Risk of transmission and features of hepatitis C after needlestick injuries

Episode of Hepatitis C viral infection in the people of Swat, Pakistan

Infectious agents cause serious diseases in humans worldwide and are responsible for the high rate of morbidity and mortality. The prevalence and epidemiology of infectious disease (HCV) in the hospital visited patients referred by the physicians through the initial findings and their associated risk factors were studied in Swat. The data of 174 infected patients were collected during the period of 2015 to 2017 from two clinical laboratories of Tehsil Matta Swat. Inform consent form was taken before blood collection. After taking informed consent blood samples were collected and ICT test was performed and then ICT positive cases were conform through PCR. A total of 174 ICT positive samples [106 male and 68 females] were included in this study. Age was considered from 10 to 72 years. Of the 174 ICT strip positive, 99 [63 males, 36 females] were confirmed through PCR. The prevalence rate was recorded 56.89%. I.V/I.M injection was recorded in 100% of the individuals. Visits to the barber shop was reported in (58%) of the individuals, married individuals were (81.0), surgical operation was reported in (44.8%), sharing toothbrush was observed in (29.9%), piercing was reported in (39.7%), family history was reported in (26.4%), dental treatment was observed in (21.8%), jaundice were (13.2%) and tattooing was (1.7%). Blood transfusion, surgical operations, Jaundice, family history and dental treatment were found significant risk factors for acquiring HCV infection. It was concluded that proper implementation of precautionary measures should be needed to control the spread of HCV in far near future.

Systematic overview of hepatitis C infection in the Middle East and North Africa

AIM

To assess the quality of and to critically synthesize the available data on hepatitis C infections in the Middle East and North Africa (MENA) region to map evidence gaps.

METHODS

We conducted an overview of systematic reviews (SRs) following an a priori developed protocol (CRD42017076736). Our overview followed the preferred reporting items for systematic reviews and meta-analyses guidelines for reporting SRs and abstracts and did not receive any funding. Two independent reviewers systematically searched MEDLINE and conducted a multistage screening of the identified articles. Out of 5758 identified articles, 37 SRs of hepatitis C virus (HCV) infection in populations living in 20 countries in the MENA region published between 2008 and 2016 were included in our overview. The nine primary outcomes of interest were HCV antibody (anti-) prevalences and incidences in different at-risk populations; the HCV viremic (RNA positive) rate in HCV-positive individuals; HCV viremic prevalence in the general population (GP); the prevalence of HCV co-infection with the hepatitis B virus, human immunodeficiency virus, or schistosomiasis; the HCV genotype/subtype distribution; and the risk factors for HCV transmission. The conflicts of interest declared by the authors of the SRs were also extracted. Good quality outcomes reported by the SRs were defined as having the population, outcome, study time and setting defined as recommended by the PICOTS framework and a sample size > 100.

RESULTS

We included SRs reporting HCV outcomes with different levels of quality and precision. A substantial proportion of them synthesized data from mixed populations at differing levels of risk for acquiring HCV or at different HCV infection stages (recent and prior HCV transmissions). They also synthesized the data over long periods of time (e.g., two decades). Anti-HCV prevalence in the GP varied widely in the MENA region from 0.1% (study dates not reported) in the United Arab Emirates to 2.1%-13.5% (2003-2006) in Pakistan and 14.7% (2008) in Egypt. Data were not identified for Bahrain, Jordan, or Palestine. Good quality estimates of anti-HCV prevalence in the GP were reported for Algeria, Djibouti, Egypt, Iraq, Morocco, Pakistan, Syria, Sudan, Tunisia, and Yemen. Anti-HCV incidence estimates in the GP were reported only for Egypt (0.8-6.8 per 1000 person-year, 1997-2003). In Egypt, Morocco, and the United Arab Emirates, viremic rates in anti-HCV-positive individuals from the GP were approximately 70%. In the GP, the viremic prevalence varied from 0.7% (2011) in Saudi Arabia to 5.8% (2007-2008) in Pakistan and 10.0% (2008) in Egypt. Anti-HCV prevalence was lower in blood donors than in the GP, ranging from 0.2% (1992-1993) in Algeria to 1.7% (2005) in Yemen. The reporting quality of the outcomes in blood donors was good in the MENA countries, except in Qatar where no time framework was reported for the outcome. Some countries had anti-HCV prevalence estimates for children, transfused patients, contacts of HCV-infected patients, prisoners, sex workers, and men who have sex with men.

CONCLUSION

A substantial proportion of the reported outcomes may not help policymakers to develop micro-elimination strategies with precise HCV infection prevention and treatment programs in the region, as nowcasting HCV epidemiology using these data is potentially difficult. In addition to providing accurate information on HCV epidemiology, outcomes should also demonstrate practical and clinical significance and relevance. Based on the available data, most countries in the region have low to moderate anti-HCV prevalence. To achieve HCV elimination by 2030, up-to-date, good quality data on HCV epidemiology are required for the GP and key populations such as people who inject drugs and men who have sex with men.

Hepatitis C virus prevalence and genotype distribution in Pakistan: Comprehensive review of recent data

Hepatitis C virus (HCV) is endemic in Pakistan and its burden is expected to increase in coming decades owing mainly to widespread use of unsafe medical procedures. The prevalence of HCV in Pakistan has previously been reviewed. However, the literature search conducted here revealed that at least 86 relevant studies have been produced since the publication of these systematic reviews. A revised updated analysis was therefore needed in order to integrate the fresh data. A systematic review of data published between 2010 and 2015 showed that HCV seroprevalence among the general adult Pakistani population is 6.8%, while active HCV infection was found in approximately 6% of the population. Studies included in this review have also shown extremely high HCV prevalence in rural and underdeveloped peri-urban areas (up to 25%), highlighting the need for an increased focus on this previously neglected socioeconomic stratum of the population. While a 2.45% seroprevalence among blood donors demands immediate measures to curtail the risk of transfusion transmitted HCV, a very high prevalence in patients attending hospitals with various non-liver disease related complaints (up to 30%) suggests a rise in the incidence of nosocomial HCV spread. HCV genotype 3a continues to be the most prevalent subtype infecting people in Pakistan (61.3%). However, recent years have witnessed an increase in the frequency of subtype 2a in certain geographical sub-regions within Pakistan. In Khyber Pakhtunkhwa and Sindh provinces, 2a was the second most prevalent genotype (17.3% and 11.3% respectively). While the changing frequency distribution of various genotypes demands an increased emphasis on research for novel therapeutic regimens, evidence of high nosocomial transmission calls for immediate measures aimed at ensuring safe medical practices.

Modeling a dynamic bi-layer contact network of injection drug users and the spread of blood-borne infections

Injection drug users (IDUs) are at high risk of acquiring and spreading various blood-borne infections including human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV) and a number of sexually transmitted infections. These infections can spread among IDUs via risky sexual and needle-sharing contacts. To accurately model the spread of such contagions among IDUs, we build a bi-layer network that captures both types of risky contacts. We present methodology for inferring important model parameters, such as those governing network structure and dynamics, from readily available data sources (e.g., epidemiological surveys). Such a model can be used to evaluate the efficacy of various programs that aim to combat drug addiction and contain blood-borne diseases among IDUs. The model is especially useful for evaluating interventions that exploit the structure of the contact network. To illustrate, we instantiate a network model with data collected by a needle and syringe program in Chicago. We model sexual and needle-sharing contacts and the consequent spread of HIV and HCV. We use the model to evaluate the potential effects of a peer education (PE) program under different targeting strategies. We show that a targeted PE program would avert significantly more HIV and HCV infections than an untargeted program, highlighting the importance of reaching individuals who are centrally located in contact networks when instituting prevention programs.

Manual accidents, biological risk control, and quality indicators at a children's hospital in north-east Italy

Background

Working in health care carries the risk of transmission of infected blood to patients by hospital workers and to other health personnel in the form of occupational infections. Conscientious application of the standard precautions is the main method used to avoid needle stick injuries, contamination of skin and mucous membranes, cuts with sharp tools, and inadequate disposal and recapping of needles. The aim of this work was to investigate in Friuli Venezia Giulia, a region in north-east Italy, the enhancement carried out to prevent situations of biologic risk for health care workers, and to verify the related laboratory analyses.

Methods

Biological accidents occurring during the years 2012–2013 in the departments of oncology and pediatric-obstetric surgery, and in the intensive care unit at Burlo Garofolo Children’s Hospital in Trieste (a large town in Friuli Venezia Giulia) were reviewed, and a new panel of tests was introduced for patients and health care workers, to also detect human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV), and aspartate transaminase and immunoglobulin G. All tests were submitted for external quality assessment.

Results

In total, 230 nosocomial events were reported by health care workers in the above-mentioned hospital departments in 2012–2013. There were 158 accidents in 2012, including 55 accidental needle stick injuries (34.81%), 59 blood splashes (37.34%), and 44 cuts with infected instruments (27.84%). The risk of sustaining a cut was related to movement error during surgery when the appropriate procedure was not followed or when devices were being assembled and passed between doctors and nurses. Most accidents happened among physicians compared to nurses; the high percentage of needle stick injuries (34.81%) versus nurses (25.94%) were due to incorrect recapping of needles after use. No cases of health care workers being infected with HCV, HBV, or HIV were identified. In 2013, the number of biological accidents decreased to 61, comprising two needle stick injuries (3.27%), 35 blood splashes (57.37%), and 25 cuts with contaminated instruments (40.98%). The number of subcutaneous abscesses with scarring resulting from cuts with sharp instruments decreased from three in 2012 (one of which was the subject of medicolegal proceedings) to none in 2013. Although our study population was relatively small, we did detect a statistically significant decrease in the number of needle stick injuries (P<0.05, χ² test).

Conclusion

In this early experience at a maternal and child health institution in the Friuli Venezia Giulia region, application of a safety protocol, centralized organization of HIV tests, improved external quality assessment, and introduction of internal quality control for immunoglobulin G contributed to a decrease in the number of work-related biological accidents and their complications, which have the potential to result in medicolegal problems.

Cost effectiveness of screening strategies for early identification of HIV and HCV infection in injection drug users

OBJECTIVE

To estimate the cost, effectiveness, and cost effectiveness of HIV and HCV screening of injection drug users (IDUs) in opioid replacement therapy (ORT).

DESIGN

Dynamic compartmental model of HIV and HCV in a population of IDUs and non-IDUs for a representative U.S. urban center with 2.5 million adults (age 15-59).

METHODS

We considered strategies of screening individuals in ORT for HIV, HCV, or both infections by antibody or antibody and viral RNA testing. We evaluated one-time and repeat screening at intervals from annually to once every 3 months. We calculated the number of HIV and HCV infections, quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs).

RESULTS

Adding HIV and HCV viral RNA testing to antibody testing averts 14.8-30.3 HIV and 3.7-7.7 HCV infections in a screened population of 26,100 IDUs entering ORT over 20 years, depending on screening frequency. Screening for HIV antibodies every 6 months costs $30,700/QALY gained. Screening for HIV antibodies and viral RNA every 6 months has an ICER of $65,900/QALY gained. Strategies including HCV testing have ICERs exceeding $100,000/QALY gained unless awareness of HCV-infection status results in a substantial reduction in needle-sharing behavior.

DISCUSSION

Although annual screening for antibodies to HIV and HCV is modestly cost effective compared to no screening, more frequent screening for HIV provides additional benefit at less cost. Screening individuals in ORT every 3-6 months for HIV infection using both antibody and viral RNA technologies and initiating ART for acute HIV infection appears cost effective.

An overview about hepatitis C: a devastating virus

Hepatitis C (HCV) is the disease that has affected around 200 million people globally. HCV is a life threatening human pathogen, not only because of its high prevalence and worldwide burden but also because of the potentially serious complications of persistent HCV infection. Chronicity of the disease leads to cirrhosis, hepatocellular carcinoma and end-stage liver disease. HCV positive hepatocytes vary between less than 5% and up to 100%, indicating the high rate of replication of viral RNA. HCV has a very high mutational rate that enables it to escape the immune system. Viral diversity has two levels; the genotypes and Quasiaspecies. Major HCV genotypes constitute genotype 1, 2, 3, 4, 5 and 6 while more than 50 subtypes are known. All HCV genotypes have their particular patterns of geographical distribution and a slight drift in viral population has been observed in some parts of the globe.

Hepatitis C virus in Pakistan: a systematic review of prevalence, genotypes and risk factors

In Pakistan more than 10 million people are living with Hepatitis C virus (HCV), with high morbidity and mortality. This article reviews the prevalence, genotypes and factors associated with HCV infection in the Pakistani population. A literature search was performed by using the keywords; HCV prevalence, genotypes and risk factors in a Pakistani population, in Pubmed, PakMediNet and Google scholar. Ninety-one different studies dating from 1994 to May 2009 were included in this study, and weighted mean and standard error of each population group was calculated. Percentage prevalence of HCV was 4.95% +/- 0.53% in the general adult population, 1.72% +/- 0.24% in the pediatric population and 3.64% +/- 0.31% in a young population applying for recruitment, whereas a very high 57% +/- 17.7% prevalence was observed in injecting drug users and 48.67% +/- 1.75% in a multi-transfused population. Most prevalent genotype of HCV was 3a. HCV prevalence was moderate in the general population but very high in injecting drug users and multi-transfused populations. This data suggests that the major contributing factors towards increased HCV prevalence include unchecked blood transfusions and reuse of injection syringes. Awareness programs are required to decrease the future burden of HCV in the Pakistani population.

Impact of infection control activities on the rate of needle stick injuries at a tertiary care hospital of Pakistan over a period of six years: an observational study

Background

Accidental exposure to blood and body fluids is frequent among health care workers. They are at high risk of nosocomial transmission of blood borne pathogens due to injuries caused by used sharps. We are reporting impact of surveillance and educational program on the rate of needle stick injuries among health care workers at a tertiary care hospital in Pakistan.

Methods

At Aga Khan University Hospital sharp injuries are reported to infection control office. To reduce these incidents a quality improvement project was inducted in the year 2005. Health care workers were educated; surveillance data from 2002 to 2007 was analyzed and compared with various risk factors.

Results

During study period 1382 incidents were reported. Junior doctors sustained highest number of injuries (n = 394; 28.5%) followed by registered nurses (n = 283; 20.4%). Highest number of incidents was reported during blood collection (19%). An increasing trend was observed in the pre intervention years (2002–04). However noticeable fall was noted in the post intervention period that is in year 2006 and 2007. Major decline was noted among nurses (from 13 to 5 NSI/100 FTE/year). By relating and comparing the rates with various activities directly linked with the use of syringes a significant reduction in incidents were found including; hospital admissions (p-value 0.01), surgeries and procedures performed (p = 0.01), specimens collected in the laboratory (p = 0.001) and patients visits in clinics (p = 0.01).

Conclusion

We report significant reduction in needle stick injuries especially during post intervention study period. This is being achieved by constant emphasis on improving awareness by regular educational sessions, implemented as a quality improvement project.

Verletzungen mit Hepatitis-C-Virus-kontaminierten Nadeln

The risk of infection after injury with a needle contaminated with hepatitis C virus (HCV) is thought to be about 3%, but this assumption is mainly based on studies published in the 1990's, which were limited by small sample sizes and insensitive HCV-RNA assays. We therefore investigated needle injuries at the Hannover Medical School over a period of 6 years and performed a systematic review of the literature identifying 22 studies with a total of 6,956 injuries with HCV contaminated needles. Between 2000 and 2005, 1,431 occupational injuries were reported at our institution and two-thirds were needle injuries. Index patients were known to be HCV infected in 166 cases but there were no cases of HCV seroconversion during follow-up. Analysis of published data showed seroconversion rates of 0-10.3% with a mean of 0.75% (52/6,956). The risk of acute HCV infection was lower in Europe with 0.42% compared to Eastern Asia with 1.5% of cases where an HCV viremia was reported during follow-up. In summary, the risk of acquiring an HCV infection after a needlestick injury is lower than frequently reported. Worldwide differences in HCV seroconversion rates suggest that genetic factors might provide some level of natural resistance against HCV. Future studies should address not only the frequency of acute hepatitis but also factors associated with a higher risk of becoming HCV infected.

Poor knowledge--predictor of nonadherence to universal precautions for blood borne pathogens at first level care facilities in Pakistan

Background

We conducted an assessment of knowledge about blood borne pathogens (BBP) and use of universal precautions at first level care facilities (FLCF) in two districts of Pakistan.

Methods

We conducted a cross-sectional survey and selected three different types of FLCFs ; public, general practitioners and unqualified practitioners through stratified random sampling technique. At each facility, we interviewed a prescriber, a dispenser, and a housekeeper for knowledge of BBPs transmission and preventive practices, risk perception, and use of universal precautions. We performed multiple linear regression to assess the effect of knowledge score (11 items) on the practice of universal precautions score (4 items- use of gloves, gown, needle recapping, and HBV vaccination).

Results

We interviewed 239 subjects. Most of the participants 128 (53%) were recruited from general practitioners clinics and 166 (69.5%) of them were dispensers. Mean (SD) knowledge score was 3.8 (2.3) with median of 4. MBBS prescribers had the highest knowledge score while the housekeepers had the lowest. Mean universal precautions use score was 2.7 ± 2.1. Knowledge about mode of transmission and the work experience alone, significantly predicted universal precaution use in multiple linear regression model (adR² = 0.093).

Conclusion

Knowledge about mode of transmission of blood borne pathogens is very low. Use of universal precautions can improve with increase in knowledge.

Accidental exposure to HCV antibody-positive blood in hospital and pre-emptive one-shot interferon alpha-2b treatment

AIMS

Infection with hepatitis viruses following blood exposure accidents, such as needle stick injuries, is a serious issue for medical staff. In particular, although accidental exposure to hepatitis C virus (HCV) occurs frequently, postexposure prophylactic measures have not been established yet. In this study we investigate the efficacy of recombinant alpha-2b interferon (IFN) as a single, 10 MU intramuscular injection for preventing transmission.

METHODS

264 incidents of accidental blood to HCV antibody-positive blood, occurring between 1993 and 2003 in the Social Insurance Chukyo Hospital, were surveyed. Accident reports, which described in detail the circumstances and the presence or absence of infectious disease in the blood, and accidental exposure to HCV antibody-positive blood was investigated.

RESULTS

Pre-emptive IFN treatment was given in 115 out of 157 cases occurring between 1993 and 1998. One case developed acute HCV. Phylogenetic analysis provided evidence that the accident caused the infection and the patient was cured by immediate IFN therapy. Between 1999 and 2003, the exposed were in principle followed-up without IFN treatment; IFN treatment was only given when requested. As a result, IFN was given in 14 of 107 cases. During this period, no transmission was observed.

CONCLUSION

Taken together, the benefits of pre-emptive IFN treatment were considered unremarkable and a follow-up without treatment, or immediate IFN therapy after confirmation of the onset, was recommended.

Accidents with potentially hazardous biological material among workers in hospital supporting services

Descriptive study was carried out to characterize the occupational accidents involving potentially contaminated material among workers of hospital supporting services. The study reviewed records of workers involved in these accidents and attended at a specialized outpatient clinic of a large tertiary care hospital between January 1997 and October 2001. A total of 2814 workers from different professional categories were attended during this period. Of these, 147 (5.2%) belonged to the hospital supporting services and were the victims of 156 accidents, auxiliary cleaning personnel (80.2%), and over a third of the workers had not received any dose of hepatitis B vaccine (35.4%). Most accidents were due to sharp injuries (96.8%) caused by inadequately discarded hollow needles. Chemoprophylaxis for HIV was not indicated in only 23.1% of cases. We conclude that these workers are also exposed to the possibility of acquiring blood-borne pathogens and that periodical education programs are needed.

Management of healthcare workers after occupational exposure to hepatitis C virus

The increasing rate of hepatitis C virus (HCV) infection in the community means that there is increased risk of occupational exposure for healthcare workers. In metropolitan hospitals in Victoria, we found that 80-150 healthcare workers have occupational exposures from HCV-infected patients annually. As there is a 1.8%-3% risk of transmission of HCV from a needlestick injury, two to five healthcare workers are likely to acquire HCV each year in Victoria. These needlestick injuries pose a personal, legal and professional risk to healthcare workers and their patients. Recent information shows that early antiviral treatment of acute HCV infection has high cure rates. Current local and international protocols for management of healthcare workers exposed to HCV do not address these issues. We propose a management protocol after needlestick injury that is stratified according to the likelihood of HCV acquisition and potential risk of staff-to-patient transmission, and that is consistent with the current legal and clinical context of HCV infection in Australia.

Managing occupational risks for hepatitis C transmission in the health care setting

Hepatitis C virus (HCV) infection is a significant contemporary health problem in the United States and elsewhere. Because it is primarily transmitted via blood, hepatitis C infection presents risks for both nosocomial transmission to patients and occupational spread to health care workers. Recent insights into the pathogenesis, immunopathogenesis, natural history, and treatment of infection caused by this unique flavivirus provide a rationale for the use of new strategies for managing occupational hepatitis C infections when they occur. This article reviews this developing information. Recently published data demonstrate success rates in the treatment of "acute hepatitis C syndrome" that approach 100\%, and although these studies are not directly applicable to all occupational infections, they may provide important clues to optimal management strategies. In addition, the article delineates approaches to the prevention of occupational exposures and also addresses the difficult issue of managing HCV-infected health care providers. The article summarizes currently available data about the nosocomial epidemiology of HCV infection and the magnitude of risk and discusses several alternatives for managing exposure and infection. No evidence supports the use of immediate postexposure prophylaxis with immunoglobulin, immunomodulators, or antiviral agents. Based on the very limited data available, the watchful waiting and preemptive therapy strategies described in detail in this article represent reasonable interim approaches to the complex problem of managing occupational HCV infections, at least until more definitive data are obtained.

Occupational risk of blood-borne viruses in healthcare workers: a 5-year surveillance program

OBJECTIVE

This study presents the results of a 5-year surveillance program involving the prospective follow-up of healthcare workers (HCWs) in the Veneto region of Italy exposed to blood-borne viruses.

DESIGN

All HCWs who reported an occupational exposure to blood-borne infection joined the surveillance program. Both HCWs and patients were tested for viral markers (hepatitis B surface antigen [HBsAg], antibody to hepatitis B surface antigen [anti-HBs], antibody to hepatitis B core antigen [anti-HBc], antibody to hepatitis C virus [anti-HCV], HCV RNA, and antibody to human immunodeficiency virus [HIV]) and had these markers plus transaminases assayed at 3, 6, and 12 months and then yearly thereafter. Moreover, a program of hepatitis B virus (HBV) prophylaxis was offered to those whose anti-HBs levels were less than 10 IU/mL.

PARTICIPANTS

Two hundred forty-five HCWs (156 women and 89 men) with a mean age of 37 (+/- 10) years who reported occupational exposure during the 5-year period.

RESULTS

At the time of exposure, 1 HCW was positive for HBsAg (0.4%) and 2 were positive for HCV RNA (0.8%). Among the patients involved, 28 (11.4%) were positive for HBsAg, 68 (27.8%) were positive for HCV RNA, 6 (2.4%) were positive for HIV, and 147 (60.0%) were negative for all viral markers (4 patients were positive for both HCV and HIV). During the follow-up period after exposure (mean, 2.7 [+/- 1.6] years), there was no increase in transaminases or seroconversions to any of the viral markers.

CONCLUSION

Our accurate postexposure follow-up revealed a lack of transmission of HBV, HCV, and HIV.

Preventing the spread of hepatitis B and C viruses: where are germicides relevant?

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are the most prevalent bloodborne pathogens. Infections caused by these organisms can become chronic and may lead to liver cirrhosis and carcinoma. Limited chemotherapy is now available, but only HBV can be prevented through vaccination. Both viruses are enveloped and relatively sensitive to many physical and chemical agents; their ability to survive in the environment may not be as high as often believed. As a result, their spread occurs mainly through direct parenteral or percutaneous exposure to tainted body fluids and tissues. Careful screening of and avoiding contact with such materials remain the most effective means of protection. Nevertheless, the indirect spread of these viruses, although much less common, can occur when objects that are freshly contaminated with tainted blood enter the body or contact damaged skin. Germicidal chemicals are important in the prevention of HBV and HCV spread through shared injection devices, sharps used in personal services (such as tattooing and body piercing), and heat-sensitive medical/dental devices (such as flexible endoscopes) and in the cleanup of blood spills. Microbicides in vaginal gels may also interrupt their transmission. General-purpose environmental disinfection is unlikely to play a significant role in the prevention of the transmission of these viruses. Testing of low-level disinfectants and label claims for such products against HBV and HCV should be discouraged. Both viruses remain difficult to work with in the laboratory, but closely related animal viruses (such as the duck HBV) and the bovine viral diarrhea virus show considerable promise as surrogates for HBV and HCV, respectively. Although progress in the culturing of HBV and HCV is still underway, critical issues on virus survival and inactivation should be addressed with the use of these surrogates.

Hepatitis C screening and prevalence among urban public safety workers

This study examines the prevalence of anti-hepatitis C virus by using an enzyme-linked immunoassay test (EIA-2) in 2447 volunteers (including 1560 police, 678 fire, and 209 emergency medical service personnel) and a self-reported questionnaire on potential occupational and non-occupational risk factors. Subjects consisted of 76% men, 54.8% blacks, and 40.3% whites. Twenty-eight individuals (1.1%) tested positive, with prevalence rates of 1.1% and 1.3%, respectively, among blacks and whites. Although firefighters and emergency medical service workers had a higher prevalence (2.3% and 2.8%) than police (0.6%), the overall prevalence was lower than that typical of urban populations. In a multivariate analysis, the most important risk factors were behavioral, with no significant occupational exposure risk observed. Previously reported racial differences were not detected in this study, most likely because the subjects were of similar socioeconomic status.

Risk of infection from needle reuse at a phlebotomy center

OBJECTIVES

This study determined infection risk for HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) from needle reuse at a phlebotomy center that possibly exposed 3810 patients to infection.

METHODS

We used a model for the risk of infection per blood draw, supplemented by subsequent testing results from 1699 patients.

RESULTS

The highest risk of transmission was for HBV infection: 1.1 x 10(-6) in the best case and 1.2 x 10(-3) in the (unlikely) worst case. Subsequent testing yielded prevalence rates of 0.12%, 0.41%, and 0.88% for HIV, HBV, and HCV, respectively, lower than National Health and Nutrition Examination Survey III prevalence estimates.

CONCLUSIONS

The infection risk was very low; few, if any, transmissions are likely to have occurred.

Hepatitis C virus transmission in a pediatric oncology ward: analysis of an outbreak and review of the literature

Hospital-related hepatitis C virus (HCV) infections continue to occur even after the introduction of blood donor screening. We report an outbreak of HCV in nine patients of a pediatric oncology ward in 1996/1997. Sequencing of the hypervariable genomic region 1 (HVR1) of the E2/NS1 region showed near identity between HCV isolates from these patients as evidence for infection with the same virus. Despite a detailed and careful investigation, the source of infection and the mode of virus transmission could not be established. Based on a review of the current literature about nosocomial HCV infection and HCV infection in children, hypotheses for possible means of transmission in this outbreak are discussed.

Transmission of viral disease in the operating room setting

The transmission of viral disease in the operating room is an evolving problem. Advances in transfusion medicine have made blood supply safer than ever, whereas changes in transfusion practice have minimized the amount of blood transfused. The epidemiology of viral infection is changing in both the general population and among healthcare workers. Vaccination and prevention hold the key to future risk reduction for patients and providers.

The occupational hazards of emergency physicians

Emergency physicians are exposed to a variety of occupational hazards. Among these are infectious diseases, such the human immunodeficiency virus, hepatitis B and C viruses, and tuberculosis. Hepatitis G virus is transmissible but may not be a cause of illness. The likelihood of being exposed to these agents appears to be higher in the ED than other medical settings but estimates of the prevalence of these diseases in the ED vary, depending on the patient population served. Estimates of risk for contracting these infections are reviewed. Measures to prevent these exposures can reduce risk, but compliance is low, particularly for those involving changes in the behavior of emergency physicians (such as not recapping needles). Latex allergy is a hazard of health care workers. Its prevalence is reported to be quite high, but these findings are difficult to interpret in the absence of a universally accepted definition of the condition. Its prevalence in emergency physicians is not known. Other noninfectious hazards include workplace violence and exposure to nitrous oxide. The health effects of rotating shift work may put emergency physicians at increased risk of coronary artery disease and impaired reproductive health. Emotional stress is another hazard of emergency physicians, and may lead to burnout.

Hepatitis C: public health strategies

Hepatitis C virus (HCV) is a major global public health problem. As with many recently discovered diseases, there is still considerable controversy within the scientific community regarding the prevalence, incidence and socio-economic burden of acute and chronic hepatitis C. New infections continue to occur. Given the substantial morbidity and mortality attributable to HCV-related chronic liver disease, each country, irrespective of its economic status, should develop an HCV-related public health plan for the prevention of new HCV infections. The source of HCV infection includes transfusion of blood or blood products from unscreened donors, transfusion of blood products that have not undergone viral inactivation, parenteral exposure to blood through the use of contaminated and inadequately sterilized instruments and needles used in medical, dental and "traditional" medicine, individuals undergoing procedures such as haemodialysis, persons who participate in high risk sexual practices, household or sexual contacts with HCV-infected persons and infants of HCV-infected mothers. In many countries, the relative contribution of the various sources of infection has not been defined with population-based epidemiological studies. Wherever possible, such studies should be performed to enable countries to prioritise their preventive measures and to make the most appropriate use of available resources.