Epidemiology of Perioperative Bloodborne Infections

1
Epidemiology of Perioperative Bloodborne
Infections

• UCSF Department of Surgery
• Grand Rounds
• March 29, 2006

2
Case

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

3
Brief Outline

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

4
HIV

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

5
Hepatitis B

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

6
Hepatitis C

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

7
Worldwide healthcare workerto patient
transmission

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

8
Unanswered Questions

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

9
Federal Regulations

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

10
Surveillance

• Exposure Prevention Information Network (EPINet)
• Dr. Janine Jagger (1991) UVa.
• International Health Care Worker Safety Center
• gt1500 US hospitals 70 facilities
• National Surveillance System for Health Care
  Workers (NaSH)
• CDC (1995)
• 80 facilities in 28 states

11
California

• 1996 Senate Bill
• Sharps Injury Control Program
• Voluntary reporting
• 90 of Hospitals report
• Weaknesses
• No reporting of non-sharps injuries (ie
  mucocutaneous exposures)
• No sample of non hospital-based HCWs

12
Surveillance (ctd)

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

13
Exposure Data in OR

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

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Trends OR lags in prevention
15
38 dropin injuries in patient rooms(all
devices)only 5.7 dropin OR injuries
16
OR Personnel

• Surgeons or 1st assistants (up to 59)
• Scrub nurses/techs (19)
• Anesthesiologists (6)
• Circulating nurses (6)

17
Exposure in OR

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

18
Trends in Needle injuries
19
33 declinehollow bore needles27
increasesuture needles
20
Exposure in OR

• Passing instruments hand to hand (16)
• Most self-inflicted
• But up to 24 by co-worker
• Non-dominant hand most common site
• Relatively few (lt0.05) are highest risk
• ie hollow bore needles
• Up to 1/3 devices come into contact with patient
  after HCW

21
Poor reporting

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

22
Exposure in OR

• Types of procedures
• High blood volume
• Poor visibility
• Length of time

23
Bloodborne Infections in Developing Countries
(DCs)

• Concerning given global epidemics
• Lack of data
• 70 of global HIV cases are in Sub-Saharan Africa
• But only 4 of worldwide cases of occupational
  HIV infection from this region
• 4 of global HIV cases are in North
  America/Europe
• But 90 of worldwide cases of occupational HIV
  infection are reported from this region

24
Needlestick Injuries in DCs

• 90 global surgical need in DCs
• WHO 90 of needlestick injuries in DCs
• 35 million HCWs globally
• 3 million get a NSI each year
• 40 of HCV/HBV in HCW is from occupational
  exposure
• 2.5 of HIV

25
Risk factors for injuries in DCs

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

26
Developing Countries (ctd.)

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

27
Effect on the health workforce

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

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Epi Conclusions

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

29
Thanks

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