Simultaneous transmission of human immunodeficiency virus and hepatitis C virus from a needle-stick injury

Blood-Borne Infection Prevention in Combat Sports: Position Statement of the Association of Ringside Physicians

ABSTRACT

The Association of Ringside Physicians (ARP) emphasizes the importance of screening combat sports athletes for blood-borne infections, including hepatitis B, HIV, and hepatitis C, to mitigate transmission risks and ensure participant safety. Although transmission of hepatitis B and C and HIV in combat sports is rare, protecting athletes is of utmost importance. It is the recommendation of the ARP that all fighters participating in combat sports, in which the presence of blood is a common occurrence and is allowed during competition, should undergo testing for HIV, hepatitis B (HBV), and hepatitis C (HCV). Testing should be conducted using serum samples, because rapid tests are not considered acceptable for accurate results. Testing for HBV, HCV, and HIV should optimally be done within 3 months of competition, but within 6 months is acceptable. Athletes whose tests suggest active HBV, HCV, or HIV infection should be disqualified from competition in sports where blood is common and allowed. Athletes with cured prior HCV infection may be cleared for competition in all combat sports. Athletes with prior HBV infection and no detectable HBV DNA in blood can be cleared for competition in all combat sports. Athletes with latent HBV infection with detectable HBV DNA in blood have a small risk of disease reactivation, so they should not be cleared.

Factors Associated with Workplace Injuries Among Shift Work Nurses: A Cross-Sectional Study in an Ecuadorian Sample

Background/Objectives: Shift work schedules and mental and physical workloads affect the sleep homeostasis of nurses, increasing the risk of occupational injuries. This study aimed to investigate the relationship between sleep disturbances caused by shift schedules and the occurrence of needlestick and sharps injuries (NSIs) among nurses, considering significant worker and occupational factors. Methods: A total of 348 nurses from five hospitals of Santiago de Guayaquil, Ecuador, participated in this cross-sectional survey. Data on sociodemographic and occupational characteristics, work schedules, and NSI incidents during the previous six months were collected. Emotional status, sleepiness, and insomnia symptoms were assessed using validated questionnaires. Additionally, nurses with night shifts (fixed or rotating) were specifically assessed to estimate the relationship between NSIs and insomnia or sleepiness symptoms related to these types of shift work using logistic regression analyses. Results: Nurses whose schedule included night shifts showed a higher prevalence of NSIs than those with other shifts (33.2% vs. 29.0%; p < 0.05). High levels of depression, anxiety, and stress were associated with having had an NSI in the previous six months. Logistic regression showed that female sex (adjusted odds ratio, aOR 4.62, 95% CI: 1.65-12.97), less experience in the current clinical setting (aOR 3.12, 95% CI: 1.46-6.57), the use of psychotropic drugs (aOR 4.46, 95% CI: 1.51-13.17), and insomnia and sleepiness symptoms due to shift work (aOR 2.61, 95% CI: 1.15-5.91) increased NSI risk among nurses with night shifts. Conclusions: There is an acute need to explore the complex relationship between sleep troubles linked to shift work schedules, occupational factors, and the risk of occupational injuries and propose preventive strategies for enhancing nurses' sleep health and workplace safety.

Spectrum of Dyslipidemias in Treatment-Naïve Human Immunodeficiency Virus-Infected Patients Presenting to an HIV Clinic of a Tertiary Care Hospital

Introduction

HIV/AIDS is a major communicable disease worldwide, especially in developing countries where disease prevalence is over 90%. The National AIDS Control Programme of Pakistan reported around 160,000 HIV cases (140,000-190,000) with a 5% prevalence among traditional risks groups. HIV infection is thought to affect lipids metabolism adversely, thus resulting in increased morbidity and mortality. The aim of the study was to find out the frequency and types of dyslipidemia in patients with HIV not taking anti-retroviral therapy, presenting to an HIV clinic at a tertiary care hospital.

Methods

This cross-sectional study was conducted at the HIV clinic of Jinnah Hospital from January 2020 to July 2020. A total of 280 treatment-naïve patients, fulfilling the inclusion protocol, were included through non-probability consecutive sampling after informed consent. Blood samples of 5 mL were taken using aseptic measures and following standard procedure after ensuring overnight fasting by a nurse and were sent immediately to the pathology laboratory of Allama Iqbal Medical College. The results of the lipid profile were collected the next day and noted in the proforma. Dyslipidemia and type of dyslipidemia were recorded as per operational definition. Data were analyzed by SPSS software, version 27.0 (IBM Corp., Armonk, NY). Cross-tabulation was done to assess the relationship of gender, BMI, and family history on dyslipidemia, and a chi-square test was applied to check statistical significance.

Results

Among 280 treatment-naïve HIV-infected patients, the majority of patients were females (52%). The mean duration of HIV was 9.31 + 2.13 months. About 55% of patients had a BMI of more than 25 kg m². A family history of dyslipidemia was found in 62% of the patients. Dyslipidemia was observed in 70% of patients with maximum derangement seen in total cholesterol level (62%). After applying the chi-square test, a significant relation was identified between BMI and family history with dyslipidemia in HIV-infected individuals (p-value = 0.00).

Conclusion

A considerable proportion of treatment-naïve HIV patients have underlying dyslipidemia with a significant relationship with higher BMI and a family history of dyslipidemia. The findings of this study highlight the importance of early screening for dyslipidemia in HIV patients.

2021 European guideline on HIV testing in genito-urinary medicine settings

Testing for HIV is critical for early diagnosis of HIV infection, providing long-term good health for the individual and prevention of onward transmission if antiretroviral treatment is initiated early. The main purpose of the 2021 European Guideline on HIV Testing in Genito-Urinary Settings is to provide advice on testing for HIV infection in individuals aged 16 years and older who present to sexually transmitted infection, genito-urinary or dermato-venereology clinics across Europe. The guideline presents the details of best practice and offers practical guidance to clinicians and laboratories to identify and offer HIV testing to appropriate patient groups.

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

BACKGROUND

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Mathematical Analysis of the Transmission Dynamics of HIV Syphilis Co-infection in the Presence of Treatment for Syphilis

The re-emergence of syphilis has become a global public health issue, and more persons are getting infected, especially in developing countries. This has also led to an increase in the incidence of human immunodeficiency virus (HIV) infections as some studies have shown in the recent decade. This paper investigates the synergistic interaction between HIV and syphilis using a mathematical model that assesses the impact of syphilis treatment on the dynamics of syphilis and HIV co-infection in a human population where HIV treatment is not readily available or accessible to HIV-infected individuals. In the absence of HIV, the syphilis-only model undergoes the phenomenon of backward bifurcation when the associated reproduction number ([Formula: see text]) is less than unity, due to susceptibility to syphilis reinfection after recovery from a previous infection. The complete syphilis-HIV co-infection model also undergoes the phenomenon of backward bifurcation when the associated effective reproduction number ([Formula: see text]) is less than unity for the same reason as the syphilis-only model. When susceptibility to syphilis reinfection after treatment is insignificant, the disease-free equilibrium of the syphilis-only model is shown to be globally asymptotically stable whenever the associated reproduction number ([Formula: see text]) is less than unity. Sensitivity and uncertainty analysis show that the top three parameters that drive the syphilis infection (with respect to the associated response function, [Formula: see text]) are the contact rate ([Formula: see text]), modification parameter that accounts for the increased infectiousness of syphilis-infected individuals in the secondary stage of the infection ([Formula: see text]) and treatment rate for syphilis-only infected individuals in the primary stage of the infection ([Formula: see text]). The co-infection model was numerically simulated to investigate the impact of various treatment strategies for primary and secondary syphilis, in both singly and dually infected individuals, on the dynamics of the co-infection of syphilis and HIV. It is observed that if concerted effort is exerted in the treatment of primary and secondary syphilis (in both singly and dually infected individuals), especially with high treatment rates for primary syphilis, this will result in a reduction in the incidence of HIV (and its co-infection with syphilis) in the population.

Epidemiology, transmission, diagnosis, and outcome of Hepatitis C virus infection

Hepatitis C infection is one of the main causes of chronic liver disorders worldwide. Nearly three percent (3%) of the world population has an HCV infection. Prevalence of HCV infection was higher in some groups such as injected drug users (IDUs) and HIV positive populations. Acute hepatitis has proven asymptomatic in most cases, and delay of diagnosis might lead to late onset of hepatocellular carcinoma and cirrhosis. Some host characteristics such as age, gender, body mass index, and viral properties are associated with HCV outcome hepatitis. Although disease progression is typically slow, some risk factors such as alcohol abuse and coinfection of patients with HBV and HIV can worsen the disease. On the other hand, viral overload is one of the main causes of prediction of HCV infection outcome. Prevalence of HCV infection will increase if we do not consider means of transmission, virus behaviors, and immunologic responses. Rapid diagnostic tests can help us to create preventive strategies among undeveloped villages and prisoners. Screening and training of the high-risk population such as IV drug users, dialysis patients, and hemophiliacs must be one of main HCV preventive programs. The present review is intended to help health policymakers to design suitable preventive and management programs.

Development of peptide inhibitors of HIV transmission

Treatment of HIV has long faced the challenge of high mutation rates leading to rapid development of resistance, with ongoing need to develop new methods to effectively fight the infection. Traditionally, early HIV medications were designed to inhibit RNA replication and protein production through small molecular drugs. Peptide based therapeutics are a versatile, promising field in HIV therapy, which continues to develop as we expand our understanding of key protein-protein interactions that occur in HIV replication and infection. This review begins with an introduction to HIV, followed by the biological basis of disease, current clinical management of the disease, therapeutics on the market, and finally potential avenues for improved drug development.

Coinfection Dynamics of Two Diseases in a Single Host Population

A susceptible-infectious-susceptible (SIS) epidemic model that describes the coinfection and cotransmission of two infectious diseases spreading through a single population is studied. The host population consists of two subclasses: susceptible and infectious, and the infectious individuals are further divided into three subgroups: those infected by the first agent/pathogen, the second agent/pathogen, and both. The basic reproduction numbers for all cases are derived which completely determine the global stability of the system if the presence of one agent/pathogen does not affect the transmission of the other. When the constraint on the transmissibility of the dually infected hosts is removed, we introduce the invasion reproduction number, compare it with two other types of reproduction number and show the uniform persistence of both diseases under certain conditions. Numerical simulations suggest that the system can display much richer dynamics such as backward bifurcation, bistability and Hopf bifurcation.

Risk Factors for Hepatitis C Virus (HCV) Infection in Areas with a High Prevalence of HCV in the Republic of Korea in 2013

Background/Aims

The prevalence of hepatitis C virus (HCV) infection in Busan, Gyeongnam, and Jeonnam Provinces in Korea is more than twice the national average. This study aimed to examine whether demographic and lifestyle characteristics are associated with HCV infection in these areas.

Methods

A case control study was performed at three study hospitals. HCV cases were matched with two controls for sex and age. Patient controls were selected from non-HCV patients at the same hospital. Healthy controls were subjects participating in medical checkups. Conditional logistic regression models were used.

Results

A total of 234 matched-case and patient- and healthy-control pairs were analyzed. The significant risk factors for both controls were sharing razors (adjusted odds ratio [aOR], 2.39 and 3.29, respectively) and having more than four lifetime sexual partners (aOR, 2.15 and 6.89, respectively). Contact dockworkers (aOR, 1.91) and tattoos (aOR, 2.20) were significant risk factors for the patient controls. Transfusion (aOR, 5.38), a bloody operation (aOR, 5.02), acupuncture (aOR, 2.08), and piercing (aOR, 5.95) were significant risk factors for the healthy controls. Needle stick injuries and intravenous drug abuse were significant in the univariate analysis.

Conclusions

More education concerning the dangers of sharing razors, tattoos and piercings is required to prevent HCV infection. More attention should be paid to needle stick injuries in hospitals and the community.

Prevalence and correlates of needle-stick injuries among active duty police officers in Tijuana, Mexico

Introduction

Police officers are at an elevated risk for needle-stick injuries (NSI), which pose a serious and costly occupational health risk for HIV and viral hepatitis. However, research on NSIs among police officers is limited, especially in low- and middle-income countries. Despite the legality of syringe possession in Mexico, half of people who inject drugs (PWID) in Tijuana report extrajudicial syringe-related arrests and confiscation by police, which has been associated with needle-sharing and HIV infection. We assessed the prevalence and correlates of NSIs among Tijuana police officers to inform efforts to improve occupational safety and simultaneously reduce HIV risks among police and PWID.

Methods

Tijuana's Department of Municipal Public Safety (SSPM) is among Mexico's largest. Our binational, multi-sectoral team analyzed de-identified data from SSPM's 2014 anonymous self-administered occupational health survey. The prevalence of NSI and syringe disposal practices was determined. Logistic regression with robust variance estimation via generalized estimating equations identified factors associated with ever having an occupational NSI.

Results

Approximately one-quarter of the Tijuana police force was given the occupational health survey (N=503). Respondents were predominantly male (86.5%) and ≤35 years old (42.6%). Nearly one in six officers reported ever having a NSI while working at SSPM (15.3%), of whom 14.3% reported a NSI within the past year. Most participants reported encountering needles/syringes while on duty (n=473, 94%); factors independently associated with elevated odds of NSIs included frequently finding syringes that contain drugs (adjusted odds ratio (AOR): 2.98; 95% confidence interval (CI): 1.56–5.67) and breaking used needles (AOR: 2.25; 95% CI: 1.29–3.91), while protective factors included being willing to contact emergency services in case of NSIs (AOR: 0.39; 95% CI: 0.22–0.69), and wearing needle-stick resistant gloves (AOR: 0.43; 95% CI: 0.19–0.91).

Conclusions

Tijuana police face an elevated and unaddressed occupational NSI burden associated with unsafe syringe-handling practices, exposing them to substantial risk of HIV and other blood-borne infections. These findings spurred the development and tailoring of training to reduce NSI by modifying officer knowledge, attitudes and enforcement practices (e.g. syringe confiscation) – factors that also impact HIV transmission among PWID and other members of the community.

Six-week follow-up after HIV-1 exposure: a position statement from the Public Health Agency of Sweden and the Swedish Reference Group for Antiviral Therapy

In 2014 the Public Health Agency of Sweden and the Swedish Reference Group for Antiviral Therapy (RAV) conducted a review and analysis of the state of knowledge on the duration of follow-up after exposure to human immunodeficiency virus (HIV). Up until then a follow-up of 12 weeks after exposure had been recommended, but improved tests and new information on early diagnosis motivated a re-evaluation of the national recommendations by experts representing infectious diseases and microbiology, county medical officers, the RAV, the Public Health Agency, and other national authorities. Based on the current state of knowledge the Public Health Agency of Sweden and the RAV recommend, starting in April 2015, a follow-up period of 6 weeks after possible HIV-1 exposure, if HIV testing is performed using laboratory-based combination tests detecting both HIV antibody and antigen. If point-of-care rapid HIV tests are used, a follow-up period of 8 weeks is recommended, because currently available rapid tests have insufficient sensitivity for detection of HIV-1 antigen. A follow-up period of 12 weeks is recommended after a possible exposure for HIV-2, since presently used assays do not include HIV-2 antigens and only limited information is available on the development of HIV antibodies during early HIV-2 infection. If pre- or post-exposure prophylaxis is administered, the follow-up period is recommended to begin after completion of prophylaxis. Even if infection cannot be reliably excluded before the end of the recommended follow-up period, HIV testing should be performed at first contact for persons who seek such testing.

Comparison of Rapid Point-of-Care Tests for Detection of Antibodies to Hepatitis C Virus

OraSure had the highest sensitivity at 92.7% followed closely by Chembio's three blood tests. False results were associated with HIV, and hepatitis B core antibody. The OraSure and Chembio blood tests have good performance characteristics.

Background. Hepatitis C is one of the most prevalent blood-borne diseases in the United States. Despite the benefits of early screening, among 3.2 million Americans who are infected with hepatitis C virus (HCV), 50%–70% are unaware of their infection status.

Methods. Data were collected between 2011 and 2014, from 1048 clients who were in the following groups: (1) injection drug users, (2) women at sexual risk, (3) gay and bisexual men, and (4) transgender individuals. The sensitivity and specificity of point-of-care tests included (1) the MedMira rapid human immunodeficiency virus (HIV)/HCV antibody test, (2) MedMira hepatitis B (HBV)/HIV/HCV antibody test, (3) Chembio HCV Screen Assay used with both whole blood and (4) oral specimens, (5) Chembio HIV-HCV Assay also used with both whole blood and (6) oral specimens, (7) Chembio HIV-HCV-Syphilis Assay, and (8) OraSure HCV Rapid Antibody Test used with whole blood. The gold standard for the HCV tests were HCV enzyme immunoassay (EIA) 2.0.

Results. OraSure had the highest sensitivity at 92.7% (95% confidence interval [CI] = 88.8%–96.5%) followed closely by Chembio's 3 blood tests at 92.1% (95% CI = 87.7%–96.4%), 91.5% (95% CI = 87.2%–95.7%), and 92.3% (95% CI = 88.4%–96.2%). The sensitivities of MedMira HIV/HCV and MedMira HIV/HCV/HBV tests were the lowest, at 79.1% (95% CI = 72.6%–85.5%), and 81.5% (95% CI = 75.2%–87.8%), respectively. Specificity for the OraSure was 99.8% (95% CI = 99.4%–100%); specificity for the Chembio blood tests was 99.2% (95% CI = 98.6%–99.9%), 99.4% (95% CI = 98.8%–99.9%), and 99.3% (95% CI = 98.8%–99.9%); and specificity for the MedMira was100% and 100%. False-negative results were associated with HIV and hepatitis B core antibody serostatus.

Conclusions. The OraSure and Chembio blood tests (including those multiplexed with HIV and syphilis) appear to good performance characteristics. This study has identified potential limitations of rapid testing in those testing positive for HIV and HBcAb. There should be discussion of updates to the 2013 CDC guidance.

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

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

2014 European Guideline on HIV testing

Testing for HIV is one of the cornerstones in the fight against HIV spread. The 2014 European Guideline on HIV Testing provides advice on testing for HIV infection in individuals aged 16 years and older who present to sexually transmitted infection, genito-urinary or dermato-venereology clinics across Europe. It may also be applied in other clinical settings where HIV testing is required, particularly in primary care settings. The aim of the guideline is to provide practical guidance to clinicians and laboratories that within these settings undertake HIV testing, and to indicate standards for best practice.

Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis

This report updates US Public Health Service recommendations for the management of healthcare personnel (HCP) who experience occupational exposure to blood and/or other body fluids that might contain human immunodeficiency virus (HIV). Although the principles of exposure management remain unchanged, recommended HIV postexposure prophylaxis (PEP) regimens and the duration of HIV follow-up testing for exposed personnel have been updated. This report emphasizes the importance of primary prevention strategies, the prompt reporting and management of occupational exposures, adherence to recommended HIV PEP regimens when indicated for an exposure, expert consultation in management of exposures, follow-up of exposed HCP to improve adherence to PEP, and careful monitoring for adverse events related to treatment, as well as for virologic, immunologic, and serologic signs of infection. To ensure timely postexposure management and administration of HIV PEP, clinicians should consider occupational exposures as urgent medical concerns, and institutions should take steps to ensure that staff are aware of both the importance of and the institutional mechanisms available for reporting and seeking care for such exposures. The following is a summary of recommendations: (1) PEP is recommended when occupational exposures to HIV occur; (2) the HIV status of the exposure source patient should be determined, if possible, to guide need for HIV PEP; (3) PEP medication regimens should be started as soon as possible after occupational exposure to HIV, and they should be continued for a 4-week duration; (4) new recommendation-PEP medication regimens should contain 3 (or more) antiretroviral drugs (listed in Appendix A ) for all occupational exposures to HIV; (5) expert consultation is recommended for any occupational exposures to HIV and at a minimum for situations described in Box 1 ; (6) close follow-up for exposed personnel ( Box 2 ) should be provided that includes counseling, baseline and follow-up HIV testing, and monitoring for drug toxicity; follow-up appointments should begin within 72 hours of an HIV exposure; and (7) new recommendation-if a newer fourth-generation combination HIV p24 antigen-HIV antibody test is utilized for follow-up HIV testing of exposed HCP, HIV testing may be concluded 4 months after exposure ( Box 2 ); if a newer testing platform is not available, follow-up HIV testing is typically concluded 6 months after an HIV exposure.

HIV-1 Nef interacts with HCV Core, recruits TRAF2, TRAF5 and TRAF6, and stimulates HIV-1 replication in macrophages

Tumor necrosis factor receptor-associated factor (TRAF) signaling plays a central role in many biological activities, such as the regulation of immune and inflammatory responses and control of apoptosis, which are key events in the pathogenesis of the human immunodeficiency virus (HIV)-1 and the hepatitis C virus (HCV) infections. Here we show that TRAF2, TRAF5 and TRAF6 interact with the HIV-1 Nef protein, an immunomodulatory viral protein expressed and released by cells infected by the virus. We also found that TRAF2 and TRAF5 interact with the HCV Core protein. Interestingly, we observed that HIV-1 Nef interacts with HCV Core. The activation of TRAF (2, 5, 6) - mediated by HIV-1 Nef and HCV Core - enhanced the activation of the nuclear factor-kappa B (NF-κB) and increased HIV-1 replication in monocyte- derived macrophages (MDMs). The knockdown of TRAF2, TRAF5 and TRAF6 resulted in decreased NF-κB activation and reduced HIV-1 replication in MDMs. Our results reveal a mechanism by which the activation of the TRAF pathway by HIV-1 Nef and HCV Core favors the replication of HIV-1 in macrophages and could be a critical factor for optimal replication of HIV-1 in macrophages of HIV-HCV-coinfected patients.

The management of needlestick injuries

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Rapid progression to decompensated cirrhosis, liver transplant, and death in HIV-infected men after primary hepatitis C virus infection

BACKGROUND

We and others have shown that primary hepatitis C (HCV) infection in men infected with human immunodeficiency virus (HIV) causes early-onset liver fibrosis; however, little is known about the long-term natural history of the liver disease in these HIV-infected men.

METHODS

We followed a cohort of HIV-infected men with primary HCV infection in New York City.

RESULTS

Four men who were not cured after their primary HCV infection developed decompensated cirrhosis within 17 months to 6 years after primary HCV infection. Three died within 8 years of primary HCV infection, and 1 survived after liver transplant done 2 years after primary HCV infection. Three of the 4 men had AIDS at the time of primary HCV infection, and the most rapid progression occurred in the 2 men with the lowest CD4 counts at the time of HCV infection. Liver histopathology was most consistent with HCV-induced damage even though some had exposures to other potential hepatotoxins.

CONCLUSIONS

Primary HCV infection resulted in decompensated cirrhosis and death within 2-8 years in 4 HIV-infected men. The rapid onset of fibrosis due to primary HCV infection in HIV-infected men cannot therefore be considered benign. The rate of continued progression to liver failure may be proportional to the degree of underlying immunocompromise caused by HIV infection. More research is needed to better define the mechanisms behind accelerated liver damage.

Parasite co-transmission and the evolutionary epidemiology of virulence

Hosts are often co-infected by several parasite genotypes of the same species or even by different species and this is known to affect virulence evolution. However, epidemiological models typically assume that only one of the co-infecting strains can be transmitted at the same time, which is often at odds with the observed biology. Here, I study the effect of co-transmission on virulence evolution in a case where parasites compete for host resources. For co-infections by strains of the same species, increased co-transmission selects for less virulent strains. This is because co-transmission aligns the interests of co-infecting strains, thus decreasing the selective pressure for increased within-host competitiveness. For co-infection caused by different parasite species, the evolutionary outcome depends on the respective virulence of the two parasite species. Finally, I investigate asymmetric scenarios, for example that of plant viruses that require "helper" molecules produced by viruses from another species to be transmitted. These results show that even if parasite strains compete for host resources, the prevalence of co-infections can be a poor predictor of virulence evolution.

HIV transmission

HIV-1 is transmitted by sexual contact across mucosal surfaces, by maternal-infant exposure, and by percutaneous inoculation. For reasons that are still incompletely understood, CCR5-tropic viruses (R5 viruses) are preferentially transmitted by all routes. Transmission is followed by an orderly appearance of viral and host markers of infection in the blood plasma. In the acute phase of infection, HIV-1 replicates exponentially and diversifies randomly, allowing for an unambiguous molecular identification of transmitted/founder virus genomes and a precise characterization of the population bottleneck to virus transmission. Sexual transmission of HIV-1 most often results in productive clinical infection arising from a single virus, highlighting the extreme bottleneck and inherent inefficiency in virus transmission. It remains to be determined if HIV-1 transmission is largely a stochastic process whereby any reasonably fit R5 virus can be transmitted or if there are features of transmitted/founder viruses that facilitate their transmission in a biologically meaningful way. Human tissue explant models of HIV-1 infection and animal models of SIV/SHIV/HIV-1 transmission, coupled with new challenge virus strains that more closely reflect transmitted/founder viruses, have the potential to elucidate fundamental mechanisms in HIV-1 transmission relevant to vaccine design and other prevention strategies.

Transmission of hepatitis C virus by occupational percutaneous injuries in South Korea

Korea is an endemic area of hepatitis. Hepatitis C virus (HCV) infections caused by occupational percutaneous injuries are a serious problem for healthcare workers and there has been a gradual increase in the number of HCV infections. We therefore determined the transmission rate of HCV after occupational percutaneous injury. This was a retrospective cohort study reviewing all occupational blood exposure reports made between January 1, 2004, and December 31, 2008, at a university-affiliated acute care hospital. Over the 5-year study period, there were 1,516 accidents of occupational exposure to blood; of these, 327 (21.6%) were to the blood of HCV-infected patients and 3 (0.9%) healthcare workers became infected with HCV (95% CI 0.6-8.8). In Korea, although the bloodborne accidents leading to exposure to HCV occurred frequently (21.6%), the transmission rate was very low (0.92%).

Comparison of monolisa HCV Ag/Ab ULTRA with two anti-HCV assays for the detection of HCV infection in hospital setting

In this study, we compared the performance of three serological assays (Monolisa HCV Ag/Ab ULTRA, Innotest HCV Ab IV enzyme immunoassay--EIA, and Ortho HCV 3.0 enzyme-linked immunosorbent assay--ELISA) for the detection of HCV infection. Ninety plasma samples were collected, representing 63 samples from groups at risk for acquiring HCV infection and 27 HCV RNA-positive samples. The results of Ortho HCV 3.0 ELISA, Innotest HCV Ab IV, and Monolisa HCV Ag/Ab ULTRA were fully concordant for 27 HCV RNA-positive samples. Ortho HCV 3.0 ELISA test and Innotest HCV Ab IV also gave the same results for risk groups, while three samples were found to be reactive by Monolisa HCV Ag/Ab ULTRA and were consequently found negative for HCV RNA. As two of the solely Monolisa HCV Ag/Ab ULTRA-positive samples were also hepatitis B s antigen (HBsAg)-positive, neutralization of HBsAg was performed but no arguments for the HBsAg interference were observed. In conclusion, the non-specific reactive signal was observed, in three samples using Monolisa HCV Ag/Ab ULTRA, to be negative by other serological assays, and observed to be negative in an HCV RNA assessment, a result that could not be attributed to the interference with HBsAg. In the context of diagnostic testing, no test for various HCV genotypes was observed to be superior to any other.

Compliance with sharps waste standards by a sample of Sydney acupuncture premises

AIM

To examine current practices with regard to the safe collection, storage and disposal of sharps waste in acupuncture premises and to determine compliance with the NSW Public Health (Skin Penetration) Regulation 2000 and the NSW Health Skin Penetration Code of Best Practice.

METHODS

A random sample of acupuncturists in the City of Sydney local government area was selected and surveyed using a structured questionnaire.

RESULTS

All 26 acupuncturists surveyed had sharps disposal bins and complied with the Regulation, but the following elements of the Code were not uniformly followed: regular disposal of sharps (77%), disposal through a waste contractor (23%) and placement of bins out of reach of visitors (8%).

CONCLUSION

Regular disposal of sharps containers in acupuncture premises could be improved.

Performance characteristics of a combined hepatitis C virus core antigen and anti-hepatitis C virus antibody test in different patient groups

We evaluated the performance of a hepatitis C virus (HCV) antigen/antibody combination test [Murex HCV Antigen/Antibody Combination Test (Murex Ag/Ab test)] by comparing it with the current third-generation HCV antibody enzyme immunoassay (anti-HCV). A total of 403 serum samples were consecutively collected from four patient groups: healthy controls (n=100); HCV-infected patients (HCV group, n=102); Human immunodeficiency virus (HIV)/HCV-infected patients (HIV/HCV group, n=100); and patients with uremia (uremia group, n=101). Performances were evaluated for the Murex Ag/Ab, anti-HCV, and HCV RNA in the HIV/HCV and uremia patient groups. In the HCV group, all 102 samples showed concordant positive and negative results for anti-HCV, Murex Ag/Ab, and HCV RNA tests. In the HIV/HCV group, all 100 samples were positive for both anti-HCV and Murex Ag/Ab tests, whereas 88 patients (88%) were HCV RNA positive. In the uremia group, 14 (69.0%) of the 23 anti-HCV-positive patients were HCV RNA positive, whereas 14 (77.8%) of the 18 Murex Ag/Ab-positive patients were HCV RNA positive. None of anti-HCV-negative or Murex Ag/Ab-negative patients were HCV RNA positive. Based on the HCV RNA assay, the sensitivities for both anti-HCV and Murex Ag/Ab assays were 100%, whereas the specificities of these two assays were 89.7% and 95.4%, respectively. With good sensitivity and specificity, the Murex Ag/Ab assay could be a useful alternative diagnostic tool, especially in immunocompromised populations, such as patients with uremia or those infected with HIV.

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.

Infection control guidelines for prevention of health care-associated transmission of hepatitis B and C viruses

Viral hepatitis was first identified as an occupational hazard for health care workers more than 60 years ago. For the past few decades, hepatitis B has been one of the most significant occupational infectious risks for health care providers. With the increasing prevalence of hepatitis C infections around the world, occupational transmission of this flavivirus from infected patients to their providers has also become a significant concern. Several factors influence the risk for occupational blood-borne hepatitis infection among health care providers, among them: the prevalence of infection among the population served, the infection status of the patients to whom workers are exposed (ie, the source patient's circulating viral burden), the types and frequencies of parenteral and mucosal exposures to blood and blood-containing body fluids, and whether the patient or provider has been immunized with the hepatitis B vaccine. This article reviews patient-to-provider, patient-to-patient, and provider-to-patient transmission of hepatitis B and C in the health care setting. Current prevention strategies, precautions, and guidelines are discussed.

A case study of delayed HIV-1 seroconversion highlights the need for Combo assays

Summary

This report describes a case in which a patient took at least four months to seroconvert to anti-HIV positivity. A concomitant CMV infection probably contributed to the profound immune suppression observed. It is essential that fourth generation HIV antigen/antibody combo assays be used to ensure that such cases are not missed.

2008 European Guideline on HIV testing

Testing for HIV is one of the cornerstones in the combat against HIV infection. The 2008 European Guideline on HIV Testing provides advice on testing for HIV infection in individuals aged 16 years and older who have sought evaluation and treatment at sexually transmitted infection services for dermatovenereology clinics across Europe. Its aim is to provide practical guidance to clinicians in these settings who undertake HIV testing and suggest appropriate standards for the audit of service provision.

Liver fibrosis during an outbreak of acute hepatitis C virus infection in HIV-infected men: a prospective cohort study

Outbreaks of acute hepatitis C virus (HCV) infection are occurring in HIV-infected men who have sex with men. We evaluated risk factors and liver histopathology in 11 consecutively enrolled men with newly acquired HCV infection that was diagnosed on the basis of antibody seroconversion, new elevations in alanine aminotransferase level, and wide fluctuations in HCV RNA level. Ten patients reported unprotected anal intercourse, and 7 reported "club-drug" use, including methamphetamine. Liver biopsy showed moderately advanced fibrosis (Scheuer stage 2) in 9 patients (82%). No cause of liver damage other than acute HCV infection was identified. The specific pathways leading to periportal fibrosis in HIV-infected men with newly acquired HCV infection require investigation.

Hepatitis C virus quasispecies in HIV-infected women: role of injecting drug use and highly active antiretroviral therapy (HAART)

Despite the high frequency of HCV and HIV coinfection, little is known about HCV quasispecies in HIV-positive patients. The current analysis included 236 HIV+/anti-HCV+ women enrolled in the Women's Interagency HIV Study (WIHS). Hypervariable region 1 of the second envelope gene was analyzed by single-strand conformation polymorphism (SSCP). The relationship between the HCV quasispecies and clinical and demographic features were analyzed in multivariate models. Age over 40 years and high HCV RNA load were the only factors significantly associated with quasispecies complexity, assessed as the number of SSCP bands. High HIV and HCV plasma loads were associated with quasispecies stability over time, as reflected by stable SSCP band patterns. However, women who were actively injecting drugs were 3 times more likely to experience quasispecies changes than their noninjecting counterparts. No affect on HCV quasispecies dynamics was noted in relation to CD4 count or highly active antiretroviral therapy (HAART).

CONCLUSION

among HIV/HCV coinfected patients, HCV quasispecies complexity and dynamics correlate more closely with HIV and HCV plasma loads than with CD4+ cell counts. Active drug use is associated with quasispecies changes probably due to repeated superinfections with new HCV strains. This needs to be considered when planning treatment and prevention strategies for HCV in coinfected individuals.

Acute HIV infection: the impact of anti-retroviral treatment on cellular immune responses

The overall value of initiating anti-retroviral therapy during the acute phase of human immunodeficiency virus type 1 (HIV-1) infection remains unclear. From a clinical perspective, the lack of data from controlled randomized clinical trials limits understanding of long-term effects of treatment on the clinical course of HIV infection. Based on available data, the impact of anti-retroviral therapy during acute infection on the immune response against HIV-1 is not particularly encouraging. Recent observations on the very early depletion of lymphocyte reservoirs in the gastrointestinal tract may partially explain the limited benefit of anti-retroviral therapy initiated during the acute phase of HIV-1 infection. This may also help to explain the dichotomy between early observations demonstrating apparent immunological benefit with early anti-retroviral treatment that were associated none the less with inability to control viral replication following treatment interruption.

Intérêt d'un nouveau test combiné antigène–anticorps pour le dépistage de l'infection par le virus de l'hépatite C : réduction de la fenêtre sérologique au cours de l'hépatite C aiguë chez le sujet co-infecté par le VIH

BACKGROUND

The aim of this study was to determine the clinical benefit of a new combined antigen-antibody immunoenzymatic assay (Monolisa HCV Ag-Ab Ultra, Biorad) in the setting of acute HCV infection in HIV infected patients.

PATIENTS AND METHODS

The performance of this assay was first evaluated in 160 HIV positive samples from uninfected and chronically HCV infected patients. To assess the performance of the Ag-Ab assay in the context of acute hepatitis C, 94 stored frozen serums from 20 recently diagnosed cases were retrospectively tested for HCV-RNA and presence of anti-HCV antibodies, in parallel with the new assay.

RESULTS

In HIV infected patients, the sensitivity and specificity of the Ultra assay was 100% with a strong discrimination between positive and negative samples. In HCV acutely infected patients, the Ag-Ab assay significantly reduced the seronegative period, allowing an earlier diagnosis compared to a 3rd generation ELISA in 65% of the cases. The combined assay became positive on the same bleed as the first HCV-RNA detection for 13 patients out of 20. Nevertheless, in one case, characterized by an absence of seroconversion over one year but a continuous viral replication above 1 million IU/ml, the combined assay did not improve HCV infection diagnosis.

CONCLUSION

Use of this new assay as a first line screening would significantly reduce the long seronegative window period seen in HCV infection allowing earlier HCV diagnosis and rapid clinical management. However, in case of clinical acute hepatitis C, sensitive HCV-RNA detection should remain the gold standard.

Negative-strand hepatitis C virus (HCV) RNA in peripheral blood mononuclear cells from anti-HCV-positive/HIV-infected women

BACKGROUND

Hepatitis C virus (HCV) has been reported to replicate in peripheral blood mononuclear cells (PBMCs), particularly in patients coinfected with HCV and human immunodeficiency virus (HIV). However, there are limited data regarding the prevalence of and the factors associated with extrahepatic replication.

METHODS

The presence of negative-strand HCV RNA in PBMCs was evaluated by a strand-specific assay for 144 anti-HCV-positive/HIV-infected women enrolled in the Women's Interagency HIV Study. One to 5 PBMC samples obtained from each woman were tested. Multivariate analyses were used to assess for associations with the clinical and demographic characteristics of the women.

RESULTS

Negative-strand HCV RNA was detected in 78 (25%) of 315 specimens, and, for 61 women (42%), > or = 1 specimen was found to have positive results. The presence of negative-strand HCV RNA in PBMCs was significantly positively associated with an HCV RNA plasma level of > or = 6.75 log copies/mL (P=.04) and consumption of > or = 7 alcoholic drinks per week (P=.02). It was also negatively associated with injection drug use occurring in the past 6 months (P=.03). A negative association with a CD4+ CD38+ DR+ cell percentage of > 10% and a positive association with acquired immunodeficiency syndrome were borderline significant (P=.05).

CONCLUSIONS

HCV replication in PBMCs is common among HIV-coinfected women and appears to be a dynamic process related to lifestyle, virologic, and immunologic factors.

Early detection of hepatitis C virus infection by use of a new combined antigen-antibody detection assay: potential use for high-risk individuals

The performance of a new combined antigen-antibody assay (Monolisa HCV Ag-Ab Ultra; Bio-Rad Laboratories) was evaluated in the context of acute hepatitis C in human immunodeficiency virus-infected patients. The combined assay became positive as early as the first PCR and earlier than a third-generation enzyme-linked immunosorbent assay in 65% of the cases. Reduction of the long period of HCV seronegativity should improve the diagnosis of hepatitis C infection, especially in high-risk populations.

Mass needle stick injury in children from the Western cape

Illegal dumping of contaminated medical waste occurs commonly in South Africa. There is little information on the management and outcome of the children exposed to and injured by medical waste. On 15 September 1999, 54 children where involved in a mass exposure incident. 44 presented the same evening and 10 following day. Used needles and syringes were discarded on their soccer field. Children gave one another injections and played darts with the discarded needles. Parents were counselled and blood was drawn for HIV and Hepatitis B virus (HBV) serology. All were given HBV vaccination (HBVV). Stat doses of zidovudine (ZDV) and lamivudine (LMV) were given to all with visible wounds or history of percutaneous injury. Younger children were given prophylaxis as we considered their histories unreliable. Further visits were conducted at the community clinic for patient convenience. Children were reviewed at weeks 1 and 3 for drug adherence and side effects. At week 4, the second HBVV was given. At 3 months and 6 months HIV and HBV serology were repeated. 18/44 (40 per cent) had entry wounds. 44/54 (81 per cent) were given antiretroviral treatment (ART). Initial screening for HIV was negative in all, 6 had antibodies to HBV surface antigen, and 2 were HBV surface antigen positive. At week 1 all patients on ART were seen but at week 3 only 30 (55 per cent) attended. 41 (75 per cent) attended at 4 weeks, 8 non-attendees being located by primary healthcare workers. At 3 months, none of the 35 (64 per cent) children had seroconverted for either virus. 44 (81 per cent) attended at 6 months and all serology was negative. All were also Hepatitis C negative. The exposure incident sensitized the community to HIV. Follow up of patients after mass exposure is difficult and time-consuming. Adherence to ART was poor and should be carefully monitored. ZDV was probably adequate for this incident. In a non-mobile community a 3 month visit unnecessary.

Natural history and predictors of severity of chronic hepatitis C virus (HCV) and human immunodeficiency virus (HIV) co-infection

Co-infection by the hepatitis C virus (HCV) is observed in up to 30% of HIV-infected individuals. In studies conducted in the 'pre-HAART era', the late consequences of HCV-related chronic liver disease were overshadowed by extra-hepatic causes of deaths, related to severe immune deficiency, and the impact of HCV infection on mortality of HIV-infected patients was low. While the development of HAART has resulted in a significant decrease in morbidity and mortality amongst HIV-infected patients, this clear benefit allowed the expression of liver-related complications associated with HCV chronic infection. The impact of HCV on HIV remains debated but HIV infection significantly modifies the natural history of HCV infection. HIV infection increases levels of HCV viraemia by 2- to 8-fold, resulting in a significant decrease in spontaneous recovery of acute hepatitis. HIV co-infection also worsens the histological course of HCV infection by increasing and accelerating the risk of cirrhosis or leading to rare but lethal fibrosing cholestatic hepatitis. Liver disease is now one of the leading causes of morbidity and mortality in co-infected patients, even if HAART and especially protease inhibitors, may decrease the severity of the liver disease and the liver-related mortality. Several non-exclusive pathogenic processes explain the increasing rate of liver complications associated with HCV-related liver disease.

Risk factors for hepatitis C virus transmission to health care workers after occupational exposure: a European case-control study

BACKGROUND

Additional studies are required to identify risk factors for hepatitis C virus (HCV) transmission to health care workers after occupational exposure to HCV.

METHODS

We conducted a matched case-control study in 5 European countries from 1 January 1991 through 31 December 2002. Case patients were health care workers who experienced seroconversion after percutaneous or mucocutaneous exposure to HCV. Control subjects were HCV-exposed health care workers who did not experience seroconversion and were matched with case patients for center and period of exposure.

RESULTS

Sixty case patients and 204 control subjects were included in the study. All case patients were exposed to HCV-infected fluids through percutaneous injuries. The 37 case patients for whom information was available were exposed to viremic source patients. As risk factors for HCV infection, multivariate analysis identified needle placement in a source patient's vein or artery (odds ratio [OR], 100.1; 95% confidence interval [CI], 7.3-1365.7), deep injury (OR, 155.2; 95% CI, 7.1-3417.2), and sex of the health care worker (OR for male vs. female, 3.1; 95% CI, 1.0-10.0). Source patient HCV load was not introduced in the multivariate model. In unmatched univariate analysis, the risk of HCV transmission increased 11-fold for health care workers exposed to source patients with a viral load >6 log(10) copies/mL (95% CI, 1.1-114.1), compared with exposures to source patients with a viral load < or =4 log10 copies/mL.

CONCLUSION

In this study, HCV occupational transmission was found to occur after percutaneous exposures. The risk of HCV transmission after percutaneous exposure increased with deep injuries and procedures involving hollow-bore needle placement in the source patient's vein or artery. These results highlight the need for widespread adoption of needlestick-prevention devices in health care settings, together with other preventive measures.

Reducing percutaneous injuries at an academic health center: a 5-year review

BACKGROUND

The University of Connecticut Health Center Employee Health Service collected and used National Surveillance System for Hospital Health Care Workers (NaSH) data to (1) improve surveillance of health care worker blood and body fluid exposures (BBFEs) and (2) target specific interventions for higher-risk groups (nursing staff, medical and dental students, and residents).

METHODS

All 870 BBFE incidents were abstracted from the NaSH database from the 1997 through 2002 academic years. Incidence rates per 100 full-time-equivalent workers were determined for each targeted occupation group with 95% confidence intervals.

RESULTS

The number of percutaneous injuries declined among medical/dental students and nursing staff, and to a lesser degree for residents. The incidence rates decreased from 7.9% in 2000 to 2001 to 2.6% in 2001 to 2002 for students and from 9.2% in 1997 to 1998 to 2.7% in 2001 to 2002 for nursing staff.

CONCLUSIONS

Data from a surveillance database provided guidance for administrative, educational, and engineering control interventions. Active surveillance and periodic review of interventions are important aspects to reduce BBFEs in targeted high-risk occupational groups, especially when the workforce has a high turnover, as is typical in academic health centers.