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Guthrie S, Bienkowska-Gibbs T, Manville C, Pollitt A, Kirtley A, Wooding S. The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation. Health Technol Assess 2016; 19:1-291. [PMID: 26307643 DOI: 10.3310/hta19670] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme supports research tailored to the needs of NHS decision-makers, patients and clinicians. This study reviewed the impact of the programme, from 2003 to 2013, on health, clinical practice, health policy, the economy and academia. It also considered how HTA could maintain and increase its impact. METHODS Interviews (n = 20): senior stakeholders from academia, policy-making organisations and the HTA programme. Bibliometric analysis: citation analysis of publications arising from HTA programme-funded research. Researchfish survey: electronic survey of all HTA grant holders. Payback case studies (n = 12): in-depth case studies of HTA programme-funded research. RESULTS We make the following observations about the impact, and routes to impact, of the HTA programme: it has had an impact on patients, primarily through changes in guidelines, but also directly (e.g. changing clinical practice); it has had an impact on UK health policy, through providing high-quality scientific evidence - its close relationships with the National Institute for Health and Care Excellence (NICE) and the National Screening Committee (NSC) contributed to the observed impact on health policy, although in some instances other organisations may better facilitate impact; HTA research is used outside the UK by other HTA organisations and systematic reviewers - the programme has an impact on HTA practice internationally as a leader in HTA research methods and the funding of HTA research; the work of the programme is of high academic quality - the Health Technology Assessment journal ensures that the vast majority of HTA programme-funded research is published in full, while the HTA programme still encourages publication in other peer-reviewed journals; academics agree that the programme has played an important role in building and retaining HTA research capacity in the UK; the HTA programme has played a role in increasing the focus on effectiveness and cost-effectiveness in medicine - it has also contributed to increasingly positive attitudes towards HTA research both within the research community and the NHS; and the HTA focuses resources on research that is of value to patients and the UK NHS, which would not otherwise be funded (e.g. where there is no commercial incentive to undertake research). The programme should consider the following to maintain and increase its impact: providing targeted support for dissemination, focusing resources when important results are unlikely to be implemented by other stakeholders, particularly when findings challenge vested interests; maintaining close relationships with NICE and the NSC, but also considering other potential users of HTA research; maintaining flexibility and good relationships with researchers, giving particular consideration to the Technology Assessment Report (TAR) programme and the potential for learning between TAR centres; maintaining the academic quality of the work and the focus on NHS need; considering funding research on the short-term costs of the implementation of new health technologies; improving the monitoring and evaluation of whether or not patient and public involvement influences research; improve the transparency of the priority-setting process; and continuing to monitor the impact and value of the programme to inform its future scientific and administrative development.
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Sarin SK, Kumar M, Lau GK, Abbas Z, Chan HLY, Chen CJ, Chen DS, Chen HL, Chen PJ, Chien RN, Dokmeci AK, Gane E, Hou JL, Jafri W, Jia J, Kim JH, Lai CL, Lee HC, Lim SG, Liu CJ, Locarnini S, Al Mahtab M, Mohamed R, Omata M, Park J, Piratvisuth T, Sharma BC, Sollano J, Wang FS, Wei L, Yuen MF, Zheng SS, Kao JH. Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update. Hepatol Int 2016; 10:1-98. [PMID: 26563120 PMCID: PMC4722087 DOI: 10.1007/s12072-015-9675-4] [Citation(s) in RCA: 1746] [Impact Index Per Article: 218.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023]
Abstract
Worldwide, some 240 million people have chronic hepatitis B virus (HBV), with the highest rates of infection in Africa and Asia. Our understanding of the natural history of HBV infection and the potential for therapy of the resultant disease is continuously improving. New data have become available since the previous APASL guidelines for management of HBV infection were published in 2012. The objective of this manuscript is to update the recommendations for the optimal management of chronic HBV infection. The 2015 guidelines were developed by a panel of Asian experts chosen by the APASL. The clinical practice guidelines are based on evidence from existing publications or, if evidence was unavailable, on the experts' personal experience and opinion after deliberations. Manuscripts and abstracts of important meetings published through January 2015 have been evaluated. This guideline covers the full spectrum of care of patients infected with hepatitis B, including new terminology, natural history, screening, vaccination, counseling, diagnosis, assessment of the stage of liver disease, the indications, timing, choice and duration of single or combination of antiviral drugs, screening for HCC, management in special situations like childhood, pregnancy, coinfections, renal impairment and pre- and post-liver transplant, and policy guidelines. However, areas of uncertainty still exist, and clinicians, patients, and public health authorities must therefore continue to make choices on the basis of the evolving evidence. The final clinical practice guidelines and recommendations are presented here, along with the relevant background information.
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Affiliation(s)
- S K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - M Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - G K Lau
- Division of Gastroenterology and Hepatology, Humanity and Health Medical Centre, Hong Kong SAR, China
- The Institute of Translational Hepatology, Beijing, China
| | - Z Abbas
- Department of Hepatogastroenterlogy, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - H L Y Chan
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - C J Chen
- Genomics Research Center, Academia Sinica, National Taiwan University, Taipei, Taiwan
| | - D S Chen
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - H L Chen
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - P J Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - R N Chien
- Liver Research Unit, Chang Gung Memorial Hospital and University, Chilung, Taiwan
| | - A K Dokmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Ed Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - J L Hou
- Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Guangzhou, China
| | - W Jafri
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - J Jia
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | | | - C L Lai
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - H C Lee
- Internal Medicine Asan Medical Center, Seoul, Korea
| | - S G Lim
- Division of Gastroenterology and Hepatology, National University Health System, Singapore, Singapore
| | - C J Liu
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - S Locarnini
- Research and Molecular Development, Victorian Infectious Diseases Reference Laboratory, Melbourne, Australia
| | - M Al Mahtab
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - R Mohamed
- Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - M Omata
- Yamanashi Hospitals (Central and Kita) Organization, 1-1-1 Fujimi, Kofu-shi, Yamanashi, 400-8506, Japan
| | - J Park
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - T Piratvisuth
- NKC Institute of Gastroenterology and Hepatology, Prince of Songkla University, Songkhla, Thailand
| | - B C Sharma
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
| | - J Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - F S Wang
- Treatment and Research Center for Infectious Diseases, Beijing 302 Hospital, Beijing, China
| | - L Wei
- Peking University Hepatology Institute, Beijing, China
| | - M F Yuen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Hong Kong, Pofulam, Hong Kong
| | - S S Zheng
- Department of Hepatobiliary and Pancreatic Surgery, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China
| | - J H Kao
- Graduate Institute of Clinical Medicine and Hepatitis Research Center, National Taiwan University College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Lewis JD, Enfield KB, Sifri CD. Hepatitis B in healthcare workers: Transmission events and guidance for management. World J Hepatol 2015; 7:488-97. [PMID: 25848472 PMCID: PMC4381171 DOI: 10.4254/wjh.v7.i3.488] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 11/22/2014] [Accepted: 12/16/2014] [Indexed: 02/06/2023] Open
Abstract
Hepatitis B virus (HBV) is the most efficiently transmissible of the bloodborne viruses that are important in healthcare settings. Healthcare workers (HCWs) are at risk for exposure to HBV from infected patients and, if infected, are similarly at risk of transmitting HBV to patients. Published cases of HBV transmission from HCW to patient are relatively rare, having decreased in frequency following the introduction of standard (universal) precautions, adoption of enhanced percutaneous injury precautions such as double-gloving in surgery, and routine HBV vaccination of HCWs. Here we review published cases of HCW-to-patient transmission of HBV, details of which have helped to guide the creation of formal guidelines for the management of HBV-infected HCWs. We also compare the published guidelines for the management of HBV-infected HCWs from various governing bodies, focusing on their differences with regard to vaccination requirements, viral load limits, frequency of monitoring, and restrictions on practice. Importantly, while there are differences among the recommendations from governing bodies, no guidelines uniformly restrict HBV-infected HCWs from performing invasive or exposure-prone procedures.
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Affiliation(s)
- Jessica D Lewis
- Jessica D Lewis, Costi D Sifri, Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, United States
| | - Kyle B Enfield
- Jessica D Lewis, Costi D Sifri, Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, United States
| | - Costi D Sifri
- Jessica D Lewis, Costi D Sifri, Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, United States
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Sugimoto S, Nagakubo S, Ito T, Tsunoda Y, Imamura S, Tamura T, Morohoshi Y, Koike Y, Fujita Y, Ito S, Fujita S, Tachikawa N, Komatsu H. A case of acute hepatitis B related to previous gynecological surgery in Japan. J Infect Chemother 2012; 19:524-9. [PMID: 23011232 DOI: 10.1007/s10156-012-0477-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 09/06/2012] [Indexed: 01/27/2023]
Abstract
A 41-year-old woman became ill with acute hepatitis B after gynecological surgery performed by a surgeon who was hepatitis B surface antigen positive. The surgeon was positive for hepatitis B e antigen, and HBV DNA concentrations in the serum, saliva, and sweat of the surgeon were very high. HBV genotype and partial HBV DNA sequences from the HBV-infected surgeon were identical to those in the HBV-infected patient. Extensive research by the committee including infection control and prevention specialists judged the source of infection to be a surgeon infected with HBV. Transmission of HBV from a healthcare worker to patients who are not immune to HBV can actually happen. This case report illustrates the importance of a stringent policy of a nationwide HBV universal vaccination program.
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Affiliation(s)
- Shinya Sugimoto
- Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, 56 Okazawa-cho, Hodogaya-ku, Yokohama, Kanagawa, 240-8555, Japan
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Bhat M, Ghali P, Deschenes M, Wong P. Hepatitis B and the infected health care worker: public safety at what cost? CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:257-60. [PMID: 22590698 PMCID: PMC3352840 DOI: 10.1155/2012/348240] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 08/16/2011] [Indexed: 02/06/2023]
Abstract
Public safety and the right of the health care worker to practise without prejudice based on underlying illness may be at odds for those affected by the hepatitis B virus (HBV). Nevertheless, HBV does not preclude entry into a health care profession, and the risk of transmission from health care worker to patient is not uniform across the spectrum of health care fields. In the present article, the authors present an overview of the literature regarding transmission of HBV from the health care worker to the patient, and the current recommendations that vary from province to province within Canada. The establishment of national guidelines to standardize monitoring of HBV infection among health care workers would improve health care workplace safety and patient care.
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Affiliation(s)
- Mamatha Bhat
- Department of Gastroenterology & Hepatology, McGill University Health Centre, Montreal, Quebec, Canada.
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Buster EHCJ, van der Eijk AA, de Man RA, Schalm SW. Doctor-to-patient transmission of Hepatitis B virus: the potential of antiviral therapy for prevention. Scand J Gastroenterol 2009:45-9. [PMID: 15696849 DOI: 10.1080/00855920410010997] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Hepatitis B virus (HBV)-infected health-care workers (HCWs) have infected patients during medical procedures. In many countries HBV-infected HCWs are restricted in performing exposure prone procedures based on either HBeAg status or serum HBV DNA level. To prevent loss of skilled HCWs and to minimize transmission risk, highly viraemic HCWs can be offered antiviral therapy. Nucleoside analogues have proven to be effective in reducing transmission of HIV and HBV in the setting of vertical mother-to-infant transmission. Following the same rationale, suppression of viral load in HBV-infected HCWs could minimize the risk of doctor-to-patient transmission to such an extent that job modifications are no longer indicated. To limit the risk of drug resistance, the use of combination therapy is advocated. We describe two chronic HBV-infected HCWs treated with antiviral therapy, eventually leading to well-tolerated and highly effective combination therapy with lamivudine and tenofovir, with continuation of medical practice.
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Affiliation(s)
- E H C J Buster
- Dept. of Gastroenterology & Hepatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
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7
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Rosenheim M, Cadranel JF, Stuyver L, Dorent R, Golliot F, Astagneau P, Di Martino V, Delcourt A, Gandjbakhch I, Huraux JM, Lunel F. Nosocomial transmission of hepatitis B virus associated with endomyocardial biopsy. ACTA ACUST UNITED AC 2006; 30:1274-80. [PMID: 17185969 DOI: 10.1016/s0399-8320(06)73535-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES A high prevalence of chronic hepatitis B has been previously reported in heart transplant recipients in our center. Nosocomial transmission of hepatitis B has been therefore suggested. The aim of the present study was to investigate an outbreak of hepatitis B infection in heart transplant recipients and to to look for nosocomial acquisition of hepatitis B in these patients. METHODS In a retrospective case-control study, review of transvenous endomyocardial biopsy (TEB) procedure, line probe assay and DNA sequencing for characterization of the outbreak isolate genotypes were performed in order to assess the possible risk of nosocomial transmission of hepatitis B in the setting of heart transplantation. Case was defined as a patient negative for HBsAg before heart transplantation and positive after. Controls were matched with cases by date of transplantation and time-interval of HBV infection occurrence in the cases patients. RESULTS Transmission of HBV was associated with the number of HBsAg positive patients undergoing TEB the same day and in the same ward (OR=1.17, per additional encounter; 95%CI=1.01-1.37, P=0.02) and with the total number of TEB undergone after a HBsAg positive patient (OR=1.43 for additional encounter, 95%CI=0.97-2.1, P=0.056) but not with the number of biopsies. The virological study identified eight different strains. No common devices nor gloves, drapes, or medical solution were shared among patients during TEB. One staff member, but no surgeon, was HBsAg positive. No further case occurred after implementation of control measures. CONCLUSIONS Patient-to-patient transmission during TEB sessions was demonstrated by the virological and the case-control studies. This transmission occurred without evidence of blood contact through vials or devices. There is strong evidence that this transmission may be due to the spread of infective blood droplets on the environmental surfaces and the material during the TEB procedure.
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Affiliation(s)
- Michel Rosenheim
- Service de Santé Publique, Groupe Hospitalier Pitié Salpétrière, Paris.
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8
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Reitsma AM, Closen ML, Cunningham M, Lombardo PA, Minich HNF, Moreno JD, Nichols RL, Pearson RD, Sawyer RG, Wispelwey B, Tereskerz PM. Infected Physicians and Invasive Procedures: Safe Practice Management. Clin Infect Dis 2005; 40:1665-72. [PMID: 15889366 DOI: 10.1086/429821] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2004] [Accepted: 12/29/2004] [Indexed: 12/16/2022] Open
Abstract
There is currently no public policy that provides guidance concerning whether and when physicians infected with hepatitis B virus (HBV), hepatitis C virus (HCV), and/or human immunodeficiency virus (HIV) can safely perform invasive procedures. A committee of experts in the fields of medicine, law, and biomedical ethics and 1 community member, aided by an advisory board, was established to produce recommendations for policy reform. An extensive literature review was conducted for these 3 infectious diseases, medicine, surgery, epidemiology, law, and bioethics to gather all relevant data. Special recommendations are made regarding the management of physicians who are infected with HIV, HBV, and/or HCV. This policy proposal includes a list of exposure-prone procedures and a decision chart that indicates under what conditions infected physicians can practice beyond the need for disclosure of their serological status.
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Affiliation(s)
- Angelique M Reitsma
- The Center for Biomedical Ethics, University of Virginia Health Science Center, Charlottesville, VA 22908-0758, USA.
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9
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Affiliation(s)
- Miriam J Alter
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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10
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Bruguera M, Forns X. Epidemiología actual de las hepatitis virales: ¿quién las padece y quién puede protegerse? Enferm Infecc Microbiol Clin 2004; 22:443-7. [PMID: 15482684 DOI: 10.1016/s0213-005x(04)73137-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
MESH Headings
- Adult
- Child
- Child, Preschool
- Female
- Food Contamination/prevention & control
- Food Handling
- Hepatitis, Viral, Human/congenital
- Hepatitis, Viral, Human/epidemiology
- Hepatitis, Viral, Human/prevention & control
- Hepatitis, Viral, Human/transmission
- Humans
- Infant
- Infant, Newborn
- Male
- Middle Aged
- Occupational Diseases/epidemiology
- Occupational Diseases/prevention & control
- Pregnancy
- Pregnancy Complications, Infectious
- Prevalence
- Renal Dialysis
- Risk Factors
- Seafood/virology
- Sexual Behavior
- Spain/epidemiology
- Substance Abuse, Intravenous
- Transfusion Reaction
- Transplantation/adverse effects
- Vaccination
- Viral Hepatitis Vaccines
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Johnston BL, Conley JM. Nosocomial transmission of bloodborne viruses from infected health care workers to patients. Can J Infect Dis 2003; 14:192-6. [PMID: 18159455 PMCID: PMC2094936 DOI: 10.1155/2003/567290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023] Open
Affiliation(s)
- B Lynn Johnston
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia
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12
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Affiliation(s)
- W. Keith Paver
- PHLS North West, Public Health Laboratory, Withington Hospital, Manchester, UK; and
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13
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Puro V, De Carli G, Scognamiglio P, Porcasi R, Ippolito G. Risk of HIV and other blood-borne infections in the cardiac setting: patient-to-provider and provider-to-patient transmission. Ann N Y Acad Sci 2001; 946:291-309. [PMID: 11762993 DOI: 10.1111/j.1749-6632.2001.tb03918.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Health care workers (HCWs) face a well-recognized risk of acquiring blood-borne pathogens in their workplace, in particular hepatitis B and C viruses (HBV/HBC) and human immunodeficiency virus (HIV). Additionally, infected HCWs performing invasive exposure-prone procedures, including in the cardiac setting, represent a potential risk for patients. An increasing number of infected persons could need specific cardiac diagnostic procedures and surgical treatment in the future, regardless of their sex or age. The risk of acquiring HIV, HCV, HBV infection after a single at-risk exposure averages 0.5%, and 1-2%, and 4-30%, respectively. The frequency of percutaneous exposure ranges from 1 to 15 per 100 surgical interventions, with cardiothoracic surgery reporting the highest rates of exposures; mucocutaneous contamination by blood-splash occurs in 50% of cardiothoracic operations. In the Italian Surveillance (SIROH), a total of 987 percutaneous and 255 mucocutaneous exposures were reported in the cardiac setting; most occurred in cardiology units (46%), and in cardiovascular surgery (44%). Overall, 257 source patients were anti-HCV+, 54 HBsAg+, and 14 HIV+. No seroconversions were observed. In the literature, 14 outbreaks were reported documenting transmission of HBV from 12 infected HCWs to 107 patients, and 2 cases of HCV to 6 patients, during cardiothoracic surgery, especially related to sternotomy and its suturing. The transmission rate was estimated to be 5% to 13% for HBV, and 0.36% to 2.25% for HCV. Strategies in risk reduction include adequate surveillance, education, effective sharps disposal, personal protective equipment, safety devices, and innovative technology-based intraoperative procedures.
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Affiliation(s)
- V Puro
- Dipartimento di Epidemiologia, Istituto Nazionale per le Malattie Infettive Lazzaro Spallanzani-IRCCS, Rome, Italy.
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Abstract
Viruses are important causes of nosocomial infection, but the fact that hospital outbreaks often result from introduction(s) from community-based epidemics, together with the need to initiate specific laboratory testing, means that there are usually insufficient data to allow the monitoring of trends in incidences. The most important defenses against nosocomial transmission of viruses are detailed and continuing education of staff and strict adherence to infection control policies. Protocols must be available to assist in the management of patients with suspected or confirmed viral infection in the health care setting. In this review, we present details on general measures to prevent the spread of viral infection in hospitals and other health care environments. These include principles of accommodation of infected patients and approaches to good hygiene and patient management. They provide detail on individual viral diseases accompanied in each case with specific information on control of the infection and, where appropriate, details of preventive and therapeutic measures. The important areas of nosocomial infection due to blood-borne viruses have been extensively reviewed previously and are summarized here briefly, with citation of selected review articles. Human prion diseases, which present management problems very different from those of viral infection, are not included.
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Affiliation(s)
- C Aitken
- Department of Virology, St. Bartholomew's and the Royal London Hospital, London EC1A 7BE, United Kingdom.
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15
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Ross RS, Viazov S, Gross T, Hofmann F, Seipp HM, Roggendorf M. Transmission of hepatitis C virus from a patient to an anesthesiology assistant to five patients. N Engl J Med 2000; 343:1851-4. [PMID: 11117977 DOI: 10.1056/nejm200012213432505] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- R S Ross
- Institute of Virology, National Reference Center for Hepatitis C, University of Essen, Germany.
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Abstract
Exposure to blood-borne pathogens poses a serious risk to health care workers (HCWs). We review the risk and management of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections in HCWs and also discuss current methods for preventing exposures and recommendations for postexposure prophylaxis. In the health care setting, blood-borne pathogen transmission occurs predominantly by percutaneous or mucosal exposure of workers to the blood or body fluids of infected patients. Prospective studies of HCWs have estimated that the average risk for HIV transmission after a percutaneous exposure is approximately 0.3%, the risk of HBV transmission is 6 to 30%, and the risk of HCV transmission is approximately 1.8%. To minimize the risk of blood-borne pathogen transmission from HCWs to patients, all HCWs should adhere to standard precautions, including the appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments. Employers should have in place a system that includes written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational exposures that may place a worker at risk of blood-borne pathogen infection. A sustained commitment to the occupational health of all HCWs will ensure maximum protection for HCWs and patients and the availability of optimal medical care for all who need it.
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17
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Beltrami EM, Williams IT, Shapiro CN, Chamberland ME. Risk and management of blood-borne infections in health care workers. Clin Microbiol Rev 2000; 13:385-407. [PMID: 10885983 PMCID: PMC88939 DOI: 10.1128/cmr.13.3.385] [Citation(s) in RCA: 146] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Exposure to blood-borne pathogens poses a serious risk to health care workers (HCWs). We review the risk and management of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections in HCWs and also discuss current methods for preventing exposures and recommendations for postexposure prophylaxis. In the health care setting, blood-borne pathogen transmission occurs predominantly by percutaneous or mucosal exposure of workers to the blood or body fluids of infected patients. Prospective studies of HCWs have estimated that the average risk for HIV transmission after a percutaneous exposure is approximately 0.3%, the risk of HBV transmission is 6 to 30%, and the risk of HCV transmission is approximately 1.8%. To minimize the risk of blood-borne pathogen transmission from HCWs to patients, all HCWs should adhere to standard precautions, including the appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments. Employers should have in place a system that includes written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational exposures that may place a worker at risk of blood-borne pathogen infection. A sustained commitment to the occupational health of all HCWs will ensure maximum protection for HCWs and patients and the availability of optimal medical care for all who need it.
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Affiliation(s)
- E M Beltrami
- HIV Infections Branch, Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Public Health Service, U.S. Department of Health and Human Services, Atlanta, Georgia 30333, USA.
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18
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Rosenheim M, Astagneau P, Dorent R, Lunel F, Stuyver L, Golliot F, Delcourt A, Cadranel JF, Brucker G, Gandbakhch I, Huraux J. Transmission nosocomiale du virus de l'hépatite Bassociée au cathétérisme veineux chez des transplantés cardiaques. Med Mal Infect 1998. [DOI: 10.1016/s0399-077x(98)80030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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19
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Abstract
The relationship between infection control standards and surgical gloving practices is an important issue in combating infectious disease. For their own and their patients' protection, health care personnel must rely on the barrier qualities of gloves more than ever before. Both surgical and examination gloves fail frequently, which puts health care providers and patients at risk of acquiring fluid-borne pathogens. This paper discusses current guidelines, the risk of infection by viral and bacterial pathogens, controversial issues involving gloving practices, and recommendations to improve infection control practices.
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Affiliation(s)
- D Rabussay
- Department of Biology, San Diego State University, CA, USA
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20
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Abstract
BACKGROUND Transmission of hepatitis B virus (HBV) to patients by infected surgeons who carry hepatitis B e antigen (HBeAg) has been documented repeatedly. In the United Kingdom HBeAg-positive surgeons are not permitted to perform certain procedures that carry a risk that patients might be exposed to the blood of a health care worker. There are no practice restrictions for carriers of hepatitis B surface antigen without detectable HBeAg, unless transmission has been demonstrated. METHODS In four unconnected cases of acute hepatitis B, surgery was identified as a possible source, so we tested the surgical teams for serologic markers of HBV infection. In each case a surgeon was found to be infected with the virus. HBV DNA was amplified by a nested polymerase chain reaction from serum from the four infected surgeons and the four patients, and direct nucleotide sequencing of two regions of the HBV genome was performed. Alternative sources of infection were ruled out. Other patients on whom three of the surgeons had recently performed procedures were offered testing. RESULTS All four surgeons were carriers of HBV, but none had detectable serum HBeAg. The nucleotide sequences of HBV DNA from the surgeons were indistinguishable from those from the corresponding patients. The screening of other exposed patients identified at least two other patients who had probably acquired hepatitis B infection from one of these surgeons. CONCLUSIONS Surgeons who are carriers of HBV without detectable serum HBeAg can transmit HBV to patients during procedures.
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21
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Esteban JI, Gómez J, Martell M, Cabot B, Quer J, Camps J, González A, Otero T, Moya A, Esteban R. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996; 334:555-60. [PMID: 8569822 DOI: 10.1056/nejm199602293340902] [Citation(s) in RCA: 222] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND In the course of a study conducted in 1992 through 1994 of the efficacy of screening blood donors for antibodies to hepatitis C virus (HCV), we found that two patients had acquired hepatitis C after cardiac surgery, with the transmission apparently unrelated to blood transfusions. Because their surgeon had chronic hepatitis C, we sought to determine whether he was transmitting the virus to his patients. METHODS Of 222 of the surgeon's patients who participated in studies of post-transfusion hepatitis between 1988 and 1994, 6 contracted postoperative hepatitis C, despite the use of only seronegative blood for transfusions. All six patients had undergone valve-replacement surgery. Analyses were performed to compare nucleotide sequences encompassing the hypervariable region at the junction between the coding regions for envelope glycoproteins E1 and E2 in the surgeon, the patients, and 10 controls infected with the same HCV genotype. RESULTS The surgeon and five of the six patients with hepatitis C unrelated to transfusion were infected with HCV genotype 3; the sixth patient had genotype 1 and was considered to have been infected from another source. Thirteen other patients of the surgeon had transfusion-associated hepatitis C and were also infected with genotype 1. The average net genetic distance between the sequences from the five patients with HCV genotype 3 and those from the surgeon was 2.1 percent (range, 1.1 to 2.5 percent; P < 0.001), as compared with an average distance of 7.6 percent (range, 6.1 to 8.3 percent) between the sequences from the patients and those from the controls. The results of phylogenetic-tree analysis indicated a common epidemiologic origin of the viruses from the surgeon and the five patients. CONCLUSIONS Our findings provide evidence that a cardiac surgeon with chronic hepatitis C may have transmitted HCV to five of his patients during open-heart surgery.
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Affiliation(s)
- J I Esteban
- Department of Medicine, Hospital General Universitari Vall d'Hebron, Universitat Autònoma, Barcelona, Spain
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22
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Harpaz R, Von Seidlein L, Averhoff FM, Tormey MP, Sinha SD, Kotsopoulou K, Lambert SB, Robertson BH, Cherry JD, Shapiro CN. Transmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control. N Engl J Med 1996; 334:549-54. [PMID: 8569821 DOI: 10.1056/nejm199602293340901] [Citation(s) in RCA: 162] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although about 1 percent of surgeons are infected with hepatitis B virus (HBV), transmission from surgeons to patients is thought to be uncommon. In July 1992, a 47-year-old woman became ill with acute hepatitis B after undergoing a thymectomy in which a thoracic-surgery resident who had had acute hepatitis B six months earlier assisted. METHODS To determine whether the surgeon transmitted HBV to this patient and others, we conducted chart reviews, interviews, and serologic testing of thoracic-surgery patients at the two hospitals where the surgeon worked from July 1991 to July 1992. Hepatitis B surface antigen (HBsAg) subtypes and DNA sequences from the surgeon and from infected patients were determined. RESULTS Of 144 susceptible patients in whose surgery the infected surgeon participated, 19 had evidence of recent HBV infection (13 percent). One of the hospitals was selected for additional study, and none of the 124 susceptible patients of the other thoracic surgeons at this hospital had evidence of recent HBV infection (relative risk, infinity; 95 percent confidence interval, 4.7 to infinity). No evidence was found for any common source of HBV other than the infected surgeon. The HBsAg subtype and the partial HBV DNA sequences from the surgeon were identical to those in the infected patients. Transmission of the infection was associated with cardiac transplantation (relative risk, 4.9; 95 percent confidence interval, 1.5 to 15.5) but not with other surgical procedures. The surgeon was positive for hepatitis B e antigen and had a high serum HBV DNA concentration (15 ng per milliliter). Our investigations identified no deficiencies in the surgeon's infection-control practices. CONCLUSIONS In this outbreak there was surgeon-to-patient HBV transmission despite apparent compliance with recommended infection-control practices. We could not identify any specific events that led to transmission.
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Affiliation(s)
- R Harpaz
- Hepatitis Branch, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
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23
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Brucker G. Les risques de transmission d'une infection du personnel soignant vers les patients. Med Mal Infect 1995. [DOI: 10.1016/s0399-077x(05)81355-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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24
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Abstract
Much attention has been directed towards nosocomial transmission of viruses as a result of clear evidence of patient-to-staff and staff-to-patient transmission of the blood-borne viruses HIV and hepatitis B virus. Although the relatively long incubation periods of these viruses, together with the frequency of asymptomatic infections, renders problems for surveillance it has been possible to study modes of transmission and levels of risk over a number of years. Information on trends of incidence of other nosocomial virus infections has been difficult to obtain for a number of reasons. Often, an outbreak in the health care setting parallels an epidemic in the community. Although it may be possible to define nosocomial transmission from recording dates of onset of illness relative to admission date and, at times, demonstrate circulation of a common strain by molecular techniques, the relative contributions of patient-to-staff and staff-to-patient transmission may be difficult to clarify. In this review, details are presented of the major viruses associated with nosocomial transmission with examples of infections to and from staff where these have occurred. The major defences against patient-to-staff and staff-to-patient transmission are awareness of potential risks, education and adherence to infection control policies, immunization of staff, effective decontamination and sterilization and the adoption of 'Universal Precautions' in patient care. In addition, there may be occasions when additional measures should be considered including isolation, cohorting and the use of specific chemo- and immunoprophylaxis.
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Affiliation(s)
- D J Jeffries
- Department of Virology, Medical College of St Bartholomew's Hospital, West Smithfield, London, UK
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25
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Schaffner W, Mishu-Allos B. Protecting patients when their surgeon or dentist is infected with a blood-borne virus. J Hosp Infect 1995; 30 Suppl:156-62. [PMID: 7560946 DOI: 10.1016/0195-6701(95)90015-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The vast majority of surgeons and dentists infected with either hepatitis B or HIV do not transmit these infections to patients. When such transmission from health care provider to patients does occur, the precise mechanism of transmission usually remains enigmatic. Attempts to forestall these rare events have produced substantial debate as well as legislative and regulatory initiatives. The routine immunization of medical and dental students with hepatitis B vaccine will eventually eliminate surgeons and dentists as sources of this infection. Serological screening of surgeons and dentists for HIV infection has been considered impractical. Thus, emphasis has been placed on enhancing measures that reduce the risk of blood contact between health care provider and patient. These include developing safer techniques and procedures. When an infected surgeon or dentist is discovered, a review of their professional circumstances is undertaken. In the US many hepatitis B-infected persons are permitted to continue practice; most HIV-infected persons stop performing invasive procedures. Not completely reassured, some patients inquire of their dentist's or surgeon's HIV antibody status.
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Affiliation(s)
- W Schaffner
- Vanderbilt University School of Medicine, Nashville, TN 37232, USA
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26
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Abstract
Transmission of HIV from healthcare worker to patient has been documented in one report. Though the means of transmission in that case remains unknown, procedures that involve exposure to blood or mucous membranes are thought to carry an increased risk. Because of previous evidence of transmission of hepatitis B by cardiothoracic surgeons, they have been identified as a group known to perform exposure-prone invasive procedures with a risk of viral transmission. A retrospective review of 612 patients of a cardiothoracic surgeon who is HIV-positive was conducted in an attempt to identify any instance of viral transmission. A total of 189 patients received HIV testing and counseling. No positive test results were obtained.
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Affiliation(s)
- T J Babinchak
- Division of Infectious Diseases, Allegheny General Hospital, Pittsburgh 15212
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27
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Mishu B, Schaffner W. HIV Transmission from Surgeons and Dentists to Patients: Can Models Predict the Risk? Infect Control Hosp Epidemiol 1994. [DOI: 10.2307/30145552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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28
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Abstract
OBJECTIVES (1) To identify reasons for non-uptake of hepatitis B vaccine by health care staff; (2) to determine whether fully vaccinated staff are aware of the need to consider booster vaccinations in the future. DESIGN Semi-structured anonymous questionnaire survey of health care staff. SETTING Croydon health district, south London. SUBJECTS 462 health care staff. RESULTS 300 staff (65%) responded. The reasons given by staff for non-uptake included fear of side-effects or injections, misconceptions about hepatitis B transmission, the alternative use of homeopathic vaccine, pressure of work, difficulties in arranging vaccination, forgetfulness, and 'inertia'. Of the 54 unvaccinated staff, 55.6% believed themselves to be at high risk of contracting hepatitis B as a result of their occupation; 33% of 202 fully vaccinated staff were unaware of the use of booster doses of vaccine to maintain long-term immunity. CONCLUSIONS The level of awareness and understanding about hepatitis B vaccination of any group of health care staff should not be assumed. A number of specific educational and organisational issues need to be addressed when implementing staff vaccination programmes. Without the use of automatic call-recall systems the long-term success of staff hepatitis B vaccination programmes may be in doubt.
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Affiliation(s)
- M J Briggs
- Department of Public Health Medicine, Croydon Health Authority, Surrey
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Bell DM, Shapiro CN, Gooch BF. Preventing HIV transmission to patients during invasive procedures. J Public Health Dent 1993; 53:170-3. [PMID: 8396645 DOI: 10.1111/j.1752-7325.1993.tb02697.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- D M Bell
- HIV Infections Branch, Centers for Disease Control and Prevention, Atlanta, GA 30333
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Risks to surgeons and patients from HIV and hepatitis: guidelines on precautions and management of exposure to blood or body fluids. Joint Working Party of the Hospital Infection Society and the Surgical Infection Study Group. BMJ (CLINICAL RESEARCH ED.) 1992; 305:1337-43. [PMID: 1304744 PMCID: PMC1883893 DOI: 10.1136/bmj.305.6865.1337] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Struve J. Hepatitis B virus infection among Swedish adults: aspects on seroepidemiology, transmission, and vaccine response. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES. SUPPLEMENTUM 1992; 82:1-57. [PMID: 1386474 DOI: 10.3109/inf.1992.24.suppl-82.01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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