Probable transmission of HIV from an orthopedic surgeon to a patient in France

No longer 'written off' - times have changed for the BBV-infected dental professional

There is a recognised potential risk of transmission of blood-borne viruses (BBVs) from infected healthcare workers to patients during exposure prone procedures (EPPs). The restrictions placed on performance of EPPs by infected clinicians in the UK have had a particularly significant impact on dentists because of the exposure-prone nature of most dental procedures and the difficulties in identifying alternative career pathways in the profession that do not involve EPPs. More recently, the significant positive impact of antiviral drugs on viral load, together with a re-categorisation of EPPs in dentistry have resulted in evolution of the guidance with a consequent significant improvement to the career prospects of dentists infected with BBVs. This paper provides an update for practitioners on the progress that has been made and outlines the current position with respect to practice restrictions.

Human Immunodeficiency Virus (HIV) Transmission in Dentistry

HIV transmission in the health-care setting is of concern. To assess the current position in dentistry, we have reviewed the evidence to November 1, 2005. Transmission is evidently rare in the industrialized nations and can be significantly reduced or prevented by the use of standard infection control measures, appropriate clinical and instrument-handling procedures, and the use of safety equipment and safety needles. We hope that breaches in standard infection control will become vanishingly small. When occupational exposure to HIV is suspected, the application of post-exposure protocols for investigating the incident and protecting those involved from possible HIV infection further reduces the likelihood of HIV disease, and also stress and anxiety.

Attitudes of nurses toward HIV-infected colleagues in Japan

BACKGROUND

Nurses may be unwilling to accept HIV-infected colleagues who can continue to work with patients if the provider-to-patient transmission risks have been appropriately assessed.

AIMS

To assess the factors associated with nurses' willingness to accept HIV-infected colleagues as coworkers.

DESIGN

Descriptive and cross-sectional.

METHODS

An anonymous online survey targeting Japanese nurses working in hospitals or clinics (n = 992). Logistic regression analysis was used to evaluate factors associated with their willingness to accept HIV-positive colleagues before or after a risk assessment.

RESULTS

Respondents who avoided contact with, and expressed discriminatory views about, HIV-infected colleagues were less willing to accept them. After undertaking an appropriate risk assessment, a high level of knowledge regarding HIV transmission increased the likelihood of acceptance towards HIV-infected colleagues.

CONCLUSIONS

The use of risk assessment may increase nurses' willingness to accept HIV-infected colleagues, particularly among co-workers with a high level of knowledge about HIV.

Look-back investigation of a health care worker infected with human immunodeficiency virus

We report the referral of an HIV-infected surgeon and a subsequent first-ever recommended look-back investigation in Hong Kong. Efficient coordination and effective implementation of the look-back investigation yielded a high response rate of 92.3% of priority patients, with none tested HIV positive. Our experience reconfirmed the very small risk of provider-to-patient HIV transmission and the crucial importance of infection control.

Healthcare-associated viral and bacterial infections in dentistry

Infection prevention in dentistry is an important topic that has gained more interest in recent years and guidelines for the prevention of cross-transmission are common practice in many countries. However, little is known about the real risks of cross-transmission, specifically in the dental healthcare setting. This paper evaluated the literature to determine the risk of cross-transmission and infection of viruses and bacteria that are of particular relevance in the dental practice environment. Facts from the literature on HSV, VZV, HIV, Hepatitis B, C and D viruses, Mycobacterium spp., Pseudomonas spp., Legionella spp. and multi-resistant bacteria are presented. There is evidence that Hepatitis B virus is a real threat for cross-infection in dentistry. Data for the transmission of, and infection with, other viruses or bacteria in dental practice are scarce. However, a number of cases are probably not acknowledged by patients, healthcare workers and authorities. Furthermore, cross-transmission in dentistry is under-reported in the literature. For the above reasons, the real risks of cross-transmission are likely to be higher. There is therefore a need for prospective longitudinal research in this area, to determine the real risks of cross-infection in dentistry. This will assist the adoption of effective hygiene procedures in dental practice.

Hepatitis C virus infection among transmission-prone medical personnel

Hepatitis C virus (HCV)-infected physicians have been reported to infect some of their patients during exposure-prone procedures (EPPs). There is no European consensus on the policy for the prevention of this transmission. To help define an appropriate preventive policy, we determined the prevalence of HCV infection among EPP-performing medical personnel in the Academic Medical Center in Amsterdam, the Netherlands. The prevalence of HCV infection was studied among 729 EPP-performing health care workers. Serum samples, stored after post-hepatitis B virus (HBV) vaccination testing in the years 2000–2009, were tested for HCV antibodies. Repeat reactive samples were confirmed by immunoblot assay and the detection of HCV RNA. The average age of the 729 health care workers was 39 years (range 18–66), suggesting a considerable cumulative occupational exposure to the blood. Nevertheless, only one of the 729 workers (0.14%; 95% confidence interval [CI]: <0.01% to 0.85%) was tested and confirmed to be positive for anti-HCV and positive for HCV RNA, which is comparable to the prevalence of HCV among Amsterdam citizens. Against this background, for the protection of personnel and patients, careful follow-up after needlestick injuries may be sufficient. If a zero-risk approach is desirable and costs are less relevant, the recurrent screening of EPP-performing personnel for HCV is superior to the follow-up of reported occupational exposures.

The HIV positive dentist in the United Kingdom - the dilemma of the undiagnosed clinician

This article considers the position of the HIV positive dentist in the United Kingdom who is unaware of their HIV status, or who at least has had no positive HIV test result. It outlines the current UK guidance that relates to HIV positive dentists, and the challenges to those guidelines. It considers how the behaviour of a practising seropositive dentist who has had no positive test result might be interpreted by regulatory bodies and the courts, and highlights the importance of clinicians being fully aware of their HIV status.

HIV transmission in the dental setting and the HIV-infected oral health care professional: workshop 1C

This workshop addressed two important issues: first, the global evidence of HIV transmission from health care provider to patient and from patient to health care provider in the general health care environment and the dental practice setting; second, in the era of highly active antiretroviral therapy, whether oral health care professionals living with HIV pose a risk of transmission to their patients and whether standard infection control is adequate to protect both the patient and the oral health care professional in dental practice. The workshop culminated in a general discussion and the formulation of a consensus statement from the participating delegates, representing more than 30 countries, on the criteria under which an HIV-infected oral health care professional might practice dentistry without putting patients at risk. This consensus statement, the Beijing Declaration, was agreed nem con.

Confidentiality of the medical records of HIV-positive patients in the United Kingdom - a medicolegal and ethical perspective

This article examines the legal and ethical issues that surround the confidentiality of medical records, particularly in relation to patients who are HIV positive. It records some historical background of the HIV epidemic, and considers the relative risks of transmission of HIV from individual to individual. It explains the law as it pertains to confidentiality, and reports the professional guidance in these matters. It then considers how these relate to HIV-positive individuals in particular.

Current risks of occupational blood-borne viral infection

BACKGROUND

Human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and other viruses remain occupational risks for both surgeons and patients in the operating room environment. In the past, this concern attracted great attention, but recently, this subject has been given much less attention.

METHODS

Review of the literature over the past 50 years on occupational risks of viral infection in the operating room.

RESULTS

Transmission of HIV still looms as a potential pathogen in the operating room, but no case has been documented in the United States. Infection with HBV can be prevented by a safe and effective vaccine. Chronic HCV infection is present in more than three million U.S. residents and remains a risk that can be managed only by adhering to strict infection control practices and avoiding blood exposure.

CONCLUSIONS

The risks of viral infection in the operating room remain the same as a decade ago even though attention to this issue has waned. The avoidance of blood exposure to prevent transmission of both known and unknown blood-borne pathogens continues to be a goal for all surgeons.

SHEA guideline for management of healthcare workers who are infected with hepatitis B virus, hepatitis C virus, and/or human immunodeficiency virus

This guideline provides the updated recommendations of the Society for Healthcare Epidemiology of America (SHEA) regarding the management of healthcare providers who are infected with hepatitis B virus (HBV), hepatitis C virus (HCV), and/or the human immunodeficiency virus (HIV). For the reasons cited in the guideline, SHEA continues to recommend that, although some aspects of the approach to and administrative management of each of these infectious syndromes in healthcare providers are similar, separate management strategies for healthcare workers who are infected with these unrelated viruses remain appropriate. As we did in both prior iterations of this document, SHEA emphasizes the use of appropriate infection control procedures to minimize exposure of patients or providers to blood, emphasizes that transfers of blood from patients to providers and from providers to patients should be avoided, and recommends that infected healthcare providers should not be totally prohibited from participating in patient-care activities solely on the basis of a bloodborne pathogen infection. The types of procedures assessed by the panel as associated with an increased risk for provider-to-patient transmission of these pathogens are discussed in detail. For each pathogen, recommendations are graduated according to the relative viral load level of the infected provider (Tables 1 and 2). However, SHEA emphasizes that, because of the complexity of these cases, each such case will be slightly different from the next, and each should be independently considered in context.

HIV testing of health care workers in England--a flawed policy

A new Department of Health policy in England, published in 2007, recommended changes to the pre-employment health checks performed on health care workers before taking up their employment. The policy proposed that all new health care workers should receive immunization against TB and hepatitis B and should be offered testing for hepatitis C and HIV. It also advanced a new requirement that staff who perform exposure-prone procedures must be tested for TB, hepatitis B and C and HIV and must test negative for these diseases. Essentially mandatory HIV testing has been introduced for a large number of health care workers. The aim of the recommendations is to protect patients from contracting serious communicable diseases from health care professionals. Secondary objectives of the directive are to maintain confidence in the workforce and reduce the burden of patient notification exercises. This essay explores some of the shortcomings of this policy and examines the reasons why this policy will fail to meet its objectives. The justification for this new guidance is questioned and some of the ethical issues are highlighted.

The HIV positive dentist in the United Kingdom--a legal perspective

In 1991, the United Kingdom Advisory Panel (UKAP) was set up under the aegis of the Expert Advisory Group on AIDS (EAGA) to consider individual cases of HIV infected healthcare workers. Policy and guidance relating to HIV infected healthcare workers is set out in a Department of Health report. Although more recently the EAGA has advised that an HIV positive dentist may under certain conditions provide clinical treatment for patients who are also HIV positive, the advice from UKAP relating to exposure-prone procedures means, in effect, that dentists who become HIV positive must cease contemporary clinical dentistry. The plight of dentists who become HIV positive and face this situation has been poignantly described as '...the dental practice equivalent of clearing your desk and being escorted off the premises.'

Healthcare Workers and HIV Health Issues

Should healthcare workers (HCWs) be routinely tested for HIV? The authors reviewed the literature on the risk and incidence of HIV transmission from HCW to patients and offer recommendations for HIV testing in HCWs in Singapore. Management of HCWs who are tested seropositive for HIV infection is also discussed in this paper. Key words: AIDS, HIV testing, occupational, transmission

Article Commentary: Occupational Risks of Blood Exposure in the Operating Room

Bloodborne pathogens continue to be a source of occupational infection for healthcare workers, but particularly for surgeons. Over 1 per cent of the U.S. population has one or more chronic viral infections. Hepatitis B is the infection that has the longest known role as an occupational pathogen, but infection with this virus is largely preventable with the use of the effective hepatitis B vaccine. Hepatitis C affects the largest number of people in the United States, and there is no vaccine available for the prevention of this infection. HIV infection still has not been associated with a documented transmission in the operating room environment, but six cases of probable occupational transmission have been reported. A total of 57 healthcare workers have had documented occupational infection since the epidemic of HIV infection began. Infection of blood-borne pathogens to patients from infected surgeons remains a concern. Surgeons who are e-antigen-positive for hepatitis B have been well documented to be an infection risk to patients in the operating room. Only four surgeons have been documented to transmit hepatitis C, although other transmissions have occurred in the care of patients when practices of infection control have been violated. No surgical transmission of HIV to a patient has been identified at this time. Prevention of occupational infection requires use of protective barriers, avoidance of exposure risk by modification of techniques, and a constant awareness of sharp instruments in the operating room. Blood exposure in the operating room carries risk of infection and should be avoided. It is likely that other infectious agents will emerge as operating room threats. Surgeons must maintain vigilance in avoiding blood exposure and percutaneous injury.

Written off

David Croser considers the appalling situation faced by UK dentists if they are diagnosed HIV positive.

Infected health care workers and patient safety: a double standard

US policy regarding health care worker-to-patient transmission of bloodborne pathogens, issued in 1991, is flawed. We review current evidence of such nosocomial infections and conclude that a standardized national policy is needed, which includes improved surveillance and follow-up of blood exposures to patients and targeted practice restrictions for infected practitioners performing exposure-prone procedures.

Transmission of HIV-1 from an obstetrician to a patient during a caesarean section

We describe a probable case of HIV-1 transmission from a healthcare worker (HCW) to a patient during a caesarean section. Genetic distance comparisons of the viral sequence of the C2V4 region of the viruses from the patient and the obstetrician showed an average nucleotide sequence divergence of 3% (2.8-3.1). HIV can be transmitted from an infected HCW to a patient when percutaneous injuries with subsequent exposure of the patient to the blood of the HCW can occur.

Rights and duties of HIV infected health care professionals

In 1991, the CDC recommended that health care workers (HCWs) infected with HIV or HBV (HbeAg positive) should be reviewed by an expert panel and should inform patients of their serologic status before engaging in exposure-prone procedures. The CDC, in light of the existing scientific uncertainty about the risk of transmission, issued cautious recommendations. However, considerable evidence has emerged since 1991 suggesting that we should reform national policy. The data demonstrates that risks of transmission of infection in the health care setting are exceedingly low. Current policy, moreover, does not improve patient safety. At the same time, implementation of current national policy at the local level poses significant human rights burdens on HCWs. Consequently, national policy should be changed to ensure patient safety while protecting the human rights of HCWs. This article proposes a new national policy, including: (1) a program to prevent bloodborne pathogen transmission; (2) a responsibility placed on infected HCWs to promote their own health and well-being and to assure patient safety; (3) a discontinuation of expert review panels and special restrictions for exposure-prone procedures; (4) a discontinuation of mandatory disclosure of a HCW's inflection status; and (5) the imposition of practice restrictions if a HCW is unable to practice safely because of a physical or mental impairment or failure to follow careful infection control techniques. A new national policy, focused on management of the workplace environment and injury prevention, would achieve high levels of patient safety without discrimination and invasion of privacy.

Comportement et conditions de travail exposant au sang : analyse des pratiques dans trois établissements de soins du Maroc

OBJECTIVE

As in other countries, Moroccan health-care workers are exposed to occupational blood exposure (OBE) hazards. The purpose of this study was to estimate the occupational safety and hygiene conditions determining the OBE risk for health-care workers. WORKERS AND METHODS: In March 2000, a multicentric study was carried out in Morocco on 420 health-care workers, with an anonymous questionnaire. The study included health-care workers in the Taza and Temara hospitals and health centers, as well as in a Rabat public medical analysis laboratory.

RESULTS

The participation rate was 67.8% (285/420). The population was mainly female (61%) with a mean age of 41.4 years (+/-7 years). Health-care workers answered that: occupational hygiene and safety were inadequate (55.1%); wearing single-use gloves was rare (34.5%); resheathing used needles was frequent (74.5%); safe containers were often missing (67%). In 1999, the annual average incidence of OBE was 1.5 (+/-4.3) per capita. If we consider the whole career of health-care workers, the incidence reached about 14.3+/-28.1 per capita. The absence of post-exposure chemoprophylaxis was the rule.

CONCLUSION

The study shows that there is a need to improve occupational hygiene and safety conditions for Moroccan health-care workers in order to reduce OBE hazards.

Infected Physicians and Invasive Procedures: Safe Practice Management

There is currently no public policy that provides guidance concerning whether and when physicians infected with hepatitis B virus (HBV), hepatitis C virus (HCV), and/or human immunodeficiency virus (HIV) can safely perform invasive procedures. A committee of experts in the fields of medicine, law, and biomedical ethics and 1 community member, aided by an advisory board, was established to produce recommendations for policy reform. An extensive literature review was conducted for these 3 infectious diseases, medicine, surgery, epidemiology, law, and bioethics to gather all relevant data. Special recommendations are made regarding the management of physicians who are infected with HIV, HBV, and/or HCV. This policy proposal includes a list of exposure-prone procedures and a decision chart that indicates under what conditions infected physicians can practice beyond the need for disclosure of their serological status.

Evaluation of policies regarding physicians infected with blood-borne pathogens

OBJECTIVE

Formulating an effective approach to preventing surgeon-to-patient transmission of blood-borne pathogens has been controversial. The objective of our study was to evaluate current community hospital policies, if any, regarding restrictions on surgeons (general surgeons and obstetricians and gynecologists) infected with blood-borne pathogens operating on patients.

DESIGN

A survey on hospital policies regarding surgeons infected with blood-borne pathogens was sent to infection control officers at Northern California community hospitals (n = 113).

RESULTS

Forty-five hospitals responded to the survey. Of these, only 6 (13.3%) had a policy. Of the 39 (86.7%) that did not have a policy, only 3 hospitals were planning on implementing one.

CONCLUSIONS

Many community hospitals are uninterested in instituting a policy regarding the practice of surgeons infected with blood-borne pathogens. Possible reasons include the lack of concern on the individual level, difficulty in defining exposure-prone procedures, and the nature of the relationship between medical staff and community hospitals.

Infection of patients by bloodborne viruses

BACKGROUND

Despite taking precautions, healthcare workers performing invasive procedures run a small risk of infection by bloodborne viruses. When injury occurs, the viral status of the patient is often unknown and testing requires informed consent, which may be refused. On the other hand, although the chance of transmission of infection from a healthcare worker to a patient is extremely small, such personnel have an obligation of disclosure and, if seropositive, are barred from performing invasive procedures.

METHODS

The medical literature on bloodborne virus transmission between carers and patients was reviewed, and the UK Department of Health, General Medical Council and Royal College of Surgeons of England guidelines on the risk management of these infections were read, along with secondary references from all sources.

RESULTS AND CONCLUSION

Patients have complete protection of confidentiality and the right to refuse testing, but these rights do not apply to the healthcare worker. When injured in circumstances in which the patient cannot or will not permit testing, carers can only submit to the risks of prophylactic treatment or go into denial. Infection may have devastating professional, personal and financial implications to carers and their dependants. Ways to re-establish a just balance between the legitimate rights of patients and healthcare workers are discussed.

Serial nosocomial transmission of Plasmodium falciparum malaria from patient to nurse to patient

BACKGROUND

Nosocomial transmission of malaria is a rare phenomenon in the United States.

OBJECTIVE

To describe the probable transmission of Plasmodium falciparum malaria from a patient to a healthcare worker and then from the healthcare worker to another patient.

DESIGN

Case series.

SETTING

Two community hospitals in Massachusetts.

INTERVENTION

Routine medical and supportive care.

MEASUREMENTS

Clinical and laboratory evaluation.

RESULTS

A nurse developed falciparum malaria after a needlestick injury from a patient with documented falciparum malaria. Three days prior to her diagnosis, she cared for another patient, who subsequently developed falciparum malaria. That patient's parasite isolate genetically matched the nurse's isolate by two independent DNA fingerprinting techniques.

CONCLUSION

After extensive evaluation, we believe that a nurse who had acquired falciparum malaria via needlestick subsequently transmitted malaria to another patient via a break in standard precautions. The implications of this mechanism of transmission are discussed.

Legal issues for healthcare workers with bloodborne infectious disease

The risk of bloodborne disease transmission in dental settings is very low. Available data support the low risk of transmission. The rate of occupational injuries among dental health care workers has decreased over the last decade and, other than the 1990 case of HIV transmission in a dental office, there have been no additional reports of bloodborne disease transmission by dental health care workers. However, public policy and judicial decisions focus less on science and more on emotion. Although many infection control organizations have updated their policies to remain current with science, the USPHS's policy remains as released in 1991. It would be prudent for these guidelines to be updated to reflect current scientific evidence and be inclusive for all bloodborne pathogens.

Molecular investigation of two possible cases of accidental HIV-1 transmission in South Africa

HIV-1 sequences from two possible transmission cases in South Africa were examined for evidence of genetic linkage. HIV-1-seropositive blood samples were obtained from a donor and recipient within 8 months following a blood transfusion and from a healthcare worker and her patient within 10 months following a needle-stick injury. A 700-bp region in env and 550-bp region in gag were analyzed. All sequences were phylogenetically associated with HIV-1 subtype C, the predominant HIV-1 subtype in South Africa. The nucleotide sequences from the blood transfusion case grouped together significantly with a bootstrap value of 100%. These samples were 98% and 100% identical in the predicted amino acid sequences of env and gag, respectively. In contrast, sequences from the needle-stick case showed only 67% and 80% amino acid identity in env and gag, respectively, and were separated on a phylogenetic tree. Molecular analysis suggested that HIV transmission occurred in the blood transfusion case but not in the case of the needle-stick injury. These data emphasize the need for molecular investigation of epidemiologically linked cases of HIV transmission.

Effectiveness of the hands-free technique in reducing operating theatre injuries

BACKGROUND

Operating theatre personnel are at increased risk for transmission of blood borne pathogens when passing sharp instruments. The hands-free technique, whereby a tray or other means are used to eliminate simultaneous handling of sharp instruments, has been recommended.

AIMS

To prospectively evaluate the effectiveness of the hands-free technique in reducing the incidence of percutaneous injuries, contaminations, and glove tears arising from handling sharp instruments.

METHODS

For each of 3765 operations carried out in main and surgical day care operating theatres in a large urban hospital, over six months, circulating nurses recorded the proportion of use of the hands-free technique during each operation, as well as other features of the operation. The hands-free technique, considered to be used when 75% or more of the passes in an operation were done in this way, was used in 42% of operations. The relative rate of incidents (percutaneous injuries, contaminations, and glove tears) in operations where the hands-free technique was used and not used, with adjustment via multiple logistic regression for the different risk profiles of the two sets of operations, was calculated.

RESULTS

A total of 143 incidents (40 percutaneous injuries, 51 contaminations, and 52 glove tears) were reported. In operations with greater than 100 ml blood loss, the incident rate was 4% (18/486) when the hands-free technique was used and 10% (90/880) when it was not, approximately 60% less. When adjusted for differences in type and duration of surgery, emergency status, noisiness, time of day, and number present for 75% of the operation, the reduction in the rate was 59% (95% CI 23% to 72%). In operations with less than 100 ml blood loss, the corresponding rates were 1.4% (15/1051) when the hands-free technique was used and 1.5% (19/1259) when it was not used. Adjustment for differences in risk factors did not alter the difference.

CONCLUSIONS

Although not effective in all operations, use of the hands-free technique was effective in operations with more substantial blood loss.

Lookback investigation of patients potentially exposed to HIV type 1 after a nurse-to-patient transmission

A nurse-to-patient transmission of HIV type 1 was recently documented in a French hospital. The origin of the transmission remained unclear. To inform patients who may have been exposed to the nurse while they had received care, a lookback investigation that included mailings and a viral screening was conducted for 7580 patients. No other case of nurse-to-patient transmission of HIV-1 was identified.

HIV and AIDS in the workplace

Since the onset of the HIV epidemic, AIDS and HIV infection have presented tremendous challenges to infected individuals seeking to remain productive in the workplace, to employers coping with the special needs of such individuals, and to physicians who treat and counsel exposed or infected personnel. OEM physicians should strive to ensure that employers are familiar with legislation and guidelines protecting the rights of infected employees, and they should support rational workplace policies applying to employees with HIV infection or AIDS. When the potential for occupational HIV exposure exists, OEM physicians should ensure that adequate training around exposure prevention, triage, and treatment is provided. OEM physicians who treat individuals with occupational HIV exposures should involve themselves in institutional efforts to prevent exposures through the use of safer devices and procedures, and they should ensure that immediate and adequate clinical evaluation of exposures is available at all times.

Risk of HIV and other blood-borne infections in the cardiac setting: patient-to-provider and provider-to-patient transmission

Health care workers (HCWs) face a well-recognized risk of acquiring blood-borne pathogens in their workplace, in particular hepatitis B and C viruses (HBV/HBC) and human immunodeficiency virus (HIV). Additionally, infected HCWs performing invasive exposure-prone procedures, including in the cardiac setting, represent a potential risk for patients. An increasing number of infected persons could need specific cardiac diagnostic procedures and surgical treatment in the future, regardless of their sex or age. The risk of acquiring HIV, HCV, HBV infection after a single at-risk exposure averages 0.5%, and 1-2%, and 4-30%, respectively. The frequency of percutaneous exposure ranges from 1 to 15 per 100 surgical interventions, with cardiothoracic surgery reporting the highest rates of exposures; mucocutaneous contamination by blood-splash occurs in 50% of cardiothoracic operations. In the Italian Surveillance (SIROH), a total of 987 percutaneous and 255 mucocutaneous exposures were reported in the cardiac setting; most occurred in cardiology units (46%), and in cardiovascular surgery (44%). Overall, 257 source patients were anti-HCV+, 54 HBsAg+, and 14 HIV+. No seroconversions were observed. In the literature, 14 outbreaks were reported documenting transmission of HBV from 12 infected HCWs to 107 patients, and 2 cases of HCV to 6 patients, during cardiothoracic surgery, especially related to sternotomy and its suturing. The transmission rate was estimated to be 5% to 13% for HBV, and 0.36% to 2.25% for HCV. Strategies in risk reduction include adequate surveillance, education, effective sharps disposal, personal protective equipment, safety devices, and innovative technology-based intraoperative procedures.

Hepatitis C in a ward for cystic fibrosis and diabetic patients: possible transmission by spring-loaded finger-stick devices for self-monitoring of capillary blood glucose

OBJECTIVE

To identify the routes of transmission in a nosocomial outbreak of hepatitis C virus (HCV) infection.

DESIGN

Epidemiological investigation, including screening for HCV of hospitalized patients, and a retrospective cohort study, review of hygiene and medical practices, and molecular comparison of HCV isolates.

SETTING

A specialized care unit for cystic fibrosis (CF) and diabetic patients at an acute-care facility in the south of France.

RESULTS

Of the 57 CF patients (age in 1995: 2-28 years), 38 (66.7%) were tested and 22 (57.9%) were anti-HCV positive. Eight (50%) of 16 patients with anti-HCV antibody tested by polymerase chain reaction were viremic. No patients had received blood products or had any history of intravenous drug use. All 18 (100%) patients with CF who had ever undergone self-monitoring of capillary blood glucose in the unit were anti-HCV positive, compared to 4 (20%) of 20 who had not (relative risk, 5.0; 95% confidence interval, 2.1-12.0). Seventy (39.5%) of the patients with diabetes were screened for anti-HCV; 12 (18.8%) tested positive, with 3 (25%) positive for HCV-RNA. Patients with diabetes had routine capillary blood glucose monitoring while hospitalized and shared with CF patients the same spring-triggered devices for capillary blood glucose monitoring. The disposable platform of the devices was not changed between patient use. All HCV isolates belonged to the type 1, subtype b, and phylogenetic analysis showed a close homology by sequencing of NS5b and E2/HVR regions.

CONCLUSION

As reported earlier for the hepatitis B virus, shared spring-triggered devices for capillary blood glucose monitoring by finger puncture may transmit HCV. Strict application of Standard Precautions procedures is warranted in any healthcare setting.

Mycobacterium xenopi spinal infections after discovertebral surgery: investigation and screening of a large outbreak

BACKGROUND

Mycobacterium xenopi spinal infections were diagnosed in 1993 in patients who had undergone surgical microdiscectomy for disc hernia, by nucleotomy or microsurgery, in a private hospital. Contaminated tap water, used for rinsing surgical devices after disinfection, was identified as the source of the outbreak. Several cases were recorded in the 4 years after implementation of effective control measures because of the long time between discectomy and case detection. The national health authorities decided to launch a retrospective investigation in patients who were exposed to M xenopi contamination in that hospital.

METHODS

Mailing and media campaigns were undertaken concurrently to trace exposed patients for spinal infections. Patients were screened by magnetic resonance imaging (MRI), and the scans were reviewed by a radiologist who was unaware of the diagnosis. Suspected cases had discovertebral biopsy for histopathological and bacteriological examination.

FINDINGS

Of 3244 exposed patients, 2971 (92%) were informed about the risk of infection and 2454 (76%) had MRI. Overall, 58 cases of M xenopi spinal infection were identified (overall cumulative frequency 1.8%), including 26 by the campaign (mean delay in detection 5.2 years, SD 2.4, range 1-10 years). Multivariate analysis showed that the risk of M xenopi spinal infection was related to nucleotomy and high number of patients per operating session.

INTERPRETATION

Failures in hygiene practices could result in an uncontrolled outbreak of nosocomial infection. Patients who have been exposed to an iatrogenic infectious hazard should be screened promptly and receive effective information.

Surgeon-patient barrier efficiency monitored with an electronic device in three surgical settings

Blood-borne viral pathogens are an occupational threat to health care workers (HCWs), particularly those in the operating room. A major risk is posed by accidental penetrating injury, but skin contamination with body fluids from an infected patient, with prolonged intimate cutaneous contact, is a frequent occurrence during surgery, carrying further risk of transdermal infection. We have monitored barrier failure in three surgical settings (microsurgery, orthopedic surgery, general surgery) by means of an electronic surveillance device. A total of 111 surgical procedures were monitored: 67 microsurgeries, 22 orthopedic surgeries, and 22 general surgeries. Of the 278 electronic alarms signaling barrier failure, 44 (15.8%) were associated with glove perforation, 39 of which (88.6%) were not perceived by the operator. In 16 of those, the skin was visibly stained with the patient's blood. Altogether, 76 of the alarms (27.3%) were consequent to contacts caused by soaked gowns/sleeves, and 121 (43.5%) were attributed to hydration of latex porosities; 37 alarms (13.4%) were unexplained false positives. On only one occasion did a surgeon observe blood stains on his hands without a previous alarm; this event was classified as a device failure due to incorrect wiring. Double-gloving offered satisfactory protection against skin contamination during microsurgery but not during orthopedic surgery. The data presented here indicate that electronic monitoring of the surgical barrier enables prompt detection of barrier failure, especially at the level of the gloves, thereby limiting skin contamination with patients' body fluids during surgery.

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.