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Epidemiology of Perioperative Bloodborne Infections

Epidemiology of Perioperative Bloodborne Infections. UCSF Department of Surgery Grand Rounds March 29, 2006. Case.

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Epidemiology of Perioperative Bloodborne Infections

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  1. Epidemiology of Perioperative Bloodborne Infections UCSF Department of Surgery Grand Rounds March 29, 2006

  2. Case • “I was putting in an IV catheter in a patient who lost access. As I took the needle out, my fingertip hit the tip of the needle and punctured my skin. It bled spontaneously. I knew the patient was Hepatitis C and HIV positive…” • Sulkowski, MS et al. JAMA 2002

  3. Brief Outline • HIV, Hepatitis B, Hepatitis C • Surveillance and Reporting Systems • Exposure Data from OR • Data from Developing Countries

  4. HIV • HIV risk from patient to surgeon is low • No difference in HIV infection between HCW’s and population • 138 individuals with probable occupationally acquired HIV infection: 6 surgeons • 56 HCW’s w/documented seroconversion after percutaneous exposure (0 surgeons) • PEP recommended

  5. Hepatitis B • 1.25 million people in US w/chronic HBV • 5% of acute HBV -> chronic HBV • HBV transmission is 30% cases when naive host has hollow bore needle stick from chronically infected patient • Must confirm effective immunization • Many surgeons check titers q 10 years

  6. Hepatitis C • 4 million in US w/ chronic HCV • 75% acute HCV clinically occult (like HBV) • 50-80% acute HCV become chronic • Up to 20% chronic HCV advance to cirrhosis • 0.5% rate of conversion after hollow bore needle sticks (new data: from 1.8%) • May require 1 year of testing after exposure to convert • HCV blood exposure to conjunctiva = transmission risk of HCV needlestick

  7. Worldwide healthcare workerto patient transmission • 1991-2005 (Perry et al., forthcoming) • 133 reported total cases of transmission • HIV: 2 surgeons-> 3 pts (0.09% pts infected) • HBV: 12-> 91 pts (2.96% pts infected) • HCV: 11-> 39 pts (0.36% pts. infected) • HBV: Surgeon->pt transmission • Most commonly when e antigen positive • Many without evidence of injury to hands

  8. Unanswered Questions • All cases but 1: surgeons transmitted • One US surgeon transmitted HCV to at least 14 patients: Still operating • What restrictions should exist for infected surgeons? • Do we treat blood exposure of a patient = exposure to a HCW?

  9. Federal Regulations • OSHA mandates a sharps injury log • No requirement to report to state or federal bodies • State and regional reporting systems vary greatly

  10. Surveillance • Exposure Prevention Information Network (EPINet) • Dr. Janine Jagger (1991) UVa. • International Health Care Worker Safety Center • >1500 US hospitals; 70 facilities • National Surveillance System for Health Care Workers (NaSH) • CDC (1995) • 80 facilities in 28 states

  11. California • 1996 Senate Bill • Sharps Injury Control Program • Voluntary reporting • 90% of Hospitals report • Weaknesses: • No reporting of non-sharps injuries (ie mucocutaneous exposures) • No sample of non hospital-based HCW’s

  12. Surveillance (ctd) • Massachusetts Surveillance System for Sharps Injuries • Mass. Dpt Public Health (2001) • 100 hospitals; required by State Law • VA • Automated Safety Incident Surveillance (1998)

  13. Exposure Data in OR • 33% (Highest proportion) of hospital-based percutaneous injuries (Epinet 2003) • vs pt rooms, ER, clinics • 16.5% (2nd) for hospital-based non-percutaneous injuries 1995-2001 (NaSH) • Blood exposure events in 6-50% of surgical procedures (1997) • Cuts or needle sticks 1.7-15%

  14. Trends: OR lags in prevention

  15. 38% dropin injuries in patient rooms(all devices)only 5.7% dropin OR injuries

  16. OR Personnel • Surgeons or 1st assistants (up to 59%) • Scrub nurses/techs (19%) • Anesthesiologists (6%) • Circulating nurses (6%)

  17. Exposure in OR • Suture Needles cause the highest proportion of percutaneous injuries (up to 77%) • From direct observational study (1992) • Mostly in muscle and fascial closure • Especially in using fingers to manipulate • Scalpels more likely to cause serious injury

  18. Trends in Needle injuries

  19. 33% declinehollow bore needles27% increasesuture needles

  20. Exposure in OR • Passing instruments hand to hand (16%) • Most self-inflicted • But up to 24% by co-worker • Non-dominant hand most common site • Relatively few (<0.05%) are highest risk • ie hollow bore needles • Up to 1/3 devices come into contact with patient after HCW

  21. Poor reporting • Surgeons do not report up to 70% of injuries • inconvenient to follow-up after a case • not willing to stop a case • assume exposure is “low-risk” • do not want to have serostatus known • Rarely participate in post-exposure strategies

  22. Exposure in OR • Types of procedures • High blood volume • Poor visibility • Length of time

  23. Bloodborne Infections in Developing Countries (DC’s) • Concerning given global epidemics • Lack of data • 70% of global HIV cases are in Sub-Saharan Africa • But only 4% of worldwide cases of occupational HIV infection from this region • 4% of global HIV cases are in North America/Europe • But 90% of worldwide cases of occupational HIV infection are reported from this region

  24. Needlestick Injuries in DC’s • 90% global surgical need in DC’s • WHO: 90% of needlestick injuries in DC’s • 35 million HCW’s globally • 3 million get a NSI each year • 40% of HCV/HBV in HCW is from occupational exposure • 2.5% of HIV

  25. Risk factors for injuries in DC’s • Prevalence of infections • > 20 bloodborne pathogens (malaria/herpes/syphilis) • Vaccine availability • Low health expenditure and lack of devices • High ratio of patients per HCW • High Demand for injections • 95% injections are therapeutic (not for vaccination) • 80-90% pts visiting clinics in Ghana received an injection

  26. Developing Countries (ctd.) • Uganda: HIV prevalence in Mulago • Medical Wards 60%; Surgical 30% • 2004 Mulago survey (nurses/midwives) • 57% stick in last year; 4.18/person/year • 55% (Mbarara) • In 3 years of training • 6/1000 clinicians would acquire HIV • 10/1000 would acquire Hepatitis B

  27. Effect on the health workforce • Ass. Surgeons East Africa (ASEA) Survey • Deterrent to career choice in surgery • Further exacerbates the shortage in health care workers with direct patient contact • Attrition • Alternative career choice • Migration and brain drain • We have the potential to share effective technologies with our partners • UCSF and ACS

  28. Epi Conclusions • Suture needles cause the majority of injuries in the OR • The OR lags far behind in prevention • As surgeons we underreport injuries • Risks to patients • Risks to other members in OR • Major problem for health care workers in the developing world

  29. Thanks • Fellow contributors • Dr. Janine Jagger at International Health Care Worker Safety Center (UVa)

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