Differences in frequencies were tested using the Chi square test and p < 0.05 was considered statistically significant.

Results

A total of 228 exposed HCWs/HCSs were followed up during the study, made up of 101 exposed HCWs/HCSs administered lamivudine/zidovudine (3TC/AZT) for 3 days; 75 exposed HCWs/HCSs administered lamivudine/zidovudine (3TC/AZT) for 28 days; and 52 exposed HCWs/HCSs administered lamivudine/zidovudine/lopinavir-ritonavir (3TC/AZT/LPV-RTV) for 28 days. The frequency of adverse events was 28 % (n = 28) in exposed HCWs/HCSs administered 3TC/AZT for 3 days, 91 % (n = 68) in exposed HCWs/HCSs administered 3TC/AZT for 28 days and 96 % (n = 50) in exposed HCWs/HCSs administered 3TC/AZT/LPV-RTV for 28 days. Nausea was the most commonly reported adverse events in all three regimens. Adherence was complete in all exposed HCWs/HCSs administered 3TC/AZT for 3days, 56 % (n = 42) in exposed HCWs/HCSs administered 3TC/AZT for 28 days and 62 % (n = 32) in exposed HCWs/HCSs administered 3TC/AZT/LPV-RTV for 28 days. In the Cox regression multi-variate analysis, exposed HCWs/HCSs administered 3TC/AZT for 3 days were 70 % less likely to report adverse events compared with exposed HCWs/HCSs administered 3TC/AZT for 28 days (Adjusted HR = 0.30 [95 % CI, 0.18-0.48], p < 0.001). Exposed HCWs/HCSs administered 3TC/AZT for 3 days were 75 % more likely to adhere to the schedule compared with exposed HCWs/HCSs administered 3TC/AZT for 28 days (Adjusted HR = 1.75 [95 % CI, 1.16-2.66], p = 0.008).

Conclusion

The intolerance to adverse events was cited as the sole reason for truncating PEP, thereby indicating the need for adequate, appropriate and effective counselling, education, active follow-up (possibly through mobile /phone contact) and management of adverse events. Education on the need to complete PEP schedule (especially for exposed HCWs/HCSs on 28-day schedule) can lead to increased adherence, which is very critical in minimizing the risk of HIV sero-conversion. The present results also indicate that cohort event monitoring could be an effective pharmacovigilance tool in monitoring adverse events in exposed HCWs/HCSs on HIV post-exposure prophylaxis.

[HIV prophylaxis kits. A concept for emergency treatment in the context of postexposure prophylaxis]

Occupational transmission of HIV among healthcare personnel is rare but has repeatedly been published in the literature. Early initiation of postexposure HIV prophylaxis (HIV-PEP) is crucial to prevent virus transmission. For this reason the need for HIV-PEP has to be evaluated immediately and if necessary, started as soon as possible. This article presents an early intervention program in a university hospital which enables healthcare personnel immediate 24/7/365 access to a HIV-PEP prophylaxis kit following occupational HIV exposure.

Evolution of the global burden of viral infections from unsafe medical injections, 2000-2010

Background

In 2000, the World Health Organization estimated that, in developing and transitional countries, unsafe injections accounted for respectively 5%, 32% and 40% of new infections with HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV). Safe injection campaigns were organized worldwide. The present study sought to measure the progress in reducing the transmission of these viruses through unsafe injections over the subsequent decade.

Methods

A mass action model was updated, to recalculate the number of injection-related HIV, HCV and HBV infections acquired in 2000 and provide estimates for 2010. Data about the annual number of unsafe injections were updated. HIV prevalence in various regions in 2000 and 2010 were calculated from UNAIDS data. The ratio of HIV prevalence in healthcare settings compared to the general population was estimated from a literature review. Improved regional estimates of the prevalence of HCV seropositivity, HBsAg and HBeAg antigenemia were used for 2000 and 2010. For HIV and HCV, revised estimates of the probability of transmission per episode of unsafe injection were used, with low and high values allowing sensitivity analyses.

Results

Despite a 13% population growth, there was a reduction of respectively 87% and 83% in the absolute numbers of HIV and HCV infections transmitted through injections. For HBV, the reduction was more marked (91%) due to the additional impact of vaccination. While injections-related cases had accounted for 4.6%–9.1% of newly acquired HIV infections in 2000, this proportion decreased to 0.7%–1.3% in 2010, when unsafe injections caused between 16,939 and 33,877 HIV infections, between 157,592 and 315,120 HCV infections, and 1,679,745 HBV infections.

Conclusion

From 2000 to 2010, substantial progress was made in reducing the burden of HIV, HCV and HBV infections transmitted through injections. In some regions, their elimination might become a reasonable public health goal.

Best practice for needlestick injuries

PURPOSE

Needlestick injuries (NSIs) are a significant health hazard. Occupational transmission of bloodborne pathogens among healthcare workers (HCWs) is rare but has been repeatedly reported in the literature.

METHODS

In October 2010, new regulations were introduced for medical aftercare of HCWs following NSIs at the University Hospital Frankfurt. In June 2013, a university hospital-wide early intervention program was introduced that gives HCWs immediate 24/7/365 access to an HIV postexposure prophylaxis kit after confirmed or probable occupational HIV exposure.

RESULTS

Interdisciplinary collaboration between the attending surgeon and occupational health as well as infectious disease specialists facilitates optimal postexposure medical treatment of HCWs who suffer NSIs. Complete reporting of NSIs is a prerequisite for achieving optimal treatment of the affected HCWs.

CONCLUSION

An NSI is an emergency and needs to be evaluated immediately and, if necessary, treated as soon as possible. A standardized algorithm for initial diagnostic and treatment has proven to be helpful.

How often are major blood-borne pathogens found in eye patients? A serosurvey at an eye hospital in Southern China

BACKGROUND

The hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV) and treponema pallidum (TP) are blood-borne pathogens. They can lead to nosocomial and occupational infections in health care settings. We aimed to identify the prevalence of and risk factors associated with HBV, HCV, HIV and TP infections among patients with eye diseases at a tertiary eye hospital in Southern China.

METHODS

From July 2011 to June 2012, a total of 26,386 blood units were collected from eye patients, including inpatients and the day surgery patients at Zhongshan Ophthalmic Center, one of the biggest eye hospitals in China. Based on the primary diagnoses from this period, the subjects were classified into different ocular disease groups. All blood samples were tested for HBsAg, anti-HCV, anti-HIV and anti-TP.

RESULT

The overall prevalence of HBV, HCV, TP and HIV was 9.79%, 0.99%, 2.43% and 0.11%, respectively. The prevalence of HBsAg was much lower among patients younger than 20 years compared to other age groups. In addition, the risk of HBsAg was associated with the male gender, ocular trauma and glaucoma. The prevalence of TP increased with age and the prevalence among patients older than 30 was higher than that in patients younger than 20 years.

CONCLUSIONS

The prevalence of HBV, HCV, HIV and TP in patients with eye diseases was identified. This information can be utilised to strengthen the health education and implementation of universal safety precautions to prevent the spread of blood-borne pathogens in health care settings.

High prevalence but low awareness of hepatitis C virus infection among heroin users who received methadone maintenance therapy in Taiwan

BACKGROUND

This study investigates the prevalence and correlates of hepatitis C virus (HCV) infections among heroin dependent individuals who received methadone maintenance therapy in Taiwan. Also, we investigate users' awareness of HCV.

METHODS

Participants were 773 heroin users entering the methadone maintenance treatment (MMT) program at Tsaotun Psychiatric Center in Taiwan. The presence of HCV antibodies was detected. Multivariate logistic regression was used to identify the relationship between HCV infection and correlates.

RESULTS

The prevalence of HCV infection was 90.8%. All participants who were HIV-positive were also infected with HCV. Multivariate logistic regression analysis showed that the route of heroin administration (injection), HIV-infection, and criminal records were significantly related to HCV infection. Few (34.8%) HCV positive heroin users were aware of their infection.

CONCLUSION

An extremely high prevalence of HCV infection but low awareness of their infection status was found among MMT patients in Taiwan. These findings highlight the importance of education regarding risky behaviors and the necessity for HCV treatment for this population in Taiwan.

The management of needlestick injuries

BACKGROUND

An estimated 1 million needlestick injuries (NSIs) occur in Europe each year. The Council Directive 2010/32/EU on the prevention of NSIs describes minimum requirements for prevention and calls for the implementation of local, national and Europe-wide reporting systems. The Directive is to be implemented by all EU member states by 11 May 2013. The purpose of this study was to assess (and improve) the procedures for the reporting and treatment of needlestick injuries in a German tertiary-care hospital.

METHODS

We carried out a prospective observational study of the NSI reporting system in the hospital over a period of 18 months and determined the incidence of NSIs, the prevalence of blood-borne pathogens among index patients, the rate of initiation of post-exposure prophylaxis, and the rate of serological testing of the affected health care personnel.

RESULTS

519 instances of NSI were reported to the accident insurance doctor over the period of the study, which consisted of 547 working days. 86.5% of the index patients underwent serological study for hepatitis B and C (HBV and HCV) and for the human immune deficiency virus (HIV); this resulted in two initial diagnoses (one each of active hepatitis B and hepatitis C) in the index patient. 92 of 449 index patients, or one in five, was infected with at least one blood-borne pathogen. HIV post-exposure prophylaxis was initiated in 41 health care workers. One case of hepatitis C virus transmission arose and was successfully treated. Other than that, no infection was transmitted.

CONCLUSION

Complete reporting of NSIs is a prerequisite for the identification of risky procedures and to ensure optimal treatment of the affected health care personnel. The accident insurance doctor must possess a high degree of interdisciplinary competence in order to treat NSI effectively.

Occupational hazards to dental staff

Dental professionals are predisposed to a number of occupational hazards. These include exposure to infections (including Human Immunodeficiency Virus and viral hepatitis); percutaneous exposure incidents, dental materials, radiation, and noise; musculoskeletal disorders; psychological problems and dermatitis; respiratory disorders; and eye insults. Percutaneous exposure incidents remain a main concern, as exposure to serious infectious agents is a virtual risk. Minimizing percutaneous exposure incidents and their consequences should continue to be considered, including sound infection control practices, continuing education, and hepatitis B vaccination. Basically, for any infection control strategies, dentists should be aware of individual protective measures and appropriate sterilization or other high-level disinfection utilities. Strained posture at work disturbs the musculoskeletal alignment and leads to stooped spine. The stooped posture also involved certain groups of muscles and joints. This may lead to diseases of the musculoskeletal system. Continuous educating and appropriate intervention studies are needed to reduce the complication of these hazards. So, it is important for dentists to remain constantly up-to-date about measures on how to deal with newer strategies and dental materials, and implicates the need for special medical care for this professional group.

Outcomes of a consultation service to emergency medicine clinicians for postexposure management of occupational bloodborne pathogen exposures

Potential bloodborne pathogen exposures, many of which occur after hours and are evaluated by emergency medicine physicians, are an important occupational hazard. Emergency medicine physicians might not be as conversant with the latest US Public Health Service guidelines as occupational medicine physicians. This research presents an efficient model in which a single expert occupational medicine physician provides guidance to many emergency medicine clinicians. Outcomes evaluation indicates that the service was widely utilized and highly rated.

Quantification of HIV-1 viral RNA in the blood in needles used for venous puncture in HIV-infected individuals

INTRODUCTION

Occupational HIV infection among healthcare workers is an important issue in exposures involving blood and body fluids. There are few data in the literature regarding the potential and the duration of infectivity of HIV type 1 (HIV-1) in contaminated material under adverse conditions.

METHODS

We quantified HIV-1 viral RNA in 25×8mm calibre hollow-bore needles, after punctures, in 25 HIV-1-infected patients selected during the sample collection. All of the patients selected were between the ages of 18 and 55. Five samples were collected from 16 patients: one sample for the immediate quantification of HIV-1 RNA in the plasma and blood samples from the interior of 4 needles to be analyzed at 0 h, 6 h, 24 h, and 72 h after collection. In nine patients, another test was carried out in the blood from one additional needle, in which HIV-1 RNA was assessed 168 h after blood collection. The method used to assess HIV-1 RNA was nucleic acid sequence-based amplification.

RESULTS

Up to 7 days after collection, HIV-1 RNA was detected in all of the needles. The viral RNA remained stable up to 168 h, and there were no statistically significant differences among the needle samples.

CONCLUSIONS

Although the infectivity of the viral material in the needles is unknown, the data indicate the need to re-evaluate the practices in cases of occupational accidents in which the source is not identified.

[Blood-borne infections and the pregnant health care worker. Risks and preventive measures]

Due to the increasing proportion of women in health care, as well as changes in working conditions (implementation of safety devices, minimally invasive/endoscopic procedures) the question arises whether the applicable laws and regulations for the protection of working mothers are outdated and should be updated.Individual risk analysis, as well as the inclusion of the pregnant health care worker in the decision-making process with regard to continuation or modification of the work practice serves as a protection of the expectant mother and unborn child and allows a continuation of the occupational activities.

AN IMPULSIVE DIFFERENTIAL MODEL ON POST EXPOSURE PROPHYLAXIS TO HIV-1 EXPOSED INDIVIDUAL

An impulsive differential model for post exposure prophylaxis (PEP) to HIV-1 exposure is proposed with presence of drugs. Two therapy strategies (the Drugs Perfect Adherence strategy and the Drugs Therapy Breaks strategy) are studied. The threshold [Formula: see text] is obtained for the model. The safe-dose threshold ([Formula: see text]) and the unsafe-dose threshold ([Formula: see text]) for PEP treatment are evaluated for the impulsive model under the Drugs Prefect Adherence strategy. The numerical simulations show that, in addition to the sufficient dosing of drug and to the sufficiently frequent dosing of drug, the basic reproduction number Rcis also responsible for the different final outcome of PEP treatment.

Surgeons' and residents' double-gloving practices at 2 teaching hospitals in Ontario

BACKGROUND

Surgeons and residents are at increased risk of exposure to blood-borne pathogens owing to percutaneous injury (PI) and contamination. One method known to reduce risk is double-gloving (DG) during surgery.

METHODS

All surgeons and residents affiliated with the University of Western Ontario (UWO) and McMaster University in 2005 were asked to participate in a Web-based survey. The survey asked respondents their specialty, the number of operations they participated in per week, their age and sex, the proportion of surgeries in which they double-gloved (DG in ≥75% surgeries was considered to be routine), and the average number of PIs they sustained per year and whether or not they reported them to an employee health service.

RESULTS

In total, 155 of 331 (47%) eligible surgeons and residents responded; response rates for UWO and McMaster surgeons were 50% and 39%, respectively, and for UWO and McMaster residents, they were 52% and 47%, respectively. A total of 43% of surgeons and residents reported routine DG; 50% from McMaster and 36% from UWO. Using logistic regression to simultaneously adjust for participant characteristics, we confirmed that DG was more frequent at McMaster than at UWO, with an odds ratio of 3.32 (95% confidence interval 1.35-8.17). Surgeons and residents reported an average of 3.3 surgical PIs per year (2.2 among McMaster participants and 4.5 among UWO participants). Of the 77% who reported at least 1 injury/year, 67% stated that they had not reported it to an employee health service.

CONCLUSION

Percutaneous injuries occur frequently during surgery, yet routine DG, an effective means of reducing risk, was carried out by less than half of the surgeons and residents participating in this study. This highlights the need for a more concerted and broad-based approach to increase the use of a measure that is effective, inexpensive and easily carried out.

Ongoing use of conventional devices and safety device activation rates in hospitals in Ontario, Canada

This study assessed voluntary compliance with the use of sharp safety devices in lieu of conventional ones and the activation status of these safety devices: VanishPoint syringes, Terumo Surshield butterflies, and Insyte Autoguard IV catheters. Sharps disposal containers from various wards in three private, not-for profit, university-affiliated Ontario hospitals were audited during 9 days in August 2007. In the 149 audited sharps containers, 55% of all syringes found were conventional compared with 45% that were safety syringes. In the three hospitals, the percentages of conventional (non-safety) vs. safety syringes found in used sharps containers were as follows, respectively: (i) 72% conventional and 28% safety, (ii) 55% conventional and 45% safety, and (iii) 65% conventional and 35% safety. In addition, it was found that 77% of 2131 Terumo butterflies, 97% of 1117 Insyte Autoguard IV catheters, and 87% of 4897 VanishPoint syringes in the containers had been activated. This study, carried out approximately 1 year before it was legally required to use safety instead of sharp conventional devices, found that most devices in use were conventional ones. It was also found that only the activation rate for the safety IV device was acceptable.

Postexposure prophylaxis for HIV

Health care workers are at risk for human immunodeficiency virus (HIV) and other infectious pathogens through exposure to blood and body fluids. Antiretroviral medications have been prescribed for postexposure prophylaxis following occupational exposure to the HIV since the early 1990s. This practice has since been extended to nonoccupational situations, such as sexual assaults. The efficacy of prophylactic therapy may be highly time-dependent and should be initiated as soon as possible. Wound care management and referral for social, medical, or advocacy services remain important for all cases.

Molecular epidemiology of HCV genotypes among injection drug users in Taiwan: Full-length sequences of two new subtype 6w strains and a recombinant form_2b6w

Human immunodeficiency virus type 1 (HIV-1) circulating recombinant form (CRF) 07_BC strain has caused serious outbreaks among injection drug users in Taiwan since 2004. The objective of this study was to conduct a molecular epidemiological study of HCV genotypes in intravenous drug users in Taiwan. Blood samples and questionnaires from 591 intravenous drug users infected with HIV-1 were collected nationwide. In total, 180 samples were selected for HCV genotyping using multiplex PCR and phylogenetic analysis of the core, E1 and NS5B regions. The Inno-Lipa assay was used to confirm multiple infections with different genotypes. Eighty percent had a single infection with subtype 1b being the most common subtype (24%), 12% had double infections and two had triple infections. In addition, three recombinant forms (RFs)-2a1a, 3a1b, and 2b6w were identified. Phylogenetic analyses showed that the 3a, 6a, and 6n strains were clustered with strains present in Thailand and mainland China. Full-length sequence analysis showed that two 6w strains shared 89.4-90.2% sequence homology with the 6(r) strain from the Guangdong Province, China. Bootscan analysis revealed that the recombination breakpoint of RF_2b6w was located at the NS2-NS3 junction. In summary, the distribution of HCV genotypes among Taiwanese intravenous drug users was complex and more than 12% of the drug users were infected with more than one genotype of HCV.

Needlestick injuries during surgical procedures: a multidisciplinary online study

BACKGROUND

Needlestick injuries are common during surgical procedures. Following such an injury, local protocols should be followed to minimize the risk of infection.

AIMS

To identify who sustains such injuries, under what circumstances and what actions are taken to minimize the risk and in response to intraoperative needlestick injuries.

METHODS

A questionnaire was submitted via e-mail to all staff in a National Health Service trust who took part in operations. The results were checked against occupational health department (OHD) records.

RESULTS

One hundred and thirty-six of 255 appropriate responders completed the questionnaire (53%). Fifteen of 31 consultants (48%), 12/36 junior doctors (33%), 0/39 midwives (0%) and 8/30 theatre staff (27%) reported having had at least one intraoperative needlestick injury over the past year. Awareness of local protocols was significantly worse in the junior doctor group. Ninety-three percent of consultants, 67% of junior doctors and 13% of theatre staff did not comply with local protocols. The length of time it takes to do so (48%) and a perceived low infection risk of the patient (78%) were the commonest reasons for this. Hand dominance, role during surgery and double gloving were not significant risk factors; however, rare use of a no-touch technique was. Comparison with OHD records suggested that a maximum of 16% of intraoperative needlestick injuries were dealt with in accordance to local policy.

CONCLUSIONS

Non-compliance with needlestick injury protocols is commonest among senior surgical staff. A revision of the protocol to reduce the time it takes to complete it may improve compliance.

Occupational blood exposure accidents in the Netherlands

BACKGROUND

To make proper evaluation of prevention policies possible, data on the incidence and associated medical costs of occupational blood exposure accidents in the Netherlands are needed.

METHODS

Descriptive analysis of blood exposure accidents and risk estimates for occupational groups. Costs of handling accidents were calculated.

RESULTS

Each year, an estimated 13,000-15,000 blood exposure accidents are reported in the Netherlands, 95% in occupational settings. Hepatitis B (HBV) vaccination is offered free of charge only to people in risk groups, the seroprevalence of HBV, hepatitis C (HCV) and human immunodeficiency virus (HIV) is low and few infections are related to blood exposure accidents. High-risk accidents occur mainly in hospitals. In nursing homes and home care settings, the majority of the accidents are low-risk. Limited data are available about occurrence of accidents in other occupational groups. Associated medical costs from occupational blood exposure accidents are mainly determined by the initial risk management.

CONCLUSIONS

Accidents must be managed effectively to prevent infection and reduce anxiety in injured employees. While strategies to reduce HCV and HIV infection should be primarily aimed at reducing the occurrence of high-risk accidents, vaccination can prevent HBV infection and cut the costs of handling low-risk accidents. The implementation of vaccination strategies, safe working policies and the proper use of safe equipment should be monitored better.

Accidental exposure to biological material in healthcare workers at a university hospital: Evaluation and follow-up of 404 cases

The care and follow-up provided to healthcare workers (HCWs) from a large teaching hospital who were exposed to biological material between 1 August 1998 and 31 January 2002 is described here. After exposure, the HCW is evaluated by a nurse and doctor in an emergency consultation and receives follow-up counselling. The collection of 10 ml of blood sample from each HCW and its source patient, when known, is made for immunoenzymatic testing for HIV, HBV and HCV. Evaluation and follow-up of 404 cases revealed that the exposures were concentrated in only a few areas of the hospital; 83% of the HCWs exposed were seen by a doctor responsible for the prophylaxis up to 3 h after exposure. Blood was involved in 76.7% (309) of the exposures. The patient source of the biological material was known in 80.7% (326) of the exposed individuals studied; 80 (24.5%) sources had serological evidence of infection with 1 or more agents: 16.2% were anti-HCV positive, 3.8% were HAgBs positive and 10.9% were anti-HIV positive. 67% (273) of the study population completed the proposed follow-up. No confirmed seroconversion occurred. In conclusion, the observed adherence to the follow-up was quite low, and measures to improve it must be taken. Surprisingly, no difference in adherence to the follow-up was observed among those exposed HCW at risk, i.e. those with an infected or unknown source patient. Analysis of post-exposure management revealed excess prescription of antiretroviral drugs, vaccine and immunoglobulin. Infection by HCV is the most important risk of concern, in our hospital, in accidents with biological material.

Barriers to the reporting and management of needlestick injuries among surgeons

OBJECTIVE

Needlestick injuries are common within surgical practice and carry the risk of transmission of blood borne viruses. Key to reducing this risk is an accessible system of reporting and involvement of occupational health services. We aimed to identify surgeons' attitude and experience dealing with such injuries and identify why in many cases needlestick injuries go unreported.

METHODS

70 questionnaires were hand delivered to surgeons and trainees across 3 UK hospitals and a variety of surgical specialties. The number of injuries and reporting practice was identified. Surgeons were asked to identify from a list the reasons why they did not report their injuries and record importance on a 5-point scale (0-4).

RESULTS

52 surgeons and trainees replied (75%). 42 (81%) had suffered at least 1 needlestick injury with 4 (8%) reporting more than 20. 8 (19%) had reported all their injuries to occupational health with no significant difference in reporting between consultants and trainees (P = 0.2). 12 (23%) felt that reporting of injuries helped to reduce transmission rates. 18 (35%) said that a needlestick had caused them moderate or significant anxiety. The top reasons for not reporting were (0-4). (1) Process too time consuming (2.7), (2) transmission risk very low (2.6), (3) do not want to disrupt operating list (2.0), (4) post exposure prophylaxis ineffective (1.3).

CONCLUSIONS

Most surgeons and trainees do not report all their needlestick injuries to occupational health despite many reporting injury related anxiety. The process is felt to take too long and the perceived risk of viral transmission is low.

Revisiting perioperative chemotherapy: the critical importance of targeting residual cancer prior to wound healing

BACKGROUND

Scientists and physicians have long noted similarities between the general behavior of a cancerous tumor and the physiological process of wound healing. But it may be during metastasis that the parallels between cancer and wound healing are most pronounced. And more particularly and for the reasons detailed in this paper, any cancer remaining after the removal of a solid tumor, whether found in micrometastatic deposits in the stroma or within the circulation, may be heavily dependent on wound healing pathways for its further survival and proliferation.

DISCUSSION

If cancer cells can hijack the wound healing process to facilitate their metastatic spread and survival, then the period immediately after surgery may be a particularly vulnerable period of time for the host, as wound healing pathways are activated and amplified after the primary tumor is removed. Given that we often wait 30 days or more after surgical removal of the primary tumor before initiating adjuvant chemotherapy to allow time for the wound to heal, this paper challenges the wisdom of that clinical paradigm, providing a theoretical rationale for administering therapy during the perioperative period.

SUMMARY

Waiting for wound healing to occur before initiating adjuvant therapies may be seriously compromising their effectiveness, and patients subsequently rendered incurable as a result of this wait. Clinical trials to establish the safety and effectiveness of administering adjuvant therapies perioperatively are needed. These therapies should target not only the residual cancer cells, but also the wound healing pathway utilized by these cells to proliferate and metastasize.

Characteristics of persons and jobs with needlestick injuries in a national data set

BACKGROUND

Physicians, nurses, and others are at risk of needlesticks, yet little national information is available regarding incidence across demographic and occupational categories.

METHODS

Analysis was conducted on national data on occupational injuries for 1992-2003 from the Bureau of Labor Statistics (BLS). Because BLS data were limited to cases with 1 or more days of work loss, and reasons related to reporting of incidents, the data only reflected a subset of all needlesticks. Nevertheless, the data were internally consistent across categories so that relative magnitudes were reliable. Statistical tests for differences in proportions were conducted that compared needlesticks with all other occupational injuries and employment.

RESULTS

Cases with 1 or more days of work loss numbered 903 per year, on average, from 1992 through 2003. Women comprised 73.3% (95% CI: 72.5%-74.2%) of persons injured. For those reporting race, white, non-Hispanic comprised 69.3% of the total (95% CI: 68.1%-70.4%); black, non-Hispanic, 14.8% (95% CI: 13.9%-15.6%); and Hispanic, 13.8% (95% CI: 12.9%-14.6%). The age bracket 35 to 44 years had the highest percentage of injuries at 34.0% (95% CI: 33.1%-34.9%). Ages over 54 years reported smaller percentages of needlestick injuries than either all other injuries or employment. Occupations with greatest frequencies included registered nurses, nursing aides and orderlies, janitors and cleaners, licensed practical nurses, and maids and housemen. Occupations with greatest risks included biologic technicians, janitors and cleaners, and maids and housemen. Almost 20% (95% CI: 18.88%-20.49%) of needlesticks occurred outside the services industry. Seven percent (95% CI: 6.56%-7.53%) of needlesticks resulted in 31 or more days of work loss in contrast to 20.46% (95% CI: 20.44%-20.48%) of all other injuries.

CONCLUSION

In this nationally representative sample, the most frequent demographic and occupational categories were women; white, non-Hispanic; ages 35 to 44 years; and registered nurses.

Undetectable HIV-1 viral load in the fluid of bullous skin lesion in a patient receiving highly active antiretroviral therapy

Health-care workers may be exposed to bullous fluid while caring for bullous skin diseases in HIV-infected patients. Given that bullous fluid is a filtrate of plasma, it may be assumed that HIV viral load (VL) in bullous fluid is close to plasma VL. This was documented in a patient who had discontinued antiretroviral therapy because of nevirapine-associated toxic epidermal necrolysis, but no data are available in patients receiving antiretrovirals. An HIV-infected woman was admitted for leg cellulitis with a large bullous lesion. Her plasma HIV RNA had been undetectable for two years under the combination of efavirenz and boosted lopinavir. Bullous fluid analysis revealed undetectable HIV-1 RNA, while efavirenz and lopinavir concentrations were 1.4 and 3.4 microg/mL, respectively. The ratio of bullous fluid/plasma concentrations was 0.74 for efavirenz and 0.26 for lopinavir. These data may help us evaluate the need for antiretroviral prophylaxis after occupational exposure to bullous lesions fluid.

Sharps injuries and bloodborne pathogen exposures in home health care

Home health care is one of the fastest growing industries in the United States. Approximately 20,000 provider agencies deliver home health care services to 7.6 million individuals with acute illness, long-term health conditions, permanent disability, or terminal illness. The home health care setting poses many challenges that likely increase the risk of sharps injuries. Home health nurses face unique challenges in preventing and reporting sharps injuries in the home. This article examines the nature of and risk factors for sharps injuries in the home health care setting, the scope of the problem, the legislative and regulatory framework relevant to sharps injuries, and the role of occupational health nurses in promoting a culture of safety to prevent sharps injuries and bloodborne pathogen exposures.

Sharps Injuries and Bloodborne Pathogen Exposures in Home Health Care

Home health care is one of the fastest growing industries in the United States. Approximately 20,000 provider agencies deliver home health care services to 7.6 million individuals with acute illness, long-term health conditions, permanent disability, or terminal illness. The home health care setting poses many challenges that likely increase the risk of sharps injuries. Home health nurses face unique challenges in preventing and reporting sharps injuries in the home. This article examines the nature of and risk factors for sharps injuries in the home health care setting, the scope of the problem, the legislative and regulatory framework relevant to sharps injuries, and the role of occupational health nurses in promoting a culture of safety to prevent sharps injuries and bloodborne pathogen exposures.

Human immunodeficiency virus postexposure prophylaxis for occupational exposure in a medical school hospital in Thailand

This is a retrospective review of occupational exposure to human immunodeficiency virus (HIV) and subsequent postexposure prophylaxis (PEP) among healthcare workers (HCWs) in King Chulalongkorn Memorial Hospital (KCMH), Bangkok, Thailand. From January 2002 to December 2004, data were collected from incident reports, the hospital's infectious diseases unit and the emergency department. There were 315 reported episodes of occupational exposure among 306 HCWs. Nurses (34.0%) were the HCWs most frequently exposed and percutaneous injury (91.4%) was the most common type of exposure. One-third of the source patients tested were infected with HIV. PEP was initiated following 200 (63.5%) of the 315 exposures and was started within 24h in >95% of cases. The most commonly prescribed PEP regimen was zidovudine, lamivudine and nelfinavir. Fifty-six percent of HCWs given PEP completed a four-week course but the remainder discontinued PEP prematurely due to side-effects, or after negative results from the source, or following informed risk reassessment or from their own accord. No exposed HCW acquired HIV during the study period. Appropriate counselling and careful risk assessment are important in achieving effective HIV PEP among HCWs.

Needlesticks and surgical residents: who is most at risk?

OBJECTIVE

Exposure to blood-borne diseases remains an occupational risk. Mandates have improved training in how to report exposures for all health-care workers. How exposure rates of surgical residents correlate with experience and mandatory training to reduce risk is not known. It was hypothesized that enhanced training would result in an increased reporting of exposures by surgical trainees and that risk would be greater in the first years of training.

DESIGN

Retrospective review of occupational health records and operative case logs, prospective survey.

METHODS

Occupational Health Services provides both initial and annual training to General Surgery house staff at the Medical College of Wisconsin. Initial training consists of a blood-borne pathogen review and a detailed explanation of exposure reporting. Mandatory annual training is provided during Surgical Grand Rounds. Training was enhanced beginning June 2005 using a videotape outlining surgical risks and specific countermeasures. The numbers of reported exposures per year before and after enhanced training were compared. Exposures were self-reported. As most exposures occurred in the operating room, rate of exposure was calculated for each year of training using the total number of cases done each year reported by the general surgical residents.

RESULTS

Surgical residents reported 118 needlestick injuries over 6 years. Senior and chief residents demonstrated a significantly lower exposure rate than junior residents (nonparametric Mood's median test, p < 0.0001). No significant difference in the injury rate was found per 1000 cases after enhanced training.

CONCLUSIONS

Increasing surgical experience lowered the needlestick injury rate. Assuming no change in self-reporting rates by year, enhanced training and reporting guidelines did not seem to change risk. More specific training for junior residents, as well as passive prevention solutions, may be necessary to positively impact their exposure risk.

Costs of needlestick injuries and subsequent hepatitis and HIV infection

BACKGROUND

Physicians, nurses and other healthcare workers (HCWs) are at risk of bloodborne pathogens infection from needlestick injuries, but costs of needlesticks are little studied.

METHODS

We used the cost-of-illness and incidence approaches. We used the perspective of the medical provider (medical costs) and the individual (lost productivity). Data on needlesticks, infections from hepatitis B and C (HBV, HCV) and human immune-deficiency (HIV) among HCWs, as well as data on per-unit costs were culled from research literature, Centers for Disease Control and Prevention reports, and Bureau of Labor Statistics reports. We also generated estimates based upon industry employment and scenarios for source-patients. These data and estimates were combined with assumptions to produce a model that generated base-case estimates as well as one-way and multi-way probabilistic sensitivity analyses. Future costs were discounted by 3%.

RESULTS

We estimated 644,963 needlesticks in the healthcare industry for 2004 of which 49% generated costs. Medical costs were $107.3 million of which 96% resulted from testing and prophylaxis and 4% from treating long-term infections (34 persons with chronic HBV, 143 with chronic HCV, and 1 with HIV). Lost-work productivity generated $81.2 million, for which 59% involved testing and prophylaxis and 41% involved long-term infections. Combined medical and work productivity costs summed to $188.5 million. Multi-way sensitivity analysis suggested a range on combined costs from $100.7 million to $405.9 million.

CONCLUSION

Detailed methodology was developed to estimate costs of needlesticks and subsequent infections for hospital-based and non-hospital-based health care workers. The combined medical and lost productivity costs comprised roughly 0.1% of all occupational injury and illness costs for all jobs in the economy. We did not account for lost home production or pain and suffering costs, however, nor did we estimate benefit/cost ratios of specific interventions to reduce needlesticks.

Surveillance of HIV exposure and postexposure prophylaxis among health care workers in Greece

OBJECTIVE

Many developed countries have implemented surveillance systems for monitoring occupational exposure to HIV. The aim of the present study was to analyze surveillance data on HIV postexposure prophylaxis (PEP) for health care workers (HCWs) in Greece.

DESIGN

All data reported to the Hellenic Centre for Disease Control and Prevention between January 1996 and June 2005 were analyzed. SAMPLE AND MEASUREMENT: 188 reported occupational exposures to HIV were analyzed, retrospectively.

RESULTS

Most exposures were in the physicians (37.8%), followed by the nursing personnel (18.6%). Nearly 38% of the HCWs were males and the predominant type of biological material involved in the exposure was blood (74.5%). Two drugs were used for PEP in 23.4% of the HCWs, and 3 drugs in 66.5% of the reported cases.

CONCLUSIONS

Greek guidelines provide guidance for treating HCWs after occupational exposure to HIV. In our study, antiretroviral treatment, a three-drug regimen in the majority of the cases, was prescribed after evaluation of specially appointed physicians. The surveillance system of occupational exposure to HIV in HCWs should be further developed and enhanced in order to monitor and evaluate the risk factors surrounding the incidents.