Hepatitis B immune globulin for accidental exposures among medical personnel: final report of a multicenter controlled trial

Role of alcohol in pathogenesis of hepatitis B virus infection

Hepatitis B virus (HBV) and alcohol abuse often contribute to the development of end-stage liver disease. Alcohol abuse not only causes rapid progression of liver disease in HBV infected patients but also allows HBV to persist chronically. Importantly, the mechanism by which alcohol promotes the progression of HBV-associated liver disease are not completely understood. Potential mechanisms include a suppressed immune response, oxidative stress, endoplasmic reticulum and Golgi apparatus stresses, and increased HBV replication. Certainly, more research is necessary to gain a better understanding of these mechanisms such that treatment(s) to prevent rapid liver disease progression in alcohol-abusing HBV patients could be developed. In this review, we discuss the aforementioned factors for the higher risk of liver diseases in alcohol-induced HBV pathogenies and suggest the areas for future studies in this field.

Human Monoclonal Antibodies as Adjuvant Treatment of Chronic Hepatitis B Virus Infection

Despite the availability of an effective prophylactic vaccine leading to sterilizing immunity, hepatitis B virus (HBV) is responsible for chronic liver disease in more than 250 million individuals, potentially leading to cirrhosis and hepatocellular carcinoma. Antiviral drugs able to completely suppress virus replication are indeed available but they are, by and large, unable to eradicate the virus. Several alternative new treatment approaches are currently being developed but none have so far captured the interest of clinicians for possible clinical development. A constant feature of chronic HBV infection is T-cell exhaustion resulting from persistent exposure to high antigen concentrations as shown by the high expression of programmed cell death protein 1 (PD-1) by HBV-specific CD8 T cells. One way of tackling this problem is to develop HBV-specific neutralizing antibodies that would clear excess envelope proteins from the circulation, allowing for nucleos(t)ide analogs or other antiviral drugs now in preclinical and early clinical development to take advantage of a reconstituted adaptive immunity. Several fully human monoclonal antibodies (mAb) have been developed from HBV-vaccinated and subjects convalescent from acute hepatitis B that show different properties and specificities. It is envisaged that such neutralizing mAb may be used as adjuvant treatment to reduce viral protein load, thus rescuing adaptive immunity in an effort to optimize the effect of antiviral drugs.

Prevalence of Needlestick Injuries, Attitude Changes, and Prevention Practices Over 12 Years in an Urban Academic Hospital Surgery Department

OBJECTIVE

Needlestick injury prevalence, protection practices, and attitudes were assessed. Current medical students were compared with 2003 data to assess any changes that occurred with engineered safety feature implementation.

BACKGROUND

Risk of occupational exposure to bloodborne pathogens is elevated in the operating room particularly with surgeons in training and nurses.

METHODS

A cross-sectional survey was distributed to medical students (n = 358) and Department of Surgery staff (n = 247).

RESULTS

The survey response rate was 24.8%. Needlestick injuries were reported by 38.7% of respondents (11% high risk), and the most common cause was "careless/accidental." Needlestick injury prevalence increased from medical students to residents and fellows (100%). Thirty-three percent of injured personnel had at least one unreported injury, and the most common reason was "inconvenient/too time consuming." Needlestick injury prevalence and double-glove use in medical students did not differ from 2003, and 25% of fellows reported always wearing double gloves. The true seroconversion rate for bloodborne pathogens was underestimated or unknown. The concern for contracting a bloodborne pathogen significantly decreased (65%) compared to 2003, and there were significantly less medical students with hepatitis B vaccinations (78.3%). Level of concern for contracting a bloodborne pathogen was predictive of needlestick injury.

CONCLUSIONS

Needlestick injury and occupational exposure to bloodborne pathogens are significant hazards for surgeons and nurses. Attitudes regarding risk are changing, and the true seroconversion risk is underestimated. Educational efforts focused on needlestick injury prevalence, seroconversion rates, and double-glove perforation rates may be effective in implementing protective strategies.

Hepatitis B Virus Genotype E Infection among Egyptian Health Care Workers

BACKGROUND AND OBJECTIVES

Health Care Workers (HCWs) are at a high risk of needle stick injuries and HBV infection in Egypt; this problem is further aggravated by low Hepatitis B (HB) vaccination coverage. Limited data are available on the prevalence of HBV infection in Egyptian HCWs. In this study, we aimed to assess the HBV infection rate and genotypes among Egyptian HCWs.

METHODS

Five hundred and sixty-four (564) HCWs were included. Of them, 258 (45.74%) were health care providers and 306 (54.25%) were non-health care providers. All HCWs completed both the study questionnaires and provided a blood sample for HBV testing. Indeed, all HCWs were tested for Hepatitis B surface antigen (HBsAg) and antibody to Hepatitis B core antigen (anti-HBc), by enzyme-linked immunosorbent assay. HBVDNA was checked for HCWs who tested positive for HBsAg and/or anti-HBc, by nested Polymerase Chain Reaction (PCR). HBVDNA positive HCWs were further subjected to HBV genotyping.

RESULTS

The mean age of included HCWs was 33.0 ± 9.8 years, of whom 319 (56.56%) were males. The mean duration of health care work was 9.3 ± 6.7 years. The frequency of HBsAg and anti-HBc were 1.4%, and 24.5%, respectively. Old age and prolonged duration of health care work were significantly associated with anti-HBc seropositivity. Among 140 HCWs positive for HBsAg and/or anti-HBc, 14 (10 %) had positive HBVDNA by PCR. HBV/E (n = 7), HBV/D (n = 3) and co-infection with E and D (n = 4) genotypes were detected.

CONCLUSION

Egyptian HCWs have a significantly high rate of HBV exposure. The detection of HBV/E genotype among Egyptian HCWs suggests prevalent transmission of HBV/E among Egyptian populations.

Hepatitis B reactivation during or after direct acting antiviral therapy - implication for susceptible individuals

The FDA issued a warning following 24 cases of HBV reactivation during DAA therapy for HCV, including individuals with inactive, occult and past HBV infection. Clinical presentations ranged from asymptomatic fluctuations in HBV DNA to fulminant hepatic failure, liver transplantation and death. The mechanism is unknown. Areas covered: HCV/HBV coinfection is common, particularly in regions endemic for HBV. HCV and HBV utilize host factors to support replication; both viruses evade/impair host immunity. Clinical presentations of HBV reactivation during DAAs are summarized. Other causes of HBV reactivation are revisited and recent data regarding HBV reactivation are presented. Expert opinion: HBV reactivation during DAAs for HCV occurs, with life-threatening consequences in some individuals. The risk of HBV reactivation is observed in all HBV stages. The rapid removal of HCV likely alters and liberates host-viral ± viral-viral interactions that lead to increased HBV replication. As immune reconstitution occurs with HCV removal, host recognition of HBV DNA likely ensues followed by vigorous host immune responses leading to liver injury (HBV flare). These cases highlight the importance of HBV testing prior to initiating DAA therapy, the need for close monitoring of HBV during therapy and timely administration of anti-HBV therapy to prevent serious sequelae.

Hepatitis B Virus e Antigen Regulates Monocyte Function and Promotes B Lymphocyte Activation

Hepatitis B virus (HBV) e (HBe) antigen is a nonstructural virus component with great immune regulation roles. It regulates adaptive immunity response and participates in persistent infection development. However, its roles on monocytes and B lymphocytes were rarely studied. Herein, we studied HBe roles on U937 and Hmy2.CIR by creating HBe stably transfected cells using lentivirus. We detected the motility of HBe-U937 through transwell migration assay. Cytokines that primarily produced by monocytes, including BAFF, B-cell activating factor (BAFF), interleukin (IL)-6, IL-10, tumor necrosis factor (TNF)-α, and A proliferation inducing ligand (APRIL), were measured in culture supernatants of transfected U937, and serum BAFF, IL-6, and IL-10 were detected in HBe-positive and HBe-negative HBV-infected patients. Among these, BAFF mRNA and membrane-bound BAFF were further detected. Activation and inhibition markers of B lymphocytes on HBe-Hmy2.CIR and proliferation of transfected Hmy2.CIR after coculture with transfected U937 were also detected. We found that U937 migration was inhibited by HBe. BAFF expression was increased in HBe-U937, however, membrane-bound BAFF on HBe-U937 was decreased. In addition, Serum BAFF in HBe-positive patients was higher than in HBe-negative patients. IL-6 and IL-10 were increased in HBe-U937 after being stimulated by lipopolysaccharide (LPS), however, serum IL-6 and IL-10 were not associated with HBe status in patients. Besides, TNF-α and APRIL expression were basically the same in GV166-U937 and HBe-U937. B lymphocyte activation markers CD86 and Tspan33 were raised in HBe-Hmy2.CIR. However, inhibition markers Lyn and CD32b had no differences between HBe-Hmy2.CIR and control. Proliferation of transfected Hmy2.CIR was not affected by coculture with transfected U937, however, HBe transfection itself enhanced Hmy2.CIR proliferation. Altogether, these revealed that HBe can inhibit U937 migration and promote cytokines, including BAFF, IL-6, and IL-10, production in U937. Besides, HBe enhances BAFF release from U937 and increases BAFF concentration in vivo. In addition, HBe antigen facilitates Hmy2.CIR activation and proliferation through direct induction.

The acceptable duration between occupational exposure to hepatitis B virus and hepatitis B immunoglobulin injection: Results from a Korean nationwide, multicenter study

BACKGROUND

Postexposure prophylaxis for occupational exposure to hepatitis B virus (HBV) plays an important role in the prevention of HBV infections in health care workers (HCWs). We examined data concerning the acceptable duration between occupational exposure and administration of a hepatitis B immunoglobulin (HBIG) injection in an occupational clinical setting.

METHODS

A retrospective analysis was conducted with data from 143 cases of HCWs exposed to HBV in 15 secondary and tertiary teaching hospitals between January 2005 and June 2013. Data were taken from the infection control records of each hospital.

RESULTS

Active vaccination after HBV exposure was started in 119 cases (83.2%) and postvaccination testing for hepatitis B antibody showed positive seroconversion in 93% of cases. In 98 cases (68.5%), HBIG was administered within 24 hours after HBV exposure; however, 45 HCWs (31.5%) received an HBIG injection more than 24 hours postexposure and 2 among the 45 received an injection after 7 days. Although 31.5% received an HBIG injection more than 24 hours postexposure, no cases of seroconversion to hepatitis b antibody positivity occurred.

CONCLUSIONS

For susceptible HCWs, HBIG administered between 24 hours and 7 days postexposure may be as effective as administration within 24 hours in preventing occupational HBV infection.

Postexposure management of healthcare personnel to infectious diseases

Healthcare personnel (HCP) are at risk of exposure to various pathogens through their daily tasks and may serve as a reservoir for ongoing disease transmission in the healthcare setting. Management of HCP exposed to infectious agents can be disruptive to patient care, time-consuming, and costly. Exposure of HCP to an infectious source should be considered an urgent medical concern to ensure timely management and administration of postexposure prophylaxis, if available and indicated. Infection control and occupational health departments should be notified for management of exposed HCP, identification of all contacts of the index case, and application of immediate infection control measures for the index case and exposed HCP, if indicated. This article reviews the main principles of postexposure management of HCP to infectious diseases, in general, and to certain common infections, in particular, categorized by their route of transmission, in addition to primary prevention of these infections.

A randomized prospective study of glove perforation in orthopaedic surgery: is a thick glove more effective?

We compared perforation rates among operative staff who were randomly assigned either thick latex surgical gloves or conventional gloves for use in performing total knee arthroplasty. A total of 1120 gloves were assessed in 70 total knee arthroplasties. Additionally, the degree of tactile sensitivity provided by the gloves was compared using a two-point discrimination (TPD) test. Perforation occurred in 27 surgeries (38.5%) and in 48 gloves (4.29%). Binary logistic regression analysis revealed that the operator was a risk factor for perforation rate (Odds ratio 14.448, P < .0.01) and that the type of glove was not (P = .896). In the TPD test, tactile sensitivity was lower for a thick outer glove than the conventional double glove (P < .001 for each site). Not only did thick surgical gloves lower tactile sensitivity, they also offered no superior protective effect over conventional gloves.

New HIV diagnosis after occupational exposure screening: the importance of reporting needlestick injuries

We describe three new diagnosis of HIV infection as a direct result of testing following occupational exposures (NSIs) in a low-prevalence setting. In each case the finding was unexpected. Our series provides a reminder of the importance of prompt reporting of NSIs by healthcare workers, access to rapid HIV testing and post-exposure prophylaxis with antiretrovirals to prevent transmission.

Polyclonal immunoglobulins and hyperimmune globulins in prevention and management of infectious diseases

Immunoglobulin therapy has a rich history of use in preventing and treating infectious diseases; however, clinical data on the efficacy of immunoglobulin is lacking for many infectious diseases. Immunoglobulin therapy is routinely used in postexposure prophylaxis for bacterial infections, including tetanus, botulism, and diphtheria, and viral infections, including hepatitis A and B and varicella. Immunoglobulin therapy has also been used in many severe and life-threatening infections where treatments are limited, including toxic shock syndrome, respiratory syncytial virus infection, and cytomegalovirus infection. The authors review the evidence for the use of immunoglobulin therapy in common adult infectious diseases.

Hospital epidemiology and infection control in acute-care settings

Health care-associated infections (HAIs) have become more common as medical care has grown more complex and patients have become more complicated. HAIs are associated with significant morbidity, mortality, and cost. Growing rates of HAIs alongside evidence suggesting that active surveillance and infection control practices can prevent HAIs led to the development of hospital epidemiology and infection control programs. The role for infection control programs has grown and continues to grow as rates of antimicrobial resistance rise and HAIs lead to increasing risks to patients and expanding health care costs. In this review, we summarize the history of the development of hospital epidemiology and infection control, common HAIs and the pathogens causing them, and the structure and role of a hospital epidemiology and infection control program.

Role of HLA allele polymorphism in chronic hepatitis B virus infection and HBV vaccine sensitivity in patients from eastern Turkey

Human leukocyte antigen (HLA) alleles have been associated with the clinical outcomes of hepatitis B virus (HBV) infection, which range from spontaneous recovery to hepatocellular carcinoma. In this study involving subjects from eastern Turkey, the frequencies of HLA-B35, HLA-CW4, HLA-DQ2, and HLA-DQ8 were markedly higher in the chronic HBV group than those in the spontaneously recovered group; the frequencies of HLA-A11 and HLA-A24 in the nonresponsive HBV vaccine group were markedly higher than those in the responsive HBV vaccine group; and the frequency of HLA-CW6 in the nonresponsive HBV vaccine group was significantly lower than in the responsive group. A complete understanding of HLA types associated with the progression to chronic HBV infection and their effects within the cell at the molecular level will be an important contribution in the development of new HBV vaccines and new treatment strategies for chronic HBV infection.

Pegylated interferon α-2b up-regulates specific CD8+ T cells in patients with chronic hepatitis B

AIM: To investigate the effect of pegylated interferon (IFN) α-2b on specific CD8+ T lymphocytes in patients with chronic hepatitis B (CHB).

METHODS: Twenty-one patients with CHB were treated with pegylated IFN α-2b. Periphery blood mononuclear cells were isolated from fresh heparinized blood by Ficoll-Hypaque density gradient centrifugation (density: 1.077 g/L, Pharmingen) at weeks 0, 4, 8, 12, and 24, respectively. Frequency of circulating hepatitis B virus (HBV) epitope-specific CD8 T cells was detected by flow cytometry. Cytokines were detected by cytometric bead assay.

RESULTS: The frequency of circulating HBV core or env-specific CD8 T cells was higher (P < 0.05), the number of HBV core specific CD8 T cells was greater at week 24 (P < 0.05), the level of Th1-type cytokines [interleukin (IL)-12, tumor necrosis factor-α, and IFN-γ] was higher, while that of Th2-type cytokines (IL-4, IL-6, and IL-10) was lower in responders than in non-responders (P < 0.05) after pegylated IFN α-2b treatment. The IL-6 level was correlated with HBV DNA (r = 0.597, P = 0.04), while the inducible protein-10 (IP-10) level was correlated with serum alanine aminotransferase (ALT) (r = 0.545, P = 0.005). The IP-10 level at week 8 after pegylated IFN α-2b treatment could predict the normalization of ALT in CHB patients (positive predict value = 56%, negative predict value = 92%).

CONCLUSION: Pegylated IFN α-2b can enhance the immune response of CHB patients by increasing the frequency of HBV specific CD8+ T cells and regulating the Th1/Th2 cytokines.

Vírus da hepatite B: avaliação da resposta sorológica à vacina em funcionários de limpeza de hospital-escola

A hepatite viral B constitui um dos mais importantes problemas de saúde pública em todos os continentes. O vírus da hepatite B se transmite por via parenteral e, sobretudo, por via sexual. O objetivo foi avaliar a população ativa dos funcionários de limpeza do hospital da Faculdade de Medicina de Botucatu-UNESP, que receberam esquema completo de vacinação contra a hepatite B, medir os níveis de anticorpo contra o AgHBs (anti-HBs) e avaliar a sua relação com as condições epidemiológicas gerais, de vida pessoal e profissional e de risco de infecção pelo vírus da hepatite B.

HBV-Specific Adaptive Immunity

The successful control of HBV infection requires an efficient expansion of distinct elements of the adaptive immune system (B cells, helper and cytotoxic T cells) that, due to the hepatotropic nature of HBV, need to operate in the liver parenchyma. In this respect, we will discuss broad features of HBV immunity in patients with resolved or chronic HBV infection and analyze how the liver environment can directly modulate HBV-immunity.

Understanding the immunopathogenesis of chronic hepatitis B virus: an Asian prospective

The study of hepatitis B virus (HBV) immunity has been mainly focused on understanding the differences between subjects who are able to control HBV infection and patients with persistent infection. These studies have been instrumental in increasing our knowledge on the pathogenesis of the disease caused by HBV. However, it is possible that heterogeneity of host and virus factors which segregate in ethnically distinct HBV infected populations might modify important aspects of the immune response against HBV. In this review, we reexamine the kinetics and the pattern of HBV-specific immunity associated with control or persistence of infection. We then discuss how the epidemiological, genetic and viral characteristics peculiar to Asian patients can impact the profile of HBV-specific immunity.

Immune response and tolerance during chronic hepatitis B virus infection

The hepatitis B virus (HBV) is a hepatotropic non-cytopathic DNA virus that despite the presence of an effective prophylactic vaccine is estimated to infect 300 million people, with a particularly high prevalence in Asia and Africa. It causes liver diseases that vary greatly in severity from person to person. Some subjects control infection efficiently and clear the virus from the bloodstream either without clinically evident liver disease or with an acute inflammation of the liver (acute hepatitis) that can resolve without long-term clinical sequelae. Other patients fail to clear the virus and develop chronic infection. Most chronically infected patients remain asymptomatic without life-threatening liver disease but 10-30% develop liver cirrhosis with possible progression to liver cancer. Outcome of infection and the pathogenesis of liver disease are determined by virus and host factors, which have been difficult tofully elucidate because the host range of HBV is limited to man and chimpanzees. However, the study of animal models of related Hepadnavirus infections and transgenic mouse able to express individual HBV genes or replicate the entire viral genome have clarified several aspects connected to HBV infection. Furthermore, the ability to analyze many immunological phenomena ex vivo through direct quantification of Ag-specific T cells in humans and chimps has considerably increased our knowledge of HBV pathogenesis. Here, we will discuss the distinctions of HBV adaptive immunity between resolved and persistently infected patients and the host/viral factors that can cause and maintain them.

Effect of the introduction of an engineered sharps injury prevention device on the percutaneous injury rate in healthcare workers

OBJECTIVE

To evaluate the effect of introducing an engineered device for preventing injuries from sharp instruments (engineered sharps injury prevention device [ESIPD]) on the percutaneous injury rate in healthcare workers (HCWs).

METHODS

We undertook a controlled, interventional, before-after study during a period of 3 years (from January 1998 through December 2000) at a major medical center. The study population was HCWs with potential exposure to bloodborne pathogens. HCWs who sustain a needlestick injury are required by hospital policy to report the exposure. A confidential log of these injuries is maintained that includes information on the date and time of the incident, the type and brand of sharp device involved, and whether an ESIPD was used.

INTERVENTION

Introduction of an intravenous (IV) catheter stylet with a safety-engineered feature (a retractable protection shield), which was placed in clinics and hospital wards in lieu of other IV catheter devices that did not have safety features. No protective devices were present on suture needles during any of the periods. The incidence of percutaneous needlestick injury by IV catheter and suture needles was evaluated for 18 months before and 18 months after the intervention.

RESULTS

After the intervention, the incidence of percutaneous injuries resulting from IV catheters decreased significantly (P<.01), whereas the incidence of injuries resulting from suture needle injuries increased significantly (P<.008).

CONCLUSION

ESIPDs lead to a reduction in percutaneous injuries in HCWs, helping to decrease HCWs' risk of exposure to bloodborne pathogens.

A pilot study to measure the compressive and tensile forces required to use retractable intramuscular safety syringes

BACKGROUND

A pilot study was conducted at the Tampa Veterans Administration Patient Safety Center. The objective was to determine the forces required to operate retractable safety syringes to evaluate potential adverse occupational health and patient safety issues.

METHODS

Four brands (100 each) of retractable syringes were tested, using a digital force gauge, in air and in a simulated patient material (SPM). Compressive and tensile forces were measured while activating the retraction mechanism and withdrawing saline into the syringe barrel, respectively.

RESULTS

The mean compressive force was greater in SPM than in air in all 4 devices. There was a statistically significant compressive force difference between activation in air and SPM in devices 1 and 2 (P </= .05). The tensile forces for all devices were lower than the compressive forces. Analysis of variance was used to compare the groups, and the results showed that the means were significantly different (P < .001).

CONCLUSION

This pilot study has implications for device selection, training for users, design issues for manufacturers, and patient safety, as well as potential for future needlestick and ergonomic injuries. We recommend replication of this study with a computer-controlled force testing apparatus, and by testing multiple needle and syringe sizes.

The immune response during hepatitis B virus infection

Hepatitis B virus (HBV) is a major cause of chronic liver inflammation worldwide. Recent knowledge of the virological and immunological events secondary to HBV infection has increased our understanding of the mechanisms involved in viral clearance and persistence. In this review, how the early virological and immunological events might influence the development of a coordinate activation of adaptive immunity necessary to control HBV infection is analysed. The mechanism(s) by which high levels of viral antigens, liver immunological features, regulatory cells and dendritic cell defects might maintain the HBV-specific immunological collapse, typical of chronic hepatitis B patients, is also examined.

Needlestick injuries in a tertiary care centre in Mumbai, India

Accidental exposure from blood/body fluid of patients is a risk to healthcare workers (HCWs). Percutaneous injury is the most common method of exposure to blood-borne pathogens. A policy was formulated at our institute, a tertiary care centre in central Mumbai, and we report a six-year (1998--2003) ongoing surveillance of needlestick injuries. Of the 380 HCWs who reported needlestick injuries, 45% were nurses, 33% were attendants, 11% were doctors and 11% were technicians. On source analysis, 23, 15 and 12 were positive for Hepatitis B surface antigen (HBsAg), human immunodeficiency virus (HIV) and hepatitis C virus (HCV), respectively. Immediate action following potential exposure included washing the wound with soap and water, encouraging bleeding and reporting the incident to the emergency room. Analysis of the source of injuries revealed that known sources accounted for 254 injuries, and unknown sources from garbage bags and Operating Theatre instruments accounted for 126 injuries. Most needlestick injuries occurred during intravenous line insertion (N=112), followed by blood collection (N=69), surgical blade injury (N=36) and recapping needles (N=36). Immediate postexposure prophylaxis (PEP) for HCWs who sustained injuries with hepatitis-B-virus-positive patients included booster hepatitis B immunization for those positive for antiHBs. A full course of immunization with hepatitis B immunoglobulin was given to those who were antiHBs negative. All staff who sustained injury with HIV were given immediate antiretroviral therapy (AZT 600 mg/day) for six weeks. Subsequent six-month follow-up showed zero seroconversion.

Vaccines for preventing hepatitis B in health-care workers

BACKGROUND

Hepatitis B virus (HBV) causes acute and chronic liver diseases. Hepatitis B vaccination is recommended for health-care workers.

OBJECTIVES

To assess the beneficial and harmful effects of hepatitis B vaccination in health-care workers.

SEARCH STRATEGY

We searched the trial registers of The Cochrane Hepato-Biliary Group, The Cochrane Library, MEDLINE, and EMBASE to February 2003.

SELECTION CRITERIA

Randomised trials comparing any dose, injection route, injection site, or schedule of hepatitis B plasma-derived vaccines (PDV) or recombinant vaccines (RV) versus placebo, no intervention, or another hepatitis B vaccine in health-care workers.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted the data independently. The reviewers assessed the methodological quality of the trials regarding generation of the allocation sequence, allocation concealment, double blinding, and follow-up. The results were presented as relative risk (RR) with 95% confidence intervals (CI).

MAIN RESULTS

We identified 21 randomised trials, all with one or more methodological weaknesses. Four trials demonstrated that PDV versus placebo significantly decreased hepatitis B events at maximum follow-up (RR 0.51, 95% CI 0.35 to 0.73). RV did not differ significantly from PDV in eliciting a protective hepatitis B surface antibody (anti-HBs) level in two trials. Both vaccines were well tolerated. Low-dose vaccine (1 or 2 microg) by the intradermal route resulted in significantly more participants without protective anti-HBs level compared with high-dose (10 or 20 microg) by the intramuscular route (RR 1.41, 95% CI 1.13 to 1.76). The intradermal route caused significantly more local adverse events, while the intramuscular route caused significantly more systemic adverse events. The gluteal injection produced significantly more participants without protective anti-HBs level than the deltoid injection. The prevalence of anti-HBs seroconversion by rapid vaccination (0, 1, and 2 months) was significantly lower than that by standard vaccination (0, 1, and 6 months). Booster vaccinations with different RV doses (2.5, 5, 10, 20, or 40 microg) produced similar prevalence of anti-HBs seroconversion in three trials assessing participants who did not respond to previous HBV vaccination.

AUTHORS' CONCLUSIONS

PDV significantly prevents hepatitis B events. RV seems to be able to elicit similar protective anti-HBs levels. The intramuscular route with 20 microg RV was significantly more effective compared with the intradermal route with 2 microg RV as was the standard schedule compared with a rapid schedule and deltoid intramuscular injection compared with the gluteal intramuscular injection. It is unclear if booster vaccination of non-responders offers higher anti-HBs seroconversion and hepatitis B vaccine prevents the infection of hepatitis B mutants in health-care workers.

Kinetics of the immune response during HBV and HCV infection

The innate immune system has a role not only in protecting the host during the initial period of virus infection, but also in shaping the nature of the adaptive immune response. In this review, we follow the kinetics of the virologic and immunologic events occurring from the time of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. We primarily discuss how the early events after infection might influence the development of the adaptive immune response in these 2 important viral infections and how new strategies for more efficient preventive and therapeutic vaccines can be derived from this knowledge.

Back to the future: antibody-based strategies for the treatment of infectious diseases

Before antibiotics, sera from immune animals and humans were used to treat a variety of infectious diseases, often with successful results. After the discovery of antimicrobial agents, serum therapy for bacterial infections was rapidly forsaken. In the last two decades, problems with treatment of newly emerged, re-emerged, or persistent infectious diseases necessitated researchers to develop new and/or improved antibody-based therapeutic approaches. This article reviews some information on the use of antibodies for the treatment of infectious diseases, with special reference to the most seminal discoveries and current advances as well as available treatment approaches in this field.

Nosocomial spread of viral disease

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.

[Occupational exposures to blood-borne pathogens in health care workers]

OBJECTIVE

To determine the rate of occupational exposures to blood-borne pathogens in different occupations of health care workers. To analyze the characteristics and outcome of the occupational exposure.

MATERIAL AND METHODS

We have evaluate occupational exposures to blood-borne pathogens reported by health care workers during 1996-1999. The following data were collected: characteristics of the workers, type of occupational exposure, immunity status of the exposed worker, infectivity of the source patient and follow up serologic testing of the worker.

RESULTS

A total of 407 occupational exposures were reported. The highest rate of occupational exposure was found among nurses (61.6%). Needlestick accident was the most often occupational exposure reported (84.5%). Mucosal exposures with accidental splashes were reported in 15.2% of cases. In 14.5% of these accidents workers were at risk for occupational transmission of blood-borne pathogens. Among the different occupations of health care workers, the rate of exposures with a source infected patient was higher in medical staffs (28.3%) than nurses (13.9%) The rate of exposures with a source infected patient was higher in accidental splashes than in percutaneous exposures (33.8% vs 13.3%), besides in none of the accidental splashes, employees had used appropriate barrier precautions. There were no cases of transmission of occupational blood-borne infections.

CONCLUSIONS

Although nurses are the health care workers with highest rates of occupational exposures, medical staffs are the most often occupationally exposed to a source infected patient. Universal barrier precautions are no appropriately used in most of the occupational accidents, specially in those involving mucosal exposures.

Determination of the protective effects of neutralizing anti-hepatitis B virus (HBV) immunoglobulins by epitope mapping with recombinant HBV surface-antigen proteins

Anti-hepatitis B virus (HBV) surface-antigen immunoglobulins prepared from human sera are clinical reagents which have been approved for prophylactic treatment in HBV-exposed persons. The passive immunoprophylaxis with immunoglobulins is meant to cross-link viral particles, which are then further cleared by the host's own immune system. While antibodies specific for both anti-S- and anti-preS proteins have been proved to serve as effective anti-viral agents, so far the fine antigen specificity of clinical immunoglobulin preparations has not been determined. Using recombinant proteins covering the hepatitis B surface antigen, in the present study, the specificity of a commercially available immunoglobulin preparation was determined and immunodominant epitopes were mapped. Here, it is shown that the major reactivity of anti-HBV immunoglobulins is directed against the S-protein, and that no reactivity to the preS2 but a weak binding activity to the preS1 region was detectable. The antigen reactivity within the preS1 region was biased to the C-terminal region, which indicates the presence of a putative B-cell epitope. The evaluation of the antigen specificity and determination of novel protective epitopes will provide valuable information for the further development and improvement of prophylactic HBV immunoglobulins.

Risk and management of blood-borne infections in health care workers

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.

Risk and management of blood-borne infections in health care workers

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.

Human immunodeficiency virus and other blood-borne viral pathogens in the athletic setting. Committee on Sports Medicine and Fitness. American Academy of Pediatrics

Because athletes and the staff of athletic programs can be exposed to blood during athletic activity, they have a very small risk of becoming infected with human immunodeficiency virus, hepatitis B virus, or hepatitis C virus. This statement, which updates a previous position statement of the American Academy of Pediatrics, (1) discusses sports participation for athletes infected with these pathogens and the precautions needed to reduce the risk of infection to others in the athletic setting. Each of the recommendations in this statement is dependent upon and intended to be considered with reference to the other recommendations in this statement and not in isolation.

The effect of blood on the antiviral activity of sodium hypochlorite, a phenolic, and a quaternary ammonium compound

OBJECTIVE

To assess the virucidal activity of three disinfectants (sodium hypochlorite, a phenolic, and a quaternary ammonium compound) in the presence and absence of blood.

METHODS

Disinfectants at varying concentrations (hypochlorite: 5,000, 500, or 50 ppm; phenolic: 1:10 or 1:128 dilution; quaternary ammonium compound: 1:10 or 1:128 dilution) were added to either saline or whole blood (final concentration, 80% or 20% blood) and mixed. Test organisms included an attenuated vaccine strain of poliovirus type 1 (prototype for relatively resistant hydrophilic viruses) and herpes simplex virus (HSV) type 1 (prototype for relatively susceptible lipophilic viruses). Virus was added to create a viral-blood suspension. Viral survival was tested at room temperature at the following times: 0, 15 seconds, 30 seconds, 1 minute, 2 minutes, 5 minutes, and 10 minutes. A neutralizer stopped the reaction, and virus was assayed using a plaque technique.

RESULTS

In the absence of blood, complete inactivation of HSV was achieved within 30 seconds with 5,000 (1:10 dilution of bleach) and 500 (1:100 dilution of bleach) ppm chlorine, 1:10 and 1:128 diluted phenolic (use dilution), and 1:10 and 1:128 diluted quaternary ammonium compound (use dilution). In the presence of 80% blood, only 5,000 ppm hypochlorite, 1:10 phenolic, and 1:10 or 1:128 quaternary ammonium compound were effective. In the absence of blood, complete inactivation of polio was achieved within 30 seconds by 5,000 and 500 ppm chlorine and 1:10 quaternary ammonium compound. In the presence of 80% blood, no solution tested was capable of completely inactivating poliovirus within 10 minutes.

CONCLUSIONS

Our data suggest that, in the absence of visible blood, environmental surfaces may be disinfected with a diluted hypochlorite solution (1:10 or 1:100), a phenolic, or a quaternary ammonium compound. Based on our studies using HSV, which has similar susceptibilities to disinfectants as human immunodeficiency virus (HIV), phenolics at their use dilution and 1:100 diluted hypochlorite are unlikely to inactivate HIV or hepatitis B virus reliably in the presence of blood. Hypochlorite at a final concentration of 5,000 ppm (1:10 dilution) should be used to decontaminate blood spills, but, even after decontamination, care should be used to avoid sharps injuries.

Update on diagnosis, management, and prevention of hepatitis B virus infection

Acute and chronic hepatitis B virus (HBV) infection is a leading cause of liver disease worldwide. It is estimated that approximately 350 million people worldwide have chronic HBV infection and that 1 million persons die each year from HBV-related chronic liver disease. In the past decade, significant progress in the understanding of the molecular virology and pathogenesis of HBV infection has been made. In addition, effective treatment modalities have been developed for persons with chronic infection. Worldwide, prevention of HBV transmission has become a high priority. In 1992, the Global Advisory Group to the World Health Organization recommended that all countries integrate hepatitis B vaccine into national immunization programs by 1997. Currently, 80 countries have done so and several others are planning to. Many countries have reported dramatic reductions in the prevalence of chronic HBV infection among children born since the hepatitis B vaccine was introduced into infant immunization schedules. Recent reports from Taiwan indicate a reduction in the incidence of liver cancer among children as a result of widespread hepatitis B vaccination programs.